Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown

cause. An external trigger (eg, cigarette smoking, infection, or trauma) that triggers an
autoimmune reaction, leading to synovial hypertrophy and chronic joint inflammation
along with the potential for extra-articular manifestations, is theorized to occur in
genetically susceptible individuals. See the image below.

Rheumatoid changes in the

hand. Photograph by David Effron MD, FACEP.
See Rheumatoid Arthritis: In and Out of the Joint, a Critical Images slideshow, to help
identify the distinguishing features of RA as well as the signs of extra-articular
manifestations of this disfiguring disease.
Signs and symptoms
In most patients with RA, onset is insidious, often beginning with fever, malaise,
arthralgias, and weakness before progressing to joint inflammation and swelling.
Signs and symptoms of RA may include the following:
 Persistent symmetric polyarthritis (synovitis) of hands and feet (hallmark feature)
 Progressive articular deterioration
 Extra-articular involvement
 Difficulty performing activities of daily living (ADLs)
 Constitutional symptoms
The physical examination should address the following:
 Upper extremities (metacarpophalangeal joints, wrists, elbows, shoulders)
 Lower extremities (ankles, feet, knees, hips)
 Cervical spine
During the physical examination, it is important to assess the following:
 Stiffness
 Tenderness
 Pain on motion
 Swelling
 Deformity
 Limitation of motion
 Extra-articular manifestations
  Rheumatoid nodules

Plain radiograph of the knee shows osteopenia with enlargement of the distal femoral epiphysis.
Epiphyseal overgrowth is thought to result from chronic hyperemia.

Widespread osteopenia, carpal crowding (due to cartilage loss), and several erosions affecting the
carpal bones and metacarpal heads in particular in a child with advanced juvenile idiopathic arthritis
(JIA).

Basic radiographic changes include the following:

  Soft-tissue swelling
 Osteopenia and/or osteoporosis
 Joint-space narrowing
 Bony erosions
 Intra-articular bony ankylosis
 Periosteitis
 Growth disturbances
 Epiphyseal compression fracture
 Joint subluxation
 Synovial cysts
The main limitation of conventional radiography is that it does not allow direct
examination of the articular cartilage, synovium, and other important noncalcified
structures in a joint.

Magnetic Resonance Imaging

To improve visualization of synovial hypertrophy and improve detection of
cartilaginous erosions when an inflammatory arthritis is suspected, contrast-
enhanced sequences should be performed. MRI provides the most sensitive
radiologic indicator of disease activity. MRI can depict synovial hypertrophy,
define soft tissue swelling, and demonstrate excellent detail of the status of
articular cartilage and overall joint integrity

(A) T2-weighted MRI shows high signal in both hips, which may be due to hip effusions or synovitis.
High signal intensity in the left femoral head indicates avascular necrosis. (B) Coronal fat-saturated
gadolinium-enhanced T1-weighted MRI shows bilateral enhancement in the hips. This indicated
bilateral active synovitis, which is most pronounced on the right. Because the image was obtained
with fat saturation, the hyperintensity in both hips is pathologic, reflecting an inflamed pannus.

Imaging
Imaging assessment of the disease is increasingly important. Plain radiographs and CT
scans are important in delineating bony architecture, but ultrasound, with power
Doppler, and MRI are increasingly used to demonstrate both soft tissue involvement
and the presence of active synovitis. Of particular relevance to the spine is that MRI
allows better documentation of neural compromise and soft tissue involvement.

When imaging the cervical spine for features of RA, particular emphasis is placed on the
craniocervical junction. Instability is most often recognized by translatory motion of the
atlas against the axis, seen as an increased distance between the anterior ring of the
atlas (anterior atlantoaxial or atlantodental distance) and the anterior cortex of the
odontoid process. In all age groups, this distance should be minimal (accepting that the
gap appears wider in children owing to the incomplete bone formation). The
encroachment of the spinal canal, however, arises from the reduction in the posterior
atlantoaxial interval through impingement of the spinal cord by the posterior ring of the
atlas. Potential atlantoaxial instability may be unmasked through extension-flexion
views (Fig. 297-3 ). A caveat in this assessment is that early basilar invagination can lead
to the atlas “slipping” down the axis; in this setting, the anterior atlantoaxial distance
may be minimal—misleading the observer to assume regular alignment—whereas the
posterior ring of the atlas narrows the spinal canal. This situation can be identified by
assessing the position of the atlas relative to the length of the axis. Almost invariably,
the atlas will have migrated to the middle third of the axis from its physiologic position
in the upper vertical third.

