Arthritis

TYPES OF JOINTS 1. Fibrous – sutures, syndesmoses 2. Cartilaginous – discovertebral junction, growth plate 3. Synovial – appendicular skeleton, apophyseal joint WHAT MAKES-UP A SYNOVIAL JOINT? • Two apposing bones • Joint space o Hyaline cartilage at articular surface o Synovial fluid • Fibrous joint capsule lined by synovial membrane

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SYNOVIAL JOINT

Eburnation Heberden’s nodes Bouchard’s nodes “joint mice” General term for degenerative changes affecting any type of joint (fibrous, cartilaginous, or synovial) Most frequent articular affliction Extraspinal Osteoarthritis  Synovial joints Spinal Intervertebral (osteo)chondrosis Spondylosis deformans Osteoarthritis Ligamentous degeneration

EXTRASPINAL DJD: OSTEOARTHRITIS • Alterations in the bone and cartilage • Findings: Loss of joint space Eburnation Osteophytosis Cyst formation • • •

DISCOVERTEBRAL JUNCTION

CLASSIFICATION OF ARTHRITIS I. Degenerative Disease II. Rheumatoid Arthritis and related diseases III. Crystal-induced and related diseases IV. Infectious V. Neurogenic and Traumatic VI. Primary synovial disease VII. Miscellaneous WHAT TO LOOK FOR: • Morphology of articular lesions • Distribution in the body ABCDs

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Alignment Bone mineralization Cartilage, also search for Erosions Distribution Soft tissues

WHAT IS THE MOST COMMON TYPE OF ARTHRITIS? Degenerative Joint Disease

Joint space narrowing Sclerosis Osteophytosis

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Also: Sublaxation Malalignment Fibrous ankylosis Intraarticular bodies

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Pathogenesis: Physical forces on joint a. abnormal force b. weak cartilage or subchondral bone ↓ Articular cartilage disruption ↓ Greater stress on subchondral bone ↓ Osseous degenerative changes ↓ Vicious cycle Overload ↓ Microfractures in subchondral bone ↓ Repair resulting in “stiffness” of bone (reduced shock absorption) ↓ Increased force to overlying cartilage ↓ Vicious cycle

STRESSED & NON-STRESSED SEGMENTS OF THE JOINTS

Joint “Loose bodies”

Thinning of cartilage Vascular invasion Infarction Necrosis of subchondral Joint space loss Bone sclerosis

OSTEOARTHRITIS - Usual sites: Hand Distal interphalangeal (DIP) Proximal interphalangeal (PIP) Metacarpals (MCP) Wrist 1st CMC, trapezioscaphoid area Should Acromioclavicular er Sternoclavicular Hip Superolateral joint space narrowing Knee Medial > patellofemoral > lateral Foot TMT 1st MTP

OSTEOARTHRITIS – Radiographic Features: • Asymmetric joint space narrowing • Osteophyte formation • Reactive subchondral sclerosis (eburnation) • Subchondral cysts (degenerative cysts, geodes) • No erosions • Normal mineralization • Intraarticular loose bodies (joint mice)

Osteophytosis

Entheses / “Enthesopathy” • Degenerative osteophytes at tendon and ligament insertions

Subchondral Cysts

Heberden’s and Bouchard’s nodes • Osteophyte formation and soft tissue swelling secondary to osteoarthritis • Location: DIP: Heberden’s nodes

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PIP: Bouchard’s nodes

JOINTS OF THE SPINE

INTERVERTEBRAL (OSTEO)CHONDROSIS Joint space narrowing • Dehydration PRIMARY OSTEOARTHRITIS • Unknown cause • Familial Middle-aged female Hands: DIP, PIP, base of thumb Bilaterally symmetric • Erosive osteoarthritis Very painful and debilitating “Gullwing configuration” of Erosive OA

Vacuum disc = nitrogen gas

SECONDARY OSTEOARTHRITIS • Trauma or microtrauma over the years DEGENERATIVE DISEASE OF THE SPINE • Osteoarthritis • Intervertebral (osteo)chondrosis Dehydration of intervertebral disc • Spondylosis deformans Osteophyte formation after degeneration of outer fibers of anulus fibrosus • Ligamentous degeneration Calcification and ossification OSTEOARTHRITIS IN THE SPINE • Apophyseal and costovertebral joints • Joint space narrowing and sclerosis • Normal intervertebral disc and vertebral body

Schmorl’s nodes = elevated pressure on disc causes prolapse

SUBCHONDRAL SCLEROSIS • Usually affects anterior vertebral body; common at L4

Bilaterally symmetric

Uniform joint space narrowing

FORESTIER’S DISEASE • Cervical spine

Marginal erosions

WHAT ARE THE INFLAMMATORY ARTHRITIDES? • Rheumatoid Arthritis and Related Diseases (Arthritis of Collagen and Collagen-like diseases) • •

