F:\clinical series`arthitis
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Transcript of F:\clinical series`arthitis
CLINICAL SERIES:
ARTHRITISBY: Ahmed AL-Jabri R2
AIM
• JOINT inflammation : Articular vs periarticular ?
• Inflammatory vs non-inflammatory ? • focus on septic arthritis AND crystal induced
arthritis
Normal Joint..Normal Joint..
Articular Vs. Periarticular
Clinical feature Articular Periarticular
Anatomic structure
Painful site
Pain on movement
Swelling
Synovium, cartilage, capsule
Diffuse, deep
Active/passive, all planes
Common
Tendon, bursa, ligament, muscle, bone
Focal “point”
Active, in few planes
Uncommon
Inflammatory Vs. Noninflammatory
Feature Inflammatory Noninflammatory
Pain (when?)
Swelling
Erythema
Warmth
AM stiffness
Systemic features
î ESR, CRP
Synovial fluid WBC
Examples
Yes (AM)
Soft tissue
Sometimes
Sometimes
Prominent
Sometimes
Frequent
WBC >2000
Septic, RA, SLE, Gout
Yes (PM)
Bony
Absent
Absent
Minor (< 30 ‘)
Absent
Uncommon
WBC < 2000
OA, AVN
Inflammatory Vs. Noninflammatory
Feature Inflammatory Mechanical
Morning stiffness
Fatigue
Activity
Rest
Systemic
>1 h
Profound
Improves
Worsens
Yes
< 30 min
Minimal
Worsens
Improves
No
Acute Monoarthritis - differential diagnosis
– Septic arthritis
– Crystal arthritis• Gout (uric acid)• Pseudogout/calcium pyrophosphate deposition disease
(CPPD)
What are other differentials foracute monoarticular pain?
Monoarthritis - differential diagnosis
Psoriatic arthritis– Onycholysis– Subungual hyperkeratosis– Pitting– Extensor surfaces, scalp, natal
cleft, umbilicus– Other associated features eg
uveitis, inflammatory bowel disease, enthesitis, Ankylosing spondylitis
Monoarthritis - differential diagnosis
Reactive arthritis• Prodromal GI /GUInfection egcampylobacter, salmonella, shigella, Yersinia,chlamydia• Pustular psoriasis and • circinate balanitis
Q: Physical examination of a patient with reiter’s syndrome may be expected to reveal :
• Waxy plaques on the palms and soles• Sausage-like swelling of the fingers• Painful, shallow ulcers in the mouth• Iritis• All of the above • Non of the above
Q: Physical examination of a patient with reiter’s syndrome may be expected to reveal :
• Waxy plaques on the palms and soles• Sausage-like swelling of the fingers• Painful, shallow ulcers in the mouth• Iritis• All of the above
Monoarthritis - differential diagnosis
– Trauma - # and haemarthroses (warfarin, bleeding disorders)
Others to think about• Osteonecrosis/AVN (steroids/alcohol)• Severe pain but good ROM
• Monoarticular RA
• Monoarticular OA
• Prosthetic joint - loosening, # or infection
• Periarticular pathology
Is it an articular or extra-articular problem?
• ARTICULAR PERI-ARTICULAR
• pain all planes pain in plane of tendon• active = passive active < passive• capsular swelling/effusion linear swelling• joint line tenderness localised tenderness• diffuse erythema/heat localised erythema/heat
WHAT DO WE HAVE ?
Olecranon bursitis
42 YRS OLD MALE presents with pain, warmth, and swelling over his posterior elbow. The pt reports frequntly having to lean on his elbow while performing electrical work as part of his job. Although he is able to flex and extend the joint , flexion results in increased pain. After aspiration and cell count of the fluid obtained, which of the following is the minimum WBC count suggestive of infection ?
• WBC > 500 per mm3 .• WBC > 7,000 per mm3 • WBC > 10,000 per mm3 • WBC > 50,000 per mm3 • WBC > 100,000 per mm3
42 YRS OLD MALE presents with pain, warmth, and swelling over his posterior elbow. The pt reports frequntly having to lean on his elbow while performing electrical work as part of his job. Although he is able to flex and extend the joint , flexion results in increased pain. After aspiration and cell count of the fluid obtained, which of the following is the minimum WBC count suggestive of infection ?
• WBC > 500 per mm3 .• WBC > 7,000 per mm3 • WBC > 10,000 per mm3
• SEPTIC BURSITIS ACCOUNTS FOR 33% OF ALL OLECRANON BURSITIS .
