The document summarizes different types of arthritis including septic arthritis, gout, and crystal induced arthritis. It discusses the clinical features that distinguish articular from periarticular involvement as well as inflammatory from non-inflammatory arthritis. Diagnostic testing of synovial fluid such as cell count and microscopy for crystals is emphasized. Treatment of conditions like septic arthritis with antibiotics is outlined.

1. CLINICAL SERIES: ARTHRITIS BY: Ahmed AL-Jabri R2

2. AIM JOINT inflammation : Articular vs periarticular ? Inflammatory vs non-inflammatory ? focus on septic arthritis AND crystal induced arthritis

3. Normal Joint..

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. 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. 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. Acute Monoarthritis - differential diagnosis Septic arthritis Crystal arthritis Gout (uric acid) Pseudogout/calcium pyrophosphate deposition disease (CPPD)

8. What are other differentials for acute monoarticular pain?

9. Monoarthritis - differential diagnosis Psoriatic arthritis Onycholysis Subungual hyperkeratosis Pitting Extensor surfaces, scalp, natal cleft, umbilicus Other associated features eg uveitis, inflammatory bowel disease, enthesitis, Ankylosing spondylitis

10. Monoarthritis - differential diagnosis Reactive arthritis Prodromal GI /GU Infection eg campylobacter, salmonella, shigella, Yersinia,chlamydia Pustular psoriasis and circinate balanitis

11. Q: Physical examination of a patient with reiter’s syndrome may be expected to reveal : Waxy plaques on the palms and soles Sausage-like swelling of the fingers Painful, shallow ulcers in the mouth Iritis All of the above Non of the above

12. Q: Physical examination of a patient with reiter’s syndrome may be expected to reveal : Waxy plaques on the palms and soles Sausage-like swelling of the fingers Painful, shallow ulcers in the mouth Iritis All of the above

13. Monoarthritis - differential diagnosis Trauma - # and haemarthroses (warfarin, bleeding disorders)

14. Others to think about Osteonecrosis/AVN (steroids/alcohol) Severe pain but good ROM Monoarticular RA Monoarticular OA Prosthetic joint - loosening, # or infection Periarticular pathology

15. Is it an articular or extra-articular problem? ARTICULAR PERI-ARTICULAR pain all planes pain in plane of tendon active = passive active < passive capsular swelling/effusion linear swelling joint line tenderness localised tenderness diffuse erythema/heat localised erythema/heat

16. WHAT DO WE HAVE ?

17. Olecranon bursitis

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 ? WBC > 500 per mm3 . WBC > 7,000 per mm3 WBC > 10,000 per mm3 WBC > 50,000 per mm3 WBC > 100,000 per mm3

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 ? WBC > 500 per mm3 . WBC > 7,000 per mm3 WBC > 10,000 per mm3 SEPTIC BURSITIS ACCOUNTS FOR 33% OF ALL OLECRANON BURSITIS .

20. What is the expected WBC counts in aspirated synovial fluid from a patient with septic arthitis ?

21. It will be a turbid/purulent fluid, USUALLY > 50,000 wbc/mm3 ( 5000-50,000) > 75% PMN WBC What is the expected WBC counts in aspirated synovial fluid from a patient with septic arthitis ?

22. A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most consistent with __. rheumatoid arthritis viral infection gonococcal arthritis systemic lupus erythematosus (SLE) rheumatic fever

23. A patient presents with acute polyarthritis. Joint fluid shows less than 10,000 WBCs, mostly lymphocytes. This is most consistent with __. rheumatoid arthritis viral infection gonococcal arthritis systemic lupus erythematosus (SLE) rheumatic fever In the other conditions, the WBC count is usually higher, with predominantly PMNs.

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

25. How do you get septic arthritis?

26. Pathogenesis

27. Who gets septic arthritis?

28. Who gets septic arthritis? common organisms Staphylococci or Streptococcus young adults, significant incidence gonococcal arthritis Elderly & immunocompromised gram -ve organisms Anaerobes more common with penetrating trauma

29. Who gets septic arthritis? pre-existing joint disease prosthetic joints IV drug abuse, alcoholism diabetes, steroids, immunosuppression previous intra-articular steroid injection

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

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

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 ? Joint aspiration MRI of the knee Colchicine PO Stress-dose steroids Indomethacin PO

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 ? Joint aspiration

34. 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. 10-15% of cases, > one joint - so polyarticular presentation does not exclude sepsis presence of fever not reliable indicator- if clinical suspicion high - treat

35. Kocher et al. 1999 Hx of fever Nonweightbearing ESR >40mm/hr WBC >12,000/mm3

37. What investigations are useful in septic arthritis?

38. Investigations Synovial fluid aspiration volume/viscosity/cellularity/ appearance gram stain/culture Absence of organism does not exclude septic arthritis polarised light microscopy (crystals) NB suspected prosthetic joint sepsis should ALWAYS be referred to orthopaedics

39. Investigations Always blood cultures significant proportion blood cultures + ve in absence of + ve synovial fluid cultures FBC ESR & CRP BUT absence of raised WBC, ESR or CRP Do not exclude diagnosis of sepsis - if clinical suspicion high always treat

