TBL 1 Joint pain

8/7/2019 TBL 1 Joint pain

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TBL 1TBL 1

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TriggerTriggery A 40-year-old man is complaining left hip pain on

walking for the past one year. The pain was initially mildbut the last two months, the pain is worsening. He hasto use a walking stickto ambulate. Due to the pain, he isalso having difficultyon squatting.

y He claims that he was diagnosed to have dislocation ofhis left hip joint following a fall from a height three yearsago. As his place of staying is far to reach to the hospital,his dislocated hip joint was delayed for more than 12hours to be reduced by the doctor upon admission tothe A&E unit.

y No pain elsewhere to anyother parts of the body. Nomorning stiffness to the joints of the fingers. No stiffnessof the back.

y No historyof night sweats, loss of appetite, and weight.

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y Examination revealed the following findings: Trendelenburgs sign is elicitedon the left side.

Movement ofleft hip joint:x R

ange from 0 90degrees on flexion, 0 20degrees onexternal rotation, 0 15degrees on internal rotation

y X-rayofleft hip is taken and showsabnormalities of the femoral head.

y

Blood investigations done revealed normallevel ESR and white count.

y He is advised to undergone surgery but herequested todelay the surgery.

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ANATOMIC

AL

ANATOMIC

AL

STRUCTURES OF THE HIPSTRUCTURES OF THE HIP

JOINT THAT RELATED TOJOINT THAT RELATED TO

THIS PATIENT PROBLEMTHIS PATIENT PROBLEM

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WHY HE H

AD LEFT HIP

WHY HE H

AD LEFT HIPJOINT PAIN?JOINT PAIN?

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Why he hadleft hip joint pain?Why he hadleft hip joint pain?

y His dislocated hip joint was delayed for morethan 12 hours to be reduced local bloodsupply to femoral head is disrupted for too

long - the bone cells die - develop AVNy Early AVN usually causes very mild symptoms

(groin pain) or no symptoms at all. Later on,

the patients develop constant and veryintensive groin pain. Successively, patients withAVN develop symptoms as with hiposteoarthritis.

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y The secondary OA develops after previous

damage to the hip joint in which the bone

and cartilage do not heal properly. The joint

is nolonger smooth and these irregularitiesultimatelylead to more wear on the joint.

y the pain in early stage is due to

inflammation of the synoviallining. In the

later stages, when the cartilage is worn away,

the pain and stiffness come from the friction

of raw bones grinding on each other.

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WHY THE P

AIN

IS ON

LYW

HY THE PA

IN

IS ON

LYEXPERIENCED ONEXPERIENCED ONWALKING?WALKING?

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y At rest no movement no pressure

applied

y On walking - apply more pressure and

friction occur in the joint cause pain

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Is there any relationship of previousIs there any relationship of previous

trauma with his current problem?trauma with his current problem?

Yes.Hip dislocation

Late complication:Avascular necrosis

Secondaryosteoarthritis

Delayed reduction

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ETIOLOGICAL CAUSES OFETIOLOGICAL CAUSES OF

CHRONIC JOINT PAINCHRONIC JOINT PAIN

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Etiologyof chronic joint painEtiologyof chronic joint pain

1. Degenerative osteoarthritis ( primary

and secondary)

2. Rheumatoid arthritis

3. Crystalline deposition arthropathy

4. Haemophilic arthritis

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Degenerative osteoarthritisDegenerative osteoarthritis

Clinical presentation:

a. History: Age: primary OA: over 50; secondary OA:

can occur at 30or even 20 Pain:

x felt at groin may radiate toknee

x Occurs after periodof activity later becomes

constant Stiffness noticed after rest ( increase

progressively until putting on socks & shoesbecomes difficult)

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b. Physical examination:

Positive trendelenburgs sign

Limb: lies in external rotation & adduction (

appears short), some fixed flexion

Rarely : muscle wasting

Tenderness upon deep pressure

Restricted movements

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painpain

c. Investigations: X- ray:

x 4 CARDINAL SIGNS:

x Assymetrical narrowing of the joint space

x Sclerosis of subchondral bone

x Cysts

x Osteophytes

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What isWhat is trendelenburgtrendelenburg sign?sign?

y To checkefficacyof the abductor mechanism of hip.

y Demonstrate by: asking the pt to standon affectedleg with the

normalleg liftedoff the ground

y Normally: when one leg is liftedoffthe centre of gravity shifts

to the opposite side abductor mechanism contracts pullsthe pelvis down on the stance side moves opposite pelvis togo up

y If the abductor mechanism fails opposite pelvis drop down

y Seen in gluteus medius palsy, fracture neckof femur, arthritis ofhip anddislocations of hip.

