Edema of periarticular tissues

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CHAPTER VI.
JOINT SYNDROME
- Characteristics of arthralgia.
- Diagnostic value of arthralgias in various diseases.
- Differential and diagnostic signs of diseases accompanied by arthralgia.
The term "arthralgia" comes from two Greekwords: arthros - joint and algos - pain, i.e. joint pain. We often talk about pain in the joint. The causes of arthralgia may be inflammation of the joint, dystrophic changes in it, infectious or infectious allergic diseases, a tumor process in any organ or system, accompanied by joint syndrome, hemoblastosis, trauma, some somatic and skin diseases. This is far from a complete list of possible causes of arthralgia, since almost all rheumatic diseases, which according to modern classification of about 100 forms, are accompanied by arthralgia.
Arthralgia by nature, timeappearance, duration are distinguished by a significant variety, which is due to the strength of the stimulus, the state of the receptor apparatus, the individual sensitivity of the patient. When determining the cause of arthralgia, it is necessary to consider the following very important circumstance. Subjectively, children of the first years of life often complain of general pain in the extremities or point to the site remote from the inflammation focus, in which the pain radiates. On the one hand, this is explained by the tendency of the growing organism to generalized, generalized reactions, and on the other hand, the child's inability to determine the nature and localization of pain. In this regard, often allowed diagnostic errors.

BASIC ARRALGES IN CHILDREN

Short-term, "volatile", joint painarise mainly at night, more often in the joints of the lower extremities - knee and ankle. Their occurrence is associated with the increased growth of the child in the so-called stretching periods, with intense physical activity and playing sports. Clinically and radiological joints are usually not changed, and over time, the pain passes without any intervention. The exception is the Osgood-Schlatter disease, characterized by the defeat of the apophysis of the tibia in the region of its tuberosity. This disease is observed more often in boys aged 13-17 years. Inflammation is absent. Children feel pain in the knee joint and in the region of tuberosity of the tibia during movements, jumps and walking. In the same area, there is sometimes a swelling. Radiographically there is a thickening of the soft tissues over the apophysis of the tibia. The disease passes through 1-2 years without special therapy. With severe pain, rest and anesthetics can be recommended.
The main cause of arthralgia in children arearthritis - various kinds of inflammatory processes, both directly in the joints, and not related to them. This is to some extent due to the fact that the synovial membrane of the joint is one of the bridgeheads of immunological reactions. It is rich in lymphoid cells and reacts to antigenic stimuli like lymph nodes. Released with this biologically active substances, irritating the sensitive nerve endings, can cause pain in the joint. With the development of arthritis, the increase in pain is due to mechanical factors - increased tissue pressure, the appearance of effusion in the joint, fluctuations in osmotic pressure, etc. With arthralgia, resulting from the inflammatory process in the joint, pain is most often in the second half of the night or in the morning, i.e. after a long rest. This is the so-called morning, or "starting", pain associated with the defeat of soft tissue - fibrous and synovial joints.
In this case, arthralgia decrease after movement and in the evening.
With rheumatism - rheumatic feverintense pain in the joints can appear in 2-3 weeks. after angina at the same time as subfebrile temperature, most often without clinical signs of arthritis.
At the same time or 1-2 weeks later. there are changes in the heart (rheumatic carditis) or, more rarely, the nervous system (chorea). In some cases, arthralgia disappears after 7-10 days without consequences, in others true rheumatoid arthritis develops. The pain intensifies, the large joints of the lower extremities are more often affected, and the symmetry of the lesion is not necessary. Inflammation as it passes from one joint to another. The first ones are affected by knee and ankle, then wrist, elbow joints.
Sometimes joint pain with rheumatismaccompanied by fever to 38-39 ° C. Polyarthralgia is often observed without visible changes in the joints. A distinctive feature of the rheumatic process in joints is its acute character without transition to a chronic course. The joints are not deformed, and the volume of movements is completely preserved in them. For differential diagnosis of rheumatic polyarthralgias, it is necessary to use immunological tests and instrumental methods for studying the cardiovascular and nervous systems.
Often, persistent arthralgia accompany exacerbationschronic tonsillitis or acute tonsillitis, can be observed in infectious diseases (the entrance gates of the infection are most often the nasopharynx, urino-genital organs and intestines), against intestinal infections (yersiniosis, salmonella, shigellosis, etc.). With the latter, the inflammation of the synovium is reactive and can develop after 1-1.5 weeks. from the onset of infection. The infectious agent in the synovial fluid, as a rule, is not detected. This kind of joint manifestations are called reactive arthritis.
Chlamydial infection induces the so-calledurethro-oculosynovial syndrome. In this case, the disease often begins with a low-symptom urethritis, and then arthralgia, arthritis and conjunctivitis join. This symptom complex is called Reiter's disease. The defeat of joints (knee, ankle, foot joints), as a rule, is asymmetric. Characteristic arthralgia, the development of arthritis. The joint of the big toe is more often affected. There are blue-purple discoloration of the skin of the finger and a "sausage-shaped" defogation of it. The process extends to the sacroiliac joint (usually on one side). Diagnostically, in addition to the triad of clinical symptoms, it is important to detect chlamydia in scrapings from the urethra and from the conjunctiva, the presence of a positive serological response, as well as an x-ray sign - unilateral sakroileitis. Reiter's disease in 65% of cases occurs in children with a histocompatibility antigen B27.
The most common arthralgia followed by arthritisoccur in children with juvenile rheumatoid arthritis (JRA). This is a complex disease of unclear etiology with autoimmune pathogenesis, which has two main forms - joint and systemic, or articular-visceral (joints are more common). The disease has a chronic, progressive nature. In 40-50% of cases, patients become disabled. Pain can occur in one, two, or at once in several joints. Persistent soreness in one joint, most often in the right or left ankle, may be accompanied by eye damage - unilateral or bilateral rheumatoid uveitis, often complete loss of vision. With persistent monoarthritis, especially in young children, consultation of the oculist is necessary. When 2-3 (oligoarthritis) and more (at first large) joints are involved in the inflammatory process, the symmetry of the lesion is typical. The period of arthralgia without visible changes in the joint is most often short-term (1-2 weeks). Later, typical inflammatory changes occur with a violation of the configuration of the joint and the limitation of the volume of movements in it due to muscle contractures. Sometimes, with an allergy-like variant of JRA, arthralgia is especially intense. Emerging in the morning hours, they are usually accompanied by temperature rises to 39-40 ° C and the appearance of allergic rashes on the extensor surfaces of the extremities.
This triad of symptoms in this case is of great diagnostic significance.
In general, the diagnosis is complex, and at the same timeuse the diagnostic criteria of the American and Eastern European rheumatic association. Early detection of the disease and observation of the child in a rheumatologist are important, since with JRA requires rather serious and long-term therapy, including non-steroidal anti-inflammatory ("basic") drugs, and sometimes corticosteroids. The treatment is carried out under the control of clinical and laboratory and instrumental studies.

