Osteoarthritis, Crystal arthritis and Soft Tissue Rheumatism Flashcards
What is osteoarthritis?
Articular cartilage thinning or loss
Is osteoarthritis a consequence of aging?
Yes
What are some risk factors for osteoarthritis?
Age Female Obesity Previous injury Muscle weakness Proprioceptive deficits Genetic elements Acromegaly Joint inflammation Crystal deposition in cartilage
What is the pathogenesis of OA?
- Normal joint - healthy cartilage is lubricated by synovial fluid
- OA causes the cartilage to begin breaking down, making it thinner and then creating cracks in the surface
- Gaps in the cartilage can expand until they reach the bone
- Synovial fluid leaks into cracks which form in the bones surface when the replacement cartilage wears away. This causes further damage and can lead to cysts or bone deformities
- If not treated, damage can progress to the point where the bones in the joint become permanently deformed
What are the two types of OA?
Idiopathic
Secondary
What can OA be secondary to?
Previous injury
Calcium crystal deposition disease
Rheumatoid arthritis
At what sites is OA likely to occur?
Hip Knee Foot (mtp joints) Cervical spine Lumbar spiner Hand - DIP, PIP, IP, MCP, CMC
What are the symptoms of OA?
Pain - worse on activity, relieved by rest (mechanical pain)
Stiffness - Morning usually lasts less than 30 minutes
What would be seen on examination of OA?
Crepitus
Joint swelling - bony enlargements due to osteophytes
Joint tenderness
Joint effusion
What are bony enlargements at the DIPs called?
Heberdens nodes
What are bony enlargements at the PIPs called?
Bouchards nodes
What else may be seen in the hands of an OA patient?
Squaring of the hand
What may be seen in the knee of an OA patient?
Osteophytes Effusions Crepitus Restriction of movement Genu varus Valgus deformities Bakers cyst
What may be seen in the hip of an OA patient?
Pain in groin or radiating to knee
Pain in hip from lower back
Restricted hip movements
What may be seen in the spine of an OA patient?
Cervical - pain and restriction of neck movement
Lumbar - Pain on standing or walking for some time
Spinal stenosis
How is OA diagnosed?
Clinical + Radiological
- Loss of joint space
- Subchondral sclerosis
- Subchondral cysts
- Osteophytes
What are the categories for the Kellgren-Lawrence Radiographic grading scale of osteoarthritis?
Grade 0 - No radiographic findings of OA
Grade 1 - Minute osteophytes of doubtful significance
Grade 2 - Definitive osteophytes with unimpaired joint space
Grade 3 - Definitive osteophytes with moderate joint space narrowing
Grade 4 - Definitive osteophytes with severe joint space narrowing and subchondral sclerosis
Do symptoms of OA tend to improve?
Yes - not fully however
What is the non-pharmacological management of OA?
Explanation - not because of normal use
Physiotherapy - Muscle strengthening
Common sense measures - weight loss, exercise, trainers, walking stick, insoles
What is the pharmacological management of OA?
Analgesia - Paracetamol, compound analgesics, topical analgesia
NSAIDs - topical/systemic, may give additional symptomatic relief, consider risk/benefit ratio
Pain modulators - Tricyclics (amitriptyline, anti-convulsants)
Intra-articular - steroids
What is the surgical management of OA?
Arthroscopic washout, loose body, soft tissue trimming
Joint replacement
What is gout?
Inflammation in the joint triggered by uric acid crystals
What two factors contribute to purine levels?
Diet
DNA/RNA
What can lead to increased uric acid levels?
Excess consumption
Over production
Under excretion
What is the clinical level for hyperuricaemia?
> 0.42mmol/l
What are some reasons for increased urate production?
Inherited enzyme defects Psoriasis Haemolytic disorders Alcohol High dietry intake
What are some reasons for reduced urate excretion?
Chronic renal impairment Volume depletion Hypothyroidism Diuretics Cytotoxics
What gender does gout affect more?
Men
How many joints does Acute gout usually affect?
Just one
What are the three most commonly affected joints by acute gout?
MTP
Ankle
Knee
How long does acute gout take to settle?
10 days without treatment
3 Days with treatment
What are the characteristics of acute gout?
Abrupt onset
Often overnight
May have normal uric acid
What is chronic tophaceous gout?
Chronic joint inflammation
What is chronic tophaceous gout associated with?
Diuretics
High serum uric acid
Tophi
May have acute attacks
What are the investigations for chronic tophaceous gout?
Raised inflammatory markers Serum uric acid raised Synovial fluid Renal impairment X-ray
What will polarising microscopy show in gout synovial fluid?
Needle shaped negatively birefringent crystals
What is the acute treatment for chronic tophaceous gout?
NSAIDs
Colchicine
Steroids
What is the prophylaxis treatment for chronic tophaceous gout?
Allopurinol
Febuxostat
When should prophylaxis be started for chronic tophaceous gout?
2-4 weeks after acute attack
What are the two types of calcium pyrophophate deposition disease?
Calcium pyrophosphate
Calcium hydroxyappatite crystals
What age group is CPPD common in?
The elderly
Where does CPPD affect?
Fibrocartilage
- Knees
- Wrists
- Ankles
What happens to chondrocalcinosis with age?
Increases with age
What are acute attacks of CPPD caused by?
Calcium pyrophosphate crystals (pseudogout)
What shape are calcium pyrophosphate crystals?
Envelope shaped
Mildly positive birefringent
What happens to the inflammatory markers in CPPD?
Marked rise
What are the associations in CPPD?
Hyperparathyroidism Hypercalcaemia Haemochromotosis Hypomagnesia Hypothyroidism Gout Neuropathic joints Aging Amyloidosis Trauma
What is the treatment for CPPD?
NSAIDs
Colchicine
Steroids
Rehydration
What does hydroxyapatite cause?
Milwaukee shoulder
What are the characteristics of hydroxyapatite deposition?
Release of collagenases, serine proteinases and IL-1
Acute and rapid deterioration
Females
50-60 years
What is the treatment for hydroxyapatite deposition/
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 the ligaments, tendons, muscles or nerve near a joint
Is the pain in STR localised or general?
Localised
What should you consider with generalised soft tissue pain?
Fibromyalgia
What should be considered with neck pain?
Muscular
Self-limiting
OA of cervical spine
Occipital migrane
Where is the commonest area for soft tissue pain?
Shoulder
What are causes of shoulder pain?
Adhesive capsulitis Rotator capsulitis Calcific tendonitis Impingement Partial rotator cuff tears Full rotator cuff tears
What are possible diagnoses for Elbow, wrist, pelvis and foot pain?
Elbow - medial and lateral epicondylitis
Wrist - De-Quervains tenosynovitis
Pelvis - Trochanteric, iliopsoas, ischiogluteal bursitis and stress enthesopathies
Foot - plantar fascitis
What are the investigations and treatment for STR?
X-ray MRI Pain control Rest and Ice PT Steroid injections Surgery
What gender and age does joint hypermobility syndrome usually affect?
Females
Childhood
What is the modified brighton score?
Testing hypermobility
What are features of hypermobility?
Arthralgia
Premature osteoarthritis
Normal investigations
