General rheumatology Flashcards
What are the three types of joint?
Fibrous
Fibrocartilaginous
Synovial
What is a primary cartilaginous joint? Where are these found in the body?
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
What is a secondary cartilaginous joint? Where are these found in the body?
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
What is synovium?
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
What cells make up the synovium?
Macrophages and fibroblast-like synoviocytes
How is cell-to-cell interaction in the synovial layer mediated?
Cadherin-II (a transmembrane protein)
What is the tole of synoviocytes in the synovial layer?
They release hyaluronan fluid into the joint space which helps to retain fluid in the joint
What is synovial fluid?
A highly viscous fluid secreted by the synovial cells which has a similar consistency to plasma.
What is the part of a bone which directly contributes to the joint called?
the epiphyseal bone
What is the shaft of a bone called?
the metaphysis
Describe the structure of epiphyseal bone. What is the clinical significance of this?
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.
What is hyaline cartilage? Describe it’s structure
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.
What is the role of a ligament?
To stabilise a joint. They are variably elastic and this contributes to the stiffness or laxity of joints
What is the role of tendons?
Tendons are inelastic. They transmit muscle power to bones.
What is an enthesis?
The point where a tendon or ligament joints a bone. May be the site of inflammation
Describe the structure of collagen
Collagens consist of three polypeptide (alpha) chains wound into a triple helix. Every third polypeptide is glycine.
What is elastin?
An insoluble protein polymer, secreted as tropoelastin, which is the main component of elastic fibres
What is the function of proteoglycans?
They bind extracellular matrix together, retain solube molecules in the matrix and assist with cell binding
What is the difference between arthralgia and arthritis?
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)
What are the likely causes of joint pain in young men?
Reactive arthritis
Ankylosing spondylitis
What are the likely causes of joint pain in young women?
Systemic lupus erythematosus
Rheumatoid arthritis
Sjogren’s syndrome
What are the likely causes of joint pain in young adults regardless sex?
Psoriatic arthropathy
Enteropathic Arthropathy
What are the likely causes of joint pain in middle-aged men?
Gout
What are the likely causes of joint pain in middle-aged women?
Rheumatoid arthritis
What are the likely causes of joint pain in middle-aged adults regardless sex?
Osteoarthritis
What are the likely causes of joint pain in elderly adults regardless sex?
Osteoarthritis
Polymyalgia rheumatica
Pseudogout
What are possible causes of joint pain at any age?
Lyme disease Endocarditis Acute Hep. B infection HIV Parvovirus
What is the difference between an articular and a peri-articular problem?
An articular problem is pain arising from the joint itself. A periarticular problem is pain arising from the structures surrounding the joint
What is enthesitis?
Inflammation at the site of attachment of ligaments, tendons and joint capsules
What are causes of periarticular pain?
Enthesitis
Bursitis
Tendinitis
What are the cuases of a large-joint monoarthritis?
Osteoarthritis Gout Psuedogout Trauma Septic arthritis
What is a common cause of acute, non-traumatic monoarthritis or oligoarthritis in young adults?
Disseminated gonorrhoea infection
What is the key investigation to carry out in the case of an acute, non-traumatic mono-arthritis?
Synovial fluid aspiration with gram stain and culture, and analysis for crystals in gout and pseudogout
How do you test for carpel tunnel syndrome?
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
What are the common findings on a simple blood test in rheumatoid arthritis?
- Evidence of a non-specific acute-phase response. I.e. raised inflammatory markers- ESR/CRP
- Normocytic, normochromic anaemia
- Thrombocytosis
What might be indicated by a hypochromic microcytic anaemia in a patient with RA?
Iron deficiency due to NSAID-induced GI bleeding
What might be indicated by a raised alkaline phosphatase?
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
At what titre does the disease specificity of autoantibodies increase?
> 1:160
How is measurement of auto-antibodies clinically useful? What are the drawbacks to measuring auto-antibodies?
- 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
What is bone scintigraphy? What is it used for?
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
What is ultrasound used for?
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)
What is DXA used for?
Measurement of bone mineral densitt in the diagnosis and monitoring of osteoporosis
What is arthroscopy?
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.
Why might a needle be inserted into a joint?
- Aspiration of fluid for disagnosis
- Aspiration of fluid to relieve pressure
- Injection of corticosteroid
- Injection of local anaesthetic
What are the most common indicators for joint aspiration?
