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Project: Ghana Emergency Medicine Collaborative Document Title: Arthritis and Arthrocentesis Author(s): Joe Lex, MD (Temple University School of Medicine) License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

GEMC- Arthritis and Arthrocentesis- Resident Training

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Page 1: GEMC- Arthritis and Arthrocentesis- Resident Training

Project: Ghana Emergency Medicine Collaborative

Document Title: Arthritis and Arthrocentesis

Author(s): Joe Lex, MD (Temple University School of Medicine)

License: Unless otherwise noted, this material is made available under the

terms of the Creative Commons Attribution Share Alike-3.0 License:

http://creativecommons.org/licenses/by-sa/3.0/

We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to

use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable

version. The citation key on the following slide provides information about how you may share and adapt this

material.

Copyright holders of content included in this material should contact [email protected] with any

questions, corrections, or clarification regarding the use of content.

For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use.

Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a

replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to

your physician if you have questions about your medical condition.

Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.

1

Page 2: GEMC- Arthritis and Arthrocentesis- Resident Training

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2

Page 3: GEMC- Arthritis and Arthrocentesis- Resident Training

Arthritis and

Arthrocentesis

Joe Lex, MD, FACEP, MAAEM

Temple University School of Medicine

3

Page 4: GEMC- Arthritis and Arthrocentesis- Resident Training

What’s a

joint like you

doing in a

nice girl like

this??

Source Undetermined 4

Page 5: GEMC- Arthritis and Arthrocentesis- Resident Training

Objectives

1. Differentiate among the three

types of joints

2. Explain the pathology of joint

inflammation

3. Develop a differential for arthritis,

based on number of joints

involved, location, and other

characteristics 5

Page 6: GEMC- Arthritis and Arthrocentesis- Resident Training

Objectives

4. Explain usefulness of various

synovial fluid studies.

5. Demonstrate an appropriate

technique for large joint

arthrocentesis

6. Explain the pathophysiology and

treatment for gout

6

Page 7: GEMC- Arthritis and Arthrocentesis- Resident Training

Objectives

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

“rheumatism”

8. Be aware of quackery as it

applies to treatment of arthritis

7

Page 8: GEMC- Arthritis and Arthrocentesis- Resident Training

History of Arthritides

• 1680s: Sydenham describes gout,

rheumatism, chorea

• 1808: term “rheumatic fever”

• 1876: urate crystals postulated to

cause gout

• 1883: gonococcal arthritis

• 1907: osteoarthritis described

8

Page 9: GEMC- Arthritis and Arthrocentesis- Resident Training

Thomas Sydenham

(1624-1689)

Source Undetermined

9

Page 10: GEMC- Arthritis and Arthrocentesis- Resident Training

Three Joint Types

• Synarthroses: suture lines of skull

• Amphiarthroses: fibrocartilaginous

unions of pubic symphysis and

lower third of sacroiliac joint

• Diarthroses = Synovial: most other

joints

10

Page 11: GEMC- Arthritis and Arthrocentesis- Resident Training

Synarthrosis

Gray's Anatomy (Wikipedia)

11

Page 12: GEMC- Arthritis and Arthrocentesis- Resident Training

Amphiarthroses

Source Undetermined 12

Page 13: GEMC- Arthritis and Arthrocentesis- Resident Training

Diarthrosis = Synovial Joints

• Subchondral bone, convex against

concave, covered by cartilage

• Cartilage: collagen + proteoglycan

• Lubricated, slide on each other

• Surrounded by capsule supported

by ligaments, tendons, and muscle

• Lined with synovial membrane

13

Page 14: GEMC- Arthritis and Arthrocentesis- Resident Training

Typical Joint Structure

Madhero88 (Wikimedia Commons)

14

Page 15: GEMC- Arthritis and Arthrocentesis- Resident Training

Pathophysiology

• Joint trauma causes decreased

proteoglycans

– If trauma persistent, damage

irreparable

• Inflammation characterized by

polymorphonuclear white cells

– May be immunologic (rheumatoid,

reactive)

