List I - Core Conditions Flashcards
1
Q
What is osteoarthritis?
A
- Defined as a disorder of synovial joints which occurs when damage triggers repair processes leading to structural changes within a joint
- Joint damage may occur through repeated excessive loading and stress of a joint over time or by injury
- Damage to hyaline cartilage
2
Q
What are the typical features altering the structure of the joint in osteoarthritis?
A
- Localised loss of cartilage
- Remodelling of adjacent bone and the formation of osteophytes (new bone at joint margins)
- Mild synovitis (inflammation of the synovial membrane that lines the joint capsule
- In some people these repair processes may alleviate symptoms but in others they cannot fully compensate for the joint damage, and symptoms of pain and stiffness may occur
- Any synovial joint can be involved, most commonly peripheral joints are involved
- Knees
- Hips
- Small joints of the hand
3
Q
How common is osteoarthritis in the UK?
A
- 18% of UK population aged over 45 years have sought treatment for osteoarthritis of the knee
- 8% hip
- 6% hand and wrist
- Prevalence is higher in women than in men
4
Q
What are the risk factors for developing osteoarthritis?
A
- Genetic
- Biological
- Increasing age
- Female sex - more common in the hip
- Obseity
- High bone density
- Low bone density
- Biomechanical
- Joint injury and damage
- Joint laxity and reduced muscle strength
- Joint malalignment
- Exercise stresses
- Occupational stresses
5
Q
What are the complications of osteoarthritis?
A
- Joint deformity
- Functional impairment and disability
- Hand involvement may affect grip and pinch strength causing difficulty with activities such as opening jars, turning keys or door handles, lifting saucepans, fastening buttons and writing
- Knee and hip involvement may cause difficulty walking, climbing stairs, dressing, driving
- Psychosocial impact - may affect self confidence, self esteem, sleep quality, relationships and ability to self care for others
- Occupational impact
- Falls
- Chronic pain syndrome
6
Q
What is the prognosis of hand osteoarthritis?
A
- Generally good
- Interphalageal joint involvement usually becomes asymptomatic after a few years
- Involvement of the 1st CMC joint generally has a poorer prognosis
7
Q
What is the prognosis of hip osteoarthritis?
A
- Poorer prognosis than hand or knee osteoarthritis
- Significant proportion of people require hip replacement within 5 years of diagnosis
8
Q
What is the prognosis of knee osteoarthritis?
A
- Knee involvement has a variable prognosis
- Some people improve spontaneously
- Some remain stable and some have progressively worsening symptoms and structural changes on x-ray which eventually require joint surgery
9
Q
When should a diagnosis of osteoarthritis be suspected?
A
- Suspect osteoarthritis if alternative conditions have been excluded and a person is 45 years or more with suggestive clinical features
- Typical features include:
- History:
- Activity related joint pain - typically only one or a few joints are affected at a time, pain develops over months or years
- No morning joint related stiffness
- Functional impairment - hand may affect grip and pinch strength, knee and hip may cause difficulty walking
- Examination:
- Bony swelling and joint deformity
- Joint effusions (uncommon except the knee)
- Joint warmth and/or tenderness (may be synovitis)
- Muscle wasting and weakness
- Restricted and painful range of joint movement, crepitus (grating sound or sensation produced by friction between bone and cartilage)
- Joint instability
10
Q
How does osteoarthritis of the hand present?
A
Typically affects the first carpometacarpal (CMC) joint at the base of the thumb, distal interphalangeal (DIP) joint, and the proximal interphalangeal (PIP) joint
- Pain can radiate distally towards the thumb or proximally to the wrist and distal forearm, and is often exacerbated by pinching actions or strong grip.
- There may be wasting of the thenar muscles at the base of the thumb.
- The CMC joint may develop a fixed flexion deformity, with hyperextension of the distal joints.
- In advanced disease, there may be ‘squaring’ at the joint caused by subluxation (partial dislocation), formation of osteophytes, and remodelling of the bones.
- Initially, there may be features of inflammation such as pain, warmth, redness, and swelling of affected DIP and PIP joints.
- As disease progresses, there may be ulnar or radial deviation at affected joints
May have associated features such as:
- Mucoid cysts (painful mucus-filled cysts) adjacent to the joint on the dorsum of the finger, which may cause longitudinal ridging of the nail.
