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2286007845425Septic Arthritis00Septic Arthritis15576557845425Epidemiology: mortality up to 15%; less common than gout / pseudogout; 85% monoarticular; hips more common in children (20% in adults); knees more common in adults (50%); shoulder 10%; SI joint 10%; 15% pauciarticular; source found in 50% (eg. Skin, UTI, RS); irreversible joint damage in ?Risk factors: presence 2-3x ? risk; >80yrs, rheumatoid arthritis, diabetes, recent joint OT, cellulitis over prosthesis, hip/knee prosthesis, immunosuppression, ETOH, IVDU, haemophilia, cancer, haemodialysis; 15x ? risk if infection over jointCause: Neonate: staph aureus, grp B strep, G-ives, gonorrhoea, H influenzae, candida Infant: staph aureus, strep, G-ive H influenzae, pneumococcus Child (>36/12): staph aureus, strep, G-ives, gonorrhoea, Adult: staph aureus (50%; 80% if diabetes or rheumatoid arthritis), grp A strep (40%), G-ives (esp IVDU), gonorrhoea, H influenzae, Grp B and G strep TB and fungal cause subacute septic arthritisAssessment: more gradual onset than gout; systemic symptoms in 20%; may be recent trauma; joint pain and swelling in >80%; fever in 60%; effusion in 80%; marked limitations of movement; may be less obvious in elderly / immunocompromised00Epidemiology: mortality up to 15%; less common than gout / pseudogout; 85% monoarticular; hips more common in children (20% in adults); knees more common in adults (50%); shoulder 10%; SI joint 10%; 15% pauciarticular; source found in 50% (eg. Skin, UTI, RS); irreversible joint damage in ?Risk factors: presence 2-3x ? risk; >80yrs, rheumatoid arthritis, diabetes, recent joint OT, cellulitis over prosthesis, hip/knee prosthesis, immunosuppression, ETOH, IVDU, haemophilia, cancer, haemodialysis; 15x ? risk if infection over jointCause: Neonate: staph aureus, grp B strep, G-ives, gonorrhoea, H influenzae, candida Infant: staph aureus, strep, G-ive H influenzae, pneumococcus Child (>36/12): staph aureus, strep, G-ives, gonorrhoea, Adult: staph aureus (50%; 80% if diabetes or rheumatoid arthritis), grp A strep (40%), G-ives (esp IVDU), gonorrhoea, H influenzae, Grp B and G strep TB and fungal cause subacute septic arthritisAssessment: more gradual onset than gout; systemic symptoms in 20%; may be recent trauma; joint pain and swelling in >80%; fever in 60%; effusion in 80%; marked limitations of movement; may be less obvious in elderly / immunocompromised2286005189220Joint Pain00Joint Pain15582905189220Mono-arthritis: trauma; gout / pseudogout; septic; osteoarthritis: TB; viral (reactive); Lyme disease; avascular necrosis; rheumatoid arthritisOligoarthritis: Lyme, Reiter’s, ankylosing spondylosis, rheumatic feverPolyarticular: infective: endocarditis, yersinia, typhus, viral (parvovirus, rubella, Hep B, hep C, Ross River virus) Autoimmune: rheumatoid arthritis, psoriasis, Reiter’s, ankylosis spondylosis, SLE, rheumatic fever, amyloid, sarcoid, serum sickness, IBD, osteoarthritis, dermatomyositis, polymyalgia rheumatica Other: acromegaly, haemochromatosisMigratory: gonorrhoea, rheumatic fever, Lyme disease, viral, SLEOnset <6/52: gonorrhoea, viral, reactive, rheumatic feverOnset >6/52: rheumatoid arthritis, psoriasis, SLE, scleroderma, dermatomyositisInflammatory: rheumatoid arthritis; inflamm osteoarthritis; CT disease (eg. SLE, vasculitis); seronegative arthritis (eg. Psoriasis); gout; pseudogout; drug induced; post-infectious (eg. RF); infectiousNon-inflammatory: neoplastic/paraneoplastic (eg. Hyperplastic pul osteoarthropathy); sarcoidosis; endocrine (eg. Haemochromatosis, acromegaly); haem (eg. Haemophilia, leukaemia)00Mono-arthritis: trauma; gout / pseudogout; septic; osteoarthritis: TB; viral (reactive); Lyme disease; avascular necrosis; rheumatoid arthritisOligoarthritis: Lyme, Reiter’s, ankylosing spondylosis, rheumatic feverPolyarticular: infective: endocarditis, yersinia, typhus, viral (parvovirus, rubella, Hep B, hep C, Ross River virus) Autoimmune: rheumatoid arthritis, psoriasis, Reiter’s, ankylosis spondylosis, SLE, rheumatic fever, amyloid, sarcoid, serum sickness, IBD, osteoarthritis, dermatomyositis, polymyalgia rheumatica Other: acromegaly, haemochromatosisMigratory: gonorrhoea, rheumatic fever, Lyme disease, viral, SLEOnset <6/52: gonorrhoea, viral, reactive, rheumatic feverOnset >6/52: rheumatoid arthritis, psoriasis, SLE, scleroderma, dermatomyositisInflammatory: rheumatoid arthritis; inflamm osteoarthritis; CT disease (eg. SLE, vasculitis); seronegative arthritis (eg. Psoriasis); gout; pseudogout; drug induced; post-infectious (eg. RF); infectiousNon-inflammatory: neoplastic/paraneoplastic (eg. Hyperplastic pul osteoarthropathy); sarcoidosis; endocrine (eg. Haemochromatosis, acromegaly); haem (eg. Haemophilia, leukaemia)2286001142365Joint Aspirate00Joint Aspirate15582904662170Infected00Infected61264804663440>85-90%00>85-90%26924004669155Opaque00Opaque42849804669790>25,000-50,000>10,000 in paediatrics00>25,000-50,000>10,000 in paediatrics61264803960495>50%00>50%428498039668452000-50,000002000-50,00026924003966845Turbid00Turbid42849804309745Intermediate00Intermediate15309851142365Use 18-21G needleKnee: flex 30°, medial approach 1cm inf to femoral condyleShoulder: inferior and laterla to coracoid process, directs posteromedially to glenoidWrist: distal to radial border on ulnar side of ECRL and ECRBAnkle: antlat, just medial to TA tendonElbow: lateral, just distal to head of radiusBacteria grows on culture in >50%; surface Ag of H influenzae and S pneumoniae; intracellular crystals strongly suggests gout/pseudogoutUrate crystals = needle shaped, strong negative birefringenceCa pyrophosphate crystals = rod shaped / rhomboid, weak positive birefringenceComplications: infection rate 1:10,000; damage to articular cartilage00Use 18-21G needleKnee: flex 30°, medial approach 1cm inf to femoral condyleShoulder: inferior and laterla to coracoid process, directs posteromedially to glenoidWrist: distal to radial border on ulnar side of ECRL and ECRBAnkle: antlat, just medial to TA tendonElbow: lateral, just distal to head of radiusBacteria grows on culture in >50%; surface Ag of H influenzae and S pneumoniae; intracellular crystals strongly suggests gout/pseudogoutUrate crystals = needle shaped, strong negative birefringenceCa pyrophosphate crystals = rod shaped / rhomboid, weak positive birefringenceComplications: infection rate 1:10,000; damage to articular cartilage42837103619500<20000<20042837103248660WCC00WCC26911303619500Clear / straw00Clear / straw26911303248660Appearance00Appearance61252103613150<25%00<25%61252103248660% PMN00% PMN15582904309745Partially Treated00Partially Treated15582903966845Inflammatory00Inflammatory15582903619500Normal00Normal246380539750Red Joint00Red Joint 00 2413008688070Haemarthrosis00Haemarthrosis15754358688705Causes: trauma (fracture / ligament); bleeding diathesis; anticoagulation; neuropathic joint; acute pseudogout; AVM; haemangiomaInvestigation: XR +/- CT to exclude fracture; FBC and coag; if fat globules floating in aspirate, suggests fractureManagement: RICE; aspiration may help symptoms; immediate clotting factor replacement to 40-50% normal00Causes: trauma (fracture / ligament); bleeding diathesis; anticoagulation; neuropathic joint; acute pseudogout; AVM; haemangiomaInvestigation: XR +/- CT to exclude fracture; FBC and coag; if fat globules floating in aspirate, suggests fractureManagement: RICE; aspiration may help symptoms; immediate clotting factor replacement to 40-50% normal2413007200265Pseudogout00Pseudogout15754357201534Epidemiology: M=F; usually >60yrs (old age is strongest risk factor); knee in 50%; polyarticular in 5%; also wrist, shoulder, elbow, anklePathophysiology: release of calcium pyrophosphate crysals into joint from calcified cartilage following minor trauma, surgery or illness depositied in cartilage synovitisInvestigations: bloods: serum calcium ? in 5%; ? ESR in 5%; IgM RF +ive in 10%; urate normal XR: shows fracture chondrocalcinosis (calcification of intra-articular cartilage) and degenerative changes Mng: supportive, NSAIDs, colchicine00Epidemiology: M=F; usually >60yrs (old age is strongest risk factor); knee in 50%; polyarticular in 5%; also wrist, shoulder, elbow, anklePathophysiology: release of calcium pyrophosphate crysals into joint from calcified cartilage following minor trauma, surgery or illness depositied in cartilage synovitisInvestigations: bloods: serum calcium ? in 5%; ? ESR in 5%; IgM RF +ive in 10%; urate normal XR: shows fracture chondrocalcinosis (calcification of intra-articular cartilage) and degenerative changes Mng: supportive, NSAIDs, colchicine2413003392805Gout00Gout15754353392805Epidemiology: most common inflammatory arthritis in developed countries; M>F; 95% >30yrs; females usually post-menopausal; familial tendency in 50%; monoarticular in 90%; legs in 85% (75% big toe), also subtalar and anklePathophysiology: 90% ? renal urate excretions (eg. hypovolaemia, acidosis, diuretics, cyclosporin, aspirin, renal transplant, heavy ETOH use, tacrolimus, levodopa, hyperparathyroidism, sudden cessation allopurinol) 10% ? urate production (eg. Liver, beer, shellfish, cancer, post-chemo, psoriasis); more likely at low temp and dehydrationAssessment: onset of pain over hours, often at night; max at 6-12hrs; may be precipitated by minor trauma; may be febrile; gouty tophi on dorsum of toes, fingers, olecranon bursa, helix of earInvestigation: bloods: urate >0.42mmol/L (in 80% acute gout; in 5% general population; urate <0.45 in untreated patient almost excludes gout); ?WCC but no toxic changes on blood film; may be ? ESR XR: periarticular punched out erosions if previous attacks Joint aspirate: urate crystals and negative birefringence on joint aspirate USS: tophaceous material and erosions, deposition of crystals on cartilageManagement: colchicine 0.5mg/hr PO until improvement of symptoms / diarrhoea / reach 6mg; then 0.5mg TDS NSAIDS – avoid aspirin during acute attack Steroids: prednisone 10mg BD for 3-5/7 then taper; use if can’t take colchicine / NSAIDs; intra-articular steroid can also be usedChronic management: allopurinol (don’t use in acute attack; but continue if already on it)Refer if: urate >0.600Epidemiology: most common inflammatory arthritis in developed countries; M>F; 95% >30yrs; females usually post-menopausal; familial tendency in 50%; monoarticular in 90%; legs in 85% (75% big toe), also subtalar and anklePathophysiology: 90% ? renal urate excretions (eg. hypovolaemia, acidosis, diuretics, cyclosporin, aspirin, renal transplant, heavy ETOH use, tacrolimus, levodopa, hyperparathyroidism, sudden cessation allopurinol) 10% ? urate production (eg. Liver, beer, shellfish, cancer, post-chemo, psoriasis); more likely at low temp and dehydrationAssessment: