1. Arthritis of the HandsArthritis of the Hands

2. On the AgendaOn the Agenda
 NormalNormal
 OsteoarthitisOsteoarthitis
 Rheumatoid arthritisRheumatoid arthritis
 CPPD crystal depositionCPPD crystal deposition
 GoutGout
 Psoriatic arthritisPsoriatic arthritis

3. Normal Hand X-rayNormal Hand X-ray

4. Osteoarthritis (DJD)Osteoarthritis (DJD)
 Gradual degeneration ofGradual degeneration of
articular cartilagearticular cartilage
 Joint pain relieved with restJoint pain relieved with rest
 Morning stiffness resolves withinMorning stiffness resolves within
30 minutes30 minutes
 Traditionally affects DIPs, 1Traditionally affects DIPs, 1stst
IPIP
 No systemic symptomsNo systemic symptoms
 Painless nodulesPainless nodules
– Heberden’s at DIPsHeberden’s at DIPs
– Bouchard’s at PIPsBouchard’s at PIPs

5. OA – Radiographic findingsOA – Radiographic findings
 Joint space narrowingJoint space narrowing
 Osteophyte formation (whiteOsteophyte formation (white
arrow)arrow)
 Subchondral sclerosis (blackSubchondral sclerosis (black
arrows)arrows)

6.  Joint space narrowingJoint space narrowing
distallydistally
 Marginal osteophytesMarginal osteophytes
 Relatively unchangedRelatively unchanged
proximal structuresproximal structures

7. Another example of OAAnother example of OA
 Oblique and AP viewsOblique and AP views
 11stst
carpal metacarpalcarpal metacarpal
shows decreased jointshows decreased joint
space and subchondralspace and subchondral
sclerosissclerosis
 22ndnd
and 3and 3rdrd
DIP showsDIP shows
osteophytes andosteophytes and
subchondral sclerosissubchondral sclerosis
(Heberden’s nodes)(Heberden’s nodes)

8. Rheumatoid ArthritisRheumatoid Arthritis
 SystemicSystemic inflammatory diseaseinflammatory disease
 Affects synovial membranesAffects synovial membranes
 Pannus (granulation tissue)Pannus (granulation tissue)
develop in joint spaces anddevelop in joint spaces and
erode into the articular cartilageerode into the articular cartilage
and boneand bone
 Prolonged morning stiffness (>1Prolonged morning stiffness (>1
hr)hr)
 PIPs, MCPs, and wristPIPs, MCPs, and wrist
commonly involvedcommonly involved
 Symmetric joint involvementSymmetric joint involvement

9. RA radiography - earlyRA radiography - early
 Earliest signs include softEarliest signs include soft
tissue swelling due totissue swelling due to
effusion, tenosynovitis,effusion, tenosynovitis,
and edemaand edema
 Periarticular osteopeniaPeriarticular osteopenia
 Marginal erosions oftenMarginal erosions often
first seen at 2first seen at 2ndnd
and 3and 3rdrd
MCPs and 3MCPs and 3rdrd
PIPPIP
articulationsarticulations

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

11. Advanced RAAdvanced RA
 Boutonniere (top)Boutonniere (top)
 Swan neckSwan neck
 Labs:Labs:
– +RF in 80%: IgM against+RF in 80%: IgM against
Fc of IgGFc of IgG
– Elevated ESRElevated ESR
– Anemia of chronicAnemia of chronic
diseasedisease

12. RA - LateRA - Late
 Complete MCPComplete MCP
involvementinvolvement
 Large marginalLarge marginal
erosions have nearlyerosions have nearly
destroyed the jointsdestroyed the joints
 Bones are lucent dueBones are lucent due
to osteopeniato osteopenia
 Ulnar deviationUlnar deviation

13. RA Bone ScanRA Bone Scan
 Technetium-99 boneTechnetium-99 bone
scanscan
 Uptake shown inUptake shown in
subclinicalsubclinical
inflammation of jointsinflammation of joints
 SymmetricalSymmetrical
 PolyarticularPolyarticular

