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Radiographic InterpretationinRheumatology

Ajchara Koolvisoot, MD.

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General Approach toMusculoskeletal

Imaging

A Alignment

B Bone C Cartilage D Disc S Soft tissue

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Key Terms in ReportingSkeletal Diseases

Arthritis & bone disease Joint space : narrow, ankylosis

Subchondral bone

margin : smooth, irregular

erosion, osteophyte / syndesmophyte

bone : osteopenia, sclerosis, cyst

Alignment : deformity Adjacent bone : osteopenia, osteolytic /

sclerosis

Periosteal reaction : solid, interrupted type

Soft tissue : swelling, calcification

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Key Terms in Reporting :

Osteolysis / bony destruction

Geographic Motheaten Permeative Large, well-definedor ill-defined hole

Small, countableholes

Tiny, uncountableholes

benign malignant

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Key Terms in Reporting :Periosteal Reaction

Solid type Slowing-growing process

Interrupted type Rapid-growing process

Lamellated/

Onion-skin

Sunburst/sunray

Hair-on-end

benign malignant

Codmans

triangle

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Musculoskeletal Imaging :Differential Diagnosis Universal DDx

Vascular Infection

TraumaAutoimmuneMetabolicInflammation

NeoplasmCongenitalDrug

Specific DDx

VITAMIN C+D

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Differential Diagnosis :Logical & Systematic

Approach History & Physical examination

Demographics

Suttons law

Radiographic hallmarks

Pattern approach

Common

diseases &their hallmarks

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Demographics

Age 20-40 >40SpA OA / DISHRA Gout/CPPD

CNTD HOASeptic

Septic

Sex Male FemaleSpA CNTD

Gout RA2OA 1OAHOA

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Common RheumaticDiseases

Osteoarthritis Rheumatoid arthritis Crystal-induced arthritis : Gout & CPPD

Septic arthritis : Bacterial & TB

CNTD Spondyloarthropathies DISH Tumors : osteosarcoma, MM,

metastasis

Rheum.manifestations in systemic dis.

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Radiographic Hallmarks

Osteophytes Degenerative

( OA ) Erosion Inflammation

( RA )

Punch-out Metabolic ( Gout )

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General DDx of Joint Diseases

Feature Inflamation Degenerative Metabolic

Symmetry Symmetric Asymmetric Asymmetric

Joint involved Polyartic. Monoartic. Mono/

polyartic.

Alignment Abnormal Abnormal Normal

Bone density Decreased Normal/increased Normal

Erosion Poorly-defined Absent Sharply-

defined

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Pattern Approach

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Radiographic Reading

Describe type of X-rays Joint space Joint surface Subchondral bone Adjacent bone Alignment Periosteal reaction ( if

present ) Soft tissue

Always specify which one / side is/are abnormal

ABCDS

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CaseApproach

1. Radiographic Reading

2. Most likely diagnosis

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Case 1 : 64 yo man- painful both knees 6yrs

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Osteoarthritis

Characteristic : Non-uniform joint space narrowingIrregular joint surfaceSubchondral sclerosis / cystOsteophytesDeformity

Common location : Knee, DIP, PIP, 1 st CMC, 1 st MTPSpine : lower C, lower L

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Case 2 : 22 yo man fever & painful Rt knee 3wks

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Septic arthritis

Soft tissue swelling with joint effusion Localized osteopenia Diffuse joint space loss Marginal or central erosion May occur with periosteal reaction

Chronic granulomatous disease ( TB )

Characterized by extensive osseous destruction

with minimal reactive sclerosis

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TB arthritis

Phemisters triad : Juxtaarticular osteopenia

Peripherally located erosion

Gradual narrowing of joint space

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Comparison of TB & PyogenicArthritis

TB Pyogenic

Soft tissue swelling +

+

Osteoporosis + + Joint space loss Late Early

Marginal erosion + +

Bone proliferation + +( sclerosis, periostitis )

Bone ankylosis + +

Slow progression + -

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Case 3 : 68 yo man Severe back pain & lethargy 2mths

