2. Arthritis
Although the word "arthritis" means joint
inflammation, the term is used to describe various
diseases and conditions that affect joints, the tissues
that surround the joint, and other connective tissue.
3. TYPES OF ARTHRITIS
I. DEGENERATIVE ARTHRITIS
II. INFLAMMATORY ARTHRITIS
III. METABOLIC ATHRITIS
IV. INFECTIOUS ARTHRITIS
V. CONNECTIVE TISSUE ARTHRITIS
4. DEGENERATIVE ARTHRITIS
1. Primary Osteoarthritis:-Idiopathic(spontaneous)
no specific cause known but tend to be associated
with aging
1. Secondary osteoarthritis:-caused by previous
injury to affected bone,can began at young age.
5. INFLAMMATORY ARTHRITIS
1. Rheumatoid arthritis:- autoimmune diseases
involves chronic inflammation of synovium within
joint(involves multiple joint on both side)
2. Psoriatic arthritis:-autoimmune diseases which
associated with psoriasis.
3. Ankylosing spondylitis
4. Reiter syndrome
5. Erosive osteoarthritis
6. METABOLIC ATHRITIS
1. Gout :- Caused by deposition of monosodium urate
monohydrate crystal
2. Calcium Pyrophosphate Dihydrate Crystal
Deposition Disease (Pseudogout) :-caused by
deposition of calcium pyrophosphate crystal
11. Features of Inflammatory arthritis
Marginal bone erosion.
Uniform joint space narrowing.
Soft-tissue swelling.
Fluid (f), Cartilage(c), Pannus(P), Marginal erosions(Arrows)
12. Rheumatoid Arthritis
Rheumatoid arthritis is a progressive, chronic, systemic
inflammatory disease affecting primarily the synovial
joints.
Onset is usually between 20 and 60 years of age, with the
highest incidence among the 40- to 50-year-old group.
Under 40 females to male ratio is 3:1 and over 40 equal,
1:1 ratio incidence.
The detection of rheumatoid factor, representing specific
antibodies in the patient's serum, is an important
diagnostic finding
13. Symptoms:-
Low-grade fever, fatigue, weight loss, muscle soreness, and
atrophy.
Symmetric peripheral joint pain and swelling, particularly
of the hands.
Pathologic Features:-
Initial synovial inflammation within joints, bursae, and
tendon sheaths, with cellular infiltrate, hyperemia, edema,
and increased synovial fluid.
Synovium becomes hypertrophied to form granulation
tissue (pannus), which spreads over cartilage surface.
14. At the bare areas pannus directly invades into the bone,
resulting in marginal erosions and cartilage destruction.
A rheumatoid nodule is diagnostic and consists of three
distinct zones: fibrinoid degeneration and necrosis
(central), radial palisading of fibroblasts (middle), and
fibrous tissue with small cell infiltrate (outer).
15. Rheumatoid affecting MCP, PIP, MTP and other
joints in a symmetrical fashion.
Joint involvement Distribution
16. Radiologic Features
Early radiographic changes are most commonly seen in the
hands and feet.
Bilateral and symmetric distribution, periarticular soft
tissue swelling(these are typically the first radiographic
signs of rheumatoid arthritis.), juxta-articular osteoporosis,
juxta-articular solid or laminated periostitis, marginal
erosions and cysts, and uniform loss of joint space.
Later, radiographic changes may be seen, including marked
deformities with subluxation, dislocation, articular bony
destruction, bony fusion, and complete destruction of joint
space.
17. Hand
Earliest changes are seen at the metacarpophalangeal and
PIP joints.
Evaluation should include the AP ,Oblique and
Semisupination view of the hands (Norgaard projection)
for marginal erosions on metacarpal heads and deformities
like ulnar deviation, boutonniere, swan neck, spindle digit.
18. Posteroanterior radiographs showing small bone erosion about the metacarpophalangeal
joint with osteopenia(arrow) and more extensive involvement in second image
(arrows)with alterations of the fifth metatarsal head and proximal phalanx.
19. Rheumatoid arthritis.(a)Postero-anterior and (b)oblique hand radiographs show
joint space narrowing, bone erosions, and osteopenia of the metacarpophalangeal,
distal radioulnar, radiocarpal , and midcarpal joints (arrows).
Note subluxation of proximal interphalangeal joints.
