ARTHRITIS

dr. John Kurniawan

 ANATOMI

A, A representation of a synovial joint shows the articular cortex, which corresponds to

the thin, white line within the joint capsule that is usually capped by articular cartilage.
The bone immediately beneath the articular cortex is called subchondral bone. Within the
joint capsule is the synovial membrane and synovial fluid. B, On conventional radiographs,
the articular cortex (solid white arrow) and subchondral bone (solid black arrows) are visible
but the cartilage and synovial fluid are not (dotted white arrow).
Lumbar Vertebrae AP view
Lumbosacral joint - - Lateral view
PELVIS
HIP JOINT AP VIEW
Knee anteroposterior view
Knee Lateral
Elbow Joint - Cubital region : Lateral view
Hand and Wrist
 CLASSIFICATION OF ARTHRITIS
Category Hallmarks Types Remarks

Hypertrophi Bone formation Primary osteoarthritis Most common; mechanical stress; hands, hips, and knees most common
c arthritis Osteophytes

Secondary osteoarthritis Degenerative joint disease (DJD) secondary to prior trauma, or avascular necrosis

Charcot arthropathy Fragmentation; joint destruction; sclerosis; most often secondary to diabetes

CPPD Chondrocalcinosis; DJD in unusual sites

Erosive Erosions Rheumatoid Carpals, metacarpal-phalangeal joints, proximal interphalangeal joints of hands;
arthritis osteoporosis; soft-tissue swelling

Gout Juxtaarticular erosions with overhanging edges; long-latency; metatarsal-phalangeal

joint of big toe; no osteoporosis

Psoriatic Juxtaarticular erosions of distal interphalangeal joints of hands; pencil-in-cup

deformity; enthesophytes

Hemophilia Remodeling from hemarthroses and hyperemia; same changes in knee in female-
think of juvenile rheumatoid arthritis

Ankylosing spondylitis HLA-B27+; bilateral sacroiliac (SI) joints; syndesmophytes

Seronegative Rheumatoid factor negative; HLA-B27+; SI joints; syndesmophytes reactive arthritis,

spondyloarthropathies psoriasis

Infectious Osteopenia and soft tissue swelling; early and Pyogenic Early destruction of articular cortex; osteoporosis
arthritis marked destruction of most or all of the TB Gradual and late destruction of articular cortex; marked osteoporosis
articular cortex
The imaging hallmarks of the three major categories of arthritis. A, Hypertrophic
arthritis features subchondral sclerosis (solid black arrow) and marginal osteophyte production
(solid white arrow). B, Erosive (inflammatory) arthritis features characteristic marginal lytic
erosions (solid white and black arrows). C, Infectious arthritis features destruction of the articular
cortex (dotted white arrow).
Osteoarthritis. The hallmarks of
osteoarthritis are demonstrated in this
patient's right hip. There is marginal
osteophyte formation (solid white arrow), a
process by which osseous transformation of
cartilaginous excrescences and metaplasia of
synovial lining cells leads to the production of
bony protrusions at or near the joint. There
is also subchondral sclerosis (solid black
arrows), representing reaction of the bone to
the mechanical stress to which it is subjected
when its protective cartilage has been
destroyed. Subchondral cyst formation is also
present (dotted black arrow)
Osteoarthritis of hip (A) and knee (B). In osteoarthritis, destruction of the cartilaginous
buffer between the apposing bones of a joint leads to narrowing of the joint space most often on
the weight-bearing side of the joint. In the hip (A), the superior and lateral surface is most
affected (solid white arrow) while in the knee (B), the medial compartment is more affected (solid
black arrow)
Osteoarthritis of the hands (A and B). In the hands, osteoarthritis affects primarily the
distal and then proximal interphalangeal joints. There are osteophytes at the distal and
proximal phalangeal joints (solid white arrows) and the joint spaces are narrowed. There is also
subchondral sclerosis present at the carpal-metacarpal joint of the thumb (solid black arrow).
Osteoarthritis of the hands occurs most often in older women.
Some Causes of Secondary
Osteoarthritis
 Trauma
 Infection
 Avascular necrosis
 Calcium pyrophosphate deposition
disease
 Rheumatoid arthritis
Secondary osteoarthritis, right hip. Notice the marked discrepancy between the two
hips with severe and advanced osteoarthritis of the right hip (solid black arrow) and a normal
left hip (solid white arrow). The radiographic findings of secondary osteoarthritis are the same
as those for the primary form except it occurs at an atypical age for primary osteoarthritis, it
has an atypical appearance for primary osteoarthritis, and it may appear in an unusual location
for primary osteoarthritis. This patient had a slipped capital femoral epiphysis on the right, and
it was never attended to medically
Erosive osteoarthritis. A type of primary osteoarthritis characterized by more severe
inflammation and by the development of erosive changes, erosive osteoarthritis may feature
bilaterally symmetrical changes like the osteophytes of DJD but with marked inflammation
(swelling and tenderness). The erosions are typically centrally located within the joint (solid black
arrows) and, combined with the small osteophytes associated with the disease (solid white arrows),
produce what has been called the gull-wing deformity.
Charcot arthropathy of knees. As a hypertrophic arthritis, a Charcot joint will demonstrate
extensive subchondral sclerosis. The hallmark findings of a Charcot joint, however, are
fragmentation of the bones surrounding the joint, which produces numerous small, bony
densities within the joint capsule (solid white arrows) as well as joint space destruction (solid black
arrows). The most common cause of a Charcot joint of the knee is diabetes
Charcot arthropathy of foot. This patient had previously undergone an amputation of the
phalanges of the second toe (solid white arrow) for diabetic gangrene but the destruction and
marked fragmentation of the great toe are manifestations of Charcot neuropathy (solid black
arrows). Charcot neuropathy can produce some of the most dramatic examples of total joint
destruction of any arthritis
Chondrocalcinosis. Chondrocalcinosis refers only to calcification of the articular cartilage
(solid white arrows) or fibrocartilage and is seen in about 50% of adults over the age of 85, most
of whom are asymptomatic. If this patient had acute pain, redness, swelling, and limitation of
motion, the combination would be called pseudogout.
Calcium pyrophosphate deposition disease (CPPD). CPPD arthropathy produces
changes similar to osteoarthritis but differs from it in that CPPD affects joints not usually
affected by primary osteoarthritis. A, Hook-shaped bony excrescences along the 2nd and 3rd
metacarpal heads are a common finding in CPPD (solid white arrows). The radiocarpal joint is
narrowed (solid black arrow). B, In the wrist, characteristic findings include calcification of the
triangular fibrocartilage (solid white arrow), separation of the scaphoid (S) and the lunate (L)
(scapholunate dissociation) and collapse of the capitate (C) toward the radius (solid black arrow)
 Some Causes of Erosive Arthritis

