MSK and Rheum - Osteoarthritis, RA, Osteoporosis Flashcards
Osteoarthritis - what is it?
‘Wear and tear of synovial joints’
Osteoarthritis - what are the 4 key XRAY changes that you see?
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
Osteoarthritis - what is the classic presentation?
Joint pain and stiffness
Worsened by activity
Osteoarthritis - commonly affected joints?
Hips
Knees
Sacro-iliac joints
Wrist
Cervical spine
Distal-interphalangeal joints in the hands (DIPs)
The MCP joint at the base of the thumb
Osteoarthritis - what are the signs in the hands?
- Heberden’s nodes (in the DIP joints)
-
Bouchard’s nodes (in the PIP joints)
- Weak grip
Osteoarthritis - diagnosis?
XRAY
Clinical picture
Ascertain that there is no morning stiffness or stiffness lasting less than 30 minutes
Osteoarthritis - management?
- Patient education - lifestyle, weight loss, physio
- 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
Rheumatoid arthritis (RA) - what is it?
Autoimmune condition that causes chronic inflammation of synovial lining of joints, tendon sheaths and bursa
Rheumatoid arthritis (RA) - what is a characteristic feature?
Tends to be symmetrical and affects multiple joints
Therefore symmetrical polyarthritis
Rheumatoid arthritis (RA) - antibodies that can be present in RA patients?
Rheumatoid factor (RF)
anti-CCP - Cyclic citrullinated peptide antibodies, more sensitive and specific
RA - what is Palindromic Rheumatism?
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
RA - what joints are almost never affected in RA?
The distal interphalangeal joints almost never affected by RA
Enlarged painful distal interphalangeal joints, most likely Heberden’s nodes due to OA
RA- what are the specific deformities seen in the hands?
- 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)
RA - extra-articluar manifestations
Carpal tunnel syndrome
Pulmonary fibrosis
Anaemia of chronic disease
Felty’s syndrome - (triad of RA, neutropenia and splenomegaly)
Episcleritis and scleritis
RA - diagnosis?
- 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.
- Diagnostic criteria come from the American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR) from 2010:
Patients are scored based on:
- The joints that are involved (more and smaller joints score higher)
- Serology (rheumatoid factor and anti-CCP)
- Inflammatory markers (ESR and CRP)
- 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
RA - what are the findings you might see on XRAY? (LESS)
LESS for rheumatoid:
Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopaenia)
RA - management?
- Initial step - DMARD (methotrexate 1st, sulfasalazine, leflunomide, hydroxychloroquine) with bridging prednisolone
- Use DAS28 score to assess response to treatment
- TNF-inhibitor (anti-TNF) used if an inadequate response to at least two DMARDs including methotrexate, examples: etanercept, infliximab, adalimumab
- Rituximab
All the biologics can lead to reactivation of dormant infections such as TB or HepB
RA - side effects of management drugs?
- 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
Osteoporosis - what is osteoporosis and osteopenia?
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
Osteoporosis - what are the risk factors?
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
Osteoporosis - why are post-menopausal women more prone to osteoporosis?
Oestrogen is protective against osteoporosis
Unless they are on HRT postmenopausal women have less oestrogen
Osteoporosis - what is the FRAX tool?
Gives a prediction of the risk of a fragility fracture over the next 10 years
Osteoporosis - what is a DEXA scan, what does it measure and what do the results stand for?
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
Osteoporosis - how do you decide on which management option to start from the FRAX score?
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