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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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288
ACUTE SINGLE
JOINT PAIN
The GP overview
is is a very common problem in primary care. Usually, there are few physical signs, although
occasional ly a genuine monoarth ritis with a ll the cla ssical sig ns of ina mmation wi ll present. Overa ll,
the most likely aetiolog ical factor is trau ma, though other conditions may al ready aect a joint. I n the
elderly, an exacerbation of osteoarth ritis is common; thi s condition may also cause multiple joint pai n.
e knee is probably the single most frequently aected joint.
Differential diagnosis
COMMON
acute exacerbation of osteoarthritis (OA)
traumatic synovitis
gout/pseudogout
chondromalacia patellae (CP) and other anterior knee pain syndromes
traumatic haemarthrosis (e.g. aer cruciate ligament injury)
OCCASIONAL
fracture
Reiter’s disease
psoriatic arthritis
rheumatoid arthritis (RA)
patellar tendinitis, Osgood–Schlatter’s disease
RARE
septic arthritis (SA)
haemophilia
local tropical infections (e.g. Madura foot [mycetoma pedis], lariasis)
malignancy (usually secondary)
avascular necrosis
recurrent joint subluxation
.
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ACUTE SINGLE JOINT PAIN 289
Ready reckoner
OA CP/anterior
knee pain
Traumatic
synovitis
Gout Traumatic
haemarthrosis
Sudden onset Possible No Ye s Possible Ye s
History of acute trauma Possible No Ye s Possible Ye s
Recurrent problem Yes Yes No Ye s No
Several joints painful Possible No No Possible No
Hot, red joint No No No Ye s Possible
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, uric acid, X-ray, joint aspiration (in monoarthritis of large joint).
SM A L L PR I N T: Rheumatoid factor/anti-CCP antibodies, clotting studies/factor VIII assay,
arthroscopy.
FBC/ESR/CRP: WCC and ESR/CRP raised in infection, systemic inammatory
conditions; Hb may be reduced in the latter.
Uric acid: Once attack has subsided, useful to add weight to clinical diagnosis of gout
(especially if considering treatment with allopurinol).
Rheumatoid factor may be useful if symptoms suggest possible RA (consider anti-CCP
antibodies if rheumatoid factor is negative).
X-ray: Essential if fracture suspected. May also reveal OA, avascular necrosis, malignancy
and help to distinguish between RA and psoriatic arthritis.
Sterile aspiration of joint uid: To look for pus (septic arthritis), blood (haemarthrosis) and
crystals (gout/pseudogout).
Clotting studies/factor VIII assay: If haemophilia a possibility.
Arthroscopy: May be required urgently in secondary care if trauma has resulted in a
haemarthrosis.
TOP TIPS
Autoimmune blood tests can be misleading in possible arthritis. e diagnosis should
be clinical; blood testing simply adds weight and prognostic information to the clinical
assessment. Positive tests can be found in normal patients – beware of inappropriately
labelling an insignicant problem as a signicant arthritis on the basis of a blood test.
Gout is very painful, will limit movement and may cause a slight fever. Septic arthritis gives
a similar picture but with marked restriction of movement and, usually, a high fever. If in
doubt, arrange urgent assessment.
In obscure cases, question and examine the patient carefully. For example, in Reiter’s disease,
symptoms of urethritis or conjunctivitis may have been minimal or forgotten; in psoriatic
arthritis, there may only be insignicant skin lesions.
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290 SYMPTOM SORTER
If one joint is red, very hot, intensely painful with marked limitation of movement and
systemic illness, septic arthritis must be excluded – admit.
Haemarthrosis usually develops rapidly aer trauma and indicates signicant damage
requiring immediate referral; eusion due to synovitis usually takes a day or longer to
accumulate and is less urgent.
Septic arthritis is notoriously easy to miss in a patient with coexisting RA. e systemic
signs may be absent and the diagnosis may mistakenly be viewed as a are-up of rheumatoid
arthritis.
A young adult male with a monoarthritis of the knee not caused by trauma is likely to have
Reiter’s disease.
