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Xray imaging in non inflammatory arthritis
The document provides an overview of non-inflammatory arthritis, including the different types and their radiographic manifestations. It discusses osteoarthritis and its primary and secondary causes. Key features described include joint space narrowing, osteophytes, subchondral sclerosis for osteoarthritis. Neuropathic arthritis is characterized by the 6 D's. Osteonecrosis shows a radiolucent crescent sign and preserved joint space. Connective tissue diseases like scleroderma and mixed connective tissue disease demonstrate characteristic bone changes and calcifications. Metabolic disorders such as acromegaly, hemochromatosis, hyperparathyroidism, and gout each have distinct radiographic findings discussed in the summary.
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Xray imaging in non inflammatory arthritis
- 1. By: DR. RAMANSHINGADE 2ND YR. RESIDENT GUIDE: DR. KANCHANA PACHCHIGAR TUTOR • Greenspan • Yochum and Rowe • Radiopedia.org • Learninradiology.com References: Xray Imaging in Non Inflammatory Arthritis
- 2. The constituent structuresof a synovial/diarthrodial joint.
- 3. Definition of Arthritis •Diseasethat affects bones on both sides of the joint space and •Narrows the space between them
- 4. Narrowing of thejoint space
- 5. Radiographic features ofarthritides
- 6.
- 7.
- 8.
- 9. Classification of Arthritides •InflammatoryArthritis •Non-inflammatory Arthritis
- 10. Non Inflammatory Arthritis DegenerativeArthritis (Osteoarthritis) Primary Secondary Connective Tissue Arthropathy Scleroderma MCTD Metabolic & Endocrine Arthritis Acromegaly Hemochromatosis Haemophilia Gout Hyperparathyroidism
- 11. 2 forms ofOsteoarthritis Primary form • Idiopathic Secondary form • Posttraumatic • Congenital disorders • Neuropathic Arthritis • Avascular Necrosis
- 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. •Hip •Knee •Spine • Interphalangeal jointsof the hand Common Sites
- 14. Hallmark radiographic features •localized joint space narrowing • subchondral sclerosis • osteophytes • cyst or pseudocyst Osteoarthritis of Large joints
- 15. narrow joint space subchondralsclerosis osteophytes
- 16.
- 17. Superolateral migration offemoral head with typical Eggers cyst in acetabulum. Egger’s CystSuperolateral migration
- 18. Medial migration ofthe femoral head
- 19. Postel coxarthropathy (aka rapidlydestructive arthrosis) • occurs predominantly in women • characterized by rapid chondrolysis • no/very little reparative changes • mimics Charcot joint or infectious arthritis
- 20. Right hip PostelCoxarthropathy
- 22. Osteoarthritis of leftknee L L
- 24. AP and lateral bothknee radiographs bilateral knee osteoarthritis.
- 25. Advanced osteoarthritis withloose bodies
- 26. Narrowing of thefemoropatellar joint compartment
- 27.
- 28. Patellar Tooth signon AP projection
- 29. •Not due tomechanical stress • F:M = 10:1 • Most Often involves DIP joints • Sclerosis • Osteophyte formation • 1st MCP joint of thumb Osteoarthritis of Hand
- 30. Hallmark radiographic features •Heberden nodes • Bouchard nodes • joint space narrowing • subchondral sclerosis Osteoarthritis of Hand
- 32. Heberden Nodes Bouchard Nodes Degenerativechanges in the 1st carpometacarpal joint
- 34. Osteoarthritis of bilateralfirst metatarsophalangeal joints
- 35. hallmark radiographic features •Facet narrowing and eburnation • Foraminal stenosis • Stenosis of spinal canal • Narrowing of IVDS Degenerative Disease of the Spine
- 36. Osteoarthritis of thefacet joints Subchondral sclerosis Narrowing of facet joints
- 37.
- 38. Encroachment of theneural foramina by posterior osteophytes Posterior osteophytes with Neural foraminal stenosis
- 39. Vacuum disc phenomenon Prominentosteophytes Vacuum disc phenomenon
- 40. Secondary Osteoarthritis • Anotherprocess 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)
- 41. Secondary Osteoarthritis causes • Trauma(most common) • Avascular Necrosis • Neuropathic arthritis • Congenital Disorders • Haemophilia • RA Bottom Line: Any arthritis can lead to 2° OA
- 42. • most commoncause of secondary/atypical osteoarthritis • changes similar to those in primary osteoarthritis • history of previous trauma • younger age group Posttraumatic Osteoarthritis
- 43. Severe osteoarthritic changesdue to previous dislocation
- 44. Severe post-traumatic osteoarthritisfollowing distal fibula fracture.
