DDx: Joint Pain Flashcards Preview

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Flashcards in DDx: Joint Pain Deck (46):
1

Differential Diagnosis of Joint Pain

Antinuclear antibodies (ANA): nonspecific finding in SLE, Sjogren and scleroderma.  Antinuclear antibodies characteristically occur in IgM form in patients with RA, but they are found less frequently than rheumatoid factors.

Anti-U1-ribonucleoprotein (RNP) antibodies are found in patients with mixed connective tissue disease, which is characterized by features of systemic sclerosis, polymyositis, and SLE.

Anti-Ro/SSA and anti-La/SSB antibodies are present in 10% to 60% of patients with SLE; however, these antibodies are less specific than anti-dsDNA antibodies because they can also be present in patients with rheumatoid arthritis, systemic sclerosis, and Sjögren syndrome.

Rheumatoid Arthritis

Ankylosing spondylitis 

CPPD deposition disease

Gout 

Infective endocarditis 

Lyme disease

Osteoarthritis

Psoriatic arthritis

Peripheral arthritis associated with IBD

Reactive arthritis

Infectious arthritis

Systemic lupus erythematosus

Viral arthritis

Trochanteric bursitis

Anserine bursitis

Patellofemoral pain syndrome

Enteropathic Arthritis

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Ankylosing spondylitis 

Inflammatory disorder of the axial skeleton; may have peripheral involvement; apical pulmonary fibrosis; back pain.

Hx: Onset of ankylosing spondylitis usually occurs in the teenage years or 20s and manifests as persistent pain and morning stiffness involving the low back that is alleviated with activity. This condition also may be associated with tenderness of the pelvis.

Differs from rheumatoid arthritis because ankylosing spondylitis uncommonly has peripheral involvement and usually involves the lumbar spine.

Dx: MRI of the sacroiliac joints is most likely to establish the diagnosis.

CRx: Sacroiliitis; squaring of the vertebral bodies; bridging vertical enthesophytes

3

de Quervain tenosynovitis

Caused by inflammation of the abductor pollicis longus and extensor pollicis brevis tendons in the thumb. It is usually associated with repetitive use of the thumb but can also be associated with other conditions, including pregnancy, rheumatoid arthritis, and calcium apatite deposition disease. The typical presentation is of pain on the radial aspect of the wrist that occurs when the thumb is used to pinch or grasp. Examination findings include localized tenderness over the distal portion of the radial styloid process and pain with resisted thumb abduction and extension. 

4

Ganglion cysts

Swellings that overlie either joints or tendons most typically on the dorsal surface, develop as a result of chronic irritation of the wrist. If the cyst is not painful, no intervention is required.

5

Gout (Crystal-induced synovitis) 

Gout includes a group of clinical disorders ranging from acute, exquisitely painful, monoarticular arthritis to chronic, crippling, destructive polyarthritis. 

Gouty arthritis Inflammatory response to monosodium urate crystals deposited into synovial tissue, bursae, and tendon sheaths due to chronic uric acid supersaturation of serum; urate deposits cause joint and tissue destruction over time.

Progresses through three distinct stages: asymptomatic hyperuricemia, which may last several decades; acute intermittent gout; and chronic tophaceous gout, which usually develops only after years of acute intermittent gout. 

Hx: In the case of gout, frequently (75%) the first episode occurs in the great toe metatarsophalangeal joint (commonly referred to as podagra). It is important to note that the most common form of arthritis at this site is osteoarthritis. An active gouty joint is notable for warmth, swelling, and significant pain. 

Estrogen promotes uric acid excretion, so women typically do not develop gout until the postmenopausal period. 

Cx:

Tophi: Painless, persistent, generally noninflammatory nodules, which develop in tissues and tendons and are palpable on physical examination but also may occur as nodular lesions within joints or tissues

Tophi develop concomitantly with progressive gouty arthritis; although typically noninflammatory, an acute inflammatory response and local damage can occur at these sites

Dx: Arthrocentesis is performed in patients presenting with acute monoarticular arthritis to diagnose infection or crystal-induced arthritis.  A definitive diagnosis of gout is made by demonstrating negatively birefringent monosodium urate crystals within synovial fluid leukocytes.

Tx: Advise patients with gout to avoid alcohol, because alcohol increases uric acid production and may impair uric acid excretion. Foods high in purines (eg, organ meats, red meat, seafood) also should be avoided. 

Gout treatment is focused on either dealing with an acute attack or preventing disease in the future.

