Antirheumatic Drugs
Drugs used to treat rheumatoid arthritis
The Hip
The intraarticular injection of the hip is difficult and should not be done in routine practice. In contrast, infiltration of the major trochanter in case of periarthritis of the hip is easy and gives good results.
Periartritis of the Hip
Technique: The patient is laying in lateral decubitus on the nonpainful
side. It's easy to palpate the upper board of the major trochanter.
The needle is inserted perpendicular to the skin, until a depth where
there is no longer resistance. Material: Needle 0.90 x 50 mm. A longer needle is necessary in obese
women.
Product: Methylprednisolone, triamcinolone, or paramethasone;
sometimes an anesthetic can be useful. Dosage: 1-2 ml.
The Knee
Intraarticular Knee
With Intraarticular Hydrops.
Technique: There are several approaches, but the high lateral external way on the external side of the bursa suprapatellaris is the simplest and the least painful. The patient is laying in dorsal decubitus with the leg in extension. First localize the bursa suprapatellaris. One can move this bursa by giving a pressure on the internal part of it. The needle is inserted horizontally. As soon as one feels resistance, in particular when synovial fluid is present in the syringe after Read more [...]
Radiocarpal Joint.
Technique: The injection of the wrist is performed via the dorsal approach. The patient sits down with the palm of the hand laying in extension on the couch. The processus styloideus is localized as well as the joint space. The needle is placed perpendicularly on the skin and inserted one finger width medially from the top of the processus styloideus at the radiocarpal joint space.
Material: Needle 0.55 x 25 mm. Anesthesia is not necessary.
Product: Methylprednisolone, triamcinolone, paramethasone.
Dosage: 0.50-1 ml.
Trapezometacarpal Joint.
Technique: Hand in pronation; the joint approached from the posterior way. The basis of the first metacarpal is localized just under the anatomic snuff box. The needle is inserted perpendicularly to the bone. Trapezometacarpal osteoarthritis, osteophytes, subluxa-tions, or chondrolysis may make the intraarticular injection difficult and painful. Experience has taught that juxtaarticular injections often give satisfactory results. Therefore it is not necessary to take an intraarticular approach when difficulties may arise.
Material: Needle 0.50 X 16 mm.
Product: Methylprednisolone, triamcinolone, paramethasone.
Dosage: 0.30-0.50 ml.
Carpal Tunnel.
Technique: Read more [...]
Depending on the pathology, the injection will be intraarticular or — and this is most often the case — periarticular.
Intraarticular Elbow
There are two approaches.
Port of Entry Under the Olecranon or Posterior.
Technique: The patient sits down with the elbow in flexion and supported by, say, the back of a chair. The top of the epicondylus is localized and a prick perpendicular in the direction of the upper point of the olecranon is given, followed by an inclined move inward and backward. The presence of intraarticular fluid will facilitate this technique.
Material: Needle 0.80 x 40 mm. Local anesthesia is not necessary.
Product: Methylprednisolone, triamcinolone, paramethasone.
Amount: 1 ml.
Radio humeral or External Approach.
Technique: When intraarticular fluid is present, which is often the case in rheumatoid arthritis patients, the fluid will accumulate around the radial head. The joint is then easily approachable. The patient places his elbow in a right angle (90°) on the couch. The needle is inserted perpendicularly under the epicondylus in the direction of the radial head.
Material: Needle 0.80 x 40 mm or 0.55 x 25 mm. Local anesthesia is not necessary.
Product: Methylprednisolone, triamcinolone, Read more [...]
Infiltration in the shoulder can be given intra- or periarticularly based on the pathologic finding.
Intraarticular Shoulder
Scapulohumeral Joint
The anterior approach is more easy than the posterior one and therefore should be preferred.
Intra- and Periarticular Injection Techniques
Technique: The patient sits with the shoulder in external rotation. The punction site is located on the crossing of the line which runs a finger width under the clavicula and a finger width medial of the external board of the acromion. The needle should be brought into the joint space perpendicularly.
Material: Needle 0.55 x 25 mm or 0.80 x 40 mm.
For punction: 0.90 x 50".
Local anesthesia is not necessary.
Product: Methylprednisolone, triamcinolone, paramethasone.
Amount: 1 ml.
Acromioclavicular Joint.
Technique: This joint is easy of access. The patient sits with the shoulder in external rotation. One marks with the finger the prominence at the external end of the clavicula. The needle is inserted perpendicularly just beside this prominence.
Material: Needle 0.55 x 25 mm.
Sometimes local anesthesia is necessary because the injection of corti-costeroids can be painful. It is therefore better to use an association of corticosteroids Read more [...]
The local intra- and periarticular administration of corticosteroids is an attractive treatment of rheumatic diseases. A quick and maximal effectiveness is to be expected with a minimum of systemic effects. The side effects remain limited on the conditions that the indication for administration was correct and that the technique and aseptic conditions are perfect, and that the number of injections is kept to a minimum.
This therapeutic approach, developed by Hollander in the early 1950s, remains a half century later an important adjunctive treatment for rheumatic diseases. Rheumatoid arthritis and related conditions, osteoarthritis in an active phase, and periarticular rheumatic diseases are the most prominent indications for this kind of management.
The corticosteroid preparations used are suspensions of methylpred-nisolone, triamcinolone, or paramethasone. Rarely the combination suspensions and solutions are indicated. This is also true for the association of corticosteroids and anesthetics. The local tolerance of the products is excellent. In very rare cases, a microcrystal arthropathy and pain can immediately follow injection.
Joint destruction has been reported after local injection because hypo-algesia induced Read more [...]
Definition
Ehlers-Danlos syndrome is a heritable disorder of connective tissue (HDCT) characterized by a triad of articular hypermobility, skin hyperex-tensibility, and cutaneous scarring. It is a heterogeneous condition.