- Heberden’s and Bouchard’s nodes (bony nodules on the dorsum of the finger next to the DIP and PIP joints, respectively).
11
Q
How does osteoarthritis of the hip present?
A
May present with:
- Deep pain in the anterior groin on walking or climbing stairs, with possible referred pain to the lateral thigh and buttock, anterior thigh, knee, and ankle.
- Pain which may occur at rest and may disturb sleep.
- Painful restriction of internal rotation with the hip flexed.
- An antalgic gait — a lurch towards the affected hip with less time spent weight-bearing on that side; the pelvis is held normally.
In advanced disease, there may be:
- A Trendelenburg gait — a lurch towards the affected hip with less time spent weight-bearing on that side and the pelvis tilting down on the unaffected side, caused by wasting and weakness of the gluteal and anterior thigh muscles
- A fixed flexion external rotation deformity, with compensatory increased lumbar lordosis and pelvic tilt. The lower limb can be significantly shortened.
12
Q
How does osteoarthritis of the knee present?
A
Osteoarthritis of the knee:
- Typically is bilateral and symmetrical, affecting the medial tibiofemoral, lateral tibiofemoral, or patellofemoral compartments, with pain localized to the affected compartment.
- Unilateral osteoarthritis of the knee is usually secondary to predisposing trauma or disease.
- Medial tibiofemoral involvement causes anteromedial pain, mainly on walking.
- Lateral tibiofemoral involvement causes anterolateral pain, mainly on walking.
- Patellofemoral involvement causes anterior knee pain worsened on inclines or stairs, particularly when going down; and progressive aching on prolonged sitting that is relieved by standing.
13
Q
What are the associated features of OA of the knee?
A
May have associated features including:
- Giving way — due to altered patella tracking, weak quadriceps muscles, severe patellofemoral involvement, and altered load-bearing mechanics. Note: weakness of the quadriceps is suggested if passive extension of the knee joint is greater than active extension.
- Locking (inability to straighten the knee) — suggests loose meniscal cartilage in the joint.
- Crepitus and tenderness along the joint line or with pressure on the patella.
- Restricted flexion and extension.
- Small-to-moderate effusions.
14
Q
What are the features of OA of the knee in advanced disease?
A
In advanced disease, there may be:
- Bony swelling of the femoral condyles and lateral tibial plateau.
- Varus (bow-legged), or less commonly valgus (knock-knee), deformity.
- An antalgic gait.
15
Q
What are the typical radiological features of osteoarthritis?
A
- Subchondral bone thickening and/or cysts; osteophyte formation (new bone formation at joint margins; loss or narrowing of the joint space (provides an estimate of the severity of cartilage damage)
- Structural changes on x-ray may not correlate with reported symptoms and functional impairment
- LOSS
- Loss if joint space
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
16
Q
How should a person with osteoarthritis be initially managed in primary care setting?
A
- In the presence of a diagnosis offer an individualised management plan based on the person’s expectations and goals:
- Provide information - Arthritis Research UK
- Advise on self care
- Loose weight
- Muscle strengthening
- TENS
- Simple analgesia - paracetamol and NSAIDs
- Arrange regular review
17
Q
If initial self management and/or drug treatments are ineffective or not tolerated, who can the person with osteoarthritis be referred to?
A
- Physiotherapist
- Occupational therapist
- Podiatrist
- Orthopaedic surgeon
- Pain clinic
- Psychology or mental health services
18
Q
What are the surgical options for osteoarthritis?
A
- Hips
- Cemented hip replacement - metal femoral component is cemented into the femoral shaft, this is accompanied by a cemented acetabular polyethylene cup
- Uncemented hip replacements are becoming increasingly popular, particularly in younger more active patients - they are more expensive than conventional hip replacements
- Hip resurfacing is sometimes used where a metal cap is attached over the femoral head - often this is used in younger patients and has the advantage that the femoral neck is preserved which may be useful of conventional arthroplasty is needed later in life
19
Q
How is recovery from arthroplasty for osteoarthritis managed?
A
- Physiotherapy and a course of home exercises
* Walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery
20
Q
What is the advice to patients who have had hip replacement operation for osteoarthritis?
