radiology of joint disease...radiology of joint disease my practical approach prevalence/hx joint...

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

page 1 of 16Radiology of Joint DiseaseMy Practical Approach

© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info

Radiology of Joint Disease My Practical Approach

Prevalence/HxJoint AnatomyOrdered List

OA

Phytes

EOA

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Ken Schreibman, PhD/MD, FACRUniversity of Wisconsin - MadisonProfessor, Musculoskeletal Section9 Faculty, 5 Fellows

My Practical Approach to ArthritisRadiology of Joint Disease is HardIt took me 10 years to begin to understand itAnother 10 years to figure out how to teach itMay not be possible to teach in one hour

Ordered list of 5 most common arthropathiesCan download PowerPoints & handouts

for this and all my lectures




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FeaturesNon-uniform joint

space narrowingOsteophytes!

Gullwing Erosions

Uniform narrowingMarginal Erosions!

Sharp Erosions withoverhanging edges

Resembles OAChondrocalcinosis

Pencil-in-CupSausage Digit

My Ordered ListIs it…

OA?

EOA?

RA?

Gout?

CPPD?

Psoriatic?

DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base

DIPs (Symmetric)Women > 50yo

MCPs, Carpus, C1-2Big Joints (Symmetric)

RandomFavors Toes (1st)

Unusual distribution for OAFavors Patella-Femoral

Hands, Feet, SpineSI Joints (Asymmetric)

Topics




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Prevalence of ArthritisArthritis is one of the

most prevalent chronic health problems

The nation’s leading cause of disabilityCosts US economy

$128 billion annually

US Adult Population

≈ 225 Million

20%(46M)

Diagnosedwith Arthritis

Adults >65 yo50% have Arthritis

2005(most recent

available data)arthritis.org




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>100 conditions affect joints*RA:1.3M‡=3% all arthritisDecreased from 2.1M (5%) 1995

Gout:3M†=7% all arthritis Increased from 2.1M (5%) 1995

CPPD:?No prevalence data

Seronegative Spondylarthritides:up to 2.4M‡ (5%)

Prevalence of ArthritisPrevalence of Types of Arthritis

*arthritis.org

2005(most recent

available data)

46 MillionDiagnosed

with Arthritis…

OA = 27M†

(59% of allArthritis)

and those of uswho look at joints

suspect OA ismore like

> 80%†ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35‡ARTHRITIS&RHEUMATISM,2008,v58,n1,p15-25

RA

Gout

CPPD

SNSA




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Arthritis is Ancient: Gout“king of diseases and disease of kings”

2600BC (Egypt): Described in the great toe400BC (Greece): Hippocrates wrote about it1599 Shakespeare

(Henry IV, Part 2) Falstaff:“A pox of this gout! or a gout of this pox! for the one or the other plays the rogue with my great toe.”

1799 James Gillray(British caricaturist):

wikipedia.org© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info



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4500BC (Tennessee)Native American skeletal

1661JacobJordaens(Flemish Baroquepainter)

The Familyof the Artist

Arthritis is Ancient: RA

wikipedia.org

MCPs

PIPs

Rheumatoid Nodules

wikipedia.org

http://www.schreibman.info/



http://www.arthritis.org/media/chapters/ind/documents/prevalence fact sheet.pdf


http://www.arthritis.org/media/chapters/ind/documents/prevalence fact sheet.pdf

http://www.rheumatology.org/about/newsroom/prevalence/prevalence-two.pdf

http://www.rheumatology.org/about/newsroom/prevalence/prevalence-one.pdf


http://en.wikipedia.org/wiki/Gout


http://en.wikipedia.org/wiki/Rheumatoid_arthritis

http://en.wikipedia.org/wiki/Jacob_Jordaens






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150,000,000BC (late Jurassic period)Osteophytes have been found in fossils of:Toe of Allosaurus fragilis*TMJ of Pliosaurus brachyspondylus**

Arthritis is Ancient: OA

*wikipedia.org

wikipedia.org

**Palaeontology 2012 May 16

Harvard Museum of Comparative Zoology




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Old Diseases = Old Names (misnomers)“Osteoarthritis”Osteo=“Bone”… but it’s not disease of boneitis=“inflamed”… but it’s not inflammatory disease

“Rheumatoid” Arthritis“resembles Rheumatic Fever”…

but it has nothing to do with rheumatic fever (not caused by Streptococcus pyogenes)

