Joint Pain Flashcards
Generally do inflammatory and non-inflammatory joint pain both elicit and immune response?
- inflammatory = involves an immune response
- non-inflammatory = no immune involvement
In inflammatory joint pain, would we expect to see swelling, and if so would this be acute or chronic?
- swelling is likely to be present
- swelling will be chronic
In inflammatory joint pain, would we expect to see few or lots of joints affected?
- lots of joints affected, could be oligoarthritis or polyarthritis (at least 5 joints)
In inflammatory joint pain, there is increased inflammation, What 2 inflammatory markers might we expect to see raised?
1 - C-reactive protein (CRP) or the erythrocyte sedimentation rate (ESR) elevated
2 - CRP and IL-6
3 - CRP and creatine kinase
4 - creatine kinase and ESR
1 - CRP and ESR
- both are associated with immune function
You are asked to review a 35-year-old male, who presents with a 2 days history of a painful, swollen right knee. What are your differential diagnosis?
1) Post-traumatic hemarthrosis (fluid in joint due to trauma)
2) Gout
3) Septic arthritis
4) All of the above
4) All of the above
What is septic arthritis?
1 - infection inside a joint
2 - joint damage has caused a systematic sepsis like response
3 - infection of all joints in the body
1 - infection inside a joint
- can affect the joint (synovial) fluid and joint tissues
- microorganisms enter joint causing fever, joint pain, swelling, redness, and warmth
Septic arthritis is an infection in the joint (synovial) fluid and joint tissues caused by microorganisms that are able to enter joints causing fever, joint pain, swelling, redness, and warmth. This can be incredibly dangerous. What % mortality does this generally have?
1 - 11%
2 - 20%
3 - 1%
4 - 30%
1 - 11%
- if not treated quickly can lead to amputation
Septic arthritis is an infection in the joint (synovial) fluid and joint tissues caused by microorganisms that are able to enter joints causing fever, joint pain, swelling, redness, and warmth. This can be incredibly dangerous with an 11% mortality. What needs to be done as soon as possible?
1 - amputate the infected joint
2 - aspirate the joint and the let infection settle on its own
3 - surgically open the joint and remove infection
4 - treat infection with antibiotics
4 - treat infection with antibiotics
What are the 4 most common symptoms that patients present with in septic arthritis?
1 - typically hot swollen joint
2 - unwell (fever and generally very unwell)
3 - pyrexia (raised body temp >38 degrees)
4 - decreased ROM
Septic arthritis can be very dangerous with an 11% mortality. What are a few of the most common risk factors?
- diabetes (autoimmune disorder)
- infections
- prosthetic joints
- RA
- immunosuppressive medication (common in RA)
Any organism can be implicated in septic arthritis, but what is the most common organism that causes this?
1 - Staphylococcus aureus
2 - Escheria coli
3 - Faecalbacterium prauznutzi
4 - Streptococcus
1 - Staphylococcus aureus
If you suspect someone has septic arthritis and they present with a hot swollen joint, what must you always do?
1 - send for an X-ray
2 - aspirate the fluid from the joint
3 - treat with steroid injection
4 - provide NSAIDs
2 - aspirate the fluid from the joint
- important to test the fluid for infection
In a patient with suspected septic arthritis we must always aspirate the fluid from the joint to assess if an infection is present. What key instance must we never aspirate a joint, even if we suspect septic arthritis unless the patient is in surgery?
1 - if patient is allergic to needles
2 - if patient doesn’t want an aspiration
3 - if patient has a prostatic joint
4 - if patient is already on antibiotics for something else
3 - if patient has a prostatic joint
In a patient with suspected septic arthritis we must always aspirate the fluid from the joint. Why is this important?
- sample the fluid for infection before treatment
- gram staining
- bacterial cultures
- crystal formation
In a patient with suspected septic arthritis we must always aspirate the fluid from the joint. However if it is not possible to aspirate the joint. What else could you do?
1 - gas analysis
2 - urine and/or saliva sample
3 - biopsy of joint
4 - detailed medical history
2 - urine and/or saliva sample
- patient may also be septicaemia
What is international normalised ratio (INR)?
1 - normalised ratio of drug to weight
2 - normalised ratio of anaesthetic medication to weight
3 - normalised prothrombin time
4 - normalised pathway for prescribing medications
3 - normalised prothrombin time
- calculation based on a prothrombin time (from liver)
- essentially how quickly the blood is able to clot
The international normalized ratio (INR) is a calculation based on a prothrombin time (from liver), essentially how quickly the blood is able to clot. What is a normal INR?