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RheumathoidRheumathoid arthritisarthritisy Clinical presentation:

History:

x Usually woman of30-40years old with pain, swelling andloss ofmobility in proximal joints of fingers ( commonly: MP joints , PIP

joints of fingers, wrist, knees, elbows and ankles). Previous historyofmuscle pain, tiredness, LOW.

Physical examination:

x Hand:

x ulnar deviation of fingers and hands

x

Boutonniere deformityx Swan neckdeformity

x z deformityof thumb

x Triggers fingers & thumb

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y Elbow: flexion deformity

y Knees: triple deformity (1) flexion at the knee

2) posterior subluxation of the tibia3) external rotation of tibia(abduction)

y Ankle: Equinus deformity

y Foot: valgus feet, hammer toe, Hallux valgus (bunions)

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y Extra-articular features

Rheumatoid nodule(underskin/tendon/sclera/viscera)

Lymphadenopathy

Vasculitis

Muscle weakness

Visceraldisease(affectinglungs/heart/kidneys/brain/GIT)

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y Investigation:

Lab test: low Hb, elevated ESR, CRP andRh factor

Radiological features: reduced joint space, erosionof articular margin, subchondral cyst with juxta-articular rarefaction.

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Crystalline depositionCrystalline deposition arthropathyarthropathy

Sign & symptoms Joint involved Investigations

Gout (urate

crystals)

Usually male40yo

Acute: sudden pain & sweelingof MT-PH joint of big toe, ankle,

or olecranon bursaeChronic: recurrent attacks,

chronic pain, stiffness &deformities of joints

tophy

MT-Ph joint ofbig toe, ankle,

olecranonbursae * pinnae

ears

X ray ( chronicgout) : increase joint

spaceIncrease serum uric

acisSynovial fluid urate

crystals

Pseudogout (

calciumpyrophosp

hate)

Like those of gout Usuallyknee (menisci &

articularcartilage)

X ray: calcificationofknee, wristm hips,

IV discSynovial fluid

birefringet crystals

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X rayof goutX rayof gout

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HaemophilicHaemophilic arthritisarthritis

y Signs & symptoms:

Young boys with positive family history

Sudden painful bilateral hemorrhagic effusion

into the knee, ankle, elbows.

y Joint involves:

Knee, elbow, ankle

y Investigations: Xray: Bone resorption, cyst formation,

osteoporosis,

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ProvisionaldiagnosisProvisionaldiagnosis

SECONDARY OSTEOARTHRITIS

yWorsening hip pain

y Positive trendelenburgs sign.

y RestrictedROM

y Increase ESR and white cell count

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WHAT CAN RESULT TO LIMITWHAT CAN RESULT TO LIMIT

JOINT MOVEMENT?JOINT MOVEMENT?(Causes of reduced range of

movement)

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Range of Movement (ROM)Range of Movement (ROM)

y Range of motion is the distance and

direction of movement of a joint

y Each specific joint has a normal range of

motion that is expressed in degrees

y Limited range of motion is a term

meaning that a specific joint or body part

cannot move through its normal range ofmotion

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ROM ofROM of HHipip JJointoint

Type of movement Normal Values (in

degrees)

This patient

Hip flexion 0-125 0 90

Hip extension 115-0

Hip hyperextension 0-15

Hip abduction 0-45

Hip adduction 45-0

Hip lateral rotation(external rotation)

0-45 0 20

Hip medial rotation(internal rotation)

0-45 0 15

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Causes of reducedROMCauses of reducedROM

y The major causes of reduced range of

movement can be categorized into three

main causes which is:

(1) SWELLING

(2) STIFFNESS

(3) PAIN

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Causes of reducedROM of HipCauses of reducedROM of Hip

JointJointy Fractures

y Dislocation

y osteoarthritis

y Rheumatoid Arthritisy Ankylosing spondylitis

y Mechanical backpain

y Septic joint (septic hip)

y Syphilis

y Legg-Calve-Perthes disease

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What actually the causes to result inWhat actually the causes to result in

femoral headdeformities?femoral headdeformities?Radiological presentation?Radiological presentation?

