175

NOTES
176
NOTES
 177

65. LOW BACK PAIN

(< 6 weeks acute, > 12 weeks chronic)
Etiologies
SPINAL NON SPINAL
Mechanical Non-Mechanical
(Common, Non-specific) (Unrelated to time or activity)
Sprain, Strain Fracture Gynaecological
Disc prolapse Cancer (secondaries in spine from lung, Renal
Osteoarthritis (OA) breast, prostate, thyroid, kidney) Pancreatic
Spondylosis Infections (osteomyelitis) Aortic
Spondylolisthesis Cauda equina syndrome

Initial assesment
Backache

Spinal Non-Spinal
(gynecological, renal, pancreatic, aortic aneurysm)
Any Neurological features

urgent? non-urgent?
e.g., cauda equina e.g.,root lesion
syndrome
Questionnaire
1. How did the back pain start?
Acute = injury or trauma?
2. Where is your pain?
Ask patient to indicate on a diagram of body.
3. What makes the pain worse?
Movement makes it worse. Rest relieves (Mechanical).
Worse even at rest (Non-mechanical, inflammatory).
4. Pain of spine origin = Restricted to back or referred to lower limb.
5. Does pain radiate along the legs (Sciata or disc prolapse)
6. Pain referred to spine from abdomen, pelvis, back is unaffected by spine movement.
7. Any pins and needles or leg weakness?
8. Bowel & bladder working normally? If abnormal = refer urgently.
9. Fever, weight loss, unwell symptoms? (Non-mechanical / inflammatory causes.)
10. Have you taken steroid tablets? (If yes = consider osteoporotic fracture)
11. What pain killers are you taking now?
12. How are you managing at work / home? (This helps to open up discussion to include psychosocial
aspects)
178

Red flag conditions (Alarm symptoms)

(Indicate possible underlying spinal pathology or nerve root problems of potentially more serious
conditions in patients with low backache.)
Do MRI even if X-rays are normal
Age < 20 years or > 55 years.
Non mechanical pain. Constant, progressive pain unrelieved by rest, unrelated to time or
activity
Thoracic pain
Feeling unwell – malaise, weight loss. (infection, diskitis, spinal abscess)
Difficulty with micturition, urinary retention, fecal incontinence or loss of anal tone. (cauda
equina lesion)
Trauma (Major)
Past medical history – carcinoma, tuberculosis, Human Immunodeficiency Virus (HIV), systemic
steroid use.
Osteoporosis
Structural spinal deformity
Indicators for nerve root problems
Unilateral leg pain > low back pain
Radiates to foot or toes
Numbness and paraesthesia in same distribution
Straight leg raising test induces more leg pain
Localised neurology (limited to one nerve root)
Prognosis reasonable (50% recovery at 6 weeks).
Features of Cauda Equina Syndrome
Difficulty with micturition
Loss of anal sphincter tone or faecal incontinence
Saddle anaesthesia
Progressive motor weakness / gait disturbance
Sensory level
Features of simple mechanical low back pain
(Common, Non specific backache)
Pain varies with physical activity (Improves with rest).
Sudden onset, precipitated by lifting or bending.
Recurrent episodes.
Age 20–55.
Pain limited to back or upper leg.
No clear-cut nerve root distribution.
Systemically well.
Prognosis good (90% recovery at 6 weeks).
Examination
First inspect the back and the spine. Ask the patient to show the exact site of pain
Look for prominence of spine and for tenderness by firm palpation and gentle hitting
Test EHL (Extensor hallucis longus)
Ask the patient to dorsiflex the great toe against resistance. Weakness of dorsiflexion is the sign of
neurological deficit in compressive lesions of spine.
SLR Test (Straight Leg Raising).
Ask the patient to lie down, and lift each leg straight to 90 degrees Pain at the back (Lumbar spine)
similar to the patient’s pain is a positive SLR test.
Deep Tendon Reflexes (DTR) : Brisk or exaggerated reflexes indicate pressure on spinal cord.
Plantar reflex.
 179

Physical signs in lumbar root compression

Disc level Root Sensory loss Weakness Reflex loss
L3/L4 L4 Inner calf Inversion of foot Knee
L4/L5 L5 Outer calf and dorsum of foot Dorsiflexon of hallux / toes Hamstring
L5/S1 S1 Sole and lateral foot Plantar flexion Ankle

