Arthritis and Arthrocentesis

Arthritis and Arthritis and ArthrocentesisArthrocentesis

Joe Lex, MD, FACEP, MAAEMJoe Lex, MD, FACEP, MAAEMTemple University School of MedicineTemple University School of Medicine

[email protected]@[email protected]@joelex.net @JoeLex5 @JoeLex5

mailto:[email protected]


Not About TraumaNot About Trauma

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What’s a joint What’s a joint like you like you

doing in a doing in a nice girl like nice girl like

this??this??

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ObjectivesObjectives

1. Differentiate among the three 1. Differentiate among the three types of jointstypes of joints

2. Explain the pathology of joint 2. Explain the pathology of joint inflammationinflammation

3. Develop a differential for arthritis, 3. Develop a differential for arthritis, based on number of joints based on number of joints involved, location, and other involved, location, and other characteristicscharacteristics

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4. Explain usefulness of various 4. Explain usefulness of various synovial fluid studies.synovial fluid studies.

5. Demonstrate an appropriate 5. Demonstrate an appropriate technique for large joint technique for large joint arthrocentesisarthrocentesis

6. Explain the pathophysiology and 6. Explain the pathophysiology and treatment for gouttreatment for gout

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7. Differentiate “rheumatic fever” 7. Differentiate “rheumatic fever” from “rheumatoid arthritis” from from “rheumatoid arthritis” from “rheumatism”“rheumatism”

8. Be aware of quackery as it 8. Be aware of quackery as it applies to treatment of arthritisapplies to treatment of arthritis

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History of ArthritidesHistory of Arthritides

• 1680s: Sydenham describes gout, 1680s: Sydenham describes gout, rheumatism, chorearheumatism, chorea

• 1808: term “rheumatic fever”1808: term “rheumatic fever”• 1876: urate crystals postulated to 1876: urate crystals postulated to

cause goutcause gout• 1883: gonococcal arthritis1883: gonococcal arthritis• 1907: osteoarthritis described1907: osteoarthritis described

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Thomas Sydenham Thomas Sydenham (1624-1689)(1624-1689)

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Three Joint TypesThree Joint Types

• Synarthroses: suture lines of skullSynarthroses: suture lines of skull• Amphiarthroses: fibrocartilaginous Amphiarthroses: fibrocartilaginous

unions of pubic symphysis and unions of pubic symphysis and lower third of sacroiliac jointlower third of sacroiliac joint

• Diarthroses = Synovial: most other Diarthroses = Synovial: most other jointsjoints

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SynarthosisSynarthosis

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AmphiarthrosesAmphiarthroses

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Diarthrosis = Synovial JointsDiarthrosis = Synovial Joints

• Subchondral bone, convex against Subchondral bone, convex against concave, covered by cartilageconcave, covered by cartilage

• Cartilage: collagen + proteoglycanCartilage: collagen + proteoglycan• Lubricated, slide on each otherLubricated, slide on each other• Surrounded by capsule supported Surrounded by capsule supported

by ligaments, tendons, and muscleby ligaments, tendons, and muscle• Lined with synovial membraneLined with synovial membrane

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Typical Joint StructureTypical Joint Structure

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PathophysiologyPathophysiology

• Joint trauma causes decreased Joint trauma causes decreased proteoglycans proteoglycans – If trauma persistent, damage If trauma persistent, damage

irreparableirreparable• Inflammation characterized by Inflammation characterized by

polymorphonuclear white cellspolymorphonuclear white cells– May be immunologic (rheumatoid, May be immunologic (rheumatoid,

reactive)reactive)

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Joint vs. PeriarticularJoint vs. Periarticular

ArthritisArthritis• Generalized Generalized

pain, warmth, pain, warmth, swelling, swelling, tendernesstenderness

• Discomfort Discomfort with joint with joint motion motion

Periarticular Periarticular inflammation: inflammation: bursitis, tendinitis, bursitis, tendinitis, localized cellulitislocalized cellulitis

• Focal tenderness, Focal tenderness, swelling swelling notnot uniform uniform

• Pain only with Pain only with certain movementscertain movements

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Monarticular vs. PolyarticularMonarticular vs. Polyarticular

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If Polyarticular and…If Polyarticular and…

……symmetric symmetric rheumatoid, drug rheumatoid, drug inducedinduced

……asymmetric asymmetric rubella, acute rubella, acute rheumatic fever, gonococcalrheumatic fever, gonococcal

……migratory migratory gonococcal or rubella gonococcal or rubella

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Location, Location, LocationLocation, Location, Location

• First MTP joint: goutFirst MTP joint: gout• MCP and PIP joints: rheumatoidMCP and PIP joints: rheumatoid• DIP and first carpometacarpal DIP and first carpometacarpal

joint: osteoarthritis joint: osteoarthritis • Knee: septic arthritis, pseudogout, Knee: septic arthritis, pseudogout,

goutgout

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Causes of Migratory ArthritisCauses of Migratory Arthritis• Rheumatic feverRheumatic fever• Subacute bacterial Subacute bacterial

endocarditisendocarditis• Henoch-Schönlein Henoch-Schönlein

purpurapurpura• Cefaclor (Ceclor®) Cefaclor (Ceclor®)

hypersensitivity hypersensitivity (kids)(kids)

• Septicemia: Septicemia: staphylococcal, staphylococcal, streptococcal, streptococcal, meningococcal, meningococcal, gonococcalgonococcal

• Mycoplasma, Mycoplasma, histoplasmosis, histoplasmosis, coccidioidomycosiscoccidioidomycosis

• Lyme diseaseLyme disease

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Arthritis with…Arthritis with…

……low-grade fever low-grade fever any any inflammatory arthritis inflammatory arthritis

