Management of the nontraumatic hot swollen joint

To audit the management of nontraumatic hot swollen joints presenting to a large UK university teaching hospital and to design a simple emergency department (ED) algorithm to improve patient care based on existing guidelines and our experience.

Prospective audit.

Between 2 February and 8 May 2009, 77 patients were enrolled. Median age was 58 years (range 19-89 years) and 57% were male patients. The most commonly affected joint was the knee (38%), with the knee, wrist, ankle, hip and elbow comprising 87% of affected joints. Thirty-three (43%) joints were aspirated; no organisms were found on microscopy or cultured in any aspirates; crystals were found in eight aspirates. Twenty-four patients were admitted. Gout was the most common final diagnosis in 14 (18%) patients, with cellulitis being the next most common diagnosis (n=9; 12%). Bursitis (n=7; 9%), nonspecific arthritis (n=7; 9%) and reactive arthritis (n=6; 8%) were also not uncommon. Four (5%) patients were treated for possible septic arthritis. It was noticed that many patients spent a long time in the ED waiting firstly for a decision to aspirate, and secondly for a senior clinician to perform this.

Patients presenting with nontraumatic hot swollen joints are common and the knee, wrist, ankle, hip and elbow are commonly affected. Joint aspirate is required to rule out septic arthritis, should be considered early and appropriate personnel called, and can show the presence of gout or pseudogout. Septic arthritis should still be considered in patients with a negative aspirate in whom there is high clinical suspicion. Our simple ED algorithm may improve patient care.