clinical perspectives of knee joint
TRANSCRIPT
Tibiofemoral Joint – formed between tibia and femur
A HINGE JOINTPatellofemoral joint – formed between the
patella and the femur A GLIDING JOINT
Femurproximal – head and neck of
femur, greater trochanter
distal – medial and lateral
condyles and epicondyles
Patella – largest sesamoid bone in body
Tibia – tibial plateau forms knee joint with femur
The fibula is not a part of the knee joint
The Quadriceps – Knee Extension
1. Vastus Medialis2. Vastus Lateralis3. Vastus Intermedius4. Rectus Femoris – 2 joint
muscle that also acts as a hip flexor
The Hamstrings- knee flexion
3 muscles:1. Biceps Femoris2. Semimembranosus3. Semitendinosus
The Adductors (Groin)Adduct the thigh
1. Adductor Longus2. Adductor Magnus3. Adductor Brevis4. Gracilis
The Sartorius: - flexes,
abducts, and laterally rotates thigh
- longest muscle in the body, “tailor’s muscle”
- Crosses hip and knee joint
The Iliotibial Tract(IT Band)
- neither a muscle or tendon, but a long, thick band of tissue that inserts into the lateral tibia (Gerdy’s Tubercle)
1. ACL – Anterior Cruciate Ligament2. PCL – Posterior Cruciate Ligament3. MCL – Medial Collateral Ligament4. LCL – Lateral Collateral Ligament
MCL:- Medial Collateral
Ligament- Runs from
medial femur to medial tibia
LCL:- Lateral Collateral
Ligament- Runs from lateral
femur to head of fibula
A “c”-shaped piece of fibrocartilage located in the knee joint between the femur and attached to the top of the tibia
Cartilage = meniscus
Medial
- larger and more C-shaped
- more firmly attached to tibia - has attachments to MCL
Lateral
- smaller and more round or O-shaped- not firmly attached to tibia and LCL
Mostly avascular – little or no blood supplyOnly the outer 20% has a blood supply* Does not have the ability to heal itself unless
there is a small tear in the outer 20%
1. Stability2. Shock absorption3. Lubrication and nutrition4. Allows adequate weight distribution
Normal Torn
TraumaFractures around kneeLigamentous sprainsMuscular strains
Degenerative conditionsOsteoarthritis of knee jointOsteochondritis dessicansTraumatic arthritis
Inflammatory conditionsRheumatoid arthritisJuvenile RheumatismNeuropathic jointHemophilic arthritisBursitisOther conditions
InfectionSuppurative arthritisTuberculosis
Tumors around knee jointTumors of boneTumors of soft tissue
Metabolic conditionsRicketsScurvyGoutOchronotic ArthritisOsteoporosis
Congenital and Developmental conditionsGenu valgumGenu varumGenu recurvatumCongenital dislocation of patellaCongenital discoid meniscus
Fractures around kneeSupra condyler femur fractureFractures of the isolated condyleTibial condyle and plateau fractureFracture patellaTibial tuberosity avulsion
Fractures of the femoral condyle at metaphysis level extending in to knee joint
Fractures of the isolated condyleHoffa’s FractureEpicondyler avulsions
Both condyle fractures Isolated condyle fractures Tibial spine fracture
>200,000 injuries/year>100,000 reconstructions/yearHigher incidence in femalesMales = contact
Females = noncontact
1. MOI: twisting of knee forced hyperextension lateral blow to knee
*foot must be firmly anchored to playing surface
2. 50% of people describe a “pop” in knee 3. Knee fills with blood quickly
Hemarthrosis4. Usually immediate loss of motion5. Knee feels unstable
Anterior Drawer Test:
examiner attempts to slide the tibia forward which may indicate a torn ACL ligament
Who needs surgery? - Activity level? - Level of Competition - Age?
ArthroscopicGraft options
Patellar TendonSemitendinosusGracilisCadaverSynthetic
1. MOI: excessive hyperextension hyperflexion
tibia forced posteriorly (blow to front of knee)“dashboard knee”
Possibly 90% of all PCL injuries due to motor vehicle accidents?
