Ch 21: Arthritis & Back Pain Flashcards
Name a common cause of acute arthritis in young adults.
Hematogenous gonococcal infection
If Gram stains show Neisseria gonorrhoeae, they will appear as….
….gram-negative diplococci within neutrophils.
What is tenosynovitis?
inflammation of the tendon sheath where muscle attaches to bone
The primary (________) site of gonococcal infection is often asymptomatic. If disseminated gonococcal infection is suspected, where else should cultures be obtained from?
mucosal
blood, pharynx, rectum, urethra or cervix
What characteristic pattern is seen in oligoarthritis?
involvement of 1 - 3 joints in an asymmetric pattern
What are the common causes of oligoarthritis?
infection, crystal deposition (i.e. gout and pseudogout), and trauma
If a patient with acute arthritis has acrally located joints that are affected (i.e. wrist, elbow, knee, or ankle), what procedure should be done in the emergency department?
arthrocentesis
A specialist and/or ultrasound guidance should be considered for arthrocentesis of the _________ and ____.
shoulders and hips
Name the 4 classes of synovial fluid.
normal class I -- noninflammatory class II -- inflammatory class III -- septic class IV -- hemorrhagic
Describe normal synovial fluid.
high viscosity transparent clear with < 200 leukocytes per mL and < 25% of those leukocytes are neutrophils negative gram stain and culture
Describe class I (noninflammatory) synovial fluid.
high viscosity transparent light yellow with < 200 - 2,000 leukocytes per mL and < 25% of those are neutrophils negative gram stain and culture
Describe class II (inflammatory) synovial fluid.
low viscosity cloudy dark yellow 200 - 50,000 leukocytes per mL and > 50% of those are neutrophils negative gram stain and culture
Describe class III (septic) synovial fluid.
low viscosity cloudy dark yellow usually > 50,000 leukocytes per mL and > 50% of those are neutrophils gram stain and culture usually positive
Describe class IV (hemorrhagic) synovial fluid.
variable viscosity cloudy pink to red usually > 2,000 leukocytes per mL with lots of RBCs often > 50% of those are neutrophils negative gram stain and culture
What do fat globules in the synovial fluid indicate?
They strongly suggest intra-articular fracture.
When crystals are seen on synovial fluid analysis, how is gout differentiated from pseudogout?
polarizing microscopy
Is it possible for a class I or class II synovial fluid to show bacteria on Gram stain or culture?
yes, but it is rare
What percent of cases of gonococcal infection have a positive culture or Gram stain?
25%
Acute arthritis in the presence of normal joint fluid usually indicates….
…..trauma or osteoarthritis.
What conditions are associated with inflammatory (class II) synovial fluid?
acute gout, pseudogout, Reiter syndrome, rheumatoid arthritis, rheumatic fever
A tear in the ________ ________ ________ is the most common cause of hemarthrosis in the knee when no fracture is present.
anterior cruciate ligament
Hemorrhagic synovial fluid may also be seen in what other 2 conditions?
hemophilia and synovial neoplasms
________ fractures are particularly difficult to locate and require careful correlation with clinical findings (e.g. localized tenderness in the anatomic ________).
Scaphoid
snuffbox
The symptoms and signs of acute gouty arthritis include warmth, _________, induration, and extreme ____ in a joint, most commonly the ___________________ joint of the great toe. The next most commonly involved joint is the ____.
hyperemia, pain
metatarsophalangeal
knee
It is not helpful to order a ____ ____ _____ in an acute attack of gout.
uric acid level
NSAIDs may be used for the treatment of gout, namely ____________, however _______ is contraindicated because small doses may cause _____________.
indomethacin
aspirin
hyperuricemia
What is the recommended dosing strategy of indomethacin in treating acute gout?
50 mg, PO, Q 8 hrs for 2 days or until pain is tolerable, then rapidly taper dose to discontinuation.
Indomethacin should not be used in patients with ______ _____ disease and reducing dosing is required in patients with _______ or _____ impairment.
peptic ulcer
hepatic, renal
Name 3 other NSAIDs which are alternative to indomethacin.
ibuprofen
naproxen
ketorolac
In select patients with gastrointestinal contraindications, ____ __________ may be a viable alternative. For example, _________ (Celebrex), give 800 mg once, followed by 400 mg on day 1, then 400 mg BID x 7 days.
COX-2 inhibitors
celecoxib
Response to __________ strongly supports a diagnosis of gout.
colchicine
What type of drugs can be used in patients with gout who cannot take NSAIDs or colchicine?
Alternatively, a single dose of ___________________ _______ can be used in the patient who cannot tolerate oral medications to boost the patient’s endogenous steroid production and provide relief.
corticosteroids
adrenocorticotropic hormone
What kind of crystals are found in the joint of a patient with pseudogout?
calcium pyrophosphate
Pseudogout differs from gout in that the most commonly affected joint is….
….the knee.
What is chondrocalcinosis?
Chondrocalcinosis is a finding on imaging studies and means deposition of calcium in the cartilage. Calcium depositions have been found in other soft tissues as well.
