L01 EAU-MSB-M.pptx osteoarthritis osteoporosis

Osteoarthritis

1. Medicine Ibrahim Burhan Abdillahi Orthopedic Surgery Consultant East Africa University [email protected] Musculoskeletal system block Faculty of Medicine

2. Musculoskeletal System Examination of joints Rheumatoid arthritis Examination of joint fluid Osteoarthritis Infective arthritis Ankylosing spondylitis Reactive arthritis ( reiter’s syndrome) SLE Sjogren’s syndrome Gout Osteomyelitis Osteoporosis Rickets and osteomalacia Paget’s disease Back pain Vasculitis Polyarteritis nodosa Kawasaki’s disease Wegener’s granulomatosis Churg-strauss syndrome Bachets’s syndrome

3. Examination of joints General Principles Inspection Palpation Passive movement

4. Inspection Skin Swelling Deformity Muscle wasting

5. Palpation Warmth Tenderness Swelling

6. Passive movement Joint must be put through a full range of movement. Joint movement may be active performed by the patient or passive performed by the examiner. Limitation of passive movement indicates something wrong in or around the joint and it is more specific to joint problem as compared to the active movement . Movement must be attempted gently and it wil be restricted if the joint is painful, having tense effusion or fixed deformity. The joint may have limited extension (called fixed flexion deformity) or limited flexion (called fixed extension deformity). Instability of joint that is characterized by abnormal movement is usually due to weak surrounding ligaments. It is tested by attempting to move the joint gently in abnormal direction. Joint crepitus is a grating sensation or noise from the joint and indicates irregularity of the articular surface.

7. Rheumatoid Arthritis is a chronic symmetrical polyarthritis of unknown cause. RA is characterized by chronic inflammatory synovitis of mainly peripheral joints along with systemic disturbances and extra-articular features. Course of disease is prolonged with exacerbations and remissions

8. RA Characteristics Symmetrical inflammatory polyarthritis Extra-articular involvement Progressive joint damage causing severe disability

9. Etiology Genetic factor Autoimmunity Immune complexes are common in the synovial fluid and circulation There is defect in cell mediated immunity Female gender Cigarette smoking

10. Signs Swelling Warmth Tenderness Limitation of movement Deformities Subcutaneous nodules Extra articular features

11. Symptoms Joint pain Morning stiffness General symptoms Extra-articular symptoms

12. Pattern of joint involvement Proximal interphalangeal & metacarpophalangeal joints of fingers Wrist, knee, ankle and toe Distal interphalangeal joint spared

13. Spinal cord and vertebral body The spinal cord is shorter than the vertebral column, each spinal cord segment at lower levels is located above the similarly numbered vertebral body. Spinal cord segment Relationship Vertebral body C1~C4 = C1 ~ C4 C5~T4 - 1 C4 ~ T3 T5~T8 - 2 T3 ~ T6 T9~T12 - 3 T6 ~ T9 L1~L5 = T10 ~ T12 S1~Co1 = L1

14. Spinal cord and vertebral body During the process of the development of the embryo, in the third month of fetal life the length of spinal cord is equal to the vertebral canal, but after that time the rate of growth of the vertebral column exceeds that of the spinal cord; so that the spinal cord is shorter than the vertebral column. The relation between spinal cord segments and vertebral bodies is shown in this table. Minus 1, 2, 3 , equal, be equal to, located between and , face

15. Spinal cord and vertebral body Lateral view

16. Question Which spinal segment is involved in the injury of the C4 vertebral body? ----- spinal segment

17. Question Which spinal segment is involved in the injury of the T3 vertebral body? ----- spinal segment

18. Question Which spinal segment is involved in the injury of the T7 vertebral body? -----spinal segment

19. Deformities Synovial effusion of knee Valgus and varus deformities of knee joint Spindling of fingers Swan neck deformity of hand Buttonhole deformity of hand Z-deformity of thumb Carpal tunnel syndrome Lateral deviation of the toes of the feet Subluxation of metacarpophalangeal joints of hand Subluxation of metatarsophalangeal joints of feet Atlanto -axial subluxation

20. investigation There is no specific test for the diagnosis of RA, but there are investigations which may be helpful in the diagnosis of RA. Rheumatoid factor –RA factor ANA –antinuclear antibodies CBC, CP, ESR RADIOGRAPHY SYNOVIAL FLUID ASPIRATION

