Approach to the patient with monoarticular pain - PowerPoint PPT Presentation

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Approach to the patient with monoarticular pain

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Chest often normal. Mantoux positive. Investigations in acute monoarthritis ... Aspiration/drainage. Antibiotics- parenteral then oral if septic. NSAIDs, other ... – PowerPoint PPT presentation

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Title: Approach to the patient with monoarticular pain


1
Approach to the patient with monoarticular pain
  • Caroline Gordon
  • Department of Rheumatology
  • City Hospital and
  • University of Birmingham

2
Assessment of joint pain
  • Site (distribution)
  • Type
  • Associated features
  • Duration and onset
  • Risk factors
  • Physical signs
  • Differential diagnosis

3
Structures associated with a joint
4
Site of pain
  • Patient complains of pain in the knee
  • Is pain coming from the joint arthritis
  • Is pain from the surrounding tissues
  • tendonitis, enthesitis, bursitis
  • or bone pain
  • Is there pain in other joints?

5
Site and distribution of pain
  • Is it joint, peri-articular or muscle pain?
  • Which joint is involved?

Achilles tendonitis
6
What type of joint pain?
  • Is it inflammatory?
  • Is it mechanical or degenerative?
  • Pain worse at rest
  • and improved by exercise
  • Pain worse on exercise
  • and improved by rest

7
Other inflammatory features?
  • Early morning stiffness?
  • Redness?
  • Warmth?
  • Tenderness?
  • Swelling?

8
Duration and onset
  • Is it acute or chronic?
  • What were circumstances of onset?
  • Is it getting rapidly or slowly worse?
  • Have there been any previous episodes?

9
Differential diagnosis
  • Acute Inflammatory
  • Septic arthritis
  • Crystal arthritis
  • Haemarthrosis
  • Other
  • Chronic
  • TB arthritis
  • Acute non-inflammatory
  • usually trauma related
  • cartilage or ligamentous
  • aseptic necrosis
  • Chronic
  • Osteoarthritis

10
Systemic features?
  • Fever
  • Malaise
  • Weight loss
  • Loss of appetite
  • Infections- skin, respiratory, urinary etc

11
Past medical history- risk factors
  • Predisposition to infection?
  • Associations with gout/other crystals
  • Recent infection
  • Joint replacement
  • Diabetes mellitus
  • Chronic systemic disease/malignancy
  • Dehydration
  • Renal failure
  • Hypertension
  • Hypercholesterolaemia

12
Other risk factors
  • Family history of
  • gout
  • haemophilia or other bleeding disorder
  • Social history of
  • alcoholism
  • drug abuse

13
Treatment history
  • Risks for sepsis
  • Corticosteroids
  • Cytotoxic drugs
  • IV drug use/abuse
  • Risks for gout
  • Diuretics
  • Nephrotoxic drugs
  • Risks for haemarthrosis
  • anticoagulation

14
Clinical features of inflammatory monoarthritis
  • Fever
  • Erythema
  • Local pain and tenderness
  • Inflammatory signs
  • Impaired function
  • Signs of infection
  • Petechiae or purpura
  • Gouty tophi

15
Gouty tophi
16
Differential diagnosis of monoarthritis
  • Inflammatory
  • septic arthritis
  • crystal arthritis eg gout, pseudogout (CPPD)
  • haemarthrosis (bleed)
  • Non-inflammatory
  • osteoarthritis

17
Features suggesting infection
  • Fever
  • Lymph nodes
  • Erythema and heat
  • One joint flare in RA
  • One or few joints-sequential/additive
  • Other risk factors

18
Tuberculous infection
  • Indolent
  • Mild fever
  • Rarely warmth/redness
  • Some tenderness/swelling
  • Usually monoarthritis
  • Chest often normal
  • Mantoux positive

19
Investigations in acute monoarthritis
  • FBC (WC diff) , ESR or viscosity or CRP
  • Renal function urate
  • Blood cultures
  • Synovial fluid
  • Swabs, urine, stool
  • X-rays

20
Synovial fluid analysis
  • Infection or crystals ? (or blood ?)
  • Cell count and differential
  • Gram stain /- Ziel-Nielsen stain
  • Culture for bacteria including TB
  • Polarised light microscopy for crystals

