CLINICAL SERIES:   ARTHRITIS BY:  Ahmed AL-Jabri  R2
AIM <ul><li>JOINT inflammation : Articular vs periarticular ? </li></ul><ul><li>Inflammatory vs non-inflammatory ?  </li><...
Normal Joint..
Articular Vs. Periarticular Clinical feature Articular  Periarticular Anatomic structure Painful site  Pain on movement Sw...
Inflammatory Vs. Noninflammatory Feature Inflammatory Noninflammatory Pain (when?) Swelling Erythema Warmth AM stiffness S...
Inflammatory Vs. Noninflammatory Feature Inflammatory Mechanical Morning stiffness Fatigue Activity Rest Systemic >1 h Pro...
Acute Monoarthritis - differential diagnosis <ul><ul><li>Septic arthritis  </li></ul></ul><ul><ul><li>Crystal arthritis </...
<ul><li>What are other differentials for </li></ul><ul><li>acute monoarticular pain? </li></ul>
Monoarthritis - differential diagnosis <ul><ul><li>Psoriatic arthritis </li></ul></ul><ul><ul><li>Onycholysis </li></ul></...
Monoarthritis - differential diagnosis <ul><li>Reactive arthritis </li></ul><ul><li>Prodromal GI /GU </li></ul><ul><li>Inf...
Q: Physical examination of a patient with reiter’s  syndrome may be expected to reveal :  <ul><li>Waxy plaques on the palm...
Q: Physical examination of a patient with reiter’s  syndrome may be expected to reveal :  <ul><li>Waxy plaques on the palm...
Monoarthritis - differential diagnosis <ul><ul><li>Trauma  - # and haemarthroses (warfarin, bleeding disorders) </li></ul>...
Others to think about <ul><li>Osteonecrosis/AVN (steroids/alcohol) </li></ul><ul><li>Severe pain but good ROM  </li></ul><...
Is it an articular or extra-articular problem? <ul><li>ARTICULAR PERI-ARTICULAR </li></ul><ul><li>pain all planes pain in ...
WHAT DO WE HAVE ?
Olecranon bursitis
42 YRS OLD MALE  presents with pain, warmth, and swelling over his posterior  elbow. The pt reports frequntly having to le...
42 YRS OLD MALE  presents with pain, warmth, and swelling over his posterior  elbow. The pt reports frequntly having to le...
What is the expected WBC counts in aspirated synovial fluid from a patient with septic arthitis ?
<ul><li>It will be a turbid/purulent fluid,  </li></ul><ul><li>USUALLY > 50,000 wbc/mm3  ( 5000-50,000) </li></ul><ul><li>...
A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most con...
A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most con...
Septic arthritis <ul><li>15-30 per 100,000 population </li></ul><ul><li>Fatal in 11% of cases  </li></ul><ul><li>Delayed o...
<ul><li>How do you get septic arthritis? </li></ul>
Pathogenesis
<ul><li>Who gets septic arthritis? </li></ul>
Who gets septic arthritis? <ul><li>common organisms Staphylococci or Streptococcus </li></ul><ul><li>young adults, signifi...
Who gets septic arthritis? <ul><li>pre-existing joint disease </li></ul><ul><li>prosthetic joints </li></ul><ul><li>IV dru...
<ul><li>What are the signs and </li></ul><ul><li>symptoms of septic </li></ul><ul><li>arthritis? </li></ul>
Symptoms & signs of septic arthritis <ul><li>Typically hot, swollen, red tender joint with reduced range of movement, diff...
55 YRS OLD  female with h/o RA presents with progressive swelling and pain in her knee for 6 days. She is on prednisone an...
55 YRS OLD  female with h/o RA presents with progressive swelling and pain in her knee for 6 days. She is on prednisone an...
Symptoms & signs of septic arthritis <ul><li>In pre-existing inflammatory joint disease symptoms in affected joint(s), out...
