A. Examination of the Patient
Two helpful clinical clues for diagnosing arthritis are the joint pattern and the presence or absence of extra-articular manifestations. The joint pattern is defined by the answers to three questions: (1) Is inflammation present? (2) How many joints are involved? and (3) What joints are affected? Joint inflammation manifests as warmth, swelling, and morning stiffness of at least 30 minutes’ duration. Overlying erythema occurs with the intense inflammation of crystal-induced and septic arthritis. Both the number of affected joints and the specific sites of involvement affect the differential diagnosis (Table 20–1). Some diseases—gout, for example—are characteristically monarticular, whereas other diseases, such as rheumatoid arthritis, are usually polyarticular. The location of joint involvement can also be distinctive. Only two diseases frequently cause prominent involvement of the distal interphalangeal (DIP) joint: osteoarthritis and psoriatic arthritis. Extra-articular manifestations such as fever (eg, gout, Still disease, endocarditis), rash (eg, systemic lupus erythematosus [SLE], psoriatic arthritis, Still disease), nodules (eg, rheumatoid arthritis, gout), or neuropathy (eg, polyarteritis nodosa, granulomatosis with polyangiitis narrow the differential diagnosis further.
Table 20–1.Diagnostic value of the joint pattern. |Favorite Table|Download (.pdf) Table 20–1. Diagnostic value of the joint pattern.
|Characteristic ||Status ||Representative Disease |
|Inflammation || |
Rheumatoid arthritis, systemic lupus erythematosus, gout
|Number of involved joints || |
Oligoarticular (2–4 joints)
Polyarticular (≥ 5 joints)
Gout, trauma, septic arthritis, Lyme disease, osteoarthritis
Reactive arthritis, psoriatic arthritis, inflammatory bowel disease
Rheumatoid arthritis, systemic lupus erythematosus
|Site of joint involvement || |
First metatarsal phalangeal
Osteoarthritis, psoriatic arthritis (not rheumatoid arthritis)
Rheumatoid arthritis, systemic lupus erythematosus, calcium pyrophosphate deposition disease (not osteoarthritis)
B. Arthrocentesis and Examination of Joint Fluid
If the diagnosis is uncertain, synovial fluid should be examined whenever possible (Table 20–2). Most large joints are easily aspirated, and contraindications to arthrocentesis are few. The aspirating needle should never be passed through an overlying cellulitis or psoriatic plaque because of the risk of introducing infection. For patients who are receiving direct-acting oral anticoagulants or long-term anticoagulation therapy with warfarin, joints can be aspirated with a small-gauge needle (eg, 22F); the international normalized ratio (INR) should be less than 3.0 for patients taking warfarin (eFigure 20–1).
Table 20–2.Examination of joint fluid. |Favorite Table|Download (.pdf) Table 20–2. Examination of joint fluid.
|Measure ||(Normal) ||Group I (Noninflammatory) ||Group II (Inflammatory) ||Group III (Purulent) |
|Volume (mL) (knee) ||< 3.5 ||Often > 3.5 ||Often > 3.5 ||Often > 3.5 |
|Clarity ||Transparent ||Transparent ||Translucent to opaque ||Opaque |
|Color ||Clear ||Yellow ||Yellow to opalescent ||Yellow to green |
|WBC (per mcL) ||< 200 ||< 2000 ||2000–75,0001 ||> 100,0002 |
|Polymorphonuclear leukocytes ||< 25% ||< 25% ||50% or more ||75% or more |
|Culture ||Negative ||Negative ||Negative ||Usually positive2 |