Referensi

https://emedicine.medscape.com/article/331715-overview

https://www.clinicalkey.com/#!/content/book/3-s2.0-
B9780323287821002975?scrollTo=%23hl0000209
Osteoarthritis
Osteoarthritis (see the image below) is the most common type of joint disease, affecting
more than 30 million individuals in the United States alone. [1] It is the leading cause of
chronic disability in older adults, costing the US greater than $185 billion annually. [2] It
can be thought of as a degenerative disorder arising from the biochemical breakdown of
articular (hyaline) cartilage in the synovial joints. However, the current view holds that
osteoarthritis involves not only the articular cartilage but the entire joint organ, including
the subchondral bone and synovium. (See the image below.)

Anteroposterior (AP)
radiograph of the hip reveals severe superior migration of the femoral head
(which reflects loss of articular cartilage), subchondral sclerosis, prominent
osteophytes, and a large Egger cyst in the superior acetabulum. Mild
flattening of the superior aspect of the femoral head is present.
Signs and symptoms
Symptoms of osteoarthritis include the following:
 Deep, achy joint pain exacerbated by extensive use - The disease’s primary
symptom
 Reduced range of motion and crepitus - Frequently present
 Stiffness during rest (gelling) - May develop, with morning joint stiffness usually
lasting for less than 30 minutes
Osteoarthritis of the hand
 Distal interphalangeal (DIP) joints are most often affected
 Proximal interphalangeal (PIP) joints and the carpometacarpal (cmc) joints at
the base of the thumb are also typically involved
  Heberden nodes, which represent palpable osteophytes in the DIP joints, are more
characteristic in women than in men
 Inflammatory changes are typically absent, less pronounced, or go unnoticed

Clinical Clarification
 Osteoarthritis is a disorder of the joints (most commonly knees, hips, spine, and small hand
joints 2) characterized by pain and functional loss 1

 Modern definition of osteoarthritis is a painful degenerative process involving progressive

deterioration of all structures of the joint and remodeling of subchondral bone that is not
primarily inflammatory 1

o It is important to distinguish true osteoarthritis from asymptomatic structural joint

degeneration that is essentially universal during the normal aging process 1

 Most common form of arthritis 1

Classification
 Clinical diagnosis of osteoarthritis may be made in a patient who meets all of the following
criteria: 3

o Age older than 45 years

o Activity-related joint pain

o Either no morning joint stiffness or morning joint stiffness lasting 30 minutes or less

Diagnosis
Clinical Presentation

 From Garg A et al: Recognizing psoriatic

arthritis in the dermatology clinic. J Am Acad Dermatol. 63(5):733-748, 2010, Figure 11.
Heberden and Bouchard nodes in osteoarthritis. - Psoriasis patient with bony enlargements
overlying the distal interphalangeal (Heberden nodes, red arrows) and proximal interphalangeal
(Bouchard nodes, yellow arrows) joints suggestive of osteoarthritis and not psoriatic arthritis.
Radiographic features
Key radiographic features are joint space narrowing, sclerosis, and osteophytosis. If all three of these findings
are not present, another diagnosis should be considered.

Joint space narrowing

 characteristically asymmetric
 least specific: present in many other pathological processes
Sclerosis

 sclerotic changes occur at joint margins

 frequently seen unless severe osteoporosis is present
Osteophytosis

 i.e. development of osteophytes

 common DJD finding
 will also be diminished in the setting of osteoporosis
 some osteophytes carry eponymous names, as discussed below
It affects the distal interphalangeal joints (Heberden nodes), the proximal interphalangeal joints (Bouchard
nodes), (mnemonic H-D, B-P) and the base of the thumb in a bilaterally symmetric fashion. If it is not bilaterally
symmetric, the diagnosis of primary osteoarthritis should be questioned.

