Orthopaedics & Rheumatology Flashcards
Osteoarthritis features
Occurs in the synovial joints
Commonly affected Joints
Hips
Knees
Distal interphalangeal (DIP) joints in the hands
Carpometacarpal (CMC) joint at the base of the thumb
Lumbar spine
Cervical spine (cervical spondylosis)
- Imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint
Presentation
- Joint paint and Stiffness at the end of the day and after activity
- Reduced function of joint, Restricted range of motion
- Crepitus on movement
- Effusions (fluid) around the joint
Signs in Hands
- Heberden’s nodes (in the DIP joints)
- Bouchard’s nodes (in the PIP joints)
- Squaring at the base of the thumb (CMC joint)
- Weak grip
Signs in Hip
* Chronic history of groin ache following exercise and relieved by rest
* Red Flag: rest pain, night pain and morning stiffness > 2 hours
Causes: genetic factors, overuse and injury
RF
Obesity
Age
Trauma
Female
Occupation
Osteoarthritis on Xray
LOSS
- Loss of joint space
- Osteophytes forming at joint margins
- Subchondral sclerosis
- Subchondral cysts
Osteoarthritis Management
- Weight loss
- Aerobic + Muscle Strength Excercises
- Topical NSAID
- Oral NSAID (+PPI)
- Do not offer paracetamol or weak opioids
- intra-articular steroid injections - Short lived.
- Joint replacement
Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:
* avoiding flexing the hip > 90 degrees
* avoid low chairs
* do not cross your legs
* sleep on your back for the first 6 weeks
HLA DR4
Rheumatoid Arthritis features
Autoimmune inflammatory arthritis
RF
Smoking
obesity
Female
- Chronic inflammation in the synovial lining of the joints, tendon sheaths and bursa - Stiff, swollen + painful joints
- Worst in morning but relieve with activity
- Often Symmetrical
Commonly affected joints
- Metacarpophalangeal (MCP) joints
- Proximal interphalangeal (PIP) joints
- Wrist
- Metatarsophalangeal (MTP) joints (in the foot)
- palpation: tenderness and synovial thickening: “boggy” feeling.
- +ve ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints
Hand Signs
- Z-shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP and flexed DIP)
- Boutonniere deformity (hyperextended DIP and flexed PIP)
- Ulnar deviation of the fingers at the MCP joints
Swan neck and boutonniere deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.
Rheumatoid Arthritis Ix
- 1st line: Rheumatoid factor (RF)
- 2nd line: if RF -ve: AntiCCP - much higher specificity than RF
- Inflammatory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
Results
- RF is positive in 70-80% of patients with rheumatoid arthritis, high titre levels are associated with severe progressive disease (but NOT a marker of disease activity.)
- Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis
- llowing early detection of patients suitable for aggressive anti-TNF therapy
Rheumatoid F : Rose-Waaler test: sheep red cell agglutination
Rheumatoid Arthritis Xray
- Periarticular osteopenia
- Boney erosions
- Soft tissue swelling
- periarticular erosions
- subluxation (a type of dislocation)
- Joint destruction and deformity (in more advanced disease)
Rheumatoid Arthritis Management
- Initial: DMARD + Bridging Prednislone (short course)
- Flare up: Corticosteroid (oral or IM)
- TNF inhibitors: considered if 2 DMARDs didn’t work.
DMARD Choices
- Methotrexate: Once weekly - can cause pneumonitis
- Sulfasalazine (Orange urine and male infertility (reduces sperm count))
- Leflunomide (Hypertension and peripheral neuropathy)
- Hydroxychloroquine: should only be considered for initial therapy if mild or palindromic disease
TNF Inhibitors
- Etanercept (can cause TB reactivation)
- Infliximab (can cause TB reactivation)
- adalimumab: monoclonal antibody, subcutaneous administration
Monitoring:
- CRP + DAS28 disease monitoring
- Methotrexate users: Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis.
What is palindromic rheumatism?
- self-limiting episodes of inflammatory arthritis
- pain, stiffness and swelling typically affecting only a few joints.
- symptoms last days, then completely resolve
- Rheumatoid factor or anti-CCP antibodies may indicate that it will progress to rheumatoid arthritis.
Rheuamtoid Arthritis Complications
- Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
- Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
- Osteoporosis
- ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
- increased risk of infections
- Depression
- Felty’s syndrome (RA + splenomegaly + low white cell count)
- Amyloidosis
Poor Prognostic features
- rheumatoid factor positive
- anti-CCP antibodies
- poor functional status at presentation
- X-ray: early erosions (e.g. after < 2 years)
- extra articular features e.g. nodules
- HLA DR4
- insidious onset
Where does Atlantoaxial Subluxation occur
- Atlantoaxial subluxation occurs in the cervical spine.
- Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1).
- Subluxation can cause spinal cord compression and is an emergency.
- This needs to be considered when a patient is having a general anaesthetic and requires intubation.
- MRI can be used to visualise changes in these areas as part of a pre-operative assessment.
Psoriatic Arthritis Features
inflammatory arthritis associated with psoriasis
- Psoriatic arthritis occurs in 10-20% of patients with psoriasis (arthritis can appear befor skin changes)
- seronegative spondyloarthropathy
5 Patterns
1. Symmetrical: very similar to rheumatoid arthritis - most common
2. Asymmetrical oligoarthritis: typically affects hands and feet
3. Sacroiliitis
4. DIP joint disease (10%)
5. Arthritis mutilans (severe deformity fingers/hand, ‘telescoping fingers’)
Other Signs
- Psoriatic skin lesions
- Enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis
- Tenosynovitis: typically of the flexor tendons of the hands
- Dactylitis: diffuse swelling of a finger or toe
- Nail pitting + onycholysis
Psoriatic Arthritis Investigations & Management
Psoriasis Epidemiological Screening Tool (PEST) as a way of screening for psoriatic arthritis in patients with psoriasis. It involves questions about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist.
Xray
- ‘pencil-in-cup’ appearance - periarticular erosions and bone resorption.
- periostitis
- New born formation
Management
- mild peripheral arthritis/mild axial disease: NSAID
- Severe: DMARD
- Apremilast: phosphodiesterase type-4 (PDE4) inhibitor → suppression of pro-inflammatory mediator synthesis and promotion of anti-inflammatory mediators
Better prognosis than Rheumatoid Arthritis
Reactive Arthritis
Reiter’s Syndrome
- HLA-B27 associated seronegative spondyloarthropathies
- Triad of urethritis, conjunctivitis and asymmetrical arthritis post STI (Chlamydia trachomatis)
- Develops within 4wk can last 4-6m or maybe chronic (rare)
Also seen
- dactylitis
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)#
Management
- symptomatic: analgesia, NSAIDS, intra-articular steroids
- sulfasalazine and methotrexate are sometimes used for persistent disease
sexually acquired reactive arthritis, SARA
non STI form (Post-dysenteric form)
- Shigella flexneri
- Salmonella typhimurium
- Salmonella enteritidis
- Yersinia enterocolitica
- Campylobacter
Septic Arthritis
how does it differ from reactive arthritis?
Feaures, Causative Organisms, Ix & Management
Features
- Acute, swollen joint (mostly knee)
- Restricted movement in 80% of patients
- Examination findings: warm to touch/fluctuant
- Fever: present in the majority of patients
Causative Organsisms
- Staphylococcus Aureus
- Neiseria Gonorrohoeae - In sexually active young adult.
- Commonly spread by Haematogenously from distant bacterial infections e.g. abscesses
- Can also occur in prosthetic joint replacement.
Ix
- Synovial fluid sampling is obligatory - radiographic guidance needed
- Blood cultures
Management
- flucloxacillin or clindamycin if penicillin allergic
- 2 week IV then 2-4wk Oral
- Needle Aspiration for joint decompression.
In Reactive Arthritis you are unable to aspirate joint
Common Joint, Diagnosis, Management & Prophylaxis
Gout
form of crystal arthropathy
Risk Factors
- Male
- Family history
- Obesity
- High purine diet (e.g., meat and seafood)
- Alcohol
- Diuretics
- Cardiovascular disease
- Kidney disease
- Chronically high blood uric acid levels.
- Urate crystals are deposited in the joint, causing it to become inflamed.
- Present with single acute hot, swollen and painful joint
Commonly Affected Joint
- The base of the big toe – the metatarsophalangeal joint (MTP joint)
- The base of the thumb – the carpometacarpal joint (CMC joint)
- Can affect larger joints such as knee
Diagnosis
- Clinical + Raised Blood Urate (a uric acid level ≥ 360 umol/L)
- Joint Aspiration: Needle-shaped monosodium urate crystals, negatively birefringent of polarised light.
- XRays: Maintained joint space, lytic lesions in the bone, Punched out erosions, Erosions can have sclerotic borders with overhanding edges, joint effusion
Management
- Lose weight and avoid alcohol especially during acute episode
- 1st line: NSAID + PPI
- 2nd line: Colcichine given if NSAID contraindicated due to Renal or Gastric Issues.