20. Oblique radiograph of the hand shows the
swan neck deformity of the second through
fifth fingers
21. Radiograph of the
hands demonstrates
the boutonnière
deformity in the
small and ring fingers
of the right hand and
in the ring finger of
the left hand
22. Wrist
Earliest change is erosion of ulnar styloid, multiple carpal
erosions , most common location for bony ankylosis, carpal
radial rotation, zigzag deformity.
Postero-anterior wrist
radiograph shows osteopenia
and joint space narrowing of
the distal radioulnar
,radiocarpal, and midcarpal
joints with erosions of the
scaphoid (arrow) and the
ulnar styloid process
(arrowhead).
23. Feet
Earliest changes seen at the fourth and fifth metatarsal
phalangeal joints.
Changes are parallel and are identical to that seen in the
hands; Lanois deformity—dorsal subluxation of the
metatarsal-phalangeal joints, with fibular deviation.
Radiograph of foot
show joint space
narrowing and
bone erosions of
both
metatarsophalang
eal joints and
interphalangeal
joints(arrows).
24. Lateral radiograph of the foot of
shows fluid in the retrocalcaneal
bursa (arrow) associated with
erosion of the
calcaneus (curved arrow).
25. Cervical spine
Most commonly affected area of the spine; involved in up to 70%
of rheumatoid patients.
Increased atlantodental interspace > 3 mm (especially in
flexion), odontoid erosions, subluxations (especially C3, C4, and
C5).
Narrowed intervertebral discs, apophyseal joints show erosions
and narrowed joint space and may ankylose.
Tapered spinous processes and generalized osteoporosis.
26. Lateral cervical spine radiograph shows erosions of dens(straight arrows)
with narrowing of facet joints(curved arrow).
Lateral flexion radiograph shows widening of atlantodens interval
(arrowheads).
27. Hips
Uniform loss of joint space (axial migration), minimal
erosions, protrusio acetabuli , particularly bilaterally.
Anteroposterior
radiograph of the right
hip shows erosions of the
femoral head and
acetabulum, concentric
narrowing of the hip
joint, and acetabular
protrusio.
28. Anteroposterior
pelvis radiograph
shows bilateral
involvement of hips,
with uniform diffuse
joint space
narrowing, bone
erosions, osteopenia,
and acetabular
protrusion(arrows).
Note bone sclerosis
related to
involvement of
sacroiliac
joints(arrowheads).
29. Knees: uniform loss of joint space, marginal erosions
(particularly at the tibial condyles), and osteoporosis; often
associated with large Baker’s cysts.
Anteroposterior knee radiograph shows
diffuse and uniform joint space
loss(arrows) with osteopenia.
30. Anteroposterior (A)
and lateral (B)
radiographs of the
knee shows
periarticular
osteoporosis, joint
effusion, and uniform
reduction of joint
space.
31. Juvenile rheumatoid arthritis
Chronic polyarthritis resembling rheumatoid arthritis
clinically and histologically beginning before 16 years
of age.
Synonyms include Still’s disease and juvenile chronic
arthritis.
More common in females < 16 years, with peak
incidence at 2-5 and 9-12 years.
32. TYPES
Adult form (seropositive) Poorest prognosis
Seronegative form:- Classic systemic ,Polyarticular
Pauciarticular-monoarticular
Distinct lack of rheumatoid factor
Symptoms include fever, characteristic rash,
lymphadenopathy, iridocyclitis (especially in
monoarticularforms), no subcutaneous nodules, and
growth disturbance.
Distinct lack of rheumatoid arthritis
33. Radiologic Features
General features include soft tissue swelling, osteoporosis,
periostitis, growth disturbances, ankylosis, loss of joint
space, erosions, subluxations, and epiphyseal compression
fractures.
Target sites include cervical spine, hands, feet, knees, and
hips.
Cervical spine: atlantoaxial dislocations, hypoplastic C2-C4
vertebral bodies and discs with ankylosed apophyseal
joints.
Tarsal and carpal ankylosis common.
Growth deformities: brachydactyly, ballooned epiphyses,
squashed carpi, and squared patellae.
34. A. Lateral Lumbar. Note that osteoporosis and compression fractures have produced a
biconcave appearance of the endplates.
B. Lateral Cervical. Observe the vertebral body hypoplasia of the second, third,
fourth, and fifth segments.
C. Lateral Cervical. Note that the vertebral bodies are hypoplastic in combination with
posterior joint ankylosis. These are characteristic cervical spine changes
35. Radiograph of both hands shows destructive changes in the metacarpophalangeal and
interphalangeal joints.
