Calcification of the Sacrotuberous Ligament

Just by chance we recently detected a calcification of both sacrotuberous ligaments in an elderly lady. The structure between a to b and c to d an the picture look like bones, but it’s a calcification of ligaments.

Rakhi S. Bhadada and colleagues published a short article on a man with multiple membrane calcifications as a consequence of fluorosis. Link: http://www.japi.org/september2007/PC-633.htm.

The reason fort he calcification in our elderly lady remains unclear. No fluorosis.

Looking at and Touching Joints in Rheumatoid Arthritis

Mrs. A. R. is 52 years old and is suffering from rheumatoid arthritis since 1994. Last rheumatoid factor has been measured at 392 IU/ml; CRP has been 3.5 mg/l. At the last consultation two joints still were swollen. DAS28 = 3.64, RADAI 4.0. She has been receiving 40 mg adalimumab s.c. every two weeks since 2003. X-ray charts of hands and feet showed erosive disease, which hasn’t progressed in recent years.

This is a photograph of the actual rheumatologic examination. The joints with circles are synovialitically swollen in the palpatory examination.

If you look at the photograph of the hands, you might get the impression that also the MCP-3 joint of the left hand and the MCP-5 joint of the right hand are synovialitically swollen. Actually these swellings are due to post arthritic osteoarthritis, which aren’t activated, but might show acceleration in the future, which isn’t due to inflammation.



The X-ray chart shows erosive disease.

All in all in rheumatoid arthritis you need to look at joints, feel the joints, and use X-ray (or another equal method) to evaluate, where the disease stands. Relying on one method only might under- or overestimate disease activity and lead to wrong therapeutic decisions. So, a quick look isn’t giving the best of care.

Related blogpost: http://rheumatologe.blogspot.de/2012/06/malingerer-with-erosive-rheumatoid.html

The Rheumatoid Horror Picture Show

Here you see X-ray-charts of a woman born 1936, who has been admitted to our hospital yesterday afternoon (first time here, first time seeing a rheumatologist, 05.07.). She is suffering from rheumatoid arthritis (rheumatoid factor positive) since the 1970ies. She had been treated with parenteral gold and methotrexate. And some sugery had been done (heroicmeasures?). Last Saturday (30.06.) she suffered from severe pain in the right lower arm without any known trauma. She presented herself here with pain on palpation of the right lower arm, told about a sensory disturbance, and had a diffuse hematoma of the inner side of the right lower arm. Here are the X-rays we did yesterday afternoon:

We are of course surprised, why she has been sent to rheumatology instead of orthopedic surgery. We will try to find someone to operate on her. For DMARDs or biologics it seems too late as other joints don't show inflammation.

Rheumatoid Arthritis - Radiographic Progression

Today I dictated the findings in our patient's x-rays and I saw two women with rapid progression.

Here are the x-rays of one patient, who showed up for the first time two weeks ago, is now at our day clinic. She was born in 1983 and suffers from rheumatoid arthritis for at least seven years, but didn't look for professional help. She just go prescription pain killers by her GP.

The carpalia are destructed and fused into an os carpale.

Also the heads of the metatarsalia show erosive disease.

The second woman was born in 1958. We treated her until 2010, when she wanted to frequent a rheumatologist closer to her home. We gave the advice to chance therapy to Enbrel as she already suffered from erosive disease. Here are the two x-rays of March 2010.

And now two years after these pictures, we have made these x-rays today.

I think one can easily see the dramatic changes and the rapid progression of the disease.

The second metacarpalia must have been broken and healed during the past two years.

These two examples demonstrate, how important it might be to act within a small limit of time.