Knee Therapy Explains

1. Dian Evans, PhD, FNP-BC, ENP-C, FAANP, FAAN
NRSG 544

2.  Please read chapters 40-41 in Campo and
Lafferty procedure book

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

21. https://www.youtube.com/watch?v=-0ROu4hCXwQ

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