Rheumatology

• Osteoarthritis is often described as “wear and tear” in the joints.
• Osteoarthritis occurs in the synovial joints and results from genetic factors, overuse and injury.
• Osteoarthritis is thought to result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint.
• Risk factors for osteoarthritis include obesity, age, occupation, trauma, being female and family history.
• Commonly affected joints in osteoarthritis include hips, knees, distal interphalangeal (DIP) joints in the hands, carpometacarpal (CMC) joint at the base of the thumb, lumbar spine, cervical spine (cervical spondylosis), and fingers.
• Osteoarthritis leads to deformity, instability and reduced function of the joint.
• General signs of osteoarthritis are: Bulky, bony enlargement of the joint, Restricted range of motion, Crepitus on movement, Effusions (fluid) around the joint.
• Signs in the Hands include Heberden’s nodes (in the DIP joints), Bouchard’s nodes (in the PIP joints), Squaring at the base of the thumb (CMC joint), Weak grip, Reduced range of motion.
• The carpometacarpal joint at the base of the thumb is a saddle joint, with the metacarpal bone sitting on the trapezius bone, using it like a saddle.
• Non-pharmacological management involves patient education and lifestyle changes, such as therapeutic exercise, weight loss, and occupational therapy.
• Pharmacological management recommended by the NICE guidelines (2022) are: Topical NSAIDs first-line for knee osteoarthritis, Oral NSAIDs where required and suitable (co-prescribed with a proton pump inhibitor for gastroprotection), Weak opiates and paracetamol are only recommended for short-term, infrequent use.
• NSAIDs (e.g., ibuprofen or naproxen) are very effective for musculoskeletal pain, but must be used cautiously, particularly in older patients and those on anticoagulants, such as aspirin or DOACs.
• NSAIDs should be used intermittently, only for a short time during flares, and have several potential adverse effects, including gastrointestinal, renal, cardiovascular, and exacerbating asthma.
• There is little evidence that opiates help with chronic pain, and they are associated with side effects, risks, tolerance, dependence and withdrawal.
• The WHO pain ladder is not helpful in chronic pain, and paracetamol and opiates are not recommended for regular use in osteoarthritis.
• NSAIDs cause hypertension by blocking prostaglandins (prostaglandins cause vasodilation) and should be used very cautiously with a history of high blood pressure.
• The four key x-ray changes in osteoarthritis can be remembered with the “LOSS” mnemonic: Loss of joint space, osteophytes (bone spurs), subarticular sclerosis (increased density of the bone along the joint line), and subchondral cysts (fluid-filled holes in the bone).
• X-ray reports might describe findings of osteoarthritis as degenerative changes.
• Osteoarthritis presents with joint pain and stiffness, which tend to worsen with activity and at the end of the day, in the reverse of the pattern in inflammatory arthritis, where symptoms are worse in the morning and improve with activity.
• Psoriatic arthritis is an inflammatory arthritis associated with psoriasis.
• Psoriatic arthritis can vary in severity from mild stiffening and soreness in the joints to complete joint destruction in arthritis mutilans.
• Reactive arthritis involves synovitis in one or more joints in response to an infective trigger.
• Psoriatic arthritis occurs in 10-20% of patients with psoriasis, usually within 10 years of developing the skin condition.
• Reactive arthritis typically causes acute monoarthritis, affecting a single joint (most often the knee), presenting with a warm, swollen and painful joint.
• Arthritis can occur before the skin changes.
• Psoriatic arthritis is most common in middle age but can occur at any age.
• A significant differential of reactive arthritis is septic arthritis, where an infection is inside the joint.
• Patients with reactive arthritis do not have an infection in the joint.
• Psoriatic arthritis is part of the seronegative spondyloarthropathy group of conditions.
• Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation in the synovial lining of the joints, tendon sheaths and bursa.
• The most common triggers of reactive arthritis are gastroenteritis or sexually transmitted infections.
• Psoriatic arthritis may be associated with extra-articular manifestations, particularly uveitis and inflammatory bowel disease.
• Rheumatoid arthritis is a type of inflammatory arthritis.
• Chlamydia may cause reactive arthritis.
• Gonorrhoea typically causes septic arthritis rather than reactive arthritis.
• Synovial inflammation in rheumatoid arthritis is called synovitis.
• Reactive arthritis is a seronegative spondyloarthropathy.
• There are 5 recognised patterns of psoriatic arthritis: asymmetrical oligoarthritis, symmetrical polyarthritis, distal interphalangeal arthritis, arthritis mutilans, and psoriatic arthritis pustulosis.
• There is a link with the HLA B27 gene.
• Ankylosing spondylitis (AS) is an inflammatory condition affecting the axial skeleton, mainly the spine and sacroiliac joints, causing progressive stiffness and pain.