Monoarticular arthritis: Difference between revisions

m (Rossdonaldson1 moved page Monoarticular Arthritis to Monoarticular arthritis)
(Add verified PubMed references (PMIDs 22670394, 33971340))
 
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==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>
*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
 
==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==
{{Differential Diagnosis Monoarthritis}}
 
===[[Septic Arthritis]]===
*[[Gonococcal arthritis]]
*Nongonococcal Arthritis
*Nongonococcal Arthritis
*Arthritis-Dermatitis Syndrome
*Arthritis-Dermatitis Syndrome


See [[Septic Arthritis (General)]]
===Crystal-Induced Monoarthritis===
 
==Crystal-Induced Monoarthritis==
*[[Gout]]
*[[Gout]]
*[[Pseudogout]]
*[[Pseudogout]]


==Traumatic==
===Traumatic===
*Fracture
*[[Fracture]]
*ligamentous
*Ligamentous injury
*Overuse
*Overuse


==Ischemic==
===Ischemic===
*Avascular necrosis
*[[Avascular necrosis]]
*Decompression illness
*[[Decompression sickness]]
*Spontaneous osteonecrosis
*Spontaneous osteonecrosis
*pain in abscence of trauma
**Pain in absence of trauma
*femoral head, medial conyle of knee
**Femoral head, medial condyle of knee


==Hemorrhagic==
===Hemorrhagic===
*Posttraumatic
*Posttraumatic
**Joint aspiration if tense
*[[Hemophilia]]
**RICE
*Systemic [[anticoagulation]]
*Hemophilia
*Systemic anticoagulation


==Neoplastic==
===Neoplastic===
*Mets
*Metastases
*Osteochondroma
*Osteochondroma
*Osteoid osteoma
*Osteoid osteoma
*Pigmented villonodular synovitis
*Pigmented villonodular synovitis


==Systemic Disease==
===Systemic Disease===
*Remote infxn, infectious endocarditis
*Remote infection, infectious [[endocarditis]]
*Rheumatic fever
*[[Rheumatic fever]]
*Seronegative (no RF) spondyloarthropathies (AS, IBS, psoriatic, reactive or Reiter's)
*Seronegative (no RF) spondyloarthropathies ([[ankylosing spondylitis]], [[IBD]], [[psoriatic arthritis|psoriatic]], [[reactive arthritis]])
*Rheumatoid arthritis, SLE
*[[Rheumatoid arthritis]], [[SLE]]
*Sarcoidosis, amyloidosis
 
===Periarticular (Non-Articular)===
*[[Bursitis]]
*[[Tendinitis]]
*[[Cellulitis]]
 
==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


==Periarticular (mimic joint involvement)==
===Synovial Fluid Analysis===
*Cellulitis
{{Arthrocentesis diagnostic chart}}
*Tendonitis
*WBC >50,000/mm³ with >90% PMNs: highly suggestive of septic arthritis
*Bursitis
*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


==Pediatric==
===Laboratory===
*[[Transient (Toxic) Synovitis (Hip)]]  
*[[CBC]] with differential, [[ESR]], [[CRP]]
**Children 3-10yo
*Blood cultures (positive in ~50% of septic arthritis)
**1-3 wks after viral illness
*[[Uric acid]] (may be normal during acute gout flare)
*[[Slipped Capital Femoral Epiphysis (SCFE)]]
*GC/CT NAAT if disseminated gonococcal infection suspected
**portly pubescent
 
*[[Legg Calve Perthes Disease]]  
===Imaging===
**young school-age children
*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:
**[[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
 
===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
 
===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==
==See Also==
*[[Septic arthritis]]
*[[Gout]]
*[[Pseudogout]]
*[[Pseudogout]]
*[[Gout]]
*[[Arthrocentesis]]
*[[Septic Arthritis (Hip)]]
*[[Gonococcal arthritis]]
*[[Septic Arthritis (General)]]
 
*[[Arthritis]]
==External Links==


==References==
==References==
<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.
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