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Summary

This on-demand webinar is a part of an orthopedic teaching series aimed at medical professionals. Attendees will learn how to assess and manage patients with hot, swollen joints, and gain an understanding of the difference between septic and inflammatory arthritis. Discussions will also include the relevant history-taking, examination procedures, and investigations for differentials and risk factors. This session will significantly improve clinical practice for medical professionals working with joint swelling.

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Learning objectives

Learning Objectives:

  1. Identify the key steps in assessing and managing patients with acutely swollen joints
  2. Distinguish between different causes of swollen joints and pick up important risk factors for septic arthritis
  3. Understand the clinical features and investigations used to diagnose septic arthritis
  4. Develop an appropriate management plan and be aware of operative and non-operative therapies
  5. Recognize systemic signs of infection and inflammation associated with other joint conditions.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So our session today today is about the acute, hot, swollen joints. Uh oh, geez, if I'm checking two screens because I have my chat here, which I'll be looking at most of the time, Esopus is if you have any questions or anything that's not clear. You can always stop me. So eso this is part of our arthritic teaching Siris. This is the hot, swollen joints webinar. Um, the next one will be pediatric presentations on the 26th of May. So if you do have the time, make sure to check it out. That's if it's about myself before I start. So my name is Omar. This okay? I'm a clinical teaching fellow. I worked at the Royal Blackbird currently, and I have an interest in orthopedics. So our session today before we start, I want to go over a little bit about the learning objectives and what we are going to do. So hopefully by the end of today, we will be able to assess patients with acutely swollen joints. We would be able to differentiate. The cause is off acutely swollen joints manage those patients and also be aware of the operative a non operative options. Um, there is some questions in the middle and a little bit of the end of that, I think, have some clinical relevancy, so we'll try and go through them. So just before we start, this is a clinical scenario on your the surgical F one on take when you're called to see this patient. So it's a 65 year old man in the knee. He's complaining off a little bit of pain and swelling in the right knee. He doesn't feel particularly ill, but he has a temperature of 38.5 and he's unable to wait there hasn't used off one and temperature off 38.5. Like I said, so he's not scoring for anything else. His observations are okay, so the first thing we're thinking about is how to approach the case. So when approaching any case like that, I think the first important thing is obviously history taking, um, so and that's going with the sample pneumonic. Obviously, if you have more time and the patient is stable, you can take a full detail history. But this is more like the bare minimum. I will talk a little bit more about the sample pneumonic later. You want to then examine the patient. So this is doing a systematic A to the assessment. If the patient is acutely and well, and then specifically looking at the joint. So examining the joints, using the look, feel and more approach, then we're going to do our investigations, which could be that side bloods or imaging. So history wise. So this is what you need to know, at least, eh? So if it's an acutely and well patients, you want to do your 80 assessment, you want to do your ample history just to find a little bit more about the patient. So first is allergies. So we want to identify the patient's allergies because obviously, when we identify what the problem is, we will give them. The medication on board will try and treat them. So we need to know if you're allergic to anything, whether that's antibiotics or anything else. The current medication they're on are they on any anticoagulants, any high anti hypertensive? Any other medications that could explain or interact with whatever we will give them? Uh, past medical history. Is there anything that's, uh, in their past medical history that can lead us to what the problem is. The last meal and drink. Like I said before and we will talk a little bit more about it later. They might need to go to theater. So this is very important in documenting on their events leading to admission. And I will explore more about the events leading to admission. So this is the minimum that you need to ask during your history. Obviously, there's a lot more questions that we need to go through. But depending on the scenario, so history wise, uh, again minimum, you need to ask Sokratis. Right? So we want to understand. When did it start with a couple of days ago? Was it a few hours ago? Is it more of a chronic presentation? And this is very important to different year between ALS. The cause is off, uh, joint swelling. You want to know exactly where the joint swelling is the time frame