Arthritis Flashcards
_______ is the most common arthropathy in adults
Osteoarthritis
Osteoarthritis results in the destruction of __________, the cardinal features of __________ loss and remodeling of ____________.
destruction of bone causing pain
articular cartilage loss
and remodeling of subchondral bone
Primary OA is ________; usually results from a combination of ________ and _______
idiopathic
results from suceptibility(risk factors(age,race)) and joint loading
Secondary OA results from _________, ________, or _________
joint injury, congenital inflamm, or joint instability
*OA presents with Decreased _______, _________, and _______ that worsens ______
decreased ROM
crepitus
and pain that worsens throughout the day/with use
OA can be seen in 5 joints
DIP(herberden's nodes) PIP (Bouchard's) Hip Knee and spine
*with OA ______, ________, and ________ are typically spared
MCP(except thumbs)
elbows
ankles
*With OA is pain more typical in the AM or PM?
PM, b/c worse with use
______ nodes are herberden’s nodes
____ nodes are Bouchard’s
DIP - Herb
PIP - Bouchard
*With OA _______ is the best evaluation tool
X-Ray
What is seen on XR with OA? (4)
joint space loss/assymt narrowing
subchondral sclerosis
bone cysts
osteophytes
With OA, what do you expect of the synovial fluid analysis? (5)
yellow color, 200-300 WBCs, 25% PMNs, negative culture, negative crystals
OVERALL LOOKS PRETTY NORMAL
Normal age of onset of OA is after _____yo
40yo
sx of OA include ______, _______, and ________
pain, stiffness, and gelling
OA is normally seen is ______joint(s)
one
what’s the prognosis for OA
slowly progressive
*What is the first line tx for OA
tylenol
what 3 reccomendations can help with OA pain
wt reduction, aerobic/resistance exercise, altering joint loading with PT bracing or a cane
what are the 4 alternative tx to 1st line in OA
NSAIDs -oral and topical
viscosupplement injection
intraarticular steroids (cortisone)
joint replacement (absolute last resort)
Avoid treating OA with _______, unless pain is refractory to other measures, then use _________
narcotics weak opioids (tramadol 10mg)
name the 5 alternative tx for arthritis
glucosamine chondrotin
acupuncture for the knee
prolotherapy - injection of nat subs to promote healing
Platelet rich plasma
Articular injections (such as lidocaine and steroids) are variable in relieving pain, but could be diagnostic for ___________
SI joint arthritis
-if injections relieves pain this is diagnostic for SI arthritis
viscosupplements usually require ______; pts feel relief after _____ injections; you can repeat the tx every _____ months
a series of injections
pts feel relief after 2-3 injections
repeat every 6 mo
_______ can be injected peri-articularly, though usually not covered by insurance
Platelet rich plasma
PRP
what is prolotheraphy? and 3 examples?
injection of any substance to promote growth of normal cells or fix CT laxity
growth factor, growth factor stimulation, dextrose (ASK THEM NOT TO TAKE NSAIDS)
platelets are normally ____% of plasma…. in PRP platelets are _____%
6%
94%
________ and _________ debridement(arthroscopy) is helpful to inc ROM and function.
It’s NOT efficacious for ______ and _______
shoulder and elbow
NOT for: hip and Knee
With joint arthroplasty pts are ___________ immeadiately to ward of ________ or _________
weight bearing (WBAT) ward of ROM dysfxn or clot
with artificial hips you are concerned about _________ or _________
fracture around the replacement
dislocation
what is RTSA
reverse replacement components (making the humerus the socket and the glenoid the ball)
RA stiffness is worse in the AM/PM?
AM
What is RA
autoimmune, chronic inflamm and errosive joint dz with synovitis affecting multiple joints(polyarticular) with other systemic effects
_____ is the most chronic inflamm arthritis
RA
females/males are affected by RA more freq
Females
RA does/does not run in families
does
common age of onset for RA
25-55yo
less than ___yo is considered juvenile RA
16
RA typically affects the small/large joints?
symmetrical/assym?
