Ch363-approach to MSK diseases Flashcards
1
Q
در بیماری های روماتولوژی رد فلگ های تشخیص چیان 5؟
چه علایمی میبینیم که به اینا شک میکنیم؟
A
There are several urgent conditions that must be diagnosed promptly to avoid significant morbid or mortal sequelae. These “red flag” diagnoses include septic arthritis, acute crystal-induced arthritis (e.g., gout), and fracture.
Each may be suspected by its acute onset and monarticular or focal musculoskeletal pain.
1-gout 2-septic arthritis 3-Fracture 4-vascular ischaemia 5-carpal tunnel syndrome
2
Q
در بیماری که با شکایت اسکلتی عصلنی اومده goal های ما در ارزیابی ش چیه؟ 4
A
Accurate diagnosis
Timely provision of therapy
Avoidance of unnecessary diagnostic testing
Identification of acute, focal/monarticular “red flag” conditions
3
Q
در بیماری که با شکایت اسکلتی عصلنی اومده مراحل اپروچ ما در ارزیابی ش چیه؟ 7
A
Determine the chronology (acute vs chronic)
Determine the nature of the pathologic process (inflammatory vs noninflammatory)
Determine the extent of involvement (monarticular, polyarticular, focal, widespread)
Anatomic localization of complaint (articular vs nonarticular)
Consider the most common disorders first
Consider the need for diagnostic testing
Formulate a differential diagnosis
4
Q
حداکثر زمانی که میطوله تا علایم و یافته های یه بیماری msk جوری باشه که به یه recognizable diagnostic entity
برسیم؟
A
Many musculoskeletal disorders resemble each other at the outset, and some may take weeks or months (but not years) to evolve into a recognizable diagnostic entity.
This consideration should temper the desire to establish a definitive diagnosis at the first encounter.
5
Q
علل مختلفanckle pain?
6
A
ankle pain can result from a variety of pathologic conditions involving disparate anatomic structures, including :
1-gouty arthritis,
2-calcaneal fracture,
3-Achilles tendinitis,
4-plantar fasciitis,
5- cellulitis,
6-and peripheral or entrapment neuropathy.
6
Q
What are articular and periarticular structures?
A
Articular structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule, and juxtaarticular bone.
Nonarticular (or periarticular) structures, such as supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin, may be involved in.
7
Q
بیماری هایNon-articular بیشتر مسول شکایت های MSK اند یا آرتیکولار؟
A
Although musculoskeletal complaints are often ascribed to the joints, nonarticular disorders more frequently underlie such complaints.
8
Q
علائم Characteristic بیماری های آرتیکولار ؟ ۷
A
Articular disorders may be characterized by
1-deep or diffuse pain,
2-pain or limited range of motion on active and passive movement,
3-and swelling (caused by synovial proliferation, effusion, or bony enlargement),
4- crepitation,
5-instability,
6- “locking,”
7- deformity.
9
Q
علائم Characteristic بیماری های نان آرتیکولار ؟
A
1-nonarticular disorders tend to be painful on active, but not passive (or assisted), range of motion.
2-Periarticular conditions often demonstrate point or focal tenderness in regions adjacent to articular structures, may radiate or be elicited with a specific movement or position, and have physical findings remote from the joint capsule.
3-Moreover, nonarticular disorders seldom demonstrate swelling, crepitus, instability, or deformity of the joint itself.
10
Q
انیولوژی های بیماری های التهابی مفصل؟ 5
A
Inflammatory disorders may be:
1-infectious (Neisseria gonorrhoeae or Mycobacterium tuberculosis),
2-crystal-induced (gout, pseudogout),
3-immune-related (rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]),
4- reactive (rheumatic fever, reactive arthritis),
5-or idiopathic.
11
Q
What are the four cardinal signs of inflammation which inflammatory disorders may be identified by any of them?
A
Inflammatory disorders may be identified by any of the four cardinal signs of inflammation (erythema, warmth, pain, or swelling)
12
Q
در افتراق التهابی از غیر التهابی، علایم سیستمیک التهاب کدامن؟
A
fatigue
fever
rash
weight loss
در مورد fatigue: اختصاصی نیست
13
Q
در افتراق التهابی از غیر التهابی، چه یافته هایی در وورک اپ ها به نفع التهاب اند؟ 4
A
elevated erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP],
thrombocytosis
anemia of chronic disease
hypoalbuminemia
14
Q
کدام علامته ک به طور شایع در بیماری های مزمن مفصلی وجود داره؟
چه فرقی در التهابی و غ التهابی داره؟
A
Articular stiffness commonly accompanies chronic musculoskeletal disorders.
🌸The duration of stiffness may be prolonged (hours) with inflammatory disorders (such as RA or polymyalgia rheumatica) and improves with activity.
🌸By contrast, intermittent stiffness (also known as gel phenomenon) is typical of noninflammatory conditions (such as osteoarthritis [OA]), shorter in duration (<60 min), and is exacerbated by activity.
15
Q
اتیولوژی بیماری های غ التهابی مفصلی؟
A
1-Noninflammatory disorders may be related to trauma (rotator cuff tear)
2-repetitive use (bursitis, tendinitis)
3-degeneration or ineffective repair (OA),
4-neoplasm (pigmented villonodular synovitis)
5- pain amplification (fibromyalgia)
16
Q
Ddx of fatigue? 9
A
1-Fatigue may be profound with inflammation (as seen in RA and polymyalgia rheumatica)
2-but may also be a consequence of fibromyalgia (a noninflammatory disorder)
3- chronic pain
4-poor sleep
5-depression
6-anemia
7-cardiac failure
8-endocrinopathy
9-malnutrition
17
Q
What are non-inflammatory disorders characterised by?
A
Noninflammatory disorders are often characterized by
1-pain without synovial swelling or warmth
2-absence of inflammatory or systemic features
3-daytime, intermittent gel phenomena rather than prolonged morning stiffness
4-and normal (for age) or negative laboratory investigations.
18
Q
شایع ترین اتیولوژی های Muscular skeletal pain که اول باید اینارو Exclude کنیم بعد بریم سراغ بقیه چیان؟
A
1-trauma
2-fracture
3-overuse syndromes
4-and fibromyalgia
are among the most common causes of musculoskeletal pain, these should be considered during the initial encounter. If excluded, other frequently occurring disorders should be considered according to the patient’s age.
