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Flashcards in Arthritides Deck (31)
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1

Types of Joints: describe and give example of each of the following:
-fibrous/bony
-cartilaginous
-synovial

Fibrous/bony: minimal to no motion
(e.g skill sutures)

Cartilaginous: limited motion
(e.g intervertebral discs, pubic symphysis)

Synovial: freely mobile, comprised of 2 or more bones.
(e.g knee, shoulder, hip)

2

Describe the type of joint for each of the following:
-hip
-shoulder
-knee
-ankle

Hip:
-ball and socket, lots of motion, stable

Shoulder: ball on small tee; more motion, less stable.

Knee: round condyles on flat surface; ligaments essential

Ankle: limited plane of motion

3

Osteoarthritis (OA)
-aka
-what is this?
-risk factors
-MC age in men and women?
-pathophys

aka: degenerative arthritis or joint dz

What; loss of articular cartilage- leading to exposed bone.
*MC form of arthritis

Risk factors:
-age, female, previous injury
-obesity
-heavy physical labor
- + family hx
-sports activities

MC age in:
-men = 45YO
-women = 55YO

Pathophys:
-triggered by damage to normal articular cartilage
-chondrocytes react by releaseing degradative enzymes causing subchondral sclerosis and osteophytes. (bony outgrowths associated with the degeneration of cartilage at joints)
-superficial erosions leading to complete loss of cartilage
-joint space narrowing and possible deformity.

4

Features of OA;
-general signs and sx

General S&S:
-joint pain, swelling, crepitation, tenderness, effusions
-radiating pain and bursitis in hands, hips knees, and spine
-tenderness on palpation and on passive motion are late signs

*pain is relieved with rest. *

-multiple joints in older pt
-hip and knee seen in middle age
-single joint in the young

5

Features of OA:
-hands
-- location of dz
-- common features found on exam

-shoulder
--sx
--MC seen with what otehr conditions?

Hands:
-location: Distal interphalangeal joints and Proximal interphalangeal joints.

-Feature:
--Heberdens nodes (DIP)
--Bouchards nodes (PIP)

Shoulder:
-sx: progressive anterior shoulder pai, worse with motion
-difficulty with overhead activities, sleeping, and axillary hygiene.

-MC seen with rotator cuff dz/tears, AC joint arthritis.

6

Features of OA:
-hip
--sx & signs

-knee
--signs and Sx

-spine
--signs and sx

Sx & Signs:
-deep groin pain
-can radiate anterior thigh, knee buttock
-difficulty putting on socks/shoes
-pain with abduction.

Knee:
-signs and Sx:
--crepitus, effusion, limited motion
-difficulty doing stairs, getting out of low chairs off of toilets
-pain with kneeling/squatting

Spine:
-Cervical: pain and stiffness, aching pain down arm
-Lumbar: pain across low back/buttocks with loss of motion flex/ext

7

Dx of OA

clinical dx supported by H&P, labs and imaging

-no specific labs
-plain XRAY

8

OA:
-XRAY Findings
-tx

Xray findings:
-joint space narrowing
-surface irregularity
-osteophytes
-subchondral sclerosis
-subchondral cysts

Tx:
-non-Rx:
--weight loss
--exercise
--PT/OT
--braces
--Heat/cold
--Rest

-Rx:
--acetaminophen
--NSAIDS (naproxen/ibuprofen)
--Tramadol
--Opiods
--Intraarticular injections ---glucocoritcoid = triamcinolone methylprednisolone.
---Hyaluronans = synvisc, hyalagen

Surgical:
-Arthroscopy (dont typically do this, may aggravate underlying arthritis)
-Total joint replacement (**GOLD STANDARD for severe knee, hip, or shoulder joint arthritis)
-Chondrocyte grafting (for small, isolated defects)



THIS IS NOT AN INFLAMMATORY ARTHRITIS.

9

Rheumatoid Arthritis:
-cause
-pathophys

Cause: breakdown of immune tolerance to synovial inflammation. Complex interaction of genetic and environmental factors.

Pathophys:
-plasma cells produce abys
-MF and lymphocytes produce pro-inflamm cytokines and chemokines
-synovium thickens, hyperplastic synovial tissue (pannus) releases inflammatory mediators which erods the cartilage.

