This presentation provides a comprehensive review of imaging in arthritis : Degenerative/Inflammatory/Infective/Metabolic.

1. IMAGING IN ARTHRITIS
DR. NAVNI GARG
MBBS,DNB (RADIOLOGY)
gargnavni@gmail.com

2. DEFINITION
Inflammation of a joint.
ARTHROS- joint
IT IS - inflammation
When joints are inflamed they can develop
stiffness, warmth, swelling, redness and pain.

3. Imaging Modalities
1-Radiographs
 Still the most widely used investigation
 Skeletal survey – disease distribution
 Treatment monitoring
 Not sensitive for early disease
Best practice & research clinical rheumatology:2004, 2008

4. 2-Ultrasound
 Joint effusion
 Synovial thickening & hypervascularity
 Erosions
 Monitor disease activity & progression
 Guided aspiration & injections
(El- Miedany et al. Joint Bone Spine 68(3),2001)
Best practice & research clinical rheumatology:2004, 2008

5. 3-Computed Tomography
 Limited role
 Imaging of CV junction
 Better demonstration of
new bone formation and
bony ankylosis
Best practice & research clinical rheumatology:2004,

6. 4-Magnetic Resonance Imaging
 Gold standard for synovial imaging
 Detection of active synovitis
 Bone marrow changes
 Scoring
 Early detection of erosions ( MRI erosions progress to radiographical
erosions with in 2 yrs)
Sugimoto H et al. Semin Musculoskel Radiol 60(11): 1203-10,2001)
(Savnik et al. Eur Radiol 12(5): 1203-10,2002)
Best practice & research clinical rheumatology:2004,
2008

7. 5-Radionuclide scanning
 Radiolabelled polyclonal human Ig
 Highly sensitive:
detection of inflammatory changes
 Poor specificity
Best practice & research clinical rheumatology:2004, 2008

8. Radiological
Approach
 Alignment
 Bone density
 Cartilage/joint space
 Distribution
 Erosions
 Soft tissue changes

9. Bone Density
Reduced bone density
RA, Juvenile chronic
arthritis
Pyogenic (after 10 days)
Tuberculous
Reiter (Acute)
Hemophilia
Scleroderma
Maintained bone density
OA
CPPD
Gout
Psoriasis
AS
Reiter chronic or recurrent
Pigmented villonodular
synovitis

10. Cartilage-Joint Space
3 Types of changes
a. Increase – overgrowth, effusion or interposition:
e.g. Early arthritis
Psoriatic
Pigmented villonodular synovitis
Gout
a. Decrease – cartilage destruction
Uniform (inflammatory arthritis)
Non-Uniform (degeneration)
c. Ankylosis - Bony
fibrous

11. Arthropathy Distribution in Small Joints
Distal Proximal General
Psoriasis RA Gout
Reiter’s Syndrome CPPD
Osteoarthritis
Sarcoid
Bilateral Symmetry
Rheumatoid Arthritis
Multicentric Reticulohistiocytosis

12. Erosions
 Distal -Psoriasis
Erosive OA
Reiter’s
 Proximal – RA
CPPD
 Non – erosive - SLE
Rheumatic fever (rare)

13. Demographics
0-20
years
20-40 years >40 years
Juvenile chronic
arthritis
Ankylosing spondylitis Degenerative joint
disease
Septic arthritis Psoriasis DISH
Reiter’s Gout
Rheumatoid arthritis Pseudogout
scleroderma Hypertrophic
osteoarthropathy
SLE
Synoviochondrometaplasia

14. Radiographic Views
REGION OF INTEREST VIEWS
SPINE: Intervertebral disc
Apophyseal joints
Costovertebral joints
Lateral, AP
Oblique, Lateral
AP
SACROILIAC JOINTS AP cephalad angulation(25-30)
PA caudal angulation (20-25)
SYMPHYSIS PUBIS AP
HIP AP, Frog leg
KNEE: Femorotibial
Patellofemoral
AP
Skyline, lateral
ANKLE, FOOT AP, Oblique, Dorsiplanter, obliques
SHOULDER:Acromioclavicular
glenohumeral
Sternoclavicular
AP Cephalad angulation 10
AP int n ext rotation
PA
ELBOW AP, Oblique
WRIST PA, Oblique, PA ulnar flexion
HAND PA, Oblique, Norgaard view

