Arthropathies

Question 1

What are the pathological stages of Rheumatoid arthritis

Answer 1

1. Autoimmune response to unknown antigen
   - recruitment of specific inflammatory cells to joint
2. Synovial tissue proliferation
   - becomes invasive
3. Pannus formation (thickened granulation tissue)
   - produces proteases + collagenases
4. Enzyme mediated erosion
   - starts with subchondral cartilate –> moves to articular
5. Joint instability

Question 2

What are the clinical features of Rheumatoid arthritis

Answer 2

• Tends to be a subacute/insidious onset

Tendons: tenosynovitis

• common early feature
• typically extensor tendon sheath of dorsum of hand

Joints

• swelling, tenderness, pain + stiffness
• Typically MCPs, wrists + MTPs

Rheumatoid nodules

• subcutaneous
• characteristically at elbows

Question 3

What is the diagnostic criteria for Rheumatoid Arthritis

Answer 3

4 out of the 7 features:

• 1. Morning stiffness
• 2. Arthritis of 3+ joint areas
• 3. Arthritis of hand joints
• 4. Symmetrical arthritis
• 5. Rheumatoid nodules
• 6. Serum rheumatoid factor
• 7. Radiographic changes

Question 4

What are the investigations for Rheumatoid Arthritis

Answer 4

• Inflammatory markers: CRP + ESR
• Rheumatoid factor: 70%, may not be present early on
• Anti-CCP: more specific than rheumatoid factor
• X-ray

Question 5

What is felty’s syndrome

Answer 5

Complication of Rheumatoid arthritis (10+ yrs)

Triad of features:

• Neutropenia
• Splenomegaly
• Extra-articular features: ulcers, vasculitis etc

Question 6

What is the management of Rheumatoid arthritis

Answer 6

1. Symptom relief: NSAIDs
2. Modification of disease: DMARDs esp methotrexate
3. Adjuvant steroids:
   - For systemic illness
   - While DMARDs are being initiated
   - For inflammation/vasculitis
4. Biologics
   - for disease remission
   - Anti-TNF alpha
   - Alongside methotrexate

Question 7

What is the pathological process of Osteoarthritis

Answer 7

1. Progressive cartilage damage + loss
2. Reactive bone hypertrophy (osteophytes)
3. Subchondral sclerosis + cyst formation

Question 8

What is the classification of Osteoarthritis

Answer 8

1. Primary/Idiopathic
2. Secondary
   - Trauma
   - Obesity (esp knees)
   - Congenital (e.g. hip dysplasia)
   - Complication of inflammatory/septic arthritis
   - Acromegaly
   - Haemophilia

Question 9

What are the clinical features of Osteoarthritis

Answer 9

1. Joint pain
   - insidious onset + stepwise progression
   - Usually larger joints
   - Variable symmetry
   - aggravated by activity, relieved by rest
2. Bone swellings (nodes)
   - Heberden’s (DIP)
   - Bouchard’s (PIP)

Question 10

What are the investigations for Osteoarthritis

Answer 10

X-ray: LOSS

• L: loss of joint space
• O: osteophytes
• S: subchondral sclerosis
• S: subchondral cysts

Negatives:

• Inflammatory markers
• RF, ANA + synovial aspirate

Question 11

What is the management of Osteoarthrtis

Answer 11

Goal is to relieve pain + maintain function

1. Conservative
   - Weight loss
   - Low impact exercise
   - soft collar for short term
2. Medical
   - NSAIDs
   - Steroids (intra-articular injections)
3. Surgical
   - Joint replacement
   - V. high success rate for hip + knee

Question 12

What is Gout

Answer 12

Synovitis due to crystal formation + deposition