ARTHROPATHIES > Ocular Affectation

BlackAngel - Keratoconjunctivitis in association with Sjogren’s Syndrome/Mi

kulicz/Gaugerot’s/Autoimmune exocrinopathy
TRIAD
I. INFLAMMATORY a. xeropthalmia : dry eyes tested through Schirmer’s Test and Ros
A. Rheumatoid Arthritis e Bengal Dye
- chronic inflammatory systemic disorder b. Xerostomia : dry mouth; bilat. parotiditis tested through sponge
- affects mostly at the diarthrodial joints on the tongue
c. Arthritis
Epidemiology
- W > M ; 2:1 > Hematologic
- genetic - Anemia in association with Felty Syndrome:
- 1% prevalence at 20 - 60 yo SLLANT
- Race: caucasian > african americans a. Splenomegaly
b. Lyphadenopathy
Etiology c. Leukopenia : decrease WBC
- unknown cause d. Anemia
- hypothesis: e. A rthritis
f. Neutropenia : decrease WBC
 Infection : staphylococcus aureus, Epstein Barr Virus g. Thrombocytopenia : decrease platelet
 Abnormal functioning of T-Cells from the thymis gland
 Genetics: majority has Human Leukocyte Antigen - DR4 b. Intra-Articular
 (+) Rheumatoid factor: strongest hypothesis with ~85% have series o - bilateral, symmetrical, diarthrodial
f antibodies with no known use - most common to least common
- Mama Wants Pip K M SACHET
Pathophysiology 1. MCP, Wristn PIP Joint
1. synovial inflammation - swan neck defomtiy: DIP flexion, PIP hyperextension, caused
2. Synovium becomes hypertrophic by rupture of Extensor Digitorum Communis of the DIP or contracture of the i
3. Formation of granulation tissues - PANNUS (hallmark) ntrinsic and deep flexor muscles of the fingers
4. Adhesions and fibrous or bony ankylosis : possible reflex inhibition - Boutenniere Defornity : DIP hyperextension and PIP flexion,
caused by weakness or rupture of the central tendon (terminal portion of extens
Clinical Manifestations or hood) holds the lateral bands in place. Management: ring orthosis
a. Extra-Articular - Ulnar Drift/Z-Deformity : wrist to the radial side and MCP to
> Skin: the ulnar side. Management: resting hand splint at night and functional hand spl
- Rheumatoid Nodules [the most common and all are RF(+)] int in the daytime ; palms flat with gripping parellel to the hand
 Extensor surface of the hand 2. Knee
 Olecranon - Flexion Contracture
 Achilles - Subluxation : decrease muscle strength
 Ischial tube - Baker’s Cyst : posterior; impingement to the tibial nerve whic
 Over MTP joint h is a branch of the sciatic nerve
 Flexor surface of finger 3. MTP
> Lungs - Hammer Toe : MTP extended, PIP in flexion, DIP is in neutr
- Caplan’s Syndrome: Combination of RA + Pneumoconiosis al ; gait(-push off , apropulsive). Accomodation: high toe box, rocker bottom sh
oes
> Peripheral Neuropathies - Hallux Valgus
- due to nerve impingement - Claw Toes : DIP and PIP flexion , walking pain sensation on
pebbles
 4. Shoulder
- Glenohumeral Subluxation : most common , limited IR somet
imes adduction/abduction
Diagnostic Criteria
5. Ankle and Foot 1987 Revised Criteria for the Classification of RA
- posterior subluxation : rigid heel counter for accomodation
- Flat Foot : collapsed longitudinal arch. Shoe inserts for accom
odation
- Splay Foot : collapsed tranvers arch

6. Cervical
- limited rotation at AA joint
- subluxation leading to SCI
- Hangman’s Fracture: fracture of the Odontoid that sublux upwa
rds, may lead to death due to asphyxia

7. Hip
- LOM: IR
- groin pain leading to a limping gait and (+)Trendelenburg

8. Elbow
- flexion contracture
- LOM: pronation and supination

9. TMJ
- LOM: mouth opening with normal protrusion and side motion
- (+)tension headache

c. Systemic manifestation
- body malaise
- low grade fever
- weight loss
- fatigue
Diagnosis
- Laboratories:
- American College of Rheumatoid Revised Criteria of Functional Status
 ESR
 RF
 CBC
 Synovial Fluid Analysis
- Radiographic:
 Marginal erosion c juxtaarticular osteoporosis

- Classification of Prognosis
 - one or more joint involved: most common to least
KAWT
 Knee
 Ankle
 Wrist
 TMJ
- cataract irritation, loss of vision, band keratopathy

C. Polyarticular Arthritis
- mostly small joints intially
- comprises the 25% og JRA patients
- relatively good prognosis
- onset is insidious

II. SERONEGATIVE ARTHRITIS AND SPONDYLOARTHROPATHIES

A. Ankylosing Spondylitis
- aka Von Bechterew’s Disease / Strumpell
- chronic, systemic inflammatory due to
- hallmark: bilateral sacroilitis

Epidemiology
-M>F;3:1
- onset: late adolescent - early adulthood
- 90% have HLAB 27 confirms the positivity of an autoimmune disease

