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Hello and welcome to Noon Conference hosted by MRI Online

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to learn alongside top radiologists from around the world.

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of case-based micro-learning courses across all Key RAD

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Radiology subspecialties.

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Today we are honored to welcome Dr. Dennis Beki

0:39

for a lecture entitled Introduction to Arthritis Part Two.

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Dr. Beki is an academic diagnostic radiologist

0:46

with over 30 years of experience in bone

0:49

and joint radiology.

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He is a senior MSK specialist radiologist at King's College

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Hospital and senior lecturer in Imaging

0:57

sciences at King's College.

1:00

Dr. Beki is also a member of the Arthritis Subcommittee

1:03

of the European Skeletal Society, a member

1:06

of the Polish Medical Radiology Society, an honorary member

1:09

of the Ukrainian Association of Radiologists

1:12

and the editor in chief of Radiology Online Journal.

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He has published over 50 papers in educational exhibits

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and teaches radiology residents worldwide in the uk, Poland,

1:24

Ukraine, and Israel.

1:25

We're grateful to Dr. Beki for being here

1:28

to share his expertise with us.

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At the end of the lecture, please join Dr.

1:31

Beki in a q and a session

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where he will address questions you may

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have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

1:40

as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

1:45

Beki, please take it from here.

1:48

Thank you so much and good afternoon.

1:51

Welcome to part two of Introduction to Arthritis.

1:55

In today's lecture, we will discuss several different types

1:58

of arthritis, provide their target approach diagrams,

2:02

and show you multiple images.

2:04

We will follow the same pattern as we did in part one

2:08

and we will go over these in detail today.

2:11

We will cover juvenile, rheumatoid arthritis,

2:15

erosive osteoarthritis, septic arthritis, the

2:20

spondyloarthropathies, reactive arthritis,

2:23

psoriatic arthritis, diffuse idiopathic skeletal, hyperos,

2:27

ptosis, and finally, gout.

2:31

Juvenile rheumatoid arthritis is a polyarthritis seen in the

2:35

pediatric population with variable radiographic findings.

2:40

Clinically, the disease starts

2:41

before the age of 16 years of age.

2:44

It is usually located in the larger joints

2:47

and joint changes are distinct

2:49

from adult rheumatoid arthritis.

2:52

However, the distribution can be similar.

2:56

The radiographic findings include erosions

2:59

that are late manifestations, osteopenia,

3:03

bone edema, periosteal reaction

3:07

and growth disturbances, including epi overgrowth,

3:11

early growth, plate closure, muscle contractors and ankylos.

3:17

Changes in the cartilage with cartilage destruction

3:20

and erosions are late manifestations in this disease.

3:25

The distribution is noted in the diagram.

3:29

Changes are commonly seen in the wrist,

3:32

metacarpophalangeal joints of the fingers, but not the thumb

3:37

and the proximal interphalangeal joints

3:40

in the skeleton jile.

3:42

Rheumatoid arthritis can affect the cervical spine,

3:45

the shoulders, the elbow, the hip and the knee.

3:49

No manifestations are seen in the foot.

3:52

Extra findings include stills disease,

3:56

which is systemic juvenile idiopathic arthritis.

4:00

Systemic means it may affect not only the joints

4:03

but other parts of the body including the

4:05

liver, lungs, and heart.

4:09

This is sometimes referred to stills disease,

4:11

but can occur any time during childhood,

4:16

but it is most commonly starts at about two years of age.

4:21

Uveitis, tendinitis and bursitis with soft tissue swelling

4:25

and deformity are seen.

4:28

Juvenile rheumatoid arthritis is a diagnosis of exclusion

4:32

when inflammatory changes do not match other

4:36

inflammatory diseases.

4:41

Juvenile rheumatoid arthritis is also known

4:44

as juvenile idiopathic arthritis.

4:47

In this image of the hands, we can see typical ankylos

4:51

of the carpal bones

4:52

and marked perticular osteopenia.

4:58

In this patient with juvenile rheumatoid arthritis,

5:01

there are multiple erosions in the carpals

5:04

and in the base of the metacarpal bone.

5:07

Diffuse joint space narrowing is also noted throughout

5:13

Notice that the epi diseases are not closed indicating the

5:17

patient's young age.

5:20

Here we see two different patients

5:21

with juvenile rheumatoid arthritis.

5:24

In the image labeled A,

5:26

we see multiple erosions affecting the carpal bones

5:29

and the metacarpophalangeal joints.

5:33

Collapse of the scaphoid and lunate bone are noted

5:35

and perticular osteopenia is noted across the

5:39

metacarpal phalangeal joints.

5:42

In the image labeled B, we see an X-ray of an adult

5:46

with a history of juvenile rheumatoid arthritis.

5:50

The bones are for shortened and the bone length is abnormal

5:54

because of premature growth, plate closure

5:58

and al overgrowth.

6:01

We also see multiple examples of severe joint malalignment.

6:05

Perticular osteopenia is also noted in this patient.

6:11

Juvenile rheumatoid arthritis, as we mentioned,

6:14

can affect larger joints as well.

6:17

Here we see an image of the shoulder

6:19

demonstrating large erosions of the humerus, glenoid

6:23

and acromion in a patient

6:25

with juvenile idiopathic arthritis.

6:30

In this radiograph of a child's pelvis,

6:33

erosions in joint space narrowing

6:35

of the right hip joint are present.

6:38

No other findings are appreciated.

6:42

We will now move on to erosive osteoarthritis.

