Assistant Professor, University of Nevada, Las Vegas School of Medicine
Baker Cyst Popliteal cyst is a common finding blood pressure medication diabetes buy warfarin 5mg otc, seen in ~48% of patients with rheumatoid arthritis blood pressure chart jpg generic warfarin 1mg free shipping, and can be detected with ultrasound blood pressure wrist watch purchase warfarin cheap online. It extends posteriorly and may be directed inferiorly or superiorly in the soft tissues in the posterior aspect of the knee joint heart attack 6 minutes warfarin 1mg. Rupture of the Baker cyst leads to extravasation of the inflammatory content into the soft tissues of calf, producing pain and swelling that may be mistaken for thrombophlebitis. Joint Effusion Fluid can be best demonstrated in the knee joint on the lateral projection. Rice Bodies Bearing macroscopic similarity to grains of polished white rice, these small, usually uniform in size intra-articular or intrabursal loose bodies are commonly associated with rheumatoid arthritis and are thought to represent a complication of chronic inflammatory process. Occasionally, they also may be seen in seronegative inflammatory arthritis and even in tuberculous arthritis. These particles contain collagen, fibrinogen, fibrin, reticulin, elastin, mononuclear cells, blood cells, and some amorphous material. Anteroposterior (A) and lateral (B) radiographs of the right knee of a 52-year-old woman joints show tricompartmental involvement. Anteroposterior (C) and lateral (D) radiographs of both knees of a 50-year-old man show uniform narrowing of the medial, lateral, and femoropatellar joint compartments associated with joint effusions. Note the lower signal intensity of the fluid as compared to the slightly higher signal of the pannus. Anteroposterior (A) and lateral (B) radiographs of the ankle show uniform joint space narrowing of the tibiotalar, subtalar, Chopart, and Lisfranc joints. Anteroposterior radiograph of the left hip of a 59-year-old woman with advanced rheumatoid polyarthritis demonstrates the typical erosions of the femoral head and acetabulum, and acetabular protrusio. Small Joint Involvement Rheumatoid arthritis characteristically affects the small joints of the wrist, as well as the metacarpophalangeal and proximal interphalangeal joints of the hands and feet. As a rule, the distal interphalangeal joints in the hand are spared, although in advanced stages of the disease even these may be affected. This latter point, however, is controversial, because some investigators believe that if the distal interphalangeal joints are involved, the condition may represent juvenile idiopathic arthritis or another form of polyarthritis, not classic rheumatoid arthritis. A: Lateral radiograph of the heel of a 49-year-old woman shows retrocalcaneal bursitis (arrow) without osseous erosions. B: Lateral radiograph of the foot of a 55-year-old woman who presented with a heel pain shows fluid in the retrocalcaneal bursa (arrow) associated with erosion of the calcaneus (curved arrow). Note the bone erosions in the talus and navicular bones containing enhancing inflammatory pannus (arrows). Norgaard view of both hands of a 33-year-old woman shows early erosions of both pisiform bones (arrows). A: Dorsovolar radiograph of both hands of a 50-year-old woman shows erosion of the right triquetral bone (arrow). Anteroposterior radiograph of the left knee of a 35-year-old woman with rheumatoid arthritis shows a large synovial cyst in the proximal tibia. Open arrows point to erosive changes of the articular cartilage; curved arrows indicate joint effusion. Photograph of fibrinous loose bodies recovered from the knee joint of the patient with rheumatoid arthritis. A: Lateral radiograph of the right elbow of a 39-year-old man demonstrates erosions of the olecranon process (arrow), olecranon bursitis (open arrow), and rheumatoid nodules on the dorsal aspect of the forearm (curved arrows). Note the characteristic pitlike cortical erosions at the site of the rheumatoid nodules (arrowheads). B: A 68-year-old woman with rheumatoid arthritis had a large rheumatoid nodule at the lateral side of the elbow joint. In addition to the characteristic changes exhibited in large joint involvement, the small joints may also show radiographic features specific for these sites. Soft Tissue Swelling this earliest sign of rheumatoid arthritis usually has a fusiform, symmetric shape. It is periarticular in location and represents a combination of joint effusion, edema, and tenosynovitis. A: Longitudinal ultrasound image of the left second metacarpophalangeal joint of a 60-year-old man with rheumatoid arthritis shows hypoechoic triangular area at the site of distended joint capsule, representing joint effusion and synovial thickening. B: Power Doppler color scale of the same area shows increased vascularity consistent with synovial hyperemia from active inflammation. Loss of Articular Cortex this is another early radiographic sign of inflammatory arthritis: the so-called articular (or subchondral) cortex becomes indistinct or completely lost. Marginal Erosions Other early radiographic signs of articular abnormalities manifest as marginal erosions at so-called bare areas. These are the sites within the joint capsule that are not covered by articular cartilage. The most common locations for these erosions are the radial aspects of the second and third metacarpal heads and the radial and ulnar aspects of the bases of the proximal phalanges. Synovial inflammation in the prestyloid recess, a diverticulum of the radiocarpal joint that is intimate with the styloid process of ulna, as Resnick pointed out, produces marginal erosion of the styloid tip. A: Very early radiographic feature is the loss of so-called articular cortex of the metacarpal head on the radial aspect (arrow). B: In another patient, the metatarsal heads are affected in similar manner (arrows), but to a slightly greater extent. Invasion of inflammatory pannus (P) into the articular areas not covered by the articular cartilage (so-called bare areas) causes marginal erosions (arrows).
