Joint Disease. All the Arthropathies

302 Pages·1987·49.971 MB·302\302

by  E. C. Huskisson and F. Dudley Hart (Auth.)

JOINT DISEASE:
AH the arthropathies
E. C. HUSKISSON
Consultant Physician and Senior Lecturer
The Royal Hospital of Saint Bartholomew, London
F. DUDLEY HART
Consulting Physician
Westminster Hospital, London
Fourth Edition
WRIGHT
Bristol
1987
© IOP Publishing Limited. 1987
All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
permission of the Copyright owner.
Published under the Wright imprint by
IOP Publishing Limited
Techno House, Redcliffe Way, Bristol BS1 6NX
First edition, 1973
Secon d edition, 1975
Third edition, 1978
Fourth edition, 1987
British Library Cataloguing in Publication Data
Huskisson, E. C.
Joint disease: all the arthropathies
4th ed.
1. Joints—Diseases
I. Title II. Hart, F. Dudley
616.77 RC932
ISBN 0 7236 0571 8
Typeset by
Severntype Repro Services, Wotton-under-Edge, Glos. GLI2 7EA
Printed in Great Britain by
Butler & Tanner Ltd., Frome and London
INTRODUCTION
To make a diagnosis, the human brain functions as a computer, fitting the presence and absence of
clinical features to the known characteristics of diseases. In order to make the correct diagnosis, it is
therefore necessary to know as much about the rarest disease as the commonest, and this book aims
to provide such information. It is not intended for reading, but for consultation when information is
required. It is not a textbook, and having no pictures, makes no attempt to replace the experience of
seeing patients, which is essential to learning rheumatology.
The information is organized as follows:
Definition of disease X, including aetiology if known, and inheritance.
Incidence or prevalence of arthritis in disease X; age and sex, type and stage of disease X in which
arthritis is particularly seen; family history; persons specially predisposed.
Joints affected. How many? Which? How often? Symmetrical or asymmetrical? Migratory?
Symptoms y including speed of onset and precipitating factors.
Signs.
Course of the arthritis and of the underlying disease. If episodic, frequency, regularity, and duration
of attacks. Effect of treatment.
Associations, radiological findings and useful laboratory tests.
Treatment.
Where possible, the exact frequency of any occurrence is given; this is based on a survey of the
literature and modified by personal experience. Where it is not possible to give exact frequencies,
the following approximations are used:
Usual: at least 90 per cent.
Common : at least 70 per cent.
Often: 40-70 per cent.
Occasional: 10-40 per cent.
KJWUòiunui. i\j—HKß per uciu.
ΓUΓnΜcΛo/ΙmΜmΟΜoΛnΜ:· lleacses tthhaan n 1 1Λ 0 *>p/*e*·r cent.
Rare : less than 1 per cent.
One or two recent references are given where possible, as a starting point for those seeking further
information.
vu
CLASSIFICATION OF THE ARTHROPATHIES
INFECTIVE Aspergillosis
Blastomycosis
Infections due to Bacteria, Spirochaetes, Coccidioidomycosis
and Mycoplasma Cryptococcosis
Anaerobic infections Histoplasmosis
Atypical mycobacterial infection Mycetoma
Brucellosis Sporotrichosis
Cat-scratch fever
Clutton's joints Other Types of Invasion
Fish fancier's finger
Plant Thorn Synovitis
Glanders
Gonococcal arthritis
Sea-Urchin Arthritis
Leprosy
Lyme disease
Melioidosis POST-INFECTIVE
Meningococcal infection
Bacillary dysentery
Mycoplasma arthritis
Henoch-Schönlein purpura
Rat-bite fever
Jaccoud's syndrome
Salmonella arthritis
Navajo arthritis
Septic arthritis
Osteitis pubis
Septic focus syndrome
Reactive arthritis
Subacute bacterial endpcarditis
Reiter's disease
Syphilis
Rheumatic fever
Tuberculosis
Scarlet fever
Typhoid fever
Yersinia arthritis
Weil's disease
Yaws
METABOLIC AND CRYSTAL
Infections due to Viruses
DEPOSITION DISEASE
Adenovirus arthritis
Chikungunya Acute calcific periarthritis
Dengue Agammaglobulinaemia
Erythema infectiosum Amyloidosis
Herpes zoster Chondrocalcinosis articularis
Lymphogranuloma venereum Dysproteinaemic arthropathy
Mumps Familial histiocytic dermatoarthritis
O'nyong nyong Farber's disease
