arthritis overview

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I have given this lecture at various fora including for Orthopaedic Surgeons & GP

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ARTHRITIS : 

ARTHRITIS Dr. Arjun Viegas Consultant Orthopaedic Surgeon, SIOR Pune

LIFE EXPECTANCY : 

LIFE EXPECTANCY 1947 - 45 years. 2000 - 62 years. MORE OLD PEOPLE.

MAGNITUDE OF PROBLEM : 

MAGNITUDE OF PROBLEM 100 million population. 100 lac arthritic people. 10% crippling condition.

PREVENTIONISBETTER THANCURE : 

PREVENTIONISBETTER THANCURE

Slide 6: 

EXERCISES DIET. ACTIVITIES OF DAILY LIVING. EARLY DIAGNOSIS & PRVENTION OF PROGRESS OF ARTHRITIS PREVENTION

ARTHRITIS: DEFINITION : 

ARTHRITIS: DEFINITION INFLAMATION OF THE JOINT AND SOFT TISSUE SURROUNDING IT. MULTIPLE CAUSES & TYPES

ARTHRITS TYPES : 

ARTHRITS TYPES DEGENERATIVE : OA METABOLIC: GOUT RHEUMATOID ARTHRITIS INFECTIVE: TB, PYOGENIC

ARTHRITS TYPES : 

ARTHRITS TYPES SERONEGATIVE ARTHROPATHY NEUROPATHIC ARTHROPATHY POST TRAUMATIC MISCELLENEOUS

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT HISTORY CLINICAL EXAMINATION RADIOLOGY HAEMATOLOGICAL INVESTIGATIONS SPECIAL TESTS IF ANY DIAGNOSIS

OSTEOARHTHRITIS : 

OSTEOARHTHRITIS DEGENERATIVE CONDITION “Morphologic, biochemical, molecular & biomechanical changes of both cells & matrix leading to softening, fibrillation, ulceration & loss of articular cartilage, sclerosis & eburation of subchondral bone, osteophytes and subchondral cyst”. AAOS, 1995: 21-25

OA: EPIDEMIOLOGY : 

OA: EPIDEMIOLOGY MORE IN OLDER PEOPLE OBESITY SOCIAL HABITS

OA : 

OA COMMONEST JOINTS INVOLVED: KNEE, HIP, IP, MP JOINTS SPINE FACET JOINTS

OA: PROBLEMS : 

OA: PROBLEMS Pain. Muscle Spasm. Deformity. Restriction of movements.

OA: REASON OF PAIN : 

OA: REASON OF PAIN SYNOVIUM : INFLAMMATION SUBCHONDRAL BONE : MICROFRACTURES, INCREASED INTRAOSSEOUS PRESSURE OSTEOPHYTES: STRECHING OF NERVES LIGAMENTS : STRECHING CAPULES : INFLAMMATION, STRECHING MUSCLE : SPASM

OA: CLINICAL EXAMINATION : 

OA: CLINICAL EXAMINATION TENDERNESS, SWELLENG CREPITATION DEFORMITY: e.g. FFD, VARUS SPASM DECREASED MOVEMENTS LIGAMENTOUS LAXITY

OA : INVESTIGATIONS: X-RAY : 

OA : INVESTIGATIONS: X-RAY AP / LATERAL SINGLE JOINT WEIGHT BEARING SKY LINE VIEW STRESS VIEWS

OA : X-RAY AP / LATERAL VIEW : 

OA : X-RAY AP / LATERAL VIEW NARROWING OF JOINT SPACE: MEDIAL COMPARTMENT FIRST OSTEOPHYTES LOOSE BODIES SUBCHONDRAL CYSTS

OA : X-RAY S.J.W.B.VIEW : 

OA : X-RAY S.J.W.B.VIEW CORRECT INFORMATION OF THE JOINT SPACE WHEN PATIENT IS STANDING. VARUS / VALGUS DEFORMITTY

OA : OTHER TESTS : 

OA : OTHER TESTS SEROLOGY: TO RULE OUT OTHER CAUSES OF ARTHRITIS e.g. RA. SYNOVIAL FLUID ASPIRATION SYNOVIAL BIOPY ( RARELY USED).

