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1. Project: Ghana Emergency Medicine Collaborative
Document Title: Arthritis and Arthrocentesis
Author(s): Joe Lex, MD (Temple University School of Medicine)
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2

3. Arthritis and Arthrocentesis Joe Lex, MD, FACEP, MAAEM Temple University School of Medicine
3

4. What’s a joint like you doing in a nice girl like this??
Source Undetermined
4

5. Objectives 1. Differentiate among the three types of joints 2. Explain the pathology of joint inflammation 3. Develop a differential for arthritis, based on number of joints involved, location, and other characteristics
5

6. Objectives 4. Explain usefulness of various synovial fluid studies. 5. Demonstrate an appropriate technique for large joint arthrocentesis 6. Explain the pathophysiology and treatment for gout
6

7. Objectives 7. Differentiate “rheumatic fever” from “rheumatoid arthritis” from “rheumatism” 8. Be aware of quackery as it applies to treatment of arthritis
7

8. History of Arthritides •1680s: Sydenham describes gout, rheumatism, chorea •1808: term “rheumatic fever” •1876: urate crystals postulated to cause gout •1883: gonococcal arthritis •1907: osteoarthritis described
8

9. Thomas Sydenham (1624-1689)
Source Undetermined
9

10. Three Joint Types •Synarthroses: suture lines of skull •Amphiarthroses: fibrocartilaginous unions of pubic symphysis and lower third of sacroiliac joint •Diarthroses = Synovial: most other joints
10

11. Synarthrosis
Gray's Anatomy (Wikipedia)
11

12. Amphiarthroses
Source Undetermined
12

13. Diarthrosis = Synovial Joints •Subchondral bone, convex against concave, covered by cartilage •Cartilage: collagen + proteoglycan •Lubricated, slide on each other •Surrounded by capsule supported by ligaments, tendons, and muscle •Lined with synovial membrane
13

14. Typical Joint Structure
Madhero88 (Wikimedia Commons)
14

15. Pathophysiology •Joint trauma causes decreased proteoglycans –If trauma persistent, damage irreparable •Inflammation characterized by polymorphonuclear white cells –May be immunologic (rheumatoid, reactive)
15

16. Joint vs. Periarticular Arthritis •Generalized pain, warmth, swelling, tenderness •Discomfort  with joint motion Periarticular inflammation: bursitis, tendinitis, localized cellulitis •Focal tenderness, swelling not uniform •Pain only with certain movements
16

17. Monarticular vs. Polyarticular
Source Undetermined
17

18. If Polyarticular and… …symmetric  rheumatoid, drug induced …asymmetric  rubella, acute rheumatic fever, gonococcal …migratory  gonococcal or rubella
18

19. Location, Location, Location •First MTP joint: gout •MCP and PIP joints: rheumatoid •DIP and first carpometacarpal joint: osteoarthritis •Knee: septic arthritis, pseudogout, gout
19

20. Causes of Migratory Arthritis •Rheumatic fever •Subacute bacterial endocarditis •Henoch-Schönlein purpura •Cefaclor (Ceclor®) hypersensitivity (kids) •Septicemia: staphylococcal, streptococcal, meningococcal, gonococcal •Mycoplasma, histoplasmosis, coccidioidomycosis •Lyme disease
20

21. Arthritis with… …low-grade fever  any inflammatory arthritis …high fever, chills  septic arthritis …kidney stones  gout …genital ulcers  reactive arthritis …urethral discharge  reactive arthritis, gonococcus
21

22. Arthritis and… …isoniazid, procainamide, hydralazine  lupus …thiazide diuretics  gout (increase serum uric acid level) –Chlorthalidone (Hygroton®) –Hydrochlorothiazide (HydroDIURIL®, Esidrix®, Oretic®) –Indapamide (Lozol®)
22

23. Some Scalp and Skin Findings
Alopecia
SLE, psoriasis
ECM
Lyme
Malar rash
SLE, dermato- myositis
Rash
Rubella
Pustules
Gonococcemia
Tophi
Gout
Elbows, knees
Psoriasis
SubQ nodules
RA
Tight skin
Scleroderma
Hyper- keratosis
Reactive
23

