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106 Cards in this Set

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when does gout have a peak incidence in men
50's
what is the MC cause of inflammatory arthritis in men over age 30
gout; hyperurecemia and deposition of urate crystals cause attacks of inflammatory arthritis (tophi can also tubular and interstitial dz in the kidneys)
what is the upper limit of uric acid levels (point at which gout CAN develop)
-above 7 mg/dL for men (above 6 for women)
-gout can dvlp at lower levels though
why do women have lower normal values of uric acid than men (before menopause)
-bc the estrogen levels promote renal excretion of uric acid
how is uric acid formed in the body
-Hypoxanthine is converted to Xanthine using Xanthine Oxidase
-xanthine is coverted to uric acid using xanthine oxidase
what enzyme do humans lack that predispose us to gout
-they lack uricase that oxidizes uric acid to allantoin
what organ excretes uric acid from the body
-kidney
-the rest is oxidize by bacteria in the gut
why do urate crystals deposit in the ears and toes
-the lower temperatures of the peripheral structures cause the urate crystals to have decreased solubility
how does gout look on radiograph
-periarticular erosions (may have an overhanging edge or punched out lesion)
what are the 4 classifications of gout
-primary
-secondary
-overproducer
-unders secretor
what is primary gout
-uric acid levels are high due to disorders of uric acid metabolism
what is secondary gout
gout is a minor clinical feature secondary to a number of genetic or acquired diseases
what class of gout to most pts with hyperurecemia have (primary, secondary, overproducer, under secretor)
-90% are under secretors
list some diseases that cause secondary gout
-those in which there are excessive rates of cell turnover (myeloproliferative and lymphpproliferative disorders, hemolytic anemias, psoriasis)
name a cause of prmary gout
-HGPRT deficency (part of Lesch-Nyham syndrome of spasticity, mental retardatiion, self mutilation)
name other commonly affected areas of the foot of gout
-ankle, tarsal area and knee
affected gout joints are red, hot, swollen; what can this be confused with
-cellulitis or thrombophlebitis
with the exception of arthritis, what is the MC complication of gout
-renal disease
-pts can dvlp uric acid kidney stones
describe the bony erosions of gout on xray
-boney erosions tend to be round with sclerotic margin and have been described as rat bite, cyst like or punched out
-martels sign
how can you distinguish gout from other arthrides from radiographs
-gout has destructive lesions in the bone that are remote from the articular surface
what is Martels sign
-gout lesions with overhanging margins
what is mandatory for a diagnosis of gout
-synovial fluid monosodium urate crystals
-needle shaped with negative befringence (bright yellow)
what lab values can be elevated during a gouty attack
-synovial fluid leukocytes
-uric acid level (maybe)
-ESR
-WBC
treatment of acute gout
Colchicine, NSAIDS,
Mechanism and dose of colchicine for acute gout
-inhibits inflammation, inhibit microtubule formation
-0.5 mg taken hourly until pain reduction, max 8 mg per day
what is colchicine given in small incremental doses
-to limit GI issues
MC NSAID for acute gout
-indomethacin
Indomethacin dose for acute gout attack
50 mg PO tid
Tx choices for chronic gout
-colchicine, allopurinol, uricosurics (probenicid, sulfinpyrazone)
allopurinol dose for chronic gout
-300 mg po once or twice a day
what drugs can cause gout
-salicylates
-diuretics
-TB meds
-warfarin
-nicotinic acid (niacin for high cholesterol)
what deposits in the joints with pseudogout
-Calcium pyrphosphate dihydrate crystal
how can CPPD (calcium pyrophosphate dihydrate crystal disease) be diagnosed
-calcium pyrophosphate crystals in the synovial fluid
-needle or rhomboid shape
-positive befringence
disease of the nerves that leads to underlying bone and joint abnormalities
charcot - neuropathic osteoarthropathy
describe the French Theory of charcot
-neurovascular theory; damage to nerve centers with an alteration of sympathetic control of blood flow to bones and joints leads to persistent hyperemia and active bone resorption
describe the German theory of charcot
Neurotramatic theory; extreme progression of degenerative joint disease following loss of proprioception and protective sensation
MC causes of Charcot
-DM (#1)
