Andrew J Grainger Consultant and Hon Associate Professor Leeds, UK

Transkript

1 Andrew J Grainger Consultant and Hon Associate Professor Leeds, UK

2 Joint Is there arthritis present? What sort of arthritis? How bad is the arthritis? Monitor disease progression Clinically disease may be apparent before radiographic changes Radiographic changes occur slowly Not all changes readily reverse

3 May be earliest CR sign Still likely preceded by clinical findings Non-specific Synovium Effusion Blood Pus RA

4 May be earliest CR sign Still likely preceded by clinical findings Non-specific Synovium Effusion Blood Pus RA Look at pattern Smooth fusiform

5 Gout different patients Look at pattern Irregular lumps - Typical of gout

6 Look at opacity Urate more opaque than normal soft tissue Frank calcium in tophus usually implies renal disease Gout - different patients

7 Gout Chronic Tophi Renal Failure Irregular lumps CPPD Hydroxyapatite

8 CPPD Cause of much confusion Radiological Diagnosis Pyrophosphate deposition occurs in cartilage and synovium

9 Pyrophosphate deposition disease Looks like osteoarthritis May not see calcium deposition Clue is the atypical distribution of arthritis Midcarpal Joint

10 Pyrophosphate deposition disease Looks like osteoarthritis May not see calcium deposition Clue is the atypical distribution of arthritis Midcarpal Joint Metacarpal phalangeal joints

11 CPPD Pseudogout is a clinical diagnosis Sloughing of crystals into joint CPPD often idiopathic but association with other conditions Hyperparathyroidism Haemochromatosis Wilsons disease

12 Hydroxyapatite Deposition Originally reported in tendons and soft tissues Can be seen as intra-articular or periarticular deposition May follow trauma Strong link with OA May be asymptomatic

13 Hydroxyapatite Deposition Originally reported in tendons and soft tissues Can be seen as intra-articular or periarticular deposition May follow trauma Strong link with OA May be asymptomatic

14 Hydroxyapatite Deposition Originally reported in tendons and soft tissues Can be seen as intra-articular or periarticular deposition May follow trauma Strong link with OA May be asymptomatic

15 Hydroxyapatite Deposition Originally reported in tendons and soft tissues Can be seen as intra-articular or periarticular deposition May follow trauma Strong link with OA May be asymptomatic

16 Scleroderma

17 May be diffuse - Sausage digit of Psoriatic arthritis Psoriatic Arthritis - different patients

18 = Cartilage Loss Is it focal or diffuse Symmetrical or asymmetrical? Asymmetrical favours focal cartilage loss More typically seen in osteoarthritis Symmetrical favours a process causing global cartilage thinning Think inflammatory arthritis Including septic Rheumatoid Osteoarthritis Ankylosing Spondylitis

19 Small joints of hand can be a catch Joint space loss can appear symmetrical on a single view Osteoarthritis Normal OA

20 Seronegative arthritides Juvenile arthritides Occasionally RA and OA Psoriatic AS Chronic JIA

21 Just as useful as a sign In some arthropathies joint space is lost late Gout In PsA fibrous tissue may prevent joint space loss Similar effect with large effusion Gout - different patients

22 Just as useful as a sign In some arthropathies joint space is lost late Gout In PsA fibrous tissue may prevent joint space loss Similar effect with large effusion Psoriatic Arthritis

23 Joint Space Morphology of the erosion is key Round or irregular? Well defined versus poorly defined and osteopenic erosion Sclerotic margin? Associated with new bone formation?

24 Joint Space Know the early sites Medial metatarsal heads Radial side metacarpal heads Ulnar side of wrist Ulna styloid Erosion affecting the distal side of the IP, MCP and MTP joints is unusual in the absence of proximal erosion

25 Joint Space Very common problem All imaging modalities Normal anatomical features v erosion Conventional radiographs Normal contours Ligament attachments Relative areas of over penetration US and MRI Normal contours Vascular channels

26 Joint Space Tendency to over call Very common sites in the wrist and phalangeal bases Phalangeal bases Ligament/capsular attachment Commonly seen Erosion will normally be seen on proximal side of joint before distal

27 Joint Space Pitfall areas in wrist Radial aspect of capitate Radial aspect of the hamate

28 Joint Space Pitfall areas in wrist Bases of Middle and Ring Metacarpal and adjacent corners of Capitate and Hamate Ulnar base of 5 th Metcarpal and adjacent hamate

29 Joint Space Wawer et al. Skeletal Radiol 2014;43:1377

30 Joint Space Typically inflammatory arthritis erosions are located where cartilage is unprotected Marginal erosions Bare area All RA

31 Joint Space Earliest sign Subtle discontinuity of the cortical line dot-dash Later Osteopenic unmarginated Eventually Well defined with sclerotic margins

32 Joint Space tries to heal Chronically develop sclerotic margins

33 Joint Space Erosions are very characteristic Punched out erosions Sclerotic margins Often extensive intraosseous extension May see marginal erosions Also periarticular and central Marginal Periarticular Central

34 Joint Space Punched out round erosions Very typical in gout Marginal/Central/Periarticular

35 Joint Space Central erosions occur in a a variety of conditions Erosive/inflammatory OA Classic Gout Psoriatic arthropathy

36 Joint Space Entheseal erosion At enthesis site Associated with new bone enthesophyte Typical for arthritis associated with enthesitis Seronegative SpA Psoriatic arthritis

37 Joint Space Typical for arthritis associated with enthesitis Seronegative SpA Psoriatic arthritis

38 Joint Space May occur at any enthesis site AS different patients

39 Joint Space Comment on other subchondral changes Cysts Sclerosis Osteophytes Osteochondral bodies Heterotopic OA Neuropathic Joint

40 Joint Space Sclerosis Romanus Lesions Periosteal new bone formation typical of seronegative arthritides

41 Joint Space Can be really tricky Helpful if not uniform I find preservation of bone density more useful to report

42 Joint Space Osteopaenia Rheumatoid arthritis Juvenile arthritis Infective arthritis Preserved Seronegative Crystal Neuropathic

43 Ligamentous & Capsular Laxity Malalignment

44 Jaccouds Reversible Subluxation No erosion Classically SLE

45 RA OA PsA Not just a case of imaging a single joint Advantages of imaging the hand, wrist and feet Joint distribution tells us a lot