19
Q
معیار زمانی برای اکیوت و کرونیک چیه؟
A
اگر بیش از ۶ هفته طول کشیده باشه کرونیک و اگر زیر ۶ هفته س اکیوته
20
Q
در اپروچ به بیماری که با Musculoskeletal complaints اومده اگه اکیوت و ارتبکولار بود به چیا شک میکنیم? 6
A
1-Acute arthritis 2-septic arthritis 3-gout 4-pseudogout 5-reactive arthritis 6- initial presentation of chronic arthritis
21
Q
در اپروچ به بیماری که با Musculoskeletal complaints اومده و کرونیکه و ما میخوایم بفهمیم التهابی عه یا نه، چجوری میفهمیم؟ 4
A
1- is there a prolonged morning stiffness?
2-Is there soft tissue swelling?
3-Are there systemic symptoms?
4-Is the ESR or CRP elevated?
اگر جواب بله بود پس التهابیه
22
Q
در اپروچ به بیماری که با Musculoskeletal complaints اومده ارتبکولاره و کرونیکه، اگه مشخص شد که غیر التهابیه اقدام بعدی ؟
A
باید بررسی کنیم که ایا DIP, CMC1(carpometacarpal) Hip Or knee joints درگیر شده اند یا نه؛ اگه شدن : OA اگه نشدن: 1-Osteonecrosis 2-charcot arthritis 3-Haemochromatosis
23
Q
در اپروچ به بیماری که با Musculoskeletal complaints اومده ارتیکولاره و کرونیکه، اگه مشخص شد که التهابیه اقدام بعدی ؟
A
باید بیینیم چندتا مفصل درگیر شده اند:
🌻اگر بین ۱تا ۳ مفصل باشه:
Chronic inflammatory mono/oligoarthritis:
1-TB
2-fungal infection
3-Psoriatic arthritis
4-Reactive arthritis
5-pauciarticular JIA: Juvenile idiopathic arthritis
🌻اگر بیشتر از ۳ (یعنی ۴تا و بیشتر):
Chronic inflammatory polyarthritis
24
Q
در بیماری با Chronic inflammatory polyarthritis، چه تشخیص هایی مطرحه و چجوری میرسیم به اینا؟
A
اول میایم میبینیم که درگیری سیمتریک هست یا نیست: 🌸If yes: Are PIP, MCP, MTP Joints involved? 💓If yes: Rheumatoid arthritis 💓If no: SlE-scleroderma-Polymyositis
🌸If no:
Psoriatic arthritis
reactive arthritis
enteropathic arthritis
25
بعد از رول اوت اتیولوژی های شایع درد اسکلتی عضلانی چه اتیولوژی هایی رو باید فکر کنیم بهشون؟
🎆those aged <60 years
are commonly affected by repetitive use/strain disorders, gout (men only), RA, spondyloarthritis, and uncommonly, infectious arthritis.
🎆Patients aged >60 years are frequently affected by OA, crystal (gout and pseudogout) arthritis, polymyalgia rheumatica, osteoporotic fracture,
and uncommonly, septic arthritis.
These conditions are between 10 and
100 times more prevalent than other serious autoimmune conditions,
such as SLE, scleroderma, polymyositis, and vasculitis.
26
کدام بیماری ها هستن که در سنین خاص شایع ترند؟
SLE and reactive arthritis occur more frequently in the young,
whereas fibromyalgia and RA are frequent in middle age
and OA and polymyalgia rheumatica are more prevalent among the elderly.
27
کدوم بیمعری های MSK در مردها شایع ترند؟ ۳
Gout, spondyloarthritis, and ankylosing spondylitis are more common in men
28
کدوم بیماری های MSK در سفیدپست ها شایع ترند؟
polymyalgia rheumatica, giant cell arteritis, and granulomatosis with
polyangiitis (GPA; formerly called Wegener’s granulomatosis) commonly affect whites, whereas sarcoidosis and SLE more commonly
affect African Americans.
29
در کدوم بیماری های MSK ، Familial aggregation شایع اند؟ ۳
یعنی مثلا میبینیم در چند نفر از اعضای خانواذه وجود داره. مثلا بچها مشابه والدین
Familial aggregation is most common with
ankylosing spondylitis, gout, and Heberden’s nodes of OA.
30
از لحاظ زمانی کدوم بیماری های اسکلتی عضلانی :
شروع ناگهانی؟
پیشرفت تدریحی؟
The onset of disorders such as septic arthritis or gout tends to be abrupt,
whereas OA, RA, and fibromyalgia may have more indolent presentations.
31
```
شکایت بیمار در کدوم بیماری های اسکلتی عضلانی :
Chronic
intermittent
migratory
additive
```
The patients’ complaints may evolve differently and be classified as
chronic (OA),
intermittent (crystal or Lyme arthritis)
migratory (rheumatic fever, gonococcal or viral arthritis),
or additive (RA, psoriatic arthritis).
32
```
هر کدوم از بیماری های زیر از نظر تعداد مفصلیرکه درگیر میکنند در کدام کتگوری قرار میگیرن؟
Infectious arthritis
RA
OA
Crystal arthritis
```
monarticular (one joint), oligoarticular or pauciarticular
(two or three joints), or polyarticular (four or more joints).
Although crystal and infectious arthritis are often mono or oligoarticular, OA
and RA are polyarticular disorders.
33
بیماری های نان ارتیکولار از نظر Distribution چجوری طبقه بندی میشن؟
در هر دسته چه بیماری هایی؟
Nonarticular disorders may be
classified as either focal or widespread.
Complaints secondary to tendinitis or carpal tunnel syndrome are typically focal
whereas weakness and myalgia, caused by polymyositis or fibromyalgia, are more
widespread in their presentation.
34
کدوم بیماری هان که هم میتونن قرینه و غیرقرینه باشن هم اولیگو و پلی؟ ۲
OA
| Psoriatic arthritis
35
اندام فوقانی و تحتانی هر کدوم بیشتر در کدوم بیماری ها درگیر میشن؟
ستون مهره و اگزیال چطور؟
📒The upper extremities are frequently involved in RA and OA.
📕whereas lower extremity arthritis is characteristic of reactive arthritis and gout at their onset.
📗Involvement of the axial skeleton is common in OA and ankylosing spondylitis but is infrequent in RA, with the notable exception of the cervical spine.
