This document provides an overview of arthritis, including its classification, features of different types of arthritis like rheumatoid arthritis and juvenile idiopathic arthritis, and their clinical presentation, pathogenesis, diagnosis and treatment. Rheumatoid arthritis most commonly affects women aged 35-50 and can be diagnosed based on criteria involving joint swelling in at least one joint, morning stiffness for over one hour, and positive rheumatoid factor or anti-CCP antibodies. Juvenile idiopathic arthritis can affect children under 16 and presents as oligoarticular or polyarticular arthritis for over six weeks, with radiographic findings including joint space narrowing and erosions.

1. ARTHRITIS
BY: MOSAB ELKHAIR

2. REFERENCE
• DR.HYTHAM NAFADY LECTURE
• KAPLAN MEDICALS
• RADIOPEDIA
• DR.MAMDUH MAHFOZ LECTURE

3. CLASSIFICATION OF ARTHRITIS
Degenerative
Inflammatory
Crystal disease
Endocrine / metabolic.
Hematologic
Traumatic
Neuropathic
Neoplastic

4. DEGENERATIVE
Primary Secondary Erosive

5. Unknown
Rheumatoid arthritis.
A- adult B- juvenile
2. Ankylosing spondylitis.
3. Psoriatic arthritis
4.Rieter syndrome.
Connective
tissue Disease
(Acquired )
Systemic lupus
erethematosus.
Scleroderma.
Polymyositis and
dermatomyositis.
Vasculitis
a. polyarteritis nodosa.
B. hypersensitivity angitis
C. Wagner granulomatosis.
Infective
1. bacterial
2. Rickettsia
3. viral
4. fungal
5. Parasitic
Inflammatory
Bowl disease:
Ulcerative Colitis
Whipple
Regional Enteritis
Inflammatory Arthritis

6. CRYSTAL DISEASE
Gout
Calcium Pyrophosphate
Dihydrate deposition
disease
Hydroxyapatite

7. ENDOCRINE /METABOLIC
Hyperparathyroidism.
Acromegaly.
Scurvy.
Thyroid acropathy.
Hypothyroidism.
Alkaptonuria.

8. HEMATOLOGIC
Hemophilia.
Sickle Cell
disease

9. NEOPLASTIC
Synovial masses.
Plexiform neurofibroma.
Primary juxta articular tumor.
Metastatic malignant tumor.
Leukemia – lymphoma – multiple myeloma.

10. EPISODE ONE

11. • ETIOLOGY.
• EPIDEMIOLOGY.
• PATHOGENESIS.
• CLINICAL PRESENTATION.
• LABORATORY FINDING.
• DIAGNOSIS.
• TREATMENT.
• RADIOLOGICAL FINDING.

12. ETIOLOGY
• UNKNOWN.
• MAY BE TRIGGERED AS A REACTION TO AN INFECTIOUS AGENT (MYCOPLASMA,
PARVOVIRUS) IN A SUSCEPTIBLE HOST.
• OF THE ENVIRONMENTAL FACTORS, ONLY CIGARETTE SMOKING SEEMS TO BE
ASSOCIATED WITH RA .

13. EPIDEMIOLOGY
• WOMEN ARE AFFECTED 3× MORE THAN MEN.
• 80% OF CASES THE AGE OF ONSET IS BETWEEN 35 AND 50 YEARS.

14. PATHOGENESIS
• INITIATION PHASE OF NONSPECIFIC INFLAMMATION
• FOLLOWED BY AN AMPLIFICATION PHASE RESULTING FROM T-CELL ACTIVATION,
• FINALLY THE STAGE OF CHRONIC INFLAMMATION AND TISSUE INJURY.
• THE PREDOMINANT INFILTRATING CELL IS THE T LYMPHOCYTE..
• DISEASES LIKE HUMAN IMMUNODEFICIENCY VIRUS (HIV), IN WHICH T CELLS ARE DECREASED,
WILL CHARACTERISTICALLY IMPROVE PREEXISTING RA;
THIS IS ALSO THE REASON WHY RA IS VERY RARE IN PATIENTS
WITH HIV

15. CLINICAL PRESENTATION
• DIAGNOSTIC CRITERIA—NEED 4OF THE FOLLOWING DIAGNOSTIC CRITERIA.
• MORNING STIFFNESS (>1 H) FOR 6 WEEKS
• SWELLING OF WRISTS, MCPS, PIPS FOR 6 WEEKS
• SWELLING OF 3 JOINTS FOR 6 WEEKS
• SYMMETRIC JOINT SWELLING FOR 6 WEEKS
• RF POSITIVE OR ANTI-CYCLIC CITRULLINATED PEPTIDE (ANTI-CCP)
• CRP OR ESR
X-RAY ABNORMALITIES AND NODULES ARE NOT NECESSARY FOR THE DIAGNOSIS OF RA.

