Unstable pelvic insufficiency fracture in a patient with rheumatoid arthritis

The occurrence of pelvic insufficiency fractures in patients with rheumatoid arthritis has not previously been well emphasized. These fractures are difficult to detect clinically, and appropriate radiological investigation is necessary for diagnosis. A 72-year-old woman with rheumatoid arthritis presented with severe left groin pain. Pelvic radiographs showed parasymphyseal fractures, and marked instability of these fractures was observed at the follow-up 2 weeks later. Computed tomographic scan of the sacrum showed a widened linear fracture gap in the left sacral ala. Because the patient's pain was so severe that she could not change position, external fixation was performed to achieve rapid pain relief and early mobilization. Although most patients with these fractures respond well to simple conservative treatments, parasymphyseal fractures combined with sacral fractures may cause disruption of the pelvic ring and occasionally need operative management.     

Insufficiency fractures of the pubic ramus

Seven elderly women with insufficiency fractures of the pubic ramus are described. The predisposing factors for this condition were osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. The clinical presentation included progressive inguinal pain, limping, and inability to walk. Because initial radiographs were diagnostic only in four cases, bone scintigraphy and computed tomography were necessary to confirm the diagnosis and detect additional fractures. In most patients, bed rest, non-weight-bearing ambulation, symptomatic treatment, and therapy for osteoporosis resulted in rapid improvement, and long-term follow-up showed complete or partial recovery. In one case, no recovery was achieved because of noncompliance with treatment. Insufficiency fracture of the pubic ramus should be suspected in cases of unexplained inguinal or hip-area pain and inability to walk in the elderly. The clinical suspicion should be supplemented by radiological investigation. Bone scintigraphy and computed tomography are useful means for early and accurate diagnosis. The risk factors for this condition should be identified and treated. If therapy is initiated early and pursued, this type of fracture has a benign outcome.     

Stress fractures of the pubic rami in rheumatoid arthritis.

OBJECTIVE--To draw attention to and detail the features of stress fractures of the pubic rami in patients with rheumatoid arthritis (RA). METHODS--Twenty two cases were collected prospectively over a four year period from patients undergoing active rheumatological surveillance in Leeds. Both old and new fractures were included. Information was obtained from the patients, clinical notes, and radiological investigations. RESULTS--All patients were women (mean age 68.1 years) with longstanding (mean disease duration 24.2 years) seropositive RA. Nineteen (86%) were receiving regular prednisolone treatment and all patients had radiological evidence of osteoporosis, with vertebral crush fractures in 10 (63%) of the 16 who had vertebral x ray examination. There was no biochemical evidence of osteomalacia. Nineteen (86%) presented with pain in the low back, groin, or hip and three were asymptomatic. Pain developed gradually in seven with an acute onset in the remainder. Six gave a history of a fall but only seven were x rayed at the onset of symptoms and initial radiographs were negative in five of these. In eighteen the fracture had either minimal or no effect on their mobility. Fractures affected all four pubic rami and in four all four were fractured. All but one patient (who had multiple fractures) made an uneventful recovery over two to four weeks with conservative management. CONCLUSIONS--Stress fractures of the pubic rami in RA appear to be more common than had been recognised. The low grade nature of symptoms, the minimal effect on mobility, and the absence of significant trauma are typical features and suggest that many more stress fractures may go unrecognised.     

Sacral insufficiency fractures: an often unsuspected cause of low back pain.

We describe a patient with sacral insufficiency fractures presenting as acute onset low back pain without antecedent trauma. Sacral insufficiency fractures are an often unsuspected cause of low back pain. The clinical presentation and plain radiograph findings can mimic metastatic disease, leading to unnecessary investigations and treatment. However, the location, linearity, and appearance of these fractures on computed tomography is very characteristic and obviates the need for further evaluation.     