36
```
در هر کدام از کوموربیدتی های زیر چه Muscular skeletal consequences ممکنه وجود داشته باشه ک در هیستوری بایذ حواسمون بش باشه؟
DM
Renal insufficiency
depression or insomnia
myeloma
cancer
osteoporosis
using glucocorticoids
diuretics
chemotherapy
```
Certain comorbidities may have musculoskeletal consequences. This is especially so for
❤️diabetes mellitus
(carpal tunnel syndrome),
🧡renal insufficiency (gout),
depression or insomnia (fibromyalgia),
💛myeloma (low back pain),
💚cancer (myositis),
💙and osteoporosis (fracture)
💜 when using certain drugs such as
glucocorticoids (osteonecrosis, septic arthritis),
💖diuretics or chemotherapy (gout)
37
```
کدوم بیماری های روماتولوژیک با علایم زیر همراهند؟
راش
تب
ابنورمالیتی های ناخن
میالژی
```
A variety of musculoskeletal disorders may be associated with systemic features such as :
fever (SLE, infection)
rash (SLE, psoriatic arthritis)
nail abnormalities (psoriatic or reactive arthritis)
myalgias (fibromyalgia, statin- or drug-induced myopathy)
weakness (polymyositis, neuropathy)
38
در کدوم بیماری های روماتو لوژیک درگیری چشم داریم؟ 3
Behçet’s disease
sarcoidosis
spondyloarthritis
39
در کدوم بیماری های روماتو لوژیک درگیری GI داریم؟ 2
scleroderma
inflammatory bowel disease
40
در کدوم بیماری های روماتو لوژیک درگیری genitourinary داریم؟ 2
reactive arthritis
gonococcemia
41
در کدوم بیماری های روماتولوژیک درگیری سبستم عصبی داریم؟
Lyme disease
vasculitis
42
منظور از Great masqueraders چیه و به چه بیماری هایی گفته میشه؟ 7
syphilis and tuberculosis were labeled as the “great masqueraders” as their protean symptoms and potential for multi-organ involvement may result in delays in diagnosis and treatment.
In the modern era, other serious diagnoses (including lupus, sarcoidosis, vasculitis and lymphoma) have also been labeled as great masqueraders.
7-All of these are either uncommon or rare, and are overshadowed by
the most common masquerader with musculoskeletal complaints—
fibromyalgia.
43
فیبرومیالژیا چیه؟
Fibromyalgia is a pain amplification disorder unified by sleep disturbance, exaggerated pain and sensitivity
(owing to lowered pain thresholds), and a multiplicity of symptoms
with a paucity of abnormalities on clinical examination or laboratory
testing.
44
یافته های معاینه در فیزیکال اگزم؟
Tender “trigger points” are often found and include tenderness over the epicondyles, trochanteric bursae, anserine bursae, and muscles (gluteal, trapezius, supraspinatus)
that often are misdiagnosed as other nonarticular conditions.
45
فیبرومیالژی با چه بیماری هایی mis diagnosedمیشه؟ 4
fibromyalgia is frequently underrecognized or misdiagnosed as :
1-arthritis
2-lupus
3-multiple sclerosis
4-autoimmune disease and etc
46
What are the comorbidities of fibromyalgia? 13
```
Fibromyalgia has numerous
comorbidities including
1-irritable bowel syndrome,
2-dysmenorrhea,
3-migraine,
4-depression,
5-anxiety,
6-memory loss,
7-non-anatomic paresthesia or dysesthesia,
10-fatigue,
11- myalgias,
12-temporomandibular joint pain,
13-and multiple chemical sensitivities.
```
47
چرا تشخیص بیماری های روماتولوژی در افراد مسن یا بالای ۶۵ سال خیلی سخته؟
Musculoskeletal disorders
in elderly patients are often not diagnosed because the signs and symp-
toms may be insidious, overlooked, or overshadowed by comorbidities.
These difficulties are compounded by the diminished reliability of laboratory testing in the elderly, who often manifest nonpathologic abnormal results.
48
در لب تست هایی ک ار پیرا میگیریم چه ازمایش هایی به صورت نان پاتولوژیک ابنورمال اند و مارو در تشخیص ب اشتباه میندازن؟
For example, the ESR may be misleadingly elevated
and low-titer positive tests for rheumatoid factor (RF)
and antinuclear antibodies (ANAs) may be seen in up to 15% of elderly patients.
49
پیرا بیشتر مستعد کدوم بیماری های روماتولوژیک اند؟
```
geriatric patients are particularly prone to
1-OA, osteoporosis,
4-osteoporotic fractures,
2-gout, pseudogout,
3-polymyalgia rheumatica,
5-vasculitis,
6-and drug-induced disorders
```
به ترتیب شیوع
50
کدام بیماران روماتولوژیکو ادمیت میکنیم؟
(1) acute onset of inflammatory arthritis (possibly gout or septic arthritis);
(2) undiagnosed systemic or febrile illness;
(3) musculoskeletal trauma;
(4) exacerbation or deterioration of an existing autoimmune disorder (e.g., SLE);
(5) new medical comorbidities (e.g., thrombotic event, lymphoma, infection) arising in patients with an established rheumatic disorder.
Notably, rheumatic patients are seldom if ever admitted because of widespread
pain or serologic abnormalities or for the initiation of new therapies.
51
Ddx of Acute monoarticular inflammatory arthritis and acute inflammatory polyarthritis?
اقدام بعدی ای که برای تشخیص انجام میدیم در دو این دو دسته چه تفاوتی با هم داره؟
💜Acute monarticular inflammatory arthritis may be a “red flag” condition (e.g., septic arthritis, gout, pseudogout) that will require arthrocentesis and, on occasion, hospitalization if infection is suspected.
💜However, new-onset inflammatory polyarthritis will have a wider
differential diagnosis (e.g., RA, hepatitis-related arthritis, chikungunya
arthritis, serum sickness, drug-induced lupus, polyarticular septic
arthritis) and may require targeted laboratory investigations rather
than synovial fluid analyses.
52
در بیمار با شکایت روماتولوژیک ک تب داره و Multisystem disorders داره به چیا شک میکنیم؟
Patients with febrile, multisystem disorders will require exclusion of :
1-crystal
2-infectious
3-or neoplastic etiologies
and an evaluation driven by the dominant symptom/finding with the
greatest specificity.
Conditions worthy of consideration may include :
gout or pseudogout, vasculitis (giant cell arteritis in the elderly or polyarteritis nodosa in younger patients), adult-onset Still’s disease, SLE, antiphospholipid antibody syndrome, IgG4-related disease, and sarcoidosis.
Lastly, overly aggressive and unfo-
53
مهم ترین علت بستری شدن بیماران باPreexisting rheumatic diagnosis چیه؟
It is important to note that when established rheumatic disease patients are admitted to the hospital, it is usually not for a medical problem related to their autoimmune disease, but rather because of either a comorbid condition or complication of drug therapy.
54
در بیمارانی که Chronic inflammatory disorders دارند ریسک ابتلا ب چه بیماری های دیگه ای زیاده؟ 3
Patients with chronic inflammatory disorders (e.g., RA, SLE, psoriasis) have
an augmented risk of infection, cardiovascular events, and neoplasia.