6:46

Erosive arthritis is a disorder

6:48

that most often involves the hands of postmenopausal women.

6:53

It can begin abruptly with pain, swelling, and tenderness.

6:58

Distal interphalangeal joints are involved most frequently

7:02

as we see in the diagram followed

7:04

by proximal interphalangeal joints.

7:08

Clinical findings include an inflammatory form

7:11

of osteoarthritis of the hands, which affect the DIP

7:16

and PIP joints

7:18

and the first carpal metacarpal joint of the hand

7:22

most frequently like osteoarthrosis.

7:26

The combination of osteophyte formation

7:29

and central erosions, which causes a characteristic

7:33

biconcave articular surface is called the gall wing

7:37

or seagull deformity.

7:39

It can also look like a pencil and cup deformity,

7:43

but this is less frequent.

7:46

The radiographic findings include joint space narrowing,

7:50

sclerosis of bone with productive bone changes

7:53

and osteophyte formation with possible ankylos.

7:59

The cartilage demonstrates subc chondral central erosion.

8:04

This type of arthritis has the same distribution

8:07

as osteoarthrosis with a preference

8:10

for the interphalangeal joint.

8:13

DIP more than PIP.

8:17

The extra findings is

8:19

that this disorder occurs primarily in older

8:22

pause menopausal women.

8:25

The soft tissues in this disorder demonstrate rheumatoid

8:28

arthritis like proliferative interarticular synovitis

8:33

and soft tissue swelling noted about the joint.

8:38

Here we have the AP radiographs of two different patients.

8:43

In patient A. We see erosive changes at the proximal

8:47

interphalangeal joints two through five

8:50

and at the distal interphalangeal joints three through five.

8:56

We see typical gall wing deformity in the dis in the distal

9:00

interphalangeal joints of digit three demonstrated

9:04

by the white arrow and ankylosing

9:07

of the proximal interphalangeal joints of the fourth finger

9:11

demonstrated by the yellow arrow

9:14

Ankylos occurs late in this disease.

9:18

Inpatient B joint space narrowing

9:21

with central erosions are noted gullwing deformities

9:25

of the proximal interphalangeal joint two through four

9:29

and distal interphalangeal joint two as well

9:32

as carpal metacarpal.

9:34

Degenerative changes noted at the base

9:37

of the thumb are present.

9:40

Additionally, ankylos

9:42

of the distal interphalangeal joint three is noted.

9:49

This image demonstrates a ball catcher's views

9:51

of the hands in a patient with erosive osteoarthritis.

9:57

Bilateral extensive damage is noted in the

9:59

interphalangeal joints.

10:01

Note the symmetrical distribution

10:04

and sparing of the metacarpal Phil a**l joint.

10:09

Here we see a typical galling appearance

10:11

of the distal interphalangeal joints,

10:14

which is classically seen in erosive osteoarthritis.

10:19

It has also been reported in psoriatic

10:22

and more rarely in rheumatoid arthritis

10:25

with post rheumatoid osteoarthrosis.

10:30

Now we move on to our next disorder, a disorder

10:33

that usually affects one joint at a time.

10:37

Septic arthritis. Septic arthritis

10:40

demonstrates rapid destruction of one joint

10:43

with extensive erosions, destructive bony changes

10:47

and joint effusion.

10:50

Clinically septic arthritis is usually an

10:53

acute monoarthritis.

10:55

It is secondary to bacteremia, local spread of infection

10:59

or a complication of surgery or infection.

11:03

It leads to rapid joint destruction

11:05

and requires prompt aspiration or drainage

11:09

and treatment with intravenous antibiotics.

11:13

Since septic arthritis only affects one joint at a time,

11:17

we don't have a target approach image for this disorder.

11:21

In the joint we see joint effusion with someti,

11:24

which sometimes contains gas thickened synovium

11:28

and erosion in the bones.

11:31

After a few days,

11:33

extra articular osteoporosis may be seen followed by erosion

11:37

and joint face narrowing.

11:40

This disease moves rapidly.

11:42

There may be adjacent bone marrow edema

11:45

that one can see on magnetic resonance imaging.

11:49

Late stage changes in the bones include

11:52

ankylosing ansing.

11:55

Cartilage destruction occurs late in the disease.

11:59

As I stated earlier, the distribution is monoarthritis.

12:04

It is most common in the knees in adults and knees

12:07

and hips in children most commonly infants up

12:12

to 12 months of age.

12:14

Additional findings include the constitutional findings

12:18

of fever and bacteria in the synovial joints.

12:23

Many times the the joint itself is red and hot.

12:28

However, many times we're not given this information In

12:32

the patient history.

12:34

The soft tissues demonstrate erythema, warmth and swelling.

12:39

Magnetic resonance imaging shows thickening

12:41

and enhancing synovium without synovial proliferation

12:46

and the presence of micro absences.

12:51

Here we see a severely destructive example

12:54

of septic arthritis.

12:56

This image could suggest the possibility

12:58

of an aggressive malignancy.

13:00

However, this patient presented

13:02

with marked soft tissue swelling, erythema,

13:05

and warmth of the tissues.

13:07

The patient reported that these changes

13:10

happened rapidly over seven days time.

13:14

Radiographically we see enormous soft tissue swelling

13:17

of the third finger with extensive erosions of the joint

13:22

and some bone fragments along

13:24

with a perme malignancy like appearance.

13:30

Here's a nice example of infectious arthritis

13:33

as a complication of a fingertip abscess.