15. Basic terminologies
 Monoarticular – single joint
 Pauciarticular - 2-4 joints
 Polyartricular - >4 joints
 Enthesis – bone-tendon jn, bone-ligament jn
 Enthesopathy – inflammation at lig or tendon
insertion (enthesis)
 Hyperostosis – exuberant calcification of ligament or
tendon
 Osteophyte – degenerative bony outgrowth
continuous with underlying cortex
 Spondylophyte – spinal osteophyte

16.  Syndesmophyte – inflammatory ossification within
spinal ligament
 Marginal /Non-marginal

17. Phytes of the spine: these areas of ossification seen at
or close to the vertebral body.
a. Syndesmophytes: ossification of Sharpey fibers of annulus fibrous and
the deep fibers of the ALL, which appear as a smooth vertical
ossification that connects 2 vertebral bodies across the disc space. AS
is the prototype of such phytes, which may also be seen in reactive,
psoriatic, or enteropathic arthropathies.
b. Marginal osteophytes: horizontal projections at the level of the vertebral
endplate, with its cortex and medulla continuous with those of the parent
bone. If large, they may become vertical and join another marginal
phyte at an adjacent level and are usually seen in degenerative joint
disease (DJD) or posttraumatic conditions.
c. Nonmarginal osteophytes (tractional osteophytes): about 2 to 3 mm
away from the endplate, are also continuous with the cortex and
medulla, and start horizontally but may become vertical as in the
marginal ones). Smaller phytes are seen in DJD or spondylosis
deformans; however, larger ones (also called nonmarginal
syndesmophytes) are seen in psoriatic and reactive arthritis.
d. Paraspinal phytes: Ossification of structures outside the vertebral body
or disc, usually the ALL The ossification is separated from the vertebral
body by a thin, lucent cleft. This pattern is normally associated with
diffuse idiopathic skeletal hyperostosis.

18. Classification
 DEGENERATIVE
 INFLAMMATORY/INFECTIVE
 METABOLIC

19. DEGENERATIVE ARTHRITIS
 DJD
 DISH
 OPLL
 Erosive osteoarthritis
 Neurotrophic
arthropathy
 Synoviochondrometapl
asia

20. 1-Degenerative joint disease
 Most common joint disorder
 Intrinsic degeneration of articular cartilage
 Pain/stiffness/crepitus/deformity with normal lab studies
 JOINTS: 1st CMC, 1st MCP, DIP, hip, knee, spine
Altered chondrocyte fn
loss of chondroitin sulftae
Fissuring/fibriillation/flaking/
vascularisation
Loss of joint space

21. Eight Essential Roentgen Sign
 Asymmetric distribution
 Non-uniform reduction of joint space
 Osteophytes
 Subchondral sclerosis
 Subchondral cysts (Geodes)
 Intra-articular loose bodies
 Intra-articular deformity
 Joint subluxation

22. Cx spine: lat view LS spine: AP view

25. Saggital T2WI: knee
Saggital T2WI foot
Axial T2WI: knee

26. Vaccum Sign of Knuttsen
Collection of nitrogen in disc
 Reliable plain film sign to exclude infection
 Disc is degenerative
 Intersegmental motion present
 Only in extension views
 Physiological-Joint other than spine

27. 2.Erosive Osteoarthritis
 Symmetrical inflammation
 DIP and PIP jt
 Middle age females
 DJD + central erosions
+ periostitis+ ankylosis
 D/D: RA (no DIP)
Psoriasis(Fluffy periostitis)
DJD( No erosions)
Semin muscul radiol 2003

28. 3.Diffuse Idiopathic Skeletal Hyperostosis
(DISH; Forestier’s disease)
 Ligamentous calcification and ossification
 Spinal (Tx > Cx > Lx) and extraspinal site (T7-T11,C4-7,L1-
L3)
 Upto 20% DM; 50% OPLL
 Radiological criteria:
1. Flowing ossification anterolateral aspect of ≥4 contiguous
vertebral bodies
2. Preserved IV disc ; no signs of disc degeneration(Exclude
DJD)
3. Absent apophyseal jt ankylosis (Exclude Seronegative
arthritis)

