Joints And Bursae

Question 1

What is the most important consideration in the evaluation of a swollen, warm, and painful joint?

Answer 1

Septic arthritis
An acutely hot, swollen and tender joint with restriction of movement is bacterial nongonococcal septic arthritis until proven otherwise

Question 2

What is septic arthritis?

Answer 2

Invasion of a joint by an infectious agent, with proliferation and dinflammation
- bacterial arthritis is a subset of septic arthritis

Question 3

What are the two types of bacterial septic arthritis?

Answer 3

Bacterial nongonococcal septic arthritis
Gonococcal septic arthritis

Question 4

Features of bacterial nongonococcal septic arthritis

Answer 4

No clinical pattern but some indications
- joint pain (85%)
- joint swelling (78%)
- fever (57%)
- rapid onset of exquisite pain

Question 5

If clinical evaluation cannot rule out septic arthritis?

Answer 5

Do arthrocentesis, if still unsure Admit for parenteral abx

Question 6

Features of gonococcal septic arthritis

Answer 6

• Prodromal phase with migratory arthritis in sexually active young adults
• pain and swelling settle on one or more septic joints
• vesiculopustular lesions, especially on the fingers

Question 7

Synovial fluid analysis in gonococcal septic arthritis?

Answer 7

Often neg
- only 25% of cases yield positive id of organism
- culture pharynx, urethra and rectum before the abx

Question 8

How do you diagnose septic arthritis?

Answer 8

No single diagnositic parameter is sufficiently sensitive to screen patients for septic arthritis, including WBC count
- bedside US is useful to ID effusion and guide aspiration
- radiographs if trauma, tumor, AVN, or osteoporosis are considerations
- MIR is not helpful
- arthrocentesis

Question 9

Arthrocentesis considerations in septic arthritis

Answer 9

• Dont go through cellulitis or impetigo
• Consult ortho prior to taping a prosthetic joint
• anticoagulants are not an absolute contraindication

Question 10

MCC of septic arthritis in adults?

Answer 10

Gonococcal

Question 11

Synovial fluid for septic arthritis

Answer 11

When suspected, aspirate fluid, obtain analysis and culture to direct treatment

Question 12

What labs dont help direct treatment in septic arthritis?

Answer 12

Glucose, protein, and lactate dehydrogenase levels

Question 13

What labs suggest septic arthritis?

Answer 13

Elevated synoval lactate
Novel biomarker presepin

Question 14

Number of joints in nongonococcal septic arthritis?

Answer 14

85% are single joints

Question 15

Risk factors for multi-joint septic arthritis

Answer 15

• Staph and strep pneumonia
• RA, immunocompromised, gout, DM, renal disease
• joint d/o that is migratory (Rheumatic fever, lyme, viral arthritis)

Question 16

Risk factors for non gonococcal septic arthritis

Answer 16

Injection drug use
DM
RA
Prosthetic joint
Immunosuppressed/hiv
Age >80
Skin ulceration/infection
Hemophilia
Hypogammaglobulinemia
Malignancy
Liver disease
ETOH
Steroid therapy

Question 17

Risk factors for gonococcal septic arthritis

Answer 17

HIV
Injection drug use
Pregnancy
Menses
SLE
Complement deficiency

Question 18

Contraindication for joint aspiration?

Answer 18

Hemophilia can cause hemarthrosis
- anticoagulants are generally safe. Even DOACs

Question 19

Gout treatment without renal insufficiency

Answer 19

First line:
- NSAIDS 3-7 days
- indomethacin 50mg TID
- naproxen 250-500 mg BID
Alternate agent
- colchicine - 1.2mg then 0.6mg in 1 hr after 12 hrs 0.6mg SID or BID

Question 20

Gout treatment with renal insufficiency

Answer 20

Dont give NSAIDs
May need narcotics - since cant give NSAIDS
- prednisone is first line treatment
- - Careful if they have DM, CHF, or HTN