13:37

Findings include soft tissue swelling, erosions

13:41

and joint space narrowing

13:42

of the distal interphalangeal joint.

13:45

The subc chondral sclerosis

13:47

and osteophyte formation are caused

13:49

by secondary osteoarthritis.

13:54

This is a radiographic of of the pelvis in a patient

13:58

with tuberculous arthritis of the left hip joint only.

14:02

Subtle joint space narrowing

14:04

with minimal subc chondral sclerosis

14:06

of the left hip are noted.

14:08

These radiographic findings are non-specific

14:12

and most likely would be the result of osteoarthritis

14:16

because of the patient's severe discomfort

14:19

and the lack of concrete findings.

14:21

MRI was performed.

14:25

The pelvic MRI seen in this image

14:27

of the same patient was surprising

14:29

because of the multiple large abscesses that we see

14:33

when abscess formation is this extensive

14:37

and the clinical findings are minimal.

14:39

Always think of tuberculous arthritis.

14:43

The organism was found in the joint aspiration

14:46

and the patient was started on the proper antibiotic course.

14:53

Spondyloarthritis comprises a group of inflammatory diseases

14:57

of the peripheral joints

14:58

and spine with various clinical manifestations.

15:03

These disorders have some key features in common

15:06

including joint inflammation,

15:09

especially the sacroiliac joints

15:12

emphasis especially of the lumbar spine.

15:16

The presence of HLA B 27 antigen and are

15:21

and are usually rheumatoid factor negative.

15:26

When I learned about these disorders,

15:28

we called them the seronegative spondyloarthropathies.

15:33

These disorders can further be divided into an axial

15:36

and peripheral type.

15:39

Ankylosing spondylitis is the most common axial type

15:43

and the prototypical type of spondyloarthritis.

15:47

The most common peripheral type are psoriatic arthritis,

15:51

reactive arthritis,

15:53

and enteropathic arthritis associated

15:56

with inflammatory bowel disease.

15:59

You should remember that inflammatory bowel diseases cause

16:03

sacro iliac joint inflammation as well

16:06

and use it in your differential.

16:10

Let's discuss about the bit,

16:12

a bit about the clinical features

16:14

for spondyloarthritis of the spine.

16:17

As you can see in the chart, many signs

16:19

and symptoms are associated with this disorder.

16:23

Inflammatory back pain that has an insidious onset

16:27

that improves with exercise

16:29

but not with rest, back pain at night,

16:34

morning back stiffness greater than

16:36

or equal to 30 minutes alternating gluteal pain,

16:42

arthritis, enthesis of the calcaneus, uveitis,

16:47

dactylitis, psoriasis, and Crohn's disease or colitis.

16:53

Spondyloarthritis demonstrates a good respond response

16:57

to non-steroidal anti-inflammatory agents.

17:01

There is a family history of the disease usually

17:05

and the presence of HLB 27 antigen

17:08

and an elevated CRP do occur regularly.

17:14

The classification criterion

17:15

for spondyloarthritis was developed by the assessment

17:19

of Spondyloarthritis International Society

17:23

and include greater than

17:25

or equal to three months of back pain with an age

17:29

of onset less than

17:31

or equal to 45 years along with

17:35

sacroiliac sacroiliitis on imaging plus greater than

17:40

or equal to one clinical feature that we just spoke about

17:44

above or HLA B 27 positive

17:49

and two other clinical features now

17:54

that we have done with the clinical formalities.

17:56

Let's talk about some diseases.

17:58

Ankylosing spondylitis is an axial arthropathy

18:02

that develops early changes at the vertebral body corners

18:06

referred to as shiny corners.

18:09

The presence of ddes bytes

18:11

and the presence of sacroiliitis occur in this disorder.

18:16

ZTEs are bony bridges that develop in the anterior fibers

18:20

of the annulus fibrosis of the intervertebral disc.

18:24

These bony bridges connect one vertebrae with its adjacent

18:29

vertebra above and below.

18:32

Remember that CDEs macrophytes are vertical.

18:35

They are not horizontal like osteophytes.

18:40

Clinically, these patients present

18:42

with significant back pain,

18:44

morning stiffness and disability.

18:47

The disease onset is in the third and fourth decades

18:51

and the prevalence is about 1%.

18:54

I've seen many, many examples of this disorder in my career.

19:00

Ankylosing spondylitis is the prototypical type

19:03

of sero negative axial spondyloarthropathy

19:07

that affects the spine and s sacroiliac joints primarily,

19:11

but can affect other joints like the shoulders, hips, rib

19:16

heels, and small joints of the hands and feet.

19:21

Radiographic findings include shiny sclerotic

19:25

vertebral body corners, straightening

19:28

of the anterior vertebral body contour

19:32

and the development of bamboo's bamboo spine

19:36

with sacroiliitis.

19:38

We will show you examples of all these in a moment.

19:43

Let's first talk about enthesitis.

19:46

Inflammation of the antitheses is one of the hallmarks

19:49

of spondyloarthropathy.

19:52

The earliest sign

19:53

of ankylosing spondylitis is edema at the antitheses,

19:58

which is only visible on MRI imaging

20:00

as we see demonstrated in image number

20:03

three by the white arrow.

20:07

In a later stage sclerosis of the corners

20:10

of the vertebral bodies will present,

20:12

which can be termed shiny corners

20:15

and be seen on conventional radiographs or ct.

