Rhematologic Disorders of MSK Flashcards
What is a rheumatologist disorder? Basic concepts.
Rheumatology is the study of inflammatory disorders of the connecAve Assues • ConnecAve Assue – Skin, tendons, ligaments, bones, blood vessels, muscle, joints • Over 140 disorders • Most common presentaAons include disorders of the musculoskeletal system
Joints/bones: Arthralgia, ArthriAs
– Tendons, ligaments: TendoniAs/bursiAs
– Muscle: Myalgia, MyosiAs
Systemic problem
what comprises the MSK system?
.
RA definition
Definition – symmetric inflammatory peripheral
polyarthriAs characterized by destrucAon of joints
through erosion of carAlage and bone.
• Most common inflammatory arthriAs
– 1% of the populaAon
– 2:1 female to male raAo
– Peak incidence between ages 40 to 60
• Onset usually insidious over months.
Cause is not known
– Complex interacAon between genes and
environment
– Breakdown of immune tolerance and synovial
inflammaAon
How is rheumatoid arthritis treated?
Early treatment with a disease modifying drug is
standard of care
• Non-disease modifying
– NSAIDs
– Prednisone
• Disease modifying
– Methotrexate
– Hydroxychloroquine
– Sulfasalazine, leflunomide
– Biological agents: TNF-alpha blockers, abatacept, rituximab,
and tocilizumab.
Goal of treatment is clinical remission if possible
• Control of disease prevents bone erosions and
subsequent deformity and loss of funcAon
• All disease modifying drugs are
immunosuppressive and have side effects
• Joint arthroplasty for end-stage disease
Spondylarthropathies
Ankylosing SpondyliAs
- PsoriaAc ArthriAs
- Enteropathic ArthriAs and ReacAve ArthriAs
- UndifferenAated.
How is spondyloarthropathy treated?
.
How does crystalline arthropathy present?
.
how is crystalline arthropathy treated?
.
how to myositis treated?
.
How does myositis present?
.
How does relapsing polychondritis/PMR/CTD present.
.
How is relapsing polycrodritis/PRM/CTD treated
Case 1: 60 y/o woman presents for the first time with sudden onset of severe bilateral shoulder pain with difficulty moving her arm. She also complains of bilateral hip pain and sever stiffness. so stiff she cannot get out of bed w/o assistance. Fatigue, tiredness, overall not well. Controlled long term diabetes.
Systemic- shoulders and hips, overall fatigue
Case 2: 55 y/o M c/o sever r knee pain. Getting bilateral knee pain intermittently for past 5 yers. stiffness in the morning. lately right knee pain is worse. pain up and down stairs. smoker. hx of HTN.
Systemic or not systemic
non systemic
Case 3: 38 y/o F, stiff all over body, thought it was b/c of exercise but hands are especially stiff. takes 1.5 hours before they feel better. swelling in a few of her joints. relatively tired, hard to concentrate and type.
Systemic or not systemic
systemic
DD: RA
osteoarthritis most commonly in the …
inflammatory or not inflammatory?
Knees
also in hips
non-inflammatory
osteoarthritis most commonly in the …
inflammatory or not inflammatory?
What joints of the hands?
Knees
also in hips
non-inflammatory
PIP and first CMC joint
x-ray features: join stays
extra bones - burst
suchondral sclerosis
Osteoarthritis.
OA is a progressive disease represenAng the failed
repair of joint damage that, in the preponderance of
cases, has been triggered by abnormal intra-arAcular
stress.
• All of the Assues of the joint are involved, including
the arAcular carAlage, subchondral bone, ligaments,
menisci (when present), periarAcular muscles and
peripheral nerves.
• OA may be iniAated by an abnormality in any of
these Assues. Thus, OA is not a disease merely of
carAlage but is a failure of the synovial joint.
Osteoarthritis findings (epi)
Most common type of arthriAs
– OA of the knee, hand, or hip have a similar prevalence of
~20-30% of adults
– More than half of individuals over age 55 have
radiographic evidence, goes up to 90% at age 70
– Slight female predominance in older age, but both sexes
affected
OsteoarthriAs: Classification
Idiopathic
– Localized
– Generalized (3 or more sites)
• Secondary
– Trauma, congenital, crystalline arthropathy,
osteonecrosis, inflammatory arthriAs, sepAc
arthriAs, Paget’s disease, Diabetes, Charcot/
neuropathic arthropathy, hypothyroidism,
acromegaly, frostbite
Damage to normal arAcular carAlage by physical forces
(can be single events of macrotrauma or repeated
microtrauma)
– Chondrocytes react to this injury by releasing degradaAve
enzymes
– inadequate repair responses
• Fundamentally defecAve carAlage fails under normal
joint loading, thereby leading to osteoarthriAs.
– type II collagen gene defect
– ochronoAc carAlage that fails because of deleterious
pigment deposiAon
Osteoarthritis: diagnosis
History is important – gradual onset of symptoms,
lack of inflammaAon, someAmes history of prior
injury or overuse or other secondary trigger
• Physical exam – crepitance, hypertrophic changes,
lack of erythema or warmth, usually not much
tenderness
• X-ray will confirm diagnosis – asymmetric joint space
narrowing, sclerosis near the joint line, and spurring
are characterisAc
Osteoarthritis nodes - hands
Heberden’s nodes - DIP joint bony nodules
- Bouchard’s nodes - PIP joint bony nodules
- Both “nodes” are diagnosAc for hand OA
– 10 Ames more common in women than men,
and have a strong geneAc component
Base of thumb :1st CMC
joint
– Very commonly affected
• Treatment
– NSAIDs or Tylenol
– CorAcosteroid injecAons
parAcularly for base of
thumb
– Rarely ever surgery
Genetic factors for RA
GeneAc factors clearly important
– HLA “shared epitope” is strongest risk factor
– Non-HLA genes such as PTPN22, STAT4, TNFAIP3
• Environmental factors
– Cigareoe smoking increases both risk of disease
and severity of disease
RA Diagnosis
Symmetric pain and swelling in small joints of
hands, wrists, feet, ankles most common,
followed by knees, elbows, shoulders
– Morning sAffness – beoer with acAvity
– ConsAtuAonal symptoms – faAgue, even
weight loss are common, but fever is VERY
RARE
– Steady, progressive, addiAve onset is most
common presentaAon