Main Clinical Features
Early Manifestations
The skin is thin and splits easily leaving ugly gaping pigmented, papyraceous scars, especially over the knees and scalp. Joint laxity can lead to recurrent dislocations and instability, commonly with effusions.
Late Manifestations
Rupture of major arteries occurs (only) in Ehlers-Danlos syndrome type IV. A tendency to bleeding is seen. Osteoarthritis occurs frequently in unstable joints.
Confirming the Diagnosis — Investigations
Early Phase
This is based on the positive family history and the clinical features.
Late Phase
In Ehlers-Danlos syndrome type IV there is a deficiency of collagen type III.
Diagnostic Difficulties
Difficulties may arise in distinguishing Ehlers-Danlos syndrome from other heritable disorders of connective tissue that share common features, e.g., benign joint hypermobility syndrome, osteogenesis imperfecta, Marfan's syndrome.
Epidemiology and Historical Data
Types I (gravis), II (mitis), and III (hypermobile) are Read more [...]
Definition
Osteogenesis imperfecta is a common disorder of bone fragility associated with blue sclerae.
Main Clinical Features
Early Manifestations
In severe cases death may occur in utero from multiple fractures. In less severe cases fractures are less frequent, but severe deformities may result in short stature.
Late Manifestations
Other features may include blue sclerae and deafness.
Confirming the Diagnosis
Early Phase
The finding of a positive family history, blue sclerae, and recurrent fractures will point to the correct diagnosis.
Late Phase
In some cases the disease becomes clinically apparent with the onset of osteoporosis in middle age.
Diagnostic Difficulties
The differential diagnosis is between osteogenesis imperfecta and nonacci-dental injury, with which it can be confused.
Epidemiology and Historical Data
Osteogenesis imperfecta is seen in all ethnic groups. Evidence suggests that it dates back to antiquity.
Pathophysiology
The disease has a mainly dominant role of inheritance. Recessive forms are rare. It is in effect a congenital form of osteoporosis, due in most cases to a mutation(s) in collagen I genes (COL1A1; COL1A2).
Management
Fractures are treated by conventional Read more [...]
Definition
Marfan's syndrome is a heritable disorder of connective tissue characterized by long slender extremities, dislocation of the ocular lens (ectopia lentis), and aortic dilatation and/or aneurysm formation.
Main Clinical Features
Early Manifestations
Tall stature, long slender arms and legs, spidery fingers (arachnodactily), scoliosis, joint laxity, pes planus, hallux valgus, ectopic lentis may be apparent in infancy or early childhood.
Late Manifestations
During the adolescent growth spurt the abnormalities in body shape (marfa-noid habitus) become more pronounced, especially tall height, scoliosis, and thoracic cage deformities (pectus excavatum and carinatum). Aortic aneurysm may occur in adult life, which may result in fatal rupture. Mitral valve prolapse can also occur.
Confirming the Diagnosis — Investigations
Diagnosis remains based solely on clinical features and the autosomal dominant inheritance pattern.
The marfanoid habitus is confirmed by
1. Span:height ratio > 1.03
2. Upper segment:lower segment ratio 11 %
4. Foot:height ratio > 15%
5. Arachnodactily
6. Scoliosis
7. Pectum excavatum/carinatum
8. Ectopia lentis
Aortic root dilatation can be recognized by serial echocardiography.
Diagnostic Read more [...]
May 17th, 2012 by admin
Benign joint hypermobility syndrome should not be confused with Marfans or Ehlers-Danlos syndrome
Diagnostic Difficulties
The principal bar to diagnosis is (1) lack of awareness of the condition and (2) failure to look for evidence of hypermobility as part of the examination of the musculoskeletal system. This results in
1. Misdiagnosis — usually in favor of rheumatoid/juvenile chronic arthritis or of psychoneurosis
2. The inappropriate use of useless and potentially harmful drug therapy
3. Unnecessary suffering, frustration, and loss of faith in orthodox medicine
Specialist expert advice may be needed in distinguishing benign joint hypermobility syndrome from other heritable disorders of connective tissue (see next section).
Benign joint hypermobility syndrome should not be confused with Marfans or Ehlers-Danlos syndrome.
Epidemiology and Historical Data
Hypermobility has been identified in population surveys in all parts of the world, with the prevalence varying from 5% to 20% depending on age, gender, and ethnic background. There is general agreement that it is most prevalent in people of Indian origin, followed by those of African origin, followed by Europeans. Women are more hypermobile than men. There are few data on the epidemiology of the hypermobility syndrome (as opposed to hypermobility itself). Read more [...]
Hereditary Connective Tissue Disorders
The molecular composition and organization of connective tissue are extraordinary complex. Much remains unknown about the genes — their number, structure, chromosomal location, and regulation — that control synthesis, organization, and metabolism of this tissue.
Definition
Hypermobility is a common, benign, heritable disorder of connective tissue (HDCT), characterized by joint laxity, tissue fragility, and a predisposition to the effects of trauma, overuse, and mechanical failure. It is an overlap syndrome, which encompasses many of the features encountered in the "classical" heritable disorders of connective tissue such as the Marfan and Ehlers-Danlos syndromes and osteogenesis imperfecta, but in a much more benign form. There are no life-threatening complications. It is therefore generally referred to as the benign joint hypermobility syndrome (BJHS).
Heritable disorder of connective tissue characterized by joint laxity, tissue fragility, and mechanical failure. Arthralgias due to tendonitis, capsulitis, recurrent dislocations. Active teenagers and young adults. Benign prognosis — adaptation of life style.
Main Clinical Features
Early Manifestations
Joint laxity Read more [...]