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ARTHRITIS - Disease that affects bones on both sides of the joint space and Narrows the space in between them Classification Hypertrophic Hallmarks Bone production Sclerosis Infectious Hallmark Destruction of articular cortex Erosive Hallmark Erosions Hypertrophic Arthritis (Osteoarthritis) Degenerative arthritis Charcot arthropathy x-ray changes : - Sclerosis - Osteophyte formation - Decreased joint space Hypertrophic Arthritis Classification Degenerative arthritis Charcot arthropathy Charcots Arthropathy General Disturbance in sensation leads to multiple microfractures Pain sensation intact from muscles and soft tissue Causes Shoulders syrinx, spinal tumor Hips tertiary syphilis, diabetes Feet diabetes Charcot arthropathy is a progressive musculoskeletal condition characterized by joint dislocation, fractures and deformities. It results in progressive destruction of bone and soft tissue of weight-bearing joints, most commonly in the foot and ankle. It is most commonly due to diabetes. Findings X-ray findings Fractures Soft tissue swelling Destruction and/or dislocation of joint Sclerosis Osteophytosis

Infectious Arthritis More common in adult Usually from local trauma-surgery or accident Children may can be affected with osteomyelitis Destruction of articular cartilage & cortex Tends to affect one joint (DDx from gout) Infectious Arthritis Causes Usually staph - early destruction of articular cortex Rapid course (unlike most arthritides) TB spreads via bloodstream from lung More protracted course In children, spine most common; in adults, knee Severe osteoporosis Healing with ankylosis common in both (ankylosis - Stiffness or, more often, fusion of a joint) Septic Arthritis - A plain X-ray is not so useful to diagnose the early stages of septic arthritis. - However, it may be a useful test to rule out other medical conditions that share similar symptoms with septic arthritis. - Septic arthritis usually has to go untreated for at least two weeks before the damage it causes can be detected on an x-ray. - X-ray finding: Destruction of articular cartilage & cortex - A scan of the joint may help to confirm the diagnosis. Radiographic Findings y of TB of the Bones (Other than the Vertebral Column) 1. bony rarefaction- at first merely show as osteoporosis, ie. Loss of trabecular pattern and reactive hyperemia, decalcification 2. bony destuction- is present in epiphysis and metaphysis and the cortex outline of the articular surface is lost 3. heavy overcalcification ring calcification may be seen with abscess

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4. the dense image of a sequestrum, this is surrounded by an osteolytic ring representing the fibrous ring joint space narrowing-necrosis and separation of articular cartilage Erosive Arthritis Types Rheumatoid arthritis Gout Erosive osteoarthritis Rheumatoid variants Psoriatic arthritis Ankylosing spondylitis Erosive Arthritis More Types Connective tissue disease Scleroderma SLE Jaccoud's arthropathy Sarcoidosis Rare Amyloid Rheumatoid Arthritis GENERAL - Bilaterally symmetrical - Radiocarpal jt most commonly narrowed - Periarticular demineralization st nd - Begins MCP jts of 1 and 2 fingers - Large joints usually no erosions Can lead to 2 DJD Marked narrowing of joint space with intact articular cortex, think of RA Little or no sclerosis Especially, hips and knees

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TB of spine (Potts disease) - Spine is the most common site of musculoskeletal TB, which is involved in the thoracic or lumbar spine. - The initial focus is in a vertebral body, near the disc, it soon spreads across the disc, the disc is infected secondarily which it destroys to involve the neighboring vertebral body. - The erosion of the vertebral endplates of contiguous vertebral led to disc narrowing. Radiographic Findings of Potts Disease bone destruction wedging compressive fracture Kyphosis joint space narrowing Paraspinal abscess may be present Three types: 1) Edge type (Intervertebral type) quite common in adults 2) Central type The infection begins in the center of vertebral body. 3) subperiosteal type Paravertebral abscess involves para spine area which surrounds the vertebral bodies. Pus commonly spreads to the neighboring psoas , then extends to iliac fossa, femoral triangle, and spinal cord or roots. Erosive Arthritis X- RAY FINDINGS: Synovial proliferation (pannus formation) Inflammation Erosions seen in small joints (hands) better than large (hips) Destroy portion of cortex Synovium -A layer of connective tissue which lines sheaths of tendons at freely moving articulations. Pannus - A membrane of granulation tissue covering the normal surface of the articular cartilages in rheumatoid arthritis.

