Musculoskeletal. Zara Mullan

Transcription

1 Musculoskeletal Zara Mullan

2 Introduction Sample Questions Joints Bones Osteoarthritis Inflammatory arthritis Acute monoarthropathy; septic arthritis, gout & pseudogout Osteoporosis Osteomalacia

3 Sample Questions What s the difference between osteoporosis and osteomalacia? What treatments would you offer for RA? Describe (with a labelled illustration) a synovial joint.

4 Joints

5 Types of joints Joints Solid Synovial Fibrous Cartilagenous Hinge, ball & socket, saddle, pivot Sutures, gomphosis, syndesmosis Pubic symphysis, synchondrosis

6 Types ofjoints Features of synovial joints Layer of hyaline cartilage over articulating surfaces Joint capsule; inner synovial membrane & outer fibrous membrane Synovial membrane produces synovial fluid Fibrous membrane formed by dense CT surrounding and adding stability to joint

7 Bones

8 Bone remodelling Life long process Two main cell types involved: Osteoblasts BLAST OUT new bone Osteoclasts breaks bone down Modulated by: Vitamin D Stimulates osteoclasts PTH stimulates osteocytes/osteoclasts Calcitonin Inhibits osteoclasts, stimulates osteoblasts

9 Bone healing 1. Reactive Phase Fracture and inflammatory phase Granulation tissue formation 2. Reparative Phase Cartilage Callus formation Lamellar bone deposition 3. Remodeling Phase Remodeling to original bone contour

10 Management of any Patient BIO PSYCHO SOCIAL

11 Osteoarthritis

12 Overview Extremely common 8.5 million in the UK (good for exams) Degenerative process affecting the whole joint cartilage, bone, synovium, capsule and muscle. Risk factors: Obesity Previous bone fracture occupation Increasing age Female Family Hx Any joint but most commonly load bearing and high usage joints: hips, knees, spine, hands.

13 Pathophysiology Severe wear and tear/faulty repair/damage to joint Cartilage becomes damaged Bone rubs against bone Bone overgrowth Inflammation of soft tissues around joint PAIN and loss of function

14 Symptoms and signs Symptoms: pain, stiffness and swelling in a joint. Progressive onset usually over months/years. Worst at the end of the day. <30 mins in the morning Signs: soft tissue swelling (not red and hot), bony swelling, limited movement, crepitation. Heberden s Bouchard s

15 Investigations Common exam question XR signs LOSS Loss of joint space Osteophytes Subchondral cysts Subarticular sclerosis

16 Management Conservative most important! Exercise, weight control, walking aids, knee supports, physiotherapy, occupational therapy. Pharmacological Pain control WHO pain ladder Anti inflammatory NSAIDs and steroid injections Surgical Arthroscopy and debridement Replacement Hip replacements have better outcomes than knee replacements Both will last around 20 years depending on use consider age

17 Rheumatoid arthritis

18 Inflammatory arthritis Rheumatoid arthritis Spondyloarthropathies Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Reiter s syndrome Behçet s disease Enteropathic arthropathies Whipples disease Don t worry about these. (more for clinical years)

19 Overview Affects 1% of UK population Autoimmune symmetrical deforming polyarthropathy Presents at any age, most commonly middle age Risk factors: smoking, HLA DR1/DR4, rheumatoid factor, anti CCP antibody status, FHx Usually affects small joints (hands and feet) but can affect any joint

20 Pathophysiology Immune mediated inflammatory process monocyte invasion of joint setting up an inflammatory cascade and producing a synovitis Formation of an inflammatory pannus Chronic inflammation leads to erosion of joint Joint becomes deformed and tendons rupture RA is a systemic disease therefore has extrarticular manifestations

21 Symptoms and signs Symptoms: Painful, stiff, swollen joints in a symmetrical pattern. Worse in the morning and >30mins duration. Relieved by activity. Signs: Early boggy swelling in small joints of the hand. Later joint damage, deformity Hand signs Z thumb Ulnar deviation of fingers Subluxation of MCPJs Boutonniere/swan neck Rupture of extensor tendons Muscle wasting Wrist subluxation

22 Symptoms and signs Extra articular manifestations Rheumatoid nodules skin and lung Pulmonary fibrosis Atlanto axial joint subluxation Pericardial effusion Many more!

23 Investigations Rheumatoid factor +ve in 70% Anti CCP 98% specific FBP normocytic anaemia (anaemia of chronic disease) Inflammatory markers ESR and CRP X ray LESS Loss of joint space Extra articular osteopaenia Soft tissue swelling Subluxation

24 Management Refer to rheumatology early and be aggressive Control pain with NSAIDs and Paracetamol (GP and by Rheumatology) Monitor DAS 28 (Disease Activity Score) Start 2 DMARDS together (methotrexate / penicillamine) Then if failed after 6 months use biologics Rheumatology only Treat flares with steroids Exercise / Physio / OT Control cardiovascular risk Surgery if severe disease

25 Drugs in rheumatology:analgaesia WHO pain ladder Most pain will be controlled with paracetamol and NSAIDs (ibuprofen, naproxen, indomethacin, NOT diclofenac risk of cardiac events) NSAIDs be careful if poor renal function. Usually co prescribe a PPI (e.g. omeprazole) If require opiates start with cocodamol or tramadol if night pain (tramdol is a bad choice in the elderly) Rarely require strong opiates

