Inflammatory arthritis

1. INFLAMMATORY ARTHRITIDES
Dr.Priyanka Rana

2. • The inflammatory arthritides are characterized
by multiple joint involvement with
inflammatory changes either within the joints,
the enthesis or periarticular soft tissues.
1. Rheumatoid arthritis:- autoimmune diseases
involves chronic inflammation of synovium
within joint(involves multiple joint on both
side)
2. Ankylosing spondylitis .
3. Psoriatic arthritis:-autoimmune diseases
which associated with psoriasis.
4. Erosive osteoarthritis.

3. Rheumatoid Arthritis
• Rheumatoid arthritis is a progressive, chronic, systemic
inflammatory disease affecting primarily the synovial joints
• Onset is usually between 20 and 60 years of age, with the
highest incidence among the 40- to 50-year-old group.
• Under 40 females to male ratio is 3:1 and over 40 equal, 1:1
ratio incidence.
• The detection of rheumatoid factor, representing specific
antibodies in the patient's serum, is an important
diagnostic finding .
• Low grade fever ,fatigue, weight loss, muscle soreness, and
atrophy.
Symmetric peripheral joint pain and swelling, particularly of
the hands

4. Pathology
• Initial synovial inflammation within joints, bursae, and
tendon sheaths, with cellular infiltrate, hyperemia,
edema,and increased synovial fluid.
• Synovium become shypertrophied to form granulation
tissue (pannus), which spreads over cartilage surface.
• At the bare areas pannus directly invades in to the bone ,
resulting in marginal erosions and cartilage destruction.
• A rheumatoid nodule is diagnostic and consists of three
distinct zones: fibrinoid degeneration and necrosis
(central), radial palisading of fibroblasts (middle), and
fibrous tissue with small cell infiltrate (outer).

7. The 2010 American College of
Rheumatology/European League against
Rheumatism Classification Criteria for RA

8. Radiologic Features
 Early radiographicchanges are mostcommonlyseen in the hands and
feet.
 Bilateral and symmetric distribution, periarticular soft tissue
swelling(these are typically the first radiographic signs of rheumatoid
arthritis.), juxta-articular osteoporosis, juxta-articular solid or
laminated periostitis, marginal erosionsand cysts, and uniform loss of
jointspace.
 Later, radiographic changes may be seen, including markeddeformities
with subluxation, dislocation, articular bony destruction, bony fusion,
and complete destruction of jointspace.
 Hand: earliest changes are seen at the metacarpophalangeal and PIP
joints. Evaluation should include the semisupinationviewof the hands
(Norgaard projection) for marginal erosions on metacarpal heads and
deformities like ulnardeviation, boutonniere, swan neck, spindledigit.

9.  Wrist: earliest change is erosion of ulnar styloid, multiple carpal
erosions (spotty carpal sign), most common location for bony
ankylosis, carpal radial rotation, zigzag deformity, Terry Thomas’sign.
 Feet: earliestchanges seen at the fourthand fifth metatarsal phalangeal
joints. Changes parallel and are identical to that seen in the hands;
Lanois deformity—dorsal subluxation of the metatarsal-phalangeal
joints, with fibulardeviation.
 Cervical spine: most commonly affected area of the spine; involved in
up to 70% of rheumatoid patients. Increased atlantodental interspace>
3 mm (especially in flexion), odontoid erosions, subluxations
(especially C3, C4, and C5). Narrowed intervertebral discs, apophyseal
joints show erosions and narrowed joint space and may ankylose.
Tapered spinous processes and generalizedosteoporosis.
 Hips: uniform loss of joint space (axial migration), minimalerosions,
protrusioacetabuli (mostcommoncause),particularly bilaterally.
 Knees: uniform loss of jointspace, marginal erosions (particularlyat
the tibial condyles), and osteoporosis; often associated with large
Baker’scysts.

12. Marginal erosion
Erosions
Soft tissue
swelling

13. Rheumatoid Arthritis
• Deformities
– Subluxations at the MCPs and MTPs
– Ulnar deviation of the digits
– Swan-neck and Boutonniere deformities

14. Severe ulnar deviation
Severe erosions of
MCPs
Complete destruction
of the wrist
Resorption of the
carpals and the heads
of the metacarpals
Radial deviation of the
wrist

15. Boutonniere deformity
of the thumb
Flexion with dislocation of
the first MCP joint
Hyperextension of the
IP joint

16. Rheumatoid wrist: articular destruction, carpal fusion and carpal
collapse.
Severe destruction of the distal radius and ulna.