24. Physical Exam
Source Undetermined
24

25. Physical Exam 1.Warmth and effusion 2.Synovial thickening 3.Deformity 4.Tenderness: generalized or localized, articular or periarticular 5.Limited range of motion 6.Pain on movement
25

26. Lab Studies •Limited diagnostic value •“Screening tests” –Bacterial: usually elevated WBC –Chronic rheumatic: mild anemia –ESR/CRP  in most inflammatory •RF, ANA, ASO titers, Lyme serologies: for follow-up •Uric acid: not helpful in gout
26

27. X-ray Findings (Chronic) Soft tissue swelling Erosions Calcification Osteoporosis Narrowed joint space Deformity Separation (fractures)
Source Undetermined
27

28. X-ray Findings (Septic)
Source Undetermined
Source Undetermined
28

29. Hallmark X-ray Findings
Osteoarthritis = Osteophytes
Source Undetermined
Source Undetermined
29

30. Hallmark X-ray Findings
Erosions = Rheumatoid or Gout
Source Undetermined
Source Undetermined
Source Undetermined
30

31. Hallmark X-ray Findings
Chondrocalcinosis = Pseudogout
Source Undetermined
31

32. Hallmark X-ray Findings
Enthesitis = Insertion Site Inflammation (HLA-B27)
Source Undetermined
32

33. Other Imaging •Ultrasound: joint effusions; tendons and ligaments of shoulder •CT scan: SI, sternoclavicular joint •MRI: knee cruciate ligaments •Contrast MRI: differentiate synovitis from synovial fluid in rheumatoid disease
33

34. Other Imaging •99mtechnetium methylene diphosphonate (99mTc MDP) –Osteomyelitis, stress fractures •Gallium: gathers at proliferation of serum proteins and leukocytes –Infection
34

35. Arthrocentesis
35

36. Arthrocentesis •Critical diagnostic adjunct •Can be painless, safe, and simple when performed correctly •Diagnostic or therapeutic
Source Undetermined
36

37. Indications •Obtain joint fluid for analysis •Drain tense hemarthroses •Instill analgesics and anti- inflammatory agents •Prosthetic joints: only to rule out infection
37

38. Contraindications •Absolute: infection of any kind covers area to be punctured •Relative –Bleeding diatheses, anticoagulant therapy –Bacteremia
38

39. Procedure •Cleanse skin with povidone-iodine, then air dry •Remove povidone-iodine with isopropyl alcohol –Intra-articular povidone-iodine can cause chemical irritation, inhibit bacterial growth leading to spuriously negative cultures in early septic joint
39

40. Procedure •Place sterile drapes •Inject local anesthetic into skin –25- to 30-gauge needle –Intraarticular anesthetic can inhibit bacterial growth, cause spuriously negative culture in early septic joint
40

41. Procedure •Aspirate large joints with large- bore needle (18 or 19 gauge) –Smaller joints: smaller-bore needle •Choose syringe size based on anticipated fluid volume •Remove as much fluid as possible –Optimizes diagnosis –Relieves pain from distention
41

42. Arthrocentesis •Fat globules: diagnostic of fracture •Intraarticular morphine can provide relief for up to 24 hours –1 to 5 mg diluted in normal saline solution to a total volume of 30 ml
42

43. Sternoclavicular Joint
43
Gray's Anatomy (Wikipedia)

44. Elbow – Lateral Approach
Flex elbow 90o Prep skin Insert needle in palpable bony notch between lateral epicondyle and olecranon
44

45. Knee – Lateral Approach
Extend knee, quadriceps and patella relaxed so patella can move mediolaterally. Needle into joint space just lateral to patella near its upper pole, parallel to the posterior (articular) surface.
45

46. Knee – Medial Approach
46
Source Undetermined

47. Knee – Medial Approach
47
Source Undetermined

48. Knee – Medial Approach
48
Source Undetermined

49. Knee – Medial Approach
49
Source Undetermined

50. Knee – Medial Approach
50
Source Undetermined

51. Knee – Medial vs. Lateral •Follow “Sutton’s Law” •William “Slick Willie” Sutton (1901 – 1980): professional bank robber
51

