Ancyclostoma Brazillienses Force Out Of The Skin

Metatarsocuneiform JointMetatarsocuneiform Exostosis

Figure 20-69 A, Exostosis at the metatarsocuneiform joint. B, X-ray film of the affected metatarsocuneiform joint.

Figure 20-69 A, Exostosis at the metatarsocuneiform joint. B, X-ray film of the affected metatarsocuneiform joint.

Approximately 30% of patients with diabetes mellitus have disease-related dermatologic problems. Neurotrophic foot ulcers are very common in diabetic patients. Figure 20-72 shows bilateral neurotrophic ulcers. Painless plantar ulcers heal slowly after apparently insignificant trauma. The ''diabetic foot'' is characterized by chronic sensorimotor neuropathy, autonomic neuropathy, and poor peripheral circulation. The sensorimotor neuropathy results in a loss of normal sensation, which prevents the detection of traumatic events. See also Figure 15-14, which depicts diabetic dry gangrene of the big and fourth toes;Figure 15-15, which depicts a patient with the classic lesion of necrobiosis lipoidica diabeticorum;and Figure 15-16, which is a close-up photograph of the same skin lesion in another patient. It is common for diabetic patients, owing to the decreased sensitivity in their feet, to present with foreign bodies in their toes or feet. Figure 20-73 shows a foreign body protruding from the tip of the right third toe of a diabetic patient. This patient had dropped a needle on the carpet and later stepped on the needle, which penetrated the toe. Only after noticing it visually did the patient seek medical attention.

Bullosis diabeticorum (Fig. 20-74) is a relatively uncommon, noninflammatory, blistering condition of unknown origin that occurs in patients with long-standing diabetes. The tense bullae develop on normal-appearing skin in acral areas (feet, lower legs, hands). It has been associated with insulin-dependent diabetes mellitus, as well as non-insulin-dependent (type 2) diabetes. Intraepidermal and subepidermal blisters occur spontaneously, usually without trauma, and heal within 2 to 6 weeks. Treatment consists of aspiration of the bullae and topical antibiotics.

Figure 20-71 Squamous cell carcinoma on the plantar surface.

Bacterial and fungal infections are common in diabetic patients. Figure 20-75 depicts bacterial cellulitis and tinea pedis in a diabetic patient. Tinea pedis produces macerated, scaling, fissured toe webs;inflammatory epidermis;and thick, hypertrophic, discolored nails. Necrotizing fasciitis is a very severe form of cellulitis that can develop in diabetic patients. It involves the deep fascial structures underlying the skin and is caused by a mixture of aerobic and anaerobic gram-negative organisms. Figure 20-76 shows necrotizing fasciitis. Notice the sharply demarcated painful area of the infection. Surgical debridement and broad-spectrum antibiotics are necessary to treat the infection.

Scleroderma, or progressive systemic sclerosis, is a chronic multisystem disease manifested by thickening of the skin and varying degrees of organ involvement. There is a broad spectrum of disease manifestations of scleroderma, ranging from limited skin lesions associated with calcinosis, Raynaud's phenomenon, esophageal motility problems, sclerodactyly, and telangiectasia (CREST variant) to full encasement of the body by diffuse sclerosis. Calcification of the soft tissues can produce a stony-hard tissue and can range from a small area of involvement to

Neurotrophic Joint Xray FootCalcinosis Pics ToesCalcium Deposit Baby FootDiabetic Septic Ankle

massive calcium deposits. Figure 20-77A shows Raynaud's phenomenon and calcinosis cutis in a patient with the CREST syndrome. Note the telangiectases of the fingertips. Figure 20-77B shows calcinosis cutis of the heel in the same patient. Commonly, the distal finger pad assumes a tapered appearance, with a tuft of scarred tissue between the fingertip and the nail bed. Ulceration can also occur, which can lead to osteomyelitis. Figure 20-78 shows the plantar view of the hallux in the same patient with CREST syndrome; note the characteristic tapering of the digit and pterygium inversus (growth of soft tissue along the ventral aspect of the nail plate).

Figure 20-79 shows a subungual presentation of malignant melanoma of the hallux. Determine the cause of all subungual pigmented lesions. Unusual pigmentation under the nail, especially if of long duration, should always be regarded with suspicion. Subungual melanomas represent approximately 20% of melanomas in dark-skinned and Asian populations, in comparison with about 2% of cutaneous melanomas in white populations. Ultraviolet radiation exposure seems to be an important risk factor for cutaneous melanoma; however, because ultraviolet radiation is unlikely to penetrate the nail plate, it does not appear to be a risk factor for subungual melanomas. There is a considerable predominance of subungual melanoma localized on the thumb (58% of all affected fingers) and the hallux (86% of all affected toes).

