Limits and perspectives of ultrasound in the diagnosis and management of rheumatic diseases

Musculoskeletal sonography (MSUS) has played a growing role in the diagnosis and management of rheumatic diseases, enabling the imaging of synovitis, bone erosion, and cartilage damage in the early phase of arthritis. “Dynamic” evaluation of tendons and help in guiding needle positioning in interventional manoeuvres are some of the other reasons for its success. MSUS, particularly when coupled with power Doppler (PD) examination, has recently been shown to be an efficient tool for monitoring disease activity and progression in rheumatoid arthritis, spondyloarthritis, crystal-related arthropathy, and osteoarthritis, with general consensus on its interesting results. More specifically, the PD signal has proved to be a simple and promising tool for short-term monitoring of synovial vascularity changes induced by steroids or biological agents in RA patients. MSUS has some limits, because of the physical properties of US and the quality of the equipment; it is, moreover, an operator-related imaging technique, with few standardized protocols. Future goals should be standardization of the examining approach in grey scale and Doppler ultrasound (US), including use of new equipment (3D US), extensive use in other fields (i.e. connective tissue diseases and vasculitis), and possible new applications (e.g. thoracic US).     

浮针疗法对腕部腱鞘炎患者的疼痛治疗

浮针疗法是进针点选择在病痛局部周围,针体行进在皮下,针尖指向病灶,主要治疗局限性痛症的一种新型针刺治疗方法。本文运用该法治疗３７例腕部腱鞘炎,并与常规体针法进行比较,结果表明浮针疗法首次针刺镇痛效应显著好于常规针法,显效病例所需治疗次数少于常规疗法。表明浮针疗法有肯定,迅速的镇前作用。     

桡骨茎突狭窄性腱鞘炎的治疗进展

桡骨茎突狭窄性腱鞘炎,是一种常见的慢性运动系统损伤疾病,多引起关节处疼痛并伴活动时加重,对人们的日常生活造成影响。目前针对此病的治疗方法较多且各有疗效,可以分为保守治疗和手术治疗两种。本病的治疗难点在于根治,保守治疗常常能在急性期缓解疼痛,改善腕部功能,但其远期作用甚微,容易复发。手术治疗能够提高本病的治愈率,但作为有创治疗,存在一系列风险,当遇到顽固性桡骨茎突狭窄性腱鞘炎时才建议选用。笔者认为,患者教育为治疗中重要一环,并且对本病进行分级,根据疾病发展的不同情况合理选用多种手法综合治疗本病,能够有效治愈本病。     

Does Radial Styloid Abnormality in de Quervain’s Disease Affect the Outcome of Management?

Radiological changes have been described in de Quervain’s disease of the wrist. The author analyzed the clinical data of 114 patients who reported to the orthopedic clinic of a Regional Referral Hospital for a period of 4 years [2003 to 2007]. Radiographs of the wrist were available for 39 cases, of which 14 [35.89%] were found abnormal. Two patients with abnormal radiographs [14.28%] required surgery where as 7 out of 25 [28%] with normal radiographs were managed surgically. Radial styloid abnormality was not found statistically significant [p < 0.05], and the outcome of management was irrespective of the changes in the radial styloid.     

雌激素水平与绝经后妇女腱鞘炎的相关性研究

目的 探讨雌激素水平与绝经后妇女腱鞘炎的关系.方法 选取74例绝经妇女,其中32例为腱鞘炎患者(A组),42例同期健康体检的绝经妇女为对照组(B组);42例正常行经的健康体检妇女为正常对照组(C组).均进行雌激素水平测定,并进行相关性分析.结果 A组与B组之间,雌激素(E2)水平分别为(89.7066±126.7458)pmol/L和(45.6768±30.6342)pmol/L,差异无统计学意义(P>0.05);A组与C组雌激素水平分别为(89.7066±126.7458)pmol/L和(626.7384±361.5348)pmol/L,差异有统计学意义(P<0.01).结论 绝经后妇女腱鞘炎发病与雌激素水平变化无明显关系.     

Effectiveness of Interventions of Specific Complaints of the Arm, Neck, and/or Shoulder: 3 Musculoskeletal Disorders of the Hand. An Update

Huisstede BM, van Middelkoop M, Randsdorp MS, Glerum S, Koes BW. Effectiveness of interventions of specific complaints of the arm, neck, and/or shoulder: 3 musculoskeletal disorders of the hand. An update.

Objectives

To provide an evidence-based overview of the effectiveness of conservative and surgical interventions for trigger finger, Dupuytren's, and De Quervain's diseases.

