Arthritides Flashcards
Define Arthritides
Types of arthritis
Key Manifestations of Arthritis
Pain
Swelling
Limited motion
Types of Joints
Fibrous/Bony
Cartilaginous
Synovial
Fibrous/Bony Joint Motion
Minimal to no motion
Cartilaginous Joint Motion
Limited motion
Synovial Joint Motion
Freely mobile
Comprised of 2+ bones
May have meniscus
Define Osteoarthritis
Degenerative arthritis or joint disease
Pathophysiology of Osteoarthritis
Damage to normal articular cartilage
Chondrocytes react by releasing degradative enzymes
Bone reacts with subchondral sclerosis & osteophytes
Degredation of cartilage & bony reaction
Complete loss of cartilage
Joint space narrowing & possible deformity
Hypertrophy/hyperplasia of osteocytes -> subchondral sclerosis -> osteophyte formation
Predisposing Factors of Osteoarthritis
Age Female sex Previous injury Obesity Heavy physical labor Positive family history Sports activities
Features of Osteoarthritis
Joint pain Swelling Crepitation Tenderness Effusions Hands, hips, knees, spine Tenderness on palpation & on passive motion (late signs)
Osteoarthritis in the Hands
Middle-aged & elderly women
Strong family history
DIP & PIP joints
Location of Heberden’s Nodes
DIP
Location of Bouchard’s Nodes
PIP
Osteoarthritis in the Shoulder
Progressive anterior shoulder pain, worse with motion
Difficulty with overhead activities, sleeping, axillary hygiene
Seen frequently with rotator cuff disease/tears, AC joint arthritis
Osteoarthritis of the Hip
Pain deep in the groin- can radiate to anterior thigh, knee, & buttock
Starts with prolonged standing/walking becoming intolerable
Then difficulty putting on socks/shoes
Pain with abduction
Osteoarthritis of the Knee
Difficulty doing stairs, getting out of low chairs, off of toilets
Pain with kneeling/squatting
Osteoarthritis of the Cervical Spine
Pain & stiffness
Aching pain down the arm
Osteoarthritis of the Lumbar Spine
Pain across low back/buttocks with LOM flex/ext
Can develop spinal stenosis
Diagnosis of Osteoarthritis
Clinical supported by H&P, labs, & imaging
No specific labs
X-ray sufficient
Findings on Osteoarthritis Imaging
Joint space narrowing Surface irregularity Osteophytes Subchondral sclerosis Subchondral cysts
Non-pharmacological Treatment of Osteoarthritis
Moderate weight loss Exercises PT/OT Braces Heat/cold Rest
Pharmacologic Treatment of Osteoarthritis
Acetaminophen NSAIDs Tramadol Opioids Intra-articular Injections
Benefits of Glucocorticoid Intra-Articular Injection for Osteoarthritis
Slow cartilage degradation
Provide pain relief
Benefits of Hyaluronans Intra-Articular Injection for Osteoarthritis
Macromolecules absorb water & may protect cartilage
How to Perform a Knee Injection/Aspiration
Thorough skin prep Supero-lateral portal Patient supine Sit with knee at eye level Little pain when slow Aspiration/injection
Surgical Treatment for Osteoarthritis
Arthroscopic procedures
Total joint replacement
Chondrocyte grafting
Arthroscopic Procedures
