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Rheumatology > General rheumatology > Flashcards

General rheumatology Flashcards

1
Q

What are the three types of joint?

A

Fibrous
Fibrocartilaginous
Synovial

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2
Q

What is a primary cartilaginous joint? Where are these found in the body?

A

A joint at which the bones are united by a plate of hyaline cartilage so that the joint is immovable and strong. These joints are temporary in nature because after a certain age the cartilaginous plate is replaced by the bone. Examples of this type of joint are between the epiphyses and diaphysis of a growing long bone, the costochondral joint and the first chondrosternal joint

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3
Q

What is a secondary cartilaginous joint? Where are these found in the body?

A

Known as “symphyses”. Fibrocartilaginous and hyaline joints, usually occurring in the midline.

Examples in human anatomy are the manubriosternal joint intervertebral discs, and the pubic symphysis

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4
Q

What is synovium?

A

Synovium is the lining of the joint capsule. It is a few cells thick and is vascular. Its surface is smooth and non-adnerent and is permeable to proteins and crystalloids. As there are no macroscopic gaps, it is able to retain normal joint fluid even under pressure. Tendon sheaths and bursae are also lined by synovium

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5
Q

What cells make up the synovium?

A

Macrophages and fibroblast-like synoviocytes

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6
Q

How is cell-to-cell interaction in the synovial layer mediated?

A

Cadherin-II (a transmembrane protein)

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7
Q

What is the tole of synoviocytes in the synovial layer?

A

They release hyaluronan fluid into the joint space which helps to retain fluid in the joint

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8
Q

What is synovial fluid?

A

A highly viscous fluid secreted by the synovial cells which has a similar consistency to plasma.

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9
Q

What is the part of a bone which directly contributes to the joint called?

A

the epiphyseal bone

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10
Q

What is the shaft of a bone called?

A

the metaphysis

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11
Q

Describe the structure of epiphyseal bone. What is the clinical significance of this?

A

Epiphyseal bone is highly vascular and comprises a light framework of mineralized collagen enclosed in a thin coating of tougher, cortical bone.

This is clinically important as the ability of this structre to sithstand pressure is low and it collapses and fractures when the normal intra-articular covering of hyaline cartilage is worn away as in osteoarthritis. Loss of hyaline cartilage also leads to the abnormalities of bone growth and remodelling typical of OA.

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12
Q

What is hyaline cartilage? Describe it’s structure

A

Hyaline cartilage forms the articular surface of joints. It is avascular and relies on diffusion from synovial fluid for its nutrition. It is rich in type II collagen that forms a meshwork enclosing giant macromolecular aggregates of proteoglycan.

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13
Q

What is the role of a ligament?

A

To stabilise a joint. They are variably elastic and this contributes to the stiffness or laxity of joints

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14
Q

What is the role of tendons?

A

Tendons are inelastic. They transmit muscle power to bones.

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15
Q

What is an enthesis?

A

The point where a tendon or ligament joints a bone. May be the site of inflammation

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16
Q

Describe the structure of collagen

A

Collagens consist of three polypeptide (alpha) chains wound into a triple helix. Every third polypeptide is glycine.

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17
Q

What is elastin?

A

An insoluble protein polymer, secreted as tropoelastin, which is the main component of elastic fibres

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18
Q

What is the function of proteoglycans?

A

They bind extracellular matrix together, retain solube molecules in the matrix and assist with cell binding

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19
Q

What is the difference between arthralgia and arthritis?

A

Arthralgia describes joint pain when the join appears normal on examination

Arthritis is the term used when there is objective evidence of oin inflammation (swelling, deformity or an effusion)

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20
Q

What are the likely causes of joint pain in young men?

A

Reactive arthritis

Ankylosing spondylitis

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21
Q

What are the likely causes of joint pain in young women?

A

Systemic lupus erythematosus
Rheumatoid arthritis
Sjogren’s syndrome

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22
Q

What are the likely causes of joint pain in young adults regardless sex?

A

Psoriatic arthropathy

Enteropathic Arthropathy

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23
Q

What are the likely causes of joint pain in middle-aged men?

