Approach to Articular and Musculoskeletal Disorders

APPROACH TO ARTICULAR AND MUSCULOSKELETAL DISORDERS Emmanuel C. Perez, MD, MPH March 6, 2014; 1:00-3:00 PM Internal Medicine “I only see grown men cry when: they see their first born, when their favourite basketball or sports team wins the series, and when they have gout.” – Dr. Perez OUTLINE  Pain in or around a joint  Evaluation of patients with musculoskeletal complaints  Approach to patient with articular and musculoskeletal complaints  Drug-induced musculoskeletal conditions  Arthritis  Specific types of arthritis OBJECTIVES  To localize musculoskeletal complaints by differentiating between clinical features of articular and non-articular conditions  To determine the nature of the pathology by distinguishing between inflammatory and noninflammatory articular conditions  To discuss specific physical examination maneuvers employed in articular and musculoskeletal disorders  To discuss appropriate laboratory, serological examinations and ancillary procedures used in the diagnosis of articular disorders  To differentiate between normal and pathologic synovial fluid characteristics

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Laboratory examinations Arthrocentesis Imaging procedures Algorithm for the diagnosis of musculoskeletal complaints Case

 To present an algorithm for the evaluation of articular and musculoskeletal disorders

PAIN IN OR AROUND A JOINT  Musculoskeletal complaints are usually due to pain, and you must differentiate whether the pain was emanating from certain structures or from a certain pathologic condition  The history helps define the pathology  Mechanical vs. inflammatory  The physical examination helps define which anatomical part in involved  Articular vs. periarticular or somewhere around the joint vs. referred

EVALUATION OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTS  Anatomic localization of complaints  Articular vs. non-articular  Determination of the nature of the pathologic process (take note of the hallmarks of inflammation: Calor, rubor, tumor, dolor, and function laesa)  Inflammatory vs. non-inflammatory  Determination of the extent of involvement  Monoarticular vs. polyarticular  Focal vs. widespread  Determination of chronology  Acute vs. chronic JOINT ANATOMY  It is important to differentiate which structures are closely associated to joints and which are non-joint structures. When we’re talking about the joint, these particular parts are involved:  Hyaline articular cartilage  Joint space  Fibrocartilaginous pads  Synovium  Joint capsule  Anything other than the items mentioned like the bones, skin and subcutaneous tissue, soft tissue structures like bursa, enthesis, tendons and tendon sheaths, and muscles are all periarticular or non-articular.  For example, if there is inflammation of the synovium, you have synovitis and it is a hallmark of arthritis. If you have destruction of the hyaline articular cartilage, then that may be a form of pathology involving a specific part of arthritis.

Transcriber: Junjun’s Group Formatting: Junjun Mendoza Editor: John Henry Amper

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ANATOMIC LOCALIZATION OF COMPLAINTS ARTICULAR  Deep or diffuse pain  Limited range of motion on BOTH active and passive movement  Swelling, bone crepitation, joint instability, locking or gross deformity on physical examination

NON-ARTICULAR  Point or focal tenderness  Limited range of motion ONLY on active movement  Physical findings remote from the joint capsule

 For example, if you have inflammation of the bursa, or inflammation of the tendons or ligaments, then you would definitely have point or focal tenderness. DETERMINATION OF THE NATURE OF THE PATHOLOGIC PROCESS INFLAMMATORY NON-INFLAMMATORY  Infections, crystal induced, immune- related,  Trauma, repetitive use through recreational or reactive or idiopathic occupational activities, ineffective repair/ degeneration, neoplasm, pain amplification  Cardinal signs of inflammation  Pain but without the cardinal signs of inflammation  If not all are present, at least majority of  There’s usually an absence of warmth, sometimes them. So there has to be a form of swelling, with minimal swelling, but usually no rubor or calor redness, warmth, etc.  (+)Systemic symptoms  No systemic symptoms (minimal morning stiffness)  Arthritis in association with skin manifestations or eye conditions, or pathologies in the GIT or in the kidneys  Laboratory evidence of inflammation  Normal lab exams CAUSES OF MORNING STIFFNESS INFLAMMATORY  Precipitated by prolonged rest  Several hours in duration  IMPROVES with activity and NSAIDs (usually improves before lunch, or it could take 2-3 hours for severe inflammatory arthritis. It basically improves within the day when the patient starts moving the joints and taking NSAIDs)

