Locomotor system 2
Inhoudsopgave
SLE – Sjögren ................................................................................................................................ 8
Systemische ziekten ........................................................................................................................ 8
SLE ................................................................................................................................................. 8
Sjögren .......................................................................................................................................... 11
Anti-fosfolipide syndroom .............................................................................................................. 14
Scleroderma – myositis ............................................................................................................... 15
Scleroderma (systemische sclerose) .............................................................................................. 15
Polymyositis/dermatomyositis (PM/DM).......................................................................................... 17
Vasculitis .................................................................................................................................... 21
Classificatie .................................................................................................................................. 21
Polyarteritis nodosa ....................................................................................................................... 22
Leukocytoclastische vasculitis ....................................................................................................... 23
Granulomateuze vasculitis ............................................................................................................. 24
Giant cell arteritis........................................................................................................................... 24
Vasculitis samenvatting ................................................................................................................. 25
Casussen ...................................................................................................................................... 26
Cervicale wervelkolom ................................................................................................................ 27
Epidemiologie en risicofactoren van spinale aandoeningen .............................................................. 27
Anatomie ....................................................................................................................................... 29
Symptomen en tekens.................................................................................................................... 31
Pathologie cervicale wervelkolom ................................................................................................... 32
Casus 1 ......................................................................................................................................... 34
Casus 2 ......................................................................................................................................... 36
Cervicale spondylosis .................................................................................................................... 37
Reumatoïde artritis (RA) ................................................................................................................. 40
DD van brachialgie ......................................................................................................................... 42
Wervelkolom aandoeningen: .......................................................................................................... 45
Spondyloartritis .......................................................................................................................... 46
1
, Inleiding ........................................................................................................................................ 46
Pathogenese ................................................................................................................................. 47
Axiale spondyloartritis .................................................................................................................... 47
Psoriatische artritis ........................................................................................................................ 49
IBD-gerelateerde spondyloartritis ................................................................................................... 51
Reactieve artritis ............................................................................................................................ 51
Behandeling .................................................................................................................................. 53
Post-infectieuze artritis ............................................................................................................... 55
Meest voorkomende oorzaken in België .......................................................................................... 55
Diagnose ....................................................................................................................................... 55
Behandeling .................................................................................................................................. 55
Sarcoïdose .................................................................................................................................. 56
Symptomen ................................................................................................................................... 56
Diagnose ....................................................................................................................................... 56
Löfgren syndroom .......................................................................................................................... 56
Behandeling .................................................................................................................................. 57
Gegeneraliseerde pijnsyndromen ................................................................................................ 58
Fibromyalgie diagnose ................................................................................................................... 58
Pijnsensitisatie! ............................................................................................................................. 59
Behandeling .................................................................................................................................. 59
Chronisch vermoeidheidsyndroom ................................................................................................. 59
Degeneratieve aandoeningen van de lumbale wervelkolom .......................................................... 61
Anatomie ....................................................................................................................................... 61
Casus............................................................................................................................................ 62
Discushernia ................................................................................................................................. 64
Cauda equina syndroom ................................................................................................................ 67
Spinaal kanaal stenose .................................................................................................................. 70
Bovenste lidmaat – traumatologie ................................................................................................ 73
Essentiële feiten ............................................................................................................................ 73
