JOINT DISEASE
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
Inflammation
Fluids
Genes
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Autoimmunity
Other Immune
HIV infections
The Anti-Immunization Activists
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Infections
Nutrition
Environmental Lung Disease
Violence, Accidents, Poisoning
Heart
Vessels
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Men
Women
Breast
Pituitary
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Bones
Joints
Muscles
Skin
Nervous System
Eye
Ear
Autopsy
Lab Profiling
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Serum Proteins
Renal Function Tests
Adrenal Testing
Arthritis Labs
Glucose Testing
Liver Testing
Porphyria
Urinalysis
Spinal Fluid
Lab Problem
Quackery
Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

Musculoskeletal
Taiwanese pathology site
Good place to go to practice

Bone, Joint, Soft Tissue
Photo Library of Pathology
U. of Tokushima

Musculoskeletal
Utah cases for path students
Juliana Szakacs MD

Soft Tissue and Muscle
Iowa Virtual Microscopy
Have fun

Bone and Joints
Brown Digital Pathology
Some nice cases

Joint Exhibit
Virtual Pathology Museum
University of Connecticut

Joint Disease
From Chile
In Spanish

Musculoskeletal
Photos, explanations, and quiz
Indiana U.

KCUMB Students
"Big Robbins" -- Bones / Joints / Soft Tissue Tumors
Lectures follow Textbook

QUIZBANK: Bone & joint #'s 57-106

INTRODUCTION

{49499} ochronosis ("alkaptonuria"), femoral head

"OSTEOARTHRITIS" ("osteoarthrosis", "degenerative joint disease"; Lancet 350: 503, 1997; Med. Clin. N.A. 81: 85, 122, 1997; Ann. Int. Med. 133: 635, 2000; Postgrad. Med. 114: 11, 2003; Lancet 365: 965, 2005; Clin. Orth. 427-S, 2004; Med. Clin. N.A. 93: 1, 2009 from KU).

KASHIN-BECK DISEASE is an ancient, endemic, deforming disease of bones and joints seen today only in Tibet and some of the other remoter areas of Mainland China. (Formerly it was seen in North Korea, Mongolia, and Siberia but has vanished as nutrition has improved.) It begins in childhood and cripples up to 90% of people in some of the poorest communities. The underlying lesion is evidently non-formation of the little arteries that should supply the cartilage plates (Int. Ortho. 25: 151, 2001), explaining both the arthritis and the dwarfing of the limbs. The cartilage itself undergoes necrosis (J. Bone Min. Metab. 24: 319, 2006). The cause is almost certainly selenium deficiency plus vitamin E deficiency (Clin. Rheum 16: 441, 1997; NEJM 339: 1112, 1998 -- Beijing finally completed a study and found supplementing helps keep their Kashin-Beck region kids from getting crippled: Osteoarthriis & Cartilage 17: 144, 2009) and maybe iodine deficiency (NEJM 339: 1156, 1998; selenium-plus-iodine animal model Osteoarth. Cart. 15: 1171, 2007) coupled with fulvic acid in the drinking water. (The fulvic acid comes from rotting organic material; it poisons procollagen type II processing Eur. J. Biochem. 202: 1141, 1991; J. Tox. 35: 79, 1992; Am. J. Clin. Nut. 57(S2): 259S, 1993; Int. Ortho. 25: 188, 2001). Animal model: Biochem. J. 289: 829, 1993. Histopathology Virch. Arch. A. 423: 483, 1993. Conference in Beijing Br. Med. J. 318; 485, 1999. It's still part of life in parts of China: J. Rheum. 35: 696, 2008; Tibet Am. J. Clin. Nutr. 78: 137, 2003 (as the rich in China get richer, the Belgians have to come in to run tests and offer selenium and iodine supplements on China's poor kids). The "official" line from China today (2010) seems to be that it's a genetic disease... uh. Kashin-Beck
Kashin-Beck

{10946} spurred spine
{24637} spur, histology
{24638} eburnation
{24639} "cyst" formation in articular bone
{24640} joint mouse
{40180} femoral head, eroded cartilage
{45612} x-ray, showing narrowed joint spaces

"Osteoarthritic" lipping
WebPath Tutorial -- comments are down right now

"Osteoarthritic" lipping
WebPath Tutorial -- comments are down right now

Osteoarthritis
Femoral heads
Webpath -- comments are down right now

RHEUMATOID ARTHRITIS ("RA"; poem NEJM 320: 674, 1989; Lancet 358: 903, 2001; Lancet 373: 659, 2009; Lancet 376: 1094, 2010; molecules NEJM 365: 2205, 2011)

Renoir
Renoir

{25016} rheumatoid arthritis, ulnar deviation
{25017} rheumatoid arthritis, ulnar deviation
{38225} rheumatoid arthritis, hand
{45602} rheumatoid arthritis, x-ray
{45648} rheumatoid arthritis, foot

