aPPROACH TO JJOINT PAIN? Flashcards
What is non- articular pain? What are examples of non- articular pain?
- Pain only in certain movements
- Tender at a specific point
Examples • Referred pain • Soft tissue (bursitis, tendonitis) • Neuropathic • Periarticular (MSK) • Ischaemic pain
What is articular pain?
- Pain in all range of movements
* Tender along entire joint line
What are the features of inflammatory pain?
- Morning stiffness >1hr (>30min is also diagnostic!!)
- Worse early morning or night
- Better with movement
- Warmth, redness, swelling (though may also be present in mechanical)
What are the differentials for mechanical pain?
OA (hand/hip/spine)
Trauma
What are the differentials of inflammatory polyarthritis (>5)?
Symmetrical
- RA
- Psoriatic arthritis
- SLE
- Mixed CTD
Asymmetrical
- Psoriatic arthritis
- Reactive arthritis
What are the differentials of inflammatory oligoarthritis (<5)?
Essentially PAIR
- Psoriatic arthritis
- Ankylosing spondylitis
- Enteropathic arthritis
- Reactive arthritis
- Disseminated gonococcal
What are the differentials for Monoarthritis?
- Gout
- Pseudogout
- Septic arthritis
- Reactive arthritis (rarer
What are the differentials for migratory polyarthritis?
- Henoch Schonlein Purpura – ROJAK (palpable purpura & oedema in dependent areas, joint pain, abdo pain, kidney injury
- Acute Rheumatic Fever – JONES (joint pain, myocarditis, Subcutaneous nodules, Erythema Marginatum, Chorea)
- Disseminated Gonococcal Arthritis
What is the history to elicit for gout?
- Joint distribution
- Demographics
- PC
- PMH
- Complications
- Aetiology
Joint distribution: 1st MTPJ, Ankle, Knee (or in jt w OA)
Demographics: middle-aged male patient
PC
- Max pain peak within 12- 24 hours- MUST ASK
- Intermittent (ddx is palindromic RA)
- Triggers (eg seafood buffet, read meats, alcohol, change in meds / diuretic use)
- Typical hx: went to sleep fine, woke up w excruciating pain
PMH
- Gout Hx
- Predisposing factor: *Metabolic syndrome
Complications – AKI (frothy/ blood urine, lethargy); Renal Stones
Aetiology – Cancer due to TLS (LOW, LOA, infections, anaemia, fever)
What is the history to elicit for pseudo gout?
- Joint distribution
- Demographics
- PMH
- Joint distribution: Knee, wrists
- Demographics: elderly woman
- History of OA
What is the history to elicit for septic arthritis?
- Joint distribution
- Demographics
- PC
- Risk factors
Joint distribution: knee, hips
Demographics: very young or old (seen commonly in children/ elderly)
Orthopaedic Emergency, Severe Pain in ALL ROM, a/w fever +/- systemic toxicity
Risk Factors (To Elicit!)
- Skin trauma
- History of bacteraemia / penetrating ‘injury’ (eg IA injection, jt aspirate, acupuncture)/nearby OM / IVDU
- Chronic joint injury (eg gout, OA, RA)/prosthetic joint
- Immunocompromised
What is the history to elicit for rheumatoid arthritis?
- Joint distribution
- Joint deformities
- PC
Classically bilat symmetrical deforming peripheral polyarthritis
Joint distribution – wrists, MCPJ, PIPJ (ALWAYS DIPJ sparing, but note possibility of concurrent OA esp in older pts
Possible deforming arthropathy – swan neck, boutonniere, Z thumb, ulnar subluxation, wrist dorsal subluxation
Extra-articular features: Just remember to ask for 1) MM 2) AA Subluxation 3) Incompetent Valves 4) Sicca
What is the history to elicit for ankylosing spondylitis?
- Symptoms
- Joint distribution
- Complications
Symptoms. joint distribution
- Ask about back pain: spondylitis
- Alternating buttock pain: sacroilitis
- Chest pain/reduced chest expansion +/- dyspnoea: costochondral joints
- Other joint involvement: hips, shoulders
Complications: 6As
- Acute anterior uveitis (30%) -> if untreated = permanent dmg and blindness. Severe eye pain, redness, photophobia and blurred vision = EMERGENCY
- Apical lung fibrosis (aka ILD)
- AR: early diastolic murmur
- AV conduction defects: 1st degree AV block
- Achilles tendinitis, plantar fasciitis: signs of Enthesitis
- Amyloidosis: infiltrative Dz causing IgA Nephropathy
What are the symptoms to ask for in psoriatic arthritis?
5 patterns of joint involvement
- Spondyloarthropathy (ie Spondylitis, sacroiliitis, enthesitis)
- Oligoarthritis -> MOST COMMON
- RA type (ie Symmetrical Polyarthritis).
- Interphalangeal (distal) arthritis -> affects DIPJ in hands and feet
- Arthritis mutilans
Skin: Scaly, erythematous rash, dactylitis. Important to check: scalp for rash and dandruff, belly button, buttock cleft
Nail changes – pitting, oncholysis, beau lines etc
May also have eye involvement (anterior uveitis), enthesitis, dactylitis
What are the symptoms to ask for in reactive arthritis/ reiter’s syndrome?
- joint distribution
- classic triad
Typically, acute asymmetrical Oligoarthritis (knees, hips)
Affects peripheral joints; lower > upper
Occurs 1-4 weeks after GI/GU infection
Classic TRIAD of Reiter’s syndrome
- Can’t see: Conjunctivitis
- Can’t pee: Urethritis or cervicitis
- Can’t climb a tree: arthritis
What are the symptoms to ask for in reactive arthritis/ reiter’s syndrome?