A

Gout

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24
Q

What are the likely causes of joint pain in middle-aged women?

A

Rheumatoid arthritis

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25
Q

What are the likely causes of joint pain in middle-aged adults regardless sex?

A

Osteoarthritis

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26
Q

What are the likely causes of joint pain in elderly adults regardless sex?

A

Osteoarthritis
Polymyalgia rheumatica
Pseudogout

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27
Q

What are possible causes of joint pain at any age?

A 
Lyme disease
Endocarditis
Acute Hep. B infection
HIV
Parvovirus
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28
Q

What is the difference between an articular and a peri-articular problem?

A

An articular problem is pain arising from the joint itself. A periarticular problem is pain arising from the structures surrounding the joint

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29
Q

What is enthesitis?

A

Inflammation at the site of attachment of ligaments, tendons and joint capsules

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30
Q

What are causes of periarticular pain?

A

Enthesitis
Bursitis
Tendinitis

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31
Q

What are the cuases of a large-joint monoarthritis?

A 
Osteoarthritis
Gout
Psuedogout
Trauma
Septic arthritis
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32
Q

What is a common cause of acute, non-traumatic monoarthritis or oligoarthritis in young adults?

A

Disseminated gonorrhoea infection

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33
Q

What is the key investigation to carry out in the case of an acute, non-traumatic mono-arthritis?

A

Synovial fluid aspiration with gram stain and culture, and analysis for crystals in gout and pseudogout

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34
Q

How do you test for carpel tunnel syndrome?

A

Tinnel test
Pain in the fingers induced by percussion of the median nerve at the palmar wrist,

Phalen’s test- forced flexion of the wrist for 60s to test for carpal tunnel syndrome symptoms

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35
Q

What are the common findings on a simple blood test in rheumatoid arthritis?

A
  1. Evidence of a non-specific acute-phase response. I.e. raised inflammatory markers- ESR/CRP
  2. Normocytic, normochromic anaemia
  3. Thrombocytosis
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36
Q

What might be indicated by a hypochromic microcytic anaemia in a patient with RA?

A

Iron deficiency due to NSAID-induced GI bleeding

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37
Q

What might be indicated by a raised alkaline phosphatase?

A

Bony disease e.g. Paget’s disease, osteomalacia, bony metastases
Growing children

N.B. Alkaline phosphatase is also produced in the liver and placenta. Thus raised levels are also seen in cholestasis and pregnancy

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38
Q

At what titre does the disease specificity of autoantibodies increase?

A

> 1:160

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39
Q

How is measurement of auto-antibodies clinically useful? What are the drawbacks to measuring auto-antibodies?

A
  • They help establish a diagnosis in patients with clinical features suggestive of an autoimmune disease
  • They can sometimes be used to monitor disease activity and provide prognostic data e.g. seropositive RA (RF/anti-CCP positive RA) is associated with more erosive joint disease and extra-articular manifestations than seronegative RA
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40
Q

What is bone scintigraphy? What is it used for?

A

A tracer which, following IV injection, localises to sites of increased bone turnover and blood circulation. ‘Hot spots’ are non-specific and occur in osteomyelitis, septic arthritis, following surgery or trauma, malignancy and Paget’s disease. Should be used in combination with other imaging tests to confirm diagnosis

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41
Q

What is ultrasound used for?

A

Assessment of soft tissue and peri-articular changes such as hip joint effusion, Baker’s cyst, and inflamed/damaged tendons. Sometimes used to assess bone density (at the heel) as a screening procedure prior to dual energy X-ray absorptiometry (DXA)

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42
Q

What is DXA used for?

A

Measurement of bone mineral densitt in the diagnosis and monitoring of osteoporosis

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43
Q

What is arthroscopy?

A

A surgical procedure which uses a thin telescope with a light source (an arthroscope) to look inside joints. Particularly useful for visualizing the knee and shoulder joints. Biopsies can be taken, surgery performed in certain conditions (e.g. repair or trimming of meniscal tears) and loose bodies removed.

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44
Q

Why might a needle be inserted into a joint?

