Arthritis and Arthrocentesis

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Arthritis and Arthrocentesis

• Joe Lex, MD, FAAEM
• Temple University Hospital
• joe_at_joelex.net

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(No Transcript)
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Not About Trauma
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Whats a joint like you doing in a nice girl like
this??
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Objectives

• 1. Differentiate among the three types of joints
• 2. Explain the pathology of joint inflammation
• 3. Develop a differential for arthritis, based on
  number of joints involved, location, and other
  characteristics

Objectives
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Objectives

• 4. Explain usefulness of various synovial fluid
  studies.
• 5. Demonstrate an appropriate technique for large
  joint arthrocentesis
• 6. Explain the pathophysiology and treatment for
  gout

Objectives
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Objectives

• 7. Differentiate rheumatic fever from
  rheumatoid arthritis from rheumatism
• 8. Be aware of quackery as it applies to
  treatment of arthritis

Objectives
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History of Arthritides

• 1680s Sydenham describes gout, rheumatism,
  chorea
• 1808 term rheumatic fever
• 1876 urate crystals postulated to cause gout
• 1883 gonococcal arthritis
• 1907 osteoarthritis described

History
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Thomas Sydenham (1624-1689)
History
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Three Joint Types

• Synarthroses suture lines of skull
• Amphiarthroses fibrocartilaginous unions of
  pubic symphysis and lower third of sacroiliac
  joint
• Diarthroses Synovial most other joints

Types
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Synarthosis
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Amphiarthroses
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Diarthrosis Synovial Joints

• Subchondral bone, convex against concave, covered
  by cartilage
• Cartilage collagen proteoglycan
• Lubricated, slide on each other
• Surrounded by capsule supported by ligaments,
  tendons, and muscle
• Lined with synovial membrane

Types
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Typical Joint Structure
Structure
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Pathophysiology

• Joint trauma causes decreased proteoglycans
• If trauma persistent, damage irreparable
• Inflammation characterized by polymorphonuclear
  white cells
• May be immunologic (rheumatoid, Reiters)

Path
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Joint vs. Periarticular

• Arthritis
• Generalized pain, warmth, swelling, tenderness
• Discomfort ? with joint motion

• Periarticular inflammation bursitis, tendinitis,
  localized cellulitis
• Focal tenderness, swelling not uniform
• Pain only with certain movements

Pearls
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Monarticular vs. Polyarticular
Pearls
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If Polyarticular and

• symmetric rheumatoid, drug induced
• asymmetric rubella, acute rheumatic fever,
  gonococcal
• migratory gonococcal or rubella

Poly
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Location, Location, Location

• First MTP joint gout
• MCP and PIP joints rheumatoid
• DIP and first carpometacarpal joint
  osteoarthritis
• Knee septic arthritis, pseudogout, gout

Location
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Causes of Migratory Arthritis

• Rheumatic fever
• Subacute bacterial endocarditis
• Henoch-Schönlein purpura
• Cefaclor (Ceclor) hypersensitivity (kids)

• Septicemia staphylococcal, streptococcal,
  meningococcal, gonococcal
• Mycoplasma, histoplasmosis, coccidioidomycosis
• Lyme disease

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Arthritis with

• low-grade fever ? any inflammatory arthritis
• high fever, chills ? septic arthritis
• kidney stones ? gout
• genital ulcers ? Reiters disease
• urethral discharge ? Reiters, gonococcus

Symptoms
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Arthritis and

• isoniazid, procainamide, hydralazine ? lupus
• thiazide diuretics ? gout (increase serum uric
  acid level)
• Chlorthalidone (Hygroton)
• Hydrochlorothiazide (HydroDIURIL, Esidrix,
  Oretic)
• Indapamide (Lozol)

Causes
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Some Scalp and Skin Findings
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Physical Exam
Exam
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Physical Exam

