Orthopedic – Rheumatology PDF

Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi Orthopedic – Rheumatology 1. History taking Anamnesis is needed, and the steps are represented by the acronym SAMPLE: (S: Symptoms A: Allegies M: Medica9on: knowing which drugs the pa9ent is t...

Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi Orthopedic – Rheumatology 1. History taking Anamnesis is needed, and the steps are represented by the acronym SAMPLE: (S: Symptoms A: Allegies M: Medica9on: knowing which drugs the pa9ent is taking can be a useful cue to understand which pathology they might have P: Pathologies: both current and previous ones L: Last meal: for anes9hesia (oral tract intuba9on, the pa9ent should go to the OR in an empty stomach) E: Environment that allows to understand “what happened” to them, the reason of the visit) Symptoms of seronega9ve spondyloarthri9s: Eyes: signs of uvei9s Skin: signs of psoriasis Axial structure: search signs sacroilii9s, spondyli9s Peripheral ar9cula9ons: signs of arthri9s, enthesi9s, dactyli9s Gut: IBD, enterogenic reac9ve arthri9s 1.1 Imaging X-ray to check for fracture, osteoarthri9s (osteophytes, joint narrowing, calcifica9ons), osteolysis, osteoporosis. MRI to check for edema, bone bruises, ligaments condi9on, meniscal condi9on 1.2 Laboratory tests 1.2.1 Synovial -luid analysis Check for: Colour: o Clear (colorless) = normal o Slightly deeper yellow = osteoarthri9s o Dark yellow (cloudy) = inflamma9on o White (cloudy) = crystals WBC: o 50000 c/μL = sep9c Viscosity: o High = normal o Moderate = inflammatory o Low = infec9ous 2. Classi)ication Non-inflammatory – osteoarthri9s Inflammatory: o Sep9c arthri9s o Crystal induced: Gout, Pseudogout o Seroposi9ve: Rheumatoid arthri9s, Lupus, Sjogren’s o Seronega9ve: Spondyloarthri9s: § Axial – ankylosing spondyli9s § Peripheral – psoria9c arthri9s, reac9ve arthri9s, IBD(inflammatory bowel disease)- associated 1 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 3. Articular vs non-articular disorders Ar/cular disorders Sympyoms: Deep pain Painful/limited ac9ve and passive ROM Signs: Swelling of joint Crepita9on Joint instability Locking Non-ar/cular disorders Symptoms: Localized pain Painful ac9ve ROM but not passive one Pain remote from joint Rare: swelling, crepita9on joint instability, deformity 4. In)lammatory vs non-in)lammatory disorders Inflammatory disorders may be iden9fied by: Local symptoms: erythema, warmth, pain, or swelling Systemic symptoms: fa9gue, fever, rash, weight loss Laboratory findings: elevated erythrocyte sedimenta9on rate [ESR], C reac9ve protein [CRP], thrombocytosis, or hypoalbuminemia. 5. Clinical history AGE Young - Systemic lupus erythematosus (SLE) and reac9ve arthri9s Middle age - Fibromyalgia and rheumatoid arthri9s Elderly - osteoarthri9s and polymyalgia rheuma9ca SEX Men - gout, spondylarthri9s, and ankylosing spondyli9s Women - rheumatoid arthri9s, fibromyalgia, osteoporosis, and lupus 6. Laboratory investigations Complete blood count, including a white blood cell (WBC) and differen9al count ESR or CRP Serum uric acid Serologic tests for RF, Cyclic an9citrullinated pep9de (CCP or ACPA) an9bodies, ANAs, Complement levels, Lyme and an9neutrophil cytoplasmic an9bodies (ANCA), An9streptolysin O (ASO) 9ter 2 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 7. Rheumatoid arthritis 7.1 common deformities of the hand in rheumatoid arthritis Fusiform swelling —synovi9s of PIP joints, causing them to appear spindle-shaped. Boutonnière deformity —flexion of the PIP and hyperextension of the DIP joint caused by weakening of the central slip of the extrinsic extensor tendon and a palmar displacement of the lateral bands. Swan-neck deformity — results from contrac9on of the flexors (intrinsic muscles) of the MCPs, resul9ng in flexion contracture of the MCP joint, hyperextension of PIP, and flexion of the DIP joint. Hitchhiker thumb hyperextension of IP joint with flexion of MCP and exaggerated adduc9on of first metacarpus. Causes inability to pinch. Also referred to as a “Z-deformity.” “Piano key” ulnar head — secondary to destruc9on of ulnar collateral ligament leading to a floa9ng ulnar styloid. 7.3 Rheumatoid arthritis vs Osteoarthritis This is the difference between osteoarthri9s and rheumatoid arthri9s. Sclerosis of the bone and osteophytes are typical of osteoarthri9s, osteopenia and symmetry (having a problem in the same ar9cula9on both on the lej and right side of the body) are typical of rheumatoid arthri9s. This is something you check during history taking. If the pa9ent tells you “I have pain in my lej shoulder” and not in the right one, this is informa9on regarding the symmetry of the pain. Marginal erosion is typical of rheumatoid arthri9s and can be seen with X-rays. Cysts and narrowing are present in both pathologies. There are a lot of specific palerns for each disease. 