Spontaneous multiple insufficiency fractures after pelvic abscess and sepsis in a rheumatoid arthritis patient treated with high-load corticosteroid therapy: a case report

We report the unique occurrence and treatment of spontaneous multiple insufficiency fractures after sepsis in a patient with rheumatoid arthritis (RA). The patient was a 53-year-old woman with a 13-year history of RA. Her disease activity was not influenced by a disease-modifying antirheumatic drug (DMARD) regimen that included bucillamine, d-penicillamine, gold, sulfasalazine, and methotrexate. Due to an increased disease activity, her DMARD treatment regimen was changed to leflunomide. She had also undergone corticosteroid therapy with prednisolone ranging from 10 to 15 mg daily over the previous 8 years. She first presented with a wound infection at the surgical site of resection arthroplasty on her left foot, which had caused hematogenous dissemination that led to pelvic abscess and sepsis. For the next 2 years, she experienced multiple insufficiency fractures in parts of the ilium, sacral body, sacral ala, three thoraco-lumbar vertebral bodies (T12, L1, and L2), and subcapital femoral neck without low energy trauma. Postmenopausal osteoporosis, pelvic abscess, sepsis, decreasing daily activity, high RA disease activity, and high-load corticosteroid therapy were considered to be the causes of these fractures. Nonspecific symptoms such as low back pain and fever delayed diagnosis, which may have led to secondary fractures. Although her course after treatment was satisfactory during the study period, we recommend taking repetitive radiographs to detect insufficiency fracture for RA patients with continuing pain and reducing the corticosteroid dose to prevent infection and fracture.     

Stress fractures in rheumatoid arthritis

Four cases of rheumatoid arthritis with a total of 12 undisplaced stress fractures of the lower extremities are described. Pain, swelling and disability arising from these fractures were initially mistaken for rheumatoid synovitis. Three patients had osteoporosis, and one had osteomalacia. A high index of suspicion is necessary in the diagnosis of these fractures. Radiographs and, if necessary, bone scans are indicated in rheumatoid patients presenting with spontaneous pain in the lower extremities in association with tenderness localized over the bone rather than the joint, particularly in the absence of other signs of rheumatoid activity.     

Arthrites septiques spontanées à streptocoques de la symphyse pubienne

Septic arthritis of the pubic symphysis is uncommon, and usually occurs in patients with predisposing conditions (female incontinence surgery, sports). Staphylococcus aureus and Pseudomonas aeruginosa are the main bacteria responsible of these infections. Streptococcal infections of the pubic symphysis are uncommon. We report three cases of streptococcal infections of the pubic symphysis that occurred in the absence of predisposing condition such as surgery or endocarditis. The diagnosis of septic arthritis was difficult, particularly in one patient who underwent an orchidopexy for a suspected of spermatic cord torsion before diagnosis was corrected. All three patients had a favourable outcome after an antibiotic treatment combining amoxicillin and rifampicin. Septic arthritis of the pubic symphysis should be suspected in patients with sudden groin pain, pubic tenderness and fever to avoid traumatic treatments and useless investigations.     

The relation of extraarticular tenderness to inflammatory joint disease and personality in patients with rheumatoid arthritis.

We measured the pain tenderness threshold at 16 fibrositic tender points in 44 consecutive patients with rheumatoid arthritis (RA) attending the outpatient rheumatology clinic of a university hospital. Pressure threshold measurements were transformed to z units to equalize the weights of the values at different anatomic sites and were then summed. This pain tenderness score correlated with the joint score index (p less than 0.02, r = -0.363), signifying a low pain threshold in the patients with a high joint score index. In contrast to this, the pain tenderness score was not explained by either personality factors or the generalized disease activity measuring variables (erythrocyte sedimentation rate, C-reactive protein). Our results show that the fibrositic point tenderness is real in RA, and that the tenderness is augmented near the active joints. The pain tenderness score of patients with RA is not affected by the subject's personality but may relate to sensitization of the pain fibers in arthritic joints.     

