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MBBS - Y1 > Week 4 - monoarticular joint pain > Flashcards

Week 4 - monoarticular joint pain Flashcards

1
Q

Describe the presentation of acute joint pain and swelling. (LO1)

A
  • Very common in A&E.
  • Can be caused by a wide number of different pathologies.
  • When it seems to be acute monoarthritis, it is important to differentiate between septic arthritis and other types of monoarthritis.
  • Knowing the difference between the presentation of each pathology is key to a quick diagnosis.
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2
Q

What are some key factors to find out about in the investigation of acute joint pain and swelling? (LO1)

A
  • Onset.
  • Site.
  • Timeframe.
  • Precipitating factors (trauma or surgery).
  • Other symptoms (systemic symptoms such as fever).
  • Previous episodes and past medical history.
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3
Q

Describe the initial investigation (before tests) of acute joint pain and swelling. (LO1)

A
  • Look, feel, move.
  • Check for redness, swelling, skin changes.
  • Compare to contralateral joint.
  • Check for joint effusion (patella tap/sweep test).
  • Check nearby joints for involvement.
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4
Q

Describe the investigation of acute joint pain and swelling. (LO1)

A
  • Blood tests: FBC, CRP - to check for tissue injury or sepsis.
  • ESR - to check for rheumatological causes.
  • Joint aspiration is performed - syringe used to remove fluid from joint.
  • Fluid is inspected visually and also sent for tests.
  • Tests of joint fluid include: WBC, microscopy, culture and sensitivity and light microscopy.
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5
Q

Describe the joint aspiration results of a normal joint. (LO1)

A
  1. Appearance: Clear.
  2. White cells (x10⁶/L): Normal (<200).
  3. Neutrophils (%): Low (<25%).
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6
Q

Describe the joint aspiration results of a joint with non-inflammatory arthritis. (LO1)

A
  1. Appearance: Clear/straw-coloured.
  2. White cells (x10⁶/L): Moderate (<2000).
  3. Neutrophils (%): Low (<25%).
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7
Q

Describe the joint aspiration results of a joint with inflammatory arthritis. (LO1)

A
  1. Appearance: Clear/cloudy yellow.
  2. White cells (x10⁶/L): High (>2000).
  3. Neutrophils (%): Low (<25%).
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8
Q

Describe the joint aspiration results of a joint with septic arthritis. (LO1)

A
  1. Appearance: Turbid (thick with suspended matter).
  2. White cells (x10⁶/L): Very high (>50,000).
  3. Neutrophils (%): High (>75%).
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9
Q

List the differentials for acute joint pain and swelling. (LO1)

A
  • Gout.
  • Pseudogout.
  • Rheumatoid arthritis (rare to present as monoarticular but possible).
  • Septic arthritis.
  • Musculoskeletal injury - haemarthrosis.
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10
Q

Describe the features of septic arthritis as a differential for acute joint pain and swelling. (LO1)

A
  • Infection of joint.
  • Can cause irreversible articular cartilage damage.
  • May lead to sepsis and possibly mortality.
  • Joint aspiration is the main way to diagnose.
  • Managed with empirical antibiotics and surgical washout and irrigation of the affected joint.
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11
Q

Describe the features of gout as a differential for acute joint pain and swelling. (LO1)

A
  • Caused by monosodium urate crystals in joint.
  • Form due to hyperuricaemia.
  • Typically episodic.
  • Identified via joint aspiration microscopy.
  • Treated with NSAIDs.
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12
Q

Describe the features of pseudogout as a differential for acute joint pain and swelling. (LO1)

A
  • Caused by deposits of calcium pyrophosphate crystals.

- Typically affects proximal joints.

