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Question 1 of 10
1. Question
A 55-year-old man presents to the emergency department complaining of right knee pain. The patient has a past medical history for hypertension, hyperlipidemia, and osteoarthritis. He started developing symptoms over the weekend while on vacation with his friends. He admits to eating more meat and drinking more alcohol than his usual intake this weekend. Vital signs are all unremarkable. Physical examination is remarkable for an edematous, erythematous, and painful right knee. The knee is painful with passive and active range of motion. An arthrocentesis is performed and reveals rhomboid shaped, positively birefringent crystals. What is the most likely diagnosis?
Correct
Pseudogout generally affects middle-aged and elderly patients. Pseudogout is a type of crystal-induced synovitis that is caused by calcium pyrophosphate crystals. These crystals are positively birefringent and are rhomboid shaped. Patients will present complaining of joint pain, swelling, and redness. Joints most commonly affected are the knee, wrist, ankle, and elbow. Pseudogout is a type of inflammatory arthritis that is diagnosed and confirmed by synovial fluid analysis. Synovial fluid for an inflammatory arthritis will have a white blood cell count between 200 and 50 000 with a predominance of neutrophils (generally greater than 50%). The appearance of the synovial fluid will be cloudy and yellow with positive birefringent, rhomboid shaped crystals. Treatment includes the use of nonsteroidal anti–inflammatory drugs and opioid analgesics. Corticosteroids are an option in patients with a history chronic kidney disease or patients the provider thinks may be of benefit. Avoid corticosteroids in uncontrolled diabetics given the risk of worsening hyperglycemia. Colchicine is not routinely used due to its side effect profile, however, it may be used in refractory cases or in cases where NSAIDs and corticosteroids cannot be used.
Gout (A) is also a type of inflammatory crystal-induced synovitis, however, it is caused by uric acid crystal deposition. Gout generally affects middle-aged and elderly patients. Uric acid crystals are needle shaped and are negatively birefringent. Patients will present complaining of arthritis, edema, and erythema. The joints most commonly affected are the great toe, tarsal joints, and knee. Synovial fluid analysis will be similar to pseudogout, as both are an inflammatory arthritis. Differentiating the two is based on the characteristic crystal formation. Thus, crystal analysis is imperative to the correct diagnosis. However, treatment remains the same as with pseudogout and so synovial fluid analysis is performed more to rule out septic arthritis. Osteoarthritis (B) is a symmetric and chronic polyarticular joint disease distinguished by the lack of constitutional symptoms. Patients may present with acute exacerbations of monoarticular pain that consists on joint pain and inflammation. Synovial fluid analysis will demonstrate a white blood cell count of less than 200 cells with fewer than 25% neutrophils. The synovial fluid will be have a clear and transparent appearance without crystals. Treatment consists of rest and analgesics. Septic arthritis (D) is a condition that can rapidly lead to irreversible joint destruction if not recognized and treated. Patients will typically present with a monoarticular arthritis and may have associated fever, chills, and malaise. Septic arthritis should be differentiated from periarticular processes such as cellulitis, bursitis, and tendinitis. A true arthritis will produce pain that is exacerbated through active and passive range of motion. Synovial fluid analysis for septic arthritis will demonstrate a significantly elevated white blood cell count typically greater than 50 000 cells with a predominance of neutrophils (greater than 50%). The synovial fluid will be cloudy and yellow in appearance. Admission for parenteral antibiotics and repeated needle aspiration, arthroscopy, or open surgical drainage is required.
Incorrect
Pseudogout generally affects middle-aged and elderly patients. Pseudogout is a type of crystal-induced synovitis that is caused by calcium pyrophosphate crystals. These crystals are positively birefringent and are rhomboid shaped. Patients will present complaining of joint pain, swelling, and redness. Joints most commonly affected are the knee, wrist, ankle, and elbow. Pseudogout is a type of inflammatory arthritis that is diagnosed and confirmed by synovial fluid analysis. Synovial fluid for an inflammatory arthritis will have a white blood cell count between 200 and 50 000 with a predominance of neutrophils (generally greater than 50%). The appearance of the synovial fluid will be cloudy and yellow with positive birefringent, rhomboid shaped crystals. Treatment includes the use of nonsteroidal anti–inflammatory drugs and opioid analgesics. Corticosteroids are an option in patients with a history chronic kidney disease or patients the provider thinks may be of benefit. Avoid corticosteroids in uncontrolled diabetics given the risk of worsening hyperglycemia. Colchicine is not routinely used due to its side effect profile, however, it may be used in refractory cases or in cases where NSAIDs and corticosteroids cannot be used.