of the swelling. So is it on and off for the last one year? And now it's a little bit worse. Or is it out of nowhere? They have severe onset joint swelling and pain. Um, is there any precipitating factors so, including trauma or surgery. So what were they doing when, when Before the swelling happened, where they just sitting at home doing anything? Or did they suffer a fall where they're trying to over the playing? Any contact sports, um, involved in some sort of accidents? And you also want to find out. Obviously, if there's any past surgical history at any prosthetic joints, that's good. Explain why there is a swelling obviously won't find about the extra baiting or leaving factors. Clarify the patient's level off pain and ability to wait there, and that will be very important. Are they able to weight bear at all? Because some conditions will present as very accurately swollen, unable to wait there completely unable to passively or actively flex in the joints? Or are they still able to eat better, but with a little bit of faint? And finally, you want to do a systems review, so you want to see if there's any signs of infection and he gets the intestinal symptoms Energen it a genital urinary symptoms as that can be talked to reactive arthritis, the same thing with skin changes and psoriatic arthritis. Following that, you want to examine the patient, so we took her history. Now it's time to do the examination. So in any obviously, acutely and what patient you want to do on a three assessment. If they're not acutely and well or you've done your 80 assessment, you still need to specifically examine the joint. So you want to look, feel and move the joint. And in your scenario that we talked about a 65 year old coming in with a right swollen joint, you're basically inspecting for readiness on any swelling, any skin changes or scars, and it's very important to compare this to the contralateral joints. Make sure that it is on document. What is the difference? Um, especially if the contralateral joint is normal. We want to check for focal tenderness if there is any evidence off fusion on also importantly, documenting the range of motion on documenting the range of motion, comparing it with the other side. So is it's 20 degrees, or is he unable to? Or is the patient unable to completely move or flex the joint? We also want to inspect the rest of the body looking for any other joint involvement. You can have multiple joint involvement in multiple conditions. So, for example, with rheumatoid arthritis, you might you might expect to see some other joint involvement, not just the presenting knee on. We also want to look for systemic science. Any systemic signs of sepsis, any systemic signs of infection? Anything else that could lead us to a diagnosis? Uh, moving on. So we want to, uh, investigating the patient. This is more off a outline off the investigations you want to do, For example, in the case that we got somebody with a right swollen knee, we'll talk specifically about what investigations you do in different conditions. But for this case, you want to start with your routine. But so that includes full blood counts. Your knees and LFT is syrupy. And yes, or basically, if you have any increase in white cells, you have an increase in therapy or years, or that is a marker of inflammation on. It will be due to your diagnosis. A serum uric is important. Um, uh, it could be elevated in God's, and we will talk about calculator. But what we're trying to do here is we're trying to identify the coast. Is it an infection? or is it got image? It can also be done so playing film radiographs in this in defense of the condition. But it's, for example, with septic arthritis early on, you are not expecting to see anything, but it's very important, especially if there is a history of trauma. It's important to rule out any other trauma or any other causes s, so it might be something you would consider. Joint aspiration is the most important one here, because it is the one that will tell us what the diagnosis is. So with joint aspiration, you know there's two aspects to it. So the first aspect is visually, we inspected the aspirate after doing it, and what you want to look at and documents is the pass it e the color. And if there is any presents off frank loss, because that obviously will lead us the thing that there is a new infection happening there on leader, something that it might be septic arthritis. Afterwards, you can send the aspirate for white cell count microscopy, culture and sensitivity and like microscopy for crystals and as you can see in this table. So with septic arthritis, for example, you expect the pure. It's off the aspirated to be turbid. You expect very high white cell count, and you expect high neutrophil count. But, for example, if it's inflammatory arthritis, you expect high cell count, but not as high as in septic arthritis and the moderate on neutrophil. Okay, so now that we talked in general about how we want to approach a patient with a hot, swollen joint, you want to think off the differentials and all the causes that can cause this. So, as you can see, the first important one is septic arthritis and cervical tractors is probably the most serious one. And it's