RADIOLOGI MUSKULOSKELETAL

Hermina Sukmaningtyas
 MODALITAS IMEJING

RADIOGRAFI KONVENSIONAL
USG
CT SCAN
MRI
ANGIOGRAFI
PET/SPECT
KEDOKTERAN NUKLIR/ BONE SCAN
BMD DXA
PEMILIHAN MODALITAS

RADIASI
KETERSEDIAAN
COST/BENEFIT
SOFT TISSUE VS BONE
BAGIAN TULANG

1.EPIFISIS ------------ (3)

2.GARIS EPIFISIS--- (5)

3.METAFISIS --------- (6)

4.DIAFISIS------------- (7)
STRUKTUR TULANG

TERDIRI DARI :
1. PERIOSTEUM.

2. CORTEX, Tdd:
- Str. Compactum
3. MEDULLA.
- Str.Spongiosum
 RADIOLOGIS :

❑ BATAS METAFISIS DAN DIAFISIS TAK

TAMPAK.

❑ MEDULLA LEBIH RADIOLUSEN.

❑ PERIOSTEUM TAK TAMPAK .

 SUSUNAN TULANG SECARA
BIOKIMIAWI

❖ H20 -----------------------------------25%

❖ BAHAN ORGANIK ----------------30%.

❖ BAHAN ANORGANIK ------------45%

* CA FOSFAT.
* CA CARBONAT
 PATOLOGI
1. KONGENITAL : - POLIDAKTILI

- MIKROSEFALI

2. TRAUMA : - AKIBAT UMUM: FRAKTUR

DAN DISLOKASI.

- BERSIFAT EKSTERNAL,
INTERNAL,RINGAN YANG
TERUS MENERUS.

3. RADANG.

4. TUMOR.

5. DEGENERASI.
 FRAKTUR

Disrupsi kontinuitas tulang

Peran Radiologi:
1. Diagnosis dan evaluasi tipe fraktur dan dislokasi
2. Monitoring hasil terapi dan komplikasi

Evaluasi fraktur:
3. Lokasi anatomi dan perluasan
4. Tipe : inkomplit, komplit
5. Alignment: displacement, angulasi, rotasi, shortening,
distraksi
6. Arah garis fraktur terhadap aksis longitudinal
7. Gambaran fraktur khusus: impaksi, depresi, kompresi
8. Keadaan khusus yang menyertai: fraktur dengan dislokasi
atau diastasis
9. Tipe khusus: stress/ pathologic fracture
 FOTO POLOS
SYARAT :

1. 2 PROYEKSI

2. SATU SENDI TERFOTO

3. BANDINGKAN YANG NORMAL DAN YANG

SAKIT
 TULANG PANJANG :
1/3 PROXIMAL

1/3 TENGAH

1/3 DISTAL
A. Aposisi baik,
alignment jelek.

B. Aposisi baik,
alignmen baik.
C. Aposisi dan alignment jelek
 Tipe fraktur

1. Green stick fracture

2. Avulsi fracture
3.Fraktur
Transversal

4.Fraktur

Longitudinal
5.Fraktur kompresi

6.Fraktur
kominutif
7. Fraktur
impresi
PERBEDAAN FRAKTUR ANAK-ANAK
DAN DEWASA

DEWASA ANAK

SERING TUNGKAI LENGAN BAWAH DAN

BAWAH SEKITAR SIKU

PENYEMBUHAN LEBIH CEPAT

LAMBAT

REMODELLING REMODELLING BAIK

KURANG
 A.FRAKTUR PERGELANGAN
TANGAN DAN TANGAN
1. FRAKTUR RADIUS
DISTAL :
* Fr. COLLES’

* Fr. SMITH
2. FRAKTUR METAKARPAL :

SERING TERJADI PADA

METAKARPAL V
SETELAH MENINJU
( BOXER’S FRACTURE )
 3.FRAKTUR BENNET

FRAKTUR DISLOKASI
PADA BASIS
METAKARPAL
B. FRAKTUR PADA LENGAN
BAWAH
FRAKTUR RADIUS
DAN ULNA :
*FRAKTUR MONTEGGIA
→ fraktur ulna + dislokasi
kaput radii

* FRAKTUR GALLEAZI:
fraktur 1/3 distal radius –
radiocarpal + dislokasi sendi
radioulnar
 C.FRAKTUR PADA LENGAN
ATAS
1. FRAKTUR
SUPRAKONDILER
HUMERUS

