2. TYPES OF ARTHRITIS
DEGENERATIVE ARTHRITIS
1. Primary Osteoarthritis:-Idiopathic(spontaneous) no
specific cause known but tend to be associated with
aging
2. Secondary osteoarthritis:-caused by previous injury
toaffected bone,can began atyoung age.
3. INFLAMMATORYARTHRITIS
1. Rheumatoid arthritis:- autoimmunediseases
involves chronic inflammation of synoviumwithin
joint(involves multiple jointon both side)
2. Psoriatic arthritis:-autoimmunediseaseswhich
associated with psoriasis.
3. Ankylosing spondylitis
4. Reitersyndrome
5. Erosiveosteoarthritis.
7. Common Radiological Features of
Arthritis
⚫ Soft tissue
swelling
⚫ Subchondral
sclerosis and
erosion
⚫ Narrowing of
jointspace
⚫ Jointeffusion.
⚫ Osteophytes
formation
⚫ Suchondral
cystic lesion.
⚫ Periarticular
osteoporosis
8. DEGNERATIVE ARTHRITIS
OSTEOARTHRITIS
• Non-inflammatory degeneration of jointcartilagewith secondary
effects on adjacent bone.
• It is degenerativeconditionaffecting articulationespecially those
which bearweightorsubjected to much wearand tear
• Itaffects individualsaged 50 years and olderand much morecommon
in women than men.
• Generally, in osteoarthritis, the largediarthrodial jointssuch as the hip
or knee and the small joints such as the interphalangeal joints of the
hand are most often affected; the spine, however, is just as frequently
involved in thedegenerativeprocess
• It begins focallyand gradually increases in size.
• Initial loss of chondroitinsulfate leads to fibrillationand flaking, with
secondarystresseffects on adjacent bone.
• Escape of synovial fluid intosubchondral bone forms subchondral
bonecysts
9. Osteoarthritis of the Large Joints
⚫The hipand knee joints are the mostcommon sitesof
osteoarthritis
⚫There radiographic features of degenerative jointdisease in
the hip:-
• Narrowing of the joint space as a resultof thinning of the
articularcartilage.
• Subchondral sclerosis (eburnation) caused by reparative
processes (remodeling)
• Osteophyte formation (osteophytosis) as a result of
reparative processes in sites not subjected to stress (so-
called low-stress areas), which are usually marginal
(peripheral) in distribution
10. • Cystor pseudocyst
formation resulting from
bonecontusions that lead
to microfractures and
intrusionof synovial fluid
into the altered spongy
bone in the acetabulum,
these subchondral cyst-
like lesionsare referred to
as Eggers cysts
11.
12. ⚫AP radiograph of the
hipdemonstrates the
radiographic
hallmarks of
osteoarthritis:
narrowing of the joint
space, particularly at
the weight-bearing
segment (arrow);
formation of
marginal osteophytes
(open arrows); and
subchondral sclerosis
posterior
13. ⚫CT of osteoarthritisof
the hip shows
diminution of the joint
space, osteophytes, and
subchondral cysts in
the femoral head.
14. ⚫ Anteroposterior (A) and
lateral (B) radiographs of
the knee
⚫ Demonstrate narrowing
of the medial
femorotibial and
femoropatellar
compartments,
subchondral sclerosis,
and osteophytosis, which
are typical features of
osteoarthritis. Note that
osteophytes that were
not obvious on the
frontal projection are
much better
demonstrated on the
lateral radiograph.
15. MRI of osteoarthritis. (A)
Sagittal proton density-
weighted MRI of a shows
involvementof the
femoropatellar
compartment. Note joint
space narrowing,
subchondralcyst (arrow),
and osteophytes (open
arrows)
(B) Coronal T2-weighted
fat-suppressed
MR image showscomplete
destruction of articular
cartilage of the lateral joint
compartment (arrows),
subchondral edema (open
arrows), and degenerative
tearof the lateral meniscus
(curved arrow).
16. COMPLICATION OF
OSTEOARTHRITIS
Anteroposterior (A) and lateral (B)
radiographs of the knee
demonstrate predominant
involvementof the medial
femorotibial and femoropatellar
joint compartments, with
formation of two large
osteochondral bodies.
⚫Osteochondral bodies.
17. ⚫ MRI of
osteochondral body.
A low-signal
intensity
osteocartilaginous
loose body in the
anterior joint space
is revealed on T1-
weighted sagittal
image (A) and T2-
weighted (B) sagittal
MR images of the
knee (arrows).
18. Osteoarthritis of the Small Joints
Primary Osteoarthritisof the Hand
⚫The mostcommonly affected small joints those of the
hand, particularly the proximal and distal interphalangeal
and the firstcarpometacarpal articulations
⚫In the distal interphalangeal joints, if hypertrophic
phenomena supervene and osteophytes are prominent,
degenerativechanges areaccompanied by Heberden nodes.
⚫Similar deformities in the proximal interphalangeal joints
are called Bouchard nodes .If the degenerative changes
involve the firstcarpometacarpal joint, they may result in
an odd deformation of the thumb.
19. Xray shows degenerative changes in the distal
interphalangeal joints, manifested by Heberden
nodes, and in the proximal interphalangeal joints,
manifested by Bouchard nodes. Note also
degenerative changes in the first carpometacarpal
joint (arrow).
20. ⚫ Radiograph of both
hands in addition to
the typical Heberden
and Bouchard nodes
shows deformative
changes at the first
carpometacarpal
articulations, resulting
in an odd configuration
of both thumbs.
21. Secondary Osteoarthritis of the Hand:-
⚫The mostcharacteristic secondary osteoarthriticchanges
in the small joints may be observed in acromegalic and
heamochromaticpatients.