Acute attacks

Therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, or colchicine (if initiated within 36 hours of an attack).[Corticosteroids can provide quick relief, but should be reserved if initial therapy fails.]

NSAIDs are effective but should be avoided in patients who are older, who have chronic kidney disease, heart failure, peptic ulcer disease, or are on anticoagulation therapy. In these situations, intra-articular or systemic glucocorticoids are preferred. Oral colchicine is also an effective treatment for acute gout if initiated within 36 hours of an attack.

Uric acid-lowering therapy:

Patients with recurrent episodes of gout who are at risk for joint damage are candidates for uric acid-lowering therapy. Management or prevention of recurrent gout and chronic tophaceous gout requires drug therapy to achieve and maintain serum uric acid levels below 6 mg/dL (0.35 mmol/L). First-line therapy is with xanthine oxidase inhibitors (allopurinol or febuxostat)Allopurinol is typically safe and effective and is considered first-line therapy for most patients with an indication for uric acid lowering treatment.

As uric acid-lowering therapy can precipitate an attack, it is recommended that prophylactic therapy with colchicine or low-dose NSAIDs be used in the first 3 to 6 months of uric acid-lowering therapy. Uricosuric agents (eg, probenecid, sulfinpyrazone) are occasionally effective in patients with low uric acid excretion (<600 mg [35.4 mmol] daily) but are not effective in patients with a glomerular filtration rate <40 mL/min/1.73 m2.

6

Enteropathic Arthritis

Arthritic conditions associated with gastrointestinal disease.  

Up to 20% of patients with Crohn disease or ulcerative colitis develop inflammatory joint disease. Polyarthritis that resembles seronegative rheumatoid arthritis develops in 20% of these patients, whereas 10% to 15% of these patients develop spondylitis and sacroiliitis. The risk for inflammatory joint disease associated with Crohn disease or ulcerative colitis increases in patients with more advanced colonic conditions and additional concomitant extraintestinal manifestations, including abscesses, erythema nodosum, uveitis, and pyoderma gangrenosum. Peripheral arthritis associated with inflammatory bowel disease (IBD) is often classified as one of two types. In type I arthropathy, the peripheral arthritis tends to be acute, affects only a few joints, tends to occur early in the course of IBD, may worsen with flares of IBD, and is often self-limited. In type II arthropathy, more joints tend to be involved and symptoms may be migratory. Joint pain is usually not related to IBD activity, and symptoms may wax and wane over years. In patients with arthritis sensitive to flares of IBD, treating the underlying gastrointestinal disease is indicated. Additional treatment for sacroiliitis and peripheral joint disease is otherwise symptomatic.

7

Infectious arthritis

Usually monoarticular but may be oligoarticular; may be migratory; more often affects large joints. Patients present with hot, red, and swollen joints with limited range of motion. Joint fluid analysis is essential. Septic arthritis may develop in joints affected by rheumatoid arthritis.

Characterized by fever, arthritis, and exquisite joint tenderness. May occur as a complication of other arthritis syndromes. The source of infection (skin, lungs) often is evident. Usually occurs in previously abnormal joints.

8

Infective endocarditis 

Characterized by involvement of large proximal joints, fever with leukocytosis, and heart murmur. Obtain blood cultures in all patients with fever and polyarthritis. RF is a common finding in patients with endocarditis.

9

Lyme disease

Multisystem inflammatory disease caused by Borrelia burgdorferi. Early disease: erythema migrans rash and cardiac abnormalities. Late disease: intermittent monoarthritis or oligoarthritis that may become chronic. Rash and tick exposure or travel to an endemic area are important for the diagnosis. Obtain ELISA test; confirm a positive result with Western blot.

Doxycycline is the treatment of choice in patients who are not pregnant and >8 years old.  IV

Cefriaxone is reserved for early disseminated and late disease as oral doxycycline is very effective in resolving EM.

10

Osteoarthritis

Degeneration of articular cartilage, most often affecting the DIP, PIP, first CMC, first MTP, hip, and knee joints and the cervical and lumbar spine.

Hx: Common sites of osteoarthritis in the hand include the first carpometacarpal joint (base of the thumb), as well as the distal and proximal interphalangeal joints. Involvement of the carpometacarpal joint leads to “squaring” of the contour of the joint.

Pain occurs with use; minimal soft-tissue swelling and morning stiffness.

Characterized by joint-space narrowing with associated bony enlargement (osteophytes) with no acute signs of inflammation. Patients may have acute exacerbation of joint symptoms, especially after use.

