ARTHRITIS.pdf

 ARTHRITIS SUBSPEC DR TAMAYO NOV 2016

CLASSIFICATION OF DISEASES AFFECTING THE JOINTS Infectional arthritis  Degenerative arthritis  Arthritis associated with metabolic diseases  Neuropathic joints  Neoplasms of the joints  Systemic disease manifestations  Local joint disturbances  INFECTIONAL ARTHRITIS Acute  Caused by strep staph or gonococcal o Chronic arthritis  Caused by tuberculus bacilli o

INFECTIONAL RHEUMATIC FEVER  Rheumatoid arthritis  o Has ulnar drift Ankylosing spondylitis  –probably inflectional  Loss of the intervertebr intervertebral al movements o o Whole spine becomes a rigid tube Sporiatic arthritis  o Due to complications of psoriasis Have joint problems o

NEOPLASMS OF THE JOINTS Cysts that may occur inside the joint  Xanthomas or hemangiomas joint tumors or synovial  tumors TRAUMATIC ARTHRITIS Joint surface has been founded in traumatic injuries  Eg fall from a height on the feet  Structure of the cartilage lining of the joint o o Will appear as if there is no fracture Manifestations  o Pain Swelling o o Loss of motion Due to  o direct indirect trauma o Eg fall on feet but spine gets the problem – compression fracture in the spine EXAMINATION  st o 1  examine lower extremity for callus formation nd 2  examine thoracolumbar spine o rd o 3  examine the distal radius and ulna When patient falls and lands on feet they will suddenly force sudden flexion and can cause compression 

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DEGENERATIVE ARTHRITIS More common  Old age  Generalized or localized  Localized  o Secondary to previous trauma Structural deformity o Happens in patients who has problems with the joints Eg genu varum Weight bearing area  is only on the medial side Patient will have early  arthritic changes in the medial compartment of the  joint Will become more  bow legged Due to rheumatoid arthritis that has been o burned out o Unknown cause 

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ARTHRITIS ASSOCIATED WITH METABOLIC DISEASE Gout  o Most common metabolic disease Due to derangement in purine metabolism o o Uric acid circulates in the bloodstream and eventually lodges in the joints as tophi o Causes erosion in the joint surface and will eventually destroy joint NEUROPATHIC JOINTS Tabes dorsalis  o Disk herniations Loss of intervertebral disk space o o Compression of the spinal cord Patient will manifest neurologic deficits and o  joint problems on the cervical spine Syringomyelia  o Tumorlike formation inside the spinal cord See syringe present in the spinal cord o o Manifest neurologic deficits and joint problems in the cervical spine

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SYSTEMIC DISEASE MENIFESTATION Serum sickness  Hemophilia  Pulmonary osteodistrophy  LOCAL JOINT DISTURBANCES 1. Asceptic\avascular necrosis When joint loses blood supply causing necrosis  and will become soft 2. Unknown etiology a. Juvenile osteoarthritis b. Legg-calve- parthes disease o Happens in children and adolescents c. Oasgold shciatters disease o Necrosis of the attachment of the bottleneck region Commonly in adolescents that o engages in strainous sports most ommonly kicking sports like soccer or rugby Sudden pull of the quadriceps muscle o on the patella attached to the patellar tendon Pull- slight avulsion of the patellar o tendon on the tibial tuberosity causing loss of BS to the area thus necrosis of the area of the bone 3. Ostechondritis dessicans Cartilage that spills of from the subchondral area  and dessicates and flows around as a freely moving body in the joint The rest of the cartilage are healthy except for a  tear or sloughing off of the cartilage leaving raw bone Cartilage spills of In a non weight bearing area  Symptoms of pain swelling and limitation of  motion Treatment:  cartilage transplant o

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use arthroscopic surgical instruments to prevent opening up the jointminimally invasive technique

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Pigmented villonodular synovitis Attacks the synovial that normally attacks the  cartilage of the joints Knees- Most common joint affected  Vilous or nodules that grow into the synovial  gland Synovial gland will get inflamed – villonodular  synovitis will stick to the cartilage of the joint o Slowly eat up the cartilage of the joint involved Osteochondromatosis A lot of joints who m anifest joint disturbances  because of cartilage pills of from the area New growths that will happen in certain areas of  the bone Show up as m ultiple masses all over the skeletal  system Masses of cartilaginous new growths either  inside or outside the joint Look like cauliflowers  Cartilaginous in nature upon incision biopsy  Cartilaginous tumor  o May be benign or malignant (chondrosarcoma)

Flexion or extension deformity

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HISTORY

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4 5  6  decade of life Pain swelling of the joint Limitation of motion Measure ROM o o Muscle strength Neurologic exam of the extremity o

XRAY       

Narrowing joint space Increased density and thickening of subchondral bone Subchondral cysts and marginal exclences or osteophytes spurs loss of fluid space deformity subchondral cysts

2 FORMS OF OSTEOARTHRITIS 1. PRIMARY Degenerative process affecting the articular cartilage  of a previously healthy joint 2. 

