Swollen Joints Flashcards
What are the three ways a joint can become swollen
Due to soft tissue swelling
Knee effusion
Inappropriate deposition of tissue
What is knee effusion
When fluid accumulates within the intraarticular space of the knee
Can be blood- irritates
Or synovial fluid
What is it called when fluid accumulates within the eintraarticular space of the knee
Knee effusion
What two fluids can accumulate in the knee causing a knee effusion
Blood or synovial fluid
What symptoms occur due to knee effusion
Pain
Swelling
Reduced range of movement in the knee
A patient presents with swelling and pain in his right knee. He states than he hasn’t been able to bend or straighten his knee completely in the past couple of days. What’s the diagnosis
A knee effusion
What is haemarthrosis
Accumulation of blood in a joint
What is haemarthrosis mostly caused by
ACL ruptures
Patella dislocation
Meniscal tears
What is it called when blood accumulates in a joint
Haemarthrosis
What is liphaemarthrosis
Accumulation of fat and blood in a joint following a fracture
When does lipohaemarthrosis occur
After a fracture
A patient comes in with pain and swelling in his knee following a tibial condyle fracture. He has limited movement of his knee and his knee is very warm. What is mostly likely occurring in his knee joint
Lipohaemarthrosis
What investigations would you do if you suspect a patient is suffering from either haemarthrosis or lipohaemarthrosis
Blood tests
Imaging- X-rays
Synovial fluid- basic tests
When taking blood tests from a patient with suspected haemarthrosis, what would you test for?
Full blood count- white blood cells and haemoglobin
Inflammatory markers- CRP/ESR
Blood cultures
What is the normal appearance, WCC, crystals and culture of an aspiration sample without haemarthrosis
Appearance- clear viscous fluid
WCC- 0-200 cells/uL
Crystals- none
Culture- sterile
If a patient has haemarthrosis, what would the appearance, WCC, crystal and culture of their knee aspiration sample be
Appearance- red, pink or brown and highly viscous
WCC- 0-200 cells/uL- normal
Crystals- none- normal
Culture- sterile- normal
A patient has haemarthrosis and has an X- ray taken. What would be seen on the image
Some fluid accumulation in the joint
What is the management of both haemarthrosises
Manage the fracture/ dislocation/ ligament tear
Synovial fluid aspiration
What is rheumatoid arthritis
Autoimmune condition affecting synovium- thin layer of connective tissue that lines inside of joints
What are the auto-antibodies that cause rheumatoid arthritis
Anti-cyclic citrullinated peptide antibodies
Also known as anti-CCP
How is rheumatoid arthritis caused
Anti-CCP antibodies attack synovium
Leads to inflammation
Causes formation of pannus- abnormal tissue growth in joints- causes swelling, pain and can cause damage
Pannus is erosive- can destroy articular cartilage and bone
What sex does rheumatoid arthritis affect more
Females
2-4 times greater in females compared to males
What is the peak onset of rheumatoid arthritis
30-50 years
In rheumatoid arthritis there is a bilateral distribution of small joints. What does this mean?
Means that the joints affected on one side of the body are the same joints affected on the other side of the body.
Eg. Arthritis in knuckle of middle finger on left hand means arthritis in knuckle of middle finger on right hand
Where does rheumatoid arthritis affect first then spread to
Affects distal joints to begin with then can spread more proximally
What are the key symptoms of rheumatoid arthritis
Painful joints
Stiffness- typically in the morning
Swollen joints
Erythematous- superficial reddening of the skin
Hot joints
A female patient aged 45 experiences pain in both her hand- specifically her phalangeal joints. They appear to be swollen and hot to touch. What is the assumed diagnosis?
Rheumatoid arthritis
What tests would you carry out to confirm a patient has rheumatoid arthritis after they have come in with the symptoms
Blood tests
X rays
What would you test for in a blood test when investigating rheumatoid arthritis and why
Full blood count- may have anaemia or raised platelets
CPR/ESP- may be raised- inflammation
Presence of anti-CPP antibodies or rheumatoid factor
You take some X-rays of a suspected rheumatoid arthritis patient. What on the X-ray would confirm your suspicions
Loss of joint space
Juxta-articular osteoporosis- bone loss around the joints
Marginal erosions- breaks in the bone- occur edge of joint
Soft tissue swelling
When would you perform an aspirate for rheumatoid arthritis
When the affected area is large- eg. Large joint
Not when area is small- eg. Hands
If a patient has rheumatoid arthritis, what would the appearance, WCC, crystal and culture of their aspiration sample be
Appearance- yellowish/ green- low viscosity- abnormal
WCC- 2,000-100,000 cells/uL- higher than normal
Crystals- none- normal
Culture- sterile- normal
What is the management of rheumatoid arthritis
Steroids- Glucocorticoids- short term only
Immunosuppressants- methotrexate
A female aged 45 comes in with pain and swelling in both her hands. An aspiration sample is taken. The results show a yellow liquid with a low viscosity, with white blood cell count 6000, no crystals and a sterile culture. What’s the diagnosis?
