Joint pain

ARTHRITIS

Monoarticular

Polyarticular

Acute: 1.Septic 2. Crystal induced 3.Trauma 4.hemorrhage

Chronic: 1.OA 2.Chronic infection 3.Joint neoplasm

Acute: 1.Acute Rheumatic Fever 2.Gonococcal arthritis 3.Post-viral arthritis (common) 4.Immune complex arthritis

Chronic: 1.RA 2.OA 3.Gouty arthritis 4.Psoriatic arthritis 5.Fibromyalgia

History
Demography
Age: elderly or young
Gender: male or female If female: pre or postmenopausal?

Family history of joint pain?

History of presenting complaint

What would patient normally present

with?
Joint pain Swelling Stiffness Restricted movement Deformity

Joint pain
What causes the joint pain?
Arthralgia
Arthritis (5signs) Rubor Calor Dolor Tumor Functio laesa

Joint pain
Origin of pain?
Articular?
Periarticular?

Disease chronology
Acute Insidious Acute flares

Joint pain
Extraarticular manifestation Disease course
Intermittent Migratory

Joint pain
Distribution
Number of joints involved
Pattern Symmetry Axial involvemnent

Pattern

1987 American College of Rheumatology Revised Criteria for Classification of Rheumatoid Arthritis
1) Morning stiffness > 1 hour 2) Arthritis 3 joints with swelling 3) Arthritis of hands and wrist joint with swelling 4) Symmetrical arthritis 5) Rheumatoid nodules 6) Demonstration of abnormal amounts of serum rheumatoid factor 7) Radiological changes typical of rheumatoid arthritis

For classification of Rheumatoid Arthritis, at least four of these seven criteria must be met. Criteria 1 through 4 must have been present for at least 6 weeks.
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Examination
Inflammatory joint disease:
Synovial hypertrophy Joint effusions Pain on movements

Degenerative or mechanical joint joint disease:

Bony overgrowth of

Erythema and

warmth Limited range of motion Joint tenderness

the joints (osteophytes) Limited range of motion Crepitus during active or passive range of motion Joint deformity

Osteoarthritis: Heberdens nodes

RA:: knee swelling and popliteal cyst

Extra-articular Manifestations

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chitra & lorna

Gouty Arthritis

Rheumatological investigations
Blood
Fbc RP/LFT/Uric acid/Ca/Mg/PO4 CRP/ESR

Blood culture
ASOT Parvovirus B19 IgG/IgM RF/ANA/Anti-Sm/ Anti-ds DNA/ANCA

Complete blood count Anemia Many inflammatory arthritides, especially SLE, RA, IBD, and human parvovirus B19 infection

Thrombocytopenia Thrombocytosis

SLE, human parvovirus B19 infection Acute-phase reaction, vasculitis, infection

Leukopenia

SLE, RA, Felty's syndrome, Sjgren's syndrome, human parvovirus B19 infection
RA, vasculitis, reactive arthritis, infection SLE, RA, IBD, sarcoidosis, dermatomyositis, scleroderma, Churg-Strauss syndrome, PAN, eosinophilic fasciitis, cholesterol emboli

Leukocytosis Eosinophilia

Rheumatoid factor

Healthy persons; RA, SLE, Sjgren's syndrome, sarcoidosis, reactive arthritis, PMR, polymyositis, psoriatic arthritis, endocarditis, chronic infections, cancer, chronic liver disease, many nonrheumatic causes

Inflammatory markers: elevated ESR or Creactive protein (CRP) Antinuclear antibody

Infection, most inflammatory arthritides, advanced age, PMR, giant cell arteritis, cancer, anemia, pregnancy; menses

Healthy persons; SLE, RA, scleroderma, Sjgren's syndrome, vasculitis, polymyositis, medications, many nonrheumatic causes

Hepatic transaminase: elevated aspartate transaminase or alanine transaminase

Elevated alkaline phosphatase Electrocardiogram: atrioventricular block Double-stranded DNA AntiSS-A (anti-Ro) and antiSS-B (anti-La) antibodies HLA-B27 Elevated uric acid False-positive VDRL Cytoplasmic antineutrophil cytoplasmic autoantibody (c-ANCA)

SLE, PAN, sarcoidosis, hemochromatosis, Sjgren's syndrome, infectious hepatitis, polymyositis

Bone metastases, Paget's disease, osteomalacia, PMR, ankylosing spondylitis, hyperparathyroidism Lyme disease, neonatal lupus, ankylosing spondylitis SLE, especially lupus nephritis Sjgren's syndrome, SLE; healthy persons

Healthy persons; spondyloarthropathies, reactive arthritis Gout, psoriatic arthritis, Paget's disease; healthy persons SLE, anticardiolipin antibody syndrome Wegener's granulomatosis

Laboratory investigations
UFEME
Urinalysis Hematuria Proteinuria SLE, Wegener's granulomatosis, PAN SLE; Wegener's granulomatosis, amyloidosis

Synovial fluid aspiration

+gram staining

blunt ended crystal with weak positive birefringence

Radiography

OA
Radiology (4 classic findings) narrowing of joint space (uni-compartmental) intraosseous cysts osteophytes subchondral sclerosis

Osteoarthritis: knee

Gouty arthritis

Stage 1 : soft tissue swelling & periarticular osteoporosis

Stage 2 : juxta-articular erosion (arrow)

Stage 3 : Joint deformity

Normal hand

Rheumatoid arthritis

Treatment Arthritis
Conservative treatment
Pharmacological Non- pharmacological

Surgical treatment

Pharmacological: Acute monoarthritis

NSAIDs (eg: T.ibuprofen 200-400mg/4-6hrly) T. Colchicine 1.2mg stat, then 0.6mg every 6-12

hrly T. prednisolone 20-30mg OD Im triamcinolone acetonide 60-80mg Intra-articular corticosteriod therapy Septic arthritis: -IV Flucloxacillin 1-2g 6 hrly ( or IV vancomycin if MRSA)

TX: Acute polyarthritis

High dose aspirin 100mg/kg/day

High dose prednisolone(0.5-1mg/kg/day)

Tx: Chronic monoarthritis

Indomethacin 75mg stat, followed by 50 mg qid.

After 24-48 hrs, reduced doses are given for a further week Xanthine oxidase inhibitor: ( T. Allopurinol 300mg OD) T. Colchicine 1.2mg stat, then 0.6mg every 6-12 hrly

Tx : Chronic polyarthritis
DMARDs
-commonly used = antimalarials (e.g. hydroxychloroquine), gold, methotrexate, sulfasalazine - single regimen with methotrexate -combination therapy - methotrexate, sulfasalazine, and chloroquine - methotrexate and cyclosporine -new drugs: TNF inhibitors +/ methotrexate, leflunomide (Arava)

NSAID

Thank you =)