……high fever, chills high fever, chills septic arthritis septic arthritis ……kidney stones kidney stones gout gout……genital ulcers genital ulcers reactive arthritis reactive arthritis……urethral discharge urethral discharge reactive reactive

arthritis, gonococcusarthritis, gonococcus

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Arthritis and…Arthritis and…

……isoniazid, procainamide, isoniazid, procainamide, hydralazine hydralazine lupus lupus

……thiazide diuretics thiazide diuretics gout gout (increase serum uric acid level)(increase serum uric acid level)– Chlorthalidone (Hygroton®)Chlorthalidone (Hygroton®)– Hydrochlorothiazide (HydroDIURIL®, Hydrochlorothiazide (HydroDIURIL®,

Esidrix®, Oretic®)Esidrix®, Oretic®)– Indapamide (Lozol®)Indapamide (Lozol®)

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Some Scalp and Skin FindingsSome Scalp and Skin FindingsAlopeciaAlopecia SLE, psoriasisSLE, psoriasis ECMECM LymeLymeMalar rashMalar rash SLE, dermato-SLE, dermato-

myositismyositisRashRash RubellaRubella

PustulesPustules GonococcemiaGonococcemia TophiTophi GoutGoutElbows, Elbows, kneesknees

PsoriasisPsoriasis SubQ SubQ nodulesnodules

RARA

Tight skinTight skin SclerodermaScleroderma Hyper-Hyper-keratosiskeratosis

Reiter’sReiter’s

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Physical ExamPhysical Exam

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Physical ExamPhysical Exam

1.1. Warmth and effusion Warmth and effusion 2.2. Synovial thickening Synovial thickening 3.3. Deformity Deformity 4.4. Tenderness: generalized or Tenderness: generalized or

localized, articular or periarticularlocalized, articular or periarticular5.5. Limited range of motion Limited range of motion 6.6. Pain on movement Pain on movement

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Lab StudiesLab Studies

• Limited diagnostic value Limited diagnostic value • ““Screening tests”Screening tests”

– Bacterial: usually elevated WBC Bacterial: usually elevated WBC – Chronic rheumatic: mild anemia Chronic rheumatic: mild anemia – ESR/CRP ESR/CRP in most inflammatory in most inflammatory

• RF, ANA, ASO titers, Lyme RF, ANA, ASO titers, Lyme serologies: for follow-up serologies: for follow-up

• Uric acid: Uric acid: notnot helpfulhelpful in gout in gout

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X-ray Findings (Chronic)X-ray Findings (Chronic)

SSoft tissue swelling oft tissue swelling

EErosions rosions

CCalcification alcification

OOsteoporosis steoporosis

NNarrowed joint spacearrowed joint space

DDeformity eformity

SSeparation (fractures)eparation (fractures)

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X-ray Findings (Septic)X-ray Findings (Septic)

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Hallmark X-ray FindingsHallmark X-ray Findings

Osteoarthritis = OsteophytesOsteoarthritis = Osteophytes

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Erosions = Rheumatoid or GoutErosions = Rheumatoid or Gout

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Chondrocalcinosis = PseudogoutChondrocalcinosis = Pseudogout

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Hallmark X-ray FindingsHallmark X-ray FindingsEnthesitis = Insertion Site Enthesitis = Insertion Site Inflammation (HLA-B27) Inflammation (HLA-B27)

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Other ImagingOther Imaging

• Ultrasound: joint effusions; Ultrasound: joint effusions; tendons and ligaments of shouldertendons and ligaments of shoulder

• CT scan: SI, sternoclavicular jointCT scan: SI, sternoclavicular joint• MRI: knee cruciate ligaments MRI: knee cruciate ligaments • Contrast MRI: differentiate Contrast MRI: differentiate

synovitis from synovial fluid in synovitis from synovial fluid in rheumatoid diseaserheumatoid disease

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Other ImagingOther Imaging

• 99m99mtechnetium methylene technetium methylene diphosphonate (99mTc MDP)diphosphonate (99mTc MDP)– Osteomyelitis, stress fracturesOsteomyelitis, stress fractures

• Gallium: gathers at proliferation of Gallium: gathers at proliferation of serum proteins and leukocytesserum proteins and leukocytes– InfectionInfection

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ArthrocentesisArthrocentesis

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• Critical diagnostic adjunct Critical diagnostic adjunct • Can be painless, safe, and simple Can be painless, safe, and simple

when performed correctlywhen performed correctly• Diagnostic or therapeuticDiagnostic or therapeutic

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Indications Indications

• Obtain joint fluid for analysisObtain joint fluid for analysis• Drain tense hemarthroses Drain tense hemarthroses • Instill analgesics and anti-Instill analgesics and anti-

inflammatory agentsinflammatory agents• Prosthetic joints: only to rule out Prosthetic joints: only to rule out

infectioninfection

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ContraindicationsContraindications

• Absolute: infection of any kind Absolute: infection of any kind covers area to be punctured covers area to be punctured

• RelativeRelative– Bleeding diatheses, anticoagulant Bleeding diatheses, anticoagulant

therapytherapy– BacteremiaBacteremia

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ProcedureProcedure

• Cleanse skin with povidone-iodine, Cleanse skin with povidone-iodine, then air drythen air dry

• Remove povidone-iodine with Remove povidone-iodine with isopropyl alcoholisopropyl alcohol– Intra-articular povidone-iodine can Intra-articular povidone-iodine can

cause chemical irritation, inhibit cause chemical irritation, inhibit bacterial growth leading to spuriously bacterial growth leading to spuriously negative cultures in early septic jointnegative cultures in early septic joint

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ProcedureProcedure

• Place sterile drapesPlace sterile drapes• Inject local anesthetic into skinInject local anesthetic into skin

