Schreibman JointDisease Handout

Radiology of Joint Disease page 1 of 16
My Practical Approach
Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach
Ken Schreibman, PhD/MD, FACR Topics My Ordered List
Prevalence/Hx University of Wisconsin - Madison Prevalence/Hx Is it… Features Distribution
Joint Anatomy Professor, Musculoskeletal Section Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP
Ordered List 9 Faculty, 5 Fellows Ordered List  OA? space narrowing L4-5, C5-6
Osteophytes! DIPs, PIP, Thumb base
OA OA
Phytes
My Practical Approach to Arthritis Phytes EOA? Gullwing Erosions DIPs (Symmetric)
Women > 50yo
EOA Radiology of Joint Disease is Hard EOA  RA? Uniform narrowing MCPs, Carpus, C1-2
RA It took me 10 years to begin to understand it RA
Marginal Erosions! Big Joints (Symmetric)
Another 10 years to figure out how to teach it
Gout May not be possible to teach in one hour Gout  Gout? Sharp Erosions with Random
overhanging edges Favors Toes (1 ) st
CPPD Ordered list of 5 most common arthropathies CPPD

PA Can download PowerPoints & handouts PA
CPPD? Chondrocalcinosis Unusual
Resembles OA distribution for OA
Favors Patella-Femoral
WOW for this and all my lectures WOW Psoriatic? Sausage Digit
Pencil-in-Cup Hands, Feet, Spine
SI Joints (Asymmetric)
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© 2015 Ken L Schreibman, PhD/MD 1 of 94 © 2015 Ken L Schreibman, PhD/MD 2 of 94
Prevalence of Arthritis Prevalence of Arthritis
Types of Arthritis
Prevalence/Hx Arthritis is one of the Prevalence/Hx >100 conditions affect joints* 46 Million
Joint Anatomy most prevalent chronic Joint Anatomy
Ordered List
US Adult 20% Ordered List
RA:1.3M‡=3% all arthritis Diagnosed
health problems Population Decreased from 2.1M (5%) 1995 RA with Arthritis…
OA The nation’s leading
(46M) OA  OA = 27M†
≈ 225 Diagnosed Gout:3M†=7% all arthritis
Phytes cause of disability Million with Arthritis
Phytes Increased from 2.1M (5%) 1995 Gout (59% of all
EOA Costs US economy EOA CPPD:? Arthritis)
CPPD
RA $128 billion annually Adults >65 yo RA No prevalence data
SNSA and those of us
Gout Gout Seronegative Spondylarthritides: who look at joints
CPPD
50% have Arthritis CPPD up to 2.4M‡ (5%) suspect OA is
PA 2005 PA more like 2005
WOW (most recent WOW > 80% (most recent
available data) available data)
www.schreibman.info arthritis.org www.schreibman.info *arthritis.org †ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35
© 2015 Ken L Schreibman, PhD/MD 3 of 94 © 2015 Ken L Schreibman, PhD/MD ‡
ARTHRITIS&RHEUMATISM,2008,v58,n1,p15-25 4 of 94
Arthritis is Ancient: Gout Arthritis is Ancient: RA
Prevalence/Hx “king of diseases and disease of kings” Prevalence/Hx 4500BC (Tennessee)
Joint Anatomy Joint Anatomy Native American skeletal
Ordered List
2600BC (Egypt): Described in the great toe Ordered List 1661Jacob
OA 400BC (Greece): Hippocrates wrote about it OA Jordaens
Phytes 1599 Shakespeare Phytes (Flemish Baroque
EOA (Henry IV, Part 2) Falstaff: EOA painter)
“A pox of this gout! or a gout The Family Rheumatoid Nodules
RA of this pox! for the one or the RA
Gout other plays the rogue with Gout of the Artist
CPPD my great toe.” CPPD
1799 James Gillray MCPs
PA PA
WOW (British caricaturist): WOW PIPs
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©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

