Arthritis/Rhuem - MSK Flashcards
1
Q
SEPTIC ARTHRITIS
A
- acute onset, sev pain, decreased ROM, usually monoarticular, usually large joint
- RFs = age, prosthetic joints, comorbidities or chronic disease
- mcc neonate = staph aureus and group B strep
- mcc 6m-2y = h.influenza
- mcc child = staph aureus and group B strep - mc source = otitis
- mcc adult = Neisseria gonorrhea -mc source <60yo = STD
- mcc RA pt = staph aureus
2
Q
Septic Arthritis - other causes
A
- viral: rubella, hepatitis
- fungus: immunocompromised pts
- mycobacterium: mc hip and knee, also thoracic spine (Pott’s Disease)
- Lyme’s Disease: tick transmits the bacteria Borrelia burgdorferi
- bite -> bull’s eye rash (erythema migrans) -> systemic dz (intermittent migratory episodes of polyarthritis, especially knee) -> cardiac and neurological manifestations
- dx = joint fluid analysis of needle aspiration, ELISA or Western-blot
- tx = adults doxycycline, child amoxicillin
3
Q
OSTEOARTHRITIS
A
- mc form of arthritis
- 2nd mc form of disability
- 70% of those >65yo have radiographic evidence of OA
- M=F, except >55yo there are more F affected
- wear and tear joint breakdown
- microscopic changes: chondrocyte hyper cellularity, cartilage breakdown (fissuring, pitting), osteophyte “spur” formation, synovitis -> inflammation, decreased proteoglycans, subchondral bone sclerosis (but no bony erosion), juxta-articular bone cysts
4
Q
OA types
A
- Primary = idiopathic
- main jts = knee, DIP (heberden’s nodes) + PIP (bouchard’s nodes) > MTP, CMC (especially 1st CMC), hip, spine/spondylosis with associated disc degenerative changes (especially Joints of Luschka or the superiolateral uncinate processes on the cervical vertebrae) = spondylosis, ACJ, 1st MTP
- Secondary = due to underlying cause
- chronic/acute trauma (overuse syndrome), connective tissue dz, endocrine, metabolic, infectious, neuropathic (Charcot arthritis)
- main jts = shoulder, elbow
5
Q
OA sxs
A
-dull aching pain worse with activity, better with rest
stiff joint < 30min
-gel phenomenon (temporary stiffness improves with a bit of ranging)
-joint “gives away”
-clunking, locking due to cartilage fragments
-crepitus and pain on ranging
-localized jt tenderness
-joint enlargement (synovitis, osteophytes and increased intraarticular fluid)
6
Q
OA XRay
A
- asymmetric joints involved (unilateral findings)
- asymmetric jt space narrowing: (knee more medial, hip more lateral)
- subchondral bony sclerosis
- osteophytes
- bony cysts
- loose bodies (cartilage fragments)
- no osteopenia (no bone “washout”)
7
Q
OA Tx
A
- weight loss
- PT/OT
- maintain or improve ROM
- assistive devices
- Joint Protection and Energy Conservation exercises
- Meds
- NSAIDs, tylenol
- opioids rare (tramadol best, esp for knee)
- intermittent intraarticular steroids (not PO)
- intraarticular hyaluronic acid (Synvisc, Hyalgan…)
8
Q
RHEUMATOID ARTHRITIS
A
- 1% of the population, F:M 2:1
- genetic – altered major histocompatability complex on chromosome 6’s HLA-DR4 allele
- systemic autoimmune joint breakdown due to attack on the synovium, typically in an insidious onset pattern
- microscopic changes: synoviocyte proliferation and hypertrophy, T-cell infiltrates, panus formation
- granulation tissue membrane destroys marginal cartilage and bone
- made of inflammatory cells, fibroblasts, small blood vessels
9
Q
RA types and Sxs
A
-Insidious Onset: mc form, ~70% of all RA; weeks to months
+ constitutionals; low grade fever without chills
-diffuse myalgia, initial symmetric joint involvement, morning stiffness > 1hr
-swollen, erythematous joints: MCP > PIP (DIPs are NOT involved in RA), carpals, ankle, MTP
