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10.19 Joints
at 8:30 by Dr. Lorusso
110
Pathology
Professional
10/19/2011

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Term
What are synarthroses?
Definition
"solid joints" provide structural integrity and minimal movement
Term
What are two examples of synarthroses?
Definition
fibrous (cranial sutures, teeth/jaw)
cartilaginous (pubic symphysis)
Term
Joints with a joint space and wide range of motion are characteristic of what type of joint?
Definition
synovial
Term
What is the half life of cartilage?
Definition
proteoglycans- weeks
type II collagen- years
Term
What is the most common joint disesase?
Definition
osteoarthritis
Term
What's another name for osteoarthritis?
Definition
degenerative joint disease
Term
T/F Osteoarthritis is characterized by/caused by inflammation.
Definition
false, osteoarthritis is not really an "itis"
Term
What is the pathological mechanism underlying osteoarthritis?
Definition
articular cartilage is eroded over time. This is a disease intrinsic to cartilage
Term
What are the typical features of osteoarthritis on clinical presentation?
Definition
age (aging) related, insidious onset (no apparent inciting event), oligoarticular
Term
What is secondary osteoarthritis? What causes it? Who gets it? Which joints does it affect?
Definition
~5% of cases of osteoarthritis that presents in younger patients and is trauma related. Occurs in knees and hips (baseball elbow, basketball knees, etc.)
Term
What causes osteoarthritis?
Definition
multifactorial (multiple genes), and environmental factors such as aging and stress/trauma
Term
Describe the pathophysiology of osteoarthritis.
Definition
chondrocyte injury causes chondrocytes to proliferate (inflammatory mediators such as collagenase, protease, and proteoglycans), there is cartilaginous matrix remodeling and inflammatory changes of synovium and subchondral bone. Chronic inflammation and chondrocyte dropout causes marked loss of cartilage and extensive subchondral bone changes
Term
What is the morphology of osteoarthritis?
Definition
superficial tpye II collagen molecules are degraded, vertical and horizontal fibrillation and cracking, granular soft articular surface, chondrocytes die and are sloughed, cartilage is dislodged and "tumbles" into joint="joint mice"
Term
What happens when there is bone against bone in osteoarthritis?
Definition
exposed bone becomes the new articular surface and bone against bone friction causes burnishing. Apperance is that of ivory and is called "bone eburnation"
Term
What are the clinical symptoms of osteoarthritis?
Definition
pain that worsens with use, morning stiffness, limited ROM, one or few joints involved, heberden nodes in women, chronic progressive
Term
Which joints are commonly involved in osteoarthritis?
Definition
hips, knees, vertebrae, PIP, DIP
Term
T/F Rheumatoid arthritis is a localized joint disorder.
Definition
false! it is a chronic systemic disorder
Term
What tissues does rheumatoid arthritis affect?
Definition
joing, skin, heart, lungs, blood vessels
Term
What percent of the worlds population has rheumatoid arthritis?
Definition
1%
Term
What is the typical RA pt?
Definition
women are 3-5x more likely than men
age is >40
Term
What morphological changes occur with RA.
Definition
nonsuppurative synovitis, destruction of articular cartilage and ankylosis of joint
Term
What is ankylosis?
Definition
stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint which may be the result of injury or disease
Term
What is the histological appearance of RA?
Definition
dense, perivascular lymphocytic infiltrate, angiogenesis, increased vascularity, hemosiderin; free floating fibrin aggregates form rice bodies, superficial synovial neutrophilia, increased osteoclastic activity in underlying bone (erosions, subchondral cysts, osteoporosis), pannus formation
Term
What is a pannus?
Definition
a mass of synovium and synovial stroma consisting of inflammatory cells, granulation tissue, and fibroblasts, which grows over the articular cartilage and causes its erosion
Term
What percent of people have rheumatoid nodules?
Definition
1/4 of affected people
Term
Where do rheumatoid nodules manifest?
Definition
pressure areas,= ulnar forearms, elbows, lumbosacral region
Term
What do rheumatoid nodules look like grossly?
Definition
subcutaneous round/oval nodules
Term
What do rheumatoid nodules look like histologically?
Definition
fibrinoid necrosis rimmed by activated macrophages and plasma cells
Term
What is fibrinoid necrosis?
Definition
necrosis in which the necrotic tissue has some staining reactions resembling fibrin and becomes deeply eosinophili, homogenous and refractile
Term
What is rheumatoid vasculitis?
Definition
in pts with high titer of RF, affects small to medium arteries, similar to polyarteritis nodosa (except kidneys are not usually involved)
Term
What causes RA?
Definition
genetically predisposed person gets arthritogenic agent and tehre is a breakdown of self tolerance
Term
What genetic characteristics cause you to be susceptible to RA?
Definition
HLA-DRB1 allele, PTPN22
Term
What are the environmental arthritogens?
Definition
thought to be EBV, retroviruses, parvovirus, mycobacteria, borrelia, proteus, mycoplasma and citrullinated proteins (PERM PB, C, M)
Term
What type of autoimmune reaction causes RA?
