Diagnosis and Management of Acute Joint Pain in the Emergency Department

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.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology, Etiology, and Pathophysiology
7. 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
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. 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
11. 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
12. Special Populations
    1. Patients With Prosthetic Joints
    2. Immunocompromised Patients
    3. Patients With HIV
13. 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
14. Disposition
15. Summary
16. Time-and Cost-Effective Strategies
17. Risk Management Pitfalls for Managing Acute Joint Pain in the Emergency Department
18. Case Conclusions
19. Clinical Pathways
    1. Clinical Pathway for Emergency Department Workup and Management of Monoarticular Arthritis
    2. Clinical Pathway for Emergency Department Management of Acute Gout
20. 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
21. 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

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...

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...

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...

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Clinical Pathway for Emergency Department Workup and Management of Monoarticular Arthritis

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Tables and Figures

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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

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

Points and Pearls Excerpt

• There are 6 broad categories of arthritis (with some overlap): (1) infectious, (2) degenerative, (3) autoimmune, (4) crystal deposition-related, (5) reactive, and (6) traumatic.
• Although joint pain has traditionally been thought of as either monoarticular or polyarticular, do not eliminate a disease based solely on these binary classifications, as some can present with single or multiple joints.
• The number of affected joints, their locations, and symmetry of distribution can help identify the cause of the joint pain. (See Table 2.)
• There are no disease-modifying treatments for osteoarthritis; symptom relief is the main focus. Intra-articular injections of corticosteroids or hyaluronic acid can be performed in the ED.
• Pregnant and menstruating women and patients with a complement deficiency are most at risk for gonococcal arthritis. Antibiotic recommendations for gonococcal arthritis were updated by the CDC in 2020.