Rheumatology Lectures Flashcards
What type of joint does osteoarthritis affect?
Synovial joints.
Where are female patients most likely to get osteoarthritis?
Hips.
Where are obese patients most likely to get osteoarthritis?
Knees
Where are manual labourers most likely to develop osteoarthritis?
Hand.
Where are farmers most likely to develop osteoarthritis?
Hips
Where are footballers most likely to develop osteoarthritis?
Knees
How long does morning stiffness occur in osteoarthritis?
Less than 30 minutes.
When should you not administer intra-articular corticosteroid injections in osteoarthritis?
Prior to joint replacement due to immunosuppression.
How long do prosthetic joint replacements generally last?
10-15 years.
Define subarticular sclerosis.
Bone overgrowth around articular surface.
Define osteophytes.
Calcified bone overgrowth at joint margins.
Define crepitus.
Crunching sensation when moving joint.
Define Bouchard’s nodes.
Proximal interphalangeal joint bone swelling.
Define Heberden’s nodes.
Distal interphalangeal joint bone swelling.
Define joint effusion.
Increased intra-articular fluid.
List 6 bones susceptible to Paget’s disease.
1) skull
2) thoracic spine
3) lumbar spine
4) pelvis
5) femur
6) tibia
Before menopause how much more likely are women to get rheumatoid arthritis than men?
3x.
What small joint is usually sparred in rheumatoid arthritis?
Distal interphalangeal joint.
List 3 joints that are usually first affected by rheumatoid arthritis.
1) metacarpophalangeal joint (MCP)
2) proximal interphalangeal joint (PIP)
3) metarsophalangeal joint (MTP)
When can you get a false positive rheumatoid factor?
Hepatitis C.
How do disease modifying antirheumatic drugs work?
Inhibit inflammatory cytokines.
What is the main side effect of DMARDs?
Increased infection risk due to immune system suppression.
How long do DMARDs take to have an effect in rheumatoid arthritis?
6 weeks.
What is the gold standard DMARD for rheumatoid arthritis?
Methotrexate.
List 7 side effects of methotrexate.
1) mouth ulcers
2) nausea
3) diarrhoea
4) neutropenia
5) thrombocytopenia
6) abnormal LFTs
7) renal impairment
What is main disadvantage of biological therapy in treating rheumatoid arthritis?
Very expansive.
List 4 types of biological therapy to treat rheumatoid arthritis and an example for each.
1) TNF-α blockers (e.g. IV infliximab)
2) B cell inhibitors (e.g. IV rituximab)
3) T cell activation inhibitors (e.g. abatacept)
4) interleukin blockers (e.g. tocilizumab)
What type of biological agent is used as a first line to treat rheumatoid arthritis?
TNF-α blockers.
List 7 differences of osteoarthritis compared to rheumatoid arthritis.
1) slower onset
2) affects overused joints (e.g. footballers knee)
3) asymmetrical
4) shorter morning stiffness <30 mins
5) pain increases with use
6) no swelling
7) no systemic symptoms
List 7 differences of rheumatoid arthritis compared to osteoarthritis.
1) faster onset
2) affects smaller joints first (MCP, PIP, MTP) —> larger joints
3) symmetrical
4) longer morning stiffness >60 mins
5) pain eases with use
6) hot and red swelling
7) systemic symptoms
Define ulnar deviation.
Swelling of metacarpophalangeal joints causes fingers to drift towards little finger. (MCP)
Define Z thumb deformity.
Metacarpophalangeal joint hyperextension, proximal interphalangeal joint flexion. (MCP h, PIP f)
Define swan neck deformity.
Proximal interphalangeal joint hyperextension, distal interphalangeal joint flexion. (PIP h, DIP f)
Define Boutonniere’s deformity.
Proximal interphalangeal joint flexion, distal interphalangeal joint hyperextension. (PIP f, DIP h)
What crystals are found in gout?
Monosodium urate.
What percentage of hyperuricaemic patients develop gout?
20%.
Where joint does gout tend to effect?
1st MTP, i.e. big toe.
What environmental factor affects gout?
Temperature (cold).
How many joints does gout tend to effect?
1.
List 5 precipitate of gout.
1) heavy meal
2) heavy drinking
3) cold
4) trauma
5) infection
When is serum uric acid measured in gout and why?
2 weeks after attack, levels fall immediately after an attack.
When is allopurinol prescribed in gout and why?
3 weeks after attack, may trigger another attack.
List 7 common joints affected by gout.
1) big toe MTP
2) ankle
3) foot
4) small hand joints
5) wrist
6) elbow
7) knee
What Latin phrase can sum up gouty joints?
Calor, dolor, rubor, tumour.
What can pseudogout be mistaken for and why?
Septic arthritis, hot joint and fever.
Define chrondrocalcinosis.
Linear calcification parallel to articular surface.
What joints are generally affected in pseudogout? (2)
1) wrist
2) knee
List 4 differences of gout compared to pseudogout.
1) monosodium urate crystals
2) generally affects 1st MTP (big toe)
3) needle shaped crystals
4) negatively birefringent
List 4 differences of pseudogout compared to gout.