Rheumatoid Arthritis
From Chile
In Spanish

Rheumatoid arthritis

WebPath Tutorial -- comments are down right now

Rheumatoid nodule
Clickable
WebPath Tutorial -- comments are down right now

Rheumatoid nodule

WebPath Tutorial -- comments are down right now

Chronic synovitis in rheumatoid arthritis

WebPath Tutorial -- comments are down right now

{49503} pannus, gross
{49504} pannus, gross
{46391} pannus, gross, up close
{24636} pannus, micro, eroding bone
{10313} pannus, micro, eroding bone
{19415} pannus, showing lymphocytes
{19418} pannus, showing lymphocytes

{24635} rheumatoid arthritis, damaged joint
{24633} rheumatoid arthritis, mutilated joints
{46392} rheumatoid arthritis, x-ray showing erosions
{24634} destruction of finger joints in rheumatoid arthritis

Renoir

{30286} rheumatoid disease of axis
{30288} rheumatoid disease of axis

{12473} rheumatoid nodule, patient
{09000} rheumatoid nodule, histology
{08999} rheumatoid nodule, histology

JUVENILE IDIOPATHIC ARTHRITIS ("juvenile rheumatoid arthritis"; "Still's disease"): Review Ped. Clin. N.A. 52: 413, 2005; Lancet 369: 767, 2007; Lancet 377: 2138, 2011.

"THE REACTIVE ENTHESOPATHIES" (seronegative spondyloarthropathies, HLA-B27 family; these are NOT "variants of rheumatoid arthritis")

{46390} ankylosing spondylitis
{49505} ankylosing spondylitis
{49506} ankylosing spondylitis

{12289} Reactive arthritis, scaly rash
{12290} Reactive arthritis, scaly rash

POLYMYALGIA RHEUMATICA is a poorly-understood, very underdiagnosed, very common pain syndrome without any known anatomic correlate or joint findings, usually occurring in folks over age 50, with morning stiffness and pain especially in the neck, shoulders, and/or pelvic girdle. The sed rate and CRP are reliably elevated and the response to a low dose of a glucocorticoid is dramatic. It runs with the more ominous temporal arteritis. See Lancet 381: 63, 2013.

LOW BACK PAIN (remember there's also "neck pain"). Review Br. Med. J. 310: 929, 1995; update Lancet 369: 726, 2007. I strongly recommend the Lancet 2007 article, and not just because it urges practitioners to consider referring patients for manipulation.

{11449} Pott's disease

Joint TB
Pittsburgh Pathology Cases

Richard Hallgren PhD
Guide to Osteopathic Manipulation

SUPPURATIVE ARTHRITIS ("septic arthritis", i.e., bacterial infection in a joint; Lancet 375: 846, 2010)

Gonococcal arthritis
WebPath Tutorial -- comments are down right now

SYNOVIAL BIOPSY

RELAPSING POLYCHONDRITIS (Ann. Int. Med. 129: 114, 1998)

Relapsing Polychondritis

CALCIUM CRYSTAL DEPOSITION DISEASE:

{14258} pseudogout (or so they tell me...)
{14261} pseudogout (ditto)

"Osteoarthritic" lipping
WebPath Tutorial -- comments are down right now

SYNOVIAL SARCOMA

PIGMENTED VILLINODULAR SYNOVITIS

{09655} pigmented villonodular synovitis, gross

FIBROUS HISTIOCYTOMAS

{25592} dermatofibroma, gross
{12203} dermatofibroma, darkly pigmented
{12774} dermatofibroma, gross
{12775} dermatofibroma, gross; this one was quite vascular
{12777} dermatofibroma, gross
{39954} dermatofibroma, section
{24260} dermatofibroma, histology (good spindle-cell histiocytes)

{21145} malignant fibrous histiocytoma, buttock; you need only recognize this is a deep soft-tissue cancer (i.e., probably a sarcoma)
{09019} malignant fibrous histiocytoma, histology; you need only recognize this is a spindle-cell malignancy
{09021} malignant fibrous histiocytoma; you need only recognize this is a malignancy; the cells do remind me of those in a granuloma

TENDONS AND BURSAE

{12025} bursitis

{49523} Dupuytren's contracture

The late sequelae of prosthetic joints is only now coming under study. One group suggests that when there is a metal-on-metal joint, tiny particles excite an immune / inflammatory response that is responsible for lysis of nearby bone (J. Bone Joint. Surg. Am. 88: 1183, 2006).

Famous arthritics (Clin. Rheum. 8: 442, 1989): John Madison (rheumatoid arthritis); Renoir (rheumatoid arthritis; his disability influenced his painting style and thus the development of impressionism); Columbus (reactive arthritis? also Arch. Int. Med. 152: 274, 1992).

Bunion
Hallux valgus
WebPath Tutorial -- comments are down right now

Gout

WebPath Tutorial -- comments are down right now

Gout
X-ray
WebPath Tutorial -- comments are down right now

Gout
Tophus
WebPath Tutorial -- comments are down right now

Gout
Uric acid crystals
WebPath Tutorial -- comments are down right now

Gout
Photomicrograph of tophus
KU Collection

Dislocated knee
Tom Demark's Site

Dislocated knee
Ischemic complications
Tom Demark's Site

BIBLIOGRAPHY / FURTHER READING

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