17. Rheumatoid foot
Multiple osseous
erosions and defects
at the medial and
lateral margins of
the metatarsal heads
Marginal erosions
at the bases of the
proximal phalanges
(arrows)

18. Rheumatoid foot
Medial and lateral
erosions of the 5th
metatarsal head
Subluxation of the 5th
MTP joint

19. Rheumatoid foot
Characteristic erosion
along the medial
margin of the proximal
phalanx of the great toe
Subchondral cyst at the
base of the distal
phalanx

20.  Anteroposterior (A)and
lateral (B) radiographs
of the knee shows
periarticular
osteoporosis, joint
effusion, and lack of
osteophytosis.

21. Anteroposterior
radiograph of the right
hip shows erosions of the
femoral head and
acetabulum, concentric
narrowing of the hip
joint, and acetabular
protrusio.

22. (A) Lateral radiograph
of the foot of shows
fluid in the
retrocalcaneal bursa
(arrow) associatedwith
erosion of the
calcaneus (curved
arrow).
MRI demonstrates bone
erosion in the posterior
process of thecalcaneus
arrowhead) associated
with extensive
surrounding bone
marrow edema and
retrocalcaneal and
retro-Achilles bursitis
(arrows).

23. Xray demonstrates
erosions in the
radiocarpal and
intercarpal articulations
as well asthe
carpometacarpal joint,
bilaterally (openarrows).
Note, in addition, subtle
erosions of the head of
the first, third, fourth,
and fifth metacarpals of
the left hand and of the
head of the second
metacarpal of the right
hand (arrows). A small
erosion at the base ofthe
middle phalanx of the
ring finger of the left
hand (arrowheads) and
the erosion in the right
triquetropisiform joint
(curved arrow) are also
well seen.

24. Oblique radiograph of
the hand shows the
swan neck deformityof
the second through
fifth fingers

25. Radiograph of the
hands demonstrates
the boutonnière
deformity in the
small and ringfingers
of the right hand and
in the ring finger of
the left hand

26.  Radiograph of the
hands demonstrates
the main-en-lorgnette
deformity- the
telescoping the fingers
secondary to
destructive joint
changes and
dislocations in the
metacarpophalangeal
joints

27. MRI
A sagittalspin
echo T1-
weighted MR
image shows
inflammatory
pannuseroding
odontoid
(arrow) and
cranial settling
with cephalad
migration of C2
impinging on
the medulla
oblongata
(openarrow).

28. USG
Sonography
showsthickened
synovial tissue
(arrows).

29. MRI MR images of the
left shoulder of a
show largearticular
and periarticular
erosions, joint
space narrowing,
joint effusion, anda
tear of the supra-
spinatus tendon
(arrows)
Coronal T1-
weighted MRIof
the right kneein
demonstrates
a joint effusionwith
inflammatory
pannus (arrow).

30. Juvenile rheumatoid arthritis
 Chronic polyarthritis resembling
rheumatoidarthritis clinically and
histologically beginning before 16 years of
age
 Synonyms include Still’sdiseaseand
juvenile chronic arthritis.
 Morecommon in females < 16 years,
with peak incidence at 2-5 and 9-12
years.

31. TYPES
 Adult form (seropositive) Poorestprognosis
 Seronegative form:- Classic systemic,Polyarticular
Pauciarticular-monoarticular
 Distinct lack of rheumatoidfactor
 Symptoms include fever, characteristic rash,
lymphadenopathy, iridocyclitis (especially in
monoarticularforms), no subcutaneous nodules,and
growthdisturbance.
 Distinct lack of rheumatoidarthritis

32. Radiologic Features
 General features include soft tissueswelling,
osteoporosis, periostitis, growth disturbances,
ankylosis, loss of joint space, erosions, subluxations,
and epiphysealcompression fractures.
 Target sites include cervical spine, hands, feet, knees,
and
• hips.
 Cervical spine: atlantoaxial dislocations, hypoplastic
C2-C4 vertebral bodies and discs with ankylosed
apophyseal joints.
 Tarsal and carpal ankylosiscommon.
 Growth deformities: brachydactyly, ballooned
epiphyses, squashed carpi, and squaredpatellae.

