3 Bone Disorders

Question 1

MC type of arthritis?

Answer 1

DJD (osteoarthritis)

Question 2

Common symptoms of osteoarthriths?

Answer 2

Stiffness
Pain
Deformity
Joint effusion (intermittent)
Decreased joint motion (2/2 osteophytes)

Question 3

Herberden nodes?

Answer 3

osteoarthritis fusiformswelling of the joints -> nodules at the DIP

Question 4

Bouchard nodes?

Answer 4

osteoarthritis

Fusiform swelling at the joints -> nodules at the PIP

Question 5

RA vs OA?

Answer 5

RA is the MCPs and PIPS
- RA shifts and deforms the fingers medially

OA is PIPS and DIPS
- OA just causes herberden and bouchard nodes and painful looking joints w no medial deformity

Question 6

Radiographic findings for osteoarthritis?

Answer 6

Joint space narrowing
Subchondral sclerosis
Subchodral cysts
Osteophytes at the joint margin

Question 7

EBM Therapy for OA?

Answer 7

Based on pain management, it is a progressive disease

Recommendations
Strong
- strengthening exe
- NSAIDS
- TKA 
Moderate
- wt loss
Limited
- tibial osteotomy
Inconclusive
- corticosteroids
- tylenol/opoids etc 
- arthroscipic partial meniscectomy

Question 8

Standard 1st line for OA?

Answer 8

1. PT
2. Wt loss
3. Pain management (NSAIDS, tylenol)
4. Glucosamine and chondroitin
   1,500mg/day and 1,200 mg/day x 8 weeks

Question 9

Standard 2nd line therapy for OA?

Answer 9

1. Intra-articular corticosteroids - q 3 months
2. Unloader brace
3. Intra-articular viscosupplement inj
   - supartz, eflexxa, synvisc, hyalgan
4. PRP

Question 10

Surgery options for OA?

Answer 10

1. Proximal tibia osteotomy (HTO) (younger pts)
   - realignment, offloads arthritic compartment
2. Total/partial joint arthroplasty
   - unacceptable loss of function/pain
3. Arthrodesis (fusion)

Question 11

MC inflammatory arthritis?

Answer 11

RA

Question 12

What is RA?

Answer 12

Systemic autoimmune d/o

Primarily affects synovial membrane

Tends to have systemic effects

• interstitial lung disease
• CVD
• increased infection rate

Question 13

RA symptoms?

Answer 13

1. Pain and morning stiffness >1hr x 6 weeks
   - OA comes and goes, RA = long flare
2. Swelling in 2+ joints
3. Systemic symptoms
4. Rheumatoid factors (RFs) or anti-CCPs
5. Joint contractures, effusions, deformity, painful motion
6. Joints = warm, synovial bogginess

Question 14

RA common tendon problems?

Answer 14

Acute carpal tunnel syndrome - common finding

Tendon rupture
- MC = EPL (extensor pollicus longus)

Rheumatoid nodules appear -> trigger finger in hand

Question 15

Joint aspiration in RA?

Answer 15

Typically produces less fluid than expected

- enlargement comes from synovial hypertrophy

Question 16

Labs for RA?

Answer 16

Rheumatoid factors - not specific
Anticyuclic citrullinated peptide antibody (ACPA/anti-CCP) - more specific
CRP, ESR - elevated

Question 17

RA radiographic findings?

Answer 17

Periarticular osteopenia and bony erosion at joint margin

Atlanto-axial instability 2/2 erosion of ligaments
- important to consider when planning surgery

Question 18

RA tx?

Answer 18

DMARD - methotrexate
Hydroxycholoroquine
Sulfasalazine 
NSAID/Glucocorticoid
Corticosteroid (carpal tunnel)
orthotics
PT (ROM, strengthening)
Paraffin bath - hot wax 
Surgery

Question 19

OA vs RA?

Answer 19

Slide 35

OA

• elderly
• M>F
• asymmetric
• DIP
• Hip, knee, CMC
• M
• symmetric
• MCPs
• hands/feet
• ulnar deviation/claw toes
• • RF, + ACPA

Question 20

Idiopathic OA of the spine?

Answer 20

DISH

Question 21

What is DISH?

Answer 21

Diffuse idiopathic skeletal hyperostosis
- OA in the spine

Ossification spanning 4+ intervertebral disks

Question 22

MC area for DISH to present?

Answer 22

Thoracic and throcolumbar spine

Question 23

Pt population for DISH?

Answer 23

White men
- male:female 2:1

Age 60+

Question 24

Symptoms and signs of DISH?

