Approach to Arthritis patient

Dr. Ashish GohiyaAssistant 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.

Chronology • Onset

– 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

• Complement level

• ASO

• Synovial fluid (acute monoarthritis)

Poor predictive value, Costly

Imaging

• X- ray

• USG

• Radionuclide scintigraphy– Metabolic status– Extent of musculoskeletal system

• CT Scan – In accessible sites

• MRI– Bone marrow involvement– Soft tissue involement