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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.

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My aching joints l.jpg

My Aching Joints!

Jon Roebuck CPT MC

WRAMC Rheumatology

February 7, 2002


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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


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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


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History

  • Musculoskeletal emergencies

    • Septic arthritis

    • Subacute bacterial endocarditis

    • Osteomyelitis

    • Necrotizing fasciitis

    • Systemic vasculitis

    • Acute myelopathy

    • Deep venous thrombosis

    • Compartment syndrome


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Red flags

  • History of significant trauma

  • Hot, swollen joint

  • Weakness

    • Focal

    • Diffuse

  • Neurogenic pain

  • Claudication pain


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General history

  • Joints involved

  • Chronicity

  • Exercise

    • Aggravates or alleviates

  • AM stiffness

  • Swollen joints

    • Rubor, Calor, Dolor, Tumor

  • Fatigue


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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


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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


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Physical Exam

  • Now is it inflammatory?

  • Warmth

  • Erythema

  • effusion


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Physical Exam

  • Joints involved

    • Small joint symmetric

    • Monoarthritis/oligoarthritis

  • Swelling observed?

  • Rashes

  • Nodules

  • Mucosal sores

  • Weakness


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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


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This is bad


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Refer this one to us(after the ECHO)


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Don’t forget the eyes


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This might be bad


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Close-upPalpable purpura


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Inflammatory

Crosses bridge of nose

Spares nasolabial fold

Classic malar


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Bad malar

  • Same features

  • Possibly discoid

  • Secondarily infected


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Subtle malar


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Classic heliotrope

  • Periorbital edema

  • Lilac hue

  • Specific for dermatomyositis


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Most common skin rash

Papulosquamous eruption over joints

Not as specific as heliotrope

Gottren’s papules


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Koebner phenomenon


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Decision time

  • Acute monoarthritis

  • Acute polyarthritis

    • Symmetric

  • Chronic mono/pauciarthritis

  • Chronic polyarthritis


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MONARTHRITIS

MONARTHRITIS


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Infection

Bacterial

viral

Crystalline

Hemarthrosis

Trauma

Hemophilia

Pigmented synovitis

Early presentation of systemic disease

Acute monoarthritis


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Most important intervention…

Aspiration

Cell count

Gram stain/culture

Crystal exam

Acute monoarthritis


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Arthrocentesis technique

  • Considerations

    • Needle and syringe size

    • Skin sterilization

    • Local anesthesia

    • Comfort of you and patient


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Knee

  • Rheumatology

    • Medial

    • anesthesia

  • Orthopedics

    • Lateral

    • Superior

  • If you only know one joint…


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What’s in that joint?

  • Inflammatory crystals

    • Gout

    • Pseudogout

    • Basic calcium phosphate

  • Fat

  • Cholesterol

  • Junk


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Crystal diagnosis

  • Polarized light microscopy

    • Bright objects on dark background?

    • Crystal morphology?

    • Birefringent?

    • YAG Vs. ABC


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Keep it straight

Chondrocalcinosis: XRAY diagnosis

=

Pseudogout

=

+


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fat

Cholesterol

Other crystals


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Most important intervention…

Rheumatology referral

Call us

On call Doc each day

202 782 6734(5)

Acute monoarthritis


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Chronic monoarthritis

  • Rheumatology referral

  • Atypical infection

    • Fungal

    • Mycobacterial

  • Atypical systemic disease

    • RA, SLE, SNSA

  • May need synovial biopsy


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POLYARTHRITIS

POLYARTHRITIS


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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


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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


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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


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Physical Exam

  • The entire exam is important

  • However…

  • Hands are the gateway to rheumatologic diagnosis


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Physical Exam

  • I mentioned swelling

    • Synovial

    • Bony

  • Big difference, not always so obvious


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Noninflammatory


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Noninflammatory

  • Osteoarthritis

  • Primary

  • Secondary

    • Hyperparathyroidism

    • Hemachromatosis

    • Acromegaly

    • Hypo/hyperthyroid


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Inflammatory


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Fusiform swelling


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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)


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Boggy MCPs


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Prevent this


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And this


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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!!


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Lupus

  • Very similar to RA

  • Rashes and other criteria helpful

  • Serologic eval


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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


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How do you prevent deformity in lupus?

  • Trick question

  • Nonerosive/nondeforming arthritis

  • Jaccoud’s arthropathy


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More handsnails and sausages


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Distribution isn’t everything

  • Not all DIP disease is OA


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Distribution isn’t everything

  • Not all DIP disease is OA


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Classic DIP disease in PSA


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Psoriatic arthritis

  • OA-like

    • DIPs

    • Nails

  • RA-like

  • Seronegative variety

  • Mutilans

  • oligoarthritis


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Gouty arthropathy


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Can be severe and deforming


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Gout

Pearls

  • Clinical/microscopic diagnosis

  • Uric acid is not helpful acutely

  • Allopurinol is not acute treatment


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Inflammatory OA


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What might this be?


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Flag sign


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Capillaroscopy


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Scleroderma


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Nodular fibrosing lesions

Ulnar preference

Intralesional injection

Softening and flattening of nodules

Best early in course

Dupuytren’s


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Arachnodactyly


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Not sure if its inflammatory?

  • Serologies

  • XRAYS

    • If chronic

  • Rheumatology referral!!


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Inflammatory

ESR

CRP

Platelets

Anemia chronic DZ

Urinalysis

TSH

Noninflammatory

No help

Clinical and XRAY diagnosis

Serology


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Laboratory assessment

  • When you you order an ANA

    • RF for that matter

  • Confirm clinical suspicion

  • Very poor screening test

    • Positive predictive value very low


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Antinuclear Antibodies

  • 1 in 10-20 of population are ANA+

    • 5-10%

  • 1 in 1000-2000 have lupus

    • Similar rates for other autoimmune disease


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Antinuclear Antibodies

AssumptionANA 5% of normals ANA 10% of Normals

ANA+ in SLE99%99%

ANA+ in normal5%10%

Prevalence of SLE1:20001:2000

If 2000 people have ANA tests:

-Number ANA+ with SLE11

-Number ANA+ without SLE100200

-liklihood of SLE in ANA+ group1/1001/200

-15% haveMSK symptoms300300

-ANA + in that group1530

-Therefore liklihood of SLE in pts

with MSK symptoms and ANA+1/151/30


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Inflammation on film

INFLAMMATORY XRAY CHANGES


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Osteoarthritis

Asymmetric joint narrowing

Osteophytes

Subchondral sclerosis

Subchondral cysts

Rheumatoid arthritis

Symmetric joint narrowing

Osteopenia

Marginal erosions

Soft tissue swelling

XRAYSonly if chronic


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SOFT TISSUE SWELLING


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Early erosion


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Erosions and periarticular osteopenia


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Did you really need the XRAY?


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Can be confusing!


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What if it’s outside the joint?

  • Bursitis

  • Tendonitis

  • Tenosynovitis

  • Entrapment syndromes

  • Sprains

  • Etc. etc. etc.


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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!


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Soft tissue injections

  • Whole new lecture

  • Water soluble steroid preferable

  • Any questions about particular sites?


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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!


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What disease is this?


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Any questions?


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