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Diagnostic Imaging Interpretation > Arthritis > Flashcards

Arthritis Flashcards

1
Q

Degenerative Arthritis Types

A
  • Increased bone/calcifications
    • Degenerative joint disease
    • DISH
    • Synoviochondraplasia
    • Neurotrophic arthropathy
    • Erosive arthritis
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2
Q

Inflmmatory Arthritis Types

A
  • Bone erosions and soft tissue swelling
    • Rheumatoid arthritis
    • Psoriatric arthritis
    • Reactive arthritis
    • Ankylosing spondylitis
    • Osteitis condensans ilii
    • Osteitis pubis
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3
Q

Metabolic Arthritis Types

A
  • Soft tissue masses within periarticular soft tissue
    • may be calcified
  • Relative preservation of the joint space
  • May have inflammatory changes
  • May have secondary degenerative changes

Gout, CPPD, HADD

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4
Q

Infectious Arthritis Types

A
  • Soft tissue swelling
  • Joint and bone destruction
  • More agressive and progressive than other forms of arthritis

Septic arthritis

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5
Q

Arthritis Flow Chart

A
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6
Q

Axial Skeleton Arthritis

A
  • Most common
    • DJD
  • Less common
    • DISH
    • RA
    • Ankylosing spondylitis
    • Psoriatric arthritis
    • Osteitis condensans ilii
    • Osteitis pubis
  • Rare
    • Reactive arthritis
    • Infective
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7
Q

Appendicular Skeleton Arthritis

A
  • Most common
    • DJD
  • Less common
    • RA
    • Psoriatric
    • Gout
    • CPPD
    • HADD
    • Synoviochondrometaplasia
  • Rare
    • Neurotrophic
    • Erosive osteoarthritis
    • Reactive arthritis
    • Infection
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8
Q

Degenerative Arthritis

A

DJD

  • Osteoarhritis
  • Most common form of arthritis
  • Small joints of hands, larger weight bearing joints (spine, knee, hip)
  • May affect any joint
  • Often disparity between clinical and radiographic features

Clinical Features

  • >40 yrs (often >60yrs)
  • Inc males 45 yrs, primary osteoarthritis
  • Insidious onset, intermittent exacerbations
  • Aching pain, stiffness (am), swelling
  • Joint crepitus
  • Decreased motion
  • May have inflammatory episodes

Pathogenesis

  • Cartilage destruction and reactive changes in surrounding tissues
  • Cartilage metaplasia at joint margins and capsular insertion stress resulting in bone remodelling
  • Augmentation of subchondral bone structural capacity
  • Synovial fluid intrusion into subchondral bone through weakened cartilage and cortical microfractures

Pathologic and Radiographic Features

  • Cartilage destruction and reactive change in surrounding tissues
    • Loss of joint space
    • Asymetrical pattern
  • Cartilage metaplasia at joint margins and capsular insertion stress
    • Osteophytes
    • Remodeling of bone - continuation of bone not calcifications
  • Augmentation of subchondral bone structural capacity
    • Subchondral sclerosis
  • Synovial fluid intrusion into subchondral bone through weakened cartilage and cortical microfractures
    • Subchondral geodes and cysts
  • Secondary changes
    • Intraarticular loose bodies (joint mice), intraarticular deformity: joint subluxation
    • Possible joint fusion at end range
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9
Q

Kellgren-Lawrence Grading Scale

A
  • Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
  • Grade 2: definite osteophytes, definite narrowing of joint space
  • Grade 3: moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour
  • Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour
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10
Q

DJD Hip

A
  • Asymmetrical loss of joint space
  • Upward and outward migration of femoral head
  • Medial or central joint space loss less common
  • Synovial subchondral cyst-like formation (geode or Egger’s cyst)
  • Sclerosis
  • Osteophytes
  • Buttressing of medial femoral neck
  • Lack of internal rotation
  • Secondary changes
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11
Q

DJD Knee

A
  • Loss of joint space
    • Medial most common, lateral joint space, patellofemoral joint less common
  • Subchondral sclerosis
  • More pronounced on tibia
  • Osteophytes
  • Loose bodies/calcifications
  • Subluxation (genu vara)
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12
Q

DJD AC Joint

A
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13
Q

DJD 1st Metatarsal Phalangeal

A
  • Hallux rigidus
  • Sclerosis
  • Joint space loss
  • Osteophyte formation
  • Osseous bunion
  • Subluxation
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14
Q

DJD 1st Carpometacarpal Joint

A
  • Sclerosis and loss of joint space
  • Lateral subluxation
  • Also sclerosis and loss of joint space in scaphoidtrapezoid/trapezium joints
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15
Q

DJD PIPs and DIPs

A
  • Osteophytes
  • Heberden’s nodes (DIP’s)
  • Bouchard’s nodes (PIP’s)
  • Primary DJD in fingers
  • May appear more symmetrical as becomes widespread
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16
Q

DJD Cervical Spine

A

DJD in the cervical spine is a can affect any of the joints:

  • Intervertebral Discs
  • Facet Joints
  • Uncovertebral joints

Degenerative Disc Disease

  • Radiographic Features
    • ​Decreased disc height
    • Osteophytes (circumferential, anterior and posterior)
    • Endplate sclerosis
    • Intercalary bone = calcification of the anterior annulus of disc
    • Displacment (anterior, retro, laterolisthesis)

Facet Arthritis

  • Radiographic Features
    • Decreased joint space
    • Subchondral sclerosis
    • Osteophytes
    • Possible antero/retrolisthesis
    • AP projection shows sharp osteophytic projections and sclerosis through smooth articular pillar boarder
    • IVF encroachment from osteophytes
    • Facet hypertrophy
    • Asymetrical

Uncovertebral Arthritis

  • Radiographic Features
    • Osteophytes over uncinate process
    • Foraminal encroachment with possible nerve and artery interference
    • Sharpening of tip of uncinate process (early), bulbous enlargment of uncinate process (late)
    • Psuedofracture line across posterior margin of lower half of vertebral body (lateral projection)
    • Hypertrophy of uncinate process
17
Q

DJD Thoracic Spine

A

Facet Arthritis

  • Radiographic Features
    • Decreased joint space
    • Sclerosis
    • May refer to low lumbar spine and iliac crest = Maignes Syndrome

Costovertebral/costotransverse arthritis​

  • Radiographic Features
    • Lower thoracic segments
    • May simulate upper gastrointestinal disease: Roberts syndrome

Degenerative Disc Disease

  • Radiographic Features
    • Mid-low thoracic spine
    • Osteophytes (absence on left – aortic pulsations)
    • Mild disc narrowing
    • Minimal sclerosis
    • Inc kyphosis
18
Q

DJD Lumbar Spine

A

Degnerative Disc Disease

  • Radiographic Features
    • L4-L5 most common
    • Early: retrolisthesis, anterior/lateral osteophytes, vacuum phenomenon (nitrogen accumulation in fissured disc)
    • Late: claw/bridging osteophytes, decreased disc height, subluxations
    • Lateral best view for diagnosis, AP for lateral osteophytes
    • Vacumm Phenomenon = Nitrogen accumulation in fissured disc
    • Hemispherical spondylosclerosis

Facet Arthritis

  • Radiographic Features
    • L4 and L5 most common
    • Loss of joint space • Sclerosis
    • Osteophytes
    • Subluxation (esp anterolisthesis)
    • AP: decreased joint space, sclerosis
    • Lateral: sclerosis, anterolisthesis/retrolisthesis (may need flexion/extension views)
    • Oblique: decreased joint space, sclerosis, osteophytes

Degenerative Spondylolisthesis

  • Radiographic Features
    • Most common at L4
    • No pars defects
    • > 50yrs
    • Predominantly female (6:1)
    • Disc space narrowing
    • Facet sclerosis
    • Change in pedicle/facet angle
19
Q

Inflammatory Arthritis Pathogenesis

A
  • Formation of synovitis (inflammation) within joint and oedema
  • Soft tissue swelling
  • Formation of pannus (granulation tissue)
  • Destroys cartilage uniformly – symmetrical joint space loss
  • Creates erosions in bone where not protected by cartilage – marginal erosions
20
Q

Rhuematoid Arthritis

A

RA is a connective tisue disorder that affects the synovial joints within the body creating an inflmmatory repsonse, the body then attacks and breaks down these joints.

