project: ghana emergency medicine collaborative document title: arthritis and arthrocentesis...

Project: Ghana Emergency Medicine Collaborative

Document Title: Arthritis and Arthrocentesis

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

License: 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/

We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material.

Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content.

For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use.

Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition.

Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.

1

Attribution Key

for more information see: http://open.umich.edu/wiki/AttributionPolicy

Use + Share + Adapt

Make Your Own Assessment

Creative Commons – Attribution License

Creative Commons – Attribution Share Alike License

Creative Commons – Attribution Noncommercial License

Creative Commons – Attribution Noncommercial Share Alike License

GNU – Free Documentation License

Creative Commons – Zero Waiver

Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ

Public Domain – Expired: Works that are no longer protected due to an expired copyright term.

Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)

Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.

Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ

Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair.

To use this content you should do your own independent analysis to determine whether or not your use will be Fair.

{ Content the copyright holder, author, or law permits you to use, share and adapt. }

{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }

{ Content Open.Michigan has used under a Fair Use determination. }

2

Arthritis and Arthritis and ArthrocentesisArthrocentesisArthritis and Arthritis and

ArthrocentesisArthrocentesis

Joe Lex, MD, FACEP, MAAEMJoe Lex, MD, FACEP, MAAEMTemple University School of MedicineTemple University School of Medicine

33

WhatWhat’’s a joint s a joint like you like you

doing in a doing in a nice girl like nice girl like

this??this??

WhatWhat’’s a joint s a joint like you like you

doing in a doing in a nice girl like nice girl like

this??this??

Source Undetermined4

ObjectivesObjectivesObjectivesObjectives

1. Differentiate among the three 1. Differentiate among the three types of jointstypes of joints

2. Explain the pathology of joint 2. Explain the pathology of joint inflammationinflammation

3. Develop a differential for arthritis, 3. Develop a differential for arthritis, based on number of joints based on number of joints involved, location, and other involved, location, and other characteristicscharacteristics

5


4. Explain usefulness of various 4. Explain usefulness of various synovial fluid studies.synovial fluid studies.

5. Demonstrate an appropriate 5. Demonstrate an appropriate technique for large joint technique for large joint arthrocentesisarthrocentesis

6. Explain the pathophysiology and 6. Explain the pathophysiology and treatment for gouttreatment for gout

6


7. Differentiate 7. Differentiate ““rheumatic feverrheumatic fever”” from from ““rheumatoid arthritisrheumatoid arthritis”” from from ““rheumatismrheumatism””

8. Be aware of quackery as it 8. Be aware of quackery as it applies to treatment of arthritisapplies to treatment of arthritis

7

History of ArthritidesHistory of ArthritidesHistory of ArthritidesHistory of Arthritides

• 1680s: Sydenham describes gout, 1680s: Sydenham describes gout, rheumatism, chorearheumatism, chorea

• 1808: term 1808: term ““rheumatic feverrheumatic fever””

• 1876: urate crystals postulated to 1876: urate crystals postulated to cause goutcause gout

• 1883: gonococcal arthritis1883: gonococcal arthritis

• 1907: osteoarthritis described1907: osteoarthritis described

8

Thomas Sydenham Thomas Sydenham (1624-1689)(1624-1689)

Thomas Sydenham Thomas Sydenham (1624-1689)(1624-1689)

Source Undetermined

9

Three Joint TypesThree Joint TypesThree Joint TypesThree Joint Types

• Synarthroses: suture lines of skullSynarthroses: suture lines of skull

• Amphiarthroses: fibrocartilaginous Amphiarthroses: fibrocartilaginous unions of pubic symphysis and unions of pubic symphysis and lower third of sacroiliac jointlower third of sacroiliac joint

• Diarthroses = Synovial: most other Diarthroses = Synovial: most other jointsjoints

10

SynarthrosisSynarthrosisSynarthrosisSynarthrosis

Gray's Anatomy (Wikipedia)

11

http://en.wikipedia.org/wiki/Suture_(anatomy)#mediaviewer/File:Gray188.png

AmphiarthrosesAmphiarthrosesAmphiarthrosesAmphiarthroses

Source Undetermined 12

Diarthrosis = Synovial JointsDiarthrosis = Synovial JointsDiarthrosis = Synovial JointsDiarthrosis = Synovial Joints

• Subchondral bone, convex against Subchondral bone, convex against concave, covered by cartilageconcave, covered by cartilage

• Cartilage: collagen + proteoglycanCartilage: collagen + proteoglycan

• Lubricated, slide on each otherLubricated, slide on each other

• Surrounded by capsule supported Surrounded by capsule supported by ligaments, tendons, and muscleby ligaments, tendons, and muscle

• Lined with synovial membraneLined with synovial membrane

13

Typical Joint StructureTypical Joint StructureTypical Joint StructureTypical Joint Structure

Madhero88 (Wikimedia Commons)

14

http://commons.wikimedia.org/wiki/File:Joint.svg

PathophysiologyPathophysiologyPathophysiologyPathophysiology

• Joint trauma causes decreased Joint trauma causes decreased proteoglycans proteoglycans – If trauma persistent, damage If trauma persistent, damage

irreparableirreparable

• Inflammation characterized by Inflammation characterized by polymorphonuclear white cellspolymorphonuclear white cells– May be immunologic (rheumatoid, May be immunologic (rheumatoid,

reactive)reactive)

15

Joint vs. PeriarticularJoint vs. PeriarticularJoint vs. PeriarticularJoint vs. Periarticular

ArthritisArthritis

• Generalized Generalized pain, warmth, pain, warmth, swelling, swelling, tendernesstenderness

• Discomfort Discomfort with joint with joint motion motion

Periarticular Periarticular inflammation: inflammation: bursitis, tendinitis, bursitis, tendinitis, localized cellulitislocalized cellulitis

• Focal tenderness, Focal tenderness, swelling swelling notnot uniform uniform

• Pain only with Pain only with certain movementscertain movements

16

Monarticular vs. PolyarticularMonarticular vs. PolyarticularMonarticular vs. PolyarticularMonarticular vs. Polyarticular


If Polyarticular and…If Polyarticular and…If Polyarticular and…If Polyarticular and…

……symmetric symmetric rheumatoid, drug rheumatoid, drug inducedinduced

……asymmetric asymmetric rubella, acute rubella, acute rheumatic fever, gonococcalrheumatic fever, gonococcal

