Types of Joints: describe and give example of each of the following:
- fibrous/bony
- cartilaginous
- synovial
Fibrous/bony: minimal to no motion
(e.g skill sutures)
Cartilaginous: limited motion
(e.g intervertebral discs, pubic symphysis)
Synovial: freely mobile, comprised of 2 or more bones.
(e.g knee, shoulder, hip)
Describe the type of joint for each of the following:
- hip
- shoulder
- knee
- ankle
Hip:
-ball and socket, lots of motion, stable
Shoulder: ball on small tee; more motion, less stable.
Knee: round condyles on flat surface; ligaments essential
Ankle: limited plane of motion
Osteoarthritis (OA)
- aka
- what is this?
- risk factors
- MC age in men and women?
- pathophys
aka: degenerative arthritis or joint dz
What; loss of articular cartilage- leading to exposed bone.
*MC form of arthritis
Risk factors:
- age, female, previous injury
- obesity
- heavy physical labor
- family hx
- sports activities
MC age in:
- men = 45YO
- women = 55YO
Pathophys:
- triggered by damage to normal articular cartilage
- chondrocytes react by releaseing degradative enzymes causing subchondral sclerosis and osteophytes. (bony outgrowths associated with the degeneration of cartilage at joints)
- superficial erosions leading to complete loss of cartilage
- joint space narrowing and possible deformity.
Features of OA;
-general signs and sx
General S&S:
- joint pain, swelling, crepitation, tenderness, effusions
- radiating pain and bursitis in hands, hips knees, and spine
- tenderness on palpation and on passive motion are late signs
*pain is relieved with rest. *
- multiple joints in older pt
- hip and knee seen in middle age
- single joint in the young
Features of OA:
- hands
- location of dz
- common features found on exam
- shoulder
- -sx
- -MC seen with what otehr conditions?
Hands:
-location: Distal interphalangeal joints and Proximal interphalangeal joints.
- Feature:
- -Heberdens nodes (DIP)
- -Bouchards nodes (PIP)
Shoulder:
- sx: progressive anterior shoulder pai, worse with motion
- difficulty with overhead activities, sleeping, and axillary hygiene.
-MC seen with rotator cuff dz/tears, AC joint arthritis.
Features of OA:
- hip
- -sx & signs
- knee
- -signs and Sx
- spine
- -signs and sx
Sx & Signs:
- deep groin pain
- can radiate anterior thigh, knee buttock
- difficulty putting on socks/shoes
- pain with abduction.
Knee:
- signs and Sx:
- -crepitus, effusion, limited motion
- difficulty doing stairs, getting out of low chairs off of toilets
- pain with kneeling/squatting
Spine:
- Cervical: pain and stiffness, aching pain down arm
- Lumbar: pain across low back/buttocks with loss of motion flex/ext
Dx of OA
clinical dx supported by H&P, labs and imaging
- no specific labs
- plain XRAY
OA:
- XRAY Findings
- tx
Xray findings:
- joint space narrowing
- surface irregularity
- osteophytes
- subchondral sclerosis
- subchondral cysts
Tx:
- non-Rx:
- -weight loss
- -exercise
- -PT/OT
- -braces
- -Heat/cold
- -Rest
- Rx:
- -acetaminophen
- -NSAIDS (naproxen/ibuprofen)
- -Tramadol
- -Opiods
- -Intraarticular injections —glucocoritcoid = triamcinolone methylprednisolone.
- –Hyaluronans = synvisc, hyalagen
Surgical:
- Arthroscopy (dont typically do this, may aggravate underlying arthritis)
- Total joint replacement (**GOLD STANDARD for severe knee, hip, or shoulder joint arthritis)
- Chondrocyte grafting (for small, isolated defects)
THIS IS NOT AN INFLAMMATORY ARTHRITIS.
Rheumatoid Arthritis:
- cause
- pathophys
Cause: breakdown of immune tolerance to synovial inflammation. Complex interaction of genetic and environmental factors.
Pathophys:
- plasma cells produce abys
- MF and lymphocytes produce pro-inflamm cytokines and chemokines
- synovium thickens, hyperplastic synovial tissue (pannus) releases inflammatory mediators which erods the cartilage.
RA:
- presentation
- -course
- -systemic sx
- -joint sx
presentation: Course: -gradual insidious onset -sx wax and wane -involve multiple joints, characteristically symmetric
Systemic Sx:
- early morning stiffness of affected joints
- generalized afternoon fatigue and malaise
- anorexia
Joint sx:
- pain
- swelling
- stiffness
- erythema
RA:
- imaging
- -what test is MC?
- -what is seen from the MC test?
Imaging;
- MC test is XRAY.
