Radiology of Joint Disease My Practical Approach

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 Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP Professor, Musculoskeletal Section  OA? space narrowing L4-5, C5-6 Ordered List 9 Faculty, 5 Fellows Ordered List Osteophytes! DIPs, PIP, Thumb base OA OA Gullwing Erosions DIPs (Symmetric) Phytes My Practical Approach to Arthritis Phytes EOA? Women > 50yo EOA Radiology of Joint Disease is Hard EOA Uniform narrowing MCPs, Carpus, C1-2  RA? Marginal Erosions! Big Joints (Symmetric) RA It took me 10 years to begin to understand it RA Another 10 years to figure out how to teach it Sharp Erosions with Random Gout May not be possible to teach in one hour Gout Gout? overhanging edges Favors Toes (1st) CPPD CPPD Resembles OA Unusual distribution for OA Ordered list of 5 most common arthropathies CPPD? Chondrocalcinosis Favors Patella-Femoral PA PA  Can download PowerPoints & handouts Pencil-in-Cup Hands, Feet, Spine WOW for this and all my lectures WOW Psoriatic? Sausage Digit SI Joints (Asymmetric) www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD 1 of 94 © 2015 Ken L Schreibman, PhD/MD 2 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Prevalence of Arthritis Prevalence of ArthritisTypes of Arthritis Prevalence/Hx Arthritis is one of the Prevalence/Hx >100 conditions affect joints* 46 Million Joint Anatomy Joint Anatomy most prevalent chronic RA:1.3M‡=3% all arthritis Diagnosed Ordered List US Adult 20% Ordered List health problems Population Decreased from 2.1M (5%) 1995 RA with Arthritis… OA (46M) OA The nation’s leading ≈ 225 Gout:3M†=7% all arthritis OA = 27M† Phytes Diagnosed Phytes Gout cause of disability Million with Arthritis Increased from 2.1M (5%) 1995 (59% of all EOA EOA Costs US economy CPPD:? CPPD Arthritis) RA RA $128 billion annually Adults >65 yo No prevalence data SNSA and those of us Gout 50% have Arthritis Gout Seronegative Spondylarthritides: who look at joints CPPD CPPD up to 2.4M‡ (5%) suspect OA is PA 2005 PA more like 2005 (most recent > 80% (most recent WOW available data) WOW 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

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Arthritis is Ancient: Gout Arthritis is Ancient: RA Prevalence/Hx “king of diseases and disease of kings” Prevalence/Hx 4500BC (Tennessee) Joint Anatomy 2600BC (Egypt): Described in the great toe Joint Anatomy Native American skeletal Ordered List Ordered List 400BC (Greece): Hippocrates wrote about it 1661Jacob OA OA Jordaens Phytes 1599 Shakespeare Phytes (Flemish Baroque EOA (Henry IV, Part 2) Falstaff: EOA painter) “A pox of this gout! or a gout Rheumatoid Nodules RA RA The Family of this pox! for the one or the of the Artist Gout other plays the rogue with Gout CPPD my great toe.” CPPD MCPs PA 1799 James Gillray PA WOW (British caricaturist): WOW PIPs www.schreibman.info wikipedia.org www.schreibman.info wikipedia.org wikipedia.org © 2015 Ken L Schreibman, PhD/MD 5 of 94 © 2015 Ken L Schreibman, PhD/MD 6 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 2 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 Osteo=“Bone”… but it’s not disease of bone Ordered List Ordered List 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 CPPD CPPD (not caused by Streptococcus pyogenes) 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 © 2015 Ken L Schreibman, PhD/MD 7 of 94 © 2015 Ken L Schreibman, PhD/MD 8 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Old Diseases = Old Names (misnomers) PowerPoint Model: BoneJoint Prevalence/Hx Prevalence/Hx White Line = “Reiter’s Disease” CorticalB Bone Joint: 2 bones meet Joint Anatomy 1942:HansConradJuliusReiter Joint Anatomy O Bones flair out at ends Ordered List Inflammatory arthritis Ordered List OA Eye inflammation (conjunctivitis or uveitis) OA BN Metaphysis Phytes Urethritis in men or cervicitis in woman Phytes OE 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 GrayN Fill = PA 1945: Interrogated in Nuremberg; released 1947 PA Trabecular Bone WOW 2009: Disease renamed “Reactive Arthritis” WOW (Cancellus)E 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

