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Periarticular Disorders of the Extremities
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Periarticular Disorders

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Periarticular Disorders

  1. 1. Peri-articular Disorders<br />Patrick Carter MPAS, PA-C<br />Clinical Medicine 1<br />April 18,2011<br />
  2. 2. Objectives<br />Define crystal deposition disease<br />Describe the etiology, epidemiology, signs and symptoms, diagnosis and treatment of acute gout<br />Discuss the prevention of gout<br />Discuss the complications of gout<br />Describe the etiology, epidemiology, signs and symptoms, diagnosis and treatment of chronic gout<br />Describe the etiology, epidemiology, signs and symptoms, diagnosis and treatment of pseudogout<br />
  3. 3. Objectives<br />Compare and contrast bursitis, tendinitis and other periarticular disorders<br />Discuss the etiology, epidemiology, risk factors, clinical presentation and treatment of periarticular disorders by joint or location<br />
  4. 4. Crystal Deposition Arthritis<br />Gout<br />Urate crystals<br />Pseudogout<br />Calcium pyrophosphate crystals<br />
  5. 5. Gout<br />Essentials of diagnosis<br />Acute onset, usually nocturnal and monoarticular, often 1st MTP joint<br />Identification of urate crystals in joint fluid or tophi is diagnostic<br />Postinflammatory desquamation and pruritus<br />Hyperuricemia in most cases<br />Dramatic response to NSAIDs or colchicine<br />Tophi formation with chronic gout<br />
  6. 6. Gout<br />
  7. 7. General Considerations<br />Often familial<br />Hyperuricemia due to overproduction or underexcretion of uric acid<br />Characterized by recurring acute arthritis early and chronic deforming arthritis later<br />Common in Pacific Islanders<br />May be secondary to acquired hyperuricemia<br />
  8. 8. Risks for Acute Attacks<br />Alcohol ingestion<br />Changes in diet (NPO due to abdominal surgery)<br />Rapid fluctuations in serum urate levels<br />
  9. 9. Epidemiology<br />90% of gout patients are men<br />Usually age > 30<br />Postmenopausal women<br />5-10% of patients will also have uric acid kidney stones<br />
  10. 10. Origin of Hyperuricemia<br />Primary – idiopathic; increased production or purine or decreased renal clearance of uric acid<br />Secondary<br />Myeloproliferative disorders<br />Lymphoproliferative disorders<br />Carcinoma and sarcoma<br />Chronic hemolytic anemias<br />Cytotoxic drugs<br />Psoriasis<br />
  11. 11. Origin of Hyperuricemia<br />Secondary<br />Intrinsic kidney disease<br />Functional impairment of tubular transport<br />Drug-induced (thiazides)<br />Hyperlacticacidemia (EtOH, lactic acidosis)<br />Hyperketoacidemia (DKA, starvation)<br />Diabetes insipidus<br />Bartter’s Syndome<br />
  12. 12. Characteristics<br />Tophus<br />Nodular deposit of monosodium urate monohydrate crystals with associated foreign body reaction<br />Cartilage, subcutaneous, periarticular, tendon, bone, kidneys<br />Relationship between hyperuricemia and gouty arthritis is unclear<br />
  13. 13. Signs and Symptoms<br />Attack has sudden onset, usually nocturnal<br />Can occur after alcohol excess or change in medication<br />Sometimes there is not an apparent cause<br />Most common in MTP joint of great toe (“podagra”)<br />
  14. 14. Signs and Symptoms<br />Can develop in the periarticular soft tissues (i.e., the arch of the foot)<br />Involved joints are swollen and exquisitely tender<br />Overlying skin is tense, warm and dusky red<br />Fever is common<br />
  15. 15. Signs and Symptoms<br />Local desquamation and pruritus during recovery is characteristic but not always present<br />Tophi usually seen only after several acute attacks<br />Tophi may be on ears, hands, feet, olecranon and prepatellar bursas<br />Can evolve into chronic, deforming polyarthritis<br />
  16. 16. Laboratory Findings<br />Serum uric acid is elevated ( > 7.5 mg/dL) in 95% of patients<br />Sed rate and WBC’s may be elevated during an acute attack<br />Examination of tophi or joint fluid under polarized light shows sodium urate crystals – needle-like and negatively birefringent<br />
