gemc- arthritis and arthrocentesis- resident training
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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.TRANSCRIPT
Project: Ghana Emergency Medicine Collaborative
Document Title: Arthritis and Arthrocentesis
Author(s): Joe Lex, MD (Temple University School of Medicine)
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2
Arthritis and
Arthrocentesis
Joe Lex, MD, FACEP, MAAEM
Temple University School of Medicine
3
What’s a
joint like you
doing in a
nice girl like
this??
Source Undetermined 4
Objectives
1. Differentiate among the three
types of joints
2. Explain the pathology of joint
inflammation
3. Develop a differential for arthritis,
based on number of joints
involved, location, and other
characteristics 5
Objectives
4. Explain usefulness of various
synovial fluid studies.
5. Demonstrate an appropriate
technique for large joint
arthrocentesis
6. Explain the pathophysiology and
treatment for gout
6
Objectives
7. Differentiate “rheumatic fever” from “rheumatoid arthritis” from
“rheumatism”
8. Be aware of quackery as it
applies to treatment of arthritis
7
History of Arthritides
• 1680s: Sydenham describes gout,
rheumatism, chorea
• 1808: term “rheumatic fever”
• 1876: urate crystals postulated to
cause gout
• 1883: gonococcal arthritis
• 1907: osteoarthritis described
8
Thomas Sydenham
(1624-1689)
Source Undetermined
9
Three Joint Types
• Synarthroses: suture lines of skull
• Amphiarthroses: fibrocartilaginous
unions of pubic symphysis and
lower third of sacroiliac joint
• Diarthroses = Synovial: most other
joints
10
Synarthrosis
Gray's Anatomy (Wikipedia)
11
Amphiarthroses
Source Undetermined 12
Diarthrosis = Synovial Joints
• Subchondral bone, convex against
concave, covered by cartilage
• Cartilage: collagen + proteoglycan
• Lubricated, slide on each other
• Surrounded by capsule supported
by ligaments, tendons, and muscle
• Lined with synovial membrane
13
Typical Joint Structure
Madhero88 (Wikimedia Commons)
14
Pathophysiology
• Joint trauma causes decreased
proteoglycans
– If trauma persistent, damage
irreparable
• Inflammation characterized by
polymorphonuclear white cells
– May be immunologic (rheumatoid,
reactive)
15
Joint vs. Periarticular
Arthritis
• Generalized
pain, warmth,
swelling,
tenderness
• Discomfort
with joint
motion
Periarticular
inflammation:
bursitis, tendinitis,
localized cellulitis
• Focal tenderness,
swelling not uniform
• Pain only with
certain movements
16
Monarticular vs. Polyarticular
Source Undetermined 17
If Polyarticular and…
…symmetric rheumatoid, drug
induced
…asymmetric rubella, acute
rheumatic fever, gonococcal
…migratory gonococcal or
rubella
18
Location, Location, Location
• First MTP joint: gout
• MCP and PIP joints: rheumatoid
• DIP and first carpometacarpal
joint: osteoarthritis
• Knee: septic arthritis, pseudogout,
gout
19
Causes of Migratory Arthritis
• Rheumatic fever
• Subacute bacterial
endocarditis
• Henoch-Schönlein
purpura
• Cefaclor (Ceclor®)
hypersensitivity
(kids)
• Septicemia:
staphylococcal,
streptococcal,
meningococcal,
gonococcal
• Mycoplasma,
histoplasmosis,
coccidioidomycosis
• Lyme disease
20
Arthritis with…
…low-grade fever any
inflammatory arthritis
…high fever, chills septic arthritis
…kidney stones gout
…genital ulcers reactive arthritis
…urethral discharge reactive
arthritis, gonococcus
21
Arthritis and…
…isoniazid, procainamide,
hydralazine lupus
…thiazide diuretics gout
(increase serum uric acid level)
– Chlorthalidone (Hygroton®)
– Hydrochlorothiazide (HydroDIURIL®,
Esidrix®, Oretic®)
– Indapamide (Lozol®)
22
Some Scalp and Skin Findings
Alopecia SLE, psoriasis ECM Lyme
Malar rash SLE, dermato-
myositis
Rash Rubella
Pustules Gonococcemia Tophi Gout
Elbows,
knees
Psoriasis SubQ
nodules
RA
Tight skin Scleroderma Hyper-
keratosis
Reactive
23
Physical Exam
Source Undetermined
24
Physical Exam
1. Warmth and effusion
2. Synovial thickening
3. Deformity
4. Tenderness: generalized or
localized, articular or periarticular
5. Limited range of motion
6. Pain on movement
25
Lab Studies
• Limited diagnostic value
• “Screening tests”
– Bacterial: usually elevated WBC
– Chronic rheumatic: mild anemia
– ESR/CRP in most inflammatory
