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Medicine - Year 1 > Monoarticular joint pain - Clinical Medicine > Flashcards

Monoarticular joint pain - Clinical Medicine Flashcards

1
Q

Which major joint are affected by arthritis?

A
  • Knee
  • Hip
  • Shoulder
  • Elbow
  • Ankle
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2
Q

Describe the types of joints

A

Fibrous - fibrous joint bone joined to another bone by fibrous tissue

Primary cartilaginous - bone joined by hyaline cartilage

Seconday cartilaginous - cartilage united by fibrous tissue

Synovial

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3
Q

Label the structures of the synovial joint

A
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4
Q

List the structure of the synovial joint

A
  • Periosteum
  • Articulatng bone
  • Articulating cartilage
  • Synovial or joint cavity
  • Fibrous capsule & Synovial membrane = Articular capsule
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5
Q

What does the synovial membrane lining the joint produce?

A

Synovial fluid

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6
Q

Describe the role of the synovial fluid

A

It is rich in nutrition and so provides nutrition to the hyaline cartilage

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7
Q

a) Does hyaline cartilage have blood supply and give a reason for your answer
b) Where does hyaline cartilage derive its nutrition from?
c) Once the hyaline cartilage is damged how is it repaired?

A

a) No beacuse there are no blood vessels
b) Synovial fluid (produced by the synovial membrane)
c) Repairs by forming fibrous tissue

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8
Q

What is osteoarthritis?

A

OA is the degeneration/break down of the entire joint - cartilage, synovium, ligaments and bone

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9
Q

a) Which joints are most commonly affected by OA?
b) Within the hands which joints are usually affacted?
c) Describe the deformities seen in the hands due to OA and why this occurs

A

a) Knees, hips and hands
b) MTP, DIP and PIP joints
c) Bochard’s nodes on PIP and Heberden’s nodes on DIP. This is due to osteophytes

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10
Q

Describe the onset of OA and which age it particulary affects

A

Onset is gradual, usually > 40 years old

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11
Q

List some risk factors of OA

A
  • Increasing age
  • Female gender
  • Occupation
  • Muscle weakness
  • Obesity
  • Inflammatory joint disease
  • Lack of osteoporosis
  • Trauma
  • Metabolic conditons e.g., alkaptonuria, acromegaly
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12
Q

Describe the symptoms/clinical features of osteoarthritis

A
  • Onset is gradual and worse on activity
  • Pain at day and especially night
  • Pain using joint
  • Stiffness
  • Swelling
  • Deformity
  • Weakness
  • Reduced mobility
  • Daily activities compromised
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13
Q

What are the radiological features of osetoarthritis?

A

LOSS

Loss of joint space

Osteophytes

Subchondral cysts

Subchondral scelerosis

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14
Q

Which movement is first lost in OA of hip?

A

Internal rotation

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15
Q

Describe the appearence of the synovial joint in osteoarthritis

A
  • Hyaline cartlage is eroded
  • Bone is exposed
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16
Q

How does OA manifest itself in the knee?

A
  • Usually both knees
  • Pain on walking especially up and down- stairs and hills
  • Stiffness
  • Visible deformity of knee often described as” knobbly”
  • Swelling of knee
  • Wasting of thigh muscles
  • Warm knee to touch
  • Knees may “give way”
  • Crepitus
  • Tender on feeling around knee
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17
Q

How does OA manifest itself in the hip?

A
  • Constant nagging pain
  • Worse at night
  • Cannot get into a comfortable position at night
  • Pain radiation into knee
  • Back pain due to altered gait
  • Painful walking-antalgic gait
  • May need a walking stick in opposite hand
  • Stiff hip unable to cut toenails, put on tights, socks and shoes
  • Progressive shortening of leg
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18
Q

How does OA manifests itself in the shoulder?