• Warmth and effusion
• Synovial thickening
• Deformity
• Tenderness generalized or localized, articular
  or periarticular
• Limited range of motion
• Pain on movement

Exam
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Lab Studies

• Limited diagnostic value
• Screening tests CBC, ESR
• Bacterial usually elevated WBC
• Chronic rheumatic mild anemia
• ESR elevated in most inflammatory
• RF, ANA, ASO titers, Lyme serologies for
  follow-up
• Uric acid not helpful in gout

Labs
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X-ray Findings (Chronic)

• Soft tissue swelling
• Erosions
• Calcification
• Osteoporosis
• Narrowed joint space
• Deformity
• Separation (fractures)

Xray
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X-ray Findings (Septic)
Xray
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Hallmark X-ray Findings
Osteoarthritis Osteophytes
Xray
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Hallmark X-ray Findings
Erosions Rheumatoid or Gout
Xray
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Hallmark X-ray Findings
Chondrocalcinosis Pseudogout
Xray
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Hallmark X-ray Findings
Enthesitis Insertion Site Inflammation
(HLA-B27)
Xray
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Other Imaging

• Ultrasound joint effusions tendons and
  ligaments of shoulder
• CT scan SI, sternoclavicular joint
• MRI knee cruciate ligaments
• Contrast MRI differentiate synovitis from
  synovial fluid in rheumatoid disease

Image
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Other Imaging

• 99mtechnetium methylene diphosphonate (99mTc MDP)
• Osteomyelitis, stress fractures
• Gallium gathers at proliferation of serum
  proteins and leukocytes
• Infection

Image
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Arthrocentesis

• Critical diagnostic adjunct
• Can be painless, safe, and simple when performed
  correctly
• Diagnostic or therapeutic

Tap
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Indications

• Obtain joint fluid for analysis
• Drain tense hemarthroses
• Instill analgesics and anti-inflammatory agents
• Prosthetic joints only to rule out infection

Tap
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Contraindications

• Absolute infection of any kind covers area to be
  punctured
• Relative
• Bleeding diatheses, anticoagulant therapy
• Bacteremia

Tap
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Procedure

• Cleanse skin with povidone-iodine, then air dry
• Remove povidone-iodine with isopropyl alcohol
• Intra-articular povidone-iodine can cause
  chemical irritation, inhibit bacterial growth
  leading to spuriously negative cultures in early
  septic joint

Tap
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Procedure

• Place sterile drapes
• Inject local anesthetic into skin
• 25- to 30-gauge needle
• Intraarticular anesthetic can inhibit bacterial
  growth, cause spuriously negative culture in
  early septic joint

Tap
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Procedure

• Aspirate large joints with large-bore needle (18
  or 19 gauge)
• Smaller joints smaller-bore needle
• Choose syringe size based on anticipated fluid
  volume
• Remove as much fluid as possible
• Optimizes diagnosis
• Relieves pain from distention

Tap
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Arthrocentesis

• Fat globules diagnostic of fracture
• Intraarticular morphine can provide relief for up
  to 24 hours
• 1 to 5 mg diluted in normal saline solution to a
  total volume of 30 ml

Tap
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Sternoclavicular Joint
Tap
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Sternoclavicular Joint
Tap
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Acromioclavicular Joint
Tap
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Shoulder Posterior Approach
Tap
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Shoulder Anterior Approach
Tap
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Elbow Lateral Approach
Flex elbow 90o Prep skin Insert needle in
palpable bony notch between lateral epicondyle
and olecranon
Tap
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Elbow Lateral Approach
Tap
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Elbow Posterior Approach
Tap
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Wrist Approach
Tap
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Wrist Approach
Tap
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Wrist Approach
Tap
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Intercarpal Approach
Tap
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Knee Lateral Approach
Tap
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Knee Lateral Approach
Extend knee, quadriceps and patella relaxed so
patella can move mediolaterally. Needle into
joint space just lateral to patella near its
upper pole, parallel to the posterior (articular)
surface.
Tap
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Knee Lateral Approach
Tap
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Knee Medial Approach
Tap
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Knee Medial Approach
Tap
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Knee Medial Approach
Tap
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Knee Medial Approach
Tap
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Knee Medial Approach
Tap
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Knee Medial vs. Lateral