55
علل Acute gout در بیماران بستری؟
| چجوری خودشو نشون میده ک‌ما بهش شک کنیم؟
Certain conditions, such as acute gout, can be precipitated in hospitalized patients by surgery, dehydration, or medications and should be
considered when hospitalized patients are evaluated for the acute onset
of a musculoskeletal condition.
56
بازو های معاینه در بیماران روماتولوژی؟
The musculoskeletal examination depends largely on careful inspection, palpation, and a variety of specific physical maneuvers to elicit diagnostic signs.
Although most articulations of the appendicular skeleton can be
examined in this manner, adequate inspection and palpation are not
possible for many axial (e.g., zygapophyseal) and inaccessible (e.g.,
sacroiliac or hip) joints. For such joints, there is a greater reliance on specific maneuvers and imaging for assessment.
57
در معاینه بیمار رومتولوژیک چجوری میتونیم Level of pain را Quantify کنیم؟
One Standard would be to count the number of tender joints on palpation of 28 easily examined joints
(proximal interphalangeals
[PIPs], metacarpophalangeals [MCPs], wrists, elbows, shoulders, and
knees).
58
علل True articular swelling ?
نحوه افتراق اینا از هم؟
🍎bony hypertrophy
🍏synovial effusion
or proliferation
Synovial effusion can be distinguished from synovial hypertrophy or bony
hypertrophy by palpation or specific maneuvers.
59
What is bulge sign?
small to moderate knee effusions may be identified by the “bulge sign” or “ballottement of the patellae.”
60
مشخصات bursal efusions که در معاینه برای افتراق ار سینوویال افیوژن و غیره مهمن چیان؟
Bursal effusions (e.g., effusions of the
olecranon or prepatellar bursa) are often focal, periarticular, overlie
bony prominences, and are fluctuant with defined borders.
فلاکچوانت یعتی وقتی فشار میدیم تعییر میکنه سایزش و به معنی وجود مایع در اون زیره
61
روش ارزیابی Joint stability ؟
Joint stability can be assessed by stabilizing the proximal joint, by palpation, and by the application of manual stress to the distal appendage.
62
What are flexion contractures?
The patient will attempt to minimize the pain by
maintaining the joint in the position of least intraarticular pressure and greatest volume, usually partial flexion.
For this reason, inflammatory
effusions may give rise to flexion contractures. Clinically, this may be
detected as fluctuant or “squishy” swelling in larger joints and grape-
like compressibility in smaller joints. Inflammation may result in fixed
flexion deformities or diminished range of motion—especially on
extension, when intraarticular pressure is increased.
Contractures may reflect (سابقه) یا قبلی antecedent synovial inflammation or trauma.
63
عللل Subluxation or dislocation?
Subluxation or dislocation, which may be secondary to traumatic, mechanical, or inflammatory causes, can be assessed by inspection and palpation.
64
روش ارزیابی Range of motion ؟
Active and passive
range of motion should be assessed in all planes, with contralateral comparison.
A goniometer may be used to quantify the arc of movement.
Each joint should be passively manipulated through its full range of
motion (including, as appropriate, flexion, extension, rotation, abduction, adduction, lateral bending, inversion, eversion, supination, pronation, medial/lateral deviation, and plantar- or dorsiflexion).
65
In which conditions we have extreme or a low range of motion?
E🥕xtreme range of motion may be seen with hypermobility syndrome, with joint pain and connective tissue laxity, often associated with Ehlers-Danlos or Marfan’s syndrome.
🥕Limitation of motion is frequently caused by inflammation, effusion, pain, deformity, contracture, or restriction
from neuromyopathic causes.
66
دفورمیتی های مفصلی نتیجه چی اند؟
Joint deformity usually
indicates a long-standing or aggressive pathologic process. Deformities may result from ligamentous destruction, soft tissue contracture,
bony enlargement, ankylosis, erosive disease, subluxation, trauma, or
loss of proprioception.
67
اگر در لمس مفاصل صدا ها خیلی بلند و خشن شده باشن میتونه نشون دهنده چه بیماری ای باشه؟
Minor joint crepitus is common during joint palpation and maneuvers but may indicate significant cartilage
degeneration as it becomes coarser (e.g., OA).
68
ماهیچه هارو از چه نظر معاینه میکنیم؟
Examination of the musculature will document
strength, atrophy, pain, or spasm.
Appendicular muscle weakness
should be characterized as proximal or distal.
69
چجوری Muscle strength ا ارزیابی میکنیم؟
Muscle strength should
be assessed by observing the patient’s performance (e.g., walking, rising from a chair, grasping, writing).
🌶Strength may also be graded on a 5-point scale:
0 for no movement;
1 for trace movement or twitch;
2 for movement with gravity eliminated;
3 for movement against gravity only;
4 for movement against gravity and resistance;
and 5 for normal
strength
70
علل درد فوکال و یه طرفه دست؟ ۵
Focal or unilateral hand pain may result from trauma, overuse, infection, or a reactive or crystal-induced arthritis.
71
علل روماتولوژیک شکایت دو طرفه دست؟
bilateral hand complaints commonly suggest a degenerative (e.g., OA), systemic, or inflammatory/immune (e.g., RA) etiology.
72
What are Heberden’s and Bouchard’s nodes?
OA (or degenerative arthritis) may manifest as distal
interphalangeal (DIP) and PIP joint pain with bony hypertrophy sufficient to produce Heberden’s (DIP) and Bouchard’s(PIP) nodes, respectively.
73
درد در قاعده شصت و CMC بیانگر چیه؟
Pain, with or without bony swelling, involving the base of the thumb (first carpometacarpal joint) is also highly suggestive of OA.
74
الگوی درگیری RA در دست؟
RA tends to cause symmetric, polyarticular involvement of the PIP, MCP, intercarpal, and carpometacarpal joints (wrist) with pain and palpable synovial tissue hypertrophy.
75
در دست سوریاتیک ارتریت الکوی درگیری ش شبیه چ بیماری ای عه؟
| وجه افتراق؟
Psoriatic arthritis may mimic
the pattern of joint involvement seen in OA (DIP and PIP joints),
🍓but can be distinguished by the presence of inflammatory signs (erythema, warmth, synovial swelling), with or without carpal involvement, nail
pitting, or onycholysis.
76
در مورد DIP و PIP ، هر کدام ار لترال، مدیال ، دورسال و ونترل شون، سرنخ برای چه بیماری ای عه؟
Whereas lateral or medial subluxations at the PIP or DIP joints are most likely due to inflammatory OA or psoriatic
arthritis,
dorsal or ventral deformities (swan neck or boutonnière deformities) are typical of RA.
