HUSMSERVIÇO DE DIAGNÓSTICO POR IMAGEM

ARTRITES

R1 RÉGIS SILVA

Osteoartrite- É a DAD mais comum – primária e secundária

- Primária: mulheres, IFD e IFP e base do polegar e bilateral

- Achados :

- Estreitamento do espaço articular

- Esclerose

- Osteófitos

- Hiperostose esquelética idiopática: mecanismo não parece ser o stress e não é tão incapacitante

- OA erosiva: osteoporose e erosões; dolorosa e debilitante(kellgren)

- ATM, AC, SI e sínfise púbica

Osteoarthritis (DJD). Plain film of a finger with osteoarthritis (DJD) of the distal and proximal interphalangeal joints. Both joints demonstrate joint space narrowing, subchondral sclerosis, and osteophytosis, which are hallmarks of DJD.

Diffuse Idiopathic Skeletal Hyperostosis (DISH). A lateral view of the lumbar spine shows extensive osteophytosis without significant disk space narrowing or sclerosis. This is a classic picture for diffuse idiopathic skeletal hyperostosis.

Primary Osteoarthritis. Bilateral hand films in a patient with primary osteoarthritis. Present are classic findings of osteophytosis, joint space narrowing, and sclerosis at the distal interphalangeal joints, the proximal interphalangeal joints, and at the base of the thumb. This is bilaterally symmetric, which is typical for primary osteoarthritis.

Osteoarthritis of the Sacroiliac (SI) Joint. A young woman who is a professional dancer complained of left-sided hip pain. An anteroposterior film of the pelvis demonstrated left SI joint sclerosis, joint irregularity, and erosions. A complete workup to rule out a human leukocyte antigen (HLA) –B27 spondyloarthropathy was negative, and no laboratory or clinical evidence for infection was found. Her clinical history pointed to this being completely occupation-related, and an aspiration biopsy to rule out infection was therefore not performed. This is not an unusual appearance for degenerative joint disease of the SI joint

Subchondral Cyst or Geode of the Shoulder. This patient has marked degenerative joint disease (DJD) of the shoulder, with joint space narrowing, sclerosis, and osteophytosis. A large lytic process (arrows) is seen in the humeral head, which is a subchondral cyst or geode often seen in association with DJD. Because of the DJD in the shoulder, a biopsy to rule out a more sinister lesion in the humeral head should be avoided.

Artrite Reumatóide- Doença do tec. Conjuntivo

- Pode acometer qualquer articulação

- Achados:

- Edema de partes moles

- Osteoporose

- Estreitamento do espaço articular

- Erosões marginais

- Processo proximal de simetria bilateral

- Erosões marginais nas grandes articulações

- Migração axial do femur

- Elevação do ombro

- AR + DAD

Rheumatoid Arthritis. An erosive arthritis affecting primarily the carpal bones and the metacarpophalangeal joints is seen that has associated osteoporosis and soft tissue swelling (note the soft tissue over the ulnar styloid processes). It is a bilaterally symmetric process in this patient, which is classic.

Migration of the Femoral Head. A drawing of the hip showing routes of migration of the femoral head. Osteoarthritis of the hip tends to cause superior (S) migration of the femoral head in relation to the acetabulum, whereas rheumatoid arthritis tends to cause axial (A) migration of the femoral head in relation to the acetabulum.

Rheumatoid Arthritis of the Hip. Note the severe joint space narrowing in this patient with rheumatoid arthritis. The femoral head has migrated in an axial direction, with fairly concentric joint space narrowing. Minimal secondary degenerative changes have occurred, as noted by the sclerosis in the superior portion of the joint; however, these have been diminished somewhat by the osteoporosis that usually accompanies rheumatoid arthritis.

Rheumatoid Arthritis in the Shoulder. An anteroposterior view of the shoulder in this patient with rheumatoid arthritis shows that the distance between the acromion and the humeral head is diminished (arrowheads). Ordinarily, this space is about 1 cm in width to allow the rotator cuff to pass freely beneath the acromion. This is a common finding in rheumatoid arthritis as well as in calcium pyrophosphate dihydrate deposition disease.

Secondary Degenerative Joint Disease (DJD) in the Knee in a

Patient With Rheumatoid Arthritis.

