Joints

Question 1

Osteoarthritis: primary and secondary causes

Answer 1

degenrative joint disease DJD

idopathic (primary) with aging

men: hips predominate
women: knee and hands predominate
secondary: repeated injuries to a joint, hemochroatosis, obesity

Question 2

Osteoarthritis: etiology

Answer 2

Degeneration of cartilage outpaces repair. 80-90% by age 65. Mechanical defects due to muscle strength or obesity.

Question 3

Osteoarthritis phases

Answer 3

chondrocyte injury

chondrocyte proliferate

chondrocyte drop out with a loss of cartilage

Question 4

Osteoarthritis presentation on the bone

Answer 4

superficial roughened and cracked cartilage.

bone eburnation (exposed bone on surface0 looks like polished ivory and underlying bone sclerosis

joint mice (loose bodies of cartilage)

subchondral cysts of synovial fluid

ostephytes (bone spur): extra bone at joint edge

Question 5

osteoarthritis presentation

Answer 5

insidious typically involving one or a few joints. Deep achy pain. morning stiffness. worse with use. creptius of joint. limited range of motion. vertebral osteophytes impinge on nerve root.

herberden nodes: osteophytes at DIP in women.

Question 6

Osteoarthritis areas of risk

Answer 6

hips

knees

lower lumbar

cervical

dip

pip

first carpmetacarpal

spares: wrists, elbows, shoulders

Question 7

Rheumatoid arthritis. etiology, gender, and age risk factor

Answer 7

systemic autoimmune inflammatory disease

nonsuppurative proliferative inflammatory synovitis often destroying cartilage with later ankylosis of the joint

female > male

age: any but most often 40-70

some genetic susceptibility

Question 8

Rheumatoid arthritis: pannus

Answer 8

exuberant inflamed synovium

chronic inflammation with T cells 9mostly CD4), B cells, plasma cells, macrophages

granulation tissue with hemosiderin

erodes articular cartilage

erodes bone: juxtarticular cysts, subchondral cysts, osteoporosis

Question 9

Rheumatoid arthritis pathogenesis

Answer 9

AG exposure in a susceptible host creating an ongoing autoimmune process. 80% have rheumatoid factor (autoAB against Fc portion or IgG) but is not specific. AB to citrullin modified peptides (anticyclic citrullinated peptide or CCP Ab) more specific

TNF major role

Synovial fluid: high protein content, low mucin content, inflammation

Question 10

Rheumatoid arthritis: clinical presentation joints and spread

Answer 10

clinical course variable: can have periods of remission

10% acute onset but most insidious. May be preceded by malaise, fatigue, myalgia

symmetric with small joints before large. PIP MCP, MTP (note OA is DIP). Later writs, ankles, elbow, knees (spares hips)

joints: swollen, warm painful and stiff with inactivity

Question 11

Rheumatoid arthritis diagnosis X ray and other features

Answer 11

X ray: juxta articular osteopenia. Bone erosions with narrowing of joint space from loss of articular cartilage. Joint effusions.

Radial deviation of wrist

ulnar deviation of fingers

flexion hyperextension of fingers (swan neck; boutonniere)

synovial cysts: Baker cyst (back of knee)

Question 12

Rheumatoid arhtritis: clinical features: rheumatoid nodules

Answer 12

most common cutaneous manifestation (25%)

areas subject to pressure: ulnar aspect of forearm, elbow, occiput, lumbrosacral

fibrinoid necrosis surrounded by macrophages

Question 13

Rheumatoid arthritis: clinical features: blood vessels

Answer 13

vasculitis: does not involve kidneys.

Can be obliterative endarteritis of vasa nervorum and digital arteries (neuropathies, ulcers, and gangrene).