⚫These include soft-tissue prominence and enlargement of
the terminal tuftsand the bases of the terminal phalanges;
there mayalso be widening of somearticularspaces and
narrowing of others.beak-like osteophytes at the heads of
the metacarpalsare a prominent feature
22. Radiograph of both
hands of a shows
widening of someand
narrowing of other
joint spaces,
enlargementof the
distal tufts and the
bases of terminal
phalanges, and beak-
like osteophytes
affecting particularly
the heads of the
metacarpals
23. Degenerative Diseases of the Spine
Degenerativechanges may involve thespineat the
following sites:
⚫The synovial joints—atlantoaxial, apophyseal,
costovertebral, and sacroiliac—leading toosteoarthritis of
thesestructures
⚫The intervertebral disks, leading to the condition known as
degenerativedisk disease
⚫The vertebral bodies and annulus fibrosus, leading to the
condition known as spondylosis deformans
⚫The fibrous articulations, ligaments, or sites of ligament
attachment to the bone leading to thecondition known as
diffuse idiopathicskeletal hyperostosis (DISH).
24.
25. ⚫ Osteoarthritisof the facet
joints. Oblique radiograph
of the lumbar spine
demonstrates advanced
osteoarthritisof the facet
joints. Narrowing of the
joint spaces, eburnation of
thearticular margins, and
small osteophytes (arrows)
aresimilar to thechanges
seen in osteoarthritis of the
largesynovial joints.
26. ⚫Degenerative changes of thevertebral facet jointsare
very common, particularly in the mid and lower
cervical and the lower lumbarsegments
⚫Involvement of the apophyseal joints may exhibit a
“vacuum phenomenon” which in factrepresents gas in
the joint. This finding is almost pathognomonic for a
degenerative process.
27. Osteoarthritis of the apophyseal joints. (A) Oblique
radiograph of the lumbosacral spine demonstrates a
vacuum phenomenonof the facet joint L5-S1 (arrow) and
eburnationof the subarticular bone (arrowheads)
CT section through both facets clearlydemonstrates the
presence of gas
28. INFLAMMATORY ARTHRITIS
⚫Rheumatoid Arthritis:-
⚫Rheumatoid arthritis is a progressive, chronic, systemic
inflammatory disease affecting primarily the synovial
joints
⚫Onset is usually between 20 and 60 yearsof age, with the
highest incidence among the 40- to 50-year-old group.
⚫Under 40 females to male ratio is 3:1 and over 40 equal,
1:1 ratio incidence.
⚫The detection of rheumatoid factor, representing specific
antibodies in the patient's serum, is an important
diagnostic finding
29. ⚫ Low-grade fever, fatigue, weight loss, musclesoreness, and atrophy.
⚫ Symmetric peripheral jointpain and swelling, particularlyof the hands.
Pathologic Features:-
⚫ Initial synovial inflammation within joints, bursae, and tendon
sheaths, with cellular infiltrate, hyperemia, edema,and increased
synovial fluid.
⚫ Synovium becomes hypertrophied toform granulation tissue (pannus),
which spreads overcartilagesurface.
⚫ At the bareareas pannus directly invades into the bone, resulting in
marginal erosionsand cartilagedestruction.
⚫ A rheumatoid nodule isdiagnosticand consistsof threedistinctzones:
fibrinoid degeneration and necrosis (central), radial palisading of
fibroblasts (middle), and fibrous tissue with small cell infiltrate
(outer).
30. Radiologic Features
⚫ Early radiographicchanges are mostcommonlyseen in the hands and
feet.
⚫ Bilateral and symmetric distribution, periarticular soft tissue
swelling(these are typically the first radiographic signs of rheumatoid
arthritis.), juxta-articular osteoporosis, juxta-articular solid or
laminated periostitis, marginal erosionsand cysts, and uniform loss of
jointspace.
⚫ Later, radiographicchanges may be seen, including marked deformities
with subluxation, dislocation, articular bony destruction, bony fusion,
and completedestructionof jointspace.
⚫ Hand: earliest changes are seen at the metacarpophalangeal and PIP
joints. Evaluation should include the semisupinationviewof the hands
(Norgaard projection) for marginal erosions on metacarpal heads and
deformities like ulnardeviation, boutonniere, swan neck, spindledigit.
31. ⚫ Wrist: earliest change is erosion of ulnar styloid, multiple carpal
erosions (spottycarpal sign), mostcommon location for bony
ankylosis, carpal radial rotation, zigzag deformity, TerryThomas’ sign.
⚫ Feet: earliestchanges seen at the fourthand fifth metatarsal phalangeal
joints. Changes parallel and are identical to that seen in the hands;
Lanois deformity—dorsal subluxation of the metatarsal-phalangeal
joints, with fibulardeviation.
⚫ Cervical spine: most commonly affected area of the spine; involved in
up to 70% of rheumatoid patients. Increased atlantodental interspace >
3 mm (especially in flexion), odontoid erosions, subluxations
(especially C3, C4, and C5). Narrowed intervertebral discs, apophyseal
joints show erosions and narrowed joint space and may ankylose.
Tapered spinous processes and generalized osteoporosis.
⚫ Hips: uniform loss of jointspace (axial migration), minimal erosions,
protrusioacetabuli (mostcommoncause),particularly bilaterally.
⚫ Knees: uniform loss of jointspace, marginal erosions (particularlyat
the tibial condyles), and osteoporosis; often associated with large
Baker’scysts.
32.
33. ⚫ Anteroposterior (A) and
lateral (B) radiographs
of the knee shows
periarticular
osteoporosis, joint
effusion, and lack of
osteophytosis.
34. Anteroposterior
radiograph of the right
hip shows erosionsof the
femoral head and
acetabulum, concentric
narrowing of the hip
joint, and acetabular
protrusio.
35. (A) Lateral radiograph
of the foot of shows
fluid in the
retrocalcaneal bursa
(arrow) associated with
erosion of the
calcaneus (curved
arrow).
MRI demonstrates bone
erosion in the posterior
process of thecalcaneus
arrowhead) associated
with extensive
surrounding bone
marrow edema and
retrocalcaneal and
retro-Achilles bursitis
(arrows).
36. Xray demonstrates
erosions in the
radiocarpal and
intercarpal articulations
as well as the
carpometacarpal joint,
bilaterally (open arrows).
Note, in addition, subtle
erosions of the head of
the first, third, fourth,
and fifth metacarpals of
the left hand and of the
head of the second
metacarpal of the right
hand (arrows). A small
erosionat the baseof the
middle phalanx of the
ring finger of the left
hand (arrowheads) and
the erosion in the right
triquetropisiform joint
(curved arrow) are also
well seen.
