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5. Referred pain: particularly common in the knee due to hip and prostate
disease and in the shoulder due to some abdominal conditions, esophageal
conditions, cardiac conditions, neurologic conditions neurological conditions
and pulmonary conditions
The Arthropathies
1. Anklosing Spondylitis (Marie Strumpell Disease): a chronic condition
of the spine (bamboo spine) and sacro-iliac joints in which early
inflammatory changes are followed by progressive restriction of spinal
movement, with radiological calcification of spinal ligaments (seronegative
disorder).
a. Signs: chest expansion reduced (< 5cm), limited spinal movements,
tender bony points (heel)
b. Symptoms: gradual onset of low backache and/or pain in buttocks
c. X-ray: shows bamboo spine, and "whiskering" of ischial tuberosities
d. Labs: ESR >, mild anemia, (-) latex fixation, synovial fluid shows
inflammatory/neutrophils
e. Tx: Exercises, NSAIDS
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 gastric
dilatation)
NOTE* The WBC's in joint aspirate in a septic joint is usually higher then
100,000, however, in gonococcal arthritis the WBC's is usually below
50,000
g. Tx: antibiotics, rest, aspirations (?? damage to the joint), open
debridement (permits lysing of adhesions and debridement of necrotic bone
or soft tissue present, arthrotomy performed in patients with advancing
osteomyelitis
2. Serologic tests:
a. Erythrocyte Sedimentation Rate: nonspecific, reflects the presence of
tissue injury and inflammation, as a screening test may be overrated
b. C-reactive protein (CRP): nonspecific test for inflammation, a most
sensitive indicator of rheumatic fever
c. Rheumatoid factor: are a heterogenous group of antiglobulin antibodies
primarily found in patients with rheumatoid arthritis. The antibodies react to
specific antigenic determinants on the crystallizable fragment of human IgG.
RF has been found among several classes of immunoglobulins, including IgM,
IgA, IgG, and IgE
d. Latex fixation: are also used to detect RF, with IgG used as the antigen
e. Antinuclear antibodies (ANA): are a heterogenous group of antibodies
detecting many nuclear constituents; including deoxyribonucleic acid (DNA),
deoxynucleoprotein (DNP), histone, and ribonucleicacid (RNA). The ANA
antibodies were 1st noted in the sera of patients with SLE. Only a test
reactive for double- stranded DNA is diagnostic for SLE
f. Histocompatibility antigens (HLA-B27): is associated with the
seronegative diseases
g. VDRL: screening test for syphilis (but not specific for it)
h. ASO titer: done with CRP where Rheumatic fever is suspected
i. LE prep: rarely done today because of the accuracy of the ANA
4. Uric Acid: May be normal during acute gouty attacks 5. Test for
Lyme disease (Lyme titer)
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. These
changes 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 the
following table. Synovial fluid characteristics in individual arthropathies are shown with other
laboratory features of the conditions.
NON-INFLAMMATORY INFLAMMATORY
Crystals No No No Yes
IDENTIFICATION OF CRYSTALS. Uric acid crystals are needle-shaped and strongly negatively
birefringent (blue across the plane of the first-order red compensator); pyrophosphate
crystals have square ends and are weakly positively birefringent (blue along the plane of the
compensator).
SPECIAL TESTS
1. 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 high
incidence of false positives in other conditions and the test has little diagnostic value.
Charcot Foot
1. Disorders producing a Charcot joint: Diabetes mellitus (most common
cause), tabes dorsalis, leprosy, syringomyelia, spina bifida,
meningomyelcoele, congenital insensitivity to pain, chronic alcoholism,
spinal cord injury and compression (all have decrease in pain sensation in
the presence of uninterrupted physical activity in common)
3. Pathogenesis:
a. Sensory-motor neuropathy: Loss of protective sensation, absent DTR's,
diminished vibratory sense, muscle weakness, ankle equinus b. Autonomic
neuropathy: Sympathetic denervation loss of vasomotor control, increased
peripheral blood flow, increased artiovenous shunting, increased bone blood
flow, hyperemia
c. Minor trauma: Repetitive moderate stress, repetitive impulse loading,
trabecular microfractures, inadequately protected fractures and sprains,
surgery
d. Other factors: Metabolic abnormalities which weaken bone, renal
transplantation, immunosuppressive treatment, steroid-induced
osteoporosis, decreased cartilage growth activity, glycosylation of collagen
4. Diagnosis:
a. Medical history, clinical manifestation, and radiologic findings
b. Technium and Gallium scans, MRI (low signal Intensity in T, and T2-
weighted images within the bone marrow space adjacent to the
involved joint), and bone biopsy and cultures in equivocal cases
5. Treatment: Based on the acuteness of symptoms, the anatomic pattern
of bone and joint destruction, the degree of involvement (deformity,
fractures instability, etc.) and the presence of infection a. Immobilization: At
least 3 months of non-weight-bearing cast immobilization prior to resumption
of partial weight-bearing (always check the asymptmatic limb during this
time)
b. Orthoses and shoes: A patella tendonbearing brace with molded shoes to
decrease the load on the foot
c. Surgery: Ostectomy, arthrodesis
i. Criteria for surgery: Instability, deformity, recurrent ulceration, refractory
to conservative treatment, must be quiescent, circulation intact, no active
infection, medically stable