Musculoskeletal System. Part-3
DISEASES OF JOINTS
1
•Both movement and mechanical stability.
• Solid (nonsynovial)
• and cavitated (synovial).
•The solid joints, known as syn...
1. Osteoarthritis
2. Rheumatoid Arthritis
3.Gout and Pseudo gout.
4.Childhood Arthritis (Juvenile
Idiopathic Arthritis).
3
Rheumatoid Arthritis
Osteoarthritis.
Gout .
Systemic Lupus Erythematosus
4
Arthritis
“arthr” = joint
“itis” - inflammation
“Arthritis can affect babies
and children, as well as
people in the prime ...
• Leading cause of disability.
• Affects 1 in 6 individuals
• 2/3 individuals with arthritis are women
• One of the most p...
• # 1: Arthritis isn’t serious
• #2: Arthritis is an old person’s disease
• #3:Arthritis is a normal part of aging
• #4: N...
Articular/hyaline cartilage
-acts as a shock absorber
- allows for friction-free movement
- not innervated!
Synovial membr...
Rheumatoid Arthritis
“A chronic autoimmune disease characterized
by the
inflammation of the synovial joints”
9
Rheumatoid Arthritis: PIP Swelling
• Swelling is confined
to the area of the
joint capsule
• Synovial thickening
feels lik...
• “A chronic autoimmune disease
characterized by the inflammation of
the synovial joints”.
• Has a symmetrical bilateral e...
• RHEUMATOID ARTHRITIS
• Rheumatoid arthritis is a chronic systemic
inflammatory disorder that may affect many
tissues and...
• Genetic predisposition, environment, and
autoimmunity have pivotal roles in the
development, progression, and chronicity...
Symptoms
•Morning stiffness lasting
more than half an hour
•Simultaneous symmetrical
joint swelling
•Not relieved by rest
...
15
X-rays are an important diagnostic test for
monitoring the disease progression
Patients may reveal NO changes
on an X-ray ...
Nodules
17
Diagnosis
• CBC
• Radiographs of
• involved joints
• CT/MRI scans
• Direct arthroscopy
• Synovial/Fluid aspirate
• Synovia...
Inflammatory Markers: ESR and CRPTest
ESR rates for men: 0-15mm/hr
ESR rates for women: 0-20mm/hr
The level of CRP in the
...
Antibody Tests:
Rheumatoid Factor Test and CCP
Other blood tests check for the
presence of antibodies that are not
normall...
Direct arthroscopy
Benefits
•Minimally
invasive
•Less tissue
damage
•Fewer
complications
•Reduced pain
•Quicker
recovery t...
22
23
Synovectomy
•Increases function of the joint
•Decreases pain and inflammation
•Beneficial as an early treatment option
•No...
25
26
27
• Synovial/Fluid aspirate
Synovial membrane biopsy
• Arthrocentesis.
• synovial fluid is aspirated
• and analysed for infl...
29
Arthography
A radiopaque substance or air is injected into the
joint, which outlines soft tissue structures
surrounding th...
CT/MRI scans
MRI is particularly sensitive for the
early and subtle features of RA
MRI is particularly sensitive for the
e...
Newly Diagnosed
The major goal is to relieve pain and
inflammation and prevent further joint damage
Anxiety, depression, a...
Medications
• There are four types of medications used to
treat RA:
– Non-steroidal anti-inflammatory drugs
(NSAIDs)
– Dis...
Alternative Medicine
Olive leaf extract
Aloe Vera
Green Tea
Omega 3
Ginger Root Extract
Cats Claw
34
The most commonly observed vitamin and
mineral deficiencies in patients with RA are:
o folic acid
o vitamin C
o vitamin D
...
36
Osteoarthritis
Most common form of arthritis
Over 3 millions.
Osteoarthritis is defined as “a
degenerative joint disease c...
• OSTEOARTHRITIS (DJD)
• Osteoarthritis, also called degenerative joint
disease, is the most common type of joint
disease ...
