This document provides an overview of inflammatory joint conditions and childhood arthropathies. It defines synovial joints and describes the structure and functions of synovial fluid. Rheumatoid arthritis is characterized as an autoimmune disease that causes inflammation in the joints, commonly affecting the hands and feet. The stages of rheumatoid arthritis progression and its clinical features are outlined. Childhood arthropathies like juvenile idiopathic arthritis can affect multiple joint types and have different subtypes depending on symptoms. Diagnosis and treatment of both conditions involve examinations of synovial fluid, blood tests, imaging and medications.

1. SHYAM SHAH MEDICAL
COLLEGE,REWA
DEPARTMENT OF ORTHOPEDIC
TOPIC – INFLAMMATORY JOINT CONDITIONS – GENERAL ASPECTS ,
SYNOVIAL FLUID EXAMINATION , CLASSIFICSTION , RHEUMATOID
ARTHRITIS AND CHILDHOOD ARTHROPATHIES

2. JOINT
A joint or
articulation (or
articular surface) is
the connection made
between bones in the
body which link
the skeletal
system into a
functional whole.

3. Structural classification of Joints
• Based on strucutre joints cn be classified into
3 types :-
• Fibrous joint
• Cartilaginous joint
• Synovial joint

4. Synovial joint
• A synovial joint is a connection between
two bones consisting of a cartilage lined
cavity filled with fluid
• Synovial joints are the most flexible type
of joint between bones, because the
bones are not physically connected and
can move more freely in relation to each
other.
• Contents :-
 Joint cavity: They have the characteristic
space between the bones that is filled
with synovial fluid
 Articular capsule
 Articular cartilage

5. Synovial fluid
Synovial fluid is a viscous, non-Newtonian fluid
found in the cavities of synovial joints.
It has a yolk-like consistency
The inner membrane of synovial joints is called
the synovial membrane and secretes synovial
fluid into the joint cavity
The fluid contains hyaluronic acid secreted by
fibroblast-like cells in the synovial membrane
and interstitial fluid filtered from the blood
plasma.

6. Functions of Synovial Fluid
Reduction of friction - synovial fluid lubricates the
articulating joints.
Shock absorption - as a dilatant fluid, synovial fluid
is characterized by the rare quality of becoming more
viscous under applied pressure.
Nutrient and waste transportation - the fluid
supplies oxygen and nutrients and removes carbon
dioxide and metabolic wastes from the chondrocytes
within the surrounding cartilage.

7. Reasons for Synovial Fluid
Examination
Joint aspiration may be performed to diagnose and assist in
the treatment of joint disorders and/or problems. By analyzing
the fluid obtained during the procedure, the following
conditions may be determined.



1. Gout
2. Various types of
arthritis
3. Joint infection
Joint aspiration can also be performed to remove a large
collection of fluid around a joint.
Removing the fluid will decrease the pressure, relieve pain,
and improve movement of the joint.

8. Risks involved in synovial fluid
Aspiration
As with any surgical procedure,
complications can occur. Some possible
complications may include, but are not
limited to, the following:




Discomfort at the aspiration
site
 Bruising at the aspiration site
Swelling at the aspiration site
Infection at the aspiration site

9. Laboratory Tests of Synovial
Fluid
• Gross examination for color and clarity
• Appearance



 Clear and light yellow – Normal
 Turbid or cloudy – elevated cell count, crystals, cartilage
debris
 Bloody
 Hemorrhagic fluid – homogenously bloody
 Traumatic aspirate – streaks of blood
 Color – varies based on bacterial infection, cell or crystal
presence
•Leukocyte count and differential
•Measure glucose, proteins, uric acid, and lactic
dehydrogenase (LDH)
•Culture the fluid to see if any bacteria grows

10. Classification of Synovial Fluid
Normal
Non-
inflammatory
Inflammator
y
Septic Hemorrhagic
Volume
(ml)
<3.5 >3.5 >3.5 >3.5 >3.5
Viscosity High High Low Mixed Low
Clarity Clear Clear Cloudy Opaque Mixed
Color
Colorless/stra
w
Straw/yellow Yellow Mixed Red
WBC/mm3 <200 <2,000
5,000-
75,000
>50,000
Polys (% <25 50-70 >70
Similar to blood
level
Similar to blood
level
Gram stain
<25
Negative Negative Negative
Often
positive
Negative

11. Arthritis
• Arthritis is the
inflammation of one or
more joints , leading to
pain and stiffness that
can worsen with age.
• Arthritis affects the
joints, the tissue that
surrounds the joints
and tissues connected
with joints.