B. Juvenile Rheumatoid Arthritis / Still’s Disease Etiology

- uncommon crippling disease of the young - unknown cause but strongly hereditary
- boys=girls, childhood , genetics
Pathophysiology
Clinical Manifestation: - immunomediated
 Growth retardation - starts at the enthesis(ligamentous and capsular attahcment of the bones)
 Micrognathia leading to abnormal speech
Clinical Manifestation
 LOM and contractures - morning back pain / sacroilitis (earliest manifestation)
Special Test:
Classification
> Gaenslen’s Test
A. Systemic Onset
> Approximation/Gapping
- (+) extra-articular manifestation in addition to arthritis
- Bone Tenderness
- boys > girls ; median onset: 5yo
- enthesis
- (+) cardiac involvement
- peripheral arthritis
- polyarhtiritis, anemia, leukocytosis
- loss of spinal mobility
- high fever with (+) still’s rash/evanescent rash (salmon pink rash at the tr
- Aortitis
unk that’s vanishing)
- rule out JRA if the rash lasts for >24hrs
B. Reiter’s Syndrome
B. Pauciarticular Arthritis - TRIAD: Conjunctivitits, arthritis, Non-Gonococcal urethritis
- girls > boys ; 2-4yo - M > F : STD
- most frequent type of Arthritis
 - M = F : Food borne (Chlamydia, Salmonella, Yersinia, Shigella, Camptylo - systemic, immunomediated disorder characterized by the presence of anti-b
bactrer) odies to a number of nucleus (+ANA)
- F > M , 8 : 1, greater in women during child bearing age
Clinical Manifestations - 2 - 4x greater in blacks and hispanics
- Conjunctivitis - may be hereditary
- Urethritis - unknown etiology
- Keratoderma Blenorrhagicum: dry scaly skin in the palms and toes - (+) of regulatory mechanism in immune response
- Arthritis
- Circinate Balanitis : painless ulceration of the glans penis Clinical Manifestation
- Serositis
C. Inflammatory Bowel Disease - Hematologic: Felty’s Syndrome
- general term for a group of chronic inflammatory disorder of unknown cau - Immunologic
se involving the GIT - Neurologic: epilepsy/psychosis
- white > blacks & orientals - Renal : Renal nephritis
-M>F - Oral Ulcers
- peak age: 15 - 35yo - Arthritis: Jacoud’s (non-erosive)
- Discoid Rash: Anterior neck and scalp
Types - Malar Rash
a. Crohn’s Disease - ANA : hallmark of SLE
- whole GIT (mouth to anus) - Photosensitivity
b. Ulceration Colitis
- affectation of the colon B. Polymyositis/ Dermatomyositis (PM - DM)
- straited muscle involvement with symmetrical weakness of skeletal muscle
Clinical Manifestation s including the heart, with or without the presence of rash
- pain - Most common: 40-60yo
- vomiting - children: 5-15 yo
- diarrhea -M=F
- most common joint affectation: knee - unknown cause
- theories: due to viral infection and autoimmune disturbances
D. Psoriatic Arthritis Pathophysiology
- benign, inflammatory skin disease with genetic predisposition - abnormal recognition of the self in which the anti-bodies of the individual
- features of the bilat. RA and seronegative spondyloarthritis attacks it’s own self causing damage to the muscle and skin leading to weakness in th
- polyarthritis with psoriasis e skeletal and articular muscles
- M = F ; onset 30 - 50yo Clinical manifestation
- skin lesions usually antedate arthritis - profound weakness of skeletal muscles
- (+) HLA - B27 - weakness of respiratory and swallowing muscles
- joint diseases are rare but bony erosions are common
Clinical manifestation Classification
- DIP : MC affectation A.
- Auspitz Sign
- Koebner Phenomenon : formation of new lesions of areas exposed to traum C. Scleroderma/ Progressive Systemic Sclerosis
a D.
- Onchylosis : losening or separation of nail from nail bed
- X-Ray: Arthritis Mutilant / Pencil in Cup Deformity IV. CRYSTAL-INDUCED
A. Gout
III. Connective Tissue Disesase
B. Pseudogout
A. Systemic Lupus Erythematosus
 - osteophytes extending to the length of the spine leading to spinal fusion
V. DEGENERATIVE - hallmark: ossification spanning to 3 or more
A. OsteoArthritis Radiographic Features
- a slowly progressive musculoskeletal disorder affecting the joints of: hands A: Alignement may be abnormal
(pinch grip involvement), spine, weight bearing joints of the LE B: Bony Spurs (osteophytes)
- the most common articular disorder C: Cartilage Space narrowing
- aka: DJD, hypertrophic arthritis, DDD, Kellegren’s Syndrome D: Deformities
-increases with age E: Erosion (Gullwing Sign
-W>M S: slowly progressive
- radiohgraphic evidence in < 50-80% of those 65yo
- estimated 2-3% of the adult population has a symptomatic OA B.
Risk Factors
- Obesity
- Hereditary
- Age
- Previous joint trauma
- Abnormal joint mechanics
- Smoking

Patholophysiology
- EARLY: hyper-cellularity of the chondrocytes, cartilage breakdown, minimal
inflammation
- LATE: cartilage fissuring, pitting, erosion, osteophyte spur formation at the jo
int margins, subchondral bone sclerosis(eburnation), cyst formation in the juxta-artic
ular bone

Classification
a. Primary OA
- idiopathic
- affectation: knee, MTP, PIP, CMC, Hip, Spine
- Joints Typically involve:
1. DIP joints (hands) : Heberden’s
2. PIP joints (hands) : Bouchards
3. 1st CMC joints of the thumb: worst most disabling affectation of the
hand
4. AC joint
5. Hip
6. Knee joint
7. 1st MTP : Hallux Valgus

b. Secondary OA
- follows a recognizable underlying cause
- affectation: elbows and shoulder
c. Erosive Inflammation OA
d. Diffuse Idiopathic Skeletal Hypertosis (DISH)
- a varient of primary OA