30. ENTHESOPATHY of the iliac crest, ischial tuberosities, and greater trochanters and
spur formation in the appendicular skeleton (olecranon, calcaneum, patellar
ligament) are frequently present
'whiskering' enthesophytes

31. Synovial portion of the SI joints is normal with ossification of the anterior and
superior articular portions of the SI joint
The bulky paraspinal phytes of diffuse idiopathic skeletal hyperostosis may be
confused for PsA; however, the preserved disc spaces, and lack involvement of
apophyseal and upper SI abnormalities exclude an underlying inflammatory cause.

32. 4.Neurotrophic Arthropathy
 Impairement of joint proprioception (charcot’s jt)
 UL-Syringomyelia (atrophic type)
 LL- DM (MC), Leprosy, MMC
HYPERTROPHIC (6 d’s) ATROPHIC
Distension Resorbed articular surfaces
Density Tapered ends
Debris Amputated appearance
Dislocation Licked-candy stick appearance
Disorganization
Destruction

33. PA view Lt foot

34. Charcot Arthropathy of Shoulder from Syringomyelia. The hallmarks of
Charcot arthropathy are fragmentation of bone (white arrows), destruction of
the joint (black arrows), soft tissue swelling and sclerosis of bone. The
shoulder "joint" is dislocated.

35. Non infective Infective
RA Tubercular
JRA Non-
tubercular
AS
Reiter
Psoriatic
SLE
Scleroderma, etc

36. Basic pathophysiology

37. 1-RHEUMATOID ARTHRITIS

38. Rheumatoid Arthritis
S –
Symmetrical
S - Synovial
S - Small Joints

39. ..
 JOINTS: small joints of hand ,feet and spine(Cx-
70%), and LC large joints
 Earliest change : STS of MCP (Haygarth’s nodes),
PIP, ulnar styloid process
 FEET: earliest changes at 4 & 5 MTP jt
 Fibrous > bony ankylosis
Absent DIP Joint involvement

40.  General radiological features
 B/L symmetry
 Uniform loss of joint space
 Periarticular soft tissue
swelling
 Marginal erosions
 Juxtra-articular osteopenia
 Juxtra-articular periostitis
 Large pseudocysts
 Joint deformity

41. Terminologies related to RA
 Jelling phenomenon
 Spindle digit
 Marginal erosions ( rat bite)
 Boutonniere deformity
 Swan neck deformity
 Ulnar deviation
 Zig-zag deformity
 Dot dash appearance/ spotty carpal sign
 Hitchhiker’s thumb
 Terry-thomas sign

42. HITCHHIKER
THUMB

43. CARPAL FUSION
EROSION OF ULNAR STYLOID
SUBLUXATION OF MCP JOINTS

44. A. BOUTONNIERE
B. SWAN NECK
DEFORMITY

45. Terminologies related to RA
 Fibular deviation
 Lanois’ deformity
 Protusio acetabuli( MC cause)
 Atlantoaxial instability (ADI >3mm)
 Summation effect
 Baker’s cyst
 Caplan syndrome ( RA + Pneumoconiosis )
 Felty syndrome (RA + leukopenia +
splenomegaly)

46. Bakers cyst Protrusio acetabuli

47. RA: KNEE
Nuclear scan: B/L knee

48. FLEXIONEXTENSION
AAD

49. FLEXION
Post ContrastEXTENSION
Sag T1 WISagT2 WI

50. 2-Juvenile Rheumatoid Arthritis
 Persistant arthritis in ≥ 1 jt for > 6wks in child
<16 yrs after excluding other causes
 Prognosis good - <20% children have
progressive destructive disease
Seropositive JRA – 5 -15%
 Adolescent females
 Peripheral erosive polyarthritis (nearly identical
with adult RA)

51. Seronegative JRA
Features Systemic Polyarticular Pauciarticular
Incidence 20% 50% 30%
Sex ratio 1:1 1:2 1:3
Systemic
findings
Pronounced Mild -moderate Uncommon(iritis
)
joints Less common
(Any)
Wrist, foot,
Knee, ankle
Larger jts, rare in
small jts
symmetry Variable Symmetrical Absent
Cx spine Rare common Rare
X-Ray findings Rare common Less common
Prognosis Recurrence variable Resolution
Complication Heart disease,
polyarthritis
Growth
disturbances
chronic
polyarthritis

