Detail radiological finding of various types of arhtritis

1. Dr. SHOPNIL PRASLA
Jr-1 ,DEPARTMENT OF RADIOLOGY
MVP DR VASANTRAO PAWAR MEDICAL COLLEGE

2. TYPES OF ARTHRITIS
DEGENERATIVE ARTHRITIS
1. Primary Osteoarthritis:-Idiopathic(spontaneous) no
specific cause known but tend to be associated with
aging
2. Secondary osteoarthritis:-caused by previous injury
to affected bone,can began at young age.

3. 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.

4. 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

5. INFECTIOUS ARTHRITIS
1. Septic arthritis:-Life and limb threatening bacterial
infection of the joint.
CONNECTIVE TISSUE ARTHRITIS:-
1. Systemic lupus erythematous

6. Target sites of various arthritis in a joint.

7. Common Radiological Features of
Arthritis
 Soft tissue
swelling
 Subchondral
sclerosis and
erosion
 Narrowing of
joint space
 Joint effusion.
 Osteophytes
formation
 Suchondral
cystic lesion.
 Periarticular
osteoporosis

8. DEGNERATIVE ARTHRITIS
 OSTEOARTHRITIS
• Non-inflammatory degeneration of joint cartilage with secondary
effects on adjacent bone.
• It is degenerative condition affecting articulation especially those
which bear weight or subjected to much wear and tear
• It affects individuals aged 50 years and older and much more common
in women than men.
• Generally, in osteoarthritis, the large diarthrodial joints such as the hip
or knee and the small joints such as the interphalangeal joints of the
hand are most often affected; the spine, however, is just as frequently
involved in the degenerative process
• It begins focally and gradually increases in size.
• Initial loss of chondroitin sulfate leads to fibrillation and flaking, with
secondary stress effects on adjacent bone.
• Escape of synovial fluid into subchondral bone forms subchondral
bone cysts

9. Osteoarthritis of the Large Joints
 The hip and knee joints are the most common sites of
osteoarthritis
 There radiographic features of degenerative joint disease in
the hip:-
• Narrowing of the joint space as a result of thinning of the
articular cartilage.
• Subchondral sclerosis (eburnation) caused by reparative
processes (remodeling)
• Osteophyte formation (osteophytosis) as a result of
reparative processes in sites not subjected to stress (so-
called low-stress areas), which are usually marginal
(peripheral) in distribution

10. • Cyst or pseudocyst
formation resulting from
bone contusions that lead
to microfractures and
intrusion of synovial fluid
into the altered spongy
bone in the acetabulum,
these subchondral cyst-
like lesions are referred to
as Eggers cysts

12.  AP radiograph of the
hip demonstrates the
radiographic
hallmarks of
osteoarthritis:
narrowing of the joint
space, particularly at
the weight-bearing
segment (arrow);
formation of
marginal osteophytes
(open arrows); and
subchondral sclerosis
posterior

13.  CT of osteoarthritis of
the hip shows
diminution of the joint
space, osteophytes, and
subchondral cysts in
the femoral head.

14.  Anteroposterior (A) and
lateral (B) radiographs of
the knee
 Demonstrate narrowing
of the medial
femorotibial and
femoropatellar
compartments,
subchondral sclerosis,
and osteophytosis, which
are typical features of
osteoarthritis. Note that
osteophytes that were
not obvious on the
frontal projection are
much better
demonstrated on the
lateral radiograph.

15. MRI of osteoarthritis. (A)
Sagittal proton density-
weighted MRI of a shows
involvement of the
femoropatellar
compartment. Note joint
space narrowing,
subchondral cyst (arrow),
and osteophytes (open
arrows)
(B) Coronal T2-weighted
fat-suppressed
MR image shows complete
destruction of articular
cartilage of the lateral joint
compartment (arrows),
subchondral edema (open
arrows), and degenerative
tear of the lateral meniscus
(curved arrow).

16. COMPLICATION OF
OSTEOARTHRITIS
Anteroposterior (A) and lateral (B)
radiographs of the knee
demonstrate predominant
involvement of the medial
femorotibial and femoropatellar
joint compartments, with
formation of two large
osteochondral bodies.
 Osteochondral bodies.

17.  MRI of
osteochondral body.
A low-signal
intensity
osteocartilaginous
loose body in the
anterior joint space
is revealed on T1-
weighted sagittal
image (A) and T2-
weighted (B) sagittal
MR images of the
knee (arrows).

