Rheumatoid Arthritis & JIA Flashcards
Inflammatory joint pathologies are generally characterized by an ____ response
osteolytic
Degenerative joint pathologies are generally characterized by an ____ response
osteoblastic
If Rheumatoid arthritis (RA) creates ankylosis, it is usually what type?
fibrous
RA generally occurs (unilateral/bilateral) and (symmetrical/asymmetrical)
bilateral
symmetrical
What is the most common inflammatory arthropathy?
Rheumatoid Arthritis
In what age group does RA begin most commonly?
20s - 60
(can occur at any age, biased toward younger)
RA generally affects ____ sized joints first, and moves to ____ sized joints
smaller to larger
TRUE/FALSE:
A patient who complains of pain only in the distal interphalangeal joints is more likely to have RA
FALSE
(RA does not like DIPs in early stage)
TRUE/FALSE:
A patient who complains of pain only in the metacarpophalangeal joints is more likely to have RA
TRUE
(DJD doesn’t like MCP, RA does)
Most inflammatory conditions follow a symptomatic pattern of ____
exacerbation/remission
Chronically inflamed synovium is called a _____
pannus
What causes cartilage destruction in RA?
proteases (chondrolytic enzymes) secreted by synovium destroy hyaline cartilage in uniform fashion
Why is joint space loss in RA uniform?
chemically mediated destruction of cartilage (not biomechanical)
Inflamed synovial tissue against the bare area causes ____ radiographically
marginal erosion
Bone destruction in the bone around a joint in RA causes ____ radiographically
periarticular (juxta-articular) osteopenia
Tendon sheathes and bursa are lined with ____
synovium
What causes ulnar deviation of the fingers in RA?
rupture of tendon pulleys allows tendons to pull to ulnar side (tendon subluxation)
What are the clinical findings of RA?
- exacerbation/remission pattern
- warm, swollen, painful jts (bilateral), crepitus
- ^pain/tenderness with motion, worst after disuse (morning; lasts longer than DJD)
- deformities & tendon subluxation
- Rheumatoid nodules (*Haygarth’s nodes)
- secondary jt degeneration
- ACD -> fatigue (marrow fibrosis)
- bursitis/tendinitis/tenosynovitis
Name 4 systemic findings of RA.
- carpal tunnel syndrome (bilateral)
- Sjogren syndrome (atrophy of mucus mem. -> dysphagia, constipation, etc.)
- Vasculitis (Raynaud phenomenon)
- Pleuropulmonary (Pericardial Dz, Emphysema w/o smoking Hx)
What is the term for severe deformities of the digits in RA?
arthritis mutilans
What is a swan neck deformity?
flexion of DIP jt, extension of PIP jt
What is a Boutonniere deformity?
extension of DIP jt, flexion of PIP jt
What joints are commonly affected by RA?
- wrists + hands (MCP, PIP)
- ankles + feet (MTP)
- c/s
- hip
- knee
- GH jt
- AC jt
- elbow
What are the relevant lab findings for RA?
- ^ESR & CRP
- positive rheumatoid factor (RF; 70%)
- positive Anti-CCP (cyclic citrullinated peptides)
- low RBC & platelets (anemia of chronic disease (ACD))
When should labs be taken in a patient with suspected RA?
during period of exaccerbation
Which lab finding is more specific for RA?
Anti-CCP
(less sensitive, more specific)
Which lab finding is more sensitive for RA?
RF
(less specific, more sensitive)
What are the general radiographic characteristics of RA?
- marginal erosions (AKA “rat bite” lesions)
- juxta/periarticular osteopenia
- periarticular soft tissue swelling
- bilateral, uniform loss of jt space
- subchondral bone cysts (pseudo-cysts)
- deformities
- juxta-articular periostitis (linear)
- ankylosis (rare; fibrous)
- no osteophytes
What are the specific radiographic findings of RA in the hand?
- MCP (Haygarth nodes = radial margins of 2nd & 3rd met heads + prox. phalange base)
- PIP (Heberden nodes = radial margins of prox. phalange base)
- Swan-neck or Boutonniere deformities
- ulnar deviation/drift
- Hitchhiker’s thumb (hyperext. of IP thumb jt)
- arthritis mutilans
- marginal erosions
What are the specific radiographic findings of RA in the wrist?
