Inflammatory Arthritis

Arthiritis

1. Radiographic evaluation of Inflammatory Arthritis OSR Dr. Yash Kumar Achantani

2. Arthritis Although the word "arthritis" means joint inflammation, the term is used to describe various diseases and conditions that affect joints, the tissues that surround the joint, and other connective tissue.

3. TYPES OF ARTHRITIS DEGENERATIVE ARTHRITIS INFLAMMATORY ARTHRITIS METABOLIC ATHRITIS INFECTIOUS ARTHRITIS CONNECTIVE TISSUE ARTHRITIS

4. DEGENERATIVE ARTHRITIS Primary Osteoarthritis :-Idiopathic(spontaneous) no specific cause known but tend to be associated with aging Secondary osteoarthritis :-caused by previous injury to affected bone,can began at young age.

5. INFLAMMATORY ARTHRITIS Rheumatoid arthritis :- autoimmune diseases involves chronic inflammation of synovium within joint(involves multiple joint on both side) Psoriatic arthritis :-autoimmune diseases which associated with psoriasis. Ankylosing spondylitis Reiter syndrome Erosive osteoarthritis

6. METABOLIC ATHRITIS Gout :- Caused by deposition of monosodium urate monohydrate crystal Calcium Pyrophosphate Dihydrate Crystal Deposition Disease ( Pseudogout ) :-caused by deposition of calcium pyrophosphate crystal

7. INFECTIOUS ARTHRITIS Septic arthritis :-Life and limb threatening bacterial infection of the joint. CONNECTIVE TISSUE ARTHRITIS Systemic lupus erythematous

8. Anatomy of Synovial Joint

9. Common Radiological Features of Arthritis Soft tissue swelling Subchondral sclerosis and erosion Narrowing of joint space Joint effusion. Osteophytes formation Suchondral cystic lesion. Periarticular osteoporosis

10. INFLAMMATORY ARTHRITIS Auto immune Arthritis Rheumatoid arthritis Seronegative Spondyloarthropathies Psoriatic arthritis Ankylosing spondylitis Reiter syndrome Erosive OA

11. Features of Inflammatory arthritis Marginal bone erosion. Uniform joint space narrowing. Soft-tissue swelling. Fluid (f), Cartilage(c), Pannus (P), Marginal erosions(Arrows)

12. Rheumatoid Arthritis Rheumatoid arthritis is a progressive, chronic, systemic inflammatory disease affecting primarily the synovial joints. Onset is usually between 20 and 60 years of age, with the highest incidence among the 40- to 50-year-old group. Under 40 females to male ratio is 3:1 and over 40 equal, 1:1 ratio incidence. The detection of rheumatoid factor, representing specific antibodies in the patient's serum, is an important diagnostic finding

13. Symptoms:- Low-grade fever, fatigue, weight loss, muscle soreness, and atrophy. Symmetric peripheral joint pain and swelling, particularly of the hands. Pathologic Features:- Initial synovial inflammation within joints, bursae , and tendon sheaths, with cellular infiltrate, hyperemia, edema, and increased synovial fluid. Synovium becomes hypertrophied to form granulation tissue (pannus), which spreads over cartilage surface.

14. At the bare areas pannus directly invades into the bone, resulting in marginal erosions and cartilage destruction. A rheumatoid nodule is diagnostic and consists of three distinct zones: fibrinoid degeneration and necrosis (central), radial palisading of fibroblasts (middle), and fibrous tissue with small cell infiltrate (outer).

15. Rheumatoid affecting MCP, PIP, MTP and other joints in a symmetrical fashion. Joint involvement Distribution

16. Radiologic Features Early radiographic changes are most commonly seen in the hands and feet. Bilateral and symmetric distribution, periarticular soft tissue swelling(these are typically the first radiographic signs of rheumatoid arthritis.), juxta-articular osteoporosis, juxta-articular solid or laminated periostitis, marginal erosions and cysts, and uniform loss of joint space. Later, radiographic changes may be seen, including marked deformities with subluxation, dislocation, articular bony destruction, bony fusion, and complete destruction of joint space.

17. Hand Earliest changes are seen at the metacarpophalangeal and PIP joints. Evaluation should include the AP ,Oblique and Semisupination view of the hands (Norgaard projection) for marginal erosions on metacarpal heads and deformities like ulnar deviation, boutonniere, swan neck, spindle digit.