Digital Sclerosis
Figure 20-77 Calcinosis, Raynaud's phenomenon, esophageal motility problems, sclerodactyly, and telangiectasia (CREST) syndrome. A, Telangiectases of the fingertips. B, Calcinosis cutis of the heel.
Pterygium Inversus Unguium

Cutaneous larva migrans is caused by animal hookworms, commonly the dog parasites Ancylostoma braziliense or Ancylostoma caninum. The creeping eruption occurs when the skin comes in direct and prolonged contact with the hookworm larva contained in the feces of dogs, cats, or humans. Moist areas visited by the infected animals, such as beaches or exposed soil covered by porches, are common sites for acquiring infection. The clinical appearance is that of a raised, serpiginous, erythematous, pruritic eruption, and it represents the paths of migration within the epidermis. Because the organism lacks collagenase and cannot disrupt the basement membrane, the parasite is unable to invade the dermis. The lesions migrate about 1 to 2 cm per day and may evolve into bullae. Topical application of thiabendazole is the treatment, although the infection is usually self-limited. Figure 20-80 shows the sole of a foot of an infected 31-year-old man after a beach vacation in Jamaica.

Pain in the heel and pain in the first metatarsophalangeal joints are common complaints, most often caused by mechanical factors. Plantar fasciitis is an inflammation caused by excessive stretching of the plantar fascia. The plantar fascia is a broad band of fibrous tissue that runs along the bottom surface of the foot, attaching at the bottom of the calcaneus and extending to the forefoot. When the plantar fascia is excessively stretched, plantar fasciitis can occur, leading to heel pain, arch pain, and heel spurs. Tight calf muscles or a tight Achilles tendon may cause the foot to flatten, which can lead to a painful ''bowstringing'' of the fascia. The most common causes of excessive stretching of the plantar fascia are as follows:

• Overpronation (flatfoot), which results in the arch's collapsing with weight bearing A foot with an unusually high arch

• A sudden increase in physical activity

• Excessive weight on the foot, usually attributed to obesity or pregnancy

• Improperly fitting footwear

Figure 20-80 Cutaneous larva migrans. A, Sole of foot. B, Close-up photograph of lesion.

Figure 20-80 Cutaneous larva migrans. A, Sole of foot. B, Close-up photograph of lesion.

Overpronation is the leading cause of plantar fasciitis. Overpronation occurs in the walking process, when a person's arch collapses with weight bearing, causing the plantar fascia to be stretched away from the calcaneus. With plantar fasciitis, the patient experiences pain on the inside of the foot where the heel and arch meet. The pain is often acute upon arising in the morning or after a long rest, because while resting, the plantar fascia contracts back to its original shape. As the day progresses and the plantar fascia continues to be stretched, the pain often subsides. However, heel pain can be secondary to several other causes. Table 20-3 lists the most common disorders associated with heel pain.

Table 20-4 lists disorders associated with first metatarsophalangeal joint pain. Sesamoiditis is a common ailment that affects the forefoot, typically in young people who engage in physical activity such as dancing or jogging. This is a common problem among ballet dancers and people who play the position of catcher in baseball. Any activity that places constant force on the ball of the foot—even walking—can cause sesamoiditis. Its most common symptom is pain in the ball of the foot, especially on the medial or inner side. Sesamoiditis is a general description for any irritation of the sesamoid bones, which are tiny bones within the tendons that run to the big toe. The sesamoids function as a pulley, increasing the leverage of the tendons controlling the toe. With walking and pushing off against the toe, the sesamoids

Table 20-3 Disorders Causing Heel Pain

Plantar calcaneal spur (enthesopathy)

Plantar fasciitis

Inferior calcaneal bursitis

Atrophy of plantar fat pad

Rheumatoid arthritis

Ankylosing spondylitis

Reiter's syndrome

Gout

Fracture

Neoplasm

Foreign body

Nerve entrapment

Table 20-4 Disorders Causing Pain in the First Metatarsophalangeal Joint

Osteoarthritis

Bursitis/capsulitis

Fracture

Sesamoiditis

Gout

Rheumatoid arthritis Reiter's syndrome Septic arthritis are involved;eventually they can become irritated and even fractured. Because the bones are actually within the tendons, sesamoiditis is a form of tendinitis. Sesamoiditis typically can be distinguished from other forefoot conditions by its gradual onset. The pain usually begins as a mild ache and increases gradually as the aggravating activity is continued;the pain may build to an intense throbbing.

