inflammation of the enthesis. the enthesis is where the tendon inserts on the bone
in AS when are sxs worse?
in the AM better with exercise
Criteria for AS
dx based on LBP sxs >3 months and : elevated ESR or CRP +HLA B-27 (not specific) -symmetrical sacrolitis -diminished chest excursion -limited spinal ROM + schober's test (<5 cm sig) -extra-articular fx - uveitis,aoritis
RA has to be present how long to be RA?
does having HLA b-27 make the dx for AS?
NO. its not speicifc what makes it? HISTORY. right age group, sacrolitis, lbp hx
Late changes of AS on the xray will show what classic sign?
AS travels from ____ to ____ over time
SI joint to elevation
AS patients can't do what?
can't touch their toes. loss of flexibility of the spine due to sclerosis. tests with SCHOBER'S test.
It's not the ____ that is involved but the ______ that fuse in AS
It's not the disc space that is involved but the ligaments that fuse in AS
When there is no give to the spine, as in AS, you worry about what with trauma?
Fracture. increased in these patients.
Whats the best tx for AS?
indocin its lipid soluble and fast acting
What does work in AS as well other than indocin?
TNF INHIBITORS (ETANERCEPT, INFLIXIMAB, Humera )
Remember no drug restores __________
What comes first psoriasis or arthritis ?
psoriasis in 85 perfect of pts
Psoriatic arthritis involves the _________ and has a _______ which helps differentiate it from other arthropathies
spine :) and has a rash.
what is classic of psoriatic arthritis?
oligoarthritis (4 joints or less) and asymmetrical (sausage digits-dactylitis)
Sometimes psoriatic arthritis are like RA but you distinguish how?
skin manifestations and the pattern will show you.
What disease processes worsens PA? Sexually active male with multiple partners with abruput PA and no family history....
HIV. thus we must HIV test patients sexually active with PA.
What nail changes will you see in psoriasis?
onychomycosis and pitting.
What is the classic deformity on the fingers of psoriatic arthropathy?
pencil in cup deformities due to bone resorption
what drugs do you use for PA?
similar to RA methotrexate and biologics (TNF inhibitors)
NEVER prescribe what for PA?
oral steroids-- initially does great but as your taper you get erythroderma PA (crisis)
Reiter's syndrome is also known as what?
what is reiter's triad?
oligoarthritis urethritis conjunctivitis
what is reiter's associated with?
what lesions with you see in reiters?
keratoderma blenorrhagicom (blisters on feet ) and mucus membranes (balanitis)
can also have nail changes, knee efusion, and inflammation of the Achilles tendon
dx is made based on what?
in parvovirus b19 patient comes in had child that was sick how do you diagnose
IgM for B-19 and history
Enteropathic arthritis is what
enteropathic arthropy patients have some ____ problem that presents first
antibodies attack the joint space and its called what?
molecular mimicry- lost immune protection and initial antigen can't tell difference between the disease and the joint.
what are the drugs for enteropathic?
methotrexate, TNF and steroids. CHECK HIV!
at what level does uric acid precipitate and crystallize?
6.8 or greater.
what drugs block the distal convoluted tubule so they don't allow the elimination of uric acid?
DX BY NEGATIVELY(YELLOW) BIREFRINGENT NEEDLE-SHAPED CRYSTALS
What is a genetic predisposition to gout? what is the enzyme that is lacking?
lesch-nyhan syndrom HGPRT
what is the classic presentation of Gout?
monoarticulation of the padagra. red and hot. can migrate.
Gold standard for diagnosis gout
must prove the crystal formation, or a tophus contiaining urate crystals.
there has to be have evidence of crystals.
Why can't you use allopurinol or uloric during an acute gout attack?
During an acute attack that is not the time to introduce long term therpy Allopurinol and uloriic which would cause more uric acid out of the tissue and you will worsen their attack
What do you use to treat acute gout attacks?
symptomatic therapy COLCHICINE NSAIDs: INDOCIN STEROIDS: INTRARTICULAR OR ORAL
Chroic gout is treated with?
allopurinol or uloric
What do tophi feel like?
which is more common gout or psuedogout?
what are the key diagnostic characteristics of psuedogout?
