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Orthopaedic Surgery > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Define rheumatoid arthritis

A

Chronic symmetrical inflammatory polyarthritis of unknown origin

It’s involve the small joint
Mostly affects young females
And has extra articular manifestations

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2
Q

What are the risk factors for rheumatoid arthritis?

A

Genetic’s – HL8 types

Females

Smoking if rheumatoid factor (+) or ACPA (+)

Stress

Infections - EBV, CMV an E. coli

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3
Q

What is the pathogenesis of rheumatoid arthritis?

A

It targets the synovium

Inflammatory cascade is activated to release inflammatory cytokines TNF-alpha, IL-1 and IL-6

Stimulates the synovium to produce pannus

Release of degrading proteolytic enzymes

Activates osteoclasts

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4
Q

Describe clinical picture of rheumatoid arthritis

A

Acute insidious onset of pain

Early morning stiffness - wrist, mcp and pip

Monoarticular

Gradual loss of joint function

Constitutional symptoms

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5
Q

What are the articular manifestations of early rheumatoid arthritis?

A

Boggy tender soft tissue swelling at MCP and PIP

Inability to fully closed fist secondary to synovitis

Saville sign

Swelling of the dorsum of the wrist secondary to ulnar synovitis

Wasting of intrinsic hand muscles

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6
Q

What are the articular manifestations of advanced rheumatoid arthritis?

A

Swan neck deformity
> flexion of MCP + DIP
> extension of PIP

Bouttonierre deformity
> flexion of PIP
> hyperextension of DIP

Z-deformity of thumb
> flexion of MCP
> hyperextension of IP

Ulnar deviation + subluxation + dislocation of MCP

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7
Q

What are the extra articular manifestations of rheumatoid arthritis?

A

Rheumatoid nodules

Tenosynovitis

Scleritis or episcleritis

Pericardial effusion

Idiopathic lung disease

Leg ulcer

Anaemia

Carpal tunnel syndrome

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8
Q

What is the classification criteria for rheumatoid arthritis?

A

A. Joint involvement

B. Serological abnormality - RF (+), ACPA (+)

C. Acute phase reactant

D. Duration of symptoms >6 weeks

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9
Q

Describe the synovial fluid of a patient with rheumatoid arthritis

A

Straw coloured

5000 to 50,000 WBC

> 50% polymorphs

RF (+)

Decreased glucose

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10
Q

What are the x-ray findings of rheumatoid arthritis?

A

Soft tissue swelling

Periarticular osteopenia

Erosions

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11
Q

What is the medical management of rheumatoid arthritis?

A

First educate the patient

Methotrexate weekly
Chloroquine daily
Sulfasalazine daily

Analgesias
> paracetamol

Anti-inflammatories
> Ibuprofen
> diclofenac
> indomethacin

Steroids
> prednisone

Biologics
> Infliximab
> Tocoluzimab
> Rituximab
> Abethacept
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12
Q

What does the indications for joint replacement in rheumatoid arthritis?

A

Improvement of function / restoration of movement

Not responding to medical treatment

Severe pain

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13
Q

What is the classification of primary generalized osteoarthritis?

A 
>4 joints affected:
• DIP/PIP
• Base of thumb 
• C5-C7
• AC joint
• Lumbar spine
• Hips + knees
• Big toe

Females

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14
Q

What is the classification of primary localized osteoarthritis?

A

Nodal arthritis

Worse on dominant side

Joints:
• DIP (Heberden nodes)
• PIP (Bouchard nodes)
• 1 CMC
• 1st MTP

Flexion deformity and lateral deviation of the distal phalanx

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15
Q

What are the symptoms of osteoarthritis?

A

Mechanical pain that is worse with movement and better with rest

Morning stiffness <30mins

Muscle spasm

No constitutional symptoms

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16
Q

What are the signs of osteoarthritis?

A

Swelling and tenderness of the joints

Boney (hard) joints

Crepitus

Palpable osteophytes

Deformity

Periarticular muscle atrophy

17
Q

What are the x-ray findings of osteoarthritis?

