INTRODUCTION

Musculoskeletal and Connective Tissue Disorders

 Some musculoskeletal disorders affect primarily the

joints, 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)

Arthritis has multiple causes, including

infection, autoimmune disorders, crystal-induced inflammation, and noninflammatory tissue degeneration (eg, osteoarthritis).

Arthritis may affect

single joints (monarthritis) or multiple joints (polyarthritis) in a symmetric or asymmetric manner. Joints may suffer fractures or sprains

History
Focus on systemic and extra-articular symptoms as well as joint symptoms. Many symptoms, including fever, chills, malaise, weight loss, Raynaud's syndrome, mucocutaneous symptoms (eg, rash, eye irritation or pain, photosensitivity), and GI or cardiopulmonary symptoms, can be associated with various joint disorders.

 Discomfort that occurs with motion when

attempting to move a joint after a period of rest occurs in rheumatic disease.

stiffness upon standing that necessitates walking

slowly after sitting for several hours is common in osteoarthritis.

Stiffness is more severe and prolonged in

inflammatory joint disorders.

 Morning stiffness in peripheral joints that lasts > 1 h can be

an important early symptom of RA

In the low back, morning stiffness that lasts > 1 h may

reflect spondylitis.

Distinguishing Inflammatory vs Noninflammatory Features in Joint Disease

Symptom
Systemic symptoms Onset

Inflammatory
Prominent, including fatigue Insidious Usually affecting multiple joints >1h Morning Lessen with activity Worse after periods of rest May also hurt with use

Noninflammatory
Unusual Gradual 1 joint or a few weightbearing joints < 30 min As day progresses Worsen with activity Lessen with rest

Morning stiffness Worst time of day Effect of activity

on symptoms

Physical Examination
Each involved joint should be inspected and

palpated, and the range of motion should be estimated.

With polyarticular disease, certain nonarticular

signs (eg, fever, wasting, rash) may reflect systemic disorders.

The rest position of joints is noted, along with any erythema, swelling, deformity, and skin abrasions or punctures. Involved joints are compared with their uninvolved opposites or with those of the examiner. Patterns of joint involvement should be noted. Symmetric involvement of multiple joints is common in systemic diseases (eg, RA);

 Monarticular (involving one joint) or asymmetric

oligoarticular (involving 4) joint involvement is more common in osteoarthritis and psoriatic arthritis. and the larger joints and spine are affected more in spondyloarthropathies.
motion. It may be caused by roughened articular cartilage or by tendons; crepitus-causing motions should be determined and may suggest which structures are involved.

Small peripheral joints are commonly affected in RA,

Crepitus, a palpable or audible grinding produced by

DIAGNOSIS
Joint pattern Presence or Absence of extra articular manifestation

Joint pattern
Answer to following three Qs
Is inflammation present?

How many joints are involved?

What joints are affected?

Diagnostic value of the joint pattern

Characteristics Inflammation No of involved joints Status Present Absent Monoarticular Oligoarticular (2-4 joints) Polyarticular ( 5joints) Diseases RA, SLE, Gout OA Gout, trauma, septic, OA Lyme disease Reiters disease, psoriatic, IBD RA, SLE

Site of joint involvement

DIP MCP, Wrists Ist MTP

OA, Psoriatic RA, SLE Gout, OA

Testing

Laboratory testing and imaging studies often provide

less information than the history and physical examination.

However, few investigations may be warranted in

some patients, extensive testing is often not.

 Blood tests: Supportive

Antinuclear

antibodies (ANA) and complement in SLE factor and anti-citrullinated peptide (CCP)

Rheumatoid

in RA
Occasionally

useful: HLA-B27 in spondyloarthropathy and antineutrophil cytoplasmic antibodies (ANCA) in certain vasculitides

 Imaging studies:

Plain x-rays in particular reveal mainly bony abnormalities, and most joint disorders do not affect bone primarily. However, imaging may help in the initial evaluation of relatively localized, unexplained persistent or severe joint and particularly spine abnormalities

 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 be

visible in intra-articular cartilage.

 Arthrocentesis: is the process of puncturing the

joint with a needle to withdraw fluid.

Examination of synovial fluid is the most accurate way to

exclude infection, diagnose crystal-induced arthritis, and otherwise determine the cause of joint effusions.
It is indicated in all patients with severe or unexplained

monarticular joint effusions and in patients with unexplained polyarticular effusions.

 Classification of synovial effusions

Gross Norma Noninflam l matory Examinati on (Group I)
Volume (mL) (Knee) Viscosity Color Routine laboratory examination WBC (mm3) PMN leukocytes (%) Crystals present Culture Mucin clot Glucose (AM fasting) <3.5 High Colorless to straw Often >3.5 High Straw to yellow

Inflamm atory (Group II)

Often >3.5 Low Yellow Cloudy

Septic (Group III)

Often >3.5 Variable Yellowwhite Cloudy

Crystal (Group IV)

Often >3.5 Variable Yellow Cloudy

Hemorr hagic (Group V)

Often >3.5 Variable Red Xanthochro mic

<200 <25 No Negative Firm Nearly equal to blood

200-2,000 <25 No Negative Firm Nearly equal to blood

2,00075,000 >50 often No Negative Friable <50 mg% lower than blood

Often >100, 000 >75 No Often positive Friable >50 mg% lower than blood

2,00075,000 >50 often Yes Negative Friable >50 mg% lower than blood

50-10,000 <50 No Negative

Nearly equal to blood

 Differential diagnosis by joint fluid groups

Group I Noninflammator y
Osteoarthrosis Traumatic arthritis Osteochondritis dissencans Osteochondromat osis Neuropathic

Group II Infalmmatory
Rheumatoid arthritis Lupus erythematosus Reiters syndrome Ankylosing spondylitis Regional eneritis Ulcerative colitis Psoriasis

Group III Septic

Bacterial Mycobacteria l Fungal

Group IV Crystalinduced
Gout CPPD crystal depositon disease Apatiteassociated arthropathy

Group V Hemorrhagic
Traumatic arthritis Hemophiliac arthropathy Anticoagulation Pigmented villonodular tenosynovitis Neuropathic osteoarthropathy Synovial hemangioma

osteoarthropathy Pigmented villonodular tenosynovitis