Diagnostic features of some diseases

Intervertebral disc prolapse
Most common lesion : L5 - S1 Acute onset of pain
Pain in mid-gluteal region, posterior part of thigh,
posterior heel, plantar surface of foot, 4th and 5th
toe. Absent ankle jerk.
Next most common lesion : L4 - L5 Pain in hip, groin, posterolateral thigh, lateral calf,
dorsum 1st, 2nd and 3rd toe.
Less common lesion : L3 - L4 Pain in anterior part of thigh and knee.
Less common lesion : L3 - L4 Inverted Lasegue’s sign (pain with hyperextension of
limb with patient in prone position).
Collapse of vertebra Acute onset of pain
Trauma Local tenderness, deformity
Metastatic bone disease
Myeloma
Lymphoma

Tuberculosis of spine or sacroiliac joint Insidious onset.

Duration more than a month.
Weight loss, fever, raised ESR, local tenderness,
Usually middle of sacroiliac area.

Spinal cord tumour Pyramidal, posterior column signs.

Osteoarthritis of spine chronic nature of pain

Pain centred over the spine.
Stiffness, limitation of movement, relief by rest. No
systemic symptoms (fever, malaise), Normal ESR

Spondyloarthropathy Younger age group.

SSA Morning stiffness of back
Reiter’s syndrome Tenderness over sacroiliac joint
Reactive arthritis Limitation of chest expansion
High ESR

Lumbar Canal Stenosis Pain in one or both legs on walking, relieved by rest.
Signs of root compression
Confirmed by CT / MRI
180

Investigations (choices include)

Plain X-rays (best for structural deformities)
Blood count and ESR
Serum calcium, phosphorus and alkaline phosphatase
Serum acid phosphate and prostate - specific antigen (PSA in men)
Serum protein electrophoresis, immunoglobulins
Radionuclide bone scan
MRI (best option for radicular symptoms, diskitis, or neoplasm.)
Recommendations for diagnosis and treatment for acute low back pain.
Diagnosis
Diagnostic triage (non-specific low back pain, radicular syndrome, specific pathology)
History taking and physical examination to exclude red flags.
Physical examination for neurological screening (including straight leg raising test)
Consider psychosocial factors if there is no improvement.
X-rays not useful for non-specific low back pain.
Treatment (choices include)
Reassure patients (favourable prognosis)
Advise patients to stay active
Prescribe medication if necessary (preferably at fixed time intervals):
Paracetamol
Non-steroidal anti-inflammatory drugs
Consider muscle relaxants or opioids
Discourage bed rest
Consider spinal manipulation for pain relief
Do not advise back-specific exercises.
Recommendations for diagnosis and treatment of chronic low back pain
Diagnosis
Diagnostic triage to exclude specific pathology and nerve root pain.
Assessment of prognostic factors (yellow flags) such as work related factors, psychosocial distress,
depressive mood, severity of pain and functional impact, prior episodes of low back pain, extreme
symptom reporting, and patient’s expectations.
Imaging is not recommended unless a specific cause is strongly suspected.
Magnetic Resonance Imaging is best option for radicular symptoms, diskitis, or neoplasm.
Plain radiography is best option for structural deformities.
Treatment (choices include)
Recommended - Cognitive behaviour therapy, supervised exercise therapy, brief educational
interventions, and multidisciplinary (biopsychosocial) treatment, short term use of non-steroidal anti-
inflammatory drugs and weak opioids.
To be considered - Continue education and short courses of manipulation and mobilisation,
noradrenergic or noradrenergic-serotoninergic antidepressants, muscle relaxants, and capsicum
plasters.
Not recommended - Passive treatments (for example, ultrasound and short wave) and gabapentin.
Invasive treatments are in general not recommended in chronic non-specific low back pain.
 181

Treatment for acute and chronic low back pain

Effectiveness Acute low back pain Chronic low back pain
Beneficial Advice to stay active, non-sterodial Exercise therapy, intensive
anti-inflammatory drugs (NSAIDs) multidisciplinary treatment
programmes
Trade off Muscle relaxants Muscle relaxants
Likely to be beneficial Spinal manipulation, behaviour Analgesics, acupuncture,
therapy, multidisciplinary treatment antidepressants,
programmes (for subacute low behaviour therapy, NSAIDs, spinal
back pain) manipulation