  17. 17. Sodium Urate Crystals<br />Sodium urate crystals appear yellow under polarized light.<br />
  18. 18. Imaging Studies<br />Early in the disease, x-rays are normal<br />Later, “rat bite” lesions may develop<br />Rat bite lesions adjacent to a soft-tissue tophus are diagnostic of gout<br />
  19. 19. Imaging Studies<br />“Rat bite” is a punched out lesion with an overhanging rim of cortical bone<br />
  20. 20. Differential Diagnosis<br />Acute gout<br />Cellulitis<br />Acute infectious arthritis<br />Pseudogout<br />Chronic gout<br />Chronic RA<br />Chronic lead intoxication<br />
  21. 21. Treatment of Acute Attack<br />NSAIDs – treatment of choice for acute gout<br />Traditionally, indomethacin 25-50 mg PO q 8 hours until attack resolves (usually 5 – 10 days)<br />Contraindications are active PUD, impaired renal function, allergy to NSAIDs<br />Can use Cox II inhibitors instead<br />
  22. 22. Treatment of Acute Attack<br />Corticosteroids – oral, IV or injected into joint<br />Reserved for patients unable to take NSAIDs<br />Analgesics – NOT aspirin<br />Bed rest until attack has been resolved for 24 hours<br />Early ambulation can trigger a recurrence<br />
  23. 23. Treatment Between Attacks<br />Focused on minimizing urate deposition in the tissues<br />Dietary changes<br />Low-purine diet (avoiding meats, seafood, gravies, yeast, alcohol, beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower and mushrooms)<br />Weight loss<br />Reduction of EtOH consumption<br />Increased fluids<br />
  24. 24. Treatment Between Attacks<br />Avoidance of hyperuricemic medications<br />Thiazide and loop diuretics<br />Low doses of aspirin<br />Niacin<br />Colchicine – for frequent attacks; used for prophylaxis at 0.6 mg PO bid<br />
  25. 25. Treatment Between Attacks<br />Reduction of serum uric acid<br />Gout not controlled by colchicine prophylaxis<br />No need to treat asymptomatic hyperuricemia<br />Two classes of agents can be used<br />Uricosuric agents – undersecretors; less than 800 mg/d in 24-hour urine<br />Allopurinol – overproducers; more than 800 mg/d in 24-hour urine<br />
  26. 26. Treatment Between Attacks<br />Uricosuric drugs<br />Block tubular reabsorption of filtered urate<br />Can be given with colchicine<br />Probenecid 0.5 g daily to start; gradually increase to 1-2 g daily<br />Sulfinpyrazone 50-100 mg bid to start; gradually increase to 200-400 mg bid<br />
  27. 27. Treatment Between Attacks<br />Uricosuric drugs<br />Patients need to maintain good urinary output (2000 mL or more)<br /> Aspirin > 3 g daily is uricosuric<br />Allopurinol – lowers plasma urate levels and facilitates tophus mobilization<br />Used in overproducers and tophaceous gout<br />
  28. 28. Treatment Between Attacks<br />Allopurinol<br />Can be used in patients who do not respond to uricosuric agents<br />Most frequent adverse event is the precipitation of an acute gout attack<br />Hypersensitivity rash in 2% of patients can progress to toxic epidermal necrolysis<br />Initial dose is 100 mg/d, increased weekly depending on response<br />
  29. 29. Treatment Between Attacks<br />Allopurinol drug interactions<br />With ampicillin causes a rash in 20% of patients<br />Increases the half-life of probenecid, but probenecid increases excretion of allopurinol<br />Potentiates azathioprine, so need to reduce dose of azathioprine by 75% before starting allopurinol, and use only if necessary<br />
  30. 30. Chronic Tophaceous Gout<br />Tophaceous deposits can be shrunk with allopurinol therapy<br />Need to maintain serum uric acid level under 5 mg/dL<br />May require use of allopurinol and an uricosuric agent<br />Surgical excision of large tophi<br />
  31. 31. Chronic Tophaceous Gout<br />
  32. 32. Prognosis<br />Without treatment, an acute attack can last from a few days to several weeks<br />Intervals between attacks shorten as the disease progresses<br />Chronic gout occurs after several inadequately treated attacks<br />Younger patient = more progression<br />