Kocher et al. 1999 <ul><li>Hx of fever </li></ul><ul><li>Nonweightbearing </li></ul><ul><li>ESR >40mm/hr </li></ul><ul><li...
 
<ul><li>What investigations are useful </li></ul><ul><li>in septic arthritis? </li></ul>
Investigations <ul><li>Synovial fluid aspiration </li></ul><ul><ul><li>volume/viscosity/cellularity/ appearance </li></ul>...
Investigations <ul><li>Always  blood cultures  </li></ul><ul><li>significant proportion blood cultures + ve in  absence of...
Other investigations <ul><li>CRP useful for monitoring response to treatment  </li></ul><ul><li>Urate may be normal in acu...
Other tests? <ul><li>If skin pustule is present, suggestive of gonococcal infection, then skin swab should be taken  </li>...
Antibiotic treatment of septic arthritis <ul><li>Local and national guidelines </li></ul><ul><li>Liaise with micro. guided...
SEPTIC ARTHRITS: Oral Antibiotics <ul><li>Amoxicillin (25 mg/kg per dose administered every 6 hours)  </li></ul><ul><li>Ce...
Arthrocentesis <ul><li>Critical diagnostic adjunct  </li></ul><ul><li>Can be painless, safe, and simple when performed cor...
Indications  <ul><li>Obtain joint fluid for analysis </li></ul><ul><li>Drain tense hemarthroses  </li></ul><ul><li>Instill...
Arthrocentesis <ul><li>Fat globules: diagnostic of fracture </li></ul><ul><li>Intraarticular morphine can provide relief f...
Shoulder – Posterior Approach Tap
Shoulder – Anterior Approach Tap
Elbow – Lateral Approach Tap Flex elbow 90 o Prep skin Insert needle in palpable bony notch between lateral epicondyle and...
Elbow – Lateral Approach Tap
Elbow – Posterior Approach Tap
Wrist Approach Tap
Wrist Approach Tap
Wrist Approach Tap
A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opp...
A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opp...
Knee – Lateral Approach Tap
Knee – Lateral Approach Extend knee, quadriceps and patella relaxed so patella can move mediolaterally. Needle into joint ...
Knee – Lateral Approach Tap
Knee – Medial Approach Tap
Knee – Medial Approach Tap
Knee – Medial Approach Tap
Knee – Medial Approach Tap
Knee – Medial Approach Tap
Ankle Tap Palpate the medial and lateral malleoli with your thumb and index finger.  The joint space is located one to one...
Ankle Tap Palpate the dorsalis pedis artery and choose a puncture site anywhere on the anterior aspect of the ankle, avoid...
Ankle – Lateral  Approach Tap
Ankle – Medial Approach Tap
Synovial Fluid Analysis <ul><li>Identify crystals, pus  </li></ul><ul><li>Analyze color, clarity, cell count, differential...
Synovial Fluid Cell Count <ul><li>Noninflammatory vs. inflammatory </li></ul><ul><li>ED wet mount prep </li></ul><ul><ul><...
Synovial Fluid Analysis Normal Non-inflammatory Inflammatory Infectious Trans-parent Transparent Cloudy Cloudy  Clear Yell...
Septic arthritis: SMS <ul><li>with a short history of a hot, swollen, tender joint (or joints) plus restriction of movemen...
gout
Gout <ul><li>Caused by monosodium urate crystals </li></ul><ul><li>Most common type of inflammatory monoarthritis </li></u...
Acute Gouty Arthritis
Risk Factors <ul><li>Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis. </li></u...
Microscopic appearance of the crystals of gout include all of the following EXCEPT: <ul><li>needle-shaped urate crystals <...
Microscopic appearance of the crystals of gout include all of the following EXCEPT: <ul><li>needle-shaped urate crystals <...
Urate Crystals <ul><li>Needle-shaped </li></ul><ul><li>Strongly negative birefringent </li></ul>
CPPD Crystals Deposition Disease <ul><li>Can cause monoarthritis clinically indistinguishable from gout – hence called  Ps...