CHONDROCALCINOSIS ON X-RAY POSITIVELY BIREFRINGENT(BLUE) ROD or RHOMBOID-SHAPED CRYSTALS
What is the classic triad of dissemmnated gonococcal infection?
from immunoglobulins binding together and your immune system that is tryign to encapsulate this and then walking on it. Its like a pebble in your shoe.
Whats the difference between a rheumatoid nodule and an effusion of the elbow when they both look alike?
effusion is fluid rheumatoid is rubbery.
A DAS28 score measures what?
disease activity of RA
A score greater than ____ implies active disease. Less than ____ is well controlled and less than _____ is remission
5.1 3.2 2.6
The majority of patients with RA have what kind of course/prognosis?
polycyclic with relapses
How much shorter withe life span of an RA patient?
2 years shorter MC causes of death: infections and cardiovascular disease
Steinbrocker's RA functional classification would rank a patient who can perform self-care but limited in both vocatoinal and avocational acitivities as what class?
What DMARDS is the first line for RA?
What directions should you give to a patient taking methotrexate?
take on an empty stomach
What is tocilizumad (acemra) directed against?
IL-6 receptors. used to treat moderate to severe RA
JIA is seen in patients of what age
less than 16
what is the criteria for JIA?
less than 16 and exclusion of other causes of childhood arthritis. ANA is positive commonly.
in OA what is being attacked?
What is the "gelling phenomenon" in OA?
Most common phenomenon seems to be difficulty initiating joint movement after inactivity, epitomized by the problem older people with OA have in getting started after sitting down a while.
What are the nodes that are formed in OA and where are they located?
Herbeden's (DIP) Bouchards (PIP)
OA has what joints involved?
cervical spine, lumbar spine, hips, knees, pip, DIP, big toe
in OA or RA is the elbow involved?
In OA or RA is the hip involved
What will you see on xray with OA?
bony sclerosis loss of cartilage osteophytes
DISH has what kind of appearance grossly?
candle wax dripping down the spine
Unline Spinal Stenosis and lumber arthrosis what is preserved in DISH?
intervertebral disk space
For maximal joint relief what two things can be used together?
glucosamine and CSO4
what joint is most responsive to the Glu/CSO4 combination?
knee with moderate to severe OA pain
Calcium is essential for?
Muscle contraction Nerve function Blood clotting, and many other functions
T/F Bones have priority over serum calcium levels.
false. Serum has priority over bone!
bone softening from excessive resorption of Ca+ from extracellular bone matrix
Where is calcium absorbed in the digestive tract?
in duodenum & jejunum (proximal SI)
How is calcium excreted?
75% bowel 25% kidney
How are phosphates excreted?
25% Bowel 75% Kidney
so remember calcium-bowel. phosphate-kidney. don't let her trick you.
PTH causes an upregulation of what type of bone cells?
what controls absorption and deposition of calcium in bone?
when calcium is low what is released?
When PTH is released what response is then given in response to hypocalcemia?
Osteocytes release calcium stored in the lacunar spaces
what is the active form of vitamin D?
1,25(OH)2 Vit D3
What secretes calcitonin?
thyroid gland C-cells
Osteoperosis is common in who?
white or asian smoking women with a fracture history that are <127 pds that are older and really skinny.
Testosterone, estrogen and progesterone are bone_______
thus a lack of any of these can make u more likely for osteoporosis
what is the most serious complication of osteopersosi?
How do we diagnose osteoperosis
The gold standard in detection has been bone mineral density measurement. BMD can detect osteoporosis before a fracture occurs so that treatment to prevent fracture can be initiated. It can also predict future fracture risk and DXA (dual energy x-ray absorptiometry) BMD measurements have the additional advantage of measuring the rate of bone loss. This is helpful when monitoring the effects of therapy.
Patient has a T score of -1.9 how would you classify that?
osteopenic. -1 to -2.5
osteoperosis is for which range for t scores?
-2.5 or lower.
If a patient has a score of -3.0 and a fx what would you classify them as?
Who gets a BMD scan?
>65 y/o women >70 y/o men youngr postmenopause women and men with one or more risk factors presence of fragility fx loss of height >1.5 inches
BMD testing shoudl be every 2 years in these patients:
Estrogen deficient women at risk for osteoporosis Individuals with vertebral abnormalities Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy Individuals with primary hyperparathyroidism Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy
what does the FRAX tool for?
used by the WHO to determine fracture risk.
are biomarkers helpful in diagnosis of osteoperosis?