Unknown Analgesics, acupuncture, continue Epidural steroid injections, EMG

education, epidural steroid injections, biofeedback, lumbar supports,
lumbar supports, massage, massage, transcutaneous
multidisciplinary treatment (for acute electrical nerve stimulation,
low back pain), transcutaneous traction, local injections.
electrical nerve stimulation, traction,
temperature treatments,
electromyographical biofeedback

Unlikely to be beneficial Specific back exercises –

Ineffective or harmful Bed rest Facet joint injections

Key points for clinical practice
Most episodes of acute low back pain have a favourable prognosis, but recurrences within a year
are common.
Diagnosis should focus on excluding specific pathology and nerve root pain
Imaging might be indicated only in patients with red flag conditions. (Alarm symptoms)
Bad posture is a common cause for backache.
Commonest site for intervertebral disk prolapse is L4-L5.
Straight leg raising test (SLR), dorsiflexion of great toe (to rule out weakness of extensor hallucis
longus (EHL), ankle jerk and knee jerk reflexes should be checked in all patients.
For acute or recurrent low back pain with or without referred leg pain, bed rest for 2-7 days is worse
than placebo or ordinary activity. Continuation of ordinary activity gives equivalent or faster
symptomatic recovery and less chronic disability than rest.
There is no evidence to support the use of traction, lumbar corsets and support, plaster jackets or
joint injections for acute low back pain.
Refer to orthopedic surgeon if
- pain is severe.
- numbness of foot or leg is present.
- SLR is positive or there is weakness of EHL (i.e., dorsiflexon of great toe is not possible)
- patient has features of cauda equina syndrome.
- no relief with routine treatment.
182
NOTES
 183

66. ARTHRITIS

ARTHRITIS
(Acute < 8 weeks; Chronic > 8 weeks)

↓ ↓ ↓ ↓ ↓
Inflammatory Non-Inflammatory Mono arthritis Pauciarthritis Polyarthritis
Septic (infection) Trauma (2 - 5 joints) (5 or more joints)

↓ ↓ ↓
Crystal Osteoarthritis (OA)
- Gout Cartilage tear
- Pseudogout tuberculosis / fungi / indolent infection CTD
gonococcus seronegative arthritis viruses
foreign body (plant thorn) reactive primary
osteoarthritis (OA) psoriatic osteoarthritis
trauma ankylosing spondylitis
pigmented synovitis enteropathic
synovial sarcoma early polyarthritis
early pauci / polyarthritis
Etiologies

Acute Chronic

i. Infection Gonococcal
Meningococcal
Staphylococcal
Streptococcal
Viral-(dengue, rubella)
Lymphogranuloma
Syphilis
Yersinia
Lyme’s disease May be recurrent
Acute lepra reaction May be recurrent

ii. Immune-mediated Rheumatic fever May be recurrent

Serum sickness Drug reactions
Henoch-Schönlein purpura May be recurrent

iii. Collagen disease Rheumatoid arthritis Remission & relapse

Systemic lupus erythematosis Remission & relapse
Progressive systemic sclerosis
Sjögren’s syndrome
Polymyalgia rheumatica
Relapsing polychondritis May be recurrent
184

iv. Reactive Arthritis Bacillary dysentery (Shigella)

Ulcerative colitis
Crohn’s disease
Whipple’s disease

v. Metabolic Gout May be recurrent

Crystal arthritis May be recurrent

vi. Haematologic Haemophilia May be recurrent

Sickle cell disease

vii. Malignancy Pulmonary osteoarthropathy

viii. Miscellaneous Sarcoidosis

Diagnositc clues in patients presenting with Joint Pain

Clues from history and physical Diagnoses to consider

examination

Sudden onset of pain in seconds / minutes Fracture, internal derangement, or trauma,

loose body.

Onset of pain over several hours or Infection, crystal deposition disease,

one to two days. inflammatory arthritic conditions.

Insidious onset of pain over days / weeks. Indolent infection, osteoarthritis, infiltrative
disease, tumor.

Intravenous drug use, immunosuppression. Septic arthritis.

Previous acute attacks in any joint, Crystal deposition disease,

spontaneous inflammatory arthritic conditions.

Recent prolonged course of corticosteroid Infection, avascular necrosis.

therapy.

Coagulopathy, use of anticoagulants. Haemarthrosis.

Urethritis, conjunctivitis, diarrhea, and rash. Reactive arthritis.

