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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


Musculoskeletal pain l.jpg
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


History l.jpg
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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Refer this one to us(after the ECHO)




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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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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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Decision time

  • Acute monoarthritis

  • Acute polyarthritis

    • Symmetric

  • Chronic mono/pauciarthritis

  • Chronic polyarthritis


Monarthritis l.jpg
MONARTHRITIS

MONARTHRITIS


Acute monoarthritis l.jpg

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

=

+


Other crystals l.jpg

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


Polyarthritis l.jpg
POLYARTHRITIS

POLYARTHRITIS


Acute or chronic polyarthritis l.jpg
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


Inflammatory symmetric small joint l.jpg

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

  • Osteoarthritis

  • Primary

  • Secondary

    • Hyperparathyroidism

    • Hemachromatosis

    • Acromegaly

    • Hypo/hyperthyroid




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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)





How do i prevent deformity l.jpg
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 l.jpg
Lupus

  • Very similar to RA

  • Rashes and other criteria helpful

  • Serologic eval


Acr criteria l.jpg

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 l.jpg
How do you prevent deformity in lupus?

  • Trick question

  • Nonerosive/nondeforming arthritis

  • Jaccoud’s arthropathy


More hands nails and sausages l.jpg
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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Psoriatic arthritis

  • OA-like

    • DIPs

    • Nails

  • RA-like

  • Seronegative variety

  • Mutilans

  • oligoarthritis




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Gout

Pearls

  • Clinical/microscopic diagnosis

  • Uric acid is not helpful acutely

  • Allopurinol is not acute treatment







Dupuytren s l.jpg

Nodular fibrosing lesions

Ulnar preference

Intralesional injection

Softening and flattening of nodules

Best early in course

Dupuytren’s



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Not sure if its inflammatory?

  • Serologies

  • XRAYS

    • If chronic

  • Rheumatology referral!!


Serology l.jpg

Inflammatory

ESR

CRP

Platelets

Anemia chronic DZ

Urinalysis

TSH

Noninflammatory

No help

Clinical and XRAY diagnosis

Serology


Laboratory assessment l.jpg
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 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 l.jpg
Inflammation on film

INFLAMMATORY XRAY CHANGES


Xrays only if chronic l.jpg

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 l.jpg
What if it’s outside the joint?

  • Bursitis

  • Tendonitis

  • Tenosynovitis

  • Entrapment syndromes

  • Sprains

  • Etc. etc. etc.


Depends on your comfort level l.jpg
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 l.jpg
Soft tissue injections

  • Whole new lecture

  • Water soluble steroid preferable

  • Any questions about particular sites?


Summary l.jpg
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!