Medical Management of Rheumatic Musculoskeletal & Connective Tissue Disease

407 Pages·1997·106.839 MB·English

by  Jan Dequeker

Medical
Management
of Rheumatic
Musculoskeletal
and Connective
Tissue Diseases
Jan Dequeker
University Hospitals
Leuven, Belgium
Gabriel Panayi
Guy’s Hospital
London, England
Theodore Pincus
Vanderbilt University School Medicine
Nashville, Tennessee
Rodney Grahame
Guy’s Hospital
London, England
MARCEL
MARCELD EKKEIRN,C . NEWY ORK BASEL HONGK ONG
DEKKER
http://avaxhome.ws/blogs/ChrisRedfield
Library of Congress Cataloging-in-Publication Data
Medical managemento f rheumatic musculoskeletal and connective tissue
diseases / Jan Dequeker ... [et al.].
--
p. cm. (Clinical guides to medical management)
Includes index.
ISBN 0-8247-9847-3 (hardcover : alk. paper)
1. Connective tissues-Diseases. 2. Arthritis. 3. Rheumatism.
I. Dequeker, Jan. 11. Series.
DNLM: 1. Rheumatic Diseases. 2. Connective Tissue Diseases.
3. Diagnosis, Differential. 4. Vasculitis. 5. Bone Diseases.
WE 544 M489 19971
RC924.M413 9 97
616.7-dc21
DNLM/DLC
97-22374 Congress of Library for
CIP
The publisher offers discounts on book when ordered in bulk quantities. For
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Copyright 8 by MARCEL DEKKER, INC. All Rights Reserved.
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MARCEL DEKKER, INC.
270 Madison Avenue, New York, New York 10016
hnp://www.dekker.com
Current printing (last digit):
1 0 9 8 7 6 5 4 3 2 1
PRINTED IN THE UNlTED STATESO F AMERICA
Preface
Musculoskeletal diseases, such as osteoarthritis, rheumatoid arthritis, sys-
temic lupus erythematosus, gout, spondylitis, osteoporosis, soft tissue rheu-
matism, and regional musculoskeletal pain syndromes, collectively affect
more than one-third of all adults in developed countries. The prevalence of
musculoskeletal diseasesw ill increase because oft he increasing average age
of the world’s population. How well future physicians (primary care and
specialist) manage musculoskeletal diseasesw ill be an important factor af-
fecting quality of life and health care costs.
Although there are many good textbooks on rheumatology, most of
them focus mainly on inflammatory rheumatic diseases. We have lackeda
core book that covers the management of musculoskeletal diseases and is
useful for practicing clinicians and students. Many physicians come into
contact with musculoskeletal symptomas nd connective tissue diseases with-
out having much training in this field. Even when clinical information on
rheumatology has been available,i t has often been restricted to stereotypic
descriptions of the end stages of diseases;f or example, that gout is big-toe
arthritis and tophi, rheumatoid arthritis is ulnar deviation and swan-neck
deformity, and osteoarthritisi s osteophyte formation.
The purpose of this book is to provide the essentials on musculoskele-
tal and connective tissue diseases, based on the knowledge of experienced
iii
Preface
teachers from theU nited States and Europe, that a correct diagnosis and
appropriate management can be established from the onset of the first
symptoms. “Rheumatism” is not a disease but a diagnostic problem to be
solved. Any of more than 200 different disease entities-benign, invalidat-
ing, acute, chronic, and even neoplastic diseases- can be behind a musculo-
skeletal complaint.
The booki s organized ina logical and practical way, givingd iagnostic
and management concepts for the early phase of each disease, plus back-
ground information on the pathophysiology, epidemiology, and impact of
the disease on thep atient and society. The reader will be able to codify and
identify quickly the essentials of each musculoskeletal disease by referring
to the chapter outlines, tables, figures, and index.
Chapter 1 covers the skills involved in taking a patient’s history and
giving a physical examination. The approachm ay seem simplisticb, ut over-
reliance on laboratory andra diographic testing has ledt o oversight of these
basic diagnostic techniques. In the diagnosis of musculoskeletal diseases
more than for any other diseases, a careful reading of the clinical signs
and patient’s history is essential and cannot be substituted by technology.
Therefore, rheumatology may serve as a model in the clinical education of
the physician in training.
Clinical thinking and problem solving skills are of particular impor-
tance to those working with systemic connectivet issue diseases. Chapter 2
provides guidelines for problem oriented differential diagnosis. The physi-
cian who comes to the correct diagnosis by cluster analysis of symptoms,
which need to be substantiated by only one or two technical tests, should
find this greatly satisfying.
Other chapters coverg eneral broad diagnostic-pathogenetic topics
such as infectous diseases, polyarthritis, spondylarthropathy, multisystem