NON-INFLAMMATORY  Precipitated by brief periods of rest  Lasts 90% of MCTD 30% of SLE (specific) 60% of Sjogrens, SCLE, neonatal lupus, ANA (-) lupus 50% of Sjogrens, 15% lupus 40% of diffuse scleroderma Polymyositis (PM), dermatomyositis PM with pneumonitis + arthritis

ARTHROCENTESIS  Withdrawal of synovial fluid from an effused joint which has diagnostic as well as therapeutic role  This is also used to rule out gouty arthritis regardless of an increase or decrease in uric acid  Contraindications  Infection in overlying skin or soft tissue  Severe coagulation disorder  Diagnostic  SF exam including crystal identification  Therapeutic  Relieve pain by decreasing joint pressure  Instillation of steroids and other antiinflammatory medications to prevent reaccumulation of fluid

Transcriber: Junjun’s Group Formatting: Junjun Mendoza Editor: John Henry Amper

 Man with gout due to alcohol bingeing undergoing anthrocentesis

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GROSS EXAMINATION OF SYNOVIAL FLUID

 Viscosity

 Mucin Clot

 Color

 Clarity

MICROSCOPIC EXAMINATION OF SYNOVIAL FLUID 3  WBC and differential count – 200 to 2000 cells/mm  Special stains  Wright’s stain, Gram stain, Congo red stain, PAS stain, Prussian blue stain, Alizerin Red-S stain

COMPENSATED POLARIZED MICROSCOPIC EXAMINATION (under the light microscope)

MSU Crystals -crystals outside the cell

Transcriber: Junjun’s Group Formatting: Junjun Mendoza Editor: John Henry Amper

Crystal Pyrophosphate Dihydrate (CPPD) Crystals -crystals engulfed by the cell

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MICROBIOLOGIC STUDIES  Gram stain and Acid-fast stain methods  Preferred since results are quickly obtained and it could be established whether the arthritis is due to microbial organisms  Culture studies to isolate microorganisms using appropriate culture media

SYNOVIAL FLUID CHARACTERISTICS  Usually, we have 75 (+)

 In terms of viscosity, the synovial fluid becomes less viscous when inflammatory cells are present as seen in inflammatory and infectious arthritis.  Highest WBC count is observed in Septic Arthritis. DIFFERENTIAL DIAGNOSIS BY JOINT FLUID GROUPS GROUP I NON-INFLAMMATORY  Osteoarthritis  Avascular  necrosis  Osteochondritis  dessicans  Villonodular  Synovitis

GROUP II INFLAMMATORY  Rheumatoid  arthritis  Crystal-induced  arthritis  Psoriatic arthritis  Reactive arthritis  SLE  Rheumatic fever  Scleroderma  Amyloidosis  Myxedema  Ochronosis

GROUP III SEPTIC  Bacterial arthritis  TB arthritis

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GROUP IV HEMARTHROSIS Trauma Charcot’s joint Hemorrhagic diasthesis Hemophilia joint Hemangioma PVNS High levels of anticoagulants

INTERPRETATION OF SYNOVIAL FLUID ASPIRATION

Transcriber: Junjun’s Group Formatting: Junjun Mendoza Editor: John Henry Amper

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IMAGING PROCEDURES  X-rays  CT scan  MRI

 Ultrasound  Bone scan (scintigraphy)  Bone mineral densitomety (DXA)

 Radioimaging modalities are not usually requested when dealing with Acute Monoarthritis but when you are highly suspecting that there are soft-tissue tears, for example a basketball player or a football player comes to you limping, complaining of pain in the knees and there’s some sort of effusion then X-rays will not be appropriate to obtain in this patient because soft tissue structures would not show clearly on x-rays. You might have to use CT scan or MRI. Sometimes patients would complain of swelling in the popliteal area, which means there is some form of cystic lesions which is diagnosed through ultrasound.

 Advanced Osteoarthritis on x-ray: diminution or joint spaces or joint space narrowing in the medial portion.  As Dr. Perez said, “may matatalas na buto.. nagkakanto na siya. Kasi usually ang bones natin very smooth ang bone surface area niya no, pag medyo nagka-kanto na tumutulis na siya, that is a hallmark of osteoarthritis.”

 Osteoarthritis of the hips. Delineation of the joint space is not seen

DIAGNOSTIC IMAGING TECHNIQUES FOR MUSCULOSKELETAL DISORDERS  “You might want to study this ‘cause there’s probably an exam question from this table, okay?” – Dr. Perez METHOD ULTRASOUND RADIONUCLIDE SCINTIGRAPHY

IMAGING TIME (HOUR)