Associated Conditions <ul><li>Hyperparathyroidism </li></ul><ul><li>Hypercalcemia </li></ul><ul><li>Hypocalciuria </li></u...
CPPD Crystals <ul><li>Rod or rhomboid-shaped </li></ul><ul><li>positive birefringent </li></ul>
<ul><li>THANK-YOU </li></ul>
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clinical seriesarthitis

  1. 1. CLINICAL SERIES: ARTHRITIS BY: Ahmed AL-Jabri R2
  2. 2. AIM <ul><li>JOINT inflammation : Articular vs periarticular ? </li></ul><ul><li>Inflammatory vs non-inflammatory ? </li></ul><ul><li>focus on septic arthritis AND crystal induced arthritis </li></ul>
  3. 3. Normal Joint..
  4. 4. Articular Vs. Periarticular Clinical feature Articular Periarticular Anatomic structure Painful site Pain on movement Swelling Synovium, cartilage, capsule Diffuse, deep Active/passive, all planes Common Tendon, bursa, ligament, muscle, bone Focal “point” Active, in few planes Uncommon
  5. 5. Inflammatory Vs. Noninflammatory Feature Inflammatory Noninflammatory Pain (when?) Swelling Erythema Warmth AM stiffness Systemic features î ESR, CRP Synovial fluid WBC Examples Yes (AM) Soft tissue Sometimes Sometimes Prominent Sometimes Frequent WBC >2000 Septic, RA, SLE, Gout Yes (PM) Bony Absent Absent Minor (< 30 ‘) Absent Uncommon WBC < 2000 OA, AVN
  6. 6. Inflammatory Vs. Noninflammatory Feature Inflammatory Mechanical Morning stiffness Fatigue Activity Rest Systemic >1 h Profound Improves Worsens Yes < 30 min Minimal Worsens Improves No
  7. 7. Acute Monoarthritis - differential diagnosis <ul><ul><li>Septic arthritis </li></ul></ul><ul><ul><li>Crystal arthritis </li></ul></ul><ul><ul><ul><li>Gout (uric acid) </li></ul></ul></ul><ul><ul><ul><li>Pseudogout/calcium pyrophosphate deposition disease (CPPD) </li></ul></ul></ul>
  8. 8. <ul><li>What are other differentials for </li></ul><ul><li>acute monoarticular pain? </li></ul>
  9. 9. Monoarthritis - differential diagnosis <ul><ul><li>Psoriatic arthritis </li></ul></ul><ul><ul><li>Onycholysis </li></ul></ul><ul><ul><li>Subungual hyperkeratosis </li></ul></ul><ul><ul><li>Pitting </li></ul></ul><ul><ul><li>Extensor surfaces, scalp, natal cleft, umbilicus </li></ul></ul><ul><ul><li>Other associated features eg uveitis, inflammatory bowel disease, enthesitis, Ankylosing spondylitis </li></ul></ul>
  10. 10. Monoarthritis - differential diagnosis <ul><li>Reactive arthritis </li></ul><ul><li>Prodromal GI /GU </li></ul><ul><li>Infection eg </li></ul><ul><li>campylobacter, </li></ul><ul><li>salmonella, shigella, </li></ul><ul><li>Yersinia,chlamydia </li></ul><ul><li>Pustular psoriasis </li></ul><ul><li>and </li></ul><ul><li>circinate balanitis </li></ul>
  11. 11. Q: Physical examination of a patient with reiter’s syndrome may be expected to reveal : <ul><li>Waxy plaques on the palms and soles </li></ul><ul><li>Sausage-like swelling of the fingers </li></ul><ul><li>Painful, shallow ulcers in the mouth </li></ul><ul><li>Iritis </li></ul><ul><li>All of the above </li></ul><ul><li>Non of the above </li></ul>