52. Ankle
Palpate the medial and lateral malleoli with your thumb and index finger. The joint space is located one to one and a half cm above the line joining the tips of the malleoli.
52

53. Ankle
Palpate the dorsalis pedis artery and choose a puncture site anywhere on the anterior aspect of the ankle, avoiding the dorsalis pedis artery.
53

54. Synovial Fluid Analysis
54
Source Undetermined

55. Synovial Fluid Analysis •Identify crystals, pus •Analyze color, clarity, cell count, differential, Gram’s stain, crystals •Positive Gram’s stain: diagnostic for septic arthritis •Negative Gram’s stain: does not rule out septic arthritis
55

56. Synovial Fluid Cell Count •Noninflammatory vs. inflammatory •ED wet mount prep –1 to 2 WBCs per high-power field consistent with noninflammatory –>20 WBC/HPF suggests inflammation or infection •Septic: >50,000 WBC/mm3 (also rheumatoid, gout, pseudogout)
56

57. Normal
Non- inflammatory
Inflammatory
Infectious
Trans- parent
Transparent
Cloudy
Cloudy
Clear
Yellow
Yellow
Yellow
<200
<2000
200 – 50,000
>50,000
<25%
<25%
>50%
>50%
Negative
Negative
Negative
Positive
Appear- ance
Clarity
WBCs
PMNs
Culture
Synovial Fluid Analysis
57

58. Other Synovial Fluid Analysis •Glucose, lactic acid, viscosity, mucin clot, and total protein: limited utility, not recommended •Appropriate container –Cellular analysis: lavender (ethylenediaminetetraacetic acid) –Crystal analysis: green (heparin) –Chemical analysis, serology: red
58

59. Crystal Studies •Monosodium urate: needle shaped, birefringent negative –Parallel to compensator: yellow –Perpendicular: blue •Calcium pyrophosphate: polymorphic, birefringent positive –Parallel to compensator: blue –Perpendicular: yellow
59

60. Crystal Studies
Sodium urate crystals viewed under polarized light with a red plate makes those in the plane of the long axis of the red plate yellow, which indicates that they are negatively birefringent.
60
Source Undetermined

61. Crystal Studies
Calcium pyrophosphate crystal viewed under polarized light with a red plate. The crystal is aligned in the long axis of the red plate, so that it is bluish-white, which indicates that it is weakly positively birefringent.
61
Source Undetermined

62. Specific Arthritides There are more than 90
Preiser’s disease: avascular necrosis of scaphoid
62
Source Undetermined

63. Septic Arthritis •Hematogenous spread •Direct inoculation •Direct spread from bony or soft tissue infections
63

64. Septic Arthritis •Synovium infected before degrading enzymes released •Children: hematogenous most common •Postoperative infection: ~10% of joint surgeries
64

65. Causes •Staphylococcus aureus: most common (even in sickle cell) •Others: streptococcus, Gram negatives, anaerobes •N. gonorrhoeae: 20% monarticular •<6 months: E. coli, group B strep •IV drug users: S. aureus, Gram negatives
65

66. Clinical Features •Based on host’s concurrent medical conditions •Painful, hot, swollen •Typical: single joint –Knee: 40% to 50% –Hip: 13% to 20% –Shoulder: 10% to 15% •20% polyarticular
66

67. Clinical Features •History of fever: 80% •Shaking chills: 20% •Elevated sedimentation rate more common than leukocytosis •Blood cultures grow causative organism ~50% of the time •Radiographs not often useful
67

68. Management •Admit for joint drainage, IV antibiotics •Empiric therapy based on Gram’s stain •Parenteral narcotic analgesics, articular immobilization control pain and discomfort
68

69. Gouty Arthritis
69

70. Gouty Arthritis •Pod = foot; agra = trap, hunt •Podagra: foot goddess, a bad- tempered virgin, who attacked victims after they overindulged •Father was Dionysus (Bacchus), god of wine •Mother was Aphrodite (Venus), goddess of love
70