• Follow Suttons Law
• William Slick Willie Sutton (1901 1980)
  professional bank robber

Tap
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Ankle
Palpate the medial and lateral malleoli with your
thumb and index finger. The joint space is
located one to one and a half cm above the line
joining the tips of the malleoli.
Tap
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Ankle
Palpate the dorsalis pedis artery and choose a
puncture site anywhere on the anterior aspect of
the ankle, avoiding the dorsalis pedis artery.
Tap
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Ankle Lateral Approach
Tap
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Ankle Medial Approach
Tap
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Subtalar Joint
Tap
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Synovial Fluid Analysis

• Identify crystals, pus
• Analyze color, clarity, cell count, differential,
  Grams stain, crystals
• Positive Grams stain diagnostic for septic
  arthritis
• Negative Grams stain does not rule out septic
  arthritis

Fluid
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Synovial Fluid Cell Count

• Noninflammatory vs. inflammatory
• ED wet mount prep
• 1 to 2 WBCs per high-power field consistent with
  noninflammatory
• gt20 WBC/HPF suggests inflammation or infection
• Septic gt50,000 WBC/mm3 (also rheumatoid, gout,
  pseudogout)

Fluid
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Synovial Fluid Analysis
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Other Synovial Fluid Analysis

• Glucose, lactic acid, viscosity, mucin clot, and
  total protein limited utility, not recommended
• Appropriate container
• Cellular analysis lavender (ethylenediaminetetraa
  cetic acid)
• Crystal analysis green (heparin)
• Chemical analysis, serology red

Fluid
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Crystal Studies

• Monosodium urate needle shaped, birefringent
  negative
• Parallel to compensator yellow
• Perpendicular blue
• Calcium pyrophosphate polymorphic, birefringent
  positive
• Parallel to compensator blue
• Perpendicular yellow

Xtals
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Crystal Studies
Xtals
Sodium urate crystals viewed under polarized
light with a red plate makes those in the plane
of the long axis of the red plate yellow, which
indicates that they are negatively birefringent.
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Crystal Studies
Xtals
Calcium pyrophosphate crystal viewed under
polarized light with a red plate. The crystal is
aligned in the long axis of the red plate, so
that it is bluish-white, which indicates that it
is weakly positively birefringent.
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Specific ArthritidesThere are more than 90
Preisers disease avascular necrosis of scaphoid
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Septic Arthritis

• Hematogenous spread
• Direct inoculation
• Direct spread from bony or soft tissue infections

Septic
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Septic Arthritis

• Synovium infected before degrading enzymes
  released
• Children hematogenous most common
• Postoperative infection 10 of joint surgeries

Septic
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Causes

• Staphylococcus aureus most common (even in
  sickle cell)
• Others streptococcus, Gram negatives, anaerobes
• N. gonorrhoeae 20 monarticular
• lt6 months E. coli, group B strep
• IV drug users S. aureus, Gram negatives

Septic
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Clinical Features

• Based on hosts concurrent medical conditions
• Painful, hot, swollen
• Typical single joint
• Knee 40 to 50
• Hip 13 to 20
• Shoulder 10 to 15
• 20 polyarticular

Septic
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Clinical Features

• History of fever 80
• Shaking chills 20
• Elevated sedimentation rate more common than
  leukocytosis
• Blood cultures grow causative organism 50 of
  the time
• Radiographs not often useful

Septic
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Management

• Admit for joint drainage, IV antibiotics
• Empiric therapy based on Grams stain
• Parenteral narcotic analgesics, articular
  immobilization control pain and discomfort