Evaluation for sepsis in a single inflamed joint
Confirmation of gout or pseudogout by polarised light
What symptoms are caused by nerve root compression due to cervical disc prolapse or spondylotic osteophytes?
Unilateral neck pain radiating to interscapular and shoulder regions
Pins and needles and neurological signs in the arms
What are the possible causes of neck pain?
Cervical nerve root compression
RA
Ankylosing spondylitis
Fibromyalgia
What is fibromyalgia?
Chronic widespread pain often in young women with no underlying cause; large psychological overlay in some patients
What condition causes pain and stiffness in the shoulder girdle?
Polymyalgia rheumatica
Which muscles make up the rotator cuff?
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
What is the main symptom of rotator cuff tendinitis and impingement?
A painful arc between 70° and 180°
What causes prevention of active abduction of the shoulder through the first 90°?
Tears
What is adhesive capsulitis of the shoulder?
Also known as frozen shoulder- Thickening and contraction of the glenohumeral joint capsule and formation of adhesions cause pain and loss of movement.
What is tennis elbow?
Inflammation of the insertion site of the wrist extensor tendon into the lateral epicondyle
What is golfer’s elbow?
Inflammation of the insertion site of the wrist flexor tendon into the medial epicondyle
What are the symptoms of tennis/golfer’s elbow?
Local tenderness radiating to the forearm on using the affected muscles
What are the symptoms of a fracture of the femoral neck?
Pain in the hip, usually after a fall
Leg shortened
Leg externally rotated
What might cause pain over the trochanter which is worse going up stairs and when abducting the hip?
Trochanteric bursitis
Tear of the gluteus medius tendon at its insertion to the trochanter
What is meralgia paraesthetica? What are the symptoms?
Lateral cutaneous nerve of the thigh compression
Causes numbness and increased sensitivity to light touch over the antero-lateral thigh
What is haemarthrosis? What is a common site for this?
Bleeding into a joint. The knee is a common sight- torn menisci and cruciate ligaments may cause haemarthosis
What causes patella tap on examination?
An effusion at the knee joint associated with inflammatory artritides, OA and psuedogout
What happens if there is an effusion at the knee with a connection to a bursa? What is the complication of this?
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.
What is the main differential for a ruptured Baker’s cyst? How is the diagnosis confirmed?
Differential= DVT
Diagnosis is confirmed using ultrasound
How is a ruptured Baker’s cyst treated?
Analgesia
Rest with the leg elevated
Aspiration
Injection of corticosteroids into the knee joint
What are the common causes of lower back pain in 15-30 year olds?
Mechanical Prolapsed vertebral disc Akylosing spondylitis Spondylolisthesis Malignancy- Hodgkin's
What are the common causes of lower back pain in 30-50 year olds?
Mechanical
Prolapsed vertebral disc
Degenerative joint disease
Malignancy
What are the common causes of lower back pain in 50+?
Degenerative joint disease Osteoporosis Paget's disease Malignancy Myeloma
What are the mechanical causes of lower back pain?
Lumbar disc prolapse Osteoarthritis Fractures Spondylolisthesis Spinal stenosis
What are the inflammatory causes of lower back pain?
Ankylosing spondylitis
Infection
Whar are the serious causes of lower back pain?
Metastases Multiple myeloma Tuberculosis osteomyelitis Bacterial osteomyelitis Spinal and root canal stenosis
What features in the history and examination might indicate a mechanical cause of lower back pain?
Often sudden onset
Pain worse in the evening
Morning stiffness is absent
Exercise aggrevates pain
What features in the history and examination might indicate a inflammatory cause of lower back pain?
Gradual onset
Pain worse in the morning- morning stiffness is present
Exercise relieves pain
What features in the history and examination are the ‘red flags’ for a serious cause of lower back pain?
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
When is further investigation not required in an adult presenting with back pain?
In young adults with a history suggestive of mechanical back pain and with no physical signs
In which individuals with lower back pain is a full blood count, ESR and serum biochemistry required?
When pain is likely to be due to malignancy, infection or a metabolic cause
What additional test should be done in a patient with lower back pain if secondary prostatic disease is suspected
Prostate-specific antigen
When are spinal X-rays indicated in a patient suspected of having lower back pain?
If there are red flag symptoms and signs which indicate a high risk of more serious underlying problems
How is mechanical back pain managed?
