Monoarticular arthritis: Difference between revisions

No edit summary
(Add verified PubMed references (PMIDs 22670394, 33971340))
 
(25 intermediate revisions by 6 users not shown)
Line 1: Line 1:
==Septic Arthritis==
==Background==
===Gonococcal Arthritis===
*Monoarticular arthritis (monoarthritis) refers to inflammation of a single joint<ref>Genes N, Chisolm-Straker M. Monoarticular arthritis update: Current evidence for diagnosis and treatment in the emergency department. Emerg Med Pract. 2012 May;14(5):1-19; quiz 19-20. PMID 22670394</ref>
Healthy, young sexually active adults
*The critical EM question is: Is this septic arthritis?
*Septic arthritis is a joint emergency requiring urgent drainage — delay increases risk of joint destruction
*Other common causes include crystal arthropathy ([[gout]], [[pseudogout]]) and traumatic hemarthrosis<ref>Keret S, et al. Approach to a patient with monoarticular disease. Autoimmun Rev. 2021 Jul;20(7):102848. PMID 33971340</ref>
*[[Arthrocentesis]] is the key diagnostic procedure and should be performed on any hot, swollen joint without clear alternative diagnosis


Women > men
==Clinical Features==
===History===
Suppurative monoarthritis (may be preceded by polyarthralgias)
*Onset (acute vs. subacute), joint involved, trauma history
*Prior episodes (recurrent suggests crystal disease)
*Fever, chills, constitutional symptoms
*Recent infection, skin break, surgery, or injection
*Sexual history (disseminated gonococcal infection)
*History of gout, pseudogout, or autoimmune disease
*Immunosuppression, IV drug use, prosthetic joint


Knee, wrist, ankle
===Physical Exam===
*Joint warmth, erythema, effusion, decreased range of motion
*Pain with passive range of motion (highly suggestive of intra-articular process)
*Overlying skin: cellulitis, track marks, surgical scars, tophi
*Assess for signs of systemic infection
*Examine other joints (polyarticular process may present initially as monoarticular)


===Arthritis-Dermatitis Syndrome===
===Red Flags for Septic Arthritis===
-Triad: dermatitis, tenosynovitis, migratory polyarthritis (hematogenous spread of bacteria and immune complexes)
*Fever with acute monoarthritis
*Recent bacteremia, skin infection, or surgical procedure
*Prosthetic joint with new pain/swelling
*Immunosuppressed patient
*IV drug use
*Non-weight-bearing or unable to flex joint


-Skin lesions: scattered small painless erythematous macules or petechiae-->pustular -->necrotic lesions
==Differential Diagnosis==
{{Differential Diagnosis Monoarthritis}}


-Transient painful extensor tenosynovitis (writs, hands, ankles)
===[[Septic Arthritis]]===
*[[Gonococcal arthritis]]
*Nongonococcal Arthritis
*Arthritis-Dermatitis Syndrome


-Asymmtric polyarthralgia of extremity joints
===Crystal-Induced Monoarthritis===
*[[Gout]]
*[[Pseudogout]]


DiagnosisCx everything - jt, mucosal surfaces, lesions
===Traumatic===
*[[Fracture]]
*Ligamentous injury
*Overuse


TreatmentCTX 1gIV qd OR
===Ischemic===
*[[Avascular necrosis]]
*[[Decompression sickness]]
*Spontaneous osteonecrosis
**Pain in absence of trauma
**Femoral head, medial condyle of knee


Cefotax 1g q8
===Hemorrhagic===
*Posttraumatic
*[[Hemophilia]]
*Systemic [[anticoagulation]]


Empirically treat Chlamydia
===Neoplastic===
*Metastases
*Osteochondroma
*Osteoid osteoma
*Pigmented villonodular synovitis


===Nongonococcal Arthritis===
===Systemic Disease===
Fulminant presentation (abrupt, swelling, toxicity and fever) unless elderly
*Remote infection, infectious [[endocarditis]]
*[[Rheumatic fever]]
*Seronegative (no RF) spondyloarthropathies ([[ankylosing spondylitis]], [[IBD]], [[psoriatic arthritis|psoriatic]], [[reactive arthritis]])
*[[Rheumatoid arthritis]], [[SLE]]


-Hematogenous
===Periarticular (Non-Articular)===
*[[Bursitis]]
*[[Tendinitis]]
*[[Cellulitis]]


-Contiguous
==Evaluation==
===Arthrocentesis (Key Diagnostic Study)===
*Perform [[arthrocentesis]] on any acute hot, swollen joint unless clear alternative diagnosis
*'''Do not delay arthrocentesis for imaging'''
*Overlying cellulitis is a relative contraindication — consult orthopedics


-Direct traumatic implantation
===Synovial Fluid Analysis===
{{Arthrocentesis diagnostic chart}}
*WBC >50,000/mm³ with >90% PMNs: highly suggestive of septic arthritis
*Crystals: negatively birefringent (gout), positively birefringent (pseudogout)
*Note: crystals and infection can coexist — always send culture even if crystals present
*Gram stain: positive in ~50% of non-gonococcal septic arthritis
*Culture: gold standard; also send blood cultures


