Osteoarthritis and Crystal Arthropathies

Question 1

What is the prevalence of osteoarthritis?

Answer 1

1/3 of population in > 45’s, 1/2 of population in > 70’s

Question 2

What is osteoarthritis?

Answer 2

Articular cartilage thinning or loss

Question 3

What are risk factors for cartilage loss?

Answer 3

Age, female, obesity, previous injury, muscle weakness, proprioceptive deficits, genetics, acromegaly, joint inflammation, crystal arthropathies

Question 4

What are the types of osteoarthritis?

Answer 4

Idiopathic, secondary (previous injury, calcium crystal deposition disease etc)

Question 5

What is the distribution of osteoarthritis?

Answer 5

Hip, knee, cervical and lumbar spine, MTP joints, DIP, PIP, 1st IP, 1st MCP, CMC

Question 6

What are the symptoms of osteoarthritis?

Answer 6

Pain = worse on activity and relived by rest (mechanical pain)
Stiffness

Question 7

What can be seen on examination of patients with osteoarthritis?

Answer 7

Crepitus, joint swelling (bony enlargements due to osteophytes), joint tenderness and effusions

Question 8

What are the clinical features of osteoarthritis of the hands?

Answer 8

DIP, PIP and 1st CMC joints, bony enlargements of DIPs (Heberden’s nodes) and of PIPs (Bouchard’s nodes), squaring of hands

Question 9

What are the clinical features of osteoarthritis of the knees?

Answer 9

Osteophytes, effusions, crepitus, reduced ROM, genu varus or valgus, Baker’s cyst

Question 10

What are the clinical features of osteoarthritis of the hip?

Answer 10

Pain may be felt in groin or radiating to knee (pain felt at hip may also be radiating from the lower back), reduced ROM

Question 11

What are the clinical features of osteoarthritis affecting the cervical spine?

Answer 11

Pain and restriction of neck movement

Question 12

What are the clinical features of osteoarthritis of the lumbar spine?

Answer 12

Pain on standing or walking for some time, osteophytes causing spinal stenosis (if encroaching on spinal cord or pinching nerve root)

Question 13

What are the radiological signs of osteoarthritis?

Answer 13

Loss of joint space, subchondral sclerosis and cysts, osteophytes

Question 14

What is the Kellgren-Lawrence Radiographic Grading Scale of osteoarthritis?

Answer 14

Grade 0 = no radiographic findings of osteoarthritis
Grade 1 = minute osteophytes of doubtful clinical significance
Grade 2 = definite osteophytes with unimpaired joint space
Grade 3 = Definite osteophytes with moderate joint space narrowing
Grade 4 = definite osteophytes with severe joint space narrowing and subchondral sclerosis

Question 15

What is the natural history of osteoarthritis?

Answer 15

Small joints of hands = over 2 years pain improves but swelling gets worse
Knees = 1/3 improve, 1/3 stay the same, 1/3 get worse
Hip = 10% come of surgical waiting lists as symptoms improve

Question 16

What are the non-pharmacological treatments of osteoarthritis?

Answer 16

Physiotherapy = muscle strengthening, proprioceptive

Weight loss exercise, trainers, walking stick, insoles

Question 17

What are some pharmacological managements of osteoarthritis?

Answer 17

Analgesia = paracetamol, compound/topical analgesia
NSAIDs = topical/systemic, consider risk/benefit ratio
Pain modulators = tricyclics (e.g amitryptiline), anticonvulsants (e.g Gabapentin)
Intra-articular steroids

Question 18

What are some surgical treatments of osteoarthritis?

Answer 18

Arthroscopic washout, loose body, soft tissue trimming, joint replacement

Question 19

What is gout?

Answer 19

Inflammation in joint triggered by uric acid crystals

Question 20

What are some causes increased urate production?

Answer 20

Inherited enzyme defects, myeloproliferative/lymphoproliferative disorders, psoriasis, haemolytic disorders, alcohol, high dietary purine intake

Question 21

What are some causes of reduced urate excretion?

Answer 21

Chronic renal impairment, volume depletion (e.g heart failure), hypothyroidism, diuretics, cytotoxics (e.g cyclosporin)

Question 22

What is the epidemiology of gout?

Answer 22

1.4% UK prevalence, 7% in men > 65 and 3% in women >85, more common in men (4:1), rare in women before menopause

Question 23

What are some features of acute gout?