14. Calcium pyrophosphate dihydrateCalcium pyrophosphate dihydrate
crystals (CPPD)crystals (CPPD)
 ““Pseudogout”Pseudogout”
 Associated with metabolic diseases such asAssociated with metabolic diseases such as
hyperparathroidism, hemochromatosis,hyperparathroidism, hemochromatosis,
hypothyroidismhypothyroidism
 Compared to gout:Compared to gout:
– Large joints affected (2Large joints affected (2ndnd
to 5to 5thth
MCPs, radio-carpal)MCPs, radio-carpal)
– Rhomboid crystalsRhomboid crystals
– Positive birefringencePositive birefringence
– Calcification of articular cartilageCalcification of articular cartilage
– No cortical erosionsNo cortical erosions

15. CPPDCPPD
 ChondrocalcinosisChondrocalcinosis
 Distal radius and MCPs (2Distal radius and MCPs (2ndnd
and 3and 3rdrd
))
 Cartilage destructionCartilage destruction
similar to OA –similar to OA –
differentiate by locationdifferentiate by location
 Location similar to RA –Location similar to RA –
differentiate by absense ofdifferentiate by absense of
erosionserosions
 Calcium deposition atCalcium deposition at
triangular fibrocartilage oftriangular fibrocartilage of
the wrist (picture)the wrist (picture)

16.  CPPDCPPD
 Diffuse condrocalcinosisDiffuse condrocalcinosis
at the radiocarpal joint,at the radiocarpal joint,
the MCP joints and thethe MCP joints and the
PIPPIP
 Joint space narrowing,Joint space narrowing,
sclerosis, andsclerosis, and
subchondral cysts withinsubchondral cysts within
the carpalsthe carpals

17. Brief summary so farBrief summary so far

18. GoutGout
 Disorder of purine metabolismDisorder of purine metabolism
– overproduction versus– overproduction versus
underexcreationunderexcreation
 Deposition of urate crystals inDeposition of urate crystals in
joint spacesjoint spaces
 Middle-aged menMiddle-aged men
 Acute onset of extreme painAcute onset of extreme pain
in small joints with rednessin small joints with redness
and swellingand swelling
 Needle shaped crystals withNeedle shaped crystals with
negative bifringencenegative bifringence
 Asymmetric, monoarticularAsymmetric, monoarticular

19. GoutGout

20. Gout RadiographyGout Radiography
 All joints of hand and wristAll joints of hand and wrist
possible (2possible (2ndnd
-5-5thth
PIP mostPIP most
common)common)
 Soft tissue swellingSoft tissue swelling
 Well demarcated osseousWell demarcated osseous
erosions with sclerotic rims anderosions with sclerotic rims and
overhanging edgesoverhanging edges
 No decrease in bone densityNo decrease in bone density
 TophiTophi notnot calcifiedcalcified
 Relative sparing of joint spaceRelative sparing of joint space
until late in the diseaseuntil late in the disease
 Long latent period betweenLong latent period between
onset of symptoms andonset of symptoms and
radiographic changesradiographic changes

21. More goutMore gout

22. Psoriatic ArthritisPsoriatic Arthritis
 HLA-B27 positive, RF negativeHLA-B27 positive, RF negative
 InflammatoryInflammatory
 SeronegativeSeronegative
spondyloarthropathyspondyloarthropathy
 Asymmetric and bilateralAsymmetric and bilateral
 Primarily distal involvementPrimarily distal involvement
associated with nail changesassociated with nail changes
 No periarticular osteoporosisNo periarticular osteoporosis
 Five different patternsFive different patterns
 Usually accompanies skinUsually accompanies skin
diseasedisease

23. Psoriatic Arthritis – Rad findingsPsoriatic Arthritis – Rad findings
 Asymmetric proliferative erosions with ill-Asymmetric proliferative erosions with ill-
defined marginsdefined margins
 Periosteal reactionPeriosteal reaction
 Soft tissue swellingSoft tissue swelling
 ““Pencil-in-cup” deformityPencil-in-cup” deformity
 Resorption of distal phalangeal tuftsResorption of distal phalangeal tufts
 SubluxationSubluxation

24. Psoriatic arthritisPsoriatic arthritis

26. All done. Any questions?All done. Any questions?

27. SourceSource
 http://rad.usuhs.mil/medpixhttp://rad.usuhs.mil/medpix
 Additional listed on requestAdditional listed on request