Transcript Slide 1

Arthritis
Dr. Ahmed Refaey
Arthritis
• Degenerative arthritis “ osteo-arthritis”
• Inflammatory arthritis
* autoimmune ( RA – scleroderma- SLE-dermatomyositis )
* seronegative ( AS- psoriasis-Reiters- enteropathic )
* erosive
• Metabolic arthritis
Degenerative arthritis ( OA )
• 1ry : age related
• 2ry : underlying disease
• Joints involved : weight bearing joints
* hip- knee- spine- DIP-PIP-1st CMC- 1st MTP
* Joints spared : MCP, wrist, elbow, shoulder,
ankles
Radiographic features
• 5 hallmark signs:
• Narrowing of joint space,
usually asymmetrical
• Subchondral sclerosis
• Subchondral cysts
• Osteophytes
• Lack of osteoporosis
Degenerative OA
• Spine
* posterior joints ( facets )
* uncovertebral joints ( Luschka)
* costovertebral joints
* IVD
- decrease disc space , osteophytes,
misalignment , vaccum phenomenon,
schmorl’s nodules
• SIJ : usually unilateral, targets the middle of
the joint
• Shoulder : AC joint is more commonly involved
than glenohumeral joint
• Hands : Heberden’s & Bouchard’s nodules
• Knees : the 3 compartments, but medial
femero-tibial compartment is most
often involved
• Isolated DJD of patello-femoral articulation is
unusual , underlying conditions like CPPD,
hemochromatosis, old trrauma should be
considered
Arthritis
• Degenerative arthritis “ osteo-arthritis”
• Inflammatory arthritis
* autoimmune ( RA – scleroderma- SLE-dermatomyositis )
* seronegative ( AS- psoriasis-Reiters- enteropathic )
* erosive
• Metabolic arthritis
• Inflammatory arthritis
* autoimmune ( RA – scleroderma- SLE-dermatomyositis )
* seronegative ( AS- psoriasis-Reiters- enteropathic )
* erosive
• * autoimmune ( RA – scleroderma- SLEdermatomyositis )
Rheumatoid arthritis “RA”
• Symmetric, may involve any synovial joint
• Inflammatory process with hyperplastic
synovitis “ pannus “
• F > M …… after 50 y, F = M
• General radiographic features reflect the
underlying pathologic changes of chronic
synovial joint inflammation with associated
hyperemia, edema & pannus formation
Radiographic features
• The 1st feature is fusiform periarticular soft
tissue swelling arising from capsular
distension by exessive fluid accumulation.
blood flow to the synovium leads to a 2nd
early radiographic feature of juxta-articular
osteoporosis , due to hyperemia.
• After1-2 years, osseous erosions become
apparent , occuring at the unprotected bone
margins “ bare areas” in which the pannus has
direct osseous contact, but later involving the
subchondral bone giving subchondral cysts
• Joint spaces narrow uniformly as the cartilage
is destroyed by the enzymatic nature of pannus
• Later stages of the disease give rise to joint
deformities resulting from tendon and
ligaments laxity and ruptures & contractures.
• Later, 2ry OA may develop
Radiological features sequences of RA
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Soft tissue swelling
Periarticular osteoporosis
Marginal erosions
Symmetrical decrease joint space
Joint deformity
2ry OA
OA
vs
RA
• Hands
* bilateral symmetrical involvement of MCP & PIP
* characteristic joint deformities include swan neck
deformity, boutenniere deformity & Z-shaped
deformity of thumb.
* ulnar deviation of MCPs.
• Wrist
* erosions involving the radial & ulnar styloid
processes, distal radio- ulnar, radio-carpal joints and
waist of scaphoid, triquatral and pisiform.
• Feet
* bilateral symmetrical involvement of MTPs
* fibular deviation of MTPs
• Elbow
* joint effusion is recognized by a +ve fat pad
sign
• Schoulder
* gleno-humeral & acromio-clavicular joints
may be affected
* resorption of distal clavicle
* rotator cuff tear
DD of resorption of distal clavicle
Rheumatoid arthritis
Hyperparathyroidism
Scleroderma
• Hips
* symmetrical decrease in all joint components
* absence of sclerosis & osteophytes formation
unless 2ry OA has developed.
• Knees
* symmetrical , tricompartmental narrowing
* soft tissue swelling in the form of suprapatellar
effusion or large Backer;s cyst.
• Cervical spines
* affected in > 50% of patients
* preference of atlanto-axial joints
* the more chronic the disease, the greater of cervical
involvement.
* most of patients are asymptomatic despite cervical
involvement
* lateral views in flexion & extension ( atlanto-axial
subluxation) , due to laxity of transverse ligament
Lateral radiograph of the neck with the head in •
flexion shows an increased distance between
the anterior border of the dens and the posterior
border of the anterior tubercle of C1 (blue line)
from ligamentous laxity caused by rheumatoid
arthritis. The "pre-dentate space," as this is
called, should be less than 3 mm in the adult. The
red line above should smoothly connect all of the
spinolaminar white lines of each vertebral body
but clearly is directed posterior to the
spinolaminar white line of C1 (green arrow) since
C1 is subluxed forward on C2.