“Gout” vs “Pseudo-gout”Radiographically, these look nothing like each other

CDC Public Health Image Library




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Old Diseases = Old Names (misnomers)“Reiter’s Disease”1942:HansConradJuliusReiterInflammatory arthritisEye inflammation (conjunctivitis or uveitis)Urethritis in men or cervicitis in womanReiter was a Nazi

Head of the Reich Health OfficeWidely considered expert on vaccinesImplicated in experimenting with typhus on

Buchenwald concentration camp internees

1945: Interrogated in Nuremberg; released 19472009: Disease renamed “Reactive Arthritis”Seminars in Arthritis and Rheumatism

2003, Feb, vol 32, No 4 © 2015 Ken L Schreibman, PhD/MDwww.schreibman.info



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BONE

White Line =Cortical Bone

Gray Fill =Trabecular Bone

(Cancellus)

BONE

BONE

BONE

BONE

PowerPoint Model: BonePowerPoint Model: JointJoint: 2 bones meetBones flair out at endsMetaphysis

Can see on radiographs:Trabecular boneCortical boneJoint space between bones

Black rectangle = Radiograph




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PowerPoint Model: Joint

R,S 14yoM

BONE

BONE Cortex

Trabecular

JointSpace

UnfusedGrowthPlates

Knee RadiographAP view




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PowerPoint Model: JointStuff inside joints we

can’t see on radiographs:CartilageArticularHyaline [Gr] “resembling glass”

SynoviumNormally very thin (1-3 cells)

Synovial fluidNormally just wetting amount

BONE

BONE

This is too much fluid (i.e. Effusion)


http://en.wikipedia.org/wiki/Osteoarthritis

http://upload.wikimedia.org/wikipedia/commons/4/4e/Allosaurus_fragilis_skeleton_in_Bergamo.jpg

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-4983.2012.01151.x/pdf

http://www.oceansofkansas.com/kronosar.html


http://phil.cdc.gov/phil/quicksearch.asp


http://www.sciencedirect.com/science/journal/00490172/32/4









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Joint Disease = Cartilage DamageImaging joint disease =

“seeing cartilage”RadiographsCan’t see cartilage directlyWe see it indirectly by

looking at joint space widthArthrogram-CTInject contrast into joint,

then do a CT scanMultiplanar reformat

BONE

BONE




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Arthrogram - CTBONE

BONE

R,S 14yoM


Knee Arthrogram-CTCoronal Reformat

Cortex

Intra-ArticularContrast

Trabecular

Cartilage is dark tissue between white cortex and white contrast

Kind of like an Oreo:Dark Cookie=CartilageLight Cream=Contrast




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Joint Disease = Cartilage DamageImaging joint disease =

“seeing cartilage”RadiographsWe see it indirectly by

looking at joint space widthArthrogram-CTInject contrast into joint MRI!Can see cartilage directlyWithout injecting contrast

BONE

BONE




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MRIBONE

BONE

R,S 14yoM

Knee MRI CoronalPD fat-suppressed

Knee MRI CoronalCartilage Sensitive

Articular (hyaline) cartilage: light gray

Meniscal (fibro-cartilage): black




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5 Most Common ArthropathiesIs it…

OA?

EOA?

RA?

Gout?

CPPD?

Psoriatic?

Features Distribution




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Osteoarthritis (OA)THE most common

joint diseaseAt least 60% of ALL

arthritis is OA…In my experience it’s

more like 80-90%Primary OAEffects specific joints

Secondary OACan effect any joint

“Osteoarthrosis”

46 MillionDiagnosed

with Arthritis…

OA = 27M†

(59% of allArthritis)

2005(most recent

available data)†ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35

and those of uswho look at joints

suspect OA ismore like

> 80%







http://www.rheumatology.org/about/newsroom/prevalence/prevalence-two.pdf






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OA = Disease of Hyaline CartilageArticular hyaline cartilage

is the diseased tissueLoss of hyaline cartilageProximal&Distal articular surfaces

Non-Uniforme.g. Knee: Medial > Lateral

Progressive – worsens with time

Non-Uniform joint narrowing Asymmetrice.g. Dominant hand > other hand

BONE

to OA

BONE




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OA: Knees

M,G 46yoM

Knee RadiographRIGHT - AP view

Knee RadiographLEFT- AP view

Features OANon-Uniform joint narrowingMedial compartment > Lateral

Asymmetric (here L > R)




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OA = Bone Producing DiseaseIn OA, joints make boneSub-cortical sclerosisArticular cortex thickensStress response?

OSTEOPHYTES!Bony spurs from jointsCan occur either after the

joint is narrowed…or before the joint narrows

to OA




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Osteophytes: Knees

P,C 67yoF


Knee RadiographLateral view

MedialCompartment

LateralCompartment Patella-

FemoralCompartment




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Let’s Talk about “Phyte Club”Suffix phyte: “abnormal growth”3 Types of phytes:Osteophytes

@ Joints

Enthesophytes@ Ligament/Tendon

insertions

Syndesmophytes@ Disks (Annulus Fibrosis)

doddleme.com© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info



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EnthesophytesEnthesophytes are… nothingBone spurs at ligament/tendon insertionsNot osteophytes (which occur at joints)Not pathologyCommon in calcaneus “Heel spurs”Not plantar fasciitis

PHYTECLUB

L,E 62yoF@ plantar fascia

@ Achilles tendon insertion






http://news.doddleme.com/news-room/fight-club-gets-a-sequel-this-time-as-graphic-novel/







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OsteophytesOccur at Joints in DJD

(Degenerative Joint Disease)Extend from joint edges

Occur at Disks in DDD (Degenerative Disk Disease)Extend from vertebral

bodies corners In DDD disk bulges outwardOsteophytes extend out

around bulging disk

Extend horizontallyTypically extend anteriorly

Body

Body

Nucleus

Body

Body

NucleusAnnulus

PowerPoint Model: Spine

PHYTECLUB




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Spine: Osteophytes Horizontal

Body

Body


D,R 66yoM

Lumbar SpineLateral view

PHYTECLUB

L3

L4

L5

S1




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Osteophytes vs SyndesmophytesWhile OsteophytesExtend horizontally from

corners of vertebral body

SyndesmophytesExtend vertically along

Annulus FibrosusThinCover multiple levelsCervicalThoracicLumbar

Body

Body

NucleusAnnulus


PHYTECLUB




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Syndesmophytes Vertical

Body

Body

Nucleus

PHYTECLUB

W,D 52yoM

Thoracic SpineLateral view Extend vertically

along Annulus Fibrosus

Thin Cover multiple

levelsCervicalThoracicLumbar





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Syndesmophytes Vertical PHYTECLUB

W,D 52yoM

Royal Botanical GardenKandy, Sri Lanka 2005


Lumbar SpineAP view

FusedSI

Joints

“Bamboo Spine”

AnkylosingSpondylitis




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OA?













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Distribution: OASpineLower

Cervical SpineC5-C6

Lower Lumbar SpineL4-L5

Andreas Vesalius: “De humani corporis fabrica”1543 p.163

J,W 48yoF

C1

C2

C3

C4

C5

C6

C7

Cervical SpineLateral view

F,D 34yoF

L5

L4

L3

L2

L1


“VacuumDisk”




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Distribution: OALower ExtremityCommon in the HipCommon in the KneeUncommon in the AnkleNot simply due to weightbearing

Common 1st MTP Joint


D,M 52yoF

FootAP view

FootLateral view

O-phyte “Hallux Limitus”“Hallux Rigidus”aka “OA”

Non-uniform narrowingOsteophytes




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PelvisAP view

OA: HipsNon-uniform narrowingHip: Superior weightbearing surface

PowerPoint Model: Hip

Acetabulum

FemoralHead

to OA

OAK,K 44yoM

Symptomaticside

Asymptomaticside

Asymmetry: to OA

Normal width

NarrowedSuperiorly




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Asymmetry ProgressiveWorsens over time

to OA

to OA

K,K 44yoM

2 years earlier 2 months later

TotalHip

ProsthesisNarrowedSuperiorly

Normal width




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Asymmetry ProgressiveWorsens over time

Osteophytes?Often not seen on AP viewBest seen on frog-leg view

to OA

to OA

to OA

mi9.com

What’s a frog-leg view?