NO. they are just helpful for monistorying patients treated with antiresoptive agents
what is the bioactive from of vitamin D
what type of exercise should you promote for prevention and tx of osteoperosis
weight bearing and resistance training
What are some other things you can teach for your patients?
balance, fall prevention and safety.
What is first line tx for osteopersosis?
how do bisphosphanates work?
they cause apoptosis of osteoclasts
if they can't tolerate bisphophanates and are 5 years postmenopausal what should you give
calcitonin. (nasal spray or subcu)
Paget's disease is an upregulation of what cells?
osteoblastas and clasts but in a disproportinate way causing irradic, woven bone
who is pagets common in?
males over 50
What do you commonly see in pagets?
enlarged Skull, tinnitus and bowed legs
What is characteristic with pagets?
salt and pepper pattern on xray. abnormal alkphos
what is the MC complication of pagets?
osteogenic sarcomas (bone tumors)
bone scan is _______ but not ______ in pagets.
sensitive but not specific
first line for pagets?
What are the 5 categories of non articular rheumatism?
Myofascial pain can manifest in many ways. How does it affect the digestive tract?
nonarticular rheumatism is most common in persons aged
Persons with inflammatory syndromes experience pain _______movement and may have signs of __________ and __________
during swelling redness
Persons with noninflammatory syndromes experience pain _______movement, during _______.
Criteria of fibromyalgia
Chronic widespread pain in all 4 quadants of the body (above and below the waist, left and right sides) >3 months duration.
Fibromyalgia is most common in who?
what are the defining characteristics of fibromyalgia?
pain and tenderness
hypothyroidism and polymyagia rheumatica often mimic fibromyalgia. How do you differentiate?
TSH and ESR
What are the 9 trigger points of the body
occipital lower cervical (C5-7) trapezius rhomboid (medial scapula) pectoralis lateral condyle of the elbow sacroiliac trochenter medial aspect of the knee
Do you give pain meds to fibromyaglia patients?
What is tx for fibromyaglia?
TCA SSRI Antiepileptics but non opoids
Chronic fatigue syndrom is characterized by?
a reduction of atleast 50% of ADLs. without other explanantion for one year or more and accompanied by cognitive difficulties.
usually CFS patients have a _________ ______ which subsides but then the fature continues for a year or more after.
How do you dx CFS?
its a diagnosis of exclusion
What lab may be low?
ESR (0 to 3 mm/hr) not increased as there is no inflammation
What will you see on PE of CFS?
crimson crescents purple/crimson discoloration of both anterior tonsillar pillars in the abscence of pharyngitis
shotty adenopathy (neck axilla, inguinal)--> pea sized rubbery mobile nodes
CFS syndrome patients should have rst, moderative activity, and run marathons?
no. rest, moderate activity, no exercise
Polymyalgia Rheumatica is widespread aching and stiffness that likes what region?
limb girdle muscles in older adults
what can PMR occur with?
giant cell arteritis
Most common patient with PMR?
>50 (70-80) white women.
What is almost diagnostic of PMR?
prompt and complete response to low dose corticosteroids (24 to 48 hrs)
What is the typical complaints of a PMR patient?
pain worse in morning stiffness after long car rides difficulty getting dressed in the morning or in a low chair.
What is the Gold standard for diagnosing PMR?
ESR and CRP elevation
What is given to PMR patients?
10-15 mg of prednisone that is then tapered slowly to 5-7.5 mg
how long do you give corticosteroids to PMR patients?
some can stop within a year but most go for 2-3 years.
What is the criteria for joint hypermobility syndrome?
A beighton score of 4/9 or greater (current or historically) arthralgia for 3 months or longer in 4 or more joints
Beighton criteria gives 2 points if bilateral for the following:
-hyperextension of elbows (10 degrees or more) -touch passively, the forearm with the thumb, while wrist is in flexion -passive extension of the 5th finger, more than 90 degrees -hyperexctension of the knees (10 degrees or more)- genu recurvatum -touch the floor with the palms, when bending over with knees extended
tendonitis can be caused by suddent intense injury but is most often the result of a reptitive minor injury of the affected area that is reproducible on _______
deep bursae are found where?
between bones and overlapping muscles i.e. subscromial and illiopsoas bursae
superficial bursae are found where?
between bones and tendons/skins i.e. olecranon and prepatellar bursae
What are some causes of bursitits?
repetitive use, trauma, infection, or systemic inflammatory disease
TMJ a _________ joint that connects the jaw to the skull
TMJ most commonly found in
females that are 20-40.