Poliomyelitis Gaucher's disease
Psittacosis Gout
Ross River virus disease Haemochromatosis
Rubella Type 2 hyperlipoproteinaemia
Smallpox Type 4 hyperlipoproteinaemia
Vaccination Hypophosphataemic spondylopathy
Varicella Idiopathic oedema
Viral hepatitis Intervertébral disc calcification in children
Milwaukee shoulder
Amoebiasis Morquio-Brailsford syndrome
Mucopolysaccharidoses
Bilharzia arthropathy Multicentric reticulohistiocytosis
Ochronosis
Infections due to Worms
Osteoarthritis
Acanthocheilonema perstans Pyrophosphate arthropathy
Chylous arthritis Tumoral calcinosis
Guinea-worm arthritis Wilson's disease
Onchocerciasis Winchester syndrome
Toxocaral arthritis
Infections due to Fungi MECHANICAL AND TRAUMATIC
Actinomycosis Chondromalacia patellae
African histoplasmosis Gamekeeper's thumb
vni
CLASSIFICATION (Continued)
Gemi amoris Transient osteoporosis of the hip
Hoffa's disease Transient painful osteoporosis
Hypermobility syndromes Transient synovitis of the hip
Instability of the pubic symphysis Werner's syndrome
Long-leg arthropathy
Occupational arthropathies
Repetition strain syndrome NORMALITY WITH SYMPTOMS
Sacroiliac strain
Synovial pleat syndrome Non-disease
Temporomandibular pain-dysfunction Psychogenic rheumatism
syndrome
Tennis leg
Traumatic arthritis DIETARY AND POISONS
Fluorosis
Kashin-Beck disease
THE RHEUMATIC DISEASES, Scurvy
CONNECTIVE TISSUE DISEASES AND
Toxic epidermal syndrome
VASCULITIS SYNDROMES
Ankylosing spondylitis
Cardiolipin syndrome SOFT-TISSUE SYNDROMES
Churg-Strauss syndrome SIMULATING ARTHRITIS
Juvenile chronic arthritis
Back-pocket sciatica
Mixed connective-tissue disease
Bursitis
Palindromic rheumatism
Camptocormia
Polyarteritis nodosa
Camptodactyly
Polymyalgia rheumatica
Carpal tunnel syndrome
Polymyositis and dermatomyositis
Cavalryman's disease
Rheumatoid arthritis
Compression neuropathies
Scleroderma
Deep-vein thrombosis
Scleroderma-like syndromes
De Quervain's tenosynovitis
Systemic lupus erythematosus
Diffuse idiopathic skeletal hyperostosis
Takayasu's disease
Dupuytren's contracture
Wegener's granulomatosis
Fibrositis
Frozen hip
Frozen shoulder
IDIOPATHIC AND MISCELLANEOUS
Garrod's fatty pads
Acro-osteolysis Golfer's elbow
Ankylosing vertebral hyperostosis Hereditary angio-oedema
Arthrogryposis multiplex congenita Jumper's knee
Behçet's syndrome Juxta-articular adiposis dolorosa
Down's syndrome Knuckle-pad syndrome
Eosinophilic fasciitis Lymphoedema praecox
Familial arthropathy with rash, uveitis and Morton's metatarsalgia
mental retardation Myositis ossifie an s
Familial Mediterranean fever Neuralgic amyotrophy
Handigodu syndrome Osgooi-Schlatter's disease
Hereditary progressive arthro-ophthalmopathy Plantar fasciitis
Hereditary vascular and articular calcification Ponderous purse disease
Intermittent hydrarthrosis Rib-tip syndrome
Kniest syndrome Sever's disease
Leri's pleonosteosis Shoulder-hand syndrome
Macrodystrophia lipomatosa Sudeck's atrophy
Mseleni joint disease Tennis leg
Osteochondromatosis Tennis thumb
Pigmented villonodular synovitis Tietze's disease
Pseudoxanthoma elasticum Traveller's ankle
Relapsing polychondritis Trigger finger or thumb
Sarcoidosis Trochanteric syndrome
Temporomandibular arthropathy Xiphoid syndrome
IX
CLASSIFICATION (Continued)
PHARMACOLOGICAL Dermatological
For classification see p. 36 Acne arthralgia
See also Drug-induced SLE Angiokeratoma corporis difrusum
See also Serum sickness Cutaneous polyarteritis nodosa
Erythema multiforme
Erythema nodosum
Nail-patella syndrome
ARTHRITIS WITH DISEASE OF Psoriatic arthropathy
OTHER MAJOR SYSTEMS Pustulolotic arthro-osteitis
Pyoderma gangrenosum
Endocrine
Sweet's syndrome
Acromegaly Urticaria
Antithyroid arthritis syndrome
Addison's disease Neoplastic
Diabetes mellitus For classification see p. 84
Diabetic cheiroarthropathy See also :
Hyperparathyroidism Atrial myxoma
Hypoparathyroidism Carcinoid syndrome
Hypothyroidism Carcinoma arthritis
Thyroid acropachy Haemangioma
Hypertrophie osteoarthropathy
Haematological Leukaemia, acute and chronic
Haemophilia Lipoma arborescens
Leukaemia, acute and chronic Myeloma
