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Clinical Problem Solving > Joint Pain > Flashcards

Joint Pain Flashcards

1
Q

Examples of Joint Pain

A

• Osteoarthritis
• Rheumatoid Arthritis
• Back Pain
• Hot Joint (Gout, Septic Arthritis)

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2
Q

Pathological Process

A

• Very often helpful to identify the underlying pathological process
• Some presentations arise from different underlying pathological processes

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3
Q

Inflammation

A

A change in tissues brought about by the immune system

It can be a normal response due to:
• Irritation
• Infection

But can be due to abnormality of the immune system

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4
Q

Inflammation: Pathology

A

Immune cells flock to site

Change capillaries (increased blood flow, redness and warmth)

Increased leakage of fluid (swelling)

Stimulates pain receptors

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5
Q

Arthritis: Chronic Type

A

May be acute or chronic

Most chronic conditions get periodically worse and better

Exacerbations of a chronic condition are when it is acutely worse

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6
Q

Arthritis: Mono vs Poly

A

Mono-Arthritis: Affect just one joint

Poly-Arthritis: Affect many joints

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7
Q

Joint Structure: Types of Joints

A

Fibrous
Fibrocartilaginous
Synovial

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8
Q

Fibrous Joint Examples

A

• Skull
• Fibrous tissue uniting the bones but little movement

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9
Q

Fibrocartilaginous Joint Examples

A

• Between Vertebrae,
• Symphisis Pubis
• Permit some movement

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10
Q

Synovial Joint Examples

A

• Ball-and-socket joint (shoulder joint)
• Hinge joint (knee)
• Permit extensive movement

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11
Q

Synovial Joint Structure

A

• The articular surfaces of bones covered with cartilage
• Layer of synovial fluid
• Lubrication
• Capsule around the joint
• Ligaments hold joint together

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12
Q

Menisci

A

Some synovial joints (eg the knee) have disks of cartilage within the joint to enhance stability

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13
Q

How to differentiate one cause of joint pain from another

A

• History (family and personal past medical history)
• Examination
• Investigation
• Injury
• Activities such as sports

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14
Q

SQITARS’

A

• Site
• Quality
• Intensity
• Timing
• Aggravating factors
• Relieving factors
• Associated Symptoms, Impact on Function

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15
Q

Consent

A

• Patient has capacity
• Patient is sufficiently informed
• Patient is not subject to coercion or undue influence
• And has reached a clear decision

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16
Q

Examination

A

Close examination of affected joint(s)

Compare with unaffected joint if possible

Look for signs of inflammation

Estimate range of movement
• Passive and active

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17
Q

Investigations/Tests

A

• Investigations
• Acute arthritis – may need to aspirate (remove with needle) synovial fluid
• Can image joints with x-rays/CT scan/MRI
• Blood markers for inflammation

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18
Q

Arthritis: Presentations

A

An affected joint may be:
• Painful
• Stiff

Restricted range of movement

Inflamed, such as thickening, swelling, redness and tenderness

19
Q

Mono-Arthritis

A

• Most commonly acute

Inflammation due to:
• Trauma
• Infection
• Accumulation of crystals in joint

20
Q

Infections (Mono-Arthritis)

A

Produce septic arthritis

Infected joint:
• Often exquisitely painful and tender
• Painful on movement
• Red, Swollen

Other signs of infection:
• Fever

21
Q

Septic Arthritis (Mono-Arthritis)

A

Most rapid and destructive bone disease

Mortality 10%

22
Q

Septic Arthritis: Investigation/Tests

A

• Joint aspiration for culture and sensitivity
• Blood cultures
• Inflammatory markers

23
Q

Gout (Mono-Arthritis)

A

Due to crystals in the joint

Crystals of uric acid

1st Metatarsophalangeal (most common site)

24
Q

Pseudogout

A

Due to crystals in the joint

Crystals of pyruvic acid

25
Q

Causes of Gout

A

• Genetic factors (60%)
• Obesity / alcohol
• Renal disease
• Medications eg diuretics
• Diet red meat, seafood

26
Q

Polyarthritis

A

Degeneration in joints:
• Osteoarthritis

Changes in immune system:
• Consequence of systemic (general body)
infection
• Viral infections- transient synovitis

Disorder of immune system:
• Auto-immune
• Rheumatoid arthritis

27
Q

What is Rheumatoid Arthritis? What happens in joints?

