Managing an acutely swollen joint

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Managing an acutely swollen joint
Yorkshire Emergency Medicine ST3 Emergency Care
Musculoskeletal Training Day
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Introduction

• An acute mono-arthritis
• should always be treated as septic arthritis
  until proven otherwise.
• Failure to treat septic arthritis is a medical
  disaster.
• 50 of cartilage proteoglycan is lost within 48
  hours bone loss is evident within 7 days
• mortality of Staph. aureas arthritis is 10
• Oxford Handbook of Acute Medicine

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Aim to

• General presentation
• Assessment
• Differential diagnosis
• Investigations
• Discuss more common causes

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Presentation

• Hot swollen red joint
• Ache exacerbated by movement
• Joint line tenderness
• Restricted range of movement
• Inability to weight bear
• Systemic features of fever or malaise

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Approach

• Distinguish whether pain is articular or
  periarticular
• Articular
• warmth, tenderness swelling about the joint
  with painful movements in all directions
• Periarticular (outside joint capsule e.g.
  bursitis)
• Tenderness swelling localised to a small area,
  with pain on passive movement only felt in
  limited planes

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Assessment

• Look for any risk factors for infection
• Diabetes mellitus
• Immunodeficiency state
• Underlying structural joint disease
• (e.g. rheumatoid arthritis or deforming
  arthropathy)
• Sexual impropriety or intravenous drug abuse
• Predisposes to sacroileitis ACJ infection) Risk
  factors for gout
• Risk factors for gout
• Alcohol, High purine diet, drugs (thiazides,
  frusemide)
• Evidence of multi-system disease
• Rash, Oro-genital ulceration, ocular/GIT/renal/res
  piratory symptoms

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Conditions that mimic mono-arthritis

• Bone pain or fracture
• Tendinitis e.g. wrist, shoulder, knee
• Bursitis e.g. olecranon or pre-patella bursae
• Neuropathic pain
• Soft tissue pain

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Differential diagnosis of a monoarthritis

• Trauma
• Traumatic synovitis
• Haemarthrosis
• Fracture
• Haemophilia
• Ruptured intra-articular ligaments
• Non-Traumatic
• Infective
• Crystals
• Uric acid (gout)
• Calcium pyrophosphate (psuedogout)
• Hydroyapatite

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Differential diagnosis of a monoarthritis

• Monoarticular presentation of
• Rheumatoid arthritis
• Seronegative arthritis (e.g. Reiters, psoriasis)
• SLE
• Miscellaneous
• Pigmented villonodular synovitis
• Secondary deposits
• Osteosarcoma

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Investigations

• Blood tests
• FBC ? WBC in infection crystal arthritis
• CRP/ESR ? with inflammatory arthritis
• ? ESR normal CRP SLE
• UEs, LFTs Impaired in sepsis
• Glucose ?Diabetes
• Uric acid ?Gout
• Immunology RF, ANA, anti-dsDNA, compliment level

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Investigations

• Synovial fluid analysis
• WBC
• Microbiology
• Polarised microscopy
• X-ray
• Exclude trauma
• Chondrocalcinosis e.g. gout
• Arthritis
• Not helpful in septic arthritis in acute stage

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Traumatic arthritis

• Joint pain
• Tenderness with ?ROM
• Haemarthroses intra-articular fracture or
  ligament rupture
• X-ray exclude fracture
• Rx analgesia
• appropriate splintage
• written advice MICE
• fracture clinic/MSK clinic as required
• consider early physiotherapy

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Septic arthritis

• Typically only 1 joint affected
• Red, painful swollen
• No movement usually tolerated
• Held in position of most comfort (slight flexion)
• Fever, shaking rigors
• Ix FBC, ESR or CRP, Blood cultures, joint
  aspiration
• X-rays limited value early
• Rx IV antibiotics
• Refer to orthopaedics

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Acute Gout

• Typically 1st MTPJ or Knee
• PPT by trauma, diet, renal failure,
  myeloproliferative disease cytoxics
• Look for tophi
• Aspiration -ve birefringent crystals
• X-rays soft tissue swelling
• punched out lesions in
  periarticular bone (late)
• Serum uric acid may be ?
• Rx NSAID (colchicine)

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Acute Pseudogout

• Typically Knees, wrist or hips
• Associated hyperparathyroidism,
  haemochromatosis, Wilsons disease,
  hypothyroidism, hypophosphatemia diabetes etc.
• Aspiration weakly ve birefringent crystals
• X-ray calcification in joint, menisci, tendon,
  ligaments
• bursae
• Rx symptomatically with NSAID referral

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Osteoarthritis

• Elderly patients with acute flares
• Careful assessment
• X-rays asymmetrical joint space narrowing
• osteophyte formation
• subchondral cyst formation
• joint line sclerosis
• Rx NSAID (if tolerated), paracetamol
• Graduated exercise
• Avoid splintage if possible

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Rheumatoid arthritis

• Persistent symmetrical deforming peripheral
  arthropathy
• Typically swollen painful hand feet ? larger
  joints
• Persistent or relapsing mono-arthropathies
• Extra-articular SC nodules, asculitis, pulmonary
  fibrosis, splenomegaly, anaemia, pericarditis,
  scleritis, etc.
• Rhuematoid factor ve in 70 of cases
• X-rays soft tissue swelling, peri-articular
  osteoporosis, joint space narrowing, bony
  erosion, subluxation etc.
• Rx NSAID, splintage, referral.

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Other arthropathies

• Viral arthritis
• Rheumatic fever
• Sero-negative spondyloarthropathies
• Ankylosing spondylitis
• Reiters syndrome
• Psoriatic arthritis
• Enteropathic arthritis
• Gonococcal arthritis

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Yorkshire Emergency MedicineST3 Emergency Care
Musculoskeletal Training Day

• ?
• Any Questions

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Managing an acutely swollen joint

• Common is common
• Distinguish whether pain is articular or
  periarticular
• Careful history examination
• Differential diagnosis
• Consider traumatic cause
• Always consider Septic arthritis