"My Hands are Aching"

Anatomy of the HAND
1. Bones
2. Joints
  1. Causes of Swollen Joints
    1. Acute
    2. Chronic
      1. Osteoarthritis
      2. Rheumatoid arthritis
3. Synovial Fluid Contents
  1. Water
  2. Inorganic salts & macromolecules
  3. Hyaluronic acid
  4. Lubricin
  5. Aggrecans
  6. Neutrophils, Lymphocytes, Monocytes, Macrophage
4. Intrinsic muscles
5. Blood supply
6. Innervation
Examination of the hand
1. extrinsic flexors
  1. Flex thumb IP joint
  2. Stabilize PIP and have patient flex each DIP in succession
  3. Volar flex wrist
2. intrinsic muscles
  1. Touch small finger to the thumb so the nails are parallel
  2. Flex MCP and straighten PIP
  3. Pinch paper between thumb and radial side of index finger in the first webspace
3. Neurological
  1. Radial c5-c8
  2. Median c5-T1
  3. Ulnar c8-T1
4. Special tests:
  1. Phalen’s Test (test for carpal tunnel syndrome)
  2. Tinel’s Test (test for carpal tunnel syndrome)
  3. Finkelstein’s Test (test for DeQuervain’s Tenosynovitis)
Autoimmunity: RHEUMATOID ARTHRITIS
1. Normal Immune tolerance mechanism:
2. Loss of self-tolerance
  1. 1- Bystander T cell activation
  2. 2- Molecular mimicry
  3. 3- Polyclonal lymphocyte activation
  4. 4- Altered self
  5. 5- Release of sequestered antigens
  6. 6- Availability of cryptic epitopes
3. Complications of RA:
  1. Symmetric swelling of small peripheral joints
  2. Symmetric swelling of elbows, shoulders, hips, and knees
  3. Anemia in Rheumatoid Disease
    1. due to reduction in RBC production by bone marrow.
  4. Prognosis:
    1. Progression when diagnosed
    2. Presence of rheumatoid nodules
    3. Positive for rheumatoid factor or anti-CCP
    4. decrease life span by 10-15 years but highly variable
Pathogenesis of RA
1. Infiltration of synovial membrane with:
  1. Lymphocytes
  2. Plasma cells
  3. Dendritic cells
  4. Macrophages
  5. Cytokines involved:
    1. TNF, IL-1, IL6 and IL-15
2. Investigations:
  1. From History + Physical Examination:
    1. Morning stiffness
    2. Symmetrical swelling of 3 or more joints
    3. Rheumatoid nodules
  2. Imaging & laboratory findings:
    1. Radiographic changes of RA (X-ray\MRI)
    2. High ESR or C-reactive protein
    3. RF+ and\or Anti-ccp+
3. Management:
  1. Pharmacological
  2. Non-pharmacological
4. Psychological effect:
Epidemiology of RA:
1. Prevalence: 0.5-1%
2. 3 cases per 10,000 population
3. More common in women

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"My Hands are Aching"

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