Erosions Joint space narrowing ARTHRITIS OF COLLAGEN AND COLLAGEN-LIKE DISEASES • Seropositive Rheumatoid arthritis • Seronegative (rheumatoid factor negative) Ankylosing spondylitis Inflammatory bowel disease Reiter’s syndrome - Psoriasis Scleroderma SLE RHEUMATOID ARTHRITIS • Uniform narrowing • Bilaterally symmetric • Periarticular swelling • Marginal erosions • Juxtaarticular osteoporosis • No new bone formation • Subluxations • Synovial cysts

Pathophysiology Acute synovitis ↓ Exudation of plasma ↓ Altered capillary permeability ↓ Accumulation of RBC ↓ Hemosiderin deposition • •

Thickening of synovial membrane Elevated synovial fluid cell

Atlantoaxial subluxation

RHEUMATOID ARTHRITIS • Marked erosive changes • Ulnar deviation at the wrist • “Penciling of ulna” • Fingers Swan-neck deformity Boutonniere deformity

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Cervical spine Atlantoaxial subluxation (25%)

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Predilection of the proximal joints of the hands and feet (carpal, MCP/tarsal, MTP)

Penciling of ulna Erosion of ulnar styloid process “Ulnar deviation”

RHEUMATOID ARTHRITIS • Proximal joints of hands and feet • Atlantoaxial subluxation • Swan-neck deformity • Boutonniere deformity • Ulnar deviation • Fibular deviation ADULT RA & JUVENILE RA Adult RA Age Older No.of joints Polyarticular involved Spontaneous No resolution Involvement Hands, feet, larger jts Periostitis More rare Effect of N/A immature skeleton JRA: Apophyseal joint fusion

Swan neck and Boutonniere Synovitis of flexor tendon sheath

JRA: Widespread ankylosis

Juvenile RA Younger Monoarticular or pauciarticular Up to 50% Central large jts – hips, knees Uncommon Growth disturbance

INFLAMMATORY BOWEL DISEASE SERONEGATIVE Negative for Rheumatoid factor Most patients have (+)HLA B-27 Bamboo spine Pencil-in-cup deformity “Can’t see, can’t pee, can’t climb a tree” “Whiskering” = Enthesopathy Arthritis mutilans • Ankylosing spondylitis • Inflammatory Bowel Disease • Reiter’s syndrome • Psoriasis • Scleroderma • SLE ANKYLOSING SPONDYLITIS: Sacroiliac joint

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Bilateral sclerosis

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Bilateral fusion

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Syndesmophytes

PSORIASIS

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Unilateral sacroiliac sclerosis

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Syndesmophytes Thicker

Pencil-in-cup “pencil” – blunted distorted osseous surface ↓ Protruding into ↓ “cup” – expanded osseous surface

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Non-marginal Skip segments

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Subcutaneous and periarticular calcification (but without significant erosion)

REITER’S SYNDROME • Erosive calcaneal enthesopathy

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Uveitis, urethritis, arthritis Venereal disease or dysentery (Shigella) Marked soft tissue swelling Fluffy periostitis

DJD RA JRA AS IBD Psoriasis Reiter’s Scleroderm a SLE

AGE >40 20-50 <16

M:F Varies 1:2 1:1

15-35 Varies 30-50 15-35 20-50

1-10:1 1:1 1:1 5:1 1:3

TYPICAL Axial, knee MCP, wrist Cervical, wrist Axial Axial SI, hand SI, foot Hand

20-40

1:9

Hand

CRYSTAL-INDUCED & RELATED DISEASE • Gout Monosodium urate crystals Erosions with overhanging edges • CPPD • HADD • Hemochromatosis • Wilson’s • Alkaptonuria

SCLERODERMA • Acro-osteolysis Resorption of distal phalangeal tufts

GOUTY ARTHRITIS

TYPICAL DISTRIBUTION OF ARTHRITIS IN THE HIPS

CPPD

TYPICAL DISTRIBUTION OF ARTHRITIS IN THE HANDS

INFECTIOUS ARTHRITIS • Acute Pyogenic Septic • Chronic Pyogenic Tuberculous Other SEPTIC • • • •

ARTHRITIS Monoarthritis Do aspiration Rapid course Poorly defined bone destruction

TYPICAL DISTRIBUTION OF ARTHRITIS IN THE WRISTS

CMC (first carpometacarpal) CCMC (common carpometacarpal) ST (scaphotrapezial) MC (midcarpal) RC (radiocarpal) DRUJ (distal radioulnar joint)

TYPICAL DISTRIBUTION OF ARTHRITIS IN THE KNEES

NEUROPATHIC OR TRAUMATIC • Primary neurologic disease • Diabetes Most common DIABETES ARTHRITIS • Repeated trauma, extensive deformity • “Charcot joint”

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Lisfranc deformity (1st-2nd metatarsal base)

MISCELLANEOUS • Hemophilia • Amyloidosis • Lipoid dermatoarthritis (reticulohistiocytosis) • Idiopathic chondrolysis • Relapsing polychondritis • Hypertrophic osteoarthropathy HEMOPHILIC ARTHRITIS