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PubMed2003

Gonococcal arthritis.

Gonococcal arthritis results from blood dissemination of Neisseria gonorrhoeae from primary sexually acquired mucosal infection. The disease has become rare in Western countries since the introduction of effective control programmes, but it still needs to be recognized promptly to avoid systemic, potentially life-threatening involvement, destructive changes associated with chronic arthritis and spread of the infection. Sexually active women are predominantly affected. Clinical features include polyarthralgia, sometimes migratory, tenosynovitis, arthritis, constitutional symptoms and skin lesions, which are mild and easily unnoticed. True arthritis occurs in less than 50% of cases. Primary mucosal infection may be asymptomatic.N. gonorrhoeae is a fragile micro-organism which is difficult to culture. Sampling of blood, synovial fluid, skin lesion, genito-urinary tract, pharynx and rectum must be performed before starting antibiotics. Samples should be plated immediately on fresh, pre-warmed appropriate media and sent quickly to the laboratory. Culture of N. gonorrhoeae is of tremendous importance not only for definite diagnosis but also for determination of drug susceptibility. When culture is negative, rapid response to antimicrobial treatment will allow a probable diagnosis. Penicillin resistance has developed worldwide in recent years, and penicillin is no longer the initially recommended antibiotic for gonococcal arthritis. Patients should be started on a third-generation cephalosporin and later switched to ampicillin or penicillin only when sensitivity to these antimicrobials has been demonstrated. Oral therapy substitutes the intravenous or intramuscular route after signs and symptoms have improved, in order to complete 7 days of antimicrobial therapy. Effusions should be aspirated until disappearance. Purulent effusions are rare but may require longer antibiotic treatment. The patient's sexual partner must be examined and treated. Patients should be tested and eventually treated for Chlamydia, syphilis and HIV, and educated about the sexual mode of transmission and means of preventing sexually transmitted diseases.

Anti-Bacterial Agents↗

PubMed1994

The hyoid syndrome: a pain in the neck.

This paper reports on 13 patients with a pain syndrome arising from the region of the greater cornu of the hyoid bone. It is often missed and yet is readily treatable. The syndrome causes pain on swallowing in the region of the hyoid which may radiate to the ear, face and lower jaw or may be felt also in the pharynx. Treatment by an injection of a mixture of depomedrone and one per cent lignocaine is very effective. The underlying pathology is discussed and it is suggested that in some cases the pain and discomfort experienced by patients may be due to tenosynovitis of the intermediate tendon of the digastric muscle. Greater recognition of this relatively common condition would not only result in more effective treatment but would also avoid unnecessary investigation and surgery.

Adult↗

PubMed2001

Understanding work-related upper extremity disorders: clinical findings in 485 computer users, musicians, and others.

Four hundred eighty five patients whose chief complaints were work related pain and other symptoms received a comprehensive upper-body clinical evaluation to determine the extent of their illness. The group had a mean age of 38.5 years. Sixty-three percent of patients were females. Seventy percent were computer users, 28% were musicians, and 2% were others engaged in repetitive work. The time between the onset of symptoms and our initial visit ranged from 2 weeks to over 17 years. A majority sought care within 30 months with the greatest number of them seeking care before 12 months. Fifty nine percent of subjects were still working when seen despite increasing pain and symptoms such as weakness, numbness, tingling, and stiffness. Following a history, a physical assessment utilizing commonly employed clinical tests were performed including evaluation of joint range of motion, hyperlaxity, muscle tenderness, pain, strength, and imbalance. Neurologic tests included Tinel's sign performed in wrist, elbow, tricipital sulcus, and neck and tests for thoracic out syndrome (TOS). Specific tests such as Finkelstein's test for deQuervain's tenosynovitis, Phalen's test for carpal tunnel syndrome and grip strengths were included in the examination protocol. Significant findings included postural misalignment with protracted shoulders (78%), head forward position (71%), neurogenic TOS (70%), cervical radiculopathy (0.03%), evidence of sympathetic dysfunction (20%), and complex regional pain syndrome (RSD) (0.6%). Hyperlaxity of fingers and elbows was found in over 50%, carpal tunnel syndrome in 8%, radial tunnel syndrome in 7%, cubital tunnel in 64%, shoulder impingement in 13%, medial epicondylitis in 60%, lateral epicondylitis in 33%, and peripheral muscle weakness in 70%. We conclude that despite initial presentation distally, work-related upper-extremity disorders are a diffuse neuromuscular illness with significant proximal upper-body findings that affect distal function. While neurogenic TOS remains a controversial diagnosis, the substantial number of patients with positive clinical findings in this study lends weight to the concept that posture related neurogenic TOS is a key factor in the cascading series of physical events that characterize this illness. A comprehensive upper-body examination produces findings that cannot be obtained through laboratory tests and surveys alone and lays the ground work for generating hypotheses about the etiology of work related upper-extremity disorders that can be tested in controlled investigations.

