JOINT SWELLING

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.

JOINT SWELLING

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.

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, rheumatoid arthritis, 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 rheumatoid arthritis, 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 rheumatoid arthritis 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 rheumatoid arthritis 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. VDRL (Charcot joints)
2. 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 (rheumatoid arthritis)
13. Therapeutic trial of colchicine (gout)
14. Bone scan (osteomyelitis)

Book Source Details

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

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Joint redness: Introduction (review 36 causes)
• Next Book Extract About Joint redness: Monarticular Joint Pain (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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