Fracturen van de clavicula en schoudergordel ................................................................................. 73
Proximale humerale fracturen ........................................................................................................ 75
Humerale shaft fracturen ............................................................................................................... 76
2
, Fracturen rond de elleboog............................................................................................................. 76
Voorarm fracturen.......................................................................................................................... 77
Fracturen van de pols en hand ........................................................................................................ 78
Zenuw en pees injuries ................................................................................................................... 79
Radiculopathie vs. perifere pijnsyndromen................................................................................... 80
Zenuw(wortel) compressie vs. gerefereerde pijn .............................................................................. 80
Radiculaire pijn .............................................................................................................................. 80
Pseudoradiculair?/gereferreerde pijn .............................................................................................. 81
DD van beenpijn............................................................................................................................. 81
Spondylolysis en spondylolisthesis .............................................................................................. 87
Terminologie .................................................................................................................................. 87
Classificatie .................................................................................................................................. 87
Isthmic spondylolisthesis ............................................................................................................... 88
Degeneratieve spondylolisthesis .................................................................................................... 88
Symptomen ................................................................................................................................... 89
Diagnose ....................................................................................................................................... 89
Behandeling .................................................................................................................................. 90
Fragility (pathologische) fracturen van de wervelzuil ..................................................................... 92
Definitie......................................................................................................................................... 92
Oorzaken ....................................................................................................................................... 92
VCF ............................................................................................................................................... 92
Metastatic spine disease (MSD) ...................................................................................................... 94
Imaging: bottumoren ................................................................................................................... 98
Doel .............................................................................................................................................. 98
RX bij de initiële diagnose van bottumoren....................................................................................... 98
Belangrijke discriminatoren ............................................................................................................ 98
Globale aanpak botlaesies‼ ........................................................................................................... 99
Matrix en mineralisatie ..................................................................................................................101
Solitaire vs. multipele botlaesies ...................................................................................................101
Advanced beeldvorming ................................................................................................................102
Botvormende tumoren ..................................................................................................................102
Kraakbeenvormende tumoren .......................................................................................................104
Fibreuze (en andere) tumoren ........................................................................................................105
3
, Maligne tumoren ...........................................................................................................................107
Imaging van infectie................................................................................................................... 111
Osteomyelitis ...............................................................................................................................111
Spinale infectie .............................................................................................................................113
Facet septische artritis ..................................................................................................................115
Septische artritis ...........................................................................................................................115
Beeldvorming spondyloartritis ................................................................................................... 116
Sacroiliitis ....................................................................................................................................116
Assessment van spondyloartritis International Society....................................................................117
Ankylosing spondylitis ...................................................................................................................117
Psoriase spondylitis ......................................................................................................................118
CRMO/SAPHO ..............................................................................................................................118
DISH (Forestier ziekte) ...................................................................................................................119
Degeneratieve spine .....................................................................................................................119
Spinale infecties........................................................................................................................ 120
Pathofysiologie van spinale infecties! .............................................................................................120
Klinische presentatie.....................................................................................................................121
Radiografische evaluatie ...............................................................................................................123
Behandeling .................................................................................................................................124
Conclusies: spinale infectie...........................................................................................................125
Spinale tumoren ........................................................................................................................ 126
Spinale column tumoren (SCT) ......................................................................................................126
