JOINTS.power point of students teachersb

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1. JOINTS

2. SUPPURATIVE ARTHRITIS
•Routes: hematogenous, direct inoculation or
contiguous infections
•Risk factors: immune deficiencies, severe
illness, joint trauma, chronic arthritis,
intravenous drug abuse
•Sudden development of acutely painful and
swollen joint with restricted range of motion,
systemic findings
•Usually single joint (knee, hip, shoulder)

3. Gram stain of joint fluid

4. TUBERCULOUS ARTHRITIS
•Chronic progressive arthritis, usually
monoarticular in knee and hip; usually after
osteomyelitis or hematogenous spread
•Leads to fibrous ankylosis of joint with
obliteration of joint space
•X-rays: marginal erosion of hip and knee
joints, with destruction of subchondral bone
on both sides of joint and loss of joint space
•Micro: granulomas with caseous necrosis

5. GOUT AND GOUTY ARTHRITIS
•Gout is due to hyperuricemia and deposition
of monosodium urate crystals in joints and
viscera and uric acid kidney stones
•Serum urate > 7 mg/dl (saturation threshold
at normal body T
0
& blood Ph)
•1
0
gout (90%) or 2
0
gout (10%)
•Risk factors for gout with hyperuricemia are
age > 30 years, familial history of gout,
alcohol use, obesity, thiazide administration,
lead

6. Gouty arthritis
•Sites: 50% have initial attack in first
metatarsophalangeal joint; also ankles,
heels, knees, wrists, fingers, elbows
•Transient attacks of acute arthritis =>
chronic gouty arthritis with tophi (large
aggregates of urates crystals & the
surrounding inflammatory reaction in
joints & other sites) and urate
nephropathy

7. Gouty arthritis ctd
•Urate crystals develop in synovial lining cells
•=> release of crystals attracts neutrophils
and complement
•=> attracts more neutrophils, releases free
radicals, releases lysosomal enzymes
•=> acute arthritis
•=> repeated attacks of acute arthritis cause
chronic arthritis and formation of tophi in
synovial membranes and periarticular tissue,
which eventually damages joints

8. Gouty arthritis ctd
•Gross: chalky white appearance of
gouty deposits
•Micro: early & late – tophi
•Gout crystals are long, slender, needle
shaped

9. Acute gout

10. Chronic gout

11. X-ray
• Late Early

12. Urate crystals

13. Mic: tophi

14. Rheumatoid arthritis
•Chronic systemic inflammatory
disorder affecting synovial lining of
joints, bursae and tendon sheaths; also
skin, blood vessels, heart, lungs,
muscles
•F:M (3:1), 40-70yrs
•Sites: small bones of hand affected first
then wrist, elbow, knee

15. Pathophysiology: Rheumatoid arthritis
•HLA-DR
•Arthitogenic microbial antigen =>
•Autoimmune T helper activation =>
•macrophages & synovial cells release of TNF
& IL => protease, Pg, osteoclasts, pannus
•Circulating immune complexes deposit =>
destroy joints
•80% have IgM autoantibodies to Fc portion of
IgG (Rheumatoid factor)

16. Rheumatoid arthritis
•X-ray: joint effusions, juxta-articular osteopenia,
erosions and narrowing of joint space
•Diagnosis: morning stiffness, arthritis in 3+ joint
areas, arthritis in hand joints, symmetric arthritis,
rheumatoid nodules, rheumatoid factor, typical
radiographic changes
•Micro: proliferative synovitis, lymphoplasmacytic
infiltrate with variable germinal centers,
osteoporosis; pannus formation (synovium, synovial
stroma with inflammatory cells, granulomatous
tissue, fibroblasts), progressing to fibrous ankylosis
=> bony ankylosis
•Skin: rheumatoid nodules in 25%; Blood vessels:
small to medium size vessels

17. Acute rheumatoid arthritis

18. Chronic rheumatoid arthritis

19. Chronic rheumatoid arthritis

20. X-ray

21. Rheumatoid nodules

22. Rheumatoid nodules

23. Rheumatoid arthritis

24. Pannus destorying the articular
cartilage

25. JUVENILE RHEUMATOID
ARTHRITIS
•Common connective tissue disease in
children age 15 years or less
•Either oligoarticular (<5 joints), polyarticular
(5 or more joints) or systemic
•Compared to classic rheumatoid arthritis,
oligoarthritis, systemic, large joints,
rheumatoid nodules & rheumatoid factors are
absent, ANA tve
•Associated with HLA-DRB1, infections by
mycobacteria, bacteria, viruses
•Sites: knees, wrists, elbows, ankles

26. DEGENERATIVE JOINT DISEASE
(OSTEOARTHRITIS)
•Progressive erosion of articular
cartilage
•1
0
due to aging
•2
0
to trauma, congenital deformity,
obesity, diabetes, & younger patients
•Usually age 50+ years (present in 80%
at age 65 years)
•Sites: Wt. bearing joints – hips (men),
knees & hands (women), vertebrae

27. Pathogenesis:
•Aging & mechanical effects, genetic
factors
•Changes in composition & mechanical
properties of cartilage => reduce tensile
strength & the resilience of the articular
cartilage
•Cartilage degradation may be mediated
by IL-1, TNF & NO

28. Osteoarthritis
•Symptoms: pain worse with use of
joint, crepitus, limited range of motion,
nerve root compression; Heberden
nodes (osteophytes at DIP joints)

29. Osteophytes

30. Femoral head

31. OSTEOARTHRITIS

32. Mic: osteoarthritis

33. ANKYLOSING
SPONDYLOARTHRITIS
•Chronic inflammatory disease of axial
joints, especially sacroiliac
•Affects teenage boys, 90% are HLA-B27
positive
•Chronic synovitis destroys articular
cartilage and causes bony ankylosis
•Symptoms: low back pain that gets
progressively worse

34. CALCIUM PYROPHOSPHATE
CRYSTAL DEPOSITION DISEASE
•Also called pseudogout, chondrocalcinosis
•Age 50+ years, calcium pyrophosphate
crystals develop first in menisci and
intervertebral discs, may seed the joint and
elicit neutrophilic response
•Knee is common site; 50% have involvement
of several joints at diagnosis
•50% get significant joint damage

35. Non-neoplastic disease of the joint
BAKER’S CYST
•Synovial cyst in popliteal space
•Due to herniation of synovial membrane
through posterior joint capsule or escape of
joint fluid from bursae
•Associated with degenerative joint disease,
neuropathic arthropathy, rheumatoid arthritis

36. BURSITIS
•Pain, erythema, swelling around bursae
that lie between muscles, tendons and
bony prominences
•Usually due to chronic trauma;
associated with cysts, fluid and loose
bodies

37. Carpal tunnel syndrome
•Symptoms due to compression of
median nerve
•By trauma, masses within canal
(hemangioma, lipoma, ganglia),
rheumatoid arthritis, amyloidosis

38. Intervertebral disc prolapse or
herniation
•Anterior herniation => asymptomatic
•Posterior herniation puts pressure on
nerve roots or spinal canal and
produces symptoms

39. Ganglion
•Small cyst-like mass, near joint capsule
or tendon sheath
•Wrist common
•Due to cystic/myxoid degeneration
•May be due to injury or overuse of joint
•May cause pain, weakness, bone
changes, partial disability of joint

40. Ganglion

41. Ganglion

42. OSTEOCHONDRITIS DISSECANS
•Probably due to trauma
•Joint pain, joint effusions, locking of
joint
•Most commonly at lateral aspect of
medial femoral condyle near
intercondylar notch
•Viable/necrosis of subchondral bone
and adjacent articular cartilage

43. SPONDYLOSIS DEFORMANS
•Due to anterior protrusion of disc;
affects lumbar spine
•Common form of spinal disease seen
radiographically or at autopsy
•Present in 50% of population at age 50;
associated with heavy physical labor

44. JOINT TUMORS
Fibroma of tendon sheath
Giant cell tumor of tendon sheath
•Solitary, slow-growing, painless nodule
on tendon sheaths of flexor surfaces of
wrists/fingers, ankle/toes
Synovial chondromatosis (synovial
chondrometaplasia, synovial
osteochondromatosis)

45. Pigmented villonodular synovitis
(PVNS)
•Rare
•Neoplastic-like villonodular hyperplasia of
synovium and tendon sheaths in young
adults composed of mononuclear cells and
multinuclear giant cells with hemosiderin
deposition
•Develops in synovial lining of joints, tendon
sheaths and bursae, usually of knee (80%),
almost always monoarticular
•Locally aggressive; may recur