Espondiloartropatias HLA-B27- Espondilite anquilosante

- Doença inflamatória intestinal

- Artrite psoriática

- S. de Reiter

- Anquilose ossea

- Formação proliferativa de novo osso

- Predominantemente axial

- Sindesmófitos – marginais e simétrico ; ñ marginais e assimétricos

- Comprometimento da SI é comum

- A. psoriática e Reiter: predomínio distal, erosões e edema

Psoriasis With Syndesmophytes

Marginal, Symmetric Syndesmophytes in Ankylosing Spondylitis. Bilateral marginal syndesmophytes are seen bridging the disk spaces throughout the lumbar spine in this patient. This is a so-called bamboo spine and is classic for ankylosing spondylitis and inflammatory bowel disease.

Syndesmophytes in Psoriatic Arthritis. Large, bulky, nonmarginal, asymmetric syndesmophytes (arrows) are seen in this patient with psoriatic arthritis

Ankylosing Spondylitis. Bilateral symmetric sacroiliac joint sclerosis and erosions are seen in this patient with ankylosing spondylitis. Inflammatory bowel disease could have a similar appearance. Although this is classic for these two disorders, it would not be that unusual for psoriatic disease or Reiter syndrome to have this same appearance. Although less likely, it would be possible for infection and even degenerative joint disease to be bilateral in this fashion

Fusion of the Sacroiliac (SI) Joints in Ankylosing Spondylitis. Bilateral complete fusion of the SI joints in this patient with ankylosing spondylitis makes the SI joints totally indistinguishable. Inflammatory bowel disease could have a similar appearance.

Causes of Sacroiliac Joint Disease

- Ankylosing spondylitis

- Inflammatory bowel disease

- Psoriatic arthritis

- Reiter syndrome

- Infection

- Degenerative joint disease

- Gout

Psoriatic Arthritis With Sacroiliac (SI) Joint Disease. Unilateral SI sclerosis and erosions are seen in this patient with psoriatic arthritis. Ankylosing spondylitis and inflammatory bowel disease virtually never have this appearance.

CT of the Sacroiliac (SI) Joints in Psoriasis. A CT scan through the SI joints in this patient with psoriatic arthritis shows unilateral SI joint sclerosis and erosions (arrows), typical for psoriatic arthritis or Reiter disease.

Ankylosing Spondylitis With Hip Disease. Anteroposterior view of the pelvis in this patient with ankylosing spondylitis shows bilateral complete fusion of the sacroiliac joints. Concentric left hip joint narrowing is present with axial migration of the femoral head. This would be a typical finding in rheumatoid arthritis or, as in this example, in ankylosing spondylitis. Note the secondary degenerative joint disease changes in the left hip as well.

Psoriatic Arthritis. A. Cartilage loss at the proximal interphalangeal joints of the third, fourth, and fifth digits in this hand is apparent, with erosions noted most prominently in the fourth digit (arrow). These erosions are not sharply demarcated but are covered with fluffy new bone. These are termed proliferative erosions. Note also the periostitis along the shafts of each of the proximal phalanges. B. Advanced psoriatic arthritis. Fusion or ankylosis is apparent across the proximal interphalangeal joints of the second through the fifth digits. Several of the distal interphalangeal joints are also ankylosed. Severe joint space narrowing at the metacarpophalangeal joints is noted. This distal distribution is typical for psoriatic arthritis in advanced stages.

Reiter Syndrome. Lateral view of a calcaneus in a patient with Reiter syndrome shows poorly defined new bone on the posteroinferior margin of the calcaneus with a calcaneal spur which is also poorly defined. This is typical of psoriatic or Reiter disease, as opposed to the well-formed calcaneal spur in degenerative joint disease.

Reiter Syndrome. Anteroposterior view of the large toe in a patient with Reiter disease shows fluffy periostitis (arrow) in the erosions adjacent to the interphalangeal joint of the great toe. Marked soft tissue swelling is also present throughout the great toe. These changes are typical in appearance and location for Reiter disease or psoriatic arthritis.

Artrite Induzida por Cristais

Gota

-Cristais de urato de monossódio na cartilagem articular

- 4 – 6 anos para causar alterações radiológicas

- Achados:

- Erosões bem definidas

- Nódulos de tec. mole

- Distribuição aleatória nas mãos sem osteoporose pronunciada

- MTF do halux

- Acentuada deformidade e condrocalcinose

Pseudogota

-Tríade

- Dor intermitente

- Condrocalcinose

- Destruição articular

- Condrocalcinose: medial e lateral do joelho, fibrocartilagem triangular do punho e sínfise púbica.

