OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• rheumatology
• back pain in the ED
• the swollen joint and its diagnostic workup
• assessment of joint function and arthritis severity
• extra-articular clinical features of rheumatologic conditions

• the patient with joint pain needs to be carefully evaluated to determine the most likely cause
• is it a single joint involvement or multiple joints, and if so, what is the pattern of joint involvement?
• are there extra-articular clinical features that may provide a clue?

• septic arthritis - usually single joint, particularly if follows a penetrating injury, but may involve more joints if haematological spread such as salmonella or gonococcal.
  • haematological spread is more likely in children under 12 months or in adults
  • haematological spread of bacteraemia to bone in children older than 12 months tends to affect distal metaphyses of bones of the lower limb as an osteomyelitis rather than joints, but untreated, may spread into the adjacent joint to form a secondary septic arthritis.
• hip pain such as paediatric “irritable hip” or viral synovitis
• post-traumatic
• any of the causes of polyarthritis outlined below, especially gout, pseudogout and seronegative arthritis such as reactive arthritis
• haemoarthrosis (+/- trauma)
• crystal deposition due to triamcinolone injection
• consider also pathologies located near the joint as a cause of the pain such as:
  • bursitis
  • sciatica / lumbar disc prolapse
  • “over-use” chondritides of adolescents and the older child such as Perthe's disease, Sever's disease, Kohler's disease, Scheuermann's disease of the spine.
  • reflex sympathetic dystrophy (RSD) / complex regional pain syndrome / causalgia
  • referred pain - eg. shoulder pain due to cardiac or diaphragmatic pain

• rheumatoid arthritis:
  • difficulty doing up buttons, etc
  • may improve with nocturnal NSAID supps
• ankylosing spondylitis:
  • mid-low back pain/stiffness radiating to buttocks/thighs
  • usually males 20-40yr old but does affect women too
  • improved with exercise, NSAIDs
• polymyalgia rheumatica:
  • difficulty getting out of bed
  • marked diurnal variation
  • Dx criteria:
    • age > 50; ESR > 50mm/h;
    • bilat. shoulder/pelvic girdle morning stiffness:
      • > 1h duration AND > 1 month clinical course
    • response to low dose steroids (eg. 15mg/d prednisolone)
    • minor criteria: LOW, night sweats, fever, symmetric tender prox. muscles, raised AP/GGT, low HB, normal CK/EMG/muscle Bx
    • 50% will have temporal arteritis incl. 10-20% of those with no symptoms of temporal arteritis
• osteoarthritis:
  • short duration of stiffness (< 15min)
  • pain may be worsened by prolonged use
• myxoedema

• systemic lupus erythematosus (SLE)
  • a negative ANA ie. less than 1:180 titre will rule this out
• rheumatic fever:
  • non-infectious immune disease caused by group A b-haemolytic streptococcus
  • esp. 5-20yr olds
  • acute migratory or additive symmetric oligoarthritis esp. knees, ankles, elbows, wrists
  • most have fevers > 38degC & other features - carditis, erythema marginatum, chorea, etc.
• SBE
• serum sickness eg. 1-2wks post cefaclor Rx
• parainfectious:
  • hep B:
    • usually precedes onset of jaundice & seems to be related to level of Abs
    • esp. PIP, knee, ankle & MP
  • gonorrhoea:
    • F:M = 4:1
    • esp. knee, ankle, wrist assoc. with fever, chills, migratory tenosynovitis & in 2/3rds a characteristic rash consisting of haemorrhagic necrotic pustules esp. on sides of fingers
  • rubella (esp. young women)
  • Lyme disease:
    • 50-60% untreated pts by 6mths ⇒ large knee effusions with minimal pain
  • Reiter's syndrome
• Henoch Schonlein purpura

• aetiology:
  • tabes dorsalis (knees)
  • syringomyelia (shoulder, elbow)
  • diabetes (foot)
  • leprosy
  • overzealous administration of intraarticular steroids

