Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Final Year Medicine Notes Musculoskeletal System
Letuda's Note
Musculoskeletal system
Version 1.0
Written and edited by,
Prithwiraj Maiti
R.G.Kar Medical College
Email ID: prithwiraj2009@yahoo.in
Table of contents
Content
Page no.
Diseases of bones and joints
Osteoarthritis
2
Ankylosing spondylitis
3
Reiter's disease
4
Rheumatoid arthritis
5
Gout
9
Connective tissue disorders
SLE
12
Scleroderma
16
Miscellaneous
Antiphospholipid syndrome
18
Polymyalgia rheumatica
19
2
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.
Risk factors:
1. Age related
2. Obesity
3. Secondary osteoarthritis in the affected joint (Ex: RA, Gout etc.).
Clinical features:
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.
Commonly involved joints:
Big joints: Hip, knee, vertebrae
Small joints: PIP, DIP, sometimes MTP.
On examination:
No signs of active inflammation
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).
3
Investigation:
X-Ray of the affected joint: It shows intra-articular space.
Treatment:
1. Weight reduction
2. Analgesics
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
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.
Ankylosing spondylitis
It is a seronegative spondylo-arthropathy with extra-articular involvement.
Clinical features:
Anterior uveitis
Arthropathy:
Back pain: Inflammatory in nature
Limited movement
Ankylosis: Severely reduced spine movement
Peripheral arthritis
Chest wal expansion causing shortness of breath.
4
Apical fibrosis
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:
1. X-Ray ? MRI spine
2. Spirometry
3. Echocardiogram
4. HLA-B27: +Ve.
Treatment:
Physiotherapy + Exercise
Analgesics
DMARDs: Hydroxy-chloroquine/ Infliximab (should be tried by an expert).
Reiter's disease
It is a seronegative spondylo-arthropathy.
Clinical features:
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.
Sometimes, cutaneous manifestations are seen (pustular lesion:
Keratoderma blennorrhagicum).
5
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:
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:
a. Polyarthritis
Typically involved joints:
Small joints: PIP, MCP, MTP
Large joints: Wrist, elbow
Pattern: Bilateral symmetrical.
b. Pain and stiffness
Most prominent in the morning
Stiffness may last even upto 20 mins or more
As the day progresses, joint symptoms gradually ease off.
c. Associated symptoms
Swelling + Tenderness + Deformity + Functional impairment.
On examination:
a. If active: tenderness, swelling, temperature (due to tenosynovitis)
6
b. Permanent deformity:
Swan neck deformity:
Hyperextension of PIP +
Hyperflexion of DIP
Button hole deformity:
Hyperextension of DIP +
Hyperflexion of PIP
Z deformity of hand: Radial deviation of wrist + Ulnar deviation of
fingers.
2. 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)
Investigations:
1. Full blood count: Hb, TC, DC, ESR
Hb: Normal/ may be
Probable causes of Hb in RA:
Probable cause
Type of anemia
Anemia of chronic inflammation
Normocytic normochromic anemia
GI bleed due to NSAID use
Iron deficiency anemia
Use of methotrexate
Folate deficiency anemia
7
TC:
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.
3. X-Ray joint:
Radiological changes appear almost 6 months after the onset of disease.
Changes are:
Juxta-articular osteopenia (bony decalcification)
Subluxation
Deformity.
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
2. Disease modifying anti-rheumatoid drugs (DMARDs)
3. Surgery.
Supportive treatment
Joint rehabilitation:
Exercise
Physiotherapy
Splinting.
8
NSAIDs:
Non selective COX inhibitors:
Ibuprofen
Indomethacin
Diclofenac.
Selective COX-2 inhibitors:
Etoricoxib.
Corticosteroids:
In case of severe inflammation, short course systemic corticosteroid
is used to secure acute inflammation
If long term steroid is required, patients are kept on minimal
effective dose of steroids.
DMARDs
Non-biological agents
Biological agents
Methotrexate (MTX)
Anti-TNF agents
Non anti-TNF agents
Sulfa-salazine
Infliximab
Rituximab
Leflunomide
Etanarcept
Tosilizumab
Adalimumab
Golimumab
Surgery
Reconstructive surgery for permanent deformities.
9
Protocol of using various treatment options in RA
RA Confirmed
Symptomatic NSAID
Joint rehabilitation
Active disease?
1. Clinical feature
2. Inflammatory markers
3. Disease activity score
Activity low
Activity moderate/ high
Corticosteroid if required
Corticosteroid
Single/ co-DMARDs (MTX
+
based)
1 DMARD
Specialist referral to consider
biological agents
(Preferable: MTX)
If long term steroid is given:
Add PPI + Bisphosphonate
Long term DMARD: Monitor
full blood count and LFT
Gout
It is a metabolic disease associated with abnormal amount of urate in the body
and characterized by acute recurrent mono-arthritis initially and later chronic
deforming polyarthritis.
