MSK - arthritis Flashcards by Katie Cox

Outline osteoarthritis

Chronic

Cartilage deterioration → bones rub together → stiffness, pain, less mobility

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Main risk factors of OA?

Age
Weight
Intense sport or forces 
Hereditary 
Female gender and menopause

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Explain the cycle of obesity and OA

Obesity increases pressure on knee joints
This leads to joint pain/arthritis 
Limited mobility 
Lack of physical activity 
Obesity

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Where are the main sites of OA?

Spine
Knees
Fingers
Hips

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Signs and symptoms of OA?

Pain gets worse throughout day as use increases
Little morning stiffness
Joint instability, bony enlargement, less mobility, crepitus, some swelling

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What abnormalities can be seen on an OA radiograph?

Osteophytes
Subchondral cysts
Sclerosis
Small space between bones

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What are the 3 main types of OA management + examples?

Conservative - weight loss, analgesics, physio

Injections - steroids, lubrications gel, platelet plasma

Operative - replace, realign, excise

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What are the names of DIP and PIP nodes?

Bouchard’s - proximal

Heberdens - distal

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What are the 3 functional classifications of joints?

Synarthoses - no movement

Amphiarthoses - limited movement

Diarthosese - free movement

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What makes up the synovium?

Type A synoviocyte - phagocytic
Type B synoviocyte - hyaluronic acid
Type 1 collagen

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What are the main components of articulation cartilage?

Chondrocytes

ECM:
Type 2 collagen
Proteoglycan, aggrecan
Water

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What is a function of aggrecan?

Interacts with hyaluronic acid to from proteoglycan aggregates

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Why does cartilage heal poorly?

It is avascular

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What are the two types of arthritis?

Osteo, degenerative

Inflammatory

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5 manifestations of inflammation?

Redness 
Pain
Heat
Swelling
Loss of function

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Pathophysiology of inflammation?

Increased blood flow
Leucocytes to tissues
Activation of these
Cytokine produced

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What are the 3 main causes of joint inflammation?

Infection
Crystals
Autoimmunity

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What causes septic arthritis?

Infection usually from blood

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Septic arthritis risk (3)

Intravenous drug use
Immunosuppressed
Pre existing joint damage

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What is the usual presentation of SA?

Mono arthritis

Acute pain, redness, heat, swelling, fever

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How is SA diagnosed and treated?

Joint aspiration sent for gram stain and culture

Treatment of surgical lavage and IV antibiotics

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What organisms can cause SA?

Staphylococcus aureus
Stretococci
Gonococcus

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How does gonococcal SA present differently?

Usually polyarthritis

Less likely to cause joint destruction

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2 types of Crystal arthritis?

Gout

Pseudogout

What is gout caused by?

Deposition of urate crystals | This caused by high uric acid levels

What causes hyperuricaemia?

Genetics Increased consumption of purine rich foods Kidney failure- reduced excretion

What causes pseudogout?

Deposition of calcium pyrophosphate dihydrate crystals

What are 3 risk factors for pseudogout?

Osteoarthritis Elderly Inter current infection

What are the clinical features of gout?

Acute rapid onset monoarthritis Can be in foot, ankle, knee, wrist, finger, elbow Tophi can also be seen

What is the most commonly affected joint on gout?

First metatarsophalangeal joint - podagra

How can crystal arthritis present on radiography?

Rat bite erosions

What is the difference between gout and pseudogout aspirations? And how is it analysed?

Under microscope using polarised light G - needle crystals, negative birefringence PG - rhomboid crystals , positive birefringence

How can rheumatoid arthritis be classified?

Chronic Auto immune Inflammatory

What are 3 main signs of RA?

Polyarthritis - often hands and wrists Symmetrical Early morning joint stiffness

What can be detected in the blood of RA patients?

Rheumatoid factor - an autoantibody against IgG

What is the main site of pathology in RA?

Synovium- synovitis, tenosynovitis, bursitis

What are some extra articular features of RA?

Fever, weight loss, subcutaneous nodules ``` Vasuculitis Episcleritis Neuropathies Feltys syndrome Lung disease Amyloidosis ```

What is Felty’s syndrome?

Triad of splenomegaly, leukopenia, RA

What are the subcutaneous nodules in RA?

Centre of fibrinogen necrosis surrounded by histiocytes and connective tissue Approx 30% patients

Explain the pathogenesis of RA in regards to the synovium

Synovium becomes a mass of tissue (pannus) due to : Neovascularisation Lymohangiogenesis Imflammatiry cells excess due to an excess of pro inflammatory cytokines

What is the dominant pro inflammatory cytokine in RA and what is it produced from?

TNF-a produced by activated macrophages

Name a treatment for RA

TNFa inhibitors

What are the 2 antibodies in RA?

Rheumatoid factor (IgM antibody against IgG) Antibodies to citrullinated protein antigens (ACPA) - highly specific to RA

What is the citrulliantion of peptides and what enzyme is involved?

Arginine → citrulline Peptidyl arginine deaminases (PADs)

What are the treatment options for RA?

DMARDs 1st: methotrexate with hydroxychloroquine/salfasalazine 2nd: biological therapies, Janus Kinase inhibitors Glucocorticoids (prednisolone)

Give 4 examples of biological therapies for RA?

Anti TNFa B cell depletion, rituximab Modulation of T cell co stimulation Inhibition of IL6 signalling , tocilizumab

Outline some of the differences in presentation between OA and RA

RA : 30-50yrs, rapid onset, bilateral symmetric, better with movement, morning stiffness, PIP & MCP joints, wrist ankle elbow, systemic symptoms, red warm joint swelling, serum positive, high CRP & ESR OA : >50yrs, slow onset, assymetric, worse with movement, no morning stiffness, DIP & CMC joints, bony joint swelling , serum negative

Radiological differences between OA and RA?

RA : osteopenia, bony erosions OA : subchondral sclerosis, osteophytes Both have joint space narrowing

What is one difference between RA and psoriatic arthritis?

PA is seronegative , no rheumatoid factors

How can psoriatic arthritis present?

Asymmetrical arthritis in IPJs Symmetrical involve,ent of some small joints (rheumatoid pattern) Spinal and sacroiliac joint inflammation (spondyloarthritis) Oligoarthritis of large joints Arthritis mutilans

What is reactive arthritis and when does it normally occur?

Sterile inflammation of joints | Follows urogenital or gastrointestinal infections , 1-4 weeks after

What 2 conditions can reactive arthritis present in?

HIV and hepatitis C

What are 3 extra articular manifestations of reactive arthritis?

Skin inflammation Eye inflammation Enthesitis

What is a risk factor for reactive arthritis?

Young adults with genetic predisposition with environmental trigger

Differences between septic and reactive arthritis?

SA : positive synovial fluid culture, antibiotic therapy, joint lavage RA : negative culture, no ab therapy, no joint lavage

What is systemic lupus erythematous?

Autoimmune disease affecting multiple organs

What do the autoantibodies in SLE attack?

Nucleus - nucleic acids and proteins

What are the 2 autoantibodies in SLE and their differences?

Antinuclear antibodies - high SLE sensitivity but not specific Anti-double stranded DNA antibodies - high specificity for SLE