11. Joint pain/swelling Flashcards
History joint pain/swelling
see MSK system
DDX general joint pain/swelling
Infection:
- septic arthritis
- osteomyelitis
- reactive arthritis
Immune:
- osteoarthritis
- rheumatoid arthritis
- juvenile idiopathic arthritis
- polymyalgia rheumatica
- Ankylosing spondylitis
Metabolic
- rickets
- gout
- pseudogout
Neoplastic
- sarcoma
- myeloma
Other
- ganglion cysts
- sarcoidosis
What is osteoarthritis
Disorder of synovial joints where damage triggers repair processes leading to structural changes within a joint
key features of osteoarthritis
Slower onset
Activity related pain
Asymmetrical
Fewer joints
Activity related history
Commonly affected joints: hips, knees, sacro-iliac joints, DIPs, CMC joint at base of thumb, Wrist, Cervical spine
X-ray changes osteoarthritis
LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis (increased density of bone along the joint line)
Subchondral cysts (fluid filled holes within the bone)
o/e hand signs osteoarthritis
heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in PIP joints)
Squaring at the base of the thumb at carpo-metacarpal joint
Weak grip
Reduced range of motion
plan establishing a diagnosis osteoarthrits
NICE (2014) suggests that a diagnosis can be made without any investigations if the patient is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30 minutes.
X-ray
Management osteoarthritis
Management
1. Patient education and lifestyle advice eg weight loss
+ Physiotherapy to improve strength to support the joint
+ Occupational therapy and orthotics to support activities and function
Analgesia
1. topical NSAID or topical capsaicin
2. Add oral nsaid and consider also prescribing PPI to protect stomach
3. Consider opiates (? i wouldn’t)
4. Intra-articular steroid injections
5. Joint replacement. Knee and hip are most commonly replaced
What is rheumatoid arthritis
Autoimmune condition causing chronic inflammation of the synovial lining of joints and tenon sheaths and bursa
Key features of rheumatoid arthritis
Quick onset
Rest related pain
Symmetrical
Multiple joints
More common in women
Distal polyarthropathy
Rest related pain (Worse after rest, improves with exercise)
DIPS spared
o/e hand signs rheumatoid arthritis - insp and palp
Palpation of synovium wll give a “boggy” feeling
Z shaped deformity of the thumb
Swan neck deformity (flexed DIP with hyperextended PIP)think of swans flexing
Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCPs)
Genetic associations rheumatoid arthritis
HLA DR4 (a gene often present in RF positive patients)
HLA DR1 (a gene occasionally present in RA patients)
Autoantibodies rheumatoid arthritis
Rheumatoid factor (RF) - positive in 70% of patients
Cyclic citrullinated peptide antibodies (anti-CCP) - more sensitive and specific than rheumatoid factor
systemic symptoms of rheumatoid arthritis
fatigue, weight loss, flu like illness, muscle aches and weakness
plan investigating rheumatoid arthritis
- Check rheumatoid factor
+ Inflammatory markers such as CRP and ESR - If RF negative, check anti-CCP antibodies
- X-ray of hands and feet
+ USS can evaluate and confirm synovitis
X-ray findings rheuamtoid
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions
Management rheumatoid arthritis
Inducing remission
1. Short course of steroids “as a bridge”
2. Or NSAIDs/COX-2 inhibitors (naproxen) but co-prescribe with PPIs
Ongoing DMARDs
1. Monotherapy with methotrexate, leflunomide, or sulfasalazine. Hydroxychloroquine if particularly mild
2. Dual therapy
3. Methotrexate PLUS a biological usually TNF inhibitor such as adalimumab, infliximab, etanercept
4. Methotrexate plus rituximab (anti-CD20)
what DMARDs are safe in pregnancy
sulfasalazine or hydroxychloroquine
Emergency complication of rheumatoid arthritis
Spinal cord compression
Atlantoaxial subluxation occurs in the cervical spine. The axis (C2) and the odontoid peg shift within the atlas (C1).
This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas. Subluxation can cause spinal cord compression and is an emergency. This is particularly important if the patient is having a general anaesthetic and requiring intubation. MRI scans can visualise changes in these areas as part of pre-operative assessment.
What is polymyalgia rheumatic
inflammatory vasculitis that causes pain and stiffness in the shoulders, pelvic girdle and neck. There is a strong association to giant cell arteritis and the two conditions often occur together.