20:20

Finally, syn deses are formed within the anterior fibers

20:24

of the annulus fibrosis connecting one vertebral body

20:28

to another in a vertical fashion.

20:32

Here we see three different patients with typical features

20:35

of early stage ankylosing spondylitis.

20:39

Image number one demonstrates a nice example

20:42

of shiny corners of the anterior corner

20:45

of the vertebral bodies where the emphasis is located.

20:49

Also, we seek clear squaring

20:52

of the anterior vertebral bodies rather than the con,

20:57

which is normally present in patient number two,

21:02

we clearly see diffuse squaring of the vertebral bodies

21:06

and sh and shiny corners on the sagittal CT slice.

21:12

Finally, in image number three, this patient has edema

21:16

of the antitheses of the vertebral bodies,

21:18

which is visible on the sagittal stir image

21:22

and indicated by the white arrow.

21:27

As the disease worsens CDEs macrophytes develop.

21:31

These images show CDEs macrophytes in the lumbar spine

21:35

and ossification of the paraspinal ligaments.

21:39

Ossification occurs in the fibers of the annulus fibrosis.

21:43

Therefore, it is vertical extending from the vertebral body

21:48

below to the vertebral body above.

21:51

As we see in these images,

21:54

this appearance is specific for ankylosing spondylitis.

21:59

Notice also in the AP view of the spine

22:02

that the sacroiliac joints are fused.

22:06

Because of these findings, the spine loses its flexibility

22:10

and can easily fracture even after minor trauma.

22:16

A PN lateral views

22:17

of the lumbar spine demonstrate the appearance

22:20

of classic bamboo spine.

22:22

In ankylosing spondylitis, we see fusion

22:26

of the lumbar spine with vertical CDEs, macrophytes

22:30

and ossification of the paraspinal ligaments.

22:34

This is indicated by the black arrow.

22:37

A rigid bamboo spine is prone to hyperextension fractures

22:42

even after minor trauma.

22:45

Always keep in mind the possibility

22:47

of occult fractures in patients with ankylosing spondylitis.

22:54

Here we have similar examples, but in the cervical spine, AP

22:58

and lateral views of the cervical spine demonstrates the

23:01

straightening of the cervical spine with complete fusion

23:05

by syndemic bytes noted anteriorly

23:08

and posteriorly at the vertebral body margin

23:12

and complete fusion across the APOE joint.

23:16

Notice that the vertebral body's anteriorly are also

23:20

straightened indicated by the black arrow.

23:26

Another common sign

23:27

that we see in ankylosing spondylitis is the dagger sign.

23:32

This is best seen on AP views of the lumbosacral spine

23:36

and is caused by fusion

23:37

of the spinous processes in the midline indicated

23:41

by the black arrow.

23:42

Again, notice the bilateral fusion

23:45

of the S sacroiliac joints in this patient.

23:50

Finally, we come to sacroiliitis,

23:53

which is an important hallmark of spondyloarthropathies.

23:57

Pathologically S sacroiliitis starts

24:00

with inflammation which is visible on MRI as perticular

24:05

edema with or without the presence of erosion.

24:09

These erosions can be visible on both MRI

24:12

and conventional radiography later in the disease.

24:17

Fatty metaplasia is noted on the MRI

24:20

alongside the sacroiliac joint.

24:22

As we see in the right image,

24:26

the X-ray demonstrates bilateral subc chondral sclerosis

24:30

and erosions of the S sacroiliac joint.

24:34

A P one weighted post contrast MRI

24:37

of the same patient shows an irregular contour

24:39

of the SI joint caused by inflammation in the

24:44

presence of erosions.

24:46

There is no enhancement in the subc chondral bone

24:49

and bone marrow edema.

24:51

No joint effusion is present on this study.

24:57

The differential diagnosis of sacroiliitis occurred.

25:00

It includes osteoarthritis, which is commonly

25:06

demonstrated by bilateral subc chondral sclerosis without

25:09

erosions of the S sacroiliac joint.

25:13

This is demonstrated clearly in image number one

25:16

and indicated by the black arrowhead.

25:19

In image number two, we see osteitis condensed San Ilei,

25:25

which presents as bilateral triangular shaped regions

25:29

of sclerosis adjacent to the sacro iliac joint.

25:35

Here we see later stages of sacroiliitis

25:38

with complete joint ankylos

25:40

and ligamentous ankylos of the bilateral

25:43

IAL lumbar ligaments.

25:46

Degenerative changes are noted at the bilateral hip joints

25:50

and at the synthesis pubis

25:55

ankylosing spondylitis can affect the

25:57

appendicular skeleton as well.

26:00

The hatchet sign is a circumscribed somewhat flat erosion

26:05

of the lateral dorsal aspect of the humeral head,

26:08

causing the humeral head to appear like a hatchet.

26:12

This deformity is typical for ankylosing spondylitis.

26:19

The hatchet sign differs from the deformity seen in

26:21

avascular necrosis

26:26

where there is progressive collapse of the articular surface

26:29

of the humeral head.

26:32

Here we see two different patients on the left

26:35

early in their disease

26:37

and then several months later in the follow-up images on the

26:40

right notice the flattening and

26:43

and complete destruction of the humeral head.

26:47

This is classic in osteo in VA vascular necrosis.

26:54

Psoriatic arthritis falls in this group as well.

26:58

The key findings that we see in psoriatic arthritis include

27:02

erosions and bone proliferations predominantly in a distal

27:07

distribution presenting most often

27:09

as a typical pathognomonic pattern,

27:12

but sometimes as a confusing subtype,

27:16

which we will talk about in a bit.