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13
Q

Describe the features of rheumatoid arthritis as a differential for acute joint pain and swelling. (LO1)

A
  • Autoimmune disease.
  • Small joints in hands and feet.
  • Swollen, painful and red with stiffness.
  • Systemic symptoms: fatigue, weight loss and fever.
  • ESR will show raised inflammatory markers.
  • NSAIDs for pain.
  • DMARDs for management.
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14
Q

Describe the features of traumatic injury as a differential for acute joint pain and swelling. (LO1)

A
  • Haemarthrosis - bleeding in the joint cavity.
  • Bloods and plain film radiographs.
  • Management: RICE.
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15
Q

What is crystal arthritis? (LO2)

A
  • A type of arthritis causing severe pain due to crystals being deposited in the joints.
  • 2 main types: gout, pseudogout.
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16
Q

Describe the pathophysiology of gout. (LO2)

A

Gout is the consequence of hyperuricaemia and high levels of uric acid crystal formation.

Prolonged hyperuricaemia leads to the formation of urate crystals which deposit in the synovium of the joint.

Inflammation is then caused in the joint due to phagocytosis of the crystals by polymorphonuclear leukocytes.

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17
Q

List the at-risk groups for gout. (LO2)

A
  • Men >40 years.
  • Women after menopause - oestrogen levels drop as oestrogen would help remove uric acid.
  • Obese people.
  • Diuretic users.
  • Cancer patients.
  • Those with hypertension and renal disease.
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18
Q

What are two ways in which gout could occur? (LO2)

A

Overproduction of uric acid or the underexcretion of uric acid.

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19
Q

List some causes of the overproduction of uric acid. (LO2)

A
  • Excess purines in the diet.
  • Alcohol abuse.
  • Myeloproliferative disorder - abnormal production of WBCs.
  • Lymphoproliferative disorder - excess production of lymphocytes.
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20
Q

List some causes of the underexcretion of uric acid. (LO2)

A
  • Renal disease.

- Polycystic kidney disease (when cysts grow on the kidneys and cause damage).

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21
Q

Drugs are also capable of causing hyperuricaemia. List some of them. (LO2)

A
  • Alcohol.
  • Thiazides.
  • Lasix.
  • Aspirin.
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22
Q

List the two types of gout. (LO2)

A
  • Chronic gout.

- Acute gout.

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23
Q

List the clinical features of acute gout. (LO2)

A
  • Extremely painful.
  • Joint swelling.
  • Shiny, red skin.
  • Warm joint.
  • Multiple joints in severe cases.
  • First metatarsophalangeal joint most commonly affected.
  • Can affect ankles, knees, elbows, wrists and hands too.
  • Attacks usually resolve themselves.
  • If untreated, attacks become more frequent and bony erosive damage occurs.
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24
Q

List the clinical features of chronic gout. (LO2)

A
  • Appears in patients with long-standing hyperuricaemia who have had many flares.
  • Bony erosions form - deformity.
  • Can lead to deterioration of kidney function and uric acid stones forming in the urinary tract.
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25
Q

List the 3 main investigations for gout. (LO2)

A
  • Synovial fluid analysis.
  • Blood tests.
  • Radiology.
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26
Q

Describe the findings of a synovial fluid analysis as an investigation of gout. (LO2)

A
  • Synovial fluid aspirated from symptomatic joint.
  • Examined with microscope under polarised light.
  • Crystals are needle-shaped.
  • Strong negative birefringence - appear yellow if parallel to plane of light and blue if perpendicular.
  • Gram tests should be done to rule out infection.
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27
Q

Describe the findings in a blood test as an investigation of gout. (LO2)

A
  • WBC elevated.
  • CRP elevated.
  • ESR elevated.
  • Serum uric acid elevated - 1/3 of patients have normal uric acid in acute flare-ups.
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28
Q

Describe the radiological findings in gout. (LO2)

A

Erosion of the bone with overhanging edges.

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29
Q

Describe the management of acute gout. (LO2)

A
  • NSAIDs.
  • Colchicine if patient is unable to have NSAIDs.
  • Corticosteroids if patient is unable to have NSAIDs or colchicine.
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30
Q

Describe the management of chronic gout. (LO2)

A
  • Uricosuric agents - most commonly allopurinol - inhibits enzyme Xanthine oxidase.
  • Diet control.
  • Alcohol consumption reduced.
  • Colchicine prophylaxis.
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31
Q

What is pseudogout? (LO2)

A

A disease caused by the deposition of calcium pyrophosphate dihydrate (CPPD) crystals in a joint.

