Arthritis: Inflammation
of a joint, marked by pain, heat, redness, and swelling. Arthritic
disorders are among the most common chronic conditions that is painful
and disabling. There are different types of arthritic disorders they
include: Rheumatoid arthritis, Osteoarthritis, Septic arthritis, Gout, Intermittent hydrarthrosis, Traumatic arthritis, Schonlein-Henoch purpura, and Hemophilic arthrosis.
Rheumatoid arthritis or RA:
This chronic, systemic inflammatory disease mainly attacks peripheral
joints and surrounding muscles, tendons, ligaments, and blood vessels.
Spontaneous remissions and unpredictable exacerbation’s mark the course
of rheumatoid arthritis. This disorder has the potential to cripple and
in some cases patient becomes totally disable from severe articular
deformity or associated extra articular symptoms, or both. In most
patients, the disease follows an intermittent course and allows normal
activity.
Cause: Rheumatoid Arthritis is believed to have an autoimmune basis, though the exact cause remains unknown.
Symptoms:
Early stage – may experience:
Fatigue
Malaise
Anorexia
Persistent low-grade fever
Weight loss
Lymphadenopathy
May experience vague articular symptoms
Later stage:
Joint pain – joint symptoms occur bilaterally and symmetrically
Tenderness
Warmth and swelling
Stiffness
Paresthesias in hands and feet
Stiff , weak, and painful muscles
May develop rheumatoid nodules ( subcutaneous, round or oval, non
tender masses, usually on pressure areas, such as the elbow)
Advance signs:
Joint deformities and diminished joint function
Treatment:
Salicylates – such as aspirin to decrease inflammation and relieve joint pain
Nonsteroidal anti inflammatory agents – such as ibuprofen
Antimalarials
Corticosteroids – such as prednisone
Immunosuppressives – such as cyclophosphamide and azathioprine, are also therapeutic
Supportive measures include: Adequate sleep and frequent rest period.
Physical
therapy program – Range of motion exercises and carefully
individualized therapeutic exercises, forestalls loss of joint function.
Application of heat relaxes muscles and relieves pain. Ice packs are effective during acute episodes.
Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty.
Osteoarthritis
Osteoarthritis: The most common form of arthritis,
this chronic condition causes deterioration of the joint cartilage and
formation of reactive new bone at the margins and subchondral areas of
the joints. Degeneration results from a breakdown of chondrocytes, most
often in the hips and knees.
Disability depends on the site and severity of involvement and can
range from minor limitation to severe disability in people with hip or
knee involvement. The rate of progression varies, and joints may remain
stable for years in an early stage of deterioration.
Cause: The exact cause is unknown. Primary
osteoarthritis, a normal part of aging, results from varies things,
such as: metabolic, genetic, chemical, and mechanical factors.
Secondary osteoarthritis usually follows an identifiable
predisposing event, most commonly trauma or congenital deformity which
may lead to degenerative changes.
Symptoms:
Signs and symptoms increases with poor posture, obesity, and occupational stress
Joint pain – that occurs particularly after exercise or weight bearing and that is usually relieved by rest.
Stiffness in the morning and after exercise that is usually relieved by rest
Aching during changes in weather
‘Grating’ of the joint during motion
Limited movement
Irreversible changes in the distal joints (Heberden’s nodes) and
proximal joints (Bouchard’s nodes) occur in osteoarthritis of the
interphalangeal joints.
Nodes may be painless at first but eventually become red, swollen, and tender, causing numbness and loss of dexterity.
Treatment:
Non narcotic analgesics
In some cases, intra articular injections of corticosteroids.
Patients who have severe osteoarthritis with disability or
uncontrollable pain may undergo one or more of the following surgical
procedures:
-Arthroplasty (partial or total) – replacement of a deteriorated joint or part with a prosthetic appliance.
-Arthrodesis – surgical fusion of bones; used primarily in the spine
-Osteoplasty – scraping of deteriorated bone from a joint
-Osteotomy – excision of bone to change alignment and relieve stress
Septic Arthritis
Septic arthritis: is a medial emergency. Bacteria
invade a joint, resulting in inflammation of the synovial lining. If
the organisms enter the joint cavity, effusion and pyogenesis follow,
with eventual destruction of bone and cartilage.
Septic arthritis can lead to ankylosis and even fatal septicemia.
Prompt antibiotic therapy and joint aspiration or drainage cure most
patients.
Causes: In most cases, bacteria spread from a
primary site of infection, usually in adjacent bone or soft tissue,
through the bloodstream to the joint.
Infecting organisms include four strains of gram positive
cocci:Staphylococcus aureus, Streptococcus pyogenes, Streptococcus
pneumoniae, and Streptococcus viridans.
Two strains of gram negative cocci: Neisseria gonorrhoeae and Hemophilus influenzae.
Several gram negative bacilli: Escherichia coli, Salmonella, and Pseudomonas to name a few.