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 RA r Plates RA [Gr] “resembling glass” Space a Gout B b Gout B Synovium e CPPD O c CPPD O Normally very thin (1-3 cells) u PA N l PA  N  Synovial fluid a This is too much WOW E Cortex r WOW fluid (i.e.E Effusion) Normally just wetting amount www.schreibman.info R,S 14yoM www.schreibman.info © 2015 Ken L Schreibman, PhD/MD 11 of 94 © 2015 Ken L Schreibman, PhD/MD 12 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 3 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Joint Disease = Cartilage Damage Arthrogram - CT Prevalence/Hx B Imaging joint disease = Prevalence/Hx KindB of likeKnee an RadiographOreo: Knee Arthrogram-CT Joint Anatomy Joint Anatomy AP view Coronal Reformat Ordered List O “seeing cartilage” Ordered List DarkO Cookie=Cartilage Light Cream=Contrast OA N Radiographs OA N 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 r Gout B Gout B a Arthrogram-CT b CPPD O CPPD O e Inject contrast into joint, c N N u PA then do a CT scan PA Cartilage is dark tissue between l a WOW E Multiplanar reformat WOW white Ecortex and white contrast Cortex r www.schreibman.info www.schreibman.info R,S 14yoM © 2015 Ken L Schreibman, PhD/MD 13 of 94 © 2015 Ken L Schreibman, PhD/MD 14 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 Articular (hyaline) Phytes E We see it indirectly by 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 © 2015 Ken L Schreibman, PhD/MD 15 of 94 © 2015 Ken L Schreibman, PhD/MD 16 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 5 Most Common Arthropathies  Osteoarthritis (OA) Prevalence/Hx Is it… Features Distribution Prevalence/Hx THE most common 46 Million Joint Anatomy  OA? Joint Anatomy joint disease Diagnosed Ordered List Ordered List At least 60% of ALL with Arthritis… OA OA OA = 27M† Phytes EOA? Phytes arthritis is OA… In my experience it’s (59% of all EOA  RA? EOA more like 80-90% Arthritis) RA RA Primary OA and those of us Gout Gout? Gout Effects specific joints who look at joints CPPD CPPD? CPPD Secondary OA suspect OA is PA PA Can effect any joint more like 2005 WOW WOW > 80% (most recent Psoriatic? “Osteoarthrosis” available data) www.schreibman.info www.schreibman.info †ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35 © 2015 Ken L Schreibman, PhD/MD 17 of 94 © 2015 Ken L Schreibman, PhD/MD 18 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 4 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 © 2015 Ken L Schreibman, PhD/MD 19 of 94 © 2015 Ken L Schreibman, PhD/MD 20 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 OSTEOPHYTES! to OA EOA Compartment Patella- RA  RA Femoral Bony spurs from joints Medial Compartment Gout Can occur either after the Gout Compartment CPPD CPPD joint is narrowed… PA PA WOW or before the joint narrows WOW www.schreibman.info www.schreibman.info P,C 67yoF © 2015 Ken L Schreibman, PhD/MD 21 of 94 © 2015 Ken L Schreibman, PhD/MD 22 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach PHYTE Let’s Talk about “Phyte Club” CLUB Enthesophytes Prevalence/Hx Suffix phyte: Prevalence/Hx Enthesophytes are… nothing Joint Anatomy Joint Anatomy Bone spurs at ligament/tendon insertions Ordered List “abnormal growth” Ordered List OA 3 Types of phytes: OA Not osteophytes (which occur at joints) Phytes Osteophytes Phytes Not pathology EOA EOA Common in calcaneus  @ Joints  @ Achilles RA RA “Heel spurs” tendon Enthesophytes Not plantar fasciitis Gout @ Ligament/Tendon Gout insertion CPPD insertions CPPD PA Syndesmophytes PA WOW @ Disks (Annulus Fibrosis) WOW @ plantar