1 / 100

The Red Hot Joint

The Red Hot Joint. James Bateman Rheumatologist. One Real Case from UHNS which tells you all you need to know about hot joints You are an FY1 in GP. 31 year old presents to his with a 1 day history of painful clavicle/sternum. Temporary patient at the surgery.

fifi
Download Presentation

The Red Hot Joint

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Red Hot Joint James Bateman Rheumatologist

  2. One Real Case from UHNS which tells you all you need to know about hot jointsYou are an FY1 in GP • 31 year old presents to his with a 1 day history of painful clavicle/sternum. • Temporary patient at the surgery

  3. Differential Diagnosis at this stage?

  4. What do you think? HPC PMHx Drug History Social History Systemic enquiry What are you going to do?

  5. In A&E • What are you going to do?

  6. What are you sending the fluid for? What will it tell you?

  7. Gram positive cocci

  8. Other Imaging…

  9. Diagnosis: Septic arthritisWhats missing?

  10. Pathogenesis

  11. FY1 in GP • 70 year old lady, • Painful knee • AF on warfarin • DM type II • Hypertensive on BFZ and ACEi • Left knee is painful and swollen • Struggling to weight bear • What are you going to do?

  12. In ED what are you going to do? History Investigations Treatments? Procedures? Imaging? In what order?

  13. What Now? Do you need to do anything else?

  14. What’s if you see this?

  15. 92 year old female with swollen knee

  16. 21 year old students with a swollen ankle and tenosynovitis

  17. Case 1 • 82 year old lady • Admitted acute on chronic knee pain 3-4 days • Recent excision of shin BCC with skin graft complicated by cellulitis • Ex Not unwell afebrile MEWS O • Warm, slightly tender knee effusion, tolerating 90 flexion • ? Wound infection started on antibiotics • CRP 187

  18. Radiological abnormality? Differential diagnosis? Further investigations? Management? Case 1

  19. Example • DB 45 year old man • PMH RA on sulphasalazine • 4 day history painful hot swollen red right big toe • Differential? • Investigations?

  20. Case 3 • 82 year old man • PMH LVF,AF, TIA, BPH • DH Aspirin, bumetanide, ramipril, digoxin, statin • Referred with acute on chronic wrist pain needing MST • WBC 13, CRP 155, Cr 143, XR OA changes • Diagnosis and plan?

  21. What single investigation is going to give you the answer? • Joint Aspiration: • Need: green needle • Need: Sterile field • Syringe • Microbiologist • White topped bottle

  22. What are other differentials for monoarticular pain?

  23. Monoarthritis - differential • Monoarticular sero-ve spondyloarthritis eg psoriatic and reactive arthritis • Monoarticular RA

  24. Monoarthritis - differential • Haemarthroses (warfarin, bleeding disorders) • Trauma – fracture, internal derangement, haemarthroses

  25. Others to think about • Osteonecrosis/AVN (steroids/alcohol/SLE) • Prosthetic joint - loosening, # or infection

  26. Others to think about • Periarticular pathology • Cellulitis

  27. Septic arthritis • 15-30 per 100,000 population • Fatal in 11% of cases in UK • Delayed or inadequate treatment leads to irreversible joint damage

  28. How do you get septic arthritis?

  29. Who gets septic arthritis ?

  30. Who gets septic arthritis? • pre-existing joint disease • prosthetic joints • low SE status, IV drug abuse, alcoholism • diabetes, steroids, immunosuppression • Skin lesions e.g. ulcers, particularly in context RA often source of infection

  31. Which organisms cause septic arthritis?

  32. Which organisms? • common organisms Staphylococci or Streptococcus • Elderly & immunocompromised gram -ve organisms

  33. Which organisms? • Anaerobes more common with penetrating trauma • Pseudomonas - IV drug abusers • young adults - significant incidence gonococcal arthritis

  34. Who gets septic arthritis? • poor prognostic features: older pre-existing joint disease & presence of synthetic material within joint

  35. What are the signs and symptoms of septic arthritis?

  36. Symptoms & signs of septic arthritis • Symptoms usually present for < 2/52 • Typically hot, swollen, red tender joint with reduced range of movement, difficulty weight bearing • Night and rest pain • Large joints more commonly affected than small • majority of joint sepsis in hip or knee • Systemic upset (MEWS)

  37. 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% of cases > one joint • presence of fever not reliable indicator

  38. Features of gonococcal arthritis ?

  39. Women>men Menses, pregnancy 1-3% arthritis 1day- weeks after sexual encounter Migratory (70%), Tenosynovitis (70%), monoarthritis (32%), polyarthritis (10%) Fever, Dermatitis (pustules, vesicular, haemorrhagic bullae, mac.papular) Gonococcal arthritis

More Related