- DAD de DDPC: ombro, cotovelo, a. radiocarpal, patelofemural e MCF

Most Common Location of Chondrocalcinosis in Calcium Pyrophosphate Dihydrate Deposition Disease

KneeTriangular fibrocartilage of wristSymphysis pubis

Hallmarks of Gout

Well-defined erosions (sclerotic margins)Soft tissue nodulesRandom distributionNo osteoporosis

Gout. Sharply marginated erosions, some with a sclerotic margin, are noted throughout the carpus and proximal metacarpals. These erosions are classic in gout. Note the absence of marked demineralization. Gout. A sharply marginated erosion with an overhanging edge (arrow) and a sclerotic margin is

seen in the metatarsophalangeal in the great toe in this patient with gout. This appearance and location are classic for gout, whereas psoriatic arthritis and Reiter disease usually involve the interphalangeal joint and do not have erosions that are this sharply marginated.

Advanced Gout. Marked diffuse and focal soft tissue swelling is present throughout the hand and wrist in this patient with long-standing gout. Destructive, large, well-marginated erosions, some with overhanging edges, are noted near multiple joints. The focal areas of soft tissue swelling are called tophi, some of which are calcified. These only calcify with coexistent renal disease.

Chondrocalcinosis in the Knee. Cartilage calcification known as chondrocalcinosis is seen in the fibrocartilage (white arrow) and in the hyaline articular cartilage (black arrow) in this patient with calcium pyrophosphate dihydrate deposition disease.

Chondrocalcinosis in the Wrist. This patient with calcium pyrophosphate dihydrate deposition disease exhibits chondrocalcinosis in the triangular fibrocartilage of the wrist (curved arrow). A small amount of chondrocalcinosis is also seen in the second metacarpophalangeal (small arrow). Triangular ligament calcification is one of the more common locations for chondrocalcinosis to occur.

Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD) Arthropathy. Degenerative joint disease (DJD) of the elbow is seen in this patient with CPPD. Note the joint space narrowing, with minimal sclerosis and large osteophytes (arrows). Osteophytes of this nature are termed drooping osteophytes and are often seen in CPPD. The elbow is an unusual place for DJD to occur except in the setting of CPPD or trauma.

Colagenoses- Esclerodermia

- LES

- Dermatomiosite

- DMTC

- Osteoporose e perda de tecido mole

- LES: desvio ulnar das falanges

- Calcificação de tec moles na esclerodermia e dermatomiosite

Systemic Lupus Erythematosus. Marked soft tissue wasting, as noted by the concavity in the hypothenar eminence, and ulnar deviation of the phalanges, seen primarily in the right hand, are hallmarks of systemic lupus erythematosus.

Scleroderma. Diffuse subcutaneous soft tissue calcification is seen throughout the hands and wrists in this patient with scleroderma. Soft tissue wasting and osteoporosis are also present, as well as bone loss in multiple distal phalanges secondary to the vascular abnormalities often present in this disease.

Sarcoid. Anteroposterior view of the hand in this patient with sarcoid demonstrates classic changes of bony involvement with this granulomatous process. Note the lacelike pattern of destruction, which is seen most prominently in the proximal phalanges and in the distal third phalanx.

Hemochromatosis. Anteroposterior view of the hand in this patient with hemochromatosis shows severe joint space narrowing throughout the hand, which is most marked at the metacarpophalangeal joints. Associated sclerosis at the metacarpophalangeal joints with large osteophytes seen off the metacarpal heads suggests degenerative joint disease (DJD). These are very unusual joints for DJD to occur in, yet this is the classic appearance of hemochromatosis.

Artropatia Neuropática ou de Charcot

-Destruição, luxação e osso heterotópico

- Início estreitamento do espaço articular

- Pé diabético 1º e 2º tarso-metatarso

- Paralisia

Charcot Joint. Anteroposterior view of the knee in this patient with tabes dorsalis shows the classic changes of a neuropathic or Charcot joint. Note the severe joint destruction, the subluxation, and the heterotopic new bone (arrow).

Charcot Spine. Anteroposterior view of the spine in this paraplegic patient shows severe destruction of the L2 and L3 vertebral bodies and the intervening disk space, heterotopic new bone (arrow), and malalignment or dislocation. Numbers indicate lumbar vertebrae.

Lisfranc Charcot Joint. Dislocation of the second and third metatarsals along with joint destruction and large amounts of heterotopic new bone are present in the foot of this diabetic patient. These findings are classic for a Charcot joint, which has been termed a Lisfranc fracture-dislocation. It is most commonly seen secondary to trauma rather than as a Charcot joint but is the most common neuropathic joint seen today.

Hemofilia

ARJ

Paralisia

- Crescimento excessivo das extremidades com diáfise grácil

- Com ou sem destruição articular

- ARJ e Hemofilia alargamento da fosso intercondilar

Juvenile Rheumatoid Arthritis (JRA). A lateral view of the knee in this patient with JRA shows the classic findings of overgrowth of the ends of the bones and associated gracile diaphyses. These changes can also be seen in patients with hemophilia or paralysis.