Note also joints ankylosis in both wrists. the periarticular soft tissue swelling and
periostitis (arrows)
36. Radiograph of
both knees shows
overgrowth of the
medial condyles,
one of the
characteristic
features of this
disorder
37. Ankylosing Spondylitis
A chronic inflammatory disorder principally affecting the
articulations, ligaments, and tendons of the spine and
pelvis, often resulting in complete polyarticular ankylosis.
Synonyms include Marie-Strumpell disease, rhizomelic
spondylitis, pelvospondylitis ossificans, and rheumatoid
spondylitis.
Onset is usually between 15 and 35 years and involves males
10:1.
Initiates at the sacroiliac joints bilaterally, then ascends the
spine.
38. • Pain and tenderness, especially over bony protuberances, and
increasing stiffness and sciatica is often bilateral or may alternate
from side to side.
• Complications include iritis, aortitis, valvular incompetence,
aneurysms, conduction blocks, upper lobe pulmonary fibrosis,
inflammatory bowel disease, renal failure owing to secondary
amyloidosis, carrot-stick fractures, Andersson’s lesion, and
prosthesis ankylosis.
• The most commonly involved areas are the sacroiliac joints, spine,
and proximal large joints of the shoulder, hip, and rib cage.
39. Pathologic Features
In synovial joints, the initial change
is that of a non-specific synovitis
similar to rheumatoid arthritis,
except that it is less extensive and
of lower intensity (pannus
formation), with subsequent
fibroplasia and cartilaginous
metaplasia, leading to resultant
ossification.
In cartilage joints, the initial
subchondral osteitis is replaced by
fibrous tissue that subsequently
ossifies. In the outer annulus fibers
this forms syndesmophytes.
At entheses, inflammatory changes
at ligamentous attachments result
in bony erosions, sclerosis, and
periostitis.
40. Ankylosing spondylitis affecting the
axial skeleton and large peripheral
joints in an asymmetrical fashion.
Joint involvement Distribution
41. Radiologic Features
Shiny Corner sign(small erosions with surrounding reactive
sclerosis at sup. and inf. vertebral end plates)
Vertebral body squaring.(loss of normal concavity of
anterior border)
Marginal syndesmophyte formation.
Bamboo sign.(late fusion and ligamentous ossification)
Dagger sign.(single central radio-dense line due to
ossification of supraspinous and interspinous ligaments)
Trolley track sign.(central line by supra and interspinous
lig. And two side lines of ossification-apophyseal joints)
42. Lateral radiograph
of the lumbar spine
demonstrates
squaring of the
vertebral bodies
secondary to small
osseous erosions at
the corners. This
finding is an early
radiographic
feature of
ankylosing
spondylitis. Note
also the formation
of syndesmophytes
at the L4- 5 disk
space.
43. (A) A lateral radiograph of the
lower lumbar spine of shows
early inflammatory changes
manifesting by so-called shiny
corners (Romanus lesion)
(arrowheads) and squaring of
the vertebral bodies (arrows).
A. AP Sacrum. Note that bilateral
sacroiliitis is clearly seen with
erosions, hazy joint margin, and
subchondral iliac sclerosis (arrows).
44. (A) Lateral radiograph of the
cervical spine shows anterior
syndesmophytes bridging the
vertebral bodies and posterior
fusion of the apophyseal joints,
together with paravertebral
ossifications, producing a
“bamboo-spine” appearance.
(B) radiograph the fusion of the sacroiliac
joints and the involvement of both hip joints,
which show axial migration of the femoral
heads
45.
46.
47.
48.
49. Psoriatic Arthritis
Psoriasis is a common skin disorder associated with joint
disease and characterized by peripheral joint destruction and
deformity
Age 20-50 years with male and female equally affected.
Arthritis is usually in peripheral joints, especially DIP joints.
Soft tissue findings: fusiform soft tissue swelling around the
joints which can progress so that whole digit is swollen
(sausage digit or dactylitis).
Marginal erosions also often show fluffy periostitis from new
bone formation. i.e. has both erosive and productive changes.
51. Radiologic Features
General features include soft tissue swelling, normal
bone mineralization, erosions, and tapered bone ends,
prominent juxta-articular fluffy periostitis, and joint-
space widening or bony ankylosis.
