Download Lisfranc Charcot Joint.

Imaging approach to joint
diseases
Werner Harmse
July 2010
Arthritis
• Indicates an abnormality of the joint as the
result of a
– degenerative,
– inflammatory,
– infectious, or
– metabolic process.
• Affects articular surfaces on both sides of
joint
• Results in joint space narrowing
Classification of arthritides
•
Degenerative
– Osteoarthritis: Primary, Secondary
•
Inflammatory
– Rheumatoid arthritis
– Seronegative spondyloarthropathies: AS, Reiter’s, Psoriasis, Enteropathic
arthropathies
– Connective tissue disease: Scleroderma, SLE, Dermatomyositis
– Erosive OA
•
Metabolic
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Crystal deposition: Gout, CPPD, etc
Other deposition: Hemochromatosis, Wilson’s, Alkaptonuria, Amyloidosis
Endocrine: Acromegaly, Hyper-parathyroidism
Haemophilia
Infective
– Pyogenic
– TB
– others
Imaging of joint disease
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X-ray
Ultrasound
MRI
CT
Arthrography
Nuclear medicine
Ultrasound
• Multiplanar real time soft tissue imaging
• Helpful in diagnosing joint effusions
especially in septic arthritis, as well as
other fluid collections
• Also used in evaluating for tendonitis and
tendon rupture
CT
• Computed tomography (CT) is effective in evaluating
degenerative and inflammatory changes of various joints
• Findings are similar to plain film radiography, only being
able to demonstrate it more clearly
• Multiplanar reformations can be done with MDCT
• Valuable in planning of surgery
• In the assessment of spinal stenosis secondary to
degenerative changes, CT examination may also be
performed after myelography especially if MRI is
contraindicated
MRI
• Excellent contrast between soft tissues and bone.
• Articular cartilage, fibrocartilage, cortex, and spongy bone can be
distinguished
• excellent for demonstrating synovial abnormalities in rheumatoid
arthritis.
• Because synovitis is often accompanied by joint effusion, this too
can be effectively demonstrated by MRI
• Occasionally, MRI may provide some additional information in
osteoarthritis and hemophilic arthropathy
• Most important role is in evaluation of the spine.
– Demonstrate hypertrophy of the ligamentum flavum or the vertebral
facets
– Grade foraminal and spinal stenosis
– Evaluate degenerative and inflammatory disc disease
• Also very valuable in evaluating joint related injuries
Nuclear medicine
• Used to evaluate the pattern of disease activity and
monitor response
– how many joints are affected,
– which joints are the most affected,
– are there unsuspected sites with disease involvement)
• Investigate sites of possible infection
• A negative bone scan is reassuring and confirms the
absence of active arthritis, while a positive bone scan
can demonstrate disease presence and activity before it
becomes apparent on a radiograph.
• Bone scans have been used to predict erosions in
rheumatoid disease and has also been shown to be a
good predictor of disease progression in osteoarthritis
X-rays: what to look for
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•
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Alignment
Bone
Cartilage
Distribution
Soft tissues
X-rays: what to look for
• Alignment
– Subluxation and/or dislocation
• Common in RA and SLE
• Bone
– Osteoporosis
• Periarticular osteoporosis in RA
– Erosions
• Aggressive with no sclerotis margin: RA, psoriasis
• Non-aggressive (fine sclerotic border): gout, usually overhanging
• Location: Marginal – inflammatory; Central – Erosive OA (gull wing)
– Bone production
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Osteophytes: at sites of cartilage loss and degeneration typical in OA
Subchondral sclerosis: typical of OA
Ankylosis: seronegative inflammatory arthropathies eg AS
Periosteal reaction: psoriasis, Reiter’s (distinguish from RA)
– Subchondral cysts
• OA and CPPD, also RA and AVN
X-rays: what to look for
• Cartilage
– Joint space
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Normal joint space: Gout; or any early arthropathy
Eccentric narrowing: OA
Uniform narrowing: All others
Wide joint space: early inflammatory process
– Calcification: CPPD
X-rays: what to look for
• Distribution
– Single joint: Infective; crystal deposition; post
traumatic
– Hands and feet
• proximal: RA, CPPD, SLE
• Distal: Reiter’s(feet), psoriasis(hands), scleroderma
• Symmetrical: RA, SLE
– SI joints
• Asymmetrical: Reiter’s, Psoriasis
• Symmetrical: AS, Enteropathic, Reiter’s, Psoriasis
• Also DJD, infection, gout
X-rays: what to look for
• Soft tissues
– Swelling
• Symmetrical around joint: all inflammatory, but most common
in RA
• Assymmetrical: most commonly d.t. osteophytes rather than
true swelling in OA
• Lumpy, bumpy: gout (tophus)
• Entire digit: Psoriasis, Reiter’s
– Calcification
• Soft tissue: Gout
• Cartilage: CPPD
• Subcutaneous: Scleroderma, dermatomyositis
X-rays
• First important decision to make is if
arthritis is present or not
– Almost all arthritides lead to joint space
narrowing, except gout
• Then decide if it falls in the broader
degenerative or inflammatory group as
most a fall in one of these two.
