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Aspirarion of joint.pptx
- 3. To discuss the evaluation and management of joint pain To describe the most common etiologies for joint pain and how to differentiate them To demonstrate the proper techniques for performing arthrocentesis and trigger point injections for diagnostic and therapeutic purposes
- 5. History/Physical Exam: - Severe pain - Fever, chills, lethargy - IV drug use - Local redness, swelling, heat, tenderness - Restricted motion - Is process monoarticular or polyarticular and which joints are involved - Is pain superimposed on chronic pain - Medications (thiazide diuretics) Past medical history (PMH) ◦ Joint prosthesis ◦ Intra-articular injection ◦ Joint trauma (consider radiologic imaging) Family History (FH) ◦ Up to 18% of people with gout have a family history of gout
- 6. - Trauma - Hemorrhage - Inflammatory Conditions - Toxic synovitis - Crystal induced arthritis: Gout and pseudogout - Arthritis - Rheumatoid - Osteo - Psoriatic - Infection - Septic joint, Reiter’s syndrome, acute disseminated gonorrhea (Fitz-Hugh-Curtis syndrome) - Is there only one joint or are multiple joints involved? - Gout is most common cause of inflammatory arthritis in adults - JRA is the most common cause of inflammatory arthritis in children - Septic arthritis requires urgent diagnoses and treatment and can occur in pediatrics as well as in adults
- 7. Sweep Test
- 8. To rule out an infectious etiology ◦ Synovial fluid evaluation (joint aspiration) ◦ CBC with diff, CRP, ESR and blood cultures ◦ Consider a plain film to assess baseline joint status For suspected gout/pseudogout ◦ Synovial fluid analysis of crystals ◦ CBC, uric acid level: 10% of patients with gout will have normal serum uric acid levels
- 9. Indications for arthrocentesis Need to obtain synovial fluid for diagnosis Drainage of hemarthrosis when conservative management is unsuccessful Instillation of local analgesic and anti-inflammatory agents into a joint Contraindications Soft tissue infection overlying proposed site of aspiration (absolute contraindication) Uncooperative patient (relative contraindication) Known coagulopathy or receiving anticoagulant therapy (relative contraindication)
- 13. Advantages of Ultrasound-guided injections Precise Needle placement into joints for aspiration or injection Injection into tendon sheaths or bursa Aspiration and injection of ganglion cysts Ultrasound important tool in diagnosing and treating baker’s cyst In a clinical setting, a Baker’s cyst can mimic the presentation of DVT – US can aide in diagnosis/Tx
- 14. Obtain 2-10 mL of synovial fluid in purple or green top tube, 1 mL in red and 1 mL in gray top Normal synovial fluid is viscous and will “string” Synovial fluid analysis includes: Protein and Glucose, Cell count and differential, Gm stain and C&S, crystals ◦ Normal synovial fluid is clear, straw-colored containing fewer than 200 white cells per microliter, of which less than 25% are polymorphonuclear neutrophils ◦ Serum glucose > 40 mg/dL in synovial fluid suggests infection ◦ Normal synovial fluid protein is 1/3 that of serum ◦ Urate crystals are diagnostic for gout ◦ Calcium crystals are diagnostic for pseudogout
- 15. Normal Traumatic Inflammatory Infected Clarity Clear Clear to slightly turbid Slightly turbid to turbid Turbid to very turbid Viscosity Very viscous Mildly reduced Moderately reduced Greatly reduced WBC/mm3 13-180 300-3000 3000-50,000 15,000- >200,000 % polys 6.5 (0-25) 0-30 40-80 50-100 Glucose (diff vs serum) <10mg/ 100mL less than plasma <20mg/ 100mL less than plasma 10-40mg/ 100mL less than plasma >40mg/ 100mL less than plasma Mucin clot Good Good-Fair Fair-Poor Poor to very poor Crystals None None +/- none Differential diagnosis DJD, trauma, osteo- chondromatosis Rheumatic fever Lupus, Gout Pseudogout Reiter’s syndrome RA, Psoriatic arthritis, Ankylosing spondylitis Septic joint TB arthritis GC arthritis
- 16. Lab studies • Culture & sensitivity C&S • WBC • Gram stain • Polarized crystal light studies-to r/o gout or pseudogout
- 17. Preparation Large-Joint Dose (mg) Small-joint Dose (mg) Triamcinolone hexacetonide 20 2–6 Triamcinolone acetonide 20 2–6 Prednisolone tebutate 25 2.5–7.5 Methylprednisolone acetate 40 3.5–10.5 Triamcinolone diacetate 20 2–6 Prednisolone acetate 30 3–9 Dexamethasone acetate 5 0.5–1.5 From Gray RG, Gottlieb NL: Corticosteroid injections in RA
- 19. Acute attack: ◦ NSAIDs are first-line treatment Maximum doses for first 3 days, then taper over 4 days Ibuprofen: 600-800 mg PO tid ◦ Colchicine is second line for acute attack in patient’s unable to tolerate NSAIDs Should be used within 12-24 hrs of onset of attack Dosing: 1mg followed by 0.5 mg q2h until absence of symptoms or GI side effects ◦ Joint aspiration ◦ Corticosteroids Methylprednisolone 40 mg IM/IV every day for 3-4 days Prednisone: 40 mg PO every day fro 3-4 days and then taper over 7-14 days Chronic Suppressive Therapy: ◦ Xanthine oxidase inhibitors: Allopurinol considered first line treatment for chronic management Dosing: start at 100 mg daily and adjust every 2-4 weeks until goal of serum uric acid is <6 mg/dL for 3-6 mo. ◦ Uricosuric agents: Probenacid considered second line treatment for chronic management Dosing: Start at 250 mg PO bid and gradually increase to 500-2000 mg PO until desired SUA
