370.3: Arthritis (OA + RA)

Question 1

Osteoarthritis (OA)

Answer 1

Degenerative Disease that affect weight-bearing joints. Effects all components:

1. Articular cartilage
2. Menisci
3. Bone

Question 2

What are risk factors for OA?

Answer 2

1. Age
2. Female
3. Hereditary Gene defect
4. Joint alignment/injury
5. Obesity
6. Injuries (trauma, overuse, abnormal stress)

Question 3

Idiopathic OA (primary OA)

Answer 3

1. Unknown cause
2. Not associated with known risk factors
3. Most common type
4. Usually asymmetrical involvement

Question 4

Secondary OA

Answer 4

Associated with risk factors:

1. Joint stress
2. Congenital abnormalities
3. Joint instability caused by trauma

Question 5

What are physical characteristics of osteoarthritis (OA)?

Answer 5

1. Erosion
2. Subchondral sclerosis (thickening + hardening)
3. Formation of born spurs (osteophytes)

Question 6

What is the role of chondrocytes in osteoarthritis (OA)?

Answer 6

1. Chondrocytes constantly remodel and maintain integrity of cartilage
2. Create cartilage matrix by producing type 2 COLLAGEN + PROTEOGLYCANS
3. Cannot effectively synthesize elements needed for maintaining cartilage

Question 7

What happens to articular cartilage in osteoarthritis (OA)?

Answer 7

1. Early, loses white/glistening appearance, becomes yellow-grey or brownish-grey
2. Surface areas flake off and deeper layers develop longitudinal fissures (FIBRILLATION)

Question 8

What is the pathophysiology of osteoarthritis (OA)?

Answer 8

1. Cartilage becomes thin/absent, leaving the SUBCHONDRAL bone unprotected
2. Sclerotic bone growth increase at the joint margins and bony outgrowths (OSTEOPHYTES) develop
3. Synovial membrane becomes thickened, bits of bone and cartilage migrate into SYNOVIAL FLUID
4. Pain and inflammation

Question 9

What are the link all manifestations of osteoarthritis (OA)?

Answer 9

1. New bone growth in hands
2. Complete stiffness unusual except in hips
3. Muscles around affected joint may be weaker and affect coordination + posture
4. HEBERDEN’S Nodes (DIP)
5. BOUCHARD’S Nodes (PIP)

Question 10

Heberden Nodes (DIP)

Answer 10

Bony swellings of the joint closest to the fingertip.

Aka DIP joint (distal interphalangeal)

Question 11

Bouchard’s Nodes (PIP)

Answer 11

Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (PIP, the middle joints of fingers or toes). Caused by formation of calcific spurs of the articular cartilage.

Question 12

What are diagnostic tests for osteoarthritis (OA)?

Answer 12

1. Bone scan
2. CT Scan
3. MRI
4. X-ray
5. Synovial Fluid Analysis

Question 13

What is the role of NSAIDS for osteoarthritis (OA)?

Answer 13

1. Reduces pain
2. Reduces inflammation
3. Inhibits prostaglandins (inflammatory)

Ex. Ibuprofen, naproxen, voltaren

Question 14

What is the role of COX-2 Inhibitors for osteoarthritis (OA)?

Answer 14

COX2 = secondary enzyme which selectively inhibits without disrupting GI system

Ex. Meloxicam, celecoxib, rofecoxib

Question 15

What are the 2 types of steroid injections for osteoarthritis (OA)?

Answer 15

1. Cortisone/ Corticosteroid
   = ⬇️ inflammation around affected area
   = more effective than NSAIDS
2. Viscosupplemetation
   = insertion of small amount of HYALURONIC ACID into joint capsule
   = Lubricating substance within joints lost in OA

Question 16

What are Cell-surface antigens that are unique to every person?

Answer 16

1. Human Leukocyte Antigens (HLAs)

2. Major Histocompatibility Complex (MHC)

Question 17

What are the general characteristics of Rheumatoid Arthritis (RA)?

Answer 17

1. Chronic inflammation of the connective tissue, esp joints
2. Chronic, SYMMETRICAL, and erosive inflammation of synovial tissue of joints
3. Progressive development of joint destruction, deformity, and disability

Question 18

What are risk factors for Rheumatoid Arthritis (RA)?

Answer 18

1. Age
2. Female
3. Weight (inflammation active in adipose tissue)
4. Smoking
5. Genetics (⬆️ HLAs)

Question 19

What is the pathophysiology of Rheumatoid Arthritis (RA)?

Answer 19

1. Initial immune response to an antigen
2. Triggers formation of abnormal immunoglobulin (IgG)
3. RF antibodies develop against IgG
4. RF+IgG Form antibody-antigen immune complexes that deposit on SYNOVIAL membranes or articular cartilage
5. Activation of complement system causes local inflammation
6. SYNOVITIS

T-helper (CD4) cells and cytokines also involved in inflammatory response

Question 20

When does joint changes begin in Rheumatoid Arthritis (RA)?

Answer 20

When hypertrophied synovial membrane invade surrounding:

1. Cartilage
2. Ligaments
3. Tendons
4. Joint capsule
5. Subchondral bone

Question 21

What is the formation of Pannus in Rheumatoid Arthritis (RA)?