38. Radiograph of the
hands demonstrates
the boutonnière
deformity in the
small and ring fingers
of the right hand and
in the ring fingerof
the left hand
39. ⚫ Radiograph of the
hands demonstrates
the main-en-lorgnette
deformity- the
telescoping the fingers
secondary to
destructive joint
changes and
dislocations in the
metacarpophalangeal
joints
43. MRI MR images of the
leftshoulderof a
show largearticular
and periarticular
erosions, joint
space narrowing,
jointeffusion, and a
tearof the supra-
spinatus tendon
(arrows)
Coronal T1-
weighted MRI of
theright knee in
demonstrates
a jointeffusion with
inflammatory
pannus (arrow).
44. Juvenile rheumatoid arthritis
⚫Chronic polyarthritis resembling rheumatoid arthritis
clinically and histologically beginning before 16 years
of age
⚫Synonyms include Still’sdiseaseand juvenilechronic
arthritis.
⚫Morecommon in females < 16 years, with peak
incidence at 2-5 and 9-12 years.
45. TYPES
⚫Adult form (seropositive) Poorest prognosis
⚫Seronegative form:- Classic systemic ,Polyarticular
Pauciarticular-monoarticular
⚫Distinct lack of rheumatoid factor
⚫Symptoms include fever, characteristic rash,
lymphadenopathy, iridocyclitis (especially in
monoarticularforms), no subcutaneous nodules, and
growthdisturbance.
⚫Distinct lack of rheumatoid arthritis
46. Radiologic Features
⚫General features include soft tissue swelling, osteoporosis,
periostitis, growth disturbances, ankylosis, loss of joint
space, erosions, subluxations, and epiphyseal compression
fractures.
⚫Target sites includecervical spine, hands, feet, knees, and
hips.
⚫Cervical spine: atlantoaxial dislocations, hypoplastic C2-C4
vertebral bodies and discs with ankylosed apophyseal
joints.
⚫Tarsal and carpal ankylosiscommon.
⚫Growth deformities: brachydactyly, ballooned epiphyses,
squashed carpi, and squared patellae.
47. A.Lateral Lumbar
Note thatosteoporosis
and compression
fractures have produced
a biconcaveappearance
of the endplates.
B.Lateral Cervical.
Observe the vertebral
body hypoplasiaof the
second, third,
fourth, and fifth
segments. The odontoid
appears enlarged. C.
Lateral Cervical. Note
that thevertebral bodies
are hypoplastic in
combination with
posterior jointankylosis.
These are characteristic
cervical spine changes
48. ⚫ Radiograph of both hands showsdestructivechanges in
the metacarpophalangeal and interphalangeal joints.
Note also joints ankylosis in both wrists. the
periarticularsoft tissueswelling and periostitis (arrows)
49. Radiograph of
both kneesof a 20-
year-old woman
showsovergrowth
of the medial
condyles, one of
the characteristic
features of this
disorder
50. Ankylosing Spondylitis
⚫ A chronic inflammatory disorder principally affecting the articulations,
ligaments, and tendons of the spine and pelvis, often resulting in complete
polyarticular ankylosis.
⚫ Synonyms include Marie-Strumpell disease, rhizomelic spondylitis,
pelvospondylitis ossificans, and rheumatoid spondylitis.
⚫ Onset is usually between 15 and 35 years and involves males 10:1.
⚫ Initiates at the sacroiliac joints bilaterally, then ascends the spine.
⚫ Pain and tenderness, especially over bony protuberances, and increasing
stiffness and sciatica is often bilateral or may alternate from side to side.
⚫ Complications include iritis, aortitis, valvular incompetence, aneurysms,
conduction blocks, upper lobe pulmonary fibrosis, inflammatory bowel
disease, renal failure owing to secondary amyloidosis, carrot-stick
fractures, Andersson’s lesion, and prosthesis ankylosis.
⚫ The most commonly involved areas are the sacroiliac joints, spine, and
proximal large joints of the shoulder, hip, and rib cage.
51. Pathologic Features In synovial joints, the initial
change is that of a non-
specific synovitis similar to
rheumatoid arthritis, except
that it is less extensiveand of
lower intensity (pannus
formation), with subsequent
fibroplasiaand cartilaginous
etaplasia, leading to resultant
ossification.
In cartilage joints, the initial
subchondral osteitis is
replaced by fibrous tissuethat
subsequently ossifies. In the
outerannulus fibers this
forms syndesmophytes.
Atentheses, inflammatory
changes at ligamentous
attachmentsresult in bony
erosions, sclerosis, and
periostitis.
53. Lateral radiograph
of the lumbarspine
demonstrates
squaring of the
vertebral bodies
secondary tosmall
osseouserosionsat
the corners. This
finding is an early
radiographic
featureof
ankylosing
spondylitis. Note
also the formation
of syndesmophytes
at the L4- 5 disk
space.
54. (A)Lateral
radiograph of the
cervical spine in a
shows anterior
syndesmophytes
bridging thevertebral
bodiesand posterior f
usion of the
apophyseal joints,
together with
paravertebral
ossifications,
producing a
“bamboo-spine”
appearance.
(B)radiograph the
fusion of the
sacroiliac joints and
the involvementof
both hip joints, which
showaxial migration
of the femoral heads
(D)MRI shows
anterior
syndesmophytes,
calcificationof
the posterior
longitudinal
ligament, and
preservation of the
intervertebral disks.
55. (A)A lateral radiograph
of the lower lumbar
spineof showsearly
inflammatory changes
manifesting by so-called
shiny corners (Romanus
lesion) (arrowheads) and
squaring of thevertebral
bodies (arrows).
(B)T2-weighted MRI in
a 26-year-old man shows
earlysignsof ankylosing
spondylitisof the lumbar
spine, the shiny corners
(arrows).
(C)T2-weighted MRI of
the sacroiliac joints in
the same patient
demonstrates bone
marrow edema adjacent
to the sacroiliac joints
and erosive changes
bilaterally, more
prominent on the left
(arrows).
