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Xray imaging in non inflammatory arthritis

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thropathyHallmark radiographic features of non-inflammatory arthritis like osteoarthritis, connective tissue arthropathy and metabolic and endocrine ar

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Xray imaging in non inflammatory arthritis

  1. 1. By: DR. RAMAN SHINGADE 2ND YR. RESIDENT GUIDE: DR. KANCHANA PACHCHIGAR TUTOR • Greenspan • Yochum and Rowe • Radiopedia.org • Learninradiology.com References: Xray Imaging in Non Inflammatory Arthritis
  2. 2. The constituent structures of a synovial/diarthrodial joint.
  3. 3. Definition of Arthritis •Disease that affects bones on both sides of the joint space and •Narrows the space between them
  4. 4. Narrowing of the joint space
  5. 5. Radiographic features of arthritides
  6. 6. Arthritis or not Normal DJD
  7. 7. Arthritis or not Normal DJD
  8. 8. Arthritis or not Normal DJD
  9. 9. Classification of Arthritides •Inflammatory Arthritis •Non-inflammatory Arthritis
  10. 10. Non Inflammatory Arthritis Degenerative Arthritis (Osteoarthritis) Primary Secondary Connective Tissue Arthropathy Scleroderma MCTD Metabolic & Endocrine Arthritis Acromegaly Hemochromatosis Haemophilia Gout Hyperparathyroidism
  11. 11. 2 forms of Osteoarthritis Primary form • Idiopathic Secondary form • Posttraumatic • Congenital disorders • Neuropathic Arthritis • Avascular Necrosis
  12. 12. Primary Degenerative Arthritis • Intrinsic degeneration of articular cartilage • Excessive wear and tear • Most commonly weight bearing joints like knees and hips • Less commonly non-weight bearing joints like knees and hips
  13. 13. •Hip •Knee •Spine • Interphalangeal joints of the hand Common Sites
  14. 14. Hallmark radiographic features • localized joint space narrowing • subchondral sclerosis • osteophytes • cyst or pseudocyst Osteoarthritis of Large joints
  15. 15. narrow joint space subchondral sclerosis osteophytes
  16. 16. Right hip osteoarthritis
  17. 17. Superolateral migration of femoral head with typical Eggers cyst in acetabulum. Egger’s CystSuperolateral migration
  18. 18. Medial migration of the femoral head
  19. 19. Postel coxarthropathy (aka rapidly destructive arthrosis) • occurs predominantly in women • characterized by rapid chondrolysis • no/very little reparative changes • mimics Charcot joint or infectious arthritis
  20. 20. Right hip Postel Coxarthropathy
  21. 21. Osteoarthritis of left knee L L
  22. 22. AP and lateral both knee radiographs bilateral knee osteoarthritis.
  23. 23. Advanced osteoarthritis with loose bodies
  24. 24. Narrowing of the femoropatellar joint compartment
  25. 25. Patellar Tooth sign
  26. 26. Patellar Tooth sign on AP projection
  27. 27. •Not due to mechanical stress • F:M = 10:1 • Most Often involves DIP joints • Sclerosis • Osteophyte formation • 1st MCP joint of thumb Osteoarthritis of Hand
  28. 28. Hallmark radiographic features • Heberden nodes • Bouchard nodes • joint space narrowing • subchondral sclerosis Osteoarthritis of Hand
  29. 29. Heberden Nodes Bouchard Nodes Degenerative changes in the 1st carpometacarpal joint
  30. 30. Osteoarthritis of bilateral first metatarsophalangeal joints
  31. 31. hallmark radiographic features • Facet narrowing and eburnation • Foraminal stenosis • Stenosis of spinal canal • Narrowing of IVDS Degenerative Disease of the Spine
  32. 32. Osteoarthritis of the facet joints Subchondral sclerosis Narrowing of facet joints
  33. 33. Bridging osteophytes Bridging osteophyte
  34. 34. Encroachment of the neural foramina by posterior osteophytes Posterior osteophytes with Neural foraminal stenosis
  35. 35. Vacuum disc phenomenon Prominent osteophytes Vacuum disc phenomenon
  36. 36. Secondary Osteoarthritis • Another process destroys articular cartilage • Degenerative changes supervene • How to recognize • Atypical age (e.g. DJD in 20 yrs age) • Atypical appearance (e.g. DJD in 1 hip only) • Atypical locations (e.g. DJD in shoulder)
  37. 37. Secondary Osteoarthritis causes • Trauma (most common) • Avascular Necrosis • Neuropathic arthritis • Congenital Disorders • Haemophilia • RA Bottom Line: Any arthritis can lead to 2° OA
  38. 38. • most common cause of secondary/atypical osteoarthritis • changes similar to those in primary osteoarthritis • history of previous trauma • younger age group Posttraumatic Osteoarthritis
  39. 39. Severe osteoarthritic changes due to previous dislocation
  40. 40. Severe post-traumatic osteoarthritis following distal fibula fracture.
