Home > All Topics > Diagnosis and Management of Acute Joint Pain in the Emergency Department

Diagnosis and Management of Acute Joint Pain in the Emergency Department

NEW Quick Search this issue!

Login

Buy This Issue

Subscribe

Free Sample

Table of Contents

About This Issue

Acute joint pain is a common complaint in the ED, but determining whether it is from life-threatening septic arthritis or benign (though painful) degenerative osteoarthritis, gout, or a postinfectious reactive arthritis is essential to making sure the patient gets timely and appropriate treatment. This issue reviews the most recent literature on managing patients in the ED with joint pain, including:

Polyarticular, monoarticular, asymmetric, symmetric: how does the presentation give clues to the cause?

Why fever is an unreliable indicator of the presence of septic arthritis.

Using patient history, vital signs, pain with range of motion, and effusion to help pinpoint the causes of joint pain.

Managing the patient with gout with safe and effective pain relief (including newer colchicine dosing recommendations), education, and referral.

Are x-rays useful? When is MRI needed?

Which laboratory test are most useful in interpreting arthrocentesis fluid samples? sWBC, sPMN, sLactate, sLDH, and/or cultures? Are serum tests useful at all?

Are IV or oral antibiotics indicated for septic arthritis? What is the latest evidence on the optimal duration of therapy?

Managing other infectious causes of arthritis: determine the presence of Lyme, chikungunya, COVID-19, gonococcal, and gastrointestinal/genitourinary arthritis.

Table of Contents

About This Issue
Abstract
Case Presentations
Introduction
Critical Appraisal of the Literature
Epidemiology, Etiology, and Pathophysiology
Differential Diagnosis
1. Infectious Arthritis
  1. Septic Arthritis
  2. Gonococcal Arthritis
  3. Lyme Arthritis
2. Degenerative Arthritis
  1. Osteoarthritis
3. Autoimmune Disease
4. Crystal Disease
  1. Gout
  2. Calcium Pyrophosphate Dihydrate Deposition Disease (Pseudogout)
5. Reactive Arthritis
  1. Postinfectious Arthritis
  2. Postviral Arthritis
    - Zika Arthritis
    - Chikungunya Arthritis
    - COVID-19 Arthritis
6. Trauma-Related Arthritis
Prehospital Care
Emergency Department Evaluation
1. History
2. Physical Examination
Diagnostic Studies
1. Serum Laboratory Testing
2. Imaging
  1. X-Rays
  2. Magnetic Resonance Imaging
  3. Ultrasound
3. Arthrocentesis
4. Synovial Fluid Examination
5. Blood Cultures
Treatment
1. Treatment of Septic Arthritis
2. Treatment of Gonococcal Arthritis
3. Treatment of Gout
  1. Pain Control
  2. Urate-Lowering Therapy
4. Treatment of Pseudogout
5. Treatment of Osteoarthritis
6. Treatment of Lyme Arthritis
7. Treatment of Reactive Arthritis
8. Treatment of Viral Arthritis
9. Treatment of Traumatic Arthritis
Special Populations
1. Patients With Prosthetic Joints
2. Immunocompromised Patients
3. Patients With HIV
Controversies and Cutting Edge
1. Duration of Treatment With Intravenous and Oral Antibiotics
2. Ultrasound for Arthrocentesis
3. Novel Therapies
4. Intra-articular Platelet-Rich Plasma
Disposition
Summary
Time-and Cost-Effective Strategies
Risk Management Pitfalls for Managing Acute Joint Pain in the Emergency Department
Case Conclusions
Clinical Pathways
1. Clinical Pathway for Emergency Department Workup and Management of Monoarticular Arthritis
2. Clinical Pathway for Emergency Department Management of Acute Gout
Tables and Figures
1. Table 1. Differential Diagnosis of Acute Joint Pain
2. Table 2. Arthritis Presentations
3. Table 3. Septic Arthritis Versus Septic Bursitis
4. Table 4. Historical Factors Indicating Risk for Septic Arthritis
5. Table 5. Ultrasound-Guided Arthrocentesis Landmarks
6. Table 6. Arthrocentesis Interpretation
7. Figure 1. Venn Diagram of Arthritis
8. Figure 2. Calcium Pyrophosphate Dihydrate Deposition Disease (Pseudogout)
9. Figure 3. Osteoarthritis of the Hand on X-ray
10. Figure 4. Gout of the Foot on X-ray
11. Figure 5. Septic Arthritis, Second Toe, on X-ray
12. Figure 6. Ultrasound of Knee With and Without Effusion
13. Figure 7. Monosodium Urate Crystals and Calcium Pyrophosphate Dihydrate Crystals
14. Figure 8. Skin Rash in Chikungunya Fever
15. Figure 9. COVID-19 Toes
References