Leukocytoclastic venulitis (purapura, skin ulcers, and nail bed infarction)

may be adjacent tendonitis, myositis

Question 14

Rheumatoid arthritis critera

Answer 14

four of the following

AM stiffness

> 2 joints arthritis

typically and joint involvement

symmetric arthritis

rheumatoid nodules

serum rheumatoid factor

typically radiologic changes

Question 15

Juvenile idiopathic arthritis: overview. Joint targets and other manifestations

Answer 15

Heterogeneous group by definition before age 16 and presents 6 weeks of oligoarticular < 5 joints, polyarticular, systemic

knees, writs, elbows, ankles (large joints)

extra articular manifestations: pericarditis, myocarditis, pulmonary fibrosis, uveitis, glomerulonephritis, growth retardation

Question 16

Juvenile idiopathic arthritis vs Rheumatoid arhtritis

Answer 16

differs: oligoarthritis is more common. systemic onset more common. large joints. absence of rheumatoid factor, absence of rheumatoid nodules, may be ANA positive.
similiar: Pannus formation. Morphology of involved joints.

Question 17

seronegative spondyloarthropathies

Answer 17

pathology in ligamentous attachment

immune mediated; no specific autoantibody. Many are +HLA B27. Rheumatoid factor negative.

Question 18

seronegative spondyloarthropathies triggers and the types (4)

Answer 18

often triggered for example infection

1. ankylosing spondyloarthritis
2. enteritis associated arthritis
3. reactive arhtritis
4. psoriatic arthritis

Question 19

Ankylosing spondyloarhtritis: risk factors gender, age, genetics, and affected area.

Answer 19

“rheumatoid spondylitis”

young adults; M>F

HLA B27 (90%)

axial joints: sacroiliac joint and apophyseal joints of vertebrae

Question 20

Ankylosing spondyloarhtritis: onset, clinical presentation, complications

Answer 20

ONset 2-3 decade with low back pain

inflammation of tendon/ligament insertion: ossification of inflammation. Fibrous and boney ankylosis

complication: 1/3 hip, knee, shoulder arthritis. Uveitis, aortitis, amyloidosis, spine fractures

Question 21

reactive arthritis (reiter syndrome) caused by and triad

Answer 21

appendicular noninfectious arthritis

< 1 month after primary infection. Genitourinary chlamydia or GI: shigella, salmonella (diarrhea)

triad: arthritis, urethritis or cervicitis (nongonococcal), and conjunctivitis

Question 22

Reiter syndrome risk factors age and genetics. Areas of damage and clinical features.

Answer 22

20-30s

HLA b27 (80%)

ankles, knees feet (lower extremity) in asymmetric pattern

sausage toe or finger from digital tendon sheath synovitis

Question 23

Reiter syndrome: other clinical features and SX patterns

Answer 23

extra articular: balantitis, conjunctivitis, heart conduction defects, aortic regurgitation

SX wax and wane with 50% recurrence

Question 24

Enteritis assoiciated arthritis

Answer 24

GI infection by yersinia, salmonella, shigella, campylobacter. Liposaccharide stimulate immune repsonse.

most often abrupt in knees and ankles

generally clears in < 1 year

Question 25

Psoratic arthritis: overview. Genetic risk factors, age, presentation, area affected

Answer 25

10% of psoriasis patients (HLA b27 and HLA Cw6) onset 30-50 insidious > acute onset; peripheral and axial 50% asymmetric in DIP of hands/feet. Pencil in cup deformity can affect large joints can cause sacriliac and spine disease

Question 26

Psoratic arthrtitis histology

Answer 26

histologically simlar to RA less severe than other seronegative arthropathies limited extra articular complications: conjunctivitis. Iritis.

Question 27

infectious arhtritis: bacterial infection age related or disease associated.

Answer 27

bacterial almost always suppurative hematogenous spread is most common <2 years: H flu. adolescentyoung adult: gonococcus (F>M) elderly and children > 2 years: S. A. Sickle cell disease: salmonella

Question 28

Infectious arthritis predisposing conditions. Area affected.

