n.

転位、転置、脱臼

WordNet

a displacement of a part (especially a bone) from its normal position (as in the shoulder or the vertebral column)
the act of disrupting an established order so it fails to continue; "the social dislocations resulting from government policies"; "his warning came after the breakdown of talks in London" (同)breakdown
an event that results in a displacement or discontinuity (同)disruption
the movement of persons from one country or locality to another
(chemistry) the nonrandom movement of an atom or radical from one place to another within a molecule
a group of people migrating together (especially in some given time period)
the periodic passage of groups of animals (especially birds or fishes) from one region to another for feeding or breeding
move periodically or seasonally; "birds migrate in the Winter"; "The workers migrate to where the crops need harvesting"
move from one country or region to another and settle there; "Many Germans migrated to South America in the mid-19th century"; "This tribe transmigrated many times over the centuries" (同)transmigrate
transfer a quantity from one side of an equation to the other side reversing its sign, in order to maintain equality
change key; "Can you transpose this fugue into G major?"
a matrix formed by interchanging the rows and columns of a given matrix
put (a piece of music) into another key

PrepTutorEJDIC

位置を変えること / 脱臼(だっきゅう) / 混乱
〈U〉〈C〉移住,(動物の)移動 / 〈C〉《集合的に》(人・動物などの)移動の群
(…から…へ)移住する《+『from』+『名』+『to』+『名』》 / (季節に応じ定期的に)〈鳥・動物が〉移動する,渡る
〈位置・順序など〉‘を'逆にする,置き換える,移す / (楽曲で)…‘を'移調する / (等式で)…‘を'移項する

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/05/09 14:27:40」(JST)

wiki en

[Wiki en表示]

In materials science, a dislocation is a crystallographic defect, or irregularity, within a crystal structure. The presence of dislocations strongly influences many of the properties of materials. The theory describing the elastic fields of the defects was originally developed by Vito Volterra in 1907,^[1] but the term 'dislocation' to refer to a defect on the atomic scale was coined by G. I. Taylor in 1934.^[2] Some types of dislocations can be visualized as being caused by the termination of a plane of atoms in the middle of a crystal. In such a case, the surrounding planes are not straight, but instead they bend around the edge of the terminating plane so that the crystal structure is perfectly ordered on either side. The analogy with a stack of paper is apt: if half a piece of paper is inserted in a stack of paper, the defect in the stack is only noticeable at the edge of the half sheet.

There are two primary types: edge dislocations and screw dislocations. Mixed dislocations are intermediate between these.

An edge-dislocation (b = Burgers vector)

Mathematically, dislocations are a type of topological defect, sometimes called a soliton. The mathematical theory explains why dislocations behave as stable particles: they can be moved around, but they maintain their identity as they move. Two dislocations of opposite orientation, when brought together, can cancel each other, but a single dislocation typically cannot "disappear" on its own.

Dislocation geometry

Figure A Crystal lattice showing atoms and lattice planes

Two main types of dislocation exist: edge and screw. Dislocations found in real materials typically are mixed, meaning that they have characteristics of both.

A crystalline material consists of a regular array of atoms, arranged into lattice planes (imagine stacking oranges in a grocery, each of the trays of oranges are the lattice planes). One approach is to begin by considering a 3D representation of a perfect crystal lattice, with the atoms represented by spheres. The viewer may then start to simplify the representation by visualising planes of atoms instead of the atoms themselves (Figure A).

Figure B Schematic diagram (lattice planes) showing an edge dislocation. Burgers vector in black, dislocation line in blue.

Edge dislocations

An edge dislocation is a defect where an extra half-plane of atoms is introduced mid way through the crystal, distorting nearby planes of atoms. When enough force is applied from one side of the crystal structure, this extra plane passes through planes of atoms breaking and joining bonds with them until it reaches the grain boundary. A simple schematic diagram of such atomic planes can be used to illustrate lattice defects such as dislocations. (Figure B represents the "extra half-plane" concept of an edge type dislocation). The dislocation has two properties, a line direction, which is the direction running along the bottom of the extra half plane, and the Burgers vector which describes the magnitude and direction of distortion to the lattice. In an edge dislocation, the Burgers vector is perpendicular to the line direction. (see also Jog (dislocations))

The stresses caused by an edge dislocation are complex due to its inherent asymmetry. These stresses are described by three equations:^[3]

where μ is the shear modulus of the material, b is the Burgers vector, ν is Poisson's ratio and x and y are coordinates.

