%0 Journal Article
%T A Debilitating Orthopaedic Complication following Corticosteroid Therapy for Polymyalgia Rheumatica
%A Paul Rai
%A Vinay Takwale
%J Case Reports in Rheumatology
%D 2014
%I Hindawi Publishing Corporation
%R 10.1155/2014/515361
%X Avascular necrosis (AVN) of the scaphoid secondary to corticosteroid use is a rare entity. Previous reports in the literature refer to chronic steroid intake. We report a case secondary to low dose, short term use. AVN has a multifactorial cellular and genetic aetiology and most frequently affects the femoral head. Diagnosis relies on a high index of suspicion and early magnetic resonance (MR) scanning. Treatment options are similar to those of traumatic scaphoid nonunions and include vascularised bone grafting and scaphoid excision. Polymyalgia Rheumatica is a common condition and its treatment is led by corticosteroid use. Mild to moderate strengths are advocated. However in our report we show that even with small doses serious adverse effects can be encountered. 1. Introduction 1.1. Nontraumatic Avascular Necrosis Avascular necrosis (AVN) is a condition that occurs at multiple sites in the body with vulnerable arterial perfusion. There are traumatic and nontraumatic causes. Avascular necrosis of the scaphoid in the absence of trauma is a rare but recognised condition. There are many known associated risk factors and precipitants of AVN. The major categories include drugs (most commonly corticosteroids [1]), infection, coagulation disorders, haemoglobinopathies, and miscellaneous causes. The common miscellaneous causes are Perthes¡¯ disease, alcohol, systemic lupus erythematosus (SLE), and pregnancy [2]. Corticosteroids are thought to induce avascular necrosis by two mechanisms: (1) intravascular thrombosis of sinusoids and capillaries in the bone marrow and (2) increasing marrow pressure, reducing intraosseous perfusion. Sinusoidal thrombosis results in vascular stasis increasing arterial occlusion further in a vicious cycle [2]. The clinical features usually consist of an initial asymptomatic period, followed by worsening pain and swelling. Restricted movement and deformity may be encountered. The radiograph changes are minimal in the first few months. Sclerosis from attempts at new bone formation appears after this time with preservation of the joint line. Late in the disease, joint line destruction and deformity become apparent. With the recent increased availability of MR scanning, changes can be seen a lot sooner with areas of low intensity signal on T1 and T2 weighted images early in the disease [3]. 1.2. Polymyalgia Rheumatica (PMR) PMR is the most common inflammatory rheumatological condition among elderly people in the United Kingdom (UK). It has an estimated prevalence of 2% in people over 60 years of age in the UK [4]. The British Society
%U http://www.hindawi.com/journals/crirh/2014/515361/