Diagnose en behandeling ..............................................................................................................128
Spinal cord injury....................................................................................................................... 129
SCI ...............................................................................................................................................129
ASIA score ....................................................................................................................................129
Diagnose ......................................................................................................................................130
Hypovolemische shock/neurogene shock/spinale shock‼ ..............................................................130
Neurologie en het spinaal kanaal (herhaling!) ............................................................................. 131
Cervicobrachialgie ........................................................................................................................131
Cervicale myelopathie (SCS) .........................................................................................................132
Spinal cord injury ..........................................................................................................................133
4
, ASIA score ....................................................................................................................................133
Hypovolemische shock/neurogene shock/spinale shock‼ ..............................................................134
Conus medullaris/cauda equina ....................................................................................................134
Lumbo-sciatica .............................................................................................................................135
Spinaal kanaal stenose .................................................................................................................135
Spinopelvische pathologie ......................................................................................................... 136
Anatomie ......................................................................................................................................136
SI-gewricht ...................................................................................................................................137
Coccygodynie ...............................................................................................................................140
Stress fracturen van sacrum ..........................................................................................................141
Onderste lidmaat: de heup......................................................................................................... 142
Anatomie ......................................................................................................................................142
Semiologie! ..................................................................................................................................142
Articulaire pathologie ....................................................................................................................143
Weke delen pathologie ..................................................................................................................146
Onderste lidmaat: de knie .......................................................................................................... 151
Anatomie ......................................................................................................................................151
Semiologie ...................................................................................................................................151
Articulaire pathologie ....................................................................................................................152
Patello-femorale pathologie ..........................................................................................................157
Zwelling rond de knie.....................................................................................................................159
Infecties van het bewegingsstelsel ............................................................................................. 160
Osteomyelitis ...............................................................................................................................160
Prosthetic joint infection (PJI) .........................................................................................................162
Necrotiserende fascitis .................................................................................................................163
Septische artritis ...........................................................................................................................164
Kinder orthopedie...................................................................................................................... 165
Uitlijning en rotatie ........................................................................................................................165
Beenlengteverschil .......................................................................................................................166
Lang postuur.................................................................................................................................168
Voet deformiteiten ........................................................................................................................168
Kniepijn ........................................................................................................................................169
5
, Frequente klachten .......................................................................................................................170
Pediatrische heuppathologie .........................................................................................................172
Onderste lidmaat: enkel en voet................................................................................................. 176
Anatomie ......................................................................................................................................176
Semiologie ...................................................................................................................................177
Enkelartrose .................................................................................................................................178
Pes planus/pes valgus = platvoeten ...............................................................................................178
Pes cavus = holvoeten ...................................................................................................................180
Hallux valgus bij volwassenen .......................................................................................................180
Lesser toe deformiteit ...................................................................................................................182
Charcot-Marie-Tooth disease (CMT)...............................................................................................182
Ankle sprain (omgeslagen enkel)....................................................................................................183
Osteochondrale lesie van de talus .................................................................................................184
Tarsaal tunnel syndroom ...............................................................................................................185
Interdigitale neuroma (Morton’s) ....................................................................................................186
Peespathologie .............................................................................................................................187
