Clinical Correlate on joint scheme Flashcards
What makes a person high risk for infection?
What are some signs of infection in the joint?
What joints are usually infected?
Steroid therapy -Immunodeficiency -Diabetes -IV drug abuse -Other: UTI, pneumonia, Bite, thorn, invasive procedure
Resistive to passive ROM, joint pain and swelling, fever
Hips, knees, ankles, wrists
52 y/o patient presents with a swollen painful knee having a history of SLE as well as steroid therapy. She complains of a 4 day onset and has a low grade fever. Upon PE you feel a boggy crepitus joint cavity around the knee. What’s the first thing you should do, or order?
A) X-ray the joint
B) CBC and White count differential
C) Gram stain
D) Synovial fluid analysis
Many or all of these would be done, so how do you choose first? According to Dr. Winfield a joint aspiration will do a few things for you. 1) , give you fluid to gram stain (fast) and culture, determine the type of antibiotic you need, cell count, and crystal ID 2) reduce swelling 3) pain relief for the patient.
The next best would be probably be a gram stain, CBC with white count diff, and maybe also a BUN test (uric acid crystals).
You may not need to x-ray the joint at all, but it may determine if the bone is infected
What’s another name for uric acid and how does it get into the joints? What events commonly trigger this? What’s the presentation?
monosodium urate which supersaturates the serum and precipitates into the tissues.
Triggers: start or stop medication (even if uric acid levels are lowered it could trigger a gout attack), diuretics
Presentation-
Red, swollen, painful joint with possible fevers and chills.
Often starts at night.
Initial episodes 50% time start with the first metatarsophalangeal joint (big toe)
Usually lasts 5-7 days → resolves spontaneously.
The time line of onset and resolution, as well as joint location help separate this from an infection.
What are some ways to separate Articular vs Non-articular issues when searching for a diagnosis? How do you make this determination and which tissues are involved in both of these definitions?
Articular
⇓ Active/Passive motion range
Pain provoked/aggravated by movement
Tissues: synovium, synovial fluid, articular cartilage, intra-articular ligaments, joint capsule, and joint bones.
Non-articular
Joint motion is preserved (especially Passive; Active may be limited by pain)
Tenderness by palpation
Tissues
Regional bursa, Tendons, Ligaments, muscles, fascia, nerves, skin.
What are some clinical identifiers of RA?
Inflammatory****** Waxing and waning disease activity - >1 hour of morning stiffness******* - Improvement with use - Systemic symptoms (fever or malaise)***
What are some clinical identifiers of osteoarthritis?
Most common form of arthritis “wear and tear”
Pain after use that improves with rest No systemic symptoms Often single joint*** distal interphalangeal joint swelling*** Non-inflammatory***
Risk Factors Age Obesity Occupation repetitive bending, physical labor Female Trauma
Locations-spine hip knee hands
What are the clinical criteria of OA of the knee?
Knee pain with at least 3 of following:
1. Age > 50 years old 2. Stiffness < 30 minutes 3. Crepitus 4. Bony tenderness 5. Bony enlargement 6. No palpable warmth
What are some non pharmacological interventions for osteoarthritis? What about other managment?
Weight loss – especially for hip and knee OA
- Work simplification
- Use of a cane or a walker
- Physical therapy (quadriceps muscle strengthening)
- OMT
NSAIDs, opioid analgesics
corticosteroid injections
surgical intervention
WHATS THE TAKE HOME MESSAGE FOR THIS LECTURE?
Know the material and then integrate it into solid clinical presentations. Work your way through the scheme using the clues you have.
A 50 y/o patient complaining of joint pain a few nights prior comes into your office for a PE. Her vitals indicate a low grade fever and she has swelling on the first metatarsalphalangeal joint which is painful when she moves it. She takes a few medications including ibuprofen and a diuretic, but other than the joint pain feels and appears healthy. Her favorite hobby is gardening and you notice scaring from previous cuts along the knuckles. Her patient history states that her last visit was due to an infection in her hand about 1 years prior. What is the likely cause of her condition?