10

RA:
-presentation
--course
--systemic sx
--joint sx

presentation:
Course:
-gradual insidious onset
-sx wax and wane
-involve multiple joints, characteristically symmetric


Systemic Sx:
-early morning stiffness of affected joints
-generalized afternoon fatigue and malaise
-anorexia

Joint sx:
-pain
-swelling
-stiffness
-erythema

11

RA:
-imaging
--what test is MC?
--what is seen from the MC test?

Imaging;
-MC test is XRAY.
-XRAY shows:
--joint space narrowing
--soft tissue swelling*
--bony erosions
--osteopenia about joint
--laxity leading to deformity and bone displacement
--destruction/fusion late

12

RA Hand:
-signs and sx

Signs and Sx
-swollen, painful MP and PIP joints
-tender, limited motion
-reduced grip strength
-tendon ruptures, triggering
-*ulnar deviation at MP joints*
-swan neck (weird curve at DIP) and boutonniere (thumb deformity that makes it curved out)
-soft tissue swelling in hands

13

RA
-wrist
-elbow
-shoulder
-hips
-knee
-foot

Wrist:
-loss of extension
-carpal drift
-tendon rupture

Elbow:
-nodules
-loss of extension
-olecranon bursitis
-ulnar neuritis

Shoulder:
-adhesive capsulitis
-rotator cuff dz
-joint destruction

Foot:
-similar to hand; MP joint involved, toe deformities, heel & ankle pain

Knee:
-synovitis and effusion
-Bakers cyst (popliteal cyst)
-loss of flexion

Hips: late
-groin pain
-loss of rotation

14

Extra-articular RA:
-manifestations

Manifestations:
-skin and pulmonary nodules*
-pericarditis
-splenomegaly
-neuropathy
-vasculitis
-episcleritis
-lymphadenopathy

15

RA:
-dx
--labs
--imaging
--criteria

Labs:
-RF
-Anti-CCP
-ESR
-CRP
-synovial fluid (turbid, yellow)

Imaging:
-xray

Criteria:
-clinical dx can be made when:
-inflammatory arthritis in 3 or more joints for more than 6 weeks
-positive RF and ACCP
-elevated CRP and ESR

Based on point system, dx requires greater than 6 points.
-Joint involvement:
--1 large joint = 0
--2-10 large joints = 1
--1-3 small joints =2
--4-10 small joints = 3
--greater than 10 = 5

-Serology
--negative RF and negative ACPA = 0
--low positive RF and low positive ACPA = 2
--high positive RF or high positive ACPA = 3

-Acute phase reactants:
--normal CRP and normal ESR = 0
--abnormal CRP and abnormal ESR = 1

-Duration of sx:
--less than 6 wks = 0
--greater than 6 wks = 1

**ACCP = ACPA (;

16

RA:
-general Tx

Manage acute flares:
-NSAIDs and glucocorticoids
--relieve discomfort, dont stop progression

DMARDS: disease modifying anti-rheumatic drugs
--non-biologics
--biologics

Surgery for soft tissues and joints:
--synovectomy, tendon repairs, removal of nodules
--total joint replacement, fusion

-PT/OT, bracing, support groups
-Heat/cold
-orthotics and splints
-therapeutic exercise
-PT/OT

17

RA RX acute pain

NSAIDS: aspirin,
when first seen or during flare:

ibuprofen, naproxen

Glucocorticoids (systemic)

18

RA and DMARDS
-what are the nonbiologic and biologic medicatinons?