27:18

Clinically. Psoriatic arthritis is a peripheral type

27:22

of spondyloarthritis

27:24

and presents as a peripheral arthritis with

27:26

or without sacroiliitis and spondylitis.

27:31

It frequently is proceeded by pori, psoriasis of the skin,

27:36

but can occur without skin disease in up to 20% of patients.

27:41

It does not occur early in the disease

27:44

but rather much later, sometimes as late as 20 years

27:48

after initial diagnosis.

27:52

The hands are most frequently involved followed by the feet.

27:56

Other locations are the spine sacro, iliac joints

28:00

and less frequently the knee, elbow, ankle and shoulder.

28:06

Radiographically psoriatic arthritis

28:09

demonstrates small bony erosions at the bare

28:12

areas of the joint.

28:13

However, distal to these areas are small regions

28:18

of productive bone called whiskering.

28:22

They are not osteophytes.

28:25

This disease tends to be asymmetric.

28:29

The distribution of psoriatic arthritis is,

28:32

as we see in the diagram, the spine and s sacro.

28:35

Iliac joints can show axial psoriatic changes

28:40

in the hands and feet.

28:41

The distal joints are more commonly affected than the

28:45

proximal joints.

28:46

As we see in both images.

28:49

The tris gafi joint is commonly involved along

28:52

with the pisiform joint in the feet.

28:56

An osteopathy is prominent at the insertion

28:59

of the Achilles tendon.

29:01

Changes like that in the hand occur at all metatarsal phal

29:06

joints and distal interphalangeal joints.

29:12

There are five subtypes of psoriatic arthritis

29:16

because of these different patterns of the diagnosis

29:19

of psoriatic arthritis can sometimes be challenging

29:23

in the mall and right classification systems.

29:26

The subtype include distal inner financial arthritis

29:30

of the hands and feet, asymmetric mono

29:36

or oligo arthritis, meaning just a few random findings,

29:42

symmetric polyarthritis with a similar appearance

29:45

to rheumatoid final column involvement with spondylitis

29:49

and sacroiliitis and finally arthritis mutilate.

29:56

Here we see an example of sausage digits,

29:58

which are typical appearance of dactylitis

30:02

with soft tissue swelling and pencil and cup deformity.

30:06

In a patient with psoriatic arthritis, notice

30:09

that the metacarpophalangeal joints are not involved.

30:14

Remember, in rheumatoid arthritis,

30:15

they are usually involved.

30:19

Psoriatic arthritis can be progressive.

30:22

If we look at image number two, I'm sorry,

30:25

if we look at image number one,

30:27

we see marginal erosions indicated by the black arrow

30:31

and subtle bone proliferation indicated by the blue arrow

30:36

of the interphalangeal joint.

30:38

This is a classic appearance of psoriatic arthritis.

30:43

Later on in image two changes progress to typical pencil

30:48

and cup deformity.

30:50

The distribution

30:51

and bone formation makes the diagnosis

30:54

of rheumatoid arthritis unlikely

30:59

marginal erosions of in the absence

31:01

of distal interphalangeal joint involvement in other joints

31:05

makes the diagnosis

31:06

of erosive osteoarthritis unlikely as well.

31:10

Although pencil and cup changes can look like the gall wing

31:14

deformity in erosive arthritis.

31:19

Here we see another example of pencil and cup deformity.

31:23

In the image on the left, we see pencil

31:25

and cup deformity of the first

31:27

and fifth to in the image on the right

31:31

acro osteolysis is noted with resorption of the terminal TTS

31:35

of digits two through five

31:38

erosions are noted at the metatarsal phal joint

31:41

of the second and third

31:43

digit peros.

31:47

Titis is another possible finding in psoriatic arthritis

31:52

in the patient with psoriatic arthritis.

31:54

Notice the subtle peros titis of the distal phx

31:58

of the great toe indicated by the black arrowhead.

32:04

Additionally, there are small erosions of the tufts

32:06

of the digits two

32:08

and three on the left indicated by the white arrows.

32:15

I will now move on to discuss the characteristics

32:18

of reactive arthritis, which for many years was referred to

32:23

as writer syndrome

32:25

and previously was associated with OC infection

32:29

and with UR arthritis, arthritis and conjunctivitis.

32:34

It has been found recently

32:36

that this reactive arthritis is a sterile arthritis

32:40

following soon

32:41

after an infection in the body,

32:44

usually in the genital urinary tract

32:47

or enteric in origin, it is caused by a cross reaction

32:52

of an antigen reaction to bacteria as well

32:55

as synovial tissue.

32:58

Reactive arthritis is classified as a type

33:01

of S negative spondyloarthropathy.

33:05

The clinical presentation is usually transient following an

33:09

infection and involving one or two large joints.

33:14

The classic triad consists of arthritis, conjunctivitis

33:19

and UR arthritis and in women Citis.

33:24

To help you remember the classical triad,

33:27

there are two old mnemonics.

33:29

The first one is can't see, can't pee,

33:33

and can't climb a tree,

33:35

and the second one is can't see, can't pee sore knee.

33:42

Again, we have our distribution diagram

33:44

and as we can see clearly this is a disease of the foot,

33:48

particularly the kinley tendon insertion, the midfoot

33:52

and the great toe.

33:54

Additionally, it can affect the scro iliac joints, knee

33:57

and ankle findings in the hands are less likely.

