Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Joint Disorder
Joint Disorder - Key Features
1. In a patient presenting with joint pain, distinguish benign from serious pathology (i.e. sarcoma, septic joint):
(a) by taking pertinent history
(b) investigating in a timely and appropriate manner (i.e. aspirate, blood work, Xray).
• History: OPQRST, course, characteristics of joint involvement (pain, swelling, loss of function of joint), pattern of joint involvement (symmetrical? Mono vs poly vs non-articular? Axial vs peripheral), extra-articular features (skin, eyes, lungs, pulmonary, GI, psychiatric), ADL limitations, general health (including fever, infection, family hx, constitutional symptoms, sexual history), treatments attempted
• Investigations:
-BLOODWORK: CBC, BUN, Cr, acute phase reactants (ESR, complement C3 and C4, fibrinogen, CRP, ferritin, albumin); serology: autoantibodies (RF present in 80% of RA/50% of Sjogren’s; ANA present in 98% of SLE; anti-ds DNA in 50-70% of SLE; c-ANCA present in >90% of Wegener’s;
-URINALYSIS to detect disease complications (active sediment, proteinuria)
-SYNOVIAL FLUID ANALYSIS: 3 C’s: cell count and differential; culture and gram stain (bacterial, mycobacteria, fungal); crystal examination
-RADIOLOGY: plain film for bone pathology; CT for SI joints/ankle joints/spinal canal; MRI for tendons/bursae/ligaments; US for tendons/bursae/effusions
2. In a patient presenting with non-specific MSK pain, make a specific rheumatologic diagnosis when one is evident through hx, phys, and investigations (i.e. gout, fibromyalgia, monoarthropathy vs. polyarthropathy). (note: chart contains key words/phrases, and is not comprehensive)
| Disease | History | Physical | Investigations |
|---|---|---|---|
| Gout | -Acute attacks of mono or oligo arthritis (esp. knee, ankle, 1st MTP); subside within days -Males >45yrs old; EtOH and dietary excess |
-Red, swollen, tender joint -Joint mobility may be limited (if cellulitis, joint mobility preserved) |
-Joint aspirate: >90% aspirates show monosodium urate crystals (negative birefringence) -punched-out/’holes in bones’ on xray |
| Fibromyalgia | -Chronic (at least 3 mos), diffuse pain with characteristic tender points -F>M; ages 25-45 |
-11/18 tender points with 4kg force -Joint examination normal |
-Laboratory exams normal -Workup includes TSH, ESR, laboratory sleep assessment |
| OA | -Insidious onset, gradually progressive, intermittent flare-ups -Signs and symptoms localized to affected joints (not systemic) |
-Joint line tenderness -Bony enlargement at affected joints (Bouchard’s=osteophytes at PIP; Heberden’s= at DIP) |
-CBC, ESR normal -RF, ANA negative |
| RA | -Symmetrical joint involvement; polyarthritis (3 or more joints) for >6wks -Morning stiffness >30min, improving with use |
-Joint effusions -Tenosynovitis |
-Positive serology: RF+ in 80% -Increased ESR in 50-60% |
| SLE | -Multisystemic -Photosensitivity, Raynaud’s, CNS symptoms (headache, seizures, psychosis, neuropathy) |
-Malar rash, alopecia, cardiac and pulmonary serositis, oral/nasal ulcers | -ANA+ in 98% -Anti-DS DNA+ in 50-70% |
| Ankylosing Spondylitis | -Mid and low back stiffness -Pain at rest |
-Restricted ROM (decreased Schober test) -Decreased chest wall expansion |
-Xray: SI joint = ‘pseudowidening’ of joint due to erosion with joint sclerosis; late change = bony fusion -MRI/CT can detect inflammation if no changes on xray and clinically suspect Ank Spond |
DDx Monoarthropathy: infectious, inflammatory, crystal-induced (gout/CPPD), hemarthrosis, neoplasm, degenerative
DDx Polyarthropathy: infectious (lyme disease, viral ie. EBV/parvo, bacterial endocarditis, septicemia, gonococcus), post-infectious (rheumatic fever, reactive arthritis, enteric infections) , inflammatory (seropositive/seronegative)
3. In a patient presenting with a monoarthropathy, rule out infectious causes (i.e. STDs).
• N. Gonorrheae accounts for 75% of septic arthritis in young sexually active adults; S. aureus: all ages; Gram negatives: affect immunocompromised pts; S. Pneumonia: children; H. influenzae: infants, esp if not immunized
• Investigations: blood and urine cultures; if high index of suspicion for gonococcal infection, also C&S of endocervical/urethral/rectal/oropharyngeal; synovial fluid for CBC and diff, gram stain, culture, crystals
4. In pts presenting with MSK pain, include referred and visceral sources of pain in the differential dx (i.e. angina, slipped capital epiphysis presenting as knee pain, neuropathic pain).