Gout (A) is also a type of inflammatory crystal-induced synovitis, however, it is caused by uric acid crystal deposition. Gout generally affects middle-aged and elderly patients. Uric acid crystals are needle shaped and are negatively birefringent. Patients will present complaining of arthritis, edema, and erythema. The joints most commonly affected are the great toe, tarsal joints, and knee. Synovial fluid analysis will be similar to pseudogout, as both are an inflammatory arthritis. Differentiating the two is based on the characteristic crystal formation. Thus, crystal analysis is imperative to the correct diagnosis. However, treatment remains the same as with pseudogout and so synovial fluid analysis is performed more to rule out septic arthritis. Osteoarthritis (B) is a symmetric and chronic polyarticular joint disease distinguished by the lack of constitutional symptoms. Patients may present with acute exacerbations of monoarticular pain that consists on joint pain and inflammation. Synovial fluid analysis will demonstrate a white blood cell count of less than 200 cells with fewer than 25% neutrophils. The synovial fluid will be have a clear and transparent appearance without crystals. Treatment consists of rest and analgesics. Septic arthritis (D) is a condition that can rapidly lead to irreversible joint destruction if not recognized and treated. Patients will typically present with a monoarticular arthritis and may have associated fever, chills, and malaise. Septic arthritis should be differentiated from periarticular processes such as cellulitis, bursitis, and tendinitis. A true arthritis will produce pain that is exacerbated through active and passive range of motion. Synovial fluid analysis for septic arthritis will demonstrate a significantly elevated white blood cell count typically greater than 50 000 cells with a predominance of neutrophils (greater than 50%). The synovial fluid will be cloudy and yellow in appearance. Admission for parenteral antibiotics and repeated needle aspiration, arthroscopy, or open surgical drainage is required.
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Question 2 of 10
2. Question
A 67-year-old man with a history of gout presents with atraumatic left knee pain. Physical examination reveals an effusion with overlying warmth and erythema. There is pain with passive range of motion. He reports a history of gout in this joint in the past. What is the appropriate next step?
Correct
Septic arthritis is a bacterial or fungal infection of a joint typically spread hematogenously unless there is direct bacterial contamination. The synovium is highly vascular and lacks a basement membrane making it susceptible to bacterial seeding. Certain conditions predispose individuals to septic arthritis including diabetes, sickle cell disease, immunocompromise, alcoholism or pre-existing joint disease like rheumatoid arthritis or gout. Fever is present in less than half of cases of septic arthritis so with clinical suspicion an arthrocentesis is indicated. The knee is the most common joint affected and patients have pain (especially on passive range of motion) and decreased range of motion often accompanied by warmth, erythema and fever. This patient may have an acute gouty flare, but the clinician must exclude an infection. On joint fluid analysis, the white blood cell count of a septic joint is typically > 50,000.
Indomethacin (B) is a non-steroidal anti-inflammatory agent commonly used in the treatment of acute gout. Gout is arthritis caused by deposition of monosodium urate monohydrate crystals in the joint space. Acute flares involve a monoarticular arthritis with a red, hot, swollen and tender joint. Acute episodes of gout result from overproduction or decreased secretion of uric acid. However, measurement of serum uric acid (C) does not correlate with the presence or absence of an acute flare. A radiograph of the knee (D) may show chronic degenerative changes associated with gout but will not help to differentiate gouty arthritis versus septic arthritis.