• RF, ANA, ASO titers, Lyme
serologies: for follow-up
• Uric acid: not helpful in gout 26
X-ray Findings (Chronic)
Soft tissue swelling
Erosions
Calcification
Osteoporosis
Narrowed joint space
Deformity
Separation (fractures)
Source Undetermined
27
X-ray Findings (Septic)
Source Undetermined Source Undetermined
28
Hallmark X-ray Findings
Osteoarthritis = Osteophytes
Source Undetermined
Source Undetermined
29
Hallmark X-ray Findings
Erosions = Rheumatoid or Gout
Source Undetermined Source Undetermined Source Undetermined 30
Hallmark X-ray Findings
Chondrocalcinosis = Pseudogout
Source Undetermined 31
Hallmark X-ray Findings
Enthesitis = Insertion Site
Inflammation (HLA-B27)
Source Undetermined 32
Other Imaging
• Ultrasound: joint effusions;
tendons and ligaments of shoulder
• CT scan: SI, sternoclavicular joint
• MRI: knee cruciate ligaments
• Contrast MRI: differentiate
synovitis from synovial fluid in
rheumatoid disease
33
Other Imaging
• 99mtechnetium methylene
diphosphonate (99mTc MDP)
– Osteomyelitis, stress fractures
• Gallium: gathers at proliferation of
serum proteins and leukocytes
– Infection
34
Arthrocentesis
• Critical diagnostic adjunct
• Can be painless, safe, and simple
when performed correctly
• Diagnostic or therapeutic
Source Undetermined
36
Indications
• Obtain joint fluid for analysis
• Drain tense hemarthroses
• Instill analgesics and anti-
inflammatory agents
• Prosthetic joints: only to rule out
infection
37
Contraindications
• Absolute: infection of any kind
covers area to be punctured
• Relative
– Bleeding diatheses, anticoagulant
therapy
– Bacteremia
38
Procedure
• Cleanse skin with povidone-iodine,
then air dry
• Remove povidone-iodine with
isopropyl alcohol
– Intra-articular povidone-iodine can
cause chemical irritation, inhibit
bacterial growth leading to spuriously
negative cultures in early septic joint
39
Procedure
• Place sterile drapes
• Inject local anesthetic into skin
– 25- to 30-gauge needle
– Intraarticular anesthetic can inhibit
bacterial growth, cause spuriously
negative culture in early septic joint
40
Procedure
• Aspirate large joints with large-
bore needle (18 or 19 gauge)
– Smaller joints: smaller-bore needle
• Choose syringe size based on
anticipated fluid volume
• Remove as much fluid as possible
– Optimizes diagnosis
– Relieves pain from distention 41
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
42
Sternoclavicular Joint
43
Gray's Anatomy (Wikipedia)
Elbow – Lateral Approach
Flex elbow 90o
Prep skin
Insert needle in
palpable bony
notch between
lateral epicondyle
and olecranon
44
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. 45
Knee – Medial Approach
46 Source Undetermined
Knee – Medial Approach
47
Source Undetermined
Knee – Medial Approach
48
Source Undetermined
Knee – Medial Approach
49
Source Undetermined
Knee – Medial Approach
50
Source Undetermined
Knee – Medial vs. Lateral
• Follow “Sutton’s Law”
• William “Slick Willie” Sutton (1901
– 1980): professional bank robber
51
Ankle
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.
52
Ankle
Palpate the
dorsalis pedis
artery and
choose a
puncture site
anywhere on
the anterior
aspect of the
ankle, avoiding
the dorsalis
pedis artery.
53
Synovial Fluid Analysis
54
Source Undetermined
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
55
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/mm3 (also
rheumatoid, gout, pseudogout)
56
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
Synovial Fluid Analysis
57
Other Synovial Fluid Analysis
• Glucose, lactic acid, viscosity,
mucin clot, and total protein:
limited utility, not recommended
• Appropriate container
– Cellular analysis: lavender
(ethylenediaminetetraacetic acid)
– Crystal analysis: green (heparin)
– Chemical analysis, serology: red
58
Crystal Studies
• Monosodium urate: needle
shaped, birefringent negative
– Parallel to compensator: yellow
– Perpendicular: blue
• Calcium pyrophosphate:
polymorphic, birefringent positive
– Parallel to compensator: blue
– Perpendicular: yellow 59
Crystal Studies
Sodium urate crystals viewed under polarized
light with a red plate makes those in the plane of
the long axis of the red plate yellow, which
indicates that they are negatively birefringent.