Sickle-cell disease Osteoid osteoma
Thalassaemia, major and minor Synovioma
Renal
Neurological
Dialysis arthropathy
Compression neuropathies
Renal transplantation
Hemiplegia
Neuropathic Arthritis Secondary to Disease
of Bone
Gastroenterological Avascular necrosis
Chronic active hepatitis Chondrodysplasic rheumatism
Cirrhosis of the liver Francois syndrome
Coeliac arthritis Melorheostosis
Crohn's disease Osteochondritis dissecane
Enteropathic synovitis Osteomalacia and rickets
Intestinal bypass arthritis Paget's disease
Pancreatic carcinoma and pancreatitis Periostitis deformane
Ulcerative colitis Perthes' disease
Whipple's disease Thiemann's disease
INCIDENCE OF ARTHROPATHIES
So that a correct diagnosis may be made, the frequency of different arthropathies must be known, as
well as their clinical features and the clinical features of the case. For example, though rheumatoid
arthritis is usually polyarticular, it is a much more likely cause of arthritis of a single joint than
pigmented villonodular synovitis. The exact frequency of many diseases is not known, but in
rheumatological practice in England one might expect-to see the arthropathies in the following
proportions:
Several times each week:
Rheumatoid arthritis.
Osteoarthritis.
Normality with symptoms (psychogenic rheumatism or non-disease).
Frozen shoulder, tennis elbow, fibrositis and other varieties of soft-tissue rheumatism.
Traumatic arid occupational arthropathies.
Several times each month:
Gout. Pyrophosphate arthropathy.
Psoriatic arthropathy.
Reiter's disease.
Ankylosing spondylitis.
Polymyalgia rheumatica.
Drug-induced arthropathies.
Several times each year:
Systemic lupus erythematosus.
Polyarteritis nodosa.
Polymyositis and dermatomyositis.
Septic arthritis.
Tuberculous arthritis.
Scleroderma.
Juvenile chronic arthritis.
Palindromic rheumatism.
Hypertrophie osteoarthropathy and other arthropathies associated with malignant disease.
Neuropathic joints.
Shoulder-hand syndrome.
Anky losing vertebral hyperostosis.
Arthritis associated with ulcerative colitis, rubella, sarcoidosis and erythema nodosum.
The remainder are rare and should be diagnosed with caution. In other parts of the world, and in
other specialties such as paediatrics, the relative incidence of the arthropathies may be quite
different.
CAUSES OF JOINT PAIN1
1. Joint disease: The arthropathies.
2. Bone disease: Fractures, primary or secondary tumours, osteochondritis, osteomyelitis, etc.
3. Soft-tissue lesions:
Sprains and strains.
Tenosynovitis.
Overuse syndromes.
'Soft-tissue rheumatism'.
Direct trauma.
Bursitis.
4. Arthralgia: Defined as joint pain in the absence of objective evidence of joint disease. This
occurs in a variety of conditions, including:
a. THE ARTHROPATHIES, either preceding the development of local signs or in some conditions
in which there may be no local signs. Important examples are polymyalgia rheumatica and
temporal arteritis, systemic lupus erythematosus and polyarteritis nodosa.
b. INFECTIONS, particularly viral and rickettsial.
Virus infections: influenza (25 per cent of cases), glandular fever, psittacosis, yellow fever
and sandfly fever.
Rickettsial infections: all types of typhus.
Bacterial infections: septicaemia, subacute bacterial endocarditis, typhoid and salmonella
infections, and brucellosis.
Spirochaetal infections: secondary syphilis, leptospirosis and relapsing fever.
Protozoal and metazoal infections: kala-azar and many other tropical, febrile conditions.
c. DRUGS (see p. 36), immunization and allergies.
d. PROTEIN ABNORMALITIES, e.g. mixed IgG IgM cryoglobulinaemia.2
5. Referred pain is particularly common in the shoulder joint when it may be due to:
a. Abdominal conditions: liver abscess, subphrenic abscess, gallbladder disease, peritonitis.
b. Oesophageal conditions: hiatus hernia.
c. Cardiac conditions: myocardial ischaemia.
d. Neurological conditions: cervical cord or brachial plexus lesions.
e. Pulmonary conditions: apical tumours, pleurisy, pneumothorax.
Pain in the knee is often due to hip disease.