77
چه یافته هایی در دست دال بر Haemochromatosis اند؟
Hemochromatosis should be considered when degenerative changes (bony hypertrophy) are seen at the second
and third MCP joints with associated radiographic chondrocalcinosis
or episodic, inflammatory wrist arthritis.
78
داکتیلیتیس چیه؟
| علل شایع؟ 7
Dactylitis manifests as soft tissue swelling of the whole digit and may have a sausage-like appearance.
Common causes of dactylitis include :
```
1-psoriatic arthritis,
2-spondyloarthritis,
3-juvenile spondylitis,
4-mixed connective tissue disease,
5-scleroderma,
6-sarcoidosis,
7-and sickle cell disease.
```
79
علت Soft tissue swelling over the dorsum of the hand and wrist ?
Soft tissue swelling over the dorsum of the hand and wrist may suggest an
inflammatory extensor tendon tenosynovitis possibly caused by gonococcal infection, gout, or inflammatory arthritis (e.g., RA).
80
یافته های tenosynovitis در معاینع؟
| اختصاصی و غیر اختصاصی
Tenosynovitis is suggested by 1-localized warmth, swelling, or pitting edema
and may be confirmed when :
1-the soft tissue swelling tracks with tendon movement during flexion and extension of fingers,
2- or when pain is induced while
stretching the extensor tendon sheaths (flexing the digits distal to the
MCP joints and maintaining the wrist in a fixed, neutral position).
81
یافته های کارپانال تونل در دست؟
pain in the wrist that may radiate with paresthesia to the thumb, second and third fingers, and radial half of the fourth finger and, at times, atrophy of thenar musculature.
82
روش تشخیص قطعی کارپال تونل؟
The low sensitivity and moderate specificity of these tests ( phalen & Tinel) may require nerve conduction velocity testing to confirm a suspected diagnosis.
83
در بیماری که با درد شانه اومده هیستوزی چه بیماری هایی رو میگیریم؟ 6
```
1-history of trauma,
2-fibromyalgia,
3-infection,
4-inflammatory disease,
5-occupational hazards,
6-or previous cervical disease.
```
Fibromyalgia should be suspected when glenohumeral pain is
84
در بیماری که با درد شانه اومده، اگر در تمام حرکت هاو planes درد داشته باشه؟
اگر در انجام یه حرکت خاص درد داشته باشه؟
🍓arthritis is suggested by pain on movement in all planes.
🍓pain with specific active motion suggests a periarticular (nonarticular) process.
85
درد شانه، اگه یه درد ارجاعی باشه منشاش از کجاهاس؟ 5
1-Shoulder pain is referred frequently from the cervical spine
2-but may also be referred from intrathoracic lesions (e.g., a Pancoast tumor)
3-or from gallbladder,
4-hepatic,
5- or diaphragmatic disease
These same visceral causes may also manifest as focal scapular pain.
86
در بیماری که با درد شانه اومده چه سرنخ هایی اگ ببینیم ممکنه به فیبرومیالژی ختم شه؟۳
1-diffuse periarticular (i.e., subacromial, bicipital) pain,
2-tender points (i.e., trapezius or supraspinatus),
3-and a sleep disturbance.
87
در بیماری که با درد شانه اومده با چع روشی میفهیمم درگیری گلنوهومرال داره یا نه؟
Glenohumeral involvement is best detected by placing the thumb over the glenohumeral joint just medial and inferior to the coracoid process and applying pressure anteriorly while internally and externally rotating the humeral head. Pain localized to this region is indicative of glenohumeral pathology.
88
در بیماری که با درد شانه اومده اگر Synovial infusion اومد زیر دستمون چ عللی مطرحه؟ ۴
Synovial effusion or tissue is seldom palpable but, if present, may suggest infection, RA, amyloidosis, or an acute tear of the rotator cuff.
89
بهترین پوزیشن معاینه تاندون بایسیپیتال؟
Anterior to the subacromial bursa, the bicipital tendon traverses the bicipital groove.
This tendon is best identified by palpating it in its groove as the patient rotates the humerus internally and externally.
Direct pressure over the tendon may reveal pain indicative of bicipital tendinitis.
90
ارتوروز شانه ، بیشتر در کدوم مفصل شانه س؟
Whereas OA and RA commonly affect the acromioclavicular joint,
OA seldom involves the glenohumeral joint, unless there is a traumatic or occupational cause.
91
در بیماری که با درد شانه اومده چه یافته هایی نشانه تاندونتیت روتیتور کاف اند؟
Rotator cuff tendinitis is suggested by
1-pain on active abduction (but not passive abduction),
2-pain over the lateral deltoid muscle,
3-night pain, 🌙🌘
4-and evidence of the impingement signs (pain with overhead arm activities).
92
چه تستی برای تشخیص Impingement syndrome انجام میشه؟
| تست مثبت چیه؟
The Neer test for impingement is performed by the examiner raising the patient’s arm into forced flexion while stabilizing and preventing rotation of the scapula.
A positive sign is present if pain develops before 180° of forward flexion.
93
پاره شدن روتیتور کاف در چه سنی شایعه؟ علت؟
تست تسخیصی؟ کی مثبت عه؟
با چی میشه تشخیص قطعی داد که پاره شده؟
🍋Tear of the rotator cuff is common in the elderly and often results from trauma;
🍋it may manifest in the same manner as tendinitis. The drop arm test is abnormal with supraspinatus pathology and is demonstrated by passive abduction of the arm to 90° by the examiner.
🍋If the patient is unable to hold the arm up actively or unable to lower the arm slowly without dropping, the test is positive.
🍋Tendinitis or tear of the rotator cuff is best confirmed by magnetic resonance imaging (MRI) or ultrasound.
94
۳ منشا کلی درد زانو؟
1-pain may result from intraarticular (OA, RA) or
2-periarticular (anserine bursitis, collateral ligament strain) processes
3-or be referred from hip pathology.
95
در هیستوری از کسی که با زانو درد اومده چی میپرسیم؟
1-A careful history should delineate the chronology of the knee complaint
2-and whether there are predisposing conditions, trauma, or medications that might underlie the complaint.
For example, patellofemoral disease (e.g., OA) may cause anterior knee pain that worsens with climbing stairs.
96
در کسی که با زانو درد اومده چی مواردی رو معاینه میکنیم؟
1-Observation of the patient’s gait is also important.
2-The knee should be carefully inspected in the upright (weight-bearing) and supine positions for swelling, erythema, malalignment, visible trauma, muscle wasting, and leg length discrepancy.
97
What is The most common malalignment in the knee?
The most common malalignment in the knee is genu varum (bowlegs) or genu valgum (knock-knees) resulting from asymmetric cartilage loss medially or laterally.
