Disease Process Joint inflammation begins with congestion and edema of the synovial membrane and joint capsule, which develops into synovitis. Thickened layers of granulation tissue invade and destroy the cartilage and joint capsule. The fibrous granulation tissue deforms, ossifies, occludes, and immobilizes the joint. Eventually the disease spreads to major organ systems, including the heart, lungs, kidneys, and eyes.

Symptoms

Early
Nonspecific symptoms of fatigue, malaise, low-grade fever, anorexia, weight loss

Midcourse
Tenderness, pain, and stiffness in affected joints (most often the fingers) that occurs in a bilateral, symmetric pattern and spreads to the wrists, elbows, knees, and ankles; diminished joint function; paresthesia; joint contractures and deformities

Late
Subcutaneous rheumatoid nodules, leg ulcers, lymphadenopathy, inflammation and dryness of mucous membranes, episcleritis, pericarditis, valvular lesions, splenomegaly, pneumonitis
Complications: Acute rheumatoid arthritis (ARA) is characterized by abrupt onset and progressive, relentless deterioration of joints and then other major body systems without remission and with poor or no response to medical treatment. The prognosis in these cases is poor.

Diagnostic Tests

Clinical evaluation
ARA: presence of five or more of the following: morning stiffness; pain/tenderness in at least one joint; swelling in at least one joint; symmetric joint swelling; fatigue, malaise, weight loss; paresthesia; Raynaud’s syndrome; subcutaneous nodules; major organ involvement; pericarditis; valvular lesions; vasculitis; pneumonitis; fibrosis; tenosynovitis; ankylosis; Felty’s syndrome (splenomegaly and leukopenia); joint deformities; ulnar drift

Rheumatoid factor
Positive in 95% of cases

Synovial analysis
Opaque color; increased volume and turbidity; decreased viscosity and complement; 3,00050,000 WBCs/{micro};l; polymorphonuclear cells predominant

Erythrocyte sedimentation rate
Elevated in 90% of cases

Complete blood count
Hypochromic anemia, elevated WBCs

Radiology
Soft tissue swelling, narrowed joint space, marginal erosions

Treatments

Surgery
Synovectomy for pain relief; repair of ruptured tendon sheaths to prevent deformity and subluxation; osteotomy to change weight-bearing surfaces; total joint replacement to increase mobility.

Drugs
Aspirin, nonsteroidal antiinflammatory drugs, gold compounds/penicillamine to reduce pain and inflammation; oral or intraarticular injections of corticosteroids to reduce inflammation; immunosuppressive/antineoplastic agents.

General
Whirlpool, moist compresses, paraffin gloves to reduce pain and edema; therapy and exercise to increase range of motion, strength, and endurance; balance of activity and rest; splints, canes, walkers to aid mobility; emotional support to adapt to disability.

Disease Process The water content of the hyaline cartilage increases, and the protein-carbohydrate molecules decrease. The cartilage becomes softer and sheds flakes into the joint. The shedding rubs away the cartilage and increases the friction coefficient in the joint, setting up an erosive cycle. As the cartilage erodes, underlying bone is exposed. Fibrous tissue forms in the joint capsule, causing inelasticity and limiting joint movement. New bone, formed in the subchondral area and at joint margins, is stiff and subject to microfractures and callus formation. Deterioration of the weight-bearing surface combined with the bony overgrowth leads to joint hypertrophy and deformity.

Symptoms

Early
Deep, aching joint pain that is aggravated by exercise and that worsens as the day progresses; stiffness following inactivity

Midcourse
Reduced joint motion, tenderness, crepitus, grating sensation, flexion contractures, joint enlargement

Late
Tenderness on palpation, pain with passive range of motion, increase in degree and duration of pain, joint deformity and subluxation

Potential Complications Osteoarthritis of the spine can cause compression of the spinal cord, leading to weakness in the extremities, incontinence of bowel and bladder, and impotence.

Diagnostic Tests

Clinical evaluation
Any of above manifestations; Heberden’s or Bouchard’s nodules of finger joints

Gait analysis
Altered motion patterns

Radiology
Narrowed joint space; increased density of subchondral bone; pseudocysts in subchondral marrow; osteophytes at joint periphery

Erythrocyte sedimentation rate
Normal/moderate increase

Synovial analysis
High viscosity; yellow, transparent color; negative culture; WBC 2002,000/{micro};l; ,25 polymorphonuclear leukocytes

Treatments

Surgery
Osteotomy, laminectomy, fusion, total joint replacement if conservative therapy fails.

Drugs
Aspirin, nonsteroidal antiinflammatory drugs, muscle relaxants.

General
Exercise: isometric, isotonic, isokinetic, strengthening, stretching, range of motion, balance exercise; rest; massage, moist heat for pain; elastic bandages for support; canes, walkers to aid mobility Teaching: avoid soft chairs, recliners, pillows under knees; use firm bed and hard chairs; wear sturdy, lowheeled shoes.