Morton's neuroma is a common foot problem associated with pain, swelling, or an inflammation of an interdigital nerve, usually at the ball of the foot between the third and fourth toes. The digital nerve traveling between the toes becomes entrapped or pinched during the push-off phase of walking just before the nerve separates into two separate nerves to supply sensation to the toes. Neuroma formation is attributable to compression of the interdigital nerve against the intermetatarsophalangeal bursa. Symptoms of this condition include sharp pain, burning, and even a lack of feeling in the affected area. Morton's neuroma may also cause numbness, tingling, or cramping in the forefoot. A patient may also complain that it feels as if a marble or pebble were inside the ball of the foot. Neuromas or neural swellings usually develop in only one foot and are more common in women than in men. Symptoms of Morton's neuroma often occur during or after application of significant pressure on the forefoot area, while walking, standing, jumping, or sprinting. It can also be caused by footwear selection; footwear with pointed toes or high heels can often lead to this condition. Constricting shoes can also pinch the nerve between the toes, causing discomfort and extreme pain.

In the evaluation of a patient with foot pain and a possible Morton's neuroma, palpate the area to try to elicit pain by squeezing the toes from the side. Next, try to feel the neuroma by

Table 20-5 Clinical Features Differentiating Rheumatoid Arthritis from Osteoarthritis

Clinical Feature

Rheumatoid Arthritis*

Osteoarthritis'

Patient's age (years)

3-80

Older than 45

Morning stiffness

More than 1 hour

Less than 1 hour

Disability

Often great

Variable

Joint distribution

Distal interphalangeal joint

Rare

Very common

Proximal interphalangeal joint

Very common

Common

Metacarpophalangeal joint

Very common

Absent

Wrist

Very common

Absent

Soft tissue swelling

Very common

Rare

Interosseous muscle wasting

Very common

Rare

Swan-neck deformity

Common

Rare

Ulnar deviation

Common

Absent

*See Figures 20-57 and 20-58. {See Figure 20-59.

*See Figures 20-57 and 20-58. {See Figure 20-59.

Sex

Female

Male

Male

Female

Male, female

Pain onset

Gradual

Gradual

Abrupt

Gradual

Gradual

Stiffness

Very common

Common

Absent

Common

Absent

Swelling

Common

Common

Common

Common

Common

Redness

Absent

Uncommon

Common

Uncommon

Absent

Deformity

Flexion of PIP and MCP;

Frequent DIP, PIP,

None in acute stage;

Flexion and lateral

Thenar muscle

swan-neck,{

and MCP

resembles rheumatoid

deviation of DIP

atrophy

boutonniere

involvement;

arthritis if deposits

and PIP}

deformities; ulnar

''sausage-

occur in tendon sheaths

deviation*

shaped'' digits5

in chronic gout

DIP, distal interphalangeal joint; MCP, metacarpophalangeal joint; PIP, proximal interphalangeal joint.

•Needlepoint pitting of the nails is often associated with psoriatic arthritis. See Figures 8-14 and 8-15.

"See Figure 20-55.

{See Figure 20-58.

{See Figure 20-57.

}See Figure 20-59.

Table 20-6 Clinical Features Differentiating Diseases Affecting the Hands and Wrists

Clinical Psoriatic Carpal Tunnel

Feature Rheumatoid Arthritis Arthritis* Acute Gout** Osteoarthritis Syndrome

DIP, distal interphalangeal joint; MCP, metacarpophalangeal joint; PIP, proximal interphalangeal joint.

•Needlepoint pitting of the nails is often associated with psoriatic arthritis. See Figures 8-14 and 8-15.

"See Figure 20-55.

{See Figure 20-58.

{See Figure 20-57.

}See Figure 20-59.

pressing your thumb into the third interspace. Hold the patient's first, second, and third meta-tarsal heads with one of your hands and the fourth and fifth metatarsal heads in the other, and push half the foot up and half the foot down slightly. In many cases of Morton's neuroma, this maneuver causes an audible click, known as Mulder's sign.

Table 20-5 summarizes the clinical features that differentiate rheumatoid arthritis from osteoarthritis. Table 20-6 summarizes some of the features of diseases affecting the hands and wrists. Table 20-7 outlines the clinical features that differentiate common musculoskeletal disorders affecting the elbow. Table 20-8 lists the clinical features that differentiate significant diseases affecting the knee. Table 20-9 lists the clinical features differentiating diseases of the foot. Table 20-10 summarizes the normal joint ranges of motion.