Adolescent↗

PubMed2002

[Calcium pyrophosphate deposits--a chameleon].

Calcium Pyrophosphate Dihydrate (CPPD) crystals deposit in articular fibro- or hyaline cartilage (chondrocalcinosis), joint capsules, synovium, periarticular ligaments and tendons resulting in an age dependent prevalence. These calcifications may be asymptomatic or may manifest as acute pseudogout arthritis, pseudorheumatoid arthritis, bursitis, tenosynovitis, tendinitis, polymyalgic syndrome or chronic pyrophosphate arthropathy. The diagnosis is based on the presence of intracellular CPPD crystals in synovial fluid detected by polarizing microscopy, the characteristic radiological changes and the typical clinical presentations. The therapy is symptom oriented or disease specific in case of an underlying metabolic disease such as hemochromatosis, hyperparathyroidism, hypophosphatasia, hypomagnesemia or hypothyroidism.

Calcium Pyrophosphate↗

PubMed1996

A comparison of ciprofloxacin, norfloxacin, ofloxacin, azithromycin and cefixime examined by observational cohort studies.

1. The safety in everyday clinical usage of three 4-quinolone antibiotics, (ciprofloxacin, norfloxacin and ofloxacin), was compared with similar data for azithromycin and cefixime, each agent being examined by Prescription-Event Monitoring (PEM) during the early post-marketing period. 2. In PEM the exposure data are derived from general practitioner prescriptions confidentially provided by the Prescription Pricing Authority. Outcome data are provided by questionnaires (green forms) on which the prescribing medical practitioner records event data. When necessary, further information is obtained from a number of sources which include follow-up of all pregnancies and the patients' life-time medical record. 3. The main outcome measures were demographic information, including the patient's date of birth and sex; the indication for prescribing the drug being monitored; the reason for stopping treatment; the start and stop dates of treatment and the events recorded during and after treatment. 4. The final cohort for each of the five antibiotics exceeded 11000 patients. The only event significantly related to the use of all five antibiotics was nausea/vomiting. This was also the most frequent adverse event causing treatment to be discontinued with norfloxacin, ofloxacin and azithromycin (relevant information was not requested in the studies of ciprofloxacin and cefixime). Vaginal candidiasis was significantly more frequently associated with the use of the three 4-quinolones than with azithromycin and cefixime but it was frequently delayed until the week or two after the cessation of therapy. Within each event, as recorded in these studies, the highest event rates (the number of events per 1000 patients) in the week following the start of therapy were: 9.2 for diarrhoea with cefixime; 4.9 for nausea/vomiting with ofloxacin; 2.4 for rash with azithromycin; 2.2 for abdominal pain with norfloxacin; 1.5 for headache/migraine with ofloxacin; 1.4 for malaise/lassitude with ofloxacin; 1.2 for dizziness with norfloxacin. Uncommon events (reported in less than 1:1000 patients) included rare cases of allergic phenomena, convulsions and pseudomembranous colitis. There were no reports of tendinitis, tenosynovitis or tendon rupture in children but tendon disorders were reported in the two months following the start of treatment in 20 adults. A total of 307 pregnancies were reported. Thirty-eight of the 55 women who received these drugs during the first trimester of pregnancy gave birth to healthy babies. No congenital abnormalities were reported. Apart from one case of unconfirmed pseudomembranous colitis, none of the other 2468 deaths that occurred in these studies was attributed to the antibiotics. 5. These five antibiotics are acceptably safe antimicrobial agents when used in general medical practice. PEM is an effective method for monitoring the safety of recently introduced antimicrobial agents.

Adult↗

PubMedDate not supplied

Enteropathogenicity of Dutch and German avian reoviruses in SPF white leghorn chickens and broilers.

