"My Hands are Aching"

"My Hands are Aching"

1. Anatomy of the HAND

   • Bones
   • Joints
     • Causes of Swollen Joints
       • Acute
       • Chronic
         • Osteoarthritis
         • Rheumatoid arthritis
   • Synovial Fluid Contents
     • Water
     • Inorganic salts & macromolecules
     • Hyaluronic acid
     • Lubricin
     • Aggrecans
     • Neutrophils, Lymphocytes, Monocytes, Macrophage
   • Intrinsic muscles
   • Blood supply
   • Innervation

2. Examination of the hand

   • extrinsic flexors
     • Flex thumb IP joint
     • Stabilize PIP and have patient flex each DIP in succession
     • Volar flex wrist
   • intrinsic muscles
     • Touch small finger to the thumb so the nails are parallel
     • Flex MCP and straighten PIP
     • Pinch paper between thumb and radial side of index finger in the first webspace
   • Neurological
     • Radial c5-c8
     • Median c5-T1
     • Ulnar c8-T1
   • Special tests:
     • Phalen’s Test (test for carpal tunnel syndrome)
     • Tinel’s Test (test for carpal tunnel syndrome)
     • Finkelstein’s Test (test for DeQuervain’s Tenosynovitis)

3. Autoimmunity: RHEUMATOID ARTHRITIS

   • Normal Immune tolerance mechanism:
   • Loss of self-tolerance
     • 1- Bystander T cell activation
     • 2- Molecular mimicry
     • 3- Polyclonal lymphocyte activation
     • 4- Altered self
     • 5- Release of sequestered antigens
     • 6- Availability of cryptic epitopes
   • Complications of RA:
     • Symmetric swelling of small peripheral joints
     • Symmetric swelling of elbows, shoulders, hips, and knees
     • Anemia in Rheumatoid Disease
       • due to reduction in RBC production by bone marrow.
     • Prognosis:
       • Progression when diagnosed
       • Presence of rheumatoid nodules
       • Positive for rheumatoid factor or anti-CCP
       • decrease life span by 10-15 years but highly variable

4. Pathogenesis of RA

   • Infiltration of synovial membrane with:
     • Lymphocytes
     • Plasma cells
     • Dendritic cells
     • Macrophages
     • Cytokines involved:
       • TNF, IL-1, IL6 and IL-15
   • Investigations:
     • From History + Physical Examination:
       • Morning stiffness
       • Symmetrical swelling of 3 or more joints
       • Rheumatoid nodules
     • Imaging & laboratory findings:
       • Radiographic changes of RA (X-ray\MRI)
       • High ESR or C-reactive protein
       • RF+ and\or Anti-ccp+
   • Management:
     • Pharmacological
     • Non-pharmacological
   • Psychological effect:

5. Epidemiology of RA:

   • Prevalence: 0.5-1%
   • 3 cases per 10,000 population
   • More common in women

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