According to the American College of Rheumatology's clinical criteria, osteoarthritis of the knee can be diagnosed if knee pain is accompanied by at least three of the following features: age greater than 50 years, morning stiffness lasting less than 30 minutes, crepitus, bone tenderness, bone enlargement, and no palpable warmth. 

Morning joint stiffness that persists for less than 30 minutes

Px: Passive range of motion of the knee often elicits pain at the extremes of flexion and extension. 

Dx: Diagnosed (clinically) if knee pain is accompanied by at least three of the following features: age greater than 50 years, stiffness lasting less than 30 minutes, crepitus, bone tenderness, bone enlargement, and no palpable warmth. 

CRX: Asymmetric joint-space narrowing; osteophytes; subchondral sclerosis and cystic changes; degenerative disk disease with collapse of disks; degenerative joint disease with facet joint osteophytes; these findings lead to spondylolisthesis (anterior/posterior misalignment of the spine) and kyphosis

Tx: Weight loss for overweight or obese patients with lower extremity osteoarthritis coupled with both aerobic exercise as well as exercise to strengthen muscles proximate to the involved joint (ie, quadriceps muscle strengthening for knee osteoarthritis). More specifically, medial knee compartment osteoarthritis may benefit from heel inserts (5-10 degrees of lift), which help relieve the pressure on the medial compartment. Adaptive devices such as a cane in the hand contralateral to the painful joint may help by unloading forces on the knee or hip. Knee taping or bracing improves knee alignment, thus improving pain. Referral to physical or occupational therapy for active and passive range of motion exercise instruction or joint protection education may be helpful.

Rx: Acetaminophen is first-line pharmacologic therapy for osteoarthritis because it is safe, effective, and inexpensive. Patients with an inadequate response can be started on NSAIDs, preferably at the lowest effective dose to limit side effects (eg, gastrointestinal and renal toxicity, exacerbation of congestive heart failure and hypertension). Although cylcooxygenase-2-selective NSAIDs are somewhat less likely to cause gastrointestinal ulcers, they are not more effective than nonselective NSAIDs, are significantly more expensive, and are associated with an increased risk for adverse cardiovascular events.

Intra-articular glucocorticoids may be effective in providing pain relief and improving function. Successful injections provide pain relief for an average of 3 months.  Intra-articular injection may be particularly useful in patients who obtain no relief from acetaminophen and have contraindications to the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as chronic kidney disease, hypertension and a history of peptic ulcer disease.

Total joint arthroplasty should be considered for patients who do not adequately respond to nonsurgical methods. Replacement of the damaged joint restores normal biomechanics and often results in dramatic improvements in quality of life. 

11

Osteonecrosis

Osteonecrosis (also known as aseptic, avascular, atraumatic or ischemic necrosis) occurs in disorders that disrupt the circulation of bone through micro-occlusion, abnormal endothelial function, or increased intraosseous pressure.  It is a common complication of long-term glucocorticoid use, possibly due to effects on osteocytes or abnormal plasma lipid levels causing microemboli.  Osteonecrosis causes bone and bone marrow infarction.  Abnormal bone remodeling subsequently results in trabecular thinning and collapse over months to years. Osteonecrosis of the femoral head is characterized by pain in the groin, thigh, or buttock that is worsened by activity and relieved by rest.  Progression of the disease can lead to reduced range of motion (usually abduction and internal rotation), rest pain, and joint instability.  In the first few months, x-rays are often normal, and MRI is a more sensitive test.  Osteonecrosis ("dry socket") typically presents with gradual onset of pain in the weight-bearing joints (hip most common).

12

Peripheral arthritis associated with IBD

Up to 20% of cases of IBD involve arthritis. The arthritis usually is nondestructive, involves the lower extremities, and reflects active bowel disease. May be indistinguishable from ankylosing spondylitis.

13

Polymyalgia rheumatica (PMR)

Age >50

Subacute-to-chronic (>1 month) pain in the shoulder, neck, and hip girdles

Morning stiffness lasting >1 hour

Constitutional symptoms

Elevated erythrocyte sedimentation rate >40 mm/h

No other apparent explanation for symptoms

Px: The physical examination is frequently unremarkable with patients having no focal tenderness or pain with active or passive range of motion.  Signs of inflammation in the joints are absent.  When asked to identify the location of their pain, patients typically indicate the soft tissues and not the joints. 

Tx: Low-dose glucocorticoids are the treatment of choice for PMR (eg, prednisone 10-20 mg daily).  Rapid and thorough relief of symptoms is expected, and failure to improve rapidly on prednisone should call the diagnosis into question. 