fascia www.schreibman.info doddleme.com www.schreibman.info L,E 62yoF © 2015 Ken L Schreibman, PhD/MD 23 of 94 © 2015 Ken L Schreibman, PhD/MD 24 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 5 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach PHYTE PHYTE CLUB Osteophytes 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 Body OA Body Phytes (Degenerative Disk Disease) Phytes L4 EOA  Extend from vertebral EOA RA bodies corners Annulus Nucleus RA Gout In DDD disk bulges outward Gout L5 Osteophytes extend out Body Body CPPD around bulging disk CPPD S1 PA  Extend horizontally PA WOW Typically extend anteriorly WOW www.schreibman.info www.schreibman.info D,R 66yoM © 2015 Ken L Schreibman, PhD/MD 25 of 94 © 2015 Ken L Schreibman, PhD/MD 26 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach PHYTE PHYTE CLUB Osteophytes vs Syndesmophytes CLUB Syndesmophytes Vertical  Lumbar Spine Thoracic Spine Prevalence/Hx While Osteophytes PowerPoint Model: Spine Prevalence/Hx Lateral Extend view vertically Lateral view Joint Anatomy Joint Anatomy along Annulus  Extend horizontally from Fibrosus Ordered List corners of vertebral body Ordered List  Thin OA Syndesmophytes OA  Cover multiple Phytes Body Phytes levels Body  Extend vertically along 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 © 2015 Ken L Schreibman, PhD/MD 27 of 94 © 2015 Ken L Schreibman, PhD/MD 28 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach PHYTE CLUB Syndesmophytes Vertical  My Ordered List Lumbar Spine Lumbar Spine Prevalence/Hx Lateral view AP view Prevalence/Hx Is it… Features Distribution Joint Anatomy Joint Anatomy Non-uniform joint Hips, Knees, 1st MTP  OA? space narrowing L4-5, C5-6 Ordered List Ordered List Osteophytes! DIPs, PIP, Thumb base OA OA Phytes Ankylosing Phytes EOA Spondylitis EOA RA RA Gout “Bamboo Spine” Gout CPPD Fused CPPD PA SI PA Royal Botanical Garden WOW Joints Kandy, Sri Lanka 2005 WOW www.schreibman.info W,D 52yoM www.schreibman.info © 2015 Ken L Schreibman, PhD/MD 29 of 94 © 2015 Ken L Schreibman, PhD/MD 30 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 6 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Distribution: OA Distribution: OA Cervical Spine Lumbar Spine Prevalence/Hx Spine C1 Lateral view Lateral view Prevalence/Hx Lower Extremity Joint Anatomy Lower L1 Joint Anatomy Common in the Hip Ordered List Ordered List Cervical C2 L2 Common in the Knee OA Spine OA Phytes C3 Phytes Uncommon in the Ankle C5-C6 L3 Not simply due to weightbearing EOA Lower C4 EOA RA RA Common 1st MTP Joint C5 Lumbar L4 Foot O-phyte “Hallux Limitus” Gout Gout AP view Spine C6 “Hallux Rigidus” CPPD L4-L5 L5 CPPD aka “OA” PA C7 “Vacuum PA Non-uniform Disk” narrowing Foot WOW J,W 48yoF F,D 34yoF WOW D,M 52yoF Osteophytes Lateral view www.schreibman.info Andreas Vesalius: “De humani corporis fabrica” www.schreibman.info Andreas Vesalius: “De humani corporis fabrica” © 2015 Ken L Schreibman, PhD/MD 1543 p.163 31 of 94 © 2015 Ken L Schreibman, PhD/MD 1543 p.163 32 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 Pelvis Ordered List Asymmetry  to OA Hip OA Narrowed Normal OA Prosthesis Acetabulum Superiorly widthAP view Progressive Narrowed Phytes Phytes Worsens over time Superiorly EOA EOA Normal RA RA width Femoral Symptomatic Asymptomatic Gout Head side side Gout CPPD CPPD PA Asymmetry: PA to OA WOW OA  WOW 2 years earlier 2 months later www.schreibman.info K,K 44yoM www.schreibman.info K,K 44yoM © 2015 Ken L Schreibman, PhD/MD 33 of 94 © 2015 Ken L Schreibman, PhD/MD 34 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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 Ordered List Ordered List Asymmetry  to OA Unlike knees&feet which X-ray OA Progressive OA Phytes Phytes should be done standing cassette Worsens over time  EOA EOA Cassette slides into Osteophytes? to OA “Bucky Grid” RA Often not seen on AP view RA Gout Gout  Minimize x-ray scatter Best seen on frog-leg view  Dr Gustav Bucky  CPPD CPPD (9/3/1880-2/19/1963) Tray PA What’s a frog-leg view? PA  1913: Moving grid WOW WOW (Berlin) Marty age 15 www.schreibman.info mi9.com www.schreibman.info © 2015 Ken L Schreibman, PhD/MD 35 of 94 © 2015 Ken L Schreibman, PhD/MD 36 of 94