15

Page 16: GEMC- Arthritis and Arthrocentesis- Resident Training

Joint vs. Periarticular

Arthritis

• Generalized

pain, warmth,

swelling,

tenderness

• Discomfort

with joint

motion

Periarticular

inflammation:

bursitis, tendinitis,

localized cellulitis

• Focal tenderness,

swelling not uniform

• Pain only with

certain movements

16

Page 17: GEMC- Arthritis and Arthrocentesis- Resident Training

Monarticular vs. Polyarticular

Source Undetermined 17

Page 18: GEMC- Arthritis and Arthrocentesis- Resident Training

If Polyarticular and…

…symmetric rheumatoid, drug

induced

…asymmetric rubella, acute

rheumatic fever, gonococcal

…migratory gonococcal or

rubella

18

Page 19: GEMC- Arthritis and Arthrocentesis- Resident Training

Location, Location, Location

• First MTP joint: gout

• MCP and PIP joints: rheumatoid

• DIP and first carpometacarpal

joint: osteoarthritis

• Knee: septic arthritis, pseudogout,

gout

19

Page 20: GEMC- Arthritis and Arthrocentesis- Resident Training

Causes of Migratory Arthritis

• Rheumatic fever

• Subacute bacterial

endocarditis

• Henoch-Schönlein

purpura

• Cefaclor (Ceclor®)

hypersensitivity

(kids)

• Septicemia:

staphylococcal,

streptococcal,

meningococcal,

gonococcal

• Mycoplasma,

histoplasmosis,

coccidioidomycosis

• Lyme disease

20

Page 21: GEMC- Arthritis and Arthrocentesis- Resident Training

Arthritis with…

…low-grade fever any

inflammatory arthritis

…high fever, chills septic arthritis

…kidney stones gout

…genital ulcers reactive arthritis

…urethral discharge reactive

arthritis, gonococcus

21

Page 22: GEMC- Arthritis and Arthrocentesis- Resident Training

Arthritis and…

…isoniazid, procainamide,

hydralazine lupus

…thiazide diuretics gout

(increase serum uric acid level)

– Chlorthalidone (Hygroton®)

– Hydrochlorothiazide (HydroDIURIL®,

Esidrix®, Oretic®)

– Indapamide (Lozol®)

22

Page 23: GEMC- Arthritis and Arthrocentesis- Resident Training

Some Scalp and Skin Findings

Alopecia SLE, psoriasis ECM Lyme

Malar rash SLE, dermato-

myositis

Rash Rubella

Pustules Gonococcemia Tophi Gout

Elbows,

knees

Psoriasis SubQ

nodules

RA

Tight skin Scleroderma Hyper-

keratosis

Reactive

23

Page 24: GEMC- Arthritis and Arthrocentesis- Resident Training

Physical Exam

Source Undetermined

24

Page 25: GEMC- Arthritis and Arthrocentesis- Resident Training

Physical Exam

1. Warmth and effusion

2. Synovial thickening

3. Deformity

4. Tenderness: generalized or

localized, articular or periarticular

5. Limited range of motion

6. Pain on movement

25

Page 26: GEMC- Arthritis and Arthrocentesis- Resident Training

Lab Studies

• Limited diagnostic value

• “Screening tests”

– Bacterial: usually elevated WBC

– Chronic rheumatic: mild anemia

– ESR/CRP in most inflammatory

• RF, ANA, ASO titers, Lyme

serologies: for follow-up

• Uric acid: not helpful in gout 26

Page 27: GEMC- Arthritis and Arthrocentesis- Resident Training

X-ray Findings (Chronic)

Soft tissue swelling

Erosions

Calcification

Osteoporosis

Narrowed joint space

Deformity

Separation (fractures)

Source Undetermined

27

Page 28: GEMC- Arthritis and Arthrocentesis- Resident Training

X-ray Findings (Septic)

Source Undetermined Source Undetermined

28

Page 29: GEMC- Arthritis and Arthrocentesis- Resident Training

Hallmark X-ray Findings

Osteoarthritis = Osteophytes

Source Undetermined

Source Undetermined

29

Page 30: GEMC- Arthritis and Arthrocentesis- Resident Training

Hallmark X-ray Findings

Erosions = Rheumatoid or Gout

Source Undetermined Source Undetermined Source Undetermined 30

Page 31: GEMC- Arthritis and Arthrocentesis- Resident Training

Hallmark X-ray Findings

Chondrocalcinosis = Pseudogout

Source Undetermined 31

Page 32: GEMC- Arthritis and Arthrocentesis- Resident Training

Hallmark X-ray Findings

Enthesitis = Insertion Site

Inflammation (HLA-B27)

Source Undetermined 32

Page 33: GEMC- Arthritis and Arthrocentesis- Resident Training

Other Imaging

• Ultrasound: joint effusions;

tendons and ligaments of shoulder

• CT scan: SI, sternoclavicular joint

• MRI: knee cruciate ligaments

• Contrast MRI: differentiate

synovitis from synovial fluid in

rheumatoid disease

33

Page 34: GEMC- Arthritis and Arthrocentesis- Resident Training

Other Imaging

• 99mtechnetium methylene

diphosphonate (99mTc MDP)

