Examining the Forearm Intersection through Palpation and Ultrasonography

BACKGROUND

Forearm intersection syndrome causes pain, swelling, and a rub at the dorsal distal forearm where the first extensor compartment muscles intersect with the second compartment tendons. Although primary care settings tend to treat mild cases, high-performance athletes may suffer from severe symptoms that require surgery. This proof-of-concept study aims to help detect the anatomical substrate of forearm intersection syndrome using palpation and ultrasonography when available.

METHODS

Five individuals were studied using independent palpation and ultrasonography to identify the first dorsal compartment muscles and the second dorsal compartment tendons. The distances between the dorsal (Lister's) tubercle of the radius and the ulnar and radial edges of the first dorsal compartment muscles were measured to determine the location and extent of the muscle-tendon intersection. The palpatory and ultrasonographic measurements were compared using descriptive statistics and the paired t-test.

RESULTS

The mean distances from the dorsal tubercle of the radius to the ulnar and radial borders of the first dorsal compartment muscles were 4.0 cm (SE 0.42) and 7.7 cm (SE 0.56), respectively, based on palpation. By ultrasonography, the corresponding distances were 3.5 cm (SD 1.05, SE 0.47) and 7.0 cm (SD 1.41, SE 0.63). Both methods showed a similar overlap length. However, ultrasonography revealed a shorter distance between the dorsal tubercle of the radius and the ulnar border of the first compartment than palpation (p = 0.0249).

CONCLUSIONS

Our findings indicate that a basic knowledge of anatomy should help health professionals diagnose forearm intersection syndrome through palpation and, if available, ultrasonography.

Palpation and Ultrasonography Reveal an Ignored Function of the Inferior Belly of Omohyoid: A Case Series and a Proof-of-Concept Study

BACKGROUND

Palpation, a traditional haptic ability, is used daily by practitioners of all medical and surgical specialties to assess patients. In the current study, one of the authors, in a routine clinical setting, was able to deduce the dynamic features of the putative inferior belly of omohyoid. This led to a proof-of-concept study that yielded results consistent with the clinical findings.

METHODS

The first part of the study involved a survey of 300 rheumatic disease patients in whom the greater supraclavicular fossa was explored by palpation. While the patient kept the head straight, the clinician placed his middle three fingers 2.5-3 cm dorsal to the clavicle in the window between the sternocleidomastoid and trapezius clavicular insertions, explored the supraclavicular fossa, and palpated the paired contractile inferior belly of the assumed omohyoid during flexion in the three orthogonal planes. In the second part of the study, five normal subjects were examined in a similar manner by the same clinician and had independent ultrasonography performed on the dominant side. Descriptive statistics were used, and Yates' corrected chi-squared test was applied to certain nominal variables. Additionally, a comparative anterolateral bilateral neck dissection was performed in a cadaveric specimen.

RESULTS

Both studies showed that the contractile structure was the inferior belly of omohyoid and that its contraction occurred during anterior neck flexion and was opposite to the side of neck rotation, resembling the sternocleidomastoid.

CONCLUSIONS

Palpation uncovered a previously unknown function of the inferior belly of omohyoid, suggesting that physical examination of the musculoskeletal system based on palpation may lead to hypotheses worthy of exploration.

Palpation of the lateral bands of the extensor apparatus of the fingers. Anatomy of a neglected clinical finding

