GP Student Handbook Joint Symptoms

Question 1

Which blood tests are appropriate in joint pain

Answer 1

ESR
CRP
Urate
Anti-CCP

Question 2

What is the use of anti-ccp blood test?

Answer 2

Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the diagnosis of rheumatoid arthritis, with high specificity, presence early in the disease process, and ability to identify patients who are likely to have severe disease and irreversible damage.

Question 3

Important points to cover in the assessment of joint pain?

Answer 3

• Pain – site/radiation
• Is the pain worse on activity or rest? Is it worse at night?
• Does the pain keep the patient awake?
• Does the pain limit the patient’s activity?
• Stiffness of joint, especially morning stiffness
• Swelling
• Redness
• Heat
• Joint instability
• Locking
• History of trauma

Question 4

Osteoarthritis (OA):
What is it?
Which joints?

Answer 4

In osteoarthritis, the protective cartilage on the ends of your bones breaks down, causing pain, swelling and problems moving the joint. Bony growths can develop, and the area can become inflamed (red and swollen).
• Most commonly affected joints are knees, hips, small joints of the hands and the spine

Question 5

Rheumatoid Arthritis (RA):
What is it?
Epidemiology
Presentation?
Test?
Non-rheumatological effects?

Answer 5

RA is a chronic systemic inflammatory disease, characterized by a symmetrical, deforming, peripheral polyarthritis. It increases the risk of cardiovascular disease by 2–3 fold.

Epidemiology:
• Rheumatoid arthritis affects about 1% of the population. The onset is usually between the ages of 40 and 70 and the female: male ratio is approximately 3:1.

Typical presentation: Symmetrical swollen, painful, and stiff small joints of hands and feet, worse in the morning. This can fluctuate and larger joints may become involved.
Tests: Rheumatoid factor (rhf) is positive in ~70%. Anticyclic citrullinated peptide antibodies (anti-ccp) are highly specific (~98%) for ra with a reasonable sensitivity (70–80%); they may also predict disease progression.

Non-rheumatological effects:
CV mortality, increased rate of atherosclerosis formation

Question 6

Gout:
Presentation?
Cause?
Risk factors?

Answer 6

Gout typically presents with an acute monoarthropathy with severe joint inflammation. >50% occur at the metatarsophalangeal joint of the big toe (podagra).
Other common joints:
-ankle, foot, small joints of the hand, wrist, elbow, or knee. It can be polyarticular.

Cause: It is a disorder of purine metabolism characterized by hyperuricaemia and the deposition of monosodium urate crystals in articular or peri-articular tissues and in the renal tract

Risk factors:
• Older Age
• Gender: urate levels are higher in men than in women and also an increased risk in prevalence of gout in men of all ages
• Diet: Red meat and seafood increase risk, low-fat dairy reduces rik
• Alcohol
• Drugs: loop and thiazide diuretics, high dose aspirin of (>3000 mg/day)
• Obesity
• Renal insufficiency
• Hypertension
• Heart failure

Question 7

Pre-patellar bursitis:
What is it?
Cause?
S/S?

Answer 7

Prepatellar bursitis is an inflammation of the bursa in the front of the kneecap (patella).
It occurs when the bursa becomes irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the knee.

Cause
Prepatellar bursitis is often caused by pressure from constant kneeling.
A direct blow to the front of knee can also cause prepatellar bursitis.
Increases risk with rheumatoid arthritis or gout.

S/S
Pain with activity, but not usually at night
Rapid swelling on the front of the kneecap
Tenderness and warmth to the touch
Bursitis caused by infection may produce fluid and redness, as well as fever and chills

Question 8

Bakers cyst, what is it?

Answer 8

Popliteal cyst/bursa (herniation of joint synovium) can cause swelling and discomfort behind the knee.

Usually caused by a degenerative knee, inflammation or cartilage tear

Rupture may result in pain and swelling in the calf mimicking DVT.

Treat underlying knee synovitis. Surgical cyst removal may be necessary if persistent problems.

Question 9

Septic arthritis:
What is it?
Presentation?
Organism?
Treatment?

Answer 9

Disease Description:
• Inflammation of a joint due to an infection
• Monoarticular more common than polyarticular

Presentation:

• Pain (Increases with motion –> Inability to weight bear)
• Swelling
• Fever

Organisms:
• Staphylococcus aureus is the most common
• Other organisms include Neisseria gonorrhoeae and gram-negative rods.

Treatment:
• IVantibiotics guided by Gram stain if positive (see following)
• Empiric IV antibiotics if Gram stain negative (see following)
• Orthopedic consultation for surgical treatment

(Other Key Issues:
• Pediatric cases are often associated with bacteremia, and seeding can occur via the intra-articular physes.
• Gonococcal arthritis is a migratory arthritis associated with dermatitis and tenosynovitis)

Question 10

Osteomyelitis
Disease Description: 
Diagnostic Tests:
Organisms:
Treatment:

Answer 10

Disease Description: Osteomyelitis is an infectious process that affects any part of the bone, including the periosteum, the cortex, or the marrow. Depending on the time course of the infection, it can be an acute, subacute, or chronic process.
Osteomyelitis is often characterized by its source: contiguous or hematogenous spread of bacterial infection or the consequence of vascular insufficiency.

Diagnostic Tests: X-ray, Full blood count (FBC), ESR, CRP ± magnetic resonance imaging (MRI) and computed tomography (CT)

Organisms:
*Staphylococcus aureus;
Also Streptococcus species, gram-negative bacilli, Pseudomonas aeruginosa, and Staphylococcus epidermidis

Treatment:

• Broad spectrum empiric antibiotic treatment should begin immediately if the patient is unstable or if there are no immediate plans to obtain bone biopsy.
• Consider oxacillin 1 to 2 g IV q6 hours; if methicillin-resistant S. aureus (MRSA) is suspected, consider vancomycin 25 mg/kg (initial dose), then 15 mg/kg IV q12 hours* and cefepime 2 g IV q8 hours. If chronic osteomyelitis is suspected, consider vancomycin as well as piperacillin-tazobactam 3.375 to 4.5 g IV q6 hours.

Other key issues: Consult appropriate services (eg, orthopedics and infectious diseases) for long-term management and biopsy.

Question 11

Red flag for infection?

Answer 11

(i.e. for septic arthritis or osteomyelitis)
• Sudden onset of redness, swelling, heat, and reduced movement of the knee
• Difficulty weight bearing
• High temperature/ systemically unwell

Question 12

Red flag for bone metastases?

Answer 12

• History of primary malignancy (e.g. prostate, lung, melanoma)
• Risk factors for malignancy e.g. smoking
• Persistent, non-mechanical bone pain
• Pain at night or at REST
• Unexplained weight loss
• Low impact fracture

Question 13

Management of OA?

Answer 13

• Management of OA in the initial stages involves analgesia, normalising BMI and keeping active
• As the pain and severity of OA worsens, patients may require steroid injections and/or consideration of referral to orthopaedics with a view to joint replacement surgery

Question 14

Acute gout:
Common sites?
S/S?
DDx?
Management?

Answer 14

Metatarsophalangeal (MTP) joint of the big toe (75%), proximal interphalangeal (PIP) joints of the hands

Symptoms/Signs include severe pain, swollen and hot joint (usually monoarticular), overlying skin is erythematous and shiny

DDx: Septic artritis

Management of gout is NSAID treatment, if this is contraindicated then consider use of colchicine for 3 days. Be aware of significant side effects of this, most commonly diarrhoea