Hands, Hips, Knees
Poly/ oligo /
Pain on joint movement, reduced range of movements. ‘Squaring of the hand’ – deformity of the CMC joint of the thumb
Gradual onset (over years), gradual increase in main and reduction in function
Unusual under 60. Age-related degeneration. Can be secondary to joint damage – e.g. trauma, RA
Increased incidence in sportsmen/women, trauma increases the risk at the affected joint
X-ray! Will show joint space narrowing, sclerosis of bone margins, cyst formation, osteophyte formation
Conservative: analgesia, physiotherapy and encourage exercise (this will not cause further joint damage)
Surgical: in later stages of the disease, joint replacement greatly relieves pain and improves function. Highly effective
Rheumatoid Arthritis
Hands, shoulders, feet, sometimes knees
Usually most apparent at the hands. Deformities (subluxation, swan necking, z-thumb, nodules etc). Nodules common on the forearm, especially at pressure points. Look for signs of steroid use
Very variable. Some may come on acutely overnight, others over several weeks or months. Often the first signs in the feet (walking on marbles)
More common in women. Can be any age, most commonly 30-50. 2x as common in women.
Genetic factors involved. Some genes identified (HLA-DL1 &4) – associated with worse prognosis.
Smoking, stress, infection.
Rheumatoid factor – only present in 50% of cases. Anti-CCP – more specific.
Blood tests – may show anaemia, ESR and CRP raised.
Diagnosis usually clinical, imaging not widely used
Steroids – can be used to induce remission in acute disease. Sometimes given long-term, low dose.
DMARD’s – disease modifying anti-rheumatid drugse.g. methotrexate, sulfasalazine, hydrochlorequinereduce irreversible joint damage. Most require regular blood monitoring. Anti-TNF-α – highly effective, given IV, reduced disease progression, and improves symptoms. VERY EXPENSIVE – NICE only recommends it to be used when DMARD’s have failed.
Hands, Feet
Gouty tophi (chronic gout), hot, red, tender, swollen joint.
Acute – episodes last up to 7 days. Hot, red, tender, swollen joint
Chronic – presents with gouty tophi.
Much more common in men (10:1). Some cases are genetically inherited (X-linked), most cases have a genetic component.
Age related – urate acid levels rise with age.
Associated with a diet high in purines (meat) and alcohol.Thiazide diuretics greatly increase the risk.
Anything that increases the level of purines or urates in the blood – e.g. high rate of cell death – chemotherapy
Aspiratie joint – rule out infection, check for crystals (needle shaped, negatively birefringent)
Serum urate – raised in 60% (not diagnostic), Inf markers , x-ray – may show punched out erosnions, and flecked calcifications
Acute – use NSAID’s to relieve acute attack, then start on allopurinol.
Chronic – allopurinol is the treatment of choice.
Dont give allopurinol in an acute attack! – it can make it worse! Allopurinol will not relieve an acute attack
Knee, hands, elbows, shoulder, Tarsal joints
Hot, red, tender, swollen joint.
Acute – hot, red, tender swollen joints.
Chronic – can resemble RA, or OA. Often interspersed with acute epdisodes
Increases with age. Often accompanies OA
Phosphate metabolism disorders
Aspiratie joint – rule out infection, check for crystals (rhomboid, positively birefringent)
NSAID’s not as useful as gout, but may still be beneficial for some.
Intra-articular steroid injections, or oral steroids are usually the first line.
No real ‘allopurinol’ equivalent
Systemic multi-organ involvement, (often lungs and oesophagus) usually with hand signs
Hands and arms: pigment changes, telangiectasia, sclerodactyly, digital pitting, Reynaud’s,
Any age, most commonly 30-50. 4x as common in women
Genetic factors
Systemic. Typically photosensitive skin rashes (often on the face), and organ involvement (most commonly kidneys)
May have hand signs similar o RA – but the deformities will reduce under pressure, and function is usually not affected. Look for rash on face, arms, chest and shoulders
Often lots of non-specific symptoms – low-grade fever, tiredness, general malaise. May also have multi-organ involvement. Mouth ulcers, hair loss, Reynaud’s, depression
10x as common in women. Any age, often between 25-35, and between 5-60
Smoking, stress. Genetic factors
ANA’s – present in 90% of cases but non-specific. Anti-dsDNA – present in 60% of cases, and specific. Anaemia, leukopenia, thrombocytopaenia. ↑ESR and CRP
DMARD’s and steroids used in a similar way to RA. Treat organ and nerological involvements specifically and individually.
If a joint is hot, red, tender and swollen – then always aspirate it! – and it is joint sepsis, until proven otherwise





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