Arthritis Flashcards
What is the commonest joint problem worldwide?
OA
Which type of joints does OA affect
Synovial
Risk factors OA
AGE!! Joint trauma/injury Occupational FH Obesity F>M Gout
Which joint do Heberden’s nodes affect
Distal interphalangeal
Which joint do Bouchard’s nodes affect
Proximal interphalangeal
Clinical signs of OA
Crepitus on movement Pain on movement Heberden's nodes (DIP) Bouchard's Nodes (PIP) Restricted movement Bony enlargement Joint effusion Bony instability
What is the RF in OA
-ve
X-ray signs of OA
Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis
Ix for OA
Examination
FBC
RF
X-ray
Symptoms OA
Pain Worse on movement and or weight bearing Better on rest Stiffness <30 mins in the morning Swelling around the joint Crepitus Decrease ROM
Difference in morning stiffness between OA and RA
RA prolonged morning stiffness
OA typically lasts <30 mins
Conservative Rx of OA
Patient education
Exercise
Weight loss
Lifestyle change
Non-Pharmacological Rx of OA
Thermotherapy
Electrotherapy
Aids and devices
Manual therapy
Which non-pharmacological Rx do NICE NOT recommend
Acupuncture
Nutraceuticals
Pharmacological Rx of OA
Oral analgesia: NSAIDS
Topical analgesia: Capsaicin
Steroid I/A injections
Surgery options for OA
Joint replacement/Arthroplasty
Osteotomy
Arthrodesis
Who is given surgery in OA
People with severe OA that is impact got QO
When other managements have been tried and failed
Which signs would suggest the diagnosis is NOT OA
Trauma
Prolonged morning stiffness
Rapid deterioration of symptoms
Hot swollen joints
What type of arthritis is gout
Inflammatory
What is the pattern of gout disease
Recurrent attacks
Aetiology Gout
M>F Increasing Age Red meat Alcohol FH gout Obesity Hypertension DM
What causes gout
Elevated levels uric acid in the blood
Triggering factors for gout
Alcohol
Dehydration
Diuretics
Where in the body is gout most common
1st MTP of big toe
Symptoms of gout
Red Hot Swollen Fiery painful joint Peeling overlying skin
Ix for gout
Serum urate (may be helpful) ASPIRATION
What are tophi
Massive accumulations of uric acid
What is the typical presentation of gout
1st MTP of big toe
Hot, red, swollen, painful
Rx acute flares of gout
High dose NSAIDs (Colcichine if NSAIDS CI)
Rest and elevate the joint
Steroid injections
What is given in acute flares of gout if NSAIDS are CI
Colchicine
What is a common side effect of Colchicine
Diarrhoea
When should you treat hyperuricaemia
Single attack of polyarticular gout Urate calculi Renal insufficiency Tophaceous gout If 2nd attack within 1 yr
Which Rx lower uric acid
Xanthine Oxidase inhibitors
Uricosuric agents
How do uricosuric agents work?
They increase rate excretion of uric acid in urine
Should you treat asymptomatic hyperuricaemia
No
Given examples of Xanthine Oxidase Inhibitors
Allopurinol
Febuxosat
Ddx for gout
Septic arthritis
Cellulitis
Reactive arthritis
Pseudogout
What is it important to differentiate gout from
An infection of some sort
e.g septic arthritis
Overproduction causes of hyperuricaemia
Malignancy Lymphoproliferative disorders Tumour lysis syndrome Severe exfoliative psoriasis Drugs Inborn errors of metabolism HGPRT deficiency
Under excretion causes of hyperuricaemia
Elderly Male Renal impairment Hypertension Hypothyroidism Drugs Exercise, starvation, dehydration Lead poisoning
Which joint does Pseudogout typically affect
Knee
What cause pseudo gout
Calcium Pyrophosphate Deposition in the joints
Symptoms of pseudo gout
Similar to gout Attacks of joint: Pain Swelling Redness Tenderness Warmth Red, fiery hot joint
Rx for pseudo gout
NSAIDs
Steroid injections
Manage episodes as they arise
Is there prophylaxis for pseudo gout?
No
What type of arthritis is ankylosing spondylitis
Seronegative arthritis
Which antigen is seronegative arthritis commonly associated with
HLA B27
What is ankylosing spondylitis
Chronic inflammatory rheumatic disorder with a predilection for axial skeleton and sacroiliac joints
What is the typical onset (gender and age) of Ankylosing Spondylitis
M>F
20-30s (young)
What is meant by a seronegative arthritis
Rheumatoid factor is negative (RF -ve)
What is the typical clinical picture of ankylosing spondylitis
young male (<30yrs) Gradual onset lower back pain Worse during night Morning spinal stiffness relieved by exercise Progressive loss of spinal movements
Dx for ankylosing spondylitis
Bloods:
including HLA-B27 and RF
MRI of spine!!
Is there a cure for ankylosing spondylitis
No cure
Rx for ankylosing spondylitis
No cure
Physio.