……migratory migratory gonococcal or rubella gonococcal or rubella

18

Location, Location, LocationLocation, Location, LocationLocation, Location, LocationLocation, Location, Location

• First MTP joint: goutFirst MTP joint: gout

• MCP and PIP joints: rheumatoidMCP and PIP joints: rheumatoid

• DIP and first carpometacarpal DIP and first carpometacarpal joint: osteoarthritis joint: osteoarthritis

• Knee: septic arthritis, pseudogout, Knee: septic arthritis, pseudogout, goutgout

19

Causes of Migratory ArthritisCauses of Migratory ArthritisCauses of Migratory ArthritisCauses of Migratory Arthritis

• Rheumatic feverRheumatic fever

• Subacute bacterial Subacute bacterial endocarditisendocarditis

• Henoch-Schönlein Henoch-Schönlein purpurapurpura

• Cefaclor (Ceclor®) Cefaclor (Ceclor®) hypersensitivity hypersensitivity (kids)(kids)

• Septicemia: Septicemia: staphylococcal, staphylococcal, streptococcal, streptococcal, meningococcal, meningococcal, gonococcalgonococcal

• Mycoplasma, Mycoplasma, histoplasmosis, histoplasmosis, coccidioidomycosiscoccidioidomycosis

• Lyme diseaseLyme disease

20

Arthritis with…Arthritis with…Arthritis with…Arthritis with…

……low-grade fever low-grade fever any any inflammatory arthritis inflammatory arthritis

……high fever, chills high fever, chills septic arthritis septic arthritis

……kidney stones kidney stones gout gout

……genital ulcers genital ulcers reactive arthritis reactive arthritis

……urethral discharge urethral discharge reactive reactive arthritis, gonococcusarthritis, gonococcus

21

Arthritis and…Arthritis and…Arthritis and…Arthritis and…

……isoniazid, procainamide, isoniazid, procainamide, hydralazine hydralazine lupus lupus

……thiazide diuretics thiazide diuretics gout gout (increase serum uric acid level)(increase serum uric acid level)– Chlorthalidone (Hygroton®)Chlorthalidone (Hygroton®)

– Hydrochlorothiazide (HydroDIURIL®, Hydrochlorothiazide (HydroDIURIL®, Esidrix®, Oretic®)Esidrix®, Oretic®)

– Indapamide (Lozol®)Indapamide (Lozol®)22

Some Scalp and Skin FindingsSome Scalp and Skin FindingsSome Scalp and Skin FindingsSome Scalp and Skin Findings

AlopeciaAlopecia SLE, psoriasisSLE, psoriasis ECMECM LymeLyme

Malar rashMalar rash SLE, dermato-SLE, dermato-myositismyositis

RashRash RubellaRubella

PustulesPustules GonococcemiaGonococcemia TophiTophi GoutGout

Elbows, Elbows, kneesknees

PsoriasisPsoriasis SubQ SubQ nodulesnodules

RARA

Tight skinTight skin SclerodermaScleroderma Hyper-Hyper-keratosiskeratosis

ReactiveReactive

23

Physical ExamPhysical ExamPhysical ExamPhysical Exam

Source Undetermined

24

Physical ExamPhysical ExamPhysical ExamPhysical Exam1.1. Warmth and effusion Warmth and effusion

2.2. Synovial thickening Synovial thickening

3.3. Deformity Deformity

4.4. Tenderness: generalized or Tenderness: generalized or localized, articular or periarticularlocalized, articular or periarticular

5.5. Limited range of motion Limited range of motion

6.6. Pain on movement Pain on movement

25

Lab StudiesLab StudiesLab StudiesLab Studies

• Limited diagnostic value Limited diagnostic value

• ““Screening testsScreening tests””– Bacterial: usually elevated WBC Bacterial: usually elevated WBC

– Chronic rheumatic: mild anemia Chronic rheumatic: mild anemia

– ESR/CRP ESR/CRP in most inflammatory in most inflammatory

• RF, ANA, ASO titers, Lyme RF, ANA, ASO titers, Lyme serologies: for follow-up serologies: for follow-up

• Uric acid: Uric acid: notnot helpfulhelpful in gout in gout26

X-ray Findings (Chronic)X-ray Findings (Chronic)X-ray Findings (Chronic)X-ray Findings (Chronic)

SSoft tissue swelling oft tissue swelling

EErosions rosions

CCalcification alcification

OOsteoporosis steoporosis

NNarrowed joint spacearrowed joint space

DDeformity eformity

SSeparation (fractures)eparation (fractures)

Source Undetermined

27

X-ray Findings (Septic)X-ray Findings (Septic)X-ray Findings (Septic)X-ray Findings (Septic)

Source Undetermined Source Undetermined

28

Hallmark X-ray FindingsHallmark X-ray FindingsHallmark X-ray FindingsHallmark X-ray Findings

Osteoarthritis = OsteophytesOsteoarthritis = OsteophytesOsteoarthritis = OsteophytesOsteoarthritis = Osteophytes

Source Undetermined

Source Undetermined

29


Erosions = Rheumatoid or GoutErosions = Rheumatoid or GoutErosions = Rheumatoid or GoutErosions = Rheumatoid or Gout

Source Undetermined Source Undetermined Source Undetermined 30


Chondrocalcinosis = PseudogoutChondrocalcinosis = PseudogoutChondrocalcinosis = PseudogoutChondrocalcinosis = Pseudogout



Enthesitis = Insertion Site Inflammation Enthesitis = Insertion Site Inflammation (HLA-B27) (HLA-B27)

Enthesitis = Insertion Site Inflammation Enthesitis = Insertion Site Inflammation (HLA-B27) (HLA-B27)


Other ImagingOther ImagingOther ImagingOther Imaging

• Ultrasound: joint effusions; Ultrasound: joint effusions; tendons and ligaments of shouldertendons and ligaments of shoulder

• CT scan: SI, sternoclavicular jointCT scan: SI, sternoclavicular joint

• MRI: knee cruciate ligaments MRI: knee cruciate ligaments

• Contrast MRI: differentiate Contrast MRI: differentiate synovitis from synovial fluid in synovitis from synovial fluid in rheumatoid diseaserheumatoid disease

33

Other ImagingOther ImagingOther ImagingOther Imaging

• 99m99mtechnetium methylene technetium methylene diphosphonate (99mTc MDP)diphosphonate (99mTc MDP)– Osteomyelitis, stress fracturesOsteomyelitis, stress fractures

