articular diseases, arthritis
DESCRIPTION
Excellent review chapter on arthritis and periarticular diseases.TRANSCRIPT
2216
PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders
Approach to Articular and Musculoskeletal DisordersJohn J. Cush
(Table 393-1) -
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articular non-articular inflammatory noninflammatory
acute chronic localized (monarticular)widespread polyarticular
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ARTICULAR VERSUS NONARTICULAR
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INFLAMMATORY VERSUS NONINFLAMMATORY DISORDERS
Neisseria gonorrhoeae Mycobacterium tuberculosis
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393
TABLE 393-1 EVALUATION OF PATIENTS WITH MUSCULOSKELETAL COMPLAINTS
SECTION 3 DISORDERS OF THE JOINTS AND ADJACENT TISSUES
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2217CHAPTER 393
Approach to Articular and Musculoskeletal Disorders
Figure 393-1
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Fig. 393-2
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Initial rheumatic history and physicalexam to determine1. Is it articular?2. Is it acute or chronic?3. Is inflammation present?4. How many/which joints are involved?
Is it articular?Nonarticular conditionConsider
Trauma/fractureFibromyalgiaPolymyalgia rheumaticaBursitisTendinitis
Is complaint > 6 wk?
Acute Chronic
Consider
Infectious arthritisGoutPseudogoutReactive arthritis
of chronic arthritis
Is inflammation present?1. Is there prolonged morning stiffness?2. Is there soft tissue swelling?3. Are there systemic symptoms?4. Is the ESR or CRP elevated?
Chronicinflammatory
arthritis
How manyjoints involved?
Are DIP, CMC1, hip orknee joints involved?
Chronic inflammatorymono/oligoarthritisConsider
Indolent infectionPsoriatic arthritisReactive arthritisPauciarticular JIA
Chronic inflammatorypolyarthritis
Is involvementsymmetric?
Are PIP, MCP, orMTP jointsinvolved?
ConsiderPsoriatic arthritisReactive arthritis
Rheumatoidarthritis
Osteoarthritis
No Yes
Musculoskeletal Complaint
Yes
No
No Yes
No Yes
No Yes
No Yes
>31– 3
Unlikely to be osteoarthritisConsider
OsteonecrosisCharcot arthritis
Chronicnoninflammatory
arthritis
Unlikely to be rheumatoid arthritisConsider
SLESclerodermaPolymyositis
ALGORITHM FOR MUSCULOSKELETAL COMPLAINTS
FIGURE 3931 Algorithm for the diagnosis of musculoskeletal complaints.
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PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders
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CLINICAL HISTORY-
age
sex race-
Racial predilections
Familial aggregation
onset, evolution duration
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extent distribution -
monarticular oligoarticular
pauciarticular polyarticular
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precipitating events
(Table 393-2)
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rheumatic review of systems
Trauma/fracture Low back pain
Age <60 years Age >60 years
Repetitive strain injury (Tendinitis, Bursitis)
Osteoarthritis
Gout (males only)Gout
Pseudogout
Rheumatoid arthritis Polymyalgia rheumatica
Osteoporotic fracture
Infectious arthritis(GC, viral, bacterial, Lyme)
Septic arthritis (bacterial)
MOST COMMON MUSCULOSKELETAL CONDITIONS
Fibromyalgia
Orthopedic evaluation
FRE
QU
EN
CY
More
Less
Psoriatic, Reactivearthritis, IBD arthritis
FIGURE 3932 Algorithm for consideration of the most common musculoskeletal conditions.