Cx: PMR is frequently associated with giant cell arteritis (GCA), also known as temporal arteritis.  Symptoms of GCA include headache, jaw claudication, vision loss, or tenderness over the temporal artery.  If GCA is suspected, patients should be considered for an expedited temporal artery biopsy and receive significantly higher doses of glucocorticoids (eg, prednisone 40-60 mg or higher daily).

14

[Pseudogout] Calcium pyrophosphate dihydrate (CPPD) deposition disease

Deposition of CPPD crystals in and around joints, most commonly the wrist, MCP joints, shoulder, and knee.

May be asymptomatic or have a varied presentation resembling rheumatoid arthritis, osteoarthritis, or gout-like inflammation. Cartilage calcification termed chondrocalcinosis, especially in the knee, symphysis pubis, shoulder, hip, and triangular cartilage of wrist, are pathognomonic.

Hx: No history of trauma; May be monoarticular or acute oligoarticular, with hot and red joints; may be chronic polyarticular in 5% of cases.

Osteoarthritis in unusual places (wrist, elbow, metacarpophalangeal joints, shoulder) without a history of trauma suggests CPPD deposition.

Px: Osteoarthritis in unusual places (wrist, elbow, metacarpophalangeal joints, shoulder)

Dx: Defined by finding CPPD crystals in synovial fluid and by chondrocalcinosis on radiographs.

Polarized microscopy reveals weakly positive birefringent crystals in synovial fluid. Radiographs show chondrocalcinosis.

Cartilage calcification termed chondrocalcinosis, especially in the knee, symphysis pubis, shoulder, hip, and triangular cartilage of wrist, are pathognomonic.

 

15

Psoriatic arthritis

Hx: There are five patterns of joint involvement in psoriatic arthritis: involvement of the distal interphalangeal joints; asymmetric oligoarthritis; symmetric polyarthritis (similar to that of rheumatoid arthritis); arthritis mutilans (extensive osteolysis of the digits with striking deformity); and spondylitis (axial disease). Characteristic features of psoriatic arthritis include enthesitis (inflammation of sites where tendons or ligaments insert into bone), dactylitis (inflammation of an entire digit), and tenosynovitis (inflammation of the synovial sheath surrounding a tendon). 

Common involvement of DIP joints, with fusiform swelling of digits and skin and nail changes consistent with psoriasis.

Synovial and entheseal swelling; may involve the DIP joints; dactylitis (sausage digits) present.

Characterized by joint distribution and appearance similar to that of reactive arthritis. Predilection for distal interphalangeal joints, often with concomitant nail pitting and onycholysis.

CRX: Destructive arthritis with erosions and osteophytes; DIP involvement; “pencil-in-cup” deformity on hand radiograph; arthritis mutilans

16

Reactive arthritis

Reactive arthritis occurs in both men and women, and enthesitis and oligoarthritis are common.

Hx: The classic triad of arthritis, urethritis, and conjunctivitis occurs in only about one third of patients. Manifests within 2 months of an episode of bacterial gastroenteritis or nongonococcal urethritis or cervicitis in a genetically predisposed patient.

Reactive arthritis was previously called Reiter syndrome, which referred to the coincidence of arthritis, conjunctivitis, and urethritis (or cervicitis). However, only about one third of patients have all three symptoms. Reactive arthritis usually affects the peripheral joints, often in the lower extremities, although inflammatory back pain also may be present.

Patients may also present with heel pain with enthesitis; keratoderma blennorrhagicum on the palms or soles; or circinate balanitis on the penis.

Differs from rheumatoid arthritis in that it is oligoarticular and asymmetric?

Presents as symmetric? inflammatory oligoarthritis, most often involving weight-bearing joints; may include tendon insertion inflammation (enthesitis).

Extra-articular manifestations include conjunctivitis, urethritis, stomatitis, and psoriaform skin changes (hyperkeratotic lesions on the palms and soles). Infection with Salmonella, Shigella, Yersinia, Campylobacter, or Chlamydia species within 3 wk prior to onset of initial attack.

are diagnostic when present.

Reactive arthritis is classically characterized by oligoarthritis, nongonococcal urethritis, and conjunctivitis.  It usually follows an acute gastrointestinal (eg, Salmonella, Yersinia) or genitourinary (eg, Chlamydia) infection and causes subacute to chronic, rather than acute, symptoms.

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Rheumatoid Arthritis

Rheumatoid arthritis is a symmetric polyarthritis that involves the small joints of the hands and feet as well as other joints throughout the body.

