Endgames Picture Quiz

Rusty joints

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6197 (Published 14 October 2011) Cite this as: BMJ 2011;343:d6197
  1. Marieke van Onna, rheumatology trainee1,
  2. B Sweder van Asbeck, internist2,
  3. Johannes W G Jacobs, rheumatologist1
  1. 1Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, 3508 GA Utrecht, Netherlands
  2. 2Department of Internal Medicine, University Medical Centre Utrecht
  1. Correspondence to: M van Onna mariekevanonna{at}hotmail.com

A 47 year old white man presented to the outpatient clinic with progressive pain and stiffness of hands and feet of five years duration. During this time he once experienced swelling of the knuckles of his right hand that resolved spontaneously within a week. Diclofenac 50 mg twice daily had not been effective. A year ago ankle osteoarthritis had been diagnosed arthroscopically. He did not smoke or drink alcohol. His father, who had diabetes, also had painful joints. On examination, he was noted to be tanned, with a body mass index of 27. He had subtle arthritis of the second and third metacarpophalangeal joint of the left hand and third metacarpophalangeal joint of the right hand, Heberden’s nodes of several distal interphalangeal hand joints, and crepitus of ankle and knee joints bilaterally. The liver was palpable 3 cm below the right costal margin. Otherwise, physical examination was unremarkable. Laboratory tests and radiographs (fig 1) were ordered.

Fig 1 Radiograph of hands and wrists


  • 1 What are the differential diagnoses for this patient’s joint problems?

  • 2 What abnormalities can be seen on the radiograph?

  • 3 What is the most likely clinical diagnosis?

  • 4 How is this clinical diagnosis confirmed?

  • 5 How can this condition be treated?


1 What are the differential diagnoses for this patient’s joint problems?

Short answer

The main differential diagnoses are primary osteoarthritis, secondary osteoarthritis as a result of haemochromatosis, rheumatoid arthritis, psoriatic arthritis, and crystal arthropathies (calcium pyrophosphate deposition disease and chronic gout).

Long answer

At first sight our patient seemed to have signs and symptoms of primary (idiopathic) osteoarthritis (Heberden’s nodes, crepitus of knee joints). However, primary osteoarthritis cannot be the cause of all his joint problems.

Firstly, his second and third metacarpophalangeal joints and his ankles are affected, and these joints are rarely affected by primary osteoarthritis. Secondly, one episode with swelling could suggest subtle but persistent arthritis, although …

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