Plain Film Diagnosis of Arthritides (The Basic Edition)

1
Plain Film Diagnosis of Arthritides(The Basic
Edition)

• Jacob Walter, M4

2
Four main categories of arthritis

• Degenerative
• Osteoarthritis (OA)
• Secondary Systemic hemochromatosis, hemophilia
• Inflammatory
• Seropositive rheumatoid arthritis (RA)
• Seronegative reactive arthritis, ankylosing
  spondylitis, psoriatic arthritis, and
  enteropathic arthritis (assoc with IBD)
• Infectious
• Crystal deposition
• Calcium pyrophosphate deposition disease (CPPD)
• Monosodium urate crystals - Gout

This is not a complete list, but will hopefully
get you started
3
When evaluating arthritis, take into account

• Location bilateral/unilateral, which joint(s)
• Which part of the joint is involved, even or
  uneven
• Demographics age, gender
• Presence of osteophytes, erosions, new bone
  formation, subchondral cysts, sclerosis
• Soft tissue swelling
• Or, ABCDEs Alignment, Bone proliferation,
  Cartilage (joint space loss), Density (bone),
  Erosions, soft tissues

4
Degenerative

• Osteoarthritis (OA)
• Secondary Systemic hemochromatosis, hemophilia

5
Degenerative - Osteoarthritis

• Characteristics
• Uneven loss of joint space
• Osteophyte formation
• Normal bone mineralization
• Relative absence of erosions
• Subchondral cysts and new bone formation/sclerosis
  
• Asymmetric distribution, usually hands, feet,
  knees and hips
• Not as common in shoulders, elbows
• Associated with changes d/t age, and mechanical
  forces

http//uwmsk.org8080/EvasMSKTF/
6
OA cont.

• Hand/Wrist
• DIP and PIP involvement, sparing of MCP
• Osteophyte formation with soft tissue swelling
  (Heberdon node at DIP, Bouchard at PIP)
• Usually 1st metacarpal/trapezium/navicular
  involvement in wrist
• Feet
• Most commonly 1st MTP joint

http//podiatryonline.com/
7
OA cont.

• Knee
• Medial joint involvement more common
• Varus deformity of joint, lateral tibial
  subluxation
• Hip
• Most often superiolateral joint involvement with
  loss of cartilage and osteophyte formation
• Medial sclerosis/new bone formation in femoral
  neck cortex buttressing

http//uwmsk.org8080/EvasMSKTF/
Cyst
Osteophyte
Buttressing
STATdx
8
Erosive OA

• OA with an inflammatory component
• Same OA distribution, but may see erosions or
  ankylosis
• Often postmenopausal women

http//uwmsk.org8080/EvasMSKTF/
9
Degenerative SystemicHemochromatosis

• Abnormal iron deposition throughout the body,
  including articular cartilage
• Demonstrates some overlap with CPPD, Fe inhibits
  pyrophosphatase and can lead to crystal
  deposition in cartilage (chondrocalcinosis)
• Uniform joint space loss
• Bilateral symmetrical distribution
• Beak-like osteophytes
• Subchondral cysts/sclerosis
• Osteoporosis

http//uwmsk.org8080/EvasMSKTF/
10
Hemochromatosis cont

• Most often in wrist and hand, esp. 2nd and 3rd
  MCP joints
• Flattened metacarpal heads
• Systemic disease may appear similar to CPPD, but
  with more indolent course and predominance of
  osteophytes

http//uwmsk.org8080/EvasMSKTF/
11
Degenerative - Systemic

• Hemophilia
• Repetitive hemarthrosis and intraosseous bleeding
  are causative
• Overgrown/ballooned epiphyses
• Subchondral cysts
• Tissue swelling, evidence of hemarthrosis
• Osteoporosis
• Late uniform space loss
• Sporadic, asymmetric distribution
• Late osteoarthritis changes
• Knee gt elbow gt ankle gthip (joints most likely to
  receive trauma)

http//uwmsk.org8080/EvasMSKTF/
12
Hemophilia cont

• Pseudotumors
• Bleeding in to soft tissues, subperiosteal, or
  intraosseous areas
• May cause some bone destruction or periosteal
  bone formation
• Do not confuse with malignancy

http//radiographics.rsnajnls.org/cgi/content/full
/23/4/852
13
Inflammatory

• RA
• Seronegative
• Reactive
• Ankylosing Spondylitis
• Psoriatic
• Enteropathic

14
Inflammatory SeropositiveRheumatoid Arthritis

• Periarticular soft tissue swelling
• Osteoporosis
• Uniform joint space loss
• Marginal erosions ? severe subchondral erosions
• No bone formation (no osteophytes)
• Subluxations
• Synovial cysts
• Bilateral and symmetric
• Generally not present in axial skeleton, except
  C-spine
• Hands gt feet gt knees gt hips gt C-spine gt shoulders
  gt elbows