the one that we need to, uh, rule out first and identify first. Other causes are crystal. Arthritis has gotten pseudogout. He more throws. Is the active arthritis. Ah, more articular hesitation of inflammatory arthritis and dramatic synovitis. We're going to focus today on septic arthritis and little arthritis. Uh, we will talk a little bit about the rest of the ends, but our focus for today will be the first to, uh, by the way, I'm looking at the chart, So if there's any questions, I'm happy to answer them. So septic arthritis is the most serious course off one arthritis. And when we say, obviously, my arthritis will be just a presentation with one swollen joints. It is an emergency, and it can cause joint damage and severe osteoarthritis, and it can have some complications, such as osteomyelitis eso. That's why identifying it early and treating it with early antibiotics is extremely important and quickly going over some off. The pathogens that can cause this so the most common in adults is stuff for us. Streptococcus can also cause, um, septic arthritis. In sexually active younger patients, gonorrhea is the most common, and in those with sickle cell disease, they're more susceptible to salmonella. So some of the risk factors that increases the chance off getting septic arthritis is increasing age. So, uh, usually the older population population are at a higher risk. Pre existing joint disease eso, for example, rheumatoid arthritis can increase the risk of getting septic arthritis being immune, suppressed or debit is a sweet. No diabetes in general increases the risk of infection. Chronic kidney disease, having a hip or knee prestige is also increases the risk and intravenous drug use. So with septic arthritis, it's important to understand, expect what the typical clinical feature is, so it typically presents with a single swollen joint, causing severe pain and prior Xia. Now I know that typically by Rexy, it is one of the things we all think about when it comes to septic arthritis. But it should be noted that absence off a wreck. See, I should not rule article ritis. Just just that somebody doesn't have a fever doesn't mean it's not subject. Arthritis is something else. It can still be septic arthritis. They're usually unable to wait there, and they have a very limited range of motion that might be associated with pain. On examination, you expect a red swollen and warm joint. You expect pain on active and passive movements on you. Expect an effusion, so this swelling and pain is expected to happen over a few days, and this is important. It's It's over days, maybe a day, two days to up, sometimes two a week. So it is a cute, but it's not. It's a cute as a gout, for example, which we will talk about later. So typically, 24 hours. Plus, you know, the most commonly affected joints is the knee Um, and as you can see here, I was mentioning this point earlier. In 40 to 50% of the patient, there's actually no fever. So that's why you cannot use fever as a as a factor to rule it out. 85% is more arthritis. That means there is, um It could be possible to get a patient with more than one swollen joint with septic ours arthritis. Other than the knee, which is the most commonly involved joint, it can also affect the hip, the shoulder and the ankle. So investigations is very similar to what we mentioned before. So routine bloods therapy es or will show you this any infection, if any information your it's it's not gonna You don't expect it to be abnormal in septic arthritis, but you needed to rule out gout. Uh, and we will touch more about your it later when we reached out blood cultures specifically of the patient s septic. You want to do blood cultures? Onda aspiration aspirating the joints. Now, the very important thing here that I think is really vital to remember is that before you, if you want to aspirated and if you suspect septic arthritis, you should aspirate. You should always do it before we give any antibiotics. And so both cultures and escalation is the same. Obviously, if the patient is extremely unwell and he cannot wait to get his knee aspirated or the joint aspirated, then that is a little bit tricky. But the general rule of thumb is if you suspect septic arthritis, they should get us an aspiration. And if you're going to aspirate, do it before you start the antibiotics, uh, then obviously going to send the aspirate as they aspirated for gram stain, leukocyte count, microscopy and culture. If it is a patient with a prosthetic joint, Uh, then also it should be aspirated. But the difference here is it should not be done outside of theater because there is an increased risk off Tradjenta infection. Eso. If you have a patient that presents to ET with the prosthetic joint and you suspect it's a septic joints, then you want to immediately contact orthopedics on. Refer the patients on, inform them that you have a patient that might need an aspiration in theater. Uh, imaging also can be important now, Like I said before in the early stages, uh, there you don't really, um, expect to see anything. But eventually it might progress to demonstrate a capsule and soft tissue swelling or even joint space widening. But most of the time it might be normal. So management off. Septic