Arthritis

Question 1

Stiffness rarely lasting longer than 15 minutes

Pain on motion worse with activity or weight bearing, relieved with rest

Flexion contracture, varus/valgus deformity, Heberden/Bouchard nodes

Crepitus

Answer 1

osteoarthritis

Question 2

RF for osteoarthritis

Answer 2

90% have this by age 40
Hereditary, mechanical factors, obesity, contact sports, jobs w/ frequent bending/carrying

Question 3

Loss of articular cartilage leading to pain and deformity + hypertrophy of bone at articular margin in weight bearing joints

Primary = DIP/PIP joints, CMC joint, hip, knee, cervical/lumbar

Secondary = injury to the joint from trauma or overuse or metabolic disease

Answer 3

osteoarthritis

Question 4

XR: loss of joint space, sclerosis, subchondral cysts, osteophytic/lipping of marginal bone

Labs: lack of inflammatory markers

Answer 4

osteoarthritis

Question 5

How do you tx osteoarthritis

Answer 5

Activity modification/splinting, exercise, weight reduction, NSAIDs, topical or otherwise
Intra-articular injections (steroid, hyaluronate, PRP), duloxetine (cymbalta), PT

Joint arthroplasty

Question 6

Sudden onset, frequently nocturnal

MCJ = metatarsophalangeal joint (podagra) or ankle, tarsal, knee

Severe pain, redness, swelling, with maximum severity reached over several hours
Fever is common

Answer 6

gout

Question 7

What are RFs for gout

Answer 7

Alcohol excess, med changes, hospitalization, fasting before procedures

Mostly adult men

Question 8

Elevated levels of uric acid deposition due to overproduction or underexcretion of renal uric acid
– excess monosodium urate crystals depositing in tissue
Causing recurrent attacks of acute inflammatory arthritis, usually monoarticular

Tophi = masses from this with associated foreign body reaction

Answer 8

gout

Question 9

What are triggers for gout

Answer 9

Triggers = thiazide/loop diuretics, ACEI, pyrazinamide, ethambutol, aspirin, purine rich foods

Question 10

PE: Marked tenderness to palpation, swelling, erythema, limited ROM

Arthrocentesis → monosodium urate crystals in synovial fluid (birefringent needle shaped)

Labs: elevated ESR, WBC

XR: normal early, joint destruction later (punched-out erosions”mouse bite” w/ overhanging rim of cortical bone)

Answer 10

gout

Question 11

How do you treat gout acutely

Answer 11

NSAIDs first line (indomethacin and naproxen)
Oral steroids (intra-articular injection for monoarticular)
Colchicine if symptoms <36 hours

Question 12

How do you treat gout between attacks

Answer 12

Avoid alcohol (beer), purines (liver, seafood, yeasts), avoid diuretics, niacin, aspirin
Colchicine + canakinumab prophylaxis
Urate lowering = allopurinol + febuxostat (not acutely), probenecid (not in renal issues)

Question 13

How do you treat gouts more severely?

Answer 13

Pegloticase in hospital setting

IL-1 inhibitors in hospitalization

Question 14

Asymptomatic – generally acute and recurrent in one joint, knee MCJ, with wrists 2nd, more common in femeale/elderly

Answer 14

pseudogout

Question 15

Calcium pyrophosphate deposition disease, causing precipitation of these crystals in connective tissues

Answer 15

pseudogout

Question 16

PE: Marked tenderness to palpation, swelling, erythema, limited ROM

Presence of CPPD crystals (positive, birefringent rhomboid-shaped) in synovial fluid (joint aspiration to distinguish)

– XR evidence of CPPD crystals (chondrocalcinosis) to differentiate; calcification of cartilage

No bony erosions

Answer 16

pseudogout

Question 17

psuedogout tx

Answer 17

Joint aspiration + intra-articular steroid injection

NSAIDs for acute attacks

Colchicine w/n 24 hours and for prophylaxis

Short term immobilization

Question 18

Stiffness, pain, swelling, worse in the morning >30 minutes, improves later in the day
Carpal tunnel common

