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GENERAL INFORMATION
Many orthopedic problems
involve the joints, as joints serve as the junction between your
body’s bones and involve many tendons, muscles, and ligaments.
Joints allow us to bend and straighten our bodies in order to
perform coordinated movements. They also adjust during movements to
give us leverage and bear the loads as we move. Similar structures
make up almost all the joints in our bodies.
Many conditions can cause
joint pain. Several common causes found in an orthopedic setting
are described below.
RHEUMATOID
ARTHRITIS
Rheumatoid arthritis is a
chronic inflammation of the fluid membranes that surround the joints
in the body. Over time, the inflammation causes erosion of
cartilage and bone in an affected joint as well as damage to
supporting structures like ligaments and tendons. The exact cause
of rheumatoid arthritis, such as it being related to a virus or
bacteria, is not known, but it is known that it is an autoimmune
process. This means that the body reacts to its own defenses in a
negative way that leads to a further destruction and progression of
the disorder.
Anyone can have
rheumatoid arthritis, although it is often seen in families, women
of child-bearing years, and Native Americans. The joints in the
fingers, feet, wrists, knees, elbows, and ankles are most commonly
affected. Though there are many forms of rheumatoid, it is a
condition that usually starts without warning with joint pain over a
couple of months. The initial joints that are affected remain a
problem while the condition progresses to other joints in a
symmetrical fashion. It is common to experience flares and
exacerbations with periods of remissions.
Rheumatoid arthritis
causes swelling, warmth, and tenderness in the joints or sheaths
surrounding the tendons, sometimes referred to as “marshmallow
joints”. Nodules or deformities can frequently develop. Stiffness
is common in the morning and after increased activity and use. In
addition, rheumatoid might cause general weakness, fatigue, weight
loss, or low fever.
Diagnosis of rheumatoid
arthritis involves a careful history and physical examination.
X-rays may be taken of problematic joints to look for
signs of rheumatoid, such as narrowed joint spaces, erosions at the
margins of joints, signs of demineralization around the joints, or
fusion of joints from uncontrolled inflammation. Joints may be
aspirated to evaluate the joint fluid for rheumatoid or other
suspected causes of inflammation. Laboratory tests that can
sometimes be helpful in diagnosing the disorder might be performed
if more evidence is needed to confirm the diagnosis of rheumatoid.
Treatment of rheumatoid
arthritis involves lifestyle modifications of pacing activities with
rest and maintaining a balanced diet.
Physical therapy
may be recommended to help maintain motion and strength. In
addition, there are many medications that can be used to treat
rheumatoid. These might include one or a combination of
anti-inflammatory medications, steroids, or disease modifying
anti-rheumatoid drugs (called “DMARDs”) which work to slow the
disease progression. A newer category of medication called
"biologics" aim at fighting the actual autoimmune process itself.
OSTEO-ARTHRITIS
Osteo-arthritis is the
most common cause for chronic joint pain in the United States. It
is a “wear-and-tear” process that involves progressive degeneration
of the cartilage that lines our joints that articulate with each
other. When this process is started, it leads to subsequent damage
to underlying bone and reactive formation of new bone at the margins
of the cartilage. Because of the nature of the process, osteo-arthritis
usually affects people in their fifties or older (with a
predominance for women greater than men in this age group), but may
be accelerated by trauma or past injuries involving a joint (called
“post-traumatic arthritis”).
The symptoms of osteo-arthritis
progress from occasional to more and more frequent over a period of
time. A cracking or gritty sensation may be present with movement
of the affected joint, and overuse may aggravate the discomfort,
leading to limited motion. Swelling, increased fluid in the joints,
morning stiffness, and sometimes deformity in the joints are also
common. Unlike rheumatoid arthritis, osteo-arthritis may only
involve one joint or it may involve multiple joints, and not
necessarily symmetrically. Systemic symptoms such as fever are not
involved. Osteo-arthritis most frequently affects joints in the
knees, hips, shoulders, spine, wrists & hands, or previously injured
joints.
Diagnosis of osteo-arthritis
involves a careful history and physical examination.
X-rays
of affected joints might show common signs of osteo-arthritis such
as bone spurs (called “osteophytes”), sclerosis, cysts, and narrowed
joint spaces from lost cartilage.
Laboratory tests
to
test for generalized inflammation or to test the composition of
joint fluid might be performed to determine if there might be a
different cause for joint pain.
It is impossible to
predict how quickly or to what extent osteo-arthritis will progress
in every individual. There are many options for treatment of osteo-arthritis,
and methods selected should be based on both a patient’s functional
impairment and quality of life as well as objective evaluation of
the extent of the process. It can not be overstated the importance
of weight reduction in overweight individuals in reducing the loads
on joints and slowing the progression and symptoms of osteo-arthritis.
