27. Acute Joint Pain Flashcards
What diagnosis must you exclude in a patient with acute joint pain?
Septic arthritis
What are 4 articular causes of single acutely painful joints in adults?
Trauma
Gout
Pseudogout
Septic arthritis
What are 5 peri-articular causes of single acutely painful joints in adults?
Ligament injury Tendinitis Bursitis Fascitis Epicondylitis
What are 2 non-articular causes of single acutely painful joints in adults?
Nerve entrapment
Radiculopathy
Pain that is worse on movement and improves with rest is likely to be…
Non inflammatory
Acute joint pain- list 4 causes with rapid onset
Septic arthritis
Gout
Pseudogout
Trauma
Joint pain- list 2 causes with insidious onset
Bursitis
Tendonitis
What are 6 common risk factors for gout?
Thiazide diuretics Recent heavy alcohol intake Chronic renal failure Chemotherapy Hx renal stones Hx gout
What are 2 common risk factors for septic arthritis?
Immunosuppression (diabetes, HIV, steroids)
Prosthetic joints
What are 3 risk factors for haemarthrosis?
Coagulopathies (haemophilia)
Anticoagulant use (warfarin)
Trauma
Acute joint pain- what do you need to ask about in PMHx?
Recent GI or urethral infection: take a sexual hx as gonoccal infection can be asymptomatic + lead to septic arthritis
Previous episodes? (recurrent conditions- crystal arthropathies + overuse)
Rheumatological conditions?
Why is the pattern of joint involvement important in acute joint pain?
Involvement of joints sequentially= gonococcus + rheumatic fever
Several joints simultaneously= chronic polyarthritis
What should you do on joint examination?
Look, feel, move
Look: erythema, scars, swelling, muscle wasting, bony deformities, asymmetry
Feel: effusions, tenderness on bones, ligaments, tendons along joint line, temperature + neurovascular status
Move: test full range of passive + active movement
What are articular conditions more likely to present with?
Diffusely inflamed joint (red, hot, painful)
Pain on passive + active motion
What are peri-articular conditions more likely to present with?
Focal point of tenderness on palpation
Pain worse on active instead of passive movement
What should be examined beyond joints?
Skin: Tophi, 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 (associated with inflammatory arthropathies e.g. RA)
Describe the possible results of arthrocentesis
Crystals may be present in gout Infection: cloudy aspirate Blood: haemarthrosis seen in trauma Fat globules: fracture White cells: inflammation
What are second line investigtions after arthrocentesis for acute joint pain?
Cultures FBC CRP ESR PT for coagulopathy in haemarthrosis RA?: Rheumatoid factor, anti-CCP + ANA Serum urate (though often L/N in acute gout) Plain radiographs MRI: soft tissue injury
What is acute management of gout?
Colchinine (contra indicated in patients with renal or hepatic impairment)
NSAIDs
Corticosteroid injections
What is the chronic management of gout?
Decrease urate production: allopurinol + febuxostat
Increase urate excretion: sulfinpyrazone + probenecid
Increase degradation of urate: rasburicase
Joint pain- what may present with chronic onset?
Osteoarthritis
Give 3 drugs that can predispose to gout?
Thiazides
Low-dose aspirin
Ciclosporin
What class of drugs can predispose to osteoporosis?
Steroids
How do the crystals differ in gout and pseudogout?
G: Urate: Negatively bi-refringent + needle shaped
P: Calcium pyrophosphate: Positively bi-refringent + rhomboid
Why must colchicine always be prescribed with allopurinol in the first 6 weeks?
Initial doses of allopurinol can paradoxically result in acute gout
Describe the management of septic arthritis
Analgesia
Take blood cultures
Give broad spectrum Abx
Joint aspiration + lavage
What is the most likely infective organism in a native joint?
Staphylococcus aureus
What is the most likely infective organism in a prosthetic joint?
Staphylococcus epidermis
Give 4 features of osteoarthritis on a plain radiograph
Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts