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Pelvis RadiographsLying on x-ray tableNot weight-bearingUnlike knees&feet which

should be done standingCassette slides into “Bucky Grid”Minimize x-ray scatterDr Gustav Bucky

(9/3/1880-2/19/1963)

1913: Moving grid(Berlin)

X-raycassette

Tray

Marty age 15


http://www.nlm.nih.gov/exhibition/historicalanatomies/vesalius_home.html






http://mi9.com/wallpaper/free-frog-3d-wallpaper-for-desktop_81226/







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AP Pelvis

X-R

AYS

Internally Rotated

Head

GreaterTrochanter

LesserTrochanter

APview ofFemurs

Hip joint width

B,A 16yoF© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info



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Frog Leg Lateral

X-R

AYS

B,A 16yoF

Externally Rotated

Lateralview ofFemurs

GT

LT




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PelvisAP view

Osteophytes: HipsSuperior narrowingAsymmetryOsteophytes?None on AP

R,C 81yoF

Right HipFrog-leg view

Osteophyte!

NarrowedSuperiorly




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PelvisAP view

Sub-Cortical Sclerosis: Hips

R,C 81yoF

“Isn’t thissub-corticalsclerosis?”

Not sub-cortical sclerosis

Normal appearance of acetabular roof

sourcil: [Fr] “eyebrow”

blogburo247.ru




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Sub-Cortical Sclerosis: Hips

R,C 81yoF

This is sub-cortical sclerosis! This isn’t a French

model’s eyebrow

This looks more like this guy’s

eyebrow…flickr.com




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Distribution: OAUpper ExtremityUncommon in the Shoulder1º OA spares glenohumeral joint2º OA from trauma, rotator cuff tear

D,H 63yoM

ShoulderOblique view

Severe osteoarthritic narrowing GH jt

Complete loss of acromial-humeral

space =Chronic rotator

cuff tear





http://blog.rue-du-bien-etre.com/l-atelier-du-sourcil-premier-rendez-vous/

http://buro247.ru/beauty/collections/3958.html


http://www.flickr.com/photos/o_caritas/5711154/







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Distribution: OAUpper ExtremityUncommon in the Shoulder1º OA spares glenohumeral joint2º OA from trauma, rotator cuff tearVery common acromioclavicular jt.Narrows w/age usually not symptomatic

Uncommon in the ElbowHand/WristCommon at the Thumb baseSTT & CMC (Spares rest of wrist)

Common at the PIPs & DIPs(Spares MCPs)




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OA: HandsNarrows DIPs & PIPsNon-uniform narrowingSub-cortical sclerosis

S,H 73yoF

Left HandPA view




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OA: HandsNarrows DIPs & PIPsNon-uniform narrowingSub-cortical sclerosis

Spares MCPsNarrows Thumb BaseThumb CMC jointSpares the other CMCs

Scaphoid-Trapezoid-Trapezium jtSpares other intercarpal jtsSpares radiocarpal joint

S,H 73yoF

Left HandPA view




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OA: HandsSymmetry?Has similar

distribution in both hands

One hand (dominant) usually more severely involvedHere right

thumb > leftS,H 73yoF

Left HandPA view

Right HandPA view




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Osteophytes: HandsBest seen on lateral

C,C 76yoF

HandPA view

HandLateral view




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Gullwing Erosions


OA?

EOA?














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Erosive OsteoarthritisOccurs in women>50As does conventional OA

Involves DIPs (PIPs)

As does conventional OA

“Gullwing Erosions”

T,M 64yoF

Left HandPA view




OA

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Erosive OsteoarthritisLeft HandPA view

Right HandPA view

Symmetry

T,M 64yoF




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Gullwing Erosions



OA?

EOA?

RA?







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RA = Disease of SynoviumNormal synovium is very thin 1-3 cells thick

RA synovium hypertrophies 8-10 cells thick “Pannus”Contains increased blood vesselsIncreased blood flow (hyperemia)

Contains inflammatory cellsIncluding osteoclasts

Causes EROSIONSCartilageBone

BONE

BONE

hopkins-arthritis.org




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RA = Disease of SynoviumInflamed pannus effects the articular cartilage uniformlyUniform cartilage lossUniform joint narrowingSynovial osteoclasts erode cortical boneCentral erosionsMarginal erosionsPannus tends to heap up at

margins of joint capsule

BONE

BONE

BONE

BONE

to RA




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RA = Disease of SynoviumSynovial hyperemia causes bone resorption, bone lossWithin the joint capsule“Peri-articular osteopenia”This is subtle on radiographsRadiographic technique dependent

May not even be present on pts treated with Bisphosphonates to prevent loss of bone mass

