MSK and Rheum - Osteoarthritis, RA, Osteoporosis

Question 1

Osteoarthritis - what is it?

Answer 1

‘Wear and tear of synovial joints’

Question 2

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

Answer 2

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

Question 3

Osteoarthritis - what is the classic presentation?

Answer 3

Joint pain and stiffness

Worsened by activity

Question 4

Osteoarthritis - commonly affected joints?

Answer 4

Hips

Knees

Sacro-iliac joints

Wrist

Cervical spine

Distal-interphalangeal joints in the hands (DIPs)

The MCP joint at the base of the thumb

Question 5

Osteoarthritis - what are the signs in the hands?

Answer 5

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

Question 6

Osteoarthritis - diagnosis?

Answer 6

XRAY

Clinical picture

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

Question 7

Osteoarthritis - management?

Answer 7

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

Question 8

Rheumatoid arthritis (RA) - what is it?

Answer 8

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

Question 9

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

Answer 9

Tends to be symmetrical and affects multiple joints

Therefore symmetrical polyarthritis

Question 10

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

Answer 10

Rheumatoid factor (RF)

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

Question 11

RA - what is Palindromic Rheumatism?

Answer 11

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

Question 12

RA - what joints are almost never affected in RA?

Answer 12

The distal interphalangeal joints almost never affected by RA

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

Question 13

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

Answer 13

• 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)

Question 14

RA - extra-articluar manifestations

Answer 14

Carpal tunnel syndrome

Pulmonary fibrosis

Anaemia of chronic disease

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

Episcleritis and scleritis

Question 15

RA - diagnosis?

Answer 15

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.

3. 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

Question 16

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

Answer 16

LESS for rheumatoid:

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

Question 17

RA - management?

Answer 17

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

Question 18

RA - side effects of management drugs?

Answer 18

• 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

Question 19

Osteoporosis - what is osteoporosis and osteopenia?

Answer 19

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

Question 20

Osteoporosis - what are the risk factors?

Answer 20

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

Question 21

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

Answer 21

Oestrogen is protective against osteoporosis

Unless they are on HRT postmenopausal women have less oestrogen

Question 22

Osteoporosis - what is the FRAX tool?

Answer 22

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

Question 23

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

Answer 23

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

Question 24

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

Answer 24

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

Question 25

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

Answer 25

**All 4 NORMAL** Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)

Question 26

Osteoporosis - lifestyle management?

Answer 26

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

Question 27

Osteoporosis - pharmacological management?

Answer 27

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

Question 28

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?

Answer 28

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