Arthritis is Ancient: OA Old Diseases = Old Names (misnomers)
Prevalence/Hx 150,000,000BC (late Jurassic period) Prevalence/Hx “Osteoarthritis”
Joint Anatomy Osteophytes have been found in fossils of: Joint Anatomy
Ordered List Ordered List
Osteo=“Bone”… but it’s not disease of bone
Toe of Allosaurus fragilis* itis=“inflamed”… but it’s not inflammatory disease
OA TMJ of Pliosaurus brachyspondylus** OA
Phytes Phytes “Rheumatoid” Arthritis
EOA EOA “resembles Rheumatic Fever”…
RA RA but it has nothing to do with
Gout Gout rheumatic fever
Harvard Museum of Comparative Zoology (not caused by Streptococcus pyogenes)
CPPD CPPD
PA PA “Gout” vs “Pseudo-gout”
WOW wikipedia.org WOW Radiographically, these look nothing like each other
www.schreibman.info *wikipedia.org **Palaeontology 2012 May 16 www.schreibman.info CDC Public Health Image Library
Old Diseases = Old Names (misnomers) PowerPoint Model: Bone
Joint
Prevalence/Hx “Reiter’s Disease” Prevalence/Hx WhiteBLine = Joint: 2 bones meet
Joint Anatomy 1942: Hans Conrad Julius Reiter Joint Anatomy Cortical Bone
Ordered List Ordered List O Bones flair out at ends
Inflammatory arthritis N
OA Eye inflammation (conjunctivitis or uveitis) OA B Metaphysis
Phytes Urethritis in men or cervicitis in woman Phytes E
O
EOA Reiter was a Nazi EOA Can see on radiographs:
N Trabecular bone
RA Head of the Reich Health Office RA E
Gout Widely considered expert on vaccines Gout B Cortical bone
CPPD Implicated in experimenting with typhus on CPPD O Joint space between bones
Buchenwald concentration camp internees GrayNFill =
PA 1945: Interrogated in Nuremberg; released 1947 PA Trabecular Bone
WOW 2009: Disease renamed “Reactive Arthritis” WOW E
(Cancellus) Black rectangle = Radiograph
www.schreibman.info Seminars in Arthritis and Rheumatism www.schreibman.info
© 2015 Ken L Schreibman, PhD/MD 2003, Feb, vol 32, No 4 9 of 94 © 2015 Ken L Schreibman, PhD/MD 10 of 94
PowerPoint Model: Joint PowerPoint Model: Joint
Prevalence/Hx B Knee Radiograph Prevalence/Hx B Stuff inside joints we
Joint Anatomy AP view Joint Anatomy
Ordered List O Ordered List O can’t see on radiographs:
OA N OA N Cartilage
Phytes E Unfused Phytes E Articular
EOA Growth EOA Hyaline
Joint T [Gr] “resembling glass”
RA Space r Plates RA
Gout B a
b Gout B Synovium
CPPD O e CPPD O Normally very thin (1-3 cells)
c
PA N u PA  N  Synovial fluid
l This is too much
WOW E Cortex a
r WOW fluid (i.e.EEffusion) Normally just wetting amount
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Joint Disease = Cartilage Damage Arthrogram - CT
Prevalence/Hx
Joint Anatomy
B Imaging joint disease = Prevalence/Hx
Joint Anatomy
B of likeKnee
Kind AP
Radiograph
anview
Oreo: Knee Arthrogram-CT
Coronal Reformat
Ordered List O “seeing cartilage” Ordered List Dark O Cookie=Cartilage
OA N Radiographs OA Light
N Cream=Contrast
Intra-Articular
Phytes E Can’t see cartilage directly Phytes E Contrast
EOA We see it indirectly by EOA
RA looking at joint space width RA T
Gout B Arthrogram-CT Gout B a
r
O O b
CPPD Inject contrast into joint, CPPD e
c
PA N then do a CT scan PA N is dark tissue between
Cartilage u
l
WOW E Multiplanar reformat WOW white Ecortex and white contrast Cortex ar
www.schreibman.info www.schreibman.info R,S 14yoM
Joint Disease = Cartilage Damage MRI
Prevalence/Hx B Imaging joint disease = Prevalence/Hx B Knee MRI Coronal Knee MRI Coronal
Joint Anatomy Joint Anatomy PD fat-suppressed Cartilage Sensitive
Ordered List O “seeing cartilage” Ordered List O
OA N Radiographs OA N
We see it indirectly by Articular (hyaline)
Phytes E Phytes E cartilage: light gray
EOA looking at joint space width EOA
RA Arthrogram-CT RA
Gout B Inject contrast into joint Gout B
CPPD O MRI! CPPD O Meniscal (fibro-
PA N Can see cartilage directly PA N cartilage): black
WOW E Without injecting contrast WOW E
www.schreibman.info www.schreibman.info R,S 14yoM
5 Most Common Arthropathies  Osteoarthritis (OA)
Prevalence/Hx Is it… Features Distribution Prevalence/Hx THE most common 46 Million
Joint Anatomy Joint Anatomy
Ordered List  OA? Ordered List
joint disease Diagnosed
with Arthritis…
OA OA At least 60% of ALL
Phytes EOA? Phytes
arthritis is OA… OA = 27M†
In my experience it’s (59% of all
EOA  RA? EOA more like 80-90% Arthritis)
RA RA Primary OA
Gout  Gout? Gout Effects specific joints
and those of us
who look at joints
CPPD CPPD Secondary OA
PA
CPPD? PA Can effect any joint
suspect OA is
more like 2005
WOW Psoriatic? WOW “Osteoarthrosis” > 80% (most recent
available data)
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ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35