– 25- to 30-gauge needle25- to 30-gauge needle– Intraarticular anesthetic can inhibit Intraarticular anesthetic can inhibit

bacterial growth, cause spuriously bacterial growth, cause spuriously negative culture in early septic jointnegative culture in early septic joint

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ProcedureProcedure

• Aspirate large joints with large-Aspirate large joints with large-bore needle (18 or 19 gauge) bore needle (18 or 19 gauge) – Smaller joints: smaller-bore needle Smaller joints: smaller-bore needle

• Choose syringe size based on Choose syringe size based on anticipated fluid volumeanticipated fluid volume

• Remove as much fluid as possibleRemove as much fluid as possible– Optimizes diagnosis Optimizes diagnosis – Relieves pain from distentionRelieves pain from distention

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• Fat globules: diagnostic of fractureFat globules: diagnostic of fracture• Intraarticular morphine can provide Intraarticular morphine can provide

relief for up to 24 hoursrelief for up to 24 hours– 1 to 5 mg diluted in normal saline 1 to 5 mg diluted in normal saline

solution to a total volume of 30 mlsolution to a total volume of 30 ml

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Sternoclavicular JointSternoclavicular Joint

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Acromioclavicular JointAcromioclavicular Joint

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Shoulder – Posterior ApproachShoulder – Posterior Approach

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Shoulder – Anterior ApproachShoulder – Anterior Approach

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ElbowElbow

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Elbow – Lateral ApproachElbow – Lateral Approach

Flex elbow 90o

Prep skin

Insert needle in palpable bony

notch between lateral epicondyle

and olecranon

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Elbow – Lateral ApproachElbow – Lateral Approach

http://www.youtube.com/watch?v=E3ZQRECRgpI

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Elbow – Posterior ApproachElbow – Posterior Approach

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Wrist ApproachWrist Approach

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Wrist ApproachWrist Approach

http://www.youtube.com/watch?v=L6ZK7RohUVE

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Intercarpal ApproachIntercarpal Approach

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Knee – Lateral ApproachKnee – Lateral Approach

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Extend knee, quadriceps and patella relaxed so patella can move mediolaterally. Needle into joint space just lateral to patella near its upper pole, parallel to the posterior (articular) surface.

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Knee – Medial ApproachKnee – Medial Approach

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Knee – Medial vs. LateralKnee – Medial vs. Lateral

• Follow “Sutton’s Law”Follow “Sutton’s Law”• William “Slick Willie” Sutton (1901 William “Slick Willie” Sutton (1901

– 1980): professional bank robber– 1980): professional bank robber

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AnkleAnklePalpate the medial and lateral malleoli with your thumb and index finger. The joint space is located one to one and a half cm above the line joining the tips of the malleoli.

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AnkleAnklePalpate the dorsalis pedis artery and choose a puncture site anywhere on the anterior aspect of the ankle, avoiding the dorsalis pedis artery.

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Ankle – Lateral ApproachAnkle – Lateral Approach

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Ankle – Medial ApproachAnkle – Medial Approach

http://www.youtube.com/watch?v=Du1dy6nkAlU&list=UU_yjveGdyx6mqqHkHaD-_bg&index=7

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Subtalar JointSubtalar Joint

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Synovial Fluid AnalysisSynovial Fluid Analysis

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• Identify crystals, pus Identify crystals, pus • Analyze color, clarity, cell count, Analyze color, clarity, cell count,

differential, Gram’s stain, crystalsdifferential, Gram’s stain, crystals• Positive Gram’s stain: diagnostic Positive Gram’s stain: diagnostic

for septic arthritisfor septic arthritis• Negative Gram’s stain: does not Negative Gram’s stain: does not

rule out septic arthritisrule out septic arthritis

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Synovial Fluid Cell CountSynovial Fluid Cell Count

• Noninflammatory vs. inflammatoryNoninflammatory vs. inflammatory• ED wet mount prepED wet mount prep

– 1 to 2 WBCs per high-power field 1 to 2 WBCs per high-power field consistent with noninflammatoryconsistent with noninflammatory

– >20 WBC/HPF suggests >20 WBC/HPF suggests inflammation or infectioninflammation or infection

• Septic: >50,000 WBC/mmSeptic: >50,000 WBC/mm33 (also (also rheumatoid, gout, pseudogout)rheumatoid, gout, pseudogout)

NormalNormalNon-Non-

inflammatoryinflammatory InflammatoryInflammatory InfectiousInfectiousTrans-Trans-parentparent TransparentTransparent CloudyCloudy Cloudy Cloudy

ClearClear YellowYellow YellowYellow Yellow Yellow <200<200 <2000<2000 200 – 50,000200 – 50,000 >50,000>50,000<25%<25% <25%<25% >50%>50% >50%>50%

NegativeNegative NegativeNegative NegativeNegative Positive Positive

Appear-Appear-anceance

ClarityClarityWBCsWBCsPMNsPMNsCultureCulture


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Other Synovial Fluid AnalysisOther Synovial Fluid Analysis

• Glucose, lactic acid, viscosity, Glucose, lactic acid, viscosity, mucin clot, and total protein: mucin clot, and total protein: limited utility, not recommendedlimited utility, not recommended

• Appropriate container Appropriate container – Cellular analysis: lavender Cellular analysis: lavender

(ethylenediaminetetraacetic acid)(ethylenediaminetetraacetic acid)– Crystal analysis: green (heparin)Crystal analysis: green (heparin)– Chemical analysis, serology: redChemical analysis, serology: red

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Crystal StudiesCrystal Studies

• Monosodium urateMonosodium urate: needle : needle shaped, birefringent negative shaped, birefringent negative – Parallel to compensator: yellowParallel to compensator: yellow– Perpendicular: bluePerpendicular: blue

• Calcium pyrophosphateCalcium pyrophosphate: : polymorphic, birefringent positive polymorphic, birefringent positive – Parallel to compensator: blueParallel to compensator: blue– Perpendicular: yellowPerpendicular: yellow

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Sodium urate crystals viewed under polarized light with a red plate makes those in the plane of the long axis of the red plate yellow, which indicates that they are negatively birefringent.

