A common problem in the emergency department. Management is simple if approached methodically.

History:

Trauma – was there an injury to the joint, recent or remote.


Onset – over weeks, days or hours.


Pain – assess the degree of associated discomfort.


Other joints – any concurrent or previous involvement.


Fever – systemic symptoms, fever, chills, malaise etc.


General Health – medical conditions, medications, previous surgery (recent or remote)

Physical:

Joint – which joint; are other affected.


Is it the joint? – distinguish joint from bursa, soft tissue, bone.


Swelling – amount, temperature, tenderness


ROM – important in considering diagnosis.


Systemic – general physical exam.

Investigation:

X-Ray

• look for fracture, joint destruction, abnormal calcification, bone erosion, soft tissue swelling.
  
  
  
  Aspiration
• send for STAT Gram stain, C&S, Microscopy, biochemistry, WCC + ESR, Blood cultures, Urate, Rheumatoid Screen
• see Joint fluid analysis
  
  
  

  Management:

  
  
  Trauma:

• Swelling follwing an acute injury requires examination and X-Ray to
• Assess bony/ligamentous injury.
• If there was a remote injury with a skin wound consider infection. (a common presentation for infective bursitis.)

Infection:

• Serious and essential to exclude.
• Acute onset painful swelling with systemic symptoms and a very limited
• ROM in a hot, tender joint
• Xray negative
• Aspiration of pus or turbid fluid. G-stain +ve for bacteria.
• May have raised WCC and ESR

Treatment:

• SPLINT JOINT, IV ANTIBIOTICS (broad spectrum)
• URGENT OR for surgical drainage/debridement

Gout:

• Previous episodes, recent surgery, malignancy, medication, EtOH.
• Fever, tophi, osteoarthritis
• Calcification on X-ray eg. Of menisci, "punched out" lesions.
• WCC/ESR raised, Urate > 7.5 mg/dl (in gout), neutrophils
• And negatively birefringent needle-like crystals in aspirate.

Treatment:

• Splint, NSAID (Indocid), underlyling condition, lower urate.

Pseudogout:

• Older patient (> 60 yrs), large joints.
• Associated with diabetes, hypothyroidism, hyper-parathyroidism, haemochromatosis, ochronosis, true gout.
• Positively birefringent crystals.

Treatment:

• Splint, NSAID

Rheumatological Disease


Always think about disease such as rheumatoid arthritis, SLE, Reiter’s, ankylosing spondylitis, psoriatic arthritis etc.