Rheumatoid arthritis: x-ray changes Early x-ray findings loss of joint space juxta-articular osteoporosis soft-tissue swelling Late x-ray findings periarticular erosions subluxation Gout General - Long latent period between onset of symptoms and bone changes - Asymmetric and monoarticular - More common in males st - Most common at 1 MT-P joint - Tophi rarely calcify - Olecranon bursitis is common Gout Findings

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Juxta-articular erosions o Sharply marginated with sclerotic rims o Overhanging edges (rat-bites) No joint space narrowing until later Little or no osteoporosis Soft tissue swelling Tophi rarely calcified involving an entire, single digit within the hand. The appearance of a sausage digit (cocktail sausage) is classically associated with the single x-ray pattern of involvement seen in some patients with psoriatic arthritis, and may be the initial manifestation of the disease. Ankylosing Spondylitis Ankylosing spondylitis (AS) refers to inflammation of the joints in the spine. AS is also known as rheumatoid spondylitis or Marie-Strmpells disease (among other names). Squaring of vertebral bodies Bamboo-spine from continuous syndesmophytes Peripheral large joint erosive arthritis Imaging of Infectious Arthritis - Conventional Radiography - Arthrography - Ultrasound - Nuclear Medicine Studies - CT - MRI Arthrography Used only in conjunction with joint aspiration Joint aspiration is the most effective procedure for diagnosis of infectious arthritis - Provides synovial fluid for diagnosis - Relieves joint pressure cause by accumulation of fluid/ pus Injection of contrast into the joint confirms needle placement Radiographs obtained after contrast may reveal: - Destruction of the articular cartilage - Hypertrophic alterations to the synovium Irregular or contracted joint capsule in chronic infection Ultrasound for Infectious Arthritis Alone, US is unable to confirm the diagnosis of septic arthritis However, US is a very sensitive modality for demonstrating joint effusion

Gout: Bony erosions are typically punched out with sclerotic margins and overhanging edges "rat bite erosions". Erosive osteoarthritis is typically bilateral and symmetrical, and it occurs in the interphalangeal, particularly distal interphalangeal, joints of the hands. The disease most commonly occurs in postmenopausal women, and it may be hereditary. The erosions are centrally located in contrast to the marginal erosions in rheumatoid arthritis. Joints assume a gull-wing configuration, with central erosions flanked by raised lips of bone. Rheumatoid Variants Psoriatic Arthritis Ankylosing Spondylitis Psoriatic Arthritis Almost always accompanies skin disease, especially nail changes Involves DIP joints of hands > feet Cup-in-pencil deformity Resorption of terminal phalanges No osteoporosis Psoriatic Arthritis X-ray Findings Psoriatic arthritis patients often have osteolysisloss of boneon their x-rays. The pencil-in-cup deformity at the DIP joint is classic for psoriatic arthritis. Other x-ray findings seen in psoriatic arthritis include: swelling of non-bony structures, joint space narrowing joint erosions and/or spontaneous joint fusions. These findings can also occur with: erosive osteoarthritis and rheumatoid arthritis as well Sausage finger with swelling of middle joint (PIP) X-ray of the hand with diffuse fusiform softtissue swelling of the entire 3rd digit. This sign refers to fusiform soft-tissue swelling

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May be effective in guiding needle aspiration of joint MRI for Infectious Arthritis Not commonly used for imaging suspected septic arthritis as dx can readily be confirmed with less expensive modalities Advantages: Extremely sensitive for detection of infectious arthritis More specific for infectious arthritis than conventional radiography or CT Can provide images in any place Disadvantages Expensive Not needed to establish diagnosis MR Findings in Infectious Arthritis Early Stages of Infection: T2 images reveal distention of joint capsule by nonspecific highintensity fluid Later Stages of Infection: Can detect joint effusion, cartilage destruction, narrowing of joint and cellulitis around joint MRI can readily detect extension of the infectious process into adjacent bone marrow and the transition to osteomyelitis T2 images reveal infected fluid and blood in the joint of inhomogeneous intermediate signal intensity T2 images also reveal an area of signal hyperintensity in the soft tissue around the affected joint Infectious Arthritis Summary Conventional radiography and joint aspiration are the mainstays of infectious arthritis diagnosis Arthrography and less commonly CT or Ultrasound may play a role in guiding joint aspiration MRI has little role in the dx of infection arthritis but may be used to evaluate for complications, particularly osteomyelitis

Nuclear Medicine Studies for Infectious Arthritis Most rapid method for determination of the site and distribution of joint infection Scintigraphy studies are sensitive indicators of altered osteoblastic activity Limited by: Poor specificity Inability to accurately delineate complex anatomy Local disturbances in vascular perfusion, clearance rate, permeability and chemical binding 3- or 4- phase bone scan with T99m MDP is the most commonly used nuc med study Bone Scan for Infectious Arthritis 3-phase T99 MDP Bone Scan findings Increased blood flow adjacent to the joint Prominent activity on blood pool images on both sides of the affected area A fourth phase (delayed 24 hour imaging) shows: Diminution of activity This is in contrast to osteomyelitis which invariably has increased activity on delayed images CT for Infectious Arthritis Not standard for evaluation of joint infections but can be used to guide complex joint aspirations When used, CT findings include: Water density fluid in the joint space and associated irregularity and narrowing of the joint Soft tissue swelling Articular erosion and subchondral bone destruction Effective in dx early infectious arthritis: Synovial thickening Small joint effusion Can identify air bubbles in infections caused by gas forming organisms Caution b/c air bubbles can also represent a degenerative process in SI and facet joints and are also common after hip dislocation