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Junior Surgery > Painful Joint > Flashcards

Painful Joint Flashcards

1
Q

What is osteoarthritis

A

The most common form of arthritis
- joint damage that results from a disparity between the stress applied to the articular cartilage and the ability of the cartilage to withstand stress
Commonly affects the hip, knee, DIP, PIP, thumb CMJ and hallux MTP joints
Usually spares the MCPJs

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2
Q

Clinical features of OA

A

Progressive pain
- initially activity related pain, progresses to a constant rest pain
- stiffness characteristically worse after periods of rest but lasts under 30min
Morning stiffness
Waxing and waning course
Muscle wasting
Loss of mobility
Deformity
Joint instability

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3
Q

OE of OA

A

Look: bone swelling, muscle wasting
Feel: joint line tenderness, possible effusions, crepitus
Move: limited range of movement

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4
Q

Red flags of OA

A

Age <45
Severe morning stiffness
Severe night pain
Fever / systemic symptoms

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5
Q

OA risk factors

A

Age
Obesity
FH
Female ( esp post menopausal)
Hypermobility
Previous trauma
Occupation

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6
Q

Protective factor for OA

A

Osteoporosis

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7
Q

What is the LOSS acronym for looking for OA in X-rays

A

Loss of joint space
Osteophytes
Sclerosis
Subchondral cysts

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8
Q

Causes of secondary OA

A

Pre existing joint damage: inflammatory, septic, crystal arthritis, AVN, trauma
Metabolic disease: acromegaly, chondrocalcinosis, haemochromatosis
Systemic disease: haemophilia, haemoglobinopathies, neuropathies

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9
Q

What is the difference between localised and generalised OA

A

Localised affects either hip, knee, shoulder
Generalised affects many joints and is classically worse in the hands

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10
Q

Clinical features of hip OA

A

Unilateral
Deep pain in the anterior groin initially on walking or climbing stairs
Pain may be referred to the buttock, thigh, knee or ankle. This can then progress to gait abnormalities

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11
Q

What is the trendelenburg gait

A

Lurch towards the affected hip with less time spent weight bearing on that side
Pelvis tilts towards unaffected side - due to wasting and weakness of the gluteal and anterior thigh muscles

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12
Q

OE of hip OA

A

Painful and decreased internal and external rotation of the hip
Positive trendelenburg test

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13
Q

Clinical features of knee OA

A

Bilateral and symmetrical at presentation
Strong relationship with obesity

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14
Q

What is unilateral knee OA likely to be indicative of

A

Previous trauma or soft tissue injuries
Pain usually localised to a specific compartment of the knee

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15
Q

What is seen in advanced knee OA

A

Varus (bow legged) deformity
Antalgic gait

Valgus deformity is less common

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16
Q

OE of knee OA

A

Moderate joint effusion, decreased range of movement, crepitus, quadriceps wasting

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17
Q

What does locking suggest in knee OA

A

Loose meniscal cartilage in the joint

18
Q

What does giving way indicate in knee OA

A

Giving way may be due to weak quadriceps muscles, severe patellofemoral involvement or altered load bearing mechanisms

19
Q

What is shoulder OA

A

Far less common than knee, hand or hip OA
Most commonly seen in women >70
Associated with increased BMI and previous shoulder injuries

20
Q

What is nodal generalised OA

A

Joints of the hands are affected one by one over many years
- first presents with painful swelling and impairment of function
- typical in menopausal women
- familial tendency thought to have autoimmune aetiology
- DIPs affected more than PIPs
- heberden (DIP) and bouchard (PIP) nodes

21
Q

OE of nodal generalised OA

A

Bony swelling and fixed adduction deformities - squared hand
Thenar muscle wasting will be seen
Other MCPJs generally spared

Once disease progresses, there may be ulnar or radial deviation at affected joints

22
Q

What is erosive OA

A

Rare
Characteristic cysts seen on X-RAY
Poor prognosis

23
Q

What is crystal associated OA

A

Calcium pyrophosphate deposition in the cartilage leads to chondrocalcinosis
This can be asymptomatic or lead to the signs / symptoms of OA
Knees and wrists affected

24
Q

Pathophysiology of OA

A

In a normal synovial joint, the articular cartilage maintains the distance between the bone ends
In OA, wear and tear leads to erosion of this cartilage resulting in narrowing of joint space
There is inflammation and thickening of the joint capsule and synovium - capsular fibrosis
This causes progressive cartilage loss leading to eburnation
Small cysts develop beneath this abnormal bone surface and osteophytes form

25
Q

What can happen to muscles secondary to OA

A

As the joint becomes less mobile and less used
There may be secondary atrophy of the associated muscles

26
Q

Radio graphic features of OA

A
  • joint space narrowing
  • sclerosis
  • osteophyte formation
  • cystic formation
27
Q

What are the best indicators of pain in OA

A

Poor quadriceps strength
Depressed mood

28
Q

Investigations in OA

A

Bloods: to rule out other pathologies
X-RAY: 2 views to confirm OA presence
CT / MRI: if X-RAY does not correlate with clinical picture

29
Q

Management of OA

A

The goals are to minimise pain, optimise function and slow the process of joint damage
1. Patient education including regular and consistent exercise, weight loss
2. Physiotherapist: strength, stability, range of movement
3. Reduction of mechanical factors: cushioned footwear, walking aids
4. Splints for ankles / wrists
5. Offset bracing of the knee: allows weight re-distribution
6. Pain relieving meds
7. Intra-articular X-RAY guided corticosteroid injections

30
Q

Pain relieving medications used in OA

A

Topical NSAID is 1st line
Oral NSAID +PPI if no response to this
- paracetamol and weak opioids not recommended for long term use

31
Q

What is a total replacement arthroplasty

A

Common in the knee / hip
Delayed for longer in the knee where possible due to poorer long term outcomes
Joint replacements typically last 10-15 years but is variable

32
Q

What is a one compartment arthroplasty

A

Can occur in the knee if just one side of the articular surface is diseased
- must be clear history of mechanical locking

33
Q

Complications of total hip replacement

A
  • leg length discrepancy
  • dislocation
  • infection
  • periprosthetic fracture
  • persistent pain
  • polyethene wear of the acetabular compartment
  • neurovascular injury
34
Q

Complications of a prosthetic joint infection

A

Systemic upset
Joint will be aspirated in aseptic conditions on 3 separate occasions
Management usually involves removal of the prosthesis and lengthy course of abx to clear infection before a new prosthesis

35
Q

Why are cartilaginous loose bodies able to survive and grow

A

The cartilage has 2 sources of nutrition - the synovial fluid as well as the bone marrow

36
Q

4 zones of articular cartilage

A
  1. Superficial tangential zone
  2. Middle zone
  3. Deep zone
  4. Calcified zone
37
Q

What is the 1st change to occur in OA

A

Water content increases in the cartilage leading to increased permeability and decreased strength

38
Q

Function of chondrocytes in cartilage

A

Produce collagen and proteoglycans to maintain the matrix

39
Q

Function of type II collagen in chondral cartilage

A

Gives tensile strength

40
Q

Where does articular cartilage derive its nutrition from

A

Synovial fluid
Blood in the subchondral bone marrow

41
Q

What are the characteristics of mature articular cartilage (3As)

A

Avascular
Aneural
Alymphatic

42
Q

What types of arthritis present with soft tissue swelling

A

Psoriatic arthritis
Rheumatoid arthritis

Junior Surgery (6 decks)

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