21
Aspirate after correcting clotting if necessary
22
Synovial fluid analysis
  • Macroscopic
  • Cells
  • Chemistry
  • turbid
  • not viscous
  • poor mucin clot
  • increased gt50,000/mm3
  • gt90 neutrophils
  • low glucose in infection

23
Aspirate to distinguish infection from crystals
24
Septic arthritis due to Staph. aureus
25
X-ray changes in infection
  • Soft tissue swelling
  • Joint space narrowing
  • No reactive osteopenia or sclerosis early
  • Destruction and flattening of weight-bearing
    surfaces (eg hip)
  • Diffuse loss of cortex not discrete erosion
  • Late sclerosis/fusion

26
X-ray change in infection
27
Crystal arthritis
  • GOUT
  • urate crystals
  • Middle aged males
  • Post-menopausal female
  • Peripheral small joints
  • Medium sized joints less
  • PSEUDOGOUT (CPPD)
  • calcium pyrophosphate dihydrate
  • Elderly females gt males
  • Medium large joints most
  • May be associated with OA

28
Gout
Usually monoarticular at onset
29
Uric acid crystals
30
X-rays in gout
31
Severe tophaceous gout
32
PseudogoutCalcium pyrophosphate arthropathy
33
CPPD arthropathyoften associated with
osteoarthritis
34
Aspirate to distinguish infection from crystals
35
Calcium pyrophosphate crystals
36
Chondrocalcinosisassociated with CPPD arthritis
37
Chondrocalcinosis in the triangular ligament
38
Treatment of acute inflammatory monoarthritis
  • Reverse anticoagulation if appropriate
  • Aspiration/drainage
  • Antibiotics- parenteral then oral if septic
  • NSAIDs, other analgesia
  • Rest
  • Physiotherapy
  • Other therapy if crystals confirmed

39
Treatment of septic arthritis
  • Antibiotics
  • Staph aureus
  • Strep/H. infl
  • Gram negative
  • Penicillin allergic
  • Flucloxacillin
  • Sodium fucidate
  • Vancomycin
  • Amoxicillin
  • Gentamycin
  • Cefuroxime
  • Erythromycin

40
Type of pain associated features of inflammation
  • Is it inflammatory?
  • What makes the pain worse/better?
  • Is there morning stiffness/gelling?
  • Has there been any swelling?
  • Is the joint tender to touch?
  • Has the joint been red or warm?

41
Acute inflammatory monoarthritis
  • Infection-acute/chronic
  • Crystals-gout/CPPD
  • Trauma
  • Bleed (haemarthrosis-coagulopathy)
  • Other inflammatory arthritis
  • Tumour (very rare)

42
Clinical features of osteoarthritis
  • SYMPTOMS
  • Use-related pain
  • Mild am stiffness
  • Inactivity gelling
  • Loss of joint motion
  • Instability
  • Disability
  • SIGNS
  • Periarticular tenderness
  • Bony swelling joint margin
  • Cool effusions
  • Coarse crepitus
  • Restricted painful movement
  • Instability

43
Osteoarthritis monoarticular or polyarticular
44
Osteoarthritis (OA)
  • Joint failure
  • Dysregulation of normal tissue turnover repair
  • Extremely common age-related disorder
  • Major cause of disability inability to work
    gt50yrs

45
Pathological features of OA
  • Focal areas of destruction of articular cartilage
    (fibrillation and erosion)
  • Hypertrophy of subchondral bone, joint margin
    capsule (synovial metaplasia)
  • Pseudocysts

46
Normal and OA joint
47
Radiological changes of OA
  • Joint space narrowing
  • Subchondral bone sclerosis and cysts
  • Marginal osteophyte formation

48
Normal knee and osteoarthritis
49
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50
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51
Management of osteoarthritis
  • Establish diagnosis
  • Analgesia
  • Education
  • Exercise
  • Walking stick etc
  • Surgery
  • clinical assessment
  • X-rays
  • blood tests
  • paracetamol, codeine
  • future expectations
  • physio
  • OT
  • plan appropriate time
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