34:03

Findings seen later in the disease include Ill-defined

34:06

erosions like psoriatic arthritis.

34:08

However, typically in reactive arthritis, the

34:12

calcaneus is involved.

34:15

Bony proliferation is also noted,

34:17

but also juxta articular osteoporosis

34:21

and enthesopathy may be seen.

34:24

The disorder demonstrates uniform joint space narrowing

34:28

with an asymmetric distribution.

34:31

As we see in the diagram, the extra findings are

34:36

that this disorder is usually triggered

34:39

by a preceding infection.

34:42

Swelling of the soft tissues occurs with the development

34:44

of most commonly sausage toes, so when you think of writer's

34:50

syndrome, think of the feet.

34:54

This patient suffers from an episode

34:56

of campo bacteria gastroenteritis.

35:00

After a few weeks, clinical symptoms of arthritis developed

35:05

in the image on the right, we see erosions at the base

35:08

of the third proximal phx

35:09

and at the head of the fifth proximal phx indicated

35:13

by the white arrow heads on the left,

35:16

there is an erosion at the base of the third proximal phx

35:20

and lytic changes of the head of the first proximal phx

35:24

demonstrated by the yellow arrowhead.

35:28

Based on these nonspecific imaging findings alone,

35:31

it is difficult to diagnose reactive arthritis, but

35:36

because the patient had an enteric infection previously,

35:39

it makes the diagnosis more likely.

35:44

Now we move on to one of my favorite diseases,

35:47

diffuse idiopathic skeletal hyperos ptosis.

35:51

This is a disease of the axial skeleton

35:54

that has some small peripheral findings.

35:58

In the past D few idiopathic skeletal hyper osis,

36:02

the dish syndrome was known as fors FDA's disease.

36:08

Resnick etal produced the diagnostic criterion,

36:11

which has become the definitive description

36:13

of this disorder.

36:16

Dish is characterized by bony proliferation at tenderness

36:21

and ligamentous insertions of the spine

36:23

and pelvis mostly affecting the elderly.

36:28

It is a painful disorder.

36:31

Diffuse idiopathic skeletal hypers doses presents

36:35

as continuous bulky ossification

36:39

along the anterior aspects of the thoracolumbar spine

36:45

with relative preservation of disc space.

36:49

Because this disorder occurs in the elderly,

36:52

there may be some disc space narrowing which has occurred

36:56

prior to the development of dish

36:58

because of the common finding of degenerative changes

37:02

that may be seen at the IVD in in in elderly patients.

37:09

The key finding in dish are bulky masses of bone

37:13

that develop anteriorly to the vertebral bodies

37:17

in the lumbar spine

37:18

and right laterally in the thoracic spine

37:22

because the pulsating aorta on the left

37:25

prohibits development, the definition that

37:30

that it must occur over four continuous levels

37:34

is an arbitrary number

37:36

because there were three fellows in training at the time

37:39

that Resnick defined the entity, and I know this

37:43

because I heard it from Don Resnick's own mouth

37:47

using our A-B-C-D-S mnemonic for the radiologic finding,

37:53

the articular component demonstrates no erosions.

37:57

The bones show calcification

37:59

or ossification of the anterior longitudinal ligament

38:03

and paraspinal connective tissues.

38:05

As we see in image one on the left,

38:10

these are lumpy and bumpy masses of bone.

38:14

Please note that they fill in the area anterior

38:17

to the vertebral body margin as well.

38:21

You can still see the concavity in the vertebral body,

38:24

but it is filled in by bony proliferation.

38:30

Enthesopathy or whiskering can be seen in the pelvis at the

38:34

iliac crest, ischial tuberosities and greater tro caners.

38:39

When we speak of the cartilage,

38:41

the disc space is typically preserved

38:44

unless there has been previous degenerative disc disease.

38:48

Then further degeneration is halted

38:51

as a protective mechanism.

38:54

Many thing the distribution is throughout the lower thoracic

38:58

spine and usually there is no involvement of the synovial

39:03

inferior part of the scro iliac joint.

39:06

Although ossification of the ligamentous part

39:09

of the scro iliac joint can occur,

39:13

the extra findings are that the spine is prone

39:15

to severe fracture

39:17

after minor trauma, not unlike ankylosing spondylitis.

39:23

The soft tissue component is

39:25

that there is increased susceptibility to fractures.

39:29

This should not be confused with the findings

39:33

of a bamboo spine, which is the hallmark

39:36

of ankylosing spondylitis.

39:39

This is clearly seen in the right image

39:42

labeled bamboo spine.

39:45

The syn dema bytes are vertical

39:47

and are in the outer fights of the annulus fibrosis

39:53

dish demonstrates bulky ossification

39:56

and calcification anterior

39:58

to the anterior longitudinal ligament

40:01

and the paraspinal spinal connective tissue over at least

40:06

four contiguous levels.

40:08

Again, typically the disc heights are preserved.

40:13

Other causes of ligamentous ossification in the spine are

40:18

severe osteoarthritis

40:20

and less likely vitamin A toxicity

40:24

and the rare disease fluorosis.

40:28

Here's the pelvis of another patient with dish enthesopathy

40:33

of the iliac crest is issue tuberosities

40:36

and greater trochanters is clearly visible.

40:39

The inferior aspect

40:41

of the S sacroiliac joint is normal in dish

40:45

ossification of the ligaments in the upper part

40:48

of the scro iliac joint is present and clearly visualized.

