2 The plan Overview of Osteoarthritis and Rheumatoid arthritis Case scenarios 1 and 2Symptoms and signsClinical findingsEpidemiology/ Risk factorsManagement
3 Case scenario 1A 67 year old lady comes to see you complaining of increasing pain in her handsWhat do you do?HistoryExaminationManagement
4 HistoryMostly affects her thumbs but also the small joints of her fingers.Pain is worse at the end of the day and after she has been gardening.Noticed slight swelling of her joints. Pain eased by paracetamol when at its worst.PMH - Hypertension (amlodipine 5mg.)No alcohol; doesn’t smoke. Retired secretary.
8 Examination findingsHands are not grossly deformed although she does have a mild Z shaped deformity of the thumbNo skin lesions at her elbows or behind the ears.Generally tender over all PIPs and DIPs with some hard swellingsShe can do up buttons and write her name, although this causes some discomfort
9 What are your differential diagnoses? OsteoarthritisRheumatoid arthritis
10 What investigations would you like? Bloods – ESR?X-rayWhat x-ray changes would you expect?
11 May be none… or…. Subchondral sclerosis Joint space narrowing OsteophytesZ-deformityMay also get subchondral cysts in late/severe OA.
12 OA of hands Usually as part of nodal osteoarthritis Mainly women > 40s or 50sUsually base of the thumb and DIPsJoints may be swollen and tenderFunction usually goodLinked with increased risk OA knee.Nodal OA likely to be passed mother to daughter.
13 Osteoarthritis in general Weight bearing joints – knees, hipsUse – shoulders, handsSpine (especially C-spine)
14 Who? > late 40s - “wear and tear” Female Family hx OA Overweight Previous joint injury/operationPhysically demanding job – repetitive movementsJoint abnormality eg Perthes’PMH – gout, Rheumatoid arthritis
18 Case scenario 2A 34 year old lady comes to see you giving an 8 week history of pain affecting the small joints of her hand.What do you want to know?
19 continued Pain and stiffness worst first thing in the morning Improves after about 1hourGeneral malaiseNoticed her hands are slightly swollenPMH – nilDH – OCPWhat else do you want to know?Smokes 10/day; <14units alcohol/weekOccupation = SecretaryGrandmother had problems with her hands
20 Examination What might you find? What else should you look for/check? Slight swelling over MCP and PIP joints both handsTender on palpationNo obvious deformityWhat else should you look for/check?Temp 37.5No skin changes elbows or scalpRight eye slightly red around cornea – not painful
22 What is Rheumatoid arthritis? Definition“a multisystem autoimmune inflammatory condition that typically affects the small joints of the hands and feet”
23 Symptoms and signs Differentiate OA from RA Worse in morning Morning stiffnessSmall joints of handSymmetricalMCPs and PIPs > DIPs
24 Typical hand signs? Ulnar deviation of fingers DIPs spared Guttering of MCPsWasting of intrinsic hand musclesCarpal tunnel syndromeBoutonniere = button hole = because of tendon injury/damageSwan neck = because hyperextension of PIP and flexion of DIP = caused by a lax volar plate
25 Other bony features? C- spine Feet Cervical subluxation Neck pain Atlanto-axial instabilityFeetSubluxation of metatarsal headsClaw toes
26 Diagnostic criteria of RA Diagnosis can be made if these are all present:Inflammatory arthritis involving three or more joints.Positive RF and anti-CCPRaised CRP or ESRDuration of symptoms > six weeksExcluded similar diseases:Psoriatic arthritisAcute viral polyarthritisGout/psuedogoutSLE
29 What does the patient want? I – what does she think it is?C – what is she worried/concerned about/how is it affecting them?E – what does she want from you today?Patient is concerned that she has been late to work recently because of disruption to her morning routine
30 SO WHAT ARE YOU GOING TO DO FOR HER? InvestigationsBloodsFBC, U+E, LFTs, ESR, CRP, RF, anti-CCPImagingX-ray findings?
31 “Pencil in cup” deformity Loss of joint spaceDeformitySoft tissue swelling“Pencil in cup” deformityBony erosionPeriarticular osteopaenia
34 Biologics (after failure to respond to 2 DMARDS) Anti-TNF alphaInfliximab, Adalimumab, EtanerceptWhat test should be done prior to starting biologics?Side effectsAllergic reactions; TB reactivation; increased risk infection