gemc- arthritis and arthrocentesis- resident training

Project: Ghana Emergency Medicine Collaborative

Document Title: Arthritis and Arthrocentesis

Author(s): Joe Lex, MD (Temple University School of Medicine)

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Arthritis and

Arthrocentesis

Joe Lex, MD, FACEP, MAAEM

Temple University School of Medicine

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

Objectives

7. Differentiate “rheumatic fever” from “rheumatoid arthritis” from

“rheumatism”

8. Be aware of quackery as it

applies to treatment of arthritis

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

Thomas Sydenham

(1624-1689)

Source Undetermined

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

Synarthrosis

Gray's Anatomy (Wikipedia)

Amphiarthroses

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

Typical Joint Structure

Madhero88 (Wikimedia Commons)

Pathophysiology

• Joint trauma causes decreased

proteoglycans

– If trauma persistent, damage

irreparable

• Inflammation characterized by

polymorphonuclear white cells

– May be immunologic (rheumatoid,

reactive)

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

Monarticular vs. Polyarticular

If Polyarticular and…

…symmetric rheumatoid, drug

induced

…asymmetric rubella, acute

rheumatic fever, gonococcal

…migratory gonococcal or

rubella

Location, Location, Location

• First MTP joint: gout

• MCP and PIP joints: rheumatoid

• DIP and first carpometacarpal

joint: osteoarthritis

• Knee: septic arthritis, pseudogout,

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

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

Arthritis and…

…isoniazid, procainamide,

hydralazine lupus

…thiazide diuretics gout

(increase serum uric acid level)

– Chlorthalidone (Hygroton®)

– Hydrochlorothiazide (HydroDIURIL®,

Esidrix®, Oretic®)

– Indapamide (Lozol®)

Some Scalp and Skin Findings

Alopecia SLE, psoriasis ECM Lyme

Malar rash SLE, dermato-

myositis

Rash Rubella

Pustules Gonococcemia Tophi Gout

Elbows,

Psoriasis SubQ

nodules

Tight skin Scleroderma Hyper-

keratosis

Reactive

Physical Exam

Source Undetermined

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

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

X-ray Findings (Septic)

Source Undetermined Source Undetermined

Hallmark X-ray Findings

Osteoarthritis = Osteophytes

Source Undetermined

Erosions = Rheumatoid or Gout

Source Undetermined Source Undetermined Source Undetermined 30

Chondrocalcinosis = Pseudogout

Enthesitis = Insertion Site

Inflammation (HLA-B27)

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

Other Imaging

• 99mtechnetium methylene

diphosphonate (99mTc MDP)

– Osteomyelitis, stress fractures

• Gallium: gathers at proliferation of

serum proteins and leukocytes

– Infection

Arthrocentesis

• Critical diagnostic adjunct

• Can be painless, safe, and simple

when performed correctly

• Diagnostic or therapeutic

Source Undetermined

Indications

• Obtain joint fluid for analysis

• Drain tense hemarthroses

• Instill analgesics and anti-

inflammatory agents

• Prosthetic joints: only to rule out

infection

Contraindications

• Absolute: infection of any kind

covers area to be punctured

• Relative

– Bleeding diatheses, anticoagulant

therapy

– Bacteremia

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

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

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

Sternoclavicular Joint

Gray's Anatomy (Wikipedia)

Elbow – Lateral Approach

Flex elbow 90o

Prep skin

Insert needle in

palpable bony

notch between

lateral epicondyle

and olecranon

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

Source Undetermined

Knee – Medial vs. Lateral

• Follow “Sutton’s Law”

• William “Slick Willie” Sutton (1901

– 1980): professional bank robber

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.

Palpate the

dorsalis pedis

artery and

choose a

puncture site

anywhere on

the anterior

aspect of the

ankle, avoiding

the dorsalis

pedis artery.

Synovial Fluid Analysis

Source Undetermined

• 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

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)

Normal

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-

Clarity

Culture

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

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.