Arthritis or not
DJD
AVN
Inflammatory vs Degenerative
• Joint inflammation is characterized by
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bone erosions (marginal)
osteopenia
soft-tissue swelling
uniform joint space loss
• Degenerative cause of joint space narrowing is
characterized by
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osteophytes
bone sclerosis
subchondral cysts or geodes
asymmetric joint space narrowing
lack of inflammatory features such as bone erosions
Inflammatory
Inflammatory
• Evaluate the number of joints involved
– If only a single joint is involved consider infective
arthritis
• Features of any inflammatory arthritis
• But erosions often not acutely present
• Joint space may be initially widened due to effusion
– Seen easily with ultrasound
• Widening also seen in more indolent infections i.e. TB and
fungal
• Phemister triad in TB arthritis
– periarticular osteoporosis,
– peripherally located osseous erosions,
– gradual diminution of the joint space
Progression of TB of the knee over 1 year
Inflammatory
• If multiple joints are involved consider a
systemic arthritis
• Now evaluate hands and feet
– If proximal with no bony proliferation consider
rheumatoid arthritis
– If distal with features of bony proliferation
consider seronegative spodyloarthropathies
eg. AS, Reiter’s, psoriasis and enteropathic
arthropathies
Rheumatoid arthritis
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Women aged 30 – 60
Rheumatoid factor
General features of inflammatory arthritis
Additionally joint subluxation and subchondral
cysts may also be present
• In the hands, target sites include the MCP, PIP,
midcarpal, radiocarpal, and distal radioulnar
joints, with predilection for the ulnar styloid
process
• Involvement is usually bilateral and fairly
symmetric
Rheumatoid arthritis
• Ulnar deviation occurs at the MCP joints.
• Swan neck and Boutonniere deformities.
• In the feet, target sites include the MTP, PIP (incl 1st IP)
and intertarsal joints
• Important to closely evaluate the lateral aspect of the
fifth metatarsal head – often 1st site of bony erosion
• Also affects tendon sheaths and bursae like the
retrocalcaneal bursa:
– Loss of the normal radiolucent triangle between the
posterosuperior margin of the calcaneus and the adjacent
Achilles tendon suggests the presence of bursal fluid, with
subjacent calcaneal erosions indicating inflammation
Rheumatoid arthritis
• Other peripheral joints also affected
include the knees, the hips, the sacroiliac
and glenohumeral joints.
• Spinal involvement affects the C1-C2
articulation
– the odontoid process may be eroded
– and the anterior atlantodens interval may be
abnormally widened (3 mm in adults),
especially with neck flexion
Small erosions at the 5th
MTP joint
a) Normal shoulder X-rays
in patient with rheumatoid
arthritis. (b) Ultrasound of
same patient demonstrates
1.5 cm erosion.
Synovial enhancement with GdDTPA. (a) Three-dimensional
gradient-echo image of a wrist
following IV Gd-DTPA shows
extensive enhancing synovitis and
distention of the synovial cavity. (b)
Repeat MRI with Gd-DTPA following
3 months of disease-modifying
antirheumatic drug (DMARD) therapy
shows marked reduction in the
amount of enhancing tissue but
similar distention of the synovial
cavity (note the dorsally displaced
extensor tendons).
Seronegative
spondyloarhtropathies
• Psoriasis, AS, Reiter’s and enteropathic
arthritides.
• HLA B27 usually positive
• Hands and feet show more distal involvement.
