Clinical Aspects of Arthritis

Question 1

What are the 2 methods of joint examination, which follows which?

Answer 1

1) GALS - Gait, arms, legs and spine

2) REMS - Regional examination of the musculoskeletal system

Question 2

Why was GALS introduced?

Answer 2

It was found a lot of inpatients in hospital never had a MSK examination but the majority had MSK problems often affecting function. A minority also had MSK problems directly relating to their admission. Thus GALS was introduced as a screening tool

Question 3

Why was REMS introduced?

Answer 3

GALS is a screening examination but REMS is much more detailed and useful information if further examination is deemed necessary

Question 4

Problems with the hands can often be main features in arthritis, name 3 conditions causing arthritis which present characteristic hand deformities?

Answer 4

1) Osteoarthritis
2) Rheumatoid arthritis
3) Gout
4) Psoriatic arthritis

Question 5

What are the 4 main features of the hands of a patient with rheumatoid arthritis?

Answer 5

1) Ulnar deviation of fingers
2) Swan neck deformity (hyperextension of MIP joint and hyperflexion of DIP joint)
3) Rheumatoid nodules over bony prominences (cam be compressed)
4) Symmetrical deformities on both hands

Question 6

Why is it necessary to examine the elbows of a person with rheumatoid arthritis?

Answer 6

Get rheumatoid nodules over the elbows aswell

Question 7

Rheumatoid disease can also cause vasculitis too, give 4 presentations of that vasculitis?

Answer 7

1) Gangrene due to vasculitis of blood supply
2) Nail fold infarct
3) Rash caused by vasculitis
4) Venulitis (appears as spots on the skin)

Question 8

Is osteoarthritis an inherited condition?

Answer 8

Its is a familial condition

Question 9

What are the 3 main features of the hands of a patient with osteoarthritis?

Answer 9

1) Nodes at the ends of the fingers - these are bony hard swellings
2) Symmetrical deformities on both hands
3) Deformity spares the PIP joints and wrists (just affects MIP and DIP joints)

Question 10

What is osteoarthritis?

Answer 10

Disease of the synovial joints whereby there is slowly progressive destruction of the articular cartilage that affects the weight bearing joints and digits. As the articular cartilage wears away the bones then rub against eachother, causing pain and stiffness

Question 11

What are the 4 components of a synovial joint?

Answer 11

1) Joint capsule (strengthened by ligaments)
2) Synovial membrane (lines capsule, produces synovial fluid)
3) Synovial fluid (lubricates the joint, little is actually found in the cavity)
4) Hyaline (articular cartilage) - where the bones actually meet

Question 12

What are the 2 features of the radiological appearance of OA?

Answer 12

1) Bone spurs

2) Reduced joint space

Question 13

What is primary OA?

Answer 13

OA where no obvious pre-disposing cause is evident, also called wear and tear arthritis

Question 14

Mutation of what gene has been found in some cases of primary OA?

Answer 14

mutation of type 2 collagen gene

Question 15

How does the prevalence of primary OA change with age?

Answer 15

Increases with age (18-24 = 4% affected, 75-79 = 85% affected)

Question 16

Is primary OA more common in males or females?

Answer 16

Before 45 - more common in males

After 55 - more common in females

Question 17

What is secondary OA?

Answer 17

OA with a clear association with some predisposing condition which may be virtually any abnormality of the joint

Question 18

Which 5 conditions have been linked to secondary OA?

Answer 18

1) Congenital abnormal joint (slipped femoral epiphyses)
2) Trauma to a joint
3) Abnormal stresses on a joint (weight bearing demands of obesity, association with particular sports, occupations)
4) Previous inflammation
5) Neuropathic joints eg. DM

Question 19

What are the 3 prominent features of the hands of a patient with psoriatic arthritis?

Answer 19

1) Assymetrical deformity - one hand usually worse than another
2) Telescoping of the digits - appear shortened and if gently pulled can restore to full length, due to eating away of phalanges by the disease and called arthritis mutilans
3) Dactylitis - inflammation of isolated digits - can be toes or fingers

Question 20

What is the main cause of dactylitis?