18. Posteroanterior radiographs showing small bone erosion about the metacarpophalangeal joint with osteopenia(arrow) and more extensive involvement in second image (arrows)with alterations of the fifth metatarsal head and proximal phalanx.

19. Rheumatoid arthritis.(a) Postero -anterior and (b)oblique hand radiographs show joint space narrowing, bone erosions, and osteopenia of the metacarpophalangeal, distal radioulnar , radiocarpal , and midcarpal joints (arrows). Note subluxation of proximal interphalangeal joints.

20. Oblique radiograph of the hand shows the swan neck deformity of the second through fifth fingers

21. Radiograph of the hands demonstrates the boutonnière deformity in the small and ring fingers of the right hand and in the ring finger of the left hand

22. Wrist Earliest change is erosion of ulnar styloid, multiple carpal erosions , most common location for bony ankylosis, carpal radial rotation, zigzag deformity. Postero -anterior wrist radiograph shows osteopenia and joint space narrowing of the distal radioulnar , radiocarpal , and midcarpal joints with erosions of the scaphoid (arrow) and the ulnar styloid process (arrowhead).

23. Feet Earliest changes seen at the fourth and fifth metatarsal phalangeal joints. Changes are parallel and are identical to that seen in the hands; Lanois deformity—dorsal subluxation of the metatarsal-phalangeal joints, with fibular deviation. Radiograph of foot show joint space narrowing and bone erosions of both metatarsophalangeal joints and interphalangeal joints(arrows).

24. Lateral radiograph of the foot of shows fluid in the retrocalcaneal bursa (arrow) associated with erosion of the calcaneus (curved arrow).

25. Cervical spine Most commonly affected area of the spine; involved in up to 70% of rheumatoid patients. Increased atlantodental interspace > 3 mm (especially in flexion), odontoid erosions, subluxations (especially C3, C4, and C5). Narrowed intervertebral discs, apophyseal joints show erosions and narrowed joint space and may ankylose. Tapered spinous processes and generalized osteoporosis.

26. Lateral cervical spine radiograph shows erosions of dens(straight arrows) with narrowing of facet joints(curved arrow). Lateral flexion radiograph shows widening of atlantodens interval (arrowheads).

27. Hips Uniform loss of joint space (axial migration), minimal erosions, protrusio acetabuli , particularly bilaterally. Anteroposterior radiograph of the right hip shows erosions of the femoral head and acetabulum, concentric narrowing of the hip joint, and acetabular protrusio .

28. Anteroposterior pelvis radiograph shows bilateral involvement of hips, with uniform diffuse joint space narrowing, bone erosions, osteopenia, and acetabular protrusion(arrows). Note bone sclerosis related to involvement of sacroiliac joints(arrowheads).

29. Knees: uniform loss of joint space, marginal erosions (particularly at the tibial condyles), and osteoporosis; often associated with large Baker’s cysts. Anteroposterior knee radiograph shows diffuse and uniform joint space loss(arrows) with osteopenia.

30. Anteroposterior (A) and lateral (B) radiographs of the knee shows periarticular osteoporosis, joint effusion, and uniform reduction of joint space.

31. Juvenile rheumatoid arthritis Chronic polyarthritis resembling rheumatoid arthritis clinically and histologically beginning before 16 years of age. Synonyms include Still’s disease and juvenile chronic arthritis. More common in females < 16 years, with peak incidence at 2-5 and 9-12 years.

32. TYPES Adult form (seropositive) Poorest prognosis Seronegative form:- Classic systemic , Polyarticular Pauciarticular-monoarticular Distinct lack of rheumatoid factor Symptoms include fever, characteristic rash, lymphadenopathy, iridocyclitis (especially in monoarticularforms ), no subcutaneous nodules, and growth disturbance. Distinct lack of rheumatoid arthritis

33. Radiologic Features General features include soft tissue swelling, osteoporosis, periostitis, growth disturbances, ankylosis, loss of joint space, erosions, subluxations, and epiphyseal compression fractures. Target sites include cervical spine, hands, feet, knees, and hips. Cervical spine: atlantoaxial dislocations, hypoplastic C2-C4 vertebral bodies and discs with ankylosed apophyseal joints. Tarsal and carpal ankylosis common. Growth deformities: brachydactyly , ballooned epiphyses, squashed carpi, and squared patellae.