These equations suggest a vertically oriented dumbbell of stresses surrounding the dislocation, with compression experienced by the atoms near the "extra" plane, and tension experienced by those atoms near the "missing" plane.^[3]

Screw dislocations

Top right: edge dislocation.

Bottom right: screw dislocation.

Figure C Schematic diagram (lattice planes) showing a screw dislocation.

A screw dislocation is much harder to visualize. Imagine cutting a crystal along a plane and slipping one half across the other by a lattice vector, the halves fitting back together without leaving a defect. If the cut only goes part way through the crystal, and then slipped, the boundary of the cut is a screw dislocation. It comprises a structure in which a helical path is traced around the linear defect (dislocation line) by the atomic planes in the crystal lattice (Figure C). Perhaps the closest analogy is a spiral-sliced ham. In pure screw dislocations, the Burgers vector is parallel to the line direction.^[4]

Despite the difficulty in visualization, the stresses caused by a screw dislocation are less complex than those of an edge dislocation. These stresses need only one equation, as symmetry allows only one radial coordinate to be used:^[3]

where μ is the shear modulus of the material, b is the Burgers vector, and r is a radial coordinate. This equation suggests a long cylinder of stress radiating outward from the cylinder and decreasing with distance. Please note, this simple model results in an infinite value for the core of the dislocation at r=0 and so it is only valid for stresses outside of the core of the dislocation.^[3] If the Burgers vector is very large, the core may actually be empty resulting in a micropipe, as commonly observed in silicon carbide.

Mixed dislocations

In many materials, dislocations are found where the line direction and Burgers vector are neither perpendicular nor parallel and these dislocations are called mixed dislocations, consisting of both screw and edge character.

Partial Dislocations

Dislocations can decompose into partial dislocations in order to facilitate movement through a crystal lattice.

Observation of dislocations

Transmission electron micrograph of dislocations

When a dislocation line intersects the surface of a metallic material, the associated strain field locally increases the relative susceptibility of the material to acidic etching and an etch pit of regular geometrical format results. If the material is strained (deformed) and repeatedly re-etched, a series of etch pits can be produced which effectively trace the movement of the dislocation in question.

Transmission electron micrograph of dislocations

Transmission electron microscopy can be used to observe dislocations within the microstructure of the material.^[5] Thin foils of metallic samples are prepared to render them transparent to the electron beam of the microscope. The electron beam suffers diffraction by the regular crystal lattice planes of the metal atoms and the differing relative angles between the beam and the lattice planes of each grain in the metal's microstructure result in image contrast (between grains of different crystallographic orientation). The less regular atomic structures of the grain boundaries and in the strain fields around dislocation lines have different diffractive properties than the regular lattice within the grains, and therefore present different contrast effects in the electron micrographs. (The dislocations are seen as dark lines in the lighter, central region of the micrographs on the right). Transmission electron micrographs of dislocations typically utilize magnifications of 50,000 to 300,000 times (though the equipment itself offers a wider range of magnifications than this). Some microscopes also permit the in-situ heating and/or deformation of samples, thereby permitting the direct observation of dislocation movement and their interactions. Note the characteristic 'wiggly' contrast of the dislocation lines as they pass through the thickness of the material. Note also that a dislocation cannot end within a crystal; the dislocation lines in these images end at the sample surface. A dislocation can only be contained within a crystal as a complete loop.

Field ion microscopy and atom probe techniques offer methods of producing much higher magnifications (typically 3 million times and above) and permit the observation of dislocations at an atomic level. Where surface relief can be resolved to the level of an atomic step, screw dislocations appear as distinctive spiral features – thus revealing an important mechanism of crystal growth: where there is a surface step, atoms can more easily add to the crystal, and the surface step associated with a screw dislocation is never destroyed no matter how many atoms are added to it.