Table 20-7 Clinical Features Differentiating Diseases Affecting the Elbow

Rheumatoid Psoriatic

Clinical Feature Arthritis Arthritis Acute Gout* Osteoarthritis Tennis Elbow

Table 20-7 Clinical Features Differentiating Diseases Affecting the Elbow

Age (years)

3-80

10-60

Sex

Female

Male

Pain onset

Gradual

Gradual

Stiffness

Very common

Common

Swelling

Common

Common

Redness

Absent

Uncommon

Deformity

Flexion

Flexion

contractures, contractures, usually bilateral usually bilateral contractures, contractures, usually bilateral usually bilateral

30-80

50-80

20-60

Male

Female

Male, female

Abrupt

Gradual

Gradual

Absent

Common

Occasional

Common

Common

Absent

Common

Absent

Absent

Flexion contractures

Flexion contractures

None

only in chronic state only in chronic state

•See Figure 20-61, which shows a patient with chronic tophaceous gout and painless tophi on the elbows.

Table 20-8 Clinical Features Differentiating Diseases Affecting the Knee

Rheumatoid Psoriatic

Clinical Feature Arthritis Arthritis Acute Gout

Osteoarthritis Torn Meniscus

Table 20-8 Clinical Features Differentiating Diseases Affecting the Knee

Age (years)

3-80

10-60

30-80

50-80

20-60

Sex

Female

Male

Male

Female

Male

Pain onset

Gradual

Gradual

Abrupt

Gradual

Abrupt

Stiffness

Very common

Common

Absent

Common

Occasional

Swelling

Common

Common

Common

Common

Common

Redness

Absent

Uncommon

Common

Absent

Absent

Deformity

Flexion contractures

Flexion contractures

Flexion contractures only

Flexion contractures

None

in chronic state in chronic state

Table 20-9 Clinical Features Differentiating Diseases Affecting the Foot

Rheumatoid Psoriatic Clinical Feature Arthritis Arthritis Acute Gout

Osteoarthritis Reiter's Syndrome

Table 20-9 Clinical Features Differentiating Diseases Affecting the Foot

Osteoarthritis Reiter's Syndrome

Age (years)

3-80

10-60

30-80

50-80

10-80 (peak, 30s)

Sex

Female

Male

Male

Female

Male

Pain onset

Gradual

Gradual

Abrupt

Gradual

Gradual

Stiffness

Very common

Common

Common

Common

Common

Swelling

Common

Common

Very common

Uncommon

Common

Redness

Uncommon

Uncommon

Very common

Uncommon

Common

Joint predilection

Abductovalgus

Fusiform swelling

First MTP (may also have

Hallux

Ankle, heel, toes

and deformity deformity of of DIP hallux abductovalgus abductovalgus (''sausage'' swelling of

MTP deformity) deformity digits)

and deformity deformity of of DIP hallux abductovalgus abductovalgus (''sausage'' swelling of

MTP deformity) deformity digits)

DIP, distal interphalangeal joint; MTP, metatarsophalangeal joint.

Table 20-10 Normal Joint Ranges of Motion

Joint Flexion Extension Lateral Bending Rotation

Cervical spine

Thoracic and lumbar spine

Shoulder

Elbow

Wrist

Metacarpophalangeal joint Hip

Knee Ankle Subtalar

First metatarsophalangeal joint

90° with knee extended 120° with knee flexed 135° 50°

30° with knee extended

Abduction; 180° Pronation; 80° Radial motion; 20°

Abduction; 45°

Inversion; 20°

Adduction; 50° Supination; 80° Ulnar motion; 55°

Adduction; 30°

Eversion; 10°

Useful Vocabulary

Listed here are the specific roots that are important for understanding the terminology related to musculoskeletal diseases.

Root

Pertaining to

Example

Definition

ankyl(o)-

stiff

ankylosis

Immobility or stiffness of a joint

arthr(o)-

joint

arthrogram

Radiograph of a joint

chir(o)-

hand

chirospasm

Writer's cramp

dactyl(o)-

finger or toe

dactylospasm

Cramping of a digit

myo-

muscle

myopathy

Disease of muscle

oste(o)-

bone

osteomalacia

A condition marked by softening of the bones

pod-

foot

podiatrist

Specialist in conditions of the foot

scolio-

twisted

scoliosis

Lateral deviation of the spine

spondyl(o)-

vertebrae

spondylitis

Inflammation of vertebrae

teno-

tendon

tenotomy

Surgical cutting of a tendon

Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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