Joint X-Ray


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Joint X-Ray

  1. 1. NP/FP Outreach Curriculum in Rheumatology September 16, 2010 Dr. Sherry Rohekar
  2. 2. OutlineIntroduction to imaging modalitiesFocus on plain radiography OA RA PsA AS Gout Pseudogout
  3. 3. X-raysTaking a 2-dimensional image of a 3-dimensional structureSuperimposition of structures can thus obscure pathologyQuality is also affected by patient positioning, exposure techniquesMultiple views of the same area are usefulGood for: fractures, bone lesions, osteophytes, joint space narrowing, erosions, cysts
  4. 4. Computed Tomography (CT)Also uses x-rays, but is superior than plain radiographs Improved contrast 3-D imagingAttenuation of the x-ray beam travelling through tissues is measured from multiple anglesSubstantially increased patient exposure to radiation when compared to plain filmsGood for: fractures, subluxations, sclerosis, cystic bone lesions, evaluation of surgical hardware
  5. 5. Ultrasound (US)Uses the interaction of sound waves with living tissue to produce an imageDoppler modes allow the determination of the velocity of moving tissues (i.e., blood flow)User dependent, so requires an experienced technician who can make real-time measurementsDifficult to assess all planesGood for: joint effusions, tenosynovitis, ganglia, erosions in RA, bursitis, tendonitis, and for guided injections/aspirations
  6. 6. Magnetic Resonance Imaging(MRI)Based on the absorption and emission of energy in the radiofrequency range of the electromagnetic spectrumNo ionizing radiation exposure, superior soft tissue contrast resolution, excellent for the assessment of soft tissues, can image in multiple planesTakes a long time to get access to scannerGood for: tenosynovitis, joint effusions, synovial proliferation, cysts, erosions, cartilage loss, reactive bone changes
  7. 7. Nuclear ScintigraphyIn addition to showing anatomy, also provides information about underlying physiologyMost commonly used for MSK imaging: technitium- 99m methylene diphosphate (Tc-MDP)Can detect synovial hyperemia on the blood pool phase and periarticular uptake on the delayed phase in joints affected by inflammatory arthritisVERY nonspecific, most rheumatologists consider the results to not be useful in clarifying the diagnosisGood for: determining total number and symmetry of joints involved
  8. 8. Approach to an ImageSoft tissues: effusions, calcification, massesMineralization: diffuse demineralization, periarticular demineralizationJoint narrowing and subchondral bone: narrowing, subchondral sclerosis, intraarticular bodies, ankylosisErosions: central (articular surface), marginal (bare area), periarticular, mutilansProliferation: osteophytes, periostitisDeformity: varus/valgus, flexion/extension, subluxation, dislocation, collapseDistribution: monoarticular, pauciarticular, polyarticular, symmetric/asymmetric
  9. 9. OsteoarthritisJoint space narrowing, osteophytes, subchondral sclerosis, cystsJoint effusions are not uncommonEarly osteophytes look like sharpening of the joint edgesDistribution: weight bearing joints (hips, knees, back)In the hands: DIPs, PIPs, CMC of thumbShoulder: glenohumeral OA usually secondary to rotator cuff disease
  10. 10. Rheumatoid ArthritisRA characterized by synovial proliferation (pannus), bursitis and nodules Can cause ill-defined soft tissue planes and prominances on plain films Nodules appear as focal soft tissue masses especially at the olecranon bursa and areas of frictionTenosynovitis can appear as diffuse soft tissue swelling, commonly seen at the wristPeriarticular osteoporosis is an early finding , but can also see generalized osteoporosis
  11. 11. Rheumatoid ArthritisCharacteristic lesions are erosions in the marginal (bare) area Pannus erodes the bone at the margin of the joint capsule where the redundant synovium exits, next to the articular cartilageOsseous proliferation is not commonly seen with RA, but can be seen with secondary OA in joints with RASubchondral cysts may be largeEarliest changes are usually in the hands and feet Ulnar styloid soft tissue swelling, extensor carpi ulnaris tenosynovitis
  12. 12. Marginal erosion ErosionsSoft tissueswelling
  13. 13. Rheumatoid ArthritisDeformities Subluxations at the MCPs and MTPs Ulnar deviation of the digits Swan-neck and Boutonniere deformities
  14. 14. Severe ulnar deviationSevere erosions ofMCPsComplete destructionof the wristResorption of thecarpals and the headsof the metacarpalsRadial deviation of thewrist
  15. 15. Boutonniere deformityof the thumbFlexion with dislocation ofthe first MCP jointHyperextension of theIP joint
  16. 16. Rheumatoid wrist: articular destruction, carpal fusion and carpalcollapse.Severe destruction of the distal radius and ulna.
