Acute Joint Pain Flashcards
What is the ‘must exclude diagnosis’ in any patient presenting with acute joint pain?
Septic arthritis
Construct a differential diagnosis for acute joint pain by dividing it into articular, peri-articular and non-articular pathology.
- Articular Trauma Gout Pseudogout Septic arthritis Seronegative spondyloarthropathies Transient synovitis Others: amyloidosis, sarcoidosis, vasculitides, SLE, haemarthrosis
Peri-articular
Ligament injury
Tendinitis
Others: Bursitis, fasciitis, epicondylitis
- Non-articular
Nerve entrapment
Radiculopathy
Others: bone malignancy, osteomyelitis
List the seronegative spondyloarthropathies.
Reactive arthritis
Ankylosing spondylitis
Psoriatic arthritis
Enteropathic arthritis
List some key features of the history that are important to ask the patient about.
Pain Trauma Risk factors for gout Risk factors for septic arthritis Risk factors for haemarthrosis
Describe different patterns of pain and how they relate to the causes of joint pain.
Worse with movement + better with rest = non-inflammatory (e.g. osteoarthritis)
Acute-onset = septic arthritis, gout/pseudogout, trauma
Insidious onset = bursitis, tendonitis (overuse)
Chronic onset = osteoarthritis
List some risk factors for gout.
Thiazide diuretics
Chemotherapy
Chronic renal failure
Recent heavy alcohol intake
List some risk factors for septic arthritis.
Prosthetic joints
Immunosuppression
Trauma
List some risk factors for haemarthrosis.
Coagulopathy
Anticoagulants
Trauma
List some significant features of the past medical history of a patient with joint pain.
Recent GI or urogenital infections (reactive arthritis or septic arthritis)
Previous episodes of joint pain
Rheumatological disease
Which diseases are associated with sequential involvement of several joints?
Septic arthritis (gonococcal) Rheumatic fever
Which diseases are associated with simultaneous involvement of multiple joints?
Chronic polyarthritis (e.g. rheumatoid arthritis, psoriatic arthritis)
List some key features of the drug history of a patient with joint pain.
Thiazide diuretics, aspirin and chemotherapy – increases uric acid levels and precipitates gout
Steroids – increase risk of atypical fractures
Outline a basic approach to joint examination.
Look
Feel
Move
Describe briefly how articular conditions can be distinguished from peri-articular conditions on joint examination.
Articular – more likely to see diffuse joint inflammation and pain on active AND passive motion
Peri-articular – focal point of tenderness on palpation and pain is usually much worse on active movement
List some features of joint disease that you may see on the skin of a patient.
Tophi
Rheumatoid nodules
Rash (e.g. psoriasis, SLE)
List three signs of psoriasis that can be seen on the nails.
Pitting
Onycholysis
Subungual hyperkeratosis
Why is uveitis a significant sign in a patient with joint pain?
Associated with HLA-B27 positive inflammatory arthropathies
Why are mouth ulcers a significant sign in patients with joint pain?
Associated with inflammatory bowel disease, which, in turn, is associated with polyarthropathy
Why is pulmonary fibrosis a significant finding in patients with joint pain?
It can be caused by rheumatological disease (e.g. rheumatoid arthritis)
It can also be caused by the treatment of certain rheumatological diseases (e.g. methotrexate)
Describe the use of arthrocentesis in the diagnosis of crystal arthritis.
Gout – needle-shaped crystals with negative birefringence
Pseudogout – rhomboid-shaped crystals with positive birefringence
Describe the aspirate in septic arthritis.
Cloudy
High WCC (especially neutrophils)
Bacteria visible on microscopy
What would the presence of blood in a joint aspirate suggest?
Haemarthrosis (due to trauma or coagulopathy)
What would the presence of white cells in the absence of crystals, blood and infection in a joint aspirate suggest?
Reactive arthritis Enteropathic arthritis Psoriatic arthritis Rheumatic fever Rheumatoid arthritis
What would a non-inflammatory aspirate (normal WCC and clear) suggest?
Trauma
Osteoarthritis
What are the five different types of psoriatic arthritis?
Asymmetrical oligoarthritis Symmetrical polyarthritis Distal interphalangeal joint predominance Arthritis mutilans Psoriatic spondylitis
List some other investigations that may be useful in a patient with joint pain.
Cultures – to check for sepsis or to identify GI or urogenital infection
Bloods
FBC, CRP and ESR – to check for signs of infection/inflammation
Clotting screen – check for coagulopathy that could cause haemarthrosis
List some specific rheumatological investigations that may be performed in a patient with joint pain.
Rheumatoid factor
Anti-cyclic citrullinated peptide antibodies
ANA
Why is measuring serum urate rarely useful in the acute setting?
Serum urate is usually normal/low in acute gout
Which joint is most commonly affected in gout?
Metatarsophalangeal joint of the big toe (podagra)
Outline the acute management of gout.
Colchicine
NSAIDs
Corticosteroid injections
Describe the chronic management of gout.
Drugs that decrease production of urate – allopurinol + febuxostat (xanthine oxidase inhibitors)
Drugs that increase excretion of urate – sulfinpyrazone + probenecid
Drugs that increase degradation of urate – rasburicase
Describe the typical presentation of septic arthritis.
Very painful joint developed acutely with/without trauma
It will be red, hot, swollen and tender
Painful to both active and passive movement
What is bicipital tendonitis caused by?
Overuse (repetitive lifting motions)
What triad of symptoms is associated with reactive arthritis?
Uveitis
Urethritis
Arthritis
Which types of infections are associated with reactive arthritis?
GI infections (e.g. Salmonella and Shigella) Urogenital infections (e.g. Chlamydia trachomatis)
Which organisms most commonly cause septic arthritis in:
Native joints
Prosthetic joints
- Native joints
Staphylococcus aureus - Prosthetic joints
Staphylococcus epidermidis
List some radiographic features of osteoarthritis.
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