  • Selectively targets synovial tissue: joints, tendons, bursae
  • Bilateral, symmetrical, progressive
  • Other body systems may be involved: heart, lungs, blood vessels, nerves, eyes

Clinical Features

  • 20-60 yrs
  • Increased females 3:1 20-40yrs, equal >40yrs
  • Insidious onset articular pain, swelling, tenderness, stiffness (am),
  • Bilateral and symmetrical
  • Fatigue, malaise, muscle weakness, fever
  • Rheumatoid nodules (20%) elbows, knees, ankles, hands, sacrum
  • Laboratory: anaemia, inc ESR, CRP, rheumatoid factor (70%)
  • Periods of remission and exacerbation
  • Gradual progression of deformity and disability

Radiographic Features

  • Acute synovitis with oedema
    • Periarticular soft tissue swelling
  • Synovial proliferation forming pannus (vascular granulation tissue)
  • Juxtaarticular hyperaemia
    • Juxtaarticular osteoporosis
  • Pannus destruction of cartilage
    • Uniform loss of joint space
  • Pannus eroding bare area
    • Marginal erosions
  • Pannus intrusion into marrow spaces
    • Subchondral cysts
  • Secondary changes
    • Joint deformity, Joint destruction, ligamentous laxity, altered muscles
    • Fibrosis of pannus filling joint cavity - fibrous ankylosis (possibly bony ankylosis)
    • Secondary degenerative changes

Distribution

  • Wrist/Hand to MCP
  • Ankle/Feet to MTP
  • Elbow • Knee
  • Glenohumeral
  • Hip
  • Bilateral and symmetrical
21
Q

RA Wrist

A
  • Bilateral and symmetrical
  • 60% of cases have early prominence at wrist:
  • Ulnar styloid erosion
  • Carpal erosion and dislocation
22
Q

RA Hands

A
  • Bilateral and symmetrical
  • MCP erosion (rarely PIP and DIP erosion)
  • Subluxations
  • Swan neck deformity
    • Extension PIP, flexion DIP
  • Boutonnierre deformity
  • Hitchhiker’s thumb
  • Ulnar deviation
23
Q

RA Feet

A
  • MTP marginal erosions
  • Subluxations
24
Q

RA Elbow

A
  • Erosions – tapering of ends of bones
25
Q

RA Knees

A
  • Bilateral and symmetrical
  • Symmetrical loss of joint space
  • Subchondral cysts
  • Juxta-articular osteopenia
26
Q

RA Hip

A
  • Central loss of joint space
  • Most common cause of bilateral protrusio acetabulae
27
Q

RA Shoulder

A
  • Symmetrical loss of GH joint space
  • Humeral erosions
  • Subacromial bursa may be involved
  • Distal clavicle erosions
28
Q

RA Spine

A
  • Most commonly involves cervical spine
    • 50-80% of cases • Contraindication due to instability
    • Flexion cervical views
    • Erosions of dens and atlantoaxial ligament insertions
    • Facet joint erosions, subluxations (stepladder)
  • May involve thoracolumbar region
    • 5% of cases
    • Discovertebral endplate irregularities, sclerosis, loss of disc height
    • Resembles advanced DDD or infection

Radiographic Features

  • Increased ADI
  • Dens erosions
  • Endplate erosions C3-C5
  • Anterolesthesis C3 (Step ladder)
29
Q

Psoriatric Arthritis

A
  • Psoriatic arthritis (PsA) is the second most common inflammatory arthropathy, after rheumatoid arthritis diagnosis, in early arthritis clinics.
  • Most patients have established psoriasis, often for years, prior to the onset of joint pain and swelling; in addition, associated features of nail disease, dactylitis, enthesitis, spondylitis or uveitis may be present.
  • Spinal findings in up to 50% of patients with skin disease

Clinical Features

  • 20-50 yrs
  • Early: DIP/PIP swelling, redness, pain, sausage digit
  • Inc ESR, negative rheumatoid factor, 30-75% have HLA-B27 antigen
  • Pathologic features similar to RA