  17. 17. Rheumatoid footMultiple osseouserosions and defectsat the medial andlateral margins ofthe metatarsalheadsMarginal erosionsat the bases of theproximal phalanges(arrows)
  18. 18. Rheumatoid footMedial and lateralerosions of the 5thmetatarsal headSubluxation of the 5thMTP joint
  19. 19. Rheumatoid footSubchondral cyst at thebase of the distalphalanxCharacteristic erosionalong the medialmargin of the proximalphalanx of the great toe
  20. 20. Soft tissue findingsin rheumatoidkneeSynovial effusionin thesuprapatellarpouch andposterior recesses
  21. 21. Atlantoaxialsubluxation in RAAlways a concern inpatient withlongstanding RAand neck pain orcervical neurologicalsymptoms
  22. 22. Order a view of the atlantoaxial articulation through an open mouthto fully assess. This shows lateral atlantoaxial subluxation of theodontoid process with respect to the lateral masses of the atlas.
  23. 23. Psoriatic ArthritisCharacterized by erosions and bony proliferations  RA does not typically have new bone formationAsymmetric distributionTypical “ray” distribution (involves several joints along a single digit)Can involve the axial skeleton, as in ankylosing spondylitis (AS)Soft tissue findings: fusiform soft tissue swelling around the joints; can progress so the whole digit is swollen (sausage digit or dactylitis)“Fluffy” periostitis at the enthesesMarginal erosions also often show fluffy periostitis from new bone formation
  24. 24. Psoriatic ArthritisDeformities Pencil and cup – end of bone looks like it has been through a pencil sharpener, reciprocating bone becomes cupped Telescoping of one bone into another Complete destruction of bone (arthritis mutilans)
  25. 25. Psoriatic handsErosive changesat the DIPs andPIPsSparing ofMCPs andwrists
  26. 26. Arthritis mutilansPencil and cup deformityPencilling
  27. 27. PsoriaticarthritisAsymmetricinvolvementSoft tissueswelling andperiostealreaction in 2ndand 3rd fingers
  28. 28. Periosteal reactions
  29. 29. Bony ankylosis of DIP joint
  30. 30. Psoriatic ArthritisSpine Asymmetric sacroiliitis Chunky, asymmetrical syndesmophytes (bony bridges between vertebrae)
  31. 31. Chunky, non-marginalsyndesmophytes typical ofpsoriatic arthritis
  32. 32. Asymmetricsacroiliitiswith leftsidederosions andsclerosis
  33. 33. Ankylosing SpondylitisChanges begin at SI joints and lumbosacral junction, then typically move up the spineSI joints: Initially subchondral sclerosis Then, small erosions cause “pseudowidening” of the SI joints Erosions occur first at iliac side, which has thinner cartilage Remember that the synovial part of the SI joint is the anterior, inferior portion Reactive sclerosis with eventual fusion
  34. 34. Ankylosing SpondylitisSpine Early changes include squaring of the anterior vertebral body Enthesitis (whiskering) and sclerosis (shiny corners) where Sharpey’s fibres mineralize Progressive mineralization of Sharpey’s fibres to form osseous bridging syndesmophytes Ossification of the interspinous ligamentsMost commonly involved peripheral joint is the hip
  35. 35. Erosions and sclerosis on iliacsideBilateral sacroiliitis witherosions, bony sclerosis andjoint width abnormalitiesBilateral sacroiliitis,definite erosions, severejuxta-articular bonysclerosis and blurring of thejoint
  36. 36. Advanced ASFused sacroiliacjointsAnkylosis of thelower lumbarspine (bamboospine)
  37. 37. Cervical spine in ASShiny cornersSquaring of the vertebralbodiesSyndesmophytes
  38. 38. GoutErosions and masses, especially in the peripheral jointsMasses may be dense, due to crystals or associated calcificationErosions are juxtaarticular from adjacent soft tissue tophi or intraosseous crystal deposition Appear rounded with a well circumscribed sclerotic marginDeformity occurs earlyOlecranon and prepatellar bursitis may calcify
  39. 39. Gouty changes in the bigtoeErosions due to tophi
  40. 40. Olecranonbursitis witherosions due togout
  41. 41. Large, destructive tophus of first MTP
  42. 42. Pseudogout (CPPD)Usually manifests as OA in an unusual distributionProminant osteophytesSoft-tissue calcification in the joint capsule, synovium, bursa, tendons, ligaments, periarticular soft tissuesChondrocalcinosis (cartilage calcification) Linear and regular deposits in articular cartilage, coarse deposits in fibrocartilageNo erosionsSubchondral cysts are prominantNo periosteal reaction or new bone formation
  43. 43. Chondrocalcinosis
  44. 44. Calcifications at the MCPs
  45. 45. Chondrocalcinosis of the Multiple cyststriangular ligament
  46. 46. SummaryKnowing the typical radiographic features of the various rheumatic diseases is important Can help you pare down your list of differentialsAlways a good idea to look at images yourself Often imaging is done with preconceived notions  “No fractures” Ask specifically for evidence of inflammatory arthritis if that is what you suspect