40:55

The cervical spine also can be affected by dish.

40:58

Typically bulky ossification

41:00

and calcification is seen anterior to the vertebral disc.

41:05

Mild atypical narrowing of the facet joints is noted,

41:09

but there is no sign of degenerative disc disease.

41:14

The sagittal CT

41:15

of the cervical spine on the left shows classic dish.

41:22

Here's a nice example

41:23

of the complications seen in ankylosing spondylitis

41:27

and sometimes rarely in dish.

41:30

The spine becomes rigid

41:32

and then it is prone to fracture even

41:34

after mild trivial trauma.

41:37

These fractures are most often hyperextension fractures.

41:42

The patient has minor trauma which

41:44

however resulted in an unstable hyperextension fracture

41:48

with neurologic complications.

41:54

I have finally come to the last disorder

41:56

that we will discuss today.

41:58

Gout is a relatively common disorder

42:01

with very specific findings

42:03

and is seen in patients who have diabetes

42:06

and who have kidney disease.

42:09

Gout is an inflammatory arthropathy caused by the deposition

42:13

of sodium ate crystals in

42:15

and about joints in the peripheral soft tissues and tendons.

42:21

The first metatarsal choal joint is the most

42:24

common often affected.

42:26

Classically, the diagnosis is made clinically by the level

42:30

of urate in the blood

42:32

and is secondarily supported by joint aspiration

42:36

or radiographic findings.

42:40

The articular changes in gout present

42:42

as punched out erosions greater than five millimeters in

42:46

size with an overhanging edge of new bone.

42:52

Demineralization is normal in this disease.

42:56

It does not occur.

42:58

Chondrocalcinosis or osteonecrosis can

43:01

however occur a joint effusion, which is the earliest sign

43:06

and preservation of the joint space may be present.

43:11

The distribution, again is like in the diagram.

43:13

The red circles indicate the common locations

43:17

and the yellow circles.

43:19

Those locations that are less frequently affected.

43:23

The extra findings are

43:25

that gout is more most commonly a disease of men

43:29

and demonstrates hyperuricemia.

43:33

The soft tissue findings include tophi,

43:35

which are eccentric nodular soft tissue swelling due

43:39

to crystal deposition about the joint.

43:43

Many times these are hyperdense on radiography

43:45

because of the presence of urate crystals also

43:50

and prepro bursitis may occur.

43:56

Here we see radiographs which demonstrate findings

43:58

of gout characteristic.

44:01

Radiographic changes in chronic gout typically demonstrate

44:05

well-defined punched out eccentric erosions

44:09

with sclerotic margins in a marginal

44:12

and extra articular distribution.

44:16

These erosions have the characteristic overhanging edges

44:20

and can be referred to as right ba rat bite erosions

44:25

and important characteristic

44:27

of this disorder is there is preservation of joint basis.

44:33

Hyperdense perticular soft tissue swelling

44:36

because of the presence of underlying tophi are noted

44:39

and are pathognomonic for this disease.

44:43

These tophi are seen in ligamentous structures

44:46

around the joints.

44:50

Another patient in which we see typical involvement

44:53

of the first metatarsal phal joint

44:56

with punched out erosions.

44:59

The soft tissue swelling represents a tophus.

45:03

The dislocation is not a common finding in gout,

45:07

but in this case the result of the erosions

45:10

and ligamentous injury.

45:15

As we have said, soft tissue density is common in gout.

45:19

Here we see typical dense soft tissue swelling surrounding

45:22

the first metatarsal phal joints in a

45:25

bilateral distribution.

45:27

This is indicated by the black arrow.

45:29

We also see the extra articular erosions at a medial side

45:34

of the distal metatarsal joint which have sclerotic margins.

45:39

They're most commonly

45:41

and notably seen on the right side

45:45

as a technique that comes into use for the diagnosis

45:48

of gout is called dual energy ct.

45:52

Here we see the same patient

45:54

with gout showing the urate crystal deposition

45:58

in the three DD reconstruction.

46:01

The crystal depositions are color coded green

46:04

and can be seen surrounding the metatars phalangeal joints

46:08

and at the insertion of the right achilles tendon indicated

46:12

by the yellow arrow.

46:14

The green pixels in the nail bed of the digits.

46:17

One in five on the left are artifacts caused

46:20

by keratin in the thickened nails.

46:25

Dual energy CT is a non-invasive method

46:27

of urate crystal detection

46:29

that can make joint aspiration unnecessary.

46:33

This technique simultaneously scans the subject at two

46:37

different energy levels

46:39

because ate crystal show different attenuation At these

46:43

energy levels, the crystals are easily identified

46:46

with high accuracy.

46:50

Here we have another case with typical gouty tophi

46:54

and juxta articular erosion seen on the plane radiograph.

46:59

The dual energy CT image on the right shows gouty

47:02

attenuation in the first metatarsal phal joint

47:06

and second metatarsal phal joint as well

47:10

as interphalangeal joints of the third digit.

47:13

Dual energy CT is useful

47:16

for the diagnosis when findings are not typical.

47:20

It is also useful to show the extent of disease

47:25

in this case a bone tumor was suspected there.

47:29

There are some findings that could support the diagnosis

47:32

of an osteosarcoma or chondro sarcoma,

47:35

however, this was proven to be gout by dual energy ct.

47:39

As we will see here,

47:42

we see the corresponding dual energy ct,

47:44

three dimensional reconstruction images

47:47

of the previous case.