56. A.AP Sacrum. Note
that bilateral
sacroiliitis is clearly
seen with erosions,
hazy joint margin,
and subchondral iliac
sclerosis (arrows).
B.Axial CT: Sacroiliac
Joints. Observe the
erosive iliac lesions
(arrows) and the
subchondral sclerosis
arrowheads).
57. Psoriatic Arthritis
⚫ Psoriasis is a common skin disorder associated with joint
diseaseand characterized by peripheral jointdestructionand
deformity:
⚫ Age 20-50 years with maleand femaleequally affected.
⚫ Arthritis is usually in peripheral joints, especially DIP joints.
⚫ Soft tissue findings: fusiformsoft tissueswelling around the
joints which can progress so that whole digit is swollen
(sausagedigitordactylitis)
⚫ Marginal erosionsalsooften show fluffy periostitis from new
bone formation
58. Radiologic Features
⚫ General features include soft tissue swelling, normal bone
mineralization, erosions, and tapered bone ends, prominent juxta-
articular fluffy periostitis, and joint-space widening or bonyankylosis.
⚫ Hands and feet: asymmetric involvement and ray pattern, most
commonly involves DIP joints, no osteoporosis, mouse ears sign,
widened joint space owing to fibrous tissue deposition and bone
resorption, pencil-in-cupdeformity, opera glass hand deformity, no
ulnardeviation.
⚫ Sacroiliac joint: involved in up to 50% of psoriaticarthritispatients,
usually bilateral but asymmetric and unusual to be narrowed and
ankylosed.
⚫ Spine: atlantoaxial subluxation and dislocation, normal apophyseal
joints (except in the cervical spine),syndesmophytes of two types—
non—marginal, marginal (non-marginal are the most common)—
broad-based and tapered, asymmetric, unilateral, and mostcommon in
the upper lumbarand lowerthoracicspine.
59.
60. RAY PATTERN
PA Hand.
Note the
erosive
changes are
present at
the three
jointsof the
second digit
(arrows).
This pattern
of arthritis
is virtually
diagnostic
of psoriasis
64. Oblique
radiograph of the
lumbarspine in a
showsa
characteristic
single coarse
syndesmophyte
bridging the
bodiesof L3 and
L4. The right
sacroiliac joint is
alsoaffected.
(B) AP radiograph
of the lumbar
spine with
psoriasis reveals
paraspinal
ossification at the
levelof L2-3.
65. A.PA Hand.
Fluffyand Linear.
Note that close to
the joint nearthe
site of articular
erosion, the
periosteal new
bone is typically
fluffy
arrowheads).
Farther down the
shaft a linear
pattern may be
seen (arrow).
B.Great Toe:
Fluffy. Note that
adjacentto the
erosions a fluffy
and irregular type
of periostitis can
be seen
arrowheads). The
entire distal
phalanx is
sclerotic, a
reliablesign of
psoriatic arthritis
involving the
great toe.
66. Note severe joint
destruction, especially at
the metatarsophalangeal
articulations, has resulted
in fibulardeviation and
dorsal dislocation of the
digits (Lanois’ deformity).
The presence of a pencil-
in-cupdeformity (arrow) at
the interphalangeal joint of
the big toeand osseous
ankylosis of the first
metatarsophalangeal and
second and third proximal
interphalangeal
articulations (arrowheads)
makes the diagnosis of
psoriatic arthritis most
likely
ARTHRITIS MUTILANS
67. DIFFERENTIAL DIAGNOSIS
Rheumatoid arthritis
⚫there is a MCP joint predominance in rheumatoid arthritis
(RA) vs interphalangeal predominantdistribution in PsA
⚫bone proliferation not a feature in RA
⚫osteoporosis not a feature in PsA
Erosive osteoarthritis
• gull wing” central erosions are present in erosive OA vs
“mouseears” peripheral bareareaerosions in PsA
reactive arthritis (Reitersyndrome)
⚫“tends to involve feet > hands
68. REITER’S SYNDROME
⚫ A triad of urethritis, conjunctivitis, and polyarthritis, usually following
sexual exposureor, less commonly, certain types of dysentery.
⚫ Ittypically occurs between theagesof 18 and 40, and is as much as 50
times more prevalent in males
⚫ Jointsymptoms typically consistof an asymmetric painful effusion,
especiallyof the lower extremity
⚫ Pain at the plantarorAchillescalcaneal attachment (lover’s heels) in a
young male patientshould suggest thediagnosis.
⚫ These jointsymptomsareof shortdurationand self-limiting within 2-3
months, butrecurrencesarecommon.
69. Radiologic Features
⚫ Swelling, osteoporosis, uniform loss of jointspace, erosions, periostitis.
⚫ Specific targetsites: forefoot, calcaneum, ankle, knee, sacroiliac, spine.
⚫ Foot: metatarsophalangeal and interphalangeal joints. Dorsal
subluxationof the proximal phalangesand fibulardeviationof thedigits
results in the Lanois deformity.
⚫ Calcaneum: plantarand Achilles insertions.
⚫ Ankle: loss of jointspace, swelling, periostitis.
⚫ Sacroiliac: erosions, sclerosis, loss of joint margin, asymmetric
involvementand often unilateral.
⚫ Spine: thoracolumbar, asymmetric, skip non-marginal syndesmophytes
and, rarely, atlantoaxial instability
⚫ Knee: the only change usually visible at the knee is effusion and,
occasionally, periostitisof thedistal femoral metaphysis. A Pellegrini-
Stieda typecalcification of the medial collateral ligament may beseen
70. Xray foot shows the thin layer of periosteal new bone at
the phalangeal baseat the third metatarsophalangeal joint
(arrows). There is alsoa notablediminished density in
the metatarsal head (arrowhead).
71. Xray Finger show
marginal erosions
(arrows), linearperiostitis
(arrowheads), and soft
tissue swelling (crossed
arrows) at the proximal
interphalangeal joint.
72. CALCANEUS. A. Early
Erosive Changes: Achilles
Tendon. Shows small
lucent defects (arrows)
and adjacent periostitis
(arrowhead).