Selected cases have also been treated in the past with methotrexate and oral gold salts heart attack treatment order warfarin 2mg otc. Also good results have been reported after subcutaneous injections of adalimumab and intra-articular injections of infliximab arrhythmia quiz online buy warfarin 2 mg without a prescription. Surgical intervention is often necessary for the relief of persistent pain and the correction of severe deformities arteria bologna 7 dicembre order warfarin paypal. The indications for this type of surgery are loss of the joint space blood pressure machine purchase discount warfarin, synovial proliferation with joint destruction, loss of normal alignment, and uncontrollable pain. The pathophysiologic hallmark of this condition is formation of pannus, which refers to hypertrophied synovium that develops as inflammatory response. The destructive action of pannus is responsible for progressive erosions and joint surface damage and ligament and joint capsule tearing, all leading to joint deformities and instability. The course of the disease varies from patient to patient, and there is a striking tendency toward spontaneous remissions and exacerbations. Currently, rheumatoid arthritis is considered to be a heterogeneous autoimmune disorder, with genetic factors playing an important role in the disease expression. Multiple genome-wide association studies have been conducted, but the results have generally been disappointing. Their work "focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease-this being the appropriate current paradigm underlying the disease construct `rheumatoid arthritis. These complexes activate the complement system, which releases mediators responsible for producing inflammation within the joint structures. Because rheumatoid factors can be found in the serum and in joint fluids of patients with nonrheumatoid disorders, their presence alone is not diagnostic of rheumatoid arthritis. They have been studied for decades and were once thought to be the only critical serologic marker of rheumatoid arthritis; this, however, is not the case, because rheumatoid factors can be found in the joint fluid of patients with nonrheumatoid disorders. Although the rheumatoid factor is still widely used, it has lost much of the luster of the past. Nevertheless, finding high titers of these factors in a joint effusion strongly suggests the diagnosis of rheumatoid arthritis. Early in the course of disease, rheumatoid factors may be demonstrated in the synovial fluid before they are positive in the serum, allowing early diagnosis. In synovial fluid, IgM and IgG rheumatoid factors can combine to form immune complexes. The complement system is activated, resulting in the attraction of polymorphonuclear leukocytes into the joint space. Patients with rheumatoid arthritis with subcutaneous nodules almost always will have positive rheumatoid factors, generally in high titer. Interesting, however, is the fact that frequency and severity of rheumatoid nodules has greatly deceased in population and the disease is strikingly different in this respect from two generations ago. These antibodies are directed at one or all of the following proteins: alpha enolase, fibrinogen, and vimentin. In all cases, the arginine in these proteins has been replaced by the plant amino acid citrulline. There are several factors known to accelerate this loss of tolerance, including smoking and infections, particularly Proteus infections of the gums. Clinical Features Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness and severe motion impairment in the affected joints. The clinical presentation varies between the patients, but an insidious onset of pain with symmetrical swelling of the joints of the hands is the most common finding. Some patients may present with palindromic onset, monoarticular presentation, extra-articular synovitis (such as tenosynovitis and bursitis), and general symptoms such as malaise, fatigue, anorexia, weight loss, and low-grade fever. Imaging Features Rheumatoid arthritis is characterized by a diffuse, usually multicompartmental, symmetric narrowing of the joint space associated with marginal or central erosions, periarticular osteoporosis, and periarticular soft tissue swelling; subchondral sclerosis is minimal or absent and formation of osteophytes is lacking. Regardless of the size of the joint and the site of involvement, certain imaging features can be identified that are characteristic of this inflammatory process. Osteoporosis In rheumatoid arthritis, unlike osteoarthritis, osteoporosis is a striking feature. In the early stage of the disease, osteoporosis is localized to periarticular areas (juxta-articular osteoporosis), but with progression of the condition, a generalized osteoporosis can be observed. Joint Space Narrowing this is usually a symmetric process with concentric narrowing of the joint. Concentric narrowing in the hip joint leads to axial migration of the femoral head, which in more advanced stages may result in acetabular protrusio. In addition, cephalad migration of the humeral head may be seen secondary to destructive changes in the shoulder joint and rupture of the rotator cuff. In the knee joint, all three compartments are commonly narrowed in a uniform manner. The loss of the articular cartilage is caused by inflammation and pannus formation. There is little evidence of bone repair or osteophyte formation, and there is invariably associated joint effusion.