2. Mild hemarthrosis3. Posterior knee pain4. Walk with knee
slightly flexed, avoid full extension
5. Posterior sag of tibia6. Surgery?
MOI: Blow to the outside of the knee = Valgus Force Possible overuse – breaststroke in swimmers
Commonly associated with meniscal injuries – attached to medial meniscus
No surgery
Valgus Stress Test:tests for injury to the MCL ligament
MOI: Blow to inside of the knee – Varus force
Grade III tear may require surgery
Varus Stress Test:tests for injury to the LCL ligament
1. MOI: Rotation of the knee as the knee extends during rapid cutting or pivoting
2. Signs and Symptoms:- pain- joint line tenderness- catching or locking- knee buckling or giving way- swelling- incomplete flexion- clicking on stair climbing
3. Surgery?Meniscectomy: removal of the
meniscus- Total meniscectomy = osteoarthritis
Depends on location of tear, type of tear, and blood supply
- bucket handle- Flap tear- Transverse tear- Horn tear
Apley’s Compression
Tear of the medial meniscus, anterior cruciate ligament (ACL), and medial collateral ligament (MCL)
Osteoarthritis of knee jointOsteochondritis dessicansTraumatic arthritis
Disease of the joints characterized by:
– Progressive articular cartilage loss
– New subchondral bone formation
– New bone and cartilage formation at joint margins
– Low level synovitis
& PAIN!
– Joint Pain
– Typical Pain Pattern
– Xray FindingsStanding filmsAP with 30 deg
flexion
– No Sign of Zebras
Pathogenesis of Osteoarthritis
An Interplay of Factors
Dieppe, American Academy of Orthopaedic Surgeons, 1995
Age10-fold increase from
3065Genetics (generalized)Gender
Men <50: higher riskWomen >50: higher
riskNutritional
Low vitamin C and D intake
Joint Biomechanical Risk FactorsJoint traumaObesity (knee, hip, hand)OccupationAbnormal joint
biomechanicsDysplasia,
malalignment, instability, abnormal innervation
Knee extensor wknessSports w/ joint risk
50% decrease in OA with with 11#
wt lossLarger effect in
women (Felson et. al.
Ann Int Med 1992, Framingham Heart
Cohort data)
Jobs requiring repetitive knee
bending/moderate activity predict higher rates of osteoarthritis
Felson et alAnnals of Int Med 1992
11 lb / 50% risk reduction rule
Break that vicious cycle:
Team approach is critical
Disuse
Weight Gain
Pain and stiffness
Regular aerobic walking for knee OA LOE 1a for knee OA LOE IV for hip OA
Home-based quad strength exercises LOE 1a for knee OA LOE IV for hip OA
Water-based exercise for hip OA LOE 1b
Medial or lateral unloading
Medial tibio-femoral OA
TENS effective in some with knee or hip OA Short-term, 2-4 weeks
Acupuncture relieves pain (no effect on function)
Pulsed Electromagnetic Field Therapy Meta-analysis 2009
Thermotherapies
Tylenol, max 4 gm/day analgesic of choiceLOE 1a, but modest pain relief if OA
mild/modNSAIDs—LOE 1aTramadol: LOE 1a in short-term trials
No long-term trialsMore side-effects than Tylenol
Glucosamine
No disease modifying drug for OA (yet)
Considerations before treatment:Surgical candidate?
Don’t waste the timePrevious injections?
Beneficial in KNEEBeneficial in HIPShort-duration benefits: 2-4 weeks
Effective in knee and hip (LOE 1a)Delayed effect (1-3 weeks)Long duration (6 months)Weekly injections, 3-5xMight delay need for joint replacement
X
Arthroscopy Joint replacementCartilage transplantation
Cochrane review 2008: NO BENEFIT for undiscriminated OA (mechanical or inflammatory causes)
LOE IIIUniversally
recommended to improved pain, function, QOLUnicompartmentalTotal joint replacement
Osteo-Articular Transplant (OAT) procedures
Autologous Chondrocyte Implantation (ACI)
Cadaver allografts
Due to intraarticular fractures
Malunions lead to joint arthrosis
Primary cartilage insult leading to repair by fibrocartilage and arthrosis
Treatment is TKR if tri compartmental OA
In children and adolescents
Small segments of nactrotic subchondral bone
Pain stiffness and locking
Rest/ debridment of joint/ replacment
Rheumatoid arthritisJuvenile RheumatismNeuropathic jointHemophilic arthritisBursitisOther conditions
Synovitis chronic infl, synovial hypertrophy, effusion Destruction proteolytic enzymes, pannus Deformity articular destruction, capsular stretching,
tendon rupture
nodules tendon sheath vasculitis myopathy and neuropathy reticulo-endothelial system visceral - lungs, heart, kidneys, brain, GI
myopathy, tiredness, weight loss, malaise proximal finger joints wrists, feet, knees, shoulders start up pain tendon crepitus
joint destruction pain deformity instability
joint space narrowing peri-articular osteopenia erosions
stop synovitis prevent deformity reconstruct rehabilitate
10% improve 60% intermittent, slowly worsening 20% severe joint erosion, multiple surgery 10% completely disabled
Diabetes is the leading cause:1/700, 0.16-2.5% of all diabeticsUsually in the 5th or 6th decade of lifeRelated to duration and control of diabetesInvolvement includes:
Tarsometatarsal/metatarsophalangeal joints Ankles Knees Upper limbs (rare)
Giurini. Charcot's disease in diabetic patients. Postgrad Med 1991; Brower. Sinha. Neuro-arthropathy (Charcot joints) in diabetes mellitus (clinical study of 101 cases). Medicine (Baltimore) 1972; 51:191 .