Answer 24

Symptoms

• Stiffness of spine (esp in morning/evening)
• Symptoms x months/years
• Often asymptomatic and incidental finding on CXR

Signs

• stiffness sin spine - forward flexion/extension
• reduced hip motion - common
• knee arthritis - common

Question 25

DISH diagnostic criteria?

Answer 25

- Ossification spanning 4+ intervertebral disks - preservation of intervertebral disc height - peripheral enthesis (hip/patella/olecranon) - absence of other spine pathology

Question 26

Radiographs for DISH show?

Answer 26

Disk height preserved but segments are fused Normal SI joints Ossification is on the anterior longitudinal ligament ?posterior longitudinal ligament - so its more anterior than posterior

Question 27

DISH and surgery?

Answer 27

Heterotopic ossification (HO) occurs 5x more following hip replacement in pts w DISH (Bone forming where it shouldnt be)

Question 28

DISH tx?

Answer 28

Exercise/walking NSAIDS (pain is usually min) Surg - last resort

Question 29

What is osteoporosis?

Answer 29

Low bone strenght Low bone mass -> microarchitectural deterioration Increased fragility of the bone Increased risk of fracture (hip/spine)

Question 30

Types of Osteoporosis?

Answer 30

Primary type I - estrogen/testosterone Primary type II - Ca++ metabolism Secondary - hormone, metabolic or neoplastic abn

Question 31

Primary type I osteoprosis?

Answer 31

Women:Men 6:1 | - estrogen/testosterone deficiency -> trabecular bone loss

Question 32

Primary type II osteoporosis?

Answer 32

70+ yrs - senile osteoporosis Women:men 2:1 Caused by altered metabolism and intrinsic problems in bone formation -> decrease in formation of new bone

Question 33

Typical presentation of type I/II osteoporosis?

Answer 33

Type I - vertebral compression fx (MC) - distal radius fx Type II - hip fx - pelvis fx

Question 34

Risk factors for osteoporosis?

Answer 34

Lifestyle - Low CA intake - High caffeine/salt - Vitamin D insufficiency - Smoking - Etoh - Low physical activity - Falling - Thinness Genetic - CF, marfans, OI Hypogonadal stage Endocrine: adrenal insufficiency, cushings, DM, hyperparathyroidism, thyrotoxicosis GI: CD, Gastric bypass, IBS Heme: hemophelia, SCD, MM Rheum diseases Meds: heparin

Question 35

Risk assessement for osteoprosisis?

Answer 35

WHO - FRAX (fracture risk assessment) - 10 yr risk assessment Only used if DEXA is unavailable

Question 36

PE for osteoporosis?

Answer 36

Normal in early stages Advanced disease - TTP over fracture - spinal deformity - loss of height (>2”) - lax abdominal muscles - exaggerated thoracic kyphosis (dowagers hump)

Question 37

Diagnostic test for Osteoporosis?

Answer 37

DEXA 0 to -1 - normal -1 to -2.5 - osteopenia < -2.5 - osteoporosis

Question 38

Osteoporosis screening?

Answer 38

BMD testing for: ``` Women Post menopausal <65 w 1+: - famhx - hx of low-trauma fx >45 yrs - current tobacco - low body wt (<127) All women >65 regardless of risk factors ``` Men - low trauma fx - GnRH agonist for prostata ca Anyone - primary hyperparathyroidism - long term glucocorticoid tx - diseases that cause bone loss

Question 39

Osteoporosis prevention?

Answer 39

``` Calcium and vitamin D Reg wt bearing exercise Avoid ETOH/Tobacco Maintain body weight Reduce fall risk ```

Question 40

who needs Osteoporosis tx?

Answer 40

Women BMD 2 SD below w/o risk factors Women BMD 1.5 below w risk factors Caucasian women >70yrs w multiple risk factors - dont need BMD testing, just treat

Question 41

Pharm tx for osteoporosis drug classes

Answer 41

A. Antiresorptive agents | B. Anabolic agents

Question 42

Concerns for osteoporosis meds?

Answer 42

Lots of SE

Question 43

Types of antiresorptive drugs

Answer 43

1. Diphosphonates | 2. Nondisphonphonates

Question 44

What are the diphosphonates?

Answer 44

1. Diphosphonates - alendronate, - risedronate - ibandronate - Zoledronic acid

Question 45

What are the nondiphosphonates?

Answer 45

2. Nondisphonphonates - denosumab - SERM

Question 46

What are the anabolic agents?

Answer 46

B. Anabolic agents | - PTH

Question 47

SE of diphosphonates?

Answer 47

Diphosphonates - GI disturbance

Question 48

SE of Denosumab

Answer 48

Infections

Question 49

SE of SERMS?

Answer 49

SERM - DVT/PE, stroke, nosebleed