Gout - Gouty Arthritis

Gout:

Gout is a medical condition, a metabolic disease in which crystals of Uric acid (Monosodium urate) gets deposited in joints and tissues. These crystals are the by-product of body’s Protein degradation.

Causes:

The proteins that we consume in our diet get digested and undergo various steps of degradation in our body. Uric acid is produced during this process is usually excreted from intestine and kidneys.

High levels of Uric acid can be produced due to

Intake of protein rich diet- high purine dietAbnormalities in chemical pathways that leads to excessive production of uric acidCertain drugs like Aspirin (Salicylates), Diuretics (Kidney drugs) interfere with the excretion of uric acid thereby raising its level in blood.

The body’s own overproduction of uric acid is an inherited condition and is present from birth.

Symptoms :

Uric acid is deposited in the form of crystals (Monosodium urate) in joints and tendon. This result in intense irritation, inflammation and pain in the joints and tendon tissues. The joint becomes hot, red and swollen.

Classically the big toe joint of the foot is affected, but ankles, knees, elbows and joints of hand and feet can be involved. Large joints like hip and shoulder joints tend to be spared.

Predisposing factors:

Men are more likely to be affected than women.The commonest age for the first attack is between 30 and 60.

Risk factors include.

A high alcohol intake. Alcohol by itself  does not cause gout, but it will stimulate gout attacks in those who are affectedA protein rich diet.Certain races, like Maoris and Polynesian- who have higher blood levels of uric acid are more susceptible to goutObesity,Conditions that cause high cell turnover, such as polycythaemia (increased red cells), lymphomas and various other cancers can increase blood uric acid levels.A family history of gout,Drugs like Diuretics (drugs increasing urine flow) or low dose salicylates,Kidney diseases,

Some percentage of patients suffering from Gout can have renal colic due to deposition on uric acid crystals in the kidneys.

Diagnosis:

History and complaints

Sudden onset of severe pain, swelling and redness of joint in great to of the foot.Sometimes swelling of joints of foot, ankles and handsHistory of similar episodes in the past.

Examination:

Red, tender, swelling of joint of great toe or other involved joints.Long standing cases uric acid crystals deposit in tendons, tissues appear as swellings called Gout tophi. More common around the elbow, wrists, finger and toe joints and sometimes on the earlobe.

Investigations:

Blood tests: Raised blood uric acid levelsDoubtful cases: Fluid examination from Gout swelling for Uric acid crystals.X rays: in long standing cases shows joint destruction

Treatment:

Acute attack:

Acute attack of gout is characterised by hot, swollen, red and painful joint of great to of foot.

Non-steroidal anti-inflammatory drugs in acute attacks help in reducing the pain and swelling. They should be given in high doses initially.Colchicine is one of the oldest known drugs and can be taken during acute painful phase.New drugs are available that can be given during acute attacks which can reduce blood levels of Uric acid.

Drug treatment:

Drugs in the treatment of gout are given to control the levels of uric acid in blood and to prevent long term complications. Drug dosage should be adjusted according to the levels of uric acid in the blood.

Allopurinol is one of the oldest and common drug used to control the levels of uric acid in blood. This drug inhibits xanthine oxidase which converts xanthine into uric acid.Probenicid and Sulphinpyrazone – Promotes excretion of uric acid through kidneys.

Prevention:

Once you are diagnosed with Gout, you’re a patient of gout for your life.

Avoid Protein rich diet – High Purine foodsAvoid Dehydration: especially in hot weathersAvoid unaccustomed strenuous exercise.Care should be taken in patients on long term diuretics and low dose aspirin.

Regular medications to control the uric acid levels by the advice of physician or orthopedician.

Complications of untreated Gout:

Long term complications of uncontrolled gout can cause

Joint damage (Arthritis),Formation of gout tophi (swellings around the joint) andRare complication of chronic kidney disease.

Intoeing in children

Intoeing in children

Intoeing or Intoe gait is walking pattern in which the feet turn or point inward instead of pointing straight. It also called as pigeon toed gait. It is usually noticed by parents or grandparents when the child starts walking. In some cases children may have intoeing due to other reasons. In case of severe intoeing, child may trip and fall as the toes get locked with other heel.

Intoeing is usually seen in 10% of children aged between 2 to 5 years. It is usually benign condition and foot can be corrected by the age of 8 years. Intoeing gait with pain, limp, and swelling may need attention from orthopedic doctor.

Causes:

There are three most common conditions causing intoeing.

Metatarsus adductus - Curved foot.Tibial torsion – twisted shinFemoral anteversion – twisted thigh bone

Sometimes these conditions are associated with other orthopedic problems. Some of these conditions run in families as there is some genetic predisposition.

1. Metatarsus adductus: It is a condition in which half of the foot in the front is turned inwards with toes pointing to the center of body axis. Some deformities may be mild and flexible and some may be severe and rigid. In severe cases foot can resemble like a club foot. It usually corrects by the age 4 to 6 months. If the deformity is not getting corrected by the age of 9 months and foot are rigid manipulation and serial plaster cast will correct the deformity.  Surgery is seldom required.

2. Tibial torsion: This is a condition in which lower part of the child’s leg (Tibia) is twisted inwards. This usually starts in the mother’s womb in which developing fetus legs rotate to accommodate in the womb. After the birth the child’s leg gradually remodels back to normal position. As the child starts walking the foot and toes point inwards because lower end of leg bone is twisted inwards. This usually corrects by the age of 8 years. Use of splints, braces or shoes do not help. Surgery to correct the rotation of tibia is considered in severe deformities or if deformity persists or beyond 8 to 10 years.

3. Femoral anteversion : This is condition in which the childs thigh bone (Femur) is rotated inwards. This occurs at the hip joint where the thigh bone is rotated inwards. As the thigh bone is rotated inwards the knee and feet are also turned inward while walking. Children with this condition usually sits in W position. Excessive femoral anteversion gets corrected by the age of 6 years. Surgery is considered in children above 9 years,  when the deformity is severe, unstable gait, frequent fall due to tripping. Surgery involves cutting of the upper end of thigh bone and rotating it back to normal position.