B. Pathophysiology. The
inflamed pre-Achilles
bursa (arrowheads)
becomes the site for
pannus formation and
subsequent subperiosteal
resorption of theadjacent
calcaneus (arrow).
C. Advanced Erosive
Changes. Note that the
lucent defects are larger
(arrows), with prominent
periostitis (arrowheads).
Note the fluffy calcaneal
spurowing to
inflammatory
enthesopathy (crossed
arrow).
74. AP radiograph of
the lumbarspine
with reactive
arthritis
demonstratesa
paraspinal
ossification
bridging the L2
and L3 vertebrae.
75. Erosive Osteoarthritis
⚫ Inflammatory variantof degenerativediseases involving the
interphalangeal jointsof the hands.
⚫ Common in females 40-50 years old.
⚫ The onsetof erosiveosteoarthritis is characterized byepisodicand
acute inflammation of the DIP and PIP joints of both hands in a
symmetric manner.
⚫ Pain, edema, redness, nodules, and restricted motionare found at the
involved articulationsof the hands.
⚫ The Pathological featuresarecartilagedegenerationand synovial
proliferation.
76. Radiologic Features
⚫ Involvementof the ulnarcompartmentof thecarpus is significantly
spared differentiating involvementfrom rheumatoid arthritis.
⚫ Radiographic changes arecharacterized byosteophytes, loss of joint
space, and sclerosis. Osteophytesare identical tothoseseen in DJD.
⚫ Theyare marginal in origin, taperdistally, and areoften largerat the
distal articularcomponent.
⚫ Loss of jointspace is usually non-uniform, with adjacentsubchondral
sclerosis.
⚫ Superimposed changes of erosions, periostitis, and ankylosison these
degenerative featuresarecharacteristicof erosiveosteoarthritis.
⚫ Boneerosionsaredistinctivelycentrally located on the proximal
articularsurfaceand moreperipherallyat thedistal articularsurface.
77. Radiologic Features
⚫At DIP and PIP
jointsof hands.
⚫Erosions (gull
wings sign),
sclerosis,
osteophytes,
periostitis
(mouse ears
sign), ankylosis,
and non-
uniform loss of
jointspace.
79. ⚫ Radiograph of both hands shows erosions of the distal
interphalangeal joints with typical “gullwing” configuration
due tocentral erosionsand peripheral osseous proliferation
80. HANDS. A. Target
Distribution. Note
the selective
involvementof
the distal
interphalangeal
joints (arrows).
B. Radiologic
Features. Shows on
closer inspection
of these involved
joints reveals
osteophytes,
sclerosis, loss of
jointspace, cystic
erosions, and
deformity.
81. Differential diagnosis
⚫The main differential considerations are rheumatoid
arthritis, psoriasis, and non-inflammatory
degenerative jointdisease.
⚫Rheumatoid arthritis rarely involves the distal
interphalangeal jointsand has a positive latex test.
⚫Psoriatic arthropathy is characterized by discrete
marginal erosions with adjacent fluffy periostitis
(mouseears sign).
⚫Non-inflammatory DJD will show no erosions but will
otherwiseappear identical toerosiveosteoarthritis.
82. METABOLIC ARTHRITIS
Gout
• Disorderof purine metabolism in which hyperuricemia leads to
depositionof sodium monouratecrystals intocartilage, synovium,
periarticular, and subcutaneous tissues.
• Thesecrystalsevokea strong inflammatoryarthritisusually in the
lowerextremity.
• Affects males 20:1, usually in the 4th and 5th decades.
• Fourstagesapparent: asymptomatic hyperuricemia, acutegouty
arthritis (especially at the first metatarsophalangeal joint),
polyarticulargoutyarthritis (chronic, long-standing disease), and
chronic tophaceous gout (soft tissue accumulations of sodium
monourate).
• Accumulation of thesecrystals (tophi) results in synovial pannus, bony
marginal erosions, cartilagedegradation, and bonedestruction.
83. Radiologic Features
⚫General features include dense soft tissue tophi,
preservation of joint space, bone erosions (marginal,
periarticular overhanging margin sign, intraosseous)
normal bonedensity, periosteal new bone, secondary
degenerative joint changes, chondrocalcinosis, and
avascular necrosis.
⚫The most frequently targeted areas of involvement are the
first metatarsophalangeal joint, other metatarsophalangeal
joints, the hands, and wrists.
⚫Spineand sacroiliacarticulations show infrequenterosions.
Occasional epidural tophi occur leading tocompression
myelopathy.
84.
85. Xray foot shows
Asymmetric periarticular
erosions thatsparepartof
the joint are typical of
gout arthritis, seen here
involving the first
metatarsophalangeal joint
of the right foot.
Note thecharacteristic
overhanging edge at the
site of erosion (arrows)
and thesoft-tissue mass
representing a tophus
(curved arrows);
osteophytesand
osteoporosisareabsent,
and the joint is partially
preserved (open arrow).
87. PA Foot. Show the soft
tissue swelling in a juxta-
articularpositionabout the
great toe. The tophi have
calcified with juxta-
articular erosions and
relative preservation of the
joint space. This is the
characteristic plain film
finding of gouty arthritis
B. T1-Weighted MRI,
Coronal Foot. C. T1-
Weighted MRI, Sagittal
Foot.
Show the low signal
intensity in thearea
of the tophi erosion of the
bony structures, which
correlates with the plain
film findings. The signal
intensity in gouty tophi is
low on T1- and T2-
weighted images.
88. A.Fingers. Note the
large tophi and erosive
changes.
B.Hand. Shows
multiple areas of bone
destruction owing to
the presence of tophi. A
large intraosseous
tophus is seen in the
second digit (arrow).
Numerous erosions are
also visible in the carpal
bones, creating the
spotty carpal
sign(arrowheads)..
C.Spotty Carpal Sign.
Note that multiple
carpal erosions
have resulted in this
appearance.
D.Metacarpal
Destruction. Observe
that at the base of the
metacarpals
extensive bony
destruction has
occurred from adjacent
tophi (arrows).
E.Radioulnar Erosion.
