Approaches to Joint disease Leila. Aghaghazvini MD Dr. Shariati
Hospital Tehran university of medical science
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Conventional Radiography Arthrography Ultrasound Nuclear
Medicine Studies CT MRI
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Infectious arthritis can generally be divided into two
categories: Pyogenic or septic arthritis Most commonly caused by
Staphylococcus aureus, Neisseria gonorrhea, Klebsiella pneumoniae,
Candida albicans, and Serratia marcescens Non-pyogenic arthritis
Most commonly caused by tuberculosis or fungal infections including
actinomycosis, cryptococcosis, coccidioidomycosis,histoplasmosis,
and sporotrichosis
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Infectious agents can enter the joint space in several ways
Direct invasion of the synovial membrane Penetrating wound
Post-surgical following joint replacement Infection of adjacent
soft tissue Hematogenous spread from a blood borne infection Spread
from a focus of osteomyelitis in adjacent bone
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Modality of choice for initial evaluation of suspected joint
infections Diagnosis can be made when characteristic findings are
present Early plain film findings: Periarticular osteoporosis Soft
tissue swelling Joint effusion Joint space loss Later plain film
findings: Periosteal reaction Marginal and central erosions and
destruction of subchondral bone Subluxation or dislocation
Intra-articular bony ankylosis
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Alone, US is unable to confirm the diagnosis of septic
arthritis However, US is a very sensitive modality for
demonstrating joint effusion May be effective in guiding needle
aspiration of joint
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3-phase T99 MDP Bone Scan findings Increased blood flow
adjacent to the joint Prominent activity on blood pool images on
both sides of the affected area A fourth phase (delayed 24 hour
imaging) shows: Diminution of activity This is in contrast to
osteomyelitis which invariably has increased activity on delayed
images
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Click Her Tc99m-MDP bone scan including blood pool image (upper
left corner) and 4-hour delay images (lower and upper right corner)
shows markedly increased uptake of radionuclide tracer at
interphalangeal joint with osteomyelitis of proximal and distal
phalanges of the left great toe. RT = right; LT = left; HR =
hour.
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Early Stages of Infection: T2 images reveal distention of joint
capsule by nonspecific high- intensity fluid Later Stages of
Infection: Can detect joint effusion, cartilage destruction,
narrowing of joint and cellulitis around joint MRI can readily
detect extension of the infectious process into adjacent bone
marrow and the transition to osteomyelitis T2 images reveal
infected fluid and blood in the joint of inhomogeneous intermediate
signal intensity T2 images also reveal an area of signal
hyperintensity in the soft tissue around the affected joint
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Coronal Stir Image of Pelvis
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Conventional radiography and joint aspiration are the mainstays
of infectious arthritis diagnosis Arthrography and less commonly CT
or Ultrasound may play a role in guiding joint aspiration MRI has
little role in the dx of infection arthritis but may be used to
evaluate for complications, particularly osteomyelitis
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hallmarks -soft tissue swelling -osteoporosis - joint space
narrowing - marginal erosions proximal process, bilaterally
symmetric away from the weight-bearing portion of the joint. Hip :
RA: the femoral head tends to migrate axially OA: migrate
superolaterally Shoulder: high riding ( torn rotator cuff,
CPPD)
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Hallmarks of Rheumatoid Arthritis Soft tissue swelling
Osteoporosis Joint space narrowing Marginal erosions Proximal
distribution (hands) Bilateral symmetry
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- Soft tissue edema - Erosion( far from articular cortex) - No
osteoporosis - Tophus MTP the most common site
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1) Decrease in joint space - hip: superolateral - Knee: 2)
Osteophyte 3) subchondral Sclerosis 4) subchondral Cyst DD:
erosion( lateral view) Loose body (Knee)
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-Decrease in joint space Sclerosis osteophyte
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Joint narrowing OA: weight bearing RA: sym Erosion OA: neg,
irregularity RA: pos Subchondral sclerosis and cyst: OA: pos RA:
neg (erosion in AP view ) Sclerosis: OA: common RA: neg, secondary
Osteoporosis: OA: neg RA: often
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The only disorder that will cause osteophytes without sclerosis
or joint space narrowing is diffuse idiopathic skeletal
hyperostosis
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Charcot Disease Charcot Disease:
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The most common site, intraarticular portion of bone plain
graphy: -steroid, cvd, radiation, sca, casson dis, fracture 1 )No
2) osteoporosis and sclerosis 3)subcortical lucency 4) Flattened
and scleroisis 5) osteoarthritis MRI the best modality
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Freiberg: metatars Kohler: navicular Osgood schlatter: Tibial
tubersity Kienback: Lunate Osteochondritis Dis: The most common
site site, knee,ankle