Orthopaedics & Rheumatology History

Question 1

Joint Pain

Answer 1

History

• PC (SOCRATES)
  
  • Joints most affected
  • Onset
  • Time of day
  • Degree of disability
    
    • How does the disability affect activities of daily living? (dressing, washing etc.)
• PMH
  
  • Trauma to joint
  • Extra-articular symptoms
    
    • Eyes, mouth (dry)
    • Skin
      
      • Psoriasis (+/- nail changes)
      • SLE (butterfly)
    • Neck (RA)
    • Lungs
    • Abdo (constipation)
    • Urinary tract (reactive arthritis)
    • Anaemia
  • Systemic upset
• Screen for depression
• DH
• FH
  
  • Autoimmune disease
• SH
  
  • Smoking
  • Alcohol
  • Diet

Differentials

• Acute
  
  • Trauma (haemarthrosis)
  • Septic arthritis
  • Gout
  • Psoriatic
  • RA
• OA
• SLE
• Systemic sclerosis
• Ankylosing spondylitis
• Reactive arthritis

Investigations

• FBC (low Hb)
• ESR + CRP
• RF (anti-CCP if RF -ve)
• Anti-nuclear antibodies
• Serum urate
• Aspiration
  
  • Polarised light microscopy
• X-ray
• DAS28 (disease activity score, RA)

Management

• General
  
  • Lifestyle advice
    
    • Exercise/Rest, weight loss, smoking
  • Physio/Occupational therapy
  • Mobility aids
• Drugs
  
  • OA
    
    • Simple analgesia
      
      • Paracetamol, topical NSAID, NSAIDs (+ PPI)
    • Opioids (codeine)
    • Corticosteroid injection
    • Surgery
  • RA
    
    • Methotrexate + other DMARD (+ short-term corticosteroids)
    • Symptom relief
      
      • Simple analgesia
        
        • NSAIDs / COX-2 inhibitors (celecoxib)
      • Corticosteroids (acute flare ups)
    • Disease progression
      
      • DMARDs (1st line)
        
        • Methotrexate
        • Sulfasalazine
        • Hydroxychloroquine
      • TNF-alpha inhibitors (failure to respond to 2 DMARDs)
        
        • Infliximab
        • Etanercept
        • Adalimumab
      • Rituximab (refractory)
        
        • Anti-CD20
  • Gout
    
    • Acute
      
      • NSAIDs / Colchicine
    • Prevention
      
      • Lifestyle advice
        
        • Lose weight, reduce alcohol, avoid fasting, purine-rich foods, low-dose aspirin (increase serum urate)
      • Allopurinol
  • Psoriatic
    
    • Same as RA

Question 2

X-ray findings in arthropathies

Answer 2

• OA
  
  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis/cysts
• RA
  
  • Loss of joint space
  • Subluxation
  • Periarticular erosions
  • Juxta-articular osteopenia/osteoporosis
• Gout
  
  • Normal joint space
  • Peri-articular erosions (‘punched out’)
  • Soft tissue swelling
• Psoriatic
  
  • Resorption of terminal phalanges
  • ‘Pencil-in-cup’ sign
• Jaccoud’s arthropathy
  
  • Associated with SLE
  • Non-erosive
  • Characterised by ulnar deviation at MCP

Question 3

Connective tissue diseases

Answer 3

Common features

• Autoimmune disease
• Symptoms
  
  • Raynauds
  • Dry eyes, mouth
  • Fever / malaise / fatigue
  • Arthralgia / arthritis
• Antinuclear antibodies

Specific

• SLE
  
  • Relapsing/remitting constitutional symptoms
  • Malar ‘butterfly’ rash, discoid rash
  • Photosensitivity
  • Mouth ulcers
  • Arthritis
  • Chest pain
  • Migraine
• Scleroderma (CREST)
  
  • Skin thickening
  • Calcinosis, telangiectasia in hands
  • Severe Raynaud’s
  • Oesophageal dysmotility
  • Pulmonary fibrosis
• Sjorgen’s
  
  • Dry eyes, mouth
• Polymyositis / Dermatomyositis
  
  • Proximal muscle inflammation
  • Rash
  • Severe muscle involvement - aspiration, respiratory failure
  • Risk of malignancy

Common mangement (vasculitis also)

• Mild - symptomatic relief only
• Moderate
  
  • Steroids
  • Methotrexate
  • Azathioprine
• Severe
  
  • High dose steroids
  • Cyclophosphamide
  • Mycophenolate

Question 4

Temporal arteritis explanation

Answer 4

Who ia affected?

• > 50 years, typically > 60
• More common in women

What is it?

• Temporal arteritis is a type of inflammatory condition that affects blood vessels, particularly the temporal artery that supplies the head

What causes it?

• TA is an autoimmune disease. The immune system defends the body against infection by recognising and attacking bacteria and viruses. Sometimes the immune makes a mistake and recognises it’s own cells as foreign so attacks them.

Symptoms?

• Headache
• Jaw pain when eating
• Vision loss
• Scalp pain when combing hair

Complications?

• Usually presents as a bad headache and visual disturbance. If left untreated this can lead to blindness, therefore its very important to seek treatment straight away.
• Stroke is another complication

What treatment?

• High dose steroids which dampen down the immune system.
• May have to take long term to prevent symptoms recurring
• Side effects
  
  • Weaken bones
  • Predispose to infection
  • Weight gain
  • Stomach ulcers
  • Depression
• ​Don’t stop steroids suddenly
• Low dose aspirin

Follow up

• Bloods to check inflammation