My Hands are Aching

My Hands are Aching

1. Demography

   • Name: Farida
     • complains from pain in the joints
       • joints of the wrist
         • flexor retinacula
         • radio ulnar articulation
         • radiocarpal
         • ulnar articulation
         • carpal tunnel
           • carpal tunnel syndrome
             • compression of
           • contents
             • median nerve
             • tendons
               • flexor digitorum superficialis
               • flexor digitorum profundus
               • flexor pollicis longus
           • posteriorly by carpals
           • anteriorly by flexor retinaculum
       • joints of the hand
         • distal interphalangeal
           • between second and third phalanges
             • hinge joint
               • flexion
               • extension
         • proximal interphalangeal
           • between first and second phalanges
         • metacarpophalangeal
           • between metacarpals and first phalanges
             • condyloid joint
               • abduction
               • adduction
         • carpometacarpal
           • between metacarpals and carpals
             • gliding joint
               • except the thumb which is a saddle joint
                 • opposition
         • intercarpal
           • between the carpals
             • gliding joint
               • all movements
       • presented to clinic with
         • stiffness specially in the morning
         • swelling of the joints
         • pain in the joints
       • investigations
         • blood tests
           • In some cases some biomarkers are detected
             • RF factor
               • IgM antibody against self IgG
                 • IgG binds to cryptic epitope
                   • This epitope can be a free DNA from damaged cells
                   • Conformational changes occur in the Fc region of IgG
                     • This exposes sites that allow binding of IgM (RF)
                       • The complex accumulates in joints and other areas causing complications
             • anti-CCP antibodies
               • against
         • X-ray
           • findings
             • periarticular osteopenia
               • due to activation of osteoclasts
                 • RANKL production by activated T-cells
             • deformities
               • ulnar deviation
                 • bending of the bones towards the ulna medially
               • radial deviation
                 • bending of the bones towards the radius laterally
                   • opposite to
               • Boutonnière
                 • flexion of the proximal interphalangeal joint and extension of the distal one
               • swan neck
                 • extension of the proximal interphalangeal joint and flexion of the distal one
                   • opposite to
               • foot
                 • claw toe
                 • Bunion
               • ankylosis
                 • fusion of the bones
             • bone erosions
             • osteoporosis
             • narrowing of the joints spaces
             • subluxation
               • partial dislocation of a joint
         • lead to diagnosis
       • brother suggested decrease in
   • Age: 45 years old
   • occupation: typist
     • common problem of being a typist

2. Joint structure

   • 2 bones
   • articular cartilage
   • capsule
   • synovial membrane
     • leads to
       • pannus formation
         • contains
           • proliferated synovial cells
           • inflammatory cells
           • cytokines
             • IL-1, IL-8, IL-6,IL-17, TNF, IFN-gamma
   • synovial fluid

3. Rheumatoid arthritis

   • symptoms
   • treatment
     • DMARDs
     • NSAIDs
     • glucocorticoids
   • systemic disease
     • vasculitis
     • pulmonary nodules
     • Felty's syndrome
     • vision problems
   • Autoimmune disease
     • Genetic
     • Environmental
       • Citrullination of self proteins
         • Citrullinated Collagen 2 And fibrinogen
     • Th1 and Th17
       • activate
         • B cells
           • plasma cells
           • by
         • macrophages
           • release
             • IL-1
             • TNF-alfa
               • stimulates
                 • chondrocytes and fibrocytes
                   • to release
                     • Collagenases and MMPs
     • failure of tolerance
       • types
         • peripheral
           • T-reg cells are involved
         • central
           • Negative selection in the thymus is involved
   • causes proliferation of