Dr. Ebraheim’s educational animated video describes the condition of rheumatoid arthritis, the etiology, signs and symptoms, the diagnostic tests and indications, and the treatment options and prognosis.
Rheumatoid Arthritis involves the synovium of the joints. The condition of rheumatoid arthritis will result in deformities. Rheumatoid Arthritis occurs in females more than males. There may be a hereditary component with Rheumatoid Arthritis. Rheumatoid Arthritis has spontaneous remissions and exacerbations. The disease can have a systemic nature.
Pain and stiffness of joints especially in the morning (morning stiffness). Rheumatoid Arthritis is typically polyarticular, bilateral and symmetrical and most commonly affects the hands and feet.
x-rays show periarticular erosions at the time of diagnosis. Osteopenia and minimal osteophyte formation favor the diagnosis of rheumatoid arthritis.
Pathogenesis
Rheumatoid Arthritis is an autoimmune disease. The disease has two components: immunological reaction. Increased degradative enzymes. The IgM (Rheumatoid factor) is produced by the plasma cell as ana antibody to the native IgG, which is altered in RA. 70% of patient with RA have rheumatoid factor positive. Leucocytes are attracted to the immune complex forming deposits over the inflammatory surface of the synovium. These leucocytes ingest fibrin and immune complex and is called the Rheumatoid cells. The leucocytes release lysosomal enzymes that cause acute inflammatory response and tissue necrosis as well as inflammatory mediators ( IL-1, IL-6, TNF alpha). The chondrocytes respond to stimulation by TNF- alpha, IL-1 and other inflammatory mediators causing cells to become activated and secrete more metalloproteinases which lead to cartilage damage. The synovium becomes hypertrophied (pannus), showing intimal hyperplasia and infiltration by plasma cells and lymphocytes.
Stages of Rheumatoid Arthritis
Early: acute: hot swollen tender joints (synovitis)
•MCP swelling
•Wrist swelling
•Flexor sheath synovitis
Complicated: digital vasculitis, ecchymosis, skin atrophy, nodules.
Advanced
•Swelling of MCP joints
•Lateral slippage of extensor tendon ruptures
•Ulnar deviation of fingers
•Xrays show destruction of MCP with subluxation, ulnar deviation and wrist destruction.
•Finger deformities: Mallet, boutonniere, Swan neck
The thumb is also involved. These changes occur due to proliferation, inflammation and hypertrophy of the synovium. Involvement of the distal radioulnar joint is usually associated with rupture of the extensor digiti minimi.
Rheumatoid nodules
25% of patients with RA will have subcutaneous nodules on extensor surfaces of elbow and forearm. Nodules are often multiple and seen along the ulnar margin of the forearm or pulp of the digits. Vasculitis is more common in patients with SC nodules, it is strongly seropositive disease (aggressive) with less favorable prognosis.
Treatment
•Synovitis: splint and medical treatment
•Joint space narrowing, bone erosions and osteopenia: synovectomy.
•Joint destruction/fixed deformity/ loss of hand function: surgery based on condition
Before operating on RA patients, x-ray of the cervical spine is needed because the patient may have subluxation of C1-C2.
Metacarpophalangeal joint arthroplasty of the fingers usually results in decreased extensor lag and improvement of the ulnar drift.
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