Radiographic Interpretation in Rheumatology

Ajchara Koolvisoot, MD.

General Approach to Musculoskeletal Imaging A Alignment B Bone C Cartilage D Disc S Soft tissue

Key Terms in Reporting Skeletal 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

Key Terms in Reporting : Osteolysis / bony destruction

Geographic
Large, well-defined or ill-defined hole

Motheaten
Small, countable holes

Permeative
Tiny, uncountable holes

benign

malignant

Key Terms in Reporting : Periosteal Reaction

Lamellated/ Onion-skin Sunburst/sunray Hair-on-end Codmans triangle

Solid type
Slowing-growing process

Interrupted type
Rapid-growing process

benign

malignant

Musculoskeletal Imaging : Differential Diagnosis

Universal DDx

VITAMIN C+D

Vascular Infection Trauma Autoimmune Metabolic Inflammation Neoplasm Congenital Drug

Specific DDx

Differential Diagnosis : Logical & Systematic Approach

History & Physical examination Demographics Suttons law Radiographic hallmarks Pattern approach

Common diseases & their hallmarks

Demographics
Age
20-40 SpA RA CNTD Septic Male SpA Gout 2OA HOA >40 OA / DISH Gout/CPPD HOA

Septic

Sex

Female CNTD RA 1OA

Common Rheumatic Diseases

Osteoarthritis Rheumatoid arthritis Crystal-induced arthritis : Gout & CPPD Septic arthritis : Bacterial & TB

CNTD Spondyloarthropathies DISH Tumors : osteosarcoma, MM, metastasis Rheum.manifestations in systemic dis.

Radiographic Hallmarks
Osteophytes ( OA ) Erosion ( RA ) Punch-out Metabolic ( Gout ) Inflammation Degenerative

General DDx of Joint Diseases

Feature Symmetry Joint involved polyartic. Alignment Bone density Normal Erosion defined Poorly-defined Absent SharplyAbnormal Decreased Abnormal Normal/increased Normal Inflamation Symmetric Polyartic. Degenerative Asymmetric Monoartic. Metabolic Asymmetric Mono/

Pattern Approach

Radiographic Reading
Describe type of X-rays Joint space Joint surface Subchondral bone ABCDS Adjacent bone Alignment Periosteal reaction ( if present ) Soft tissue Always specify which one / side is/are abnormal

Case Approach
1.Radiographic Reading 2.Most likely diagnosis

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

Osteoarthritis
Characteristic : Non-uniform joint space narrowing Irregular joint surface Subchondral sclerosis / cyst Osteophytes Deformity

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

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

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

TB arthritis

Phemisters triad :

Juxtaarticular osteopenia Peripherally located erosion Gradual narrowing of joint space

Comparison of TB & Pyogenic Arthritis

TB Soft tissue swelling + Osteoporosis Joint space loss Marginal erosion Bone proliferation
( sclerosis, periostitis )

Pyogenic +

+ Late + + + +

+ Early + + + -

Bone ankylosis Slow progression

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

Osteoblastic Metstasis
5 Bees Lick Pollen Brain ( medulloblastoma ) Bronchus Breast Bowel ( espeically carcinoid ) Bladder Lymphoma Prostate

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

Neuropathic Joint
Hypertrophic : 5Ds ( 6Ds ) Atrophic Density Resorbed articular surface Debris Tapered bone end Dislocation Disorganization Destruction ( Distension )

Neuropathic Joint : Sites of Involvement

Disease UE H DM Syphilis Syringom.
+ +

Predominant type C Hypertrophic Hypertrophic Atrophic

+

Spine T

LE

L H K A F S E W
++ + +++ + + +++ ++ +

+ +++ ++

+++ ++

++

Case 5 : 15 yo boy fever, weight loss, painful progressive swelling of Rt.thigh 5 mths

Osteosarcoma
Location : Femur ( 40% ) > tibia, humerus

Codmans triangle

Characteristics : Typical mixed osteolysis + sclerosis Poorly-dened, intramedullary, metaphyseal lesion cortex and

extended through or

produced a soft tissue mass + Periosteal reaction Codman s

Sunburst/sunray sunburst

triangle

Case 6 : 58 yo man low back pain 4 yrs

Osteoarthritis : Spine
Common location C5, C6 L4, L5 Osteophytes Sclerosis Intervertebral disc Loss of disc height Vaccum phenomenon

Vacuum phenomenon

Case 7 : 71 yo lady painful, swollen both hands 2 wks

Chondrocalcinosis

Chondrocalcinosis
WHIP A DOG Wilsons disease Hemophilia / hemochromatosis Hyperparathyroidism / hypothyroidism Hypomagnesemia / Hypophosphatasia Idiopathic Pseudogout Amyloidosis DM Ochronosis

Case 8 : 45 yo female symmetrical pain in both hands, knees & feet with severe deformity

RA :