Psoriatic patches or nail changes such Psoriatic arthritis.

as pitting

Use of diuretics, presence of tophi, history of Gout or renal stones.

alcoholic binges.

Eye inflammation, low back pain Ankylosing spondylitis.

Young adulthood, migratory polyarthralgias, Gonococcal arthritis of the tendon sheaths of

inflammation. hands and feet, dermatitis.

Hilar adenopathy, erythema nodosum Sarcoidosis.

 185

Comparison of major arthritides

Features Osteo arthritis Rheumatoid arthritis Crystal Seronegative

Onset gradual gradual acute variable

Inflammation – + + +

Pathology degeneration pannus microtophi enthesitis

No of joints polyarthritis polyarthritis monoarthritis oligo or poly

Types of joints large small small or large large

Location weight-bearing wrists feet, ankles sacroiliac

spine
peripheral

Special articular Bouchard’s nodes ulnar deviation, crystals en bloc spine

diagnosis Heberdeen’s nodes swan neck, boutonniere enthesopathy

Bone changes osteophytes osteoporosis, erosions erosions erosions

ankylosis

Extra articular subcutaneous nodules, tophi, bursitis uveitis

features pulmonary, cardiac, conjunctivitis
splenomegaly aortic
pulmonary
psoriasis
IBD

Blood test(s) Normal +RF, ESR↑ ↑Uric acid HLA -B 27

186

Investigations (choices include)

Mono arthritis Polyarthritis
ESR
CRP
Rheumatoid factor (RA)
Uric acid
Other ANA Other
tests CBC tests
Urine analysis
Blood sugar
X-ray/other imaging

Synovial fluid analysis (SFA) (Rheumatic fever) ASO titre

Throat swab
(Gout) Crystals in Synovial Fluid
No diagnosis after SFA / or Analysis (SFA)
monoarthritis persists 24 hr urinary uric acid
(ankylosing spondylitis) HLA B 27
Imaging modalities
Synovial biopsy (collagen vascular disease) ANA, LE cells

Assessment of arthritis
Direct assessment Indirect assessment
1. Arthroscopy 1. Acute phase response ESR, CRP
2. Synovial biopsy 2. Complete haemogram (CBC)
3. Synovial fluid aspiration and analysis (SFA) 3. Liver function test (LFT)
(arthrocentesis)
4. Imaging studies
– Plain radiography
– Ultrasonography
– Bone scan
– DEXA scanning
– Magnetic Resonance Imaging

Imaging techniques
X ray USG CT Scan MRI
Irritable hip + + – +
Noctural limb pain – – + –
Acute arthritis + +/– – +
Vasculitis – +/– – +
Chronic pain syndrome – – + –

Assessment of joint disease

Biopsy Arthroscopy Arthrocentesis
Acute arthritis +/– +/– +
Chronic arthritis +/– +/– +
Joint instability – + –
Vasculitis + – –
 187

Interpretation of tests

Normal Abnormal Comments

ESR >100 Screening test for inflammatory process.

> 100 is highly abnormal and is associated
with significant illness. Always correlate ESR
with clinical findings

CRP 470-1000 mg/dl 1-10 Seen in acute rheumatoid arthritis, SLE,

vasculitis

ASO >200 (child)

>330 (adults) Indicates recent streptococcal infection

LE cells Are seen in peripheral blood, synovial fluid

or pleural fluid in SLE patients.

Uric acid 2-8 mg/dL > 8 mg/dl If elevated there is a possibility of gout.
If normal, still gout cannot be excluded.

HLA-B 27 Positive in ankylosing spondylitis, (8% of

patients only with background activity).
Negative result does not mean anything.

Calcium 8-10 mg/dl If elevated it may be associated with

excess of parathyroid hormone
Synovial fluid See below
analysis

Analysis of joint fluid (Synovial fluid analysis) (SFA)

Normal Noninflammatory Inflammatory Septic

Appearance Clear Clear, yellow Clear to opaque

yellow-white Opaque

WBC/mm <200 <2,000 >2,000 > 2,000

Polymorphs <25% <25% >50 > 25%

Culture negative negative negative positive

approximately approximately serum 25% less than
Glucose serum glucose glucose serum glucose < 25%
Crystal, RA, CTD
Conditions Trauma, OA Infection
sero negative
188