52. AP RT knee

53. Coronal T1 WI
Sag FS T2
WI
Coronal T2 WI

54. JRA Adult onset RA
Joint space loss Late Early
Bony erosion Late Early
Bony ankylosis Common Rare
Periostitis Common Rare
Growth
disturbance
Present Absent
Epiphyseal
compression
Seen Less common
Deformity Radial deviation of
MCP joint with ulnar
deviation of wrist
Ulnar deviation of MCP
joint with radial
deviation of wrist
Cohen PA et al. Eur J Radiology ; 2000; 33 (2)
RCNA2004

55. 3-Ankylosing Spondylitis
(Marie Strumpell’s disease/ Bechterew’s disease)
 Chronic inflammatory disorder of articulation, lig
and tendon of SPINE & PELVIS
 SI jt> thoracolumber> lumbosacral
 15-35 yrs M:F ( 10: 1)
 ≈90% HLA B27
 Inflammation Erosion Ankylosis
Extra - articular features - Acute anterior uveitis,
aortitis, AR, pulmonary fibrosis, Amyloidosis,
arachnoiditis

56. Halmark of AS)
 B/L symmetrical, Illiac side more involve
 Lower 2/3 of jt
GRADES
1- Pseudo widening-hazy margin
subchondral osteoporos
2 & 3-Erosive & sclerotic change (MC stage seen)
Rosary bead appearance
4-Ankylosis- Star sign
Ghost join margin
RCNA 2004:121-
134

58. T1WI (Coronal) T2 WI (Coronal)
AP view of B/L SI Jt Axial CT b/l SI jt

59. D/D of sacroiliac disease
DISEASE B/L symmetrical B/L asymmetrical Unilateral
AS +++ +(early) +( early)
Enteropathic +++ - -
Hyper PTH +++ - -
Osteitis condensans illi +++ + +
Psoriatic + +++ ++
Reiter’s ++ ++ +++
RA _ + +++
Infection - - +++
OA - + ++
Gout + + +
DISH +( upper jt) - -
Essential’s of skeletal radiology: Yochum & Rowe

60. SPINE : AS
 All joints
 Romanus sign –outer annulus enthesitis --- erosions
 Squaring -erosion+ periostitis
 Barrel shaped vertebra
 Shiny corner sign-reactive transient sclerosis
 Marginal syndesmophyte –
bamboo/poker spine
 Trolley track appearance –
apophyseal capsule,spinal ligament
& ligamentum flavum
 Dagger appearance
 Atlanto axial instability( 2-15 %) & shiny dens sign
 Carrot stick fracture

62. Barrel-Shaped Vertebra. Note that the anterior body contour is convex owing to
corner erosions and subligamentous new bone formation.
ROMANUS LESION. Lateral Lumbar. Note the early anterior body margin erosions
(arrow). This is an infrequently observed sign before the formation of
syndesmophytes. A localized surrounding reactive sclerosis (shiny corner sign) is
also present

63. Enthesopathy
 Erosions with marked sclerosis
(WHISKERING)
 Iliac crest, ischial tuberosity &
calcaneum
Saggital T2WI

64. Lateral Cervical, Carrot-Stick Fracture. Note that a fracture has occurred at
the C6 interspace following trivial trauma to this completely ankylosed
spine. B and C. Lumbar Spine, Andersson’s Lesion. Observe that a
fracture has occurred through an ankylosed segment, producing
hypermobility, sclerosis, and body destruction, simulating an infection or a
neurotrophic process. These severe degenerative changes occurred within
1 year after trauma.

