Approach to Athralgia and Arthritis

7/28/2019 Approach to Athralgia and Arthritis

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APPROACH TO

ATHRALGIA ANDARTHRITIS


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intra-articular or extra-articular

Inflammation or non inflammation

Acute or chronic

Monoarthritis or polyarthritis


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Arthralgia : joint tenderness, without abnormalities Also includes

altered pain sensation (eg, fibromyalgia) early rheumatic syndrome (eg, arthralgias of systemic lupus

erythematosus [SLE]). Arthritis :

Periarticular inflammation : bursa

JOINT PAIN


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1.

(joint pain)

arthralgia arthritis periarticular

inflammation


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InflammatoryMorning stiffness > 30 minutes

Symptoms improve with activity

Swelling is often present

Non-inflammatoryMorning stiffness < 30 minutes

Symptoms worse with activity

Swelling may or may not be present

ARTHRITIS


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1. Presence of swelling joint

2. Local warmth (as in inflammatory arthritis)

3. Tenderness along the joint line

4. Redness (e.g. septic arthritis. acute gout. etc.)

5. Range of motion (often reduced)

6. Any deformity

SIGN OF ARTHRITIS


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Joint effusion

Synovialproliferation

JOINT SWELLING


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BALLOTTEMENT


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The ripple test. (A) Empty the suprapatellar pouch as for th e patella tap test.

(B) Stroke the me dial side of the j oint to displace excess fluid to thelateral side of the joint.

(C) Stroke the lateral side while watching the medial side closely for abulge or ripple as fluid rea ccumulates. This test may be negative if theeffusion is tense.

RIPPLE TEST


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inflammatory arthritis

synovial hypertrophy synovial effusion inflammation of periarticular structures

noninflammatory arthritis formation of osteophytes synovial cysts Thickening

effusions


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PERIARTICULAR INFLAMMATION


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TENDERNESS ALONG THE JOINT LINE


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LIMITATION RANGE OF MOVEMENT


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structural damage

Inflammation

contracture of surrounding soft tissues

LIMITATION ROM


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Weakness

result of disuse atrophy

Weakness with painmusculoskeletal cause (eg, arthritis,tendonitis) rather than a pure myopathicor neurogenic cause

OTHER SIGNS


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Crepitation

OTHER SIGNS


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Deformity


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Acute


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Number of involved joints

Monoarthritis - one joint.

Oligoarthritis - 2-4 joints.

Polyarthritis -5 or more joints.


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Acute monoarthritis Acute polyarthritis Chronicmonoarthritis

Chronic polyarthritis

Pyogenic

Gout

Pseudogout

Acute rheumatic fever

Traumatic arthritis

Reiters disease

Psoriasis

Rheumatoid arthritis

Hemophilic arthritis

Acute rheumatic fever

Pyogenic (2-3 )

esp. GC, salmonella

SLE

Serum sickness

Reiters disease

Psoriatic arthritis

Ankylosing spondylitis

Viral

Leukemia

Hemophilic

Chronic infection (TB,

pyogenic, fungus)

Osteoarthritis

Gout

Pseudogout

Avascular necrosis

Tumor

Neuropathic

Rheumatoid

Gout

Pseudogout

Osteoarthritis

Psoraitic

Ankylosing spodylitis

SLE

Other connective

tissue diseases

Hypertrophic

osteoarthropathy

Neuopathic


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Inflammatory

Septic Arthritis

Gout and Pseudogout

Noninflammatory

TraumaOsteonecrosis

ACUTE MONOARTHRITIS


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Inflammatory

Chronic infectious arthritis

Systemic rheumatic disease presenting with monoarticular

involvement

Noninflammatory

Osteoarthritis

Ischemic necrosis

Osteosarcoma

Metastatic tumor

CHRONIC MONOARTHRITIS


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ACUTE POLYARTHRITIS

Rheumatic fever

Gonococcal Arthritis

Polyarticular goutPolyarticular pseudogout

Viral arthritis (eg, hepatitis B infection, parvovirus B-19

infection)