2. FRAKTUR
EPIKONDILUS MEDIAL
ATAU LATERAL
3. FRAKTUR
INTERKONDILUS HUMERI

4. FRAKTUR COLLUM
CHIRURGICUM
 D. FEMUR

FRAKTUR KOLUM FEMORIS

 E.TUNGKAI BAWAH
(FRAKTUR TIBIA PROXIMAL)
F. FRAKTUR PERGELANGAN KAKI
( FRAKTUR POTT)
 INTERVAL FOTO :
a. Saat mendiagnosis.

b. Pasca reposisi.

c. 1 sampai 2 minggu pada kontrol posisi.

d. 3 sampai 8 minggu pada evaluasi kalus.

e. Setiap perubahan beban.

f. Sebelum pulang dari RS.

 5. KOMPLIKASI
TERDIRI DARI :
1. DELAYED UNION; tidak menyambung dalam waktu 16-
18 minggu
2. NON UNION: tidak menyambung, ada gap
3. MAL UNION: Penyatuan posisi fragmen tulang tidak
anatomis
4. PSEUDOARTHROSIS; VARIAN NON UNION →
False joint tidak sembuh sampai 8 bulan
 KOMPLIKASI FRAKTUR

1. ATROFI SUDDECK (RSDS/ Reflex

Sympathetic Dystrophic Syndrome)
2. KEKAKUAN SENDI.
3. NEKROSIS AVASKULER.
4. DISUSE OSTEOPOROSIS
Suddeck atrophy
DISLOKASI
Adalah lepasnya kepala
Sendi dari cekungan
Sendi (DISRUPSI KOMPLIT
PERSENDIAN)→ TIDAK ADA
KONTAK PERMUKAAN SENDI
SAMA SEKALI
SUBLUKSASI: MASIH ADA
KONTAK PERMUKAAN SENDI
ARTIKULATIO COXAE
Yang dinilai :
Gr. Shanton : garis lengkung yang
dibentuk tepi bawah ramus superior os
pubis dan tepi medial kolum femoris.
Gr. Skinner : garis horisontal yang
ditarik melalui tepi atas trochanter
mayor dan tepi bawah ramus superior
pubis
 TUMOR TULANG

MODALITAS:
RADIOGRAFI KONVENSIONAL
CT SCAN
MRI
BONE SCAN
ANGIOGRAFI
Ganas
34,2%

Laki-laki = Wanita
>>> dekade 1 & 2

Jinak
65,8%
 Eksisi tumor
• Limb salvage
• Amputasi TUMOR TULANG
• Kemoterapi
• radioterapi
• INSIDENSI
• < 1 % dari semua tumor
• 0,9/100.000 jiwa (USA,2010)
• >>> dekade 1&2
• Jinak >> osteoma
• Ganas : >> osteosarcoma

• PATOFISIOLOGI
• Peningkatan aktifitas osteoklas dan osteoblas
• KLINIS
• Nyeri
• Benjolan /pembengkakan
• Riwayat trauma
• Gejala neurologis
• Fraktur patologis
• PROSEDUR
• DIAGNOSTIK
• Klinis
• Fisik
• Radiologis
• Laboratorium
• Biopsi
• STADIUM KLINIS
• KLASIFIKASI
PENDEKATAN DIAGNOSTIK
RADIOGRAFI TUMOR TULANG
E

• USIA

• LOKASI LESI

•
TEPI LESI
• TIPE DESTRUKSI TULANG
• TIPE REAKSI PERIOSTEAL

• TIPE OPASITAS & MATRIKS LESI

• UKURAN & JUMLAH LESI

•
PERLUASAN KE JARINGAN LUNAK
 USIA PASIEN

Gambar 6. Predileksi usia pada lesi tulang

(Diambil dari www.radiology.rsna.org/content/246/3/662.full.pdf) 10
 LOKASI LESI

Terminologi yang digunakan untuk mendeskripsikan lokasi

lesi pada tulang Lokasi yang sering pada tumor dan tumor-like lesions pada tulang panjang
dimensi transversal dan longitudinal
(Diambil dari Orthopedic Imaging A practical Approach) (Diambil dari www.radiology.rsna.org/content/246/3/662.full.pdf)
TIPE DESTRUKSI
TULANG

3 tipe :
1. Tipe geografik (Lodwick Tipe I)
2. Tipe moth-eaten (Lodwick Tipe II)
3. Tipe permeative (Lodwick Tipe III)
TEPI LESI & TIPE DESTRUKSI TULANG

• Lesi geografik tipe 1A

• Lesi geografik tipe 1B.

