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
Motheaten
Permeative
Large, well-defined or ill-defined hole
Small, countable holes
Tiny, uncountable holes
benign
malignant
Key Terms in Reporting : Periosteal Reaction
Lamellated/ Onion-skin
Solid type Slowing-growing process
benign
Sunburst/sunray Hair-on-end
Interrupted type Rapid-growing process
malignant
Codman’s triangle
Musculoskeletal Imaging : Differential Diagnosis • Universal DDx
“VITAMIN C+D”
• Specific DDx
Vascular Infection Trauma Autoimmune Metabolic Inflammation Neoplasm Congenital Drug
Differential Diagnosis : Logical & Systematic Approach • History & Physical examination • Demographics • Sutton’s law • Radiographic hallmarks • Pattern approach
Common diseases & their hallmarks
Demographics • Age
20-40 SpA RA CNTD Septic
>40 OA / DISH Gout/CPPD HOA
Septic
• Sex
Male SpA Gout 2ºOA HOA
Female CNTD RA 1ºOA
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
Degenerative
( OA ) • Erosion
Inflammation
( RA ) • Punch-out
Metabolic ( Gout )
General DDx of Joint Diseases Feature
Inflamation
Degenerative
Metabolic
Symmetry
Symmetric
Asymmetric
Asymmetric
Joint involved
Polyartic.
Monoartic.
Mono/
polyartic. Alignment
Abnormal
Bone density
Decreased
Abnormal
Normal
Normal/increased
Normal Erosion defined
Poorly-defined
Absent
Sharply-
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
Phemister’s triad :
Juxtaarticular osteopenia Peripherally located erosion Gradual narrowing of joint space
Comparison of TB & Pyogenic Arthritis TB
Pyogenic
• Soft tissue swelling
+
+ • Osteoporosis
+
+
• Joint space loss
Late
• Marginal erosion
+
+
• Bone proliferation
+
+
Early
( sclerosis, periostitis )
• 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
Predominant type C
Spine T
LE
L H K A F S E W
H DM
Hypertrophic
Syphilis
Hypertrophic
Syringom. +
Atrophic
+
++ +
+
+++
+
+
+
+++ ++
+ +++ ++
+
+++ ++
++
Case 5 : 15 yo boy – fever, weight loss, painful progressive swelling of Rt.thigh 5 mths
Osteosarcoma • Location :
Femur ( 40% ) > tibia, humerus
• Characteristics : Typical – mixed osteolysis +
Codman’s triangle
sclerosis
Poorly-defined, intramedullary,
extended through
metaphyseal lesion
cortex and
produced a soft tissue mass
Sunburst/sunray sunburst
triangle
+ Periosteal reaction – or
Codman s
Case 6 : 58 yo man – low back pain 4 yrs
Osteoarthritis : Spine • Common location
Vacuum phenomenon
C5, C6 L4, L5 Osteophytes Sclerosis Intervertebral disc Loss of disc height “Vaccum phenomenon”
Case 7 : 71 yo lady – painful, swollen both hands 2 wks
Chondrocalcinosis
Chondrocalcinosis • “WHIP A DOG” Wilson’s 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 Down’s 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
Asymmetry
• Soft tissue swelling
Symmetry
Eccentric/nodule
• Soft tissue calcification • Osteoporosis
RA
Fusiform
Occasional
Rare
Absent/mild
Moderate/severe • Joint space narrowing
Frequently absent
Eccentric
Marginal
Frequent
Rare
Diffuse • Erosion Sclerotic margin Location
Intra/extra-articular
Intra-articular
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 finger tips • Periosteal reaction – lamellated pattern ( onionskin ) • Location : tibia, fibula, 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
• Sign
Lumbar / Thoracic vertebra Vertebral body, pedicle
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 flowing ossification > 4
vertebra
( common T > C > L )
Bumpy spinal contour
Radiolucent area beneath the deposited
bone
( halo space between the ossification
SI joint – narmal
Intervertebral disc space – normal
Apophyseal joint - normal
and the anterior aspect of spine )
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 Ewing’s 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
fluffy 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 finding ( normal film & bone scan ) I – Clinical finding, normal film, abnormal bone scan & MRI II – Osteopenia, cystic areas, bony sclerosis III – Crescent sign ( linear hypodensity along subchondral bone ) Subchondral collapse without flattening 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 )
SI involvement asymmetry
Bilat, symmetry
Syndesmophyte
Fine
Non-AS ( secondary
Unilat,
Thick
Margin to margin Non-margin to
non-margin
Ascending
( LàT àC )
Skipped
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
• Distribution Symmetric • Predominant pattern Lytic > sclerotic • Diffuse osteopenia Common • Diffuse osteosclerosis Rare • Morphology Well-defined Uniform size
Asymmetric Lytic/sclerotic Rare Common Poorly-defined Varying size
