my aching joints
Download
Skip this Video
Download Presentation
My Aching Joints!

Loading in 2 Seconds...

play fullscreen
1 / 86

My Aching Joints - PowerPoint PPT Presentation


  • 684 Views
  • Uploaded on

My Aching Joints!. Jon Roebuck CPT MC WRAMC Rheumatology February 7, 2002. Musculoskeletal Pain. 1 in 7 patient visits to primary care Many benign conditions Some are life threatening Pays to know which is which Arthritis Leading causes of disability and absenteeism.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'My Aching Joints' - salena


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
my aching joints

My Aching Joints!

Jon Roebuck CPT MC

WRAMC Rheumatology

February 7, 2002

musculoskeletal pain
Musculoskeletal Pain
  • 1 in 7 patient visits to primary care
  • Many benign conditions
  • Some are life threatening
    • Pays to know which is which
  • Arthritis
    • Leading causes of disability and absenteeism
goals of the lecture
Goals of the Lecture
  • Classification of joint problem
    • Inflammatory Vs. Noninflammatory
    • Acute Vs. chronic
  • Approach to monoarthritis
  • Approach to polyarthritis
  • Rheumatology referral
    • When to order ANA, RF
  • Summary of points
  • Questions
history
History
  • Musculoskeletal emergencies
    • Septic arthritis
    • Subacute bacterial endocarditis
    • Osteomyelitis
    • Necrotizing fasciitis
    • Systemic vasculitis
    • Acute myelopathy
    • Deep venous thrombosis
    • Compartment syndrome
red flags
Red flags
  • History of significant trauma
  • Hot, swollen joint
  • Weakness
    • Focal
    • Diffuse
  • Neurogenic pain
  • Claudication pain
general history
General history
  • Joints involved
  • Chronicity
  • Exercise
    • Aggravates or alleviates
  • AM stiffness
  • Swollen joints
    • Rubor, Calor, Dolor, Tumor
  • Fatigue
historical distinctions
Inflammatory

Symmetric joint involvement

Stiffness > 1hr

R/C/D/T

Improves with exercise

Constitutional complaints

Noninflammatory

One or very few joints

Stiffness <30min

No pain at rest

Worsen with exercise

No constitutional

Historical distinctions
physical exam
Physical Exam
  • Is it really the joint?
  • Articular
    • Painful, limited active ROM
    • Painful, limited passive ROM
  • Periarticular
    • Painful, limited active ROM
    • Full, unlimited passive ROM
physical exam9
Physical Exam
  • Now is it inflammatory?
  • Warmth
  • Erythema
  • effusion
physical exam10
Physical Exam
  • Joints involved
    • Small joint symmetric
    • Monoarthritis/oligoarthritis
  • Swelling observed?
  • Rashes
  • Nodules
  • Mucosal sores
  • Weakness
physical exam refer these patients
Physical ExamRefer these patients!
  • Skin as a clue to systemic disease
  • Vasculitis
  • Psoriasis
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Still’s rash
  • Malar and discoid lesions
  • Dermatomyositis
classic malar
Inflammatory

Crosses bridge of nose

Spares nasolabial fold

Classic malar
bad malar
Bad malar
  • Same features
  • Possibly discoid
  • Secondarily infected
classic heliotrope
Classic heliotrope
  • Periorbital edema
  • Lilac hue
  • Specific for dermatomyositis
gottren s papules
Most common skin rash

Papulosquamous eruption over joints

Not as specific as heliotrope

Gottren’s papules
decision time
Decision time
  • Acute monoarthritis
  • Acute polyarthritis
    • Symmetric
  • Chronic mono/pauciarthritis
  • Chronic polyarthritis
monarthritis
MONARTHRITIS

MONARTHRITIS

acute monoarthritis
Infection

Bacterial

viral

Crystalline

Hemarthrosis

Trauma

Hemophilia

Pigmented synovitis

Early presentation of systemic disease

Acute monoarthritis
acute monoarthritis26
Most important intervention…

Aspiration

Cell count

Gram stain/culture

Crystal exam

Acute monoarthritis
arthrocentesis technique
Arthrocentesis technique
  • Considerations
    • Needle and syringe size
    • Skin sterilization
    • Local anesthesia
    • Comfort of you and patient
slide28
Knee
  • Rheumatology
    • Medial
    • anesthesia
  • Orthopedics
    • Lateral
    • Superior
  • If you only know one joint…
what s in that joint
What’s in that joint?
  • Inflammatory crystals
    • Gout
    • Pseudogout
    • Basic calcium phosphate
  • Fat
  • Cholesterol
  • Junk
crystal diagnosis
Crystal diagnosis
  • Polarized light microscopy
    • Bright objects on dark background?
    • Crystal morphology?
    • Birefringent?
    • YAG Vs. ABC
keep it straight
Keep it straight

Chondrocalcinosis: XRAY diagnosis

=

Pseudogout

=

+

other crystals
fat

Cholesterol

Other crystals
acute monoarthritis33
Most important intervention…

Rheumatology referral

Call us

On call Doc each day

202 782 6734(5)

Acute monoarthritis
chronic monoarthritis
Chronic monoarthritis
  • Rheumatology referral
  • Atypical infection
    • Fungal
    • Mycobacterial
  • Atypical systemic disease
    • RA, SLE, SNSA
  • May need synovial biopsy
polyarthritis
POLYARTHRITIS

