CLINICAL IMAGAGINGAN ATLAS OF DIFFERENTIAL DAIGNOSISEISENBERG

1. 10Arthritides

2. CLINICAL IMAGAGING
AN ATLAS OF DIFFERENTIAL DAIGNOSIS
EISENBERG
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig B 10-1 Osteoarthritis of the fingers.

4. • Fig B 10-2 Erosive osteoarthritis of the hand.
Narrowing of the proximal and distal
interphalangeal joints with erosions and spur
formation.

5. • Fig B 10-3 Rheumatoid arthritis. Characteristic
erosion of the ulnar styloid process (arrow) by
an adjacent tenosynovitis of the extensor
carpi ulnaris tendon. Note the associated soft-
tissue swelling.

6. • Fig B 10-4 Rheumatoid arthritis of the pelvis and hips.
There is narrowing of the hip joints bilaterally with
some reactive sclerosis. Note the relative preservation
of the subchondral cortical margins. In contrast to
degenerative disease, the joint space narrowing in
rheumatoid arthritis is symmetric and not confined to
weight-bearing surfaces. Note also the obliteration of
both sacroiliac joints.

7. • Fig B 10-5 Mutilating rheumatoid arthritis.
Opera-glass hand (main en lorgnette
deformity) due to extensive destruction and
telescoping of bone ends.

8. • Fig B 10-6 Rheumatoid arthritis. (A) Sagittal
T1-weighted image shows a distended joint as
indicated by low signal surrounding the distal
humerus (h). (B) T1-weighted, fat-suppressed
image after contrast administration shows
diffuse enhancement of the pannus.22

9. • Fig B 10-7 Juvenile rheumatoid arthritis. (A) Severe
deossification of the carpal bones with joint space
narrowing and even obliteration. Note the virtual ankylosis
between the distal radius and the proximal carpal row. (B)
Multiple subluxations, especially involving the
metacarpophalangeal joints. There is diffuse periarticular
soft-tissue swelling with moderate osteoporosis.

10. • Fig B 10-8 Psoriatic arthritis. Bizarre pattern of
asymmetric bone destruction, subluxation, and
ankylosis. Note particularly the pencil-in-cup
deformity of the third proximal interphalangeal
joint and the bony ankylosis involving the wrist
and the phalanges of the second and fifth digits.

11. • Fig B 10-9 Psoriatic arthritis. Views of both hands and wrists
demonstrate ankylosis across many of the interphalangeal
joints with scattered erosive changes involving several
interphalangeal joints, most of the metacarpophalangeal
joints, and the interphalangeal joint of the right thumb.
Note the striking asymmetry of involvement of the carpal
bones, an appearance unlike that expected in rheumatoid
arthritis.

12. • Fig B 10-10 Reactive arthritis. Erosive changes
about the metatarsophalangeal joint of the
fifth digit. The erosions involve the
juxtaarticular region, leaving the articular
cortex intact.

13. • Fig B 10-11 Reactive arthritis. Striking bony
erosion (arrows) at the insertion of the
Achilles tendon on the posterosuperior margin
of the calcaneus.

14. Fig B 10-12 Ankylosing spondylitis. Bilateral symmetric
obliteration of the sacroiliac joints with prominent
syndesmophytes in the lower lumbar spine.

15. • Fig B 10-13 Ankylosing spondylitis. Oblique
fracture of the midcervical spine, with anterior
dislocation of the superior segment, is seen in a
patient who fell while dancing and struck his
head. The fracture extends through the lateral
mass and lamina. Because of loss of flexibility and
osteoporosis, patients with ankylosing spondylitis
can suffer a fracture with relatively slight trauma.

16. • Fig B 10-14 Ankylosing spondylitis. Irregular
proliferation of new bone (whiskering) along
the inferior pubic ramus.

17. • Fig B 10-15 Jaccoud's arthritis. Frontal views of
the hands and wrists demonstrate mild ulnar
deviation with pronounced flexion of the
proximal interphalangeal joints. There is no
evidence of joint space narrowing or bone
erosion.

18. • Fig B 10-16 Gout. Severe joint effusion and
periarticular swelling about the proximal
interphalangeal joint of a finger. Note the
associated erosion of articular cartilage.

19. • Fig B 10-17 Gout. Two examples of typical rat-
bite erosions about the first
metatarsophalangeal joint (arrows). The cyst-
like lesions have thin sclerotic margins and
characteristic overhanging edges.

20. • Fig B 10-18 Gout. Diffuse deposition of urate
crystals in periarticular tissues of the hand
produce multiple large, lumpy soft-tissue
swellings representing gouty tophi. Note the
erosive changes that typically involve the carpal
bones and the distal interphalangeal and
metacarpophalangeal joints of the fifth digits.

21. • Fig B 10-19 Gout. (A) Frontal radiograph of the knee shows
an osteolytic lesion involving the internal condyle and
intercondylar area of the distal femur with a well-defined
sclerotic margin (arrows). (B) Coronal T1-weighted MR
image shows a well-defined lesion of heterogeneous signal
intensity with a scalloped margin (arrows), which
communicates with the joint space. Marrow surrounding
the lesion shows normal intensity. The small erosions of the
femoral condyles and adjacent soft-tissue masses
(arrowheads) presumably represent juxta-articular tophi.23

22. • Fig B 10-20 Hemophilia. The intracondylar
notch is markedly widened and there are
coarsened trabeculae, narrowing of the joint
space, and hypertrophic spurring.

