Acute Joint pain

Question 1

Which diagnosis MUST BE excluded in a patient with acute joint pain

Answer 1

Septic arthritis

Can destroy articular cartilage within days - has mortality of 10% due to bacteraemia

Question 2

What are the main causes of a single, acutely painful joint?

Answer 2

1. Articular - trauma, gout, pseudogout, septic arthritis, seronegative spondyloarthropathy, transient synovitis
2. Peri-articular - ligament injury, tendinitis, bursitis, fasculitis
3. Non-articular - nerve entrapment, radiculopathy

Question 3

Pain that worsens with movement and improves with rest is likely to be noninflammatory/inflammatory

Answer 3

Non-inflammatory

Question 4

Acute onset pain (few hours) is more likely to be?

Answer 4

Septic arthritis, gout, pseudogout

Question 5

Chronic onset joint pain suggests?

Answer 5

Osteoarthritis

Question 6

What are the RFs for gout

Answer 6

Thiazide diuretics, recent heavy alcohol intake, chronic renal failure, chemotherapy, hx of renal stones, PMH of gout

Question 7

What are the RFs for septic arthritis

Answer 7

Immunosuppression and prosthetic joints

Question 8

What are the RFs for haemarthrosis

Answer 8

Coagulopathy (haemophilia), anticoagulant use (typically warfarin) or trauma

Question 9

Which type of arthritis can develop after recent GI or urethral infection

Answer 9

Reactive arthritis

Question 10

Involvement of several joints simultaneously suggests a presentation of?

Answer 10

Rheumatoid or psoriatic arthritis

Question 11

If the joint is diffusely inflamed (red, hot painful), and there is pain on passive and action motion, what condition is It likely to be?

Answer 11

Articular condition (e.g. gout/pseudogout/septic arthritis)

Question 12

If there is a focal point of tenderness and pain is much worse on active movement than passive movement, what condition is it likely to be?

Answer 12

Periarticular condition (e.g. bursitis/tendonitis)

Question 13

What do tophi suggest?

Answer 13

Chronic gout

Question 14

Subcutaeneous nodules (on the elbows and ears are called rheumatoid nodules). What are these indicative of?

Answer 14

Rheumatoid arthritis

Question 15

In the nails: pitting, sublingual hyperkeratosis, and oyncholysis are all signs of?

Answer 15

Psoriasis which indicates psoriatic arthritis

Question 16

Lung signs suggestive of fibrosis (e.g. end inspiratory fine crackles/clubbing) could suggest?

Answer 16

Rheumatoid arthritis

Question 17

When unsure about septic arthritis or if it is a crystal arthropathy, what do you do

Answer 17

Arthrocentesis

Question 18

Crystals after investigation indicate that gout is present. How to distinguish the types of gout?

Answer 18

Urate = gout

Calcium pyrophosphate = pseudogout

Question 19

Cloudy aspirate (from arthrocentesis) with high WCC, high neutrophils, and bacteria visible on microscopy indicate?

Answer 19

Septic arthritis

Question 20

If fat globules are present in haemarthrosis, what does this indicate

Answer 20

Fracture/trauma

Question 21

After arthrocentesis, if there are no crystals/blood/infection but there is WCC raised, what could this be?

Answer 21

Reactive arthritis, rheumatoid arthritis, psoriatic arthritis, rheumatic fever

Question 22

The presence of irate crystals and polymorphonuclear cells (WCC) is what diagnosis

Answer 22

Acute gout

Question 23

Describe the acute and chronic management of gout

Answer 23

Acute: colchicine (contraindicated if renal/hepatic impairment), NSAIDS, corticosteroid injections

Chronic: decrease urate production (allopurinol or febuxostat), increase urate excretion (sulfinpyrazone and probenecid), increase degradation of urate (rasburicase)

Question 24

Allopurinol and febuxostat work how?

Answer 24

Xanthine oxidase inhibitors

Question 25

If a patient has developed an acutely painful joint, with evidence of trauma, the joint is red, hot, swollen and tender - painful to both active and passive movement. The patient is pyrexic and has yellow, turbid aspirate upon arthrocentesis. What must you be worried about?

What do you do?

Answer 25

Septic arthritis

Start analgesia, take blood cultures and start broad spectrum antibiotics

Once septic arthritis confirmed by microbiologist, do joint aspiration and lavage via orthopaedic surgeons

Question 26

A patient has history of urethral and eye symptoms, as well as an inflamed joint. What is the diagnosis?

Answer 26

Reactive arthritis

Typically causes uveitis, urethritis, arthritis (can’t see, can’t pee, can’t climb a tree)