tbl 1 joint pain
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TBL 1TBL 1
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TriggerTriggery A 40-year-old man is complaining left hip pain on
walking for the past one year. The pain was initially mildbut the last two months, the pain is worsening. He hasto use a walking stickto ambulate. Due to the pain, he isalso having difficultyon squatting.
y He claims that he was diagnosed to have dislocation ofhis left hip joint following a fall from a height three yearsago. As his place of staying is far to reach to the hospital,his dislocated hip joint was delayed for more than 12hours to be reduced by the doctor upon admission tothe A&E unit.
y No pain elsewhere to anyother parts of the body. Nomorning stiffness to the joints of the fingers. No stiffnessof the back.
y No historyof night sweats, loss of appetite, and weight.
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y Examination revealed the following findings: Trendelenburgs sign is elicitedon the left side.
Movement ofleft hip joint:x R
ange from 0 90degrees on flexion, 0 20degrees onexternal rotation, 0 15degrees on internal rotation
y X-rayofleft hip is taken and showsabnormalities of the femoral head.
y
Blood investigations done revealed normallevel ESR and white count.
y He is advised to undergone surgery but herequested todelay the surgery.
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ANATOMIC
AL
ANATOMIC
AL
STRUCTURES OF THE HIPSTRUCTURES OF THE HIP
JOINT THAT RELATED TOJOINT THAT RELATED TO
THIS PATIENT PROBLEMTHIS PATIENT PROBLEM
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WHY HE H
AD LEFT HIP
WHY HE H
AD LEFT HIPJOINT PAIN?JOINT PAIN?
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Why he hadleft hip joint pain?Why he hadleft hip joint pain?
y His dislocated hip joint was delayed for morethan 12 hours to be reduced local bloodsupply to femoral head is disrupted for too
long - the bone cells die - develop AVNy Early AVN usually causes very mild symptoms
(groin pain) or no symptoms at all. Later on,
the patients develop constant and veryintensive groin pain. Successively, patients withAVN develop symptoms as with hiposteoarthritis.
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y The secondary OA develops after previous
damage to the hip joint in which the bone
and cartilage do not heal properly. The joint
is nolonger smooth and these irregularitiesultimatelylead to more wear on the joint.
y the pain in early stage is due to
inflammation of the synoviallining. In the
later stages, when the cartilage is worn away,
the pain and stiffness come from the friction
of raw bones grinding on each other.
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WHY THE P
AIN
IS ON
LYW
HY THE PA
IN
IS ON
LYEXPERIENCED ONEXPERIENCED ONWALKING?WALKING?
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y At rest no movement no pressure
applied
y On walking - apply more pressure and
friction occur in the joint cause pain
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Is there any relationship of previousIs there any relationship of previous
trauma with his current problem?trauma with his current problem?
Yes.Hip dislocation
Late complication:Avascular necrosis
Secondaryosteoarthritis
Delayed reduction
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ETIOLOGICAL CAUSES OFETIOLOGICAL CAUSES OF
CHRONIC JOINT PAINCHRONIC JOINT PAIN
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Etiologyof chronic joint painEtiologyof chronic joint pain
1. Degenerative osteoarthritis ( primary
and secondary)
2. Rheumatoid arthritis
3. Crystalline deposition arthropathy
4. Haemophilic arthritis
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Degenerative osteoarthritisDegenerative osteoarthritis
Clinical presentation:
a. History: Age: primary OA: over 50; secondary OA:
can occur at 30or even 20 Pain:
x felt at groin may radiate toknee
x Occurs after periodof activity later becomes
constant Stiffness noticed after rest ( increase
progressively until putting on socks & shoesbecomes difficult)
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b. Physical examination:
Positive trendelenburgs sign
Limb: lies in external rotation & adduction (
appears short), some fixed flexion
Rarely : muscle wasting
Tenderness upon deep pressure
Restricted movements
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painpain
c. Investigations: X- ray:
x 4 CARDINAL SIGNS:
x Assymetrical narrowing of the joint space
x Sclerosis of subchondral bone
x Cysts
x Osteophytes
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What isWhat is trendelenburgtrendelenburg sign?sign?
y To checkefficacyof the abductor mechanism of hip.
y Demonstrate by: asking the pt to standon affectedleg with the
normalleg liftedoff the ground
y Normally: when one leg is liftedoffthe centre of gravity shifts
to the opposite side abductor mechanism contracts pullsthe pelvis down on the stance side moves opposite pelvis togo up
y If the abductor mechanism fails opposite pelvis drop down
y Seen in gluteus medius palsy, fracture neckof femur, arthritis ofhip anddislocations of hip.