Cortical thinning causes bone bowing/deformity

BONE

BONE





http://www.hopkins-arthritis.org/arthritis-info/rheumatoid-arthritis/rheum_clin_path.html








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OA vs RADisease of

Cartilage

NonuniformNarrowing

Produces boneSubcortical

SclerosisOsteophytes

BONE

BONE

Disease of Synovium

UniformNarrowing

Resorbs bonePeriarticular

OsteopeniaErosions




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OA vs RADisease of

Cartilage

NonuniformNarrowing

Produces boneSubcortical

SclerosisOsteophytes

Disease of Synovium

UniformNarrowing

Resorbs bonePeriarticular

OsteopeniaErosions

H,A 51yoFV,D 50yoF

KneeAP view

KneeAP view




OA

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EOA

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RA: Marginal Erosions

A,F 69yoF

Left HandPA view

Right HandPA view

Mirror ImageSymmetry




OA

Phytes

EOA

RA

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RA: Erosions

T,H M

MarginalErosions

CentralErosions

HandPA view




OA

Phytes

EOA

RA

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CPPD

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Gullwing Erosions



OA?

EOA?

RA?







OA

Phytes

EOA

RA

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Distribution: OA vs RABig JointsHipsKneesAnklesShouldersElbowsSpineC1-C2HandsAll the MCP jtsEntire Wrist


OA RA













OA

Phytes

EOA

RA

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OA vs RA: HipsAlso, since

with RA there is

bone loss/ resorption, there can

be thinning of medial

acetabular wall…


Acetabulum

FemoralHead

OA

Non-uniform cartilage loss

Superior Narrowing


Acetabulum

FemoralHead

UNIFORM cartilage loss

MEDIAL Narrowing

RA




OA

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RA: Hips

H,K 51yoM

MEDIAL NarrowingMirror Image Symmetry

ThinnedMedial

AcetabularWalls

PelvisAP view




OA

Phytes

EOA

RA

Gout

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Protrusio AcetabuliThe degree of bone loss in RA can be so great that the medial acetabular wall not only thins, it protrudes into the pelvis…

PelvisAP view




OA

Phytes

EOA

RA

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Distribution OA vs RA: HandsOADIPsPIPsThumb

baseCMCSTT

SparesMCPsRest

of the wrist

Z,S 26yoFS,H 73yoF

HandPA view

HandPA view RA

MCPsEntire

wristDRUJ

SparesDIPsPIPs




OA

Phytes

EOA

RA

Gout

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RA: Ligamentous LaxityParticularly in the handMCPsWristThe bones drift in the

ULNAR direction

I,I 60yoF

“Ulnar deviation”

of the MCPs

HandPA view




OA

Phytes

EOA

RA

Gout

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Normally, lunate sits½ over radius and

½ over ulna

RA: Ligamentous LaxityParticularly in the handMCPsWristThe bones drift in the

ULNAR direction

R,T 47yoF

Right HandPA view

Left HandPA view

“Ulnar translocation of the carpus”

RadiusUlna

L

Lunate drifted towards ulna

Lunate drifted towards ulna

L












OA

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EOA

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RA: Ligamentous Laxity

O,J 42yoF

C1

C2

C3

C4

C5

C6

C7


EXTENSION


FLEXION

C1C2

C3

C4

C5

C6

C7

C1

C2

C1 C2

C1-C2Instability

10mm!

Normal < 3mm © 2015 Ken L Schreibman, PhD/MDwww.schreibman.info



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68 of 94



Gullwing Erosions



OA?

EOA?

RA?




OA looks nothing like RA!OA has osteophytesNot everything with

osteophytes is OA

RA has erosionsNot everything with

erosions is RA




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69 of 94



Gullwing Erosions





OA?

EOA?

RA?

Gout?

CPPD?






Radiographically, Gout & CPPD look very different!




