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PassPMR - 06 Rheumatology > 1- Arthritis (RA, OA, Septic & Charcot Joint) > Flashcards

1- Arthritis (RA, OA, Septic & Charcot Joint) Flashcards

1
Q

Diarthrodial joint components: πŸ”‘πŸ”‘ Dr. Jamal OSCE Joint Station Anatomy

  1. List 4 components of diarthrodial joints 2. List 6 types of synovial joints 3. List 3 types of joints overall
A

Diarthrodial Joints = Synovial Joint

  • Freely movable joints held together by a joint capsule.

Componenets of Synovial Joint

  1. Type II hyaline cartilage
  2. Subchondral bone
  3. Synovial membrane
  4. Synovial fluid
  5. Joint capsule

Morphology of Synovial Joints

  1. Pivot joints: C1-2.
  2. Plane (gliding) joints: AC.
  3. Ball and socket: Hip.
  4. Hinge joints: elbow joint.
  5. Saddle joints: 1st CMC.
  6. Condyloid joints: MCP.

Joint Type

  1. Synovial joints
  2. Fibrous joints
  3. Cartilaginous joints

Ref: wikipedia.

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2
Q

In general, which arthritis affects:

a) proximal joints
b) distal joints
c) spine
d) symmetric SI joints
e) asymmetric SI joints

A

a) proximal - RA and crystal deposition diseases
b) distal - OA, seronegative, psoriatic
c) spine - spondyloarthropathies
d) symmetric SI joints - ank spond, enteropathic
e) asymmetric SI joints - reactive arthritis, psoriatic arthritis

Ref: MSK Imaging The Requisites p288

Psoriatic arthritis is a great mimicker

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3
Q

How are subchondral erosions caused by inflammatory and noninflammatory joint disease?

A

Inflammatory joint disease

Pannus intrusion into subchondral bone

Noninflammatory joint disease

Liquefaction of subchondral bone after pressure necorsis, or synovial intrusion at joint surfaces worn down to bone

Ref: MSK Imaging The Requisites p288

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4
Q

Composition of Diarthrodial Joints πŸ”‘πŸ”‘ Dr. Jamal

A

πŸ’‘ Diarthrodial joints are also known as true joint or movable joint, or synovial joint, that allows free movement of the joints

  1. Type II hyaline cartilage
  2. Subchondral bone
  3. Synovial membrane
  4. Synovial fluid
  5. Joint capsule

Cuccurollo 4th Edition Chapter 3 Rheumatology pg101

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5
Q

What is RA? How does it affect joints?

A

RHUMATOID ARTHRITIS

  • Chronic, systemic, inflammatory, autoimmune disorder of unknown etiology
  • Primarily affects the synovial lining of diarthrodial joint and leads to articular destruction.
  • Chronic, symmetric erosive synovitis develops and leads to articular destruction.

PANNUS FORMATION

πŸ’‘ Pannus formation is the most important destructive element in RA

  • Pannus is a synovial membrane-derived tissue that overgrows cartilage
  • Membrane of granulation tissue that covers the articular cartilage at joint margins.
  • Macrophage-like cells invade β†’ marginal periarticular bone and cartilage destruction
  • Fibroblast-like invade β†’ joint ankylosis
  • Osteoclasts invade bone β†’ marginal erosion

Cuccurollo 4th Edition Chapter 3 Rheumatology pg101-102

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6
Q

Morning Stiffness: OA, RA, Ankylosing Spondylitis πŸ”‘πŸ”‘

A

Cuccurollo 4th Edition Chapter 3 Rheumatology pg103

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7
Q

2010 ACR Criteria for RA β€œ532” πŸ”‘πŸ”‘

A
  • To apply this criteria, the patient must have at least one joint with definite clinical synovitis (swelling) that is not best explained by another disease process.
  • A score of β‰₯6/10 is needed for classification of a patient as having definite RA.

πŸ’‘ 5-3-2, 5 joint, 3 labs, 2 duration and inflammation

  • 5 for joint
  • 3 for serology (RF, ACPA or anti-CCP)
  • 2 for duration 6wks and acute phase reactants (ESR, CRP)

Cuccurollo 4th Edition Chapter 3 Rheumatology pg102

Rheumatology Secrets - 4th Edition (2019)

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8
Q

What clinical and laboratory findings predict a patient with early undifferentiated arthritis will develop RA?

A

πŸ’‘ 5-3-2

  1. Higher number of joints involved (mean β‰₯7 joints) ← remember the criteria
  2. Positive RF
  3. Positive anticyclic citrullinated peptides (anti-CCP) antibodies
  4. Elevated C-reactive protein (CRP)
  5. Prolonged morning stiffness (>90 min)
  6. Female sex
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9
Q

Onset Pattern of RA.

A

Acute β†’ 10% to 20%

  • Several days
  • Severe muscle pain & Less symmetric

Intermediate β†’ 20% to 30%

  • Several weeks
  • Systemic complaints more noticeable

Insidious β†’ 50% to 70%.