66 (a) OSTEOARTHRITIS
Treatment (choices include)
Drugs
- Simple analgesics (paracetamol)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) : oral or topical
Physiotherapy
Surgery
- Joint replacement
- Arthroscopy
- Osteotomy.
Miscellaneous
- Advice on diet and exercise
- Walking aids
- Insoles
66 (b) RHEUMATOID ARTHRITIS
Treatment (choices include)
NSAIDs
indomethacin (INDOCAP SR)
DMARDS (disease modifying anti-rheumatic drugs)
hydroxychloroquine HCQs (200-400 mg OD)
methotrexate FOLITRAX (5-7.5 mg/week)
pencillamine
sulphasalazine SAAZ (500-1000 mg)
levamisole
leflunomide (10-20 mg/day)
azathioprine (50 mg/day)
sodium aurothioglucose (25-50 mg)
New DMARDS
leglunomide
Biological agents (inhibit tumor necrosis factor TNF)
infleximab, etanercept
Steroids
systemic
intra articular
Physiotherapy
Surgery
 189

66 (c). GOUT
Diagnosis (American College of Rheumatology)
(Six or more of these criteria are needed to make a diagnosis)
More than one attack of acute arthritis
Maximum inflammation developed within one day
Attack of monoarthritis
Redness over joints
Painful or swollen first metatarsophalangeal joint.
Unilateral attack on first metatarsophalangeal joint
Unilateral attack on tarsal joint
Tophus (proved or suspected)
Hyperuricaemia
Symmetric swelling within a joint on radiograph
Subcortical cysts without erosions on radiograph
Joint fluid culture negative for organisms during attack.
Investigations
Test(s) Comment
Serum urate concentration Level may go down during an acute attack.
Full blood count To exclude myeloproliferative disorders; raised white cell count may
indicate septic arthritis.
Renal function Hyperuricaemia can occur in renal failure; reduce dose of allopurinol.
Fasting lipids, glucose Hyperlipidaemia, diabetes, hypothyroidism, and possibly
and thyroid function hyperthyroidism are associated with gout.
Urinary urate excretion Uricosurics are contraindicated in patients with high urinary excretion
of urate. Some advise measuring this if the serum urate concentration
is >0.8 mmol/l because of risk of renal stone formation.
Treatment of gout
Acute attack
INDOCAP (Indomethacin) (NSAIDs) 25-50 mg PO or
COLCHINCINDON / GOUNTNIL TDS (Colchicine) (max 6 mg PO) or 1-2 mg IV or
WYSOLONE (prednisolone) steroids 30 mg twice daily for 2 days, then 20 mg twice daily for
2 days and 10 mg twice daily for 2 days.)
Life style management These following changes can decrease the incidence of recurrent gout.
- avoid foods high in purine (e.g., meats, beans, peas, spinach, beer)
- decrease intake of alcohol, (wine better than beer!)
- avoid dehydration
- lose weight
- drink a glass of skimmed milk a day.

Prophylaxis
Hypouricemic therapy is for tophi, frequent attacks, nephrolithiasis (goal uric acid is < 5 mg/dl,
however, do not start until 2-4 wks after acute attack as increase in serum uric acid concentration
can precipitate an attack).
(allopurinol) ZYCORIL/ALORIC 100 mg/day (max 600 mg) (xanthine oxidase inhibitor); side effects:
hypersensitivity, rash, diarrhea, dyspepsia, headache, renal failure, BM suppression, and hepatitis.
(probenecid) BENCID 250 mg bd for 1 week and then 500 mg bd or sulfinpyrazone (uricosuric
agents) for underexcreters (urine UA < 600 mg/24 hrs).
190

Keypoints for clinical practice

Serum urate concentrations can go down during an attack of gout.
Oral steroids may be safer alternative to non-steroidal anti-inflammatory drugs or colchicine for the
management of acute gout.
Urate lowering drugs are usually needed only for patients with frequent attacks of gout.
Asymptomatic hyperuricaemia does not require treatment.
Uricosuric drugs should not be used in patients with significant renal impairment or a history of renal
stones.
Patients with gout and either tophaceous deposits, gouty erosive changes on radiographs, or more
than two attacks per year should be offered urate lowering treatment.
 191