  41. 41. Left knee Posttraumatic osteoarthritis. L
  42. 42. • destructive articular disease that occurs secondary to a loss or impairment in joint proprioception • disturbance in sensations leads to multiple microfractures • fragmentation of the bone and cartilage Neuropathic Arthritis
  43. 43. Causes Shoulders • Syrinx • Spinal Tumor Hips • Tertiary syphilis • Diabetes Feet • Diabetes
  44. 44. 6 D’s of Neuropathic Arthritis • Dense bones (subcondral sclerosis) • Distension of joint • Destruction of bone and cartilage • Disorganization • Debris (loose bodies) • Dislocation
  45. 45. Typical Neuropathic (Charcot) joint
  46. 46. Typical charcot joint in man with syphilis
  47. 47. Licked candy stick configuration
  48. 48. • defined as death of the osseous cellular components and marrow due to inadequate blood supply • definite anatomic predisposition for osteonecrosis at the epiphyseal centers • usually escapes clinical detection and is diagnosed only with bony imaging Avascular Necrosis (Ischemic or Osteonecrosis)
  49. 49. • Spontaneous (idiopathic) • Trauma (fracture, dislocation) • Alcoholism • Corticosteroid therapy • Surgery • Hemoglobinopathy Common causes -
  50. 50. • Collapse of articular cortex • Fragmentation • Mottled trabecular pattern • Sclerosis (Snowcap sign) • Subchondral cysts • Crescent sign (Subchondral fracture) Radiographic features
  51. 51. Classical sites of Osteonecrosis • head of femur • neck of talus • waist of scaphoid
  52. 52. Snowcap and Crescent signs
  53. 53. Collapsed Articular Cortex
  54. 54. Epiphyseal Fragmentation
  55. 55. Osteonecrosis of humeral head after sustaining fracture of the left humeral neck Crescent sign Increased bone density Healed Fracture
  56. 56. Pregnancy related Avascular necrosis.
  57. 57. Osteonecrosis of right humeral head following chemotherapy
  58. 58. • Developmental dysplasia of the hip • Slipped capital femoral epiphysis Secondary to Congenital Diseases Includes
  59. 59. •Putti's triad for developmental dysplasia of the hip include : Superolateral displacement of proximal femur . Increase in acetabular angle. Small capital femoral epiphysis. Developmental dysplasia of the hip
  60. 60. Radiograph demonstrates Developmental Dysplasia of Hip in a 6 months old female baby.
  61. 61. Developmental Dysplasia of Hip in a 12 years old female.
  62. 62. • Loss of Capener triangle sign • Decreased height of femoral epiphysis • Absence of intersection of epiphysis by line tangent to lateral cortex of femoral neck • Herndon hump Slipped capital femoral epiphysis Radiographic features:
  63. 63. Radiograph demonstrates absence of Carpener triangle in left hip. Carpener Triangle Absence of Carpener Triangle
  64. 64. Absence of intersection of epiphysis by lateral femoral cortical line.