RHEUMATOID ARTHRITIS : 

RHEUMATOID ARTHRITIS RA IS AN IMMUNO-INFLAMATORY DISEASE INVOLVING THE ARTICULAR CARTILAGE, SUBCHONDRAL BONE, SYNOVIUM & EXTRA ARTCULAR TISSUES.

RA: EPIDEMIOLOGY : 

RA: EPIDEMIOLOGY MORE IN FEMALES 4:1 STARETS IN YOUNG AGE GROUP 30 TO 40 YR.

RA : SYMPTOMS : 

RA : SYMPTOMS PAIN EXACERBATION AND REMISSION MORNING STIFFNESS PLOYARTHRALGIA MORNIG PAIN SWELLING

RA : DIAGNOSTIC CRITERIA : 

RA : DIAGNOSTIC CRITERIA AMERIACN SOCIETY OF RHEUMATOLOGY MODIFIED CRITERIA 1987 FOUR OUT OF SEVEN

ARA CRITERIA : 

ARA CRITERIA MORNING STIFFNESS SMALL JOINT INVOLVEMENT SYMMETRICAL JOINT INVOLVEMENT POLYARTHRALGIA RHEUMATOID NODULES RA FACTOR TEST +VE X RAY CHANGES

Slide 28: 

SUBCUTANEOUS NODULES

RA:CLINICAL EXAMINATION : 

RA:CLINICAL EXAMINATION MULTIPLE TENDER JOINTS SWELLING RESTRICTED MOVEMENTS RHEUMATOID NODULES DEFORMITIES

RA : DEFORMITIES : 

RA : DEFORMITIES HAND: SWAN NECK DEFRMITY BOUTONNIERE DEFORMITY ULNAR DRIFT OF THE HAND Z DEFORMITY OF THE THUMB ELBOW : FLEXION DEFORMITY

RA : DEFORMITIES : 

RA : DEFORMITIES KNEE: FLEXION DEFORMITY TRIPPLE DEFORMITY FOOT AND ANKLE: EQUINUS DEFORMITY HALLUX VALGUS HAMMER TOE.

Slide 32: 

Z DEFORMITY OF THUMB

Slide 33: 

SWAN NECF DEFORMITY BUTTONHOLE DEFORMITY

Slide 34: 

SWAN NECK DEFORMITY

Slide 35: 

HALLUX VALGUS, HAMMER TOES

RA : EXTRAARTICULAR MANIFESTATIONS : 

RA : EXTRAARTICULAR MANIFESTATIONS SYSTEMIC: CONSTITUTIONAL SYMPTOMS MUSCULOSKELETAL: WASTING, TENOSYNOVITIS, BURSITIS, OSTEOPOROSIS HAEMATOLOGICAL: ANAEMIA, THROMBOCYTOSIS, EOSINOPHILIA

RA : EXTRAARTICULAR MANIFESTATIONS : 

RA : EXTRAARTICULAR MANIFESTATIONS LYMPHATIC:SPLENOMEGALY OCCULAR: EPISCERITIS, SCLERTIS VASCULITIS CARDIAC: PERICARDITIS, MYOCARDITIS, CONDUCTION DEFECTS. PULMONARY: PL. EFFUSION, BRONCHIOLITIS.

Slide 38: 

EYE :SCERITIS

RA : INVESTIGATIONS : 

RA : INVESTIGATIONS X- RAY: SOFT TISSUE SWELLING PERIARTICULAR OSTEOPOROSIS. SUBCHONDRAL CYSTS. SUBCHONDRAL EROSIONS. UNIFORM JOINT SPACE REDUCTION NO OSTEOPHYTES.

Slide 40: 

OSTEOPOROSIS

Slide 41: 

UNIFORM JOINT SPACE REDUCTION

Slide 42: 

PROTRUSIO ACETABULUM

Slide 43: 

RHEUMATOID HAND:MP JOINT SUBLUXATION

RA : HEMATOLOGICAL INVESTIGATIONS : 

RA : HEMATOLOGICAL INVESTIGATIONS ANAEMIA RAISED ESR EOSINOPHILIA RA FACTOR TEST POSITIVE CRP

RA:SYNOVIAL FLUID EXAMINATION : 

RA:SYNOVIAL FLUID EXAMINATION

RA: SYNOVIAL BIOPSY : 

RA: SYNOVIAL BIOPSY CONFIRMATIVE RHEUMATOID VILLUS FORMATION, PANNUS FORAMATION

SERONEGATIVE ARTHROPATHY : 

SERONEGATIVE ARTHROPATHY RA FACTOR NEGATIVE. TYPES ANKYLOSING SPONDYLOSIS PSORIATIC ARTHROPATHY REITER’S DISEASE JRA INFLAMATORY BOWEL DISEASE, etc.