Hands and feet: Asymmetric involvement and ray
pattern, most commonly involves DIP joints, no
osteoporosis, mouse ears sign, widened joint space
owing to fibrous tissue deposition and bone
resorption, pencil-in-cup deformity, opera glass hand
deformity, no ulnar deviation.
52. 1.Joint space narrowing
2.Fulffy periostitis
3.Sausage digit(Soft tissue swelling of entire digit)
4.Erosion of terminal tufts
5.Mouse ear type of articular erosion
6.Interphalyngeal ankylosis
7.Soft tissue swelling
53. Early Distal
Interphalangeal Joint
Changes. Note that
erosions (arrows),
periostitis
(arrowheads), and
soft tissue swelling
characterize the
earliest abnormalities
Combination of
erosions and fluffy
periostitis produces
the mouse ears
appearance in
psoriasis.
MOUSE EAR SIGN
54. PA Hand.
Note the
erosive
changes are
present at
the three
joints of the
second digit
(arrows).
This pattern
of arthritis
is virtually
diagnostic
of psoriasis
RAY PATTERN
57. A. PA Hand. Note
that close to the joint
near the site of
articular erosion, the
periosteal new bone is
typically fluffy
(arrowheads). Farther
down the
shaft a linear pattern
may be seen (arrow).
B. Great Toe:
Note that adjacent to
the erosions a fluffy
and irregular type of
periostitis can be seen
(arrowheads). The
entire distal phalanx is
sclerotic, a reliable
sign of
psoriatic arthritis
involving the great
toe.
58.
59. Sacroiliac joint: Involved in up to 50% of psoriatic
arthritis patients, usually bilateral but asymmetric and
unusual to be narrowed and ankylosed.
Spine: atlantoaxial subluxation and dislocation,
normal apophyseal joints (except in the cervical
spine), syndesmophytes of two types—non—
marginal, marginal (non-marginal are the most
common)—broad-based and tapered, asymmetric,
unilateral, and most common in the upper lumbar and
lower thoracic spine.
63. Oblique
radiograph of the
lumbar spine
showing a
characteristic
single coarse
syndesmophyte
bridging the
bodies of L3 and
L4.
(B) AP radiograph
of the lumbar
spine with
psoriasis reveals
paraspinal
ossification at the
level of L2-3.
64. Note severe joint
destruction, especially at
the metatarsophalangeal
articulations, has resulted
in fibular deviation and
dorsal dislocation of the
digits (Lanois’
deformity). The presence
of a pencil-in-cup
deformity (arrow) at the
interphalangeal joint of
the big toe and osseous
ankylosis of the first
metatarsophalangeal and
second and third proximal
interphalangeal
articulations (arrowheads)
makes the diagnosis of
psoriatic arthritis most
likely
ARTHRITIS MUTILANS
Arthritis mutilans is the most severe and destructive form of
psoriatic arthritis. Fortunately, it's rare. It damages the small
joints in your fingers and toes so badly that they become
deformed.
65. DIFFERENTIAL DIAGNOSIS
Rheumatoid arthritis
there is a MCP joint predominance in rheumatoid arthritis
(RA) vs interphalangeal predominant distribution in PsA
bone proliferation not a feature in RA
osteoporosis not a feature in PsA
Erosive osteoarthritis
• “gull wing” central erosions are present in erosive OA vs
“mouse ears” peripheral bare area erosions in PsA
Reactive arthritis (Reiter syndrome)
“tends to involve feet > hands
66. REITER’S SYNDROME
A triad of urethritis, conjunctivitis, and polyarthritis, usually
following sexual exposure or, less commonly, certain types of
dysentery.
It typically occurs between the ages of 18 and 40, and is as much
as 50 times more prevalent in males
Joint symptoms typically consist of an asymmetric painful
effusion, especially of the lower extremity
Pain at the plantar or Achilles calcaneal attachment (lover’s
heels) in a young male patient should suggest the diagnosis.
These joint symptoms are of short duration and self-limiting
within 2-3 months, but recurrences are common.
67. Radiologic Features
Swelling, osteoporosis, uniform loss of joint space,
erosions, periostitis.
Specific target sites: forefoot, calcaneum, ankle, knee,
sacroiliac jt, spine.
Foot: metatarsophalangeal and interphalangeal joints.
Dorsal subluxation of the proximal phalanges and
fibular deviation of the digits results in the Lanois
deformity.
Calcaneum: Erosive changes at plantar and Achilles
insertions.
Ankle: loss of joint space, swelling, periostitis.