Hx: Usually is a symmetric polyarthritis affecting large and small joints; it rarely presents as monoarthritis. Soft tissue (synovial) swelling rather than bony enlargement of the PIP and MCP joints.  RA can affect most joints; however, the lumbar spine, thoracic spine. and distal interphalangeal joints are spared.  Flares may be monoarticular and present as pseudoinfectious arthritis.

Inflammatory signs (fatigue, prolonged morning stiffness), rheumatoid nodules, and inflammatory synovial fluid. 

Extra-articular: Vasculitis, dry eyes, dyspnea, or cough can all be seen. Cough and dyspnea may signal respiratory interstitial disease.

Morning stiffness lasting more than 60 minutes

Acute rheumatoid arthritis sometimes mimics gout. The greater the number of joints involved, the more likely that rheumatoid arthritis is the diagnosis.

Dx: Rheumatoid factor is positive in 80% of cases. Synovial fluid analysis including Gram stain and culture usually will distinguish a flare from infectious arthritis.

CRX: Bony erosions; periarticular osteopenia; subluxations; soft-tissue swelling; MCP and PIP involvement on hand radiograph

synovial fluid leukocyte count greater than 5000/µL (5 × 109/L).

Tx: 

DMARDs: Experts recommend that patients begin disease-modifying antirheumatic drugs (DMARDs) within 3 months of the onset of rheumatoid arthritis.

Methotrexate (Folic acid antimetabolite)

DMARD that is most likely to provide durable long-term response; often the initial choice

Takes 1-2 mo for full effect; frequently used in combination with other medications. Contraindicated in pregnancy and use with caution in patients who may become pregnant, have underlying liver or lung disease, immunosuppression, or infection. Folic acid supplementation prevents toxicity without interfering with efficacy.

Hydroxychloroquine (Antimalarial agent with lysosomotropic action that affects immune regulation and inflammation)

Early, mild, and nonerosive disease; in combination with methotrexate or when methotrexate is contraindicated

Takes 2-6 mo for full effect; frequently used in combination regimens. Use with caution in patients who are pregnant or who have antimalarial allergy, G6PD deficiency, or retinal disease. Perform annual ophthalmologic examination.

Sulfasalazine (Unknown mechanism)

Early, mild, and nonerosive disease; in combination with methotrexate or when methotrexate is contraindicated

Takes 1-2 mo for full benefit. Use with caution in patients with sulfonamide or aspirin allergy, G6PD deficiency, kidney or liver disease, blood disease, or asthma.

Leflunomide (Pyrimidine synthesis inhibitor)

In combination with methotrexate or when methotrexate is contraindicated for progressive disease

Contraindicated in pregnancy; use with caution in patients who may become pregnant (known teratogen) or have liver disease.

Biologic Agents:

TNF inhibitors (adalimumab, etanercept, certolizumab pegol, golimumab, infliximab)(Immunomodulation)

When adequate disease control is not achieved with one or more oral DMARDs, biologic therapy is indicated. The preferred initial biologic agent is a tumor necrosis factor α (TNF-α) inhibitor such as etanercept, which is usually added to baseline methotrexate therapy. Use of a TNF-α inhibitor in addition to methotrexate is significantly more effective in controlling joint damage and improving function compared with single-agent therapy with either medication alone.

Testing for latent tuberculosis required before starting therapy.

Interleukin-1 receptor antagonist (anakinra) (Immunomodulation)

Uncontrolled disease despite use of DMARDs

Testing for latent tuberculosis required before starting therapy.

T-cell costimulatory blocker (abatacept)(Immunomodulation) (down-regulation of T cells)

Uncontrolled disease despite use of DMARDs

Testing for latent tuberculosis required before starting therapy.

B-cell depleting agent (rituximab)(Monoclonal antibody against CD20)

Uncontrolled disease despite use of DMARDs

Testing for latent tuberculosis required before starting therapy.

Anti-inflammatory Agents

NSAIDs (Inhibit cyclooxygenase)

Mild disease without erosions; as an adjunctive analgesic in more serious disease

NSAIDs do not prevent disease progression. Use with caution in patients with chronic kidney disease or ulcer disease.

Glucocorticoids (Suppress inflammation at multiple points along the inflammatory cascade)

Low-dose or intra-articular injections when NSAIDs do not control symptoms and when DMARDs have not yet produced an effect

High-dose glucocorticoids are useful in treating serious extra-articular manifestations (eg, vasculitis).

