T&O - Acutely Swollen Joint Flashcards
Acutely Swollen Joint
History Taking
Initial Assessment
Investigations
Joint Aspiration
Differential Diagnoses
1.) History Taking
- SQITARS, ability to weight bear, PMH
- systemic sx: fever/rigors, lethargy
- other sx: associated skin changes (psoriatic arthritis), GI (enteropathic arthritis), GU (reactive arthritis)
2.) Initial Assessment
- joint examination, redness/swelling/skin changes
- focal tenderness, joint effusion, range of motion
3.) Investigations
- routine bloods; inc ESR (rheumatological cause) and serum urate (suspected gout)
- plain film X-ray, joint aspiration
4.) Joint Aspiration - aspirate synovial fluid, send for WCC, MC+S
- non-inflammatory: clear, moderate WCC
- inflammatory: cloudy yellow, high WCC
- septic: turbid, very high WCC and high neutrophils
5.) Differential Diagnoses
- must exclude septic arthritis
- MSK injury, haemarthrosis, flare of OA
- RA, (pseudo)gout, spondyloarthropathies
- lyme disease/arthritis
Features of Joint Pain
Joint vs Soft Tissues
Non-Inflammatory Conditions
Inflammatory Conditions
Impact on Life
1.) Joint vs Soft Tissues - joint pain w/ normal joint examination suggests referred pain from soft tissues
- sprains, strains, bruises, contusions
2.) Non-Inflammatory Conditions - OA, fibromyalgia
- pain is worse on use and relieved by rest
- localised, short lasting (30mins) stiffness
- joint swelling is less common unless knee related
3.) Inflammatory Conditions - RA, gout, psoriatic/reactive arthritis, polymyalgia rheumatica
- pain is not relieved by rest
- generalised, prolonged morning stiffness (>2hrs)
- joint swelling is also very common
4.) Impact on Life
- daily activities, work, social, mood, ICE
Septic Arthritis
What is it?
Risk Factors
Clinical Features
Investigations
Management
1.) What is it? - infection of a joint
- main organisms: S. aureus, gonorrhoea (most common in young adults), salmonella
- bacteraemia, direct inoculation, adjacent osteomyelitis
- can cause irreversible articular cartilage damage
- complications are severe OA and osteomyelitis
2.) Risk Factors
- age (>80), existing joint disease, immunosuppression
- CKD, hip/knee prosthesis, IV drug use
3.) Clinical Features
- single swollen joint causing severe pain +/- pyrexia
- red, swollen, warm, effusion may be present
- unable to weight bear, pain on active and passive movement, joint is rigid
4.) Investigations
- routine bloods: ESR and urate levels,
- blood cultures, esp in evidence of sepsis
- joint aspiration before antibiotics given
- X-ray: soft tissue swelling, fat pad shift, ↑joint space
- CT/MRI if uncertain diagnosis
5.) Management
- empirical antibiotics
- irrigation and debridement for native joint
Rheumatoid Arthritis
Clinical Features
Investigations
EULAR Classification
Management
1.) Clinical Features - swollen, painful, red joints
- autoimmune inflammatory condition/features
- affects small joints in the hand and feet
- systemic sx: fatigue, lethargy, pyrexia, weight loss
2.) Investigations
- routine bloods: ↑CRP, ↑ESR, normocytic anaemia
- RF and anti-CCP/ACPA can also aid diagnosis
- X-ray: ↓joint space, periarticular osteopenia, juxta-articular erosions, subluxations, soft tissue swelling
3.) EULAR Classification - diagnostic criteria for RA using 4 categories, score >6/10 definitive for RA
- joint distribution (0-5): ↑no and smaller joints ↑score
- serology (0-3): RF and ACPA, the more +ve, ↑score
- duration (0-1): <6wks = 0, >6wks = 1 point
- acute phase reactants: abnormal CRP/ESR = 1 point
4.) Management - by rheumatologists
- NSAIDs for pain, DMARDs, biologic agents
- methotrexate (weekly) is gold standard for RA
Gout (+Pseudogout)
Pathophysiology
Clinical Features
Investigations
Management
Pseudogout
1.) Pathophysiology - inflammatory arthritis due to collection of monosodium urate crystals in a joint
- often due to hyperuricaemia, however, not all cases of gout will have high serum urate levels
2.) Clinical Features
- mainly 1st MTPJ, but also knee, elbow, wrist, fingers
- episodic, triggered by stress/illness/dehydration
- flare-ups can last from days to weeks
3.) Investigations
- diagnosis: joint aspiration showing thin needle-shaped negatively birefringent urate crystals in the synovial fluid
- X-rays only show soft tissue swelling
4.) Management
- treated acutely with NSAIDs and colchicine
- multiple episodes given allopurinol (↓uric acid) to prevent remission
5.) Pseudogout - mimics gout, deposits of calcium pyrophosphate crystals within the joint
- affects proximal joints, knee and wrist most common
- risk factors: ↑age, hypercalcaemia
- diagnosed by joint aspiration showing positively birefringent rhomboid-shaped crystals
- also treated with NSAIDs
Haemarthrosis
What is it?