Onderste lidmaat: traumatologie ............................................................................................... 189
Hoe ontstaan fracturen?................................................................................................................189
Mechanisme‼ ...............................................................................................................................189
Types fracturen .............................................................................................................................189
Genezing van fractuur ...................................................................................................................190
Klinische presentatie.....................................................................................................................191
Behandeling .................................................................................................................................191
Heupdislocatie .............................................................................................................................192
Bekkenfractuur .............................................................................................................................193
Proximale femurfracturen‼ ............................................................................................................193
Femurschaft fracturen ..................................................................................................................195
Distale femurfracturen ..................................................................................................................195
Patella fracturen ...........................................................................................................................196
Knie dislocatie ..............................................................................................................................196
Tibia fracturen...............................................................................................................................196
Enkelfracturen ..............................................................................................................................198
Calcaneus fracturen .....................................................................................................................198
6
, Lisfranc dislocatie .........................................................................................................................198
Fracturen bij kinderen ...................................................................................................................199
Compartiment syndroom! (ACS) ....................................................................................................199
Open fractuern .............................................................................................................................201
Tendinopathie ........................................................................................................................... 202
Definitie........................................................................................................................................202
Biomechanica van een pees ..........................................................................................................202
Risicofactoren! .............................................................................................................................202
Meest voorkomende tendinopathieën ............................................................................................203
Klinische presentatie van tendinopathie .........................................................................................203
Behandeling tendinopathie ............................................................................................................204
Specifieke tendinopathieën ...........................................................................................................205
Bot en weke delen tumoren ........................................................................................................ 209
Epidemiologie ...............................................................................................................................209
Algemeen overzicht.......................................................................................................................209
Symptomen bot- en weke delen tumoren .......................................................................................209
Klinisch onderzoek ........................................................................................................................210
Beeldvorming ...............................................................................................................................210
Work up ........................................................................................................................................212
Casussen .....................................................................................................................................212
Bovenste lidmaat: bewegingstherapie en rehabilitatie ................................................................ 213
Rotator cuff impingement syndroom ..............................................................................................213
Tenniselleboog (laterale epicondylitis) ...........................................................................................216
Carpaal tunnel syndroom (CTS) .....................................................................................................217
Dupuytren’s contractuur = palmaire fibromatose............................................................................218
Ziekte van de Quervain ..................................................................................................................219
Complex regionaal pijnsyndroom...................................................................................................221
7
,SLE – Sjögren
Systemische ziekten
= systemische auto-immuunziekten
= bindweefsel ziekten (sensu lato) (sensu stricto = Marfan, Ehlers Danlos…)
= collageen vasculaire ziektes
- In concreto:
o SLE (systemische lupus erythematosus) = LED (lupus erythematosus
disseminatus) = het prototype
o Polymyositis/dermatomyositis
o Systemische sclerose (diffuus type en CREST)
o Sjögren
o Systemische vasculitides
o (RA)
SLE
Initiële dominante manifestaties van SLE
- Artralgie en/of artritis (55%)
- Huid ziekte (20%)
- Nefritis (5-10%)
- CZS-ziekte (5%)
- Serositis (sera: pleura, pericardia) (5-10%)
- Koorts (5-10%)
- Anemie (2%)
- Thrombocytopenie (2%)
- Leukopenie (2%)
- Andere (thromboflebitis, vermoeidheid, pneumonitis, keelpijn, braken, Raynaud, vals+
syfilis serologie) (1%)
American College of Rheumatology (ACR) criteria voor lupus
- Malaire rash (butterfly rash in het gezicht)
- Orale ulceratie
- Discoïde rash (zeer omschreven, diskvormige rash)
- Fotosensitiviteit
- Artritis
- Serositis
o Pleurisy of pericarditis
- Neurologische aandoening
o Convulsies
o Psychose
8
, - Nieraandoening
o Proteïnurie (>0.5 g/dag)
o Cellulaire afzetting in urine
- Hematologische aandoening
o Leukopenie (<4000/ml)
o Lymfopenie (<15 000/ml)
o Hemolytische anemie
o Thrombocytopenie (<100 000/ml)
- Immunologische aandoening
o Positieve antilichamen voor dubbel-stranded DNA
o Anti-Sm antilichamen
o Positieve antifosfolipide antilichamen: IgG of IgM anticardiolipine OF een
positieve lupus anticoagulant OF een biologische vals-positieve test voor
syphilis
- Anti-nucleaire antilichamen (ANA) positief)
ð SLE bij minstens 4 criteria (van de hoofdgroep) aanwezig
→ Ulnaire deviatie van MCP en zwanenhalsdeformiteiten, maar NOOIT erosies te zien op RX
Butterfly rash:
9
, Discoïde rash (hierbij niet veel interne organen aangedaan):
Labo
- Hematologische abnormaliteiten
- Immunologische aandoeningen:
o ANA: >85% (in hoge titers!)
