Background Several published recommendations for management of the acute swollen joint exist; the 2006 BSR recommendations for management of the hot swollen joint, and the EULAR/EFORT 2009 recommendations for management of acute knee swelling. Common to these recommendations are that affected patients undergo history taking, examination of musculoskeletal system, blood tests to include full blood count, inflammatory markers and renal function, plain X rays of the affected joint, and aspiration of the swollen joint.
Objectives In this audit, we set a standard of expecting management of 90% of patients with acute swollen joints to be in line with these recommendations.
The importance of joint aspiration is acknowledged by the fact that knee joint aspiration is deemed an “essential GIM procedure” by JRCPTB (Joint Royal Colleges Postgraduate Training Board) for all registrars training in General Internal Medicine, and competence is “desirable” more junior grades of medical trainees. Therefore, in cases of knee swelling, we documented whether knee aspiration was performed, prior to rheumatology referral.
Methods Over 3 months, case notes of medical inpatients referred to the rheumatology registrar with acute joint swelling (less than 6 weeks onset) were reviewed.
Results 23 patients were identified. History documented in 18/23, examination of joints in 2/23. 16/23 had appropriate blood tests. 5/23 patients had X rays of affected joints. No aspiration of joints other than knees was undertaken prior to rheumatology referral. 15/23 patients had knee swelling. 3 had knee aspiration prior to rheumatology referral; 1 was done by orthopaedics, and 2 knee aspiration procedures were done by a renal medical trainee. Median time to rheumatology referral was 4 days.
Conclusions Lack of awareness of important differential diagnoses may be one factor contributing to the low uptake of appropriate management steps. 2 patients audited were referred with MTP swelling, but on rheumatology review, acute knee synovitis was also present. The acute knee swelling had not been detected, reflecting either lack of full history and musculoskeletal examination, or difficulty in recognizing synovitis. Poor uptake of knee aspiration may reflect lack of experience or time of seniors on the medical ward to teach joint aspiration. In this audit, knee aspirations done by the general medical team were performed by a medical trainee who had recently gained independence in knee aspiration during rotation on the rheumatology ward.
To improve management of acute joint swelling on the medical ward, clinical guidelines are published within the general medical guidance folder of our trust intranet. Rheumatology registrars and consultants also undertake supervision for knee aspiration for medical trainees. A joint model in our clinical skills lab is also available to aid teaching knee aspiration to trainees.
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Landewe RB, Gunther KP, Lukas C, Braun J et al. EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee. Ann Rheum Dis 2010; 69(1):12-9.
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Disclosure of Interest None declared