• Gallium: gathers at proliferation of Gallium: gathers at proliferation of serum proteins and leukocytesserum proteins and leukocytes– InfectionInfection

34

ArthrocentesisArthrocentesisArthrocentesisArthrocentesis

35

http://www.accessemergencymedicine.com/video.aspx?file=1279787688001


• Critical diagnostic adjunct Critical diagnostic adjunct

• Can be painless, safe, and simple Can be painless, safe, and simple when performed correctlywhen performed correctly

• Diagnostic or therapeuticDiagnostic or therapeutic

Source Undetermined

36

Indications Indications Indications Indications • Obtain joint fluid for analysisObtain joint fluid for analysis

• Drain tense hemarthroses Drain tense hemarthroses

• Instill analgesics and anti-Instill analgesics and anti-inflammatory agentsinflammatory agents

• Prosthetic joints: only to rule out Prosthetic joints: only to rule out infectioninfection

37

ContraindicationsContraindicationsContraindicationsContraindications

• Absolute: infection of any kind Absolute: infection of any kind covers area to be punctured covers area to be punctured

• RelativeRelative– Bleeding diatheses, anticoagulant Bleeding diatheses, anticoagulant

therapytherapy

– BacteremiaBacteremia

38

ProcedureProcedureProcedureProcedure

• Cleanse skin with povidone-iodine, Cleanse skin with povidone-iodine, then air drythen air dry

• Remove povidone-iodine with Remove povidone-iodine with isopropyl alcoholisopropyl alcohol– Intra-articular povidone-iodine can Intra-articular povidone-iodine can

cause chemical irritation, inhibit cause chemical irritation, inhibit bacterial growth leading to spuriously bacterial growth leading to spuriously negative cultures in early septic jointnegative cultures in early septic joint

39


• Place sterile drapesPlace sterile drapes

• Inject local anesthetic into skinInject local anesthetic into skin– 25- to 30-gauge needle25- to 30-gauge needle

– Intraarticular anesthetic can inhibit Intraarticular anesthetic can inhibit bacterial growth, cause spuriously bacterial growth, cause spuriously negative culture in early septic jointnegative culture in early septic joint

40


• Aspirate large joints with large-Aspirate large joints with large-bore needle (18 or 19 gauge) bore needle (18 or 19 gauge) – Smaller joints: smaller-bore needle Smaller joints: smaller-bore needle

• Choose syringe size based on Choose syringe size based on anticipated fluid volumeanticipated fluid volume

• Remove as much fluid as possibleRemove as much fluid as possible– Optimizes diagnosis Optimizes diagnosis

– Relieves pain from distentionRelieves pain from distention41


• Fat globules: diagnostic of fractureFat globules: diagnostic of fracture

• Intraarticular morphine can provide Intraarticular morphine can provide relief for up to 24 hoursrelief for up to 24 hours– 1 to 5 mg diluted in normal saline 1 to 5 mg diluted in normal saline

solution to a total volume of 30 mlsolution to a total volume of 30 ml

42

Sternoclavicular JointSternoclavicular JointSternoclavicular JointSternoclavicular Joint

43

Gray's Anatomy (Wikipedia)

http://en.wikipedia.org/wiki/Sternoclavicular_articulation#mediaviewer/File:Gray325.png

Elbow – Lateral ApproachElbow – Lateral ApproachElbow – Lateral ApproachElbow – Lateral Approach

Flex elbow 90o

Prep skin

Insert needle in palpable bony

notch between lateral epicondyle

and olecranon

44

Knee – Lateral ApproachKnee – Lateral ApproachKnee – Lateral ApproachKnee – 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 ApproachKnee – Medial ApproachKnee – Medial ApproachKnee – Medial Approach

46Source Undetermined


47

Source Undetermined


48

Source Undetermined


49

Source Undetermined


50

Source Undetermined

Knee – Medial vs. LateralKnee – Medial vs. LateralKnee – Medial vs. LateralKnee – Medial vs. Lateral

• Follow Follow ““SuttonSutton’’s Laws Law””

• William William ““Slick WillieSlick Willie”” Sutton (1901 Sutton (1901 – 1980): professional bank robber– 1980): professional bank robber

51

AnkleAnkleAnkleAnklePalpate 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

AnkleAnkleAnkleAnklePalpate 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 AnalysisSynovial Fluid AnalysisSynovial Fluid AnalysisSynovial Fluid Analysis

54

Source Undetermined


• Identify crystals, pus Identify crystals, pus

• Analyze color, clarity, cell count, Analyze color, clarity, cell count, differential, Gramdifferential, Gram’’s stain, crystalss stain, crystals

• Positive GramPositive Gram’’s stain: diagnostic s stain: diagnostic for septic arthritisfor septic arthritis

• Negative GramNegative Gram’’s stain: does not s stain: does not rule out septic arthritisrule out septic arthritis

55

Synovial Fluid Cell CountSynovial Fluid Cell CountSynovial Fluid Cell CountSynovial Fluid Cell Count

• Noninflammatory vs. inflammatoryNoninflammatory vs. inflammatory

• ED wet mount prepED wet mount prep– 1 to 2 WBCs per high-power field 1 to 2 WBCs per high-power field

consistent with noninflammatoryconsistent with noninflammatory

– >20 WBC/HPF suggests >20 WBC/HPF suggests inflammation or infectioninflammation or infection

• Septic: >50,000 WBC/mmSeptic: >50,000 WBC/mm33 (also (also rheumatoid, gout, pseudogout)rheumatoid, gout, pseudogout)

56

NormalNormalNon-Non-

inflammatoryinflammatory InflammatoryInflammatory InfectiousInfectious

Trans-Trans-parentparent TransparentTransparent CloudyCloudy Cloudy Cloudy

ClearClear YellowYellow YellowYellow Yellow Yellow

<200<200 <2000<2000 200 – 50,000200 – 50,000 >50,000>50,000

<25%<25% <25%<25% >50%>50% >50%>50%

NegativeNegative NegativeNegative NegativeNegative Positive Positive

Appear-Appear-anceance

ClarityClarity

WBCsWBCs

PMNsPMNs

CultureCulture


57

Other Synovial Fluid AnalysisOther Synovial Fluid AnalysisOther Synovial Fluid AnalysisOther Synovial Fluid Analysis

