Clinical Aspects of Arthritis Flashcards
What are the 2 methods of joint examination, which follows which?
1) GALS - Gait, arms, legs and spine
2) REMS - Regional examination of the musculoskeletal system
Why was GALS introduced?
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
Why was REMS introduced?
GALS is a screening examination but REMS is much more detailed and useful information if further examination is deemed necessary
Problems with the hands can often be main features in arthritis, name 3 conditions causing arthritis which present characteristic hand deformities?
1) Osteoarthritis
2) Rheumatoid arthritis
3) Gout
4) Psoriatic arthritis
What are the 4 main features of the hands of a patient with rheumatoid arthritis?
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
Why is it necessary to examine the elbows of a person with rheumatoid arthritis?
Get rheumatoid nodules over the elbows aswell
Rheumatoid disease can also cause vasculitis too, give 4 presentations of that vasculitis?
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)
Is osteoarthritis an inherited condition?
Its is a familial condition
What are the 3 main features of the hands of a patient with osteoarthritis?
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)
What is osteoarthritis?
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
What are the 4 components of a synovial joint?
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
What are the 2 features of the radiological appearance of OA?
1) Bone spurs
2) Reduced joint space
What is primary OA?
OA where no obvious pre-disposing cause is evident, also called wear and tear arthritis
Mutation of what gene has been found in some cases of primary OA?
mutation of type 2 collagen gene
How does the prevalence of primary OA change with age?
Increases with age (18-24 = 4% affected, 75-79 = 85% affected)
Is primary OA more common in males or females?
Before 45 - more common in males
After 55 - more common in females
What is secondary OA?
OA with a clear association with some predisposing condition which may be virtually any abnormality of the joint
Which 5 conditions have been linked to secondary OA?
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
What are the 3 prominent features of the hands of a patient with psoriatic arthritis?
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
What is the main cause of dactylitis?
Psoriatic arthritis
Psoriatic arthritis is obviously associated with psoriasis, what are the 3 most common places to have psoriasis?
1) Elbows
2) Knees
3) Lower back
What are the 2 forms of gout?
1) Acute gout: diagnosed and treated in general practice
2) Chronic tophaceous gout: harder to treat, seen in rheumatology
How does chronic tophaceous gout appear?
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
Can chronic tophaceous gout be treated?
Yes - by lowering uric acid levels although it will take around 5 years for the nodules to disappear
Aswell as the hands and elbows where can rheumatoid nodules commonly appear?
On the ankles - the Achilles tendon
What is Still’s disease?
A severe version of juvenile idiopathic arthritis, with arthritis get rash (which tends to appear for a few hours in the evening) and splenomegaly
Give 4 endocrine diseases which can cause arthritis?
1) Diabetes mellitus
2) Thyrotoxicosis
3) Acromegaly
4) Vit D deficiency - Ricketts (bowed knees develop arthritis)
What is the prayer sign and why is it shown in people with DM?
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
What type of joint abnormality may appear in hypercholesterolaemia?
Xanthomatous nodules in the heels - cholesterol deposits in the joints
What is ankylosing spondylitis?
Inflammation of the joints of the spine - if left untreated then the joints fuse
Why was radiotherapy treatment for ankylosing spondylitis stopped even though it cured the joint deformity? 2
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
What is dermatomyositis?
Systemic onset disease - have skin complaint with inflammation of the muscles
Which rash beneath the eyes is characteristic of dermatomyositis?
Heliotrope rash (purple colouring)
What is the treatment for dermatomyositis?
Immunosuppressants and steroids
Why is it often necessary to investigate for malignancy in patients with dermatomyositis?
It is a paraneoplastic condition
Why could vitamin C deficiency (scurvy) lead to arthritis?
If have scurvy can get spontaneous bleeding into the skin and joints - this can lead to arthritis
What is the genetic defect in Marfan’s syndrome?
Defect in fibrillin so have faulty collagen
Give 6 clinical features of Marfan’s syndrome?
1) Hyper elastic skin
2) lens dislocation
3) Aortic dilatation
4) Arachnodactyly - long fingers
5) Long arms
6) Hypermobile joints
What is pseudo gout and which joint does it affect?
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
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?
Calcium hydroxyapaptite - bilaterally swollen shoulders
Vasculitis is often associated with arthritis, give 3 forms of vascultitis?
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
As well as causing vasculitis, sarcoidosis can affect the internal organs, what condition does it cause in the lungs?
Pulmonary fibrosis
