MSK Flashcards
Osteoarthritis definition
Non inflammatory wear and tear of joints from loss of articular cartilage (this is a hyaline cartilage).
Osteoarthritis epidemiology
Most common type of arthritis
Age
Female
Synovial joints
Osteoarthritis risk factors
- Age -cumulative and traumatic insult
- Female - especially after menopause
- Occupation - manual labour and hands, football and knees, faming and hips
- Genetics - polyarticular disease, OA hip less common in afro Caribanan and Asian
- Obestity - links between BMI and hip and knee OA. Obestity is a low grade inflamatory state to incrase of IL-1 and TNF
- Joint trauma
- Gout
Inflamatory artheritis
Osteoarthritis pathophysiology
Age relates dynamic reaction pattern of a joint in response to injury
Articular cartilage (produced by chondrocytes) is the one which is most affected
It causes changes to underlying bones at the joint margins
* There is ore wear to the cartilage then tehere is new cartalage being made. * Threre is faulty cartilage which unergoes erosio and causes disorderd repair, fubrillations and cartilage ulceration which all increases the stress on the bnne * This leads to microfractures and cysts on the bone which cuases abnormal sclerotic subchondral bone and overgrowth at joint margins (osteophytes) * * It is a metabolically acitve and dynamic process Medicated by the cytoline - IN-1, TNF-aloha, NO
Osteoarthritis key presintations
- Elderly with joint pain
- Improves with rest and worse with activity
- Heberden’s and bouchardes nodes in fingers
- Hip - groin pain
- XR – Osteophytes, joint space narrowing, subchondral cysts and subarticular sclerosis.
Osteoarthritis signs
- Morning stiffness
- Worse at the end of the day
- Pain increases with use
- Asymmetrical joint involvement
- Joints are most commonly affected - knee, vertebrae, hip
- Joint swelling - osteophytes grow outwards- bony enlargement, effusion, synovitis, bony swelling
Tenderness and deformities
Osteoarthritis symptoms
- Joint pain on movement
- Hip and groin pain
- Pain at the end of the day
- Crepitus - crunching sensation when moving the joint
Functional impairment - walking and activities of daily living
Osteoarthritis test
X ray - LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Bloods - normal - CRP may be slightly raised, reumatoid factor and antinuculaur antobbodies negative
MRI
aspiration of synovial fluid?
Osteoarthritis diffrential
Differential diagnosis
Rehumatoid arthritis
Gout
Psoriatic arthritis
Osteoarthritis treatmetn
Treatment
- Lifesytle - education, activity and exercise, weight loss, physiotherapy, occupational therapy, walking stick for hips, hot/cold pads
Medication -
* Topical - NSAIDs and Capsaicin
* Oral - paracetamol and sometimes NSAIDs
* Opioids - dihydrocodeinone
* Transdermal patches - buprenorphine, lignocaine
* Intra - articular steroid injections - hyaluronic acid
Surgery -
* Osteophyte removal/fusion
* Joint replacement if very severe
* Arthroscopy, Only for loose bodies, Indications ,Uncontrolled pain (particularly at night)
Significant limitation
* Arthroplasty - put in fake cartilage
* Osteotomy - cutting bone to reshape it
Rheumatoid arthritis definition
Definition
Chronic systemic inflamatory disease dur to immune complexes in the synovai joints which causes symmetrical deforming polyarthritis
Rheumatoid arthritis epidemiology
Epidemiology
Common 0.5-1% of the population
Linked to autoimmune conditions
More common in females
Rheumatoid arthritis causes
Aetiology
- Autoantibodeis presant - reumatoid factors - anti cycclic citrullinated peptide, immune complexs
- Immunoglobulins and cytokines presnet in synovial fluid
- Defective cell mediated immunity
- Association with other organ specific autoimmune conditions
Rheumatoid arthritis risk factors
Risk Factors
Increasing age
Female
Family history
Smoking
Stress
Infection
Rheumatoid arthritis pathophysilogy
Pathophysiology
- Inflammation of the lining of the synovial joints
- Synovium thickens and is infiltrated by inflammatory cells
