1. Arthritis of the Hands

2. On the Agenda Normal Osteoarthitis Rheumatoid arthritis
CPPD crystal deposition
Gout
Psoriatic arthritis

3. Normal Hand X-ray

4. 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

5. OA – Radiographic findings
Joint space narrowing
Osteophyte formation (white arrow)
Subchondral sclerosis (black arrows)

6. Joint space narrowing distally
Marginal osteophytes
Relatively unchanged proximal structures

7. 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)

8. 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

9. 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

10. Severe erosive changes at radio-ulnar joints carpal bones at the metacarpal heads
Bilaterally symmetric

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

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

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

14. 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

15. 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)

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

17. Brief summary so far

18. 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

19. Gout

20. 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

21. More gout

22. 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

23. 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

24. Psoriatic arthritis

26. All done. Any questions?

27. Source
Additional listed on request