Bones? Did someone say bones? 12/31/2012. W.R Reinus, MD MBA FACR
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1 William R. Reinus, MD MBA FACR Temple University Medical Center Aug 2012 (55) 1 Bones? Did someone say bones? 2
2 ABC S OF ARTHRITIS Arthritis: By definition, any disease that is jointcentered: Both sides of the joint involved symmetrically. If not, think about underlying bone disease with or without 2 ry arthritis. Imaging only two possible types of changes: Destructive bone & cartilage destroyed. Productive sclerosis & osteophyte formation. 3 ABC S OF ARTHRITIS Yields four arthritis imaging categories: DESTRUCTIVE, PRODUCTIVE, BOTH, NEITHER. 4
3 ABC S OF ARTHRITIS: Destructive Rheumatoid (RA) Robust Seronegative Still s Disease Felty s Syndrome Etc. Juvenile Chronic Atx. SEPTIC Psoriatic Reiter s Syndrome Ankylosing Spondylitis Inflammatory Bowel Disease (Usually Crohn s) Dermatolipoid (Multicentric Reticular Histiocytosis) Bechet s Disease Sarcoidosis Hyperparathyroidism FMF Amyloidosis GOUT* Neuropathic* 5 ABC S OF ARTHRITIS: Productive 1 ry Osteoarthritis 2 ry Osteoarthritis TRAUMA NEUROPATHIC* Gout* CPPD AVN Acromegally Hemochromatosis Hemophilia Ochronosis Homocysteinuria Porphyria Neuromuscular Disease 6
4 ABC S OF ARTHRITIS: Both Erosive Osteoarthritis. Burned out destructive arthropathy. Gout. Neuropathic Arthritis. 7 ABC S OF ARTHRITIS: Neither Systemic Lupus Erythematosis Arthritis. Jaccoud s Arthritis. 8
5 Arthropathies: Prevalence 9 ABC S OF ARTHRITIS MANY ARTHROPATHIES NEED A STRATEGY TO ANALYZE IMAGES: Focus on the hand. Use the alphabet. 10
6 ABC S OF ARTHRITIS Soft tissue Alignment Bone Cartilage/Joint space Distribution Extraordinary Findings Classify Category 11 ABC S OF ARTHRITIS Soft tissue Alignment Bone Cartilage/Joint space Distribution Extraordinary Findings Differential within Category 12
7 ABC S OF ARTHRITIS: Soft Tissue Masses: Around Joints. Extensor surfaces. Too much: Sausage Digit. Capsular Swelling. Too little: Thenar/Hypothenar Wasting. Inflammation 13 SOFT TISSUE: Mass Rheumatoid Nodule 14
8 SOFT TISSUE: Mass Rheumatoid Nodule 15 SOFT TISSUE: Mass Tophus 16
9 SOFT TISSUE: Sausage Digit 17 SOFT TISSUE: Capsular Swelling 18
10 SOFT TISSUE: Capsular Swelling 19 SOFT TISSUE: Wasting 20
11 SOFT TISSUE: Wasting 21 SYNOVITIS:RA MRI exquisitely sensitive. Important in dx of early disease. Following activity. Has relevance: Biologics. 22
12 ISOLATED SYNOVITIS: 53yo woman c 5 th MTP joint pain Synovitis before identifiable PF erosive dz. 23 RA: 65yo woman with ankle pain and swelling. Rheumatoid nodules and synovitis... 24
13 EARLY RA: 52yo man 25 EARLY RA: 52yo man 26
14 CRYPTOGENIC RA PT, FDL & Peroneal tenosynovitis. 27 ABC S OF ARTHRITIS: Alignment Subluxations & Dislocations. Ulnar Drift. Shovel Deformity. Swan Neck Deformity. Boutonnière Deformity. 28
15 ALIGNMENT: Ulnar Drift 29 ALIGNMENT: Swan Neck Deformity 30
16 ALIGNMENT:Boutonnière Deformity 31 ABC S OF ARTHRITIS: Bones Osteopenia: Periarticular. Diffuse. Sclerosis. Periosteal reaction. 32
17 BONES: Periarticular Osteopenia 33 BONES: Osteopenia 34