The enteropathogenicity of avian reoviruses (ARVs), isolated from chickens affected with malabsorption syndrome (MAS) from The Netherlands and Germany was studied. In the first trial seven different ARVs isolated from MAS cases were inoculated in 1-day-old specific pathogenic free (SPF) white leghorns. The pathogenicity was compared with 2 ARVs isolated from cases of tenosynovitis, namely reference strain S1133 and a Dutch strain. Although a difference in the severity of the clinical disease was observed, all reoviruses could induce vacuolar degeneration and sloughing of the epithelium of the small intestine at day 2 post inoculation (PI) till day 7 PI. Two Dutch and one German ARV derived from MAS causing the most severe intestinal lesions at day 2 PI, were further studied in the second trial using SPF broilers. These reoviruses did not cause weight gain depression in the broilers although lesions in the small intestine were present from day 1 up to day 4 PI and were more severe than in the white leghorn chickens. In one of the inoculated groups apical denuded villi were already present at day 1 PI. At day 7 PI the small intestine of the infected broilers appeared to be normal. Reovirus antigen was detected in the cytoplasm of the enterocytes at the tip and middle section of the affected villi both in layers and in broilers. To study the role of intestinal CD4+ and CD8+ T-cells and macrophages/monocytes in the pathogenesis of ARV, the numbers of these cells of the jejunal villi of one infected and the control broiler groups were compared. CD4+ T-cells were detected in low numbers and only in the infected broiler group at day 14 PI. The numbers of CD8+ T-cells and macrophages/monocytes were significantly higher in the infected broiler group than in the control broiler group at day 7 and 14 PI and at day 7 PI respectively. Our study indicates that the reovirus alone cannot induce intestinal lesions as found in MAS chickens. Moreover, CD8+ T-cells may play a major role in the pathogenesis and or reovirus clearance in the small intestine.

Animals↗

PubMed2002

Industrial medicine and acute musculoskeletal rehabilitation. 3. Cumulative trauma disorders of the upper limb in computer users.

UNLABELLED: This self-directed learning module highlights various cumulative trauma disorders of the upper limb that may be seen in computer users. The biomechanics and ergonomics of computer users are addressed in relationship to specific neurologic and musculoskeletal conditions within the neck and upper limbs. In addition to a general overview of these conditions, a case presentation is used to show the evaluation and treatment of a computer user who has carpal tunnel syndrome and concomitant de Quervain tenosynovitis. OVERALL ARTICLE OBJECTIVES: (a) To review the important anatomic and ergonomic basis for upper limb cumulative trauma disorders in computer users and (b) to provide an example of evaluation and treatment.

Acute Disease↗

PubMed2000

Osteoarticular disorders of renal origin: disease-related and iatrogenic.

Osteoarticular disorders significantly limit the quality of long-term survival with chronic renal failure. beta 2M amyloidosis is a complication of chronic renal failure that has been recognized mostly in patients receiving long-term haemodialysis. Patients with beta 2M amyloidosis typically present with the triad of shoulder periarthritis, carpal tunnel syndrome, and flexor tenosynovitis of the hands. Other musculoskeletal manifestations of beta 2M amyloidosis include destructive spondyloarthropathy, cervico-occipital pseudotumours, bone cysts, and pathological fractures. At present, only renal transplantation may slow or halt the progession of beta 2M amyloidosis. Crystal-induced arthropathy, most commonly caused by basic calcium phosphate crystals, is an important cause of acute joint inflammation in the patient with renal failure. The incidence of bone and joint infection is increased in patients undergoing dialysis. Haemodialysis and peritoneal dialysis are also associated with an erosive or destructive arthropathy of finger joints, which is not explained by local amyloid deposition.

Amyloidosis↗

PubMed1999

Delayed rupture of the flexor pollicis longus tendon after inappropriate placement of the pi plate on the volar surface of the distal radius.

The pi plate (Synthes Ltd, Paoli, PA) was designed to fit the unique contour of the dorsal aspect of the distal radius. Complications of pi plate fixation of the dorsal distal radius have been previously reported to include both extensor tenosynovitis and delayed extensor tendon rupture. We report a case of rupture of the flexor pollicis longus tendon associated with inappropriate placement of the pi plate on the volar surface of the distal radius.

Aged↗

PubMed2003

Infectious complications associated with toothpick injuries of the hand.