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RheumathoidRheumathoid arthritisarthritisy Clinical presentation:
History:
x Usually woman of30-40years old with pain, swelling andloss ofmobility in proximal joints of fingers ( commonly: MP joints , PIP
joints of fingers, wrist, knees, elbows and ankles). Previous historyofmuscle pain, tiredness, LOW.
Physical examination:
x Hand:
x ulnar deviation of fingers and hands
x
Boutonniere deformityx Swan neckdeformity
x z deformityof thumb
x Triggers fingers & thumb
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y Elbow: flexion deformity
y Knees: triple deformity (1) flexion at the knee
2) posterior subluxation of the tibia3) external rotation of tibia(abduction)
y Ankle: Equinus deformity
y Foot: valgus feet, hammer toe, Hallux valgus (bunions)
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y Extra-articular features
Rheumatoid nodule(underskin/tendon/sclera/viscera)
Lymphadenopathy
Vasculitis
Muscle weakness
Visceraldisease(affectinglungs/heart/kidneys/brain/GIT)
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y Investigation:
Lab test: low Hb, elevated ESR, CRP andRh factor
Radiological features: reduced joint space, erosionof articular margin, subchondral cyst with juxta-articular rarefaction.
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Crystalline depositionCrystalline deposition arthropathyarthropathy
Sign & symptoms Joint involved Investigations
Gout (urate
crystals)
Usually male40yo
Acute: sudden pain & sweelingof MT-PH joint of big toe, ankle,
or olecranon bursaeChronic: recurrent attacks,
chronic pain, stiffness &deformities of joints
tophy
MT-Ph joint ofbig toe, ankle,
olecranonbursae * pinnae
ears
X ray ( chronicgout) : increase joint
spaceIncrease serum uric
acisSynovial fluid urate
crystals
Pseudogout (
calciumpyrophosp
hate)
Like those of gout Usuallyknee (menisci &
articularcartilage)
X ray: calcificationofknee, wristm hips,
IV discSynovial fluid
birefringet crystals
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X rayof goutX rayof gout
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HaemophilicHaemophilic arthritisarthritis
y Signs & symptoms:
Young boys with positive family history
Sudden painful bilateral hemorrhagic effusion
into the knee, ankle, elbows.
y Joint involves:
Knee, elbow, ankle
y Investigations: Xray: Bone resorption, cyst formation,
osteoporosis,
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ProvisionaldiagnosisProvisionaldiagnosis
SECONDARY OSTEOARTHRITIS
yWorsening hip pain
y Positive trendelenburgs sign.
y RestrictedROM
y Increase ESR and white cell count
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WHAT CAN RESULT TO LIMITWHAT CAN RESULT TO LIMIT
JOINT MOVEMENT?JOINT MOVEMENT?(Causes of reduced range of
movement)
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Range of Movement (ROM)Range of Movement (ROM)
y Range of motion is the distance and
direction of movement of a joint
y Each specific joint has a normal range of
motion that is expressed in degrees
y Limited range of motion is a term
meaning that a specific joint or body part
cannot move through its normal range ofmotion
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ROM ofROM of HHipip JJointoint
Type of movement Normal Values (in
degrees)
This patient
Hip flexion 0-125 0 90
Hip extension 115-0
Hip hyperextension 0-15
Hip abduction 0-45
Hip adduction 45-0
Hip lateral rotation(external rotation)
0-45 0 20
Hip medial rotation(internal rotation)
0-45 0 15
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Causes of reducedROMCauses of reducedROM
y The major causes of reduced range of
movement can be categorized into three
main causes which is:
(1) SWELLING
(2) STIFFNESS
(3) PAIN
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Causes of reducedROM of HipCauses of reducedROM of Hip
JointJointy Fractures
y Dislocation
y osteoarthritis
y Rheumatoid Arthritisy Ankylosing spondylitis
y Mechanical backpain
y Septic joint (septic hip)
y Syphilis
y Legg-Calve-Perthes disease
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What actually the causes to result inWhat actually the causes to result in
femoral headdeformities?femoral headdeformities?Radiological presentation?Radiological presentation?