PathophysiologyPathophysiology
39
40
41
42
43
Primary & Secondary Osteoarthritis
• Primary Osteoarthritis –
no identifiable reason for
arthritis development.
• Secondar...
Risk Factors for OA
• Age
• Family History
• Excess weight
• Joint injury
• Complications of other types of
arthritis.
45
Signs & Symptoms of OA
• Joint pain
• Feeling joints “locking”
• Joint “creaking”
• Stiff joints in the morning
• Joint sw...
Diagnosis
Clinical history
X-rays
Physical Assessment
MRIs
Joint Aspirate
47
48
49
• Morphology. In the early stages of osteoarthritis
the chondrocytes proliferate, forming clusters.
Concurrently, the wate...
• Grossly this manifests as a granular soft articular
surface. Eventually, chondrocytes die and full-
thickness portions o...
OsteotomyOsteotomy
One of the most common
surgeries for osteoarthritis
Displacement osteotomy: a
bone is “redesigned
surgi...
Total Hip Replacement
Hip replacements involve replacement of a
damaged hip with an artificial acetabulum
and femoral comp...
INFECTIOUS ARTHRITIS
• Bacterial Arthritis
• Bacterial infections almost always cause an
acute suppurative arthritis.
• Tu...
• CRYSTAL-INDUCED ARTHRITIS
• Articular crystal deposits are associated with a
variety of acute and chronic joint disorder...
• Two most important crystal arthropathies:
gout, caused by urates,
• Pseudo-gout, caused by calcium
pyrophosphate.
56
Classification of Gout.
• Primary gout (90% of cases)
• Overproduction of uric acid
• Diet
• Unknown enzyme defects (80% t...
• Secondary gout (10% of cases)
• Overproduction of uric acid with increased
urinary excretion
• Increased nucleic acid tu...
• Gout rarely appears before 20 to 30 years of
hyperuricemia.
• Genetic predisposition.
• addition to the well-defined X-l...
60
61
62
63
GOUT / PSEUDOGOUT
64
• Calcium Pyrophosphate Crystal Deposition
Disease (Pseudo-Gout)
• Calcium pyrophosphate crystal deposition
disease (CPPD)...
66
JOINT TUMORS
• BENIGN
–1. GANGLION (SYNOVIAL CYST)
–2. GIANT CELL TUMOR OF TENDON
SHEATH,
–3. PVNS, PIGMENTED VILLONODULAR...
GANGLION AND SYNOVIAL CYST
•A ganglion is a small (1-1.5 cm) cyst that is almost
always located near a joint capsule or te...
• TENOSYNOVIAL GIANT-CELL TUMOR
(LOCALIZED AND DIFFUSE)
• Tenosynovial giant-cell tumour is the term for
several closely r...
70
71
Types of LupusTypes of Lupus
Systemic Lupus Erythematosus
(SLE) :
The most common type of lupus.
Any tissue in the body ma...
Questions? 
75
76
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  • Biurate has the OPPOSITE polarization pattern of pyrophosphate. In GOUT, as seen here, the yellow needles are vertical and the blue needles are horizontal, under polarization. IN PSEUDOGOUT, the OPPOSITE is seen.
