Page 364 - Medicine and Surgery

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360 Chapter 8: Musculoskeletal system

throughout the tissues of the rheumatoid joint. It is There is often associated muscle weakness and gen-
thought that they provoke further inflammation and eralised osteopenia due to immobility, which may be
activate the complement system. Patients who test further exacerbated by treatment with steroids.
positive for IgM rheumatoid factor have a more se-
vere pattern of joint damage.
Clinical features (extra-articular)
Long-standing inflammation and effusion distends

See Fig. 8.1.
the joint capsule causing laxity of the ligaments. The
overall result is joint instability and continued use
leads to joint deformity. Investigations
Blood: Anaemia (usually normochromic normo-
Afteravariableperiod,synovialinflammationmaybe-

cytic), with raised inflammatory markers (ESR, CRP).
come quiescent. Deformities, if already present, may
Immunology: IgM rheumatoid factor is present in
continue to deteriorate through secondary degenera-
70%.
tive changes.
X-ray: Early changes include soft tissue swelling, pe-

riarticular osteopenia and marginal erosion of bone.
Later there is progressive loss of joint space, more ex-
Clinical features (articular)
tensive erosive changes and bone destruction, joint
Classically,rheumatoidarthritispresentsasaninsidious,
subluxation and secondary degenerative changes.
progressive, symmetrical polyarthritis with pain, and
stiffness particularly after periods of inactivity, swelling
and limitation of joint movement. Occasionally a more Management
rapid onset and progression is seen. Fifty per cent of Treatment strategies are multimodal and include physi-
patients presenting with episodic monoarthritis (palin- cal interventions, symptom-controlling drugs, steroids,
dromic rheumatism) will develop rheumatoid arthritis diseasemodifyingantirheumaticdrugs(DMARD),anti-
over the subsequent months or years. cytokines and surgery.
Hands and wrists: Initially there is muscle wasting Non-pharmacological interventions include patient

and involvement of metacarpophalangeal and prox- education, physical therapy, psychological support
imal interphalangeal joints. Later there is subluxation (e.g. patient support groups), occupational ther-
at metacarpal phalangeal joints and ulnar deviation apy, nutritional and dietary advice, appliances and
of fingers. Characteristic fixed flexion (Boutonni` ere) footwear.
or hyperextension (swan neck) deformities develop at Symptom control is generally with nonsteroidal anti-
the proximal interphalangeal joints. Tender swelling inflammatory drugs, which reduce pain and stiff-
of the ulnar styloid, subluxation and deviation of the ness(ibuprofen,indomethacin,diclofenac,etc.)These
hand may occur. Carpal tunnel syndrome can occur. havenotbeenshowntopreventjointerosionsbutthey
Feet and ankles: These are affected in 50% of cases, can result in greater joint movement.

usually developing a few years after onset. Swelling of CoxII inhibitors should be used in preference to stan-
the metatarsal phalangeal joints progresses to ham- dard NSAIDs in patients who are at high risk of de-
mer toe deformities with associated ulceration due to veloping serious gastrointestinal adverse effects (e.g.
pressure over the metatarsal heads. patients over 65 years of age, those using other medi-
Knees are affected with severe effusions, Baker’s cyst cations that increase the risk of upper GI bleeding or

formation, quadriceps wasting, flexion deformities those requiring a prolonged course of maximal dose
and lateral angular deviation. NSAIDs). Cox II inhibitors are relatively contraindi-
Cervical spine inflammation and bone damage results cated in patients with cardiovascular disease, a pre-

in joint instability and risks atlantoaxial subluxation vious history of peptic ulcer disease or previous GI
with resulting cervical myelopathy. bleeding.
Other joints involved include the temporomandibular Oral, intravenous or intra-articular steroids are used

joint causing a stiff painful jaw and the cricoarytenoid to suppress inflammation, and may be administered.
joint causing hoarse voice and inspiratory stridor. High doses may be required at times of exacerbation,