Anatomy

Anatomy

1. Anatomy

   • Synovial Joints
     • Synovial Membrane(synovium)
       • Produces a synovial fluid
         • lubrication, free movement, and nutrition of the cartilage since it doesn’t have a blood supply
         • viscous, non-Newtonian fluid found in the cavities of synovial joints.
           • hyaluronic acid
           • lubricin
           • collagenases
           • proteinases
     • They allow free movement
     • Articular surfaces of the bone
       • Hyaline cartilage(articular cartilage)
     • Intra-capsular (intra-articular) structures can be found; meniscus, labrum, tendons, and disc.
     • A synovial sheath .
   • Bones
     • 14 phalanges
     • 8 Carpals
       • Trapezium
       • Trapezoid
       • Capitate
       • Hamate
       • Scaphoid
       • Lunate
       • Triquetrium
       • Pisiform
     • 5 metacarpals
   • Arteries
     • Superficial Palmar Arch
       • mainly by ulnar a.)
       • is superficial to the long flexor tendons just deep to the palmar aponeurosis. On the lateral side of the palm, the arch communicates with the superficial br. of the radial artery.
     • Deep Palmar Arch
       • mainly by radial a
       • penetrates the origin of the hypothenar muscles; access the deep plane of the palm to anastomose with the deep palmar arch derived from the radial artery.
   • Nerves
     • Ulnar N.: medial 2/3 of the palm & dorsum + medial 11/2 fingers
     • Median N.: Lateral 2/3 of the palm + lateral 3 1/2
     • Radial n.: lateral 2/3 of the dorsum of hand + lateral 3 1/2 fingers
   • Muscles
   • Joints
     • Wrist Joint
       • Synovial , Ellipsoid , biaxial
         • Articular disc that separates the head of ulna from the triquetral .
     • Mid-Carpal Joint
       • Synovial joints
         • Between the two rows of carpal bones
           • Positioning of the hand in abduction , adduction , flexion and particularly extension
     • Carpometacarpal Joint
       • Between the distal row of carpal bones and proximal end of the metacarpal bones .
         • more stability than mobility.
     • Metacarporhalangeal Joints
       • Between the distal heads of the metacarpals and the proximal phalanges of the digits .
     • Interphalangeal Joints
       • Hinge Joints
         • Between the phalanges of the hand .

2. Diseases that affect 1 or > joints

   • Infectious diseases
     • acute and chronic septic arthritis
   • Inflammatory diseases-
     • autoimmune disorders such as rheumatoid arthritis
   • Degenerative diseases
     • osteoarthritis

