Joints

Question 1

What are the differences between noninflammatory and inflammatory joint diseases?

Answer 1

Noninflammatory Disease:
- No synovial membrane inflammation
- No systemic signs & symptoms
- Synovial fluid – Cartilage debris/%WBC/PMN
- < 25%, high viscosity
Inflammatory Disease:
- Synovial membrane inflammation caused by immune complexes (rheumatoid factor + antigen in membrane or blood) in the blood & synovial tissue. RF = autoantibodies in RA.
- Systemic signs & symptoms (fever, etc.)
- Synovial fluid contains rheumatoid factor/%PMNs 50%-80%, low viscosity

Question 2

Neither the cause nor are the risk factors known, & thus is also referred to as idiopathic osteoarthritis

Answer 2

Primary osteoarthitis

Question 3

Caused by chronic, excessive, or abnormal forces that damage the joint surfaces, underlying bone, & leads to joint instability. Also joint instability may cause the abnormal forces

Answer 3

Secondary osteoarthritis

Question 4

Bone spurs

Answer 4

Osteophytes

Question 5

Pathological traits include: Initial changes = joint Narrowing, thinning/softening cartilage; Erosion of the articular cartilage; Abnormal pressure produces sclerosis (thickening & hardening) of bone underneath the cartilage a.k.a. eburnation; Bone cysts filled with fluids, communicates with the joint; Formation of bone spurs or osteophytes; Soft tissue around joint swelling & inflammation

Answer 5

Primary and secondary osteoarthritis

Question 6

Causes include joint trauma (strains, dislocations, fractures), long-term mechanical stress, joint inflammation, joint instability, neurologic disorders (decreased pain proprioceptive reflexes), and chronic joint bleeding due to excessive PTH (hemophilia and hyperparathyroidism)

Answer 6

Secondary osteoarthritis

Question 7

What are some clinical features of patients with OA?

Answer 7

1. Pain relieved by rest
2. Joint stiffness lasting 15-20 minutes after immobility (RA lasts hours)
3. Reduced ROM, crepitus, and deformities due to intra-articular changes and periarticular inflammation
4. Muscle spasms, contractors and atrophy adjacent to joints

Question 8

What are some symptoms of OA?

Answer 8

1. Hip involvement: pain in butt upper/medial thigh
2. Knee Joint involvement: pain, crepitus,, effusion during WB. Varus or valgus deformities
3. Lumbar & Cervical Spine involvement: affects the facet joints. Radicular pain from compression of spinal nerves by osteophytes which form at the facet joint margins.

Question 9

What are symptoms in hands and feet in OA?

Answer 9

Hands: Most often Heberden’s Nodes at the DIPs in OA

Feet: Hallux valgus and bunion deformities of the first metatarsophalangeal joint

Question 10

Chronic systemic inflammatory disease of unknown etiology with features of:

• Chronic inflammation of synovial joints
• Significant but not diagnostic serologic data suggesting an immune disorder
• Variable extra-articular signs and symptoms

Answer 10

Rheumatoid Arthritis

Question 11

What is the pathophysiology or RA?

Answer 11

1. Inflammation begins as a synovitis in which, the inflamed synovial membrane releases PMNs, lymphocytes, and plasma cells into the joint cavity/synovial fluid.
2. Inflammation leads to tissue repair or the proliferation phase of new synovial cells and new blood vessels, changing the synovial tissue into a sheet like granulation tissue called joint pannus

Question 12

contains inflammatory cells (PMN [neutrophils & macrophages) that secrete lytic enzymes and chemical mediators of inflammation which, destroys synovial tissue, hyaline cartilage, and erodes underlying bone

Answer 12

Joint pannus

Question 13

As a joint becomes progressively immobile, and the joint space becomes completely obliterated with JP that transformed to a collagen scar causing

Answer 13

Ankylosis

-process can be slowed with AROM during inflammatory flares

Question 14

What occurs during an RA “flare”

Answer 14

1. increased pain
2. swelling
3. decreased ROM
4. decreased function

Question 15

What are signs of RA?

Answer 15

1. Bouchard’s Nodes at the proximal interphalangeal joint (PIPs)
2. Deformity and dislocation at the metacarpophalangeal joints.
3. Ulnar deviation of the fingers with anterior slippage of PIPs
4. Elbow: subcutaneous nodules, painless & small (< 2 cm in diameter)

Question 16

What are extra-articular symptoms during a flare in RA?

Answer 16

1. Low grade fever
2. Loss of appetite
3. Fatigue
4. Anemia

Question 17

How is RA conservatively treated?

Answer 17

1. Anti-inflammatory drugs slow the progression
2. Rest is beneficial during a flare
3. Gentle & regular AROM exercises
4. Moist heat or ice during a flare
5. Splinting may prevent or delay joint deformities

Question 18

What are the surgical treatments of RA?

Answer 18

1. Synovectomy
2. Soft-tissue releases
3. Arthroplasty: reshaping the joint & implanting an artificial joint surface or prosthesis
4. Arthrodesis: surgical immobilization or fusion of the joint causing artificial ankylosis – a last resort.

Question 19

A metabolic disease characterized by a disturbance in purine metabolism resulting in the formation of sodium urate crystals

Answer 19

Gouty arthritis

Question 20

What are found in the synovial fluid of joints and soft tissues affected with gouty arthritis?

Answer 20

Sodium urate crystals?

Question 21

What are sodium rate crystals due to?

Answer 21

an increase in the serum uric acid, a normal end product of purine metabolism

Question 22

What are the clinical features of gouty arthritis?

Answer 22

1. More common in men 30-40 y/o
2. Less common in females and especially rare in women before menopause.
3. Initial acute attack usually occurs in a single joint – most common 1st metatarsophalangeal joint

Question 23

What are the symptoms of gouty arthritis?

Answer 23

1. Pain is usually severe
2. May be caused by exercise, physical, and emotional stress
3. Swelling, heat, extreme pain on palpation
4. Redness at the 1st MTP Joint
5. Destruction of articular cartilage
6. Systemic: fever, tachycardia

Question 24

How do you treat gouty arthritis?

Answer 24

1. Specific medication for control of inflammation and uric acid metabolism
2. Rest
3. Elevation
4. Ice or moist heat as tolerated