GUIDED BY-DR.

USHA JAIPAL
PRESENTED BY-DR. SONAL SARAN
 RHEUMATOID ARTHRITIS
Rheumatoid arthritis (RA) is a chronic systemic
inflammatory disease predominantly affecting
diarthrodial joints and frequently a variety of other
organs.
Peak incidence is between 4th and 6th decade.
Females are two to three times more affected than
males.
Genetic and autoimmune factors are mainly
responsible for the initiation of disease process.
 PATHOGENESIS
The pathologic hallmark of RA is synovial
membrane proliferation and outgrowth
associated with erosion of articular
cartilage and subchondral bone.

There is role of both cellular and

humoral immune mechanism in the
onset of inflammation.
C/F
Small joints of Hand-Pain/Stiffness > 1HR.
The pattern of joint involvement is typically
polyarticular and symmetrical and involves-
proximal interphalangeal (PIP)
metacarpophalangeal (MCP)
wrist, elbow, shoulder, knee, ankle,MTP joints and
cervical spine.
The distal interphalangeal (DIP) joints of the fingers
are usually spared.
C/F
FEVER/MALAISE/HEADACHE
JOINT SWELLING/TENDERNESS.
With persistent inflammation, a variety of
characteristic joint changes develop like-
Z-deformity
Swan neck deformity
Boutonniere deformity.
DIAGNOSTIC INVESTIGATION
CLINICAL.
MRI IOC for early detection of disease
ULTRASOUND
X-RAYS.
CT SCAN.
SYNOVIAL FLUID ASPIRATION
ANEMIA,RAISED ESR
SEROLOGICAL TESTS.
DIAGNOSIS
Guidelines for classification

a. Four of seven criteria are required to classify a

patient as having rheumatoid arthritis (RA).

b. Patients with two or more clinical diagnoses are not

excluded.
DIAGNOSIS
Criteria

a. Morning stiffness: Stiffness in and around the

joints lasting 1 h before maximal improvement.

b. Arthritis of three or more joint areas: The 14

possible joint areas involved are right or left proximal
interphalangeal, metacarpophalangeal, wrist, elbow,
knee, ankle, and metatarsophalangeal joints.
DIAGNOSIS
c. Arthritis of hand joints: Arthritis of wrist,
metacarpophalangeal joint, or proximal
interphalangeal joint.
d. Symmetric arthritis: Simultaneous involvement of
the same joint areas on both sides of the body.
e. Rheumatoid nodules: Subcutaneous nodules over
bony prominences, extensor surfaces, or juxtaarticular
regions observed by a physician.
DIAGNOSIS
f. Serum rheumatoid factor: Demonstration of
abnormal amounts of serum rheumatoid factor.
g. Radiographic changes: Typical changes of RA on
posteroanterior hand and wrist radiographs that must
include erosions or unequivocal bony decalcification
localized in or most marked adjacent to the involved
joints.
Flow chart shows approach to radiographic evaluation of arthritis.
 RA of the metatarsophalangeal joints.

left foot shows concentric joint space narrowing and subcortical cysts in all of the
metatarsophalangeal joints. Erosions are seen in the second and fourth
metatarsophalangeal joints, which are deformed to some extent
 Advanced RA. Radiograph of the hand shows severe destruction and mutilation of the
radiocarpal, intercarpal, carpometacarpal, and metacarpophalangeal joints.

. Intercarpal ankylosis is noted. There is also subluxation and deviation of the

fourth and fifth fingers.
Radiograph of the right hand shows cysts along the radial aspect of the head of the second
metacarpal (*).
Advanced RA. Radiograph shows mutilation and deformity of the left elbow.
Posteroanterior wrist radiographs show discontinuity of bone cortex representing erosion
(arrow) with development of osteopenia.
 RA of the wrist.

Radiograph shows a ballooned ulnar styloid process. There are small cysts
(*) in the styloid process and scaphoid bone. The radiocarpal joint space is
narrowed.
 Longstanding arthritis of the shoulder joint.

Radiograph of the left shoulder shows a deep erosion (*) at a typical site.
Narrowing of joint spaces in long-standing RA. Radiograph (detail view) shows narrowing of
the joint spaces of the second and fourth metacarpophalangeal joints (*).