18. Osteoarthritis of the Small Joints
Primary Osteoarthritis of the Hand
 The most commonly affected small joints those of the
hand, particularly the proximal and distal interphalangeal
and the first carpometacarpal articulations
 In the distal interphalangeal joints, if hypertrophic
phenomena supervene and osteophytes are prominent,
degenerative changes are accompanied by Heberden nodes.
 Similar deformities in the proximal interphalangeal joints
are called Bouchard nodes .If the degenerative changes
involve the first carpometacarpal joint, they may result in
an odd deformation of the thumb.

19. Xray shows degenerative changes in the distal
interphalangeal joints, manifested by Heberden
nodes, and in the proximal interphalangeal joints,
manifested by Bouchard nodes. Note also
degenerative changes in the first carpometacarpal
joint (arrow).

20.  Radiograph of both
hands in addition to
the typical Heberden
and Bouchard nodes
shows deformative
changes at the first
carpometacarpal
articulations, resulting
in an odd configuration
of both thumbs.

21. Secondary Osteoarthritis of the Hand:-
 The most characteristic secondary osteoarthritic changes
in the small joints may be observed in acromegalic and
heamochromatic patients.
 These include soft-tissue prominence and enlargement of
the terminal tufts and the bases of the terminal phalanges;
there may also be widening of some articular spaces and
narrowing of others.beak-like osteophytes at the heads of
the metacarpals are a prominent feature

22. Radiograph of both
hands of a shows
widening of some and
narrowing of other
joint spaces,
enlargement of the
distal tufts and the
bases of terminal
phalanges, and beak-
like osteophytes
affecting particularly
the heads of the
metacarpals

23. Degenerative Diseases of the Spine
Degenerative changes may involve the spine at the
following sites:
 The synovial joints—atlantoaxial, apophyseal,
costovertebral, and sacroiliac—leading to osteoarthritis of
these structures
 The intervertebral disks, leading to the condition known as
degenerative disk disease
 The vertebral bodies and annulus fibrosus, leading to the
condition known as spondylosis deformans
 The fibrous articulations, ligaments, or sites of ligament
attachment to the bone leading to the condition known as
diffuse idiopathic skeletal hyperostosis (DISH).

25.  Osteoarthritis of the facet
joints. Oblique radiograph
of the lumbar spine
demonstrates advanced
osteoarthritis of the facet
joints. Narrowing of the
joint spaces, eburnation of
the articular margins, and
small osteophytes (arrows)
are similar to the changes
seen in osteoarthritis of the
large synovial joints.

26.  Degenerative changes of the vertebral facet joints are
very common, particularly in the mid and lower
cervical and the lower lumbar segments
 Involvement of the apophyseal joints may exhibit a
“vacuum phenomenon” which in fact represents gas in
the joint. This finding is almost pathognomonic for a
degenerative process.

27. Osteoarthritis of the apophyseal joints. (A) Oblique
radiograph of the lumbosacral spine demonstrates a
vacuum phenomenon of the facet joint L5-S1 (arrow) and
eburnation of the subarticular bone (arrowheads)
CT section through both facets clearly demonstrates the
presence of gas

28. INFLAMMATORY ARTHRITIS
 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

29.  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.
 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).

30. 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.
 Hand: earliest changes are seen at the metacarpophalangeal and PIP
joints. Evaluation should include the semisupination view of the hands
(Norgaard projection) for marginal erosions on metacarpal heads and
deformities like ulnar deviation, boutonniere, swan neck, spindle digit.

31.  Wrist: earliest change is erosion of ulnar styloid, multiple carpal
erosions (spotty carpal sign), most common location for bony
ankylosis, carpal radial rotation, zigzag deformity, Terry Thomas’ sign.
 Feet: earliest changes seen at the fourth and fifth metatarsal phalangeal
joints. Changes parallel and are identical to that seen in the hands;
Lanois deformity—dorsal subluxation of the metatarsal-phalangeal
joints, with fibular deviation.
 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.
 Hips: uniform loss of joint space (axial migration), minimal erosions,
protrusio acetabuli (most common cause),particularly bilaterally.
 Knees: uniform loss of joint space, marginal erosions (particularly at
the tibial condyles), and osteoporosis; often associated with large
Baker’s cysts.

33.  Anteroposterior (A) and
lateral (B) radiographs
of the knee shows
periarticular
osteoporosis, joint
effusion, and lack of
osteophytosis.

34. Anteroposterior
radiograph of the right
hip shows erosions of the
femoral head and
acetabulum, concentric
narrowing of the hip
joint, and acetabular
protrusio.