(By contrast, traditional optical microscopy, which is not appropriate for the direct observation of dislocations, typically offers magnifications up to a maximum of only around 2000 times).

After chemical etching, small pits are formed where the etching solution preferentially attacks the sample surface around the dislocations intercepting this surface, due to the more highly strained state of the material . Thus, the image features indicate points at which dislocations intercept the sample surface. In this way, dislocations in silicon, for example, can be observed indirectly using an interference microscope. Crystal orientation can be determined by the shape of the etch pits associated with the dislocations (in the case of the illustration below; 100 elliptical, 111 – triangular/pyramidal).

Dislocations in silicon, orientation 100
Dislocations in silicon, orientation 111
Dislocation in silicon, orientation 111

Sources of dislocations

Dislocation density in a material can be increased by plastic deformation by the following relationship: . Since the dislocation density increases with plastic deformation, a mechanism for the creation of dislocations must be activated in the material. Three mechanisms for dislocation formation are homogeneous nucleation, grain boundary initiation, and interfaces between the lattice and the surface, precipitates, dispersed phases, or reinforcing fibers.

The creation of a dislocation by homogeneous nucleation is a result of the rupture of the atomic bonds along a line in the lattice. A plane in the lattice is sheared, resulting in 2 oppositely faced half planes or dislocations. These dislocations move away from each other through the lattice. Since homogeneous nucleation forms dislocations from perfect crystals and requires the simultaneous breaking of many bonds, the energy required for homogeneous nucleation is high. For instance, the stress required for homogeneous nucleation in copper has been shown to be , where G is the shear modulus of copper (46 GPa). Solving for , we see that the required stress is 3.4 GPa, which is very close to the theoretical strength of the crystal. Therefore, in conventional deformation homogeneous nucleation requires a concentrated stress, and is very unlikely. Grain boundary initiation and interface interaction are more common sources of dislocations.

Irregularities at the grain boundaries in materials can produce dislocations which propagate into the grain. The steps and ledges at the grain boundary are an important source of dislocations in the early stages of plastic deformation.

The surface of a crystal can produce dislocations in the crystal. Due to the small steps on the surface of most crystals, stress in some regions on the surface is much larger than the average stress in the lattice. This stress leads to dislocations. The dislocations are then propagated into the lattice in the same manner as in grain boundary initiation. In single crystals, the majority of dislocations are formed at the surface. The dislocation density 200 micrometres into the surface of a material has been shown to be six times higher than the density in the bulk. However, in polycrystalline materials the surface sources cannot have a major effect because most grains are not in contact with the surface.

The interface between a metal and an oxide can greatly increase the number of dislocations created. The oxide layer puts the surface of the metal in tension because the oxygen atoms squeeze into the lattice, and the oxygen atoms are under compression. This greatly increases the stress on the surface of the metal and consequently the amount of dislocations formed at the surface. The increased amount of stress on the surface steps results in an increase in dislocations.^[6]

The stresses produced by a dislocation source may be visualized by photoelasticity in a gamma-irradiated LiF single crystal. The tensile stress along the glide plane is red. The compressive stress is dark green:
Dislocation source (schematic)
LiF irradiated with gamma. The slip plane is visible as a diagonal line, with compressive forces showing green and tensile forces showing red.

Dislocations, slip and plasticity

Until the 1930s, one of the enduring challenges of materials science was to explain plasticity in microscopic terms. A simplistic attempt to calculate the shear stress at which neighbouring atomic planes slip over each other in a perfect crystal suggests that, for a material with shear modulus G, shear strength τ_m is given approximately by:

As shear modulus in metals is typically within the range 20 000 to 150 000 MPa, this is difficult to reconcile with shear stresses in the range 0.5 to 10 MPa observed to produce plastic deformation in experiments.

