More likely:

Less likely:

If a systemic arthritis is suspected, a complete physical examination is required. In particular:

• Back pain:

musculoskeletal (facet, disc, muscle etc.)

spondylolisthesis (resulting in lateral recess or central stenosis; facet or ligamentous or muscle pain)

arthritides.

Note: space occupying lesions, bone tumour or infection, or referral from visceral organs is now unlikely.

Noticeable skin lesions, either past or present, may indicate psoriatic arthritis. (However, these are usually more prominent in males.) Skin changes may also occur with many connective tissue disorders, including scleroderma, SLE, dermatomyositis etc.

The hand radiograph demonstrates narrowing of joint spaces and early evidence of a swan neck deformity. There are MCP subluxations of digits 2–5, and generalised loss of bone density. Rheumatoid arthritis is the diagnosis.

Refer to Smith^[1] for an outline of the American College of Rheumatology criteria for the diagnosis of rheumatoid arthritis.

Rheumatoid arthritis is essentially of unknown aetiology, although it is believed that immunological, hormonal, genetic and environmental factors (including infection) may all contribute to its pathogenesis. In addition, like many chronic disorders, the progression of the disease may be influenced by psychosocial elements.

The joint pathology of rheumatoid arthritis is illustrated in Figure 18.1.

Figure 18.1

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Please also refer to the readings for more detail.

Fundamental features include:

(Children can have a related form of the disease.)

For further information please refer to the ‘further reading section’ at the end of this chapter.

Please refer to Smith^[1] and to Gupta and Bhagia,^[2] who provide an extensive description of the effect of the disease on each joint.

The images in Figures 18.2 to 18.7 illustrate the typical changes that can occur in rheumatoid arthritis.

Figure 18.2

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Figure 18.3

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Figure 18.4

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Figure 18.5

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Figure 18.6

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Figure 18.7

(Source: Netter illustration from www.netterimages.com. © Elsevier, Inc. All rights reserved.)

Rheumatoid arthritis is associated with pain and instability. Depending on the severity of the disease, an individual may need to cope with a number of issues, including:

For further information please refer to the further reading section at the end of this chapter.

Lateral epicondylitis (aka ‘tennis elbow’), involves the extensor carpi radialis brevis tendon, at its origin at the lateral epicondyle, or over the radial head. It may be due to repetitive loads, or direct trauma to that area. It generally causes pain and swelling at the tenoperiosteal junction, and weakness of the wrist extensors. There may also be a reduction in the range of motion at the elbow and proximal radioulnar joints.

Considering that Margaret presented with wrist pain only, this diagnosis is a surprising one. (It is possible, however, that the patient does not remember accompanying symptoms which may have led to the diagnosis of lateral epicondylitis.)