47:49

The large mass about the right first metatarsal phal joint

47:53

of the great toe is gouty in nature.

47:59

Classic radiographic finding in gout are punched out lesions

48:02

with overhanging edges as seen here indicated by the arrow.

48:08

The borders of the erosions in gout may be sclerotic

48:12

because of the slow progression of the disease.

48:17

This is the final case for today. It is somewhat difficult.

48:21

We see small bilateral erosions

48:24

of the proximal interphalangeal joints on both

48:28

sides of the joints.

48:29

The arrowheads demonstrate these erosions.

48:33

These erosions are more ju articular than is

48:37

usually seen in gout.

48:38

However, this is a proven case of gout

48:42

based on the distribution.

48:44

Rheumatoid arthritis

48:45

and psoriatic arthritis would have been an option as well.

48:49

However, then the erosions would have been more marginally

48:53

located in the bare areas of the joint

48:56

not covered in cartilage.

49:00

Additionally, the metacarpophalangeal joints are spared

49:03

making the dis diagnosis

49:05

of rheumatoid arthritis less likely.

49:10

What I have tried to do in this talk is to share

49:12

with you the radiographic findings of various arth disease.

49:16

I hope you found this helpful and insightful In part three.

49:20

We will discuss CPBD, crystal deposition disease,

49:24

scleroderma, systemic lupus, erythema ptosis,

49:29

sarcoid, neuropathic arthropathy, hemophilia

49:34

C-M-O-C-R-M-O, and Safo syndrome.

49:41

Thank you so much. Thank You for your time.

49:44

Thank you so much Dr. Bki.

49:46

At this time we will open the floor

49:47

for any questions from our audience.

49:49

You may submit your questions through the q

49:51

and a feature in Zoom

49:57

and we'll wait just a few moments to see if those pop in.

50:00

Dr. Bki, are you able to see the q and a box?

50:03

No, I can't. I'm, let me see if I drop this one box.

50:06

If I wait a minute. I think I can hang on.

50:13

Participants chat

50:17

And then there's an icon about two away from

50:19

those that say q and a.

50:26

Uh, mine says chat share.

50:28

Mine says audio video participants. Oh, participant one.

50:32

Okay, 1 32, chat, share, pause, annotate,

50:36

remote control and more probably and more q and a.

50:40

There it is.

50:49

Let's see. What are the differential characteristics

50:53

between erosive arthritis

50:55

and psoriatic arthritis in a hand radiograph?

50:59

Well, the most important differential is that

51:03

erosive arthritis tends

51:04

to affect more than one digit at a time.

51:07

Psoriatic arthritis can have a ray distribution in

51:11

that it affects one finger on one hand

51:15

and three fingers on another.

51:17

It's very, very, uh, as it can be very, very asymmetric.

51:22

Another thing about psoriatic,

51:26

remember there are erosions, but the erosions move slowly.

51:31

Therefore, the body has the time

51:34

to build up bony whiskering

51:37

and bony production behind the erosion,

51:41

so you wanna see this pattern of an erosion

51:44

with a bony mound behind it or whiskers of bone behind it.

51:50

That's your way of knowing

51:51

that you're looking at psoriatic arthritis.

51:56

Okay. I hope that answers that one.

51:58

Thank you for your nice talk.

51:59

What are the challenges we need to deal with when we use MRI

52:02

for arthritis patients?

52:04

Are there types of arthritis that are hard to diagnose

52:07

by conventional MRI methods?

52:11

Arthritis is a bony disease. It's a disease of bones.

52:16

MR is a good imaging, uh, modality for soft tissues,

52:20

for ligaments, for muscles, for cartilage,

52:24

but not necessarily for bone.

52:27

Therefore, plain film remains the gold standard

52:31

for diagnosing the arth in these cases.

52:36

Do you recommend ultrasound to look at early erosions along

52:39

with x-ray imaging?

52:41

I am not, uh, uh, I don't know ultrasound,

52:46

peripheral ultrasound reg, uh, rare like,

52:49

excuse me, I don't know.

52:50

Ultrasound of the musculoskeletal system.

52:54

I was trained in the United States,

52:56

and even though I work in the United Kingdom, I'm American,

52:59

so, uh, and I have never learned that technique.

53:03

Basically, I use plain films

53:06

to diagnose the arthritic using the methods

53:09

that I described in lectures one

53:13

and two, they look like there's more here.

53:15

I just have to pull the thing down.

53:19

Can you show some MRI cases of gout? No, I can't.

53:22

This is a, a lecture on plane radio radiography, not mr.

53:28

Sometimes increased soft tissue density seen in bunion along

53:32

with the medial head of the first

53:34

how degeneration from gouty tophi.

53:39

Most cases you will have hyperuricemia.

53:44

The clinician will know that the patient has gout

53:48

because they take blood work and there is hyperuricemia.

53:53

Without hyperuricemia, gouty tophi will not develop.

53:58

So therefore I understand what you're talking about.

54:02

Sometimes the bunion may look that way,

54:05

but uh, you have to have the, the,

54:09

the blood work

54:10

and you have to have the hyperuricemia present.

54:15

I hope that answered your questions as well as I could.

54:19

That was a great job. Dr.

54:21

Bki, thank you so much for taking that time

54:23

to answer questions and share your lecture with us today.

54:26

Uh, so you can access the recording of today's conference

54:29

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54:31

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54:34

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54:37

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54:39

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54:42

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54:46

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54:47

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54:49

Thanks again and have a great day.