40. Other investigations CRP useful for monitoring response to treatment Urate may be normal in acute gout and of no diagnostic value in acute gout or sepsis Measure urea, electrolytes & liver function for end organ damage (poor prognostic feature) Renal function may influence antibiotic choice

41. Other tests? If skin pustule is present, suggestive of gonococcal infection, then skin swab should be taken If history suggests possibility of genitourinary or respiratory tract infection then culture sputum (and CXR) & urine & take anogenital & throat swabs where appropriate If periarticular sepsis – appropriate swabs and cultures

42. Antibiotic treatment of septic arthritis Local and national guidelines Liaise with micro. guided by gram stain Conventionally given iv for 2 weeks or until signs improve, then orally for around 4 weeks

43. SEPTIC ARTHRITS: Oral Antibiotics Amoxicillin (25 mg/kg per dose administered every 6 hours) Cephalexin (37.5 mg/kg per dose administered every 6 hours) Clindamycin (13 mg/kg per dose administered every 8 hours) Cloxacillin (31 mg/kg per dose administered every 6 hours) Dicloxacillin (25 mg/kg per dose administered every 6 hours) Penicillin V (22 mg/kg per dose administered every 4 hours)

44. Arthrocentesis Critical diagnostic adjunct Can be painless, safe, and simple when performed correctly Diagnostic or therapeutic Tap

45. Indications Obtain joint fluid for analysis Drain tense hemarthroses Instill analgesics and anti-inflammatory agents Prosthetic joints: only to rule out infection Tap

46. Arthrocentesis Fat globules: diagnostic of fracture Intraarticular morphine can provide relief for up to 24 hours 1 to 5 mg diluted in normal saline solution to a total volume of 30 ml Tap

47. Shoulder – Posterior Approach Tap

48. Shoulder – Anterior Approach Tap

49. Elbow – Lateral Approach Tap Flex elbow 90 o Prep skin Insert needle in palpable bony notch between lateral epicondyle and olecranon

50. Elbow – Lateral Approach Tap

51. Elbow – Posterior Approach Tap

52. Wrist Approach Tap

53. Wrist Approach Tap

54. Wrist Approach Tap

55. A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opposite side. pronation supination flexion and extension

56. A patient has wrist inflammation that is too subtle to detect visually. It may best be detected by comparing __ to the opposite side. pronation supination flexion and extension With even minimal inflammation, there will be a noticeable decrease in the flexion-extension range of motion

57. Knee – Lateral Approach Tap

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

59. Knee – Lateral Approach Tap

60. Knee – Medial Approach Tap

61. Knee – Medial Approach Tap

62. Knee – Medial Approach Tap

63. Knee – Medial Approach Tap

64. Knee – Medial Approach Tap

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.

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.

67. Ankle – Lateral Approach Tap

68. Ankle – Medial Approach Tap

69. Synovial Fluid Analysis Identify crystals, pus Analyze color, clarity, cell count, differential, Gram’s stain, crystals Positive Gram’s stain: diagnostic for septic arthritis Negative Gram’s stain: does not rule out septic arthritis Fluid

70. Synovial Fluid Cell Count Noninflammatory vs. inflammatory ED wet mount prep 1 to 2 WBCs per high-power field consistent with noninflammatory >20 WBC/HPF suggests inflammation or infection Septic: >50,000 WBC/mm 3 (also rheumatoid, gout, pseudogout) Fluid

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

72. Septic arthritis: SMS with a short history of a hot, swollen, tender joint (or joints) plus restriction of movement; septic arthritis until proven otherwise If clinical suspicion high investigate & treat as septic arthritis even in absence of fever

73. gout

74. Gout Caused by monosodium urate crystals Most common type of inflammatory monoarthritis Typically: first MTP joint, ankle, midfoot, knee Pain very severe; cannot stand bed sheet May be with fever and mimic infection The cutaneous erythema may extend beyond the joint and resemble bacterial cellulitis

75. Acute Gouty Arthritis

76. Risk Factors Primary gout: Obesity, hyperlipidemia, diabetes mellitus, hypertension, and atherosclerosis. Secondary gout: alcoholism, drug therapy (diuretics, cytotoxics), myeloproliferative disorders, chronic renal failure.

77. Microscopic appearance of the crystals of gout include all of the following EXCEPT: needle-shaped urate crystals positively birefringent negatively birefringent Non of the above

78. Microscopic appearance of the crystals of gout include all of the following EXCEPT: needle-shaped urate crystals positively birefringent

79. Urate Crystals Needle-shaped Strongly negative birefringent

80. CPPD Crystals Deposition Disease Can cause monoarthritis clinically indistinguishable from gout – hence called Pseudogout. Often precipitated by illness or surgery. Pseudogout is most common in the knee (50%) and wrist. Reported in any joint (Including MTP). CPPD disease may be asymptomatic (deposition of CPP in cartilage).

81. Associated Conditions Hyperparathyroidism Hypercalcemia Hypocalciuria Hemochromatosis Hypothyroidism Gout Aging

82. CPPD Crystals Rod or rhomboid-shaped positive birefringent

83. THANK-YOU