3. Joint Arthritis

   • inflammation of the joints
     • the term is used to describe many rheumatic diseases that affect the joints.
       • Injury
         • Degenerative arthritis
           • inflammation, breakdown, and eventual loss of the cartilage of the joints.
             • hands, feet, spine, and large weight-bearing joints, such as the hips and knees.
               • Osteoarthritis
       • Genetic
         • Rheumatoid Arthritis
           • signs and symptoms
             • fever, malaise, arthralgias, and weakness
               • progresses to joint inflammation and swelling
             • Persistent symmetric polyarthritis (synovitis) of hands and feet
               • hallmark feature)
             • Progressive articular deterioration
             • Extra-articular involvement
             • Difficulty performing activities of daily living (ADLs)
           • onset is insidious
             • Investigations
               • Blood Investigations
                 • Anti-CCP(cyclic citrullinated peptide)
                   • identifying autoantibodies
                 • normocytic anemia :anemia of chronic disease(ACD)
                   • The most common cause is a long-term (chronic) disease.
                 • High Erythrocyte sedimentation rate and C-reactive protein (CRP) level
                   • markers of inflammation
                 • Rheumatoid factor (RF)
                   • RF antibody can attach to normal body tissue, resulting in damage.
               • Joint imaging
                 • Plain x-ray
                   • symmetric joint
                   • soft tissue swelling
                   • space loss
                   • subchondral erosions.
             • Clinical Findings
               • Rheumatoid nodules
                 • firm, noticeable lumps that form underneath the skin
               • Characteristic deformities
                 • Z deformity of the thumb
             • Pathohistology
               • synovial cell hyperplasia and proliferation
               • dense perivascular inflammatory cell infiltrates (frequently forming lymphoid follicles)
               • RA joint is hypoxic
                 • angiogenesis
               • Activation of osteoclasts and chondrocytes
           • History Taking
             • basic patient details and statement of presenting problem.
               • Where
               • Progression
               • Quality
               • Alleviating factors
               • Beliefs
           • Physical Examination of the hand
           • Causes
             • not fully understood
           • Complications
             • Haematological
               • Anemia of chronic disease
               • Iron deficiency anemia
               • Bone marrow hypoplasia with anemia
             • Vasculitis
               • Digital arteritis
               • Ulcers
             • Cardiac
               • Pericarditis
               • Myocarditis
               • Endocarditis
             • Pulmonary
               • Pleural effusions
               • Bronchiolitis
             • Neurological
               • Cervical cord compression
               • Peripheral neuropathy
             • Systemic
               • Weight loss
               • Susceptibility to infection
             • Lymphatic
               • Splenomegaly
             • Musculoskeletal
               • Osteoporosis
               • Bursitis
           • Pathophysiology
             • Autoreactive T cells are activated by antigen-presenting cells presenting self-peptide to CD4 cells.
               • Macrophages exacerbate the disease by secreting TNF usually found in rheumatoid synovial tissues, resulting in cartilage destruction via effects on chondrocytes
                 • Rheumatoid factors are released as a consequence to the activation of B cells.
                   • Macrophages also release the chemokine IL-8 which recruit neutrophils that cause more damages to the tissues
                     • Inflammation
                     • Cartilage damage and joint space narrowing
                     • Bone erosion
                   • During the process of the disease, cells are damaged releasing anti-DNA. RF then binds the DNA-anti-DNA forming a complex that binds and damages basement membranes.
           • Management
             • Pharmacotherapy
               • NSAIDs
                 • Ibuprofen Ketoprofen Acetyl salicylic acid Naproxen Diclofenac Indomethacin Piroxicam
               • Disease Modifying Anti-Rheumatic Drugs (DMARDs).
                 • Methotrexate
                   • Hydroxychloroquine
                     • Sulfasalazine
                       • Leflunomide
                 • Minocycline
                 • Control current inflammatory features
                   • Reduce joint damage and deformity
                     • Reduce long-term disability
               • Non-TNF biologic therapy
                 • preventing full T-cell activation
                   • B-Cell Depletion
                     • Interleukin-1 Receptor Antagonists
             • Physiotherapy
               • Cold/Hot Applications
                 • cold in acute
                   • where intra-articular heat increase is undesired
                     • cold-pack, ice, nitrogen spray, and cryotherapy
                 • hot in chronic
                   • Analgesia
                   • Relieve muscle spasms
                     • elasticity of periarticular structures obtained
               • Electrical Stimulation
                 • Transcutaneous electrical nerve stimulation (TENS) therapy
               • Hydrotherapy
                 • exercises in a pool
               • Rehabilitative Treatment
                 • Joint Protection Strategies
               • Therapeutic Exercise
                 • swimming, walking, and cycling with adequate resting periods are recommended
             • Intermittent splinting
               • external supports applied to body parts
                 • decrease inflammation
                 • relieve pain
                 • protect a joint
                 • improve function
                 • correct deformity
           • Prognosis
             • 40% of RA
               • disabled within 3 years
             • 80% are moderately to severely disabled
               • within20 years
             • life expectancy could be shortened
       • Autoimmunity
         • RA and Systemic lupus erythematous.
           • SLE: It can affect the skin, joints, kidneys, brain, and other organs.
     • Infection
       • Septic Arthritis
         • most common in the knees and hips
           • may lead to permanent joint damage
             • life threatening
       • Reactive Arthritis
         • triggered by an infection in another part of the body
           • the knees and the joints of your ankles and feet

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