• Lesi geografik tipe 1C

• Lesi mouth eaten tipe 2

• Lesi permeative tipe 3

(Diambil dari www.radiology.rsna.org/content/246/3/662.full.pdf)

 TIPE REAKSI PERIOSTEAL
(Diambil dari Orthopedic Imaging A practical Approach) 3

Reaksi periosteal tipe buttress

 TIPE REAKSI PERIOSTEAL

Unilamellated Multilamellated
 TIPE REAKSI PERIOSTEAL

Codman triangle Perpendicular

TIPE OPASITAS DAN MATRIKS MINERALISASI
LESI
Gambar 22 . Matriks tumor
(Diambil dari Orthopedic Imaging A practical Approach)
3

(Diambil dari www.radiology.rsna.org/content/246/3/662.full.pdf)

10
 UKURAN DAN JUMLAH LESI

Gambar 24. Multiplicity of lesion

(A) Multiple myeloma ditandai dengan banyaknya lesi osteolitik. (B) gambaran
metastasis dengan multiple fokus lesi, pada laki-laki 66 tahun dengan karsinoma prostat.
Tampak lesi osteoblastik tersebar pada pelvis dan femur.
(Diambil dari Orthopedic Imaging A practical Approach) 3
 KETERLIBATAN KORTIKAL

Gambar 25. Aneurysmal bone cyst (ABC)

(a) Proyeksi AP pelvis menunjukkan lesi litik ekspansil acetabulum kanan dengan penipisan korteks
(panah) dan trabekulasi honeycomb. (b) Proyeksi AP tibia fibula proksimal menunjukkan lesi litik
ekspansil pada metafisis proksimal fibula, dengan honeycombing minimal (panah hitam). (c)
Proyeksi AP distal antebrachii dan pergelangan tangan menunjukkan lokasi yang khas dari ABC
pada distal metafisis radius
(Diambil dari www.radiology.rsna.org/content/246/3/662.full.pdf) 8
PERLUASAN KE JARINGAN LUNAK

Gambar 26. Massa jaringan lunak/soft-tissue.

(Diambil dari Orthopedic Imaging A practical Approach) 3
  
PERBEDAAN LESI BENIGNA DAN MALIGNA

Gambar 27. Lesi benigna versus lesi maligna.

(Diambil dari Orthopedic Imaging A practical Approach)
 TUMOR JINAK TULANG
BONE FORMING (OSTEOGENIC)
OSTEOMA
OSTEOID OSTEOMA
OSTEOBLASTOMA
CARTILAGE-FORMING (CHONDROGENIC)
ENCHONDROMA (CHONDROMA)
PERIOSTEAL CHONDROMA
ENCHONDROMATOSIS (OLLIER DISEASE)
OSTEOCHONDROMA
CHONDROBLASTOMA
CHONDROMYXOID FIBROMA
FIBROCARTILAGINOUS MESENCHYMOMA
FAT (LIPOGENIC)
INTRAOSSEUS LIPOMA
UNKNOWN
SIMPLE BONE CYST
ANEURYSMAL BONE CYST (ABC)
INTRAOSSEUS GANGLION
LESI FIBROUS, FIBROOSSEUS DAN
FIBROHISTIOSITIK
FIBROUS CORTICAL DEFECT DAN
NONOSSIFYNG FIBROMA
BENIGN FIBROUS HISTIOCYTOMA
FIBROUS DYSPLASIA
FIBROCARTILAGINOUS DYSPLASIA
FOCAL FIBROCARTILAGINOUS DYSPLASIA
PERIOSTEAL DESMOID
DESMOPLASTIC FIBROMA
OSTEOFIBROUS DYSPLASIA
VASCULAR
ARTERIOVENOUS MALFORMATION
INTRAOSSEUS (AVM
INTRAOSSEUS)
HEMANGIOMA
CYSTIC ANGIOMATOSIS
HEMATOPOETIC
GIANT CELL TUMOR
• LANGERHANS CELL HISTIOCYTOSIS
(EOSINOPHILIC GRANULOMA)
 1. OSTEOMA
paling sering ditemukan
usia 10 – 79 tahun, >> dekade 4 dan 5
laki-laki = wanita
>> sinus paranasalis (sinus frontal dan ethmoid (75%),
tabula interna, eksterna kalvaria serta mandibula
ukuran 1,5 – 2 cm
Asimptomatik
Gardner’s syndrome (poliposis intestinal, osteoma,
dan massa kutan serta subkutan)
Radiologis :
lesi padat, massa sklerotik seperti ivory melekat
pada korteks, batas tegas. Reaksi periosteal ringan.
Destruksi tulang (-), lesi satelit (-)
2.OSTEOID OSTEOMA