60
Source Undetermined
Crystal Studies
Calcium pyrophosphate crystal viewed under polarized
light with a red plate. The crystal is aligned in the long axis
of the red plate, so that it is bluish-white, which indicates
that it is weakly positively birefringent. 61
Source Undetermined
Specific
Arthritides There are more than 90
Preiser’s
disease:
avascular
necrosis of
scaphoid 62
Source Undetermined
Septic Arthritis
• Hematogenous spread
• Direct inoculation
• Direct spread from bony or soft
tissue infections
63
Septic Arthritis
• Synovium infected before
degrading enzymes released
• Children: hematogenous most
common
• Postoperative infection: ~10% of
joint surgeries
64
Causes
• Staphylococcus aureus: most
common (even in sickle cell)
• Others: streptococcus, Gram
negatives, anaerobes
• N. gonorrhoeae: 20% monarticular
• <6 months: E. coli, group B strep
• IV drug users: S. aureus, Gram
negatives 65
Clinical Features
• Based on host’s concurrent
medical conditions
• Painful, hot, swollen
• Typical: single joint
– Knee: 40% to 50%
– Hip: 13% to 20%
– Shoulder: 10% to 15%
• 20% polyarticular 66
Clinical Features
• History of fever: 80%
• Shaking chills: 20%
• Elevated sedimentation rate more
common than leukocytosis
• Blood cultures grow causative
organism ~50% of the time
• Radiographs not often useful
67
Management
• Admit for joint drainage, IV
antibiotics
• Empiric therapy based on Gram’s
stain
• Parenteral narcotic analgesics,
articular immobilization control
pain and discomfort
68
Gouty Arthritis
69
Gouty Arthritis
• Pod = foot; agra = trap, hunt
• Podagra: foot goddess, a bad-
tempered virgin, who attacked
victims after they overindulged
• Father was Dionysus (Bacchus),
god of wine
• Mother was Aphrodite (Venus),
goddess of love 70
Gouty Arthritis
• Thought to be limited to men who
had indulged in dietary or sexual
excess
71
Gouty Arthritis
• Galen (129-199 AD), an
ex-gladiatorial surgeon in
Rome, described gout as
a discharge of the four
humors of the body in
unbalanced amounts into
the joints (hence gout =
gutta, a drop)
72
Pierre Roche Vigneron (Wikimedia Commons)
Be temperate in wine, in
eating, girls and sloth
Or the gout will seize you
and plague you both
73
Benjamin Franklin:
Pathophysiology
• Uric acid crystal deposits from
supersaturated extracellular fluid
• Risk factors: obesity, hypertension,
diabetes, alcohol, proximal loop
diuretics, lead poisoning
• During attack: crystals ingested by
PMNs inflammation
74
Pathophysiology
• Middle-aged men, post-
menopausal women
• Increased uric acid usually present
for 20 years before first attack
• Uric acid often normal
75
Presentation
• Great toe MTP joint in 75%
– Also tarsal, ankle, knee, wrist
– Up to 40% polyarticular
• Pain excruciating at onset
– Can mimic septic joint
– Usually self-limited
• Systemic symptoms usually
minimal or absent 76
Presentation
• Subsequent attacks closer
together, more joints, last longer
• Long-term: kidney stones
77 Source Undetermined
Presentation
• Tophi: foreign body granulomas
with crystals as nidus, in musculo-
tendinous unit – olecranon bursa,
Achilles tendon, hands, knees, etc.