  33. 33. Pseudogout<br />Chondrocalcinosis is the presence of calcium-containing salts in articular cartilage<br />Pseudogout is its clinical correlate<br />Usually patients > 60 years<br />Acute, recurrent arthritis of large joints<br />Most common in knees and wrists<br />
  34. 34. Pseudogout<br />May be familial<br />Commonly associated with metabolic disorders – hemochromatosis, hyper-parathyroidism, ochronosis, DM, hypothyroidism, Wilson’s disease, and gout<br />Often develops 24-48 hours after surgery, like gout<br />
  35. 35. Pseudogout<br />Diagnosed by identification of calcium pyrophosphate crystals in joint aspirate<br />Crystals are rhomboid shaped, blue when parallel and yellow when perpendicular<br />Xrays show calcification of cartilaginous structures and signs of DJD<br />
  36. 36. Pseudogout Crystals<br />
  37. 37. Pseudogout<br />Does not improve with colchicine<br />Treatment is directed at primary disease, if present<br />NSAIDs may help treat the acute episodes<br />Colchicine may help with prophylaxis<br />Resistant cases may be treated with steroid injections<br />
  38. 38. Non crystal <br />Peri-articular Disorders<br />
  39. 39. General Considerations<br />Can cause pain that may be confused with arthritis<br />True cause of pain can often be determined at the bedside with careful examination<br />Presence and localization of swelling is helpful to determine cause<br />Tendinitis causes little swelling<br />
  40. 40. General Considerations<br />Examination done by direct palpation, passive and active ROM, and isometric loading against resistance<br />With synovitis, palpation causes generalized tenderness over entire synovial surface<br />Bursitis tenderness is localized to the bursa<br />
  41. 41. General Considerations<br />With tendinitis, active ROM or isometric loading is best to elicit pain<br />Rarely tender with passive ROM unless it stretches the inflamed tendon<br />
  42. 42. Shoulder<br />Most common causes of shoulder pain<br />Subacromial bursitis<br />Rotator cuff Tendinitis<br />Biceps tendinitis<br />
  43. 43. Shoulder<br />Rotator cuff problems<br />Most common cause of shoulder pain<br />Usually caused by overuse of the arm in an overhead position<br />Acute impingement may be caused by a fall on the arm or shoulder<br />Pain on active abduction of the shoulder<br />
  44. 44.
  45. 45. Rotator Cuff Tendintis<br />Supraspinatus most commonly affected<br />Caused by injury or overuse of arm with elevation and forward flexion<br />Begins with edema and hemorrhage of the rotator cuff, which evolves to fibrotic thickening and rotator cuff degeneration with tendon tears and bone spurs<br />
  46. 46. Rotator Cuff Tendintis<br />Patients complain of dull aching in shoulder that impairs sleep<br />Severe pain with active abduction overhead<br />Tender over lateral aspect of humeral head below acromion<br />Passive forward flexion to 90 degrees impinges the inflamed rotator cuff and confirms the diagnosis<br />
  47. 47. Rotator Cuff Tendinitis<br />Treatment<br />NSAIDS<br />Steroid Injections<br />Physical Therapy<br />Surgical decompression if refractory to conservative treatment<br />
  48. 48. Bicipital Tendinitis<br />Involves the long head of the biceps as it traverses the bicipital groove<br />Anterior shoulder pain radiating down biceps into forearm<br />Painful and limited abduction and external rotation of the arm<br />Tender to direct palpation of the biciptial groove<br />Pain along tendon by resisting supination of forearm with elbow at 90 degrees<br />
  49. 49. Bicipital Tendinitis<br />
  50. 50. Bicipital Tendinitis<br />Treatment<br />NSAIDs<br />Rupture may develop which results in “Popeye” bulge in belly of biceps muscle after retraction of the long head of the biceps (May be painless in elderly)<br />In Elderly surgery not indicated<br />In Young patients <br />Ortho referral for surgical correction<br />
