++
The various causes of the painful arm can be considered with the diagnostic model (Table A12).
++
++
-
Usually 2–5 yrs
-
Child refuses to use arm
++
-
Parental help
-
Support elbow with one hand, flex elbow then suddenly twist forearm into full supination or
-
Gently alternate supination and pronation
++
Note: If uncooperative, send home in sling (may resolve itself)
++
-
Rest from offending activity
-
RICE and oral NSAIDs if acute
-
Exercises-strengthening, e.g. dumbbell exercise over table—palm facing down for lateral epicondylitis; palm facing up for medial epicondylitis or towelette wringing exercise
++
Additional (if refractory):
++
++
For chronic recurrent traumatic bursitis with a synovial effusion:
++
++
Consider an injection of 1 mL of long-acting corticosteroid with LA into the tendon sheath adjacent to the swelling.
+++
Raynaud phenomenon and disorder
++
Exclude and treat underlying causes, e.g. CTDs.
++
-
Total body protection from cold
-
Gloves and thick woollen socks
-
Avoid smoking
-
Vasodilators (e.g. amlodipine (o) 5–20 mg/d or nifedipine SR 30–60 mg/d) in cold weather
-
Topical glyceryl trinitrate ointment—over radial artery or dorsum of hand
-
Consider sympathectomy
+++
Carpal tunnel syndrome
++
Exclude rheumatoid, granulomatous disorders, endocrine disorders, Paget disease, hypothyroidism, amyloidosis
++
-
Surgical decompression (best)
-
Injection of LA corticosteroid into tunnel
-
US therapy
-
Neutral wrist splints (bedtime)
+++
Arthralgia/arthritis: diagnostic strategy model
+++
Probability diagnosis
++
+++
Serious disorders not to be missed
++
-
Infection:
-
Cancer:
-
bronchogenic carcinoma
-
leukaemia/lymphoma
-
secondary malignancy
++
++
-
rheumatoid arthritis (RA)
-
connective tissue disorders: SLE, scleroderma, polymyositis and dermatomyositis, other
+++
Pitfalls (often missed)
++
++
Note the pattern of joint involvement (monoarticular or polyarticular), immediate and more recent history, family history and drug use.
++
Enquire whether the joint pain is acute or insidious and confined to specific joints or fleeting as in rheumatic fever.
++
A systematic examination of the affected joint or joints should look for signs of inflammation, deformity, swelling and limitation of movement.
++
Searching for associated systemic disease such as connective tissue disorders and infection demands examination of the chest, heart and abdomen.
++
-
FBE
-
EBR & CRP
-
Uric acid
-
Urine analysis
-
Joint X-rays
-
Synovial fluid analysis and culture
-
RA factor
-
Autoantibodies (ANA, dsDNA, ENA), anti-CCP antibody (for RA)
-
Other tests according to findings of tests for infection (e.g. specific serology, blood culture)
++
Red flag pointers for polyarthritis
++
-
Explanation: patient education and reassurance that arthritis is not the crippling disease perceived by most patients.
-
Rest: during an active bout of inflammatory activity only.
-
Exercise: a graduated exercise program is essential to maintain joint function. Aim for a good balance of relative rest with sensible exercise.
-
Heat: recommended is a hot water bottle, warm bath or electric blanket to soothe pain and stiffness. Advise against getting too cold.
-
Diet: if overweight it is important to reduce weight to ideal level.
-
Physiotherapy: referral should be made for specific purposes such as exercises and supervision of a hydrotherapy program.
-
Occupational therapy: refer for advice on aids in the home.
-
Simple analgesics (regularly for pain): paracetamol (avoid codeine or dextroproproxyphene preparations and aspirin if recent history of dyspepsia or peptic ulceration).
-
NSAIDs and aspirin: the first-line drugs for more persistent pain or where there is evidence of inflammation. The risk versus benefit equation always has to be weighed carefully. As a rule, NSAIDs should be used sparingly if possible. Aim for short courses of 14–20 d. The COX2 specific inhibitors should be considered where there is an indication for an NSAID but the risk of NSAID-induced ulceration and bleeding is high.
-
Intrarticular corticosteroids: as a rule IA corticosteroids are not recommended but occasionally can be very effective for an inflammatory episode of distressing pain (e.g. a flare-up in an osteoarthritic knee).
-
Viscosupplementation: IA hylans have a use, esp. for OA of knee.