A
  • Pain at night disturbs sleep
  • Day-time with painkillers - pain tolerable
  • Stiffness difficulty wiping bottom
  • Stiffness unable to get food to mouth
  • Stiffness difficulty washing and combing hair
  • Stiffness difficulty dressing
  • Stiffness unable to raise arm
  • Marked crepitus
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19
Q

a) What does the treatment of OA focus on?
b) List the treatment options

A

a) Treatment focuses on relieiving symptoms and improving function

b)

  • Patient education
  • Excercise
  • Weight control
  • Use of analgesia/orthosis (splint)
  • Surgery
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20
Q

List non-operative managment of OA

A
  • Education
  • Lifestyle advice e.g., weight loss, regular excercise, avoidance of impact-loading activites
  • NSAIDs
  • Physiotherapy
  • Support and braces
  • TENS
  • Intra-articular corticosteroid injections
  • Capsaicin (An active component of chili peppers - capsaicin creams and patches help relieve pain)
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21
Q

List operative management of osteoarthritis

A
  • Arthroplasty (Joint replacement)
  • Arthrodesis (Joint fusion)
  • Osteotomy (joint realignment)
  • Joint excision
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22
Q

a) List the pros of a joint replacement
b) List the cons of a joint replacement

A

a) Pros

  • Almost instant cure of arthritic pain
  • Return of mobility
  • ‘Normal life’ - get life back
  • Majority of joints are long lasting, only few need revisions

b) Cons

  • Operation
  • Major complictions e.g., death
  • Other complications e.g., infection
  • Revision surgeries
  • Need to be careful
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23
Q

What do the NICE guidlines say about referring for consideration of a joint replacememnt

A
  • Patients should be referred before there is prolonged and established functional limitation and severe pain
  • Patient-specific factors (including age, sex, smoking, obesity) should not be barriers to referral for joint surgery
  • Offer regular reviews to all people with symptomatic osteoarthritis e.g., reviewing the effictiveness and tolerabilty of treatments
  • Annual reviews should be considered if the person has one or more of:
  • Other illnesses or conditions
  • Troublesome joint pain, more than one joint affected
  • Or are taking drugs for their osteoarthritis
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24
Q

List complications of a joint replacement surgery

A
  • Infection
  • Metal on metal
  • Dislocations
  • Venous thromboembolism
  • Aseptic looseing
  • Leg length discrepancy
  • Nerve palsy
  • Fracture
  • Ongoing pain
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25
Q

a) How are infections reduced in joint replacement surgey
b) What do you do if an infection occurs?
c) what do you not do?

A

a) Reduced by clean filtered air and prophylactic antibiotics
b) Contact orthopaedic department and refer early
c) Do not aspirate outisde an operating theatre and do not start antibiotics unless patient’s life is in imminent danger

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26
Q

Why is there increased venous thromboebolism in hip and knee replacements?

A
  • They are immobile
  • There are alteration in the blood
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27
Q

How is venous thromboebolism reduced after joint replacement surgery?

A
  • Early mobilisation post-op
  • TED stockings
  • Intra-operatively calf pumps
  • Chemical prophylaxis e.g., warfarin, aspirin, Rivaroxaban (factor Xa inhibitor) daily oral requires no tests
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28
Q

Which crystals are involved in:

A) Gout

b) Pseudogout

A

a) Monosodium urate (uric acid)
b) Calcium pyrophosphate dihydrate (CPPD)

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29
Q

Describe the difference in synovial fluid between normal synovial fluid and crystal synovitis. Include volume (ml), viscosity, colour, WBC/mm3, PMN (%) (type of WBC called granular leukocyte/granulocyte) and crystals (present/not)

A

Normal

  • _​_Volume (ml) = <3.5
  • Viscosity = Very high
  • Colour = Clear
  • WBC/mm3 = 200
  • PMN (%) = <25%
  • Crystals = None

Crystal synovitis

  • Volume (ml) = >3.5
  • Viscosity = Low
  • Colour = Straw/opaque
  • WBC/mm3 = >10,000
  • PMN (%) = >50%
  • Crystals = Present
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30
Q