Answer 21

Granulation tissue formed to cover the entire articular cartilage.

PANNUS = a highly vascularized fibrous scar tissue.
Errores and destroys entire surface of cartilage. Scars and shortens support structures (tendons + ligaments)

Results:

1. Laxity (slack/loose)
2. Subluxation
3. Contracture

CYTOKINES further contribute to cartilage destruction

Question 22

What are the signs of Stage 1 (Early) Rheumatoid Arthritis (RA)?

Answer 22

No destructive changes in X-ray

Question 23

What are the signs of Stage 2 (Moderate) Rheumatoid Arthritis (RA)?

Answer 23

1. Osteoporosis with or without slight bone/cartilage destruction
2. NO joint deformities
3. Adjacent muscle atrophy

Question 24

What are the signs of Stage 3 (Severe) Rheumatoid Arthritis (RA)?

Answer 24

1. Evidence of cartilage + bone destruction and osteoporosis
2. Joint deformity (ex. Ulnar deviation)
3. Extensive muscle atrophy
4. WITHOUT fibrous or bony ANKYLOSIS

Question 25

What are the signs of Stage 4 (Terminal) Rheumatoid Arthritis (RA)?

Answer 25

1. Evidence of cartilage + bone destruction and osteoporosis 2. Joint deformity (ex. Ulnar deviation) 3. Extensive muscle atrophy 4. WITH fibrous or bony ANKYLOSIS

Question 26

Fibrous Ankylosis

Answer 26

Breakdown of bone resulting in fibrous connective tissue. Results in complete joint immobility.

Question 27

Bony Ankylosis

Answer 27

Stage 5 No pain or swelling any more. Bone of joint collapses, forming a single unit of two bones. Makes joint extension impossible.

Question 28

What are clinical manifestations of Rheumatoid Arthritis (RA)?

Answer 28

1. Insidious onset 2. Overall pain, swelling, and stiffness of joints and muscles (esp after sleep or rest) 3. Fatigue, sleep disturbances 4. Low grade FEVER 5. Loss of ROM 6. Loss of strength 7. Joint deformity

Question 29

What are common joints involved in Rheumatoid Arthritis (RA)?

Answer 29

1. Proximal interphalangeal (PIP) 2. Metacarpo-phalangeal (MCP) 3. Wrists, elbows, + shoulders 4. Cervical spine 5. Hips, knees, ankles 6. Metatarso-phalanges (MTP) BILATERAL, SYMMETRICAL

Question 30

Swan Neck Deformity

Answer 30

Deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it (PIP hyperextension with DIP flexion).

Question 31

Boutonnière Deformity

Answer 31

Deformed position of the fingers or toes, in which the joint nearest the knuckle (the proximal interphalangeal joint, or PIP) is permanently bent toward the palm while the farthest joint (the distal interphalangeal joint, or DIP) is bent back away. (PIP flexion with DIP hyperextension).

Question 32

What are physical signs in the hands of Late Stage (Stage 4) Rheumatoid Arthritis (RA)?

Answer 32

1. Boutonnières deformity of thumb 2. Ulnar deviation of metacarpo-phalange all joints 3. Swan Neck Deformities of fingers

Question 33

What are extra-articular manifestations of Rheumatoid Arthritis (RA)?

Answer 33

1. Systemic symptoms (fatigue, FEVER) 2. Renal: PROTEINURIA 3. Raynauds neuropathy 4. Pericarditis m, myocarditis, mitral valve disease 5. Pleuritis, pulmonary fibrosis, pleural effusion 6. Anemia 7. Rheumatic nodules 8. Vasculitic skin lesions 9. Felty’s Syndrome (splenomegaly, leukopenia, lymphadenopathy, thrombocytopenia, leg ulcers)

Question 34

Sjogren’s Syndrome

Answer 34

Chronic inflammatory disorder characterized by lymphocytic infiltration of lacrimales and salivary glands. Impaired secretion of saliva and tears. SICCA COMPLEX = dry mouth (XEROSTOMIA) and dry eyes (KERATOCONJECTIVITIS SICCA)

Question 35

Rheumatoid Nodules

Answer 35

1. Within first 2 years of onset 2. Develop around small blood vessels 3. Firm, mobile, painless 4. Easily broken down or become infected 5. Appear over extensor surface of joints

Question 36

What are diagnostic tests for Rheumatoid Arthritis (RA)?

Answer 36

1. Positive RF 2. ⬆️ ESR (Erythrocytes Sedimentation Rate) 3. ⬆️ CRP (C-reactive protein) 4. ANA (Anti-nuclear antibodies) 5. Synovial Fluid Analysis ➡️ Early = straw-coloured with many fibrin flecks ➡️ High WBC, mostly neutrophils

Question 37

What are Acute Phase Reactants in Rheumatoid Arthritis (RA)?

Answer 37

1. C-reactive Protein (CRP) = nonspecific response to inflammatory stimuli 2. Erythrocyte Sedimentation rate (ESR) = inflammatory connective tissue disease 3. C4 Complement = leads to inflammatory response