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J MSK > Arthritis > Flashcards

Arthritis Flashcards

1
Q

which arthritis is seropositive

A

rheumatoid arthritis

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2
Q

what conditions (other than rheumatoid arthritis) are seropositive

A

lupus
sjorgens
scleroderma
vasculitis

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3
Q

what are the seronegative types of arthritis (4)

A

ankylosing spondylitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis

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4
Q

are women or males more likely to get rheumatoid arthritis (and by how much)

A

women are 3 times more likely

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5
Q

which age group does rheumatoid arthritis affect

A

any age

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6
Q

what are the risk factors for rheumatoid arthritis (2)

A

genetics (HLA-DR4 gene)

smoking (increases likelihood of RA antibodies)

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7
Q

what are the triggers of rheumatoid arthritis

A

stress
infection
trauma

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8
Q

after a trigger, what happens in early rheumatoid arthritis (2)

A

autoantibodies (produced by B cells) react to trigger and affect synovium
cause hypertrophy of synovium (synovitis)

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9
Q

what type of hypersensitivity reaction is rheumatoid arthritis

A

type IV

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10
Q

what happens in early rheumatoid arthritis that continues in well established rheumatoid arthritis

A

synovitis

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11
Q

which type of cell (osteoclast or osteoblast) is activated in rheumatoid arthritis

A

osteoclast

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12
Q

what is the function of an osteoclast in rheumatoid arthritis

A

it ‘chews’ up bone = causes erosions

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13
Q

what time period distinguishes established rheumatoid arthritis from early rheumatoid arthritis

A

2 years since symptom onset

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14
Q

which joints are typically affected in rheumatoid arthritis (7+1 not)

A 
wrist 
knee 
ankle 
hip 
TMJ 
first 2 vertebrae 
PIP

NOT DIP joints

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15
Q

is the distribution of affected joints in rheumatoid arthritis symmetrical or asymmetrical

A

symmetrical

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16
Q

how does rheumatoid arthritis present (7)

A 
joint pain 
joint swelling 
early morning stiffness (>30 mins) 
improvement of symptoms with exercise 
rheumatoid nodules 
dry eyes 
corneal ulcers
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17
Q

what is early morning stiffness a red flag for

A

rheumatoid arthritis

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18
Q

what relieves the symptoms of rheumatoid arthritis

A

exercise

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19
Q

what investigations would you do for rheumatoid arthritis (3)

A

autoantibodies
xray
MRI

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20
Q

which autoantibodies are present in rheumatoid arthritis (2)

A 
rheumatoid factor (aka rheumatoid IgM) 
anti-CCP antibodies (aka ACPA)
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21
Q

what is bad about looking for rheumatoid factor in rheumatoid arthritis

A

it is not specific to rheumatoid and not everyone with rheumatoid will have it

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22
Q

is rheumatoid factor or anti-CCP antibodies preferred for diagnosis of rheumatoid arthritis

A

anti-CCP antibodies

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23
Q

is it possible to have neither anti-CCP antibodies and rheumatoid factor, but still have rheumatoid arthritis

A

yes

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24
Q

what does more anti-CCP antibodies in rheumatoid arthritis mean

A

worse condition

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25
Q

what would you see on xray of early rheumatoid arthritis

A

not much

swelling

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26
Q

what would you see on xray of late rheumatoid arthritis

A 
erosions 
osteopenia (less density) around joints
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27
Q

when would you do an MRI for rheumatoid arthritis

A

after xray if xray wasnt diagnostic

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28
Q

what is the assessment score for rheumatoid arthritis

A

DAS28 assessment score

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29
Q

what does a DAS28 score of <2.6 mean

A

no rheumatoid arthritis

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30
Q

what does a DAS28 score of >5.1 mean

A

active rheumatoid arthritis

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31
Q

how does DAS28 assessment score work

A

squeeze joints (28, doesnt include feet) and count how many are tender/swollen

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32
Q

what is the symptomatic treatment for rheumatoid arthritis

A 
aspirin 
paracetamol 
NSAIDs (eg ibuprofen) 
steroid (eg prednisolone) 
opioids (eg codeine, morphine)
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33
Q

what is the long term treatment of rheumatoid arthritis

A

DMARDs

biologics

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34
Q

what is the first line DMARD for rheumatoid arthritis

A

methotrexate

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35
Q

what is the second line DMARD for rheumatoid arthritis after methotrexate

A

sulfasalazine

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36
Q

what is the third line DMARD for rheumatoid arthritis after methotrexate + sulfasalazine

A

hydroxycholorquine

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37
Q

what would you add on to methotrexate + sulfasalazine + hydroxychloroquine if the combination therapy wasnt working

A

biologics

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38
Q

which DMARD is used in replace of methotrexate if the side effects of methotrexate occur

A

leflunomide

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39
Q

what is the therapeutic window for long term treatment of rheumatoid arthritis

A

3 months from symptom onset (not a long time!)

