The evaluation of an acutely swollen knee must begin with a very thorough history. Important questions to ask include mechanism of injury, duration, acuity of onset, aggravating symptoms, or if swelling occurred without trauma. A knee effusion with a history of recent injury may suggest a derangement such as a ligament or meniscal tear, while an atraumatic effusion would have a higher suspicion for septic arthritis. A history of previous surgery should be determined in every patient who presents with knee swelling. Systemic symptoms of inflammation or infection should be investigated as well. Patients commonly complain of swelling and stiffness with decreased range of motion.[1]

Red Flags

Red flags include fever, non-weight bearing, loss of distal pulses, loss of sensation distal to the knee. These red flags typically need immediate evaluation.

Exam

A knee joint effusion will demonstrate swelling around the patella and distend of the suprapatellar space. Patients may have a restricted range of motion along with pain with ambulation. The exam should include observation of gait, palpation of the external knee, range of motion, joint line tenderness, McMurray tests, Thessaly test, duck walk, patellar tendon stability (ACL, PCL, valgus, varus), and a patellofemoral joint test (compression test).[4] Both the ballottement test and bulge test are done to look for knee effusion. The ballottement test is done by pressing upward on the medial aspect of the knee 2 to 3 times, then tapping the lateral patella to see if it floats outward due to effusion. Always compare the exam with the unaffected knee.  In septic arthritis, the following symptoms are the only ones to occur in more than 50% of patients: joint pain, a history of joint swelling, and fever.[5]

In patients presenting with an acutely swollen knee, initially plain, weight-bearing radiographs in 2 planes should be ordered to look for a fracture, in case of trauma. A fabella, a sesamoid bone located inside the gastrocnemius may be seen on an x-ray. It is a radio-opaque marker for the posterior border of a knee's synovium. The fabella sign or displacement of the fabella is seen with a synovial effusion and popliteal mass. The same lateral knee radiograph may show an increased opacity and widening of the suprapatellar bursa, which should be assessed if the fabella sign is seen. Another reason for plain radiographs is to detect erosive disease found in rheumatoid arthritis (RA), or joint space narrowing found both in osteoarthritis and RA.[6]

An ultrasound of the effusion can help assess a complicated effusion from a simple effusion and can also be used to performed arthrocentesis. A Saline load test may be utilized to determine if a wound near a joint communicates with the joint. In the knee, 155 mL of saline is needed to reach 95% sensitivity.

Arthrocentesis and subsequent synovial fluid analysis should be done in all cases of unexplained knee effusion. The aspirated fluid should be analyzed for cell counts, Gram stain, cultures, and crystal analysis. Hemarthrosis is commonly caused by joint trauma. Fat droplets (detected by polarized microscopy) also indicate an articular fracture. Other clotting disorders like hemophilia can cause hemarthrosis in the absence of trauma.  

The synovial fluid aspirate should be analyzed for[7]:

• Complete blood count (CBC) with differential (white blood cell [WBC], polymorphonuclear leukocytes)
• Crystal examination of synovial fluid
• Culture and Gram staining of synovial fluid
• Viscosity (RA: expect decreased viscosity and poor mucin clot formation)
• Glucose
  • Low level of synovial-fluid glucose is suggestive of an infected joint, but low glucose levels are present in only about 50% of patients with septic joints and can also occur in rheumatoid arthritis
  • Fasting glucose levels are usually reduced to less than half of the simultaneously obtained blood levels
• The presence of crystals cannot exclude septic arthritis with certainty.[8] Septic arthritis occurs concurrently with gout or pseudogout in less than 5% of cases.

Septic Arthritis

• Joint fluid appears cloudy or purulent
• Cell count with WBC greater than 50,000 is considered diagnostic for septic arthritis. However, lower counts may still indicate infection (not sensitive)[8]
• Prosthetic joint with WBC greater than 1100 is considered septic
• Gram stains only identify infective organism one-third of time
• Glucose less than 50% of serum level

Non-Inflammatory Synovial Fluid

• Contains less than 60 to 180 cells per mL, most of which should be mononuclear
• Synovial fluid is considered to be non-inflammatory if it contains less than 2000 cells/mL, but most samples of synovial fluids from pts with osteoarthritis contain less than 500 cells per ml.
• The most common cause of non-inflammatory effusions of the knee (synovial fluid white blood cell count less than 2000 cells/mcL) is osteoarthritis; other causes include osteonecrosis, Charcot arthropathy, sarcoidosis, amyloidosis, hypothyroidism, and acromegaly. Inflammatory arthritis (synovial fluid white blood cell greater than 2000 cells/mL) can be caused by infection, autoimmune disease, and crystal-induced arthritis. Aspiration of dark brown serosanguinous fluid should raise the possibility of pigmented villonodular synovitis.