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Calcium pyrophosphate crystal viewed under polarized light with a red plate. The crystal is aligned in the long axis of the red plate, so that it is bluish-white, which indicates that it is weakly positively birefringent.

Specific Specific ArthritidesArthritides

There are more than 90There are more than 90

Preiser’s disease: avascular necrosis of scaphoid

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Septic ArthritisSeptic Arthritis

• Hematogenous spreadHematogenous spread• Direct inoculationDirect inoculation• Direct spread from bony or soft Direct spread from bony or soft

tissue infections tissue infections

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Septic ArthritisSeptic Arthritis

• Synovium infected before Synovium infected before degrading enzymes releaseddegrading enzymes released

• Children: hematogenous most Children: hematogenous most commoncommon

• Postoperative infection: ~10% of Postoperative infection: ~10% of joint surgeriesjoint surgeries

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CausesCauses

• Staphylococcus aureusStaphylococcus aureus: most : most common (even in sickle cell)common (even in sickle cell)

• Others: streptococcus, Gram Others: streptococcus, Gram negatives, anaerobesnegatives, anaerobes

• N. gonorrhoeaeN. gonorrhoeae: 20% monarticular: 20% monarticular• <6 months: <6 months: E. coliE. coli, group B strep , group B strep • IV drug users: IV drug users: S. aureus,S. aureus, Gram Gram

negativesnegatives

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Clinical FeaturesClinical Features

• Based on host’s concurrent Based on host’s concurrent medical conditionsmedical conditions

• Painful, hot, swollenPainful, hot, swollen• Typical: single jointTypical: single joint

– Knee: 40% to 50%Knee: 40% to 50%– Hip: 13% to 20%Hip: 13% to 20%– Shoulder: 10% to 15%Shoulder: 10% to 15%

• 20% polyarticular20% polyarticular

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Clinical FeaturesClinical Features

• History of fever: 80%History of fever: 80%• Shaking chills: 20% Shaking chills: 20% • Elevated sedimentation rate more Elevated sedimentation rate more

common than leukocytosis common than leukocytosis • Blood cultures grow causative Blood cultures grow causative

organism ~50% of the timeorganism ~50% of the time• Radiographs not often usefulRadiographs not often useful

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ManagementManagement

• Admit for joint drainage, IV Admit for joint drainage, IV antibiotics antibiotics

• Empiric therapy based on Gram’s Empiric therapy based on Gram’s stainstain

• Parenteral narcotic analgesics, Parenteral narcotic analgesics, articular immobilization control articular immobilization control pain and discomfortpain and discomfort

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Gouty ArthritisGouty Arthritis

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• Pod = foot; agra = trap, huntPod = foot; agra = trap, hunt• Podagra: foot goddess, a bad-Podagra: foot goddess, a bad-

tempered virgin, who attacked tempered virgin, who attacked victims after they overindulgedvictims after they overindulged

• Father was Dionysus (Bacchus), Father was Dionysus (Bacchus), god of winegod of wine

• Mother was Aphrodite (Venus), Mother was Aphrodite (Venus), goddess of lovegoddess of love

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• Thought to be limited to men who Thought to be limited to men who had indulged in dietary or sexual had indulged in dietary or sexual excessexcess

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• Galen (129-199 AD), an Galen (129-199 AD), an ex-gladiatorial surgeon in ex-gladiatorial surgeon in Rome, described gout as Rome, described gout as a discharge of the four a discharge of the four humors of the body in humors of the body in unbalanced amounts into unbalanced amounts into the joints (hence gout = the joints (hence gout = gutta, a drop)gutta, a drop)

Be temperate in Be temperate in wine, in eating, wine, in eating, girls and sloth girls and sloth Or the gout will Or the gout will seize you and seize you and

plague you bothplague you both

Katzenjammer Kids & The CaptainKatzenjammer Kids & The Captain

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• Uric acid crystal deposits from Uric acid crystal deposits from supersaturated extracellular fluid supersaturated extracellular fluid

• Risk factors: obesity, hypertension, Risk factors: obesity, hypertension, diabetes, alcohol, proximal loop diabetes, alcohol, proximal loop diuretics, lead poisoningdiuretics, lead poisoning

• During attack: crystals ingested by During attack: crystals ingested by PMNs PMNs inflammation inflammation

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• Middle-aged men, post-Middle-aged men, post-menopausal women menopausal women

• Increased uric acid usually present Increased uric acid usually present for 20 years before first attack for 20 years before first attack

• Uric acid often normalUric acid often normal

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PresentationPresentation

• Great toe MTP joint in 75%Great toe MTP joint in 75%– Also tarsal, ankle, knee, wristAlso tarsal, ankle, knee, wrist– Up to 40% polyarticularUp to 40% polyarticular

• Pain excruciating at onset Pain excruciating at onset – Can mimic septic jointCan mimic septic joint– Usually self-limitedUsually self-limited

• Systemic symptoms usually Systemic symptoms usually minimal or absentminimal or absent

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• Subsequent attacks closer Subsequent attacks closer together, more joints, last longertogether, more joints, last longer

• Long-term: kidney stonesLong-term: kidney stones

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• Tophi: foreign body granulomas Tophi: foreign body granulomas with crystals as nidus, in musculo-with crystals as nidus, in musculo-tendinous unit – olecranon bursa, tendinous unit – olecranon bursa, Achilles tendon, hands, knees, etc.Achilles tendon, hands, knees, etc.