-Postop
===Laboratory===
*[[CBC]] with differential, [[ESR]], [[CRP]]
*Blood cultures (positive in ~50% of septic arthritis)
*[[Uric acid]] (may be normal during acute gout flare)
*GC/CT NAAT if disseminated gonococcal infection suspected


CausesBacterial
===Imaging===
*X-ray of affected joint: chondrocalcinosis (pseudogout), fracture, joint destruction
*Ultrasound: confirm effusion, guide arthrocentesis
*MRI if osteomyelitis or periarticular abscess suspected


Mycobacterial
==Management==
===Septic Arthritis===
*Emergent orthopedic consultation for surgical drainage/washout
*Empiric IV antibiotics after arthrocentesis:
**[[Vancomycin]] (MRSA coverage) for most patients
**Add gram-negative coverage ([[ceftriaxone]] or [[cefepime]]) for immunocompromised, elderly, or IV drug users
**[[Ceftriaxone]] alone if gonococcal arthritis suspected
*Prosthetic joint infection: orthopedic consultation for operative management


Spirochete (lyme, syphilis)
===Crystal Arthropathy===
*[[Gout]]: NSAIDs ([[indomethacin]], [[naproxen]]), [[colchicine]], or [[corticosteroids]] (PO or intra-articular)
*[[Pseudogout]]: NSAIDs, [[colchicine]], or intra-articular/systemic corticosteroids
*Avoid [[allopurinol]] initiation or changes during acute flare


Fungal
===Traumatic===
*Splinting, pain management
*Orthopedic follow-up for hemarthrosis or fracture


VIral (HIV, Hep B, Rubella, etc)
==Disposition==
===Admit===
*Septic arthritis (for surgical drainage and IV antibiotics)
*Prosthetic joint infection
*Sepsis from joint source
*Unable to rule out septic arthritis with pending cultures in high-risk patient


Postinfectious
===Discharge===
 
*Crystal arthropathy with adequate pain control
DiagnosisSynovial fluid aspiration
*Traumatic arthritis/hemarthrosis with orthopedic follow-up arranged
 
*Provide return precautions: fever, worsening pain/swelling, inability to bear weight
Cx - if only one test, use BCx bottles (may enhance yield)
*Primary care or rheumatology follow-up for gout/pseudogout management
 
Grm stain - 80% positive in gram-positive infxn; less sens in gram-negative
 
Cell count with dif - >50,000-150,000; PMN > 90%
 
TreatmentPCN-ase resistant synthetic PCN:
 
Nafcillin 1-2g
 
Cefazolin 1-2g
 
AND
 
3rd gen ceph
 
OR
 
Vanc*
 
*new evidence suggests significantly increased rate of MRSA septic arthritis
 
**cell counts are as low as 20,000 in MRSA Cx + synovial fluid
 
==Crystal-Induced Monoarthritis==
#[[Gout]]
#[[Pseudogout]]
 
==Traumatic==
#Fracture
#ligamentous
#Overuse
 
==Ischemic==
#Avascular necrosis
#Decompression illness
#Spontaneous osteonecrosis
#pain in abscence of trauma
#femoral head, medial conyle of knee
 
==Hemorrhagic==
#Posttraumatic
##Joint aspiration if tense
##RICE
#Hemophilia
#Systemic anticoagulation
 
==Neoplastic==
#Mets
#Osteochondroma
#Osteoid osteoma
#Pigmented villonodular synovitis
 
==Systemic Disease==
#Remote infxn, infectious endocarditis
#Rheumatic fever
#Seronegative (no RF) spondyloarthropathies (AS, IBS, psoriatic, reactive or Reiter's)
#Rheumatoid arthritis, SLE
#Sarcoidosis, amyloidosis
 
==Periarticular==
these conditions mimic joint involvement...
#Cellulitis
#Tendonitis
#Bursitis
 
==Pediatric==
#Acute Transient Synovitis
##Children 3-10yo
##1-3 wks after viral illness
##Self-limited
#[[Slipped Capital Femoral Epiphysis (SCFE)]]  (portly pubescent)
#[[Legg Calve Perthes Disease]] (young school-age children)


==See Also==
==See Also==
[[Pseudogout]]
*[[Septic arthritis]]
 
*[[Gout]]
[[Gout]]
*[[Pseudogout]]
 
*[[Arthrocentesis]]
[[Septic Arthritis (Hip)]]
*[[Gonococcal arthritis]]


[[Septic Arthritis (General)]]
==External Links==


==Source==
==References==
H-N   
<references/>


[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:Rheum]]
[[Category:Symptoms]]
[[Category:Rheumatology]]

