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Hand

Hand

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Early Changes of Inflammatory Arthritis: This picture shows swelling and mild erythema / bluish tinge at the second, third and fifth PIP joints. Note the loss of the skin folds over the affected joints indicating that synovitis is present. The MCP’s look “full” and could be inflamed. The DIP joints of 3rd DIP and possibly 1st and 4th look enlarged and could represent synovitis or possibly a concomitant Heberden’s node of osteoarthritis. This could represent early RA (with coexisting OA in DIP joints) or early PsA if there is synovitis in the DIPs. (Image Credit: Ms. Nancy Roper) — Early Changes of Inflammatory Arthritis

Early Changes of Inflammatory Arthritis: The subject in this picture is having difficulty straightening the fingers and they look puffy. In particular the MCPs of 2nd and 3rd digits look swollen and the proximal digits look puffy. Also note that there is a fullness just inferior to the right wrist that is probably involving the dorsal extensor tendon sheath. This will be seen better in the next picture. This could represent early RA based on the distribution. (Image Credit: Dr. Lori Albert) — Early Changes of Inflammatory Arthritis

Early Changes of Inflammatory Arthritis: This picture shows another view of the swelling in the right wrist. There is fluid in the dorsal tenosynovial sheath producing a “tuck sign” (rather than diffuse swelling, the swelling bunches up on the dorsum of the wrist, especially with finger extension). This is usually painless compared with a wrist effusion. (Image Credit: Dr. Lori Albert) — Early Changes of Inflammatory Arthritis

Inflammatory Arthritis (Before Treatment): This third set of hands demonstrates widespread effusions in PIPS and MCPs producing puffy digits. There is mild erythema over the inflamed joints. The right wrist is swollen as well. This is typical of early rheumatoid arthritis or the arthritis associated with collagen vascular diseases. (Image Credit: Ms. Nancy Roper) — Inflammatory Arthritis (Before Treatment)

Inflammatory Arthritis (After Treatment) (Image Credit: Ms. Nancy Roper) — Inflammatory Arthritis (After Treatment)

Osteoarthritis: Here we see enlargement of the DIP joints. It is fairly uniform, and we also can appreciate some enlargement of the PIP joints in many digits. This swelling looks more “hard” and nodular (however, palpation will be needed to confirm this). (Image Credit: Dr. Jack Reynolds) — Osteoarthritis

Inflammatory Arthritis: There are classic changes of longstanding rheumatoid arthritis to be seen here. Can you name them? Subluxation of MCPs, swan neck deformities (4th and 5th digits bilaterally). (Image Credit: Dr. Jack Reynolds) — Inflammatory Arthritis

Inflammatory Arthritis: This patient has difficulty closing the fingers on the right hand, especially at the level of the PIP joints. This could be the result of PIP effusions and/or associated tenosynovitis. This might also be seen in early scleroderma or mixed connective tissue disease with “puffy” fingers, but this is usually bilateral. (Image Credit: Ms. Nancy Roper) — Inflammatory Arthritis

Typical Ulnar Deviation of Rheumatoid Arthritis (Pronation) (Image Credit: Ms. Nancy Roper) — Typical Ulnar Deviation of Rheumatoid Arthritis (Pronation)

Typical Ulnar Deviation of Rheumatoid Arthritis (Supination) (Image Credit: MS. Nancy Roper) — Typical Ulnar Deviation of Rheumatoid Arthritis (Supination)

Boutonniere Deformity: These hands show other chronic changes of inflammatory arthritis- Boutonniere deformities are affecting the right 3rd and 5th and left 3rd and 4th digits. (Image Credit: Ms. Nancy Roper) — Boutonniere Deformity

Volar Subluxation: Contrast the appearance of fluid in the dorsal tenosynovial sheath in the previous picture with the “dinner fork” wrist seen in this picture. This arises from chronic inflammation in the wrist followed by damage and volar subluxation of the carpal bones on the distal radius and ulna. (Image Credit: Ms. Nancy Roper) — Volar Subluxation

Tuck Sign: This patient with rheumatoid arthritis has a “tuck sign” on the dorsum of the left wrist. (Image Credit: Dr. Lori Albert) — Tuck Sign

Psoriatic Arthritis: Here we see what appears to be involvement of just the DIP joints of the second and third digits. This could be OA or psoriatic arthritis. We will have to look for clues such as symmetry of joint involvement, rash or nail changes to help us. (Image Credit: Dr. Jack Reynolds) — Psoriatic Arthritis

Psoriatic Arthritis: On closer inspection the appearance of the nail of the index finger reveals typical psoriatic changes which helps to make the correct diagnosis. (Image Credit: Dr. Jack Reynolds) — Psoriatic Arthritis

Osteoarthritis: Significant DIP swelling is seen in an asymmetric distribution in these hands. This looks similar to what might be seen in psoriatic arthritis. However, the changes at the base of the thumbs (squaring and subluxation) indicates that this is most likely osteoarthritis. (Image Credit: Ms. Nancy Roper) — Osteoarthritis

Tophus (Gout): In this picture, a single DIP is involved with dramatic swelling – it is too big to be OA alone. There is no other evidence for psoriatic arthritis. There is also the appearance of material extruding from under the skin– this is a tophus associated with gouty arthritis of the DIP joint. (Image Credit: Dr. Jack Reynolds) — Tophus (Gout)

Onycholysis (Psoriatic Arthritis of Nails): This shows typical changes of psoriasis affecting the nails- thickening and lifting of the nail. Can also see pits and more dramatic onycholysis. (Image Credit: Dr. Jack Reynolds) — Onycholysis (Psoriatic Arthritis of Nails)

Dermatomyositis: These hands show the classic rash of dermatomyositis with scaling rash over the MCPs and DIPs of the hands. (Image Credit: Dr. Jack Reynolds) — Dermatomyositis

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Dr. Lori Albert, University of Toronto ©2015

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