RHEUM: Osteroporosis, osteomalacia, gout,fibromyalgia and hypermobility

Question 2

What is hypermobility?

Answer 2

Where joints move beyond normal limits due to laxity of ligaments, capsules and tendons. Can affect many joints.

Question 3

Who does hyper mobility affect?

Answer 3

People with familial history (but there isn’t any genetic testing)
Women, Asian people

Question 4

What is the clinical presentation of hypermobility?

Answer 4

PC: Presents in childhood, or young adulthood. Pain around the joints, worse after activity. Pain is generalised. Fatigued
PMH: Recurrent subluxations and recurrent dislocations
On examination:
- Soft tissue rheumatism, abnormal skin - thin, hyper extensible, striae, marfanoid habits, arachnodactyly, drooping eyelids, myopia, hernias, prolapses or uterine or rectal contents

Question 5

What scoring system is used for Hypermobility?

Answer 5

Beighton score - a point is given for each manoeuvre a pt can do. Score is out of 9.

Question 6

What is the aim of Hypermobility syndrome treatment?

Answer 6

Treated based on improving pain and reducing disability

Question 7

What non-drug treatment is available for hyper mobility?

Answer 7

Strengthening exercises to reduce joint subluxation.
Posture and balance exercises
Splinting
Specialist pain management

Question 8

What pharmacological treatment is available for hyper mobility?

Answer 8

Paracetamol

Question 9

What is a DEXA scan?

Answer 9

Measures the amount of radiation absorbed by the bones - indicating bone mineral density - BMD

Question 10

Where should a DEXA scan reading be done to classify and manage OA?

Answer 10

At the hip - neck of femur to confirm OA and monitor treatment .

Question 11

What scores can bone density be represented as?

Which score is key for the WHO classification of OA?

Answer 11

Z score ( how much bone mineral density falls below mean of pts age)

T score (how much bone mineral density falls below mean of healthy young person)

T SCORE - CLINICALLY IMPORTANT

Question 12

How is OA defined?

Answer 12

Degenerative joint disorder where there is progressive loss of articular cartilage accompanied by new bone formation and capsular fibrosis

Question 13

What are the aetiology possibilities for OA?

Answer 13

Failure of normal cartilage subject to abnormal or incongruous loading for long periods

Damaged or defective cartilage failing under normal conditions of loading

Break up of cartilage due to defective stiffened subchondral hone passing more load to it

Question 14

What are the key features of cartilage in OA

Answer 14

Loss of elasticity with reduced tensile strength

Cellularity and proteoglycan content are reduced

Question 15

What are the RF for OA?

Answer 15

Age- over 65 
Women are more symptomatic than men 
Obesity- hand and knee 
Trauma and joint malalignment  
Fhx

Question 16

What are the most common joints to be affected by OA?

Answer 16

Hip, knee and spine

Question 17

What are the symptoms of OA?

Answer 17

Pain provoked by movement and weight bearing
Pain starts off intermittent but as it progresses becomes constant
Knee-inactivity gelling and feeling that joint will give way is common

Question 18

What are the xray features of OA?

Answer 18

LOSS

loss of joint space
osteophytes
subchondral scerlosis
subchondral cysts

Question 19

What is the aim of treatment?
(regarding osteoarthritis)

Answer 19

Pain improvement and reduce disability

Question 20

What non-drug therapy is recommended in patients with OA?

Answer 20

Hip and Knee- strengthening and range of movement exercises
Weight loss to reduce joint loading
Laterally wedged insoles or walking stick

Question 21

What pharmacological therapy is given for OA?

Answer 21

Paracetamol is first line
NSAIDs- short term
Topical NSAIDS, topical rubefacients and capsaicin can be used.
Intra- articular corticosteroids can be offered.

Question 22

What surgical therapy is offered in OA?

Answer 22

If physio and pharmatherapy is not helpful- joint replacement surgery can be offered

Question 23

What is fibromyalgia

Answer 23

A common disorder of central pain processing characterized by chronic widespread pain in all 4 quadrants of the body (both sides and above and below the waist)

Allodynia, a heightened and painful response to innocuous stimuli, is often present.

Question 24

What is the pathogenesis of fibromyalgia?

