ACT 1 - Rheumathology Flashcards
Osteoporosis - definition
Bone weakening die to porous in bone
Osteoporosis - demografics
1 in 2 female above 50%
In male 1 in 5 - common as a secondary cause to another condition
Osteoporosis - Pathogenesis
Bone remodels through life
Peak bone density at 30, and then lose 1% a year. Women after menopause lose 2.5% a year.
Regulated by hormones
Osteoblast build bone (PTH, Vit. D, TH, interleukin)
Osteoclast reabsorbed bone (Estrogen, Progesterone, Calcitronin, Androgens)
Osteoporosis - Environmental Risk factors
smoking alcohol Calcium deficient diet lack of weight-bearing exercise Hormone deficiency Lack of Vit. D
Osteoporosis - Medical Risk Factors
- Eating disorder
- Malabsorption syndrome (Celiac)
- Chronic organ failure
- Prolonged immobilization
- Endocrine Disorder (cushions, Diabetes Mellitus, thyrotoxicosis)
Osteoporosis - Screening methods
DEXA - dual energy Xray - medicare rebate
Osteoporosis - medications
Biophosphonates - inhibit bone reabsortion
Selective Estrogen modulators - slow bone loss
Hormone replacement therapy - normalises oestrogen levels which slow down bone loss
Osteoporosis - Osteo treatment
Supervised resistance training Balance exercises
OT assessment at home
Gp medication review for dizziness Optomotrist for eye testing.
Increase: calcium, vitamin D levels
Decrease: smoking and alcohol
Osteomyelitis - definition
Bone infection - progressive inflammatory destruction of bone
Osteomyelitis - Demographics
Children
affects long bone and spine
Osteomyelitis - Cause
Staphylococus aureus – approx 80%
Gram – negative bacteria
Fungal infections in chronically ill Salmonella in Sickle Cell
Osteomyelitis - common infection sites
Long bones
Vertebra - Lx> Tx > Cx Radius
SIJ
Osteomyelitis - Pathophys - 5 phases
Blood borne bacterial spread
- Acute inflammatory inflammation
- Pus formation at bone periosteum
- Necrosis - sequestrum (segment of dead bone)
- Formation new bone (involcrum) to surround infection
- Resolution - anti biotic therapy and pressure release (surgery)
Osteomyelitis - classification
- spread from contiguous source - trauma/ post-surgery
- secondary osteomyelitis in patients with vascular insufficiency
Osteomyelitis - Clinical presentation kids
- Often present with symptoms prior radiograph evidence
- Often muted or covert symptoms
Malaise, pain, fatigue, - Often with history of trauma
- Pseudoparalysis
Osteomyelitis - Clinical presentation adults
- Usually immuno-compromised or elderly
- Bone tenderness
- Limp or decreased limb function
- Muscle spasm or other soft tissue involvement (this is often the initial symptom!)
- Pyrexia and malaise (if infection spread)
Osteomyelitis - diagnosis
difficult to diagnose MRI - children Biopsy raised ESP Radionucleide x-ray
Osteomyelitis - treatment
- immediate referral from osteo
- antibiotic
- drainage
- surgery
Osteoarthritis - demographic
40+
70+
obesity
Osteoarthritis -pathophys
Primary: disease of articular cartillage
Secondary: decrease friction of joints
resist tension
resist heavy compression
Osteoarthritis - Clinical presentation
Usually gradual and slow onset
Weightbearing joints
Pain
- Stiffness first thing in the morning that eases Pain worst at the end of the day
- Relieved by rest
- Worse with colder weather
Signs
- Bony enlargement Crepitus
- Restricted movement Tenderness on palpation
Osteoarthritis - Diagnosis
X-ray if changes treatment
Osteoarthritis - Radiological findings
Loss of joint space
Osteophytic growth Subchondral bone cyst Subchondral sclerosis
Asymmetrical distribution Intra-articular loose bodies Articular deformity
Vacuum phenomenon
Osteoarthritis - Management
Provide education and reassurance
Medication
- Slow-release paracetamol is the most common
Correct risk factors that are modifiable
Weight loss Injury Overuse
Exercise
Manual therapy to address biomechanical compensations Joint replacement
Rheumatoid Arthritis (RA) - Definition