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Crystal Deposition ArthropathiesThree crystals can deposit in joints:Hydroxyapatite: Usually in shoulders (calcific tendonitis/bursitis)

Uric acid (monosodium urate): “Gout”Calcium pyrophosphate dihydrate: “Pseudogout”

microscopyu.com

Uric acid

BirefringenceNeedlesStronglyNegative

CPPD

BirefringenceRhomboidsWeaklyPositivediseaseaday.com ard.bmj.com




OA

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EOA

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71 of 94

GoutJoint fills with crystals

While these destroy cartilage,Presence of crystals in the

joint PRESERVES joint widthCrystals erode cortex slowlyTakes 6-10 years to see erosions

Erosions are sharply definedWell-corticated marginsOverhanging edges“Rat-bite”

Calcified soft tissue tophi are rare

BONE

BONE




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72 of 94

Gout: Favors Toes (1st)

BONE

BONE

D,W 80yoM

Classic gout erosion

1st toeSharp marginOverhanging

edges

Marginal erosions

Diff Dx:GoutRA

FootAP view





http://www.microscopyu.com/articles/polarized/polarizedintro.html

http://www.diseaseaday.com/gout-excruciating-pain-caused-by-crystals-in-the-joints/

http://ard.bmj.com/content/58/5/261/F2.expansion








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73 of 94

Gout: Favors Toes (1st)Erosions can be quite

small……or

totally erode

phalangesR,B 30yoM

FootAP view

M,B 78yoM

FootAP view




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74 of 94

Gout: Random Distribution

A,J 66yoM

FootAP view

HandPA view

Classic “rat-bite” erosion1st toeSharp marginOverhanging

edges

Same “rat-bite”

erosion




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75 of 94



Gullwing Erosions





OA?

EOA?

RA?

Gout?

CPPD?









OA

Phytes

EOA

RA

Gout

CPPD

PA

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76 of 94

Chondrocalcinosis“Cartilage calcified”Can be subtle…Sometimes obviousCommon sites:KneePubic symphysisWristTFC (Triangular

fibrocartilage)

H,W 63yoM

KneeAP view




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CPPD

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77 of 94

Chondrocalcinosis“Cartilage calcified”Can be subtleSometimes obviousCommon sites:KneePubic symphysisWristTFC (Triangular

fibrocartilage)Not all chondrocalcinosis = CPPD

M,Y 76yoF

TFC

Lunate-TriquetrumJoint

WristPA view




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PA

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78 of 94

Clues to CPPD:1)Chondrocalcinosis2)Distribution unusual

for OA

CPPD: WristWrist

PA view

TFC

TFC

HandPA view

M,Y 76yoF

NarrowingSTT &Thumb CMC(Typical for OA)

Spared DIPs & PIPs

(Somewhat atypical for OA)

Narrowed MCPs(Atypical for OA)Typical for CPPD!












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79 of 94

CPPD: Knees

B,L 70yoF

Bilateral KneesAP view

Bilateral KneesSunrise view

Chondrocalcinosis

Lateral compartment narrowed > Medial

Atypical for OA

Patellofemoral compartments narrowed >> MedialAtypical for OA, …but typical for CPPD!




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80 of 94

CPPD SLAC WristScapho-Lunate Advanced Collapse

Loss of the S-L ligament DiastasisCapitate then

descends downbetween S & LCausing entire

wrist to collapse“CPPD is one of

the major causesof SLAC*”

*Radiology 1990;177: 459-461

W,M 88yoF

LS

TFC

C

WristPA view

F,C 58yoM

LS

C

WristPA view




OA

Phytes

EOA

RA

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CPPD

PA

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81 of 94



Gullwing Erosions




Pencil-in-CupSausage Digit


OA?

EOA?

RA?

Gout?

CPPD?

Psoriatic?






Hands, Feet, SpineSI Joints (Asymmetric)




OA

Phytes

EOA

RA

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CPPD

PA

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82 of 94

PsoriasisPsoriasis is the most

prevalent autoimmune disease in the US

7.5 million Americans (2% of population)125 million worldwide (2-3% of population)Up to 30% develop psoriatic arthritis15% the arthritis precedes the skin disease

psoriasis.orgPlaque Psoriasis Guttate Psoriasis Inverse Psoriasis Pustular Psoriasis Erythrodermic




OA

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EOA

RA

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CPPD

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83 of 94

Psoriatic Arthritis: 5 TypesSymmetric Like RA; milder, less deformity.

Asymmetric “Sausage digit”. Usually mild.

psoriasis.org L,J 65yoF

Left HandPA view

3 Clues to PA:1) “Sausage” digit2) “Pencil-in-cup” erosion3) Unilateral SI-itis

Sausage Digit

Right HandPA view

0Sausage digit is not a tasty meat product*0Finger or toe swells

from tip to base0Shaped like a

cocktail sausage*voices.yahoo.com

Pencilin

cuperosion




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84 of 94

Symmetric arthritis Like RA; milder, less deformity.

