ORTHOPEDIC PT 2

ARTHRITIC AND CONNECTIVE TISSUE DISEASES

JESSIE ANNE MANLUTAC
SEPTEMBER 29, 2021
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INFLAMMATION INDUCED BY INFECTIOUS AGENTS

OUTLINE
● Bacterial
I. Classification of Rheumatic Diseases ● Viral
II. Rheumatoid Arthritis ● Spirochetes
A. Characteristics of RA ● Tuberculous - induce infectious arthritis
B. Joints affected ● Fungal - induce infectious arthritis
C. ACR Clinical Diagnostic Criteria of RA (Arnett et
al., 1987) SERONEGATIVE SPONDYLOARTHROPATHIES
D. Clinical manifestation: periods of active dse ● Ankylosing Spondylitis
E. Common deformities in RA ● Psoriatic Arthritis
F. Nalebuff deformity ● Reiter's Syndrome
G. Assessment & Evaluation ● Inflammatory Bowel Disease
H. Staging: Disease Progression
III. Osteoarthritis NON-INFLAMMATORY ARTHRITIS
A. Risk Factors ● Degenerative, post traumatic or Overuse (OA,
B. Characteristics Posttraumatic Aseptic Necrosis)
C. Outcome measures OA - most common
D. Diagnostic procedures Inherited or Metabolic
IV. RA vs OA ● Lipid Storage Disease
V. Myofascial Pain Syndrome & Fibromyalgia ● Hemochromatosis
A. Myofascial Pain Syndrome ● Ochronosis
B. Fibromyalgia ○ Hypogammaglobulinemia
C. Diagnosis ○ Hemoglobinopathies
D. Prognosis
E. Fibromyalgia and MPS
II. RHEUMATOID ARTHRITIS
● An autoimmune, chronic, inflammatory, systemic
INTRODUCTION: ARTHRITIS VS. ARTHROSIS
disease primarily affecting the synovial lining of the
● Arthritis - both inflammatory and noninflammatory
joints as well as other connective tissues
causes that affect joints and other connective tissues
● Has fluctuating course
● Arthrosis - limitation of a joint without the
● RA - symmetric, bilateral (e.g. may affect (B) hands)
inflammation
● OA - unilateral (has possibility to become bilateral in
later stages)
I. CLASSIFICATION OF RHEUMATIC DISEASES
A. CHARACTERISTICS OF RA
● Intermittent in nature
I - Inflammatory ● Early inflammatory changes in the joint structures
leading to joint space narrowing and pannus
II - Non Inflammatory formation
● Exposed cancellous bone with dse. progression
III - Crystal Induced ● Fibrosis, ankylosis, and subluxation may eventually
cause deformity and disability
IV- Seronegative Spondyloarthropaties ● Inflammatory changes can also occur in tendon
sheaths and eventually rupture if subjected to friction
INFLAMMATORY CTD ● Extra-articular manifestation can occur
● Rheumatoid Arthritis ○ Rheumatoid nodules may appear outside
● Juvenile Idiopathic Arthritis from the joint
● Systemic Lupus Erythematosus ○ May also manifest with muscle weakness,
● Progressive Systemic Sclerosis atrophy and fatigue
● Idiopathic Inflammatory Myopathies
● Mixed Connective Tissue Disease B. JOINTS AFFECTED
● Psoriatic Arthritis ● MCP
● Wrist
INFLAMMATORY CRYSTAL-INDUCED DISEASES ● PIP
● Gout - formation of crystals ● Knee
● Pseudogout - inflammation common in MTP* and ● MTP
MCP joints; formation of calcium crystals crystals ● Shoulder
ACERET, AGUINALDO, CASANOVA, CASTRO, LABSTIDA, MAGALLANES, SALAO, SULAYAO 1
● Ankle 4. Mannerfelt Syndrome - rupture of the flexor pollicis
● Cervical longus
● Hip
● Elbow
● TMJ