3 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 7.4 Laboratory >indings in RA patients (ESR): Usually elevated. Can be normal in pa9ents with early limited disease. ESR can be elevated because of inflamma9on and hypergammaglobulinemia. C-reac9ve protein (CRP): Usually elevated. May be more ideal than ESR in following disease ac9vity because it is not influenced by hypergammaglobulinemia. RF: Posi9ve in 60% to 80%, with a specificity of 80% to 86% for RA. RF posi9vity is associated with extraar9cular manifesta9ons including subcutaneous nodules. Note that several diseases with arthri9s can have a posi9ve RF such as hepa99s C (40%–75%), SLE (20%), Sjögren’s syndrome (SS, 70%), tuberculosis (60%), and subacute bacterial endocardi9s (45%–68%). ACPA: The most common clinically available ACPA is called an9body to cyclic citrullinated pep9de (an9-CCP). Several versions of an9-CCP tes9ng are available, with sensi9vi9es ranging from 57% to 67% and specificity ranging from 93% to 99%. An9-CCP is posi9ve in 10% to 15% of RF−RA pa9ents. An9nuclear an9bodies (ANAs): Posi9ve in 30% to 50%. 4 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 8. Crystal induced arthritis 8.1 Gout Gout is the most common inflammatory arthri9s in men and in older women. It is caused by deposi9on of monosodium urate monohydrate crystals in and around synovial joints. The risk of developing gout increases with age and with serum uric acid (SUA) levels. 8.1.1 Clinical Features The classical presenta9on is with an acute monoarthri9s, which affects the first MTP joint in over 50% of cases. Typical features include: rapid onset, reaching maximum severity in 2–6 hours, and ojen waking the pa9ent in the early morning severe pain, ojen described as the ‘worst pain ever’ extreme tenderness, such that the pa9ent is unable to wear a sock or to let bedding rest on the joint marked swelling with overlying red, shiny skin self-limi9ng over 5–14 days, with complete resolu9on. 8.1.2 Investigation Iden9fica9on of urate crystals in the aspirate from a joint, bursa or tophus. The synovial fluid may be turbid due to an elevated neutrophil count, may reveal crystals. A biochemical screen: elevated ESR and CRP and with a neutrophilia renal func9on, uric acid, glucose and lipid profile àassocia9on with metabolic syndrome Hyperuricemia is usually present in gout, but levels may be normal during an alack because serum urate falls during inflamma9on. 8.1.3 Treatment Acute Oral colchicine given in doses of 0.5 mg twice or 3 9mes daily is the treatment of first choice in acute gout. Oral prednisolone (15–20 mg daily) or intramuscular methylprednisolone (80–120 mg daily) for 2–3 days are highly effec9ve and are a good choice in elderly pa9ents where there is an increased risk of toxicity with colchicine and NSAID. 5 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 8.2 Calcium Pyrophosphate Deposition Disease The deposi9on of CPP crystals in ar9cular 9ssues is most common in the elderly, occurring in 10–15% of persons aged 65–75 years and 30–50% of those >85 years. Muta9ons in the ANKH gene, as described in both familial and sporadic cases, can increase elabora9on and extracellular transport of pyrophosphate. There are decreased levels of car9lage glycosaminoglycans that normally inhibit and regulate crystal nuclea9on. 8.2.1 Clinical Manifestation CPPD arthropathy may be asymptoma9c, acute, subacute, or chronic or may cause acute synovi9s superimposed on chronically involved joints (50% knee). 8.2.2 Diagnosis Defini/ve diagnosis Requires demonstra9on of typical rhomboid or rodlike crystals (generally weakly posi9vely birefringent or nonbirefringent with polarized light) in synovial fluid or ar9cular 9ssue. In as many as 50% of cases, episodes of CPPD-induced inflamma9on are associated with LOW-GRADE FEVER AND, ON OCCASION, TEMPERATURES AS HIGH AS 40°C (104°F). In such cases, synovial fluid analysis with microbial cultures is essen9al to rule out the possibility of infec9on. 8.2.3 Treatment Acute Treatment by rest, joint aspira9on, and NSAIDs or by intraar9cular glucocor9coid injec9on may result in more rapid return to prior status. Chronic For pa9ents with frequent recurrent alacks, daily prophylac9c treatment with low doses of colchicine may be helpful in decreasing the frequency of the alacks. Severe polyar9cular alacks usually require short courses of glucocor9coids. 6 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 9. Psoriatic Arthritis Psoria9c Arthri9s is recognized as a progressive inflammatory musculoskeletal disease which if untreated leads to impaired func9on and long-term adverse outcomes. Psoria9c arthri9s occurs in 5–30% of pa9ents with cutaneous psoriasis. In a minority of pa9ents (10–15%), the symptoms of psoria9c arthri9s appear before involvement of the skin. Pi}ng and ridging of the nails is a common sign of psoriasis and in psoria9c arthri9s. Pi}ng Ridging Dactyli9s 10. Transient synovitis (/arthritis), Septic arthritis, Legg- Calvè-Perthes 10.2 Laboratory investigations 7 Clinics - Guidani 13.12.2024 Dheerasinghe, Nesi 11. Reactive/Post infective Arthritis Reac9ve arthri9s refers to acute, non-purulent arthri9s, complica9ng an infec9on elsewhere in the body. The iden9fica9on of bacterial species triggering the clinical syndrome and the finding of an associa9on with HLA-B27 led to the unifying concept of reac9ve arthri9s as a clinical syndrome triggered by specific e9ologic agents in a gene9cally suscep9ble host. Clinical manifesta9ons can be triggered by enteric infec9on (several Shigella, Salmonella, Yersinia, and Campylobacter species), genital infec9on (Chlamydia trachoma9s), nasopharyngeal infec9on (Chlamydia pneumoniae). 11.1 Clinical features The clinical manifesta9ons range from an isolated, transient monoarthri9s or enthesi9s to severe mul9system disease. Addi9ve arthri9s or tendini9s. Arthri9s typically persists for 3–5 months, but more chronic courses do occur. 8