– Osteomyelitis, stress fractures

• Gallium: gathers at proliferation of

serum proteins and leukocytes

– Infection

34

Page 36: GEMC- Arthritis and Arthrocentesis- Resident Training

Arthrocentesis

• Critical diagnostic adjunct

• Can be painless, safe, and simple

when performed correctly

• Diagnostic or therapeutic

Source Undetermined

36

Page 37: GEMC- Arthritis and Arthrocentesis- Resident Training

Indications

• Obtain joint fluid for analysis

• Drain tense hemarthroses

• Instill analgesics and anti-

inflammatory agents

• Prosthetic joints: only to rule out

infection

37

Page 38: GEMC- Arthritis and Arthrocentesis- Resident Training

Contraindications

• Absolute: infection of any kind

covers area to be punctured

• Relative

– Bleeding diatheses, anticoagulant

therapy

– Bacteremia

38

Page 39: GEMC- Arthritis and Arthrocentesis- Resident Training

Procedure

• Cleanse skin with povidone-iodine,

then air dry

• Remove povidone-iodine with

isopropyl alcohol

– Intra-articular povidone-iodine can

cause chemical irritation, inhibit

bacterial growth leading to spuriously

negative cultures in early septic joint

39

Page 40: GEMC- Arthritis and Arthrocentesis- Resident Training

Procedure

• Place sterile drapes

• Inject local anesthetic into skin

– 25- to 30-gauge needle

– Intraarticular anesthetic can inhibit

bacterial growth, cause spuriously

negative culture in early septic joint

40

Page 41: GEMC- Arthritis and Arthrocentesis- Resident Training

Procedure

• Aspirate large joints with large-

bore needle (18 or 19 gauge)

– Smaller joints: smaller-bore needle

• Choose syringe size based on

anticipated fluid volume

• Remove as much fluid as possible

– Optimizes diagnosis

– Relieves pain from distention 41

Page 42: GEMC- Arthritis and Arthrocentesis- Resident Training

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

42

Page 43: GEMC- Arthritis and Arthrocentesis- Resident Training

Sternoclavicular Joint

43

Gray's Anatomy (Wikipedia)

Page 44: GEMC- Arthritis and Arthrocentesis- Resident Training

Elbow – Lateral Approach

Flex elbow 90o

Prep skin

Insert needle in

palpable bony

notch between

lateral epicondyle

and olecranon

44

Page 45: GEMC- Arthritis and Arthrocentesis- Resident Training

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. 45

Page 46: GEMC- Arthritis and Arthrocentesis- Resident Training

Knee – Medial Approach

46 Source Undetermined

Page 47: GEMC- Arthritis and Arthrocentesis- Resident Training

Knee – Medial Approach

47

Source Undetermined

Page 48: GEMC- Arthritis and Arthrocentesis- Resident Training

Knee – Medial Approach

48

Source Undetermined

Page 49: GEMC- Arthritis and Arthrocentesis- Resident Training

Knee – Medial Approach

49

Source Undetermined

Page 50: GEMC- Arthritis and Arthrocentesis- Resident Training

Knee – Medial Approach

50

Source Undetermined

Page 51: GEMC- Arthritis and Arthrocentesis- Resident Training

Knee – Medial vs. Lateral

• Follow “Sutton’s Law”

• William “Slick Willie” Sutton (1901

– 1980): professional bank robber

51

Page 52: GEMC- Arthritis and Arthrocentesis- Resident Training

Ankle

Palpate 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.

52

Page 53: GEMC- Arthritis and Arthrocentesis- Resident Training

Ankle

Palpate the

dorsalis pedis

artery and

choose a

puncture site

anywhere on

the anterior

aspect of the

ankle, avoiding

the dorsalis

pedis artery.