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40
Q

what is the purpose of long term treatment for rheumatoid arthritis

A

prevention of deformities/disease progression

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41
Q

when on DMARDs for long term treatment of rheumatoid arthritis, what needs to be monitored and why

A

bloods

for infection, immunosuppression, liver function (side effects of DMARDs)

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42
Q

what are the 2 indications for stopping methotrexate use in rheumatoid arthritis

A

pregnancy

side effects

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43
Q

how long before conception must methotrexate be stopped in rheumatoid arthritis

A

3 months

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44
Q

what DMARD is used in replacement of methotrexate in pregnancy for someone with rheumatoid arthritis

A

sulfasalazine or hydroxychloroquine

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45
Q

what DMARD is used in replacement of methotrexate when side effects occur, in someone with rheumatoid arthritis

A

leflunomide

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46
Q

what are the side effects of methotrexate (7)

A 
pneumonitis (SOB and cough) 
infection/immunosuppression 
mouth ulcers 
hepatitis 
leucopenia 
pulmonary fibrosis 
nausea, diarrhoea
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47
Q

what is the dosage of methotrexate for someone with rheumatoid arthritis

A

15mg once per week

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48
Q

what supplement needs to be taken alongside methotrexate

A

5mg folic acid

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49
Q

how does methotrexate work

A

lowers antibodies in blood

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50
Q

what is a general side effect of all DMARDs

A

infection/immunosuppression

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51
Q

how does sulfasalazine work

A

the antibodies attack the sulfasalazine instead of the joint synovium

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52
Q

what are the side effects of sulfasalazine (5)

A 
infection/immunosuppression 
nausea 
rash
mouth ulcers 
neutropenia
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53
Q

what is the mechanism of hydroxychloroquine (what type of drug is it)

A

antimalarial drug

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54
Q

what are the side effects of hydroxychloroquine (6)

A 
irreversible retinopathy 
infection/immunosuppression 
GI disturbance 
headache 
rash 
blood disorders
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55
Q

apart from the 4 DMARDs that are in the ‘standard’ rheumatoid treatment pathway, what are the other DMARDs that could be used in rheumatoid arthritis (3)

A

gold IM
penicillamine PO
azathioprine

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56
Q

after the ineffective use of 3 DMARDs, which biologic is used for rheumatoid arthritis

A

anti-TNF

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57
Q

what does an anti-TNF end in

A

-umab

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58
Q

when are biologics indicated for use in rheumatoid arthritis

A

DAS28 >5.1 = active disease
AND
when 2 DMARDs have been ineffective

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59
Q

what are the side effects of anti-TNF agents

A

infection/immunosuppression/reactivation of TB
skin cancer risk
exacerbation of heart failure or pulmonary fibrosis

60
Q

what drug is used to treat a flare up of rheumatoid arthritis

61
Q

what environmental factors are recommended in the treatment of rheumatoid arthritis

A

stop SMOKING!

stop drinking

62
Q

what treatment may be required if complications arise in rheumatoid arthritis

A

surgery - joint fusion, joint replacement

63
Q

what are the complications of rheumatoid arthritis in the hands (6)

A 
swan necking 
boutonnieres
z shaped thumb 
trigger finger 
extensor synovitis 
bilateral carpal tunnel syndrome
64
Q

what is the common complaint of people with complications of untreated rheumatoid arthritis in the feet

A

like theyre ‘walking on pebbles’

65
Q

what is trigger finger, and how does it occur in rheumatoid arthritis

A

the inflammation of finger tendons = get caught on ‘pulleys’ when bending = painful

66
Q

what is extensor synovitis and how does it occur in rheumatoid arthritis

A

the inflammation of the tendon sheath + tendons inside it = tendon degeneration and rupture, so needs replaced