- XRAY shows:
- -joint space narrowing
- -soft tissue swelling*
- -bony erosions
- -osteopenia about joint
- -laxity leading to deformity and bone displacement
- -destruction/fusion late
RA Hand:
-signs and sx
Signs and Sx
- swollen, painful MP and PIP joints
- tender, limited motion
- reduced grip strength
- tendon ruptures, triggering
- ulnar deviation at MP joints
- swan neck (weird curve at DIP) and boutonniere (thumb deformity that makes it curved out)
- soft tissue swelling in hands
RA
- wrist
- elbow
- shoulder
- hips
- knee
- foot
Wrist:
- loss of extension
- carpal drift
- tendon rupture
Elbow:
- nodules
- loss of extension
- olecranon bursitis
- ulnar neuritis
Shoulder:
- adhesive capsulitis
- rotator cuff dz
- joint destruction
Foot:
-similar to hand; MP joint involved, toe deformities, heel & ankle pain
Knee:
- synovitis and effusion
- Bakers cyst (popliteal cyst)
- loss of flexion
Hips: late
- groin pain
- loss of rotation
Extra-articular RA:
-manifestations
Manifestations:
- skin and pulmonary nodules*
- pericarditis
- splenomegaly
- neuropathy
- vasculitis
- episcleritis
- lymphadenopathy
RA:
- dx
- -labs
- -imaging
- -criteria
Labs:
- RF
- Anti-CCP
- ESR
- CRP
- synovial fluid (turbid, yellow)
Imaging:
-xray
Criteria:
- clinical dx can be made when:
- inflammatory arthritis in 3 or more joints for more than 6 weeks
- positive RF and ACCP
- elevated CRP and ESR
Based on point system, dx requires greater than 6 points.
- Joint involvement:
- -1 large joint = 0
- -2-10 large joints = 1
- -1-3 small joints =2
- -4-10 small joints = 3
- -greater than 10 = 5
- Serology
- -negative RF and negative ACPA = 0
- -low positive RF and low positive ACPA = 2
- -high positive RF or high positive ACPA = 3
- Acute phase reactants:
- -normal CRP and normal ESR = 0
- -abnormal CRP and abnormal ESR = 1
- Duration of sx:
- -less than 6 wks = 0
- -greater than 6 wks = 1
**ACCP = ACPA (;
RA:
-general Tx
Manage acute flares:
- NSAIDs and glucocorticoids
- -relieve discomfort, dont stop progression
DMARDS: disease modifying anti-rheumatic drugs
- -non-biologics
- -biologics
Surgery for soft tissues and joints:
- -synovectomy, tendon repairs, removal of nodules
- -total joint replacement, fusion
- PT/OT, bracing, support groups
- Heat/cold
- orthotics and splints
- therapeutic exercise
- PT/OT
RA RX acute pain
NSAIDS: aspirin,
when first seen or during flare:
ibuprofen, naproxen
Glucocorticoids (systemic)
RA and DMARDS
-what are the nonbiologic and biologic medicatinons?
Nonbiologics:
- methotrexate(first line), sulfasalzine, leflunomide
- hydroxychlorquine, cyclosporine, gold salts, azathioprine
Biologics:
- TNF inhibitors
- entanercept (enbrel)
- infliximab (remicade)
- adalimumab (Humira)
Methotrexate:
- SE
- CI
SE:
- ulcerative stomatitis
- leukopenia
- predisposition to infection
- nausea
- abd pain
- fatigue
- fever
- dizziness
- pna
- pulm fibrosis
CI:
- renal dysfunction
- pregnancy or possible pregnancy
Gout:
- MC joint affected
- pathophys
- causes
MC joint = first metatarsophalangeal joint (podagra= gout of this big toe)
Patho:
- precipitation of monosodium urate cyrstals in joint space
- over time joint space is damaged.
- tophi is pathopneumonic for gout
Causes:
- decreased excretion of uric acid
- increased production of uric acid
- increased purine intake
Gout;
- risk factors
- presentation
Risks:
- increased age
- menopause = less estrogen = less excretion of uric acid = build up of uric acid = gout.
- alcohol
- meat
- seafood
Presentation:
- severe pain
- redness/warmth
- swelling/disability
- worse at night
- overlying skin becomes tense
- anything that touches this hurts, even the sheets on your bed!
Gout:
- dx
- tx
Dx:
- synovial fluid analysis:
- -needle-shaped NEGATIVE birefringent urate crystals
- elevated serum urate level
-Xray
Tx:
- resolves in a few days to weeks
- NSAIDS first choice! naproxen or indomethacin**)
- colchicine
- glucocorticoids (intraarticular or PO when multiple joints)
- treat hyperurcemia:
- -reduced intake of purines (purines broken down into uric acid)
- -Xanthine oxidase inhibitors: allopurinol *** DOC to lower serum urate levels.
- -Uricosuric Drugs: probenecid; increase urinary excretion.
How do we prevent recurrent attacks of gout?
Lifestyle changes: weight loss, decrease alcohol intake
Diet:
- decreasing meat and fish
- increase dairy products
Lowering serum uric acid:
- uricosuric agens = probenacid
- xanthine oxidase inhibitors = allopurinol
Pseudogout:
- aka
- cause
- presentation
- dx
aka: calcium pyrophosphate dehydrate (CPPD) cyrstal deposition dz
OR chondrocalcinosis
Cause: trauma, hypomagnesemia, hyperparathyroidism
Presentation: -similar to gout but less severe
-usually occurs in knee or other large peripheral joints
Dx:
- synovial fluid: rhomboid-or-rod shhaped crystals
- POSITIVE birefringent crystals
X-rays:
-chondrocalcinosis