PURPOSE: Although rare, hand injury caused by toothpicks can result in serious complications similar to hand injury produced by human biting. To emphasize its clinical significance this article describes a group of patients sustaining hand injury induced by toothpicks. METHOD: Eight patients who developed cellulitis, abscess, septic arthritis, and/or pyogenic tenosynovitis of flexor tendons after toothpick injuries of the hand were treated at our hospital. Seven of them required admission for antibiotics and surgical treatment. RESULTS: The 7 admitted patients required multiple debridements (3 times on average) to control infection and administer intravenous antibiotics for mixed aerobic and anaerobic infections showing in wound cultures. The average hospital stay for the 7 patients was 26 days. At follow-up evaluation, 4 patients had full recovery of hand function after various cutaneous flap resurfacing of the wounds or staged tendon reconstruction, whereas the remaining 4 patients had arthritis with flexion contracture of interphalangeal joints or persistent paresthesia of the finger. CONCLUSIONS: Patients injured by contaminated toothpicks should be treated with antibiotics that inhibit the growth of both aerobic and anaerobic organisms immediately after these organisms have been identified from cultures. Moreover early surgical treatment might avoid complications and obtain satisfactory results.

Adult↗

PubMed1999

Case report. Initial manifestation of gout after carpal tunnel release.

A carpal tunnel release was performed on a patient with recurrent carpal tunnel syndrome and asymptomatic hyperuricaemia with no prior history of gouty arthritis. Intraoperatively, the patient was found to have tenosynovitis without crystals or tophaceous deposits in the carpal tunnel. Postoperatively, the patient developed an acutely inflamed hand, which responded dramatically to anti-gout medications. We report this patient as an initial attack of gout after a carpal tunnel release.

Acute Disease↗

PubMed2000

Biomechanical effectiveness of taping the A2 pulley in rock climbers.

Circular taping around the proximal phalanx is frequently used by rock climbers to treat tenosynovitis and to prevent injuries to the A2 pulley. The aim of this study was to determine the biomechanical effectiveness of such taping. Devices were built to measure physiological bowstringing in vivo, and to determine the force of bowstringing as well as the force applied to the pulley tape. Two kinds of taping on 16 fingers were measured during the typical crimp grip position. Taping over the A2 pulley decreased bowstringing by 2.8% and absorbed 11% of the force of bowstringing. Taping over the distal end of the proximal phalanx decreased bowstringing by 22% and absorbed 12% of the total force. Circular taping is minimally effective in relieving force on the A2 pulley. It is probably ineffective in preventing pulley ruptures.

Athletic Injuries↗

PubMed2001

Magnetic resonance imaging of soft tissue changes in rheumatoid arthritis wrist joints.

An increasingly aggressive therapeutic strategy, improved treatment options, and encouraging preliminary results have attracted growing attention to the potential of magnetic resonance imaging (MRI) in the diagnosis, prognostication, and monitoring of rheumatoid arthritis (RA). MRI offers multiplanar imaging with unprecedented soft tissue contrast and high spatial resolution. Synovitis, the primary joint lesion in RA, can be detected and monitored. By contrast, conventional radiography shows only the late signs of preceding synovitis. Other soft tissue changes, such as tenosynovitis, tendonitis, enthesitis, joint effusions, and ligament and tendon tears, can be visualized. Unfortunately, the image resolution in most clinically available MR units is insufficient for evaluation of wrist joint cartilage. Preliminary data suggest that MRI is a valuable tool in the diagnosis and prognostication of RA. The superior sensitivity of MRI may be of major significance in both clinical trials and practice. In trials, MRI may allow reductions in the trial size and length because of its more sensitive separation of responders from nonresponders. Thus, although thorough validation is awaited, particularly concerning the reproducibility and prognostic value, MRI seems to be a very promising method for assessment of both established and early RA.

Arthritis, Rheumatoid↗

PubMed2002

Musculoskeletal sonography of the postoperative orthopedic patient.

Musculoskeletal sonography has an important role in the evaluation of the postoperative orthopedic patient. One major advantage of sonography over magnetic resonance imaging and computed tomography is that artifact from metal, which is common after orthopedic surgery, is relatively limited. This allows a clear assessment of the soft tissues for abnormalities such as tendon tear, tenosynovitis, joint effusion, and soft tissue infection. Sonography also has a role in evaluation of recurrent soft tissue tumor, bone healing, and limb amputation. This article first discusses the basic technical aspects of musculoskeletal sonography and is followed by sonographic examples of normal anatomy. Common applications of musculoskeletal sonography in evaluation of the postoperative orthopedic patient are reviewed, including sonography after tendon surgery, assessment of soft tissues adjacent to orthopedic hardware, recurrent musculoskeletal soft tissue tumors, sonography of bone healing, and evaluation of limb amputation. Guidelines and pitfalls of these applications are reviewed.

Amputation, Surgical↗

PubMed2002

MR imaging of the tendons of the foot and ankle.