  51. 51. Subacromial Bursitis<br />Largest and most frequently inflamed shoulder bursa<br />Pain in the lateral aspect of the shoulder<br />Often accompanies rotator cuff tendinitis<br />Differs from rotator cuff tendinitis by presence of pain on direct palpation beneath the acromion process<br />Full passive ROM<br />Pain increased with active resisted abduction<br />
  52. 52. Subacromial Bursitis<br />
  53. 53. Subacromial Bursitis<br />Treatment<br />NSAIDs<br />Prevent aggravating movements<br />Steroid Injection<br />Ortho referral for refractory or recurrent<br />
  54. 54. Adhesive Capsulitis<br />AKA “frozen shoulder”<br />Loss of full passive and active ROM in all directions<br />May follow bursitis or tendinitis<br />Prolonged immobilization of shoulder <br />May be associated with DM, TB, cervical spine disease, upper extremity injuries, CAD, and chronic pulmonary disease<br />
  55. 55. Adhesive Capsulitis<br />Treatment<br />Refer to Ortho<br />Arthrography confirms diagnosis<br />Steroid Injections<br />NSAIDs<br />Physical Therapy<br />Manipulation under anesthesia<br />Difficult to treat once established<br />
  56. 56. Elbow<br />Most common causes of elbow pain are epicondylitis and olecranon bursitis<br />Epicondylitis<br />Medial – golfer’s elbow<br />Lateral – tennis elbow<br />Both are overuse syndromes<br />
  57. 57. Olecranon Bursitis<br />Posterior Elbow<br />Acutely Inflamed<br />Need to Aspirate fluid<br />Gram Stain & Culture to R/O Infection<br />Urate Crystals for Gout<br />Treatment<br />NSAIDS<br />Prevent aggravating condition<br />Inject Steroids<br /><ul><li>If Infection then Antibiotics
  58. 58. If Gout then Gout Rx</li></li></ul><li>Lateral Epicondylitis<br />Actually caused more by pulling weeds, screwdriver, briefcase<br />Pain over lateral aspect of elbow<br />Caused by small tears to extensor aponeurosis<br />
  59. 59. Lateral Epicondylitis<br />Treatment<br />NSAIDs<br />Rest<br />Ultrasound Ionophoresis<br />Steroid Injection<br />Avoid activity x 1 month<br />Forearm band<br />Improvement takes several months<br />Occasionally Surgical release required<br />
  60. 60. Medial Epicondylitis<br />Less common than lateral epicondylitis<br />Work related repetitive activities also with swimming & baseball<br />Reproduce pain with resisting wrist flexion and pronation with elbow extended<br />
  61. 61. Medial Epicondylitis<br />Treatment<br />NSAIDs<br />Rest<br />Ultrasound Ionophoresis<br />Steroid Injection<br />No activity x 1 month<br />Physical Therapy<br />Occasional Surgical release if sx > 1 yr<br />
  62. 62. De Quervain’s Disease<br />
  63. 63. DeQuervain’sTenosynovitis<br />
  64. 64. DeQuervain’sTenosynovitis<br />Finkelstein’s test<br />
  65. 65. DeQuervain’s Tenosynovitis<br />Tenosynovitis of the extensor pollicis brevis and abductor pollicis longus tendons.<br />Overuse condition, generally due to radial deviation<br />Pain on grasping with their thumb, such as with pinching.<br />Dx is clinical. + Finkelstein’s test<br />Tx- Rest, splint, NSAIDs, cortisone injection, surgery for failure of conservative treatment.<br />
  66. 66. Carpal Tunnel Syndrome<br />Compression of the median nerve in the carpal tunnel. <br />Most often chronic but may be acute<br />Presents with parasthsia along the median nerve distribution with symptoms often occurring at night. May reveal thenar atrophy.<br />Dx- + tinnels sign, + Phalen’s test, PNCV/EMG to confirm<br />Tx- Cock up wrist splint at night, Vit B6, cortisone injection. Most require surgical release of the carpal ligament to prevent permanent nerve damage.<br />
  67. 67. Carpal Tunnel Syndrome<br />
  68. 68. Wrist and Hand<br />Trigger finger<br />Painful clicking in the affected finger during active use<br />Locking sensation when extending the flexed finger<br />Caused by thickening of the A1 retinacular pulley in the palm, causing entrapment of the tendon within the tendon sheath<br />
  69. 69. Trigger Finger<br />
  70. 70. Hip<br />Hip has 3 main bursae<br />Most clinically significant is the trochanteric bursa<br />Trochanteric bursitis<br />Hip pain<br />Tender to direct palpation<br />Full passive ROM<br />