A
  1. Aspiration of fluid for disagnosis
  2. Aspiration of fluid to relieve pressure
  3. Injection of corticosteroid
  4. Injection of local anaesthetic
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45
Q

What are the most common indicators for joint aspiration?

A

Evaluation for sepsis in a single inflamed joint

Confirmation of gout or pseudogout by polarised light

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46
Q

What symptoms are caused by nerve root compression due to cervical disc prolapse or spondylotic osteophytes?

A

Unilateral neck pain radiating to interscapular and shoulder regions
Pins and needles and neurological signs in the arms

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47
Q

What are the possible causes of neck pain?

A

Cervical nerve root compression
RA
Ankylosing spondylitis
Fibromyalgia

48
Q

What is fibromyalgia?

A

Chronic widespread pain often in young women with no underlying cause; large psychological overlay in some patients

49
Q

What condition causes pain and stiffness in the shoulder girdle?

A

Polymyalgia rheumatica

50
Q

Which muscles make up the rotator cuff?

A

Supraspinatus
Infraspinatus
Subscapularis
Teres minor

51
Q

What is the main symptom of rotator cuff tendinitis and impingement?

A

A painful arc between 70° and 180°

52
Q

What causes prevention of active abduction of the shoulder through the first 90°?

A

Tears

53
Q

What is adhesive capsulitis of the shoulder?

A

Also known as frozen shoulder- Thickening and contraction of the glenohumeral joint capsule and formation of adhesions cause pain and loss of movement.

54
Q

What is tennis elbow?

A

Inflammation of the insertion site of the wrist extensor tendon into the lateral epicondyle

55
Q

What is golfer’s elbow?

A

Inflammation of the insertion site of the wrist flexor tendon into the medial epicondyle

56
Q

What are the symptoms of tennis/golfer’s elbow?

A

Local tenderness radiating to the forearm on using the affected muscles

57
Q

What are the symptoms of a fracture of the femoral neck?

A

Pain in the hip, usually after a fall
Leg shortened
Leg externally rotated

58
Q

What might cause pain over the trochanter which is worse going up stairs and when abducting the hip?

A

Trochanteric bursitis

Tear of the gluteus medius tendon at its insertion to the trochanter

59
Q

What is meralgia paraesthetica? What are the symptoms?

A

Lateral cutaneous nerve of the thigh compression

Causes numbness and increased sensitivity to light touch over the antero-lateral thigh

60
Q

What is haemarthrosis? What is a common site for this?

A

Bleeding into a joint. The knee is a common sight- torn menisci and cruciate ligaments may cause haemarthosis

61
Q

What causes patella tap on examination?

A

An effusion at the knee joint associated with inflammatory artritides, OA and psuedogout

62
Q

What happens if there is an effusion at the knee with a connection to a bursa? What is the complication of this?

A

There is formation of a cyst- Baker’s cyst- in the popliteal fossa. The main complication of this is rupture- ruptured Baker’s cyst- which allows escape of fluid into the soft tissue of the popliteal fossa and upper calf causing sudden and severe pain, swelling and tenderness.

63
Q

What is the main differential for a ruptured Baker’s cyst? How is the diagnosis confirmed?

A

Differential= DVT

Diagnosis is confirmed using ultrasound

64
Q

How is a ruptured Baker’s cyst treated?

A

Analgesia
Rest with the leg elevated
Aspiration
Injection of corticosteroids into the knee joint

65
Q

What are the common causes of lower back pain in 15-30 year olds?

A 
Mechanical
Prolapsed vertebral disc
Akylosing spondylitis
Spondylolisthesis
Malignancy- Hodgkin's
66
Q

What are the common causes of lower back pain in 30-50 year olds?

A

Mechanical
Prolapsed vertebral disc
Degenerative joint disease
Malignancy

67
Q

What are the common causes of lower back pain in 50+?

A 
Degenerative joint disease
Osteoporosis
Paget's disease
Malignancy
Myeloma
68
Q

What are the mechanical causes of lower back pain?

A 
Lumbar disc prolapse
Osteoarthritis
Fractures
Spondylolisthesis
Spinal stenosis
69
Q

What are the inflammatory causes of lower back pain?