34. A. Lateral Lumbar. Note that osteoporosis and compression fractures have produced a biconcave appearance of the endplates. B. Lateral Cervical. Observe the vertebral body hypoplasia of the second, third, fourth, and fifth segments. C. Lateral Cervical. Note that the vertebral bodies are hypoplastic in combination with posterior joint ankylosis. These are characteristic cervical spine changes

35. Radiograph of both hands shows destructive changes in the metacarpophalangeal and interphalangeal joints. Note also joints ankylosis in both wrists. the periarticular soft tissue swelling and periostitis (arrows)

36. Radiograph of both knees shows overgrowth of the medial condyles, one of the characteristic features of this disorder

37. Ankylosing Spondylitis A chronic inflammatory disorder principally affecting the articulations, ligaments, and tendons of the spine and pelvis, often resulting in complete polyarticular ankylosis . Synonyms include Marie- Strumpell disease, rhizomelic spondylitis, pelvospondylitis ossificans , and rheumatoid spondylitis. Onset is usually between 15 and 35 years and involves males 10:1. Initiates at the sacroiliac joints bilaterally, then ascends the spine.

38. Pain and tenderness, especially over bony protuberances, and increasing stiffness and sciatica is often bilateral or may alternate from side to side. Complications include iritis , aortitis , valvular incompetence, aneurysms, conduction blocks, upper lobe pulmonary fibrosis, inflammatory bowel disease, renal failure owing to secondary amyloidosis, carrot-stick fractures, Andersson’s lesion, and prosthesis ankylosis . The most commonly involved areas are the sacroiliac joints, spine, and proximal large joints of the shoulder, hip, and rib cage.

39. Pathologic Features In synovial joints, the initial change is that of a non-specific synovitis similar to rheumatoid arthritis, except that it is less extensive and of lower intensity (pannus formation), with subsequent fibroplasia and cartilaginous metaplasia, leading to resultant ossification. In cartilage joints, the initial subchondral osteitis is replaced by fibrous tissue that subsequently ossifies. In the outer annulus fibers this forms syndesmophytes . At entheses , inflammatory changes at ligamentous attachments result in bony erosions, sclerosis, and periostitis.

40. Ankylosing spondylitis affecting the axial skeleton and large peripheral joints in an asymmetrical fashion. Joint involvement Distribution

41. Radiologic Features Shiny Corner sign(small erosions with surrounding reactive sclerosis at sup. and inf. vertebral end plates) Vertebral body squaring.(loss of normal concavity of anterior border) Marginal syndesmophyte formation. Bamboo sign.(late fusion and ligamentous ossification) Dagger sign.(single central radio-dense line due to ossification of supraspinous and interspinous ligaments) Trolley track sign.(central line by supra and interspinous lig . And two side lines of ossification- apophyseal joints)

42. Lateral radiograph of the lumbar spine demonstrates squaring of the vertebral bodies secondary to small osseous erosions at the corners. This finding is an early radiographic feature of ankylosing spondylitis. Note also the formation of syndesmophytes at the L4- 5 disk space.

43. (A) A lateral radiograph of the lower lumbar spine of shows early inflammatory changes manifesting by so-called shiny corners ( Romanus lesion ) (arrowheads) and squaring of the vertebral bodies (arrows). A. AP Sacrum. Note that bilateral sacroiliitis is clearly seen with erosions, hazy joint margin, and subchondral iliac sclerosis (arrows).

44. ( A) Lateral radiograph of the cervical spine shows anterior syndesmophytes bridging the vertebral bodies and posterior fusion of the apophyseal joints, together with paravertebral ossifications, producing a “bamboo-spine” appearance. (B) radiograph the fusion of the sacroiliac joints and the involvement of both hip joints, which show axial migration of the femoral heads

45. Psoriatic Arthritis Psoriasis is a common skin disorder associated with joint disease and characterized by peripheral joint destruction and deformity Age 20-50 years with male and female equally affected. Arthritis is usually in peripheral joints, especially DIP joints. Soft tissue findings: fusiform soft tissue swelling around the joints which can progress so that whole digit is swollen (sausage digit or dactylitis ). Marginal erosions also often show fluffy periostitis from new bone formation. i.e. has both erosive and productive changes.