POLYARTHRITIS

acute or chronic polyarthritis
Acute or chronic polyarthritis
  • Careful history and physical exam
  • Synovitis?
    • No– your problem
    • Yes– our problem
      • Referral. To be helpful
        • Cbc, esr, crp, RF, ANA, bun/cr, UA, TSH
what to write on the referral
What to write on the referral
  • What is it?
  • Sometimes it’s a differential
  • Sometimes it’s fairly obvious
  • Sometimes you have no idea
    • We may not either
inflammatory symmetric small joint
Acute (<6 weeks)

Viral

Parvo

Hepatitis

HIV

EBV

Bacterial

Rheumatic fever

Post-streptococcus

Chronic (>6 weeks)

RA

SLE

Other CTD

Chronic sequelae of the acute DX’s

Inflammatorysymmetric, small joint
physical exam39
Physical Exam
  • The entire exam is important
  • However…
  • Hands are the gateway to rheumatologic diagnosis
physical exam40
Physical Exam
  • I mentioned swelling
    • Synovial
    • Bony
  • Big difference, not always so obvious
noninflammatory42
Noninflammatory
  • Osteoarthritis
  • Primary
  • Secondary
    • Hyperparathyroidism
    • Hemachromatosis
    • Acromegaly
    • Hypo/hyperthyroid
acr criteria for ra
ACR Criteria for RA
  • Morning stiffness
    • >1hr
  • Arthritis of 3 or more joint areas
    • Soft tissue swelling or fluid
  • Arthritis of hands
    • Wrist, MCP, PIP
  • Rheumatoid nodules
    • Subcutaneous nodules over bony prominences
  • Serum rheumatoid factor
  • Radiographic changes

(4/7 criteria satisfy classification criteria)

how do i prevent deformity
How do I prevent deformity?
  • Early aggressive therapy
    • Multiple DMARDs
  • Staunch monitoring of disease and medications
  • Low threshold to increase therapy
    • Any evidence of breakthrough disease
  • RHEUMATOLOGY referral!!
lupus
Lupus
  • Very similar to RA
  • Rashes and other criteria helpful
  • Serologic eval
acr criteria
Renal involvement

Ana

Serositis

Hematologic abnormalities

Oral ulcers

Neurologic sxs

Malar rash

Arthritis

Immunologic

Discoid lesions

Sun sensitivitiy

Notable exclusions

Raynauds

Fatigue

Arthralgias

ACR Criteria
how do you prevent deformity in lupus
How do you prevent deformity in lupus?
  • Trick question
  • Nonerosive/nondeforming arthritis
  • Jaccoud’s arthropathy
distribution isn t everything
Distribution isn’t everything
  • Not all DIP disease is OA
distribution isn t everything55
Distribution isn’t everything
  • Not all DIP disease is OA
psoriatic arthritis
Psoriatic arthritis
  • OA-like
    • DIPs
    • Nails
  • RA-like
  • Seronegative variety
  • Mutilans
  • oligoarthritis
slide60
Gout

Pearls

  • Clinical/microscopic diagnosis
  • Uric acid is not helpful acutely
  • Allopurinol is not acute treatment
dupuytren s
Nodular fibrosing lesions

Ulnar preference

Intralesional injection

Softening and flattening of nodules

Best early in course

Dupuytren’s
not sure if its inflammatory
Not sure if its inflammatory?
  • Serologies
  • XRAYS
    • If chronic
  • Rheumatology referral!!
serology
Inflammatory

ESR

CRP

Platelets

Anemia chronic DZ

Urinalysis

TSH

Noninflammatory

No help

Clinical and XRAY diagnosis

Serology
laboratory assessment
Laboratory assessment
  • When you you order an ANA
    • RF for that matter
  • Confirm clinical suspicion
  • Very poor screening test
    • Positive predictive value very low
antinuclear antibodies
Antinuclear Antibodies
  • 1 in 10-20 of population are ANA+
    • 5-10%
  • 1 in 1000-2000 have lupus
    • Similar rates for other autoimmune disease
antinuclear antibodies72
Antinuclear Antibodies

AssumptionANA 5% of normals ANA 10% of Normals

ANA+ in SLE 99% 99%

ANA+ in normal 5% 10%

Prevalence of SLE 1:2000 1:2000

If 2000 people have ANA tests:

-Number ANA+ with SLE 1 1

-Number ANA+ without SLE 100 200

-liklihood of SLE in ANA+ group 1/1001/200

-15% haveMSK symptoms 300 300

-ANA + in that group 15 30

-Therefore liklihood of SLE in pts

with MSK symptoms and ANA+ 1/151/30

inflammation on film
Inflammation on film

INFLAMMATORY XRAY CHANGES

xrays only if chronic
Osteoarthritis

Asymmetric joint narrowing

Osteophytes

Subchondral sclerosis

Subchondral cysts

Rheumatoid arthritis

Symmetric joint narrowing

Osteopenia

Marginal erosions

Soft tissue swelling

XRAYSonly if chronic
what if it s outside the joint
What if it’s outside the joint?
  • Bursitis
  • Tendonitis
  • Tenosynovitis
  • Entrapment syndromes
  • Sprains
  • Etc. etc. etc.
depends on your comfort level
Depends on your comfort level
  • Conservative therapy and follow up
  • Local injections
    • Very few absolute contraindications
      • Achilles
      • Through an active infection or abnormal skin
  • Refer to us!
soft tissue injections
Soft tissue injections
  • Whole new lecture
  • Water soluble steroid preferable
  • Any questions about particular sites?
summary
Summary
  • Red flags
  • Inflammatory Vs. Noninflammatory
    • History, PE, Lab, XRAY
    • If unsure, REFER!
  • Hands as a gateway to diagnosis
  • When to order ANA
  • When to refer
    • Never a wrong time!
ad