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Chapter 14: The ArthropathiesCauses of Joint PainThe ArthropathiesLab Testing for the Arthropathies Articular DisordersAffecting the Heel Synovial Fluid AnalysisCharcot Foot



THE ARTHROPATHIESCauses of Joint Pain: A Summary1. Joint disease: the arthropathies

2. Bone disease: fractures, primary or secondary tumors, osteochondritis,osteomyelitis, etc.

3. Soft-tissue lesions: sprains and strains, tenosynovitis, overusesyndrome, direct trauma, bursitis, "soft tissue rheumatism"

4. Arthralgia: defined as joint pain in the absence of objective joint disease,seen witha. The Arthropathies- either preceding the development of local signs or insome conditions in which there may be no local signs. Important examplesare polymyalgia rheumatica and temporal arteritis, SLE, and polyarteritisnodosa.b. Infections- particularly viral and rickettsial

i. Viral: influenzia (25% cases), glandular fever, psittacosis, yellow fever,sandfly feverii. Rickettsial: all types of typhusiii. Bacterial: septicemia, subacute bacterial endocarditis, thyphoidsalmonella, gonorrheaiv. Spirochaetal infections: secondary syphilis, leptospirosis, relapsing feverv. Protozoan/metazoan: kala-azar and other tropical diseasesc. Drugs- immunizations, serum sicknessd. Protein abnormalities- e.g. mixed IgG IgM cryoglobulinemia

5. Referred pain: particularly common in the knee due to hip and prostate

disease and in the shoulder due to some abdominal conditions, esophagealconditions, cardiac conditions, neurologic conditions neurological conditionsand pulmonary conditions

6. Psychogenic: Joint pain may be a manifestation of psychologicaldisturbance and "rheumatism" may become a source of complaint in theanxious or neurotic patients

The Arthropathies1. Anklosing Spondylitis (Marie Strumpell Disease): a chronic conditionof the spine (bamboo spine) and sacro-iliac joints in which earlyinflammatory changes are followed by progressive restriction of spinalmovement, with radiological calcification of spinal ligaments (seronegativedisorder).a. Signs: chest expansion reduced (< 5cm), limited spinal movements,tender bony points (heel)b. Symptoms: gradual onset of low backache and/or pain in buttocksc. X-ray: shows bamboo spine, and "whiskering" of ischial tuberositiesd. Labs: ESR >, mild anemia, (-) latex fixation, synovial fluid showsinflammatory/neutrophils



e. Tx: Exercises, NSAIDS

2. Arthrogryphosis Multiplex Congenita: a rare congenital disordercharacterized by stiff, deformed joints and muscle wasting.a. Clinical features: painless deformities (equinovarus feet, flexiondeformities of knees), stiff jointsb. Tx: correction of deformities, surgical and nonsurgical

3. Avascular necrosis: a group of conditions in which bone infarction is notassociated with sepsis but is usually due to interference with blood supply,either by abnormalities of the vessel wall such as arteritis, pressure on thevessels from outside, trauma, thrombosis, or embolism. Clinical diseaseresults only when the surface of the joint is involved causing arthritis. Thecondition may be:a. Traumatic: following fracturesb. Secondary to existing arthropathies: RA, severe OA, psoriatic arthropathy,neuropathic joint

c. Secondary to systemic conditions: sickle cell disease (particularly sicklecellthalassemia and sickle-cell-hemoglobin C disease), high dose steroidtherapy, pregnancy, extensive burns endocarditis, Caisson disease, andsclerodermad. Idiopathic: avascular necrosis may occur in middle aged men and is thecause of Perthes' disease in childrene. Types: Legg- Calve'- Perthe's disease (femoral capital epiphyses), Blount'sdisease (proximal tibial epiphysis), Osgood Schlatter's disease (tibialtuberosity), Sever's disease (calcaneal apophysis), Freiberg's disease (2ndmetatarsal head), Diaz/ Mauchet (talus), Islen's disease (base of 5thmetatarsal), Thieman's disease (phalanges), Kohler's disease (navicular and

patella), Treve's disease (medial sesamoid), Buchman's disease (medialcuneiform)f. X-rays: small areas of infarction which appear sclerotic or porotic, areas of joint surface collapse into underlying infarction producing flattening, necroticosteochondral fragments may separate completely or partiallyg. Tx: immobilation, physical therapy, surgery

