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Orthopaedics > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Questions to ask about a patient with musculoskeletal complaints

A
  1. inert vs contractile structures (articular/extra-articular)?
  2. inflammatory vs non-inflammatory?
  3. duration and distribution?
  4. extra-articular manifestations/complications?
  5. could it be referred pain?
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2
Q

Describe the capsular pattern of arthritis with reference to the shoulder and hip

A

Shoulder: limited external rotation and abduction
Hip: limited internal rotation and adduction

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3
Q

Signs of pain being inflammatory (rather than non-inflammatory)

A
  • morning stiffness for > 1 hour
  • prominent night-time symptoms
  • exercise improves/ rest worsens sx
  • good response to NSAIDS
  • constitutional symptoms
  • systemic manifestations
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4
Q

What is the compression test and explain its relevance

A

Slight pressure across carpal/tarsal joints

–> elicits pain in synovitis

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5
Q

Etiology of Rheumatoid Arthritis

A
  1. genetics (HLA)
  2. sex (females)
  3. environmental (smoking, stress, infection)
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6
Q

Inflammatory cytokines involved in RA

A
  • Tumour necrosis factor
  • Interleukin-1
  • Interleukin-6
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7
Q

Typical hx of RA

A 
Young female
Insidious onset
Pain
Early morning stiffness of several hours
Hands and wrists
Constitutional symptoms (fatigue, lethargy, fever)
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8
Q

Joint distribution of RA

A 
COMMON
wrists, MCPJ, PIPJ, MTPJ, knees, ankles
LESS COMMON
elbows, C1/C2, shoulders, hips
RARE
crico-arytenoid, temperomandibular
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9
Q

Early RA of hands

A
  1. boggy tender swellings around MCP and PIP
  2. filling of valleys between MCPs
  3. spindling of fingers due to fusiform swelling of PIPs
  4. loss of fist/ loss of grip strength (tenosynovitis)
  5. swelling over wrist dorsum
  6. wasting of small hand muscles
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10
Q

Advanced RA of hands

A
  1. Swan neck deformity
  2. Boutonniere deformity
  3. Z deformity of thumb
  4. ulnar deviation
  5. subluxation and dislocation of MCPJ
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11
Q

Poor prognostic signs in RA

A
  1. early appearance of erosions
  2. RF/ACPA positivity
  3. rheumatoid nodules
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12
Q

Extra-articular manifestations in RA

A
  1. Peri-articular: rheumatoid nodules, tenosynovitis
  2. Eyes: scleritis, sicca
  3. Lung: pleurisy, fibrosis, nodules
  4. Cardiac: effusions, atherosclerosis
  5. Skin: leg ulcers (vasculitis)
  6. Neurological: carpal tunnel, cervical myelopathy
  7. Haematological: Anaemia, Felty’s Syndrome
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13
Q

Felty’s syndrome

A
  1. RA
  2. Splenomegaly
  3. Neutropenia
    - -> susceptible to infection
    - -> associated with severe disease
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14
Q

Special Investigations for RA

A
  1. FBC
  2. ESR/CRP
  3. RF
  4. ACPA
  5. Synovial fluid
  6. Radiology
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15
Q

X-rays of early RA

A
  • soft tissue swelling
  • peri-articular osteopaenia
  • erosions at margins of small joints
    [U/S better at picking up erosions and tenosynovitis but time-consuming)
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16
Q

Medical Rx of RA

A
  1. DMARDs: methotrexate (mainstay), sulfasalazine, chloroquine
  2. Biologics (against TNFa, IL-6, B-lymphocytes)
  3. Steroids
  4. Anti-inflammatories (diclofenac, ibuprofen, indomethacin)
  5. Analgesics (paracetamol, amitriptyline)
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17
Q

Indications for joint replacement in RA

A
  1. pain due to joint damage not responding to medical management
  2. improvement of function/ restoration of movement
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18
Q

Causes of Mono-Arthritis

A
  • septic arthritis
  • trauma (fracture, internal derangement, haemarthrosis)
  • crystal deposition disease
  • osteoarthritis
  • juvenile idiopathic arthritis
  • coagulopathy
  • AVN
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19
Q

Polyarthritides that can present with mono-articular onset

A 
RA
JIA
Viral arthritis
sarcoid
reactive arthritis
psoriatic arthritis
enteropathic arthritis
20
Q

Contents of synovial fluid analysis

A
  1. gram stain/culture (infection)
  2. crystals (gout/pseudogout)
  3. blood (haemarthrosis)
  4. WCC (2k-50k = inflammatory; >50k = pyarthrosis)
21
Q

Diagnostic studies in monoarthritis

A 
ALWAYS
- Xray
- FBC and Diff
- Uric acid (may be low in acute gout!)
SELECTED
- blood/urine cultures
- clotting profile
- ESR
RARELY
- serology (RF, ANF)
22
Q