NOTES:
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291
ARM AND
SHOULDER PAIN
The GP overview
Arm pain is a common presentation with a wide dierential. Many generalised disorders, such
as arthritis, neuropathy and polymyalgia, cause widespread symptoms, which may involve the
arm – these are not considered here. Instead, this section concentrates on pain specic to the
arm, or pain characteristically referred to the arm.
Differential diagnosis
COMMON
simple muscular strain
epicondylitis (tennis or golfer’s elbow)
subacromial bursitis/capsulitis
cervical spondylosis
angina
OCCASIONAL
bicipital tendonitis
acromioclavicular and sternoclavicular joint pain
acute calcic tendonitis
de uervain’s tenosynovitis
carpal tunnel (CT) syndrome
cervical rib
brachial and ulnar neuritis (including post-herpetic pain)
cervical and thoracic disc prolapse
RARE
GORD
malignancy: local bone cancer, spinal cord, spine and lung
subclavian aneurysm
multiple sclerosis
syphilitic aortitis
thoracic outlet syndrome
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292 SYMPTOM SORTER
Ready reckoner
Epicondylitis Muscle strain Cervical spondylosis Bursitis/capsulitis Angina
Worse moving arm/hand Ye s Yes Possible Ye s No
Hand paraesthesiae No No Possible No Possible
Exercise related Possible Possible No Possible Yes
Local arm tenderness Ye s Possible No Possible No
Limitation of movement Possible Possible Possible Ye s No
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, TFT, ECG/secondary care cardiac investigations, nerve conduction
studies, chest and neck X-ray.
SMALL PRINT: Other X-rays/bone scan, MRI scan, lumbar puncture, syphilis serology.
FBC, ESR/CRP: May be anaemia and raised ESR/CRP ininammatory or malignant
conditions.
TFT: Myxoedema and carpal tunnel syndrome signicantly associated.
Neck X-ray sometimes useful to conrm diagnosis of cervical spondylosis and assess its
severity: But cervical spondylosis on X-ray does not correlate well with symptoms and may
just be an incidental nding.
ECG/secondary care cardiac investigations: To pursue possible diagnosis of angina.
Nerve conduction studies: Will help conrm nerve entrapment (e.g. carpal tunnel).
CXR: For apical tumour.
Other X-rays/bone scans: If bony tumour (especially secondaries) suspected. Calcium
deposits may be seen in acute calcic tendonitis.
MRI scan, lumbar puncture: If MS suspected; scanning may also be helpful to visualise
possible cord lesion (all likely to be arranged aer specialist referral).
Syphilis serology: In the rare case of possible syphilis.
TOP TIPS
It is tempting to view arm pain as a welcome ‘quickie’; in fact, a careful history is important
to exclude the more unusual serious pathologies and the examination should usually serve
only to conrm an already formulated diagnosis.
Patients with arm pain – especially if it is accompanied by intermittent paraesthesiae – are
oen inappropriately concerned that the diagnosis may be angina or a stroke. Make sure
these fears are properly explored.
e natural history of many of the more common problems (e.g. subacromial bursitis,
epicondylitis) can be quite prolonged. Making this clear from the outset helps maintain the
patient’s trust in you if the symptoms do take some time to settle.
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ARM AND SHOULDER PAIN 293
Getting the patient to indicate the site of pain is a useful ploy in shoulder discomfort.
Diuse pain is typical of capsulitis and subacromial bursitis, whereas, with sternoclavicular
or acromioclavicular joint problems, or bicipital tendonitis, the area is more likely to be very
localised.
Beware of persistent paraesthesiae with arm pain, especially if the patient also complains of
arm or hand weakness; either there is serious nerve compression or some other signicant
neurological pathology.
Angina may present only with arm pain. Enquire carefully to establish the pattern of the
pain.
Apical lung tumour (Pancoast tumour) may cause severe arm pain long before any signs are
evident. Investigate smokers with unexplained arm pain.
Consider the other less common diagnoses if the pain is severe and persistent, the diagnosis
is not obvious from the history and the patient displays unrestricted arm movements.
NOTES:
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294
CALF PAIN
The GP overview
Calf pain is usually innocent, except when accompanied by swelling. It is oen caused by cramp,
which is especially common in the elderly. In this group it can cause signicant distress, through
the havoc wreaked on sleep. Some of the less likely diagnoses, such as peripheral vascular disease,
have important implications, so careful assessment is necessary.