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DiagnosisDiagnosis

• Rule out cellulitis, septic arthritis Rule out cellulitis, septic arthritis particularly if knee joint particularly if knee joint

• All may have fever, leukocytosis, All may have fever, leukocytosis, elevated ESRelevated ESR

• Uric acid level not helpful Uric acid level not helpful • X-rays: soft-tissue swelling (acute) X-rays: soft-tissue swelling (acute)

or joint destruction (chronic)or joint destruction (chronic)

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Uric Acid LevelsUric Acid Levels

• Uric acid normal in ~40%Uric acid normal in ~40%• Tophi can form in cool body areas Tophi can form in cool body areas

without hyperuricemiawithout hyperuricemia• Acute attack Acute attack pain pain increased increased

cortisol cortisol uric acid diuresis uric acid diuresis normalized levelnormalized level

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DiagnosisDiagnosis

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DiagnosisDiagnosis

• Definitive diagnosis: Definitive diagnosis: birefringent joint fluid birefringent joint fluid crystals with polarizing crystals with polarizing microscope (a yellow microscope (a yellow crystal against a red crystal against a red background) and background) and negative joint fluid negative joint fluid cultureculture

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Acute Therapy – Colchicine Acute Therapy – Colchicine

• Not diagnostic: works on Not diagnostic: works on pseudogoutpseudogout

• Contraindication: hematologic, Contraindication: hematologic, renal, hepatic dysfunctionrenal, hepatic dysfunction

• Extravasation from IV Extravasation from IV tissue tissue necrosisnecrosis

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Acute Therapy – Colchicine Acute Therapy – Colchicine

• Inhibits microtubule formationInhibits microtubule formation• Most effective in first 24 hours Most effective in first 24 hours • 0.6 mg / hour until pain controlled, 0.6 mg / hour until pain controlled,

max 6 mg or side effects (GI) max 6 mg or side effects (GI) • Average toxic dose: 6.7 mgAverage toxic dose: 6.7 mg• Toxicity precedes improvement in Toxicity precedes improvement in

more than 50%more than 50%

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Acute Therapy – OtherAcute Therapy – Other

• NSAIDs effective, indomethacin NSAIDs effective, indomethacin most common (75 to 200 mg/day) most common (75 to 200 mg/day) – Contraindicated in PUD, GI bleedContraindicated in PUD, GI bleed

• If resistant: prednisone taper If resistant: prednisone taper – 40 mg/day first 3 to 5 days40 mg/day first 3 to 5 days

• Adrenocorticotrophic hormone Adrenocorticotrophic hormone – ACTH 40 IU to 80 IU IMACTH 40 IU to 80 IU IM

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PseudogoutPseudogout

• Calcium pyrophosphate dihydrate Calcium pyrophosphate dihydrate (CPPD) crystal-deposition disease (CPPD) crystal-deposition disease

• Knee: most common joint Knee: most common joint • Polyarticular possiblePolyarticular possible• Pain less severe, patients olderPain less severe, patients older• Risk: hypothyroid, Wilson’s Risk: hypothyroid, Wilson’s

disease, hyperparathyroid, disease, hyperparathyroid, hemochromatosis, etc.hemochromatosis, etc.

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DiagnosisDiagnosis

• Common: elevated ESR, WBCCommon: elevated ESR, WBC• X-ray may show joint calcification X-ray may show joint calcification • Joint fluidJoint fluid

– Weakly positive birefringent crystals Weakly positive birefringent crystals on polarized microscopyon polarized microscopy

– Appear rhomboidal on regular light Appear rhomboidal on regular light microscopymicroscopy

• Treatment: same as goutTreatment: same as gout

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ChondrocalcinosisChondrocalcinosis

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OsteoarthritisOsteoarthritis

• Degenerative joint diseaseDegenerative joint disease• Most common form of arthritis Most common form of arthritis • Loss of articular cartilage, reactive Loss of articular cartilage, reactive

changes at joint margins changes at joint margins • Synovitis in advanced disease Synovitis in advanced disease • May have painful bone-to-bone May have painful bone-to-bone

interfaceinterface

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Presentation / DiagnosisPresentation / Diagnosis

• Chief complaint: painChief complaint: pain• No systemic symptoms No systemic symptoms • Hands: Bouchard’s, Heberden’s Hands: Bouchard’s, Heberden’s

nodes (osteophyte spurs) nodes (osteophyte spurs) • Knee: active & passive crepitusKnee: active & passive crepitus• Routine lab tests: normalRoutine lab tests: normal• Radiographs: joint- space Radiographs: joint- space

narrowing, osteophyte formationnarrowing, osteophyte formation

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Heberden’s and Bouchard’sHeberden’s and Bouchard’s

Over DIP Over PIP

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TreatmentTreatment

• Judicious exercise for muscle Judicious exercise for muscle strengtheningstrengthening

• Relieve muscle spasmRelieve muscle spasm• Support joint Support joint • Acetaminophen comparable to Acetaminophen comparable to

ibuprofen for short-term treatment ibuprofen for short-term treatment • Ultimately joint replacementUltimately joint replacement

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Gonococcal ArthritisGonococcal Arthritis

• Woman : men :: 4:1 Woman : men :: 4:1 • Fever, chills, arthralgias, migratory Fever, chills, arthralgias, migratory

tenosynovitistenosynovitis• Progresses to arthritis: knee, Progresses to arthritis: knee,

ankle, wristankle, wrist• Characteristic rash: countable Characteristic rash: countable

hemorrhagic necrotic pustules hemorrhagic necrotic pustules • Rarely have cervicitis or urethritisRarely have cervicitis or urethritis

