Review of Connective Tissue Conditions Flashcards
what is tendinitis
Small tears causing localised inflammation in a tendon
what is a tendon made out of
- dense fibrocallagenous tissue made out of fibroblasts which make collagen type I
- Collagen type I is laid down in regular long fibres
what is the cause of tendinitis
- Overuse
- Collagen disorders- such as marfans
- Renal dialysis - effects clearance and new production of collagen so can cause the tendons to become more brittle
What are the common sites of tendinitis
Lateral epicondylitis - tennis elbow
Achilles tendonitis
Supraspinatus tendinitis
Anywhere there is a tendon
What is the treatment of tendinitis
RICE
Analgesia and NSAIDs
Stretching
Surgery
What is long term complication of tendinitis
tendinosis
What is tendinosis
Chronic injury and failed healing
Can lead to full thickness tears
what can heal an achilles tendon
Partial tears in Achilles tendon may heal by forming herterotopic calcified regions due to the prostaglandins
30% of tendon injuries can cause
heterotrophic ossification
what are achilles tendon rupture
Achilles tendon rupture in athletes usually occurs at 2–6 cm above the insertion point.
What do prostaglandins induce
- they also induce hypertrophic ossification
- cause the conversion of fibroblasts to a chondrocytes or an osteoblast
what do NSAIDS help prevent
help prevents the hypertrophic ossification
- is both supporting in that it treats symptoms but it also prevents complications
What is a hypertrophic ossification
Previously damaged tendon that calcifies becomes more brittle and may rupture
How does the tendon repair itself
Extrinsic
- peripheral fibroblasts
- for tendons such as achilles, rotator cuff tendons that are open and not enclosed
intrinsic
- fibroblasts from tendons itself
- such as the hand flexors
- any tendon covered by a tendon sheath
How long does a tendon take to heal
- can take up to a whole year to heal itself
Why does tendon take a while to heal
- avascular
- rely on peripheral and intrinsic fibroblasts
What are the phases of healing for a tendon
- Inflammation = pain, swelling and redness, decreased collagen synthesis and increased inflammatory cells
- Repair = collagen fibre production, decreased collagen fibre organisation, decreased inflammatory cells
- Remodelling - proper collagen fibre alignment and increased tissue strength
What are the two types of enthesis
Fibrous
Fibrocartilaginous
describe he two types of enthesis
Fibrous - collagen type I fibres get integrated into the bone
Fibrocartilaginous
- small section of fibrocartilage at attachment site
- go from tendon collagen type 1 to fibrocartilage which is also collagen type 1 which is unmineralised and then it becomes mineralised the collagen type I will then integrate into the bone matrix
- this transitions the tendon and it goes stiffer in each of these tendons therefore there is a gradual change in mechanical properties
anything that is inserting into the bone is an
Enthesis
describe the histology of fibrous enthesis
- sharply fibres - can see the collagen from the tendon inserting through the periosteum and into the bone
name some examples of fibrous enthesis
Peridontal ligament
deltoid
where is the insertion point for the fibrous enthesis
insertion point is a long distance away from the joint
describe the histology of fibrouscartialge enthesis
- hybrid of fibrocollagenous tissue with some chondrocytes in there that can calcify
- tendon, dense regular connective tissue and then going into the hybrid tissue
- stacks of chondrocytes getting produced - Get a transitional tissue between cartilage and bone, able to withstand bending
where is the insertion point for the fibrocartilage enthesis
close to the joint
what is ethesitis
Inflammation of the enthesis
- any point of attachment point for tendon/ligament inserting into the bone
What are the agues of enthesitis
Recurring stress
Autoimmune disease
- Key pathological lesion in spondyloarthritides
- Associated with HLA B27 arthropathies
describe the pathogenesis of enthesitis
- Vasodilation
- inflammatory response
- the inflammatory response with lots of proinflammaotry cytokines causes it to become more inflamed
- causes the release of COX2 and COX2 to release chondrocytes so we get ossification at the enthesis
what does normal enthesis have at its insertion point
lots of small transcortical vessels
What are comorbid conditions for enthesitis
Inflammatory bowel disease
Psoriatic arthritis
Ankylosing spondylitis
where is the tendinitis
- in the belly of the tendon
where is the inflammation with enthesitis
insertion point
What is an ethesophyte
bony protrusion at a tendon insertion point
Where does the enthesophyte originate from
Enthesophytes originate from the insertion of joint capsule, ligament or tendons.