4. Drug Induced SLE (the Hydralazine Syndrome): a conditionresembling SLE but induced by procainamide, hydralazine, isoniazid, oralcontraceptives, penicillin, sulfonamides, tetracycline, griseofulvin,phenylbutazone, reserpine and methyldopa. It is suggested that patients

with this condition have a heredity "lupus diathesis" which is made manifestonly when the drug is given. Arthritis occurs in 50% of the cases and canoccur synchronously or up to 4 weeks prior to the skin rash.a. X-rays: normalb. Labs: L.E. cells (90%), A.N.A. (100%)c. Tx: stop the drug, steroids for symptoms prn

5. Erthema Nodosum: an acute self-limiting condition characterized by thedevelopment of crops of tender nodules in the skin of the lower leg and



arthritis occurring in 50% of the cases occurring with the nodules orpreceding them by up to 4 weeks. The nodules are first bright red, later darkred, and then fade like bruises. This condition occurs in sarcoidosis (commonin Great Britain), various infections (particularly strep, measles, etc.),ulcerative colitis, malignant diseases, and drug sensitivities.a. Joints affected: knees and ankles most commonlyb. Symptoms: sudden onset of pain without swellingc. Signs: variable (none to red swollen joints), fever commond. X-rays: normale. Labs: >ESR, LA Fix occasionally (+), must do complete work up to findcausef. Tx: rest, MAIDS

6. Gaucher's Disease: a rare condition transmitted as an autosomalrecessive trait characterized by the abnormal accumulation of glucocerebrosides in reticulo-endothelial cells. The characteristic feature isthe Gaucher cell, a lipid filled macrophage that contributes to the arthritis

and eventually avascular necrosis. Severity is variable and can occur at anyage.a. Joints affected: hips are most common, 70% unilateralb. Symptoms: pain and stiffnessc. Signs: hip held in flexion and adduction with limb shorteningd. Course: untreated hip involvement will progress to complete destruction of the joint with secondary OAe. X-ray: areas of porosis/sclerosis, aseptic necrosis, Ehrlenmeyer flaskappearance of lower end of femurf. Labs: anemia, sometimes leukopenia and thrombocytopenia, bone biopsyshows Gaucher cells (lipid-filled "bubbly' macrophages)

g. Tx: rest, immobilization with no weight- bearing in early cases, surgery inadvanced cases

7. Gonococcal arthritis: arthritis due to gonococcal infection of the joints,beginning 3-17 days after being infected.a. Joints affected: knee is the most common area, ankles(40%), asymetrical,polyarticular (75%), "Gonorrheal heel"b. Symptoms: sudden onset of severe pain and swelling, fever, rigorsc. Signs: Warmth, erythema, tenderness, edema of joint and periarticular softtissuesd. Course: effective treatment produces complete cure in 1-4 weeks

e. Associations: skin lesions (50% cases) maculopapular, hemorrhagicf. X-ray: normal in the acute stageg. Labs: mild leukocytosis, >ESR, gonococcal antibodies detectable (90%),organism may be recovered from the blood and genital tracth. Tx: Penicillin (procaine penicillin 1-2 megaunits + benzylpenicillin 1megaunit daily for 5 days) or tetracycline 250mg. q.d.s. for 7 days. VDRLshould be done before treatment, since antibiotics may mask early signs of concurrent Syphilis.



8. Gout: a disorder of purine metabolism, characterized by hyperuricemiaand the deposition of urate crystals in joints, resulting in acute attacks of arthritis. In the later stage there is deposition of urate in the soft tissues andthe kidney, with a chronic arthritis.a. Joints affected: 1st m.p.joint (75%), monoarticular (90%)b. Symptoms: prodromal irritability with sudden onset of pain often 3-6 am,precipitated by surgery, trauma, starvation, alcoholic excess, and drugs(ASA, thiazides), usually males>femalesc. Signs: red/hot/swollen/tender joint, between attacks the joints are normaluntil tophaceous stage, must differentiate from septic arthritisd. Variants: Secondary gout (5%) cases due to myeloproliferative disorders(polycythemia rubra/vera) and during the treatment of malignant disease.Other variants are renal failure, Lesch-Nyhan syndrome and glycogenstorage disease (von Gierke's disease)e. X-ray: normal in early stages, with the joint space preserved until late inthe disease, periarticular swelling and punched out/radiolucent areas in theaffected joints

f. Labs: synovial fluid and tophaceous deposits contain needle-shapedcrystals which are strongly negatively birefringent, uric acid greater than6mg./100ml, >ESR (uric acid serum levels may not be elevated during acuteattack)g. Tx: responds to indocin, phenylbutazone or colchicine (.6 mg./hr until relief or NVD), if no response then ACTH. Later uricosurics or allopurinol (used intophaceous gout)

