Musculoskeletal Notes

Musculoskeletal Musculoskeletal Diseases Types: Soft tissue: tennis elbow, mechanical back pain, repetitive strain Degenerative: osteoarthritis, cervical spondylosis Inflammatory: rheumatoid arthritis, seronegative SpA, crystal arthritis, connective tissue disease Other: fibromyalgia, normality, metabolic disease Female Causes of arthritis Cartilage death - osteoarthritis Synovial inflammation and overgrowth - rheumatoid arthritis Inflammation and new bone formation at entheses - ankylosing spondylitis Crystals in synovial fluid - gout Young adults Children Middle age Elderly Cartilage death Male Ankylosing spondylitis (1:2) Rheumatoid arthritis Trauma Juvenile idiopathic arthritis (JIA) Gout Osteoarthritis (knee) Osteoarthritis (hip) Osteoporosis Psoriatic arthritis Rheumatoid arthritis In OA, the cartilage dies in patches, which results in the bones sitting more closely together and eventually rubbing against each other The joint space is narrower The bone just under the cartilage surface becomes thick and sclerotic (deep yellow colour) The bone at the edges grows out as if to support the failing joint and these are called osteophytes The capsule becomes thickened and fibrotic and the synovium may develop small areas of inflammation Occurs more in women than men and is more common in the elderly Synovial inflammation and overgrowth In RA, the synovium becomes inflamed with a mixture of acute and chronic changes leading to stiffness, pain and destruction Persistent inflammation causes generalised cartilage loss (narrowing the joint space) and thinning (osteoporosis) of the bone close to the joint (juxta-articular osteoporosis) Synovial cells become overgrown and invasive, eating into the corners of the bones forming erosions More frequent in women than men and commonly starts in the 30-50 year range Inflammation and new bone formation at entheses The main site of this pathology is in the spine, where enthuses abound. However, the pathology can occur at many other sites, including important entheses that are not close to joints, such as where the plantar fascia of the foot joins to the anterior margin of the calcaneus. Ankylosing = sticking together Spondylitis = inflamed spine New bone forms little spurs called syndesmophytes in the spine, which grow into the area of the ligaments Recurrent attacks means the spurs lengthen forming complete bridges across intervertebral discs Results in a loss of motion More common in men between 15 and 30 Crystals in synovial fluid In gout, sodium urate crystals form in the synovial fluid and attract major onslaught from polymorphonuclear leucocytes which migrate into the joint and set up a severe acute inflammatory response Serum urate levels are kept above crystallisation concentrations by serum proteins When this system fails, urate levels rise too high causing gout The first joint affected is the proximal interphalangeal joint of the big toe, called podagra Does not occur in children or women before the menopause and starts over the age of 40 Osteoarthritis Mechanically induced joint failure Insufficient cartilage repair response stimulus Focal loss of articular cartilage in part of a synovial joint is accompanied by hypertrophy of the sub-chondral bone and margins of the joint A thickened synovial lining produces excess synovial fluid ? effusion Microfractures on the articular surface allows new bone to be laid down, forming cysts Women are 10 times more likely to have Hebeden's node than men. Almost any joint can be affected Causes: age, gender, genes, obesity, hypermobility, trauma, occupation, joint shape ? Target sites There is an imbalance in breakdown by chrondrocytes and synthesis Clinical features Systemically well, complaining of aching/burning, localised to a joint Gradually increasing , asymmetry over years Worse on activity, relieved by rest. Possibly suffers night pain X-ray & examination sufficient ? Decreased joint space ? Sclerosis ? Osteophytes ? Subchondral cysts Blood tests to exclude septic or inflammatory arthritis 

Buy the full version of these notes or essay plans and more in our Musculoskeletal Notes.