A

Joint space narrowing/loss of joint space

Osteophytes in the joint space

Subchondral sclerosis

Subchondral bone cysts

Malalignment

Gullwing sign in DIP + PIP

18
Q

What is the medical management of osteoarthritis?

A

Weight loss and exercise

Analgesia:
• Paracetamol
• NSAIDs
• Opioids

Corticosteroids

19
Q

When is anthroplasty the indicated in osteoarthritis?

A

Unresponsive to medical treatment

Pain wakes patient from sleep

Unable to stand for >20 minutes

Loss of joint function

20
Q

What are the causes of secondary gout?

A

Alcohol

Polycythaemia

Psoriasis

Leukaemia

Obesity

Polycystic kidney disease

Hypothyroidism

Hyperparathyroidism

Drugs
• Cyclosporine
• Thiazides
• Lasix
• Ethambutol
• Aspirin
21
Q

What are the symptoms of acute gout?

A

Pain, swelling and redness that awakens the patient

Monoarticular

First MTP joint involvement

22
Q

How is gout diagnosed?

A

Clinically

Aspirate joint synovial fluid to visualise crystals is the gold standard

Increased serum uric acid

X-ray shows soft tissue swelling and lifting cortex

23
Q

What are the complications of Chronic gout?

A

Stones

Interstitial fibrosis

Acute urate nephropathy

24
Q

How would you manage an acute gout attack?

A

Bedrest

NSAIDS
• 75mg Voltaren IM STAT

Colchicine
• 0.5mg 8hrly until UA <0.3mmol/l

Advice on diet/alcohol

25
Q

What is the treatment for chronic gout?

A

Allopurinol

26
Q

What is the hallmark sign of ankylosing spondylitis?

A

Sacroiliitis

27
Q

Describe the symptoms of ankylosing spondylitis

A

Usually in males 20-30yrs

Insidious onset of inflammatory backpain from sacroiliac joints

Radiates to posterior thigh and buttocks

28
Q

What are the signs of ankylosing spondylitis

A

Loss of lumbar lordosis

Schöbers test <5cm

Pain with Patrick’s test

Chest expansions <2cm

Large lower limbs

Achilles tendinitis

Dactylitis

29
Q

Describe the features of inflammatory backpain

A

Insidious onset

Symptoms for >3 months

Morning stiffness lasting >60 minutes

Nocturnal pain

Better with movement

Worse with Reese

Back mobility decrease in all planes

30
Q

Describe the X-ray features of ankylosing spondylitis

A

Squaring of the vertebrae

Early/Bridging syndesmophytes

Romanus lesion (erosion)

Preservation of spaces

Ivory corner (white)

31
Q

What is the medical management of ankylosing spondylitis?

A

NSAIDs

Sulfasalazine

Intra-articulate steriods

32
Q

What is the surgical management of ankylosing spondylitis?

A

Hip replacement

Anthroplasty

33
Q

List the clinical features of reactive arthritis

A

Previous infection within two weeks

Asymmetrical arthritis

Conjunctivitis

Urethritis

Dactylitis

Achilles tendonitis

Keratoderma blenorragica (soles, palms)

34
Q

What the laboratory finding of reactive arthritis?

A

Increased ESR, CRP and WCC

Anaemia

RF (-)

Polymorphs in synovial fluid

HLA B27 (+)

35
Q

What is the treatment of reactive Arthritis

A

Bedrest

Passive movement

NSAIDs

Interarticular steroids

Methotrexate

36
Q

What are the extra-articulate manifestations of psoriatic arthritis?

A

Psoriatic plaque

Nail dystrophy and putting

Uveitis

Enthesitis

Plantar fasciitis

37
Q

What is the treatment for Psoriatic Arthritis?

A

NSAIDs

Methotrexate

Chloroquin

Intra-articulate steroids

Orthopaedic Surgery (3 decks)

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