evaluation of joint pain sarah lewis mhs, pa-c
TRANSCRIPT
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Evaluation of Joint PainSarah Lewis MHS, PA-C
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Classifications and Different Strategies1. Anatomically2. Rule-out critical conditions first
“Joint Emergencies”
3. Mono vs Poly articular4. Inflammatory vs non
inflammatory
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ANATOMICALLY
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Anatomy
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Anatomic Sources of Pain?Source Examples Clues
Dermis
Soft Tissue
Muscle
Bone
Vascular
Nervous
Synovial
Other
Rheumatologic
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JOINT EMERGENCIES
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Red FlagsAcute Onset
◦Pain ◦Weakness◦Numbness
Fever?Red Hot Swollen Joint?History of Cancer?Weight Loss?Underlying Bleeding Disorder?
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FeverFever suggests a subset of infectious and
rheumatic illnesses including :◦ Infectious arthritis (bacterial or viral)◦Postinfectious or reactive arthritis (enteric
infection, rheumatic fever, inflammatory bowel disease)
Rheumatoid arthritis and Still's diseaseSystemic rheumatic illness (vasculitis, SLE)Crystal-induced arthritis (gout and
pseudogout)Other diseases such as cancer, sarcoidosis,
and mucocutaneous disorders
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Joint emergencies1. Septic Joint: infection of the joint requires
immediate surgical wash out 2. Compartment syndrome: fasciotomy to
prevent neuromuscular, and vascular damage
3. Acute myelopathy- cord impingement/nerve impingement motor dysfunction
4. Osteomyelitis: infection of bone5. Avascular necrosis: bone necrosis due to
vascular injury6. Cancer-Usually Mets
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Septic Joints
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MONOARTICULAR VS. POLYARTICULAR
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Mono ArticularDJDCrystalline ArthropathiesHemarthrosisAvascular NecrosisOsteomyelitisTendonitis/ Synovitis/ EpicondylitisSeptic ArthritisTraumaTumor
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Case65 year old man with left great
toe pain X2 daysHad this before, he thinksMeds: HCTZ, ASA, simvastatin;
NKDAQuestions?
◦HPI◦ROS◦PE
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Poly ArticularPolyarthritis (table 1- slide 20)Viral arthritis (table 2- slide 22)Postinfectious or active arthritisFibromyalgiaMultiple sites of bursitis or tendinitisSoft tissue abnormalitiesHypothyroidismNeuropathic painMetabolic bone diseaseDepression
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Case21 year old male with left elbow
and right ankle pain, no feverYesterday discharged from
hospital for “STDs”PE: L elbow and right ankle
appear slightly swollen, more pink. Active or passive ROM
Any questions?
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Case27 year old female comes in
complaining of multiple joint and “neck” pain
Son recently sick with “slapped checks” rash
PE: low fever, faint lacy rash, no focal MSK findings
. . .
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THOROUGH H&P
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HistoryGeneral/ConstitutionalENT-Sore Throat, Oral Ulcers, DysgeusiaGI-Critical!!! Abdominal
Pain/Diarrhea/Hematochezia/IBS symptomsGU- Hematuria/Dysuria/DischargeSoft Tissue SymptomsPMH- Sickle Cell, RA, RF,DJD, LE, Gout EtcFam Hx- Sickle Cell, RA, RF,DJD, LE, Gout EtcMedications-Diuretics, Procainamide,
Statins, OthersAllergies
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Physical ExaminationEyes-Conjunctivitis/Uveitis?Mouth-Oral Ulcers?Chest-Pulmonary Findings?Abdomen- Organomegaly?Rectal-Mets from Prostate
Disease?
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Physical Examination- cont.MS- All Joints, Soft TissuesDon’t forget the back !!Inspect for:
◦ Redness, swelling or rash◦ Symmetry/ tone◦ ROM
Palpate for:◦ Heat◦ Crepitus◦ Tenderness◦ Strength
Pain articular or juxta-articular
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Evaluation of oligoarthralgia
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Lab Studies - Arthrocentesis/ Joint Fluid Analysis
• Arthrocentesis/ Joint Fluid Analysis for Cell Count Crystals Culture
◦ A positive synovial fluid culture establishes the diagnosis of infectious arthritis.
◦ A bloody effusion should lead to consideration of a coagulopathy, pseudogout, tumor, trauma, or a Charcot joint; subsequent evaluation includes a PT, PTT, platelet count, and bleeding time.
◦ Bone marrow elements = intraarticular fracture.◦ A noninflammatory synovial fluid (eg, <2000 WBCs or <75
percent neutrophils) should lead to consideration of osteoarthritis, soft tissue injury, or viral infection.
◦ Inflammatory joint fluid with crystals = gout or pseudogout.◦ A sterile inflammatory joint fluid raises the suspicion of
systemic rheumatic disorders
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Lab Studies CBCESR, CRPBlood CulturesAntibody tests (and
autoantibodies)Uric acid
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Diagnostic Summary
“Patients with a history of significant trauma or focal bone pain should have plain radiographs of the affected joint to rule out fracture, tumor, or metabolic bone disease.