OA = Disease of Hyaline Cartilage OA: Knees
Prevalence/Hx B Articular hyaline cartilage Prevalence/Hx Knee Radiograph Knee Radiograph
Joint Anatomy Joint Anatomy RIGHT - AP view LEFT- AP view
Ordered List O is the diseased tissue Ordered List
OA N Loss of hyaline cartilage OA
Phytes E Proximal&Distal articular surfaces Phytes
EOA Non-Uniform  to OA EOA
RA e.g. Knee: Medial > Lateral RA
Gout B Progressive – worsens with time Gout Features OA
CPPD O Non-Uniform joint narrowing  CPPD Non-Uniform joint narrowing
PA N Asymmetric PA Medial compartment > Lateral
WOW E e.g. Dominant hand > other hand WOW Asymmetric (here L > R)
www.schreibman.info www.schreibman.info M,G 46yoM
OA = Bone Producing Disease Osteophytes: Knees
Prevalence/Hx In OA, joints make bone Prevalence/Hx Knee Radiograph Knee Radiograph
Joint Anatomy Joint Anatomy AP view Lateral view
Ordered List Sub-cortical sclerosis Ordered List
OA Articular cortex thickens OA
Phytes Stress response? Phytes Lateral
EOA
RA
OSTEOPHYTES!
Bony spurs from joints
to OA EOA
RA
Compartment
Medial
Patella-
Femoral
Compartment
Gout Gout Compartment
CPPD
Can occur either after the CPPD
joint is narrowed…
PA PA
WOW
or before the joint narrows WOW
www.schreibman.info www.schreibman.info P,C 67yoF
Let’s Talk about “Phyte Club” PHYTE
CLUB Enthesophytes
Prevalence/Hx Suffix phyte: Prevalence/Hx Enthesophytes are… nothing
Ordered List
“abnormal growth” Ordered List
Bone spurs at ligament/tendon insertions
OA 3 Types of phytes: OA Not osteophytes (which occur at joints)
Phytes Osteophytes Phytes Not pathology
EOA @ Joints EOA Common in calcaneus @ Achilles
RA RA “Heel spurs”
Enthesophytes Not plantar fasciitis
tendon
Gout Gout insertion
@ Ligament/Tendon
CPPD insertions CPPD
PA Syndesmophytes PA
WOW @ Disks (Annulus Fibrosis) WOW @ plantar fascia
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PHYTE
CLUB Osteophytes PHYTE
CLUB Spine: Osteophytes Horizontal 
Prevalence/Hx Occur at Joints in DJD PowerPoint Model: Spine Prevalence/Hx Lumbar Spine PowerPoint Model: Spine
Joint Anatomy (Degenerative Joint Disease) Joint Anatomy L3 Lateral view
Ordered List  Extend from joint edges Ordered List
OA Occur at Disks in DDD OA
Phytes (Degenerative Disk Disease)
Body Phytes L4 Body
EOA  Extend from vertebral EOA
RA bodies corners Annulus Nucleus RA
Gout In DDD disk bulges outward Gout L5
CPPD Osteophytes extend out
around bulging disk
Body CPPD Body
S1
PA  Extend horizontally PA
WOW Typically extend anteriorly WOW
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PHYTE
CLUB Osteophytes vs Syndesmophytes PHYTE
CLUB Syndesmophytes Vertical 
Prevalence/Hx While Osteophytes PowerPoint Model: Spine Prevalence/Hx Lumbar
 Extend
Lateral
Spine
view vertically Thoracic Spine
Lateral view
Joint Anatomy  Extend horizontally from Joint Anatomy along Annulus