o Anti-dsDNA: actieve SLE
o Reumatoïde factor: lage titer
o CIC, C-consumptie (↓C4, ↓THC, ↑C3d)
Kliniek
- Nier betrokkenheid
o Slechte prognose
o Urine sediment abnormaliteiten (casts, hematurie), proteïnurie en/of
nierfunctie↓: 50% van SLE ptn
Biopsie: meer dan 95% van ptn
Terminale nierinsufficiëntie: zeldzaam (<5%)
o Dus niet alleen creatinine in bloed meten, want laat teken → sediment
abnormaliteiten en proteïnurie gaat sneller
o Glomerulonefritis: van mild (mesangiaal) tot ernstig diffuus proliferatief
o Meestal graduel progressief, soms acuut
o Behandeling: immuunsuppressieve dosis corticosteroïden + cytostatica
Immuunfluorescentie glomerulus → immuuncomplex depositie:
10
Inhoudsopgave
SLE – Sjögren ................................................................................................................................ 8
Systemische ziekten ........................................................................................................................ 8
SLE ................................................................................................................................................. 8
Sjögren .......................................................................................................................................... 11
Anti-fosfolipide syndroom .............................................................................................................. 14
Scleroderma – myositis ............................................................................................................... 15
Scleroderma (systemische sclerose) .............................................................................................. 15
Polymyositis/dermatomyositis (PM/DM).......................................................................................... 17
Vasculitis .................................................................................................................................... 21
Classificatie .................................................................................................................................. 21
Polyarteritis nodosa ....................................................................................................................... 22
Leukocytoclastische vasculitis ....................................................................................................... 23
Granulomateuze vasculitis ............................................................................................................. 24
Giant cell arteritis........................................................................................................................... 24
Vasculitis samenvatting ................................................................................................................. 25
Casussen ...................................................................................................................................... 26
Cervicale wervelkolom ................................................................................................................ 27
Epidemiologie en risicofactoren van spinale aandoeningen .............................................................. 27
Anatomie ....................................................................................................................................... 29
Symptomen en tekens.................................................................................................................... 31
Pathologie cervicale wervelkolom ................................................................................................... 32
Casus 1 ......................................................................................................................................... 34
Casus 2 ......................................................................................................................................... 36
Cervicale spondylosis .................................................................................................................... 37
Reumatoïde artritis (RA) ................................................................................................................. 40
DD van brachialgie ......................................................................................................................... 42
Wervelkolom aandoeningen: .......................................................................................................... 45
Spondyloartritis .......................................................................................................................... 46
1
, Inleiding ........................................................................................................................................ 46
Pathogenese ................................................................................................................................. 47
Axiale spondyloartritis .................................................................................................................... 47
Psoriatische artritis ........................................................................................................................ 49
IBD-gerelateerde spondyloartritis ................................................................................................... 51
Reactieve artritis ............................................................................................................................ 51
Behandeling .................................................................................................................................. 53
Post-infectieuze artritis ............................................................................................................... 55
Meest voorkomende oorzaken in België .......................................................................................... 55
Diagnose ....................................................................................................................................... 55
Behandeling .................................................................................................................................. 55
Sarcoïdose .................................................................................................................................. 56
Symptomen ................................................................................................................................... 56
Diagnose ....................................................................................................................................... 56
Löfgren syndroom .......................................................................................................................... 56
Behandeling .................................................................................................................................. 57
Gegeneraliseerde pijnsyndromen ................................................................................................ 58
Fibromyalgie diagnose ................................................................................................................... 58
Pijnsensitisatie! ............................................................................................................................. 59
Behandeling .................................................................................................................................. 59
Chronisch vermoeidheidsyndroom ................................................................................................. 59
Degeneratieve aandoeningen van de lumbale wervelkolom .......................................................... 61
Anatomie ....................................................................................................................................... 61
Casus............................................................................................................................................ 62
Discushernia ................................................................................................................................. 64
Cauda equina syndroom ................................................................................................................ 67
Spinaal kanaal stenose .................................................................................................................. 70