- ulnar styloid process erosion (early finding)
- carpal erosions (spotty carpal sign)
- bony ankylosis (midcarpal)
- rotation deformities (zig-zag wrist)
- scapholunate dissociation (Terry-Thomas’ sign, VISI/DISI)
What is “zig-zag” wrist?
radial rotation of proximal carpal row & ulnar drift at MCPs
What are the specific radiographic findings of RA in the feet?
- MTPs (5th toe, lat side met. head is earliest, then medial side from 4-1)
- Lanois deformity
- hallux valgus
- PIPs
- calcaneal erosions at tendon attachments (marginal erosions, periarticular osteopenia)
(can also see pencil-in-cup deformity)
What are the specific radiographic findings of RA in the cervical spine?
- atlantoaxial jt instability, ^ADI (dens erosion, transverse lig rupture, dens Fx)
- basilar invagination
- facet jt erosion –> fusion
- SP erosion (pencil sharpened spinous)
- disc narrowing
- no osteophytes
- subluxations (stair-step deformity)
What is your next step before treating the cervical spine in a patient with RA?
flexion/extension radiographs
(unless minimal series shows ^ADI, stress xrays unnecessary)
What is the main concern for a patient with RA who has transverse ligament rupture?
Guillotine effect
What referral would you make for a patient with RA affecting the cervical spine?
neurosurgical referral
(chronic instability)
What is stair-step deformity in the cervical spine?
multiple levels of unstable spondylolistheses
(contraindication to adjusting)
What percent of RA patients have cervical spine involvement?
up to 80%
In patients with RA, if the cervical spine is involved, they will also have ____ involvement
hand
What are the specific radiographic findings of RA in the hips?
(larger jt = later stage)
- uniform loss of jt space (axial migration)
- erosions
- femoral head destruction (small femoral head)
- bilateral protrusio acetabuli = Otto pelvis
What is the term for unilateral axial migration of the femoral head into the pelvis?
protrusio acetabuli
What is the term for bilateral axial migration of the femoral head into the pelvis?
Otto pelvis
What are the specific radiographic findings of RA in the knees?
- uniform loss of jt. space
- jt. effusion (^incidence of baker cysts, “fullness” in post. knee)
- no osteophytes
- marginal erosions
- osteoporosis
- subchondral cysts
What are the specific radiographic findings of RA in the shoulders?
(larger jt = later stage)
- uniform loss of GH jt space
- marginal erosions (simulates Hill-Sach)
- rotator cuff tear d/t subacromial bursitis (supraspinatus tendon)
- clavicular erosions (tapered distal clavical)
What are the differential diagnoses for clavicular erosions?
- PTOC
- RA
- HPT
- septic arthritis
What are the specific radiographic findings of RA in the elbows?
- 90% have +/ve fat pad sign
- pancompartmental loss of jt space
- marginal erosions
- bursitis
What are other names for juvenile idiopathic arthritis (JIA)?
- juvenile rheumatoid arthritis (JRA)
- juvenile chronic arthritis (JCA)
Define juvenile idiopathic arthritis
an inflammatory arthropathy with an onset prior to 16 years of age
(i.e., a 30 year old that comes into your office would have JIA, bc different manifestations than adult onset RA)
Lab results that are positive for RF are termed ____, while labs that are negative for RF are termed ____
seropositive
seronegative
What sex is most affected by JIA?
Female
What systemic symptoms may present with JIA?
- chronic, low-grade fever (99-100 F)
- rash
- lymphadenopathy
- iridocyclitis
- ACD (fatigue)
- receded-hypoplastic mandible (bird-like facies)
- shorter height, less muscular (d/t low energy)
What joints are targeted by JIA?
- c/s
- hands
- wrist
- feet
- knees
- hips
What age group is primarily affected by JIA?
peaks at 2-5 yrs and 9-12 yrs
What are the radiologic features of JIA?
- soft tissue swelling
- osteoporosis (transverse growth arrest lines)
- periostitis (more than in adult RA)
- uniform jt. space loss (late stage)
- articular erosions (less than RA)
- growth disturbances (ballooned epiphyses, early closure of growth plates –> smaller bones)
- bony ankylosis (IP, carpals, tarsals, cervical facets)
How does ankylosis in JIA compare to RA?
- JIA = bony
- RA = fibrous