  • Several months
  1. Morning stiffness in the involved joints lasting 1 hour or more
  2. Nonspecific diffuse musculoskeletal pain
  3. Joint swelling, erythema
  4. Muscle atrophy
  5. Constitutional symptoms: Fatigue, malaise
  6. Low-grade fever without chills

Cuccurollo 4th Edition Chapter 3 Rheumatology pg102-103

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10
Q

Poor Prognostic Factors in RA πŸ”‘πŸ”‘

A

πŸ’‘ Confirmed diagnosis + Radiology

  1. RF (+)
  2. CCP antibodies
  3. Rheumatoid nodules
  4. Persistent synovitis
  5. X-ray consistent with erosive disease
  6. Insidious onset

Cuccurollo 4th Edition Chapter 3 Rheumatology pg112

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10
Q

List 6 Investigations for RA

A
  1. Complete blood count (CBC):
    • Thrombocytosis, hypochromic microcytic anemia, eosinophilia
  2. Elevated acute phase reactants:
    • Erythrocyte sedimentation rate (ESR)
    • C-reactive protein (CRP)
  3. Rheumatoid factor (RF)
  4. Antibodies to cyclic citrullinated peptides (ACPA/CCPs)
    • Specific for RA and correlated with aggressive disease
  5. Synovial fluid analysis
    • R/O crystal disease or septic joint
  6. Hypocomplementemia

Cuccurollo 4th Edition Chapter 3 Rheumatology pg104

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11
Q

List 4 conditions with RF+ other than RA. πŸ”‘πŸ”‘

A

πŸ’‘ 70% to 80% of patients with RA are RF (+).

  • CTD: Systemic lupus erythematosus, Scleroderma
  • Muscles: Polymyositis
  • Glands: SjΓΆgren’s
  • Serogenative: Reactive arthritis, Psoriatic arthritis
  • Virus: Viral hepatitis, Influenza

Cuccurollo 4th Edition Chapter 3 Rheumatology pg104

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12
Q

List 2 conditions with Anti-CCP(+) other than RA.

A

Sensitivity of 80% and specificity of 90% to 95%.

  1. Psoriatic arthritis (same joint affection)
  2. Tuberculosis [TB]

Cuccurollo 4th Edition Chapter 3 Rheumatology pg104

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13
Q

Radiological Findings in RA πŸ”‘πŸ”‘

A

INFLAMMATORY SYNOVITIS (EFFUSION) β†’ PANNUS (CARTILAGE - BONE - JOINT)

  1. Soft tissue swelling
  2. Marginal bone erosions (near attachment of joint capsule)
  3. Uniform joint space narrowing (loss of articular cartilage)
  4. Periarticular osteopenia (bone washout)
  5. Joint Subluxation
  6. Malalignment and fusion of joints

SPECIFIC

  1. Erosion of the ulnar styloid
  2. Erosion of the metatarsal head of the MTP joint
  3. Radial deviation of the radiocarpal joint
  4. Ulnar deviation and volar subluxation seen at the MCP joint

Cuccurollo 4th Edition Chapter 3 Rheumatology pg104

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14
Q

Answer πŸ”‘πŸ”‘ EXAM 2021 Pic of arthritic hand, name the joint/bone and the findings

A
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15
Q

Answer πŸ”‘πŸ”‘ EXAM 2021 Pic of arthritic hand, name the joint/bone and the findings

A
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16
Q

Q1: RA Patient presents with bilateral upper limb pain and weakness. Dx & Inv πŸ”‘πŸ”‘ MOCK 22

Q2: RA Patient presented with unsteady gait. Why? Investigation? Leak 21

A

Cervical Spine Instability

  • Subluxation or instability at the A-A joint.
    1. Rupture/Tenosynovitis of transverse ligament of C1
    2. Odontoid or atlas erosion

Complication

  • Cervical Myelopathy

Investigation

  1. Lateral Flexion-Extension Xray β†’ Measure Atlantoaxial space in Flexion normally < 3.5mm
  2. MRI β†’ Cervical myelopathy

Precaution

  • Pre-op C-spine flexion-extension x-rays are recommended in RA patients prior to surgery to ensure there is no cervical instability

Cuccurollo 4th Edition Chapter 3 Rheumatology pg107

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17
Q

Case with Atlantoaxial distance 5 mm. πŸ”‘πŸ”‘

  1. What is normal distance?
  2. Name the ligament that provides stability.
  3. List 2 conditions which predispose to AA instability.
A

Atlantoaxial distance

< 3.5mm is normal

< 3.5mm is unstable

< 10mm indicates surgery in RA.

Ligament

Transverse ligament

Conditions

  1. Arthritides: Rheumatoid Arthritis, Seronegative Arthrtopathy (PSA, ASp)
  2. Pediatrics: JIA,
  3. Congenital: Down syndrome, Marfan disease
  4. Acquired: Trauma, Surgery

Ref: https://radiopaedia.org/articles/atlanto-axial-subluxation

Ref: http://www.orthobullets.com/spine/2049/atlantoaxial-instability.