- 45. Left knee Posttraumaticosteoarthritis. L
- 46. • destructive articulardisease 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
- 47. Causes Shoulders • Syrinx •Spinal Tumor Hips • Tertiary syphilis • Diabetes Feet • Diabetes
- 48. 6 D’s ofNeuropathic Arthritis • Dense bones (subcondral sclerosis) • Distension of joint • Destruction of bone and cartilage • Disorganization • Debris (loose bodies) • Dislocation
- 49.
- 50. Typical charcot jointin man with syphilis
- 51. Licked candy stickconfiguration
- 52. • defined asdeath 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)
- 53. • Spontaneous (idiopathic) •Trauma (fracture, dislocation) • Alcoholism • Corticosteroid therapy • Surgery • Hemoglobinopathy Common causes -
- 54. • Collapse ofarticular cortex • Fragmentation • Mottled trabecular pattern • Sclerosis (Snowcap sign) • Subchondral cysts • Crescent sign (Subchondral fracture) Radiographic features
- 55. Classical sites ofOsteonecrosis • head of femur • neck of talus • waist of scaphoid
- 56. Snowcap and Crescentsigns
- 57.
- 58.
- 59. Osteonecrosis of humeralhead after sustaining fracture of the left humeral neck Crescent sign Increased bone density Healed Fracture
- 60. Pregnancy related Avascularnecrosis.
- 61. Osteonecrosis of righthumeral head following chemotherapy
- 62. • Developmental dysplasiaof the hip • Slipped capital femoral epiphysis Secondary to Congenital Diseases Includes
- 63. •Putti's triad fordevelopmental dysplasia of the hip include : Superolateral displacement of proximal femur . Increase in acetabular angle. Small capital femoral epiphysis. Developmental dysplasia of the hip
- 67. Radiograph demonstrates DevelopmentalDysplasia of Hip in a 6 months old female baby.
- 68. Developmental Dysplasia ofHip in a 12 years old female.
- 69. • Loss ofCapener 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:
- 70. Radiograph demonstrates absenceof Carpener triangle in left hip. Carpener Triangle Absence of Carpener Triangle
- 71. Absence of intersectionof epiphysis by lateral femoral cortical line.
- 72. Radiograph demonstrates Herndonhump and secondary osteoarthritis.
- 73. Non Inflammatory Arthritis ConnectiveTissue Arthropathy Scleroderma MCTD Metabolic & Endocrine Arthritis Acromegaly Hemochromatosis Gout Haemophilia Hyperparathyroidism
- 74. Scleroderma • generalized systemicinflammatory 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
- 75. CREST syndrome Calcinosis Raynaud phenomenon Esophagealdysmotility Sclerodactyly Telangiectasia
- 76. • atrophy ofthe 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
- 77. Atrophy of the softtissues at the distal phalanges of the index, middle, and ring fingers R
- 78. Soft-tissue calcifications in the distalphalanges of the left hand, a typical feature of Scleroderma L
- 79. Acroosteolysis (arrow), soft tissue calcifications,and destructive changes of the distal interphalangeal joint of the middle finger. R
- 80. Subcutaneous calcifications alongwithdestructive changes in distal IP joints L
- 81. Destructive changes inthe distal interphalangeal joints, as well as soft-tissue calcifications L
- 82. Flexion contracture inscleroderma patient
- 83. Mixed Connective TissueDisease • 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
- 84. Radiographic features arecombination of different conditions • Tuft resorption and DIP erosions (Scleroderma) • Erosive arthritis (Rheumatoid arthritis) • Deforming, nonerosive arthritis (SLE)
- 85. Abnormal tapering ofthe distal soft tissues and early surface erosion of the phalangeal condyle.
- 86. Subtle surface erosionsand Progressive erosions
- 87.
