MSK - Arthritides Flashcards
What is osteoarthritis and primary cause? / RFs?
Asymetrical degenerative synovial disease where cartilage destruction exceeds repair = pain and instability
‘wear and tear’ cause
Obesity, age, female, occupation, hereditary predisposition?postemnopausal?
Secondary cause?
Altered joint architecture and stability = further damage.
Pre-existing condition s.e.g. Rh or septic arthritis,
developmental dyspasia o hip
Wilsons, acromegaly, haemochromotosis
Trauma
Presentation of osteoarthritis?
Morning stiffness <30mins, joint pain with gradual nset, worse with activity and better with rest
High-use and weight bearing joints HIP, KNEE, DIP, PIP, 1st CMV, wrist
Late = night pain, instability, deformity and loss of function
Osteoarthritis O/E?
SQUARING BASE OF THUMB, heberdens and bouchards nodes, effusion and erytherma
Ix for osteoarthritis?
XRAY = LOSS Loss of joint pasce Osteophytes Subarticular sclerosis Subchondral cysts
Joint aspirationn = straw coloured aspirate with high viscosity
what is the management of osteoarthritis?
Lifestyle + physio Occ.therapy Intra-articular steroids Joint replacement Stepwise analgesia: 1) Oralparacetomol +- topical NSAID/capsaicin 2) Oral NSAID + PPI 3) Opiates
WHat is rheumatoid arthritis (RA) and Rfs?
Autoimmune condition causing chronic > 6weeks inflammation of the synovial lining, tendon sheaths and bursa, Characterised by symetrical polyarthritis >4 + extraarcticular manifestations
HLADR4 (common) HLADR1 Smoking Dhx Women more than men in middle age
Articular presentation of RA?
small joints = wrist, ankle. MCP, PIP, MTP (knees, elbows, hips, shoulders)
DIP SPARING
rapid onset or chronic
Systemic = weight loss, fatigue, malaise
Signs of articular RA?
Swan Neck = hyperextended PIP and flexed DIP
Boutonnieres = DIP extendsion and PIP flexion
Radial deviation of wrist
Ulnar deviation at CP
Z deformity on thumb
Extra-articular presentation of RA?
RHEUMATOID NODULES episcleritis/scleritis Secondary Sjorens/sicca Lymphadenopathy Pulmonary fibrosis/pleuritis/bronchiolitis obliterans Pericarditis Carpel tunnel syndrome Tenosynovitis/bursitis
Amyloidosis, Feltys syndrome and ACD
What is Feltys syndrome?
RA, neutropenia and splenomgealy
Ix for RA?
Serology for RF Abs, CCP Abs,
Bloods = elevated CRP, ESR, anaemia and low albumin
Xray = joint space narrowing, joint destruction, deformity, boney reosions at joint margimns , periarticular osteopaenia
Soft tissue swelling
ELAR score 6+ = RA
Mx for RA?
SHort course steroids
NSAIDS/COX2 (PPIs)
Surgery
DMARDS
Progression of DMARDS for RA?
hydroxychloroquine if mild
1) Methotrextae, leflunomide, sulfasalazine
2) 2 in combo
3) methotrexate + biologic e.g. anti-TNF (infliximab/adalimumab)
4) Methotrextae + rituximab
Risk of rituximab and anti-TNF?
immunosuppression -> serious infections or TB/hep B reactivation
Rituximab can cause night sweats and thrombocytopaenia
what are the seronegative spondyloathropathies?
No Rh factor
HLA-B27 association and Men>women
PEAR Psoriatic athritis Enterohepatic arthritis Ankylosing sponylitis Reactive athritis
What is ankylosing athritis and RFs?
Inflammatory athropathy of axial skeleton and peripheral joints, tendos/ligamens and extraarticular sites
+ve FHx
HLA-B27
ERAP-1 or IL-23R genes
Early in males, usually early 20s
What is reactive athritis?
Sterile, seronegative joint inflammatio n that develops in response to extra-articular infection
RFS: HLAD-B27 (70-80%)
?sexual behaviour and STIs
20-30 years M>F
What is Reiters syndrome?
Triad of reactive arthritis, urethritis and conjunctivitis
Articular presentation of AS?
> 3months inflammatory back pain, sacrolilac joints and axial spine>peripheral joints
Early = pain and stiffness late = spinal fusion, kyphosis, loss of lumbar lordosis and eneck extesnion
articular Presentation of Reactive athritis?
1-4 weeks post infection
GI = salmonella, shigella, yesinina, campylobacter
GU = chamydia trachomatic, gonorrhoea
Asymetrical, oligoarthritis and lower extremitis >upper
Extraarticular presentation of AS?
Anterior uveitis >40%
Apical lung fibrosis and aortic regurgitation
Psoriasis
IBD symptoms
Reactive Arthritis extra-articular presentation?