Hindfoot pain from tendon pathology is common and seen in a wide range of patients from young athletes to older sedentary individuals. Magnetic resonance (MR) is an excellent technique for imaging tendons and for identifying injuries that can be treated with surgery. MR also demonstrates the presence of bone marrow edema, which is a cause of pain and often a marker for adjacent tendon injury. Finally, MR can reveal other etiologies that cause similar hindfoot pain, such as osteochondral injuries and impingement. In this article, we review the normal MR appearance of the ankle tendons and tendon sheath fluid. MR protocols for imaging the various ankle tendon groups are presented. We discuss the MR appearance of tendon pathology, including tendonosis/ tendinopathy, tenosynovitis and peritendonosis, partial and complete tears, subluxation and dislocation, and entrapment. The Achilles, medial, lateral, and anterior tendon groups are discussed separately so as to focus on the MR appearance specific to each region of the ankle.

Ankle↗

PubMed2002

[Imaging in rheumatology].

SUMMARY: Conventional radiography, ultrasonography, scintigraphy, computed tomography, and magnetic resonance imaging (MRI) are important diagnostic tools in rheumatology additional to clinical investigation. Radiography provides information both of the juxtaarticular and the abarticular bone. It is relevant in the diagnosis of rheumatoid arthritis, osteoarthritis, spondylarthropathies, and osteoporosis, and for the investigation of other regions like the thorax. Sonography is superior to radiography to delineate soft tissue structures such as effusions, tenosynovitis, tendinitis, paratendinitis, bursitis, and soft-tissue tumors, but also to evaluate bone surfaces. It helps to perform injections and punctures. Furthermore it is a new diagnostic tool for the diagnosis of temporal arteritis, Takayasu's arteritis, and Sjögren's syndrome. Echocardiography, abdominal and pleural sonography are also frequently used. MRI is useful to detect soft tissue lesions and bone lesions. It is helpful to depict synovial membrane, tendon, tendon sheaths, ligaments, cartilage, destructive joint processes, and rupture of synovial cysts. MRI is an established imaging technique in diagnosis of sacroiliitis and cervical arthritis as well as in diagnosis of osteonecrosis. It is an important diagnostic modality for demonstrating early arthritis. MRI is also of interest in diagnosis of neurological disorders of connective tissue diseases or vasculitis in rheumatology. Bone scintigraphy is an established imaging technique in diagnosis of skeletal diseases as well as in diagnosis of tumors. "Hot spots" are seen in locations of high bone turn over. Scintigraphy is also helpful to localize or exclude inflammation.

Diagnosis, Differential↗

PubMed2003

Magnetic resonance imaging in early detection of rheumatoid arthritis.

Magnetic resonance imaging (MRI) is the modality of choice in early diagnosis and management of rheumatoid arthritis (RA). The pathologic processes in RA involve synovitis, joint effusion, proliferation of fibrovascular connective tissue, and the formation of pannus. Other imaging techniques available for imaging of RA include ultrasound, scintigraphy, computed tomography, and plain radiography (PR). MRI provides high sensitivity in detecting inflammatory changes in the joints. Several studies report high intra- and interobserver reliability and low variation for MRI. MRI allows detection and, in some cases, quantification of synovial changes. Dynamic MRI is a new technique that utilizes rate of synovial enhancement in evaluation of inflammatory changes. MRI allows visualization of erosions in three orthogonal planes. MRI has been shown in many studies to have much greater sensitivity than PR in detecting erosions. Use of a contrast agent further increases the sensitivity in detecting erosions and differentiates and outlines synovial proliferation from fluid collection. Other manifestations of RA such as intraosseous cysts, tenosynovitis, bone marrow edema, and carpal tunnel syndrome can also be visualized on magnetic resonance images. Advances in MRI include contrast-enhancement, dynamic, and quantitative techniques. MRI assists in the early detection of RA, which allows earlier initiation of treatment with disease-modifying therapies.

Arthritis, Rheumatoid↗

PubMed2004

Applications of ultrasound in arthritis.

The current article demonstrates some of the common sonographic features of the major arthritides. In rheumatoid arthritis, sonography shows the primary intra-articular location of the joint synovitis and bone erosion as well as any associated tenosynovitis. In early disease, this distribution can be distinguished from that of the spondyloarthropathies, in which the changes are typically centered on the entheses. These can be similarly differentiated from the chrystal arthropathies and osteoarthritis. In addition to its role in helping to make an accurate initial diagnosis, ultrasound is able to provide information as to disease activity and the efficacy of therapeutic agents.

Arthritis↗