SECNDARY Degenerative process precipitated by specific factors (joint incongruity) Deformity of joint o Genu varus Genu valgus  

LOCAL JOINT DISTURBANCES Asceptic necrosis due to blockage of the arteries  in the femoral head When arteries becomes inadequate- there will be  no more blood supply to the femoral head Femoral head- has minimal blood supply from  the top because it is a bone that moves around Arteries on the neck \ obturator artery o and parts of the circumflexion areteries- Only blood supply that it would rely upon If the patient sustains a femoral neck fracture  o Happens commonly in the elderly Total disruption of the blood supply to o the femoral head Reason why femoral head will o eventually necrose and flatten causing Pain angulation of the pelvis o treatment- replace femoral head with partial hip prosthesis  

OSTEOARTHRITIS osteoarthosis chondromalasic arthrosis hypertrophic  arthritis arthritis deformans o each has its own peculiar definition but stands for one peculiar degenerative joint disease Idiopathic slowly progressive disease disease of  diarthrodial joints (cartilage on the opposing surface) o Symphysis pubis and skull sutures- will not have it Occurring late in life  Characterized by focal degeneration of articular  cartilage subchondral bone thickening (scheloris) Osteochondral osteophytes (spurs)  Cystic degeneration of joint space  

Hip- different o Total destruction of the bone o Socket is no longer congruent with the ball Peculiar osteophytic spurs o

CLINICAL MANIFESTATIONS Pain and swelling  Synovitis with effusion   joint thick and fluctuant – increased fluid o inside Progressive loss of motion  Resulting deformity 

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ETIOLOGY 

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Second decade of life (changes apparent after midage) o Symptoms minimal and as it grows it will become apparent in middle age Sex equality affected after 50 more severe and generalized in o females-due to loss of hormones

HEREDITY

Sex influence dominant in males o o recessive in females SYMPTOMS insidious onset localized to one joint  on and off then will become localized and o persistent o localized in 1 joint aggravated by activity and relieved by rest  intensified by low barometric pressure  stiffness at rest loosens with activity  prominent on rising in the morning  heat and salicylates gives relief  

PHYSICAL FINDINGS creaking and grating sensation on motion  advanced stage- progressive loss of motion  o knee can no longer be bent at 90 degrees or cant be extended fully with later fixed deformity  LABORATORY ESR normal  Blood count and chemistry negative  Need to rule out rheumatoid arthritis  SYNOVIAL FLUID ANALYSIS TO DIFFERENT FROM: RHEUMATOID Cell count rarely exceeds exceeds normal  Sugar and total proteins less than 5.5 gm s%  IN RHEUMTOID: Fluid is thin turbid clots on standing (+ropes test)  TREATMENT: 1. conservative a. rest b. ROM exercise to prevent stiffness c. Abstain from weight bearing -prescribe walkers crutches or canes d. Decrease vertical loads (diet for obese)

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MEDICATION ASA  Acetaminophen  NSAIDS  Steroids  Hyaluronidase acid joint injection- like synovial fluid to  put additional lubricant in the joint and preserve the status of the knee for several months or years SURGICAL TREATMENT Debridement  Osteotomies- end result  o Joint will have equal weight bearing equal size and stress of the knee Total joint replacement  Last resort o o Life span for implants- will also deteriorate degenerate break or separate o With good care would last patient 10-20 years o Prosthesis embedded intramedullarily   

Arthroscopic debridment Osteotomy Total joint replacement

SURGICAL   

JUVENILE RHEUMATOID ARTHRITIS -happens in young adolescents or toddlers or children GENERALIZZED MULTISYSTEM DISEASE CHARACTERIZED BY: High fever  Rash- malar rash  Lymphadenopathy  Splenomegaly  CLINICAL PICTURE Joints are warm and swollen  Patient ill and anicteric  Weight  2 spike fever  Greater ESR  + CRP  +RH factor- most important  XRAY  

RHEUMATOID ARTHRITIS chronic inflammatory systemic disease of the youth  and middle aged characterized by severe proliferative proliferative changes in the synovial  membranes and pariarticular structures cause- unknown  THEORIES OF CAUSATION infection  endocrine  allergy  metabolic  autoimmune  CLINICAL PICTURE insidious onset less than 40 years if age  greater in females  constitutional symtoms  o fatigue malaise o o weakness fatigue o Sometimes fever o number of joint involved (hands feet then knees)  XRAY    

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Debridment Osteotomies Total joint replacement

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Joint space narrowed Bone destruction Flattening of epiphyseal center Bony ankyloses

GOUT 

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Hereditary condition of disturbed uric acid m etabolism where ureate crystals are deposited in the the joints and subcutaneous tissue Loss of metabolic enzyme xanthene oxidase st 1  metatarsophalangeal joint of the toe -Most common attack st Podagra- sudden attack of pain in the 1  metatarso phalangeal joint in patients with gout

CLINICAL PICTURE Hyperuremic or years precipitated by certain factors  (trauma cold diet) FAMILY HISTORY Hereditary  Renal ureate stones  TREATMENT Colchicine 1\100 gr every hour until relief is felt or  st toxic symptoms are felt- 1  line of defense ASA  Phenylbutazone  NSAIDs 

bones osteoporotic  joint narrowing articular cortex thickening  joint deformity

INTERIM TREATENT Allopurinol 

in the hand characteristic ulnar drift of fingers

SURGICAL 

LABORATORY RESULTS elevated ESR  hypochromic normocytic anemia  +Rh factor 

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Debridment Excision of Total joint arthroplasty

TREATMENT Remove focus (infection eliminate)  High caloric diet  Hematinics- because patient will manifest normocytic  hypochromic anemia Splinting- to prevent flexion deformities  MEDICATION Salicylates  NSAIDS  Cortisone  Gold treatment 

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