usia 8 bulan-70 tahun

laki-laki > wanita
khas : nyeri memberat malam hari dan
berkurang dengan aspirin, ibuprofen
dan naproxen
>> Ekstremitas bawah (metafisis dan
diafisis tulang panjang) femur dan
tibia
Radiologis : nidus osteoid diameter <
1 cm dengan bagian sklerotik atau
lusen disekitarnya
 3. OSTEOBLASTOMA
(GIANT OSTEOID OSTEOMA, OSTEOGENIC
FIBROMA)
Jarang
usia 5-45 tahun
75% dekade 1, 2 atau 3
Laki-laki > wanita (2-3 : 1)
~ osteoid osteoma namun lebih besar, > 1,5 cm, sering >2 cm
>> vertebrae dan tulang panjang terutama ekstremitas bawah
bagian metafisis
nyeri dan bengkak lama daerah lesi, tidak memberat pada malam
hari, tidak berkurang dengan aspirin
Radiologi 3 tipe :
1. Giant osteoid osteoma
diameter > 2 cm, sedikit sklerosis reaktif ,
reaksi periosteal
2. Blow-out expansion
Lesi opak kecil pada bagian tengahnya.
3. Lesi agresif ~ tumor maligna
Lesi periosteal tanpa sklerosis perifokal tetapi tampak
lapisan tipis penutup tulang periosteal yang baru terbentuk
 4. ENCHONDROMATOSIS (OLLIER DISEASE)
Enchondromas→ asimptomatik
Metafisis ke diafisis tulang panjang
dekade pertama kehidupan
Kx : massa tulang yang bisa dipalpasi
pada jari, pemendekan asimetris pada
ekstremitas, deformitas tulang, dengan
atau tanpa fraktur patologis
>> tulang tubular panjang (femur,
tibia dan fibula)
Radiologis : lesi radiolusen multiple
homogen, bentuk oval atau
memanjang, bisa disertai kalsifikasi.
Terkadang ditemukan pada tulang
pendek
Enchondromatosis → multiple
enchondroma, terdiri dari 3 :
1. Ollier disease
kelainan nonherediter ditandai
enchondromas multiple ,
distribusi unilateral
2. Sindrom Maffuci
kelainan nonherediter, lebih
jarang, terdiri dari multiple
enchondromas dan hemangioma
3. Metachondromatosis
terdiri dari multiple enchondroma
dan osteochondroma, bersifat
herediter
 5. OSTEOCHONDROMA
~ exostosis multiple herediter,
osteocartilaginous exostosis
sering ditemukan
usia 10-35 tahun
>> dekade 2
Wanita >> laki-laki
metafisis tulang panjang ekstremitas
(femur distal, proksimal, humerus
proksimal, tibia proksimal), tulang pipih
(ilium dan scapula)
Radiologis : lesi pedunculated bertangkai,
tumbuh menjauhi sendi, lesi sessile, basis
lebar menempel pada korteks.
Penting !! → menyambungnya korteks
dari tulang host dengan korteks
osteochondroma dan menyambungnya
medulla lesi dengan medulla tulang host
 6.FIBROUS DYSPLASIA
Monostotic fibrous dysplasia
Mengenai satu tulang
>> femur, terutama collum femur, tibia
dan tulang kosta
Lesi yang lebih banyak jaringan osseus
densitasnya lebih tinggi dan sklerotik,
apabila lebih banyak jaringan fibrous
lebih lusen, dengan ground-glass
appearance, milky atau smooky appearance
Polyostotic fibrous dysplasia
Mengenai beberapa tulang
>> pelvis, tulang panjang, kranium, tulang
kosta dan femur proksimal (90% unilateral)
Korteks pada umumnya intak, tetapi mengalami
penipisan karena komponen ekspansif lesi dan
tepi dalam korteks
scalloping
Lesi berbatas tegas
Lebih agresif
7. GIANT CELL TUMOR (OSTEOCLASTOMA)