- 88. Subluxation of IPjoint of the thumb and advanced ulnar deviation
- 89. Juxta-articular demineralization anderosive articular disease
- 90. Metabolic & EndocrineArthritis Acromegaly Hemochromatosis Gout Haemophilia Hyperparathyroidism
- 91. Acromegaly • result ofexcessive 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
- 92. Indices for Acromegaly oSesamoid 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
- 93. • initially, wideningof joint spaces in hand, particularly MCP joints • later, thinning of the joint cartilages with osteophyte formation • beak-like osteophytes • Spade phalanx sign Radiographic features
- 94. Sesamoid Index andHeel Pad Thickness
- 95. Spade phalanx sign NORMALACROMEGALY
- 96. Characteristic abnormalities inacromegalic hand
- 97.
- 98. Hyperparathyroidism • aka generalizedosteitis fibrosa cystica or Recklinghausen disease of bone • result of overactivity of the parathyroid glands • leads to hypercalcemia • 3 subtypes – primary, secondary and tertiary
- 99. 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
- 100. Subperiosteal resorption ison the radial sides of proximal and middle phalanges
- 101. Subchondral resorption resultedin widening of the sacroiliac joints.
- 102. Brown tumor indistal radius
- 103. Brown tumor indistal clavicle
- 104. Chondrocalcinosis at theknee and the symphysis pubis
- 105.
- 106. Typical hyperparathyroidism arthropathy at the distalinterphalangeal joints of the index and middle fingers.
- 107.
- 108. Hemochromatosis • characterized byiron 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
- 109. • features typicalof osteoarthritis • different pattern of joint involvement in hand • second and third metacarpophalangeal joints • hook-like osteophytes • chondrocalcinosis Radiographic features
- 110. Osteoarthritic features inwoman with hemochromatosis
- 111. Magnified radiograph demonstratesinvolvement of the metacarpal heads
- 112.
- 113.
- 114. Hemophilia • group ofdisorders 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
- 115. Radiographic features • widenedintercondylar femoral notch • squared inferior margin of the patella • haemophilic pseudotumours • periarticular erosions • features of osteoarthritis
- 117. Widened intercondylar notchwith joint effusion L
- 118. Haemophilic arthropathy withsubtle haemarthrosis
- 119. Advanced degenerative changes,with near-complete loss of joint L
- 120.
- 121. Gout • metabolic disordercharacterized 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)
- 122. Radiographic features • Articularerosion with preservation of part of joint • Overhanging edge of erosion • Lack of osteoporosis • Periarticular swelling • Tophi
- 123. Periarticular erosions andsoft tissue masses, representing tophi
- 124. Multiple articular andperiarticular erosions associated with large tophi.
- 125. Typical involvement ofthe first MTP joint with “overhanging edge”. Overhanging Edge
- 126.
- 127. Tophus with densecalcifications adjacent to the olecranon process.
- 128. 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
- 129. Summary Scleroderma • Resorptionof 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
- 130.
- 131.
- 132.
- 133.
- 134.
- 135.
- 136.
Editor's Notes
- #3 diarthrodial joint – synonymous with synovial joint It is important to note that the radiographic joint space is a reflection of joint cartilage, which occupies up to 99% of the space between opposing bones on an x-ray. Which consists of articular surfaces of two bones covered with articular cartilage and perichondrium with anatomic joint space within, which is lined by synovial membrane and filled with synovial fluid
- #5 The cardinal sign of an arthritic process is narrowing of the radiographic joint space. Thinning of the articular cartilage reduces the space mechanically
- #15 Marginal osteophytes occur at the periphery of the femoral head or the margins of the fovea (Figure 8-11). Central osteophytes extend from the subarticular surface and appear on radiographs as flat or button-like bony projections producing contour deformities of the femoral head. Periosteal or synovial osteophytes form as bony outgrowths from periosteum or synovial membranes. This is most apparent in the medial femoral neck, producing cortical thickening or a line of new bone formation termed buttressing. Buttressing bone is thought to be due to altered stress loads on the femoral neck and is most commonly seen with OA and less often with osteonecrosis.
- #19 Osteoarthritic pseudocysts in the acetabulum are termed Egger cysts
- #20 RDO has been defined by cartilage space narrowing of at least 2 mm per year whereas, in the usually seen form of OA, cartilage space narrowing of 0 to 0.8 mm is noted yearly. Rapid, marked bone loss from the femoral head and acetabulum occurs
- #21 Anteroposterior radiograph of the right hip of a 72-year-old man who had pain in the hip for 4 months shows the typical appearance of Postel coxarthropathy, which often mimics Charcot joint or infectious arthritis. Note the destruction of the articular portion of the femoral head, which is laterally subluxed. The same destructive process has led to widening of the acetabulum
- #22 Anteroposterior radiograph of the right hip of a 44-year-old man shows destructive changes of the femoral head and acetabulum.
