Gout

Deposition of sodium urate monohydrate crystals in synovial membranes,

articular cartilage, ligaments, bursae leading to destruction of cartilage

Age of onset is usually greater than 40 years; males much more often
than females

Causes:
o
Idiopathic Gout

M:F = 20:1

Overproduction of uric acid

Abnormality of renal urate excretion

o
Secondary Gout

Rarely cause for radiographically apparent disease

Myeloproliferative disorders, e.g. polycythemia vera,

leukemia, lymphoma, multiple myeloma

Blood dyscrasias

Myxedema, hyperparathyroidism

Chronic renal failure

Glycogen storage disease

Myocardial infarction

Lead poisoning

Stages:
o
Asymptomatic hyperuricemia
o
Acute monarticular gout
o
Polyarticular gout
o
Chronic tophaceous gout = multiple large urate deposits

Location:
o
Joints: hands + feet (1st MTP joint most commonly affected
= podagra), elbow, wrist

Carpometacarpal compartment especially common), knee,

shoulder, hip, sacroiliac joint (15%, unilateral)
o
Ear pinna > bones, tendon, bursa

Radiologic features usually not seen until 6-12 years after initial attack

Radiologic features present in 50% of inflicted patients

Soft tissue findings

o
Calcific deposits in gouty tophi in 50% (only calcium urate crystals
are opaque)
o
Eccentric juxta-articular lobulated soft-tissue masses (hand, foot,
ankle, elbow, knee)
o
Bilateral olecranon bursitis
o
Aural calcification


o
o
o
o
o
o

Joint findings
Preservation of joint space initially
Absence of periarticular demineralization
Erosion of joint margins with sclerosis
Cartilage destruction late in course of disease
Periarticular swelling (in acute monarticular gout)
Chondrocalcinosis (menisci, articular cartilage of knee) resulting in
secondary osteoarthritis

The great toe demonstrates extensive juxta-articular erosions

with soft tissue swelling and little osteoporosis

Bone findings
"Punched-out" lytic bone lesion sclerosis of margin
"Mouse / rat bite" from erosion of long-standing soft-tissue tophus
"Overhanging margin" (40%)
Ischemic necrosis of femoral / humeral heads
Bone infarction
Coexisting disorders:
o
Psoriasis
o
Glycogen storage disease Type I
o
Hypo- and hyperparathyroidism
o
Downs syndrome
o
Lesch-Nyhan syndrome (choreoathetosis, spasticity, mental
retardation, self-mutilation of lips + fingertips)
Treatment: colchicine, allopurinol (effective treatment usually does
not change x-ray findings)
o
o
o
o
o

Rheumatoid Arthritis

General Considerations
Cause unknown
o Possible genetic predisposition
o Questionable reaction to antigen from Epstein-Barr virus
Age-Highest incidence 40-50 years
o Female preponderance 3:1 under the age of 40; equal distribution
over 40 years
Pathogenesis
o Injury to synovial endothelial cells leads to
o Synovitis with synovial hypertrophy which leads to
o Impaired nutrition with necrosis of cartilage and resultant
o Joint narrowing
Subluxation
Ankylosis
Clinical findings
Diagnostic criteria of American Rheumatism Association (at least 4 criteria
should be present):
o Morning stiffness for >1 hour
o Swelling of >3 joints, particularly of wrist, metatarsophalangeal or
proximal interphalangeal joints for >6 weeks
o Symmetric swelling
o Typical radiographic changes
o Rheumatoid nodules
Biochemical tests
o Positive rheumatoid factor
Rheumatoid factor
Positive in 85-94%
IgM-antibody
o Antinuclear antibodies
Positive in many
o LE cells
Positive in some
o Positive latex flocculation test
Imaging Findings
Location
o Usually symmetric involvement of true, diarthrodial joints
Target areas

o Proximal joints of hands and wrists

All five MCP (metacarpal), PIP )proximal interphalange) joints
and interphalangeal joint of thumb
All wrist compartments
Especially radiocarpal, inferior radioulnar, pisiformtriquetral joints
Early signs
o Fusiform periarticular soft-tissue swelling (result of effusion)
o Regional osteoporosis (disuse and local hyperthermia)
o Widened joint space (rare to see)
o Marginal and central bone erosions in small joints of hands and
wrists
Less common in large joints
Site of first erosion is classically base of proximal phalanx of
4th finger
o Erosion of the ulnar styloid and narrowing of the distal radioulnar
joint
o Atlantoaxial subluxation >2.5 mm (in >6%)
o Giant synovial cysts
Late signs
o Diffuse loss of interosseous space
o Flexion and extension contractures with ulnar subluxation and
dislocation
o Marked destruction of joint spaces
o Extensive destruction of bone ends
o Bony fusion
o Elevation of humeral heads (from rotator cuff tears)
o Resorption of distal clavicle
o Erosion of superior margins of posterior portions of ribs 3-5
o Destruction and narrowing of disk spaces
Irregular vertebral body outlines
Absence of osteophytosis
o Destruction of zygapophyseal joints without osteophyte formation
o Resorption of spinous processes
o "Stepladder appearance" of cervical spine due to subluxations
o Protrusio acetabuli (from osteoporosis)
o Synovial herniation and cysts (eg, popliteal cyst)
o Calcaneal plantar spur
Complications
Extra-articular manifestations (76%)
o Feltys syndrome (<1%)
Rheumatoid arthritis (present for >10 years)
Splenomegaly

