Rheumatology Board Review

Karen Law

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN:
  9781118127919
• eBook ISBN:
  9781118475843
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Medicine

The field encompassed by rheumatology has evolved rapidly over the last decade to include multiple immune-modulating and biologic medications, new classification criteria, significant updates on bone metabolism, and completely new paradigms of treatment based on groundbreaking studies published within the last 5 years. Although much has been adopted as standard of care based on new data, most textbooks do not reflect these practice changes.

Rheumatology Board Review highlights the latest advances in the field and new standards of care, including references to current citations in the medical literature. It provides international standards and guidelines and is designed to convey a maximum amount of information quickly and efficiently, with many helpful schematics, radiographs, and tables.

Rheumatology Board Review offers chapter coverage of:

• Non-inflammatory joint and soft tissue disorders
• Selected topics in rheumatoid arthritis
• Selected topics in systemic lupus erythematosus
• Antiphospholipid antibody syndrome
• IgG4-related disease
• Myopathies
• Selected topics in pediatric rheumatology
• HIV and rheumatic diseases
• Miscellaneous arthropathies
• Osteoporosis
• Review of musculoskeletal radiology
• Study design, measurement, and basic statistical analysis
• Update on vasculitis

Rheumatology Board Review is a must-have reference for rheumatology fellows and professionals seeking a concise yet thorough review of state-of-the-art rheumatology.

CHAPTER 1
Non-Inflammatory Joint and Soft Tissue Disorders

Laura Paxton^1,3, Schartess Culpepper-Pace², Karen Law³

¹Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA

²Rheumatology and Internal Medicine, Chen Medical Centers, Miami, FL, USA

³Emory University School of Medicine, Atlanta, GA, USA

Introduction

Rheumatologists often manage non-inflammatory arthritides and associated soft tissue disorders, including osteoarthritis, carpal tunnel syndrome, and gout. The diagnosis of these conditions as well as recent innovations in treatment will be reviewed here.

Carpal Tunnel Syndrome

Epidemiology

• One of the most common and frequently diagnosed entrapment neuropathies
  • Accounts for up to 90% of entrapment neuropathies
  • Prevalence in the US population up to 5% of the general population
    • Estimated lifetime risk of 10%
    • Females affected more frequently than men
    • Peak age range 40–60 years
  • Risk factors include prolonged wrist flexion or extension, repeated use of flexor muscles, and exposure to vibration
    • Systemic medical conditions i.e. diabetes, hypothyroidism, obesity, pregnancy, vitamin toxicity or deficiency can predispose
    • Many cases remain idiopathic

Pathology

• Median nerve entrapment is caused by chronic pressure at the level of the carpal tunnel
• Compression of the median nerve is secondary to surrounding structures: carpal bones, flexor tendons, and the fibrous transverse carpal ligament leading to median nerve dysfunction
  • Carpal tunnel anatomy (Figure 1.1)
    • Superiorly: transverse carpal ligament
    • Posteriorly: carpal bones
    • Nine flexor tendons: (four) flexor digitorum profundus, (four) flexor digitorum superficialis, flexor pollicis
    • Median nerve
• Repetitive compressive injury to the median nerve leads to demyelination
  • Blood flow may also be interrupted, altering the blood–nerve barrier

Figure 1.1 Components of the carpal tunnel (Color plate 1.1).

Clinical Presentation

• Symptoms may include tingling and numbness, in the distribution of the median nerve (first three fingers and radial aspect of the fourth finger); pain involving the entire hand, decreased grip strength, and reduced dexterity
  • Symptoms occasionally worse at night (awakenings with paresthetica nocturna: sensation of tingling, burning or numb hand possibly secondary to flexion of wrist at night)
• Patients with carpal tunnel syndrome (CTS) occasionally report subjective swelling of the hands and/or wrists
• Atrophy of the thenar eminence occurs in later stages (this finding is associated with poor response to surgical decompression)

Diagnosis

• Combination of the clinical history, examination, provocative tests, electrodiagnostic studies
  • Phalen's test is positive when flexion at the wrist for 60 seconds causes pain and/or paresthesias in median nerve distribution
    • Sensitivity ranges from 67–83%
    • Specificity ranges from 40–98%
  • Tinel's test is positive when tapping over the volar surface of the wrist (course of median nerve) causes pain and/or paresthesias in the distribution of the median nerve
    • Sensitivity ranges from 48–73%
    • Specificity reported as high as 100%
  • Electrodiagnostic studies lack standardized diagnostic criteria currently, making them inadequate as a universally recognized gold standard
    • Nerve conduction studies provide objective information regarding the median nerve across the carpal tunnel
      • Findings include prolonged motor and sensory latencies of median nerve
      • Reduction in median nerve compound motor or sensory action potential amplitude
      • Reductions in sensory and motor conduction velocities
      • Rules out other polyneuropathies included in the differential diagnosis
  • Ultrasonography may reveal flattening of the median nerve within the tunnel and bowing of the flexor retinaculum
    • Cross-sectional area of the median nerve is the most predictive of CTS; it has also been used in the classification of the severity of CTS
  • Magnetic resonance imaging assists in the determination of the severity of nerve compression; it is also helpful in observing anatomical structures that may be contributing to symptoms, i.e. ganglion cysts, bony deformities
    • Swelling of the median nerve and increased signal intensity on T2- weighted images assist in diagnosing CTS

Treatment

• Mild to moderate symptoms
  • Oral anti-inflammatories
  • Oral corticosteroids may be effective in reducing edema and tenosynovitis associated with CTS
  • Carpal bone mobilization and hand splints are often fir...

Table of contents

• Cover
• Title page
• Copyright page
• List of Contributors
• Preface
• CHAPTER 1: Non-inflammatory joint and soft tissue disorders
• CHAPTER 2: Selected topics in rheumatoid arthritis
• CHAPTER 3: Selected topics in systemic lupus erythematosus: B cells in lupus and lupus nephritis
• CHAPTER 4: Antiphospholipid antibody syndrome
• CHAPTER 5: IgG4-related disease
• CHAPTER 6: Myopathies
• CHAPTER 7: Selected topics in pediatric rheumatology
• CHAPTER 8: HIV and rheumatic diseases
• CHAPTER 9: Miscellaneous arthropathies
• CHAPTER 10: Osteoporosis
• CHAPTER 11: Review of musculoskeletal radiology
• CHAPTER 12: Study design, measurement, and basic statistical analysis
• CHAPTER 13: Update on vasculitis
• Index
• End User License Agreement