1) calcium pyrophosphate crystals
2) generally affects wrist or knee
3) rhomboid shaped crystals
4) positively birefringent
Clinically define osteoporosis.
Bone mineral density more than 2.5 standard deviations below peak bone mass.
Clinically define osteopenia
Bone mineral density between 1 and 2.5 standard deviations below peak bone mass.
List the causes of osteoporosis using SHATTERED acronym.
S) steroids H) hyperthyroidism and hyperparathyroidism A) alcohol and smoking T) thin T) testosterone E) early menopause R) renal and liver failure E) erosion of bone D) deficiency of calcium and vitamin D
What is the age of peak bone mass?
25 years old.
What factor has the most affect on peak bone mass?
Genetics.
List 3 factors that affect bone strength.
1) bone mineral density
2) bone size
3) bone quality
Define Colles’ fracture.
Fracture of wrist, after falling on outstretched arms.
When do neck of femur fractures generally occur?
Elderly falling on back or side.
Define kyphosis.
Abnormally concave spine.
Define lordosis.
Inward curve of cervical and lumbar spine. (concave)
Define kyphosis.
Outward curve of thoracic spine. (convex)
Define enthesis.
Site of ligament attachment to bone.
Define enthesitis.
Inflammation of enthesis, site of ligament attachment to bone.
Define syndesmophytes.
Bone growth attached to spinal ligaments, seen in ankylosing spondylitis.
Define Achilles tendinitis.
Achilles’ tendon inflammation, back of heel pain.
Define plantar fasciitis.
Plantar fascia inflammation, back of heel pain.
Define bamboo spine.
Vertebral body fusion by syndesmophytes, seen in ankylosing spondylitis.
Define ankylose.
Abnormal bone adhesion in a joint.
Define spondylus.
Vertebra.
What is Schober’s test? (5)
1) test for ankylosing spondylitis
2) mark 5th lumbar spinous process
3) mark 10cm above 5th spinous process when erect
4) mark moves to >15cm above spinous process when bent forwards (healthy individuals)
5) mark moves to <15cm above spinous process when bent forwards (ankylosing spondylitis)
Define telescopic fingers.
Bone resorption collapsing soft tissue of fingers.
What percentage of psoriatic arthritis patients have arthritis mutilans pattern of inflammation?
5%.
The treatment of psoriatic arthritis is similar to what other condition?
Rheumatoid arthritis.
When does reactive arthritis occur?
1-3 weeks post infection.
List 3 types of spondyloarthopathies.
1) ankylosing spondylitis
2) psoriatic arthritis
3) reactive arthritis
What phrase sums up the symptoms of reactive arthritis? (3)
1) can’t see (conjunctivitis, uveitis)
2) can’t wee (urethritis, cervicitis)
3) can’t climb a tree (arthritis, enthesitis)
List 8 common sites for fibromyalgia pain.
1) skull (base)
2) breast (upper edge)
3) neck
4) shoulder (upper back)
5) elbow
6) buttock (upper, outer)
7) hip
8) knee (above, inside)
How do low dose antidepressants and anticonvulsants treat fibromyalgia? (2)
1) induce muscle relaxation
2) normalise sleeping patterns
How long do antidepressants and anticonvulsants take to take effect in fibromyalgia?
1 month.
How long does it take for septic arthritis to destroy a joint?
24 hours.
What percentage of septic arthritis occurs in over 65s?
45%.
How may a child act in septic arthritis?
Limping or protecting the joint.
What percentage of septic arthritis affects only 1 joint?
90%.
List 3 common sites for septic arthritis.
1) knee (50%)
2) hip
3) shoulder
What should you always do in septic arthritis before giving antibiotics?
Aspirate joint fluid.
Who does osteomyelitis predominantly affect?
Children.
How do adolescents and adults generally get osteomyelitis?
Infection secondary to trauma.
Why do elderly get osteomyelitis?
Due to risk factors (e.g. diabetes mellitus).
Where does osteomyelitis present with pain and very few other signs/symptoms> (3)
1) hip
2) vertebrae
3) pelvis
Define surgical debridement.
Removal of dead, damaged or infected tissue.
Which out of osteoid osteoma and osteoblastoma erode surrounding bone?
Osteoblastoma.
Which out of osteoid osteoma and osteoblastoma is self limiting?
Osteoid osteoma, 7 years generally.
Define nidus.
Disorganised mix of small blood vessels, tiny rods of bone (trabeculae) and unmineralised bone tissue (osteoid). Found in osteoid osteoma and osteoblastoma.
What is the most common benign bone tumour?
Osteochondroma.
What is the function of EXT1 and EXT2? (2)
1) produce heparin sulfate
2) heparin sulfae regulates growth of growth plate
Define exostosis.
Lateral bony projection with a hyaline cartilage cap.
Are giant cell tumours benign or malignant?
Benign, but can be malignant in elderly.
List 4 bone tumours that occur in long bone diaphysis.
1) osteochondroma
2) osteosarcoma
3) Ewing’s sarcoma
4) giant cell tumour
List 2 bone tumours that occur in the medullary cavity.