- #23 Anteroposterior (A) and lateral (B) projections of the knee of a 57-year-old woman demonstrate narrowing of the medial femorotibial and femoropatellar compartments, subchondral sclerosis, and osteophytosis, which are the typical features of osteoarthritis. Note that osteophytes that were not obvious on the frontal projection are much better-demonstrated on the lateral radiograph.
- #26 Anteroposterior (A) and lateral (B) radiographs of the knee of a 66-year-old man with advanced osteoarthritis demonstrate predominant involvement of the medial femorotibial and femoropatellar joint compartments, with formation of two large osteochondral bodies.
- #27 Lateral radiograph of the knee (A) and axial radiograph of the patella (B) of a 72-year-old woman demonstrate narrowing of the medial femoropatellar joint compartment and osteophyte formation on the medial aspect of the joint.
- #28 (A) Axial view of the patella demonstrates dentate structures (the “tooth” sign), which represent degenerative ossifications (enthesopathy) at the insertion of the quadriceps tendon into the base of patella, as seen on the lateral view(B) in this 55-year-old man.
- #29 Occasionally, the tooth sign can also be demonstrated on the anteroposterior projection of the knee, seen here in a 54-year-old woman.
- #33 Interphalangeal osteoarthritis. Dorsovolar radiograph of right hand of a 74-year-old woman shows degenerative changes in the distal interphalangeal joints, manifested by Heberden nodes, and in the proximal interphalangeal joints, manifested by Bouchard nodes. Note also degenerative changes in the first carpometacarpal joint.
- #34 Interphalangeal and carpometacarpal osteoarthritis. Dorsovolar radiograph of both hands of a 52-year-old woman with osteoarthritis in addition to the typical Heberden and Bouchard nodes shows deformative changes at the first carpometacarpal articulations, resulting in an odd configuration of both thumbs.
- #35 Dorsoplantar radiograph of the great and second toes of the feet of a 33-year-old man shows osteoarthritis of the first metatarsophalangeal joints, which are known as hallux rigidus (hallux limitus). Note the narrowing of the joint space, subchondral sclerosis, and marginal osteophytes. Degenerative arthritis and stiffness due to bone spurs that affects the MTP joint at the base of the hallux (big toe) is called hallux rigidus or stiff big toe.
- #37 Osteoarthritis of the facet joints. Oblique radiograph of the lumbar spine in a 68-year-old man demonstrates advanced osteoarthritis of the facet joints. Narrowing of the joint spaces, eburnation of the articular margins, and small osteophytes are similar to the changes seen in osteoarthritis of the large synovial joints.
- #39 Conventional lateral tomogram of the cervical spine in a 56-year-old man demonstrates encroachment of the neural foramina by posterior osteophytes.
- #40 In degenerative disk disease, the vacuum phenomenon in the disk space is common. These radiolucent collections of gas, principally nitrogen, are related to the negative pressure created by abnormally altered joint or disk spaces. Vacuum phenomena involving the intervertebral disc relate to the accumulation of gas, principally nitrogen, in crevices within the intervertebral disk or vertebra. While they can commonly occur with intervertebral disc degerative disease, their appearance does not uniformly indicate "degenerative" disc disease, as gaseous collections may accompany other processes (vertebral osteomyelitis, Schmorl node formation, spondylosis deformans, vertebral collapse with osteonecrosis) affecting the disc and adjacent vertebral bodies.
- #44 Decreasd range of movement. Not much pain. Recent onset. Past history of right hip dislocation….65y/M Severe osteoarthritic changes right hip: Loss of joint space, marginal sclerosis, osteophytes, sub-articular cyst formation, bone fragments. In this instance previous dislocation. The head has not collapsed and there is no evidence of avascular necrosis at this time.