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FemoralFemoral HHeadead DDeformityeformity

Secondary osteoarthritis of the hip

y This is the inevitable sequel to avascular

necrosis, but may alsooccur when

dislocation of the hip is accompanied by afracture involving the articular surfaces

y It is also seen as late as 5- 10years after

injury; the cause then is less clear, but it ispossibly arise from articular cartilage

damage concurrent with the initial injury

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Radiological Presentation ChecklistsRadiological Presentation Checklists

y Center-Edge Angle

y Acetabular Head Index

y Acetabular Angle

y Mechanical Sharp Angley Head Lateral Shift

y Head Superior Shift

y Pelvic Anteroposterior Tilt

y Pelvic Lateral Tilt

y Leg-Length Discrepancy

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Mild flattening of the superior aspect of the femoral head is presentMild flattening of the superior aspect of the femoral head is present

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Avascular necrosis with secondaryosteoarthritisAvascular necrosis with secondaryosteoarthritis

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DiscussDiscuss the related pathogenesis /the related pathogenesis /

pathological process in thispathological process in thispatientpatient

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Secondary OsteoarthritisSecondary Osteoarthritis

y The term secondaryosteoarthritis is appliedwhen an underlying recognizable localorsystemic factor exists

y

These include conditions leading to jointdeformityor destruction of cartilage,followed by signs and symptoms typicallyseen with primaryosteoarthritis

y

In secondaryosteoarthritis a younger agegroup is generally involved than in the caseof primaryosteoarthritis

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Secondary OsteoarthritisSecondary Osteoarthritis

Examples of preexisting conditions leading to secondaryosteoarthritis changes in joints include:

y acute and chronic trauma

y Legg- Clave- Perthes disease

y developmentaldysplasia of the hip

y rheumatoid arthritisy bleeding dyscrasias

y Achondroplasia

y Infection

y crystaldeposition disease

y neuropathic disorders

y overuse of intaarticular steroids

y multiple epiphysealdysplasia

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HowHow to assess clinically: History,to assess clinically: History,

examination & investigationexamination & investigation

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History takingHistory taking

PAIN

y Onset

y Nature / Character

y Site

y Intensity

y Aggravating & relieving factors

y Referred pain

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Physical ExaminationPhysical Examination

General Examination

y Look

y Feel

y Move

Specific Examination

y Trendelenburgs hip test

y Thomas test for FFD of hip

y Limb length measurement

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InvestigationInvestigation

y Full Blood Count (FBC)

y Renal Profile

y Erythrocyte sedimentation rate (ESR)

y C- Reactive Protein (CRP)

y VDRL

y Rheumatoid factor

y Urinalysis

y Radiology (X- Ray, CT Scan & MRI)

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y Is ESR & white count important

investigation?

yWhat doyou thinkthe possible surgical

treatment being offered?

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y Children

Newborn : 0 to2 mm/hr

Neonatal to puberty: 3 to13 mm/hr

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Does it important todo it?Does it important todo it?

y Yes /no

y Because ESR is an important indicator

when a condition or disease is suspected

of causing inflammation.

y it rarelyleads directly to a specific

diagnosis.

y However , It can also be important as apreoperative assessment.

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y Conditions which increases ESR

Rheumatoid arthritis

Multiple myeloma

polymyalgia rheumatica

Osteomyelitis

tuberculosis

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White blood countWhite blood count

y The white blood count for this patient is

within the normal range.

The wbc is also not an important indicator.

yWhy

As the increase of the level indicates infectionwhether it is caused by bacteria or even virus.

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TreatmentTreatment

y Early

y Intermediate

y Late!!

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EarlyEarly

y 3 principles Relieve pain

Increased movements

Reduce load

y Relieve pain NSAIDsx Reduce the congestion in the subchondral bonex Drawbackulceration and bleeding (git)

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y Joint mobility

Increased range and power reduce pain andimprove function

y Load reduction Walking stick

Wearing soft-soled shoes

Avoiding prolonged, stressful activity

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IntermediateIntermediate

y Symptoms increaseddespite the

conservative treatment

y Realignment osteotomy

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LateLate

y Indication for radical surgery are

unrelieved pain and progressive disability

y Total hip joint replacement (arthroplasty)

is the operation of choice.y Arthrodesis is occasionally indicated if

stiffness is not a drawback

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Thankyou~~~~

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TBL 1 Joint pain