Mono/Oligoarticular Arthritis Flashcards
(85 cards)
1
Q
What is the most common “true arthritic” condition?
A
Osteoarthritis
2
Q
What are the 2 non-inflammatory conditions most commonly seen in men and women 18-34?
A
- Injury/overuse
2. low back pain
3
Q
What are the 3 most common inflammatory conditions seen in men 18-34?
A
- spondyloarthropathies
- gonococcal arthritis
- gout
4
Q
What are the 3 most common inflammatory conditions seen in women 18-34?
A
- SLE
- RA
- gonococcal arthritis
5
Q
What are the 4 most common non-inflammatory conditions affecting men 35-65?
A
- injury/overuse
- low back pain
- osteoarthritis
- entrapment syndromes
6
Q
What are the 3 most common inflammatory conditions affecting men 35-65?
A
- spondyloarthropathies
- gout
- bursitis
7
Q
What are the 7 common non-inflammatory conditions affecting women 35-65?
A
- injury/overuse
- low back pain
- osteoarthritis
- osteoporosis
- fibromyalgia
- entrapment syndromes
- Reynaud’s
8
Q
What are the 2 most common inflammatory conditions affecting women 35-65?
A
- RA
2. Bursitis
9
Q
What are the 4 most common non-inflammatory conditions affecting men over 65?
A
- osteoarthritis
- low back pain
- osteoporosis
- fracture
10
Q
What are the 6 most common inflammatory conditions affecting men AND women over 65?
A
- gout
- bursitis
- RA
- pseudogout
- polymyalgia rheumatica
- septic arthritis
11
Q
What are the 5 non-inflammatory conditions most frequently affecting women over 65?
A
- osteoporosis
- OA
- fibromyalgia
- low back pain
- fracture
12
Q
What is the differentiation between acute and chronic musculoskeletal conditions ?
A
6 weeks makes it chronic
13
Q
In the acute setting (less than 6 weeks), what is inflammation a sign of?
A
bone, joint or soft tissue infection
14
Q
How does joint pain differ between inflammatory and non-inflammatory conditions?
A
Inflammatory is painful with activity and rest.
non-inflammatory= just during activity
15
Q
How does joint swelling differ between inflammatory and non-inflammatory conditions?
A
I = spongy/ soft tissue swelling NI= bony (if at all)
16
Q
How does morning stiffness differ in inflammatory and non-inflammatory conditions?
What is morning stiffness a sign of?
A
I = takes over 60 minutes to "warm up" stiff joints NI = variable, but less than 60 minutes
Morning stiffness is a sign of how much edema is in the synovial joints over night
17
Q
What are the characteristics of the following in an inflammatory condition:
- ESR, CRP
- WBC of synovial fluid
- synovial fluid % PMN
- Hb
A
- increased
- > 2000
- > 75%
- normal or decreased
18
Q
What are the characteristics of the following in a non-inflammatory condition?
- ESR, CRP
- WBC of synovial fluid
- synovial fluid % PMN
- Hb
A
- normal
- less than 2000
- less than 75%
- normal
19
Q
The most common laboratory feature of inflammation is the ______________. The synthesis of many proteins by the liver is upregulated by ______.
A
acute phase response.
Liver increases protein production in response to IL6
20
Q
What are the “surrogate markers” for IL-6 and show that inflammation is occuring?
A
CRP
Ferritin
fibrinogen
C3, C4
21
Q
How do ESR and CRP differ?
Which is faster?
Which is more specific?
A
CRP takes several hours/overnight to obtain. It is a DIRECT measure of acute phase response and so is more specific.
ESR relies on the fact that RBC are coated with fibrinogen/acute phase proteins that cause it to rouleaux. It only takes hours to perform.
Less specific bc it is increased in age, pregnancy, nephrotic syndromes, anemia etc
22
Q
What are the 2 major signs that the pain a patient is describing is non-articular?
What are examples of non-articular pain that can often be confused for joint pain?
A
- pain on active movement only
- ability to localize the pain
- bursitis
- tendonitis
- cellulitis
23
Q
How do pain/tenderness differ between articular and non-articular disorders?
Which can be localized? Which is superficial?
A
A = localized to joint, deep/poorly localized, referral patterns NA = localized to tendons, bursa, muscle, bone, "point tenderness", superficial
24
Q
How does pain with movement differ from articular and non-articular disorders?
A
A = active and passive movement, many planes
NA= active movement, specific planes
25
How does swelling differ from articular and non-articular disorders?