May aggravate underlying arthritis
Total Join Replacement
Gold standard for severe knee, hip, or shoulder joint arthritis
Chondrocyte Grafting
Perhaps for small, isolated defects
Benefits of Total Joint Replacement
Relieves pain
Corrects deformity
Improves function
Infections & Joint Replacements
More susceptible due to implant
Replacements & Loosening
May be due to bone resorption or macrophage response
Follow-up x-rays
Replacements & Periprosthetic Fractures
Metal creates stress risers
Difficult to treat
Rheumatoid Arthritis
Women > men
Autoimmune disease that primarily involves joints
Breakdown of immune tolerance to synovial inflammation
Pathophysiology of Rheumatoid Arthritis
Prominent immunologic abnormalities
Plasma cells produce antibodies
Macrophages migrate to synovium
Macrophages & lymphocytes produce pro-inflammatory cytokines & chemokines in synovium
Synovium thickens over time
Hyperplastic synovial tissue releases inflammatory mediators
Clinical Presentation of Rheumatoid Arthritis
Gradual, insidious onset
Symptoms wax & wane
Usually multiple joints
Can cause significant disability
Systemic Symptoms of Rheumatoid Arthritis
Early morning stiffness
Generalized afternoon fatigue & malaise
Anorexia
Generalized weakness & fever
Joint Symptoms of Rheumatoid Arthritis
Pain
Swelling
Stiffness
Erythema
Rheumatoid Arthritis Imaging
X-ray (initially)
MRI, ultrasound (shows more damage)
Findings on X-ray for Rheumatoid Arthritis
Joint space narrowing Soft tissue swelling Bony erosions Osteopenia Laxity -> deformity Destruction/fusion (late)
Rheumatoid Arthritis in the Hand
Swollen, painful MP, PIP joints Reduced grip strength Tendon ruptures, triggering Joint deformities (ulner deviation) 5% carpal tunnel
Rheumatoid Arthritis of the Wrist
Loss of extension
Carpal drift
Tendon rupture
Rheumatoid Arthritis of the Elbow
Loss of extension
Olecranon
bursitis
Ulnar neuritis
Rheumatoid Arthritis of the Shoulder
Adhesive capsulitis
Rotator cuff disease
Joint destruction
Rheumatoid Arthritis of the Foot
MP joint involvement
Toe deformities
Heel, annkle pain
Rheumatoid Arthritis of the Knee
Synovitis & effusion
Backer’s cyst
Loss of flexion
Rheumatoid Arthritis of the Hip
Groin pain
Loss of rotation
Locations of Extra-Articular Rheumatoid Arthritis
Skin & pulmonary nodules Pericarditis Splenomegaly Neuropathy Vasculitis Episcleritis Lymphadenopathy
Laboratory Findings in Rheumatoid Arthritis
Rheumatoid factor Anti-CCP ESR CRP Synovial fluid: elevated WBCs
Diagnosis of Rheumatoid Arthritis
Inflammatory arthritis in 3+ joints for 6+ weeks
Positive RF & ACCP
Elevated ESR & CRP
Have excluded gout, CPDD, viral arthritis, SLE, psoriatic arthritis
General Treatment of Rheumatoid Arthritis
Management of acute flares
Use DMARDs early
Surgery for soft tissues & joints
Helping the patient manage
How to manage acute flares of rheumatoid arthritis?
NSAIDs
Glucocorticoids
Types of DMARDS
Non-biologics
Biologics
How to help the patient manage?
