MedEd arthritides Flashcards
What is osteoarthritis?
asymetrical degenerative synovial joint disease
cartilage destruction exceeds repair causing pain and instabiility
What are the 2 types of arthritis and who is more likely to have each?
Primary- obese, older, female, occupation using hands eg hairdresser
Secondary- when someone already has an altered/damaged joint eg RA, septic arthritis, congenital, trauma
How will someone with osteoarthritis present?
Morning stiffness for around 15 mins
Joint pain worse with activity better with rest
More common in high use or weight bering joints- hips, knee, DIP, PIP, wrist
Late night pain
Loss of function
What will you see on examination in osteoarthritis?
Crepitus Effusion Erythema Squaring of base of thumb Hebeden's and bouchard's nodes
What acronym is used to remember what you see on xray in osteoarthritis? What does it stand for
LOSS: loss of joint space osteophytes subarticular sclerosis subchondral cysts- fluid filled hole following joint line
What is the first line investigation for osteoarthritis? What others might you do
X ray
Joint aspirate
Who is more likely to have primary osteoarthritis?
Older people
Obese people
Females post menopause
Those who use joints in their occupation eg hairdresser
What is secondary osteoarthritis?
When someone’s joint is already damaged for some reason and then they get it
How is osteoarthritis managed? Give first, second and third line
Oral paracetamol +- topical NSAID/capasaicin
Oral NSAID+PPI
Opiates- use with caution as after a few weeks the analgesic effects will wear off and they have side effects
Short term management= intraarticular steroids
What do you need to co prescribe with NSAIDs?
PPI
What is RA?
autoimmune chronic and progressive inflammation of synovial lining, tendon sheaths and bursa
How long do you have to have inflammation for a diagnosis of RA?
6 weeks or more
Who is more likely to get RA?
HLA DR4 HLA DR1 Smokers Females Family hx
How is RA diagnosed?
Clinical
What are the 2 main features of RA?
Symmetrical polysrthritis (>4 joints) Extraarticular manifestations
How many joints need to be affected in RA?
4 or more
How will someone with RA classically present?
Pain and stiffness in hands and wrists
Worse when they wake up
Resolves over the morning
Fatigue but no other systemic symptoms
What is seen on examination in RA?
Swelling
Tenderness
Small joint affected- wrist, ankle, MCP, PIP, MTP
DIP is spared
What joint is spared in RA?
DIP
What are chronic signs of RA
Ulnar deviation at MCP
Radial deviation at wirst
Z deformity of the thumb
Swan neck deformity- distal joint is flexed
Boutonnieres deformity- proximal joint is flexed
What joints are flexed in boutonieres vs swan neck deformity? How do you remember this?
boutonieres- proximal
swan neck- distal
B is before s in the alphabet
What are extra art features of RA
Rheumatoid nodules Felty's syndrome- RA, splenomegaly, neutropenia episcleritis/scleritis lymphadenopathy pericadarditis carpel tunnel syndrome pulmonary fibrosis/pleuritis bursitis
What ix are done for RA? What is seen?
RF ab- high
Anti CCP antibody- high
ESR- high
When should you refer someone for RA? When is urgent referral done
Anyone with persistent synovitis
Urgent referral if- small joints of hands/feet, multiple joints, <3 months
How is RA managed?
Short course steroids
NSAIDs/ COX 2 inhib
DMARDs
Surgery
Describe how dmards are prescribed stepwise in RA
Hydroxychloroquine if mild
Then one out of methotrexate, leflunomide or sulfasalazine
Then give 2 of the above in combination
Then give methotrexate and a biologic (anti TNF)
Then give methotrexate and rituximab
What is the main way to differentiate osteoarthritis and RA?
Osteo= asymmetrical RA= symmetrical
What joints are flexed v extended in swan neck deformity
DIP- flexed
PIP- extended
What is ankylosing spondylitis?
Chronic progressive inflammation of axial skeleton (can effect peripheral joints), also affects tendon/ligament attachments are extra art sights
Who is more like to get AS?
HLA b27
Male
ERAP 1 and IL-23R
Family hx
How will someone with AS present?
Pain and stiffness of lower back and hips
Worse in morning
Better with movement
Chronic onset
Pmhx of tendon/ligament pathology eg plantar fascitis
What are extra art features of AS?
Anterior uveitis Apical lung fibrosis Aortic regurg Psoriasis IBD
What are later changes of AS?
Khyphosis
Loss of lumbar lordosis
Neck extension
Causes question mark posture
What clinical tests are done in AS and what do you see?
Schober’s test
Tragus to wall
Stress test
What is seen on xray/MRI in AS
Sacroilitis
Bamboo spine
What is reactive arthritis?
Sterile, seronegative joint inflammation in response to extra art infection
Who is more likely to get reactive arthritis?
HLA b27
Male
20-30 yrs old
hx of previous infection
What syndrome is associated with reactive arthritis and what is it?
Reiters syndrome- cant see, cant pee and cant climb a tree
How will someone with reactive arthritis classically present?
painful swollen one joint no speicific pain trigger no fever able to weight bear previous infection
What are extra art features of reactive arthritis?
Reiter’s triad: arthritis+urethritis+ conjunctivitis
Keratoderma blenorrhagicum- vesicles which are plaque like or pustular on the soles and palms
Circinate balantis- painless ulcers/plaques on the shaft or glans
Oral ulcers
If you have sickle cell what infective organism for osteomyelitis are you particularly susceptible to?
Salmonella
What joints are affected in osteoarthritis?