35. (A) Lateral radiograph
of the foot of shows
fluid in the
retrocalcaneal bursa
(arrow) associated with
erosion of the
calcaneus (curved
arrow).
MRI demonstrates bone
erosion in the posterior
process of the calcaneus
arrowhead) associated
with extensive
surrounding bone
marrow edema and
retrocalcaneal and
retro-Achilles bursitis
(arrows).

36. Xray demonstrates
erosions in the
radiocarpal and
intercarpal articulations
as well as the
carpometacarpal joint,
bilaterally (open arrows).
Note, in addition, subtle
erosions of the head of
the first, third, fourth,
and fifth metacarpals of
the left hand and of the
head of the second
metacarpal of the right
hand (arrows). A small
erosion at the base of the
middle phalanx of the
ring finger of the left
hand (arrowheads) and
the erosion in the right
triquetropisiform joint
(curved arrow) are also
well seen.

37. Oblique radiograph of
the hand shows the
swan neck deformity of
the second through
fifth fingers

38. 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

39.  Radiograph of the
hands demonstrates
the main-en-lorgnette
deformity- the
telescoping the fingers
secondary to
destructive joint
changes and
dislocations in the
metacarpophalangeal
joints

40.  Radiograph of the cervical spine

41. MRI
A sagittal spin
echo T1-
weighted MR
image shows
inflammatory
pannus eroding
odontoid
(arrow) and
cranial settling
with cephalad
migration of C2
impinging on
the medulla
oblongata
(open arrow).

42. USG
Sonography
shows thickened
synovial tissue
(arrows).

43. MRI MR images of the
left shoulder of a
show large articular
and periarticular
erosions, joint
space narrowing,
joint effusion, and a
tear of the supra-
spinatus tendon
(arrows)
Coronal T1-
weighted MRI of
the right knee in
demonstrates
a joint effusion with
inflammatory
pannus (arrow).

44. 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.

45. 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

46. 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.

47. 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. The odontoid
appears enlarged. C.
Lateral Cervical. Note
that the vertebral bodies
are hypoplastic in
combination with
posterior joint ankylosis.
These are characteristic
cervical spine changes

48.  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)

49. Radiograph of
both knees of a 20-
year-old woman
shows overgrowth
of the medial
condyles, one of
the characteristic
features of this
disorder

50. 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.
 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.

51. 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
etaplasia, 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.

52. Radiologic Features

53. 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.

54. (A) Lateral
radiograph of the
cervical spine in a
shows anterior
syndesmophytes
bridging the vertebral
bodies and posterior f
usion 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
(D)MRI shows
anterior
syndesmophytes,
calcification of
the posterior
longitudinal
ligament, and
preservation of the
intervertebral disks.

55. (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).
(B) T2-weighted MRI in
a 26-year-old man shows
early signs of ankylosing
spondylitis of the lumbar
spine, the shiny corners
(arrows).
(C) T2-weighted MRI of
the sacroiliac joints in
the same patient
demonstrates bone
marrow edema adjacent
to the sacroiliac joints
and erosive changes
bilaterally, more
prominent on the left
(arrows).

56. A. AP Sacrum. Note
that bilateral
sacroiliitis is clearly
seen with erosions,
hazy joint margin,
and subchondral iliac
sclerosis (arrows).
B. Axial CT: Sacroiliac
Joints. Observe the
erosive iliac lesions
(arrows) and the
subchondral sclerosis
arrowheads).

57. 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

58. 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.
 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.

60. 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

61. Pencil and cup deformity
Pencilling

62.  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

63. Non- Marginal
Syndesmophyte.
Note the thick,
vertical ossifications
that arise just
beyond the vertebral
body margins
(arrows).

64. Oblique
radiograph of the
lumbar spine in a
shows a
characteristic
single coarse
syndesmophyte
bridging the
bodies of L3 and
L4. The right
sacroiliac joint is
also affected.
(B) AP radiograph
of the lumbar
spine with
psoriasis reveals
paraspinal
ossification at the
level of L2-3.

65. A. PA Hand.
Fluffy and Linear.
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:
Fluffy. 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.

66. 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

67. 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

68. 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.

