27. Acute Joint Pain

Question 1

What diagnosis must you exclude in a patient with acute joint pain?

Answer 1

Septic arthritis

Question 2

What are the articular causes of single acutely painful joints in adults?

Answer 2

Trauma, gout, pseudogout and septic arthritis

Question 3

What are the peri-articular causes of single acutely painful joints in adults?

Answer 3

ligament injury, tendinitis, bursitis, fascitis, epicondylitis

Question 4

What are the non-articular causes of single acutely painful joints in adults?

Answer 4

Nerve entrapment, radiculopathy

Question 5

Acute joint pain- pain that is worse on movement is likely to be…

Answer 5

Non inflammatory

Question 6

Acute joint pain- rapid onset likely to be…

Answer 6

septic arthritis, gout, pseudogout and trauma

Question 7

Joint pain- insidious onset likely to be…

Answer 7

bursitis, tendonitischronic onset- osteoarthritis

Question 8

What are common risk factors for gout?

Answer 8

thiazide diuretics, recent heavy alcohol intake, chronic renal failure and chemotherapy, history of real stones, gout in the past

Question 9

What are common risk factors for septic arthritis?

Answer 9

Immunosuppressants and prosthetic joints

Question 10

What are risk factors for haemarthrosis?

Answer 10

Coagulopathies, anticoagulant use, trauma

Question 11

Acute joint pain- what do you need to ask about in PMHx?

Answer 11

Recent GI or urethral infection, take a sexual history as gonoccal infection can be asymptomatic and lead to septic arthritis
Have they had any previous episodes
Have they had any rheumatological conditions

Question 12

Why is the pattern of joint involvement important in acute joint pain?

Answer 12

Involvement of joints sequentially= gonococcus and rheumatic fever
Several joints simultaneously= chronic polyarthritis

Question 13

What should you look out for on joint examination?

Answer 13

Look, feel, move
Look- erythema, scars, swelling, muscle wasting, bony deformities, asymmetry
Feel- effusions, tenderness on bones, ligaments, tendons along joint line
Move- test full range of movement at the joint, passive and active

Question 14

What are articular conditions more likely to present with?

Answer 14

Diffusely inflamed joint, pain on passive and active motion

Question 15

What are peri-articular conditions more likely to present with?

Answer 15

Focal point of tenderness on palpation, pain worse on active instead of passive movement

Question 16

What should be examined beyond joints?

Answer 16

Skin for tophi and rheumatoid nodules, rashes
Nail- pitting, subungual hyperkeratosis, onycholysis (signs of psoriasis)
Uveitis- inflammation of middle layer of eye
Mouth ulcers- possible crohn’s
Lung fibrosis

Question 17

Describe the possible results of arthrocentesis

Answer 17

Crystals may be present in gout
Infection- cloudy aspirate
Blood- haemarthrosis seen in trauma
Fat globules- fracture
White cells- inflammation

Question 18

What are second line investigtions after arthrocentesis for acute joint pain?

Answer 18

cultures, FBC, CRP, ESR, PTLook for rheum antibodies
Serum urate
Plain radiographs
MRI- soft tissue injury

Question 19

What is acute management of gout?

Answer 19

Colchinine (contra indicated in patients with renal or hepatic impairment)
NSAIDs
Corticosteroid injections

Question 20

What is the chronic management of gout?

Answer 20

Decrease urate production- allopurinol and febuxostat
Increase urate excretion: sulfinpyrazone and probenecid
Increase degradation of urate: rasburicase (not nice approved, high cost)