- #47 also known as Charcot joint Neuropathic arthropathy comprises a spectrum of destructive processes in the joint associated with neurosensory deficit. Pathognomonic for neuropathic joints are fragmentation of the bone and cartilage, which are discharged as debris into the joint; chronic synovitis with accumulation of varying amounts of fluid in the joint; and joint instability manifested by subluxation and dislocation
- #48 also known as Charcot joint Neuropathic arthropathy comprises a spectrum of destructive processes in the joint associated with neurosensory deficit. Pathognomonic for neuropathic joints are fragmentation of the bone and cartilage, which are discharged as debris into the joint; chronic synovitis with accumulation of varying amounts of fluid in the joint; and joint instability manifested by subluxation and dislocation
- #49 also known as Charcot joint Neuropathic arthropathy comprises a spectrum of destructive processes in the joint associated with neurosensory deficit. Pathognomonic for neuropathic joints are fragmentation of the bone and cartilage, which are discharged as debris into the joint; chronic synovitis with accumulation of varying amounts of fluid in the joint; and joint instability manifested by subluxation and dislocation
- #50 Neuropathic joint. Anteroposterior radiograph of the right hip of a 57-year-old woman with neurosyphilis (tabes dorsalis) shows the typical features of neuropathic (Charcot) joint. There is complete disorganization of the joint, fragmentation, and subluxation. The absence of osteoporosis is a characteristic feature of the neuropathic joint. This condition represents the most severe manifestation of degenerative joint disease.
- #52 Diabetes, Foot. Note that the distal metatarsals are tapered, producing a licked candy stick configuration.
- #53 there is a definite anatomic predisposition for osteonecrosis at the epiphyseal centers, especially in the femoral head, humeral head, and distal femur
- #55 frog-lateral view of the hip
- #56 While it can affect any bone, and half of cases show multiple sites of damage, avascular necrosis primarily affects the joints at the shoulder, knee, and hip. The classical sites are: head of femur, neck of talus and waist of scaphoid.
- #57 BITE AND CRESCENT SIGNS. AP Hip. Note the homogeneous increase in density (snow cap sign) involving the upper aspect of the head with a curvilinear inferior border (bite sign) (arrows). Beneath the articular cortex a subchondral fracture (crescent sign) can be seen (arrowhead).
- #58 Collapsed Articular Cortex. Observe the sharp, angular deformity (arrow) in the weight-bearing cortex (step defect). Sclerosis of the femoral head is also evident.
- #59 Epiphyseal Fragmentation. Note that multiple cystic and linear lucencies produce a mottled, fragmented appearance to the femoral head. This is owing to a combination of fractures, subchondral cysts, and localized repair response.
- #63 Osteoarthritis is believed to be caused by trauma, either overt or as an accumulation of microtrauma over years, although there is also a hereditary form called primary osteoarthritis that occurs primarily in middle-aged women.
- #64 Incidence = 1.5/1k births F:M=8:1 Left:right=2:1
- #65 The center-edge (C-E) angle of Wiberg is helpful in evaluating the development of the acetabulum and its relation to the femoral head. A baseline is projected, connecting the centers of the femoral heads. The C-E angle is formed by two lines originating in the center of the femoral head, one drawn perpendicular to the baseline into the acetabulum, and the other connecting the center of the femoral head with the superior acetabular lip. Values below the lowest normal value given for each age group indicate hip dysplasia.
- #68 36 degree acetabular angle.
- #69 The Andrén-von Rosen line. (A) With at least 45 degrees of hip abduction and internal rotation, the line is drawn along the longitudinal axis of the femoral shaft. In normal hips, it intersects the pelvis at the upper edge of the acetabulum. (B) In subluxation or dislocation of the hip, the line bisects or falls above the anterosuperior iliac spine.
- #70 Osteoarthritis is believed to be caused by trauma, either overt or as an accumulation of microtrauma over years, although there is also a hereditary form called primary osteoarthritis that occurs primarily in middle-aged women.
- #72 Also slight decrease in epiphyseal height is noted.
- #73 Chronic stages of this disorder exhibit reactive bone formation along the superolateral aspect of the femoral neck, along with remodeling; this creates a protuberance and broadening of the femoral neck, which gives it a “pistol-grip” appearance known as a Herndon hump
- #75 Acrosclerosis = Peripheral predilection for changes in the skin Thibierge-Weissenbach syndrome = Combination of soft tissue calcification, scleroderma, Raynaud’s phenomenon, and generalized telangiectasia
- #76 CREST syndrome is a common variation of scleroderma seen as the association of calcinosis, Raynaud’s disease, oesophageal dysmotility, sclerodactyly and telangiectasia Others synonyms include progressive systemic sclerosis (PSS), and acrosclerosis (Yochum and Rowe)
- #78 A 24-year-old woman with scleroderma presented with atrophy of the soft tissues at the distal phalanges of the index, middle, and ring fingers (arrows).