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32
Q

List the at-risk groups for pseudogout. (LO2)

A
  • The elderly.
  • Those with hypothyroidism.
  • Those with hyperparathyroidism.
  • Those with haemochromatosis.
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33
Q

What is the cause of pseudogout? (LO2)

A

The exact cause is unknown, however, it is associated with osteoarthritis and attacks are often preceded by other illnesses.

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34
Q

List the clinical features of pseudogout. (LO2)

A
  • Pain.
  • Swelling.
  • Stiffness.
  • Wrist and knees commonly affected.
  • Appearance of affected joint is similar to gout.
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35
Q

Describe findings of a synovial fluid analysis as an investigation of pseudogout. (LO2)

A
  • Calcium pyrophosphate dihydrate (CPPD) crystals appear as small and rod-shaped.
  • Weak positive birefringence.
  • Gram test should be done to rule out infection.
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36
Q

Describe the radiological findings in pseudogout. (LO2)

A
  • Calcification can be seen on the meniscus of the knee or triangular cartilage of the wrist.
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37
Q

Describe the management of pseudogout. (LO2)

A
  • Analgesia.
  • Joint injection of steroids.
  • Losing weight, physiotherapist and pain control.
  • Occasionally a joint replacement is done.
38
Q

Describe the basic epidemiology of osteoarthritis. (LO3)

A
  • In the UK, about 8.75 million people >45 have received treatment for osteoarthritis.
  • 33% of people in that age group.
  • Prevalence of osteoarthritis in <30s is about 1%. In >40s, it rises to 10%.
39
Q

Explain the pathophysiology of osteoarthritis. (LO3)

A
  • Our joints are maintained due to a homeostatic balance between synthesis and degradation of cartilage matrix.
  • Osteoarthritis occurs when the cartilage is worn down so the bones involved in joints rub and cause friction.
  • This then causes remodelling of the underlying bone.
40
Q

What are two ways in which osteoarthritis could occur? (LO3)

A
  • Reduced rate of formation of the cartilage.

- Increased rate of degration of the cartilage.

41
Q

How does degradation of the cartilage occur? (LO3)

A
  • Matrix metalloproteinases are enzymes released by chondrocytes due to IL-1.
  • These enzymes break down collagen and proteoglycans which make up the articular cartilage.
  • When underlying subchondral bone is exposed, the result is sclerosis and remodelling of the bone.
  • The formation of osteophytes follows as well as bone cysts.
  • Joint space progressively narrows.
42
Q

Describe the presentation of osteoarthritis. (LO3)

A
  • Pain.
  • Stiffness of the joint.
  • Reduced range of movement.
  • Coarse crepitus - grating sound when moving the joint.
43
Q

Describe the first line of investigations for osteoarthritis. (LO3)

A
  • Clinical - look, feel, move.

- Radiological - x-rays.

44
Q

Describe the findings of a clinical investigation of osteoarthritis. (LO3)

A
  • Pain.
  • Stiffness.
  • Reduced movement.
45
Q

Describe the radiological findings of osteoarthritis. (LO3)

A

X-rays would be used only to confirm a clinical diagnosis.

  • Osteophytes.
  • Narrowing joint space.
  • Subchondral cysts.
  • Subchondral sclerosis.
46
Q

What are some other investigations (apart from x-rays and clinical) that can be used to confirm osteoarthritis? (LO3)

A

MRI of affected joint - shows cartilage loss, bone marrow lesions and meniscal tears. (Should only be ordered to exclude other causes of joint pain such as avascular necrosis.)

47
Q

List the 3 levels of management of osteoarthritis. (LO3)

A
  1. Non-pharmacological.
  2. Pharmacological.
  3. Surgical.
48
Q

Describe the non-pharmacological management of osteoarthritis. (LO3)

A
  • Educate patients on how to manage it.
    E.g. exercise, weight loss, comfortable footwear, physiotherapy, walking/mobility aids.

More often than not, patients are in too much pain to carry out these methods. Simple analgesia could help with this.