Anemia, malaise, fatigue, vasculitis, scleritis, rheumatoid nodules, renal disease, pleuropericarditis, ocular symptoms, trigger finger from nodules

Symmetric

Answer 18

rheumatoid arthritis

Question 19

RF for rheumatoid arthritis

Answer 19

Women > men
Peak onset late 40s, early 50s
Hands, wrists, knees, feet, ankles MC

Question 20

Acute + chronic inflammation in synovium, causing proliferative + erosive joint changes – etiology unknown

– Genetic predisposition, hormonal changes, infectious agents

Answer 20

rheumatoid arthritis

Question 21

PE: pain and swelling, limited ROM, synovial hypertrophy with “BOGGY” feeling, joint aspiration = little fluid, reduced grip strength, extensor surface nodules
Ulnar drift of toes fingers
Knee = ligament laxity, effusion, genu valgum
Heel pain from retrocalcaneal bursitis

RF, anti-CCP, IgM antibody, CRP, ESR
Anemia of chronic disease is common
XR

Answer 21

rheumatoid arthritis

Question 22

rheumatoid arthritis tx

Answer 22

Steroids – bridge gap between slow acting DMARDs:
→ Methotrexate, but can add sulfasalazine (2nd), leflunomide, hydroxychloroquine

Refractory = janus kinase inhibitors

Biologics – TNF-alpha added to methotrexate (etanercept, infliximab, adalimumab), or nonTNF (abatacept)

Omega 3 supplements, analgesics, splints/therapy, custom shoes

Selective surgery

Question 23

PEAR-U Sero-negative spondyloarthropathies

Answer 23

Psoriatic arthritis
Enteropathic arthritis (IBD)
Ankylosing spondylitis
Reactive arthritis (reiter)
Undifferentiated spondyloarthropathy

Question 24

What are RFs for sero-negative spondyloarthropathies

Answer 24

Males
<40
spine/SI joints
Enthesopathy
Ocular formation

Question 25

HLA-B27 genetic marker is often seen in

Answer 25

Sero-negative spondyloarthropathies

Question 26

DIP joint with scaly, cutaneous lesions, commonly with nail disorders, pitting, ridging, onycholysis psorasis preceding onset XR: pencil in cup deformity

Answer 26

psoriatic arthritis

Question 27

How do you treat psoratic arthritis

Answer 27

TNF inhibitor → methotrexate

Question 28

Crohn’s and UC Peripheral – oligoarthritis of large joints, paralleling bowel disease Spondylitis – indistinguishable from ankylosing spondylitis, independent course of bowel disease

Answer 28

enteropathic arthritis

Question 29

How do you treat enteropathic arthritis

Answer 29

Control intestinal inflammation = eliminate peripheral arthritis, can add NSAID (if not exacerbating)

Question 30

Morning stiffness relieved by activity and leaning forward Late teens, early twenties, males > females Primarily affecting axial skeleton - sacroiliitis and kyphosis

Answer 30

ankylosing spondylitis

Question 31

PE: limited spinal motion, progresses in cephalad direction FABER maneuver stresses SI joint Achilles enthesopathy, anterior uveitis XR: “shiny corner sign” where annulus attaches to vertebral body, “bamboo spine”

Answer 31

ankylosing spondylitis

Question 32

How do you treat ankylosing spondylitis

Answer 32

NSAIDS, then TNF

Question 33

Arthritis, urethritis, conjunctivitis, mucocutaneous lesions STI and dysenteric disease common Pain in large joints of lower extremity with enthesitis of achilles tendon, dactylitis, sacroiliitis, nongonococcal urethritis, anterior uveitis, cutaneous ulcerations

Answer 33

reactive arthritis

Question 34

“Reiter syndrome” – acute spondyloarhtropathy precipitated by GI/GU infection “Can’t see, can’t pee, can’t climb a tree”

Answer 34

reactive arthritis

Question 35

how do you tx reactive arthritis

Answer 35

NSAIDs, then sulfasalazine or methotrexate – may need to treat chlamydial infection