Arthritis

Question 1

Describe the differences in presentation between OA and RA?

Answer 1

OA = pain ON movement
= no AM stiffness/stiffness <30mins
RA = more painful after extended periods of rest
= AM stiffness (>30mins)

OA - typically larger joints e.g. hips and knees
RA = typically smaller joints e.g. feet and hands

Question 2

How does TB present osteologically?

Answer 2

Adults - as secondary disease

Kids - as primary disease

Most common in spine and invades causing caseating granulomas (Pott’s disease)

Will have other common signs of TB - fever, night sweats etc.

Question 3

How is TB arthritis treated?

Answer 3

9 months of TB drug treatment

Question 4

Define Septic arthritis/infectious arthritis

Why is it a medical emergency?

Answer 4

Severe acute inflammation of the joint

It can cause permeant destruction of the joint

Question 5

How is septic arthritis most likely to present?

What is the diagnostic feature?

What other investigation must also be done and why?

Answer 5

Joint aspiration - purulent

Will have severely acutely inflamed joint - most commonly knee

Blood cultures - most commonly bactereamia present

Question 6

Treatment of septic arthritis

Answer 6

1. Wash out infected joint

2. 4-6 weeks of antibiotic treatment starting with IV flucloxicillin

Question 7

What is the most common cause of joint disease?

Answer 7

Osteoarthritis

Question 8

What causes osteoarthritis?

Answer 8

Missmatch between collagen breakdown and production

Chondrocytes die and matrix no longer work adequately -> fissured cartilage

Eburation occurs when bone is exposed as cartilage wears away fully

Question 9

What does eburnation lead to in OA which can cause nerve damage or irriation?

Answer 9

Eburnation leads to osteophytes

Osteophytes are caused by abnormal bone repair and overgrowths

Question 10

In what conditions would you find pannus and rheumatoid nodules and explain what each are?

Answer 10

RA

Pannus - granulation tissue in joint space

R nodules - NECROTISING granulation tissue in subcutaneous tissue in particular pressure points and organs

Question 11

What is arthritis in <16 yo called?

Answer 11

Idiopathic juvenile arthritis

Question 12

What score system is used in RA to establish the level of disease progression and treatment options?

How does it work?

Answer 12

DAS28 (disease activity score)

Test tenderness and swelling of 28 joints

Question 13

What are the Xray findings you would see in OA?

Answer 13

LOSS

Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis

Question 14

How do you diagnose OA?

Answer 14

Clinical diagnosis if:

• > 45
• joint pain on movement
• <30mins of AM stiffness

Question 15

What is the drug management of RA?

Answer 15

1. Methotrexate
2. Methotrexate + other immunosuppresant (e.g. leflunomide/sulfasalazine)
3. Methotrexate + Biological therapy (anti-TNF)
4. Methotrexate + rituximab

Question 16

Describe each of the following deformities that can be found in RA:

• Swan neck deformity
• Bouchard’s nodes
• Ulnar deviation of MCP joints
• Z shaped thumb
• Boutonniere deformity

Answer 16

Swan neck deformity - dip down at PIP joint and high at DIP joint

Bouchard’s nodes - swelling around PIP joints

Ulnar deviation at MCP - full fingers move toward pinky

Z-shaped thumb

Boutonniere deformity - high at PIP joint and low at DIP joint

Question 17

What antibodies are associated with RA?

What one is most specific?

Answer 17

RF

Anti-CCP

Question 18

Describe the pattern of distribution of rheumatic arthritis

Answer 18

Bilateral

Question 19

What radiological features are seen in RA?

Answer 19

periarticular osteopenia and erosions

Question 20

What defines “primary” OA?

Answer 20

Don’t know cause of OA

Question 21

What is Felty’s syndrome?

Answer 21

RA
Splenomegaly
Neutropenia

Question 22

Describe some of the changes seen in the hands of OA patient?

Answer 22

DIP swelling = Haberdens nodes
PIP swelling = Bouchards nodes
Squaring of base of thumb

Remember Haberdens sounds like heberdies -> far away -> DIP joints

Question 23

What drug management is used for OA?

What is important when giving patients analgesias?

What further lifestyle advice is given?

What other management can be used?

Answer 23

1. Oral paracetamol w/ topical NSAID/capsicum
2. Oral NSAID (remember PPI)
3. Oral opioids (co-codamol/codiene) - v rare

Take when you need but as little as often - try to limit reliance on drugs

Weight loss
Physio

Intra-articular steroid injections
Joint replacement

Question 24

Is psoriatic arthritis likely to present at the same time as psoriasis?

Answer 24

No - not in young and fit individuals

Question 25

Common side effect of hydroxychloroquine?

Answer 25

Retinopathy and corneal deposits

Question 26

How can RA present:

• ocularly
• dermatological
• respiratory
• renal
• cardiovascular

Answer 26

Ocular - Sjorgen's syndrome
Derm. - rheumatoid nodules
Resp - pulmonary fibrosis + rheumatoid nodules
Renal - chronic renal failure
Cardiovascular - pericarditis

Question 27

Describe how rheumatoid nodules would appear?

Answer 27

Hard
Painless
Often numerous

Question 28

RA is caused by a self response to synovial fluid produced by the synovial membrane in joints.
The synovial membrane covers the articular surfaces of the joints. T/F?

Answer 28

F - synovial membrane only extends from the margins of one articular surface to the next within the synovial cavity

See diagram in lower limb anatomy

Question 29

What is the radiological sign of psoriatic arthritis?

Answer 29

Pencil in cup

Question 30

What is a severe form of psoriatic arthritis presentation?

Answer 30

Arthritis mutilans - hands all muddled up and weird

Question 31

An inflammatory arthritis with dactylitis and DIP involvement?

Answer 31

Psoriatic arthritits

Dactylitis = digit swelling