- 20. Ganglion cysts
- 22. Slipped capital femoral epiphysis (SCFE) Legg-Calve-Perthes (aeseptic necrosis) Toxic synovitis ◦ Common cause of hip pain in children before puberty (4-10 yrs). It is a transient inflammatory arthritis. Its cause is not known, but boys are affected more often than girls (4 to 1). ◦ Associated with fever, hip, thigh or knee pain ◦ CBC, ESR, CRP, US of joint, x-ray, MRI, joint aspiration
- 23. Avascular necrosis of hip in pediatrics Risk factors: age less than 4, male gender
- 24. Risk factors: Sickle cell disease, alcoholism, oral steroid use
Editor's Notes
- Reiter’s syndrome: A “reactive” arthritis with a high male to female ratio (20:1). The primary infectious site is usually urogenital or occasionally intestinal. Classic infection is Chlamydia urethritis. 90% of patients possess the HLA-B27 antigen. Diagnosis of Reiter’s syndrome should be used only for patients who have classic triad (uveitis, urethritis, and arthritis). The arthritis usually involves the large joints of the lower limbs. The spine is also involved frequently, especially the sacroiliac joints. The urethritis should be appropriately diagnosed (culture) and treated with antibiotics Doxycycline 100 mg BID x 10 days. The painful arthritis can be treated with NSAIDs, etc. Recurrences often occur even after treatment, and many patients develop chronic joint disease. Gonococcal arthritis Disseminated gonococcal infection (DGI) Last reviewed: June 9, 2011. Gonococcal arthritis is inflammation of a joint (usually just one) due to a gonorrhea infection. See also: Non-gonococcal bacterial arthritis Causes, incidence, and risk factors Gonococcal arthritis is an infection of a joint. It occurs in people who have gonorrhea caused by the bacteria Neisseria gonorrhoeae. It affects women more often than men, and it is most common among sexually active adolescent girls. Two forms of gonococcal arthritis exist: One involves skin rashes and many joints, usually large joints such as the knee, wrist, and ankle The second, less common form involves the spread of the bacteria through the blood (disseminated gonococcemia), which leads to infection of a single joint Symptoms Fever Lower abdominal pain, may have liver tenderness and enlargement Joint pain for 1 to 4 days Pain in the hands or wrists due to tendon inflammation Pain or burning during urination Single joint pain Skin rash (sores are slightly raised, pink to red, and may later contain pus or appear purple) Signs and tests Blood cultures should be checked in all cases of possible gonococcal arthritis. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001489/
- CRP is more sensitive than ESR in acute inflammation (Colombet, et al, 2010, American Journal of Medicine). ESR elevates as a result of fibrinogen entering the blood causing RBCs sticking together = ESR. Elevated ESR indicates an inflammatory process has been going on for at least several days. CRP is synthesized in the liver. Its physiologic role is to bind to phosphocholine expressed on the surface of dead or dying (apoptosis) cells in order to activate the complement/immune system, which enhances phagocytosis by macrophages. Levels of CRP begin to rise within 2 hours of an insult, and has a half-life of about 18 hours. The rapid action of CRP makes it a participant in the acute or first phase of the inflammatory process, which is why it is often called an "acute-phase protein."
- An arthrocentesis is the most important diagnostic procedure for evaluation of the acutely inflamed joint
- Normal Uric acid levels are 2.4-6.0 mg/dL (female) and 3.4-7.0 mg/dL (male). Hyperuricemia > 11 may cause risk of renal stones and renal impairment
- Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms.
- Ganglion or synovial cysts are common, non-neoplastic soft tissue tumors that may occur in any joint, but most often occur on or around joints and tendon sheaths in the hands and feet
- Legg-Calve-Perthes disease (LCPD) is avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip. In the vast majority of instances, the disorder is unilateral.
- The incidence rate in boys (13.35 per 100,000) is higher than in girls (8.07 per 100,000). When compared with white children, black children have a higher incidence rate at 3.94 times, and Hispanic children have a 2.54 times higher incidence rate. SCFE mainly occurs between the ages of 10 and 16 years. 20% of patients have bilateral involvement at the time of presentation. The risk of SCFE is increased in children who are obese, as well as in children with other medical issues such as hypothyroidism, low growth hormone level, pituitary tumors, craniopharyngioma, Down syndrome, renal osteodystrophy, and adiposogenital syndrome. A slight downward trend has occurred for average ages over several years, with some data finding the average age for boys at 12.7 years and girls at 11.2 years. This change could be due to the phenomenon of children maturing at a younger age.