RHEUMATOLOGY: ARTHRITIS| S.M.

CHOK (Manchester Medical School)

Disease
Osteoarthritis

Location
Hands, Hips,
Knees
Poly/ oligo /
monoarthritis

Rheumatoid
Arthritis

Hands,
shoulders,
feet,
sometimes
knees
symmetrical
small joints
polyarthritis

Examination

Presentation

Epidemiology

Pain on joint
movement, reduced
range of movements.
Squaring of the
hand deformity of
the CMC joint of the
thumb

Gradual onset (over

years), gradual
increase in main
and reduction in
function

Unusual under
60. Age-related
degeneration.
Can be secondary
to joint damage
e.g. trauma, RA

Most apparent at the

hands: MCP, PIP,
wrist joints, NOT DIP
joints.

Early morning
stiffness, lasts for
several hours
(improve with
activities).

Joints: warm and

tender, pain and
stiffness
Deformities (Zthumb, swan neck,
subluxation,
boutonniere etc).
Muscles: wasting,
inflamed flexor
tendon sheaths
Nodules common on
the forearm,
especially at pressure
points.
Signs of steroid use
(bruising)

Aetiology
Increased incidence in
sportsmen/women, trauma
increases the risk at the
affected joint

Investigations

Treatment

X-ray! Will show joint

space narrowing,
sclerosis of bone
margins, cyst
formation,
osteophyte formation

Conservative: analgesia,
physiotherapy and
encourage exercise
(this will not cause
further joint damage)
Surgical: in later stages
of the disease,joint
replacement greatly
relieves pain and
improves
function. Highly
effective

Very variable. Some

may come on
acutely overnight,
others over several
weeks or months.
Often the first signs
in the feet (walking
on marbles)
Worse in summer
or hot weather

M:F = 1:2
risk if 3x higher
before
menopause
same risk after
menopause
Can be any age,
most commonly
30-50.

Genetic factors involved.

HLA-DL1: poor prognosis
HLA-DL4: 50-75% of pts, poor
prognosis
?contraceptive pills delay onset
but do not reduce risk
?sex hormones involvement

Rheumatoid factor:
only present in 50%
of cases.
Anti-CCP more
specific.
Blood tests
anaemia
ESR and CRP raised.

Smoking, stress, infection.

Diagnosis usually
clinical, imaging not
widely used

Steroids can be used

to induce remission in
acute disease.
Sometimes given longterm, low dose.
DMARDs disease
modifying antirheumatid drugse.g.
methotrexate,
sulfasalazine,
hydrochlorequine
reduce irreversible
joint damage. Most
require regular blood
monitoring. Anti-TNF-
highly effective, given
IV, reduced disease
progression, and
improves
symptoms. VERY
EXPENSIVE NICE only
recommends it to be
used when DMARDs
have failed.

RHEUMATOLOGY: ARTHRITIS| S.M.CHOK (Manchester Medical School)

Others:
shoulders, knees,
feet, elbow (less
common) affected
carpal tunnel
eyes: dry, scleritis,
episcleritis
anaemia (normocytic/chromic)
Sjogren: dry eyes
and mouth
Raynaud's
Kidney: nephrotic
syndrome, failure
Lungs: pleural
effusion, pleurisy,
fibrosis (lower)
Heart: pericarditis
Gout

Hands, Feet
Monoarthritis

Pseudogout

Knee, hands,
elbows,
shoulder,
Tarsal joints
Monoarthritis

Gouty tophi
(chronicgout), hot,
red, tender, swollen
joint.

Hot, red, tender,

swollen joint.

Acute episodes
last up to 7 days.
Hot, red, tender,
swollen joint
Chronic presents
with gouty tophi.

Acute hot, red,

tender swollen
joints.
Chronic can
resemble RA, or
OA. Often
interspersed with
acute epdisodes

Much more
common in men
(10:1). Some
cases are
genetically
inherited (Xlinked), most
cases have a
genetic
component.
Age related
urate acid levels
rise with age.

Associated with a diet high in

purines (meat) and alcohol.
Thiazidediuretics greatly
increase the risk.
Anything that increases the
level of purines or urates in the
blood e.g. high rate of cell
death chemotherapy!

Aspiratie joint rule

out infection, check
for crystals (needle
shaped, negatively
birefringent)
Serum urate raised
in 60% (not
diagnostic), Inflam
markers , x-ray
may show punched
out erosnions, and
flecked calcifications

Increases with
age.Often
accompanies OA

Phosphatemetabolismdisorders

Aspiratie joint rule

out infection, check
for crystals(rhomboid,
positively
birefringent)

Acute use NSAIDs to

relieve acute attack,
then start allopurinol.
Chronic allopurinol is
the Tx of choice.
Dont give allopurinol in
an acute attack! it can
make it worse!
Allopurinol will not
relieve an acute attack

NSAIDs not as useful

as gout, but may still be
beneficial for some.
Intra-articular steroid
injections, ororal
steroids are usually the
first line.
No real allopurinol

RHEUMATOLOGY: ARTHRITIS| S.M.CHOK (Manchester Medical School)

Systemic
Sclerosis

Systemic
multi-organ
involvement,
(often lungs
and
oesophagus)
usually with
hand signs

Hands and arms:

pigment changes,
telangiectasia,
sclerodactyly, digital
pitting, Reynauds,

SLE

Systemic.
Typically
photosensitive
skin rashes
(often on the
face), and
organ
involvement
(most
commonly
kidneys)

May have hand signs

similar o RA but the
deformities will
reduce under
pressure, and
function is usually
not affected. Look for
rash on face, arms,
chest and shoulders

Often lots of nonspecific symptoms

low-grade fever,
tiredness, general
malaise. May also
have multi-organ
involvement.
Mouth ulcers, hair
loss,
Reynauds,depressi
on

Any age, most

commonly 30-50.
4x as common in
women

Genetic factors

10x as common in
women. Any age,
often between
25-35, and
between 5-60

Smoking, stress. Genetic factors

If a joint is hot, red, tender and swollen then always aspirate it! and it is joint sepsis, until proven otherwise

ANAs present in
90% of cases but nonspecific. Anti-dsDNA
present in 60% of
cases,
andspecific.Anaemia,
leukopenia,
thrombocytopaenia.
ESR and CRP

DMARDs and steroids

used in a similar way
to RA. Treat organ and
nerological
involvements
specifically and
individually.