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Download Infection of bone,joint and soft tissue
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Infection of bone,joint and soft tissue • 化脓性骨髓炎(purulent osteomyelitis) – 金黄色葡萄球菌(staphylococcus aureus) – Infection pathway • 血行感染(haematogenous spread) • 直接延伸(direct extend) • 开放性骨折(open fracture) Acute Purulent Osteomyelitis • clinical symptom： • pathology：metaphysis－cortex of bone－ subperiosteum abscess －medullary cavity of bone－ sequestrum(死骨）－plerosis(修复) Acute Purulent Osteomyelitis • X-ray film： – Soft tissue • Muscle interspace clouding • Subcutaneous fat clouding – bone • Destruction of bone • Sequestrum(死骨) • Parallel periosteal proliferation(平行骨膜反应） Acute Purulent Osteomyelitis • CT：It is better than X-ray plain film. Acute Purulent Osteomyelitis • MRI：It is better than X-ray and CT. It can make early diagnosis, low signal in T1WI and high signal in T2WI. The wall of the abscess should be enhancement after injection of Gd-DTPA. 急 性 化 脓 性 骨 髓 炎 Acute Purulent Osteomyelitis 双侧胫骨骨髓炎 Both tibiae acute purulent osteomyelitis 胫骨中下段感染 Chronic Purulent Osteomyelitis • X-ray：bone hyperplasia or sclerosis, diaphysis asper(粗糙)，medullary cavity of bone narrow, destruction of bone, sequestrum • CT：similar to X-ray • MRI：hyperostosis osteosclerosis(骨质增 生硬化),sequestrum and periosteal proliferation are low signal. MRI can show abscess cavity and fistula cannulas(瘘管) high signal. Chronic Purulent Osteomyelitis(慢性骨髓炎) 慢性硬化性骨髓炎 （Garre Osteomyelitis ） • Periosteal proliferation(骨膜增生)， cortex thickening， osteosclerosis， medullary cavity constriction or emphraxis(闭塞), no destruction and sequestrum 慢性局限性骨髓炎 （Brodie abscess of bone） • Low toxicity(低毒性)pyogenic infection • Metaphysis(干骺端) • Light symptom • Round destruction surrounded by osteosclerosis Brodie abscess of bone 慢性局限性骨髓炎 Pyogenic Arthritis X-ray：articular capsule swelling, joint subluxation or dislocation，bone destruction(首先见于持重面），joint space constriction，even bone stiff(强直) CT：similar to X-ray film MRI：MRI can display synovitis, hydrarthrosis, destruction of articular cartilage. It is better than X-ray and CT. 化 脓 性 关 节 炎 Pyogenic Arthritis Tuberculosis of Bone • X-ray film – TB of Long bone: epiphysis and metaphysis osteoporosis and destruction, sediment sequestrum(泥沙样死骨) – TB of Diaphysis：metacarpal bone(掌骨), metatarsal bone(跖骨)destruction, “tambour” (骨“气鼓”征) – TB of Spine：collapse of vertebra， intervertebral space constriction, vertabral body confluence(融合)，cold abscess, calcification Tuberculosis of Bone • CT： – TB of bone：destruction of bone, sediment sequestrum, soft tissue swelling – TB of spine: bone destruction, sequestrum, cold abscess • MRI： – TB of spine TB of spine 脊柱结核 Tuberculosis of Joint –X-ray film • Soft tissue swelling，joint space constriction，articular bone destruction(首先见于非持重面） • Synovium TB of joint –CT similar to X-ray film –MRI hydrarthrosis, synovium swelling, articular cartilage and bone destruction, cold abscess 关节结核(TB of joint) infection of soft tissue • CT：hyperemia, edema, abscess • MRI：it is best for making early diagnosis in infection of soft tissue 膝前皮下软组织脓肿 Arthritis Definition l Disease that affects bones on both sides of the joint space and l Narrows the space in between them Classification l Hypertrophic n Hallmarks l l l Infectious n Hallmark l l Bone production Sclerosis Destruction of articular cortex Erosive n Hallmark l Erosions Hypertrophic Arthritis l l Degenerative arthritis n Primary