Deceleration collisions are most commonly associated with secondary collisions with people or loose objects in the vehicle blood pressure medication hydralazine buy discount warfarin 5 mg, which can become missiles causing deadly injuries heart attack karaoke demi lovato cheap 5 mg warfarin overnight delivery. Lateral-Impact or T-Bone Collision the mechanism of the lateral-impact collision is similar to that of the frontalimpact collision blood pressure water pill purchase warfarin mastercard, with the addition of lateral energy displacement (Figure 1-6) blood pressure study cheap warfarin 5mg without a prescription. Lateral displacement injuries range from cervicalmuscle strain to fracture or subluxation with neurologic deficit. Injuries appear on the side of the impact and are common, as are injuries to the lower extremities. Injury is due to direct force either from inward bowing of the door on the side of the impact or from an unrestrained passenger being propelled across the seat. Injuries vary from soft-tissue injuries to flail chest, lung contusion, pneumothorax, hemothorax, or possible traumatic aortic dissection. Occupants on the side of the impact are likely to have pelvic, hip, or femur fractures. Pelvic injuries may also include dislocation, bladder rupture, and urethral injuries. Emergency care providers do need to be aware that many new vehicles are equipped with side airbags and air curtains (Figure 1-7). They pose a hazard to responders, if those safety devices did not activate in the collision. Rear-Impact Collision In the most common form of rear-impact collision, a stationary car is struck from the rear by a moving vehicle (Figure 1-8). Or a slower-moving car may be impacted Figure 1-7 Side airbags and air curtains pose a hazard to responders, if the devices did not activate in the collision. The sudden increase in acceleration produces posterior displacement of the occupants and possible hyperextension of the cervical spine if the headrest is not properly adjusted. If the seat back breaks and falls backward into the rear seat, there is greater chance of lumbar-spine injury. Rapid forward deceleration may also occur if the car suddenly strikes something in the front or if the driver applies the brakes suddenly. Note deformity of the auto anterior and posterior as well as interior deformity and headrest position. Shutterstock) Rollover Collision During a vehicle rollover, the body may be impacted from any direction. Emergency care providers must be alert for clues that suggest the car turned over (such as roof dents, scratches, debris, and deformity of roof posts). Lethal injuries often occur in this form of collision because of the greater likelihood of occupants being ejected. Occupants ejected from the car are three times as likely to be killed or have serious injuries. Rotational Collision A rotational mechanism is best described as what occurs when one part of the vehicle stops and the rest of the vehicle remains in motion. A rotational collision usually occurs when a vehicle is struck in the front or rear lateral area. The results are a combination of the frontal-impact and the lateral-impact mechanisms with the same possibilities of injuries of both mechanisms. Occupant Restraint Systems Restrained occupants are more likely to survive a collision, because they are protected by occupant restraint systems from much of the impact inside the auto and are unlikely to be ejected from the auto. If the lap belt is in place and the victim is subjected to a frontal deceleration crash, the body tends to fold together like a clasp knife (Figure 1-11). The compression forces that are produced when a body is suddenly folded at the waist may injure the abdomen or the lumbar spine. The three-point restraint or cross-chest lap belt (Figure 1-12) secures the body much better than a lap belt alone. The chest and pelvis are restrained, so life-threatening injuries are much less common. The head is not restrained, and therefore the neck is still subjected to stresses that may cause fractures, dislocations, or spinal-cord injuries. Clavicle fractures (at the point where the chest strap crosses) are common, as are chest-wall injuries. Air bags are designed to inflate from the center of the steering wheel and the dashboard to protect the front-seat occupants in case of a frontal deceleration crash. If functioning properly, they cushion the head and chest at the instant of impact, thus effectively decreasing injury to the face, neck, and chest. The driver whose car hits more than one object is unprotected after the initial collision. Air bags also do not prevent "down and under" movement, so drivers who are extended (tall drivers and drivers of small, low-slung autos) may still impact the dash with their legs and suffer leg, pelvis, or abdominal injuries. It is important for occupants to wear chest and lap belts even when the car is equipped with air bags. Researchers have recently shown that some drivers who appear uninjured after deceleration crashes have been later found to have serious internal injuries. A clue to possible internal injuries to the driver is the condition of the steering wheel. A deformed steering wheel is just as important a clue in an auto equipped with an air bag as in those that are not. Thus, a quick "lift and look" under the air bag should be part of the routine examination of the steering wheel (Figure 1-13). Just like frontal airbags, they only protect the driver during the initial collision. Some vehicles have air bags that come down from the roof to protect the head, and at least one make of auto has air bags under the dash to protect the legs.
