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Finals Revision Flashcards > MSK and Rheum - Osteoarthritis, RA, Osteoporosis > Flashcards

MSK and Rheum - Osteoarthritis, RA, Osteoporosis Flashcards

1
Q

Osteoarthritis - what is it?

A

‘Wear and tear of synovial joints’

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2
Q

Osteoarthritis - what are the 4 key XRAY changes that you see?

A

LOSS

  • *L**oss of joint space
  • *O**steophytes - bony spurs that grow around joints
  • *S**ubchondral sclerosis - increased desnity of bone along joint line
  • *S**ubchondral cysts - fluid-filled holes in bone
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3
Q

Osteoarthritis - what is the classic presentation?

A

Joint pain and stiffness

Worsened by activity

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4
Q

Osteoarthritis - commonly affected joints?

A

Hips

Knees

Sacro-iliac joints

Wrist

Cervical spine

Distal-interphalangeal joints in the hands (DIPs)

The MCP joint at the base of the thumb

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5
Q

Osteoarthritis - what are the signs in the hands?

A
  • Heberden’s nodes (in the DIP joints)
  • Bouchard’s nodes (in the PIP joints)
    • Weak grip
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6
Q

Osteoarthritis - diagnosis?

A

XRAY

Clinical picture

Ascertain that there is no morning stiffness or stiffness lasting less than 30 minutes

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7
Q

Osteoarthritis - management?

A
  1. Patient education - lifestyle, weight loss, physio
  2. Stepwise analgesia:
  • Paracetamol and topical NSAIDs (Topical NSAIDs only indicated for OA of knee or hand)
  • Oral NSAIDs, and maybe PPI to protect stomach
  • Opiates, codeine and morphine
    3. Intra-articular steroid injections
    4. Joint replacement
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8
Q

Rheumatoid arthritis (RA) - what is it?

A

Autoimmune condition that causes chronic inflammation of synovial lining of joints, tendon sheaths and bursa

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9
Q

Rheumatoid arthritis (RA) - what is a characteristic feature?

A

Tends to be symmetrical and affects multiple joints

Therefore symmetrical polyarthritis

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10
Q

Rheumatoid arthritis (RA) - antibodies that can be present in RA patients?

A

Rheumatoid factor (RF)

anti-CCP - Cyclic citrullinated peptide antibodies, more sensitive and specific

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11
Q

RA - what is Palindromic Rheumatism?

A

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve

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12
Q

RA - what joints are almost never affected in RA?

A

The distal interphalangeal joints almost never affected by RA

Enlarged painful distal interphalangeal joints, most likely Heberden’s nodes due to OA

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13
Q

RA- what are the specific deformities seen in the hands?

A
  • Z shaped deformity to the thumb
  • Swan neck deformity (hyperextended PIP with flexed DIP)
  • Boutonnieres deformity (hyperextended DIP with flexed PIP)
  • Ulnar deviation of the fingers at the knuckle (MCP joints)
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14
Q

RA - extra-articluar manifestations

A

Carpal tunnel syndrome

Pulmonary fibrosis

Anaemia of chronic disease

Felty’s syndrome - (triad of RA, neutropenia and splenomegaly)

Episcleritis and scleritis

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15
Q

RA - diagnosis?

A
  1. DAS28 is the Disease Activity Score. It is based on the assessment for 28 joints and points are given for:
  • Swollen joints
  • Tender joints
  • ESR/CRP result

2. Health Assessment Questionnaire (HAQ)

This questionnaire measures functional ability. NICE recommend using this at diagnosis to check the response to treatment.

  1. Diagnostic criteria come from the American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR) from 2010:

Patients are scored based on:

  1. The joints that are involved (more and smaller joints score higher)
  2. Serology (rheumatoid factor and anti-CCP)
  3. Inflammatory markers (ESR and CRP)
  4. Duration of symptoms (more or less than 6 weeks)

Scores are added up and a score greater than or equal to 6 indicates a diagnosis of RA

NICE recommend performing x-rays of the hands and feet of all patients with suspected rheumatoid arthritis

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16
Q

RA - what are the findings you might see on XRAY? (LESS)

A

LESS for rheumatoid:

Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopaenia)

17
Q

RA - management?