Your physician might recommend conservative methods of treatment
such as anti-inflammatory medications or glucosamine / chondroiten
supplements, and/ or physical or occupational therapy.
Cortisone injections
are commonly used to settle the pain
caused by inflammation if your arthritis is in the earlier stages.
Visco-suppementation injections (e.g. Synvisc injections)
are another option for early but troublesome arthritis to lubricate
the joints.
If your arthritis is
severe or does not respond to conservative methods of treatment,
there are several surgeries that might be recommended.
Arthroscopy surgery in the joint can sometimes be used to
smooth out worn, rough cartilage for a period of time to avoid more
extensive procedures. More definitive surgical options are
arthrodesis (or fusion) of the arthritic joint. This is not as
commonly done because of the restricted motion that results, but
might be considered for certain patients.
Total joint
replacement is a very effective and definitive option for
those patients who have severe arthritis and who want to retain a
relatively normal level of activity and ability.
GOUT
Gout is an inflammatory
reaction to the accumulation of a certain type of crystals in one or
more joints. The presence of these crystals is the result of a lack
of an enzyme that is required to metabolize the compound uric acid
in the body. In gouty arthritis, uric acid is either over-produced
or unable to be removed properly from the body’s kidneys. Disorders
that cause over production of uric acid include inherited or
congenital defects, bone marrow disorders, or diets high in uric
acid (red meats and wine, anchovies, alcohol). Disorders that
hinder the removal of uric acid from the body are usually related to
improper functioning of the kidneys, as with kidney failure or
certain medications that have effects on the kidneys.
Gout can be an acute or
chronic problem. Gout is rarely seen in persons under thirty years
old; rather, first episodes are usually seen in post-menopausal
women or men in their fifties. Injury, surgery, fasting, or
excessive food or alcohol intake can trigger attacks. Early
episodes are usually limited to one joint, especially the big toe,
whereas a history of multiple attacks might involve more and more
joints. Ankles, heels, knees, wrists, fingers, and elbows are the
most commonly affected joints. Attacks might last days up to weeks,
getting more frequent and severe with lasting symptoms as the
chronic condition develops. Affected joints are very painful, red
and swollen, tender to touch, and produce stiffness and limited
motion. Fever is not uncommon with gout, and other systemic
problems with the kidneys may result. As gout progresses to a
chronic condition, the swelling becomes more permanent, and the
presence of visible nodular masses called "tophi" in pressure points
is common.
The diagnosis of gout is
made with a careful history and physical examination. Confirmation
of the diagnosis can be made by one or more
laboratory tests
including analysis of joint fluid, urinalysis, and/ or possibly
blood tests. X-rays or other diagnostic tests might
performed to rule out other causes of joint pain, but may only show
signs of gout in its chronic stages.
Acute attacks of gout
usually resolve on their own in one to three weeks.
Anti-inflammatory medications are often a mainstay in the treatment
of attacks, as well as other medications that might decrease the
production of uric acid in the body or increase its removal. If
gouty arthritic attacks affect multiple joints and/ or are resistant
to treatment with anti-inflammatory or steroid medication may be
recommended that can help prevent the triggering of future
attacks.
INFECTED (SEPTIC)
JOINT
Infected joints are an
unwanted orthopedic problem. Infected joints occur when harmful
bacteria enter the joints and cause an inflammatory reaction that
can lead to damage in the bone, cartilage, tendons, and ligaments.
This can occur from a variety of sources. Bacteria can be
introduced to a joint through:
-
Blunt trauma
-
Spread of existing
infections in the bone or soft tissues (muscles, tendons, fat)
-
Spread of existing
wound infections
-
Spread of existing
infections in another part of the body that spreads through the
blood (examples are infections in the urinary tract or lungs)
-
Surgery
-
Infected
artificial prosthesis
Several bacteria are
considered harmful if they overwhelm a joint. The most common
bacteria that cause joint infections usually limit themselves to one
joint, such as the knee or hip. However, other bacteria might cause
joint pains that migrate around the body. Tendons also become
inflamed leading to decrease in motion. Infections cause intense
pain, redness, swelling, warmth and tenderness. There may be
purulent drainage from an open wound, or the joint may be puffy and
fluctuant. Depending on the bacteria involved, a rash might be
present on the extremities or whole body. Fever is almost always
present.
Diagnosis of an infected
joint involves a careful history and physical examination. To
confirm an infection, the joint is often aspirated for analysis of
the fluid. In addition, laboratory tests
of your
blood or urine might be considered to determine the source or scope
of a possible infection. X-rays might be taken,
especially if an injury was involved.
Almost all people with
infected joints are treated in the hospital. Antibiotics will
likely be given through an intravenous line (an “IV”). Other
additional methods of management might include surgery to openly
drain, irrigate, or debride the affected area. Infected joints are
usually kept immobilized while being treated. Antibiotics are often
continued taken orally even when you leave the hospital.
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