53

Page 54: GEMC- Arthritis and Arthrocentesis- Resident Training

Synovial Fluid Analysis

54

Source Undetermined

Page 55: GEMC- Arthritis and Arthrocentesis- Resident Training

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

55

Page 56: GEMC- Arthritis and Arthrocentesis- Resident Training

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)

56

Page 57: GEMC- Arthritis and Arthrocentesis- Resident Training

Normal

Non-

inflammatory Inflammatory Infectious

Trans-

parent Transparent Cloudy Cloudy

Clear Yellow Yellow Yellow

<200 <2000 200 – 50,000 >50,000

<25% <25% >50% >50%

Negative Negative Negative Positive

Appear-

ance

Clarity

WBCs

PMNs

Culture

Synovial Fluid Analysis

57

Page 58: GEMC- Arthritis and Arthrocentesis- Resident Training

Other Synovial Fluid Analysis

• Glucose, lactic acid, viscosity,

mucin clot, and total protein:

limited utility, not recommended

• Appropriate container

– Cellular analysis: lavender

(ethylenediaminetetraacetic acid)

– Crystal analysis: green (heparin)

– Chemical analysis, serology: red

58

Page 59: GEMC- Arthritis and Arthrocentesis- Resident Training

Crystal Studies

• Monosodium urate: needle

shaped, birefringent negative

– Parallel to compensator: yellow

– Perpendicular: blue

• Calcium pyrophosphate:

polymorphic, birefringent positive

– Parallel to compensator: blue

– Perpendicular: yellow 59

Page 60: GEMC- Arthritis and Arthrocentesis- Resident Training

Crystal Studies

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.

60

Source Undetermined

Page 61: GEMC- Arthritis and Arthrocentesis- Resident Training

Crystal Studies

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. 61

Source Undetermined

Page 62: GEMC- Arthritis and Arthrocentesis- Resident Training

Specific

Arthritides There are more than 90

Preiser’s

disease:

avascular

necrosis of

scaphoid 62

Source Undetermined

Page 63: GEMC- Arthritis and Arthrocentesis- Resident Training

Septic Arthritis

• Hematogenous spread

• Direct inoculation

• Direct spread from bony or soft

tissue infections

63

Page 64: GEMC- Arthritis and Arthrocentesis- Resident Training

Septic Arthritis

• Synovium infected before

degrading enzymes released

• Children: hematogenous most

common

• Postoperative infection: ~10% of

joint surgeries

64

Page 65: GEMC- Arthritis and Arthrocentesis- Resident Training

Causes

• Staphylococcus aureus: most

common (even in sickle cell)

• Others: streptococcus, Gram

negatives, anaerobes

• N. gonorrhoeae: 20% monarticular

• <6 months: E. coli, group B strep

• IV drug users: S. aureus, Gram

negatives 65

Page 66: GEMC- Arthritis and Arthrocentesis- Resident Training

Clinical Features

• Based on host’s concurrent

medical conditions

• Painful, hot, swollen

• Typical: single joint

– Knee: 40% to 50%

– Hip: 13% to 20%

– Shoulder: 10% to 15%

• 20% polyarticular 66

Page 67: GEMC- Arthritis and Arthrocentesis- Resident Training

Clinical Features

• History of fever: 80%

• Shaking chills: 20%

• Elevated sedimentation rate more

common than leukocytosis

• Blood cultures grow causative

organism ~50% of the time

• Radiographs not often useful

67

Page 68: GEMC- Arthritis and Arthrocentesis- Resident Training

Management

• Admit for joint drainage, IV

antibiotics

• Empiric therapy based on Gram’s

stain

• Parenteral narcotic analgesics,

articular immobilization control

pain and discomfort

68

Page 69: GEMC- Arthritis and Arthrocentesis- Resident Training

Gouty Arthritis

69

Page 70: GEMC- Arthritis and Arthrocentesis- Resident Training

Gouty Arthritis

• Pod = foot; agra = trap, hunt

• Podagra: foot goddess, a bad-

tempered virgin, who attacked

victims after they overindulged

• Father was Dionysus (Bacchus),

god of wine

• Mother was Aphrodite (Venus),

goddess of love 70

Page 71: GEMC- Arthritis and Arthrocentesis- Resident Training

Gouty Arthritis

• Thought to be limited to men who

had indulged in dietary or sexual

excess

71

Page 72: GEMC- Arthritis and Arthrocentesis- Resident Training

Gouty Arthritis

• Galen (129-199 AD), an

ex-gladiatorial surgeon in

Rome, described gout as

a discharge of the four

humors of the body in

unbalanced amounts into

the joints (hence gout =

gutta, a drop)

72

Pierre Roche Vigneron (Wikimedia Commons)

Page 73: GEMC- Arthritis and Arthrocentesis- Resident Training

Be temperate in wine, in

eating, girls and sloth

Or the gout will seize you

and plague you both

73

Benjamin Franklin:

Page 74: GEMC- Arthritis and Arthrocentesis- Resident Training

Pathophysiology

• Uric acid crystal deposits from

supersaturated extracellular fluid

• Risk factors: obesity, hypertension,

diabetes, alcohol, proximal loop

diuretics, lead poisoning

• During attack: crystals ingested by

PMNs inflammation

74

Page 75: GEMC- Arthritis and Arthrocentesis- Resident Training

Pathophysiology

• Middle-aged men, post-

menopausal women

• Increased uric acid usually present

for 20 years before first attack

• Uric acid often normal

75

Page 76: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Great toe MTP joint in 75%

– Also tarsal, ankle, knee, wrist

– Up to 40% polyarticular

• Pain excruciating at onset

– Can mimic septic joint

– Usually self-limited

• Systemic symptoms usually

minimal or absent 76

Page 77: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Subsequent attacks closer

together, more joints, last longer

• Long-term: kidney stones

77 Source Undetermined

Page 78: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Tophi: foreign body granulomas

with crystals as nidus, in musculo-

tendinous unit – olecranon bursa,

Achilles tendon, hands, knees, etc.

78

Source Undetermined Source Undetermined

Page 79: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis

• Rule out cellulitis, septic arthritis

particularly if knee joint

• All may have fever, leukocytosis,

elevated ESR

• Uric acid level not helpful

• X-rays: soft-tissue swelling (acute)

or joint destruction (chronic)

79

Page 80: GEMC- Arthritis and Arthrocentesis- Resident Training

Uric Acid Levels

• Uric acid normal in ~40%

• Tophi can form in cool body areas

without hyperuricemia

• Acute attack pain increased

cortisol uric acid diuresis

normalized level

80

Page 81: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis

81

Source Undetermined Source Undetermined

Page 82: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis

• Definitive diagnosis:

birefringent joint fluid

crystals with polarizing

microscope (a yellow

crystal against a red

background) and

negative joint fluid

culture

82

Source Undetermined

Page 83: GEMC- Arthritis and Arthrocentesis- Resident Training

Acute Therapy – Colchicine

• Not diagnostic: works on

pseudogout

• Contraindication: hematologic,

renal, hepatic dysfunction

• Extravasation from IV tissue

necrosis

83

Page 84: GEMC- Arthritis and Arthrocentesis- Resident Training

Acute Therapy – Colchicine

• Inhibits microtubule formation

• Most effective in first 24 hours

• 0.6 mg / hour until pain controlled,

max 6 mg or side effects (GI)

• Average toxic dose: 6.7 mg

• Toxicity precedes improvement in

more than 50%

84

Page 85: GEMC- Arthritis and Arthrocentesis- Resident Training

Acute Therapy – Other

• NSAIDs effective, indomethacin

most common (75 to 200 mg/day)

– Contraindicated in PUD, GI bleed

• If resistant: prednisone taper

– 40 mg/day first 3 to 5 days

• Adrenocorticotrophic hormone

– ACTH 40 IU to 80 IU IM

85

Page 86: GEMC- Arthritis and Arthrocentesis- Resident Training

Pseudogout

• Calcium pyrophosphate dihydrate

(CPPD) crystal-deposition disease

• Knee: most common joint

• Polyarticular possible

• Pain less severe, patients older

• Risk: hypothyroid, Wilson’s

disease, hyperparathyroid,

hemochromatosis, etc. 86

Page 87: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis

• Common: elevated ESR, WBC

• X-ray may show joint calcification

• Joint fluid

– Weakly positive birefringent crystals

on polarized microscopy

– Appear rhomboidal on regular light

microscopy

• Treatment: same as gout 87

Page 88: GEMC- Arthritis and Arthrocentesis- Resident Training

Chondrocalcinosis

88 Source Undetermined

Page 89: GEMC- Arthritis and Arthrocentesis- Resident Training

Osteoarthritis

• Degenerative joint disease

• Most common form of arthritis

• Loss of articular cartilage, reactive

changes at joint margins

• Synovitis in advanced disease

• May have painful bone-to-bone

interface

89

Page 90: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation / Diagnosis

• Chief complaint: pain

• No systemic symptoms

• Hands: Bouchard’s, Heberden’s

nodes (osteophyte spurs)