• Glucose, lactic acid, viscosity, Glucose, lactic acid, viscosity, mucin clot, and total protein: mucin clot, and total protein: limited utility, not recommendedlimited utility, not recommended

• Appropriate container Appropriate container – Cellular analysis: lavender Cellular analysis: lavender

(ethylenediaminetetraacetic acid)(ethylenediaminetetraacetic acid)

– Crystal analysis: green (heparin)Crystal analysis: green (heparin)

– Chemical analysis, serology: redChemical analysis, serology: red58

Crystal StudiesCrystal StudiesCrystal StudiesCrystal Studies

• Monosodium urateMonosodium urate: needle : needle shaped, birefringent negative shaped, birefringent negative – Parallel to compensator: yellowParallel to compensator: yellow

– Perpendicular: bluePerpendicular: blue

• Calcium pyrophosphateCalcium pyrophosphate: : polymorphic, birefringent positive polymorphic, birefringent positive – Parallel to compensator: blueParallel to compensator: blue

– Perpendicular: yellowPerpendicular: yellow59


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


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 Specific ArthritidesArthritides

There are more than 90There are more than 90

Specific Specific ArthritidesArthritides

There are more than 90There are more than 90

Preiser’s disease: avascular necrosis of scaphoid

6262

Source Undetermined

Septic ArthritisSeptic ArthritisSeptic ArthritisSeptic Arthritis

• Hematogenous spreadHematogenous spread

• Direct inoculationDirect inoculation

• Direct spread from bony or soft Direct spread from bony or soft tissue infections tissue infections

63

Septic ArthritisSeptic ArthritisSeptic ArthritisSeptic Arthritis

• Synovium infected before Synovium infected before degrading enzymes releaseddegrading enzymes released

• Children: hematogenous most Children: hematogenous most commoncommon

• Postoperative infection: ~10% of Postoperative infection: ~10% of joint surgeriesjoint surgeries

64

CausesCausesCausesCauses

• Staphylococcus aureusStaphylococcus aureus: most : most common (even in sickle cell)common (even in sickle cell)

• Others: streptococcus, Gram Others: streptococcus, Gram negatives, anaerobesnegatives, anaerobes

• N. gonorrhoeaeN. gonorrhoeae: 20% monarticular: 20% monarticular

• <6 months: <6 months: E. coliE. coli, group B strep , group B strep

• IV drug users: IV drug users: S. aureus,S. aureus, Gram Gram negativesnegatives

65

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

• Based on hostBased on host’’s concurrent s concurrent medical conditionsmedical conditions

• Painful, hot, swollenPainful, hot, swollen

• Typical: single jointTypical: single joint– Knee: 40% to 50%Knee: 40% to 50%

– Hip: 13% to 20%Hip: 13% to 20%

– Shoulder: 10% to 15%Shoulder: 10% to 15%

• 20% polyarticular20% polyarticular66

Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

• History of fever: 80%History of fever: 80%

• Shaking chills: 20% Shaking chills: 20%

• Elevated sedimentation rate more Elevated sedimentation rate more common than leukocytosis common than leukocytosis

• Blood cultures grow causative Blood cultures grow causative organism ~50% of the timeorganism ~50% of the time

• Radiographs not often usefulRadiographs not often useful

67

ManagementManagementManagementManagement

• Admit for joint drainage, IV Admit for joint drainage, IV antibiotics antibiotics

• Empiric therapy based on GramEmpiric therapy based on Gram’’s s stainstain

• Parenteral narcotic analgesics, Parenteral narcotic analgesics, articular immobilization control articular immobilization control pain and discomfortpain and discomfort

68

Gouty ArthritisGouty ArthritisGouty ArthritisGouty Arthritis

69


• Pod = foot; agra = trap, huntPod = foot; agra = trap, hunt

• Podagra: foot goddess, a bad-Podagra: foot goddess, a bad-tempered virgin, who attacked tempered virgin, who attacked victims after they overindulgedvictims after they overindulged

• Father was Dionysus (Bacchus), Father was Dionysus (Bacchus), god of winegod of wine

• Mother was Aphrodite (Venus), Mother was Aphrodite (Venus), goddess of lovegoddess of love

70


• Thought to be limited to men who Thought to be limited to men who had indulged in dietary or sexual had indulged in dietary or sexual excessexcess

71


• Galen (129-199 AD), an Galen (129-199 AD), an ex-gladiatorial surgeon in ex-gladiatorial surgeon in Rome, described gout as Rome, described gout as a discharge of the four a discharge of the four humors of the body in humors of the body in unbalanced amounts into unbalanced amounts into the joints (hence gout = the joints (hence gout = gutta, a drop)gutta, a drop)

72

Pierre Roche Vigneron (Wikimedia Commons)

http://commons.wikimedia.org/wiki/File:Galen_detail.jpg

Be temperate in Be temperate in wine, in eating, wine, in eating, girls and sloth girls and sloth

Or the gout will Or the gout will seize you and seize you and

plague you bothplague you both73

Benjamin Franklin:


• Uric acid crystal deposits from Uric acid crystal deposits from supersaturated extracellular fluid supersaturated extracellular fluid

• Risk factors: obesity, hypertension, Risk factors: obesity, hypertension, diabetes, alcohol, proximal loop diabetes, alcohol, proximal loop diuretics, lead poisoningdiuretics, lead poisoning

• During attack: crystals ingested by During attack: crystals ingested by PMNs PMNs inflammation inflammation

74


• Middle-aged men, post-Middle-aged men, post-menopausal women menopausal women

• Increased uric acid usually present Increased uric acid usually present for 20 years before first attack for 20 years before first attack

• Uric acid often normalUric acid often normal

75

PresentationPresentationPresentationPresentation

• Great toe MTP joint in 75%Great toe MTP joint in 75%– Also tarsal, ankle, knee, wristAlso tarsal, ankle, knee, wrist

– Up to 40% polyarticularUp to 40% polyarticular

• Pain excruciating at onset Pain excruciating at onset – Can mimic septic jointCan mimic septic joint

– Usually self-limitedUsually self-limited

• Systemic symptoms usually Systemic symptoms usually minimal or absentminimal or absent

76


• Subsequent attacks closer Subsequent attacks closer together, more joints, last longertogether, more joints, last longer

• Long-term: kidney stonesLong-term: kidney stones



• Tophi: foreign body granulomas Tophi: foreign body granulomas with crystals as nidus, in musculo-with crystals as nidus, in musculo-tendinous unit – olecranon bursa, tendinous unit – olecranon bursa, Achilles tendon, hands, knees, etc.Achilles tendon, hands, knees, etc.

