Emergency Medicine

ACUTE ARTHROPATHY

General Medical Emergencies 107

MANAGEMENT

1 Give the patient an NSAID in a known relapsing case, or if there is strong
clinical suspicion of gout, such as ibuprofen 600 mg orally once, then
200–400 mg orally t.d.s. or naproxen 500 g orally, followed by 250 mg orally
t.d.s.

2 Give prednisone 50 mg orally daily for 3 days instead, then tapered over
10–14 days in patients with renal or gastrointestinal disease unable to take
NSAIDs.

3 Reserve colchicine 1 mg orally then 0.5 mg orally up to 1 h later, if the patient
ca nnot tolerate eit her steroids (hea r t fa i lure or d iabetes) or NSA IDs (rena l or
gastrointestinal disease).
(i) Do not repeat the colchicine dose for at least 3 days.

4 Refer the patient back to the GP or to medical outpatients.

5 Refer the patient immediately to the orthopaedic team for joint aspiration if
septic arthritis cannot be excluded (see p. 105).

Pseudogout

1 This is much less common than gout, typically affecting the knee, wrist or
shoulder, and is associated with diabetes, osteoarthritis, hyperpara-
thyroidism, haemochromatosis and many other rare conditions.

2 X-ray may show chondrocalcinosis, and joint aspiration shows weakly
positive birefringent crystals under polarizing light microscopy.

3 Treatment is as for acute gout, with referral back to the GP or to medical
outpatients for follow-up.

Traumatic arthritis

DIAGNOSIS

1 Severe joint pain is usually associated with obvious trauma, although
occasiona lly t he trauma is mild or even forgotten.

2 Haemarthroses may also occur spontaneously in haemophilia A (factor VIII
deficiency), haemophilia B (Christmas disease with factor IX deficiency) or
severe von Willebrand’s disease (with deficiency of both von Willebrand’s
factor and factor VIII).

3 Request an X-ray, although it may not always demonstrate an obvious
fracture.
(i) Suspect a fracture when there is supporting evidence of a
haemarthrosis with a joint effusion or periosteal elevation (e.g.
scaphoid or radial head).

4 Arrange joint aspiration performed by a senior ED doctor to look for a
haemorrhagic joint effusion, with fat globules f loating on the surface in
cases of intra-articular fracture, if there is doubt about the diagnosis.