9. Hemophilia: a group of disorders of blood coagulation mechanisms dueto deficiencies of various factors. The most common form is inherited bymales, the females being unaffected carriers. It is inherited as an X-linked

recessive trait. Attacks of arthritis are due to hemorrhage into joints andrecurrent hemoarthrosis leads to a degenerative arthropathy which ischaracteristic of hemophilia.a. Joints affected: knee (70%), ankle (20%), monoarticular, asymmetricalb. Symptoms: sudden onset of very severe pain sometime after mild traumac. Signs: joint is red, warm, swollen and very tender, after repeated attacksthere is limited ROM and crepitus, eventually muscle wastingd. Course: complete recovery but later deformities and degenerativechangese. X-ray: normal with early attacks, later small superficial erosions and cystsappear with a loss of joint space and flattening of joint surfaces

f. Labs: prolonged PTT time, confirmed by Factor VIII assay, blood stainedsynovial fluidg. Tx: complete immobilization while in the acute stage, give missing factor(cyroprecipitate or fresh plasma), analgesics, avoid aspiration, gentlephysiotherapy

10. Hypothyroidism: deficiency of thyroid hormone may cause a variety of rheumatic manifestations: pain and stiffness in proximal muscles,polyarthritis, monoarthritis associated with osteolytic lesions usually in



children, carpal tunnel syndrome, secondary gout, hypercholecterolemia.a. Joints affected: knees, wrists, ankles, usually bilateral and symmetricalb. Labs: confirm by > cholesterol, < thyroxin level, abnormal EKGc. Tx: thyroxin

11. Neuropathic Joint (Charcot): disorganization of a joint and destructionof joint surfaces associated with diminished pain sensation which is mostcommonly due to: tabes dorsalis, diabetes mellitus, syringomyelia,Charcot-Marie-Tooth disease, meningomyelocele, hemiplegia, andleprosy.a. Joints affected: monoarticular, depends on localization of pain lossb. Symptoms: 50% have acute onset of pain and swelling, pain is absent inthe later stagesc. Signs: acute stage, red/warm/tender/swollen joint; chronic stage, bonyswelling and recurrent effusion/instability/crepitus/grotesque deformitiesd. Course: acute inflammatory stage lasts for up to 6 months, withsubsequent slow progression for years until deformities occur

e. X-ray: sclerosis of the bone ends, loss of the joint space, loose bodies,massive osteophytes, periarticular calcification, fracturesf. Labs: essentially normal chemistries. Do immunologic tests (antibodies tolisted bacterial infections)g. Tx: rest in the acute stage, MAIDS, stabilization with braces and splints,arthrodesis for instability

12. Conditions associated with neuropathic joints:a. Tabes Dorsalis: knee is most common site (70%), with ankle and feet(30%), Argyll Robinson pupil (80%), absent DTR'sb. Syringomyelia: 50% have cervical spondylosis on x-ray, loss of pain and

temperature in the upper extremities, equinus deformities c. DiabetesMellitus: 1 % of diabetics and 5% with diabetic neuropathy have aneuropathic joint, foot is most common site (80%), absent ankle jerk,sensory loss

13. Osteoarthritis: a common degenerative condition of a joint surfaceassociated with aging. OA may be primary or secondary to: obesity,unrecognized congenital hip dislocation, any condition causing irregularity of the joint surface including avascular necrosis, repeated trauma, septic orother arthritis. There is a wide spectrum of clinical manifestations:

a. Secondary OAone jointdefinite cause

Primary OAone to six jointsno definite causeHeberden's nodes(sometimes)

Primary generalized OApolyarticularHeberden's nodesusually

b. Joints involved: D.I.P. joints of the hands, lumbar spine, 1st M.P.J., P.I.P. orM.C.P. of hands

NOTE* Heberden's nodes occur over the distal ipj's, and Bouchar’ s nodes



occur over the proximal ipj's (Bouchard's nodes are associated with gastricdilatation)

c. Symptoms: pain with or after movement/relieved by rest, worse towardsevening, stiffness of affected joints after immobility, but not generalizedmorning stiffness (post static dyskinesia)d. Signs: bony swelling and tenderness, acute episodes may be accompaniedby warmth/erythema/effusione. Course: chronic with exacerbations, sometimes related to traumaf. X-ray: degenerative changes with non-uniform loss of joint space/loss of subchondral bone (subchondral sclerosis)/subchondral cysts (do not breakthrough the cortex)/osteophytes/later, irregularity of the joint surface/jointmiceg. Labs: ESR normal, synovial fluid: see charth.Tx: NSAIDS, physiotherapy, surgery if symptoms severe and persistent