Answer 28

predisposing conditions: immunodeficiency, abnormal joint, debilitation, iv drug abuse, arthritis swollen hot joint GC: often subacute. One joint: KNee > hip > shoulder > elbow drug abuse axial joints

Question 29

Infectious arthritis: tuberculosis

Answer 29

monoarticular typically from adjacent osteomyelitis or hematogenous spread vertebrae, hips, knees ankles

Question 30

infectious arthritis: viral

Answer 30

parvovirus B19 HCV, HBV HIV

Question 31

infectious arthritis lyme disease

Answer 31

2 weeks- 2 years after bite from ixodes 60-80% of untreated; prominent in late disease remitting/migratory arthritis in large joints knees > shoulders > elbows > ankles chronic synovitis with organisms near vessels borrellia burgdofreri

Question 32

gout: etiology

Answer 32

uric acid from purine metabolism: crystal are negative birefringent end point of hyperuricemia acute arrthritis from monosodium urate precipitation in joint, can become chronic tophi: mass deposits of urates urate nephorpathy common if chronic

Question 33

Gout primary and secondary causes

Answer 33

10% population has hyperuricemia. gout in 0.5% of this population. Primary gout (90%): unknown cause or known enzyme defects (partial HGPRT) secondary gout: increased nucleic acid turnover (AML) or chronic renal disease

Question 34

gout

Answer 34

monosodium urate precipitates from supersaturated synovial fluid. negative birefringence. precipitates better at lower temperatures. Crystal initiate acute and chronic inflammation. Dissolve over time and symptoms abate. acute arthritis joint aspirate samples need to be polarized for crystals and cultured.

Question 35

gout phases

Answer 35

asymptomatic hyperuricemia acute arthritis: 50% first MTP joint foot. Instep > ankles > heels > knees > wrists intercritical gout: no sx chronic tophaceous gout

Question 36

gout tophi

Answer 36

pathogenomonic of gout: large deposits of urate. macrophages, lymphocytes and giant cells location. Tophaceous arthritis: joints and periarticular tissue. Inflammation destroys synovium, joint and adjacent bone. SKin, soft tissues and organs

Question 37

gout risk factors

Answer 37

> 30 years (ie duration of hyperuricemia) genetic predisposition heavy drinking obesity drugs (thiazides) PB toxicity

Question 38

calcium prophosphate crystal deposition disease overview and age risk factor

Answer 38

pseudo gout or chondrocalcinosis > 50 years; increases to 50% at 85 years usually asymptomatic. mimic other forms of arthritis. acute, subacute, or chronic knee > wrist

Question 39

CPPD primary and secondary disease

Answer 39

heriditary or idopathic secondary; prior joint damage, hyperparathyrodism, hypothyrodism, hemochromatosis, diabetes

Question 40

ganglion cyst

Answer 40

< 2cm cyst near joint or tendon sheath wrist is most common cystic or myxoid degeneration of tissue no communication with joint space

Question 41

synovial cyst

Answer 41

connected to a joint capsule or bursa baker cyst: popliteal synovial cyst often seeting of rheumatoid arthritis

Question 42

tenosynovial giant cell tumor

Answer 42

T (1;2): express CSF-1, attract macrophages classification: diffuse (pigmented villonodular synovitis) and localized (giant cell tumor of tendon sheath) macrophages and giant (macrophage) cells: hemosiderin and lipid vacuoles

Question 43

diffuse tenosynovial giant cell tumor

Answer 43

pigmented villonodular synovitis (PVNS) joint synovium diffusely affected red/brown to yellow from hemosiderin lush villous surface 80% knee locking or swelling; later decrease range of motion can erode bone and create a mass often recurs after excision

Question 44

localized tenosynovial giant cell tumor

Answer 44

well circumscribed often attached to synovium or tendon slow growing painless fingers and wrists (most common soft tissue tumor of hand; especially fingers)