  • Msk.3.final

    1. 1. Musculoskeletal System. Part-3 DISEASES OF JOINTS 1
    2. 2. •Both movement and mechanical stability. • Solid (nonsynovial) • and cavitated (synovial). •The solid joints, known as synarthroses, provide structural integrity and allow for minimal movement. 2
    3. 3. 1. Osteoarthritis 2. Rheumatoid Arthritis 3.Gout and Pseudo gout. 4.Childhood Arthritis (Juvenile Idiopathic Arthritis). 3
    4. 4. Rheumatoid Arthritis Osteoarthritis. Gout . Systemic Lupus Erythematosus 4
    5. 5. Arthritis “arthr” = joint “itis” - inflammation “Arthritis can affect babies and children, as well as people in the prime of their lives” 5
    6. 6. • Leading cause of disability. • Affects 1 in 6 individuals • 2/3 individuals with arthritis are women • One of the most prevalent chronic diseases Skeletal remains fromhumans living 4500BC show signs of arthritis • By 2031 approximately 7 millions people will be living with Arthritis. • Has caused more deaths than melanoma, asthma, orHIV/AIDS. • Only 1.3% of research is dedicated to arthritis. 6
    7. 7. • # 1: Arthritis isn’t serious • #2: Arthritis is an old person’s disease • #3:Arthritis is a normal part of aging • #4: Not much can be done for those living with arthritis • #5: People with arthritis can’t exercise 7
    8. 8. Articular/hyaline cartilage -acts as a shock absorber - allows for friction-free movement - not innervated! Synovial membrane/ synovium -secretes synovial fluid -nourishes cartilage -cushions the bones 8
    9. 9. Rheumatoid Arthritis “A chronic autoimmune disease characterized by the inflammation of the synovial joints” 9
    10. 10. Rheumatoid Arthritis: PIP Swelling • Swelling is confined to the area of the joint capsule • Synovial thickening feels like a firm sponge
    11. 11. • “A chronic autoimmune disease characterized by the inflammation of the synovial joints”. • Has a symmetrical bilateral effect on joints • Results in joint deformity and immobilization • Multiple factors increase one’s risk 11
    12. 12. • RHEUMATOID ARTHRITIS • Rheumatoid arthritis is a chronic systemic inflammatory disorder that may affect many tissues and organs-skin, blood vessels, heart, lungs, and muscles-but • Principally attacks the joints, producing a nonsuppurative proliferative and inflammatory synovitis that often progresses to destruction of the articular cartilage and ankylosis of the joints. 12
    13. 13. • Genetic predisposition, environment, and autoimmunity have pivotal roles in the development, progression, and chronicity of the disease. • About 1% of the world's population is afflicted by rheumatoid arthritis, women three to five times more often than men. • It is most common in those 40 to 70 years old 13
    14. 14. Symptoms •Morning stiffness lasting more than half an hour •Simultaneous symmetrical joint swelling •Not relieved by rest •Fever •Weight loss •Fatigue •Anaemia •Lymph node enlargement •Nodules •Reynaud's phenomenon14
    15. 15. 15
    16. 16. X-rays are an important diagnostic test for monitoring the disease progression Patients may reveal NO changes on an X-ray in the early stages 16
    17. 17. Nodules 17
    18. 18. Diagnosis • CBC • Radiographs of • involved joints • CT/MRI scans • Direct arthroscopy • Synovial/Fluid aspirate • Synovial membrane biopsy • Arthrocentesis No single test is specific to Rheumatoid Arthritis 18
    19. 19. Inflammatory Markers: ESR and CRPTest ESR rates for men: 0-15mm/hr ESR rates for women: 0-20mm/hr The level of CRP in the blood is normally low Increasing amount suggests inflammation 19
    20. 20. Antibody Tests: Rheumatoid Factor Test and CCP Other blood tests check for the presence of antibodies that are not normally present in the human body. 20
    21. 21. Direct arthroscopy Benefits •Minimally invasive •Less tissue damage •Fewer complications •Reduced pain •Quicker recovery time •Outpatient basis 21
    22. 22. 22
    23. 23. 23
    24. 24. Synovectomy •Increases function of the joint •Decreases pain and inflammation •Beneficial as an early treatment option •Not a cure! 24
    25. 25. 25
    26. 26. 26
    27. 27. 27
