Musculoskeletal topic 1 Flashcards
About arthritis and rheumatological conditions
What is rheumatoid arthritis?
an autoimmune condition that causes chronic inflammation in the synovial lining of the joints, tendon sheaths and bursa. It is a type of inflammatory arthritis.
- tends to affect multiple small joints symmetrically across both sides of the body
What are the causes of Rheumatoid arthritis?
autoimmune system
genetic –> Human leukocyte antigen HLA-DR1 & HLA-DR4
environment –> smoke, pathogen (gut bacteria)
Explain how rheumatoid arthritis forms and affects the joints.
- citrullination, which arginine –> citrulline
- causes the immune cells not to recognise the cells and lead to produce specific autoantibodies and attack own cells in the joints
- synovial cells proliferate and cause pannus
- pannus can cause damage to the cartilage and other soft tissues and erode bone
Clinical features of RA
- muscle weakness
- malaise
-fever - rheumatoid nodules at the elbow, arms and wrists
- stiffness usually lasts more than 45min in the morning
- anaemia
- Baker (popliteal) cyst at the knee joint
- Ulnar deviation
- Boutonniere deformity
- Swan neck deformity
Where does RA usually occur in?
Affects multiple joints:
* Metacarpophalangeal (MCP)
* Proximal inter-phalangeal (PIP)
* Metatarsophalangeal (MTP)
if it further worsens:
* Shoulders
* Elbows
* Knees
* Ankles
What are the symptoms for a flare of RA
- Swollen
- Warm
- Red
- Painful
What is Felty syndrome?
And what triad does it consist of ?
Complication of RA, life-threatening infection
- Rheumatoid arthritis
- Splenomegaly
- Granulocytopenia
What investigation would you do on RA?
Blood tests such as:
- Rheumatoid factor
- anticitrullinated peptide (anti-CCP) antibody
- CRP & ESR
- X-ray
- Ultrasound / MRI to detect any synovitis
How would you manage RA?
- Disease-modifying anti-rheumatic medications (DMARDs)
Methotrexate
Leflunomide
Sulfasalazine - Biologic therapies
What examples of biologics can you give when managing RA?
adalimumab
infliximab
etanercept
Rituximab
Rheumatoid arthritis often/rarely________ affects the distal interphalangeal joints
Rheumatoid arthritis very rarely affects the distal interphalangeal joints.
Enlarged and painful distal interphalangeal joints are more likely to represent Heberden’s nodes due to osteoarthritis.
When will you recommend an urgent rheumatology referral?
When patient experiences persistent synovitis along with their RA
what tools are used to monitor disease activity and response to treatment of RA?
Disease Activity Score 28 Joints (DAS28) score
Give some side effect for the following:
Methotrexate
Leflunomide
Sulfasalazine
Hydroxychloroquine
Anti-TNF medications
Rituximab
Methotrexate: Bone marrow suppression and leukopenia, and highly teratogenic
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Orange urine and male infertility (reduces sperm count)
Hydroxychloroquine: Retinal toxicity, blue-grey skin pigmentation and hair bleaching
Anti-TNF medications: Reactivation of tuberculosis
Rituximab: Night sweats and thrombocytopenia
What is Osteoarthritis?
Result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint.
What is the synovial joint made of?
articular cartilage and synovium
What cells maintain the articular cartilage? And what’s its job
Chondrocyte
they produce extracellular matrix-like
type II collagen–> structural support
proteoglycan –> elasticity
Where are the common affected area of osteoarthritis?
- Hips
- Knees
- Distal interphalangeal (DIP) joints in the hands
- The carpometacarpal (CMC) joint at the base of the thumb
- Lumbar spine
- Cervical spine (cervical spondylosis)
What clinical features would you see in osteoarthritis?
- joint pain and stiffness
- worsen with activity & end of the day
- deformity
- instability
- Restricted range of motion
- Crepitus on movement (cracking sounds)
- Effusions (fluid) around the joint
In what condition where you can make a diagnosis without any investigation into Osteoarthritis
- patient over 45
- has typical pain associated with activity
- no morning stiffness / stiffness that lasts under 30 minutes
What are the mnemonics used to monitor X-rays in Osteoarthritis?
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
What are the non-pharmacological management methods for osteoarthritis?
Therapeutic exercise
weight loss
occupational therapy
What are the pharmacological management methods for osteoarthritis?
topical NSAIDs
oral NSAIDs w PPI
joint replacement (standard in hips and knees)
Intra-articular steroid injections
differences between osteoarthritis and rheumatoid arthritis
Osteoarthritis:
- degenerative disease
- cartilage loss
- morning stiffness - less than 30min
- asymmetrical
- only affects the distal phalangeal & thumb bones
_____________________________________
Rheumatoid arthritis:
- autoimmune disease
- inflamed synovium
- morning stiffness - more than 30min
- symmetrical
- extra-articular involment
What is polymyalgia rheumatica
It’s an immune-mediated disease that causes pain and stiffness in the shoulders, pelvic girdle and neck.