67. NECK PAIN

Etiologies
Mechanical
Postural, Disc prolapse, Whiplash injury, Cervical spondylosis
Inflammatory
Infections, Rheumatoid arthritis, Spondylitis, Polymyalgia rheumatica, Juvenile idiopathic arthritis
Metabolic
Osteoporosis, Paget’s disease, Osteomalacia
Neoplasia
Metastases, Reticuloses, Myeloma, Intrathecal tumors
Other
Fibromyalgia, Torticollis
Referred pain
Pharynx, Cervical lymph nodes, teeth, Angina pectoris, Aortic aneurysm, Pancoast tumour, Diaphragm

Physical signs on cervical root compression

Root Muscle weakness Sensory loss Reflex loss
C5 Biceps, deltoid Upper lateral arm Biceps
C6 Brachioradialis Lower lateral arm Supinator
thumb, index finger

C7 Triceps, finger and wrist extensors Middle finger Triceps

68. BONE PAIN (CHRONIC)

Etiologies
Secondary cancer deposits (less commonly, primary bone tumours)
Chronic infection (osteomyelitis)
Paget’s disease
Osteonecrosis
Metabolic bone disease (e.g., osteomalacia, hyperparathyroidism)
Subacute or chronic bone pain usually has the following characteristics :
- well localised to the site of origin (no radiation).
- predominant at or confined to night-time.
- not clearly worsened by movement or usage.
(unlike joint or periarticular pain).
- not readily reproduced by clinical examination.
 191

67. NECK PAIN

Etiologies
Mechanical
Postural, Disc prolapse, Whiplash injury, Cervical spondylosis
Inflammatory
Infections, Rheumatoid arthritis, Spondylitis, Polymyalgia rheumatica, Juvenile idiopathic arthritis
Metabolic
Osteoporosis, Paget’s disease, Osteomalacia
Neoplasia
Metastases, Reticuloses, Myeloma, Intrathecal tumors
Other
Fibromyalgia, Torticollis
Referred pain
Pharynx, Cervical lymph nodes, teeth, Angina pectoris, Aortic aneurysm, Pancoast tumour, Diaphragm

Physical signs on cervical root compression

Root Muscle weakness Sensory loss Reflex loss
C5 Biceps, deltoid Upper lateral arm Biceps
C6 Brachioradialis Lower lateral arm Supinator
thumb, index finger

C7 Triceps, finger and wrist extensors Middle finger Triceps

68. BONE PAIN (CHRONIC)

Etiologies
Secondary cancer deposits (less commonly, primary bone tumours)
Chronic infection (osteomyelitis)
Paget’s disease
Osteonecrosis
Metabolic bone disease (e.g., osteomalacia, hyperparathyroidism)
Subacute or chronic bone pain usually has the following characteristics :
- well localised to the site of origin (no radiation).
- predominant at or confined to night-time.
- not clearly worsened by movement or usage.
(unlike joint or periarticular pain).
- not readily reproduced by clinical examination.
192

69. COMMON ORTHOPEDIC PROBLEM(S)

Signs and symptoms Possible diagnosis Investigations Treatment

History of contact or Sprains and strains, X-ray NSAIDs, Proper splintage,

accident fractures, dislocation reduction of dislocation
and splintage.

Acute on chronic pain Acute attack of RA, Blood examination and NSAIDs and joint
stress fracture radiological examination stabilisation
pathological fracture

Pediatric/adolescent Hematogenous X-Rays in the early stage, Splintage, 4th generation

with systemic symptoms osteomyelitis, may show pathological Cephalosporins, Amino
and pain, swelling near Pyogenic arthritis dislocation or increased glycosides, NSAIDs
the joint joint space, Hematological
examination.

Diabetes, Hematogenous Hematological examination Decompression,

immunocompromised or osteomyelitis, Radiology debridement.
long term steroid use Pyogenic arthritis
Cellulitis

Involving multiple joints, Inflammatory arthritis, Hematological examination NSAIDs,

and associated systemic Fibromyalgia Radiology immunomodulators,
manifestation. steroids

Acute pain coming in crystal arthropathy Hematological examination NSAIDs,

early hours involving steroids
multiple joints of toe Uricosuric drugs
mostly.

History of plaster Acute Compartment Essentially clinical Immediate splitting of the

application to the limb syndrome awareness of the condition POP cast.
and sudden increased
pain in hands and legs,
Loss of pulsations, and
movements of digits
painful.

Sudden acute pain in OA Loose body, Radiological examination R.I.C.E.

knee of elderly degenerative rupture NSAIDs
of the ligament

Acute pain in limbs with Hypocalcemia Serum calcium levels Administration of

muscles going in spasms intravenous calcium.