This study aimed to determine by ultrasonography, and cadaveric dissection, whether the firm cords felt by palpation at the sides of the proximal phalanx (PP), actively flexing, and extending the proximal interphalangeal (PIP) joint while keeping the metacarpophalangeal (MCP) joint extended are the lateral bands (LBs) of the extensor apparatus. If so, palpation of the LBs could help evaluate hand conditions that impact the digits' intrinsic muscles. To this end, the PP of the middle and ring fingers of the dominant hand of seven subjects were studied by palpation on both sides. Ultrasonography (US) was performed with a hockey-stick transducer placed on the ulnar side. Five cadaveric hands were dissected, exposing the dorsal extensor apparatus. On palpation, a firm cord was consistently felt at the PP's sides in all subjects. These cords moved widely forward on PIP flexion and backward with PIP extension. By US scanning, the cords corresponded to the LBs. However, the forward movement had only a median of 1.8 mm (range 0.7-3 mm) in the middle finger and a median of 1.1 mm (range 0.3-2.7 mm) in the ring finger compared with an estimated 5-10 mm upon palpation. Cadaveric dissection confirmed the forward movement of the LBs in PIP flexion. We concluded that the firm cords felt at the PP sides are the LBs of the extensor apparatus. We confirmed their movement with the active flexion/extension of the PIP joint. Comparing the wide palpatory and the meager US motion, a haptic illusion of motion may be present.

Dynamic changes in the infrapatellar knee structures with quadriceps muscle contraction. An in vivo study

OBJECTIVE

To determine the effect of knee flexion and submaximal isometric quadriceps muscle (Q) contraction on the patellar tendon (PT), the infrapatellar fat pad (IPFP), and the deep infrapatellar bursa (IPB) from extension to full flexion.

METHODS

In Study 1, the dominant knee of seven healthy subjects was studied in full extension and at 60° flexion during relaxation and Q contraction. Each knee was inspected and palpated, the transverse infrapatellar diameter was measured by plicometry, and measurements of the anteroposterior (AP) thickness of the IPFP were made by ultrasound (US). In Study 2, the dominant knee of seven healthy subjects was studied by US in full flexion, and then, at 15° decrements, down to 60° flexion during relaxation and Q contraction. Both studies had IRB approval. Results were analyzed with the Wilcoxon test and descriptive statistics.

RESULTS

In Study 1, Q contraction caused straightening of the patellar tendon (PT), a statistically significant widening of the IPFP by plicometry, and an increased AP thickness of the IPFP by US, in both knee positions. In Study 2, in full knee flexion, the PT contacted the tibial cortex in all seven subjects. Upon increasing extension, the PT-tibial cortex contact was lost in all subjects nearing 90° flexion. The contraction of the Q made the concave PT straight, grew the width of the underlying IPFP, and the apron of the IPFP moved distally within the IPB in all knee positions. A small amount of bursal fluid was present in all seven subjects.

CONCLUSION

Q contraction makes the IPFP bulge anteriorly, on both sides of the PT, and distally into the IPB, with possible biomechanical implications. In full knee flexion, the PT contacted the tibia, confirming a fulcrum at this site.

Homelessness: cause and effects

In today’s world, wealth accumulates in ever fewer hands. People who live at the margin of the socioeconomic system and are infirm are most prone to become homeless. Many medical and psychiatric problems beset this population. Among them, rheumatic and musculoskeletal diseases are, at the same time, illnesses and barriers to care. Healthcare innovations may decrease the lot of these unfortunate. To correct the root of the problem, we should also set our moral compass to a more egalitarian society.

The rheumatology physical examination: making clinical anatomy relevant

To review the importance of physical examination in the diagnostic process of musculoskeletal conditions vis-a-vis the development of sensitive and powerful technologies such as MRI and high-resolution ultrasound. Because the physical examination of the musculoskeletal system is an exercise of applied clinical anatomy, the authors tested, in one-to-one practical examinations, the basal knowledge of musculoskeletal anatomy of rheumatology trainees, rheumatologists, and other professionals of musculoskeletal medicine. The results of the authors' surveys were disappointing, with a correct response rate of 50 to 60% depending on the locales. To correct this deficit, the authors gave many active-learning, case-centered seminars throughout the Americas and some overseas that may have fostered an interest in the study of clinical anatomy. There was an increased interaction between anatomy departments and clinicians, and that daily use of clinical anatomy would make anatomy relevant, improve clinical skills, and probably reduce the overall costs of the health care system.Key Points• Knowledge of musculoskeletal anatomy is the basic diagnostic tool in the regional pain syndromes• Knowledge of musculoskeletal anatomy helps understand the musculoskeletal involvement in the regional and systemic rheumatic disorders• An active-learning methodology was used since 2006 to review the anatomy that is relevant for rheumatology trainees and practitioners of musculoskeletal medicine• A skilled, anatomy-based physical examination and a well-thought diagnostic hypothesis could reduce the use of expensive technologies that, being too sensitive, may lead the unaware clinician astray.

