Мир М.Афзал Атлас клинического диагноза
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11
ATLAS
OF
CLINICAL
DIAGNOSIS
coalescing
in a
circular ring
of
1-5
cm
diameter
(11.30).The
lesions
may
occur
at any
age, even
in
children.
A
dissemi-
nated
form
of
granuloma annulare
is
thought
to be
related
to
overt
or
latent diabetes
mellitus
(see 9.159;
p.
188).
Approximately
one-half
of the
lesions clear
up
sponta-
neously
over
a
period
of 2-3
years.
Diabetic bullae
(bullosis
diabeticorum),
which resemble
but are not
caused
by
burns
(11.31),
occur
in
long-
standing diabetics with neuropathy.
The
bullae
are of
rapid
onset
and are
sometimes
first
discovered when getting
out
of
bed in the
morning. They
may be
unilateral
or
bilateral
and
usually appear
on the
toes, plantar
and
dorsal
surfaces
of
the
foot,
and on the fingers
(see also
9.158-9.162;
pp.
187-8).
The
blisters
are
tense, containing serous
but
sometimes haemorrhagic
fluid, and
their
base
and the
adjoining
skin
are not
inflamed.
Diabetic
amyotrophy
(proximal lower extremity motor
neuropathy) usually involves
the
muscles supplied
by the
femoral
nerve, principally
the
quadriceps group.
It
results
in
a
progressive,
painful,
bilateral
and
usually asymmetri-
cal,
weakness
and
wasting
of the
thigh muscles
(11.32,
11.33),
with loss
of the
knee jerk
but
with very little sensory
impairment.
The
syndrome mostly
affects
poorly con-
trolled diabetic patients
in
their middle age,
is
heralded
by
recent
weight
loss,
and is
slowly reversible.
The
classic cutaneous lesion
of a
glucagonoma
(necrolytic
migratory
erythema]
begins
as
erythema
of the
skin,
becomes indurated
and
develops central blistering,
which
bursts
and
leaves
a
crust
(11.34).
The
rash
is
most
prominent
on the
perineum, along intertriginous
folds
(11.35,
11.36),
around
the
mouth
and on the
tongue (see
2.74;
p.
81).
The
characteristic
waxing
and
waning skin rash
is
considered
to be the
hallmark
of the
syndrome
but
only
occurs
in
approximately two-thirds
of
patients.
The
other
features
of the
syndrome
are
diabetes, hypoaminoaci-
daemia, weight loss
and
anaemia.
11.30
A
reddish
dermal
plaque
with
well-
defined
margin
11.31
Diabetic
bullae.
Note
necrobiosis
lipoidica
diabeticorum
11.32
and
11.33
Diabetic
amyotrophy
with
asymmetrical
flattening
of
thigh
muscles
11.34
Migratory
necrolytic
erythema:
erythematous
plaques
with
irregular
margins
and
central
crusting
THE
LEGS
223
Approximately
5% of
patients with Graves' disease
develop localized
myxoedema
(often
after
being rendered
euthyroid
or
hypothyroid with treatment), usually
affect-
ing
the
anterior aspect
of the leg
(pretibial
myxoedema).
Sometimes
the
hands
or
face
may be
involved, particularly
if
the
affected area
is
subjected
to
constant trauma.
The
skin
is
thickened, raised, nontender
and
violaceous with
coarse hair
and
nonpitting oedema
(11.37).
In
Cushing's
syndrome purple striae
can be
found
on the
abdomen, buttocks
(11.38)
and on the
thighs
(11.39).
The
phenomenon
is
caused
by
thinning
of the
skin, which looks
parched
and
transparent. There
is
usually underlying mus-
cular weakness
and
wasting particularly
affecting
the
lower
limb-girdle
muscles.
The
feet
are
enlarged, broad
and
bulky
(11.40,11.41)
in
acromegaly.