In 1934, Egon Orowan, Michael Polanyi and G. I. Taylor, almost simultaneously realized that plastic deformation could be explained in terms of the theory of dislocations. Dislocations can move if the atoms from one of the surrounding planes break their bonds and rebond with the atoms at the terminating edge. In effect, a half plane of atoms is moved in response to shear stress by breaking and reforming a line of bonds, one (or a few) at a time. The energy required to break a single bond is far less than that required to break all the bonds on an entire plane of atoms at once. Even this simple model of the force required to move a dislocation shows that plasticity is possible at much lower stresses than in a perfect crystal. In many materials, particularly ductile materials, dislocations are the "carrier" of plastic deformation, and the energy required to move them is less than the energy required to fracture the material. Dislocations give rise to the characteristic malleability of metals.

When metals are subjected to "cold working" (deformation at temperatures which are relatively low as compared to the material's absolute melting temperature, T_m, i.e., typically less than 0.4 T_m) the dislocation density increases due to the formation of new dislocations and dislocation multiplication. The consequent increasing overlap between the strain fields of adjacent dislocations gradually increases the resistance to further dislocation motion. This causes a hardening of the metal as deformation progresses. This effect is known as strain hardening (also “work hardening”). Tangles of dislocations are found at the early stage of deformation and appear as non well-defined boundaries; the process of dynamic recovery leads eventually to the formation of a cellular structure containing boundaries with misorientation lower than 15° (low angle grain boundaries). In addition, adding pinning points that inhibit the motion of dislocations, such as alloying elements, can introduce stress fields that ultimately strengthen the material by requiring a higher applied stress to overcome the pinning stress and continue dislocation motion.

The effects of strain hardening by accumulation of dislocations and the grain structure formed at high strain can be removed by appropriate heat treatment (annealing) which promotes the recovery and subsequent recrystallisation of the material.

The combined processing techniques of work hardening and annealing allow for control over dislocation density, the degree of dislocation entanglement, and ultimately the yield strength of the material.

Dislocation climb

Dislocations can slip in planes containing both the dislocation and the Burgers Vector. For a screw dislocation, the dislocation and the Burgers vector are parallel, so the dislocation may slip in any plane containing the dislocation. For an edge dislocation, the dislocation and the Burgers vector are perpendicular, so there is only one plane in which the dislocation can slip. There is an alternative mechanism of dislocation motion, fundamentally different from slip, that allows an edge dislocation to move out of its slip plane, known as dislocation climb. Dislocation climb allows an edge dislocation to move perpendicular to its slip plane.

The driving force for dislocation climb is the movement of vacancies through a crystal lattice. If a vacancy moves next to the boundary of the extra half plane of atoms that forms an edge dislocation, the atom in the half plane closest to the vacancy can "jump" and fill the vacancy. This atom shift "moves" the vacancy in line with the half plane of atoms, causing a shift, or positive climb, of the dislocation. The process of a vacancy being absorbed at the boundary of a half plane of atoms, rather than created, is known as negative climb. Since dislocation climb results from individual atoms "jumping" into vacancies, climb occurs in single atom diameter increments.

During positive climb, the crystal shrinks in the direction perpendicular to the extra half plane of atoms because atoms are being removed from the half plane. Since negative climb involves an addition of atoms to the half plane, the crystal grows in the direction perpendicular to the half plane. Therefore, compressive stress in the direction perpendicular to the half plane promotes positive climb, while tensile stress promotes negative climb. This is one main difference between slip and climb, since slip is caused by only shear stress.

One additional difference between dislocation slip and climb is the temperature dependence. Climb occurs much more rapidly at high temperatures than low temperatures due to an increase in vacancy motion. Slip, on the other hand, has only a small dependence on temperature.

References

^ Vito Volterra (1907) "Sur l'équilibre des corps élastiques multiplement connexes", Annales scientifiques de l'École Normale Supérieure, Vol. 24, pp. 401–517
^ G. I. Taylor (1934). "The Mechanism of Plastic Deformation of Crystals. Part I. Theoretical". Proceedings of the Royal Society of London. Series A 145 (855): 362–387. doi:10.1098/rspa.1934.0106. JSTOR 2935509.
^ ^a ^b ^c ^d R. E. Reed-Hill (1994) "Physical Metallurgy Principles" ISBN 0-534-92173-6
^ James Shackelford (2009). Introduction to Materials Science for Engineers (7th ed.). Upper Saddle River, NJ 07458: Pearson Prentice Hall. pp. 110–111. ISBN 0-13-601260-4.
^ Spence, J. C. H. et al. (2006). "Imaging dislocation cores - the way forward". Philos. Mag. 86: 4781. doi:10.1080/14786430600776322.
^ Marc André Meyers, Krishan Kumar Chawla (1999) Mechanical Behaviors of Materials. Prentice Hall, pp. 228–231, ISBN 0132628171.