18 BONES: Sclerosis Ivory Phalanx 35 BONES: Periosteal Reaction 36
19 BONES: Periosteal Reaction 37 ABC S OF ARTHRITIS: Cartilage Spaces Narrowing Smooth. Irregular. Gullwing. Mickey Mouse. None. Erosions: Periarticular. Juxtaarticular. Ankylosis: Disease. Iatrogenic (Fusion). 38
20 CARTILAGE SPACE: Narrowing SMOOTH IRREGULAR GULL WING 39 EROSION: Periarticular 40
21 RHEUMATOID ARTHRITIS 19yo girl with 3 rd MCP joint pain. 41 RHEUMATOID ARTHRITIS: MRI 42
22 DISEASE ACTIVITY: 38yo woman Erosions without edema. Not ACTIVE. 43 EROSION: Juxtaarticular 44
23 CARTILAGE SPACES: Ankylosis 45 ARTHRITIS MUTILANS: Main en Lorgnette Marie-Léri syndrome AKA: Arthritis mutilans, Arthropathia mutilans, Main en lorgnette (French), Rheumatoid acro-osteolysis, Secondary acroosteolysis syndrome, Secondary arthritis mutilans syndrome, Trophopathia myelodysplastica. 46
24 ARTHRITIS MUTILANS: Main en Lorgnette Description: Peculiar hand deformity with extreme mobility of the joints so that the fingers may be extended and shortened like a telescope. Osteolysis of the articular surfaces of the fingers. DDx: Arthritis: RA, Psoriasis & Reiter s, MRH, JCA. Congenital Insensitivity to Pain. Thévenard s syndrome (Congenital sensory and autonomic neuropathy with acroulceration). 47 ARTHRITIS MUTILANS 48
25 ARTHRITIS MUTILANS 49 ARTHRITIS MUTILANS 50
26 ABC S OF ARTHRITIS: Distribution Joints Affected: Predominant Extremity Involvement. Large Joints. Small Joints: Proximal. Distal. Spine: Which part? C, T, L. Disks, Facets, UVJ, Atlantoaxial. Symmetry. 51 ABC S OF ARTHRITIS: Extra Findings Clinical Information: Age & Gender. Laboratory Results: RF, ANA, AMA, UA, CCP Ab, Etc. Unusual Features: Lung disease. Subperiosteal resorption. AA subluxation. Ankylosis. Periostitis. 52
27 EXTRA FINDINGS: Clinical Age Group Age of Onset Disorder Young (< 20 years) Middle (> 20 years) Older patients (> 55 years) < 20 years onset years Young adults years > 55 years Juvenile chronic arthritis Hemophilia Septic arthritis Ankylosing spondylitis Reiter s Enteropathic arthropathies Rheumatoid arthritis Psoriatic arthritis Osteoarthritis DISH CPPD 53 EXTRA FINDINGS: Lung Disease RA Nodules Effusions PA Htn Interstitial Infiltrates Caplan s Syndrome Ankylosing Spondylitis Interstitial Upper Lung Field Infiltrates SLE Effusions, not infiltrates 54
28 EXTRA FINDINGS: Rashes Psoriatic Arthritis Extensor surfaces Palms & Soles Trunk 55 EXTRA FINDINGS: Rashes Reactive Arthritis Keratodermia Blennorrhagicum. Palms and soles Resembles pustular psoriasis. 56
29 EXTRA FINDINGS: Rashes SLE Malar Rash 57 REFERENCES 58
30 REFERENCES Arthritis in Black and White, Anne C. Brower, 2nd edition, 1997, W. B. Saunders Company. Diagnostic Imaging of Musculoskeletal Disorders, A Systematic Approach. Bonakdarpour A, Reinus WR, Khurana J. Springer Press, Amersham Health. Bone and Joint Imaging, Donald Resnick, 3rd edition, 2001, W. B. Saunders Co. Bone and Joint Teaching File. 59 Wow! Bones! And I thought they were just good eats! 60
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