Septic
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Gouty Arthritis

• Podagra foot goddess, a bad-tempered virgin, who
  attacked victims after they overindulged
• Thought to be limited to men who had indulged in
  dietary or sexual excess

Gout
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Gouty Arthritis

• Galen (129-199 AD), an ex-gladiatorial surgeon in
  Rome, described gout as a discharge of the four
  humors of the body in unbalanced amounts into the
  joints (hence gout gutta, a drop)

Gout
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Patron saint against gout
St. Tropez Feast 12/29
Gout
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Be temperate in wine, in eating, girls and sloth
Or the gout will seize you and plague you both
Gout
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Pathophysiology

• Uric acid crystal deposits from supersaturated
  extracellular fluid
• Risk factors obesity, hypertension, diabetes,
  alcohol, proximal loop diuretics, lead poisoning
• During attack crystals ingested by PMNs ?
  inflammation

Gout
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Pathophysiology

• Middle-aged men, post-menopausal women
• Increased uric acid usually present for 20 years
  before first attack
• Uric acid often normal

Gout
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Presentation

• Great toe MTP joint in 75
• Also tarsal, ankle, knee, wrist
• Up to 40 polyarticular
• Pain excruciating at onset
• Can mimic septic joint
• Usually self-limited
• Systemic symptoms usually minimal or absent

Gout
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Presentation

• Subsequent attacks closer together, more joints,
  last longer
• Long-term kidney stones

Gout
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Presentation

• Tophi foreign body granulomas with crystals as
  nidus, in musculo-tendinous unit olecranon
  bursa, Achilles tendon, hands, knees, etc.

Gout
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Diagnosis

• Rule out cellulitis, septic arthritis
  particularly if knee joint
• All may have fever, leukocytosis, elevated ESR
• Uric acid level not helpful
• X-rays soft-tissue swelling (acute) or joint
  destruction (chronic)

Gout
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Uric Acid Levels

• Uric acid normal in 40
• Tophi can form in cool body areas without
  hyperuricemia
• Acute attack ? pain ? increased cortisol ? uric
  acid diuresis ? normalized level

Gout
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Diagnosis
Gout
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Diagnosis

• Definitive diagnosis birefringent joint fluid
  crystals with polarizing microscope (a yellow
  crystal against a red background) and negative
  joint fluid culture

Gout
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Acute Therapy Colchicine

• Not diagnostic works on pseudogout
• Contraindication hematologic, renal, hepatic
  dysfunction
• Extravasation from IV ? tissue necrosis

Gout
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Acute Therapy Colchicine

• Inhibits microtubule formation
• Most effective in first 24 hours
• 0.6 mg / hour until pain controlled, max 6 mg or
  side effects (GI)
• Average toxic dose 6.7 mg
• Toxicity precedes improvement in more than 50

Gout
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Acute Therapy Other

• NSAIDs effective, indomethacin most common (75 to
  200 mg/day)
• Contraindicated in PUD, GI bleed
• If resistant prednisone taper
• 40 mg/day first 3 to 5 days
• Adrenocorticotrophic hormone
• ACTH 40 IU to 80 IU IM

Gout
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Pseudogout

• Calcium pyrophosphate dihydrate (CPPD)
  crystal-deposition disease
• Knee most common joint
• Polyarticular possible
• Pain less severe, patients older
• Risk hypothyroid, Wilsons disease,
  hyperparathyroid, hemochromatosis, etc.

