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MD2 Rheumatology > Approach to Joint Pain > Flashcards

Approach to Joint Pain Flashcards

1
Q

How can joint disorders be classified? Give an example of each

A

Disorders of the cartilage, e.g. OA

Disorders of the synovial membrane, e.g. RA

Disorders of the synovial fluid, e.g. gout, septic arthritis

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2
Q

What processes can cause OA?

A

Primary (mechanical)

Secondary to long-standing joint disease (e.g. RA)

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3
Q

List 8 Sx important to ask about when taking a Hx from a patient with a musculoskeletal complaint

A

Joint symptoms: pain, swelling, stiffness

Constitutional symptoms: fever, malaise

Extra-articular manifestations: rash, eye Sx, bowel/urinary Sx

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4
Q

What are the 4 main aspects of any musculoskeletal examination?

A

Inspection

Palpation

Movements

Function

(+ special tests, general examination for extra-articular manifestations or other co-morbidities)

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5
Q

What Ix are commonly performed during diagnosis of musculoskeletal disorders?

A

Imaging: plain, U/R, CT, MRI

Bloods: for inflammation (e.g. ESR, CRP), Abs (e.g. RhF, ANA), others (e.g. urate, Ca2+)

Synovial fluid analysis

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6
Q

Give 4 examples of joint disorders in which ESR may be elevated

A

RA

SLE

Gout

Pseudo-gout

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7
Q

What possible patterns of disease are seen with joint disorders?

A

Temporal: acute vs subacute vs chronic, inflammatory vs mechanical Sx

Anatomic: assess NUMBER of joints affected (mono, oligo if 2-5, poly if >5), SYMMETRY of joint involvement, and whether joint involvement is predominantly PERIPHERAL or AXIAL

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8
Q

List 6 characteristics of mechanical joint pain

A

Chronic pain (months to years)

Slowly worsening

Worse with movement

Improved by rest

Not much swelling

Little stiffness (lasts for mins; usually 30 mins is cut-off)

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9
Q

List 6 characteristics of inflammatory joint pain

A

Acute or subacute pain (days to weeks)

May change quickly

Better with movement

Worse with rest

Swelling may be prominent

Stiffness prolonged (hours, and worse in the morning after prolonged immobility)

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10
Q

Mrs Smith is a 55 year old woman who presents with 1 year of gradually worsening R knee pain

Pain is worse after walking or prolonged standing and better with rest

What else would you like to ask?

A

Better localisation of site of pain

Associated features, e.g. clicking, locking, “giving way”

PHx of previous or recent injury, AI conditions

Menopausal status

Rx: pain medications

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11
Q

Give 2 DDx for pain in the upper lateral thigh

A

Gluteal tendonopathy

Intertrochanteric bursitis

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12
Q

What small joints are typically affected in OA?

A

DIPs (RA never affects these!)

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13
Q

What is the limitation of urate and Ca2+ measurement in the setting of musculoskeletal disorders?

A

Non-specfici

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14
Q

Inflammatory arthritis which is migratory - classic of which musculoskeletal disorder?

A

SLE

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15
Q

Which is the better form of imaging for joint pathology: MRI or CT? What can U/S be used for?

A

MRI (CT good for suspected # not deteced on XR)

U/S useful for detecting joint effusions

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16
Q

Describe the typical anatomical pattern of RA vs psoriatic arthritis

A

RA: classically symmetrical, peripheral joints

Psoriatic: classically asymmetrical oligoarthropathy

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17
Q

Give an example of a joint disorder primarily affecting the axial skeleton

A

Ankylosing spondylitis

18
Q

What does a description of a joint “giving way” under strain suggest about the nature of the pathology?

A

Usually indicates ligamentous injury

19
Q

What does “clicking/locking” of the joint indicate about the pathology?

A

Suggests meniscal problem

20
Q

Mrs Smith, 55 years old, presents with 1 year of gradually worsening R knee pain, worse after walking or prolonged standing, better with rest

Does not remember injuring the knee but it has “given way” a few times lately while she was walking and she almost fell

Otherwise well but struggles with weight

FHx: mother had OA and required TKR a few years ago

What should you look for on physical examination?

A

LOOK: posture (varus or valgus deformity), gait abnormalities, WARDS

FEEL: warmth, joint effusion, tenderness, crepitus, etc

MOVE: assess active and passive movement of joint (if passive > active, problem is with the surrounding structures not the joint itself)

Examine the joint above and below, and examine the back (pain can radiate from the back to the knee)

21
Q

What is the most sensitive part of the hip examination when assessing for true hip pathology?

