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SYNOVIUM & CRYSTAL
SYNOVITIS
SYNOVIUM
Differentiates from the mesenchymal
tissue around the articular disc
Clears the articular surface by the fifth
...
HISTOLOGY
Fatty, fibrofatty, or fibrous and contains
type1 and 3 collagen.
Two types of cells- type A- macrophages
like ...
Subsynovial tissue contains macrophages
and fibroblasts and precursors of the
synovial cells,which give rise to the new
m...
SYNOVIAL FLUID
 Clear viscous yellow fluid which does not clot
on standing (no fibrinogen).
 Knee joint-0.5ml of fluid.
...
 Proteins are present in lower conc than in
plasma.
 Albumin is the major protein(2/3rd) and others
are alpha2-macroglob...
 In an inflamed synovium protein content
increases.
 In severly inflamed joints protein is similar to
that in serum.
 C...
FUNCTIONS OF SYNOVIAL FLUID
Hold joints together.
Lubrication.
Cushions.
Nourishes.
CRYSTAL SYNOVITIS
Mainly two types.
Monosodium urate crystals- gout.
Calcium pyrophosphate crystals-
pseudogout.
Gout
GOUT(MONOSODIUM URATE
ARTHROPATHY)
a/c or c/c.
Sites- monoarticular, first
metatarsophalangeal joint.
Ankle,knee,wrist,...
INCIDENCE
0.3/1000 population.
AGE
Men –after mid twenties.
Women –after menopause.
RISK FACTORS
 Male sex
 * Meat
 * Seafood
 * Alcohol (10 or more grams per day)
 * Diuretics
 * Obesity
 * Hyperten...
PATHOLOGY
 It affects both upper and lower limbs with acute
attacks. Less often it presents with painful,
tophaceous depo...
 a/c- ingestion of microcrystals of urate by
neutrophils and release lysosomal enzymes.
 Solubility of urate in body flu...
CLINICAL FEATURES
 Pain ,swelling,tenderness and increased temp of
the first metatarsophalangeal joint.
 Attacks can be ...
 Two extremities.
 Obese,alcoholic with family history of gout and
no tophi.
 Old,frail,taking thiazide diuretics and w...
 Tophi can occur in long standing cases of gout.
 10% cases kidney may be affected.
 HTN and c/c renal failure.
 Renal...
INVESTIGATIONS
o typical presentations such as inflammation of the first
metatarsophalangeal joint (also known as podagra)...
 * Renal uric acid secretion (as detected by a 24-
hour urine sample) helpful in diagnosis, in
patients with a family his...
 Although a raised serum uric acid level is an
important risk factor for gout, the use of serum
uric acid as a diagnostic...
 Radiographs may be useful in chronic gout,
when punched out lesions, areas of sclerosis and,
in the latter stages, tophi...
 Urate crystals can be identified using polarising
microscope and are found as needle-shaped
crystals inside neutrophils....
TREATMENT
 INDOMETHACIN(200mg/day).
 Ideally pt should have only one attack of gout.
 It can be achieved by xanthine ox...
 Aspiration of affected joint and intra-articular
steroid injection terminates a/c attack.
 In those are at risk of renal stones, necessary to
ensure that they pass large amount of alkaline
urine.
COMPLICATIONS
 Renal disease
 Renal colic .
 Chronic urate nephropathy results from
widespread deposition of urate crys...
 Gout patients who have a 24-hour urinary
excretion of uric acid above 1100 mg have a
50% risk of developing urate and ox...
 * Severe degenerative arthritis
 * Secondary infections
 * Recurrent painful episodes
 * Carpal tunnel syndrome (rare...
PSEUDOGOUT(PYROPHOSPHATE
ARTHROPATHY)/ CHONDROCALCINOSIS
 Deposition of calcium pyrophosphate dihydrate.
 Pathology is similar to that of gout.
 Large joints-knee.
 Severe pai...
PRECIPITATING FACTORS
 Dehydration
 Intercurrent illness
 Hyperparathyroidism
 Long-term use of steroids
 Hypothyroid...
INVESTIGATION
 Crystals have got a characteristic appearance
under polarising microscope with weak
birefringes.
 Radiogr...
 Ultrasound may also be a useful diagnostic tool.
 Aspiration of the joint fluid: raised white cell
count which is predo...
MANAGEMENT
 Joint aspiration and instillation of local steroid.
 Indomethacin and phenylbutazone to control a/c
attacks ...
PROGNOSIS
 Acute attacks usually resolve within 10 days.
 Some patients develop progressive joint damage
with functional...
