Rosen & Barkin's 5-Minute Emergency Medicine Consult (72 page)

DIAGNOSIS

• Chronic progressive joint pain:
  
  • Worse with weight bearing, improved with rest
    
• Asymmetric joint involvement:
  
  • Involves hand, foot, knee, hip, and spine joints
    
• Morning joint stiffness usually <30 min
  
• Joint deformity late in presentation with limited range of motion
  
• Heberden nodes at the distal interphalangeal joints
  
• Bouchard nodes at the proximal interphalangeal joints
  
• Absence of systemic symptoms
  
• Crepitus common
  

• Thorough joint exam with assessment of range of motion and functional ability
  
• Radiographic exam: Typical findings in OA are decreased joint space, irregular bone at the joint margin, and osteophytes.
  
• Synovial fluid analysis in the setting of effusion may be therapeutic and diagnostic (see below), but is absolutely necessary if presents with warmth and erythema so as to rule out a septic joint or gout.
  
• ESR, CRP, and CBC if infection is in the differential as arthrocentesis may be indicated if a more superficial infection cannot be ruled out (e.g., septic bursitis, cellulitis, etc.).
  

Synovial fluid exam typically reveals the following:

• Clear
  
• Elevated leukocyte cell count, but <4,000/mm
  ³
  
• <25% polymorphonuclear leukocytes
  
• Glucose level similar to blood levels (95–100%)
  

• Radiographs
  
• Joint space narrowing
  
• Osteophyte formation
  
• Marginal bone erosion
  
• Subchondral sclerosis
  

• Gout or pseudogout
  
• Septic arthritis
  
• Rheumatoid arthritis
  
• Charcot joint
  
• Hemarthrosis
  
• Overlying bursitis or soft tissue infection
  

TREATMENT

The general goal of treatment is to provide relief from symptoms. A patient may have significant radiographic evidence of disease but have very few symptoms. Therefore the treatment regimen is tailored to the patient’s symptomatology.

Immobilization of affected joint may be indicated until fracture is excluded.

• Pain management acutely
  
• Begin a daily medication that can be managed on follow-up with primary care physician.
  
• Instructions for gentle strengthening exercises
  
• Avoidance of unnecessary joint immobilization
  

Intra-articular (IA) arthrocentesis and injection:

• Ultrasound (US) guidance is recommended when expertise and instrument is available
  
• Shown to be an effective low-risk intervention for OA with or without effusion
  
• Though relatively rare in larger joints, dry tap is a possible finding due to anatomic features of joint and periarticular soft tissue (e.g., fat pad).
  
  • US very useful in this case
    
• Careful attention must be given to aseptic technique while joint is in proper position to reduce muscle tension, exposing joint space.
  
• Vapor coolant or lidocaine 1% or 2% can be used for local anesthesia.
  
• Usually 1.5 in or greater 22G or 18G hypodermic needle should be used with 1 syringe for arthrocentesis and another for IA corticosteroid injection.
  
• If septic joint cannot be ruled out, corticosteroids should not be administered after arthrocentesis.
  

Corticosteroid dosing equivalents:

• Small joints—wrist and foot:
  
  • Methylprednisolone 10–20 mg, triamcinolone 10 mg, betamethasone 0.75–1.5 mg
    
• Medium-sized joints—elbow and ankle:
  
  • Methylprednisolone 40–80 mg, triamcinolone 20 mg, betamethasone 3–6 mg
    
• Large joints—knee and shoulder:
  
  • Methylprednisolone 80–120 mg, triamcinolone 40 mg; betamethasone 6–9 mg
    
• Some studies show triamcinolone to be more efficacious than other corticosteroids; the author recommends this, if available.
  

General guidelines:

• Acetaminophen is drug of choice initially as it has a safer medication profile compared with NSAIDs and has been shown to be as efficacious in some patients.
  
• If one class fails, consider another class (e.g., salicylates vs. COX-2 inhibitors).
  