5-8,6% dari seluruh tumor primer tulang

dan 23% dari seluruh tumor jinak tulang
Usia 20-40 tahun
Wanita > laki-laki
>> Tulang panjang (tibia proksimal,
femur distal, radius distal dan humerus
proksimal), subartikuler, vertebrae
(>>sacrum)
Lesi agresif, >> soliter, jarang multiple
Radiologis : lesi osteolitik, radiolusen,
zona transisi sempit tanpa tepi sklerotik,
reaksi periosteal (-)
 TUMOR GANAS

1.OSTEOSARCOMA
❑UMUR 10-25 THN
❑PREDILEKSI : FEMUR DISTAL,
TIBIA PROKSIMAL, HUMERUS
PROXIMAL, PELVIS.
❑LOKASI: METAFISIS.
❑RADIOLOGIS :
SUN RAY APP---RX PERIOSTEAL.
SOFT TISSUE SWELLING.
DESTRUKSI TULANG ---OSTEOLITIK,
OSTEOBLASTIK, CAMPURAN.
❑ SEGITIGA CODMAN
 2. SARCOMA EWING

❖USIA MUDA
❖PREDILEKSI : TULANG
PANJANG, IGA, PELVIS.
❖LOKASI : DIAFISIS.
❖SIFAT RADIOSENSITIF
❖Radiologi:
❖Permeative, lamellated
periosteal reaction, soft tissue
mass, saucerization
SAUCERIZATION
IMAGING FOR
ARTHRITIS
 OUTLINE

Introduction to imaging modalities

Focus on plain radiography
OA
RA
PsA
AS
Gout
Pseudogout
 X-RAYS

Taking a 2-dimensional image of a 3-dimensional structure

Superimposition of structures can thus obscure pathology
Quality is also affected by patient positioning, exposure
techniques
Multiple views of the same area are useful
Good for: fractures, bone lesions, osteophytes, joint space
narrowing, erosions, cysts
 COMPUTED TOMOGRAPHY (CT)

Also uses x-rays, but is superior than plain radiographs

Improved contrast
3-D imaging
Attenuation of the x-ray beam travelling through tissues is
measured from multiple angles
Substantially increased patient exposure to radiation when
compared to plain films
Good for: fractures, subluxations, sclerosis, cystic bone lesions,
evaluation of surgical hardware
 ULTRASOUND (US)

Uses the interaction of sound waves with living tissue to produce

an image
Doppler modes allow the determination of the velocity of moving
tissues (i.e., blood flow)
User dependent, so requires an experienced technician who can
make real-time measurements
Difficult to assess all planes
Good for: joint effusions, tenosynovitis, ganglia, erosions in RA,
bursitis, tendonitis, and for guided injections/aspirations
 MAGNETIC RESONANCE IMAGING
(MRI)

Based on the absorption and emission of energy in the

radiofrequency range of the electromagnetic spectrum
No ionizing radiation exposure, superior soft tissue
contrast resolution, excellent for the assessment of soft
tissues, can image in multiple planes
Takes a long time to get access to scanner
Good for: tenosynovitis, joint effusions, synovial
proliferation, cysts, erosions, cartilage loss, reactive
bone changes
 NUCLEAR SCINTIGRAPHY

● In addition to showing anatomy, also provides information

about underlying physiology
● Most commonly used for MSK imaging: technitium-99m
methylene diphosphate (Tc-MDP)
● Can detect synovial hyperemia on the blood pool phase and
periarticular uptake on the delayed phase in joints affected by
inflammatory arthritis
● VERY nonspecific, most rheumatologists consider the results
to not be useful in clarifying the diagnosis
● Good for: determining total number and symmetry of joints
involved
 APPROACH TO AN IMAGE

● Soft tissues: effusions, calcification, masses

● Mineralization: diffuse demineralization, periarticular
demineralization
● Joint narrowing and subchondral bone: narrowing,
subchondral sclerosis, intraarticular bodies, ankylosis
● Erosions: central (articular surface), marginal (bare area),
periarticular, mutilans
● Proliferation: osteophytes, periostitis
● Deformity: varus/valgus, flexion/extension, subluxation,
dislocation, collapse
● Distribution: monoarticular, pauciarticular, polyarticular,
symmetric/asymmetric
 OSTEOARTHRITIS

