Musculoskeletal Disorders

These photos are of the left hand of a full-term, newborn infant with focal ring constrictions of the third, fourth, and fifth fingers; secondary edema and discoloration are also seen.

A 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.

Cyanosis involving the hands and toes of a 12-year-old girl was first noted 3 months before medical evaluation was sought. Her fingers and palms were red, the nail beds were cyanotic, and her palms were cold and sweaty. The girl's toes were cyanotic when she was standing. Her hands and feet reverted to a normal color when the limbs were elevated.

Systemic lupus erythematosus (SLE) was diagnosed in an 18-year-old man who presented with polyarthritis, fever, hypoxia, fatigue, anemia, neutropenia, and abnormal urinary sediment. A renal biopsy showed diffuse mesangial proliferative glomerulonephritis (World Health Organization class II). Serologic tests were positive for fluorescent antinuclear antibody (FANA), SS-A, SS-B, anti-Sm and anti-dsDNA antibodies, and rheumatoid factor; a direct Coombs' test result was positive as well.

A 55-year-old man complains of fatigue. Although he sleeps 8 hours every night, he has to push himself to perform his usual daily activities. He has also experienced loss of libido and episodic impotence, which he ascribes to the fatigue.

An 82-year-old woman complains that for the past 6 months, she has "not felt like herself." Previously, she was very active and energetic; in fact, 9 months earlier, she had vacationed in Hawaii. It now takes all of her energy just to get out of bed.

Is it prudent to prescribe an oral bisphosphonate for an elderly woman with osteoporosis who has had acute hemorrhaging from a lower colonic diverticulum, for which a transfusion of 3 units of packed red blood cells was required?

ABSTRACT: Early treatment with disease-modifying anti-rheumatic drugs (DMARDs)--alone or in combination-- can prevent joint damage and minimize disability. Until recently, the DMARDs used predominantly in patients with rheumatoid arthritis had been methotrexate, sulfasalazine, and hydoxychloroquine. Older DMARDs such as gold, d-penicillamine, and azathioprine have fallen out of favor because of their long- term toxicities or modest benefit. Six newer DMARDs--leflunomide, etanercept, infliximab, adalimumab, rituximab, and anakinra--have greatly expanded the current treatment options.

Primary care physicians may want to consider consulting a physiatrist to help with this aspect of management. Physiatrists, or physical medicine and rehabilitation physicians, are specifically trained to employ exercise programs in the management of various musculoskeletal conditions.

A 13-year-old boy presented with an explosive eruption of numerous, small, round, erythematous, itchy plaques on his lower back and lower limbs of 2 weeks' duration. Some of the lesions were scaly. His nails were normal. There was no evidence of arthritis or joint deformity. He had a sore throat a month before the onset of the rash but did not seek medical attention. He was not taking any medication and had no history of joint pain or family history of skin problems.

Primary care physicians are usually the first to see patients with joint pain; consequently they represent the "front line" of RA care. This fact-coupled with the projection that the number of rheumatologists is expected to decline by 20% during the next 2 to 3 decades-underscores the pivotal role that primary care clinicians are now expected to play in the early diagnosis of RA.

For 2 years, a 79-year-old man had postprandial fullness and epigastric discomfort. He also experienced regurgitation and substernal pain after eating that was relieved by belching. He had a history of hypertension and gout. The patient’s vital signs were normal. Laboratory test results were within normal limits.

For 2 years, a 79-year-old man had postprandial fullness and epigastric discomfort. He also experienced regurgitation and substernal pain after eating that was relieved by belching. He had a history of hypertension and gout. The patient’s vital signs were normal.

ABSTRACT: To determine the stability of the injury, examine phalangeal and metacarpal fractures for intra-articular involvement. Suspect carpal bone fracture in any patient with wrist pain and tenderness; proper splinting is essential to prevent avascular necrosis of the bone, arthritis, and chronic disability. After successful reduction of a distal or proximal interphalangeal joint dislocation, order follow-up x-ray films. Apply stress testing of the joint space to all injured joints to ensure ligamentous integrity. Carpal and carpometacarpal dislocations require immediate consultation with a hand specialist. Therapy for bite wounds includes copious irrigation, debridement (in the operating room if necessary), and antibiotic prophylaxis. A patient with an infected bite wound requires hospitalization and intravenous antibiotics.

Exercise is a safe and effective therapy for patients with osteoarthritis or rheumatoid arthritis. It can reduce pain, increase flexibility and strength, and prevent deconditioning. To help motivate patients to initiate and adhere to an exercise program, educate them about these benefits, encourage them to set specific goals, recommend that they commit to a routine for at least 6 to 8 weeks (the minimum time needed to appreciate significant results), and warn them not to be discouraged by initial soreness. An exercise program for a patient with arthritis should include stretching (to improve joint flexibility), strengthening (to prevent deconditioning of the muscles that keep the joints stable), and aerobic exercise (to enhance overall fitness). Isotonic strengthening exercise is particularly important because it can reverse muscle wasting. Recommend that patients exercise for 30 minutes a day, 5 days a week. Water exercise is especially beneficial.

