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Our appreciation is extended to Dr. Peter D. Miller, Indiana University Department of Radiology, for contributing this case.

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Woman with disability.

• Osteoarthritis
• Rheumatoid arthritis
• Infectious arthritis
• Calcium pyrophosphate crystal deposition disease
• Psoriatic arthritis
• Autoimmune chronic polyarthritis
• Juvenile idiopathic arthritis

Woman with disability.

Clinical (hands / wrists):

• Bilateral, symmetrical joint involvement, usually involving carpal joints, MCP joints, PIP joints
• Hyperplasia of synovial cells
• Location in wrist/hand: distal radioulnar joint, ulna and radial styloid, scaphoid, triquetrum, pisiform, radiocarpal, midcarpal, carpometacarpal, MCP and PIP joints
• Erosions, joint space narrowing, soft tissue swelling and ulnar translocation
• Pannus is synovial mass which results in marginal erosions at junction of articular cartilage and bare area of bone.
• Chronic synovial inflammation damages tendons and leads to capsular and ligamentous laxity.
• Clinical symptoms: insidious onset, joint swelling, bilateral, 30% rheumatoid negative
• 4 out of 7 criteria for diagnosis:
  • Morning stiffness lasting more than 1 hour
  • Arthritis of 3 or more joints
  • Arthritis of the hands
  • Symmetric arthritis
  • Positive rheumatoid factor
  • Rheumatoid nodules
  • Radiographic changes
• Physical exam: joint swelling, erythema, pain, tenderness to palpation, joint malalignment, neuropathy of median or ulnar nerve
• Most common in young women 40-60 y/o
• Treatment: medications, physical therapy, synovectomy and tenosynovectomy, arthroplasty or arthrodesis, treat tendon ruptures

Radiographs:

• Negative except soft tissue swelling in early stages
• First sign, ulnar styloid tip erosion and erosions of distal radius and ulna
• Triquetrum and pisiform affected in early stages, as well as erosions of radial aspect of trapezium
• Juxta-articular osteopenia
• Chondral loss of carpal bones with gradual obliteration of joints
• Bony ankylosis of midcarpal in late stages
• Radial deviation of radiocarpal joint and ulnar deviation at MCP joints
• Dorsal subluxation of the ulna.

MRI:

• Best to see synovium, articular cartilage and marrow
• T1, FS PD FSE coronal, axial, sagittal are best sequences
• Marrow edema, early joint effusions, hypertrophied synovium, tenosynovitis, partial tendon tears, pannus (intermediate to hyperintense on T2 and enhances avidly)

• Early rheumatoid may not have any radiographic findings
• 30% are rheumatoid factor negative
• Early sign in wrists is erosions of distal radius, ulna, pisiform and triquetrum
• Proximal joints have hand/wrist and symmetric involvement

1. Statdx.com. Rheumatoid arthritis hands and wrist.  8/26/2011.

Woman with disability.