Exercise
NSAIDS
DMARDS:
Sulfasalazine
Anti-TNF
Anti IL-7
Surgery:
joint replacement
Spinal surgery
Clinical features of ankylosing spondylitis
Low back pain
Back stiffness which improves with activity
Lasting >3/12
Limited ROM of lumbar spine in both lateral and forward flexion
Limitation of chest expansion
Bilateral sacroilitis
What are potential extra articular features of ankylosing spondylitis
Uveitis Aortic valve incompetence Heart blood Restrictive pulmonary disease Apical fibrosis IBD Osteoporosis Spinal fractures Acute iritis Cauda Equina syndrome
What are the clinical criteria for the New York Classification system (Ankylosing spondylitis)
Low back pain >3 months with stiffness that improves on activity
Limited ROM of lumbar spine (both lateral and forward flexion)
Reduced chest expansion (compared to normal values for age and sex)
What are the radiological criteria for the New York Classification system (Ankylosing Spondylitis)
Sacroilitis grade >2 bilaterally
OR
Sacroillitis grade 3-4 unilaterally
What combination of clinical and radiological is needed to diagnose Ankylosing Spondylitis according to the NY classification
1 radiological + 1 clinical classification
What are the 2 classification systems used for Ankylosing Spondylitis
New York Classification
ASAS Classification
Describe the ASAS classification for ankylosing spondylitis
Patients with >3 months history of back pain and <45yrs
WITH Sacroilitis on imaging + >1 SpA feature
Or
WITH HLA-B27 +ve + 2 or more SpA features
What are the SpA features of the ASAS classification system (ankylosing spondylitis)
Inflammatory back pain Arthritis Enthesitis Uveitis Dactylitis Psoriasis Crohn's/Colitis Good response to NSAIDS FH of SpA HLA-B27 +ve Increased CRP
Describe grade 0 Radiological sacroilitis
Normal
Describe grade 1 radiological sacroilitis
Suspicious changes
Describe grade 2 radiological sacroilitis
Minimal abnormality small localised areas with erosion of sclerosis without alteration in joint width
Describe grade 3 radiological sacroilitis
Unequivocal abnormality - moderate or advances sacroilitis with 1 or more of: erosions, evidence of sclerosis, widening, narrowing or partial ankylosis
Describe grade 4 radiological sacroiliac
Severe abnormality - total ankylosis
What is psoriatic arthritis
Chronic inflammatory arthritis occurring in those affected with the autoimmune disease psoriasis
Does psoriatic arthritis always occur in those with psoriasis
No joint involvement only occurs in 10-4% of those with psoriasis
What type of arthritis is psoriatic arthritis
Seronegative (RF-ve)
Which antigen does psoriatic arthritis have a strong association with
HLA B27
Nails signs of psoriatic arthritis
Nail pitting Nail discolouration Nail thickening Dactylitis Palmar-plantar pustulosis
What is Dactylitis
Sausage fingers
Ix for psoriatic arthritis
Xray
Bloods:
HLA B27
RF
Does the severity of skin disease correlate to the severity of join disease in psoriatic arthritis
No
Types of psoriatic arthritis
Symmetrical DIP joint Asymmetrical Spinal Psoriatic arthritis mutilans
Rx for psoriatic arthritis
NSAIDS
Corticosteroids
DMARDS
Biologics
Physio.
OT
DMARDs used to treat psoriatic arthritis
Sulfasalazine
Methotrexate
Leflunomide
Cyclosporine
Biologics used to treat psoriatic arthritis
Ant-TNF therapy
Anti Il-17 and IL-23
Symptoms of psoriatic arthritis
Swollen fingers and toes Painful joints Plaques on skin Reduced ROM of joints Fatigue Nail changes: pitting, discolouration, thickening
What is reactive arthritis
Inflammatory arthritis that develops in response to an infection in a distant site in the body (cross reactivity)
What type of arthritis is reactive
Seronegative (RF -ve)
What is the classic triad of Reiter’s Syndrome
Asymmetric oligoarthritis
Urethritis
Conjunctivitis
Ix for Reactive arthritis
RF (-ve) ESR CRP HLA-B27 Cultures (e.g stool, swabs)
Which types of infection are most likely to cause reactive arthritis
Urogenital (e.g sexually transmitted - e.g Chlamydia)
GI (e.g diarrhoea)
Throat infection (streptococcus)
Clinical features of reactive arthritis
Painful swollen joints Dactylitis Conjunctivitis Mouth ulcers Urethritis
Cure for reactive arthritis
No specific cure
Rx for acute reactive arthritis
NSAIDs
Joints steroid injection
Abx. (in chlamydia for contacts aw well)
Splinting
Define chronic reactive arthritis
Symptoms last >6 months
Rx for chronic reactive arthritis
NSAIDs
DMARDs:
Sulphasalazine
Methotrexate
What is enteropathic arthritis commonly associated with
Ulcerative colitis
Crohn’s Disease
Which antigen is strongly associated with reactive arthritis
HLA-B27
Which antigen is strongly associated with enteropathic arthritis
HLA-B27
Rx for enteropathic arthritis
NSAIDs (difficult to sue)
DMARDs (e.g Sulfasalazine)
Steroids
Biologics (anti-TNF)
What is enteropathic arthritis
Chronic inflammatory arthritis associated with the occurrence of IBD
What is septic arthritis
Infection of the joint
Which joint does septic arthritis commonly affect
knee
Risk factors for septic arthritis
Age DM OA RA Chronic renal failure Immunocompromised IV drug abuse Recent joint surgery Skin infection
Common organisms for septic arthritis
Staph. Aureus
Haemophilus influenza
Strep. Pyogenes
E.coli
Route of infection for septic arthritis
Haematogenous (commonest) Eruption of bone abscess Direct invasion Penetrating wound Intra-articular injury Arthroscopy
Clinical features of septic arthritis
Acutely inflamed painful joint Fever (systemic symptoms) Tender joint Warmth over joint Redness Pain to move joint
Ix for septic arthritis
Bloods:
FBC, WCC, ESR, CRP
Urgent joint aspiration!!!
Blood cultures
X-ray
USS
Urgent Ix for septic arthritis
Urgent joint aspiration
Rx for septic arthritis
Fluids
Analgesia
IV Abx (then switched to oral)
Arthrocentesis
Ddx for septic arthritis
Acute osteomyelitis Trauma Irritable joint Haemophilia Rheumatic fever Gout