Book Reading

dr. Francisco Gilbert Timothy

dr. Adam Moeljono, Sp.OT (K) Spine
Section 1
General Orthopaedics
Chapter 3
Inflammatory rheumatic
disorders

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Rheumatoid arthritis

• Most common chronic inflammatory joint disease

• Prevalence in population is 1-2% among 40 to 50 years
• Women : men= 3:1
• Caucasians

• Cause
• Genetic susceptibility
• Immunological reaction preferentially on synovial tissue
• Inflammatory reaction in joints and tendon sheaths
• RF and anti-CCP or ACPA
• Perpetuation of the inflammatory process
• Articular cartilage destruction

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• Pathology • Pathology
Joints and tendons Extra-articular tissue
• Stage 1: pre clinical • Rheumatoid nodules
• Stage 2: synovitis • Lymphadenopathy
• Stage 3: destruction • Vasculitis
• Stage 4: deformity • Muscle weakness
• Visceral disease

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• Clinical features
• Early vs late

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• Blood investigations
• Synovial biopsy
• Imaging
• X-rays
• Ultrasound scanning and MRI

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• Diagnosis
• Bilateral, symmetrical polyarthritis, proximal joints of hands or feet,
6 weeks
• Subcutaneous nodules, periarticular erosions in X-ray
• Differential Diagnosis
• Serronegative inflammatory polyarthritis, ankylosing spondylitis,
Reiter’s disease / reactive arthritis, polyarticular gout, Ca
pyrophosphate deposition disease, sarcoidosis, Lyme disease, viral
arthritis, polymyalgia rheumatica, osteoarthritis

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• Treatment
Principles of medical management
• Identify as early as possible
• Start DMARD immediately
• Consider combination of multiple DMARD
• If DMARD fail progress rapidly to biological therapy (TNF inhibitors,
T-cell costimulation inhibitors, IL-6 inhibitors, B cell depleting
therapies)
Physiotherapy and occupational therapy
• Preventative splinting and orthotic
Surgical management
• Soft tissue procedures
• Hard tissue procedures

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• Complications
• Fixed deformities
• Muscle weakness
• Joint ruptures
• Infection
• Spinal cord compression
• Systemic vasculitis
• Amyloidosis
• Prognosis
• RF, anti CCP, periarticular
erosions, rheumatoid
nodules, severe muscle
wasting, joint contractures,
vasculitis

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Axial Spondyloarthropathies

• Spine and sacroiliac joints

• Ankylosing spondylitis is the end stage
• Women : men= 1 : 2

• Cause
• HLA-B27
• Bacterial antigen
• Antibody response
• Pathology
• Synovitis of diarthroidal joints
• Inflammation at the fibro-osseous junctions of syndesmotic joints
and tendons

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• Clinical features
• Backache and stiffness
• Referred pain
• Pain and swelling of joints
• Tenderness at Achilles tendon
insertion
• Slight flattening of the lower
back
• Limitation of extension in the
lumbar spine
• Typical posture
• Wall test
• Marked line of vision
restriction
• Extraskeletal manifestation Typical posture

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• Imaging
• X-ray (SI joints, vertebrae)
• MRI
• Special investigations
• ESR, CRP, HLA-B27

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• Differential diagnosis
• Mechanical disorders, diffuse idiopathic hyperostosis (Forestier
disease), other seronegative spondyloarthropathies
• Treatment
• Maintain satisfactory posture and preserve movement
• Anti inflammatory drugs
• TNF inhibitors for sever disease
• Operations to correct deformity or restore mobility
• Complications
• Spinal fractures, hyperkyphosis, spinal cord compression,
lumbosacral nerve root compression

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Peripheral spondyloarthropathies
Reiter’s syndrome and reactive arthritis
• Cause
• HLA-B27, bowel or genitourinary infections
• Clinical features
• Acute phase, chronic phase
• Differential diagnosis
• Gout and infective arthritis, gonococcal arthritis, enteropathic
arthritis
• Treatment
• Clear responsible organism

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Psoriatic arthritis
• Cause
• Psoriasis family history, HLA-
B27
• Pathology
• Chronic synovitis; arthritis
mutilans
• Clinical features
• Arthritis of DIP
• Arthritis mutilans
• Asymmetrical large joint
oligoarthritis
• Sacroiliitis and spondylitis

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• Imaging
• X-ray, ultrasound and MRI
• Diagnosis
• Asymmetrical joint distribution
• Involvement of DIP
• Sacroiliitis or spondylitis
• Absence of rheumatoid nodules
• Treatment
• NSAIDS, immunosuppressive

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Enteropathic arthritis
• Peripheral arthritis
• Flare up of bowel disease
• Sacroiliitis and spondylitis
• No temporal relationship to GI inflammation
• Complications
• Septic arthritis of the hip, psoas abscess, osteopaenia

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Juvenile idiopathic arthritis • Complications
• Clinical features • Ankylosis, growth defects,
fractures, iridocyclitis,
• Systemic, oligoarticular, amyloidosis
polyarticular, enthesitis
related • Prognosis
• Treatment
• General, local

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Connective tissue disease

Systemic lupus erythematosus (SLE)

• Joint pain overshadowed by systemic symptoms
• Characteristics clinical features
• Butterfly rash, Raynaud’s phenomenon, peripheral vasculitis,
splenomegaly, ANA positive
• Treatment
• Corticosteroid, hydroxychloroquine, immunosuppressants,
cytotoxics, biological therapy
• Complications
• Avascular necrosis

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Thanks!