A = synovial effusion, synovial thickening, bony enlargement
NA= not usually present, but if it is it is not limited to articular areas
26
On physical exam you note crepitation, instability and locking of the joint. Is this likely to be articular or non-articular?
Articular
27
What are the radiographic changes associated with articular disorders? Non-articular?
A= Present in chronic conditions, uncommon in acute conditions except trauma
NA= soft tissue calcifications
28
What are 4 local non-articular disorders?
| 3 systemic non-articular disorders?
Local:
1. bursitis
2. fracture
3. septic bursitis
4. tendonitis
Systemic:
fibromyalgia
hypothyroidism
osteoporosis
29
How can you differentiate monoarticular, oligoarticular and polyarticular?
Mono- 1
Oligo - 2 or 3
Poly- more than 3 joints involved
30
A man helped his son move furniture recently. He now has aching discomfort in subdeltoid region. It gets worse at night and when he abducts his arm. What is the likely cause?
Rotator cuff tendinitis (subacromial bursitis)
31
A 35 year old body builder has been experiencing pain over the anterior aspect of his shoulder. It gets worse when he flexes his elbow and supinates.
You ask and he claims the pain is not any worse at night. What is the likely problem?
Bicipital tendonitis
32
A 42 year old woman comes to the office complaining of shoulder pain that has been getting progressively worse. She has limited motion of her shoulder. You try to passively move her shoulder and notice that it has limited movement.
The pain is deep and worse at night.
What is the likely cause?
Frozen shoulder (capsulitis)
33
A 30 year old comes in and has been experiencing difficulty gripping. He has pain at the lateral epicondyle of the humerus.
It gets worse with resisted dorsiflexion of the wrist . What is the likely cause?
tennis elbow (lateral epicondylitis)
34
A 50 year old comes in with pain and tenderness at the medial epicondyle of the humerus. It is aggrevated by wrist flexion. What is the likely problem?
golfer's elbow (medial epicondylitis)
35
A patient comes in with a swollen and painful elbow. The pain is NOT aggrevated by movement. What is the likely problem? What is the first thing you should do?
olecronan bursitis- get joint fluid to test for s. aureus (25% of cases)
36
A 45 year old woman presents with lateral hip and thigh pain aggrevated by position and activity. It occurs more often at night. She is able to move her hip normally. What is the likely problem?
trochanteric bursitis
37
A soccer player presents with circuscribed painful swelling anterior to the patella. What is the likely problem and what is your first mode of action?
Prepatellar bursitis- tap it to check for infection
38
A patient presents with pain over the medial aspect of the upper tibia (inner knee). What is the problem?
Anserine bursitis
39
A patient presents with pain on the undersurface of their heel. It is aggrevated by dorsiflexion. What is the likely problem? What is the cause and what would you see on radiograph?
Plantar fasciitis- caused by repetitive trauma
| You would see plantar spurs on x-ray
40
What are the 6 most common monoarticular disorders?
1. septic joint
2. trauma
3. gout/pseudogout ("crystal-induced arthritis")
4. OA
5. osteonecrosis of bone
6. juvenile arthritis (pauciarticular)
41
A patient presents with monoarticular joint pain that came on in seconds to minutes. What are the 2 main things on the differential?
1. trauma
| 2. fracture
42
A patient presents with monoarticular joint pain that came on over hours to days. What are the 2 main things on the differential?
1. acute infection
| 2. crystal-induced arthritis
43
A patient presents with monoarticular joint pain that come on over days to weeks. What are the 3 main things on the differential?
1. chronic infection
2. osteoarthritis
3. bone tumors
44
What is the main consideration if the patient has had joint damage in the past and now are presenting with monoarthritis?
internal derangement- known OA--> cartilage breaks off and worsens the problem
45
What is the main consideration if a patient presents with monoarthritis and has a history of IV drug use?
Septic arthritis
46
What 4 conditions would make you think about osteonecrosis of bone?
1. corticosteroid use
2. renal failure
3. sustained joint trauma
4. sickle cell disease
47
A person is having monoarthritis. They have a history of coagulopathy and treatment with anticoagulants. What is number one on the differential?
Hemarthrosis
48
What diagnostic/lab test should be done for ALL cases of monoarticular arthritis? What 3 things are you investigating the possibility of?
Obtain synovial fluid to check for:
1. hemarthrosis
2. infection
3. crystals
49
When you obtain synovial fluid, if it is clear it is unlikely to be ______________ which would be translucently opaque.
If it is white and chalky, it is probably _________.