Answer 23

Usually monoarthropathy = 1st MTP>ankle>knee,

may have normal uric acid levels, renal impairment (may be cause or effect)

Question 24

What is the onset of acute gout?

Answer 24

Abrupt onset, usually overnight = normally settles in 10 days without treatment (3 days with treatment)

Question 25

What are some features of chronic tophaceous gout?

Answer 25

Chronic joint inflammation, may get acute attacks, often diuretics associated, high serum uric acid, tophi

Question 26

What are some investigation result positive for gout?

Answer 26

Raised inflammatory markers, serum uric acid usually raised, synovial fluid shows needle shaped negatively birefringent crystals on polarising microscopy, x-ray

Question 27

What is the treatment for acute gout?

Answer 27

NSAIDs, colchicine, steroids

Question 28

What is prophylactic treatment for gout?

Answer 28

Allopurinol, februxostat, start 2-4 weeks after acute attack, require cover with NSAIDs etc

Question 29

Who gets calcium phosphate deposition disease, and where does it occur?

Answer 29

More common in elderly = chondrocalcinosis increases with age Affects fibrocartilage = knees, wrists, ankles

Question 30

What are the two kinds of calcium phosphate deposition diseases?

Answer 30

Calcium pyrophosphate and calcium hydroxyapatite crystals

Question 31

What causes acute attacks of calcium phosphate deposition disease?

Answer 31

Calcium pyrophosphate crystals (pseudogout) = rhomboid mildly positive birefringent crystals, marked rise in inflammatory markers

Question 32

What is the treatment for pseudogout?

Answer 32

NSAIDs, colchicine, steroids, rehydration

Question 33

What causes Milwaukee shoulder?

Answer 33

Hydroxyapatite crystal deposition in or around the shoulder joint = release of collagenases, serine proteases and IL-1

Question 34

What are some features of Milwaukee shoulder?

Answer 34

Acute and rapid deterioration, occurs in females aged 50-60

Question 35

How is Milwaukee shoulder treated?

Answer 35

NSAIDs, intra-articular steroid injection, physiotherapy, partial or total arthroplasty

Question 36

What is soft tissue rheumatism?

Answer 36

General term to describe pain that is caused by inflammation/damage to ligaments, tendons, muscles or nerves near a joint

Question 37

Where is the pain of soft tissue rheumatism felt?

Answer 37

Confined to specific site (e.g neck, shoulder etc)

Question 38

What are some features of soft tissue rheumatism of the neck?

Answer 38

Muscular, usually self limiting, consider osteoarthritis of cervical spine etc

Question 39

What are some features of soft tissue rheumatism of the shoulder?

Answer 39

Most common site, adhesive capsulitis, rotator cuff tendinosis, calcific tendonitis, impingement, partial or full rotator cuff tears

Question 40

What are some features of soft tissue rheumatism of the elbow, wrist and foot?

Answer 40

``` Elbow = medial and lateral epicondylitis, cubital tunnel syndrome Wrist = De-Quervain's tenosynovitis, carpal tunnel syndrome Foot = plantar fasculitis ```

Question 41

What are some features of soft tissue rheumatism of the pelvis?

Answer 41

Trochanteric and iliopsoas, ischiogluteal bursitis, stress enthesopathies

Question 42

What are some investigations that can be done for soft tissue rheumatism?

Answer 42

Tests usually unnecessary, x-ray (calcific tendonitis), MRI if fails to settle, identify precipitating factors

Question 43

What are some treatments of soft tissue rheumatism?

Answer 43

Pain control, rest and ice compression, physiotherapy, steroid injections, surgery

Question 44

What is the aetiology of joint hypermobility syndrome?

Answer 44

More common in females, general or local, linked to Marfan's syndrome and Ehlers Danlos syndrome, usually presents in childhood or 30's

Question 45

What is the modified Beighton score for joint hypermobility syndrome?

Answer 45

>10 degrees hyperextension of the elbows Passively tough the forearm with the thumb while flexing the wrist Passive extension of fingers or a 90 degree or more extension of the 5th finger Knees hyperextension >= 10 degrees Touching the floor with the palms of the hands when reaching down without bending the knees

Question 46

What score on the modified Beighton score indicates joint hypermobility syndrome?

Answer 46

If score > 4/9

Question 47

What are some features of joint hypermobility syndrome?

Answer 47

Presents with arthralgia, premature osteoarthritis, normal investigations, treated with physiotherapy