Pubic osteomyelitis in athletes]

INTRODUCTION: Pubic osteomyelitis has been described in three situations: children in whom Staphylococcus aureus is the preeminent pathogen; elderly patients who have undergone genitourinary procedures, and parenteral drug abusers. In contrast, pubic osteomyelitis in athletes has been described less often. We report three cases of acute staphylococcal pubic osteomyelitis in young athletic men and present a review of the literature. EXEGESIS: The clinical presentation in each case was acute groin, hip, or perineal pain; fever; inability to bear weight; and pubic symphysis tenderness. The diagnosis was established by blood culture and radiologic changes. CONCLUSIONS: Staphylococcus aureus pubic osteomyelitis should be suspected in athletes who have febrile hip or groin pain. The pathogenesis of this disease is thought to involve preexisting trauma or athletic injury and subsequent seeding of this area during transient bacteremia. Prolonged antimicrobial therapy is required for the cure, and debridement with curettage may be necessary if patients have persistent infection or sequestra.     

Shoulder joint involvement in patients with newly diagnosed rheumatoid arthritis. Prevalence and associations

OBJECTIVE: To estimate the prevalence of reduced function, compared to normative values, and tenderness in the shoulder in patients with newly diagnosed rheumatoid arthritis (RA), and to investigate associated factors. METHODS: Eighty consecutive patients with RA, participating in a prospective study of early rheumatoid arthritis, were examined and assessed within one year of the onset of symptoms. RESULTS: The prevalence of tenderness from any of the shoulder joints was 50%, while 30% had decreased shoulder function, compared with age matched controls, in at least one shoulder. Both tender shoulder joints and decreased shoulder function were related to higher age and more severe disease, reflected by disability (HAQ) and the patient's assessment of pain and global disease activity. CONCLUSION: The shoulder girdle is involved early and often in rheumatoid arthritis and involvement is associated with a substantially more severe disease status. The study suggests that the shoulder should be given attention in patients with newly diagnosed rheumatoid arthritis, and that both tenderness and shoulder function should be evaluated.     

Does ethanol affect the reliability of pelvic bone examination in blunt trauma?

STUDY OBJECTIVE: We sought to determine whether the reliability of clinical evaluation for pelvic bone fracture after trauma is compromised by a serum ethanol level of 100 mg/dL or greater. METHODS: This is a retrospective case control study of trauma registry patients presenting from October 1, 1995, to March 31, 1997, to an urban level I trauma center. Inclusion criteria were as follows: blunt trauma, age 13 years or older, and Glasgow Coma Scale score of 13 or greater. Exclusion criteria were as follows: isolated penetrating injury and suspected spinal injury. Patients were separated into 2 groups: those with an ethanol level of 100 mg/dL or greater, and those with an ethanol level of less than 100 mg/dL. Physician performance in clinical identification of pelvic bone fracture by using a complaint of pain, pelvic tenderness, with or without deformity, was compared between the 2 groups. RESULTS: Seven hundred sixty-three patients met inclusion criteria. Fifty-five (7. 2%) patients had a pelvic fracture, 75% of which were isolated acetabulum or pubic ramus fractures. Two hundred six control patients without pelvic fractures were randomly selected. The sensitivity and specificity of the complaint of pain and tenderness, deformity, or both for identification of a pelvic fracture was not significantly different between the ethanol groups. Five (9%) of 55 patients with pelvic fractures had neither a complaint of pain nor bony tenderness or deformity on examination. This was not statistically associated with an ethanol level of 100 mg/dL or greater (P =1.000). CONCLUSION: In our study, clinical evaluation for pelvic fracture in trauma patients with a Glasgow Coma Scale score of 13 or greater was not compromised by an ethanol level of 100 mg/dL or greater. The most common reason for clinically missed pelvic fractures was the presence of additional painful distracting injuries.     

Rheumatoid arthritis in the elderly, presenting as polymyalgia rheumatica.

Two elderly patients presented with generalized aches and pains (particularly in the shoulders and the pelvic girdle), stiffness, fatigue, anemia, and an elevated erythrocyte sedimentation rate, but there were no signs or symptoms directly referable to the joints. Two and five months later respectively, pain, swelling, and signs of synovitis appeared in several joints in a symmetrical pattern, and a diagnosis of rheumatoid arthritis was made. Rheumatoid arthritis in the elderly may resemble polymyalgia rheumatica. On the other hand, synovitis in many patients with polymyalgia rheumatica may resemble rheumatoid arthritis. In the elderly, the differentiation of these two entities may be difficult. Moreover, patients initially presenting with the signs and symptoms of polymyalgia may eventually manifest typical rheumatoid arthritis.     

