bone and joints Flashcards
History of sore joints. Key questions to history?
- Which joints?
- Morning stiffness?
- night pain?
- joint swellings?
- associated with psoriasis, inflammatory bowel disease or other autoimmune disease.
- extraarticular features.
Clinical features of osteoarthritis?
- Bony tenderness
- Bony enlargement
- crepitus
- deformity
- lack of inflammatory features; boggy, joint swelling, or prolonged morning stiffness.
Locations:
- Hands: DIP and PIP joints, base of thumbs
- Hips
- Knees.
Other differentials of multiple joint pains?
- Non articular - bursitis
- Polyarticular
- Crystal arthropathies - gout and pseudo gout
- inflammatory arthropathies - rheumatoid arthritis, psoriatic arthritis
- Wide spread pain
- fibromyalgia
- polymyalgia rheumatoica.
Features of inflammatory arthritis?
- Pain at night
- Pain in the morning
- Prolonged stiffness >1 hour
- intermittent joint swelling
Investigations for suspected inflammatory arthritis?
- inflammatory markers: ESR or CRP
- Autoimmune serology: Rheumatoid factor, anti-CCP
- Imaging; x-ray and ultrasound
- Fluid biopsy
Osteoarthritis manamgenet:
Non-pharm
- Weight loss - dietitian referral
- Exercise - muscle strengthening
- Educations -
- Occupational therapy - splints, walking aids.
Pharma:
- Paracetamol
- NSAIDS
- PPI - in conjuction with NSAIDs
- Opioids
- Corticosteroid injections - minimal evidence -
- Hyaluronic acid - minimal evidence
- Topical NSAIDs and capsaicin cream -
What therapy is particular helpful in hand OA?
Topical naiads and capsaicin cream
Complementary or alternative therapy useful in OA?
- Chondroitin sulphate
- Glucosamine supphate
limited evidence in: every other complementary:
- Acupuncture
- Fish oil
- avocado
- greenlipped mussels, giner, indian frankincense, phytodolor, pine bark extracts, chinese herbal medicine, turmeric, vitamin A, C, E, B.
Indications for surgery in OA?
- significant functional disability and pain despite conservative measures.
What are features that would suggest inflammatory back pain? i.e. spondylar arthropathies
- morning stiffness >30min
- improvement
- awaking in the second half of the night
- alternating buttock pain
Ddx of spondyloarthritides
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- arthritis of inflammatory bowel
- juvenile spondylar arthropathiees
Investigations of spondyloathritides?
- X-ray - AP pelvic, and lumbar spine X-ray
- HLA - B27
- inflammatory markers - ESR and CRP
- Renal and LFTs
How to diagnose Ankylosing Spondylitis
Sacroillitis on conventional X-ray +
History of inflammatory back pain
Non-radiographic axial SpA: lacking radiographic changes, but with history features - may warrant MRI spine
Management of Ankylosing Spondylitis?
NON-PHARM:
- Exercise
- Spinal stretching program
- Physio
- Smoking changes
PHARM:
- NSAIDs
- DMARDs
What DMARDS are used in AK?
- Sulphasalazine and methotrexate.
Side effects of sulphasalazine
- Rash
- GIT upset
- headaches
- Dizziness.
- Tinnitus
- Photosensitivity
- Orange discolouration of body secretions
Do you need regular monitoring of sulphasalazine
Yes:
- LFTs and FBE
- every 2-4 weeks
- then every 3 months when stable
DDX of mono arthritis?
- Crystal arthropathies
- gout
- pseudo gout - Infection
- septic joint
- Reactive arthritis
- Osteoarthritis
- Seronegative arthritis: Psoriatic arthritis, reactive arthritis and inflammatory arthropathy associated with inflammatory bowel disease are also known to cause monoarthritis,
Investigations of mono arthritis? Suspecting gout.
1.Serum uric acid
2. Joint aspiration for microscopy/culture and sensitivity, cell count and differential and crystal analysis.
3. FBE, LFTs, electrolytes
4 ESR and CRP -
5. Blood cultures if suspecting infection
6. radiographs to assess for erosions
what does gout look like on aspiration?
Monosodium urate crystals are needle-shaped crystals with negative birefringence
Management of gout?
NON-PHARM:
1 Diet - reduce purine - shellfish, offal,
- refrain from sugar-sweetened drinks
2. Reduce alcohol
2. Weight loss - consider dietician referral
3.
PHARMA: Acute setting: 1. NSAIDs 2. Colchicine 3. Steroid - oral in polyarticular gout
Long term -
1. Allopurinol
What is the target serum uric acid level?
Less than 0.36 for non-tophaceous gout
<0.3 for tophaceous gout
What is allopurinol hypersensitivity syndrome?
Rare; estimated 0.1% - high mortality 27%
Symptoms: severe cutaneous reactive - Stevens-Johnson syndrome, eosinophilia, leukocytosis, fever and multi organ failure.
Risk factors: pre-existing renal impairment, diuresis, recent initiation of allopurinol.
Alternative to allopurinol?
as adjunct to allopurinol - consider probenecid
Second like - instead of allopurinol
- febuxostat
- probenecid
ottawa ankle rule for fracture
Plain X-ray of pain in the malleolar zone +
1. bony tenderness alone the distal 6cm of posterior edge of distal fibula and tibia.
Plain x-ray if: pain in the mid foot +
1. Tenderness over the navicular or 5th metatarsal
Plain x-ray if - inability to weight bear, or more than 4 steps.
Management of avulsion fracture:
Conservative management: Non-weight bearing as necessary progressing to partial then full weight bearing usually takes 3-4 weeks Simple analgesia NSAIDs may impair fracture healing
When to consider surgical referral
surgical assessment of avulsion fracture is indicated if fracture is displaced by more than 2mm, or involves greater than 30% of articulation with the cuboid
When can she return to dancing?
Need to progress throat a structured rehabilitation program:
- Partial to full weight bearing
- Regaining normal ROM in ankle movement
- Regain calf strength
- regain normal balance and proprioception
- returning to dance drills that do not require jumping and landing.