Definition
T cell mediated
Term
What is rheumatoid factor?
Definition
autoantibody to Fc portion of autologous IgG, usually IgM molecules
Term
RF is a marker of __.
Definition
disease activity (not causative)
Term
Besides RF, other antibodies found in RA patients are...
Definition
antibody to citrulline-modified peptides, anti-cyclic citrullinated peptide (CCP) antibodies
Term
What are the symptoms of RA?
Definition
variable, usually slow, insidious onset with generalized malaise, fatigue and muscle pain, joints become affected weeks to months later. Symmetric arthritis involving small joints that are swollen and painful, stiff in the morning and following activity
Term
What can you see on x ray of RA?
Definition
joint effusion, narrowing of joint space, loss of articular cartilage
Term
Which joints are generally affected by RA?
Definition
small joints: hands (MCP, PIP), wrist, elbow, ankle, knee
Term
What serologic tests are run for RA dx?
Definition
RF and anti-CCP antibody are fairly specific
Term
Diagnosis of RA requires at least ___ of the following criteria:
Definition
4
morning stiffness, arthritis in 3 or more areas, arthritis of hand joints, symmetric arthritis, rheumatoid nodules, serum rheumatoid factor, characteristic radiographic findings
Term
What are the goals of RA tx and what drugs are used?
Definition
relieve pain and inflammaiton and stop or slow joint destruction; corticosteroids, methotrexate and TNF-antagonists
Term
How do you get infectious arthritis?
Definition
direct inoculation, bacteremia/sepsis, contiguous spread from soft tissue abscess, spread from osteomyelitis
Term
What are the systemic findings of infectious arthritis?
Definition
fever, leukocytosis, elevated sed rate
Term
What organisms cause infectious arthritis?
Definition
gonococcus, staphylococcus, streptococcus, haemophilus influenza, gram-negative bacilli
Term
infectious arthritis in a child under 2 yoa=
Definition
haemophilus influenza
Term
infectious arthritis in late adolescence/ early adulthood=
Definition
gonococcus
Term
Infectious arthritis in older children and adults=
Definition
staphylococcus
Term
Infectious arthritis in sickle cell disease pt=
Definition
salmonella
Term
What age groups get infectious arthritis from TB?
Definition
all, but esp adults
Term
Describe where you get infectious arthritis by TB?
Definition
monoarticular, hips, knees, ankles
Term
What characterizes infectious arthritis caused by tb?
Definition
granulomas, caseous necrosis
Term
Chronic infectious arthritis caused by TB leads to...
Definition
joint destruction/fibrous ankylosis
Term
What is the appearance of lyme disease organisms?
Definition
spirochete
Term
What is the course/symptoms of lyme dissease?
Definition
skin infection followed by dissemination (a few weeks to 2 years), arthritis involving large joints (knees, shoulders, elbows and ankles), migratory and transient
Term
What tyeps of crystals cause gout?
Definition
monosodium urate
Term
What types of crystals cause pseudogout?
Definition
calcium pyrophosphate
Term
At what uric acid level do you get crystal deposition in joints?
Definition
>6.8 mg/dL
Term
What are the four stages of gout?
Definition
acute arthritis, chronic arthritis, tophi, urate nephropathy
Term
What are the predisposing factors to gout?
Definition
age of pt and duration of hyperuricemia, genetic predisposition, heavy alcohol consumption, obesity, drugs that reduce urate excretion, lead toxicity
Term
When is MSU less soluble?
Definition
at lower temperatures and in synovial fluid
Term
How is gout precipitated?
Definition
pricipitation event (trauma) releases nucleating agents that set off cascade
Term
What is the morphology of gout?
Definition
negatively birefrigent MSU crystals, dense neutrophilic infiltrate, crystals within neutrophils, macrophages, lymphocytes, plasma cells
Term
What does it mean to say that MSU crystals are birefrigent?
Definition
urate cyrstals appear yellow when their long axes are aligned parallel to that of a red compensator filter
Term
What is tophaceous arthritis?
Definition
follows multiple bouts of acute arthritis, urates may encrust articular surface, synovium becomes fibrotic and thickened, joint cartilage destruction --> bone erosions, ankylosis --> loss of joint function
Term
What is the pathognomonic hallmark of gout?
Definition
tophi
Term
What are tophi?
Definition
urate crystal aggregates surrounded by macrophages, lymphocytes and foreign body giant cells
Term
Where do tophi occur?
Definition
joints, tendons, soft tissue, kidneys, skin
Term
What is gouty nephropathy?
Definition
MSU crystals in the renal medullary interstitium. May include intra-tubular uric acid crystals, tophus formation, uric acid renal stones
Term
What is the clinical course of gout?
Definition
asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout, chronic tophaceous gout
Term
When does asymptomatic hypercemia occur in men? women?
Definition
puberty in men, menopause in women
Term
What is a typical presentation of acute new onset gouty arthritis?