67
Q

how does carpal tunnel syndrome occur in rheumatoid arthritis

A

synovial tissue inflammation = compression of median nerve

68
Q

what is bilateral carpal tunnel syndrome suggestive of

A

rheumatoid arthritis

69
Q

how does carpal tunnel syndrome present

A

weakness in thenar (thumb) muscles

numbness in digits 1-3 and lateral half of digit 4

70
Q

when do flare ups of rheumatoid arthritis usually occur

A

after birth

71
Q

rheumatoid arthritis is a risk factor for which body system

A

cardiovascular

72
Q

what is osteoarthritis

A

the gradual thinning of cartilage in joints

73
Q

what is the most common type of arthritis

A

osteoarthritis

74
Q

which age group is osteoarthritis most common in

75
Q

are men or women more likely to get osteoarthritis

76
Q

what are the risk factors for osteoarthritis (7)

A 
elderly 
women>men 
genetics 
occupation - heavy lifting
sports
previous injury in joint 
obesity
77
Q

what part of cartilage is lost in osteoarthritis

A

the matrix

78
Q

what cell attempts to replace the cartilage matrix in osteoarthritis

A

chondrocytes

79
Q

what happens to the synovial fluid in osteoarthritis

A

it dissects into bone = cyst formation

80
Q

is there increased or decreased bone turnover in osteoarthritis

81
Q

which joints are typically affected in osteoarthritis (5+1)

A 
base of thumb (trapezium) 
fingers (DIP and PIP) 
knees 
first MTP
carpometacarpal

joints with previous injury/gout/infection

82
Q

are the joints affected in osteoarthritis symmetrical or asymmetrical

A

asymmetrical

83
Q

when is pain worst in osteoarthritis

A

after exercise, at end of day

84
Q

what relieves pain in osteoarthritis

85
Q

is the onset of osteoarthritis gradual or sudden

86
Q

is morning stiffness present in osteoarthritis, if so for how long?`

A

ye s

<30 mins

87
Q

how would osteoarthritis present on examination

A

crepitations/creaking

88
Q

what knee abnormality is associated with osteoarthritis

A

bakers cyst

89
Q

how does a bakers cyst occur in osteoarthritis

A

excess fluid in knee from matrix being replaced in osteoarthritis

90
Q

what bony enlargement occurs at the DIP joints in osteoarthritis

A

heberdens nodes

91
Q

what bony enlargement occurs at the PIP joints in osteoarthritis

A

bouchards nodes

92
Q

what bony enlargement occurs at the base of the thumb

A

squaring of thumb base

93
Q

how is osteoarthritis diagnosed

A

xray

bloods - to exclude rheumatoid arthritis

94
Q

what are you looking for on an xray of someone with osteoarthritis

A 
LOSS;
loss of joint space 
osteophytes (rough bit on otherwise smooth bone) 
subchondral cysts 
sclerosis (white on xray)
95
Q

can osteoarthritis be cured

96
Q

what is the first line treatment for painful osteoarthritis

A

weight loss
paracetamol
physiotherapy

97
Q

what is the treatment of an osteoarthritis flare up

98
Q

what is the treatment of osteoarthritis that is still painful with paracetamol, weight loss etc

A

surgery - arthrodesis, excision/resection arthroplasty, joint replacement

99
Q

what is an excision/resection arthroplasty

where is it used in osteoarthritis

A

removal of a diseased joints

used in small joints

100
Q

what is arthrodesis

where is it used in osteoarthritis

A

fusion of bones in a joint in a position of function

used in small joints

101
Q

when is joint replacement used in severe osteoarthritis

A

in large joints (eg shoulder, hip) when paracetamol etc is ineffective

102
Q

contraindications of total hip replacement in osteoarthritis

A

age <65
cardio/resp problems
obesity (wont make much difference)

unless you explain risks and pain is so bad that they still want it

103
Q

complications of total hip replacement in osteoarthritis (6)

A

aseptic loosening - presents as thigh pain, loosening of bone to replacement, common
hip dislocation
breakage
nerve damage
infection
cant do intense exercise (though usually irrelevant)

104
Q

when is a hemiarthroplasty used in osteoarthritis

A

in elderly with little movement requirements (eg care home, bed ridden)

105
Q

what is it called when someone has a combination of rheumatoid arthritis and osteoarthritis