4 most common are?
small joints
symmetric
hands feet wrists ankle
RA CAN affect cervical spine, shoulders, elbows _______, and ________ but is uncommon
hips and knees
symptoms of RA are _________ and ________
persistent and progressive
what are the 6 cardinal symptoms of RA
warm tender swollen morning stiffness improved with moderate activity possible synovitis and eventual deformity of the joint
what is a pannus
The synovial capsule (which can be hyperplastic in RA)
what’s the pathophys of RA
self reactive T cells activate B cells and macrophages drive the chronic inflamm response
osteoclast activation at the site of the pannus is related to….
focal bone erosion
RA will usually have accompanying _______ symptoms (list 5)
constitutional
fatigue, fever, wt loss, myalgia, and anemia
20-30% of RA pts also suffer from
osteoporosis
RA hand deformities (3)
ulnar deviation
swan neck (DIP flexed)
Boutonniere (DIP extended)
RA can result in complication in (3)
Lungs - Pulm effusion
Ocular- episcleritis
Skin - gramulomatous base ulcer
Xray findings on RA are…
typically only seen in late stages
Previously RA used to be a DDX of exclusion, now the pt must score ____ points on ACR guidelines
6 or more
Early RA can often be Dx by ______ and _______
lab findings(anti-CCP) and early joint involvement
_______ is the best lab to get for RA along with evidence of soft tissue swelling/acute flare ups
XR
_____ and ______ are typically elevated in RA
ESR and CRP
CBC of an RA pt can show
anemia of chronic dz
____ is positive in ~80% of RA pts and may be low in early RA
Rheumatoid Factor
*_________ is present in early dz and can be a marker for dz progression.
Anti-CCP
*______ and _____ is 99% specific for RA dx
Anti-CCP
RF
*What color is the synovial fluid in Inflammatory Processes (RA)
WBC?
PMN?
culture and crystals?
yellow or opalescent
3,000-5,0000
PMNs 25-50%
culture and crystals are negative
*What is seen on the pannus of RA?
focal errosions
Compare Xray of OA vs RA
Both have a narrowing of the joint space
RA: sclerosis
OA: osteophytes, uneven edges, joint instability
OA has thinned ________ and __________ happens as a result
cartilage
bone rubbing against each other
RA has ________ errosion and the synovial membrane is _________________
focal errosion
synovial mem is swollen and inflammed
What is the goal of RA medication therapy
reduce pain, preserve fxn, and prevent deformity
what are the 3 types of medication we use for RA?
glucocorticoids, DMARDs, and Biologics
Glucocoricoids can be injected intra-articularly to relieve RA pain, but what must you rule out first??
rule out septic joint!
the DMARDs ___________ and ___________ combined with NSAIDs are good for mild sx of RA
hydroxychlorquine and sulfasalazine
What’s the DMARD for moderate to severe RA sx
methotrexate
What is the caution for using biologics for RA (3)?
increases risk of infection
reactivation of latent Tb
use with caution in hepatitis
NSAIDs are used in RA to….
reduce pain and swelling (no fx on underlying dz)
*Primary joints affected in RA
MCP and PIP
*Primary joints affected OA
DIP and carpometacarpal
*__________ nodes are present in OA but absent in RA
Heberden’s
*what are the joint characteristics of RA vs OA
RA: warm soft tender
OA: hard and bony
*Stiffness in RA vs OA
RA: worse after rest (am stiffness)
OA: worse after effort (pm stiffness)
*In RA, RF is _______, anti-CCP is _______, and ESR and CRP are _________
+ RF
+ anti-CCP
ESR and CRP are elevated
In OA, RF is ________, anti-CCP is ________, and ESR and CRP are ________.