21. You can see positive RA factor in diseases like Normal population: elderly person, relatives of patients with rheumatoid arthritis JD: Sjorgens syndrome 95%, rheumatoid arthritis 70%, SLE 50%, systemic sclerosis 30%, polymyositis / dermatomyositis 50%, mixed connective tissue disease Autoimmune chronic active hepatitis Chronic infection : TB, infective endocarditis , leprosy, kalaazar

22. X-ray features in progression of RA Stage 1- peri -articular osteoporosis Stage 2- loss of articular cartilage Stage 3- bony erosions Stage 4- subluxation and ankylosis

23. Diagnosis criteria of RA American Rheumatism Association revised criteria Morning stiffness of more than 1hr Arthritis of 3 or more joint areas Arthritis of hand joints Symmetrical arthritis Rheumatoid nodules Rheumatoid factor Radiological changes Duration of 6 weeks or more Diagnosis of RA made with 4 or more criteria

24. Differential diagnosis Rheumatic fever SLE Osteoarthritis Gouty arthritis Septic arthritis

25. Rheumatic fever Migratory arthritis Raised ASO – AntiStreptolysin O titer Dramatic response to aspirin Carditis and erythema marginatum may occur in adults but chorea and subcutaneuous nodules virtually never do

26. SLE Butterfly rash Discoid rash Photosensitivity Alopecia Higher titer to anti-DNA Renal involvement (e.g. proteinuria ) CNS involvement

27. Osteoarthritis No systemic features Joint pain is characteristically relieved by rest while the pain of RA is increased by inactivity. Morning stiffness is much less and for short period In contrast to RA, it spares wrist and metocarpophalangeal joints and commonly involves distal interphalangeal joints to produce heberden nodes especially in women. Joint swelling is hard due to bony hypertrophy. Slight effusion may be present particularly in the knee, while in RA joint swelling is soft due to effusion and synovial thickening. It mostly involves weight bearing joints e.g. spine, hip, and knee.

28. Gouty arthritis Intermittent and monoarticular in early years, later it may become polyarticular that mimics RA. Gouty tophi can resemble rheumatoid nodules. Early history of intermittent monoarthritis and the presence of synovial urate crystals are distinctive features of gout.

29. Septic arthritis Sudden onset of acute arthritis usually monoarticular and most often are weight bearing joints and wrists. Fever & chills. Frequent presence of primary focus of infection elsewhere e.g. gonococcal infection, infective endocarditis . I/V drug abuse. Joint effusion are large, with WBC count more than 50000/ microL . Gram stain and culture are mostly positive. Response to appropriate antibiotics.

30. Other D/D are polymyalgia rheumatica , seronegative arthritis, postviral arthritis e.g. hepatitis B & hypertropic pulmonary osteoarthropathy .

31. Management Non- pharmacological treatment Pharmacological treatment Surgical intervention

32. Non- pharmacological management Rest Exercise Heat and cold Splits Weight loss

33. Pharmacological treatment NSAIDs Low dose corticosteriods DMARDs Immunosuppressive drugs

34. Single Choice Questions Q1. A 12yo boy is admitted to the ED following a fall. On examination, there is deformity and swelling of the forearm. The ability to flex the fingers of the affected limb is impaired. However, there is no sensory impairment, imaging confirms a displaced forearm fracture. Which of the nerves listed below is likely to have been affected? Ulnar PIN –posterior interosseous nerve AIN- anterior interosseous nerve Axillary Radial

35. Single Choice Questions Q2. Which of the muscles listed below is not innervated by the median nerve? Flexor pollicis brevis Lateral two lumbricals Pronater teres Opponens pollicis Adductor pollicis

36. Single Choice Questions Q3. A 25 yo man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination, he has lost extension of the fingers in the right hand. Which of the nerves listed below is most likely to have been divided? Median Musculocutaneous Radial Ulnar Axillary

37. Single Choice Questions Q4. Which of the structures listed below articulates with the head of the radius superiorly? Capitulum Trochlea Lateral epicondyle Ulna Medial epicondyle

