Rheumatoid Hands

Question 1

What deformities should you comment on during examination?

Answer 1

• Subluxation at MCP joint
• Z thumb deformity
• Swan-Neck & Boutannaires deformity
• Ulnar deviation of fingers, Radial deviation at wrist
• Dorsal subluxation of ulna at carpal joint

Question 2

What signs should you comment on during examination?

Answer 2

• Nail fold infarcts & Vasculitities
• Rheumatoid nodules
• Palmar erythema
• Wasting of 1st dorsal interossei (and other small muscles of the hands)

Question 3

Which joint should be commented on regarding whether it is spared or affected?

Answer 3

Terminal Interphalangeal Joints

Question 4

How may you report the status of rheumatoid arthritis during the summary?

Answer 4

Active (inflammed joints?) or Inactive

Question 5

What is the significance of Rheumatoid Nodules?

Answer 5

Indicates SEROPOSITIVE & more AGGERSSIVE arthritis

Question 6

Where are nodules found in RA?

Answer 6

Flexor & Extensor tendons of the hands
Sacrum
Achilles tendon

Sclera
Lungs
Myocardium

Question 7

What skin lesions are normally found in RA?

Answer 7

Nail fold infarcts

Vasculitities

Question 8

Causes of anaemia in RA?

Answer 8

Anaemia of chronic disease

Megaloblastic anaemia

• Folate deficiency
• Due to methotrexate use

Felty Syndrome

Question 9

What is Felty’s Syndrome?

Hint: Father Christmas

Answer 9

SANTA

S - splenomegaly
A - anaemia
N - neutropenia
T - thrombocytopenia
A - arthritis (rheumatoid)

Felty’s syndrome is strongly associated with
+VE Rheumatoid Factor

Question 10

What are some pulmonary manifestations of rheumatoid arthritis?

Answer 10

Rheumatoid nodules
Fibrosis alveolitis
Pleural effusion

Question 11

What are some occular manifestations of rheumatoid arthritis?

Answer 11

Slecritis
Episcleritis

Sjogrens syndrome

Question 12

What is Sjogrens syndrome?

Answer 12

1. Fatigue
2. Dry eyes (keratoconjunctivitis sicca)
3. Dry mouth (xerostomia)

Systemic autoimmune disorder in association with a connective tissue disorder (usually RA, but can be other).

Question 13

What autoimmune conditions may Sjogrens syndrome be associated with?

Answer 13

Autoimmune thyroid disease
Myasthenia Gravis
Autoimmune liver disease

Question 14

What antibodies may be seen in Sjogrens syndrome?

Answer 14

Anti-Ro (SSA)
Anti-SSB

(Think SS = Sjogrens Syndrome A or B)
(Think Sjo rhymes with Ro)

Question 15

Which antibody is specific to rheumatoid arthritis?

Answer 15

Anti-cyclic citrullinated peptide antibodies

or Anti CCP antibodies

Detection contributes to differential diagnosis and severity of condition

Question 16

What is the point criteria of joint involvement for rheumatoid arthritis?

Answer 16

1 medium-large joint = 0

2-10 medium-large joints = 1

1-3 small joints = 2

4 - 10 small joints = 3

> 10 small joints = 5

Question 17

What is the point criteria of serology for rheumatoid arthritis?

Answer 17

-ve RF or ACCP = 0

+ve RF or ACCP

• Low titre = 2
• High titre = 3

Question 18

What is the point criteria for duration of synovitis for rheumatoid arthritis?

Answer 18

< 6 weeks = 0

> 6 weeks = 1

Question 19

What is the point criteria for acute phase reactants for rheumatoid arthritis?

Answer 19

Normal CRP / ESR = 0

Abnormal CRP / ESR = 1

Question 20

What score definitively diagnoses someone with rheumatoid arthritis?

Answer 20

6 or more

Question 21

How would you treat mild-moderate rheumatoid arthritis?

What about pregnancy?

Answer 21

NSAIDs for flair ups and symptoms (appropriate PPI should be given)

1st line - Methotrexate to reduce progression

Pregnancy (symptoms usually diminish during)
1st line - Prednisolone
2nd line - SSZ or HCQ

Question 22

What biologic agents are available for treatment of rheumatoid arthritis?

Answer 22

Three TNF-a inhibitors

1. Infliximab
2. Etanercept
3. Adalimumab

One IL-1 inhibitor
4. Anakinra