Reported associations: Leprosy Alcoholism Uremia Amyloidosis Pernicious anemia Syphillis (tertiary) Syringomyelia Spina Bifida Myelomeningocele Cord compression Cauda Equina lipoma
MS Poliomyelitis Connective Tissue disorder Charcot-Marie-Tooth disease Congential sensory neuropathies Ehlers-Danlos syndrome Familial dysautonomia Thalidomide embryopathy Intraarticular steroids
Radiographics. 2000;20:S279-S293
Storey GO.Charcot joints. Rheumatol Phys Med. 1970 Aug;10(7):312-20.
Problems with patella – most common cause of knee pain
Anatomy:- Patella is a sesamoid bone formed in Quad tendon- Patellofemoral joint – patella and femur- Compression forces –
<body weight during walking2.5 x body weight during stairs
“Jumper’s Knee”Inflammation and degeneration of the tendon
that connects the kneecap (Patella) to the shin bone (Tibia).
A gradual degenerative change that occurs beneath the patella
Caused by acute trauma, repeated microtrauma, or improper alignment of the patella in the trochlear groove
Weak vastus medialis (VMO) can cause improper alignment
Prevention: strengthen quadsMinimize squats, downhill
running, biking with low seat
1. Painful swelling over tibial tuberosity(patellar tendon insertion)
2. Usually occurs between 9-13 years of age3. Pain increases with activity
Occurs where IT Band rubs over femur at the knee joint
Common in running (esp. downhill) or any activity with repetitive flexion
Hills or stairs increase painLots of IT Band stretching
“Baker’s Cyst”Fluid accumulation in posterior knee
(popliteal space)Patient usually complains of a mass behind
the knee
“Housemaid’s Knee”Tender swelling over
the kneecap (prepatellar bursa)
Pes anserine bursitis is an irritation or inflammation of a bursa in your knee. The pes anserine bursa is located on the inner side of the knee just below the knee joint.
Tendons of three muscles attach to the shin bone (tibia) over this bursa
Suppurative arthritisTuberculosis
Bacterial: staphylococcus
streptococcus
Gonococcus
H. pneumonia
gram negative organisms
Mycobacterium:TB, atypical TB
Fungi: candida
Spirochete: lyme (borrelia burgdorfi)
Viral: HIV, Hepatitis B, C
Tumors of boneTumors of soft tissue
Signs/Symptoms:Pain, characteristically more intense at night,
relieved by NSAIA and eliminated by excisionVertebral lesions may cause scoliosis
Age:10-30 years
Sex:M > F (2:1)
Anatomic Distribution:Nearly every location, most frequent in femur,
tibia, humerus, bones of hands and feet, vertebrae and fibula
Over 50% of cases in femur or tibiaMetaphysis of long bones
Central radiolucent nidus with or without a radiodense center; surrounded by thickened sclerotic bone
Central hemorrhagic nidus surrounded by dense rim of
sclerotic bone
Nidus contains interlacing network of osteoid and bony
trabeculae with variable amount of mineralization, lying in vascular fibrous tissue
Signs/Symptoms:PainGait disturbances
Age:80% of patients < 30 years
Sex:M >> F (3:1)
Anatomic Distribution:Predilection for vertebral columnMetaphysis of long bones
Radiographic Findings:Similar to osteoid osteoma, though much larger (up
to 11.0 cm)
Gross and Microscopic Findings:Similar to osteoid osteoma, though much larger nidus
Ancillary Testing:N/A
Prognosis/Treatment:Curettage followed by bone graftingIf incompletely removed, tumor may recurMalignant change to osteosarcoma has been rarely
reported
Most frequent primary malignant bone tumor
Malignant cells must produce osteoidMost tumors arise de novo, though others
arise in the setting of:Paget’s diseasePrevious RTPrevious chemo (especially alkylating agents)Fibrous dysplasiaOsteochondromatosisChondromatosisChronic osteomyelitis
Signs/Symptoms:Pain and swellingPathologic fracture is uncommon
Age:Peak in 2nd decade with gradual decrease thereafter
Sex:M > F
Anatomic Distribution:50% arise around the kneeMetaphysis of long bones
An 11-year-old male was seen in consultation for an increasingly painful distal femoral lesion associated with a soft tissue mass.