Bilateral Symmetry Uniform joint space narrowing : PIP, MCP, wrist Marginal erosion Juxtaarticular osteopenia Deformity : ulnar deviation, Boutoniere, swan-neck

Atlanto-axial Subluxation

Common :

RA SpA Downs syndrome

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

Lytic bone lesion

Most lesions are usually benigns,

except for metastasis & MM GAMMA-FISH

Giant cell tumor Aneurysmal bone cyst Metastasis Myeloma Angioma Fibrous dysplasia Infection ( osteomyelitis ) Simple bone cyst Hyperparathyroidism

Giant Cell Tumor

Characteristic :

Expansile lesions of the epiphysis Eccentric location Well-defined, non-sclerotic border

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

Chonic Tophaceous Gout

Clue : Asymmterical involvement Well-defined bony lytic lesion Preserved joint space Punch-out lesion Normal mineralization

Overhanging

Differential Diagnosis : Gout & RA

Gout
Distribution Soft tissue swelling Soft tissue calcification Osteoporosis Moderate/severe Joint space narrowing Diffuse Erosion Sclerotic margin Location Eccentric Frequent Intra/extra-articular Marginal Rare Intra-articular Frequently absent Asymmetry Eccentric/nodule Occasional Absent/mild

RA
Symmetry Fusiform Rare

Case 11: 54 yo lady finger pain with activity & intermittent swelling

Erosive OA

Gull-wing appearance

Case 12 : 28 yo man prolonged fever with back pain at mid-thoracic region 3 mths

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 legs with chronic cough & weight loss 4 mths

Hypertrophic Osteoarthropathy ( HOA )

Hypertrophic Osteoarthropathy ( HOA )

Triad : Clubbing of fingers, periostitis, arthritis Localized soft tissue swelling at nger tips Periosteal reaction lamellated pattern ( onionskin ) Location : tibia, bula, radius, ulnar Joint soft tissue swelling ( knee, ankle, wrist, hand ) Periarticular osteopenia Normal joint space & No erosion

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

CA Metastasis

Spinal Metastasis
Location Lumbar / Thoracic vertebra Vertebral body, pedicle

Sign

Altered bone density Decreased : motheaten, permeative Increased : localized, ivory vertebra Cortical destruction Disc space preserved Pathologic collapse Decreased posterior vertebral height Endplate disruption

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

Diffuse Idiopathic Skeletal Hyperostosis ( DISH )

Spine Anterolateral owing ossication > 4 ( common T > C > L ) vertebra

Bumpy spinal contour Radiolucent area beneath the deposited ( halo space between the ossication
and the anterior aspect of spine )

bone

SI joint narmal Intervertebral disc space normal Apophyseal joint - normal

DISH : Halo Space

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

Motheaten / Permeative Bone Destruction

H-LEMMON Histiocytosis X Lymphoma Ewings sarcoma Metastasis Multiple myeloma Osteomyelitis Neurobalstoma

Malignant Neoplasm : Primary & Secondary

Primary Secondary Incidence 30% 70% Bony expansion +++ + Joint involvement Length of lesion >10 cm 2-4 cm Periosteal reaction +++ + Solitary lesion +++ + Multiple lesion + +++ Soft tissue mass +++ +

Case 17 : 48 yo female pain & swelling 3rd finger 5 mths

Sausage-shaped digit (dactylitis) Enthesitis Spondyloarthropathies

Peripheral Arthritis in SpA

Similar to those of RA BUT

Sausage-shaped swelling Less / lack of osteopenia More BONY ankylosis Evidence of enthesitis : Achilles & plantar fascia

uffy periostitis dactylitis

Case 18 : 47 yo man Bilateral hip pain 3 yrs

Avascular Necrosis of Bone : Plain Film

Staging of jt.space O Suspected, no clinical nding ( normal lm & bone scan ) I Clinical nding, normal lm, abnormal bone scan & MRI II Osteopenia, cystic areas, bony sclerosis III Crescent sign ( linear hypodensity along subchondral bone ) Subchondral collapse without attening femoral head IV Flattening of femoral head & normal V Joint space narrowing & acetabular abnormalities + OA change

Crescent Sign

Case 19 : 36 yo man back pain & stiffness 10 yrs

Differential Diagnosis of SpA

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

SI involvement asymmetry Syndesmophyte non-margin

Bilat, symmetry

Unilat,

Fine

Thick

Margin to margin Non-margin to Ascending Skipped

( LT C )

Non-AS

A S

Case 20 : 57 yo man Weight loss, cachexia & polyuria

Multiple Myeloma

Diffuse osteopenia Multiple osteolytic lesions Well-circumscribed without surrounding sclerosis Relatively uniform in size Location : Skull, pelvis, rib, spine
MM Metastasis Asymmetric Lytic/sclerotic Rare Common Poorly-defined Varying size

Distribution Symmetric Predominant pattern Lytic > sclerotic Diffuse osteopenia Common Diffuse osteosclerosis Rare Morphology Well-defined Uniform size