10
Types:
1. Acute gouty arthritis
2. Chronic tophaceous gout.
Cause:
Hyperuricemia
Primary
Secondary
Idiopathic
Production of uric acid
Excretion of uric acid
Enzyme defect
Myeloproliferative/
Renal failure
lymphoproliferative
disorders (during tumor
lysis syndrome)
Drugs (Thiazide)
Chronic hemolytic
anemia
Cytotoxic drugs
Clinical features:
Acute gout (Acute gouty arthritis)
1. Onset: Abrupt
2. Precipitating factors:
a. High protein diet
b. Alcohol
c. Surgery
d. Infection
e. Rapid fluctuation of urate level (may be caused by drugs used to treat
gout itself, i.e. allopurinol)
f. Drugs: Thiazide.
11
3. Typical episode:
Joints affected: Typically 1st MTP joint, but feet, ankle and knee can also
be affected: 1 or >1 joints may be affected. If >1 joints get affected,
symptoms are usually asymmetrical.
Symptoms and signs:
Severe pain and swelling
On examination: Tenderness, Temperature, Swol en joint
Systemic feature + Fever
[Attack may also start in the soft tissue and arch of the foot]
Chronic gout (Chronic hyperuricemia)
It is seen particularly in foot due to deposition of monosodium urate.
Affected tissue
Soft tissue
Joint
Kidney
Pinna/ extensor
Recurrent acute attacks
surface of arm
Uric acid stone may lead
may lead to chronic
to urolithiasis ? urate
deforming polyarthritis
nephropathy
Firm/ hard in
consistency
May ulcerate with
release of white gritty
substance (tophi)*
[*: Urate crystals coming out as cheesy substance]
Investigations:
During acute attack:
1. WBC count:
2. Serum uric acid: (But normal uric acid level does not exclude gout)
12
3. Aspiration of joint fluid: Needle shaped, negatively birefringent crystals
4. CRP:
5. Temperature:
6. Culture-sensitivity: To rule out septic arthritis (Gram stain +Ve)
7. Imaging studies.
Treatment:
Gout
Prophylaxis/ management in
Acute gout
between attacks
Steroid (in case
Dietary
Avoid
Uric acid lowering
NSAIDs
Colchicine
of C/I to NSAID/
modification
hyperuricemic drugs
agents
Colchicine)
Non-selective
Short course of
Thiazide/ Loop
Hypouricemic
Avoid: Alcohol/
Uricosuric drugs
COX inhibitors
oral steroid
diuretics
drugs
Lentils/ Spinach/
Cauliflower/
Beans/ Peas/
Intra-articular
Mushroom/
Xanthine oxidase
COX-2 Selective
Probenecid
steroid
Chicken
inhibitor*
Allopurinol
Sulfa-pyrazone
Febuxostat
[*: Should always be started with prophylactic dose of NSAIDs/ Colchicine to prevent acute
flare up as rapid lowering of uric acid level can precipitate acute gout]
SLE
Non-organ specific autoimmune disease in which auto-antibodies are produced
against varieties of autoantigens.
Clinical features:
1. Systemic: Fever + Weight loss + Anorexia + Myalgia
2. Skeletal:
Polyarthritis: Usually symmetrical, non-erosive arthritis
13
Joints affected: Small joints (PIP/ MCP/ Wrist)
Signs of inflammation: +Ve
Deformity: Rare (Jaccoud's arthropathy: Permanent deformity due to
capsular subluxation).
3. Skin:
Photosensitivity
Photosensitive rash/ Malar rash/ Butterfly rash: Typically
erythematous rashes over chick, bridge of the nose, chin, ears
Discoid lupus: Scaly, circular, scarring rashes over scalp, eyes, face
and sun-exposed parts of arm, back and chest.
Alopecia
Raynaud's phenomenon
Livdo reticularis
Cutaneous vasculitis: Leading to nail fold infarct/ splinter
hemorrhage/ distal gangrene
4. CVS:
Pericarditis
Myocarditis ? Cardiac failure
14
Atypical endocarditis of Libman-Sacks: Usually silent, but may lead to
chronic valvular regurgitation: most commonly MR.
5. CNS:
Focal neurodeficit causing:
Headache
Seizure
Psychosis
CVA
Peripheral/ cranial neuropathies.
6. Eye:
Conjunctivitis
Visual loss (due to transient retinal vasculitis).
7. Endocrine:
Hashimoto's thyroiditis
SIADH.
8. Lungs:
Pleurisy
Pleural effusion
ILD
Pneumonitis.
9. Lympho-reticular:
Lymphadenopathy
Splenomegaly.
10. GIT:
Mouth ulcers
Mesenteric vasculitis (leading to ischemic colitis):
Abdominal pain
Melena
Intestinal perforation.
11. Kidney:
Glomerulonephritis: Leading to AKI/ CKD.