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Gonococcal ArthritisGonococcal Arthritis

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DiagnosisDiagnosis

• Blood cultures usually negative Blood cultures usually negative • Synovial fluid cultures positive in Synovial fluid cultures positive in

less than 50%less than 50%• Gram’s stain positive more often Gram’s stain positive more often

than culturethan culture• Cervical, urethral, pharyngeal, Cervical, urethral, pharyngeal,

rectal cultures positive ~75% rectal cultures positive ~75%

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TreatmentTreatment

• Admit to hospital Admit to hospital • Ceftriaxone 1 g IM or IV daily, and Ceftriaxone 1 g IM or IV daily, and

24 to 48 hours after improvement24 to 48 hours after improvement• Ciprofloxacin 500 mg twice daily Ciprofloxacin 500 mg twice daily

orally for total 7 days of antibioticsorally for total 7 days of antibiotics• Spectinomycin 2 grams IM every Spectinomycin 2 grams IM every

12 hours if beta-lactam allergic12 hours if beta-lactam allergic

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Viral ArthritisViral Arthritis

• Most common: rubella, hepatitis B Most common: rubella, hepatitis B • Also mumps, adenoviruses, Also mumps, adenoviruses,

Epstein-Barr virus, enterovirusesEpstein-Barr virus, enteroviruses• Deposition of soluble immune Deposition of soluble immune

complexes in synovium with complexes in synovium with resultant inflammationresultant inflammation

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Rubella ArthritisRubella Arthritis

• Often young womenOften young women• Rash several days beforeRash several days before• Acute, symmetric, usually Acute, symmetric, usually

polyarticularpolyarticular• Resolves within weeks Resolves within weeks • Recent infection or vaccination Recent infection or vaccination • Virus isolated from synovial fluidVirus isolated from synovial fluid

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RubellaRubella

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Hepatitis B ArthritisHepatitis B Arthritis

• Usually with or after prodrome of Usually with or after prodrome of fever and lymphadenopathyfever and lymphadenopathy

• Often precedes jaundiceOften precedes jaundice• May be sudden and severeMay be sudden and severe• PIP, knee, ankle, MP joints most PIP, knee, ankle, MP joints most

commonly involvedcommonly involved• Salicylates may be helpfulSalicylates may be helpful

Emergency Medicine

LymeLyme

• Spirochete: Spirochete: Borrelia burgdorferiBorrelia burgdorferi• Vector: Vector: Ixodes damminiIxodes dammini on East on East

Coast and MidwestCoast and Midwest• Arthritis Arthritis latelate manifestation manifestation• Within 6 months, half of untreated Within 6 months, half of untreated

have frank arthritishave frank arthritis– AsymmetricAsymmetric– Most common in kneesMost common in knees

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• Minimal joint pain, usually afebrileMinimal joint pain, usually afebrile• Severity of initial presentation Severity of initial presentation

predictive of subsequent arthritispredictive of subsequent arthritis• Chronic arthritis more common in Chronic arthritis more common in

patients positive for HLA-DR4patients positive for HLA-DR4• Joint fluid inflammatory with PMN Joint fluid inflammatory with PMN

predominancepredominance• Diagnosis is clinicalDiagnosis is clinical

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IxodesIxodes

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SpondyloarthropathiesSpondyloarthropathies

• Seronegative: negative rheumatoid Seronegative: negative rheumatoid factorfactor

• Sacroiliac involvementSacroiliac involvement• Peripheral joint inflammationPeripheral joint inflammation• Changes of ligamentous and Changes of ligamentous and

tendinous insertion into bonetendinous insertion into bone• Genetic: HLA-B27Genetic: HLA-B27

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SpondyloarthropathiesSpondyloarthropathies

• Ankylosing spondylitisAnkylosing spondylitis• Reactive arthritis (e.g. Reiter’s Reactive arthritis (e.g. Reiter’s

syndrome)syndrome)• Psoriatic arthritisPsoriatic arthritis• Arthropathy of inflammatory bowel Arthropathy of inflammatory bowel

diseasedisease

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Ankylosing SpondylitisAnkylosing Spondylitis

• Male predominanceMale predominance• Back painBack pain• X-ray evidence of sacroiliitisX-ray evidence of sacroiliitis• Symmetrically squared vertebral Symmetrically squared vertebral

bodies, then “bamboo spine”bodies, then “bamboo spine”• Morning stiffness, improves with Morning stiffness, improves with

exerciseexercise

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• Uveitis: most common extra-Uveitis: most common extra-articular manifestationarticular manifestation

• Peripheral joints involved in ~30% Peripheral joints involved in ~30% of patients with enthesopathic of patients with enthesopathic involvement (plantar fasciitis and involvement (plantar fasciitis and Achilles tendinitis)Achilles tendinitis)

• Goal of therapy: control pain, Goal of therapy: control pain, decrease inflammationdecrease inflammation

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Reactive ArthritisReactive Arthritis

• AKA arthritis urethritica, venereal AKA arthritis urethritica, venereal arthritis, polyarteritis entericaarthritis, polyarteritis enterica

• Described by German military Described by German military physician Hans Reiter in 1916 physician Hans Reiter in 1916

• ““Reiter's syndrome” being phased Reiter's syndrome” being phased out, partly due to Reiter's typhoid out, partly due to Reiter's typhoid experiments in Nazi concentration experiments in Nazi concentration campscamps

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• Occurs in genetically susceptible Occurs in genetically susceptible host after infection with GU host after infection with GU C. C. trachomatistrachomatis, or GI shigella, , or GI shigella, salmonella, yersinia, campylobactersalmonella, yersinia, campylobacter