Answer 24

It can be induced by deliberate sleep deprivation.
Reduced REM and delta wave sleep –>causes hyper-activation in response to noxious stimulation, and neural activation in brain regions associated with pain perception in response to non-painful stimuli.

Question 25

How would you assess a patient with osteoporosis?

Answer 25

* Patients are categorised as low, intermediate or high risk based on the risk calculator. For QFracture, this is based on the percentage, and patients above 10% are considered for a DEXA scan. * For FRAX, this is based on the NOGG guideline chart (linked to on the online FRAX tool), which advises whether to arrange a DEXA scan or start treatment. These suggestions do not apply to specific groups. For example, NICE CKS (April 2023) suggest: * A DEXA may be arranged without calculating the risk in patients over 50 with a fragility fracture * Treatment may be started without a DEXA in patients with a vertebral fracture In FRAX: Using the T score (Bone mineral density score) use the FRAX assessment tool (plug in RF -AR, sex, age, steroid use) p242 Z2F

Question 26

What Management for osteoporosis ? Non-pharmacological?

Answer 26

Lifestyle: ``` Stop smoking Avoid falls Activity and exercise Good Ca + Vit D intake Reduce alcohol Healthy weight ```

Question 27

What management for osteoporosis? Pharmacological?

Answer 27

Vit D + Ca supplements - Calcichew-D3 1st line for osteoperosis Bisphosphonates e.g. Alendronate 70mg weekly If above not tolerated : Denosumab - monoclonal AB that blocks ostoeclasts HRT for early menopause women

Question 28

How do Bisphosphonates work? What are some side effects ?

Answer 28

MOA: reduce activity of osteoclasts stopping resorption of bone 1. Reflux and oesophageal erosions (empty stomach and sit upright for 30 mins) 2. Atypical fractures e.g. femoral 3. Osteonecrosis of the jaw 4. Osteonecrosis of the external auditory canal

Question 29

Treatment of fibromyalgia ?

Answer 29

Tailor to pain, function and associated symptoms : depression / fatigue / sleep disturbance Drug: Low dose Amitryptytline Pregabalin CBT

Question 30

What blood tests to rule out other causes of fibromyalgia ?

Answer 30

BLOODS: ESR, CRP, FBC, U+E, LFT, Ca, CK, TFT

Question 31

What is Gout ?

Answer 31

Crystal arthropathy related to hyperuricemia . Depositition of monosodium urate crystals in joints and soft tissues.

Question 32

How does Gout present?

Answer 32

The monosodium urate crystals that deposit in soft tissues and joints cause acute and chronic arthritis. Hot swollen joint Can affect >1 joint but most commonly 1st metatarsal (podagra) Soft tissue deposits of uric acid - tophi urate nephropathy + uric acid stones.

Question 33

Typical joints affected by Gout?

Answer 33

Base of big toe - (metatarso-pharyhgeal joint) Wrists Base of thumb (carpo-metacarpal joint)

Question 34

Which type of Gout are older women with OA likely to get?

Answer 34

Pseudogout important DD in diagnosis of gout called by pyrophosphate crystals in older woman with OA

Question 35

What investigation and its result is patho-mnemonic for Gout?

Answer 35

Aspiration of joint will reveal: ``` Monosodium Urate Crystals are PM also will find: No bacterial growth MSU crystals = needle shaped -ve befringement of polarised light ```

Question 36

What would you seen on XRay of a joint with Gout?

Answer 36

Joint space is maintained Lytic lesions in bone Punched out erosions of bone Erosions can have sclerotic borders with overhanging edges Joint effusion

Question 37

What is management of acute flare of Gout?

Answer 37

NSAIDs e.g. ibuprofen- 1st line Colchicine - 2nd line Steroids - 3rd line

Question 38

What should be used for Gout if NSAIDS are not suitable? Give an example of pt where NSAIDS not suitable?

Answer 38

Pts not suitable for NSAIDS : Renal impairment Significant heart disease 2nd line choice: Colchicine Side effects of Colchicine are GI upset and diarrohea

Question 39

What is the prophylactic treatment of Gout? When specifically can you start this treatment?

Answer 39

Allopurinol - urate lowering Only start once flare up has stopped. Once started can continue through subsequent flares ``` Lifestyle changes: lose weight hydration reduce alcohol reduce purine based food e.g. meat / seafood ```

Question 40

How would you differenciate between Pseudo-Gout and Gout ?

