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MSK > Rheumatoid Arthritis + OA + Hip Pain > Flashcards

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
Biologic examples
Infliximab / Etanercept = Anti-TNF | Ritixumab = B cell depletion (Anti-CD20)
26
What other conditions have positive RF
``` Sjogren SLE Scleroderma Felty IE ```
27
What suggests poor prognosis
``` 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 ```
28
What are SE of DMARD
``` Immunosuppression Methotrexate pneumonitis Oral ulcers Hepatotoxicity / cirrhosis Teratogenicity ```
29
What do you get if on DMARD
CXR before methotrexate | Regular FBC + LFT monitoring
30
What causes RA
Autoimmune Genetics Environment
31
What is autoimmune part
``` RF ACPA Anti-CCP ANA+ve Can get sero-ve RA ```
32
What genetics are involved
Lots of genes different to immune | HLA genes - DR1/DR4
33
Environment role
Infections - EBV / CMV / E.coli / mycoplasma | Smoking
34
What do these 3 roles together lead too
Formation of immune complex | Loss of tolerance and autoimmunity
35
What is pathophysiology of rheumatoid arthritis
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
What causes cartilage and bone destruction
Cytokines activity fibroblasts / osteoclasts Osteoclast activated under RANKL produced by synovial Invade cartilage and produce proteases to break down
37
SE of biologics
Infusion reaction Immunosuppression Reactive of TB
38
What is OA
Degenerative joint disorder Wear, tear and repair Loss of articular hyaline cartilage + new bone formation Repair / remodelling = restriction and loss of function
39
What is pathology behind OA
``` Inflammation Synovial hypertrophy Subchondrial changes Loss of cartilage Joint effusion Remodellnig = loss of function ```
40
What causes primary OA
Micro-trauma on top of RF
41
What are RF for OA
``` Age Occupation Persistent physical activity Obesity Female FH DDH Joint abnormality ```
42
What joints are most commonly affected
Knee and hip = most common MIP and DIP in hands (DIP NEVER in RA) C-MCP in thumb
43
What are secondary causes
``` Trauma - fractures / cartilage injury / meniscal surgery / osteomyeltiis Repetitive trauma due to job Joint deformity - subluxation DDH Inflammatory - RA Vascular - AVN Metabolic - acromegaly/ haemochromatosis ```
44
What are the symptoms of oA
``` 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
Where does back arthritis refer to
Buttock
46
Where does hip arthritis refer too
Groin and as far as knee
47
What score to measure hip arthritis
Oxford
48
What are the signs of arthritis
``` Boechards - PIP Heberden - DIP Fixed flexion deformity Reduced ROM Crepitus on motion Muscle wasting Reduction function Normal bloods ```
49
How do you Dx
X-ray Dx can be made if >45, activity related pain and no morning stiffness Bloods to exclude other pathology = normal
50
What does X-ray show
``` Osteophytes Loss of joint space Subchondral cyst Subchondral sclerosis - increased density Loose body ```
51
When would you do bloods
If concerned about inflammatory cause
52
How do you Rx OA non-pharmalogical
``` 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
What are pharmalogical Rx's
``` Analgesia Topical NSAID + paracetamol = 1st line Oral NSAID + capsaicin = 2nd line Intra-articular steroid Opiates with caution ```
54
What do you give with NSAID
PPI Avoid if on aspirin Better to use intermittently
55
When do you do surgery
If pain affecting QOL | Tried non surgical Rx
56
What surgery
Arthroplasty (joint replacement) = 1st line Osteotomy - cut out Arthrodesis - fusion
57
What is needed post op
Physio Walking stick / crutch Avoid low chairs / flexing hip
58
What should you beware of
Prolonged stiffness Rapid deterioration Hot swollen joint
59
What are complications of THR
``` VTE - LMWH 4 weeks Intraoperative fracture Nerve injury Wound and joint infection Dislocation ```
60
What are reasons for revision
Aseptic loosening Pain Dislocation INfection
61
What are CI intra-articular steroid
Neutropenia as may worsen infection
62
Differences in aetiology OA and RA
``` OA = degeneration RA = autoimmune ```
63
Differences in gender
``` OA = equal RA = F ```
64
Differences in age
``` OA = elderly RA = any ```
65
Differences in joints affected
``` OA = large / weight bearing such as hip or knee or DIP RA = MCP / PIP but never DIP ```
66
Typical Hx OA
``` Pain following use Improves rest Stiffness <30 minutes Unilateral No systemic Hard bony swelling O/E ```
67
Typical Hx RA
``` Morning stiffness >30 minutes Improves with use Bilateral Systemic Sx Soft bone swelling O/E ```
68
X-ray OA
Loss joint space Subchondral sclerosis Subchondral cyst - in bone Osteophytes - outside of bone
69
X-ray RA
``` Loss joint space Juxta-articular osteoporosis Periarticular erosions Osteopenia Subluxation Swelling ```
70
Causes of Hip pain
``` OA Inflammatory arthritis Referred lumbar Greater trochanteric bursitis Pubic symphysis dysfunction Transient osteoporosis Meralgia paraesthetica AVN ```
71
Where does referral lumbar come from
Trapped femoral nerve | Stretch test may be +Ve
72
Pubic symphysis dysfunction
Common in pregnancy due to ligament laxity Pain over pubic symphysis Radiates to groin and medial thigh Waddling gait
73
Transient idiopathic osteoporosis
3rd trimester of pregnancy Groin pain causing limited ROM Unable to weight bear Elevated ESR
74
Meralgia paraesthetica
Cutaneous compression of lateral cutaneous nerve causing burning sensation over lateral high Common in obese / pregnancy
75
AVN
Can be gradual or sudden High dose steroids Previous fracture / dislocation
76
What causes greater trochanteric hip syndrome / bursitis
``` Repeated movement Lateral hip pain Localised over greater trochanter Worse on movement and if you press Can't lie on side ```
77
How common
Very common | 20% of hip pain complaints
78
Who is at risk
Women 50-70 | OA of hip / spine
79
How do you Rx
``` Conservative Analgesia Anti-inflammatory Physio Steroid injection ```
80
What is true hip pain
Often at groin
81
What can you do for loose body
Arthroscopic avulsion if causing mechanical sx such as locking
82
What is typical of hip pain
Pain in lateral hip Extends into groin Worse on movement of hip Night pain
83
How can you check if hip pain
``` Give steroid injection If doesn't help at all unlikely to be from hip X-ray pelvis MRI back May be coming from back ```

MSK (21 decks)

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