Inflammatory Arthritis

Inflammatory Arthritides
Rheumatoid Arthritis:
Adult
Juvenile
Rheumatoid Variants:
Ankylosing spondylitis
Reiters syndrome
Psoriatic arthritis
Enteropathic arthritis
Erosive Osteoarthritis

Group of different systemic disorders

that have one common important
feature:
Inflammatory pannus eroding
articular cartilage and bone

The Rheumatological History

Essential part of consultation

Establishment of rapport with patient
Make patient comfortable before you start
Start with open questions. Tell me about your joint
problems
Fill in details with focused (closed) questions.
Which joints are affected? Do they feel stiff? Do they
swell?

Symptomatology
Constant pain? Sign of malignancy
Intermittent locking - loose body
Stiffness worse at rest & relieved by exercise ? Ankylosing spondylitis
Slow insidious onset - OA
Minor injury may precipitate frozen shoulder

Presenting Complaints

Joint pain
Joint stiffness
Joint swelling
Joint deformity
Systemic illness

Adult RA
progressive, chronic, systemic inflammatory
disease affecting primarily synovial joints
women 3X more affected than men
disease varies from patient
spontaneous remissions & exacerbation
usually presence of antibody, rheumatoid factor

RA Classification - ACR Criteria

morning stiffness
Arthritis involving 3 or more joints
Arthritis of hand joints
Symmetrical arthritis
Rheumatoid nodules
Serum rheumatoid factor
X-ray changes

Large Joint Involvement

Osteoporosis, periarticular
Concentric narrowing of joint space
in the knee, all 3 joint compartments
involved
in the hip, medial or axial migration
of fem. head
there may be protusio acetabuli

RA Small Joint Involvement

radial deviation of wrist in
radiocarpal joint
telescopingof the fingers
(main en lorgnette)
hallux valgus and hammertoes
ankylosis of the wrist

Cervical Spine in Rheumatoid Arthritis

Rheumatoid Arthritis
Differential Diagnosis
Infectious arthritis
Viral
Bacterial
Polymyalgia rheumaticaB27
spondyloarthropathy
Fibromyalgia syndrome
Osteoarthritis
Crystal arthropathy

Blood Test
ESR
CRP (acute phase reactants)
FBC
Auto-antibodies: RA factor; dsDNA
antibodies
Renal panel: FEME, S Creatinine
LFT

Treatment of RA
General Measures
Education
Exercise
Physiotherapy
Diet
Pharmacotherapy

Prevention of Deformity
1. Prevention of deformity is often
possible
2. The use of a splint reduces the
likelihood of stiffening
3. The use of a suitable splint ensures
that joints are able to get into the most
useful position even if they become
seriously damaged
4. With your co-operation, even
seriously damaged joints may remain
perfectly useful

Surgery for Rheumatoid

Arthritis
Diagnosis
Tendons
tenosynovitis
tendon rupture
Nerve involvement
eg. CTS
Joint involvement
synovectomy
osteotomy
arthrodesis
arthroplasty

Surgery for Rheumatoid Arthritis

Tendon Involvement
Tenosynovitis
Tendon rupture

Surgery for joint involvement in

Rheumatoid Arthritis
Chronic Synovitis
Intra-articular steroids
dangers
Radioisotopes
dangers
Synovectomy
open or arthroscopic?

Surgical Synovectomy
Should be undertaken early
Synovectomy and joint debridement
Accessibility in joints
Recurrence
Joint stiffness

Total Joint Replacement

Indications
severe arthritis
deformity
uncontrolled pain
stiffness in joints
limited ambulation

Total Joint Replacement

Treatment of choice in disabled
patients with severe joint
destruction
Problems of soft bone, steroids,
thin skin, wound healing,
infection and loosening

Psoriatic Arthritis
1. Destructive changes DIPJ of the hand
with occasional involvement of terminal
tufts.
2. Oligo-articular assymmetric involvement
limited to severe swelling &
associated joint destruction of a
single digit sausage digit
3. Polyarthritic form: indistinguishable
from RA

Ankylosing Spondylitis
Bechterevs Disease
Marie-Strumpell Disease
chronic, progressive,
inflammatory synovial joints of
spine, adjacent soft tissues,
sacroiliac joints hips, knees,
shoulder

Ankylosing Spondylitis
7X more common in men
young age
RA factor negative
HLA-B27 positive (95% of cases)
diffuse, poliferative synovitis, diathrodal joints
exhibiting features similar to those seen in RA.

Ankylosing Spondylitis
Sacro-iliitis - erosion of margins of SI joint
CT detects early changes
In spine, Romanus lesion at anterosuperior &
anteroinferior margins of vertebral bodies
adjacent to insertion of annulus fibrosus
Squaring of vertebral bodies
Syndesmophytes. Bamboo spine

Laboratory Data
Gout:
raised S Uric Acid
synovial fluid crystals
raised ESR & CRP
raised TW & polymorphs
counts

Enteropathic Arthropathy
Associated with:
ulcerative colitis
regional enteritis
intestinal lipodystrophy
(Whipples Disease)
men, in 4th & 5th decades
Symmetric involvement of sacro-iliac joint

Reiters Syndrome
peripheral asymmetric inflammatory arthritis
urethritis, conjunctivitis, mucocutaneous rash
predilection for lower limb joints e.g. the foot
coarse syndesmophytes bridging vertebral bodies
sacro-iliitis

General Considerations
Symptoms:

urethritis
conjunctivitis
mucocutaneous lesions

Point to Reiters syndrome