Arthritides
monoarticular polyarticular
3
Hand Anatomy Review
DIP joint
PIP joint MCP
joint
Sesamoid
bones =
ovoid
nodules
embedded
in tendons;
# variable
Carpal
in between
bones
people
radius
ulna
Conventional Radiography of Hands
ABCS
Alignment
Bone mineralization
Cartilage
Soft tissue
PA and oblique views
low dose radiation for hands, therefore
serial studies are relatively safe
Rheumatoid Arthritis
Imaging in RA
fibrous
capsule
synovium
cartilage
Marginal areaswhere synovium
Cross section through
directly touches bone (without
cadaveric MCP joint
cartilage in between)are
designated with small black arrows.
Joint Pathology: Progressive Stages
Synovitis pannus* joint destruction
Pannus = granulation tissue
1. acute synovitis
2. continued synovitis,
pannus formation,
cartilage destruction,
mild osteoporosis
3. fibrous ankylosis,
subsidence of
inflammation
4. bony ankylosis,
advanced osteoporosis
Hands & Wrists
Almost always affected in RA
MCPs, PIPs swollen and/or deformed
DIPs spared
Ulnar deviation at MCP
Radial deviation at the carpals
Swan-neck deformities
ulnar deviation
Boutonnire deformities
Neuropathy, e.g. carpal tunnel syndrome
Gout
Dorsoplantar views of both feet show an asymmetric arthritis involving the great toes
predominantly as well as other joints. This arthritis is characterized by well
marginated erosions, a large area of soft tissue swelling related to tophus, with
relative preservation of the joint space given the amount of periarticular erosion
present. The findings are typical of gout, which spares the joint space itself until late
in the disease. The erosions with their overhanging edges have been called "Mickey
Mouse ears" or "cookie cutter" type erosions.
RA of the Hands
f one metacarpal phalangeal joint (MCP) is involved with rheumatoid arthritis, then
typically all of the joints are involved. In this image we see that every MCP joint is
affected. The DIP (distal interphalangeal) joints are relatively spared. This patient has
also developed ligamentous abnormalities due to RA. A radial deviation of the carpus
and ulnar deviation of the digits give the hands a characteristic zig-zag pattern.
arthritis
erosions (arrows) are noted in the periarticular areas of the toes in this patient with
rheumatoid arthritis
multiple erosions and marked joint space narrowing are noted in a pancarpal
distribution in this patient with rheumatoid arthritis
RA of the Hips
This is an image of advanced RA in the hips. At first glance, the plain film resembles
OA but note the joints are narrowed symetrically unlike OA. There exists, however,
some subchondral sclerosis due to intervening secondary OA. The hips look like
they will migrate right into the middle of the pelvis this is called protrusio acetabulae.
Differential Diagnoses
Feature Also seen in
Carpal erosions Gout
Ulnar deviation & volar SLE, Jaccouds syndrome
subluxation of proximal 2 to rheumatic fever
phalanges
Narrow joint space Osteoarthritis
Bony destruction Sarcoid
(punched-out lesion)
Swell, erode, cyst Psoriatic arthritis
18
Summary : Key Points
Conventional radiography and MRI are especially
useful in imaging RA Chronic, progressive changes
are evident in the hands and wrists
Plain Radiography
Narrowing of medial
Subchondral sclerosis
Subchondral cysts
Marginal Osteophytosis
Plain Radiography: Hand
Narrowing of DIP and
PIP joints compared to
MCP joints
Subchondral sclerosis of
DIP, PIP and 1st CMC
joints.
OA of the Hip
This is an image of DJD or OA of the finger joints. Note the narrowing of the joint
spaces and the increased density around the joints due to the subchondral sclerosis
(black arrows). There are also a few osteophytes (white arrow).
OA of the Knee
These are plain film images of a right knee with narrowing of the medial compartment
and a widening of the lateral compartment. There are also a number of osteophytes
and a large subchondral cyst where the bones have been rubbing on each other.
erosions (arrows) are noted at the articular margins of the tibia in this patient with
juvenile chronic arthritis
OA of the Spine
The left image is OA of the spine with resulting scoliosis. Note the asymmetric disk
space as well as the large osteophytes which develop in attempt to bear some of the
weight of the body (arrow). The right image is a photo of a gross spine from another
patient with OA of the spine. Note the the large bulky osteophytes and subchondral
sclerosis of the abnormal disk as compared to the normal disk above (arrow).
Ankylosing Spondylitis
AP radiograph of the pelvis shows classic changes of ankylosing spondylitis. Note that
the sacroiliac joints are obliterated bilaterally with osseous fusion. In addition, there is
joint space narrowing of both hips, concentric in nature, which is similar to rheumatoid
arthritis in the distribution of joint destruction. However, note that there is extensive
sclerosis of both the femur and the acetabulum as while as large collar osteophytes.
This differs significantly from rheumatoid arthritis. Inflammatory sclerotic changes of the
large bones are common in patients with ankylosing spondylitis
Progression of Sacroiliitis in Ankylosing Spondylitis
n AP radiograph of the pelvis from 1975 shows that the sacroiliac joints are normal
radiographically. A subsequent radiograph in 1981 shows that there is irregularity of
the sacroiliac joints, more so on the iliac side of the joint. This is due to the fact that
the cartilage thickness of the ilium is less than that of the sacrum and hence bone
erosions appear first on the iliac side. A follow-up radiograph in 1982 demonstrates
that both the sacral and iliac sides of both sacroiliac joints show conspicuous
erosion and sclerosis. The findings are characteristic of the symmetric seronegative
spondylarthropathies, including ankylosing spondylitis and arthritis associated with
inflammatory bowel disease.