Explain the pathology of gout

A
  • Prolonged hyperuricemia leads to the formation of monosodium urate crystals by:
    1. Over production of uric acid (exogenous or endogenous)
    2. Underexcretion of uric acid (abnormal renal ahndling of urate)
    3. A combination of both
  • These deposit in the synovium, connective tissues and kidneys.
  • Joint inflammation is mediated by phagocytosis of the crystals by polymorphonuclear leucocytes.
  • Uric acid crystal deposition in the kidneys can cause interstitial nephritis, renal stones and acute tubular damage.
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31
Q

What are causes of hyperuricemia due to to over production?

A
  • Excess dietry purines (e.g., seafood shellfish (including anchovies, sardines, herring, mussels, codfish, scallops, trout, and haddock). Some meats, such as bacon, turkey, and organ meats like liver)
  • Alcohol abuse
  • Myeloproliferative disorder
  • Lymphoproliferative disorder
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32
Q

What are causes of hyperuricemia due to under excretion?

A
  • Renal disease
  • Polycystic kidney disease
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33
Q

List the drugs that cause hyperuricemia

A

CAN’T LEAP

Cyclosporine

Alcohol

Nicotinic acid

Thiazides

Lasix (frusemid)

Ethambutol (anti-tuberculosis treatment)

Aspirin (low dose)

Pyrazinamide (anti-tuberculosis treatment)

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34
Q

Describe the changes in uric acid in menopausal women

A

After menopause hyperuricemia increase in women due to loss of uricosuric effect of oestrogen

35
Q

What are the four stages of gout?

A
  1. Asymptomatic hyperuricemia
  2. Acute gouty attacks
  3. Intercritical gout
  4. Advanced tophaceous gout
36
Q

What are predisposing/risk factors of gout?

A
  • Immediate postop period after major surgery
  • Stroke
  • Fasting
  • Alcohol abuse
  • Large intake of food with purine content
  • Local infection
  • Diuretic use
  • Male gender
  • Hypertension and renal disease
  • Cancer
  • Psoriasis
37
Q

a) What are the clinical features of acute gout?
b) What are the clinical features of chronic gout?

A

a)

  • Extremly painful
  • Joint swelling
  • Shiny skin
  • Skin redness
  • Warmth

b)

  • Bony erosions
  • Tophi - can rupture, leading to discharge of chalky-white material, and can become infected
  • Deformity
38
Q

What are lab test taken when gout is suspected?

A
  • Joint fluid analysis
  • WBC in jont fluid (5,000-50,000/mm3) neutrophils
  • Culture to rule out infection
  • S.uric acid test & WBC < 15,000/mm3
  • Renal function
  • Urine dipstick -haematuria (gout and kidney stones)
39
Q

Discuss the differential diagnosis of gout

A
  • Degree of inflammation – different from Rheumatoid arthritis so match by pseudogout or infection (culture to rule out infection)
40
Q

What symptom is charcteristic of gout?

A

Podagra (1st MTP joint pain)

41
Q

What are the core non-medication aspect of managment of gout?

A
  • Patient education
  • Diet - low purine
  • Reduce alcohol
  • Weight reduction
42
Q

Why does alcohol cause hyperuricemia?

A

Alcohol increases serum urate production and reduces renal clearance

43
Q

What is the treatment for acute gouty attacks?

A
  • NSAIDs or COX II inhibitors
  • Oral colchicine
  • Oral steroids in patients who are unable to tolerate NSAIDs or colchicine.
  • Local steroid injection
  • Joint rest & local ice
44
Q

Describe the treatment for intercritical gout - 2 or more attacks in a year

A
  • Colchicine prohylaxis - 1st 3-6 months to reduce frequency of attacks
  • Allopurinal - (uricosuric agent/drugs) 1st line drug or febuxostat in those that cannot tolerate allopurinal
  • Diet
  • Alcohol
45
Q

a) How long after should allopurinal be given after an acute gouty attack?
b) Describe the recommended dosage in a person with no renal insufficency and in a person with renal sufficiency

A
  • Not started for 2-3 weeks after an acute attack
  • 100-900 mg/day
  • Renal insufficiency - 100mg/day
46
Q

a) Describe the action of uricocuric agents
b) What are the 3 types of uricosuric agents?

