Acute Arthropathies“I’ve got a painful, swollen knee
doctor”
By Dr Mahya Mirfattahi GP ST1
HDR LRCH
9th December 2009
What could it be?
• Septic arthritis• Septic bursitis• Crystal arthropathies – gout, pseudogout• Acute exacerbation of osteoarthritis• Acute attack of rheumatoid arthritis• Trauma• Seronegative spondyloarthropathy• Viral infection• Lupus
Clinical assessment - History
• Patient demographics– Age, gender, ethnicity, obese
• History– Pain, swelling, stiffness, duration (short), site, preceding trauma,
other joints affected, previous episodes, systemic symptoms
• Past medical history– Joint prosthesis, osteoarthritis, previous trauma, inflammatory
arthritis, psoriasis, recent episodes of illness, diabetes mellitus, hypertension, recent corticosteroid joint injection, haemophilia
• Current medications– Bendroflumethiazide, aspirin, immunosuppressant therapy
Clinical assessment - Examination
• Look– Swelling, redness, scars, tophi, psoriatic plaques,
nails, nodules, joint deformities, ulcers
• Feel – Warmth, effusion, swellings
• Move– Restriction, crepitus, ability to weight bear, painful
movements
• Systemic features
Case 1
• 67 year old man
• Type 2 diabetic, suffers with ulcers on legs dressed by district nurse. LT catheter.
• Presents with acute history of painful, hot, swollen red knee
• Struggles to walk into surgery
• Feverish today
• Ulcers weeping
What would you like to do?
• History– Further enquiries reveal recent corticosteroid
injection in knee for OA symptoms
• Examination– Temp 37.8, tachycardic, red, hot, effusion,
unable to weight bear, restriction of movement
• Consider risk factors• What is the mandatory investigation?
Joint aspiration
Septic arthritis
• Overall mortality 10% in adults• Suppurative inflammation in joint space• Majority monoarticular• Large > small joints
– 50% knee, hip 20%, shoulder 8%, ankles 7%, elbow & IPJ 1-4%
• Most commonly haematogenous spread• Can be direct penetrating wound or neighbouring
infection• Children, neonates, elderly & immunosuppressed
Pathogens
• 90% non-gonococcal– staph aureus 50-80%, streptococcus 15-20%,
haemophilus influenzae b 20% (infants 6mo-2yrs), anaerobes 5%
• Gonococcal – young, sexually active– Pustular skin lesions (dermatitis-arthritis syndrome)– Tenosynovitis– Migratory arthralgias– Hand > knee, wrist, ankle, or elbow
Risk factors for septic arthritis
• Previously damaged joints • Prosthetic joints• Immunocompromised states• Systemic drugs – corticosteroids, DMARDS, biological
agents• IV drug abuse• Alcohol abuse• Diabetes• Previous intra-articular corticosteroid injection• Cutaneous ulcers• Indwelling catheters• >65 yrs old
Management
• If confident, joint aspirate to dryness & urgent gram stain
• Admit patient – discuss with orthopaedic on-call SHO
• Blood tests• Cultures – 3x blood, MSU, swabs• Plain XR• Start empirical antibiotics – 1st line flucloxacillin
IV 2g QDS• Discuss with microbiologist• Long duration of antibiotic therapy
Case 2
• 78 year old male
• Hypertensive, aspirin, osteoarthritis, renal impairment, obese
• Complains of painful, hot swollen knee
• Noticed swellings on hands
• Previous episode of joint pain in big toe 6mo ago settled with OTC NSAIDs
What will you do next?
• History– Further questioning reveals that had knee
arthroscopy last yr, likes alcohol
• Examination
• Investigations– Joint fluid aspirate, blood tests, plain XR
• What are his risk factors?