arthritis. Now, if the patient is septic, then obviously early resuscitation and investigations will take priority. Uh, usually, the management is usually empirical antibiotics Do check your local guidelines before you prescribe, uh, again, I put between brackets and I think I'll mention it more than once. Today is do the cultures and aspirate first, then start the antibiotics. Usually it's a long term therapy for 4 to 6 weeks on. Usually it's two weeks of IV antibiotics, and some patients might be able to switch to oral antibiotics if they're improving. He also needs surgical irrigation and wash out. So if you suspect septic arthritis, you need to take an aspirated take cultures start the antibiotics on, then refer to Ortho on been formed in the patient. Will needs will probably need an irrigation wash out. So just to summarize septic arthritis, so it's an important diagnosis because, like we said, it can cause severe damage to the joints. It can goes complications such as osteomyelitis. It presents with an acutely painful, swollen and tender joints. They're usually unable to wait there on, um, or passively move. And it's usually the city is over days, blood, cultures and aspiration always before antibiotics and early treatment with antibiotics and surgical intervention is very important. Is there any questions about septic arthritis? Okay, so I have some questions off my own. Um, please. I'll give you a couple of minutes. You can read the question, Um, and please type the letter in the Jets. We'll go over the answer after that. Just think two questions. And then we'll move over to God. Yeah. So yeah. Esther and Calvin both both said he Ah, which were few seconds to see if anybody else would like to attempt in. Answer to the question before we have one. Yeah, there's one more on Siris. Yes. Okay. So yeah. So this is a 45 year old gentleman who's coming to India with two days history off. Increasing right knee pain examination shows that it's hot Red rights need with a flexion off only 20%. So 20 degrees. So limited range of motion observations is a little bit tacky on his temperature is 37.9 and there's an increased water content. CRP. So it's asking us what's the following best management option. And I think the the first important thing is to ah, think is you know what the diagnosis. So at this point, we all think that it it might be septic arthritis. So So, yes, I see a lot of he's actually, yeah, so the it's septic arthritis. So the most important thing here is urgent orthopedic review, as he will probably needs a watch out on interrogation in theater. So this is a typical presentation of septic arthritis and adults, like we said, acute onset pain and immobility of the joints with fever and raise inflammatory markers. Um, and he should be reviewed urgency by the orthopedic team for aspiration and concentration off a wash out before, obviously, you refer to the orthopedic team. There is a few things you would have to do yourself. So that includes all the investigations of bloods. It would have to aspirate on the start antibiotics according to your local guidance, Um, depending really on what the guidance is, right? So the next question again. I'll give a few minutes for this question, and then we will move on. Yeah, so I see a c on day. See? Question Mark. Yeah, a lot of sees. Good. It's zero to know that you're all listening to me. Um, so, yeah, it's a 27 year old man, uh, who has fever and severe pain in his knee. And I'm not going to read the whole question, but it basically looks like a young man sexually active, presenting with what looks like septic arthritis. And as we said before, um, see is the correct answer. And in young adults with septic arthritis, uh, nice, very good area is the most common organisms. Pounds Okay, so there will be more questions at the end, but I'll move on now to crystal arthropathies. So under Kristen Arthropathy is there's two conditions. So this gout and they're pseudo gout. So God is an inflammatory arthritis on. It's a collection off monosodium your it crystals in the joint, and it's basically caused by hyper uricemia leading to crystallization off the ureter in the joint space is important to know that not all cases off hyper uricemia result in counts. And not everybody who gets gout has hyper uricemia. So if you do a urine sample in somebody who has gout, not you won't be sure. It's not always a fact that they're your it will be high. And also, if somebody has hyper you see me. A doesn't mean that they will get gout, so it's classically affects the first metatarsal full in jail joint the first mtp J. And as you can see, it's in the picture there. UH, what worth the notes that it can also affect the elbows, the knees, the wrists and the fingers s So it's not just the empty PJ that it effects. It's very, very rapid onset. It's hours, and it causes severe paid heat swelling. And everything. On a very classical presentation that you get is a somebody who woke up in the middle of the night with extremely severe, uh, paying in the first empty PJ that they cannot tolerate and they presented to ET. So within a few hours it becomes it flares up out of nowhere, becomes very angry, very red, very hot and swollen and extremely painful