57. Joint Disorder (26%) Flashcards
In a patient presenting with joint pain, distinguish benign from serious pathology. Name examples of serious pathologies. (2)
- sarcoma
- septic joint
In a patient presenting with a monoarthropathy, rule out what ?
infectious causes. (e.g., sexually transmitted diseases).
In patients presenting with musculoskeletal pain, include referred and visceral sources of pain in the differential diagnosis.
Name some examples (3)
- angina
- glissement de l’épiphyse fémorale capitale se présentant comme une douleur au genou (dlr référée)
- neuropathic pain
Describe use of X-ray in ligamentous injuries
Clinically diagnose ligamentous injuries. Do NOT do an X-ray examination.
In a patient presenting with joint pain, include systemic conditions in the differential diagnosis.
Name examples
- Granulomatose de Wegener
- Lupus
- Ulcerative colitis
In assessing patients with a diagnosed rheumatologic condition, search for disease-related complications.
Name example (1)
iritis
Differentiate joint vs. soft tissue pain
- Arthritis: Pain on ROM, decreased ROM, swelling, erythema
- Soft tissue: ROM preserved, tendernes over bursae, tendons, or ligaments
Name DDX Monoarthritis (7)
- Trauma
- Infection (Septic arthritis)
- Crystal-induced arthritis
- Osteoarthritis
- Systemic (Gonoccocal, non-gonococcal, mycobacterial, fungal, lyme)
- Mechanical derangement
- Neoplasm
Hemarthrosis is associated with which conditions ? (3)
- fractures intra-articulaires
- luxations
- lésions ligamentaires
Gonoccocal joint infx presents how?
- present as purulent arthritis
- or a triad of tenosynovitis, vesiculopustular skin lesions, and polyarthralgias
Non gonococcal bacterial joint infections should be suspected in who? (3)
in IV drug users, immunocompromised, prosthetic joint
List Crystal-induced arthritis (2)
Gout (cristaux d’urate monosodique )
Pseudogout (CPPD)
Name causes of Systemic arthritis (4)
- Spondylarthrite séronégative (Arthrite réactive, Arthrite psoriasique, Arthrite associée aux maladies inflammatoires de l’intestin)
- Polyarthrite sarcoïde
- Polyarthrite rhumatoïde
- Troubles myélodysplasiques et leucémiques
Name redflags of joint pain (6)
- Articulations chaudes/enflées
- SX B
- Raideur matinale > 30 minutes
- Douleur nocturne
- Faiblesse
- Neurologique (douleur brûlante, engourdissement ou paresthésie)
Describe history : Joint pain
- Red flags
- Joint pain (OPQRST)
- Prior joint pain/similar episodes
- Systemic arthritis (morning stiffness>1h)
- Trauma
- Travel (Lyme)
- Seronegative spondyloarthritis (GI/GU complaints)
- Family history
- PMH (immunosuppression)
- Habits (IVDU, STI risk)
When to suspect : Spondylarthrite séronégative (4)
suspect in
* enthésite (l’inflammation des sites d’insertion du tendon, du ligament, de la capsule articulaire ou d’un fascia sur l’os)
* dactylite (inflammation grave des articulations des doigts et des orteils)
* conjonctivite/uvéite
* psoriasis
Describe physical exam : Joint pain
- Vitals, temperature (high-grade fever)
- Soft tissue swelling, warm, effusion
- Passive/Active ROM
- Extraarticular : Tophi, Skin changes (Psoriasis, Malar rash, Erythema nodosum), Eye involvement
Describe investigations : Joint pain (3)
- Imaging (XR, US, CT, MRI). Consider avoiding imaging in absence of trauma or focal bone pain
- Joint aspiration
- Consider labs
Describe joint aspirations
Gross appearance
Crystal analysis
White cell count and differential
* <2,000/mm3 usually non-inflammatory
* >20,000 suspect septic arthritis
Gram stain and Culture
What labs to consider in joint pain : (6)
- CBC
- LFT
- ESR/CRP
- ANA, RF, Anti-CCP
- (HLA)-B27
- Coags (in hemarthrosis)
Décrire présentation/questionnaire : Fibromyalgie
Décrire EP : Fibromylagie
- Neurologique : possible de retrouver allodynie, trouble d’équilibre et sensibilité aux 9 paires de points douloureux (pas obligatoire pour poser diagnostic)
- Articulaire : devrait être normal
- Tout ce qui est pertinent pour confirmer ou infirmer une autre condition
Décrire bilans : Fibromylagie
- Bilan d’exclusion : FSC, CRP, CPK, TSH
- Maladies chroniques, syndrome métabolique, obésité peuvent augmenté légèrement la CRP
- CRP > 20 considérer investigation supplémentaire
- Tout autre investigation doit être justifiée par trouvailles au questionnaire ou à l’examen objectif
Décrire tx : Fibromylagie
- Traitement pharmacologique : approche par symptôme (Antidépresseur 3 cycliques, SNRS ou gabapentinoïdes, Éviter les opiacés et les benzo)
