Acute Monoarthritis: Diagnosis in Adults

 

Am Fam Physician. 2016 Nov 15;94(10):810-816.

Author disclosure: No relevant financial affiliations.

Acute monoarthritis can be the initial manifestation of many joint disorders. The most common diagnoses in the primary care setting are osteoarthritis, gout, and trauma. It is important to understand the prevalence of specific etiologies and to use the appropriate diagnostic modalities. A delay in diagnosis and treatment, particularly in septic arthritis, can have catastrophic results including sepsis, bacteremia, joint destruction, or death. The history and physical examination can help guide the use of laboratory and imaging studies. The presence of focal bone pain or recent trauma requires radiography of the affected joint to rule out metabolic bone disease, tumor, or fracture. If there is a joint effusion in the absence of trauma or recent surgery, and signs of infection (e.g., fever, erythema, warmth) are present, subsequent arthrocentesis should be performed. Inflammatory synovial fluid containing monosodium urate crystals indicates a high probability of gout. Noninflammatory synovial fluid suggests osteoarthritis or internal derangement. Pitfalls in the diagnosis and early treatment of acute monoarthritis include failure to perform arthrocentesis, administering antibiotics before aspirating the joint when septic arthritis is suspected (or failing to start antibiotics after aspiration), and starting treatment based solely on laboratory data, such as an elevated uric acid level.

Monoarthritis refers to the clinical presentation of pain or swelling in a single joint.1 The diagnosis can pose a considerable challenge in the primary care setting because the pain may be limited to the joint, or it may represent early manifestation of a systemic disease.2 Understanding the clinical clues associated with potential diagnoses and using an evidence-based, systematic clinical approach are of utmost importance.3 A delay in diagnosis and treatment, particularly with septic arthritis, can have catastrophic results including sepsis, bacteremia, joint destruction, or death.35 Pitfalls in the diagnosis and early treatment of acute monoarthritis include failure to perform arthrocentesis, administering antibiotics before aspirating the joint when septic arthritis is suspected (or failing to start antibiotics after aspiration), and starting treatment based solely on laboratory data, such as an elevated uric acid level.35

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Radiography is not necessary for an accurate diagnosis of monoarthritis in the absence of trauma or focal bone pain.

C

3, 4

Analysis of synovial fluid distinguishes infectious and inflammatory causes of acute monoarthritis from noninflammatory causes.

C

3, 4, 11, 14

Gouty arthritis may be diagnosed without synovial fluid analysis using a diagnostic rule.

C

24

Disseminated gonococcal infections may not result in septicemia or positive synovial fluid cultures; therefore, cultures should be obtained from the potentially infected mucosal site.

C

31, 32

Inflammatory synovial fluid containing monosodium urate crystals, particularly in the presence of podagra, is highly suggestive of gout.

C

23, 24

Erythrocyte sedimentation rate and C-reactive protein level are more useful for following a disease course than discriminating the presence or absence of the disease in patients with monoarthritis.

C

19, 33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Radiography is not necessary for an accurate diagnosis of monoarthritis in the absence of trauma or focal bone pain.

C

3, 4

Analysis of synovial fluid distinguishes infectious and inflammatory causes of acute monoarthritis from noninflammatory causes.

C

3, 4, 11, 14

Gouty arthritis may be diagnosed without synovial fluid analysis using a diagnostic rule.

C

24

Disseminated gonococcal infections may not result in septicemia or positive synovial fluid cultures; therefore, cultures should be obtained from the potentially infected mucosal site.

C

31, 32

Inflammatory synovial fluid containing monosodium urate crystals, particularly in the presence of podagra, is highly suggestive of gout.

C

23, 24

Erythrocyte sedimentation rate and C-reactive protein level are more useful for following a disease course than discriminating the presence or absence of the disease in patients with monoarthritis.

C

19, 33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Etiology of Acute Monoarthritis

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The Authors

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JONATHAN A. BECKER, MD, is an associate professor in the Department of Family and Geriatric Medicine and program director for the Family Medicine Residency at the University of Louisville (Ky.) School of Medicine....

JENNIFER P. DAILY, MD, is an assistant professor in the Department of Family and Geriatric Medicine and associate director of the University of Louisville and Kentucky One Health Primary Care Sports Medicine Fellowship at the University of Louisville.

KATHERINE M. POHLGEERS, MD, MS, is a primary care sports medicine fellow at the University of Louisville School of Medicine. At the time the article was submitted, Dr. Pohlgeers was a third-year family medicine resident at the University of Louisville School of Medicine.

Address correspondence to Jonathan A. Becker, MD, University of Louisville, 201 Abraham Flexner Way, Ste. 690, Louisville, KY 40204 (e-mail: jon.becker@louisville.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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