Musculoskeletal and Connective Tissue Disorders

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I N T R O D U C T I O N

Musculoskeletal and Connective

Tissue Disorders


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Some musculoskeletal disorders affect primarily thejoints, 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)


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Arthritis has multiple causes, including

infection,

autoimmune disorders,

crystal-induced inflammation, and

noninflammatory tissue degeneration (eg, osteoarthritis).


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Arthritis may affect

single joints (monarthritis) or

multiple joints (polyarthritis) in a symmetric or asymmetricmanner.

Joints may suffer fractures or sprains


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History

Focus on systemic and extra-articular symptoms aswell as joint symptoms.

Many symptoms, including fever, chills, malaise,weight loss, Raynaud's syndrome, mucocutaneoussymptoms (eg, rash, eye irritation or pain,photosensitivity), and GI or cardiopulmonary

symptoms, can be associated with various jointdisorders.


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Discomfort that occurs with motion whenattempting to move a joint after a period of restoccurs in rheumatic disease.

stiffness upon standing that necessitates walkingslowly after sitting for several hours is commonin osteoarthritis.

Stiffness is more severe and prolonged ininflammatory joint disorders.


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Morning stiffness in peripheral joints that lasts > 1 h can bean important early symptom of RA

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

reflect spondylitis.


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Distinguishing Inflammatory vsNoninflammatory Features in Joint Disease

Symptom Inflammatory Noninflammatory

Systemic symptoms Prominent, including fatigue Unusual

Onset Insidious GradualUsually affecting multiple joints 1 joint or a few weight-

bearing joints

Morning stiffness > 1 h < 30 min

Worst time of day Morning As day progresses

Effect of activity Lessen with activity Worsen with activity

on symptoms Worse after periods of rest Lessen with rest

May also hurt with use


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Physical Examination

Each involved joint should be inspected andpalpated, and the range of motion should beestimated.

With polyarticular disease, certain nonarticularsigns (eg, fever, wasting, rash) may reflectsystemic disorders.


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Monarticular (involving one joint) or asymmetricoligoarticular (involving 4) joint involvement is morecommon in osteoarthritis and psoriatic arthritis.

Small peripheral joints are commonly affected in RA,and the larger joints and spine are affected more inspondyloarthropathies.

Crepitus, a palpable or audible grinding produced by

motion. It may be caused by roughened articularcartilage or by tendons; crepitus-causing motionsshould be determined and may suggest whichstructures are involved.


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DIAGNOSIS

Joint pattern

Presence or Absence of extra articular manifestation


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Joint pattern

Answer to following three Qs

Is inflammation present?

How many joints are involved?

What joints are affected?


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Diagnostic value of the joint patternDiseasesStatusCharacteristicsRA, SLE, GoutOAPresentAbsentInflammationGout, trauma, septic, OA

Lyme disease

Reiters disease, psoriatic,

IBD

RA, SLE

Monoarticular

Oligoarticular

(2-4 joints)

Polyarticular( 5joints)

No of involved joints

OA, Psoriatic

RA, SLE

Gout, OA

DIP

MCP, Wrists

Ist MTP

Site of joint involvement


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Testing

Laboratory testing and imaging studies often provideless information than the history and physical

examination.

However, few investigations may be warranted insome patients, extensive testing is often not.


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Blood tests: Supportive

Antinuclear antibodies (ANA) and complement in SLE

Rheumatoid factor and anti-citrullinated peptide (CCP)in RA

Occasionally useful: HLA-B27 in spondyloarthropathyand antineutrophil cytoplasmic antibodies (ANCA) incertain vasculitides


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Imaging studies:

Plain x-rays in particular reveal mainly bony

abnormalities, and most joint disorders do not affectbone primarily.

However, imaging may help in the initial evaluation of

relatively localized, unexplained persistent or severe jointand particularly spine abnormalities


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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 bevisible in intra-articular cartilage.


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Arthrocentesis: is the process of puncturing thejoint with a needle to withdraw fluid.

Examination of synovial fluid is the most accurate way toexclude infection, diagnose crystal-induced arthritis, andotherwise determine the cause of joint effusions.

It is indicated in all patients with severe or unexplainedmonarticular joint effusions and in patients with

unexplained polyarticular effusions.


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Classification of synovial effusions

Gross

Examinati

on

Norma

l

Noninflam

matory

(Group I)

Inflamm

atory

(GroupII)

Septic

(Group

III)

Crystal

(Group

IV)

Hemorr

hagic

(GroupV)

Volume (mL)

(Knee)

Viscosity

Color

Routine

laboratory

examination

WBC (mm3)

PMN leukocytes

(%)Crystals present

Culture

Mucin clot

Glucose (AM

fasting)

100,

000

>75No

Often

positive

Friable

>50 mg%

lower

than blood

Often >3.5

Variable

Yellow

Cloudy

2,000-

75,000

>50 oftenYes

Negative

Friable

>50 mg%

lower

than blood

Often >3.5

Variable

Red

Xanthochro

mic

50-10,000


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Differential diagnosis by joint fluid groups

Group INoninflammator

y

Group IIInfalmmatory

Group IIISeptic

Group IVCrystal-

induced

Group VHemorrhagic

Osteoarthrosis

Traumatic arthritis

Osteochondritis

dissencans

Osteochondromat

osis

Neuropathic

osteoarthropathyPigmented

villonodular

tenosynovitis

Rheumatoid

arthritis

Lupus

erythematosus

Reiters

syndrome

Ankylosing

spondylitis

Regional eneritis

Ulcerative colitis

Psoriasis

Bacterial

Mycobacteria

l

Fungal

Gout

CPPD crystal

depositon

disease

Apatite-

associated

arthropathy

Traumatic arthritis

Hemophiliac

arthropathy

Anticoagulation

Pigmented

villonodular

tenosynovitis

Neuropathic

osteoarthropathySynovial

hemangioma


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Musculoskeletal and Connective Tissue Disorders

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