Arthritis and soft tissue rheumatism

Question 1

What is generalised OA?

Answer 1

OA in three or more sites

Question 2

When is OA pain worse?

Answer 2

During activity, relieved by rest

usually morning stiffness lasting 30 mins

Question 3

What will you hear in an OA joint?

Answer 3

Crepitus

Question 4

Why is an OA joint enlarged?

Answer 4

Osteophytes

Question 5

OA joint distribution?

Answer 5

foot, knee, hip, cervical spine, lumbar spine, hand

Question 6

Which joints does OA affect in hand?

Answer 6

DIP, PIP, and 1st CMC joints

Question 7

Heberdens nodes

Answer 7

DIP

Question 8

Douchards nodes

Answer 8

PIP

Question 9

What might the thumb look like in OA?

Answer 9

Squared off

Question 10

What kind of cyst might you find in the knee in OA?

Answer 10

Bakers cyst

Question 11

Where might you feel OA hip pain?

Answer 11

may feel in groin
may radiate to knee
may feel in lower back

Question 12

Intra-articular pharmacological management of OA?

Answer 12

Steroids

Hyaluronic acid

Question 13

Surgical management of OA

Answer 13

Arthroscopic washout
Loose body
Soft tissue trimming
Joint replacement

Question 14

Which condition are urate crystals found in?

Answer 14

Gout

Question 15

Which type of crystals are found in gout?

Answer 15

Urate

Question 16

Birefringent in gout?

Answer 16

Negative

Question 17

How does the body respond to gout?

Answer 17

Acute inflammatory response with phagocytosis of crystals

Question 18

Psoriasis and hyperuricemia?

Answer 18

Psoriasis can cause hyperuricemia

Question 19

Which foods are high in purine?

Answer 19

Red meat
Seafood
Corn syrup

Question 20

Causes of reduced urate excretion

Answer 20

Chronic renal impairment
Volume depletion eg heart failure
Hypothyroidism
Diuretics
Cytotoxics eg cyclosporin

Question 21

Which cytotoxics can cause reduced urate excretion?

Answer 21

Ciclosporin

Question 22

Ciclosporin and renal function

Answer 22

Ciclosporin causes a reduced renal blood flow and glomerular filtration rate

Question 23

Causes of increased urate production

Answer 23

Inherited enzyme defects
Myeloproliferative/Lymphoproliferative disorders
Psoriasis
Haemolytic disorders
Alcohol (beer, spirits)
High dietary purine intake (red meat, seafood, corn syrup

Question 24

How would you treat hydroxyapatite?

Answer 24

NSAID
Intra-articular steroid injection
Physiotherapy
Partial or total arthroplasty

Question 25

Prophylactic treatment for gout and when you should start it

Answer 25

Allopurinol Febuxstat -Start 2-4 weeks after acute attack -Provide cover with NSAIDS etc

Question 26

Treatment for acute attacks of gout?

Answer 26

NSAIDs Allopurinol Colchicine Steroids

Question 27

Calcium pyrophosphate deposition disease

Answer 27

Commoner in elderly Chondrocalcinosis increases with age Related to osteoarthritis Affects fibrocartilage - knees, wrists, ankles Acute attacks related to shedding of calcium pyrophosphate crystals (pseudogout) Calcium pyrophosphate crystals-envelope shaped, mildly positively birefringent

Question 28

Inflammatory markers in CPPD

Answer 28

Raised inflammatory markers in CPPD

Question 29

Hydroxyapatite

Answer 29

“Milwaukee shoulder” Hydroxyapatite crystal deposition in or around the joint. Release of collagenases, serine proteinases and IL-1 Acute and rapid deterioration. Females, 50-60 years

Question 30

Which mediators are released in hydroxyapatite?

Answer 30

Collagenases Serine proteases IL-1

Question 31

CPDD crystal deposition disease associations

Answer 31

``` Hyperparathyroidism Familial hypocalciuric hypercalcemia Hemochromatosis Hemosiderosis Hypophosphatasia Hypomagnesia Hypothyroidism Gout Neuropathic joints Aging Amyloidosis Trauma ```

Question 32

Treatment for CPDD

Answer 32

NSAIDS Steroids Colchicine Rehydration

Question 33

Causes of pseudogout

Answer 33

``` Lack of fluid (dehydration). An attack of any severe illness. Overactivity of the parathyroid glands (hyperparathyroidism). Long-term use of steroid medicine. Underactive thyroid gland (hypothyroidism). Any cause of arthritis. Haemochromatosis Wilson's disease Acromegaly Kidney dialysis. Surgery or injury. Low magnesium level in the blood (hypomagnesaemia). ```

Question 34

Hydroxyapatite

Answer 34

Hydroxyapatite (HA) crystal deposition disease (HADD) is a well-recognized systemic disease of unknown etiology that is caused by para-articular and/or intra-articular deposition of HA crystals. The disease is clinically manifested by localized pain, swelling, and tenderness about the affected joint along with variable limitation of joint motion, although not all patients are symptomatic. Plain radiographs may show calcifications of varying size and shape in the para-articular tendons, bursae, and capsule. The disease may be mono- or polyarticular in distribution. The shoulder is most commonly involved with calcification in the supraspinatus tendon. When intra-articular, HA crystals can cause joint destruction. Any joint can be involved; the shoulder is most commonly affected, resulting in "Milwaukee shoulder." Treatment of HADD usually requires use of analgesics, local heat, needling with or without aspiration of the calcific deposits, steroid injections, and, at times, even surgery for relief of pain.

Question 35

Soft tissue rheumatism vs fibromyalgia

Answer 35

Pain should be confined to a specific site e.g. shoulder, wrist etc. More generalised soft tissue pain – consider fibromyalgia

Question 36

Some patients with reactive arthritis may suffer from a triad of symptoms (Reiters), what is the triad?

Answer 36

Urethritis Uveitis Arthritis

Question 37

Where does enteropathic arthritis affect?

Answer 37

Spine and peripheral joints

Question 38

Nail changes often seen in psoriatic arthritis

Answer 38

Pitting and oncholyitis (lifting of the nail from the nail bed)

Question 39

Common sites for enthesitis

Answer 39

``` Common sites for enthesitis are: at the top of the shin bone behind the heel (Achilles tendon) under the heel where the ribs join to the breast bone If your ribs are affected, you may experience chest pain, and you may find it difficult to expand your chest when breathing deeply. ```

Question 40

Dactylitis

Answer 40

Sausage digit

Question 41

Common first sign of scleroderma/systemic sclerosis

Answer 41

Swelling of the fingers

Question 42

Common enthsopathies in reactive seronegative autoimmune arthritis

Answer 42

- Plantar fasciitis | - Achilles insertional tendonitis

Question 43

Bamboo spine in which condition?

Answer 43

Ankylosing spondylitis

Question 44

Which kind of arthritis may someone with ankylosing spondylitis develop?

Answer 44

Knee or hip

Question 45

Conditions associated with ankylosing spondylitis

Answer 45

Associated conditions include aortitis, pulmonary fibrosis and amyloidosis.

Question 46

Treatment for ankylosing spondylitis

Answer 46

Treatment consists of physiotherapy, exercise, simple analgesia and DMARDs for more aggressive disease. Surgery is mainly reserved for hip and knee arthritis and kyphoplasty to straighten out the spine is controversial and carries considerable risk.