-
Glucosamine: a natural amine-sugar, has mixed value for osteoarthritis, esp. of the knee: 1500–2000 mg/d with food, 3–4 mth trial.
-
Referral for surgical intervention: for debilitating and intractable pain or disability. Examples include OA of hip, knee, shoulder, first CMC joint of thumb and first MTP joint.
++
-
ESR usu. raised according to active disease
-
Anaemia (normochromic and normocytic) may be present
-
Rheumatoid factor— +ve in ∼70–80%, not specific
-
Anti-cyclic citrinullated peptide AB test—specific
-
X-ray changes
+++
Management principles
++
Give patient education, support and appropriate reassurance. The diagnosis generally has distressful implications so the patient and family require careful explanation and support. It should be pointed out that the majority of patients have little or no long-term problems. Refer to rheumatologist for shared care.
++
-
Rest and splinting: this is necessary where practical for any acute flare-up of arthritis.
-
Exercise: it is important to have regular exercise esp. walking and swimming. Hydrotherapy in heated pools.
-
Referral to physiotherapists and occupational therapists: expertise in exercise supervision, physical therapy and advice regarding coping in the home and work is important.
-
Joint movement: each affected joint should be put daily through a full range of motion to keep it mobile and reduce stiffness.
+++
Pharmaceutical agents
++
-
simple analgesics (e.g. paracetamol)
NSAIDs
-
glucocorticoids: prednisolone 5–10 mg (o) /d
Consider: in severe disease or failure of other agents
-
DMARDs, e.g. hydroxychloroquine
gold compounds (IM or orally)
D-penicillamine
sulfasalazine
immunosuppressive agents, e.g. methotrexate, azathioprine, cyclophosphamide, leflunomide, cyclosporin
++
Standard initial drug therapy RA
++
++
++
++
Consider: addition of a biological DMARD, e.g. adalimumab, entanercept, anakira.
+++
Connective tissue disorders
++
The main CTDs have the common feature of arthritis or arthralgia. They include SLE, scleroderma, polymyositis and Sjögren syndrome. Other common features include vasculitis and multisystem involvement. They are autoimmune diseases and should be referred for shared care.
+++
Systemic lupus erythematosus (SLE)
++
Arthritis is the commonest clinical feature of SLE (over 90%). It is a symmetrical polyarthritis involving mainly small and medium joints, esp. the proximal interphalangeal and carpal joints of the hand.
++
The initial presentation is similar to rheumatoid arthritis. If suspected, test ANA and if +ve DNA and ENA Antibodies (Abs).
++
-
ESR—proportional to disease activity
-
Antinuclear antibodies—+ve in at least 95%
-
ds DNA Abs → 95% specific for SLE but present in only 60%
-
ENA Abs, esp. Sm—highly specific
-
Rheumatoid factor—+ve in 50%
-
LE test—inefficient and not used
++
-
Mild—NSAIDs/aspirin (for arthralgia)
-
Moderate—low-dose antimalarials (e.g. hydroxychloroquine)—up to 6 mg/kg once/d
-
Moderate to severe—corticosteroids (mainstay drug); immunosuppressive drugs (e.g. azathioprine, methotrexate + folic acid)
-
Consider fish body oil 0.2 mg/kg (o) daily
++
This can present as a polyarthritis affecting the fingers of the hand in 25% of patients, esp. in the early stages. Scleroderma mainly affects the skin, presenting with Raynaud phenomenon in over 85%.
+++
Investigations (no specific diagnostic tests)
++
-
ESR may be raised
-
Antinuclear Abs → 90% +ve
-
Rheumatoid factor—+ve in 30%
-
Antinucleolar and anticentromere Abs—specific
++
-
Analgesics and NSAIDs for pain
-
Avoid vasospasm (no smoking, β blockers, ergotamine)
-
CCBs as for Raynaud
-
D-penicillamine for skin or systemic involvement
-
Proton-pump inhibitors for GORD
+++
Polymyositis and dermatomyositis
++
Arthralgia and arthritis occur in ∼50% of patients and may be the presenting feature before the major feature of muscle weakness and wasting of the proximal muscles of the shoulder and pelvic girdles appear. The small joints of the hand are usually affected and it may resemble rheumatoid arthritis. Polymyositis + associated rash = dermatomyositis.
