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Aching Hands

History

Physical examination: examining structures of the hand

Anatomy of the Hand

Bones

Joints

Carpal bones

Proximal row:

- Scaphoid

- Lunate

- Triquetrium

- Pisiform

Distal row:

- Trapezium

- Trapezoid

- Capitate

- Hamate

Wrist joint:

between distal surface of radius and scaphoid and lunate. Type: synovial ellipsoid

Mid-carpal joint: lies between proximal and distal rows of carpal bones. Type: synovial plane

Carpometacarpal joint: lies between distal row of carpal bones and proximal end of metacarpal bones. Type: synovial plane, except the one between trapezium and metacarpal bone of the thumb (synovial saddle)

Metacarpophalangeal joint: lies between metacarpals and proximal phalanges. Type: synovial ellipsoid

Ligaments

- Anterior radiocarpal ligaments

- Posterior radiocarpal ligaments

- Radial collateral ligament

- Ulnar collateral ligament

- Intercarpal ligament

Muscles

1st layer:

2nd layer:

3rd layer:

4th layer:

Nerve supply:

- ulnar nerve

- median nerve

- radial nerve

Blood supply

Arteries:

Veins:

Flexor retinaculum

It is a strong band which is attached to pisiform and hamate bones medially and trapezium and scaphoid laterally, forming the carpal tunnel

Superficial structures:

Deep structures:

Carpal tunnel syndrome

Compression of median nerve

- Tingling

- Numbness

- Shooting pain

- Weakened grip

Neurological examination

Other causes of Hand pain:

Stenosing tenosynovitis

Osteoarthritis

Rheumatoid arthritis

Traumatic injury

Risk factors of hand pain:

- Old age

- Occupation

- Smoking

- Obesity

Immunity of RA

Loss of self-tolerance = autoimmune disease

Gene susceptibility:

- Expression of certain MHC alleles may allow presentation of self antigens/ abnormal selection or regulation of self-reactive lymphocytes

Previous inflammation or injury:

1. Bystander T-cell activation: activated APCs in infected tissues express co-stimulators that can activate self-reactive T-cells

2. Molecular mimicry: microbial antigens that are similar to self-antigens can activate T and B cells, producing autoimmune antibodies

3. Polyclonal lymphocyte activation: microbes or toxins can induce polyclonal activation of T and/or B cells

4. Altered self: self antigens could be perceived as foreign by:

1. Haptens binding to self-antigens, resulting in a new antigen that can stimulate immune response

2. Enzymatic modification of antigens, resulting in changes to the original antigen that are perceived as foreign.

e.g: citrullination: conversion of arginine to citrulline by peptidyl arginine deaminase> major cause of RA

5. Release of sequestered antigens (antigens in brain, eye, testes, ovaries)

6. Availability of cryptic epitopes

Pathogenesis of RA

It is a systemic autoimmune disease

Triggered by both genetic and environmental factors

Events of the disease:

1. Infiltration of synovial membrane> entrance of immune cells

2. Formation of lymphoid follicles> B and T cells interact with synovial membrane

3. Immune complexes> activation of synovial macrophages

4. TNF, IL-1, IL-6 production> damage to bony tissue

5. Activation of osteoclasts and chondrocytes> destruction of bones and cartilages

6. Hypoxia> neoangiogenesis

Signs and symptoms of RA:

Articular:

- Heat

- Pain/ morning stiffness

- Swelling of joints

- Deformities: swan neck/ boutonniere/ ulnar deviation

Extra-artucular:

- Dry eyes

- Scleritis

- Pulmonary fibrosis

- Rheumatoid nodules

- Anemia

- Renal damage

- osteoporosis

- Vasculitic skin rash

Investigations

- ESR

- CRP

- Rheumatoid factor

- Anti-CCP

- X-ray/ MRI

Treatment:

- Pharmacological:

1. NSAIDS: ibuprofen/ piroxicam/ naproxen

2. DMARDs (disease modifying anti-rheumatic drugs):

- Methotrexate: inhibits DHFR, has immunosuppressive and anti-inflammatory effects

- Leflunimide: arrests cells of autoimmune lymphocytes

- Minocycline: a tetracycline antibiotic

3. Biologic therapies: tumor necrosis factor inhibitors and non-tumor necrosis biologic therapy

4. Glucocorticoids

- Non-pharmacological:

1. Physical therapy

2. Oils and herbs

3. Cryotherapy

4. Chiropractic therapy

5. Infrared heat therapy

Other complications:

- Felty syndorme

- Baker's cyst

- Sjogren's syndrome

Prevention:

- Healthy diet

- Exercise

- Quit smoking

- Compliance to medications