n Secondary Charcot arthropathy 1º Degenerative Arthritis l Intrinsic degeneration of articular cartilage l Excessive wear and tear n Most commonly hips and knees n Less commonly shoulders and elbows 1º DJD of knees affects medial, weight-bearing surface 1º DJD of hips affects superior, weight-bearing surface 1º Degenerative Arthritis Hands l Not due to mechanical stress l F:M 10:1 l Most often involves DIP joints l n Sclerosis n Marginal osteophyte formation 1st MCP joint of thumb n 1º DJD of Hands 2º Degenerative Arthritis l Another process destroys articular cartilage l Degenerative changes supervene l How to recognize n Atypical locations (CPPD and knee) n Atypical appearance (Marked DJD of 1 hip) n Atypical age (DJD in 20 year-old) 2º Degenerative Arthritis Causes l Trauma l Infection l Avascular necrosis l CPPD l RA l Hemophilia 2º Degenerative Arthritis More Causes l Hemochromatosis l Acromegaly l Ochronosis l Wilson's Disease l Bottom line: Any arthritis can end as DJD R3 2º DJD of right ankle following fracture Calcium Pyrophosphate Deposition Disease (CPPD) n May be idiopathic or associated with l Hyperparathyroidism, hemochromatosis n Symmetric involvement: knees (most common), wrists, MCPs n Sudden onset of pain and fever n Clinically l Tender, swollen, red, LOM CPPD Findings n l Calcification of articular cartilage l Knee, hip, shoulder l Triangular fibrocartilage of ulna l Symphysis n Large subchondral cysts n Preferential involvement of femeropatellar compartment Chondrocalcinosis Hypertrophic Arthritis Classification l l Degenerative arthritis n Primary n Secondary Charcot arthropathy Charcot’s Arthropathy General l Disturbance in sensation leads to multiple microfractures l Pain sensation intact from muscles and soft tissue l Causes n Shoulders – syrinx, spinal tumor n Hips – tertiary syphilis, diabetes n Feet – diabetes Charcot’s Arthropathy Findings l X-ray findings n Fragmentation n Soft tissue swelling n Destruction of joint n Sclerosis n Osteophytosis Charcot’s Knees-Diabetes Charcot’s Shoulder - Syrinx Charcot’s Arthropathy of Foot - Diabetes Classification l Hypertrophic n Hallmarks l Bone production Sclerosis Infectious l l n Hallmark l l Destruction of articular cortex Erosive n Hallmark l Erosions Infectious Arthritis l More common in adults n Usually from local trauma-surgery or accident n Children get osteomyelitis l Destruction of articular cartilage & cortex l Tends to affect one joint (DDx from gout) n Fingers from human bites n Feet from diabetes n Hips from THRs Normal joint Normal articular cortex Infectious Arthritis Causes l Usually staph - “early” destruction of articular cortex n l TB spreads via bloodstream from lung n More protracted course In children, spine most common; in adults, knee n Severe osteoporosis n l Rapid course (unlike most arthritides) Healing with ankylosis common in both Acetabular white line R3 Septic arthritis of hip with pathologic fracture Normal hip Septic arthritis of toe TB septic arthritis over 1 year Classification Erosive Arthritis l Hypertrophic n Hallmarks Bone production l Sclerosis Infectious l l n Hallmark l l Destruction of articular cortex Erosive n Hallmark l Erosions Erosive Arthritis General l Synovial proliferation (pannus formation) l Inflammation l Erosions seen in small joints (hands) better than large (hips) n Destroy portion of cortex Erosive Arthritis Types l Rheumatoid arthritis l Gout l Hemophilia l Erosive osteoarthritis l Rheumatoid variants n