49
Q

Describe the pharmacological management of osteoarthritis. (LO3)

A

Mostly to help with pain management. Work your way up through the ladder depending on the severity of pain.

  • Simple analgesics.
  • NSAIDs.
  • Opioids.
50
Q

Describe the surgical management of osteoarthritis. (LO3)

A
  • This should come after all other treatments have been exhausted as surgery is invasive.
  • Arthroplasty (total joint replacement).
  • Hemiarthroplasty (half joint replacement).
  • Excision of femoral head.
  • Osteotomy - realignment.
  • Arthrodesis - fusion.
51
Q

When would a hemiarthroplasty be performed over a full arthroplasty? (LO3)

A
  • Hemiarthroplasty in a hip involves replacing the femoral head with a prosthesis.
  • More commonly performed in elderly patients.
  • This because a hemiarthroplasty doesn’t offer much in terms of mobility and function.
  • A lot of elderly patients do not want or need a lot of mobility anyways.
52
Q

List the complications of osteoarthritis. (LO3)

A
  • Stress fractures.
  • Cartilage breakdown so loose tissue collects in the joint (chondrolysis).
  • Infection in the joint.
  • Osteonecrosis (bone death).
  • Deterioration of tendons and ligaments around the joint.
  • Pinched nerve (OA of the spine).
53
Q

Describe the prognosis of osteoarthritis. (LO3)

A
  • Chronic disease, progressive.
  • Prognosis depends on severity of the disease.
  • Those severely disabled by it can undergo a total joint replacement surgery which gives the best long-term outcome in terms of quality of life and functionality.
  • In some cases, a hemiarthroplasty would help reduce symptoms but wouldn’t offer the same functionality as a total arthroplasty would.
54
Q

Describe the epidemiology of septic arthritis. (LO4)

A
  • Uncommon, seen more in children, young adults and in the elderly.
  • More common in developing countries.
  • More common in those with predisposing factors.
  • Less common than osteomyelitis (infection INSIDE the bone).
  • Common in hip and knee but presents at any synovial joint.
55
Q

Describe the pathophysiology of septic arthritis. (LO4)

A
  • Infection reaches joint via haematogenous route (through bloodstream), direct spread from metaphysis or penetrating surgery.
  • Bacterium settles in the synovium, leading to inflammation.
  • Proliferation of bacteria causes an inflammatory response by the host with lots of leukocytes migrating to the joint.
  • Enzymes and breakdown products may damage the delicate articular cartilage very quickly.
56
Q

Which bacteria most commonly cause septic arthritis? (LO4)

A
  • Staphylococcus aureus.
  • In sexually active adults: Neisseria gonorrhoeae.
  • In an infant prior to vaccination: Haemophilus influenzae.
57
Q

Describe the presentation of septic arthritis. (LO4)

A
  • Acutely swollen joint.
  • Fever.
  • Systematically unwell.
  • Weight-bearing unbearable.
  • Movement causes INTENSE pain.
  • If joint is superficial, an effusion is palpable.

Additional presentations in children:

  • Distressed,
  • Unwell.
  • Difficult to assess.
58
Q

Describe the investigations of septic arthritis. (LO4)

A
  • WBC - high.
  • CRP - high.
  • ESR - high.
  • X-rays initially normal but later, would see destruction.
  • Ultrasound to check for joint effusion.
  • Any joint suspected must be aspirated and fluid sent to urgent gram stain, culture and examination for crystals.
59
Q

Describe the management of septic arthritis. (LO4)

A
  • Analgesia for pain.
  • Splint limb if possible.
  • Aspiration preferably before antibiotics.
  • Give appropriate antibiotics as advised by microbiologist.
  • Treatment with aspiration or surgical with arthroscopy/arthrotomy.
  • Chances are slim of full recovery if articular joint is destroyed so if so, arthroplasty needed.
60
Q

List some complications of septic arthritis. (LO4)

A
  • Reinfection.
  • Joint destruction.
  • Avascular necrosis.
  • Seeding of infection can occur to the spine or other organs.
61
Q

Describe the prognosis of septic arthritis. (LO4)

