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