Data Sources

The Cochrane Library, PEDro, PubMed, Embase, and CINAHL were searched to identify relevant studies.

Study Selection

Two reviewers independently applied the inclusion criteria to select potential relevant studies from the title and abstracts of the references retrieved by the literature search. Relevant (Cochrane) reviews and randomized controlled trials (RCTs) were included.

Data Extraction

Two reviewers independently extracted the data and performed a methodologic quality assessment.

Data Synthesis

A best-evidence synthesis was performed to summarize the results of the included trials. One Cochrane review (trigger finger) and 13 RCTs (trigger finger [6], Dupuytren's [4], De Quervain's [3]) were included. The trials reported on physiotherapy (De Quervain's), steroid injections (trigger finger, De Quervain's), surgical treatment (trigger finger, De Quervain's), and a postsurgical treatment (Dupuytren's). For trigger finger, moderate evidence was found for the effectiveness of steroid injections in the short-term (1-4wk) but not for long-term outcomes. Limited evidence was found for the effectiveness of staples compared with sutures in skin closure and for intermittent compression after surgery to treat Dupuytren's disease. For other interventions, no evidence was found.

Conclusions

Indications for effectiveness of some interventions for trigger finger, Dupuytren's, and De Quervain's diseases were found. Because only a few RCTs were identified, it is difficult to draw firm conclusions. High-quality RCTs are clearly needed in this field.     

US guided injections in arthritis

US guided procedures for diagnosis or treatment of different forms of arthritis are becoming more and more important. This review describes general considerations for fluid aspiration, articular or periarticular injections and biopsies by US guidance according to the recent literature. Guidelines regarding instrumentation, different techniques, pre- and postprocedural care as well as complications are outlined and in the second part a more detailed overview of different interventions in joints, tendons and other periarticular regions (nerves, bursae, etc.) is included. Furthermore, some newer, more sophisticated techniques are briefly discussed.     

Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE) syndrome in an elderly Spanish patient: Ruling-out polymyalgia rheumatica and management

BackgroundThe Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE) syndrome is a rare rheumatological disorder of the elderly with pitting edema and tenosynovitis of the hands as notable features.Aim of the workThis case report presents an elderly male patient with RS3PE without arthritis after ruling out polymylagia rheumatica (PMR) or any associated malignancy.Case presentationA 73-year-old white man presented to the Hospital of Navarra, Spain with pain and weakness in both upper extremities, predominantly in wrists, associated with symmetrical swelling of dorsum of both hands of two months duration. The patient was febrile (37.5 °C) had pitting edema in both hands, with no signs of arthritis, associated with shoulder girdle muscles weakness without pelvic involvement. The lower limbs and feet were not involved. The differential diagnosis of PMR was raised adding to the clinical diagnostic dilemma. Erythrocyte sedimentation rate was 66 mm/1st hour and C-reactive protein 126.4 mg/L. Extended diagnostic work showed negative autoimmune biomarkers with normal complement. No joint erosion was found on plain x-ray radiography of the affected joints. Thoracic and abdominal CT scan was performed with no evidence of a neoplastic disease. The patient was finally diagnosed with RS3PE showing a rapid response to low doses of prednisone (20 mg/day) and without any further flares on follow up.ConclusionRS3PE could be diagnosed even without polyarthritis and successfully treated by low dose steroids after excluding any related malignancy. Excluding PMR is important to avoid exposing the patient to unwanted higher steroid doses.     

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.     

de Quervain’s tenosynovitis: a review of the rehabilitative options

de Quervain’s tenosynovitis is an overuse disease that involves a thickening of the extensor retinaculum, which covers the first dorsal compartment. A case study approach was utilized in this article to demonstrate many of the available medical and occupational therapy modalities to treat this condition. A 34-year-old right hand-dominant female who works in a daycare facility presents with radial side wrist pain during lifting activity for the past 4–6 weeks. The patient was diagnosed with de Quervain’s tenosynovitis and conservative care was initiated. Conservative care involved anti-inflammatory medication and corticosteroid injections as well as occupational therapy to include splinting, activity modification, modalities, manual treatment, and therapeutic exercise. Although conservative care assisted the patient with her symptoms initially, she returned with increased pain and discomfort after 2 months time. At that point, surgery was discussed and performed to release the first dorsal compartment as well as the sub-compartment. The patient was provided with a splint postoperatively and initiated occupational therapy for edema and scar management, therapeutic exercise, and desensitization. Ultimately, the patient was able to return to work pain free.