A survey of anatomical items relevant to the practice of rheumatology: pelvis, lower extremity, and gait

This study aimed to generate a minimum list of structural and functional anatomical items about the pelvis/hip, knee, ankle/foot, gait, and lower limb innervation, which are most relevant to the practice of rheumatology. To determine their perceived relevance to clinical practice, seven members of the Mexican Clinical Anatomy Task Force compiled an initial list of 470 anatomical items. Ten local and international experts according to a 0-10 Likert scale ranked these items. Of the original list, 101 (21.48%) items were considered relevant (global rate >40). These included 36/137 (26.27%) pelvis and hip items, 25/82 (30.48%) knee items, 22/168 (13.98%) ankle/foot items, 11/68 (16.17%) neurologic items, and 7/15 (46.66%) gait-related items. We propose that these 101 anatomical items of the lower extremity, when added to the 115 anatomic items of the upper extremity and spine we previously reported, may represent an approximation to the minimal anatomical knowledge central to the competent practice of rheumatology. The meager representation of ankle and foot items may reflect a lesser emphasis in these anatomical regions during rheumatologic training. Attention to these and related items during rheumatologic training and beyond may sharpen the rheumatologist's ability in the differential diagnosis of regional pain syndromes as well as strengthen an endangered art: the rheumatologic physical examination.

A survey of anatomical items relevant to the practice of rheumatology: upper extremity, head, neck, spine, and general concepts

This study aimed to identify the anatomical items of the upper extremity and spine that are potentially relevant to the practice of rheumatology. Ten rheumatologists interested in clinical anatomy who published, taught, and/or participated as active members of Clinical Anatomy Interest groups (six seniors, four juniors), participated in a one-round relevance Delphi exercise. An initial, 560-item list that included 45 (8.0 %) general concepts items; 138 (24.8 %) hand items; 100 (17.8 %) forearm and elbow items; 147 (26.2 %) shoulder items; and 130 (23.2 %) head, neck, and spine items was compiled by 5 of the participants. Each item was graded for importance with a Likert scale from 1 (not important) to 5 (very important). Thus, scores could range from 10 (1 × 10) to 50 (5 × 10). An item score of ≥40 was considered most relevant to competent practice as a rheumatologist. Mean item Likert scores ranged from 2.2 ± 0.5 to 4.6 ± 0.7. A total of 115 (20.5 %) of the 560 initial items reached relevance. Broken down by categories, this final relevant item list was composed by 7 (6.1 %) general concepts items; 32 (27.8 %) hand items; 20 (17.4 %) forearm and elbow items; 33 (28.7 %) shoulder items; and 23 (17.6 %) head, neck, and spine items. In this Delphi exercise, a group of practicing academic rheumatologists with an interest in clinical anatomy compiled a list of anatomical items that were deemed important to the practice of rheumatology. We suggest these items be considered curricular priorities when training rheumatology fellows in clinical anatomy skills and in programs of continuing rheumatology education.

Educational impact of a clinical anatomy workshop on 1st-year orthopedic and rheumatology fellows in Mexico City

We aim to study the educational impact of a clinical anatomy workshop in 1st-year orthopedic and rheumatology fellows. First-year rheumatology fellows (N = 17) and a convenience sample of 1st-year orthopedic fellows (N = 14) from Mexico City in the 9th month of training participated in the study. The pre- and the post- workshop tests included the same 20 questions that had to be answered by identification or demonstration of relevant anatomical items. The questions, arranged by anatomical regions, were asked in five dynamic stations. Overall, the 31 participants showed an increase of correct answers, from a median of 6 (range 1 to 12) in the pre-workshop test, to a median of 14 (range 7 to 19) in the post-workshop test. In the pre-workshop test, the correct median answers were 7 (range 2 to 12) in the orthopedic fellows and 5 (range 1 to 10) in the rheumatology fellows (p = 0.297). Corresponding scores in the post-workshop were 15 (range 10 to 19) and 12 (range 7 to 18) (p = 0.026) showing a significant difference favoring the orthopedic group. Our clinical anatomy workshop was efficacious, in the short term, as a teaching instrument for 1st-year orthopedic and rheumatology fellows. The post-workshop scores, although significantly improved in both groups, particularly in the orthopedic fellows, were still suboptimal. Further refinements of our workshop might yield better results.