DIFFERENTIAL DIAGNOSIS
 Acute gout
 Septic arthritis
 Osteoarthritis
 Rheumatoid arthritis
 Hydroxyapatite crystals can seen ageing joints,
synovial fluid or peritendonitis tissue.
 Can be stained by alizarin re...
 In shoulder it is called milwaukee shoulder.
 It is due to discharge of the apatite crystal into
the joints from the pe...
Thank
you
Synovium & crystal synovitis
Synovium & crystal synovitis
Synovium & crystal synovitis
Synovium & crystal synovitis
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Synovium & crystal synovitis

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Synovium & crystal synovitis

  1. 1. SYNOVIUM & CRYSTAL SYNOVITIS
  2. 2. SYNOVIUM Differentiates from the mesenchymal tissue around the articular disc Clears the articular surface by the fifth month in utero.
  3. 3. HISTOLOGY Fatty, fibrofatty, or fibrous and contains type1 and 3 collagen. Two types of cells- type A- macrophages like phagocytic cells and type B- resemble fibroblasts. Responsible for the secretion of hyaluronic acid and protein.
  4. 4. Subsynovial tissue contains macrophages and fibroblasts and precursors of the synovial cells,which give rise to the new membrane after synovectomy. Rich in vascular plexus and lymphatics.
  5. 5. SYNOVIAL FLUID  Clear viscous yellow fluid which does not clot on standing (no fibrinogen).  Knee joint-0.5ml of fluid.  Viscosity depends on conc of hyaluronic acid.  Lowered in ageing,osteoarthritis,and trauma.  96% water and 4%solutes with a specific gravity of 1.010 and a ph of 7.3-7.6.  Reduced in osteoarthritis and after trauma.
  6. 6.  Proteins are present in lower conc than in plasma.  Albumin is the major protein(2/3rd) and others are alpha2-macroglobulin,lipoproteins, and IgM.
  7. 7.  In an inflamed synovium protein content increases.  In severly inflamed joints protein is similar to that in serum.  Clots due to significant increase in fibrinogen.
  8. 8. FUNCTIONS OF SYNOVIAL FLUID Hold joints together. Lubrication. Cushions. Nourishes.
  9. 9. CRYSTAL SYNOVITIS Mainly two types. Monosodium urate crystals- gout. Calcium pyrophosphate crystals- pseudogout.
  10. 10. Gout
  11. 11. GOUT(MONOSODIUM URATE ARTHROPATHY) a/c or c/c. Sites- monoarticular, first metatarsophalangeal joint. Ankle,knee,wrist,fingers and elbow. Distal and lower extremity joints are involved more often.
  12. 12. INCIDENCE 0.3/1000 population.
  13. 13. AGE Men –after mid twenties. Women –after menopause.
  14. 14. RISK FACTORS  Male sex  * Meat  * Seafood  * Alcohol (10 or more grams per day)  * Diuretics  * Obesity  * Hypertension  * Coronary heart disease  * Diabetes mellitus  * Chronic renal failure  * High triglycerides
  15. 15. PATHOLOGY  It affects both upper and lower limbs with acute attacks. Less often it presents with painful, tophaceous deposits (± discharge) in Heberden's and Bouchard's nodes.  * Most patients with hyperuricaemia never develop gout and gouty patients may not have hyperuricaemia at presentation.  * Patients can be over-excreters of uric acid, normo-excreters or under-excreters.  * Most cases of primary gout are due to undersecretion.  * Fewer than 10% are due to overproduction.
  16. 16.  a/c- ingestion of microcrystals of urate by neutrophils and release lysosomal enzymes.  Solubility of urate in body fluids increases deposits accumulate.  Plasma uric acid level lowers and deposits go into solutions.
  17. 17. CLINICAL FEATURES  Pain ,swelling,tenderness and increased temp of the first metatarsophalangeal joint.  Attacks can be provoked by surgery,trauma.  Mild attacks resolve with in 2 days.  More severe attacks take 7 to 10 days to resolve.
  18. 18.  Two extremities.  Obese,alcoholic with family history of gout and no tophi.  Old,frail,taking thiazide diuretics and with tophi.
  19. 19.  Tophi can occur in long standing cases of gout.  10% cases kidney may be affected.  HTN and c/c renal failure.  Renal stones can occur in 10% cases.  Renal disease is the major cause of death in gout.
  20. 20. INVESTIGATIONS o typical presentations such as inflammation of the first metatarsophalangeal joint (also known as podagra) with hyperuricaemia.  * Demonstration of monosodium urate (MSU) crystals in synovial fluid or tophi confirms the diagnosis of gout.  * Since gout can present atypically examine all samples of synovial fluid aspirated from joints for MSU crystals, even if not inflamed at the time.  * Gram staining and culture of synovial fluid should be done, even if MSU crystals are found, since gout and sepsis can co-exist.  * Fasting glucose and lipids should be performed to rule out hyperglycaemia and hyperlipidaemia as gout is commonly associated with metabolic syndrome.