Answer 40

Aspiration fluid Pseudo gout: pyrophosphate rhomboid crystals Gout Needle shaped monosodium urate crystals

Question 41

What are some non-modifiable and modifiable risk factors for Gout?

Answer 41

Nonmodifiable * Male sex * Age over 50 years * Family history of gout * Inherited syndrome with uric acid overproduction (eg. Lesch–Nyhan syndrome) Modifiable * Obesity * Hypertension * Chronic kidney disease * Diabetes * Metabolic syndrome * Medications (eg. thiazide diuretics, ACE inhibitors and aspirin)

Question 42

What is pathognomonic Xray finding in pseudo gout ?

Answer 42

Chondrocalcinosis - thin white line in middle of joint space Severe cases - joint washout (arthrocentesis) Joint changes similar to )A LOSS L- loss of joint space O- osteophytes S- sub articular sclerosis S- subchondral cysts

Question 43

What is osteoporosis?

Answer 43

low bone mass, deterioration of bone tissue, and disruption of bone architecture that leads to compromised bone strength and an increased risk of fracture

Question 44

Risk factors for osteoporosis?

Answer 44

``` Advanced age (>65 years) Female gender Caucasian or south Asians Fhx Low body weight (58 kg or body mass index [BMI] <21) early menopause (age<45) - Calcium/vitamin D deficiency - Inadequate physical activity - Cigarette smoking - Excessive alcohol intake (>3 drinks/day) - Iatrogenic: e.g. corticosteroids, aromatase inhibitors ```

Question 45

Characteristic gait of a patient with osteomalacia?

Answer 45

waddling gait

Question 46

Which medical conditions put patients at risk of developing Vit D deficiency and therefore osteomalacia?

Answer 46

``` Malabsorption disorders e.g. IBD Chrons Lack of sunlight diet CKD - kidneys needed to metabolise to active form Drug - anticonvulsants Inherited - hypophosphatemic rickets liver disease - cirrhosis ```

Question 47

What risk factors for Vit D deficiency in population (therefore getting osteomalacia?)

Answer 47

``` Darker skin Stay in doors a lot colder / northern climates Wear covered clothing low exposure to sunlight ```

Question 48

1. Briefly explain relationship between Vit D, Ca, phosphate | 2. How they become deranged in osteomalacia?

Answer 48

1. Vit D essential for Ca and Phos absorption from intestines and kidney. 2. Low vit D leads to lack of Ca and Phos in blood causing defective bone mineralisation. Low Ca causes increased PTH (2nd hyperparathyroidism) which makes mineralisation problem worse as it stimulates Ca resorption from bones.

Question 49

Symptoms of osteomalacia?

Answer 49

``` fatigue Proximal myopathy - waddling gait Muscle /bone tenderness Bone pain Pathological / abnormal fractures ```

Question 50

Treatment of osteomalacia?

Answer 50

``` Vitamin D (colecalciferol) e.g. 50,000 IU weekly for 6w Vit D serum below 25 nmol/L is deficient ```

Question 51

Define osteomalacia

Answer 51

Defective bone mineralisation causing soft bones in adults due to low vitamin D. When this happens in children before growth plates have closed it is called Rickets.

Question 52

Which drugs can increase risk of gout?

Answer 52

Diuretics- particularly thiazide like and loop pyrazinamide ciclosporin tarcolimus

Question 53

Signs and symptoms of fibromyalgia?

Answer 53

``` Unrefreshed sleep Joint and muscle stiffness Profound fatigue Numbness Headaches IBS/ Bladder syndrome Depression and anxiety Poor concentration and memory fibrofog. ```

Question 54

Risk factors of fibromyalgia?

Answer 54

Female Age - 40-50 usually May have obvious trigger = emotional trauma, physical e.g. painful arthritis.

Question 55

Allopurinol - mechanism of action?

Answer 55

Xanthine oxidase inhibitor so reduces rate formation.

Question 56

Compare gout and pseudo gout?

Answer 56

Gout = male, needle shaped negatively birefringent monosodium rate crystals (under polarised light) Pseudogout = women, usually with PMH of OA. Weakly positive birefringent rhomboid crystals made of calcium pyrophosphate

Question 57

Late XR findings of gout?

Answer 57

Joint effusion Punched out erosions Reduced joint space