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18
Q

List 2 Shoulder Deformities in RA

A
  1. Glenohumeral (GH) arthritis β†’ Limit internal rotation like OA
  2. Adhesive capsulitis
  3. Rotator cuff injuries:
    1. Superior subluxations
    2. Tears
    3. Fragmenting of tendons secondary to erosion of the greater tuberosity

Cuccurollo 4th Edition Chapter 3 Rheumatology pg107

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19
Q

List 2 Elbow Deformities in RA πŸ”‘

A
  1. Subcutaneous nodules
  2. Olecranon bursitis
  3. Ulnar neuropathies

Cuccurollo 4th Edition Chapter 3 Rheumatology pg107

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20
Q

What are the common deformities of the hand in RA? πŸ”‘πŸ”‘

A

BOUTONNIÈRE DEFORMITY

Weakness or rupture of extensor hood β†’ lateral bands slip downward (sublux)

  1. MCP hyperextension
  2. PIP flexion
  3. DIP hyperextension

SWAN NECK DEFORMITY

  1. Flexor tenosynovitis β†’ MCP flexion contracture
  2. Contracture of the intrinsic (lumbricals, interosseous) β†’ PIP hyperextension
  3. Contracture of deep finger flexor muscles and tendons β†’ DIP flexion

Tx: Swan neck ring splint

ULNAR DEVIATION OF THE FINGERS

Flexor/extensor mismatch:

  1. Radial deviation of the wrist (weak ECU)
  2. Ulnar deviation of the fingers (stretch of finger flexor tendon)

INSTABILITY OF THE CARPAL BONES

  • Ligament laxity & Carpal bone erosions
  • Carpal bones rotate in a zigzag pattern.

FLOATING ULNAR HEAD (PIANO-KEY SIGN)

  • Synovitis at the ulnar styloid leads to rupture of the ulnar collateral ligament
  • Ulnar head β€œfloats up” dorsally in the wrist

DE QUERVIAN’S TENOSYNOVITIS

  • Tenosynovitis of the EPB and APL tendons
  • Thickening of the tendon sheath results in tenosynovitis and inflammation
  • Test: Finkelstein’s test

PSEUDOBENEDICTION SIGN

  • Rupture of extensor tendons of the fourth and fifth digit due to sharp, elevated ulnar styloid.
  • Inability to fully extend the fourth and fifth digit

RESORPTIVE ARTHROPATHY Ψ§Ω„ΨͺΩ‡Ψ§Ψ¨ المفاءل Ψ§Ω„Ψ₯Ω…Ψͺءاءي

  • Osteoclastic bone resorption β†’ Telescoping appearance of the digits
  • Most serious arthritic involvement

Cuccurollo 4th Edition Chapter 3 Rheumatology pg106-107

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21
Q

Lower Extremity Deformities in RA

A

HIP DEFORMITIES

  1. Protrusio acetabuli:
    • Deepening of the acetabulum with medial migration of the femoral head
  2. Hip arthritis

KNEE DEFORMITIES

  1. Quadriceps atrophy
    • Weak knee extension
    • Flexion contractures
    • Increased amount of force though the patella
    • Increased intra-articular pressure in the knee joint, causing the synovial fluid to drip into the popliteal space (i.e., popliteal or Baker’s cyst)

ANKLE DEFORMITIES

  1. Tarsal tunnel syndrome:
    • Synovial inflammation can lead to compression of the posterior tibial nerve

FOOT DEFORMITIES

  1. Hammer toe deformities
    • Hyperextension of the MTP and DIP joints with flexion of the PIP joint
  2. Claw toe deformities:
    • Hyperextension at the MTP joint and flexion of the PIP and DIP joints
    • Pain on the metatarsal heads on weight bearing
  3. Hallux valgus deformity:
    • Lateral deviation of the toes

Cuccurollo 4th Edition Chapter 3 Rheumatology pg108

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22
Q

Answer

A

(A) Buttonhole (the third finger) deformity.

(B) Swan-neck (the second finger) deformity.

(C) Ulnar deviation of MTP

(D) Hallux valgus and toes overriding.

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23
Q

Extra-articular manifestations are more common in patients with the following findings πŸ”‘πŸ”‘

A
  1. RF (+)
  2. Rheumatoid nodules
  3. MHC class HLA DRB1 alleles
  4. Severe articular disease

Cuccurollo 4th Edition Chapter 3 Rheumatology pg108

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24
Q

Extraarticular manifestations of RA πŸ”‘πŸ”‘

A

EYE

  1. Keratoconjunctivitis sicca (dry eye syndrome) β†’ SjΓΆgren’s Syndrome
  2. Episcleritis β†’ Scleritis

SYSTEMIC

  1. Malaise, fatigue, weight loss.

NEUROLOGY

  1. Subluxation C1-C2: Destruction of the transverse ligament
  2. Cervical myelopathy (UMN)
  3. Radiculopathy
  4. Mononeuritis multiplex β†’ inflammatoryβ€”not due to compression
  5. Peripheral neuropathy (distal symmetric sensory, sensorimotor, or autonomic).
  6. Entrapment neuropathies β†’ synovial inflammation and joint postures

MOUTH

  1. Dryness of the mouth (decreased salivary secretion) β†’ SjΓΆgren’s Syndrome

PYLMONARY

  1. Inflammation of the cricoarytenoid joint β†’ dysphagia, dysphonia
  2. Interstitial lung disease
  3. Pleurisy
  4. Caplan’s Syndrome