Septic Arthritis
- Patient will be complaining of fever, monoarticular pain with decreased ROM
- Labs will show WBC > 50,000 with > 75% PMNs
- Diagnosis is made by arthrocentesis
- Most commonly caused by:
- Age < 35: N. gonorrhea, S. aureus overall
- Treatment is IV ABX, surgical washout
Incorrect
Septic arthritis is a bacterial or fungal infection of a joint typically spread hematogenously unless there is direct bacterial contamination. The synovium is highly vascular and lacks a basement membrane making it susceptible to bacterial seeding. Certain conditions predispose individuals to septic arthritis including diabetes, sickle cell disease, immunocompromise, alcoholism or pre-existing joint disease like rheumatoid arthritis or gout. Fever is present in less than half of cases of septic arthritis so with clinical suspicion an arthrocentesis is indicated. The knee is the most common joint affected and patients have pain (especially on passive range of motion) and decreased range of motion often accompanied by warmth, erythema and fever. This patient may have an acute gouty flare, but the clinician must exclude an infection. On joint fluid analysis, the white blood cell count of a septic joint is typically > 50,000.
Indomethacin (B) is a non-steroidal anti-inflammatory agent commonly used in the treatment of acute gout. Gout is arthritis caused by deposition of monosodium urate monohydrate crystals in the joint space. Acute flares involve a monoarticular arthritis with a red, hot, swollen and tender joint. Acute episodes of gout result from overproduction or decreased secretion of uric acid. However, measurement of serum uric acid (C) does not correlate with the presence or absence of an acute flare. A radiograph of the knee (D) may show chronic degenerative changes associated with gout but will not help to differentiate gouty arthritis versus septic arthritis.
Septic Arthritis
- Patient will be complaining of fever, monoarticular pain with decreased ROM
- Labs will show WBC > 50,000 with > 75% PMNs
- Diagnosis is made by arthrocentesis
- Most commonly caused by:
- Age < 35: N. gonorrhea, S. aureus overall
- Treatment is IV ABX, surgical washout
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Question 3 of 10
3. Question
In which setting is allopurinol contraindicated for the treatment of gout?
Correct
Allopurinol therapy should never be initiated until an acute attack has subsided. Allopurinol is a xanthine oxidase inhibitor that decreases uric acid production but also produces a more soluble metabolite. Allopurinol is therefore effective regardless of the cause of the hyperuricemia. Gout is caused by deposition of uric acid crystals in the synovium, bursae, tendon sheaths, skin, heart valves, and kidneys, which can lead to arthritis, tophi, renal stones, and gouty nephropathy. Typically, patients present with acute, exquisitely tender, monoarticular arthritis. The joint is usually warm and erythematous. The first metatarsophalangeal joint (MTP) joint is most commonly affected. Detecting negatively birefringent, needle-like crystals in the synovial fluid from an arthrocentesis confirms the diagnosis. First line treatment are NSAIDs. Indomethacin has traditionally been the NSAID of choice, but any NSAID can be used with similar efficacy.
Ethanol metabolism blocks renal excretion of uric acid which increases the risk for developing gouty arthritis. However, allopurinol is not contraindicated in individuals who consume ethanol (B). Hyperuricemia (C) is present (usually >8 mg/dL) in the gout patient, and when symptomatic, these patients should be treated. Colchicine (D) can be used in combination with allopurinol to help decrease the likelihood of a gouty flare while the uric acid level is decreasing after an acute attack has subsided. Colchicine decreases inflammation associated with lactic acid production and phagocytosis of urate; it terminates most gouty attacks within 6 to 12 hours but is limited by GI side effects.
Gout
- Patient will be a middle-aged man
- Complaining of acute onset of pain in the first MTP (Podagra)
- Labs will show needle-shaped crystal with negative birefringence
- Most commonly caused by uric acid crystals
- Treatment is:
- Acute: NSAIDs, steroids, colchicine
- Chronic: allopurinol or colchicine
- Comments: Can be triggered by loop and thiazide diuretics
Incorrect
Allopurinol therapy should never be initiated until an acute attack has subsided. Allopurinol is a xanthine oxidase inhibitor that decreases uric acid production but also produces a more soluble metabolite. Allopurinol is therefore effective regardless of the cause of the hyperuricemia. Gout is caused by deposition of uric acid crystals in the synovium, bursae, tendon sheaths, skin, heart valves, and kidneys, which can lead to arthritis, tophi, renal stones, and gouty nephropathy. Typically, patients present with acute, exquisitely tender, monoarticular arthritis. The joint is usually warm and erythematous. The first metatarsophalangeal joint (MTP) joint is most commonly affected. Detecting negatively birefringent, needle-like crystals in the synovial fluid from an arthrocentesis confirms the diagnosis. First line treatment are NSAIDs. Indomethacin has traditionally been the NSAID of choice, but any NSAID can be used with similar efficacy.