Self-assessed efficacy of a clinical musculoskeletal anatomy workshop: A preliminary survey

OBJECTIVE

To survey the efficacy of a practical workshop on clinical musculoskeletal anatomy held in five American countries.

METHODS

A self-assessment competence questionnaire sent to participants 1-3 months after the workshop. Results were compared to the results of a practical, instructor-assessed, pre-workshop test.

RESULTS

The response rate of participants was 76.4%. The overall, self-assessed competence score for anatomical items that had been included in the pre-test was 76.9 (scale 0-100) as compared to an overall score of 48.1 in the practical, pre-workshop test (p<0.001). For items that were addressed in the workshop, but not included in the pre-test, self-assessed competence was rated at 62.9. Differences in anatomical knowledge between individuals from different countries and professional groups noted in the practical pre-test were no longer present in the post-test self-assessment.

CONCLUSIONS

From this preliminary data and supporting evidence from the literature we believe that our anatomy workshop provides an effective didactic tool for increasing competence in musculoskeletal anatomy.

Preworkshop knowledge of musculoskeletal anatomy of rheumatology fellows and rheumatologists of seven North, Central, and South American countries

OBJECTIVE

To report the baseline knowledge of clinical anatomy of rheumatology fellows and rheumatologists from Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay.

METHODS

The invitation to attend a workshop in clinical anatomy was an open call by national rheumatology societies in 4 countries or by invitation from teaching program directors in 3 countries. Prior to the workshop, a practical test of anatomic structures commonly involved in rheumatic diseases was administered. The test consisted of the demonstration of these structures or their function in the participant's or instructor's body. At one site, a postworkshop practical test was administered immediately after the workshop.

RESULTS

There were 170 participants (84 rheumatology fellows, 61 rheumatologists, and 25 nonrheumatologists). The overall mean ± SD number of correct answers was 46.6% ± 19.9% and ranged from 32.5-67.0% by country. Rheumatology fellows scored significantly higher than nonrheumatologists. Questions related to anatomy of the hand scored the lowest of the regions surveyed.

CONCLUSION

Rheumatology fellows and rheumatologists showed a deficit in knowledge of musculoskeletal anatomy that is of central importance in rheumatologic assessment and diagnosis. This gap may hinder accurate and cost-effective rheumatologic diagnosis, particularly in the area of regional pain syndromes. Presently, widespread use of musculoskeletal ultrasound (MSUS) by rheumatologists may be premature, since a key component of expert-level MSUS is the integration of an accurate knowledge of anatomy with the views obtained with the ultrasound probe.

Clinical anatomy of the pelvis and hip

The contents of this review may appear odd. After a brief description of the coxofemoral joint, the entities discussed include ilioinguinal neuropathy within the context of the nerves that may be damaged during lower abdominal surgery, meralgia paresthetica, piriformis syndrome with the appropriate caveats, trochanteric syndrome, "ischial bursitis" and trochanteric syndrome caused by ischemia. These cases were chosen to stress our belief that rheumatologists are first and foremost internists. We further believe that being current in other pathologies such as peripheral neuropathies and certain vascular syndromes sooner or later benefits our patients.

Clinical anatomy of the ankle and foot

This paper emphasizes the anatomical substrate of several foot conditions that are seldom discussed in this context. These include the insertional and non-insertional Achilles tendinopathies, plantar fasciopathy, inferior and posterior heel spurs, foot compartment syndromes, intermetatarsal bursitis and Morton's neuroma. It is a rather superficial anatomical review of an organ that remains largely neglected by rheumatologists. It is our hope that the cases discussed and the cross examination by instructors and participants will stimulate study of the foot and the attention it deserves.

