Hot Joints

Mr Mike Rafferty does an overview of the three main conditions that cause hot joints - gout, pseudogout and septic arthritis.

 

Lecture by

Video Duration: 8 minutes

  • Gout
    Created by Lara
    General
    Epidemiology

    A crystal arthropathy

    Gout is a hyperuricaemia and deposition of sodium urate crystals in joint spaces.

    Gout occurs in men more than women, due to males having higher uric acid blood levels, however female incidence goes up as diuretics are used. Incidence is mostly in over 50s and has an incidence in the UK of 3-7%


    Pathology

    Deposits of sodium urate crystals - Needle shaped

    These deposits are in the synovium of joints, most commonly the first metatarsophalangeal joint (The Big Toe). The also affect the hands at the metacarpophalangeal joints and the pinna of the ear.

    Uncommon locations for acute gout attacks include the ankle, knee and hip. The cause of increased incidence in lower limbs is thought to be gravitational bias in crystal deposition.

    The sodium urate crystals can also from in the kidney and cause chronic nephropathy in severe cases. Renal disease is the most serious complication of chronic gout.

    Top three causes

    Idiopathic decreased uric acid excretion (commonest)

    Impaired excretion due to secondary cause (Thiazide diuretics)

    Increased uric acid production

    High dietary purine intake

    Clinical Features
    Symptoms

    PAIN. Gouty attacks can be very painful. There is acute inflammation around the affected joint with warmth and swelling. It is usually a monoarthritis but more than one joint can be affected.

    The nature of the attacks categorises the gout:

    Acute - a singular attack with a second attack likely within 2 years

    Chronic Interval - chronic gout with acute episodes

    Chronic Polyarticular - chronic gout of more than one joint

    Tophaceous - a chronic gout that also deposits in soft tissues i.e. the pinna and Achilles tendon

    Renal stones - 5% of kidney stones are uric acid stones

    Signs
    • Hyperuriceamia >6mg/100ml
    • Raised inflammatory markers: High leucocytes and high ESR
    • Tophi - large smooth deposits in skin, tendons and joints
    • Clinical presentation is highly indicative of gout
    Investigations
    Cultures

    Urine

    (Can be done to check renal involvement)

    Bloods

    Bloods

    (Serum uric acid and kidney function)

    Imaging

    X - Ray

    (Useful in polyarticular as the crystals can calcify)

    Scopic/Biopsy

    Joint Fluid Microscopy - exclude concurrent infection

    Functional

    None

    Treatment
    Conservative

    Pain relief - it responds to NSAIDs very well

    Change diet to reduce purine intake - cut beer, spinach offal and carbonated drinks

    Medical

    NSAIDS

    Colchicine

    Allopurinol (Xanthine oxidase inhibtor)

    Surgical

    Repair or replacement of affected joints usually removal of tophi.