Diagnositic studies in chronic monoarthritis

A
  1. arthroscopy
  2. MRI
  3. bone scan
23
Q

Aetiology of Osteoarthritis

A
  1. Primary - localised/generalised
  2. Developmental - DDH, Perthe’s, SUFE
  3. Traumatic - fx, occupational strain, internal derangement)
  4. Inflammatory (septic arthritis, TB, RA)
  5. Metabolic (crystal arthritis, haemochromatosis, alkaptonuria)
  6. Endocrine (acromegaly, DM, hypothyroidism, obesity)
24
Q

Symptoms of OA

A

Mechanical pain
Stiffness 15-30 minutes
Muscle spasm

25
Q

Joints of OA

A 
COMMON
DIP, PIP, 1st carpometacarpal, 
acromioclavicular, 
knees, hips, 
spine, 1st MTP
ATYPICAL
wrists, elbow, gleno-humeral, 
ankles, MCPs, MTP 2-5
26
Q

Signs of OA

A
  1. Swelling of OA joints - firm, bony
  2. Tenderness at joint margin
  3. Crepitus
  4. Warmth
  5. Osteophytes
  6. Limitation of function and mobility
  7. Periarticular muscle atrophy
27
Q

Radiology of OA

A
  1. typical joint involvement
  2. loss of joint space
  3. osteophyte formation (spurs)
  4. subchondral sclerosis
  5. bone cysts
  6. malalignment/ deformity
  7. gull wing sign in PIP and DIP
28
Q

Treatment of OA

A
  1. Weight loss
  2. Exercise
  3. Heat/massage
  4. Simple analgesics
  5. NSAIDS
  6. Intra-articular corticosteroids
  7. Osteotomy
  8. Arthroplasty
  9. Dietary supplements
29
Q

Indications for arthroplasy in OA

A
  1. severe unresponsive pain (cannot stand in place for 20-30 minutes)
  2. loss of joint function
30
Q

Important crystals in arthropathies

A

Uric acid –> gout
Calcium pyrophosphate –> pseudogout
Calcium hydroxyapatite –> calcifying peri-arthritis

31
Q

Where does uric acid come from

A

10-30% dietary purines

60-90% liver

32
Q

Where is uric acid excreted

A

75% renal

25% intestinal

33
Q

Define gout

A

inflammatory reaction in synovial joints and/or periarticular tissues due to deposition of urate crystals due to hyperuricaemia

34
Q

Aetiology of Hyperuricaemia

A

PRIMARY

  1. overproduction (enzyme abnormalities)
  2. decreased secretion (low GFR, tubular issues)
  3. combination of above

SECONDARY

  1. Drugs (reduce renal excretion)
  2. Overproduction
  3. Underexcretion
35
Q

Drugs causing hyperuricaemia

A 
Cyclosporine
Alcohol
Nicotinic Acid
Thiazides
Lasix
Ethambutol
Aspirin
Pyrazinamide
36
Q

Secondary overproduction of uric acid

A 
Purine rich foods
Myelo/Lymphoproliferative disorders
Psoriasis
Obesity
Fructose ingestion
37
Q

Secondary underexcretion of uric acid

A 
keto-acidosis
lactate acidosis
renal disease
polycystic kidneys
lead nephropathy
hyperparathyroidism
hypothyroidism
38
Q

DDX for Gout

A
  1. cellulitis
  2. septic arthritis
  3. pseudogout
39
Q

Diagnosis of Gout

A
  1. Serum uric acid (may be normal)
  2. Synovial fluid microscopy (crystals under polarised light)
  3. XRay: Soft tissue swelling
40
Q

Common sites of gout tophi

A 
Olecranon
1st MTPJ
Earlobes
Tendons
Peri-articular
41
Q

Mx of acute gout

A
  1. Colchecine 0.5mg stat and then 2-3 times daily
  2. NSAID eg. voltaren, indocid, other (check renal function)
  3. Corticosteroids: prednisone 0.5mg/kg
42
Q

Mx of interval/chronic gout

A
  1. remove precipitating factors

2. determine kidney function

43
Q

Indications for uric acid lowering therapy

A
  1. > 3 acute attacks per year
  2. tophi
  3. bony/cartilage destruction on X-ray
  4. gout with renal disease
  5. uric acid kidney stones
  6. uric acid >0.54mmol/l
44
Q

Uric acid lowering drugs

A
  1. uricosuric: probenecid
  2. xantine oxidase inhibitors: allopurinol
  3. other: lisinopril, losartan, oxypurinol, uricase, citrosoda
45
Q

Probenecid contraindications

A
  1. kidney stones

2. renal impairment

46
Q

Side effects of allopurinol

A
  1. skin reactions
  2. GIT symptoms
  3. bone marrow suppression
  4. precipitate acute gout

Orthopaedics (2 decks)

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