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TYPES OF JOINTS - Eburnation

1. Fibrous – sutures, syndesmoses - Heberden’s nodes


2. Cartilaginous – discovertebral junction, growth - Bouchard’s nodes
plate - “joint mice”
3. Synovial – appendicular skeleton, apophyseal • General term for degenerative changes affecting
joint any type of joint (fibrous, cartilaginous, or
synovial)
WHAT MAKES-UP A SYNOVIAL JOINT? • Most frequent articular affliction
• Two apposing bones • Extraspinal
• Joint space - Osteoarthritis
o Hyaline cartilage at articular surface  Synovial joints
o Synovial fluid • Spinal
• Fibrous joint capsule lined by synovial membrane - Intervertebral (osteo)chondrosis
- Spondylosis deformans
SYNOVIAL JOINT - Osteoarthritis
- Ligamentous degeneration

EXTRASPINAL DJD: OSTEOARTHRITIS


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

• Joint space narrowing


• Sclerosis
DISCOVERTEBRAL JUNCTION • Osteophytosis

• Also:
- Sublaxation
- Malalignment
- Fibrous ankylosis
- Intraarticular bodies
• Pathogenesis:
Physical forces on joint
a. abnormal force
b. weak cartilage or subchondral
bone

CLASSIFICATION OF ARTHRITIS Articular cartilage disruption
I. Degenerative Disease ↓
II. Rheumatoid Arthritis and related diseases Greater stress on subchondral bone
III. Crystal-induced and related diseases ↓
IV. Infectious Osseous degenerative changes
V. Neurogenic and Traumatic ↓
VI. Primary synovial disease Vicious cycle
VII. Miscellaneous
Overload
WHAT TO LOOK FOR: ↓
• Morphology of articular lesions Microfractures in subchondral bone
• Distribution in the body ↓
Repair resulting in “stiffness” of bone
ABCDs (reduced shock absorption)

• Alignment Increased force to overlying cartilage
• Bone mineralization ↓
Vicious cycle
• Cartilage, also search for Erosions
• Distribution
• Soft tissues

WHAT IS THE MOST COMMON TYPE OF ARTHRITIS?


Degenerative Joint Disease
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 Osteophytosis
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) Entheses / “Enthesopathy”
• Subchondral cysts (degenerative cysts, geodes) • Degenerative osteophytes at tendon and
• No erosions ligament insertions
• Normal mineralization
• Intraarticular loose bodies (joint mice)

Subchondral Cysts

Heberden’s and Bouchard’s nodes


• Osteophyte formation and soft tissue swelling
secondary to osteoarthritis
• Location:
- DIP: Heberden’s nodes
- 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 Schmorl’s nodes = elevated pressure on disc causes
• Osteoarthritis prolapse
• 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
SUBCHONDRAL SCLEROSIS
• Usually affects anterior vertebral body; common Bilaterally symmetric
at L4

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 Pathophysiology
narrowing Acute synovitis
ARTHRITIS OF COLLAGEN AND COLLAGEN-LIKE DISEASES ↓
• Seropositive Exudation of plasma
- Rheumatoid arthritis ↓
• Seronegative (rheumatoid factor negative) Altered capillary permeability
- Ankylosing spondylitis ↓
- Inflammatory bowel disease Accumulation of RBC
- Reiter’s syndrome ↓
- Psoriasis Hemosiderin deposition
- Scleroderma
- SLE • Thickening of synovial
membrane
RHEUMATOID ARTHRITIS • Elevated synovial fluid cell
• Uniform narrowing
• Bilaterally symmetric
• Periarticular swelling
• Marginal erosions
• Juxtaarticular osteoporosis
• No new bone formation
• Subluxations
• Synovial cysts
Atlantoaxial subluxation

RHEUMATOID ARTHRITIS
• Marked erosive changes
RHEUMATOID ARTHRITIS
• Ulnar deviation at the wrist
• Proximal joints of hands and
• “Penciling of ulna”
feet
• Fingers • Atlantoaxial subluxation
- Swan-neck deformity
• Swan-neck deformity
- Boutonniere deformity
• Boutonniere deformity
• Cervical spine • Ulnar deviation
- Atlantoaxial subluxation (25%) • Fibular deviation
• Predilection of the proximal joints of the hands ADULT RA & JUVENILE RA
and feet (carpal, MCP/tarsal, MTP) Adult RA Juvenile RA
Age Older Younger
Penciling of ulna
No.of joints Polyarticular Monoarticular or
- Erosion of ulnar styloid process
involved pauciarticular
- “Ulnar deviation”
Spontaneous No Up to 50%
resolution
Involvement Hands, feet, Central large jts –
larger jts hips, knees
Periostitis More rare Uncommon
Effect of N/A Growth
immature disturbance
skeleton

JRA: Apophyseal joint fusion

Swan neck and Boutonniere


- Synovitis of flexor tendon sheath

JRA: Widespread ankylosis


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 PSORIASIS
• SLE • Unilateral sacroiliac sclerosis
• Pencil-in-cup
ANKYLOSING SPONDYLITIS: Sacroiliac joint “pencil” – blunted distorted osseous surface
• Bilateral sclerosis ↓
Protruding into

“cup” – expanded osseous surface

• Bilateral fusion

• Syndesmophytes
• Syndesmophytes
- Thicker
- Non-marginal
- Skip segments

• Subcutaneous and periarticular calcification (but


without significant erosion)

REITER’S SYNDROME
• Erosive calcaneal enthesopathy

AGE M:F TYPICAL


DJD >40 Varies Axial, knee
• Uveitis, urethritis, arthritis RA 20-50 1:2 MCP, wrist
• Venereal disease or dysentery (Shigella) JRA <16 1:1 Cervical,
wrist
• Marked soft tissue swelling
AS 15-35 1-10:1 Axial
• Fluffy periostitis
IBD Varies 1:1 Axial
Psoriasis 30-50 1:1 SI, hand
Reiter’s 15-35 5:1 SI, foot
Scleroderm 20-50 1:3 Hand
a
SLE 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 GOUTY ARTHRITIS
- Resorption of distal phalangeal tufts
TYPICAL DISTRIBUTION OF ARTHRITIS IN THE HIPS

CPPD

INFECTIOUS ARTHRITIS
• Acute
- Pyogenic
- Septic
• Chronic
- Pyogenic
- Tuberculous
TYPICAL DISTRIBUTION OF ARTHRITIS IN THE HANDS - Other

SEPTIC ARTHRITIS
• Monoarthritis
• Do aspiration
• Rapid course
• Poorly defined bone destruction

TYPICAL DISTRIBUTION OF ARTHRITIS IN THE WRISTS

NEUROPATHIC OR TRAUMATIC
• Primary neurologic disease
• Diabetes
- Most common
CMC (first carpometacarpal)
CCMC (common carpometacarpal) DIABETES ARTHRITIS
ST (scaphotrapezial)
• Repeated trauma, extensive deformity
MC (midcarpal)
RC (radiocarpal) • “Charcot joint”
DRUJ (distal radioulnar joint) • Lisfranc deformity (1st-2nd metatarsal base)

TYPICAL DISTRIBUTION OF ARTHRITIS IN THE KNEES


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

HEMOPHILIC ARTHRITIS