diseases, crystal arthropathy, localized painful conditions, metabolic bone
disesases, and hereditary connective tissue diseases. The final chapter is
devoted to current intra- and periarticular injection techniques feasable in
general medical practice.
The chapters on diseases are structured according to the following
model:
Definition
Clinical features
early manifestations
late manifestations
Confirmation of the diagnosis: Investigations
Differential diagnosis
Epidemiology and historical data
Preface
Pathophysiology
Management
Atypical forms
Prognosis: Impact of the disease
Each chapter is constructed around the most prevalent disease entity
in thep articular disease category. The chapter starts with the definition of
the disease, then moves on to the early and late clinical features, how
to confirm the diagnosis, difficulties in diagnosis, incidenceo fd isease,
pathophysiology and management, atypical.p resentations, and finally, pa-
tient prognosis and thei mpact of the disease on society.
Theb ooki sr ichlyi llustratedw ithd rawings,t ables,a ndp hotographs
to present readers with the many clinical features of rheumatism. New
imagingt e chniquesw, hent h eya rer elevanft ord iagnosisa, ndm orei n -
depth pathophysiological mechanisms for the majore ntities are included to
help students understand the basic mechanisms behinda disease process.
We, and particularly the coordinator of the book, Prof. Dr. Jan
Dequeker, president of ILAR (International League of Associations for
Rheumatology), together with Prof. Dr. Rodney Grahame, president of the
Standing Committee on Education and Publiation, in the name of the
regional leaguesP ANLAR( Pan-AmericanL eagueo f Associations for
Rheumatology), AFLAR (African League Against Rheumatism), APLAR
(Asian Pacific League of Associations for Rheumatology), and EULAR
(EuropeanL eagueA gainstR heumatism)w, antt oe nsuret hatp hysicians
learn the principles of comprehensive care of musculoskeletal and connec-
tive tissue diseases and do not give up on rheumatic patients before imple-
menting the effective and appropriate diagnostic and management mea-
sures that can be learned from this book.
The creation of this book required the Help of a number of dedicated
people. We must thank our expert collaborators in particular: for critically
reading and correcting our manuscripts, Jo Verwilghen, Rend Westhovens,
and Chester W. Fink; for providing excellent images, Pierre Schotsmans et
al. (Pfizer, Belgium); for X-ray pictures, J. Malghem and Peter Brys; for
permission to reproduce their publication on injection techniques, Roche-
Syntex Belgium; for pictures of intraarticular injections, Guy Isaacs; and
for secretarial assistance, Josette Cartois andA nnemieke Vandereijcken.
Jan Dequeker
Gabriel Panayi
Theodore Pincus
Rodney Grahame
This Page Intentionally Left Blank
Contents
Preface iii
1. History and Physical Examination of a Patient with a
Rheumatic Problem
1 History 1
2 PhysicaEl xamination 6
3 Screening History and Physical Examination 12
4 DetailedJ ointE xamination 13
5 Conclusions 47
2. Differential Diagnosis 49
l Diagnosis Problem Solving Strategy 49
2 PathognomonicC linicalS igns 57
3 Differential Diagnosis Arthritis and Tendonitis 59
3. Infectious and Postinfectious Arthritis 63
1 SepticA rthritis
vii
viii Contents
2 Viral Arthritis 69
3 Reactive Arthritis 74
4. Polyarthritis: Rheumatoid Arthritis and Related Conditions 101
1 Rheumatoid Arthritis 101
2 Juvenile Chronic Arthritis 146
References 152
5. Ankylosing Spondylitis and Related Conditions 153
1 Clinical Features 153
2 Confirming the Diagnosis - Investigations 156
3 DiagnosticD ifficulties 160
4 Epidemiology and Historical Data 162
5 Pathophysiology 162
6 Management 163
7 AtypicaFl orms 164
8 Impact of Disease and Prognosis 173
Reference 174
6. Inflammatory Systemic Rheumatic Diseases 175
1 Systemic Lupus Erythematosus 175
2 Polymyositis and Dermatomyositis 190
3 Scleroderma:S ystemicS clerosis 197
4 VasculiticD iseases 205
5 Polymyalgia Rheumatica/Giant Cell Arteritis 207
6 Takayasu’sA rteritis 212
7 Polyarteritis Nodosa 214
8 Wegener’s Granulomatosus 219
9 HypersensitivityV asculitis 223
10 Adamantiades-Behget’sS yndrome 225
7. Crystal-InducedA rthtitis 229
1 Gout 229
2 Pseudogout 23 8
HydroxyapatiteA rthritis 242
4 Alkaptonuria-Ochronosis 246
8. LocalizedP ainfulC onditions 249
1 Osteoarthritis-Osteoarthrosis 249
Contents ix
Soft Tissue (Overuse) Rheumatism
MechanicalB ack Pain: Spondylosis
Hypertrophic Osteoarthropathy
Fibromyalgia
9B. oneD iseases 293
1 Osteoporosis
Paget’sD isease
Reflex Sympathetic Algodystrophy Syndrome
10. Hereditary Connective Tissue Disorders 341
1 Benign Joint Hypermobility Syndrome
Marfan’s Syndrome
Osteogenesis Imperfecta
Ehlers-Danlos Syndrome
11. Current Intra- and Periarticular Injection Techniques
in Rheumatology 353
1 Upper Limbs
LowerL imbs
Index 79