46. Psoriatic arthritis affecting PIP, DIP and large joints in an asymmetrical fashion. Joint involvement Distribution

47. Radiologic Features General features include soft tissue swelling, normal bone mineralization, erosions, and tapered bone ends, prominent juxta-articular fluffy periostitis, and joint-space widening or bony ankylosis. Hands and feet: Asymmetric involvement and ray pattern, most commonly involves DIP joints, no osteoporosis, mouse ears sign, widened joint space owing to fibrous tissue deposition and bone resorption, pencil-in-cup deformity, opera glass hand deformity, no ulnar deviation.

48. 1.Joint space narrowing 2.Fulffy periostitis 3.Sausage digit(Soft tissue swelling of entire digit) 4.Erosion of terminal tufts 5.Mouse ear type of articular erosion 6.Interphalyngeal ankylosis 7.Soft tissue swelling

49. Early Distal Interphalangeal Joint Changes. Note that erosions (arrows), periostitis (arrowheads), and soft tissue swelling characterize the earliest abnormalities Combination of erosions and fluffy periostitis produces the mouse ears appearance in psoriasis. MOUSE EAR SIGN

50. PA Hand. Note the erosive changes are present at the three joints of the second digit (arrows). This pattern of arthritis is virtually diagnostic of psoriasis RAY PATTERN

51. Pencil and cup deformity Pencilling

52. A. PA Hand . Note that close to the joint near the site of articular erosion, the periosteal new bone is typically fluffy (arrowheads). Farther down the shaft a linear pattern may be seen (arrow). B. Great Toe : Note that adjacent to the erosions a fluffy and irregular type of periostitis can be seen (arrowheads). The entire distal phalanx is sclerotic, a reliable sign of psoriatic arthritis involving the great toe.

53. Sacroiliac joint: Involved in up to 50% of psoriatic arthritis patients, usually bilateral but asymmetric and unusual to be narrowed and ankylosed . Spine: atlantoaxial subluxation and dislocation, normal apophyseal joints (except in the cervical spine), syndesmophytes of two types—non—marginal, marginal (non-marginal are the most common)—broad-based and tapered, asymmetric, unilateral, and most common in the upper lumbar and lower thoracic spine.

54. Non- Marginal Syndesmophyte . Note the thick, vertical ossifications that arise just beyond the vertebral body margins (arrows).

55. Oblique radiograph of the lumbar spine showing a characteristic single coarse syndesmophyte bridging the bodies of L3 and L4. (B) AP radiograph of the lumbar spine with psoriasis reveals paraspinal ossification at the level of L2-3.

56. Note severe joint destruction, especially at the metatarsophalangeal articulations, has resulted in fibular deviation and dorsal dislocation of the digits (Lanois’ deformity). The presence of a pencil-in-cup deformity (arrow) at the interphalangeal joint of the big toe and osseous ankylosis of the first metatarsophalangeal and second and third proximal interphalangeal articulations (arrowheads) makes the diagnosis of psoriatic arthritis most likely ARTHRITIS MUTILANS Arthritis mutilans is the most severe and destructive form of psoriatic arthritis. Fortunately, it's rare. It damages the small joints in your fingers and toes so badly that they become deformed.

57. DIFFERENTIAL DIAGNOSIS Rheumatoid arthritis there is a MCP joint predominance in rheumatoid arthritis (RA) vs interphalangeal predominant distribution in PsA bone proliferation not a feature in RA osteoporosis not a feature in PsA Erosive osteoarthritis “gull wing” central erosions are present in erosive OA vs “mouse ears” peripheral bare area erosions in PsA Reactive arthritis (Reiter syndrome) “tends to involve feet > hands

58. REITER’S SYNDROME A triad of urethritis, conjunctivitis, and polyarthritis, usually following sexual exposure or, less commonly, certain types of dysentery. It typically occurs between the ages of 18 and 40, and is as much as 50 times more prevalent in males Joint symptoms typically consist of an asymmetric painful effusion, especially of the lower extremity Pain at the plantar or Achilles calcaneal attachment (lover’s heels) in a young male patient should suggest the diagnosis. These joint symptoms are of short duration and self-limiting within 2-3 months, but recurrences are common.

59. Radiologic Features Swelling, osteoporosis, uniform loss of joint space, erosions, periostitis. Specific target sites: forefoot, calcaneum , ankle, knee, sacroiliac jt , spine. Foot: metatarsophalangeal and interphalangeal joints. Dorsal subluxation of the proximal phalanges and fibular deviation of the digits results in the Lanois deformity. Calcaneum : Erosive changes at plantar and Achilles insertions. Ankle: loss of joint space, swelling, periostitis .