Neutropenia
Age
40-70 years
F>M
Rare in African-Americans
o Sjgrens syndrome (15%)
Keratoconjunctivitis
Xerostomia
Rheumatoid arthritis
o Pulmonary manifestations
Pleural effusion, mostly unilateral, without change for months
Usually not associated with parenchymal disease
Interstitial fibrosis with lower lobe predominance
Rheumatoid nodules (30%)
Well-circumscribed
Peripheral
Frequent cavitation
o Caplans syndrome
Hyperimmune reactivity to silica inhalation with rapidly
developing multiple pulmonary nodules
o Pulmonary hypertension secondary to arteritis
Subcutaneous nodules
o In 5-35% with active arthritis over extensor surfaces of forearm
o Other pressure points (eg, olecranon) without calcifications (DDx to
gout)
Cardiovascular involvement
o Pericarditis (20-50%)
o Myocarditis (arrhythmia, heart block)
o Aortitis (5%) of ascending aorta aortic valve insufficiency
Rheumatoid vasculitis
Neurologic sequelae
o Distal neuropathy (related to vasculitis)
o Nerve entrapment (atlantoaxial subluxation, carpal tunnel syndrome,
Baker cyst)
Lymphadenopathy (up to 25%)
o Splenomegaly (1-5%)

Rheumatoid Arthritis. Severe rheumatoid arthritis of the wrist and hand. The ulnar
styloid is destroyed with the rest of the distal ulna (white arrow), there is
destruction of the carpal bones (yellow arrow) and there is dislocation of the 1st
metacarpal on the destroyed trapezium (blue arrow). All of the bones are
osteopenic.

Rheumatoid Arthritis, both feet. There are innumerable intra-articular erosions

(white circles) involving not only the great toes but all toes. There are multiple
subluxations of the joints (white arrows)

Lateral radiograph of the neck with the head in flexion shows an increased
distance between
the anterior border of the dens and the posterior border of the anterior tubercle of
C1 (blue line) from ligamentous laxity caused by rheumatoid arthritis. The "predentate space," as this is called, should be less than 3 mm in the adult. The red
line above should smoothly connect all of the spinolaminar white lines of each
vertebral body but clearly is directed posterior to the spinolaminar white line of
C1 (green arrow) since C1 is subluxed forward on C2.

Frontal images of both the right(above) and left wrists (below) show advanced changes
of rheumatoid arthritis with soft tissue swelling (yellow arrows), narrowing of the
radiocarpal joint space blue arrow). erosions (red arrows), and destruction of the ulnar
styloid (green arrow). The intercarpal joints are destroyed as are all of the carpalmetacarpal joints of both hands. Note the symmetric appearance of the disease.

Erosive Osteoarthritis
Inflammatory Osteoarthritis

General Considerations
Inflammatory arthritis which most commonly occurs in women over the age
of 60
It is a form of osteoarthritis with a strong inflammatory component
Usually involves hand
o Hip and knee are rarely involved
Clinical Findings
Onset is more acute than typical osteoarthritis
Swelling
Erythema
Warmth
Tenderness
Usually begins in DIP joints and progresses to PIP joints
Typically rheumatoid factor negative
Imaging Findings
Typically bilateral, poly-articular and relatively symmetrical involvement
Central erosions are a hallmark resulting in gull-wing appearance
o Central erosion proximally with marginal proliferation distally at both
the DIP and PIP joints
o Gull-wing configuration is not specific for erosive osteoarthritis and

may be seen with rheumatoid and psoriatic arthritis

Most frequently seen in DIP joints of hands
Spares MCP joints
Frequent involvement of the carpal-metacarpal joint of the thumb
May produce cortical thickening similar to psoriatic arthritis
Ankylosis may occur
In the foot, erosive osteoarthritis may involve either the metatarsal-

phalangeal joint or interphalangeal joint of the great toe

Differential Diagnosis
Osteoarthritis erosions and ankylosis usually not seen
Rheumatoid arthritis erosions are usually marginal
Psoriatic arthritis systemic findings, foot may be involved
Treatment

 Conservative treatment
Course of the disease is not dramatically changed by any mode of therapy
Prognosis
Good
o Inflammatory component frequently self-extinguishes leaving

changes of typical osteoarthritis

Has been associated with hypothyroidism, autoimmune thyroiditis,
hyperparathyroidism, chronic renal disease, scleroderma, Sjgren's
syndrome, and calcium pyrophosphate dihydrate arthropathy

Erosive Osteoarthritis. (Above). Frontal radiograph of the hand demonstrates an arthritis

which affects mainly the DIP and PIP joints (white arrows) and carpal-metacarpal joint of
thumb (yellow arrow). There are small osteophytes and erosions (white circle). (Below)
The characteristic lesion of erosive osteoarthritis is shown in close-up. There is a
central erosion of the proximal part of joint (yellow arrow) and bone overgrowth peripherally
(white arrows) resembling a seagull's wings.
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