Diagnosing synovitis of the hand and wrist

Summary: This article provides excellent pictures and descriptions for the physical examination of synovitis of the hands. The descriptions are detailed as well as possible to facilitate reproducibility. The study found that the examination of the wrist joint line at the capitate yielded the best combination of sensitivity and specificity. Resulting positive predictive values never exceeded 80%. Negative predictive values were stronger. Note that this study yielded higher sensitivity than a prior study reviewed here that did not use a structured examination.

Patients: Adults with “history of morning stiffness in the small joints of their hands and/or pain in the small joints of the hands and wrist, with or without swellings. Onset of symptoms was not less than 3 months.”

Examiners: Experienced rheumatologists who were blinded to the reference standard. Unclear is the examiners were blinded to the patients’ histories.

Examination method:

A Delphi method with 21 rheumatologists identified 4 examination methods thought to be the most important. Below are brief descriptions for some of the maneuvers, but the article provides much more detail with figures.

1. MCP scissor – examine MCP joint lines for swelling or tenderness while MCPs flex 90 degrees
2. MCP squeeze – to assess tenderness on sides of MCPs
3. PIP 4-finger – examine for swelling or tenderness while squeezing joint from sides
4. Wrist 2-thumb – follow third meta-carpal proximally till encountering capitate. Follow capitate proximally until dimple at the wrist joint line.

Reference standard: Ultrasonographer who was blinded to the study who assessed :components of synovitis (i.e. effusion, proliferation and hyperaemia)”

Results:

Finding	Sensitivity	Specificity
Wrist 2-thumb	80%	54%
MCP scissor (swelling at second MCPjoint)	74%	50%
MCP squeeze
PIP 4-finger

Reference:

Almoallim H, Attar S, Jannoudi N, Al-Nakshabandi N, Eldeek B, Fathaddien O, & Halabi H (2012). Sensitivity of standardised musculoskeletal examination of the hand and wrist joints in detecting arthritis in comparison to ultrasound findings in patients attending rheumatology clinics. Clinical rheumatology, 31 (9), 1309-17 PMID: 22673791

How well can an expert examiner detect synovitis of the fingers?

Summary:

Even an expert has difficulty and only detected by palpation 25% of finger joints that had swelling by ultrasounds.

Patients:

• The authors examined 165 finger tendons from “33 consecutive patients who has originally presented with polyarthritis and clinical suspicion of inflammatory arthritis of the hands and wrists (symptoms < 24 months)”

Examiner:

• “senior rheumatologist trained in the detection of musculoskeletal disorders (AS), who disregarded ultrasonography findings”

Reference standard:

• Ultrasound

Results:

52% (17 patients) had flexor tenosynovitis by ultrasound.

Performance of the expert clinical examiner.

	Sensitivity (%)	Specificity (%)
Tenderness	87	47
Crepitus	56	76
Swelling	25	100

Citation:

Hmamouchi I, Bahiri R, Srifi N, Aktaou S, Abouqal R, & Hajjaj-Hassouni N (2011). A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis. BMC musculoskeletal disorders, 12 PMID: 21549008

Diagnosing Gout

Clinical Diagnosis of Gout

Patients: In a study of 381 patients recruited by family physicians because of monoarthritis, 57% had positive crystals and one patient had a bacterial infection.

Results: The family physicians had an accuracy of:

• Sensitivity 97%
• Specificity 28%

The authors then created a prediction rule for the 328 patients that the family physicians suspected had gout:

Male sex 2.0 points
Previous patient-reported arthritis attack 2.0 points
Onset within 1 d 0.5 points
Joint redness 1.0 points
MIP involvement  2.5 points
Hypertension or and cardiovascular diseases 1.5 points
Serum uric acid level >5.88 m9/dL  3.5 points

The prediction rule had an accuracy of:

• 8 or more points
  • Sensitivity 92% (193/209)
  • Specificity 88% (77/88)
• 4 or less points
  • Sensitivity 99% (208/209)
  • Specificity 50% (44/88)

If 4 or less points, the NPV is 98%.

If 8 or more points, the PPV=95%.

Comment: Even if using the prediction rule developed in this study, physicians should consider aspirating most all joints with monoarthritis as value even in joints suggestive of gout had a one in 20 chance of an alternative diagnosis. Also, the label of gout may affect future decision making and life-long medications.

References:

1. Janssens HJ, Fransen J, van de Lisdonk EH, van Riel PL, van Weel C, & Janssen M (2010). A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Archives of Internal Medicine, 170 (13), 1120-6 PMID: 20625017

2. Peláez-Ballestas I, Hernández Cuevas C, Burgos-Vargas R, Hernández Roque L, Terán L, Espinoza J et al. (2010) Diagnosis of chronic gout: evaluating the american college of rheumatology proposal, European league against rheumatism recommendations, and clinical judgment. J Rheumatol 37 (8):1743-8. DOI: 10.3899/jrheum.091385 PMID: 20551101.