60. Sacroiliac: erosions, sclerosis, loss of joint margin, asymmetric involvement and often unilateral. Spine: thoracolumbar, asymmetric, skip non-marginal syndesmophytes and, rarely atlantoaxial instability. Knee: the only change usually visible at the knee is effusion and, occasionally, periostitis of the distal femoral metaphysis. A Pellegrini-Stieda type calcification of the medial collateral ligament may be seen

61. X-ray foot shows the thin layer of periosteal new bone at the phalangeal base at the third metatarsophalangeal joint (arrows). There is also a notable diminished density in the metatarsal head (arrowhead).

62. Xray showing marginal erosions (arrows), linear periostitis (arrowheads), and soft tissue swelling (crossed arrows) at the proximal interphalangeal joint.

63. CALCANEUS. A. Early Erosive Changes: Achilles Tendon. Shows small lucent defects (arrows) and adjacent periostitis (arrowhead). B. Pathophysiology. The inflamed pre-Achilles bursa (arrowheads) becomes the site for pannus formation and subsequent subperiosteal resorption of the adjacent calcaneus (arrow). C. Advanced Erosive Changes. Note that the lucent defects are larger (arrows), with prominent periostitis (arrowheads). Note the fluffy calcaneal spur owing to inflammatory enthesopathy (crossed arrow).

64. MEDIAL COLLATERAL LIGAMENT CALCIFICATION. Note the irregular linear density adjacent to the medial epicondyle (arrow). This is a Pellegrini-Stieda type of calcification within the medial collateral ligament and may be seen in approximately 10% of Reiter’s syndrome patients

65. Erosive Osteoarthritis Inflammatory variant of degenerative diseases involving the interphalangeal joints of the hands. Common in females 40-50 years old. The onset of erosive osteoarthritis is characterized by episodic and acute inflammation of the DIP and PIP joints of both hands in a symmetric manner. Pain, edema, redness, nodules, and restricted motion are found at the involved articulations of the hands. The Pathological features are cartilage degeneration and synovial proliferation.

66. Osteoarthritis affecting the DIP, base of thumb, knees, hips, lumbar and cervical spine. Joint involvement Distribution

67. Radiologic Features Involvement of the ulnar compartment of the carpus is significantly spared differentiating involvement from rheumatoid arthritis. Radiographic changes are characterized by osteophytes, loss of joint space, and sclerosis. Osteophytes are identical to those seen in DJD. They are marginal in origin, taper distally, and are often larger at the distal articular component. Loss of joint space is usually non-uniform, with adjacent subchondral sclerosis. Superimposed changes of erosions, periostitis, and ankylosis on these degenerative features are characteristic of erosive osteoarthritis. Bone erosions are distinctively centrally located on the proximal articular surface and more peripherally at the distal articular surface.

68. Radiologic Features At DIP and PIP joints of hands. 1.Erosions (gull wings sign). 2. Nodes. 3. Interphalyngeal ankylosis .

69. Gull Wings Sign . Shows characteristic biconcave articular contour (arrows).

70. Radiograph of both hands shows erosions of the distal interphalangeal joints with typical “gullwing” configuration due to central erosions and peripheral osseous proliferation

71. HANDS. A. Target Distribution. Note the selective involvement of the distal interphalangeal joints (arrows). B. Radiologic Features. Shows on closer inspection of these involved joints reveals osteophytes, sclerosis, loss of joint space, cystic erosions, and deformity.

72. Differential diagnosis The main differential considerations are rheumatoid arthritis, psoriasis, and non-inflammatory degenerative joint disease. Rheumatoid arthritis rarely involves the distal interphalangeal joints and has a positive latex test. Psoriatic arthropathy is characterized by discrete marginal erosions with adjacent fluffy periostitis (mouse ears sign). Non-inflammatory DJD will show no erosions but will otherwise appear identical to erosive osteoarthritis.

73. From left to right: Rheumatoid affecting MCP, PIP, MTP and other joints in a symmetrical fashion. Psoriatic arthritis affecting PIP, DIP and large joints in an asymmetrical fashion. Ankylosing spondylitis affecting the axial skeleton and large peripheral joints in an asymmetrical fashion. Osteoarthritis affecting the DIP, base of thumb, knees, hips, lumbar and cervical spine.