Fibrosus
Ordered List corners of vertebral body Ordered List  Thin
OA OA  Cover multiple
Syndesmophytes
Phytes  Extend vertically along Body Phytes levels Body
Cervical
EOA Annulus Fibrosus EOA Thoracic
RA  Thin Annulus Nucleus RA Lumbar Nucleus
Gout  Cover multiple levels Gout
CPPD Cervical Body CPPD Body
PA Thoracic PA
WOW Lumbar WOW
www.schreibman.info www.schreibman.info W,D 52yoM
PHYTE
CLUB Syndesmophytes Vertical  My Ordered List
Prevalence/Hx Lumbar Spine
Lateral view
Lumbar Spine
AP view Prevalence/Hx Is it… Features Distribution
Joint Anatomy Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP
Ordered List Ordered List  OA? space narrowing L4-5, C5-6
OA OA
Phytes Phytes
EOA
Ankylosing EOA
RA Spondylitis RA
Gout “Bamboo Spine” Gout
CPPD Fused CPPD
PA SI PA
Royal Botanical Garden
WOW Joints Kandy, Sri Lanka 2005 WOW
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Distribution: OA Distribution: OA
Cervical Spine Lumbar Spine
Prevalence/Hx Spine C1 Lateral view Lateral view Prevalence/Hx Lower Extremity
Joint Anatomy L1 Joint Anatomy
Ordered List
Lower Ordered List
Common in the Hip
OA Cervical C2
L2 OA Common in the Knee
Phytes
Spine C3 Phytes Uncommon in the Ankle
C5-C6 Not simply due to weightbearing
EOA L3 EOA
RA
Lower C4
RA Common 1st MTP Joint
Lumbar C5 L4 Foot “Hallux Limitus”
Gout Spine Gout AP view
O-phyte
“Hallux Rigidus”
CPPD L4-L5
C6
L5 CPPD aka “OA”
PA C7 “Vacuum PA Non-uniform
WOW Disk” WOW
narrowing Foot
J,W 48yoF F,D 34yoF D,M 52yoF Osteophytes Lateral view
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© 2015 Ken L Schreibman, PhD/MD 1543 p.163 31 of 94 © 2015 Ken L Schreibman, PhD/MD 1543 p.163 32 of 94
OA: Hips OA: Hips
Prevalence/Hx PowerPoint Model: Hip Non-uniform narrowing to OA  Prevalence/Hx Non-uniform narrowing  to OA
Joint Anatomy Hip: Superior weightbearing surface Joint Anatomy Hip: Superior weightbearing surface Total
Ordered List Ordered List Hip
Narrowed Pelvis Asymmetry  to OA Prosthesis
OA Normal
AP view OA
Phytes
Acetabulum Superiorly width
Phytes
Progressive Narrowed
Worsens over time Superiorly
EOA EOA
Normal
RA RA width
Gout
Femoral Symptomatic Asymptomatic Gout
Head side side
CPPD CPPD
PA Asymmetry: PA
WOW OA
to OA  WOW 2 years earlier 2 months later
www.schreibman.info K,K 44yoM www.schreibman.info K,K 44yoM
OA: Hips Pelvis Radiographs
Prevalence/Hx Non-uniform narrowing  to OA Prevalence/Hx Lying on x-ray table
Joint Anatomy Hip: Superior weightbearing surface Joint Anatomy
Not weight-bearing
Asymmetry  to OA Unlike knees&feet which X-ray
OA OA
Phytes
Progressive Phytes should be done standing cassette
Worsens over time 
EOA EOA Cassette slides into
RA
Osteophytes?  to OA RA “Bucky Grid”
Often not seen on AP view  Minimize x-ray scatter
Gout Best seen on frog-leg view Gout 
CPPD CPPD  Dr Gustav Bucky
(9/3/1880-2/19/1963) Tray
PA What’s a frog-leg view? PA  1913: Moving grid
WOW WOW (Berlin) Marty age 15
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AP Pelvis Frog Leg Lateral
Prevalence/Hx Prevalence/Hx
Joint Anatomy AP Joint Anatomy
Ordered List view of Ordered List
X-RAYS
X-RAYS
OA Femurs OA Lateral
Phytes Greater Phytes view of
EOA Trochanter EOA Femurs
RA Hip joint width RA
Head Externally Rotated
Gout Gout
GT
CPPD CPPD
PA Lesser
PA
Internally Rotated LT
WOW Trochanter WOW
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Osteophytes: Hips Sub-Cortical Sclerosis: Hips
Prevalence/Hx Superior narrowing Right Hip Pelvis Prevalence/Hx Not sub-cortical sclerosis APPelvis
Joint Anatomy Asymmetry Frog-leg view AP view Joint Anatomy view
Ordered List Ordered List sourcil: [Fr] “eyebrow” Normal
Osteophytes? appearance of
OA None on AP OA
Phytes Phytes acetabular roof
EOA EOA
RA Narrowed RA “Isn’t this
Superiorly
Gout Gout sub-cortical
CPPD CPPD sclerosis?”
PA PA
WOW Osteophyte! WOW buro247.ru blog
www.schreibman.info R,C 81yoF www.schreibman.info R,C 81yoF
Sub-Cortical Sclerosis: Hips Distribution: OA
Prevalence/Hx Prevalence/Hx Upper Extremity
Joint Anatomy
This is Joint Anatomy
sub-cortical Uncommon in the Shoulder
OA sclerosis! This isn’t a French OA
1º OA spares glenohumeral joint
2º OA from trauma, rotator cuff tear
model’s eyebrow
Phytes Phytes Shoulder
Oblique view
Complete loss of
EOA EOA acromial-humeral
RA RA space =
Gout Gout Chronic rotator
This looks more cuff tear
CPPD like this guy’s CPPD
PA eyebrow… PA Severe osteoarthritic
WOW flickr.com WOW narrowing GH jt
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Distribution: OA OA: Hands
Prevalence/Hx Upper Extremity Prevalence/Hx Left Hand Narrows DIPs & PIPs
PA view
Joint Anatomy Uncommon in the Shoulder Joint Anatomy
Non-uniform narrowing
1º OA spares glenohumeral joint Sub-cortical sclerosis
OA 2º OA from trauma, rotator cuff tear OA
Phytes Very common acromioclavicular jt. Phytes
Narrows w/age usually not symptomatic
EOA EOA
RA
Uncommon in the Elbow RA
Gout Hand/Wrist Gout
CPPD Common at the Thumb base CPPD
STT & CMC (Spares rest of wrist)
PA Common at the PIPs & DIPs PA
WOW (Spares MCPs) WOW
www.schreibman.info www.schreibman.info S,H 73yoF
OA: Hands OA: Hands
Prevalence/Hx Left Hand
PA view Narrows DIPs & PIPs Prevalence/Hx Left Hand
PA view Symmetry? Right Hand
PA view
Ordered List
Non-uniform narrowing Ordered List
Has similar
OA Sub-cortical sclerosis OA distribution in
Phytes Spares MCPs Phytes
both hands
EOA EOA One hand
Narrows Thumb Base (dominant)
RA Thumb CMC joint RA
Gout Gout usually more
Spares the other CMCs severely
CPPD Scaphoid-Trapezoid-Trapezium jt CPPD
involved
PA Spares other intercarpal jts PA Here right
WOW Spares radiocarpal joint WOW thumb > left
www.schreibman.info S,H 73yoF www.schreibman.info S,H 73yoF
Osteophytes: Hands My Ordered List
Prevalence/Hx Hand
PA view Best seen on lateral Prevalence/Hx Is it… Features Distribution
Joint Anatomy Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP
Ordered List
Hand
Lateral view Ordered List  OA? space narrowing
Osteophytes!
L4-5, C5-6
DIPs, PIP, Thumb base
OA OA
Phytes Phytes EOA? Gullwing Erosions DIPs (Symmetric)
Women > 50yo
EOA EOA
RA RA
Gout Gout
CPPD CPPD
PA PA
WOW WOW
www.schreibman.info C,C 76yoF www.schreibman.info