16. EXCLUSION CRITERIA
• JOINTS ARE NEVERINVOLVED IN RA:
• DIPS
• JOINTS OF THE LOWER BACK

17. • THE 2010 ACR - EULAR CLASSIFICATION CRITERIA FOR RHEUMATOID
ARTHRITIS 4 HAS A MAXIMAL SCORE OF 10 AND REQUIRES A SCORE OF >6
FOR A DIAGNOSIS OF RA TO BE MADE:

18. EULAR CLASSIFICATION CRITERIA
• JOINT INVOLVEMENT
• 0: LARGE JOINT
• 1: 2-10 LARGE JOINTS
• 2: 1-3 SMALL JOINTS (WITH OR WITHOUT INVOLVEMENT OF LARGE JOINTS)
• 3: 4-10 SMALL JOINTS (WITH OR WITHOUT INVOLVEMENT OF LARGE JOINTS)
• 5: >10 JOINTS (AT LEAST 1 SMALL JOINT)
• SEROLOGY
• 0: NEGATIVE RF AND NEGATIVE ANTI-CCP
• 2: LOW-POSITIVE RF OR LOW-POSITIVE ANTI-CCP
• 3: HIGH-POSITIVE RF OR HIGH-POSITIVE ANTI-CCP
• ACUTE PHASE REACTANTS
• 0: NORMAL CRP AND NORMAL ESR
• 1: ABNORMAL CRP AND ABNORMAL ESR
• DURATION OF SYMPTOMS
• 0: <6 WEEKS
• 1: >6 WEEKS

19. WORK UP
• LABORATORY FINDINGS
• RF OR ANTI-CCP (MORE SPECIFIC)
• ANEMIA
• ESR OR C-REACTIVE PROTEIN (CRP)
• X-RAYS
• SYNOVIAL FLUID ANALYSIS

20. AGGRESSIVE
• AGGRESSIVE DISEASE IS LIKELY TO OCCUR WITH THE FOLLOWING FEATURES :
• HIGH TITERS OF RF
• DIFFUSE RHEUMATOID NODULES
• EARLY JOINT EROSIONS
• LATE AGE OF ONSET
• CERTAIN SUBTYPES OF THE HLA-DR4

21. CLINICAL PEARL
• CONSIDER ATLANTOAXIAL SUBLUXATION IN PATIENTS WITH RA WHO COMPLAIN OF
OCCIPITAL HEADACHES AND UPPER EXTREMITY TINGLING AND NUMBNESS.
• ALWAYS RULE OUT SUBCLINICAL SUBLUXATION IN PATIENTS WITH RA WHO ARE UNDERGOING SURGERY AND
INTUBATION ELECTIVELY.
• REFER ALWAYS TO A SPINE SURGEON (ORTHOPEDIC SPECIALIST OR NEUROSURGEON) IF THE RADIOLOGIC TESTING
IS POSITIVE.
• IF A PATIENT WITH RA PRESENTS WITH A SWOLLEN PAINFUL CALF, CONSIDER A RUPTURED
BAKER CYST.

23. Natural history of disease

26. MSK MANIFESTATIONS

28. HAND
• DISTRIBUTION:
• MCP
• PIP
• NEVER DIP.

30. Periarticular soft tissue swelling

32. JUXTAARTICUALR
OSTEOPOROSIS

35. Marginal bone erosions

37. NARROWING OF THE JOINT SPACE

39. JUXTA-ARTICULAR
PERIOSTITIS

40. Subcortical cysts

42. SUBLUXATION
• Loss of parallel articular surfaces.

43. DISLOCATION

44. BOUTONNIÈRE DEFORMITY
“MEANS: BUTTON HOLE"

45. ACUTE(TRAUMATIC) BOUTONNIÈRE
DEFORMITY
• THIS FLEXION DEFORMITY OF THE PROXIMAL INTERPHALANGEAL JOINT IS DUE TO INTERRUPTION OF THE CENTRAL
SLIP OF THE EXTENSOR TENDON SUCH THAT THE LATERAL SLIPS SEPARATE AND THE HEAD OF THE PROXIMAL
PHALANX POPS THROUGH THE GAP LIKE A FINGER THROUGH A BUTTON HOLE (THUS THE NAME,
FROM FRENCH BOUTONNIÈRE "BUTTON HOLE")

