Hand X-Ray Changes

You need to look at some images online to get some pattern recognition.

With any investigation, you need to reference findings back to the patient you just examined.

For example (I have borrowed this example from notes provided to me) - “this X-ray has evidence of a symmetrical deforming polyarthropathy with erosive change consistent with my clinical findings and diagnosis of RA. In more detail specific abnormalities include…”.

Likewise, if findings are discordant with your examination findings, then mention this, and discuss how/if it changes your differential. Don't just state what you see on the X-Ray.

Osteoarthritis - LOSS

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

Rheumatoid arthritis - LOSED

Loss of joint space
Osteopaenia (juxta-articular)
Soft tissue swelling
Erosions (marginal bony erosions)
Deformities

Gout

Periarticular “punched out” or “rat-bitten” erosions with overhanging edges and sclerotic margins
Normal joint space
Soft tissue swelling
May see dense tophi (can be calcified in renal disease)
Normal bone density maintained

Psoriatic arthritis

The hallmark of psoriatic arthritis is the combination of erosive change with bone proliferation, in a predominantly distal distribution (e.g. interphalangeal more than metacarpophalangeal joints).
Destructive arthritis with erosions and osteophytes
Pencil in cup deformity of hands
DIP involvement
Arthritis mutilans with telescoping
Periostitis along shaft of digit
Normal bone density
Soft tissue swelling
Ankylosis

SLE

Non-erosive joint deformities
Soft tissue swelling
Juxt-articular osteopenia, osteoporosis
High rates of osteonecrosis

Scleroderma:

Soft tissue calcifications (calcinosis cutis)
Resorption of distal phalangeal tufts (acro-osteolysis)
In late disease articular erosions, cartilage narrowing, ankylosis (especially DIPs), subluxation of first CMC