A

Ankylosing spondylitis

Infection

70
Q

Whar are the serious causes of lower back pain?

A 
Metastases
Multiple myeloma
Tuberculosis osteomyelitis
Bacterial osteomyelitis
Spinal and root canal stenosis
71
Q

What features in the history and examination might indicate a mechanical cause of lower back pain?

A

Often sudden onset
Pain worse in the evening
Morning stiffness is absent
Exercise aggrevates pain

72
Q

What features in the history and examination might indicate a inflammatory cause of lower back pain?

A

Gradual onset
Pain worse in the morning- morning stiffness is present
Exercise relieves pain

73
Q

What features in the history and examination are the ‘red flags’ for a serious cause of lower back pain?

A 
Age 55
Constant or progressive pain
Nocturnal pain
Worse pain on being supine
Fever, night sweats, weight loss
History of malignancy
Abdominal mass
Thoracic back pain
Morning stiffness
Bilateral or alternating leg pain
Neurological disturbance (including sciatica)
Sphincter disturbance
Current or recent infection
Immunosupression e.g. steroids, HIV
Leg claudication or exercise related leg weakness/numbness (spinal stenosis)
Bladder, bowel or sexual function deficits; saddle anaesthesia= cauda equina
74
Q

When is further investigation not required in an adult presenting with back pain?

A

In young adults with a history suggestive of mechanical back pain and with no physical signs

75
Q

In which individuals with lower back pain is a full blood count, ESR and serum biochemistry required?

A

When pain is likely to be due to malignancy, infection or a metabolic cause

76
Q

What additional test should be done in a patient with lower back pain if secondary prostatic disease is suspected

A

Prostate-specific antigen

77
Q

When are spinal X-rays indicated in a patient suspected of having lower back pain?

A

If there are red flag symptoms and signs which indicate a high risk of more serious underlying problems

78
Q

How is mechanical back pain managed?

A

Analgesia
Brief rest
Physiotherapy
Exercise programs reduce risk of long-term problems

79
Q

What are the symptoms of prolapse of the intervertebral disc?

A

Sudden onset of severe back pain, often following a strenuous activity. Pain is often clearly related to position and is aggravated by movement. Muscle spasm leads to a sideways tilt when standing. Radiation of pain and clinical findings depend on the disc affected. May be radiation along the sciatic nerve supply (sciatica)

80
Q

What age group is more commonly affected by prolapse of the intervertebral disc?

A

younger people (age 20-40) because the disc degenerates with age and in elderly people is no longer capable of prolapse

81
Q

What is the likely cause of sciatica in older patients?

A

Compression of the nerve root by osteophytes in the lateral recess of the spinal canal

82
Q

What discs are most commonly affected by prolapse?

A

The lowest three discs (L4, L5, S1)

83
Q

How is prolapse of the intervertebral disc managed in the acute stage?

A

Bed rest on a firm mattress
Analgesia
Epidural corticosteroid injection in severe cases

84
Q

When is surgery considered in prolapse of the intervertebral disc?

A

For severe or increasing neurological impairment e.g. foot-drop or bladder symptoms

85
Q

Disc prolapse at what vertebral level causes sciatica?

A

S1

86
Q

At what level is spondylolisthesis most common?

A

L4/5

87
Q

What is spondylolisthesis?

A

Slipping forward of one vertebra on another due to a defect in the pars interarticularis of the vertebra. May be congenital or acquired e.g. trauma

88
Q

What are the symptoms of spondylolisthesis?

A

Mechanical pain which worsens throughout the day
Pain may radiate to one or other leg
May be signs of nerve root irritation

89
Q

How is spondylolisthesis treated?

A

Small spondylolisthesis, often associated with degenerative disease of the lumbar spine, may be treated conservatively with simple analgesics

A large spondylolisthesis causing severe symptoms should be treated with spinal fusion

90
Q

What is spinal stenosis?

A

Narrowing of the lower spinal canal, compressing the cauda equina and resulting in back and buttock pain typically coming on after a period of walking and easing with rest (therefore sometimes called spinal claudication)

91
Q

What causes spinal stenosis?