- #79 A 32-year-old woman with progressive systemic sclerosis exhibits soft-tissue calcifications in the distal phalanges of the right hand, a typical feature of this disorder.
- #80 A dorsovolar radiograph of the fingers of a 44-year-old woman reveals acroosteolysis (arrow), soft tissue calcifications, and destructive changes of the distal interphalangeal joint of the middle finger.
- #81 this xray left hand shows Subcutaneous calcifications alongwith destructive changes in distal IP joints of middle, ring and little fingers.
- #83 Flexion contracture in PIP joints with acroosteolysis of distal phalanx of thumb
- #84 An overlap syndrome is an autoimmune disease of connective tissue in which a patient presents with symptoms of two or more diseases. Examples of overlap syndromes include mixed connective tissue disease and scleromyositis. Diagnosis depends from which diseases the patient shows symptoms and has positive antibodies for in their lab serology.
- #86 Moderate juxta-articular demineralization associated with periarticular soft-tissue swelling and abnormal tapering of the distal soft tissues (A). Close-up view of proximal interphalangeal joint of this patient (8) demonstrates capsular distension and early surface erosion of the phalangeal condyle (arrows).
- #87 Subtle surface erosions (closed arrows) of the metacarpal head and base of proximal phalanx simulating early rheumatoid arthritis (A). In (8) and (C) progressive erosions (open arrows) of the proximal interphalangeal joint can be seen occurring over a 21-month period.
- #88 Subtle surface erosions (closed arrows) of the metacarpal head and base of proximal phalanx simulating early rheumatoid arthritis (A). In (8) and (C) progressive erosions (open arrows) of the proximal interphalangeal joint can be seen occurring over a 21-month period.
- #89 subluxation of interphalangeal joint of the thumb and advanced ulnar deviation with subluxation of the second through fifth metacarpophalangeal joints
- #90 Juxta-articular demineralization and erosive articular disease (A). Close-up view of the wrist (B) shows near-total loss of cartilage in the carpal and radiocarpal joints associated with erosive articular disease. Ulnar drift of the carpus is also demonstrated. Close-up of the MCP joints (C) demonstrates joint narrowing, erosive articular disease and mild reactive sclerosis of the second MCP joint.
- #92 Acromegaly is the result of excessive growth hormone (GH) production, most commonly from an adenoma of the pituitary. Degenerative joint changes in acromegaly are the result of hypertrophy of articular cartilage, which is not adequately nourished by synovial fluid because of its abnormal thickness.
- #93 For additional 25 lb. 1 mm can be added to basic value.
- #94 Spade phalanx sign refers to distal phalanges shape in acromegaly which terminal phalangeal tufts become hypertrophied and have a "spade appearance".
- #96 Dorsovolar radiograph of both hands of a 42-year-old man with acromegaly shows widening of some and narrowing of other joint spaces, enlargement of the distal tufts and the bases of terminal phalanges, and beak-like osteophytes affecting particularly the heads of the metacarpals. Note the soft tissue prominence and the large sesamoid bones at the first metacarpophalangeal joints. The sesamoid index (derived by multiplying the vertical and horizontal diameters of the sesamoid bone) is 48 in this patient; normally, it should not exceed 20 to 25.
- #97 Acromegalic arthropathy. Characteristic abnormalities in acromegalic hand include prominence of the soft tissue, enlargement of the tufts and bases of the distal phalanges, widening of the metacarpophalangeal joints, and beak-like osteophytes at the radial aspect of the metacarpal heads (metacarpal hooks). Note also markedly enlarged sesamoid bone at the first metacarpophalangeal joint.
- #98 Dorsovolar radiograph of both hands of a 42-year-old man with acromegaly shows widening of some and narrowing of other joint spaces, enlargement of the distal tufts and the bases of terminal phalanges, and beak-like osteophytes affecting particularly the heads of the metacarpals. Note the soft tissue prominence and the large sesamoid bones at the first metacarpophalangeal joints. The sesamoid index (derived by multiplying the vertical and horizontal diameters of the sesamoid bone) is 48 in this patient; normally, it should not exceed 20 to 25.