External links

Defects in Crystals/ Prof. Dr. Helmut Föll website Chapter 5 contains a wealth of information on dislocations;
DoITPoMS Online tutorial on dislocations, including movies of dislocations in bubble rafts;
Scanning Tunneling Microscope – Gallery Image gallery, including a dislocations page, seen at the atomic level of metal surfaces, by the surface physics group at the Faculty of Physics, Vienna University of Technology, Austria.
Volterra, V., "On the equilibrium of multiply-connected bodies," trans. by D. H. Delphenich
Somigliana, C., "On the theory of elastic distortions," transl. by D. H. Delphenich

UpToDate Contents

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1. 肩関節脱臼および整復 shoulder dislocation and reduction
2. 指脱臼の整復 digit dislocation reduction
3. 膝関節（脛骨大腿骨）脱臼および整復 knee tibiofemoral dislocation and reduction
4. 小児または思春期のアスリートにおける肘関節損傷 elbow injuries in the child or adolescent athlete
5. Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach

English Journal

Modeling the contraction of the pelvic floor muscles.

Brandão FS1, Parente MP2, Rocha PA2, Saraiva MT3, Ramos IM1, Natal Jorge RM2.
Computer methods in biomechanics and biomedical engineering.Comput Methods Biomech Biomed Engin.2016 Mar;19(4):347-56. doi: 10.1080/10255842.2015.1028031. Epub 2015 May 8.
We performed numerical simulation of voluntary contraction of the pelvic floor muscles to evaluate the resulting displacements of the organs and muscles. Structures were segmented in Magnetic Resonance (MR) images. Different material properties and constitutive models were attributed. The Finite Ele
PMID 25953072

Quantifying the internal deformation of the rodent spinal cord during acute spinal cord injury - the validation of a method.

Bhatnagar T1,2, Liu J2,3, Yung A2,4, Cripton P1,2,5, Kozlowski P2,4, Tetzlaff W2,3, Oxland T1,2,5.
Computer methods in biomechanics and biomedical engineering.Comput Methods Biomech Biomed Engin.2016 Mar;19(4):386-95. doi: 10.1080/10255842.2015.1032944. Epub 2015 Apr 20.
Visualization and analysis of the rodent spinal cord subject to experimental spinal cord injury (SCI) has almost completely been limited to naked-eye observations, and a single measure of gross spinal cord motion due to injury. This study introduces a novel method which utilizes MRI to quantify the
PMID 25894327

Nanoindentation of hcp metals: a comparative simulation study of the evolution of dislocation networks.

Alhafez IA1, Ruestes CJ, Gao Y, Urbassek HM.
Nanotechnology.Nanotechnology.2016 Jan 29;27(4):045706. doi: 10.1088/0957-4484/27/4/045706. Epub 2015 Dec 14.
Using molecular dynamics simulation, we study the nanoindentation of three hcp metals: Mg, Ti, and Zr. Both the basal and two prismatic surface planes are considered. We focus on the characterization of the plasticity generated in the crystal. The similarities to, and the differences from, the behav
PMID 26655887

Objective and subjective evaluations of the Nurotron Venus cochlear implant system via animal experiments and clinical trials.