46. SWAN NECK DEFORMITY

47. ULNAR DEVIATION & PALMAR SUBLUXATION
AT MCP JOINTS

49. ARTHRITIS MUTILANS ( OPERA GLASS HAND)
• MARKED BONY RESORPTION
AND THE CONSEQUENT COLLAPSE OF SOFT TISSUE
DD: PSORIATIC ARTHRITIS
• Sever polyarticular joint deformity

50. • DISTAL ENDS OF RADIUS & ULNA.
• CAPRAL BONES (SPECIALLY
TRIQUETRIUM & PISIFORM).

51. RA OF THE WRIST

52. Erosion of the ulnar styloid
process
Pathology:
Pannus formation in
• The prestyloid recess,
• Extensor carpi ulnaris tendon sheath or
• Radioulnar joint.

53. EROSION OF THE CARPAL BONES

54. SPOTTY CARPAL SIGN
• Multiple carpabl bone erosions

55. SUDEK’S ATROPHY
• Demineralizatio of
bone.
• Joint space
preserved.
• Soft tissue atrophy.

56. TB

59. MARGINAL BONE EROSIONS

60. LANIOS DEFORMITY

61. .

64. Olecranon bursitis

69. PROTRUSIO ACETABULAE
• P R O T R usio:
• Paget
• Rheumatoid arthritis (& other inflammatory
arthritides).
• Osteogenesis imperfecta, Osteomalacia,
osteoporosis
• Traumatic
• Rickets.

75. ROTATORY ATLANTO-AXIAL SUBLUXATION
Type 1 Type 2 Type 3 Type 4
Incidence Most common Rare Rare
neurologica
l deficit
Most benign high risk high risk
Facet joint Unilateral
facet
subluxatioin
Unilateral
facet
subluxation
Bilateral facet
subluxation
Bilateral facet
subluxation
C1 ant /
post
displacemen
t
No anterior
displacemen
t
Anterior
displacemen
t
Anterior
displacemen
t
Posterior
displacement
.
Transverse
ligament
Intact injured injured

76. Anterior subluxation
Lateral view Flexion view Open mouth view
Bone erosions

80. NON MSK RA FEATURES

81. PULMONARY
• DISEASE MAY INVOLVE THE INTERSTITIUM, AIRWAY, AND/OR PLEURA

82. CARDIOVASCULAR DISEASE
• ACCELERATED CORONARY ARTERY AND CEREBROVASCULAR
ATHEROSCLEROSIS 8 CONTRIBUTING SIGNIFICANTLY TO THE EXCESS MORTALITY
OF RA
• PERICARDITIS
• VASCULITIS: OCCURS MORE COMMONLY WITH A SEVERE EROSIVE DISEASE,
RHEUMATOID NODULES, HIGH RF TITERS

83. CUTANEOUS INVOLVEMENT
• RHEUMATOID NODULES
• ARE USUALLY SEEN IN PRESSURE AREAS: ELBOWS, OCCIPUT, LUMBOSACRAL 3
• OCCURS IN RF-POSITIVE PATIENTS

84. OCULAR INVOLVEMENT
• KERATOCONJUNCTIVITIS SICCA (DRYNESS OF THE CONJUNCTIVA AND CORNEA )
• UVEITIS
• EPISCLERITIS

85. ASSOCIATIONS
• FELTY SYNDROME: RHEUMATOID ARTHRITIS, SPLENOMEGALY, AND
NEUTROPENIA
• CAPLAN SYNDROME : RHEUMATOID ARTHRITIS AND PNEUMOCONIOSIS

87. JUVENILE IDIOPATHIC(RHEUMATOID ) ARTHRITIS
• ETIOLOGY.
• EPIDEMIOLOGY.
• PATHOGENESIS.
• CLINICAL PRESENTATION.
• LABORATORY FINDING.
• DIAGNOSIS.
• TREATMENT.
• RADIOLOGICAL FINDING.