  12. 12. Q: Physical examination of a patient with reiter’s syndrome may be expected to reveal : <ul><li>Waxy plaques on the palms and soles </li></ul><ul><li>Sausage-like swelling of the fingers </li></ul><ul><li>Painful, shallow ulcers in the mouth </li></ul><ul><li>Iritis </li></ul><ul><li>All of the above </li></ul>
  13. 13. Monoarthritis - differential diagnosis <ul><ul><li>Trauma - # and haemarthroses (warfarin, bleeding disorders) </li></ul></ul>
  14. 14. Others to think about <ul><li>Osteonecrosis/AVN (steroids/alcohol) </li></ul><ul><li>Severe pain but good ROM </li></ul><ul><li>Monoarticular RA </li></ul><ul><li>Monoarticular OA </li></ul><ul><li>Prosthetic joint - loosening, # or infection </li></ul><ul><li>Periarticular pathology </li></ul>
  15. 15. Is it an articular or extra-articular problem? <ul><li>ARTICULAR PERI-ARTICULAR </li></ul><ul><li>pain all planes pain in plane of tendon </li></ul><ul><li>active = passive active < passive </li></ul><ul><li>capsular swelling/effusion linear swelling </li></ul><ul><li>joint line tenderness localised tenderness </li></ul><ul><li>diffuse erythema/heat localised erythema/heat </li></ul>
  16. 16. WHAT DO WE HAVE ?
  17. 17. Olecranon bursitis
  18. 18. 42 YRS OLD MALE presents with pain, warmth, and swelling over his posterior elbow. The pt reports frequntly having to lean on his elbow while performing electrical work as part of his job. Although he is able to flex and extend the joint , flexion results in increased pain. After aspiration and cell count of the fluid obtained, which of the following is the minimum WBC count suggestive of infection ? <ul><li>WBC > 500 per mm3 . </li></ul><ul><li>WBC > 7,000 per mm3 </li></ul><ul><li>WBC > 10,000 per mm3 </li></ul><ul><li>WBC > 50,000 per mm3 </li></ul><ul><li>WBC > 100,000 per mm3 </li></ul>
  19. 19. 42 YRS OLD MALE presents with pain, warmth, and swelling over his posterior elbow. The pt reports frequntly having to lean on his elbow while performing electrical work as part of his job. Although he is able to flex and extend the joint , flexion results in increased pain. After aspiration and cell count of the fluid obtained, which of the following is the minimum WBC count suggestive of infection ? <ul><li>WBC > 500 per mm3 . </li></ul><ul><li>WBC > 7,000 per mm3 </li></ul><ul><li>WBC > 10,000 per mm3 </li></ul><ul><li>SEPTIC BURSITIS ACCOUNTS FOR 33% OF ALL OLECRANON BURSITIS . </li></ul>
  20. 20. What is the expected WBC counts in aspirated synovial fluid from a patient with septic arthitis ?
  21. 21. <ul><li>It will be a turbid/purulent fluid, </li></ul><ul><li>USUALLY > 50,000 wbc/mm3 ( 5000-50,000) </li></ul><ul><li>> 75% PMN WBC </li></ul>What is the expected WBC counts in aspirated synovial fluid from a patient with septic arthitis ?
