The document discusses several common rheumatological disorders seen in orthopedic departments, including osteoarthritis, gouty arthritis, calcium pyrophosphate deposition disease, and rheumatoid arthritis. It provides details on the prevalence, clinical features, imaging findings, classifications, and treatment approaches for each condition.

1. Common Rheumatological disorders in Orthopaedics Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University

3. Prevalence of rheumatic disease in rural Thailand (Nakornayok Province) N=2455, age > 15 yrs J Rheumatol 1998; 25: 1382-7 Diagnosis Prevalence % OA Myofascial pain syndrome Low back pain Arthralgia Epicondylitis Gout RA Seronegative Tendinitis Myalgia MCTD Unclassified CTD 11.3 6.3 4.0 3.2 1.4 0.16 0.12 0.12 0.09 0.09 0.04 0.04

4. Osteoarthritis

6. Classification of Osteoarthritis I. Primary (idiopathic) A. Localized (principal site) 1 . Hip (superolateral, superomedial, medial, inferoposterior) 2. Knee (medial, lateral, patellofemoral) 3. Spinal apophyseal 4. Hand (interphalangeal, base of thumb) 5. Foot (first metatarsophalangeal joint, midfoot, hindfoot) 6. Other (shoulder, elbow, wrist, ankle) B. Generalized 1. Hands (Heberden's nodes) 2. Hands, knees and spinal apophyseal (generalized OA)

7. Classification of Osteoarthritis II. Secondary A. Dysplastic 1. Chondrodysplasias 2. Epiphyseal dysplasias 3. Congenital joint displacement 4. Developmental disorders (Perthes' disease, epiphysiolysis) B. Post-traumatic 1. Acute 2. Repetitive 3. Postoperative C. Structural failure 1. Osteonecrosis 2. Osteochondritis

8. Classification of Osteoarthritis II. Secondary D. Post-inflammatory 1. Infection 2. Inflammatory arthropathies E. Endocrine and metabolic 1. Acromegaly 2. Ochronosis 3. Hemochromatosis 4. Crystal deposition disorders F. Connective tissue 1. Hypermobility syndromes 2. Mucopolysaccharidoses

10. CLINICAL FEATURES 2) Stiffness Initially, intermittent < 30 minutes 3) Swelling and deformity Superficial joints (knee or IP joints) * Bowlegs or knock knees

11. CLINICAL FEATURES 4) Loss of function Specific to the site involved * Poor grip : osteoarthritis of hands *Difficult grooming : osteoarthritis of the shoulders *Restricted walking distance, limp, fatigue : osteoarthritis of the hips and knees

13. Heberden’s & Bouchard’s node

14. OA HIP

15. OA knee Bowel leg

16. Imaging Plain radiographs most useful form of imaging, not most sensitive Cardinal features - asymmetric narrowing of the joint space - sclerosis of subchondral bone under area of cartilage loss - cysts close to the subchondral bone plate - osteophytes at joint margins, and bone remodeling -intraarticular loose bodies , deformity, subluxation

17. Laboratory Investigations **No reliable diagnostic test Synovial fluid Nonspecific : non- inflammation *increased volume, decreased viscosity *mild pleocytosis, and slight increase in protein

25. OA treatment guideline Tramadol opioid Rheumato/ortho consultation Tramadol or COX-2 inhibotor Tramadol or opioid NSAIDS +/- anagesics Diagnosis of OA nonpharmacologic +/- acetaminophen +/- topical agent symptoms not improve NAIDS contraindication GI risk kidney risk No risk

27. GOUT

28. Hyperuricemia Serum urate conc. > 7 mg/dL ( 7 men , 6 women ) Strong correlate *** BSA : BW, Ht ** Age * Sex Prevalence : 2.3 - 17.6 % of the populations Annual incidence rate of gout 4.9 % for levels > 9 mg/dl 0.5 % for levels 7 - 8.9 mg/dl 0.1 % for levels < 7 mg/dl GOUT

29. Incidence 0.20 - 0.35 per 1000 Prevalence 1.60 - 13.6 per 1000 Increase incidence with * Age * Sex * Serum urate level Gout - Epidemiology Prevalence 0.7-1.4 % in men 0.5-0.6% in women Prevalence in age > 65 4.4-5.2 % in men 1.8-2.0 % in women But onset of gout after age > 60 men and women is almost equal, and onset after 80,women seem predominate GOUT

30. Four stages: 1) Asymptomatic hyperuricemia 2) Acute gouty arthritis 3) Intercritical (or interval) gout 4) Chronic tophaceous gout Spectrum of Gout GOUT

33. Acute Gouty arthritis GOUT

34. Definitive diagnosis : aspiration of the joint : intracellular needle-shaped crystals : negative birefringence with compensated polarized light microscopy Acute Gouty arthritis GOUT

35. Acute Gouty arthritis GOUT

36. Acute Gouty arthritis Strongly negative birefringent crystal GOUT

38. Acute Gouty arthritis GOUT

39. Intercritical Gout Second attack within 6 mo - 2 yrs Diagnosis : difficult or inconclusive GOUT

40. Characters * chronic polyarticular gout * without pain-free intercritical periods * average of 11.6 years * severe crippling disease Chronic tophaceous gout GOUT

41. Chronic tophaceous gout GOUT

42. Chronic tophaceous gout

43. Therapeutic aims * To terminate the acute attack * To prevent recurrences * To prevent or reverse complications ( deposition of MSU or UA crystals ) * To prevent or reverse associated features ( obesity, hyper TG & HT ) TREATMENT OF GOUT GOUT

48. CPPD Calcium pyrophosphate dihydrate deposition disease

58. A , Acute pseudogout. B , Pseudo-osteoarthritis. C , Pseudo-rheumatoid arthritis with boutonniere deformity. D , Pseudo-rheumatoid arthritis showing ulnar deviation, interosseous muscle atrophy, and metacarpophalangeal and wrist joint involvement. The patients in A , C , and D are siblings.

64. Rheumatoid Arthritis

65. Rheumatoid arthritis

66. Rheumatoid arthritis

67. Treatment Guideline