78
Source Undetermined Source Undetermined
Diagnosis
• Rule out cellulitis, septic arthritis
particularly if knee joint
• All may have fever, leukocytosis,
elevated ESR
• Uric acid level not helpful
• X-rays: soft-tissue swelling (acute)
or joint destruction (chronic)
79
Uric Acid Levels
• Uric acid normal in ~40%
• Tophi can form in cool body areas
without hyperuricemia
• Acute attack pain increased
cortisol uric acid diuresis
normalized level
80
Diagnosis
81
Source Undetermined Source Undetermined
Diagnosis
• Definitive diagnosis:
birefringent joint fluid
crystals with polarizing
microscope (a yellow
crystal against a red
background) and
negative joint fluid
culture
82
Source Undetermined
Acute Therapy – Colchicine
• Not diagnostic: works on
pseudogout
• Contraindication: hematologic,
renal, hepatic dysfunction
• Extravasation from IV tissue
necrosis
83
Acute Therapy – Colchicine
• Inhibits microtubule formation
• Most effective in first 24 hours
• 0.6 mg / hour until pain controlled,
max 6 mg or side effects (GI)
• Average toxic dose: 6.7 mg
• Toxicity precedes improvement in
more than 50%
84
Acute Therapy – Other
• NSAIDs effective, indomethacin
most common (75 to 200 mg/day)
– Contraindicated in PUD, GI bleed
• If resistant: prednisone taper
– 40 mg/day first 3 to 5 days
• Adrenocorticotrophic hormone
– ACTH 40 IU to 80 IU IM
85
Pseudogout
• Calcium pyrophosphate dihydrate
(CPPD) crystal-deposition disease
• Knee: most common joint
• Polyarticular possible
• Pain less severe, patients older
• Risk: hypothyroid, Wilson’s
disease, hyperparathyroid,
hemochromatosis, etc. 86
Diagnosis
• Common: elevated ESR, WBC
• X-ray may show joint calcification
• Joint fluid
– Weakly positive birefringent crystals
on polarized microscopy
– Appear rhomboidal on regular light
microscopy
• Treatment: same as gout 87
Chondrocalcinosis
88 Source Undetermined
Osteoarthritis
• Degenerative joint disease
• Most common form of arthritis
• Loss of articular cartilage, reactive
changes at joint margins
• Synovitis in advanced disease
• May have painful bone-to-bone
interface
89
Presentation / Diagnosis
• Chief complaint: pain
• No systemic symptoms
• Hands: Bouchard’s, Heberden’s
nodes (osteophyte spurs)
• Knee: active & passive crepitus
• Routine lab tests: normal
• Radiographs: joint- space
narrowing, osteophyte formation 90
Heberden’s and Bouchard’s
Over DIP Over PIP
91
Source Undetermined
92
Source Undetermined
Treatment
• Judicious exercise for muscle
strengthening
• Relieve muscle spasm
• Support joint
• Acetaminophen comparable to
ibuprofen for short-term treatment
• Ultimately joint replacement
93
Gonococcal Arthritis
• Woman : men :: 4:1
• Fever, chills, arthralgias, migratory
tenosynovitis
• Progresses to arthritis: knee,
ankle, wrist
• Characteristic rash: countable
hemorrhagic necrotic pustules
• Rarely have cervicitis or urethritis 94
Gonococcal Arthritis
95 Source Undetermined
Source Undetermined
Gonococcal Arthritis
96
Source Undetermined
Source Undetermined
Diagnosis
• Blood cultures usually negative
• Synovial fluid cultures positive in
less than 50%
• Gram’s stain positive more often
than culture
• Cervical, urethral, pharyngeal,
rectal cultures positive ~75%
97
Treatment
• Admit to hospital
• Ceftriaxone 1 g IM or IV daily, and
24 to 48 hours after improvement
• Ciprofloxacin 500 mg twice daily
orally for total 7 days of antibiotics
• Spectinomycin 2 grams IM every
12 hours if beta-lactam allergic
98
Viral Arthritis
• Most common: rubella, hepatitis B
• Also mumps, adenoviruses,
Epstein-Barr virus, enteroviruses
• Deposition of soluble immune
complexes in synovium with
resultant inflammation
99
Rubella Arthritis
• Often young women
• Rash several days before
• Acute, symmetric, usually
polyarticular
• Resolves within weeks
• Recent infection or vaccination
• Virus isolated from synovial fluid
100
Rubella
101 Source Undetermined
Source Undetermined
Hepatitis B Arthritis
