plain film diagnosis of arthritides (the basic edition)
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Plain Film Diagnosis of Arthritides (The Basic Edition). Jacob Walter, M4. Four main categories of arthritis. Degenerative Osteoarthritis (OA) Secondary – Systemic: hemochromatosis, hemophilia Inflammatory Seropositive – rheumatoid arthritis (RA) - PowerPoint PPT PresentationTRANSCRIPT
Plain Film Diagnosis of Arthritides(The Basic Edition)
Jacob Walter, M4
Four main categories of arthritis Degenerative
Osteoarthritis (OA) Secondary – Systemic: hemochromatosis, hemophilia
Inflammatory Seropositive – rheumatoid arthritis (RA) Seronegative – reactive arthritis, ankylosing spondylitis, psoriatic
arthritis, and enteropathic arthritis (assoc with IBD) Infectious Crystal deposition
Calcium pyrophosphate deposition disease (CPPD) Monosodium urate crystals - Gout
This is not a complete list, but will hopefully get you started
When evaluating arthritis, take into account… Location – bilateral/unilateral, which joint(s) Which part of the joint is involved, even or
uneven Demographics – age, gender Presence of osteophytes, erosions, new bone
formation, subchondral cysts, sclerosis… Soft tissue swelling Or, ABCDE’s: Alignment, Bone proliferation,
Cartilage (joint space loss), Density (bone), Erosions, soft tissues
Degenerative
Osteoarthritis (OA)Secondary – Systemic: hemochromatosis, hemophilia
Degenerative - Osteoarthritis Characteristics
Uneven loss of joint space Osteophyte formation Normal bone mineralization Relative absence of erosions Subchondral cysts and new
bone formation/sclerosis Asymmetric distribution, usually
hands, feet, knees and hips Not as common in shoulders,
elbows Associated with changes d/t
age, and mechanical forces
http://uwmsk.org:8080/EvasMSKTF/
OA cont.
Hand/Wrist DIP and PIP involvement,
sparing of MCP Osteophyte formation with
soft tissue swelling (Heberdon node at DIP, Bouchard at PIP)
Usually 1st metacarpal/trapezium/navicular involvement in wrist
Feet Most commonly 1st MTP
joint
http://podiatryonline.com/
OA cont.
Knee Medial joint involvement
more common Varus deformity of joint,
lateral tibial subluxation Hip
Most often superiolateral joint involvement with loss of cartilage and osteophyte formation
Medial sclerosis/new bone formation in femoral neck cortex; buttressing
http://uwmsk.org:8080/EvasMSKTF/
STATdx
Cyst
Buttressing
Osteophyte
Erosive OA
OA with an inflammatory component
Same OA distribution, but may see erosions or ankylosis
Often postmenopausal women
http://uwmsk.org:8080/EvasMSKTF/
Degenerative – SystemicHemochromatosis Abnormal iron deposition
throughout the body, including articular cartilage
Demonstrates some overlap with CPPD, Fe inhibits pyrophosphatase and can lead to crystal deposition in cartilage (chondrocalcinosis)
Uniform joint space loss Bilateral symmetrical
distribution “Beak-like” osteophytes Subchondral cysts/sclerosis Osteoporosis
http://uwmsk.org:8080/EvasMSKTF/
Hemochromatosis cont
Most often in wrist and hand, esp. 2nd and 3rd MCP joints
Flattened metacarpal heads
Systemic disease may appear similar to CPPD, but with more indolent course and predominance of osteophytes
http://uwmsk.org:8080/EvasMSKTF/
Degenerative - Systemic Hemophilia
Repetitive hemarthrosis and intraosseous bleeding are causative
Overgrown/ballooned epiphyses
Subchondral cysts Tissue swelling, evidence
of hemarthrosis Osteoporosis Late uniform space loss Sporadic, asymmetric
distribution Late osteoarthritis changes Knee > elbow > ankle >hip
(joints most likely to receive trauma)
http://uwmsk.org:8080/EvasMSKTF/
Hemophilia cont
Pseudotumors Bleeding in to soft