- #99 primary hyperparathyroidism - a parathyroid adenoma is the commonest cause ( ≈ 80%) followed by parathyroid hyperplasia ( ≈ 15%) 2 secondary hyperparathyroidism - a diffuse, adenomatous hyperplasia, renal osteodystrophy tertiary hyperparathyroidism - an autonomous parathyroid adenoma caused by the chronic overstimulation of hyperplastic glands in renal insufficiency Normal sr. ca. 8.8 to 10.6 mg/dl
- #100 subperiosteal bone resorption - classically affects the radial aspects of the proximal and middle phalanges of the 2nd and 3rd fingers
- #101 subperiosteal resorption Thirty year-old patient with chronic renal failure and elevated parathyroid hormone. Subperiosteal resorption is most evident on the radial sides of proximal and middle phalanges. Note the shaggy outer cortical surface in the mid-to-distal shaft of the middle finger proximal phalanx.
- #102 Subchondral resorption resulted in widening of the sacroiliac joints in this patient with hyperparathyroidism arthropathy.
- #103 Brown tumours (osteitis fibrosa cystica) can occur in any site, seen here in the distal radius (arrows). Additionally, resorptive changes are evident at the growth plates (small arrows).
- #104 A brown tumour (also known as osteitis fibrosa cystica or rarely osteoclastoma) is one of the manifestations of hyperparathyroidism. It represents a reparative cellular process, rather than a neoplastic process. Plain film Well-defined, purely lytic lesions that provoke little reactive bone. The cortex may be thinned and expanded, but will not be penetrated. A well-defined, mildly expansile lesion is observed in the distal clavicle approximately 1cm proximal to the distal articular surface. The lesion is soap-bubbly in appearance with mild cortical thinning. There is no evidence of cortical violation or overlying periosteal reaction. Overall bone density appears moderately diminished. The acromioclavicular joint appears widened, with an indistinct distal clavicular articular surface. The cortex along the medial aspect of the humeral neck appears thinned and feathery on the external rotation view.
- #105 Primary hyperparathyroidism. With chondrocalcinosis (calcification of cartilage) at the knee (A) and the symphysis pubis (B). Other sites where this may be present are the triangular fibrocartilage
- #106 Phosphate retention leads to increase in the phosphate × calcium product and precipitation of amorphous calcium phosphate in the arteries and soft tissues. AP radiograph of the left hand shows metastatic calcificationsaround the second and fifth metacarpophalangeal joints (large arrows) and along the second proximal phalanx (small arrow). More typically these calcifications are seen around the large joints.
- #107 Typical hyperparathyroidism arthropathy at the distal interphalangeal joints of the index and middle fingers. Note also beginning of the resorption of the distal tufts (acroosteolysis).
- #108 Typical hyperparathyroidism arthropathy at the distal interphalangeal joints of the index and middle fingers. Note also beginning of the resorption of the distal tufts (acroosteolysis).
- #109 Primary haemochromatosis results from a genetic error of metabolism, with increased absorption of iron from the gastrointestinal tract. Secondary haemochromatosis results from increased intake and tissue accumulation of iron from a known cause such as excessive dietary intake, cirrhosis, multiple transfusions and refractory anaemia.
- #110 thers is relative sparing of IP joint with invovlment of MCP joints Another typical feature of the disease is the presence of hook-like osteophytes generally seen on the radial aspect of the metacarpal heads. Chondrocalcinosis is seen in association with the metacarpal changes, usually best appreciated in the wrist.
- #111 JSN with subchondral sclerosis with osteophyte formation.
- #112 A coned-down magnified radiograph of the second and third metacarpophalangeal joints of the right hand demonstrates characteristic involvement of the metacarpal heads.
- #113 Patient with haemochromatosis demonstrating classical hook osteophytes arising on the radial aspects of the index and middle finger metacarpal heads (arrows).
- #114 Oblique radiographs of both hands of a 53-year-old woman with hemochromatosis show beak-like osteophytes arising from the heads of the second and third metacarpals on the radial aspect. The interphalangeal, metacarpophalangeal, and carpal articulations are also affected
- #115 Haemophilia A is more common affecting 1 in 10 000, XLR Blood products in the joint lead to an inflammatory response by the synovium and the release of destructive enzymes.