Joint erosions

 several joints may exhibit degenerative erosions

o temporomandibular joint
o acromioclavicular joint
o sacroiliac joints
o symphysis pubis
Subchondral cyst

 also known as a geode

 cystic formations that occur around joints in a variety of disorders, including DJD, rheumatoid
arthritis, calcium pyrophosphate dihydrate crystal deposition disease (CPPD) and avascular necrosis.

Diagnostic Imaging
Radiographs to profile the thumb CMC joint include PA, lateral, and oblique views of the
hand or, alternatively, PA and lateral views of the wrist. A Robert view of the thumb
CMC joint is also helpful because it is a true PA view of the joint ( Figure 11.15 ). The
Robert view requires special positioning of the arm and hand that some patients may
find difficult, particularly if they have limited or painful motion of the shoulder. The
Robert view is obtained with the arm and hand in a combination of positions, including
shoulder flexion, shoulder internal rotation, and wrist hyperpronation, so that the
dorsal surface of the thumb can be placed directly on the radiograph cassette. Advanced
 imaging studies such as MRI or CT scanning are seldom necessary for operative
procedures or surgical decision making about the thumb CMC joint.

Open full size image

FIGURE 11.15
Robert's true PA radiograph of the thumb carpometacarpal (CMC) joint of a 52-year-old female with
stage III CMC osteoarthritis.
Eaton and colleagues have described a widely accepted radiographic staging system for
thumb CMC joint degenerative arthritis 32 :

 Stage I: Normal or slight widening of the joint shadow due to synovitis

 Stage II: Mild joint shadow narrowing with osteophyte formation of 2 mm or less

 Stage III: Marked joint shadow narrowing with osteophyte formation of more than
2 mm

 Stage IV: Stage III disease with scaphotrapezialtrapezoidal osteoarthritis

Although helpful for radiographic description and explanation, this staging system has
never shown correlation with the intraoperative extent of disease or treatment outcome,
irrespective of the treatment chosen.

Radiograph of hand showing large osteophytes and joint-space narrowing at several

distal and proximal interphalangeal joints and the carpometacarpal joint.

Radiograph demonstrating hip osteoarthritis, including joint space narrowing, superior migration of
the femur within the acetabulum, and subchondral sclerosis.
Radiograph of both knee joints showing narrowed joint space (black arrow) with presence of
osteophytes (white arrow), consistent with osteoarthritis.

Referensi:

https://www.clinicalkey.com/#!/content/book/3-s2.0-
B9781455774272000113?scrollTo=%23hl0001331

https://emedicine.medscape.com/article/330487-overview

https://radiopaedia.org/articles/osteoarthritis?lang=us
SEPTIC ARTHRITIS

Go to:

SOURCE OF INFECTION
Acute septic arthritis may develop as a result of hematogenous seeding, direct introduction, or
extension from a contiguous focus of infection. The pathogenesis of acute septic arthritis is
multifactorial and depends on the interaction of the host immune response and the adherence
factors, toxins, and immunoavoidance strategies of the invading pathogen. Neisseria
gonorrhoeae and Staphylococcus aureus are used in discussing the host-pathogen interaction in
the pathogenesis of acute septic arthritis. While diagnosis rests on isolation of the bacterial
species from synovial fluid samples, patient history, clinical presentation, laboratory findings,
and imaging studies are also important. Acute nongonococcal septic arthritis is a medical
emergency that can lead to significant morbidity and mortality. Therefore, prompt recognition,
rapid and aggressive antimicrobial therapy, and surgical treatment are critical to ensuring a good
prognosis. Even with prompt diagnosis and treatment, high mortality and morbidity rates still
occur. In contrast, gonococcal arthritis is often successfully treated with antimicrobial therapy
alone and demonstrates a very low rate of complications and an excellent prognosis for full
return of normal joint function. In the case of prosthetic joint infections, the hardware must be
eventually removed by a two-stage revision in order to cure the infection.
Most septic joints develop as a result of hematogenous seeding of the vascular synovial
membrane due to a bacteremic episode (86, 113). Although a rare cause, acute septic arthritis
may also occur as a result of joint aspiration or local corticosteroid joint injection (74, 86). In
addition, bacterial arthritis may arise secondary to penetrating trauma (such as human or animal
bite or nail puncture) or after trauma to a joint without an obvious break in the skin. The direct
introduction of bacteria during joint surgery has increasingly been a source of bacterial arthritis,
particularly in association with knee and hip arthroplasties. When a bone infection breaks
through the outer cortex and into the intracapsular region, a joint infection may also result,
especially in children (9, 117). In infants, small capillaries cross the epiphyseal growth plate and
permit extension of infection into the epiphysis and joint space (22). In children older than 1
year, osteomyelitis infection presumably starts in the metaphyseal sinusoidal veins and is usually
contained by the growth plate. The joint is spared unless the metaphysis is intracapsular. The
infection spreads laterally, where it breaks through the cortex and lifts the loose periosteum to
form a subperiosteal abscess. In adults, the growth plate has resorbed and the infection may
again extend to the joint spaces.