 Rheumatoid arthritis
 Gout
 Psoriatic arthritis
 Ankylosing spondylitis (spine)
 Rheumatoid variants
Box 23-2 Some Causes of Erosive Arthritis

 Reactive arthritis (formerly known as Reiter

syndrome)
 Sarcoid
 Hemophilia
Rheumatoid arthritis, hand (A) and wrist (B). A, In the hand, the erosions of RA tend to
involve the proximal joints: the carpal-metacarpal joints, metacarpal-phalangeal (solid white
arrows), and proximal interphalangeal joints. Late findings in the hands include deformities such
as ulnar deviation of the fingers at the MCP joints, subluxation of the MCP joints, and
ligamentous laxity leading to deformities of the fingers, which are also present in this hand. B, In
the wrist, erosions of the carpals (dotted white arrow), ulnar styloid (solid white arrow), and
narrowing of the radiocarpal joint space (solid black arrow) are commonly seen.
Rheumatoid arthritis of the hip. The larger joints (hips and knees) usually show no erosions,
but there may be marked uniform narrowing of the joint space with little or no subchondral
sclerosis (solid black arrow). If this were primary osteoarthritis, you would expect far more
subchondral sclerosis and osteophyte production for this degree of joint space narrowing
Rheumatoid arthritis of the cervical spine. RA tends to involve the cervical spine by
producing ligamentous laxity, which can lead to forward subluxation of C1 on C2 (atlantoaxial
subluxation). The distance between the anterior border of the dens (D) and the posterior
border of the anterior tubercle of C1 (T) is called the predentate space and is normally no
more than 3 mm. This patient's predentate space measured 8 mm (solid black arrow). RA may also
cause fusion of the facet joints (solid white arrow).
Gout. Gout most commonly affects the metatarsal-phalangeal joint of the great toe, as in this
patient. As an erosive arthritis, the hallmark of gout is the sharply marginated, juxtaarticular
erosion which may have a sclerotic border (solid white arrows). The overhanging edges of gouty
erosions have been called rat bites. The metatarsal-phalangeal joint space is not particularly
narrowed, and there is no periarticular osteoporosis.
Olecranon bursitis in gout. Olecranon bursitis is a common manifestation of gout (large soft
tissue mass around elbow shown by solid white arrows) and its presence alone should alert you to
the possibility of underlying gout. This patient also displays erosions adjacent to the elbow joint
(solid black arrow).
Psoriatic arthritis, hand (A) and foot (B). A, Psoriatic arthritis typically involves the small
joints of the hands, especially the distal interphalangeal (DIP) joints (solid white arrows) leading to
telescoping of one phalanx into another (pencil-in-cup deformity). B, In the foot of another
patient with psoriasis, there is ankylosis of the 2nd toe (solid black arrow) and more pencil-in-cup
deformities (dotted white arrows).
Ankylosing spondylitis. Ankylosing spondylitis is an enthesopathy, a process that produces
inflammation with subsequent calcification and ossification at and around the entheses, which
are the insertion sites of tendons, ligaments, and joint capsules (solid white arrow points to bony
overgrowth at the ischial tuberosity). Bilaterally symmetrical sacroiliitis is the hallmark of
ankylosing spondylitis. This eventually leads to bony fusion or ankylosis of the SI joints until they
disappear as joints altogether (solid black arrows). The symphysis pubis is also ankylosed (dotted
black arrow).
Ankylosing spondylitis, frontal (A) and lateral (B) spine. In the spine, there is ossification
of the outer fibers of the annulus fibrosus producing thin, bony bridges joining the corners of
adjacent vertebrae called syndesmophytes (solid white arrows). Progressive ossification
connecting adjacent vertebral bodies produces the bamboo-spine appearance seen in this case,
which is characteristic of ankylosing spondylitis
Septic arthritis and osteomyelitis, middle finger.
The hallmark of infectious arthritis, especially the
pyogenic form, is destruction of the articular cartilage
and long contiguous segments of the adjacent articular
cortex from proteolytic enzymes released by the
inflamed synovium. This patient has septic arthritis (the
distal interphalangeal joint is destroyed) which has
extended to the subjacent bone as osteomyelitis and
destroyed either side of the joint space as well (solid and
dotted white arrows). The time course of septic arthritis,
unlike other arthritides, is usually quite rapid. This
infection was the result of a human bite