Arthritis Flashcards
Stiffness rarely lasting longer than 15 minutes
Pain on motion worse with activity or weight bearing, relieved with rest
Flexion contracture, varus/valgus deformity, Heberden/Bouchard nodes
Crepitus
osteoarthritis
RF for osteoarthritis
90% have this by age 40
Hereditary, mechanical factors, obesity, contact sports, jobs w/ frequent bending/carrying
Loss of articular cartilage leading to pain and deformity + hypertrophy of bone at articular margin in weight bearing joints
Primary = DIP/PIP joints, CMC joint, hip, knee, cervical/lumbar
Secondary = injury to the joint from trauma or overuse or metabolic disease
osteoarthritis
XR: loss of joint space, sclerosis, subchondral cysts, osteophytic/lipping of marginal bone
Labs: lack of inflammatory markers
osteoarthritis
How do you tx osteoarthritis
Activity modification/splinting, exercise, weight reduction, NSAIDs, topical or otherwise
Intra-articular injections (steroid, hyaluronate, PRP), duloxetine (cymbalta), PT
Joint arthroplasty
Sudden onset, frequently nocturnal
MCJ = metatarsophalangeal joint (podagra) or ankle, tarsal, knee
Severe pain, redness, swelling, with maximum severity reached over several hours
Fever is common
gout
What are RFs for gout
Alcohol excess, med changes, hospitalization, fasting before procedures
Mostly adult men
Elevated levels of uric acid deposition due to overproduction or underexcretion of renal uric acid
– excess monosodium urate crystals depositing in tissue
Causing recurrent attacks of acute inflammatory arthritis, usually monoarticular
Tophi = masses from this with associated foreign body reaction
gout
What are triggers for gout
Triggers = thiazide/loop diuretics, ACEI, pyrazinamide, ethambutol, aspirin, purine rich foods
PE: Marked tenderness to palpation, swelling, erythema, limited ROM
Arthrocentesis → monosodium urate crystals in synovial fluid (birefringent needle shaped)
Labs: elevated ESR, WBC
XR: normal early, joint destruction later (punched-out erosions”mouse bite” w/ overhanging rim of cortical bone)
gout
How do you treat gout acutely
NSAIDs first line (indomethacin and naproxen)
Oral steroids (intra-articular injection for monoarticular)
Colchicine if symptoms <36 hours
How do you treat gout between attacks
Avoid alcohol (beer), purines (liver, seafood, yeasts), avoid diuretics, niacin, aspirin
Colchicine + canakinumab prophylaxis
Urate lowering = allopurinol + febuxostat (not acutely), probenecid (not in renal issues)
How do you treat gouts more severely?
Pegloticase in hospital setting
IL-1 inhibitors in hospitalization
Asymptomatic – generally acute and recurrent in one joint, knee MCJ, with wrists 2nd, more common in femeale/elderly
pseudogout
Calcium pyrophosphate deposition disease, causing precipitation of these crystals in connective tissues
pseudogout
PE: Marked tenderness to palpation, swelling, erythema, limited ROM
Presence of CPPD crystals (positive, birefringent rhomboid-shaped) in synovial fluid (joint aspiration to distinguish)
– XR evidence of CPPD crystals (chondrocalcinosis) to differentiate; calcification of cartilage
No bony erosions
pseudogout
psuedogout tx
Joint aspiration + intra-articular steroid injection
NSAIDs for acute attacks
Colchicine w/n 24 hours and for prophylaxis
Short term immobilization
Stiffness, pain, swelling, worse in the morning >30 minutes, improves later in the day
Carpal tunnel common
Anemia, malaise, fatigue, vasculitis, scleritis, rheumatoid nodules, renal disease, pleuropericarditis, ocular symptoms, trigger finger from nodules
Symmetric
rheumatoid arthritis
RF for rheumatoid arthritis
Women > men
Peak onset late 40s, early 50s
Hands, wrists, knees, feet, ankles MC
Acute + chronic inflammation in synovium, causing proliferative + erosive joint changes – etiology unknown
– Genetic predisposition, hormonal changes, infectious agents
rheumatoid arthritis
PE: pain and swelling, limited ROM, synovial hypertrophy with “BOGGY” feeling, joint aspiration = little fluid, reduced grip strength, extensor surface nodules
Ulnar drift of toes fingers
Knee = ligament laxity, effusion, genu valgum
Heel pain from retrocalcaneal bursitis
RF, anti-CCP, IgM antibody, CRP, ESR
Anemia of chronic disease is common
XR
rheumatoid arthritis
rheumatoid arthritis tx
Steroids – bridge gap between slow acting DMARDs:
→ Methotrexate, but can add sulfasalazine (2nd), leflunomide, hydroxychloroquine
Refractory = janus kinase inhibitors
Biologics – TNF-alpha added to methotrexate (etanercept, infliximab, adalimumab), or nonTNF (abatacept)
Omega 3 supplements, analgesics, splints/therapy, custom shoes
Selective surgery
PEAR-U Sero-negative spondyloarthropathies
Psoriatic arthritis
Enteropathic arthritis (IBD)
Ankylosing spondylitis
Reactive arthritis (reiter)
Undifferentiated spondyloarthropathy
What are RFs for sero-negative spondyloarthropathies
Males
<40
spine/SI joints
Enthesopathy
Ocular formation
HLA-B27 genetic marker is often seen in
Sero-negative spondyloarthropathies
DIP joint with scaly, cutaneous lesions, commonly with nail disorders, pitting, ridging, onycholysis
psorasis preceding onset
XR: pencil in cup deformity
psoriatic arthritis
How do you treat psoratic arthritis
TNF inhibitor → methotrexate
Crohn’s and UC
Peripheral – oligoarthritis of large joints, paralleling bowel disease
Spondylitis – indistinguishable from ankylosing spondylitis, independent course of bowel disease
enteropathic arthritis
How do you treat enteropathic arthritis
Control intestinal inflammation = eliminate peripheral arthritis, can add NSAID (if not exacerbating)
Morning stiffness relieved by activity and leaning forward
Late teens, early twenties, males > females
Primarily affecting axial skeleton - sacroiliitis and kyphosis
ankylosing spondylitis
PE: limited spinal motion, progresses in cephalad direction
FABER maneuver stresses SI joint
Achilles enthesopathy, anterior uveitis
XR: “shiny corner sign” where annulus attaches to vertebral body, “bamboo spine”
ankylosing spondylitis
How do you treat ankylosing spondylitis
NSAIDS, then TNF
Arthritis, urethritis, conjunctivitis, mucocutaneous lesions
STI and dysenteric disease common
Pain in large joints of lower extremity with enthesitis of achilles tendon, dactylitis, sacroiliitis, nongonococcal urethritis, anterior uveitis, cutaneous ulcerations
reactive arthritis
“Reiter syndrome” – acute spondyloarhtropathy precipitated by GI/GU infection
“Can’t see, can’t pee, can’t climb a tree”
reactive arthritis
how do you tx reactive arthritis
NSAIDs, then sulfasalazine or methotrexate
– may need to treat chlamydial infection