• The 2 alternative medications below have been shown to have a small but positive effect by meta-analysis of recent studies and can be considered adjuncts.
  
• Postprandial administration is recommended for all these. Patients at increased risk for GI bleeding (e.g., history of peptic ulcer disease, etc.) should be placed on COX-2 inhibitors or alternatively a proton pump inhibitor can be given with a nonselective COX inhibitor.
  
• NSAIDs:
  
  • Celecoxib (reversible COX-2–selective) 400 mg PO mg PO q24:
    
    • Note: Contraindicated in sulfonamide allergy
      
  • Ibuprofen (reversible nonselective COX): 400–600 mg PO q6h
    
  • Naprosyn (reversible nonselective COX): 500 mg PO q12h
    
  • Meloxicam (reversible nonselective COX): 7.5 mg PO q12h or 7.5–15 mg PO q24h
    
• Analgesics:
  
  • Acetaminophen: 500 mg (peds: 10–15 mg/kg, do not exceed 5 doses/24 h) PO q4–6h, do not exceed 4 g/24 h
    
  • Tramadol: 50 mg PO q4–6h:
    
    • Note: Use cautiously in elderly, patients with seizure disorders, concurrently using antidepressants, or in hepatic or renal dysfunction.
      
  • Other opioid narcotics rarely used
    
• Alternative therapies (separate or in combination):
  
  • Glucosamine: 500 mg PO q8h
    
  • Chondroitin: 1200 mg PO q24h
    
• Lifestyle modification:
  
  • Weight loss for the obese
    
  • Strengthening exercises
    

FOLLOW-UP

Rarely indicated in the absence of fracture

• Ambulatory and capable of activities of daily living
  
• Improvement in symptoms (i.e., pain)
  

• Consider referral to sports medicine clinic for definitive management
  

• Hepper CT, Halvorson JJ, Duncan ST, et al. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: A systematic review of level I studies.
  J Am Acad Orthop Surg
  . 2009;17(10):638–646.
  
• National Center for Complimentary and Alternative Medicine. The NIH Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT).
  J Pain Palliat Care Pharmacother
  . 2008;22(1):39–43.
  
• Sconfienza LM, Serafini G, Silvestri E, eds.
  Ultrasound-guided Musculoskeletal Procedures
  . Springer. 2012. 1–9.
  
• Stephens MB, Beutler Al, O’Connor FG. Musculoskeletal injections: A review of the evidence.
  Am Fam Physician
  . 2008;78(8):971–976.
  
• Vangsness CT Jr, Spiker W, Erickson J. A review of evidence-based medicine for glucosamine and chondroitin sulfate use in knee osteoarthritis.
  Arthroscopy
  . 2009;25(1):86–94.
  

CODES

• 715.90 Osteoarthrosis, unspecified whether generalized or localized, involving unspecified site
  
• 715.94 Osteoarthrosis, unspecified whether generalized or localized, hand
  
• 715.97 Osteoarthrosis, unspecified whether generalized or localized, ankle and foot
  

BASICS

• Previously called JRA
  
• JIA comprises persistent, unexplained arthritis lasting >6 wk, occurring <17 yr of age, and affecting a heterogeneous group of children.
  
• Prevalence up to 1 in 1,000 children
  
• Girls > boys for most forms
  
• Classified into 7 subgroups: Systemic onset, polyarticular RF
  ⁺
  , polyarticular RF-, pauciarticular, psoriatic, enthesitis, other or unclassified.
  
• Subtypes are based on number, type, and symmetry of joints involved; presence of systemic symptoms; skin involvement; family history; and lab values.
  
• Up to 20% of JIA patients remain unclassified or are classified in multiple categories.
  
• Natural course of the disease depends on the subtype (pauciarticular with overall best prognosis), but full resolution occurs in <50% of JIA patients.
  
• Many will have a fluctuating course and ongoing disease through adulthood.