78


DiagnosisDiagnosisDiagnosisDiagnosis

• Rule out cellulitis, septic arthritis Rule out cellulitis, septic arthritis particularly if knee joint particularly if knee joint

• All may have fever, leukocytosis, All may have fever, leukocytosis, elevated ESRelevated ESR

• Uric acid level not helpful Uric acid level not helpful

• X-rays: soft-tissue swelling (acute) X-rays: soft-tissue swelling (acute) or joint destruction (chronic)or joint destruction (chronic)

79

Uric Acid LevelsUric Acid LevelsUric Acid LevelsUric Acid Levels

• Uric acid normal in ~40%Uric acid normal in ~40%

• Tophi can form in cool body areas Tophi can form in cool body areas without hyperuricemiawithout hyperuricemia

• Acute attack Acute attack pain pain increased increased cortisol cortisol uric acid diuresis uric acid diuresis normalized levelnormalized level

80


81



• Definitive diagnosis: Definitive diagnosis: birefringent joint fluid birefringent joint fluid crystals with polarizing crystals with polarizing microscope (a yellow microscope (a yellow crystal against a red crystal against a red background) and background) and negative joint fluid negative joint fluid cultureculture


Acute Therapy – Colchicine Acute Therapy – Colchicine Acute Therapy – Colchicine Acute Therapy – Colchicine

• Not diagnostic: works on Not diagnostic: works on pseudogoutpseudogout

• Contraindication: hematologic, Contraindication: hematologic, renal, hepatic dysfunctionrenal, hepatic dysfunction

• Extravasation from IV Extravasation from IV tissue tissue necrosisnecrosis

83

Acute Therapy – Colchicine Acute Therapy – Colchicine Acute Therapy – Colchicine Acute Therapy – Colchicine

• Inhibits microtubule formationInhibits microtubule formation

• Most effective in first 24 hours Most effective in first 24 hours

• 0.6 mg / hour until pain controlled, 0.6 mg / hour until pain controlled, max 6 mg or side effects (GI) max 6 mg or side effects (GI)

• Average toxic dose: 6.7 mgAverage toxic dose: 6.7 mg

• Toxicity precedes improvement in Toxicity precedes improvement in more than 50%more than 50%

84

Acute Therapy – OtherAcute Therapy – OtherAcute Therapy – OtherAcute Therapy – Other

• NSAIDs effective, indomethacin NSAIDs effective, indomethacin most common (75 to 200 mg/day) most common (75 to 200 mg/day) – Contraindicated in PUD, GI bleedContraindicated in PUD, GI bleed

• If resistant: prednisone taper If resistant: prednisone taper – 40 mg/day first 3 to 5 days40 mg/day first 3 to 5 days

• Adrenocorticotrophic hormone Adrenocorticotrophic hormone – ACTH 40 IU to 80 IU IMACTH 40 IU to 80 IU IM

85

PseudogoutPseudogoutPseudogoutPseudogout

• Calcium pyrophosphate dihydrate Calcium pyrophosphate dihydrate (CPPD) crystal-deposition disease (CPPD) crystal-deposition disease

• Knee: most common joint Knee: most common joint

• Polyarticular possiblePolyarticular possible

• Pain less severe, patients olderPain less severe, patients older

• Risk: hypothyroid, WilsonRisk: hypothyroid, Wilson’’s s disease, hyperparathyroid, disease, hyperparathyroid, hemochromatosis, etc.hemochromatosis, etc.

86


• Common: elevated ESR, WBCCommon: elevated ESR, WBC

• X-ray may show joint calcification X-ray may show joint calcification

• Joint fluidJoint fluid– Weakly positive birefringent crystals Weakly positive birefringent crystals

on polarized microscopyon polarized microscopy

– Appear rhomboidal on regular light Appear rhomboidal on regular light microscopymicroscopy

• Treatment: same as goutTreatment: same as gout87

ChondrocalcinosisChondrocalcinosisChondrocalcinosisChondrocalcinosis


OsteoarthritisOsteoarthritisOsteoarthritisOsteoarthritis

• Degenerative joint diseaseDegenerative joint disease

• Most common form of arthritis Most common form of arthritis

• Loss of articular cartilage, reactive Loss of articular cartilage, reactive changes at joint margins changes at joint margins

• Synovitis in advanced disease Synovitis in advanced disease

• May have painful bone-to-bone May have painful bone-to-bone interfaceinterface

89

Presentation / DiagnosisPresentation / DiagnosisPresentation / DiagnosisPresentation / Diagnosis

• Chief complaint: painChief complaint: pain

• No systemic symptoms No systemic symptoms

• Hands: BouchardHands: Bouchard’’s, Heberdens, Heberden’’s s nodes (osteophyte spurs) nodes (osteophyte spurs)

• Knee: active & passive crepitusKnee: active & passive crepitus

• Routine lab tests: normalRoutine lab tests: normal

• Radiographs: joint- space Radiographs: joint- space narrowing, osteophyte formationnarrowing, osteophyte formation

90

HeberdenHeberden’’s and Bouchards and Bouchard’’ssHeberdenHeberden’’s and Bouchards and Bouchard’’ss

Over DIP Over PIP

91

Source Undetermined

92

Source Undetermined

TreatmentTreatmentTreatmentTreatment

• Judicious exercise for muscle Judicious exercise for muscle strengtheningstrengthening

• Relieve muscle spasmRelieve muscle spasm

• Support joint Support joint

• Acetaminophen comparable to Acetaminophen comparable to ibuprofen for short-term treatment ibuprofen for short-term treatment

• Ultimately joint replacementUltimately joint replacement

93

Gonococcal ArthritisGonococcal ArthritisGonococcal ArthritisGonococcal Arthritis

• Woman : men :: 4:1 Woman : men :: 4:1

• Fever, chills, arthralgias, migratory Fever, chills, arthralgias, migratory tenosynovitistenosynovitis

• Progresses to arthritis: knee, Progresses to arthritis: knee, ankle, wristankle, wrist

• Characteristic rash: countable Characteristic rash: countable hemorrhagic necrotic pustules hemorrhagic necrotic pustules