6. Psychogenic: Aches and pains are common in normal people, particularly women. Some have a
tendency to joint pains from childhood which continue throughout life, often related to weather
conditions (so-called 'rheumatism'). Joint pain may be a manifestation of psychological
disturbance and rheumatism may become a source of complaint in anxious or neurotic
patients.
REFERENCES
1. Hart F. D. (1970) Annals of Physical Medicine 10, 257.
2. Meltzer M. et al. (1966) American Journal of Medicine 40, 837.
xii
HISTORY
1. Background Information. Age, sex, race, occupation.
2. Main Complaint
a. When did it start?
b. How did it start? (Sudden, gradual, time of day.)
c. Precipitating factors:
Trauma, excessive or unusual activity.
Infection—sore throat, urethral discharge, septic lesions such as boils.
Unusual sexual exposure.
Foreign travel.
Contact with infectious diseases.
Drugs, vaccination, injections, surgery.
Excess of food or alcohol.
Exposure to sunlight or cold.
Emotional stress.
d. Pattern of joint involvement:
How many joints?
First joint or joints affected.
Subsequent joints affected.
Pattern of development: episodic, migratory, additive, simultaneous.
Symmetry or asymmetry.
Severity—worst affected joint or joints.
e. Time pattern. If symptoms are persistent:
Relation to time of day.
Night pain and interference with sleep.
Morning stiffness.
If symptoms are episodic:
Frequency of episodes.
Regularity of episodes.
Duration of episodes.
/ Aggravating and relieving factors:
Effect of rest and exercise, activity and immobility, and treatments.
g. Resultant problems:
Extent of disability; note ability to carry out essential tasks of daily living, washing,
bathing, eating, toilet activities, walking, sitting and standing, stairs, etc.
Ability to follow usual occupation.
Particular disabilities, e.g. painful movements or difficult activities.
3. Associated Symptoms
a. General. Malaise. Fatigue.
b. Specific. Fever. Rash. Diarrhoea and other abdominal symptoms.
Weight loss. Pains elsewhere. Symptoms referable to other systems.
4. Past Medical History
Rheumatic fever. Psoriasis.
Tuberculosis. History of arthritis in childhood.
Record details of past complaints, investigations, etc.—frequent fruitless investigation and
polysymptomatosis are characteristic accompaniments of psychogenic rheumatism.
5. Family History
Enquire particularly for osteoarthritis, ankylosing spondylitis, iritis, psoriasis, Behçet's
disease, gout, rheumatoid arthritis, ulcerative colitis and Crohn's disease.
6. Social, Psychological and Domestic Details
Work and home circumstances.
Unusual or deficient diet.
Possibly contributory emotional and social problems.
Mental attitude. Motivation.
7. Drugs and Other Treatments
Present treatment for arthritis—dose and regimen.
Past treatment; benefit; side effects; outcome (if stopped, why?).
Drugs for other diseases.
Xlll
EXAMINATION
1. General
Appearance: well or ill?
Obvious diagnosis such as myxoedema or acromegaly.
Pallor, pigmentation and skin ra§hes.
Posture.
Gait.
2. Examination of Joints
a. Appearance:
Overlying skin: colour and consistency (smooth, shiny, etc.).
Swelling?
Resting position. Deformities.
b. Palpation:
Warmth?
Nature of swelling. Effusion, soft-tissue or bony swelling.
Tenderness. Localization and severity.
c. Active movement:
Range.
Pain?
Crepitus.
Power.
d. Passive movement:
Range.
Pain?
Crepitus.
Stability.
Are deformities correctible?
3. Soft Tissues
Muscles. Power. Wasting.
Tendons. Palpable abnormality (thickening, localized swelling): Tenderness. Crepitus.
Functional abnormalities such as triggering. Rupture.
Bursae. Swelling. Tenderness. Signs of inflammation.
Ligaments. Tenderness. Stability.
Tendon sheath swelling?
Nodules. Tophi, etc.
4. Complete Physical Examination Essential. Look particularly for:
1. Non-articular features of rheumatoid arthritis, nodules, peripheral neuropathy,
lymphadenopathy, etc.
2. Tophi.
3. Rashes. Remember that psoriasis may be minimal and hidden in the natal cleft or scalp. Look
at hands for vasculitic lesions. Many other arthropathies are associated with skin lesions
including purpura, erythema nodosum, scleroderma, rubella and dermatomyositis.
4. Finger clubbing or other evidence of malignant disease such as hepatomegaly or lymph-node
enlargement.
5. Temporal arteritis.
6. Evidence of infection from boils to tuberculosis. Examine genital tract if suspicious of
gonorrhoea or Reiter's disease.
7. Splenomegaly and lymphadenopathy.
8. Evidence of gastrointestinal disease including perianal disease such as fissure or fistula
associated with ulcerative colitis.
9. Fever.
xiv