Arthritis

Question 1

Describing joint disease?

Answer 1

1. Onset – insidious, gradual, sudden, explosive
2. Distribution – symmetrical or asymmetrical, Large or small joints, Axial or peripheral joints
3. Pattern – intermittent, migratory, additive and acute versus chronic, distal (OA) versus proximal joints (RA)
4. Number - Monoarticular or polyarticular
5. Systemic or localized disease – fatigue, fever, morning stiffness and weight loss
6. Inflammatory (RA) or non-inflammatory (OA)

Question 2

Joint examination findings?

Answer 2

Range of motion - extent that a joint can be moved within its particular abilities
- Active ROM (by the patient alone) vs Passive ROM (by the examiner)

Question 3

What can range of motion indicate?

When is ROM decreased?

Answer 3

1. Pain in active ROM = periarticular
2. Pain in active + passive ROM = articular
   Note: ROM is decreased in trauma, chronic arthritis, lack of use and congenital problems

Question 4

What instrument measures ROM?

Answer 4

goniometer
- a ruler that pivots in the center and measures ROM in degrees

Question 5

Causes of back pain?

Answer 5

1. trauma
2. osteodegenerative disorders
   - OA, spondylosis, herniated disks
3. neoplasm
4. inflammation

Question 6

Sciatica?

Answer 6

pain from irritation of the sciatic nerve as it passes through the foramen
- Sciatica is worse on sitting, coughing and Valsalva maneuver and decreases on lying supine

Question 7

Most common cause of back pain?

Answer 7

95% caused by disk herniation at L4-5 and L5-S1
1. L4-5 causes disability on walking on toes
2. L5-S1 causes disability on walking on heels

Question 8

Clinical features of inflammatory arthritis?

Answer 8

1. pain in the morning
2. soft tissue swelling
3. sometimes warmth and erythema is present
4. aggravated by rest
5. relieved by movement
6. morning stiffness for >30 minutes
7. sometimes systemic features are present
8. high ESR and CRP
9. WBC > 2000 in synovial fluid

Question 9

Examples of inflammatory arthritis?

Answer 9

1. septic
2. rheumatoid
3. SLE
4. gout

Question 10

Clinical features of non-inflammatory arthritis?

Answer 10

1. pain in the evening
2. bony swelling
3. no erythema and warmth
4. aggravated by movement
5. relieved by rest
6. morning stiffness <30 minutes
7. no systemic features
8. normal ESR and CRP
9. WBC < 2000 in synovial fluid

Question 11

Examples of non-inflammatory arthritis?

Answer 11

1. trauma
2. hemarthrosis
3. osteoarthritis

Question 12

Osteoarthritis?

Answer 12

It’s a degenerative joint disease – wear and tear of the cartilage, it is more mechanical than inflammatory

Question 13

Epidemiology of osteoarthritis?

Answer 13

Occurs in 30% of adults, with age, genetics, previous trauma, obesity, & metabolic disorders such as gout

Question 14

Symptoms of OA?

Answer 14

1. asymmetrical joint involvement
2. pain on joint use

Question 15

Findings on physical exam of OA?

Answer 15

1. crepitus
2. reduced ROM
3. pain on ROM
4. Heberden nodes - bony enlargements that develop at the distal interphalangeal joints
5. Bouchard nodes - bony enlargements that develop at the proximal interphalangeal joint

Question 16

Radiological findings in OA?

Answer 16

1. Normal mineralization
2. Non-uniform joint space loss
3. Subchondral joint space loss
4. Subchondral new bone formation
5. Subchondral cysts
6. Osteophyte formation

Question 17

What joints are most affected by OA?

Answer 17

Mostly affects hands, feet, knees, hip joints.

Question 18

Treatment of OA?

Answer 18

1. Physiotherapy
2. Weight loss, cane to reduce weight bearing
3. Chondroitin sulfate/glucosamine sulfate
4. NSAIDs plus other analgesics
5. Intraarticular steroids
6. Joint replacement in advanced disease

Question 19

Rheumatoid arthritis?

Answer 19

• An inflammatory, multisystemic disease with flares and remissions
• characteristic chronic deformities
• positive Rheumatoid Factor

Question 20

Epidemiology of rheumatoid arthritis?

Answer 20

Most common autoimmune disease – in 1 – 2% of the population, F>M and family history

Question 21

Symptoms of RA?