Prophylaxis
Recommended if >2 attacks in 12m
* Allopurinol or Febuxostat - lower serum uric acid
* Change NSAID to Colcichine if commencing allopurinol
IMPORTANT to rule out Septic Arthritis First
- oral steroids may be considered if NSAIDs and colchicine are contraindicated.
- a dose of prednisolone 15mg/day is usually used
Pseudo Gout
form of crystal arthropathy
RF
- > 65y
- haemochromatosis
- hyperparathyroidism
- low magnesium, low phosphate
- acromegaly, Wilson’s disease
- Arthopathy caused by deposition of calcium pyrophosphate dihydrate crystals in the synovium
- Knee, wrist and shoulders most commonly affected
- joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
- X-ray: chondrocalcinosis + LOSS (osteoarthritis)
Management
- aspiration of joint fluid, to exclude septic arthritis
- NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
IMPORTANT to rule out Septic Arthritis First
Osteomyelitis
Inflammation in a bone and bone marrow, usually by bacterial infection.
subclassified into:
- Haematogenous osteomyelitis: RF: sickle cell anaemia, IVDU, immunosuppression d, infective endocarditis
- Non-haematogenous osteomyelitis: RF: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
Presentation
- Fever
- Pain and tenderness
- Erythema
- Swelling
Haematogenous Osteomyelitis
- Baceteremia, monomicrobial
- most common in children
- vertebral osteomyelitis most common form of haematogenous osteomyelitis in adults
Non-Haematogenous Osteomyelitis
- contiguous spread of infection from adjacent soft tissues to the bone from site of trauma (usually)
- Polymicrobial, common in adults
Microbiology
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate
Investigations
MRI is the imaging modality of choice, with a sensitivity of 90-100%
Blood tests will show raised inflammatory markers (e.g., WBC, CRP and ESR).
Management
flucloxacillin for 6 weeks
clindamycin if penicillin-allergic
rifampicin or fusidic acid added for the first 2 weeks in acute
Chronic: Abx for 3m
Differs from septic arthritis as this within the bone/bone marrow and arthritis is in the joint
Ankylosing spondylitis features
HLA-B27 associated spondyloarthropathy
RF
- Male (3:1)
- 20s
- Inflammatory condition affecting the axial skeleton (mainly the spine and sacroiliac joints), causing progressive stiffness and pain
- Insidious onset
- Stiffness is usually worse in the morning and improves with exercise
- Can awaken patient from sleep
Examination
- Reduced lateral flexion
- Reduced forward flexion - Schober’s test +ve
- Reduced Chest Expansion
Other features - the ‘A’s
* Apical fibrosis
* Anterior uveitis
* Aortic regurgitation
* Achilles tendonitis
* AV node block
* Amyloidosis
* and cauda equina syndrome
* peripheral arthritis (25%, more common if female)
*
Ankylosing spondylitis Investigation & Management
HLA-B27 is of little use in making the diagnosis as it is positive in:
* 90% of patients with ankylosing spondylitis
* 10% of normal patients
XRay
- sacroiliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- ‘bamboo spine’ (late & uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- chest x-ray: apical fibrosis
Management
- encourage regular exercise such as swimming
- NSAIDs are the first-line treatment
- physiotherapy
- Anti-TNF medications are second-line (e.g., adalimumab, etanercept or infliximab)
- Secukinumab or ixekizumab are third-line (monoclonal antibodies against interleukin-17)
- Upadacitinib is another third-line option (JAK inhibitor)
If the x-ray is negative for sacroiliac joint involvement in ankylosing spondylitis but suspicion for AS remains high, the next step in the evaluation should be obtaining an MRI
Osteoporosis Features
Risk Factors
- Age - POST MENOPausal
- Female
- corticosteroid use
- smoking
- alcohol
- low body mass index
- family history
- RA
- sedentary lifestyle
- premature menopause
- Caucasians and Asians
- endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
- multiple myeloma, lymphoma
- gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. coeliac’s), gastrectomy, liver disease
- chronic kidney disease
- osteogenesis imperfecta, homocystinuria
- Presence of bone mineral density (BMD) of less than 2.5 standard deviations (SD) below the young adult mean density.
- Bone mineral density (BMD) is measured using a DEXA scan (Z value and T Value, T is used in this context)
- If BMD -1 to -2.5 = Osteopenia
- Pathophysiology: Increased bone breakdown by osteoclasts + decreased bone formation by osteoblasts → loss of bone mass.
Medications that may worsen osteoporosis (other than glucocorticoids):
- SSRIs
- antiepileptics
- proton pump inhibitors
- glitazones
- long term heparin therapy
- aromatase inhibitors e.g. anastrozole