15
Investigation:
1. Full blood count: Hb (hemolytic anemia may occur), TC , Platelet
2. ESR:
Infection
3. CRP: Usual y normal but may
Pleurisy
Serositis
4. Urea/ creatinine: Normal/
Pericarditis
5. Autoantibodies:
a. Antinuclear antibody (ANA): Sensitive but not specific
b. Anti ds-DNA/ Anti-Sm antibody: Specific but not sensitive
c. RA factor + Anti SS-A+ Anti SS-B: May be nonspecifically +Ve (overlap
syndrome)
d. Antiphospholipid antibody may be +Ve in following cases:
Biological false +Ve test for syphilis
Anticardiolipin antibody
Lupus anticoagulant.
6. Urine R/E + M/E:
RBC +/ RBC cast +/ Dysmorphic RBC
Proteinuria +Ve.
7. Other relevant investigations depending on organ involvement.
Treatment:
1. Cutaneous disease:
Sunscreen lotion
Topical steroid
Hydroxy-chloroquine.
2. Arthritis:
NSAIDs
Hydroxy-chloroquine.
3. Steroid:
Indications are:
Glomerulonephritis
16
Pericarditis/ myocarditis
CNS manifestations
Significant immune hemolytic anemia/ immune thrombocytopenia.
4. Immunosuppression:
Cyclophosphamide/ Mycophenolate mofetil: For lupus nephritis
Mycophenolate Mofetil/ Azathioprine: For CNS vasculitis.
Scleroderma
Disorder characterized by progressive fibrosis of skin and internal organs.
Types:
1. Diffuse cutaneous sclerosis
2. Limited cutaneous sclerosis (CREST syndrome)
3. Localized cutaneous sclerosis.
Clinical features:
1. Systemic: Malaise + Weight loss
2. Skin:
a. Initially subcutaneous pitting edema
b. Progressive fibrotic thickening of skin: Overlying skin becomes tightly
bound to subcutaneous tissues (Hidebound skin): Trunk/ extremities
c. Pigmentation/ Depigmentation
d. Telangiectasia: Lips/ tip of the finger/ buccal mucosa
e. Cutaneous vasculitis: Nail-fold infarct/ Splinter hemorrhage/ Digital
gangrene.
3. Skeletal: Poly-arthralgia
4. CVS:
a. Pericarditis
b. Heart block
c. Myocardial fibrosis---- Heart failure
d. RHF secondary to PAH.
5. Esophagus:
Dysphagia due to hypomotility.
17
6. Lungs:
a. PAH
b. ILD: Pulmonary fibrosis.
7. GIT:
Features due to intestinal dysmotility:
a. Abdominal pain
b. Bloating
c. Constipation
d. Diverticular disease (due to bacterial overgrowth).
8. Kidney:
Scleroderma renal crisis: Accelerated hypertension with rapidly progressing
nephropathy.
CREST syndrome
C. Chondro-calcinosis cutis
R. Raynaud phenomenon
E. Esophageal dysmotility
S. Sclerodactyly
T. Telangiectasia.
Investigations of scleroderma:
1. Hb:
2. ESR: Usually normal
3. Urea creatinine Na+ K+: To assess renal function
4. Urea R/E and M/E: RBC +Ve and Protein +Ve in renal crisis
5. ECG/ Echocardiogram: To assess PAH and condition of right heart
6. Autoantibodies:
Anti Scl-70: +Ve in diffuse systemic sclerosis
Anti-centromere antibody: +Ve in CREST syndrome.
7. Organ specific investigations if required.
18
Treatment:
There is no effective therapy to halter disease process.
Therapy is mainly supportive and organ-specific:
Affected organ
Skin (Raynaud
Esophageal
Bacterial
PAH
phenomenon)
disease
overgrowth
CCB
PPI
Tetracycline
Bosentan
Losartan
Sildenafil
Sildenafil
Prostaglandin
Antiphospholipid syndrome
Disorder characterized by recurrent venous thrombosis and recurrent
miscarriage.
Clinical features:
Although it occurs in many patients with SLE, it may also occur in an
isolated manner
Females are more affected
Recurrent unprovoked DVTs
DVTs at unusual sites: lymph vein, portal vein, hepatic vein, renal vein,
adrenal vein, cerebral venous sinus
Recurrent miscarriage.
19
Investigations:
1. Autoantibodies:
False +Ve VDRL
Anticardiolipin antibody +Ve
Lupus anticoagulant.
2. Investigations to rule out underlying SLE
3. Coagulation profile: aPTT
Treatment: Anticoagulant.
Polymyalgia rheumatica
It is a syndrome characterized by pain/ stiffness usually in the neck, shoulder, hip.
Clinical features:
1. Age: Middle aged to elderly
2. Manifestations:
I. Pain and stiffness:
Slowly progressive [Note: No muscle weakness/ wasting].
Typically affecting:
Shoulder: Difficulty in combing hair
Pelvic girdle: Difficulty in climbing upstairs/rising from a chair.
II. Poly-arthralgia/ arthritis:
Usually mild, affecting knee/ wrist.
III. Pyrexia + Fatigue + Malaise + Weight loss
IV. Psychiatric depression
V. May/ may not overlap with giant cell arteritis.
Investigations:
1. Hb:
2. ESR:
3. ALP: May be
4. CK: Normal
Treatment: Low dose prednisolone.
This post was last modified on 01 September 2021