A
  • If treated quickly, good prognosis.
  • If joint destruction occurs, prognosis is very poor.
  • If left untreated, then death.
62
Q

List the four types of joints in our body. (LO5)

A
  • Fibrous joints - bones connected by fibrous tissue.
  • Primary cartilaginous joints - composed entirely of hyaline cartilage (also called synchondroses).
  • Secondary cartilaginous joints - composed of fibrocartilage.
  • Synovial joints - articular surfaces enclosed within a capsule that contains synovial fluid.
63
Q

What are the 3 main synovial joints? (LO5)

A
  • Hip.
  • Knee.
  • Elbow.
64
Q

List some of the most common types of synovial joints. (LO5)

A
  • Ball and socket.
  • Hinge.
  • Saddle.
  • Planar.
  • Pivot.
  • Condyloid.
65
Q

What can cause major synovial joints to become damaged or worn down? (LO5)

A
  • Inflammatory disease.
  • Trauma to the bone.
  • Tumours.
66
Q

What is a joint replacement? (LO5)

A
  • Known as arthroplasty.
  • Many joints can be replaced.
  • There are several reasons for having joint replacements but most often is to relieve pain.
67
Q

Which joints are most commonly replaced? (LO5)

A
  • The knee.
  • The hip.
  • The shoulder.
68
Q

What are the 3 possible types of arthroplasty. (LO5)

A
  • Total arthroplasty - complete joint replacement.
  • Hemiarthroplasty - only one side of the joint is resurfaced.
  • Excision arthroplasty - a joint is removed without being replaced.
69
Q

List some conditions where an arthroplasty is the last treatment. (LO5)

A
  • Rheumatoid arthritis.
  • Osteoarthritis.
  • Osteonecrosis.
  • Joint injuries.
70
Q

What are some indications for patients that need a total arthroplasty? (LO5)

A
  • Patient with severe arthritis, e.g. osteoarthritis, rheumatoid arthritis, post-traumatic arthritis.
  • The arthritis causes significant pain and interferes with daily activities such as getting dressed or walking.
  • Medical management has failed to control pain and/or restore function.
71
Q

What are some indications for patients that need a hemiarthroplasty? (LO5)

A
  • When trauma has damaged one side of the joint and interfered with the other side, a hemiarthroplasty is used to replace the damaged side.
72
Q

Why would an excision arthroplasty be used? (LO5)

A
  • As a last resort or as an interim treatment.
  • E.g. it can be part of the treatment of an infected arthroplasty where the infected artificial joint has to be excised without replacement until clinical and haematological markers of infection return to normal and a revision joint replacement can be done.
  • Can also be used when the functional expectation is low and therefore is more beneficial to remove the joint rather than replace it.
73
Q

What are the 2 criteria for performing a joint replacement? (LO5)

A
  • If it almost instantly cures pain.

- If it allows the patient to return to normal life/regain mobility.

74
Q

Briefly describe the NICE guidelines on treating joint disorders. (LO5)

A
  1. Offer advice on activity, exercise, weight loss, etc.
  2. Offer treatment for pain: paracetamol, then paracetamol and/or topical NSAIDs, then as a last resort, oral NSAIDs.
  3. Refer for consideration of surgery before there is prolonged and established limitation on function.
  4. Offer regular reviews to those with symptomatic osteoarthritis to monitor effectiveness of treatment and long-term course of the condition.
  5. Annual reviews if the patient has other illnesses/conditions, troublesome joint pain in more than one joint or is taking any drugs to manage osteoarthritis.
75
Q

Define haematogenous spread of infection. (LO6)

A

The spread of pathogens through the blood to a distant site.

76
Q

What are two MSK conditions associated with haematogenous spread of infection? (LO6)

A
  1. Reactive arthritis.

2. Septic arthritis.

77
Q

Describe the key features of reactive arthritis. (LO6)

A
  • Occurs after enteric bacterial infections - “post-infectious”.
  • Usually a polyarthritis.
  • No bacterial invasion of the joint but is instead immune mediated.
78
Q

List some infections that could precede reactive arthritis. (LO6)

A
  • Campylobacter (GI infection).
  • Yersinia.
  • Salmonella.
  • Shigella.
  • Chlamydia.
79
Q

What is reactive arthritis known as when it’s preceded by chlamydia? (LO6)

A

Reiter’s syndrome.