A tumor endoprosthesis is useful in elderly rheumatoid arthritis patient with acute intercondylar fracture of the distal femur

The purpose of this paper is to report the use of total knee arthroplasty using a tumor prosthesis in the treatment of elderly patients with an intercondylar fracture of the distal femur. Supracondylar fractures of the femur in patients with rheumatoid arthritis are difficult to treat due to joint deformity. We present outcomes for treating intercondylar fractures of the distal femur in rheumatoid arthritis patient using a tumor endoprosthesis. This technique allows early mobilization of the patient, with restoration of a good range of knee motion. A tumor prosthesis appears to be a viable treatment option for intercondylar femoral fractures in elderly patients. It is well tolerated and permits early ambulation and return to activities of daily living.     

Inflammatory spinal disease in psoriatic arthritis: a report from the GRAPPA 2010 annual meeting

Diagnosing axial disease in patients with psoriatic arthritis (PsA) has been largely dependent on identifying inflammatory back pain (IBP), which itself has been difficult to define. We review the criteria used to identify IBP in patients with ankylosing spondylitis (AS) and other forms of spondyloarthritis. Recently, the Ankylosing SpondyloArthritis International Society (ASAS) developed a list of clinical and radiographic criteria for identifying IBP in patients with AS. However, it is more difficult to identify IBP in patients with PsA because generally they have less pain than patients with rheumatoid arthritis or AS. Further, PsA patients may have clinical symptoms of pain but negative radiographs. It may be more useful to identify sacroiliitis or syndesmophytes by magnetic resonance imaging (MRI), since MRI identifies lesions in the sacroiliac joints and the spine much earlier than can be detected on radiographs. In summary, all patients with PsA should be assessed for axial involvement with history, physical examination, and imaging. Patients with psoriasis whose history includes onset of back pain before age 40 years, the presence of night pain, and improvement with exercise but not with rest, or who have limited neck or back mobility, should be referred to a rheumatologist.     

Rheumatic manifestations of infective endocarditis

Summary Rheumatic manifestations are common and varied in infective endocarditis. We performed a retrospecitive case analysis on 87 patients with 93 episodes of infective endocarditis admitted to Flinders Medical Centre over an 11 year period (1980–1990). Disabling musculoskeletal symptoms and signs were documented in 22 (25%) of the patients. Thirteen patients developed severe or moderately severe low back pain during their illness, two with radiological evidence of a septic discitis or vertebral osteomyelitis. Two patients developed polyarthralgia/arthritis, four had septic arthritis (all with acute Staphylococcus aureus endocarditis), three developed severe loin pain, two acute gout, two had severe buttock pain and sacroiliac joint tenderness and two each developed disabling jaw/facial pain, neck/scapular pain and flank pain respectively. Five patients presented initially to the orthopaedic or rheumatological unit for management of their musculoskeletal symptoms. Four of seven patients with Streptococcus bovis endocarditis demonstrated prominent low back pain supporting a previously noted association between this organism and back symptoms. Furthermore, in one patient who had three separate episodes of endocarditis involving three different organisms, florid back symptoms were only seen in the infective episode involving Streptococcus bovis.     

Elderly onset rheumatoid arthritis complicated by polymyalgia rheumatica

We report herein the case of a 70-year-old patient with elderly onset rheumatoid arthritis associated with severe muscle pain in shoulder and pelvic girdle. The patient revealed erosive polyarthritis with high titers of rheumatoid factor. Muscle pain started one month after the onset of rheumatoid arthritis followed by muscle weakness and muscle atrophy. Synovial effusion and edema in the soft tissue outside of the articular capsule in the knee joint were confirmed ultrasonographically. Administration of prednisolone at 20 mg/day dramatically abolished the muscular manifestations. The coexistence of an early stage of elderly onset rheumatoid arthritis and polymyalgia rheumatica was considered due to the presence of seropositive erosive arthritis and severe muscle manifestations at the same time.     