Autoimmune disease that causes pain, swelling, and stiffness in the joints, and may cause severe joint damage, loss of function, and disability. The disease may last from months to a lifetime, and symptoms may improve and worsen over time
Rheumatoid Arthritis (RA)- epidemiology
W 3>1
40+
Affects 1-2% pop
Rheumatoid Arthritis (RA) - Clinical features
- Early stage Insidious onset Joint pain and stiffness MCP and PIP sleep disturbance painful walking Morning stiffness last hours swelling tenderness on joint palpation
- Late stage
Joint deformity, subluxation, instability
Systemic symptoms
Rheumatoid Arthritis (RA) - types of joint deformities
- boutonnière
- swan neck
- Z deformity
- Ulnar deviation
Rheumatoid Arthritis (RA) - Other clinical features
- Blood: anemia
- SKin: Rheumatoid nodules, vasculitis
- Eye: scleritis, sjogrens syndrome
- Lung: pleural effusion, nodules
- Cardiac: pericarditis, myocarditis, atherosclerosis
- renal: amyloidosis
- Neurological: pheripheral neuropathy
Rheumatoid Arthritis (RA) - Diagnosis
- persistent joint pain and swelling
- bilat joint RA
- morning stiffness > 30min
Rheumatoid Arthritis (RA) - investigations
- ESR/ CRP
- Anti CCP
- Xray
Rheumatoid Arthritis (RA) - MAnagement
- analgesic, NSAID
- Education
- Anti rheumatic drugs
- REST on flare up
- Exercise
- Diet
Ankylosis Spondylitis - Definition
Fusion of Tx and SIJ
Ankylosis Spondylitis - Epidemology
- Start < 30
- M 2>1
- HLA-B27 positive
- Genetic
Ankylosis Spondylitis - pathogenesis
Immune response to HLA-B27 leads to inflammation and tissue destruction
Ankylosis Spondylitis - clinical features
- LBP, SIJP
- restricted Lx AROM
- Ankylosis SIJ
- movement restriction + deformity
Ankylosis Spondylitis - other clinical features
- Enthesitis (tendon attachment point inflammation) ankle
- Ant. Uveitis (eye inflammation)
- peripheral arthritis
- Bowel inflammation
Late stage:
- Osteoporosis
- pulmonary fibrosis
- Aortic valve incompetence
Ankylosis Spondylitis - diagnosis
- Xray SIJ
- MRI
- ESR/ CRP (inflammation in body)
Ankylosis Spondylitis - Management
- Education
- Keep active
- NSAID
- TNF inhibitors
Dmards (Anti rheumatic drug)
Psoriatic arthritis - Definition
Autoimmune disease characterised by red scaly patches
Psoriatic arthritis - Epidemology
M=W
30-50yr
Psoriatic arthritis - classification
- Distal predominant: DIP + PIP
- Oglioarticular: Joints <5
- Polyarticular > 5
- Spondylitis: SIJ + Cx
- Arthritis Mutilans: Distal predominant - bone erosion
Psoriatic arthritis - Clinical features
Pheripheral Arthritis:
- gradual onset
- multiple joints
- symetrical
Axial Arthritis
- mimic AS
- progress to ankylosis
Psoriatic arthritis - Other clinical features
Dactylitis (swelling entire digit)
Enthesitis (AS)
Tendonitis/Tenosynovitis
Psoriatic arthritis - Diagnosis
- Diagnosed by clinical features
- test rheumatoid factor and Anti-CPP
- Xray
Psoriatic arthritis - Management
- control of skin lesions
- refer to dermatologist
UV therapy
DMARDS
Biologic Medications
Septic Arthritis - Definition
Infectious Arthritis due to bacteria
- staph A
- Gonorrhoea
Septic Arthritis - Epidemiology
60+ and kids Immunocompromised Joint replacement Joint trauma Osteomyelitis RA
Septic Arthritis - Clinical Features
Swelling in joint (red + hot)
Restricted Joint range
systemic symptoms
Septic Arthritis - Diagnosis
Synovial fluid aspirate
ESR/CRP
Xray/ MRI
Septic Arthritis -Management
Medical interventions immediately
fluid aspiration + surgical drainage
Antibiotic
Systemic Lupus - Definition
SLE = Lupus
Autoimmune disease by multi systemic clinical manifestations
Systemic Lupus - Epidemiology
Women 15-35
Asia-indigenous
Joint skin and mucosa symptoms
Systemic Lupus - Epidemiology
Women 15-35
Asia-indigenous
Joint skin and mucosa symptoms
genetic
Environmental
- UV
- Epsein barr virus
- Drug induced
Hormonal: Oestrogen
Systemic Lupus - Pathogenesis
recurrent activation of immune system. Antibodies and protein lead to inflammation and tissue destruction
Systemic Lupus - Clinical features
- Butterfly rash
- Arthritis: periphery of 2+ joints, symmetrical, bilat.