Clinical Features
Investigations
Management
1.) What is it? - bleeding into a joint cavity
- usually occurs due to trauma but can also occur in patients with bleeding disorders (e.g. Haemophilia A) or on anticoagulants
2.) Clinical Features
- acutely swollen joint usually after trauma
- may be ligament (e.g. ACL) or meniscal injury w/ it
3.) Investigations
- routine bloods: inc clotting
- plain X-rays, joint aspiration (definitive)
4.) Management - usually conservatively
- RICE and sufficient analgesia
- correct underlying coagulopathies
Spondyloarthropathies
What are They?
Reactive Arthritis
Psoriatic Arthritis
Ankylosing Spondylitis
Enteropathic Arthropathy
What are They? - group of seronegative inflammatory conditions associated with HLA-B27
- can all present with axial arthritis, oligo/monoarthritis, or enthesitis and dactylitis (fingers)
- more common in men and young adults
1.) Reactive Arthritis - often develops after a GU or GI infection, tends to attack joints in the lower limbs
2.) Psoriatic Arthritis - in patients w/ psoriasis
- asymmetrical oligoarthritis, commonly affects the small joints of the feet and hands (mainly DIPJs)
- most patients also have nail lesions e.g. pitting
3.) Ankylosing Spondylitis - long term inflammation of the spine and other parts of the body
- most patients present with back pain
4.) Enteropathic Arthropathy - inflammatory arthritis related to people with IBD
Osteomyelitis
Haematogenous Osteomyelitis
Non-Haematogenous Osteomyelitis
Clinical Features
Investigations
Management
1.) Haematogenous Osteomyelitis - results from bacteraemia and is usually monomicrobial
- most common form in children (affects metaphysis)
- vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
- risk factors: IVDU, sickle cell anaemia, infective endocarditis, immunosuppression (HIV or medication)
- S.aureus is the most common organism (Salmonella in sickle cell anaemia)
2.) Non-Haematogenous Osteomyelitis - spreads from adjacent soft tissues or from direct injury/trauma
- often polymicrobial
- most common form in adults (affects epiphysis)
- risk factors: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
3.) Clinical Features
- symptoms tend to develop gradually over a few days
- pain (most common), warmth, erythema and swelling of the soft tissue surrounding the affected bone
- proximal joints (hips etc) may only present with pain
- systemic sx (e.g. fever, malaise) may be present
- chronic osteomyelitis: systemic sx often absent, a draining sinus tract may be seen
4.) Investigations
- bloods: FBC, CRP, blood cultures, VBG, G+S
- WCC is normal in chronic osteomyelitis
- diagnosed using an MRI scan (CT is second line)
5.) Management
- IV flucloxacillin for 6 weeks (clindamycin if allergic) via a PICC line
- surgical removal of any infected necrotic bone
- may need urgent surgical debridement in necrotising soft tissue infection or secondary systemic infection
