Bones & Joints Case Studies

Question 1

You are an 18 year old male with right elbow pain. A week ago you were mucking about with your friends when your friend shoved you and you tripped and fell forward, breaking your fall with an outstretched right hand. There was immediate pain and swelling but it wasn’t that bad and you could still move your arm so you weren’t concerned. There is some difficulty straightening the arm. The pain comes on every time you move. Some bruising around the area came on later that day. The pain hasn’t improved much after a week so that’s why you’re seeking help now. You haven’t tried anything to relieve the pain.

Questions

1) For the following conditions, what are the reasons for and against them being the diagnosis? What are additional history/physical examination/investigation findings that would confirm the diagnosis?

Gout

Septic arthritis

Fracture

2) Which diagnosis is most likely given the information provided?

Answer 1

DX

• Gout:

1. Might be triggered by trauma.
2. Usually in big toe (elbow is an unusual location).
3. Associated redness, swelling, and pain quite severe.
4. There may be previous personal history or there is a
5. family history.
6. Blood tests might indicate high urate levels.
7. There will be response to anti-inflammatories like
8. ibuprofen (e.g. nurofen).

• Septic Arthritis
  
  1. There will be associated fever, fatigue, loss of appetite.
  2. Significant pain, swelling, redness.
  3. If no penetrating injury/procedure, very unusual in
  4. immunocompetent.
  5. Diagnosed and treated with surgery (and antibiotics in hospital).
• Fracture
  
  • Immediate pain and swelling supportive of fracture.
  • No improvement over 1 week supports fracture over
  • simple soft tissue injury.
  • X-rays can confirm.

2) Which diagnosis is most likely given the information provided?

Fracture should be excluded.

Question 2

You are a 66 year old Caucasian female with mid back pain. This started after slipping on a rug yesterday and landing on your bottom. The pain got worse during the day. You find it difficult to stand/sit for long periods at a time. The pain doesn’t radiate anywhere, there is no problem with urination/bowel motions. You lead quite a sedentary lifestyle. You went into menopause early at age 40 year old. You don’t spend much time in the sun. You’ve had no recent unexplained weight loss, loss of appetite, night sweats. You are up to date with your 2 yearly mammograms.

Questions

1) What are the red flags in this case?
2) What are your differential diagnoses?
3) What are the risk factors for the underlying pathology?

Answer 2

Red flags:

• Age > 50.
• Low Impact Trauma.

Differential Diagnosis

1. Fracture.
2. Fracture secondary to underlying osteoporosis.
3. Fracture secondary to underlying cancer.
4. Infection in the spine.
5. Bleeding into the spine

Risk Factors for Osteoporosis

• Female.
• Post menopausal.
• Caucasian.
• Sedentary lifestyle.
• Possible vitamin D deficiency.
• Early menopause.