38. Single Choice Questions Q5. A 27 yo man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply? From its proximal medial border From its proximal lateral border From its proximal posterior surface From the proximal end From the distal end -c

39. Single Choice Questions Q6. Which of the nerves listed below is directly responsible for the innervation of the lateral aspect of flexor digitorum profundus ? Ulnar AIN- anterior interosseous nerve-c Radial nerve Median nerve PIN- posterior interosseos nerve

40. Single Choice Questions Q7. The first root of the brachial plexus commonly arises at which of the following levels? C3 C5-c C6 C7 C8

41. Single Choice Questions Q8. When the brachial plexus is injured in the axilla as a result of a crutch palsy or Saturday palsy or sleep while your partner is tugged in your armpit like cuddling position, which of the nerves listed is most commonly affected? Thoracodorsal nerve Suprascapular nerve Radial nerve -c Ulnar nerve Long thoracic of bell nerve

42. Single Choice Questions Q9. A 21 yo Elman football club player injuries his right humerus and on examination is noted to have minor sensory deficit overlying the point of deltoid insertion into the humerus . Which of the nerves listed below is most likely to have been affected? Radial Axillary -c Musculocutaneous Median Subscapular

43. Single Choice Questions Q10. Which of the following muscles does not attach to the radius? Pronator quadratus Biceps Brachioradialis Supinator Brachialis -c

44. Single Choice Questions Q11. How many phalanges are there in the hand? 10 12 13 14-c 15

45. Single Choice Questions Q12. A 22 yo attends clinic complaining of tingling in his hand. He has radial deviation of his wrist and there is mild clawing of his fingers. With the 4 th and 5 th digits being relatively spared. What is the most likely lesion? Ulnar nerve damage at the wrist Ulnar nerve damage at the elbow -c Radial nerve damage at the elbow Median nerve damage at the wrist Median nerve damage at the elbow

46. Single Choice Questions Q13. Which of the following is not an intrinsic muscle of the hand? Opponens pollicis Palmaris longus -c Flexor pollicis brevis Flexor digiti minimi brevis Opponens digiti minimi

47. Combination Therapy Combination therapy can be considered for patients who failed to respond individual agent The combination of methotrexate chloroquine and sulphasalazine is more effective than methotrexate alone The combination of cyclosporin and methotrexate is more effective than methotrexate alone

48. Newer Therapy Tumor necrotic factor (TNF) inhibitor: It combines with circulating TNF which is one of the major cytokines responsible for inflammation in rheumatoid arthritis etanercept , injected as 25 mg twice weekly show good short-term efficacy and safety for reduction of inflammation. Side effect is local irritation at the site of injection. It is an expensive drug. Interleukins (IL-1 & IL-6) receptor blocker It has been shown to have rapid anti-inflammatory effect

49. Follow-up Ask the patient for severity of joint pain, duration of morning stiffness, fever, fatigue and weight loss. Look for joint swelling, deformities distribution of involved joints and wasting of muscle around the joint. Feel for the warmth & tenderness. Move to assess range of passive movement & muscle power. Examine for extra-articular manifestation Make sure that the patient is taking medicines in proper dosage and assess for the side effects

50. Prognosis The course and prognosis in RA are very variable. After 10 years the disease pattern is as following Complete remission in 25% Moderate impairment in 40% Severe disability in 25% Severely crippled 10%

51. Poor prognostic factors High titers of rheumatoid factor Insidious onset of disease More than a year of active disease without remission Early development of nodules or erosion Extra – articular manifestations Severe functional impairment

52. Surgical procedures in RA and OA Soft tissue release (decompression) Tendon repairs and transfers Synovectomy Osteotomy Excision arthroplasty Joint replacement Arthrodesis

53. Felty’s Syndrome Felty’s syndrome is the association of splenomegaly and neutropenia with rheumatoid arthritis involving less than 1 % of RA patients Age of onset 50-70 F greater than M Incidence less than 1% RA patients Long –standing RA Deforming but inactive disease seropositive

54. Common clinical features Splenomegaly Lymphagenopathy Weight loss Skin pigmentation Keratoconjunctivitis sicca Nodules Vasculitis Leg ulcers Recurrent infections