Rheumatoid arthritis
What joints does osteoarthritis affect
Synovial joints
What is the pathophysiology of osteoarthritis
Excessive/ uneven loading of joint
Swollen cartilage due to damage- increase proteoglycan content in extracellular matrix- new chondrocyte formation
After initial attempts to repair- several years- proteoglycan content falls- cartilage becomes soft and loses elasticity
Articular cartilage damaged, flaking and fibrillation occur in normally smooth surface
Cartilage erodes- bone touches bone
What kind of arthritis erodes cartilage and leads to bone touching bone
Osteoarthritis
What sex is more likely to suffer from osteoarthritis
Female
What are some risk factors of osteoarthritis
Increasing age
Previous trauma to joint
Occupation
Increased BMI- overweight/ obesity
Previous infection/ bleeding into joint
Genetics
What are some symptoms of osteoarthritis
Joint pain that worsens during exercise, but relieved by rest
Morning stiffness that lasts less than 30 mins
Bony swelling and deformities
Reduced range of movement
Crepitus- grinding/creaking sensation on moving joint
Tenderness around joint
‘Flares’- swelling, inflammation and increased pain
A female patient aged 55 comes in with pain in knee- its swollen and cant move it properly. She says it hurts when she does exercise but the pain goes away during rest. What’s the diagnosis and why?
Osteoarthritis
Name 4 differences between osteoarthritis and rheumatoid arthritis
If you suspect a patient has osteoarthritis what investigations do you do and what do you check for
Take bloods- CRP may be raised in flare- otherwise nothing specific- diagnosis usually on clinical presentation and examination findings
X- ray- Loss of joint space
- Osteophyte formation
- Subchondral sclerosis
- Subchondral cysts
(LOSS)
When would you take a synovial fluid sample from a patient that you suspects has osteoarthritis
If they are in flare and need to rule out other conditions
What would a synovial fluid sample of a patient with osteoarthritis show- appearance, WCC, crystals and culture
Appearance- normal viscosity- large volume
WCC- 0-2000 cells/uL- slightly higher than normal
Crystals- usually none- normal
Culture- sterile- normal
What is the management strategy for a patient with osteoarthritis
Basic- Analgesia
-Exercise
-Weight loss if overweight
Advanced- steroid injection
Extreme- joint replacement- arthroplasty
When would you suspect a patient has septic arthritis instead of any other type of arthritis
When they have a fever
As well as common symptoms of arthritis
What is the pathophysiology of septic arthritis
Most common cases staphylococcus aureus bacteria present in blood
Trauma or surgery causes direct inoculation
Or can be caused by contiguous spread- spread from nearby- eg. Bone infection
What are some symptoms of septic arthritis
Pain
Reduced range of movement
Inability to weight bear
Swollen, hot joint
Painful palpation
Feeling generally unwell- fever
You see a patient and suspect the have septic arthritis- what investigations would you do
Bloods
X-ray
What would an x-ray of a person with septic arthritis show
Could see joint space widening or effusion
Or could just be normal
What would the blood results of a person with septic arthritis be- appearance, WCC, crystals and culture
Appearance- cloudy with low viscosity- abnormal
WCC- 50,000- 200,000- very high
Crystals- usually none- normal
Culture- positive- abnormal
Why do you need to take bloods, not just an x-ray if you suspect a patient has septic arthritis
X-ray can sometimes look normal
Septic arthritis caused by bacteria- blood will contain bacteria and WBC- triggers immune respones so WCC high and culture will be positive
What is the management strategy for a patient with septic arthritis
Immediate IV antibiotics
Surgery to wash out joint
What are some symptoms of gout
Swollen, red and tender joint- Patient may not be able to tolerate palpation
Acute onset pain- reaches peak over 6-12 hours
Symptoms usually resolve in 2 weeks
What is the pathophysiology of gout
Crystals form due to high levels of urate
Deposition of monosodium urate crystals within joint cause pain
Crystals lead to inflammation and damage joint
What causes high urate levels
Kidney not removing urate
Increased production of urate
What are some risk factors of gout
Affects males more than females
40-60 years old
Increased consumption of meat/seafood/alcohol/sugar
Diuretics
Obesity
Diseases that have high metabolic turnover- eg. Psoriasis, leukaemia or chemotherapy
A patient comes in with suspected gout. What investigations would you do?
Bloods
X-rays
You take bloods from a patient with suspected gout. What would the results be if the patient has indeed got gout.
Raised urate levels and CRP/ESP
You take an X-ray of a patient with suspected gout. What would the images look like if the patient has indeed got gout.
If gout is early- may not be able to see anything
If repeated attacks- may see punched out lesions
May see crystal deposition in soft tissue- gout tophi
What would the results synovial fluid aspirate of a person with gout show. Appearance, WCC, crystals, culture.
Appearance- clear, low viscosity- normal
WCC- 500-200,000- high
Crystals- needle shaped- abnormal
Culture- sterile- normal
How do you manage an acute attack of gout
NSAIDS- reduce inflammation and treat pain
Rest
Ice packs
Elevate limb
Management after an acute attack of gout
Urate- lower therapy- allopurinol long term to prevent future attacks
Manage diet
Weight loss