71. Gouty Arthritis •Thought to be limited to men who had indulged in dietary or sexual excess
71

72. Gouty Arthritis •Galen (129-199 AD), an ex-gladiatorial surgeon in Rome, described gout as a discharge of the four humors of the body in unbalanced amounts into the joints (hence gout = gutta, a drop)
72
Pierre Roche Vigneron (Wikimedia Commons)

73. Be temperate in wine, in eating, girls and sloth Or the gout will seize you and plague you both
73
Benjamin Franklin:

74. Pathophysiology •Uric acid crystal deposits from supersaturated extracellular fluid •Risk factors: obesity, hypertension, diabetes, alcohol, proximal loop diuretics, lead poisoning •During attack: crystals ingested by PMNs  inflammation
74

75. Pathophysiology •Middle-aged men, post- menopausal women •Increased uric acid usually present for 20 years before first attack •Uric acid often normal
75

76. Presentation •Great toe MTP joint in 75% –Also tarsal, ankle, knee, wrist –Up to 40% polyarticular •Pain excruciating at onset –Can mimic septic joint –Usually self-limited •Systemic symptoms usually minimal or absent
76

77. Presentation •Subsequent attacks closer together, more joints, last longer •Long-term: kidney stones
77
Source Undetermined

78. Presentation •Tophi: foreign body granulomas with crystals as nidus, in musculo- tendinous unit – olecranon bursa, Achilles tendon, hands, knees, etc.
78
Source Undetermined
Source Undetermined

79. Diagnosis •Rule out cellulitis, septic arthritis particularly if knee joint •All may have fever, leukocytosis, elevated ESR •Uric acid level not helpful •X-rays: soft-tissue swelling (acute) or joint destruction (chronic)
79

80. Uric Acid Levels •Uric acid normal in ~40% •Tophi can form in cool body areas without hyperuricemia •Acute attack  pain  increased cortisol  uric acid diuresis  normalized level
80

81. Diagnosis
81
Source Undetermined
Source Undetermined

82. Diagnosis •Definitive diagnosis: birefringent joint fluid crystals with polarizing microscope (a yellow crystal against a red background) and negative joint fluid culture
82
Source Undetermined

83. Acute Therapy – Colchicine •Not diagnostic: works on pseudogout •Contraindication: hematologic, renal, hepatic dysfunction •Extravasation from IV  tissue necrosis
83

84. Acute Therapy – Colchicine •Inhibits microtubule formation •Most effective in first 24 hours •0.6 mg / hour until pain controlled, max 6 mg or side effects (GI) •Average toxic dose: 6.7 mg •Toxicity precedes improvement in more than 50%
84

85. Acute Therapy – Other •NSAIDs effective, indomethacin most common (75 to 200 mg/day) –Contraindicated in PUD, GI bleed •If resistant: prednisone taper –40 mg/day first 3 to 5 days •Adrenocorticotrophic hormone –ACTH 40 IU to 80 IU IM
85

86. Pseudogout •Calcium pyrophosphate dihydrate (CPPD) crystal-deposition disease •Knee: most common joint •Polyarticular possible •Pain less severe, patients older •Risk: hypothyroid, Wilson’s disease, hyperparathyroid, hemochromatosis, etc.
86

87. Diagnosis •Common: elevated ESR, WBC •X-ray may show joint calcification •Joint fluid –Weakly positive birefringent crystals on polarized microscopy –Appear rhomboidal on regular light microscopy •Treatment: same as gout
87

88. Chondrocalcinosis
88
Source Undetermined

89. Osteoarthritis •Degenerative joint disease •Most common form of arthritis •Loss of articular cartilage, reactive changes at joint margins •Synovitis in advanced disease •May have painful bone-to-bone interface
89

90. Presentation / Diagnosis •Chief complaint: pain •No systemic symptoms •Hands: Bouchard’s, Heberden’s nodes (osteophyte spurs) •Knee: active & passive crepitus •Routine lab tests: normal •Radiographs: joint- space narrowing, osteophyte formation
90

91. Heberden’s and Bouchard’s
Over DIP
Over PIP
91
Source Undetermined

92. 92
Source Undetermined

93. Treatment •Judicious exercise for muscle strengthening •Relieve muscle spasm •Support joint •Acetaminophen comparable to ibuprofen for short-term treatment •Ultimately joint replacement
93