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Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach AP Pelvis Frog Leg Lateral Prevalence/Hx Prevalence/Hx

Joint Anatomy Joint Anatomy X

AP X

- - RAYS Ordered List view of RAYS Ordered List Femurs OA OA Lateral Phytes Greater Phytes view of EOA Trochanter EOA Femurs Hip joint width RA RA Externally Rotated Gout Head Gout GT CPPD CPPD PA PA Lesser LT WOW Trochanter Internally Rotated WOW www.schreibman.info B,A 16yoF www.schreibman.info B,A 16yoF © 2015 Ken L Schreibman, PhD/MD 37 of 94 © 2015 Ken L Schreibman, PhD/MD 38 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Osteophytes: Hips Sub-Cortical Sclerosis: Hips Prevalence/Hx Superior narrowing Right Hip Pelvis Prevalence/Hx Not sub-cortical sclerosis Pelvis Joint Anatomy Asymmetry Frog-leg view AP view Joint Anatomy AP 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 Superiorly “Isn’t this 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 © 2015 Ken L Schreibman, PhD/MD 39 of 94 © 2015 Ken L Schreibman, PhD/MD 40 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Sub-Cortical Sclerosis: Hips Distribution: OA Prevalence/Hx This is Prevalence/Hx Upper Extremity Joint Anatomy Joint Anatomy Uncommon in the Shoulder Ordered List sub-cortical Ordered List sclerosis! This isn’t a French 1º OA spares glenohumeral joint OA model’s eyebrow OA 2º OA from trauma, rotator cuff tear 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 www.schreibman.info R,C 81yoF www.schreibman.info D,H 63yoM © 2015 Ken L Schreibman, PhD/MD 41 of 94 © 2015 Ken L Schreibman, PhD/MD 42 of 94

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Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Distribution: OA OA: Hands Prevalence/Hx Prevalence/Hx Left Hand Upper Extremity PA view Narrows DIPs & PIPs Joint Anatomy Uncommon in the Shoulder Joint Anatomy Non-uniform narrowing Ordered List 1º OA spares glenohumeral joint Ordered List OA 2º OA from trauma, rotator cuff tear OA Sub-cortical sclerosis Phytes Very common acromioclavicular jt. Phytes Narrows w/age usually not symptomatic EOA Uncommon in the Elbow EOA RA 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 © 2015 Ken L Schreibman, PhD/MD 43 of 94 © 2015 Ken L Schreibman, PhD/MD 44 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach OA: Hands OA: Hands Prevalence/Hx Left Hand Prevalence/Hx Left Hand Right Hand PA view Narrows DIPs & PIPs PA view Symmetry? PA view Joint Anatomy Non-uniform narrowing Joint Anatomy Has similar Ordered List Ordered List Sub-cortical sclerosis distribution in OA OA both hands Phytes Spares MCPs Phytes One hand EOA Narrows Thumb Base EOA RA RA (dominant) Thumb CMC joint usually more Gout Spares the other CMCs Gout 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 © 2015 Ken L Schreibman, PhD/MD 45 of 94 © 2015 Ken L Schreibman, PhD/MD 46 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Osteophytes: Hands My Ordered List Prevalence/Hx Hand Prevalence/Hx Is it… Features Distribution PA view Best seen on lateral st Joint Anatomy Hand Joint Anatomy Non-uniform joint Hips, Knees, 1 MTP Lateral view  OA? space narrowing L4-5, C5-6 Ordered List Ordered List Osteophytes! DIPs, PIP, Thumb base OA OA Gullwing Erosions DIPs (Symmetric) Phytes Phytes EOA? Women > 50yo EOA EOA RA RA Gout Gout CPPD CPPD PA PA WOW WOW www.schreibman.info C,C 76yoF www.schreibman.info © 2015 Ken L Schreibman, PhD/MD 47 of 94 © 2015 Ken L Schreibman, PhD/MD 48 