xray imaging in non inflammatory arthritis
DESCRIPTION
thropathyHallmark radiographic features of non-inflammatory arthritis like osteoarthritis, connective tissue arthropathy and metabolic and endocrine arTRANSCRIPT
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By: DR. RAMAN SHINGADE 2ND YR. RESIDENT
GUIDE: DR. KANCHANA PACHCHIGAR
TUTOR
• Greenspan• Yochum and Rowe• Radiopedia.org• Learninradiology.com
References:
Xray Imaging in Non Inflammatory Arthritis
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The constituent structures of a synovial/diarthrodial joint.
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Definition of Arthritis
•Disease that affects bones on both sides of the joint space and
•Narrows the space between them
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Narrowing of the joint space
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Radiographic features of arthritides
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Arthritis or not
Normal DJD
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Arthritis or not
Normal DJD
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Arthritis or not
Normal DJD
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Classification of Arthritides
•Inflammatory Arthritis
•Non-inflammatory Arthritis
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Non Inflammatory ArthritisDegenerative Arthritis (Osteoarthritis)
Primary
Secondary
Connective Tissue Arthropathy Scleroderma
MCTD
Metabolic & Endocrine Arthritis Acromegaly
Hemochromatosis
Haemophilia
Gout
Hyperparathyroidism
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2 forms of Osteoarthritis
Primary form • Idiopathic
Secondary form • Posttraumatic• Congenital disorders• Neuropathic Arthritis• Avascular Necrosis
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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
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•Hip
•Knee
• Spine
• Interphalangeal joints of the hand
Common Sites
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Hallmark radiographic features
• localized joint space narrowing
• subchondral sclerosis
• osteophytes
• cyst or pseudocyst
Osteoarthritis of Large joints
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narrow joint spacesubchondral sclerosis
osteophytes
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Right hip osteoarthritis
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Superolateral migration of femoral head with typical Eggers cyst in acetabulum.
Egger’s CystSuperolateralmigration
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Medial migration of the femoral head
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Postel coxarthropathy(aka rapidly destructive arthrosis)
• occurs predominantly in women
• characterized by rapid chondrolysis
• no/very little reparative changes
• mimics Charcot joint or infectious arthritis
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Right hip Postel Coxarthropathy
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Osteoarthritis of left knee
L L
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AP and lateral both knee radiographs bilateral knee osteoarthritis.
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Advanced osteoarthritis with loose bodies
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Narrowing of the femoropatellar joint compartment
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Patellar Tooth sign
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Patellar Tooth sign on AP projection
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•Not due to mechanical stress
• F:M = 10:1
•Most Often involves DIP joints• Sclerosis• Osteophyte formation
• 1st MCP joint of thumb
Osteoarthritis of Hand
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Hallmark radiographic features
• Heberden nodes
• Bouchard nodes
• joint space narrowing
• subchondral sclerosis
Osteoarthritis of Hand
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Heberden Nodes
Bouchard Nodes
Degenerative changes in the 1st carpometacarpal joint
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Osteoarthritis of bilateral first metatarsophalangeal joints
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hallmark radiographic features
• Facet narrowing and eburnation
• Foraminal stenosis
• Stenosis of spinal canal
• Narrowing of IVDS
Degenerative Disease of the Spine
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Osteoarthritis of the facet joints
Subchondral sclerosis
Narrowing of facet joints
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Bridging osteophytes
Bridging osteophyte
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Encroachment of the neural foramina by posterior osteophytes
Posterior osteophytes withNeural foraminal stenosis
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Vacuum disc phenomenon
Prominent osteophytes
Vacuum disc phenomenon
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Secondary Osteoarthritis
• Another process 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)
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Secondary Osteoarthritiscauses
• Trauma (most common)• Avascular Necrosis• Neuropathic arthritis• Congenital Disorders• Haemophilia• RA
Bottom Line: Any arthritis can lead to 2° OA
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•most common cause of secondary/atypical osteoarthritis
• changes similar to those in primary osteoarthritis
• history of previous trauma
• younger age group
Posttraumatic Osteoarthritis
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Severe osteoarthritic changes due to previous dislocation
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Severe post-traumatic osteoarthritis following distal fibula fracture.
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Left knee Posttraumatic osteoarthritis.
L
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• destructive articular disease 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
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Causes
Shoulders • Syrinx• Spinal Tumor
Hips • Tertiary syphilis• Diabetes
Feet • Diabetes
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6 D’s of Neuropathic Arthritis
• Dense bones (subcondral sclerosis)
• Distension of joint
• Destruction of bone and cartilage
• Disorganization
• Debris (loose bodies)
• Dislocation
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Typical Neuropathic (Charcot) joint
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Typical charcot joint in man with syphilis
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Licked candy stick configuration
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• defined as death 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)
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• Spontaneous (idiopathic) • Trauma (fracture, dislocation)• Alcoholism• Corticosteroid therapy• Surgery • Hemoglobinopathy
Common causes -
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• Collapse of articular cortex• Fragmentation•Mottled trabecular pattern• Sclerosis (Snowcap sign)• Subchondral cysts • Crescent sign (Subchondral fracture)
Radiographic features
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Classical sites of Osteonecrosis
• head of femur
• neck of talus
• waist of scaphoid
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Snowcap and Crescent signs
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Collapsed Articular Cortex
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Epiphyseal Fragmentation
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Osteonecrosis of humeral head after sustaining fracture of the left humeral neck
Crescent sign
Increased bone density
Healed Fracture
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Pregnancy related Avascular necrosis.