on. There could be possible systematic upset. You could you could have a fever, you could have just generally and well, it doesn't mean that it is sepsis or septic arthritis. I need classically effects, Middle age mint. So, like I was saying, a middle aged man in the middle of the night wakes up with this extreme pain in their big toe and they present to the hospital. So the investigations that you would do so joint aspiration and microscopy are the gold standard. The most important thing here. So crystal identification is the gold standard on it. It's classically a thin, needle shaped, monosodium you rate crystals. However, you really don't need it if the diagnosis is clear from the clinical picture. So, like I was saying, if I get a middle aged man and the needy with what I was saying before very, very sudden onset pain in the big toe, the first MTP j red hot swollen, then you don't really need to ask for it. But if you're not sure whether they notice is, the aspiration will confirm the diagnosis. So if you want to double check, you can always just taken aspirated serum. Uric acids can also help you with that diagnosis. It is, it is important to know that during an acute phase, serum uric acid can be normal. So if you get somebody presenting with acute gout, you take your uric acid's it. It will probably come back normal, so that should not make you doubt your diagnosis necessary. I'm just checking the chance to get, uh, white cell count CRP, and these are may all be elevated. As like we said before, it's an inflammatory condition, management wise. So there's two things we need to think about. So it's controlling the pain and inflammation and preventing this from happening again. So controlling the pain and inflammation you can use and say it's or colchicine, and if they're not working or contra indicated because of any reason, then you can also use steroids. A prevention wise, you can use a urine lowering therapy such as allopurinal. Very important to note. Allopurinol should not be started during an acute attack. So if somebody comes with an acute attack and they're not on allopurinol, do not start it. Control the pain and inflammation first with NSAIDs and coaches in and ask him to follow up. After that, you'd attack results and then we can consider starting a low purine. All that is because allopurinol can can worsen the acute attack. It's also worth a note that if somebody how the gout's had gout before and and it resolved so they don't have an acute attack, they come to you now for, um, to start a preventive therapy. Are you referring therapy And you want to start allopurinol. You need to cover that allopurinol with consciousness or end states because other pirin all can increase the risk, often gout attack happening within the induction period. So if you're starting somebody on our Punal at COLCHICINE or end stage, as long as they're not contraindicated, Okay, so that is God's again. A few more questions to more questions. Before we move over, I'll give you a few minutes to type in the answer in the chart. Just so you know, the normal your eight is, I think, let's send 500 micromoles. So this is this is high your it. Okay, Have we have a lot of mixed answers this time? Eso not Everybody's agreeing. So you have a few a Zen a C and B. I'll give it a few minutes, actually to see What other think? Okay, I see. Okay, so you can still answer. I'll just go over the question first, and, uh ah, just read what's happening here. So you have 68 year old, uh, who wants to discuss called Prevention. So this is not an acute attack despite lifestyle medication modification. Excuse me. He had four flares in the past year. So he's having this a lot, and obviously it's impacting his life. He doesn't have any other issues or health conditions. And his last gout attack was six weeks ago. So again, not acute. Recent blood tests showed how your eight. So what are we thinking? So this is somebody who had multiple got attacks and what we're trying to do here is your eight lowering therapy. Now we said that you're if lowering therapy is allopurinol, that might might be my mistake because I just mentioned it without having it on the slides. A zoo was saying earlier, If you're going to start somebody on the urethra in therapy, for example, allopurinol, you should always cross cover with either call chasing or NSAID. It's because allopurinol increases the risk off acute gout attacks happening. So if you were to give them allopurinol you need to cover with coaches. And that is according to the nice garden. So the correct answer is be so the current nice guidance advice is your It's lowering therapy for gout patients who suffer from two or more attacks per year. So he had four attacks. And when commencing a uric lowering therapy, cultures in cover should be co prescribed for even up to six months from initiation. Yeah, I hope that makes sense. Okay, uh, next question before we move on to suit God. Okay, so I see a be from the, uh okay. A few years, A few B's. Okay. So, uh, again, the wrist, if you can still continue to answer a while, I just go over the question. So, uh, this is very similar. I'm going to read the whole question to the biggest one. The only difference is so he is currently