Gao N1,2,3, Xu XD1,2,3, Chi FL1,2,3, Zeng FG4, Fu QJ5, Jia XH1,2,3, Yin YB1,2,3, Ping LC6, Kang HY7, Feng HH8, Wu YZ1,2,3, Jiang Y1,2,3.
Acta oto-laryngologica.Acta Otolaryngol.2016 Jan;136(1):68-77. doi: 10.3109/00016489.2015.1086022. Epub 2015 Sep 18.
CONCLUSION: This study described objective and subjective evaluations of the Nurotron® Venus™ Cochlear Implant System and indicated that this system produced a satisfactory performance.OBJECTIVE: To observe the performance of the Nurotron® Venus™ cochlear implant (CI) system via electrophysiol
PMID 26382170

Japanese Journal

Optimization of Dislocation Edge Stress Effects for Si N-Type Metal--Oxide--Semiconductor Field-Effect Transistors

Liao Ming-Han,Chen Ci-Hua,Chang Li-Chen,Yang Chen,Yu Ming-Yuan,Liu Gan-Han,Kao Si-Cha
Jpn J Appl Phys 52(4), 04CC20-04CC20-4, 2013-04-25
… The comprehensive investigation on the effect of dislocation edge stress for Si N-type metal--oxide--semiconductor field-effect transistors (N-MOSFETs) is presented in this work by the experimental measurement and proposed simulation model. … The accurate stress measurement in Si oxide dimension (OD) region with and without dislocation edge stress treatment is extracted by atomic force microscope (AFM)--Raman technique with the nanometer level space resolution. …
NAID 150000106683

Energetics of Quantum Dot Formation and Relaxation of InGaAs on GaAs(001)

Pristovsek Markus,Kremzow Raimund,Kneissl Michael
Jpn J Appl Phys 52(4), 041201-041201-7, 2013-04-25
… QD were only found above 40--50% of indium, while for lower indium contents a dislocation network forms. …
NAID 150000106605

Edge Dislocation Assisted Free Carrier Optical Absorption in Nitride Quantum Wells

Vaidya Ratnakar G.,Sankeshwar Nandkumar S.,Mulimani Basavraj G.
J Phys Soc Jpn 82(4), 043706-043706-5, 2013-04-15
… A theory of free carrier absorption (FCA) assisted by edge dislocation scattering in a two-dimensional electron gas (2DEG), is developed. … The work identifies dislocation strain to have dominant influence on FCA, and may be useful for the exploration of subband structure. … The influence of QW width and dislocation density on FCA is also discussed. …
NAID 150000107023

SiC溶液成長の最近の展開(<特集>SiCの現状と今後の展開)

原田俊太,山本祐治,関和明,宇治原徹
日本結晶成長学会誌 40(1), 25-32, 2013-04-00
… Actually, high quality SiC crystal with very low threading dislocation density was obtained applying the dislocation conversion during the solution growth. …
NAID 110009597460

Related Pictures

★リンクテーブル★

リンク元	「100Cases 27」「100Cases 16」「migration」「rearrangement」「migrate」

「100Cases 27」

　　[★]

☆case27　関節痛

■症例

37歳　女性

主訴：関節痛

現病歴：数ヶ月、膝の痛みがだんだん強くなっていると感じていた。痛みは手や足の小関節に多く、朝歩くときに最もこわばる。痛みはジクロフェナクを飲むと和らぐ。そのほかの症状として疲労感を感じ、最近、体重が３ヶ月で４ｋｇ減っている。

喫煙歴：なし。

飲酒歴：機会飲酒

既往歴：なし

家族歴：既婚、子供は２人

服薬歴：ジクロフェナク

職業歴：legal sevretary

身体所見 examination

　顔貌　青白、臨床的な貧血を認める。近位指節間関節・中手指節関節　腫脹・effusionを伴う疼痛。中足趾節関節　圧痛。それ以外は正常。

検査　 investigation

　血液検査

　　Hb低下

　　ESR 上昇

　　尿素軽度上昇

　　クレアチニン軽度上昇

　　正常：白血球、MCV、血小板、ナトリウム、カリウム、グルコース、アルブミン

　尿検査

　　蛋白(-)、尿糖(-)、潜血(-)、

■問題

　本症例では診断とその根拠を考えるのは簡単なので、鑑別疾患をあげてその疾患に特徴的な症候を列挙しましょう。

■関節痛 DIF.283

　V Vascular

　　血友病 hemophilia　血友病性関節症(急性：疼痛、腫脹、熱感(SOR.241)