• Osseous attachment sites of ligaments and
tendons are more involved than in RA.
• Entheseal involvement leads to increased
density and irregular bone proliferation
(perisotitis).
• Ankylosis more common
Psoriatic arthritis
• Hallmarks
– signs of inflammatory arthritis combined with
– periostitis, enthesitis, and a distal joint distribution in the
extremities
• Findings may be bilateral or unilateral and symmetric or
assymmetric
• Hands more than feet
• Involvement of several joints in a single digit, with softtissue swelling, produces what appears clinically as a
“sausage digit”
• Aggressive erosions leading to “Pencil in cup”
appearance and resorption of terminal tufts
• Fuzzy/fluffy bony proliferation and periostitis
• Ivory phalanx
• Mouse ears: Bone production adjacent to erosions
• SI joint involvement usually bilateral – may be
symmetrical or not
Psoriatic arthritis. Dorsovolar
radiograph of the hand of a 57year-old woman shows the
typical presentation of psoriatic
polyarthritis. The “pencil-in-cup”
deformity in the interphalangeal
joint of the thumb is
characteristic of this form of
psoriasis.
Psoriatic Arthritis. A. Cartilage loss at the PIP joints of
the 3rd, 4th, and 5th digits in this hand is apparent, with
erosions noted most prominently in the 4th digit (arrow).
These erosions are not sharply demarcated but are
covered with fluffy new bone. Note also the periostitis
along the shafts of each of the proximal phalanges. B.
Advanced psoriatic arthritis. Fusion across the PIP joints
of the 2nd to 5th digits. Several of the DIP joints are also
ankylosed. Severe joint space narrowing at the
metacarpophalangeal joints is noted.
Reactive arthritis (Reiter’s)
• Sterile inflammatory arthritis following an
infection at a different site
• Young men aged 25-35
• Similar to psoriasis in inflammation,
proliferation, periostitis and ethesitis
• Feet more than hands – particularly MTP
joints and heels
• Axial skeleton may also be affected
A CT scan through the SI joints shows unilateral SI joint sclerosis and
erosions (arrows), typical for psoriatic arthritis or Reiter disease.
Ankylosing spondylitis
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Idiopathic inflammatory arthritis
96% are HLA B27+, Men aged 20 – 40
More commonly affects axial skeleton
Spine involvement is characterized
– by osteitis, syndesmophyte formation, facet
inflammation, and eventual facet joint and vertebral
body fusion.
• Sacroiliac joint disease is bilateral and
symmetric.
• Other peripheral joints, such as the hips and
glenohumeral joints, may be involved.
Ankylosing spondylitis
• SI joints show early erosions best seen at
inferior aspects
• Sclerosis follows with eventual ankylosis
• Spine involvement usually centered at
thoracolumbar or lumbrosacral junction
• Osteitis at anterior discovertebral junctions with
erosions, sclerosis “shiny corner” and squaring
of vertebral bodies
• Syndesmophytes form with eventual fusion of
the vertebral bodies (bamboo spine).
• Also interspinous ligament calcification
Enteropathic arthritis
• Occur with Crohn’s disease, Ulcerative colitis and
Whipple disease
• Spine and sacroiliac and peripheral joints may be
affected.
• Spine: squaring of the vertebral bodies and the formation
of syndesmophytes are common features.
• Sacroiliitis, usually bilateral and symmetric
– radiographically indistinguishable from ankylosing spondylitis
• In addition, patients may also exhibit a peripheral
arthritis, the activity of which generally approximates the
activity of the bowel disease.
Degenerative
• Joint space narrowing, Osteophyte
formation, Bone sclerosis and
Subchondral cysts are seen in the
absence of inflammatory changes
• Consider age, joints involved and x-ray
appearance to distinguish between
– Typical osteoarthritis
– Atypical osteoarthritis
Typical osteoarthritis
• Result of articular cartilage damage and wear and tear
from repetitive microtrauma that occurs throughout life,
although genetic, hereditary, nutritional, metabolic, preexisting articular disease, and body habitus factors may
contribute in some cases. Usually after 4th or 5th decade
• Typical sites
– AC joints – small osteophytes from 4th decade
– 1st CMC joint, IP joints of hands, MCP to a lesser degree, 1st
MTP
(joint space narrowing may be symmetrical in hands, unlike larger
joints)
– Knee – medial joint space as well as patellofemoral. Often
formation of osteochondral bodies
– Hip – superior migration
(A) Sagittal PD of pt with OA of the
right knee shows involvement of the
femoropatellar compartment. Note joint
space narrowing, subchondral cyst
(arrow), and osteophytes (open
arrows). (B) Coronal T2 fatsat image
shows complete destruction of articular
cartilage of the lateral joint
compartment (arrows), subchondral
edema (open arrows), and tear of the
lateral meniscus (curved arrow). (C)
Sagittal T2-fatsat in another patient
shows osteoarthritis of the knee
complicated by multiple osteochondral
bodies (arrows).