Can you see bursitis or tendonitis on xray?
no but it will exclude other joint/bone problems.
blood tests plus MRI and diagnostic u/s are helpful but not required.
On occasion, cortisone shots to the inflamed area (_____________ or ________ ) may be helpful for tendonitis/bursitis
tendon SHEATH or bursa
When do you do labs with TMJ?
when other diseases are suspected such as RA or gout.
Carpal tunnel is the entrapment of what nerve?
is carpal tunnel a diagnosis
not usually. its usually a manifestation of an underlying process.
in servere cases of carpal tunnel what is done?
carpal tunnel release sx
Thoracic outlet syndrome is defined as what?
compression of the neurovascular structures in the area just above the first rib behind the clavicle.
What is the most common facet of thoracic outlet?
what are the 3 causes of thoracic outlet syndrome?
bony factors soft tissue factors trauma
Tietze syndrome is characterized by what?
costocondritis has NO palpable edema/swelling. true or false?
both tietze syndome and costochondritis are characterized by chest wall tenderness mostly which ribs?
RSD is actually which type of CRPS?
type 1 excessive sympathetic reaction of the joints and periarticualr soft tissues to any insult.
what is type 2 CRPS?
causalgia.its from partial nerve injury where the nerve is inflamed or irritated
what is seen on radiographs with CRPS?
Patient comes in after stubbing his toe 12 days ago. He describes the pain as burning, shooting and aching. The patient seems to be sweating perfusely. His toe seems to be swollen, cool, blue and damp. He is insensitive to heat and cold. On xray there is no bone break but osteopenia seems to be evident. What does this patient have?what phase?
CRPS phase 2.
tendon joinging to bone
What type of strength do minerals provide?
What type of strength does collagen type 1 provide
What is released as bone is broken down?
bone builders (ossification)
chemical exachange pathway in the lacunae
bone absorption (move over bone) uses acidophillic cytoplasm to remove old bone and forms puts for laying down new bone
What are the two major types of matricies?
interstitium and basement membrane
mesenchymal cells and forms the stroma of organs
thin sheet like membrane comprised of endo- and epithelial cells.
provides mechanical support, forms a semipermeable filtration barrier (kidney,placenta) regulates cell attachment, migration and differentiation
Collagen type 1
skin tendon bone
collagen type II
Where is hyaline cartilage found?
lines the joints
Collagen provides ____% of the cartilage matrix
Whats great about hyaline cartilage?
allows movement without damage
Crystals are desposited where in cartilage?
on the surface of type II collagen
Crystals are deposited where in bone?
within the fibrils and on the surface of type I collagen
Fibrocartilage has a ______ _________ feel. and is found where?
soft leathery pubic symphysis, cranium, rib cage
What is ground substance?
type II collagen, elastin, proteoglycans
What is the tide line?
interface where synovium and bone meet. disappears with cellular maturation
Is the tideline present during skeletal growth?
Type A synoviocytes
phagocytose actively cell debris and waste of synovial fluid.
type B synoviocytes
nutritional value of synovial fluid
What are the 2 methods of lubrication?
boundary lubrication and weeping lubrication
What does boundary lubrication use?
what does weeping lubrication use?
What color is normal synovial fluid?
clear to pale yellow
Monosodium urate crystals
fine, needline like NEGATIVELY yellow biferingent.
short, rhomboid POSITIVELY blue biferingent
transluscent and appear as stacked panes of glass
--> hyperlipidemic state
cannont be seen w/o EM or Alizarin red stain
--> milwakee shoulder (hydroxyapatite crystals in the joint because bone rubbing on bone )
Patient presents with pain worse in the Am, warmth over extremeties, morning stiffness for 2 hours and elevated ESR/CSP. do they have inflammatory or noninflammatory complaints?
where can you have rheumatic signs and symptoms that you wouldn't really expect?
ocular- sicca, visual loss, conjunctivitis
oral-gential ulcers, herpes
Patient is able to move against gravity but not against resistance during muscle strength testing. What level would you grade them?
Normal muscle strength is rated as?
When do you do arthrocentesis?
any undiagnosed mono- or poly-arthritis with an efusion. suspected infection suspected crystalline arthritis