26 Drugs in rheumatology: steroids Used in OA/RA injected directly into the joint to reduce pain Begins working within a few days Lasts for weeks/months Short courses of IM/IV steroid in pulses reduces the severity and duration of a flare but carries the risk of side effects Long term oral steroids

27 Drugs in rheumatology: DMARDS Slow the progression of inflammatory arthritis by altering the immune response Many types but and lots of side effects. A few examples are given below Often teratogenic and often cause immunosuppression Initiate 2 simultaneously to speed access to biologics at 6 months Mechanism Side effect 1 Side effect 2 Methotrexate Leflunomide Dihydrofolate reductase inhibitor Inhibits pyrimidine synthesis Mucositis Bonemarrow suppression Pulmonary fibrosis Lifethreatening hepatic toxicity

28 OA vsra Important in exams

29 The acute monoarthropathy Common presentation Common examination topic Requires rapid differentiation to rule out septic arthritis Investigate with; thorough history, joint examination, joint aspiration

30 Acute monoarthropathy History: Onset: sudden or gradual How many joints are involved Which joints are affected? Systemic symptoms History of trauma Loss of function Recent GI or GU symptoms

31 Differential diagnosis Septic arthritis Crystal arthropathies Trauma Haemarthrosis Inflammatory arthropathies Reactive arthritis

32 Septic arthritis Presentation: Single swollen joint with pain on active or passive movement may present as polyarticular arthritis in 15% Fevers/ rigors common, but not universal Patient maybe systemically unwell Common sites: Knee 50%, Wrists (7%), ankles (7%) and hips (20%) also common Risk factors: Previous joint damage/diseases Joint prostheses Immunosupression HIV, steroid injection, STIs, IVDUs

33 Septic arthritis Treatment ALWAYS ASPIRATE IV Antibiotics empirical Rx to cover s.aureus, Strep spp. Analgesia Splinting

34 Crystal arthropathies: gout Deposition of monosodium urate crystals within joint Reflects an imbalance between urate production & secretion Presentation: Acute pain in a swelling joint peaks at 6 12 hours 50% of attacks affect first metatarsal joint Other sites; knee, midtarsal, wrist, ankle, small hand joints, elbows Risk factors Drugs (thiazide and loop diuretics, low dose salicylates), High purine foods Alcohol excess Chemotherapy Vascular disease, Hypertension Impaired renal function FHx Hyperlipidemia

35 Gout Ix: Joint aspiration shows needle shaped monosodium urate crystals with negative birefringence under polarised light Serum urate may be raised Management: Strong NSAID (diclofenac) Colchicine Corticosteroids Prevention: Manage risk factors Allopurinol don t start during acute attack, don t stop during acute attack Febuxostat if allopurinol contraindicated

36 Crystal arthropathies :pseudogout Calcium pyrophosphate crystals DDx for acute monoarthropathy Tends to affect larger joints than gout (knee, wrist, hip) Risk factors; Age OA RA Hypothyroidism Hyperparathyroidism Ix: Joint aspiration shows rhomboid shaped calcium pyrophosphate crystals and positive birefringence under polarised light Management: analgesia, NSAIDs, trial of steroids. Self limiting

37 Osteoporosis brittlebones progressive systemic skeletal disease with reduced bone density and microarchitecture deterioration Increases markedly with age: 2% at 50 years, >25% at 80 years in women Think honeycomb

38 Osteoporosis Risk factors : Family history, older, female AND SHATTERED Steroids >5mg/day pred Hyperthyroidism Alcohol intake > 4 units/day and smoking Thin (BMI <22) Testosterone levels decreased (prostate Ca) Early menopause Renal or liver failure Erosive/inflammatory bone disease Dietary deficiency of calcium/diabetes

39 Osteoporosis Diagnosis: DEXA scan T score Lowbone mass (osteopenia) T score 1 to 2.5 Osteoporosis T score < 2.5 Severe osteoporosis T score < 2.5. TREAT & repeat DEXA in 2 years

40 Osteoporosis Combination of: Drugs Bisphosphonates > 65yrs without fracture, <65yrs with fracture AND addition RF Denosumab monoclonal ab against osteoclasts Strontium ranelate Diet calcium/ vitamin D supplements Exercise Bisphosphonates: AVN of jaw Atypical femoral Fractures Gi irritation Manage falls risk reduce polypharmacy, modify home, hip protectors

41 Osteomalacia softbones Inadequate mineralisation of bone matrix Rickets in Children Vitamin D deficiency leads to low calcium/phosphate, causing secondary hyperparathyroidism Causes: lack of sunlight, poor diet, malabsorption, liver & kidney disease Management Dietician input Sunlight exposure Vit D supplementation Pain management Orthopaedic intervention Know sources of Vit D and Iron. Common question on EOP

42 Sample Questions What s the difference between osteoporosis and osteomalacia? What treatments would you offer for RA? Describe (with a labelled illustration) a synovial joint.

43 Any Questions?