- Éducation
- Psychothérapie PRN
- Exercices physiques et autogestion
- Référer en ergothérapie, réadaptation interdisciplinaire ou services spécialisés de main d’oeuvre (selon les besoins) PRN
- Physiothérapie PRN
Name a few Diagnostic Differentiators for Wegener’s granulomatosis, lupus, ulcerative colitis
Name signs/symptoms : Gout
- Acute arthritis -> painful, swelling, erythema, usually lower extremity (most common 1st MTP), limited joint mobility
- Tophi (monosodium rate crystals) > rate deposit in cartilage / tendon bursa / soft tissue / synovial
- Renal > nephropathy, calculi, acidic urine
Describe investigations : Gout
- Hyperuricemia is NOT diagnostic of acute attack (normal 15-480). Helpful to determine efficacy of prophylaxis
- Consider synovial fluid aspiration for rate crystals (especially if septic arthritis is still on the differential)
- Imaging Options (uncertain usefulness in primary care) - when diagnostic testing is necessary, use synovial fluid aspiration especially if septic arthritis is still on the differential (X-rays usually not useful u/s (low quality evidence, Dual energy CT)
Describe dx : Gout (4)
New York Criteria : >= 2 of the following:
* > or = 2 attack of painful joint swelling with complete resolution within 2 weeks
* Unilateral first MT joint attack (podagral)
* Response to colchicine (major reduction in inflammation within 48 hrs)
* Tophi (proven or suspected)
Describe lifestyle tx : Gout (6)
- Limit purine intake + limit high fructose intake
- Avoid alcohol
- Avoid meats, sardines, shellfish, beans, peas
- Consider diet <1600 kcal / day (show to reduce serum uric acid)
- Weight loss. Given risk factors include HTN / obesity / CAD / DM / dyslipidemia
- Avoid thiazides, consider losartan instead
Describe acute gout tx (4)
- use topical ice as an adjunct treatment
- NSAID (Naproxen)
- Colchicine
- Corticosteroids - if NSAID + colchicine contraindicated (ex. On warfarin), avoid in poor diabetes control, infection (ex. prednisone)
Describe urate lowering therapy for gout (1)
Allopurinol
Which patients should be considered for prophylactic urate lowering therapy ? (5)
- ≥ 1 tophi
- radiographic damage from gout
- ≥ 2 flares / year
- > 1 lifetime flare but <2 / year
- first flare and CKD stage ≥3, SU >535 umol/L, or urolithiasis
- Do NOT Rx for first flare w/ none of the above conditions
Describe : Rheumatoid Arthritis (4)
- Chronic autoimmune disorder causing (usually symmetrical) erosive synovitis of peripheral joints (small and large), swelling, stiffness, pain
- Morning stiffness ≥ 1 hour, improves w/ use, worsens w/ rest
- Joint damage > ⬇️ motion, instability, deformity, crepitus
- Constitutional symptoms (fatigue, rarely wt loss)
- Vasculitis
- Lymphocytic Infiltrates - rheumatoid nodules, pulmonary fibrosis, pleural effusion, pulmonary nodules, pericarditis, Hashimoto’s thyroiditis, hepatosplenomegaly
- Joint Deformities - Boutonniere, Swan neck, claw toe, hammer toe, mallet toe
Name dx criteria : Rheumatoid Arthritis
At least 4 of the following:
* Moring stiffness around joints for ≥ 1 hour
* Arthritis ≥ 3 joint areas (soft tissue swelling)
* Arthritis of hand joints (wrist, MCP, PIP)
* Symmetric arthritis. Bilateral involvement PIP, MCP or MTP joints
* Rheumatoid nodules
* Serum rheumatoid factor elevated
* Radiographic changes on hand and wrist views (erosions, decalcification)
Name investigations : Rheumatoid Arthritis
- Bloodwork : RF, anti-cyclic citrullinated peptide (anti-CCP), CRP/ESR, FSB (elevated platelets)
- X-ray (diagnostic erosions rarely seen in disease <3 month, I Consider imaging of hands + feet q6mo in recent onset)
- Joint aspiration
Name Complications of Untreated Rheumatoid Arthritis (6)
- Anemia
- Scleritis
- Deformities - hands, frozen shoulders, nodules
- Pericarditis
- More Infections
- ?malignancy (unsure if related to DMARDs)
Describe pharmacotx : Rheumatoid Arthritis
- NSAIDS - symptom relief but do NOT alter course of illness. Use lowest effective dose for shortest time possible. Offer a PPI
- Disease-modifying anti-rheumatic drug (DMARDs) - start ASAP - adjust q3-6mo
- Corticosteroids (adjunct to the above to manage flares, bridge DMARDs, max 3/yr). Can use as short term bridging when starting a new synthetic DMARD but taper rapidly
- Gastro protection if >65y/o or history of PUD
Name examples DMARDs
- Methotrexate
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine
- Cyclosporine
- Azathioprine
