APPROACH TO JOINT PAIN

Question 1

DDx

Answer 1

Traumatic / Peri-articular:
Fracture
Ligament
Soft tissue injury
Bursa
Muscle
Dislocations
Traumatic Hemarthrosis

Infectious:
Septic Arthritis
Gonococcal arthritis
Lyme Disease
Osteomyelitis

Inflammatory:
Crystal-induced synovitis
Reactive Arthritis
IBD associated arthritis
Seronegative Spondyloarthropathies
Rheumatoid arthritis

Degernerative: Osteoarthritis

Neoplastic

Referred Pain

Question 2

HPI

Answer 2

Onset: gradual or sudden
Position: IN or AROUND the joint
Monoarticular, Oligoarticular, Polyarticular
Pain at Rest or Motion
Weight bearing, effect on function
Timing: worse at the end of the day or morning
Aggravating factors
Alleviating factors

Question 3

Clinical Features of Articular Pain

Answer 3

Joint Effusion
Deformities
ALL ROM limited
Pain w/ aROM and pROM
Tender Joint Line

Question 4

Preceding Events

Answer 4

Trauma
Drug Exposures
Preceding Illnesses (GU, GI)
Recent travel
Recent exposures: tick bites, IVDU, Sexual Exposures, Alcohol
Recent surgery

Question 5

Associated Symptoms

Answer 5

Fevers, chills
Nausea, Vomiting, Pre-syncopy / syncopy
Edema, warmth, erythema (including cellulitis)
Red eye, rash, mouth ulcer
Abdominal pain, diarrhea
STI symptoms

Question 6

Red Flags

Answer 6

Immunocompromised
STI
IVDU
Fever
Non weight-bearing
Rapid progression / onset
Swollen, painful, red, hot

Question 7

Relevant PMHx

Answer 7

Previous joint injury
Psoriasis
IBD
AS
Bleeding Diathesis
Gout

Question 8

Relevant SHx

Answer 8

PROSTHETIC JOINT

Question 9

Investigations

Answer 9

Arthrocentesis and Synovial Fluid Analysis:
Gram Stain
Culture
Leukocyte Count with differential
Wet prep for crystals

CBC sensitivity 60% for non gonococcal septic arthritis
CRP, ESR for monitoring treatment
Lyme titer
Rheumatoid factor
Antinuclear antibodies
HLA-B27
Lupus anticoagulant

Question 10

Approach to knee aspiration

Answer 10

Medial or Lateral approach
Prep with alcholol
Anesthetize with Xylocaine
Prep with chlorhexidine
Prep sterile field
Identify the midpoint of the patella
Insert 18 g needle 1 cm inferior to the patellar edge
Direct the needle posterior to the patella and horizontally towards the joint space

Question 11

Contraindications to Arthrocentesis

Answer 11

Overlying cellulitis
Coagulopathy
Consult ortho for aspirating prosthetic joints