The
increase
in the
size
of the
feet
affects
both
11.35
and
11.36
Glucagonoma
syndrome:
erythemafous,
inflammatory
plaques
of the
scrotum,
penile
shaft
and
intertriginous
11.37
Pretibial
myxoedema:
a
raised,
reddish
plaque
with
irregular
margins
11.38
Cushing's syndrome:
purplish
striae
11.39
Scattered,
purplish,
streaky striae
11.40
and
11.41
Acromegaly:
large,
square,
bulky
feet
224
11
ATLAS
OF
CLINICAL
DIAGNOSIS
the
anteroposterior
and
transverse dimensions.
It is
caused
by
thickening
of the
skin
and
soft
tissues,
and is
particu-
larly
noticeable over
the
heels
and the
lateral borders.
Sometimes
the
pads
of the
feet
are so
thickened that
the
toes
cannot
be
placed
on the floor
(11.42).
In
pseudohypoparathyroidism,
the
short
third,
fourth
and
fifth
metacarpals (see 9.145-9.147;
pp.
184-5)
and
metatarsals create dimples
on the
dorsum
of the
corre-
sponding hand
and
foot,
with shortening
of one or
more
fingers
and
toes
(11.43,11.44).
Polydactyly
(11.45)
is
characteristically seen
in the
Lawrence-Moon-Biedl
syndrome (see also 9.148;
p.
185).
The
absence
of
hair
and a
reduced muscular bulk
in the
lower
extremities
of
a'male patient
(11.46,11.47)
add
sub-
stance
to
other
features
of
hypopituitarism
(see 1.96
and
1.99-1.102;
p.
20).
11.42
Acromegalic foot
with
thickened
sole
and
heel
11.43
Pseudohypopara-
thyroidism:
short
third,
fourth
and
fifth
toes
11.44
A
short
fourth
toe due
to
a
corresponding
short
metatarsal bone
11.45
Lawrence-Moon-Biedl
syndrome:
polydactyly
11.46
and
11.47
Hypopituitarism:
absent
hair
THE
LEGS
225
Locomotor
problems
Spot diagnosis
of a
condition
affecting
the
locomotor
system
of the
lower limbs involves
a
visual scrutiny
of the
bones
and
joints
and
their dynamic behaviour
on
walking.
By
the
time most clinicians look
at the
legs, they have
already gained
some
diagnostic impressions
from
looking
at
the
rest
of the
body.
For
example, this
may be the
time
to add
some
final
confirmatory
touches
to the
diagnosis
of
Marfan's
syndrome,
by
looking
at the
tall
figure of the
standing patient
(11.48),
by
measuring
the
span versus
the
height (11.49),
and by
looking
at the
feet
for the
presence
of
arachnodactyly
(11.50).
11.48
and
11.49
Marfan's
syndrome:
tall
figure
with
long
extremities
11.50
Arachnodactyly:
long,
webbed
toes
11
ATLAS
OF
CLINICAL
DIAGNOSIS
226
Paget's disease
of
bone
is a
very common
and
visually
arresting condition
of the
elderly. Part,
or all of a
bone
or
several bones
may be
involved.
The
affected tibia
is
often
bent laterally
(11.51)
with bone destruction followed
by
excessive bone deposition,
a
high bone turnover,
and an
increased vascularity, which
is
often
demonstrable
by
warmness
of the
overlying skin.
The
condition
is
often
symptomless
but may
produce intractable pain.
An
osteogenic sarcoma
is a
rare complication.
Paget's
disease
of
the leg
should
be
distinguished from
the
sabre tibia
(11.52)
of
late congenital syphilis, which
is
caused
by
osteoperiostitis with laying down
of new
bone over
the
tibia.
The
middle third
of the
tibia becomes wide with
palpable irregularities along
the
anterior shin.
Osteoarthrosis
of the
knee joint often produces swelling
and
distortion
of the
surface markings
of the
joint
(11.53,
11.54).
The
knee joint
is the
largest superficial joint
in the
body,
and its
swelling
can be
appreciated readily
by
inspec-
tion.
For
this purpose,
the
joint
can be
conveniently divided
into
two
parts:
the
main femorotibial articulation
and the
patellofemoral compartment.