Inflammatory Synovial Fluid

• Greater than 2000 leukocytes/mL
  • Traumatic: Less than 5000  (w/RBCs)
  • Toxic Synovitis: 5000 to 15,000 and less than 25% polymorphs
  • Acute Rheumatic Fever:  10,000 to 15,000 and 50% polymorphs
  • JRA 15,000 to  80,000 and 75% polymorphs
• Greater 50,000 leukocytes/mL;
  • Although other diseases including trauma, may produce WBC cells in joint fluid, levels greater than 50,000/mm3 are usually due to infectious arthritis.
  • Usually causes most intense synovial fluid leukocytosis, w/ 50,000 to 200,000 cells/mL and usually over 90% PMNs
  • Lower leukocyte counts are more common early in course of bacterial arthritis and in patients with disseminated gonococcal infection
  • Non-infectious conditions such as gout, pseudogout, acute rheumatic fever, reactive arthritis, and RA can cause a markedly inflammatory synovial effusion. Finding of greater than 90% PMNs despite relatively low total leukocyte count should prompt concern about infection or crystal-induced disease. However, the presence of crystals cannot exclude septic arthritis with certainty[9]
• Septic arthritis 80,000 to 200,000 and greater than 75% polymorphs
  • In synovial fluid WBC count and percentage of polymorphonuclear cells from arthrocentesis are the most powerful predictors for septic arthritis. The LR is increased as the synovial fluid WBC count increased.
  • For counts greater than 50,000/microL (LR, 7.7; 95% CI, 5.7-11.0) and for counts greater than 100,000/microL (LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a PMN cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47)[5]

• Septic joint: Once the lab studies have been sent, start intravenous (IV) antibiotics for the suspected infective agent. The most common bacterial causes include staphylococci (40%), streptococci (28%), gram-negative bacilli (19%), mycobacteria (8 percent), gram-negative cocci (3%), gram-positive bacilli (1%), and anaerobes (1%). Also, orthopedic consult may be necessary. Drainage of the joint is associated with rapid recovery and low morbidity. Arthroscopy allows visualization of the joint, provides the ability to lyse adhesions, drains any purulent pockets, and can facilitate debridement of necrotic material if needed.[10]
• Ligamentous injuries: The patient can be placed in a knee brace with an outpatient referral to an orthopedic surgeon.
• Fractures: These may need to be referred to a surgeon depending on severity. The Salter-Harris classification can be used for pediatric fractures involving the growth plate.
• Rheumatologic conditions: Anti-inflammatories (NSAIDs) or acetaminophen can be used, and the patient should be referred to a rheumatologist.
• For acute pain and swelling, treatment should be individualized. This includes splints, cold or ice packs, partial or non-weight-bearing braces, non-steroidal anti-inflammatories (NSAIDs), or other analgesics. If the joint has a large effusion causing pain, drainage may be an effective treatment. The fluid sample should be obtained and tested/cultured before starting antibiotics. Intra-articular steroids should be held until infection, or other contraindications have been ruled out first.[6]

• Infection
  • Bacterial
  • Mycobacterial
  • Spirochete (Lyme, syphilis)
  • Viral
• Crystal (gout and pseudogout)
• Spondyloarthritis
  • Reactive arthritis
  • Inflammatory bowel disease
• Hemarthrosis
• Acute injury
• Osteoarthritis
• Osteonecrosis

Poor outcomes may occur in septic arthritis if the patient has any of the following[11]:

• Sixty years old or greater
• Affected area is the hip or shoulder joint
• Current or history of rheumatoid arthritis
• If the patient has been on appropriate therapy for 7 days and still has positive findings on synovial fluid cultures 
• If greater than 7 days pass before starting treatment

Risks of delaying treatment beyond 24 to 48 hours include a permanent limitation in joint function and subchondral bone loss. Bacterial invasion can lead to permanent damage to articular cartilage. An infection in a prosthetic joint may result from a local infection that is left untreated and has spread to the prosthesis via blood flow to the area.[10]

Managing knee effusions requires an interprofessional team of healthcare professionals that includes a nurse, laboratory technologists, and a number of physicians in different specialties. Without proper management, the morbidity and mortality may be increased from an undiagnosed septic knee effusion. The moment the triage nurse sees an acute knee effusion, the emergency department physician must be notified to determine whether there is a high suspicion for septic arthritis.

The best outcome for a patient can be achieved with a coordinated therapy plan between multi-specialty and interprofessional teams. This includes the moment the patient is in triage in the ER, to the diagnosis of the septic knee, to orthopedic management, and finally post-hospitalization treatment. Essential in timely diagnosis is the diagnostic laboratory. Consultation with the pharmacist and infectious disease physician about the choice and administration of antibiotics will increase efficacy and patient safety. If the patient requires any resources for home, the social worker and case manager should be notified. Finally, due to knee pain and decreased mobility, a physical therapist must be consulted for early ambulation.

Using this shared decision-making model, communication among providers is a key element for the best result. This interprofessional approach must use evidence-based medicine and a unique, integrated care pathway. The best prognosis and outcomes depend on the early recognition of potential complications. (Level III)