Surgical treatment of the rheumatoid cervical spine in patients aged 70 years or older

OBJECTIVE: To investigate whether surgery is appropriate for elderly rheumatoid arthritis patients who are already approaching their statistical life expectancy. PATIENTS AND METHODS: The subjects were 10 patients who underwent cervical spine surgery for rheumatoid arthritis at an age of over 70 yr. The pain grade and neurological deficit class according to Ranawat, peri-operative complications, causes of death and pre-operative cardiopulmonary function were assessed. RESULTS: Good pain relief was achieved. Relief of pain enabled the patients, who could not sit up even in bed because of intolerable neck pain, to ride in a wheel chair without using a neck collar. Only one death was related to surgery. Pre-operative cardiopulmonary function was not significantly different compared with that of elderly patients undergoing other surgical procedures. CONCLUSION: Surgery is a valuable option for the management of elderly patients with rheumatoid cervical spine since it can improve the quality of life.     

The lateral metacarpophalangeal/metatarsophalangeal squeeze: an alternative assignment criterion for rheumatoid arthritis

We have proposed an alternate assignment criterion for rheumatoid arthritis (RA), pain on squeezing the MCP or MTP joints. The performance of this criterion has been evaluated in 90 patients with RA and in 122 patients with other rheumatological disorders (non-RA). The proportions of patients with various numbers of sites positive (from 0 to 4) were assessed according to diagnosis; most patients with RA had at least one site positive, in comparison to non-RA where most patients had no sites positive. The diagnostic performance of 2+ or 3+ sites was similar, but 3+ is probably preferable because this simultaneously indicated both symmetry and hand and foot involvement. In conclusion, the lateral MCP/MTP squeeze performs well in comparison to many other existing clinical criteria for RA and could substitute for non-independent features (e.g. swelling and arthritis). It is easier to elicit than searching for pain and/or tenderness as fewer sites have to be examined and inter-observer variation was less than with many other clinical criteria.     

The assessment of pain in rheumatoid arthritis: disease differentiation and temporal stability of a behavioral observation method

An observation method for the assessment of pain behaviors in patients with rheumatoid arthritis (RA) has been developed. We investigated the extent to which the frequencies of pain behaviors differentiated patients with RA and patients with chronic low back pain from depressed and nondepressed, pain free, control subjects. The reliability of the pain behavior frequencies of patients with RA across 2 observation sessions also was determined. Total pain behavior scores clearly differentiated patients with RA and low back pain from depressed and nondepressed, pain free, control subjects. Pain behavior observed in patients with RA showed a high degree of stability over time. The results of our study suggest that the behavioral observation method will prove useful in the assessment of RA pain in clinical and research settings.     

Prevalence of dermatophytosis in patients with rheumatoid arthritis

OBJECTIVE: The prevalence of dermatophytic infections in rheumatoid arthritis is unknown. This study investigated the prevalence of dermatophytosis in patients with rheumatoid arthritis and the relationship between sulfasalazine, low-dose methotrexate and steroid therapy. METHODS: We examined 53 consecutive patients with rheumatoid arthritis for evidence of dermatophytosis and compared them 55 with age- and sex-matched, nonimmunocompromised controls recruited from the low back pain population. Nail scrapings were obtained from the subjects, and the clinical diagnosis of dermatophytosis was confirmed with a potassium hydroxide preparation. RESULTS: In 32% of the rheumatoid arthritis population we found dermatophytosis, compared with 16% of the control group, although statistical significant was only borderline. Tinea pedis was the most frequent type of dermatophytosis in both groups. The prevalence of dermatophytosis in patients receiving sulfasalazine, low-dose methotrexate, and steroid therapy was not found to be significantly increased. CONCLUSIONS: This study shows a slightly higher prevalence of dermatophytosis in rheumatoid arthritis population than in controls. Sulfasalazine, low-dose methotrexate, and steroid therapy had no effect on the prevalence of dermatophytic infections in patients with rheumatoid arthritis.