Treatment of joint roughness by painkillers:
Panadol, aspirin ... within a specific dose with attention to the development of the digestive system.
------------------------
Some musculoskeletal diseases mostly affect the joints and cause arthritis. Others affect the bones (e.g., fractures, Paget's disease of the bone, tumors), the muscles or other extra-articular soft tissues (e.g., fibromyalgia, myositis) or periarticular (e.g., bursitis, tendonitis sprain). The causes of arthritis can be diverse, and include infections, autoimmune diseases, crystal-induced inflammation and minimal inflammatory diseases of bone and cartilage (eg, osteoarthritis). Arthritis can affect a single joint (monoarthritis) or several (polyarthritis) symmetrically or asymmetrically, with or without vertebral involvement.
Anamnesis:
In addition to joint symptoms, the doctor must also look for systemic and extra-articular symptoms. Many of them, such as fever, chills, malaise, weight loss, Raynaud's phenomenon, mucocutaneous symptoms (rash, erythema or eye pain, photosensitivity) and digestive or cardiopulmonary, can be associated with various joint diseases.
Pain is the most common symptom in joint diseases (see Pain in and around the joints). The history should investigate the type, location, intensity, factors that aggravate and relieve it and the time of evolution (if it is of recent or recurrent onset). The doctor should determine if the pain worsens at the beginning of the joint movement or after prolonged use, if it appears upon waking or during the day. In general, pain originating from superficial structures is better located than that originating from deep. Pain caused by small distal joints tends to be better localized than that of large proximal joints. Joint pain can be a referral for extra-articular structures or other joints. Often, arthritis causes continuous pain; on the other hand, neuropathies usually cause a dull and deep or burning and superficial pain.
Stiffness is the difficulty of movement of a joint, although for the patient stiffness may also indicate weakness, fatigue or fixed limitation of movement. The doctor must differentiate the inability to move a joint from rejection to doing so because of pain. The stiffness characteristics can orient the cause as follows:
- A nuisance that appears with the movement when starting to move a joint after a period of rest suggests a rheumatic disease.
- The stiffness is more severe and prolonged the greater the joint inflammation.
- The theater sign (brief stiffness of the knee or hip when standing up after several hours of sitting, which forces the patient to walk slowly) is frequent in osteoarthritis.
- Morning stiffness in peripheral joints that lasts> 1 h may be an important early sign of joint inflammation, as in the case of RA, psoriatic arthritis or chronic viral arthritis (see Differences between inflammatory and non-inflammatory joint disease according to their features).
- In the lower back, a morning stiffness that lasts> 1 h may reflect spondylitis.
Fatigue is the desire to rest due to fatigue. It is distinct from weakness, inability to move and rejection of movement due to the pain it causes. Fatigue may reflect the activity of a systemic inflammatory disorder. Doctors should try to distinguish fatigue from drowsiness.
Instability (lack of support of a joint) may suggest weakness of the ligaments or other structures that stabilize the joint, and can be assessed by tests of overload during the physical examination. It is more frequent in the knee and is usually due to an internal disorder of the joint.
Physical exam:
It is necessary to inspect and palpate each affected joint and estimate the range of motion. In polyarticular disease, some non-articular signs (such as fever, malaise, rash) may reflect a systemic condition.
The resting position, the presence of erythema, swelling, deformations and abrasions or perforations in the skin should be observed. The affected joints must be compared with those on the opposite side not affected or with the examiner's joint.
The joint is gently palpated, observing the presence and location of pain, heat and swelling. It is important to determine if there is pain in the joint line or over the insertion of tendons or joint bag. The presence of soft masses, lumps or tissues in normal spaces or concavities (representing joint effusion or synovial proliferation) should be observed. Palpation of a swollen joint makes it possible to differentiate between a joint effusion, synovial thickening and an increase in capsular or bone size. Pain that initially appears to originate in a larger joint may actually come from small joints (e.g., acromioclavicular, tibioperonea, radiocubital, sternocubital) near the area. It should be observed if there is an increase in bone size (often due to osteophytes).
First, the active range of motion must be evaluated (the maximum range at which the patient can move the joint); A limitation may be due to weakness, pain or stiffness, or mechanical alterations. Then the passive range of motion is evaluated (the maximum range at which the examiner can move the joint); Generally, a limitation of passive movements reflects a mechanical abnormality (eg, scars, swelling, deformations) and no weakness or pain. In an inflamed joint (e.g., from infection or gout), active and passive movements can be very painful.
The inability to reproduce pain with movement or palpation of the joint suggests the possibility of referred pain.
It is necessary to observe the patterns of joint disease. A symmetric multiple joint condition is more common in systemic diseases (such as rheumatoid arthritis); a monarticular condition (affecting only one joint) or asymmetric oligoarticular (involving ≤ 4 joints) is more common in osteoarthritis and psoriatic arthritis. In rheumatoid arthritis, small peripheral joints are affected, and in spondyloarthropathies, larger joints and the spine. However, in the early stages of the disease it may not be possible to determine the complete condition pattern.
The presence of crepitation, a palpable or audible grinding caused by the movement of damaged joint structures should be observed. It can be caused by a rough articular cartilage or tendons; movements that produce crepitation, which may indicate the affected structures, must be determined.
In each joint, specific signs should be sought. The details of the physical exam and arthrocentesis procedures are treated separately for the following joints:
- ankle
- Elbow
- Foot
- Hand
- Hip
- Knee
- shoulder
- Doll
- Neck and back joints.