• In atlanto-axial subluxation, ADI ( anterior
atlanto-axial interval) > 3 mm, or vertical
atlanto-axial subluxation and superior
migration of odontoid process , necessitate an
MRI for evaluation of true cord space.
• Rheumatoi factor
is +ve in 70-80 % of patients with RA, also +ve in 5%
of individuals who don’t have RA.
• Diseases need flexion/extension views of C.spine
* RA
* trauma
* down syndrome
• Olecranon bursitis seen only in
* RA
* gout
Protrusio acetabuli
• Protrusio-acetabuli , seen only in PROT
* paget disease
* RA
* osteogenesis imperfecta
* trauma
Scleroderma
• Soft tissue abnormalities + erosive arthritis
• Radiographic features :
* soft tissue calcification
* acro-osteolysis “ tuft resorption”
* erosive changes of PIP & DIP
Systemic lupus erythematosis “ SLE “
• Non-erosive arthritis ( > 90% )
• Distribution similar to RA
• Soft tissue swelling may be the only indicator
Dermatomyositis
• Widespread cutaneous and subcuataneous ,
sheath like calcification is the hallmark.
Arthritis
• Degenerative arthritis “ osteo-arthritis”
• Inflammatory arthritis
* autoimmune ( RA – scleroderma- SLE-dermatomyositis )
* seronegative ( AS- psoriasis-Reiters- enteropathic )
* erosive
• Metabolic arthritis ( crystal deposition – endocrine )
• seronegative
( AS- psoriasis-Reiters- enteropathic )
Ankylosing spondylitis “ AS”
• Chronic ,progressive, inflammatory condition
involving mainly the synovial and
cartilagenous joints of axial skeleton and the
large proximal appendicular skeleton
• Joint involvement in axial & appendicular
skeleton is typically bilateral & symmetrical.
• Enthesopathy is a prominent feature
• SIJ
* the classic site of initial involvement
* changes involving both the ligamentous and
synovial portions of the joint , but predominent in
middle & lower thirds. The iliac side shows earlier
and greater radiographic involvement than sacral
side
*changes : erosions reactive sclerosis  ankylosis
• Spine
* typically ascends the spine contiguously without skip
lesions and progress bilaterally and symmetrically
• Contiguous thoracolumbar involvement
-Vertebral body "squaring": early osteitis
- Syndesmophytes (Calcification of the outer portion of
the anulus fibrosus )
- Bamboo spine: late fusion and ligamentous
ossification
• the classic spinal findings are thin, vertical
ossification ( syndesmosis) , that bridge
adjacent vertebrae and cause ankylosis of
multiple segments resemble a piece of
bamboo >> ( bamboo sign ).
• The classic bamboo sign occurs in a minority
of patients and takes an average of 10 years to
develop.
• Appendicular skeleton
* usually the proximal large joints “ hip &
shoulders” , giving a picture of any
inflammatory disorder as bilateral symmetrical
concentric joint space narrowing , mild
erosions, subchondral cyts, ankylosis
Psoriatic arthritis
• 2:1 hand to feet ratio
• Axial involvement in 50% of patients
• Hands and feet
* normal bone density
* sausage digit = swelling and inflammation of entire
length of finger “ dactylitis”
* erosions in bare area like RA with subsequent fluffy
periosteal newbone formation , produces “ mouse ear
“ appearance
* An “ ivory phalanx” is uncommon presentation but
unique and specific for psoriatic arthritis
* erosions may progress centrally in distal articular
surface giving “ pencil in a cup” deformity.
* acro-osteolysis “ terminal tuft resorption”
• A characteristic feature of psoriatic arthritis is
its propensity to involve all of the joints in one
digit, this termed as “ ray pattern “.
• So, changes in psoriatic arthritis are mixture of
bone resorption and bone production
* bone resorptions : pencil in a cup, marginal
erosions, resorption of terminal tufts
* bone production : mouse ear appearance,
ivory phalanx
Reiter’s arthritis
• Polyarthritis that targets the large joints of
lower extremity , small joints of feet and axial
skeleton.
• A minority of patients have the classic triad
( conjunctivitis – urethritis – arthritis )
* Reiter’s syndrome considered a form of
reactive arthritis pericipitated by bacterial
infection in GU or GIT.
Radiographic features
• Feet
* the most commonly involved site “ calcaneous –
MTP & IPJ of 1st digit “ being specifically affected.
* calcaneal erosions followed by fluffy periosteal
new bone occurs at the insertion of the plantar
fascia & Achilis tendon “ enthesitis”.
* these inflammatory heel spurs are typically
bilateral , present in 60% of patients and highly
suggestive of Reiter’s disease.
• Large joints of lower extremity
* knee and ankle joints are frequently affected
. The radiographic findings are consistent with
other inflammatory arthritis: soft tissue
swelling, joint effusion, loss of joint space, and
erosions , in addition to bony productive
changes and typically no osteopenia
• SIJ & spine
* the same as psoriatic arthritis
* radiologic differentiation between spondylitis
caused by psoriatic arthritis and spondylitis
caused by reiter’s arthritis is impossible , only
on clinical bases.
