year 5

template
condition*
basic science
aetiology/epidemiology
pathology
presenting features
investigations
differential diagnosis
principles of management
complications and outcome
prevention
initiate appropriate action
prescribe
how/who to refer to

condition
basic science
aetiology/epidemiology
pathology
presenting features
investigations

differential diagnosis
principles of management
complications and outcome
prevention

blood
cardiovascular
musculoskeletal
osteoarthritis
basic science

degenerative joint disease - osteoarthrosis

erosion of cartilage (fragmentation/fibrillation of surface) leads to
secondary changes in underlying bone
cystic lesions and osteophytes
osteophytes cause heberdens nodes and cervical spondylosis
eburnation = bone:bone articulation

aetiology/epidemiology

females>males
the elderly
genetics esp. generalised nodal
occupation, trauma

pathology

primary
o classic: one/two weightbearing joints
o generalised nodal: middle-aged womens fingers
secondary: following an insult
o bone: infection, Pagets, aseptic necrosis
o cartilage: infection, RA, gout
o dynamics: fracture, abnormal load, acromegaly, charcots joints
endemic: Kashin-Beck, Mseleni

presenting features

pain on movement and crepitus, worse at end of day

joint gelling
instability
clinical dx if
o >45
o activity related joint pain
o none / <30mins of morning stiffness
heberdens, bouchards

investigations

X-Ray
o LOSS

CRP may be

Loss of joint space

Osteophytes
Subarticular sclerosis
Subchondral cysts
raised

differential diagnosis
septic arthritis, gout, rheumatoid, malignancy

principles of management

conservative
o aids e.g. walking stick
o exercise
o analgesia and NSAIDS
PCM and topical NSAIDS
Oral NSAIDS, COX2i, opioids
o intra-articular steroid injections
o TENS
surgical unremitting pain and progressive disability
o osteotomy: corrects deformity, changes bone shape, relieves pain
e.g. closing wedge, opening wedge
o joint replacement over 60s

partial: elderly and frail / one joint compartment

total: both articular surfaces concave polyethylene, convex
metallic +/- acrylic grout
arthrodesis: irreversible fusion
spine, tarsus, wrist
where loss of movement does not produce unacceptable
immobility
excision arthroplasty: girdlestone hip
arthroscopy: joint washouts (washout alone is not a treatment for
OA), debridement, cartilage shaving, biopsy

o
o

complications and outcome

prevention
weight loss, occupational

rheumatoid arthritis
basic science

systemic chronic inflammatory disorder invariably involving joints

chronic inflammation and proliferation of synovium erodes articular
cartilage
many systemic features

aetiology/epidemiology

females > male

75% HLA-DR4 positive
most have rheumatoid factor

pathology

articular cartilage eroded by inflammation

joint capsule swells and cartilage is lost
synovial hyperplasia and adjacent osteoporosis

presenting features

symmetrical swollen painful and stiff small joints of hands and feet
worse in morning
+/- larger joints
also:
o sudden onset widespread arthritis
o palindromic RA: recurring mono/polyarthritis
o persistent monoarthritis: often knee, shoulder, hip
o systemic illness with extra-articular symptoms
o recurrent soft tissue problems e.g. frozen shoulder, carpal tunnel
early: inflamed joints, tenosynovitis, bursitis
late: deformities, hand extensor tendon rupture, atlanto-axial subluxation
(rare)
extra-articular:
o subcutaneous nodules
o lymphadenopathy
o anaemia of chronic disease
o vasculitis
o lungs: fibrosing alveolitis, obliterative bronchiolitis,

o
o
o
o
o

Raynauds
splenomegaly
eyes: uveitis, scleritis
amyloid
Sjgrens

investigations

Rheumatoid factor positive in 70%

ACPA highly specific for RA
anaemia, raised CRP/ES/plt
X-ray:
o soft-tissue swelling
o juxta-atricular osteopenia
o reduced joint space
o later: erosions, subluxation, carpal destruction
US and MR better at identifying synovitis and detecting erosions than XR

diagnosis

test those with 1 or more joints with swelling not better explained by
another disease
A-D score 6+ is diagnostic
o A: joint involvement (number of)
o B: serology (anti-CCP/RF)
o C: acute phase reactants (CRP/ESR)
o D: duration (6 weeks+)

differential diagnosis
principles of management

DAS28 for monitoring aim for <3

early DMARDS and biologics improves outcomes
steroids for acute exacerbations IM, intra-articular, oral
NSAIDs for symptom control
specialist physio and OT

drugs
1. DMARDs - start within 3 months.
a. methotrexate, sulfasalazine and hydroxychloroquine combo
b. others leflunomide, IM gold.
*immunosuppression, pneumonitis from MTX
2. Immunologics specialist initated

a.
b.
c.
d.

TNF e.g infliximab, etanercept

B-cell depletion: rituximab
IL-1 and IL-6 depletion: tocilizumab
T-cell function disruption: abatacept
* serious infection, TB HBV reactivation, worsening heart failure,
hypersensitivity, local reactions, blood disorders.

complications and outcome

increased risk of CV and cerebrovascular disease as atherosclerosis

accelerated
10% severe disability
20% mild symptoms
rest in between
infections more common do blood cultures

in children

stills disease many forms of jeuvenile chronic arthritis, only some similar
to adult
disease remits in 75%

nervous
ear
eye
nose
skin
throat and mouth
psychiatry & mental health
gum
female
male
respiratory
substance abuse
trauma
urinary