Erosive Osteoarthritis Erosive Osteoarthritis
Prevalence/Hx Left Hand Occurs in women>50 Prevalence/Hx Left Hand Right Hand
PA view PA view PA view
Joint Anatomy As does conventional OA Joint Anatomy
OA Involves DIPs (PIPs) OA
Phytes As does conventional OA Phytes Symmetry
EOA “Gullwing Erosions” EOA
RA RA
Gout Gout
CPPD CPPD
PA PA
WOW WOW
www.schreibman.info T,M 64yoF www.schreibman.info T,M 64yoF
My Ordered List RA = Disease of Synovium
Prevalence/Hx Is it… Features Distribution Prevalence/Hx B Normal synovium is very thin
Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP Joint Anatomy  1-3 cells thick
Ordered List  OA? space narrowing
Osteophytes!
L4-5, C5-6
DIPs, PIP, Thumb base Ordered List O
RA synovium hypertrophies
OA OA N  8-10 cells thick
Phytes EOA? Gullwing Erosions DIPs (Symmetric)
Women > 50yo Phytes E  “Pannus”
EOA EOA  Contains increased blood vessels
RA
 RA? Uniform narrowing MCPs, Carpus, C1-2
RA Increased blood flow (hyperemia)
Gout Gout B  Contains inflammatory cells
O Including osteoclasts
CPPD CPPD  Causes EROSIONS
PA PA N Cartilage
WOW WOW E Bone
www.schreibman.info www.schreibman.info hopkins-arthritis.org
RA = Disease of Synovium RA = Disease of Synovium
Prevalence/Hx B Inflamed pannus effects the Prevalence/Hx Synovial hyperemia causes
Joint Anatomy B articular cartilage uniformly Joint Anatomy B bone resorption, bone loss
Ordered List O
O Ordered List O
N Uniform cartilage loss Within the joint capsule
OA N OA N
Phytes E Uniform joint narrowing Phytes
“Peri-articular osteopenia”
E Synovial osteoclasts erode E This is subtle on radiographs
EOA EOA Radiographic technique dependent
RA cortical bone RA May not even be present on pts
B
B Central erosions B
Gout O Gout O treated with Bisphosphonates to
CPPD O Marginal erosions  to RA CPPD prevent loss of bone mass
PA
N
N Pannus tends to heap up at PA
N Cortical thinning causes bone
WOW E
E margins of joint capsule WOW E bowing/deformity

OA vs RA OA vs RA
Prevalence/Hx Disease of Disease of Prevalence/Hx Disease of Knee Knee Disease of
AP view AP view
Joint Anatomy Cartilage B Synovium Joint Anatomy Cartilage Synovium
Ordered List Nonuniform O Uniform Ordered List Nonuniform Uniform
OA Narrowing N Narrowing OA Narrowing Narrowing
Phytes Produces E Resorbs Phytes Produces Resorbs
EOA bone bone EOA bone bone
Subcortical Periarticular Subcortical Periarticular
RA Sclerosis B Osteopenia RA Sclerosis Osteopenia
Gout Osteophytes Erosions Gout Osteophytes Erosions
CPPD
O CPPD
PA N PA
WOW E WOW
www.schreibman.info www.schreibman.info V,D 50yoF H,A 51yoF
RA: Marginal Erosions RA: Erosions
Prevalence/Hx Left Hand Right Hand Prevalence/Hx Hand
Joint Anatomy
PA view PA view
Joint Anatomy
PA view Marginal
Ordered List Ordered List Erosions
OA OA
Phytes Phytes
EOA EOA
RA RA
Gout Gout
CPPD CPPD Central
PA Mirror Image PA Erosions
WOW Symmetry WOW
www.schreibman.info A,F 69yoF www.schreibman.info T,H M
My Ordered List Distribution: OA vs RA
Prevalence/Hx Is it… Features Distribution Prevalence/Hx Big Joints
Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP Joint Anatomy OA RA
Ordered List  OA? space narrowing
Osteophytes!
L4-5, C5-6
DIPs, PIP, Thumb base Ordered List
Hips
Knees
OA OA Ankles
Women > 50yo Phytes Shoulders
EOA  RA? Uniform narrowing MCPs, Carpus, C1-2 EOA Elbows
RA RA Spine
Gout Gout C1-C2
CPPD CPPD Hands
PA PA All the MCP jts
WOW WOW Entire Wrist
www.schreibman.info www.schreibman.info Andreas Vesalius: “De humani corporis fabrica”
© 2015 Ken L Schreibman, PhD/MD 59 of 94 © 2015 Ken L Schreibman, PhD/MD 1543 p.164 60 of 94

