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

History:  Woman with disability.
Click these images to enlarge them.

Click for galleryClick for galleryClick for galleryClick for galleryClick for galleryClick for galleryWhich choices apply? Please respond with TRUE or FALSE.
Congenital anomaly

True or False
Joint space narrowing

True or False
Bony erosions

True or False
Neuropathic joints

True or False
Soft tissue masses

True or False
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Same images are again shown below. Can you select the actual diagnosis?

Osteoarthritis.Rheumatoid arthritis.Calcium pyrophosphate crystal deposition disease.Psoriatic arthritis.Lupus.Click for galleryClick for galleryClick for galleryClick for galleryClick for galleryClick for gallery
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Findings:  Right wrist. Extensive carpometacarpal, intercarpal and radiocarpal joint space narrowing with extensive bony erosions throughout the carpal bones and distal radius and ulna. Left wrist. Stable severe joint space loss of the carpometacarpal, intercarpal and radiocarpal joint spaces. Bony erosions throughout the carpal bones. Widening of the scapholunate joint space. Migration of the capitate proximally.


Differential diagnosis:

  • Osteoarthritis
  • Rheumatoid arthritis
  • Infectious arthritis
  • Calcium pyrophosphate crystal deposition disease
  • Psoriatic arthritis
  • Autoimmune chronic polyarthritis
  • Juvenile idiopathic arthritis
Diagnosis:  Rheumatoid arthritis
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Key Points - Rheumatoid arthritis:

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

Radiologic overview:

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)

Key points:

  • 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

References:

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