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DPD 2020 > Joint pain > Flashcards

Joint pain Flashcards

1
Q

What is arthritis and how is it classified?

A

Inflammation of the joint.

Inflammatory: seronegative, seropositive, infectious or crystal induced, e.g. rheumatoid, SLE, psoriatic.

Non-inflammatory (degenerative): e.g. osteoarthritis.

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2
Q

What are the seropositive inflammatory arthritis?

A 
Rheumatoid arthritis.
Lupus.
Scleroderma.
Vasculitis.
Sjogren's.
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3
Q

What are the seronegative inflammatory arthritis?

A

Ankylosing spondylitis.
Psoriatic arthritis.
Reactive arthritis.
IBD arthritis.

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4
Q

Give an example of infectious inflammatory arthritis.

A

Septic arthritis.

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5
Q

What are the crystal-induced inflammatory arthritis?

A

Gout.

Pseudogout.

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6
Q

Give an example of non-inflammatory (degenerative) arthritis.

A

Osteoarthritis.

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7
Q

Screening questions for joint pain?

A

Do you suffer from any pain or stiffness in your arms, legs, neck or back?
Do you have any difficulty with stairs or steps?
Do you have any difficulty with washing or dressing?

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8
Q

Joint pain: history of presenting complaint

A

SOCRATES.
Chronology, sudden onset/gradual, recurrent?
Relationship to trauma/exercise?
Joint pain, stiffness, swelling, bone pain, muscle weakness?
Knee- locking, giving way, grinding, clicking?
Morning stiffness: OA <1hr, RA hrs.
Associated symptoms: rash, red eye (iritis), urethritis?- reactive arthritis.

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9
Q

What are the clinical features of osteoarthritis?

A

Degenerative process- wear and repair- abnormal bone remodelling
Mainly large, weight bearing joints (back, knee, hip, ankle, hands) and DIP.
Asymmetrical.
Usually less deformity.
Morning stiffness <1hr.

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10
Q

What are the clinical features of rheumatoid arthritis?

A 
Autoimmune process.
Mainly small joints of hand.
PIP (not DIP), MCP, wrists, elbows, neck.
Also hips, knees, ankles.
Symmetrical.
Gross deformity.
Tendon rupture.
Subluxation.
Morning stiffness >1hr.
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11
Q

What are the clinical features of psoriatic arthropathy?

A

Seronegative inflammatory arthritis (RhF and ACCP -ve).

Personal or FHx of psoriasis.

Similar to RA in distribution, except: 
> initial oligoarticular involvement
> DIP joints
> marked dactylitis- swelling of whole finger
> sacroiliitis-lower back/hip pain
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12
Q

GALS screen: arms

A 
Hands behind head with elbows back.
Supination and pronation of elbow.
'Squeeze my fingers'.
Opposition of thumb and fingers.
Squeeze metacarpal joints.
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13
Q

GALS screen: legs

A

Hand over the knee and flex to feel for crepitus.
Passive internal rotation of hip (foot moves externally).
Ankle flex/extend- tibiotalar joint affected in OA.
Eversion and inversion of foot
Supination of foot- subtalar joint affected in RA.

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14
Q

GALS screen: spine

A

Lateral flexion of cervical spine (mid-cervical region, 1st movement affected in OA cervical spondylosis)- ears towards shoulders

Bending forward- need to ensure the movement does not come from the hips.

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15
Q

What are the clinical features of rheumatoid arthritis in the hands?

A

Ulnar deviation.
Subluxation at MCP joints.
Rheumatoid nodules.
Boutonnieres deformity [flexion of DIP, hyperextension of PIP]
Swan neck deformity [flexion of DIP, hyperextension of PIP]
Z line thumb- hyperextension of IP, flexion of MCP]

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16
Q

What are the clinical features of osteoarthritis in the hands?

A

Heberden’s nodes- DIP

Bouchard’s nodes- PIP

17
Q

Epidemiology of rheumatoid arthritis?