• Rarely have cervicitis or urethritisRarely have cervicitis or urethritis94



Source Undetermined


96

Source Undetermined

Source Undetermined


• Blood cultures usually negative Blood cultures usually negative

• Synovial fluid cultures positive in Synovial fluid cultures positive in less than 50%less than 50%

• GramGram’’s stain positive more often s stain positive more often than culturethan culture

• Cervical, urethral, pharyngeal, Cervical, urethral, pharyngeal, rectal cultures positive ~75% rectal cultures positive ~75%

97


• Admit to hospital Admit to hospital

• Ceftriaxone 1 g IM or IV daily, and Ceftriaxone 1 g IM or IV daily, and 24 to 48 hours after improvement24 to 48 hours after improvement

• Ciprofloxacin 500 mg twice daily Ciprofloxacin 500 mg twice daily orally for total 7 days of antibioticsorally for total 7 days of antibiotics

• Spectinomycin 2 grams IM every Spectinomycin 2 grams IM every 12 hours if beta-lactam allergic12 hours if beta-lactam allergic

98

Viral ArthritisViral ArthritisViral ArthritisViral Arthritis

• Most common: rubella, hepatitis B Most common: rubella, hepatitis B

• Also mumps, adenoviruses, Also mumps, adenoviruses, Epstein-Barr virus, enterovirusesEpstein-Barr virus, enteroviruses

• Deposition of soluble immune Deposition of soluble immune complexes in synovium with complexes in synovium with resultant inflammationresultant inflammation

99

Rubella ArthritisRubella ArthritisRubella ArthritisRubella Arthritis

• Often young womenOften young women

• Rash several days beforeRash several days before

• Acute, symmetric, usually Acute, symmetric, usually polyarticularpolyarticular

• Resolves within weeks Resolves within weeks

• Recent infection or vaccination Recent infection or vaccination

• Virus isolated from synovial fluidVirus isolated from synovial fluid

100

RubellaRubellaRubellaRubella


Source Undetermined

Hepatitis B ArthritisHepatitis B ArthritisHepatitis B ArthritisHepatitis B Arthritis

• Usually with or after prodrome of Usually with or after prodrome of fever and lymphadenopathyfever and lymphadenopathy

• Often precedes jaundiceOften precedes jaundice

• May be sudden and severeMay be sudden and severe

• PIP, knee, ankle, MP joints most PIP, knee, ankle, MP joints most commonly involvedcommonly involved

• Salicylates may be helpfulSalicylates may be helpful

102

LymeLymeLymeLyme

• Spirochete: Spirochete: Borrelia burgdorferiBorrelia burgdorferi

• Vector: Vector: Ixodes damminiIxodes dammini on East on East Coast and MidwestCoast and Midwest

• Arthritis Arthritis latelate manifestation manifestation

• Within 6 months, half of untreated Within 6 months, half of untreated have frank arthritishave frank arthritis– AsymmetricAsymmetric

– Most common in kneesMost common in knees103


• Minimal joint pain, usually afebrileMinimal joint pain, usually afebrile

• Severity of initial presentation Severity of initial presentation predictive of subsequent arthritispredictive of subsequent arthritis

• Chronic arthritis more common in Chronic arthritis more common in patients positive for HLA-DR4patients positive for HLA-DR4

• Joint fluid inflammatory with PMN Joint fluid inflammatory with PMN predominancepredominance

• Diagnosis is clinicalDiagnosis is clinical104

IxodesIxodesIxodesIxodes

106Centers for Disease Control and Prevention (Wikimedia Commons)

http://commons.wikimedia.org/wiki/Lyme_disease#mediaviewer/File:Ixodes_ricinus_ticks.jpg

SpondyloarthropathiesSpondyloarthropathiesSpondyloarthropathiesSpondyloarthropathies

• Seronegative: negative rheumatoid Seronegative: negative rheumatoid factorfactor

• Sacroiliac involvementSacroiliac involvement

• Peripheral joint inflammationPeripheral joint inflammation

• Changes of ligamentous and Changes of ligamentous and tendinous insertion into bonetendinous insertion into bone

• Genetic: HLA-B27Genetic: HLA-B27

107

SpondyloarthropathiesSpondyloarthropathiesSpondyloarthropathiesSpondyloarthropathies

• Ankylosing spondylitisAnkylosing spondylitis

• Reactive arthritis (e.g. ReiterReactive arthritis (e.g. Reiter’’s s syndrome)syndrome)

• Psoriatic arthritisPsoriatic arthritis

• Arthropathy of inflammatory bowel Arthropathy of inflammatory bowel diseasedisease

108

Ankylosing SpondylitisAnkylosing SpondylitisAnkylosing SpondylitisAnkylosing Spondylitis

• Male predominanceMale predominance

• Back painBack pain

• X-ray evidence of sacroiliitisX-ray evidence of sacroiliitis

• Symmetrically squared vertebral Symmetrically squared vertebral bodies, then bodies, then ““bamboo spinebamboo spine””

• Morning stiffness, improves with Morning stiffness, improves with exerciseexercise

109


110

Source Undetermined

Source UndeterminedSource Undetermined


• Uveitis: most common extra-Uveitis: most common extra-articular manifestationarticular manifestation

• Peripheral joints involved in ~30% Peripheral joints involved in ~30% of patients with enthesopathic of patients with enthesopathic involvement (plantar fasciitis and involvement (plantar fasciitis and Achilles tendinitis)Achilles tendinitis)

• Goal of therapy: control pain, Goal of therapy: control pain, decrease inflammationdecrease inflammation

111

Reactive ArthritisReactive ArthritisReactive ArthritisReactive Arthritis

• AKA arthritis urethritica, venereal AKA arthritis urethritica, venereal arthritis, polyarteritis entericaarthritis, polyarteritis enterica

• Described by German military Described by German military physician Hans Reiter in 1916 physician Hans Reiter in 1916

• ““Reiter's syndromeReiter's syndrome”” being phased being phased out, partly due to Reiter's typhoid out, partly due to Reiter's typhoid experiments in Nazi concentration experiments in Nazi concentration campscamps

112


• Occurs in genetically susceptible Occurs in genetically susceptible host after infection with GU host after infection with GU C. C. trachomatistrachomatis, or GI shigella, , or GI shigella, salmonella, yersinia, campylobactersalmonella, yersinia, campylobacter

• Disease of men 15 to 35 years old; Disease of men 15 to 35 years old; arthritis develops 2 to 6 weeks after arthritis develops 2 to 6 weeks after episode of urethritis or dysenteryepisode of urethritis or dysentery

