Acute Arthropathies “ I’ve got a painful, swollen knee doctor ”

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 • 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 • 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 • 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? • 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 • 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 (www.arc.org.uk) • Patient uk • www.ukgoutsociety.org • www.arthritiscare.org.uk