Monoarthritis

1. 
62 year old lady ,known case of asthma (mild course
on prn nebulizers)
Came with ho 5 days painfull RIGHT knee ,
associated with redness and limping gait , she had
ho trauma 2 days prior she slept and felt down on
her right knee
On the third day pt applied analgesic patch , on
fourth day develop redness.fifth day attend the
clinic

2. 
Examination :
Right knee :fullness (slight )redness in the site of
redness is well demarcated .Tender , warm , pain
restrict the full range of movement
Special knee examination is negative .
Reflexes not done because of pain
She came to the clinic due to cause of redness

3. 
Fracture
Septic arthritis
Allergy due to traditional treatment
Differential diagnosis

5. 
 General information
 Defintions
 General approach
 Common DDx
Outline

6. 
 Acute monoarthritis is a common medical
emergency with wide differential diagnosis.
 It can be the initial manifestation of many joint
disorders.
 The most common diagnoses in the primary care
setting are osteoarthritis, gout, and trauma.

8. 
 It is important to understand the prevalence of
specific etiologies and to use the appropriate
diagnostic modalities.
 A delay in diagnosis and treatment, particularly in
septic arthritis, can have catastrophic results
including sepsis, bacteremia, joint destruction, or
death.

9. 
Precise diagnosis of the
underlying cause of monoarthritis relies on a
good history, physical examination findings,
and results of focused investigations.

10. 
 Monoarthritis refers to the clinical presentation
of pain or swelling in a single joint.
 General terms :
• Oligoarthritis is the involvement of 2-4 joints.
• Polyarthritis is the involvement of 5 or more
joints.

11. 
 Specific symptoms and/or patient
characteristics help narrow the underlying
possible causes of monoarticular pain
 It is important to obtain a detailed history of
number of joints involved , the character of
the joint pain, including pain quality, time of
onset, exacerbating or remitting factors,
severity, and duration.

12. 
Abrupt onset, joint symptoms develop over
minutes to hours, occur in the setting of
trauma, crystalline synovitis, or infection.
With an insidious pattern, joint symptoms
develop over weeks to months, typical of
most forms of arthritis, including rheumatoid
arthritis (RA) and osteoarthritis.
Onset

13. 
Considered either acute or chronic.:
• Acute symptoms : those that have been present for
less than 6 weeks
• chronic symptoms are defined as those that have
lasted for 6 weeks or longer.
Duration

14. 
 Patterns of joint involvement are:
(1) Migratory ( inflammation persists for only a few
days in each joint (as in acute rheumatic fever or
disseminated gonococcal infection).
(2) Additive or Simultaneous (inflammation persists in
involved joints as new ones become affected)
(3) Intermittent (episodic involvement occurs, with
intervening periods free of joint symptoms (as in gout,
pseudogout, or Lyme arthritis).
Pattern

15. 
 Symmetric arthritis is characterized by
involvement of the same joints on each side of
the body , is typical of RA and SLE.
 Asymmetric arthritis is characterized by
involvement of different joints on the 2 sides.
 This is typical of psoriatic arthritis, reactive arthritis,
and Lyme arthritis.
Symmetry

16. 
 The distal interphalangeal joints of the fingers
are usually involved in psoriatic arthritis, gout, or
osteoarthritis but are usually spared in RA.
 Joints of the lumbar spine are typically involved
in ankylosing spondylitis but are spared in RA.
Distribution

17. 
 Symptoms may worsen with immobility
(“morning stiffness”). However, morning
stiffness lasting more than one hour reflects a
severity of joint inflammation which rarely
occurs in diseases other than rheumatoid arthritis
or polymyalgia rheumatica.
 the pain usually aggravated by motion and
weightbearing and is lessened by rest seen in OA
Relation to mvement

18. 
Important historical points include the following :
 Hot or swollen joints may suggest infection.
 Constitutional symptoms (high-grade fever, weight loss,
malaise) also raise the suspicion of infection or sepsis.
 Weakness may be a symptom , lack of strength can also be
due to pain in the joint or periarticular tissues or myopathy.
 Burning pain, numbness, or paresthesia may suggest an
acute myelopathy, radiculopathy, or neuropathy.

19. 
 The presence of extraarticular symptoms may help to limit the
differential diagnosis:
 Signs and symptoms of multisystem involvement (fatigue, rash,
adenopathy, alopecia, oral and nasal ulcers, pleuritic chest pain,
Raynaud phenomenon, or dry eyes and mouth) are often
observed in patients with systemic rheumatic diseases.
 Gastrointestinal or genitourinary complaints and recent sexual
exposures suggest possible infectious portals of entry or may be
associated with a seronegative spondyloarthritis (eg, reactive
arthritis, psoriasis, or inflammatory bowel disease).
Associated symptoms