14. Osteochondritis Dissecans: a condition characterized by the

separation of avascular osteochondral fragments from the surface of the joints. If separation is complete, loose bodies are found within the joint.a. Joints affected: knee is most common (85%), monoarticular (75%), anklefrequentlyb. Symptoms: pain (mild) worse after exercisec. Signs: often none, effusion occasionallyd. Course: acute a isode recovers after a few months with OA following aftera few years (50%)e. X-ray: separation of a fragment or fragments of bone from the jointsurface, sclerosis of the fragment and the crater from where it comes from,osteoarthritic changes later

f. Labs: uneventfulg. Tx: immobilization in non-weight bearing cast/ spontaneous healing inyounger cases, with surgery for fixation of a fragment or removal of loosebodies

15. Paget's Disease of Bone (osteitis deformans): a disorder of unknown etiology affecting one or more bones particularly the skull, femur,and tibia. The condition is rare before the age of thirty. Approx. 80% of patients with radiological changes also have symptoms, usually bone painand deformities.Areas of increased density and of decreased density.a. Symptoms: pain indistinguishable from OA, limp

b. Course: chronic and slowly progressive leading to OAc. X-ray: 1st change is localized porosis (in skull called osteoporosiscircumscripta), bone often expanded and thickened, with fractures of thelong bones. Distinct border between normal and abnormal boned. Labs: >Alk Phos, Ca normal (ALK PHOS reaches extremely high serumlevels)e. Tx: analgesics, disodium etidronate (inhibits bone resorption andmineralization)



16. Palindromic Rheumatism: an uncommon condition, probably a variantof RA, characterized by recurrent/acute/self-limiting attacks of arthritis.a. Joints affected: hands, wrists, knees and feet, with each patient having 1-3prominent sitesb. Symptoms: sudden onset of severe pain and stiffnessc. Signs: swollen/red/tender jointd. Course: attacks occur at irregular intervals, averaging 20 per year. Theremay be years of freedom between attacks or hundreds of attacks in oneyear. Attacks last a few hours/days, seldom more than 1 week, withcomplete recovery follows the attacke. X-rays: normalf. Labs: >ESR, latex fix (+) 50% casesg. Tx: indomethacin, phenylbutazone or ASA for acute attacks, gold therapymay produce remission

17. Psoriatic Arthritis: a common skin disease (psoriasis) with associatedarthritis in 10% of cases, with the skin manifestation preceeding the arthritis

by many years. A seronegative disease. Sometimes joint symptoms precedeskin lesionsa. Joints affected: polyarticular, with small joints of the hands predominating(70%). There are three patterns (distal type- d.i.p.j.'s and p.i.p.j.'s,seronegative indistinguishable type- joint involvement indistinguishable fromRA, deforming type- causes arthritis mutilans)b. Symptoms: pain is seldom prominant except in the deforming typec. Signs: acute stage- red/hot/swollen joint (sausage toe), chronic stage-swollen jointsd. X-rays: erosions within the joint, sclerosis of the joint margins, proliferationof bone, cysts, ankylosis, destruction of bone ends in the deforming type,

mushrooming of the joint surfacese. Labs: ESR normal except in the acute stage, (+) HLA-B27 (in many cases),latex fix (-)f. Associations: pitting of the nails (90%), hyperuricemia (30%)g.Tx: analgesic and NSAIDS, avoid systemic steroids, avoid antimalarialscause exfoliative dermatitis)

18. Pyrophosphate Arthropathy: a condition caused by the deposition of crystals of calcium pyrophosphate dihydrate (CPPD) into joints. This conditiondoes not resemble gout and should not be called pseudogout. The termchondrocalcinosis articularis should be reserved for the radiological

appearance of cartilage calcification. There are three clinical patterns of thedisease: recurrent acute arthritis, chronic degenerative arthritis(resembles RA), and chronic arthritis with acute episodes. Typical onset isage 60.a. Joints affected: knee is most common site, can affect ankles/toes/fingers,usually monoarticular and symmetrical b. Symptoms: pain and stiffness,sudden onsetc. Signs: acute red/ hot/ swollen jointd. Course: attacks last weeks/months



e. Associations: diabetes mellitus present in up to 50% cases, hypercalcemia,hemochomatosisf. X-ray: affected joints eventually show calcification of cartilage anddegenerative changesLabs: synovial fluid changes (see synovial fluid chart), >ESR, leukocytosis,crystals seen microscopically in fluid and biopsy-crystals polarizeg. Tx: injection of joints with hydrocortisone, indomethacin