CARDIAC

  1. Pericarditis β†’ Diffuse ST elevations
  2. Valvular heart disease

GI

  1. Gastritis
  2. Peptic ulcer disease (PUD) β†’ Secondary NSAIDs

RENAL

  1. Glomerulonephritis β†’ Secondary NSAIDs

SKIN

  1. Subcutaneous rheumatoid nodules (Pressure points: Extensor surface ie olecranon)
  2. Vasculitic lesions

BLOOD

  1. Hypochromic microcytic anemia
  2. Thrombocytosis
  3. Lymphadenopathy
  4. Felty’s syndrome: Classic triad of RA, splenomegaly, leukopenia

Cuccurollo 4th Edition Chapter 3 Rheumatology pg108-109

Ref: Current dx and treatment in rheumatology textbook pg 263; uptodate article – neurologi manifestations of rheumatoid arthritis.

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25
Q

Subcutaneous Nodules Are Seen in

A
  1. Rheumatoid arthritis
  2. Gout

Cuccurollo 4th Edition Chapter 3 Rheumatology pg108

  1. Systemic lupus erythematosus (SLE)
  2. Rheumatic fever (RF)
  3. Systemic sclerosis (calcinosis)
  4. Vasculitis
  5. Xanthoma

Rheumatology Secrets 4th Edition Chapter 5 pg46

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26
Q

List 2 nerve entrapment in RA πŸ”‘πŸ”‘

A
  1. Ulnar nerve (cubital tunnel)
  2. Median nerve (carpal tunnel)
  3. Posterior interosseous branch of the radial nerve
  4. Posterior tibial nerve (tarsal tunnel)
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27
Q

List 4 neurological manifestations of RA (rheumatoid arthritis). πŸ”‘πŸ”‘

A

NEUROLOGY

  1. Subluxation C1-C2: Destruction of the transverse ligament
  2. Cervical myelopathy (UMN)
  3. Radiculopathy
  4. Mononeuritis multiplex β†’ inflammatoryβ€”not due to compression
  5. Peripheral neuropathy (distal symmetric sensory, sensorimotor, or autonomic).
  6. Entrapment neuropathies β†’ synovial inflammation and joint postures

Cuccurollo 4th Edition Chapter 3 Rheumatology pg108-109

Ref: Current dx and treatment in rheumatology textbook pg 263; uptodate article – neurologi manifestations of rheumatoid arthritis.

28
Q

What is Felty’s syndrome? What condition is it associated with?

A

SHE FELT HER SPLEEN

  1. RA
  2. Leukopenia/neutropenia (decreased WBC).
  3. Splenomegaly (enlarged spleen).
29
Q

Rehab plan RA. OSCE: Patient with independent level on function. Advice him πŸ”‘πŸ”‘

A

πŸ’‘ ECR.POLICE.MS

EDUCATION

  • Home exercise program

PROTECTION & ORTHOSIS

  • Joint protection education
  • Rest (acute inflammation)
  • Splinting is used to immobilize the joint (acute inflammation)

OPTIMAL LOADING

  1. Stretch
    • Avoided in acute stage
    • Tendon is inflamed and might worsen β†’ tendon rupture
    • Joint is swollen β†’ capsular rupture
  2. ROM Exercises
    • PROM to prevent soft tissue contracture
  3. Isometric exercise
    • Generates maximal muscle tension with minimal fatigue and stress
    • Restores and maintains strength
    • Least amount of periarticular bone destruction and joint inflammation/pain
  4. Aerobic
    • Bike and pool low intensity for 15-20 minutes / 2-3 days a week

ICE & MODALITIES

  1. Acute β†’ Cryotherapy for pain relief
  2. Chronic β†’ Superficial moist heat for pain relief and increase collagen extensibility.

Cuccurollo 4th Edition Chapter 3 Rheumatology pg110-113

30
Q

What type of resistance exercise should be used in RA with mild disease and why? πŸ”‘πŸ”‘ EXAM

A

ISOMETRIC EXERCISES

  1. Causes the least amount of periarticular bone destruction and joint inflammation/pain, especially during an acute flare
  2. Restores and maintains strength
  3. Generates maximal muscle tension with minimal work, fatigue, and stress
  4. Isotonic and isokinetic exercise may exacerbate the flare and should be avoided

Cuccurollo 4th Edition Chapter 3 Rheumatology pg110

31
Q

List some of assisted devices for rheumatological case. πŸ”‘πŸ”‘

32
Q

Discuss the detrimental effects of prolonged rest

A
  1. Low Coordination
  2. Low CV fitness
  3. Muscle atrophy
  4. Joint stiffing and decreased ROM
  5. Low Bone density

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg584

33
Q

RA patient discuss the benefits of exercise program πŸ”‘

A
  1. Increase muscle bulk and endurance
  2. Increase bone density
  3. Increase joint ROM
  4. Improve CV fitness (aerobic capacity)
  5. Improve psych wellbeing
  6. Improve ADLs and QoL
34
Q

What are the signs of excessive exercise in patients with rheumatic disease?

A
  1. Post exercise pain >2 hours
  2. Increased fatigue
  3. Increase weakness
  4. Increase joint swelling

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg585

35
Q

Compare the indications and contraindications of passive and active range-of-motion (ROM) exercise in patients with rheumatic disease. When should forceful stretching of a tendon or joint be avoided?

