HD 5 - Clinico-pathology of musculoskeletal disorders Flashcards by Sasha Richardson

Name 2 inflammatory rheumatological diseases.

Rheumatoid arthritis
Psoriatic Arthritis
Enteropathic
Ankylosing spondylitis
Reactive Arthritis
Juvenile Idiopathic Arthritis
Gout

How well did you know this?

Not at all

Perfectly

Name 1 mechanical rheumatological disease.

Osteoarthritis
Back & Neck pain
Sports injuries

How well did you know this?

Not at all

Perfectly

Name 1 connective tissue disease rheumatological disease.

Sjogren’s syndrome
SLE
Scleroderma

How well did you know this?

Not at all

Perfectly

What joints does osteoarthritis affect?

Polyarthritis, affecting distal interproximal pharyngeal joints

How well did you know this?

Not at all

Perfectly

What happens to the finger movements in osteoarthririts?

Reduced finger flexion

How well did you know this?

Not at all

Perfectly

Define osteoarthritis.

Condition in which low-grade inflammation results in pain in the joints, caused by wearing of the cartilage that covers and acts as a cushion inside joints

Degenerative joint disease

How well did you know this?

Not at all

Perfectly

Why do people suffer pain with osteoarthritis?

As the bone surfaces become less well protected by cartilage, the patient experiences pain upon weight bearing, including walking and standing.

How well did you know this?

Not at all

Perfectly

What happens to muscles and ligaments if patient has osteoarthritis?

Due to decreased movement because of the pain, regional muscles may atrophy, and ligaments may become more slack.

How well did you know this?

Not at all

Perfectly

What are the symptoms of osteoarthritis?

Localised pain
Increased on weight-bearing
Advanced disease causes non-weight bearing/ nocturnal pain (probably through raised intraosseous pressure)
Night pain = cartilage worn away (no nerve fibres) & bone compressed (has nerves)
Short-lived/absent early morning stiffness (<30 mins)
May be asymptomatic

How well did you know this?

Not at all

Perfectly

What are the hand signs of osteroarthritis?

Heberden’s (DIP)/Bouchard’s (PIP) Nodes – bony swellings of distal and proximal interproximal pharyngeal joints
1st CMC squaring (carpometocarpal)
Generalised wasting

How well did you know this?

Not at all

Perfectly

What are the knee signs of osteroarthritis?

Quadriceps wasting – front thigh mucles
Crepitus
Cool effusion

How well did you know this?

Not at all

Perfectly

What are the hip signs of osteroarthritis?

Reduced rotation (internal)

Antalgic gait/Trendelenburg gait = pelvis tilting down on affected side of sore leg, therefore more pressure on opposite foot

How well did you know this?

Not at all

Perfectly

What radiographic changes are shown in osteoarthritis?

Sclerosis - whitening
Subchondral bone cysts
Joint space narrowing
Osteophytes - benign outgrowths of bone

How well did you know this?

Not at all

Perfectly

How many hip and knee replacements take place per year in uk due to osteosrthritis?

> 160,000

How well did you know this?

Not at all

Perfectly

How is osteoarthritis managed?

Pharmacological: Analgesics, NSAIDs, Coxibs with omeprazole, injections (steroid/hyaluronan)
Non-pharmacological: Quads exercises, weight loss if BMI >25, provision of aids/orthoses, education & support, glucosamine sulphate 1.5g od (+/- chondroitin)
Surgical: Total hip/knee replacements and Resurfacing (not done really anymore)

How well did you know this?

Not at all

Perfectly

What joints are affected in rheumatoid arthritis?

Polyarthritis: symmetrical = affects every synovial joint except distal inter-pharyngeal joints
Z thumb = enlargement over the joint

How well did you know this?

Not at all

Perfectly

What effect does rheumatoid arthritis have on hands?

Reduced finger flexion, difficulty holding a fork

How well did you know this?

Not at all

Perfectly

What are the typical features of rheumatoid arthritis according to ARA?

Symmetrical arthritis
Hand joints
At least 3 areas
Morning stiffness >60 minutes
Rheumatoid nodules
Serum rheumatoid factor (RF) = antibody which binds to Fc portion of an antibody = BINDS TO ITSELF
Radiographic changes

How well did you know this?

Not at all

Perfectly

On the EULAR/ACR criteria in 2010, how many points were needed to show rheumatoid arthritis?

6 or more

How well did you know this?

Not at all

Perfectly

What is the genetic susceptibility to rheumatoid arthritis?

Onset may be associated with HLA DR4
Severity predicted by presence of TNFa polymorphisms, HLA DR4 & RF/CCP
Twin studies show weak, variable effect
Hence environmental triggers likely

What are the early radiographic changes in rheumatoid arthritis?

Peri-articular osteoporosis – thinner blacker bone

Peri-articular erosions (action of synovitis on ‘bare area’ of bone)

What are the late radiographic changes in rheumatoid arthritis?

Joint space narrowing
Subluxation/dislocation
Ankylosis

What are the extra-articular manifestations of rheumatoid arthritis in the body?

Nodules = growth of abnormal tissue
Lymphadenopathy
Lung = Pleurisy /effusion/ fibrosis
Heart = pericarditis
Skin
Muscle = atrophy/ myositis
Bone = osteoporosis, also spine has moth eaten look so beware in dental chair 
Eye
Secondary Sjogren’s syndrome
Vasculitis

How is rheumatoid arthritis managed?