A) Viral infection
B) Gout
C) Osteoarthritis
D) Rhumatoid arthritis
B) correct-indicated by the evening onset and first appearance on the first metatarsalphalangeal joint (big toe) and the diuretic which can lead to crystal formation.
A) Was meant to throw a curve ball because gout has similar symptoms to an infection: fever, swelling, pain, and her last appointment and occupation are there to raise suspicion.
C and D) arthritis types can blend together and these were there as red herrings.
36 y/o female presents with fairly recent trauma to the left knee joint (5 months prior) while playing ultimate Frisbee with some only friends at a high school reunion. Apparently, someone thought it would be funny to “clip her.” No ligament tears were reported by her previous physician, but the joint is painful when used and is stiff in the morning for about 20-30 mins. What’s the likely etiology of her condition?
A) Rhumatoid arthritis
B) Osteoarthritis
C) Gout
D) Muscle strain
B) correct- clues: gender, joint pain when used, and stiffness under 30 mins.
A) Risk factors for both RA and osteoarthritis are trauma, and gender. RA pain improves with use and usually lasts longer than 1 hr in the morning.
C) Nope
D) A partial tear could be aggravated in not immobilized but there is less evidence for this. Complete tear would present differently.
You have a young 23 y/o male patient present with low back pain. He says it’s been ongoing for about 6wks and you notice he’s hunched forward which is consistent with his story of low back pain. Standing flexion exam is neg, but seated flexion exam is positive on the left side. Serologic studies are neg. What do you conclude on this information alone?
He has ankylosing spondylitis- aside from stating that the condition has a genetic predisposition. HLA-B27 (class I) all the classic signs are present.
What make Psoriatic arthritis unique and how do you detect it clinically?
Psoriasis predates the arthritis for years. This is probably the most important finding for clinical diagnosis as the joint distribution varies.
Seronegative, chronic inflammatory condition
HLA1-B27
Psoriasis-salmon colored rash, nail pitting
You have a young man 26 y/o present with abdominal cramps and pain, with recurrent diarrhea and weight loss. He’s been having problems also with aching joints but suspects the flu. Though he has no fever, chills, or any other signs of infection, and hasn’t done any recent traveling out side the US. An unusual finding is some inflammation around the eyes. He reports this isn’t the first time he’s had these symptoms. What’s your best guess at this point?
Inflammatory bowl disease with recurrent inflammmation of the intestines; arthritis often fluctuates with bowl involvement.
Genetic component -white or jewish
Age 10-60 y/o
Presents-cramps, pain, diarrhea, weight loss, hematochezia
also inflammatory eye disease and skin lesions.
How do you diagnose Inflammatory Osteoarthritis?
A) Serologic inflammatory markers are elevated: ESR, CRP
B) Swelling of the soft tissue in the PIP and DIP joints
C) Serology for ACCP is negative
D) ROM exercises are impeded
B) is correct
This is how you diagnose this disorder
A) These markers will be normal
C) This rules out RA
D) nonsense
What are the 3 major signs of an acute post infectious arthritis/reactive arthritis?
Genetic predisposition
Recent infection
Trouble with see, pee, and climb a tree
aka- conjuctivitis, urethritis, and arthritis.
What information would arthrocentesis of methaline blue reveal about whether a joint was open or closed?
If the dye traveled through the joint to the laceration it would reveal itself as an open joint.
Any deep wound in the proximity of a joint should be suspected of being what?
An open joint injury
What would you debride a bacterial infection, or traumatic injury?
To prevent bacterial colonization from foreign material (soil etc), and to clean up death neutrophils and other tissue. This can also result in poor antibiotic penetration into the affected tissue. Make a less hospitable environment for facaltative anaerobes.
Define cellulitis based on Dr. Brysacz lecture
A milder form of soft tissue infection without association of microvascular thrombosis and necrosis. No signs of systemic toxicity and can be treated adequately with antibiotic therapy.
Patient has sudden onset monoarticular pain with elevated ESR and Uric acid. Should you aspirate the joint?
yes even if you suspect gout, because they could have an underlying infection
How do you treat an osteochondroma? What about Osgood schlatter disease?