IMAGING
Radiography should be the first imaging modality used for septic arthritis. The inflamed
synovial tissue and accompanying fluid in the joint cause a symmetrical soft-tissue
swelling around the involved joint, as manifested by a widened joint space or
displacement of the fat pads around the joint. Marginal erosions or erosion of bone that
sits uncovered by cartilage but within the capsular attachment can also be seen. The
hallmark of septic arthritis is the loss of the white cortical line over a long contiguous
segment, unlike the segmental disruption seen in inflammatory arthropathies. Bacterial
infection of a joint usually causes rapid joint space loss, with aggressive erosive changes
and preservation of mineralization. The tuberculous septic joint tends to preserve the
joint and causes marginal erosions with extensive demineralization and little repair. 12

Bone scintigraphy may be used if radiographs are normal. A three-phase scan using Tc
99m methylene diphosphonate shows increased uptake in the synovium of the septic
joint and, in the third phase, increased uptake in the articular ends of the bone. Gallium-
67 citrate can be used in conjunction for additional information. However, it still may be
difficult to distinguish an inflamed joint from an infected joint.

Magnetic resonance imaging (MRI) is highly sensitive for the diagnosis of septic
arthritis, although it still lacks specificity because it cannot reliably distinguish inflamed
from infected joints. MRI has been considered the diagnostic modality of choice by
some clinicians. 12

destruction is possible. Radiographs can also evaluate late, inadequately treated stages of septic
arthritis in which generalized joint destruction, osteomyelitis, osteoarthritis, joint fusion,
calcifications in the periarticular tissues, or subchondral bone loss followed by reactive sclerosis
are seen.

Radiograph
 x-rays may be normal in the very early stage of the disease
 joint effusion may be seen
 juxta-articular osteoporosis due to hyperemia
 narrowing of the joint space due cartilage destruction in the acute phase
 destruction of the subchondral bone on both sides of a joint
 if left untreated, reactive juxta-articular sclerosis and, in severe cases, ankylosis will develop

Ultrasound
 useful in superficial joints and in children
 shows joint effusion
o echogenic debris may be present
 color Doppler may show increased peri-synovial vascularity
 can be used to guide the joint aspiration

CT
 CT features of septic arthritis are similar to those spotted on radiographs
 a fat-fluid level can be a specific sign in the absence of trauma

MRI
 sensitive and more specific for early cartilaginous damage
 T1: low signal within subchondral bone
 T2: perisynovial edema
 C+ (Gd): synovial enhancement

Involving the hip

Invoving neonatal knee

Involving TMJ with skull base osteomyelitis

involving sacroiliac joint with psoas abscess

https://radiopaedia.org/articles/septic-arthritis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC126863/

https://www.clinicalkey.com/#!/content/book/3-s2.0-B9781416066439001818?scrollTo=%23hl0000105
PSORIATIC ARTHRITIS