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FemoralFemoral HHeadead DDeformityeformity
Secondary osteoarthritis of the hip
y This is the inevitable sequel to avascular
necrosis, but may alsooccur when
dislocation of the hip is accompanied by afracture involving the articular surfaces
y It is also seen as late as 5- 10years after
injury; the cause then is less clear, but it ispossibly arise from articular cartilage
damage concurrent with the initial injury
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Radiological Presentation ChecklistsRadiological Presentation Checklists
y Center-Edge Angle
y Acetabular Head Index
y Acetabular Angle
y Mechanical Sharp Angley Head Lateral Shift
y Head Superior Shift
y Pelvic Anteroposterior Tilt
y Pelvic Lateral Tilt
y Leg-Length Discrepancy
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Mild flattening of the superior aspect of the femoral head is presentMild flattening of the superior aspect of the femoral head is present
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Avascular necrosis with secondaryosteoarthritisAvascular necrosis with secondaryosteoarthritis
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DiscussDiscuss the related pathogenesis /the related pathogenesis /
pathological process in thispathological process in thispatientpatient
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Secondary OsteoarthritisSecondary Osteoarthritis
y The term secondaryosteoarthritis is appliedwhen an underlying recognizable localorsystemic factor exists
y
These include conditions leading to jointdeformityor destruction of cartilage,followed by signs and symptoms typicallyseen with primaryosteoarthritis
y
In secondaryosteoarthritis a younger agegroup is generally involved than in the caseof primaryosteoarthritis
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Secondary OsteoarthritisSecondary Osteoarthritis
Examples of preexisting conditions leading to secondaryosteoarthritis changes in joints include:
y acute and chronic trauma
y Legg- Clave- Perthes disease
y developmentaldysplasia of the hip
y rheumatoid arthritisy bleeding dyscrasias
y Achondroplasia
y Infection
y crystaldeposition disease
y neuropathic disorders
y overuse of intaarticular steroids
y multiple epiphysealdysplasia
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HowHow to assess clinically: History,to assess clinically: History,
examination & investigationexamination & investigation
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History takingHistory taking
PAIN
y Onset
y Nature / Character
y Site
y Intensity
y Aggravating & relieving factors
y Referred pain
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Physical ExaminationPhysical Examination
General Examination
y Look
y Feel
y Move
Specific Examination
y Trendelenburgs hip test
y Thomas test for FFD of hip
y Limb length measurement
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InvestigationInvestigation
y Full Blood Count (FBC)
y Renal Profile
y Erythrocyte sedimentation rate (ESR)
y C- Reactive Protein (CRP)
y VDRL
y Rheumatoid factor
y Urinalysis
y Radiology (X- Ray, CT Scan & MRI)
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y Is ESR & white count important
investigation?
yWhat doyou thinkthe possible surgical
treatment being offered?
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y Children
Newborn : 0 to2 mm/hr
Neonatal to puberty: 3 to13 mm/hr
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Does it important todo it?Does it important todo it?
y Yes /no
y Because ESR is an important indicator
when a condition or disease is suspected
of causing inflammation.
y it rarelyleads directly to a specific
diagnosis.
y However , It can also be important as apreoperative assessment.
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y Conditions which increases ESR
Rheumatoid arthritis
Multiple myeloma
polymyalgia rheumatica
Osteomyelitis
tuberculosis
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White blood countWhite blood count
y The white blood count for this patient is
within the normal range.
The wbc is also not an important indicator.
yWhy
As the increase of the level indicates infectionwhether it is caused by bacteria or even virus.
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TreatmentTreatment
y Early
y Intermediate
y Late!!
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EarlyEarly
y 3 principles Relieve pain
Increased movements
Reduce load
y Relieve pain NSAIDsx Reduce the congestion in the subchondral bonex Drawbackulceration and bleeding (git)
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y Joint mobility
Increased range and power reduce pain andimprove function
y Load reduction Walking stick
Wearing soft-soled shoes
Avoiding prolonged, stressful activity
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IntermediateIntermediate
y Symptoms increaseddespite the
conservative treatment
y Realignment osteotomy
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LateLate
y Indication for radical surgery are
unrelieved pain and progressive disability
y Total hip joint replacement (arthroplasty)
is the operation of choice.y Arthrodesis is occasionally indicated if
stiffness is not a drawback
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Thankyou~~~~