  65. 65. Radiograph demonstrates Herndon hump and secondary osteoarthritis.
  66. 66. Non Inflammatory Arthritis Connective Tissue Arthropathy Scleroderma MCTD Metabolic & Endocrine Arthritis Acromegaly Hemochromatosis Gout Haemophilia Hyperparathyroidism
  67. 67. Scleroderma • generalized systemic inflammatory connective tissue disease of unknown cause • strong female predilection (F:M 3:1) • frequent involvement of the musculoskeletal system • predominantly affects the fingers, wrists and ankles
  68. 68. CREST syndrome Calcinosis Raynaud phenomenon Esophageal dysmotility Sclerodactyly Telangiectasia
  69. 69. • atrophy of the soft tissues at the tips of the fingers • resorption of the distal phalanges • subcutaneous and periarticular calcifications • destructive changes of the small articulations • flexion contractures Radiographic features
  70. 70. Atrophy of the soft tissues at the distal phalanges of the index, middle, and ring fingers R
  71. 71. Soft-tissue calcifications in the distal phalanges of the left hand, a typical feature of Scleroderma L
  72. 72. Acroosteolysis (arrow), soft tissue calcifications, and destructive changes of the distal interphalangeal joint of the middle finger. R
  73. 73. Subcutaneous calcifications alongwith destructive changes in distal IP joints L
  74. 74. Destructive changes in the distal interphalangeal joints, as well as soft-tissue calcifications L
  75. 75. Flexion contracture in scleroderma patient
  76. 76. Mixed Connective Tissue Disease • an example of Overlap syndrome • combine the features of SLE, scleroderma, dermatomyositis, and rheumatoid arthritis • antibody to the ribonucleoprotein (RNP) • approx. 80% patients are female
  77. 77. Radiographic features are combination of different conditions • Tuft resorption and DIP erosions (Scleroderma) • Erosive arthritis (Rheumatoid arthritis) • Deforming, nonerosive arthritis (SLE)
  78. 78. Abnormal tapering of the distal soft tissues and early surface erosion of the phalangeal condyle.
  79. 79. Subtle surface erosions and Progressive erosions
  80. 80. Terminal tuft resorption
  81. 81. Subluxation of IP joint of the thumb and advanced ulnar deviation
  82. 82. Juxta-articular demineralization and erosive articular disease
  83. 83. Metabolic & Endocrine Arthritis Acromegaly Hemochromatosis Gout Haemophilia Hyperparathyroidism
  84. 84. Acromegaly • result of excessive growth hormone (GH) production • growth of intramembranous bone tissue and subcutaneous hypertrophy • degenerative changes are the result of hypertrophy of articular cartilage • it is not adequately nourished by synovial fluid because of its abnormal thickness
  85. 85. Indices for Acromegaly o Sesamoid Index • Product of height and width (in mm.) of sesamoid bone at MCP of thumb. • Normal - <30 in females <40 in males o Heel Pad Thickness • Distance from posteroinferior surface of calcaneum to nearest skin surface • Normal <22 for 150 lb. individual
  86. 86. • initially, widening of joint spaces in hand, particularly MCP joints • later, thinning of the joint cartilages with osteophyte formation • beak-like osteophytes • Spade phalanx sign Radiographic features
  87. 87. Sesamoid Index and Heel Pad Thickness
  88. 88. Spade phalanx sign NORMAL ACROMEGALY
  89. 89. Characteristic abnormalities in acromegalic hand
  90. 90. Acromegalic osteoarthritis
  91. 91. Hyperparathyroidism • aka generalized osteitis fibrosa cystica or Recklinghausen disease of bone • result of overactivity of the parathyroid glands • leads to hypercalcemia • 3 subtypes – primary, secondary and tertiary
  92. 92. Radiographic features • Osteopaenia • Subperiosteal bone resorption • Intracoritcal bone resorption • Brown tumours (aka Osteitis Fibrosa Cystica) • Soft tissue and cartilage calcifications • Osteosclerosis • Salt and pepper sign in skull • Rugger-jersey spine
  93. 93. Subperiosteal resorption is on the radial sides of proximal and middle phalanges
  94. 94. Subchondral resorption resulted in widening of the sacroiliac joints.