Note the large erosive
excavations at the distal
radius and ulna (arrow).
The outline of the
adjacent tophus can be
seen (arrowhead).
89. Calcium Pyrophosphate Dihydrate Crystal
Deposition Disease (Pseudogout)
⚫ An inflammatory jointdiseasecaused bydepositionof CPPD into the
synovial f luid, linings, and articularcartilage.
⚫ Usually more than 30 years of age, witha peak at 60 years with equal
sex distribution.
⚫ Acute presentations (20%) may simulategoutorrheumatoid arthritis
with swollen, hot, tender joints; usually affects knees, wrists, and
hands, with attacks lasting 1-7 days.
⚫ Chronicpresentations (60%) simulatedegenerative with bony
swelling, crepitus, and stiffness.
⚫ The pathological features is crystals deposition into the chondrocyte
lacunaewithinarticularcartilagedue towhich chondrocytes
subsequently die, resulting in impaired cartilage replacement and
maintenance, followed by thinning and cracking, simulating DJD.
90. Radiologic Features
⚫Basic radiographic signs are soft tissuecalcification and
pyrophosphatearthropathy
.
⚫Cartilage calcification (chondrocalcinosis) is the most
common radiographicsign of CPPD crystal disease in the
knees, wrists, symphysis pubis, elbows, and hips.
⚫Fibrocartilage is shaggy and irregular (knee menisci, wrist
triangularcartilage, symphysis pubis).
⚫Hyaline is thin, linear, and parallel toand separated from
the adjacent subchondral bone (wrist, elbow, shoulder,
knee, hip); additional calcification in capsule, synovium,
ligaments, tendons, and blood vessels
91. ⚫ Pyrophosphatearthropathy is mostcommon in the knee, wrist, and
metacarpophalangeal joints.
⚫ Articularchanges simulate DJD, except unusual articulardistribution,
unusual intra-articulardistribution, prominentsubchondral cysts,
bonedestruction, and variableosteophytesize.
⚫ The knee is the mostcommonly involved jointradiographically and
clinically. Chondrocalcinosis of menisci,Intraarticular osseous and
calcific bodies are common. Diagnosis strongly suggested if
patellofemoral joint is selectivelyand/orseverely involved.
⚫ In the wrist, chondrocalcinosis of the triangular fibrocartilage and the
hyaline cartilages of the entire carpus. Advanced and exuberant
degenerativechanges in the radiocarpal compartment. Scaphoid moves
proximallyand the lunate moves distally (stepladderappearance).
92. A. Diagram.
Chondrocalcinosis
can be seen in
either the
fibrocartilage (FC)
or hyalinecartilage
(HC).
B and C. Meniscal
Chondrocalcinosis
(arrows).
D. Calcification.
Note the
calcification in the
meniscus (arrow),
hyaline cartilage
(arrowhead), and
synovial
membrane
(crossed arrows).
94. WRIST. A. and B.
Chondrocalcinosis. Note the
calcification within the
triangular cartilage (arrows)
and intercarpal hyaline
cartilage
C.Subchondral Cysts. Note
the cysts within the lunate
and scaphoid, with
Chondrocalcinosis.
D. Scapholunate
Dissociation (Terry Thomas’
Sign). Observe that the
scapholunate space is
widened (arrow).
E.Scapholunate Advanced
Collapse Deformity.
Observe the large
subchondral cysts within
the radius and carpus
(arrow). Observe that the
lunate has rotated
anteriorly, as noted by its
triangularshape (pie
sign) (arrowhead). There is
widening of the
scapholunate space (crossed
arrow).
96. INFECTIOUS ARTHRITIS-PYOGENIC
Septic Arthritis:-
• Mostcommon routeof jointcontamination is hematogenousspread or
directtraumatic implantation.
• Single joint involvementis seen
• The most frequently isolated organism is Staphylococcus aureus.
• The clinical feature are Chills, fever, edema, pain, and redness with
Altered gaitand a painful limp arecommon in weight-bearing joints.
• The pathological featureare purulentexudatecreates jointdistention,
• Cartilagedestruction leads toosseous destructionand loss of joint
space,Regional hyperemia leads to juxta-articularosteoporosis.
97. Radiologic Features
⚫The knee and hipare the
mostcommon sites.
⚫Jointeffusion leads to
distortion of the fat folds.
⚫Positive Waldenström’s
sign.
⚫Rapid loss of joint space;
loss of the cortical white
line and moth-eaten
pattern of bone
destruction.
⚫Bony ankylosis rarely
occurs.
98. Waldenström’s sign
An early sign of septic hip
joint disease is an increase in
the articular joint space
between the femoral head
and Köhler’s teardrop (the
inferiorand medial surface of
the acetabulum). This
measurement is taken from
the lateral aspect of Köhler’s
teardrop to the medial margin
of the femoral head; a
measurement > 11 mm or a
difference in Measurement >
2 mm, compared with the
opposite hip, is a positive sign
and is considered clinically
significant
Note:-NOT specific for
infection can aslo be seen
post traumaticand synovial
imflammatory condition
99. Xray showscomplete lossof
joint space at the third
metatarsophalangeal
articulation. This loss of
bone density is present on
both sides of the joint. The
early lesion of septic
arthritis is loss of the
normal subchondralcortical
white line (arrowhead) in
the involved third
metatarsal head. Note the
normal cortical white line
(arrows) in the second and
fourth metatarsal heads.
101. SEPTIC ARTHRITIS
WITH
PROGRESSION.
A.Initial Film. Note
the prominent soft
tissue swelling
of theentire digit
(arrow). Slight bone
destruction is
evident
(arrowhead).
B.1-Month Follow-
Up. Shows marked
soft tissue swelling
of theentire digit
(arrows). Moth-
eaten destruction of
the middle and
distal phalanx is
evident
(arrowheads).
102. (A)Dorsovolar radiograph of the
right wrist shows destruction of
the radiocarpal joint and erosive
changes of the distal radius, distal
ulna, lunate, and scaphoid
bones. Note also involvement of
the carpometacarpal articulation.
There is periosteal reaction of the
distal radius and ulna and soft-
tissue swelling.