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 9 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Erosive Osteoarthritis Erosive Osteoarthritis Prevalence/Hx Left Hand Prevalence/Hx Left Hand Right Hand PA view Occurs in women>50 PA view PA view Joint Anatomy As does conventional OA Joint Anatomy Ordered List Ordered List 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 © 2015 Ken L Schreibman, PhD/MD 49 of 94 © 2015 Ken L Schreibman, PhD/MD 50 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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  OA? space narrowing L4-5, C5-6 O Ordered List Osteophytes! DIPs, PIP, Thumb base Ordered List RA synovium hypertrophies OA Gullwing Erosions DIPs (Symmetric) OA N  8-10 cells thick Phytes EOA? Women > 50yo Phytes E  “Pannus” EOA Uniform narrowing MCPs, Carpus, C1-2 EOA  Contains increased blood vessels  RA? Marginal Erosions! Big Joints (Symmetric) RA 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 © 2015 Ken L Schreibman, PhD/MD 51 of 94 © 2015 Ken L Schreibman, PhD/MD 52 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach RA = Disease of Synovium RA = Disease of Synovium Prevalence/Hx Prevalence/Hx B Inflamed pannus effects the B Synovial hyperemia causes Joint Anatomy O articular cartilage uniformly Joint Anatomy bone resorption, bone loss Ordered List O Uniform cartilage loss Ordered List O Within the joint capsule OA N OA N E Uniform joint narrowing “Peri-articular osteopenia” Phytes E Phytes E This is subtle on radiographs EOA Synovial osteoclasts erode EOA cortical bone Radiographic technique dependent RA B RA B May not even be present on pts Gout B Central erosions Gout treated with Bisphosphonates to O Marginal erosions  to RA O prevent loss of bone mass CPPD N CPPD N PA N Pannus tends to heap up at PA Cortical thinning causes bone WOW E margins of joint capsule WOW E bowing/deformity www.schreibman.info www.schreibman.info © 2015 Ken L Schreibman, PhD/MD 53 of 94 © 2015 Ken L Schreibman, PhD/MD 54 of 94

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 10 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach OA vs RA OA vs RA Prevalence/Hx Prevalence/Hx Knee Knee Disease of Disease of Disease of AP view AP view Disease of 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 RA Subcortical Periarticular RA Subcortical Periarticular Sclerosis B Osteopenia Sclerosis Osteopenia Gout Osteophytes O Erosions Gout Osteophytes Erosions CPPD N CPPD PA PA WOW E WOW www.schreibman.info www.schreibman.info V,D 50yoF H,A 51yoF © 2015 Ken L Schreibman, PhD/MD 55 of 94 © 2015 Ken L Schreibman, PhD/MD 56 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach RA: Marginal Erosions RA: Erosions Prevalence/Hx Left Hand Right Hand Prevalence/Hx Hand PA view PA view PA view Marginal Joint Anatomy Joint Anatomy 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 © 2015 Ken L Schreibman, PhD/MD 57 of 94 © 2015 Ken L Schreibman, PhD/MD 58 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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? space narrowing L4-5, C5-6 OA RA Hips Ordered List Osteophytes! DIPs, PIP, Thumb base Ordered List Knees OA Gullwing Erosions DIPs (Symmetric) OA Ankles Phytes EOA? Women > 50yo Phytes Shoulders EOA Uniform narrowing MCPs, Carpus, C1-2 EOA Elbows  RA? Marginal Erosions! Big Joints (Symmetric) 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

©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info Radiology of Joint Disease page 11 of 16 My Practical Approach