The tubercles show central liquefaction necrosis and coalesce to form areas of caseating necrosis arrhythmia upon waking buy warfarin paypal. The imaging features of tuberculous infection of the spine are similar to those seen in pyogenic infections arteria zygomatico orbital best purchase for warfarin. There is disk space narrowing hypertension cardiovascular disease buy generic warfarin 1 mg line, and the vertebral end plates adjacent to the involved disk show evidence of destruction hypertension in african americans purchase 1mg warfarin with mastercard. Rarely, the infectious process may destroy a single vertebra or part of a vertebra (pedicle) without invasion of the disk. Tuberculosis of the spine may cause collapse of a partially or completely destroyed vertebra, leading to kyphosis and a gibbous formation. Extension of infection to the adjacent ligaments and soft tissues is also rather frequent; the psoas muscles are often the sites of secondary tuberculous infections, commonly called "cold" abscesses. The most common complication of tuberculous spondylitis, however, is compression of the thecal sac and spinal cord with resulting paraplegia. A: Lateral radiograph demonstrates classic changes of this abnormality: narrowing of the disk space and destruction of the vertebral end plates. Coccidioidomycosis Coccidioidomycosis often involves the vertebral appendages, and paraspinal soft tissue extension is common. Disk space narrowing secondary to spondylodiskitis and gibbous deformity, although occasionally present. Involvement of the spine most commonly manifests as vertebral osteomyelitis including punched-out and permeative lesions within the vertebral bodies. The treatment of spinal coccidioidomycosis combines medical management with antifungal medications and surgery including spinal fusion. There is swelling and high signal intensity of the anterior aspect of the intervertebral disk with mild prevertebral soft tissue edema. A: Photograph of a sagittal section of the thoracic spine shows complete destruction of two of the vertebral bodies including the intervertebral disk. The tuberculous abscess has extended anteriorly and posteriorly, causing compression of the spinal cord (arrow). B: Lateral conventional tomogram shows destruction of the disk and extensive erosions of the inferior aspect of the body of T8 and the superior end plate of T9. Lateral radiograph of the lower thoracic spine of a 12-year-old boy with long-standing pulmonary and spinal tuberculosis shows severe kyphosis with a gibbous formation at the site of a collapsed vertebra, a common complication of this condition. Anteroposterior radiograph of the pelvis in a 35-year-old woman with spinal tuberculosis shows an oval radiodense mass with spotted calcifications overlapping the medial part of the ilium and right sacroiliac joint (right psoas muscle) (arrows). A 39-year-old man with a history of pulmonary tuberculosis had neurologic symptoms of spinal cord compression. B: A myelogram shows complete obstruction of the flow of contrast in the subarachnoid space at the level of the disk infection (arrows). Positron emission tomography as a diagnostic tool in infection: present role and future possibilities. Coccidioidal synovitis: clinical, diagnostic, therapeutic, and prognostic considerations. The use of monoclonal antibodies and antibody fragments in the imaging of infectious lesions. Embolic osteomyelitis of the spine as a complication of infection of the urinary tract. Infectious granulomas of bones and joints, with special reference to coccidioidal granuloma. Tuberculous spondylitis and pyogenic spondylitis: comparative magnetic resonance imaging features. Septic arthritis with negative bacteriological findings in adult native joints: a retrospective study of 74 cases. Radiographic findings in early acquired syphilis: case report and critical review. Current understanding of the pathogenesis and management of chronic recurrent multifocal osteomyelitis. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. Risk factors for septic arthritis in patients with joint disease: a prospective study. Chronic complicated osteomyelitis of the appendicular skeleton: diagnosis with technetium-99m labelled monoclonal antigranulocyte antibody-immunoscintigraphy. Imaging of bone infection with labeled white cells: role of contemporaneous bone marrow imaging.
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