Remote Primary Health Care Manuals

Joint problems

Use this protocol for swollen, painful joints or limp NOT due to accident, injury or trauma

Red Flags — Urgent Medical Consult
  • Fever, unwell and joint problem
  • Child with unexplained limp or limp not getting better

Look in file notes

Ask

  • Trauma, accident or injury
  • Pain and swelling — where is it, when did it start, how bad is it
  • Movement and stiffness
  • Same sort of problems in past
  • Which joint/s affected
  • Any other problems, eg skin infections, sore throat, fever

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL

Table 7.7 Signs and symptoms of common joint problems  

Joint condition Acute rheumatic fever (ARF) Joint infection
(septic arthritis)		 Gout Rheumatoid arthritis Osteoarthritis
Usual timing Swelling begins to settle in days, gone in 2–3 weeks Onset over 0–3 days Onset overnight or 0–1 days Chronic — recurring, swelling lasts many weeks Chronic, variable. More common in older people
Joint red and hot Usually Yes Yes Usually warm No
Joint painful Yes

Very, worse with small movement

 Very Yes Yes
Joint tender to touch Often Yes Very Yes Not usually
Moving joint Painful to move

Very painful, holds joint still

Stiff, too painful to move

 Morning stiffness for more than 30 minutes Stiff after rest, in morning — better with movement
Fever Usually Usually — but may be none in early stages Usually no fever — but may have fever or chills Not common. Possible when joints acutely inflamed No
Other

Unwell. Other features of ARFxref-slash icon

Unwell. Painful limp

 May have had before — lasting days

Unwell — flu-like symptoms and tired. May have had before

Weakness, limp

Joints most often affected

Knee, ankle, elbow, wrist. Often moves from joint to joint, but may be single joint

 Single joint Big toe, foot, ankle, knee, hand, wrist

Symmetrical (same on both sides of body). Multiple joints — hand, foot, knee

 Hand, spine, hip, knee

Septic arthritis (joint infection)

Joint infection can occur with punch injury or without any visible injury

Do

  • Urgent medical consult
  • Give pain relief
  • Blood cultures
  • If very sick or transport time will be more than 4 hours — medical/specialist consult about giving antibiotics
    • Antibiotics are usually not started before transfer as joint aspiration for MC&S done in hospital
  • Put limb in splint

Gout

  • Caused by too much uric acid in the blood which can deposit in joints
  • Usually gets better over a few days without treatment but often comes back
  • Treatment can shorten time and lessen chance of it coming back

Do

THEN indometacin oral — adult 25mg, 3 times a day (tds) until pain stops

OR ibuprofen oral — 200mg, 3 times a day (tds) up to 800mg a day until pain improved

  • If contraindications to NSAIDs 
    • Give other pain relief and prednisolone oral — adult 20mg, once a day for 3–5 days
  • Provide patient education — limit intake of alcohol (especially beer and spirits), fructose-sweetened drinks (soft drinks, juice) and purine-rich foods (eg shellfish, sardines, organ meats like liver)
  • If person already taking urate-lowering (eg allopurinol) therapy — advise not to stop or change therapy during an acute attack of gout
  • If repeated attacks — medical consult — may need allopurinol to prevent further attacks after this attack has settled

Rheumatoid arthritis

  • Chronic inflammatory disease. Causes joint damage
  • Early diagnosis important to manage pain, improve function, prevent permanent joint damage and consider use of disease modifying antirheumatic drugs (DMARDs)

Do

  • Blood for FBC, UEC, HbA1c, fasting lipids, LFT, CRP, ESR RF, anti-CCP 
  • Medical consult for
    • Diagnosis — apply 2010 ACR/EULAR classification criteria 
    • Early medicines — give pain relief
    • Rheumatologist consult or review — diagnosis, inflammatory arthritis, other medicines, joint surgery
    • X-ray — chest, hands, feet
  • Ice and/or heat can help pain

  • If ongoing — refer to physio/OT

Osteoarthritis

  • Most common form of arthritis
  • Due to wear and tear of joint cartilage with age, significant injury, repetitive use, obesity

Do

  • Give pain relief AND/OR methyl salicylate rubbing cream
  • Medical consult —
    • Accurate diagnosis
    • X-ray affected joints — weight bearing for hips and knees
    • Review pain relief
    • Physio/OT referral
    • Talk about nutrition and weight loss
    • In later stages — joint replacement

Ongoing management of chronic arthritis

Includes osteoarthritis, rheumatoid arthritis, gout

  • Look in file notes for management plan and specialist letters. If no management plan — develop one including
    • Regular reviews, specialist referrals
    • Self-management — physical activity, rest, relaxation, healthy diet, weight loss if needed. Give education, refer to support group
  • Encourage  physical activity — for mobility and muscle strength — medical/physiotherapy consult
  • Refer to other allied health as needed
    • OT — aids, equipment
    • Dietitian — weight loss
    • Pharmacist — medicines review, education