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Rheumatology Flashcards

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1
Q

What is rheumatology

A 
The medical speciality dealing with diseases of the musculoskeletal system including 
Joints
Tendons
Ligaments
Muscles
Bones
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2
Q

What is a joint

A

Where two bones meets

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3
Q

Tendons

A

Cords of strong fibrous collagen tissue attaching muscle to bone

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4
Q

Ligaments

A

Flexible fibrous connective tissue which connects two bones

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5
Q

Which joint allows free movement ( diarthroses)

A

Synovial joints ( have a space between adjoining bones called the synovial cavity) and this space is filled with synovial fluid

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6
Q

Fibrous joint structural classification

A

No space between the bones

E.g. sutures in the skull, syndesmosis ( sheet of connective tissue) in the tibia and fibula joint ( ankle)

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7
Q

What kind of movement does the fibrous joint allow for

A

Synarthroses ( generally allow no movement)

Amohiarthroses ( allows very limited movement)

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8
Q

What kind of movement does the cartilaginous joint allow

A

Synarthroses

Amphiarthroses

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9
Q

Cartilaginous joint

A

Joints in which the bones are connected by cartilage

E.g. joints between the spinal vertebrae

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10
Q

What is the synovium made up of

A

1-3 cell deep lining containing macrophage like phagocytic cells ( type A synoviocyte) and fibroblast like cells that produce hyaluronic acid ( type B synoviocyte)

Type 1 collagen

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11
Q

What does synovial fluid contain

A

Hyaluronic acid rich viscous fluid

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12
Q

What is articulate cartilage made up of

A

Type II collagen

Proteoglycan ( aggrecan )

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13
Q

What is cartilage composed of

A

Specialised cells called chondrocytes
Extra cellular matrix - water, collagen and proteoglycans ( mainly aggrecan) . Cartilage is a vascular - has no blood supply so cartilage heals poorly after injuries

Aggrecan is a proteoglycan that possesses many chondrites sulfate and keratin sulfate chains
Characterised by its ability to interact with hyaluronan to form large proteoglycan aggregates

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14
Q

What is arthritis

A

Disease of the joints

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15
Q

Two types of arthritis

A

Osteoarthritis ( degenerative arthroscopic where the cartilage is worn out)

Inflammatory arthritis ( main type is rheumatoid arthritis - main problem is inflammation )

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16
Q

Pathological changes in osteoarthritis

A

Cartilage is worn out and there is bony remodelling leading to bone Spurs

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17
Q

Epidemiology of osteoarthritis

A

More prevalent as age increases
Previous joint trauma ( e.g. footballers knees)
Jobs involving heavy manual labour
Gradual onset and slowly progressive disorder

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18
Q

Joints of the hand affected by osteoarthritis

A

Distal inter phalanges joints ( DIP)
Proximal inter phalangeal joints ( DIP)
First carpometacarpal joint ( CMC)

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19
Q

Other joints affected by osteoarthritis

A

Spine
Weight bearing joints of lower limbs
esp knees and hips
First metarsophalangeal joint (MTP)

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20
Q

What can osteoarthritis be associated with

A 
Joint pain ( worse with activity but better with rest)
Joint crepitus - creaking, cracking , grinding sound on moving affected joint
Joint instability ( giving way) 
Joint enlargement - herberdens nodes 
Joint stiffness after immobility - gelling
Limited partition of range of motion
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21
Q

How can you tell from an x ray that there are subchondral bony sclerosis

A

Increased white appearance

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22
Q

What is inflammation

A

A physiological response to deal with injury or infection . But excessive / inappropriate inflammatory reactions can damage the host tissues

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23
Q

What are the manifestations of inflammation

Study These Flashcards
A 
Red ( rub or)
Pain ( donor)
Hot ( calor)
Swelling ( tumor) 
Loss of function

There is an increased blood flow
Migration of white blood cells ( leukocytes) into tissues
Activation / differentiation of leucocytes
Cytokine production - TNF alpha, IL1 , IL6 , IL17

24
Q

Causes of joint inflammation

Study These Flashcards
A

Infection
Crystal arthritis
Immune mediated ( autoimmune)

