Arthritis and soft tissue rheumatism Flashcards
What is generalised OA?
OA in three or more sites
When is OA pain worse?
During activity, relieved by rest
usually morning stiffness lasting 30 mins
What will you hear in an OA joint?
Crepitus
Why is an OA joint enlarged?
Osteophytes
OA joint distribution?
foot, knee, hip, cervical spine, lumbar spine, hand
Which joints does OA affect in hand?
DIP, PIP, and 1st CMC joints
Heberdens nodes
DIP
Douchards nodes
PIP
What might the thumb look like in OA?
Squared off
What kind of cyst might you find in the knee in OA?
Bakers cyst
Where might you feel OA hip pain?
may feel in groin
may radiate to knee
may feel in lower back
Intra-articular pharmacological management of OA?
Steroids
Hyaluronic acid
Surgical management of OA
Arthroscopic washout
Loose body
Soft tissue trimming
Joint replacement
Which condition are urate crystals found in?
Gout
Which type of crystals are found in gout?
Urate
Birefringent in gout?
Negative
How does the body respond to gout?
Acute inflammatory response with phagocytosis of crystals
Psoriasis and hyperuricemia?
Psoriasis can cause hyperuricemia
Which foods are high in purine?
Red meat
Seafood
Corn syrup
Causes of reduced urate excretion
Chronic renal impairment Volume depletion eg heart failure Hypothyroidism Diuretics Cytotoxics eg cyclosporin
Which cytotoxics can cause reduced urate excretion?
Ciclosporin
Ciclosporin and renal function
Ciclosporin causes a reduced renal blood flow and glomerular filtration rate
Causes of increased urate production
Inherited enzyme defects
Myeloproliferative/Lymphoproliferative disorders
Psoriasis
Haemolytic disorders
Alcohol (beer, spirits)
High dietary purine intake (red meat, seafood, corn syrup
How would you treat hydroxyapatite?
NSAID
Intra-articular steroid injection
Physiotherapy
Partial or total arthroplasty
Prophylactic treatment for gout and when you should start it
Allopurinol
Febuxstat
-Start 2-4 weeks after acute attack
-Provide cover with NSAIDS etc
Treatment for acute attacks of gout?
NSAIDs
Allopurinol
Colchicine
Steroids
Calcium pyrophosphate deposition disease
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
Inflammatory markers in CPPD
Raised inflammatory markers in CPPD
Hydroxyapatite
“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
Which mediators are released in hydroxyapatite?
Collagenases
Serine proteases
IL-1
CPDD crystal deposition disease associations
Hyperparathyroidism Familial hypocalciuric hypercalcemia Hemochromatosis Hemosiderosis Hypophosphatasia Hypomagnesia Hypothyroidism Gout Neuropathic joints Aging Amyloidosis Trauma
Treatment for CPDD
NSAIDS
Steroids
Colchicine
Rehydration
Causes of pseudogout
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).
Hydroxyapatite
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.
Soft tissue rheumatism vs fibromyalgia
Pain should be confined to a specific site e.g. shoulder, wrist etc.
More generalised soft tissue pain – consider fibromyalgia
Some patients with reactive arthritis may suffer from a triad of symptoms (Reiters), what is the triad?
Urethritis
Uveitis
Arthritis
Where does enteropathic arthritis affect?
Spine and peripheral joints
Nail changes often seen in psoriatic arthritis
Pitting and oncholyitis (lifting of the nail from the nail bed)
Common sites for enthesitis
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.
Dactylitis
Sausage digit
Common first sign of scleroderma/systemic sclerosis
Swelling of the fingers
Common enthsopathies in reactive seronegative autoimmune arthritis
- Plantar fasciitis
- Achilles insertional tendonitis
Bamboo spine in which condition?
Ankylosing spondylitis
Which kind of arthritis may someone with ankylosing spondylitis develop?
Knee or hip
Conditions associated with ankylosing spondylitis
Associated conditions include aortitis, pulmonary fibrosis and amyloidosis.
Treatment for ankylosing spondylitis
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.
