1. Acute Arthropathies “I’ve got a painful, swollen knee doctor”
By Dr Mahya Mirfattahi GP ST1
HDR LRCH
9th December 2009

3. What could it be? Septic arthritis Septic bursitis
Crystal arthropathies – gout, pseudogout
Acute exacerbation of osteoarthritis
Acute attack of rheumatoid arthritis
Trauma
Seronegative spondyloarthropathy
Viral infection
Lupus

4. Clinical assessment - History
Patient demographics
Age, gender, ethnicity, obese
History
Pain, swelling, stiffness, duration (short), site, preceding trauma, other joints affected, previous episodes, systemic symptoms
Past medical history
Joint prosthesis, osteoarthritis, previous trauma, inflammatory arthritis, psoriasis, recent episodes of illness, diabetes mellitus, hypertension, recent corticosteroid joint injection, haemophilia
Current medications
Bendroflumethiazide, aspirin, immunosuppressant therapy

5. Clinical assessment - Examination
Look
Swelling, redness, scars, tophi, psoriatic plaques, nails, nodules, joint deformities, ulcers
Feel
Warmth, effusion, swellings
Move
Restriction, crepitus, ability to weight bear, painful movements
Systemic features

6. Case 1
67 year old man
Type 2 diabetic, suffers with ulcers on legs dressed by district nurse. LT catheter.
Presents with acute history of painful, hot, swollen red knee
Struggles to walk into surgery
Feverish today
Ulcers weeping

7. What would you like to do?
History
Further enquiries reveal recent corticosteroid injection in knee for OA symptoms
Examination
Temp 37.8, tachycardic, red, hot, effusion, unable to weight bear, restriction of movement
Consider risk factors
What is the mandatory investigation?

8. Joint aspiration

9. Septic arthritis Overall mortality 10% in adults
Suppurative inflammation in joint space
Majority monoarticular
Large > small joints
50% knee, hip 20%, shoulder 8%, ankles 7%, elbow & IPJ 1-4%
Most commonly haematogenous spread
Can be direct penetrating wound or neighbouring infection
Children, neonates, elderly & immunosuppressed

10. Pathogens 90% non-gonococcal
staph aureus 50-80%, streptococcus 15-20%, haemophilus influenzae b 20% (infants 6mo-2yrs), anaerobes 5%
Gonococcal
young, sexually active
Pustular skin lesions (dermatitis-arthritis syndrome)
Tenosynovitis
Migratory arthralgias
Hand > knee, wrist, ankle, or elbow

11. Risk factors for septic arthritis
Previously damaged joints
Prosthetic joints
Immunocompromised states
Systemic drugs – corticosteroids, DMARDS, biological agents
IV drug abuse
Alcohol abuse
Diabetes
Previous intra-articular corticosteroid injection
Cutaneous ulcers
Indwelling catheters
>65 yrs old

12. Management If confident, joint aspirate to dryness & urgent gram stain
Admit patient – discuss with orthopaedic on-call SHO
Blood tests
Cultures – 3x blood, MSU, swabs
Plain XR
Start empirical antibiotics – 1st line flucloxacillin IV 2g QDS
Discuss with microbiologist
Long duration of antibiotic therapy

13. Case 2
78 year old male
Hypertensive, aspirin, osteoarthritis, renal impairment, obese
Complains of painful, hot swollen knee
Noticed swellings on hands
Previous episode of joint pain in big toe 6mo ago settled with OTC NSAIDs

14. What will you do next? History Examination Investigations
Further questioning reveals that had knee arthroscopy last yr, likes alcohol
Examination
Investigations
Joint fluid aspirate, blood tests, plain XR
What are his risk factors?

15. Risk factors for gout Low dose aspirin Diuretic Increasing age, male
Family history
Hypertension
Central obesity
Alcohol consumption
Renal insufficiency
Haematological disorders

16. Precipitants of attack
Dehydration
Injury
Concurrent illness
Dental extraction
Excess foods/alcohol

17. Management Investigations Rest joint
Joint aspiration –ve birefringent needle-shaped
Blood tests
Rest joint
NSAID or if unable or not responding colchicine
Consider PPI
Caution use of colchicine in IHD,CCF
Give until pain relieved
Side effects – diarrhoea, abdominal cramps

18. Prevention Review medications
Advise patients – diet, lifestyle, weight loss
Prophylaxis
Indications: uncomplicated gout >2 attacks/yr, tophi, renal insufficiency, uric acid stones, need to continue diuretics
Allopurinol
Start at 100mg od, gradually increase, monitor uric acid levels 4 weekly until normal
Delay until 2/52 after intial attack settled
Monitor creatinine
SE: rash – stop & reintroduce lower dose
Interactions
Give colchicine/NSAID first 3-6mo
Continue allopurinol in attacks if pt already taking
Referral to rheumatology if no improvement

19. Case 3
17 year old male
Recent travel to Ibiza, playing football yesterday, bad tackle, able to continue game.
Painful, swollen knee
No past medical history
Able to weight bear, but sore
Differential?

20. What would you do next? History Examination Investigations
Recent illness, STI, family history of bleeding disorders
Examination
Investigations
Joint fluid aspirate, blood tests, plain XR

21. Haemarthrosis Plain XR – fat/blood interface Common cause
Ligament injury (cruciates in sports)
Intra-articular #
Inherited haemophilias
APTT, assays for factors VIII, IX

22. Lipohaemarthrosis

23. Case 4 – a real story! 52 year old lady Presents with confusion
Osteoarthritis, TKR 6 wks ago, obese
Fever, ache in knee, coughing
Husband very concerned requests GP home visit

24. Assessment Confused to time, place & person Smelly urine
Coughing, complains of back pain, breathless
Temp 38.6, tachycardic, consolidation lower lobe, urine dip positive
Knee – scar clean, dry, healed well. No effusion. Not red. Slight warmth. Tender ROM, but no restriction.

25. What will you do next? Admit to AMU Orthopaedic review? Investigations
Yes, needs assessment
Investigations
Blood tests
Cultures – 3x blood, MSU
CXR
Plain XR Knee

26. Management Needs joint aspiration in theatre, washout of knee
May need removal of prosthesis
Empirical antibiotics intravenous long term
Discuss with microbiologist
Monitor inflammatory markers

27. Pseudogout Treatment Consider when intermittent attacks
Monoarticular – knee, wrist, hip
Can simulate bacterial infection – severe inflammation & fever
Can be symmetrical
Joint damage can be severe
Investigations
Joint aspiration = calcium pyrophosphate dehydrate crystals (CPPD), rhomboid shaped, +ve birefringent
Plain XR – chondrocalcinosis
Causes – must screen for hyperparathyroidism, haemachromatosis, hyphosphataemia, hypomagnesiaemia
Treatment
Rest, ice, NSAIDs, colchicine, intra-articular steroid injection

28. Reactive arthritis Aseptic arthritis
Occurs 2-6wks after bacterial infection elsewhere
Gastroenteritis (salmonella, campylobacter)
GU infection (chlamydia, gonorrhoea)
Can be HLA B27 +ve
Treatment – NSAIDs, physiotherapy, steroid joint injections
Reiter’s syndrome
Polyarthropathy, urethritis, irits, psoriaform rash
Follows GU/GI infection
Joint & eye changes often severe

29. Diagnosis?

30. What are these?

31. Diagnosis?

32. Diagnosis?

33. Useful Resources GP notebook
Doctors.net e-module on acute swollen joint
ARC (
Patient uk