A

PASSIVE ROM

  • Once daily to prevent the development of joint contracture
  • Passive motion with many repetitions increases joint inflammation
  • Active ROM can exacerbate inflammation in acute joints.
  • It is used for subacute or chronic joints to enhance ROM.

FORCEFUL TENDON STRETCHING

  • Should be avoided when the tendon is inflamed, very tight, or lax, because this can increase inflammation and tendon sheath fluid accumulation.
  • Forceful stretching of a very tight tendon can be very painful, and rupture might occur at the musculotendinous junction.
  • For a tight, noninflamed tendon, prolonged periods of stretch are more effective in lengthening the tendon without causing undue pain.

FORCEFUL JOINT STRETCHING

  • Should also be avoided if there is a moderate or large effusion, joint inflammation, or joint laxity, because this can cause a capsular rupture.
  • Forceful stretching of joints with much ligamentous and capsular laxity can cause joint subluxation (common in RA, juvenile A, and SLE).

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg585

36
Q

What type of aerobic exercise is used in rheumatic disease? πŸ”‘πŸ”‘ OSCE Dr. Dia’a

A

LOW INTENSITY EXERCISE

Both the bike ergometer and pool are used for aerobic exercise. Because rheumatic disease (RD) patients are often much deconditioned, low-intensity exercise for 15-20 minutes two to three times a week can increase aerobic capacity.

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg585

37
Q

Common modalities used in RA and their benefits.

A

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg584

38
Q

Name some typical gait characteristics observed in patients with RA

A
  1. Decreased velocity
  2. Decreased stride length
  3. Short single-limb stance
  4. Prolonged heel contact
  5. Longer double-limb support phase.

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg588

39
Q

Shoe modification for RA patient.

40
Q

What factors contribute to fatigue in patients with rheumatoid disease?

A

πŸ’‘ Fatigue is difficult to quantify because a decrease in overall stamina, true muscle fatigue, and lack of motivation all result in an inability to complete tasks.

  1. Medication
  2. Chronic inflammation
  3. Anemia of chronic disease
  4. Abnormal posture and gait
  5. Decreased aerobic capacity
  6. Abnormalities of the sleep cycle
  7. Atrophy of muscle secondary to disease or chronic pain
  8. Cardiovascular and pulmonary problems

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg586

41
Q

What is the purpose of prescribing orthotics for rheumatoid patient? πŸ”‘

A
  1. Decrease joint motionβ€”stabilization
  2. Decrease pain and inflammation
  3. Reduce weight through joint
  4. Joint rest
  5. Improve joint alignment
  6. Improve joint function
  7. Substitute for muscle weakness (assist)

Cuccurollo 4th Edition Chapter 3 Rheumatology pg111

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg586

Ref: first principles.

42
Q

Educate about energy conservation πŸ”‘

A

πŸ’‘ Walking and ADLs

  1. ADLs β†’ Using adaptive devices for clothing and eating
  2. Walking β†’ Energy efficient ambulation by using orthosis and assisted devices
43
Q

Principles of Joint Protection for Rheumatic Diseases πŸ”‘πŸ”‘ OSCE Dr. Dia’a

A
  1. Respect pain as a signal to stop the activity.
  2. Maintain muscle strength and joint range of motion.
    • Maintaining daily activities within the limitations of the patient’s pain helps to prevent disuse atrophy.
    • Strengthening around an unstable joint can increase stability and reduce pain.
  3. Use each joint in its most stable anatomic and functional plane.
  4. Avoid positions of deformity and forces in their direction.
    • For example: Turning resistive round doorknobs in an ulnar direction when the finger metacarpophalangeal joints are subluxed volarly and ulnarly should be avoided by use of a lever door opener.
  5. Use the largest, strongest joints available for the job.
    • For example: Using a belted waist pack rather than holding purse with hook grasp.
  6. Ensure correct patterns of movement.
    • For example: Cutting meat by holding the knife like a dagger.
  7. Avoid staying in one position for long periods.
  8. Avoid starting an activity that cannot be stopped immediately if it proves to be beyond your capability.
  9. Balance rest and activity.
  10. Reduce the force.
    • Building up handles to avoid tight grasp.
    • Use of assistive devices, such as jar openers to reduce the stress of the hand and wrist joints.
    • For osteoarthritis, the cartilage is too thin to protect against repetitive use of force.
    • Use alternative methods to accomplish the task.
    • For example, using the handrail to reduce the impact load to involved knee joints while going up and downstairs

Braddom 6th Edition Chapter 31 Rheumatology pg620 Box 31.7

44
Q

Name some appropriate techniques for joint protection. πŸ”‘πŸ”‘ OSCE Dr. Dia’a

A
  1. Avoid prolonged periods in the same position: To minimize joint stress
  2. Maintain ROM: To maintain strength
  3. Maintain good joint alignment: To reduce joint pain
  4. Avoid joint overuse during acute flare: To unload painful joint
  5. Use adaptive equipment and splints as indicated: To modify tasks