98
علت Bony swelling of knee?
Bony swelling of the knee joint commonly results from hypertrophic osseous changes seen with disorders such as OA and neuropathic arthropathy.
99
علت ورم غیر استخوانی زانو؟
Swelling caused by hypertrophy of the synovium or synovial effusion may manifest as a fluctuant, ballotable, or soft tissue enlargement in the suprapatellar pouch (suprapatellar reflection of the synovial cavity) or regions lateral and medial to the patella.
100
بیماری های التهابی که سبب درد زانو میشن؟ 4
```
Inflammatory disorders such as
1-RA,
2-gout,
3-pseudogout,
4-and psoriatic arthritis
```
may involve the knee joint and produce significant pain, stiffness, swelling, or warmth.
101
چجوری میشه از طریق bulge sign ،
| سینوویال افیوژن را تشخیص داد؟
Synovial effusions may also be detected by balloting the patella downward toward the femoral groove or by eliciting a “bulge sign.” With the knee extended, the examiner should manually compress, or “milk,” synovial fluid down from the suprapatellar pouch and lateral to the patellae. The application of manual pressure lateral to the patella may cause an observable shift in synovial fluid (bulge) to the medial aspect.
The examiner should note that this maneuver is only effective in detecting small to moderate effusions (<100 mL).
102
نحوه معاینه برای وجود baker cyst?
A popliteal or Baker’s cyst may be palpated with the knee partially flexed and is best viewed posteriorly with the patient standing and knees fully extended to visualize isolated or unilateral popliteal swelling or fullness.
103
تندرنس anserine bursa به چه معناس؟
is often tender in patients with fibromyalgia, obesity, and knee OA.
104
محل Prepatellar and infrapatellar Bursa?
Other forms of bursitis may also present as knee pain. The prepatellar bursa is superficial and is located over the inferior portion of the patella.
The infrapatellar bursa is deeper and lies beneath the patellar ligament before its insertion on the tibial tubercle.
105
چه زمانی در بیماری که با زانو درد اومده به اسیب به منیسک ها شک میکنیم؟
Damage to the meniscal cartilage (medial or lateral) frequently presents as chronic or intermittent knee pain.
Such an injury should be suspected when there is a history of trauma, athletic activity, or chronic knee arthritis, and when the patient relates symptoms of “locking” or “giving way” of the knee.
106
ایا با معاینه میشه فهمید منیسک پاره شده یا نه؟
With the knee flexed 90° and the patient’s foot on the table, pain elicited during palpation over the joint line or when the knee is stressed laterally
or medially may suggest a meniscal tear.
107
What is positive McMurray test?
A positive McMurray test may also indicate a meniscal tear. To perform this test, the knee is first flexed at 90°, and the leg is then extended while the lower extremity is simultaneously torqued medially or laterally.
A painful click during inward rotation may indicate a lateral meniscus tear,
and pain during outward rotation may indicate a tear in the medial meniscus.
108
چه زمانی در بیماری که با زانو درد اومده به اسیب به رباط crutiate شک میکنیم؟ 4
damage to the cruciate ligaments should be suspected with :’
1-acute onset of pain,
2-possibly with swelling,
3- a history of trauma,
4-or a synovial fluid aspirate that is grossly bloody.
109
چه تستی برای تشخیص اسیب رباط صلیبی انجام میدیم؟
Examination of the cruciate ligaments is best accomplished by eliciting a drawer sign. With the patient recumbent, the knee should be partially flexed and the foot stabilized on the examining surface. The examiner should manually attempt to displace the tibia anteriorly or posteriorly with respect to the femur. If anterior movement is detected, then anterior cruciate ligament damage is likely. Conversely, significant posterior movement may indicate posterior cruciate damage. Contralateral comparison will assist the examiner in detecting significant
110
نحوه ارزیابی هیپ در بیمار باHip pain
The hip is best evaluated by observing the patient’s gait and assessing range of motion.
111
علت درد یک طرفه ی عضلات گلوتئال که به پشت و خارج ران هم میرنه چیه؟
The vast majority of patients reporting “hip pain” localize their pain unilaterally to the posterior gluteal musculature.Such pain tends to radiate down the posterolateral aspect of the thigh and may or may not be associated with complaints of low back pain.
This presentation frequently results from degenerative arthritis of the lumbosacral spine or disks and commonly follows a dermatomal distribution with involvement of nerve roots between L4 and S1.
112
علت درد عصب سیاتیک؟
| به کجا میزنه؟
Sciatica is caused by impingement of the L4, L5, or S1 nerve (i.e., from a herniated disk)
and manifests as
1-unilateral
2-neuropathic pain
3-extending from the gluteal region down the posterolateral leg to the foot.
113
روش تشخیص بورسا و enthesitis در بیماری که در ناحیه تروکانتریک بورسا در خارح هیپ درد داره؟
Some individuals instead localize their “hip pain” laterally to the area overlying the trochanteric bursa. Because of the depth of this bursa, swelling and warmth are usually absent.
🍓Diagnosis of trochanteric bursitis or enthesitis can be confirmed by inducing point tenderness over the trochanteric bursa.
Gluteal and trochanteric pain are common findings in fibromyalgia. Range of movement may be limited by pain.
114
درد True hip joint به کجا میزنه؟
| کدام بورسیت ممکنه این درد رو تقلید کنه؟
Pain in the hip joint is less common and tends to be located anteriorly, over the inguinal ligament; it may radiate medially to the groin.
Uncommonly, iliopsoas bursitis may mimic true hip joint pain. Diagnosis of iliopsoas bursitis may be suggested by a history of trauma or inflammatory arthritis.
115
بیمارانی که بورسیت ایلئوپسواس دارند در چه پوزیشنی دردشون کمتر میشه؟
Pain associated with iliopsoas bursitis is localized to the groin or anterior thigh and tends to worsen with hyperextension of the hip; many patients prefer to flex and externally rotate the hip to reduce the pain from a distended bursa.
116
چه زمانی در بیماری با شکایت MSK علاوه بر هیستوری و معاینه برررسی های بیشتر لازمه؟
Additional evaluation is indicated with:
(1) monarticular conditions;
(2) traumatic or inflammatory conditions;
(3) the presence of neurologic findings;
(4) systemic manifestations;
or (5) chronic symptoms (>6 weeks) and a lack of response to symptomatic measures.
The extent and nature of the
additional investigation should be dictated by the clinical features and suspected pathologic process. Laboratory tests should be used to confirm a specific clinical diagnosis and not be used to screen or evaluate patients with vague rheumatic complaints.
