Emergency Medicine

ACUTE ARTHROPATHY

General Medical Emergencies 109

Rheumatoid arthritis

DIAGNOSIS

1 This occasionally presents as a monoarthritis, although usually it causes a
symmetrical polyarthritis affecting the metacarpophalangeal and proximal
interphalangeal joints in particular, initially with morning stiffness.
(i) Other joints affected include the elbows, wrists, hips and knees.

2 Systemic involvement may occur with malaise, weight loss, fever, myalgia,
nodules, pleurisy, pericarditis, splenomegaly, episcleritis and pancytopenia.

3 Check FBC, ESR, rheumatoid factor, ANA and DNA antibodies.

4 X-rays initially show soft-tissue swelling only and juxta-articular osteo-
porosis, followed by joint deformity.

MANAGEMENT

1 Refer the patient to the medical team for admission if systemically unwell.

2 Refer the patient to the orthopaedic team if septic arthritis cannot be
excluded, remembering that rheumatoid arthritis predisposes to septic
arthritis.

3 Otherwise commence an NSAID analgesic such as ibuprofen 200–400 mg
orally t.d.s. or naproxen 250 mg orally t.d.s. and refer the patient to medical
outpatients or the GP.

OSTEOARTHRITIS

DIAGNOSIS

1 This usually presents as a polyarthritis of insidious onset, typically affecting
the distal interphalangeal joints, hips and knees with pain on movement, but
no systemic features.

2 However, occasionally an acute monoarthritis exacerbation may be seen
associated with marked joint crepitus.

3 Request an X-ray that may show loss of joint space, osteophyte formation and
bony cysts.

MANAGEMENT

1 Refer the patient to the orthopaedic team if septic arthritis cannot be
excluded.

2 Otherwise, give the patient an NSAID analgesic and return to the care of the
GP.