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg586

45
Q

Pharmacological Treatment for RA πŸ”‘πŸ”‘

A

NON-DMARDs

  1. ASA: Gastric ulceration and bleeding, renal insufficiency, hypertension
  2. Corticosteroids: Hyperglycemia, inhibits immune response, osteoporosis, PUD

NON-BIOLOGICAL-DMARDs

  1. MTX: Myelosuppression, Stomatitis, worsens rheumatoid nodules, teratogenicity
  2. HCQ: Retinopathy, hyperpigmentation
  3. Sulfasalazine: Myelosuppression

BIOLOGICAL-DMARDs

  1. Anti-TNF agents: infliximab (Remicade), and adalimumab (Humira)
  2. Anti-B-cell antibodies: Rituximab
  3. IL-6 antagonist: Tocilizumab (Actemra)
  4. Protein kinase inhibitors: Tofacitinib (Xeljanz)

Cuccurollo 4th Edition Chapter 3 Rheumatology pg110-113

46
Q

Adverse effect of MTX long term. πŸ”‘πŸ”‘

A
  1. Cytopenia β†’ Follow CBC
  2. GI Toxicity: Stomatitis and dyspepsia
  3. Pulmonary toxicity β†’ Follow CXR
  4. Hepatic toxicity, Transaminitis β†’ Follow TFT
  5. Teratogenic

PMR Secrets 3rd Edition Chapter 68 Rheumatology pg583

47
Q

What is Osteoarthritis?

A

Osteoarthritis (OA)

  • OA is a clinical diagnosis.
  • Non-erosive, non-inflammatory progressive disorder of the joints
  • Leading to deterioration of the articular cartilage
  • OA is a disease of the cartilage initially, not bone

Pathophysiology

  • Early β†’ Hypercellularity of chondrocytes
  • Later β†’ Cartilage fissuring, pitting, and destruction
  • Loss of proteoglycans β†’ provides hydration and swelling pressure to the tissue enabling it to withstand compressional forces
  • New bone formation at the joint surfaces and margins.
  • Increased water content of OA cartilage leads to damage of the collagen network

Cuccurollo 4th Edition Chapter 3 Rheumatology pg113

48
Q

List 10 potential secondary causes of osteoarthritis (OA).

A

CONGENITAL:

  1. Legg calve perthes disease (avascular necrosis).
  2. Acetabular dysplasia.
  3. SCFE.

HYPERMOBILITY

  1. Ehlers-Danlos syndrome.
  2. Marfan syndrome.

POST-TRAUMATIC:

  1. Ligament tear (eg ACL for knee).
  2. Meniscal tear.

METABOLIC:

  1. Hemochromatosis.
  2. Acromegaly (GH effects on cartilage/bone).
  3. Paget’s disease.

SEPTIC / INFLAMMATORY JOINT

  1. Septic joint.
  2. Rheumatoid arthritis.
  3. Gout.
  4. CPPD (pseudogout).

NEURO:

  1. Neuropathic (charcot) arthropathy (DM, syringomyelia, myelomeningocele, SCI, etc).

Ref: Current dx tx in rheumatology textbook pg 599; uptodate.

49
Q

Does running or jogging predispose to osteoarthritis? (Important for Clinic) πŸ”‘

A

In the absence of previous joint injury, recreational runners do not develop osteoarthritis in the knee or hip at higher rates than others. (recent study shows its protective against OA)

Highly competitive, elite runners may have an increased risk

50
Q

What are the general principles of rehabilitation of arthritis of the knee? πŸ”‘πŸ”‘ MOCK

A
  1. Non-weight-bearing strengthening exercises should be emphasized, particularly with emphasis on the quadriceps.
  2. Exercise load should increase each week, and maintenance of cardiovascular conditioning is a must-even before a total joint replacement.
  3. Hydrotherapy provides the appropriate environment in which osteoarthritic patients can exercise at intensities that improve strength and mobility.
  4. Activities of daily living and transfer/ambulatory evaluation are essential and should include evaluation for assistive devices, including raised toilet seats, shower grab bars, reachers, and ambulatory aids to maximize independence and ensure safety in the home environment.

PMR Secrets 3rd Edition Chapter 47 Kne pg388

51
Q

What are contraindications for intra-articular steroid injections? πŸ”‘πŸ”‘ OSCE

A

PATIENT

  1. Reluctant patient or no informed consent given
  2. Pregnancy and breast feeding
  3. Distressed patient – pain may be perceived to be aggravated by an injection.

JOINT

  1. Recent fracture site
  2. Hemarthrosis – pain relief from aspiration can be dramatic
  3. Sepsis – local or systemic
  4. Large tendinopathies – Achilles
  5. Post arthroscopy β†’ separate by at least 2 months

NEEDLE

  1. Bleeding risks – anticoagulant therapy, hemophilia

STEROID & ANASTHESIA

  1. Hypersensitivity or allergy to any of the drugs used
  2. Diabetes – greater risk of sepsis; blood sugar levels may rise temporarily

IMMUNE

  1. Immunosuppressed – leukemia, chemotherapy, oral steroid
  2. Intravenous drug abuse

Injection Techniques in Musculoskeletal Medicine 5th Edition pg25 & pg121

52
Q

Name 10 complications of corticosteroid – general question including injection and systemic.