• Disease of men 15 to 35 years old; Disease of men 15 to 35 years old; arthritis develops 2 to 6 weeks after arthritis develops 2 to 6 weeks after episode of urethritis or dysenteryepisode of urethritis or dysentery

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• Polyarticular, asymmetricPolyarticular, asymmetric• Weight-bearing joints of lower Weight-bearing joints of lower

extremities commonly involved: extremities commonly involved: knees, ankles, feet, particularly knees, ankles, feet, particularly heels (“lover’s heel”) heels (“lover’s heel”)

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• Other signs appear earlyOther signs appear early• Conjunctivitis, progress to iritis, Conjunctivitis, progress to iritis,

uveitis, corneal ulcerationuveitis, corneal ulceration• Painless ulcers mouth, tongue, Painless ulcers mouth, tongue,

glans penis (balanitis circinata) glans penis (balanitis circinata) • Sausage-like fingers and toes Sausage-like fingers and toes • Keratoderma blennorrhagica on Keratoderma blennorrhagica on

palms and solespalms and soles

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Keratoderma blenorrhagica

Balanitis circinata

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• Synovial fluid: inflammatory with Synovial fluid: inflammatory with predominance of PMNspredominance of PMNs

• Antigens in synovial membrane Antigens in synovial membrane and joint fluid, cultures sterileand joint fluid, cultures sterile

• Increased ESR, WBC Increased ESR, WBC • HLA-B27 antigen in ~80% HLA-B27 antigen in ~80% • Enthesopathic x-rays, particularly Enthesopathic x-rays, particularly

at IP joint of great toeat IP joint of great toe

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• NSAID two or three times daily NSAID two or three times daily • Doxycycline twice daily x 3 monthsDoxycycline twice daily x 3 months• Intra-articular steroid injectionsIntra-articular steroid injections• If persistent: SulfasalazineIf persistent: Sulfasalazine• Chronic therapy for erosive, Chronic therapy for erosive,

deforming disease deforming disease – MethotrexateMethotrexate– Azathioprine (Imuran)Azathioprine (Imuran)

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What Happened to Reiter’s?What Happened to Reiter’s?

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• Hans Julius Reiter (1881 – 1969)Hans Julius Reiter (1881 – 1969)• German military physician on German military physician on

Western Front in 1Western Front in 1stst Hungarian Hungarian ArmyArmy

• 1916: described German 1916: described German Lieutenant with non-gonococcal Lieutenant with non-gonococcal urethritis, arthritis and uveitisurethritis, arthritis and uveitis

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• Not the first, but he got creditNot the first, but he got credit• Member of the SS during WWIIMember of the SS during WWII• Designed typhus inoculation Designed typhus inoculation

experiments that killed more than experiments that killed more than 250 prisoners at Buchenwald250 prisoners at Buchenwald

• Convicted as war criminalConvicted as war criminal

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Psoriatic ArthritisPsoriatic Arthritis

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RheumatismRheumatism

• An older term used to describe any An older term used to describe any of a number of painful conditions of a number of painful conditions of muscles, tendons, joints, and of muscles, tendons, joints, and bones.bones.

• Rheumatism weed: Canadian dogbane

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Acute Rheumatic FeverAcute Rheumatic Fever

• Believed to result from Group A Believed to result from Group A streptococcus pharyngitisstreptococcus pharyngitis

• Exact mechanism unclearExact mechanism unclear• In decline since antibioticsIn decline since antibiotics• Probable abnormal humoral Probable abnormal humoral

response to antigensresponse to antigens

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Clinical SyndromeClinical Syndrome

• Recurring self-limited episodes of Recurring self-limited episodes of fever associated with polyarthritis, fever associated with polyarthritis, carditis / valvulitis, rash, carditis / valvulitis, rash, subcutaneous nodules, or chorea subcutaneous nodules, or chorea

• Occurs 2 to 3 weeks after Occurs 2 to 3 weeks after streptococcal pharyngitisstreptococcal pharyngitis

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Diagnosis – Jones CriteriaDiagnosis – Jones Criteria

• Two major, or one major and two Two major, or one major and two minor, criteria with evidence recent minor, criteria with evidence recent Group A streptococcal infectionGroup A streptococcal infection

• Major manifestations: polyarthritis, Major manifestations: polyarthritis, carditis, chorea, erythema carditis, chorea, erythema marginatum, subcutaneous marginatum, subcutaneous nodulesnodules

• Migratory arthritis in large jointsMigratory arthritis in large joints

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• Involves heart in ~50%Involves heart in ~50%• Pericarditis, congestive heart Pericarditis, congestive heart

failure, valvular dysfunction, failure, valvular dysfunction, cardiomegaly cardiomegaly

• Neurologic: Sydenham’s chorea, Neurologic: Sydenham’s chorea, weakness, behavioral disturbanceweakness, behavioral disturbance

• Sparing of sensory functionsSparing of sensory functions

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Sinus tachycardia

Right atrial enlargement

Left atrial enlargement Left ventricular strain

RBBB pattern

1st degree AV block

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• Erythema marginatum: well-Erythema marginatum: well-demarcated, pink nonpruritic rash, demarcated, pink nonpruritic rash, usually trunk, sometimes proximal usually trunk, sometimes proximal limbs limbs – Central clearing, may last hoursCentral clearing, may last hours

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Erythema MarginatumErythema Marginatum

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• Subcutaneous nodules: firm, Subcutaneous nodules: firm, nontender under skin overlying nontender under skin overlying bony prominencesbony prominences

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Laboratory Work-UpLaboratory Work-Up