+++
Sjögren syndrome (SS)
++
SS is the dry eyes (kerato conjunctivitis sicca) in absence of any other autoimmune disease.
++
-
Features: dry eyes, dry mouth, arthralgia
-
Diagnosis: +ve ENA. Ro (SSA). La (SS-B) Abs
-
Treatment: symptomatic for sicca; hydroxychloroquine or steroids for arthritis
++
Arthritis, which can be acute, chronic or asymptomatic, is caused by a variety of crystal deposits in joints. The three main types of crystal arthritis are monosodium urate (gout), calcium pyrophosphate dihydrate and calcium phosphate (usually hydroxyapatite).
+++
The spondyloarthropathies
++
The spondyloarthropathies are a group of disorders with common characteristics affecting the spondyles (vertebrae) of the spine. Apart from back pain this group tends to present with oligoarthropathy in younger patients (
See the spondyloarthropathies).
++
The group includes: ankylosing spondylitis; reactive arthritis; inflammatory bowel disease (enteropathic arthritis); psoriatic arthritis; juvenile chronic arthritis; unclassified spondyloarthritis—partial features only.
+++
Ankylosing spondylitis
++
This usually presents with inflammatory back pain (sacroiliac joints and spine) and stiffness in young adults and 20% present with peripheral joint involvement before the onset of back pain. It usually affects the girdle joints (hips and shoulders), knees or ankles.
+++
Key clinical features
++
-
Insidious onset of discomfort
-
Age less than 40 yrs
-
Low back pain persisting for >3 mths
-
Associated morning stiffness >30 mins
-
Improvement with exercise or NSAIDs, not relieved by rest
-
Sacroiliitis
-
Limitation of lumbar spinal motion in sagittal and frontal planes
++
This is a form of reactive arthropathy in which non-septic arthritis and often sacroiliitis develop after an acute infection with specific venereal or dysenteric organisms.
++
Reiter syndrome = NSU + conjunctivitis ± iritis + arthritis
Reactive arthritis = similar syndrome without ocular or mucocutaneous lesions
+++
Enteropathic arthritis
++
Inflammatory bowel disease (ulcerative colitis, Crohn disease and Whipple disease) may be associated with peripheral arthritis and sacroiliitis.
++
Like Reiter syndrome, this can develop a condition indistinguishable from ankylosing spondylitis. It is therefore important to look beyond the skin condition of psoriasis, for ∼5% will develop psoriatic arthropathy.
+++
Management principles of spondyloarthropathies
++
-
Identify the most active elements of the disease and treat accordingly.
-
Provide patient and family education with appropriate reassurance.
-
Refer for physiotherapy for exercises, postural exercises and hydrotherapy.
-
Pharmacological agents:
-
NSAIDs (e.g. indomethacin 75–200 mg/d) to control pain, stiffness and synovitis
-
sulfasalazine (if NSAIDs ineffective)
-
intra-articular corticosteroids for severe monoarthritis and intralesional corticosteroids for enthesopathy
-
immunosuppressive agents, e.g. methotrexate, for severe cases
++
Lyme disease (known as Lyme borreliosis) is caused by a spirochete, Borrelia burgdorferi, and transmitted by Ixodes ticks, in particular the deer tick. It is not endemic in Australia and is usually seen in travellers from affected regions.
++
Diagnostic serology should be considered for patients with a history of tick bites, typical rash (a doughnut-shaped red rash ∼6 cm in diameter) at the bitesite, heart disorders (esp. arrhythmias), unusual joint arthralgia or CNS disease (usually large joints, e.g. knees).
++
Treatment is with penicillin, tetracycline or cephalosporins (e.g. doxycycline 100 mg bd for 21 d).
++
The vasculitides or vasculitis syndromes are a heterogeneous group of disorders involving inflammation and necrosis of blood vessels, the clinical effects and classification depending on the size of the vessels involved.
++
More common causes are the small vessel vasculitis effects associated with many important diseases such as rheumatoid arthritis, SLE, infective endocarditis, Henoch–Schonlein purpura and Hepatitis B. Skin lesions and arthritis are usually associated with these disorders.
++
The major vasculitides are:
++
++
The problem is fatal kidney disease if undiagnosed. If suspected order an ANCA test.
++
Note: If a CTD or vasculitide is suspected always dipstick urine (+ blood and albumin), micro-urine and check BP. If +ve indicates kidney disease and need for referral.