Pseudo
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Diagnosis

• Common elevated ESR, WBC
• X-ray may show joint calcification
• Joint fluid
• Weakly positive birefringent crystals on
  polarized microscopy
• Appear rhomboidal on regular light microscopy
• Treatment same as gout

Pseudo
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Chondrocalcinosis
Pseudo
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Osteoarthritis

• Degenerative joint disease
• Most common form of arthritis
• Loss of articular cartilage, reactive changes at
  joint margins
• Synovitis in advanced disease
• May have painful bone-to-bone interface

O A
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Presentation / Diagnosis

• Chief complaint pain
• No systemic symptoms
• Hands Bouchards, Heberdens nodes (osteophyte
  spurs)
• Knee active passive crepitus
• Routine lab tests normal
• Radiographs joint- space narrowing, osteophyte
  formation

O A
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Heberdens and Bouchards
Over DIP
Over PIP
O A
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Treatment

• Judicious exercise for muscle strengthening
• Relieve muscle spasm
• Support joint
• Acetaminophen comparable to ibuprofen for
  short-term treatment
• Ultimately joint replacement

O A
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Gonococcal Arthritis

• Woman men 41
• Fever, chills, arthralgias, migratory
  tenosynovitis
• Progresses to arthritis knee, ankle, wrist
• Characteristic rash countable hemorrhagic
  necrotic pustules
• Rarely have cervicitis or urethritis

G C
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Gonococcal Arthritis
G C
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Gonococcal Arthritis
G C
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Diagnosis

• Blood cultures usually negative
• Synovial fluid cultures positive in less than 50
• Grams stain positive more often than culture
• Cervical, urethral, pharyngeal, rectal cultures
  positive 75

G C
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Treatment

• Admit to hospital
• Ceftriaxone 1 g IM or IV daily, and 24 to 48
  hours after improvement
• Ciprofloxacin 500 mg twice daily orally for total
  7 days of antibiotics
• Spectinomycin 2 grams IM every 12 hours if
  beta-lactam allergic

G C
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Viral Arthritis

• Most common rubella, hepatitis B
• Also mumps, adenoviruses, Epstein-Barr virus,
  enteroviruses
• Deposition of soluble immune complexes in
  synovium with resultant inflammation

Virus
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Rubella Arthritis

• Often young women
• Rash several days before
• Acute, symmetric, usually polyarticular
• Resolves within weeks
• Recent infection or vaccination
• Virus isolated from synovial fluid

Virus
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Rubella
Virus
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Hepatitis B Arthritis

• Usually with or after prodrome of fever and
  lymphadenopathy
• Often precedes jaundice
• May be sudden and severe
• PIP, knee, ankle, MP joints most commonly
  involved
• Salicylates may be helpful

Virus
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Lyme

• Spirochete Borrelia burgdorferi
• Vector Ixodes dammini on East Coast and Midwest
• Arthritis late manifestation
• Within 6 months, half of untreated have frank
  arthritis
• Asymmetric
• Most common in knees

Lyme
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Presentation

• Minimal joint pain, usually afebrile
• Severity of initial presentation predictive of
  subsequent arthritis
• Chronic arthritis more common in patients
  positive for HLA-DR4
• Joint fluid inflammatory with PMN predominance
• Diagnosis is clinical

Lyme
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Presentation
Lyme
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Ixodes
Lyme
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Spondyloarthropathies

• Seronegative negative rheumatoid factor
• Sacroiliac involvement
• Peripheral joint inflammation
• Changes of ligamentous and tendinous insertion
  into bone
• Genetic HLA-B27

Sero -
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Spondyloarthropathies

• Ankylosing spondylitis
• Reactive arthritis (e.g. Reiters syndrome)
• Psoriatic arthritis
• Arthropathy of inflammatory bowel disease

Sero -
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Ankylosing Spondylitis

• Male predominance
• Back pain
• X-ray evidence of sacroiliitis
• Symmetrically squared vertebral bodies, then
  bamboo spine
• Morning stiffness, improves with exercise

Sero -
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Ankylosing Spondylitis
Sero -
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Ankylosing Spondylitis

• Uveitis most common extra-articular
  manifestation
• Peripheral joints involved in 30 of patients
  with enthesopathic involvement (plantar fasciitis
  and Achilles tendinitis)
• Goal of therapy control pain, decrease
  inflammation