• Throat culture, ESR, CRP, ASOThroat culture, ESR, CRP, ASO• Anti-DNase B 95% sensitiveAnti-DNase B 95% sensitive• Streptozyme test also documents Streptozyme test also documents

recent streptococcal infectionrecent streptococcal infection• Synovial fluidSynovial fluid

– Inflammatory (average WBC 16K)Inflammatory (average WBC 16K)– Negative cultureNegative culture

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Post-StreptococcalPost-Streptococcal

• Reactive arthritis: closely related to Reactive arthritis: closely related to ARF but distinct clinical entity ARF but distinct clinical entity

• Sterile oligoarthritis associated Sterile oligoarthritis associated with distant bacterial infectionwith distant bacterial infection

• Carditis rare, arthritis often severeCarditis rare, arthritis often severe• Treatment: penicillin, erythromycinTreatment: penicillin, erythromycin• Arthritis responds to salicylatesArthritis responds to salicylates

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Rheumatoid ArthritisRheumatoid Arthritis

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Rheumatoid ArthritisRheumatoid Arthritis

• Usually chronic: >20% acuteUsually chronic: >20% acute• Women 2 to 3 x more than menWomen 2 to 3 x more than men• Immune complexes stimulate Immune complexes stimulate

PMNs to release enzymes PMNs to release enzymes • Synovial cells proliferate, produce Synovial cells proliferate, produce

more inflammatory substancesmore inflammatory substances

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• Prodrome: fatigue, weakness, Prodrome: fatigue, weakness, musculoskeletal pain musculoskeletal pain

• Symmetric joint swelling: hands Symmetric joint swelling: hands (MP, PIP joints), wrists, elbows(MP, PIP joints), wrists, elbows

• Difficult to distinguish from viral Difficult to distinguish from viral arthropathyarthropathy

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• Long-term Long-term changes: MP and changes: MP and PIP swelling, ulnar PIP swelling, ulnar deviation, swan-deviation, swan-neck and neck and boutonnière boutonnière deformities of deformities of hands, limited hands, limited wrist dorsiflexionwrist dorsiflexion

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Swan Neck DeformitySwan Neck Deformity

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• Knee: effusion, muscle atrophy, Knee: effusion, muscle atrophy, Baker’s cystBaker’s cyst

• Retrocalcaneal bursaRetrocalcaneal bursa• Subcutaneous nodules, pulmonary Subcutaneous nodules, pulmonary

fibrosis, mononeuritis multiplexfibrosis, mononeuritis multiplex• Sjögren’s and Felty’s syndromesSjögren’s and Felty’s syndromes

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Baker’s CystBaker’s Cyst

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Subcutaneous NodulesSubcutaneous Nodules

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Felty’s SyndromeFelty’s Syndrome

• Rheumatoid arthritis Rheumatoid arthritis + splenomegaly + + splenomegaly + leukopenialeukopenia

• Frequent pneumonia Frequent pneumonia and leg ulcersand leg ulcers

• 1% of RA patients1% of RA patients

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Transverse Ligament RuptureTransverse Ligament Rupture

• C1 on C2 subluxation in 70% C1 on C2 subluxation in 70% – Frank dislocation in 25%Frank dislocation in 25%– Cord compression in 11% Cord compression in 11%

• With myelopathy:With myelopathy:– 5 years survival 80% 5 years survival 80% – 10 year survival 28%10 year survival 28%

• Anterior instability more common Anterior instability more common than posterior instabilitythan posterior instability

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Transverse Ligament RuptureTransverse Ligament Rupture

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TreatmentTreatment

• Movement increases inflammation: Movement increases inflammation: initial treatment restinitial treatment rest

• Suppress inflammation: steroids, Suppress inflammation: steroids, salicylates, gold, penicillamine, salicylates, gold, penicillamine, azathioprine, methotrexate, azathioprine, methotrexate, cyclosporine, sulfasalazinecyclosporine, sulfasalazine

Emergency Medicine

Nontraditional ThinkingNontraditional Thinking

• The Mycoplasma Theory: joint The Mycoplasma Theory: joint pain caused by subclinical pain caused by subclinical mycoplasma infection, improves mycoplasma infection, improves with doxycyclinewith doxycycline

• Glucosamine and chondroitin: Glucosamine and chondroitin: possibly useful in osteoarthritispossibly useful in osteoarthritis

Emergency Medicine

Known Not to WorkKnown Not to WorkALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO ALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET - ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET - ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA - POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA - CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY - ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY - CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON - CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON - COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS - SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM - - SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM - DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE) DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE) - SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION - SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION DIETS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET - DIETS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET - TEAS (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE - TEAS (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE - GARLIC - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH - GARLIC - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH - FASTING - GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL - FASTING - GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL - WOOD SPIDER - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN WOOD SPIDER - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP

Emergency Medicine

PearlsPearls

• The number and distribution of The number and distribution of joints involved helps pinpoint the joints involved helps pinpoint the most likely cause of arthritis. most likely cause of arthritis.

• Monarthritis is septic arthritis until Monarthritis is septic arthritis until proven otherwise. proven otherwise.

• Negative Gram’s stain of synovial Negative Gram’s stain of synovial fluid does not rule out bacterial fluid does not rule out bacterial arthritis. arthritis.

Emergency Medicine

PearlsPearls

• The most definitive test for The most definitive test for evaluating an inflamed joint for the evaluating an inflamed joint for the possibility of bacterial infection is possibility of bacterial infection is examination of synovial fluid. examination of synovial fluid.

• Delays in the diagnosis and Delays in the diagnosis and treatment of septic arthritis worsen treatment of septic arthritis worsen outcomes.outcomes.

Emergency Medicine

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Arthritis and Arthrocentesis

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