Osteoarthritis
Degenerative condition in which cartilage of the joint wears away. AKA Degenerative Arthritis
How common is osteoarthritis
Females 3x more than males
>50yo
Causes of Primary Osteoarthritis
Aging. With aging, the water content of the cartilage increases and the protein makeup of cartilage degenerates.
Causes of Secondary Osteoarthritis
Rheumatoid arthritis, gout, septic arthritis, Paget’s disease of bone, Avascular necrosis, metabolic disease e.g. acromegaly, systemic disease
Process of Osteoarthritis
Cartilage wears and degenerates.
Cartilage ulceration exposes underlying bone to stress, producing microfractures and cysts.
Bone attemts repair but produces sclerotic bone and overgrowths at joint margins calles osteophytes
Macrophages releases VEGF leading to vascularisation of the joint
Risk factors for Osteoarthritis
Genetics, increased age, female, obesity, joint injury, occupational, reduced muscle strength, joint laxity, joint misalignment, osteoporosis
Symptoms of Osteoarthritis
Joint pain, RELIEVED BY REST, WORST ON EXERCISE,joint stiffness in the morning lasting no longer than 30mins, joint instability, localised disease
Signs of Osteoarthritis
Joint tenderness Polyarticular (affects more than 5 joints) Crepitus Limitation decreases range of movement Heberdens nodes at DIP Bouchard's notes at PIP Synovitis
Differentials for Osteoarthritis
Rheumatoid arthritis (morning stiffness lasting < 30 mins, symmetrical joint pain) Gout Ankylosing spondylitis Septic Arthritis Bursitis
Investigations for Osteoarthritis
Rheumatoid Factor and anti-nuclear antibody negative
CRP normal
ESR normal
X-ray finding in Osteoarthritis
LOSS Loss of Joint Space Osteophytes Subchondral Cysts Sclerosis
Drugs for Osteoarthritis Pain
Acetaminophen
NSAIDS e.g ibuprofen, diclofenac
Duloxetine (antidepressant)
Treatment for Osteoarthritis
Exercise to increase muscle mass and strength around knee Weight loss Cortisone injections Lubrication injections Realigning bones Arthroplasty (joint replacement)
Prognosis for Osteoarthritis
Most people with OA do not become severely disabled but knee OA holds the worst prognosis and hand the best
Rheumatoid Arthritis
Autoimmune disease causing symmetrical polyarthritis and synovial inflammation. Type 3 hypersensitivity reaction
How common is RA
Females 2x more than Males
Onset 50-60yo
Causes of RA
Genetics: familial pattern with high concordance in monozygotic twins
Gender
Immunology: synovial Inflammation due to T cell Activation
Pathology of RA
Synovium shows: Increased angiogenesis Cellular hyperplasia Influx of inflammatory cells Cytokines High level of metalloproteinase
Symptoms of RA
Symmetrical, Deforming, Peripheral, Polyarthritis, Joint pain, WORST AT REST, BETTER WITH EXERCISE, morning stiffness, affect mainly hands and feet then progresses to larger joints, fatigue and weakness
Signs of RA on the Hand
Ulnar deviation of the finger and dorsal wrist subluxation
Boutonniere or swan neck deformity of fingers
Z deformity of the thumb
Raynauds
Carpal Tunnel syndrome
Investigations for RA
ESR, CRP and platelets raised
RF and anti-CCP antibodies positive
Nomochromic normocytic anaemia
X-ray: bony erosion, subluxation, carpal instability, joint involvement
Differentials for RA
Osteoarthritis SLE Gout Psoriatic arthritis Infectious arthritis
Treatment for RA
DMARDs (Disease Modifying Antirheumatic Drugs): Methotrexate (mmunosuppresant), Hydroxychloroquine (anti-malarial), Sulfasalazine (aminosalicylate) NSAIDS Glucocorticoids Exercise, physiotherapy Arthroplasty surgery
Complications of RA
Septic Arthritis
Amyloidosis
Carpal Tunnel Syndrome
Gout
Hyperuricaemia and deposition of urate crystals causing inflammatory arthritis
Tophi around the joint destruction
Renal glomerular, tubular and intersitial disease
Uric acid urolithiasis
Most commonly affects metatarsaophalangeal joint big toe, foot, ankle, knee, fingers, wrist and elbow
How common is Gout
Increases with age
More common in men
Causes of Gout
Hyperuricaemia caused by underexcretion of urate in 90% of cases and over-production of urate in 10% of cases
Urate is a metabolite of purines and ionised form of uric acid
Risk factors for Gout
Age Male Consumption of seafood, meat and alcohol especially beer Haematological cancer and chemotherapy Diuretic use Ciclosporin or tacrolimus use Obesity Insulin resistance Hypertension
Symptoms and signs of Gout