Sero -
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Reiters Syndrome

• Reactive arthritis in genetically susceptible
  host after infection with GU C. trachomatis, or
  GI shigella, salmonella, yersinia, campylobacter
• Disease of men 15 to 35 years old arthritis
  develops 2 to 6 weeks after episode of urethritis
  or dysentery

Sero -
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Reiters Syndrome

• Polyarticular, asymmetric
• Weight-bearing joints of lower extremities
  commonly involved knees, ankles, feet,
  particularly heels (lovers heel)

Sero -
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Reiters Syndrome

• Other signs appear early
• Conjunctivitis, progress to iritis, uveitis,
  corneal ulceration
• Painless ulcers mouth, tongue, glans penis
  (balanitis circinata)
• Sausage-like fingers and toes
• Keratoderma blennorrhagica on palms and soles

Sero -
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Reiters Syndrome
Sero -
Keratoderma blenorrhagica
Balanitis circinata
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Reiters Syndrome

• Synovial fluid inflammatory with predominance
  of PMNs
• Antigens in synovial membrane and joint fluid,
  cultures sterile
• Increased ESR, WBC
• HLA-B27 antigen in 80
• Enthesopathic x-rays, particularly at IP joint of
  great toe

Sero -
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Reiters Syndrome

• NSAID two or three times daily
• Doxycycline twice daily x 3 months
• Intra-articular steroid injections
• If persistent Sulfasalazine
• Chronic therapy for erosive, deforming disease
• Methotrexate
• Azathioprine (Imuran)

Sero -
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Psoriatic Arthritis
Sero -
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Rheumatism

• An older term used to describe any of a number of
  painful conditions of muscles, tendons, joints,
  and bones.

• Rheumatism weed Canadian dogbane

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Acute Rheumatic Fever

• Believed to result from Group A streptococcus
  pharyngitis
• Exact mechanism unclear
• In decline since antibiotics
• Probable abnormal humoral response to antigens

ARF
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Clinical Syndrome

• Recurring self-limited episodes of fever
  associated with polyarthritis, carditis /
  valvulitis, rash, subcutaneous nodules, or chorea
  
• Occurs 2 to 3 weeks after streptococcal
  pharyngitis

ARF
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Diagnosis Jones Criteria

• Two major, or one major and two minor, criteria
  with evidence recent Group A streptococcal
  infection
• Major manifestations polyarthritis, carditis,
  chorea, erythema marginatum, subcutaneous nodules
• Migratory arthritis in large joints

ARF
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Diagnosis Jones Criteria

• Involves heart in 50
• Pericarditis, congestive heart failure, valvular
  dysfunction, cardiomegaly
• Neurologic Sydenhams chorea, weakness,
  behavioral disturbance
• Sparing of sensory functions

ARF
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Diagnosis Jones Criteria
ARF
Sinus tachycardia
1st degree AV block
RBBB pattern
Right atrial enlargement
Left atrial enlargement
Left ventricular strain
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Diagnosis Jones Criteria

• Erythema marginatum well-demarcated, pink
  nonpruritic rash, usually trunk, sometimes
  proximal limbs
• Central clearing, may last hours

ARF
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Erythema Marginatum
ARF
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Diagnosis Jones Criteria

• Subcutaneous nodules firm, nontender under skin
  overlying bony prominences

ARF
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Laboratory Work-Up

• Throat culture, ESR, CRP, ASO
• Anti-DNase B 95 sensitive
• Streptozyme test also documents recent
  streptococcal infection
• Synovial fluid
• Inflammatory (average WBC 16K)
• Negative culture

ARF
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Post-Streptococcal

• Reactive arthritis closely related to ARF but
  distinct clinical entity
• Sterile oligoarthritis associated with distant
  bacterial infection
• Carditis rare, arthritis often severe
• Treatment penicillin, erythromycin
• Arthritis responds to salicylates

ARF
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Rheumatoid Arthritis
R A
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Rheumatoid Arthritis