19. Reiter's Disease: a triad of arthritis/conjunctivitis/urethritis whichusually follows non-specific (non-gonococcal) urethritis, occurs in males (20-1). A dermatitis may also be present. A seronegative disease.a. Joints affected: knee (90%) and ankle (75%) most common, feet (40%),polyarticular/asymetricalb. Symptoms: acute onset of joint pain and swelling, dysuria, and peniledischargec. Signs: red/hot/swollen joints in the acute staged. Course: 1st attack resolves within 6 months, rarely becomes chronic, 50%

relapse, 20% have continued relapsing/chronic arthritise. Associations: urethritis, conjunctivitis, circinate balanitis, keratodermablenorrhagica, tenosynovitis (usually achilles), plantar fasciits, heel pain,back painf. X-ray: periarticular osteoporosis with erosions, fluffy periosteal new boneformation (calcaneal spur)g. Labs: >ESR, (-) latex fixation, (+) HLA-B27 (in many cases), joint fluid isinflammatory, gonococcus found in GU tract in some cases. Other bacterialinfections may be present. Reiters disease is also seen in AIDSh. Tx: rest, analgesics, MAIDS, antibiotics (if indicated)

20. Rheumatoid Arthritis: a chronic and widespread chronic deformingpolyarthritis characterized by bilateral/symmetrical joint involvement,erosions on x-ray, positive latex fixation tests, and pathologically a chronicproliferative synovitis with villous hypertrophy, infiltration of lymphocytesand plasma cells, and lymphoid nodules. Occurs in 6% females and 2%males world-wide. An autoimmune disease a. Diagnostic criteria:

• morning stiffness

• pain on motion or tenderness in 1 joint

• swelling in 1 joint, swelling in another joint

• symmetrical joint swelling

• subcutaneous nodules

• x-ray changes typical of RA• poor mucin ppt. from synovial fluid

• characteristic histologic changes in the synovial membrane

• positive Rheumatoid factor

• characteristic histologic changes showing palisading granulomas

Definite rheumatoid arthritis= 5 of the aboveProbable rheumatoid arthritis= 3 of the above



b. Joints affected: small joints of the hands and feet (75%) especially them.p.j.'s, and the p.i.p.j's, usually bilateral and symmetrical. Also calcaneusaffecting the posterior-superior surface near the achilles insertion (forms aposterior calcaneal recess) with non-well demarcated heel spur. Larger,proximal joints are frequently involved.c. Symptoms: insidious onset of joint pains and stiffness, generalizedmorning stiffness, accompanied by general ill health, fatigue and weight losswhich can precede joint symptoms by a few months.d. Signs: swollen/tender joints with limited ROM due to effusion or synovialthickening, muscle wasting around the affected jointse. Special features: ulnar deviation hands, boutonniere deformity of p.i.p.j.,baker's cyst of knees, atlanto-axial subluxation of cervical spine, crico-arytenoid joint involvement causeshoarseness/dyspnea/dysphasia/bronchitisf. Course: either episodic or persistent, episodic has average patient having 3attacks of arthritis once every 2 years each lasting 6 months; persistent haschronic arthritis with partial remissions and exacerbations, joints tend to

become burnt outg. Non-articular manifestations:i. Periarticular soft tissues- nodules (Haygarth's nodes at affected joints),tenosynovitis, bursitis, synovial cysts, muscle wasting, ligamentous laxityii. Skin- tight like scleroderma, leg ulcersiii. Eyes- Sjogren's syndromeiv. Heart- pericarditis, granulomatous lesions in myocardiumv. Nerve- carpal tunnel syndrome/tarsal tunnel syndromevi. Blood- anemia, Felty's syndrome (splenomegaly/leukopenia)h. X-ray: early changes include periarticular osteoporosis, joint spacewidening; later changes include uniform joint space narrowing thinning of the

cortices synovial erosions, pseudocysts that erode through the cortex (OAcysts have a sclerotic boarder), subluxations and deviations joint fusions andwidespread osteoporosisi. Labs: anemia, >ESR, latex fixation (+) 80%, ANA (+), RA (+), synovial fluidchanges (see chart), blood protein (plasma fibrinogen and globin increased;decreased total protein) j. Tx: NSAIDS, rest modalities, intraarticular steroid injections, synovectomy,gold injections (Myocrisin) @ 10, 20, 30, 40 mg I.M. at weekly intervals then50 mg. weekly up to 1 g., then a maintenance dose of 50 mg. monthly if results good (must check WBC's)

