Download MBBS Final Year Medicine Notes Musculoskeletal System

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Musculoskeletal system

Table of contents

Osteoarthritis/ osteo-arthropathy

Introduction:

It is the commonest arthropathy which is non-inflammatory in nature and occurs due to degeneration of articular cartilage and secondary hypertrophy of the bone of articular margin.

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Risk factors:

1. Age related
2. Obesity
3. Secondary osteoarthritis in the affected joint (Ex: RA, Gout etc.).

Clinical features:

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Joint pain

Description:

• Typically occurs after prolonged activity of the joint, rest relieves the pain; however, in severe cases, pain may persist even at rest
• Nature: Continuous pain, without any significant stiffness of the joint
• Affected joint may show reduced range of movement (both active and passive) due to deformity.

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Commonly involved joints:

• Big joints: Hip, knee, vertebrae
• Small joints: PIP, DIP, sometimes MTP.

On examination:

• No signs of active inflammation

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• Passive movements are restricted
• Sometimes bony overgrowth may be identified:
  • While involving DIP: Heberdon's nodule
  • While involving PIP: Bouchard's nodule.
• Examination of knee: Crepitus (due to presence of loose body).

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Investigation:

X-Ray of the affected joint: It shows ?intra-articular space.

Treatment:

1. Weight reduction
2. Analgesics

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3. Exercise
4. Rehabilitation
5. Joint replacement.

Note: Although frequently prescribed, role of [Glucosamine + Chondroitin sulfate] is not established.

Peer into basics: Seronegative spondylo-arthropathy

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A group of disorders characterized by axial, skeletal and joint involvement and negative autoimmune marker. This group involves:

1. Ankylosing spondylitis
2. Psoriatic arthropathy
3. Arthropathy associated with inflammatory bowel disease
4. Reiter's disease/ Reactive arthritis.

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Ankylosing spondylitis

It is a seronegative spondylo-arthropathy with extra-articular involvement.

Clinical features:

• Anterior uveitis
• Arthropathy:
  • Back pain: Inflammatory in nature
  • Limited movement

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  • Ankylosis: Severely reduced spine movement
  • Peripheral arthritis
  • ?Chest wall expansion causing shortness of breath.

• Apical fibrosis

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• Aortic root dilation (causing AR)
• IgA nephropathy
• Achilles tendonitis ± Plantar fasciitis (Together called: Enthesopathy).

Investigation:

There is no single investigation to confirm the diagnosis. However, the following investigations may be done:

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1. X-Ray ± MRI spine
2. Spirometry
3. Echocardiogram
4. HLA-B27: +Ve.

Treatment:

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• Physiotherapy + Exercise
• Analgesics
• DMARDs: Hydroxy-chloroquine/ Infliximab (should be tried by an expert).

Reiter's disease

It is a seronegative spondylo-arthropathy.

Clinical features:

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• Often there is a preceding history of gastro-enteritis (diarrhea, vomiting) which probably triggers an immunological reaction leading to the disease
• There are 3 components of Reiter's disease:
  1. Arthritis: Asymmetrical small joint arthropathy
  2. Urethritis: Dysuria, per-urethral discharge (resembling gonococcal urethritis)
  3. Conjunctivitis.

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• Sometimes, cutaneous manifestations are seen (pustular lesion: Keratoderma blennorrhagicum).

Investigation:

No specific investigation to confirm the disease

However, gram stain with culture-sensitivity of the urethral discharge should be done to rule out any STD.

Treatment:

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Symptomatic: NSAIDs.

Rheumatoid arthritis (RA)

It is an autoimmune disease characterized by severe deformity predominantly involving small joints; causing polyarthritis and extra-articular manifestations.

Clinical features:

1. Skeletal:
   1. Polyarthritis
      • Typically involved joints:
        • Small joints: PIP, MCP, MTP
        • Large joints: Wrist, elbow

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      • Pattern: Bilateral symmetrical.
   2. Pain and stiffness
      • Most prominent in the morning
      • Stiffness may last even upto 20 mins or more

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      • As the day progresses, joint symptoms gradually ease off.
   3. Associated symptoms

      Swelling + Tenderness + Deformity + Functional impairment.

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On examination:

1. If active: tenderness, swelling, ? temperature (due to tenosynovitis)

1. Permanent deformity:
   • Swan neck deformity:

     Hyperextension of PIP + Hyperflexion of DIP

   • Button hole deformity:

     Hyperextension of DIP + Hyperflexion of PIP

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   • Z deformity of hand: Radial deviation of wrist + Ulnar deviation of fingers.

1. Extra-articular manifestations:

   System	Manifestations
   CVS	Pericarditis ± Effusion
   CNS	Entrapment neuropathy: Features of Carpal-tunnel syndrome Atlanto-occipital subluxation: May lead to high cervical myelopathy
   Eye	Scleritis/ uveitis/ red eye/ gritty eye
   Lungs	Pleurisy + Effusion Interstitial lung disease/ hypersensitivity pneumonitis Rheumatoid nodule (Caplan's syndrome/ Rheumatoid pneumoconiosis).
   Blood	Hypersplenism (Splenomegaly ± Variable cytopenia)

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Investigations:

1. Full blood count: Hb, TC, DC, ESR

Hb: Normal/ may be?

Probable causes of ? Hb in RA:

TC: ?

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DC: Variable cytopenia due to hypersplenism

CRP/ ESR: ? (having prognostic value: gradually falling level with treatment indicates inflammatory state is subsiding)

2. Autoimmune marker:
   • Anti-cyclic citrullinated peptide (anti-CCP): Sensitive as well as specific marker
   • Anti- rheumatoid factor: Sensitive but not specific.

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3. X-Ray joint:

   Radiological changes appear almost 6 months after the onset of disease.

   Changes are:

   • Juxta-articular osteopenia (bony decalcification)
   • Subluxation
   • Deformity.

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4. Other relevant investigations depending upon other extra-articular manifestations.

Treatment:

There are 3 headings in the treatment options of RA:

1. Supportive/ symptomatic treatment

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2. Disease modifying anti-rheumatoid drugs (DMARDs)
3. Surgery.

• Joint rehabilitation:
  • Exercise
  • Physiotherapy
  • Splinting.

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Supportive treatment

• NSAIDs:
  • Non selective COX inhibitors:

    Ibuprofen

    Indomethacin

    Diclofenac.

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  • Selective COX-2 inhibitors:

    Etoricoxib.

  
  

  This download link is referred from the post: MBBS Lecture Notes for all subjects (updated for 2021 syllabus) - All universities

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