A

Disc prolapse
Degenerative osteophyte formation
Tumour
Congenital narrowing of the spinal canal

92
Q

How is spinal stenosis diagnosed and treated?

A

CT/MRI to demonstrate cord compression and treatment by surgical decompression

93
Q

Which cervical discs are most commonly affected by disc disease?

A

the three lowest discs

94
Q

What is an inflammatory arthritis?

A

An arthritic condition in which the predominant feature is synovial inflammation

95
Q

What are the common symptoms seen in inflammatory arthritides?

A

Joint pain
Stiffness after rest
Morning stiffness which may last several hours (compared to OA)
Blood test shows normochromic normocytic anaemia
Raised inflammatory markers- ESR and CRP

96
Q

What are the five cancers that can metastasise to the lungs?

A 
Thyroid
Renal
Lung
Breast
Prostate
97
Q

What is leg claudication indicative of?

A

Lumbar canal stenosis

98
Q

What is thoracic back pain indicative of?

A

Ank. spon.

99
Q

Why is back pain at night a red flag?

A

Rules out mechanical pain if pain is present when lying supine
Pain worse at night suggests ank. spon.

100
Q

In what conditions is Raynaud’s seen?

A

SLE
CREST
Polymyositis
Dermatomyositis

101
Q

What conditions present as a monoarthritis?

A

Septic arthritis
Crystal arthritis
Osteoarthritis
Trauma e.g. haemarthosis

102
Q

What conditions should be excluded in a monoarthritis?

A

Septic arthritis- it can destroy a joint in under 24 hours.

103
Q

In which patients might a septic arthritic joint be less inflamed?

A
  • Immunocompromised e.g. from the immunosuppressive drugs used in rheumatological conditions.
  • If there is underlying joint disease
104
Q

What conditions present as an oligoarthritis? (<5 joints involved)

A 
Crystal arthritis
Psoriatic arthritis
Reactive arthritis
Ankylosing spondylitis
Osteoarthritis
105
Q

What conditions present as a symmetrical polyarthritis? (>5 joints involved)

A

RA
OA
Viruses e.g. hep. A, B & C

106
Q

What conditions present as an asymmetrical polyarthritis?

A

Reactive arthritis

Psoriatic arthritis

107
Q

What conditions may present as either a symmetrical or an asymmetrical polyarthritis?

A

Systemic conditions: SLE, sarcoidosis, malignancy (e.g. leukaemia) sickle-cell anaemia

108
Q

Describe the appearance, white cell count, viscosity and neutrophil count in NORMAL synovial fluid

A

Appearance: clear, colourless/straw couloured
Viscosity: normal
WBC/mm3: ≤200
Neutrophils: none

109
Q

Describe the appearance, white cell count, viscosity and neutrophil count in OSTEOARTHRITIC synovial fluid

A

Appearance: clear, straw coloured
Viscosity: Increased
WBC/mm3: ≤1000
Neutrophils: ≤50%

110
Q

Describe the appearance, white cell count, viscosity and neutrophil count in HAEMORRHAGIC synovial fluid

A

Appearance: bloody; xanthochromic
Viscosity: Varies
WBC/mm3: ≤10,000
Neutrophils: ≤50%

111
Q

Describe the appearance, white cell count, viscosity and neutrophil count in ACUTELY INFLAMMED (RA/crystal/septic) synovial fluid

A 
Appearance: Turbid; yellow
Viscosity: Reduced
WBC/mm3: 
- RA: 1-50,000
- Crystal: 5-50,000
- Septic: 10-100,000
Neutrophils: varies in RA; approx. 80% in crystal/septic
112
Q

What conditions cause haemorrhagic synovial fluid?

A

Trauma
Tumor
Haemophilia

113
Q

What are the x-ray features of osteoarthritis?

A

LOSS

Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

114
Q

What are the x-ray features of RA?

A

Juxta-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space

115
Q

What are the x-ray features of gout?

A

Periarticular erosions
Normal joint space
Soft tissue swelling

Rheumatology (13 decks)

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