EpistemisProgressive joint deformity
Specialty: Musculoskeletal.
Why it occurs
- Untreated destructive rheumatoid arthritis (ulnar deviation of fingers, swan neck or buttonhole deformity)
- Advanced erosive or degenerative osteoarthritis (Heberden and Bouchard nodules in the hands, genu varus/valgus in the knees)
- Jaccoud arthropathy (reducible joint deformity without bone erosions, secondary to systemic lupus erythematosus)
- Charcot neuropathic arthropathy (common in diabetic foot due to loss of proprioceptive sensitivity)
- Acromegaly (disproportionate bone and joint growth due to excess GH)
- Destructive chronic tophaceous gout
Initial workup
Plain x-ray of the affected joint under load (evaluates impingement of the joint space, subchondral erosions, geodes and osteophytes) | Joint MRI to evaluate extent of cartilage damage and ligament involvement | Complete blood count, Rheumatoid Factor, anti-CCP antibodies, serum uric acid.
red flags
Joint deformity that progresses rapidly in a few weeks associated with signs of massive joint instability, intractable disabling pain, local heat and signs of necrosis of the overlying skin (underlying joint infection or accelerated neuropathic arthropathy at risk of amputation).
Standard management
- Leflunomide — 10-20 mg once daily orally, indicated as a disease-modifying drug in refractory rheumatoid arthritis
- Methotrexate — 20 mg subcutaneously once a week, basis of modifying treatment
- Folate — 5 mg weekly orally administered 24-48 hours after methotrexate
- Tocilizumab (162 mg subcutaneously once a week; anti-IL-6 biological therapy to stop joint structural damage).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Musculoskeletal
- Listed causes
- 6
- Treatment options
- 4