Arthritis Flashcards
Describing joint disease?
- Onset – insidious, gradual, sudden, explosive
- Distribution – symmetrical or asymmetrical, Large or small joints, Axial or peripheral joints
- Pattern – intermittent, migratory, additive and acute versus chronic, distal (OA) versus proximal joints (RA)
- Number - Monoarticular or polyarticular
- Systemic or localized disease – fatigue, fever, morning stiffness and weight loss
- Inflammatory (RA) or non-inflammatory (OA)
Joint examination findings?
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)
What can range of motion indicate?
When is ROM decreased?
- Pain in active ROM = periarticular
- Pain in active + passive ROM = articular
Note: ROM is decreased in trauma, chronic arthritis, lack of use and congenital problems
What instrument measures ROM?
goniometer
- a ruler that pivots in the center and measures ROM in degrees
Causes of back pain?
- trauma
- osteodegenerative disorders
- OA, spondylosis, herniated disks - neoplasm
- inflammation
Sciatica?
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
Most common cause of back pain?
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
Clinical features of inflammatory arthritis?
- pain in the morning
- soft tissue swelling
- sometimes warmth and erythema is present
- aggravated by rest
- relieved by movement
- morning stiffness for >30 minutes
- sometimes systemic features are present
- high ESR and CRP
- WBC > 2000 in synovial fluid
Examples of inflammatory arthritis?
- septic
- rheumatoid
- SLE
- gout
Clinical features of non-inflammatory arthritis?
- pain in the evening
- bony swelling
- no erythema and warmth
- aggravated by movement
- relieved by rest
- morning stiffness <30 minutes
- no systemic features
- normal ESR and CRP
- WBC < 2000 in synovial fluid
Examples of non-inflammatory arthritis?
- trauma
- hemarthrosis
- osteoarthritis
Osteoarthritis?
It’s a degenerative joint disease – wear and tear of the cartilage, it is more mechanical than inflammatory
Epidemiology of osteoarthritis?
Occurs in 30% of adults, with age, genetics, previous trauma, obesity, & metabolic disorders such as gout
Symptoms of OA?
- asymmetrical joint involvement
- pain on joint use
Findings on physical exam of OA?
- crepitus
- reduced ROM
- pain on ROM
- Heberden nodes - bony enlargements that develop at the distal interphalangeal joints
- Bouchard nodes - bony enlargements that develop at the proximal interphalangeal joint
Radiological findings in OA?
- Normal mineralization
- Non-uniform joint space loss
- Subchondral joint space loss
- Subchondral new bone formation
- Subchondral cysts
- Osteophyte formation
What joints are most affected by OA?
Mostly affects hands, feet, knees, hip joints.
Treatment of OA?
- Physiotherapy
- Weight loss, cane to reduce weight bearing
- Chondroitin sulfate/glucosamine sulfate
- NSAIDs plus other analgesics
- Intraarticular steroids
- Joint replacement in advanced disease
Rheumatoid arthritis?
- An inflammatory, multisystemic disease with flares and remissions
- characteristic chronic deformities
- positive Rheumatoid Factor
Epidemiology of rheumatoid arthritis?
Most common autoimmune disease – in 1 – 2% of the population, F>M and family history
Symptoms of RA?
- morning stiffness for >1 hour
- Symmetrical joint disease
- Inflammation of hands, feet (proximal joints), knees, hips, shoulders, elbows
- Fatigue, weight loss, fever, subcutaneous nodules
Findings on PE of RA?
- Inflammation of MCP, PIP, (DIPs spared) joints
- Ulnar drift
- Subluxation of proximal phalanges
Investigations for RA?
- Rheumatoid Factor positive in 80% of cases
- RF – an autoantibody (usually IgM) against the Fc segment of IgG
- RF also positive in SBE, TB, Hep C, Sarcoidosis, Infectious mononucleosis
Xray findings of RA?
- Normal
- Periarticular swelling
- Juxta-articular osteopenia then generalized osteoporosis
- Uniform Joint space loss
- Marginal erosions
- Subluxations
How many stages are there of RA?
4
Stages 1 of RA?
the body mistakenly attacks its own joint tissue
Stage 2 of RA?
the body makes the antibodies and the joint start swelling up
Stage 3 of RA?
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
Stage 4 of RA?
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
Extra-articular manifestations of RA?
- Ocular – keratoconjuctivitis/ scleritis/
- Respiratory – pleurisy/ cavitations
- Cardiac – pericardial effusion/ pericarditis/ cardiomyopathy
- Neurologic – C spine instability
- Renal – mainly as acomplication of medications
- GIT – ischemic bowel
- Xerostomia if RA is associated with Sjogrens syndrome
Treatment of RA?
- NSAIDs first line
- Start 2nd line (Disease Modifying 3. Anti-rheumatic Drugs - DMARDs)
- Local joint injections
- Joint replacement
- Treatment is urgent in Adrenal
- Insufficiency and atlantoaxial (C1) instability
What are anti-rheumatic drugs?
- Chloroquine
- Methotrexate
- Gold
- azathioprine
- Sulfasalazine
- leflunomide
- etanercept
Risk factors for septic arthritis?
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
Causes of septic arthritis?
Neisseria gonococcus
Non-gonococcal
Lyme
Viral – Parvovirus B19, Hepatitis B, HIV
Staph aureus
Clinical features of SA?
- 80% – 90% are monoarticular whereas 10% – 20% are polyarticular
- Large peripheral joints are affected more than small ones
- Fever,
- Limited joint mobility
- Joint swelling and joint tenderness
- Elevated temperature
- Synovial effusion with tenderness
Gonococcal bacterial causes and features of SA?
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
Non-gonococcal bacterial causes and features of SA?
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
