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I N T R O D U C T I O N
Musculoskeletal and Connective
Tissue Disorders
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Some musculoskeletal disorders affect primarily thejoints, causing arthritis.
Others affect primarily the bones (eg, fractures, Paget's disease, tumors),
muscles or other extra-articular soft tissues (eg, fibromyalgia),or
periarticular soft tissues (eg, polymyalgia rheumatica, bursitis,tendinitis, sprain)
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Arthritis has multiple causes, including
infection,
autoimmune disorders,
crystal-induced inflammation, and
noninflammatory tissue degeneration (eg, osteoarthritis).
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Arthritis may affect
single joints (monarthritis) or
multiple joints (polyarthritis) in a symmetric or asymmetricmanner.
Joints may suffer fractures or sprains
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History
Focus on systemic and extra-articular symptoms aswell as joint symptoms.
Many symptoms, including fever, chills, malaise,weight loss, Raynaud's syndrome, mucocutaneoussymptoms (eg, rash, eye irritation or pain,photosensitivity), and GI or cardiopulmonary
symptoms, can be associated with various jointdisorders.
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Discomfort that occurs with motion whenattempting to move a joint after a period of restoccurs in rheumatic disease.
stiffness upon standing that necessitates walkingslowly after sitting for several hours is commonin osteoarthritis.
Stiffness is more severe and prolonged ininflammatory joint disorders.
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Morning stiffness in peripheral joints that lasts > 1 h can bean important early symptom of RA
In the low back, morning stiffness that lasts > 1 h may
reflect spondylitis.
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Distinguishing Inflammatory vsNoninflammatory Features in Joint Disease
Symptom Inflammatory Noninflammatory
Systemic symptoms Prominent, including fatigue Unusual
Onset Insidious GradualUsually affecting multiple joints 1 joint or a few weight-
bearing joints
Morning stiffness > 1 h < 30 min
Worst time of day Morning As day progresses
Effect of activity Lessen with activity Worsen with activity
on symptoms Worse after periods of rest Lessen with rest
May also hurt with use
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Physical Examination
Each involved joint should be inspected andpalpated, and the range of motion should beestimated.
With polyarticular disease, certain nonarticularsigns (eg, fever, wasting, rash) may reflectsystemic disorders.
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Monarticular (involving one joint) or asymmetricoligoarticular (involving 4) joint involvement is morecommon in osteoarthritis and psoriatic arthritis.
Small peripheral joints are commonly affected in RA,and the larger joints and spine are affected more inspondyloarthropathies.
Crepitus, a palpable or audible grinding produced by
motion. It may be caused by roughened articularcartilage or by tendons; crepitus-causing motionsshould be determined and may suggest whichstructures are involved.
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DIAGNOSIS
Joint pattern
Presence or Absence of extra articular manifestation
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Joint pattern
Answer to following three Qs
Is inflammation present?
How many joints are involved?
What joints are affected?
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Diagnostic value of the joint patternDiseasesStatusCharacteristicsRA, SLE, GoutOAPresentAbsentInflammationGout, trauma, septic, OA
Lyme disease
Reiters disease, psoriatic,
IBD
RA, SLE
Monoarticular
Oligoarticular
(2-4 joints)
Polyarticular( 5joints)
No of involved joints
OA, Psoriatic
RA, SLE
Gout, OA
DIP
MCP, Wrists
Ist MTP
Site of joint involvement
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Testing
Laboratory testing and imaging studies often provideless information than the history and physical
examination.
However, few investigations may be warranted insome patients, extensive testing is often not.
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Blood tests: Supportive
Antinuclear antibodies (ANA) and complement in SLE
Rheumatoid factor and anti-citrullinated peptide (CCP)in RA
Occasionally useful: HLA-B27 in spondyloarthropathyand antineutrophil cytoplasmic antibodies (ANCA) incertain vasculitides
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Imaging studies:
Plain x-rays in particular reveal mainly bony
abnormalities, and most joint disorders do not affectbone primarily.
However, imaging may help in the initial evaluation of
relatively localized, unexplained persistent or severe jointand particularly spine abnormalities
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If chronic RA, gout, or osteoarthritis is suspected,erosions, cysts, and joint space narrowing with
osteophytes may be visible.
In pseudogout, Ca pyrophosphate deposition may bevisible in intra-articular cartilage.
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Arthrocentesis: is the process of puncturing thejoint with a needle to withdraw fluid.
Examination of synovial fluid is the most accurate way toexclude infection, diagnose crystal-induced arthritis, andotherwise determine the cause of joint effusions.
It is indicated in all patients with severe or unexplainedmonarticular joint effusions and in patients with
unexplained polyarticular effusions.
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Classification of synovial effusions
Gross
Examinati
on
Norma
l
Noninflam
matory
(Group I)
Inflamm
atory
(GroupII)
Septic
(Group
III)
Crystal
(Group
IV)
Hemorr
hagic
(GroupV)
Volume (mL)
(Knee)
Viscosity
Color
Routine
laboratory
examination
WBC (mm3)
PMN leukocytes
(%)Crystals present
Culture
Mucin clot
Glucose (AM
fasting)
100,
000
>75No
Often
positive
Friable
>50 mg%
lower
than blood
Often >3.5
Variable
Yellow
Cloudy
2,000-
75,000
>50 oftenYes
Negative
Friable
>50 mg%
lower
than blood
Often >3.5
Variable
Red
Xanthochro
mic
50-10,000
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Differential diagnosis by joint fluid groups
Group INoninflammator
y
Group IIInfalmmatory
Group IIISeptic
Group IVCrystal-
induced
Group VHemorrhagic
Osteoarthrosis
Traumatic arthritis
Osteochondritis
dissencans
Osteochondromat
osis
Neuropathic
osteoarthropathyPigmented
villonodular
tenosynovitis
Rheumatoid
arthritis
Lupus
erythematosus
Reiters
syndrome
Ankylosing
spondylitis
Regional eneritis
Ulcerative colitis
Psoriasis
Bacterial
Mycobacteria
l
Fungal
Gout
CPPD crystal
depositon
disease
Apatite-
associated
arthropathy
Traumatic arthritis
Hemophiliac
arthropathy
Anticoagulation
Pigmented
villonodular
tenosynovitis
Neuropathic
osteoarthropathySynovial
hemangioma
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