Approach To Arthritis Patient

Approach to Arthritis patient

Dr. Ashish Gohiya Assistant Professor Department of Orthopaedics Gandhi Medical College, Bhopal

Goal • • • •

To formulate differential diagnosis. Lead to accurate diagnosis. Timely therapy. Avoid excessive diagnostic test & unnecessary treatment.

Whether the problem is • • • •

1. Articular or Nonarticular. 2. Inflammatory or Non inflammatory. 3. Acute or Chronic. 4. Localized (Mono, Oligo) Widespread (Poly) Systemic.

Articular • Articular cartilage, synovium, synovial fluid, I/A ligaments, joint capsule. • Pain & limited ROM on active and Passive Movements. • Crepitations. • Instability. • Locking .

Non Articular • Muscle, tendon, ligaments, bursa, fascia, bone nerve, vessels, skin. • Pain on active but not on passive movement. • Focal tenderness distant from articular site. • No Crepitus, instability, locking.

Inflammatory • Causes – Infectious (Septic, TB) – Crystal induced (Gout, Pseudogout) – Immune related (RA, SLE) – Reactive (Rheumatic fever,Reiters syndrome) – Idiopathic

• Signs of inflammation – Erythema, warmth, pain, swelling.

• Systemic symptoms – Morning stiffness,fatigue,fever,wt. loss.

• Lab evidence – Increased ESR, Increased CRP.

Non Inflammatory • Causes – Trauma (rotator cuff tear, meniscus tear) – Ineffective repair (Osteoarthritis) – Cellular overgrowth (Pig. Villonodular synovitis) – Pain amplification (fibromyalgia)

• Pain without swelling & warmth. • No inflammatory signs. • No lab findings.

Clinical • Age : • SLE , RF, RS – young. • OA – old

• Sex • AS, RS – Male • RA, Fibromyalgia – Female

• Race • Family • AS, Gout, RA.

• Onset

Chronology

– Acute – Septic arthritis, gout – Insidious – RA, OA

• Evolution – Chronic – OA – Intermittent – Gout – Migratory – RF, Viral Arthritis/gonococcal – Additive – RA, – Acute – Infection, Crystal

< 6wk Acute

, > 6wk Chronic

No. of Joints affected • Monoarticular(1or2) • Oligoarticular(2or3) • Polyarticular (>3)

Monoarticular • • • • • • • •

Septic arthritis TB arthritis Gout & other crystal deposition disease Seronegative spondyloarthropathy Tumors Trauma Hemophilia Monoarticular presentation of polyarticular disease.

Oligoarticular • • • •

Gout Juvenile rheumatoid arthritis (JRA) Psoriasis Seronegative spondyloarthropathy

Polyarticular • • • • •

Rheumatoid arthritis SLE Psoriasis JRA Reiters syndrome

Distribution of joints • Symmetrical – RA , Psoriasis • Non symmetrical – spondyloarthropathy, gout • Upper limb – RA • Lower limb – RS, Gout. • Axial skeleton – OA, AS

Systemic • • • • •

Fever – SLE, Infection Rash – SLE, RS Myalgia/ weakness – poymyositis Morning stiffness – inflammatory arthritis Other system involvement

Physical Examination • • • • •

Warmth, Erythema, Swelling. Articular / Periarticular swelling Jt instability Jt volume – flexion deformity ROM – Active & passive – Contracture, deformity – crepitations

Investigations • CBP, TLC, DLC • Acute phase reactants – ESR, CRP (diff. b/w inf & non inf)

• • • • • •

S. Uric acid Rheumatoid factor ANA Poor predictive value, Costly Complement level ASO Synovial fluid (acute monoarthritis)

Imaging • X- ray • USG • Radionuclide scintigraphy – Metabolic status – Extent of musculoskeletal system

• CT Scan – In accessible sites

• MRI – Bone marrow involvement – Soft tissue involement