A

Internal rotation

22
Q

Mrs Smith, 55 years old, presents with 1 year of gradually worsening R knee pain, worse after walking or prolonged standing, better with rest

Does not remember injuring the knee but it has “given way” a few times lately while she was walking and she almost fell

Otherwise well but struggles with weight

FHx: mother had OA and required TKR a few years ago

O/E: BMI 33, normotensive, afebrile, R quadriceps atrophy, mild genu varus of R knee, tenderness of R medial joint line, no effusions, ROM of R knee is 0-110 degrees while L is 0-125 degrees, knee ligaments all intact

What does the reduced R quadriceps muscle bulk suggest about the pathology?

Likely Dx?

What might have predisposed to this condition?

Ix?

A

Reduced quadriceps bulk may provide an indication of chronicity (favouring L leg over R)

Dx: OA

RFs: female, BMI, FHx

Ix: XR and MRI if persistent clicking and locking (i.e. if suspected meniscal or ligamentous involvement)

23
Q
A
24
Q

List 3 findings on XR in OA

A

Osteophytes

Reduced joint space

Subchondral sclerosis and cysts

25
Q

Do XR findings in OA correlate clinically with severity of disease?

A

Not necessarily; when deciding which knee to send for a TKR, be guided by the patient’s level of pain and discomfort, NOT the imaging findings

26
Q

Mr Smith, 75 years old, presents with 12/24 of acute pain and swelling in his R knee; pain is constant and worse when he tried to move the joint, or when touched

Does not remember injuring his knee

Can hardly bear weight on R knee

DDx?

A

Knee joint infection (i.e. septic arthritis)

Gout

Pseudo-gout

Haemarthrosis

Fracture

First onset of inflammatory arthritis (but unusual age for an initial presentation)

27
Q

What is the main pre-disposing factor for pseudo-gout?

A

Age

28
Q

List 7 RFs for septic arthritis

A

Penetrating joint injury

Surgery

Systemic sepsis

IVDU

Metal prostheses

Immunosuppression

Damaged joint (e.g. in setting of RA)

29
Q

List 5 RFs for gout

A

Chronic kidney disease (due to impaired uric acid secretion)

Hyperparathyroidism

Alcohol

Thiazide diuretics

Anything causing high metabolic turnover (e.g. post-surgery, psoriasis)

30
Q

List 3 RFs for haemarthrosis

A

Trauma

Blood-thinning medications

Bleeding disorders

Some rare tumours

31
Q

Can gout be differentiated from septic arthritis on the basis of medical interview and physical examination?

A

Often very difficult; both have acute onset pain, are not relieved by rest, and can both be accompanied by fever, swelling and redness over the joint

32
Q

Mr Smith, 75 years old, presents with 12/24 of acute pain and swelling in his R knee; pain is constant and worse when he tried to move the joint, or when touched

Does not remember injuring his knee

Can hardly bear weight on R knee

Ix?

A

General set of screening bloods (FBE, UEC, LFTs, etc)

Inflammatory markers (CRP, ESR)

If systemically unwell consider blood cultures

Consider knee aspirate

33
Q

List 1 contraindication for joint aspiration

A

Prosthetic joint

34
Q

Mr Smith, 75 years old, presents with 12/24 of acute pain and swelling in his R knee; pain is constant and worse when he tried to move the joint, or when touched

Does not remember injuring his knee

Can hardly bear weight on R knee

Synovial fluid aspirated from R knee was turbid and white; WCC in fluid was 30,000 cells/mL, and on polarising light microscopy negatively birefringent crystals were detected

Interpret the results of the synovial aspirate

Dx?

A

WCC elevated but not high enough (>50,000) for inflammatory condition; would be concerned about septic arthritis if >75-70% were neutrophils

Negatively birefrigent crystals are consistent with a Dx of gout

35
Q

Mrs Jones, 32 years old, presents with 6/52 of gradually worsening pain and stiffness in joint of her hands, wrists and feet

Previously well and has two children aged 2 and 5

DDx?

What would like to ask Mrs Jones?