117
چه لب تست هایی رو ارزیابی روتین میسنجیم؟
1-CBC
2-CRP
3-ESR
118
اتیوبوژی های بالا بودن CRP & ESR?
| اگر اکستریملی بالا باشن؟
```
may be elevated with :
1-infection,
2-inflammation,
3-autoimmune disorders,
4-neoplasia,
5-pregnancy,
6-renal insufficiency,
7-advanced age, or hyperlipidemia.
```
Extreme elevation of the acute-phase reactants (CRP, ESR) is seldom seen without evidence of serious illness (e.g., sepsis, pleuropericarditis, polymyalgia
rheumatica, giant cell arteritis, adult Still’s disease).
119
چرا سطح اوریک اسید در خانم ها پایین تز از اقایونه؟
Serum uric acid determinations are useful in the diagnosis of gout and in monitoring the response to urate-lowering therapy.
Serum values range from (4.0–8.6 mg/dL) in men; the lower values [3.0–5.9 mg/dL]) seen in women are caused by the uricosuric effects of estrogen.
120
سطح نرمال اوریم اسید ادرار ۲۴h?
هایپریوریسمیا؟
رابطه سطح اوریک اسید خون با شدت بیماری مفصلی؟
Urinary uric acid levels are
normally <750 mg per 24 h.
hyperuricemia (especially levels >535 μmol/L [>9 mg/dL]) is associated with an increased incidence
of gout and nephrolithiasis, levels may not correlate with the sever-
ity of articular disease.
121
علل افزایش سطح اوریک اسید؟ 3
Uric acid levels (and the risk of gout) may be increased by
1-inborn errors of metabolism (Lesch-Nyhan syndrome),
2-disease states (renal insufficiency, myeloproliferative disease, psoriasis),
3- drugs (alcohol, cytotoxic therapy, thiazides).
122
بالا بودن یا نبودن سطح اوریک در gout چقد سنسیتیو عه؟
تارگت گول ما برای اوریک اسید در این بیماران چنده؟
Although nearly all patients with gout will demonstrate hyperuricemia at some time
during their illness, up to 50% of patients with an acute gouty attack
will have normal serum uric acid levels.
Monitoring serum uric acid is
useful in assessing the response to urate-lowering therapy or chemo-
therapy, with the target goal being a serum urate <6 mg/dL.
123
در بیمار ی که به RA شک داریم حالا میخوایم علاوه بر روتین ها ازمایش بنویسیم چی مینویسیم؟
When considering RA,
both serum RF and anti-CCP antibodies should be obtained as these are complementary.
🍓Both are comparably sensitive, but CCP antibodies are more specific than RF.
In RA, the presence of anti-CCP and RF antibodies may indicate a greater risk for more severe, erosive polyarthritis.
124
ANAs
| در کدام بیماران مثبت میشه؟ ۸
ANAs are found in nearly all patients with SLE and may also be seen in
برای لوپوس به شدت حساسه ولی غ اختصاصی(فقط ۱ تا ۲ درصد اونایی ک مثبت میشن لوپوس تنها دارند😂)
patients with other autoimmune diseases
2-polymyositis,
3-scleroderma,
4-antiphospholipid syndrome,
5-Sjögren’s syndrome),
6-drug-induced lupus
7-chronic liver or renal disorders,
8-and advanced age.
Positive ANAs are found in 5% of adults and in up to 14% of elderly or Chronically ill individuals
125
کدام پترن ANA برای لوپوس اختصاصی عه؟
peripheral, or rim, pattern (related to autoantibodies against double-strand [native] DNA) is highly specific
and suggestive of lupus.
Diffuse and speckled patterns
are least specific.
126
پترن نوکلئولور ANA در چه بیماری هایی؟
nucleolar patterns may be seen in patients with :
1-diffuse systemic sclerosis
2-or inflammatory myositis
127
پترن سانترومری ANA در چه بیماری هایی؟
Centromeric patterns are seen in patients with limited scleroderma (calcinosis, Raynaud’s phenomenon, esophageal
involvement, sclerodactyly, telangiectasia [CREST] syndrome), primary biliary sclerosis, Sjögren’s syndrome or thyroiditis
128
اندیکاسیون اسپیریشن و انالیز مایع سینوویال؟
Aspiration and analysis of synovial fluid are always indicated in:
1-acute monarthritis
2-or when an infectious
3-or crystal-induced arthropathy is suspected.
129
محتویات مایع سینوسال را از چه نظر بررسی میکنیم و نمیکنیم؟
```
Synovial fluid may distinguish between noninflammatory and inflammatory processes by analysis of the :
1-appearance,
2-viscosity,
3-and cell count.
4-Culture and Gram stain if indicated
```
Tests for synovial fluid glucose, protein,
lactate dehydrogenase, lactic acid, or autoantibodies are not recommended because they have no diagnostic value.
130
مشخصات مایع سینویال نرمال؟
Normal synovial fluid
is
1-clear or a pale straw color :متمایل به زرد و کاهی
2-and is viscous, primarily because of the high levels of hyaluronate.
131
مشخصات مایع سینوویال التهابی؟
Inflammatory fluid is turbid (کدر) and yellow, with an
increased WBC count
(2000–50,000/μL) and a polymorphonuclear leukocyte predominance.
Inflammatory fluid has reduced viscosity (no stringing),
diminished hyaluronate,
and little or no tail following each drop of synovial fluid.
Such effusions are found in RA, gout, and other inflammatory arthritides.
132
مشخصات مایع سینویال در سپتیک ارتیریت؟ 4
Ddx? 2
Septic fluid is :
1-opaque and purulent,
2-with a WBC count usually >50,000/μL,
3-a predominance of polymorphonuclear leukocytes (>75%),
4-and low viscosity.
Such effusions are typical of septic arthritis but may also occur with RA or gout.
133
در چه بیماری های ویسکوزیته مایه سینوییال نرماله؟
Effusions caused by OA or trauma will have normal viscosity.
134
مشخصات مایع سینویال در بیماری های غ التهابی؟
Noninflammatory synovial fluid is
1-clear,
2-viscous,
3-and amber-colored, :کهربایی، زرد مایل ب قهوه ای
4-with a WBC count of <2000/μL and a
4-predominance of mononuclear cells.
135
چجوری میفهمیم Viscosity of synovial fluid چه تغیری کرده؟
The viscosity of synovial fluid is assessed by expressing fluid from the syringe one drop at a time.
Normally, there is a stringing effect, with a long tail behind each synovial drop.
136
علل مایع سینوویال هموراژیک؟
In addition, hemorrhagic synovial fluid may be seen with :
1-trauma,
2-hemarthrosis,
3- or neuropathic arthritis.