1 - 1.3 - 2.0
2 - 0.9 - 1.3
3 - >5.0
4 - 2.0 - 3.5
2 - 0.9 - 1.3
- an INR of 3.0 means patients blood is 3 times as thin as someone with an INR of 1.0
- a low INR means blood is thick so will clot quicker, hence the lower INR
In a patient with suspected septic arthritis we must always aspirate the fluid from the joint. However, if you have tried to aspirate and not been successful, what imaging could be used to guide the needle for the aspiration?
1 - CT-scan
2 - MRI
3 - X-ray
4 - doppler ultrasound
4 - doppler ultrasound
Warfarin and other medication can thin the blood and raise your INR. Why is this important in a patient you suspect may have septic arthritis?
1 - could damage blood vessels of the joint and increase risk of bleeding
2 - could damage blood vessels of the joint
3 - increased risk of bleeding into the joint
1 - could damage blood vessels of the joint and increase risk of bleeding
- if INR is too high, may not risk the aspiration at all
In a patient with suspected septic arthritis, when is the best time to start the antibiotics?
1 - immediately no matter what
2 - once all blood samples and aspirations have been taken
3 - once an aspiration has been taken
4 - after aspiration has been analysed for infection
3 - once an aspiration has been taken
- aspiration if treated with antibiotics may mask infection
Arthropathy is a pathological disease of a joint.
Arthro = joint pathy = pathological disease
What is the most common inflammatory arthropathy worldwide?
1 - lupus
2 - RA
3 - osteoarthritis
4 - gout
4 - gout
Arthropathy is a pathological disease of a joint. The most common inflammatory arthropathy worldwide is gout, which is caused by the formation and build up of what?
1 - antibody complexes in the joints
2 - hyaluronic acid
3 - uric acid
4 - acetic acid
3 - uric acid
Arthropathy is a pathological disease of a joint. The most common inflammatory arthropathy worldwide is gout, which is caused by the formation and build up of uric acid. Where does uric acid in the body come from?
1 - consumed in the diet
2 - waste product produced by the liver
3 - breakdown product of purines found in DNA
4 - medication metabolite
3 - breakdown product of purines found in DNA
- natural process as they are removed from the body via the kidneys in urine
Arthropathy is a pathological disease of a joint. The most common inflammatory arthropathy worldwide is gout, which is caused by the formation and build up of uric acid, which is from the breakdown of purines which are found in DNA throughout the body, which is then removed via the kidneys as urine. This uric acid is not very soluble and when levels of uric acid become too high this is called what?
1 - hyponatraemia
2 - hypouricaemia
3 - hypernatraemia
4 - hyperuricaemia
4 - hyperuricaemia
- saturation point is around 408 μmol/L but diagnosis >500
Monosodium urate is what causes gout and the build of this goes on to form monosodium urate crystals in joints. How is monosodium urate formed?
1 - uric acid gains proton at pH 7.4, extra proton binds K+
2 - uric acid gains proton at pH 7.4, extra proton binds Na+
3 - uric acid loses proton at pH 7.4, extra proton binds Na+
4 - uric acid loses proton at pH 7.4, extra proton binds K+
3 - uric acid loses proton at pH 7.4, extra proton binds Na+
- urate ion binds 1 Na+, becoming monosodium urate
- uric acid becomes urate and 1 Na+ gives the monosodium
Monosodium urate forms from the. breakdown of purines into uric acid, which then goes on to form monosodium urate crystals. Where do these monosodium urate crystals generally get deposited in the body?
1 - good blood flow and warm
2 - good blood flow and cold
3 - poor blood flow and warm
4 - poor blood flow and cold
4 - poor blood flow and cold
- peripheral tissues and joints (feet and hands)
- cartilage and periarticular (outside of joints)
What are some of the most common non-modifiable risk factors for gout?
- Age
- Male Sex
- Family History
- Race
- Impaired Renal function
What are the 3 most common modifiable risk factors for gout?
- BMI - Relative Risk (RR) 3
- Beer - RR 2.5
- Meat - RR 1.5
70% of patients who get gout will get podagra. What joint does this occur in?
1 - 1st metacarpophalangeal joint
2 - 2nd metatarsophalangeal joint
3 - 1st metatarsophalangeal joint
4 - talotibial joint
3 - 1st metatarsophalangeal joint
Colchicine is an anti-gout medication. What is the mechanism of action of this drug?
- inhibits leukocyte migration to joints and phagocytes
- phagocytes attempt to digest, engulf and remove crystals
- instead phagocytes release H+ that can bind with urate anions forming unionised crystals
Colchicine is an anti-gout medication. Its mechanism of action is to inhibit leukocyte and phagocytes migration to joints. Phagocytes attempt to digest, engulf and remove crystals, but why can this then accentuate the problem?
