Leanne Alblas

2nd year rheumatology trainee

Western Health 2015

 Questions
Review

of Arthritis approach
Imaging in arthritis

Inflammatory
or Mechanical

Large vs.
small joints
Deforming
vs. Non
deforming

Symmetrical
vs.
Asymmetrical

Acute,
subacute,
or Chronic

Mono-,
Oligoor
Polyarthritis

 65

yo female with an acute nondeforming symmetrical small joint

inflammatory polyarthritis

85

yo man with a chronic large joint

asymmetrical mechanical oligoarthritis

32

yo woman with a subacute

inflammatory deforming monoarthritis of
her right knee

Inflammatory

Mechanical

>30min

<30min

Better

worse

Night pain

Present

+/-

Associated swelling

Boggy

bony

Xray findings

Often minimal

OA

Impact of rest

worse

better

Early Morning Stiffness

Impact of movement

Number
Common
causes

Weeks

Monoarthritis Oligoarthrit Polyarthriti

is
s
1
2-4
5
OA
Gout
CPPD
Septic arthritis

PsA
RA (initially)
OA

RA
SLE

Acute
<6

Subacute
6

Chronic
>6

Symmetrical

Asymmetrical

RA

OA
PsA

 Single

joint

DDx

Septic arthritis
Traumatic (haemarthrosis, #)
Crystals (gout, pseudogout)
Initial presentation of RA, PsA, Ank Spond

 Eye

scleritis/iritis (A.S, RA, reactive)

Rash (SLE, Psoriasis)
Obesity (psoriasis/gout)
ILD
Basal - RA, SLE, Scleroderma,

Apical - Ank spond

Nail

changes

Ridging/pitting Psoriasis

Nailfold (capillaries) SLE, scleroderma

 Osteoarthritis
Rheumatoid

Arthritis
Psoriatic Arthritis
Ankylosing spondylitis
Gout
Pseudogout (CPPD)
SLE
Haemachromatosis

 Asymmetrical
Older

population
Involves
Features:
Crepitus

Mechanical (worse post activity)

Bony joint enlargement
Limited joint mobility

 Usually

SPARES wrists, elbows, shoulders,

ankles, MCP, 2nd-5th MTP
If present, consider 2 causes
Group

Example

Congenital

Congenital Hip Dislocation

Dysplasia

Epiphyseal

Mechanical

Joint hypermobility, valgus/varus deformity

Trauma

ACL tear, meniscectomy/prev. arthroscopy

Metabolic

HH, Haemaglobinopathy, Crystal deposition

Endocrine

Acromegaly, Thyroid

Neuropathy

DM, Syphilis

Other

End result of inflammatory/infective arthritis

 Joint

Space Narrowing
Osteophytes spurs
Subchondral cysts geodes
Sclerosis

 Hard bony enlargements

Bouchards nodes at

the PIP joints

Heberdens nodes at

the DIP joints

Often have squared first

CMC joint due to

osteophytes at that joint

Change
pic to
nonerosive

Heberdens nodes - DIP

Bouchards nodes - PIP

 JSN (usually medial >

lateral)
Osteophytes
Subchondral sclerosis

 JSN (usually medial >

lateral)
Osteophytes
Subchondral sclerosis

Subchondral
cysts

 Component

of
inflammation
Affect:
5-10% of OA patients
Typically women in 40s

Joints involved:
DIP, PIP, 1st CMC
Bilateral
Investigations
Normal ESR/CRP
Neg RF, ANA

Gull wing sign

 Component

of
inflammation
Affect:
5-10% of OA patients
Typically women in 40s

Joints involved:
DIP, PIP, 1st CMC
Bilateral
Investigations
Normal ESR/CRP
Neg RF, ANA

Gull wing sign

 Do

weight bearing views for large joints

Synovial fluid analysis
WCC<1000-2000
Age

is the biggest risk factor

Obesity is the most modifiable risk factor
Knee OA risk by 36% for every 5kg wgt gain.
Symptomatic

OA << radiological OA

Dont just assume OA is the cause

 Symmetrical

inflammatory small joint

polyarthritis
Affects F>M
Involves
PIP, wrist, elbow, shoulder, Cervical spine, knees,

ankles, MTPs
SPARES

DIPs, hips, thoraco-lumbar spine

 Uniform

JSN (Joint Space Narrowing)

Generalised osteoporosis
Marginal erosions (of bare areas)
Peri-articular soft tissue swelling
Subluxation

 Boutonniere

deforming
Soft tissue swelling/bogginess
Ulnar deviation at level of MCPs
Dele
te
this

Generalised
osteoporosis

Subluxation and ulnar

deviation of proximal
phalanx with respect to
MCPs
Erosions

 Asymmetrical

inflammatory arthritis

involving
Hands (esp. DIP)
Feet
Sacro-iliac joint (SIJ)
Spine

Peripheral
Axial

 Asymmetrical

involving

inflammatory arthritis

Hands (esp. DIP)