A

JOINT

  1. Flare of pain (2 to 10%) - Resolve within 12-24 hours
  2. Sepsis 1 in 17,000 for joint injection and 1 in 162,000 for soft tissue injection - Less in prepackaged corticosteroid in a sterile syringe

MUSCLE

  1. Steroid myopathy

TENDON

  1. Tendon rupture and atrophy - Interval between injections to a minimum of 3 months - Rest from provocative activity for 6 to 8 weeks - Avoid bilateral tendon injection.

BONE

  1. Steroid arthropathy - Interval between injections to a minimum of 3 months
  2. Osteonecrosis/AVN.

SKIN

  1. Subcutaneous fat atrophy
  2. Skin depigmentation (4%) - Resolution 6 to 24 months later
  3. Delayed soft tissue healing - Consider appropriate timing of return to activity

NERVE

  1. Nerve damage or transient paresis of an extremity
  2. Complex regional pain syndrome

VESSELS

  1. Bleeding or bruising β†’ Apply firm pressure

STEROID

  1. Facial flushing (5%) β†’ last 1 to 2 days
  2. Cataracts
  3. Raise systolic blood pressure
  4. Impaired diabetic control β†’ Rise up to a week, increased by multiple doses
  5. Suppression of the hypothalamic-pituitary axis (Cushing Syndrome) - Clinical syndrome 10–14 days after injection - Moon face, Buffalo hump, Acne-like eruptions, Flushing, Palpitations, Tremors, Dyspnoea, Weight gain, 5–8 kg, Disturbed menstruation - Spontaneous resolution at 3 months (one injection) and 6 months (two injections)
  6. Peptic ulcer disease

ALLERGIC REACTION

  1. Anaphylaxis

Injection Techniques in Musculoskeletal Medicine 5th Edition Chapter 2

Ref: Braddom pg 519.

53
Q

Provide three musculoskeletal (MSK) complications of corticosteroids. πŸ”‘πŸ”‘

A
  1. Muscle: Steroid myopathy.
  2. Tendon: Tendon rupture
  3. Joint: Steroid arthropathy
  4. Bone: Osteoporosis & Osteonecrosis

Ref: Primer on the rheumatic diseases. Table 46-3; Delisa pg 1750; Braddom pg 521.

54
Q

Presentation of OA

A

Symptoms:

  1. Joint stiffness for <30 minutes
  2. Articular gelling β†’ stiffness after immobility lasting short periods and dissipating after brief period of movement
  3. Dull aching pain increased with activity, relieved by rest
  4. Later pain occurs at rest
  5. Crepitus on ROM

Signs:

  1. Localized tenderness of joints
  2. Pain and crepitus of involved joints
  3. Enlargement of the joint

Cuccurollo 4th Edition Chapter 3 Rheumatology pg114

55
Q

List 3 Hand deformaties in OA πŸ”‘πŸ”‘

A
  1. Heberden’s nodes β†’ osteophytosis (bone spur formation) at the DIP joints
  2. Bouchard’s nodes β†’ PIP joints
  3. First CMC joint
56
Q

Diffuse idiopathic skeletal hyperostosis (DISH) distinguishes from ankylosing spondylitis? πŸ”‘πŸ”‘

A

DISH

  • Primary OA degenerative arthritis typically characterized by ossification of spinal ligaments (syndesmophytes) in the anterior spine leading to spinal fusion
  • Most commonly affects the thoracic spine but can also affect the lumbar and cervical spines
  • Ossification of the anterior longitudinal ligament, separated from vertebral body by radiolucent line

Hallmark

  • Syndesmophytes extending to the length of anterior longitudinal ligament (ALL)
  • Ossification spanning four contiguous vertebral bodies (three or more inter vertebral discs)

Patient

  • DM, obesity, hypertension, coronary artery disease, males aged greater than 50 years.

DISH is NOT associated with

  1. Sacroiliitis
  2. HLA-B27 positivity
  3. Apophyseal / Zygapophyseal / Facet joint ankylosis

Presentation

  • Stiffness in the morning or evening
  • Dysphagia with cervical involvement

Cuccurollo 4th Edition Chapter 3 Rheumatology pg114

57
Q

List 3 radiological findings of OA πŸ”‘πŸ”‘

A
  1. Asymmetric narrowing of the joint space (Kneeβ€”medial compartment)
  2. Subchondral bony sclerosis (eburnation)β€”new bone formation (white appearance)
  3. Osteophyte formation (marginal)
  4. Loose bodies
  5. Joint effusion
  6. Cyst formation in the juxta-articular bone
  7. Not associated with osteoporosis/osteopenia (no bone washout)

Cuccurollo 4th Edition Chapter 3 Rheumatology pg114-115

58
Q

Grading Scale for Osteoarthritis of the Tibiofemoral Joint

A

Grading Scale for Osteoarthritis of the Tibiofemoral Joint

59
Q

Management of OA

A

EDUCATION & RISK FACTORS

  • Weight loss
  • Activity modification

PROTECTION & ORTHOSIS

  • Joint protection and energy conservation
  • Assistive devices (cane)
  • Patellofemoral taping
  • Valgus bracing to unload the medial compartment.
  • Wedged show soles/insoles
  • Thumb orthosis for first CMC

