APPROACH TO ATHRALGIA AND ARTHRITIS

intra-articular or extra-articular Inflammation or non inflammation Acute or chronic Monoarthritis or polyarthritis

JOINT PAIN
Arthralgia : joint tenderness, without abnormalities Also includes

altered pain sensation (eg, fibromyalgia) early rheumatic syndrome (eg, arthralgias of systemic lupus erythematosus [SLE]).

Ar thritis :

Periarticular inflammation : bursa

1.

(joint pain)

arthralgia arthritis

periarticular inflammation

ARTHRITIS Inflammatory
Morning stif fness > 30 minutes Symptoms improve with activity Swelling is often present

Non-inflammatory
Morning stif fness < 30 minutes Symptoms worse with activity Swelling may or may not be present

SIGN OF ARTHRITIS

1. 2. 3. 4. 5. 6.

Presence of swelling joint Local warmth (as in inflammatory arthritis) Tenderness along the joint line Redness (e.g. septic arthritis. acute gout. etc.) Range of motion (often reduced) Any deformity

JOINT SWELLING

Joint ef fusion
Synovial proliferation

BALLOTTEMENT

RIPPLE TEST

T he ripple test. (A) Empty the suprapatellar pouch as for the patella tap test. (B) Stroke the medial side of the joint to displace excess fluid to the lateral side of the joint. (C) Stroke the lateral side while watching the medial side closely for a bulge or ripple as fluid reaccumulates . This test may be negative if the ef fusion is tense.

 inflammatory arthritis

synovial hypertrophy synovial effusion inflammation of periarticular structures

noninflammatory arthritis
formation of osteophytes synovial cysts Thickening effusions

PERIARTICULAR INFLAMMATION

TENDERNESS ALONG THE JOINT LINE

LIMITATION RANGE OF MOVEMENT

LIMITATION ROM
structural damage Inflammation contracture of surrounding soft tissues

OTHER SIGNS

Weakness
result of disuse atrophy Weakness with pain

musculoskeletal cause (eg, arthritis, tendonitis) rather than a pure myopathic or neurogenic cause

OTHER SIGNS Crepitation

Deformity

DURATION
Acute <6 weeks in duration chronic is 6 or more weeks in duration

Number of involved joints Monoarthritis - one joint. Oligoarthritis - 2-4 joints. Polyarthritis -5 or more joints.

Acute monoarthritis Acute polyarthritis

Pyogenic Gout

Chronic
monoarthritis

Chronic polyarthritis
Rheumatoid Gout

Acute rheumatic fever Chronic infection (TB, Pyogenic (2-3 ) pyogenic, fungus)

Pseudogout
Acute rheumatic fever Traumatic arthritis Reiters disease Psoriasis Rheumatoid arthritis Hemophilic arthritis

esp. GC, salmonella

SLE Serum sickness Reiters disease Psoriatic arthritis

Osteoarthritis
Gout Pseudogout Avascular necrosis Tumor

Pseudogout
Osteoarthritis Psoraitic Ankylosing spodylitis SLE Other connective tissue diseases Hypertrophic osteoarthropathy Neuopathic

Ankylosing spondylitis Neuropathic Viral Leukemia Hemophilic

ACUTE MONOARTHRITIS

Inflammatory
Septic Arthritis Gout and Pseudogout

Noninflammatory
Trauma Osteonecrosis

CHRONIC MONOARTHRITIS
Inflammatory Chronic infectious arthritis Systemic rheumatic disease presenting with monoarticular involvement Noninflammatory Osteoarthritis Ischemic necrosis

Osteosarcoma
Metastatic tumor

ACUTE POLYARTHRITIS

Rheumatic fever Gonococcal Arthritis Polyarticular gout Polyarticular pseudogout Viral arthritis (eg, hepatitis B infection, parvovirus B-19 infection) Rheumatoid Arthritis Systemic Lupus Erythematosus

CHRONIC POLYARTHRITIS
Inflammatory
Rheumatoid Arthritis Systemic Lupus Erythematosus Viral arthritis Noninflammatory Osteoarthritis

Traumatic osteoarthritis
Hemochromatosis Amyloidosis Acromegaly

Sex Age Occupation Predisposing factor Morning stif fness Severity Movement Progression Treatment Genetic Other symptoms

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.

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 spine involved in ankylosing spondylitis spared in RA.

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

Gouty arthritis

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 arthritis caused by deposition of MSU crystals in joints and connective tissue tophi and the risk for deposition in kidney interstitium or uric acid nephrolithiasis

 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.

THE FOUR STAGE OF GOUT

Asymptomatic Acute Intercritical Chronic

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 of

gout 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.

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.

MONOSODIUM URATE CRYSTAL

INTERCRITICAL SEGMENTS
Intercritical segments occur after an acute flare has
subsided, and a person may enter a stage with clinically inactive disease before the next flare.

CHRONIC
Chronic gout is characterized by chronic 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).

DIAGNOSIS

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

crystals in synovial fluid or a tophus.

Blood test Hyperuricemia is defined as a plasma urate level greater than 420 mol/l (7.0 mg/dl) in males and 360 mol/l (6.0 mg/dl) in females. Other blood tests commonly performed are white blood cell count, electrolytes, renal function, anderythrocyte sedimentation rate(ESR). However, both the white blood cells and ESR may be elevated due to gout in the absence of infection.[A white blood cell count as high as 40.0109/l (40,000/mm3) has been documented.

DIAGNOSIS
X-rays