2216

PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders

Approach to Articular and Musculoskeletal DisordersJohn J. Cush

(Table 393-1) -

-

articular non-articular inflammatory noninflammatory

acute chronic localized (monarticular)widespread polyarticular

-

-

-

ARTICULAR VERSUS NONARTICULAR

-

-

-

-

-

INFLAMMATORY VERSUS NONINFLAMMATORY DISORDERS

Neisseria gonorrhoeae Mycobacterium tuberculosis

-

-

-

-

-

-

-

-

-

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

--

Fig. 393-2

-

-

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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2218

PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders

-

CLINICAL HISTORY-

age

sex race-

Racial predilections

Familial aggregation

onset, evolution duration

-

-

extent distribution -

monarticular oligoarticular

pauciarticular polyarticular

-

-

precipitating events

(Table 393-2)

-

-

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

-

Myalgias/myopathy-

-

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

--

-

-

RHEUMATOLOGIC EVALUATION OF THE HOSPITALIZED PATIENT

-

-

-

-

-

-

PHYSICAL EXAMINATION

-

-

(Table 393-3)

pain warmth erythema swelling

--

-

-

-

stability

Subluxation dislocation

TABLE 393-3 GLOSSARY OF MUSCULOSKELETAL TERMSCrepitus

--

Subluxation

Dislocation

Range of motion

Contracture

Deformity

Enthesitis

Epicondylitis

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PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders

swellingvolume

-

range of motion

-

Contracturescrepitus

deformity

-

-

-

-

APPROACH TO REGIONAL RHEUMATIC COMPLAINTS

-

HAND PAIN-

-

(Fig. 393-3)

-

-

-

-

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

-

-

-

SHOULDER PAIN

-

(Fig. 393-4)

-

-

-

--

-

-

KNEE PAIN

-

-

genu varum genu valgum -

-

Clavicle

Humerus

Bicipitaltendon

Glenohumeral(shoulder) joint

Acromion

Acromioclavicularjoint

Subacromialbursa

Supraspinatusmuscle

Subscapularismuscle

Supraspinatustendon

FIGURE 3934 Origins of shoulder pain.

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2222

PART 15Immune-Mediated, Inflammatory, and Rheumatologic Disorders

Baker’s cyst

--

-

-

-

-

HIP PAIN

(Fig. 393-5)

-

-

-

LABORATORY INVESTIGATIONS-

-

-

-

--

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

-

-

-

-(Table 393-4)

-

c R e -s t -

--

-

-

--

Fig. 393-6

Chlamydia trachomatis N. gonorrhoeae

M. tuberculosis

DIAGNOSTIC IMAGING IN JOINT DISEASES

-

-

-

-(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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2224

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

--

-

(Fig. 393-7)MRI

(Fig. 393-8)

-

-

-

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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