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A long-term deficiency of dietary vitamin C
(ascorbic acid) results in scurvy.
Today its being found almost exclusively in infants
between the ages of 8 and 14 months who are fed on
pasteurized or boiled milk preparations (infantile
scurvy) because process of heating the milk leads to
disruption of vitamin C and the appearance of
clinically apparent disease develops after deficiency
of the vitamin has existed for 4 to 10 months.
Occasionally the elderly are affected, when the diet
is compromised (adult scurvy).
Vitamin C is essential to the formation of intercellular substances
such as collagen, osteoid, and endothelial linings.
In small blood vessels, the deficiency of intercellular cement
promotes vascular fragility, as evidenced by the increased
occurrence of tissue hemorrhages.
Cartilage cells do not proliferate at their normal rate but will still
Bone cells are also inhibited in their activity, producing
Petechial hemorrhages, swollen, red, and ulcerated gums, palatal
petechiae, hematuria, melena, hematemesis, and secondary
infections, when combined with characteristic radiographic
changes and depressed levels of serum ascorbic acid (< 0.6
mg/100 mL), ensures accurate diagnosis.
A generalized decrease
in bone density will be
evident in combination
with thinning of the
cortex and loss of
Dense zone of
(white line of Frankel):
Enhancement of the
zone of calcified
cartilage occurs owing
to delayed conversion
Ring epiphysis (Wimberger’s
The peripheral margin of the
epiphysis appears dense, whereas
the central portion is more
Corner (angle) sign:
Irregularity of the metaphyseal
margins frequently occurs
secondary to infractions of the
These bony protuberances occur
at the metaphyseal margins and
extend at right angles away from
the shaft axis.
Scorbutic zone (Trümmerfeld’s
Directly beneath the zone of
provisional calcification a
radiolucent band may be
disordered osteoid formation.
Extensions of extravasated
blood frequently lift the
periosteum away from the
bone and will later calcify,
especially during healing.
The identification of radiodense lines at the metaphysis
and about the epiphysis, metaphyseal fractures,
osseous beaks, epiphyseal displacements, and
diaphyseal periostitis allows an accurate diagnosis of
Leukemia can lead to periostitis and diaphyseal
destruction in combination with bandlike metaphyseal
radiolucency, but fracture and epiphyseal separation
are not identified.
Syphilis produces symmetric destructive foci in the
metaphyses, particularly in the proximal tibia, but the
distinctive findings are not confused with those of
Gout (podagra) results from an inborn error of purine
metabolism that causes hyperuricaemia and deposition of
monosodium urate (MSU) crystals in joints and soft tissues
resulting in recurrent episodes of acute arthritis.
Transmitted as an autosomal dominant condition with low penetrance
in women. Only 5–10% of cases occur in women, in whom it usually
occurs post-menopausally. Symptomatically primary gout usually
begins in the third decade of life, but can occur earlier.
Associated with either excessive breakdown of nuclear proteins
(e.g. blood dyscrasias, leukaemia, lymphoma, myeloma, collagen storage
Or decreased renal excretion of uric acid
(e.g. chronic renal disease, diuretics, low-dose salicylates).
Characterized by acute
inflammatory monoarticular or
oligoarticular arthritis, usually in
the early hours of the morning.
Most common sites of involvement
are in the lower extremity,
especially at the first
intertarsal joints, and knees.
Up to 60% of the initial attacks will
occur at the first
Distinctively, the affected joint is
swollen and hot, but dry, in
contrast to other arthritides, which
are usually moist.
Tophi characteristically have a
predilection for relatively avascular
Tendons and subcutaneous layers
of the elbow, forearm, hand, knee,
foot, helix of the ear, synovium,
periarticular soft tissues, and
Tophi close to the skin surface may
ulcerate and extrude their contents
to the exterior.
The effects on bones and joints are
often severely destructive and
deforming and may require surgery.
Rarely, tophi may deposit within the
spinal canal and act as a space-
occupying mass, resulting in various
A tophus may
gradually erode an
producing a protruding
lip of bone.
Soft Tissue Changes:
In acute attacks evidence of joint
effusion may be visible;
however, the most important
and readily identifiable finding
is the presence of tophi.
Tophi are manifested as a
localized increase in soft tissue
density from 5 mm up to as
large as 5 cm in size.
Distinctively, they are eccentric;
are usually, but not always,
periarticular; and occur in
predictable locations such as the
forearm, elbow, dorsum of the
hand, knee, ankle, and forefoot.
calcification within the tophus
may be apparent.
Marginal: Intra-articular loss of the
cortex and underlying bone up to 2-3
mm in size may be apparent. These
may further enlarge and spread to
involve the central articular region.
Periarticular: Occur within the
metaphysis or diaphysis; are eccentric;
have a dense, sclerotic margin; and
often have a protruding lip of bone
extending away from the bone into the
soft tissues (overhanging margin sign).