- The articular border is not involved
where do osteophytes originate from
Osteophytes originate from the border of the articular cartilage
what is the difference between enthesophyte and osteophytes
- Osteophytes originate from the border of the articular cartilage
- enthesophyte- originate from the insertion of joint capsule, ligament or tendons
What is the treatment for enthesitis
RICE
Non-steroidal anti-inflammatories
Usually part of treatment of an associated polyarthritis
- Sulfasalazine
- methotrexate
Anti-TNF therapy
- restricted for use for severe autoimmune enthesrtiis
local radiotherapy
corticosteroid injection
injection of hyperosmolar dextrose
what does RICE stand for
Rest
Ice
compression
elevation
Anti-TNF treatment can ..
Resolve enthesitis
What does the tendon sheath do
Protects and nourishes tendons
- Cushions tendons
- Guides tendons
Tendon nutrition
- Synovial fluid from tendosynovial sheath
- Vincula blood supply (via mesotendon)
describe the structure fo the tendon sheath
- same structure as the synovial membrane in the joint
- has type A and Type B synoviocytes that line the inner cavity
- has loose areolar connective tissue
How does rheumatoid arthritis affect the tendon sheath
it can affect any synovial membrane therefore causes inflammation
what is tenosynovitis
- Isolated inflammation
Describe De Quervain’s tenosynovitis
De Quervain’s tenosynovitis
- fibrosis and narrowing of tendon sheath
- caused by tendons and sheath rubbing over radial styloid process
- caused by overuse
What is trigger finger
Enlargement of tendon within the sheath therefore the tendon is outside of the tendon sheath that has been damaged and the tendon gets stuck in the tendon sheath
What is the management of tenosynovitis
Treatment
- RICE
- Splintting
- Anti-inflammatories
- Corticosteroid injections
Surgery
- Trigger finger - cut the annular ligament - giving more space for the tendons to move
- De Quervains shave down radial styloid process
describe the epidemiology of lupus
- 10-50:100,000 in Britain = over 30,000
- 90% female
- More common in blacks than whites
What is the whole name of lupus
Systemic lupus erythematosus
describe the pathophysiology of lupus
- antibodies against a wide range of self antigens
- ANA antibodies against intranucelar proteins such as DNA and RNA
what are the symptoms of lupus
Non specific fatigue, fever, arthralgia weight changes, and dermatological
- Small joints of hands, wrist and knees - causing them to become stretched and loose
- Migratory asymmetrical pain not related to swelling
- Malar facial rash in butterfly pattern
- Photosensitivity
- Discoid lesions
- Alopecia
Renal nephritic disease
Neuropsychiatric
Pulmonary
Gastrointestinal - e.g. spelnomeagly
Cardiac
Hematologic
where does the lupus malar rash extend
Malar facial rash extends over cheeks and bridge of nose
- gets worse when exposed to UV light
describe why a malar facial rash occurs
Immune complexes cause damage to blood vessels and connective tissue
- So any tissue with a rich capillary network at risk
what is lupus arthritis
Jaccoud arthropathy (nonerosive) hand deformities - Due to tendinitis / tenosynovitis.
How many patients develop lupus arthritis
- 90% of SLE patients develop arthralgia/arthritis
what staining do you use for lupus patients
More than 95% of patients with SLE are positive for ANA
- Titre extent of dilution that still gives a dectable pattern (but does not correlate with disease activity)
what are the patterns of ANA staining
Homogeneous
- Antigen double stranded DNA (ds-DNA), histones
Speckled
- SS-A /Ro, SS-B/La (Sjögren syndrome), Sm (Smith antigen), RNP
How do you treat lupus
Depends on severity of disease process
Simple prevention of exposure to triggers
NSAIDs
- Mild to moderate
DMARDs – moderate - severe and flares
- Cyclophosphamide very effective
- Mycophenolate mofetil
- Methotrexate
- Tacrolimus
Corticosteriods - flares
IV immunoglobins
What biological treatment can you use for lupus
Belimumab
- Inhibits BAFF (BLyS)
- BAFF causes activation of B cells so this inhibits the activation of the B cell
Rituximab
- CD20 blocker