OA vs RA: Hips RA: Hips
Prevalence/Hx PowerPoint Model: Hip PowerPoint Model: Hip Also, since Prevalence/Hx Pelvis
AP view
Joint Anatomy Non-uniform cartilage loss  UNIFORM cartilage loss  with RA Joint Anatomy
Ordered List Superior Narrowing MEDIAL Narrowing there is Ordered List
OA
Acetabulum Acetabulum bone loss/ OA Thinned
Phytes resorption, Phytes Medial
EOA there can EOA Acetabular
RA RA
Gout
Femoral Femoral be thinning
Gout
Walls
Head Head of medial
CPPD acetabular CPPD MEDIAL Narrowing
PA RA wall… PA
Mirror Image Symmetry
WOW OA WOW
www.schreibman.info www.schreibman.info H,K 51yoM
Protrusio Acetabuli Distribution OA vs RA: Hands
Prevalence/Hx The degree of bone loss in RA can be so Prevalence/Hx OA Hand Hand
RA
PA view PA view
Joint Anatomy Joint Anatomy DIPs MCPs
Ordered List
great that the medial acetabular wall not Ordered List PIPs
only thins, it protrudes into the pelvis… Entire
OA OA Thumb wrist
Phytes Phytes base DRUJ
EOA EOA CMC
STT
RA RA
Gout Gout Spares Spares
DIPs
CPPD CPPD MCPs PIPs
Rest
PA PA of the
Pelvis
WOW AP view WOW wrist
www.schreibman.info www.schreibman.info S,H 73yoF Z,S 26yoF
RA: Ligamentous Laxity RA: Ligamentous Laxity
Prevalence/Hx Particularly Hand Prevalence/Hx Particularly Right Hand Left Hand
Ordered List
in the hand Ordered List
in the hand “Ulnar translocation of the carpus”
OA MCPs “Ulnar OA MCPs Lunate drifted Lunate drifted
Phytes
Wrist deviation” Phytes
Wrist towards ulna towards ulna
EOA The bones of the EOA The bones
L
RA drift in the RA drift in the L
ULNAR MCPs ULNAR Radius
Ulna
Gout Gout
CPPD direction CPPD direction
Normally, lunate sits
PA PA ½ over radius and
WOW WOW ½ over ulna
www.schreibman.info I,I 60yoF www.schreibman.info R,T 47yoF

RA: Ligamentous Laxity My Ordered List
Prevalence/Hx Cervical Spine
Lateral view C1-C2
Cervical Spine
Lateral view Prevalence/Hx Is it… Features Distribution
Joint Anatomy EXTENSION FLEXION Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP
Ordered List Instability Ordered List  OA? space narrowing L4-5, C5-6
OA C1
OA
Phytes Phytes EOA?
Gullwing Erosions DIPs (Symmetric)
Women > 50yo
EOA C2 C1
C2 EOA  RA?Uniform narrowing MCPs, Carpus, C1-2
C1 Marginal Erosions! Big Joints (Symmetric)
RA C3 C3 RA
Gout C4 10mm! C4
Gout OA looks nothing like RA!
C5
CPPD C5
C6
CPPD OA has osteophytes RA has erosions
C6 C2
PA C7
C7 PA Not everything with Not everything with
WOW C1 C2
WOW osteophytes is OA erosions is RA
© 2015 Ken L Schreibman, PhD/MD
O,J 42yoF Normal < 3mm 67 of 94 © 2015 Ken L Schreibman, PhD/MD 68 of 94
My Ordered List Crystal Deposition Arthropathies
Prevalence/Hx Is it… Features Distribution Prevalence/Hx Three crystals can deposit in joints:
Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP Joint Anatomy Hydroxyapatite: Usually in shoulders (calcific tendonitis/bursitis)
Ordered List  OA? space narrowing L4-5, C5-6
Ordered List
OA
OA Uric acid (monosodium urate): “Gout”
Women > 50yo Phytes Calcium pyrophosphate dihydrate: “Pseudogout”
EOA  RA? Uniform narrowing MCPs, Carpus, C1-2 EOA Uric acid CPPD
RA RA
Gout  Gout? Sharp Erosions with Random
overhanging edges Favors Toes (1st) Gout
CPPD CPPD Birefringence
PA
CPPD? Resembles OA Unusual distribution for OA
Chondrocalcinosis Favors Patella-Femoral
PA Needles
Birefringence
Rhomboids
Strongly Weakly
WOW Radiographically, Gout & CPPD look very different! WOW Negative diseaseaday.com Positive ard.bmj.com
www.schreibman.info www.schreibman.info microscopyu.com
Gout Gout: Favors Toes (1st)
Prevalence/Hx Prevalence/Hx Foot
B Joint fills with crystals B AP view
Ordered List O While these destroy cartilage, Ordered List O
OA N Presence of crystals in the OA N
Phytes E joint PRESERVES joint width Phytes E
EOA Crystals erode cortex slowly EOA
Takes 6-10 years to see erosions Marginal
RA RA Classic gout erosions
Gout B Erosions are sharply defined Gout B
Well-corticated margins erosion Diff Dx:
CPPD O Overhanging edges CPPD O 1st toe Gout
N N Sharp margin RA
PA “Rat-bite” PA Overhanging
WOW E Calcified soft tissue tophi are rare WOW E edges
www.schreibman.info www.schreibman.info D,W 80yoM