Occasionally, extension of a marginal
erosion may have this overhanging
edge of bone at its periphery.
Intraosseous: Accumulations of tophi
within bone will be visible as well-
circumscribed, oval, or round punched
out radiolucencies usually within the
Sharp, excavated defect
flanked by a distinctive
bony projection, referred
to as the overhanging
Great Toe and Tarsus:
Multiple defects in
multiple bones, with
Severe erosive changes, loss of joint space, and
Sagittal Foot. The low
signal intensity in the
area 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
Multiple areas of bone
destruction owing to the
presence of tophi.
A large intraosseous
tophus is seen in the
Numerous erosions are
also visible in the carpal
bones, creating the spotty
Spotty Carpal Sign:
resulted in this
Large erosive excavations
at the distal radius and
The outline of the adjacent
tophus can be seen
ELBOW: Tophus within the olecranon bursa, which
has created an extrinsic erosion of the olecranon
SACROILIAC & PUBIC
Severe erosive and
destructive changes at
both sacroiliac and
Of incidental note is the
material present in colonic
Calcium pyrophosphate dihydrate (CPPD) crystal
deposition disease is an articular disease
characterized by the production of gout-like
symptoms (pseudo-gout) in the presence of these
The most common form of presentation is similar to
DJD, with chronic progressive joint pain,
intermittent swelling, reduced range of motion, and
Usually > 30 years of age, with a peak at 60 years; equal sex
Can be acute or chronic and may be asymptomatic.
Acute presentations (20%) may simulate gout or rheumatoid arthritis
with swollen, hot, tender joints; usually affects knees, wrists, and
hands, with attacks lasting 1-7 days.
Chronic presentations (60%) simulate DJD, with bony swelling,
crepitus, and stiffness.
Asymptomatic cases (20%) exist in which the only sign is radiographic
Other diseases are associated with CPPD deposition diabetes mellitus,
degenerative joint disease, gout, hyperparathyroidism,
hemochromatosis, Wilson’s disease, neuroarthropathy, and ochronosis.
In addition, there is a hereditary factor in Czechoslovakian, Chilean,
and Dutch populations..
Laboratory signs include a raised ESR with synovial fluid crystal
Involves predominantly the
peripheral joints, especially
the knees, wrists, hands,
ankles, hips, and elbows, in
approximate order of
In recent years, increasing emphasis has
been placed on local tissue damage as a
cause of crystal deposition which may be
age-related, secondary to trauma, or
Cartilage damage may alter proteoglycan
concentrations and inhibitory factors,
increase PPi (Inorganic Pyrophosphate)
turnover, or effect some other change that
predisposes susceptible persons to CPPD
Aging and associated metabolic disease
independently may enhance this
The pathogenesis of acute synovitis in this
disease may relate to a process of crystal
shedding, in which cartilaginous deposits
are cast into the articular cavity
Signs of arthropathy
cortex, osteophytes, and
narrowing, a key
indication of an
Bilateral Hands: Arthropathy in the second and third
metacarpophalangeal and radiocarpal joints
be seen in either the
fibrocartilage (FC) or
hyaline cartilage (HC)
In the meniscus (arrow),
cartilage (arrows) and
Subchondral Cysts: Cysts within the lunate and
scaphoid, with associated chondrocalcinosis.
(Terry Thomas’ Sign):
Scapholunate space is
The large subchondral
cysts within the radius
and carpus (arrow).
The lunate has rotated
anteriorly, as noted by its
triangular shape (pie
There is widening of the
A. Chondrocalcinosis. Curvilinear calcification paralleling the
articular surface of the humeral head (arrow).
B. Degenerative Joint Disease. Changes secondary to CPPD are
typical of degenerative change, including non-uniform loss of
joint space, osteophytes, and sclerosis.
Chondrocalcinosis within the fibrocartilage disc of
the pubic symphysis (arrowhead)
Chronic ingestion of fluorine (fluorosis) has the potential to
produce a spectrum of toxic effects.
At 1 ppm the incidence of dental caries may be reduced; 2
ppm or more can precipitate mottled tooth enamel; 8 ppm
results in osteosclerosis in 10% of individuals; and > 100
ppm causes growth disturbances, kidney damage, or
It is most commonly the result of drinking contaminated
water in certain geographic areas, especially India and
China (endemic fluorosis).
Other causes include industrial and laboratory exposure,
fluorine medications, and habitual intake of fluorine-
containing wine (wine fluorosis).
Generalized increase in bone
Diffuse calcification of multiple
ligaments, including the
sacrotuberous (arrows) and
The key findings are initial
osteopenia followed by
sclerosis, growth arrest lines,
calcification, and periostitis.
The combination of diffuse
osteosclerosis and ligamentous
calcifications is virtually
diagnostic of fluorosis.