Ankylosing spondylitis, or diseaseBekhterev, most often observed in men and boys. Pain occurs in different parts of the spine (central shape), large "root" (shoulder, hip) joints (rhizomyelic form), with or without pain in the spine, in the peripheral joints (peripheral form) or in the small joints of not only the spine but and a brush (Scandinavian form). The disease develops slowly, for 15-20 years, so children are diagnosed much less often than adults. The etiology of the disease is unknown. There is a hereditary predisposition, and also an association with the antigen of histocompatibility B27 (HLA-B27). An early symptom may be the appearance of pain in the heels - at the points of attachment of the Achilles tendon to the calcaneus, as well as in places of attachment of other tendons to the bone (enthesopathy). The pathological process extends mainly to the sacroiliac joint and spine. Progressive destruction of the cartilage with ankylosing of the ileosacral articulation is observed. The main clinical sign of the disease is ankylosis of small joints. Gradually, there is degeneration of the intervertebral discs and an articular capsule with chondroid metaplasia and subsequent ossification of the fibrous ring and capsule, and the soldering of the cartilages is synchondrosis. As a result, all articular tissues are ossified and the spine becomes completely immobile. In early diagnosis, radiographic detection of bilateral sakroileitis is important. Subsequently, with the ossification of the intervertebral ligaments, the spine on the X-ray pattern resembles a "bamboo stick". If there is a suspicion of ankylosing spondylitis, the patient should be referred to a rheumatologist and oculist for consultation, since uveitis may develop. In Bekhterev's disease, non-specific anti-inflammatory drugs (NSAIDs) and methods of functional rehabilitation are used. Treatment is ineffective.
Diffuse connective tissue diseases in children(DBST). According to various authors, arthralgia in the debut of SLE - a bright representative of DBST - occur in 80-100% of cases. Articular syndrome with SLE can have several options. For the initial period of the disease, volatile polyarthralgia and asymmetrical joint damage are characteristic. At the height of the disease, the symmetry of joint damage with signs of moderately expressed arthritis, edema of periarticular tissues, morning stiffness is more typical. In differential diagnosis, the criteria for early diagnosis of SLE are important.
Arthralgia is often one of the initialsymptoms of systemic scleroderma. They often turn into subacute or chronic arthritis, a clinical picture similar to rheumatoid. Joints are affected symmetrically. Characterized by the involvement of small hand and wrist joints in the process with minimal exudative manifestations, but marked consolidation of soft tissues, the development of flexion contractures, subluxations. For differential diagnosis of joint damage in scleroderma, changes in the skin and subcutaneous tissue (pigmentation disorder, compaction, atrophy, characteristic luster) and such radiographic signs as osteolysis or resorption of the terminal phalanges of the fingers, and sometimes calcification of soft tissues (Tibierja-Weissenbach syndrome) are very important ).
Expressed arthralgia may be due totuberculous lesion of joints. The tubercular focus is usually located in the depth of the spongy part of the bone and in the region of the epiphysis or metaphysis. Most often affected by the spine and large joints - hip, knee. The initial period of the process in the bone can develop without clinical manifestations. The patient complains of weakness, rapid fatigue, gait disturbances are possible. With the transition of the process to the articular surfaces of bones and the defeat of the synovial membrane and periarticular tissues, a sharp pain in the joint arises accompanied by painful contracture; signs of inflammation increase. X-ray picture of tuberculous lesion of the joint: pronounced osteoporosis with thinning of the cortical layer of tubular bones, formation of foci of destruction, caverns containing sequestrants, and melting of the integumentary articular cartilages. For diagnosis, the history, positive tuberculin tests, the condition of internal organs, especially the lymphatic apparatus of the thoracic and abdominal cavity, X-ray and tomography data, and puncture biopsy are important. Microbiological studies are also required (planting flora on mediums, infecting laboratory animals), but in carrying out the latter one should take into account that the prolonged use of antibiotics sharply reduces the value of their results (up to 15%). A good result (in 100% of cases) in the diagnosis of tuberculous arthritis can be obtained only if the biopsy material is successfully extracted from the bone focus.