-syringomyelia
-tabes dorsalis
what is syringomyelia (common cause of charcot)
-damage to the spinal cord due to a fluid filled sac
clinical presentation of charcot
-red, hot swollen joint
-deformed, unstable/hypermobile joint
--decreased sensation
-atrophy of intrinsics
-diminished reflexes
-spontaneous fractures/dislocations
-palpable pulses
-rocker bottom foot
-possible ulcers over dislocated/displaced bony prominences
list the 3 stages of charcot development
1. acute or developmental
2. coalescence
3. reconstruction
describe first stage of charcot
-Acute or developmental: joint laxity, subluxation, osteochondral fragments
2nd stage of charcot
coalescence; absorption of debris and fusion of bony fragments
3rd stage of charcot
reconstruction: remodelling nad revascularization of bony fragments
DDx for charcot
-acute septic arthritis
-OM
-CPPD crystal depostion dz
-Osteonecrosis (AVN)
-PVN synovitis
-gout
-psoriatic arthritis
-RA
conservative tx for charcot
-NWB, compression (jones) cast to control edema, cast immobilize for fractures, long term accomodatve footwear
surgical tx for charcot; when and what
-not performed in acute phase
-ulcer excision
-exostectomy
-resections
-lisfranc, triple, pantalar arhtrodeses
-amputation
a spirochete is a bacteria, which tick carries this spirochete bacteria (Borrellia burgdorferi) that can cause Lyme disease
-Ixodid ticks
Lyme disease has three stages; early, intermediate and late; what happens in early
-early(3-32 d incubation): erythema chronicum migrans occurs at the site of the bite (warm, painless and bullseye)
-low grade fever
-lymphadenopathy
Lyme disease has three stages; early, intermediate and late; what happens in intermediate
-1-6 months after initial exposure
-arthritis, nerve or cardiac involvement (AV block)
Lyme disease has three stages; early, intermediate and late; what happens in late
-CNS involvement (encepahalopathy, axonal polyneuropathy)
--arthritis
Tx for Lyme Dz
Doxycycline 100 mg po bid
**during the inital 24 hours of abx therapy, some pts experience Jarisch-Herxheimer reaction characterized by high fever and worsening of symptoms)
Lyme disease is a triphasic illness with stage 1 (intial weeks), stage 2 (weeks to months), stage 3 (months to years)..what are the main symptoms of each stage
stage 1: erythema chronicum migrans
stage 2: recurrent skin lesions, neurologic and cardiac abnormalities
stage 3 : arthritis
Inflammatory arthritis is inflammation of the joint lining from an immune system problem or autoimmune disease (versus degenerative arthritis): list some inflammatory arthritis
-RA
-lupus
-ankylosing spondylitis
-reiters
-psoriatic arthritis
joint pain first thing in the morning or after sitting for awhile
-inflammatory arthritis (like RA and Reiters)
joint pain at the end of the day
destructive arthritis (osteoarthritis)
immune system attacks the synovial lining of joints causing inflammation, affecting the small joints in the hands and feet first
-RA (synovitis is the inital symptom or sign)
what are some articular manifestations of RA
-pannus formation
-swan neck
-boutonniere
-hallux valgus
-hammerotes
-fibular/ulnar deviations
-even joint space narrowing
how does pannus in RA form and what does it cause
-it is the formation of proliferative and invasive granualtion tissue
-the pannus then leads to perisrticular bone and cartilage erosions and destructions
what are some extra-articualr manifestations of RA
-rheumatoid nodules
-caplans nodes in lung
-vasculitis
-pericarditis
-anemia
-dry eyes and scleritis
what is the IPJ flexion deformity in RA called
-boutonniere deformity
what is IPJ extension deformity in RA called
-swan neck
if performing sx on an RA pt, what additional preop tests are needed
-cervical xray due to C1-C2 dislocations
lateral deviation of the digits and erosion of met heads
RA
what is Felty's syndrome and when is it seen
-triad of neutropenia, splenomegaly and RA
morning stiffness that lasts at least 1 hour
RA
to dx a pt with RA, they need to meet 4 of 7 criteria. list the 7
1. morning stiffness
2. arthritis of 3 or more joints
3. arthritis of hand joints
4. symmetric arthritis (same joint on opp sides of body)
5. rheumatoid nodules
6. serum rheumatoid factor
7. radiographic changes of hand and wrist (erosions or decalcification near joint)
name 3 diseases assoc with RA
-sjogrens syndrome
-amylodosis
-feltys syndrome
drug therapy for RA
-DMARDS (gold salts, plaquenil, methotrexate, TNF inhibitors)