  71. 71. Trochanteric Bursitis<br />
  72. 72. Knee<br />Prepatellar bursitis<br />Swelling and tenderness limited to prepatellar area<br />Palpation along medial and lateral knee is unremarkable<br />May need to R/O Infection & Gout<br />Pes anserine bursitis<br />Pain along the medial aspect of the knee below the medial tibial plateau<br />Swelling uncommon<br />Tenderness to palpation of the bursa<br />
  73. 73. Prepatellar Bursitis<br />
  74. 74. Knee Effusion<br />
  75. 75. Pes Anserine Bursitis<br />
  76. 76. Knee<br />Patellar tendinitis<br />Overuse of the patellar tendon<br />Anterior knee pain exacerbated by use of the quadriceps muscles (jumping)<br />Tenderness to palpation localized to the patellar tendon<br />Iliotibial band bursitis<br />Pain over lateral aspect of the knee<br />Tenderness confined to lateral aspect of the knee without effusion<br />
  77. 77. Achilles Tendinitis<br />Posterior ankle pain reproduced by active loading of the Achilles tendon<br />Pain localized to the tendon<br />There is a risk of Achilles tendon rupture with this<br />
  78. 78. Plantar Fasciitis<br />Pain along the plantar surface of the medial heel is most common complaint<br />Severe pain with first steps of the day and gets better during the day<br />Can worse with continued exacerbating activity<br />
  79. 79. Plantar Fasciitis<br />Risk Factors<br />Obesity<br />Excessive Pronation of the foot<br />High arched foot<br />Prolonged standing<br />Excessive running<br />Diagnosis based on History & Tender over inferior heel at insertion point of fascia<br />
  80. 80. Plantar Fasciitis<br />Imaging studies are not useful in acute cases (reserved for refractory)<br />Treatment<br />Removal of offending activity<br />PT helpful in most cases<br />Ice and Heat<br />Strengthening exercises & Massage<br />NSAIDs for analgesia and inflammation<br />
  81. 81. Plantar Fasciitis<br />Treatment<br />Judicious use of intralesional steroid injections<br />Plantar fascia rupture is a risk<br />Plantar fasciotomy reserved for refractory cases after 6-12 months<br />
  82. 82. Compartment Syndrome<br />Increased pressure within a confined space compromises the circulation and function<br />Common Causes<br />Fractures<br />Ischemic-reperfusion injury<br />Hemorrhage<br />Crush Injury<br />Burns<br />Casts<br />
  83. 83. Compartment Syndrome<br /><ul><li>Most Common site is level of tibia & fibula
  84. 84. Lower extremity
  85. 85. 4 Compartment
  86. 86. Anterior
  87. 87. Lateral
  88. 88. Superficial Posterior
  89. 89. Deep Posterior</li></li></ul><li>Compartment Syndrome<br />Upper Extremity<br />Three Compartments<br />Flexor<br />Extensor<br />Mobile Wad<br />Hand & Upper Arm Less Likely<br />
  90. 90. Compartment Syndrome<br />Signs and Symptoms<br />Severe Pain – Difficult to Control<br />Pain with Passive & Active ROM & Squeezing Extremity<br />Burning or Dysethesias or Paraesthesias<br />Decreased Motor Function (late finding)<br />Five “P’s” – Not as reliable<br />Pain<br />Paraesthesia<br />Pallor<br />Pulselessness<br />Poikilothermia<br />
  91. 91. Compartment Syndrome<br />Measuring Compartment Pressures<br />Normal Pressure < 10 mm Hg<br />Intermediate 10-20 mm Hg<br />Toxic Pressures > 30 mm Hg<br />New Data supports “Delta Pressure”<br />Diastolic minus Compartment Pressure<br />< 30 mm Hg considered acute compartment syndrome<br />
  92. 92. Compartment Syndrome<br />
  93. 93. Compartment Syndrome<br />Treatment<br />Surgical fasciotomy with subsequent closure once edema decreased<br />Medical Management<br />Oxygen<br />Maintain Blood Pressure<br />Remove constrictive casts or dresings<br />Elevate limb to level of heart – not higher<br />
  94. 94. Compartment Syndrome<br />Prognosis<br />Permanent damage results with > 8 hours of ischemia<br />Nerves begin to lose conduction within 2 hours<br />Neurapraxia can occur within 4 hours<br />Functional impairment unlikely when treated < 6 hours of onset<br />
  95. 95. Questions?<br />
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