69. Radiologic Features
 Swelling, osteoporosis, uniform loss of joint space, erosions, periostitis.
 Specific target sites: forefoot, calcaneum, ankle, knee, sacroiliac, spine.
 Foot: metatarsophalangeal and interphalangeal joints. Dorsal
subluxation of the proximal phalanges and fibular deviation of the digits
results in the Lanois deformity.
 Calcaneum: plantar and Achilles insertions.
 Ankle: loss of joint space, swelling, periostitis.
 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

70. Xray 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).

71. Xray Finger show
marginal erosions
(arrows), linear periostitis
(arrowheads), and soft
tissue swelling (crossed
arrows) at the proximal
interphalangeal joint.

72. 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).

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. AP radiograph of
the lumbar spine
with reactive
arthritis
demonstrates a
paraspinal
ossification
bridging the L2
and L3 vertebrae.

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. 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.

77. Radiologic Features
 At DIP and PIP
joints of hands.
 Erosions (gull
wings sign),
sclerosis,
osteophytes,
periostitis
(mouse ears
sign), ankylosis,
and non-
uniform loss of
joint space.

78. Gull Wings Sign.
Shows characteristic
biconcave articular
contour (arrows).

79.  Radiograph of both hands shows erosions of the distal
interphalangeal joints with typical “gullwing” configuration
due to central erosions and peripheral osseous proliferation

80. 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.

81. 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.

82. METABOLIC ARTHRITIS
Gout
• Disorder of purine metabolism in which hyperuricemia leads to
deposition of sodium monourate crystals into cartilage, synovium,
periarticular, and subcutaneous tissues.
• These crystals evoke a strong inflammatory arthritis usually in the
lower extremity.
• Affects males 20:1, usually in the 4th and 5th decades.
• Four stages apparent: asymptomatic hyperuricemia, acute gouty
arthritis (especially at the first metatarsophalangeal joint),
polyarticular gouty arthritis (chronic, long-standing disease), and
chronic tophaceous gout (soft tissue accumulations of sodium
monourate).
• Accumulation of these crystals (tophi) results in synovial pannus, bony
marginal erosions, cartilage degradation, and bone destruction.

83. Radiologic Features
 General features include dense soft tissue tophi,
preservation of joint space, bone erosions (marginal,
periarticular overhanging margin sign, intraosseous)
normal bone density, periosteal new bone, secondary
degenerative joint changes, chondrocalcinosis, and
avascular necrosis.
 The most frequently targeted areas of involvement are the
first metatarsophalangeal joint, other metatarsophalangeal
joints, the hands, and wrists.
 Spine and sacroiliac articulations show infrequent erosions.
Occasional epidural tophi occur leading to compression
myelopathy.

85. Xray foot shows
Asymmetric periarticular
erosions that spare part of
the joint are typical of
gout arthritis, seen here
involving the first
metatarsophalangeal joint
of the right foot.
Note the characteristic
overhanging edge at the
site of erosion (arrows)
and the soft-tissue mass
representing a tophus
(curved arrows);
osteophytes and
osteoporosis are absent,
and the joint is partially
preserved (open arrow).

86. Demonstrating
a classic
overhanging
margin sign
(arrow),
periarticular
erosion
(arrowhead),
and
intraosseous
erosion (crossed
arrow).

87. PA Foot. Show the soft
tissue swelling in a juxta-
articular position about the
great toe. The tophi have
calcified with juxta-
articular erosions and
relative preservation of the
joint space. This is the
characteristic plain film
finding of gouty arthritis
B. T1-Weighted MRI,
Coronal Foot. C. T1-
Weighted MRI, Sagittal
Foot.
Show the low signal
intensity in the area
of the tophi erosion of the
bony structures, which
correlates with the plain
film findings. The signal
intensity in gouty tophi is
low on T1- and T2-
weighted images.

88. A.Fingers. Note the
large tophi and erosive
changes.
B. Hand. Shows
multiple areas of bone
destruction owing to
the presence of tophi. A
large intraosseous
tophus is seen in the
second digit (arrow).
Numerous erosions are
also visible in the carpal
bones, creating the
spotty carpal
sign(arrowheads)..
C. Spotty Carpal Sign.
Note that multiple
carpal erosions
have resulted in this
appearance.
D. Metacarpal
Destruction. Observe
that at the base of the
metacarpals
extensive bony
destruction has
occurred from adjacent
tophi (arrows).
E. Radioulnar Erosion.
Note the large erosive
excavations at the distal
radius and ulna (arrow).
The outline of the
adjacent tophus can be
seen (arrowhead).

