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Arthropathies/Connective Tissue Diseases

Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 13 – Arthropathies/Connective Tissue Diseases

Chapter 13
Arthropathies/Connective Tissue Diseases
Thomas H. Berquist
Suggested Reading
S, DiMasi M, Adams J, et al. In vitro and in vivo spin-echo diffusion
imaging characteristics of synovial fluid: Potential noninvasive
differentiation of inflammatory and degenerative arthritis. Skel Radiol 2000;29:320–323.
P, Roulot B, Akoka S, et al. Magnetic resonance imaging: A valuable
method for detection of synovial inflammation in rheumatoid arthritis. J Rheumatol 2001;28:35–40.
J, Fessell DP, Jacobson JA, et al. An illustrated tutorial of
musculoskeletal ultrasound: Part 1, introduction and general
principles. AJR Am J Roentgenol 2000;175:637–645.
Rose PM, Demlow TA, Szumowski J, et al. Chondromalacia patella: Fat suppressed MR imaging. Radiology 1994;193:437–440.


Rheumatoid Arthritis


FIGURE 13-1 Early RA. (A,B) Bilateral posteroanterior views of the hands showing subtle swelling (arrows) and juxta-articular osteopenia.


FIGURE 13-2 Coronal contrast-enhanced fat-suppressed T1-weighted image demonstrates early changes of RA with erosions (arrowheads) and synovial enhancement.


FIGURE 13-3 Advanced RA. (A) Erosive changes in the ulna and distal radius. (B) Several years later, there is complete erosion of the wrist. (C) Different patient with swelling and characteristic erosions of the fifth MTP joints (arrows). (D) Advanced RA in the hand with multiple subcutaneous nodules (arrows).
Suggested Reading
Brower AC. Arthritis in black and white, 2nd ed. Philadelphia: WB Saunders; 1997:195–224.
YM, Suh JS, Jeong EK, et al. Role of inflamed synovial volume of the
wrist in redefining remission of rheumatoid arthritis with gadolinium
enhanced 3D-SPGR MR imaging. J Magn Reson Imaging 1999;10:202–208.


Psoriatic Arthritis
FIGURE 13-4 Psoriatic arthritis involving the foot. (A)
Osteolysis and reparative new bone in the first and third DIP joints.
The erosive changes in the first DIP is a common location for psoriatic
arthritis. (B) Advanced changes in the DIP joints of the lesser toes with no bone demineralization.


Psoriatic arthritis both hands. Erosive changes in the interphalangeal
and DIP joints. Subluxations are not usually a prominent feature of
psoriatic arthritis.
Suggested Reading
Resnick D, Kransdorf MJ. Psoriatic arthritis. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:288–297.


Reiter Syndrome
FIGURE 13-6 Reiter involvement of the sacroiliac joint. Involvement is bilateral but asymmetric.


FIGURE 13-7 Reiter involvement of the plantar aspect of the calcaneus with irregular bone proliferation.


FIGURE 13-8 (A) Reiter involvement of the right great toe with distal joint erosions, normal bone density, and fusiform soft tissue swelling. (B) Reiter involvement of the forefoot and phalangeal and MTP joints.
Suggested Reading
Weldon WW, Scaletter R. Roentgen changes in Reiter syndrome. AJR Am J Roentgenol 1961;86:344–350.


Ankylosing Spondylitis
FIGURE 13-9 Ankylosing spondylitis. (A) AP radiograph of the pelvis showing symmetric ankylosis of the sacroiliac joints. (B) Long-standing ankylosing spondylitis with syndesmophytes, spinous ligament ossification, and a shear fracture (arrow). Patients with ankylosing spondylitis are more susceptible to spine fractures.


FIGURE 13-10 Ankylosing spondylitis of the spine seen on lateral radiographs. (A) Early changes with incomplete ankylosis. There is squaring of the vertebral bodies. (B) Early changes of ankylosing spondylitis. Note the shiny corners at the vertebral margins (arrows). (C) Advanced changes with more uniform ankylosis.
Suggested Reading
Brower AC. Arthritis in black and white, 2nd ed. Philadelphia: WB Saunders; 1997:257–272.




