Answer for BIR CoW 24 Sep 2023
RHEUMATOID ARTHRITS OF RIGHT WRIST
Findings
Loss of radiocarpal and carpometacarpal joint space noted. Architectural distortion and erosions of carpal bones noted. Erosions noted in distal radius and base of metacarpal. Juxta articular osteopenia noted in distal radio ulnar joint and base of metacarpal. Dorsal dislocation of ulna noted.
Discussion
Rheumatoid arthritis is an autoimmune, chronic synovial-based inflammatory process, with a predilection for the: Proximal interphalangeal and metacarpophalangeal joints (especially those of the index and middle fingers) Ulnar styloid Triquetrum The first radiographic changes observed in RA are soft tissue swelling and periarticular osteopenia. Bone density is reduced adjacent to the joint as a result of local synovial inflammation. The inflamed synovium slowly invades adjacent structures causing damage and destruction to the cartilage. This aggressive process leads to joint space narrowing which tends to be uniform and concentric. The erosions in RA tend to be periarticular and are often described as marginal erosions and reflect the direct mechanical action of the hypertrophied synovium and granulation tissue. These marginal erosions are the first erosive changes appreciated on radiographs. The wrist joint is commonly affected in RA, has proved to be more sensitive to changes in bone erosions than other joint areas. In the wrist, erosive changes are typically seen in the ulnar styloid, waists of the scaphoid and hamate, as well as the fifth carpometacarpal joint. The hands are involved symmetrically. Usually, the second and third MCP and the third PIP are the first joints damaged. Rheumatoid arthritis does not typically involve the distal interphalangeal joints Ankylosis characterize the later stages of RA. Fusion usually takes place in deformed or malaligned position. These alterations strongly reduce the functionality of hands and feet. LATE CHANGES - DEFORMITIES Subchondral formation Subluxation causing: Ulnar deviation of the metacarpophalangeal joints Boutonneire and Swan neck deformities Hitchiker’s thumb deformity Carpal instability: Scapholunate dislocation, Ulnar translocation Ankylosis Scallop sign : Erosion of the ulnar aspect of the distal radius which may be predictive of extensor tendon rupture (Vaughan Jackson syndrome) Pencil in cup deformity.
REFERENCES
1. Clinica Reumatologica, Università Politecnica Delle Marche, Ancona, Italy; 2Dipartimento di Radiologia S.O.D. Radiologia Clinica, Università Politecnica delle Marche, Ancona, Italy Received March 7, 2016; Accepted June 5, 2016; Epub September 15, 2016; Published September 30, 2016 2.Norgaard, F. Earliest Roentgenological Changes in Polyarthritis of the Rheumatoid Type: Rheumatoid Arthritis. Radiology 1965, 85, 325–329. [CrossRef] [PubMed] 3.Llopis, E.; Kroon, H.M.; Acosta, J.; Bloem, J.L. Conventional Radiology in Rheumatoid Arthritis. Radiol. Clin. North Am. 2017, 55, 917–941. [CrossRef] [PubMed]
Findings
Loss of radiocarpal and carpometacarpal joint space noted. Architectural distortion and erosions of carpal bones noted. Erosions noted in distal radius and base of metacarpal. Juxta articular osteopenia noted in distal radio ulnar joint and base of metacarpal. Dorsal dislocation of ulna noted.
Discussion
Rheumatoid arthritis is an autoimmune, chronic synovial-based inflammatory process, with a predilection for the: Proximal interphalangeal and metacarpophalangeal joints (especially those of the index and middle fingers) Ulnar styloid Triquetrum The first radiographic changes observed in RA are soft tissue swelling and periarticular osteopenia. Bone density is reduced adjacent to the joint as a result of local synovial inflammation. The inflamed synovium slowly invades adjacent structures causing damage and destruction to the cartilage. This aggressive process leads to joint space narrowing which tends to be uniform and concentric. The erosions in RA tend to be periarticular and are often described as marginal erosions and reflect the direct mechanical action of the hypertrophied synovium and granulation tissue. These marginal erosions are the first erosive changes appreciated on radiographs. The wrist joint is commonly affected in RA, has proved to be more sensitive to changes in bone erosions than other joint areas. In the wrist, erosive changes are typically seen in the ulnar styloid, waists of the scaphoid and hamate, as well as the fifth carpometacarpal joint. The hands are involved symmetrically. Usually, the second and third MCP and the third PIP are the first joints damaged. Rheumatoid arthritis does not typically involve the distal interphalangeal joints Ankylosis characterize the later stages of RA. Fusion usually takes place in deformed or malaligned position. These alterations strongly reduce the functionality of hands and feet. LATE CHANGES - DEFORMITIES Subchondral formation Subluxation causing: Ulnar deviation of the metacarpophalangeal joints Boutonneire and Swan neck deformities Hitchiker’s thumb deformity Carpal instability: Scapholunate dislocation, Ulnar translocation Ankylosis Scallop sign : Erosion of the ulnar aspect of the distal radius which may be predictive of extensor tendon rupture (Vaughan Jackson syndrome) Pencil in cup deformity.
REFERENCES
1. Clinica Reumatologica, Università Politecnica Delle Marche, Ancona, Italy; 2Dipartimento di Radiologia S.O.D. Radiologia Clinica, Università Politecnica delle Marche, Ancona, Italy Received March 7, 2016; Accepted June 5, 2016; Epub September 15, 2016; Published September 30, 2016 2.Norgaard, F. Earliest Roentgenological Changes in Polyarthritis of the Rheumatoid Type: Rheumatoid Arthritis. Radiology 1965, 85, 325–329. [CrossRef] [PubMed] 3.Llopis, E.; Kroon, H.M.; Acosta, J.; Bloem, J.L. Conventional Radiology in Rheumatoid Arthritis. Radiol. Clin. North Am. 2017, 55, 917–941. [CrossRef] [PubMed]
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!