Arthritis and Related Disorders Flashcards
What are the 4 Stages of RA?
I. acute stage
II. subacute stage
III. chronic-active or destructive stage
IV. chronic-inactive or skeletal collapse and deformity stage
What are the characteristics of Stage I of RA?
Acute stage
pain, swelling, inflammation
symptoms usually bilateral in PIP, MCP, and wrists
no destructive changes yet
resisting orthosis indicated for pain relief as needed
What are the characteristics of Stage II of RA?
Sub-acute stage [proliferative phase]
synovium begins to invade soft tissues producing tenosynovitis and limiting joint movement
reduction in symptoms, but decreased mobility is apparent
inflammation of synovium to joints and tendon sheathscauses mild changes in articular cartilage through formation of a pannus
night orthosis to alleviate residual pain and prevent deformities
What are the characteristics of Stage III of RA?
chronic-active or destructive stage
destruction to bone and cartilage with ensuing joint deformity
often less pain, but more obvious joint deformities
functional day orthosis is indicatedas well as night orthosis
What are the characteristics of Stage IV of RA?
chronic-inactive or skeletal collapse and deformity stage
severe joint deformity and disorganization
fibrosis replaces inflammation
joint fusion, instability, or dislocation can occur
orthoses are for comfort and to provide joint stability
what are the symtpoms of septic arthritis?
pain, swelling, decreased AROM/PROM, and loss of function in affected joints
in 45% of people with septic arthritis, previous underlying joint disease with asymmetry typically occurs, which is important for diagnosis
what is Juvenile Idiopathic arthritis (JIA)?
formerly Juvenile Rheumatoid Arthritis (JRA)
one of the most common chronic joint inflammatory disease in the pediatric population under age 16
what are the types of Juvenile Idiopathic arthritis (JIA)?
Oligoarthritis: most common, previously called pauciarticular arthritis, occurs when there are 4 or fewer joints involved in the first 6 months of the disease, found in 40% of all cases, usually in bigger joints more common in girls
Polyarthritis: found in 25% of cases, can affect larger or smaller joints, more common in girls
systemic arthritis: found in 10% of cases, entire body is affected, not just joints, fevers, faint rash, inflammation of spleen and membranes of heart and lungs impacted
what are the four grades of stenosing tenosynovitis at the A1 pulley?
Grade I: Pretriggteering, pain but no active triggering
Grade II: Active: active catching but full digit AROM
Grade III: A/B: Passive: A: cathing which requires passive extension; B: catching with inability to flex
Grade IV: contracture
what is the most common collapse deformity in the rheumatoid thumb?
boutonniere deformity
what is the second most common collapse deformity in the rheumatoid thumb?
swan-neck deformity with MCP joint hyperextension and IP joint flexion, and metacarpal adduction
In what order do the digits experience extensor tendon attrition ruptures and in what direction do they rupture?
Small finger most affected
then RF, MF, and finally the IF
tendons rupture in a radial direction, resulting in tendons shifting ulnarly
what is the preferred treatment method after attritional tendon rupture?
tendon transfer
therapy consists of edema mgmt, orthosis protection of tendon transfer, tendon transfer training, and functional re-training
during acute stage of RA, how much sleep is recommended per night?
10-12 hours for every 24 hours
encourage pt to balance activity with daytime rest to avoid fatigue
What are the two types of Scleroderma?
Diffuse Cutaneous Systemic Sclerosis
Limited Cutaneous Systemic Sclerosis
Describe Diffuse Cutaneous Systemic Sclerosis
typically presents with a rapid progression of skin thickening beginning distally
includes the trunk
there is more visceral involvement than can include kidneys and heart and often more severe hand deformities
Describe Limited Cutaneous Systemic Sclerosis
sclerosis is limited the extremities, including the limbs (distal to elbows and knees) and th head
major variant is CREST syndrome
what is CREST syndrome?
a major variant of Limited Cutaneous Systemic Sclerosis. Stands for Calcinosis, Reynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasia
with scleroderma, which type of pinch is the most important to preserve?
Lateral pinch
pt’s lose 2pt pinch, then palmar pinch, and finally lateral pinch is lost last, which is devastating to hand function
lateral pinch is the most functional
what are the goals in treating scleroderma?