What is the expected WBC counts in aspirated synovial fluid from a patient
with septic arthitis?
• It will be a turbid/purulent fluid, • USUALLY > 50,000 wbc/mm3 ( 5000-50,000)• > 75% PMN WBC
What is the expected WBC counts in aspirated synovial fluid from a patient
with septic arthitis?
A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most consistent with __.
• rheumatoid arthritis• viral infection • gonococcal arthritis • systemic lupus erythematosus (SLE) • rheumatic fever
A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most consistent with __.
• rheumatoid arthritis• viral infection • gonococcal arthritis • systemic lupus erythematosus (SLE) • rheumatic feverIn the other conditions, the WBC count is usually
higher, with predominantly PMNs.
Septic arthritis
• 15-30 per 100,000 population• Fatal in 11% of cases • Delayed or inadequate treatment leads to
irreversible joint damage
How do you get septic arthritis?
Pathogenesis
Who gets septic arthritis?
Who gets septic arthritis?
• common organisms Staphylococci or Streptococcus
• young adults, significant incidence gonococcal arthritis
• Elderly & immunocompromised gram -ve organisms
• Anaerobes more common with penetrating trauma
Who gets septic arthritis?• pre-existing joint disease
• prosthetic joints
• IV drug abuse, alcoholism
• diabetes, steroids, immunosuppression
• previous intra-articular steroid injection
What are the signs andsymptoms of septicarthritis?
Symptoms & signs of septic arthritis
• Typically hot, swollen, red tender joint with reduced range of movement, difficulty weight bearing
• Systemic upset• Night and rest pain • Symptoms usually present
for < 2/52 • Large joints more
commonly affected than small
• majority of joint sepsis in hip or knee
55 YRS OLD female with h/o RA presents with progressive swelling and pain in her knee for 6 days. She is on prednisone and states that her standard flares involve her ankles and fingers. Her vitals are normal ; afebrile . Examination reveals a moderate-sized knee effusion with warmth and tenderness and extreme pain on range of motion of the joint. Which of the following is the most appropriate next step in management ?
• Joint aspiration• MRI of the knee• Colchicine PO• Stress-dose steroids • Indomethacin PO
55 YRS OLD female with h/o RA presents with progressive swelling and pain in her knee for 6 days. She is on prednisone and states that her standard flares involve her ankles and fingers. Her vitals are normal ; afebrile . Examination reveals a moderate-sized knee effusion with warmth and tenderness and extreme pain on range of motion of the joint. Which of the following is the most appropriate next step in management ?
• Joint aspiration
Symptoms & signs of septic arthritis
• In pre-existing inflammatory joint disease symptoms in affected joint(s), out of proportion to disease activity in other joints.
• 10-15% of cases, > one joint - so polyarticular presentation does not exclude sepsis
• presence of fever not reliable indicator- if clinical suspicion high - treat
Kocher et al. 1999
• Hx of fever• Nonweightbearing• ESR >40mm/hr• WBC >12,000/mm3
What investigations are usefulin septic arthritis?
Investigations• Synovial fluid aspiration
– volume/viscosity/cellularity/ appearance
– gram stain/culture– Absence of organism does
not exclude septic arthritis– polarised light microscopy
(crystals)
– NB suspected prosthetic joint sepsis should ALWAYS be referred to orthopaedics
Investigations
• Always blood cultures • significant proportion blood cultures + ve in
absence of + ve synovial fluid cultures• FBC ESR & CRP• BUT absence of raised WBC, ESR or CRP Do not
exclude diagnosis of sepsis - if clinical suspicion high always treat
Other investigations• CRP useful for monitoring response to
treatment • Urate may be normal in acute gout and of no
diagnostic value in acute gout or sepsis • Measure urea, electrolytes & liver function for
end organ damage (poor prognostic feature)• Renal function may influence antibiotic choice
Other tests?