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

Septic Arthritis

• Synovium infected before

degrading enzymes released

• Children: hematogenous most

common

• Postoperative infection: ~10% of

joint surgeries

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

Management

• Admit for joint drainage, IV

antibiotics

• Empiric therapy based on Gram’s

• Parenteral narcotic analgesics,

articular immobilization control

pain and discomfort

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

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)

Pierre Roche Vigneron (Wikimedia Commons)

Be temperate in wine, in

eating, girls and sloth

Or the gout will seize you

and plague you both

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

Pathophysiology

• Middle-aged men, post-

menopausal women

• Increased uric acid usually present

for 20 years before first attack

• Uric acid often normal

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

Presentation

• Tophi: foreign body granulomas

with crystals as nidus, in musculo-

tendinous unit – olecranon bursa,

Achilles tendon, hands, knees, etc.

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)

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

Diagnosis

• Definitive diagnosis:

birefringent joint fluid

crystals with polarizing

microscope (a yellow

crystal against a red

background) and

negative joint fluid

culture

Source Undetermined

Acute Therapy – Colchicine

• Not diagnostic: works on

pseudogout

• Contraindication: hematologic,

renal, hepatic dysfunction

• Extravasation from IV tissue

necrosis

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%

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

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

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

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

Source Undetermined

Treatment

• Judicious exercise for muscle

strengthening

• Relieve muscle spasm

• Support joint

• Acetaminophen comparable to

ibuprofen for short-term treatment

• Ultimately joint replacement

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

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%

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

Viral Arthritis

• Most common: rubella, hepatitis B

• Also mumps, adenoviruses,

Epstein-Barr virus, enteroviruses

• Deposition of soluble immune

complexes in synovium with

resultant inflammation

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

Rubella

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

• 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

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

Spondyloarthropathies

• Ankylosing spondylitis

• Reactive arthritis (e.g. Reiter’s

syndrome)

• Psoriatic arthritis

• Arthropathy of inflammatory bowel

disease

Ankylosing Spondylitis

• Male predominance

• Back pain

• X-ray evidence of sacroiliitis

• Symmetrically squared vertebral

bodies, then “bamboo spine”

• Morning stiffness, improves with

exercise

Source Undetermined

• 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

Reactive Arthritis

• Polyarticular, asymmetric

• Weight-bearing joints of lower

extremities commonly involved:

knees, ankles, feet, particularly

heels (“lover’s heel”)

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

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?

• Hans Julius Reiter (1881 – 1969)

• German military physician on

Western Front in 1st Hungarian

• 1916: described German

Lieutenant with non-gonococcal

urethritis, arthritis and uveitis

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

Psoriatic Arthritis

Source Undetermined

Rheumatism

• An older term used to describe any

of a number of painful conditions

of muscles, tendons, joints, and

bones.

• Rheumatism

Canadian

dogbane

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

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

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

• Involves heart in ~50%

• Pericarditis, congestive heart

failure, valvular dysfunction,

cardiomegaly

• Neurologic: Sydenham’s chorea,

weakness, behavioral disturbance

• Sparing of sensory functions

Sinus tachycardia

Right atrial enlargement

Left atrial enlargement Left ventricular strain

RBBB pattern

1st degree AV block

Source Undetermined

• Erythema marginatum: well-

demarcated, pink nonpruritic rash,

usually trunk, sometimes proximal

– Central clearing, may last hours

Source Undetermined

Erythema Marginatum

• Subcutaneous nodules: firm,

nontender under skin overlying

bony prominences

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

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

Rheumatoid Arthritis

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

Presentation

• Prodrome: fatigue, weakness,

musculoskeletal pain

• Symmetric joint swelling: hands

(MP, PIP joints), wrists, elbows

• Difficult to distinguish from viral

arthropathy

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

Baker’s Cyst

Source Undetermined

Subcutaneous Nodules

Source Undetermined

Felty’s Syndrome

• Rheumatoid arthritis

+ splenomegaly +

leukopenia

• Frequent pneumonia

and leg ulcers

• 1% of RA patients

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

Nontraditional Thinking

• The Mycoplasma Theory: joint

pain caused by subclinical

mycoplasma infection, improves

with doxycycline

• Glucosamine and chondroitin:

possibly useful in osteoarthritis

Known Not to Work

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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

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.

gemc- arthritis and arthrocentesis- resident training

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joint space

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