Atypical osteoarthritis
• Osteoarthritis, but
– involved joint is not one commonly affected by osteoarthritis,
– the severity of the findings are excessive or unusual, or
– the age of the patient is unusual,
• then other less common causes for cartilage damage
and osteoarthritis should be considered.
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Trauma,
Crystal deposition disease,
Neuropathic joint,
Hemophilia.
Other possible causes include congenital and developmental
anomalies, such as dysplasia, that disrupt normal biomechanics.
Atypical osteoarthritis
• Trauma (injury or repetitive stresses)
– most common cause,
– usually relatively young patient, with marked
asymmetric involvement
• CPPD
– Atypical in joint distribution, excessive subchondral
cyst formation and calcium deposition
(chondrocalcinosis)
– Knee most commonly affected
– Radiocarpal and 2nd & 3rd MCP joints
– Chondrocalcinosis of triangular fibrocartilage and
menisci (also pubic symphysis and hip labrum)
Atypical osteoarthritis
• Haemochromatosis
– Also chondrocalcinosis, with overlap of CPPD findings
– More extensive MCP involvement
– Metacarpal radial hooklike or drooping osteophytes are more
common
• Neuropathic joint
– Late disease is characteristic with severe joint destruction
• sclerosis, fragmentation, subluxation, heterotopic new bone
formation
– Early disease is similar to OA but distribution is characteristic
• Midfoot and hips in DM
• Bilateral shoulder joints in a syrinx or spinal tumour
• Hips in tertiary syphilis
Lisfranc Charcot Joint.
Dislocation of the second
and third metatarsals along
with joint destruction and
large amounts of
heterotopic new bone are
present in the foot of this
diabetic patient. These
findings are classic for a
Charcot joint
Atypical osteoarthritis
• Haemophilia
– Repetitive intra-articular haemorrhage may cause cartilage
damage
– Young patients
– Osteophytes, sclerosis and subchondral cyst, but also erosions
– Joint space narrowing is more symmetrical
– Epiphyseal overgrowth
– Knees – squaring of patella and widening of the intercondylar
notch
– Repeated hemorrhage may produce a large expansile and
destructive abnormality known as hemophiliac pseudotumor,
most commonly involving the femur and pelvis
– overlap between of hemophilia and juvenile chronic arthritis;
however, knee, ankle, and elbow involvement are more common
in hemophilia.
• Remember: Any cause of arthritis can eventually end in
secondary or atypical osteoarthritis
Advanced haemophilic arthropathy in the elbow
Others
• Juvenile Idiopathic Arthritis (previously known as
JRA)
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Soft tissue swelling and osteopenia
Delayed joint space narrowing and erosive changes
Possible periostitis and later joint fusion
Osseous overgrowth of the epiphyses due to chronic
hyperemia and
– Bone undergrowth due to premature growth plate
fusion.
– Three sub types:
• Oligo articular (Prev. pauci articular)
• Poly articular
• Systemic disease
JIA
• Oligo-articular
– Affects 4 or fewer joints in the first 6 months of
illness.
– Often ANA positive
– 50% of JIA cases.
– Usually involves the knees, ankles, and
elbows but smaller joints such as the fingers
and toes may also be affected. The hip is not
affected unlike polyarticular JRA.
– Usually asymmetrical
JIA
• Poly-articular
– Affecting 5 or more joints in the first 6 months of disease.
– More common in small girls to that of boys.
– Usually the smaller joints are affected, such as the fingers and
hands, although weight-bearing joints such as the knees, hips,
and ankles may also be affected. Can include neck and jaw as
well.