- #116 Haemorrhage and synovial inflammation in the joint lead to periarticular hyperaemia Chronic hyperemia causes overgrowth of the epiphysis and widening of the intercondylar notch in the growing child. Squaring of the inferior pole of the patella (seen in 20-30% of patients with hemophilia) is another form of overgrowth massive subperiosteal and intraosseous bleeding can lead to the formation of large expansile lesions, termed haemophilic pseudotumours synovial inflammation may also lead to periarticular erosions
- #117 subperiosteal bone resorption - classically affects the radial aspects of the proximal and middle phalanges of the 2nd and 3rd fingers
- #118 a soft tissue shadow surrounding the knee joint, s/o joint effusion Periarticular osteoporosis and epiphyseal enlargement are seen at left knee radiograph with widened intercondylar notch. There is also evidence of joint effusion in favour of hemarthrosis.
- #119 Radiographs showing some of the features of haemophilic arthropathy in this patient with haemophilia. There is epiphyseal enlargement of the radial head, loss of joint space and a subtle haemarthrosis indicated by displacement of the posterior fat pad.
- #121 27-year-old man with hemophilia and two osseous pseudotumors in right lower extremity, new lesion at distal femur (arrowheads). In tibial lesion, septa have thinned or disappeared, although new irregular calcifications (arrow) have developed within distal region. Most develop in the muscles of the pelvis and lower extremity, where the large muscles have a rich blood supply, or in bone following intraosseous bleeding. Pseudotumours appear as well defined,unilobular or multiloculated, lytic, expensile lesions of variable size. It can involve metadiaphysis and epiphysis of long bones.
- #122 Occurs in approximately1% of the population; male : female ratio of 20 : 1.
- #123 subperiosteal bone resorption - classically affects the radial aspects of the proximal and middle phalanges of the 2nd and 3rd fingers
- #124 Dorsovolar radiograph of the left hand of a 43-year-old man with tophaceous gout shows multiple sharply marginated periarticular erosions and soft tissue masses at the proximal interphalangeal joints of the index and middle fingers, representing tophi.
- #125 Dorsovolar radiograph of the left hand of a 43-year-old man with tophaceous gout shows multiple sharply marginated periarticular erosions and soft tissue masses at the proximal interphalangeal joints of the index and middle fingers, representing tophi (arrows)
- #126 Oblique radiograph of the right foot of a 58-year-old man with a 3-month history of gout shows the typical involvement of the first metatarsophalangeal joint. Note the characteristic “overhanging edge” of the erosive changes and preservation of the lateral portion of the joint.
- #127 Dorsovolar radiograph of both hands of a 60-year-old man with gout shows articular and periarticular erosions. In addition, note the presence of intraosseous defects in the phalanges consistent with intraosseous tophi.
- #128 Gouty tophus. Lateral radiograph of the elbow of a 73-year-old man with a 30-year history of gout shows a tophus with dense calcifications adjacent to the olecranon process, which exhibits a small erosion.
- #132 loss of capener triangle decreased epiphyseal height
- #133 Figure 15.16 Gouty arthritis. Dorsoplantar radiograph of the left foot of a 62-year-old man with a long history of tophaceous gout shows multiple erosions involving the big and small toes and the base of the fourth and fifth metatarsals. The first metatarsophalangeal joint is partially preserved, a characteristic feature of gouty arthritis. A large soft-tissue swelling of the great toe represents a tophus.
- #134 Radiographs of the hands showing spadelike tufts and metacarpophalangeal joint space widening.
- #135 Brown tumours of the hands in a patient with hyperparathyroidism. Brown tumours consist of fibrous tissue, woven bone and supporting vasculature, but no matrix. The osteoclasts consume the trabecular bone that osteoblasts lay down and this front of reparative bone deposition followed by additional resorption can expand beyond the usual shape of the bone, involving the periosteum thus causing bone pain. The characteristic brown coloration results from hemosiderin deposition into the osteolytic cysts. Hemosiderin deposition is not a distinctive feature of brown tumors; it may also be seen giant cell tumors of the bone.
- #136 20 years old male with hand pains and swellings. Note acrosteolysis and globular soft tissue calcifications characteristic of progressive systemic sclerosis.