Practice Essentials
Psoriatic arthritis (PA) is a specific type of arthritis that has been diagnosed in
approximately 23% of those who have psoriasis. [1] PA can occur in any age
group; however, in most patients, it manifests itself between 30 and 50 years
of age. On average, PA appears about 10 years after the first signs of
psoriasis occur, but in about 1 of 7 people with PA, arthritis symptoms occur
before any skin lesions appear. Most patients with PA also have psoriasis;
patients rarely have PA without psoriasis.
A haplotype epidemiologic association with PA involves the expression of both
class I and class II human leukocyte antigen (HLA) alleles, including HLA-
B13, HLA-B17, HLA-B27, HLA-B38, HLA-B39, HLA-Cw6, HLA-DR4, and
HLA-DR7. HLA-B27 is present in 60% of individuals with the disease, as
compared with 8% of the general population.
Dactylitis, which is associated with more erosive forms of PA, is often the
initial feature of PA and may be the only feature for months to years. [2]
Guidelines on psoriatic arthritis have been published by organizations such as
the European League Against Rheumatism (EULAR), the British Society of
Rheumatology (BSR), and the American Academy of Dermatology
(AAD). [3, 4, 5]
Types of PA
Five types of PA have been defined; these types can coexist, but they tend to
occur separately in most cases:
 Arthritis involving primarily the small joints of the fingers or toes
(asymmetrical oligoarthritis) — 55-70%
 Asymmetrical arthritis, which involves the joints of the extremities — 30-
50%
 Symmetrical polyarthritis, which resembles RA — 15-70%
 Arthritis mutilans, which is a rare but deforming and destructive condition
— 3-5%
 Arthritis of the sacroiliac joints and spine (psoriatic spondylitis) — 5-33%

Onset of psoriasis and arthritis are as follows:

 Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients
(occasionally by as many as 20 years, but usually by less than 10 years)
 In as many as 15-20% of patients, arthritis appears before the psoriasis
 Occasionally, arthritis and psoriasis appear simultaneously
In some cases, patients may experience only stiffness and pain, with few objective
findings. In most patients, the musculoskeletal symptoms are insidious in onset, but an
acute onset has been reported in one third of all patients.
Findings on physical examination are as follows:
 Enthesopathy or enthesitis, reflecting inflammation at tendon or ligament insertions
into bone, is observed more often at the attachment of the Achilles tendon and the
plantar fascia to the calcaneus with the development of insertional spurs
 Dactylitis with sausage digits is seen in as many as 35% of patients
 Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus;
and erythroderma
 Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently
is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus

Radiographic features
The hallmark of PsA is the combination of erosive change with bone proliferation, in a predominantly distal
distribution (e.g. interphalangeal more than metacarpophalangeal joints). The disease most commonly involves
the hands, followed by feet. It can also affect sacroiliac joints and spine. Knees, elbows, ankles and shoulders
are less frequently involved 2.

In the hands and feet, the pattern of distribution may be that of a symmetric polyarthropathy, or asymmetric
oligoarthropathy.

Imaging findings include:

 enthesitis and marginal bone erosions; "pencil-in-cup" deformities are common, but not pathognomonic for
PsA 3
 joint subluxation or interphalangeal ankylosis may be present.
 bone proliferation results in an irregular, “fuzzy” appearance to the bone around the affected joint 2

 periostitis: may appear as a periosteal layer of new bone, or as irregular thickening of the cortex itself 2

 dactylitis: which can present as a “sausage digit” which refers to soft tissue swelling of a whole digit;
ultrasound examination of a sausage digit demonstrates underlying synovitis and tenosynovitis 4
 arthritis mutilans: a severe form of either PsA or rheumatoid arthritis caused by marked bony resorption and
the consequent collapse of soft tissue; when this affects the hands, it can cause a phenomenon sometimes
referred to as "telescoping fingers"
 ivory phalanx: classically involving the distal phalanx of the great toe
 sacroiliitis: often asymmetrical
 spondylitis: asymmetric paravertebral ossifications and relative sparing of the facet joints
Opera glass hands
Anteroposterior radiograph of the hands shows subchondral erosions of the fourth left distal
interphalangeal joint and right third and fourth proximal interphalangeal joints with periosteal
reaction. Courtesy of Bruce M. Rothschild, MD.

https://emedicine.medscape.com/article/394752-overview#a2

https://emedicine.medscape.com/article/2196539-overview

https://radiopaedia.org/articles/psoriatic-arthritis?lang=us