89. Calcium Pyrophosphate Dihydrate Crystal
Deposition Disease (Pseudogout)
 An inflammatory joint disease caused by deposition of CPPD into the
synovial fluid, linings, and articular cartilage.
 Usually more than 30 years of age, with a peak at 60 years with equal
sex distribution.
 Acute presentations (20%) may simulate gout or rheumatoid arthritis
with swollen, hot, tender joints; usually affects knees, wrists, and
hands, with attacks lasting 1-7 days.
 Chronic presentations (60%) simulate degenerative with bony
swelling, crepitus, and stiffness.
 The pathological features is crystals deposition into the chondrocyte
lacunae within articular cartilage due to which chondrocytes
subsequently die, resulting in impaired cartilage replacement and
maintenance, followed by thinning and cracking, simulating DJD.

90. Radiologic Features
 Basic radiographic signs are soft tissue calcification and
pyrophosphate arthropathy.
 Cartilage calcification (chondrocalcinosis) is the most
common radiographic sign of CPPD crystal disease in the
knees, wrists, symphysis pubis, elbows, and hips.
 Fibrocartilage is shaggy and irregular (knee menisci, wrist
triangular cartilage, symphysis pubis).
 Hyaline is thin, linear, and parallel to and separated from
the adjacent subchondral bone (wrist, elbow, shoulder,
knee, hip); additional calcification in capsule, synovium,
ligaments, tendons, and blood vessels

91.  Pyrophosphate arthropathy is most common in the knee, wrist, and
metacarpophalangeal joints.
 Articular changes simulate DJD, except unusual articular distribution,
unusual intra-articular distribution, prominent subchondral cysts,
bone destruction, and variable osteophyte size.
 The knee is the most commonly involved joint radiographically and
clinically. Chondrocalcinosis of menisci,Intraarticular osseous and
calcific bodies are common. Diagnosis strongly suggested if
patellofemoral joint is selectively and/or severely involved.
 In the wrist, chondrocalcinosis of the triangular fibrocartilage and the
hyaline cartilages of the entire carpus. Advanced and exuberant
degenerative changes in the radiocarpal compartment. Scaphoid moves
proximally and the lunate moves distally (stepladder appearance).

92. A. Diagram.
Chondrocalcinosis
can be seen in
either the
fibrocartilage (FC)
or hyaline cartilage
(HC).
B and C. Meniscal
Chondrocalcinosis
(arrows).
D. Calcification.
Note the
calcification in the
meniscus (arrow),
hyaline cartilage
(arrowhead), and
synovial
membrane
(crossed arrows).

93. Chondrocalcinosis
of the triangular
ligament
Multiple cysts

94. WRIST. A. and B.
Chondrocalcinosis. Note the
calcification within the
triangular cartilage (arrows)
and intercarpal hyaline
cartilage
C. Subchondral Cysts. Note
the cysts within the lunate
and scaphoid, with
Chondrocalcinosis.
D. Scapholunate
Dissociation (Terry Thomas’
Sign). Observe that the
scapholunate space is
widened (arrow).
E. Scapholunate Advanced
Collapse Deformity.
Observe the large
subchondral cysts within
the radius and carpus
(arrow). Observe that the
lunate has rotated
anteriorly, as noted by its
triangular shape (pie
sign) (arrowhead). There is
widening of the
scapholunate space (crossed
arrow).

95. Calcifications at the
MCPs

96. INFECTIOUS ARTHRITIS-PYOGENIC
Septic Arthritis:-
• Most common route of joint contamination is hematogenous spread or
direct traumatic implantation.
• Single joint involvement is seen
• The most frequently isolated organism is Staphylococcus aureus.
• The clinical feature are Chills, fever, edema, pain, and redness with
Altered gait and a painful limp are common in weight-bearing joints.
• The pathological feature are purulent exudate creates joint distention,
• Cartilage destruction leads to osseous destruction and loss of joint
space,Regional hyperemia leads to juxta-articular osteoporosis.

97. Radiologic Features
 The knee and hip are the
most common sites.
 Joint effusion leads to
distortion of the fat folds.
 Positive Waldenström’s
sign.
 Rapid loss of joint space;
loss of the cortical white
line and moth-eaten
pattern of bone
destruction.
 Bony ankylosis rarely
occurs.

98. Waldenström’s sign
An early sign of septic hip
joint disease is an increase in
the articular joint space
between the femoral head
and Köhler’s teardrop (the
inferior and medial surface of
the acetabulum). This
measurement is taken from
the lateral aspect of Köhler’s
teardrop to the medial margin
of the femoral head; a
measurement > 11 mm or a
difference in Measurement >
2 mm, compared with the
opposite hip, is a positive sign
and is considered clinically
significant
Note:-NOT specific for
infection can aslo be seen
post traumatic and synovial
imflammatory condition

99. Xray shows complete loss of
joint space at the third
metatarsophalangeal
articulation. This loss of
bone density is present on
both sides of the joint. The
early lesion of septic
arthritis is loss of the
normal subchondral cortical
white line (arrowhead) in
the involved third
metatarsal head. Note the
normal cortical white line
(arrows) in the second and
fourth metatarsal heads.