Risk factors for gout
• Low dose aspirin• Diuretic• Increasing age, male• Family history• Hypertension• Central obesity• Alcohol consumption• Renal insufficiency• Haematological disorders
Precipitants of attack
• Dehydration
• Injury
• Concurrent illness
• Dental extraction
• Excess foods/alcohol
Management
• Investigations– Joint aspiration –ve birefringent needle-shaped– Blood tests
• Rest joint• NSAID or if unable or not responding colchicine• Consider PPI• Caution use of colchicine in IHD,CCF• Give until pain relieved• Side effects – diarrhoea, abdominal cramps
Prevention• Review medications• Advise patients – diet, lifestyle, weight loss• Prophylaxis
– Indications: uncomplicated gout >2 attacks/yr, tophi, renal insufficiency, uric acid stones, need to continue diuretics
• Allopurinol– Start at 100mg od, gradually increase, monitor uric acid levels 4 weekly
until normal– Delay until 2/52 after intial attack settled– Monitor creatinine– SE: rash – stop & reintroduce lower dose– Interactions – Give colchicine/NSAID first 3-6mo – Continue allopurinol in attacks if pt already taking
• Referral to rheumatology if no improvement
Case 3
• 17 year old male
• Recent travel to Ibiza, playing football yesterday, bad tackle, able to continue game.
• Painful, swollen knee
• No past medical history
• Able to weight bear, but sore
• Differential?
What would you do next?
• History– Recent illness, STI, family history of bleeding
disorders
• Examination
• Investigations– Joint fluid aspirate, blood tests, plain XR
Haemarthrosis
• Plain XR – fat/blood interface
• Common cause– Ligament injury (cruciates in sports)– Intra-articular #
• Inherited haemophilias – APTT, assays for factors VIII, IX
Lipohaemarthrosis
Case 4 – a real story!
• 52 year old lady
• Presents with confusion
• Osteoarthritis, TKR 6 wks ago, obese
• Fever, ache in knee, coughing
• Husband very concerned requests GP home visit
Assessment
• Confused to time, place & person• Smelly urine• Coughing, complains of back pain,
breathless• Temp 38.6, tachycardic, consolidation
lower lobe, urine dip positive• Knee – scar clean, dry, healed well. No
effusion. Not red. Slight warmth. Tender ROM, but no restriction.
What will you do next?
• Admit to AMU
• Orthopaedic review?– Yes, needs assessment
• Investigations– Blood tests– Cultures – 3x blood, MSU– CXR– Plain XR Knee
Management
• Needs joint aspiration in theatre, washout of knee
• May need removal of prosthesis
• Empirical antibiotics intravenous long term
• Discuss with microbiologist
• Monitor inflammatory markers
Pseudogout
• Consider when intermittent attacks• Monoarticular – knee, wrist, hip• Can simulate bacterial infection – severe inflammation & fever• Can be symmetrical• Joint damage can be severe• Investigations
– Joint aspiration = calcium pyrophosphate dehydrate crystals (CPPD), rhomboid shaped, +ve birefringent
– Plain XR – chondrocalcinosis– Causes – must screen for hyperparathyroidism,
haemachromatosis, hyphosphataemia, hypomagnesiaemia
• Treatment – Rest, ice, NSAIDs, colchicine, intra-articular steroid injection
Reactive arthritis
• Aseptic arthritis• Occurs 2-6wks after bacterial infection elsewhere
– Gastroenteritis (salmonella, campylobacter)– GU infection (chlamydia, gonorrhoea)
• Can be HLA B27 +ve• Treatment – NSAIDs, physiotherapy, steroid joint
injections• Reiter’s syndrome
– Polyarthropathy, urethritis, irits, psoriaform rash– Follows GU/GI infection– Joint & eye changes often severe
Diagnosis?
What are these?
Diagnosis?
Diagnosis?
Useful Resources
• GP notebook
• Doctors.net e-module on acute swollen joint
• ARC (www.arc.org.uk)
• Patient uk
• www.ukgoutsociety.org
• www.arthritiscare.org.uk
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