Clinical

Question 1

How do you perform a joint pain history?

Answer 1

WIPE

Open question
HPC inc. SOCRATES - site, onset, character, radiation, alleviating factors, timings, exacerbating factors & severity

Ask about:
1. Swelling & redness
2. Stiffness
3. Loss of function e.g. locking (meniscus)/giving way (ligaments)
4. Deformity
5. Paraesthesia/LOS/weakness/paralysis

PMHx & surgical history
Medications & allergies
Family Hx
Social Hx (Whos at home? Job? Independent with ADLs? Smoking/drinking/drugs?)
ICE

Question 2

Differential diagnoses of joint pain?

Answer 2

RA/OA
Meniscal/ligamentous injury
Gout unlikely
Referred pain from hip/spine

Question 3

How to investigate joint pain?

Answer 3

Radiograph of knees fully weight bearing with 2 views AP & lateral

Question 4

What is osteoarthritis?

Answer 4

A degenerative condition affecting articular cartilage of synovial joints most commonly affecting hip/knee/hands - primary (wear and tear as get older) or secondary (due to injury/infection/DDH/SUFE)

Clinical features:
Pain/stiffness worse on activity & in morning
Swelling but no warmth
Heberdens (DIP) & Bouchards (PIP)

X-ray signs = LOSS
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

Question 5

What is the pathogenesis of OA?

Answer 5

1. Articular cartilage splits and is eroded decreasing joint space
2. Inflammation/thickening of synovium & joint capsule
3. Cartilage continually damaged so bone rubs on bone thickening subchondral plate
4. Irregular outgrowths called osteophytes form
5. Reactive thickening of synovium due to inflammation
6. Sub-chondral cysts may develop on bone

Question 6

How is OA managed?

Answer 6

Conservative: healthy weight, regular exercise, physiotherapy

Medical: analgesia, NSAIDs, topical solutions & steroid injections

Surgery: arthroscopy/arthrocentesis or TKR/THR (if pain is poorly managed, if deformed, to improve poor mobility or if other measures failed)

Question 7

What are the complications of TKR?

Answer 7

Immediate: bleeding, neurovasculature injury (popliteal a), tourniquet injury (ischaemia) & DVT

Early: wound infection/dehiscence, fat embolism & common peroneal n. palsy

Late: prosthesis loosening or periprosthetic #

Question 8

How to perform a knee examination?

Answer 8

Look Feel Move & Special tests (5)

1. WIPE then gain consent and ask for pain at beginning
2. Inspect knee from standing front, lateral and back for muscle wasting, swelling, erythema & scars
3. Ask patient to walk to assess for antalgic gait
4. Palpate for effusion with patellar tap test
5. Palpate joint temp & tibial condyles/tuberosity, fibula head, medial/lateral joint lines, around patella, femoral condyles & in popliteal fossa
6. Active/passive flexion and extension
7. Valgus/varus stress test & Mcmurrays test for meniscal injury
8. Anterior/posterior drawer test
9. Patella apprehension test: lateral deplacement
10. Conclude exam by examining joint above/below, assessing neurovasculature of LL & ordering AP/lateral radiograph of both knees weight-bearing

Question 9

How do you perform a knee examination?

Answer 9

Look Feel Move & Special tests (2)

1. WIPE then gain consent and ask for pain at beginning
2. Inspect both hips for muscle wasting, swelling, redness & scars
3. Gait inspection
4. Trendelenbergs test
5. True vs apparent leg length (ASIS vs xiphisternum to medial malleolus)
6. Palpate skin for temperature, GT, femoral head & tendon of adductor longus
7. Flexion, internal/external rotation & ABD/ADD-uction actively & passively
8. To complete my examine I’d examine the knee/spine, assess neurovasculature of LL & order AP/lateral weight-bearing radiographs of both hips/knees
9. Thomas’s test