  95. 95. Brown tumor in distal radius
  96. 96. Brown tumor in distal clavicle
  97. 97. Chondrocalcinosis at the knee and the symphysis pubis
  98. 98. Metastatic calcifications
  99. 99. Typical hyperparathyroidism arthropathy at the distal interphalangeal joints of the index and middle fingers.
  100. 100. Rugger-Jersey Spine
  101. 101. Hemochromatosis • characterized by iron deposition in various organs • may be primary (endogenous or idiopathic) or secondary • affects men 20-times more frequently than women • 50% of patients with hemochromatosis will have a slowly progressing arthritis
  102. 102. • features typical of osteoarthritis • different pattern of joint involvement in hand • second and third metacarpophalangeal joints • hook-like osteophytes • chondrocalcinosis Radiographic features
  103. 103. Osteoarthritic features in woman with hemochromatosis
  104. 104. Magnified radiograph demonstrates involvement of the metacarpal heads
  105. 105. Classical hook osteophytes
  106. 106. Advanced Hemochromatosis arthropathy
  107. 107. Hemophilia • group of disorders characterised by a tendency to bleed as a result of deficient clotting factors • deficiency of factor VIII (haemophilia A) or factor IX • arthropathy is a consequence of recurrent bleeds into joints • knees, elbows, hips and ankles are most commonly affected
  108. 108. Radiographic features • widened intercondylar femoral notch • squared inferior margin of the patella • haemophilic pseudotumours • periarticular erosions • features of osteoarthritis
  109. 109. Widened intercondylar notch with joint effusion L
  110. 110. Haemophilic arthropathy with subtle haemarthrosis
  111. 111. Advanced degenerative changes, with near-complete loss of joint L
  112. 112. Haemophilic Pseudotumors
  113. 113. Gout • metabolic disorder characterized by recurrent episodes of arthritis • monosodium urate monohydrate crystals in the synovial fluid leukocytes • great toe is the most common site of involvement in gouty arthritis • most patients are men (20:1)
  114. 114. Radiographic features • Articular erosion with preservation of part of joint • Overhanging edge of erosion • Lack of osteoporosis • Periarticular swelling • Tophi
  115. 115. Periarticular erosions and soft tissue masses, representing tophi
  116. 116. Multiple articular and periarticular erosions associated with large tophi.
  117. 117. Typical involvement of the first MTP joint with “overhanging edge”. Overhanging Edge
  118. 118. Intraosseous tophi
  119. 119. Tophus with dense calcifications adjacent to the olecranon process.
  120. 120. Summary Primary Osteoarthritis • Joint space narrowing • Osteophytes • No underlying cause Posttraumatic Osteoarthritis • Similar to 1° OA • Previous Trauma • Younger Age OA 2° to DDH • Superolateral displacement of proximal femur . • Increase in acetabular angle OA 2° to SCFE • Loss of Capener triangle sign • Absence of intersection of epiphysis Neuropathic Arthritis • 6 D’s Osteonecrosis • Radiolucent crescent • Preserved joint space
  121. 121. Summary Scleroderma • Resorption of the distal phalanges • Subcutaneous and periarticular calcifications MCTD • Combination of different conditions Acromegaly • beak-like osteophytes • Spade phalanx sign Hyperparathyroidism • Subperiosteal bone resorption • Brown tumours • Soft tissue and cartilage calcifications Hemochromatosis • 2nd & 3rd MCP joints are characteristically affected • Typical features of OA Haemophilia • Features of osteoarthritis • Widened intercondylar notch Gout • Tophi • Overhanging edge of erosions
  122. 122. SPOTS
  123. 123. SPOT 1
  124. 124. SPOT 2
  125. 125. SPOT 3
  126. 126. SPOT 4
  127. 127. SPOT 5
  128. 128. Thank You

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