Muscoskeletal Flashcards by Raina Palit

Rheumatology and bone disease: What is rheumatology?

Branch of medicine dealing with joint, bone and muscle disease
Diseases normally inflammatory
Most are “auto-immune” diseases

*arthiritis is key but not everything, can be systemic - fever, skin rash/nodules, pain and stiffness, heart and lung involvement, neurological problems etc

main ones - rheumatoid arthritis (exam questions), crystal arthritis, spondulo-arthiritis, connective tissue disease, infections, vasculitis - inflammation of blood vessels

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Rheumatology and bone disease: What are the risk factors for rheumatoid arthritis?

smoking

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Rheumatology and bone disease: What is rheumatoid arthritis?

Disease of synovial joints
Affects 1% population
Auto-immune, systemic inflammatory illness
Symmetrical joint inflammation & deformity
“extra-articular” features - features outside of the joints - systemic effects

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Rheumatology and bone disease: How does rheumatoid arthritis pain present?

Inflammatory joint pain
Early morning stiffness (>30 min)
Stiffness after rest - car journey, watching tv, office job
Ease with use/ exercise - (osteoarthritis gets worse, rheumatoid gets better with exercise)
Swelling
May have “flu-like” symptoms
Anti-inflammatory drugs:
NSAIDs eg Ibuprofen – may be helpful - reduces pain, stiffness and swelling

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Rheumatology and bone disease: What are the 4 parts of inflammation?

red, hot, painful, swollen

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Rheumatology and bone disease: Why is RA treated?

can lead to progressive joint deformity

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Rheumatology and bone disease: What deformities of the hand can you get?

Z thumb deformity - hyperextension of the pharyngeal joint and..
swelling - ‘boggy’ - firm, can be tender, spongy feeling
ulnar deviation of the fingers - due to the tendon deviation…
swan neck deformity - due to the tendons deforming
spare DIPJs
swelling and subluxation of MCPJs (when fingers drop down)

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Rheumatology and bone disease: What are the systemic features of RA?

Lungs

Nodules
Lung fibrosis - crackles with stethescope
Pleural effusions - high protein content

Cardiovascular

Pericardial inflammation/ - effusions
Myocarditis
Valve inflammation

Kidneys
- Amyloidosis - repeated episodes of inflammation

Skin

Rheumatoid nodules - will have positive test for Rheumatoid antibodies
Vasculitis - around the finger nails blood vessels occlude due to inflammation of the blood vessels wall and immunodeficiency, common in smokers

Secondary Sjogren’s syndrome

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Rheumatology and bone disease: What blood tests are done for RA?

Anaemia - normocytic/ may be macrocytic
High/ low platelets - high platelets with inflammation
High inflammatory markers – C reactive protein (CRP), Erythrocyte sedimentation rate (ESR) - may not be high
Auto- Antibodies:
Up to 75% positive for RF (Rheumatoid Factor - can get this in TB) and/ or anti-CCP (cyclic citrullinated peptide)- more specific antibody for RA

25% of RA have normal blood tests

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Rheumatology and bone disease: What do you seen in x rays of RA?

EARLY
Osteopenia (thinning) around the joints: “periarticular osteopenia”
Soft tissue swelling

LATE
Erosions
Joint space narrowing
Subluxation/ dislocation
Fusion (“ankylosis”)

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Rheumatology and bone disease: What is the treatment for RA?

IMMEDIATE RELIEF
- NSAIDs (Non-steroidal anti-inflammatory drugs eg Ibuprofen)
- Steroids
Injected into joint/ intra-muscular/ iv/ oral (will not remain on steroids long term)

CONTROL OF DISEASE (immunosuppresive)
- DMARDs (Disease Modifying Anti-Rheumatic Drugs)
Eg Methotrexate (most common drug - comes up a lot in exams), Sulfasalazine, Leflunomide, Hydroxychloroquine - tablet drugs that suppress immune system to decrease inflammation

BIOLOGIC DRUGS - hospital only drugs that do not appear on the prescription list from the GP (all either sc or iv injections)*

Anti TNF (Tumour necrosis factor) eg Infliximab, Adalimumab, Etanercept
B Cell depletion (anti CD20) eg Rituximab - reduces antibodies recognising the RA antigens
Others eg Tocilizumab (anti IL 6), Abatacept (T cell signalling blocker), Jak inhibitors - tablets
increased risk of sepsis and non melanoma skin cancers as well, been used for 20 years but don’t know side effects after that

*so these will not appear on patient’s prescription list from GP

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Rheumatology and bone disease: What are the side effects of RA drugs?

Infection

All increase risk
For biologic drugs: reactivation of TB

Bone Marrow Toxicity
- Low white cell count/ low platelets/ pancytopenia

Hepatotoxic
- Abnormal liver tests (rise in enzymes)

Gastric upset
- Nausea, diarrhoea, flatulence

Skin rashes

WE ADVISE ALL PATIENTS TO STOP DMARDs/BIOLOGIC DRUGS FOR DURATION OF COURSE OF ANTIBIOTICS & FOR UP TO 2 WEEKS AFTERWARDS

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Rheumatology and bone disease: What is methotrexate and how is it prescribed?

