Joints (arthritis) Rheumatoid arthritis

Inflammatory

dz affecting synovial joints

predominately
Hyperplasia
Severity

of synovial fibroblasts

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

common in Native Americans

More

Insidious
Usu.

over several weeks usu.

Not symmetric at the beginning

Must
If

have an inflammatory synovitis

deformity is in a non-wt bearing jnt, you can assume its due to synovitis
85%

have serum RF
start sero-(-) but become sero(+) w/ progression

May

ESR

is typically helpful to follow the inflammatory activity

Prolonged

morning stiffness is universal

Active
Bone

phase: warm, swollen jnts Structural damage

injected corticosteroids for anti-inflammation

on bone crepitus

Try

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

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

RA criteria

below:

Morning
3+jnts Arthritis

stiffness
of hand arthritis nodules

Symmetric

Rheumatoid

RF
X-ray

changes
4 of the 7

Need

1-4 must occur for at least 6 wks

Stage Stage

I Early no destruction

II Moderate no jnt deformity, osteoporosis w/ or w/out some bone and cartilage destruction III Severe cartilage and bone destruction with osteoporosis, jnt deformity
Stage

IV Terminal fibrous or bony ankylosis

Stage

Remission
5+

criteria

of the following for 2+ consecutive mos.

Morning

stiffness</=15minutes
No No No No

fatigue jnt pain tenderness

swelling

ESR

GOUT

Monosodium
Tophi

urate deposition - hyperuricemia

accumulation of crystal in articular, osseous, ST, and cartilage

Recurrent Uric

attacks of inflammation

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

Crystals
Likes

have decr solubility in low temps thats why it likes toes and ears
areas of minor trauma like 1st MTP

tophi wont form on paralyzed side -> something to do w/ CT structure and turnover
Hemiplegia
Tophi

is inflammatory cells around crystal w/ erosion of surrounding cartilage and bone. Fibrous capsule around tophi
Crystals are needle-shaped and formed radially

Three

stages: asymptomatic hyperuricemia, acute intermittent gout, Chronic tophaceous gout.

Initially

rubor, tubor, dolor and pain of jnt. Pain ncr. 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
involve 1st MTP as monoarticular site and 90% of pts overall

CHRONIC About

TOPHACEOUS GOUT

10yrs after initial dx usu.

No

pain free period but not as severe as acute

Factors

for tophi development: early onset, long active phases, 4+attacks/yr, UE or polyarticular episodes
Tophi

can also be in heart valves and sclera

Supcutaneous

gouty tophy are usu in fingers heberdens nodes

Early

onset gout

<25yoa, 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

10%

die of renal failure; 25% have renal stones

25-50%

have HTN ->due to reduced renal blood flow from urate

Hyperlipidemia/obesity

contraversial

ST swelling -> asymmetric in peripheral jnts erosions slightly removed from jnt (unique) (overhanging edge)
Xray

No osteopenia, and maintained jnt space until late

Osteoarthritis

OA

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

Garrod