A
- Advise to minimise the risk of dislocation
- Avoid flexing the hip >90 degrees
- Avoid low chairs
- Do not cross legs
- Sleep on back for the first 6 weeks
21
Q
What are the complications associated with arthroplasty?
A
- Wound and joint infection
- Thromboembolism: NICE recommend patients receive 4 weeks LMWH following hip replacement
- Dislocation
22
Q
What is RA?
A
- A chronic systemic inflammatory disease
* Early RA is defined as disease duration of 5 years or less from the onset of symptoms
23
Q
How does RA present?
A
- As inflammatory arthritis typically affecting the small joints of the hands and the feet and both sides equally and symetrically, any synovial joint can be affected
24
Q
How common is RA?
A
- Prevalence in the UK of RA is 1% - most common inflammatory arthritis
- Peak onset is 30-50 years
- 2-4 times more common in women than men
25
Q
What are the possible complications of RA?
A
- Amyloidosis
- Anaemia
- Dry eye syndrome (keratoconjunctivitis sicca), peripheral ulcerative keratitis
- Felty’s syndrome - enlarged spleen and low WCC - affects less than 1% with RA
- Fatigue
- Increased mortality
- Interstitial lung disease
- Neuropathy
- Orthopaedic problems including:
- Carpal tunnel syndrome - 10-20%
- Increased joint replacement surgery
- Tendon rupture
- Cervical myelopathy
- Vasculitis, vasculitic ulcers, rheumatoid nodules
- Weight loss
26
Q
What are the comorbidities associated with severe RA disease?
A
- Cardiovascular disease - Accelerated atherosclersis is the leading cause of death in RA
- Pericarditis is present in 30-50% of people with RA but rarely leads to tamponade
- Depression
- Lymphomas - risk is double with RA
- Serious infections
27
Q
What are the complications of RA associated with drug treatment?
A
- GI problems from NSAIDS
- Infection - immunosuppressants and glucocorticoids
- Liver toxicity - methotrexate related
- Malignancy - TNF alpha inhibitor related
- Osteoporosis - low dose dose glucocorticoid use in people with RA
28
Q
When should a diagnosis of RA be suspected?
A
- Persistent (lasting weeks rather than days) synovitis where no other underlying cause in obvious e.g. psoriatic arthritis
- RA typically causes symmetrical synovitis of the small joints of the hands and feet
Clinical features include:
- Pain - worse at rest
- Swelling - around the joint (not bone swelling) giving a boggy feel on palpation
- Stiffness - early morning usually lasting over 1 hour
29
Q
When is a poorer prognosis of RA likely?
A
- Greater number of joints affected
- Swelling and tenderness in the affected joints
- Proximal interphalangeal joints and metacarpophalangeal joints are affected and there is symmetry of joints affected
- Positive metacarpophalangeal squeeze test - pain on squeezing the metacarpophalangeal or metatarsophalangeal joints together
- Inability to make a fist or flex fingers is associated with an ability to diagnose RA from other diagnoses
30
Q
What are the features in addition to joint synovitis that RA may present with?
A
- Additional symptoms:
- Rheumatoid nodules - hard, firm, swellings over extensor surfaces occur in a third of people with RA
- Extra-articular features such as vasculitis or involvement of other body systems (eye, heart, lungs)
- Systemic features of malaise, fatigue, fever, sweats and weight loss
- Family history of RA
Presentation of RA is variable
31
Q
What are the differential diagnoses for RA?
A
Other conditions that may cause synovitis such as:
- Connective tissue disorders - SLE
- Fibromyalgia - if numerous myofascial trigger points and somatic symptoms are present
- Infectious arthritis - viral or bacterial
- Osteoarthritis
- Polyarticular gout
- Polymyalgia rheumatica - suspect if the main symptoms are shoulder pain and stiffness
- Psoriatic arthritis - commonly involves the small joints of the hands and feet, less often symmetrical, distal joints may be involved
- Reactive arthritis - suspect this if a person has recently had viral or bacterial infection
- Sarcoidosis - chest x-ray
- Septic arthritis - suspect this if a single joint is hot and swollen and signs of fever
- Seronegative spondyloarthritis
32
Q
What are the necessary investigations for suspected rheumatoid arthritis?