68. Sacroiliac: erosions, sclerosis, loss of joint margin,
asymmetric involvement and often unilateral.
Spine: thoracolumbar, asymmetric, skip non-marginal
syndesmophytes and, rarely atlantoaxial instability.
Knee: the only change usually visible at the knee is
effusion and, occasionally, periostitis of the distal
femoral metaphysis. A Pellegrini-Stieda type
calcification of the medial collateral ligament may be
seen
69. X-ray foot shows the thin layer of periosteal new bone at the
phalangeal base at the third metatarsophalangeal joint (arrows).
There is also a notable diminished density in the metatarsal head
(arrowhead).
70. Xray showing marginal
erosions (arrows), linear
periostitis
(arrowheads), and soft tissue
swelling (crossed arrows) at the
proximal interphalangeal joint.
71. CALCANEUS. A. Early Erosive Changes: Achilles Tendon. Shows small lucent defects
(arrows) and adjacent periostitis (arrowhead).
B. Pathophysiology. The inflamed pre-Achilles bursa (arrowheads) becomes the site for
pannus formation and subsequent subperiosteal resorption of the adjacent
calcaneus (arrow).
C. Advanced Erosive Changes. Note that the lucent defects are larger (arrows), with
prominent periostitis (arrowheads). Note the fluffy calcaneal spur owing to inflammatory
enthesopathy (crossed arrow).
72.
73. MEDIAL
COLLATERAL
LIGAMENT
CALCIFICATION.
Note the irregular
linear density
adjacent to the
medial epicondyle
(arrow). This is a
Pellegrini-Stieda
type of calcification
within the medial
collateral ligament
and may be seen in
approximately 10% of
Reiter’s syndrome
patients
74.
75. Erosive Osteoarthritis
Inflammatory variant of degenerative diseases involving
the interphalangeal joints of the hands.
Common in females 40-50 years old.
The onset of erosive osteoarthritis is characterized by
episodic and acute inflammation of the DIP and PIP joints
of both hands in a symmetric manner.
Pain, edema, redness, nodules, and restricted motion are
found at the involved articulations of the hands.
The Pathological features are cartilage degeneration and
synovial proliferation.
76. Osteoarthritis affecting the DIP, base
of thumb, knees, hips, lumbar and
cervical spine.
Joint involvement Distribution
77. Radiologic Features
Involvement of the ulnar compartment of the carpus is significantly
spared differentiating involvement from rheumatoid arthritis.
Radiographic changes are characterized by osteophytes, loss of joint
space, and sclerosis. Osteophytes are identical to those seen in DJD.
They are marginal in origin, taper distally, and are often larger at the
distal articular component.
Loss of joint space is usually non-uniform, with adjacent subchondral
sclerosis.
Superimposed changes of erosions, periostitis, and ankylosis on these
degenerative features are characteristic of erosive osteoarthritis.
Bone erosions are distinctively centrally located on the proximal
articular surface and more peripherally at the distal articular surface.
78. Radiologic Features
At DIP and PIP
joints of hands.
1.Erosions (gull
wings sign).
2. Nodes.
3. Interphalyngeal
ankylosis.
80. Radiograph of both hands shows erosions of the distal
interphalangeal joints with typical “gullwing” configuration
due to central erosions and peripheral osseous proliferation
81. HANDS. A. Target Distribution. Note the
selective involvement of
the distal interphalangeal joints (arrows).
B. Radiologic Features. Shows on closer
inspection of these involved
joints reveals osteophytes, sclerosis, loss of
joint space, cystic erosions, and deformity.
82. Differential diagnosis
The main differential considerations are rheumatoid
arthritis, psoriasis, and non-inflammatory
degenerative joint disease.
Rheumatoid arthritis rarely involves the distal
interphalangeal joints and has a positive latex test.
Psoriatic arthropathy is characterized by discrete
marginal erosions with adjacent fluffy periostitis
(mouse ears sign).
Non-inflammatory DJD will show no erosions but will
otherwise appear identical to erosive osteoarthritis.
83. From left to right:
Rheumatoid affecting MCP, PIP, MTP and other joints in a symmetrical fashion.
Psoriatic arthritis affecting PIP, DIP and large joints in an asymmetrical fashion.
Ankylosing spondylitis affecting the axial skeleton and large peripheral joints in an
asymmetrical fashion.
Osteoarthritis affecting the DIP, base of thumb, knees, hips, lumbar and cervical
spine.
