By: DR. RAMAN SHINGADE 2ND YR. RESIDENT

GUIDE: DR. KANCHANA PACHCHIGAR

TUTOR

• Greenspan• Yochum and Rowe• Radiopedia.org• Learninradiology.com

References:

Xray Imaging in Non Inflammatory Arthritis

The constituent structures of a synovial/diarthrodial joint.

Definition of Arthritis

•Disease that affects bones on both sides of the joint space and

•Narrows the space between them

Narrowing of the joint space

Radiographic features of arthritides

Arthritis or not

Normal DJD

Arthritis or not

Normal DJD

Arthritis or not

Normal DJD

Classification of Arthritides

•Inflammatory Arthritis

•Non-inflammatory Arthritis

Non Inflammatory ArthritisDegenerative Arthritis (Osteoarthritis)

Primary

Secondary

Connective Tissue Arthropathy Scleroderma

MCTD

Metabolic & Endocrine Arthritis Acromegaly

Hemochromatosis

Haemophilia

Gout

Hyperparathyroidism

2 forms of Osteoarthritis

Primary form • Idiopathic

Secondary form • Posttraumatic• Congenital disorders• Neuropathic Arthritis• Avascular Necrosis

Primary Degenerative Arthritis

• Intrinsic degeneration of articular cartilage

• Excessive wear and tear• Most commonly weight bearing joints like knees and

hips• Less commonly non-weight bearing joints like knees

and hips

•Hip

•Knee

• Spine

• Interphalangeal joints of the hand

Common Sites

Hallmark radiographic features

• localized joint space narrowing

• subchondral sclerosis

• osteophytes

• cyst or pseudocyst

Osteoarthritis of Large joints

narrow joint spacesubchondral sclerosis

osteophytes

Right hip osteoarthritis

Superolateral migration of femoral head with typical Eggers cyst in acetabulum.

Egger’s CystSuperolateralmigration

Medial migration of the femoral head

Postel coxarthropathy(aka rapidly destructive arthrosis)

• occurs predominantly in women

• characterized by rapid chondrolysis

• no/very little reparative changes

• mimics Charcot joint or infectious arthritis

Right hip Postel Coxarthropathy

Osteoarthritis of left knee

L L

AP and lateral both knee radiographs bilateral knee osteoarthritis.

Advanced osteoarthritis with loose bodies

Narrowing of the femoropatellar joint compartment

Patellar Tooth sign

Patellar Tooth sign on AP projection

•Not due to mechanical stress

• F:M = 10:1

•Most Often involves DIP joints• Sclerosis• Osteophyte formation

• 1st MCP joint of thumb

Osteoarthritis of Hand

Hallmark radiographic features

• Heberden nodes

• Bouchard nodes

• joint space narrowing

• subchondral sclerosis

Osteoarthritis of Hand

Heberden Nodes

Bouchard Nodes

Degenerative changes in the 1st carpometacarpal joint

Osteoarthritis of bilateral first metatarsophalangeal joints

hallmark radiographic features

• Facet narrowing and eburnation

• Foraminal stenosis

• Stenosis of spinal canal

• Narrowing of IVDS

Degenerative Disease of the Spine

Osteoarthritis of the facet joints

Subchondral sclerosis

Narrowing of facet joints

Bridging osteophytes

Bridging osteophyte

Encroachment of the neural foramina by posterior osteophytes

Posterior osteophytes withNeural foraminal stenosis

Vacuum disc phenomenon

Prominent osteophytes

Vacuum disc phenomenon

Secondary Osteoarthritis

• Another process destroys articular cartilage

• Degenerative changes supervene

• How to recognize• Atypical age (e.g. DJD in 20 yrs age)• Atypical appearance (e.g. DJD in 1 hip only)• Atypical locations (e.g. DJD in shoulder)

Secondary Osteoarthritiscauses

• Trauma (most common)• Avascular Necrosis• Neuropathic arthritis• Congenital Disorders• Haemophilia• RA

Bottom Line: Any arthritis can lead to 2° OA

•most common cause of secondary/atypical osteoarthritis

• changes similar to those in primary osteoarthritis

• history of previous trauma

• younger age group

Posttraumatic Osteoarthritis

Severe osteoarthritic changes due to previous dislocation

Severe post-traumatic osteoarthritis following distal fibula fracture.

Left knee Posttraumatic osteoarthritis.