• If skin pustule is present, suggestive of gonococcal infection, then skin swab should be taken
• If history suggests possibility of genitourinary or respiratory tract infection then culture sputum (and CXR) & urine & take anogenital & throat swabs where appropriate
• If periarticular sepsis – appropriate swabs and cultures
Antibiotic treatment of septic arthritis
• Local and national guidelines
• Liaise with micro. guided by gram stain
• Conventionally given iv for 2 weeks or until signs improve, then orally for around 4 weeks
SEPTIC ARTHRITS: Oral Antibiotics
• Amoxicillin (25 mg/kg per dose administered every 6 hours)
• Cephalexin (37.5 mg/kg per dose administered every 6 hours)
• Clindamycin (13 mg/kg per dose administered every 8 hours)
• Cloxacillin (31 mg/kg per dose administered every 6 hours)
• Dicloxacillin (25 mg/kg per dose administered every 6 hours) Penicillin V (22 mg/kg per dose administered every 4 hours)
Arthrocentesis
• Critical diagnostic adjunct • Can be painless, safe, and simple when
performed correctly• Diagnostic or therapeutic
Indications
• Obtain joint fluid for analysis• Drain tense hemarthroses • Instill analgesics and anti-inflammatory agents• Prosthetic joints: only to rule out infection
Arthrocentesis
• Fat globules: diagnostic of fracture• Intraarticular morphine can provide relief for
up to 24 hours– 1 to 5 mg diluted in normal saline solution to a
total volume of 30 ml
Shoulder – Posterior Approach
Shoulder – Anterior Approach
Elbow – Lateral Approach
Flex elbow 90o
Prep skin
Insert needle in palpable bony
notch between lateral epicondyle
and olecranon
Elbow – Lateral Approach
Elbow – Posterior Approach
Wrist Approach
Wrist Approach
Wrist Approach
A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opposite side.
• pronation
• supination
• flexion and extension
A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opposite side.
• pronation
• supination
• flexion and extension
With even minimal inflammation, there will be a noticeable decrease in the flexion-extension range of motion
Knee – Lateral Approach
Knee – Lateral Approach
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.
Knee – Lateral Approach
Knee – Medial Approach
Knee – Medial Approach
Knee – Medial Approach
Knee – Medial Approach
Knee – Medial Approach
AnklePalpate 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.
AnklePalpate the dorsalis pedis artery and choose a puncture site anywhere on the anterior aspect of the ankle, avoiding the dorsalis pedis artery.
Ankle – Lateral Approach
Ankle – Medial Approach
Synovial Fluid Analysis
• Identify crystals, pus • Analyze color, clarity, cell count, differential,
Gram’s stain, crystals• Positive Gram’s stain: diagnostic for septic
arthritis• Negative Gram’s stain: does not rule out
septic arthritis
Synovial Fluid Cell Count
• Noninflammatory vs. inflammatory• ED wet mount prep
– 1 to 2 WBCs per high-power field consistent with noninflammatory
– >20 WBC/HPF suggests inflammation or infection
• Septic: >50,000 WBC/mm3 (also rheumatoid, gout, pseudogout)
NormalNormalNon-Non-
inflammatoryinflammatory InflammatoryInflammatory InfectiousInfectious
Trans-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
ClarityClarity
WBCsWBCs
PMNsPMNs
CultureCulture
Synovial Fluid Analysis
Septic arthritis: SMS
• with a short history of a hot, swollen, tender joint (or joints) plus restriction of movement; septic arthritis until proven otherwise
• If clinical suspicion high investigate & treat as septic arthritis even in absence of fever
gout
Gout• Caused by monosodium urate crystals• Most common type of inflammatory monoarthritis• Typically: first MTP joint, ankle, midfoot, knee• Pain very severe; cannot stand bed sheet• May be with fever and mimic infection• The cutaneous erythema may extend beyond the
joint and resemble bacterial cellulitis
Acute Gouty Arthritis
Risk Factors• Primary gout: Obesity, hyperlipidemia,
diabetes mellitus, hypertension, and atherosclerosis.
• Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure.
Microscopic appearance of the crystals of gout include all of the following EXCEPT:
• needle-shaped urate crystals• positively birefringent • negatively birefringent• Non of the above
Microscopic appearance of the crystals of gout include all of the following EXCEPT:
• needle-shaped urate crystals• positively birefringent
Urate Crystals
• Needle-shaped
• Strongly negative birefringent
CPPD Crystals Deposition Disease
• Can cause monoarthritis clinically indistinguishable from gout – hence called Pseudogout.
• Often precipitated by illness or surgery.• Pseudogout is most common in the knee (50%) and
wrist.• Reported in any joint (Including MTP).• CPPD disease may be asymptomatic (deposition of
CPP in cartilage).
Associated Conditions• Hyperparathyroidism• Hypercalcemia• Hypocalciuria• Hemochromatosis• Hypothyroidism• Gout• Aging
CPPD Crystals
• Rod or rhomboid-shaped
• positive birefringent
THANK-YOU