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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
Recentl
y
•Limited kitchen and cooking chores
•Pain and stiffness of thumb and middle finger of R hand
•Prescribed NSAID, temporary relief
Past Medical History•C
ontrolled 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
elderly
BMI = 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 OA
Non-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!