Asymmetric arthritis “Sausage digit”. Usually mild.

DIP (5%) Like OA; nail changes.

Arthritis mutilans (5%)Hands/feet.

Spondylitis (5%)Stiff spine, SIs; extremities.

Psoriatic Arthritis: 5 Types

psoriasis.org B,R 53yoF

Arthritismutilans

HandPA view

Pencil-in-Cuperosion

Clue to PA



http://radiology.rsna.org/content/177/2/459.full.pdf+html



http://www.psoriasis.org/learn_statistics


http://www.psoriasis.org/psoriatic-arthritis/types

http://voices.yahoo.com/what-sausage-digit-5937326.html


http://www.psoriasis.org/psoriatic-arthritis/types






OA

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CPPD

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85 of 94

4 Seronegative Spondyloarthropathies“Seronegative”: RF factor neg.

“Spondylo”: Effects spine

All 4 cause sacroiliitisPsoriatic arthritis &

“reactive arthritis”Unilateral, asymmetric

Ankylosing spondylitis & inflammatory bowel diseaseBilateral, symmetric fusion (ankylosis)

Crohn's DiseaseAbdomenAP view

Resectionterminal

ilium

Ankylosis SIs Bilateral Symmetric

M,P 32yoF© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info



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86 of 94

How Ordered List Helps Me Is this OA?No 1st MTP osteophytes

Is this RA?Not uniform narrowingNot all MTP, no osteopenia

Is this Gout?Maybe… not 1st toe

Is this CPPD?No chondrocalcinosis

Could this be PA?Do we have SI images?

S,E 36yoM

PelvisAP view

Normal IndistinctSclerotic

UnilateralSacroiliitis

PsoriaticArthritis!

FootOblique

view




OA

Phytes

EOA

RA

Gout

CPPD

PA

WOW

87 of 94

What to Order WhenAlways start with

radiographsLeast expensive

imaging studyWell shows results of

joint disease:Narrowing & alignmentOsteophytes & erosions

Useful for following course of disease

H,B 69yoF

HandPA view

“r/o RA”

Run eyes around wrist:No Narrowing

Run eyes along MCPs:Only 1 MCP is narrowed




OA

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EOA

RA

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CPPD

PA

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88 of 94

Radiograph 1 year later

HandPA view

Radiographs: Disease Progression

H,B 69yoF

Only 1 MCP is narrowed Disease progression, now with 4 MCPs narrowed

HandPA view

“r/o RA”

Radiograph 2 years later

Further disease progression, now with ulnar deviation MCPs




OA

Phytes

EOA

RA

Gout

CPPD

PA

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89 of 94

Advanced Imaging StudiesMRI with IV

contrastWell shows

hypervascular pannusNormal synovium

does not enhance

Useful for diagnosing early RA

L,L 43yoF

HandPA view

Coronal MR HandT1 FatSat post IV contrast

Negative(even in

retrospect)

Enhancing pannus

Enhancing carpal bones

Developing erosions




OA

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RA

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PA

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90 of 94

Advanced Imaging StudiesDual-Energy CT (coming soon…)Specific for uric

acid crystals in gout

RadioGraphics 2011;31:1365–1375







http://radiographics.rsna.org/content/31/5/1365.full.pdf+html






OA

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91 of 94

Advanced Imaging StudiesFluoroscopic guided

joint injectionsUseful to prove which

joint is symptomaticWith steroids can yield

long-term reliefCan inject any joint:Hips, Knees, ShouldersFacets, AC, SIPubic symphysisAnkle, Subtalar joint

A,S 64yoF

Subtalar joint injectionLateral view




OA

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EOA

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CPPD

PA

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92 of 94

Any Final Questions?

morbidanatomy.blogspot.com




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RA

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CPPD

PA

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93 of 94

Final Exam Is this OA?No. Erosions, not phytes.

Is this RA?Does involves MTPs…Has marginal erosions…

Is this Gout?Not random enough.

Is this CPPD?No chondrocalcinosis.

Could this be PA?Pencil-in-cup erosion!

FootAP view

N,C 57yoF

PsoriaticArthritis!




OA

Phytes

EOA

RA

Gout

CPPD

PA

WOW

94 of 94

Thank you!

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http://morbidanatomy.blogspot.com/2010_04_01_archive.html



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radiology of joint disease...radiology of joint disease my practical approach prevalence/hx joint...

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