Gout: Favors Toes (1st) Gout: Random Distribution
AP view Erosions
Prevalence/Hx Foot Foot Prevalence/Hx Foot Hand
AP view AP view PA view
Joint Anatomy Joint Anatomy Same
Ordered List can be Ordered List “rat-
bite”
OA quite OA erosion
Phytes
EOA
small… Phytes
EOA
RA …or RA
Classic “rat-
Gout totally Gout bite” erosion
CPPD erode CPPD 1st toe
Sharp margin
PA PA
WOW
phalanges WOW
Overhanging
edges
www.schreibman.info R,B 30yoM M,B 78yoM www.schreibman.info A,J 66yoM
My Ordered List Chondrocalcinosis
Prevalence/Hx Is it… Features Distribution Prevalence/Hx “Cartilage calcified” Knee
AP view
Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP Joint Anatomy
Ordered List
Can be subtle…
OA
OA Sometimes obvious
Women > 50yo Phytes Common sites:
EOA EOA Knee
RA
 RA? Uniform narrowing MCPs, Carpus, C1-2
RA Pubic symphysis
overhanging edges Favors Toes (1st) Gout Wrist
CPPD CPPD  TFC (Triangular
PA
CPPD? Resembles OA Unusual distribution for OA
Chondrocalcinosis Favors Patella-Femoral
PA fibrocartilage)
WOW WOW
www.schreibman.info www.schreibman.info H,W 63yoM
Chondrocalcinosis CPPD: Wrist
Prevalence/Hx “Cartilage calcified” Wrist Prevalence/Hx Clues to CPPD: Spared DIPs Hand
Wrist
PA view PA view
Joint Anatomy Joint Anatomy & PIPs
Ordered List
Can be subtle Ordered List
1)Chondrocalcinosis (Somewhat
Sometimes obvious Lunate- 2)Distribution unusual atypical
OA Triquetrum OA for OA)
Phytes Common sites: Joint Phytes for OA
EOA Knee EOA
Pubic symphysis Narrowed MCPs
RA RA (Atypical for OA)
Gout Wrist Gout Typical for CPPD!
CPPD  TFC (Triangular TFC CPPD Narrowing TFC
fibrocartilage) STT &
PA PA Thumb CMC
WOW Not all chondrocalcinosis = CPPD WOW (Typical for OA) TFC
www.schreibman.info M,Y 76yoF www.schreibman.info M,Y 76yoF

CPPD: Knees CPPD  SLAC Wrist
Prevalence/Hx Bilateral Knees Prevalence/Hx
AP view Scapho-Lunate Advanced Collapse
Joint Anatomy Lateral compartment Joint Anatomy
Ordered List narrowed > Medial Loss
Ordered List Wrist
of the S-L ligament  Diastasis
Capitate then Wrist
OA Atypical for OA OA PA view PA view
descends down
Phytes Phytes
between S & L
EOA Chondrocalcinosis EOA Causing entire
C
RA Bilateral Knees
RA wrist to collapse
C
Gout Sunrise view Gout S
L “CPPD is one of
S L
CPPD CPPD TFC the major causes
PA Patellofemoral compartments narrowed >> Medial PA of SLAC*”
WOW Atypical for OA, …but typical for CPPD! WOW W,M 88yoF F,C 58yoM
www.schreibman.info B,L 70yoF www.schreibman.info *Radiology 1990;
© 2015 Ken L Schreibman, PhD/MD 79 of 94 © 2015 Ken L Schreibman, PhD/MD 177: 459-461 80 of 94
My Ordered List Psoriasis
Prevalence/Hx Is it… Features Distribution Prevalence/Hx Psoriasis is the most
Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP Joint Anatomy
Ordered List
prevalent autoimmune
OA
OA disease in the US
Women > 50yo Phytes 7.5 million Americans (2% of population)
EOA  RA? Uniform narrowing MCPs, Carpus, C1-2 EOA 125 million worldwide (2-3% of population)
RA
RA Up to 30% develop psoriatic arthritis
15% the arthritis precedes the skin disease
overhanging edges Favors Toes (1 ) st Gout
CPPD CPPD
PA
CPPD? Chondrocalcinosis Unusual
Resembles OA distribution for OA
Favors Patella-Femoral
PA
WOW Psoriatic? Pencil-in-Cup
Sausage Digit
Hands, Feet, Spine
SI Joints (Asymmetric) WOW Plaque Psoriasis Guttate Psoriasis Inverse Psoriasis Pustular Psoriasis Erythrodermic
www.schreibman.info www.schreibman.info psoriasis.org
Psoriatic Arthritis: 5 Types Psoriatic Arthritis: 5 Types
Prevalence/Hx Symmetric Left Hand Right Hand Prevalence/Hx Symmetric arthritis Hand
Joint Anatomy  Like RA; milder, less deformity. Joint Anatomy  Like RA; milder, less deformity.
Pencil-in-Cup
Asymmetric Asymmetric arthritis erosion
OA  “Sausage digit”. Usually mild.
OA  “Sausage digit”. Usually mild.
Phytes Phytes
EOA 3 Clues to PA: EOA DIP (5%)
1) “Sausage” digit Sausage Digit  Like OA; nail changes.
RA 2) “Pencil-in-cup” erosion 0Sausage digit is not
RA
Pencil Arthritis mutilans (5%)
Gout 3) Unilateral SI-itis
in a tasty meat product* Gout
0Finger or toe swells
CPPD cup from tip to base CPPD  Hands/feet.
PA erosion 0Shaped like a
cocktail sausage
PA Spondylitis (5%) Arthritis
WOW *voices.yahoo.com WOW  Stiff spine, SIs; extremities. mutilans
www.schreibman.info psoriasis.org L,J 65yoF www.schreibman.info Clue to PA psoriasis.org B,R 53yoF