20. 
 Erythema nodosum may be a manifestation of sarcoidosis
or inflammatory bowel disease;
 psoriatic skin plaques are associated with psoriatic
arthritis;
 oral ulcers can indicate reactive arthritis or Behçet
syndrome
 h/o trauma , medications ( steroid , diuretics )
 Fh of arthritis
 Comorbidities ( DM ( CTS) , renal insufficiency (gout),
psoriasis , osteoporosis (fracture ), myeloma (back pain ),
Obesity ( OA),

21. 
 The physical examination should focus on the
involved and contralateral joints, the surrounding
area, possible systemic manifestations, or
polyarticular involvement.
 Start with :
 Vitals
 Specific joint exams
 Systemic features( skin, nails , eyes, hand )
Physical Examination

22. 
 examination include the following:
• Inspection
• Palpation
• Assessment of range of motion
Physical examination

23. 
Signs of inflammatory joint disease :
•Synovial hypertrophy
•Joint effusions
•Pain with motion, particularly at the extremes of joint motion
•Erythema and warmth
•Limited range of motion
•Joint tenderness
Signs of degenerative or mechanical joint
disease :
•Bony overgrowth of the joints (osteophytes)
•Limited range of motion
•Crepitus during active or passive range of motion
•Joint deformity

24. 

25. 

30. 
 Is a progressive deterioration of cartilage and bone due to
failed repair of the joint damage caused by stresses on the
joint.
 It could be primary ( idiopathic)
Or secondary to :
Post trauma
Post RA
Skeletal disorders i.e scoliosis
Endocrine disorders
Metabolic
AVN
Osteoarthritis

31. 
 Symptoms consistent with osteoarthritis include pain that
tends to worsen with activity,
 morning stiffness lasting less than 30 minutes, and
asymmetric joint pain.
 Joint locking
 The most commonly affected joints are the hands( dip,
pip , 1st cmc) , knees, hips, and spine.
 Although osteoarthritis often follows an insidious course,
acute flare-ups are common and can be mistaken for other
etiologies.
Osteoarthritis

32. 
 O/E: painful joint , limited range of motion,
crepitus, effusions, instability, or deformities.
 Heberden and Bouchard nodes are pathognomonic
for osteoarthritis.
 They result from hard, bony thickening that gradually
forms around the distal and proximal interphalangeal
joints of the fingers, respectively.

34. 
Treatment
 Non pharmacological:
 Wt loss
 Physiotherapy
 Occupational therapy ( splints , brace , walker )
 Pharmacological :
 Oral : parcetamol , nsaid ,
 Joint : hyaluronic acid , corticosteroid
 Topical
 Surgical

35. 
 Is a common disorder with a 3% prevalence worldwide.
 It accounts for more than 7 million ambulatory visits in the
United States annually.
 Crystal-induced arthritis presents as a rapidly developing
monoarthritis with swelling and erythema, and most
commonly involves the first metatarsophalangeal joint.
 Over time, the joint space can be irreversibly damaged with
tophi formation.
 The presence of monosodium urate crystals indicates gout;
these crystals are identified by their needle-like appearance and
strong negative birefringence.
 Calcium pyrophosphate dihydrate crystals are polymorphic,
weakly positive under birefringent microscopy, and their
presence indicates pseudogout.
Gout

36. 
 A gout attack typically begins at night and peaks
within 24 hours, causing pain, swelling, and
erythema.
 Common clues from the patient history include
obesity, a high-calorie diet( seafood , meat , beer) ,
alcohol intake, and the use of loop and thiazide
diuretics.
 Trauma may also precipitate an acute gout flare-
up, and the presentation can closely resemble septic
arthritis.

37. 
 Treatment of acute attack :
 Nsaid
 Corticosteroid
 Colchicine
 Chronic gout :
 Conservative ( avoid food and drug )
 allopurinol

38. 
 Most commonly caused by staph aureus in adult.
 The most important risk factors for septic arthritis are a
prosthetic joint, skin infection, joint surgery, rheumatoid
arthritis, age older than 80 years, diabetes mellitus, and
renal disease.

 The most common route of entry into the joint is
hematogenous spread during bacteremia, therefore,
isolation of the causative agent through synovial fluid
culture is essential for the diagnosis and guidance of
antibiotic therapy.
Septic arthritis

39. 
 Septic arthritis is most likely to seed within a larger
joint, and to be accompanied by erythema, warmth, and
immobility.
 Although clinical manifestations have low
sensitivity, acute monoarthritis with fever should be
considered to have a bacterial etiology until proven
otherwise because of the potential consequences of
inadequate treatment.
 For example, morbidity associated with septic arthritis
includes functional deterioration, arthrodesis, and
amputation; the mortality rate is 10% to 20%.1
Septic arthritis

40. 
 One study found that among persons presenting
with acute joint pain and a predisposing condition,
10% had septic arthritis.
 When septic arthritis is suspected, it is important to
begin empiric antibiotics immediately following
arthrocentesis, because failure to initiate prompt
antibiotic therapy can lead to subchondral bone loss
and permanent joint dysfunction.

41. 
 http://emedicine.medscape.com/article/336054-
overview, Updated: Jan 23, 2014
 www.aafp.org
 www.emedicine.medscape.cpm