Arthritis

By: DR. SAURAV POUDEL 30th October

2016

Arthritis

• It is an inflammation of a joint characterized by pain, swelling and limitation of joint movement.

• Arthralgia :it is a painful joint without any associated signs of inflammation.

Classification of arthritis I. Monoarticular arthritis :• Pyogenic arthritis• Tubercular arthritis• Haemophilic arthritis• Secondary osteoarthritis• Gout• Trauma.ii. Polyarticular arthritis :• Rheumatoid arthritis• Rheumatic fever• Juvenile chronic polyarthritis• Primary osteoarthritis• Seronegative arthritis

Rheumatoid Arthritis• RA is a symmetrical destructive and deforming

polyarthritis affecting the small & large joints with associated systemic disturbance, variety of extra-articular features and the presence of circulating anti-globulin antibody.

• Incidence :-female >male (3:1)-high incidence at age 20-40 years-genetic predisposition (HLA DR4 and DR1)

Criteria for the diagnosis of Rheumatoid arthritis

i. Morning stiffness (>1 hr).ii. Arthritis of three or more joint areas.iii. Arthritis of hand joints.iv. Symmetrical arthritis.v. Rheumatoid nodules.vi. Radiological changes.vii. Duration of 6 wks or more.-diagnosis of RA is made with four or more criteria.

Symptoms

I. Insidious onset (70%):• In majority of patients the onset is insidious with joint

pain,stiffness and symmetrical swelling of peripheral joints• Initially pain is only on movement,then rest pain and early

morning stiffness are characteristic.• First affect the small joints of the fingers & toes then

wrist,elbow,shoulder ,knee e.t.c are involvedii.Acute onset (15%) acute polyarthritis with morning stiffness &

pitting oedema.iii.Systemic onset (10%) insidious onset with fever,wt.loss,

profound fatigue.iv.Palindromic (5%) recurrent acute episode of joint pain &

swelling which last only for few hours or days.

Extra-articular features a. Systemic :-fever -weight loss -fatigue -susceptibility to infectionb.Musculoskeletal:-muscle wasting - tenosynovitis -bursitis –osteoporosisc.Haematological :-anaemia -thrombocytosis -eosinophiliad.Lymphatic -splenomegaly -felty’s syndromee.Nodules :-sinuses - fistulaef.Ocular :-episcleritis -scleromalcia -scleritis -keratoconjunctival sicca

g) Vasculitis :-digital arteritis -ulcers –pyoderma gangrenosum -

mononeuritis multiplex – viseralarteritish)Cardiac :-pericarditis –myocarditis –endocarditis -conduction defects –

coronary vasculitis –granuloma aorititisi)Pulmonary :-nodules –plueral effusion –fibrosing alveolitis -bronchiolitis

–caplan’s syndrome j)Neurological -cervical cord compression –compression neuropathies –

peripheral neuropathy – mononeuritis multiplex.

Signs • Swelling: by effusion,synovial proliferation.-swelling by proximal interpharayngeal joint:spindle

appearance.-swelling by the meta-tarsophalangeal joint :broadening of

forefoot.• Warmth• Tenderness• Limitation of movement due to muscle atrophy:tendon

sheath and joint destruction.• Joint instability• Deformities :swan neck deformity,buttonniere

deformity,Z-deformity of the thumb,muscle wasting.

Z- deformity of thumb

• In the forefoot(sublaxation by metatarso phalangeal joint is followed by-

-clawing of the toes.-callosities over the exposed metatarsal heads.-painful sensation by walking on pebbles.-calcaneal erosion.

• Nodules• Popliteal cysts or baker’s cyst.

Investigation

I. To establish diagnosis :• Clinical criteria• Markers of inflammation• Serological test :RA test, ANA test, rose waaler test.• Radiographs: peripheral osteoporosis & fluid loss of joint spaces.• Synovial analysisii. To document of pathological changes :radiographs,occasionally-

arthrography,scintigraphy,USG,CT,MRI.iii. To monitor disease activity in response to therapy :• Pain• Early morning stiffness• Joint tenderness• ESR,acute phase protien (CRP)• Hb%

iv. To assess progression of disease: by• Radiographs• Functional assesmentv. To monitor for safety of drug therapy :• Haematology• Urine analysis• Biochemistry.