Peripheral
Feet
Sacro-iliac joint (SIJ)
Axial
Spine

May

precede or follow psoriasis

 Dactylitis
DIP
Nail

involvement
changes

Onycholysis
Pitting
Ridging

 Fusiform

soft tissue swelling

Bony proliferation periostitis
Joint space loss
pencil in cup
Normal bone mineralisation

Sausage like
swelling of whole digits
dactylitis

Sausage like
swelling of whole digits
dactylitis

severe erosive of 2nd & 3rd

DIPs

Sausage like
swelling of whole digits
dactylitis

severe erosive of 2nd & 3rd

DIPs

solid periosteal new bone

Pencil in cup

Pencil in cup

Ankylosis

Pencil in cup

Periostitis

Ankylosis

 Cf. to

Ankylosing spondylitis

Unilateral or asymmetrical bulky bony

outgrowths of paraverterbral spine

 Enthesitis

is a distinguishing feature

Axial

Insidious onset inflammatory back pain

Peripheral

Mono/ oligo-arthritis, usually lower limb

HLAB27

 Definite

sacroiliitis (on xray)

grade II bilaterally or
Grade III/IV unilaterally
SI

changes are usually bilateral &

symmetric

Initially involve
2/3rd of SI joint

the synovial lined lower

Grade I

Suspicious change
Irregular joint space w/o sclerosis or
well defined erosions

Grade II

Grade I

Grade II

Suspicious change
Irregular joint space w/o sclerosis or
well defined erosions

Min Abnormalities
small localised erosions/sclerosis but
Normal joint width

Grade III

Unequivocal Abnormal
mod-advanced sacroiliitis & 1 of:
erosions, sclerosis, widening,
narrowing or partial ankylosis

Grade IV

Grade III

Grade IV

Unequivocal Abnormal
mod-advanced sacroiliitis & 1 of:
erosions, sclerosis, widening,
narrowing or partial ankylosis

Completely ankylosed (fused)

Syndesmophytes

Diffuse Idiopathic Skeletal Hyperostosis

Not an arthropathy but a bone forming
condition
Normal cartilage, bony margins & synovium
Affects

older patients
Esp. thoracic spine
Assoc. with stiffness/ROM

NOTE
Normal disc spaces
Need 4 contiguous
vertrebral bodies with
ossification

Flowing ossification of
paraspinal phytes
anterior to vertebral
bodies

Get AP
view of
DISH

Ossification of
longitudinal ligament
(ant. To vertebral
bodies)
Can cause dysphagia!

 Rapid

onset painful erythematous joint

pain, swelling and erythema
Initially monoarticular (eg Podagra)
Later polyarticular

Asymmetrical
Monosodium

bifringent

urate crystals negatively

Commonly affects
Feet>Ankles>Knees> Hands >
Elbows

Increasingly recognised in axial

spine
Often involves periarticular
structures

With chronicity may develop

tophi

 Tophi
Punched

out lesions with sclerotic

borders
Overhanging edge of cortex
Normal joint space & mineralisation

Tophi in 1st 3rd MTP

& 1st IP with assoc.
erosion

Normal
mineralisation

 3rd most common inflammatory arthritis

3.4% adults
Characterised by calcium pyrophosphate

deposition in cartilage
Risk factors
Age
OA

Presentation very variable:

Acute or chronic
Mono- oligo-, poly- arthritis
Inflammatory or non-inflammatory

 Most common joints involved

Wrist
Knee
If presents <55yo, consider 2
Hyperparathyroidism
Haemachromatosis
Hypomagnasemia
Hypophophatemia
Dialysis
Trauma

causes

Chondrocalcinosis

Note:
Underlying OA
Should find bilateral
changes on xray
Also xray wrists

Calcification of
trianglular
fibrocartilage

 Typically

inflammatory small joint

polyarthritis similar to RA
However it is rarely erosive/destructive

Can

also have Rhupus

Arthritis strongly resembling RA with erosions &

positive RF
Fixed derformities

 Jaccoud

arthritis non-erosive
arthropathy
Occurs in 10-35%
Swan neck (lax joint capsule, tendons, ligaments)
MCP subluxation
Ulnar deviation

 Jaccoud

arthritis non-erosive
arthropathy
Occurs in 10-35%
Swan neck (lax joint capsule, tendons, ligaments)
MCP subluxation
Ulnar deviation

Hook like osteophytes at

MCPs esp. 2nd & 3rd

 Can

involve any joint!

Commonly
2nd & 3rd MCPs with associated pain and stiffness
PIPs, radiocarpal, knees, hips, ankles, shoulders

Can

have CPPD causing flares

Chondrocalcinosis found in 30-60%

Synovial

fluid is non-inflammatory