Education
Joint protection
Support
Painkillers
NSAIDs
DMARDs – disease modifying anti-rheumatic drugs which slows progression but cure
Surgery

What is the function of DMARDS?

Reduce symptoms of rheumatoid arthritis and prevent joint damage

What is the mechanism of action of DMARDs?

Slow action, not quick fix

What is a common technique used when DMARDs are prescribed?

Triple therapy, giving out 3 drugs at the same time

What are commonly and less commonly used DMARDs?

``` Commonly-used – TRIPLE THERAPY • Methotrexate • Sulphasalazine • Leflunomide • Hydroxychloroquine • Steroids - usually IA/IM/ rarely oral – can’t be used long term, but works well ``` ``` Less-commonly used • Myocrisin (gold) – injections • Minocycline • Cyclosporin • Azathioprine • Penicillamine ```

What combination drugs are used in rheumatoid arthritis treatment?

Methotrexate/ sulphasalazine/ hydroxychloroquine triple Methotrexate/leflunomide

Name a biologic used to treat rheumatoid arthritis?

Anti-TNF agents 1st ‘Biologic therapy’ = BIOLOGICS Infliximab (humanised anti-TNF mouse monoclonal ab) Etanercept (recombinant soluble anti-TNF receptor) Adalimumab (fully human anti-TNF monoclonal ab) Certolizumab (PEGylated anti-TNF) Golimumab (fully human anti-TNF monoclonal ab) Infection risk esp. dissemination/TB Anti CD20 monoclonal: Rituximab Anti CTLA-4 Ig: Abatacept Anti IL-6: Tocilizumab

Why does a dentist need to be aware if rheumatoid arthritic patient is on biologic therapy?

Look harder/more extensively – if pt on biologics less likely to notice symptoms of disease i.e. abscess

What joints are affected in ankylosing spondylitis?

Axial +/- oligoarthritis | ↓ spinal movement

What other conditions does ankylosing spondylitis affect in other parts of the body?

* Iritis & conjunctivitis * Pulmonary --> Upper lobe fibrosis/ Restrictive * Fatigue * Aortic valve disease

What treatment is used for ankylosing spondylitis?

* Daily exercises to maintain spinal mobility and posture, maintained with regular physiotherapy input * Education * Support * NSAIDs/coxibs * DMARDs: for peripheral arthritis * Anti-TNF drugs: for peripheral & spinal disease * Surgery - for spinal complications

What are the clinical features of ankylosing spondylitis?

* Gradual onset * Teens/twenties * Morning or nocturnal stiffness * Persistence (>6/52) * Improvement with exercise (e.g. worse at weekends) * Improvement with NSAIDs

What are the joints affected in psoriatic arthritis?

* Mono/Oligo/polyarthritis, Sparing/involving DIP (distal inter-proximal pharyngeal) * Axial: deformans

What is the moll and wright classification?

1) DIPJ only (DISTO INTERPHARYNGEAL JOINTS) 2) Arthritis mutilans 3) Clinically indistinguishable from RA 4) Asymmetrical oligoarthritis 5) Ankylosing spondylitis

What are the symptoms of psoriatic arthritis?

* More common in those with nail lesions * Dactylitis – inflammation of whole finger – sausage like fingers/toes * Iritis * Enthesitis = inflammation at ligament/tendon insertion * RF is usually negative

What is the treatment of psoriatic arthritis?

* Education * Support * Simple analgesia * NSAIDs/coxibs * DMARDs: Arthritis alone (sufasalazine), Arthritis and psoriasis (methotrexate/anti-TNF) * Surgery – only if very painful deforming joint

What joint does reactive arthritis affect mostly?

* Mono/oligoarthritis * Reduced ROM knee - Difficulty walking/ can’t go clubbing * Sterile synovitis * Typically, asymmetrical oligoarthritic (other patterns)

Who is mostly affected by reactive arthritis?

Young people

What infections can cause reactive arthritis? And how many days after does it start after the infection?

Onset peaks 10-14 days after a distant infection: Gastrointestinal (campylobacter, yersinia, salmonella) Urogenital (chlamydia) Causative infection not found in >50%

What is reiter's syndrome?

Reactive arthritis, plus: Conjunctivitis/ Urethritis May be associated with rash of hands & feet, histologically indistinguishable from psoriasis

What is the recurrance rate of reactive arthritis after treatment?

50%

What treatment is used for reiters and reactive arthritis?

usually self-limiting benefit from NSAIDs may require joint injection occasionally require DMARD therapy

What antibodies and factors are associated with sjogren's syndrome?

Anti-Ro (SS-A) & anti-La (SS-B) antibodies RF Hypergammaglobulinaemia

What is the ratio F:M of having sjogren's syndrome?

F:M, 9:1

What are the clinical features of sjogren's syndrome?

* Fatigue/malaise * Dry eyes * Xerostomia * Dyspareunia – pain during sex, due to dry mucous membranes * Arthralgia, arthritis * Raynaud’s phenomenon (with hyperviscosity) * Lung: interstitial lung disease * Renal: renal tubular acidosis

How is sjogren's syndrome managed?

Chronic incurable disease * Eye drops, ointments * Oral sprays, gels, lozenges * Vaginal lubricants * Steroids/immunosuppressants reserved for pneumonitis, glomerulonephritis, vasculitis (rare)