- maintain max ROM ( don’t expect to increase ROM)
*prevent unncessary contractures with daily ROM
*maintain MCP flexion and thumb abduction
*prevent wrist and elbow contractures
*maintain lateral pinch
*use assistive devices to improve function
*encourage optimal skincare
*use orthotics to prevent deformity
what are risk factors for OA?
trauma
obesity
genetic factors
increasing age
occupational activities
local mechanical factors
what is psoriatic arthritis?
a combination of psoriasis and inflammatory arthritis
classic finding is scaly, erythematous skin rash
pt’s with PA have negative rheumatoid factor on serology testing
what nail changes can be seen in psoriatic arthritis
pitting
onycholysis
transverse ridging
discoloration of margins of nails
what is Arthritis Mutilans?
rare subgroup of psoriatic arthritis, which can result in severe bony destruction and joint instability. Bone absorption of phalanges/metacarpals results in digits shortening. Bone and joint destruction may eventually result in collapse of finger soft tissue leading to “opera glass hand.”
what is ankylosing spondylitis?
also known as axial spondyloarthritis, is an inflammatory disease that, over time, can cause some of the bones in the spine, called vertebrae, to fuse. This fusing makes the spine less flexible and can result in a hunched posture.
what factors affect ADLs in people with scleroderma?
puffy fingers, joint pain, joint swelling, poor grip strength, poor thumb palmar abduction, poor wrist extension, poor composite index and middle finger motion, digital sores, calcium deposits, tendion friction rubs
what is caput ulnae syndrome?
an end-stage presentation of RA with destruction of the DRUJ. Retinaculum of 6th extensor compartment erodes and ECU moves ulnarly, becoming a wrist flexor. Unopposed radial wrist extensors cause wrist radial deviation and the ulnar side the wrist subluxes volarly and supinates. Prominent ulnar head
what are hyaluronate injections?
Hyalgan and Syndics
not cortisone derivatives
can be injected into a joint for viscosupplementation by chemically stimulating synovial fluid
dosage is usually 5 injections at weekly intervals
what is the correct static orthotic positioning for a thumb CMC OA?
neutral to slight palmar abduction and supination
symptoms of OA are increased with thumb pronation
how much pinch and grip strength is necessary to complete most ADLs?
20# grip
5-7# pinch
what is Vaughn-Jackson syndrome?
occurs with caput ulna and is a rupturing of the tendonds of the fourth, fifth, and occasionally sixth extensor compartments
in RA, in what direction do extensor tendons sublux?
extensor tendons at the MCPJ may sublux ulnarly due to the attenuation of the sagittal fibers on the radial side of the extensor mechanism. It will then serve more as a flexor
what is a crossed-intrinsic transfer?
used with a synovectomy in order to attempt to restore finger alignment and prevent ulnar drive. The intrinsics are released from the ulnar side of the index, long, and ring fingers, and transferred to the radial aspect of the adjacent fingers to provide additional radial stability. This should only be done if the patient has well-controlled RA
what are 3 different types of joint implants?
silicone
pyrocarbon
titanium
PIPJ replacement surgery should NOT be performed on which finger?
Index finger
Due to increased loads placed during grip and pinch, implant is likely to fail
what is the standard protocol after MCP silastic athroplasty?
*bulky hand dressing or cast for 3-5 days
*dorsal dyamic extension orthosis for daytime wear, providing active MCP flexion to 70deg and passive extensive via outrigger (x6 weeks)
*nighttime static orthosis with MCPs in neutral and slight radial deviation (3-6 months)
what is the desired MCP ROM goal follpwing MCP arthroplasty?
IF and MF 45-60 deg flexion
RF and SF 70 deg flexion
when can flexion traction be applied post-MCP arthroplasty?
at 3 weeks b/c at 21 dats the implant is clinically stable
which types of arthritis are appropriate for DMARD or anti-TNF therapy?
inflammatory arthritis such as RA, psoriatic arthritis, ankylosing spondylitis, and even IBD
what is LRTI?
Ligament reconstruction tendon interposition arthroplasty
excises the trapezium, uses FCR for interposition, and places K-wire to temporarily stabilize the construct
*the most commonly used procedure for stage IV basal joint OA
what are the indications for use of anti-TNF treaments in patients with RA?
- x-ray or MRI evidence of disease progression despite use of DMARDs
- worsening functional status
- failed DMARD therapy
which other conditions can occur at the same time as basal joint arthritis and are also differential diagnoses?
CTS
deQuervain’s
trigger thumb
what is the tx protocol after LRTI?
cast immobilization x4-6 weeks, followed by orthosis fo 13+ weeks
when is it ok to resume gripping/pinching after LRTI?
