Download Approach to a Single Painful Joint

Approach to a Single Painful
Joint
OW! It hurts!
Monoarticular Causes
• A. Septic (bacteria, fungus, parasite) ACK!!!
• B. Trauma (meniscus, ligament, overuse, fracture,
hemarthrosis)
• C. Crystal ( gout, pseudogout )
• D. Neuropathy (Charcot )
• E. AVN (ischemia)
• F. RA
• G. Lyme disease
• H. Paget’s disease (osteitis deformans)
• I. Neoplasms (osteoid osteoma, villonodular
synovitis )
History
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Onset? Trauma? Circumstances.
Joint probs b4? (OA? Knee replacement?)
Where? Migratory? Multiple?
Extraarticular sympts?
Sex/Drugs/Rock and Roll?
Physical
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Inspection (SEADS)
Palpation (milking, patellar tap)
ROM
Other joints
Rest of body
Labs and Tests
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Synovial Fluid
CBC
ESR
ANA
RF
X ray bilat joints
Management of the BIG 4
Monoarticular Pain
Infectious
Trauma
Crystal
Systemic
> 50,000c/uL
synovial fluid
evidence on xray
hx agrees
birefringent on
microscopy
bw results
cultures
IV Abx
irrigation
hospitalization
ortho consult
immobilization
NSAIDS
BUN lytes Cr
steroids
colchicine
NSAIDS
steroids
rheum consult
Things to Remember
• Septic arthritis is a medical emergency: two
potential complications are sepsis and
osteomyelitis. Always rule out septic
arthritis.
• Always tap a monoarthritis and send the
synovial fluid for cell count, Gram stain,
fluid culture, and crystals.
The case of Mr. R
• 82 yr old M w/PMHx of OA, A fib.
• Fever, malaise, swollen painful R knee x 1/52,
cannot weight bear currently. No travel. Was
found on the floor, says he “fell but couldn’t get
up”. At baseline, pt has dementia but is physically
active.
• O/E: hr 80ireg ireg, temp 37.9, pt is confused,
ROM of R knee 10-80 degress with pain. R knee
is swollen, red, tender. No obvious deformity.
• Lab: wbc is 14.8, uric acid 450uL (N: 90-360),
INR 9 (Pt gets BW done regularly.)
What could we do?
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Tell pt that they must go to the hospital.
Sepsis? Monitor vitals.
X ray both knees.
obtain BW and blood cultures
Urine culture and swabs if gonococcal cause
suspected
• Tap the joint (to obtain fluid and to relieve pain).
• Treat empirically with IVAbx until C+S comes
back.
Empiric Abx Treatment
Infectious
Cause
(adults)
Gonococcal
Gram +
cocci
Gram bacilli
Gram stain nil
Ceftriaxone
Immunocompromised?
Amino glycoside
3rd generation cephalosporin
Ceftriaxone
Yes
No
Vanco Clox
What did I see done ?
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CT head: N
X ray knees and CXR: N
BW repeated: same
Blood and urine cultures obtained.
IV Vanco + Ceftriaxone (?)
Morphine for pain. Warfarin stopped.
Tap was not done due to INR.
Dx: Hemarthrosis due to INR, R/O Septic Art.
Lesson learned
• You should ALWAYS tap and obtain
synovial fluid (no matter the INR).
• In this case < 50,000c/uL, G stain -, all
cultures -, intracellular CPPD crystals
identified on microscopy.
• Dx: Acute Pseudogout.
• IVAbx stopped and corticosteroids injected
into knee. D/C with PT referral.
References
• Cibere, J., “Acute Monoarthritis”, CMAJ,
May 30, 2000; 162(11)
• Moses,S.,“Monoarticular Arthritis”, Family
Practice Notebook.com, August 26, 2003
• The Washington Manual of Medical
Therapeutics, chap. 24
• The Merck Manual 17th ed, chap 5, 13, 21
• Sanford Guide to Antimicrobial Therapy