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Osteoblastic Metstasis

5 Bees Lick PollenBrain ( medulloblastoma )BronchusBreastBowel ( espeically carcinoid )Bladder LymphomaProstate

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Case 4 : 65 yo lady painless swelling &deformity both ankles

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Neuropathic Joint

Hypertrophic : 5Ds ( 6Ds ) AtrophicDensity Resorbed articular surface

Debris Tapered bone

end DislocationDisorganizationDestruction ( Distension )

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Neuropathic Joint : Sites of Involvement

Disease Predominant type Spine LEUE

C T L H K A F S E WH

DM Hypertrophic ++ + + +++ ++

Syphilis Hypertrophic + +++ + +++ ++ +

Syringom. Atrophic + + +++ ++ +++ +

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Case 5 : 15 yo boy fever, weight loss,painful progressiveswelling of Rt.thigh 5

mths

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Osteosarcoma

Location : Femur ( 40% ) > tibia, humerus

Characteristics : Typical mixed osteolysis +sclerosis

Poorly - dened, intramedullary, metaphyseal lesion

extended through cortex and

produced a soft tissue mass

+ Periosteal reaction

sunburst or Codman s

triangle

Sunburst/sunray

Codmans triangle

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Case 6 : 58 yo man low back pain 4yrs

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Osteoarthritis : Spine

Common location C5, C6L4, L5

OsteophytesSclerosis

Intervertebral discLoss of disc height Vaccum phenomenon

Vacuum phenomenon

C 7 71 l d

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Case 7 : 71 yo lady painful, swollen

bothhands 2 wks

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Chondrocalcinosis

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Chondrocalcinosis WHIP A DOG

Wilsons diseaseHemophilia / hemochromatosisHyperparathyroidism /

hypothyroidismHypomagnesemia /

HypophosphatasiaIdiopathicPseudogoutAmyloidosisDM

Ochronosis

Case 8 : 45 yo female symmetrical pain

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Case 8 : 45 yo female symmetrical painin both hands, knees & feet with severedeformity

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RA : Bilateral SymmetryUniform joint space narrowing : PIP, MCP, wristMarginal erosionJuxtaarticular osteopeniaDeformity : ulnar deviation, Boutoniere, swan-neck

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Atlanto-axial Subluxation

Common : RASpADowns syndrome

Case 9 : 43 yo healthy athlete man

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Case 9 : 43 yo healthy athlete man painful Rt.knee with vigorous exercise 3mths

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Lytic bone lesion

Most lesions are usually benigns,except for metastasis & MM

GAMMA-FISH

Giant cell tumor Aneurysmal bone cystMetastasisMyeloma Angioma Fibrous dysplasiaInfection ( osteomyelitis )Simple bone cystHyperparathyroidism

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Giant Cell Tumor

Characteristic : Expansile lesions of the epiphysis

Eccentric location

Well-defined, non-sclerotic border

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Case 10 : 58 yo man painful, deformedboth hands & feet 7 yrs

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Chonic Tophaceous Gout

Punch-out lesion

Clue : Asymmterical involvement

Well-defined bony lytic lesion

Preserved joint space

Normal mineralization

Overhanging

Differential Diagnosis : Gout &

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Differential Diagnosis : Gout &RA

Gout RA

Distribution Asymmetry Symmetry Soft tissue swelling Eccentric/nodule Fusiform

Soft tissue calcification Occasional Rare

Osteoporosis Absent/mildModerate/severe

Joint space narrowing Frequently absent

Diffuse Erosion Eccentric Marginal

Sclerotic margin Frequent Rare

Location Intra/extra-articular Intra-articular

Case 11: 54 yo lady finger pain with

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Case 11: 54 yo lady finger pain withactivity

& intermittent swelling

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Erosive OA

Gull-wing appearance

Case 12 : 28 yo man prolonged fever with back

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Case 12 : 28 yo man prolonged fever with backpain at mid-thoracic region3 mths

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Tuberbulous Spondylitis

Most common site of skeletal tuberculosis Common site : T12-L1

Radiographic findings :

Discovertebral lesion

Vertebral end plate + disc involvement

May occur with paraspinal abscess

Case 13 : 52 yo man swollen, painful both

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y , plegs with chroniccough & weight loss