Systemic Lupus - Other clinical features
- lupus nephritis (renal)
- Blood: anemia, leukopenia, thrombocytopenia (low white and red blood cels)
- serositis (inflammation of lung lining
- Systemic conditions
Systemic Lupus - Diagnosis
- Blood test: Antinuclear antibody ANA ENA antibody ESR/CPR Rheumatoid factor
Systemic Lupus - Management
NSAID
Antimalarials (antiparasite)
corticosteroid
immunosuppressive drugs
Reactive Arthritis - Definition
Secondary to bacterial infection at GI or GU tract
Reiters Syndrome
Reactive Arthritis - Epidemology
Rare GI infection M=W STI M>W White Low socioeconomic
Reactive Arthritis - Pathogenesis
GI or UTI infection
chlamydia, salmonela
E.coli
Immune response to bacteria leads to T cell activation and molecular arthritis
Reactive Arthritis - Clinical features
- Asymetrical Oligoarthritis on knee and ankle
- Uveitis/ conjuctivitis
- Penile lesion
- skin lesion
Reactive Arthritis - Diagnosis
Rule out other conditions
Rule out ESR CPR
Test for infection
Reactive Arthritis - Management
Antibiotics
NSAID
DMARD
general mobility
Gout - Definition
Monosodium urate crystal disorder.
urate crystal deposition on joints
Gout - Epidemology
- Men 40-50 > Women 60+
- Indigenous
- genetic 35%
- Renal disease
- prolonged use of diuretics
- Beer and soft drinks
Gout - Pathogenesis
Uric acid is unable to be filtered out by kidneys (hyperuricemia) occurs creating saturation of uric in synovial fluid and tissue later forming crystals
Gout - Stages
- Stage 1: Asymptomatic Hyperuricemia
- Stage 2: Acute gout arthritis
- Stage 3: Intercritical gout (intervals between attacks)
- Stage 4: Chronic gout and gouty arthritis
Gout - Clinical features asymptomatic Hyperuricemia
Elevated serum acid
Gout - Clinical features Gouty arthritis
- acute severe pain
- skin over joint red shinny hot and swollen
- Allodynia on joint
- Activated: alcohol, diet, starvation, surgery
- lasts 3-10 days
Gout - Clinical features inter critical gout
- Less Time between attacks.
- Low to no pain.
- Low-level inflammation causing joint destruction
- Time for aggressive management strategies
Gout - Clinical features Tophi
Stone deposits on ear, elbow, big toe
Sign only of gout (pathognomonic
Gout - Clinical features tophacious gout
High uric levels over prolonged time
more attacks more frequent
permanent joint destruction
Gout - diagnosis
Synovial fluid aspirate
Elevated serum uric acid
Xray
Gout - Management
lifestyle changes
NSAID
corticosteroids
Allopurinol
Calcium Phyrophosphate deposition disease (CPPD) - Definition
Crystal deposition on articular cartilage
chonedrocalcinosis resulting in inflammation and tissue damage
Calcium Phyrophosphate deposition disease (CPPD) - Epidemology
65+ Fx OA Joint trauma Diabetes
Calcium Phyrophosphate deposition disease (CPPD) - Clinical Features
Acute attacks mimic gout one or multiple joints Knee Synovitis swelling Systemic features
Calcium Phyrophosphate deposition disease (CPPD) - DDx
Tendonitis
RA
OA
Calcium Phyrophosphate deposition disease (CPPD) - Diagnosis
Synovial fluid analysis
Xray
Calcium Phyrophosphate deposition disease (CPPD) - Management
Treat symptoms
Cortisone to joint
Paracetamol
