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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
Causes of Gout
• Genetic factors (60%) • Obesity / alcohol • Renal disease • Medications eg diuretics • Diet red meat, seafood
26
Polyarthritis
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
What is Rheumatoid Arthritis? What happens in joints?
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
Causes/Risk Factors of Rheumatoid Arthritis + Most Affected Areas
• 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
Consequences of Rheumatoid Arthritis
• MCP bone erosion and joint displacement • Ulnar deviation • Z deformity of thumb • Increased cardiovascular risk
30
Symptoms of Rheumatoid Arthritis
• Weight loss • Fever • Fatigue • Anaemia
31
Rheumatoid Arthritis: Investigations/Tests
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
Rheumatoid Arthritis: Management
All about reducing inflammation Intervene as early as possible to reduce rate of joint damage • DMARDS • Disease modifying anti-rheumatic drugs
33
What is Osteoarthritis? What happens in joints?
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
Causes/Risk Factors of Osteoarthritis
• 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
Osteoarthritis: CONS
• Cyst • Osteophytes • Narrowing • Sclerosis
36
Osteoarthritis: Most Affected Areas
Affected joints: • High loads (knees, hips) • Repetitive movement (fingers, thumbs)
37
Osteoarthritis: Management
• 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
Back Pain: Mechanical
• 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
Which patients are at risk for serious causes of back pain?
• 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
Serious Causes of Back Pain?
• Spinal stenosis • Bone metastases • Cauda equina
41
Spinal Stenosis
A narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine
42
Bone Metastases
Bone metastasis occurs when cancer cells spread from their original site to a bone
43
Cauda Equina
A rare and severe type of spinal stenosis where all of the nerves in the lower back suddenly become severely compressed
44
What does RICE stand for in Fracture Treatment?
Rest Ice Compression Elevation

Clinical Problem Solving (7 decks)

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