Y&R 1010 - 1033 Flashcards
What is RA characterized as?
Bilateral symmetry and progressive nature of the joint disease. Targets synovial tissue, especially those joints of hand and feet and some of cervical spine
Is involvement of bone tendon or bone ligament junctions common or uncommon in RA? aka, Enthesopathy
uncommon
What other systems might be affected by RA?
Heart, lungs, small blood vessels, nervous system, eyes, and reticuloendothelial system
When does RA usually onset?
between 20-60
What is the peak age of RA?
40-50
Is RA more common in men or women? What is the ratio?
Women
3:1 ratio, especially in the 20-40 age group
After the age of 40, what happens to the guy to girl ratio of those affected by RA?
It goes to 1:1
How do signs and symptoms of RA normally begin?
In an insidious manner, but tend to flare up more in the morning, with soft tissue swelling
What is the most common sign of RA?
Articular symptoms begin in the interphalangeal and metacarpophalangeal joints and progress proximally toward the trunk
What happens in the cervical region of RA?
80% gets affected, but it is USUALLY not early on. Early on is normally the hands and feet, but rarely ever other parts of the spine
What is another acute sign of RA, what % does it affect?
Firm non-tender rheumatoid nodules may be palpable in approximately 20% of patients most commonly found immediately distal to the olecranon
Rheumatoid noducles indicate:
The disease has gotten severe
“Haygarth Nodes”
What are the lab findings of RA?
- Positive sheep agglutination test (rheumatoid factor)
- Poor mucin precipitate from synovial fluid
- Uniform joint loss space
Describe the atlantoaxial joint in regards to RA
Synovial tissue is normally present between the anterior tubercle and the anterior odontoid surface as well as between the transverse ligament and posterior portion of odontoid’s apex
What happens with “pannus” in the Atlantoaxial joint?
Pannus formation in sights of odontoid often precipitates odontoid erosion, even to the extent of complete odontoid dissolution.
What happens to the transverse ligament during RA?
It becomes stretched from tissue changes, promotoing loosening and decalcification, this can ultimately result in complete dislocation with cord compression
Describe cartilagenous articulations in RA:
At the discovertebral junction, loss of disc height and endplate erosions are common, particularly in the cervical spine
Where do entheseal changes occur during RA?
Tips of the spinous processes of cervical vertebrae, with erosions, sclerosis, and an eventual tapered appearance
What are the 3 distinct zones associated with Rheumatoid nodules?
A central focus necrosis, a middle layer of palisaded histocytes, and an outer layer fibrous tissue with plasma cell and lymphocytic infiltrate
What is generally the first radiographic sign of RA?
The density of the periarticular soft tissues is usually increased
There is a localized loss of _____ in the early stages of RA?
loss of bone density of the epiphysis and metaphysis adjacent to the involved joint
Describe, Marginal Erosions in RA (rat bite erosions):
A localized loss of articular cortex at the bare area of the joint margin with no definite sclerotic border at its edge is characteristic
Describe Juxta-Articular Periostitis:
Not a frequent sign in RA, but when present it consists of either a solid or single lamination in the metaphyseal-proximal diaphyseal region adjacent to the involved joint
Describe pseudocysts in regards to RA:
These are analagous to subchondral bone cysts of DJD and are owing to the combination of synovial fluid and intraosseous extension of synovial pannus. Frequently, they will become large, up to 4-6 cm and simulate a subarticular neoplasm or infection
What is the deformity associated with RA?
Owing to a combination of joint destruction, ligamentous laxity, and altered muscular action, subluxations, dislocations, and osseous misalignments are common and predictable
What is the most common imaging when dealing with RA?
Plain film radiography, detects EARLY RA
What film is used to get the best prognosis of RA?
MRI
What places in the hand will be affected by RA?
PIP, metacarpophalangeal joints.
- Distinct ABSENCE at the DIP joint
What are some early signs of RA?
Soft tissue changes, it will begin to SWELL, and maybe displaced skin contours (spindle digit) and fascial planes or a slight increase in periarticular soft tissue density
What is the earliest articular change in RA?
Demonstration of a marginal erosion, most common are:
- Radial margins of the 2nd and 3rd Metacarpal heads
- Radial margins of the distal and proximal ends of the proximal phalanges
What will a marginal erosion look like?
It will be visible as a lucent defect in the lateral extent of the articular cortex, its boundaries are typically irregular, and poorly defined, and will have NO sclerotic border
What happens to the bone changes in RA?
Within the adjacent bone, osteoperosis is frequent in the epiphyses and metaphyses. Later the diaphysis may be affected by osteopenia. Periosteal new bone is occasionally visible adjacent to the metaphysis and proximal diaphysis as a solid or or single lamination
What are the deformities that occur from RA?
- Following joint dislocation, pressure erosions can occur at the site of bone compression
- Boutonniere look (ext. DIP) Flexion of PIP
- Radial deviation of carpal bones and ulnar deviation of digits = ZIG ZAG anomoally
What happens at the wrist during RA?