55. Keratoconjunctivitis sicca

56. Laboratory findings Anemia Neutropenia Thrombocytopenia Impaired T and B cell immunity Abnormal liver function

57. Osteoarthritis Osteoarthritis or degenerative bone disease is the end-result of variety of patterns of joint failure, and is characterized by degeneration of articular cartilage and simultaneous proliferation of new bone, cartilage and connective tissue. Its greatest impact is on weight-bearing joints e.g hips and knees. There are no extra-articular features and no systemic illness

58. Etiology Primary Etiology is un-known Secondary When degenerative joint changes occur in response to a recognizable local or systemic factor

59. Etiology of secondary osteoarthritis Acromegaly Devolopmental hip dysplasia Rheumatoid arthritis Gout Septic arthritis Hemophilia Paget’s disease Gaucher’s disease Corticosteriod use Sickle cell disease SLE Intra-articular fracture Meniscectomy Occupational Ehlers- danlos syndrome Alkaptonuria Hemochrmatosis Wilson’s disease Chondrocalcinosis Tabes dorsalis Diabetes mellitus Syringomyelia Peripheral nerve lesions

60. Pathogenesis Osteoarthritis is a disease of cartilage. Different stimuli can start the degenerative process but the two most obvious are : Mechanical insults e.g trauma Biochemical abnormalities of cartilage (the chondrocytes in cartilage are believed to initiate the deterioration by releasing enzymes that degrade collagen and protogylcan . Break in the collagen fibers allow the uptake of water, as a result cartilage swells and splits)

61. Pathology Progressive cartilage loss until hard bone is all that remains Synovial membrane heavily infiltrated with mononuclear cells Thickening of subchondral bone with cyst formation

62. Pattern of joint involvement Nodal osteoarthritis Non-nodal osteoarthritis Erosive osteoarthritis Osteoarthritis of knees

63. distal interphalangeal joint heberden’s nodes

64. proximal interphalangeal joint ( bouchard’s nodes)

65. Clinical features The joints most frequently involved are those of spine, hips, knees and hands. The disease is confined in one or only a few joints in the majority of patients

66. Symptoms Pain -Typically in the knees, hip, hands. -worst in the evening -aggravated by use and relieved by rest -intermittent at first but later chronic Morning stiffness -usually lasting up to half an hour, stiffness also after sitting Disability -movement in the affected joints becomes increasingly limited, initially as a result of pain and muscular spasm, but later because of capsular fibrosis, osteophyte formation and remodeling of bone.

67. Signs Joint swelling -characteristically hard and bony sometimes with associated effusion Crepitus -on movement may be felt or even heard Muscle wasting -wasting of the muscles around the affected joints Joint deformities -particularly in knee joint,valgus (outward) or varus (inwards) or flexion deformities are seen with instability of the joint due to absence of normal muscular control as a result of muscle wasting

68. Hands Heberden’s nodes -these are bony swelling at the distal interphalangeal joints of the fingers and bouchard’s nodes at the proximal interphalangeal joints. -at first the joints are often red, warm, swollen and very tender (hot- heberden nodes), later the inflammation disappear leaving knobby but often painless swelling

69. Feet The metatarsophalangeal joint is often affected, sometimes called “poor man’s gout”

70. Differential diagnosis Osteoarthritis Distal interphalangeal joint involvement Number of joints involved is less Rheumatoid arthritis - proximal interphalangeal metacarpophalangeal joints involvement Number of joints involved is more

71. Investigation X-ray Narrowing of the joint space: due to loss of the cartilage Formation of osteophytes at the margin of the joints Sclerosis of the underlying bone Cyst formation Blood Blood count & ESR are characteristically normal Synovial fluid -synovial fluid is viscous and has a low cell count

72. Management General measures -weight loss in obese patient -rest and avoidance of undue trauma and physical stress -suitable walking stick -change in occupation to lighter work

73. Drug treatment -there is no drug to reverse the pathological changes. For the symptomatic relief non- steriodal anti-inflammatory drugs (NSAIDs) can be used. Intra-articular corticosteriods can be used for inflammatory exacerbations. Injections should be preceded by aspiration of any fluid in the joint

74. Physical therapy -application of heat may give some relief -proper exercises are useful to maintain muscle power -hydrotherapy for osteoarthritis of hip Surgery -joint replacement and other surgical procedures discussed in the section of rheumatoid arthritis.