Arthritis, Monoarticular

Arthritis, Monoarticular is a topic covered in the 5-Minute Emergency Consult.

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  • Localized to 1 joint, not migratory
  • 1 etiology does not exclude another
  • Infectious (septic) arthritis: Rapidly destructive process causes significant disability
    • Contiguous extension (cellulitis, osteomyelitis), hematogenous spread, direct inoculation
    • Predisposing factors:
      • Local pathology (inflammatory arthritis, trauma, prosthetic joint)
      • Immunosuppression
      • IV drug use
  • Crystalline:
    • Gout: Uric acid overproduction or underexcretion, deposited within and around joints.
    • Pseudogout: Calcium pyrophosphate
  • Noninflammatory conditions
    • Osteoarthritis (DJD), trauma (fractures, hemarthrosis), autoimmune disorders
    • Progressive joint destruction; mechanical dysfunction
      • Bone reactive changes (spurring)
      • Subchondral bony erosions


  • Infectious (septic)
    • Most common organisms nongonococcal
      • Gram-positives: Streptococcus, Staphylococcus (80%)
    • Some associations:
      • Staphylococcus aureus: (trauma, IV drug use)
      • Neisseria gonorrhea (STD)
      • Salmonella (sickle cell) but most common causes in sickle cell same (Staphylococcus, Streptococcus)
      • Less common: Fungal (chronic), spirochete (Lyme), viral (polyarticular), mycobacteria (TB)
  • Crystalline:
    • Gout: Uric acid overproduction, underexcretion within, around joints
    • Tophi: Crystal deposits near recurrent flare sites. Progressive enlargement, may ulcerate “spit out” (discharge) crystals
    • Negatively birefringent crystals
    • Pseudogout: Calcium pyrophosphate
    • Positively birefringent crystal
    • Bariatric surgery: Postoperative gout flares common, frequent, significant. Prophylactic treatment effective, recommended
  • Inflammatory
    • Diligent search for underlying cause, resultant conditions: arthridites (rheumatoid, psoriatic), inflammatory bowel disease, Reiter syndrome
  • Noninflammatory conditions
    • Osteoarthritis or degenerative joint disease (DJD), overuse, overload (obesity)
    • Trauma (fractures, hemarthrosis)
    • Hemorrhagic disorders
    • Neuropathic disorders (Charcot joint)

Pediatric Considerations
  • Infectious (septic) arthritis
    • Low incidence, high morbidity, sepsis (8%)
    • Most common: S. aureus, hip > knee, 50% coexisting osteomyelitis
    • Present like adults: Joint swollen, painful, worsened with weight bearing, movement; constitutionally ill (fever, lassitude)
    • Immediate aspiration, empiric treatment, admission mandatory
  • Inflammatory
    • A diagnosis only after septic joint excluded; then considerations same as adults
  • Noninflammatory:
  • Orthopedic considerations to not overlook:
    • Salter–Harris epiphyseal plate fractures
    • Congenital hip dysplasia
    • Slipped capital femoral epiphysis (SCFE)
      • Overweight adolescents
    • Legg–Calve–Perthes:
      • Osteonecrosis femoral head
      • Age 4–9
    • Bleeding disorders, hemorrhage

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