1) chondrosarcoma
2) enchondroma
List 5 cancer sites that metastasise to the bone.
1) lung*
2) breast*
3) prostate*
4) thyroid
5) kidney
What age are primary bone tumours generally seen in?
Children and adolescents.
What percentage of bone density must be present for a lytic tumour to be present on an x-ray?
60%.
Define Codman’s triangle.
Osteosarcoma tumour forming a triangular area of new subperiosteal bone.
List 7 methods to treat bone tumours.
1) analgesia
2) anti-inflammatory
3) radiotherapy (reduces risk of pathological fracture)
4) chemotherapy
5) hormone therapy
6) bisphosphonates (symptomatic)
7) surgical resection
List 3 general ways in which bone tumours present.
1) bone pain
2) swelling
3) pathological fracture
Define epiphysis.
End of bones that form joints with other bones.
Define diaphysis.
Bone shaft.
Define metaphysis.
In between epiphysis and diaphysis, contains growth plate. Found in children and adolescents.
Why don’t vertebral disc prolapses occur in the elderly?
Disc degenerates with age.
What 3 discs are most often affected by a prolapse (acute disc disease).
1) L4
2) L5
3) S1
Define lumbago.
Acute back pain.
Define sciatica.
Lower back pain radiating to buttock and posterior thigh.
What demographic are most likely to be affected by systemic lupus erythematosus?
Premenopausal women.
List 2 triggers of systemic lupus erythematosus.
1) UV light
2) Epstein-Barr virus
What does the arthralgia in SLE resemble?
Rheumatoid arthritis.
What is the distribution of facial erythema in SLE?
Butterfly distribution.
Define Raynaud’s phenomenon.
Digit colour change due to artery spasm, white—>blue—> red.
List 2 triggers of Raynaud’s phenomenon.
1) cold
2) emotion
What percentage of anti-phospholipid syndrome patients have SLE?
20-30%.
Define serositis.
Inflammation of serous membranes, e.g. pleuritis, pericarditis.
What does a multisystem disorder, raised ESR and normal CRP indicate?
Systemic lupus erythematosus.
What autoimmune rheumatic disease has the highest case-specific mortality.
Systemic sclerosis.
What is found in 100% of systemic sclerosis patients?
Raynaud’s phenomenon.
What does systemic sclerosis initially present with?
Raynaud’s phenomenon.
List the 2 types of systemic sclerosis.
1) limited cutaneous scleroderma (70%)
2) diffuse cutaneous scleroderma (30%)
What is another name for systemic sclerosis?
Scleroderma.
How long between the initial presentation of Raynaud’s phenomenon and skin involvement in limited systemic sclerosis?
15 years.
What type of systemic sclerosis has more rapid and more widespread skin involvement?
Diffuse cutaneous scleroderma.
Why is there GI involvement in systemic sclerosis?
There is dilation and atony of the GI tract.
What is the cure for systemic sclerosis?
There is no cure.
Define microstomia.
Small mouth.
Define calcinosis.
Calcium deposition in subcutaneous tissue.
Define sclerodactyly.
Local thickening/tightness of skin on finger/toes.
Define telangiectasia.
Widened spider-like veins.
What is limited cutaneous scleroderma also known as?
CREST syndrome.
List the acronym of CREST.
C) calcinosis R) Raynaud’s phenomenon E) oesophageal dysmotility S) sclerodactyly T) telangiectasia
Where does skin thicken in limited cutaneous scleroderma?
Distal to knees and elbows.
Where does skin thicken in diffuse cutaneous scleroderma?
Proximal to elbows and knees.
List 4 types of cancers associated with polymyositis and dermatomyositis.
1) lung
2) pancreas
3) bowel
4) ovary
Define heliotrope eyelid rash.
Lilac eyelid discolouration.
Define macular rash.
Red skin covered with bumps.
Define Gottron’s papules.
Scaly erythematous knuckle plaques.
Describe the pathology of Raynaud’s phenomenon. (3)
1) white - vasoconstriction causing skin pallor
2) blue - sluggish blood flow
3) red - hyperaemia
What percentage of population have Raynaud’s phenomenon?
5%.
How many types of Ehlers-Danlos syndrome are there?
13.
What types of Ehlers-Danlos syndrome is the most common?
Hypermobile.
What type of Ehlers-Danlos syndrome is the only one not to be genetically diagnosed?
Hypermobile, clinical diagnosis.
What causes Ehlers-Danlos syndrome?
Genetic defect in collagen, fibrillin or matrix proteins.
What is the inheritance pattern of hypermobile Ehlers-Danlos syndrome?
Autosomal dominant.
Define striae atrophicae.
Stretch marks.
Define myopic.
Short sighted.
Define astigmatism.
Blurry vision due to irregular corneal curvature.
Define pectins excavatum.
Inwardly sunken sternum.
Define pectus carinatum.
Outwardly pushed sternum.
Define Steinberg’s sign.
Thumb extends past palm when hand is in a fist.
Define Walker-Murdoch’s sign.
Thumb and little finger overlap when gripping opposite wrist.
Define pes panus.
Flat feet.