80
Q

Describe haematogenous spread of infections. (LO6)

A
  • Occurs after bacteria enter the bloodstream.
  • Bacteria circulating in the bloodstream is known as bacteraemia.
  • Bacteraemia can lead to seeding of the bacteria at distant sites leading to osteomyelitis (infection of the bone), septic arthritis or infective endocarditis.
  • Usually leads to arthritis in the hip or knee.
  • 2 weeks of antibiotics are needed to prevent osteomyelitis.
  • Risk factors for haematogenous spread to bones are previous bone disease (RA), or high virulence microorganisms, e.g. Staphylococcus aureus.
81
Q

What is meant by bacteraemia? (LO6)

A

When bacteria are circulating in the bloodstream.

82
Q

What are the risk factors for haematogenous spread of infection to the bones? (LO6)

A
  • Previous bone disease, e.g. rheumatoid arthritis.

- High virulence microorganisms, e.g. Staphylococcus aureus.

83
Q

State the most common location of infection in bone and why this happens. (LO6)

A
  1. Acute osteomyelitis typically occurs in the growing end of the long bone, where sprouting capillaries loop near the epiphyseal growth plates.
  2. The presence of capillaries and blood supply near this region increases the risk of bacterial localisation within the area.
  3. Since it is a disease of the epiphyseal growth plate, it typically affects children and adolescents and may follow non-penetrating injury to the bone.
84
Q

Describe osteomyelitis. (LO6)

A
  • Painful tender bone lesions and general febrile illness.
  • Can be seen on x-ray - periosteal reaction and bone loss.
  • Mostly an acute condition but can become chronic if necrotic bone fragments act as long-term source of infection.
  • Treatment: long-term course of antibiotics and surgical debridement of infected debris.
85
Q

How can we diagnose osteomyelitis? (LO6)

A
  • Diagnosed using blood cultures (before antibiotics).
  • If there is an open bone lesion, a bone biopsy can also be used for diagnosis.
  • Can be seen on x-ray - periosteal reaction and bone loss.
86
Q

What is the treatment for osteomyelitis? (LO6)

A

Long-term course of antibiotics and surgical debridement of infected debris.

87
Q

List the causative organisms of septic arthritis. (LO6)

A
  • Staphylococcus aureus (most common).
  • Group A + B Strep - common in adults and children.
  • Haemophilus influenzae - in unvaccinated children.
  • Neisseria gonorrhoea - in sexually active adults.
  • Mycobacterium tuberculosis - mostly in weight-bearing joints.
  • Borrelia burgdorferi - Lyme disease.
  • Gram negative bacilli - neonates, elderly and the immunosuppressed.
  • Sporothrix schenckii - fungal infection, seen in HIV patients.
88
Q

What are some clinical signs of paediatric septic arthritis? (LO6)

A
  • Hip is classically in a flexed, abducted and externally rotated position.
  • The baby will remain comfortable while in this position as the capsular joint volume is increased. When moved, it causes pain.
89
Q

What are some complications of septic arthritis in babies? (LO6)

A
  • Meningitis.
  • Osteomyelitis.
  • Cellulitis.
  • Pneumonia - more with Haemophilus influenzae infection.
90
Q

What are some common causes of septic arthritis in neonates? (LO6)

A
  • Staphylococcus aureus (most common).
  • Haemophilus influenzae.
  • Escherichia coli.
  • Group B Streptococcus.
91
Q

How do neonates and young children differ from adults in terms of haematogenous spread of infections which affect bone? (LO6)

A
  • Due to the unique anatomy, neonates and young children can have septic arthritis and osteomyelitis at the same time.
  • Their bony cortex is thin and the periosteum is loose.
  • The blood vessels which connect the metaphysis and epiphysis serves as a connection by which a bony infection (osteomyelitis) can cause spread into the joint (septic arthritis).

MBBS - Y1 (14 decks)

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