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OverviewOverview

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There are three types of joints – fibrous, fibrocartilaginousand synovial.Synovial jointsThese include the ball-and-socket joints (e.g. hip) and thehinge joints (e.g. interphalangeal).They possess a cavity and permit the opposed cartilaginousarticular surfaces to move painlessly over each other.Movement is restricted to a required range, and stability ismaintained during use. The load is distributed across thesurface, thus preventing damage by overloading or disuse.

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Synovium and synovial fluid. The joint capsule, which is connectedto the periosteum, is lined with synovium which is afew cells thick and vascular. Its surface is smooth and nonadherentand is permeable to proteins and crystalloids. Asthere are no macroscopic gaps, it is able to retain normaljoint fluid even under pressure. Macrophages and fibroblastlikesynoviocytes form the synovial layer by cell-to-cell interactionsmediated by cadherin-II. The synoviocytes releasehyaluronan into the joint space, which helps to retain fluid inthe joint. Synovial fluid is a highly viscous fluid secreted bythe synovial cells and has a similar consistency to plasma.Glycoproteins ensure a low coefficient of friction between thecartilaginous surfaces. Tendon sheaths and bursae are alsolined by synovium.

• Rheumatoid Arthritis (RA) is a chronic, autoimmune, inflammatory systemic disease of unknown etiology characterized by persistent joint inflammation(chronic symmetrical polyarthritis) that results in progressive joint destruction, joint deformity, and physical disability. RA may affect other organs and may also result in an increased risk for premature death. The average life expectancy of RA patients is decreased by 3 to 18 years compared to age and gender matched controls. Because it can affect multiple organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions.The cause of rheumatoid arthritis is not known.In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.Rheumatoid arthritis can affect people of all ages.Damage to joints can occur early and does not correlate with the severity of symptoms.The "rheumatoid factor" is an antibody that can be found in the blood of 80% of people with rheumatoid arthritis.

A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.In some people with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.

Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. The prevalence ishigh in the Pima Indian population and low in black Africansand Chinese people. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.

The cause of rheumatoid arthritis is unknown.. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited (hereditary). It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues; resulting in inflammation in various organs of the body such as the lungs or eyes. Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

Genetic and environmental factors play a part.

Gender. Women before the menopause are affectedthree times more often than men. After the menopausethe frequency of onset is similar between the sexes, suggesting an etiological role for sex hormones. The use of the oral contraceptive pillhas shown no affect on RA overall, as previouslythought, but it may delay the onset of disease.Familial. The disease is familial with an increasedincidence in first degree relatives and a highconcordance amongst monozygotic twins (up to 15%)and dizygotic twins (3.5%). In occasional families itaffects several generations.

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Genetic factors are estimated to account for up to 60%of disease susceptibility.There is a strong associationbetween susceptibility to RA and certain HLAhaplotypes. HLA-DR4, which occurs in 50–75% ofpatients, correlates with a poor prognosis, as doesHLA-DRB1Individuals with HLA-DRB1 combined with a positive rheumatoidfactor are13 times greater riskfor developing bone erosions in early disease.

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Rheumatoid arthritis is typified by widespread persistingsynovitis (inflammation of the synovial lining of joints, tendonsheaths or bursae). The cause of this is unclear, but theproduction of rheumatoid factors (RFs) by plasmacells in the synovium and the local formation of immunecomplexes play a part. The synoviocytes play a central rolein synovial inflammation. In RA the synovium becomesgreatly thickened to the extent that it is palpable as a ‘boggy’swelling around the joints and tendons. There is proliferationof the synovium into folds and fronds, and it is infiltrated bya variety of inflammatory cells, including polymorphs, and lymphocytes and plasma cells. There are disorganized lymphoid follicles. The normally sparse surface layer of lining cells becomes hyperplastic and thickened. There is marked vascular proliferation. Increased permeability of blood vessels and the synovial lining layer leads to joint effusions that contain lymphocytes and dying polymorphs.

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Hands and wrists

Shoulders

Elbows

Feet

Knees

Hips

Cervical spine

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Typically :symmetrical swollen , painful, and stiffness of small joint of hands & feet that worse in the morning. This can fluctuate ,and large joint may become involve.

Less common : sudden onset ,widespread arthritis .Systemic illness with extra -articular symptom; fatigue, low-grade fever, wight loss, lack of appetite , pericarditis and pleurisy, recurrent soft tissue problem ,polymyalgia onset-vague limb aches.

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When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can affect the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of the voice.

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Finger deformities•intrinsic plus deformity•swan neck deformity•boutonniere deformity•mallet deformity•ulnar deviation (towards the little finger) of the fingers

Thumb deformities•Type 1 is a boutonniere deformity; it is most common•Type 2 is a flexion deformity of metacarpo-phalangeal with extension of inter-phalangeal joint•Type 3 is a swan neck deformity; second most common•Type 4 is abduction of the proximal-phalanx and adduction of the metacarpal.

Wrist deformities•dorsal (backward) dislocation of the ulna bone•ulnar shifting of the wrist bones•tendon rupture•radial shifting (towards the index finger) of the metacarpals

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Caused by the tightness of the intrinsic muscles (interossei and lumbrical muscles) of the hand. When the metacarpo-phalangeal joint is extended it is not possible to flex the proximal inter- phalangeal joint.

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Swan neck deformity is a condition in which the distal joint (behind the nail) of the finger goes into flexion and the proximal joint goes into extension.

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Is caused by the stretching of the collateral ligaments of the metacarpo-phalangeal jointsstretching of the accessory ligaments causing the ulnar drifting of the flexor tendonscontracture of the intrinsic muscles of handulnar deviation or rupture of the extensor tendons.

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Boutonniere deformity is a condition in which the proximal joint (away from the knuckle joint) of the finger goes into flexion and the distal joint goes into extension.

Sjogren's syndrome is inflammation of the glands of the eyes and mouth and causes dryness of these areas.Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing.Tissue inflammation surrounding the heart, called pericarditis, can cause chest pain that typically changes in intensity when lying down or leaning forward.

Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Examples of other areas that may be affected include:

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Rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (Felty's syndrome) and can increase the risk of infections.Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure.A rare and serious complication is blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

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Complications of the condition

oRuptured tendonsoRuptured joints (Baker’s cysts)oJoint infectionoSpinal cord compression (atlantoaxial or upper cervicalospine)oAmyloidosis (rare)oSide-effects of therapySeptic arthritis

This is a serious complication with significant morbidity andmortality. Affected joints are hot and inflamed with accompanyingfever and a neutrophil leucocytosis in the blood.However, these signs are often absent, and any effusion,particularly of sudden onset, should be aspirated. Staphylococcusaureus is the most common organism. Blood culturesare often positive. Treatment is with systemic antibiotics and drainage.

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Amyloidosis

Amyloidosis is found in a very small number of people withsevere rheumatoid arthritis. RA is the most common causeof secondary AA amyloidosis. AL amyloidosis causes a polyarthritisthat resembles RA in distribution and is also oftenassociated with carpal tunnel syndrome and subcutaneousnodules.

AA amyloidosis is secondary amyloidosisAL amyloidosis primary amyloidosisATTR amyloidosis the most common form of familial amyloidosis, associated with mutations of the gene encoding transthyretin.

Complications of the condition