Osteoarthritis and Crystal Arthropathies Flashcards
What is the prevalence of osteoarthritis?
1/3 of population in > 45’s, 1/2 of population in > 70’s
What is osteoarthritis?
Articular cartilage thinning or loss
What are risk factors for cartilage loss?
Age, female, obesity, previous injury, muscle weakness, proprioceptive deficits, genetics, acromegaly, joint inflammation, crystal arthropathies
What are the types of osteoarthritis?
Idiopathic, secondary (previous injury, calcium crystal deposition disease etc)
What is the distribution of osteoarthritis?
Hip, knee, cervical and lumbar spine, MTP joints, DIP, PIP, 1st IP, 1st MCP, CMC
What are the symptoms of osteoarthritis?
Pain = worse on activity and relived by rest (mechanical pain)
Stiffness
What can be seen on examination of patients with osteoarthritis?
Crepitus, joint swelling (bony enlargements due to osteophytes), joint tenderness and effusions
What are the clinical features of osteoarthritis of the hands?
DIP, PIP and 1st CMC joints, bony enlargements of DIPs (Heberden’s nodes) and of PIPs (Bouchard’s nodes), squaring of hands
What are the clinical features of osteoarthritis of the knees?
Osteophytes, effusions, crepitus, reduced ROM, genu varus or valgus, Baker’s cyst
What are the clinical features of osteoarthritis of the hip?
Pain may be felt in groin or radiating to knee (pain felt at hip may also be radiating from the lower back), reduced ROM
What are the clinical features of osteoarthritis affecting the cervical spine?
Pain and restriction of neck movement
What are the clinical features of osteoarthritis of the lumbar spine?
Pain on standing or walking for some time, osteophytes causing spinal stenosis (if encroaching on spinal cord or pinching nerve root)
What are the radiological signs of osteoarthritis?
Loss of joint space, subchondral sclerosis and cysts, osteophytes
What is the Kellgren-Lawrence Radiographic Grading Scale of osteoarthritis?
Grade 0 = no radiographic findings of osteoarthritis
Grade 1 = minute osteophytes of doubtful clinical significance
Grade 2 = definite osteophytes with unimpaired joint space
Grade 3 = Definite osteophytes with moderate joint space narrowing
Grade 4 = definite osteophytes with severe joint space narrowing and subchondral sclerosis
What is the natural history of osteoarthritis?
Small joints of hands = over 2 years pain improves but swelling gets worse
Knees = 1/3 improve, 1/3 stay the same, 1/3 get worse
Hip = 10% come of surgical waiting lists as symptoms improve
What are the non-pharmacological treatments of osteoarthritis?
Physiotherapy = muscle strengthening, proprioceptive
Weight loss exercise, trainers, walking stick, insoles
What are some pharmacological managements of osteoarthritis?
Analgesia = paracetamol, compound/topical analgesia
NSAIDs = topical/systemic, consider risk/benefit ratio
Pain modulators = tricyclics (e.g amitryptiline), anticonvulsants (e.g Gabapentin)
Intra-articular steroids
What are some surgical treatments of osteoarthritis?
Arthroscopic washout, loose body, soft tissue trimming, joint replacement
What is gout?
Inflammation in joint triggered by uric acid crystals
What are some causes increased urate production?
Inherited enzyme defects, myeloproliferative/lymphoproliferative disorders, psoriasis, haemolytic disorders, alcohol, high dietary purine intake
What are some causes of reduced urate excretion?
Chronic renal impairment, volume depletion (e.g heart failure), hypothyroidism, diuretics, cytotoxics (e.g cyclosporin)
What is the epidemiology of gout?
1.4% UK prevalence, 7% in men > 65 and 3% in women >85, more common in men (4:1), rare in women before menopause
What are some features of acute gout?
Usually monoarthropathy = 1st MTP>ankle>knee,
may have normal uric acid levels, renal impairment (may be cause or effect)
What is the onset of acute gout?
Abrupt onset, usually overnight = normally settles in 10 days without treatment (3 days with treatment)
What are some features of chronic tophaceous gout?
Chronic joint inflammation, may get acute attacks, often diuretics associated, high serum uric acid, tophi
What are some investigation result positive for gout?
Raised inflammatory markers, serum uric acid usually raised, synovial fluid shows needle shaped negatively birefringent crystals on polarising microscopy, x-ray
What is the treatment for acute gout?
NSAIDs, colchicine, steroids
What is prophylactic treatment for gout?
Allopurinol, februxostat, start 2-4 weeks after acute attack, require cover with NSAIDs etc
Who gets calcium phosphate deposition disease, and where does it occur?
More common in elderly = chondrocalcinosis increases with age
Affects fibrocartilage = knees, wrists, ankles
What are the two kinds of calcium phosphate deposition diseases?
Calcium pyrophosphate and calcium hydroxyapatite crystals
What causes acute attacks of calcium phosphate deposition disease?
Calcium pyrophosphate crystals (pseudogout) = rhomboid mildly positive birefringent crystals, marked rise in inflammatory markers
What is the treatment for pseudogout?
NSAIDs, colchicine, steroids, rehydration
What causes Milwaukee shoulder?
Hydroxyapatite crystal deposition in or around the shoulder joint = release of collagenases, serine proteases and IL-1
What are some features of Milwaukee shoulder?
Acute and rapid deterioration, occurs in females aged 50-60
How is Milwaukee shoulder treated?
NSAIDs, intra-articular steroid injection, physiotherapy, partial or total arthroplasty
What is soft tissue rheumatism?
General term to describe pain that is caused by inflammation/damage to ligaments, tendons, muscles or nerves near a joint
Where is the pain of soft tissue rheumatism felt?
Confined to specific site (e.g neck, shoulder etc)
What are some features of soft tissue rheumatism of the neck?
Muscular, usually self limiting, consider osteoarthritis of cervical spine etc
What are some features of soft tissue rheumatism of the shoulder?
Most common site, adhesive capsulitis, rotator cuff tendinosis, calcific tendonitis, impingement, partial or full rotator cuff tears
What are some features of soft tissue rheumatism of the elbow, wrist and foot?
Elbow = medial and lateral epicondylitis, cubital tunnel syndrome Wrist = De-Quervain's tenosynovitis, carpal tunnel syndrome Foot = plantar fasculitis
What are some features of soft tissue rheumatism of the pelvis?
Trochanteric and iliopsoas, ischiogluteal bursitis, stress enthesopathies
What are some investigations that can be done for soft tissue rheumatism?
Tests usually unnecessary, x-ray (calcific tendonitis), MRI if fails to settle, identify precipitating factors
What are some treatments of soft tissue rheumatism?
Pain control, rest and ice compression, physiotherapy, steroid injections, surgery
What is the aetiology of joint hypermobility syndrome?
More common in females, general or local, linked to Marfan’s syndrome and Ehlers Danlos syndrome, usually presents in childhood or 30’s
What is the modified Beighton score for joint hypermobility syndrome?
> 10 degrees hyperextension of the elbows
Passively tough the forearm with the thumb while flexing the wrist
Passive extension of fingers or a 90 degree or more extension of the 5th finger
Knees hyperextension >= 10 degrees
Touching the floor with the palms of the hands when reaching down without bending the knees
What score on the modified Beighton score indicates joint hypermobility syndrome?
If score > 4/9
What are some features of joint hypermobility syndrome?
Presents with arthralgia, premature osteoarthritis, normal investigations, treated with physiotherapy