Bovenste lidmaat – traumatologie ................................................................................................ 73
Essentiële feiten ............................................................................................................................ 73
Fracturen van de clavicula en schoudergordel ................................................................................. 73
Proximale humerale fracturen ........................................................................................................ 75
Humerale shaft fracturen ............................................................................................................... 76
2
, Fracturen rond de elleboog............................................................................................................. 76
Voorarm fracturen.......................................................................................................................... 77
Fracturen van de pols en hand ........................................................................................................ 78
Zenuw en pees injuries ................................................................................................................... 79
Radiculopathie vs. perifere pijnsyndromen................................................................................... 80
Zenuw(wortel) compressie vs. gerefereerde pijn .............................................................................. 80
Radiculaire pijn .............................................................................................................................. 80
Pseudoradiculair?/gereferreerde pijn .............................................................................................. 81
DD van beenpijn............................................................................................................................. 81
Spondylolysis en spondylolisthesis .............................................................................................. 87
Terminologie .................................................................................................................................. 87
Classificatie .................................................................................................................................. 87
Isthmic spondylolisthesis ............................................................................................................... 88
Degeneratieve spondylolisthesis .................................................................................................... 88
Symptomen ................................................................................................................................... 89
Diagnose ....................................................................................................................................... 89
Behandeling .................................................................................................................................. 90
Fragility (pathologische) fracturen van de wervelzuil ..................................................................... 92
Definitie......................................................................................................................................... 92
Oorzaken ....................................................................................................................................... 92
VCF ............................................................................................................................................... 92
Metastatic spine disease (MSD) ...................................................................................................... 94
Imaging: bottumoren ................................................................................................................... 98
Doel .............................................................................................................................................. 98
RX bij de initiële diagnose van bottumoren....................................................................................... 98
Belangrijke discriminatoren ............................................................................................................ 98
Globale aanpak botlaesies‼ ........................................................................................................... 99
Matrix en mineralisatie ..................................................................................................................101
Solitaire vs. multipele botlaesies ...................................................................................................101
Advanced beeldvorming ................................................................................................................102
Botvormende tumoren ..................................................................................................................102
Kraakbeenvormende tumoren .......................................................................................................104
Fibreuze (en andere) tumoren ........................................................................................................105
3
, Maligne tumoren ...........................................................................................................................107
Imaging van infectie................................................................................................................... 111
Osteomyelitis ...............................................................................................................................111
Spinale infectie .............................................................................................................................113
Facet septische artritis ..................................................................................................................115
Septische artritis ...........................................................................................................................115
Beeldvorming spondyloartritis ................................................................................................... 116
Sacroiliitis ....................................................................................................................................116
Assessment van spondyloartritis International Society....................................................................117
Ankylosing spondylitis ...................................................................................................................117
Psoriase spondylitis ......................................................................................................................118
CRMO/SAPHO ..............................................................................................................................118
DISH (Forestier ziekte) ...................................................................................................................119
Degeneratieve spine .....................................................................................................................119
Spinale infecties........................................................................................................................ 120
Pathofysiologie van spinale infecties! .............................................................................................120
Klinische presentatie.....................................................................................................................121
Radiografische evaluatie ...............................................................................................................123
Behandeling .................................................................................................................................124
Conclusies: spinale infectie...........................................................................................................125
Spinale tumoren ........................................................................................................................ 126
Spinale column tumoren (SCT) ......................................................................................................126