Rheumatoid Arthritis

Systemic Lupus Erythematosus


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CHRONIC POLYARTHRITIS Inflammatory

Rheumatoid Arthritis

Systemic Lupus Erythematosus

Viral arthritis

NoninflammatoryOsteoarthritis

Traumatic osteoarthritis

Hemochromatosis

Amyloidosis

Acromegaly


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Sex

Age

Occupation

Predisposing factor

Morning stiffness

Severity

Movement

Progression

Treatment Genetic

Other symptoms


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Symmetry of joint involvement

Symmetric arthritis

involvement of the same joints on each

side of the body.RA and SLE.

Asymmetric arthritis

psoriatic arthritis, reactive arthritis

(Reiter syndrome), and Lyme arthritis.


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Distribution of affected

joints

The distal interphalangeal joints of the fingers

involved in psoriatic arthritis, gout, or

osteoarthritis

spared in RA.

Joints of the lumbar spineinvolved in ankylosing spondylitis

spared in RA.


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Extra-articular manifestations

Skin lesions

SLE, dermatomyositis, scleroderma, Lyme disease, psoriasis,

Henoch-Schnlein purpura, and erythema nodosum.

Ocular symptoms or signs

Episcleritis and scleritis -RA or Wegener granulomatosis

anterior uveitis - ankylosing spondylitis,

iridocyclitis - juvenile RA

Conjunctivitis -reactive arthritis


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Gouty

arthritis


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GOUT Gout is a metabolic disease that most often affects middle-aged

to elderly men and postmenopausal women.

It results from an increased body pool of urate with

hyperuricemia.

It typically is characterized by episodic acute and chronic arthritiscaused by deposition of MSU crystals in joints and connective

tissue tophi and the risk for deposition in kidney interstitium or

uric acid nephrolithiasis


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The first episode of acute gouty arthritis frequently begins at night with

dramatic joint pain and swelling. Joints rapidly become warm, red, and

tender, with a clinical appearance that often mimics that of cellulitis.

Early attacks tend to subside spontaneously within 310 days, and

most patients have intervals of varying length with no residual

symptoms until the next episode.

Several events may precipitate acute gouty arthritis: dietary excess,

trauma, surgery, excessive ethanol ingestion, hypouricemic therapy,

and serious medical illnesses such as myocardial infarction and stroke.


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THE FOUR STAGE OF GOUT

Asymptomatic

Acute

Intercritical

Chronic


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ASYMTOMATIC The first stage of gout arthritis is asymptomatic

stage. Uric acid is an asymptomatic condition uric acid

levels higher than normal levels but no symptoms ofgout arthritis.

This condition is called hyperuricaemia. To find

out if a person has hyperuricaemia, must be through a

blood test. At this stage, no treatment is necessary.


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ACUTE PHASE

The symptoms are pain and inflammation that can be lost in 3 to 10

days.

The affected joints will be swollen, warm and reddish. Usually the

inflammation starts from the big toe joint, and may spread to the

bottom of the foot, instep (back legs), and heels.

In some cases the inflammation may also occur in the knees,

fingers, wrists, and elbows.


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MONOSODIUM URATE CRYSTAL


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INTERCRITICAL SEGMENTSIntercritical segments occur after an acute flare has

subsided, and a person may enter a stage with clinically

inactive disease before the next flare.


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CHRONIC

Chronic gout is characterized bychronic arthritis, with soreness and

aching of joints.

People with gout may also get tophi

(lumps of urate crystals deposited in

soft tissue)usually in cooler areas of

the body (e.g., elbows, ears, distal

finger joints).


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DIAGNOSIS

Synovial fluid

A definitive diagnosis of gout is based upon the identification of monosodium urate

crystals in synovial fluid or a tophus.


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DIAGNOSIS X-rays

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Approach to Athralgia and Arthritis