Rapid-onset severe pain Joint stiffness Most common affected joints are feet Swelling and joint effusion Tenderness Tophi Erythema and warmth
Tophi
Nodular deposits of uric acid in soft tissues of the body
Differentials for Gout
Pseudogout (calcium pyrophosphate deposition disease) Septic arthritis Trauma Rheumatic Arthritis Reactive Arthritis Psoriatic Arthritis
Treatment for Acute Gout
- NSAID
- Colchicine
- Corticosteroid
Treatment for Recurrent Gout
2-3 weeks post-acute episode
- Xanthine oxidase inhibitor- Allopurinol
- Probenecid or sulfinpyrazone
- IV Pegloticase
- Suppressive therapy
Complications for Recurrent Gout
Nephrolithiasis
Acute Uric acid Nephropathy
Septic Arthritis
Infection of 1 or more joints caused by pathogenic inoculation of microbes. Occurs either by direct inoculation or via haematogenous spread
Causes of Septic Arthritis
Staphylococcus or Streptococcus
Risk factors for Septic Arthritis
Underlying joint disease RA or OA Joint prostheses IV drug abuse Alcohol use disorder Diabetes Previous intra-articular corticosteroid injection Cutaneous ulcers
Symptoms and signs of Septic Arthritis
Hot, swollen, tender, restricted movement of joint and fever
Investigations for Septic Arthritis
Synovial fluid gram stain and culture Synovial fluid WCC Blood culture Elevated WCC CPR and ESR elevated
Differentials for Septic Arthritis
Osteoarthritis, Rheumatic Arthritis, Gout, Haemarthrosis, Trauma, Bursitis, Cellulitis
Treatment for Septic Arthritis
Joint aspiration
IV Abx: flucloxacillin, clindamycin if penicillin alllergic
Complication of Septic Arthritis
Abx associated allergic reaction
Osteomyelitis
Joint destruction
Prolapsed Disc
Disc degeneration. A soft cushion of tissue between the bones in the spine pushes out and can press on nerves. Commonly affects lumbar spine
Pathophysiology of a Prolapsed Disc
Each disc has a Nucleus Pulposus surrounded by Annulus Fibrosus to provide resistance and disc stability. The normal human circadian rhythm allows for fluid shifts in and out of the disc. Degenerative changes follow a loss of hydration of the nucleus pulposus.
Risk factors for a Prolapsed Disc
Increasing age, occupation i.e. carrying excessive load, smoking, obesity
Symptoms and signs of a Prolapsed Disc
Lower back pain
numbness or tingling in your shoulders, back, arms, hands, legs or feet
neck pain
problems bending or straightening your back
muscle weakness
pain in the buttocks, hips or legs if the disc is pressing on the sciatic nerve (sciatica)
Unilateral pain
Investigations for Prolapsed Disc
MRI
CT
Differentials for Prolapsed Disc
Sprain, Strain, Spinal Tumour, Spinal Infection, Postural back pain
Treatment for Prolapsed Disc
Rest if severe pain but stay active
Paracetamol and NSAIDs
Spinal Cord Compression
Osteoporosis
Skeletal disease characterised by low bone density and micro-architectural defects in bone tissue. Results in increased bone fragility and susceptibility to fracture. Common fractures are in the hip, vertebrae and wrist.
How common is Osteoporosis
Affect 1 in 2 women and 1 in 5 men
> 50 yo
Predominance in whte, post-menopausal women
Pathophysiology of Osteoporosis
Increases osteoclast activity (more bone resorption)
Decreased osteoblast activity (less bone remodelling). Net increase in bone resorption
Bone remodelling by hormone including PTH, vitamin D, calcitonin and oestrogen
Risk factors for Osteoporosis
Steroid use (prednisolone)
Hyperthyroid, hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI<22)
Testosterone ↓
Early menopause
Renal failure/live failure
Erosive/inflammatory bone disease (RA/myeloma)
Dietary calcium ↓ and low Vit D (malabsorption) or Diabetes
Symptoms and signs of Osteoporosis
Back pain
Kyphosis
Pain and swelling at fracture sites
Investigations for Osteoporosis
DEXA scan to measure bone density
Xray
Serum Calcium, creatinine, phosphate, 25-hydroxy vitamin D, PTH, TFT
DEXA Scan Result
T score > -1 : Normal
T score < -1 but >-2.5: Osteopenia
T Score of
Differentials for Osteoporosis
RA, gout Multiple myeloma Osteomalacia CKD Primary Hyperparathyroidism Metastatic bone malignancy
Treatment for Osteoporosis
1) Bisphosphonates: Alendronic acid (PO daily), Zolendronate (IV as a single dose yearly)
2) Calcium and Vitamin D supplementation
3) Raloxifene (anti-resorptive drugs)
4) Terparatide (PTH analogue)
Complications of Osteoporosis
Hip, rib and wrist fractures
Jaw necrosis associated with bisphosphonate treatment