Complementary studies:
Laboratory and imaging studies often provide less information than the history and physical examination. Although in some patients it is useful to carry out some studies, in most cases an extensive study is not indicated. Complementary studies include
- Blood test
- Diagnostic imaging studies
- Arthrocentesis and synovial fluid analysis
Blood test:
Blood tests should be based on clinical history and physical examination data. Some studies, although not specific, can help guide the diagnosis towards a systemic rheumatic disease, such as the following:
- Antinuclear antibodies (ANA) and anti-double stranded DNA antibodies in systemic lupus erythematosus
- Rheumatoid factor and antibodies against cyclic citrullinated peptide (CCP) in rheumatoid arthritis
- HLA-B27 in spondyloarthropathy (eg, with symptoms of inflammatory back pain and normal x-rays or with uveitis of unknown cause and peripheral arthritis)
- Cytoplasmic antineutrophil antibodies (ANCA) in certain vasculitis (useful when systemic condition is suspected)
Studies such as white blood cell count, erythrosedimentation rate and C-reactive protein are not very sensitive or specific, but they can help determine the likelihood of an arthritis of inflammatory origin or due to other systemic conditions. For example, an accelerated erythrosedimentation rate or a high level of C-reactive protein suggests joint inflammation or may be due to a large number of non-joint inflammatory diseases (eg, infection, cancer). These markers may not be elevated in all inflammatory diseases.
Diagnostic imaging studies:
Often imaging studies are unnecessary. Simple radiography in particular reveals bone abnormalities, but most joint diseases do not affect the bones. However, these imaging studies can help in the initial evaluation of relatively localized, persistent or severe joint or vertebral abnormalities, with no apparent cause; they can reveal primary or metastatic tumors, osteomyelitis, bone infarctions, periarticular calcifications (as in calcified tendinitis) or other changes in deep structures that are not detected on the physical examination. If chronic rheumatoid arthritis, gout or osteoarthritis is suspected, erosions, cysts and narrowing of the joint space with osteophytes will be seen. In calcium pyrophosphate arthritis (pseudogout), calcium pyrophosphate deposits can be seen in the intra-articular cartilage.
Musculoskeletal imaging studies should begin with a simple radiography, although in the early stages it is less sensitive than MRI, CT or ultrasound. MRI is the most accurate study in fractures not visible on simple radiography, especially in the hip and pelvis, and for the study of soft tissues and internal conditions of the knee. CT is useful when MRI is contraindicated or unavailable. Ultrasound, arthrography and bone scintigraphy can help in some diseases, as well as bone, synovial fluid or other tissue biopsies.
Arthrocentesis:
Arthrocentesis is the process of puncturing a joint to remove fluid. In case of spillage, the liquid can be extracted by performing a correct arthrocentesis. The synovial fluid test allows you to exclude an infection, diagnose crystal-induced arthritis and determine the cause of joint effusion. This procedure is indicated in all patients with acute or unexplained monoarticular effusion and in those with unexplained polyarticular effusion.
Arthrocentesis is performed with a strictly sterile technique. An infection or other type of rash on the site of joint entry is a contraindication. Preparation should be made to collect the sample before beginning the procedure. Local anesthesia is used, with lidocaine and / or difluoroethane aerosol. Many joints are punctured on the extension surface to avoid nerves, arteries and veins, which are usually located on the flexion surface of the joint. It is possible to use a 20 gauge needle on most large joints. The small joints of the upper and lower extremities are easier to access with a 22 or 23 gauge needle. As much fluid as possible should be removed. Specific anatomical repairs are used (eg, see figure Arthrocentesis of the shoulder., See figure Arthrocentesis of the elbow. And see figure Arthrocentesis of the knee.). It has been shown that ultrasound guidance increases joint fluid performance.
Synovial fluid test:
The macroscopic characteristics of synovial fluid, such as its color and clarity, can be evaluated at the patient's bedside.
The macroscopic characteristics allow a tentative classification of the spill into non-inflammatory, inflammatory or infectious (see Classification of synovial effusions). The spill can also be hemorrhagic. Each type of effusion suggests a type of joint disease (see Differential diagnosis based on synovial fluid classification *). Non-inflammatory effusion may present with mild inflammation, but suggests diseases such as osteoarthritis, in which the inflammation is not severe.
Laboratory studies performed on joint fluid include cell counts, differential white blood cell count, Gram stain and culture (if infection is suspected) and fresh smear examination for cells and crystals. However, exact tests depend on the suspected diagnosis.
Microscopic examination of a fresh wet smear of synovial fluid for crystals (a single drop of joint fluid is required) with polarized light is essential for the definitive diagnosis of gout, calcium pyrophosphate arthritis and other crystal-induced arthritis. A polarizer is placed on the light source and another between the sample and the eye of the examiner. This allows the crystals with bright white birefringence to be visualized. To achieve a compensated polarized light, a first-order red plate, of the type of commercial microscopes, is inserted. The effects of a compensator can be reproduced by placing 2 bands of transparent adhesive strip on a slide located on the lower polarizer. This home system should be compared with a commercially used polarized light microscope.
The most frequent crystals are those that indicate a diagnosis of gout (monosodium urate, needle-shaped crystals of negative birefringence) and calcium pyrophosphate arthritis (calcium pyrophosphate, rhomboidal crystals or sticks with positive birefringence or without birefringence). If atypical crystals are seen in a fresh smear, less common crystals (cholesterol, liquid lipid crystals, oxalate, cryoglobulins) or artifacts (eg, slow-release corticosteroid crystals) should be considered.
Other findings in synovial fluid that sometimes indicate or suggest a specific diagnosis are the following:
- Specific microorganisms (identifiable in Gram stain or acid-resistant)
- Spicules or medullary fatty cells (caused by a fracture)
- Reiter cells (monocytes in smears with Wright stain that have phagocyted to PMN), more frequent in reactive arthritis
- Fragments of amyloid (identifiable with staining with Congo red)
- Sickle red blood cells (caused by sickle hemoglobinopathies).