Plain radiograph shows an ill-defined destructive tumor in the distal femur. Fluffy radiodense infiltrates represent malignant tumor osteoid.
Biopsy material shows two major components of this neoplasm: highly pleomorphic cells and haphazard deposits of osteoid. Note that the malignant cells fill the spaces between osteoid deposits. Lace-like osteoid deposition is very characteristic of this neoplasm.
The tan-white tumor fills most of the medullary cavity of the metaphysis and proximal diaphysis. It has infiltrated through the cortex, lifted the periosteum, and formed soft tissue masses on both sides of the bone.
Benign:ChondromaOsteochondromaChondroblastomaChondromyxoid Fibroma
Malignant:Chondrosarcoma
Benign tumor of mature hyaline cartilage
Most within bone (enchondroma)2 syndromes characterized by multiple
chondromas:Ollier’s disease
Multiple enchondromas, usually unilateralMaffucci’s syndrome
Multiple enchondromas associated with soft tissue hemangiomas
Both disorders have 25% risk of malignant transformation to chondrosarcoma
Enchondroma is the most common tumor of the bones of the hand
Signs/Symptoms:Usually asymptomatic lesions; pain with pathologic
fracture
Age:Evenly distributed
Sex:F > M
Anatomic Distribution:50% of lesions within small bones of hands and feet
(mostly the phalanges)
Localized central lytic lesion surrounded by sharp rim of sclerosis; cortex usually not involved, though
may be thin
An incidental finding of a bone lesion in the distal femur of a 38-year old female. The lesion was completely asymptomatic.
Plain radiograph showed an intarmedullary zone of stippled and ring-shaped calcifications in the distal femoral metaphysis. This mineralization pattern with radiodense stipples and rings is characteristic of mature hyaline cartilage.
Low-power microscopic examination of the biopsy specimen shows three characteristic features of this lesion: a) vague lobularity; b) abundant cartilaginous matrix, which can be focally calcified; c) low cellularity.
High-power view shows clustered and scattered chondrocytes with small, uniform, darkly stained nuclei. Occasional bi-nucleated chondrocytes are present. Importantly, there were no mitotic figures.
Ollier’s disease
Composed of mature lobules of hyaline cartilage with foci of
myxoid degeneration, calcification and endochondral
ossification; may be quite cellular
Ancillary Testing:N/A
Prognosis/Treatment:Solitary chondromas of long or flat bones need no
treatmentIf fracture occurs, treat with curettage and bone
graftingRecurrence unusual
Most frequent benign bone tumorProbably not a true neoplasm, but rather a
tumor produced by growth of aberrant foci of cartilage on the surface of bone
Autosomal dominant disorder of osteochrondromatosis with risk of malignant transformation to chondrosarcoma
Signs/Symptoms:Palpable mass of long durationPain from compression of regional structures
Age:60% of patients < 20 yearsAverage age 10 years
Sex:M > F
Anatomic Predilection:May occur in any bone; usually metaphysis of long
bones (lower end of femur, upper end of humerus and upper end of tibia are most frequent)
Projection with cortex continuous with underlying bone; may be pedunculated; cartilaginous cap with frequent calcification
A 20-year-old male presented with a painless, hard subcutaneous mass in the popliteal fossa. He stated that the mass had been present for several years and did not change in size. Two words, "painless" and "non-growing" (or very slow growing), suggest that the lesion described here is probably benign.
Plain radiograph demonstrated a pedunculated bony outgrowth at the proximal tibial metaphysis. The lesion had a uniform, cartilagenous cap with stippled calcifications. The tibial cortex and medulla were continuous with those of the lesion.