Ethanol metabolism blocks renal excretion of uric acid which increases the risk for developing gouty arthritis. However, allopurinol is not contraindicated in individuals who consume ethanol (B). Hyperuricemia (C) is present (usually >8 mg/dL) in the gout patient, and when symptomatic, these patients should be treated. Colchicine (D) can be used in combination with allopurinol to help decrease the likelihood of a gouty flare while the uric acid level is decreasing after an acute attack has subsided. Colchicine decreases inflammation associated with lactic acid production and phagocytosis of urate; it terminates most gouty attacks within 6 to 12 hours but is limited by GI side effects.
Gout
- Patient will be a middle-aged man
- Complaining of acute onset of pain in the first MTP (Podagra)
- Labs will show needle-shaped crystal with negative birefringence
- Most commonly caused by uric acid crystals
- Treatment is:
- Acute: NSAIDs, steroids, colchicine
- Chronic: allopurinol or colchicine
- Comments: Can be triggered by loop and thiazide diuretics
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Question 4 of 10
4. Question
Kanavel cardinal signs of flexor tenosynovitis include all of the following EXCEPT:
Correct
Incorrect
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Question 5 of 10
5. Question
A 17 year-old female presents to the Emergency Department with left knee and right wrist pain as well as subjective fever for the previous 2 days. Physical exam is remarkable for swollen, erythematous, and warm joints with significant effusions. Skin exam is shown below. Which of the following is the likely underlying cause of this patient’s illness?
Correct
The correct answer is disseminated gonorrhea. The skin lesions above are hemorrhagic pustules which are essentially pathognomonic for gonorrhea.
Incorrect
The correct answer is disseminated gonorrhea. The skin lesions above are hemorrhagic pustules which are essentially pathognomonic for gonorrhea.
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Question 6 of 10
6. Question
A 55-year old male with a history of hypertension and diabetes presents to the Emergency Department with a painful swollen right knee. He denies any recent trauma, but does endorse intermittent subjective fevers over the past 24 hours. Arthrocentesis demonstrates a WBC count of 120,000/mm3 as well as rhomboid shaped crystals. Initial gram stain is negative. Which of the following is the most appropriate next step in management?
Correct
The correct answer is admission and ortho consult. While this patient’s arthrocentesis is consistent with pseudogout due to the presence of rhomboid crystals, this can certainly occur in conjunction with a septic arthritis. In fact, gout and pseudogout patients are at higher risk for bacterial infection of their joints.
Incorrect
The correct answer is admission and ortho consult. While this patient’s arthrocentesis is consistent with pseudogout due to the presence of rhomboid crystals, this can certainly occur in conjunction with a septic arthritis. In fact, gout and pseudogout patients are at higher risk for bacterial infection of their joints.
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Question 7 of 10
7. Question
A 33-year old obese female presents to the Emergency Department with chronic left knee pain, which has significantly worsened over the previous 2 days. She denies any recent trauma, and has experienced no fevers or chills. Physical exam of the knee demonstrates full range of motion, both active and passive. There is no effusion, no warmth, and no valgus or varus deformity or laxity. McMurray’s as well anterior and posterior drawer tests are negatives. The patient has significant pain on palpation on the medial aspect of the knee 2-3 inches below her joint. Which of the following is the most likely cause of her symptoms?
Correct
The correct answer is anserine bursitis. The anserine bursa is located on the medial aspect of the knee 2-3 inches below the joint, and can become inflamed due to trauma, gout, or repeated stress. Treatment is generally conservative with rest, ice, elevation, and NSAIDS.
Incorrect
The correct answer is anserine bursitis. The anserine bursa is located on the medial aspect of the knee 2-3 inches below the joint, and can become inflamed due to trauma, gout, or repeated stress. Treatment is generally conservative with rest, ice, elevation, and NSAIDS.
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Question 8 of 10
8. Question
A 12-year old male presents to the Emergency Department with left-sided hip and knee pain. He denies any recent trauma or fevers, and has had gradually progressive pain. Physical exam is significant for an obese child in no acute distress. He has significant pain with range of motion testing of his left hip and knee. X-ray is shown. What is the likely cause of this child’s limp?