  21. 21.  * Renal uric acid secretion (as detected by a 24- hour urine sample) helpful in diagnosis, in patients with a family history of young onset gout, patients whose first attack of gout was under the age of 25, and patients with renal stones. Such patients are likely to be over- excreters of uric acid.
  22. 22.  Although a raised serum uric acid level is an important risk factor for gout, the use of serum uric acid as a diagnostic test is limited. It can be normal during acute gout, whilst patients with hyperuricaemia may never develop an attack. Studies suggest that the cut-off point above which a level can be considered raised is 360 µmol/l.
  23. 23.  Radiographs may be useful in chronic gout, when punched out lesions, areas of sclerosis and, in the latter stages, tophi may be seen. The first lesions usually occur in and around the first metatarsophalangeal joint.  CT scanning may be helpful in less accessible areas.
  24. 24.  Urate crystals can be identified using polarising microscope and are found as needle-shaped crystals inside neutrophils.  Distinguished from calcium pyrophosphate crystals – pleomorphic and show weak positive birefringes.
  25. 25. TREATMENT  INDOMETHACIN(200mg/day).  Ideally pt should have only one attack of gout.  It can be achieved by xanthine oxidase inhibitor(allopurinol 300mg/day).  Dose is according to serial plasma uric acid level.  First 3 months add a small dose of indomethacin to prevent a/c attacks.
  26. 26.  Aspiration of affected joint and intra-articular steroid injection terminates a/c attack.
  27. 27.  In those are at risk of renal stones, necessary to ensure that they pass large amount of alkaline urine.
  28. 28. COMPLICATIONS  Renal disease  Renal colic .  Chronic urate nephropathy results from widespread deposition of urate crystals in the interstitium of medulla and pyramids causing inflammation and fibrosis. End stage renal failure occurs in up to 25% of cases of untreated chronic tophaceous gout.
  29. 29.  Gout patients who have a 24-hour urinary excretion of uric acid above 1100 mg have a 50% risk of developing urate and oxalate kidney stones. Those with a measured urate excretion greater than 800 mg per 24 hours may benefit from allopurinol prophylaxis to prevent urate nephropathy.
  30. 30.  * Severe degenerative arthritis  * Secondary infections  * Recurrent painful episodes  * Carpal tunnel syndrome (rare)  * Nerve or spinal cord impingement
  31. 31. PSEUDOGOUT(PYROPHOSPHATE ARTHROPATHY)/ CHONDROCALCINOSIS
  32. 32.  Deposition of calcium pyrophosphate dihydrate.  Pathology is similar to that of gout.  Large joints-knee.  Severe pain,swelling, low grade temp over 24- 48hrs.  Associated with hyperparathyroidism,haemochromatosis and gout.
  33. 33. PRECIPITATING FACTORS  Dehydration  Intercurrent illness  Hyperparathyroidism  Long-term use of steroids  Hypothyroidism  Any cause of arthritis  Haemochromatosis  Wilson's disease  Acromegaly  Dialysis  Surgery or trauma
  34. 34. INVESTIGATION  Crystals have got a characteristic appearance under polarising microscope with weak birefringes.  Radiograph shows calcification in both fibro and hyaline cartilage.
  35. 35.  Ultrasound may also be a useful diagnostic tool.  Aspiration of the joint fluid: raised white cell count which is predominantly neutrophils. Glucose levels usually are normal. The joint fluid often looks purulent and septic arthritis must be excluded.
  36. 36. MANAGEMENT  Joint aspiration and instillation of local steroid.  Indomethacin and phenylbutazone to control a/c attacks $ prevent recurrence.
  37. 37. PROGNOSIS  Acute attacks usually resolve within 10 days.  Some patients develop progressive joint damage with functional limitation.  Prognosis will also be dependent on any underlying cause.
  38. 38. DIFFERENTIAL DIAGNOSIS  Acute gout  Septic arthritis  Osteoarthritis  Rheumatoid arthritis
  39. 39.  Hydroxyapatite crystals can seen ageing joints, synovial fluid or peritendonitis tissue.  Can be stained by alizarin red 5.  Whether they cause disease or result from a joint disease is not known.  Some described in joints rapidly being destroyed.
  40. 40.  In shoulder it is called milwaukee shoulder.  It is due to discharge of the apatite crystal into the joints from the periarticular tissues.
  41. 41. Thank you

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