Radiological Features of Joint Diseases

Osteoarthritis is a joint disease that can be identified through four core features on plain x-ray examination. These features include loss of joint space, osteophyte formation, subchondral sclerosis, and subchondral cyst formation. All of these features are present on the x-ray, making osteoarthritis the correct diagnosis.

Chondrocalcinosis, on the other hand, is characterized by calcium deposition in structures such as the cartilage. In gout, x-rays may only show soft tissue swelling, but chronic inflammation can lead to punched out lesions in juxta-articular bone. Late-stage gout is characterized by tophi formation and joint space narrowing.

In rheumatoid arthritis, plain films can show soft tissue swelling, juxta-articular osteoporosis, and loss of joint space. As the disease progresses, the destructive nature of the disease can lead to bony erosions, subluxation, and massive deformity. Septic arthritis, an infective process, can be identified through early plain film radiographic findings of soft tissue swelling around the joint and a widened joint space from joint effusion. With the progression of the disease, joint space narrowing can occur as articular cartilage is destroyed.

A certain percentage of individuals diagnosed with SLE exhibit positivity for rheumatoid factor.

Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive and useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%) but less sensitive (70%). Anti-Smith testing is also highly specific (>99%) but has a lower sensitivity (30%). Other antibody tests that can be used include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, and a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Overall, these investigations can help diagnose and monitor SLE, allowing for appropriate management and treatment.

Warning Signs of Craniovertebral Instability in Down’s Syndrome

Warning signs of craniovertebral instability or myelopathy in individuals with Down’s syndrome include neck pain, abnormal head posture, reduced neck movements, deterioration of gait, increased frequency of falls, and deterioration of manipulative skills. While the term atlantoaxial instability is sometimes used, occipitoatlantal subluxation is also a concern, making craniovertebral instability the preferred term.

Cervical spine x-rays are often unreliable, and primary care referrals can result in delays in reporting. Therefore, any clinical abnormality should be enough to warrant a referral to a specialist team. While neck exercises, simple analgesia, and physiotherapy may be helpful in cases of muscular neck pain, it is important to rule out craniovertebral instability first. Early detection and intervention can prevent further complications and improve outcomes for individuals with Down’s syndrome.

The rheumatoid arthritis guidelines were updated by NICE in 2018, with a new recommendation for the initial treatment approach. Instead of dual DMARD therapy, they now suggest DMARD monotherapy with a brief course of bridging prednisolone.

Rheumatoid arthritis (RA) management has been transformed by the introduction of disease-modifying therapies in recent years. Patients with joint inflammation should begin a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy, and surgery.

In 2018, NICE updated their guidelines for RA management, recommending DMARD monotherapy with or without a short course of bridging prednisolone as the initial step. Previously, dual DMARD therapy was advocated. To monitor response to treatment, NICE suggests using a combination of CRP and disease activity (using a composite score such as DAS28).

Flares of RA are often managed with corticosteroids, either orally or intramuscularly. Methotrexate is the most commonly used DMARD, but monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis. Other DMARDs include sulfasalazine, leflunomide, and hydroxychloroquine.

TNF-inhibitors are indicated for patients who have had an inadequate response to at least two DMARDs, including methotrexate. Etanercept is a recombinant human protein that acts as a decoy receptor for TNF-α and is administered subcutaneously. Infliximab is a monoclonal antibody that binds to TNF-α and prevents it from binding with TNF receptors, and is administered intravenously. Adalimumab is also a monoclonal antibody, administered subcutaneously. Risks associated with TNF-inhibitors include reactivation of tuberculosis and demyelination.

Rituximab is an anti-CD20 monoclonal antibody that results in B-cell depletion. Two 1g intravenous infusions are given two weeks apart, but infusion reactions are common. Abatacept is a fusion protein that modulates a key signal required for activation of T lymphocytes, leading to decreased T-cell proliferation and cytokine production. It is given as an infusion but is not currently recommended by NICE.

A lesion in the common peroneal nerve can result in a reduction in the strength of both foot dorsiflexion and foot eversion.

Understanding Common Peroneal Nerve Lesion

A common peroneal nerve lesion is a type of nerve injury that often occurs at the neck of the fibula. This condition is characterized by foot drop, which is the most common symptom. Other symptoms include weakness of foot dorsiflexion and eversion, weakness of extensor hallucis longus, sensory loss over the dorsum of the foot and the lower lateral part of the leg, and wasting of the anterior tibial and peroneal muscles.

Understanding Lumbar Disc Prolapse and Differential Diagnosis

Lumbar disc prolapse occurs when a herniated disc in the lumbosacral spine compresses a lumbar nerve root, resulting in sciatica symptoms such as unilateral leg pain, numbness, weakness, and loss of tendon reflexes. The most common level affected is L5/S1, and pain is usually relieved by lying down. Differential diagnosis includes osteoarthritis, osteomalacia, osteoporosis, and spinal stenosis. Osteoarthritis may cause localized back pain without radiation or sensory loss, while osteomalacia presents with raised alkaline phosphatase and parathyroid hormone levels and low 25-hydroxycholecalciferol levels. Osteoporosis is unlikely in a young patient and doesn’t typically cause pain. Spinal stenosis is a disease of the elderly, presenting with pseudo claudication and a negative straight leg raising test.