  22. 22. A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most consistent with __. <ul><li>rheumatoid arthritis </li></ul><ul><li>viral infection </li></ul><ul><li>gonococcal arthritis </li></ul><ul><li>systemic lupus erythematosus (SLE) </li></ul><ul><li>rheumatic fever </li></ul>
  23. 23. A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most consistent with __. <ul><li>rheumatoid arthritis </li></ul><ul><li>viral infection </li></ul><ul><li>gonococcal arthritis </li></ul><ul><li>systemic lupus erythematosus (SLE) </li></ul><ul><li>rheumatic fever </li></ul><ul><li>In the other conditions, the WBC count is usually higher, with predominantly PMNs. </li></ul>
  24. 24. Septic arthritis <ul><li>15-30 per 100,000 population </li></ul><ul><li>Fatal in 11% of cases </li></ul><ul><li>Delayed or inadequate treatment leads to irreversible joint damage </li></ul>
  25. 25. <ul><li>How do you get septic arthritis? </li></ul>
  26. 26. Pathogenesis
  27. 27. <ul><li>Who gets septic arthritis? </li></ul>
  28. 28. Who gets septic arthritis? <ul><li>common organisms Staphylococci or Streptococcus </li></ul><ul><li>young adults, significant incidence gonococcal arthritis </li></ul><ul><li>Elderly & immunocompromised gram -ve organisms </li></ul><ul><li>Anaerobes more common with penetrating trauma </li></ul>
  29. 29. Who gets septic arthritis? <ul><li>pre-existing joint disease </li></ul><ul><li>prosthetic joints </li></ul><ul><li>IV drug abuse, alcoholism </li></ul><ul><li>diabetes, steroids, immunosuppression </li></ul><ul><li>previous intra-articular steroid injection </li></ul>
  30. 30. <ul><li>What are the signs and </li></ul><ul><li>symptoms of septic </li></ul><ul><li>arthritis? </li></ul>
  31. 31. Symptoms & signs of septic arthritis <ul><li>Typically hot, swollen, red tender joint with reduced range of movement, difficulty weight bearing </li></ul><ul><li>Systemic upset </li></ul><ul><li>Night and rest pain </li></ul><ul><li>Symptoms usually present for < 2/52 </li></ul><ul><li>Large joints more commonly affected than small </li></ul><ul><li>majority of joint sepsis in hip or knee </li></ul>
  32. 32. 55 YRS OLD female with h/o RA presents with progressive swelling and pain in her knee for 6 days. She is on prednisone and states that her standard flares involve her ankles and fingers. Her vitals are normal ; afebrile . Examination reveals a moderate-sized knee effusion with warmth and tenderness and extreme pain on range of motion of the joint. Which of the following is the most appropriate next step in management ? <ul><li>Joint aspiration </li></ul><ul><li>MRI of the knee </li></ul><ul><li>Colchicine PO </li></ul><ul><li>Stress-dose steroids </li></ul><ul><li>Indomethacin PO </li></ul>
  33. 33. 55 YRS OLD female with h/o RA presents with progressive swelling and pain in her knee for 6 days. She is on prednisone and states that her standard flares involve her ankles and fingers. Her vitals are normal ; afebrile . Examination reveals a moderate-sized knee effusion with warmth and tenderness and extreme pain on range of motion of the joint. Which of the following is the most appropriate next step in management ? <ul><li>Joint aspiration </li></ul>
  34. 34. Symptoms & signs of septic arthritis <ul><li>In pre-existing inflammatory joint disease symptoms in affected joint(s), out of proportion to disease activity in other joints. </li></ul><ul><li>10-15% of cases, > one joint - so polyarticular presentation does not exclude sepsis </li></ul><ul><li>presence of fever not reliable indicator- if clinical suspicion high - treat </li></ul>
  35. 35. Kocher et al. 1999 <ul><li>Hx of fever </li></ul><ul><li>Nonweightbearing </li></ul><ul><li>ESR >40mm/hr </li></ul><ul><li>WBC >12,000/mm3 </li></ul>
  36. 37. <ul><li>What investigations are useful </li></ul><ul><li>in septic arthritis? </li></ul>