65. 4-Enteropathic arthropathy
 Causes-UC > Crohn’s (common)
Whipple’s
Salmonella,Shigella, Yersinia
Post bypass
Collagenous colitis
 Radiographic findings identical to AS except
Isolated SI jt mc
10-12% HLA B27
HOA can be seen

66. 5-Psoriatic arthropathy
 Skin disorder with arthropathy ≈10-15% (Nail
changes)
 HLA B27-≈75%
 Skin lesions precede arthritis – 70%
 Arthritis precedes skin lesions – 15% (concomitantly
15%)
 JOINTS- Peripheral jts hand & feet
SI jt 35 – 50%
Spine- 30 – 40%
Non marginal syndesmophyte
Radiographics 2008
RCNA 2004
Semin muscul radiol 2003

67. Psoriatic Arthropathy
Clinically – 3 groups
a. Mono or oligoarthritis with enthesitis (45%)
b. Symmetrical polyarthritis (RA) 45%
c. Predominant axial disease (AS) + peripheral
joint disease - rare 5%
RCNA 2004: 121-134

68. Radiological Features
 DIP & PIP joints of hands and feet
 All 3 jt of a digit-RAY digit(diagnostic)
 U/L; if B/L – asymmetric
 Bone erosions + Fluffy periosteal reaction ( mouse ear
appearance)
 Normal bone mineralization(d/d RA)
 N or widened jt space (d/d RA)
 Arthritis mutilans /Pencil in cup telescoping/opera glass
deformity
 Complete osseous ankylosis - frequent sequela

69. Associated resorption of tufts infrequent but diagnostic

70. X-ray PA view Foot

71. 6-Reiters Syndrome
 Sterile inflammatory arthritis – young men
 MC clamydia
 Triad- Arthritis, urethritis, conjunctivitis
 Skeletal involvement – 80%
 Peripheral asymmetric arthritis LL>SI> SPINE>UL
 Feet – MTP joints, IP joints of great toe
 Lover’s heel- calcaneum erosions/perostitis
 Sacroiliitis – 50% - U/L or asymmetric
 Syndesmophytes –Non-marginal coarse,
asymmetric
Semin muscul radiol 2003
Radiographics 2008
RCNA 2004

72. Sag FS T2 WI

73. Findings Ankylosing spondylitis and
enteropathic arthropathy
Psoriasis and Reiters
Sacroilitis Always bilaterally
symmetrical
Commonly bilaterally
asymmetric
Marginal syndesmophytes Frequent thin + vertical Broad asymmetrical
and Irregular
Paravertebral Ossification Rare Common
Pattern of spine
involvement
Ascending contiguous
progression
Random progression
frequent skip areas
Apophyseal joint
involvement
Frequent may be severe Less common
Bony ankylosis More common Less frequent
Osteitis and squaring of
vertebral body
More common Less common

74. 7-Systemic lupus
erythematorsis (SLE)
 Erosion characteristically
absent
 Finding : hand >>spine
B/L symmetrical
reversible deformities,
Osteoporosis
minimal arthropathy
soft tissue atrophy
calcinosis
Osteonecrosis
 Plain xray – May be normal
Spontaneous fractures
PA view B/l hands

75. 8-SCLERODERMA
1-Pulp atrophy associated +
calcinosis cutis/circum scripta
2-Acro-osteolysis + calcinosis is
virtually diagnostic)
3-Joints-Normal, B/l 1 MCC Jt with
erosions
X-ray PA view Rt hand

76. INFECTIVE ARTHRITIS
Infection must be always ruled out in monoarticular involvment
1.TB Arthritis
 Skeletal involvement -50% spine; 30% hip &
knee ; rest 20%
 Monoarticular involvment
 Primary focus – synovium
Semin muscul radiol 2003
Radiographics 2008

77. Tubercular Arthritis
PHEMISTER’S TRIAD (3P’S)
 Peri articular osteoporosis
 Peripheral osseous erosions
 Progressive gradual narrowing of
interosseous space
X-ray AP view Lt knee

78. TB
Coronal T2WI
AP view Lt shoulder

79. Septic Arthritis (non-tubercular)
 Monoarticular (90%)
 Knee, ankle and Hip: ≈85% cases
 Staph and gonococcus MC organism
 Differentiating features:
a) Single joint involvement
b) Presence of adjacent focus of
osteomyelitis
c) Rapid progression of radiological changes
d) Periosteal reaction
e) Intraarticular gas