Erosions, uniform joint spaces
http//uwmsk.org8080/EvasMSKTF/
15
RA cont

• In hand and wrist, often involves carpals, MCP
  joints and PIP joints
• Ulnar subluxation of proximal phalanges and
  formation of swan neck and boutonniere
  deformities
• Formation of subcutaneous rheumatoid nodules
• In the foot, erosion of distal metatarsals, and
  eventual radial subluxation of proximal phalanges
• Tarsal joint spaces may also be heavily involved

http//uwmsk.org8080/EvasMSKTF/
16
RA cont
Effusion
Bakers cyst

• Knees affected symmetrically and bilaterally
• Uniform space loss
• Outpouching of synovial cysts into adjacent bone,
  or soft tissue (Bakers cyst)
• Hips affected in 50
• Uniform cartilage loss ? axial or superomedial
  migration of femoral head
• Bone erodes on joint side, and forms on pelvic
  side leading to acetabuli protusio (acetabulum
  protrudes into pelvis)

STATdx
Erosions and joint space loss bilaterally, no
osteophytes or sclerosis
17
RA cont

• Shoulder and elbow also show bilateral, uniform
  joint space loss with osteoporosis and cysts
  formation
• Special consideration RA patients are prone to
  developing laxity of transverse ligament between
  atlas and odontoid process
• Normal distance between the two on lateral
  c-spine is 3mm in adults, 5mm in children
• Increased distance may indicate need for surgical
  fusion to prevent cord compression during flexion

http//uwmsk.org8080/EvasMSKTF/
18
Inflammatory Arthritis Seronegative

• Associated with HLA-B27
• Negative RH factor
• Axial skeleton often involved
• Sacroiliitis or spondylitis
• Enthesopathy
• Inflammation of the insertions of
  tendons/ligaments

19
Inflammatory SeronegativeReactive Arthritis
(Reiters)

• Reiters included the classic triad of arthritis,
  conjunctivitis, and urethritis
• Classical model involving chlamydial infection
  doesnt apply to all cases, and Reiter was a WWII
  war criminal, so reactive arthritis is now the
  preferred term
• Reactive arthritis may still involve chlamydial
  infection, but may also occur after
  gastroenteritis (Shigella, Salmonella,
  Campylobacter, Yersinia, C. defficile)
• Likely autoimmune reaction, joints themselves are
  not infected
• Worldwide has equal prevalence among men and women

20
Reactive cont

• Enthesopathy is prominent, with overlying tissue
  warmth and tenderness
• Soft tissue swelling (sausage digits)
• Uniform joint space loss
• Bilateral, asymmetrical
• Often begins with one joint, dont confuse with
  septic arthritis
• Areas of erosion associated with periosteal
  reaction, new bone formation
• Most often in feet, ankles, knees and SI joints
• Less in hands, hips, spine

http//uwmsk.org8080/EvasMSKTF/
21
Reactive cont
I got tired of bone pics, so heres some
chlamydia!

• Very often involves Achilles tendon insertion,
  preference for MTP and 1st IP joint in feet (vs
  DIP and PIP in psoriatic)
• In SI joint, may be on only one side or
  asymmetrically affect both sides (opposed to
  ankylosing spondylitis)
• May form large, asymmetric bony bridges between
  vertebrae (similar to psoriatic, but opposed to
  ankylosing spondylitis)

http//www.lahey.org/Medical/InfectiousDiseases/ID
_Chlamydia.asp
22
Inflammatory SeronegativeAnkylosing Spondylitis

• Bilateral, symmetrical
• Ankylosis, joint fusion, is prominent
• Before fusion, subchondral bone formation
• Post fusion, generalized osteoporosis
• No cysts or subluxation
• Erosions not a prominent feature, but are present
• SI and spine (ascending) involvement gt hips gt
  shoulders gt knees gt hands gt feet

http//uwmsk.org8080/EvasMSKTF/
23
AS cont
Dagger sign, fused spinous process ligaments

• Fusion of SI joints is classic
• Vertebral bodies initially erode at corner,
  reactive sclerosis occurs below this leading to
  squared appearance
• Eventually anulus fibrosus and longitudinal
  ligaments become ossified (syndesmophytes)
• Discs can become calcified, along with all
  ligaments including those between spinous
  processes ? bamboo spine

http//uwmsk.org8080/EvasMSKTF/
24
Inflammatory SeronegativePsoriatic Arthritis
Sausage digits

