Arthritis — narrowing the radiographicdiagnosis

Distribution of disease

Age and sex

Look for characteristic radiologicalfindings

Associated clinical illness?

Osteoarthritis — hallmarks

Primary defect is loss of cartilage

Leads to asymmetric joint space narrowing

Bone production:

Marginal osteophytes

Subchondral sclerosis

Subchondral cysts

Loose bodies (“joint mice”)

Arthritis — non-inflammatory

Osteoarthritis

Large joints

Small joints

Post-traumatic arthritis

Neuropathic arthritis

Arthritis — inflammatory

Rheumatoid arthritis

Gout

CPPD deposition disease

Septic arthritis

Seronegitive spondylarthropathies

Reiter’s

Psoriatic arthritis

Ankylosing spondylitis

Normal joints

Normal joints

Primary Osteoarthritis

= Degenerative joint disease

Idiopathic disease of small joints,especially hand and wrist

Chronic degenerative disease oflarge weight bearing joints especiallyspine, hips and knees

Weight bearing joint spaces involvedfirst and worst

Osteoarthritis—hypertrophic spurring

Osteoarthritis — progressive jointspace narrowing

Also progressive sclerosis andsubchondral cyst formation

Osteoarthritis

Superior joint space narrowing,osteophytes, subchondral cysts

Normal opposite side

Osteoarthritis — IP joint involvement

Secondary Osteoarthritis

Another process destroys articular cartilage:

Infection

Rheumatoid arthritis

CPPD

AVN

Trauma

Hemophilia

Secondary OA — primary AVN

Secondary OA – post traumatic

Inflammatory arthritis — hallmarks

Periarticular erosions

Periarticular demineralization

From regional hyperemia

Joint space narrowing

Rheumatoid Arthritis

Inflammatory arthritis– begins as synovitis

Synovial joints

Bursae

Tendons

Cartilaginous joints, ligamentous attachments notcommonly involved.

Small joints

Hands, wrists, feet

Large joints

Hips, knees, shoulders

Symmetric polyarticular disease

Rheumatoid arthritis:Progression of disease

Rheumatoid arthritis:Progression of disease

Rheumatoid Arthritis

Pathological event

Hypervascularity

Synovitis and effusion

Pannus attacks “bare”bone

Pannus attackscartilage

Radiologic findings

Periarticulardemineralization

Soft tissue swelling

Periarticular“marginal”  erosions

Joint space narrowing

Rheumatoid arthritis

Periarticular demineralization and synovitis

Rheumatoid arthritis

Joint space narrowing and early erosion

Rheumatoid arthritis

Moderate MCP erosions

Five years earlier

Rheumatoid arthritis

Carpal collapse

Rheumatoid arthritis

Ankylosis of wrist, PIPJ’s

Rheumatoid arthritisLarge joints

Concentric joint space narrowing

Rheumatoid arthritisLarge joints

Shoulder erosion and dislocation

Rheumatoid arthritisother manifestations

Tendon and bursa involvement

Non-articular synovitis

Bony erosion

Tendon rupture

Rotator cuff, Achilles, quadriceps tendons

Rheumatoid arthritisBursal involvement

Rheumatoid arthritis

Subacromial bursa involvement witherosion of  underside of clavicle

Rheumatoid arthritisother manifestations

Subluxations andDeformities

Ulnar deviation at MCP’s

Boutonniere and Swanneck deformities offingers

Mallet finger

Almost always withtypical intra-articulardisease

Rheumatoid nodules

Subcutaneous

Proximal ulna

Achilles tendon region

Lateral fingers

Rarely calcified (DDx gouty tophi)

Almost always seropositive RA

Pathologically nonspecific

Rheumatoid nodules

Other Inflammatory Arthritis

Gout

CPPD deposition disease

Seronegitive spondylarthropathies

Reiter’s

Psoriatic arthritis

Ankylosing spondylitis

Gout

Primary or secondary

Primary gout much more common in men

Initial attack most common in 5th decade

Hyperuricemia

Lower extremities > upper

Spine, hip, shoulder disease unusual

1st MTP involved in large majority (podagra)

Limited number of joints affected, asymmetric

Gout

Acute arthritis

May simulate septic arthritis

Acute synovitis with urate crystalsin joint fluid

Strong negative birefringence

Usually no radiographic findingsexcept swelling and effusion

Gout

Chronic tophaceous gout

Crystals in cartilage, subchondral bone,synovium, periarticular tissues

Pannus formation like RA

Marginal erosions may be large, withoverhanging edges

Soft tissue masses (tophi) with calcification

Extra-articular erosions

It takes years and advanced disease toget radiographic findings

Gout

Pseudogout

Acute inflammatory arthritis due to non-urate crystals

Usually CPPD (Calcium pyrophosphatedihydrate) Deposition Disease

Chondrocalcinosis is asymptomaticprecursor

Pseudogout

effusion

chondrocalcinosis

Chondrocalcinosis

Calcification in hyaline and fibrocartilage

Menisci and articular cartilage at knee

Symphysis pubis

Triangular fibrocartilage at wrist

Articular cartilage and labrum of hip

Usually due to CPPD

Middle aged and elderly men and women

May lead to destructive arthritis similar to OA

Unusual distribution e.g. shoulder or wrist

Chondrocalcinosis

Chondrocalcinosis

Septic arthritis

Acute

Staphlococcal

Gonococcal

Chronic

Tuberculous

Fungal

Hematogenous

Large joints

Direct extension

Diabetic foot with ulcer

Septic arthritis

Early

Severe pain and limitation of motion

Effusion, soft tissue swelling

Later

Joint space narrowing

Subchondral bone destruction

Bony findings indicate severe damage tocartilage

Early intervention is crucial

Don’t wait for radiographic findings!