A

DDx: RA, SLE, reactive arthritis, viral artritis (although should be over by 6/52)

Ask about systemic features (fever, allopecia, Raynaud’s, mouth ulcers, dry eyes or mouth, sun sensitivity), recent travel and illnesses (esp diarhoeal - can cause reactive arthritis), possibility of pregnancy

36
Q

Mrs Jones, 32 years old, presents with 6/52 of gradually worsening pain and stiffness in joint of her hands, wrists and feet

Previously well and has two children aged 2 and 5

Pain in the joints began 6/52 ago in her R wrist and spread to the small joints of her R hand and wrist, and hand on the L; in last 2/52 her forefoot has also been painful

Pain and stiffness is worse in the morning for several hours and improves a little around lunchtime

FHx: mother has RA

Smokes 5-10 cigarettes/day

No rashes or bowel Sx

Is sleeping poorly and not coping

DDx?

A

RA

SLE

Viral arthritis (parvovirus, Ross River virus, etc)

Psoriatic arthritis

37
Q

What is the relationship between smoking and RA?

A

Causative factor

Impacts treatment

Associated with poorer prognosis

38
Q

What are the ACR 1987 Classification criteria for RA?

A

4 of 7:

Morning stiffness >1 hour*

Swelling in 3 or more joints*

Swelling in hand joints*

Symmetric joint swelling*

Erosions or decalcification on XR

Rheumatoid nodules

Abnormal serum RhF

*Must be present for at least 6 weeks

39
Q

Mrs Jones, 32 years old, presents with 6/52 of gradually worsening pain and stiffness in joint of her hands, wrists and feet

Previously well and has two children aged 2 and 5

Pain in the joints began 6/52 ago in her R wrist and spread to the small joints of her R hand and wrist, and hand on the L; in last 2/52 her forefoot has also been painful

Pain and stiffness is worse in the morning for several hours and improves a little around lunchtime

FHx: mother has RA

Smokes 5-10 cigarettes/day

No rashes or bowel Sx

Is sleeping poorly and not coping

DDx: RA, SLE, viral arthritis, psoriatic arthritis, fibromyalgia

How will examining Mrs Jones assist in making a diagnosis?

A

Can differentiate on basis of joint involvement pattern and symmetry, can look for extra-articular features (e.g. rheumatoid nodules, psoriasis)

40
Q

Mrs Jones, 32 years old, presents with 6/52 of gradually worsening pain and stiffness in joint of her hands, wrists and feet

Previously well and has two children aged 2 and 5

Pain in the joints began 6/52 ago in her R wrist and spread to the small joints of her R hand and wrist, and hand on the L; in last 2/52 her forefoot has also been painful

Pain and stiffness is worse in the morning for several hours and improves a little around lunchtime

FHx: mother has RA

Smokes 5-10 cigarettes/day

No rashes or bowel Sx

Is sleeping poorly and not coping

O/E: afebrile, normotensive, normal general examination, soft tissue swelling (synovitis) of R 2nd and 3rd MCP, and 4th PIP and L 2nd and 3rd PIP, small effusion of the L knee and squeeze tender MTP joints bilaterally

Ix?

A

FBE

CRP, ESR

RhF

Anti-CCP

ANA

UEC

LFTs

Consider CXR to look for pulmonary fibrosis or if considering commencing methotrexate

41
Q

Mrs Jones, 32 years old, presents with 6/52 of gradually worsening pain and stiffness in joint of her hands, wrists and feet

Pain in the joints began 6/52 ago in her R wrist and spread to the small joints of her R hand and wrist, and hand on the L; in last 2/52 her forefoot has also been painful

Pain and stiffness is worse in the morning for several hours and improves a little around lunchtime

O/E: afebrile, normotensive, normal general examination, soft tissue swelling (synovitis) of R 2nd and 3rd MCP, and 4th PIP and L 2nd and 3rd PIP, small effusion of the L knee and squeeze tender MTP joints bilaterally

Ix: FBE Hb 105 WCC 6 Plt 250, CRP 12, ESR 45, RhF 52, Anti-CCP positive, ANA negative, UEC/LFTs normal

Interpret these results

A

Evidence of inflammation but not infection

Possible anaemia of chronic disease

RhF is measured as a ratio of IgG:IgM; a RhF of 52 is low titer (in 100s is more suggestive of RA; but not very specific, some elderly patients will test positive without symptoms)

Anti-CCP is more specific for RA and is positive

ANA negative makes SLE unlikely (very sensitive, so good test for those with joint symptoms but not in the general population)

42
Q

Describe the relative sensitivities and specificities of RhF and anti-CCP in the diagnosis of RA

A

RhF: sensitivity 70%, specificity 80%

Anti-CCP: sensitivity 70%, specificity 90%

MD2 Rheumatology (5 decks)

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