Analgesia
Brief rest
Physiotherapy
Exercise programs reduce risk of long-term problems
What are the symptoms of prolapse of the intervertebral disc?
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)
What age group is more commonly affected by prolapse of the intervertebral disc?
younger people (age 20-40) because the disc degenerates with age and in elderly people is no longer capable of prolapse
What is the likely cause of sciatica in older patients?
Compression of the nerve root by osteophytes in the lateral recess of the spinal canal
What discs are most commonly affected by prolapse?
The lowest three discs (L4, L5, S1)
How is prolapse of the intervertebral disc managed in the acute stage?
Bed rest on a firm mattress
Analgesia
Epidural corticosteroid injection in severe cases
When is surgery considered in prolapse of the intervertebral disc?
For severe or increasing neurological impairment e.g. foot-drop or bladder symptoms
Disc prolapse at what vertebral level causes sciatica?
S1
At what level is spondylolisthesis most common?
L4/5
What is spondylolisthesis?
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
What are the symptoms of spondylolisthesis?
Mechanical pain which worsens throughout the day
Pain may radiate to one or other leg
May be signs of nerve root irritation
How is spondylolisthesis treated?
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
What is spinal stenosis?
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)
What causes spinal stenosis?
Disc prolapse
Degenerative osteophyte formation
Tumour
Congenital narrowing of the spinal canal
How is spinal stenosis diagnosed and treated?
CT/MRI to demonstrate cord compression and treatment by surgical decompression
Which cervical discs are most commonly affected by disc disease?
the three lowest discs
What is an inflammatory arthritis?
An arthritic condition in which the predominant feature is synovial inflammation
What are the common symptoms seen in inflammatory arthritides?
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
What are the five cancers that can metastasise to the lungs?
Thyroid Renal Lung Breast Prostate
What is leg claudication indicative of?
Lumbar canal stenosis
What is thoracic back pain indicative of?
Ank. spon.
Why is back pain at night a red flag?
Rules out mechanical pain if pain is present when lying supine
Pain worse at night suggests ank. spon.
In what conditions is Raynaud’s seen?
SLE
CREST
Polymyositis
Dermatomyositis
What conditions present as a monoarthritis?
Septic arthritis
Crystal arthritis
Osteoarthritis
Trauma e.g. haemarthosis
What conditions should be excluded in a monoarthritis?
Septic arthritis- it can destroy a joint in under 24 hours.
In which patients might a septic arthritic joint be less inflamed?
- Immunocompromised e.g. from the immunosuppressive drugs used in rheumatological conditions.
- If there is underlying joint disease
What conditions present as an oligoarthritis? (<5 joints involved)
Crystal arthritis Psoriatic arthritis Reactive arthritis Ankylosing spondylitis Osteoarthritis
What conditions present as a symmetrical polyarthritis? (>5 joints involved)
RA
OA
Viruses e.g. hep. A, B & C
What conditions present as an asymmetrical polyarthritis?
Reactive arthritis
Psoriatic arthritis
What conditions may present as either a symmetrical or an asymmetrical polyarthritis?
Systemic conditions: SLE, sarcoidosis, malignancy (e.g. leukaemia) sickle-cell anaemia
Describe the appearance, white cell count, viscosity and neutrophil count in NORMAL synovial fluid
Appearance: clear, colourless/straw couloured
Viscosity: normal
WBC/mm3: ≤200
Neutrophils: none
Describe the appearance, white cell count, viscosity and neutrophil count in OSTEOARTHRITIC synovial fluid
Appearance: clear, straw coloured
Viscosity: Increased
WBC/mm3: ≤1000
Neutrophils: ≤50%
Describe the appearance, white cell count, viscosity and neutrophil count in HAEMORRHAGIC synovial fluid
Appearance: bloody; xanthochromic
Viscosity: Varies
WBC/mm3: ≤10,000
Neutrophils: ≤50%
Describe the appearance, white cell count, viscosity and neutrophil count in ACUTELY INFLAMMED (RA/crystal/septic) synovial fluid
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
What conditions cause haemorrhagic synovial fluid?
Trauma
Tumor
Haemophilia
What are the x-ray features of osteoarthritis?
LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
What are the x-ray features of RA?
Juxta-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space
What are the x-ray features of gout?
Periarticular erosions
Normal joint space
Soft tissue swelling