    28. 28. • Synovial/Fluid aspirate Synovial membrane biopsy • Arthrocentesis. • synovial fluid is aspirated • and analysed for inflammatory components • Abnormal synovial fluid: • cloudy, milky, or dark yellow • containing leukocytes • 28
    29. 29. 29
    30. 30. Arthography A radiopaque substance or air is injected into the joint, which outlines soft tissue structures surrounding the joint. 30
    31. 31. CT/MRI scans MRI is particularly sensitive for the early and subtle features of RA MRI is particularly sensitive for the early and subtle features of RA Can detect changes of Rheumatoid Arthritis prior to an X-Ray 31
    32. 32. Newly Diagnosed The major goal is to relieve pain and inflammation and prevent further joint damage Anxiety, depression, and a low self esteem commonly accompanies Rheumatoid Arthritis 32
    33. 33. Medications • There are four types of medications used to treat RA: – Non-steroidal anti-inflammatory drugs (NSAIDs) – Disease-modifying anti-rheumatic drugs(DMARDS). – Corticosteroids – Biologic Response Modifiers (“Bioligics”) 33
    34. 34. Alternative Medicine Olive leaf extract Aloe Vera Green Tea Omega 3 Ginger Root Extract Cats Claw 34
    35. 35. The most commonly observed vitamin and mineral deficiencies in patients with RA are: o folic acid o vitamin C o vitamin D o vitamin B6 o vitamin B12 o vitamin E o calcium o magnesium o zinc o selenium 35
    36. 36. 36
    37. 37. Osteoarthritis Most common form of arthritis Over 3 millions. Osteoarthritis is defined as “a degenerative joint disease characterized by destruction of the articular cartilage and overgrowth of bone” 37
    38. 38. • OSTEOARTHRITIS (DJD) • Osteoarthritis, also called degenerative joint disease, is the most common type of joint disease and is one of the most disabling conditions in developed nations. • It is characterized by the progressive erosion of articular cartilage. 38
    39. 39. PathophysiologyPathophysiology 39
    40. 40. 40
    41. 41. 41
    42. 42. 42
    43. 43. 43
    44. 44. Primary & Secondary Osteoarthritis • Primary Osteoarthritis – no identifiable reason for arthritis development. • Secondary Osteoarthritis – a likely cause for osteoarthritis exists (e.g. joint injury among professional athletes). 44
    45. 45. Risk Factors for OA • Age • Family History • Excess weight • Joint injury • Complications of other types of arthritis. 45
    46. 46. Signs & Symptoms of OA • Joint pain • Feeling joints “locking” • Joint “creaking” • Stiff joints in the morning • Joint swelling • Loss of joint flexibility • or strength 46
    47. 47. Diagnosis Clinical history X-rays Physical Assessment MRIs Joint Aspirate 47
    48. 48. 48
    49. 49. 49
    50. 50. • Morphology. In the early stages of osteoarthritis the chondrocytes proliferate, forming clusters. Concurrently, the water content of the matrix increases and the concentration of proteoglycans decreases. • Subsequently, vertical and horizontal fibrillation and cracking of the matrix occur as the superficial layers of the cartilage and type 2 collagen molecules are degrade 50
    51. 51. • Grossly this manifests as a granular soft articular surface. Eventually, chondrocytes die and full- thickness portions of the cartilage are sloughed. The dislodged pieces of cartilage and subchondral bone tumble into the joint, forming loose bodies (joint mice). • The exposed subchondral bone plate becomes the new articular surface, and friction with the opposing degenerated articular surface smooth's and burnishes the exposed bone, giving it the appearance of polished ivory. 51
    52. 52. OsteotomyOsteotomy One of the most common surgeries for osteoarthritis Displacement osteotomy: a bone is “redesigned surgically to alter the alignment or weight-bearing stress areas” “The surgical cutting of a bone” 52
    53. 53. Total Hip Replacement Hip replacements involve replacement of a damaged hip with an artificial acetabulum and femoral component. Often performed for patients with osteoarthritis or rheumatoid arthritis, femoral neck fractures, and problems related to congenital hip disease. 53