C. ACR CLINICAL DIAGNOSTIC CRITERIA OF RA

(ARNETT ET AL., 1987)
● Morning stiffness > 1hr
● Arthritis of 3 or more joints
● Symmetrical arthritis
● Hand arthritis - W/MCP/PIP
● Subcutaneous nodule F. NALEBUFF DEFORMITY
● (+) RF
● X-Ray erosion - erosion in the bone unti-unting I. Boutonniere of the thumb
nagbabago ang structure II. Boutonniere of the thumb with adduction deformity
● At least 4 out of 7 criteria must be seen in patients III. Swan neck of the thumb with adduction deformity
for 6 weeks IV. Gamekeepers thumb (torn ulnar collateral ligament)
V. Swan neck alone
D. CLINICAL MANIFESTATION: PERIODS OF VI. Arthritis Mutilans (pencil-cup deformity)
ACTIVE DSE
● Joint effusion - causes pain and LOM ● ARTHRITIS MUTILANS - "Opera Glass hand"
● Morning joint stiffness ● PIANO KEY SIGN - rupture of the UCL, up and
● Pain down movement of ulna
● Bilateral symptoms ● ULNAR DRIFT DEFORMITY - Z deformity, MCP
● Muscles - weakness and atrophy ulnar deviation, wrist radial deviation; common in
● (+) systemic sx - fever, loss of appetite, weight loss, girls
fatigue
● Deformities BY JOINTS:
KNEE
E. COMMON DEFORMITIES IN RA ● Flexion Contracture
● Baker's Cyst - palpated in the posterior aspect; are
1. Swan Neck Deformity - DIP flex, PIP ext
fluid filled sac na nakaexpose sa likod; movable
● Subluxation of the patella (Laterally)
●
MTP
● Metatarsalgia
● Hammer Toes (MC)
● Claw Toes
● Hallux Valgus
● Type of Gait: Apropulsive
2. Boutonniere Deformity - DIP ext, PIP flex Gait (Absent push-off)
SHOULDER
● Atrophy of the muscle secondary to disuse
● Muscle weakness
● Shoulder subluxation
○ GH
○ AC
○ SC
3. Vaughn Jackson Syndrome - rupture of the 4th & ANKLE
5th extensor hood ● Subluxation posterior
● Collapsed arches - Flatfoot
● Hindfoot Pronation

CERVICAL
● C1-C2-LOM: Rotation Laxity of transverse
ligament
● Hangman's Fracture/Teardrops Fx -> Asphyxia
HIP
● Protrusion acetabular: LOM: IR
● Arthritic hip-groin, medial thigh PAIN

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ELBOW ● Most common location is in the medial side of the
● Flexion Contracture knee
● Loss of Pronation/Supination

G. ASSESSMENT & EVALUATION

1. Laboratory Evaluation
● Check for presence of Rheumatoid Factor
● Erythrocyte sedimentation rate (ESR) &
C-reactive protein (CRP) may be elevated in
the active phase of arthritis
○ Determine the presence of
inflammation
Epidemiology
2. X-RAY
● Globally - 303 million have OA in 2017
● Hallmark: Erosions
● 63-94 y/o (mostly knee OA)
- May not appear during early
● F > M (31:27 million)
changes of the disease
● 250 million people have knee OA
3. MRI & USG
● More sensitive to identify synovitis & joint
A. RISK FACTORS
effusion
● Modifiable
- Smoking
H. STAGING: DISEASE PROGRESSION
- Obese
● Non-modifiable
Stage Definition - Age
Stage 1 No destructive changes on - Gender
X-rays - Genetics
Stage 2 Presence of X-ray evidence of - Ethnicity
periarticular osteoporosis,
subchondral bone destruction but B. CHARACTERISTICS
no joint deformity ● (+) capsular laxity leading to hypermobility and
Stage 3 X-ray evidence of cartilage and instability
bone destruction in addition to joint ● Contractures
deformity & periarticular ● Destruction of articular cartilage
osteoporosis ● Genetic but can be also associated with obesity,
Stage 4 Presence of bony or fibrous sports with repetitive impact twisting and occupation
ankylosis along with Stage 3 and activities that require kneeling and squatting
feature while lifting weight
● (+) crepitation and loose bodies
PROGNOSIS ● Wearing out of articular cartilage and eventual
● RA - NO CURE & PROGRESSIVE DISEASE exposure of subchondral bone
● 50% of patients with RA leads to disability over 10 ● Increased bone density along the joint line with
years osteoporosis in adjacent metaphysis
● Develop further joint deformities ● Enlargement of affected joint (nodules)
● 2-3 times higher risk of death compared to general ● MC affected joints
population
FACTORS TO DETERMINE WORSE PROGNOSIS: C. OUTCOME MEASURES
● Elevated serum titer of autoantibodies ● Visual Analog Scale (VAS)
● Presence of HLA-DRB1*04 genotype ● Western Ontario and McMAster Universities
● Involvement of many joints Arthritides Index (WOMAC)
● Extra-articular feature ● Knee INjury and Osteoarthritis Outcome Score
● Female gender (KOOS)
● Age of less than 30
● Insidious onset D. DIAGNOSTIC PROCEDURE
● Presence of systemic symptoms
1. X-ray
2. MRI
III. OSTEOARTHRITIS 3. Joint fluid analysis
● Degenerative joint disease
● Primarily affects articular cartilage of synovial joints
with eventual bone remodeling and overgrowth of
spurs
● Non inflammatory
● More common than RA
● Hallmark: pain
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IV. RA vs OA POSSIBLE CAUSES
● Chronic muscular overload secondary to repetitive
activities or that maintain in shortened position
● Acute overload of mm such as slipping and catching
oneself
● Poorly conditioned muscles
● Postural stress
● Poor body mechanics
MYOFASCIAL TRIGGER POINTS
Minimum Criteria
○ Taut band
○ Trigger point in that taut band
● Always found in the neuromuscular junction region
(endplate zone)
Features Rheumatoid Osteoarthritis MPS: Taut Bands
Arthritis ● Consist of group of tense muscle fibers that are
tender & demonstrate hard consistency on palpation
Age of onset Can happen at Usually later in ● (+) Jump Sign
any age life ○ MTrPs & TPs represent the most tender,
pressure sensitive area w/in the TBs
Speed of onset Rapid-weeks to Slow-over years How is tenderness (degree of sensitization) of TP &
months MTrP quantified?
● Pressure Algometer
Distribution Symmetrical Initially ○ Pocket sized force gauge fitted w/ disc
polyarthritis asymmetrical shaped plunger
monoarthritis → ○ Measures the Pain Pressure Threshold
polyarthritis (PPT)
○ (N): ≥ 2 kg/㎠
Joint affected Small joints of the Weight bearing
hands and feet joints, knees ,
hips