A

a) Increase excretion of uric acid in urine, reducing serum uric acid
b) Probenoid, sulfinpyrazone and benzbromarone

47
Q

What type of patients are sulfinpyrazone and probenoid ineffective in?

A

Patients with a history of chronic renal disease

48
Q

a) Describe the mechanism of allopurinol
b) When can it be used in intercritical gout?

A

a)

  • Xanathine oxidase inhibitor - inhibits convertion of xanthine into uric acid
  • Lowers serum and urinary acid excretion

b) Only used after lifestyle changes

49
Q

What is an alternative to those who cannot take allopurinal?

A

Febuxostat - selective xanthine oxidase inhibitor

50
Q

Why can’t people with kidney stone take uricosuric agents?

A

There is a small risk of uric acid stone formation

51
Q

What is pseudogout?

A

The deposition of calcium pyrophosphate dihydrate (CPPD) in joint cartilage

52
Q

List the conditions predisposing pseudogout

A
  • Hyperparathyroidism
  • Hypothyroidism
  • Hemochromatosis
  • Hypophosphatasia
  • Acromegaly
  • Gout
  • Ageing
  • Trauma
  • Infection
  • OA
53
Q

List the metabolic conditions that prdispose to CPPD disease

A
  • Hyperparathyroidism
  • Hypothyroidism
  • Hemochromatosis
  • Hypophosphatasia
  • Acromegaly
  • Gout
54
Q

What conditions can chronic pseudogout mimic?

A

OA or RhA

55
Q

Describe the clinical manifestations of pseudogout

A

Acute synovitis - patient experiencs pain, swelling, stiffness and occasionally fever. Affects wrist and knees commonly

Chronic pyrophosphate athropathy - similar to OA with a gradual onset of pain, swelling and loss of joint function. Wrist and knees commonly affected as well as hips, shoulders, elbows and MTP joints

56
Q

a) Which joint is most involved in pseudogout?
b) Which other joints can be involved?

A

a) Knee
b) Ankles, wrist and shoulders

57
Q

What can percipitate an attack of acute pseudogout?

A

Surgical procedures (parathyroidectomy) and severe medical illness

58
Q

Describethe invesigations undertaken to diagnose pseudogout and the findings

A
  • Synovial fluid examination - rhomboid shape wth weak positive birefringence
  • Gram stain and culture to exlcude infections
  • X-rays - chondrocalcinosis
  • Serum calcium in younger patients
  • Screening for other metabolic disorders if <50 years
59
Q

Describe radiographic appearence of pseudogout

A

Changes associated with chondrocalcinosis

  • White lines of chondrocalcinosis
  • Calcium deposition cause triangular fibrocartilage
  • Loss of joint space
  • Subchondral sclerosis
  • Subchondral cysts
60
Q

Discuss the differential diagnosis of pseudogout

A
  • Degree of inflammation matched by gout and active infection - however in gout it’s the 1st MTP joints and shoulder and hip are rarely affected and apid aceleration of inflammation means most likely pseudogout
  • RhA - RhA and pseudogout can coexist
  • OA
61
Q

Describe the managment of pseudogout

A
  • Analgesia/NSAIDs
  • Joint aspiration
  • Steroid injection
62
Q

a) What is the crystal compostition seen in gout?
b) What is the crystal shape under polarised light microscopy?
c) Describe the befringement under polarised light micoscopy?
d) Which joint is most commonly affected?