慢性：可動域の低下、変形、関節周囲筋萎縮(SOR.241))。家族歴

　　壊血病 scurvy　。生活環境。食事歴

　　無菌性骨壊死 aseptic bone necrosis (Osgood-Schlatter diseaseとか)

　I Inflammatory

　　感染性関節炎(細菌性関節炎(化膿性関節炎・淋菌性関節炎・結核性関節炎・嫌気性菌関節炎 )、真菌性関節炎、スピロヘータ関節炎(梅毒性関節炎・ライム関節炎)、マイコプラズマ関節炎、ウイルス性関節炎)

　N Neoplastic disorders

　　骨原性肉腫 osteogenic sarcoma

　　巨細胞腫 giant cell tumors

　D Degenerative disorders

　　degenerative joint disease

　　変形性関節症 osteoarthritis

　I Intoxication

　　痛風 gout (uric acid)

　　偽痛風 pseudogout (calcium pyrophosphate)

　　ループス症候群 lupus syndrome of hydralazine (Apresoline) and procainamide

　　gout syndrome of diuretics

　C Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.

　A Autoimmune indicates

　　関節リウマチ RA

　　血清病 serum sickness

　　全身性エリテマトーデス lupus erythematosus

　　リウマチ熱 rheumatic fever

　　ライター症候群 Reiter syndrome

　　潰瘍性大腸炎 ulcerative colitis

　　クローン病=限局性回腸炎 regional ileitis

　　乾癬性関節炎 psoriatic arthritis

　　リウマチ性多発筋痛症 polymyalgia rheumatica

　T Trauma

　E Endcrine

　　先端肥大症 acromegaly

　　閉経 menopause

　　糖尿病 diabetes mellitus

■関節炎の分類

・炎症部位の数

　単関節炎：痛風、偽痛風、離断性骨軟骨炎、血行性の化膿性関節炎のほとんど

　多関節炎：リウマチ性疾患、ウイルス性疾患、白血病での関節症状、易感染性宿主における血行性の化膿性関節炎

■関節リウマチ

　診断基準

　関節症状

　　朝のこわばり、疼痛、腫脹、関節の動揺、関節可動域制限、変形(手指、足趾、膝関節)。(SOR.211)

　　手指の近位指節間関節(PIP 関節)、中手指節関節(MP 関節)。遠位指節間関節(DIP 関節)に初発することは稀。(SOR.211)

　　左右対称性に生じることが多い。手関節、足趾、膝関節に初発する。(SOR.211)

　関節外症状

　　全身症状：発熱

　　皮膚症状：リウマトイド結節(肘の伸側、後頭部、手指)

　　眼症状：上胸膜炎(10日の経過で治癒)、強膜炎(予後不良)。稀に角膜穿孔

　　血液障害：(高頻度)貧血、白血球減少(Felty病。DMARDs投与中の場合は薬剤性の骨髄抑制を考慮)

　　アミロイドーシス：ネフローゼや下痢を来した症例で疑う。アミロイド蛋白はAA

　　腎障害：稀。アミロイドーシスの続発症か薬剤性を考慮。

　　呼吸器症状：間質性肺炎の合併多い。下肺野に好発。通常無症状。メトトレキセートなどの使用により薬剤性の急性間質性肺炎を生じることがある。

　　心・血管障害：リンパ管炎による難治性の浮腫。

　　神経症状：環軸関節亜脱臼により項部痛や脊髄症上が出現しうる。

　　骨粗鬆症

　　腱鞘滑膜炎：手指、手関節、足関節

■両側性多関節炎の鑑別疾患

　OA：遠位指節間関節を冒すのが特徴的で、近位指節間関節、中手指節関節を冒しうる。

　RA：

　SLE：軽度、症状の程度が変動する非びらん性の関節炎

　gout：単関節炎からはじまる。

　血清陰性関節炎：強直性脊椎炎、感染、ライター病：中～大関節に非対称性の関節炎。仙腸関節と遠位指節間関節にも関節炎

　急性ウイルス性関節炎：風疹。

■KEY POINTS

・RAでは遠位指節間関節は冒されない傾向がある。

・RAの全身症状は関節症状に先行することがある。

・RAの活動性と貧血及びESRは相関している。

・NSAIDsは腎機能に悪影響を与えることがある。

■initial plan

　Dx 1. 単純X線写真

　　　　・亜脱臼、関節周囲の骨萎縮(傍関節性骨骨粗鬆症,juxta-articular osteoporosis)、関節裂隙の狭小化、関節辺縁のびらん(bony erosion)

