What conditions involve the joints?
- Rheumatoid arthritis
- Osteoarthritis
- Gout and pseudogout
- Ankylosing spondylitis
- Psoriatic arthropathy
- Reactive arthritis
- IBD-related arhropathy
What conditions are connective tissue disease?
- SLE (anti-phospholipid syndrome)
- Scleroderma
- Myositis (polymyositis and dermatomyositis)
- Sjorgrens syndrome
- Fibromyalgia
What causes gout?
Build-up of uric acid. Repeated bouts can cause joint damage.
How does gout present?
A single red hot swollen tender joint (much like septic arthritis), usually occurs at night and becomes very painful within hours.
How can gout be managed?
Anti-inflammatories such as colchine or steroids
What deformations are classic of rheumatoid arthritis?
- Z-thumb
- Ulnar deviation of fingers at MCPJ
- Boutonnaires
- Swan neck deformity
What are common signs of SLE?
- Raynauds
- Arthritis
- Butterfly rash (photosensitive)
How do autoimmune responses work?
The initial cell-mediated response is activation of T cell lineage. The T helper cells (CD4, MHC class 2) release inflammatory interleukins and interferons to cause tissue damage and allow the target to be more exposed to the mounting immune response. They also activate the humoral response (B cells) which attack using autoantibodies. T-killer cells (CD8, MHC class 1) can also be deployed to directly kill the cells.
What are the signs of an inflammatory condition?
- Morning stiffness >30 mins
- Systemic symptoms (fatigue, aches, weight loss)
- Pain worse after rest/in morning
- Nighttime pain troublesome
- Acute/subacute presentation
- Tender to touch
- Severe bone pain that can be unremitting
e. g. rheumatoid arthritis
What are the signs of a non-inflammatory condition?
- Pain worse at end of the day/with use
- Pain better at night
- Long-standing/chronic nature
e. g. osteoarthritis
What is a classic presentation of fibromyalgia?
Widespread pain with normal joint examination
Where does pain in shoulder present?
From the acromioclavicular joint it is felt in the joint. Pain from the glenohumeral joint or rotator cuff is felt in the upper arm.
What does joint swelling indicate?
Intermittent could indicate inflammatory disease. Often described as rings becoming tight or sensation of walking on pebbles.
What are the terms for the different types of arthritis?
- Monoarticular: one affected joint e.g. septic arthritis
- Pauciarticular (oligoarticular): a few affected joint e.g. psoriatic arthritis
- Polyarticular: many joints affected e.g. rheumatoid arthritis
- Axial: spine is predominantly affected e.g. ankylosing spondylitis
What joints does osteoarthritis tend to affect?
- Weight bearing joints
- Part of the spine that move most (lumbar and cervical)
What is primary osteoarthritis?
Wear and tear of the joint. The dynamic process of breaking down and rebuilding the joint tissue starts to become less efficient and joint integrity and function starts to gradually decline.
What is secondary osteoarthritis?
This is due to rheumatological disease, trauma and infection etc. Long-term regular exercise and physiotherapy can help combat this with simple analgesia. If this progresses it can require orthopaedic intervention for joint replacement.
What are the features of reactive arthritis?
- Arthritis that develops following an infection - can’t pee, see or climb a tree
- Typically develops within 4 weeks of the infection, symptoms generally last around 4-6 months
- Arthritis is typically an asymmetrical oligoarthritis of the lower limbs
- Dactylitis (diffuse swelling of finger or toe)
- Symptoms of urethritis
- Eye - conjunctivitis, anterior uveitis
- Skin - circinate balanitis, keratoderma blenorrhagica
What are the features of polymyalgia rheumatica?
- Typically >60yrs old
- Usually rapid onset e.g. <1 month
- Aching, morning stiffness in proximal limb muscles e.g. shoulders, hips (not weakness)
- Also mild polyarthralgia, lethargy, depression, low grade fever, anorexia, night sweats
- Raised inflammatory markers e.g. ESR >40
What is the treatment for polymyalgia rheumatica?
Prednisolone e.g. 15mg/OD, patients typically respond dramatically to steroids, failure to do so should indicate different diagnosis
What are the features of psoriatic arthropathy?
- Psoriatic skin lesions
- Periarticular disease - tenosynovitis and soft tissue inflammation resulting in: enthesitis (inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis), tenosynovitis (e.g flexor tendons of the hands), dactylitis (diffuse swelling of a finger or toe)
- Nail changes: pitting, onycholysis
- Symmetrical polyarthritis more common than asymmetrical - DIPJ
- Sacroiliitis
What are the features of polymyositis?
- May be idiopathic or associated with CTD or malignancy
- Symmetrical proximal muscle weakness +/- tenderness
- Typically affects middle aged, female : male 3:1
What are the symptoms of polymyositis?
- Raynaud’s phenomenon
- Respiratory muscle weakness
- ILD e.g. fibrosing alveolitis or organising pneumonia
- Dysphagia
- Dysphonia
- Symmetrical proximal muscle weakness +/- tenderness
What are the investigations for polymyositis?
- Elevated CK
- Elevated LDH, ALT, AST
- EMG
- Muscle biopsy
- Anti-synthetase antibodies
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Rheumatology26
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Back Pain32
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Vasculitis25
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Orthopaedics21
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History Taking6
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Making a Diagnosis8
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Treatment16
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Medications9
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Trauma call20
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Childhood Fracture10
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Rheumatoid Arthritis27
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Osteoarthritis15
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Gout13
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Hip Pain in a Child13
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Systemic Lupus Erythematosus19
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Rotator Cuff Injury17
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Fibromyalgia12
