Arthritis/Rhuem - MSK Flashcards
(31 cards)
1
Q
SEPTIC ARTHRITIS
A
- acute onset, sev pain, decreased ROM, usually monoarticular, usually large joint
- RFs = age, prosthetic joints, comorbidities or chronic disease
- mcc neonate = staph aureus and group B strep
- mcc 6m-2y = h.influenza
- mcc child = staph aureus and group B strep - mc source = otitis
- mcc adult = Neisseria gonorrhea -mc source <60yo = STD
- mcc RA pt = staph aureus
2
Q
Septic Arthritis - other causes
A
- viral: rubella, hepatitis
- fungus: immunocompromised pts
- mycobacterium: mc hip and knee, also thoracic spine (Pott’s Disease)
- Lyme’s Disease: tick transmits the bacteria Borrelia burgdorferi
- bite -> bull’s eye rash (erythema migrans) -> systemic dz (intermittent migratory episodes of polyarthritis, especially knee) -> cardiac and neurological manifestations
- dx = joint fluid analysis of needle aspiration, ELISA or Western-blot
- tx = adults doxycycline, child amoxicillin
3
Q
OSTEOARTHRITIS
A
- mc form of arthritis
- 2nd mc form of disability
- 70% of those >65yo have radiographic evidence of OA
- M=F, except >55yo there are more F affected
- wear and tear joint breakdown
- microscopic changes: chondrocyte hyper cellularity, cartilage breakdown (fissuring, pitting), osteophyte “spur” formation, synovitis -> inflammation, decreased proteoglycans, subchondral bone sclerosis (but no bony erosion), juxta-articular bone cysts
4
Q
OA types
A
- Primary = idiopathic
- main jts = knee, DIP (heberden’s nodes) + PIP (bouchard’s nodes) > MTP, CMC (especially 1st CMC), hip, spine/spondylosis with associated disc degenerative changes (especially Joints of Luschka or the superiolateral uncinate processes on the cervical vertebrae) = spondylosis, ACJ, 1st MTP
- Secondary = due to underlying cause
- chronic/acute trauma (overuse syndrome), connective tissue dz, endocrine, metabolic, infectious, neuropathic (Charcot arthritis)
- main jts = shoulder, elbow
5
Q
OA sxs
A
-dull aching pain worse with activity, better with rest
stiff joint < 30min
-gel phenomenon (temporary stiffness improves with a bit of ranging)
-joint “gives away”
-clunking, locking due to cartilage fragments
-crepitus and pain on ranging
-localized jt tenderness
-joint enlargement (synovitis, osteophytes and increased intraarticular fluid)
6
Q
OA XRay
A
- asymmetric joints involved (unilateral findings)
- asymmetric jt space narrowing: (knee more medial, hip more lateral)
- subchondral bony sclerosis
- osteophytes
- bony cysts
- loose bodies (cartilage fragments)
- no osteopenia (no bone “washout”)
7
Q
OA Tx
A
- weight loss
- PT/OT
- maintain or improve ROM
- assistive devices
- Joint Protection and Energy Conservation exercises
- Meds
- NSAIDs, tylenol
- opioids rare (tramadol best, esp for knee)
- intermittent intraarticular steroids (not PO)
- intraarticular hyaluronic acid (Synvisc, Hyalgan…)
8
Q
RHEUMATOID ARTHRITIS
A
- 1% of the population, F:M 2:1
- genetic – altered major histocompatability complex on chromosome 6’s HLA-DR4 allele
- systemic autoimmune joint breakdown due to attack on the synovium, typically in an insidious onset pattern
- microscopic changes: synoviocyte proliferation and hypertrophy, T-cell infiltrates, panus formation