3-4 mo
therapy goal after LRTI is fxnl return of pain-free ROM. return to full strength is not a goal
which flexor tedon is most commonly ruptured in RA through attrition at the wrist?
FPL –ruptures over a volar bony spicule on the scaphoid that pierces through the wrist capsule (Mannerfelt lesion)
FDP to IF and MF may later occur
what is general post-op tx after wrist arthroplasty?
wrist support orthosis in 10-20 deg extension
at 2 weeks, initiate gentle wrist AROM
monitor for extensor lag in the digits
what is ideal arc of motion after wrist arthroplasty?
40-60 deg art of total active flexion and extension
what is the recommended orthotic wear schedule for thumb CMC/MP OA?
continuous wear until pt has minimal to no pain, then PRN. This may take 3-4 weeks and should be followed with a gradual weaning process over 1-2 weeks
what are symptoms and signs of systemic sclerosis?
tightening of skin
dryness of eyes and mouth
difficulty swallowing
calcification of soft tissues
dilated blood vessels just below the surface of the skin (telangiectasia)
HTN
inflammation of the pleura and pericardium
kidney disease
calcinosis (calcium deposits in soft tissue)
raynaud’s phenomenon
hand contracture
what is SLE?
Systemic Lupus Erythematosus
an autoimmune disease in which the body’s own tissue is treated as if it’s foreign – many manifestations
what medications are appropriate for SLE?
methylprednisolone for lupus nephritis
NSAIDs for arthritis and arthralgia
methotrexate for dermatitis and arthritis
how does RA impact joints?
chronic systemic inflammatory condition primarily affecting synovial tissue. Rheumatoid synovium overproduces fluids, which distend the joint and stretch the surrounding tissues.
RA synovium can also infiltrate the capsule, leading to ligament damage
in joints with paucity of ligaments, such as midcarpal joints, are rarely affected due to lack of synovitis in the area
in OA, which joints are most commonly affected?
DIP joints are most common
thumb CMC is second most common
What is the traction-shift test?
aka subluxation-relocation test
apply traction to thumb metacarpal followed by pressure over the dorsal aspect of the base of the metacarpal. In a case of CMC OA with subluxation, this reduces the subluxation. Test is positive for CMC OA if there is pain or crepitus with the maneuver
what is the metacarpal base compression test?
therapist grasps first MC head with one hand using thumb and IF and applies pressure on the dorsum of the thumb MC base with the other hand to create shearing across the thumb CMCJ. Positive test reproduces pain
what is the thumb adduction test?
Pt sits with elbow flexed to 90 and forearm in neutral. support the patient’s wrist in neutral. Place your ipsilateral hand do that your thumb rests dorsall over the head of the pt’s MC. Apply a downward adduction force on the thumb MC head, adduction to be in line with the second MC midaxis or until reaching a firm end feel. Positive test is reproduction of CMC pain
what is the thumb extension test?
Pt sits with elbow flexed to 90 and forearm in neutral. support the patient’s wrist in neutral. Place your thumb along the radial aspect of distal thumb MC, ~5-10mm distal to the thumb CMCJ. Extend the pt’s thumb until it comes in parallel plane to palm or reaches a firm end feel. Positive test is reproduction of thumb CMC pain.
How many ligaments are around the thumb trapeziometacarpal (TMC) joint?
16
what are the three most import ligaments at the TMC/thumb CMC joint?
dorsal ligament complex
volar beak ligament (aka volar oblique ligament)
intermetacarpal ligament
which ligament is reconstructed with a donor tendon in an LRTI procedure?
volar beak ligament (aka volar oblique ligament)
when can thumb AROM be initiated post-op mini tight-rope (suture suspensionplasty) for thumb CMC arthritis?
typically w/n 2 week post-op, after the first post-op MD visit to determine if erpaire is stable and TMC space is maintained
(cast x2 weeks, followed by removable orthosis until week 4, followed by weaning and strengthening)
what is a mini tightrope suspensionplasty?
used for suspension of thumb MC following partial or complete trapeziectomy. First MC is suspended andis prevented from subsidence into the TMC space by use of the Suture-button implant.
studies indicate immediate stability of the arthroplasty compared to LRTI
what is the typical pattern of deformity for systemic sclerosis?
Loss of MCP flexion, PIP extension, thumb abduction