- it’s known to have a close association with giant cell arteritis (GCA)
What are the potential causes of Polymyalgia rheumatica (PMR)
HLA-DR4 genes
adenovirus
Parvovirus B19
long term glucocorticoid uses
typical features of polymyalgia rheumatica
- Women
- over 50 years old
- Caucasians (white)
Clinical features of Polymyalgia rheumatica
- Bilateral shoulder pain & elbow
- Bilateral pelvic girdle pain
- Interfere with sleeps
- Last about 45mins in the morning
- Worse after rest or inactivity
- Happen more than 2 weeks
What investigations would you do to diagnose Polymyalgia rheumatica?
Blood test such as:
ESR
CRP
Creatine kinase
FBC
U&E
LFT
Calcium
Rheumatoid factor
Urine dipstick
Anti-cyclic citrullinated peptide (Anti-CCP)
Anti-nuclear antibodies (ANA)
- Chest X-Ray
What is the first-line treatment for Polymyalgia rheumatica?
Prednisone 15mg with follow-up after 1 week
What is the management of patients on long-term steroids?
(there’s a mnemonic for it)
“Don’t STOP”
Don’t - steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis
Sick day rules - steroid doses may increase if the patient becomes unwell
Treatment card - let others know they’re steroid-dependent
Osteoporosis prevention may require - bisphosphonates & calcium & vitamin D
Proton pump inhibitors might considered (omeprazole)
What is GOUT?
Inflammatory disease where uric acid precipitates into crystals that deposit in various joints around the body
where are the commonly found area of gout?
The base of the big toe - metatarsophalangeal joint (MTP joint)
The base of the thumb - carpometacarpal joint (CMC joint)
Wrist
How’s GOUT usually presented as?
Single, acute, hot, swollen and painful joint
On top of GOUT, what other differential diagnosis can be related to GOUT?
septic arthritis
Risk factors of GOUT
- Male
- Obese
- High purine diet
- Alcohol
- Diuretics
- Cardiovascular / kidney disease
- Family history of Gout
What is the clinical presentation of GOUT?
- Subcutaneous uric acid deposits in the DIP, ears and elbows
- Single, acute, hot, swollen & painful
Affects the: - Metatarsal-phalangeal joint (base of the big toe) &
- Capo-metacarpal joint (wrist)
What investigation would you do to confirm the diagnosis of GOUT?
Aspirate fluid from the joint - examine any septic arthritis.
X-ray
How will you treat GOUT?
First-line –> NSAIDs
Second-line –> Colchicine
Third-line –> steroids (prednisolone)
Prophylaxis:
- Allopurinol
- Lifestyle changes
What are the side effects and caution when taking Colchicine?
gastrointestinal discomfort: diarrhoea (dose-dependent)
not suitable for renal impairment/heart disease
It is advised to give allopurinol when the patient is diagnosed with acute flare-gout
TRUE or FALSE? WHY?
FALSE - cos first line is NSAIDs, so like ibuprofen or naproxen
and only allopurinol after the acute attack, if started then can continue during an acute attack
In the joint fluid examination after the joint aspiration, what is the different of:
- monosodium urate crystals of gout
&
- calcium pyrophosphate crystals of pseudogout
Monosodium urate crystals of gout
Needle-shaped and negatively birefringent of polarised light
Calcium pyrophosphate crystals of pseudogout
rhomboid-shaped and positively birefringent of polarised light
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis. It can vary from mild stiffening and soreness in the joints to complete joint destruction in arthritis mutilans.
What are the key factors to identify psoriatic arthritis?
- Asymmetrical oligoarthritis (1-4 joint affected only 1 side
- Symmetrical polyarthritis (more than 4 joints same side)
- Distal interphalangeal predominant pattern
- Spondylitis
- Arthritis mutilans
How do you differentiate between Psoriatic Arthritis and rheumatoid arthritis?
Psoriatic arthritis affects the distal interphalangeal (DIP) joint (which is similar to osteoarthritis) while rheumatoid arthritis rarely affects DIP joints,
What clinical presentation can you find in Psoriatic Arthritis?
- Check the skin - for psoriasis
- Pitting of the nails
- Onycholysis
- Dactylitis – inflammation of the full finger
- Enthesitis - inflammation of the entheses
What investigation would you get for Psoriatic Arthritis?
Psoriasis epidemiological screening tool (PEST)
X-Ray
What procedure must you do if you get a high Psoriasis epidemiological screening tool (PEST) score?
required to refer to the rheumatologist
Treatment and management for Psoriatic Arthritis?
–> NSAIDs
–> DMARDs
- Methotrexate
- Leflunomide
- Sulfasalazine
–> Anti-TNF
- Etanercept
- Infliximab
- Adalimumab
–> Ustekinumab - monoclonal antibody
What is osteoporosis
involves a significant reduction in bone density which makes the bones weaker and prone to fractures
risk factor of osteoporosis
- Older age
- Post-menopausal women
- Reduced mobility and activity
- Low BMI (under 19 kg/m2)
- Low calcium or vitamin D intake
- Alcohol and smoking
- Personal or family history of fractures
- Chronic diseases (e.g., chronic kidney disease, hyperthyroidism and rheumatoid arthritis)
- Long-term corticosteroids (e.g., 7.5mg or more of prednisolone daily for longer than 3 months)
- Certain medications
what investigation would you do to diagnose osteoporosis?