- granulation tissue membrane destroys marginal cartilage and bone
- made of inflammatory cells, fibroblasts, small blood vessels
9
Q
RA types and Sxs
A
-Insidious Onset: mc form, ~70% of all RA; weeks to months
+ constitutionals; low grade fever without chills
-diffuse myalgia, initial symmetric joint involvement, morning stiffness > 1hr
-swollen, erythematous joints: MCP > PIP (DIPs are NOT involved in RA), carpals, ankle, MTP
-Intermediate Onset: ~20%; days to weeks
-Acute Onset, ~10%, several days, severe myalgia is prominent
10
Q
RA Dx
A
- at least 4 of the following 7
1. morning stiffness > 1h x6wks
2. perijoint edema in at least 3 jts at once x6wks
3. at least one of the above joints is in the wrist or hand x6wks
4. symmetric joint involvement x6wks
5. + rheumatoid nodules- subQ nodules over extensor surfaces or near joints
- serum Rheumatoid Factor (RF)
- Rheumatoid XR findings(namely symmetric joint space narrowing, marginal bony erosions and periarticular osteopenia)
- subQ nodules over extensor surfaces or near joints
11
Q
RA labs
A
- 85% of RA pts have + RF (don’t have to have + RF to have RA) + RF also in SLE, scleroderma, Sjogren’s
- increased acute phase reactants erythrocyte sedimentation rate and c-reactive protein (ESR and CRP)
- CBC: thrombocytosis, hypochromic microcytic anemia, eosinophilia
- synovial fluid analysis: low viscosity but cloudy, WBC 70% PMNs
12
Q
RA Joint Deformities
A
- Boutonniere Deformity: extensor tendons slip palmarly at the PIPs resulting in flexed PIPs and hyperextended MCPs and DIPs
- Swan Neck Deformity: contracture of flexor intrinsic hand muscles/tendons resulting in hyperextended PIPs and flexed MCPs and DIPs
- wrist radial deviation
- digit ulnar deviation
- shortened digits with retracted periarticular skin folds
- tenosynovitis, especially DeQuervain’s (+ Finklestein)
- anterior sublux of C1 on C2 : tenosynovitis/laxity/rupture of C1’s transverse ligament , C2’s odontoid or C1’s arch erosion , neck motion could cause sublux to pinch cord = cervical myelopathy
- hammer toes and claw toes
- ankle laxity can lead to tarsal tunnel syndrome
- shoulder, elbow, hip and knees can also be affected
13
Q
RA Tx
A
- PT for home exercise program and joint protection techniques, isometric strengthening, heat/cold modalities
- OT for orthotics to dec pain/inflam, reduce forces thru joints, stabilize and rest joint
- rheumatology referral
- surgical options of synovectomy, arthroplasty, tendon repairs/lengthening
- mild disease (no poor Px factors present): NSAIDs, salicylates, disease modifying antirheumatic drug (DMARDs) -> hydroxychloroquine, sulfasalazine, oral gold
- mod or severe disease (+ poor Px factors present): NSAIDs, salicylates, DMARDs -> IV or IM gold, weekly or daily or IV/IM methotrexate (MTX), corticosteroids, combinations of DMARDs
14
Q
JUVENILE RHEUMATOID ARTHRITIS
A
- mc form of childhood arthritis
- unknown etiology
- onset 6wks
- rule out others: rheumatic fever, infection, SLE, vasculitis
- Systemic (Still’s Dz): 1-6yo, M=F; near 100% neg RF
- persistent daily fever and rash with multisystem findings