• Knee: active & passive crepitus

• Routine lab tests: normal

• Radiographs: joint- space

narrowing, osteophyte formation 90

Page 91: GEMC- Arthritis and Arthrocentesis- Resident Training

Heberden’s and Bouchard’s

Over DIP Over PIP

91

Source Undetermined

Page 92: GEMC- Arthritis and Arthrocentesis- Resident Training

92

Source Undetermined

Page 93: GEMC- Arthritis and Arthrocentesis- Resident Training

Treatment

• Judicious exercise for muscle

strengthening

• Relieve muscle spasm

• Support joint

• Acetaminophen comparable to

ibuprofen for short-term treatment

• Ultimately joint replacement

93

Page 94: GEMC- Arthritis and Arthrocentesis- Resident Training

Gonococcal Arthritis

• Woman : men :: 4:1

• Fever, chills, arthralgias, migratory

tenosynovitis

• Progresses to arthritis: knee,

ankle, wrist

• Characteristic rash: countable

hemorrhagic necrotic pustules

• Rarely have cervicitis or urethritis 94

Page 96: GEMC- Arthritis and Arthrocentesis- Resident Training

Gonococcal Arthritis

96

Source Undetermined

Source Undetermined

Page 97: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis

• Blood cultures usually negative

• Synovial fluid cultures positive in

less than 50%

• Gram’s stain positive more often

than culture

• Cervical, urethral, pharyngeal,

rectal cultures positive ~75%

97

Page 98: GEMC- Arthritis and Arthrocentesis- Resident Training

Treatment

• Admit to hospital

• Ceftriaxone 1 g IM or IV daily, and

24 to 48 hours after improvement

• Ciprofloxacin 500 mg twice daily

orally for total 7 days of antibiotics

• Spectinomycin 2 grams IM every

12 hours if beta-lactam allergic

98

Page 99: GEMC- Arthritis and Arthrocentesis- Resident Training

Viral Arthritis

• Most common: rubella, hepatitis B

• Also mumps, adenoviruses,

Epstein-Barr virus, enteroviruses

• Deposition of soluble immune

complexes in synovium with

resultant inflammation

99

Page 100: GEMC- Arthritis and Arthrocentesis- Resident Training

Rubella Arthritis

• Often young women

• Rash several days before

• Acute, symmetric, usually

polyarticular

• Resolves within weeks

• Recent infection or vaccination

• Virus isolated from synovial fluid

100

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Rubella

101 Source Undetermined

Source Undetermined

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Hepatitis B Arthritis

• Usually with or after prodrome of

fever and lymphadenopathy

• Often precedes jaundice

• May be sudden and severe

• PIP, knee, ankle, MP joints most

commonly involved

• Salicylates may be helpful

102

Page 103: GEMC- Arthritis and Arthrocentesis- Resident Training

Lyme

• Spirochete: Borrelia burgdorferi

• Vector: Ixodes dammini on East

Coast and Midwest

• Arthritis late manifestation

• Within 6 months, half of untreated

have frank arthritis

– Asymmetric

– Most common in knees 103

Page 104: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Minimal joint pain, usually afebrile

• Severity of initial presentation

predictive of subsequent arthritis

• Chronic arthritis more common in

patients positive for HLA-DR4

• Joint fluid inflammatory with PMN

predominance

• Diagnosis is clinical 104

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Presentation

105 Source Undetermined

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Ixodes

106 Centers for Disease Control and Prevention (Wikimedia Commons)

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Spondyloarthropathies

• Seronegative: negative rheumatoid

factor

• Sacroiliac involvement

• Peripheral joint inflammation

• Changes of ligamentous and

tendinous insertion into bone

• Genetic: HLA-B27

107

Page 108: GEMC- Arthritis and Arthrocentesis- Resident Training

Spondyloarthropathies

• Ankylosing spondylitis

• Reactive arthritis (e.g. Reiter’s

syndrome)

• Psoriatic arthritis

• Arthropathy of inflammatory bowel

disease

108

Page 109: GEMC- Arthritis and Arthrocentesis- Resident Training

Ankylosing Spondylitis

• Male predominance

• Back pain

• X-ray evidence of sacroiliitis

• Symmetrically squared vertebral

bodies, then “bamboo spine”

• Morning stiffness, improves with

exercise

109

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Ankylosing Spondylitis

110

Source Undetermined

Source Undetermined

Source Undetermined

Page 111: GEMC- Arthritis and Arthrocentesis- Resident Training

Ankylosing Spondylitis

• Uveitis: most common extra-

articular manifestation

• Peripheral joints involved in ~30%

of patients with enthesopathic

involvement (plantar fasciitis and

Achilles tendinitis)

• Goal of therapy: control pain,

decrease inflammation 111

Page 112: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

• AKA arthritis urethritica, venereal

arthritis, polyarteritis enterica

• Described by German military

physician Hans Reiter in 1916

• “Reiter's syndrome” being phased

out, partly due to Reiter's typhoid

experiments in Nazi concentration

camps 112

Page 113: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

• Occurs in genetically susceptible

host after infection with GU C.