Abstract

Acute monoarticular and polyarticular joint pain that results from infection, trauma, and autoimmune and inflammatory processes are a major cause of disability that is often preventable with early diagnosis and management. Septic arthritis presents a particular danger, with a high potential for morbidity and mortality. This issue presents an overview of the various types of acute joint pain that present to the emergency department, and outlines systematic, evidence-based strategies for diagnosis and treatment. Emerging infectious and reactive causes of arthritis, including Zika, chikungunya, and COVID-19 are reviewed. Best-practice recommendations for treatment and disposition based on diagnosis are highlighted.

Case Presentations

CASE 1

A 43-year-old man has arrived by ambulance with complaints of severe pain in his right ankle and left knee…

He is unable to ambulate. There is no history of trauma, travel, or rash.
You wonder why the patient called EMS for joint pain, but then you see his vital signs: 116 beats/min pulse, 39.2°C temperature, 100/70 mm Hg blood pressure, 22 breaths/min respiration, and pulse ox 98% on room air.
You wonder whether you should tap the joints and start empiric antibiotics...

CASE 2

A 27-year-old woman is brought into the nonacute area of the ED with complaints of severe, diffuse joint pain…

She returned last week from the Dominican Republic, where she was on her honeymoon. She also describes subjective fevers.
Her temperature is 37.7ºC; blood pressure, 130/75 mm Hg; and respiratory rate, 18 breaths/min.
The nurse approaches you with the concern that the patient has a diffuse rash and asks whether the patient should be put into isolation...

CASE 3

A 19-year-old woman presents with joint pain and swelling, most noticeably in her feet and toes…

She said she has had some difficulty walking. Her history is significant for a recent upper respiratory infection, with sore throat and headache, 3 weeks ago.
Her temperature is 37ºC; blood pressure, 110/70 mm Hg; and respiratory rate, 20 breaths/min.
You wonder whether her joint pain could be related to the upper respiratory infection...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Emergency Department Workup and Management of Monoarticular Arthritis

Subscribe to access the complete flowchart to guide your clinical decision making.

Tables and Figures

Table 1. Differential Diagnosis of Acute Joint Pain

Table 3. Septic Arthritis Versus Septic Bursitis

Table 4. Historical Factors Indicating Risk for Septic Arthritis

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Carpenter CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-796. (Systematic review) DOI: 10.1111/j.1553-2712.2011.01121.x

6. * Long B, Koyfman A, Gottlieb M. Evaluation and management of septic arthritis and its mimics in the emergency department. West J Emerg Med. 2019;20(2):331-341. (Review) DOI: 10.5811/westjem.2018.10.40974

24. * Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488. (Systematic review; 14 studies, 6242 patients) DOI: 10.1001/jama.297.13.1478

31. * Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (Oxford). 2006;45(8):1039-1041. (Practice guideline) DOI: 10.1093/rheumatology/kel163a

36. * Punzi L, Oliviero F. Arthrocentesis and synovial fluid analysis in clinical practice: value of sonography in difficult cases. Ann N Y Acad Sci. 2009;1154:152-158. (Review) DOI: 10.1111/j.1749-6632.2009.04389.x

61. * Terkeltaub RA, Furst DE, Bennett K, et al. High versus low dosing of oral colchicine for early acute gout flare: twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060-1068. (Randomized controlled trial; 184 patients) DOI: 10.1002/art.27327

Subscribe to get the full list of 86 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: arthritis, joint, monoarticular, polyarticular, autoimmune, reactive, gout, Zika, Lyme, chikungunya, COVID-19, osteoarthritis, rheumatoid, septic, infectious, osteomyelitis, gonococcal, crystal, bursitis, arthrocentesis, synovial, antibiotics