TABLE 393-2 DRUG-INDUCED MUSCULOSKELETAL CONDITIONSArthralgias
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Myalgias/myopathy-
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Tendon rupture/tendinitis
Gout-
Drug-induced lupus-
Drug-induced subacute lupus
Osteonecrosis
Osteopenia
Scleroderma-
Vasculitis-
Abbreviations: -
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2219CHAPTER 393
Approach to Articular and Musculoskeletal Disorders
RHEUMATOLOGIC EVALUATION OF THE ELDERLY
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RHEUMATOLOGIC EVALUATION OF THE HOSPITALIZED PATIENT
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PHYSICAL EXAMINATION
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(Table 393-3)
pain warmth erythema swelling
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stability
Subluxation dislocation
TABLE 393-3 GLOSSARY OF MUSCULOSKELETAL TERMSCrepitus
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Subluxation
Dislocation
Range of motion
Contracture
Deformity
Enthesitis
Epicondylitis
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PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders
swellingvolume
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range of motion
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Contracturescrepitus
deformity
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APPROACH TO REGIONAL RHEUMATIC COMPLAINTS
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HAND PAIN-
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(Fig. 393-3)
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1st CMC: OA
de Quervain'stenosynovitis
DIP: OA,psoriatic orreactive arthritis
PIP: OA, SLE,RA, psoriatic arthritis
MCP: RA,pseudogout,hemochromatosis
Wrist: RA,pseudogout,gonococcal arthritis,juvenile arthritis,carpal tunnel syndrome
FIGURE 3933 Sites of hand or wrist involvement and their poten-tial disease associations. -
-(From JJ Cush et al: Evaluation of musculoskeletal complaints,
in Rheumatology: Diagnosis and Therapeutics, 2nd ed, JJ Cush et al [eds]. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 3–20. Used with permission from Dr. John J. Cush.)
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2221CHAPTER 393
Approach to Articular and Musculoskeletal Disorders
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SHOULDER PAIN
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(Fig. 393-4)
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KNEE PAIN
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genu varum genu valgum -
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Clavicle
Humerus
Bicipitaltendon
Glenohumeral(shoulder) joint
Acromion
Acromioclavicularjoint
Subacromialbursa
Supraspinatusmuscle
Subscapularismuscle
Supraspinatustendon
FIGURE 3934 Origins of shoulder pain.
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PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders
Baker’s cyst
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HIP PAIN
(Fig. 393-5)
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LABORATORY INVESTIGATIONS-
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Anterior Posterior/lateral
Enthesitis(anterior superioriliac crest)
True hip pain,lliopsoasbursitis
Meralgiaparesthetica
Sacroiliac pain
Ischioglutealbursitis
Sciatica
Buttock painreferred from lumbosacralspine
Trochanteric bursitis/enthesitis
FIGURE 3935 Origins of hip pain and dysesthesias. (From JJ Cush et al: Evaluation of mus-culoskeletal complaints, in Rheumatology: Diagnosis and Therapeutics, 2nd ed, JJ Cush et al [eds]. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 3–20. Used with permission from Dr. John J. Cush.)
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2223CHAPTER 393
Approach to Articular and Musculoskeletal Disorders
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-(Table 393-4)
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c R e -s t -
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Fig. 393-6
Chlamydia trachomatis N. gonorrhoeae
M. tuberculosis
DIAGNOSTIC IMAGING IN JOINT DISEASES
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-(Table 393-5)
Ultrasonography
TABLE 393-4 ANTINUCLEAR ANTIBODY (ANA) PATTERNS AND CLINICAL ASSOCIATIONS
ANA Pattern Antigen Identified Clinical Correlate
Abbreviations: c Re s t
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PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders
crystal deposition on cartilage. Use of power Doppler allows for early detection of synovitis and bony erosions. Radionuclide scintigraphy is a very sensitive, but poorly specific, means of detecting inflammatory or metabolic alterations in bone or periarticular soft tissue structures. Scintigraphy is best suited for total-body assessment (extent and dis-tribution) of skeletal involvement (neoplasia, Paget’s disease) and the assessment of patients with undiagnosed polyarthralgias, looking for occult arthritis. The use of scintigraphy has declined with greater use and declining cost of ultrasound and MRI. The limited tissue con-trast resolution of scintigraphy may obscure the distinction between a bony or periarticular process and may necessitate the additional use of MRI. Scintigraphy using 99mTc, 67Ga, or 111In-labeled WBCs has been applied to a variety of articular disorders with variable suc-cess (Table 393-5). Although [99mTc] diphosphate scintigraphy may be useful in identifying osseous infection, neoplasia, inflammation, increased blood flow, bone remodeling, heterotopic bone formation, or avascular necrosis, MRI is preferred in most instances. Gallium scan-ning uses 67Ga, which binds serum and cellular transferrin and lac-toferrin and is preferentially taken up by neutrophils, macrophages,
bacteria, and tumor tissue (e.g., lymphoma). As such, it is primarily used in the identification of occult infection or malignancy. Scanning with 111In-labeled WBCs has been used to detect osteomyelitis and infectious or inflammatory arthritis. Despite their utility, 111In-labeled WBC or 67Ga scanning has largely been replaced by MRI, except when there is a suspicion of septic joint or prosthetic joint infections.
