Rheumatology Flashcards
Describe the pathology of osteoarthritis?
mechanical wear and tear damages the cartilage in synovial joints to expose the subchondral bone
formation of disorganised new bone at the margins, called osteophytes
there is synovitis (chronic inflammation in the synovium) and lack of joint space
Who is at risk of osteoarthritis?
elderly mechanical wear and tear women obesity genetic trauma or excessive loading or sports injuries
Describe the features of osteoarthritis
affects synovial joints - commonly knees, hips, small joints of the hand
joint pain - exacerbated by exercise, relieved by rest, stiffness in the morning <30 mins, reduced function, gradual onset
joint swelling and deformity
functional impairment
On examination, what would you expect in osteoarthritis?
bony swelling of joint reduced ROM crepitus muscle weakness varus deformity Heberdens nodes at the DIP joints / bouchards nodes at PIP joints antalgic gait
Describe the x-ray findings in osteoarthritis
L - loss of joint space
O - osteophytes at joint margin (disorganised new bone formed)
S - subchondral cysts (micro fracture of articular surface)
S - subchondral sclerosis (new bone laid down)
What is the step wise management for osteoarthritis?
CONSERVATIVE
patient eduction - Arthritis Research UK leaflet
weight loss
muscle strength exercises and physiotherapy
aids and devices e.g. walking sticks, shock absorbing insoles in shoes, tap turners
heat/ ice packs
MEDICAL
simple analgesia e.g. paracetamol -> topical ibuprofen gels -> codeine -> NSAIDs + PPI
intra articular corticosteroid injection
SURGICAL
refer to orthopaedics if continued pain after trying other methods and affecting quality of life
arthroplasty (knee replacement) *
what are the complications of a knee replacement?
wound infection
thromboembolism
dislocation
nerve injury
What is rheumatoid arthritis?
chronic inflammatory autoimmune disease characterised by inflammation of the synovial joint and systemic involvement
Who is particularly at risk of RA?
AFFECTS 1% OF THE POPULATION women smoking genetics autoimmune disease !!
describe the key features of RA?
symmetrical small joint polyarthritis >6 weeks - usually affects the small joints of hands and feet (MCP, PIP, wrists)
joint pain, joint swelling
morning stiffness 30mins - 1 hour , pain worse on rest
fatigue, weight loss, loss of function
which joints are not affected in RA?
DIP joints and spine
What are the different patterns of RA?
- intermittent
- migratory - starts in 1 joint, gets better, another joint affected
- additive - one joint after another affected
List the possible extra articular features of rheumatoid arthritis
MSK
rheumatoid nodules (on elbows, fingers, achilles tendon)
carpal tunnel syndrome
bursitis
osteoporosis (juxta articular)
Feltys syndrome
Atlanta axial sublimation - cervical spine pain
RESPIRATORY
pulmonary fibrosis
pleural effusion
caplans syndrome
CARDIO / BLOOD
pericarditis
ischaemic heart disease risk factor
anaemia
OPTHALMOLOGY
keratoconjunctivitis
scleritis
corneal ulceration
OTHER
depression
increased risk of infection
vasculitic lesions
What is caplans syndrome?
RA + occupational coal dust exposure = intrapulnonary fibrotic nodules
What is Feltys syndrome?
triad of:
- RA
- splenomegaly
- neutropaenia
+ leg ulcers, brown pigmentation, lymphadenopathy, thrombocytopenia
On examination, what might you find in a patient with RA?
"boggy" swollen joints (feels like a grape) \+ve squeeze test boutonniere and swan neck deformity ulnar deviation limited ROM (can't make a fist) Z thumb
How is RA diagnosed?
RA is a clinical diagnosis and should be referred to rheumatology within 2 weeks of suspicion
Can do the following tests to speed up diagnosis process:
- rheumatoid factor -> present in 70% of pts, indicates a poor prognosis
- anti- CCP -> detectable 10 years before RA (could be used as early detection??), 60% of pts and more sensitive than RF
- X - Ray of small joints in hands and feet
- FBC, U&E, LFT, CRP/ESR raised -> baseline for starting new treatments
Describe the features on x-ray in rheumatoid arthritis?
L- loss of joint space
E - erosions
S - soft tissue swelling
S- softening of bones
What does the prognosis of RA depend on?
time between onset of symptoms and treatment
anti CCP antibodies presence
FH
smoking
(DAS28 score)
How is RA managed?
for pain control: NSAIDs + PP
1st line = DMARDS e.g. oral methotrexate*, sulfasalazine, leflunomide + folic acid
add bridging prednisolone short term as methotrexate takes 6-8 weeks to have effect
if not controlled by DMARD alone after 2 trials of 6 months…
2nd line = DMARD + biologic (anti TNF alpha) e.g. infliximab, adalimumab
3rd line = methotrexate + rituximab (anti CD20 monoclonal antibody)
How is methotrexate monitored and what are its side effects?
monitor: FBC, U&E, LFT every 4-8 weeks
SE: GI upset, raised liver enzymes, hair thinning, teratogenic, bone marrow suppression
Who in the MDT is involved in patients with rheumatoid arthritis care?
rheumatologist -> monitor disease activity, prescribe drug therapy
specialist nurse -> patient education, DMARD monitoring
physiotherapist -> exercises to help stiffness
occupational therapist -> adaptions in home and how to function
orthopaedics -> if worsening function and deformity for joint replacements
List the differentials for a hot swollen joint
septic arthritis trauma gout pseudo gout cellulitis
List the risk factors for osteomyelitis
skin infection IVDU diabetics immunosuppression high alcohol intake