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach OA vs RA: Hips RA: Hips Prevalence/Hx Prevalence/Hx Pelvis PowerPoint Model: Hip PowerPoint Model: Hip Also, since 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 OA Acetabulum Acetabulum bone loss/ Thinned Phytes resorption, Phytes Medial EOA there can EOA Acetabular RA RA Femoral Femoral be thinning Walls Gout Head Head of medial Gout CPPD acetabular CPPD MEDIAL Narrowing PA RA wall… PA Mirror Image Symmetry WOW OA WOW www.schreibman.info www.schreibman.info H,K 51yoM © 2015 Ken L Schreibman, PhD/MD 61 of 94 © 2015 Ken L Schreibman, PhD/MD 62 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Protrusio Acetabuli Distribution OA vs RA: Hands Prevalence/Hx Prevalence/Hx Hand Hand The degree of bone loss in RA can be so OA PA view PA view RA Joint Anatomy great that the medial acetabular wall not Joint Anatomy DIPs MCPs Ordered List only thins, it protrudes into the pelvis… Ordered List PIPs Entire OA OA Thumb wrist Phytes Phytes base DRUJ EOA EOA CMC RA RA STT Gout Gout Spares Spares DIPs CPPD CPPD MCPs Rest PIPs PA PA Pelvis of the WOW AP view WOW wrist www.schreibman.info www.schreibman.info S,H 73yoF Z,S 26yoF © 2015 Ken L Schreibman, PhD/MD 63 of 94 © 2015 Ken L Schreibman, PhD/MD 64 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach RA: Ligamentous Laxity RA: Ligamentous Laxity Prevalence/Hx Hand Prevalence/Hx Right Hand Left Hand Particularly PA view Particularly PA view PA view Joint Anatomy in the hand Joint Anatomy in the hand “Ulnar translocation of the carpus” Ordered List MCPs Ordered List MCPs OA “Ulnar OA Lunate drifted Lunate drifted Wrist Wrist Phytes deviation” Phytes towards ulna towards ulna The bones The bones EOA of the EOA L RA drift in the RA drift in the L MCPs Radius Gout ULNAR Gout ULNAR Ulna 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 © 2015 Ken L Schreibman, PhD/MD 65 of 94 © 2015 Ken L Schreibman, PhD/MD 66 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach RA: Ligamentous Laxity My Ordered List Cervical Spine Cervical Spine Prevalence/Hx Lateral view Lateral view Prevalence/Hx Is it… Features Distribution C1-C2 st Joint Anatomy EXTENSION FLEXION Joint Anatomy Non-uniform joint Hips, Knees, 1 MTP  OA? space narrowing L4-5, C5-6 Ordered List Instability Ordered List Osteophytes! DIPs, PIP, Thumb base C1 OA OA Gullwing Erosions DIPs (Symmetric) Phytes Phytes EOA? Women > 50yo EOA C2 C1 EOA Uniform narrowing MCPs, Carpus, C1-2 C1 C2  RA? Marginal Erosions! Big Joints (Symmetric) RA C3 C3 RA Gout C4 10mm! C4 Gout OA looks nothing like RA! C5 C5 CPPD C6 CPPD OA has osteophytes RA has erosions C6 C2 PA C7 PA Not everything with Not everything with C7 osteophytes is OA WOW C1 C2 WOW erosions is RA www.schreibman.info O,J 42yoF www.schreibman.info © 2015 Ken L Schreibman, PhD/MD Normal < 3mm 67 of 94 © 2015 Ken L Schreibman, PhD/MD 68 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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  OA? space narrowing L4-5, C5-6 Hydroxyapatite: Usually in shoulders (calcific tendonitis/bursitis) Ordered List Osteophytes! DIPs, PIP, Thumb base Ordered List Uric acid (monosodium urate): “Gout” OA Gullwing Erosions DIPs (Symmetric) OA Phytes EOA? Women > 50yo Phytes Calcium pyrophosphate dihydrate: “Pseudogout” EOA Uniform narrowing MCPs, Carpus, C1-2 EOA Uric acid CPPD RA? Marginal Erosions! Big Joints (Symmetric) RA  RA  Sharp Erosions with Random  Gout Gout? overhanging edges Favors Toes (1st) Gout CPPD Resembles OA Unusual distribution for OA CPPD CPPD? Chondrocalcinosis Favors Patella-Femoral Birefringence Birefringence PA  PA Needles 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 © 2015 Ken L Schreibman, PhD/MD 69 of 94 © 2015 Ken L Schreibman, PhD/MD 70 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Gout Gout: Favors Toes (1st) Prevalence/Hx Prevalence/Hx Foot B Joint fills with crystals B AP view Joint Anatomy While these destroy cartilage, Joint Anatomy Ordered List O 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 Erosions are sharply defined Classic gout erosions Gout B Gout B Well-corticated margins erosion Diff Dx: O O 1st toe CPPD Overhanging edges CPPD Gout PA