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MedEd arthritides Flashcards

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1
Q

What is osteoarthritis?

A

asymetrical degenerative synovial joint disease

cartilage destruction exceeds repair causing pain and instabiility

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2
Q

What are the 2 types of arthritis and who is more likely to have each?

A

Primary- obese, older, female, occupation using hands eg hairdresser
Secondary- when someone already has an altered/damaged joint eg RA, septic arthritis, congenital, trauma

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3
Q

How will someone with osteoarthritis present?

A

Morning stiffness for around 15 mins
Joint pain worse with activity better with rest
More common in high use or weight bering joints- hips, knee, DIP, PIP, wrist
Late night pain
Loss of function

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4
Q

What will you see on examination in osteoarthritis?

A 
Crepitus
Effusion
Erythema
Squaring of base of thumb
Hebeden's and bouchard's nodes
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5
Q

What acronym is used to remember what you see on xray in osteoarthritis? What does it stand for

A 
LOSS:
loss of joint space
osteophytes
subarticular sclerosis
subchondral cysts- fluid filled hole following joint line
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6
Q

What is the first line investigation for osteoarthritis? What others might you do

A

X ray

Joint aspirate

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7
Q

Who is more likely to have primary osteoarthritis?

A

Older people
Obese people
Females post menopause
Those who use joints in their occupation eg hairdresser

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8
Q

What is secondary osteoarthritis?

A

When someone’s joint is already damaged for some reason and then they get it

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9
Q

How is osteoarthritis managed? Give first, second and third line

A

Oral paracetamol +- topical NSAID/capasaicin
Oral NSAID+PPI
Opiates- use with caution as after a few weeks the analgesic effects will wear off and they have side effects

Short term management= intraarticular steroids

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10
Q

What do you need to co prescribe with NSAIDs?

A

PPI

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11
Q

What is RA?

A

autoimmune chronic and progressive inflammation of synovial lining, tendon sheaths and bursa

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12
Q

How long do you have to have inflammation for a diagnosis of RA?

A

6 weeks or more

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13
Q

Who is more likely to get RA?

A 
HLA DR4
HLA DR1
Smokers
Females
Family hx
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14
Q

How is RA diagnosed?

A

Clinical

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15
Q

What are the 2 main features of RA?

A 
Symmetrical polysrthritis (>4 joints)
Extraarticular manifestations
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16
Q

How many joints need to be affected in RA?

A

4 or more

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17
Q

How will someone with RA classically present?

A

Pain and stiffness in hands and wrists
Worse when they wake up
Resolves over the morning
Fatigue but no other systemic symptoms

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18
Q

What is seen on examination in RA?

A

Swelling
Tenderness
Small joint affected- wrist, ankle, MCP, PIP, MTP
DIP is spared

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19
Q

What joint is spared in RA?

A

DIP

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20
Q

What are chronic signs of RA

A

Ulnar deviation at MCP
Radial deviation at wirst
Z deformity of the thumb
Swan neck deformity- distal joint is flexed
Boutonnieres deformity- proximal joint is flexed

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21
Q

What joints are flexed in boutonieres vs swan neck deformity? How do you remember this?

A

boutonieres- proximal
swan neck- distal

B is before s in the alphabet

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22
Q

What are extra art features of RA

A 
Rheumatoid nodules
Felty's syndrome- RA, splenomegaly, neutropenia
episcleritis/scleritis
lymphadenopathy
pericadarditis
carpel tunnel syndrome 
pulmonary fibrosis/pleuritis
bursitis
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23
Q

What ix are done for RA? What is seen?

