Joint Disease Flashcards
Clinical Features of OA
- Degeneration of cartilage - leads to hypertrophy of underlying bone (osteophytes)
- Pain from bone on bone surfaces rubbing because cartilage lost (no pain fibers in cartilage itself)
- Morning stiffness < 30 min; generally worse at end of day from use
- Later - dec ROM because bony enlargements; crepitus
- NO REDNESS OR WARMTH
- **OA of hip presents as groin pain
4 OA Xray Findings
- 1- Joint space narrowing
- 2- osteophytes
- 3- sclerosis of sub-chondral bony endplates
- 4- subcentral cysts from inc pressure transmission
**take while standing
8 General Categories of Causes of Arthritis
- OA (most common)
- Systemic immune disease - SLE, seronegative spondyloarthropathies, RA, IBD
- Crystals - gout, pseudogout
- Infectious - septic, Lyme
- Trauma
- Charcot joint (DM)
- Heme - sickle cell (avascular necrosis) or hemophilia (bleed into joints)
- Deposition diseases - Wilson’s, hemochromatosis
Clinical Features of RA
- 20 -40 yo in females > males
- NO DIPs
- Hands and wrists most common joints affected
- Ulnar deviation of MCPs
- Swan neck contractures (MCP flexed, PIP hyper-extended and DIP flexed)
- Morning stiffness that improves w/ movement thru day
- SubQ nodules on extensor surfaces and on visceral surfaces
Surgical Considerations in RA Pt
Often have cervical spine instability and subluxation - get x-rays b/f any surgery to assist in incubation
Xray Findings in RA
osteoporosis near joints and joint space narrowing from cartilage destruction later in disease
Extra-Articular RA Findings
- Atrophic skin and bruises
- Pleural effusions w/ low glucose fluid
- Pulmonary infiltrates and RA nodules of lungs
- Scleritis or dry eyes
- Rheumatic nodules, pericarditis, pericardial effusion
- Anemia of chronic disease
- Thrombocytosis
- Vasculitis - PAN, mesenteric vasculitis
- Fever, wt loss
RA Dx
- Inflammatory arthritis of 3+ joints
- Sx lasting at least 6 wks
- Elevated CRP and ESR
- Pos RF or ACPA (anti-CCP)
- Radiographic changes -erosions and de-calcifications
RA Tx
- NSAIDs for pain
- May use short term, low dose steroid for pain if needed
DMARDs (disease-modifying by dec rate of destruction)
- EARLY INITIATION
- 1st line- Methotrexate (see improvement in 4-6 wks)
- Alternatives- Leflunomide or hydroxychloroquine (requires retinal exams)
- Sulfasalazine
- Anti-TNF agents - etanercept, infliximab if still not controlled (need PPD screen)
Special Methotrexate Considerations
- BM suppression, lung and liver injury
- Monitor liver and renal labs
- Give folate supplement
Synovial Fluid in Various Joint Disease
OA / Trauma (non-inflammatory)
-Clear, yellow, blood if trauma
<2000 WBC and <25% PMNs
Inflammatory Arthritis (RA/gout/Reiter)
-cloudy yellow
>5000 WBC and 50-70% PMNs
Septic Arthritis (bacterial, Tb)
-Turbud, purulent
>50,000 WBC and >70% PMNs
Pathophysiology of Gout
- Caused by inc production of uric acid (inc cell turnover, Lesch-Nyhan) OR dec uric acid excretion (renal disease, NSAID use, diuretic use (thiazides), acidosis)
- Uric acid crystals in synovial fluid covered in IgG –> phagocytosed by PMNs –> release inflammatory mediators and proteolytic enzymes –> inflammation joint
What are tophi? Common locations?
urate crystal surrounded by giant cells –> deformity of hard and soft tissue
(extensors, pinna of ear, achilles)
Acute Gout Tx
- NSAIDs (indomethacin); can use colchicine or oral steroids if needed
- Colchicine has GI side effects and cannot be used if renal problems
Gout PPX (when is it indicated and how to decide)
- indicated if at least 2 attacks
- Meas 24 hr uric acid in urine …
- If low (<800 mg/day) then excretion problem - use probenacid
- If high (>800 mg/day) then production problem - use allopurinol
**Bridge w/ 4-6 wks NSAIDs or colchicine to prevent acute attack