Weight bearing joints eg hip, knee, DIP, PIP, wrist
What joints are affected in RA?
wrist, ankle, MCP, PIP, MTP
DIP is spared
What is used for short term management in an acute flare up of OA?
Intraarticular steroids
Why are opiates not recommended for OA?
Because there therapeutic effects wear off after a few weeks
Patients are at risk of addiction
There are bad associated side effects like pruritus and constipation
What is the triad for Felty’s syndrome?
Rheumatoid arthritis
Splenomegaly
Neutropenia
What medication is given in mild RA?
Hydroxychloroquine
What DMARDs can be prescribed in RA?
Methotrexate
Leflunomide
Sulfasalazine
What biologic agent is commonly used to treat RA alongside methotrexate? When is it given
anti TNF
It is given after 2 DMARDs have been tried in combination and haven’t been effective
What monoclonal antibody is commonly used to treat RA alongside methotrexate? When is it given
Rituximab
It is given once 2 DMARDs in combination and then methotrexate+anti TNF have been tried but have been ineffective
When is schober’s test done? How is it carried out and what is a positive result
It is a clinical test done to diagnose ankylosing spondylitis
You mark 10cm above L5 and 5 cm below
Get the patient to bend forward
If the point-point distance increases >5cm this is positive for ankylosing spondylitis
When is tragus to wall test done? How is it carried out and what is a positive result
Get the patient to stand with their back and head against the wall
Measure the distance from the tragus to the wall
If its over 15cm this is positive and suggests they have ankylosing spondylitis
In what condition is keratoderma blenorrhagicum seen? What does it look like and where on the body is it common
Seen in reactive arthritis on the soles and palms usually
Vesicles which are plaque like or pustular
What is reiter’s traid? In what condition is it seen?
Triad of arthritis, urethitis and conjunctivitis
Seen in reactive arthritis
What is circinate balanitis? In what condition is it seen and where on the body?
Painless ulcers and plaques on the shaft or glans of the penis
Seen in reactive arthritis
What are the 3 acute monoarthritides?
Septic arthritis
Gout
Pseudogout
How will septic arthritis classically present?
very painful, erythematous, swollen joint
restricted ROM
fever
How will gout classically present? Which joint is usually affected
1st MTP most commonly affected
Sudden onset severe pain of a joint
Erythematous, swelling, tenderness
How will pseudogout classically present? What joints does it usually effect?
Acute painful joint
Usually effects large joints eg the knee and also affects multiple joints because its chronic
What organisms usually cause septic arthritis in under 30s vs over 30s?
under 30= neisseria gonorrhoea
over 30= staph aureus
What is gout precipitated by?
Trauma and infection
What crystals are present in gout?
Monosodium urate
What imbalance underlies gout?
Hyperuricaemia
What is pseudogout precipitated by?
Trauma and illness
What crystals are present in pseudogout?
Calcium pyrophosphate
What are some causes of pseudogout?
Idiopathic Hyperparathyroidism Hypophosphataemia Hypomagnesia Metabolic causes
What are RF for infection in septic arthritis and RF for joint damage?
Infection: IV drug use, diabetes, immunosupression
Joint damage: RA, prosthetic joint, gout
What are RF for gout?
Alcohol High purine diet Obesity Male Diuretics
What are RF for pseudogout?
Elderly
Female
What will aspirate, MC&S and bloods in septic arthritis show?
Aspirate= turbid, yellow, low viscosity fluid, raised WCC (>90% neutrophils) MC&S= organism Bloods= elevated WCC and CRP
What will aspirate, bloods and XR in gout show?
Aspirate= turbid, yellow, low viscosity fluid, raised WCC (neutrophils), needle shaped negatively birifringent crystals Bloods= elevated WCC, CRP, uric acid (4-6 weeks later) XR= rat bite erosions
What needles are seen in gout on aspirate?
Negatively birifringent needle shaped crystals
What is seen on x ray in gout?
Rat bite erosions
What will aspirate, bloods and XR in pseudogout show?
Aspirate= turbid, yellow, low viscosity fluid, raised WCC (neutophils), rhomboid shaped positively birifringent crystals
Bloods= elevated WCC and CRP
X ray= chondrocalcinosis
What crystals are seen in pseudogout?
Rhomboid shaped positively birifringent crystals
How do you remember what crystals are in gout vs pseudogout?
Pseudo= positive for being fake= positively birifringent rhomboid shaped crystals Gout= negative and not fake= negatively birifringent needle shaped crystals
What might cause infection of the bone in osteomyelitis?
Haematogenous spread- immunosupression, diabetes etc
Contiguous spread- cellulitis, localised infection
Direct inoculation- penetrating injury, ulcers, surgery
What is osteomyelitis?
Infection of the bone leading to inflammation, necrosis and new bone formation
What are the types of osteomyelitis?
Acute
Subacute
Chronic
How long does chronic osteomyelitis have to go one for?
Over 6 weeks
How will someone with osteomyelitis classically present?
Non specific pain in the area
Fever
malaise
preceding skin lesion, infection
What will you see on examination in osteomyelitis?
Localised eythema, swelling and warmth
Reduced ROM of joint
Discharge from the wound or ulcer
What ix are done for osteomyelitis and what will you see?
Bloods- raised WCC and CRP
XR/MRI- no changed in the first 2 weeks, darkening of the affected area and periosteal thickness
Bone culture- shows the causative organism
How is osteomyelitis managed?
Supportive treatment like analgesia and immobilisation
High dose IV abx- empirical at first then after culture returns adjust and 2-4 week course
Surgical debridement- this is needed if biofilm indicates it or if there is dead bone