Diagnose en behandeling ..............................................................................................................128
Spinal cord injury....................................................................................................................... 129
SCI ...............................................................................................................................................129
ASIA score ....................................................................................................................................129
Diagnose ......................................................................................................................................130
Hypovolemische shock/neurogene shock/spinale shock‼ ..............................................................130
Neurologie en het spinaal kanaal (herhaling!) ............................................................................. 131
Cervicobrachialgie ........................................................................................................................131
Cervicale myelopathie (SCS) .........................................................................................................132
Spinal cord injury ..........................................................................................................................133
4
, ASIA score ....................................................................................................................................133
Hypovolemische shock/neurogene shock/spinale shock‼ ..............................................................134
Conus medullaris/cauda equina ....................................................................................................134
Lumbo-sciatica .............................................................................................................................135
Spinaal kanaal stenose .................................................................................................................135
Spinopelvische pathologie ......................................................................................................... 136
Anatomie ......................................................................................................................................136
SI-gewricht ...................................................................................................................................137
Coccygodynie ...............................................................................................................................140
Stress fracturen van sacrum ..........................................................................................................141
Onderste lidmaat: de heup......................................................................................................... 142
Anatomie ......................................................................................................................................142
Semiologie! ..................................................................................................................................142
Articulaire pathologie ....................................................................................................................143
Weke delen pathologie ..................................................................................................................146
Onderste lidmaat: de knie .......................................................................................................... 151
Anatomie ......................................................................................................................................151
Semiologie ...................................................................................................................................151
Articulaire pathologie ....................................................................................................................152
Patello-femorale pathologie ..........................................................................................................157
Zwelling rond de knie.....................................................................................................................159
Infecties van het bewegingsstelsel ............................................................................................. 160
Osteomyelitis ...............................................................................................................................160
Prosthetic joint infection (PJI) .........................................................................................................162
Necrotiserende fascitis .................................................................................................................163
Septische artritis ...........................................................................................................................164
Kinder orthopedie...................................................................................................................... 165
Uitlijning en rotatie ........................................................................................................................165
Beenlengteverschil .......................................................................................................................166
Lang postuur.................................................................................................................................168
Voet deformiteiten ........................................................................................................................168
Kniepijn ........................................................................................................................................169
5
, Frequente klachten .......................................................................................................................170
Pediatrische heuppathologie .........................................................................................................172
Onderste lidmaat: enkel en voet................................................................................................. 176
Anatomie ......................................................................................................................................176
Semiologie ...................................................................................................................................177
Enkelartrose .................................................................................................................................178
Pes planus/pes valgus = platvoeten ...............................................................................................178
Pes cavus = holvoeten ...................................................................................................................180
Hallux valgus bij volwassenen .......................................................................................................180
Lesser toe deformiteit ...................................................................................................................182
Charcot-Marie-Tooth disease (CMT)...............................................................................................182
Ankle sprain (omgeslagen enkel)....................................................................................................183
Osteochondrale lesie van de talus .................................................................................................184
Tarsaal tunnel syndroom ...............................................................................................................185
Interdigitale neuroma (Morton’s) ....................................................................................................186
Peespathologie .............................................................................................................................187
Onderste lidmaat: traumatologie ............................................................................................... 189
Hoe ontstaan fracturen?................................................................................................................189
Mechanisme‼ ...............................................................................................................................189