33. A.Lateral Lumbar
Note thatosteoporosis
and compression
fractures haveproduced
a biconcave appearance
of the endplates.
B.Lateral Cervical.
Observe the vertebral
body hypoplasia of the
second, third,
fourth, and fifth
segments. The odontoid
appears enlarged. C.
Lateral Cervical. Note
that the vertebral bodies
are hypoplastic in
combination with
posterior jointankylosis.
These are characteristic
cervical spinechanges

34.  Radiograph of both hands showsdestructivechanges in
the metacarpophalangeal and interphalangeal joints.
Note also joints ankylosis in both wrists. the
periarticularsoft tissueswelling and periostitis (arrows)

35. Radiograph of
both knees of a20-
year-old woman
shows overgrowth
of the medial
condyles, one of
the characteristic
features of this
disorder

36. Ankylosing Spondylitis
 A chronic inflammatory disorder principally affecting the articulations,
ligaments, and tendons of the spine and pelvis, often resulting incomplete
polyarticular ankylosis.
 Synonyms include Marie-Strumpell disease, rhizomelic spondylitis,
pelvospondylitis ossificans, and rheumatoid spondylitis.
 Onset is usually between 15 and 35 years and involves males10:1.
 Initiates at the sacroiliac joints bilaterally, then ascends the spine.
 Pain and tenderness, especially over bony protuberances, andincreasing
stiffness and sciatica is often bilateral or may alternate from side to side.
 Complications include iritis, aortitis, valvular incompetence, aneurysms,
conduction blocks, upper lobe pulmonary fibrosis, inflammatory bowel
disease, renal failure owing to secondary amyloidosis, carrot-stick
fractures, Andersson’s lesion, and prosthesisankylosis.
 The most commonly involved areas are the sacroiliac joints, spine, and
proximal large joints of the shoulder, hip, and ribcage.

37. Pathologic
Features
In synovial joints, the initial
change is that of a non-
specific synovitis similar to
rheumatoid arthritis, except
that it is less extensive andof
lower intensity (pannus
formation), with subsequent
fibroplasia and cartilaginous
etaplasia, leading toresultant
ossification.
In cartilage joints, the initial
subchondral osteitis is
replaced by fibrous tissuethat
subsequently ossifies. In the
outer annulus fibers this
forms syndesmophytes.
At entheses,inflammatory
changes at ligamentous
attachments result inbony
erosions, sclerosis, and
periostitis.

38. Radiologic Features

39. Lateral radiograph
of the lumbarspine
demonstrates
squaring of the
vertebral bodies
secondary to small
osseous erosions at
the corners. This
finding is an early
radiographic
feature of
ankylosing
spondylitis. Note
also the formation
of syndesmophytes
at the L4- 5 disk
space.

40. (A)Lateral radiograph of
the cervical spine in a
shows anterior
syndesmophytes
bridging thevertebral
bodies and posterior
fusion of the apophyseal
joints, together with
paravertebral
ossifications, producing
a
“bamboo-spine”
appearance.
(B)radiograph the fusion
of the sacroiliac joints
and the involvement of
both hip joints,which
show axial migration of
the femoral heads
(D)MRI shows
anterior
syndesmophytes,
calcification of
the posterior
longitudinal ligament,
and preservation of the
intervertebral disks.

41. (A)A lateralradiograph of the lower lumbar spine of showsearly
inflammatory changes manifesting by so-called shiny corners (Romanus lesion) (arrowheads) and squaring of the
vertebral bodies (arrows).
(B)T2-weighted MRI in a 26-year-old manshows early signs ofankylosing
spondylitis of thelumbar
spine, the shinycorners
(arrows).
(C)T2-weighted MRI of the sacroiliac joints in the same patient demonstrates bone marrow edema adjacent to the
sacroiliac joints and erosive changes bilaterally, more prominent on the left (arrows).

42. A.AP Sacrum. Note
that bilateral
sacroiliitis is clearly
seen with erosions,
hazy joint margin,
and subchondral iliac
sclerosis (arrows).
B.Axial CT: Sacroiliac
Joints. Observe the
erosive iliac lesions
(arrows) and the
subchondral sclerosis
arrowheads).

43. Psoriatic Arthritis
 Psoriasis is a common skin disorder associated with joint
diseaseand characterized by peripheral joint destruction
and deformity:
 Age 20-50 years with maleand femaleequally affected.
 Arthritis is usually in peripheral joints, especially DIP
joints.
 Soft tissue findings: fusiform soft tissue swelling
around the joints which can progress so that whole
digit is swollen (sausage digit ordactylitis)
 Marginal erosionsalsooften show fluffy periostitis from
new
• bone formation