• Usually with or after prodrome of
fever and lymphadenopathy
• Often precedes jaundice
• May be sudden and severe
• PIP, knee, ankle, MP joints most
commonly involved
• Salicylates may be helpful
102
Lyme
• Spirochete: Borrelia burgdorferi
• Vector: Ixodes dammini on East
Coast and Midwest
• Arthritis late manifestation
• Within 6 months, half of untreated
have frank arthritis
– Asymmetric
– Most common in knees 103
Presentation
• Minimal joint pain, usually afebrile
• Severity of initial presentation
predictive of subsequent arthritis
• Chronic arthritis more common in
patients positive for HLA-DR4
• Joint fluid inflammatory with PMN
predominance
• Diagnosis is clinical 104
Presentation
105 Source Undetermined
Ixodes
106 Centers for Disease Control and Prevention (Wikimedia Commons)
Spondyloarthropathies
• Seronegative: negative rheumatoid
factor
• Sacroiliac involvement
• Peripheral joint inflammation
• Changes of ligamentous and
tendinous insertion into bone
• Genetic: HLA-B27
107
Spondyloarthropathies
• Ankylosing spondylitis
• Reactive arthritis (e.g. Reiter’s
syndrome)
• Psoriatic arthritis
• Arthropathy of inflammatory bowel
disease
108
Ankylosing Spondylitis
• Male predominance
• Back pain
• X-ray evidence of sacroiliitis
• Symmetrically squared vertebral
bodies, then “bamboo spine”
• Morning stiffness, improves with
exercise
109
Ankylosing Spondylitis
110
Source Undetermined
Source Undetermined
Source Undetermined
Ankylosing Spondylitis
• Uveitis: most common extra-
articular manifestation
• Peripheral joints involved in ~30%
of patients with enthesopathic
involvement (plantar fasciitis and
Achilles tendinitis)
• Goal of therapy: control pain,
decrease inflammation 111
Reactive Arthritis
• AKA arthritis urethritica, venereal
arthritis, polyarteritis enterica
• Described by German military
physician Hans Reiter in 1916
• “Reiter's syndrome” being phased
out, partly due to Reiter's typhoid
experiments in Nazi concentration
camps 112
Reactive Arthritis
• Occurs in genetically susceptible
host after infection with GU C.
trachomatis, or GI shigella,
salmonella, yersinia, campylobacter
• Disease of men 15 to 35 years old;
arthritis develops 2 to 6 weeks after
episode of urethritis or dysentery
113
Reactive Arthritis
• Polyarticular, asymmetric
• Weight-bearing joints of lower
extremities commonly involved:
knees, ankles, feet, particularly
heels (“lover’s heel”)
114
Reactive Arthritis
• Other signs appear early
• Conjunctivitis, progress to iritis,
uveitis, corneal ulceration
• Painless ulcers mouth, tongue,
glans penis (balanitis circinata)
• Sausage-like fingers and toes
• Keratoderma blennorrhagica on
palms and soles 115
Reactive Arthritis
Keratoderma blenorrhagica
Balanitis circinata 116
Source Undetermined
Source Undetermined
Reactive Arthritis
• Synovial fluid: inflammatory with
predominance of PMNs
• Antigens in synovial membrane
and joint fluid, cultures sterile
• Increased ESR, WBC
• HLA-B27 antigen in ~80%
• Enthesopathic x-rays, particularly
at IP joint of great toe 117
Reactive Arthritis
• NSAID two or three times daily
• Doxycycline twice daily x 3 months
• Intra-articular steroid injections
• If persistent: Sulfasalazine
• Chronic therapy for erosive,
deforming disease
– Methotrexate
– Azathioprine (Imuran) 118
What Happened to Reiter’s?
119
What Happened to Reiter’s?
• Hans Julius Reiter (1881 – 1969)
• German military physician on
Western Front in 1st Hungarian
Army
• 1916: described German
Lieutenant with non-gonococcal
urethritis, arthritis and uveitis
120
What Happened to Reiter’s?
• Not the first, but he got credit
• Member of the SS during WWII
• Designed typhus inoculation
experiments that killed more than
250 prisoners at Buchenwald
• Convicted as war criminal
121
Psoriatic Arthritis
122
Source Undetermined
Source Undetermined
Source Undetermined
Rheumatism
• An older term used to describe any
of a number of painful conditions
of muscles, tendons, joints, and
bones.