Muscular Dystrophy Simulating Juvenile Rheumatoid Arthritis (JRA) or Hemophilia. Anteroposterior view of the ankle in this patient with muscular dystrophy shows subtle changes of overgrowth of the distal tibia and fibular epiphyses. Marked tibiotalar slant, which can also be present in JRA or hemophilia, is also present.

Osteocondromatose Sinovial

-Metaplasia da sinóvia

- Focos de cartilagem na articulação(calcificam)

- Joelho, quadril e cotovelo

- condromatose sinovial tumefativa

- sinovectomia

Synovial Osteochondromatosis. Anteroposterior view of the hip in this patient with left hip pain shows multiple calcified loose bodies in the hip joint, which is virtually diagnostic of synovial osteochondromatosis.

Synovial Osteochondromatosis Without Calcification. Anteroposterior view of the hip in this patient shows that the femoral neck is eroded, with the femoral head having an “apple core†�appearance. This has occurred from the pressure erosion of multiple nonossified loose bodies in the joint. This is nonossified synovial osteochondromatosis (probably more properly termed synovial chondromatosis). It usually does not cause this degree of bony erosion and is indistinguishable from pigmented villonodular synovitis.

Tumefactive Synovial Osteochondromatosis. Plain film of the shoulder (A) shows a partially calcified mass which is eroding the medial aspect of the humerus. Coronal proton-density MR (B) and T2WI (C) of the shoulder reveal a large mass encircling the humeral head, which was interpreted as a sarcoma. A biopsy was performed and called “chondrosarcoma,†which �resulted in a forequarter amputation. The intra-articular nature of the mass was not appreciated until after the radical surgery, when it was correctly recognized as synovial chondromatosis.

Sinovite Vilonodular Pigmentada

- Processo inflamatório crônico da sinóvia, edema articular, dor e destruição, hemossiderina.

Atrofia de Sudeck

Dor , edema e disfunção – pós trauma

Necrose Avascular- Esteróides, traumatismo, tx renal, AAS, colagenoses, alcoolismo.

- Aumento da densidade óssea numa articulação normal

- Achados:

- Derrame articular

- Densidade em placas ou mosqueada

- Transparência subcondral

- Colapso da superfície articular

- Unilateral

- Osteocondrite dissecante-Menor e mais focal

- trauma : joelho, talus e umero

- destacamento de fragmento ósseo

Early Avascular Necrosis of the Hip. Patchy sclerosis is present in the femoral head in this patient with a renal transplant and avascular necrosis of the right hip. No subchondral lucency or articular surface irregularity in the weight-bearing region is yet present, with the exception of a small cortical irregularity seen laterally.

Avascular Necrosis (AVN) of the Hip. Subchondral lucency (arrows) is seen in the weight-bearing portion of this hip with AVN. Patchy sclerosis throughout the femoral head is also noted.

Avascular Necrosis (AVN) of the Shoulder. Articular surface collapse is present in this shoulder with long-standing AVN. Dense bony sclerosis is also present.

Avascular Necrosis of the Hip. An axial T1WI (time of repetition 600; time of echo 20) of the hips shows a focal area of abnormality in the left femoral head (arrow), which is characteristic for AVN. The low-signal, serpiginous border is a typical finding, as is the anterior location.

Osteochondritis Dissecans. A small focal area of avascular necrosis (AVN) in the medial epicondyle of the femur (black arrows) is present, which is an area of osteochondritis dissecans. Part of the area of AVN has shed a bony fragment (white arrow) that is loose in the joint, which is known as a loose body or “joint mouse.

Osteochondritis Dissecans of the Talus. A focal area of avascular necrosis in the talus, as seen here (arrows), is called osteochondritis dissecans. The talus is the second most common site after the knee and, as in the knee, can cause a joint mouse, or loose body in the joint.

Kienbock Malacia. Avascular necrosis (AVN) of the lunate, or Kienböck malacia, is demonstrated in this patient's wrist. The increased density and partial fragmentation of the lunate are characteristic for AVN. Also, note the slightly shortened ulna (in comparison with the radius), which is called negative ulnar variance. Negative ulnar variance is said to have a high association with Kienböck malacia.

Kohler Disease. Flattening and sclerosis of the tarsal navicular (arrow) in children is thought by many to be avascular necrosis and is called Köhler disease. Others have found this to be an asymptomatic normal variant and believe that it is an incidental finding.