Appendicular Arthritis

APPENDICULAR ARTHRITIS
By
Dr. Aliaa El-Hady
MD. Rheumatology & Rehabilitation
SUTTON'S LAW -1
This law has been ascribed to Willie Sutton, a
famous bank robber. When asked why he
robbed banks, he reportedly said, "Because
that's where the money is.
" In the radiographic evaluation of
appendicular arthropathies, the "money" is
generally in a relatively small handful of
disorders. Even though over 90 different
rheumatic diseases are recognized by the ACR,
only three entities are commonly seen in most
clinical radiology practices, even including
those located in large tertiary medical centers.
Osteoarthritis (degenerative joint disease) is
the most commonly seen form of appendicular
arthritis.
The other two commonly seen arthropathies
are rheumatoid arthritis and calcium
pyrophosphate dihydrate (CPPD)
deposition disease.
Less common arthropathies that may manifest
radiographic findings in the appendicular
skeleton include septic arthritis, and gout.
Most other appendicular arthropathies are
seen only rarely.
Radiographic Hallmarks -2
In George Orwell's Animal Farm, it is stated
that "All animals are equal. But some animals
are more equal than others."

This principle is manifested in the appendicular

arthropathies, where some radiographic
findings are quite specific and can quickly lead
one to the correct diagnosis. Other findings are
less specific and are usually unhelpful in
ordering one's differential diagnosis.
In a diarthrodial joint, osteophytes are the sine
qua non of osteoarthritis.
Osteophytes can be seen in both primary and
secondary osteoarthritis
.
marked osteophytosis (arrows) is seen in
the DIP and PIP joints in these fingers
Osteophytosis is noted at the articular margin of the femoral head
Osteophytes can also be seen at various entheses
(sites of tendinous or ligamentous attachment to
bone), often due to altered or increased stress there.
In general, the presence of erosions bespeaks
some type of inflammatory disease, whether
the erosions are due to synovial hypertrophy,
.crystalline deposits, or infection
In RA, the erosions follow the development of an
inflammatory proliferation of the synovium, called
pannus. As this pannus increases in amount, it
begins to cause erosions of the chondral surface.
As the pannus increases further in amount, one
begins to see erosions at the periarticular "bare"
areas. These "bare" areas refer to bone within the
synovial space which is not covered by articular
cartilage. The articular cartilage tends to protect the
bone that it covers. The marginal "bare" areas are
not covered by cartilage, and the earliest erosions of
rheumatoid arthritis are seen here
erosions (arrows) are noted in the periarticular areas of the toes in RA
multiple erosions and marked joint space narrowing are noted in a
pancarpal distribution in this patient with rheumatoid arthritis
erosions (arrows) are
noted at the articular
margins of the tibia in
this patient with juvenile
chronic arthritis
If the inflammation proceeds unchecked,
the erosions of the bone and the cartilage
may become profound, and the joint may
finally undergo fibrous ankylosis.
The presence of crystal deposits (chondrocalcinosis
or tophi) indicates one of the crystalline
arthropathies.

In calcium pyrophosphate dyhidrate depostition

(CPPD) disease, the most common site of
radiographic calcifications is in fibrocartilage and
hyaline articular cartilage (chondrocalcinosis).
However, calcifications may also be seen in the joint
capsule or synovial membrane.
calcification may be
seen at several sites
about a joint in
CPPD
chondrocalcinosis is seen in the triangular fibrocartilage of this wrist
chondrocalcinosis is seen in both the fibrocartilage of the menisci and
in the hyaline articular cartilage of this knee
In gout, erosions are caused by tophi. These
tophi may be either intra- or extra-articular in
location. Calcifications are occasionally seen in
tophi.
The erosions of gout may appear very similar
to those seen in RA. However, in gout, there
tends to be early sparing of the articular
cartilage between the erosions, while the
cartilage is thinned much earlier in the course
of RA.
a gouty erosion (arrow) is
noted along the medial
margin of the first
metatarsal head in this
patient with gout --
relative sparing of the
articular cartilage is also
noted
Other findings, such as joint space narrowing,
subchondral cyst formation, sclerosis,
ankylosis, or subluxation are not especially
specific and may occur in a wide variety of
degenerative or inflammatory disorders in the
appendicular skeleton.
It is important to describe these findings, as
they tell us a lot about the severity of the
patient's disease -- it's just that they don't tell
us a whole lot about what specific disease is
causing them.
 PATTERN APPROACH -3
characteristic sites of joint involvement of the=
.various appendicular arthropathies
•Once learned, these patterns can be
helpful in ordering the DD.
•Although such patterns have been
described for most of the appendicular
joints, the most specific of these patterns
of joint involvement are seen in the hands
and wrists.
•Less specific patterns are seen in the hips
and knees.
typical
distribution of
arthritis in the
hands
joint compartments of the wrist -- CMC (first
carpometacarpal), CCMC (common carpometacarpal), ST
(scaphotrapezial), MC (midcarpal), RC (radiocarpal), and DRUJ
(distal radioulnar joint)
typical distribution of arthritis in the wrists
typical distribution of arthritis in the knees
typical distribution of arthritis in the hips
-Any joint in the body can be affected by 2ry OA due to
trauma, infection or another arthropathy.
However, the findings of 1ry (idiopathic) OA are usually seen
in the DIP joints of the hand, and the 1st CMC joint and
scapho-trapezial joint of the wrist. The PIP joints may
occasionally be affected.

-RA tends to involve the PIP and MCP joints of the hand and
all of the major joint compartments of the wrist (pancarpal
involvement).

-CPPD deposition disease usually initially affects the

radiocarpal (RC) joint in the wrist, but may also involve the
MCP joints of the hand.
DEMOGRAPHICS-4
-Age and gender may occasionally be useful in
narrowing the DD of the appendicular arthropathies.

-For e.g, the most common arthropathies in children

are juvenile chronic arthritis and septic arthritis,
while entities such as RA, OA and CPPD arthropathy
are generally seen in older adults.

-CPPD arthropathy affects both genders equally. RA

has a moderate female predominance, as does OA in
the older age group. Gout, on the other hand, has a
moderate to strong male predominance.
Other demographic factors, such as home
location, occupation and even ethnic
subtype can occasionally be helpful in
steering the differential toward or away
from certain disease entities.
THE SUPERIMPOSITION -5
-Most patients have several disorders
going on simultaneously.
-Patients often have more than one
arthropathy. This is most commonly
seen in patients with 2ry OA
superimposed upon some other
arthropathy.
•Virtually any arthropathy which causes cartilage
loss can lead to 2ry OA, with all of the classic signs of
OA, including osteophytosis.

• In fact, in certain patients, the changes from the 1ry

arthropathy may be significantly obscured by the
2ry OA changes.

•A clue that this is happening is that the most

distinctive sign of OA, osteophytosis, is often fairly
minimal compared to other findings such as joint
space narrowing or subchondral sclerosis.
-In fact, this is a very common presentation of RA of the
knee: marked joint space narrowing and subchondral
sclerosis, but no evident erosions, and only minimal
osteophytosis.
-In 1ry OA, on the other hand, marked joint space narrowing
is usually accompanied by moderate or marked
osteophytosis.
Other combinations of arthropathies are
possible, such as gout and CPPD, gout and
RA, RA and DISH (RADISH), etc.