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Year 2 LCRS > Musculoskeletal 6 - Osteoarthritis & Reactive Arthritis > Flashcards

Musculoskeletal 6 - Osteoarthritis & Reactive Arthritis Flashcards

1
Q

What is reactive arthritis?

A
  • Sterile inflammation in joints following infection especially urogenital (e.g. Chlamydia trachomatis) and gastrointestinal (e.g. Salmonella, Shigella, Campylobacter infections) infections
  • Reactive arthritis may be first manifestation of HIV or hepatitis C infection
  • Commonly young adults with genetic predisposition (e.g. HLA-B27) and environmental trigger (e.g. Salmonella infection)
  • Symptoms follow 1-4 weeks after infection and this infection may be mild
  • Reactive arthritis is distinct from infection in joints (septic arthritis)
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2
Q

List the important extra-articular manifestations of reactive arthritis

A
  • Sterile urethitis
  • Skin inflammation (circinate balanitis, psoriasis-like rash on hands and feet)
  • Eye inflammation (sterile conjunctivitis)
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3
Q

Describe musculoskeletal symptoms of reactive arthritis

A

Arthritis

  • Asymmetrical arthritis
  • Oligoarthritis (less than 5 joints)
  • Lower limbs are typically affected

Enthesitis

  • Heel pain (achilles tendonitis)
  • Swollen fingers (dactylitis)
  • Painful feet

Spondylitis

  • Sacroilitis (inflammation of the sacro-iliac joint)
  • Spondylitis (inflammation of the spine)
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4
Q

Compare rheumatoid arthritis and reactive arthritis

A

Rheumatoid

  • F>M
  • All ages
  • Symmetrical, polyarticular, small and large joints affected
  • No enthesopathy
  • No spondylitis
  • No urethritis
  • Subcutaneous nodules
  • Rheumatoid factor
  • HLS-DR4 association

Reactive arthritis

  • M>F
  • 20-40 years
  • Asymmetrical, oligoarticular, large joints affected
  • Enthesopathy
  • Spondylitis
  • Urethritis
  • Skin involvement K. lennorhagicum and circinate balanitis
  • No Rheumatoid factor
  • HLA-B27 associated
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5
Q

How is reactive arthritis diagnosed?

A
  • Microbiology (microbial cultures and serology for HIV/ hepatitis C)
  • Immunology (rheumatoid factor, HLA-B27)
  • Synovial fluid examination (if a single joint is swollen, check for septic arthritis using joint aspiration)
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6
Q

Compare septic arthritis and reactive arthritis

A

Septic arthritis

  • Synovial fluid culture positive
  • Antibiotic therapy used
  • Joint lavage used for large joints
  • Usually single joint affected, gonococcal arthritis affects multiple joints

Reactive arthritis

  • Sterile synovial fluid culture
  • No antibiotic therapy
  • No joint lavage
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7
Q

How is reactive arthritis treated?

A
  • In most patients, resolution occurs within 2-6 months so no antibiotic use
  • NSAIDS, intra-articular corticosteroid therapy (articular) can be used
  • Symptomatic therapy (extra articular, typically self-limiting - use of topical steroids and keratolytic agents)
  • Oral glutocorticoids and steroid-sparing agents (refractory disease)
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8
Q

Define osteoarthritis

A

Chronic slowly progressive disorder due to failure of articular cartilage that typically affecting joints of the hand (especially those involved in pinch grip), spine and weight-bearing joints (hips and knees).

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9
Q

List the joints typically affected by osteoarthritis

A
  • Joints of the hand (DIP, PIP, CMC, MCP spared)
  • Spine
  • Weight baring parts of lower limbs (knees and hips, MTP)
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10
Q

List the nodes seen in the hand in osteoarthritis

A
  • Osteophytes at the DIP joints (heberdens nodes)

- Osteophytes at the PIP joints (bouchards nodes)

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11
Q

List the commonly associated symptoms of osteoarthritis

A
  • Joint pain (worsens on activity, improves with rest)
  • Joint crepitus (creacking, cracking grinding sound on moving)
  • Joint instability
  • Joint enlargement (heberdens nodes)
  • Joint stiffness after immobility
  • Limitation of motion
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12
Q

List the radiographic features of osteoarthritis

A
  • Joint space narrowing
  • Subchondral bony sclerosis
  • Osteophytes
  • Subchondral cysts
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13
Q

Compare radiographic changes in rheumatoid arthritis vs osteoarthritis

A

RA

  • Joint space narrowing
  • Osteopenia
  • Bony erosions
  • No subchondral sclerosis or osteophytes

Osteoarthritis

  • Joint space narrowing
  • Subcondral sclerosis
  • Osteophytes (bone spurs)
  • No osteopenia or bony erosions
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14
Q

What is seen in osteoarthritis?

A
  • Defective and irreversible articular cartilage and damage to underlying bone
  • Due to excessive loading on joints and/or abnormal joint components
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15
Q

Describe the pathophysiology of osteoarthritis

A
  • Abnormal stresses (genetic, trauma, obesity, muscle weakness) on normal cartilage
  • Normal stresses (ageing, genetic, inflammation, metabolic changes, endocrine factors) on abnormal cartilage
  • Cartilage affected by carilage fibrillation, osteophyte formation and subchondral bone sclerosis
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16
Q

What are proteoglycans?

A
  • Glycoproteins containing one or more sulphated glycosaminoglycan chains
  • GAGs are repeating polymers of disaccharides (eg. heparin, keratan sulphate, heparan sulphate, chondrolin sulphate, dermatan sulphate)
  • Aggrecan is the major proteoglycan in articular cartilage
  • Retains water
17
Q

What is hyaluronic acid?

A
  • The only non-sulphated GAG

- Major component of synovial fluid where it has an important role in maintaining synovial fluid viscosity

18
Q

List the cartilage and bone changes in osteoarthritis

A

Cartilage changes

  • Reduced proteoglycan
  • Reduced collagen
  • Chondrocyte changes e.g. apoptosis

Bone changes

  • Changes in denuded sub-articular bone (proliferation of superficial osteoblasts resulting in production of sclerotic bone, and focal stress on sclerotic bone leading to focal superficial necrosis)
  • New bone formation at the joint margins (osteophytes or bone spurs - can be detected clinically, heberdens nodes/ bouchards nodes)
19
Q

How is osteoarthritis managed?

A
  • Education
  • Physical therapy – physiotherapy, hydrotherapy
  • Occupational therapy
  • Weight loss where appropriate
  • Exercise
  • Analgesia (Paracetamol, non-steroidal anti-inflammatory agents, intra-articular corticosteroid injection)
  • Joint replacement
20
Q

List the therapeutic approaches for osteoarthritis not approved in the UK

A
  • Glucosamine and chondrotin sulphate (dietary supplementation, commonly taken over the counter)
  • Intra-articular injections of hyaluronic acid (only used in knee joint - experimental)
  • No disease modifying osteoarthritis drug
21
Q

Describe the structure of normal articular cartilage

A
  • Avascular and aneural
  • Collagen (90% type II)
  • Chondrocytes
  • Proteoglycan monomers (Aggrecan) which has CAG groups which attract water

Year 2 LCRS (128 decks)

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