The specimen consisted of a pedunculated lesion, 3 x 3 x 2cm, with a lobulated cartilage cap measuring up to 0.9cm in thickness
Osteochondroma, the most common benign bone tumor, is not a neoplasm but a hamartoma. It is thought to arise from a portion of growth plate cartilage entrapped beneath the periosteum during skeletal growth. These entrapped pieces continue to grow and ossify at the same rate as the adjacent bone. When skeletal maturity is reached, osteochondromas usually stop growing.
Rare benign tumorMost common primary epiphyseal
tumor in childrenSigns/Symptoms:
Local pain and swelling; tumors 1.0 to 7.0 cm
Age:2nd decade of life
Sex:M > F
Anatomic Distribution:Epiphysis of long bones40% in distal femur or proximal tibia
Lytic lesion of epiphysis with thin sclerotic rim; thinning
without destruction of cortex
Rare benign tumorSigns/Symptoms:
Pain and swelling
Age:2nd and 3rd decades
Sex:M > F
Anatomic Distribution:Metaphysis of long bones, though may abut the
epiphysis30% of tumors in tibia
Eccentric, sharply defined radiolucency in metaphysis of long
bones; may destroy cortex
Signs/Symptoms:Local swelling and pain
Age:Adulthood (60% between 30-60 years)Rare in childhood
Sex:M > F
Anatomic Distribution:Trunk, shoulder girdle, upper ends of femur and
humerus
Ill-defined margins; fusiform thickening of shaft; perforation of
cortex
Myxoid Chondrosarcoma
Mesenchymal Chondrosarcoma
Ancillary Testing:IHC
S100 – positive
Prognosis/Treatment:Must completely excise; biopsy leads to soft tissue
implantationRADIORESISTANT; surgery is Tx of choiceRecurrence may occur 5-10 years after primary5-year survival 80%Hematogenous metastasis to lung in high grade
lesions
Giant Cell TumorEwing’s Sarcoma / Primitive
Neuroectodermal Tumor (PNET)Chordoma
Signs/Symptoms:Pain, loss of mobility, fracture
Age:80% of patients > 20 years
Sex:F > M
Anatomic Distribution:Epiphysis of long bones50% around knee with most in distal femurMost common primary epiphyseal tumor of adults
A 45-year old female presented with increasing pain and swelling around the knee. She mentioned that the symptoms had progressed over a 4-month period. Age of the patient is an important diagnostic clue. If a pathologic fracture is excluded, pain and swelling imply active growth of the lesion. Plain film demonstrates a
large, lobulated, ill-defined lesion centered in the distal femoral metaphysis. There is endosteal scalloping and periosteal thickening. Central stippled and "ring and arc" calcifications are apparent and are typical of cartilaginous matrix. Small radiolucent areas are seen at the periphery of the lesion.
Low magnification shows a moderately cellular, lobulated cartilaginous tumor.
High-power view shows scattered plump, moderately pleomorphic chondrocytes. Binucleated cells are present. Mitotic rate averaged 1 per 10 hpf.
Tumor
Geographic and Expansile
Sharp Zone of Transition between Tumor and Normal Bone/Fibula
CT scan shows a thin cortical shell around the tumor indicating the periosteum is intact and the tumor is likely benign
There was no ossification or calcification within the tumor indicating that the tumor was probably not a bone or cartilage producing tumor
Peroneal Nerve
Tumor
Peroneal Muscles
Soleus Muscle
Signs/Symptoms:May simulate osteomyelitis as patients often
present with pain, fever and leukocytosis
Age:5-20 years
Sex:M > F
Anatomic Distribution:Long bones of extremities
Gross Findings:Solid masses of degenerating gray-white tumor
Signs/Symptoms:Usually found incidentally; may cause pain
Age:Children and adolescents
Sex:M > F
Anatomic Distribution:Metaphysis of long bones, usually distal femur and
tibia
Genu valgumGenu varumGenu recurvatumCongenital dislocation of patellaCongenital discoid meniscus
Genu Valgum: “knock knees”
Genu Varum: “bowlegs”
Genu Recurvatum:
hyperextension of the knee joint
Dislocation usually occurs as a result of sudden direction changes while running and the knee is under stress or it may occur as a direct result of injury.
Usually lateral
Rehab: strengthen quads, especially VMO to hold patella in place
Each dislocation will damage cartilage which can eventually lead to traumatic arthritis
RicketsScurvyGoutOchronotic ArthritisOsteoporosis
Mineralization defect are classified according to the mineral deficiency.
