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Approach to Acute Monoarthritis

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High Uric Acid may be gout? High ESR, arthritis exacerbation?? Is it septic? ... Even though no crystals could still be gout or psuedogout all though unlikely ... – PowerPoint PPT presentation

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Title: Approach to Acute Monoarthritis


1
Approach to Acute Monoarthritis
  • Hrach Ike Kasaryan MSIV

2
Definitions
  • Acute Monoarthritis -acute inflammatory process
    that develops in a single joint over the course
    of a few days and less than two weeks

3
Differential
4
Work Up
  • Many joint disorders initially can produce pain
    and swelling in a single joint
  • Since missing important joint disorders such as
    septic arthritis can cause significant morbidity
    and mortality an appropriate approach to the
    diagnostic work up must be made
  • If taken lightly, you may get burnt and cause a
    patient serious harm and life long consequences

5
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6
Step 1History
  • Establishing the chronology of symptoms is
    important
  • Rapid onset over hours to days usually indicates
    an infection or a crystal-induced process
  • Fungal or mycobacterial infections usually have
    an indolent and protracted course but can mimic
    bacterial arthritis

7
History
  • Is there are history of Trauma?
  • Even with no Trauma, if they have osteoarthritis,
    still may have traumatic injury
  • Are there other joints involved
  • Are there any penetrating injuries?
  • Sexual history and history of illegal drug use,
    alcohol use, travel, and tick bites should be
    ascertained

8
History
  • Look for the risk Factors!!
  • A prospective, three-year study1 found that the
    most important risk factors for septic arthritis
    are a prosthetic hip or knee joint, skin
    infection, joint surgery, rheumatoid arthritis,
    age greater than 80 years, and diabetes mellitus
  • Arthritis Rheum 1995381819-25

9
History
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11
Step 2 Physical
  • determine whether the source of the pain is the
    joint or a periarticular soft tissue structure
  • Simple range of motion test can give great
    insight
  • True intra-articular problems cause restriction
    of active and passive range of motion
  • whereas periarticular problems restrict active
    range of motion more than passive range of
    motion.
  • For example a septic knee will hurt no matter
    which way you move it or touch it. Where as a
    sprain will only hurt in certain directions or
    under stress

12
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13
History of Trauma
  • Radiology studies are now in order
  • If the results show Fracture/Avulsion etc. it is
    now a matter of an ortho consult
  • If the results show ostearthritis or
    chondrocalcinosis, you no longer are chasing a
    traumatic cause of the monoarthritis and you must
    look further

14
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15
(-) Trauma or Radio work up (-)
  • In this case, some lab studies are now in order.
  • CBC, Uric Acid and ESR are general screens to
    lead us further
  • High WBC, may be infection or chronic
    inflammation?
  • High Uric Acid may be gout?
  • High ESR, arthritis exacerbation??

16
Is it septic??
  • Blood cultures should be obtained in patients
    with suspected septic arthritis.
  • However cultures are positive in only about 50
    percent of nongonococcal infections but are
    rarely positive (about 10 percent) in gonococcal
    infection
  • DONT LET NEGATIVE BLOOD CX THROW YOU OFF THE
    SEPTIC JOINT TRACK!!!

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18
To Tap or Not To Tap that is the question
19
Tapping the joint.
  • We have now reached a critical point in the
    decision tree.
  • If there is even a slight suspicion that this
    might be an infectious cause a tap is mandatory!
  • IF there is no effusion and there is still
    suspicion that the patient has septic arthritis,
    than CT guided or US guided tap should be
    undertaken.

20
why is tapping so critical??
  • Because the results will dramatically change our
    therapy! Otherwise we wouldnt do it
  • If it leads us down the infectious route, we use
    Antibiotics
  • If it leads down the RA or other immune mediated
    route we blast the patient with steroids.
  • Now think about the situation of not tapping the
    patient with septic arthritis, and blasting them
    with steroids!
  • If the wrong call is made, kiss that joint goodbye

21
Tapping the knee (medial approach)
  • Locate the inferior and superior pole of the
    patella and then draw a small circle half way
    between these marks and than move medially from
    that point until the edge of the patella
  • The skin is cleansed with betadine and then
    alcohol.
  • Than anesthetize the skin with 2 lidocaine using
    a 1 1/2 inch 25 gauge needle.