4 mths

Hypertrophic Osteoarthropathy

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Hypertrophic Osteoarthropathy( HOA )

H hi O h h

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Hypertrophic Osteoarthropathy( HOA )

Triad : Clubbing of fingers, periostitis, arthritis

Localized soft tissue swelling at nger tips

Periosteal reaction lamellated pattern ( onion -skin )

Location : tibia, bula, radius, ulnar

Joint soft tissue swelling ( knee, ankle, wrist, hand )

Periarticular osteopenia

Normal joint space & No erosion

C 14 47 l d Rt id d h t i & b k

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Case 14 : 47 yo lady Rt.sided chest pain & backpain with weight loss 3 mths

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CA Metastasis

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Spinal Metastasis

Location Lumbar / Thoracic vertebraVertebral body, pedicle

Sign Altered bone density

Decreased : motheaten,permeativeIncreased : localized, ivory vertebra

Cortical destruction

Disc space preservedPathologic collapse

Decreased posterior vertebralheight

Endplate disruption

C 15 56 d h gi b k

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Case 15 : 56 yo man dysphagia, backpain & stiffness 3 yrs

Diffuse Idiopathic Skeletal Hyperostosis

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Diffuse Idiopathic Skeletal Hyperostosis( DISH )

Spine Anterolateral owing ossication > 4 vertebra

( common T > C > L )

Bumpy spinal contour

Radiolucent area beneath the deposited bone

( halo space between the ossication

and the anterior aspect of spine )

SI joint narmal

Intervertebral disc space normal

Apophyseal joint - normal

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DISH : Halo Space

Case 16 : 12 yo man fever with Rt leg

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Case 16 : 12 yo man fever with Rt legpain & swelling 4 wks

Motheaten / Permeative Bone

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Motheaten / Permeative BoneDestruction

H-LEMMON

Histiocytosis XLymphoma

Ewings sarcomaMetastasisMultiple myeloma

OsteomyelitisNeurobalstoma

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Malignant Neoplasm : Primary & Secondary

PrimarySecondary

Incidence 30% 70%Bony expansion +++ +Joint involvement - -Length of lesion >10 cm 2-4 cmPeriosteal reaction +++ +

Solitary lesion +++ +Multiple lesion + +++Soft tissue mass +++ +

Case 17 : 48 yo female pain & swelling

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Case 17 : 48 yo female pain & swelling3 rd finger 5 mths

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Sausage-shaped digit(dactylitis)

Enthesitis

Spondyloarthropathies

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Peripheral Arthritis in SpA

Similar to those of RA BUTSausage - shaped swelling

Less / lack of osteopenia

More BONY ankylosis

Evidence of enthesitis : Achil les & plantar

fascia

u f y periostitis

dactylitis

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Case 18 : 47 yo man Bilateral hip pain 3 yr

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Avascular Necrosis of Bone : Plain Film

Staging O S uspected, no clinical nding ( normal lm & bone scan )

I Clinical nding, normal lm, abnormal bone scan & MRI

II Osteopenia, cystic areas, bony sclerosisIII Crescent sign ( linear hypodensity along subchondral bone )

Subchondral collapse without attening

of femoral headIV Flattening of femoral head & normal

jt . spaceV Joint space narrowing & acetabular

abnormalities + OA change

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Crescent Sign

Case 19 : 36 yo man back pain & stiffness 1

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Case 19 : 36 yo man back pain & stiffness 1yrs

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Differential Diagnosis of SpA

AS ( primary AS ) Non - AS ( secondary AS )

SI involvement Bilat, symmetry Unilat, asymmetry

Syndesmophyte Fine Thick

Margin to margin Non-margin tonon-margin

Ascending Skipped ( L T C )

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Non-AS

AS

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l l l

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Multiple Myeloma

Diffuse osteopenia Multiple osteolytic lesions

Well-circumscribed without surrounding sclerosisRelatively uniform in size

Location : Skull, pelvis, rib, spine

MM Metastasis Distribution Symmetric Asymmetric Predominant pattern Lytic > sclerotic Lytic/sclerotic Diffuse osteopenia Common Rare Diffuse osteosclerosis Rare Common Morphology Well-defined Poorly-defined