Differential diagnosis
COMMON
idiopathic (simple) cramp (including night cramps)
muscle stiness (unaccustomed exercise)
cellulitis
peripheral vascular disease (PVD; intermittent claudication)
muscle injury (e.g. strain)
OCCASIONAL
referred back pain (L4 and 5)
referred knee pain (arthropathy, infection)
alcoholic or diabetic neuropathy
cramps caused by underlying hypocalcaemia or electrolyte imbalance
ruptured Baker’s cyst
deep vein thrombosis (DVT)
thrombophlebitis
growing pains in children
RARE
motor neurone disease
multiple sclerosis
muscle enzyme deciency
psychological: muscle tension
lead and strychnine poisoning
ruptured Achilles tendon
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CALF PAIN 295
Ready reckoner
Cramp Stiffness Cellulitis Muscle injury PVD
Worse at night Ye s No No No No
Systemically unwell No No Possible No No
Worse with exercise Possible Ye s Possible Ye s Yes
Calf swelling No No Ye s Possible No
Cool peripheries No No No No Yes
Possible investigations
LI KE LY: None.
POSSIBLE: Urinalysis, WCC, ESR /CRP, U&E, calcium, LFT, blood glucose or HbA1c, D-dimer.
SMALL PRINT: Ultrasound, venogram, angiography.
Urinalysis: Check specic gravity, glucose and protein (over and under-hydration, diabetes,
renal failure as occasional causes of ‘simple’ cramp).
WCC and ESR/CRP: Both raised in infection. ESR/CRP raised in arthropathy.
U&E and calcium: Check renal function and electrolyte imbalance (e.g. from diuretics;
hypocalcaemia).
LFT and blood glucose or HbA1c: If suspect alcoholism or diabetes resulting in a neuropathy.
D-dimer (usually in hospital): A raised level suggests a DVT, but is not conclusive.
Ultrasound/venogram: Further tests to diagnose DVT, performed in secondary care.
Angiography will be arranged by the specialist if peripheral vascular disease is suspected.
TOP TIPS
Bear in mind that many patients will be anxious about the possibility of DVT – reassure
them about this if the diagnosis clearly lies elsewhere
Save the patient unnecessary investigation and possible anticoagulation by taking a careful
history. A muscle tear and a DVT can both produce calf swelling and warmth. e former,
though, is preceded by a dramatic and sudden pain in the calf, sometimes described as being
like a kick or a gunshot.
It can be dicult to distinguish a simple muscle strain from claudication. Muscular pains
tend to produce discomfort as soon as the patient stands; claudication usually starts aer the
patient has walked a predictable distance.
Patients with supercial phlebitis will fear the more serious DVT. Explain the dierence
to them.
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296 SYMPTOM SORTER
Consider investigating the adult patient with recent onset of apparently simple cramps if
associated with general malaise (these will be in the minority).
Claudication accompanied by nocturnal pain in the ball of the foot suggests critical
ischaemia – refer urgently.
If the clinical picture suggests a DVT then refer urgently either to A&E or according to your
local DVT pathway.
Do not overlook Achil les rupture. e presentation may sometimes be less dramatic than you
would expect. Use the calf squeeze test to ensure that the tendon is intact.
NOTES:
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297
FOOT PAIN
The GP overview
Pain in the foot is dicult for patients to ignore and so will oen present with a relatively short
history. Local causes predominate, but remember to think further aeld: Referral through S1
(lateral border of the foot) and L5 (dorsum of the foot to the big toe) nerve roots may occur.
Ankle pain is not considered here.
Differential diagnosis
COMMON
gout
verruca
bunion/hallux valgus
infected ingrowing toenail (IGTN)
plantar fasciitis
OCCASIONAL
Morton’s neuroma
metatarsalgia
arthritis (osteo and rheumatoid)
Achilles tendonitis/bursitis
oedema
foreign body
RARE
march fracture
Sever’s disease (apophysitis of the calcaneus), usually a problem of adolescence
osteochondritis: navicu lar = Köhler’s disease; head of second or third metatarsa l = Freiberg’s
disease
osteomyelitis and septic arthritis
erythromelalgia and painful polyneuropathy
ischaemia
https://t.me/med1917
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