A

a) Uric acid
b) Needle-like
c) Negative
d) 1st MTP

63
Q

a) What is the crystal compostition seen in pseudogout?
b) What is the crystal shape under polarised light microscopy?
c) Describe the befringement under polarised light microscopy?
d) Which joint is most commonly affected

A

a) Calcium pyrophosphate (CPPD)
b) Rhomboid
c) Weakly positive
d) Knee

64
Q

Describe the difference between gout and pseudogout based on: crystal composition, crystal shape, befringement, most common joint affected, radiography, first line treatment for acute and chronic

A

Gout

  • Crystal composition: Uric acid
  • Crystal shape: Needle like
  • Birefringement: Negative
  • Most common joint affected: 1st MTP
  • Radiography: “Rat-bite” erosions
  • 1st line treatment for acute: NSAIDs/Colchicine
  • 1st line treatment for chronic: Allopurinol

Pseudogout

  • Crystal composition: Calcium pyrophosphate dihydrate
  • Crystal shape: Rhomboid
  • Birefringement: Weakly positive
  • Most common joint affected: Knee
  • Radiography: Whitelines of chondrocalcinosis
  • 1st line treatment for acute: NSAIDs
  • 1st line treatment for chronic: NSAIDs / Periodic intraartciualr steroid injection
65
Q

a) An elderly female presents with acute painful swelling of her knee. She has no history of trauma and is apyrexial. Antero-posterior (AP) and lateral radiographs of her knee are shown below. What are the radiological findings?
b) What is your differential diagnosis and what is the most likely diagnosis

A

a) There is chondrocalcinosis in the bilateral tibiofemoral compartments with calcium deposition in both hyaline and fibrocartilage menisci (yellow arrow), a suprapatellar effusion (blue arrows) with effacement of suprapatella recess fat and marginal osteophytes (red arrow).
b) Gout, Pseudogout, osteoarthritis.

Chondrocalcinosis due CPPD is associated with psuedogout

66
Q

Compare and contrast the management of septic arthritis and crystal arthritis

A

Septic arthritis – aspirate but not outside of theatre

Give 3

  • Oxygen
  • IV antibiotics
  • IV fluids

Take 3

  • Urine output
  • Blood culture
  • Lactate

Crystal arthritis - synovial joint fluid analysis, x-ray

Gout

  • Patient education
  • Diet – low purine
  • Reduce alcohol
  • Weight reduction
  • Acute – NSAIDs/Colchicine
  • Chronic – Allopurinol

Pseudogout

  • Losing weight, physiotherapy, pain control and occasionally joint replacement.
  • Acute – NSAIDs
  • Chronic – NSAIDs / Periodic intraarticular steroid injection
67
Q

What are the two gold standard tests to differentiate between gout and pseudogout?

A

Joint aspiration and fluid microscopy

68
Q

Causes of OA can be primary or secondary. List causes of secondary OA.

A
  • Trauma
  • Infection - septic arthritis
  • Inflammatory e.g., RhA
  • Perthe’s disease - avascular necrosis of the femoral head in a growing person
  • Slipped upper femoral epiphysis
69
Q

Compare and contrast athroplasty vs arthodesis to treat OA

A

Arthroplasty - excision of joint

  • Pain relief
  • Keep movemement
  • May not be durable - may wear out where the implant meets the bone or the actual bearing itself

Arthrodesis - Fusion of joints

  • Pain relief
  • Sacrifice movement
  • Durable
70
Q

a) What is the term for this specific wrist osetoarthritis
b) Describe what you see on x-ray

A

a) Scaphoid lunate advanced collapse (SLAC)
b) Severe radius scaphoid osteoarthritis – no cartilage between radius and scaphoid

Associated with instability

71
Q

a) What is hallux rigidus caused by OA
b) Describe the managment of hallux rigidus

A

a) A condition where the big toe’s ability to move is severely limited and may be “frozen” and unable to move at all.

vb)

  • Analgesia
  • Orthosis – stop movement (supportive footwear)
  • Debridement osteophytes if causing impingement
  • Fuse 1st MTP joint
  • Replace joint
72
Q

According to the NICE guidlines when should you diganose OA clinically without investigation?