100. Anteroposterior
radiograph shows
extensive destruction
of the right femoral
head and neck and
right acetabulum
consistent with septic
arthritis

101. SEPTIC ARTHRITIS
WITH
PROGRESSION.
A. Initial Film. Note
the prominent soft
tissue swelling
of the entire digit
(arrow). Slight bone
destruction is
evident
(arrowhead).
B. 1-Month Follow-
Up. Shows marked
soft tissue swelling
of the entire digit
(arrows). Moth-
eaten destruction of
the middle and
distal phalanx is
evident
(arrowheads).

102. (A) Dorsovolar radiograph of the
right wrist shows destruction of
the radiocarpal joint and erosive
changes of the distal radius, distal
ulna, lunate, and scaphoid
bones. Note also involvement of
the carpometacarpal articulation.
There is periosteal reaction of the
distal radius and ulna and soft-
tissue swelling.
(B) Coronal three-dimensional
(3D) (GRE) fatsuppressed (left
part) and coronal proton density-
weighted fat-suppressed (right
part) MR images demonstrate
an erosion of the distal
ulnar(arrow) with a radiocarpal
joint effusion extending to the
distal radioulnar joint through a
complete tear of the triangular
fibrocartilage. Note the
intermediate-to-low signal
intensity of most of the effusion
and mild surrounding soft-tissue
edema (arrowheads) consistent
with synovitis due to septic
arthritis.

103. INFECTIOUS ARTHRITIS-NON PYOGENIC
Tuberculous Arthritis:-
• Tuberculosis involving the weight-bearing appendicular joints is
second only to the preferred spinal site with monoarticular
involvement
• The hip and knee are the most common sites (representing 75% of
cases), with the ankle, shoulder, elbow, pubes, and wrist being rarely
involved.
• Most patients are middle-aged or elderly, and many have received
multiple intra-articular injections of steroids for a pre-existing
unrelated joint disorder.
• The tubercle bacillus may lodge in the synovium or the metaphyseal
portion of the bone. Most tubercular arthritic lesions begin within the
metaphysis as an infectious focus with secondary spread to the joint

104.  With this mode of presentation the inflammatory changes in the
synovial membrane are extensive, leading to significant early joint
effusion.
 The infected synovial membrane becomes thickened, and granulation
tissue spreads to the free surface of the articular cartilage. This
interference with the free surface of the articular cartilage affects its
nutrition and ultimately leads to its destruction.
 Early erosions occur involving the portion of the proximal femur that is
bare of cartilage but exposed to synovium. Thus the initial erosive
lesions may simulate those of early rheumatoid arthritis
 As the entire infective process progresses, a non-uniform destruction of
the articular surface occurs.
 As cartilage and bone destruction ensue, sequestrum formation of
variable size may occur. This process often involves both surfaces of the
joint, leading to the characteristic kissing sequestrum.

105. RADIOLOGICAL FEATURES
 Early radiographic signs are joint widening, which is secondary to joint
effusion and distention, and soft tissue swelling.
 This is followed by destruction of the subchondral cortex (cortical
white line) and a moth-eaten pattern of bone destruction, often on
both sides of the joint,
 Later, narrowing of the joint occurs as the articular cartilage and bone
are destroyed. The entire process is accompanied by juxta-articular
osteoporosis, which occurs as a result of hyperemia and disuse atrophy.
• A triad (Phemister’s triad) of radiographic findings exists and is
characteristic of tuberculous arthritis: progressive and slow joint space
narrowing, juxta-articular osteoporosis, and peripheral erosive defects
of the articular surfaces.

106.  The end stage of tubercular arthritis is fibrous ankylosis of the joint.
Bony ankylosis is rare in tuberculosis, but it is a common sequela of
pyogenic arthritis
 A peculiar complication of tubercular arthritis in the knee is a focal
overgrowth of the medial epiphysis, creating a megacondyle, as a result
of localized hyperemia. This sometimes mimics a similar appearance of
the medial condyle in Still’s disease and hemophilia
 Sacroiliac joints:-The presentation is usually unilateral. (Fig. 12-67) A
pseudo-widening of the joint, early osteolytic destructive lesions, and
eventual ankylosis are the cardinal roentgen signs.