A

RF ab- high
Anti CCP antibody- high
ESR- high

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24
Q

When should you refer someone for RA? When is urgent referral done

A

Anyone with persistent synovitis

Urgent referral if- small joints of hands/feet, multiple joints, <3 months

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25
How is RA managed?
Short course steroids NSAIDs/ COX 2 inhib DMARDs Surgery
26
Describe how dmards are prescribed stepwise in RA
Hydroxychloroquine if mild Then one out of methotrexate, leflunomide or sulfasalazine Then give 2 of the above in combination Then give methotrexate and a biologic (anti TNF) Then give methotrexate and rituximab
27
What is the main way to differentiate osteoarthritis and RA?
``` Osteo= asymmetrical RA= symmetrical ```
28
What joints are flexed v extended in swan neck deformity
DIP- flexed | PIP- extended
29
What is ankylosing spondylitis?
Chronic progressive inflammation of axial skeleton (can effect peripheral joints), also affects tendon/ligament attachments are extra art sights
30
Who is more like to get AS?
HLA b27 Male ERAP 1 and IL-23R Family hx
31
How will someone with AS present?
Pain and stiffness of lower back and hips Worse in morning Better with movement Chronic onset Pmhx of tendon/ligament pathology eg plantar fascitis
32
What are extra art features of AS?
``` Anterior uveitis Apical lung fibrosis Aortic regurg Psoriasis IBD ```
33
What are later changes of AS?
Khyphosis Loss of lumbar lordosis Neck extension Causes question mark posture
34
What clinical tests are done in AS and what do you see?
Schober's test Tragus to wall Stress test
35
What is seen on xray/MRI in AS
Sacroilitis | Bamboo spine
36
What is reactive arthritis?
Sterile, seronegative joint inflammation in response to extra art infection
37
Who is more likely to get reactive arthritis?
HLA b27 Male 20-30 yrs old hx of previous infection
38
What syndrome is associated with reactive arthritis and what is it?
Reiters syndrome- cant see, cant pee and cant climb a tree
39
How will someone with reactive arthritis classically present?
``` painful swollen one joint no speicific pain trigger no fever able to weight bear previous infection ```
40
What are extra art features of reactive arthritis?
Reiter's triad: arthritis+urethritis+ conjunctivitis Keratoderma blenorrhagicum- vesicles which are plaque like or pustular on the soles and palms Circinate balantis- painless ulcers/plaques on the shaft or glans Oral ulcers
41
If you have sickle cell what infective organism for osteomyelitis are you particularly susceptible to?
Salmonella
42
What joints are affected in osteoarthritis?
Weight bearing joints eg hip, knee, DIP, PIP, wrist
43
What joints are affected in RA?
wrist, ankle, MCP, PIP, MTP | DIP is spared
44
What is used for short term management in an acute flare up of OA?
Intraarticular steroids
45
Why are opiates not recommended for OA?
Because there therapeutic effects wear off after a few weeks Patients are at risk of addiction There are bad associated side effects like pruritus and constipation
46
What is the triad for Felty's syndrome?
Rheumatoid arthritis Splenomegaly Neutropenia
47
What medication is given in mild RA?
Hydroxychloroquine
48
What DMARDs can be prescribed in RA?
Methotrexate Leflunomide Sulfasalazine
49
What biologic agent is commonly used to treat RA alongside methotrexate? When is it given
anti TNF | It is given after 2 DMARDs have been tried in combination and haven't been effective
50
What monoclonal antibody is commonly used to treat RA alongside methotrexate? When is it given
Rituximab | It is given once 2 DMARDs in combination and then methotrexate+anti TNF have been tried but have been ineffective
51
When is schober's test done? How is it carried out and what is a positive result
It is a clinical test done to diagnose ankylosing spondylitis You mark 10cm above L5 and 5 cm below Get the patient to bend forward If the point-point distance increases >5cm this is positive for ankylosing spondylitis
52
When is tragus to wall test done? How is it carried out and what is a positive result
Get the patient to stand with their back and head against the wall Measure the distance from the tragus to the wall If its over 15cm this is positive and suggests they have ankylosing spondylitis
53
