Swollen Joints (Joint Effusion)

Joints become swollen either acutely or chronically:

• Chronically swollen joints are usually the result of a degenerative or autoimmune process such as osteoarthritis and rheumatoid arthritis respectively.  

• Acutely swollen joints require prompt evaluation to determine the cause as certain conditions (such as infection) require rapid intervention to prevent long term disability.  In this section we are speaking specifically about acute, monoarticular effusions.

 Differential Diagnosis of Acutely Swollen Joints

• Reactive

• Infected

• Inflammatory

• Hemorrhagic

History and Physical

In any acutely swollen joint, the first thing to do is to attempt to rule out infection.  Infected joints must be treated rapidly with antibiotics and surgical drainage to prevent long-term poor outcomes. 

• Determine if the swelling is acute or chronic.  If acute, ask if they had previous episodes, related trauma, pain, fever, or other complaints.

• On exam, ensure  that it is a joint effusion (in the joint) and not edema (overlying the joint).

• Observe for signs of infection – swelling, redness, warmth and tenderness.

• Vital signs may show a fever and/or tachycardia

• Perform gentle range of motion on the joint.  The acutely infected or inflamed joint will be very painful to move.

If there is a suspicion of a joint infection, joint fluid should be tapped to rule out infection.  After sterile preparation, insert a needle is inserted into the joint cavity and withdraw the fluid for analysis.  The fluid will have one of three appearances:

• Cloudy fluid is either inflammatory or infectious.

• Clear or straw colored fluid is due to a reactive process.

• Bloody fluid is due to some type of trauma, either from the injury, or (less likely) the tap itself.

 Indications for aspirating a joint:

1. Suspected infection

2. Tense effusion producing pain

3. Aid in diagnosis

If the history is suggestive of a traumatic event, such as a knee sprain, or of a chronic or slowly evolving benign process such as an effusion from chronic patellofemoral syndrome, the joint does not have to be tapped.  Another indication to tap the joint would be to relieve pressure and pain, such as in the acutely swollen injured knee.  Remember a rare complication of joint aspiration is infection, so tapping should not be considered lightly.

Management

Is usually based on the clinical suspicion of infection and the functional status of the patient.  If not infectious, consider treatment with the usual methods for an acute injury PRICEMM

• Protect from further injury by bracing or splinting.

• Relative rest

• Ice for 20 minutes t.i.d.

• Compression, such as in an ACE wrap to the ankle

• Elevate if possible to help reduce swelling

• Medications – NSAIDs to control pain

• Modalities – such as e-stim may help to control swelling

If thought to be infectious, start on antibiotics and Medevac as soon as possible for definitive care including antibiotics and surgical drainage.  If unable to Medevac, the joint may be repeatedly aspirated to drain pustular material and relieve pressure until such time as Medevac is possible.

Definitive management based on the results of history, physical, and results of joint fluid aspiration:

Monoarthritis with non-inflammatory joint fluid

• Results from blunt trauma or degenerative joint disease (i.e.) patella femoral syndrome (PFS) and osteoarthritis (OA).

• Clinical Symptoms: Slowly developing joint pains and stiffness, small amount of joint effusion.

• Synovial fluid analysis: Minimal abnormalities. May have slight increased white blood cell count in fluid to 5,000

• Erythrocytes Sedimentation Rate (ESR): normal

• Treatment: PRICEMM and treat underlying condition

Monoarthritis with Inflammatory Joint Fluid

• Number of disorders in this group is extremely large.

• Must distinguish between infectious and non infectious causes such as gout

• Clinical Symptoms: Sudden onset of pain and swelling,

• Physical: Pain with passive range of motion, redness, tenderness, Fever

• Synovial fluid analysis:

  • Crystal disease such as gout will have moderate WBC 10,000-60,000, crystals in fluid, normal glucose

  • Infection will have high white count usually over 50,000, no crystals, low glucose, positive gram stain and eventually culture

• Treatment: (Gout/Pseudogout): 

  • Oral indomethacin up to 150mg initially, then 25-50mg every 8 hours.  Colchicine is an alternative 0.5 – 1.0 mg initially then 0.5mg every hour

  • Immobilize as needed for pain relief

• Treatment: (Infectious or Septic Monoarthritis)

  • Obtain appropriate cultures.

  • Empiric treatment – Ceftriaxone 1 gm qd im

  • Immobilize and reaspirate as necessary . Attempts should be made to perform serial aspirations as long as an effusion remains.

 Hemorrhagic Arthritis

• Most commonly caused by trauma resulting in major ligament tear, fracture, meniscus tear, or damage to the joint capsule which results in hemarthrosis.

• Thorough history and physical exam and plain film X-RAYS to make a diagnosis

• In the absence of trauma, acute hemorrhage suggests the presence of a bleeding diathesis (i.e.) Hemophilia A or B.

• Treatment

  • Acute – PRICEMM

  • Chronic – Definitive care for underlying cause

 Fred Schmidt, PA-C and Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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