3: Osteoarthritis and crystal arthropathies

Question 1

What is the most common type of arthritis?

Answer 1

Osteoarthritis

Question 2

What is osteoarthritis?

Answer 2

Progressive, degenerative joint inflammation due to loss of cartilage

Question 3

In osteoarthritis, much of the joint space is ___.

Answer 3

lost

Question 4

What forms at the edges of bone in osteoarthritis?

Answer 4

Bony spurs (osteophytes)

Question 5

Which protein makes up most of cartilage?

Answer 5

Type 2 collagen

Question 6

What cells form the matrix of cartilage?

Answer 6

Chondrocytes

Question 7

In osteoarthritis, the matrix of cartilage is ___.

Answer 7

lost

Question 8

Why do osteophytes form in osteoarthritis?

Answer 8

Attemped bone repair (sclerosis as well)

Question 9

Osteoarthritis tends to have a(n) (acute / gradual) onset.

Answer 9

gradual

Question 10

What type of pain do people with osteoarthritis get?

Answer 10

Mechanical pain

i.e worse on activity, relieved by rest

Question 11

When is mechanical pain of osteoarthritis at its worst?

Answer 11

End of the day

Question 12

What name is given to grinding/creaking of joints on movement?

Answer 12

Crepitus

Question 13

How long does stiffness tend to last in osteoarthritis?

Answer 13

< 30 minutes

Question 14

Osteoarthritis (does / doesn’t) affect the DIP joints.

Answer 14

does

Question 15

At which joints do:

a) Heberden’s nodes
b) Bouchard’s nodes

form during osteoarthritis?

Answer 15

a) DIP joint

b) PIP joint

Question 16

Bony enlargements seen in osteoarthritis are (soft / hard).

Answer 16

hard

Question 17

Just as in RA, osteoarthritis may cause ___ of the thumbs.

Answer 17

squaring

Question 18

What is a Baker’s cyst?

Answer 18

Swelling in the popliteal fossa

Question 19

Where is hip pain felt?

“Hip pain” described by patients may actually be caused by osteoarthritis of ___ joints.

Answer 19

groin

back joints

Question 20

When does osteoarthritis tend to start?

Answer 20

40s onwards

Question 21

Osteoarthritis is more common in (men / women).

Answer 21

women

Question 22

Occupations involving a lot of heavy ___ accelerate the onset of OA.

Answer 22

labour

Question 23

What are some underlying conditions which can accelerate the onset of OA?

Answer 23

RA

Gout

Acromegaly

Question 24

What type of arthritis must be excluded when taking a history from patients?

Answer 24

Septic arthritis

Question 25

The inflammatory markers of OA patients are **usually** \_\_\_.

Answer 25

**normal**

Question 26

What are some X-ray features of OA?

Answer 26

**LOSS:** Loss of joint space Osteophytes Sclerosis Subchondral cysts

Question 27

What are the primary hand joints affected in **OA** versus **RA**?

Answer 27

**OA** - DIPs **RA** - PIPs, MCPs

Question 28

How do joints **feel** in OA versus RA?

Answer 28

**OA** - hard, bony **RA** - soft, hot and tender

Question 29

When is stiffness at its worst in OA versus RA?

Answer 29

**At the end of the day** as opposed to in the mornings

Question 30

What sort of exercise are OA patients encouraged to do?

Answer 30

**Low impact exercise** (e.g pilates, swimming) so weight is loss **but** joints aren't damaged further

Question 31

What non-pharmacological therapies may OA patients require?

Answer 31

**Physiotherapy** **Weight loss** **Occupational therapy** - footwear, mobility aids

Question 32

What drugs can OA patients be prescribed?

Answer 32

**Analgesics** e.g paracetamol **NSAIDs** but be careful +/- Opiates, pain modulars e.g amitryptyline, IA steroids for short term relief

Question 33

If OA has progressed to a point where it causes constant pain or reduced mobility, patients may be referred for \_\_\_.