　　　　　・初期のRAで第5趾に骨びらんが一般的に見られる。

　　　　・血液検査

　　　　　・RF、抗DNA 抗体

　Tx 1. 鎮痛薬

　　　　・NSAIDs：鎮痛とこわばりの軽減

　　 2. DMARDs(メトトレキセート、レフルノミド、金製剤、ペニシラミン)

　　　　・NSAIDsで症状が治まらない場合に考慮

　　 3. 抗TNF 抗体

　　　　・重症のRAで効果がある場合がある。

■参考文献

SOR　標準整形外科学第10版医学書院

DIF　Differential Diagnosis in Primary Care Fourth Edition版 Lippincott Williams & Wilkins

「100Cases 16」

　　[★]

☆case16　膝の痛み

■glossary

indigestion 消化障害、消化不良

■症例

80歳　男性

主訴：左膝の痛みと腫脹

現病歴：左膝の痛みを2日前から認めた。膝は発熱・腫脹しており、動かすと疼痛を生じる。時々胸焼けと消化不良が見られる。6ヶ月前のhealth checkで、高血圧(172/102mmHg)と血中クレアチニンが高い(正常高値)こと以外は正常といわれた。その4週間数回血圧を測定したが、高値が継続したため、2.5mg bendrofluamethizide(UK)/ベンドロフルメチアジド bendroflumethiazide(US)で治療を開始した。最近の血圧は138/84 mmHgであった。

喫煙歴：なし。

飲酒歴：一週間に平均4unit。

既往歴：股関節に中程度(mild)の変形性関節症

家族歴：特記なし

服薬歴：アセトアミノフェン(股関節の疼痛に対して)

身体所見 examination

　血圧 142/86mmHg。体温37.5℃。脈拍88/分。grade 2 hypertensive retinopathy(高血圧症性網膜症)。心血管系、呼吸器系に検査場異常なし。手にDIPにヘバーデン結節なし。

　左膝が発熱し腫脹している。関節内に液、patellar tap陽性。90℃以上膝関節を屈曲させると痛みを生じる。右の膝関節は正常に見える。

検査　 investigation

　生化学：白血球増多、ESR 上昇、尿素高値、グルコース高値

　単純X線：関節間隙やや狭小。それ以外に異常は認めない。

■problem list

　#1 左膝の痛み

　#2 胸焼け

　#3 消化不良

　#4 高血圧

　#5 クレアチニン正常高値

　#6 股関節の変形性リウマチ

　#7 高血圧性網膜症

■考え方

　・関節痛の鑑別診断を考える。

　・VINDICATEで考えてみてもよいでしょう。

　・関節痛の頻度としては　外傷＞慢性疾患(OAなど)＞膠原病＞脊椎疾患＞悪性腫瘍

■関節痛の鑑別疾患

DIF 282

V Vascular 血友病 hemophilia, 壊血病 scurvy, 無菌性骨壊死 aseptic bone necrosis (Osgood-Schlatter diseaseとか)

I Inflammatory 淋疾 gonorrhea, ライム病 lyme disease, 黄色ブドウ球菌 Staphylococcus, 連鎖球菌 Streptococcus, 結核 tuberculosis, 梅毒 syphilis, 風疹 rubella, 単純ヘルペス herpes simplex, HIV human immunodeficiency virus, サイトメガロウイルス cytomegalovirus

N Neoplastic disorders 骨原性肉腫 osteogenic sarcoma, 巨細胞腫 giant cell tumors

D Degenerative disorders degenerative joint disease or 変形性関節症 osteoarthritis

I Intoxication 痛風 gout (uric acid), 偽痛風 pseudogout (calcium pyrophosphate), ループス症候群 lupus syndrome of hydralazine (Apresoline) and procainamide, gout syndrome of diuretics

C Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.