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MBBS - Year 1 > Clinical skills - Monoarticular joint pain > Flashcards

Clinical skills - Monoarticular joint pain Flashcards

1
Q

Major joints

A 
Hip 
Knee 
Shoulder 
Elbow 
Ankle
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2
Q

Symptoms of OA

A 
Pain esp at night 
Swelling 
Deformity 
Reduced mobility 
Daily activities compromised
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3
Q

Management of OA

A 
Lose weight if overweight 
Painkillers 
Ease off on aggravating activity 
Exercise 
Walking stick 
Shoe wear
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4
Q

Clinical management of OA

A 
NSAIDs 
Physiotherapy 
Intra-articular injections 
Joint replacement 
Excision femoral head 
Osteotomy 
Athrodesis
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5
Q

Osteotomy

A

Cutting and realignment of bone

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6
Q

Pros of joint replacement

A

Almost instant cure of arthritic pain
Return of mobility
‘Normal life’ - get life back
Majority of joints are long lasting, only few need revisions

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7
Q

Cons of joint replacement

A

Operation
Major complications e.g death
Revision surgeries
Need to be careful

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8
Q

Options of surgeries

A

Fixation method
Bearing surface
Bone preserving/ sacrificing
Hemiarthroplasty/ total

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9
Q

Cemented joint replacement

A

Coated in hydroxypapatite

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10
Q

Principles of joint replacement operations

A

Bearing surface

Fixation to bone

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11
Q

Problems w/ joint replacement surgery

A

Infections
Aseptic looseinng
Metal on metal

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12
Q

Knee replacement surgeries

A

Total knee replacement - ACL always sacrificed
Unicompartmental total knee replacement
Patellar femoral joint replacement

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13
Q

Total knee replacement

A

PCL preserving

PCL sacrificing

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14
Q

Unicompartmental tkr

A

Fixed bearing

Mobile bearing

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15
Q

Complications of surgery

A 
Infection 
Dislocation 
Thromboembolic disease 
Leg length discrepancy 
Nerve palsy 
Fracture 
Ongoing pain
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16
Q

How long do hip and knee replacements last

A

10-15 yrs

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17
Q

What properties should joint replacement material have

A 
Strength 
Elastic modulus 
Biocompatible 
Bearing surface 
Attachment to bone
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18
Q

Crystals in crystal arthritis

A 
Monosodium urate (uric acid) - gout 
Calcium pyrophosphate - Pseudogout
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19
Q

Characteristic of synovial fluid in crystal synovitis

A 
>3.5 ml
Low viscosity 
Straw/ opaque colour vs clear
>10,000 WBC/ mm3 vs 200
>50% PMN vs <25
Crystals present
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20
Q

Pathognesis of crystal arthritis

A

Over production of uric acid (exogenous or endogenous)
Underexcretion of uric acid (abnormal renal handling of urate)
A combination of both

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21
Q

Causes of hyperuricemia

A

Overproduction

Under excretion

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22
Q

Causes of hyperuricemia -overproduction

A

Excess dietary purines
Alcohol abuse
Myleoproliferative disorder
Lymphoproliferative disorder