having a urine lowering therapy initiated, but the difference is, the previous one did not have a, uh, a urinary therapy. So this one is an acute attack, but they already have your it's lowering therapy. So the correct answer is actually to continue the allopurinol and commence colchicine. And and this is what the Nice says. So nice says if a patient is already a suffering out and they're already on established, you're it lowering therapy such as allopurinol. You don't have to stop it. You can continue it, and you can add cultures into to control the the acute flare up. So just to summarize, do not start allopurinol during an acute attack. If they're already another period, you don't have to stop it. If it's not an acute attack and you're going to start allopurinol cross, cover it with coaches in, I hope that makes sense. If there's any questions, I'm happy to answer them now or at the end. So, yeah, the correct answer here is continue the allopurinol and commence college coaches in All right. So pseudo gout. So very similar to go out. But it's an inflammatory arthritis, uh, like out, um, too much of herds. Pseudo gout, being referred to as chondrocalcinosis or calcium, part of phosphate deposition disease on it's the same thing. So pseudo gout is caused by deposits off calcium by reflux fit crystals. And when those crystals does up in the joints, they they cause information on because the symptoms that we will discuss so gout is your eights. So the guard is calcium viral for straight, the most commonly affected or the knee and wrist. And it's an acute onset joint swelling the same as Scout. It is the most likely cause off acute arthritis off the knee, wrist and shoulder in those more than 65 years. So I will go quickly over as to the God because it's very similar to go to just the different crystals. Ray again, the main. The gold standard for diagnosing it is joint aspiration and microscopy, and it will so positively by rough engines from Boyne shaped crystals. It would also expect increase The white cell count increased, syrupy and increased these. Or, um, there's a couple questions about to the guards on. Then we'll, uh, we'll go over. I have a slide each about the the different causes of more arthritis. Like Like I said, we're not going to discuss them in detail today. We might do a follow up, uh, webinar if there is interest going more in detail about this coast just to summarize, So sepsis versus got the speed of concepts can be something that could help differentiating so crystals that scout and sort of got usually this in 24 hours. Septic. Arthritis is days. You might get the patient who's just had it for 24 hours. And this is when it becomes, you know, Not really sure. First, mtp J is likely got. And if you're if you're in doubt, joint aspiration is your investigation off choice? If you're not sure what the diagnosis is doing, risk it and aspirate. All right, so one more question. So someone said be okay. Okay. So for bees. Um okay. Yeah. So I'm not gonna be the whole question, because it's basically they're asking what is the following with? Hope is different yet, So they got from God, and I agree with all of you. It is B. So it's chondrocalcinosis on X ray. Uh, again, we said before chondrocalcinosis is is a calcium for powerful, effective position. This is usually seen as linear. Constipation's off the meniscus and particular cartilage on X ray of the knee so you can actually see the calcification on the knee on an X ray. Obviously get one more question and then we'll move over to the last quickly over the other coast. Okay, so we have a B and we have a C. Okay. Okay. About the C. I'll give it a couple of more minutes just for the rest. To get a chance to read the question and answer. Okay. Somebody changed their answer to be okay. So again, uh, dressed, if you feel free to answer. Well, I just read the question. So 42 year olds coming in with what? Looks like a so coming in with knee pain. Hey, had this pain for past four days on. He described the joint is being incredibly hot. You know, Terry, female swelling on the aspirated me and they find a position off calcium piriform straight. Uh, the hydrate crystals. So which of the following is a risk factor for this condition? So we have to. So I think some people said, see on, uh, couple said be so the answer is hyper barra terrorism. So yes, B is the correct answer. And that is because so, uh, happy part of it isn't is a risk factor for to the girls as it increases the serum calcium, which is also from the extra excess parathyroid hormone. As we all know, parathyroid hold morning increases calcium in a couple of ways, one of which is through calcium reabsorption in the kidney and phosphate excretion, and also through breaking down the bone on releasing calcium into the blood. So this hypercalcemia can increase the risk off pseudogout. And that is because calcium post of casts calcium power for straight ahead, right crystals is what causes sort of got. So having high calcium can increase. There's so yes, he is the correct answer so quickly over the other causes off mano arthritis. I'm worried all the time. We're supposed to finish that. Eight will probably need a couple of extra minutes. Eso other causes of mine