A
- Diagnosis is clinical - refer all people suspected of having RA for specialist assessment
- Investigations are not necessary in primary care however will speed up the process
- Rheumatoid factor - present in 60-70% of people with RA
- anti-CCP if negative for RF - present in 80% of people
- Arrange x-ray of hands and feet - help with diagnosis and determines disease severity
- Consider the following tests to speed up the diagnostic process and act as a baseline measure prior to treatment:
- Full blood count
- U and E’s
- LFT’s
- CRP or ESR - elevated up to 40% in people with RA
- USS or MRI
33
Q
What is the referral requirements for a person with suspected RA (persistent synovitis with an unknown cause)?
A
- Refer to a rheumatologist for an appointment (within 3 weeks) for specialist assessment
- Refer urgently (within 3 working days) even with normal acute phase response, negative anti-CCP antibodies or rheumatoid factor if there are any of the following:
- Small joints of the hand or feet are affected
- More than one joint is affected
- There has been delay of 3 months or longer between the onset of symptoms and the person seeking medical advice
- Consider offering NSAID at the lowest effective dose until an rheumatology appointment is available
- Do not prescribe a glucocorticoid in primary care before specialist assessment - it may mask clinical features
34
Q
What drugs treatments are available in secondary care for confirmed rheumatoid arthritis?
A
- cDMARD as monotherapy ideally within 3 months of the onset of symptoms - oral methotrexate, leflunomide or sulfasalazine
- DMARD’s are myelosuppressive
- Hydroxychloroquine may be used as an alternative for people with palindromic disease
- Short term bridging treatment with glucocorticoids may be used when starting a new cDMARD to improve symptoms while waiting for it to take effect (2-3 months)
- Additional cDMARDs can be used in combination
35
Q
What is the role of primary care in the management of someone with confirmed rheumatoid arthritis?
A
- Primary care is part of the MDT
- Ensures that all adults with RA have:
- Rapid access to specialist care for flares
- Information about when and how to access specialist care
- Ongoing drug monitoring
- DAS-28 for monitoring disease activity
- Ensuring they have achieved treatment target
- Offered annual review to assess the following:
- Disease activity and damage
- Check comorbidities
- Assess for complications such as vasculitis and disease of cervical spine, lung or eyes
- Organise appropriate cross referral
- Assess need for surgery
- Assess impact on the persons life
- Identify and manage flares
- Offer pneumococcal and yearly influenza vaccinations
- Improve the person’s understanding of RA
36
Q
What is the management of a flare of RA?
A
- Exclude septic arthritis - single hot and swollen joint especially if there are signs of sepsis
- Suspect a flare of RA if there are worsening:
- Symptoms of stiffness, pain, joint swelling or general fatigue
- Signs of joint synovitis, joint tenderness or loss of joint function
- Inflammatory markers - CRP increase from previous
- Seek specialist advice about management, offer a short term treatment with glucocortiocids either:
- As a joint injection - methylprednisolone acetate or triamcinolone acetonide for a localized RA flare
- Oral if IM not practical - reducing dose over 2-4 weeks
- 2 week course of prednisolone 10 mg daily for 7 days then 5 mg daily for 7 days then stop
- Consider offering an NSAID
37
Q
When is referral to a surgeon indicated in rheumatoid arthritis?
A
- Offer to refer people with RA for an early specialist surgical opinion if any of the following do not respond to optimal non-surgical management or before damage or deformity becomes irreversible:
- Persistent pain due to joint damage or other soft tissue cause
- Worsening joint function
- Progressive deformity
- Persistent localized synovitis
- Imminent or actual tendon rupture
- Nerve compression
- Stress fracture
- Urgent referral for people at risk of suspected or proven septic arthritis
38
Q
How should management of RA vary when considering the possibility of COVID-19?
A
- People with RA with suspected COVID-19
- Be aware that immunosuppressant treatments may have atypical presentations - people taking prednisolone may not develop fever and those taking interleukin-6 inhibitors may not develop a rise in CRP
- In people with RA with suspected COVID-19, they should:
- Continue hydroychloroquine and sulfasalazine
- Not suddenly stop prednisolone
- Only have corticosteroids if there is significant disease and there are no alternatives
- Temporarily stop other disease modifying antrheumatic drugs, JAK inhibitors and therapies, contact their rheumatology department for advice on when to restart
39
Q
What is osteoporosis?