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Systemic lupus erythematosus (SLE)

Clinically indistinguishable from the arthritis of rheumatoid arthritis; however, the arthritis in systemic lupus erythematosus is non-nodular and nonerosive.

Acute arthritis, especially monoarthritis, in an immunosuppressed patient with systemic lupus erythematosus requires a diligent workup to rule out infectious arthritis. Search for opportunistic infections in addition to the common pathogens.

 

19

Tendonitis

An acute (sudden, short-term) condition in which inflammation is caused by a direct injury to a tendon.

Rotator cuff tendinopathy (RCT) results from repetitive activity above shoulder height (eg, painting ceilings) and is common in middle-aged and older individuals.  Chronic tensile loading and compression by surrounding structures can cause microtears, fibrosis, and inflammatory calcification in the rotator cuff tendons (especially supraspinatus).  Pain may also emanate from the subacromial bursa and the tendon of the long head of the biceps.  On flexion or abduction of the humerus, the space between the humeral head and acromion is reduced, causing pressure on the supraspinatus tendon and subacromial bursa.  Impingement syndrome, a characteristic of RCT, refers to compression of these soft tissue structures.  Impingement can be demonstrated with the Neer test: With the patient's shoulder internally rotated and forearm pronated, the examiner stabilizes the scapula and flexes the humerus.  Reproduction of the pain is considered a positive test.

20

Tendinosis

A chronic (persistent or recurring) condition caused by repetitive trauma or an injury that hasn't healed.

21

Viral arthritis

Arthritis and rash lasting days to weeks, often after a flu-like illness. 

Possible causes include Epstein-Barr virus, adenovirus, human parvovirus B19, rubella, HIV, HBV, and HBC.

Patients may have morning stiffness, with symmetric involvement of the hands and wrists; they also may be RF-positive (a pseudo–rheumatoid arthritis pattern). Most cases (except those caused by human parvovirus B19) resolve in 4-6 wk.

22

SHOULDER/ELBOW/WRIST/HAND

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Lateral epicondylitis

Lateral epicondylitis is due to overuse of the extensor muscles, primarily the extensor carpi radialis brevis and the extensor digitorum communis.  The primary pathologic lesion is noninflammatory angiofibroblastic tendinosis at the common extensor origin on the lateral epicondyle of the humerus.  An analogous disorder can occur at the origin of the wrist flexors at the medial epicondyle (medial epicondylitis). Patients usually have a history of repetitive, forceful extension at the wrist.  Examination findings may include tenderness at the lateral epicondyle and reproduction of pain with resisted extension or passive flexion at the wrist.  Management includes activity modification, nonsteroidal anti-inflammatory drugs, and counterforce bracing.

24

Olecranon bursitis

Olecranon bursitis is due to repetitive pressure or friction on the elbows.  It presents with posterior elbow pain and is usually associated with visible swelling of the bursal sac.

25

Radial tunnel syndrome

Radial tunnel syndrome causes posterolateral elbow pain similar to that in lateral epicondylitis and may occur in conjunction with that condition.  Findings include weakness of extension at the wrist and third digit, reproduction of pain on resisted supination of the forearm, and pain at the radial tunnel on resisted hyperextension of the wrist.

26

Carpal Tunnel

The carpal tunnel is an anatomic space in the wrist defined by the carpal bones on the dorsal aspect and the transverse carpal ligament (flexor retinaculum) on the volar aspect.  The ligament attaches to the hamate and pisiform on the ulnar side and to the trapezium and scaphoid tuberosity on the radial side.  The carpal tunnel contains the flexor digitorum profundus tendons, the flexor digitorum superficialis tendons, the flexor pollicis longus tendon, and the median nerve.

Compression of the median nerve within the tunnel produces carpal tunnel syndrome, which is characterized by pain and paresthesias in the median nerve territory.  #1 CARDINAL SYMPTOM IS NOCTURNAL PAIN!!!!  Motor involvement causes weakness of thumb abduction and opposition,

27

Adhesive capsulitis ("frozen shoulder")

Characterized by fibrosis and contracture of the glenohumeral joint capsule. The stiff glenohumeral joint is most likely a result of chronic inflammation and fibrosis.

Hx: “Female, fat, fertile and forty” + thyroid, and parkinson’s. 

Causes a painful and stiff shoulder usually without a known inciting event. Gradual onset of shoulder stiffness, with or without mild pain, that limits their ability to flex, abduct (eg, reach overhead), or rotate the humerus. 