arthritis. We have rheumatoid arthritis. We have spondyloarthropathies and him. Oh, a closes or trauma. So rheumatoid arthritis. Um, again, I'm just going to summarize the those conditions. We're not going to talk about them in a huge detail. So as we all know, it's an autoimmune disease can affect patient's at any age, but it most commonly presents in those age 40 to 60 years old. Um, it's most common in the small joints in the hands and the feet on. It's often classically sparing that there's still interferon your joints, Uh, but it can still occur in any joins in the body again. Classically a symmetrical. That means it affects joints the same way it affects this joint on the right side, which will probably affect the same on the left side, However, obviously not all. It's a the time, so you get swollen, painful and red joints. But some of the things that might lead you to think that it might be rheumatoid arthritis is the classical stiffness that is usually worse in the morning and gets better as the day progresses. Uh, something else that might lead you to, uh, give you a clue is thie associative generalized symptoms that might make you think this might be a systemic disease. So you get fatigue, lethargy, per xia, weight loss or other M escape type symptoms like muscle pain and so on. Um, so blood test will show a Z inflammatory markers. So CRP any sort? Um, and you might get a rheumatoid factor and CCP A levels so that's anti situated protein antibodies. So those are antibodies, uh, to the individuals on protein, and they are directed against the peptides importance that are six related. So it's an ultra me in condition, basically. And you might get this two antibodies rheumatoid factor and CCP A eso might be some of the investigations you want to do if you, uh, suspect a rheumatoid arthritis treatment is usually initiated by rheumatologist. So if you suspect it's are anyways, you would refer to rheumatology. Uh, the next is a spondyloarthropathies. So this is a group of conditions compromising off multiple ones. So psoriatic arthritis and closing spondylitis, reactive arthritis on intrapelvic our property. So there's a couple here, and there is a very mouthful. They're classified as being several negative. So serum negative, meaning that rheumatoid factor negative. There is not really an antibody you can test on. Diagnose them, boy on. They're associating where we've actually a B 27. So it's a protein that is found on the surface of white cells. Onda presence of HLA b 27 your white blood cells can cause your new system to attack those otherwise healthy cells. So it's an autoimmune condition also, um, so they can all present with axial arthritis, so meaning arthritis affecting the spinal and sacroiliac joints. They can also affect any joint in the body on it can present as an older guy or throw it is or more north, right? Most of the diagnosis is made clinically. It's not an easy diagnosis. Sometimes greedy, graphically can can help. But again, it is something that you would refer on on lastly, traumatic as specifically him, or forfeit a process here. So him, arthros is is bleeding into a joint cavity. At the most common cause is traumatic injury. So if you get somebody, if somebody comes in with an activity swollen joint following trauma him or throws, it should be always your first differential and should be suspected. There could also be a concurrent ligamentous, or meniscal injury that is specifically causing the bleeding following trauma. Uh, however, trauma is not the only cause it can, either. A corn on dramatically so patient with bleeding disorder with him Ophelia or in those with anticoagulants. Routine bloods include quoting and plain film radiographs would be your investigations Here. Uh, you can do a joint aspiration if you want, and it can give you a definitive diagnosis. As you you would see the blood in the joints on. It will come back from the lab test. The management here is usually conservative, so it's rice rest, ice compression and elevation. You try and obviously ensuring a sufficient algesia. And I'm just trying to, uh, bring that swelling down. Uh, yes. Somebody said there is a feedback for me. Yes, there will be. You will get a link after this. I also have a cure code at the end. Um, so if you stay till the ends, they will be a feet that form. I'm quite conscious that we're over the time limit, so if you want to go now, you still get a link after this is over. So this was the dust lines. Eso the learning points I want to go over today is we how to assess patients with acute, swollen joints, the importance of recognizing a septic joint, all of the differentials we spoke about on how to investigate the that kind of presentation. But most importantly, if you're going to aspirate, do it first before you start antibiotics. Okay, so there's a couple more questions before we end this session. Um, first of all, I would be take any questions at the end if if there is any doubts, you want me to clear up. So this is the first question. Okay. Okay. So somebody said the D. Okay. Okay. So a few D's, So Yeah, this is, uh So it it gives us a presentation and ask us giving the most likely diagnosis. So in this case, I think we can all agree that it's