Infectious/inflammatory --> translucent/opaque
| White/chalky --> gout
50
Joint fluid should be analyzed for what 3 things?
1. cell count/differential
2. microbial stains and culture
3. analysis of crystals
51
What are the 4 types of joint fluid?
1. normal
2. non-inflammatory
3. inflammatory
4. hemorrhagic
52
You obtain joint fluid that is clear, viscous and has a WBC <200. You are only able to obtain a small amount. What kind of joint fluid is this?
Normal
53
You obtain joint fluid that is clear with yellowish hue. It is viscous and abundant. WBC <75%. What type of joint fluid is this and what are the 3 differential diagnoses?
Non-inflammatory:
1. osteoarthritis
2. osteonecrosis
3. trauma with effusion
54
You obtain joint fluid that is yellow/cream colored. It is translucent and lacks good viscousity. It has >2000 WBC and >75% neutrophils. What type of joint fluid is this and what is the differential?
Inflammatory
1. septic arthritis
2. RA
3. gout
4. spondyloarthropathy
55
You obtain joint fluid that is hemorrhagic. What is the differential?
Trauma (with or without fracture)
| Trauma (with or without coagulopathy)
56
What are the 5 steps for lab/diagnostics for monoarticular disorders?
1. obtain synovial fluid
2. radiographs
3. CBC
4. culture
5. CRP, ESR, PTT, PT,
57
When is arthroscopic visualization of the synovium and biospy helpful?
When the cause of monoarticular arthritis is NOT determined by initial history/physical and lab tests and you are suspicious of chronic arthritis.
58
A patient presents with chronic oligoarticular arthritis of the lower extremities, especially knees. They had previously been hiking in the woods in the appalachians and 4 days later had a bullseye rash. What is a viable consideration?
What are the three stages of this disease?
How long after infection does each occur?
What are the symptoms of each stage?
Lyme arthritis
Stage 1- 3 to 4 days after transmission of borrelia burdorferi from ixodes tick--> fever, malaise, myalgia, arthralgia. ERYTHEMA CHRONICUM MIGRANS (bullseye rash).
Stage 2- weeks after infection--> myalgia, arthralgia ,Bells palsy, myocarditis
Stage 3- 5 to 7 months --> arthritis, CNS, radiculopathy
59
How is the laboratory diagnosis of Lyme arthritis made?
ELISA for IgG antibodies to the spirochete
60
Gout is characterized by the deposition of ______________ in various tissue (including joints).
Nearly solid accumulations in joint, bone, cartilage, or soft tissue are called____________
monosodium urate crystals
Tophi
61
What is the response of the body to deposition of urate crystals in gout?
1. Phagocytic cells and synovial cells are triggered to release PGs, LTs, proteases, and IL1, 6 and 8, and TNFa.
2. neutrophils migrate to the tissue/joint and edema occurs
3. Fever, leukocytosis, acute phase reactants
4. Granulomatous response with mononuclear cells with fibrous capsule
62
A patient comes in to the office in bare feet. He cannot wear shoes because his socks lightly touching his 1st MTP joint (big toe) is excruciating. The pain has progressed for a few hours.
The toe is red, swollen and warm. What is the likely cause of the joint pain?
Gout
63
What is podagra?
when the 1st MTP joint is swollen in a person with gout
64
Describe the initial presentation of gout.
How many joints are involved? What is the most common site?
What are the non-joint areas involved?
How is it treated/when does it resolve?
1. acute painful monoarthritis that is sensitive to light touch (MTP podagra, feet, ankles, heels, knees)
2. cutaneous erethyma, tendonitis
3. fever/leukocytosis
4 spontaneous resolve in 3-5
65
Describe the late presentation of gout.
1. 10 years after first attack
2. remission periods shorten, inflammation becomes constant
3. tophi granulomas at ears and pressure points (forarms, achilles)
4. fingers (DIP), wrists, knees, olecranon bursa
66
Hyperuricemia is classified as uric acid levels over _____.
| What are the 2 main causes of hyperuricemia?
Uric acid over 6.7 mg/dl.
1. idiopathic over production (Leysh-Nyhan)
2. under excretion (diet of meat shellfish, beer, myeloproliferative disorder, psoriasis, CKD)
67
What genetic defect is associated with over production of urate?
HGPRT deficiency- :Lesch Nyhan
- this enzyme uses cofactor phosphoribosyl pyrophosphate (PRPP) in purine salvage pathway
- Unused PRPP drives purine synthesis leading to accumulation of uric acid
68
What are the 6 main factors that decrease urate excretion?