```
2621PART 11
Immune-Mediated, Inflammatory, and Rheumatologic Disorders
2622
INTERPRETATION OF SYNOVIAL FLUID ASPIRATION
Strongly consider synovial fluid aspiration
and analysis if there is
• Monarthritis (acute or chronic)
• Trauma with joint effusion
• Monarthritis in a patient with chronic polyarthritis
• Suspicion of joint infection, crystal-induced arthritis, or hemarthrosis
Analyze fluid for
• Appearance, viscosity
• WBC count, differential
• Gram stain, culture, and
sensitivity (if indicated)
• Crystal identification
by polarized microscopy
No
Inflammatory or
noninflammatory
articular condition
Is the WBC >2000/μL?
No
Consider
noninflammatory
articular conditions
• Osteoarthritis
• Trauma
• Other
Consider other
inflammatory
or septic arthritides
• Gram stain, culture
mandatory
Is the WBC >50,000/μL?
No
Probable inflammatory arthritis
Consider
• Trauma or mechanical
derangement
• Coagulopathy
• Neuropathic arthropathy
• Other
Yes
Consider inflammatory
or septic arthritis
No
Is the % PMNs >75%?
Yes
No
Are crystals present?
Yes
Crystal identification for
specific diagnosis
• Gout
• Pseudogout
Yes
Possible septic arthritis
FIGURE 363-6 Algorithmic approach to the use and interpretation of synovial
fluid aspiration and analysis. PMNs, polymorphonuclear (leukocytes); WBC, white
blood cell count.
Dual-energy CT
```
137
در مشاهده مایع سینویال زیر میکروسکوپ فرق gout و‌سودگوت و Chondrocalcinosis چیه؟
🌳Monosodium urate crystals (observed in gout) are seen by polarized microscopy and are long, needle-shaped,
negatively birefringent, and usually intracellular.
🌳In chondrocalcinosis and pseudogout, calcium pyrophosphate dihydrate crystals are usually short, rhomboid-shaped, and positively birefringent.
138
اگر شک داشتیم به gonoccocal arthritis اقدام بعدی؟
If gonococcal arthritis is suspected, nucleic acid amplification tests should be used to detect either Chlamydia trachomatis or N. gonorrhoeae infection.
139
اندیکاسیون کشت مایع سینوویال برای تولرکلوز و فارج؟
Synovial fluid from patients with chronic monarthritis should also be cultured for M. tuberculosis and fungi.
140
اندیکاسبون Plain x ray در بیمار با شکایت روناتولوژیک ؟ 4
| مرایا؟
Plain x-rays are most appropriate
and cost effective when there is
1- a history of trauma,
2-suspected chronic infection,
3-progressive disability,
4-or monarticular involvement; when
therapeutic alterations are considered; or when a baseline assessment is desired for what appears to be a chronic process.
However, in acute inflammatory arthritis, early radiography is rarely helpful in establishing a diagnosis and may only reveal soft tissue swelling or juxtaar ticular demineralization.
141
اندیکاسیون های Ultrasonography در msk? 8
```
1-Synovial (Baker’s) cysts
2-Rotator cuff tears
3-Bursitis, tendinitis, tendon injury
4-Enthesitis
5-Carpal tunnel syndrome
6-Urate or calcium pyrophosphate
deposition on cartilage
7-Early detection of synovial
inflammation or erosions
8-Ultrasound-guided injection/
Arthrocentesis
```
Use of power Doppler allows for early detection of synovitis and bony erosions.
142
اندیکاسیون های MRI در msk?
```
1-Avascular necrosis
2-Osteomyelitis
3-Septic arthritis, infected prosthetic joints
4-Early sacroiliitis
5-Intraarticular derangement and
soft tissue injury
6-Derangements of axial skeleton
and spinal cord
7-Herniated intervertebral disk
8-Pigmented villonodular synovitis
9-Inflammatory and metabolic
muscle pathology
```
143
اندیکاسیون های Radionuclide scintigraphy
Radionuclide scintigraphy is a very sensitive, but poorly specific, means of detecting inflammatory or metabolic alterations in bone or periarticular soft tissue structures .
Scintigraphy is best suited for total-body assessment (extent and distribution) of skeletal involvement (neoplasia, Paget’s disease) and the assessment of patients with undiagnosed polyarthralgias, looking for occult arthritis. The use of scintigraphy has declined with greater use and declining cost of ultrasound and MRI. MRI has largely replaced scintigraphy in diagnosing osseous infection, neoplasia, inflammation, increased blood flow, bone remodeling, heterotopic bone formation, or avascular necrosis.
Despite their utility, 111 In-labeled WBC or 67 Ga scanning has largely been replaced by MRI, except when there is a suspicion of septic joint or prosthetic joint infections.
18
2623
F-Fluorodeoxyglucose (FDG) is the most commonly used radiopharmaceutical in PET scanning. FDG-PET/CT scans have been seldom used in the evaluation of septic or inflammatory arthritis, but have also been useful in the evaluation of patients with fever of unknown origin or suspected large vessel vasculitis.
144
کاربرد انواع CT در شکایات MSK,?
Spiral ct
High resolution
```
Computed tomography (CT) provides detailed visualization of the
axial skeleton. Articulations previously considered difficult to visualize by radiography (e.g., zygapophyseal, sacroiliac, sternoclavicular, hip joints) can be effectively evaluated using CT. CT has been demonstrated to be useful in the diagnosis of low back pain syndromes (e.g., spinal stenosis vs herniated disk), sacroiliitis, osteoid osteoma, and stress fractures. Helical or spiral CT (with or without contrast angiography) is a novel technique that is rapid, cost effective, and sensitive in diagnosing pulmonary embolism or obscure fractures, often in the setting of initially equivocal findings. High-resolution CT can be
advocated in the evaluation of suspected or established infiltrative lung disease (e.g., scleroderma or rheumatoid lung). The recent use of hybrid (positron emission tomography [PET] or single-photon emission CT [SPECT]) CT scans in metastatic evaluations has incorporated CT to provide better anatomic localization of scintigraphic abnormalities.
```
145
What is the most sensitive diagnostic imaging diagnosis of soft tissue injuries?
MRI
🍓Because of its enhanced soft tissue resolution, MRI is more sensitive than arthrography or CT in the diagnosis of soft tissue injuries (e.g., meniscal and rotator cuff tears); intraarticular derangements; marrow abnormalities (osteonecrosis, myeloma); and spinal cord or nerve root damage, synovitis, or cartilage damage or loss.
🍓MRI can image fascia, vessels, nerve, muscle, cartilage, ligaments, tendons, pannus, synovial effusions, and bone marrow.