Typical history polymyalgia rheuamtica
PC: over 50 with 2 weeks of: bilateral shoulder and/or pelvic girdle pain AND stiffness lasting for at least 45 mins after waking
HoPC: may be accompanied by: low grade fever, fatigue, anorexia, weight loss, depression, upper arm tenderness, ask about features of temporal arteritis
Red flags: muscle strength should be normal, visual change
what examination should you do for?polymyalgia rheumatic
MSK and neuro exam of UL and LL
Cranial nerve exam assessing vision
Examine temporal artery for tenderness
Plan ?polymyalgia rheumatica
Investigations for PMR
1. Bloods: ESR and CRP
Investigations to exclude other things and before medication:
1. Do these before starting steroids: full blood count, urea and electrolytes, liver function tests, calcium, alkaline phosphatase, protein electrophoresis, thyroid stimulating hormone, creatine kinase, rheumatoid factor, and dipstick urinalysis.
2. Consider : urine Bence-jones protein, blood tests for ANA and anti-cyclic citrullinated peptide antibody, CXR,
Management:
1. Trial of oral prednisolone 15 mg daily and follow up after 1 week
2. After 3-4 weeks consider reducing dose and assess response to treatment
what is juvenile idiopathic arthritis
Condition affecting people under the age of 16 where autoimmune inflammation occurs in the joints. It is diagnosed where there is arthritis without any other cause, lasting more than 6 weeks.
key features of JIA
joint pain, swelling and stiffness
What are the 5 subtypes of JIA
Systemic JIA
Polyarticular JIA
Oligoarticular JIA
Enthesitis related arthritis
Juvenile psoriatic arthritis
typical history systemic JIA
Subtle salmon-pink rash
High swinging fevers
Enlarged lymph nodes
Weight loss
Joint inflammation and pain
Splenomegaly
Muscle pain
Pleuritis and pericarditis
another name for systemic JIA
stills disease
key complication of systemic JIA
Macrophage activation syndrome (MAS), where there is severe activation of the immune system with a massive inflammatory response.
It presents with an acutely unwell child with disseminated intravascular coagulation (DIC), anaemia, thrombocytopenia, bleeding and a non-blanching rash. It is life threatening. A key investigation finding is a low ESR.
non-infective differentials of fever lasting more than 5 days in children
Kawasaki disease, Still’s disease, rheumatic fever and leukaemia.
what is polyarticular JIA
involves idiopathic inflammatory arthritis in 5 joints or more.
The inflammatory arthritis tends to be symmetrical and can affect the small joints of the hands and feet, as well as the large joints such as the hips and knees. There are minimal systemic symptoms, but there can be mild fever, anaemia and reduced growth. Systemic symptoms are mild, unlike systemic onset JIA.
Polyarticular JIA is the equivalent of rheumatoid arthritis in adults.
What is oligoarticular/pauarticualr JIA
It involves 4 joints or less. Usually it only affects a single joint, which is described as a monoarthritis. It tends to affect the larger joints, often the knee or ankle. It occurs more frequently in girls under the age of 6 years.
most common JIA
oligoartiucalr
what is enthesitis related JIA?what is an enthesis? causes of enthesitis?
Enthesitis-related arthritis is more common in male children over 6 years.
It can be thought of as the paediatric version of the seronegative spondyloarthropathy group of conditions that affect adults. These conditions are ankylosing spondylitis, psoriatic arthritis, reactive arthritis and inflammatory bowel disease-related arthritis. Patients have inflammatory arthritis in the joints as well as enthesitis.
An enthesis (plural: entheses) is the point at which the tendon of a muscle inserts into a bone. Enthesitis is inflammation of this insertion point. Enthesitis can be caused by traumatic stress, such as through repetitive strain during sporting activities, or can be caused by an autoimmune inflammatory process. An MRI scan of the affected joint can demonstrate enthesitis, but cannot distinguish between an enthesitis due to stress or an autoimmune process.
what is juvenile psoriatic arthrtis
Psoriatic arthritis is an seronegative inflammatory arthritis associated with psoriasis, the skin condition. The pattern of joint involvement varies. Patients can have a symmetrical polyarthritis affecting the small joints similar to rheumatoid, or an asymmetrical arthritis affecting the large joints in the lower limb.
Juvenile psoriatic arthritis is associated with several signs on examination:
Plaques of psoriasis on the skin
Pitting of the nails (nail pitting)
Onycholysis, separation of the nail from the nail bed
Dactylitis, inflammation of the full finger
Enthesitis, inflammation of the entheses, which are the points of insertion of tendons into bone
Management of JIA
- referral to rheumatology for coordination of care
NSAIDS
Steroids - either oral, intramuscular or intra-artricular in oligoarthritis
Disease modifying anti-rheumatic drugs (DMARDs), such as methotrexate, sulfasalazine and leflunomide
Biologic therapy, such as the tumour necrosis factor inhibitors etanercept, infliximab and adalimumab
which JIA is associated with rasied inflammatory markers
systemic JIA (stills)
which JIA is associated with HLA-B27
enthesitis related JIA
Which JIA often has a positive ANA
Oligoarticular/ Pauciarticular
‘little girl (<6) called ANA’
which patients with JIA may be seropositive (rheuamtoid factor)
polyarticualr - older children
typical history ankylosing spondylitis
PC: young man with lower back pain and stiffness of insidious onset, stiffness worse in the morning and improves with exercise. may experience pain at night which improves on getting up
what may you find on examination ank spond
- reduced lateral flexion
- reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
- reduced chest expansion
what gene is ank spond associated with ?