tissues, subperiosteal, or intraosseous areas
May cause some bone destruction or periosteal bone formation
Do not confuse with malignancy
http://radiographics.rsnajnls.org/cgi/content/full/23/4/852
Inflammatory
RASeronegative
Reactive Ankylosing SpondylitisPsoriaticEnteropathic
Inflammatory – SeropositiveRheumatoid Arthritis Periarticular soft tissue
swelling Osteoporosis Uniform joint space loss Marginal erosions severe
subchondral erosions No bone formation (no
osteophytes) Subluxations Synovial cysts Bilateral and symmetric Generally not present in axial
skeleton, except C-spine Hands > feet > knees > hips >
C-spine > shoulders > elbows
Erosions, uniform joint spaces
http://uwmsk.org:8080/EvasMSKTF/
RA cont
In hand and wrist, often involves carpals, MCP joints and PIP joints Ulnar subluxation of proximal
phalanges and formation of swan neck and boutonniere deformities
Formation of subcutaneous rheumatoid nodules
In the foot, erosion of distal metatarsals, and eventual radial subluxation of proximal phalanges Tarsal joint spaces may also
be heavily involved
http://uwmsk.org:8080/EvasMSKTF/
RA cont
Knees affected symmetrically and bilaterally Uniform space loss Outpouching of synovial cysts
into adjacent bone, or soft tissue (Baker’s cyst)
Hips affected in 50% Uniform cartilage loss axial
or superomedial migration of femoral head
Bone erodes on joint side, and forms on pelvic side leading to acetabuli protusio (acetabulum protrudes into pelvis)
STATdx
Erosions and joint space loss bilaterally, no osteophytes or sclerosis
Baker’s cyst
Effusion
RA cont
Shoulder and elbow also show bilateral, uniform joint space loss with osteoporosis and cysts formation
Special consideration: RA patients are prone to developing laxity of transverse ligament between atlas and odontoid process Normal distance between the
two on lateral c-spine is 3mm in adults, 5mm in children
Increased distance may indicate need for surgical fusion to prevent cord compression during flexion
http://uwmsk.org:8080/EvasMSKTF/
Inflammatory Arthritis – Seronegative Associated with HLA-B27 Negative RH factor Axial skeleton often involved
Sacroiliitis or spondylitis Enthesopathy
Inflammation of the insertions of tendons/ligaments
Inflammatory – SeronegativeReactive Arthritis (Reiter’s) Reiter’s included the classic triad of arthritis,
conjunctivitis, and urethritis Classical model involving chlamydial infection doesn’t
apply to all cases, and Reiter was a WWII war criminal, so reactive arthritis is now the preferred term
Reactive arthritis may still involve chlamydial infection, but may also occur after gastroenteritis (Shigella, Salmonella, Campylobacter, Yersinia, C. defficile)
Likely autoimmune reaction, joints themselves are not infected
Worldwide has equal prevalence among men and women
Reactive cont
Enthesopathy is prominent, with overlying tissue warmth and tenderness
Soft tissue swelling (sausage digits)
Uniform joint space loss Bilateral, asymmetrical Often begins with one joint,
don’t confuse with septic arthritis
Areas of erosion associated with periosteal reaction, new bone formation
Most often in feet, ankles, knees and SI joints
Less in hands, hips, spine
http://uwmsk.org:8080/EvasMSKTF/
Reactive cont
Very often involves Achilles tendon insertion, preference for MTP and 1st IP joint in feet (vs DIP and PIP in psoriatic)
In SI joint, may be on only one side or asymmetrically affect both sides (opposed to ankylosing spondylitis)
May form large, asymmetric bony bridges between vertebrae (similar to psoriatic, but opposed to ankylosing spondylitis)
I got tired of bone pics, so here’s some chlamydia!
