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
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
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
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