Ankylosing Spondylitis
of the Spine
AP and lateral views of the lumbosacral spine show classic changes of ankylosing
spondylitis. Note bilateral symmetric sacroiliac erosive changes with sclerosis.
Characteristically, delicate vertical syndesmophytes bridge multiple vertebra causing
a "bamboo spine". On the lateral view, annular calcification is noted causing the
appearance of squared vertebral bodies
Calcaneal Spur
An ossification and calcification resulting from traction of plantar fascia upon
the periosteum (covering of bone) of the inferior surface of the calcaneum
The lateral radiograph is the best view for visualization of this condition, the spurs
are frequently bilateral and may be asymptomatic, most centres image both sides.
chondrocalcinosis is seen in both the fibrocartilage of the menisci and in the
hyaline articular cartilage of this knee.
a gouty erosion (arrow) is noted along the medial margin of the first metatarsal head in
this patient with gout -- relative sparing of the articular cartilage is also noted
Pattern Approach
Ankylosing spondylitis
onset 15 - 35 years
Reiter's
Rheumatoid arthritis
25 - 55 years
Psoriatic arthritis
Osteoarthritis
Older patients (> 55 years) > 55 years DISH
CPPD
Arthropathies with Male Predominance
Gout 20:1
DISH 3:2
CPPD 1:1
Primary osteoarthritis
(< 45 years)
Enteropathic arthropathy
Primary osteoarthritis
(> 45 years)
CPPD 1:1
ANKYLOSING SPONDYLITIS (MORBUS BECHTEREW)
Radiographs of the thoracic spine (two projections): The spinous processes are
connected by ligament calcifications (arrows). (=> picture)
ANKYLOSING SPONDYLITIS (MORBUS BECHTEREW)
Radiographs of the lumbar spine (two projections): The facet joints are destroyed by
the inflammation, the joint spaces are narrowed, partially ankylotized (arrow) and
calcified ligament bridges are present (double arrow).
Rheumatoid arthritis
PA hip radiograph: The joint space of the left hip can not be recognized.
The femoral head is completely destroyed.
Tuberculotic block vertebra
Radiographs of the lumbar spine (two projection): The erosion of adjacent vertebral
bodies and the destruction of the disc resulted in a block vertebra
Soft Tissue Calcifications
Patient with dystrophic calcification in the Achilles tendon due to recurrent trauma
and tendinitis.
Patient with multiple bilateral phleboliths in the pelvic veins.
Fibrous Dysplasia
Osteoblastoma
Giant Cell Tumor
Metastasis / Myeloma
Aneurysmal Bone Cyst
Chondroblastoma / Chondromyxoid Fibroma
Hyperparathyroidism (brown tumors) / Hemangioma
Infection
Non-ossifying Fibroma
Eosinophilic Granuloma / Enchondroma
Solitary Bone Cyst
Mnemonic = FOGMACHINES
Differential Diagnosis of Multiple Lucent Bone Lesions
Fibrous Dysplasia
Metastasis / Myeloma
Hyperparathyroidism (brown tumors) / Hemangioma
Infection
Eosinophilic Granuloma / Enchondroma
1 neuroblastoma
AP view of the legs: Short, thickened bones, widening of the epiphyseal plates
(arrow).
Rickets
AP view of the pelvis and the bones: Short, curved, deformed femurs. Signs of
earlier fractures in the middle third of the bones (arrows).
COXATHROSIS
Radiograph of the hip (AP view): The joint space is significantly narrowed on the left
side. The joint surfaces are sclerotic, irregular, subchondral pseudo-cysts are visible
in the femoral head. Acetabular new-bone formation (osteophytosis) is present
(arrow).
False joint
AP humerus radiograph: In the middle third of the humerus, the broken ends are scraped off
and between them a false joint of 0.5 cm can be seen (arrow); the periosteal callus does not
reduce the broken ends.
Osteoclastoma
Curved, thin bones with diminished bone density (arrows) and fracture of the middle
third of the tibia (double arrow) are visible.
AIR IN THE SKULL CAVITY
Skull radiograph (two projections): Left side picture: In the latero-lateral radiograph air can
be seen in the lateral ventricle (arrow). Right side picture: Face-up radiograph: In the picture
made with a horizontal beam direction, free air can be observed behind the frontal bone
(arrow).
Osteoma
Dense bone mass is present in the inner and outer laminas of the frontal bone (arrows).
Osteomyelitis
Abnormal bone structure of the right femur, crumbling of the distal metaphysis (arrow).
Irregular bone compacta, periosteal reaction in the proximal part (double arrow).
Osteomyelitis, late stage
AP radiograph of the pelvis and the lumbar spine: Multiple circumscribed hyperdense lesions
are visible in the lumbar vertebrae and the pelvic bones.
Osteoporosis
CT examination:
Unenhanced axial scans: Pathological involvement of the bone is depicted in the upper image
(soft tissue window). Lower image: the tumor extends into the bone marrow (bone window).
Plasmacytoma (Multiple myeloma)
Latero-lateral radiograph of the skull: Well-defined osteolytic areas are visible in the
bone of the calvaria (classical 'raindrop' lesions) (arrows).
Chondroma (periosteal)
Periosteal chondroma a chondroma that develops from periosteum or periosteal
connective tissue.
aneurysmal bone cyst, benign bone aneurysm; a solitary benign osteolytic lesion
expanding a long bone or within a vertebra, consisting of blood-filled spaces, and
separated by fibrous tissue containing multinucleated giant cells; such cyst's
cause swelling, pain, and tenderness.
Radiographs:
-Radiolucent lesion w/ expanded cortex arising in medullary canal of metaphysis,
aneurysmal expanded appearance of cortex is contained by periosteum & thin
shell of bone;
Marked cortical thinning and erosion and periosteal elevation;
Lesion rarely penetrates the articular surface or growth plate;
Radiographic Appearance