Introduction to joint disease Flashcards
When does osteoporosis increase in prevalence?
as age increases - starts very early on in life, lots of intervention available
What group of people does osteoporosis primarily affect?
Women after the menopause (decrease in oestrogen)
*can also affect men
What fractures are most common in osteoporosis?
Hip, wrist and spine (hip fractures are main problem - high bed occupancy and mortality)
What is the thick outer shell of bone called?
cortex
What is the meshwork of bone inside cortex called?
trabecular bone
What happens to the trabecular bone in osteoporosis?
Becomes more holey and weaker
What builds new bone?
Osteoblasts
What breaks down old bone? (resorption)
Osteoclasts
What is Osteoporosis caused by?
Reduced osteoBLAST activity and increased osteoCLAST activity (bone is being broken down quicker than its being remodelled )
What peak bone mass do patients with osteoporosis have?
low peak bone mass between 25 and 40 yrs and then 1% lost per year
What is the WHO definition for osteoporosis?
osteoporosis is a generalized skeletal disorder of low bone mass (thinning of the bone) and deterioration in its architecture, causing susceptibility to fracture.
How long does it take for bone to be remodelled?
100 days
What is bone turnover influenced by?
Hormones (oestrogen/testosterone), cytokines and prostaglandins
What are the phases in bone remodelling?
Resorption Reversal Phase Formation Resting Phase Activation
What are the signs and symptoms of osteoporosis?
- Fracture (usually first presentation)
- Reduced bone density on DXA scan
- Pain
- Reduced mobility
- Kyphosis - in vertebral fractures, curving of the spine
- Reduction in height
What are the problems that come with vertebral fractures?
- can result in height reduction of 10-20cm
- often undiagnosed
- can cause problems with indigestion, neck weakness, back pain, loss of mobility
How is Bone Mass Density determined?
by DEXA scan
When do you have peak bone mass?
Between 25 and 40 yrs and then Post maturity bone loss of 0.5-1% / year
What do women in menopause have regarding bone mass?
Accelerated bone loss around menopause due to loss of protective effect of oestrogens - important to have a diet rich in calcium and vitamin D
When are DXA scans used?
Only for high risk patients / those with established OP
What do DXA scans measure?
Usually measures bone density at hip/lower spine to get a “T score”
What T score indicated Osteoporosis?
Less than or equal to -2.5
What can portable DXA scanners scan?
ankle - not as reliable
What are the risks factors for OP?
- History of fracture (and/or in 1st degree relative)
- Smoking
- Low body weight (bone density is reduced)
- Female
- Oestrogen deficiency
- Corticosteroid use (prednisolone ≥ 7.5mg daily for 3/12 or more)
- White race
- Increase age
- Low calcium intake
- Excess alcohol
- Lack of exercise
- Recurrent falls
- Dementia
- Impaired eyesight
- Poor health/fraility - especially RA, renal disease, liver disease, IBD
What is included in the primary prevention of OP?
Lifestyle changes:
- Adequate Ca and Vit D
- Weight bearing exercise
- Reduced alcohol intake
- Stop smoking
- Reduce risk of falls esp in elderly
What is included in the secondary prevention of OP?
Pharmacological management: - Calcium - Vit D - Calcitriol - HRT - SERMS - Bisphosphonates - Calcitonin - Strontium - PTH - Denosumab In addition to lifestyle changes
What is Osteoarthritis?
Disease of wear and tear - usually limited to one or two joints (differs from rheumatoid arthritis)
What groups of people are affected by Osteoarthritis?
- Over 65s
- Onset most common at 40-60 yrs
- More common in women
- Common in obesity
What are the clinical features of OA?
- Joint pain, worsened on movement and at end of day
- May be accompanied by swelling
- Most common in knee, hands, lumbar & cervical spine
- EMS (early morning stiffness) up to 30 mins
What happens in OA (pathogenesis)?
- Cartilage gradually roughens and becomes thin
- Thickening of underlying bone
- Formation of osteophytes
- Thickening & inflammation of synovium
- Thickening and contraction of ligament
Some joints repair themselves, others don’t
What is the difference between a normal joint and a joint with mild OA?
- Normal: bone and cartilage protecting bone, meniscus is extra protection. Synovium is membrane
- Mild OA: bone underneath becomes thicker and starts to wear away cartilage. Inflammation occurs
What happens to a joint with severe OA?
Bone can touch opposing bone and is very painful, needs joint replacement
What are the goals for management of OA?
- Reduce pain
- Optimise mobility (encourage weight loss and exercise)
- Minimise joint deformity
- Patient education
- Multidisciplinary approach
What non-pharmacological management is there for OA?
- Weight reduction
- Physiotherapy
- Exercise plan
- Heat or cold packs
- Occupational therapy review
- Psychological support
- Surgery
What is some pharmacological management for OA?
- Simple analgesics
- NSAIDs – only if inflammation present
- Corticosteroids – not oral, only injections
- Chondroprotective agents
What is Rheumatoid arthritis?
- Systemic condition that can affect many joints in many ages
- Onset most common at 30-50 yrs
- Reduced life expectancy
- Female:Male = 3:1
What are the clinical features of RA?
- Slow progressive symmetrical polyarthritis
- Pain & stiffness in small joints of hands & feet
- Involvement of wrists, shoulders, elbows, knees & ankles
- Early morning stiffness (EMS) – can progress throughout the day
- Pain tends to decrease as day progresses
What are the Extra-articular symptoms of RA?
- Sjorgen’s syndrome – drying of secretions e.g. dry eyes/mouth
- Vasculitis – inflammatory condition of blood vessels
- Neuropathy
- Subcutaneous nodules
- Lymphadenopathy
- Cardiovascular disease
- Depression
- Respiratory disease
What is the pathogenesis of RA?
- Lymphocytes infiltrate synovial membrane, causing inflammation & thickening
- Formation of pannus over cartilage causes erosion into bone
- Eventual degeneration of cartilage & joint
What are the goals of management for RA?
- Relief of pain & inflammation
- Prevention of joint damage
- Preservation/improvement of functional ability
- Maintenance of lifestyle
- Multidisciplinary approach
What is the pharmacological management of RA?
- Analgesics
- NSAIDs
- Conventional DMARDs – methotrexate, sulfasalazine
- Biological DMARDs – injection, much better at managing condition
- Steroids