21. Septic Arthritis: Infection of a joint with pyogenic bacteria. Mostcommon organism is Staph aureus (50%). Can occur in any age group butmore frequent in kids and geriatrics (should be considered when examiningany monarticular erythematous, hot, swollen joint)

a.NOTE* The bacteriology in septic arthritis is most frequently as follows:Neonates: Streptococcus and gram negative organismsChildren (6months to 5 yrs): H. influenza commonTeenagers: Neisseria gonorrhea have higher incidence Adults: P. aeruginosa common after puncture wound Adults with sickle-cell: Salmonella common

Compromised patients (burn victims, drug users): Serratia marcescens pyarthrosis



Joints affected: knee most common, 90% monarticularb. Symptoms: rapid. onset of pain and swelling, can have elevatedtemperature, malaise, tachycardia, and confusionc. Signs: swelling with effusion/tenderness/warmth and painful limitation of motion, febriled. Course: untreated, leads to joint destruction (OM/ankylosis)e. X-rays: normal initially, osteoporosis after 2 weeksf. Labs: >WBC's, synovial fluid (see chart), blood culture and synovial fluidculture (+)

g. Tx: antibiotics, rest, aspirations (?? damage to the joint), opendebridement (permits lysing of adhesions and debridement of necrotic boneor soft tissue present, arthrotomy performed in patients with advancingosteomyelitis

22. Sickle-Cell Disease: a condition inherited as an autosomalintermediate, in which hemoglobin A is replaced by hemoglobin S.Heterozygotes are not anemic and do not have arthritis. Homozygotes areseverely anemic and have thrombotic crises which commonly cause arthritisas a result of local bone infarcts. Usually seen in blacks with the onset in the

first 10 years of life.a. Joints affected: polyarticular, hands and feet common sites, oftenmigratoryb. Symptoms: sudden onset of severe joint pains or backachec. Signs: often none, occasionally affected joints are swollen/red/tender,fever common in a crises, painful ankle ulcersd. Course: joint pain subsides spontaneously within days, life span greatlyreducede. X-rays: areas of osteoporosis or sclerosis, periosteal proliferation affectingthe shafts of the metatarsalsf. Labs: in vitro sickling tests and hemoglobin electrophoresis confirm the

diagnosisg. Tx: analgesics, IV bicarbonate may help, urea compounds,pentoxophylline, avoid hypoxia/hypotension/tourniquets

23. Still's Disease (Juvenile Rheumatoid Arthritis): a chronic polyarthritisresembling R.A. clinically and histologically, but beginning before the age of 16 (peak ages, 1-3 & 10-15).a. Joints affected: as with the adult + involvement of the cervicalspine/TMJ's/d.i.p.s. (more)

NOTE* The joint aspirate should undergo the following studies:C&S, gram stain, examination for crystals, WBC count and differential

NOTE* The WBC's in joint aspirate in a septic joint is usually higher then100,000, however, in gonococcal arthritis the WBC's is usually below50,000



b. commonly affected, less symmetry than RAc. Symptoms: pain often mildd. Signs: joints warm/tender/red/swollen with effusion and synovialthickening, fever (50%)e. Course: better prognosis than in adults especially if earlier onsetf. X-ray: erosions less common, periosteal reaction may occur in phalangesand metsg. Labs: >ESR, latex fixation (+) in 20% casesh. Tx: ASA, rest, maintain full ROM, gold or immunosuppressive drugs only insevere progressive cases, short course A.C.T.H. useful for severe relapse

24. Systemic Lupus Erythematosis (S.L.E.): an autoimmune conditioncharacterized by the presence of antinuclear factor and other auto-antibodies. The diagnosis is often made on the basis of multi-systeminvolvement.a. Joint pain occurs in 90% cases, and arthritis usually occurs at onset butmay precede other systemic features by up to 20 years.

b. Joints affected: Commonly seen in the p.i.p.j.'s, also in the wrists, knees,ankles and elbows, is polyarticular with a distribution resembling RAc. Symptoms: sudden onset of pain and stiffness which may be precipitatedby exposure to sunlight or stress, morning stiffness (50%)d. Signs: 50% have none, but the characteristic finding is slight soft tissueswelling, fever commone. Course: 70% survive 5 years and 50% 10 years, prognosis is much worsewith renal involvementf. Associations: rash of face (butterfly), renal disease, pericarditis, Raynaud'sphenomenon, and liver diseaseg. X-ray: usually normal

h. Labs: >ESR, ANA (+) 100%, LE cells present (80%), latex fixation (+) 30%i. Tx: prednisone 30-60 mg/day initially reducing slowly to a maintenancedose of about 15 mg.day

