JOINT SWELLING

JOINT SWELLING: Excerpt from Differential Diagnosis in Primary Care

The best approach to analysis of this symptom is anatomic and histologic (Table 43). However, if one remembers the biochemical causes of joint disease, gout, pseudogout, and ochronosis immediately come to mind. Let us discuss the conditions to be considered in an anatomic and histologic breakdown of the joint. In the skin, an abscess or hematoma is a possibility. Subcutaneous lipoma and pretibial myxedema may involve the joint area as may edema, particularly in phlebitis. Around all joints are bursae that can become inflamed and swollen, especially when torn ligaments constantly rub against them.

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JOINT SWELLING

	V	I	N	D
	Vascular	Infection	Neoplasm	Degenerative
Skin		Carbuncle
Subcutaneous Tissue		Cellulitis	Lipoma
Bursa		Bursitis
Synovium		Gonococcal arthritis Tuberculous arthritis Streptococcal arthritis	Synovioma
Ligaments of Joint
Joint Space				“Joint mice"
Cartilage				Degenerative osteoarthritis
Bone	Aseptic bone necrosis	Staphylococcal osteomyelitis Tuberculous osteomyelitis
Blood Vessels	Sickle cell anemia	Phlebitis

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JOINT SWELLING

	I	C	A	T	E
	Intoxication	Congenital or	Allergic	Trauma	Endocrine
		Collagen	Autoimmune
				Hematoma
		Lupus Rheumatoid arthritis	Reiter disease Serum sickness	Hemarthrosis
				Ruptured ligament
	Gout, pseudogout	Rheumatic fever		Hemarthrosis	Intermittent hydrarthrosis
		Ochronosis		Torn meniscus
		Hemophilia

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Next let us consider the ligaments of the joint, especially those in the knee. Weak collateral ligaments will lead to recurrent swelling from fluid accumulation in the knee. Ruptured anterior or posterior cruciate ligaments will also create intermittent pain and swelling. To diagnose this condition, bend the knee and pull the tibia and lower leg forward and backward like opening and closing a drawer. If the meniscus is ruptured, a distinct popping or locking of the joint will occur when the joint is flexed and then extended under pressure, especially with internal or external rotation of the lower leg. The synovium is the site of most pathologic conditions of the knee. Rheumatic fever, RA, lupus erythematosus, and Reiter disease are classic collagen diseases affecting the synovium. The most common infectious diseases are gonorrhea and Streptococcus organisms, but tuberculosis and brucellosis should not be forgotten. Trauma to the synovium produces hemarthrosis, but it does not take much to cause hemarthrosis in hemophilia and occasionally in other coagulation disorders. Moving on to the bone, osteomyelitis and syphilis must be considered: Staphylococcus and tuberculosis are common offenders. Aseptic bone necrosis (e.g., Osgood–Schlatter disease of the knee) is another condition of the bone that causes apparent joint swelling. Idiopathic degeneration of the cartilage is a common cause of joint disease in the form of osteoarthritis. Ochronosis may lead to degeneration, but there is usually calcification of the cartilage on radiographs.

Approach to the Diagnosis

The clinical picture will often help identify the cause of the joint swelling. If there is fever and migratory arthritis, one suspects rheumatic fever or Lyme disease. Fever with involvement of several joints would suggest RA, lupus erythematosus, or gonorrhea. Fever and involvement of one joint primarily is found in septic arthritis and tuberculosis but may be found in gonorrhea. No fever and large joint involvement may be found in osteoarthritis, gout, and pseudogout. Osteoarthritis customarily affects the distal phalangeal joints, whereas RA affects the metacarpophalangeal joints. Psoriatic arthritis also affects the distal phalangeal joints primarily. Charcot joints are usually large. The initial workup of joint swelling includes a CBC, sedimentation rate, urinalysis, chemistry panel, and x-rays of the involved joints. If a large joint is involved, joint fluid can be aspirated and analyzed. A culture should also be done. If gonococcal arthritis is suspected, urethral or cervical smears and cultures will be helpful, but culture of the fluid on special medium is most important. If gout or pseudogout is suspected, it is important to examine the joint fluid for crystals under polarized light. If RA is suspected, an RA titer will often be positive. Lupus erythematosus can be confirmed by a positive ANA and anti–double-stranded DNA antibodies. Rheumatic fever can be confirmed by a positive ASO titer or streptozyme test. If the synovial fluid has a high white count, hospitalization and initiation of parenteral antibiotics are indicated without delay.

Other Useful Tests

1. Venereal Disease Research Laboratory (VDRL) test (Charcot joints)
2. Electrocardiogram (ECG) (rheumatic fever)
3. Tuberculin test (tuberculosis of the joint)
4. Blood cultures (septic arthritis)
5. Monospot test (infectious mononucleosis with joint involvement)
6. Lyme disease antibody titer
7. Sickle cell prep
8. Coagulation profile (hemophilia)
9. Cervical or urethral smears and cultures for gonococci
10. Febrile agglutinins (infectious arthritis)
11. MRI of joint (torn meniscus)
12. Synovial biopsy (RA)
13. Therapeutic trial of colchicine (gout)
14. Bone scan (osteomyelitis)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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