Plain Film Diagnosis of Arthritides (The Basic Edition)

Plain Film Diagnosis of Arthritides(The Basic Edition)

Jacob Walter, M4

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

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, ABCDE’s: Alignment, Bone proliferation,

Cartilage (joint space loss), Density (bone), Erosions, soft tissues

Degenerative

Osteoarthritis (OA)Secondary – Systemic: hemochromatosis, hemophilia

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.org:8080/EvasMSKTF/

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/

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


STATdx

Cyst

Buttressing

Osteophyte

Erosive OA

OA with an inflammatory component

Same OA distribution, but may see erosions or ankylosis

Often postmenopausal women


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


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


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 > elbow > ankle >hip

(joints most likely to receive trauma)


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

Inflammatory

RASeronegative

Reactive Ankylosing SpondylitisPsoriaticEnteropathic

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 > feet > knees > hips >

C-spine > shoulders > elbows

Erosions, uniform joint spaces


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


RA cont

Knees affected symmetrically and bilaterally Uniform space loss Outpouching of synovial cysts

into adjacent bone, or soft tissue (Baker’s 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

Baker’s cyst

Effusion

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


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

Inflammatory – SeronegativeReactive Arthritis (Reiter’s) Reiter’s included the classic triad of arthritis,

conjunctivitis, and urethritis Classical model involving chlamydial infection doesn’t

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

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,

don’t 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


Reactive cont

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)

I got tired of bone pics, so here’s some chlamydia!

http://www.lahey.org/Medical/InfectiousDiseases/ID_Chlamydia.asp

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 > hips > shoulders > knees > hands > feet http://uwmsk.org:8080/EvasMSKTF/

AS cont

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

Dagger sign, fused spinous process ligaments


Inflammatory – SeronegativePsoriatic Arthritis Bilateral, asymmetrical Dramatic joint space loss +/-

ankylosis (arthritis mutilans) Bone proliferation, “mouse

ears” “pencil-in-cup” deformities Normal mineralization Sausage digits Hands > feet > SI > spine Usually favors DIP and PIP in

hand SI involvement usually

bilateral, asymmetrical Large bridging bone formation

in spine, similar to reactive arthritis


Sausage digits


http://www.hopkins-arthritis.org/arthritis-info/psoriatic-arthritis/diagnosis.html

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 Whipple’s disease, pancreatic disease, cirrhosis, and

infection such as Salmonella and Shigella may also be associated with arthritis

Infectious

Septic arthritis

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 Pott’s 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

Septic arthritis contUhh, do you see the problem?

http://www.learningradiology.com/images/boneimages1/bonegallerypages/Septic%20arthritis.html http://www.wheelessonline.com/ortho/tuberculous_spondylitis

Pott’s

Sedona, AZ(crystals)

GoutCPPD

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) > ankles > knees > hands > elbows

Gout cont

Uwmsk.org/residentprojects/gout.html

Erosion with overhanging edge. Joint space is preserved.

tophus

Crystal in PMN from synovial fluid, diagnostic for acute gout

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

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 > hands > hips Shoulder and elbow involved,

differentiates from OA

wikipedia

Uwmsk.org/residentprojects/gout.html

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

Documents

Plain Film Diagnosis of Arthritides (The Basic Edition)