44. Radiologic
Features
 General features include soft tissue swelling, normal bone
mineralization, erosions, and tapered bone ends, prominent juxta-
articular fluffy periostitis, and joint-space widening or bonyankylosis.
 Hands and feet: asymmetric involvement and ray pattern, most
commonly involves DIP joints, no osteoporosis, mouse ears sign,
widened joint space owing to fibrous tissue deposition and bone
resorption, pencil-in-cup deformity, opera glass handdeformity, no
ulnardeviation.
 Sacroiliac joint: involved in up to 50% of psoriaticarthritispatients,
usually bilateral but asymmetric and unusual to be narrowed and
ankylosed.
 Spine: atlantoaxial subluxation and dislocation, normal apophyseal
joints (except in the cervical spine),syndesmophytes of two types—
non—marginal, marginal (non-marginal are the most common)—
broad-based and tapered, asymmetric, unilateral, and mostcommon in
the upper lumbarand lowerthoracicspine.

46. RAYPATTERN
PA Hand.
Note the
erosive
changes are
present at
the three
joints of the
seconddigit
(arrows).
Thispattern
of arthritis
is virtually
diagnostic
of psoriasis

47. Pencil and cupdeformity
Pencilling

48.  Early Distal
Interphalangeal
Joint Changes.
Note that
erosions
(arrows),
periostitis
(arrowheads),
and soft tissue
swelling
characterizethe
earliest
abnormalities
 Combinationof
erosionsand
fluffy periostitis
produces the
mouse ears
appearance in
psoriasis.
MOUSE EAR SIGN

49. Non- Marginal
Syndesmophyte.
Note the thick,
vertical ossifications
that arise just
beyond thevertebral
body margins
(arrows).

50. A.PA Hand.
Fluffy and Linear.
Note that closeto
the joint nearthe
site of articular
erosion, the
periosteal new
bone istypically
fluffy
arrowheads).
Farther downthe
shaft a linear
pattern maybe
seen (arrow).
B.Great Toe:
Fluffy. Note that
adjacent to the
erosions a fluffy
and irregular type
of periostitis can
be seen
arrowheads). The
entire distal
phalanx is
sclerotic, a
reliable signof
psoriaticarthritis
involving the
great toe.

51. ARTHRITIS MUTILANS
Note severe joint
destruction, especially at
the metatarsophalangeal
articulations, has
resulted in fibular
deviation and dorsal
dislocation of the
digits (Lanois’
deformity). The presence
of apencil-
in-cup deformity (arrow)
at the interphalangeal
joint of the big toe and
osseous ankylosis of the
first metatarsophalangeal
and second and third
proximal interphalangeal
articulations (arrowheads)
makes the diagnosis of
psoriatic arthritis most
likely

52. Erosive Osteoarthritis
 Inflammatory variant of degenerative diseases involving the
interphalangeal joints of thehands.
 Common in females 40-50 yearsold.
 The onsetof erosiveosteoarthritis is characterized byepisodicand
acute inflammation of the DIP and PIP joints of both hands in a
symmetric manner.
 Pain, edema, redness, nodules, and restricted motionare found at the
involved articulations of thehands.
 The Pathological featuresarecartilagedegenerationand synovial
proliferation.

53. Radiologic Features
 Involvementof the ulnarcompartmentof thecarpus is significantly
spared differentiating involvement from rheumatoidarthritis.
 Radiographic changes arecharacterized byosteophytes, loss of joint
space, and sclerosis. Osteophytesare identical tothoseseen in DJD.
 Theyare marginal in origin, taperdistally, and areoften largerat the
distal articularcomponent.
 Loss of jointspace is usually non-uniform, with adjacentsubchondral
sclerosis.
 Superimposed changes of erosions, periostitis, and ankylosison these
degenerative featuresarecharacteristicof erosiveosteoarthritis.
 Bone erosions are distinctively centrally located on the proximal
articularsurfaceand moreperipherallyat thedistal articularsurface.

54. Radiologic Features
 At DIP and PIP
joints of hands.
 Erosions (gull
wings sign),
sclerosis,
osteophytes,
periostitis
(mouse ears
sign), ankylosis,
and non-
uniform lossof
jointspace.

55. Gull Wings Sign.
Showscharacteristic
biconcavearticular
contour(arrows).

56.  Radiograph of both hands shows erosions of the distal
interphalangeal joints with typical “gullwing” configuration
due to central erosions and peripheral osseousproliferation

57. HANDS. A. Target
Distribution. Note
the selective
involvementof
the distal
interphalangeal
joints (arrows).
B. Radiologic
Features. Showson
closer inspection
of these involved
joints reveals
osteophytes,
sclerosis, loss of
joint space,cystic
erosions, and
deformity.

58. Thankyou

59. Q- Three deformities in RA