The concentricity of the narrowing is a hallmark of arthritis, whereas

joint space narrowing due to degenerative changes is eccentric.
CT image shows shallow erosions with sclerotic and well-demarcated margins at the second
and fifth metacarpophalangeal joints (arrowheads).
Bone erosion in a patient with RA. Longitudinal high-resolution sonogram shows an
irregular erosion of the metacarpophalangeal joint (arrowheads).
 Synovitis of the metacarpophalangeal joint.

Longitudinal high-resolution (10.5-MHz) sonogram shows thickened

synovial tissue (arrows).
 RA of the atlantodental joint.

Axial contrast-enhanced fat-saturated spin-echo T1-weighted MR

image shows hypervascular pannus (*) around the dens axis.
Axial spin-echo T1-weighted MR image of the left wrist shows extensive synovitis of the
ulnar aspect (*) and erosions and deformity of the ulnar styloid process (arrowhead).
Axial contrast-enhanced fat-saturated T1-weighted MR image of the wrist shows multiple
intrasynovial rice bodies (arrows).
 Long-standing mutilating RA. Coronal spin-echo T1-weighted MR image of the left hand
shows severe destructive changes in the carpus and radiocarpal joint.

The carpometacarpal joints are less severely affected. Active arthritis of the
third metacarpophalangeal joint is associated with reactive edema of the bone
marrow (*).
 Figure 17. RA of the wrist.

Axial contrast-enhanced fat-saturated T1-weighted MR image shows a carpal cyst

(arrow) that communicates with the inflamed synovium via a small extension
(arrowhead). This cyst is a typical subcortical erosion.
Incidentally discovered bone cyst in a middle-aged patient with RA. Coronal spin-echo T2-
weighted MR image of the hand shows a hyperintense cyst with a sclerotic rim (arrow).
 Acute painful arthritis of the third metacarpophalangeal joint.

The enhancement of the bone marrow (*) is indicative of inflammatory involvement

or a reactive response.
Small joint effusion in a 20-year-old woman in whom RA was later diagnosed.
Acute tendovaginitis of the flexor of the middle finger in a young man with a diagnosis of RA.
Axial contrast-enhanced fat-saturated T1-weighted MR image shows fluid (*) surrounded by
enhancing synovium (arrowheads).
 Long-standing RA in a 52-year-old woman.

. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows synovitis of the

second and third metacarpophalangeal joints. A subcortical cyst (arrowhead) is seen
near the bare area. This type of lesion is called a pre-erosion or subcortical erosion by
some authors owing to the high likelihood that it will progress to a clear erosion.
 Figure 4. RA in a 75-year-old woman.

. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows

hyperenhancement of small joints in the hand (arrows), a finding that reflects
hyperemic synovial tissue. Erosions (arrowheads) and thickened, intensely
enhancing synovium are seen at the fifth metacarpophalangeal joint.
 OSTEOARTHRITIS
Most common type of arthritis.
Leading cause of disability in elderly.
Much more common in women than men.
Definition: OA is joint failure,a disease in which all
parts of joint have undergone pathologic change.initial
step in the onset of disease is failure of joint protective
mechanism.
Joint vulnerability and joint loading are the two major
factors in development of disease.
Primary osteoarthritis is mostly related to aging. With aging, the
water content of the cartilage increases, and the protein makeup of
cartilage degenerates.

Secondary osteoarthritis is caused by another disease or

condition. Conditions that can lead to secondary osteoarthritis
include obesity, repeated trauma or surgery to the joint structures,
abnormal joints at birth (congenital abnormalities), gout, diabetes,
and other hormone disorders.
 RISK FACTORS
Increasing age.
Female gender.
Obesity
Injurious physical activity.
Bridging muscle weakness.
Malalignment.
Proprioceptive deficiancies(eg.charcot arthropathy).
Genetic susceptibility.(hand and hip OA.)
 JOINTS AFFECTED IN OA
Hip
Knee
DIP(haberdens node) and PIP(bouchards node).
First carpometacarpal joint
Cervical vertebrae
First metatarsophalangeal joint.
Lower lumber vertebrae.
Involvement is asymmetric unlike RA.
 PATHOLOGICAL HALLMARKS
Cartilage is the primary target tissue for OA.
There is nonuniform loss of the cartilage.
Evidense of new bone formation is presence of
osteophytes.
There is as assymetric and nonuniform involvement of
the joints.
Capsule may become edematous and fibrotic.
Joint space narrowing is present as seen in all types of
arthritis.
 Symptoms
Pain
o Joints may ache, or the pain may feel burning or sharp. For some people, it may get
better after a while.
o Pain while sleeping or constant pain may be a sign that arthritis is getting worse.
Stiffness
o When you have arthritis, getting up in the morning can be hard.
o Joints may feel stiff and creaky for a short time, until get moving.
o May also get stiff from sitting.
The muscles around the joint may get weaker
o This happens a lot with arthritis in the knee.
Cracking and creaking
o Joints may make crunching, creaking sounds.
Limited range-of-motion
 Investigations
X-RAY-although used for evaluating OA ,are
insensitive for identifying early disease process. They
correlate poorly with patients symptom.
Synovial fluid analysis-WBCs count more than
1000/microlitre indicate inflammatory arthritis and
less likely OA.
ULTRASOUND.
MRI.
CT-scan.
BONE SCAN.
 Weight Bearing Technique
o Films obtained during weightbearing or varus and valgus stress
are necessary in early stages of osteoarthritis of the knee joint.

