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Bones are joined together by joints, which
allow varying degrees of movement between the adjacent bone ends; some joints
permit considerable movement, others allowing only limited movement.
important type of joint that permits considerable movement is the synovial
joint. Excessive movement at the joint is limited by a strong joint capsule and
an enclosing ligament, assisted by attached muscles and tendons.
In joints in
which there is only limited movement the bones are joined by fibrous or
cartilaginous tissue, e.g. the fibrocollagenous and cartilaginous intervertebral
discs between adjacent vertebral bodies.
Inflammatory disease of joints, which is grouped under the terms arthritis and
synovitis, has four main causes: degenerative, e.g. osteoarthritis; autoimmune,
e.g. rheumatoid arthritis, SLE, rheumatic fever; crystal depositions, e.g. gout
and other crystalline arthropathies; and infective, e.g. tuberculous arthritis.
Osteoarthritis is a common and important degenerative disease with both
destructive and reparative components
Osteoarthritis may arise as a primary disorder, as well as arising secondary to
other joint malfunctions (particularly abnormal loading or structural
deformities). The pathological changes involve cartilage, bone, synovium and
joint capsule, with secondary effects on muscle. Main factors in development of
osteoarthritis are ageing, abnormal load on joints, crystal deposition, and
inflammation of joints.
In general, osteoarthritis affects joints that are constantly exposed to wear
and tear. It is an important component of occupational joint disease, e.g.
osteoarthritis of the fingers in typists, and of the knee in professional
Previous abnormality of the joint predisposes to the early development of severe
osteoarthritis (sometimes called 'secondary osteoarthritis'), causes include:
• Congenital abnormality of joints.
• Trauma to joints (including trauma resulting from lack of sensory innervation).
• Inflammatory joint disease.
• Avascular necrosis of bone.
In a normal synovial joint the distance between the bone ends seen on
radiography is maintained by the thickness of articular cartilage.
The early change in osteoarthritis is destruction of articular cartilage, which
splits (fibrillation), becomes eroded and leads to narrowing of the joint space
on radiography. There is inflammation and thickening of the joint capsule and
With time, there is thickening of sub-articular bone caused by constant friction
of the two naked bone surfaces, leading to a highly polished bony articular
surface (eburnation). Small cysts develop in the bone beneath the abnormal
articular surface. Osteophytes form around the periphery of the joint by
irregular outgrowths of bone. There may be reactive thickening of the synovium
due to inflammation caused by bone and cartilage debris. Inflammatory changes
are also often seen. Atrophy of muscle is caused by disuse following immobility
of the diseased joint.
In osteoarthritis of the hands, osteophytes on the interphalangeal joints of the
fingers are termed 'Heberden's nodes' and appear as small nodules.
Rheumatoid arthritis is a common and important cause of inflammatory joint
disease, although it is but one manifestation of a generalized systemic disorder
(Rheumatoid arthritis). It is characterized by the presence of a circulating
autoantibody, 'rheumatoid factor' (seropositive arthritis), which distinguishes
this form of disease from several other inflammatory joint diseases (seronegative
Rheumatoid arthritis mainly affects peripheral synovial joints such as the
fingers and wrists, but can also affect the knees and more proximal joints.
Women are affected two to three times more commonly than men, and the usual age
of onset is between 35 and 45 years. The affected joints become swollen, painful
and warm, often with redness of the overlying skin.
In long-standing chronic disease the articular cartilage may be largely
destroyed and replaced by fibrous pannus; the underlying bone shows osteolytic
erosions, and the synovium lining the joint capsule is greatly thickened and
chronically inflamed. The loss of articular surface can lead to the development
of secondary osteoarthritic changes, particularly in weight-bearing joints such
as the knee. Unlike most other autoimmune arthropathies, rheumatoid arthritis is
chronic and progressive. It usually leads to eventual joint deformity, with
secondary features (e.g. muscle wasting) due to disuse of the disorganized
The early pathological change in rheumatoid arthritis is rheumatoid synovitis.
The synovium is swollen and shows a villous pattern. There is a great increase
in chronic inflammatory cells (mainly lymphocytes and plasma cells) in the
synovial stroma, often with an exudate comprising fluid, which produces an
effusion in the joint space, and fibrin which is deposited on the synovial
surface. Soft tissue swelling from synovial inflammation can be marked.
With time, there is articular cartilage destruction; vascular granulation tissue
grows across the surface of the cartilage (pannus) from the edges of the joint,
and the articular surface shows loss of cartilage beneath the extending pannus,
most marked at the joint margins.
The inflammatory pannus causes focal destruction of bone. At the edges of the
joint there is osteolytic destruction of bone, responsible for 'erosions' seen
on radiographs. This phase is associated with joint deformity.
The characteristic deformity and soft tissue swelling associated with
long-standing rheumatoid disease of the hands.
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