• primary familial osteoarthritis
• psoriatic arthritis
• others if extensive:
  • JCA, RhA
  • gout, sarcoidosis, haemochromatosis, multicentric reticulohistiocytosis

• ankylosing spondylitis
• opiate and opioid dependence
• Tietze's syndrome

• Dx:
  • lat.flexion view Cx spine ⇒ odontoid peg displaced > 2.5mm on atlas
• pathogenesis:
  • odontoid erosion
  • transverse ligt destruction
• aetiology:
  • rheumatoid arthritis, JCA, ankylosing spondylitis, trisomy 21

• see sacroiliitis
• ankylosing spondylitis
• other seronegative spondyloarthopathies:
  • psoriatic
  • Reiter's
  • JCA
  • IBD
• infection - septic / TB / brucellosis
• recurrent polyserositis (familial Mediterranean fever)
• ochronosis (alkaptonuria)
• consider also osteoporotic sacral insufficiency fracture (SIF)

• see also osteoarthritis
• F:M = 3:1 after 60yrs age
• men predominate prior to 60yrs
• hands (esp. if genetic risk eg. collagen gene 2A mutation or obesity):
  • DIPs (Heberden's nodes)
  • PIPs (Bouchard's nodes)
  • 1st carpoMC jt (resulting in Z deformity)
• knees (esp. if trauma, obesity)
• hips (esp. if abnormal joint shape)
• 1st MTP jt (may be asymptomatic)
• lumbosacral spine (apophyseal)

• see gout
• M:F = 8:1
• 1st MTP (75% at onset ⇒ 90% eventually)
• ankles, tarsal bones
• knees, elbow incl. olecranon bursa
• much less commonly: DIPs & PIPs
• NB. tophi esp. at DIPs, PIPs, elbows, ears, heels

• esp. 6th-8th decades
• monoarticular or pseudoRhA or gout-like pictures
• esp. knee then wrist, ankle & elbow
• XR may show calcification in joints, tendon insertions, ligts & bursae
• aspirate ⇒ calcium pyrophosphate crystals
• aetiology:
  • most are idiopathic
  • hyperPTH, haemochromatosis, hypothyroidism, hypoMg, hypophosphataemia, Wilson's disease

• F:M = 3:1; esp. 4th-6th decades; 20% have an acute presentation; inflammation increased by movement!
• esp. if HLA-DR4; Rh factor +ve in 70%;
• MCPs, PIPs, wrists
  • ⇒ ulnar deviation - subluxation of ext. tendons at MCP jts
  • ⇒ swan-neck - PIP hyperextension & compensatory DIP flexion due to IO contractures &/or shortening of extensor tendons
  • ⇒ boutonniere deformities - PIP fixed flexion contracture with DIP hyperextension due to division of extensor hood with volar slipping of ext. tendon from middle phalanx
  • ⇒ limited dorsiflexion wrist
  • ⇒ z-deformity thumb - MCP flexion & IP hyperextension due to:
    • prolapse of MC head b/n the long & short extensore tendons, or,
    • rupture of thumb flexor
• knees, ankles ⇒ muscle atrophy, Baker's cyst, retrocalcaneal bursae
• 1st & 5th MTPs, subtalar/midtarsal joints
• cervical spine ⇒ degeneration of transverse ligt of atlantoaxial jt
• TMJs (pain on chewing), cricoarytenoids (hoarseness)
• see rheumatoid arthritis for more details and extra-articular features

• persistent unexplained arthritis in a child < 16yrs for > 6weeks
• subgroups after 6 months clinical course:
  • Rh.factor positive polyarticular “juvenile RhA” (15%):
    • 90% female; late childhood; esp. hands/wrists; ANA in 75%; >50% have severe arthritis
  • Rh.factor negative polyarticular (20%):
    • 70% female; younger onset; any jts; ANA in 50%; 10-15% severe arthritis
  • pauciarticular with chronic iridocyclitis in 50% (45%):
    • 80% female; early childhood; ANA in 50%; sparing of hips/SI jts; less severe arthritis but 10-20% have eyes damage if untreated
  • pauciarticular with sacroiliitis (5%):
    • 90% male; late childhood; ANA neg; HLA-B27 in 75%; 5-10% iridocyclitis;
  • systemic onset “Still's disease” (20%):
    • 65% female; any age; any jts; high fever; rash; leukocytosis; organomegaly; polyserositis; growth retardation; 30% severe arthritis;