o Ideally, the weightbearing radiographs should be obtained with

a patient standing only on the involved leg in 15 to 20 degrees of
knee flexion.

o With the knee in extension, early joint space loss may not be
seen .

o The weightbearing technique also allows more accurate

delineation of subluxation, varus or valgus angulation, and lateral
instability
 Osteoarthritis.

Osteoarthritis. Posteroanterior radiograph shows interphalangeal joint space

narrowing, subchondral sclerosis, and osteophyte formation (arrows).
 CT-SCAN OF HIP JOINT SHOWING CHANGES OF OSTEOARTHRITIS.
CT-SCAN OF ELBOW JOINT SHOWING CHANGES OF
OSTEOARTHRITIS.
 CT-SCAN OF
HAND
SHOWING
OSTEOPHYTE
IN THE HEAD
OF 4TH
METACARPAL.
 MRI
o The MRI is most useful for patients with
very early osteoarthritis of the knee.
o For people who have knee pain without
injury and who have not responded to
cortisone shots or anti-inflammatory
medicines, the MRI can detect meniscus
cartilage degeneration that cannot be seen
on x-ray.
Figure: T1-weighted coronal MRI of the knee shows typical findings of
osteoarthritis, including narrowing and subchondral changes at the medial
femorotibial compartment and osteophyte formation.
An MRI shows a knee with chronic effusion, joint space
narrowing due to loss of femoral and tibial articular cartilage
(white arrow), and a torn meniscus (black arrow).
Figure 2 MRI image of the knee joint in
osteoarthritis demonstrating synovitis and
subchondral bone abnormalities.
A rapid MRI examination for
osteoarthritis (OA) include:

A) T2 mapping to estimate the

amount of cartilage collagen, and
B) sodium imaging to estimate
cartilage glycosaminoglycan
content, an important component
of connective tissue.

These physiologic measurements

should be more sensitive to early
changes of OA than structural
information alone.
 US-guided steroid injections in hip OA is an efficacious and safe therapeutic
approach to achieve pain control and reduction of synovial hypertrophy
avoiding the use of X-ray-guided procedure.
 Radionuclide Bone Scans

o Radionuclide Bone Scans are very sensitive in

detecting reactive bone edema associated with
osteoarthritis.

o Bone scans can also image the entire skeleton in

one examination and thus can provide the clinician
with helpful information in patients with multiple sites
of arthritic involvement.
Therapeutic ultrasound for osteoarthritis of the knee or hip

-Therapeutic ultrasound may be beneficial for people with

osteoarthritis of the knee.

-Therapeutic ultrasound may improve your physical function but

this finding could be the result of chance.

-Therapeutic ultrasound does not have any side effects.

Therapeutic ultrasound means using sound waves to try and relieve

pain or disability.

This therapy is under investigation.

DIFFERENCE B/W RA AND OA
RHEUMATOID A.
Inflammatory.
Symmetric involvement of
small joints first.
Polyarticular.
Other visceral organs also
affected.
Erosion of adjuscent bony
surface.
Morning stiffnes>1hr.
OSTEOARTHRITIS
Degenerative.
Asymmetric involvement
of large joint first.
Generally monoarticular.
Not affected.
Sclerosis of adjuscent bony
surface with osteophyte
formation.
Morning stiffnes<1hr.