2001 03 12 Acute Monoarthritis
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ZH. omg sar2001 03 12 Acute Monoarthritis
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ZH. omg sar© 2003-2006, David Stultz, MD
Acute Monoarthritis
David Stultz, MD
March 12, 2001
AAFP 1996;54:2239-43
© 2003-2006, David Stultz, MD
Acute Monoarthritis
• Inflammatory Process involving a single
joint
• Develops over a few days
• Any rheumatic disease can present as
monoarthritis
• Monoarthritis is not the initial symptom of a
systemic connective tissue disease
© 2003-2006, David Stultz, MD
Most Common Causes
• Infection
• Crystals
– Monosodium urate
– Calcium pyrophosphate dihydrate
– Basic calcium phosphate
• Trauma and Overuse
• Systemic rheumatic disease
– Rheumatoid arthritis
– Seronegative spondyloarthritis
© 2003-2006, David Stultz, MD
History
• History of previous joint problem
• History of osteoarthritis
• Timing of onset
– Rapid – Trauma with mechanical problem
– Hours-week – Infection or Crystal arthritis
• Hours-days – Gout
• Several Days – Pseudogout
– Longstanding – OA with mechanical or crystal
problem
– Weeks-Months – Inflammatory Arthritis (eg Reiters or
spondyloarthropathy
© 2003-2006, David Stultz, MD
History
• Migratory Pattern – GC or Rheumatic
Fever
• Erythema most common with infection or
crystal arthritis
• Desquamation of skin – Gout
• Monoarthritis vs Oligoarthritis (<5 joints)
• Risks for Lyme disease, HIV
© 2003-2006, David Stultz, MD
Physical Exam
• Articular vs Periarticular pain
– Articular problems cause active and passive
range of motion restriction
– Periarticular problems restrict active range
more than passive range of motion
• Inflamed joint
– Most sensitive test – stress pain (pain at
extreme range of motion)
– Most specific test – Joint effusion
© 2003-2006, David Stultz, MD
Extra-Articular Features
• Reiter’s Syndrome – Urethritis, conjunctivitis, diarrhea, rash
• Psoriatic Arthritis – Psoriatic skin rash, pitting nails
• Gouty Arthritis – Diuretics, tophi, renal stones
• Ankylosing spondylitis – Uveitis, low back pain
• Sarcoidosis – Hilar adenopathy, erythema nodosum
• GC – Tenosynovitis, pustules, sexual hx
• Coagulopathy – Bleeding tendency, anticoagulants
• Avascular necrosis – SLE, steroids, Alcohol
• Septic Arthritis – Immunosuppression, IV drugs, abnormal joint
© 2003-2006, David Stultz, MD
Joint Aspiration
• Color
– Can read newsprint through normal synovial fluid
• WBC with differential
– WBC’s, neutrophils increased in infection
• Crystal analysis
– Monosodium urate – needle shaped, (-) birefringent
– Calcium pyrophosphate dihrdrate – rhomboid, (+)
birefringent
• Gram stain and culture
© 2003-2006, David Stultz, MD
Interpretation of Synovial fluid
• WBC/mm3
– <200 – normal
– <2,000 – noninflammatory
– 2,000-20,000 – Mild (SLE)
– 20,000-50,000 – Moderate
• Rheumatoid Arthritis
• Reactivie Arthritis
– >50,000 – Severe (Sepsis, Gout)
© 2003-2006, David Stultz, MD
Labs
• CBC, blood culture (optional)
• Uric acid – not always helpful
• Xray – chondrocalcinosis, fracture
• MRI, CT, technetium bone scan
© 2003-2006, David Stultz, MD
Treatment
• Rest, Ice, Range of Motion
• Antibiotics for bacterial arthritis
• NSAIDS +/- intra-articular steroids for
noninfectious inflammatory arthritis
• Arthroscopy for internal derangement
• If uncertain dx then empiric abx and reaspiration
in 24 hours is appropriate
• If high suspicion for septic arthritis, treat with IV
abx, ortho consult
© 2003-2006, David Stultz, MD
Antibiotic Therapy
• Normal Host – Gram (+) organisms (including
MRSA and Strep)
• Immunocompromised – Gram (-) Bacteria
• Gonococcal Arthritis – Ceftriaxone
• Drain all septic joints at least q24h
© 2003-2006, David Stultz, MD
Monoarthritis
History Extra-Articular Features
Physical Exam
Inflammatory Non-Inflammatory
Joint Aspiration Radiograohy
Infection Crystals Unclear Aspiration and Injection
Antibiotics, Consult Treat with NSAIDS Treat Infection, Consult
© 2003-2006, David Stultz, MD
When to Refer
• Unable to aspirate a suspected septic joint
• Deep septic joints (hip, sacroiliac)
• Uncertain inflammatory etiology
• Persistent monoarthritis not responding to
initial therapy
• Extra-articular features suggesting a
systemic connective tissue disease