HLA B27
Investigation ank spond
- plain xray of sacroiliac joints
- if negative and still suspected, MRI
what may be found on xray in ank spond
SSS
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
why should you assess resp system in someone with ank spond, what might you find
at risk of apical fibrosis - request CXR if suspected
Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
reduced chest expansion o/e
first line management ank spond
NSAIDs
Management ank spond
- NSAIDs
- Paracetamol/codeine if poorly tolerated
- Seek specialist advice
+ Physio
+ Hydrotherapy
+ OT
criteria for rheum referal ank spond
Refer to rheumatology for a spondyloarthritis assessment if a person has low back pain starting before the age of 45 years and lasting longer than 3 months, plus four or more of the following criteria:
Low back pain starting before the age of 35 years.
Symptoms which wake them during the second half of the night.
Buttock pain.
Improvement when moving.
Improvement within 48 hours of taking a nonsteroidal anti-inflammatory drug (NSAID).
Spondyloarthritis in a first-degree relative.
Current or past arthritis.
Current or past enthesitis.
Current or past psoriasis.
complications/associations ank spond
apical fibrosis
anterior uveitis
CVS risk and heart involvement: aortic regurg, AV node block
osteoporosis and fractures
cauda equina
what are the most commonly affected joints septic arthritis
hip, knee and ankle
typical history septic arthritis
PC: hot red swollen painful joint, stiffness and reduced range of motion, systemic symptoms such as fever and lethargy
any hot/red joint
most common causative organism septic arthritis ? other causes
staph aureus
Neisseria gonorrhoea (gonococcus) in sexually active teenagers
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
Escherichia coli (E. coli)
young pt presenting with single acutely swollen joint - first ddx?
always think of gonococcus septic arthritis until proven otherwise
Gonorrhoea infection is common and delaying treatment puts the joint in danger. In your exams it might say the gram stain revealed a “gram-negative diplococcus”. The patient may have urinary or genital symptoms to trick you into thinking of reactive arthritis but remember that it is important to exclude gonococcal septic arthritis first as this is the more serious condition.
plan ?septic arthritis
Have a low suspicion until joint fluid assessed
- Aspiration for gram stain, crystal microscopy, culture and antibiotic sensitivities
- If paeds, USS, if shows effusion and with corroborating history, treat as septic arthritis
- Bloods inflammatory markers, blood culture
- Empirical IV antibiotics (local guidelines)
- Continue abx for 3-6 weeks
Patients may require surgical drainage and washout of the joint to clear the infection in severe cases.
example first line regime septic arthritis abx
Flucloxacillin for 6 weeks
if pen allergic: clindamycin
If MRSA suspected: vancomycin
If gonococcal arthritis or gram -ve susepcted : cefotaxime or ceftriaxone
what criteria can be used in children to distinguish between septic arthritis and transient synovitis of hip
The kocher criteria
fever >38.5 degrees C
non-weight bearing
raised ESR > 40
raised WCC >12
If 0 = very unlikely and can be managed in primary care with close follow up
what is osteomyelitis
an infection in the bone and bone marrow.
This typically occurs in the metaphysis of the long bones.
what is the most common causative organism osteomyelitis
staph aureus
types of osteomyelitis and how do people get it?
Chronic osteomyelitis is a deep seated, slow growing infection with slowly developing symptoms.
Acute osteomyelitis presents more quickly with an acutely unwell pt.
The infection may be introduced directly into the bone, for example during an open fracture.
Alternatively it may have travelled to the bone through the blood, after entering the body through another route, such as the skin or gums.
In what children is osteomyelitis more common
boys and children under 10 years
typical history osteomyelitis
Osteomyelitis can present acutely with an unwell child, or more chronically with subtle features. Signs and symptoms are:
- Refusing to use the limb or weight bear
- Pain
- Swelling
- Tenderness
They may be afebrile, or may have a low grade fever. Children with acute osteomyelitis may have a high fever, particularly if it has spread to the joint causing septic arthritis.
best imaging for dx of osteomyelitis
MRI
initial invetsigation osteomyelitis
xray