FIGURE 13-11
Osteoarthritis. PA view of the hand and wrist showing typical distal
and PIP joint involvement with narrowing of the metacarpophalangeal
joints. There are also typical changes at the scapho-trapezio-trapezium


FIGURE 13-12 Standing views of the knees showing typical asymmetric medial compartment narrowing.


FIGURE 13-13 AP radiograph of the pelvis demonstrating advanced degenerative arthritis in the right hip with osteophytes and bone sclerosis.
Suggested Reading
D, Braunstein EM, Brandt KD, et al. A radiographic comparison of
erosive osteoarthritis and idiopathic nodular osteoarthritis. J Rheumatol 1992;19:896–904.


Enteric Arthropathies
FIGURE 13-14
Enteric arthropathy. AP radiograph of the spine and sacroiliac joints
showing inflammatory arthropathy symmetrically involving the sacroiliac


Suggested Reading
Resnick D, Kransdor MJ. Enteric arthropathies. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:306–315.


Systemic Lupus Erythematosus
FIGURE 13-15 Systemic lupus erythematosus. (A,B) Radiographs of the hands showing metacarpophalangeal subluxations with no erosions. Note prior fusions of both thumbs.


Suggested Reading
Resnick D, Kransdorf MJ. Systemic lupus erythematosus. In: Resnick D, Kransdor MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:321–327.




FIGURE 13-16 Scleroderma. Radiograph of the hand showing soft tissue calcification, soft tissue atrophy, and tuft resorption.
Suggested Reading
Bassett LW, Blocka KLN, Furst DE, et al. Skeletal findings in progressive systemic sclerosis (scleroderma). AJR Am J Roentgenol 1981;136:1121–1126.




FIGURE 13-17 Dermatomyositis. (A) Radiographs of the elbow showing soft tissue calcification that is greater along the extensor surface. (B) AP radiographs of the knees with extensive soft tissue calcifications.


FIGURE 13-18 Myositis. Coronal T1-weighted image of the thighs showing fatty infiltration of the muscles caused by chronic myopathy.
Suggested Reading
Frazer DD, Frank JA, Dalakas MC. Inflammatory myopathies. MR imaging and spectroscopy. Radiology 1991;179:341–344.


Mixed Connective Tissue Disease/Overlap Syndromes


FIGURE 13-19
Mixed connective tissue disease. AP radiograph of the right hand
showing periarticular soft tissue calcification, most obvious in the
thumb, soft tissue swelling, joint subluxation in the phalangeal
joints, and joint space narrowing.


FIGURE 13-20 Mixed connective tissue disease. (A,B) Radiographs of both hands showing juxta-articular osteopenia and extensive soft tissue calcifications.
Suggested Reading
D, Kransdorf MJ. Mixed connective tissue disease and collagen vascular
overlap syndromes. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:349–352.


Juvenile Chronic Arthropathy


FIGURE 13-21 Still disease. (A) Chest radiographs showing a right pleural effusion. (B,C) Radiographs of both wrists showing osteopenia and soft tissue swelling.


FIGURE 13-22 Juvenile chronic arthropathy. (A,B) AP radiographs of the wrists showing marked osteopenia with carpal collapse. AP (C) and lateral (D) radiographs of the knee showing epiphyseal hyperemia and soft tissue involvement (synovitis).


Suggested Reading
Ansell BM, Kent PA. Radiological changes in juvenile chronic polyarthritis. Skel Radiol 1977;1:129–144.


FIGURE 13-23 Hemophilic arthropathy. AP (A) and lateral (B) radiographs of the right knee showing epiphyseal overgrowth and dense soft tissue swelling.


FIGURE 13-24 Hemophilic arthropathy. AP (A) and lateral (B) radiographs of the elbow showing marked joint deformity with new bone formation. Axial T1-weighted (C) and sagittal T2-weighted (D) images showing synovitis and effusion. Osseous anatomy is distorted.
Suggested Reading
Pettersson H, Ahlberg A, Nilsson IM. Radiologic classification of hemophilic arthropathy. Clin Orthop 1980;149:153–159.


FIGURE 13-25 Gout. Well-defined erosion with a large calcified tophus.


FIGURE 13-26 Gout. Swelling of the right hand and wrist with a well-defined erosion (arrow) at the fifth PIP joint.
FIGURE 13-27 Gout. Axial CT image demonstrates well-defined erosions and soft tissue mass around the first metatarsal phalangeal joint.


