for education purpose of MBBS, BHMS and BAMS students. Rheumatoid Arthritis is a quite common and troublesome disease in the society. Plenty of patients present with RA in our clinics as well as family. This brief presentation tends to cover the basic pathology behind RA, easy to identify signs and symptoms and prompt management of the disease before the deformities set in. In case of doubts or feedbacks, feel free to contact me on WhatsApp 9409012212 or Email- dr.aakashnandu@gmail.com

1. Rheumatoid Arthritis
Dr Aakash Nandu
M.S. Orthopaedics
Smit Orthopaedic Hospital

2. Introduction
• MC cause of chronic inflammatory joint disorder.
• Typical features –
1. Symmetrical polyarthritis
2. Morning stiffness
3. ESR and CRP elevated
Systemic Autoimmune disorder
Pt dies younger due to multiple organ involvement
MC Ischaemic heart disease.

3. Definition
• Auto-immune Chronic Inflammatory disorder which affects the joints
and produces an inflammatory synovitis.

4. Pathophysiology
Presentation of
Antigen to T-
cells
B and T cell
proliferation
Angiogenesis in
Synovium
Neutrophilic
infiltration &
Synovitis
Early Pannus
Formation
Sub chondral
Bone erosion
Pannus invasion
of Cartilage
Ligament Laxity
Joint instability,
Contractures,
reduced ROM

5. Pannus
• Pannus is a sheet of inflammatory granulation tissue that
spreads from the synovial membrane and invades the joint

6. Etiology
1. Idiopathic
2. Positive Family History
3. Presence of inherited MHC Antigen
4. Smoking
5. Herpes Simplex / EBV infection
6. Bacterial / Fungal Infection

7. Signs and Symptoms
• EARLY
1. Polyarthralgia
• Pain in 2 or more joints at the same time
• Most commonly involves PIP joints of fingers > toes.
• Joints are red, swollen and tender

8. Swan neck Deformity
Boutennaire Deformity
Z-deformity of thumb

9. RA hands

10. Mallet Finger
• Simple flexion deformity of distal
interphalangeal joint preventing
extension

11. • 2. Bilateral Symmetrical Polysynovitis
• 3. Morning stiffness ( >30 min)
• 4. Loss of mobility
• 5. Constitutional Symptoms (LOA, LOW, Malaise, Low grade fever)

12. Late Features
1. Spread to larger joints (wrist, ankle, knee and shoulder in order of
frequency)
2. Deformities set in
Wrist – Volar and radial deviation
Knee – flexion
Elbow – flexion
Shoulder- limited abduction
Toes - Clawed
3. Activities of daily living are affected. Quality of life affected.

13. Diagnosis
• 1. Clinical
• 2. Lab Tests – ESR, CRP, RA factor, Anti-CCP
• 2. Radiological
(EULAR Criteria)

16. Treatment
• No permanent Cure
• Only delay the symptoms
• Supportive and palliative

17. Treatment
NSAIDs
DMARDS
Surgery
Biologicals

18. 1st Line of management
• Ibuprofen, Indomethacin, Cox-2 inhibitors like Etoricoxib, Celecoxib
and Polmacoxib reduce inflammation and relieves pain.
• Steroids in low doses reduce pain and inflammation.
• Opioids like morphine, buprenorphine and tramadol provide
symptomatic relief.

19. DMARDS

20. Biological Response modifiers
• These drugs directly modify the immune system by inhibiting proteins
called cytokines – Eg. Infliximab, Adalimumab, Anakinra, Etanercept.
• Cytokine inhibition leads to suppression of immunity.
• Be careful !! Increased risk of infections…sometimes life threatening.

22. Protein A Immunoadsorption Therapy
• This is not a drug.
• It is a therapy
• Dialysis to remove the antibodies and Immune complexes that
promote the inflammation.

23. Surgeries
1. Osteotomy
Extra articular procedure for even weight distribution
Cannot be performed in active disease.
2. Arthroplasty ( Joint replacement)
Replace the root cause of disease
3. Arthrodesis
Fuse the joint in functional position

24. Arthrodesis

25. Complications
1. Deformities
2. Muscle weakness
3. Infection
4. Spinal Cord compression
5. Systemic Vasculitis
6. Amyloidosis – Renal Failure