Disease of Joints and Musculoskeletal Disorders

OSTEOARIRITIS

• Also called degenerative joint disease.
• Hip osteoarthritis is more common in men and small joints and knee OA is more common in women.
• There is damage to cartilage, remodeling and hyper­trophy of bone.
• There is bone and muscle wasting.

OSTEOARIRITIS Clinical Features

• · There is deep pain in the joint aggravated by joint movements and relieved by rest.
• · There is involvement of synovium, subchondral bone, ligament, capsule, muscle and formation of osteophytes.
• · Nocturnal pain, stiffness, synovitis.
• · There is bony crepitus over affected joints and synovial effusion.
• · There may be ‘bony deformities.
• · Fever, weight loss may occur.

Lab findings

• · In X-ray joint-space narrowing is seen
• · Osteophytes.

OSTEOARIRITIS Treatment

• Obese patient should lose weight
• Avoid prolonged standing, kneeling, squatting Medial taping of patella
• Wedged insoles in footwear
• Heat application – hot bath
• Walking, cycling, swimming reduces joint pain Walking with a cane during pain
• Proper footwear
• Analgesics
• Paracetamol Cox-2 inhibitors Ibuprofen Naproxen
• Intraarticular injection of hyaluronidase Steroids –
  • intraarticular should not be given Opioids
  • Tramadol
• Tidal irrigation of knee
• Topical therapy – Pain relievers – ointments, sprays, oils
• Glucosamine, chondroitin sulphate – it protects the cartilage and gives symptomatic improve­ment
• Surgery – Joint replacement, osteotomy, arthro­plasty
• Chondroplasty.

GOUT

• · It is a metabolic disease
• · Affects middle-aged and elderly men and women.
• · There is hyperuricemia ( increased levels of uric acid in blood)
• · There is acute or chronic arthritis with deposi­tion of monosodium urate(MSU) crystals in con­nective tissue and kidneys
• · Usually only one joint is affected
• · The great toe (first toe) is involved
• · There are Heberden’s nodes or Bouchard’s nodes in the joints
• · Joints are warm, red, painful
• · It is precipitated by alcohol, steroids, MI, stroke
• · Renal insufficiency may occur.

GOUT Lab Diagnosis

• · MSU crystals can be demonstrated in the joint
• · Serum uric acid may be increased, normal or low
• · X-ray –bony erosions may be seen.

GOUT Treatment

• For acute attack Colchicine is given – 0.6 mg every hour till relief. Colchicine is stopped if there is diarrhoea
• NSAIDs
• Steroids
• Indomethacin
• Ibuprofen
• ACTH – 40 – SO IU every 12 hours for 2 days. Uricosuric agents – probenecid, allopurinol given to increase excretion of uric acid.
• They prevent acute attacks but are not started during an attack of painful gout because they can flare-up the attack.
• Allopurinol is given in a single dose 300 mg ini­tially and increased upto SOO mg.
• Toxicity of allopurinol is skin rash, systemic vas­culitis, hepatitis, bone-marrow suppression and renal failure.
• Hypourecemic therapy is given till the patient is normourecemic and without gouty attack for 3 months. Prophylactic colchicine may be contin­ued.

INFECTIVE ARTHRITIS

• Usually caused by Staphylococcus aureus, Neisseria gonorrhoea.
• Also caused by Mycobacteria, spirochetes, fungi, vi­ruses.
• One or more joints involved.
• Affects the knee, hip, shoulder, wrist, elbow joints. There is severe pain, effusion, limitation of move­ments. Fever is usually present.
• X-ray show,? swelling and increase of joint-space. MRI and CT’may be done.
• Synovial fluid is turbid or purulent.
• Gram’s staining shows neutrophils and staphylococci. Culture of synovial fluid is usually positive.

INFECTIVE ARTHRITIS Treatment

• Antibiotics oral or parenteral Drainage of joints
• Antibiotics – Cefotaxime, Ceftriaxone, Vancomy­cin instilled into joints
• Weight- bearing should be avoided till infection subsides.

REACTIVE ARTHRITIS

• It is a non-purulent arthritis.
• It usually occurs after enteric or urogenital infections. It has a strong association with HLA B27 antigen. Age: commonly lS – 40 years.
• Sex: males and females are equally affected.

Pathology

• There is synovial inflammation, infiltration of the soft tissues of joint, cartilages with inflammatory cells.

REACTIVE ARTHRITIS Etiology

• Any bacterial, viral or parasitic infection can lead to reactive arthritis.
• Shigella, Salmonella, Clostridium etc. cause reactive arthritis commonly.
• The disease is mediated by T cells-CD4+ and CDS+.

REACTIVE ARTHRITIS Clinical features

• Constitutional symptoms-fever, malaise, weight loss, fatigue.
• There is asymmetric arthritis from 1 – 2 weeks after an infection.
• Joints of lower extremities like knees, ankle, tarsal, and metatarsal joints are affected.
• Wrist and fingers are also affected.
• Dactylitis –
  • Swollen fingers like a sausage called sau­sage-digit may be seen.
• Tendonitis.
• Chronic pain in the heels. Pneumonia. Pleuropulmonary infiltrates. Prostatitis.
• Keratoderma blenorrhagica – Skin lesions with vesicles, crusting on palms and soles are seen.
• Nails turn yellowish, brittle. There is onicholysis (nails break up), hyperkeratosis of nails.
• Cardiac involvement – conduction defects, aortic re­gurgitation may occur.

Lab tests

• · ESR increased
• · Anaemia
• · HLA B-27 positive
• · X-ray
• – Osteoporosis especially juxta articular (close to the joints)
• – Sacroileitis
• – Periosteitis
• – Spinal fusion.

REACTIVE ARTHRITIS Treatment

• NSAIDs –
• Indomethacin,
• Cox-2 inhibitors
• Sulphasalazine
• Azathioprine – 1 mg/kg/day
• Methotrexate – 15 mg/kg/week
• Glucocorticoids.