25
Infection related joint inflammation
Septic arthritis - acute presentation such as acute bacterial infection Tuberculosis - chronic presentation
26
Crystal arthritis joint inflammation
Gout | Pseudogout
27
Immune mediated joint inflammation( autoimmune)
Rheumatoid arthritis Psoriasis arthritis Reactive arthritis Systemic lupus erythematosus ( SLE)
28
Septic arthritis
Bacterial infection of a joint Risk factors ; immunosuppressed, pre existing joint damage , IVDU Untreated, it can eventually destroy a joint
29
How many joints are affected in sceptic arthritis
1 ( mono arthritis) Gonococcal sceptic arthritis is an exception : it often affects multiple joints ( poly arthritis ) it is also less likely to cause joint destruction
30
Sceptic arthritis presentation
Acute painful, red, hot, swelling of a joint, especially if there is fever Diagnosis is by joint aspiration , send sample for urgent gram stain and culture Treatment is with surgical wash out ( lavage) and IV antibiotics ( but antibiotics by itself won’t work well)
31
Common organisms which cause sceptic arthritis
Staphylococcus aureus, streptococci , gonococcus
32
Gout
Gout is the syndrome caused by deposition of Urate crystals leading to inflammation
33
Hyperuricaemia
High Uris acid levels
34
Causes of hyperuricaemia
``` Genetic tendency Increased intake of purine rich foods Reduced excretion ( kidney failure) ```
35
Pseudogout
A syndrome caused by deposition of calcium pyrophosphate dihedral ( CPDD) Crystal deposition crystals - inflammation
36
Risk factors for pseudogout
Background osteoarthritis Elderly patients Inter current infection
37
Clinical features of gout
Acute mono arthritis of rapid onset ( first metatarsophalangeal joint is the most commonly affected joint - podagra) Gout also affects other joints ; joints in foot, ankle, knee, wrist, finger, and elbow are the most frequently affected Crystal deposits ( to phi) may develop around hands, feet, elbows and ears
38
What are shown on the X days of gout
Juxta articulate ‘rat bite’ erosions at the MTPJ of the great toe
39
Crystal arthritis synovial fluid analysis
Use polarised light to see it Gout ; needle shapes crystals with negative birefringence Pseudogout ; rhomboid shaped crystals with positive birefringence
40
RA
Chronic autoimmune disease characterised by pain , stiffness and symmetric synovitis ( inflammation of the synovial membrane ) of synovial ( diarthrodial) joints
41
Overview of RA
Chronic arthritis - poly arthritis : swelling of small joints of the hand and wrists is common Symmetrical Early morning stiffness in and around joints May lead to joint damage and destruction - joint erosions Extra artcular diseases can occur Rheumatoid nodules - others such as vasculitiw and epsicoeritis Rheumatoid factor may be detected in blood - autoantibody agains IgG
42
Rheumatoid arthritis ; pattern of joint involvement
Symmetrical Poly arthritis Affects small and large joints, but particularly hands and feet ``` Common affected joints; MCP PIP Wrists Knees A led MTP ```
43
Primary site of pathology in RA
Synovial arthritis
44
Common extra articulate features of RA
Fever Weight loss Subcutaneous nodules Generally not feeling well
45
What are subcutaneous nodules
Nodules are classically found just below elbows but also on the fingers Associated with severe disease of RA so may act as a prognostic factor
46
What cytokine is the most predominant in RA
TNF alpha
47
Primary clinical treatment of RA
TNFalpha inhibition
48
Rheumatoid arthritis autoantibodies
Rheumatoid factor ( typically IgM antibodies - IgM anti IgG antibody) Antibodies to citrullinated protein antigens - mediated by enzymes termed as peptidyl arginine deiminases
49
Drug treatment of anti rheumatic drugs
1 st line treatment Methotrexate in combination with hydroxyxhloroquine or sukfasalazine 2nd line ; Biological therapies offer potent and targeted treatment strategies
50
Biological therapies of RA
Inhibition of TNF alpha B cell depletion Modulation of T cell co stimulation Inhibition of IL6 signalling
51
RA Randi graphical changes
``` Joint space narrowing - Y Subchondral sclerosis - N Osteophytes - N Osteopenia- Y Bony erosions - Y ```
52
Osteoarthritis radio graphical changes
``` Joint space narrowing - Y Subchondral sclerosis - Y Osteophytes - Y Osteopenia - N Bony erosions - N ```
53
Psoriatic arthritis
Psoriasis is an autoimmune disease affecting the skin | Rheumatoid factors are not present
54
Reactive arthritis
Sterile inflammation in joint FOLLOWING infection especially urogenital and gastrointestinal Reactive arthritis is the first manifestation of HIV or HepC infection
55
Systemic Lupus Erythematous ( SLE)
Can affect any organ
56
Clinical tests for SLE
Antinuclear antibodies ( ANA) - high sensitivity for SLE but not specific so a negative test rules out SLE but positive tests does not mean SLE Antidouble stranded DNA antibodies ( anti -ddDNA Abs) High specificity for SLE in the context of the appropriate clinical signs

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