- phagocytes release H+ that can bind with urate anions forming unionised crystals
- instead of helping they make the problem worse
Although NSAIDs and Colchicine can be used to treat acute gout attacks. What is the core long term medication that we need to be aware of?
1 - low dose of aspirin
2 - vitamin C
3 - allopurinol
4 - chlorphenamine
3 - allopurinol
- remember purinol ending sounds like purines
Although NSAIDs and Colchicine can be used to treat acute gout attacks. Long term medication includes Allopurinol. What is the mechanisms of action of Allopurinol?
- hypoxanthine is a naturally occurring purine
- hypoxanthine is converted into xanthine by xanthine oxidase
- xanthine is a purine that is converted into uric acid by xanthine oxidase
- ALLOPURINOL INHIBITS xanthine oxidase and reduces uric acid formation
patient should not get gout when on ALLOPURINOL
Once we have aspirated a joint, we need to examine the fluid and look for the presence of crystals. There are 2 different types of crystals that we might see, positive and negative birefringent crystals. How do the positive and negative crystals appear under the microscope?
- positive = rhomboid shaped
- Negative = Needle-shaped (both begin with N)
Once we have aspirated a joint, we need to examine the fluid and look for the presence of crystals. There are 2 different types of crystals that we might see, positive and negative birefringent crystals. Positive and negative crystals appear as rhomboids and needs under the microscope, respectively.
- Positive birefringent crystals = Calcium pyrophosphate crystal deposition (CPPD)
- Negative birefringent crystals = monosodium urate crystals
Which type of crystal is associated with gout and pseudogout?
- gout = Negative birefringent Needle shaped crystals (remember the Ns)
- pseudogout = positive birefringent rhomboid shaped crystals (remember the Ps)
What does the term Chondrocalcinosis mean?
- chondro = cartilage
- calcinosis = calcified
- the calcification of cartilage
If we see an X-ray like below, we shouldn’t be able to see the cartilage in the joint space as it is translucent. However, in the image below we can see something in the joint space. What is this?
1 - ligaments
2 - calcified cartilage (chondrocalcinosis)
3 - torn cartilage
4 - bone
2 - calcified cartilage
- chondrocalcinosis due to excessive build up of calcium pyrophosphate present in pseudogout
Osteoarthritis is a degenerative disease. Which joints does it commonly affect?
- hips
- knees
- small joints of the hand (DIP, PIP and Carpometacarpal joints)
Osteoarthritis is a degenerative disease. This can cause a number of signs that we can see on an X-ray in an affected joint. Use the labels below to label the affected joint:
osteophyte (bone spurs)
sub-chondral sclerosis (thickening of bone)
joint space narrowing
sub-chondral cysts (fluid filled cavities in bone)
joint space narrowing
sub-chondral cysts (fluid filled cavities in bone)
osteophyte (bone spurs)
sub-chondral sclerosis (thickening of bone)
Osteoarthritis is a degenerative disease. This can cause a number of signs that we can see on an X-ray in an affected joint, as we can see in the image below. There are 2 things that can appear on the hands of patients with osteoarthritis, what are they?
1 - ganglion cysts + heberdens nodes
2 - ganglion cysts + bouchard’s nodes
3 - heberdens nodes + warts
4 - heberdens nodes + bouchard’s nodes
4 - heberdens nodes + bouchard’s nodes
Osteoarthritis is a degenerative disease. This can cause a number of signs that we can see on an X-ray in an affected joint, as we can see in the image below. There are 2 things that can appear on the hands of patients with osteoarthritis, heberdens and bouchard’s nodes. What are these nodes?
1 - fluid filled nodes
2 - fatty infiltrate nodes
3 - bony growths
4 - cartilage expansion in joints
3 - bony growths
Osteoarthritis is a degenerative disease. This can cause a number of signs that we can see on an X-ray in an affected joint, as we can see in the image below. There are 2 things that can appear on the hands of patients with osteoarthritis, heberdens nodes + bouchard’s nodes. What is the difference between the 2?
- where they affect in the hand
- heberdens nodes = DIP joint
- bouchard’s nodes = PIP joint
Osteoarthritis is a degenerative disease. This can cause a number of signs that we can see on an X-ray in an affected joint, as we can see in the image below. There are 2 things that can appear on the hands of patients with osteoarthritis, heberdens nodes + bouchard’s nodes, which we can distinguish between by which joints they affect. The mnemonic
- High Definition
- Blood Pressure
What do each of the above relate to in heberdens nodes and bouchard’s nodes?
- High Definition = Heberdens and DIP
- Blood Pressure = Bouchard’s and PIP