- past medical hx
- joint distribution
- extra GI manifestations
History of IBD – bloody mucoid stool, diarrhea, malabsorption
2 patterns of joint involvement
- Peripheral arthritis; lower > upper
- Axial Arthritis (ie Ankylosing Spondylitis): sacroilitis or spondylitis
After all, HLA B27 is a/w ankylosing spondylitis
Extra-GI Manifestations include:
- Skin: erythema nodosum, pyoderma gangrenosum
- Joint: peripheral / axial (due to a/w Ankylosing Spondylitis)
- Eye: uveitis etc
- Liver: hepatitis
What are the symptoms to ask for in reactive arthritis/ reiter’s syndrome?
- joint distribution
- other symptoms
- sex history
Typically migratory asymmetrical polyarthritis: affects many joints progressively: ankle -> knee -> wrist -> elbow -> shoulder -> hip
Check for rash: painless skin pustules, urethral discharge, urethritis
What are the symptoms to ask for osteoarthritis?
- joint distribution
- joint deformities
Typically weight bearing joints – knees, hips, C spine, 1st MTPJ, 1st MCPJ, DIP, PIP
Heberden’s nodes, Bouchard’s nodes, thumb squaring
Differentials for homogenous antibodies?
- histone: drug induced lupus
- dsDNA: SLE (95% SEPCIFIC) –> correlates w CNS, renal activity
- RA, Sjogren’s
Differentials for speckled antibodies?
- Ro, la: SLE, Sjogren’s
Differentials for nucleolar antibodies?
- Scl- 70: diffuse cutaneous systemic sclerosis (dcSSc)
Differentials for centromere antibodies?
- Centromeric: limited cutaneous systemic sclerosis (lcSSc)
- Anti-Sm: Spef for SLE (but 30% prev)
- Anti- RNP: MCTD
- Anti – Jo, Mi-2: Polymyositis, dermatomyositis
What are the differentials for positive Rheumatoid Factor?
+ve in 75% of RA
Other AI rheum diseases eg Sjogren’s syndrome (60-80%), SLE (25-50%)
Chronic infection eg chronic hep B, hep C, TB, leprosy
In RhF+ asympt pts, screen for Sjogren’s and chronic hep B
RhF will disappear after infection has been cleared
Low titres of Rh F w mechanical arthritis (esp DIP involv) is due to OA rather than RA
Hence look at clinical features, distribution, XR to determine!
What are the differentials for positive Anti-CCP (Anti-cyclic citrullinated peptide)?
Potential impt surrogate marker for dx and prognosis in RA
- May be detected in healthy individuals (1.5-9 years) before onset of clinical RA
- May predict eventual development into RA from undx inflam arthritis
- Marker of erosive disease in RA
CCP us a SPECIFIC test for RA hence a positive CCP rules in RA -> think ccP = sPecific
What are the differentials for positive ANA (Anti-nuclear antibody)?
Useful screening test for AI diseases when clinically indicated
Can be caused by virtually anything, hence most people are ANA +ve! Therefore:
- ANA is a SENSITIVE test for SLE, hence a negative ANA rules OUT SLE -> think seNsitive = aNa
- If positive, we will send for ANA profile (anti Ro, La, dsDNA, smith etc)
- If negative: however 5% of SLE are ANA -ve (these pt usually are anti-Ro / La positive)
Not disease-specific: other causes of ANA + include
- Healthy individuals: F>M, elderly, relatives of rheum pts
- Drug-induced: Isoniazid, procainamide, hydralazine
- Hepatic disease: AI hepatitis, PBC, alcoholic liver disease
- Malignancy: leukaemia, lymphoma
- Pulmonary disease: idiopathic fibrosing alveolitis, primary pulmonary HTN
What is the disease association with dsDNA? What is the appearance?
- SLE (95% SEPCIFIC): correlates w CNS, renal activity
- homogenous
What is the disease association with histone? What is the appearance?
- Drug-induced lupus
- homogenous
What is the disease association with Ro, la? What is the appearance?
- Sjogren’s (95%), SLE
- Speckled
What is the disease association with Scl-70? What is the appearance?
- Diffuse scleroderma (30%)
- nucleolar
What is the disease association with centromeric? What is the appearance?
- Limited scleroderma/CREST (60%)
- centromere
What is the disease association with anti- SM? What is the appearance?
- Spef for SLE (but 30% prev)
- centromere
What is the disease association with anti- RNP? What is the appearance?
- MCTD
- centromere
What is the disease association with anti- Jo, Mi2? What is the appearance?
- Polymyositis, dermatomyositis
- centromere
What is the disease association with cANCA?
probably Wegener’s granulomatosis (Granulomatosis with polyangiitis)
What is the disease association with pANCA?
perinuclear staining, anti-MPO (myeloperoxidase): probably idiopathic/pri crescentic GN > MPA (Microscopic Polyangiitis) > Churg-Strauss syndrome
What is normal synovial fluid appearance?
clear & straw-coloured, contains <200 WBC/mm3 (
What is inflammatory synovial fluid appearance?
yellow & cloudy, contains >3000 WBC/mm3
What is septic synovial fluid appearance?
yellow-green, opaque and less viscous, >50,000 WBC/mm3
What is haemorrhagic synovial fluid appearance?
Red/Rusty/Brown; RBC in aspirate; Trauma /haemophilia /bleeding diathesis
What is the appearance of gout under polarised light microscopy?
Gout: negatively birefringent, needle-shaped crystals of sodium urate
What is the appearance of pseudogout under polarised light microscopy?
Pseudogout: weakly positively birefringent, rhomboid-shaped crystals of calcium pyrophosphate