14. Arthritis can mainly be divided into following
groups:-
• Connective tissue disease – connective tissue is the
tissue that holds together or divide other body tissues
and organs. Pain in the joints is the common symptom.
Scleroderma and dermatomyositis are popular
examples.
• Rheumatoid arthritis – it is a chronic autoimmune
disease that affects both the joints of the hands, wrist
or knee. It can occur in any age and often leads to long
lasting fatigue and stiffness

15. • Metabolic arthritis- Uric acid is a chemical
develops as a body classifies a substance
called purine , found in human cells and food.
The arthritis creates sudden spikes of
unbearable joint pain and even gout attack
• Infectious arthritis – This arthritis is the result
of virus or fungus that enters the joint and
stimulates inflammation.

16. Causes of arthritis
• There are no definite causes of arthritis.
Causes of arthritis depend upon the type of
arthritis. The probable causes of arthritis are :-
1. Infection
2. Immune system dysfunction
3. Injury
4. Genetic
5. Unusual metabolism

17. Symptoms of arthritis
• Swelling – arthritis causes an abnormal
enlargement of a part of body. This is due to the
accumulation of fluid.
• Pain – the feeling of constant pain in the body
• Stiffness – stiffness in the , muscle upon waking
up or sitting at one place for long duration .
One may feel stiffness in the fingers, wrist, knee,
ankle, shoulder or any other joint.
• Fever ,fatigue, chills, loss of appetite and
headache are other symptoms of arthritis.

18. Diagonosis of Athritis
Diagonosis of athritis is done to know its current and past status.
A combination of radiography , laboratory test and physical
examination may be carried out and this includes :-
 Ultrasound
 MRI
 Joint X-ray
 Blood culture
 Tear test
 Thyroid test
 Uric acid test

19. Treatment of Athritis
Arthritis can be treated by :–
Medication
Joint replacement therapy
Physical therapies
Joint assistive aids
weight loss

20. Prevention of Athritis
Following methods are used to prevent athritis :-
Stay active
Diet rich in calcium
Rest
Control weight gain
Plenty of water intake
Yoga and other light exercise

21. Rheumatoid arthritis

22. Definition
• Rheumatoid Arthritis (RA) is a chronic
inflammatory disorder that may affect
many tissues and organs, but mainly
attacks the joints producing an
inflammatory synovitis.

23. Etiology
• The cause is unknown
• Production of auto antibodies (IgM & IgG)
that attacks body own’s tissue.
• This abnormal immune response may be
genetically pre-determined.
• RA patients associated with increased
frequency of HLA-DR4.

24. Pathology
• STAGE 1: Pre-clinical
– Before RA becomes clinically apparent, immunepathology already
beginning - Raised ESR, C-reactive protein & Rheumatoid Factor.
• STAGE 2: Synovitis
– Synovial membrane inflamed & thickened.
– Joints &tendon are still intact.
• STAGE 3: Destruction
– Persistent inflammation causes joint & tendon destruction
– Articular cartilage eroded d/t proteolytic enzymes
– Bone eroded by granulation tissue & osteoclastic resorption
• STAGE 4: Deformity
– d/t articular destruction, capsule stretching,
tendon rupture

25. Clinical features
• EARLY STAGE.
– Swelling, Stiffness, Increased Warmth, Tenderness of
proximal finger joints and the wrists.
– X-ray shows soft tissue swelling and periarticular
osteoporosis
• DISEASE PROGRESSION
– Joint movement becomes restricted.
– Isolated tendon ruptures at the wrists
– Sub cutaneous nodule felt at Olecranon process-
Pathognomonic of RA

26. • LATER STAGES
Joint deformity becomes apparent
Acute pain of synovitis is replaced by more
constant ache of joint destruction
"Rheumatoid Deformities“
• Z- deformity of hand
o Ulnar deviation of fingers
o Radial displacement of wrists
• Valgus Knees
• hammer Toes
Function is increasingly disturbed. Pt need help
dressing, eating.

27. image

30. Tests
 Blood Tests
a) Normocytic hyper chromatic anemia is common
b) In active phases the ESR and CRP concentration are usually raised
c) Rheumatoid Factor (RF)
i. RF is a specific antibody in the blood
ii. A negative RF does not rule out RA. The arthritis is then called
seronegative, most common during the first year of illness and
converting to seropositive status over time
d) Anti-citrullinated Protein Antibodies (ACPAS).
 X rays
– X ray of hands and feet are generally performed in people with RA
 Ultrasounds

31. X ray changes
Early Stage
• X-rays show only the features of synovitis : soft tissue
swelling and periarticular osteoporosis
Later Stage
• marked by appearance of marginal body erosions and
narrowing of the articular space(subchondral
osteopenia) esp. in proximal joints of hands and feet
• In Advanced Disease, articular destruction and joint
deformity are obvious.