L

• destructive articular disease that occurs secondary to a loss or impairment in joint proprioception

• disturbance in sensations leads to multiple microfractures

• fragmentation of the bone and cartilage

Neuropathic Arthritis

Causes

Shoulders • Syrinx• Spinal Tumor

Hips • Tertiary syphilis• Diabetes

Feet • Diabetes

6 D’s of Neuropathic Arthritis

• Dense bones (subcondral sclerosis)

• Distension of joint

• Destruction of bone and cartilage

• Disorganization

• Debris (loose bodies)

• Dislocation

Typical Neuropathic (Charcot) joint

Typical charcot joint in man with syphilis

Licked candy stick configuration

• defined as death of the osseous cellular components and marrow due to inadequate blood supply

• definite anatomic predisposition for osteonecrosis at the epiphyseal centers

• usually escapes clinical detection and is diagnosed only with bony imaging

Avascular Necrosis(Ischemic or Osteonecrosis)

• Spontaneous (idiopathic) • Trauma (fracture, dislocation)• Alcoholism• Corticosteroid therapy• Surgery • Hemoglobinopathy

Common causes -

• Collapse of articular cortex• Fragmentation•Mottled trabecular pattern• Sclerosis (Snowcap sign)• Subchondral cysts • Crescent sign (Subchondral fracture)

Radiographic features

Classical sites of Osteonecrosis

• head of femur

• neck of talus

• waist of scaphoid

Snowcap and Crescent signs

Collapsed Articular Cortex

Epiphyseal Fragmentation

Osteonecrosis of humeral head after sustaining fracture of the left humeral neck

Crescent sign

Increased bone density

Healed Fracture

Pregnancy related Avascular necrosis.

Osteonecrosis of right humeral head following chemotherapy

•Developmental dysplasia of the hip

• Slipped capital femoral epiphysis

Secondary to Congenital Diseases

Includes

•Putti's triad for developmental dysplasia of the hip include :

Superolateral displacement of proximal femur .

Increase in acetabular angle.

Small capital femoral epiphysis.

Developmental dysplasia of the hip

Radiograph demonstrates Developmental Dysplasia of Hip in a 6 months old female baby.

Developmental Dysplasia of Hip in a 12 years old female.

• Loss of Capener triangle sign

• Decreased height of femoral epiphysis

• Absence of intersection of epiphysis by line tangent to lateral cortex of femoral neck

• Herndon hump

Slipped capital femoral epiphysis

Radiographic features:

Radiograph demonstrates absence of Carpener triangle in left hip.

Carpener Triangle

Absence ofCarpener Triangle

Absence of intersection of epiphysis by lateral femoral cortical line.

Radiograph demonstrates Herndon hump and secondary osteoarthritis.

Non Inflammatory Arthritis

Connective Tissue Arthropathy Scleroderma

MCTD

Metabolic & Endocrine Arthritis Acromegaly

Hemochromatosis

Gout

Haemophilia

Hyperparathyroidism

Scleroderma

• generalized systemic inflammatory connective tissue disease of unknown cause

• strong female predilection (F:M 3:1)

• frequent involvement of the musculoskeletal system

• predominantly affects the fingers, wrists and ankles

CREST syndrome

Calcinosis

Raynaud phenomenon

Esophageal dysmotility

Sclerodactyly

Telangiectasia

• atrophy of the soft tissues at the tips of the fingers

• resorption of the distal phalanges

• subcutaneous and periarticular calcifications

• destructive changes of the small articulations

• flexion contractures

Radiographic features

Atrophy of the soft tissues at the distal phalanges of the index, middle, and ring fingers

R

Soft-tissue calcifications in the distal phalanges of the left hand, a typical feature of Scleroderma

L

Acroosteolysis (arrow), soft tissue calcifications, and destructive changes of the distal interphalangeal joint of the middle finger.

R

Subcutaneous calcifications alongwith destructive changes in distal IP joints

L

Destructive changes in the distal interphalangeal joints, as well as soft-tissue calcifications

L

Flexion contracture in scleroderma patient

Mixed Connective Tissue Disease

• an example of Overlap syndrome

• combine the features of SLE, scleroderma, dermatomyositis, and rheumatoid arthritis

• antibody to the ribonucleoprotein (RNP)

• approx. 80% patients are female

Radiographic features are combination of different conditions

• Tuft resorption and DIP erosions (Scleroderma)

• Erosive arthritis (Rheumatoid arthritis)

• Deforming, nonerosive arthritis (SLE)

Abnormal tapering of the distal soft tissues and early surface erosion of the phalangeal condyle.

Subtle surface erosions and Progressive erosions

Terminal tuft resorption

Subluxation of IP joint of the thumb and advanced ulnar deviation

Juxta-articular demineralization and erosive articular disease

Metabolic & Endocrine Arthritis

Acromegaly

Hemochromatosis

Gout

Haemophilia

Hyperparathyroidism

Acromegaly

• result of excessive growth hormone (GH) production

• growth of intramembranous bone tissue and subcutaneous hypertrophy

• degenerative changes are the result of hypertrophy of articular cartilage

• it is not adequately nourished by synovial fluid because of its abnormal thickness

Indices for Acromegaly

o Sesamoid Index • Product of height and width (in mm.) of sesamoid bone at MCP of thumb.

