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Arthritis & Musculoskeletal Disorders
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David B Hellmann, MD, MACP John B Imboden Jr, MD
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DIAGNOSIS & EVALUATION Examination of the Patient
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In the patient with arthritis, the two clinical clues most helpful for diagnosis are the joint pattern and the presence or absence of extra-articular manifestations The joint pattern is defined by the answers to three questions: (1) Is inflammation present (2) How many joints are involved and (3) What joints are affected Joint inflammation is manifested by redness, warmth, swelling, and morning stiffness of at least 30 minutes duration Both the number of affected joints and the specific sites of involvement affect the differential diagnosis (Table 20 1) Some diseases gout, for example are characteristically monarticular, whereas other diseases, such as rheumatoid arthritis, are chiefly polyarticular The location of joint involvement can also be distinctive Only two diseases frequently cause prominent involvement of the distal interphalangeal (DIP) joint: osteoarthritis and psoriatic arthritis Extra-articular manifestations such as fever, rash, nodules, or neuropathy narrow the differential diagnosis further
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2 Cell count The synovial fluid white cell count discriminates between noninflammatory (< 2000 white cells/mcL), inflammatory (2000 75,000 white cells/mcL), and purulent (> 100,000 white cells/mcL) joint effusions Synovial fluid glucose and protein levels add little information and should not be ordered 3 Microscopic examination Compensated polarized light microscopy identifies and distinguishes monosodium urate (gout, negatively birefringent) and calcium pyrophosphate (pseudogout, positive birefringent) crystals Gram stain has specificity but limited sensitivity (50%) for septic arthritis 4 Culture Bacterial cultures as well as special studies for gonococci, tubercle bacilli, or fungi are ordered as appropriate
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Synovial fluid analysis is diagnostic in infectious or microcrystalline arthritis Although the severity of inflammation in synovial fluid can overlap among various conditions, the synovial fluid white cell count is a helpful guide to diagnosis (Table 20 3)
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If the diagnosis is uncertain, synovial fluid should be examined whenever possible (Table 20 2) Most large joints are easily aspirated, and contraindications to arthrocentesis are few The aspirating needle should never be passed through an overlying cellulitis or psoriatic plaque because of the risk of introducing infection For patients who are receiving long-term anticoagulation therapy with warfarin, joints can be aspirated with a small-gauge needle (eg, 22F) if the international normalized ratio (INR) is less than 30
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DEGENERATIVE & CRYSTALINDUCED ARTHRITIS DEGENERATIVE JOINT DISEASE (OSTEOARTHRITIS)
ESSENTIALS OF DIAGNOSIS
A degenerative disorder; no systemic symptoms Commonly secondary to other articular disease Pain relieved by rest; morning stiffness brief; articular inflammation minimal Radiographic findings: narrowed joint space, osteophytes, increased density of subchondral bone, bony cysts
A Types of Studies
1 Gross examination Clarity is an approximate guide to the degree of inflammation Noninflammatory fluid is transparent, mild inflammation produces translucent fluid, and purulent effusions are opaque Bleeding disorders, trauma, and traumatic taps are the most common causes of bloody effusions
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CMDT 2008
itive contact sports does Jobs requiring frequent bending and carrying increase the risk of knee osteoarthritis
Table 20 1 Diagnostic value of the joint pattern
Characteristic Inflammation Status Present Representative Disease Rheumatoid arthritis, systemic lupus erythematosus, gout Osteoarthritis Gout, trauma, septic arthritis, Lyme disease, osteoarthritis Reiter s disease, psoriatic arthritis, inflammatory bowel disease Rheumatoid arthritis, systemic lupus erythematosus Osteoarthritis, psoriatic arthritis (not rheumatoid arthritis) Rheumatoid arthritis, systemic lupus erythematosus (not osteoarthritis) Gout, osteoarthritis
Clinical Findings
A Symptoms and Signs
Degenerative joint disease is divided into two types: (1) primary, which most commonly affects some or all of the following: the DIP and the proximal interphalangeal (PIP) joints of the fingers, the carpometacarpal joint of the thumb, the hip, the knee, the metatarsophalangeal (MTP) joint of the big toe, and the cervical and lumbar spine; and (2) secondary, which may occur in any joint as a sequela to articular injury resulting from either intra-articular (including rheumatoid arthritis) or extraarticular causes The injury may be acute, as in a fracture; or chronic, as that due to occupational overuse of a joint, metabolic disease (eg, hyperparathyroidism, hemochromatosis, ochronosis), or neurologic disorders (tabes dorsalis; see below) The onset is insidious Initially, there is articular stiffness, seldom lasting more than 15 minutes; this develops later into pain on motion of the affected joint and is made worse by activity or weight bearing and relieved by rest Bony enlargement of the DIP (Heberden s nodes) and PIP (Bouchard s nodes) joints are occasionally prominent, and flexion contracture or varus deformity of the knee is not unusual There is no ankylosis, but limitation of motion of the affected joint or joints is common Crepitus may often be felt in the joint Joint effusion and other articular signs of inflammation are mild There are no systemic manifestations
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