arthritis.pptx

Diagnosis of Arthritides Tsitskari Maria Consultant of Vascular and Interventional Radiology Apollonion Private Hospital Four main categories of arthritis     Degenerative  Osteoarthritis (OA)  Secondary – Systemic: hemochromatosis, hemophilia Inflammatory  Seropositive – rheumatoid arthritis...

Diagnosis of Arthritides Tsitskari Maria Consultant of Vascular and Interventional Radiology Apollonion Private Hospital Four main categories of arthritis     Degenerative  Osteoarthritis (OA)  Secondary – Systemic: hemochromatosis, hemophilia Inflammatory  Seropositive – rheumatoid arthritis (RA)  Seronegative – reactive arthritis, ankylosing spondylitis, psoriatic arthritis, and enteropathic arthritis (assoc with IBD) Infectious Crystal deposition  Calcium pyrophosphate deposition disease (CPPD)  Monosodium urate crystals - Gout When evaluating arthritis, take into account…       Location – bilateral/unilateral, which joint(s) Which part of the joint is involved, even or uneven Demographics – age, gender Presence of osteophytes, erosions, new bone formation, subchondral cysts, sclerosis… Soft tissue swelling Or, ABCDE’s: Alignment, Bone proliferation, Cartilage (joint space loss), Density (bone), Erosions, soft tissues Approach to an image        Soft tissues: effusions, calcification, masses Mineralization: diffuse demineralization, periarticular demineralization Joint narrowing and subchondral bone: narrowing, subchondral sclerosis, intraarticular bodies, ankylosis Erosions: central (articular surface), marginal (bare area), periarticular, mutilans Proliferation: osteophytes, periostitis Deformity: varus/valgus, flexion/extension, subluxation, dislocation, collapse Distribution: monoarticular, pauciarticular, polyarticular, symmetric/asymmetric Degenerative  Osteoarthritis (OA)  Secondary – Systemic: hemochromatosis, hemophilia Degenerative - Osteoarthritis  Characteristics         Uneven loss of joint space Osteophyte formation Normal bone mineralization Relative absence of erosions Subchondral cysts and new bone formation/sclerosis Asymmetric distribution, usually hands, feet, knees and hips Not as common in shoulders, elbows Associated with changes d/t age, and mechanical forces OA cont.  Knee    Medial joint involvement more common Varus deformity of joint, lateral tibial subluxation Hip   Most often superiolateral joint involvement with loss of cartilage and osteophyte formation Medial sclerosis/new bone formation in femoral neck cortex; buttressing Cyst Osteophyte Buttressing STATdx Erosive OA    OA with an inflammatory component Same OA distribution, but may see erosions or ankylosis Often postmenopausal women Degenerative – Systemic Hemochromatosis        Abnormal iron deposition throughout the body, including articular cartilage Demonstrates some overlap with CPPD, Fe inhibits pyrophosphatase and can lead to crystal deposition in cartilage (chondrocalcinosis) Uniform joint space loss Bilateral symmetrical distribution “Beak-like” osteophytes Subchondral cysts/sclerosis Osteoporosis Hemochromatosis cont    Most often in wrist and hand, esp. 2nd and 3rd MCP joints Flattened metacarpal heads Systemic disease may appear similar to CPPD, but with more indolent course and predominance of osteophytes Inflammatory   RA Seronegative Reactive Ankylosing Spondylitis Psoriatic Enteropathic Inflammatory – Seropositive Rheumatoid Arthritis  RA characterized by synovial proliferation (pannus), bursitis and nodules  Can cause ill-defined soft tissue planes and prominances on plain films  Nodules appear as focal soft tissue masses especially at the olecranon bursa and areas of friction  Tenosynovitis can appear as diffuse soft tissue swelling, commonly seen at the wrist  Periarticular osteoporosis is an early finding , but can also see generalized osteoporosis http://uwmsk.org:8080/EvasMSKTF/ Inflammatory – Seropositive Rheumatoid Arthritis  Characteristic lesions are erosions in the marginal (bare) area     Pannus erodes the bone at the margin of the joint capsule where the redundant synovium exits, next to the articular cartilage Osseous proliferation is not commonly seen with RA, but can be seen with secondary OA in joints with RA Subchondral cysts may be large Earliest changes are usually in the hands and feet  Ulnar styloid