Answer 21

1. morning stiffness for >1 hour
2. Symmetrical joint disease
3. Inflammation of hands, feet (proximal joints), knees, hips, shoulders, elbows
4. Fatigue, weight loss, fever, subcutaneous nodules

Question 22

Findings on PE of RA?

Answer 22

1. Inflammation of MCP, PIP, (DIPs spared) joints
2. Ulnar drift
3. Subluxation of proximal phalanges

Question 23

Investigations for RA?

Answer 23

1. Rheumatoid Factor positive in 80% of cases
2. RF – an autoantibody (usually IgM) against the Fc segment of IgG
   - RF also positive in SBE, TB, Hep C, Sarcoidosis, Infectious mononucleosis

Question 24

Xray findings of RA?

Answer 24

1. Normal
2. Periarticular swelling
3. Juxta-articular osteopenia then generalized osteoporosis
4. Uniform Joint space loss
5. Marginal erosions
6. Subluxations

Question 25

How many stages are there of RA?

Answer 25

4

Question 26

Stages 1 of RA?

Answer 26

the body mistakenly attacks its own joint tissue

Question 27

Stage 2 of RA?

Answer 27

the body makes the antibodies and the joint start swelling up

Question 28

Stage 3 of RA?

Answer 28

the joints start becoming bent and deformed, the fingers become crooked : these misshapen joints can press on the nerves and can cause nerve pain as well

Question 29

Stage 4 of RA?

Answer 29

if not treated, the disease will progress to the last stage, in which there's no joint remaining at all and the joint is essentially fused

Question 30

Extra-articular manifestations of RA?

Answer 30

1. Ocular – keratoconjuctivitis/ scleritis/ 2. Respiratory – pleurisy/ cavitations 3. Cardiac – pericardial effusion/ pericarditis/ cardiomyopathy 4. Neurologic – C spine instability 5. Renal – mainly as acomplication of medications 6. GIT – ischemic bowel 7. Xerostomia if RA is associated with Sjogrens syndrome

Question 31

Treatment of RA?

Answer 31

1. NSAIDs first line 2. Start 2nd line (Disease Modifying 3. Anti-rheumatic Drugs - DMARDs) 3. Local joint injections 4. Joint replacement 5. Treatment is urgent in Adrenal 6. Insufficiency and atlantoaxial (C1) instability

Question 32

What are anti-rheumatic drugs?

Answer 32

1. Chloroquine 2. Methotrexate 3. Gold 4. azathioprine 5. Sulfasalazine 6. leflunomide 7. etanercept

Question 33

Risk factors for septic arthritis?

Answer 33

Liver cirrhosis, chronic renal failure Prosthetic joints Diabetes Mellitus Malignancies such as multiple myeloma & lymphoproliferative disorders AIDS Hemophilia Transplanted organs Hypogammaglobulinemia – high risk for Mycoplasma Dialysis patients – high risk of infections in joints in the axial skeleton e.g. sternoclavicular and sacroiliac joints Sickle cell disease Nephrotic syndrome

Question 34

Causes of septic arthritis?

Answer 34

Neisseria gonococcus Non-gonococcal Lyme Viral – Parvovirus B19, Hepatitis B, HIV Staph aureus

Question 35

Clinical features of SA?

Answer 35

1. 80% – 90% are monoarticular whereas 10% – 20% are polyarticular 2. Large peripheral joints are affected more than small ones 3. Fever, 4. Limited joint mobility 5. Joint swelling and joint tenderness 6. Elevated temperature 7. Synovial effusion with tenderness

Question 36

Gonococcal bacterial causes and features of SA?

Answer 36

Occurs in young sexually active adults Initial migratory polyarthralgia Tenosynovitis and polyarthritis Dermatitis (multiple vesiculopustular lesions on the trunk) Knees, wrists and ankles are commonly affected Diagnosis – clinically & positive cultures of urethra, cervix, rectum, oropharynx. Rx – Ceftriaxone, ciprofloxacin

Question 37

Non-gonococcal bacterial causes and features of SA?

Answer 37

S. aureus (60%), B-hemolytic streptococcus (15%), Pneumococcus, and Gram negative rods (15%) Risks – trauma, surgery, arthrocentesis, chronic medical illnesses (DM, SLE, chronic liver disease, RA) 50% affect knee joints Radiologically – joint space narrowing & erosion of the cortex in 7 – 14 days Rx – intravenous antibiotics and physiotherapy to prevent contractures