Definition
sudden onset of excruiciating pain in the MP joint of big toe
Term
Where is a typical location of the 2nd episode of acute gouty arthritis?
Definition
instep, ankles, heels, knees, wrist, fingers, elbow
Term
How long does gout last?
Definition
hours to weeks
Term
What is intercritical gout?
Definition
gout that follows resolution of acute episode, may be forever (rare)
subsequent episodes within months to years
Term
How long after the first episode does chronic tophaceus gout occur?
Definition
average of 12 years after first episode
Term
What does chronic tophaceous gout look like on xray?
Definition
bone resorption and loss of joint space
Term
What are two other names for pseudo-gout?
Definition
calcium pyrophosphate cyrstal deposition disease (CPPD)
chondrocalcinosis
Term
What populations (age and gender) are usually affected by pseudogout?
Definition
>50 and male=female
Term
What are the three categories of pseudogout?
Definition
sporadic, hereditary, and secondary
Term
What is secondary pseudogout?
Definition
secondary to previous trauma or metabolic derangements like diabetes, hyperparathyroidism, hemochromatosis, hypomagnesemia, hypothyroidism
Term
What is the gross morphology of pseudogout?
Definition
white-chalky friable deposits
Term
Where do calcium pyrophosphate crystals come from when they form pseudogout?
Definition
crystal seed joint from nearby articular matrix, menisci, intervertebral disks
Term
What do calcium pyrophosphate crystals look like microscopically?
Definition
geometric crystals, weakly birefringent
Term
What does it mean to say that pseudogout is weakly birefringent?
Definition
calcium pyrophosphate crystals appear blue when their long axes are aligned parallel to that of a red compensator filter
Term
What joints does pseudogout affect?
Definition
monoarticular or polyarticular; knees, wrists, elbows, shoulders, ankles
Term
How do you treat pseudogout?
Definition
supportive
Term
What percent of patients with pseudogout experience severe joint damage?
Definition
50%
Term
How big are ganglion?
Definition
<1.5 cm
Term
Where are ganglion located?
Definition
near joint capsule or tendon sheath, especially wrist
Term
What are ganglion made out of?
Definition
myxoid or cystic degeneration of conective tissue, not a true cyst because lacks epithelial lining, no communication with the joint space
Term
What is a synovial cyst?
Definition
herniation of synovium through joint capsule or massive enlargement of bursa
Term
What do you call a synovial cyst in the popliteal space in pts with rheumatoid arthritis?
Definition
"baker's cyst"
Term
What are synovial cysts lined with?
Definition
synovium that may be inflamed, fibrinous, or hyperplastic
Term
Is a tenosynovial giant cell tumor benign or malignant?
Definition
benign
Term
How does a genetic mutation cause tenosynovial giant-cell tumors?
Definition
t(1;2)(P13;q37); fuses the promoter of collagen type IV to the coding sequence for colony-stimulating factor 1 (CSF1). CSF1 is chemoattractant for macrophages which then aggregate and infiltrate
Term
What age is associated with tenosynovial giant cell tumors? What gender?
Definition
20-40; M=F
Term
What do tenosynovial giant cell tumors look like microscopically?
Definition
neoplastic cells are polyhedral and make up only a small fraction of the lesion. Heavy infiltration of macrophages with hemosiderin and/or lipid, and multinucleated giant cells
Term
How do describe the gross presentation of diffuse tenosynovial giant cell tumors?
Definition
affects one or more joints (knee, hip, ankle). Synovium is "tangled mat of red-brown folds, finger-like projections, and nodules" Can erode adjacent bones and soft tissue
Term
What's another name for diffuse tenosynovial giant cell tumor?
Definition
pigmented villonodular synovitis
Term
What is the gross description of localized tenosynovial giant cell tumor variants?
Definition
localized attached to sheath (hand). Well-circumscribed; resembles "walnut", slowgrowing mass that is often painless
Term
What are the symptoms of tenosynovial giant cell tumors?
Definition
pain, swelling, locking of joint
Term
How do you treat tenosynovial giant cell tumors?
Definition
surgical, however lesions can recur often
Term
What is suppurative?
Definition
to form pus
Term
What is spondylosis?
Definition
degenerative osteoarthritis of the joints between the spinal vertebrae and/or neural foramina. May cause pressure on nerve root with subsequent sensory and/or motor disturbances such as pain, paresthesia, or muscle weakness in the limbs
Term
What is spondylitis?
Definition
inflammation of the vertebra; a form of spondylopathy. In many cases, spondylitis involves one or more vertebral joints as well, which itself is called spondylarthritis
Term
What is spondylolysis?
Definition
defect of vertebra, particularly the pars interarticularis. Occurs most commonly in lumbar vertebrae 5 but can also occur in other lumbar vertebrae and thoracic vertebrae
Term
What is spondylolisthesis?
Definition
the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below
Term
What is a hangman's fracture?
Definition
type of spondylolisthesis in which the C2 vertebra is displaced anteriorly relative to the C3 vertebra due to fractures of the C2 vertebra's pedicles
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