Latest revision as of 10:49, 22 March 2026

Background

  • Monoarticular arthritis (monoarthritis) refers to inflammation of a single joint[1]
  • The critical EM question is: Is this septic arthritis?
  • Septic arthritis is a joint emergency requiring urgent drainage — delay increases risk of joint destruction
  • Other common causes include crystal arthropathy (gout, pseudogout) and traumatic hemarthrosis[2]
  • Arthrocentesis is the key diagnostic procedure and should be performed on any hot, swollen joint without clear alternative diagnosis

Clinical Features

History

  • Onset (acute vs. subacute), joint involved, trauma history
  • Prior episodes (recurrent suggests crystal disease)
  • Fever, chills, constitutional symptoms
  • Recent infection, skin break, surgery, or injection
  • Sexual history (disseminated gonococcal infection)
  • History of gout, pseudogout, or autoimmune disease
  • Immunosuppression, IV drug use, prosthetic joint

Physical Exam

  • Joint warmth, erythema, effusion, decreased range of motion
  • Pain with passive range of motion (highly suggestive of intra-articular process)
  • Overlying skin: cellulitis, track marks, surgical scars, tophi
  • Assess for signs of systemic infection
  • Examine other joints (polyarticular process may present initially as monoarticular)

Red Flags for Septic Arthritis

  • Fever with acute monoarthritis
  • Recent bacteremia, skin infection, or surgical procedure
  • Prosthetic joint with new pain/swelling
  • Immunosuppressed patient
  • IV drug use
  • Non-weight-bearing or unable to flex joint

Differential Diagnosis

Monoarticular arthritis

Algorithm for Monoarticular arthralgia

Septic Arthritis

Crystal-Induced Monoarthritis

Traumatic

Ischemic

Hemorrhagic

Neoplastic

  • Metastases
  • Osteochondroma
  • Osteoid osteoma
  • Pigmented villonodular synovitis

Systemic Disease

Periarticular (Non-Articular)

Evaluation

Arthrocentesis (Key Diagnostic Study)

  • Perform arthrocentesis on any acute hot, swollen joint unless clear alternative diagnosis
  • Do not delay arthrocentesis for imaging
  • Overlying cellulitis is a relative contraindication — consult orthopedics

Synovial Fluid Analysis

Arthrocentesis of synoval fluid

Synovium Normal Noninflammatory Inflammatory Septic
Clarity Transparent Transparent Cloudy Cloudy
Color Clear Yellow Yellow Yellow
WBC <200 <200-2000 200-50,000

>1,100 (prosthetic joint)

>25,000; LR=2.9

>50,000; LR=7.7

>100,000; LR=28

PMN <25% <25% >50%

>64% (prosthetic joint)

>90%

Culture Neg Neg Neg >50% positive
Lactate <5.6 mmol/L <5.6 mmol/L <5.6 mmol/L >5.6 mmol/L
LDH <250 <250 <250 >250
Crystals None None Multiple or none None
  • Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
  • The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000[3]
  • WBC >50,000/mm³ with >90% PMNs: highly suggestive of septic arthritis
  • Crystals: negatively birefringent (gout), positively birefringent (pseudogout)
  • Note: crystals and infection can coexist — always send culture even if crystals present
  • Gram stain: positive in ~50% of non-gonococcal septic arthritis
  • Culture: gold standard; also send blood cultures

Laboratory

  • CBC with differential, ESR, CRP
  • Blood cultures (positive in ~50% of septic arthritis)
  • Uric acid (may be normal during acute gout flare)
  • GC/CT NAAT if disseminated gonococcal infection suspected

Imaging

  • X-ray of affected joint: chondrocalcinosis (pseudogout), fracture, joint destruction
  • Ultrasound: confirm effusion, guide arthrocentesis
  • MRI if osteomyelitis or periarticular abscess suspected

Management

Septic Arthritis

  • Emergent orthopedic consultation for surgical drainage/washout
  • Empiric IV antibiotics after arthrocentesis:
  • Prosthetic joint infection: orthopedic consultation for operative management

Crystal Arthropathy

Traumatic

  • Splinting, pain management
  • Orthopedic follow-up for hemarthrosis or fracture

Disposition

Admit

  • Septic arthritis (for surgical drainage and IV antibiotics)
  • Prosthetic joint infection
  • Sepsis from joint source
  • Unable to rule out septic arthritis with pending cultures in high-risk patient

Discharge

  • Crystal arthropathy with adequate pain control
  • Traumatic arthritis/hemarthrosis with orthopedic follow-up arranged
  • Provide return precautions: fever, worsening pain/swelling, inability to bear weight
  • Primary care or rheumatology follow-up for gout/pseudogout management

See Also

External Links

References

  1. ↑ Genes N, Chisolm-Straker M. Monoarticular arthritis update: Current evidence for diagnosis and treatment in the emergency department. Emerg Med Pract. 2012 May;14(5):1-19; quiz 19-20. PMID 22670394
  2. ↑ Keret S, et al. Approach to a patient with monoarticular disease. Autoimmun Rev. 2021 Jul;20(7):102848. PMID 33971340
  3. ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.
Retrieved from "https://www.wikem.org/w/index.php?title=Monoarticular_arthritis&oldid=389706"