113


• Polyarticular, asymmetricPolyarticular, asymmetric

• Weight-bearing joints of lower Weight-bearing joints of lower extremities commonly involved: extremities commonly involved: knees, ankles, feet, particularly knees, ankles, feet, particularly heels (heels (““loverlover’’s heels heel””) )

114


• Other signs appear earlyOther signs appear early

• Conjunctivitis, progress to iritis, Conjunctivitis, progress to iritis, uveitis, corneal ulcerationuveitis, corneal ulceration

• Painless ulcers mouth, tongue, Painless ulcers mouth, tongue, glans penis (balanitis circinata) glans penis (balanitis circinata)

• Sausage-like fingers and toes Sausage-like fingers and toes

• Keratoderma blennorrhagica on Keratoderma blennorrhagica on palms and solespalms and soles

115


Keratoderma blenorrhagica

Balanitis circinata116

Source Undetermined

Source Undetermined


• Synovial fluid: inflammatory with Synovial fluid: inflammatory with predominance of PMNspredominance of PMNs

• Antigens in synovial membrane Antigens in synovial membrane and joint fluid, cultures sterileand joint fluid, cultures sterile

• Increased ESR, WBC Increased ESR, WBC

• HLA-B27 antigen in ~80% HLA-B27 antigen in ~80%

• Enthesopathic x-rays, particularly Enthesopathic x-rays, particularly at IP joint of great toeat IP joint of great toe

117


• NSAID two or three times daily NSAID two or three times daily

• Doxycycline twice daily x 3 monthsDoxycycline twice daily x 3 months

• Intra-articular steroid injectionsIntra-articular steroid injections

• If persistent: SulfasalazineIf persistent: Sulfasalazine

• Chronic therapy for erosive, Chronic therapy for erosive, deforming disease deforming disease – MethotrexateMethotrexate

– Azathioprine (Imuran)Azathioprine (Imuran)118

What Happened to ReiterWhat Happened to Reiter’’s?s?What Happened to ReiterWhat Happened to Reiter’’s?s?

119


• Hans Julius Reiter (1881 – 1969)Hans Julius Reiter (1881 – 1969)

• German military physician on German military physician on Western Front in 1Western Front in 1stst Hungarian Hungarian ArmyArmy

• 1916: described German 1916: described German Lieutenant with non-gonococcal Lieutenant with non-gonococcal urethritis, arthritis and uveitisurethritis, arthritis and uveitis

120


• Not the first, but he got creditNot the first, but he got credit

• Member of the SS during WWIIMember of the SS during WWII

• Designed typhus inoculation Designed typhus inoculation experiments that killed more than experiments that killed more than 250 prisoners at Buchenwald250 prisoners at Buchenwald

• Convicted as war criminalConvicted as war criminal

121

Psoriatic ArthritisPsoriatic ArthritisPsoriatic ArthritisPsoriatic Arthritis

122

Source Undetermined

Source Undetermined

Source Undetermined

RheumatismRheumatismRheumatismRheumatism

• An older term used to describe any An older term used to describe any of a number of painful conditions of a number of painful conditions of muscles, tendons, joints, and of muscles, tendons, joints, and bones.bones.

• Rheumatism weed: Canadian dogbane

123

SB Johnny (Wikipedia)

http://en.wikipedia.org/wiki/Apocynum_cannabinum#mediaviewer/File:Apocynum_cannabinum_6801.JPG

Acute Rheumatic FeverAcute Rheumatic FeverAcute Rheumatic FeverAcute Rheumatic Fever

• Believed to result from Group A Believed to result from Group A streptococcus pharyngitisstreptococcus pharyngitis

• Exact mechanism unclearExact mechanism unclear

• In decline since antibioticsIn decline since antibiotics

• Probable abnormal humoral Probable abnormal humoral response to antigensresponse to antigens

124

Clinical SyndromeClinical SyndromeClinical SyndromeClinical Syndrome

• Recurring self-limited episodes of Recurring self-limited episodes of fever associated with polyarthritis, fever associated with polyarthritis, carditis / valvulitis, rash, carditis / valvulitis, rash, subcutaneous nodules, or chorea subcutaneous nodules, or chorea

• Occurs 2 to 3 weeks after Occurs 2 to 3 weeks after streptococcal pharyngitisstreptococcal pharyngitis

125

Diagnosis – Jones CriteriaDiagnosis – Jones CriteriaDiagnosis – Jones CriteriaDiagnosis – Jones Criteria

• Two major, or one major and two Two major, or one major and two minor, criteria with evidence recent minor, criteria with evidence recent Group A streptococcal infectionGroup A streptococcal infection

• Major manifestations: polyarthritis, Major manifestations: polyarthritis, carditis, chorea, erythema carditis, chorea, erythema marginatum, subcutaneous marginatum, subcutaneous nodulesnodules

• Migratory arthritis in large jointsMigratory arthritis in large joints126


• Involves heart in ~50%Involves heart in ~50%

• Pericarditis, congestive heart Pericarditis, congestive heart failure, valvular dysfunction, failure, valvular dysfunction, cardiomegaly cardiomegaly

• Neurologic: SydenhamNeurologic: Sydenham’’s chorea, s chorea, weakness, behavioral disturbanceweakness, behavioral disturbance

• Sparing of sensory functionsSparing of sensory functions

127


Sinus tachycardia

Right atrial enlargement

Left atrial enlargement Left ventricular strain

RBBB pattern

1st degree AV block

128

Source Undetermined


• Erythema marginatum: well-Erythema marginatum: well-demarcated, pink nonpruritic rash, demarcated, pink nonpruritic rash, usually trunk, sometimes proximal usually trunk, sometimes proximal limbs limbs – Central clearing, may last hoursCentral clearing, may last hours


Erythema MarginatumErythema MarginatumErythema MarginatumErythema Marginatum



• Subcutaneous nodules: firm, Subcutaneous nodules: firm, nontender under skin overlying nontender under skin overlying bony prominencesbony prominences

131

Source Undetermined

Laboratory Work-UpLaboratory Work-UpLaboratory Work-UpLaboratory Work-Up

• Throat culture, ESR, CRP, ASOThroat culture, ESR, CRP, ASO

• Anti-DNase B 95% sensitiveAnti-DNase B 95% sensitive

• Streptozyme test also documents Streptozyme test also documents recent streptococcal infectionrecent streptococcal infection

