Hi
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I want to canvass opinion regarding suitable approach for patients presenting with newly diagnosed foot monoarthritis.
Case in point was 50 YO lady I saw this morning.
Some questions about this case;
What investigations would you do for this lady and why?
Would you do a SFA and if so what?
If not why not?
Do you do in office SFA?
If not; how do you transport what will likely be a few drops of SF to lab for SFA
Case history and PE.
She was referred by primary care physician for undiagnosed metatarsalgia – 5 years duration gradual onset and worsened recently, no prior workup. She reported being in good general health, no other joint pain, denied recollection of a traumatic event or foot surgery, denied rest pain, no weight-bearing pain on rising from bed in morning, pain worsened with increased activity, improved with rest, VAS 4: (visual analogue pain scale range 0-10; moderate pain which interferes with tasks). Episodic radiating pain into 2nd toe. No suspicion for reactive arthritis or TB.
PE; no signs of swelling, erythema, heat or skin lesions, tenderness to palpation at dorsal 2nd metatarso-phalangeal joint margins and generally at 2nd and 3rd metatarsal heads, Provocative testing with double limb stance heel raise resulted in plantar 2nd metatarsal head pain. She had hallux valgus, no hallux limitus, attenuated plantar plate stiffness of lesser digits, reducible flexible flexion deformity of all lesser toes, no pain or crepitation with passive dorsiflexion or plantarflexion of metatarso-phalangeal joints or active resistance of toe flexors.
Diagnostic ultrasound exam was significant for slightly inhomogeneous 2nd metatarso-phalangeal joint effusion and very hyperintense signal with power Doppler imaging within synovial envelope. No evidence of “Mortons neurona” but evidence of inter-metatarsal space bursa enlargement adjacent to plantar digital nerve. 2nd and 3rd plantar plates were mildly degenerated at proximal phalanx. There was evidence of a double contour sign at 2nd metatarso-phalangeal joint (a “double contour” is the US sign associated with intercritical or acute gout. It is an extra hyperechoic line representing a visible surface layer of MSU crystals in addition to the normal single hyperechoic subchondral contour). Plantar fibro-fatty pad @ metatarsal heads was unremarkable for edema and no signal with power Doppler imaging.
My ranked differential diagnosis was one or more of;
Inflammatory osteo-arthritis 2nd metatarso-phalangeal joint
Crystal deposition disease (US evidence of intercrititical gout)
Plantar digital neuritis.
plantar fibro-fatty pad overload
plantar plate defect
early rheumatoid or sero neg arthritis
haematogenous septic arthritis.
So my immediate problem is the monoarthritis. I believe it is perhaps only pain generator but may be layered on top of prior chronic injury
It is impossible to know how long this has been present and there was no prior radiographic exam.
Her joint effusion warrants an arthrocentesis, this may show MSU.
The literature without exception rightly states that presence of MSU in synovial fluid (SF) doesn’t rule out septic arthritis (SA).
So therefore it is implied that SFA with WBC and possibly culture if WBC is elevated (which would be with gout) should be approach.
I have done medical literature search to find incidence of haematogenous SA in adult foot joints and could find no data published. I have never knowingly seen this or heard anecdotes for this scenario.
I have ordered radiographic exam, and serum uric acid which will have limited value given clinical presentation – more importantly an athrocentesis with SFA for crystals next week or immediately if clinical signs for SA ensue.
Cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com
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