Pathogenesis. It's quite complex:
biochemical, biomechanical, cytokine-mediated,
to a certain extent, right?
Because you do have WBCs, but it's
< 2000 in the synovial fluid.
Now, commonly, the problem is obesity.
So you take a look at the
patient who's obese.
Apart from Diabetes Type 2
and so on and so forth,
that the patient has developed,
metabolic syndrome as you know,
the patient now is at risk of definitely
A lot of weight that the patient might…
has to then put on the knees and such.
That incidence, unfortunately,
osteoarthritis increases with age.
You can't help it, right?
But there are certain things that we can do
to maybe protect ourselves.
Depends on our, well, genetics.
Signs and symptoms. Well, important here.
As I told you,
as you move through osteoarthritis
in your head,
you're going to be comparing this
with rheumatoid arthritis.
In rheumatoid arthritis…
and that's the first time that I'm giving
you a true comparison now.
In rheumatoid arthritis, as you know,
it's a autoimmune issue, isn't it?
Autoimmune most likely going to
affect a female, no doubt.
Here, we have a lot of information.
In rheumatoid arthritis, for example,
the WBC count in the synovial fluid
can exceed 2,000 units per microliter.
They are generally in the range
of 5,000 to 50,000.
Remember, what should be
normal for synovial fluid?
It's less than 2,000 units per microliter.
Next, the patient says…
Who's your patient, a lady, young,
maybe 35 or so?
And she tells you,
"Doc, I wake up in the morning and
I'm having a hard time moving."
"How long does it take before you get better?"
"Hmm, maybe about an hour, hour
and a half." That's a long time.
That's rheumatoid arthritis.
"And then upon moving,
do your joints feel better or
do they feel worse?"
"Doc, actually, to tell you the
truth, I mean, it just…
When I start moving, it starts…they start
feeling a lot better. So I like to move."
Osteoarthritis doesn't do that.
Osteoarthritis, OA, worsens with
use. Is that clear?
It's wear and tear. And the more
wear, the more tear.
Clinically, remind me the joints again?
Reach out your hand,
and you're going to give me your DIP.
When the DIP has undergone inflammatory
then it's called Heberden nodes.
The one that will be proximal,
go in alphabetical order. H will be distal,
B will be your PIP. Those are
okay, at your PIP.
And then which finger did I have you put up?
Not the middle finger, the thumb, yeah.
The thumb. That's called your carpometacarpal
That will be affected commonly
Frequently, as I told you also, apart
from that, the knees, the spine,
the areas in which you'd expect dependency.
Now, there's a little bit of an exception.
Think about the metacarpophalangeal joint.
What are those?
At times, don't you feel like you just want
to punch me with your knuckles?
Those knuckles are your metacarpophalangeal
Notice, that is not affected here.
Commonly, it's not.
The wrist is not commonly affected
But what if you did have a patient
who is an occupation, a welder, what have you,
and deals with the hands as
an occupation for decades.
Wear and tear.
And so, therefore,
in that particular instance,
in that occupation, whatever
it may have been,
has come to be known as your Missouri
normally will not affect those
joints. Keep that in mind.
And crepitus of affected, so a
little bit of, let's say, noise.
In osteoarthritis, you'll notice here
that the DIP is affected. What
is that called again, please?
What is it called if the PIP is affected?
Good. The Bouchard.
Are your metacarpophalangeal
joint commonly affected?
Yes or no?
Wrist commonly affected? No.
Could it be affected? Yes.
What's your patient doing?
Occupation? Dealing with hands
and wear and tear over a
long period of time.
And then what about the thumb?
At what joint?
Carpometacarpal joint, CMC.
Welcome to osteoarthritis.
On your examination,
on X-ray, what are you going to find?
Well, immediately, you'll notice
the picture on the left
of an X-ray of the knee.
And you'll notice that the joint
space has indeed narrowed.
That's what happens with all that
wear and tear taking place.
In addition, you might find areas
that are a little bit…
You see that? A little bit more
opaqueness taking place?
That area of being more bright white?
The bright white area that
you're seeing there,
the bone is undergoing changes.
It's sclerotic changes.
And with that sclerosis, you might even
find what's known as osteophytes,
or bone spurs.
For example, you ride a horse
with those boots, got the spurs
sticking out of your boots.
Well, these are the spurs that are
sticking out of a knee…of a bone
That's your fun in osteoarthritis.
And what about the cartilage
that's undergoing ulceration?
And what do we call cartilage? Chondral,
so subchondral sclerosis,
subchondral type of cyst.
The joint capsule might become inflamed.
But be careful, though. Remember,
the synovial fluid.
Is it…would you call it truly inflammatory
Good. Non inflammatory. Why?
Because if you did check the synovial fluid
in osteoarthritis, WBC count,
So, by definition, not truly inflammatory.
Is that understood?
Now, once you have the cartilage
which is being ulcerated,
now it looks as though the bone is smooth.
A smooth bone is then called eburnation.
That's what we're seeing here on X-ray.
On labs, the sedimentation
rate will be normal.
Rheumatoid factor has nothing to
do with rheumatoid arthritis,
so it's not immune, remember?
So, it's therefore, non-immune.
The X-ray, I showed you, subchondral sclerosis.
What does sclerosis mean? Thickening.
And with that thickening, what
may then happen?
Give formation to osteophytes,
which are known as your bone spurs.
if they're in the PIP, you would
call them Bouchard.
If they're affecting the DIP you call
them what? Heberden. Good.
What about management?
NSAIDs, definitely a COX inhibitor.
Commonly, as I told you, obesity.
So, conservatively, tell your patient to
exercise, physical therapy and such.
Worst-case scenario, maybe
the knee is so far gone
that surgery is recommended.
And there's really no role here
for PO steroids.
Intraarticular, you could then inject, maybe,
glucocorticoids, though. Keep that in mind.
Or perhaps, hyaluronic acid. Remember?
The synovial lining,
it's producing synovial fluid
that's made up of
hyaluronic type of fluid, isn't it?