ABSTRACT: Glenohumeral joint osteoarthritis may result from trauma, concomitant shoulder pathology, or crystal deposition disease, or it may have no discernible cause. The physical examination reveals muscular atrophy, abnormalities during palpation, and limited range of motion, particularly in external rotation and flexion. Treatment includes both nonpharmacologic and pharmacologic interventions. Nonpharmacologic strategies include patient education, activity modification, and structured rehabilitation followed by transition to a long-term home exercise program. Pharmacologic treatment may involve progressively potent oral analgesics and perhaps corticosteroid injections. Surgical procedures, such as shoulder arthroplasty and arthroscopic debridement, are indicated for intractable pain and loss of function.

A 53-year-old man with a 20-year history of type 2 diabetes mellitus (for which he required insulin) sought evaluation of a hot, swollen right foot that seemed to have become “flat.” He had no pain, fever, or chills. The patient’s metatarsal bones were readily movable, consistent with Charcot joint. Further workup ruled out osteomyelitis. Plain films demonstrated extensive deformity of the tarsal and metatarsal bones with Lisfranc fracture/dislocation through the base aspects of all 5 metatarsals.

A 46-year-old man complained of “irritation” in the groin of several months’ duration. Ted Rosen, MD, of Houston noted a tender, macerated, hypopigmented plaque at the junction of the scrotum and upper inner thigh. At the periphery of the lesion was some detectable erythema and within the plaque were several small, superficial erosions.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department. The patient noted the rashwhen he awoke that morning. He had had joint pain and fever for the past7 days and generalized malaise with chills that began about 3 days earlier.He had no significant medical history.

ABSTRACT: Because of concerns raised by recent studies about the safety of hormone replacement therapy, attention has shifted to alternative therapies for prevention of osteoporosis. Resistance training has been shown to strengthen skeletal muscles, increase bone mineral density (BMD), and reduce fractures. Low-impact aerobic exercises, such as walking, improve cardiovascular fitness but do not create enough stress to increase BMD or muscle mass. A basic resistance training regimen consists of 5 or 6 weight-bearing exercises performed 2 or 3 times a week. Results can be seen in 4 to 6 weeks.

A 33-year-old man presented with joint pain and general malaise of about 2 weeks' duration and small yellowish lesions on the pinnae of the ears of about 6 months' duration. He had no urinary symptoms or conjunctivitis and was not taking any medications. His grandfather had been treated for gout.

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.

Ten weeks before presentation, this55-year-old woman noticed decreasedsensation in her feet and a bluish discolorationof her toes. These symptomsprogressed rapidly, and pain andcoldness in both feet increased in intensity.Her feet subsequently becamegangrenous. Her seropositive arthritishad been diagnosed about 6 yearsearlier. The disease had been wellcontrolled until about 10 weeks beforethis photograph was taken.

Extreme synovial inflammation resulted in the articular degradation seen in the hands of this 40-year-old woman who has Still disease, or juvenile rheumatoid arthritis (JRA).

ABSTRACT: The basic screening studies for rheumatic diseases are a complete blood cell count, a determination of the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level, a rheumatoid factor assay, an antinuclear antibody (ANA) test, a measurement of serum uric acid level, and a urinalysis. Test results must be interpreted within a clinical context; for example, a positive ANA assay suggests the possibility of a rheumatic disorder, but it is not specific for any diagnosis. Tests that reveal the nature and extent of target-organ involvement, such as renal function studies in patients with systemic lupus erythematosus, can help guide the selection of therapy. Laboratory results also reflect disease activity; the ESR and CRP level are useful gauges of the activity of most inflammatory rheumatic disorders. Finally, laboratory monitoring can help you minimize the significant toxicity associated with many of the drugs used to manage rheumatic diseases.

Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.

A 75-year-old obese woman with subacute-onset dyspnea and lower right posterior chest pain was brought to the emergency department. She had a history of diastolic heart failure, arthritis, and suspected obstructive sleep apnea. The patient was dyspneic at rest.

How effective are NSAIDs in the treatment of fibromyalgia?

ABSTRACT: Fibromyalgia syndrome (FMS) is a common condition that causes chronic pain and disability. It should be diagnosed by its own clinical characteristics of widespread musculoskeletal pain and multiple tender points. American College of Rheumatology criteria guidelines are most helpful in diagnosing FMS. The major symptoms are pain, stiffness, fatigue, poor sleep, and those of other associated conditions, for example, irritable bowel syndrome, headaches, restless legs syndrome, chronic fatigue syndrome, and depression. The pathophysiology of FMS is thought to involve central sensitization and neuroendocrine aberrations, triggered or aggravated by genetic predisposition; trauma; psychosocial distress; sleep deprivation; and peripheral nociception.

Reiter Syndrome (also called reactive arthritis) manifests as peripheral arthritis that is sometimes accompanied by such extra-articular findings as urethritis, conjunctivitis, and uveitis