Pain in the joint area is often associated withdevelopment of neoplasms, in particular synovioma - a tumor originating from the synovial membrane of the joint; chondroblastoma (Kodmaki tumor), most often localized in the proximal epiphysis of the humerus and tibia; osteoblastoclastoma, or "myeloid tumor," consisting of giant cells of osteoblasts and osteoclasts. Tumors are benign and malignant. Radiation, X-ray and histological data are of particular value in diagnosing tumors.
Arthralgias and arthritis can be one of themanifestations of the tumor process, localized not only within the supporting motor apparatus, but also outside it, in the form of paraneoplastic syndrome. In this case, there are persistent arthralgia accompanied by persistent fever, microadenopathy, progressive dystrophy and anemia. Of malignant tumors accompanied by articular syndrome, children often have neuroblastoma with changes in the thoracic and lumbar spine, long tubular bones.
Expressed arthralgias and arthritis are observed whensome hematologic diseases. Thus, in leukemia, one of the paraneoplastic syndromes is articular, characterized first by volatile arthralgias with asymmetric joint damage, and then by more arthritis with sharp permanent joint pains, exudative component and pain contractures. With leukemia, arthralgia is often accompanied by ossalgia. In these cases, the main diagnostic value is the study of the material trepanobiopsy, radiography of bones, which reveals large foci of destruction in the metaphyseal regions of the bone and areas of destruction in a compact bone substance in the form of usur (bone "eaten by a moth"). Characteristic is the flattening of vertebral bodies - leukemic breasts.
The defeat of the joints, manifested in the formarthralgia or arthritis, may be one of the signs of hemorrhagic vasculitis (Shenlaine-Henoch disease). Etiologically, hemorrhagic vasculitis is attributed to diseases of an infectious-allergic nature, but the causes of its occurrence are completely unclear. The main symptom of the disease is polymorphic, mainly hemorrhagic rash, localized on the lower limbs, large joints, buttocks. In 42-72% of patients, articular syndrome is also observed, usually in the form of arthralgias, more often symmetrical, in the large joints - knee and ankle. Sometimes arthritis develops with an exudative component in periarticular tissues or with angioneurotic edema in the joint region (Quincke's edema). Articular syndrome, as a rule, is unstable and passes without consequences for several days. The diagnosis is based on a typical exanthema and its combination with abdominal and renal syndromes.
Traumatic injury of the joint. Injuries, especially the knee joint, are most often observed in adolescents during sports, outdoor games. With minor injuries, only pain syndrome is possible, sometimes with external manifestations in the form of an abrasion or bruise. With more severe trauma, posttraumatic synovitis develops, the effusion accumulates in the joint cavity, the contours of the joint change significantly, its function is disrupted, and soreness appears when moving. In such cases, the help of a traumatologist is necessary.
Differential diagnostic signs of diseases accompanied by arthralgia and arthritis are given in Table. 7.
Table 7. Some differential-diagnostic signs of diseases accompanied by arthritis and arthralgia

Rheumatism
Infectious-allergic arthritis (with angina, viral hepatitis, influenza, measles, etc.)

Polyarthritis of small and large joints, arthralgia and arthritis (volatile nature, with complete reversibility of the process), association with infection

Duration more than 3 weeks, symmetryjoint damage, cervical spine injury, morning stiffness, rheumatoid eye disease, epiphyseal osteoporosis, narrowing of the joint space (on the roentgenogram)

Mono-oligoarthritis of the joints of the legs, enthesopathy (pain in theareas of attachment of tendons), early bilateral sakroileitis, ankylosing tarsit (defeat of the joint and tendon-ligamentous apparatus of the feet), the presence of HLA-B27

Relationship with urogenital infection (more often with chlamydia), asymmetric oligoarthritis in the "ladder" type, periostitis in the heel area, unilateral sakroileitis, conjunctivitis, urethritis, the presence of HLA-B27

Asymmetric mono-oligoarthritis, absence of deformations and pathological changes of the joints on the X-ray, resistance to anti-inflammatory therapy, high fever, a sharp increase in ESR