• Usually chronic gt20 acute
• Women 2 to 3 x more than men
• Immune complexes stimulate PMNs to release
  enzymes
• Synovial cells proliferate, produce more
  inflammatory substances

R A
145
Presentation

• Prodrome fatigue, weakness, musculoskeletal pain
  
• Symmetric joint swelling hands (MP, PIP joints),
  wrists, elbows
• Difficult to distinguish from viral arthropathy

R A
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Presentation

• Long-term changes MP and PIP swelling, ulnar
  deviation, swan-neck and boutonnière deformities
  of hands, limited wrist dorsiflexion

R A
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Swan Neck Deformity
R A
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Presentation

• Knee effusion, muscle atrophy, Bakers cyst
• Retrocalcaneal bursa
• Subcutaneous nodules, pulmonary fibrosis,
  mononeuritis multiplex
• Sjögrens and Feltys syndromes

R A
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Bakers Cyst
R A
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Subcutaneous Nodules
R A
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Feltys Syndrome

• Rheumatoid arthritis splenomegaly leukopenia
• Frequent pneumonia and leg ulcers
• 1 of RA patients

R A
152
Transverse Ligament Rupture

• C1 on C2 subluxation in 70
• Frank dislocation in 25
• Cord compression in 11
• With myelopathy
• 5 years survival 80
• 10 year survival 28
• Anterior instability more common than posterior
  instability

R A
153
Transverse Ligament Rupture
R A
154
Treatment

• Movement increases inflammation initial
  treatment rest
• Suppress inflammation steroids, salicylates,
  gold, penicillamine, azathioprine, methotrexate,
  cyclosporine, sulfasalazine

R A
155
Nontraditional Thinking

• The Mycoplasma Theory joint pain caused by
  subclinical mycoplasma infection, improves with
  doxycycline
• Glucosamine and chondroitin possibly useful in
  osteoarthritis

? ? ?
156
Known Not to Work

• ALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET
  - AMINO ACIDS - MA-HUANG - ANT VENOM - MANDELL
  ARTHRITIS DIET - ARNICA MEGAVITAMIN THERAPY -
  ASCORBIC ACID - NATURAL AND ORGANIC FOODS - BARK
  TEAS - NIGHTSHADE VEGETABLES - BEE POLLEN - OZONE
  - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA -
  CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO
  - CLAY ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS
  - ROYAL JELLY - CLOVES - RAW MILK - COD LIVER OIL
  - RHUS TOXICODENDRON - COENZYME Q-10 - ROSE HIPS
  - COFFEE ENEMAS - RUTIN - COICIS SEMEN -
  SASSAFRAS - COLONICS - SELENIUM - COPPER
  BRACELETS - SHARK CARTILAGE - CYTOTOXIC TESTING -
  SNAKE VENOM - DEVIL'S CLAW - SOAPWEED - DISMUTASE
  (SUPEROXIDE DISMUTASE) - SPANISH BAYONET - DONG
  DIET - SPANISH FLY - ELIMINATION DIETS -
  STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE
  DIET - TEAS (FEVERFEW, GINSENG, SASSAFRAS) -
  FO-TI - THIAMINE - GARLIC - VEGETARIAN DIETS -
  GERMANIUM - VOLCANIC ASH - FASTING - GINSENG -
  WATER ENEMA - GREEN-LIPPED MUSSEL - WOOD SPIDER
  - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN
  MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP

? ? ?
157
Pearls

• The number and distribution of joints involved
  helps pinpoint the most likely cause of
  arthritis.
• Monarthritis is septic arthritis until proven
  otherwise.
• Negative Grams stain of synovial fluid does not
  rule out bacterial arthritis.

158
Pearls

• The most definitive test for evaluating an
  inflamed joint for the possibility of bacterial
  infection is examination of synovial fluid.
• Delays in the diagnosis and treatment of septic
  arthritis worsen outcomes.

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