25. Ulcerative Colitis: a condition in which severe ulcerative inflammationof the colon causes fever, anemia, and the passage of blood/mucus from thebowel. Arthritis is of 4 types, colic arthritis, ankylosing spondylitis, arthritisassociated with erythema nodosum, and pseudohypertrophic osteo-

arthropathy. In ulcerative colitis 10% develop arthritis, in Crohn's disease 4%develop arthritisa. Joints affected: knees and ankles, usually 1-3 joints in each attack, usuallyasymetricalb. Symptoms: sudden onset of pain/swelling, often associated with relapse of colitisc. Signs: effusion, painful limitation of motiond. Associations: skin lesions (erythema nodosum/pyoderma gangrenosum)e. X-ray: joints normal

NOTE* Some medications precipitate SLE (see earlier chapter)



f. Labs: >ESR, Synovial fluid shows WBC's up to 40,000g. Tx: NSAIDS and analgesics, appropriate tx for colitish. Younger patients may go on to develop GI adenocarcinomas after 10 ormore years of disease.

Laboratory Testing for the Arthropathies

1. Synovial Fluid analysis: should be approached with caution so as toprevent hemoarthrosis or septic joint. When the joint is punctured anattempt should be made to extract all the fluid present. The analysis of the joint fluid is of some importance in the diagnosis of certain diseases. (Seechart)

2. Serologic tests:a. Erythrocyte Sedimentation Rate: nonspecific, reflects the presence of tissue injury and inflammation, as a screening test may be overratedb. C-reactive protein (CRP): nonspecific test for inflammation, a mostsensitive indicator of rheumatic fever

c. Rheumatoid factor: are a heterogenous group of antiglobulin antibodiesprimarily found in patients with rheumatoid arthritis. The antibodies react tospecific antigenic determinants on the crystallizable fragment of human IgG.RF has been found among several classes of immunoglobulins, including IgM,IgA, IgG, and IgEd. Latex fixation: are also used to detect RF, with IgG used as the antigene. Antinuclear antibodies (ANA): are a heterogenous group of antibodiesdetecting many nuclear constituents; including deoxyribonucleic acid (DNA),deoxynucleoprotein (DNP), histone, and ribonucleicacid (RNA). The ANAantibodies were 1st noted in the sera of patients with SLE. Only a testreactive for double- stranded DNA is diagnostic for SLE

f. Histocompatibility antigens (HLA-B27): is associated with theseronegative diseasesg. VDRL: screening test for syphilis (but not specific for it)h. ASO titer: done with CRP where Rheumatic fever is suspectedi. LE prep: rarely done today because of the accuracy of the ANA

3. CBC and differential

4. Uric Acid: May be normal during acute gouty attacks 5. Test forLyme disease (Lyme titer)

6. Test for AIDS: ELISA (and If reactive then do a Western Blot)

Articular Disorders Affecting the HeelSystemic inflammatory disorders such as RA, anklosing spondylitis, psoriaticarthritis, Reiter's syndrome, gout, and Behcet's syndrome have all beenreported to cause heel pain. Signs and symptoms of these disorders includelocal soft tissue swelling and occasional erythema associated with diffuseaching type pain. Various symptom complexes highlight certain arthritides(like Reiter's). Radiographic erosive and proliferative bone changes in these



patients include posterior and inferior calcaneal spurring, retrocaicanealswelling, Achilles tendon thickening, and posterior and inferior calcanealerosions. These changes occur in various combinations and each diseaseentity has its own usual but not exclusive calcaneal target site.



Calcaneal target sitesA: Rheumatoid ArthritisB: Ankylosing spondylosis and psoriasisC: Reiter's syndrome

McGlamry ED: Comprehensive Textbook of Foot Surgery, Williams & Wilkins, Baltimore, 1987, with permission



SYNOVIAL FLUID

After aspiration note volume, clarity, turbidity, blood-staining, and viscosity. Divide asfollows:

2 ml. in a tube containingEDTA for cell count and

differential

At least 1 ml. in a sterilecontainer for microscopy and

culture. Ask for urgent Gramstain or special culture mediaif indicated

Remainder: examine a wetfilm for crystals under

polarized light. Notepresence or absence of clotformation after standing

RESULTS: The characteristics of synovial fluid depend upon the presence or absence of inflammation of synovium. Non-inflammatory fluid is clear, viscous, fails to clot on standing,and contains less than 1000 cells per c.mm., predominantly mononuclears. Inflammatory fluid is non-viscous, may clot, and contains an increased number of white blood-cells. Thesechanges may be slight or gross, depending on the severity of the inflammatory process.Fluid with a high whitecell count is turbid and this does not necessarily mean that it is septic.