soft tissue swelling, extensor carpi ulnaris tenosynovitis http://uwmsk.org:8080/EvasMSKTF/ Inflammatory – Seropositive Rheumatoid Arthritis           Periarticular soft tissue swelling Osteoporosis Uniform joint space loss Marginal erosions  severe subchondral erosions No bone formation (no osteophytes) Subluxations Synovial cysts Bilateral and symmetric Generally not present in axial skeleton, except C-spine Hands > feet > knees > hips > C-spine > shoulders > elbows Erosions, uniform joint spaces http://uwmsk.org:8080/EvasMSKTF/ RA cont  In hand and wrist, often involves carpals, MCP joints and PIP joints  Ulnar subluxation of proximal phalanges and formation of swan neck and boutonniere deformities  Formation of subcutaneous rheumatoid nodules http://uwmsk.org:8080/EvasMSKTF/ RA Severe ulnar deviation Severe erosions of MCPs Complete destruction of the wrist Resorption of the carpals and the heads of the metacarpals Radial deviation of the wrist RA Boutonniere deformity of the thumb Flexion with dislocation of the first MCP joint Hyperextension of the IP joint RA Rheumatoid wrist: articular destruction, carpal fusion and carpal collapse. Severe destruction of the distal radius and ulna. RA Rheumatoid foot Multiple osseous erosions and defects at the medial and lateral margins of the metatarsal Marginal heads erosions at the bases of the proximal phalanges (arrows) RA Rheumatoid foot Medial and lateral erosions of the 5th metatarsal head Subluxation of the 5th MTP joint RA Rheumatoid foot Subchondral cyst at the base of the distal phalanx Characteristic erosion along the medial margin of the proximal phalanx of the great toe Effusion RA cont  Knees affected symmetrically and bilaterally    Baker’s cyst Uniform space loss Outpouching of synovial cysts into adjacent bone, or soft tissue (Baker’s cyst) Hips affected in 50% Uniform cartilage loss  axial or superomedial migration of femoral head  Bone erodes on joint side, and forms on pelvic side leading to acetabuli protusio (acetabulum protrudes into pelvis)  STATdx Erosions and joint space loss bilaterally, no osteophytes or sclerosis RA   Shoulder and elbow also show bilateral, uniform joint space loss with osteoporosis and cysts formation Special consideration: RA patients are prone to developing laxity of transverse ligament between atlas and odontoid process  Normal distance between the two on lateral c-spine is 3mm in adults, 5mm in children  Increased distance may indicate need for surgical fusion to prevent cord compression during flexion http://uwmsk.org:8080/EvasMSKTF/ RA Atlantoaxial subluxation in RA Always a concern in patient with longstanding RA and neck pain or cervical neurological symptoms Order a view of the atlantoaxial articulation through an open mouth to fully assess. This shows lateral atlantoaxial subluxation of the odontoid process with respect to the lateral masses of the atlas. Inflammatory Arthritis – Seronegative    Associated with HLA-B27 Negative RH factor Axial skeleton often involved   Sacroiliitis or spondylitis Enthesopathy  Inflammation of the insertions of tendons/ligaments Inflammatory – Seronegative Reactive Arthritis (Reiter’s)      Reiter’s included the classic triad of arthritis, conjunctivitis, and urethritis Classical model involving chlamydial infection doesn’t apply to all cases, and Reiter was a WWII war criminal, so reactive arthritis is now the preferred term Reactive arthritis may still involve chlamydial infection, but may also occur after gastroenteritis (Shigella, Salmonella, Campylobacter, Yersinia, C. defficile) Likely autoimmune reaction, joints themselves are not infected Worldwide has equal prevalence among men and women Reactive cont  Enthesopathy is prominent, with overlying tissue warmth and tenderness  Soft tissue swelling (sausage digits)  Uniform joint space loss  Bilateral, asymmetrical  Often begins with one joint, don’t confuse with septic arthritis  Areas of erosion associated with periosteal reaction, new bone formation  Most often in feet, ankles, knees and SI joints  In SI joint, may be on only one side or asymmetrically affect both sides (opposed to ankylosing spondylitis)  Less in hands, hips, spine  May form large, asymmetric bony bridges between vertebrae (similar to psoriatic, but opposed to ankylosing