-Intermediate Onset: ~20%; days to weeks
-Acute Onset, ~10%, several days, severe myalgia is prominent
10
Q
RA Dx
A
- at least 4 of the following 7
1. morning stiffness > 1h x6wks
2. perijoint edema in at least 3 jts at once x6wks
3. at least one of the above joints is in the wrist or hand x6wks
4. symmetric joint involvement x6wks
5. + rheumatoid nodules- subQ nodules over extensor surfaces or near joints
- serum Rheumatoid Factor (RF)
- Rheumatoid XR findings(namely symmetric joint space narrowing, marginal bony erosions and periarticular osteopenia)
- subQ nodules over extensor surfaces or near joints
11
Q
RA labs
A
- 85% of RA pts have + RF (don’t have to have + RF to have RA) + RF also in SLE, scleroderma, Sjogren’s
- increased acute phase reactants erythrocyte sedimentation rate and c-reactive protein (ESR and CRP)
- CBC: thrombocytosis, hypochromic microcytic anemia, eosinophilia
- synovial fluid analysis: low viscosity but cloudy, WBC 70% PMNs
12
Q
RA Joint Deformities
A
- Boutonniere Deformity: extensor tendons slip palmarly at the PIPs resulting in flexed PIPs and hyperextended MCPs and DIPs
- Swan Neck Deformity: contracture of flexor intrinsic hand muscles/tendons resulting in hyperextended PIPs and flexed MCPs and DIPs
- wrist radial deviation
- digit ulnar deviation
- shortened digits with retracted periarticular skin folds
- tenosynovitis, especially DeQuervain’s (+ Finklestein)
- anterior sublux of C1 on C2 : tenosynovitis/laxity/rupture of C1’s transverse ligament , C2’s odontoid or C1’s arch erosion , neck motion could cause sublux to pinch cord = cervical myelopathy
- hammer toes and claw toes
- ankle laxity can lead to tarsal tunnel syndrome
- shoulder, elbow, hip and knees can also be affected
13
Q
RA Tx
A
- PT for home exercise program and joint protection techniques, isometric strengthening, heat/cold modalities
- OT for orthotics to dec pain/inflam, reduce forces thru joints, stabilize and rest joint
- rheumatology referral
- surgical options of synovectomy, arthroplasty, tendon repairs/lengthening
- mild disease (no poor Px factors present): NSAIDs, salicylates, disease modifying antirheumatic drug (DMARDs) -> hydroxychloroquine, sulfasalazine, oral gold
- mod or severe disease (+ poor Px factors present): NSAIDs, salicylates, DMARDs -> IV or IM gold, weekly or daily or IV/IM methotrexate (MTX), corticosteroids, combinations of DMARDs
14
Q
JUVENILE RHEUMATOID ARTHRITIS
A
- mc form of childhood arthritis
- unknown etiology
- onset 6wks
- rule out others: rheumatic fever, infection, SLE, vasculitis
- Systemic (Still’s Dz): 1-6yo, M=F; near 100% neg RF
- persistent daily fever and rash with multisystem findings
- poly or oligoarthritis (few jts involved), growth delay, osteopenia/porosis, LAD, HSN (hepatosplenomegaly), pericarditis, pleuritis, anemia, leukocytosis, uveitis rare
- Polyarticular: >8yo, F»M, RF pos 10%, RF neg 90%
- trace systemic findings except growth retardation (early closure of epiphyseal plates), ≥5 jts involved
-Pauciarticular: knee mc, then ankle then wrist and elbows
-+ HLA-B27
i-f + antinuclear antibody (ANA) then iridiocyclitis (anterior uveitis) -> must refer to opthomalogy, slit lamp exam 4x qyr
15
Q
CRYSTAL-INDUCED SYNOVITIS
A
- Gout: monosodium and sodium urate crystals affect synovium
- Tx: NSAIDs, corticosteroids, Colchicine – stops phagocytosis of urate crystals, Allopurinol – dec urate synthesis, Probenecid – inc renal urate excretion,
- Pseudogout / Chondrocalcinosis
- calcium pyrophosphate dihydrate (CPPD) crystals affect cartilage
- Tx: NSAIDs, corticosteorids, ? colchicine