```
1. idiopathic
2, decreased renal function
3. diuretics (thiazides)
4. alcohol
5. cyclosporine, ethambutol, pyrazinamide, aspirin
6. lead
```
69
What is the essential feature for diagnosis of gout?
demonstration of gout crystal (monosodium urate) in aspirated joint fluid.
It will be spindle/needle-shaped, negatively birefringent
Parallel= yellow, perpendicular = blue
70
How does the appearance of crystal differ for gout and pseudogout?
Gout is monosodium urate which is needle shaped, yellow when parallel and negatively birefringent
Pseudogout is usually calcium pyrophosphate dihydrate (CPPD) and is rhomboid, blue when parallel and postively birefringent
71
During a gout attack, where are urate crystals seen? Where are crystals seen between attacks?
During attacks the crystals are in phagocytic cells.
| Between attacks they are extracellular in synovial fluid
72
On radiograph, what is seen in early disease of gout?
| Late disease?
```
Early- soft tissue swelling
Late:
1. preservation of joint space
2. erosion with overhanging edges at the end of capsule (dark spaces where bone should be are tophi)
3. periarticular osteopenia
```
73
What is chondrocalcinosis?
What sex is more likely to get this?
What 4 abnormalities are associated with CPPD?
Deposition of CPPD in articular cartilage
Women with increasing age
hyperparathyroidism (increases Ca)
hypophosphatasia
hypomagnesemia
hemochromatosis
74
An elderly man presents with knee swelling with severe pain that has progressed over hours. The joint is inflamed (red, warm, tender). He has a fever and is unable to use the joint. He has been recovering from an MI.
When you do arthrocentesis, what are you likely to see? How long til resolution for this man?
Pseudogout- blue rhomboid positive birefringence CPPD crystals
1-4 weeks for resolution
75
An elderly woman presents with chronic knee, wrist, hip, shoulder and ankle pain. Her 2nd and 3rd MCP joints are involved. You see bony swelling, crepitus and reduced range of motion. Signs of inflammation are superimposed and she has morning stiffness. What is the likely cause?
chronic CPPD arthropathy
76
What is the diagnostic technique for chondrocalcinosis?
radiograph :
1. calcification of knee menisicus
2. triangular cartilage of wrist
3. symphysis pubis
4. joint space narrowing
Joint fluid:
1. >20,000 WBC, >75% WBC
2. small rhomboid positively birefringent
77
```
Is osteoarthritis chronic or acute?
Inflammatory or non-inflammatory?
Mono or polyarticular?
How is it diagnosed?
At what age does it typically begin and in what joints?
females or males?
```
Chronic, NI, mono OR poly
Radiographic > clinical
It begins at 45 with hand OA, followed by knee and hip (weight bearing)
Females >males in older groups/with hand involvement
78
What are the 4 risk factors for osteoarthritis?
1. Genetics- collagen II mutation, gender, ethnicity
2. physiologic- age, weight, bone disorders, trauma
3. environmental- occupation, stress, sports
4. obesity- knee involvement
79
Describe the clinical features of osteoarthritis.
- insidious onset of pain and stiffness
- morning stiffness 30 minutes or less (opposed to inflammatory processes)
- pain gets worse with use
- stiffness recurs after bouts of imobility (churchgoer's knee)
- locking
- cool joint
80
What 2 joints of the hand are most commonly involved in osteoarthritis?
```
PIP- Bouchard's
DIP - Heberden's
Carpometacarpal joint (CMC)
```
81
A patient presents with knee pain. It is stiff in the morning for about 30 minutes. The pain feels worse after too much use. The stiffness comes back after the patient sits in church. There is crepitus with passive joint movement and the joint frequently locks. The joint is cool. What is the likely diagnosis?
Osteoarthritis
82
What is the radiographic presentation of OA?
Early:
- no findings
Late:
- bony overgrowth with spurs and osteophyte at joint margins
- asymmetric joint space narrowing
- where joint is lost, bone underneath is worn and thin (sclerosis, subchondral cysts)
83
What does MRI document in OA?
bone edema - earliest radiographic feature of OA, but not cost effective
84
What are the most common causes of osteonecrosis?
1. Avascular necrosis due to trauma/fracture of the femoral neck.
Disrupted blood supply leads to death of:
-bone marrow cells
- osteocytes
2. corticosteroid use
3. alcoholism
85
What are the most common sites of involvement of osteonecrosis?
1. proximal head of femur
2. distal femur condyles
3. lunate bones of wrist
4. proximal humerus