(B)Coronal three-dimensional
(3D) (GRE) fatsuppressed (left
part) and coronal proton density-
weighted fat-suppressed (right
part) MR images demonstrate
an erosion of the distal
ulnar(arrow) with a radiocarpal
joint effusion extending to the
distal radioulnar joint through a
complete tear of the triangular
fibrocartilage. Note the
intermediate-to-low signal
intensity of most of the effusion
and mild surrounding soft-tissue
edema (arrowheads) consistent
with synovitis due to septic
arthritis.
103. INFECTIOUS ARTHRITIS-NON PYOGENIC
Tuberculous Arthritis:-
• Tuberculosis involving theweight-bearing appendicular joints is
second only to the preferred spinal site with monoarticular
involvement
• The hip and knee are the most common sites (representing 75% of
cases), with theankle, shoulder, elbow, pubes, and wrist being rarely
involved.
• Mostpatientsare middle-aged orelderly, and many havereceived
multiple intra-articular injections of steroids for a pre-existing
unrelated joint disorder.
• The tubercle bacillus may lodge in the synovium or the metaphyseal
portionof the bone. Most tuberculararthritic lesions beginwithin the
metaphysisas an infectious focuswith secondaryspread to the joint
104. ⚫ With this mode of presentation the inflammatory changes in the
synovial membraneareextensive, leading tosignificantearly joint
effusion.
⚫ The infected synovial membrane becomes thickened, and granulation
tissue spreads to the free surface of the articular cartilage. This
interference with the free surface of the articular cartilage affects its
nutritionand ultimately leads to itsdestruction.
⚫ Early erosionsoccur involving the portionof the proximal femur that is
bare of cartilage but exposed to synovium. Thus the initial erosive
lesions maysimulate thoseof early rheumatoid arthritis
⚫ As theentire infective process progresses, a non-uniformdestructionof
thearticularsurfaceoccurs.
⚫ As cartilage and bone destruction ensue, sequestrum formation of
variablesize mayoccur. This process often involves both surfacesof the
joint, leading to thecharacteristic kissing sequestrum.
105. RADIOLOGICAL FEATURES
⚫ Early radiographic signs are jointwidening, which is secondary to joint
effusion and distention, and soft tissueswelling.
⚫ This is followed by destruction of the subchondral cortex (cortical
white line) and a moth-eaten patternof bonedestruction, oftenon
bothsides of the joint,
⚫ Later, narrowing of the jointoccursas thearticularcartilageand bone
aredestroyed. Theentireprocess is accompanied by juxta-articular
osteoporosis, which occursas a resultof hyperemiaand disuseatrophy.
• A triad (Phemister’s triad) of radiographic findings exists and is
characteristicof tuberculousarthritis: progressiveand slow jointspace
narrowing, juxta-articular osteoporosis, and peripheral erosive defects
of thearticularsurfaces.
106. ⚫ The end stage of tubercular arthritis is fibrous ankylosis of the joint.
Bony ankylosis is rare in tuberculosis, but it is a common sequela of
pyogenicarthritis
⚫ A peculiar complication of tubercular arthritis in the knee is a focal
overgrowthof the medial epiphysis, creating a megacondyle, as a result
of localized hyperemia. This sometimes mimicsa similarappearance of
the medial condyle in Still’sdiseaseand hemophilia
⚫ Sacroiliac joints:-The presentation is usually unilateral. (Fig. 12-67) A
pseudo-widening of the joint, early osteolytic destructive lesions, and
eventual ankylosisare thecardinal roentgen signs.
107. A.AP Hip. Note the
extensive resorption of
the entire femoral head,
with lateral displacement
of the femur. Observe
the destruction and
disorganization of the
acetabulum. This is an
advanced stage of
tuberculosisof the hip.
Showing the solid
periosteal new bone
formation on the
diaphysis of the
proximal femur (arrows).
B.AP Knee. Note the
symmetric narrowing of
the jointspace about the
kneearticulation.
Observe the destruction
of the articular cortex of
thedistal femur(arrows).
These represent
relativelyearly signs
of tuberculararthritis.
108. KISSING
SEQUESTRUM: HIP
JOINT. Shows the
complete resorption
of the femoral head,
with extensive
destruction of the
articularcartilage.
Note the lateral
displacement of the
femur from the
acetabulum. Thereare
many bony sequestra
scattered throughout
theacetabularand
femoral head area. An
extensivedegreeof
sequestered debris is
noted in theareaof
thegreatertrochanter.
109. Anteroposterior (A)
and lateral (B)
radiographs of the
elbowdemonstratea
large joint effusion, as
indicated by positive
anteriorand posterior
fat pad signs on the
lateral projection.
Small periarticular
erosionsare not clear
on theseviews.
(C) CT section shows
narrowing of the joint
and peripheral
erosions typical of
tuberculous infection.
110. PAbradiograph of the left
wristand hand shows
advanced arthritis
involving the left carpus.
There is complete
destruction of the
radiocarpal, ,midcarpal
and carpometacarpal
articulations as well as
whittling and sclerotic
changes in the distal
radius and ulna. Note the
osteoporosisdistal to the
affected joints and the
soft-tissueswelling.
111. NEUROTROPHIC ARTHROPATHY
⚫ Neurotrophic arthropathy is a destructive articulardisease thatoccurs
secondary toa loss or impairment in joint proprioception.
⚫ Subsequently, the involved joint undergoes premature and excessive
traumatic degenerative changes that lead to severe destruction and
instability.
⚫ Distinct lack of objective and subjective pain despite joint swelling,
instability, and crepitation.
⚫ Absent deep reflexes, analgesia, ataxia, and serology (possibly) positive for
underlying pathological cause.
⚫ The pathological features are loss of the normal protective nervous reflexes
leads to lax ligaments and muscles and abnormal joint mechanics result in
rapid and excessive degeneration of articular cartilage, hypertrophic spurs
and bone formation, fractures, and complete jointdisorganization.
⚫ The underlying conditions leading to neuropathic joint include diabetes
mellitus, syphilis, leprosy, syringomyelia, and congenital indifference to
pain.