• especially in children and elderly people, examine and consider imaging the HIP when presentation includes medial knee pain
5. Clinically diagnose ligamentous injuries. DO NOT do an Xray examination.
6. In a patient presenting with joint pain, include systemic conditions in the differential (i.e. Wegener’s granulomatosis, lupus, ulcerative colitis).
• Also consider SLE, antiphospholipid syndrome, scleroderma, Sjogren’s, polyarteritis nodosa, inflammatory bowel disease
7. In patients with a diagnosed rheumatologic condition:
a) actively inquire about pre-existing co-morbid conditions that may modify the treatment plan
b) choose the appropriate treatment plan (i.e. no NSAIDS in patients with renal failure or peptic ulcer disease)
• Considerations in addition to the above: renal impairment, liver disease, EtOH abuse, allergies, use of warfarin or anticoagulants, pregnancy
8. In assessing patients with a diagnosed rheumatologic condition, search for disease-related complications (i.e. iritis)
• Review of systems key; do ENT, lungs, cardiac, pulmonary, GI, GU, neurologic, psychiatric screening
9. In patients experiencing MSK pain:
a) actively inquire about the impact of the pain on daily life
b) treat with appropriate doses of analgesics
c) arrange for community resources and aids (cane/splints) if necessary.
• Analgesics for OA:
- -Acetaminophen 4g/day, NSAIDS (oral and topical), cox-2 inhibitors, tramadol
- -Corticosteroids: intra-articular injections
- -intra-articular hyaluronic acid, capsaicin cream, glucosamine sulfate/chondroitin
• Arthritis Society excellent resource
10. In patients with RA, start treatment with DMARDs within an appropriate time interval.
• Early intervention has greatest impact on outcome. Analgesics, NSAIDs, and steroids do not alter the course of RA; however, they should be used for symptomatic relief. Consider early referral to rheumatologist.
• In mild and early disease: DMARDs for all patients whose disease does not remit after 2 to 3 months with use of NSAIDs alone. First lines: hydroxychloroquine (200mg BID, adjusted if weight <61kg) or sulfasalazine (1000mg BID to TID). If after 6mos suboptimal, then consider other DMARDs
• Moderate to severe disease: Immediate treatment with DMARDs. Consider methotrexate or leflunomide; consider combination therapy; consider Remicade or Eternacept.
• DMARDs have a delayed onset of action (8-12wks)
Guidelines/Treatment for Specific Entities
- 1) Osteoarthritis
- Diagnosis: Clinical, as per above chart
- Management:
- Non-pharmacologic: Patient education, Self-management programs (e.g., Arthritis Foundation Self-Management Program), Weight loss (if overweight), Aerobic exercise programs especially water-based, acupuncture, Physical therapy, Range-of-motion exercises, Muscle-strengthening exercises, Assistive devices for ambulation, Patellar taping, Appropriate footwear, Lateral-wedged insoles (for genu varum), Bracing, Occupational therapy, Joint protection (ie. hip protectors) and energy conservation, Assistive devices for activities of daily living
- Pharmacologic: see item #9 above
- Guidelines: BC Guidelines http://www.bcguidelines.ca/guideline_osteoarthritis.html
- 2) Rheumatoid Arthritis
- Diagnostic Criteria: RA diagnosed if 4 or more of the following 7 criteria present (American Rheumatism Association, 1987)
- 1. Morning stiffness Joint stiffness>1hour for >6 weeks
- 2. Arthritis of three or more joint areas At least 3active joints for >6 weeks; commonly involved joints are PIp, MCp, wrist. elbow, knee, ankle, MTP
- 3. Arthritis of hand joints At least one active joint in wrist, MCP or PIP for >6 weeks
- 4. Symmetric arthritis Bilateral involvement of PIp, MCp, or MTP for >6 weeks
- 5. Rheumatoid nodules Subcutaneous nodules over bony prominences, extensor surfaces or in juxta·articular regions
- 6. Serum RF Found in 60-80% of RA patients
- 7. Radiographic changes Erosions or periarticular osteopenia, likely to see earliest changes at ulnar styloid, 2nd and 3rd MCP and PIP joints
- Management: early stages with hydroxychloroquine/sulfasalazine; mod-severe: methotrexate, leflunomide, azathioprine, gold; severe: anti-TNF drugs, cyclosporine
- -if confident of diagnosis, do baseline bloodwork (CBC, liver/renal Ix, screen Hep B, Hep C, HIV) and start sulfasalazine + MTX (provided patient not pregnant and doesn’t have other contraindications), add prednisone while awaiting specialist consult for severe symptoms
- -need to do CXR to monitor for latent TB if starting anti-TNF drugs (if fail MTX/leflunomide/etc.)