Chondrocalcinosis is associated with pseudogout, but it is not diagnostic of it. Definitive diagnosis of pseudogout depends on….
….the presence of calcium pyrophosphate crystals in synovial fluid.
For treatment of pseudogout, aspiration of the joint is often ________ for relief of symptoms, but ______ may be helpful. Unlike patients with gout, patients with pseudogout do not respond as well to __________.
adequate, NSAIDs
colchicine
Oral or ______________ corticosteroids also work well for treatment of acute pseudogout episodes.
intra-articular
The most frequent pathogen in septic oligoarthritis is…
….Neisseria gonorrhoeae.
The most common pathogen in MONOarticular septic arthritis is….
….Staphylococcus aureus.
The onset of septic arthritis is usually less ___________ than that of gout.
precipitous
Acute migratory oligoarthritis followed in 1 to 2 days by acute arthritis localized to one or two joints is especially suggestive of….
….gonococcal arthritis.
Systemic symptoms and signs of infection are suggestive, but less ______ than expected. Systemic illness, particularly _____, is not a prerequisite to the diagnosis of septic arthritis.
common
fever
The higher the _____ _____ cell count in joint fluid, the greater the likelihood of bacterial or fungal arthritis.
white blood
If gonococcal arthritis is suspected, ________, urethral, and possibly pharyngeal and ______ cultures should be obtained. If sepsis is considered likely, __ ____ _____ __ ________ should be removed from the joint.
cervical, rectal
as much fluid as possible
All patient with suspected septic arthritis should be ____________ and started on __ ___________. Also, an __________ _______ should be consulted for possible incision and drainage of the infected joint.
hospitalized
IV antibiotics
orthopedic surgeon
Osteoarthritis or degenerative joint disease most commonly involves….
…..hips, knees, spine, and the distal and proximal interphalangeal joints.
First line treatment of osteoarthritis is _____________ and ________.
acetaminophen
exercise
What is erythema marginatum?
Erythema marginatum is an evanescent nonpruritic macular rash, is one of the major Jones criteria for the diagnosis of acute rheumatic fever.
Rheumatic fever or poststreptococcal reactive arthritis may present early as acute _____________ _____ pain.
monoarticular joint
Acute rheumatic fever is diagnosed using the _______ _____ criteria.
revised Jones
Poststreptococcal reactive arthritis will have only ____ of the Jones criteria and is usually ______________.
________ is rare, and the arthritis tends to be severe, recurrent and poorly responsive to _______ and other ______.
some oligoarticular Carditis aspirin NSAIDs
Patients should be ____________ if rheumatic fever is suspected. Initial treatment is __________ and ___________.
hospitalized
penicillin and salicylates
Revised Jones criteria for diagnosis of rheumatic fever:
Major criteria include… (5 features)
Pericarditis, myocarditis, or endocarditis Chorea Subcutaneous nodules Erythema marginatum Polyarthritis
[Revised Jones] minor criteria include…. (4 features)
- Fever
- Arthralgias
- Lab findings: elevated ESR, CRP, evidence of preceding streptococcal infection (increased titer of antistreptolysin O)
- History of rheumatic fever or rheumatic heart disease; increased PR interval on ECG
Diagnosis of rheumatic fever using the revised Jones criteria requires the presence of ___ major, or ___ major and ___ minor criteria with supporting evidence of recent group A strep infection.
two major
one major and two minor
Which joints of the hands/fingers are typically involved/not involved in rheumatoid arthritis?
proximal interphalangeal joints
metacarpophalangeal joints
Distal interphalangeal joints are not typically involved.
Rheumatoid factor is positive in __% of patients, therefore a negative test does not rule out RA.
Elevated ESR and CRP are also common, but ___________ findings.
85%
nonspecific
What drugs are now being used in the management of RA symptoms?
NSAIDs, aspirin, steroids, gold, penicillamine, methotrexate, cyclosporine, and sulfasalazine
What are spondyloarthropathies?
A cluster of chronic inflammatory rheumatic diseases that include:
(think of the acronym PAIR)
psoriatic arthritis,
ankylosing spondylitis,
intestinal arthritis (inflammatory bowel disease), and
Reiter syndrome.
The spondyloarthropathies are not associated with __________ ______ but have a strong association with ______.
rheumatoid factor
HLA-B27
What is enthesitis?
Enthesitis is an inflammatory process occurring at the site of insertion of tendons into bone.
Psoriatic arthritis is an inflammatory arthritis seen in up to \_\_% of patients with \_\_\_\_\_\_\_\_\_. Nail involvement (pitting, \_\_\_\_\_\_\_\_\_, onycholysis) is a clue to the diagnosis.
40%
psoriasis
dystrophy
“Intestinal arthritis” is an inflammatory arthritis seen in patients with __________ _______ or _____ disease.
ulcerative colitis
Crohn
Initial treatment of the spondyloarthropathies is with ______ in the emergency department. _____________ or other agents can be added in consultation with a ______________ if the patient cannot take or does not respond to NSAIDs.