94. Gonococcal Arthritis •Woman : men :: 4:1 •Fever, chills, arthralgias, migratory tenosynovitis •Progresses to arthritis: knee, ankle, wrist •Characteristic rash: countable hemorrhagic necrotic pustules •Rarely have cervicitis or urethritis
94

95. Gonococcal Arthritis
95
Source Undetermined
Source Undetermined

96. Gonococcal Arthritis
96
Source Undetermined
Source Undetermined

97. Diagnosis •Blood cultures usually negative •Synovial fluid cultures positive in less than 50% •Gram’s stain positive more often than culture •Cervical, urethral, pharyngeal, rectal cultures positive ~75%
97

98. Treatment •Admit to hospital •Ceftriaxone 1 g IM or IV daily, and 24 to 48 hours after improvement •Ciprofloxacin 500 mg twice daily orally for total 7 days of antibiotics •Spectinomycin 2 grams IM every 12 hours if beta-lactam allergic
98

99. Viral Arthritis •Most common: rubella, hepatitis B •Also mumps, adenoviruses, Epstein-Barr virus, enteroviruses •Deposition of soluble immune complexes in synovium with resultant inflammation
99

100. Rubella Arthritis •Often young women •Rash several days before •Acute, symmetric, usually polyarticular •Resolves within weeks •Recent infection or vaccination •Virus isolated from synovial fluid
100

101. Rubella
101
Source Undetermined
Source Undetermined

102. Hepatitis B Arthritis •Usually with or after prodrome of fever and lymphadenopathy •Often precedes jaundice •May be sudden and severe •PIP, knee, ankle, MP joints most commonly involved •Salicylates may be helpful
102

103. Lyme •Spirochete: Borrelia burgdorferi •Vector: Ixodes dammini on East Coast and Midwest •Arthritis late manifestation •Within 6 months, half of untreated have frank arthritis –Asymmetric –Most common in knees
103

104. Presentation •Minimal joint pain, usually afebrile •Severity of initial presentation predictive of subsequent arthritis •Chronic arthritis more common in patients positive for HLA-DR4 •Joint fluid inflammatory with PMN predominance •Diagnosis is clinical
104

105. Presentation
105
Source Undetermined

106. Ixodes
106
Centers for Disease Control and Prevention (Wikimedia Commons)

107. Spondyloarthropathies •Seronegative: negative rheumatoid factor •Sacroiliac involvement •Peripheral joint inflammation •Changes of ligamentous and tendinous insertion into bone •Genetic: HLA-B27
107

108. Spondyloarthropathies •Ankylosing spondylitis •Reactive arthritis (e.g. Reiter’s syndrome) •Psoriatic arthritis •Arthropathy of inflammatory bowel disease
108

109. Ankylosing Spondylitis •Male predominance •Back pain •X-ray evidence of sacroiliitis •Symmetrically squared vertebral bodies, then “bamboo spine” •Morning stiffness, improves with exercise
109

110. Ankylosing Spondylitis
110
Source Undetermined
Source Undetermined
Source Undetermined

111. Ankylosing Spondylitis •Uveitis: most common extra- articular manifestation •Peripheral joints involved in ~30% of patients with enthesopathic involvement (plantar fasciitis and Achilles tendinitis) •Goal of therapy: control pain, decrease inflammation
111

112. Reactive Arthritis •AKA arthritis urethritica, venereal arthritis, polyarteritis enterica •Described by German military physician Hans Reiter in 1916 •“Reiter's syndrome” being phased out, partly due to Reiter's typhoid experiments in Nazi concentration camps
112

113. Reactive Arthritis •Occurs in genetically susceptible host after infection with GU C. trachomatis, or GI shigella, salmonella, yersinia, campylobacter •Disease of men 15 to 35 years old; arthritis develops 2 to 6 weeks after episode of urethritis or dysentery
113

114. Reactive Arthritis •Polyarticular, asymmetric •Weight-bearing joints of lower extremities commonly involved: knees, ankles, feet, particularly heels (“lover’s heel”)
114