Correct
The correct answer is slipped capital femoral epiphysis. A Klein line is a line drawn on an AP film along the superior aspect of the femoral neck. It should pass through a portion of the femoral head. If it does not, this is consistent with SCFE.
Incorrect
The correct answer is slipped capital femoral epiphysis. A Klein line is a line drawn on an AP film along the superior aspect of the femoral neck. It should pass through a portion of the femoral head. If it does not, this is consistent with SCFE.
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Question 9 of 10
9. Question
A 65-year old male presents to the Emergency Department with a chief complaint of right knee pain. He denies any recent trauma or infectious symptoms, and endorses gradually progressive pain over 2-3 days. Physical exam demonstrates a knee effusion with warmth and significant pain with both active and passive flexion and extension. He is afebrile. X-ray is shown below. Arthrocentesis of this joint is most likely to show which of the following?
Correct
The correct answer is positively birefringent crystals. This x-ray demonstrates chondrocalcinosis, or calcium deposition in the joint space, diagnostic of pseudogout (calcium pyrophosphate crystals). Negatively birefringent crystals are caused by uric acid crystals in gout. Fat globules can be seen in fractures, and an elevated WBC count would be expected in a septic joint. This is certainly possible in this patient as any gouty arthritis increases the risk for septic joint, however the more likely finding is calcium pyrophosphate crystals.
Incorrect
The correct answer is positively birefringent crystals. This x-ray demonstrates chondrocalcinosis, or calcium deposition in the joint space, diagnostic of pseudogout (calcium pyrophosphate crystals). Negatively birefringent crystals are caused by uric acid crystals in gout. Fat globules can be seen in fractures, and an elevated WBC count would be expected in a septic joint. This is certainly possible in this patient as any gouty arthritis increases the risk for septic joint, however the more likely finding is calcium pyrophosphate crystals.
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Question 10 of 10
10. Question
A 28-year old male is brought in to the Emergency department after being struck by a motor vehicle while crossing an intersection. The bumper struck him in the right knee and knocked him over the hood. The patient denies head injury, there was no loss of consciousness, and his only complaint on presentation is right knee pain. Physical exam of the knee demonstrates ecchymosis but no obvious deformity. Significant laxity is appreciated in the knee and positive anterior and posterior drawer signs are noted. The patient reports feeling his knee “pop back into place” while being extricated by the paramedics. Plain radiographs of the knee demonstrate no fracture. The remainder of the physical exam, including a FAST exam, labs, and vital signs are normal. Which of the following is the most appropriate next step in management?
Correct
This patient’s mechanism of injury as well as the significant ligamentous laxity is concerning for a knee dislocation. CT angiography should be performed to rule out a popliteal artery injury.
Incorrect
This patient’s mechanism of injury as well as the significant ligamentous laxity is concerning for a knee dislocation. CT angiography should be performed to rule out a popliteal artery injury.
Welcome back team! We’ve got another fun-filled virtual conference coming at you this week and it’s all about joints, what’s in ’em and when to stick needles in there. Drs. White, Wilson and Padgett will bead heading this week’s FLIPs. We’ve also got another Follow Up Rounds with current PICU star Dr. Jenna Rousseau. And for the first time this year, Dr. Kerin Jones will be presenting her X-Ray Rounds.
Core Content: Harwood & Nuss
- Chapter 147: Hand Infections
- Chapter 150: Monoarticular Arthritis
- Chapter 151: Polyarticular Arthritis
Core Content: Rosen’s
Supplementary Material
EM:RAP CorePendium
— Skin and Soft Tissue Infections
— Arthritis
Roberts and Hedges’ Clinical Procedures:
— 53.Arthrocentesis
— Paronychia
— Felon
Other Fun Stuff:
— emDOCs – Septic Joints
— emDOCs – Arthrocentesis
— CORE EM – Cellulitis
— ACEP Guidelines for Shoulder Injections <- great for shoulder dislocations!
— FOAMCast – The Knee
— Flexor Tenosynovitis
Brushing Up On X-Rays:
— Life In the Fast Lane: The Chest X-Ray
— More LITFL CXRs
— EM in 5: Elbow Xray Interpretation