4 Seronegative Spondyloarthropathies How Ordered List Helps Me
Prevalence/Hx “Seronegative”: RF factor neg. Abdomen Prevalence/Hx  Is this OA? Psoriatic
AP view
Joint Anatomy “Spondylo”: Effects spine Crohn's Disease Joint Anatomy  No 1st MTP osteophytes
Ordered List Resection Ordered List  Is this RA? Arthritis!
OA All 4 cause sacroiliitis ilium terminal
OA  Not uniform narrowing
Phytes Psoriatic arthritis & Phytes  Not all MTP, no osteopenia
EOA “reactive arthritis” EOA  Is this Gout?
RA Unilateral, asymmetric RA  Maybe… not 1st toe
Gout Ankylosing spondylitis & Gout  Is this CPPD? Normal Indistinct
Sclerotic
CPPD inflammatory bowel disease Ankylosis SIs CPPD  No chondrocalcinosis 
PA Bilateral, symmetric  Bilateral PA  Could this be PA? Unilateral Foot
 fusion (ankylosis) Oblique
 Symmetric AP view Sacroiliitis
WOW WOW  Do we have SI images? Pelvis view
www.schreibman.info M,P 32yoF www.schreibman.info S,E 36yoM
What to Order When Radiographs: Disease Progression
Prevalence/Hx Always start with Hand “r/o RA” Prevalence/Hx Hand “r/o RA” Hand
Ordered List
radiographs Ordered List
OA Least expensive OA Only 1 MCP is narrowed Disease progression,
imaging study Run eyes along MCPs:
Phytes Only 1 MCP is narrowed Phytes now with 4 MCPs narrowed
EOA Well shows results of EOA
RA joint disease: RA
Gout Narrowing & alignment Gout
CPPD Osteophytes & erosions CPPD Further disease progression,
Useful for following Run eyes
PA around wrist: PA now with ulnar deviation MCPs
WOW course of disease No Narrowing WOW Radiograph 2 years later Radiograph 1 year later
www.schreibman.info H,B 69yoF www.schreibman.info H,B 69yoF
Advanced Imaging Studies Advanced Imaging Studies
Prevalence/Hx MRI with IV Hand Coronal MR Hand Prevalence/Hx Dual-Energy CT
PA view T1 FatSat post IV contrast
Ordered List
contrast Negative Enhancing Ordered List
(coming soon…)
Well shows (even in carpal bones Specific for uric
OA Developing erosions OA
Phytes hypervascular retrospect) Phytes acid crystals in
EOA pannus EOA gout
RA Normal synovium RA
does not enhance
Gout Gout
CPPD
Useful for CPPD
diagnosing
PA early RA Enhancing PA
WOW pannus WOW
www.schreibman.info L,L 43yoF www.schreibman.info RadioGraphics 2011;
© 2015 Ken L Schreibman, PhD/MD 89 of 94 © 2015 Ken L Schreibman, PhD/MD 31:1365–1375 90 of 94

Advanced Imaging Studies Any Final Questions?
Prevalence/Hx Fluoroscopic guided Subtalar joint injection Prevalence/Hx
Lateral view
Ordered List
joint injections Ordered List
OA Useful to prove which OA
Phytes
joint is symptomatic Phytes
EOA With steroids can yield EOA
RA
long-term relief RA
Can inject any joint:
Gout Hips, Knees, Shoulders Gout
CPPD Facets, AC, SI CPPD
PA Pubic symphysis PA
WOW Ankle, Subtalar joint WOW
www.schreibman.info A,S 64yoF www.schreibman.info morbidanatomy.blogspot.com
Final Exam Thank you!
Prevalence/Hx Foot Psoriatic  Is this OA? Prevalence/Hx
AP view
Joint Anatomy Arthritis! No. Erosions, not phytes. Joint Anatomy
Ordered List  Is this RA? Ordered List
OA Does involves MTPs… OA
Phytes Has marginal erosions… Phytes
EOA  Is this Gout? EOA
RA Not random enough. RA
Gout  Is this CPPD? Gout
CPPD No chondrocalcinosis. CPPD
PA  Could this be PA? PA
WOW Pencil-in-cup erosion! WOW
www.schreibman.info N,C 57yoF www.schreibman.info media.photobucket.com

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Radiology of Joint Disease page 1 of 16

CPPD Ordered list of 5 most common arthropathies CPPD

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

Joint Anatomy  Extend horizontally from Joint Anatomy along Annulus

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info

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