• SI and spine involvement of psoriatic arthritis
is indistinguishable from Reiter's disease.
• * Hand disease predominates in psoriasis; foot
disease predominates in Reiter's disease.
• Spine disease can be differentiated from AS by
asymmetrical osteophytes and lack of
syndesmophytes.
Enteropathic arthritis
• Sero-ve spondyloarthropathy associated with
inflammatory bowel disease.
• Radiographic features of the axial skeleton
mimic ankylosing spondylitis.
• Radiographic features of appendicular
skeleton mimic RA
Erosive arthritis
• Among postmenopausal women.
• Most common bilaterally affecting IPJ , distal
> proximal
• Central joint erosion resemble gull wing on AP
view
• Differentiated from psoriatic arthritis by the
central erosion affect the proximal articular
surface while in psoriasis, central erosion of
distal articular surface.
Arthritis
• Degenerative arthritis “ osteo-arthritis”
• Inflammatory arthritis
* autoimmune ( RA – scleroderma- SLE-dermatomyositis )
* seronegative ( AS- psoriasis-Reiters- enteropathic )
* erosive
• Metabolic arthritis ( crystal deposition – endocrine )
Metabolic arthritis
• Metabolic deposition diseases result in
accumulation of crystals or other substances
in cartilage and soft tissues.
• Types:
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* crystal deposition diease
- sodium urate ( gout )
- CPPD
- basic calcium phosphate
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* other depostion diseases
- hemochromatosis
- Wilson,s diseaase
- Alkaptonuria
- •
Gout
• Recurrent attacks of arthritis, 2ry to deposition of
sodium urate crystals.
• 90 % of patients are males
• Acute gout has non-specific radiological findings, while
chronic gout is well demonstrated on the plain films
• Radiologic features usually not seen untill 6-12 years
after initial attack
• Tophi seen only on longstanding disease
• 50% of tophi are calcific
• “ tophi are radiolucent, becaome radio-opaque only
after calcium depostion
• Radiological features:
- Eccentric, well marginated osseous lesions that
have an overhanging edges of bone
- Tophi : dense lobulated soft tissue masses , may
contain calcifications, asymmetric in distribution,
causing adjacent bone erosions
- Normal bone density
- Preserved joint space
- 1st MTP is the most commonly involved
gout
CPPD
( calcium pyrophosphate deposition
disease )
• Intra-articular deposition of CPP, resulting in
chondrocalcinosis and DJD in atypical joints
• Chondrocalcinosis : calcification of hyaline and
fibrocartilage, synovium, tendons and
ligaments
• Radiological features :
• - chondrocalcinosis
• - DJD like OA , but differes in distribution
• Destinctive features :
- patello-femoral & radiocarpal predilection
- large subchondral cysts
Hemochromatosis
• 2ry to deposition of iron in joints
• Changes similar to CPPD
• Destinctive features:
- beaklike osteophytes on MCP heads ( 4th& 5th)
- generalized osteoporosis
Wilson’s disease
• Deposition of copper in joints and liver, basal
ganglia and other tissues
• Same distribution as CPPD
• Destinctive features :
- subchondral fragmentation
- generalized osteoporosis
Alkaptonuria
( Ochronosis )
• Deposition of homogentesic acid in tissues
• Same distribution as CPPD
• Radiologic features:
- IVD are most commonly affected
Hemophilia
• Arthropathy is 2ry to repeated spontaneous
hemarthrosis, which occurs in 90% of hemophiliacs
• Radiographic features:
- Acute : joint effusion & periarticular osteoporosis
- Chronic : epiphyseal overgrowth , subchondral cysts,
2ry OA
- Distinctive features in knee : widened intercondylar
notch, squared patella
- Distinctive features in elbow : enlarged radial head
and trochlear notch
hemophilia
• extensive osteoporosis,
• enlargement of the
epiphyses
• a widened intercondylar
notch (arrows).
There is widening of the •
interconylar notch,
accentuation of the
trabeculae and enlargement
of the medial epicondyle
Arthritis
• Degenerative arthritis “ osteo-arthritis”
• Inflammatory arthritis
* autoimmune ( RA – scleroderma- SLE-dermatomyositis )
* seronegative ( AS- psoriasis-Reiters- enteropathic )
* erosive
• Metabolic arthritis
www.ahmedrefaey.com
Short cases
Arthritis
1- erosive arthritis
2- psoriasis/Rhiters
3- gout
4- AS
5- erosive arthritis
6- CPPD
7- scleroderma
8- RA
9- hemochromatosis
10-hemophilia
11-AS
12-scleroderma
13-RA
14-dermatomyositis
15-CPPD
16-OA
17-gout
18-psoriasis
19-CPPD
20-scleroderma
21-marginal erosion
22-CPPD
23-psoriasis
24-psoriasis
25-ochronosis
26-OA
27-gout
28-hemophilia
29-ochronosis
30-gout
31-erosive arthritis
32-AS
33-gout
34-gout
35-AS
36-gout
37-psoriasis