– Usually symmetrical
• Systemic JIA
– Characterized by arthritis fever and rash
– Affects males and females equally.
– Systemic JIA may have internal organ involvement and lead to
serositis
11-year-old girl with juvenile idiopathic arthritis.
Anteroposterior radiograph of both knees shows bones
are osteopenic. Overgrowth of medial femoral condyles
and widened intercondylar notch are both recognized
features of juvenile idiopathic arthritis.
8-year-old girl with juvenile idiopathic arthritis. Right hand
reveals severe changes: marked osteopenia, erosions (arrows),
ankylosis of carpal bones and some interphalangeal joints, and
subluxation of proximal interphalangeal joints of index and little
fingers.
Others
• Erosive osteoarthritis
– Distribution similar to OA in hands (IP joints)
– Osteophytes
– Central gullwing erosions
– May end in ankylosis
• SLE
– Joint space narrowing and erosions are rare
– Commonly reducible MCP subluxations
Central gullwing
erosions in erosive
osteoarhtritis
Systemic lupus erythematosus. (A) Typical appearance of the thumb in
a 43-year-old woman with systemic lupus erythematosus. Note
subluxations in the first carpometacarpal and metacarpophalangeal joints
without articular erosions. (B) In anther patient, a 32-year-old woman with
SLE, the oblique radiograph of her left hand shows dislocation at the first
carpometacarpal joint (arrow) and subluxations in the
metacarpophalangeal joints of the index and middle fingers associated
with swan-neck deformities (open arrows).
Others
• Gout
– Joint space narrowing only occurs late
– Characteristic erosions – Punched out, overhanging
edges, sclerotic margins, near joint but not specifically
marginal
– Marked soft tissue swelling due to tophi
– Most common in 1st MTP
– Also IP joints and tarsal bones
– Soft tissue swelling from bursitis as in olecranon
bursitis
– Radiographic findings may at times be confusing and
appear quite unusual, thus it may be helpful to
remember, “When in doubt, think gout.”
Other diseases involving joints
• Synovial osteochondromatosis
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–
–
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caused by a metaplasia of the synovium
results in deposition of foci of cartilage in the joint
mostly deposits calcify and are seen on X-ray
knee, hip, and elbow
• Pigmented villonodular synovitis
– rare chronic inflammatory process of the synovium that causes synovial
proliferation
– swollen joint with lobular masses of synovium occurs and causes pain
and joint destruction
– rarely calcifies
– Joints with PVNS look radiographically identical to noncalcified synovial
osteochondromatosis
– Erosion in 50%: cyst-like defects of varying sizes are present which
show sclerotic margins.
– PVNS has a characteristic appearance on MR, with low-signal
hemosiderin seen lining the synovium on both T1WIs and T2WIs
Synovial
Osteochondromatosis.
Anteroposterior view of the
hip in this patient with left
hip pain shows multiple
calcified loose bodies in
the hip joint, which is
virtually diagnostic of
synovial
osteochondromatosis.
Pigmented Villonodular Synovitis (PVNS). Sagittal T1W (A) and fast spinecho T2W (B) images of an ankle with PVNS show a soft tissue mass
emanating from the ankle joint, which is low signal on both sequences and
has very low signal hemosiderin lining parts of the synovium, which is
characteristic for PVNS.
Symmetric
Erosions
Soft tissue swelling
Joint space narrowing
Inflammatory
1 joint
> 1 joint
Degenerative
Typical OA
Infection
Rheumatoid
Arthritis
Asymmetric
Osteophytes
Sclerosis
Unusual
Distribution
Severity
Age
Atypical OA
Seronegative
spondyloarthropathies
Trauma
Crystal deposition
Neuropathic
Haemophilia
Others: JRA, Gout, SLE, erosive OA,PVNS, Synovial osteochondromatosis
References
1. Jacobson et al. Radiographic evaluation of
arthritis: Inflammatory conditions. Radiology
2008; 248:378–389
2. Jacobson et al. Radiographic evaluation of
arthritis: Degenerative Joint Disease and
Variations. Radiology 2008; 248:737–747
3. Weisleder. Primer of Diagnostic Radiology
4. Brandt & Helms. Fundamentals of Diagnostic
Radiology
5. Greenspan. Orthopaedic Imaging: A ractical
approach. 4th Ed