Answer 20

Psoriatic arthritis

Question 21

Psoriatic arthritis is obviously associated with psoriasis, what are the 3 most common places to have psoriasis?

Answer 21

1) Elbows
2) Knees
3) Lower back

Question 22

What are the 2 forms of gout?

Answer 22

1) Acute gout: diagnosed and treated in general practice

2) Chronic tophaceous gout: harder to treat, seen in rheumatology

Question 23

How does chronic tophaceous gout appear?

Answer 23

Patient has large nodules on hands which can appear like rheumatoid nodules - contain a substance that looks like toothpaste - it is simply uric acid crystals which deposit around the joint

Question 24

Can chronic tophaceous gout be treated?

Answer 24

Yes - by lowering uric acid levels although it will take around 5 years for the nodules to disappear

Question 25

Aswell as the hands and elbows where can rheumatoid nodules commonly appear?

Answer 25

On the ankles - the Achilles tendon

Question 26

What is Still’s disease?

Answer 26

A severe version of juvenile idiopathic arthritis, with arthritis get rash (which tends to appear for a few hours in the evening) and splenomegaly

Question 27

Give 4 endocrine diseases which can cause arthritis?

Answer 27

1) Diabetes mellitus
2) Thyrotoxicosis
3) Acromegaly
4) Vit D deficiency - Ricketts (bowed knees develop arthritis)

Question 28

What is the prayer sign and why is it shown in people with DM?

Answer 28

Sign of arthritis - hands cant be pushed flat together, palm to palm (ie. this would be a positive prayer sign)
Due to glycosylation of the collagen in the hands due to DM

Question 29

What type of joint abnormality may appear in hypercholesterolaemia?

Answer 29

Xanthomatous nodules in the heels - cholesterol deposits in the joints

Question 30

What is ankylosing spondylitis?

Answer 30

Inflammation of the joints of the spine - if left untreated then the joints fuse

Question 31

Why was radiotherapy treatment for ankylosing spondylitis stopped even though it cured the joint deformity? 2

Answer 31

1) Skin cancer developed due to radiation
2) People who had received the treatment developed leukaemia around 20 years later as you were not only radiating the joints but also the bone marrow

Question 32

What is dermatomyositis?

Answer 32

Systemic onset disease - have skin complaint with inflammation of the muscles

Question 33

Which rash beneath the eyes is characteristic of dermatomyositis?

Answer 33

Heliotrope rash (purple colouring)

Question 34

What is the treatment for dermatomyositis?

Answer 34

Immunosuppressants and steroids

Question 35

Why is it often necessary to investigate for malignancy in patients with dermatomyositis?

Answer 35

It is a paraneoplastic condition

Question 36

Why could vitamin C deficiency (scurvy) lead to arthritis?

Answer 36

If have scurvy can get spontaneous bleeding into the skin and joints - this can lead to arthritis

Question 37

What is the genetic defect in Marfan’s syndrome?

Answer 37

Defect in fibrillin so have faulty collagen

Question 38

Give 6 clinical features of Marfan’s syndrome?

Answer 38

1) Hyper elastic skin
2) lens dislocation
3) Aortic dilatation
4) Arachnodactyly - long fingers
5) Long arms
6) Hypermobile joints

Question 39

What is pseudo gout and which joint does it affect?

Answer 39

Appears like a septic joint
Affects the wrist joint typically in older women
Crystals that are deposited are not uric acid but are calcium pyrophosphate

Question 40

Aswell as uric acid in gout and calcium pyrophosphate in pseudo gout, what other crystals can be deposited in joints, how does this usually present?

Answer 40

Calcium hydroxyapaptite - bilaterally swollen shoulders

Question 41

Vasculitis is often associated with arthritis, give 3 forms of vascultitis?

Answer 41

1) Lupus pernio (get with sarcoidosis - usually disfiguring rash affecting the face)
2) Erythema nodosum - due to sarcoidosis, the arthritis forms in the joints near the rash
3) Henoch-Schoenlein purpura - self limiting rash which commonly affects the buttocks

Question 42

As well as causing vasculitis, sarcoidosis can affect the internal organs, what condition does it cause in the lungs?

Answer 42

Pulmonary fibrosis