Anaerobic organisms, such as gram positive cocci, usually infect
adults and children over age 2. H. influenzae most often infects
children under age 2.
There are various factors that can predispose a person to septic
arthritis. Any concurrent bacterial infection (such as, upper
respiratory tract or genitourinary), or serious chronic illness (such
as renal failure, RA, diabetes, or cirrhosis) heightens susceptibility.
Intravenous drug abuse ( heroin addicts, for example) can also cause
septic arthritis. Other predisposing factors include recent articular
trauma, joint surgery, intra articular injections, and local joint
abnormalities.
Symptoms:
Acute septic arthritis begins abruptly, causing intense pain,
inflammation, and swelling of the affected joint, with low grade fever.
Most often develops in the large joints but can strike any joint,
including the spine and small peripheral joints. Systemic signs of
inflammation may not appear in some patients. If the bacteria invade
the hip, pain may occur in the groin, upper thigh, or buttock.
migratory polyarthritis sometimes precedes localization of the
infection.
Treatment:
Emergency action is needed. Seek medical attention promptly.
Antibiotic therapy (medication selection requires drug sensitivity
studies of the infecting organism) Bioassays or bactericidal assays of
synovial fluid and bioassays of blood may confirm clearing of the
infection.
Treatment requires monitoring of progress through frequent analysis
of joint fluid cultures, synovial fluid leukocyte counts, and glucose
determinations.
Propoxyphene or Codeine may be given for pain – (aspirin causes a
misleading reduction in swelling, hindering accurate monitoring of
progress)
The affected joint can be immobilized with a splint or put into traction until movement can be tolerated.
Arthrocentesis to remove grossly purulent joint fluid should be
repeated daily until fluid appears normal. Patient may require
arthrotomy with lavage of the joint with resistant infection or chronic
septic arthritis
Late reconstructive surgery is warranted only for severe joint
damage and only after all signs of active infection have disappeared,
may take up to several months. In some cases, the recommended procedure
may be arthroplasty or joint fusion.
Gout
Gout: Urate (a salt of uric acid) deposits lead to
painfully arthritic joints. Gout can strike any joint but favors those
in the feet and legs. Gout usually occurs in men older than age 30 and
in post menopausal women. Secondary gout occurs in the elderly. Gout
follows an intermittent course and often leaves patients totally free
of symptoms for years between attacks. Gout can lead to chronic
disability or incapacitation an, rarely, severe hypertension and
progressive renal disease. Prognosis is good with treatment.
Cause: Exact cause of primary gout is unknown. It
may be linked to a genetic defect in purine metabolism, which causes
overproduction of uric acid (hyperuricemia), retention of uric acid, or
both.
Secondary gout can also follow drug therapy, especially after
hydrochlorothiazide or pyrazinamide, which interferes with urate
excretion. Increased concentration of uric acid leads to urate
deposits, called tophi, in joints or tissues, causing local necrosis or
fibrosis.
Symptoms:
There are four different stages: Asymptomatic, acute, intercritical, and chronic.
Asymptomatic gout: serum urate levels rise but produce no symptoms.
As the disease progresses, it may cause hypertension or nephrolithiasis
(a condition marked by the presence of renal calculi), with severe back
pain.
Acute gout: The first acute attack strikes suddenly and peaks
quickly. It may involve a few joint, but usually involves only one
joint, this initial attack is extremely painful. Affected joints appear
hot, tender, inflamed, dusky red, or cyanotic.
The metatarsophlageal joint of the great toe usually becomes
inflamed , then the instep, ankle, heel, knee, or wrist joints. May
develop a low grade fever. Mild acute attacks often subside quickly but
tend to recur at irregular intervals. Sever attacks may persist for
days or weeks.
Intercritical : Intercritical periods are the symptom free intervals
between gout attacks. Most patients usually have a second attack within
6 months to 2 years, but in some the second attack is delayed for 5 to
10 years. Delayed attacks are more common in those who are untreated
and tend to be longer and severer that initial attacks. Such attacks
are also polyarticular, invariably affecting joints in the feet and
legs, and are sometimes accompanied by fever. A migratory attack
sequentially strikes various joints and the Achilles tendon and is
associated with either sub deltoid or olecranon bursitis.
Chronic: Eventually, chronic polyarticular gout sets in. This final,
unremitting stage of the disease is marked by persistent painful
polyarthritis, with large, subcutaneous tophi in cartilage, synovial
membranes, tendons, and soft tissue.. Tophi (a deposit of urates in the
tissues about the joints) form in fingers, hands, knees, feet, ulnar
sides of the forearms, helix of the ear, Achilles tendons, and rarely,
in internal organs, such as the kidneys and myocardium. The skin over
the tophus may ulcerate and release a chalky, white exudate of pus.
Chronic inflammation and tophaceous deposits precipitate secondary
joint degeneration, with eventual erosions, deformity, and disability.