Osteochondroma is a benign bony growth with a cartilage cap usually originating from long bone. Can be removed surgically, most do not become malignant.
Osgood schaltter is a self limiting ossicle of the proximal tibial growth plate. Manifests in kids with limping.
Do no inject with steroids as this can soften the bone around the growth plate and affect growth.
What is Virchow’s node? What does it suggest is present? What should you do as a family physician with this information?
Lump on the supraclavicular fossa, suggestive of breast cancer.
Do a mammogram, or chest x-ray. Look for breast or lung cancer.
Right side usually breast
Left-could be anything:breast, lung, GI
What is a panendoscopy and what type of malignancies should never have an incisional or excisional lymph node biopsy without doing this first?
A panendoscopy is a complete physical examination of the head and neck by pharyngoscopy, laryngoscopy, and upper GI endoscopy
Malignancies of the head and neck, with or without adenopathy
Why? you can spread it, or loose the chance to find the primary source
FNA is ok (fine needle aspirate)
How would an ultrasound be useful when exploring the nature of a mass in the supraclavicular fossa?
useful in determining whether the mass is solid or cystic
What are some complications of biopsy techniques?
Bleeding, infection, hematoma, brusing, damage to other structures (nerves, arteries, lympatics), scarring.
What are the red flags for infection of the cervical spine historically and during physical examination?
How would you distinguish a superficial from a deep infection?
Historically-
Fever and chills
Night sweats or pain, unexplained weight loss
Recent infection
Unremitting pain despite rest and NSAIDs
(high risk activities for infection IV drugs etc)
Physical findings- FEVER
Superficial-
Fever/chills and sweats
Neck pain, stiffness, swelling (w/o peritonsillar abscess)
Deep- Tachycardia
Elevation of the floor of the mouth
Bulging of the pharyngeal wall
TAKE IMMEDIATE ACTION IF:
PAIN out of proportion
Advanced airway signs (voice change, dyspnea short breath. Signify impending airway obstruction)
What do you call an infection of the: vertebrae, intervertebral disk, Epideral space, or Fascial planes?
Osteomyelitis, Discitis, Epidural abscess, Fasciitis
If you suspect a deep neck infection is meningitis, how would you perform a physical exam and what findings would you expect?
Fever >100.4, altered mental status, nuchal rigidity
Lay them supine and ask them to flex the neck, the legs should flex in response, or have them attempt to extend the leg while the hip is flexed.
What are the Historical and Physical finding red flags for neurologic maladies of the cervical spine?
Historic-major trauma or minor trauma in the elderly
Physical- Bowl or bladder incontinence Saddle anesthesia Decreased or absent anal sphinter tone Perianal or perineal sensory loss Severe or progressive neurologic defect Major motor weakness
What is the mechanism of injury in an Occipito-Atlantal Dislocation (OAD)? What is the reason for the high mortality associate with this condition, and which nerves are involved?
Hyperflexion or extension or lateral flexion
Ligamentous instability-these ligaments hold your head to your spine
CN VI X XI paresis; apnea
What’s a radiculopathy and what are the common causes of it? What would you observe upon taking a history and physical exam?
Nerve root compression at the neck with pain, tingling and numbness sometimes accompanied by loss of function
Common causes: neural foraminal narrowing from cervical arthritis in older adults
cervical disk lesion (disk degeneration or disk herniation)
C5-6 or C6-7 (most common)
History
neck stiffness
pain radiating to the shoulder/ upper extremity
aggravated by coughing sneezing or straining
paresthesias of the fingers
weakness in the extremity
Physical
Reduced lordosis
Reduced ROM
Arm pain on extension
Cervical fracture (broken neck) history and physical findings are what?
History- Significant trauma Severe pain, spasm, tenderness Radiating arm pain Global sensory – motor deficits (spinal cord injury)
Physical-
Swelling/bruising
Tenderness & spasm on palpation
Whiplash-acute cervical strain/sprain
Physical normal neruologic exam
Validity of MRI in the upper cervical spine ligaments to detect acute whiplash injury has not been demonstrated