- Generation of new blood vessels is induced which causes leucocytes into the synovium which leads to inflammation
- A tumour like pannus grows over the proliferatin leading to damae to the underlying cartilage and blockadge of th normal route of nutrition
- Cartilage becomes thin and the underlying bone becomes exposed
- This leads to a destruction of articular cartilage and subchondral bone
Rheumatoid arthritis key presintations
Key presentations
- Joint pain often worse in the morning and in the cold
- Loss of function
- Fatigue and malaise
- Extra articular involvement - pericardial effusion, pleural effusion, anaemia, uvitis
Rheumatoid arthritis signs
Signs
- Morning stiffness lasting more than 30 mins
- Pain improves with use
- Warm, red, tender joints
- Joints offten affected symetrically - Metacarpophalangeal joints, Proximal interphalangeal joint, Metatarsophalangeal joint, wrists, elbows, shoulders, knees, ankles
- Hand deformities
- Rheumatoid nodules at pressure pints - elbow
- Popliteal cysts - bulging of the synovia sack
- Carpal tunnel syndreome
Extra articular manifestations:
* Nodules on presure points
* Bursistis - inflamation of the bursa sack in the joints
* Tenosyvonitis - inflamation of tendons
* Muscle wasting
* Lymph nodes palpable
* Dleen enlarged
* Felty’s syndrome – rare
□ Triad of
® Seropositive RA
® Splenomegaly
® Neutropenia
* Anaemia - normocytic anaemia of chrons disease
* Anaemia - iron deficiency due to hepcidin inhibition from NSAIDs and prednisolone
- Nerves:
- Dry eyes
- Episleriris
- Corneal ulceration
- Sensory neuropathy
- Entrapment neuropathy - soft tissue sweeling due to inflammation at wite where rigid structues contact neres causing spinal cord compression - severe neck and occipital pain
- Myelopathy
- Atlanto-axial subluxation
Lungs
* Pleural effusion
* Diffuse fibrosinf alviolitis
* Rhuamatoid nodules
* Small airway diseas
Heart -
* Pericardial rub
* Pericarditis
* Pericardial effusion
Kidneys
* Amyloidosis
* Advanced RA
* Amyloid protein deposits
* Proteinuria
* Analgesic neuropathy
Skin:
* Vasculitis -small infarcts in the nail beds
Rheumatoid arthritis diagostic criteria
Symptoms
DIAGNOSITIC CRITERIA:
4/7
* Morning stiffness * Artherisits in 3 or more joints * Arthritis of the hands * Symmetrical * Rheumatoid nodes * Rheumatoid factor positive * Radiographic changes
Rheumatoid arthritis test
1st line test
x-ray - LESS
loss of join space
Erosions
Soft tissue swelling
Soft bones - osteopenia
* Bloods - rheumatoid factor positive in 70% of patients * Anti CCP (anticyclic citrullinated protein antibody) positive in 98% of patients highly specific!! * FBC - raised platelets, CRP, ESR, anaemia * MRI and ultrasound
Rheumatoid arthritis tretament
Treatment
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs) – suppresses inflammation, Methotrexate, Must give folate supplements as methotrexate inhibits folic acid synthesis
- NSAIDs -
- Hydroxychloroquine
- Sulfasalazine
- Biologics Rituximab, Etanercept – TNF-alpha blocker, Baricitinib
- Acute exacerbations – steroids (IM methylprednisolone)
- MDT management – rheumatologist, OT, physio, GP
rehumatoid artehritis typeical presitation
Other notes
TYPICAL PRESINTAION
40 y/o female with hand stiffness and pain
Symmetrical polyarthritis – PIP, MCPs, MTPs.
Hand deformities ulnar deviation, swan neck and boutonnieres deformity of fingers, Z deformity of thumb.
Morning stiffness >30 mins.
Complications with neck – cervical instability.
Think systemic disease with other systems frequently affected.
Ix – RF and anti-CCP, XR - LESS
Tx DMARD
rheumatoid artheritis deiiferntial
Differential diagnosis
SLE
Psoriatic arthritis
Symmetrical seronegative spondyloarthropathies
gout definiton
Definition
- Sodium urate - needle shaped and negatively birefringent under polarised light
- Neutrophils ingest the crystals and cause a proinflammatory response
gout epidemiology
Epidemiology
- Common in men over 40 - commonest tye for this catogy
- Post menopausal women
- More men than women
- Associated with hypercalcaemia