• Bilateral, asymmetrical
• Dramatic joint space loss /-ankylosis (arthritis
  mutilans)
• Bone proliferation, mouse ears
• pencil-in-cup deformities
• Normal mineralization
• Sausage digits
• Hands gt feet gt SI gt spine
• Usually favors DIP and PIP in hand
• SI involvement usually bilateral, asymmetrical
• Large bridging bone formation in spine, similar
  to reactive arthritis

http//www.hopkins-arthritis.org/arthritis-info/ps
oriatic-arthritis/diagnosis.html
http//uwmsk.org8080/EvasMSKTF/
http//uwmsk.org8080/EvasMSKTF/
25
Inflammatory SeronegativeEnteropathic Arthritis

• 20 of patients with inflammatory bowel disease
  develop arthritis
• Axial disease is very similar to AS with spine
  and SI joint involvement
• Radiographically almost identical to AS
• Progresses independently of IBD activity
• Peripheral arthritis/arthralgia waxes and wanes
  with IBD activity
• Oligoarthritis of lower extremities
• Erythema nodosum and pyoderma gangrenosa may be
  concurrent
• Whipples disease, pancreatic disease, cirrhosis,
  and infection such as Salmonella and Shigella may
  also be associated with arthritis

26
Infectious

• Septic arthritis

27
Septic arthrtitis

• Joint space destruction, both sides, due to
  release of proteolytic enzymes
• Joint effusion
• Soft tissue swelling
• Osteoporosis
• In healthy patients
• Knee, hip, and elbow common
• N. gonorrhoeae most common cause in young,
  sexually active patients
• IV drug users
• SI joint, sternal, pubic joints
• TB
• Hip, knee, intertarsal joints, spine
• TB in vertebral disc space is Potts disease
• Staph aureus is most common cause, Streptococcus
  is also common
• Gram negatives more common in diabetics
• Salmonella in sickle cell patients
• Risk factors Extremes of age, immunocompromised,
  chronic arthridities, prosthetic joints,
  diabetes, and IV drug use

28
Septic arthritis cont
Uhh, do you see the problem?
Potts
http//www.learningradiology.com/images/boneimages
1/bonegallerypages/Septic20arthritis.html
http//www.wheelessonline.com/ortho/tuberculous_sp
ondylitis
29
Sedona, AZ(crystals)

• Gout
• CPPD

30
Crystals Gout

• Monosodium urate crystal deposition
• May deposite in cartilage to produce an OA like
  disease, or in soft tissues (tophaceous gout)
• Usually males, postmenopausal females
• Tophaceous gout
• Tophi
• Relative joint space preservation
• Erosive lesions with sclerotic borders, away from
  joint space, with overhanging cortex
• Normal mineralization
• Asymmetrical, polyarticular
• May present with acute, monoarticular swelling,
  pain, and erythema.
• Feet (1st MTP) gt ankles gt knees gt hands gt elbows

31
Gout cont
Erosion with overhanging edge. Joint space is
preserved.
tophus
Crystal in PMN from synovial fluid, diagnostic
for acute gout
Uwmsk.org/residentprojects/gout.html
32
CrystalsCPPD

• Most common crystal arthropathy
• Disease spectrum includes
• Deposition in cartilage (chondrocalcinosis),
  which may lead to OA like disease or be
  asymptomatic
• Commonly develops in older population
• Associated with hyperparathyroidism and
  hemochromatosis
• Pseudogout which may present with acute attacks
  of arthritic pain similar to gout, although it is
  more common in the knees than the 1st MTP
• May be indistinguishable from septic arthritis
  without synovial fluid analysis

33
Chondrocalcinosis

• Most common in knee, pubic symphysis, and wrist
  (patients will be affected in at least one of
  these areas)
• Deposition of crystals in hyaline and/or fibrous
  cartilage
• Bilateral
• Cysts
• Normal mineralization
• Subchondral new bone formation
• /- osteophytes
• Knees gt hands gt hips
• Shoulder and elbow involved, differentiates from
  OA

wikipedia
Uwmsk.org/residentprojects/gout.html
34
Sources

• Bowen, Anne C. Arthritis in Black and White.
  Philadelphia Saunders, 1988
• Current Rheumatology Diagnosis Treatment,
  Second EditionJohn B. Imboden, David B.
  Hellmann, John H. Stone. http/accessmedicine.com
  
• Gay, Spencer B. Woodcock, Richard J Jr.
  Radiology Recall. Baltimore Lippincott, 2000
• Pretorius, E. Scott. Solomon, Jeffery A.
  Radiology Secrets. Philadelphia Mosby 2006
• Marc Gosselin, M.D., OHSU