Joint problems

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

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  

Acute rheumatic fever (ARF)

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

Supporting resources