ANKYLOSING SPONDYLOSIS : 

ANKYLOSING SPONDYLOSIS CHRONIC SYSTEMIC INFLAMMATORY DISEASE. GENETIC FACTOR, HLA B27 ENVIRONMENTAL FACTOR. AGE BELOW 40 YRS. MALE AFFECTION.

ANKYLOSING SPONDYLOSIS : 

ANKYLOSING SPONDYLOSIS ARTICULAR MANIFESTATION SPINE SACROILIAC JOINT HIP OTHER

ANKYLOSING SPONDYLOSIS : 

ANKYLOSING SPONDYLOSIS SYMPTOMS MORNING STIFFNESS MORE THAN 30 MIN REST AGGREVATES PAIN PHYSICAL ACTIVITY RELIEVES PAIN RESTRICTION OF JOINT MOVEMENT IN ALL DIRECTION.

ANKYLOSING SPONDYLOSIS : 

ANKYLOSING SPONDYLOSIS EXTRASKELETAL MANIFESTATION AI, AORTITIS ATLANTOAXIAL SUBLUXATION RENAL AMYLOIDOSIS RESTRICTIVE PULMONARY FUNCTIONS. UVEITIS

ANKYLOSING SPONDYLOSIS : CLINICAL : 

ANKYLOSING SPONDYLOSIS : CLINICAL TENDERNESS OVER SPINE, SI JOINT, HIP & OTHER JOINTS LIMITATION OF SPINE MOVEMENT DECREASED CHEST EXPANSION < 4CM STRESS TESTS FOR SACROILIAC JOINTS

ANKYLOSING SPONDYLOSIS: INVESTIGATIONS : 

ANKYLOSING SPONDYLOSIS: INVESTIGATIONS XRAY ANAEMIA RAISED ESR HLA B27 +VE PFTs

ANKYLOSING SPONDYLOSIS : X-RAY : 

ANKYLOSING SPONDYLOSIS : X-RAY SACROILIAC JOINT EROSION / FUSION BAMBOO SPINE HIP JOINT SPACE REDUCTION/ FUSION

Slide 56: 

BAMBOO SPINE

Slide 57: 

SACROILIAC JOINT SCEROSIS

Slide 58: 

HIP FUSION

PSORIASIS : 

PSORIASIS INFLAMMATORY EROSIVE ARTHRITIS WITH SKIN DISORDER EXACT ETIOLOGY NOT KNOWN. HLA B27 +VE

PSORIASIS: CLINICAL : 

PSORIASIS: CLINICAL PIP & DIP JOINT AFFECTION,SAUSAGE SHAPED DIGITS. LARGER JOINTS RARELY AFFECTED. SPINE RARELY AFFECTED

Slide 61: 

NAIL DYSTROPHY

PSORIASIS: INVESTIGATION : 

PSORIASIS: INVESTIGATION RAISED ESR RA – VE HLA B27 +VE ANAEMIA ANA MAY BE +VE

PSORIASIS: X-RAY : 

PSORIASIS: X-RAY EROSIONS & NARROWING OF SMALL FINGERS, SUBLUXATION DISSOLUTION OF DPX. RELATIVE SPARING OF MP JOINTS.

Slide 64: 

EROSION OF IP JOINTS

GOUTY ARTHRITIS : 

GOUTY ARTHRITIS METABOLIC DISORDER DEPOSITION OF URATE CRYSTALS. AFFECTS JOINTS, BURSAE, LIGAMENTS.