23. • Fig B 10-21 Hemophilia of the knee in a child.
There is demineralization and coarse
trabeculation with overgrowth of the distal
femoral and proximal tibial epiphyses. The
intercondylar notch is moderately widened.

24. • Fig B 10-22 Hemophilia. Sagittal T1-weighted
MR image shows thickened synovial tissue
with very low signal intensity due to
hemosiderin deposits and to scar and fibrous
tissue formation in this patient with chronic
arthropathy.23

25. • Fig B 10-23 CPPD arthropathy. Severe joint space
narrowing, erosive changes, and sclerosis about
the wrist. Less marked changes involve the
metacarpophalangeal joints and the proximal
interphalangeal joint of the third digit.

26. • Fig B 10-24 Systemic lupus erythematosus. (A) Flexion
of the proximal interphalangeal joint and
hyperextension of the distal interphalangeal joint result
in a boutonnière deformity. (B) Hyperextension of the
proximal interphalangeal joint and flexion of the distal
interphalangeal joint produce a swanneck deformity.19

27. • Fig B 10-25 Multicentric histiocytosis. Multiple soft-
tissue masses produce a “lumpy-bumpy” appearance.
The soft-tissue deposits of multinucleated giant cells
have produced erosions of juxta-articular bone.
Although at this stage most of the joint spaces are
spared, extensive involvement of the second
metacarpophalangeal joint has led to total joint
destruction.19

28. • Fig B 10-26 Hemochromatosis. Diffuse joint
space narrowing with scattered erosions,
osteophytes, and articular sclerosis.

29. • Fig B 10-27 Acromegaly. Widening of the
metacarpophalangeal joints, thickening of the
soft tissues of the fingers, and overgrowth of
the tufts of the distal phalanges (arrows).

30. • Fig B 10-28 Pigmented villonodular synovitis. (A)
Frontal and (B) lateral views of the elbow
demonstrate a joint effusion with nodular soft-
tissue masses extending beyond the joint
capsule. The soft-tissue mass appears dense
because of deposits of hemosiderin in it. Large
bone erosions reflect a combination of pressure
effect and direct invasion by the synovial growth.

31. • Fig B 10-29 Pigmented villonodular synovitis.
(A) Frontal radiograph of the hip shows
narrowing of the joint space and multiple
subchondral lytic defects on both sides of the
joint. (B) Coronal gradient-echo MR image
shows tissue of very low signal intensity
outlining the joint capsule. Note the
prominent deposition of hemosiderin.23

32. • Fig B 10-30 Acute staphylococcal arthritis. (A)
Several days after instrumentation of the
shoulder for joint pain, there is separation of
the humeral head from the glenoid fossa due
to fluid in the joint space. (B) Six weeks later,
there is marked cartilage and bone
destruction, with sclerosis on both sides of the
glenohumeral joint.

33. • Fig B 10-31 Septic arthritis. Coronal STIR MR
image in a child demonstrates a large, high-
signal joint effusion in the right hip that
causes the femoral head to sublux laterally
from the acetabulum. No bone erosion or
marrow edema is evident.22

34. • Fig B 10-32 Tuberculous arthritis of the knee. On both
sides of the joint there are destructive bone lesions
(arrows) involving the medial and lateral condyles and
the medial aspect of the proximal tibia. Note the
relative sparing of the articular cartilage and
preservation of the joint space in view of the degree of
bone destruction.

35. • Fig B 10-33 Tuberculous arthritis of the elbow.
Complete destruction of the joint space. The
large antecubital mass reflects marked
synovial hypertrophy resulting from chronic
granulomatous infection.19

36. • Fig B 10-34 Amyloid arthropathy. (A) Frontal radiograph shows
diffuse soft-tissue swelling around the shoulder associated with
small erosions in the humeral head (arrow). (B) Sagittal T1-weighted
MR image shows extensive periarticular deposition of an abnormal
soft tissue that is isointense relative to skeletal muscle and extends
into subchondral defects (arrow). (C) Axial gradient-echo MR image
shows distention of the subdeltoid bursa and an erosion of the
anterior humeral head, which contains material of signal intensity
less than that of fluid.23

37. • Fig B 10-35 Rapidly destructive articular disease.
(A) Frontal radiograph of the hip obtained before
the onset of symptoms shows mild osteoarthritic
changes. (B) Radiograph obtained after 6 months
of progressive pain shows flattening of the
femoral head with superolateral subluxation,
multiple subchondral defects, bone sclerosis, and
narrowing of the articular space.23

38. • Fig B 10-36 Milwaukee shoulder. (A) Frontal
radiograph shows soft-tissue swelling and
irregular calcifications (arrow) around the
shoulder. Note the anterior dislocation. (B)
Coronal T2-weighted MR image shows a large
joint effusion, resorption and deformity of the
humeral head, and complete rupture of the
rotator cuff.23