Calcipenic rickets ( vit D↓, 1-alpha hydroxylase defect, vit D receptor dysfunction, dietary Ca ↓, CRF) .
Phosphopenic ricket: Inadequate intake (Premature infants (rickets of prematurity) , Aluminum-containing antacids).
Deficient Intake: Ca, Ph, Vit D.
Poor absorption: vit D ↓, pseudo vit D↓, vit D resistance, high phytin content( soy formula), antacids, anticonvulsants, renal insufficiency, Fanconi syndrome, hepatic insufficiency, fat malabsorption (cystic fibrosis).
Increased excretion: furosemide, renal tubular dysfunction( phosphaturia, RTA with hypercalciuria), renal tubular damage e.g. cystinosis, tyrosinosis, galactosemia, fructose intolerance, wilson disease.
Local effect on bone matrix: hypophosphatasia(alp↓)
VITAMIN D DISORDERS Nutritional vitamin D deficiency; Congenital vitamin D deficiency; Secondary vitamin D deficiency; Malabsorption ; Increased degradation; Decreased liver 25-hydroxylase; Vitamin D-dependent rickets type 1; Vitamin D-dependent rickets type 2 ;Chronic renal failure.
CALCIUM DEFICIENCY Low intake Diet Premature infants (rickets of prematurity) Malabsorption Primary disease Dietary inhibitors of calcium absorption
PHOSPHORUS DEFICIENCY Inadequate intake Premature infants (rickets of prematurity) Aluminum-containing antacids
RENAL LOSSES X-linked hypophosphatemic rickets; Autosomal dominant hypophosphatemic rickets; Hereditary hypophosphatemic rickets with hypercalciuria; Overproduction of phosphatonin ( Tumor-induced rickets, McCune-Albright syndrome’ Epidermal nevus syndrome, Neurofibromatosis) ,Fanconi syndrome, Dent disease
DISTAL RENAL TUBULAR ACIDOSIS
Skeletal findings:
1. Delay in closure of the fontanelles.
2. Parietal & frontal bossing.
3. Craniotabes ( soft skull bones).
4. Enlargement of the costochondral junction (rachitic rosary).
5. The development of Harrison sulcus ( caused by pull of the diaphragmatic attachments to the lower ribs).
6. Enlargement of the wrist & bowing of the distal radius & ulna.
7. Progressive lateral bowing of the femur & tibia.
GENERAL Failure to thrive; Listlessness; Protuding abdomen; Muscle weakness (especially proximal); Fractures.
HEAD Craniotabes; Frontal bossing; Delayed fontanelle closure; Delayed dentition; caries; Craniosynostosis
CHEST Rachitic rosary; Harrison groove; Respiratory infections and atelectasis
BACK Scoliosis ,Kyphosis ,Lordosis
EXTREMITIES Enlargement of wrists and ankles; Valgus or varus deformities Windswept deformity (combination of valgus deformity of 1 leg with varus deformity of the other leg); Anterior bowing of the tibia and femur; Coxa vara; Leg pain.
HYPOCALCEMIC SYMPTOMS Tetany ; Seizures; Stridor due to laryngeal spasm
Extraskeletal manifestation of rickets vary depending upon the 1ry mineral deficiency.
Hypoplasia of the dental enamel is typical for hypocalcemic rickets, whereas abscesses of the teeth occur more often in phosphopenic rickets.
Hypocalcemic seizures, decreased muscle tone leading to delayed motor milestones, recurrent infections, increased sweating.
AntioxidantNot produced in the human bodyNecessary for collagen synthesisProlyl and lysyl hydroxylaseProcollagen triple helix4-8 months of deficiency to develop clinical
signs
Figure 2 : Corkscrew hair [3]
Figure3: gingivitis
Male>>>FemaleAssociated conditions
Hyperlipidemia, obesity, HT, CAD, DMPrecipitating Conditions
ETOH, dietary excess, traumaStress: surgery, GI bleed, MIDrugs: low dose ASA, diuretics, allopurinol
Clinical:Monoarticular ->Cluster ->Polyarticular1st MTP > 90%; any jointPeaks in 12 hoursRed, hot, swollenVery painfulDesquamation of skinTophi
Soft tissue swelling; tophi1st MTP -> any jointOverhanging edgeDestructive +++ if not treated
Aspirate the joint and look for MSU crystals under polarized microscopy