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 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 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 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 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 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 Boutonniere (top) Swan neck Labs: +RF in 80%: IgM against Fc of IgG Elevated ESR Anemia of chronic disease

RA - Late Complete MCP involvement Large marginal erosions have nearly destroyed the joints Bones are lucent due to osteopenia Ulnar deviation

RA Bone Scan Technetium-99 bone scan Uptake shown in subclinical inflammation of joints Symmetrical Polyarticular

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

CPPD 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)

CPPD Diffuse condrocalcinosis at the radiocarpal joint, the MCP joints and the PIP Joint space narrowing, sclerosis, and subchondral cysts within the carpals

Brief summary so far

Gout 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

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

More gout

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 Asymmetric proliferative erosions with ill-defined margins Periosteal reaction Soft tissue swelling “Pencil-in-cup” deformity Resorption of distal phalangeal tufts Subluxation

Psoriatic arthritis

All done. Any questions?

Source http://rad.usuhs.mil/medpix Additional listed on request