Radiographic Findings

  • Asymmetric nonmarginal syndesmophytes
  • Thoracolumbar most common
  • Paravertebral ossifications
  • Coarse, irregular, mid vertebral body to mid vertebral body
  • Complete/incomplete/floating
  • Atlantoaxial subluxation (increased ADI)
  • Sparing of facet joints (except cervical spine)
  • Sacroiliac joint involved in up to 50%
    • Unilateral or bilateral asymmetric sacroiliitis
  • Synovitis and oedema
    • Soft tissue swelling
  • No hyperaemia in bone
    • Normal bone density
  • Pannus eroding bare areas
    • Marginal erosions and tapered bone ends
    • Pencil in cup deformity
  • Healing periosteal response stimulated
    • Fluffy juxtaarticular periostitis
    • Mouse ears
  • Narrowed or widened joint space
  • Pannus fibrosis
    • Fibrotic and eventual bony ankylosis
    • Arthritis mutilans

Distribution

  • DIP, PIP hands and feet
    • May have ray pattern and include MCP
  • Knee
  • Sacroiliac joint
  • Thoracolumbar spine
  • Cervical spine
  • Hip
  • Shoulder
30
Q

DISH

A
  • Diffuse Idiopathic Skeletal Hyperostosis
  • Forrestier’s disease
  • Characterised by ligamentous calcification and ossification
  • Most prominent in anterior longitudinal ligament of spine
  • 12% of middle aged and elderly people

Distribution

  • Spine
    • C4-C7
    • T7-T11: majority of hyperostosis on right
    • L1-L3
    • SI Joint: ossification of ligamentous portion, sparing of synovial joint
    • Extraspinal sites
    • 30% of patients with spinal DISH
    • Most common at pelvis, patella, calcaneus, foot, elbow
    • Calcification of ligamentous/tendinous insertions – enthesial changes/enthesopathy

Clinical Features

  • 40-60 yrs
  • Broad spectrum of presentations
    • Asymptomatic – similar to DJD
    • Morning stiffness, low-grade spinal musculoskeletal pain
  • Facet joints spared: spinal movement relatively maintained despite anterior ossification
  • Increased kyphosis, decreased lordosis
  • 20% have dysphagia
  • 20% have ossification of the posterior longitudinal ligament (OPLL) leading to spinal stenosis
  • Associated with increased incidence diabetes
  • Can progress to ankylosis
  • May be complicated by carrot stick fracture
  • 90% in lower cervical spine
  • Neurological compromise - quadriplegia

Pathogenesis

  • Exaggerated response to form bone to unidentified stimuli
  • Calcification followed by ossification of ALL (arrowheads)
  • Begins midpoint of vertebral body and extends to bridge IVD space
  • Early: deep fibres of ALL uninvolved – lucency between calcification and vertebral body (arrows)
  • Late: deep fibres calcify and blurs with anterior vertebral body
  • May progress to fusion of vertebral bodies

Radiographic Features

  • Flowing calcification/ossification of ALL of at least 4 contiguous vertebral bodies
    • Dripping candle wax
    • Flame-shaped osteophytes
    • Flowing hyperostosis
  • Relative preservation of disc height
  • No osteophytic change or subchondral sclerosis
  • No ankylosis of facet joints
  • DJD can occur concurrently
  • Carrot Stick fracture when ankylosis occurs
31
Q

Synovial osteochrondromatosis

A
  • Synovial osteochrondromatosis; synoviochrondrometaplasia
  • 30-50 yrs, males 3:1
  • Knee (70%), hip, elbow, ankle, shoulder, wrist
  • Insidious onset of mild pain, intermittent swelling, decreased motion, crepitus
  • Acute exacerbation of pain, swelling, joint locking

May be primary or secondary to DJD; may promote DJD

Pathogenesis

  • Synovial tissue undergoes metaplastic transformation
    • Produce foci of cartilage
    • May calcify/ossify

Radiographic Features

  • Multiple loose bodies, 1-20mm
  • Rare degeneration into a chondrosarcoma
32
Q

Neuropathic Arthropathy

A
  • Loss of joint proprioception and pain sensation
  • Diabetes, syphilis, alcoholism, syringomyelia
  • Neurologic signs: altered gait, loss of deep reflexes, pain insensitivity
  • Joint:
    • Painless instability, enlargement, crepitus

Distribution

  • Hypertrophic
    • Lumbar spine
    • Knee
    • Hip
    • Foot
  • Atrophic
    • Shoulder
    • Elbow
    • Wrist