trachomatis, or GI shigella,

salmonella, yersinia, campylobacter

• Disease of men 15 to 35 years old;

arthritis develops 2 to 6 weeks after

episode of urethritis or dysentery

113

Page 114: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

• Polyarticular, asymmetric

• Weight-bearing joints of lower

extremities commonly involved:

knees, ankles, feet, particularly

heels (“lover’s heel”)

114

Page 115: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

• Other signs appear early

• Conjunctivitis, progress to iritis,

uveitis, corneal ulceration

• Painless ulcers mouth, tongue,

glans penis (balanitis circinata)

• Sausage-like fingers and toes

• Keratoderma blennorrhagica on

palms and soles 115

Page 116: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

Keratoderma blenorrhagica

Balanitis circinata 116

Source Undetermined

Source Undetermined

Page 117: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

• Synovial fluid: inflammatory with

predominance of PMNs

• Antigens in synovial membrane

and joint fluid, cultures sterile

• Increased ESR, WBC

• HLA-B27 antigen in ~80%

• Enthesopathic x-rays, particularly

at IP joint of great toe 117

Page 118: GEMC- Arthritis and Arthrocentesis- Resident Training

Reactive Arthritis

• NSAID two or three times daily

• Doxycycline twice daily x 3 months

• Intra-articular steroid injections

• If persistent: Sulfasalazine

• Chronic therapy for erosive,

deforming disease

– Methotrexate

– Azathioprine (Imuran) 118

Page 119: GEMC- Arthritis and Arthrocentesis- Resident Training

What Happened to Reiter’s?

119

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What Happened to Reiter’s?

• Hans Julius Reiter (1881 – 1969)

• German military physician on

Western Front in 1st Hungarian

Army

• 1916: described German

Lieutenant with non-gonococcal

urethritis, arthritis and uveitis

120

Page 121: GEMC- Arthritis and Arthrocentesis- Resident Training

What Happened to Reiter’s?

• Not the first, but he got credit

• Member of the SS during WWII

• Designed typhus inoculation

experiments that killed more than

250 prisoners at Buchenwald

• Convicted as war criminal

121

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Psoriatic Arthritis

122

Source Undetermined

Source Undetermined

Source Undetermined

Page 123: GEMC- Arthritis and Arthrocentesis- Resident Training

Rheumatism

• An older term used to describe any

of a number of painful conditions

of muscles, tendons, joints, and

bones.

• Rheumatism

weed:

Canadian

dogbane

123

SB Johnny (Wikipedia)

Page 124: GEMC- Arthritis and Arthrocentesis- Resident Training

Acute Rheumatic Fever

• Believed to result from Group A

streptococcus pharyngitis

• Exact mechanism unclear

• In decline since antibiotics

• Probable abnormal humoral

response to antigens

124

Page 125: GEMC- Arthritis and Arthrocentesis- Resident Training

Clinical Syndrome

• Recurring self-limited episodes of

fever associated with polyarthritis,

carditis / valvulitis, rash,

subcutaneous nodules, or chorea

• Occurs 2 to 3 weeks after

streptococcal pharyngitis

125

Page 126: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis – Jones Criteria

• Two major, or one major and two

minor, criteria with evidence recent

Group A streptococcal infection

• Major manifestations: polyarthritis,

carditis, chorea, erythema

marginatum, subcutaneous

nodules

• Migratory arthritis in large joints 126

Page 127: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis – Jones Criteria

• Involves heart in ~50%

• Pericarditis, congestive heart

failure, valvular dysfunction,

cardiomegaly

• Neurologic: Sydenham’s chorea,

weakness, behavioral disturbance

• Sparing of sensory functions

127

Page 128: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis – Jones Criteria

Sinus tachycardia

Right atrial enlargement

Left atrial enlargement Left ventricular strain

RBBB pattern

1st degree AV block

128

Source Undetermined

Page 129: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis – Jones Criteria

• Erythema marginatum: well-

demarcated, pink nonpruritic rash,

usually trunk, sometimes proximal

limbs

– Central clearing, may last hours

129

Source Undetermined

Page 130: GEMC- Arthritis and Arthrocentesis- Resident Training

Erythema Marginatum

130 Source Undetermined

Page 131: GEMC- Arthritis and Arthrocentesis- Resident Training

Diagnosis – Jones Criteria

• Subcutaneous nodules: firm,

nontender under skin overlying

bony prominences

131

Source Undetermined

Page 132: GEMC- Arthritis and Arthrocentesis- Resident Training

Laboratory Work-Up

• Throat culture, ESR, CRP, ASO

• Anti-DNase B 95% sensitive

• Streptozyme test also documents

recent streptococcal infection

• Synovial fluid

– Inflammatory (average WBC 16K)