The patient is presenting with arthritis-dermatitis syndrome, which is a symptom of disseminated gonococcal infection. This infection can manifest in two forms: bacteraemic and septic arthritis. The former is more common, with up to 60% of patients presenting with it. Symptoms can appear within one day to three months after initial infection, and up to 80% of women with gonorrhoea may not experience any genitourinary symptoms.

The most common symptom of arthritis-dermatitis syndrome is migratory arthralgias, which are typically asymmetrical and affect the upper extremities more than the lower extremities. Pain may also occur due to tenosynovitis. The associated rash is painless and not itchy, consisting of small papules, pustules or vesicles. A pustule with an erythematous base on the hand or foot can be a helpful diagnostic clue.

Symptoms may resolve spontaneously in 30-40% of cases or progress to septic arthritis in one or more joints. Unlike Staphylococcus aureus septic arthritis, gonococcal arthritis rarely leads to joint destruction.

Gout, reactive arthritis, rheumatoid arthritis, and tuberculous arthritis are all incorrect diagnoses. Gout typically presents as an acute monoarthritis, reactive arthritis is an autoimmune condition that develops in response to a gastrointestinal or genitourinary infection, rheumatoid arthritis affects small joints symmetrically, and tuberculous arthritis usually involves only one joint, with the spine being the most common site of skeletal involvement in tuberculosis.

Falls in the Elderly: Causes, Risk Factors, and Prevention

As people age, they become more prone to falls, which can result in injuries and affect their confidence and independence. In fact, around one-third of elderly individuals living in the community experience falls every year. Gait abnormalities are one of the primary causes of falls, which can be due to medical problems affecting the neurological and musculoskeletal systems, as well as the processing of senses such as sight, sound, and sensation. Other risk factors for falling include lower limb muscle weakness, vision problems, balance/gait disturbances, polypharmacy, incontinence, fear of falling, depression, postural hypotension, arthritis in lower limbs, psychoactive drugs, and cognitive impairment.

To prevent falls, it is crucial to limit these risk factors where possible and conduct a falls risk assessment for all patients, especially those in hospitals or homes. The assessment should include a thorough history of the patient’s falls, systems review, past medical history, and social history. Medication reviews are also essential to reduce the chances of falling again, particularly for patients on more than four drugs. Medications that cause postural hypotension and those associated with falls due to other mechanisms should be stopped or swapped.

When examining a patient who has fallen, a full A to E approach and assessment of all systems are necessary to rule out the cause. Investigations to consider include bedside tests, bloods, and imaging. NICE CKS recommendations suggest identifying all individuals who have fallen in the last 12 months and assessing their risk factors. For those at risk, completing the ‘Turn 180° test’ or the ‘Timed up and Go test’ and offering a multidisciplinary assessment by a qualified clinician are recommended. Individuals who fall but do not meet these criteria should be reviewed annually and given written information on falls.

Trochanteric bursitis is characterized by pain in the lateral hip/thigh area, accompanied by tenderness specifically over the greater trochanter. This condition, also known as greater trochanteric pain syndrome, typically presents as a localized issue and doesn’t affect the patient’s overall health.

Iliotibial band syndrome, on the other hand, primarily affects the knee and is unlikely to cause nighttime symptoms. Additionally, it is not common in patients of this age group.

Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve and typically results in numbness or tingling sensations, rather than pain.

Osteoarthritis is not typically associated with pain upon direct pressure over the greater trochanter.

Understanding Greater Trochanteric Pain Syndrome

Greater trochanteric pain syndrome, also known as trochanteric bursitis, is a condition that results from the repetitive movement of the fibroelastic iliotibial band. This condition is more prevalent in women aged between 50 and 70 years. The primary symptom of this condition is pain on the lateral side of the hip and thigh. Additionally, tenderness can be felt when the greater trochanter is palpated.

Dactylitis, which is often described as a ‘sausage-shaped’ digit, is not typically associated with gout affecting the middle toe. Gout most commonly affects the first metatarsophalangeal joint. Additionally, the patient’s lack of systemic symptoms, long-standing history, and localized erythema make septic arthritis, which can be linked to diabetes, an unlikely diagnosis. Dactylitis is not a characteristic symptom of rheumatoid arthritis.

Dactylitis is a condition characterized by inflammation of a finger or toe. The causes of this condition include spondyloarthritis, such as Psoriatic and reactive arthritis, sickle-cell disease, and other rare causes like tuberculosis, sarcoidosis, and syphilis.