Osteoarthritis, Crystal Arthritis and Soft Tissue Rheumatism Flashcards
What is the most common musculoskeletal disorder?
Osteoarthritis
What is osteoarthritis
Articular cartilage failure - Thinning or loss of
subchondral sclerosis
Loss of joint space
Subchondral cyst formation
What does cartilage mostly consist of
Collagen type 2 fibres linked by covalent bonds giving them good strength
How is the matrix of the cartilage formed
By the chondrocytes which are embedded within it
What are some of the contributing factors to Osteoarthritis
Age Obesity Lack of osteoporosis Occupation Sports Previous injury Muscle weakness Genetics Female vs male sex
In OA, what is there a release in?
Cytokines including IL-1, TNF and mixed metalloproteinases as well as prostoglandins by the chondrocytes
How are bone cysts caused in OA
When there is no cartilage left covering the surfaces of the joint, the bone is exposed and the synovial fluid goes into the bone causing cysts to develop
What are the two types of osteoarthritis?
Idiopathic and secondary
What joints are commonly affected in localised idiopathic OA
Hands Feet Knee Hip Spine
What is generalised idiopathic osteoarthritis
Involvement of three or more sites
What can lead to secondary OA
Previous injury
Acromegaly
Calcium crystal deposition disease
What are the common presentations of OA
Pain which is typically worse on activity and relieved by rest (mechanical pain)
Stiffness in the morning which lasts less than 30 minutes
How long does the stiffness last in RA
more than 30 mins
What are 2 of the findings found on examination of OA
Crepitus
Bony enlargements due to osteophytes
What is crepitus
Bone rubbing against bone
What joints are affected by OA
All weight bearing joints in the lower limbs
Spine (not thoracic)
Hands (DIP, PIP, 1st IP and 1st CMC and carpal metacarpal joints)
What are the names of the bony enlargements seen at DIPs
Heberdens nodes
What are the bony enlargements seen in the PIPs
Bouchards nodes
Describe the difference between Genu varus and Genu valgus
Varus = knees moving towards the midline Valgus = knees moving away from the midline
What is a Bakers cyst
A fluid filled swelling that develops at the back of the knee (popliteal fossa)
Where might pain be felt in an OA hip joint
Int he groin
radiating to the knee
radiating from the lower back
What 2 parts of the spine are most commonly affected by OA
Cervical and Lumbar
What happens in Cervical OA
Pain and restriction of movement
Osteophytes may impinge on nerve roots
What happens in Lumbar OA
Osteophytes can cause spinal stenosis if they encroach on spinal canal
What is spinal claudication
Narrowing of the spinal canal
How do we make a diagnosis of OA
Clinical and radiological Loss of joint space (due to loss of cartilage) Subchondral sclerosis Subchondral cysts Osteophytes
How do we grade OA
Kellgren-Lawrence Radiographic grading scale
0 = normal
4= late stage
What are the non-pharmacological management for OA
Physiotherapy - muscle strengthening, proprioceptive
Weight loss
Exercise
Walking stick
What are the pharmacological measures for OA
Analgesia - parqacetamol, compound analgesics, topical analgesia
NSAIDs
Pain modulators - tricyclics e.g. amitriptyline, anticonvulsants e.g. gabapentin
What intra-articular management can be given to patients with RA
Steroids (especially in later stages)
Hyaluronic acid
What surgical procedures can be done in OA
Arhtroscopic washout
Loose body
Soft tissue trimming
JOINT REPLACEMENT
What is gout?
inflammation in the joint triggered by uric acid crystals
Men are more likely to have gout than women. True or False
True
When does the incidence and prevalence of gout increase in women
After the menopause
What results in crystallisation
Hyperuricemia
What are some of the causes of hyperuricaemia
Psoriasis Haemolytic disorders Alcohol - beer and spirits High dietary purine intake (red meat, seafood etc) Inherited enzyme defects Chronic renal impairment Volume depletion (heart failure) Hypothyroidism Diuretics Cytotoxics (cyclosporin)
How long would it take for acute gout to settle on its own
about 10 days
With treatment, how long would it take for acute gout to settle
About 3 days
What joints are commonly affected in acute gout
1st MTP > ankle > knee
What is chronic tophaceous gout
Chronic joint inflammation which is often diuretic associated
What can be tests for chronic tophaceous gout
Serum uric acid is usually increased
What investigations can we do for gout
Serum uric acid Raised inflammatory markers Polarising microscopy of synovial fluid Renal impairment XRays
What is the treatment for acute gout
NSAIDs
Colchicine
Steroids
What prophylactic treatment is given for gout
Allopurinol
Febuxostat
Started 2-4 weeks after acute attack
Require cover with NSAID
What is calcium pyrophosphate deposition disease related to
Osteoarthritis
What joints does calcium pyrophosphate deposition disease affect
Fibrocartilage - knees, wrists and ankles
How does calcium pyrophosphate deposition (CPPD) disease come about
Calcium pyrophosphate gets deposited in the cartilage and causes inflammation
What causes acute attacks of CPPD
Calcium pyrophosphate crystals (psuedogout)
Describe the apparence of calcium pyrophosphate crystals
Envelope shaped
What is increased in CPPD
Inflammatory markers
Describe the treatment of CPPD
No long term treatment - just treat the flares for as and when they come using: NSAIDs Colchicine Steroids Rehydration
What is Milwaukee shoulder
Hydroxyapatite
How does Hydroxypatite occur?
Hydoxyapatite crystal deposition in or around the joint
Release of collagenases serine proteinases and IL1
Who is likely to be affected by Hydroxyapatite
Females aged between 50 and 60
What is the prognosis for Hydroxyapatite
Acute and rapid deterioration in the humeral head
What is the treatment for Hydroxyapatite
NSAIDs
Intra-articular steroid injection
Physiotherapy
Partial or total arthroplasty
What is soft tissue rheumatism
The general term to describe pain that is caused by inflammation / damage to ligaments, tendons, muscles or nerve near a joint rather than either the bone or cartilage
Where is the pain located in soft tissue rheumatism
Confined to a specific site e.g. shoulder, wrist etc.
What should be considered for more generalised soft tissue pain
Fibromyalgia
What should be considered in a patient presenting with neck pain
OA of cervical spine
Occipital migraine
Where is the most common site for soft tissue pain
The shoulder
What soft tissue injuries can occur in the shoulder joint
Adhesive capsulitis Rotator cuff tendinosis Calcific tendonitis Impingement partial rotator cuff tears full rotator cuff tears
What is a common soft tissue injury of the foot
Plantar fascitis
What are a common soft tissue injury of the elbow
Medial and lateral epicondylitis
Cubital tunnel syndrome
What are common soft tissue injuries of the wrist
De-Quervains tenosynovitis
Carpal tunnel syndrome
What are common soft tissue injuries of the pelvis
Trochanteric Ilipsoas
Ischiogluteal bursitis
Stress enthesopathies
What are the usual investigations performed for suspected soft tissue injuries
X-Ray - calcific tendonitis
MRI if fails to settle
Identify precipitating factors
What are some treatment options for soft tissue injuries
Pain control Rest and ice compressions PT Steroid injections Surgery
What 2 rare genetic syndromes are related to joint hyper mobility syndrome
Marfan’s syndrome
Ehlers Danlos syndrome
When does joint hyper mobility present ?
Childhood or 3rd decade
When is hyper mobility diagnosed using the modified brighten score
If 4/9 or more is scored
What is the treatment for Hypermobility
Physiotherapy
Explanation