N PA N Sharp margin RA “Rat-bite” Overhanging WOW E Calcified soft tissue tophi are rare WOW E edges www.schreibman.info www.schreibman.info D,W 80yoM © 2015 Ken L Schreibman, PhD/MD 71 of 94 © 2015 Ken L Schreibman, PhD/MD 72 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Gout: Favors Toes (1st) Gout: Random Distribution Prevalence/Hx Foot Foot Prevalence/Hx Foot Hand AP view Erosions AP view AP view PA view Joint Anatomy Joint Anatomy Same Ordered List can be Ordered List “rat- bite” OA quite OA erosion Phytes small… Phytes EOA EOA RA …or RA Classic “rat- Gout totally Gout bite” erosion CPPD erode CPPD 1st toe PA PA Sharp margin phalanges Overhanging WOW WOW edges www.schreibman.info R,B 30yoM M,B 78yoM www.schreibman.info A,J 66yoM © 2015 Ken L Schreibman, PhD/MD 73 of 94 © 2015 Ken L Schreibman, PhD/MD 74 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach My Ordered List Chondrocalcinosis Prevalence/Hx Is it… Features Distribution Prevalence/Hx “Cartilage calcified” Knee Non-uniform joint Hips, Knees, 1st MTP AP view Joint Anatomy Joint Anatomy Can be subtle… Ordered List  OA? space narrowing L4-5, C5-6 Ordered List Osteophytes! DIPs, PIP, Thumb base Sometimes obvious OA Gullwing Erosions DIPs (Symmetric) OA Phytes EOA? Women > 50yo Phytes Common sites: EOA Uniform narrowing MCPs, Carpus, C1-2 EOA Knee RA? Marginal Erosions! Big Joints (Symmetric) RA  RA Pubic symphysis  Sharp Erosions with Random  Gout Gout? overhanging edges Favors Toes (1st) Gout Wrist CPPD Resembles OA Unusual distribution for OA CPPD TFC (Triangular CPPD? Chondrocalcinosis Favors Patella-Femoral PA  PA fibrocartilage) WOW WOW www.schreibman.info www.schreibman.info H,W 63yoM © 2015 Ken L Schreibman, PhD/MD 75 of 94 © 2015 Ken L Schreibman, PhD/MD 76 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Chondrocalcinosis CPPD: Wrist Prevalence/Hx Wrist Prevalence/Hx HandWrist “Cartilage calcified” PA view Clues to CPPD: Spared DIPs PA view Joint Anatomy Can be subtle Joint Anatomy 1)Chondrocalcinosis & PIPs Ordered List Ordered List (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 STT & PA fibrocartilage) 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 © 2015 Ken L Schreibman, PhD/MD 77 of 94 © 2015 Ken L Schreibman, PhD/MD 78 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach CPPD: Knees CPPD  SLAC Wrist Prevalence/Hx Bilateral Knees Prevalence/Hx Scapho-Lunate Advanced Collapse AP view Lateral compartment Joint Anatomy Joint Anatomy Loss of the S-L ligament  Diastasis Ordered List narrowed > Medial Ordered List Wrist Capitate then Wrist OA Atypical for OA OA PA view PA view descends down Phytes Phytes between S & L EOA Chondrocalcinosis EOA C Causing entire C RA Bilateral Knees RA wrist to collapse Sunrise view S S Gout Gout L “CPPD is one of 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

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 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  OA? space narrowing L4-5, C5-6 prevalent autoimmune Ordered List Osteophytes! DIPs, PIP, Thumb base Ordered List disease in the US OA Gullwing Erosions DIPs (Symmetric) OA Phytes EOA? Women > 50yo Phytes 7.5 million Americans (2% of population) EOA Uniform narrowing MCPs, Carpus, C1-2 EOA 125 million worldwide (2-3% of population)  RA? Marginal Erosions! Big Joints (Symmetric) RA RA Up to 30% develop psoriatic arthritis Sharp Erosions with Random 15% the arthritis precedes the skin disease Gout Gout? overhanging edges Favors Toes (1st) Gout CPPD Resembles OA Unusual distribution for OA CPPD CPPD? Chondrocalcinosis Favors Patella-Femoral PA  PA Pencil-in-Cup Hands, Feet, Spine WOW Psoriatic? Sausage Digit SI Joints (Asymmetric) WOW Plaque Psoriasis Guttate Psoriasis Inverse Psoriasis Pustular Psoriasis Erythrodermic www.schreibman.info www.schreibman.info psoriasis.org © 2015 Ken L Schreibman, PhD/MD 81 of 94 © 2015 Ken L Schreibman, PhD/MD 82 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Psoriatic Arthritis: 5 Types Psoriatic Arthritis: 5 Types Prevalence/Hx Left Hand Right Hand Prevalence/Hx Hand Symmetric PA view PA view Symmetric arthritis PA view Joint Anatomy  Like RA; milder, less deformity. Joint Anatomy  Like RA; milder, less deformity. Pencil-in-Cup Ordered List Asymmetric Ordered List Asymmetric arthritis OA OA erosion  “Sausage digit”. Usually mild.  “Sausage digit”. Usually mild. Phytes Phytes EOA 3 Clues to PA: EOA DIP (5%) 1) “Sausage” digit Sausage Digit RA RA  Like OA; nail changes. 2) “Pencil-in-cup” erosion Pencil 0Sausage digit is not Arthritis mutilans (5%) Gout 3) Unilateral SI-itis in a tasty meat product* Gout 0Finger or toe swells  Hands/feet. CPPD cup from tip to base CPPD PA erosion 0Shaped like a PA Spondylitis (5%) Arthritis  cocktail sausage  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 © 2015 Ken L Schreibman, PhD/MD 83 of 94 © 2015 Ken L Schreibman, PhD/MD 84 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach 4 Seronegative Spondyloarthropathies How Ordered List Helps Me Prevalence/Hx Abdomen Prevalence/Hx “Seronegative”: RF factor neg. AP view  Is this OA? Psoriatic Joint Anatomy “Spondylo”: Effects spine Crohn's Disease Joint Anatomy  No 1st MTP osteophytes Ordered List Resection Ordered List Arthritis! All 4 cause sacroiliitis terminal  Is this RA? OA ilium 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 Normal Indistinct   Is this CPPD? Sclerotic CPPD inflammatory bowel disease Ankylosis SIs CPPD  No chondrocalcinosis  PA Bilateral, symmetric  Bilateral PA Could this be PA? Unilateral Foot  fusion (ankylosis) Pelvis Oblique WOW  Symmetric WOW  Do we have SI images? AP view Sacroiliitis view www.schreibman.info M,P 32yoF www.schreibman.info S,E 36yoM © 2015 Ken L Schreibman, PhD/MD 85 of 94 © 2015 Ken L Schreibman, PhD/MD 86 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach What to Order When Radiographs: Disease Progression Prevalence/Hx Hand Prevalence/HxHand Hand Always start with PA view “r/o RA” PA view “r/o RA” PA view Joint Anatomy Joint Anatomy 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 Run eyes Further disease progression, PA Useful for following 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 © 2015 Ken L Schreibman, PhD/MD 87 of 94 © 2015 Ken L Schreibman, PhD/MD 88 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Advanced Imaging Studies Advanced Imaging Studies Prevalence/Hx Hand Coronal MR Hand Prevalence/Hx MRI with IV PA view T1 FatSat post IV contrast Dual-Energy CT Joint Anatomy Negative Joint Anatomy Ordered List contrast Enhancing Ordered List (coming soon…) Well shows (even in carpal bones Specific for uric OA retrospect) Developing erosions OA Phytes hypervascular Phytes acid crystals in EOA pannus EOA gout Normal synovium RA RA does not enhance Gout Useful for Gout CPPD diagnosing CPPD 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

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Advanced Imaging Studies Any Final Questions? Prevalence/Hx Subtalar joint injection Prevalence/Hx Fluoroscopic guided Lateral view Joint Anatomy joint injections Joint Anatomy Ordered List Useful to prove which Ordered List OA OA joint is symptomatic Phytes With steroids can yield Phytes EOA long-term relief EOA RA Can inject any joint: RA 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 © 2015 Ken L Schreibman, PhD/MD 91 of 94 © 2015 Ken L Schreibman, PhD/MD 92 of 94

Radiology of Joint Disease My Practical Approach Radiology of Joint Disease My Practical Approach Final Exam Thank you! Prevalence/Hx Foot Prevalence/Hx AP view Psoriatic  Is this OA? 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 © 2015 Ken L Schreibman, PhD/MD 93 of 94 © 2015 Ken L Schreibman, PhD/MD 94 of 94