112. RADIOLOGIC FEATURES
⚫ Two basic types: hypertrophicand atrophic.
⚫ Hypertrophic: classic type in which bone production is the
dominant featureand summarized as the six Ds:
Distension: earliest finding owing toeffusion.
Density: increase in subchondral bonesclerosis.
Debris: bony intra-articularfragments.
Dislocation: jointsurfacesoften malaligned.
Disorganization: jointcomponents usuallydisrupted (bag of
bones).
Destruction: articular boneshows lossof bonesubstance
Usually predominates in the weight-bearing joints such as the
lumbarspine, hips, knees, ankle, and tarsus
113. ⚫ Atrophic: may follow hypertrophicphase
oroccuras an isolated finding, and is
especially morecommon in theshoulder,
hip, and foot.
⚫ Articularends of bone mayappear
surgicallyamputated ortapered like a
licked candy stick; absenceof six Ds.
⚫ Spine: usually lumbarregion, with large
osteophytes, prominent sclerosis,
advanced discopathy, severe
subluxations, and body fragmentation.
⚫ Knee: hypertrophic features—sclerosis,
debris, destruction, and dislocation.
⚫ Foot: hypertrophic, especially in subtalar
joints. Atrophic in forefoot, especially in
metatarsophalangeal jointregion.
114. Anteroposterior
radiograph of the
right hip of shows
thetypical features
of neuropathic
(Charcot) joint.
There is complete
disorganization of
the joint,
fragmentation, and
subluxation. The
absence of
osteoporosis is a
characteristic
featureof the
neuropathic joint.
This condition
represents the most
severe manifestation
of degenerativejoint
disease.
115. A.Hypertrophic
Pattern, AP Hip.
Observe the
density, debris,
destruction, and
dislocationof the
joint.
B.Atrophic
Pattern, AP Hip.
In contrast,
observethat
the femoral head
has been
resorbed, with a
distinct lack of
debris.
117. NEUROTROPHIC
ARTHROPATHY:
PROGRESSIVE CHANGES
WITH SYPHILIS. LUMBAR
SPINE.
Initial Study. Note that
degenerative changes are
visiblewith osteophytes and
lossof disc height.
B.3-Year Follow-Up. Note
that advancement of the
degenerative changes is most
prominent at L2 and L5.
C.6-Year Follow-Up. Observe
the severe discovertebral joint
destruction with sclerosis and
bony debris at the L2-L3 level.
D.9-Year Follow-Up. Note
that the process has extended
to the remaining lower lumbar
levels with progressive
collapse of the lumbar
vertebral bodies.
E.10-Year Follow-Up. Observe
the complete destruction of
vertebral bodies and
intervertebral disc spaceswith
exuberant bone formation and
debris, completing the process
118. NEUROTROPHIC
ARTHROPATHY:
DIABETES.
FOREFOOT. A.
Early Atrophic
Changes. Note the
tapered contour of
the second and
third metatarsal
heads. Note the
vascular
calcification
frequently seen in
diabetic patients.
B. Later Changes.
Observe that the
tapered
configuration is
easilyidentified in
association with
osteolysis of
adjacent bones.
119. CONNECTIVE TISSUE ARTHRITIS
Systemic Lupus Erythematosus
• Generalized connective tissuedisorder involving multipleorgan
systems.
• Women of childbearing ageaffected.
• Onsetwith fever, malaise, skin rash, and arthralgias.
• The pathological features are Immune complexes and fibrinoid
material aredeposited in body tissues, resulting in inflammatory
changes in blood vessels, synovium, and serous membranes.
120. Radiologic Features
⚫ Most prominent features
visible in the hands.
⚫ General features are
reversiblesubluxations,
dislocations and
deformities, normal joint
spaces, osteoporosis,
osteonecrosis, soft tissue
atrophy, and calcification.
⚫ Hand: ulnardeviation,
boutonniere, and swan-
neck deformities;
⚫ Spine: atlantoaxial
instability; steroid-
induced compression
fractures.
121. (A)Typical appearance
of the thumb SLE.
Note subluxations in
the first
carpometacarpal and
metacarpophalangeal
jointswithoutarticular
erosions.
(B)the oblique
radiograph of her left
hand shows
dislocationsat the first
carpometacarpal joint
and distal
interphalangeal joint
of the index finger
(arrows), and
subluxations in the
metacarpophalangeal
joints of the index and
middle fingers
associated with swan-
neck deformities
122. SYSTEMIC LUPUS
ERYTHEMATOSUS:
DEFORMITIES. A.
PA Hands. Note the
complete
dislocation
of the
metacarpophalange
al joints, swan-neck
deformities of the
fingers, and
boutonniere
configurationof the
thumbs bilaterally.
B. Hands. Same
patient with hands
placed firmlyon the
cassette. Note the
reversibility of all
deformities.
These deformities are reversible owing to the
tendinous and ligamentous laxity, but will
reappear immediately once the hand is moved
123. Scleroderma
⚫Systemic inflammatory connective tissue disease affecting
the skin, lungs, gastrointestinal tract, heart, kidneys, and
musculoskeletal system
⚫Morecommon in females 30-50 yearsof age.
⚫Initial peripheral pain and swelling, with high incidence of
Raynaud’s phenomenon.
⚫The pathological features are low-grade perivascular
inf lammation with atrophyand fibrosis of adjacent
collagen.
124. Radological features
Hand is mostcommonly involved
Soft tissue:-tapered, conical fingertips ,retraction of
fingertip,lossof overlying skin folds ,calcification: skin
(calcinosiscutis) intra-articular.
Bone:-Resorption—distal tufts(acroosteolysis)
Joint:-Erosivearthropathyat first metacarpal-carpal
joint
125. ⚫ SCLERODERM
A WITH
DIGITAL SKIN
RETRACTION
AND EARLY
ACROOSTEOL
YSIS.
Note theatrophy
and retraction of
the soft tissues of
the fingertipat the
fourth digit
(arrows).
Resorptionof the
distal tuft is also
seen (arrowhead).
The combination
of these two
findings is highly
indicative of
scleroderma.