Very common to get deformities in the wrist, 60% are more severe than hand changes, The extensor carpi ulnaris tendon is most commonly involved.
What happens to the distal ulna during RA?
Soft tissue swelling is the first visible location of synovitis within the joint or adjacent tendons. Secondarily, erosions of the ulnar styloid occur after subperiosteal resorption and pannus from the radioulnar joint, prestyloid recess, or overlying tendon sheath of the extensor carpi ulnaris
What happens to the distal radius during RA?
Marginal Erosions are visible at radius styloid and adjacent scaphoid, MRI will have synovial thickening. There is a loss of radiocarpal joint space with no reactive subchondral sclerosis
What else happens to the radius?
Radial rotation of the proximal carpal row often occurs, with the digital ulnar drift at the metacarpal phalangeal joints producing the zigzag deformity. A sequela complete midcarpal ankylosis may occur but will rarely fuse the radiocarpal joint
What are the most common things that happen to the foot during RA?
Normally parallels the hand. (15% it is the initial site)
- MOST COMMON: Interphalangeal joint of big toe and the metatarsal phalangeal joint
- MOST COMMON metatarsophalangeal joint affected is the 5th, decreasing in incidence toward the great toe
How do erosions happen to the foot?
Erosions are usually marginal, appearing earlier and remaining more prominent on the medial surface of each metatarsal head. The fifth metatarsal head is the exception, where the earliest erosions usually are visible on its lateral margin.
Deformities are common in the feet, and they include:
Digital fibular deviation at the metatarsal - phalangeal joints, except the 5th digit, and flexion deformities of the toes often associated with subluxation and even dislocation at these same joints (Lanois’ deformity)
- Prominent hallux valgus is INFREQUENT
- The metatarsal bones often appear spread apart and the longitudinal arch flattened
What happens to the spine during RA?
Involves cervical spine in 50-80% of patients. Pathologic fractures owing to osteopenia or avascular necrosis secondary to corticosteroid therapy with an intravertebral collection of gas in the vertebral body (intravertebral vacuum cleft sign) may also be common. CT and MRI are useful for the spine
What happens to the atlantoaxial articulation in RA?
Apophyseal joint erosions and ankylosis, atlas instability, subluxation, dislocation (ADI > 3mm), Odontoid erosion and destruction.
- Most important is the atlantoodontoid joint
- 30 - 50% chance of affecting this joint
Describe “instability” in regards to RA:
Loss of ligamentous integrity, particularly of the transverse ligament may make the atlas go anterior, lateral, or anterioinferiorly
Normally happens in 2nd - 3rd decades of the disease
- Up to 12 mm can be asymptomatic
Describe erosion in regards to atlantoaxial articulation:
The sites of bony erosion are intimately related to the locations of adjacent synovial tissue from which invading pannus originates and are analagous to the peripheral joint marginal erosion.
Describe the erosions on the odontoid:
They occur on the odontoid predominantly at the base in a circumferential manner, but they are most prominent on the posterior and anterior surfaces.
- Additional erosions may be visible on the posterior surface of the C1 anterior tubercle. The base will be narrowed. With progressive erosions, complete dissolution of the odontoid may occur
Describe Apophyseal joints in regards to C3-C7 subaxial articulations:
Erosions, loss of joint space, instability, and infrequent bony ankylosis characterize apophyseal involvment. Instability is best seen in FLEXION
What are the bone abnormalities in C3-C7 (subaxial)?
Generalized osteoporosis is a prominent and common finding, especially those using corticosteroids for more than 5 years. Early erosion and subsequent altered tapered contour of the lower spinous processes (sharp pencil).
What bone abnormalities happen to the hip during RA?
Erosions, cysts, osteoporosis, and frequently osteonecrosis of the femoral head
What happens to the SI joint during RA?
Uncommon site of involvement in contrast to anylosing spondylitis. < 25% deal with SI joint problems, Osteoporosis of the pelvis is a FREQUENT accessory finding
What happens to the shoulder during RA?
Prominent bilateral and symmetrical findings are frequent in both the glenohumeral and AC joints. Soft tissue swelling occurs as well. Rotator cuff rupture affects the shoulder and elevates humeral head.
What happens to the elbow during RA?
The extensor surface of the forearm is a common region for the development of RA nodules, enlargement of the olecranon bursa. At the joint, uniform loss of interosseous space, osteoporosis, and erosions are minimal
Describe the knee during RA:
The knee is a common site for involvement. Soft tissue swelling is prominent (suprapattelar and popliteal regions). Large BAKER’s CYSTS
What else happens to the knee during RA?
Marginal erosions of the peripheral aspects of the femur and the tibia occur. Subchondral cysts of large proportions are commonly demonstrated.
What happens to the ankle during RA?
Involvement of the tarsal joints and ankle mortise is relatively frequent. Uniform loss of joint space and occasional linear periostitis is most notable at the ankle mortise
What happens in the lungs during RA?
Nodular densities may form which may cavitate (necrobiotic nodules) and represent pulmonary rheumatoid nodules. The appearance may simulate bloodborne pulmonary metastases.
