Arthritis of the Hands

On the AgendaNormalOsteoarthitisRheumatoid arthritisCPPD crystal depositionGoutPsoriatic arthritis

Normal Hand X-ray

Osteoarthritis (DJD)Gradual degeneration of articular cartilageJoint pain relieved with restMorning stiffness resolves within 30 minutesTraditionally affects DIPs, 1st IPNo systemic symptoms Painless nodulesHeberdens at DIPsBouchards at PIPs

OA Radiographic findingsJoint space narrowing Osteophyte formation (white arrow)Subchondral sclerosis (black arrows)

Joint space narrowing distally

Marginal osteophytes

Relatively unchanged proximal structures

Another example of OAOblique and AP views

1st carpal metacarpal shows decreased joint space and subchondral sclerosis

2nd and 3rd DIP shows osteophytes and subchondral sclerosis (Heberdens nodes)

Rheumatoid ArthritisSystemic inflammatory diseaseAffects synovial membranesPannus (granulation tissue) develop in joint spaces and erode into the articular cartilage and boneProlonged morning stiffness (>1 hr)PIPs, MCPs, and wrist commonly involvedSymmetric joint involvement

RA radiography - earlyEarliest signs include soft tissue swelling due to effusion, tenosynovitis, and edemaPeriarticular osteopeniaMarginal 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 headsBilaterally symmetric

Advanced RABoutonniere (top)Swan neck

Labs:+RF in 80%: IgM against Fc of IgGElevated ESRAnemia of chronic disease

RA - LateComplete MCP involvementLarge marginal erosions have nearly destroyed the jointsBones are lucent due to osteopeniaUlnar deviation

RA Bone ScanTechnetium-99 bone scanUptake shown in subclinical inflammation of jointsSymmetricalPolyarticular

Calcium pyrophosphate dihydrate crystals (CPPD)PseudogoutAssociated with metabolic diseases such as hyperparathroidism, hemochromatosis, hypothyroidismCompared to gout:Large joints affected (2nd to 5th MCPs, radio-carpal)Rhomboid crystalsPositive birefringenceCalcification of articular cartilageNo cortical erosions

CPPDChondrocalcinosisDistal radius and MCPs (2nd and 3rd)Cartilage destruction similar to OA differentiate by locationLocation similar to RA differentiate by absense of erosionsCalcium 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

GoutDisorder of purine metabolism overproduction versus underexcreationDeposition of urate crystals in joint spacesMiddle-aged menAcute onset of extreme pain in small joints with redness and swellingNeedle shaped crystals with negative bifringenceAsymmetric, monoarticular

Gout

Gout RadiographyAll joints of hand and wrist possible (2nd-5th PIP most common)Soft tissue swellingWell demarcated osseous erosions with sclerotic rims and overhanging edgesNo decrease in bone densityTophi not calcifiedRelative sparing of joint space until late in the diseaseLong latent period between onset of symptoms and radiographic changes

More gout

Psoriatic ArthritisHLA-B27 positive, RF negativeInflammatorySeronegative spondyloarthropathyAsymmetric and bilateralPrimarily distal involvement associated with nail changesNo periarticular osteoporosisFive different patternsUsually accompanies skin disease

Psoriatic Arthritis Rad findingsAsymmetric proliferative erosions with ill-defined marginsPeriosteal reactionSoft tissue swellingPencil-in-cup deformityResorption of distal phalangeal tuftsSubluxation

Psoriatic arthritis

All done. Any questions?

Sourcehttp://rad.usuhs.mil/medpixAdditional listed on request