OPTIMAL LOADING

  • ROM, strengthening exercises
  • Flexibility, strength, and proprioception

ICE & MODALITIES

  • Ice packs for 20 minutes 2-3 times a day

MEDICATIONS

  1. Acetaminophen (initial treatment)
  2. NSAIDs (used for pain once inflammation ensues)
  3. Intra-articular injections
    • Intra-articular steroid injections (acute flares)
    • Hyaluronic acid

SURGERY

  1. Osteotomy

Cuccurollo 4th Edition Chapter 3 Rheumatology pg115-116

61
Q

Septic arthritis: Causes - Diagnostic Workup (4 things to check) - Treatment πŸ”‘πŸ”‘

A

Risk Factors

  1. Age
  2. Prosthetic joints/foreign body
  3. Comorbidities such as anemia, chronic diseases, hemophilia

Causes

  • Neonates: S. aureus
  • 6 months to 2 years old: Haemophilus influenza
  • >2 years old: S. aureus
  • Adults: STD (Neisseria gonorrhea)
  • >60 years of age: source is commonly from another focus
  • S. aureus is the most common organism causing septic arthritis in RA.

Diagnostic Approach β†’ Blood - Radiology - Sepcial

  1. Lab work: Elevated WBC, ESR, CRP
  2. Radiographic findings
    • Early: Soft tissue swelling
    • Later: Joint space narrowing, erosions, gas formation
  3. Synovial fluid analysis β†’ many bacterias consuming sugar
    • WBC >100,000
    • PMN >85%
    • Positive Culture
    • Low Glucose
  4. Bone scans

Treatment

  1. IV antibiotics
  2. Serial needle aspirations
  3. Arthroscopic lavage

Cuccurollo 4th Edition Chapter 3 Rheumatology pg134-135

62
Q

Charcot Joint: Define πŸ”‘ - Causes πŸ”‘ - Presentation - Treatment πŸ”‘

A

Charcot Joint

  • Chronic, progressively degenerative arthropathy
  • Secondary to a sensory neuropathy (loss of proprioception and pain sensation)
  • Leading to joint instability and destruction.

Causes

  1. Syringomyelia β†’ Shoulder
  2. Tabes dorsalis β†’ Syphilis β†’ Knee
  3. Diabetic neuropathy β†’ #1 cause β†’ Ankle

Presentation

  • Early findings: Painless swelling, effusion, and joint destruction
  • Late findings: Crepitation, destruction of cartilage and bones, intra-articular loose bodies
  • Subtle fractures

Radiology

  • Hypertrophic osteophytes
  • Loose bodies caused by microfractures (Bony fragments)
  • Subluxation and dislocation
  • Joint destruction

Treatment

  • Immobilization/bracing
  • Restriction of weight bearing

Cuccurollo 4th Edition Chapter 3 Rheumatology pg138

63
Q

X-ray of an ankylosed knee - give diagnosis and 2 pertinent findings

A

DDx

  1. Severe OA
  2. Charcot joint

Early in disease both have:

  1. Soft tissue swelling
  2. Osteophytes
  3. Joint effusion

Advanced Charçot joints:

  1. Bony fragments
  2. Subluxation
  3. Periarticular debris

Cuccurollo 4th Edition Chapter 3 Rheumatology pg138

64
Q

List 6 risk factors for OA, which is the strongest? πŸ”‘πŸ”‘ Leak 2021

A
  1. Age: strongest risk factor
  2. Heredity: family risk studies estimate a 50% to 65%
  3. Sex: female above 50 years old
  4. Obesity
  5. Previous joint trauma
  6. Abnormal joint mechanics (i.e., excessive knee varus or valgus; hip dysplasia)
  7. Smoking (may contribute to degenerative disc disease).
  8. Occupations/sports causing repetitive high impact loading

Rheumatology Secrets 4th Edition Chapter 51 OA pg413 q13

65
Q

What is the difference between inflammatory and non-inflammatory arthritis? πŸ”‘πŸ”‘

66
Q

Knee Joint Injection πŸ”‘πŸ”‘ MOCK Dr. Jamal

A

Anatomy

  • Knee joint capacity of approximately 120 ml

Lateral Approach

  • Plenty of space to insert the needle between the medial condyle and the patella, where even small amounts of serous fluid or blood can be aspirated with a large (19 gauge) needle

Technique

  • Knee supported in slight flexion
  • Mark medial edge of patella
  • Insert needle and angle laterally and slightly upwards under patella
  • Inject solution as bolus, and/or aspirate if required

Aftercare

  • Rest for 24 hours after injection

Practice point

  • Repeated if necessary at intervals of at least 3 months

Injection Techniques in Musculoskeletal Medicine 5th Edition pg210-211

67
Q

List 3 Factors indicating the need for TKR in advanced OA knee. πŸ”‘πŸ”‘ Dr. Jamal

A

FACTORS

  1. Functional status of the patient
  2. Pain not improving with conservative measures
  3. Xray show grade 4, advanced OA

OTHERS

  1. Age
  2. Medical co-morbidities
  3. Family support
  4. Financial capability & insurance condition

PassPMR - 06 Rheumatology (5 decks)

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