A
  1. Initial step - DMARD (methotrexate 1st, sulfasalazine, leflunomide, hydroxychloroquine) with bridging prednisolone
  2. Use DAS28 score to assess response to treatment
  3. TNF-inhibitor (anti-TNF) used if an inadequate response to at least two DMARDs including methotrexate, examples: etanercept, infliximab, adalimumab
  4. Rituximab

All the biologics can lead to reactivation of dormant infections such as TB or HepB

18
Q

RA - side effects of management drugs?

A
  • Methotrexate: pulmonary fibrosis, pneumonitis
  • Leflunomide: Hypertension and peripheral neuropathy
  • Sulfasalazine: Male infertility (reduces sperm count)
  • Hydroxychloroquine: Nightmares and reduced visual acuity, but CAN BE USED IN PREGNANCY
  • Anti-TNF medications: Reactivation of TB or hepatitis B
    • Rituximab: Night sweats and thrombocytopenia
19
Q

Osteoporosis - what is osteoporosis and osteopenia?

A

Osteoporosis is a condition where there is a reduction in the density of the bones. Osteopenia refers to a less severe reduction in bone density than osteoporosis

20
Q

Osteoporosis - what are the risk factors?

A

Main RF’s:

Age (>50 for women and >65 for men)

Female sex

Further risk factors can be remembered by the mnemonic SHATTERED FAMILY:

  • S – Steroid use
  • H – Hyperthyroidism, hyperparathyroidism
  • A – Alcohol and smoking
  • T – Thin (BMI<22)
  • T – Testosterone deficiency
  • E – Early menopause
  • R – Renal/liver failure
  • E – Erosive/inflammatory bone disease
  • D – Diabetes
    • FAMILY HISTORY
21
Q

Osteoporosis - why are post-menopausal women more prone to osteoporosis?

A

Oestrogen is protective against osteoporosis

Unless they are on HRT postmenopausal women have less oestrogen

22
Q

Osteoporosis - what is the FRAX tool?

A

Gives a prediction of the risk of a fragility fracture over the next 10 years

23
Q

Osteoporosis - what is a DEXA scan, what does it measure and what do the results stand for?

A

Bone mineral density (BMD) is measured using a DEXA scan, which stands for dual-energy xray absorptiometry

DEXA scans are brief xray scans that measure how much radiation is absorbed by the bones, indicating how dense the bone is

The bone mineral density (BMD) can be measured at any location on the skeleton, reading at hip is key for classification and management of osteoporosis

T score: T is based on young adult who is Thirty

Z score: adjusted for patient’s age, gender and ethnicity

24
Q

Osteoporosis - how do you decide on which management option to start from the FRAX score?

A

If the FRAX assessment was done without a bone mineral density (BMD) measurement the results (10-year risk of a fragility fracture) will be given and categorised automatically into one of the following:

  • low risk: reassure and give lifestyle advice
  • intermediate risk: offer BMD (DEXA) test
  • high risk: offer bone protection treatment

FRAX outcome with a BMD result will suggest one of two outcomes:

  • Treat
    • Lifestyle advice and reassure
25
Q

Osteoporosis - what are the blood results going to be like for calcium, PTH, ALP, and phosphate?

A

All 4 NORMAL

Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)

26
Q

Osteoporosis - lifestyle management?

A

Activity and exercise

Adequate calcium and vitamin D intake - if deficient, take Calcichew D3, which contains 1000mg Ca, and 800 units vitD

Stop smoking

Avoid alcohol

27
Q

Osteoporosis - pharmacological management?

A

1st line - Bisphosphonates such as Alendronate, Risedronate, Zoledronic acid

2nd line and further pharmacological treatments:

Denosumab - monoclonal antibody that works by blocking the activity of osteoclasts

Strontium ranelate - reduces rate of bone turnover, but increases risk of DVT, PE, MI

Raloxifene - used in postmenopausal women, binds to oestrogen receptors and exerts same protective action that oestrogen performs on bones by inhibiting osteoclastic action

HRT - consider in women who go through menopause early

28
Q

Osteoporosis - what do you have to inform patients about how to take bisphosphonates, and hat side effects can occur if this guidance is not followed?

A

Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving and drink with a glass of water

Side effects:

Oseophageal ulcer

Atypical fractures (e.g. atypical femoral fractures)

Osteonecrosis of the jaw

Osteonecrosis of the external auditory canal

Finals Revision Flashcards (49 decks)

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