Joints (arthritis)

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Joints (arthritis) Rheumatoid arthritis

• Inflammatory dz affecting synovial joints
  predominately
• Hyperplasia of synovial fibroblasts
• Severity is varied
• Peak age is 30-50
• About 1 of the population is affected with a
  2.5xs higher risk in women.
• May be genetic as it tends to run in families
• More common in Native Americans

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• Insidious over several weeks usu.
• Usu. Not symmetric at the beginning
• Must have an inflammatory synovitis
• If deformity is in a non-wt bearing jnt, you can
  assume its due to synovitis
• 85 have serum RF
• May start sero-(-) but become sero() w/
  progression
• ESR is typically helpful to follow the
  inflammatory activity

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• Prolonged morning stiffness is universal
• Active phase warm, swollen jnts Structural
  damage
• Bone on bone crepitus
• Try injected corticosteroids for
  anti-inflammation
• C/s neck stiffness w/ possible loss of motion
• C1 transverse lig tenosynovitis and possible
  z-jnt synovitis
• Pain doesnt always accompany instability even in
  significant myelopathy

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• Immobilization due to pain is the kiss of death
  to joint mobilizations. The result is
  contractures and deformity
• You need to keep pts ROM esp. in non-wt bearing
  jnts like shoulder and hand
• Once cartilage is completely gone, bones may fuse
  if immobilized10 remit usu in first two yrs of
  dz
• 90 of jnts that are affected are involved during
  the 1st yr
• Severe dz 10-15yr decr in life expectancy due to
  infection, pulmonary or renal dz,
  lymphoproliferative disorders, GI bleeds and
  cardiovascular

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• RA criteria below
• Morning stiffness
• 3jnts
• Arthritis of hand
• Symmetric arthritis
• Rheumatoid nodules
• RF
• X-ray changes
• Need 4 of the 7
• 1-4 must occur for at least 6 wks

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• Stage I Early no destruction
• Stage II Moderate no jnt deformity,
  osteoporosis w/ or w/out some bone and cartilage
  destruction
• Stage III Severe cartilage and bone destruction
  with osteoporosis, jnt deformity
• Stage IV Terminal fibrous or bony ankylosis

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• Remission criteria
• 5 of the following for 2 consecutive mos.
• Morning stiffnesslt/15minutes
• No fatigue
• No jnt pain
• No tenderness
• No swelling
• ESR

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• GOUT
• Monosodium urate deposition - hyperuricemia
• Tophi accumulation of crystal in articular,
  osseous, ST, and cartilage
• Recurrent attacks of inflammation
• Uric acid calculi in GU renal fxn impairment
  called gouty nephropathy
• M/c 5th decade men African-Americans
• Serum urate levels rise over time in men but
  dont in women until after menopause due to
  estrogen
• Gout in women is often due to thiazide diuretic
  use and renal failure
• Blacks due to more HTN, not genetic

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• Crystals have decr solubility in low temps thats
  why it likes toes and ears
• Likes areas of minor trauma like 1st MTP
• Hemiplegia tophi wont form on paralyzed side
  -gt something to do w/ CT structure and turnover
• Tophi is inflammatory cells around crystal w/
  erosion of surrounding cartilage and bone.
  Fibrous capsule around tophi
• Crystals are needle-shaped and formed radially

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• Three stages asymptomatic hyperuricemia, acute
  intermittent gout, Chronic tophaceous gout.
• Initially rubor, tubor, dolor and pain of jnt.
  Pain incr. Over hours. Pt. May not be able to
  walk. May get fever, chills, malaise. May last
  up to 2 weeks. Attacks become more frequent w/
  time
• ½ involve 1st MTP as monoarticular site and 90
  of pts overall

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• CHRONIC TOPHACEOUS GOUT
• About 10yrs after initial dx usu.
• No pain free period but not as severe as acute
• Factors for tophi development early onset, long
  active phases, 4attacks/yr, UE or polyarticular
  episodes
• Tophi can also be in heart valves and sclera
• Supcutaneous gouty tophy are usu in fingers
  heberdens nodes

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• Early onset gout
• lt25yoa, 3-6 of gout pts, 80 have FHx
• More severe and rapid course, 25 have
  nephrolithiasis
• Transplant gout
• 75-80 of heart transplants
• Due to cycloporine tx to prevent rejection
• Inhibits urate excretion

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• 10 die of renal failure 25 have renal stones
• 25-50 have HTN -gtdue to reduced renal blood flow
  from urate
• Hyperlipidemia/obesity contraversial
• Xray ST swelling -gt asymmetric in peripheral
  jnts erosions slightly removed from jnt (unique)
  (overhanging edge)
• No osteopenia, and maintained jnt space until late

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Osteoarthritis
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• OA
• Garrod in 1907 differentiated RA from OA10 of OA
  patients had reduced work hours and 13.7 retired
  early.
• Arthritis is the main reason for decr. Activities
  in the elderly