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IHD Part 2 306 > Muscoskeletal > Flashcards

Muscoskeletal Flashcards

1
Q

Rheumatology and bone disease: What is rheumatology?

A

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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2
Q

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

A

smoking

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3
Q

Rheumatology and bone disease: What is rheumatoid arthritis?

A

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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4
Q

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

A

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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5
Q

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

A

red, hot, painful, swollen

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6
Q

Rheumatology and bone disease: Why is RA treated?

A

can lead to progressive joint deformity

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7
Q

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

A

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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8
Q

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

A

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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9
Q

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

A

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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10
Q

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

A

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

LATE
Erosions
Joint space narrowing
Subluxation/ dislocation
Fusion (“ankylosis”)
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11
Q

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

A

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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12
Q

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

A

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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13
Q

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

A
  • 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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14
Q

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

A

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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15
Q

Rheumatology and bone disease: What is rheumatoid neck?

A
  • 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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16
Q

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

A

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

17
Q

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

A
  • 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?
18
Q

Rheumatology and bone disease: What is juvenile idiopathic arthritis?

A
  • 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
19
Q

Rheumatology and bone disease: What is spondyloarthropathy?

A
  • group of arthritis associated with hLA b27

- RF negative diseases, no antibodies associated

20
Q

Rheumatology and bone disease: What is Ankylosing spondylitis?

A

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

21
Q

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

A

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

22
Q

Rheumatology and bone disease: What is psoriatic arthritis?

A

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
23
Q

Rheumatology and bone disease: What is osteoarthritis?

A

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

24
Q

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

A

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

25
Q

Rheumatology and bone disease: What is gout?

A

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

26
Q

Rheumatology and bone disease: What happens in gout?

A

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

27
Q

Rheumatology and bone disease: Why does gout happen?

A

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
28
Q

Rheumatology and bone disease: How is gout treated?

A

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

29
Q

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

A

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

30
Q

Rheumatology and bone disease: What are connective tissue diseases?

A

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

31
Q

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

A

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

32
Q

Rheumatology and bone disease: check slide 49

A

-

33
Q

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

A

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

34
Q

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

A
  • 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

35
Q

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

A

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

36
Q

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

A
  • 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
37
Q

Rheumatology and bone disease: What is Polymyositis & Dermatomyositis?

A

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

38
Q

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

A

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)

IHD Part 2 306 (23 decks)

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