- RF
- anti-CCP
ESR and CRP are normal
name the 5 spondyloarthritides
Ankylosing Spondylitis Reiter's syndrome psoriatic arthritis arthritis of inflammatory bowel dz undiff spondyloarthropathy
what are the two cardinal clinical features of Ankylosing spondylitis (AS)
SI inflamm(sacroilitis) spinal inflammation (spondylitis) (may also present with uveitis or conjunctivits)
Symptoms of AS are most common in ____m/f, who are ___–____yo
Male
20-30yo
AS is associated with HLA___
B27
What is a syndesmophyte (AS)?
fusion of bone and CT
advancement of AS results in… (4)
Loss of ROM (but with reduced pain, higher risk of fx)
loss of height
loss of chest expansion (inc risk for pneumonia/respiratory stress)
IBD
Bamboo spine on Xray means…
ankylosing spondylitis (AS)
what are the 3 tx for ankylosing spondylitis (AS)
PT -daily exercise, stretching
NSAIDs - relieve pain and stiffness
TNF-a blockers - improve fxn, slow damage
What are the 3 TNF-a blockers, what do they do for AS?
infliximab, etanercept, adalimumab
reduce pain, improve fxn, slow progression/damage, and reduces attacks of uveitis
*What is Psoriatic Arthritis (PsA) (cardinal clinical features)?
Inflam arthritis with psoriatic skin usually preceeding joint dz by months or years
______ inflammed synovioum looks like RA, but will be negative for _____
PsA
seronegative for RF
*PsA has symmetric arthritis in the hands and feet like ______; it also presents with 2 nail sx
like RA
nails are pitting and onycholysis (nail lifting/fx)
PsA causes _________ finger features
sausage (caused by arthritis and tenosynovitis of flexor tendons)
Pencil-in-cup refers to what
Psoriatic arth, Dip looks like a cone holding a “pencil”
seen on xray and ossification of joint margins
With PsA ESR and CRP are ______, CBC shows _______, RF and ANA often ________.
elevated
CBC show normochromic, normocytic anemia
RF and ANA freq negative
What is seen on Xray of PsA spine
asymmetric sacroilitis
what are the 5 criteria that are used to dx PsA? (pt must have 3/5 minimum)
evidence of psoriasis psoriatic nail dystrophy negative RF dactylitis (inflam of entire digit) radiologic evidence of juxtarticular new bone formation (ill defined ossicifcation near joint margins)
what are the 4 tx for PsA
NSAIDs for mild
Methotrexate (skin, inflam, and improves fxn)
TNF-a blockers
reconstructive surgery may be needed for end stage dz
PsA pts should not be taking ________(med)
corticosteroids
what’s the idiom for reiter’s syndrome AKA reactive arthritis? (ReA)
Can’t see, Can’t Pee, Can’t climb a tree
ReA is a seronegative arthritis with a tetrad of…
urethritis
conjunctivitis
oligoarthritis
and mucolsal ulcers (palms and soles affected as well)
ReA typically happens after __________ or _________
STDs (ureaplasma or chlamydia) - this route mainly seen in men (18-40)
gastroenteritis (shigella, salmonella, yersina, or campylobacter)
ReA is typically (sym/asym?), affecting the large joints of the (UE/LE?)
asym
LE
Mucosal ulcers of ReA typically present as ______ or _______
balantitis
stomatitis
what is enthesopathy? (ReA)
pain and inflam around the joint
Though ReA typically affects the LE, _____ can also occur
digititis
how long does arthritis of ReA persist
3-5 mo
small pus filled vesicles that turn into small red/brown lesions found on the palms (keratoderma blennorrhagica) should make you think of….
ReA
With ReA, ESR and CRP are ______; Associated with what genetic predisposition?
elevated
HLA-B27 (30-80%)
Would you take a synovial fluid sample in suspected ReA? Why?
yes, r/o sepsis and rule in specific STD
what are the 3 tx for reiter’s syndrome?
indomethacin (NSAID)
intra-articular steroid injection
Abx to fight STD (does NOT alleviate the arthritis)
**_______ arthritis and _________ arthritis both affect younger people more commonly and occur abruptly. Which affects females more? which affects males more?
reiters syndrome/reactive arthritis (males) -palms and soles
gonnococcal arthritis (Females)
_______ and _______ arthritis typically affect those of middle age and occur insidiously.
RA
psoriatic arthritis
Gout is a systemic dz that results from altered metabolism of ________ that results in precipitation of ________ in joints
purines
sodium urate crystals
Gout affects _________ much more frequently.