115. Reactive Arthritis •Other signs appear early •Conjunctivitis, progress to iritis, uveitis, corneal ulceration •Painless ulcers mouth, tongue, glans penis (balanitis circinata) •Sausage-like fingers and toes •Keratoderma blennorrhagica on palms and soles
115

116. Reactive Arthritis
Keratoderma blenorrhagica
Balanitis circinata
116
Source Undetermined
Source Undetermined

117. Reactive Arthritis •Synovial fluid: inflammatory with predominance of PMNs •Antigens in synovial membrane and joint fluid, cultures sterile •Increased ESR, WBC •HLA-B27 antigen in ~80% •Enthesopathic x-rays, particularly at IP joint of great toe
117

118. Reactive Arthritis •NSAID two or three times daily •Doxycycline twice daily x 3 months •Intra-articular steroid injections •If persistent: Sulfasalazine •Chronic therapy for erosive, deforming disease –Methotrexate –Azathioprine (Imuran)
118

119. What Happened to Reiter’s?
119

120. What Happened to Reiter’s? •Hans Julius Reiter (1881 – 1969) •German military physician on Western Front in 1st Hungarian Army •1916: described German Lieutenant with non-gonococcal urethritis, arthritis and uveitis
120

121. What Happened to Reiter’s? •Not the first, but he got credit •Member of the SS during WWII •Designed typhus inoculation experiments that killed more than 250 prisoners at Buchenwald •Convicted as war criminal
121

122. Psoriatic Arthritis
122
Source Undetermined
Source Undetermined
Source Undetermined

123. Rheumatism •An older term used to describe any of a number of painful conditions of muscles, tendons, joints, and bones.
•Rheumatism weed: Canadian dogbane
123
SB Johnny (Wikipedia)

124. Acute Rheumatic Fever •Believed to result from Group A streptococcus pharyngitis •Exact mechanism unclear •In decline since antibiotics •Probable abnormal humoral response to antigens
124

125. Clinical Syndrome •Recurring self-limited episodes of fever associated with polyarthritis, carditis / valvulitis, rash, subcutaneous nodules, or chorea •Occurs 2 to 3 weeks after streptococcal pharyngitis
125

126. Diagnosis – Jones Criteria •Two major, or one major and two minor, criteria with evidence recent Group A streptococcal infection •Major manifestations: polyarthritis, carditis, chorea, erythema marginatum, subcutaneous nodules •Migratory arthritis in large joints
126

127. Diagnosis – Jones Criteria •Involves heart in ~50% •Pericarditis, congestive heart failure, valvular dysfunction, cardiomegaly •Neurologic: Sydenham’s chorea, weakness, behavioral disturbance •Sparing of sensory functions
127

128. Diagnosis – Jones Criteria
Sinus tachycardia
Right atrial enlargement
Left atrial enlargement
Left ventricular strain
RBBB pattern
1st degree AV block
128
Source Undetermined

129. Diagnosis – Jones Criteria •Erythema marginatum: well- demarcated, pink nonpruritic rash, usually trunk, sometimes proximal limbs –Central clearing, may last hours
129
Source Undetermined

130. Erythema Marginatum
130
Source Undetermined

131. Diagnosis – Jones Criteria •Subcutaneous nodules: firm, nontender under skin overlying bony prominences
131
Source Undetermined

132. Laboratory Work-Up •Throat culture, ESR, CRP, ASO •Anti-DNase B 95% sensitive •Streptozyme test also documents recent streptococcal infection •Synovial fluid –Inflammatory (average WBC 16K) –Negative culture
132

133. Post-Streptococcal •Reactive arthritis: closely related to ARF but distinct clinical entity •Sterile oligoarthritis associated with distant bacterial infection •Carditis rare, arthritis often severe •Treatment: penicillin, erythromycin •Arthritis responds to salicylates
133

134. Rheumatoid Arthritis
134
Source Undetermined

135. Rheumatoid Arthritis •Usually chronic: >20% acute •Women 2 to 3 x more than men •Immune complexes stimulate PMNs to release enzymes •Synovial cells proliferate, produce more inflammatory substances
135

