Rheumatoid Hand - Kate Owers 20/1/2005

Definitions of Rheumatoid Arthritis

Campbells - "A chronic, systemic inflammatory disease, most often involving the small joints of the hands & feet, although any synovial joint may be affected"

Burge " "a distal symmetrical small-joint polyarthropathy that typically affects the PIP and MCP joints of hands, wrists, ankles, MTPJs, knees and C spine " primarily a disease of the synovium but has systemic manifestations"

Burge " "a distal symmetrical small-joint polyarthropathy that typically affects the PIP and MCP joints of hands, wrists, ankles, MTPJs, knees and C spine " primarily a disease of the synovium but has systemic manifestations"

Burge " "a distal symmetrical small-joint polyarthropathy that typically affects the PIP and MCP joints of hands, wrists, ankles, MTPJs, knees and C spine " primarily a disease of the synovium but has systemic manifestations"

Commonest form of inflammatory arthritis (reported prevalence 1-3%)

Autoimmune

3F:1M, starts insidiously 4 ^th -5 ^th decade, genetic predisposition

DD: SLE, Psoriatic arthropathy, crystal deposition, spondyloarthritides

Diagnosis : primarily clinical

- although RhF (IgM autoantibody to IgG) often +ve. Rose-Waller or Latex agglutination tests

Diagnostic criteria (American Rheumatological Assoc 1987)

³ 4/7 criteria for >6/52:

1. Morning stiffness >1 hr

2. Arthritis ³ 3 joint areas (R+L " PIP, MCP, wrist, elbow, knee, ankle, MTP = 14)

3. Arthritis of hand joints (wrist, MCPJ or PIPJ)

4. Symmetrical arthritis

5. Rheumatoid nodules (granulomata composed of central fibrinoid necrosis, cellular debris & monocytes, prob 2 º to small vessel vasculitis) " extensor surface of joints

6. Rheumatoid Factor (70-80% +ve " JRA 25%)

7. Radiological changes i.e.

i. ST swelling

ii. Cartilage loss ® joint space narrowing

iii. Periarticular erosions

iv. Subchondral osteopenia

Manifestations:

1. Joints & tendons

o 3 pathological stages (Apley)

Stage 1 'synovitis'

- soft tissue swelling and periarticular osteopenia

- vascular congestion, synovial villous formation

- capsular thickening, painful, swollen joints

Stage 2 'destruction'

- narrowing joint space + erosions by proteolytic enzymes + pannus of granulation tissue in synovial reflections

- also affects tendon sheaths - 'synovium destroys cartilage and tendons' (vs. OA)

Stage 3 'deformity'

- articular destruction

- capsular stretching

- tendon ruptures

2. Extra-articular

o Vascular e.g. vasculitis, Raynaud's