NSAIDs
Sulfasalazine
rheumatologist
Reiter syndrome is a reactive arthritis with the classic triad of _________, ______________, and __________.
(What phrase helps to remember the triad?)
arthritis, conjunctivitis, and urethritis
can’t see, can’t pee, can’t climb a tree
Reiter syndrome is seen most commonly in young men ages __ to __.
15 to 35
The arthritis of Reiter syndrome affects primarily the ______-_______ joints of the lower extremities. Reactive arthritis occurs within 1 month of a _____________ (Chlamydia trachomatis) or enteral (Shigella, Salmonella, Yersinia, Campylobacter) infection. It is __________ and polyarticular. Arthrocentesis reveals a class __ inflammatory joint fluid.
weight-bearing
genitourinary
asymmetric
II
____________ improves recovery time for reactive arthritis due to Chlamydia but NOT for enteral causes. The typical reactive arthritis lasts _ to _ months, but patients can develop chronic or recurrent arthritis.
Tetracycline
4 to 5
What is the most common spondyloarthropathy?
Ankylosing spondylitis
The classic findings of ankylosing spondylitis include the following: gradual onset, age less than __, back pain and _______ _________ worse with inactivity and made better with exercise, at least 3 months’ duration, and radiographic evidence of ____________. Often a history of uveitis can be elicited.
40
morning stiffness
sacroiliitis
Viral arthritis is acute, _________, and polyarticular. The two most common viruses causing secondary arthritis are _______ and ___________. Mumps, adenoviruses, enteroviruses, and Epstein-Barr viruses have also been implicated.
symmetric
rubella
hepatitis B
Viral arthritis is caused by __________ __ ______ _________ that cause an inflammatory reaction.
deposition of immune complexes
The most frequently affected joints are the……..
The symptoms are usually self-limiting after several weeks but can last years.
proximal interphalangeal joints, metacarpophalangeal joints, knee, and ankle
ESSENTIALS OF DIAGNOSIS for systemic lupus erythematosus:
Arthritis associated with other ________ ________: rash, fever.
Positive anti–double-stranded DNA or positive ___________ ________ test.
systemic symptoms
antinuclear antibody
In the emergency evaluation of joint pain, it is important to distinguish between true articular (arthritis) and extra-articular (__________ and ________) causes.
tendonitis, bursitis
In contrast to diffuse pain, warmth, and tenderness across an arthritic joint, tendonitis generally produces more _________ pain that is reproduced with __________ of the affected tendon.
localized
stretching
Tendonitis is thought to be caused by __________ _______ resulting in damage and inflammation to the tendon and surrounding structures. If the history reveals a puncture or laceration over a tendon with erythema, pain along the tendon, fever, and severe pain on minimal passive tendon motion, an __________ process must be ruled out.
repetitive overuse
infectious
What are the adjunctive measures to treatment of tendonitis?
rest from repetitive motion, ice, splinting
______________ preparations may be appropriate for some patients. However, depot steroid administration should only be performed by an individual skilled in the procedure, because complications (e.g., local atrophy and _______ __ ___ ______) can result if corticosteroids are errantly injected into a weight-bearing tendon.
glucocorticoid
rupture of the tendon
Suspicion of an infectious tendonitis requires orthopedic consultation for possible _____ and _____ and hospital admission for appropriate intravenous antibiotics to cover presumptive _____ and _____ species.
incision and debridement
staphylococcal
streptococcal
Common sites of bursitis are _____ (_____) and _____ area.
elbow (olecranon) and prepatellar
What is a bursa?
A bursa is a sac normally containing a thin film of synovial fluid that cushions the interface between bone with ligaments and the overlying skin.
Septic bursitis is usually due to _____.
Initial outpatient therapy consists of _____ 500 mg by mouth four times daily. _____ may be substituted in penicillin allergic patients.
S. aureus
dicloxacillin
Clindamycin
_____ or clindamycin should be considered for outpatient treatment of suspected MRSA septic bursitis. Immunocompromised hosts should receive parenteral therapy with additional _____ coverage.
Trimethoprim/sulfamethoxazole
antipseudomonal
Name major (can’t miss) causes of non-orthopedic (visceral) acute back pain.
Pyelonephritis Nephrolithiasis Abdominal Aortic Aneurysm Aortic Dissection Pancreatitis Ruptured Abdominal Viscus Retroperitoneal Hemorrhage
A history of _____ or _____ _____ _____ increases the possibility that back pain is related to a vertebral fracture.
trauma
chronic steroid use
If bowel or bladder incontinence, saddle anesthesia, or bilateral neurologic deficit is reported, then an _____ _____ _____ (eg, spinal cord compression, cauda equina, or conus medullaris syndrome) is likely and must be investigated emergently.
epidural compression syndrome
Unilateral back pain in a nerve root distribution suggests _____ _____ or _____ _____ _____.
pre-eruptive zoster
nerve root compression