- poly or oligoarthritis (few jts involved), growth delay, osteopenia/porosis, LAD, HSN (hepatosplenomegaly), pericarditis, pleuritis, anemia, leukocytosis, uveitis rare
- Polyarticular: >8yo, F»M, RF pos 10%, RF neg 90%
- trace systemic findings except growth retardation (early closure of epiphyseal plates), ≥5 jts involved
-Pauciarticular: knee mc, then ankle then wrist and elbows
-+ HLA-B27
i-f + antinuclear antibody (ANA) then iridiocyclitis (anterior uveitis) -> must refer to opthomalogy, slit lamp exam 4x qyr
15
Q
CRYSTAL-INDUCED SYNOVITIS
A
- Gout: monosodium and sodium urate crystals affect synovium
- Tx: NSAIDs, corticosteroids, Colchicine – stops phagocytosis of urate crystals, Allopurinol – dec urate synthesis, Probenecid – inc renal urate excretion,
- Pseudogout / Chondrocalcinosis
- calcium pyrophosphate dihydrate (CPPD) crystals affect cartilage
- Tx: NSAIDs, corticosteorids, ? colchicine
16
Q
Gout
A
- negative birefringence
- M»F
- hyperuricemia -> urate nephropathy
- acute and chronic
- trauma, EtOH, thiazides, hereditary
- exquisitely inflamed, mainly monoarticular, joint: mc 1st MTP (podagra), also foot, ankle, heel, knee, polyarticular mc with olecranon bursae, wrists, hands, chronic tophaceous gout – cartilage and bony destruction yrs after acute attack
- lasts days to weeks
17
Q
Psuedogout
A
- positive birefringence
- M>F
- serum uric acid nl
- usually acute
- hereditary, idiopathic, trauma, surgery, acute illness, assoc with metabolic diseases
- hypothyroidism, hyperparathyroidism, hypoMg, hypoPhos, amylodosis, hemochromatosis
- less painfully inflamed, more symmetric, polyarticular joints
- mc knee
- also 1st MTP, wrist, MCP, hip, shld
- mc chronic finding is knee flexion contracture
- lasts days
18
Q
SERONEGATIVE SPONDYLOARTHROPATHIES
A
- Ankylosing Spondylitis
- Reiter’s Reactive Arthritis
- Psoriatic Arthritis
- Enteric Arthropathy (Arthritis assoc with GI Dz)
- RF, - ANA, + HLA-B27
- spondylitis
- sacroiliitis
- enthesitis
- mucocutaneous lesions
19
Q
Ankylosing Spondylitis
A
- chronic spinal synovium inflammation -> cartilage destruction -> ankylosing (“self-fusing”) of the joint
- unknown mechanism
- late adolescence -> early adulthood: rarer, but can be >F (whereas RA is F>M)
- Caucasian more common
- HLA-B27 in 90%, - RF, - ANA, inc ESR and CRP
- insidious back and buttock pain x3m, morning stiffness >1hr, with joint pain, in a younger male
- mcc joints = Bilateral SI Joints, Lumbar>Thoracic>Cervical spine
- spine involvement could lead to extrapulmonary restrictive lung disease
- enthesitis = muscle insertion inflammation
- ischial tub, greater trochanter, ASIS and iliac crest tenderness (this is why we palpate them in a spine exam)
20
Q
anky spondy XRay
A
- Bilateral SacroiliacJoints: joint space narrowing -> fusion (ankylosis)
- “pseudo-widening”: subchondral erosion and osteopenia gives a blurred, washed-out appearance
- Lumbar>Thoracic>Cervical spine involved
- Bamboo spine: ALL calcification and facet jt fusion, bridging syndesmophytes due to annulus fibrosis calcification, squared anterior vertebral body (looses its concavity) due to ALL calcification
- L+C loss of lordosis, increased T kyphosis
21
Q
anky spondy Tx
A
- posture training and education
- prevent flexion moments (sleep on belly)
- PT!!!