A

mixed picture arthritis

106
Q

which gene is associated with seronegative spondyloarthropathies

107
Q

where does ankylosing spondylitis present

108
Q

when does ankylosing spondylitis present

A

late adolescence, early adulthood

needs to be <45 for diagnosis

109
Q

what are the 4 type of seronegative spondyloarthropathies

A

ankylosing spondylitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis

110
Q

what gene is associated with ankylosing spondylitis

111
Q

where does ankylosing spondylitis present

A

back and buttock pain

112
Q

when is the pain associated with ankylosing spondylitis relieved

A

after exercise

113
Q

what posture is associated with ankylosing spondylitis

A

‘question mark spine’

114
Q

what causes ‘question mark spine’ in ankylosing spondylitis

A

LLL = Loss of Lumbar Lordosis

from fusing of lumbar vertebrae

115
Q

which examination test can confirm ankylosing spondylitis

A

schobers test

116
Q

what condition are the xray features; ‘bamboo’ spine, ‘shiny’ corners and sacroillitis associated with

A

ankylosing spondylitis

117
Q

when would you use an xray for diagnosis of ankylosing spondylitis

A

if symptom onset >6 months

118
Q

when would you use a MRI for diagnosis of ankylosing spondylitis

A

if symptom onset <6 months (wont see anything on xray)

119
Q

what is the treatment of ankylosing spondylitis

A 
physio 
occupational therapy 
NSAIDs (eg ibuprofen) 
DMARDs 
anti-TNF if severe
120
Q

can you cure ankylosing spondylitis

A

no, symptomatic treatment

121
Q

what complication is associated with ankylosing spondylitis

A

spinal fracture

122
Q

which dermatological condition is psoriatic arthritis associated with

123
Q

which gene is psoriatic arthritis associated with

124
Q

how do the hands present in psoriatic arthritis

A 
arthritis mutilans (shortened digits) 
dactylitis (sausage fingers) caused by inflammation
125
Q

what xray appearance in the hands is associated with psoriatic arthritis

A

‘pencil in cup’ deformity

126
Q

how are the tendons affected in psoriatic arthritis

A

enthesitis - inflammation of tendons where they attach to the bone

127
Q

what nail sign is associated with psoriatic arthritis

A

onycholysis - lifting of nail from nail bed

128
Q

the treatment of what other condition is the same as the treatment of psoriatic arthritis

A

rheumatoid arthritis

129
Q

what is the treatment of psoriatic arthritis

A

DMARD1 (methotrexate) + DMARD2 (sulfasalazine) + DMARD3 (hydroxychloroquine) + biologics (anti-TNF -umab)

130
Q

what is reactive arthritis

A

when an infection triggers arthritis in a genetically susceptible individual

131
Q

what gene is associated with reactive arthritis

132
Q

which joint does reactive arthritis usually occur in

133
Q

when does reactive arthritis present (in relation to the infection)

A

1-4 weeks after infection

134
Q

how does reactive arthritis present (triad)

A

reiters triad;
‘cant see, cant pee, cant bend the knee’
uveitis/conjunctivitis, urethritis, arthritis

135
Q

what is reiters triad

what condition is it associated with

A

‘cant see, cant pee, cant bend the knee’
uveitis/conjunctivitis, urethritis, arthritis

reactive arthritis

136
Q

what is the first line investigation for reactive arthritis

A

joint aspiration - to exclude septic arthritis

137
Q

what condition do you need to exclude if you suspect reactive arthritis

A

septic arthritis

138
Q

how is reactive arthritis cured

A

it is self limiting, if still there after 6 months = DMARDs

139
Q

what is the symptomatic treatment for reactive arthritis

A

steroids

antibiotics for infection

140
Q

what GI condition can arthritis be associated with

A

inflammatory bowel disease (IBD) - crohns, ulcerative colitis

141
Q

what is it called when someone has IBD and arthritis

A

enteropathic arthritis

142
Q

when is enteropathic pain worst

A

during IBD flare ups

143
Q

what is the first line investigation for enteropathic arthritis

A

joint aspiration - to exclude septic arthritis

144
Q

how is enteropathic arthritis treated (3)

A

fix IBD
DMARDs
anti-TNF (-umab)

145
Q

what is the symptomatic treatment for enteropathic arthritis

A

paracetamol
NOT NSAIDs - make IBD worse
steroids

146
Q

how can rheumatoid arthritis affect the kidneys

A

amyloidosis (deposition of amyloid in kidneys)

J MSK (30 decks)

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