Kidney involvement, with associated tubular damage, leads to chronic
renal dysfunction. Hypertension and albuminuria occur in some patients,
also urolithiasis (a formation of urinary calculi) is common.
Pseudogout also causes abrupt joint pain and swelling but results
from an accumulation of calcium pyrophosphate in periarticular joint
structures. (See below)
Treatment:
To terminate an acute attack, reduce hyperuricemia, and prevent recurrence, complications, and calculi formation.
Acute gout: Bed rest, immobilization and protection of the inflamed,
painful joints, and local application of heat or cold. Analgesics to
relieve pain. Acute inflammation requires concomitant treatment with
colchicine, until the pain subsides or nausea, vomiting,
cramping, or diarrhea develops. Phenylbutazone or indomethacin in
therapeutic doses may be prescribed. Resistant inflammation may require
corticosteroids or corticotropin, or joint aspiration and an intra
-articular corticosteroid injection per doctors orders.
Chronic gout: Aims to decrease serum uric acid level. The doctor may
order continuing maintenance dosage of allopurinol to suppress uric
acid formation or control uric acid levels.(Caution used with patients
with renal failure)
Uricosuric agents – promote uric acid excretion and inhibit
accumulation of uric acid. (not to be used on patients with calculi –
unless your doctor says otherwise)v
Adjunctive therapy emphasizes a few dietary restrictions, –
avoidance of alcohol and purine rich foods. (obesity puts additional
stress on painful joints)
In some cases, surgery may be necessary to improve joint function or
correct deformities. Tophi must be excised and drained if they become
infected or ulcerated.
Pseudogout / Calcium Pyrophosphate Disease:
Pseudogout: Also called Calcium pyrophosphate
disease: Results when calcium pyrophosphate crystals collect in
periarticular joint structures. If left untreated it can lead to
permanent joint damage in about half of the patients it affects, most
of whom are elderly.
Paseudogout causes abrupt joint pain and swelling, most commonly
affecting the knee, wrist, ankle, and other peripheral joints. These
recurrent, self limiting attacks may be triggered by stress, trauma,
surgery, severe dieting, thiazide therapy, and alcohol abuse.
Symptoms are similar to those of rheumatoid arthritis. (see rheumatoid arthritis)
Treatment: joint aspiration to relieve fluid pressure
Instillation of steroids
Analgesics, or non steriodial anti inflammatories.
If appropriate, treatment of the underlying endocrine or metabolic disorder.
Intermittent Hydrarthrosis
Intermittent hydrarthrosis: a rare, benign condition characterized by regular, recurrent joint effusions. Commonly affecting the knee joint.
Cause: unknown. Onset is usually at or soon after puberty and may be linked to familial tendencies, allergies, or menstruation.
Symptoms: May be asymptomatic. The patient may have difficulty moving the affected joint.
Treatment: No effective treatment exists
Traumatic arthritis
Traumatic arthritis: arthritis that is caused from
blunt, penetrating, or repeated trauma or from forced inappropriate
motion of a joint or ligament.
Symptoms: Swelling, pain, tenderness, joint instability, and internal bleeding.
Treatment: Analgesics, anti inflammatories,
application of cold followed by heat, and if needed, compression
dressings, splinting, joint aspiration, casting, or possibly surgery.
Schonlein-Henoch Purpura
Schonlein-Henoch purpura: A vasculitic syndrome, it
is marked by palpable purpura, abdominal pain, and arthralgia that most
commonly affects the knees and ankles, producing swollen, warm, and
tender joints without joint erosion or deformity.
Symptoms: (those mention above). Most patients have
microscopic hematuria and proteinuria 4 to 8 weeks after onset. Renal
involvement is common. It is common in children and young adults,
occurring most often in the spring after a respiratory infection.
Treatment: may include corticosteroids.
Hemophilic Arthrosis
Hemophilic arthrosis: Produces transient or
permanent joint changes. Usually precipitated by trauma,. This disorder
usually arises between ages 1 and 5 and tends to recur until about age
10. It usually affects only one joint at a time, most commonly in the
knee, elbow,, or ankle, and tends to recur in the same joint.
Symptoms: At first, the patients may feel only mild
discomfort; later, he may experience warmth, swelling, tenderness, and
severe pain with adjacent muscle spasm that leads to flexion of the
extremity. Mild hemophilic arthrosis may cause only limited stiffness
that subsides within a few days. In prolonged bleeding, however,
symptoms may subside after weeks or months or not at all. Severe
hemophilic arthrosis may be accompanied by fever and leukocytosis.
Severe, prolonged or repeated bleeding may lead to chronic hemophilic
joint disease.
Treatment: I.V. infusion of the deficient clotting
factor, bed rest with the affected extremity elevated, application of
ice packs, analgesics, and joint aspiration may be prescribed.
Physical therapy includes progressive range of motion and muscle strengthening exercises.