A
  • 45y or over
  • Activity-related joint pain
  • Either no morning joint-related stiffness
  • Or morning stiffness that lasts no longer than 30 minutes
73
Q

According to the NICE guidlines what advice should you offer patients with OA?

A

Offer advice on:

  • Activity and exercise
  • Interventions to lose weight if the person is overweight or obese
74
Q

According to the NICE guidlines what medications should you consider offering patients with OA?

A
  • Paracetamol for pain relief
  • Paracetamol and/or topical NSAIDs should be considered ahead of oral NSAIDs
  • Cyclo-oxygenase (COX-2) inhibitors or opioids
75
Q

According to the NICE guidlines when should you refer consideration of joint replacement surgery for OA and what things should not be barriers to this referral?

A
  • Before there is prolonged and established functional limitation and severe pain
  • Patient-specific factors (including age, sex, smoking, obesity) should not be barriers to referral for joint surgery
76
Q

According to the NICE guidlines you should offer regular reviwes to all people with symptomatic osteoarthritis. How do you go about doing this?

A
  • Monitoring the long-term course of the condition
  • Reviewing the effectiveness and tolerability of treatments and other points
77
Q

According to the NICE guidlines when should annual reviews be considered in a person with OA?

A
  • Other illnesses or conditions
  • Troublesome joint pain, more than one joint affected
  • Or are taking any drugs for their osteoarthritis
78
Q

List the types of mono-arthritis seen in primary care

A
  • Septic arthritis
  • Gout
  • Pseudogout
  • Osteoarthitis
  • Psoriatic arthritis
79
Q

Discuss how we differentiate between articular and non-articular pain

A

Site of pain

Which ranges of motion are painful or restricted

  • Patient with articular/true joint problem will describe pain or restricition for all ranges of motion tested in the specific joint and will describe reaching the limit of joint motion the most painful
  • Patient with non-articular problem will describe pain or restriction for only some of the ranges of motion of that particular joint, and reaching the limit of the range may not necessarily be associated with the most pain

True joint pathology is described as producing a capsular or articular pattern in the reduction of passive joint ranges of motion i.e., passive ranges of motion of the particular joint being examined are reduced approximately equally

  • Non-articular problems produce a noncapsular or non-articular pattern in the reduction of passive ranges of motion of the joint (i.e., 1 or several of that joint’s ranges of motion are reduced more than others)
  • The only exceptions to this rule are glenohumeral joints and hip joints
80
Q

a) What is the 1st line treatment for acute gout
b) What is the 2nd line treatment for acute gout?

A

a)

  • NSAIDs and PPI
  • Colchicine 500mg 2-4x per day (max 6mg per day)

b)

  • Prednisolone orally
  • Im or intra-articular steroid
81
Q

a) What is the single most important investigation to in confirming or excluding septic arthritis? including the findings
b) What other investigations can be done?

A

a) Joint aspiration for culture, microscopy and sensitivity including WCC and gram stain - the fluid itself will appear turbid and yellow, resembling pus.

b)

  • Blood tests - high white cells, high ESR/CRP
  • Blood culture
  • X-ray
82
Q

Colchicine

a) Indications and dose
b) Contra-indications
c) Cautions
d) Side-effects
e) Pregnancy and breast feeding
f) Hepatic impairment
g) Renal impairment

A

a) Acute gout
b) Blood disorders
c) Cardiac disease, elderly, GI disease
d) Abdominal pain, diarrhoea, nausea, vomiting
e) Avoid in pregnancy and cautionin breast feeding
f) Caution in mld to moderate impariment and avoid in severe impairment
g) Avoid in severe renal impaiment e.g., on dialysis

83
Q

What features on a X-ray of an acute gout attack will you see?

A
  • Soft tssue swelling
  • Peri-articular erosions

Medicine - Year 1 (61 decks)

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