The
latter
includes
the
suprapatellar extension
of the
synovial cavity
and
some-
11.51
Paget's
tibia
11.52
Sabre
tibia:
a
wider
left
leg
with
irregular
anterior
shin
margin
11.53
Osteoarthrosis:
irregular,
bulging
outline
11.54
Osteoarthrosis
with
effusion
of the
knee
joints
11.55
and
11.56
Advanced
Osteoarthrosis
with
effusion
of the
suprapatellar
pouches
THE
LEGS
11
227
times
it is
this
that bears
the
brunt
of
osteoarthrosis (11.55,
11.56).
In
such cases,
a
horseshoe-shaped swelling extends
from
the
large suprapatellar pouch
to the
inferior
border
of
the
patella,
filling in the
depressions
on
either side
of
the
patellar ligament.
The
joint
is
usually
painful
and
with
the
associated
limited
mobility there
is
rapid wasting
of the
quadriceps.
With
advanced damage
the
joint becomes unstable
and
may
develop
a
varus (11.57)
or a
valgus
deformity
(11.58).
When
there
is
also
an
effusion
with
osteoarthrosis
the
joint
tends
to be
warm although less
so
than
in
septic
arthritis
(11.59), gout,
pseudogout
(11.60),
haemarthrosis
(usually
in a
haemophiliac patient)
(11.61)
and in
rheuma-
toid
arthritis
(11.62). Since
all
these conditions raise dif-
fering
management implications,
the
cause
of the
effusion,
which
has
been detected clinically
by
palpation
(fluctua-
tion],
should
be
established
by
aspiration, microscopy
and
culture.
11.57
Osteoarthrosis:
genu
11.58
Osteoarthrosis: genu
valgum
11.59
Acute monoarthritis
with
effusion:
swollen joint
with
loss
of
surface
markings
11.60
Pseudogout
11.61
Acute effusion
of the
right knee joint
(haemarthrosis)
11.62
Effusion
of the
knee
joint
in a
patient
with
rheumatoid
arthritis
11
ATLAS
OF
CLINICAL
DIAGNOSIS
228
Osteoarthrosis
results when there
is an
imbalance between
the
mechanical demands
and the
joint stability,
as
happens
often
from
excessive mechanical pressure associated
with
obesity. Nevertheless, marked joint laxity
in the
Ehlers-Danlos syndrome with
a
normal degree
of
mechani-
cal
pressure
can
achieve
the
same result
(11.63).
Note
the
'cigarette-paper'
scars
on the
skin overlying
the
joint.
Septic
arthritis usually
has an
acute onset with malaise,
toxaemia
and
fever.
The
affected ankle (11.64)
or
knee
joint
is
painful,
swollen, warm, tender
and
semiflexed
to
relieve
the
pressure
on the
capsule
(11.65).
Acute
effusions
should always
be
regarded with suspicion
and the
safe rule
is
always
to
aspirate such joints
for
bacteriological investi-
gation.
The
objective
is
early treatment
and
prevention
of
pus
formation.
The
knee
is
among
the
most commonly affected weight-
bearing joints
to be
involved
in
rheumatoid arthritis with
synovial
hypertrophy
and
often with
effusion
(11.66).
The
11.63
Ehlers-Danlos
syndrome:
osteoarthrosis
of the
knee joint
with
thin,
whitish,
papery
scars
('papyraceous'
scars)
in the
skin
11.64
Acute swelling
of the
ankle joint
with
erythematous
overlying
skin
11.65
Septic
arthritis
of the
left
knee joint
11.66
Rheumatoid
arthritis:
thickened synovium
causing
bulging
skin
folds
THE
LEGS
.
•
-
™^?
:
«^?:i^^™
229
diagnosis
may be
made
by
association with
the
relevant
abnormalities elsewhere
and by
aspiration
(11.67,
11.68).
The
enlargement
of the
semimembranous
bursa into
the
popliteal space (Baker's cyst),
and its
rupture producing
swelling
of the
leg,
may
mimic acute
phlebothrombosis
(11.69,11.70).
In
either case,
the
patient presents with
an
acute,
painful
swelling
of the
calf.