A

400000 in UK
Females> 3:1
1% of population- low prevalence
Peak age= 40 years, but people of all ages

18
Q

Epidemiology of osteoarthritis?

A

Common
Mainly elderly
Women slightly more common than men

19
Q

Screening questions for MSK disorders

A

Pain/stiffness- arms, legs, back

Difficulty with washing and dressing

Stairs and steps hard

20
Q

Factors to ask in HPC

A

Pain
Sudden/Gradual/recurrent
Trauma
Exercise- how it affects symptoms

joint pain, stiffness, swelling, bone pain, muscle weakness

Knee- locking, grinding, clicking, giving way

Morning stiffness= hours in RA, < one hour in OA

Associated extra-articular symptoms- rash, red eye, urethritis

21
Q

GALS screen- types of abnormal gait

A

Trendelenburg gait- hip drops when leg lifted
Parkinsonian gait
Foot drop gait- high stepping
Spastic gait- after stroke- circumduction
Antalgic gait

22
Q

Rheumatoid arthritis findings on X ray

A

Joint space narrowing

Bony erosions

23
Q

Osteoarthritis findings on X ray

A

Loss of joint space/non uniform joint space narrowing
Osteophytes- Heberden’s/Bouchard’s notes
Subchondral cyst

24
Q

What is genu varum and genu valgus?

A

Genu varum= bow legs- knees away from midline

Genu valgus- knock knees -knees towards midline [leg looks like an L]

25
Q

What condition is genu varum related to?

A

Osteoarthritis

26
Q

What is genu valgus a risk factor for?

A

ACL tear

vaLgus = acL

27
Q

What investigations do you do for joint pain?

A

Bloods:
FBC- anaemia, raised WCC
CRP
ESR

Antibodies:
Rheumatoid factor
Anti - CCP
Maybe lupus etc

Uric acid

Joint aspiration - if suspect septic arthritis/crystal arthropathy-gout

Imaging
- X ray [not predictive of severity of osteoarthritis symptoms though- b/c many people have OA changes incidentally
Erosions= inflammatory disease]
- MRI- knees and back

If knee pain- arthroscopy

28
Q

Management of osteoarthritis

A

Weight loss
Exercise/ Physical therapy
Analgesia- topical NSAIDS, oral NSAIDS + gastroprotection

TENS- pain relief
Orthotic and walking aids

Surgical- joint replacement
[really functionally limited, disease for >6 months]

Manage social factors- ADLs, occupation effects
Address ICE

29
Q

Management of rheumatoid arthritis?

A

Analgesia
Steroids- prevent further inflammation + disease progression
DMARDs- methotrexate, sulfasalazine, hydroxychloroquine

Supportive- Physio, OT, Orthotics/walking aids
Biologics- antiTNFa

Refer EARLY if inflammatory arthritis- even if serology negative

30
Q

What are adjuvants that can be used alongside other drugs in WHO pain ladder?

A 
Duloxetine
Gabapentin
Pregabalin
Amitriptyline
TENS
31
Q

Case
Mrs LF- 34 year old mother
Bilateral painful swollen wrists for 6 months since birth of child

Bloods:
Negative RhF
CRP 15
Normal X ray wrists

Tried paracetamol + ibuprofen- no benefit

Difficult to pick up baby

Wrists = swollen and tender

How do you manage?

A

Increase analgesia
Refer to rheumatology

Physiotherapy

32
Q

Case

Mrs GT- 64 year old lady- BMI of 29

8 month history- painful knees
Mainly right side
Worse on walking downstairs + sitting for a few hours

Tried paracetamol

Has to travel for work - wants letter to say she can use taxis instead of public transport

Crepitus on both knees, otherwise normal

What is the management that is most likely to influence the patient’s condition?

A

Lose weight

[Exercise therapy helpful]
Diagnosis= osteoarthritis

33
Q

What is the most important cause of joint pain to rule out?

A

Septic arthritis
Medical emergency

Needs IV antibiotics

DPD 2020 (48 decks)

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