AC can be idiopathic or secondary to underlying conditions such as rotator cuff tendinopathy (most common), subacromial bursitis, paralytic stroke, diabetes mellitus, or humeral head fracture.

Dx: Diagnosis is confirmed on examination with >50% reduction in both passive and active ROM.

 

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Colles’

Colles’: A dorsally displaced, dorsally angulated fracture of the distal radius and the ulnar styloid that typically can be reduced well with closed manipulation. A short arm cast will immobilize the wrist and allow elbow mobility which will provide great functional quality of life.

29

Trigger Finger

In trigger finger (TF), one of the most common causes of hand pain and disability, the flexor tendon causes painful popping or snapping as the patient flexes and extends the digit. The patient may present with a digit locked in a particular position, most often flexion, which may require gentle, passive manipulation into full extension. Systemic causes of TF are collagen-vascular diseases, including the following [21] : RA, DM , Psoriatic arthritis, Amyloidosis, Hypothyroidism, Sarcoidosis, Pigmented villonodular synovitis.

30

Keinbock disease

AVN of lunate

31

Dupuytren’s contracture

Dupuytren disease is a fibrosing disorder that results in slowly progressive thickening and shorting of the palmar fascia and leads to debilitating digital contractures, particularly of the metacarpophalangeal (MCP) joints or the proximal interphalangeal (PIP) joints. This condition usually affects the fourth and fifth digits (the ring and small fingers). See the images below. TF results from thickening of the flexor tendon within the distal aspect of the palm. [2, 3] This thickening causes abnormal gliding and locking of the tendon within the tendon sheath. Specifically, the affected tendon is caught at the edge of the first annular (A1) pulley.

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Scaphoid fractures 

Scaphoid fractures are the most common of the carpal bone fractures.  They frequently result from falls onto an outstretched hand ("FOOSH" injury) that cause direct axial compression or wrist hyperextension.  A scaphoid fracture should be suspected in any patient with persistent wrist pain and tenderness in the anatomical snuffbox. 

 

The snuffbox is a shallow depression at the dorsoradial wrist bounded medially by the tendon of the extensor pollicis longus and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis.  The scaphoid and trapezium bones form the floor of the snuffbox.  A scaphoid fracture should be suspected in any patient with persistent wrist pain and tenderness in the anatomical snuffbox.

Failure to restore or protect potentially compromised circulation to the scaphoid may result in avascular necrosis of the proximal portion of the bone. Delayed or non-union of scaphoid fractures is also a concern, and can lead to post-traumatic arthritis.

33

De Quervian tenosynovitis

De Quervian tenosynovitis is a condition that classically affects new mothers who hold their infants with the thumb outstretched (abducted / extended).  This condition is caused by inflammation of the abductor pollicis longus (APL) and extensor pollicis brevis (APB) tendons as they pass through a fibrous sheath at the radial styloid process.  Tenderness can typically be elicited with direct palpation of the radial side of the wrist at the base of the hand.  Additionally, the Finkelstein test, which is conducted by passively stretching the affected tendons by grasping the flexed thumb into the palm with the fingers, elicits pain.

34

Interdigital (Morton) Neuroma

Interdigital (Morton) Neuroma The disorder is not a true neuroma but is a mechanically induced neuropathic degeneration of the interdigital nerves that causes numbness, aching, and burning in the distal forefoot from the metatarsal heads to the third and fourth toes.  The symptoms are worsened by walking on hard surfaces and wearing tight or high-heeled shoes.  The diagnosis of Morton neuroma is primarily made clinically.  On examination, squeezing the metatarsal joints will cause pain on the plantar surface of the foot along with crepitus between the third and fourth toes (Mulder sign).  Treatment involves metatarsal support with a bar or padded shoe inserts to decrease pressure on the metatarsal heads.  Surgery is usually reserved for patients who fail conservative treatment.

35

Monte gg ia:

proximal ulna; radial head

36

HIP/KNEE/FOOT

37

Iliotibial band syndrome

The most common cause of lateral knee pain in young athletes such as runners or cyclists.

Hx:Knife-like lateral knee pain that occurs with vigorous flexion-extension activities of the knee.  Patients often describe pain that radiates down the outside of the leg. 

Px: Pain to palpation along the band down to the knee. Stretching of the iliotibial band by adducting the knee often reproduces the pain.

Tx: Treated conservatively with rest and stretching exercises; strengthening the hip abductors, internal rotators, and knee flexors

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Trochanteric bursitis

inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur’s greater trochanter.  Excessive frictional forces secondary to overuse, trauma, joint crystals, or infection are responsible.  Patients with this condition complain of hip pain when pressure is applied (as when sleeping) and with external rotation or resisted abduction.