http://www.lahey.org/Medical/InfectiousDiseases/ID_Chlamydia.asp
Inflammatory – SeronegativeAnkylosing Spondylitis Bilateral, symmetrical Ankylosis, joint fusion, is
prominent Before fusion, subchondral
bone formation Post fusion, generalized
osteoporosis No cysts or subluxation Erosions not a prominent
feature, but are present SI and spine (ascending)
involvement > hips > shoulders > knees > hands > feet http://uwmsk.org:8080/EvasMSKTF/
AS cont
Fusion of SI joints is classic Vertebral bodies initially erode
at corner, reactive sclerosis occurs below this leading to squared appearance Eventually anulus fibrosus and
longitudinal ligaments become ossified (syndesmophytes)
Discs can become calcified, along with all ligaments including those between spinous processes bamboo spine
Dagger sign, fused spinous process ligaments
http://uwmsk.org:8080/EvasMSKTF/
Inflammatory – SeronegativePsoriatic Arthritis Bilateral, asymmetrical Dramatic joint space loss +/-
ankylosis (arthritis mutilans) Bone proliferation, “mouse
ears” “pencil-in-cup” deformities Normal mineralization Sausage digits Hands > feet > SI > spine Usually favors DIP and PIP in
hand SI involvement usually
bilateral, asymmetrical Large bridging bone formation
in spine, similar to reactive arthritis
http://uwmsk.org:8080/EvasMSKTF/
Sausage digits
http://uwmsk.org:8080/EvasMSKTF/
http://www.hopkins-arthritis.org/arthritis-info/psoriatic-arthritis/diagnosis.html
Inflammatory – SeronegativeEnteropathic Arthritis 20% of patients with inflammatory bowel disease
develop arthritis Axial disease is very similar to AS with spine and SI joint
involvement Radiographically almost identical to AS Progresses independently of IBD activity
Peripheral arthritis/arthralgia waxes and wanes with IBD activity Oligoarthritis of lower extremities Erythema nodosum and pyoderma gangrenosa may be
concurrent Whipple’s disease, pancreatic disease, cirrhosis, and
infection such as Salmonella and Shigella may also be associated with arthritis
Infectious
Septic arthritis
Septic arthrtitis
Joint space destruction, both sides, due to release of proteolytic enzymes Joint effusion Soft tissue swelling Osteoporosis In healthy patients
Knee, hip, and elbow common N. gonorrhoeae most common cause in young, sexually active patients
IV drug users SI joint, sternal, pubic joints
TB Hip, knee, intertarsal joints, spine TB in vertebral disc space is Pott’s disease
Staph aureus is most common cause, Streptococcus is also common Gram negatives more common in diabetics Salmonella in sickle cell patients Risk factors: Extremes of age, immunocompromised, chronic arthridities,
prosthetic joints, diabetes, and IV drug use
Septic arthritis contUhh, do you see the problem?
http://www.learningradiology.com/images/boneimages1/bonegallerypages/Septic%20arthritis.html http://www.wheelessonline.com/ortho/tuberculous_spondylitis
Pott’s
Sedona, AZ(crystals)
GoutCPPD
Crystals Gout Monosodium urate crystal deposition
May deposite in cartilage to produce an OA like disease, or in soft tissues (tophaceous gout)
Usually males, postmenopausal females Tophaceous gout
Tophi Relative joint space preservation Erosive lesions with sclerotic borders, away from joint space,
with overhanging cortex Normal mineralization Asymmetrical, polyarticular May present with acute, monoarticular swelling, pain, and
erythema. Feet (1st MTP) > ankles > knees > hands > elbows
Gout cont
Uwmsk.org/residentprojects/gout.html
Erosion with overhanging edge. Joint space is preserved.
tophus
Crystal in PMN from synovial fluid, diagnostic for acute gout
CrystalsCPPD Most common crystal arthropathy Disease spectrum includes:
Deposition in cartilage (chondrocalcinosis), which may lead to OA like disease or be asymptomatic
Commonly develops in older population Associated with hyperparathyroidism and hemochromatosis
Pseudogout which may present with acute attacks of arthritic pain similar to gout, although it is more common in the knees than the 1st MTP
May be indistinguishable from septic arthritis without synovial fluid analysis
Chondrocalcinosis Most common in knee, pubic
symphysis, and wrist (patients will be affected in at least one of these areas)
Deposition of crystals in hyaline and/or fibrous cartilage
Bilateral Cysts Normal mineralization Subchondral new bone formation +/- osteophytes Knees > hands > hips Shoulder and elbow involved,
differentiates from OA
wikipedia
Uwmsk.org/residentprojects/gout.html
Sources
Bowen, Anne C. Arthritis in Black and White. Philadelphia: Saunders, 1988
Current Rheumatology Diagnosis & Treatment, Second EditionJohn B. Imboden, David B. Hellmann, John H. Stone. http:/accessmedicine.com
Gay, Spencer B. Woodcock, Richard J Jr. Radiology Recall. Baltimore: Lippincott, 2000
Pretorius, E. Scott. Solomon, Jeffery A. Radiology Secrets. Philadelphia: Mosby 2006
Marc Gosselin, M.D., OHSU