C h a p t e r 4 4
Disorders of the Skeletal System: Metabolic and Rheumatic Disorders
1121
found to correlate with the amount of disease activity. A
moderate hypochromic anemia is common.
Extra-articular involvement occurring in long-stand-
ing disease include the development of rheumatic nod-
ules (Fig. 44-6A). These granulomatous lesions have a
central core of fibrinoid necrosis that is made up of a
mixture of fibrin and other proteins such as degraded
collagen.
4
The nodules may be tender or nontender,
movable or immovable, and small or large. Typically,
they are found over pressure points such as the extensor
surfaces of the ulna. The nodules may resolve spontane-
ously or be surgically removed.
Vasculitis, or inflammation of small and medium-
sized arteries, is an uncommon manifestation that pro-
duces ischemic areas in the nail fold and digital pulp
that appear as brown spots. Ulcerations may occur in
the lower extremities, particularly around the malleo-
lar areas. In some cases, neuropathy may be the only
Inflamed
synovium
Pannus
Loss
of
cartilage
Pannus-filled
erosion
Ulnar
deviation
A
B
Rheumatoid
subcutaneous
nodules
Vasculitis:
Ischemic areas in
the nail fold
Splenomegaly
Lymphadenopathy
Symmetric
polyarthritis
Neck discomfort
Nonspecific systemic
symptoms:
Low-grade fever
Fatigue
Weakness
Loss of appetite
Eye lesions:
Episcleritis
Scleromalacia
Hematologic manifestations:
Elevated ESR
Anemia
Other organ
involvement:
Pleural effusion
Pericarditis
Nephropathy
Hallux valgus and hammer toe
FIGURE 44-6.
Clinical manifestations of rheumatoid arthritis featuring
(A)
hand and finger
manifestations and
(B)
destructive joint changes. ESR, erythrocyte sedimentation rate.