In the absence of a history of trauma or following a radiograph that excludes fracture or dislocation, an effusion or other signs of inflammation are markers of infection until proven otherwise. Thus, joint aspiration is the next diagnostic step .” uptodate.com
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Radiologic Studies X-ray next slide Fluoroscopy- simultaneous image
◦ Movement◦ Procedures
CT (computed tomography) Air-filled spaces, fatty tissue, muscle, and cortical and cancellous bone Occult fractures
MRI (magnetic resonance imaging)◦ Soft tissue images◦ Contraindications: metallic implants or pacemakers or the use of
life support equipment (eg, ventilators) Bone Scan in 2 slides PET scanning (Positron emission tomography)
◦ FDG is a radiopharmaceutical analog of glucose that is taken up by metabolically active cells such as tumor cells
Ultrasound◦ Pediatric joint effusions, soft tissue, procedures
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X-RayStandardized imaging protocols are used
for most jointsDensities that can be distinguished on
radiographs are calcium, soft tissue, fat, and air.
Detect:◦Fractures◦Periosteal reaction◦Faint soft tissue calcification or ossification◦Localized lesions of bone◦Failure or complication of orthopedic hardware◦Bone dysplasias and other skeletal deformities.
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Bone ScanDetects:radionuclide activity in all three phases: blood
flow phase, blood pool phase, and uptake at the area in question
Disease examples:◦ Acute fracture ◦ Osteoid osteoma ◦ Paget disease, fibrous dysplasia, and
melorheostosis ◦ Osteomyelitis◦ Hypertrophic pulmonary osteoarthropathy ◦ shin splints ◦ Complex regional pain syndrome
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Common Causes of Polyarticular Joint Pain Distribution
DiseaseChronology
Inflammation Pattern
Symmetry
Axial involvement
Extra-articular manifestations
Female-to-male ratio
Human parvovirus B19 infection
Acute Yes Small joints Yes No Lacy rash, malar rash3:1 to 4:1
Rheumatoid arthritis
Chronic Yes Small and large joints
Yes Cervical Subcutaneous nodules, carpal tunnel syndrome
3:1 to 4:1
Systemic lupus erythematosus
Chronic Yes Small joints Yes No Malar rash, oral ulcers, serositis (pleuritis or pericarditis)
9:01
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Disease ChronologyInflammationPattern
Symmetry
Axial involvement
Extra-articular manifestations
Female-to-male ratio
Osteoarthritis Chronic No Lower extremity joints, proximal and distal interphalangeal joints, first carpometacarpal joint
Yes/No Cervical and lumbar
None 1:1 to 2:1
Fibromyalgia Chronic No Diffuse Yes Yes Myalgias, tender points, irritable bowel syndrome
9:01
Ankylosing spondylitis
Chronic Yes Large joints Yes Yes Iritis, tendonitis, aortic insufficiency
1:1 to 1:5
Psoriatic arthritis
Chronic Yes Large and small joints
Yes/No Yes/No Psoriasis, dactylitis (“sausage digits”), tendonitis, onychodystrophy
1:01
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•Viral infection: human parvovirus (especially B19), enterovirus, adenovirus, Epstein-Barr, coxsackievirus (A9, B2, B3, B4, B6), cytomegalovirus, rubella, mumps, hepatitis B, varicella-zoster virus (human herpes virus 3), human immunodeficiency virus
•Indirect bacterial infection (reactive arthritis): Neisseria gonorrhoeae (gonorrhea), bacterial endocarditis, Campylobacter species, Chlamydia species, Salmonella species, Shigella species, Yersinia species, Tropheryma whippelii (Whipple's disease), group A streptococci (rheumatic fever)
•Direct bacterial infection: N. gonorrhoeae, Staphylococcus aureus, gram-negative bacilli, bacterial endocarditis•Other infections: Borrelia burgdorferi (Lyme disease), Mycobacterium tuberculosis (tuberculosis), fungi•Crystal-induced synovitis: gout, pseudogout (calcium pyrophosphate deposition disease), hydroxyapatite•Systemic rheumatic disease: rheumatoid arthritis, systemic lupus erythematosus, polymyositis/dermatomyositis, juvenile rheumatoid arthritis, scleroderma, Sjögren's syndrome, Behçet's syndrome, polymyalgia rheumatica
•Systemic vasculitis disease: Schönlein-Henoch purpura, hypersensitivity vasculitis, polyarteritis nodosa, Wegener's granulomatosis, giant cell arteritis
•Spondyloarthropathies: ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, reactive arthritis (Reiter's syndrome)
•Endocrine disorders: hyperparathyroidism, hyperthyroidism, hypothyroidism
•Malignancy: metastatic cancer, multiple myeloma•Others: osteoarthritis, hypermobility syndromes, sarcoidosis, fibromyalgia, osteomalacia, Sweet's syndrome, serum sickness
TABLE 1DIFFERENTIAL DIAGNOSIS OF POLYARTICULAR JOINT PAIN
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