Reitiers = urethritis + conunctivitis
Keratoderman blenorrhagicum
Circinate balantis
oral ulcers
Cystitis/prostatis
How to test for AS?
Schobers Test = lumbar mobility
Tragus to wall (increased in AS)
Stress tests e.g. Gaenslens = sacrolilac joint pain
Xray features or psoriatic arthitis and Eneterohepatic arthritis?
P = pencil-in-cup appearance E = marginal syndesmophytes
Ix for reactive arthritis?
Joint aspiration gram stain, culture and sensitivies to rule out septic joint and cyrstal athropathices
Types of amyloidosis?
Primary = deposit of immunoglobulin light chains.
Associated with MM, lymphoma, waldenstrons macroglobulinaemia
Secondary = Serum amyloid A
Association with RA, IBC< chronic infections e.g. TB
Ix for amyloidosis?
Apple green birenfringence under polarised light - congo red stain
Presentation of amyloidosis?
Periorbital purpura Carpal tunnel syndrome Hepatomegaly Nephrotic syndrome Peripheral neuropathy
Primary as well = macroglossia and restrictive cardiomyopathy
What is septic arthritis and features?
Acute monoarthritis - very painful, erythermatous, swollen, restricted ROm and fever
Caused by current infection S.Aureus >30, Neisseria gonorrhoea<30
What is Gout and what causes it?
Acute monoarthritis, 1st MTP is podagra
Precipitated by trauma or infection. Crystal is monosodium urate adn caused bu hyperuricaemia from increased intake, increased production and decreased excretion
Specific causes of hyperuricaemia?
High pruine diet and alcohol, malignancy e.g. tumour lysis syndrome
What is pseudogout?
Acute monoarthritis of large joints e.g. knee. Can be polyarticular if chronic
Precipitated by illness of trauma.
Calcium pyrophsophate crystals
Causes of psuedogout?
Idiopathic, hyperPTH, hyperPO4, hypoMg, metabolic e.g. haemochromotosis, wilsons and acromegaly
RFs and Ix for septic athritis?
IV drug use, DM< immunosuppression,
Joint damage: RA, prosthetic joint or gout
Aspirate = tubid yellow low viscosirt fluid. Raised WCC 90% neutrophils
MC&S organsim
Bloods for elevated WCC and CRP
Gout RFs and Ix?
Alcohol, high purine diet, obesity, male and diabetes
Aspirate -> yellow, turbid, low viscosity with raised WCC (neutrophils). Needle shaped vely birefringent crystals
Bloods = elevated WCC, CRP and uric acid
XR = rat bite erosions
Pseudogout RFs and Ix?
Elderly and female
Aspirate -> turbid yellow low viscosity fluid. WCC (neutrophils). Rhomboid shaped, +vly birefringent crystals
Bloods = elevated WCC and CRP
Xray = chondrocalconosis
Mx for septic, gout and pseudogout?
SA = IV Abx for 2 weeks and 4 weeks oral and stop biologic therapies
Got acute : NSAIDS +- PPI, colchicine, corticosteroids
Gout prophylaxis: allopurinaol (dont give in acute) . febuxostat, probenecid
Pseudogout: intra-articular coritcosteroids +-paracetomol
Polyarticular = NSAIDS +-colchicine +-paracetomil
What is osteomyelitis?
Infection of bone from haematogenous spread, contiguous spread and direct inoaculation
Haematogenous = IVDU, immunosuppression, DM and Sickle cell
Contiguus = cellulitis and localised infection
Direct - penetrating injury, ulcers and surgery
Leads to inflammation, necrosis and new bone formation.
Mostly Staph A, Potts diease if TB
presentation of ostemyelitis?
Nonspecific pain in affected area, fever, malaise, rigors, preceding skin lesion, sore throat trauma or operation
O/E = localised erytherma, swellign and warmth, reduced ROM, and discharge from wound or affected area
Ix for osteomyelitis?
Raised WCC and CRP/ESR
No chnages onxray 1st 2 weeks then darkening and periosteal thickening
Bone culture = +ve culture
Causative organisms in osteomyelitis>
Here is a breakdown of most common causative organisms of Osteomyelitis by age group (Source BMJ Best practice):
Infants: S aureus, Group B streptococci, Aerobic gram-negative bacilli (e.g.,Escherichia coli), Candida albicans.
Children 3 months – 5 years: S aureus, Kingella kingae(increased incidence in children <4 years), Group A streptococcus, Streptococcus pneumoniae, Haemophilus influenzae(if not vaccinated), Pseudomonas(from foot puncture wounds).
Children > 5 years: Staph aureus, Group A streptococcus
Adults: Staph aureus, Coagulase negative staphylococci, aerobic gram negatives, anaerobic gram positive Peptostreptococcus spp.
Elderly: Gram negative bacilli