Diabetic foot with swelling

Diffuseperiarticulardemineralizationfrom hyperemia

Articularsurfaces andsubchondralbonedestroyed

Joint effusion

If acute symptoms, think infection, goutor pseudogout, trauma or hemorrhage

Seronegative Spondyloarthropathies

“Rheumatoid variants”

 Psoriatic arthritis

 Reiter’s syndrome

 Ankylosing spondylitis

 Inflammatory bowel disease

Psoriatic arthritis

Asymmetric

Spine

Large asymmetric osteophytes

Fingers

DIPJ

PIPJ

Severely erosive arthritis

“pencil in cup” deformity

Sacroiliitis

asymmetric

Reiter’s syndrome

Classic triad

Arthritis (50%)

Urethritis

Uveitis

Reiter’s syndrome

Asymmetric disease (unlike RA)

Foot > hand

Hip and knee

Sacroiliitis

Regional osteoporosis - maymimic RA

Enthesopathy – whiskering attendinous insertions

Proliferative plantar heel spur

Large asymmetric spinalosteophytes

Review Questions

Periarticular erosions are not acommon feature of:

Rheumatoid arthritis

Osteoarthritis

Gout

Psoriatic arthritis

Osteophytes can be seen in:

Osteoarthritis

Psoriatic arthritis

Post-traumatic arthritis

Avascular necrosis

All of the above

Septic arthritis: True or false?

The earliest radiographic sign is jointeffusion.

Joint space narrowing is an early sign.

Imaging should not be the first step inevaluation of suspected joint infection.

Joint surface erosion indicates severedisease.

Additional reading

1.Resnick, D  Target Approach to Articular Disorders,Chapter 46 in Bone and Joint Disorders 2nd editionW.B. Saunders Co. Philadelphia 1996.

2.Resnick, D (see above) Chapter 22 RheumatoidArthritis.

3.Greenspan, A  Degenerative Joint Disease,Chapter 10 in Orthopedic Radiology: A PracticalApproach  JB Lippincott Co. Philadelphia 1988

4.Jones AC et al. Diseases associated with calciumpyrophosphate deposition disease. Semin ArthritisRheum 1992; 22:188.

The End

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Slides

• 1. Arthritis A practical radiological approach
• 2. Arthritis — narrowing the radiographic diagnosis
• 3. Osteoarthritis — hallmarks
• 4. Arthritis — non-inflammatory
• 5. Arthritis — inflammatory
• 6. Normal joints
• 7. Normal joints
• 8. Primary Osteoarthritis
• 9. Osteoarthritis—hypertrophic spurring
• 10. Osteoarthritis — progressive joint space narrowing
• 11. Osteoarthritis
• 12. Osteoarthritis — IP joint involvement
• 13. Secondary Osteoarthritis
• 14. Secondary OA — primary AVN
• 15. Secondary OA – post traumatic
• 16. Inflammatory arthritis — hallmarks
• 17. Rheumatoid Arthritis
• 18. Rheumatoid arthritis: Progression of disease
• 19. Rheumatoid arthritis: Progression of disease
• 20. Rheumatoid Arthritis
• 21. Rheumatoid arthritis
• 22. Rheumatoid arthritis
• 23. Rheumatoid arthritis
• 24. Rheumatoid arthritis
• 25. Rheumatoid arthritis
• 26. Rheumatoid arthritis Large joints
• 27. Rheumatoid arthritis Large joints
• 28. Rheumatoid arthritis other manifestations
• 29. Rheumatoid arthritis Bursal involvement
• 30. Rheumatoid arthritis
• 31. Rheumatoid arthritis other manifestations
• 32. Rheumatoid nodules
• 33. Rheumatoid nodules
• 34. Other Inflammatory Arthritis
• 35. Gout
• 36. Gout
• 37. Gout
• 38. Gout
• 39. Pseudogout
• 40. Pseudogout
• 41. Chondrocalcinosis
• 42. Chondrocalcinosis
• 43. Chondrocalcinosis
• 44. Septic arthritis
• 45. Septic arthritis
• 46. Diabetic foot with swelling
• 47. Joint effusion
• 48. Seronegative Spondyloarthropathies
• 49. Psoriatic arthritis
• 50. Reiter’s syndrome
• 51. Reiter’s syndrome
• 52. Review Questions
• 53. Periarticular erosions are not a common feature of:
• 54. Osteophytes can be seen in:
• 55. Septic arthritis: True or false?
• 56. Additional reading
• 57. The End

ArthritisA practical radiologicalapproach

Adam Guttentag M.D.

All photos retain the copyrights of their original authors

© Adam Guttentag, MD