In what condition is keratoderma blenorrhagicum seen? What does it look like and where on the body is it common
Seen in reactive arthritis on the soles and palms usually | Vesicles which are plaque like or pustular
54
What is reiter's traid? In what condition is it seen?
Triad of arthritis, urethitis and conjunctivitis | Seen in reactive arthritis
55
What is circinate balanitis? In what condition is it seen and where on the body?
Painless ulcers and plaques on the shaft or glans of the penis Seen in reactive arthritis
56
What are the 3 acute monoarthritides?
Septic arthritis Gout Pseudogout
57
How will septic arthritis classically present?
very painful, erythematous, swollen joint restricted ROM fever
58
How will gout classically present? Which joint is usually affected
1st MTP most commonly affected Sudden onset severe pain of a joint Erythematous, swelling, tenderness
59
How will pseudogout classically present? What joints does it usually effect?
Acute painful joint | Usually effects large joints eg the knee and also affects multiple joints because its chronic
60
What organisms usually cause septic arthritis in under 30s vs over 30s?
under 30= neisseria gonorrhoea | over 30= staph aureus
61
What is gout precipitated by?
Trauma and infection
62
What crystals are present in gout?
Monosodium urate
63
What imbalance underlies gout?
Hyperuricaemia
64
What is pseudogout precipitated by?
Trauma and illness
65
What crystals are present in pseudogout?
Calcium pyrophosphate
66
What are some causes of pseudogout?
``` Idiopathic Hyperparathyroidism Hypophosphataemia Hypomagnesia Metabolic causes ```
67
What are RF for infection in septic arthritis and RF for joint damage?
Infection: IV drug use, diabetes, immunosupression | Joint damage: RA, prosthetic joint, gout
68
What are RF for gout?
``` Alcohol High purine diet Obesity Male Diuretics ```
69
What are RF for pseudogout?
Elderly | Female
70
What will aspirate, MC&S and bloods in septic arthritis show?
``` Aspirate= turbid, yellow, low viscosity fluid, raised WCC (>90% neutrophils) MC&S= organism Bloods= elevated WCC and CRP ```
71
What will aspirate, bloods and XR in gout show?
``` Aspirate= turbid, yellow, low viscosity fluid, raised WCC (neutrophils), needle shaped negatively birifringent crystals Bloods= elevated WCC, CRP, uric acid (4-6 weeks later) XR= rat bite erosions ```
72
What needles are seen in gout on aspirate?
Negatively birifringent needle shaped crystals
73
What is seen on x ray in gout?
Rat bite erosions
74
What will aspirate, bloods and XR in pseudogout show?
Aspirate= turbid, yellow, low viscosity fluid, raised WCC (neutophils), rhomboid shaped positively birifringent crystals Bloods= elevated WCC and CRP X ray= chondrocalcinosis
75
What crystals are seen in pseudogout?
Rhomboid shaped positively birifringent crystals
76
How do you remember what crystals are in gout vs pseudogout?
``` Pseudo= positive for being fake= positively birifringent rhomboid shaped crystals Gout= negative and not fake= negatively birifringent needle shaped crystals ```
77
What might cause infection of the bone in osteomyelitis?
Haematogenous spread- immunosupression, diabetes etc Contiguous spread- cellulitis, localised infection Direct inoculation- penetrating injury, ulcers, surgery
78
What is osteomyelitis?
Infection of the bone leading to inflammation, necrosis and new bone formation
79
What are the types of osteomyelitis?
Acute Subacute Chronic
80
How long does chronic osteomyelitis have to go one for?
Over 6 weeks
81
How will someone with osteomyelitis classically present?
Non specific pain in the area Fever malaise preceding skin lesion, infection
82
What will you see on examination in osteomyelitis?
Localised eythema, swelling and warmth Reduced ROM of joint Discharge from the wound or ulcer
83
What ix are done for osteomyelitis and what will you see?
Bloods- raised WCC and CRP XR/MRI- no changed in the first 2 weeks, darkening of the affected area and periosteal thickness Bone culture- shows the causative organism
84
How is osteomyelitis managed?
Supportive treatment like analgesia and immobilisation High dose IV abx- empirical at first then after culture returns adjust and 2-4 week course Surgical debridement- this is needed if biofilm indicates it or if there is dead bone

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