onset of pain over hours, often at night; max at 6-12hrs; may be precipitated by minor trauma; may be febrile; gouty tophi on dorsum of toes, fingers, olecranon bursa, helix of earInvestigation: bloods: urate >0.42mmol/L (in 80% acute gout; in 5% general population; urate <0.45 in untreated patient almost excludes gout); ?WCC but no toxic changes on blood film; may be ? ESR XR: periarticular punched out erosions if previous attacks Joint aspirate: urate crystals and negative birefringence on joint aspirate USS: tophaceous material and erosions, deposition of crystals on cartilageManagement: colchicine 0.5mg/hr PO until improvement of symptoms / diarrhoea / reach 6mg; then 0.5mg TDS NSAIDS – avoid aspirin during acute attack Steroids: prednisone 10mg BD for 3-5/7 then taper; use if can’t take colchicine / NSAIDs; intra-articular steroid can also be usedChronic management: allopurinol (don’t use in acute attack; but continue if already on it)Refer if: urate >0.62413001971675Prosthetic Joint Infection00Prosthetic Joint Infection15754351971675Cause: coag-neg staph (35%), staph aureus (20%), mixed flora (10%), strep (10%), gram neg bacilli (5%), enterococci (5%), anaerobes (3%), no micro-organism found (10%)Classification: early: <3/12 after OT; micro-organism usually present at time of OT Delayed: 3-24/12 after OT; more subtle presentation Late: >24/12 after OT; due to haematogenous spreadInvestigations: bloods not sensitive enough to detect; aspirate – WCC >1700 or >65% neuts = 95% sensitivity, 90% specificity; gram stain 25% sensitivity, 95% specificity; XR not sensitive or specificManagement: long term antibiotics; ?surgical revision00Cause: coag-neg staph (35%), staph aureus (20%), mixed flora (10%), strep (10%), gram neg bacilli (5%), enterococci (5%), anaerobes (3%), no micro-organism found (10%)Classification: early: <3/12 after OT; micro-organism usually present at time of OT Delayed: 3-24/12 after OT; more subtle presentation Late: >24/12 after OT; due to haematogenous spreadInvestigations: bloods not sensitive enough to detect; aspirate – WCC >1700 or >65% neuts = 95% sensitivity, 90% specificity; gram stain 25% sensitivity, 95% specificity; XR not sensitive or specificManagement: long term antibiotics; ?surgical revision241300508635Septic Arthritis (cntd)00Septic Arthritis (cntd)1575435508636Investigation: bloods: WBC and CRP ? in all causes of arthritis; WBC >11 in 50%; ESR higher in septic arthritis (>30 in 90%); blood culture +ive; if >1/52 duration XR: may show narrowing of joint space and subchondral OP (more common in subacute) Joint aspirate: >50,000 WBC (65% sensitivity, >90% specificity); >25,000 WBC (75% sensitivity and specificity); >90% PMN (75% sensitivity, 80% specificity); low Viscosity; less WBC on subacuteManagement: 2g IV flucloxacillin QID + 1.2g IV penicillin QID (cephalothin 2g QID if penicillin allergy) + gentamicin if <6yrs or IVDU; may need joint washout00Investigation: bloods: WBC and CRP ? in all causes of arthritis; WBC >11 in 50%; ESR higher in septic arthritis (>30 in 90%); blood culture +ive; if >1/52 duration XR: may show narrowing of joint space and subchondral OP (more common in subacute) Joint aspirate: >50,000 WBC (65% sensitivity, >90% specificity); >25,000 WBC (75% sensitivity and specificity); >90% PMN (75% sensitivity, 80% specificity); low Viscosity; less WBC on subacuteManagement: 2g IV flucloxacillin QID + 1.2g IV penicillin QID (cephalothin 2g QID if penicillin allergy) + gentamicin if <6yrs or IVDU; may need joint washout ................
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