Answer 33

**surgery**

Question 34

What are the most common joint replacements carried out by the NHS?

Answer 34

**Knee** **Hips** (Uncommonly shoulder, elbow, fingers)

Question 35

What are the two main crystal arthropathies? Which crystals cause them?

Answer 35

**Gout** (uric acid) **Pseudogout** (calcium pyrophosphate)

Question 36

What is **gout**?

Answer 36

**Inflammatory arthritis caused by uric acid crystals deposited in joints**

Question 37

Gout is more common in (men / women).

Answer 37

**men**

Question 38

What is the metabolic product responsible for gout?

Answer 38

**Purines**

Question 39

Apart from being a metabolite of food, purines are also produced when cells are __ \_\_.

Answer 39

**broken down**

Question 40

What is the biochemical pathway producing uric acid?

Answer 40

**Diet** **Purines** **Xanthine** **Uric acid** (simplified)

Question 41

How is uric acid excreted?

Answer 41

**Via urine**

Question 42

What is **hyperuricaemia**?

Answer 42

Serum uric acid **\> 7 mg/dL**

Question 43

Why can people with psoriasis develop gout?

Answer 43

**High cell turnover**

Question 44

Does everyone who is hyperuricaemic develop gout?

Answer 44

**No**, don't blindly treat without symptoms

Question 45

What change re: uric acid actually causes gout?

Answer 45

**Acute changes in uric acid level**

Question 46

What is the main presentation of gout?

Answer 46

**Rapid onset of severe pain in joint** **Bright-red, hot, lasts up to 2 weeks**

Question 47

What are the most common sites for gout?

Answer 47

**Hallux** **Ankle** **Knee** can affect upper limb and spine too

Question 48

Which medications can cause gout?

Answer 48

**Diuretics**

Question 49

What **must** be excluded in someone with a hot, swollen joint?

Answer 49

**Septic arthritis**

Question 50

What are depositions of uric acid in the skin called?

Answer 50

**Tophi**

Question 51

In gout, inflammatory markers will be **(raised / reduced)**.

Answer 51

**raised**

Question 52

WCC may be raised in gout - what must be excluded at this stage?

Answer 52

**Infection** osteomyelitis, cellulitis, **septic arthritis**...

Question 53

X-rays appear normal in acute attacks of gout. How may they appear after chronic attacks?

Answer 53

**Erosions** **Osteophytes** **Joint destruction**

Question 54

What is the gold standard investigation for gout?

Answer 54

**Joint aspirate**

Question 55

How is an **acute attack** of gout managed?

Answer 55

**NSAIDs** for pain (If contraindicated, **colchicine**) (If both contraindicated, **steroids**) And loads more **analgesia** (paracetamol, opiates)

Question 56

What is an inconvenient side effect of colchicine?

Answer 56

**Diarrhoea**

Question 57

What are some lifestyle recommendations for gout patients?

Answer 57

**Reduce protien intake** - red meat, beans, shellfish **Reduce alcohol intake** **Lose weight** **Drink plenty of fluids** (but not fizzy drinks)

Question 58

What drugs are used as prophylaxis for gout? Which enzyme do they inhibit?

Answer 58

**Allopurinol** or **Febuxostat** **Xanthine oxidase**

Question 59

Allopurinol is started **2-4 weeks** after acute gout in a low dose - why?

Answer 59

**Sudden changes in uric acid level will cause another episode of gout**

Question 60

Pseudogout is more common in **(young / old)** people. Which crystal is deposited?

Answer 60

**old** **calcium pyrophosphate**

Question 61

What shape are the crystals seen in: a) gout b) pseudogout?

Answer 61

**Gout** - needle shaped crystals **Pseudogout** - rhomboids

Question 62

Can patients have both gout and pseudogout?

Answer 62

**Yeah**

Question 63

Is allopurinol used in pseudogout?

Answer 63

**No** - xanthines not involved

Question 64

How is pseudogout treated?

Answer 64

**NSAIDs / colchicine / steroids** **Rehydration**