Nonbiologics:
-methotrexate(first line), sulfasalzine, leflunomide
-hydroxychlorquine, cyclosporine, gold salts, azathioprine

Biologics:
-TNF inhibitors
-entanercept (enbrel)
-infliximab (remicade)
-adalimumab (Humira)

19

Methotrexate:
-SE
-CI

SE:
-ulcerative stomatitis
-leukopenia
-predisposition to infection
-nausea
-abd pain
-fatigue
-fever
-dizziness
-pna
-pulm fibrosis

CI:
-renal dysfunction
-pregnancy or possible pregnancy

20

Gout:
-MC joint affected
-pathophys
-causes


MC joint = first metatarsophalangeal joint (podagra= gout of this big toe)

Patho:
-precipitation of monosodium urate cyrstals in joint space
-over time joint space is damaged.
-tophi is pathopneumonic for gout

Causes:
-decreased excretion of uric acid
-increased production of uric acid
-increased purine intake

21

Gout;
-risk factors
-presentation

Risks:
-increased age
-menopause = less estrogen = less excretion of uric acid = build up of uric acid = gout.
-alcohol
-meat
-seafood

Presentation:
-severe pain
-redness/warmth
-swelling/disability
-worse at night
-overlying skin becomes tense
*anything that touches this hurts, even the sheets on your bed!

22

Gout:
-dx
-tx

Dx:
-synovial fluid analysis:
--needle-shaped NEGATIVE birefringent urate crystals
-elevated serum urate level

-Xray

Tx:
-resolves in a few days to weeks
-NSAIDS first choice! naproxen or indomethacin****)
-colchicine
-glucocorticoids (intraarticular or PO when multiple joints)

-treat hyperurcemia:
--reduced intake of purines (purines broken down into uric acid)
--Xanthine oxidase inhibitors: allopurinol *** DOC to lower serum urate levels.
--Uricosuric Drugs: probenecid; increase urinary excretion.

23

How do we prevent recurrent attacks of gout?

Lifestyle changes: weight loss, decrease alcohol intake

Diet:
-decreasing meat and fish
-increase dairy products

Lowering serum uric acid:
-uricosuric agens = probenacid
-xanthine oxidase inhibitors = allopurinol

24

Pseudogout:
-aka
-cause
-presentation
-dx

aka: calcium pyrophosphate dehydrate (CPPD) cyrstal deposition dz
OR chondrocalcinosis

Cause: trauma, hypomagnesemia, hyperparathyroidism

Presentation: -similar to gout but less severe
-usually occurs in knee or other large peripheral joints

Dx:
-synovial fluid: rhomboid-or-rod shhaped crystals
-POSITIVE birefringent crystals

X-rays:
-chondrocalcinosis

25

Pseudogout:
-Tx
--single joint
--multiple joints

-prevention

Tx:
Single joint: aspirate and inject with steroids, immobilize and apply ice or cool pack

Multiple joints: NSAIDS, colchicine, or systemic steroids

Prevention:
-after 3 or more attacks = daily colchicine

26

Describe the major features of..
-osteoarthritis
-TA
-gout/pseudogout

OA:
-degeneration of cartilage leading to joint damage

RA:
-autoimmune dz that attacks synovium and soft tissue
-see swelling and damage of multiple joints

Gout/pseudo: deposition of crystals leads to joint inflammation and damage
-recurrent attacks often in big toe in gout.

27

Clinical features of each of the following
-osteoarthritis
-RA
-Crystalline arthritis (GOUT)

OA:
-dz limited to the joint
-osteophyt formation, creakign with motion
-nodes in PIP and DIP

RA:
-generalized dz that results in multiple, swollen, painful joints
-usually starts in hands and feet and progresses proximally

Gout:
-red, hot, swollen joint
-skin sensitivity/painnnnnn
-resolve over time

28

What are common imaging findings in each of the following:
-OA
-RA
-Gout

OA:
-joint space narrowing (unilateral)
-subchondral sclerosis
-osteophytes
-subchondral cysts

RA:
-joint space narrowing (bilateral)
-soft tissue swelling
-bony erosions
-osteopenia about joint

Gout:
-can see erosion and joint destruction late

29

Contrast OA and RA features in the hand

OA:
-swelling = hard, bony
-stiffness = worse after use- PM
-fingers = DIP, PIP + nodes (heberdens & Bouchards)

RA:
-swelling = soft, warm, tender
-stiffness = worst after rrest - AM
-fingers = MP and PIP + deformity

30

Compare Lab work in:
-OA
-RA
-Gout

OA:
-normal

RA:
-elevated ESR, CRP
-Rheumatoid factor and ACCP (both usually positive)

Gout:
-elevated uric acid
-crystals in joint fluid (negative vs positive)