88. EPIDEMIOLOGY
• BY DEFINITION, SYMPTOMS MUST START BEFORE 16 YEARS OF AGE.
• FEMALES ARE MORE AFFECTED WITH F:M = 2:1

89. CLINICAL PRESENTATION
• OLIGOARTICULAR OR POLYARTICULAR ARTHRITIS OF A DURATION OF SIX WEEKS
OR LONGER MUST BE PRESENT TO DIAGNOSE JIA.
• PATIENTS MAY PRESENT WITH AN ACUTE ONSET OF SYMPTOMS OR A MORE
GRADUAL ONSET.
• SYMPTOMS ARE OFTEN WORSE IN THE MORNING BUT TYPICALLY PERSIST TO
SOME EXTENT THROUGHOUT THE DAY.

90. PATHOLOGY OF JRA
• OLIGOARTICULAR JIA
• AFFECTED ≤4 JOINTS IN THE FIRST SIX MONTHS OF ILLNESS
• PEAK AGE: 1-6 YEARS
• MAINLY AFFECTS MEDIUM AND LARGE JOINTS
• POLYARTICULAR JIA
• ≥5 JOINTS ARE AFFECTED
• PEAK AGE: 1-4 YEARS; 7-10 YEARS
• MAINLY AFFECTS SMALL AND MEDIUM JOINTS
• SYSTEMIC ONSET JIA (STILL'S DISEASE, NOT TO BE CONFUSED WITH ADULT ONSET STILL'S
DISEASE)
• ARTHRITIS MAY PRESENT WEEKS TO MONTHS AFTER THE ONSET OF SYSTEMIC SYMPTOMS

91. RADIOGRAPHIC FEATURES
• THERE IS USUALLY A PREDILECTION FOR LARGE JOINTS RATHER THAN
SMALL JOINTS.
• FINDINGS ON X-RAY INCLUDE SOFT TISSUE SWELLING, OSTEOPENIA, LOSS OF
JOINT SPACE, EROSIONS, GROWTH DISTURBANCES (EPIPHYSEAL OVERGROWTH
OR "BALLOONING") AND JOINT SUBLUXATION.

92. CERVICAL SPINE RADIOGRAPHS
MAY DEMONSTRATE:
• ATLANTOAXIAL SUBLUXATION
• ODONTOID EROSIONS
• ANKYLOSIS, ESPECIALLY OF THE FACET JOINTS

93. OTHER
• HEPATOSPLENOMEGALY
• PERICARDIAL OR PLEURAL EFFUSIONS .

94. STILL DISEASE ( SYSTEMIC JRA )
• INTERMITTENT SPIKING FEVERS ARE TYPICALLY NOTED
• MIGRATORY SALMON COLORED LIGHT PINK RASH INVOLVING THE TRUNK
AND/OR EXTREMITIES
• HEPATOSPLENOMEGALY

95. ADULT-ONSET STILL DISEASE
• RARE
• BIMODAL DISTRIBUTION WITH ONE PEAK AROUND THE AGE OF 15-25 YEARS
OLD AND ANOTHER AROUND THE AGE OF 35-45 YEARS OLD 1.
• IT AFFECTS FEMALES MORE THAN MALES

96. CLINICAL PICTURE
TRIAD
• HIGH FEVERS
• ARTHRALGIA
• SALMON-COLORED RASH

97. • LESS COMMON
• SORE THROAT
• HEPATIC DYSFUNCTION
• SPLENOMEGALY
• LYMPHADENOPATHY
• ELEVATED INFLAMMATORY MARKERS (E.G. CRP), LEUKOCYTOSIS,
THROMBOCYTOSIS AND ELEVATED FERRITIN ARE COMMON 3.

98. DIAGNOSTIC CRITERIA
• THE YAMAGUCHI CRITERIA IS PROBABLY THE MOST COMMONLY USED AND
SENSITIVE SCORING SYSTEM FOR DIAGNOSING ADULT-ONSET STILL DISEASE

99. LABORATORY FINDING.
• ADULT-ONSET STILL DISEASE IS A SERONEGATIVE DISEASE MEANING A
NEGATIVE RHEUMATOID FACTOR AND ANTINUCLEAR ANTIBODIES ARE
COMMONLY FOUND.

100. RADIOGRAPHIC FEATURES
• PERICAPITATE AND TRAPEZOID-METACARPAL JOINT SPACE NARROWING
WITHOUT RADIOCARPAL INVOLVEMENT IS CHARACTERISTIC 7.
• THIS PATTERN IS RARER IN RHEUMATOID ARTHRITIS.