• Synovial fluidSynovial fluid– Inflammatory (average WBC 16K)Inflammatory (average WBC 16K)

– Negative cultureNegative culture

132

Post-StreptococcalPost-StreptococcalPost-StreptococcalPost-Streptococcal

• Reactive arthritis: closely related to Reactive arthritis: closely related to ARF but distinct clinical entity ARF but distinct clinical entity

• Sterile oligoarthritis associated Sterile oligoarthritis associated with distant bacterial infectionwith distant bacterial infection

• Carditis rare, arthritis often severeCarditis rare, arthritis often severe

• Treatment: penicillin, erythromycinTreatment: penicillin, erythromycin

• Arthritis responds to salicylatesArthritis responds to salicylates

133

Rheumatoid ArthritisRheumatoid ArthritisRheumatoid ArthritisRheumatoid Arthritis

134

Source Undetermined

Rheumatoid ArthritisRheumatoid ArthritisRheumatoid ArthritisRheumatoid Arthritis

• Usually chronic: >20% acuteUsually chronic: >20% acute

• Women 2 to 3 x more than menWomen 2 to 3 x more than men

• Immune complexes stimulate Immune complexes stimulate PMNs to release enzymes PMNs to release enzymes

• Synovial cells proliferate, produce Synovial cells proliferate, produce more inflammatory substancesmore inflammatory substances

135


• Prodrome: fatigue, weakness, Prodrome: fatigue, weakness, musculoskeletal pain musculoskeletal pain

• Symmetric joint swelling: hands Symmetric joint swelling: hands (MP, PIP joints), wrists, elbows(MP, PIP joints), wrists, elbows

• Difficult to distinguish from viral Difficult to distinguish from viral arthropathyarthropathy

136


• Long-term Long-term changes: MP and changes: MP and PIP swelling, ulnar PIP swelling, ulnar deviation, swan-deviation, swan-neck and neck and boutonnière boutonnière deformities of deformities of hands, limited hands, limited wrist dorsiflexionwrist dorsiflexion

137

Source Undetermined

Swan Neck DeformitySwan Neck DeformitySwan Neck DeformitySwan Neck Deformity

138Source Undetermined Source Undetermined


• Knee: effusion, muscle atrophy, Knee: effusion, muscle atrophy, BakerBaker’’s cysts cyst

• Retrocalcaneal bursaRetrocalcaneal bursa

• Subcutaneous nodules, pulmonary Subcutaneous nodules, pulmonary fibrosis, mononeuritis multiplexfibrosis, mononeuritis multiplex

• SjögrenSjögren’’s and Feltys and Felty’’s syndromess syndromes

139

BakerBaker’’s Cysts CystBakerBaker’’s Cysts Cyst


Subcutaneous NodulesSubcutaneous NodulesSubcutaneous NodulesSubcutaneous Nodules

141

Source Undetermined

FeltyFelty’’s Syndromes SyndromeFeltyFelty’’s Syndromes Syndrome

• Rheumatoid arthritis Rheumatoid arthritis + splenomegaly + + splenomegaly + leukopenialeukopenia

• Frequent pneumonia Frequent pneumonia and leg ulcersand leg ulcers

• 1% of RA patients1% of RA patients

142

Source Undetermined

Transverse Ligament RuptureTransverse Ligament RuptureTransverse Ligament RuptureTransverse Ligament Rupture

• C1 on C2 subluxation in 70% C1 on C2 subluxation in 70% – Frank dislocation in 25%Frank dislocation in 25%

– Cord compression in 11% Cord compression in 11%

• With myelopathy:With myelopathy:

– 5 years survival 80% 5 years survival 80%

– 10 year survival 28%10 year survival 28%

• Anterior instability more common Anterior instability more common than posterior instabilitythan posterior instability

143

Transverse Ligament RuptureTransverse Ligament RuptureTransverse Ligament RuptureTransverse Ligament Rupture

144Source Undetermined Source Undetermined


• Movement increases inflammation: Movement increases inflammation: initial treatment restinitial treatment rest

• Suppress inflammation: steroids, Suppress inflammation: steroids, salicylates, gold, penicillamine, salicylates, gold, penicillamine, azathioprine, methotrexate, azathioprine, methotrexate, cyclosporine, sulfasalazinecyclosporine, sulfasalazine

145

Nontraditional ThinkingNontraditional ThinkingNontraditional ThinkingNontraditional Thinking

• The Mycoplasma Theory: joint The Mycoplasma Theory: joint pain caused by subclinical pain caused by subclinical mycoplasma infection, improves mycoplasma infection, improves with doxycyclinewith doxycycline

• Glucosamine and chondroitin: Glucosamine and chondroitin: possibly useful in osteoarthritispossibly useful in osteoarthritis

146

Known Not to WorkKnown Not to WorkKnown Not to WorkKnown Not to WorkALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO ALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET - ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET - ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA - POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA - CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY - ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY - CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON - CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON - COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS - SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM - - SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM - DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE) DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE) - SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION DIETS - SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION DIETS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET - TEAS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET - TEAS (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE - GARLIC - (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE - GARLIC - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH - FASTING - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH - FASTING - GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL - WOOD SPIDER GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL - WOOD SPIDER - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN MACROBIOTICS - - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP HYDROGEN PEROXIDE - ZINC - KELP

147

PearlsPearlsPearlsPearls

• The number and distribution of The number and distribution of joints involved helps pinpoint the joints involved helps pinpoint the most likely cause of arthritis. most likely cause of arthritis.

• Monarthritis is septic arthritis until Monarthritis is septic arthritis until proven otherwise. proven otherwise.

• Negative GramNegative Gram’’s stain of synovial s stain of synovial fluid does not rule out bacterial fluid does not rule out bacterial arthritis. arthritis.

148

PearlsPearlsPearlsPearls

• The most definitive test for The most definitive test for evaluating an inflamed joint for the evaluating an inflamed joint for the possibility of bacterial infection is possibility of bacterial infection is examination of synovial fluid. examination of synovial fluid.

• Delays in the diagnosis and Delays in the diagnosis and treatment of septic arthritis worsen treatment of septic arthritis worsen outcomes.outcomes.

149

project: ghana emergency medicine collaborative document title: arthritis and arthrocentesis...

Documents

use of content

content open

medical content

fair use determination

copyright holders of

copyright law

party content

copyright protection