Arthritis of the Hands

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Arthritis of the Hands
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On the Agenda

• Normal
• Osteoarthitis
• Rheumatoid arthritis
• CPPD crystal deposition
• Gout
• Psoriatic arthritis

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Normal Hand X-ray
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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
• Heberdens at DIPs
• Bouchards at PIPs

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OA Radiographic findings

• Joint space narrowing
• Osteophyte formation (white arrow)
• Subchondral sclerosis (black arrows)

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• Joint space narrowing distally
• Marginal osteophytes
• Relatively unchanged proximal structures

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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 (Heberdens nodes)

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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 (gt1 hr)
• PIPs, MCPs, and wrist commonly involved
• Symmetric joint involvement

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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

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

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Advanced RA

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

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RA - Late

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

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RA Bone Scan

• Technetium-99 bone scan
• Uptake shown in subclinical inflammation of
  joints
• Symmetrical
• Polyarticular

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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

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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)

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

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Brief summary so far
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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

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Gout
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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

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More gout
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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

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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

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Psoriatic arthritis
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All done. Any questions?
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Source

• http//rad.usuhs.mil/medpix
• Additional listed on request