- -surgery for multiple DMARD failure, intractable pain, structural joint damage (can include joint replacement, fusion; surgery truly a last resort in RA patients)
- Guidelines: http://www.bcguidelines.ca/guideline_ra.html; http://rheum.ca/en/publications/treatment_recommendations_for_ra
- 3) Gout
- Management of acute attack: NSAIDs plus/minus colchicine 0.6mg po up to tid (as tolerated by GI side effects). If can’t tolerate NSAIDS (ie. renal failure/GI ulcer), can substitute oral steroid for NSAID.
- Long term Management (prevention of recurrence): if repeated attacks, measure serum uric acid and, if elevated, Rx Allopurinol (or new uric acid-lowering drug Febuxostat). Combine first 3-6 months of uric acid-lowering med (allopurinol/febuxostat) with colchicine 0.6mg po od and then d/c colchicine. (Colchicine prevents recurrences while on initial months of uric acid-lowering drug.)
- Guidelines: Laubsher T, Dumont Z, Regier L, Jensen B. Taking the stress out of managing gout. Canadian Family Physician 2009;55(12): 1209-1212.
- 4) SLE
- Diagnostic Criteria: Diagnostic Criteria of SLE: 4 or more of 11 must be present serially or simultaneously (American College of Rheumatology, 1997 update)
- Clinical (7 criteria)
- Malar rash - Classic "butterfly rash; sparing of nasolabial folds, no scarring
- Discoid rash – May cause scarring due to invasion of basement membrane
- Photosensitivity - Skin rash in reaction to sunlight
- Oral/nasal ulcers - Usually painless
- Arthritis - Symmetric, involving <2 small or large peripheral joints, non-erosive
- Serositis - Pleuritis or pericarditis
- Neurologic disorder - Seizures or psychosis
- Laboratory (4 criteria)
- Renal disorder - Proteinuria 1>0,5 g/day or 3+; cellular casts (RBC, Hb, granular, tubular, mixed)
- Hematologic disorder- Hemolytic anemia, leukopenia, lymphopenia, thromboctyopenia
- Immunologic disorder - Anti-dsDNA Ab, anti-Sm Ab, Antiphospholipid antibodies based on the finding of serum anticardiolipin Ab, lupus anticoagulant, or false positive VDRL
- Antinuclear antibody lANA) Most sensitive test (98%)
- Management: treatment directed at symptoms ie. NSAIDs for arthritis, topical steroids for rash, high dose oral/IV steroids for serositis/nephritis, hydroxychloroquine for MSK/derm involvement; MTX/anti-TNF drugs, cyclophosphamide for severe organ involvement
- -avoid sulfonamides, estrogens (can exacerbate symptoms); smoking cessation
- Guidelines: none available
- 5) Ankylosing Spondylitis
- Diagnosis: see above chart
- Management: NSAIDS, exercises → opioids if needed → anti-TNF-alpha drugs or sulfasalzine (only DMARD of use in ank spond)
- Guidelines: none available
- 6) Fibromyalgia
- Diagnostic Criteria (2):
- (1) 3 months widespread pain (ie. pain in both sides of the body; pain above and below the waist; axial skeletal pain such as cervical spine, anterior chest, thoracic spine or low back) and
- (2) pain in 11/18 tender points
- Management:
- Non pharmacologic: Physical therapy, exercise and fitness program, stress-relief methods (including massage/relaxation techniques), cognitive behavioural therapy, well-balanced diet, avoid caffeine, sleep hygiene, acupressure/acupuncture
- Pharmacologic: antidepressent esp SNRI (duloxetine), anticonvulsants (ie. gabapentin/pregabalin), muscle relaxants, NSAIDs, sleep aids
- Guidelines: http://fm-cfs.ca/resources-p.html
Study Guide
Resources
Toronto Notes 2008
Up to Date
BC Guidelines on osteoarthritis www.bcguidelines.ca/guideline_osteoarthritis.html
BC Guidelines on rheumatoid arthritis www.bcguidelines.ca/guideline_ra.html
Canadian Rheumatology Association Treatment Recommendations http://rheum.ca/en/publications/treatment_recommendations_for_ra
Laubsher T, Dumont Z, Regier L, Jensen B. Taking the stress out of managing gout. Canadian Family Physician 2009;55(12): 1209-1212.
FM-CFS Fibromyalgia Guidelines www.fm-cfs.ca/physicians.html