  37. 38. Investigations <ul><li>Synovial fluid aspiration </li></ul><ul><ul><li>volume/viscosity/cellularity/ appearance </li></ul></ul><ul><ul><li>gram stain/culture </li></ul></ul><ul><ul><li>Absence of organism does not exclude septic arthritis </li></ul></ul><ul><ul><li>polarised light microscopy (crystals) </li></ul></ul><ul><ul><li>NB suspected prosthetic joint sepsis should ALWAYS be referred to orthopaedics </li></ul></ul>
  38. 39. Investigations <ul><li>Always blood cultures </li></ul><ul><li>significant proportion blood cultures + ve in absence of + ve synovial fluid cultures </li></ul><ul><li>FBC ESR & CRP </li></ul><ul><li>BUT absence of raised WBC, ESR or CRP Do not exclude diagnosis of sepsis - if clinical suspicion high always treat </li></ul>
  39. 40. Other investigations <ul><li>CRP useful for monitoring response to treatment </li></ul><ul><li>Urate may be normal in acute gout and of no diagnostic value in acute gout or sepsis </li></ul><ul><li>Measure urea, electrolytes & liver function for end organ damage (poor prognostic feature) </li></ul><ul><li>Renal function may influence antibiotic choice </li></ul>
  40. 41. Other tests? <ul><li>If skin pustule is present, suggestive of gonococcal infection, then skin swab should be taken </li></ul><ul><li>If history suggests possibility of genitourinary or respiratory tract infection then culture sputum (and CXR) & urine & take anogenital & throat swabs where appropriate </li></ul><ul><li>If periarticular sepsis – appropriate swabs and cultures </li></ul>
  41. 42. Antibiotic treatment of septic arthritis <ul><li>Local and national guidelines </li></ul><ul><li>Liaise with micro. guided by gram stain </li></ul><ul><li>Conventionally given iv for 2 weeks or until signs improve, then orally for around 4 weeks </li></ul>
  42. 43. SEPTIC ARTHRITS: Oral Antibiotics <ul><li>Amoxicillin (25 mg/kg per dose administered every 6 hours) </li></ul><ul><li>Cephalexin (37.5 mg/kg per dose administered every 6 hours) </li></ul><ul><li>Clindamycin (13 mg/kg per dose administered every 8 hours) </li></ul><ul><li>Cloxacillin (31 mg/kg per dose administered every 6 hours) </li></ul><ul><li>Dicloxacillin (25 mg/kg per dose administered every 6 hours) Penicillin V (22 mg/kg per dose administered every 4 hours) </li></ul>
  43. 44. Arthrocentesis <ul><li>Critical diagnostic adjunct </li></ul><ul><li>Can be painless, safe, and simple when performed correctly </li></ul><ul><li>Diagnostic or therapeutic </li></ul>Tap
  44. 45. Indications <ul><li>Obtain joint fluid for analysis </li></ul><ul><li>Drain tense hemarthroses </li></ul><ul><li>Instill analgesics and anti-inflammatory agents </li></ul><ul><li>Prosthetic joints: only to rule out infection </li></ul>Tap
  45. 46. Arthrocentesis <ul><li>Fat globules: diagnostic of fracture </li></ul><ul><li>Intraarticular morphine can provide relief for up to 24 hours </li></ul><ul><ul><li>1 to 5 mg diluted in normal saline solution to a total volume of 30 ml </li></ul></ul>Tap
  46. 47. Shoulder – Posterior Approach Tap
  47. 48. Shoulder – Anterior Approach Tap
  48. 49. Elbow – Lateral Approach Tap Flex elbow 90 o Prep skin Insert needle in palpable bony notch between lateral epicondyle and olecranon
  49. 50. Elbow – Lateral Approach Tap
  50. 51. Elbow – Posterior Approach Tap
  51. 52. Wrist Approach Tap
  52. 53. Wrist Approach Tap
  53. 54. Wrist Approach Tap
  54. 55. A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opposite side. <ul><li>pronation </li></ul><ul><li>supination </li></ul><ul><li>flexion and extension </li></ul>
  55. 56. A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opposite side. <ul><li>pronation </li></ul><ul><li>supination </li></ul><ul><li>flexion and extension </li></ul><ul><li>With even minimal inflammation, there will be a noticeable decrease in the flexion-extension range of motion </li></ul>
  56. 57. Knee – Lateral Approach Tap
  57. 58. 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. Tap
  58. 59. Knee – Lateral Approach Tap
  59. 60. Knee – Medial Approach Tap
  60. 61. Knee – Medial Approach Tap
  61. 62. Knee – Medial Approach Tap
  62. 63. Knee – Medial Approach Tap
  63. 64. Knee – Medial Approach Tap
  64. 65. Ankle Tap 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.
