Rheumatoid Arthritis + OA + Hip Pain Flashcards

1
Q

What is RA and what joints are common

A
Autoimmune systemic illness 
Chronic symmetric polyarticular arthritis + other features
Hands and feet common
- PIP + MCP of hand 
- Wrist and ankle
- MTP
- Cervical spine

REMEBER - DIP never affected so more likely Hebreden node

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2
Q

When doe RA typically present

A

F>M
4th / 5th decade but from 16
Other autoimmune - DM / pernicious anaemia / alopecia
HLA DR4 / DR1

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3
Q

What are the typical symptoms of any rheumatoid arthritis

What are the typical signs in the hands

A
Symmetrical 
Pain 
Stiffness >30 minutes 
Often worse in morning and symmetrical 
Onset can be gradual or rapid 
Usually small joints of hands and feet 
Swelling 
Tenderness
Reduced ROM
Heat 
Redness 
Recurrent soft tissue infections 
Rheumatoid nodules 

Systemic - fever, weight loss, flu like illness

Hand signs

  • Boggy soft swelling
  • Z shape thumb deformity
  • Swan neck deformity (hyperextended PIP)
  • Ulnar deviation of fingers at the knuckle (MCP)
  • Radial deviation of wrist
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4
Q

What are the features needed for classification?

A
4/7 >6 weeks 
Morning stiffness >1 hour 
Arthritis >3 joints (can all be in hand) 
At least one in hand (wrist, MCP, PIP) 
Symmetric arthritis 
Rheumatoid nodules 
Serum rheumatoid factor
Erosions / bony decalcifications on X-RAy not just OA changes
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5
Q

What else can rheumatoid present with but rare

A

Extra-articular features but few joint problems

Much rarer

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6
Q

What happens to the eyes in RA

A
Keratoconjunctivitis sicca = most common 
Scleritis / episcleritis 
2nd Sjogren's
Cataract due to steroids
Corneal ulceration/ keratitis
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7
Q

What are CVS features

A

Pericarditis
Pericardial effusion
Increased lipid metabolism
IHD

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8
Q

What are features in the lung

A
Fibrosing alveolitis 
Pleural effusion 
Pulmonary fibrosis
Methotrexate pneumonitis
Bronchiolitis obliterins
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9
Q

What is Felty’s syndrome

A

RA
HSM
Neutropenia / low WCC - predisposed to severe infection as enlarged spleen destroys

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10
Q

What other diseases can present with RA

A
Anaemia chronic disease 
Vasculitis 
Amyloidosis
Raynaud's 
Osteoporosis 
Carpal tunnel
Kidney issues 
Depression
Increased risk of infection
Atlanta-axial subluxation - post surgery get AP and lateral C-spine X-ray as risk of cord compression if occurs
- MRI if it does
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11
Q

How do you Dx RA

A

Largely clinical Dx
Bloods
Immunological tests
X-Ray
USS can be used to confirm synovitis if unclear
MRI
If aspirate joint in flare would look like SA but more well

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12
Q

What are the immunological variables in RA

A

RF +Ve
If RF -ve then check anti-CCP = more sensitive but expensive

ANA +ve

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13
Q

What do bloods show

A

Increased ESR / CRP
Anaemia of chronic disease
Increased platelets

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14
Q

What are early x-ray changes

A

Loss of joint space
Juxta-articular osteopenia
Soft tissue swelling
Joint deformity

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15
Q

What are late x-ray changes

A
Unequivocal bony decalcification 
Loss of joint space
Subluxation 
Soft tissue swelling 
Peri-articular osteopenia and erosions
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16
Q

What do disease activity scores suggest DAS28

A
<2.4 = remission
>5.1 = need for biologics
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17
Q

What is important when treating

A

Early Rx needed before irreversible destruction occurs

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18
Q

How do you Rx

A

Simple analgesia - paracetamol / codeine (reduce need for NSAID)
NSAID + PPI
DMARD’s = 1st line and recommended to be started ASAP
Biologics
Manage CVS RF as accelerates atherosclerosis

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19
Q

How do you Rx flare up

A

Oral or intra-articular steroids

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20
Q

How do you monitor response and how does this change management

A

CRP
Disease activity - DAS28
If disease activity increasing then need to alter DMARD
If just painful then alter pain relief