• Normal - <30 in females <40 in males

o Heel Pad Thickness • Distance from posteroinferior surface of calcaneum to nearest skin surface

• Normal <22 for 150 lb. individual

• initially, widening of joint spaces in hand, particularly MCP joints

• later, thinning of the joint cartilages with osteophyte formation

• beak-like osteophytes

• Spade phalanx sign

Radiographic features

Sesamoid Index and Heel Pad Thickness

Spade phalanx sign

NORMAL ACROMEGALY

Characteristic abnormalities in acromegalic hand

Acromegalic osteoarthritis

Hyperparathyroidism

• aka generalized osteitis fibrosa cystica or Recklinghausen disease of bone

• result of overactivity of the parathyroid glands

• leads to hypercalcemia

• 3 subtypes – primary, secondary and tertiary

Radiographic features

• Osteopaenia

• Subperiosteal bone resorption

• Intracoritcal bone resorption

• Brown tumours (aka Osteitis Fibrosa Cystica)

• Soft tissue and cartilage calcifications

• Osteosclerosis

• Salt and pepper sign in skull

• Rugger-jersey spine

Subperiosteal resorption is on the radial sides of proximal and middle phalanges

Subchondral resorption resulted in widening of the sacroiliac joints.

Brown tumor in distal radius

Brown tumor in distal clavicle

Chondrocalcinosis at the knee and the symphysis pubis

Metastatic calcifications

Typical hyperparathyroidism arthropathy at the distal interphalangeal joints of the index and middle fingers.

Rugger-Jersey Spine

Hemochromatosis

• characterized by iron deposition in various organs

•may be primary (endogenous or idiopathic) or secondary

• affects men 20-times more frequently than women

• 50% of patients with hemochromatosis will have a slowly progressing arthritis

• features typical of osteoarthritis

• different pattern of joint involvement in hand

• second and third metacarpophalangeal joints

• hook-like osteophytes

• chondrocalcinosis

Radiographic features

Osteoarthritic features in woman with hemochromatosis

Magnified radiograph demonstrates involvement of the metacarpal heads

Classical hook osteophytes

Advanced Hemochromatosis arthropathy

Hemophilia• group of disorders characterised by a tendency to bleed as a result

of deficient clotting factors

• deficiency of factor VIII (haemophilia A) or factor IX

• arthropathy is a consequence of recurrent bleeds into joints

• knees, elbows, hips and ankles are most commonly affected

Radiographic features

• widened intercondylar femoral notch

• squared inferior margin of the patella

• haemophilic pseudotumours

• periarticular erosions

• features of osteoarthritis

Widened intercondylar notch with joint effusion

L

Haemophilic arthropathy with subtle haemarthrosis

Advanced degenerative changes, with near-complete loss of joint space

L

Haemophilic Pseudotumors

Gout•metabolic disorder characterized by recurrent episodes of

arthritis

•monosodium urate monohydrate crystals in the synovial fluid leukocytes

• great toe is the most common site of involvement in gouty arthritis

•most patients are men (20:1)

Radiographic features

• Articular erosion with preservation of part of joint

• Overhanging edge of erosion

• Lack of osteoporosis

• Periarticular swelling

• Tophi

Periarticular erosions and soft tissue masses, representing tophi

Multiple articular and periarticular erosions associated with large tophi.

Typical involvement of the first MTP joint with “overhanging edge”.

Overhanging Edge

Intraosseous tophi

Tophus with dense calcifications adjacent to the olecranon process.

Summary

Primary Osteoarthritis • Joint space narrowing• Osteophytes• No underlying cause

Posttraumatic Osteoarthritis

• Similar to 1° OA• Previous Trauma• Younger Age

OA 2° to DDH • Superolateral displacement of proximal femur .• Increase in acetabular angle

OA 2° to SCFE • Loss of Capener triangle sign• Absence of intersection of epiphysis

Neuropathic Arthritis • 6 D’s

Osteonecrosis • Radiolucent crescent • Preserved joint space

SummaryScleroderma • Resorption of the distal phalanges

• Subcutaneous and periarticular calcifications

MCTD • Combination of different conditionsAcromegaly • beak-like osteophytes

• Spade phalanx sign

Hyperparathyroidism • Subperiosteal bone resorption• Brown tumours• Soft tissue and cartilage calcifications

Hemochromatosis • 2nd & 3rd MCP joints are characteristically affected

• Typical features of OAHaemophilia • Features of osteoarthritis

• Widened intercondylar notch

Gout • Tophi• Overhanging edge of erosions

SPOTS

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