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Arthritis of the Hands. On the Agenda. Normal Osteoarthitis Rheumatoid arthritis CPPD crystal deposition Gout Psoriatic arthritis. Normal Hand X-ray. Osteoarthritis (DJD). Gradual degeneration of articular cartilage Joint pain relieved with rest

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on the agenda
On the Agenda
  • Normal
  • Osteoarthitis
  • Rheumatoid arthritis
  • CPPD crystal deposition
  • Gout
  • Psoriatic arthritis
osteoarthritis djd
Osteoarthritis (DJD)
  • Gradual degeneration of articular cartilage
  • Joint pain relieved with rest
  • Morning stiffness resolves within 30 minutes
  • Traditionally affects DIPs, 1st IP
  • No systemic symptoms
  • Painless nodules
    • Heberden’s at DIPs
    • Bouchard’s at PIPs
oa radiographic findings
OA – Radiographic findings
  • Joint space narrowing
  • Osteophyte formation (white arrow)
  • Subchondral sclerosis (black arrows)
Joint space narrowing distally
  • Marginal osteophytes
  • Relatively unchanged proximal structures
another example of oa
Another example of OA
  • Oblique and AP views
  • 1st carpal metacarpal shows decreased joint space and subchondral sclerosis
  • 2nd and 3rd DIP shows osteophytes and subchondral sclerosis (Heberden’s nodes)
rheumatoid arthritis
Rheumatoid Arthritis
  • Systemic inflammatory disease
  • Affects synovial membranes
  • Pannus (granulation tissue) develop in joint spaces and erode into the articular cartilage and bone
  • Prolonged morning stiffness (>1 hr)
  • PIPs, MCPs, and wrist commonly involved
  • Symmetric joint involvement
ra radiography early
RA radiography - early
  • Earliest signs include soft tissue swelling due to effusion, tenosynovitis, and edema
  • Periarticular osteopenia
  • Marginal erosions often first seen at 2nd and 3rd MCPs and 3rd PIP articulations
Severe erosive changes at radio-ulnar joints carpal bones at the metacarpal heads
  • Bilaterally symmetric
advanced ra
Advanced RA
  • Boutonniere (top)
  • Swan neck
  • Labs:
    • +RF in 80%: IgM against Fc of IgG
    • Elevated ESR
    • Anemia of chronic disease
ra late
RA - Late
  • Complete MCP involvement
  • Large marginal erosions have nearly destroyed the joints
  • Bones are lucent due to osteopenia
  • Ulnar deviation
ra bone scan
RA Bone Scan
  • Technetium-99 bone scan
  • Uptake shown in subclinical inflammation of joints
  • Symmetrical
  • Polyarticular
calcium pyrophosphate dihydrate crystals cppd
Calcium pyrophosphate dihydrate crystals (CPPD)
  • “Pseudogout”
  • Associated with metabolic diseases such as hyperparathroidism, hemochromatosis, hypothyroidism
  • Compared to gout:
    • Large joints affected (2nd to 5th MCPs, radio-carpal)
    • Rhomboid crystals
    • Positive birefringence
    • Calcification of articular cartilage
    • No cortical erosions
  • Chondrocalcinosis
  • Distal radius and MCPs (2nd and 3rd)
  • Cartilage destruction similar to OA – differentiate by location
  • Location similar to RA – differentiate by absense of erosions
  • Calcium deposition at triangular fibrocartilage of the wrist (picture)
  • Diffuse condrocalcinosis at the radiocarpal joint, the MCP joints and the PIP
  • Joint space narrowing, sclerosis, and subchondral cysts within the carpals
  • Disorder of purine metabolism – overproduction versus underexcreation
  • Deposition of urate crystals in joint spaces
  • Middle-aged men
  • Acute onset of extreme pain in small joints with redness and swelling
  • Needle shaped crystals with negative bifringence
  • Asymmetric, monoarticular
gout radiography
Gout Radiography
  • All joints of hand and wrist possible (2nd-5th PIP most common)
  • Soft tissue swelling
  • Well demarcated osseous erosions with sclerotic rims and overhanging edges
  • No decrease in bone density
  • Tophi not calcified
  • Relative sparing of joint space until late in the disease
  • Long latent period between onset of symptoms and radiographic changes
psoriatic arthritis
Psoriatic Arthritis
  • HLA-B27 positive, RF negative
  • Inflammatory
  • Seronegative spondyloarthropathy
  • Asymmetric and bilateral
  • Primarily distal involvement associated with nail changes
  • No periarticular osteoporosis
  • Five different patterns
  • Usually accompanies skin disease
psoriatic arthritis rad findings
Psoriatic Arthritis – Rad findings
  • Asymmetric proliferative erosions with ill-defined margins
  • Periosteal reaction
  • Soft tissue swelling
  • “Pencil-in-cup” deformity
  • Resorption of distal phalangeal tufts
  • Subluxation
  • Additional listed on request