Prescribed as once weekly dose: 15-25 mg/ wk (2.5mg tabs)
Never co-prescribe with Trimethoprim/ Septrin (folate antagonists, can cause severe risk of bone marrow suppression)
- Risk of severe bone marrow suppression: all anti-folate drugs

Lung complications

Pneumonitis (fluid, interstitial changes in lungs, most common in first 6 months of treatment) - dried cough, fever, get chest x ray and sats, occurs in less than 1% of patients
Fibrosis??? - controversial

Renally excreted
- Reduce dose/ stop or contact us if patient develops new renal impairment

Contra-indicated in both men and women pre-conception
Nausea, mouth ulcers

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Rheumatology and bone disease: What are the risks of biologic drugs?

Much greater infection risk

Stop 2 weeks prior to surgery/ significant procedure - may need to stop before extractions
Restart 2 weeks later or when wounds healing
Remember to ask your patient if they are on one of these
Contact us

Reactivation of TB/ Hep B & C

Relatively contra-indicated if patient develops cancer

May cause/ exacerbate multiple sclerosis (anti-TNF)

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Rheumatology and bone disease: What is rheumatoid neck?

can get it in longstanding RA

Erosive change at C1/C2 (and lower levels)

Leading to subluxation at the atlanto-axial level or at subaxial levels or both

Important to recognise a “rheumatoid neck” because instability can lead to neurological deficit from spinal cord compression - 1 in 10 have an unstable neck

This may be a problem with intubation or positioning a patient in the dental chair

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Rheumatology and bone disease: What do you do if a patient has rheumatoid neck?

Ask about neck pain

Ask about known “Rheumatoid Neck”

When positioning patient, check no new neck pain develops or neurological symptoms such as pins & needles/ numbness in arms/ hands/ legs

Pre intubation: flexion & extension Xrays of cervical spine & discuss with anaesthetist

Rheumatology and bone disease: How may RA affect caries/gingivitis?

Poor hand/ neck/ shoulder function can impair dental hygiene
Immuno-suppressive drugs may compound this
Remember many RA patients have co-existent osteoporosis, so may well be on bisphosphonates too (jaw necrosis)
Increasing evidence that gingivitis/ caries may be a trigger for RA in genetically susceptible individuals - microbes involved in these may trigger RA?

Rheumatology and bone disease: What is juvenile idiopathic arthritis?

Inflammatory arthritis occurring before the age of 16
Up to 50% “grow out of it” by adulthood
-Many different patterns of arthritis
Jaw underdevelopment
TMJ inflammation leads to altered mandibular growth
Malocclusion, micrognathia (under development of the jaw)
Pain, biomechanical problems

Rheumatology and bone disease: What is spondyloarthropathy?

group of arthritis associated with hLA b27

- RF negative diseases, no antibodies associated

Rheumatology and bone disease: What is Ankylosing spondylitis?

inflammation of the spine leading to new bone formation

-Progressive new bone formation/ calcification in spine = severe limitation of movement

Can have rigid, fused neck (risk of fracture) and/ or atlanto-axial subluxation

Rheumatology and bone disease: What are common features of spondyloarthropathy?

Enthesitis

Inflammation of junction between tendon/ ligament & bone
Eg Achilles tendon - loss of gutters either side of the tendon, tennis elbow

Dactylitis

“Sausage finger” or “sausage toe”
Combination of joint and tendon sheath inflammation

Skin/nail psoriasis

Inflammatory eye disease
- Iritis (also called anterior uveitis) - iris is very irregular, fibrous strands in the eye, complaining of photophobia and blurred vision

Inflammatory bowel disease
- Ulcerative colitis/ Crohn’s disease

Rheumatology and bone disease: What is psoriatic arthritis?

Swelling of proximal and distal joints, skin changes - flaky dystrophic nails due to psoriasis in the nails

asymmetrical pattern
similar thumb changes to RA
nail pitting - dented the nail bed
dactylitis - sausage toes

Rheumatology and bone disease: What is osteoarthritis?

Degenerative process, probably with exaggerated repair response
Leads to pain, stiffness, deformity, reduced joint movement, joint instability
Increases with age
Occupation / hobbies increase risk
Eg Footballers – knees (KNEES ARE BOWING), typists – hands & wrists

bones are sclerotic and whiter than they should be on an x ray

Rheumatology and bone disease: What is the treatment for osteoarthritis ?

Physiotherapy/ exercises

Weight loss (lower limb joints)

Paracetamol, co-codamol, NSAIDs

Surgery as final resort
For uncontrolled pain particularly at night
Joint failure eg knee giving way

Rheumatology and bone disease: What is gout?