A

A systemic disease

An auto-immune condition
• Immune system fails to recognise normal joint tissue as ‘self’
• Attacks as though ‘foreign’

Immune response over time causes:
• Thickening of synovial membrane
• Too much synovial fluid
• Ultimately destruction of the joint

28
Q

Causes/Risk Factors of Rheumatoid Arthritis + Most Affected Areas

A

• Small joints hands and feet
• Large joints and neck
• Lungs, eyes, pleura, pericardium
• Morning stiffness- > 30mins
• Women more than men (fourth decade)
• Genetic factors in 60%

29
Q

Consequences of Rheumatoid Arthritis

A

• MCP bone erosion and joint displacement
• Ulnar deviation
• Z deformity of thumb
• Increased cardiovascular risk

30
Q

Symptoms of Rheumatoid Arthritis

A

• Weight loss
• Fever
• Fatigue
• Anaemia

31
Q

Rheumatoid Arthritis: Investigations/Tests

A

70% of patients have elevated ‘rheumatoid factor’ (also in 10% of normal population)

70 to 80% of patients have elevated ‘Anticyclic
Citrullinated Peptide’
• Highly specific for RA

32
Q

Rheumatoid Arthritis: Management

A

All about reducing inflammation

Intervene as early as possible to reduce rate of joint damage
• DMARDS
• Disease modifying anti-rheumatic drugs

33
Q

What is Osteoarthritis? What happens in joints?

A

Imbalance between breakdown and repair in normal ‘turnover’ of joint tissues
• Especially articular cartilages
• Focal loss of cartilage

Cartilage thins and cracks with small tears
• Bone may grate on bone
• Irritation and inflammation

Can get bony overgrowths on margins – spurs, called ‘osteophytes’

Subchondral osteosclerosis

34
Q

Causes/Risk Factors of Osteoarthritis

A

• More common in women
• Age (Mainly > 50 yrs)
• Repetitive use (eg some sports and
occupations)
• Past injury of the joint
• Joint misalignment
• Obesity
• Job related
• Some genetic influence

35
Q

Osteoarthritis: CONS

A

• Cyst
• Osteophytes
• Narrowing
• Sclerosis

36
Q

Osteoarthritis: Most Affected Areas

A

Affected joints:
• High loads (knees, hips)
• Repetitive movement (fingers, thumbs)

37
Q

Osteoarthritis: Management

A

• Cannot reverse degeneration but you can try to minimise progression
• Weight loss
• Exercise & lifestyle changes
• Analgesics (pain killers)
• Anti-inflammatory drugs
• Surgery
• Joint replacement

38
Q

Back Pain: Mechanical

A

• Most common form, self limiting
• Age 20 – 55
• Acute related to lifting/ bending
• Generally relieved by rest
• Does not radiate beyond knee
• Good prognosis

39
Q

Which patients are at risk for serious causes of back pain?

A

• Age: presentation <20 >55
• Constant, progressive pain, no better with rest
• Repeat presentations
• Thoracic
• PMH: Carcinoma, TB, HIV, osteoporosis
• Unwell: sweats, weight loss
• Trauma

40
Q

Serious Causes of Back Pain?

A

• Spinal stenosis
• Bone metastases
• Cauda equina

41
Q

Spinal Stenosis

A

A narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine

42
Q

Bone Metastases

A

Bone metastasis occurs when cancer cells spread from their original site to a bone

43
Q

Cauda Equina

A

A rare and severe type of spinal stenosis where all of the nerves in the lower back suddenly become severely compressed

44
Q

What does RICE stand for in Fracture Treatment?

A

Rest
Ice
Compression
Elevation

Clinical Problem Solving (7 decks)

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