Duration of Stiffness worse in Stiffness <1 hour

morning stiffness the morning >1 and worse at the
hour end of the day
(after activity)

Systemic Fatigue, fever, -

symptoms night sweats
B. FIBROMYALGIA
● Chronic condition characterized by widespread pain
V. MYOFASCIAL PAIN SYNDROME & that covers half of the body (right or left/ up or down)
FIBROMYALGIA and has lasted for more than 3 mos
● 11/18 tender points
A. MYOFASCIAL PAIN SYNDROMES (MPS) ● Non restorative sleep
● Regional pain syndrome characterized by muscle
pain caused by MTrPs Characteristics
● Chronic, regional pain syndrome ● Early to middle adulthood
● Hallmark: (+) trigger points ● Sx develop after physical trauma
● Trigger point ● Pain is describe a muscular in origin
○ Hyperirritable area in a tight band of muscle ● Significant fluctuation of sx
○ Pain described as dull, aching and deep ● Hs higher incidence of tendonitis, h/a, irritable bowel,
○ May be active or latent TMJ dysfxn, restless leg syndrome, mitral valve
○ Decreased ROM in mm prolapse, anxiety, depression, and memory
○ Weakness problems

Contributing factors to flare

● Environmental stress, changes in barometric
pressure, cold dampness, fog, and rain and
sometime fluorescent lights
● Physical stress: repetitive activities such as typing,
playing piano, vacuuming, prolonged periods of
sitting
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 ● Emotional stress

1990 ACR Fibromyalgia Classification criteria included

tenderness at least 11 to 18 defined tender points:
● Suboccipital muscle insertion bilaterally
● The anterior aspect of C5 to C7 intertransverse
spaces bilaterally
● Mid-upper border of trapezius bilaterally
● Origin of supraspinatus muscle bilaterally
● Second costochondral junctions bilaterally FMS
● 2 cm distal to the lateral epicondyles bilaterally ● ACR criteria for the classification
● Upper outer quadrants of buttocks bilaterally ● ACR preliminary diagnostic criteria
● Greater trochanteric prominence bilaterally
● Medial fat pad of the knees bilaterally D. PROGNOSIS
● Early treatment - much better prognosis
*The pressure appropriate for detecting these tender points ● Factors associated with poor prognosis includes:
should be equal 4 kg/cm^2, enough to whiten the nail bed of ○ Long duration of disease
the fingertip of the examiner* ○ High-stress levels
○ Presence of depression or anxiety
Tender Points ○ Long-standing avoidance of work
● Occiput ○ Alcohol or drug dependence
- At the suboccipital muscle insertions ○ Moderate to severe functional impairment
● Low cervical
- At the anterior aspects of the intertransverse E. FIBROMYALGIA AND MPS
spaces at C5-C7 ● Chronic pain syndromes
● Trapezius
- At the midpoint of the upper border Characteristics MPS Fibromyalgia
● Supraspinatus
- At origins, above the scapula spine near the Gender M/F = 1/1 M/F = 1/10
medial border distribution
● Second rib
Anatomic site Regional Widespread
- Upper lateral to the second costochondral
junction
Early fatigue Unusual Common
● Lateral epicondyle
- 2 cm distal to the epicondyles
Morning stiffness Regional Generalized
● Gluteal
- In upper outer quadrants of buttocks in Trigger point Invariable Only present with
anterior fold of muscle associated MPS
● Greater Trochanter
- Posterior to the trochanteric prominence Tender point Limited region Widespread
● Knee
- At the medial fat pad proximal to the joint Response to Local anesthetic: Seldom responds
line treatment vapocoolant to any one
spray modality

Natural course Usually remits Seldom remits

M=Male; F=Female; MPS=Myofascial Pain Syndrome

FIBROMYALGIA
● MANAGEMENT
- Meds
- Energy conservation
- Activity pacing
- Stress avoidance
FMS Tender Points - Decrease alcohol and caffeine intake
- Diet mod.
- Symptomatic treatment

C. DIAGNOSIS
MPS
● Electromyography (EMG)
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