Rhuematoid arthritis Flashcards
Definition
Chronic systemic inflammatory disease characterised by a symmetrical deforming peripheral polyarthritis mainly affecting the small peripheral joints
Epidemiology
- 1% of population
- women> men 3:1 BEFORE MENOPAUSE
- typically 30-50 years
- higher prevalence in caucasians
- lifetime risk of 4% for women adn 3% for men
Aetiology
- Multi-factorial
- genetic predisposition
- HLA-DRB1
- shared epitope
- environmental
- smoking
- infectious trigger
- Specific antigen - anti-CCP
Pathogenesis
- Innate and acquired immune response
- B lymphocytes – RF, immune complexes
- T lymphocytes – cell mediated, cytokines
- Macrophage derived cytokines – TNFα, IL-6, IL-1
- Synovial fibroblasts
- Chronic inflammatory response in synovium – “synovitis” –>pannus
- Inflammatory changes not confined to joints
American college of rhuemtology criteria
Test those with >1 joint with definitive swelling which is not better explained by another disease. Add total A-D score >6/10 are diagnostic
A- joint involvement
- 1 large = 0
- 2-10 large =1
- 1-3 small =2
- 4-10 small =3
- >10 joints =5
Serology (at least 1 test result)
- Negative RF and negatie anti-CCP = 0
- Low +ve RF or low +ve anti- CCP=2
- High RF or high +ve anti CCPT = 3
Acute phase reactants
- normal CRP and normal ESR = 0
- abnormal CRP or abnormal ESR =1
Duration of symptoms
- <6 weeks = 0
- >6 or equal to = 1
Presentation
- symmetrically swollen
- Pain and swelling
- Small joints of hands, feet and wrists
- often symmetrical
- response to anti-inflammatory
- large joints may be involved
- Joint stiffness
- worse in the morning
- >30 minutes
- diurnal variation
- insidious onset
- sytemic illnes with extra-articular symptoms
Name the hand joints
Examination
- swelling - boggy synovitis
- warmth
- joint line tenderness
- deformity
- swan neck
- boutonniere
- ulnar deviation of metacarpals
- radial deviation of wrist
- muscle wasting
- extra-articular e.g nodules, iritis, anaemia
Name the bones of the hand
Joints affected in RA
Symmetrical polyarthroapthy
- MCP (metacarpal phalangeal joint) - 90%
- PIP (proximal interphalangeal joint) - 90%
- MTP (metatarsal joints) - 90%
- Wrists 80%
- Knees 80%
- Ankle/subtalar- 80%
- Shoulder -60%
- Hip 50%
- Elbow 50%
- Cervical spine -40%
Features of rhuematoid hand
- Prominent ulnar styloid
- z-shaped deformition of the thumb
- Ulnar deviation of the fingers at the MCP joints
- palmar subluxation at the MCP joints
- Boggy, welling, erythema and heat at the MCP, PIP joints
- Swan neck- deformity
- Boutonniere deformity
- Fixed flexion contracture
- palmar erythema
- wasting of the thenar eminemce related to carpal tunnel syndrom
- Rhuematoid nodules are most commonly found on bony prominences
What does this show?
Prominent ulnar styloid due to subluxation at MCP joints
What does this show?
Z-shaped deformity of the thumb -
The thumb flexes at the metacarpophalangeal joint and hyperextends at the interphalangeal joint below your thumb nai
What does this show?
Ulnar deviation of the fingers at the MCP joint
Ulnar deviation, also known as ulnar drift, is a hand deformity in which the swelling of the metacarpophalangeal joints (the big knuckles at the base of the fingers) causes the fingers to become displaced, tending towards the little finger.
what does this show?
Palmar subluxation at the MCP joints -
If the collateral ligaments become stretched and the fibers of the extensor tendon are damaged by synovial swelling, the strong flexor muscles will pull the base of the proximal phalanx in a palmar direction, so causing palmar subluxation.
What does this show?
Swan neck deformitiy - PIP hyperextension and DIP flexion
What does this card show?
Boutonniere deformity- PIP flexion and DIP hyperextension