•Joint space narrowing, osteophytes, subchondral sclerosis, cysts

•Joint effusions are not uncommon
•Early osteophytes look like sharpening of the joint edges
•Distribution: weight bearing joints (hips, knees, back)
•In the hands: DIPs, PIPs, CMC of thumb
•Shoulder: glenohumeral OA usually secondary to rotator cuff
disease
 RHEUMATOID ARTHRITIS

RA characterized by synovial proliferation (pannus), bursitis and nodules

Can cause ill-defined soft tissue planes and prominances on plain films
Nodules appear as focal soft tissue masses especially at the olecranon bursa and areas
of friction
Tenosynovitis can appear as diffuse soft tissue swelling, commonly seen at the
wrist
Periarticular osteoporosis is an early finding , but can also see generalized
osteoporosis
 RHEUMATOID ARTHRITIS

● Characteristic lesions are erosions in the marginal (bare) area

● Pannus erodes the bone at the margin of the joint capsule where the redundant
synovium exits, next to the articular cartilage
● Osseous proliferation is not commonly seen with RA, but can be seen with
secondary OA in joints with RA
● Subchondral cysts may be large
● Earliest changes are usually in the hands and feet
● Ulnar styloid soft tissue swelling, extensor carpi ulnaris tenosynovitis
 Marginal erosion

Erosions
Soft tissue
swelling
 RHEUMATOID ARTHRITIS

Deformities
Subluxations at the MCPs and MTPs
Ulnar deviation of the digits
Swan-neck and Boutonniere deformities
Severe ulnar deviation

Severe erosions of
MCPs

Complete destruction
of the wrist

Resorption of the
carpals and the heads
of the metacarpals

Radial deviation of the

wrist
Boutonniere deformity
of the thumb

Flexion with dislocation of

the first MCP joint

Hyperextension of the
IP joint
Rheumatoid wrist: articular destruction, carpal fusion and carpal
collapse.

Severe destruction of the distal radius and ulna.

Rheumatoid foot

Multiple osseous
erosions and defects
at the medial and
lateral margins of
the metatarsal
heads

Marginal erosions
at the bases of the
proximal phalanges
(arrows)
Rheumatoid foot

Medial and lateral

erosions of the 5th
metatarsal head

Subluxation of the 5th

MTP joint
Rheumatoid foot

Subchondral cyst at the

base of the distal
phalanx

Characteristic erosion
along the medial margin
of the proximal phalanx
of the great toe
Soft tissue
findings in
rheumatoid knee

Synovial effusion
in the
suprapatellar
pouch and
posterior
recesses
Atlantoaxial
subluxation in RA

Always a concern
in patient with
longstanding RA
and neck pain or
cervical
neurological
symptoms
Order a view of the atlantoaxial articulation through an open mouth
to fully assess. This shows lateral atlantoaxial subluxation of the
odontoid process with respect to the lateral masses of the atlas.
 PSORIATIC ARTHRITIS

● Characterized by erosions and bony proliferations

● RA does not typically have new bone formation
● Asymmetric distribution
● Typical “ray” distribution (involves several joints along a single digit)
● Can involve the axial skeleton, as in ankylosing spondylitis (AS)
● Soft tissue findings: fusiform soft tissue swelling around the joints; can
progress so the whole digit is swollen (sausage digit or dactylitis)
● “Fluffy” periostitis at the entheses
● Marginal erosions also often show fluffy periostitis from new bone
formation
 PSORIATIC ARTHRITIS

•Deformities
•Pencil and cup – end of bone looks like it has been
through a pencil sharpener, reciprocating bone becomes
cupped
•Telescoping of one bone into another
•Complete destruction of bone (arthritis mutilans)
Psoriatic hands

Erosive changes
at the DIPs and
PIPs

Sparing of MCPs
and wrists
Arthritis mutilans

Pencil and cup deformity

Pencilling
Psoriatic
arthritis

Asymmetric
involvement

Soft tissue
swelling and
periosteal
reaction in 2nd
and 3rd fingers
Periosteal reactions
Bony ankylosis of DIP joint
 PSORIATIC ARTHRITIS

•Spine
•Asymmetric sacroiliitis
•Chunky, asymmetrical syndesmophytes (bony
bridges between vertebrae)
Chunky, non-marginal
syndesmophytes
typical of psoriatic
arthritis
Asymmetri
c
sacroiliitis
with left
sided
erosions
and
sclerosis
 ANKYLOSING SPONDYLITIS

