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Oxford Clinical Cases > Acute Joint Pain > Flashcards

Acute Joint Pain Flashcards

1
Q

What is the ‘must exclude diagnosis’ in any patient presenting with acute joint pain?

A

Septic arthritis

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2
Q

Construct a differential diagnosis for acute joint pain by dividing it into articular, peri-articular and non-articular pathology.

A 
- 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
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3
Q

List the seronegative spondyloarthropathies.

A

Reactive arthritis
Ankylosing spondylitis
Psoriatic arthritis
Enteropathic arthritis

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4
Q

List some key features of the history that are important to ask the patient about.

A 
Pain
Trauma
Risk factors for gout 
Risk factors for septic arthritis 
Risk factors for haemarthrosis
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5
Q

Describe different patterns of pain and how they relate to the causes of joint pain.

A

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

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6
Q

List some risk factors for gout.

A

Thiazide diuretics
Chemotherapy
Chronic renal failure
Recent heavy alcohol intake

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7
Q

List some risk factors for septic arthritis.

A

Prosthetic joints
Immunosuppression
Trauma

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8
Q

List some risk factors for haemarthrosis.

A

Coagulopathy
Anticoagulants
Trauma

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9
Q

List some significant features of the past medical history of a patient with joint pain.

A

Recent GI or urogenital infections (reactive arthritis or septic arthritis)
Previous episodes of joint pain
Rheumatological disease

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10
Q

Which diseases are associated with sequential involvement of several joints?

A 
Septic arthritis (gonococcal)
Rheumatic fever
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11
Q

Which diseases are associated with simultaneous involvement of multiple joints?

A

Chronic polyarthritis (e.g. rheumatoid arthritis, psoriatic arthritis)

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12
Q

List some key features of the drug history of a patient with joint pain.

A

Thiazide diuretics, aspirin and chemotherapy – increases uric acid levels and precipitates gout
Steroids – increase risk of atypical fractures

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13
Q

Outline a basic approach to joint examination.

A

Look
Feel
Move

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14
Q

Describe briefly how articular conditions can be distinguished from peri-articular conditions on joint examination.

A

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

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15
Q

List some features of joint disease that you may see on the skin of a patient.

A

Tophi
Rheumatoid nodules
Rash (e.g. psoriasis, SLE)

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16
Q

List three signs of psoriasis that can be seen on the nails.

A

Pitting
Onycholysis
Subungual hyperkeratosis

17
Q

Why is uveitis a significant sign in a patient with joint pain?

A

Associated with HLA-B27 positive inflammatory arthropathies

18
Q

Why are mouth ulcers a significant sign in patients with joint pain?

A

Associated with inflammatory bowel disease, which, in turn, is associated with polyarthropathy

19
Q

Why is pulmonary fibrosis a significant finding in patients with joint pain?

A

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)

20
Q

Describe the use of arthrocentesis in the diagnosis of crystal arthritis.

A

Gout – needle-shaped crystals with negative birefringence

Pseudogout – rhomboid-shaped crystals with positive birefringence

21
Q

Describe the aspirate in septic arthritis.

A

Cloudy
High WCC (especially neutrophils)
Bacteria visible on microscopy

22
Q

What would the presence of blood in a joint aspirate suggest?

A

Haemarthrosis (due to trauma or coagulopathy)

23
Q

What would the presence of white cells in the absence of crystals, blood and infection in a joint aspirate suggest?

A 
Reactive arthritis 
Enteropathic arthritis 
Psoriatic arthritis 
Rheumatic fever 
Rheumatoid arthritis
24
Q

What would a non-inflammatory aspirate (normal WCC and clear) suggest?

A

Trauma

Osteoarthritis

25
Q

What are the five different types of psoriatic arthritis?

A 
Asymmetrical oligoarthritis 
Symmetrical polyarthritis 
Distal interphalangeal joint predominance 
Arthritis mutilans 
Psoriatic spondylitis
26
Q

List some other investigations that may be useful in a patient with joint pain.

A

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

27
Q

List some specific rheumatological investigations that may be performed in a patient with joint pain.

A

Rheumatoid factor
Anti-cyclic citrullinated peptide antibodies
ANA

28
Q

Why is measuring serum urate rarely useful in the acute setting?

A

Serum urate is usually normal/low in acute gout

29
Q

Which joint is most commonly affected in gout?

A

Metatarsophalangeal joint of the big toe (podagra)

30
Q

Outline the acute management of gout.

A

Colchicine
NSAIDs
Corticosteroid injections

31
Q

Describe the chronic management of gout.

A

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

32
Q

Describe the typical presentation of septic arthritis.

A

Very painful joint developed acutely with/without trauma
It will be red, hot, swollen and tender
Painful to both active and passive movement

33
Q

What is bicipital tendonitis caused by?

A

Overuse (repetitive lifting motions)

34
Q

What triad of symptoms is associated with reactive arthritis?

A

Uveitis
Urethritis
Arthritis

35
Q

Which types of infections are associated with reactive arthritis?

A 
GI infections (e.g. Salmonella and Shigella)
Urogenital infections (e.g. Chlamydia trachomatis)
36
Q

Which organisms most commonly cause septic arthritis in:
Native joints
Prosthetic joints

A
  • Native joints
    Staphylococcus aureus
  • Prosthetic joints
    Staphylococcus epidermidis
37
Q

List some radiographic features of osteoarthritis.

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Oxford Clinical Cases (29 decks)

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