107. A. AP Hip. Note the
extensive resorption of
the entire femoral head,
with lateral displacement
of the femur. Observe
the destruction and
disorganization of the
acetabulum. This is an
advanced stage of
tuberculosis of the hip.
Showing the solid
periosteal new bone
formation on the
diaphysis of the
proximal femur (arrows).
B. AP Knee. Note the
symmetric narrowing of
the joint space about the
knee articulation.
Observe the destruction
of the articular cortex of
the distal femur (arrows).
These represent
relatively early signs
of tubercular arthritis.

108. KISSING
SEQUESTRUM: HIP
JOINT. Shows the
complete resorption
of the femoral head,
with extensive
destruction of the
articular cartilage.
Note the lateral
displacement of the
femur from the
acetabulum. There are
many bony sequestra
scattered throughout
the acetabular and
femoral head area. An
extensive degree of
sequestered debris is
noted in the area of
the greater trochanter.

109. Anteroposterior (A)
and lateral (B)
radiographs of the
elbow demonstrate a
large joint effusion, as
indicated by positive
anterior and posterior
fat pad signs on the
lateral projection.
Small periarticular
erosions are not clear
on these views.
(C) CT section shows
narrowing of the joint
and peripheral
erosions typical of
tuberculous infection.

110. PAbradiograph of the left
wrist and hand shows
advanced arthritis
involving the left carpus.
There is complete
destruction of the
radiocarpal, ,midcarpal
and carpometacarpal
articulations as well as
whittling and sclerotic
changes in the distal
radius and ulna. Note the
osteoporosis distal to the
affected joints and the
soft-tissue swelling.

111. NEUROTROPHIC ARTHROPATHY
 Neurotrophic arthropathy is a destructive articular disease that occurs
secondary to a loss or impairment in joint proprioception.
 Subsequently, the involved joint undergoes premature and excessive
traumatic degenerative changes that lead to severe destruction and
instability.
 Distinct lack of objective and subjective pain despite joint swelling,
instability, and crepitation.
 Absent deep reflexes, analgesia, ataxia, and serology (possibly) positive for
underlying pathological cause.
 The pathological features are loss of the normal protective nervous reflexes
leads to lax ligaments and muscles and abnormal joint mechanics result in
rapid and excessive degeneration of articular cartilage, hypertrophic spurs
and bone formation, fractures, and complete joint disorganization.
 The underlying conditions leading to neuropathic joint include diabetes
mellitus, syphilis, leprosy, syringomyelia, and congenital indifference to
pain.

112. RADIOLOGIC FEATURES
 Two basic types: hypertrophic and atrophic.
 Hypertrophic: classic type in which bone production is the
dominant feature and summarized as the six Ds:
 Distension: earliest finding owing to effusion.
 Density: increase in subchondral bone sclerosis.
 Debris: bony intra-articular fragments.
 Dislocation: joint surfaces often malaligned.
 Disorganization: joint components usually disrupted (bag of
bones).
 Destruction: articular bone shows loss of bone substance
 Usually predominates in the weight-bearing joints such as the
lumbar spine, hips, knees, ankle, and tarsus

113.  Atrophic: may follow hypertrophic phase
or occur as an isolated finding, and is
especially more common in the shoulder,
hip, and foot.
 Articular ends of bone may appear
surgically amputated or tapered like a
licked candy stick; absence of six Ds.
 Spine: usually lumbar region, with large
osteophytes, prominent sclerosis,
advanced discopathy, severe
subluxations, and body fragmentation.
 Knee: hypertrophic features—sclerosis,
debris, destruction, and dislocation.
 Foot: hypertrophic, especially in subtalar
joints. Atrophic in forefoot, especially in
metatarsophalangeal joint region.

114. Anteroposterior
radiograph of the
right hip of shows
the typical features
of neuropathic
(Charcot) joint.
There is complete
disorganization of
the joint,
fragmentation, and
subluxation. The
absence of
osteoporosis is a
characteristic
feature of the
neuropathic joint.
This condition
represents the most
severe manifestation
of degenerative joint
disease.

115. A. Hypertrophic
Pattern, AP Hip.
Observe the
density, debris,
destruction, and
dislocation of the
joint.
B. Atrophic
Pattern, AP Hip.
In contrast,
observe that
the femoral head
has been
resorbed, with a
distinct lack of
debris.

