Grandma’s aching knees and snapping fingers

C1

Chief Complaint

Pain and stiffness of thumb and middle finger of R hand

79 y/o F

History of Present Illness

Years •Painful knees, more pronounced on walking

Recently•Limited kitchen and cooking chores•Pain and stiffness of thumb and middle finger of

R hand•Prescribed NSAID, temporary relief

Past Medical History

•Controlled on daily amlodipine

Hypertension

•2 yearly infusion of zoledronic acid

Osteoporosis

Physical Examination

• Normal vital signs; BMI 28

Musculoskeletal Exam• Crepitus on both knees without effusion• 1st and 3rd fingers of R hand would snap on flexion

and required assistance due to pain on attempted extension

Physical ExaminationStooped posture

Bilateral genu varum deformity

Non-tender bony nodes on PIP and DIP

Salient Features• 79 y/o female• Years of painful knees, pronounced when walking• Crepitus on both knees without effusion• Bilateral genu varum• Pain and stiffness of thumb and middle finger of R

hand• would snap on flexion and require assistance on

extension• Non-tender bony nodules on PIP and DIP• Diagnosed with osteoporosis, received 2 yearly

infusion of zoledronic acid• Stooped posture• Hypertension controlled on daily amlodipine

Musculoskeletal signs and symptoms in the Patient

• Painful knees, more pronounced on walking; Non-tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum

• Pain and stiffness of thumb and middle finger of R hand; would snap on flexion and require assistance on extension

• Stooped posture; previous diagnosis of osteoporosis with prescribed medication

Musculoskeletal conditions in the Patient

OsteoarthritisPainful knees, more pronounced on walking; Non-

tender bony nodules on PIP and DIP; Crepitus on both knees without effusion; bilateral genu varum

“Trigger Finger/ Digit”Pain and stiffness of thumb and middle finger of R

hand; would snap on flexion and require assistance on extension

OsteoporosisStooped posture

OsteoarthritisPatient Osteoarthritis79 years old female leading cause of disability in the

elderlyBMI = 28 ObesityPainful knees; Crepitus on both knees without effusion

affected joints include the cervical and lumbosacral spine, hip, knee.

Painful knee on walking Joint pain from OA is activity-related

Non-tender bony nodules on PIP and DIP

Presence of Heberden’s nodes in DIP and Bouchard’s nodes in PIP

Management for OANon-pharmacologic Management(1) avoiding activities that overload the joint, as evidenced by their causing pain(2) improving the strength and conditioning of muscles that bridge the joint, so as to optimize their function(3) unloading the joint, either by redistributing load within the joint with a brace or a splint or by unloading the joint during weight bearing with a cane or a crutch.

Exercise lessens pain and improves physical function consist of aerobic and/or resistance training (strengthens muscles across the joints)

Correction of Malalignment

Management for OA

“Trigger-finger/digit”Patient Trigger-finger

•Pain and stiffness of thumb and middle finger of R hand•would snap on flexion and require assistance on extension

•common disorder of later adulthood characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain

Management for “Trigger-finger/digit”

• Local steroid injection– Cortisone, prednisolone, dexamethasone, and

triamcinolone.– A mixture of steroid, 1% lidocaine, and 0.5%

bupivacaine is used, in a ratio of 2:1:1, respectively

– After injection, the patient is encouraged to move the digit.

– A follow-up appointment is made for 3-4 weeks after the treatment

Management for “Trigger-finger/digit”

• Splinting– For those patients who decline injection– MCP joint is splinted in approximately 15° of

flexion.

Osteoporosis

Patient Osteoporosis

79 y/o Advanced age

Female Female sex

Estrogen deficiency

Low calcium intake

Alcohol and cigarette consumption

Management for Osteoporosis

To maintain bone health: • Make sure there is enough calcium in your

diet• Get adequate vitamin D intake, which is

important for calcium absorption and to maintain muscle strength

• Get regular exercise, especially weight-bearing exercise.

Management for Osteoporosis

• Bisphophonates – alendronate, residronate, etidronate– Patient was given zoledronic acid

• Calcitonin– Calcitonin works by directly inhibiting osteoclast

activity via the calcitonin receptor. – Calcitonin directly induces inhibition of osteoclastic

bone resorption by affecting actin cytoskeleton which is needed for the osteoclastic activity.

Management for Osteoporosis

• Selective Estrogen Receptor Modulators (SERMs)– are a class of medications that act on the estrogen

receptors throughout the body in a selective manner

– Raloxifene (60 mg/d) - act on the bone by slowing bone resorption by the osteoclasts

What is the mechanism of action of NSAIDs?

• Most NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase(COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes.

• COX catalyzes the formation of prostaglandins and thromboxane from arachidonic acid

• Prostaglandins act as messenger molecules in the process of inflammation.

• Many aspects of the mechanism of action of NSAIDs remain unexplained, for this reason further COX pathways were hypothesized. The COX pathway was believed to fill some of this gap but recent findings make it appear unlikely that it plays any significant role in humans and alternative explanation models are proposed.

The FASEB journal : official publication of the Federation of American Societies for Experimental Biology 22 (2): 383–390

MOA of NSAIDS

Selective and Non-Selective NSAID

Philippine Brands

Primary indication

Dose Route

Alendronate Fosamax Osteoporosis 10 mg/day; 70mg/week

Oral

Risedronate Actonel Osteoporosis 5 mg/day; 35 mg/week

Oral

Ibandronate Bondronat, Bonviva

Osteoporosis 2.5 mg/day; 150mg/month

Oral

Pamidronate Aredia Bone Metastasis

90mg/3 weeks IV

Zoledronate Aclasta, Zometa

Bone Metastasis

4mg/3 weeks IV

Incadronate Bisphonal Bone metastasis

10mg/2weeks IV

Clodronate Bonefos Pagets / Bone metastasis

1600-3200md/day Oral

300mg/day IV

Bisphosphonate preparations

Thank You!