• M > F
• all share common features:
  • sacroiliac involvement
  • periph. inflammatory arthropathy:
    • asymmetric oligoarticular: hips, knees, ankles
  • seronegative for Rh.factor
  • pathologic changes around the enthesis (ligt & tendon insertion into bone)
  • genetic component related to the HLA-B27 marker
  • spondylitis esp. thoracolumbar jn

• M>F
• back discomfort with XR evidence of sacroiliitis
• symmetric squaring of vertebral bodies & later
  • ⇒ “bamboo” spine ⇒ cauda equina syndrome
• < 5cm chest expansion indicates costovertebral involvement
  • ⇒ chest pain & restrictive lung disease
• Schober's test indicates lumbar disease:
  • full lumbar flexion fails to increase by > 5cm the distance b/n L5 & a point 15cm above
• occiput-to-wall test indicates cervicothoracic lordosis:
  • failure of approximation
• periph. joints (esp. hips, sternoclavicular) in 30% pts
• extra-articular (more common in females):
  • uveitis is the most common extrarticular feature
  • enthesopathy: plantas fasciitis & Achilles tendonitis
  • aortitis ⇒ AR
  • pericarditis; conduction defects; amyloidosis;
  • iatrogenic: leukaemia or bone sarcomas if irradiation
• see also ankylosing spondylitis for more details

• esp. males 15-40yrs
• follows within 6 weeks (usually 1-3wks) of infection with Chlamydia trachomatis, Salmonella, Shigella, Yersinia, Campylobacter, HIV
• thus, is usually associated with either a diarrhoeal illness or urethritis/cervicitis preceding it.
• post-STD form: males 9x more likely than women
• post-diarrhoeal form: woman as likely as men
• women tend to have less severe disease than men
• esp. knees, ankles, feet, heels (“lover's heel”) - usually asymmetric, symptoms usually last 3-12 months.
• conjunctivitis, uveitis, oral ulcers, balanitis circinata, sausage-like digits, keratoderma blenorrhagica (waxy plaques on palms/soles), Achille's tendonitis, low back pain
• 80% have HLAB27 but only 20% of B27 +ve people will get a reactive arthritis following a trigger.

• 20% of patients with psoriasis
• several forms exist:
  • asymmetric oligoarthropathy (70%):
    • sausage digits = flexor tendon sheath effusions (also in Reiter's)
    • indicates underlying dactylitis
  • DIP (15%)
  • RhA-like symmetric polyarthropathy - severity varies with skin disease
  • ankylosing spondylitis type asymmetric spondylitis - HLA-B27+ in 75%
  • arthritis mutilans - often assoc. with sacro-iliitis

• 15-20% pts with inflammatory bowel disease (IBD)
• non-deforming asymmetric esp. larger joints lower limbs occurs > 6months after onset of bowel symptoms & abolished by colectomy.
• in 5% pts with IBD, in assoc. with HLA-B27+ve then may also have sacro-iliitis which may predate bowel symptoms
• extra-articular features

• Fleisher, Ludwig. Synopsis of Pediatric Emergency Medicine. Ch 72. 1st Ed. 1996. Williams & Wilkins
• Epstein RJ. Medicine for Examinations. 3rd Ed. 1996. Churchill Livingstone
• Rosen, Barkin. Emergency Medicine. p 2729.. 4th Ed. 1998. Mosby.
• Shojania- Can Med Assoc J, Volume 162(8).April 18, 2000.1157-1163