An
effusion
of the
knee
joint
confirmed
by
aspiration favours rheumatoid arthritis
as
the
aetiology
of the
swelling.
An
ultrasonogram
and
arthrography will help confirm
the
diagnosis.
As in the
fingers,
digital arteritis
may
result
in an
infarction
of a toe
(11.71,11.72).
Larger areas
of
ischaemia
11.67
and
11.68
Rheumatoid
arthritis
of the
hands,
knees
and
toes
11.69
and
11.70
Ruptured Baker's
cyst:
swelling
confined
to the
upper
compartment
of the leg
11.71
and
11.72
Rheumatoid
arthritis
with
digital
arteritis:
infarction
of the
third
toe
11
ATLAS
OF
CLINICAL
DIAGNOSIS
230
may
occur
in the
lower extremities, with
the
development
of
ulcers over
the
malleoli
(11.73).
These ulcers
are
often
covered with slough (11.74)
and are
difficult
to
heal. Rheumatoid vasculitis
is
frequently associated with
a
systemic
disturbance (e.g., malaise, anaemia, fever,
toxaemia).
Gout
is the
commonest form
of
crystal
arthropathy.
An
attack
of
acute gouty arthritis classically involves
the first
metatarsophalangeal joint with pain, oedema
and
intense
inflammation
(11.75,
11.76).
Exquisite tenderness
is a
prominent clinical feature
and the
patient,
who
often
wakes
up
with
the
attack, cannot bear
the
weight
of the
bedclothes
on the
affected
foot. Movements
are
very
painful
and the
patient
is
unable
to
dorsiflex
the big toe
(11.77). Most such patients have
had
asymptomatic
hyper-
uricaemia
for
many years, before
the
urate crystals accu-
mulated
in the
joint
and
provoked
an
acute attack. During
the
acute episode,
the
serum uric acid level
may be
normal.
The
diagnosis depends
on the
characteristic clinical pres-
entation
and
also
on the
demonstration
of
negatively bire-
fringent
needle-shaped urate crystals
in the
aspirated
fluid,
seen under polarized light microscopy.
11.73
and
11.74
Infarction ulcers with
well-defined,
raised
margins
and
slough
in the
base
11.75
Swollen, inflamed
first
metatarsophalangeal
joint
11.76
and
11.77
Acute
gouty
arthritis:
erythematous
skin
over
the
first
metatarsophalangeal
joint
and
loss
of
dorsiflexion
THE
LEGS
231
Recurrent attacks
and
tophaceous deposits
of
urate
produce swelling
and
distortion
of the
affected
toes
(11.78,
11.79).These
deposits sometimes invade
the
bone
and
ulcer-
ate
through
the
skin, giving rise
to a
punched-out ulcer
on
the
head
of the first
metatarsal
(11.80;
see
also
9.19-9.25;
pp.
160-1).
Pyrophosphate arthropathy (chondrocalcinosis, pseudo-
gout)
is a
progressive degenerative joint disease that
results
from
the
deposition
of
calcium
pyrophosphate
crystals
in the
joints. Like gout, acute attacks
may
occur
with
pain,
effusion
and a
systemic reaction but, unlike
gout,
both sexes
are
involved
and
larger joints such
as
the
shoulders
and
knees
are
commonly
affected
(11.81).
Sometimes
the
diagnosis
is
made incidentally
in an
elderly
patient whose radiograph
of the
knee joint shows
a rim of
calcification
in the
articular cartilage. More
often
gout
is
suspected
in a
swollen
and
painful
knee joint
(11.82).
The
correct diagnosis
is
made when pleomorphic
pyrophosphate crystals
are
discovered
in the
aspirated
fluid,
which
show weakly positive birefringence
on
polarized light microscopy.
In a few
patients,
the
condition
11.78
and
11.79
Recurrent
gouty
arthritis: tophaceous
deposits
with
overlying
shiny skin
11.80
An
ulcerated tophus
11.81
Recurrent
attacks
of
pseudogout
in the
knees
with
pre-
existing
osteoarthrosis
11.82
Acute
monoarthritis:
pseudogout