Management A. General management of the active phase:a) Physical restb) Anti-inflammatory drugsc) Maintenance exercisesB. Local measures • Rest splints • Intra-articular :corticosteroids inj.• methyl-prednisolone acetate (20-80 mg :large joints, 4-10

mg:small joints ) or triamcinolone.C. NSAIDs:• Low risk : ibuprofen - <1600 mg/day• Average risk : indomethacin 75-150 mg/day piroxicam 10-30 mg/day diclofenac 75-150 mg/day• High risk azapropazone : 1200-1800 mg/day

D. Disease modifying drugs :a) Chloroquine phosphateb) Sulphasalazinec) Methotrexated) Gold salts : Na aurothiomalatee) Oral gold : auranofin f) Penicillamineg) Prednisolone.E. immunomodultion:• Azathioprine oral• Cyclophosphamide oral• Cyclosporin oralF.ImmunotherapyG.Other measures :• Medical synovectomy :by osmic acid or radiocolloid 90 ytrium• Surgery :synovectomy,osteotomy,arthodesis,arthoplasty.

• Prognosis :• 25% remission• 40% small for impairement• 25% disasbled• 10% crippled Complication :-septic arthritis-deformity,sublaxation,swelling-tendon rupture-synovial sac rupture-juxtra-articular osteoporosis.

osteoarthritis

Is the most common form of degenerative joint disease characterized by degeneration of cartilage and hypertrophy of bone at the articular margins.

Types

• Primary osteoarthritis :common form where no predisposing factors are present.it occurs in old age mainly in weight bearing joints.in generalize variety,the trapezio-metacarpal joint of the thumb and the distal interphalangeal joints of the fingers are also affected.

• Secondary osteoarthritis : less common,there is an underlying primary disease of the joint which leads to the degeneration of the joints,occurs commonly at hip joint.

The Predisposing Factors are

• Congenital maldevelopment of a joint• Irregularity of the joint surface from previous trauma.• Previous disease of gout: gout, septic arthritis• Metabolic disorder:

haemochromatosis,hyperparathyroidism.• Neurological disorder: tabes dorsalis• Obesity• Bow legs• Most common joint to be affected is the knee, second

most common site for OA is the thumb base.

Clinical Features

i. Symptoms :• Insidious onset of joint stiffness• Deep, aching pain, which worsens with

repetitive movement• Swelling of the joint• Feeling of instability of joint and locking of

joint.

On examination :-tenderness on the joint line-crepitus on moving the joint-irregular and enlarged joint-joint deformity-restriction of range of motion-joint effusion and swelling-wasting of muscles

Investigation

X-ray of affected joint:• Narrowing of the joint space due to loss of

cartilage.• Osteosclerosis and bone cysts.• Osteophyte.Other investigation :• CBC,Hb%,ESR,C-reactive protien. • Serum uric acid .• Arthoscopy.

• Diagnosis : clinical features + radiological findings• Methods of treatment :I. Supportive treatment :• weight reduction in an obese patient• Avoidance of stress and strain to the affected joint• Local heat provides relief of pain and stiffness• Exercise for building up the muscles controlling the joint help

in providing the stability of the joint.

ii. Drug therapy :• Analgesics NSAIDs• Chondroprotective agents :glucosamine &

chondrotin sulphate.• Viscosupplementation: sodium hylarunon.III.Surgical treatment :• Osteotomy.• Joint debridement.• Joint replacement.• Arthroscopic removal of loose bodies.

osteoarthritis Rheumatiod arthritis

Degenerative disease of joint Non-suppurative inflammatory disease of joint

Age : elderly Age : middle

Degeneration of articulating cartilage Proliferation of synovial membrane

Weight bearing joints knee, hips and spine mainly involvedasymmetrical

Small hand joints are involvedsymmetrical

Systemic features absent Systemic features present

Rheumatiod nodules negative RA factor +ve

Worsen on movement Improves on movement

ESR , Hb normal ESR raised,Hb decreased

No role of steroid therapy and no use of gold and cytotoxic agent.

role of steroid therapy and use of gold and cytotoxic agent.