33. COMPLICATIONS
• Infections
• Tendon Rupture- Seen most often at wrist
• Joint Rupture
• Secondary Osteoarthritis

34. Management
Medical Management
Aim: Control Inflammation as rapidly as
possible
1. DMARDS
2. Biological Therapies (TNF inhibitors:
Infliximab , etanercept , adilamubab etc)
3. Corticosteroids ( intially oral doses of 30 mg
of prednisolone or 120 mg of
methylprednisolone
4. NSAIDS

35. Key elements in medical treatment
• Identify patients with RA as early as possible
• Start disease modifying anti rheumatic drugs
immediately
• Consider combination therapy with multiple
DMARDS
• If DMARDS fail progress rapidly to biological
therapies such as tnf inhibitors – infliximab ,
etanarcept , adalimubab

36. Newer Modalities
Anti Tnf-alfa-
etanercept,infliximab,adalimumab
Anti Il-1 - anakinra , rilonacept
T cell activation inhibitor-abatacept
Anti cd 20- rituximab
Il-6 receptor antagonist-tocilizumab

37. Physiotherapy and Occupational Therapy
1. Splintage of the joint
2. Heat therapy
3. Joint mobilisation and exercise
4. Muscle building exercise

38. Surgical Management
Early stage (Soft tissues procedures):
• Synovectomy
• Tendon repair/replacement
• Joint Stabilization
Late Stage
• Indications for Reconstructive Surgery:
• Severe joint destruction, fixed deformity and
loss of Function
• Arthrodesis
• Osteotomy
• Arthroplasty

39. JUVENILE IDIOPATHIC
ARTHRITIS AND OTHER
CHILDHOOD ARTHROPATHY

40. INTRODUCTION
Chronic inflammatory changes of the joints.
It is defined as arthritis of one or more joints with
onset below 16 yrs of age and persisting for at least 6
weeks.
Diagnostic criteria
• Intraarticular swelling
or
• 2 out of three features
I. Limitation in range of motion of joints.
II. Pain in motion.
III. Tenderness over joint.

41. Subtypes
of jia
1. Systemic
2.Oligoarthritis
– Persistent
– extended
3.Polyarthritis : rheumatoid factor negative.
4.Polyarthritis : rheumatoid factor positive.
5.Psoriatic arthritis.
6.Enthesitis related arthritis.
7.Undifferentiated arthritis.
– Fits no other category.
– Fits more than one category.

42. Pathogenesis
1. Systemic onset JIA disorder of innate
immunity.
2. ALL OTHER FORMS OF JIA DISORDER of
adaptive immunity THAT IS T LYMPHOCYTE
– BALANCE BETWEEN PRO INFLAMATORY
CYTOKINES(TNF ALFA,IL 1)AND ANTI
INFLAMMATORY CYTOKINES(IL-4,IL-10 )
DETERMINE THE OUTCOME

43. PATHOLOGY
• FIBRINOID NECROSIS
• HYPERTROPHIED SYNOVIUM
FORMS GRANNULATION TISSUE OR
FIBROUS TISSUE CALLED PANNUS
• EROSION OF BONE AND DESTROY
CARTILAGE

44. OLIGOARTICULAR JIA
1. Most common subtypes
2. Most common affected knee joint
3.Ana antibody +
– Striking association with uveitis hence periodic
examination should be done
4.Persistent-never involves more than 4 joints
5.Extended type-involves more than 4 joints

45. Polyarticular JIA
1. Involves >/= 5 joints
2.Rheumatoid factor +
– Similar to adult
– Symmetrical polyarthritis
– Rheumatoid nodules
3. Rheumatoid factor –few joints involved

46. Systemic Onset JIA
• Arthritis
• Fever – at least 2 weeks and quotidian
• Rash-maculopapular type
Non pruritic salmon coloured rash , evanescent rash involving
trunks and extremities
• Prominent visceral involvement-hepatosplenomegaly ,
lymphadenopathy,serositis.
• Most severe type
• Koebner phenomenon

47. Psoriatic arthritis
• Arthritis occurs with psoriasis or any 2 of
following
1. Dactylitis –inflammation of fingers
2. Nail pitting
• Simultaneous occurrence of both small and
large joints
• Involvement of distal inter phalangeal joint

48. Enthesis related arthritis
• Occurs in boys - characteristic feature
• Involves sacrum and ilium leading to
sacroiliitis -more common in hla b-27 + ve
• Large joints of lower extremities are
affected

49. Investigations
• Raised WBC count , platelets and microcytic
anaemia
• Ana + indicates oligo articular JIA
• Rf +indicates polyarticular JIA
• ESR , CRP increases indicating polyarticular JIA
and systemic onset JIA
• MRI is more sensitive to detect early changes.

51. Treatment
• Multidisciplinary approach
Nsaids- mainstay of treatment
Ibuprofen
Naproxen
Indomethacin
Dmards-methotrexate in polyarthritis
Sulfasalazine
leflunoimide
Intra articular steroids if nsaids not respond

52. Macrophage activation syndrome
• Also called as hemophagocytic syndrome/secondary hlh
• Devasting complication of systemic onset jia
• High spiking fever
• Increased hepatosplenomegaly
• Encephalopathy
• Fall in platlet and wbc count
• Normal esr
• High ferritin
• Increased ldh
• Increased triglyceride
 Treatment- methyl prednisoloe