The characteristics of inflammatory and non-inflammatory fluid are summarized in thefollowing table. Synovial fluid characteristics in individual arthropathies are shown with otherlaboratory features of the conditions.

IDENTIFICATION OF CRYSTALS. Uric acid crystals are needle-shaped and strongly negativelybirefringent (blue across the plane of the first-order red compensator); pyrophosphatecrystals have square ends and are weakly positively birefringent (blue along the plane of thecompensator).

SPECIAL TESTS1. Complement levels are low in rheumatoid arthritis and high in Reiter's disease.2. Latex tests parallel serum titres in patients with rheumatoid arthritis; there is a highincidence of false positives in other conditions and the test has little diagnostic value.

NON-INFLAMMATORY INFLAMMATORY

E.g., Osteo-arthrosisor Traumatic

-Arthritis

RheumatoidArthritis,

SepticArthritis

Gout orPyrophosphate

Arthropathy

Appearance Clear Often turbid Turbid Clear with Bakesof fibrin

Colour Yellow Yellow/green Brown/green Yellow

Viscosity High Low Low Low

Clots ? No Yes Yes Yes

Approx. W.B.C.(per mm.3)

1,000 30,000 100,000 10,000

Predominant cell Mononuclears Neutrophils Neutrophils Neutrophils

Crystals No No No Yes

Culture Sterile Sterile Positive Sterile



Charcot Foot1. Disorders producing a Charcot joint: Diabetes mellitus (most commoncause), tabes dorsalis, leprosy, syringomyelia, spina bifida,meningomyelcoele, congenital insensitivity to pain, chronic alcoholism,spinal cord injury and compression (all have decrease in pain sensation inthe presence of uninterrupted physical activity in common)

2. Mechanism of destruction: Precipitated by a single injury or byrepetitive moderate stress applied to bones and joints. The results arefractures, effusions, and ligamentous laxity followed by erosion of articularcartilage, fragmentation, luxation, distintegration, and finally collapse of thefoot. The consequence of trauma is a hyperemic response, which promotesadditional resorption of bone and increases the susceptibility to further injuryand progressive deterioration

3. Pathogenesis:a. Sensory-motor neuropathy: Loss of protective sensation, absent DTR's,diminished vibratory sense, muscle weakness, ankle equinus b. Autonomicneuropathy: Sympathetic denervation loss of vasomotor control, increasedperipheral blood flow, increased artiovenous shunting, increased bone bloodflow, hyperemiac. Minor trauma: Repetitive moderate stress, repetitive impulse loading,trabecular microfractures, inadequately protected fractures and sprains,surgeryd. Other factors: Metabolic abnormalities which weaken bone, renal

transplantation, immunosuppressive treatment, steroid-inducedosteoporosis, decreased cartilage growth activity, glycosylation of collagen

4. Diagnosis:a. Medical history, clinical manifestation, and radiologic findingsb. Technium and Gallium scans, MRI (low signal Intensity in T, and T2-weighted images within the bone marrow space adjacent to theinvolved joint), and bone biopsy and cultures in equivocal cases

NOTE* Eichenholtz divided the disease process into 3 radiographically distinct stages:

a. Development: The acute destructive period, which is distinguished by joint effusions, soft tissue edema, subluxation, formation of bone and cartilagedebris (detritus), intra-articular fractures, and fragmentation of boneb. Coalescence: Noted by a lessening of edema, absorption of fine debris,and healing of fractures (reparative phase of healing has begun)c. Reconstruction: Further repair and remodeling of bone take place in anattempt to restore stability and homeostasis

Neuropathic osteoarthropathy can be arrested during the Development stage if diagnosed before the disease has a chance to mature



5. Treatment: Based on the acuteness of symptoms, the anatomic patternof bone and joint destruction, the degree of involvement (deformity,fractures instability, etc.) and the presence of infection a. Immobilization: Atleast 3 months of non-weight-bearing cast immobilization prior to resumptionof partial weight-bearing (always check the asymptmatic limb during thistime)b. Orthoses and shoes: A patella tendonbearing brace with molded shoes todecrease the load on the foot

c. Surgery: Ostectomy, arthrodesisi. Criteria for surgery: Instability, deformity, recurrent ulceration, refractoryto conservative treatment, must be quiescent, circulation intact, no activeinfection, medically stable