22
Tapping the Knee
  • After marking the point of entry and skin prep,
    anesthetize the skin and subcutaneous tissue down
    to the synovium with 1-2 xylocaine without
    epinephrine

23
Tapping the knee
  • After 1 minute or so, an 18 gauge needle can then
    be inserted and fluid withdrawn.
  • As little as one or two drops can be used for
    culture , smears, and crystal ID

24
Tapping the Knee
  • synovial fluid should be sent for a white blood
    cell (WBC) count with differential (specifically,
    the percentage of polymorphonuclear neutrophilic
    leukocytes), crystal analysis, Gram staining, and
    culture
  • Superimposed cellulitis is a relative
    contraindication to arthrocentesis
  • can be performed safely in patients who are
    taking warfarin (Coumadin)
  • Removal of as much synovial fluid as possible
    offers symptomatic relief and helps to control
    infection
  • If infection is suspected, ABX should be started
    after the tap empirically and than changed when C
    and S return
  • Until infection has been ruled out,
    corticosteroids should not be injected into a
    joint.

25
So what do we do with the results after the
patient hates us for the tap?
26
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27
Fat Droplets
  • Fat droplets could indicate bone trauma and
    damage
  • Orthopedic consult would be appropriate and
    patient may need surgery

28
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29
Bloody
  • If the on tap in draws back bloody, or
    microscopically many RBCs with out WBCs, the
    diagnosis of Hemarthrosis is now made
  • If the patient has a history of a bleeding
    disorder (classically clotting factor
    difficiencies) appropriate management should be
    started
  • If patient no history of trauma or clot d/o than
    a work up for inherited clotting d/o should be
    started

30
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31
Crystals are seen
  • If positively bifringent in polarized light and
    needle like crystals are seen the dx of Gouty
    arthritis can be made
  • If negatively bifringent crystals are seen
    Pseudogout may be dx
  • How ever, the finding of crystals does not
    exclude the diagnosis of septic arthritis
  • The entire clinical picture should be considered
    when ruling out infectious causes keeping in mind
    it is the worst case scenario for the pt.
  • Along with the crystals, there will be an
    inflammatory WBC, but much less segs, and much
    lower WBC count than septic picture would have

32
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33
Non inflammatory
  • Fluid is Transparent WBC
  • We can now consider these noninflammatory dx, and
    make the appropriate theraputic decisions

34
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35
Inflammatory Fluid
  • Translucent fluid, 2000
  • With this type of numbers, the following could be
    possibilities
  • SLE, LYME, Spondyloarthropothies, Rheumatoid,
    Reactive Arthritis or others
  • Even though no crystals could still be gout or
    psuedogout all though unlikely

36
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37
Inflammatory and Septic
  • Opaque fluid (frank pus) WBC75,000 75 segs.
  • Any WBC 100,000 is infection until proven
    otherwise!!
  • With these results, the appropriate management
    could be initiated if ABX were not started
    already
  • However since we are good clinicians, we already
    started empiric Tx from high suspicion and need
    only to wait for culture and sensitivities to
    modify the ABXs.

38
  • This is an xray of a untreated septic joint
  • Notice the ulmost non-existant joint space
  • And the very irregular borders of the bone at the
    joint suggesting necrosis

39
Conclusions
  • In acute monoarthritis, Septic arthritis is the
    worst case with worst outcomes
  • Therefore, you should assume it is until you have
    reached a thresh hold to rule it out
  • 3 good rules for the Acute Monoarthritis
  • RULE OUT SEPTIC JOINT!!! RULE OUT SEPTIC JOINT,
    RULE OUT SEPTIC JOINT!!!
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