The collagen vascular diseases (connective tissue diseases) are a group of diseases that have multiple, varied systemic manifestations. Articular symptoms play a minor role in the total clinical picture and usually produce little in the way of radiographic change in the joint. Although each disease has distinct features, there is a tendency toward overlap among the diseases. The diseases to be discussed are systemic lupus erythematosus,…

Three deposition diseases are discussed in this chapter: hemochromatosis, Wilson disease, and ochronosis. Two of these diseases are extremely rare. Each has been associated with radiographic chondrocalcinosis, or calcification of hyaline or fibrous cartilage. However, if chondrocalcinosis is defined as the deposition of calcium pyrophosphate dihydrate (CPPD) crystals into hyaline or fibrous cartilage, then its association with all of these diseases becomes questionable. Whatever substance is…

Hydroxyapatite deposition disease (HADD) is an extremely common disorder causing periarticular disease in the form of tendinitis or bursitis. Only rarely does it cause true articular disease. Calcium hydroxyapatite deposits in muscles, capsules, bursae, and tendon sheaths. Although this deposition is associated with many systemic diseases, such as collagen vascular diseases, renal osteodystrophy, hypervitaminosis D, and milk-alkali syndrome, in many patients it occurs idiopathically with no…

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is a common disorder and the most common crystal arthropathy. In a typical hospital population, one to three patients per week will be observed with some manifestation of this disorder. It typically affects the middle-aged and elderly population. Some estimate the frequency to be 5 percent of this population. The clinical picture varies from the pseudogout syndrome to asymptomatic…

Gout is the oldest recognized arthropathy. It was originally called podagra, from the Greek pous , meaning foot, and agra , meaning attack. In ancient history all arthritis was called gout. Today we know it to be a specific arthropathy secondary to deposition of monosodium urate crystals. It occurs in 0.3 percent of the population, and it accounts for 5 percent of all patients with arthritis.…

Diffuse idiopathic skeletal hyperostosis (DISH), also known as ankylosing hyperostosis or Forestier disease, is not an arthropathy. The articular cartilage, adjacent bone margins, and synovium are not affected. DISH appears to be a bone-forming diathesis in which ossification occurs at skeletal sites subjected to stress, primarily at tendinous and ligamentous attachments. It is a common disorder, occurring in 12 percent of the elderly population. Its radiographic…

Neuropathic osteoarthropathy presents the most dramatic radiographic picture of all of the arthropathies. As a result, it may produce a diagnostic dilemma. Although it is known that various neurological disorders play a prominent role in the development of the osteoarthropathy, the exact pathogenesis has not been clearly established. Although chronic, repetitive, and undetected trauma creates many of the radiographic changes, it is not responsible for all…

Osteoarthritis is the most common arthropathy. Although many arthropathies lead to secondary osteoarthritic changes, this chapter deals with primary osteoarthritis and osteoarthritis secondary to alteration of normal mechanics across a weight-bearing joint. The radiographic hallmarks of osteoarthritis are as follow: 1. Normal mineralization 2. Nonuniform loss of joint space 3. Absence of erosions 4. Subchondral new bone formation 5. Osteophyte formation 6. Cysts 7. Subluxations 8.…

Ankylosing spondylitis is the chronic inflammatory disease that affects primarily the axial skeleton and only secondarily the appendicular skeleton. It is seen predominantly in males between the ages of 15 and 35 years. Of all the inflammatory arthropathies, it is the least erosive and the most ossifying. Ankylosis of a joint is the predominant characteristic. The common radiographic findings are as follows: 1. Normal mineralization before…

Reactive arthritis (formerly known as Reiter disease) is usually associated with conjunctivitis and urethritis. It is a disease predominantly of males between 15 and 35 years of age and is transmitted through either epidemic dysentery or sexual intercourse. The arthritis may be present without documentation of the other clinical manifestations. In such cases, radiographic examination may provide the appropriate diagnosis. The classic radiographic features are as…

For years psoriatic arthritis was considered part of the spectrum of rheumatoid arthritis. The classification of psoriatic arthritis as a “rheumatoid variant” persists today. However, the radiographic manifestations, along with clinical and laboratory data, establish psoriatic arthritis as a separate and distinct articular disorder. Psoriatic arthritis occurs in 5 to 8 percent of patients with severe and longstanding psoriatic skin disease. However, the arthropathy may coincide…

In the practice of rheumatology, rheumatoid arthritis is considered the everyday disease. It is a symmetrical arthritis of the appendicular skeleton, sparing the axial skeleton except for the cervical spine. The common radiographic findings are as follows: 1. Periarticular soft tissue swelling 2. Juxta-articular osteoporosis progressing to generalized osteoporosis 3. Uniform loss of joint space 4. Lack of bone formation 5. Marginal erosions progressing to severe…

In evaluating the spine, one observes the size, shape, and mineralization of the different vertebral bodies. These parameters become abnormal in various systemic diseases. For example, a large vertebral body is seen in Paget disease, a flattened vertebral body in eosinophilic granuloma, an H-shaped vertebral body in sickle cell disease, a sclerotic vertebral body in lymphoma, and an osteoporotic body in hyperparathyroidism. The arthropathies tend not…

The sacroiliac (SI) joint is perhaps the most difficult joint in the skeleton to image adequately to make an accurate diagnosis of a disorder affecting it. This is partially due to obscuration of the joint by multiple overlying soft tissue structures and variations in the obliquity of the joint within an individual and among individuals. A modified anteroposterior (AP) Ferguson view (see Chapter 1 ) is…

Pain in the shoulder is a common problem affecting all ages of the general population. It is the second most common cause of musculoskeletal pain. Radiographic diagnosis of the disease entity causing nonspecific pain begins with evaluation of how the shoulder joint has been affected. There are three areas in the shoulder joint to be observed: (1) the glenohumeral joint, (2) the subacromial space, and (3)…

As in the hip, the diagnosis of a disorder of the knee depends foremost on the evaluation of true joint space involvement. This evaluation is made most accurately through an anteroposterior (AP) standing view of the knee and a flexed lateral view (see Chapter 1 ). The joint consists of three compartments: the medial tibiofemoral compartment, the lateral tibiofemoral compartment, and the patellofemoral compartment. The various…

The assessment of hip pain depends on a systematic review of a quality anteroposterior (AP) view of the pelvis. The femurs should be internally rotated approximately 15 degrees, the pelvis should not be oblique, and the sacrococcygeal junction should not project more than 4 cm superior to the superior pubic ramus. The following should be systematically assessed on the AP view of the pelvis: 1) hip…

A systematic assessment of foot radiographs for the manifestations of arthropathies is important, because the foot may be an early site of involvement in a systemic arthropathy such as rheumatoid arthritis, or it may be the only site of involvement in arthropathies such as gout or reactive arthritis. The foot, however, can be difficult to evaluate radiographically. Arches are present in the long and short axes…

Radiographs of the hands are probably the most informative part of any screening series for arthritis. It is suggested that two views be obtained for evaluation: a posteroanterior (PA) view and a Nørgaard view of both hands and wrists (see Chapter 1 ). The former is excellent for imaging mineralization and soft tissue swelling; the latter is necessary for imaging early erosive changes. Using these two…

Evaluation of any articular disorder involves imaging the affected joints with the most appropriate modality. Imaging documents not only the extent and severity of joint involvement but also the progression or regression of disease. More importantly, in the patient who presents with vague, complex, or confusing clinical symptoms, imaging often allows a specific diagnosis to be made. The modalities available for imaging are radiography, magnetic resonance…