-humira is a TNF inhibitor
list 7 special considerations that need to be taken into account if operating on an RA patient
1. give them supplemental corticosteroids
2. discontinue aspirin or NSAIDS they are on
3. lateral cervical spine xrays
4. protect the skin during surgery
5. inc risk of infection
6. delayed wound healing
7. DVT prophylaxis
why do RA surgical pts need periop corticosteroid supplementation
-pts on exogenous steroids may dvlp sudden hypotension during sx stress bc ACTH secretion is supressed
-give hydrocortisone sodium succinate or Solumedrol
why do RA surgical pts need to discontinue NSAIDS and aspirin 7 days prior to sx
-to prevent bleeding complications
-lab testing should include bleeding time, PT, PTT, serum creatinine adn LFT for pts on longterm aspirin or NSAIDS
why should RA surgical pts get lateral cervical xrays
-atlantoaxial subluxation (c1-C2) is present in many RA pts
-flexion of nexk during anesthesia can cause nerve damage
where are heberdens nodes located and in what disease
-osteoarthritis (degenerative arthritis)
-DIPJ
where are bouchards nodes located and in what diseae
-osteoarthritis
-PIPJ
list the radiographic findings of OA
-uneven joint space narrowing
-joint mice (loose osseous bodies)
-marginal osteophytes
-subchondral sclerosis
-subchondral bone cysts
excessive and abnormal remodeling of bone that may be caused by a viral infection of osteoclasts
Pagets Disease of bone (osteitis deformans)
which bones does pagets often effect
-axial skeleton (pelvis, sacrum, spine, skull)
-long bones such as femur and tibia
there are three phases of pagets
1. osteolytic phase
2. mixed phase
3. sclerotic phase
how would a long bone with pagets look on xray
-increased cortical width
-increased bone length
-coursening of trabeculae
-bone enlargement
what are the lab features of pagets
-elevated serum alkaline phosphatase (N=44-147)
-increased urinary hydroxyproline (N=50mg/24 hours)
pagets tx
-biphosphonates
-calcium
-vit D
-calcintonin
-NSAIDS
what are the seronegative spondyloarthropathies and why are they called that
-group of inflammatory disorders that affect the axial skeleton
-they are sero negative meaning neg for rheumatoid factor
-anklylosing spondylitis
-reiters syndrom
-psoriatic arthritis
-enteropahtic spondylitis (crohns)
-reactive arthritis
what is bamboo spine and when is it seen
-spinal fusion seen in ankylosing spondylitis
what gene is common in seronegative spondyloarthropathies
HLA-B27
what is the classic triad of reiters
-conjunctivitis
-urethritis
-arthritis
when does reiters dvlp in a genetically susceptible host (one with HLA-B27)
-after a GU or GI infection
there are two characteristic lesions associated with reiters
-balanitis circinata (ulcers of the glans penis)
-kertoderma blennorrhagicum on soles of feet (clear vesicles on a red base that progress to macules, then small keratotic nodules)
soft tissue swelling in IPJ of toes and fingers causing sausage deformities
reiters
what is the most helpful radiographic characteristic of seronegative spondyloarthropathies that distinguishes it from RA
-bone proliferation
(linear or fluffy periosteal proliferation) (periostitis at tendon and ligament attachment to bone-enthesitis) (intra-articular bone formation at sites of osseous erosion)
describe the nails in psoriatic arthritis
-pitting
-transverse ridges
-subungual hyperkeratosis
-discoloration of nail
-oil spot below the nail
psoriatic arthritis is similar to RA in that it is progressive inflammatory arthritis; how does it differ
-psoriatic arthritis has underlying psoriasis, dactylitis and abscence of anti-cyclic citrulinated peptide antibodies (anti-CCP is present in RA)
resorption of the tufts of the distal phalanges of hands and feet
psoriatic arthritis
Auspitz sign
-bleeding occurs at sites of scale removal in psoriatic arthritis
what color is the synovial fluid from joints of psoriatic pts
lemon yellow
what is the name of the clinical test used for anklosing spondylitis
Wright-Schober; to detect the limitation of forward flexion of the lumbar spine
what is the radiograph hallmark of ankylosing spondylitis
-sacroliliac joint is sacroilitis
Charcot - midfoot collapse
Charcot
Blue and Yellow Gout crystals
Gout
Lyme disease- erythema chronicum migrans
psoriatic arthritis
What is this disease and what was done on the left post op?
RA - met head arthroplasty
RA
Sausage digit or psoriatic arthritis
swan neck of RA