Types fracturen .............................................................................................................................189
Genezing van fractuur ...................................................................................................................190
Klinische presentatie.....................................................................................................................191
Behandeling .................................................................................................................................191
Heupdislocatie .............................................................................................................................192
Bekkenfractuur .............................................................................................................................193
Proximale femurfracturen‼ ............................................................................................................193
Femurschaft fracturen ..................................................................................................................195
Distale femurfracturen ..................................................................................................................195
Patella fracturen ...........................................................................................................................196
Knie dislocatie ..............................................................................................................................196
Tibia fracturen...............................................................................................................................196
Enkelfracturen ..............................................................................................................................198
Calcaneus fracturen .....................................................................................................................198
6
, Lisfranc dislocatie .........................................................................................................................198
Fracturen bij kinderen ...................................................................................................................199
Compartiment syndroom! (ACS) ....................................................................................................199
Open fractuern .............................................................................................................................201
Tendinopathie ........................................................................................................................... 202
Definitie........................................................................................................................................202
Biomechanica van een pees ..........................................................................................................202
Risicofactoren! .............................................................................................................................202
Meest voorkomende tendinopathieën ............................................................................................203
Klinische presentatie van tendinopathie .........................................................................................203
Behandeling tendinopathie ............................................................................................................204
Specifieke tendinopathieën ...........................................................................................................205
Bot en weke delen tumoren ........................................................................................................ 209
Epidemiologie ...............................................................................................................................209
Algemeen overzicht.......................................................................................................................209
Symptomen bot- en weke delen tumoren .......................................................................................209
Klinisch onderzoek ........................................................................................................................210
Beeldvorming ...............................................................................................................................210
Work up ........................................................................................................................................212
Casussen .....................................................................................................................................212
Bovenste lidmaat: bewegingstherapie en rehabilitatie ................................................................ 213
Rotator cuff impingement syndroom ..............................................................................................213
Tenniselleboog (laterale epicondylitis) ...........................................................................................216
Carpaal tunnel syndroom (CTS) .....................................................................................................217
Dupuytren’s contractuur = palmaire fibromatose............................................................................218
Ziekte van de Quervain ..................................................................................................................219
Complex regionaal pijnsyndroom...................................................................................................221
7
,SLE – Sjögren
Systemische ziekten
= systemische auto-immuunziekten
= bindweefsel ziekten (sensu lato) (sensu stricto = Marfan, Ehlers Danlos…)
= collageen vasculaire ziektes
- In concreto:
o SLE (systemische lupus erythematosus) = LED (lupus erythematosus
disseminatus) = het prototype
o Polymyositis/dermatomyositis
o Systemische sclerose (diffuus type en CREST)
o Sjögren
o Systemische vasculitides
o (RA)
SLE
Initiële dominante manifestaties van SLE
- Artralgie en/of artritis (55%)
- Huid ziekte (20%)
- Nefritis (5-10%)
- CZS-ziekte (5%)
- Serositis (sera: pleura, pericardia) (5-10%)
- Koorts (5-10%)
- Anemie (2%)
- Thrombocytopenie (2%)
- Leukopenie (2%)
- Andere (thromboflebitis, vermoeidheid, pneumonitis, keelpijn, braken, Raynaud, vals+
syfilis serologie) (1%)
American College of Rheumatology (ACR) criteria voor lupus
- Malaire rash (butterfly rash in het gezicht)
- Orale ulceratie
- Discoïde rash (zeer omschreven, diskvormige rash)
- Fotosensitiviteit
- Artritis
- Serositis
o Pleurisy of pericarditis
- Neurologische aandoening
o Convulsies
o Psychose
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, - Nieraandoening
o Proteïnurie (>0.5 g/dag)
o Cellulaire afzetting in urine
- Hematologische aandoening
o Leukopenie (<4000/ml)
o Lymfopenie (<15 000/ml)
o Hemolytische anemie
o Thrombocytopenie (<100 000/ml)
- Immunologische aandoening
o Positieve antilichamen voor dubbel-stranded DNA
o Anti-Sm antilichamen
o Positieve antifosfolipide antilichamen: IgG of IgM anticardiolipine OF een
positieve lupus anticoagulant OF een biologische vals-positieve test voor
syphilis
- Anti-nucleaire antilichamen (ANA) positief)
ð SLE bij minstens 4 criteria (van de hoofdgroep) aanwezig
→ Ulnaire deviatie van MCP en zwanenhalsdeformiteiten, maar NOOIT erosies te zien op RX
Butterfly rash:
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, Discoïde rash (hierbij niet veel interne organen aangedaan):
Labo
- Hematologische abnormaliteiten
- Immunologische aandoeningen:
o ANA: >85% (in hoge titers!)
o Anti-dsDNA: actieve SLE
o Reumatoïde factor: lage titer
o CIC, C-consumptie (↓C4, ↓THC, ↑C3d)
Kliniek
- Nier betrokkenheid
o Slechte prognose
o Urine sediment abnormaliteiten (casts, hematurie), proteïnurie en/of
nierfunctie↓: 50% van SLE ptn
Biopsie: meer dan 95% van ptn
Terminale nierinsufficiëntie: zeldzaam (<5%)
o Dus niet alleen creatinine in bloed meten, want laat teken → sediment
abnormaliteiten en proteïnurie gaat sneller
o Glomerulonefritis: van mild (mesangiaal) tot ernstig diffuus proliferatief
o Meestal graduel progressief, soms acuut
o Behandeling: immuunsuppressieve dosis corticosteroïden + cytostatica
Immuunfluorescentie glomerulus → immuuncomplex depositie:
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