    54. 54. INFECTIOUS ARTHRITIS • Bacterial Arthritis • Bacterial infections almost always cause an acute suppurative arthritis. • Tuberculous Arthritis • Tuberculous arthritis is a chronic progressive monoarticular disease that occurs in all age groups, especially adults. • It usually develops as a complication of adjoining osteomyelitis or after haematogenous dissemination from a visceral (usually pulmonary) site of infection. 54
    55. 55. • CRYSTAL-INDUCED ARTHRITIS • Articular crystal deposits are associated with a variety of acute and chronic joint disorders. • Endogenous crystals shown to be pathogenic include monosodium urate (gout), calcium pyrophosphate dihydrate, and basic calcium phosphate (hydroxyapatite). • Exogenous crystals, such as corticosteroid ester crystals and talcum, and the biomaterials polyethylene and methyl methacrylate, may also induce joint disease. 55
    56. 56. • Two most important crystal arthropathies: gout, caused by urates, • Pseudo-gout, caused by calcium pyrophosphate. 56
    57. 57. Classification of Gout. • Primary gout (90% of cases) • Overproduction of uric acid • Diet • Unknown enzyme defects (80% to 90%) • Known enzyme defects (e.g., partial HGPRT deficiency, rare) • Reduced excretion of uric acid with normal production 57
    58. 58. • Secondary gout (10% of cases) • Overproduction of uric acid with increased urinary excretion • Increased nucleic acid turnover (e.g., leukaemia's and other aggressive neoplasms) • Inborn errors of metabolism (e.g., complete HGPRT deficiency) • Reduced excretion of uric acid with normal production • Chronic renal disease. 58
    59. 59. • Gout rarely appears before 20 to 30 years of hyperuricemia. • Genetic predisposition. • addition to the well-defined X-linked abnormalities of HGPRT, primary gout follows multifactorial inheritance and runs in families. • Obesity increases the risk of asymptomatic gout. • Certain drugs (e.g., thiazides) reduce excretion of urate and predispose to the development of gout. • Lead toxicity increases the tendency to develop saturnine gout 59
    60. 60. 60
    61. 61. 61
    62. 62. 62
    63. 63. 63
    64. 64. GOUT / PSEUDOGOUT 64
    65. 65. • Calcium Pyrophosphate Crystal Deposition Disease (Pseudo-Gout) • Calcium pyrophosphate crystal deposition disease (CPPD), also known as pseudo-gout and chondrocalcinosis, is one of the more common disorders associated with intra-articular crystal formation. • It usually occurs in individuals over 50 years of age and becomes more common with increasing age, rising to a prevalence of 30% to 60% in those 85 years or older. 65
    66. 66. 66
    67. 67. JOINT TUMORS • BENIGN –1. GANGLION (SYNOVIAL CYST) –2. GIANT CELL TUMOR OF TENDON SHEATH, –3. PVNS, PIGMENTED VILLONODULAR SYNOVITIS • MALIGNANT –4. SYNOVIAL SARCOMA. 67
    68. 68. GANGLION AND SYNOVIAL CYST •A ganglion is a small (1-1.5 cm) cyst that is almost always located near a joint capsule or tendon sheath. • A common location is around the joints of the wrist, where it appears as a firm, fluctuant, pea- sized translucent nodule. •It arises as a result of cystic or myxoid degeneration of connective tissue; hence the cyst wall lacks a true cell lining. •The lesion may be multilocular and enlarges through coalescence of adjacent areas of myxoid changes. 68
    69. 69. • TENOSYNOVIAL GIANT-CELL TUMOR (LOCALIZED AND DIFFUSE) • Tenosynovial giant-cell tumour is the term for several closely related benign neoplasms that develop in the synovial lining of joints, tendon sheaths, and bursae. 69
    70. 70. 70
    71. 71. 71
    72. 72. Types of LupusTypes of Lupus Systemic Lupus Erythematosus (SLE) : The most common type of lupus. Any tissue in the body may be affected including the kidneys, heart, lungs, and brain. Discoid Lupus Erythematosus (DLE): Affects the skin; skin develops lesions and scales.develops lesions and scales. Cutaneous Lupus Erythematosus : May be chronicCutaneous Lupus Erythematosus : May be chronic or acute. This type may only involve the skin oror acute. This type may only involve the skin or progress to involve other body systems.progress to involve other body systems.
    73. 73. Questions?  75
    74. 74. 76

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