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Osteonecrosis of right humeral head following chemotherapy
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•Developmental dysplasia of the hip
• Slipped capital femoral epiphysis
Secondary to Congenital Diseases
Includes
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•Putti's triad for developmental dysplasia of the hip include :
Superolateral displacement of proximal femur .
Increase in acetabular angle.
Small capital femoral epiphysis.
Developmental dysplasia of the hip
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Radiograph demonstrates Developmental Dysplasia of Hip in a 6 months old female baby.
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Developmental Dysplasia of Hip in a 12 years old female.
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• Loss of Capener 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:
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Radiograph demonstrates absence of Carpener triangle in left hip.
Carpener Triangle
Absence ofCarpener Triangle
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Absence of intersection of epiphysis by lateral femoral cortical line.
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Radiograph demonstrates Herndon hump and secondary osteoarthritis.
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Non Inflammatory Arthritis
Connective Tissue Arthropathy Scleroderma
MCTD
Metabolic & Endocrine Arthritis Acromegaly
Hemochromatosis
Gout
Haemophilia
Hyperparathyroidism
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Scleroderma
• generalized systemic inflammatory 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
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CREST syndrome
Calcinosis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
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• atrophy of the 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
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Atrophy of the soft tissues at the distal phalanges of the index, middle, and ring fingers
R
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Soft-tissue calcifications in the distal phalanges of the left hand, a typical feature of Scleroderma
L
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Acroosteolysis (arrow), soft tissue calcifications, and destructive changes of the distal interphalangeal joint of the middle finger.
R
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Subcutaneous calcifications alongwith destructive changes in distal IP joints
L
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Destructive changes in the distal interphalangeal joints, as well as soft-tissue calcifications
L
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Flexion contracture in scleroderma patient
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Mixed Connective Tissue Disease
• 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
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Radiographic features are combination of different conditions
• Tuft resorption and DIP erosions (Scleroderma)
• Erosive arthritis (Rheumatoid arthritis)
• Deforming, nonerosive arthritis (SLE)
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Abnormal tapering of the distal soft tissues and early surface erosion of the phalangeal condyle.
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Subtle surface erosions and Progressive erosions
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Terminal tuft resorption
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Subluxation of IP joint of the thumb and advanced ulnar deviation
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Juxta-articular demineralization and erosive articular disease
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Metabolic & Endocrine Arthritis
Acromegaly
Hemochromatosis
Gout
Haemophilia
Hyperparathyroidism
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Acromegaly
• result of excessive 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
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Indices for Acromegaly
o Sesamoid 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
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• initially, widening of joint spaces in hand, particularly MCP joints
• later, thinning of the joint cartilages with osteophyte formation
• beak-like osteophytes
• Spade phalanx sign
Radiographic features
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Sesamoid Index and Heel Pad Thickness
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Spade phalanx sign
NORMAL ACROMEGALY
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Characteristic abnormalities in acromegalic hand
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Acromegalic osteoarthritis
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Hyperparathyroidism
• aka generalized osteitis fibrosa cystica or Recklinghausen disease of bone
• result of overactivity of the parathyroid glands
• leads to hypercalcemia
• 3 subtypes – primary, secondary and tertiary
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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
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Subperiosteal resorption is on the radial sides of proximal and middle phalanges
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Subchondral resorption resulted in widening of the sacroiliac joints.
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Brown tumor in distal radius
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Brown tumor in distal clavicle
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Chondrocalcinosis at the knee and the symphysis pubis
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Metastatic calcifications
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Typical hyperparathyroidism arthropathy at the distal interphalangeal joints of the index and middle fingers.
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Rugger-Jersey Spine
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Hemochromatosis
• characterized by iron 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
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• features typical of osteoarthritis
• different pattern of joint involvement in hand
• second and third metacarpophalangeal joints
• hook-like osteophytes
• chondrocalcinosis
Radiographic features
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Osteoarthritic features in woman with hemochromatosis
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Magnified radiograph demonstrates involvement of the metacarpal heads
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Classical hook osteophytes
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Advanced Hemochromatosis arthropathy
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Hemophilia• group of disorders 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
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Radiographic features
• widened intercondylar femoral notch
• squared inferior margin of the patella
• haemophilic pseudotumours
• periarticular erosions
• features of osteoarthritis
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Widened intercondylar notch with joint effusion
L
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Haemophilic arthropathy with subtle haemarthrosis
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Advanced degenerative changes, with near-complete loss of joint space
L
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Haemophilic Pseudotumors
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Gout•metabolic disorder characterized 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)
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Radiographic features
• Articular erosion with preservation of part of joint
• Overhanging edge of erosion
• Lack of osteoporosis
• Periarticular swelling
• Tophi
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Periarticular erosions and soft tissue masses, representing tophi
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Multiple articular and periarticular erosions associated with large tophi.
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Typical involvement of the first MTP joint with “overhanging edge”.
Overhanging Edge
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Intraosseous tophi
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Tophus with dense calcifications adjacent to the olecranon process.
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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
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SummaryScleroderma • Resorption of the distal phalanges
• Subcutaneous and periarticular calcifications
MCTD • Combination of different conditionsAcromegaly • 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 OAHaemophilia • Features of osteoarthritis
• Widened intercondylar notch
Gout • Tophi• Overhanging edge of erosions
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SPOTS
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SPOT 1
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SPOT 2
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SPOT 3
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SPOT 4
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SPOT 5
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Thank You