– Negative culture

132

Page 133: GEMC- Arthritis and Arthrocentesis- Resident Training

Post-Streptococcal

• Reactive arthritis: closely related to

ARF but distinct clinical entity

• Sterile oligoarthritis associated

with distant bacterial infection

• Carditis rare, arthritis often severe

• Treatment: penicillin, erythromycin

• Arthritis responds to salicylates

133

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Rheumatoid Arthritis

134

Source Undetermined

Page 135: GEMC- Arthritis and Arthrocentesis- Resident Training

Rheumatoid Arthritis

• Usually chronic: >20% acute

• Women 2 to 3 x more than men

• Immune complexes stimulate

PMNs to release enzymes

• Synovial cells proliferate, produce

more inflammatory substances

135

Page 136: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Prodrome: fatigue, weakness,

musculoskeletal pain

• Symmetric joint swelling: hands

(MP, PIP joints), wrists, elbows

• Difficult to distinguish from viral

arthropathy

136

Page 137: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Long-term

changes: MP and

PIP swelling, ulnar

deviation, swan-

neck and

boutonnière

deformities of

hands, limited

wrist dorsiflexion 137

Source Undetermined

Page 138: GEMC- Arthritis and Arthrocentesis- Resident Training

Swan Neck Deformity

138 Source Undetermined Source Undetermined

Page 139: GEMC- Arthritis and Arthrocentesis- Resident Training

Presentation

• Knee: effusion, muscle atrophy,

Baker’s cyst

• Retrocalcaneal bursa

• Subcutaneous nodules, pulmonary

fibrosis, mononeuritis multiplex

• Sjögren’s and Felty’s syndromes

139

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Baker’s Cyst

140

Source Undetermined

Page 141: GEMC- Arthritis and Arthrocentesis- Resident Training

Subcutaneous Nodules

141

Source Undetermined

Page 142: GEMC- Arthritis and Arthrocentesis- Resident Training

Felty’s Syndrome

• Rheumatoid arthritis

+ splenomegaly +

leukopenia

• Frequent pneumonia

and leg ulcers

• 1% of RA patients

142

Source Undetermined

Page 143: GEMC- Arthritis and Arthrocentesis- Resident Training

Transverse Ligament Rupture

• C1 on C2 subluxation in 70%

– Frank dislocation in 25%

– Cord compression in 11%

• With myelopathy:

– 5 years survival 80%

– 10 year survival 28%

• Anterior instability more common

than posterior instability 143

Page 144: GEMC- Arthritis and Arthrocentesis- Resident Training

Transverse Ligament Rupture

144 Source Undetermined Source Undetermined

Page 145: GEMC- Arthritis and Arthrocentesis- Resident Training

Treatment

• Movement increases inflammation:

initial treatment rest

• Suppress inflammation: steroids,

salicylates, gold, penicillamine,

azathioprine, methotrexate,

cyclosporine, sulfasalazine

145

Page 146: GEMC- Arthritis and Arthrocentesis- Resident Training

Nontraditional Thinking

• The Mycoplasma Theory: joint

pain caused by subclinical

mycoplasma infection, improves

with doxycycline

• Glucosamine and chondroitin:

possibly useful in osteoarthritis

146

Page 147: GEMC- Arthritis and Arthrocentesis- Resident Training

Known Not to Work

ALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO

ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET -

ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND

ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE

POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA -

CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY

ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY -

CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON -

COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS

SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS

- SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM -

DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE)

- SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION

DIETS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET -

TEAS (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE -

GARLIC - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH -

FASTING - GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL -

WOOD SPIDER - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN

MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP

147

Page 148: GEMC- Arthritis and Arthrocentesis- Resident Training

Pearls

• The number and distribution of

joints involved helps pinpoint the

most likely cause of arthritis.

• Monarthritis is septic arthritis until

proven otherwise.

• Negative Gram’s stain of synovial

fluid does not rule out bacterial

arthritis. 148

Page 149: GEMC- Arthritis and Arthrocentesis- Resident Training

Pearls

• The most definitive test for

evaluating an inflamed joint for the

possibility of bacterial infection is

examination of synovial fluid.

• Delays in the diagnosis and

treatment of septic arthritis worsen

outcomes.

149