Hx: Caused by friction of the tendons of the gluteus medius and tensor fascia lata over the greater trochanter.  Pain is localized to the lateral hip and is worsened by direct pressure.

Patients describe pain when lying on their side or swinging their leg into a car. 

Px: Hip range of motion is normal; although patients may indicate that they believe they are having pain in the joint, nonarticular pain is often worse with active range of motion and is localized away from the joint on palpation.

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Pes Anserine bursitis

Most commonly a confounding cause of knee pain in patients with medial knee osteoarthritis, but also occurs in the setting of overuse (such as running).

Pain and tenderness over the anteromedial aspect of the proximal tibia below the joint line of the knee.

Pain is worse with climbing stairs and frequently worsens at night.

Px: Tenderness is elicited at the level of the tibial tuberosity (approximately 3.8 cm [1.5 in] below the level of the medial joint line).  Swelling may be present at the insertion of the medial hamstring muscles. 

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Prepatellar bursitis "housemaid's knee”

Hx: Pain in the anterior aspect of the knee.

Common in occupations requiring repetitive kneeling, such as concrete work, carpet laying, and plumbing. 

While bursitis in other locations is generally noninfectious, acute prepatellar bursitis is very commonly due to Staphylococcus aureus, which can infect the bursa via penetrating trauma, repetitive friction, or extension from local cellulitis. 

Dx: The diagnosis should be confirmed with aspiration of bursal fluid for cell count and Gram stain. 

Tx: If Gram stain and culture are negative, patients may be managed with activity modification and nonsteroidal anti-inflammatory drugs.  Otherwise, patients are treated with drainage and systemic antibiotics.

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Patellofemoral pain syndrome

The most common cause of knee pain in patients younger than age 45 years.  The pain is peripatellar and exacerbated by overuse (such as running), descending stairs, or prolonged sitting (theatre sign).

Hx: Anterior knee pain that is made worse with prolonged sitting and with going up and down stairs. 

Px: The pain is reproduced by applying pressure to the patella with the knee in extension and moving the patella both medially and laterally (patellofemoral compression test).

Tx: Treatment is done primarily through strengthening the quadriceps muscles and hip rotators.

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Charcot joint

Pathogenesis involves decreased proprioception, pain, and temperature perception, which can occur due to diabetes, peripheral nerve damage, syringomyelia, spinal cord injury, vitamin B12 deficiency, or tabes dorsalis.  As normal neurologic input is lost, patients unknowingly traumatize their weight-bearing joints.  This causes secondary degenerative joint disease, joint deformation, and functional limitation.  X-rays will reveal loss of cartilage, osteophyte development, and loose bodies.  In diabetes, vasculopathy also contributes to disease pathogenesis.  Associated pain is typically mild.  Management of a Charcot joint involves treating the underlying disease and providing mechanical devices (eg, special shoes) to assist in weight bearing and decrease further trauma.

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Popliteal cyst

Popliteal cyst is due to extrusion of synovial fluid from the knee joint into the gastrocnemius or semimembranosus bursa through a communication between the joint and the bursa.  Excessive synovial fluid formation (eg, due to osteoarthritis or rheumatoid arthritis) and positive pressure in the knee during extension can cause passage of fluid into the bursa and gradual enlargement of the cyst.  Popliteal cysts are often asymptomatic and present as a chronic, painless bulge behind the knee.  The diagnosis is usually apparent on examination, with a soft mass in the medial popliteal space that is most noticeable with knee extension and less prominent with flexion.  Rupture of a popliteal cyst (eg, following strenuous exercise) can cause posterior knee and calf pain, with tenderness and swelling of the calf resembling deep venous thrombosis (DVT).  An arc of ecchymosis is often visible distal to the medial malleolus ("crescent sign").  Ultrasound can rule out DVT and confirm the popliteal cyst.

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Maiso”nneuve”:

ankle with medial malleolus; fibular head

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Meniscal injury

Hx: Locking, catching, or giving way

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Ottawa ankle rules

Ottawa ankle rules are a useful guide to use to determine if radiographs are indicated after an ankle sprain. Films should be obtained if:


• The patient is unable to walk four steps immediately after the injury and in the office.
• There is tenderness over the distal 6 cm of the tibia or fibula, including the malleoli.
• There is midfoot or navicular tenderness.
• There is tenderness over the proximal fifth metatarsal.