Joints Flashcards
Define arthritis
Arthritis – literally inflammation of the joint
2 types of arthritis
Inflammatory
e.g. RA
SLE
Psoriatic arthritis
Non – inflammatory (degenerative)
e.g. OA
Classify the inflammatory arthritis
Seropositive (RA, lupus, scleroderma, sjorgens, vasculitis)
Seronegative (ankylosing spondyliis, psoriatic arthritis, reactive arthritis. inflammatory bowel disease arthritis)
Infectious (septic arthritis)
Crystal induced (gout, pseudogout)
Who is RA more common in
3 x more common in women than in men.
Peak age - 40s but can occur in people of all ages.
Which is more common OA, or RA
OA
Who does OA affect
Mainly elderly
Women slightly more common than men
Screening questions for MSK
Do you suffer from any pain or stiffness in your arms, legs, neck or back?
Do you have any difficulty with washing or dressing?
Do you have any difficulty with stairs or steps?
Be careful with the terms ‘stiffness’ and ‘weakness’ and ‘pain’ used when the patient really means ‘pins and needles
HPC for MSK
- Pain
- Chronology, sudden onset / gradual, recurrent?
- Relationship to trauma / exercise?
Ask specifically about…
Joint pain, stiffness, swelling, bone pain, muscle weakness
Knee – locking, giving way, grinding, clicking
Morning stiffness – (OA <1 hour, RA hours)
Associated symptoms (rash, red eye (iritis), urethritis – reactive arthritis)
History for MSK
Family history
PMH (other autoimmune diseases, psoriasis, other infections)
DH - what have they tried so far
SH – impact on life, describe a typical day, what have they had to give up?
What is OA
- What kind of process
- What joints does it affect
- Symmetrical?
- Deformity?
- Morning stiffness?
Not osteoporosis…
Degenerative process
Mainly large weight bearing joints (back, knee, hip, ankle, hands) and DIP
Asymmetrical
Usually less deformity
Morning stiffness < 1 hour
What is RA
- What kind of process
- What joints does it affect
- Symmetrical?
- Deformity?
- Morning stiffness?
Autoimmune process
Mainly small joints of hand
PIP (not DIP), MCP, wrists elbows, neck
(But also hips and knees and ankles)
Symmetrical
Gross deformity
Tendon rupture
Morning stiffness
> 1 hour
What type of arthritis is psoriatic arthropathy
Which condition is the distribution similar to, but how is it different
Seronegative inflammatory arthritis (RhF and ACCP –ve)
Similar to RA in distribution – EXCEPT
Initial oligoarticular involvement
DIP joints
Marked dactylitis
sacroiliitis
How does GALS work to illicit symptoms
Mainly testing the joint where the capsule is tightest and symptoms are more likely to occur
Can help to differentiate between OA and RA
Arms in GALS?
Hands behind head with elbows back
Supination and pronation of elbow
‘Squeeze my fingers’
Opposition of thumb and fingers (tip of thumb to tip of fingers)
Squeeze metacarpal joints
Legs in in GALS?
Hand over the knee to feel for crepitus
Internal rotation of hip (foot moves externally)
Ankle flex / extend - tibiotalar joint affected in OA
Supination of foot – subtalar joint affected in RA
Spine in GALS
Lateral flexion of cervical spine (mid cervical region, first movement affected in OA cervical spondylosis)
Bending forward - need to ensure the movement does not come from the hips
Gait in GALS
Antalgic gait Spastic gait (circumduction) Foot drop gait (high stepping) Parkinsonian gait Trendelenburg gait
Clinical features of RA hands
Ulnar deviation
Subluxation at MCP joints
Rheumatoid nodules
(bony erosions on xray)
Clinical features of OA hands
1 – Heberden’s nodes (DIP)
2 – Bouchard’s nodes (PIP)
Boutonnieres deformity description
Hyperextension at DIP
Flexion deformity at PIP
Swan neck deformity
Flexion deformity of DIP
Hyperextension of PIP
Z shaped thumbs describe
Hyperextension of the interphalangeal joint
Fixed flexion and subluxation of the metacarpophalangeal joint.
What happens in RA to the synovial membrane
Swollen inflamed synovial membrane
What is genu varum and genu valgus
Genu varum - bowlegs
Genu valgus – knock knees
Investigations for joint pain
- Blood tests (anaemia,↑WBC, uric acid, CRP, ESR)
Rheumatoid factor
Anti cyclic citrullinated peptide (anti CCP)
(Present in only about 70% RA) - Imaging
MRI knees and back - Synovial fluid analysis (septic arthritis, gout)
- Arthroscopy
Management of osteoarthritis
Exercise Physical therapy Weight loss TENS Orthotics and walking aids Analgesia (simple analgesia and topical NSAIDs before oral NSAIDs and opioids) Consider surgical referral
Management of rheumatoid arthritis (pharmacological and supportive)
RA:
Analgesia (as in OA, simple analgesia first)
Steroids
DMARDS (disease modifying anti-rheumatic drugs e.g. methotrexate, sulphasalazine, hydroxychloroquine)
Biological agents (Tumour necrosis factor inhibitors e.g. etanercept, infliximab)
Supportive treatment: Physio OT Orthotics PLUS all the HOLISTIC care
Which drugs are increasingly being used as adjuvant for WHO pain ladder for chronic pain especially of nerve origin
Gabapentin
Pregabalin
Amitryptiline
TENS
