Joints:

• Joint space loss at DIPJs most pronounced at the left 3rd DIPJ, with central erosions (2nd DIPJs) and osteophytosis, “gull-wing” appearance

Alignment:

• Normal

Bone:

• Normal

Soft tissue:

• Mild soft tissue swelling bilateral 2nd and 3rd DIPJs

Erosive osteoarthritis

Teaching Point: Classic “gull-wing” pattern of erosive OA

Joints:

• Bilateral erosive disease, central and marginal, right 1st IP, 4TH & 5TH DIPJs, left 2nd, 4th & 5 DIPJs, 5th PIPJ.
• Small marginal erosions at right 1st MCPJ, 5th PIPJ, left 5th MCPJ.
• Associated joint space loss, also evident at the 2nd and 3rd MCPJs bilaterally.
• No chondrocalcinosis.

Alignment:

• Radial subuxation right 1st IP and left 5th DIPJ

Bone:

• New bone formation left ulnar styloid process and right 1st IPJ.
• No periosteal reaction or periarticular osteopenia.
• Chondrocalcinosis

Soft tissue:

• Mild diffuse soft tissue swelling digits, most pronounced left little finger in keeping with dactylitis.

Psoriatic arthritis

Teaching Point: Involvement DIPJ erosive disease and new bone formation suggests seronegative disease, dactylitis suggests PsA

Joints:

• Normal

Alignment:

• Normal

Bone:

• Normal

Soft tissue:

• Normal

Normal

Teaching Point: Can be difficult not to over call subtle findings particularly when presented with a clinical history of suspected arthritis.

Joints:

• MCPJ joint space loss, most pronounced at the second and third 2nd and 3rd mcpj which also demonstrate osteophytes

Alignment:

• Normal

Bone:

• Normal

Soft tissue:

• Subtle calcification lunotriquetral ligament

CPPD arthropathy

Teaching Point:

• Chondrocalcinosis TFC is classic but remember that may not be radiographically visible in joint involved.
• Check ligaments as in this case.
• The majority of patients with CPPD arthropathy demonstrate chonedrocalcinosis of the wrist (TFC), symphysis pubis (articular disc) or knees (menisci and articular cartilage)

info_outline

Coronal reformatted CT wrist (performed for alternate reason) same patient demonstrating lunotriquetral ligament calcification

Joints:

• Uniform joint space loss right 2nd DIPJ

Alignment:

• Normal

Bone:

• Early new bone formation bilateral 1st, right 2nd and 3rd tufts, right 3rd DIPJ.
• Early resorption right 3rd tuft.
• Incidental prior trauma left 2nd tuft and right 5th metacarpal neck

Soft tissue:

• Soft tissue swelling right 2nd DIPJ.

Seronegative arthritis, most likely Psoriatic arthritis

Teaching Point: New bone formation suggests seronegative arthritis

Joints:

• Minute marginal erosion left 2nd MCPJ and early erosion left ulnar styloid process

Alignment:

• Normal

Bone:

• Early acro-osteolysis bilateral 3rd and right 5th tufts

Soft tissue:

• Bilateral soft tissue swelling over the ulnar styloids and left 2nd, 3rd and right 2nd MCPJs

Scleroderma

Teaching Point:

• Soft tissue swelling over the ulnar styloids suggesting ECU tenosynovitis, is a common finding in inflammatory arthritis, particularly in rheumatoid arthritis and this case could be mistaken for early RhA except for evidence acro-osteolysis and normal bone density.
• Psoriatic arthritis remains within the differential although there is lack of distal joint involvement and new bone formation.

Joints:

• Diffuse carpal fusion, erosions with secondary degenerative disease at the distal radioulnar, radoiocarpal and MCP joints.
• Degenerative 1st IP joint.

Alignment:

• Mild ulnar translocation, ulnar deviation at 3rd MCPJ

Bone:

• Diffuse osteopenia

Soft tissue:

• Normal

Chronic Rheumatoid Arthritis

Teaching Point:

• Note lack of distal joint involvement or new bone formation.
• Compare with contralateral hand to assess for symmetry.

Joints:

• Moderate uniform joint space loss at 4th PIPJ, mild remaining PIPJs, non-uniform at MCPJs.
• No erosions

Alignment:

• Normal

Bone:

• Mild diffuse osteopenia, moderate periarticular osteopenia at the 2nd-4th PIPJs.
• There is a more defined subchondral lucencies head 4th proximal phalynx and ulnar margin base 4th middle phalanx with thinned overlying cortex without definite erosion (intraosseous gout).

Soft tissue:

• Soft tissue swelling of increased density at the 2nd-4th PIPJs, particularly the 4th without calcification, gout top

Gout, acute.

Teaching Point: The subchondral lucencies head 4th proximal phalynx and ulnar margin base 4th middle phalanx represent intraosseous gout

Joints:

• Mild radioscaphoid, moderate to severe triscaphe and 1st CMC degenerative disease with joint space loss without erosions.
• Extensive chonedrocalcinosis TFC complex.

Alignment:

• Normal

Bone:

• Large well defined lucency with sclerotic margin distal radius in keeping with a massive subchondral cyst.
• Smaller subchondral cysts distal ulna , ulnar styloid and base 4th metacarpal.
• Ulnar positive variance without radiographic changes of ulnar abutment syndrome

Soft tissue:

• Normal

CPPD Arthropathy

Teaching Point:

• Crystal disease is associated with subchondral cyst which may large and out of context with degree degenerative disease as in this case.
• Given the size of cyst the patient is predisposed to fracture

Joints:

• Normal

Alignment:

• Normal

Bone:

• Normal

Soft tissue:

• Multiple non-calcified soft tissue nodular skin lesions

Neurofibromatosis

Teaching Point: Always closely review soft tissue for swelling, mass, foreign bodies etc.

Joints:

• Joint space loss at 1st IP and DIPJs most pronounced at the 3rd DIPJ, with central erosions (3rd and 5th DIPJs) and osteophytosis, “gull-wing” appearance.
• There is also joint space loss at the MCPJs, most pronounced at the 2nd and 3rd with associated osteophytes, 1st CMC and triscaphe joints.

Alignment:

• Widened DRUJ.
• Miradial deviation at the 3rd DIPJ

Bone:

• Normal

Soft tissue:

• Mild soft tissue swelling 3rd DIPJ

Mixed disease.

1. Erosive osteoarthritis DIPJs
2. Osteoarthritis carpus and MCPJs suggesting CPPD arthropathy (chondrocalcinosis present on knee X-ray)
3. DRUJ subluxation may relate to prior trauma (subchondral bone is normal, no erosions/periarticular osteopenia or soft tissue swelling)

Teaching Point: More than 1 pathology may be present.

Joints:

• Early degenerative changes with joint space loss and osteophytosis at MCPJs, DRUJ, radoiocarpal joint.
• No erosions

Alignment:

• Normal, Spade-like hand

Bone:

• Prominent ungal tufts.
• Thickened metacarpals and phalanges.
• Normal bone density.

Soft tissue:

• Thickened soft tissues

Acromegaly

Teaching Point: Consider underlying aetiologies for degenerative disease including trauma, crystal depositional diseases etc.