116. NEUROTROPHIA
RTHROPATHY:
ATROPHIC
FEATURES.
A. Syringomyelia,
Shoulder. Note the
amputated
appearance to the
humerus.
B. Diabetes, Foot.
Shows that the
distal metatarsals
are tapered,
producing
a licked candy
stick
configuration.

117. NEUROTROPHIC
ARTHROPATHY:
PROGRESSIVE CHANGES
WITH SYPHILIS. LUMBAR
SPINE.
Initial Study. Note that
degenerative changes are
visible with osteophytes and
loss of disc height.
B. 3-Year Follow-Up. Note
that advancement of the
degenerative changes is most
prominent at L2 and L5.
C. 6-Year Follow-Up. Observe
the severe discovertebral joint
destruction with sclerosis and
bony debris at the L2-L3 level.
D. 9-Year Follow-Up. Note
that the process has extended
to the remaining lower lumbar
levels with progressive
collapse of the lumbar
vertebral bodies.
E. 10-Year Follow-Up. Observe
the complete destruction of
vertebral bodies and
intervertebral disc spaces with
exuberant bone formation and
debris, completing the process

118. NEUROTROPHIC
ARTHROPATHY:
DIABETES.
FOREFOOT. A.
Early Atrophic
Changes. Note the
tapered contour of
the second and
third metatarsal
heads. Note the
vascular
calcification
frequently seen in
diabetic patients.
B. Later Changes.
Observe that the
tapered
configuration is
easily identified in
association with
osteolysis of
adjacent bones.

119. CONNECTIVE TISSUE ARTHRITIS
Systemic Lupus Erythematosus
• Generalized connective tissue disorder involving multiple organ
systems.
• Women of childbearing age affected.
• Onset with fever, malaise, skin rash, and arthralgias.
• The pathological features are Immune complexes and fibrinoid
material are deposited in body tissues, resulting in inflammatory
changes in blood vessels, synovium, and serous membranes.

120. Radiologic Features
 Most prominent features
visible in the hands.
 General features are
reversible subluxations,
dislocations and
deformities, normal joint
spaces, osteoporosis,
osteonecrosis, soft tissue
atrophy, and calcification.
 Hand: ulnar deviation,
boutonniere, and swan-
neck deformities;
 Spine: atlantoaxial
instability; steroid-
induced compression
fractures.

121. (A) Typical appearance
of the thumb SLE.
Note subluxations in
the first
carpometacarpal and
metacarpophalangeal
joints without articular
erosions.
(B) the oblique
radiograph of her left
hand shows
dislocations at the first
carpometacarpal joint
and distal
interphalangeal joint
of the index finger
(arrows), and
subluxations in the
metacarpophalangeal
joints of the index and
middle fingers
associated with swan-
neck deformities

122. SYSTEMIC LUPUS
ERYTHEMATOSUS:
DEFORMITIES. A.
PA Hands. Note the
complete
dislocation
of the
metacarpophalange
al joints, swan-neck
deformities of the
fingers, and
boutonniere
configuration of the
thumbs bilaterally.
B. Hands. Same
patient with hands
placed firmly on the
cassette. Note the
reversibility of all
deformities.
These deformities are reversible owing to the
tendinous and ligamentous laxity, but will
reappear immediately once the hand is moved

123. Scleroderma
 Systemic inflammatory connective tissue disease affecting
the skin, lungs, gastrointestinal tract, heart, kidneys, and
musculoskeletal system
 More common in females 30-50 years of age.
 Initial peripheral pain and swelling, with high incidence of
Raynaud’s phenomenon.
 The pathological features are low-grade perivascular
inflammation with atrophy and fibrosis of adjacent
collagen.

124. Radological features
Hand is most commonly involved
Soft tissue:-tapered, conical fingertips ,retraction of
fingertip,loss of overlying skin folds ,calcification: skin
(calcinosis cutis) intra-articular.
Bone:-Resorption—distal tufts(acroosteolysis)
Joint:-Erosive arthropathy at first metacarpal-carpal
joint

125.  SCLERODERM
A WITH
DIGITAL SKIN
RETRACTION
AND EARLY
ACROOSTEOL
YSIS.
Note the atrophy
and retraction of
the soft tissues of
the fingertip at the
fourth digit
(arrows).
Resorption of the
distal tuft is also
seen (arrowhead).
The combination
of these two
findings is highly
indicative of
scleroderma.

126. SCLERODERMA:
DIGITAL PATTERNS
OF CALCINOSIS
CUTIS.
A. Punctate. B. Sheet-
Like.