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Joint imaging

By

Dr. Firas Abdullah


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Aims of our lecture:

Radiological signs of  joint disease

Diagnosis of arthritis

Different types of arthritis

Other joint pathology

MRI of knee and shoulder


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Plain film signs of joint disease

Joint space narrowing

: due to destruction of articular 

cartilage. It occurs in practically all forms of joint 

disease, except avascular necrosis.

Soft tissue swelling

: a feature of inflammatory, and 

particularly infective arthritis. Also can be seen in 

gouty tophi.

Osteoporosis

: painful conditions and underuse of the 

bones. E.g. rheumatoid and tuberculous arthritis.


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Articular erosions

: destruction of the articular cortex and 

the adjacent trabecular bone

Causes

:

1- Inflammatory overgrowth of the synovium (pannus)

Rheumatoid arthritis , commonest

Juvenile rheumatoid arthritis (Still’s disease)

Psoriasis

Reiter’s disease

Ankylosing spondylitis

Tuberculosis.

2- Deposition of urate crystals in gout.

3- Infection: pyogenic arthritis and tuberculosis.

4- Repeated hemorrhage in hemophilia

5- Neoplastic, e.g. synovial sarcoma.


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Osteophytes, subchondral sclerosis and cysts

Features of osteoarthritis. A characteristic increase 

in the density of subchondral bone is seen in 

avascular necrosis

Alteration in the shape of the joint

: slipped 

epiphysis, developmental dysplasia of the hip, 

osteochondritis dissecans and avascular necrosis in 

its later stages.


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Joint erosion


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Diagnosis of arthritis

1. Whether one or more than one joint involved?

e.g. 

rheumatoid arthritis, infections and synovial tumours.

2. Which joints are involved? 

Rheumatoid arthritis 

Psoriatic arthritis 

Gout characteristically 

Osteoarthritis

Neuropathic arthritis

3. Is a known disease present?

e.g. haemophilia or 

diabetes.


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Rheumatoid arthritis

A polyarthritis caused by inflammatory overgrowth of synovium 

known as 

pannus

.

The earliest change is 

periarticular soft tissue swelling

and 

osteoporosis

Joint space narrowing. 

Initially small bony 

erosions

, at the joint margins. Later, extensive 

erosions 

Metatarso- or metacarpophalangeal joints, proximal 

interphalangeal joints and on the styloid process of the ulna.

Advance changes: 

Ulnar deviation

Arthritis mutilans

.


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Rheumatoid arthritis

With severe disease, there may be subluxation at the 

atlantoaxial joint, possibility of neurological symptoms from 

compression of the spinal cord by the odontoid process

A widespread erosive arthropathy is almost diagnostic of 

rheumatoid arthritis.


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Osteoarthritis

commonest form of arthritis.

The hip and the knee are frequently involved, the ankle  elbow 

are infrequently affected. 

The wrist, joints of the hand and the metatarsophalangeal joint 

of the big toe are also frequently involved.

Radiological features:

Joint space narrowing.

Osteophytes

Subchondral sclerosis

Subchondral cysts

Loose bodies


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Osteoarthritis


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Comparison of osteoarthritis and rheumatoid arthritis

Radiological feature

Osteoarthritis

Rheumatoid arthritis

Joint space narrowing 

Maximal at weight-

bearing site

Uniform

Erosions

Not occur

Is a characteristic feature

Subchondral sclerosis 

and cysts

Seen 

Not a feature

Sclerosis

Prominent feature 

Not a feature

Osteoporosis

Not occur

Often present

Joint involved

Knee, hip

Metacarpophalangeal

Distal interphalangeal

Metacarpophalangeal

Proximal interphalangeal


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Gouty Arthritis

Most commonly affects the metatarsophalangeal joint of 

the big toe.

The earliest change is soft tissue swelling

Erosions have a well-defined, often sclerotic overhanging 

edge

Usually no osteoporosis

Localized soft tissue lumps, known as tophi, may occur in 

the periarticular and occasionally show calcification.


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Gouty Arthritis

Tophi


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Joint Infection

Pyogenic bacterial infection or tuberculosis

In pyogenic arthritis, Staphylococcus aureus, there is rapid 

destruction of the articular cartilage & subchondral bone 

and a soft tissue swelling. A joint effusion is the earliest 

finding

TB arthritis, The hip and knee are the most commonly 

affected. Joint space narrowing and erosions, articular 

cortex destruction, and striking osteoporosis,


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pyogenic arthritis

TB arthritis


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Neuropathic joint (Charcot joint)

6 Ds of Charcot joint:

Increased Density (subchondral sclerosis)

Destruction

Debris (intra-articular loose bodies)

Dislocation

Distention

Disorganisation


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Charcot joint


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Avascular (aseptic) necrosis

Causes

steroid therapy

Collagen vascular diseases

Radiation therapy

Sickle cell anemia

Exposure to high pressure environments

Fractures.

The radiographic features:

Increased density of the subchondral bone with irregularity of the 

articular contour or fragmentation of the bone

A characteristic crescentic lucent line just beneath the articular 

cortex. 

The cartilage space is preserved until secondary degenerative 

changes supervene.


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Osteochondrosis

A group of disorders that affect the progress of bone 

growth by bone necrosis. It is only seen in children and 

adolescents who are still growing.

Perthe's disease: femora head

Freiberg’s disease: metatarsal heads

Kohler’s disease: navicular bone of the foot

Osgood–Schlatter’s disease: tibial tuberosity

Kienböck’s disease: lunate bone in the wrist


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Perthe's disease


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Perthe's disease

Kienböck’s disease


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Developmental dysplasia of the hip (DDH)

Abnormal development of the hip joint resulting from an 

abnormal relationship of the femoral head to the 

acetabulum.  There is a clear female predominance, and it 

usually occurs from ligamentous laxity and abnormal position 

in utero. Therefore, it is more common with oligohydramnios

pregnancies.

Risk factors include:

• female gender (M: F ratio ~1:8)
• firstborn baby
• family history
• breech presentation
• oligohydramnios


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Investigation used for diagnosis:

Ultrasound at early infancy

X ray later in life

The features: lateral and upper displacement 

of the head of the femur. Increased slope to 

the acetabular roof


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Best Regards




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