136. Presentation •Prodrome: fatigue, weakness, musculoskeletal pain •Symmetric joint swelling: hands (MP, PIP joints), wrists, elbows •Difficult to distinguish from viral arthropathy
136

137. Presentation •Long-term changes: MP and PIP swelling, ulnar deviation, swan- neck and boutonnière deformities of hands, limited wrist dorsiflexion
137
Source Undetermined

138. Swan Neck Deformity
138
Source Undetermined
Source Undetermined

139. Presentation •Knee: effusion, muscle atrophy, Baker’s cyst •Retrocalcaneal bursa •Subcutaneous nodules, pulmonary fibrosis, mononeuritis multiplex •Sjögren’s and Felty’s syndromes
139

140. Baker’s Cyst
140
Source Undetermined

141. Subcutaneous Nodules
141
Source Undetermined

142. Felty’s Syndrome •Rheumatoid arthritis + splenomegaly + leukopenia •Frequent pneumonia and leg ulcers •1% of RA patients
142
Source Undetermined

143. Transverse Ligament Rupture •C1 on C2 subluxation in 70% –Frank dislocation in 25% –Cord compression in 11% •With myelopathy: –5 years survival 80% –10 year survival 28% •Anterior instability more common than posterior instability
143

144. Transverse Ligament Rupture
144
Source Undetermined
Source Undetermined

145. Treatment •Movement increases inflammation: initial treatment rest •Suppress inflammation: steroids, salicylates, gold, penicillamine, azathioprine, methotrexate, cyclosporine, sulfasalazine
145

146. Nontraditional Thinking •The Mycoplasma Theory: joint pain caused by subclinical mycoplasma infection, improves with doxycycline •Glucosamine and chondroitin: possibly useful in osteoarthritis
146

147. Known Not to Work ALFALFA - LAPACHOL - ALOE VERA - MACROBIOTIC DIET - AMINO ACIDS - MA-HUANG - ANT VENOM - MANDELL ARTHRITIS DIET - ARNICA MEGAVITAMIN THERAPY - ASCORBIC ACID - NATURAL AND ORGANIC FOODS - BARK TEAS - NIGHTSHADE VEGETABLES - BEE POLLEN - OZONE - BIOTIN - P VITAMINS - BOWEL CLEANSING - PABA - CHUIFONG TOUKUWAN - PANAX - CINNAMON - PAU D'ARCO - CLAY ENEMAS - POWDERED ANT - CLEMANTIS PROPOLIS - ROYAL JELLY - CLOVES - RAW MILK - COD LIVER OIL - RHUS TOXICODENDRON - COENZYME Q-10 - ROSE HIPS - COFFEE ENEMAS - RUTIN - COICIS SEMEN - SASSAFRAS - COLONICS - SELENIUM - COPPER BRACELETS - SHARK CARTILAGE - CYTOTOXIC TESTING - SNAKE VENOM - DEVIL'S CLAW - SOAPWEED - DISMUTASE (SUPEROXIDE DISMUTASE) - SPANISH BAYONET - DONG DIET - SPANISH FLY - ELIMINATION DIETS - STEPHANIA - FEVERFEW - TANG-KUEI - FIT FOR LIFE DIET - TEAS (FEVERFEW, GINSENG, SASSAFRAS) - FO-TI - THIAMINE - GARLIC - VEGETARIAN DIETS - GERMANIUM - VOLCANIC ASH - FASTING - GINSENG - WATER ENEMA - GREEN-LIPPED MUSSEL - WOOD SPIDER - HAIR ANALYSIS - YUCCA - HOMEOPATHY - ZEN MACROBIOTICS - HYDROGEN PEROXIDE - ZINC - KELP
147

148. Pearls •The number and distribution of joints involved helps pinpoint the most likely cause of arthritis. •Monarthritis is septic arthritis until proven otherwise. •Negative Gram’s stain of synovial fluid does not rule out bacterial arthritis.
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149. Pearls •The most definitive test for evaluating an inflamed joint for the possibility of bacterial infection is examination of synovial fluid. •Delays in the diagnosis and treatment of septic arthritis worsen outcomes.
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