Acute inflammatory arthritis. Sudden onset – often overnight, hot painful red joint most common in big toe joint, middle of foot, wrist, finger etc can't put foot to the ground more common in men

Rheumatology and bone disease: What happens in gout?

high level of uric acid in the serum - Urate crystals precipitating out from bloodstream into joints/ soft tissues - Induces intense neutrophil-led inflammatory response Needle-shaped urate crystals under microscope

Rheumatology and bone disease: Why does gout happen?

High uric acid Patient has high serum urate (before attack; urate may be falsely low during attack) Causes of high urate: Genetic predisposition (enzyme defects) Renal impairment - kidney filters uric acid Diuretics - removal of water concentrated the uric acid Dehydration Inter-current illness High alcohol/ fructose/ red meat/ shellfish diet - Part of “metabolic syndrome” – central obesity, diabetes, high blood pressure, high cholesterol

Rheumatology and bone disease: How is gout treated?

ACUTE NSAIDs Colchicine Steroids PREVENTION OF FUTURE ATTACKS Urate lowering drugs eg Allopurinol & Febuxostat (both xanthine oxidase inhibitors) - get rid of urate through the kidneys

Rheumatology and bone disease: What can untreated gout lead to?

severe chronic gout -Chronic polyarticular tophaceous gout - collections of uric acid sitting under the skin

Rheumatology and bone disease: What are connective tissue diseases?

Group of rare auto-immune systemic diseases Certain common features - raynauds (white, blue, red), mouth ulcers, cardio respiratory disease Can be life-threatening, usually due to organ involvement Eg renal failure (glomerulonephritis), lung fibrosis, myocarditis, cerebral involvement (vascular occlusion or vasculitis) Associated with “auto-antibodies” – antibodies directed against “self” More common in women

Rheumatology and bone disease: What connective tissues diseases are there?

Systemic lupus erythematosus (SLE) - most common Scleroderma Primary Sjogren’s Polymyositis/ Dermatomyositis all associated with ANA. - anti nuclear antibody, check this with a blood test

Rheumatology and bone disease: check slide 49

Rheumatology and bone disease: What are some common features of SLE?

Non-erosive arthritis - on x ray, can bring fingers around, fingers not fixed, - jaccob's arthritis Butterfly rash across nose and cheeks - due to sunlight

Rheumatology and bone disease: What is scleroderma or systemic sclerosis?

- Progressive skin thickening & tightening Severe raynaud’s - Often leading to digital ulcers, frank tissue necrosis Can be limited to hands, feet & face (Limited systemic sclerosis LcSSc) Or widespread (Diffuse systemic sclerosis, DcSSc) LcSSc - limited - Also associated with pulmonary hypertension, severe acid reflux - Telangiectasia (tiny blood vessels), microstomia & oral tethering DcSSc - diffuse - Associated with pulmonary fibrosis (often life threatening) “Scleroderma renal crisis” – hypertensive acute renal failure

Rheumatology and bone disease: What is primary and secondary sjorgrens?

Primary - connective tissue disorder occurring on its own without an associated rheumatic illness but with its own systemic manifestations Secondary occurring with a rheumatic illness eg RA,SLE etc Associated with other auto-immune disorders including interstitial lung disease, auto-immune liver disease etc

Rheumatology and bone disease: What is primary sjogren's?

- Dry eyes and mouth - can lead to atopic shrunken parotid gland, atopic shiny glossitis Associated with Ro and La - antibodies - High immunoglobulins, high ESR, positive Rheumatoid Factor (RF) - Fatigue, joint pain Rare but serious complications: - Vasculitis (inflammation of blood vessels) - Renal involvement (renal tubular acidosis) - Neurological involvement (peripheral neuropathy) - Associated with primary biliary cirrhosis (inflammation and stricture of bile ducts) - Lymphoma - 9 fold increase in this, need to look for night sweats, weight loss, lymphadonapthy - patient complains of dry eyes as they don't have the thick lubricating tears but eyes can still stream in wind

Rheumatology and bone disease: What is Polymyositis & Dermatomyositis?

2 diseases associated with inflammation of muscles - Causes weakness of arms and thighs - Painless wasting of these muscles - Both can be associated with lung fibrosis POLYMYOSITIS Muscle involvement only DERMATOMYOSITIS Muscles & skin Photosensitivity/ Purple “heliotrope” rash around eyes Strong association with internal malignancy

Rheumatology and bone disease: how are connective tissue diseases treated?

Different for each, but include: NSAIDs/ Steroids ``` DMARDS Eg Hydroxychloroquine (first line), Azathioprine, Mycophenolate Mofetil ``` ``` Cytotoxic drugs (for life-threatening complications) Eg cyclophosphamide ``` ``` Biologic drugs Eg Rituximab (Anti-TNF drugs are contra-indicated in SLE) ```