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Published on : Dec 06, 2013
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Slide 1 - Arthritis of the Hands
Slide 2 - On the Agenda Normal Osteoarthitis Rheumatoid arthritis CPPD crystal deposition Gout Psoriatic arthritis
Slide 3 - Normal Hand X-ray
Slide 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
Slide 5 - OA – Radiographic findings Joint space narrowing Osteophyte formation (white arrow) Subchondral sclerosis (black arrows)
Slide 6 - Joint space narrowing distally Marginal osteophytes Relatively unchanged proximal structures
Slide 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)
Slide 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
Slide 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
Slide 10 - Severe erosive changes at radio-ulnar joints carpal bones at the metacarpal heads Bilaterally symmetric
Slide 11 - Advanced RA Boutonniere (top) Swan neck Labs: +RF in 80%: IgM against Fc of IgG Elevated ESR Anemia of chronic disease
Slide 12 - RA - Late Complete MCP involvement Large marginal erosions have nearly destroyed the joints Bones are lucent due to osteopenia Ulnar deviation
Slide 13 - RA Bone Scan Technetium-99 bone scan Uptake shown in subclinical inflammation of joints Symmetrical Polyarticular
Slide 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
Slide 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)
Slide 16 - CPPD Diffuse condrocalcinosis at the radiocarpal joint, the MCP joints and the PIP Joint space narrowing, sclerosis, and subchondral cysts within the carpals
Slide 17 - Brief summary so far
Slide 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
Slide 19 - Gout
Slide 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
Slide 21 - More gout
Slide 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
Slide 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
Slide 24 - Psoriatic arthritis
Slide 25 - ppt slide no 25 content not found
Slide 26 - All done. Any questions?
Slide 27 - Source http://rad.usuhs.mil/medpix Additional listed on request