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21
Q

What are non-pharmacogical options

A

Regular exercise
OT
Physio
Aids

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22
Q

What is common DMARD

A

Methotrexate = 1st line

Use short course of bridging prednisolone

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23
Q

What are other DMARD’s

A

Sulfasalazine
Lefuonmide
Hydroxychloroquine - mildest

If pregnant use hydrochloroquine or sulfasalazine

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24
Q

When are biologics given

A

Inadequate response to 2+ DMARD

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25
Q

Biologic examples

A

Infliximab / Etanercept = Anti-TNF

Ritixumab = B cell depletion (Anti-CD20)

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26
Q

What other conditions have positive RF

A
Sjogren
SLE
Scleroderma
Felty
IE
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27
Q

What suggests poor prognosis

A
Male
Younger onset 
RF +ve
Anti-CCP 
Poor functional status
More joints and organs affected 
HLA DR4
Early erosions 
Extra-articular features e.g. nodules 
Insidious onset
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28
Q

What are SE of DMARD

A
Immunosuppression
Methotrexate pneumonitis
Oral ulcers
Hepatotoxicity / cirrhosis 
Teratogenicity
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29
Q

What do you get if on DMARD

A

CXR before methotrexate

Regular FBC + LFT monitoring

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30
Q

What causes RA

A

Autoimmune
Genetics
Environment

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31
Q

What is autoimmune part

A
RF
ACPA
Anti-CCP
ANA+ve 
Can get sero-ve RA
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32
Q

What genetics are involved

A

Lots of genes different to immune

HLA genes - DR1/DR4

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33
Q

Environment role

A

Infections - EBV / CMV / E.coli / mycoplasma

Smoking

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34
Q

What do these 3 roles together lead too

A

Formation of immune complex

Loss of tolerance and autoimmunity

35
Q

What is pathophysiology of rheumatoid arthritis

A

Synovitis
Synovium hyperplasia
Infiltration inflammatory cells - CD4, MO, B-cell, lymphocyte and neutrophils
B cell = Ab + cytokines
Neoangiogensis occurs increasing vascularity
T cells = inflammation
Cytokines recruits inflammatory

36
Q

What causes cartilage and bone destruction

A

Cytokines activity fibroblasts / osteoclasts
Osteoclast activated under RANKL produced by synovial
Invade cartilage and produce proteases to break down

37
Q

SE of biologics

A

Infusion reaction
Immunosuppression
Reactive of TB

38
Q

What is OA

A

Degenerative joint disorder
Wear, tear and repair
Loss of articular hyaline cartilage + new bone formation
Repair / remodelling = restriction and loss of function

39
Q

What is pathology behind OA

A
Inflammation
Synovial hypertrophy
Subchondrial changes
Loss of cartilage 
Joint effusion 
Remodellnig = loss of function
40
Q

What causes primary OA

A

Micro-trauma on top of RF

41
Q

What are RF for OA

A
Age
Occupation
Persistent physical activity 
Obesity
Female 
FH 
DDH
Joint abnormality
42
Q

What joints are most commonly affected

A

Knee and hip = most common
MIP and DIP in hands (DIP NEVER in RA)
C-MCP in thumb

43
Q

What are secondary causes

A
Trauma - fractures / cartilage injury / meniscal surgery / osteomyeltiis
Repetitive trauma due to job
Joint deformity - subluxation
DDH 
Inflammatory - RA 
Vascular - AVN 
Metabolic - acromegaly/ haemochromatosis
44
Q

What are the symptoms of oA

A
45+ 
Activity relate joint pain
Stiffness after inactivity 
Pain worse at end of day 
Morning stiff <30 minutes compared to RA
Decreased ROM
Joint deformity
45
Q

Where does back arthritis refer to

A

Buttock

46
Q

Where does hip arthritis refer too

A

Groin and as far as knee

47
Q

What score to measure hip arthritis

A

Oxford

48
Q

What are the signs of arthritis

A
Boechards - PIP 
Heberden - DIP 
Fixed flexion deformity
Reduced ROM 
Crepitus on motion
Muscle wasting
Reduction function
Normal bloods
49
Q

How do you Dx

A

X-ray
Dx can be made if >45, activity related pain and no morning stiffness
Bloods to exclude other pathology = normal

50
Q

What does X-ray show

A
Osteophytes
Loss of joint space
Subchondral cyst
Subchondral sclerosis - increased density
Loose body
51
Q