PT
OT
Bracing
Support groups
Non-Pharmacological Treatment of Rheumatoid Arthritis
Heat/cold
Orthotics & splints
Therapeutic exercise
PT/OT
Treat of Acute Pain in Rheumatoid Arthritis
NSAIDs
Glucocorticoids: systemic
SE of Glucocorticoids
Hyperglycemia Skin fragility Osteoporosis Weight gain Adrenal insufficiency Muscle breakdown Euphoria Glaucoma
SE of NSAIDs
GI
CV
Non-Biologic Agents for Rheumatoid Arthritis
Methotrexate Sulfasalazine Leflunomide Hydroxychloroquine Cyclosporine Gold salts Azathioprine
Biologic Agents for Rheumatoid Arthritis
TNF inhibitors
Entanercept (Enbrel)
Infliximab (Remicade)
Adalimumab (Humira)
MOA of Methotrexate
Inhibits biosynthesis
AE of Methotrexate
Ulcerative stomatitis Leukopenia Predisposition to infection Nausea Abdominal pain Fatigue Fever Dizziness Pneumonia Pulmonary fibrosis
Contraindications of Methotrexate
Renal dysfunction
Pregnancy or possible pregnancy
Surgery for Rheumatoid Arthritis
Synovectomy Tendon repairs Removal of nodules Total joint replacements Fusions
Gout Characterized by
Painful joint inflammation in the first metatarsophalageal joint
Pathophysiology of Gout
Precipitation of monosodium rate crystals in joint space
Joint space damaged
Top may also form in joint space
Reasons for Gout
Decreased excretion
Increased production
Increased purine taste
Risk Factors for Gout
Increases with age Estrogen increases urinary excretion of uric acid Alcohol Meat Seafood
Clinical Presentation of Gout
Severe pain Redness/warmth Swelling/disability Onset more at night Overlying skin becomes tense
Diagnosis of Gout
Clinical criteria
Synovial fluid analysis
Elevated serum urate level
X-rays
Treatment of Acute Gout
NSAIDs
Cholchicine
Glucocorticoids
SE of Cholchicine
GI upset
Neutropenia
Peripheral neuropathy
Intra-articular Glucocorticoids
Often quickly resolves symptoms
Oral Glucocorticoids
Multiple joints
Can’t use NSAIDs or cholchicine
Treatment of Hyperuricemia
Reduced intake of purines Xanthine oxidase inhibitors (allopurinol) Uricosuric drugs (probenecid)
Preventing Recurrent Gout Attacks
Lifestyle changes
Diet
Lowering serum uric acid
Lifestyle Changes in Preventing Gout Attacks
Weight loss
Decreased ETOH intake
Diet & Preventing Recurrent Gout Attacks
Decreasing meat & fish
Increasing dairy products
Lowering Serum Uric Acid & Preventing Recurrent Gout Attacks
Uricosuric agents
Xanthine oxidase inhibitors
Define Pseudogout
Calcium pyrophosphate dehydrate (CPPD) crystal deposition disease (Chondrocalcinosis)
Etiology of Pseudogout
Trauma
Hypomagnemia
Hyperparathyroidism
Clinical Presentation of Pseudogout
Similar to gout but less severe
Large peripheral joints
Diagnosis of Pseudogout
Synovial fluid
X-rays
Treatment of Pseudogout in a Single Joint
Aspirate & inject with steroids
Immobilize
Apply ice or cool pack
Treatment of Pseudogout in Multiple Joints
NSAIDs
Colchicine
Systemic steroids
Prevention of Pseudogout After 3+ Attacks
Daily colchicine
Major Features of OA, RA, Gout/Pseudogout
OA: degeneration of cartilage leads to joint damage
RA: Autoimmune disease that attacks synovium & soft tissue
Gout: deposition of crystals leads to joint inflammation & damage
Clinical Features of OA, RA, Gout
OA: limited to the joint
RA: generalized disease- multiple, swollen, painful joints
Gout: red, hot swollen joint/skin sensitivity
Imaging Findings in OA, RA, Gout
OA: joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts
RA: joint space narrowing, soft tissue swelling, bony erosions, osteopenia about joint
Gout: erosions & joint descruction
Swelling, Stiffness, & Fingers in OA & RA
OA: hard, bony; worse after use (PM); DIP/PIP + nodes
RA: soft, warm, tender; worse after resting (AM), MP & PIP + deformity
Lab Work in OA, RA, Gout
OA: normal
RA: ESR, CRP, RF, & ACCP
Gout: elevated uric acid, crystals in joint fluid
Synovial Analysis in OA, RA, Gout
OA: clear fluid, negative for crystals
RA: slightly to moderate turbid
Gout: turbid
Goals of Treatment of Arthritides
Prevent progression, recurrence
Relief of pain
Improvement of function
Modalities of Arthritides
Lifestyle changes
Braces, OT, PT
Medications
Reconstructive surgery