spondylitis) http://uwmsk.org:8080/EvasMSKTF/ Inflammatory – Seronegative Ankylosing Spondylitis        Bilateral, symmetrical Ankylosis, joint fusion, is prominent Before fusion, subchondral bone formation Post fusion, generalized osteoporosis No cysts or subluxation Erosions not a prominent feature, but are present SI and spine (ascending) involvement > hips > shoulders > knees > hands > feet http://uwmsk.org:8080/EvasMSKTF/ AS cont Dagger sign   fused spinous process ligaments Fusion of SI joints is classic Vertebral bodies initially erode at corner, reactive sclerosis occurs below this leading to squared appearance  Eventually anulus fibrosus and longitudinal ligaments become ossified (syndesmophytes)  Discs can become calcified, along with all ligaments including those between spinous processes  bamboo spine http://uwmsk.org:8080/EvasMSKTF/ Inflammatory – Seronegative Psoriatic Arthritis           Bilateral, asymmetrical Dramatic joint space loss +/ankylosis (arthritis mutilans) Bone proliferation, “mouse ears” “pencil-in-cup” deformities Normal mineralization Sausage digits Hands > feet > SI > spine Usually favors DIP and PIP in hand SI involvement usually bilateral, asymmetrical Large bridging bone formation in spine, similar to reactive arthritis Sausage digits http://www.hopkins-arthritis.org/arthritis-info/ psoriatic-arthritis/diagnosis.html http://uwmsk.org:8080/EvasMSKTF/ http://uwmsk.org:8080/EvasMSKTF/ Inflammatory – Seronegative Psoriatic Arthritis Psoriatic arthritis Asymmetri c involvemen t Soft tissue swelling and periosteal reaction in 2nd and 3rd fingers Inflammatory – Seronegative Psoriatic Arthritis Chunky, non-marginal syndesmophytes (bony bridges between vertebrae) typical of psoriatic arthritis Infectious Septic arthritis Septic arthrtitis      Joint space destruction, both sides, due to release of proteolytic enzymes Joint effusion Soft tissue swelling Osteoporosis In healthy patients    IV drug users   TB       Knee, hip, and elbow common N. gonorrhoeae most common cause in young, sexually active patients SI joint, sternal, pubic joints Hip, knee, intertarsal joints, spine TB in vertebral disc space is Pott’s disease Staph aureus is most common cause, Streptococcus is also common Gram negatives more common in diabetics Salmonella in sickle cell patients Risk factors: Extremes of age, immunocompromised, chronic arthridities, prosthetic joints, diabetes, and IV drug use Septic arthritis cont Uhh, do you see the problem? http://www.learningradiology.com/images/boneimages1/bonegallerypages/Septic%20arthritis.html Pott’s http://www.wheelessonline.com/ortho/tuberculous_spondylitis Crystal deposition Gout CPPD Crystals Gout  Monosodium urate crystal deposition  May deposite in cartilage to produce an OA like disease, or in soft tissues (tophaceous gout)  Usually males, postmenopausal females  Tophaceous gout        Tophi Relative joint space preservation Erosive lesions with sclerotic borders, away from joint space, with overhanging cortex Normal mineralization Asymmetrical, polyarticular May present with acute, monoarticular swelling, pain, and erythema. Feet (1st MTP) > ankles > knees > hands > elbows Gout Erosion with overhanging edge. Joint space is preserved. tophus Crystal in PMN from synovial fluid, diagnostic for acute gout Uwmsk.org/residentprojects/gout.html Gout Olecranon bursitis with erosions due to gout Uwmsk.org/residentprojects/gout.html Crystals CPPD  Most common crystal arthropathy  Disease spectrum includes:  Deposition in cartilage (chondrocalcinosis), which may lead to OA like disease or be asymptomatic    Commonly develops in older population Associated with hyperparathyroidism and hemochromatosis Pseudogout which may present with acute attacks of arthritic pain similar to gout, although it is more common in the knees than the 1st MTP  May be indistinguishable from septic arthritis without synovial fluid analysis Chondrocalcinosis  Most common in knee, pubic symphysis, and wrist (patients will be affected in at least one of these areas)  Deposition of crystals in hyaline and/or fibrous cartilage  Bilateral  Cysts  Normal mineralization  Subchondral new bone formation  +/- osteophytes  Knees > hands > hips  Shoulder and elbow involved, differentiates from OA wikipedia Uwmsk.org/residentprojects/ gout.html