DEXA scan to find the bone mineral density
Qfracture tool (10yrs risk of major osteoporotic fracture score)
FRAX tool
What management would you do for osteoporosis?
increase physical activity
maintain a healthy weight
stop smoking
reduce alcohol consumption
calcium 1000mg
vitamin d 400-800IU
What is the first-line treatment for osteoporosis?
Bisphosphonates
What are the side effects of taking bisphosphonates?
- Reflux and oesophageal erosions
- Atypical fractures (e.g., atypical femoral fractures)
- Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
- Osteonecrosis of the external auditory canal
What other treatment can you use for osteoporosis other than bisphonates?
- Alendronate 70 mg once weekly (oral)
- Risedronate 35 mg once weekly (oral)
- Zoledronic acid 5 mg once yearly (intravenous)
What is bursitis?
acute/chronic inflammation of a bursa
What is a bursa?
A bursa is a sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer
Risk factors of bursitis
- Occupation
- Rheumatoid arthritis
- Gout/pseudogout
- Penetrating injury
Types of bursitis
Prepatellar – patella
Olecranon – elbow
Trochanteric – Hips
Retrocalcaneal – heals
Subacromial - shoulder
Clinical presentation of bursitis
- Pain at site of bursa
- Tenderness to palpation at the site of the bursa
- Decreased active range of motion
- Low-grade temperature (septic bursitis)
- Swelling
- Erythema (septic bursitis)
investigations of bursitis
- Gram stain and culture of fluid aspirate
- X-ray
- MRI
- physical examination
What will sepsis bursitis present with?
Low-grade fever
Erthyma
Give me treatment for bursitis
first-line - conservation management & analgesia
second-line - corticosteroid injection
third-line - surgery
what is the management and treatment for septic bursitis?
1st-line - antibiotic therapy + aspiration + conserve management + analgesia
2nd-line - surgical debridement and levage + antibiotic therapy + conserve management + analgesia
What is Paget’s disease?
A disorder with a lot of bone remodelling of excessive bone resorption & growth which leads to deformities & potential fractures.
cause of paget’s disease
infections –> measles virus
genetic mutation –> SQSTM1 gene
Where does Paget’s disease primarily affect?
skull
lumbar vertebrae
pelvis
femur
What are the phases of Paget’s disease?
Phase 1 – osteoclasts aggressively demineralise the bone (x20 times)
Phase 2 – mixed phase (lytic + blastic phase) Rapid, disorganized proliferation of new bone tissue by osteoblasts
Phase 3 – sclerotic phase, where new bone formation > resorption
the collagen is structurally disorganized, which leads to weaker bone and easily fracture
Clinical features of Paget’s disease
early symptoms - nothing
pain
hearing & vision loss
leontiasis
vision loss
osteosarcoma (bone cancer)
kyphosis (hunchback)
lower limb muscle weakness
pelvic asymmetry
bowlegs
arthritis / joint inflammation
Investigation on Paget’s disease
- X-ray – check lytic lesion & thickened bone cortex
- Bone biopsy – excludes malignancies
- Blood test INCREASE Alkaline Phosphatase; normal calcium; normal phosphate
treatment of Paget’s disease
Bisphosphonates
pain reliever
surgery
What is an alternative drug used if bisphosphonates is not available in Paget’s disease?
calcitonin
What are the cells that demineralise the bones?
Osteoclast
What is the cell that forms new bone?
osteoblast
What are the mechanisms of bone remodelling?
- osteoblast release Rank L to activated osteoclast to demineralise the bones
- osteoblast can also release OPG to inhibit the osteoclast by binding to the Rank L
What is Gian cell arteritis (GCA)
aka temporal arteritis
type of systemic vasculitis that’s affecting the medium and large arteries
Which alternative disease is GCS strongly associate with?
Polymyalgia rheumatica
what is a key complication of GCA and what group of people are commonly affected?
complication
- vision loss
- stroke
- weight gain, diabetes & osteoporosis
common in older white patients
Presentation of Giant Cell arteritis
Unilateral headache - severe and around the temple and forehead
* Scalp tenderness
* Jaw claudication
* Blurred / double vision
* Loss of vision if untreated
reduced / absent pulsation on the temporal artery
What investigation will be used to diagnose Giant Cell Arteritis?
Clinical presentation (S&S)
Raised inflammatory markers (Raise ESR)
Temporal artery biopsy (showing multinucleated giant cells)
Duplex ultrasound (showing stenosis & hypoechoic sign of temporal artery)
First line treatment for GCA?
40-60mg prednisolone daily with no visual symptoms / jaw claudication
500mg-100mg methylprednisolone daily with visual symptoms / jaw claudication
What other medication can be used to treat GCA after first-line treatment?
Aspirin - 75mg decreases vision loss and strokes
proton pump inhibitor - omeprazole
bisphosphonates and calcium and vitamin D - bone protection while on steroids