•Changes begin at SI joints and lumbosacral junction, then

typically move up the spine
•SI joints:
•Initially subchondral sclerosis
•Then, small erosions cause “pseudowidening” of the SI joints
•Erosions occur first at iliac side, which has thinner cartilage
•Remember that the synovial part of the SI joint is the anterior,
inferior portion
•Reactive sclerosis with eventual fusion
 ANKYLOSING SPONDYLITIS

•Spine
•Early changes include squaring of the anterior vertebral
body
•Enthesitis (whiskering) and sclerosis (shiny corners)
where Sharpey’s fibres mineralize
•Progressive mineralization of Sharpey’s fibres to form
osseous bridging syndesmophytes
•Ossification of the interspinous ligaments
•Most commonly involved peripheral joint is the hip
Erosions and sclerosis on iliac side

Bilateral sacroiliitis with

erosions, bony sclerosis and
joint width abnormalities

Bilateral sacroiliitis, definite

erosions, severe juxta-
articular bony sclerosis and
blurring of the joint
Advanced AS

Fused sacroiliac
joints

Ankylosis of the
lower lumbar
spine (bamboo
spine)
Cervical spine in AS

Shiny corners

Squaring of the vertebral

bodies

Syndesmophytes
 GOUT

•Erosions and masses, especially in the peripheral joints

•Masses may be dense, due to crystals or associated
calcification
•Erosions are juxtaarticular from adjacent soft tissue
tophi or intraosseous crystal deposition
•Appear rounded with a well circumscribed sclerotic
margin
•Deformity occurs early
•Olecranon and prepatellar bursitis may calcify
Gouty changes in the big
toe

Erosions due to tophi

Olecranon
bursitis with
erosions due to
gout
Large, destructive tophus of first MTP
 PSEUDOGOUT (CPPD)

Usually manifests as OA in an unusual distribution

Prominant osteophytes
Soft-tissue calcification in the joint capsule, synovium, bursa,
tendons, ligaments, periarticular soft tissues
Chondrocalcinosis (cartilage calcification)
Linear and regular deposits in articular cartilage, coarse deposits
in fibrocartilage
No erosions
Subchondral cysts are prominant
No periosteal reaction or new bone formation
Chondrocalcinosis
Calcifications at the MCPs
Chondrocalcinosis of the Multiple cysts
triangular ligament
METABOLIC BONE DISEASE
 OSTEOPOROSIS

Reduction in bone mass leading to increase risk of fracture

Ratio of mineralised bone: matrix is normal
Imbalance of bone remodelling
DEXA
OP FRACTURES
 OSTEOMALACIA

Rickets of adulthood
Deficiency or resistance to Vit D OR Phosphate
handling problem
Defective mineralization of bone
Proximal myopathy, Bony pain, malaise
Deformities much less common than with rickets

AP raised, Ca and Vit D low or normal

PO4 low or normal
 CAUSES OF
OSTEOMALACIA/RICKETS

Reduced availability of Vit D

Diet: oily fish, eggs, breakfast cereals
Elderly individuals with minimal sun exposure
Dark skin, skin covering when outside
Fat malabsorption syndromes
Kidney failure
malabsorption
Malabsorption
Coeliac
Intestinal bypass
Gastrectomy
Chronic pancreatitis

Epilepsy: phenytoin, phenobarbitones

Genetic disease
•Defective metabolism of Vitamin D
•Chronic renal failure, Vit D dependent rickets,
•Liver failure, anticonvulsants
•Receptor Defects

•Altered phosphate homeostasis

•Malabsorption, hypophosphatasia (rare, low levels of alk phos)
LOOSERS ZONES
Reaction of the periosteum
(may occur)
Indistinct cortex
Coarse trabeculation
Knees, wrists, and ankles
affected predominantly
Epiphyseal plates, widened
and irregular
Tremendous metaphysis
(cupping, fraying, splaying)
Spur (metaphyseal)
 CAUSES OF HYPERCALCAEMIA

Malignancy
Hyperparathyroidism – primary or tertiary
Increased intake
Myeloma
Sarcoid
Adrenal failure
SCURVY

Anteroposterior radiograph of
the lower extremities shows
ground-glass osteopenia.
Transverse metaphyseal lines
of increased and decreased
opacity (Trummerfeld zone) are
associated with lateral growth
of the metaphyseal calcification
zone and periosteal elevation,
which produces the
characteristic metaphyseal
beaks known as Pelkan spurs.