men(9:1) (however the ratio equalizes after menopause)
________ is the main stimulus for over production of uric acid and gout (_____ is also a culprit)
alcohol
red meat
what are the 3 cardinal features of gout
rapid onset of severe pain
erythema
and swelling of the affected joint
with gout the _____ joint is most common and this is called a _______
MTP of big toe (feet, ankles, knees, elbows also affected)
podagra
what 2 skin changes can be seen with gout
tophi (seen in chronic) - chalky deposits of urate crystals
cellulitis
45 yo man woke up in the middle of the night with an exquisetly painful joint (even the sheet on the joint hurts). He drank a 24 pack over the weekend and has a Hx of HTN, poor diet, and is overweight. dx?
gout
*what is the gold standard dx test for gout?
synovial fluid analysis (will show monosodium urate crystals)
Serum uric acid of ____ is suggestive of gout but not diagnostic.
6.8 or greater
gout synovial fluid appear __________ in color, has a ____(+/-) culture and has _______% PMNs
cloudy to yellow
negative culture
25-50% PMNs
Gout onset is typically
acute, abrupt (not insidious)
____ may be a helpful scan for gout, but ____ and ______ not indicated for gout
XR(may show errosions or tophi(CAUTION, errosions could be d/t chronic dz))
CT/MR
gout can present in what upper extremity joint?
elbow - olecrenon bursitis
what 2 NSAIDs are used for acute gout
indomethacin or indocin
________ can be used for acute gout but only within the 1st 24 hrs!
colchicine
If infection is r/o with gout _____ or _______ may be used as tx; cold packs, rest, and elevation are also helpful
cortisone injection
oral prednisone
what 3 agents are used for long term main’t of gout
colchicine
Probenecid
allopuinol (caution pt, they could have an acute flare when initiating this med)
pseudogout is also known as___________
calcium pyrophosphate dehyrate dz (CPPD)
Pseudogout affects ________ joints and is usually ______articular (mono, poly, oligo, etc)
peripheral (knee and wrist) (may affect the pubic symph)
polyarticular
what is seen in XR and synovial fluid analysis of pseudogout?
XR: chondrocalcinosis (fine line of calcifications in cartilage)
Synovium: calcium pyrophosphate crystals
what are the 3 treatments for pseudogout
NSAIDs (mainstay)
colchicone for recurrent attacks
intrarticular cortisone injection (with infxn r/o only)
*a red hot swollen joint points to…
SEPSIS (SEPTIC JOINT UNTIL PROVEN OTHERWISE)
esp in pts with recurrent infxn or recent surgery
________ most commonly involves a single joint (freq the knee) and more common in IV drug users
septic arthritis
*__________ is the most common pathogen in septic arth…. if pt is sexually active consider _______
S. aureus
N. gonorrhorea
with septic arthritis, ROM is _______, and the pt may have fever
limited
*__________ is the gold standard dx for septic arthritis
synovial fluid analysis
synovial fluid analysis of septic joint will show: Color? WBCs? PMNs? Culture? crystals?
yellow to green >50,000 wbc 75% PMNs Pos culture no crystals
why might you want to wait to tap a septic joint? whats the preferred tx?
specialist may want to do somethign different
surgery is tx, arthrotomy vs arthroscopy (IV abx)
A joint presents with all sx of septic arth EXCEPT limited ROM with overlying cellulitis… what do you do?
Do NOT tap, you risk spreading infection to joint space
what is osteomyelitis?
microbial infection of bone (d/t blood infxn, post surgery infxn, or vascular insuff/neuropathy)
vertebral osteomyelitis aka _________, is usually caused by what microorg?
septic diskitis
S. Aureus
*what is the gold standard dx in osteomyelitis?
MRI (or Xray)
*If blood culture is negative but osteomyelitis is suspect, what do you need?
guided bone biopsy with culture
Tx for spetic diskitis?
IV Abx (surgery if d/t implant infxn)
osteomeylitis of long bones occurs mainly in who? when?
children
post surgery/trauma
who does osteomyelitis of the foot occur in? (4)
diabetes (60-80% pts with foot wound), PAI, neuropathy, or post surgery
osteomyelitis of the foot requires …
debridement, but unfortunately amputation may be the only option
