Orthopedic - Rheumatology Quiz

Orthopedic - Rheumatology

• History Taking (SAMPLE): Symptoms, Allergies, Medications, Past illnesses, Last meal, and Environment. Essential for understanding patient's condition.
• Symptoms of Seronegative Spondyloarthritis: Uveitis (eye inflammation), Psoriasis (skin), signs of Sacroiliitis(axial structure), spondylitis(spinal inflammation), Peripheral arthritis & enthesitis (inflammation at the attachment points of tendons and ligaments), and Inflammatory Bowel Disease (gut).
• Imaging (1.1): X-rays for fracture, osteoarthritis (osteophytes, joint narrowing, calcifications), osteolysis, osteoporosis. MRIs for edema, bone bruises, ligaments, and meniscal conditions.
• Laboratory Tests (1.2): Synovial fluid analysis checking color (clear, yellow, dark yellow = inflammation, white= crystal), WBC count (normal, inflammation, septic), viscosity (normal, inflammatory, infectious).
• Classification of Arthritis: Non-inflammatory (osteoarthritis), Inflammatory (septic arthritis, crystal-induced - gout, pseudogout, seropositive - rheumatoid arthritis, lupus, Sjogren's, seronegative - spondyloarthritis, axial - ankylosing spondylitis, peripheral - psoriatic arthritis, reactive arthritis, Inflammatory bowel disease).

Articular vs Non-articular Disorders

• Articular Disorders: Deep pain, limited/painful active & passive range of motion, joint swelling, crepitation (a grating sound), joint instability, joint locking.
• Non-articular Disorders: Localized pain, painful active range of motion (but not passive), the pain is away/distant from the joint (not in the joint itself), joint swelling (less common), joint instability (less common), and deformity.

Inflammatory vs Non-inflammatory Disorders

• Inflammatory Disorders: Localized symptoms (redness, warmth, pain, swelling). Systemic symptoms (fatigue, fever, rash, weight loss). Elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thrombocytosis, or hypoalbuminemia (low protein).

Clinical History

• Age: Different conditions (e.g., Systemic Lupus Erythematosus [SLE] - young, Rheumatoid Arthritis - middle age, Osteoarthritis & polymyalgia rheumatica - elderly).
• Sex: Gout, spondylarthritis, and ankylosing spondylitis (men); rheumatoid arthritis, fibromyalgia, osteoporosis, lupus (women).

Laboratory Investigations

• Complete blood count (CBC), ESR, CRP, serum uric acid, RF, CCP, ANAs, complement levels, Lyme antibodies, ANCA, Antistreptolysin O (ASO) levels. All helpful in determining the type of arthritis.

Rheumatoid Arthritis

• Common Hand Deformities: Fusiform swelling (spindle-shaped), Boutonnière deformity (flexion of PIP and hyperextension of DIP), Swan-neck deformity (flexion contracture of MCP, hyperextension of PIP, and flexion of DIP), Hitchhiker thumb (hyperextension of IP joint), and piano key ulnar head deformity
• Rheumatoid Arthritis vs Osteoarthritis: Comparing these conditions and the characteristics of osteoarthritis which include sclerosis, osteophytes, osteopenia, asymmetry of pain, and less common presence of cysts and narrowing on x-rays.

Laboratory Findings in RA Patients

• ESR, CRP: Usually elevated in inflammatory conditions like RA, but may be normal in early stages of RA, or elevated due to hypergammaglobulinemia.
• RF: Positive in 60-80% of RA cases, but can be present in other conditions.
• ACPA: More specific for RA than RF, positive in 70-80% of RA patients
• ANAs: May be present in other autoimmune conditions (30-50% in RA).

Crystal-Induced Arthritis (Gout)

• Features: Acute monoarthritis, often affecting the first metatarsophalangeal (MTP) joint, severe pain, swelling, redness, and extreme tenderness. Typically begins suddenly, especially in the early morning. Self-limiting over 5-14 days.
• Investigation: Identify Urate Crystals in synovial fluid via aspiration. Biochemical screen (assessments for kidney function, acid, glucose and lipid profile for metabolic syndrome, elevated ESR, CRP, and neutrophilia levels).
• Treatment (Acute): Colchicine (oral), oral prednisolone, and intramuscular methylprednisolone. Colchicine is usually the first choice of treatment in acute gout.

Calcium Pyrophosphate Deposition Disease (CPPD)

• Features: Common in the elderly, asymptomatic to chronic conditions. Can cause acute synovitis.
• Diagnosis: Requires identification of rhomboid or rod-like crystals in the synovial fluid.
• Treatment (Acute): Rest, joint aspiration, Nonsteroidal anti-inflammatory drugs (NSAIDs), or intra-articular glucocorticoid injections. (Chronic) - in frequent cases, daily prophylactic colchicine or short courses of glucocorticoids may reduce frequency of attacks.

Psoriatic Arthritis

• A progressive inflammatory musculoskeletal disease, common in patients with psoriasis (5-30% of them). Symptoms can occur before skin manifestation

Transient Synovitis/Septic Arthritis, Legg-Calvé-Perthes

• Differential Diagnosis of issues of the hip joint that presents similarly to other types of arthritis
• Laboratory Investigation (CBC [complete blood count], ESR, and CRP results for determining the cause of the hip pain.

Reactive/Post-Infective Arthritis

• Definition: Arthritis or enthesitis, resulting from an infection elsewhere in the body (bacterial infection, genital or gastrointestinal infections).
• Clinical Features: Monoarthritis, or multiple joints involvement. Symptoms range from a transient monoarthritis to chronic conditions. Typically resolve within 3 to 5 months, but may become chronic.