Rheumatoid Arthritis Flashcards
Radiographic changes of the hand, including erosions and
decalcification.
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v upper extremity complaints are a hallmark of the RA disease
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disease severity is commonly linked to the age of onset
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A family history of RA increases the
lifetime risk from three-fold to five-fold
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symmetric
hand pain lasting 6 weeks or longer without a known etiology should
prompt consideration of inflammatory arthropathy
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Rheumatoid nodules are present
only in a minority of RA patients
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Nodules present only in the hand
F Nodules are commonly located on
extensor pads associated with synovitis but can appear in multiple
extra-articular tissues including eyes, lungs, or vocal cords
Any synovial joint may be
affected, but hand involvement is often seen as a hallmark of disease
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First joint that effected with RA ?why?
The metacarpophalangeal (MCP) joint, proximal interphalangeal (PIP) joint, and wrist are often affected first due to the relatively high synovial surface area.
Secondarily, large
joints such as the elbows, knees, hips, shoulders are affected
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Even small articular surfaces, such as the ossicles of the middle ear, can be involved
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patients may present with synovitic rheumatoid nodules around large
joints. Rheumatoid nodules may be unsightly, painful, irritating to
adjacent tendons, or cause nerve compression.
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the distal interphalangeal joint (DIP) joint
is often spared in RA
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early wrist erosions appear at the scaphoid waist, ulnar
styloid, and the distal radioulnar joint (DRUJ)
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In RA, synovitis
typically affects the radiocarpal joint more than the midcarpal
joint
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ynovitis around the wrist joint often involves the extensor compartments and may grow around the tendons
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vaughan-jackson syndrome
process is
compounded by dorsal prominence of caput ulnae leading to progressive tendon ruptures from ulnar to radial along the dorsal wrist
Tendon ruptures are often sudden and are usually painless
T though
synovitis may be painful at the site before the rupture
Osteophytes
on the radius or carpus can also lead to tendon attrition
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Mannerfelt
lesion
scaphoid osteophytes or synovitis can lead to attrition of the
flexor pollicis longus (FPL) tendon,
Tendon reconstraction achieved through tendon transfers
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once a musculotendinous unit has ruptured, that muscle is no longer useful in the setting of RA.
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patients often complain about the inability to fully extend their
fingers what are the causes ?
- ulnar subluxation of the extensor tendon due to attenuation of the radial sagittal band
- progressive subluxation and volar translation of the proximal phalanx on the metacarpal head
- ## Very rarely, loss of extension can be due to compression on the posterior interosseous nerve
Passively correctable ulnar translation of the joint or tendons can be corrected with soft-tissue surgeries
such as extensor tendon centralization (typically a synovectomy and
radial sagittal band imbrication) or a cross-intrinsic tendon transfer
to apply more dynamic radial force
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if the digit is shortened, irreducible, or the articular erosions are severe
first-line management is often joint replacements with silicone metacarpophalangeal arthroplasty
PIP joint, wrist, and elbow are treated with joint replacement in only
select cases
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swan neck and boutonniere deformities can occur in the
same hand in different digits
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swan neck less common than boutonniere deformities
F swan-neck is more
common than boutonniere
In swan-neck, the anatomic
derangement occur in the PIP
In swan-neck, the anatomic
derangement can occur at any of the three joints of the finger (MCP,
PIP, or DIP joints)
Treatment depends on the severity of
the deformity and whether the PIP joints are actively and passively
reducible
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Treatment depends on the severity of
the deformity and whether the PIP joints are actively and passively
reducible
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In contrast to swan-neck, the boutonniere deformity is caused by
pathology intrinsic to the PIP joint.
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Thumb deformities in RA
Type I: Boutonniere deformity (most common)
Type II: Boutonniere deformity with carpometacarpal (CMC)
joint dislocation or subluxation
Type III: Swan-neck deformity with metacarpal adduction
Type IV: Gamekeeper’s deformity (attenuation of MCP ulna collateral ligament)
Type V: Swan-neck deformity without metacarpal adduction
deformity
Management for thumb anomalies is largely dependent on stabilization of the metacarpophalangeal (MP) joint and tendon reconstructions
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arthrodesis of the MCP joint is the best solution
to establish stability of the MCP joint.
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arthrodesis of the MCP joint is the best solution
to establish stability of the MCP joint.
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CMC arthroplasty can be considered if the CMC joint is painful,
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PIP joint IN RA
Attenuation of volar plate
Attenuation of transverse retinacular ligament
Dorsal translation of conjoint lateral band
Flexor tenosynovitis
Rupture of flexor digitorum superficialis
MCP change
Attenuation of volar plate
Flexor tenosynovitis
Intrinsic tendon adhesion
Intrinsic muscle contracture
Rupture of extensor insertion
onto base of proximal phalanx
SLE-related arthritis may present with similar findings
as RA
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SLE deformity is more likely to be the result of soft-tissue attenuation
and laxity with sparing of the MCP joints
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Most patients complain of
pain with activities, but also note limited motion, dissatisfaction with
appearance, and pain at rest
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JIA also appears to occur less
frequently in African American and Asian populations compared to
Caucasians
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Psoriatic hand deformity can include nail deformities in about 80%
of patients
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(15%) in patients with psoriatic
arthritis variants hjave nail deformities
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30% of patients with psoriasis develop Psoriatic arthritis
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Psoriatic arthritis associated with obesity, positive
family history, and HLA-B27 positivity
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Psoriatic
arthritis of the hands typically affects the DIP joint, in contrast to RA
where the DIP joint is typically spared
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A severe form of inflammatory arthropathy of the hands, known as arthritis mutilans
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Arthritis mutilans causes
acroosteolysis of the phalanges, pencil in cup joint changes, and telescoping (opera-glass hands) of the digits
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arthrodesis is the only surgical option that may maintain
digit length and reduce pain
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Multiple systems may be affected in SLE, but joints and skin are
involved in up to 90% of patients with the disease.
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In contrast to RA, erosive arthritis and loss of articular surfaces are not typical not typical with SLE
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Jaccoud arthropathy
erosive arthritis and loss of articular surfaces are not typical. This clinical constellation results in a classicJaccoud arthropathy
where the deformity is the result of soft-tissue laxity and ligamentous
shortening rather than from direct destruction of the joints
Surgery for hand deformity in SLE is similar to
RA, but there is less need for arthroplasty and arthrodesis
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Surgical interventions for a plastic surgeon may include lipotransfer in scleroderma
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Dactylitis with fusiform swelling of a single digit (sausage
digit) is a hallmark finding.for Reiter Syndrome
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The glabrous skin on the plantar feet and palms of the hands may
develop keratoderma blennorrhagicum which is pathognomonic for reactive arthritis
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Treatment is largely medical and can be
similar to other inflammatory arthropathies
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