Clinical anatomy of the knee

The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the iliotibial tract syndrome, the anserine syndrome, bursitis of the medial collateral ligament, Baker's cyst, popliteus tendon tenosynovitis and bursitis of the deep infrapatellar bursa. These syndromes are reviewed in terms of the structures involved and their role in knee physiology. All of the discussed structures can be identified in their normal state and more so when they are affected by disease. The wealth of information gained by cross examination of the medial, lateral, posterior and anterior aspects of the knee brings to life knowledge acquired at the dissection table, from anatomical drawings and from virtual images.

Evidence-based soft tissue rheumatology: epicondylitis and hand stenosing tendinopathy

Lateral and medial epicondylitis represent overuse tendinopathies of wrist extensor and wrist flexor muscles, respectively. In lateral epicondylitis, a short-term therapeutic efficacy of glucocorticoid injection and limited evidence on the efficacy of acupuncture has been shown. De Quervain tendinopathy is caused by tendinous impingement by a thickened retinaculum. There is limited evidence on the efficacy of glucocorticoid injection in this condition.Trigger finger usually results from tendon entrapment beneath a thickened A1 flexor pulley. An association with hand tool use and diabetes has been shown in this condition, and there is evidence on the therapeutic efficacy of glucocorticoid injection. No other therapeutic modality has shown efficacy or has been assessed in a placebo-controlled clinical trial in these conditions.It can be concluded that epicondylitis and stenosing tendinopathy are readily diagnosed, and most patients recover with current therapies. However, still unsolved issues preclude a purely evidence-based approach to these entities.

Evidence-Based Soft Tissue Rheumatology IV: Anserine Bursitis

Anserine bursitis is a frequent cause of medial knee pain. Despite its name, the structure at fault causing the symptoms remains unknown. Diabetes mellitus is a known predisposing factor leading to the condition. Overweight and knee osteoarthritis are possible additional risk factors, but their role has yet to be assessed. Anserine bursitis is diagnosed clinically based on medial knee pain and localized tenderness at the inferomedial knee. Current treatment of anserine bursitis includes nonsteroidal anti-inflammatory dugs, physiotherapy, and local glucocorticoid injections. Of these, only the latter has been shown effective in clinical trials. Knowledge gaps in the epidemiology, pathology, and pathogenesis of anserine bursitis should lead to additional research efforts on this common and perplexing condition.

Heel pain: diagnosis and treatment, step by step

The differential diagnosis of heel pain is broad and can be overwhelming if a systematic approach is not used. Focused questions and physical examination can help identify heel pain as Achilles tendinopathy or plantar fasciitis, or as due to a less common cause such as gout, spondyloarthropathy, or hypercholesterolemia.

Evidence-Based Soft Tissue Rheumatology. V

Present evidence indicates that the main cause of plantar talalgia (PT) is a noninflammatory derangement at the proximal insertion of the plantar fascia. In athletes, predisposing ankle and rear-foot biomechanical abnormalities have been identified; in nonathletes, risk factors for the condition remain controversial. PT diagnosis is largely clinical, the key findings being pain and tenderness on the plantar aspect of the rear foot. Ultrasonography is a reliable confirmatory study in doubtful cases. Therapies in PT include nonsteroidal anti-inflammatory drugs, orthotic devices, night ankle dorsiflexion splints, physiotherapy, local glucocorticoid, and extracorporeal shockwave therapy. In recalcitrant cases, surgery may be offered. Of these therapies, only local glucocorticoid, as delivered by injection or iontophoresis, has shown short-term efficacy in controlled trials. The efficacy of ankle dorsiflexion splints and extracorporeal shockwave therapy is still controversial. Thus, important knowledge gaps remain on etiology, diagnosis, and treatment of PT.

