Rheumatology Flashcards
Investigations for Paget’s disease
Raised ALP Negative NM bone scan Normal/high Ca Normal phosphate High urinary excretion of hydroxyproline Urinalysis XR Bone isotopic scans Bone biopsy
Management of maintenance in bone remodelling disease
Pain management
Physiotherapy
Ca and vitamin D supplements
Define remodelling disease
Excessive breakdown and formation of bone
Disorganised remodelling of bone
Unknown aetiology
Joints commonly affected in osteoarthritis
DIPs - Heberden's nodes 1st CMC (base of thumb) Hips Knees L/C spine
Signs and symptoms of osteoarthritis
Signs:
Swelling/deformity
Pain on palpation
Limited ROM in active motion
Pain limits passive movement (flexion and internal rotation)
Resisted movement fine but can be weakness if not used
Mild synovitis
Symptoms: Pain Crepitus Gelling of joints Stiffness Bony tenderness Mild swelling
Commonly affected sites in Paget’s disease
Spine, skull, pelvis, femur, tibia
Presentation of remodelling disease
Mostly asymptomatic Bone pain at rest (unusual) Deformity OA Pathological fracture
Define osteomalacia
Loss of bone mineralisation
Quality of bone
Related to vitamin D deficiency
Bone softens due to inadequate deposits of calcium and phosphorus in bone matrix (mineralisation defect)
Define osteopetrosis
Hardening of bones
Increased sclerosis and obliteration of medullary canal
Decreased OC function
Failure of bone resorption
Risk factors for osteoporosis
Family history RA Thyroid/liver disease Spinal cord injury Poor lifestyle/physical activity Thyroid replacement Corticosteroid use Antacids LT anticonvulsant use Smoking and alcohol Menopause
Primary aetiology of osteoarthritis
Idiopathic Wear and tear/trauma/high impact sports Obesity Occupation Poor nutrition
Management of active bone remodelling disease
Short course of bisphosphonates
8wks of high dose risedronate, IV zoledronarte
Often induces sustained remission
Surgical management of fractures
Secondary aetiology of osteoarthritis
Pre-existing joint damage (gout)
Metabolic disease (haemochromatosis)
Systemic (haemophilia)
Genetics
Investigations for osteomalacia
Low Ca Low phosphate Low vitamin D Raised pH X-ray/bone scans
Management of osteoporosis
Conservative:
Lifestyle, weight-bearing exercise, avoid smoking and alcohol
Medical:
Oestrogen replacement, Ca and Vitamin D replacement
Anti-resorptive:
Bisphosphonates, RANKL inhibitors, SERM (selective osterogen reuptake modulators
Anabolic synthetic PTH
Surgical:
Vertebroplasty, kyphoplasty
Pathophysiology of Paget’s disease
Bone is softer but thickened and liable to pathological fractures
Osteomalacia vs Rickets
Similarities:
Skeletal pain, bony tenderness, fractures
Differences
Osteomalacia:
Waddling gait, hypotonia
Rickets:
Poor growth, ricketic rosary, Harrison’s groove
Management of osteomalacia
Treat cause e.g. coeliac, hypo-phosphataemia and vit D supplements
Causes of osteomalacia
Vitamin D deficiency (reduced intake and absorption, excess loss, metabolism defect - hereditary rickets, CKD, Fanconi)
Calcium deficiency
Phosphate deficiency
Phases of remodelling disease
Lytic (OC resorption)
Mixed (resorption and formation)
Sclerotic (OB formation)
Define osteoarthritis
Progressive Degenerative joint disease Age related degeneration of articular cartilage Most common joint condition 3x more common in men Typically >50s
Define osteoporosis
Loss of bone density
Micro-architectural deterioration of bone tissue
Consequent increase in bone fragility and susceptibility to fracture
Presentation of osteoporosis
Silent disease Kyphosis Pathological fractures Any low trauma fracture age >50 consider osteoporosis or bony mets NOF fracture Colles fracture Vertebral collapse/compression fractures
Causes of osteoporosis
Idiopathic:
Oestrogen decline, ageing, etc
Secondary:
Malabsorption disorders
Medications (steroids, phenytoin, heparin, aromatase inhibitors, androgen deprivation)
Rheumatology (RA, SLE, ankylosing spondylitis)
Organs (renal / liver disease)
Endocrinology (hyperparathyroidism, hyperthyroidism, premature menopause, DM, Cushing’s syndrome)
Malignancy (myeloma, lymphoma, leukaemia)
4 signs on imaging in OA - LOSS
Loss of joint space
Osteophytes
Subchondral cyst (within bone)
Subchondral thickening/sclerosis (white line)
FRAX tool score in osteoporosis
Low FRAX score:
Lifestyle changes + supplements and follow up in 5 years
Medium FRAX score :
DEXA scan
High FRAX/T score:
<2.5/fragility fracture
Pharmacological management
Classification of osteoporosis
type 1 and type 2
Type 1:
Post menopausal - low oestrogen, loss of trabecular bone, accelerated bone loss
Type 2:
Senile, >70yrs, nutritional and decreased physical activity, loss of cortical and trabecular bone, non-accelerated bone loss
DEXA scan in osteoporosis
T score:
SD the bone density is above or below the young normal mean bone mineral density from population of 20-30 years old Caucasian women (race and sex)
Z score:
SD the measurement is above or below the age, gender & ethnicity matched mineral bone density
Management of osteopetrosis
Bone marrow transplantation
Calcitriol
Presentation of osteomalacia
Bone pain Proximal Weakness Malaise Deranged calcium Deformity Fracture
Investigations for osteoporosis
Bloods (FBC, TFT, U&Es, vitamin D, bone profile, Ca)
Exclude multiple myeloma with blood and urine electrophoresis
Management of osteoarthritis
Conservative:
RICE, lifestyle change, physio, quit smoking, weight loss, walking aids, hot water bottle
Medical:
Paracetamol +/- anti-inflammatory, topical capsaicin may help, steroid and LA injections, hyaluronic acid injections, beware GI bleeding and worsening asthma with NSAIDs
Surgical:
Replace joint
Other options:
osteotomy: realignment of joint by excision and fusion to stop pain
Excision:
Removal of joint without fusion
Arthroplasty:
Replacement of all or part of joint surface by an artificial material
Investigations for osteoarthritis
History Exam Bloods (raised CRP) X-ray (AP, lateral) Arthoscopy