Pathogenesis

  • Lack of joint sensation and proprioception
  • Ineffective protective neurologic mechanisms
  • Premature and excessive traumatic degenerative changes
  • Hypertrophic (increased bone) or atrophic (decreased bone) changes

Radiographic Features

  • Hypertrophic Six D’s
    • Distended joint
    • Density increase
    • Debris production
    • Dislocation
    • Disorganisation
    • Destruction
  • Atrophic
    • May follow hypertrophic or occur independently
    • Resorbed articular surface
    • Tapered bone ends: licked candy stick
33
Q

Erosive Arthritis

A
  • Inflammatory variant of DJD
  • 40-60 yrs, females 12:1
  • Symmetric, episodic and acute inflammation of DIPs, PIPs and 1st CMC joints in hands
  • 15% develop rheumatoid arthritis
  • Nonuniform joint space loss, osteophytes, sclerosis
  • Central articular erosions on distal joint surface (gullwings), at least 2 on separate interphalangeal joints; periostitis; ankylosis
34
Q

Ankylosing Spondylitis

A
  • Chronic inflammatory disorder of the spine
  • Bony ankylosis (fusion)
  • Ligamentous calcification
  • Enthesopathy
  • Disorder of ligament/tendon attachments to bone
  • Unknown aetiology

Clinical Features

  • 15-35 yrs, males 4-15:1
  • Initial diagnosis hard due to non-specific symptoms
  • Lumbosacral aching and stiffness, into buttocks and thighs, variable intensity and distribution (>3 months)
  • Pain maximal am and om, generally eases with activity
  • Eye, vascular, pulmonary, gastrointestinal and genitourinary symptoms possible
  • Increased ESR, HLA-B27 in 90%, seronegative
  • Diagnostic criteria
    • Sacroiliitis on radiography (usually bilarteral)
    • At least 1 of the following:
      • low back pain and stiffness for >3 months, improving with activity
      • limited movement of the lumbar spine
      • reduced chest expansion

Pathogenesis

  • Synovial joints
    • Synovial inflammation producing pannus formation
    • Subchondral erosion
    • Fibrosis and interarticular osseous ankylosis
  • Entheses
    • Inflammation (bone erosion at ligament/tendon insertion)
    • Repair of erosion (new bone projects away from surface in spurlike bone spicules

Radiographic Features

  • Sacroiliitis
    • Hallmark of AS: symmetrical, bilateral sacroiliitis

Grade 1 = Pseudo widening of joint space

  • Loss of articular cortical bone form subchondral osteoporosis
  • Suspicious changes, not definitive

Grade 2 = Erosive and sclerotic changes

  • Irregular joint margin, rosary bead sign
  • Reactive sclerosis, especially in ilium
  • Small localised areas of erosions or sclerosis; normal joint space width

Grade 3 = Erosive and sclerotic changes

  • Irregular joint margin, rosary bead sign
  • Reactive sclerosis, especially ilium
  • Definite changes of erosions, sclerosis, narrowing or partial fusion

Grade 4 = Ankylosis

  • Takes 7-23 yrs from onset
  • Ghost sign: anterior joint cortex visible through fusion
  • Star sign: triangular ossification of fused upper joint space
  • Ankylosing Spondylitis

Spine

  • 60% initiate at the thoracolumbar junction
  • Discovertebral junction (entheses)
  • Remanus lesion: erosion on corner of vertebral body
  • Vertebral body squaring
  • Shiny corner sign: reactive sclerosis
  • Marginal syndesmophytes: calcification of outer disc annulus
  • Bamboo/Poker spine: ankylosis b symmetrical marginal syndesmophytes
  • Vertebral osteoporosis
  • Eventual ossification of disc spaces
  • May get pathological carrot stick fracture
  • Dagger sign: ossification of interspinous and supraspinous ligaments
  • Erosions, sclerosis, loss of joint space of facet joints
  • Trolley track sign: ossification of joint capsule, ligamentum flavum and interspinous ligaments on AP

Peripheral Joints

  • Occurs in 50% of cases
  • Hips, shoulders, heels most commonly
  • Bilateral, symmetric
  • Synovial and enthesial changes
  • Ligament calcification

Diagnostic Imaging Interpretation (9 decks)

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