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23
Q

Causes of hyperuricemia - under excretion

A

Renal disease

Polycystic kidney disease

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24
Q

Drugs causing hyperuricemia

A

CANT LEAP

Cyclosporine
Alcohol 
Nicotinic acid 
Thiazides 
Lasix (feusemide)
Ethambutol 
Aspirin (low dose)
Pyrazinamide
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25
Stages of crystal arthritis
Asymptomatic hyperuricemia A/c gouty attack Intercritical gout Advanced tophaceous gout
26
Predisposing factors of crystal arthritis
Immediate post op period after major surgery Stroke Fasting Alcohol abuse Large intake of food w/ high purine content Local infection
27
Lab tests for crystal arthritis
``` Joint fluid analysis Culture to rule out infection Renal function Urine dipstick - haemoturia (gout and kidney stone) S. uric acid and WCC < 15,000/mm3 ```
28
Differential diagnosis of crystal arthritis
Degree of infl - diff to RhA Matched only by other crystal disease (pseudogout) or infection Podagra (1st MTP joint pain) characteristic of gout
29
Core aspects of management of crystal arthritis
Patient education Diet - low purine Reduce alcohol - increases serum urate production and reduces renal clearance Weight reduction
30
Food high in purines
Red meat Animal organs Fish e.g mackerel, herring, sardines
31
Treatment of acute attacks of gout
``` Joint rest and local ice NSAIDs or COX inhibitors Oral steroids Local steroid injection Oral colchicine ```
32
Intercritical gout
2 or more attacks in a year
33
Treatment of intercritical gout
Diet Alcohol Colchicine prophylaxis - 1st 3-6 months to reduce freq. of attacks Urate lowering drugs
34
Side effects of colchicine prophylaxis
Rash Hepatoxicity Severe hypersensitivity
35
Urate lowering drugs
Allopurinol Uricosuric drugs Presence of kidney stone or tophi - allopurinol drug of choice Not started for 2-3 weeks after an a/c attack
36
Uricosuric agents
Increase excretion of uric acid in urine, reducing uric acid in blood plasma Probenoid, Sulfinpyrazone & benzobromarone Small risk of uric acid stone formation
37
Allopurinol
Most commonly used drug in lowering uric acid Xanthine oxidase inhibitor: xanthine --> uric acid Lowers serum and urinary uric acid excretion Only started after lifestyle changes
38
Alternative to allopurinol
Febuxostat
39
Pseudogout
Deposition of CPPD in joint cartilage Chondrocalcinosis Presence of CPPD crystals associated w/ aggressive, destructive OA A/c and c/c forms
40
Chondrocalcinosis
Calcified cartilage on a x-rays
41
Conditions predisposing Pseudogout
``` Ageing Hyperparathyroidism Haemochromatosis Hypomagnesia Hypophosphatasia Acromegaly Trauma Infection OA ```
42
Clinical manifestations of pseudogout
``` Asymptomatic chondrocalcinosis Radiographic evidence w/out joint symptoms Common in 8th decade No attacks occur CPPD deposition in joints Cartilage damage Acceleration of OA ```
43
Acute Pseudogout
``` a/c mono arthritic - 25% Occurs more in elderly women than men Knee most involved - symmetrical Attacks are self limiting Parathryoidectomy and severe medical illness can ppt attack ```
44
Chronic pseudogout
Can mimic OA or RhA - pseudo OA more common | CPPD crystals associated w/ more severe OA and found in 60% of knee joints at time of replacement
45
Diganosing pseudogout
History Clinical examination Joint fluid analysis X-ray
46
Lab tests for pseudogout
Ca, s. uric acid, Mg, Ferritin, PTH Synovial fluid analysis -ve Gram stain and -ve cultures CPPD crystals - rhomboid shaped and weakly +ve birefringent
47
Radiographic appearance of pseudogout
Calcium deposition at triangular fibrocartilage Subchondral sclerosis Joint space narrowing Subchondral cysts formation Most common at radiocarpal articulation and 2nd and 3rd MCP
48
Differential diagnosis of pseudogout
Degree of infl matched by gout and active infection Gout - 1st MTP Rapid acceleration of infl - Pseudogout RhA and Pseudogout can coexist
49
Evaluation of patient w/ Pseudogout
``` Hx - family hx of hereditary chondrocalcinosis or haemochromatosis Metabolic association Hyperparathyroidism Hypomagnesia Hypophosphotasia Ca, PO4, LFT, Mg, uric acid ```
50
Treatment of acute pseudogout
Joint aspiration Steroid injection Anti-infl
51
Treatment of chronic pseudogout
Anti-infl Periodic intra-articular steroid injection Associated disease managed
52
Crystal composition in gout
Needle like
53
Birefringent of gout crystals
-vely
54
Most common joints affected in gout vs pseudogout
1st MTP vs Knee
55
Radiography of gout vs peusodgout
Rat bite vs white lines of chrondocalcinosis
56
OA is a disease of the entire joint incl
Cartilage, synovium, ligaments and bone | Breakdown --> pain and stiffness
57
Causes of 2' OA
``` Trauma Infection - septic arthritis Infl -RhA Perthe's disease Slipped upper femoral epiphysis ```
58
OA in hips