A
- Disease characterised by low bone mass and structural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture
- Osteoporosis itself is asymptomatic and often remains undiagnosed until a fragility fracture occurs
40
Q
What is an osteoporotic fracture?
A
- A fragility fracture occurring as a result of osteoporosis
- Characteristically occurs in the wrist, spine, and hip but can occur in the arm, pelvis, ribs and other bones
- Fragility fracture is defined as a fracture following a fall from standing height or less, although vertebral fractures may occur spontaneously, or as a result of routine activities such as bending or lifting
41
Q
According to the World Health Organisation, what is osteoporosis?
A
- Osteoporosis is defined by a bone mineral density of -2.5 standard deviations below the mean peak mass (average of young healthy adults) as measured by a DEXA scan applied to the femoral neck and reported as a T-score
- > -1.0 = normal
- -1.0 to -2.5 = osteopenia
42
Q
What is the problem with the BMD measurement?
A
- BMD does not assess the structural deterioration in bone and consequently most osteoporotic fractures occur in women who do not have osteoporosis as defined by a T score equal to or less than -2.5
- Z score is adjusted according to demographics - age, gender, ethinicity
43
Q
What are the causes of osteoporosis?
A
- Result of an imbalance in the normal process of bone remodelling by osteoclasts and osteoblasts
- During normal ageing, bone breakdown by osteoclasts increases and is not balanced by new bone formation by osteoblasts, resulting in a combination of:
- Reduced bone mineral density measured by DXA scanning
- Changes in bone composition, architecture, size and geometry
44
Q
Which factors influence the age at which osteoporosis becomes apparent?
A
- Peak bone mass
- Depends on genetics, levels of nutrition (calcium and vitamin D), sex hormone levels (androgens and oestrogens) and level of physical activity - reached in the third decade and starts to decline in the fifth decade, accelerates after the menopause for women
- Rate of bone loss
- Depends on oestrogen deficiency in women and decreased testosterone in men and hyperparathyroidism
45
Q
What are the complications of osteoporosis?
A
- Fragility fractures
- Hip fractures - can impact their independence
- Vertebral fractures - can cause back pain, loss of height, and kyphosis
46
Q
How common is osteoporosis?
A
- Women are at greater risk of osteoporosis due to the decrease in oestrogen production at the menopause which accelerates bone loss
- Around 180000 of the fractures presenting in England and Wales each year are due to osteoporosis
47
Q
What are the risk factors for getting an osteoporotic fracture?
A
- Depends on the persons risk of falls and their bone strength determined by BMD and other risk factors - fracture risk increases as BMD decreases
- Risk factors affecting bone strength include:
- Endocrine diseases - DBM, hyperthyroidism, hyperparathyroidism
- GI conditions - Crohn’s, UC, coeliac disease and chronic pancreatitis
- CKD
- Chronic liver disease
- COPD
- Menopause
- Immobility
- BMI <18.5 kg/m2
48
Q
Which factors do not reduce BMD?
A
- Age - risk increases with age and is at least partly independent of BMD
- Oral corticosteroids - dose dependent
- Smoking
- Alcohol (3 units or more daily)
- Previous fragility fracture
- RA
- Parental history of hip fracture
49
Q
What are the risk factors for falls?
A
- Impaired vision
- Neuromuscular weakness and incoordination
- Cognitive impairment
- Use of alcohol and sedative drugs
50
Q
Which patients should be identified to assess for fragility fractures?
A
- All women over 65 years and over and all men aged 75 years and over
- All women aged 50-64 years and all men aged 50-74 years who have any of the following risk factors:
- Previous osteoporotic fragility fracture
- Corticosteroid use present or past
- History of falls
- BMI <18.5 kg/m2
- Smoker
- Alcohol intake of >14 units per week
- Secondary cause from previously identified risk factors
- All people younger than 50 years of age with any of the following risk factors:
- Current or frequent use of corticosteroids
- Untreated premature menopause
- Previous fragility fracture
- People younger than 40 years of age with any of the following risk factors:
- Current or frequent use of corticosteroids high dose >7.5 mg prednisolone daily for 3 months or more
- Previous fragility fracture of the spine, hip, forearm or proximal humerus
- History of multiple fragility fractures
51
Q
How should a person be assessed for fragility fracture risk?