• Rheumatism
weed:
Canadian
dogbane
123
SB Johnny (Wikipedia)
Acute Rheumatic Fever
• Believed to result from Group A
streptococcus pharyngitis
• Exact mechanism unclear
• In decline since antibiotics
• Probable abnormal humoral
response to antigens
124
Clinical Syndrome
• Recurring self-limited episodes of
fever associated with polyarthritis,
carditis / valvulitis, rash,
subcutaneous nodules, or chorea
• Occurs 2 to 3 weeks after
streptococcal pharyngitis
125
Diagnosis – Jones Criteria
• Two major, or one major and two
minor, criteria with evidence recent
Group A streptococcal infection
• Major manifestations: polyarthritis,
carditis, chorea, erythema
marginatum, subcutaneous
nodules
• Migratory arthritis in large joints 126
Diagnosis – Jones Criteria
• Involves heart in ~50%
• Pericarditis, congestive heart
failure, valvular dysfunction,
cardiomegaly
• Neurologic: Sydenham’s chorea,
weakness, behavioral disturbance
• Sparing of sensory functions
127
Diagnosis – Jones Criteria
Sinus tachycardia
Right atrial enlargement
Left atrial enlargement Left ventricular strain
RBBB pattern
1st degree AV block
128
Source Undetermined
Diagnosis – Jones Criteria
• Erythema marginatum: well-
demarcated, pink nonpruritic rash,
usually trunk, sometimes proximal
limbs
– Central clearing, may last hours
129
Source Undetermined
Erythema Marginatum
130 Source Undetermined
Diagnosis – Jones Criteria
• Subcutaneous nodules: firm,
nontender under skin overlying
bony prominences
131
Source Undetermined
Laboratory Work-Up
• Throat culture, ESR, CRP, ASO
• Anti-DNase B 95% sensitive
• Streptozyme test also documents
recent streptococcal infection
• Synovial fluid
– Inflammatory (average WBC 16K)
– Negative culture
132
Post-Streptococcal
• Reactive arthritis: closely related to
ARF but distinct clinical entity
• Sterile oligoarthritis associated
with distant bacterial infection
• Carditis rare, arthritis often severe
• Treatment: penicillin, erythromycin
• Arthritis responds to salicylates
133
Rheumatoid Arthritis
134
Source Undetermined
Rheumatoid Arthritis
• Usually chronic: >20% acute
• Women 2 to 3 x more than men
• Immune complexes stimulate
PMNs to release enzymes
• Synovial cells proliferate, produce
more inflammatory substances
135
Presentation
• Prodrome: fatigue, weakness,
musculoskeletal pain
• Symmetric joint swelling: hands
(MP, PIP joints), wrists, elbows
• Difficult to distinguish from viral
arthropathy
136
Presentation
• Long-term
changes: MP and
PIP swelling, ulnar
deviation, swan-
neck and
boutonnière
deformities of
hands, limited
wrist dorsiflexion 137
Source Undetermined
Swan Neck Deformity
138 Source Undetermined Source Undetermined
Presentation
• Knee: effusion, muscle atrophy,
Baker’s cyst
• Retrocalcaneal bursa
• Subcutaneous nodules, pulmonary
fibrosis, mononeuritis multiplex
• Sjögren’s and Felty’s syndromes
139
Baker’s Cyst
140
Source Undetermined
Subcutaneous Nodules
141
Source Undetermined
Felty’s Syndrome
• Rheumatoid arthritis
+ splenomegaly +
leukopenia
• Frequent pneumonia
and leg ulcers
• 1% of RA patients
142
Source Undetermined
Transverse Ligament Rupture
• C1 on C2 subluxation in 70%
– Frank dislocation in 25%
– Cord compression in 11%
• With myelopathy:
– 5 years survival 80%
– 10 year survival 28%
• Anterior instability more common
than posterior instability 143
Transverse Ligament Rupture
144 Source Undetermined Source Undetermined
Treatment
• Movement increases inflammation:
initial treatment rest
• Suppress inflammation: steroids,
salicylates, gold, penicillamine,
azathioprine, methotrexate,
cyclosporine, sulfasalazine
145
Nontraditional Thinking
• The Mycoplasma Theory: joint
pain caused by subclinical
mycoplasma infection, improves
with doxycycline
• Glucosamine and chondroitin:
possibly useful in osteoarthritis
146
Known Not to Work
ALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO
ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET -
ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND
ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE
POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA -
CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY
ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY -
CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON -
COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS
SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS
- SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM -
DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE)
- SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION
DIETS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET -
TEAS (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE -
GARLIC - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH -
FASTING - GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL -
WOOD SPIDER - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN
MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP
147
Pearls
• The number and distribution of
joints involved helps pinpoint the
most likely cause of arthritis.
• Monarthritis is septic arthritis until
proven otherwise.
• Negative Gram’s stain of synovial
fluid does not rule out bacterial
arthritis. 148
Pearls
• The most definitive test for
evaluating an inflamed joint for the
possibility of bacterial infection is
examination of synovial fluid.
• Delays in the diagnosis and
treatment of septic arthritis worsen
outcomes.
149