Slide 66: 

COMMON SITES

GOUT : CLINICAL : 

GOUT : CLINICAL AGE APPROX. 40 YRS FIRST MTP JOINT (COMMONEST), KNEE, WRIST, ELBOW, HIP. ACUET ONSET, REDNESS, SWELLING,TENDERNESS RENAL INVOLVEMENT

GOUT: INVESTIGATIONS : 

GOUT: INVESTIGATIONS RAISED ESR RAISED URIC ACID (>6mg%) URINE : CRYSTALS +NT XRAY: DECREASED JT. SPACE SOFT TISSUE SWELLING TOPHUS

Slide 69: 

DESTRUCTION OF MTP JOINT

INFECTIVE ARTHRITIS : 

INFECTIVE ARTHRITIS ACUTE / SUBACUTE / CHRONIC STAPH.AUREUS,STREPTOCOCCUS TUBERCULOSIS FUNGAL VIRAL

INFECTIVE ARTHRITIS : 

INFECTIVE ARTHRITIS CLINICAL: TENDER SWELLING WARM REDNESS DECREASED ROM DEFORMITY

INFECTIVE ARTHRITIS: INVESTIGATIONS : 

INFECTIVE ARTHRITIS: INVESTIGATIONS X RAY: IRREGULAR REDUCTION OF JOINT SPACE. DESTRUCTION OF ARTICULATING SURFACE. SOFT TISSUE SWELLING

Slide 73: 

SEPTIC ARTHRITIS ANKLE

Slide 74: 

TB KNEE

Slide 75: 

TB WRIST

INFECTIVE ARTHRITIS: INVESTIGATIONS : 

INFECTIVE ARTHRITIS: INVESTIGATIONS SYNOVIAL FLUID & BIOPSY BONE SCAN CT SCAN MRI

INFECTIVE ARTHRITIS: INVESTIGATIONS : 

INFECTIVE ARTHRITIS: INVESTIGATIONS ANAEMIA RAISED WBC COUNT RAISED ESR, CRP PCR IN TB IGG,IGM,IGA FOR TB CULTURE SENSITIVITY HIV TEST

NEUROPATHIC JOINT : 

NEUROPATHIC JOINT SEEN IN DIABETES, SYPHILIS,HANSEN’S DISEASE,CHRONIC ALCOLISM, MENINGOMYELOCOELE, SYRINGOMYELIA. CHARCOTS JOINTS

NEUROPATHIC JOINT : 

NEUROPATHIC JOINT PAINLESS INSTABILITY PRESERVED MOVEMENT DEFORMITY

NEUROPATHIC JOINT : 

NEUROPATHIC JOINT X RAY JOINT SUBLUXATION / DISLOCATION OSTEOPOROSIS CORTICAL DEFECTS SUBPERIOSTEAL NEW BONE FORMATION DESTRUCTION OF JOINT

Slide 81: 

NEUROPATHIC JOINT

POST TRAUMATIC OA : 

POST TRAUMATIC OA POST FRACTURE CAUSE MAL ALIGNMENT LOSS OF BLOOD SUPPLY INTRA ARTICULAR SCREW/ IMPLANT

POST TRAUMATIC OA : 

POST TRAUMATIC OA INVESTIGATIONS DIAGNOSIS BASED ON XRAY NO LAB CHANGES

Slide 84: 

HIP ARTHRITIS FOLLOWING NECK FEMUR FIXATION

AVN : AVASULAR NECROSIS : 

AVN : AVASULAR NECROSIS FEMUR HEAD(COMMONEST) , TALUS, SCAPHOID, CONDYLES ETIOLOGY IDEOPATHIC ALCOHOL STEROIDS POST DELIVERY SICKEL CELL DISEASE POST TRAUMATIC etc.

AVN: HIP : 

AVN: HIP CLINICAL: TENDERNESS, SWELLING min. ADDUCTION, FLEXION, EXT. ROTATION DEFORMITY, LESS ROM SHORTENING LIMP

AVN: HIP INVESTIGATION : 

AVN: HIP INVESTIGATION X RAY CYST FORMATION IN HEAD DEFORMED HEAD LATE: ACETABULAR INVOLVEMENT CT SCAN, BONE SCAN MRI LAB : NORMAL

Slide 88: 

AVN

Slide 89: 

3D SCAN

Slide 90: 

BONE SCAN

CONCLUSION : 

CONCLUSION PREVENTION IS BETTER THAN CURE. EARLY DIAGNOSIS ESSENTIAL.

CONCLUSION : 

CONCLUSION CLINICAL EXAMINATION STILL HAS A ROLE. ROUTINE & ADVANCED INVESTIGATIONS CAN CLINCH DIAGNOSIS EFFECTIVELY.

Slide 93: 

THANK YOU