most likely septic arthritis. You have knee pain, stiffness and swelling over three days. Uh, unable to wait there. A tall and systematically and well with temperature off 39.4. So this patient is unwell with what looks like septic arthritis. How long should this this patient received? Antibiotics. And yes, the correct answer is D 4 to 6 weeks now. Specifically, God bless you. Commended. The patients with septic arthritis received joint aspiration. So they need you in desperation. First on, then initial two weeks off anti off IV antibiotics. After two weeks, some patients may be able to switch to oral antibiotics for the remaining 2 to 4 weeks. But the old needs two weeks off IV and about. Okay. Next question. Yeah. Good. Okay, so we have a b and then a so again, as a young a quite young man comes in with a painful knee. Uh, he has a temperature red, swollen, limited range of motion. Um, and he didn't have any other symptoms. Now it's asked us what is the next most appropriate step in the management of this patient, and I think both answers that were given or correct. But keeping in mind the the question itself the next most appropriate would be aspiration, which is, I know before it sampling depending on if it actually saw the septic arthritis, then that would be a more often, uh, longer term is referring the patient to the gum clinic or getting him tested against a possible Connery infection. So the answer is synovial fluid sampling. Ah, so very yeah. So any acute red painful joints should be treated a septic arthritis until proven otherwise. Now he's got lines suggest that if septic arthritis must be considered any person who is systemically unwell, uh, that's with or without the temperature and an acutely painful, swollen knee. So according to nice sign of a fluid culture is the only and reliable method off evaluating potentially infected joint. Okay, this is the Uh um, ninth question on, dear is one more after this and we're done just cause relatively behind time, I might actually just go ahead on until the question straight away. Um, what's we'll give it a few seconds. So somebody said, See? Yeah, correct. It is he So So this looks like gout's, um, But they The trick here is that the patients has peptic ulcer or juvenile officer. So if this was somebody without, you know, ulcer and who doesn't have contraindications, you have to give coaches in our a buprofen or an NSAID, whatever you want. But in this case, because the patient has a general ulcer on, he comes in with a presentation of counts. Then colchicine is the right answer. So, yeah. Uh, yeah, there's a few sees. And one day, yes, same thing. Topical Diclofenic, um, again inside. And usually we give something oral also to improve the pain. So because of the past medical history, um, also seen is there Okay, last question just to clarify the previous question. Um uh, topical and stayed still carry a risk. Even if it's a little bit lower. It is lower, but it carries the risk of gastric irritation because there is still some systemic absorption. So that's why you would still avoid it if somebody has a, uh, you know, also history and this final question. Okay. Uh, yeah, you can all answer. I'm just gonna go. Kevin, you said reduce those. I'm not sure. Uh, what's you mean in in relation? To what? Because we've moved on. If you want to just clarify a question, Um, and then everyone said, How would differentiate this with a base of the thumb? Okay, this question, the the The difference here is, uh, from the history. So it says extremely painful joints at the base of the thumb which came on suddenly. So it's sudden onset. Uh, he also doesn't have history off for most your authorities. So it couldn't be a flare up if he does have, Ah, history. 40 osteoarthritis. It is a flare up. You could doubt the diagnosis because it is a no history, extremely painful and sudden onset. So that makes this Makes it likely that it's more likely to be out. But obviously you could still do more tests and an extra if you're not sure. So yes, The last question we have. We he Everybody agrees. So Yeah, it is, um is the first metatarsal awful NGO joints. And that is we usually work outs effects. Okay, but thank you, everybody for attending. I'm sorry. We ran 10 minutes late, so I was trying to do my best to get this over on, uh, within the time that I have, but apologies. Um, so we appreciate your feedback. There's a cure code here. Uh, please tell us how we can improve this If there's anything you want us to do differently. Uh, there is a pediatric presentations in orthopedics in the 26th off May So please sign up for the session and attend. If you do have the time. Ah, I will be here to take any questions from the floor. Um, if there's any questions, I'll be happy to answer. No worries. Thank you. There's an email here also, if you don't get your certificates for some reason, we do have some issues. Sometimes just email us and, uh, but hopefully, if you do the you should automatically get the certificates after completing the feedback for which you're gonna get by email or from doing the QR codes. okay if there's no questions. Thank you. Everybody is not having you here. And please join us for our session on the 26th off. May. Thank you.