Evidence-Based Soft Tissue Rheumatology

Trochanteric bursitis is a term used to name a syndrome that features pain and tenderness over the greater trochanter. Present evidence suggests that in the majority of cases, symptoms result from pathology of the gluteus medius or minimus muscles rather than a bursa. Lower limb length discrepancy, iliotibial band contracture, hip osteoarthritis and lumbar spondylosis are often mentioned, but no proved as predisposing factors. After a lumbar spine or hip and other local pathology have been considered and clinically excluded, the clinical features of the syndrome, ie lateral location of pain plus characteristic trochanteric tenderness are usually sufficient to reach a diagnosis. Most patients with trochanteric bursitis can be successfully treated with a NSAID, physiotherapy plus a local corticosteroid injection. The few refractory cases are often treated surgically. Disappointingly, none of the therapeutic interventions used in trochanteric bursitis have been validly assessed.

Evidence-Based Soft Tissue Rheumatology. Part I

Impingement into the coracoacromiohumeral space, a common cause of rotator cuff tendinopathy, may result from an impinging osteoligamentous upper boundary, abnormalities in the tendon itself, or failure of muscles that retain the humeral head on the glenoid. An overuse mechanism is clearly a risk factor in throwing athletes, whereas occupational overuse may contribute to its development in nonathletes. The subacromial anesthetic injection test remains as the acknowledged gold standard for diagnosis. There is evidence on the therapeutic efficacy of nonsteroidal antiinflammatory drugs, glucocorticoid subacromial injection, and acupuncture as compared with placebo. Also, acromioplasty appears to be better than physiotherapy. Patients with rotator cuff tendinopathy may be successfully treated with nonsteroidal antiinflammatory drugs, a glucocorticoid subacromial injection, or acupuncture. In failures of conservative therapy, surgery should be considered. Further research is required on etiology, diagnosis, natural course, and validity of many treatments currently used in this common condition.

Soft tissue infections

Several infectious processes ranging in severity from mild to overwhelming that affect the soft tissues are reviewed. Superficial infections such as impetigo, erysipelas, cellulitis, and subcutaneous bursitis are common and, for the most part, can be easily treated. Because suppurative tenosynovitis has the potential to destroy tendons, consultation with a hand surgeon should be obtained immediately. Mycobacterial and fungal tenosynovitis is usually chronic and patients present with a mass which, when excised and examined with appropriate stain and culture, reveals the unexpected diagnosis. Tropical myositis (muscle abscesses) is seen in temperate climates, primarily as a complication of AIDS. Necrotizing fasciitis and gas gangrene represent the hyperacute end of the spectrum of soft tissue restrictions. Although in most cases a history of trauma is present, spontaneous gas gangrene may arise from occult and colonic cancer. Patients do poorly unless immediate and extensive surgery is performed and appropriate antibiotics are given.

Tumors of soft tissues and bone

The recent literature pertaining to tumors of articular structures and bone is reviewed. In pigmented villonodular synovitis, the bone resorptive cell is a macrophage polykaryon rather than an osteoclast. Complete arthroscopic synovectomy was successful in most diffuse articular forms of the disease. The early synovial changes in synovial chondromatosis were described; the lesion may be difficult to distinguish from synovial chondrosarcoma. Free body removal may be sufficient to treat synovial chondromatosis. Magnetic resonance imaging has been found useful in association with plain radiographs in the diagnosis of hemangioma and synovial sarcoma. Intracapsular osteoid osteoma, a benign neoplasm, may cause chronic monoarthritis. Computed tomography is essential in the diagnosis of this lesion. Aneurysmal bone cysts frequently show fluid-fluid levels on magnetic resonance imaging. Osteosarcoma, predominantly a tumor of childhood or adolescence, may occur in individuals over age 40 with underlying bone conditions. Computed tomography and magnetic resonance imaging are complementary in defining the extent of this lesion.