When would you do bloods

A

If concerned about inflammatory cause

52
Q

How do you Rx OA non-pharmalogical

A
Graded exercise to promote movement and encourage repair 
Weight loss to reduce burden on joint 
Thermotherapy 
TENS 
Physio to improve muscle strength 
OT
Osteopath 
Shock absorbing insoles
53
Q

What are pharmalogical Rx’s

A
Analgesia
Topical NSAID + paracetamol = 1st line 
Oral NSAID + capsaicin = 2nd line
Intra-articular steroid
Opiates with caution
54
Q

What do you give with NSAID

A

PPI
Avoid if on aspirin
Better to use intermittently

55
Q

When do you do surgery

A

If pain affecting QOL

Tried non surgical Rx

56
Q

What surgery

A

Arthroplasty (joint replacement) = 1st line
Osteotomy - cut out
Arthrodesis - fusion

57
Q

What is needed post op

A

Physio
Walking stick / crutch
Avoid low chairs / flexing hip

58
Q

What should you beware of

A

Prolonged stiffness
Rapid deterioration
Hot swollen joint

59
Q

What are complications of THR

A
VTE - LMWH 4 weeks
Intraoperative fracture
Nerve injury
Wound and joint infection
Dislocation
60
Q

What are reasons for revision

A

Aseptic loosening
Pain
Dislocation
INfection

61
Q

What are CI intra-articular steroid

A

Neutropenia as may worsen infection

62
Q

Differences in aetiology OA and RA

A
OA = degeneration
RA = autoimmune
63
Q

Differences in gender

A
OA = equal
RA = F
64
Q

Differences in age

A
OA = elderly
RA = any
65
Q

Differences in joints affected

A
OA = large / weight bearing such as hip or knee or DIP
RA = MCP / PIP but never DIP
66
Q

Typical Hx OA

A
Pain following use
Improves rest
Stiffness <30 minutes 
Unilateral
No systemic
Hard bony swelling O/E
67
Q

Typical Hx RA

A
Morning stiffness >30 minutes 
Improves with use
Bilateral
Systemic Sx
Soft bone swelling O/E
68
Q

X-ray OA

A

Loss joint space
Subchondral sclerosis
Subchondral cyst - in bone
Osteophytes - outside of bone

69
Q

X-ray RA

A
Loss joint space
Juxta-articular osteoporosis
Periarticular erosions 
Osteopenia 
Subluxation
Swelling
70
Q

Causes of Hip pain

A
OA
Inflammatory arthritis
Referred lumbar 
Greater trochanteric bursitis 
Pubic symphysis dysfunction
Transient osteoporosis 
Meralgia paraesthetica
AVN
71
Q

Where does referral lumbar come from

A

Trapped femoral nerve

Stretch test may be +Ve

72
Q

Pubic symphysis dysfunction

A

Common in pregnancy due to ligament laxity
Pain over pubic symphysis
Radiates to groin and medial thigh
Waddling gait

73
Q

Transient idiopathic osteoporosis

A

3rd trimester of pregnancy
Groin pain causing limited ROM
Unable to weight bear
Elevated ESR

74
Q

Meralgia paraesthetica

A

Cutaneous compression of lateral cutaneous nerve causing burning sensation over lateral high
Common in obese / pregnancy

75
Q

AVN

A

Can be gradual or sudden
High dose steroids
Previous fracture / dislocation

76
Q

What causes greater trochanteric hip syndrome / bursitis

A
Repeated movement 
Lateral hip pain 
Localised over greater trochanter
Worse on movement and if you press
Can't lie on side
77
Q

How common

A

Very common

20% of hip pain complaints

78
Q

Who is at risk

A

Women 50-70

OA of hip / spine

79
Q

How do you Rx

A
Conservative
Analgesia
Anti-inflammatory
Physio
Steroid injection
80
Q

What is true hip pain

A

Often at groin

81
Q

What can you do for loose body

A

Arthroscopic avulsion if causing mechanical sx such as locking

82
Q

What is typical of hip pain

A

Pain in lateral hip
Extends into groin
Worse on movement of hip
Night pain

83
Q

How can you check if hip pain

A
Give steroid injection
If doesn't help at all unlikely to be from hip 
X-ray pelvis
MRI back 
May be coming from back