Psoriatic arthritis n Reiter's n Ankylosing spondylitis n Inflammatory bowel disease Erosive Arthritis More Types n Connective tissue disease l Scleroderma l SLE Jaccoud's arthropathy Sarcoidosis l l n Rare l Amyloid Rheumatoid Arthritis General l Bilaterally symmetrical n Earliest change: STS MCP, PIP, ulnar styloid l Radiocarpal jt most commonly narrowed l Periarticular demineralization l Begins MCP jts of 1st and 2nd fingers l Large joints usually no erosions Rheumatoid Arthritis General l Can lead to 2º DJD n n Marked narrowing of joint space with intact articular cortex, think of RA l Little or no sclerosis l Especially, hips and knees RA of Hips – Marked narrowing, little sclerosis R3 RA Hands RA usually involves 5th MT-P joint first RA of Foot Gout General l Long latent period between onset of symptoms and bone changes l Asymmetric and monoarticular l More common in males l Most common at 1st MT-P joint l Tophi rarely calcify l Olecranon bursitis is common Gout Findings l Juxta-articular erosions n Sharply marginated with sclerotic rims n Overhanging edges (rat-bites) l No joint space narrowing until later l Little or no osteoporosis l Soft tissue swelling l Tophi not calcified R3 Gout R3 Gout Erosive Osteoarthritis l Post-menopausal females l Changes like DJD but with marked inflammation and erosions l IP joints of hands and carpal-MCP joint of thumb l DDx: Psoriasis (skin changes) Erosive Osteoarthritis Erosive Osteoarthritis Ankylosing Spondylitis l l l HLA-B27 positive B/L SI arthritis n l Squaring of vertebral bodies l Bamboo-spine from continuous syndesmophytes l Peripheral large joint erosive arthritis Ankylosing Spondylitis Overview l Hypertrophic n n l Degenerative Arthritis l Primary l Secondary Charcot Arthropathy Infectious n Pyogenic n Tuberculous Overview l Erosive n RA n Gout n Hemophilia n Erosive osteoarthritis n Psoriatic arthritis n Reiter’s Syndrome n Ankylosing Spondylitis n Chronic Arthritis Rheumatoid Arthritis RA • • • • • • • Multilation disease(致残性疾病) Symmetric chronic polyarthropathy Incidence rate is about 1% Episode(发病) age: 40-70 F/M: 2-3/1 Small joints: hand, wrist, foot PIP，MCP（+）DIP（-） Rheumatoid Arthritis RA X-ray plain film： • • • • • • Symmetrical fusiform(梭形) soft tissue swelling Joint space: widening----narrowing Bone matrix erosion in border of articular suface Articular suface clouding，subchondral cysts Regional (periarticular) osteoporosis(骨质疏松) Amyotrophy(肌肉萎缩)，joint deformaton，fibrosum stiff，dislocation or subluxation Rheumatoid Arthritis RA MRI • synovitis early manifestation • Bone erosion pannus (血管翳) , granulation tissue(肉芽组织) • Soft tissue lesion Enhancement scan • Synovium enhancement • 5-10 minuts After Gd-DTPA injection • Dynamical enhancement MRI clinical application • Earlier diagnosis • Progress evaluation • Effect evaluation Rheumatoid Arthritis RA Rheumatoid Arthritis Rheumatoid Arthritis RA Rheumatoid Arthritis RA 平扫 增强 Bone erosion Subchondral cysts and bone erosions SE STIR SE C+ Carpal canal(腕管) syndrome ankylosing spondylitis (强直性脊柱炎) • X-ray：sacroiliitis(骶髂关节炎), small arthritis, ligament calcification “bamboo spine” • CT and MRI: similar to X-ray appearance Degenerative Osteoarthropathy • X-ray film：irregular joint space narrowing，marginal osteophytes(骨 赘),subchondral cysts, joint corpus liberum(游离体) • Spine degenerative osteoarthropathy： include disc degeneration, apophyseal joint osteoarthritis, spondylosis(关 节强直） 关节软骨变薄 关节软骨消失 关 节 软 骨 肿 胀 退行性骨关节病 退行性骨关节病 图示：颈椎退行性变