  65. 66. Ankle Tap Palpate the dorsalis pedis artery and choose a puncture site anywhere on the anterior aspect of the ankle, avoiding the dorsalis pedis artery.
  66. 67. Ankle – Lateral Approach Tap
  67. 68. Ankle – Medial Approach Tap
  68. 69. Synovial Fluid Analysis <ul><li>Identify crystals, pus </li></ul><ul><li>Analyze color, clarity, cell count, differential, Gram’s stain, crystals </li></ul><ul><li>Positive Gram’s stain: diagnostic for septic arthritis </li></ul><ul><li>Negative Gram’s stain: does not rule out septic arthritis </li></ul>Fluid
  69. 70. Synovial Fluid Cell Count <ul><li>Noninflammatory vs. inflammatory </li></ul><ul><li>ED wet mount prep </li></ul><ul><ul><li>1 to 2 WBCs per high-power field consistent with noninflammatory </li></ul></ul><ul><ul><li>>20 WBC/HPF suggests inflammation or infection </li></ul></ul><ul><li>Septic: >50,000 WBC/mm 3 (also rheumatoid, gout, pseudogout) </li></ul>Fluid
  70. 71. Synovial Fluid Analysis 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
  71. 72. Septic arthritis: SMS <ul><li>with a short history of a hot, swollen, tender joint (or joints) plus restriction of movement; septic arthritis until proven otherwise </li></ul><ul><li>If clinical suspicion high investigate & treat as septic arthritis even in absence of fever </li></ul>
  72. 73. gout
  73. 74. Gout <ul><li>Caused by monosodium urate crystals </li></ul><ul><li>Most common type of inflammatory monoarthritis </li></ul><ul><li>Typically: first MTP joint, ankle, midfoot, knee </li></ul><ul><li>Pain very severe; cannot stand bed sheet </li></ul><ul><li>May be with fever and mimic infection </li></ul><ul><li>The cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis </li></ul>
  74. 75. Acute Gouty Arthritis
  75. 76. Risk Factors <ul><li>Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis. </li></ul><ul><li>Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure. </li></ul>
  76. 77. Microscopic appearance of the crystals of gout include all of the following EXCEPT: <ul><li>needle-shaped urate crystals </li></ul><ul><li>positively birefringent </li></ul><ul><li>negatively birefringent </li></ul><ul><li>Non of the above </li></ul>
  77. 78. Microscopic appearance of the crystals of gout include all of the following EXCEPT: <ul><li>needle-shaped urate crystals </li></ul><ul><li>positively birefringent </li></ul>
  78. 79. Urate Crystals <ul><li>Needle-shaped </li></ul><ul><li>Strongly negative birefringent </li></ul>
  79. 80. CPPD Crystals Deposition Disease <ul><li>Can cause monoarthritis clinically indistinguishable from gout – hence called Pseudogout. </li></ul><ul><li>Often precipitated by illness or surgery. </li></ul><ul><li>Pseudogout is most common in the knee (50%) and wrist. </li></ul><ul><li>Reported in any joint (Including MTP). </li></ul><ul><li>CPPD disease may be asymptomatic (deposition of CPP in cartilage). </li></ul>
  80. 81. Associated Conditions <ul><li>Hyperparathyroidism </li></ul><ul><li>Hypercalcemia </li></ul><ul><li>Hypocalciuria </li></ul><ul><li>Hemochromatosis </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Gout </li></ul><ul><li>Aging </li></ul>
  81. 82. CPPD Crystals <ul><li>Rod or rhomboid-shaped </li></ul><ul><li>positive birefringent </li></ul>
  82. 83. <ul><li>THANK-YOU </li></ul>

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