A
- Exlcude non-osteoporotic causes for fragility fractures
- DEXA scan
- Consider starting drug treatment for people with vertebral or hip fractures without undertaking DXA
- For all other people with risk factors for osteoporosis, consider using the online risk calculators QFracture or FRAX which predict the absolute risk of hip fracture and major osteoporotic fractures (spine, wrist, hip, shoulder) over 10 years
- Assess for vitamin D deficiency and inadequate calcium intake
52
Q
How should a fragility fracture score be interpreted?
A
- 10 year fracture risk of 10% is considered to be the threshold for arranging a DEXA scan in men and women
53
Q
How is the QFracture risk score interpreted?
A
QFracture
- High risk
- Risk score is 10% or above
- Intermediate risk
- Risk score is close to but below 10%
- Low risk
- Risk score is below 10%
54
Q
How is the FRAX score interpreted? (Assessment of risk of fragility fractures)
A
FRAX
- High risk
- Red zone of risk chart
- Intermediate risk
- Orange zone of risk chart
- Low risk
- Green zone of risk chart
55
Q
How should high fragility risk scores be managed?
A
- DEXA scan
- Bone sparing drug treatment if the T score is -2.5 or less
- If the T score is > -2.5, modify the risk factors where possible and treat any underlying conditions
(DEXA scan for those at intermediate fragility risk score, lifestyle modification for those at low risk of fragility fracture - do not offer drug treatment to these individuals)
56
Q
What drug treatments can be prescribed to people at high risk of osteoporotic fracture?
A
- Bisphosphonates such as alendronate 10 mg once daily or 70 mg once weekly or risedronate 5 mg once daily or 35 mg once weekly if there are no contraindications and after counselling to:
- Post menopausal women and men over 50 with confirmed DEXA of -2.5 or less
- If calcium intake is inadequate:
- Prescribe 10 micrograms of vitamin D with at least 1000mg of calcium daily
- Prescribe 20 micrograms of vitamin D with at least 1000 mg of calcium daily for elderly people who are house bound or in a nursing home
- Consider prescribing HRT to women who have a premature menopause (before the age of 40)
57
Q
What lifestyle advice should be given to manage the risk of osteoporotic fractures?
A
- Take regular, tailored to the person, exercise to improve muscle strength
- Eat a balanced diet
- Stop smoking
- Drink alcohol within recommended limits
- Provide information - National Osteoporosis Society
58
Q
How should a person at risk of osteoporotic fracture be followed up?
A
- After bone sparing drug treatment, review the medication:
- Ask about adverse effects of bisphosphonates such as GI dyspepsia or reflux, symptoms of atypical fracture, new onset of pains
- Ask about adherence to treatment
- People taking oral corticosteroids - advise to continue treatment with bisphosphonates and/or calcium and vitamin D until treatment with oral corticosteroids has stopped
- For the remainder or people, review the need for continued treatment with bisphosphonates after 3-5 years
59
Q
What is polymyalgia rheumatica?
A
- A chronic, systemic rheumatic inflammatory disease characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle in people older than 50 years of age
60
Q
What causes polymyalgia rheumatica?
A
- Unknown, although genetic and environmental factors are thought to contribute to the disease susceptibility and severity
61
Q
What are the risk factors for developing PMR?
A
- Older age - risk increases with age in both men and women - highest incidence is in people older than 65 years of age with peak in the 70-80 year old age group
- Female gender
- North European ancestry - PMR is most common this group
- Infection - cyclic fluctuations and peaks in incidence have been observed in the winter months associated with mycoplasma, chlamydia pneumonia and paravovirus B19 infections
62
Q
How common is PMR?
A
- PMR is the most common inflammatory rheumatic disease in older people and one of the most common indications for long term corticosteroid treatment in the UK accounting for 22% of prescriptions
63
Q
What are the complications of PMR?
A
- Giant cell arteritis (GCA) and its complications can occur abruptly and without warning, early in the course of PMR
- 15-20% of people with PMR develop GCA and 40-50% of people with GCA have symptoms of PMR
- Complications of long term corticosteroid treatment