Head of femur loses shiny articular surface | Superior aspect is collapsed
59
OA in knees
Genau varus | Loss of space in articular cartilage causes twisting into midline
60
OA in hands
Heberden's nodes
61
Heberden's nodes
Tender, bony swellings on DIPJs
62
Orthopaedic surgery
Arthrodesis | Arthroplasty
63
Arthrodesis
Fusion - leads to loss of movement Sacrifice movement Pain relief Durable
64
Arthroplasty
Replacement Total joint arthroplasty (head and socket), pain relief, keep movement, may not be durable Hemi -arthroplasty - half Excision arthroplasty - removing joint
65
Immediate arthroplasty complications
Technical e.g. periopertaive fracture
66
Early arthroplasty complications
Infection | Dislocation - constrained or unconstrained (not as aseptic)
67
Late arthroplasty complications
``` Aseptic loosening (bone implant interface) Wear ```
68
Which pinches can a thumb do
Key pinch Tip pinch Tripod pinch
69
Elbow OA
``` Infl - RA Pain flexion/ extension Pain pronation/ supination Ulna-humeral Radiocapitellar - loss of joint space ```
70
Shoulder arthroplasty is an example of ..
Rotator cuff arthroplasty - but can be sublaxed, acromion degeneration. 'Cuff' stabilised and initiates movements of shoulder
71
Radiographic appearance of OA
LOSS Loss of joint space Osteophytes Subchondal cysts Subchondral sclerosis
72
Articular pain
From joint capsule, synovial, cartilage Diffuse, deep pain Pain on active and passive movement Swelling common and may have crepitus, instability, deformity
73
Examples of articular pain
Arthritis | Synovitis
74
Where does non-articular pain come from
Soft tissues - tendons, ligaments, bursa, muscles
75
Features of non-articular pain
Localised focal tenderness removed from joint capsules Painful active but NOT passive movement Swelling uncommon
76
Examples of non-articular pain
Bursitis Tendonitis Myostitis
77
Causes of acute infl mono arthritis
Infection Crystal induced Rheumatic disease
78
Infection as a cause of acute infl mono arthritis
Bacterial - septic arthritis Viral - ReA (rapid course) Fungal Mycobacteria
79
Rheumatic disease as a cause of acute infl mono arthritis
RhA SLE Sarcoid Usually polyarticular
80
Causes of acute non-infl monoarthrtitis
Tumour Degenerative Internal derangement Haemiarthrosis
81
Tumour as a cause of acute non-infl monoarthrtitis
Osteosarcoma | Metastatic disease
82
Degenerative causes of acute non-infl monoarthrtitis
Infl flare of OA | Erosive OA
83
Internal derangement as a cause of acute non-infl monoarthrtitis
Meniscal tear Fracture Ligament tear
84
Hemiarthrosis as a cause of acute non-infl monoarthrtitis
Trauma Over anti-coagulation Clotting disorder
85
Prevalence of RhA
0.5 -1%
86
M to F ratio of RhA
2.5 to 1
87
Diurnal variation of RhA
Worse in AM | Can also be periodic
88
Systemic symptoms of RhA
Fatigue Wt loss Swelling in salivary glands
89
Investigations in RhA
``` Systemic review FBC CRP/ ESR Raised platelets Anti - CCP ANA Joint erosions seen on X-rays ```
90
Why is PsA difficult to diagnose
Bone is affected before the skin
91
M to F ratio of PsA
1:1
92
Typical onset of PsA
During middle age
93
Prevalence of PsA
0.1 -1.0%
94
X-rays in PsA
Joint erosions | Whittling at end of phalanges - bone in cup
95
Treatment of PsA
Using anti-infl and corticosteroids
96
Who is mostly affected by ReA
Young people
97
M to F predominance of ReA
20:1
98
Which joints does ReA usually affect
Large joints e.g. knees and ankles
99
What proportion of patients w/ ReA will develop AS
1/3
100
How does ReA react to steroids
Responds well
101
Examples of intra-articular corticosteroids
Methylprednisolone | Triacinolone
102
Hydroxychloroquine
Useful for mild disease, lupus w/ skin and joint involvement 200mg daily taken w/ food
103
Side effects of hydrochloroquine
GI disturbance Headaches Skin reactions Retinal toxicity
104
Where is tophi deposited
Tophi can be formed and deposited in ANY joint or bone
105
Viscosity of synovial fluid in joint infl
Decreased
106
Non-uniform blood staining in synovial fluid
Indicative of trauma
107
Histology of OA
Wear and tear effect on articular cartilage ---> fissures & eburnation Causes degeneration and loss of ground substance (glycosaminoglycans) Results in loss of elasticity and erosion of cartilage Bones then rub together Attempt at repair causes osteophytes
108
Sclerosis vs chondrocalcinosis
Subchondral sclerosis is in the bone | Chondrocalcinosis is in the soft tissue
109
Why do we usually not see swelling in hip osteoarthritis
Hip is a very deep joint
110
What aspect of the knee does OA usually affect
Medial weight-bearing surface
111
Se of allopurinol
Fever, rash and a decreased white cell count
112
Risk factors for tophaceous gout
Hyperextension Heart failure Renal impairment
113
What can cause bilateral prepatellar bursitis
Gout

MBBS - Year 1 (93 decks)

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