Diagnosis and Management of Acute Joint Pain for the Urgent Care Clinician (Pharmacology CME and Pain Management CME)

Table of Contents

 

About This Issue

Atraumatic acute joint pain is a common complaint in urgent care. The urgent care clinician must always keep life-threatening septic arthritis, which requires ED referral, on the differential. However, benign degenerative osteoarthritis, gout, or a postinfectious reactive arthritis can often be managed in the urgent care setting. In this course, you will learn:

The 6 categories of arthritis and clues to diagnosis for each of them, including common locations, distribution, and whether the presentation is monoarticular or polyarticular.

Why fever is an unreliable indicator of the presence of septic arthritis, and which signs and symptoms should prompt immediate ED referral.

When to suspect other infectious causes of arthritis, including Lyme, Zika, chikungunya, and gonococcal arthritis.

When arthrocentesis is indicated in the urgent care setting.

How to manage patients who have gout, pseudogout, osteoarthritis, Lyme arthritis, reactive arthritis, or viral/post-viral arthritis, including with safe and effective pain management.

The differential for atraumatic acute joint pain in children.

CODING & CHARTING: Learn how to select the appropriate level of service for the management of acute joint pain presentations in urgent care.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Epidemiology, Etiology, and Pathophysiology
6. 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. Arthritis Related to Viral Disease
7. Urgent Care Evaluation of Patients with Acute Arthritis
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging
      1. X-Rays
      2. Magnetic Resonance Imaging
      3. Ultrasound
      4. Arthrocentesis
      5. Synovial Fluid Examination
      6. Blood Cultures
9. Treatment
   1. Treatment of Septic Arthritis
   2. Treatment of Gonococcal Arthritis
   3. Treatment of Gout
   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
10. Special Populations
    1. Patients With Prosthetic Joints
    2. Immunocompromised Patients
    3. Patients With HIV
11. Controversies and Cutting Edge
    1. Ultrasound for Arthrocentesis
    2. Novel Therapies
    3. Platelet-Rich Plasma
12. Disposition
13. Summary
14. Time-and Cost-Effective Strategies
15. Risk Management Pitfalls for Managing Acute Joint Pain in Urgent Care
16. KidBits: Acute Joint Pain in Children
    1. Urgent Care Evaluation
       1. History
       2. Physical Examination
    2. Diagnostic Studies
       1. Joint Fluid Analysis
       2. Serum Analysis
       3. Atypical Septic Arthritis
    3. Treatment of Septic Arthritis in Children
    4. Other Causes of Acute Joint Pain in Children
       1. Conditions Requiring Orthopedic Referral
          • Slipped Capital Femoral Epiphysis
          • Legg-Calve-Perthes Disease (Perthes)
       2. Acute Conditions
          • Kawasaki Disease
          • Henoch-Schönlein Purpura
       3. Benign Conditions
          • Transient Synovitis
          • Osgood-Schlatter Disease
          • Growing Pains
17. KidBits References
18. Critical Appraisal of the Literature
19. Case Conclusions
20. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
    4. Coding Challenge
21. Clinical Pathway for Urgent Care Management of Acute Gout
22. References
23. Acknowledgments

Abstract

Acute monoarticular and polyarticular joint pain can result from infection, trauma, autoimmune, or inflammatory processes. All types may be 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 various types of acute joint pain that may present to urgent care, and outlines systematic, evidence-based strategies for diagnosis and treatment. Emerging infectious and reactive causes of arthritis, including Zika, chikungunya, and others are reviewed. Best-practice recommendations for treatment and disposition as well as indications for emergent consultation, emergency evaluation, or specialty referral are also highlighted.

Case Presentations

A 43-year-old man arrives with complaints of severe pain in his left knee...

• He is unable to ambulate. There is no history of trauma, travel, or rash.
• You are surprised by his vital signs: temperature: 39.2°C; blood pressure: 100/70 mm Hg; heart rate, 116 beats/min; respiratory rate, 22 breaths/min; and SPO2 of 98% on room air.
• You wonder if the patient can be managed in the urgent care, or if he would be better served in the local ED...

A 27-year-old woman is brought into the urgent care clinic 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 39.2ºC; 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 isolated...

A 72-year-old woman with diabetes and hypertension presents for her third episode of redness and swelling of her right great toe...

• She states even the sheets lying on the area cause pain.
• She was previously diagnosed with cellulitis and given antibiotics.
• Her vital signs are normal.
• There is an obvious effusion of the joint. Range of motion is preserved but painful.
• She admits to dietary indiscretion of eating a lot of red meat and processed food, and admits to excessive alcohol intake prior to each episode...

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Clinical Pathway for Urgent Care Management of Acute Gout

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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

5. * 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

8. Li R, Hatcher J. Gonococcal arthritis. StatPearls [Internet]. Updated May 29, 2023. Accessed November 10, 2023. (Online textbook chapter)

11. US Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System, 2016 annual tables of infectious disease data. Accessed November 10, 2023. (US government surveillance summary)

30. US Centers for Disease Control and Prevention. Chikungunya virus: diagnostic testing. Updated January 26, 2023. Accessed November 10, 2023. (CDC guidance)

31. US Centers for Disease Control and Prevention. Dengue: areas with risk of dengue. Last reviewed July 12, 2023. Accessed November 10, 2023. (CDC guidance)

32. US Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2018. Accessed November 10, 2023. (United States government report)

34. * 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

39. * 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

46. * 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

65. United States Centers for Disease Control and Prevention. STI treatment guidelines, 2021: gonococcal infections. Updated September 21, 2022. Accessed November 10, 2023. (CDC guidelines)

66. United States Centers for Disease Control and Prevention. STI treatment guidelines, 2021: managing persons who have a history of penicillin allergy. Updated September 21, 2022. Accessed November 10, 2023. (CDC guidelines)

70. * 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

73. * FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken). 2020;72(6):744-760. (Practice guidlines) DOI: 10.1002/art.41247

74. * Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29-42. (Practice recommendations) DOI: 10.1136/annrheumdis-2016-209707

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Keywords: arthritis, joint, monoarticular, polyarticular, autoimmune, reactive, gout, pseudogout, CPPD, Zika, dengue, Lyme, chikungunya, osteoarthritis, rheumatoid, septic, infectious, gonococcal, crystal, arthrocentesis, synovial, antibiotics