Computed tomography (CT) provides detailed visualization of the axial skeleton. Articulations previously considered difficult to visualize by radiography (e.g., zygapophyseal, sacroiliac, sternoclavicular, hip joints) can be effectively evaluated using CT. CT has been demon-strated to be useful in the diagnosis of low back pain syndromes (e.g., spinal stenosis vs herniated disk), sacroiliitis, osteoid osteoma, and stress fractures. Helical or spiral CT (with or without contrast angiog-raphy) is a novel technique that is rapid, cost effective, and sensitive
INTERPRETATION OF SYNOVIAL FLUID ASPIRATION
Strongly consider synovial fluid aspirationand analysis if there is
s
Analyze fluid for
articular condition
μL?
or septic arthritides
?
Are crystals present?
articular conditions
μL?
rspecific diagnosis
Possible septic arthritis
or septic arthritis
Is the effusion?
Yes
Yes
Yes
Yes
Yes
FIGURE 3936 Algorithmic approach to the use and interpretation of synovial fluid aspiration and analysis. PMNs, polymorphonucle-ar (leukocytes); WBC, white blood cell (count).
TABLE 3935 DIAGNOSTIC IMAGING TECHNIQUES FOR MUSCULOSKELETAL DISORDERS
MethodImaging Time, h Costa Current Indications
Ultrasound <1 ++ Synovial (Baker’s) cysts
Rotator cuff tears
Bursitis, tendinitis, tendon injury
Enthesitis
Carpal tunnel syndrome
Urate or calcium pyrophosphate deposition on cartilage
Early detection of synovial inflammation or erosions
Ultrasound-guided injection/arthrocentesis
Radionuclide scintigraphy
99mTc 1–4 ++ Metastatic bone survey
Evaluation of Paget’s disease
Identifying occult arthritis in patients with undiagnosed polyarthralgia
111In-WBC 24 +++ Acute infection
Prosthetic infection
Acute osteomyelitis
67Ga 24–48 ++++ Acute and chronic infection
Acute osteomyelitis
Computed tomography (CT)
<1 +++ Herniated intervertebral disk
Sacroiliitis
Spinal stenosis
Spinal trauma
Osteoid osteoma
Stress fracture
Dual-energy CT <1 NA Uric acid deposition
Tophus localization
Magnetic resonance imaging
1/2–2 ++++ Avascular necrosis
Osteomyelitis
Septic arthritis, infected pros-thetic joints
Early sacroiliitis
Intraarticular derangement and soft tissue injury
Derangements of axial skeleton and spinal cord
Herniated intervertebral disk
Pigmented villonodular synovitis
Inflammatory and metabolic muscle pathology
aRelative cost for imaging study.
Abbreviations: NA, not commercially available; WBC, white blood cell.
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2225CHAPTER 393
Approach to Articular and Musculoskeletal Disorders
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(Fig. 393-7)MRI
(Fig. 393-8)
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AcknowledgmentThe author acknowledges the contributions of Dr. Peter E. Lipsky to this chapter in previous editions.
FIGURE 3938 Superior sensitivity of magnetic resonance imag-ing (MRI) in the diagnosis of osteonecrosis of the femoral head.
topbottom -
FIGURE 3937 Dual-energy computed tomography (DECT) scan from a 45-year-old woman with right ankle swelling around the lateral malleolus. red
arrow (Used with permission from S Nicolaou et al: AJR 194:1072, 2010.)
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