80. Coronal CT images: b/l hip jt
AP Radiograph pelvis
Nuclear scan

81. Axial post contrast T1WI b/l hip jt
Coronal T2WI b/l hip jt

82.  Isotope scan can
show changes as
early as 24-48 hrs
(Xray latent 10 days

84. 1-Gout(sodium
monourate)
Clinical Stages
a) Asymptomatic hyperuricaemia
b) Gouty arthritis
Intermittent episodes of
monoarticular acute arthritis 1st MTP joint – 75%
c) Intercritical gout
d) Tophaceous gout – Tophi in tendons, ligaments,
cartilage, bone etc.
Essential’s of skeletal radiology: Yochum &
Rowe

85. Radiological Features
 1st MTP joint, ankle, knee, elbow
 Soft tissue swelling
 Sharply marginated erosions
(marginal & periarticular) with
sclerotic borders or
overhanging edges
 Normal bone density
 No joint space narrowing until
late
5% - concomitant CPPD deposition disease
Nephrolithiasis – 20%
PA Radiograph : Rt Foot

86. 2-CPPD
 Calcium pyrophosphate dihydrate
 Acute, subacute or chronic
 Chondrocalcinosis + arthropathy + soft tissue
calcification
 JOINT: knee, wrist, hand ankle hip, pubic
symphysis, elbow , shoulder
 Arthropathy resembles DJD except unusual joints,
unusual compartment, more destruction, large
geodes & variable osteophytes Semin muscul radiol 2003

87. AP Radiograph: lt Knee

88. PA Radiograph : Rt Hand

89. Gout CPPD
(Pseudogout)
Distribution Small joint of foot and
hand
Large joints with
selective compartmental
involvement. Knee
(platello fermoral) wrist
(radiocapral
compartment).
chondrocalcinosis Less common, localized
involves fibrocartilage
only
Hallmark wide spread
involves hyaline and
fibrocartilage
Joint space Preserved Narrowing
Soft tissue swelling Present, eccentric Not seen
bony erosions Intraarticular, periarticular
and away from joint
Subchondral

90. 3.Haemophilic
Arthropathy
 Asymmetrical, u/l joint
 Knee > elbow > ankle > hip > shoulder
Semin muscul radiol 2003,
Essential’s of skeletal radiology: Yochum & Rowe

91. AP Radiograph:Rt Knee AP Radiograph: lt Knee

92. LATERAL X-RAY
SAGGITAL T2WI

93. SAGITTAL T2WI SAGGITAL T2WI

94. JRA Hemophilia
Distribution Hand, wrist, knee
and ankle
Knee, ankle and
elbow
Growth inhibition Present Absent
Bony ankylosis Present Not seen
Periostitis Present +/-
Pseudotumour Not seen Seen
Spondylits Seen (polyarticular) Not seen
Squaring of patella More common Seen

95. 4. PIGMENTED VILLONODULAR
SYNOVITIS
 Knee joint (80%), hip, ankle,
shoulder
 Age: 2rd - 4th decade M>F
 Radiology
 Lobulated Soft tissue swelling
(most common)
 Hypo on both T1 &T2 with
enhancment
 Multiple geographic lytic
lesions on both sides of joint –
most characteristic
 Preservation of joint space and
bone density – typical findings.
RCNA 2004

96. CORONAL T2WI
SAGGITAL T2WI

97. APPROACH TO ARTICULAR DISEASE

98. Radiographics 2008

99. RA JRAAS,REITER’S,PSORIATI
C
OA
EROSIVE OA
GOUT CPPD

100. FORE FOOT
RA & AS
PSORIASIS, REITER
OA
GOUT
CPPD
NEUROTROPHIC

101. MID FOOT AND HIND FOOT
RA, JCA,
OA GOUT
CPPD

102. Calcaneum
Superior
surface
Above
Tendoachilles
Achilles attachment
Plantaris attachmentPlanter
surface
R
A
AS, Psoriatic
Reiter’s GOUT
CPPD, DISH

103. Arthritis in knees and
hips

104. Take Home Message
 Always rule out septic arthritis in case of
monoarticular involvment
 MRI- Gold standard for synovial imaging, early
erosions and to differentiate between active & chronic
inflammation
 Arthrocentesis: Should always be image guided
 USG guided for appendicular skeleton
 CT & MRI guided for axial skeleton

105. Thank
You