Subcutaneous bursitis in scleroderma

We encountered 3 types of subcutaneous bursitis in our patients with scleroderma: dry bursitis characterized by a rub, sterile bursitis characterized by inflammatory effusions without crystals by polarizing microscopy, and septic (staphylococcal) subcutaneous bursitis. The latter, which occurred in 6 of 40 consecutive patients, had a protracted course, was often complicated by fistulas, and tended to involve several bursae particularly in patients with extensive calcinosis.

Lupus-like presentation of human parvovirus B19 infection

The diagnosis of systemic lupus erythematosus (SLE) was a leading initial consideration in 2 patients with rash, arthritis and hypocomplementemia. One patient also had leukopenia and thrombocytopenia. Spontaneous regression occurred. In both patients antinuclear antibodies were negative. Serologic studies indicated recent human parvovirus B19 infection. We propose adding human parvovirus B19 infection to the list of conditions that may masquerade as SLE.

Remitting, seronegative (A) symmetrical synovitis with pitting edema--two cases of RS3PE syndrome

The sparing effect of neurological damage on the development and progression of several arthritic conditions has been documented. We describe the first 2 cases of unilateral remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome in individuals with neurologic disorders. Case 1 suffered from birth trauma resulting in paresis of the right upper extremity and developed RS3PE syndrome in the nonaffected extremities. Case 2 developed RS3PE syndrome on the nonparetic side 7 years after a cerebrovascular accident resulting in hemiparesis.

Hemorrhagic subcutaneous bursitis

Hemarthrosis is a well recognized complication of a number of conditions. Hemorrhagic subcutaneous bursitis is less understood. We encountered a patient with a myeloproliferative disease who developed hemorrhagic olecranon bursitis. Upon reviewing other patients with subcutaneous bursitis, we found that hemorrhagic bursitis also occurs in the setting of traumatic or idiopathic bursitis, rheumatoid arthritis, gout, and septic bursitis.

Dynamic injection of the digital flexor tendon sheaths

Images

Arthralgias as a presenting manifestation of primary biliary cirrhosis

Two patients presenting with arthralgias had associated minor elevations in liver enzymes. Each patient's serum had a cytoplasmic pattern of fluorescence on HEp-2 cells which led to the detection of antimitochondrial antibodies. Liver biopsy in both patients revealed primary biliary cirrhosis. Awareness of this limited, articular presentation of primary biliary cirrhosis may result in early treatment and the potential to arrest liver damage in some patients.

Physiology of the retrocalcaneal bursa

To clarify the function of the retrocalcaneal bursa the hindfoot was studied by magnetic resonance imaging at various positions of the ankle joint. In normal individuals a tongue-like extension of the retromalleolar fat pad entered the bursa during plantar flexion as the angle between Achilles tendon and calcaneus widened. The reverse occurred in dorsiflexion. In contrast, in a patient with spondyloarthritis and retrocalcaneal bursitis excessive cavitary fluid prevented the intrusion of the fat pad. The sliding motion of the fat pad in and out of the bursa during ankle motion allows a more caudal, advantageous insertion of the Achilles tendon into the calcaneus.

The acute phase response in gout

We studied the acute phase response in gout. Oral temperature, white blood cell count and differential, platelet count, Westergren erythrocyte sedimentation rate (ESR), and serum levels of the acute phase reactants serum amyloid A protein (SAA) and C-reactive protein (CRP) were all elevated. The number of involved joints correlated with levels of ESR, SAA and CRP. CRP correlated with temperature, differential count, ESR and SAA. The acute phase response resolved rapidly with treatment.

Foucher's sign of the Baker's cyst

We investigated the mechanism of Foucher's sign, the change in pressure in the Baker's cyst with extension and flexion of the knee, by echography, arthrography, and computed tomography. With extension the gastrocnemius and the semimembranosus muscles approximate each other and the joint capsule compressing the cyst against the deep fascia. Opposite effects in flexion allow the cyst to relax.

Femoral osteonecrosis following soft tissue corticosteroid infiltration

A case of osteonecrosis of the hip following an 18-year course of repeated soft tissue corticosteroid infiltration in a man with ill-defined musculoskeletal complaints is described.