What is Your Diagnosis

Rheumatoid arthritis (RA): This entity is a rheumatic disease that is seropositive for the rheumatoid factor antibody in 70-80% of cases and runs a chronic relapsing clinical course. Regions most often affected are the radiocarpal joints, the styloid process of the ulna as well as the meta-carpophalangeal and proximal interphalangeal joints (Fig. 8.49). In the first place the bone is demineralized close to the joint and there is periarticular soft tissue swelling. In a later phase there is a generalized loss of joint space in the absence of new bone formation (as you would see in osteoarthritis). Erosions of the bone develop in the articular periphery where cortical bone is not protected by overlying cartilage and is therefore exposed to the synovial inflammatory response. Eventually typical subluxations with ulnar deviation in the finger joints occur. Severe joint mutilations and fusions indicate end-stage disease.

Psoriatic arthritis: Seronegative psoriatic arthritis is a complication of psoriasis. It prefers the distal interphalan-geal joints, but the iliosacral joints and the spine can also be involved. The skin manifestations, thick, pitted fingernails, and the impressive swelling of single fingers, which is also visible on radiographs ("sausage digit," Fig. 8.50), are pathognomonic.

I Consequences of Degenerative Diseases of the Shoulder Joints

Pitted Nails From Psoriatic Arthritis

Fig. 8.46a Calcifications in the subacromial bursa (arrows) indicate problems of the rotator cuff, which in turn can be due to osteoarthritis of the acromioclavicular joint, often when associated with a subacro-mial spur. b The rotator cuff, an arc of tendons of shoulder muscles, is low in water content and shows consistently low in signal in MRI for that very reason. On this image of a T2-weighted sequence, a fluid-filled defect (arrow) is visible in the cuff. This is a rupture of the rotator cuff. c The osteoarthritis of the acromioclavicular joint shown here (arrows) causes impingement that over time may contribute to rupture of the rotator cuff. d The advanced degenerative disease of the shoulder joint in this patient has completely used up the subacromial space (arrow)— bone rubs on bone. The osteophytes along the lower contour of the humeral head confirm the diagnosis.

I Shoulder Dislocation

Fig. 8.47 This CT section through the shoulder joint shows an anterior shoulder dislocation after trauma. During dislocation, the humerus banged against the anterior bony glenoid labrum, which caused an impression fracture of the humeral head—the so-called Hill-Sachs defect (arrow). The homogeneous bone sclerosis along the base of the groove and the osseous support rim at the neck of the scapula indicate that this dislocation has been present or has recurred regularly for quite some time.

I The Case of Barbara Noosh

I Rheumatoid Arthritis

I The Case of Barbara Noosh

Hill Sachs Defect Radiograph

Fig. 8.48 This radiograph of Mrs. Noosh's hand shows changes characteristic of a specific disease. Can you tell which one?

Fig. 8.49a-c Rheumatoid arthritis tends to start around the radiocarpal joint. Observe the loss of the joint space and the lytic defects in (a). Lytic defects also develop in the periphery of the finger joints (b). Advanced rheumatoid arthritis (c) is characterized by the almost complete joint destruction and ulnar deviation of the fingers. There are erosions of the periarticular cortex.

I Psoriatic Arthritis

I Psoriatic Arthritis

Sausage Digit
Fig. 8.50 The "sausage finger" (second digit) is a characteristic finding in psoriatic arthritis. The phalanges are plump, the joint spaces are diminished.

Osteoarthritis of the hand and finger joints: This condition preferentially affects the distal (Heberden type) and proximal interphalangeal joints (Bouchard type), the metacarpophalangeal joints, and the trapeziometacarpal joint of the thumb. In the example radiograph provided, the bases of the distal and middle phalanges show lateral and dorsal osteophytes, which give the joint something of a "bird in the sky" or "seagull wing" configuration (Fig. 8.51). Joint space loss is also seen.

• Diagnosis: Paul has no doubt that Mrs. Noosh suffers from a textbook case of rheumatoid arthritis and he is right, of course.

I Heberden Type and Bouchard Type Osteoarthritis

I Heberden Type and Bouchard Type Osteoarthritis

Carpometacarpal Joint Space

Fig. 8.51 a, b Changes in degenerative osteoarthritis dominate in the distal carpal joints and the distal finger joints (Heberden) (a). The degenerative changes are less pronounced at the level of the proximal interphalangeal joints (Bouchard). In addition there is degenerative change in the carpometacarpal joint of the thumb. The finger joint space (b) has the typical "bird in the sky" or "gullwing" configuration. Joint space loss is also seen. There is periarticular bone sclerosis and soft tissue swelling, resulting in the typical Heberden nodes.

Fig. 8.51 a, b Changes in degenerative osteoarthritis dominate in the distal carpal joints and the distal finger joints (Heberden) (a). The degenerative changes are less pronounced at the level of the proximal interphalangeal joints (Bouchard). In addition there is degenerative change in the carpometacarpal joint of the thumb. The finger joint space (b) has the typical "bird in the sky" or "gullwing" configuration. Joint space loss is also seen. There is periarticular bone sclerosis and soft tissue swelling, resulting in the typical Heberden nodes.

I The Case of Odi Hatburn

I The Case of Odi Hatburn

Joint Thumb Pain Joint Space Loss
Arthritis Relief Now

Arthritis Relief Now

When you hear the word arthritis, images of painful hands and joints comes into play. Few people fully understand arthritis and this guide is dedicated to anyone suffering with this chronic condition and wants relief now.

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