FIGURE 13-28 Gout. (A)
Standing radiographs of the feet demonstrate bone destruction involving
the distal first metatarsal and proximal phalanx on the right. (B) Axial T1- and sagittal post-contrast (C) fat-suppressed T1-weighted images demonstrate advanced bone and soft tissue changes of gout.


Suggested Reading
Pascual E. The diagnosis of gout and CPPD crystal arthropathy. Br J Rheumatol 1996;35:306–308.
Yuh JS, Chung C, Recht M, et al. MR imaging of tophaceous gout. AJR Am J Roentgenol 1997;168:523–527.




FIGURE 13-29
Hemochromatosis. Radiograph of the hand showing degenerative changes in
the hand and wrist, with narrowing in the metacarpophalangeal joints,
especially the second and third.
Suggested Reading
Hirsh JH, Lillen C, Troupin RH. Arthropathy of hemochromatosis. Radiology 1976;118:591–596.


Calcium Pyrophosphate Deposition Disease
FIGURE 13-30 CPPD. Standing radiographs of the knee showing meniscal calcifications and degenerative joint disease.
Suggested Reading
TC III, Resnick CS, Gierra J Jr, et al. Hand and wrist arthropathies of
hemochromatosis and calcium pyrophosphate deposition disease. Distinct
radiologic features. Radiology 1983;147:377–381.


Wilson Disease
FIGURE 13-31
Wilson disease. Advanced joint destruction with loose bodies,
fragmentation, and chronic rotator cuff tear in the right shoulder.
Suggested Reading
Menerey KA, Eides W, Brewer GJ, et al. Arthropathy of Wilson disease. Clinical and pathologic features. J Rheumatol 1988;15:331–337.


FIGURE 13-32 Ochronosis. AP (A) and lateral (B) radiographs of the thoracic spine showing diffuse disc space narrowing and disc calcification.
Suggested Reading
Brower AC. Arthritis in black and white, 2nd ed. Philadelphia: WB Saunders; 1997:367–378.


Neurotrophic Arthropathy
FIGURE 13-33 Neurotrophic arthropathy. AP radiograph of the ankle showing joint deformity, bone formation, and loose bodies.


FIGURE 13-34
Diabetic patient with neurotrophic arthropathy. AP radiograph of the
foot showing joint subluxations with tarsometatarsal fragmentation.
Suggested Reading
Sequeira W. The neuropathic joint. Clin Exp Rheumatol 1994;12:325–337.


Synovial Chondromatosis/Osteochondromatosis
FIGURE 13-35 Synovial chondromatosis. AP (A) and lateral (B)
radiographs of the knee showing multiple periarticular calcifications.
Note the lack of significant degenerative changes at this stage.


FIGURE 13-36 Noncalcified synovial chondromatosis. Arthrogram image shows multiple filling defects. The joint space is normal.
Suggested Reading
Milgram JW. Synovial chondromatosis. A histopathologic study of 30 cases. J Bone Joint Surg 1977;59A:792–801.
Peh WCG, Shek TWH, Davies AM, et al. Osteochondroma and secondary synovial osteochondromatosis. Skel Radiol 1999;28:169–174.


Pigmented Villonodular Synovitis
FIGURE 13-37 PVNS. Sagittal T1- (A) and T2- (B)
weighted images of the knee demonstrate lobulated soft tissue masses in
the knee with areas of low signal intensity on both sequences resulting
from hemosiderin deposition.
Suggested Reading
Jelinek JS, Kransdorf MJ, Utz JA, et al. Imaging of pigmented villonodular synovitis with emphasis on MR imaging. AJR Am J Roentgenol 1989;152:337–342.


Amyloid Arthropathy
FIGURE 13-38 Amyloid arthropathy. (A) Axial T1- and (B) sagittal T2-weighted images demonstrate low signal intensity (muscle density) deposits in the tibia (A) and in the anterior and posterior joint (B) with joint and bursal distention.
Suggested Reading
Cobby MJ, Adler RS, Swarz R, et al. Dialysis-related amyloid arthropathy: MR findings in four patients. AJR Am J Roentgenol 1991;157:1023–1027.

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