- deep breathing ex to maintain pulm fxn
- NSAIDs (indocin), steroids, spinal injections, sulfasalazine, MTX (physiatry and rheum referrals)
22
Q
Reiter’s Reactive Arthritis
A
- M»F, more Caucasian
- “can’t pee, can’t see, can’t climb a tree”
- nongonococcal urethritis
- conjunctivitis/uveitis/corneal ulceration
- asymmetric oligoarticular arthritis which appears 2-4 wks post GI or GU (STD!) infection: chlamydia, campylobacter, yersinia, shigella, salmonella, common in knee, heel, ankle, wrist, hand, dactylitis (sausage digits) =dusky blue tender stiff digits, -achilles enthesitis (heel pain)= “Lover’s Heel” – XRay bony erosion/periosteal changes at plantar fascia and achilles tendon insertions
- unilateral sacroiliitis
- HLA-B27, - RF, - ANA, inc ESR/CRP
23
Q
Psoriatic Arthritis
A
~5% of all psoriasis pts; M=F, mid life, -Caucasian, assoc with HIV
- unknown etio
- HLA-B27
- psoriatic skin lesions + nail pitting + asymmetric mono- and oligoarticular arthritis: knee and IPs (esp DIP – pencil-in-cup deformity), SIJs, enthesitis, “fluffy” periostitis, syndesmophytes
- PO steroids don’t help. PT referral. Rheum referral for DMARDs. MTX NOT recommended
24
Q
Enteric Arthropathy
A
- asymmetric, mono- or polyarticular, large joint arthritis associated with 10-20% of pts with Crohn’s or Ulcerative Colitis
- M»F, + HLA-B27, - RF, - ANA
- sacroiliitis, anky spondy
- erythema nodosa with Crohn’s
- pyoderma gangrenosa with UC
25
SJOGREN SYNDROME
- autoimmune-mediated exocrine gland -dysfunction
- dry eyes + dry mouth (sicca syndrome), skin lesions, parotid enlargement +/- Raynaud’s and arthralgias
- + RF, + ANA
26
Systemic Lupus Erythematosus (SLE)
- autoimmune, multisystem CT dz
- F>>>M
- constitutionals (fatigue, low grade fever, weight loss, GI complaints, malaise, nausea), alopecia, vasculitis, arthritis (small jts and knee, symmetric, migratory, nonerosive, subQ nodules), arthralgias, myalgias
- + antinuclear antibodies (ANA)
- + double-stranded DNA (dsDNA) antibodies
- + anti-smooth muscle (antiSM) antibodies
- Diagnosis any 4 of 11, occurring -simultaneously, malar butterfly rash, discoid rash, photosensitivity, painless oral ulcers, tender, nonerosive arthritis in at least 2 jts, pleuritis or pericarditis, proteinuria, seizure or psychosis, hemolytic anemia or pancytopenia, + ANA, + dsDNA or + antiSM
- Tx: NSAIDs, steroids, DMARDs
27
Scleroderma (Systemic Sclerosis)
- progressive fibrosis of multiorgan epithelium
- thickened skin on face, neck, trunk
- symmetric arthritis
- arthralgia/myalgia
- Raynaud’s Phenomenon
- Diffuse subtype
- heart, lung, kidney, GI, + ANA, - anticentromere Ab, variable course, poor px
- Limited – CREST syndrome
- Calcinosis, Raynaud’s, Esophageal dysmotility, Sclerodactyly, Telangiectasias; +anticentromere Ab, good px
28
Polymyositis/Dermatomyositis
- symmetric, proximal weakness (shld and hip girdle and anterior neck) +/- pharyngeal involvement/dysphagia (difficulty swallowing, choking, aspiration)
- DM has lilac heliotrope rash and Gottron’s Papules (scaly dermatitis over dorsal MCPs and PIPs)
- myopathic process: special EMG findings (ie, EMG diagnoses neuropathy versus myopathy)
- Dx via muscle biopsy, inc CK and LFTs
- Tx = PT for ROM and isometric strengthening, follow enzymes, steroids! (2nd line = azathioprine or MTX)
29
Polyarteritis Nodosa
- systemic necrotizing vasculitis of small-medium arteries
- mcc death = glomerulonephritis (one of the main causes of renal failure)
- M>F
- skin has palpable purpura
- arthritis
30
Giant Cell Temporal Arteritis
- large vessel vasculitis -> tender scalp/temporal area, tender masticators, headaches, 15% visual loss
- F>M
- Dx = very high ESR, temporal artery biopsy
- Tx = high dose corticosteroids
31
Polymyalgia Rheumatica
- proximal weakness, acute myalgias/arthralgias, constitutionals, morning stiffness
- often associated with GCTA
- Dx = very high ESR (>50)
- Tx = corticosteroids
