Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal Neuroradiology Pediatrics More

Arthritis
Laurens van Baardewijk, Frank Looijmans, Frank Smithuis and Matthieu
Rutten
Máxima MC, Cooperative Lumirad U.A., Amsterdam University Medical Center, Jeroen Bosch Hospital and
Radboud University Medical Center in The Netherlands
Systematic Approach
ABCDE-S Publicationdate 2023-01-15
Articular - erosions
Bone - formation In this article we provide an overview of the dif-
Bone - density ferent imaging Rndings of common joint dis-
Cartilage eases as a useful tool in daily musculoskeletal
Distribution radiology.
Extra Rndings
Arthritis is a challenging topic. A long list of di-
Soft tissue
agnoses has to be considered when looking at X
Osteoarthritis
rays of the hand and feet, each with its own ex-
Rheumatoid Arthritis
tensive set of Rndings.
Atlanto-axial subluxation
Sometimes the abnormalities are pathogno-
Basilar invagination
monic for a speciRc disease, but more often the
Juvenile Rheumatoid Arthritis
Rndings are non-speciRc because there is a lot
Erosive osteoarthritis
of overlap between diTerent joint diseases.
Septic arthritis
Spondyloarthritis - SpA
When you start looking at arthritis cases, re-
Ankylosing Spondylitis
member the following:
Sacro-iliitis
If it is the Rrst examination, then try to
Psoriatic arthritis
make a diTerential diagnosis based on
Reactive arthritis
imaging Rndings as well as patient
DiEuse Idiopathic Skeletal Hyperostosis
information and lab Rndings.
Gout
Master yourself in diagnosing
CPPD
osteoarthritis and rheumatoid arthritis
Scleroderma
and remember the distinct features
Systemic lupus erythematosus
between these two entities.
Avascular necrosis
If it is not typical osteoarthritis or
Sarcoid
rheumatoid arthritis, then use the
Amyloidosis
systematic approach in the Rrst
Neuropathic arthropathy
paragraph.
Hemophilic arthropathy
If it is a follow up case, then check disease
CRMO - chronic recurrent multifocal
progression and look for new erosions.
osteomyelitis
Remember that secondary osteoarthritis
SAPHO syndrome
can develop. Secondary osteoarthritis can
ABCDE-S overview
also be a sign of lowgrade progression of
the original disease.

You can click on all images for an enlarged view.

Systematic Approach
 JointSpaceNarrowing
This ^ow chart shows the approach to the radi-
asymmetric symmetric ographic evaluation of arthritis. In the presence
osteophytes erosions
sclerosis soft-tissueswelling of joint space narrowing, it is important to dif-
ferentiate degenerative from inJammatory
conditions.
Degenerative Inflammatory

Degenerative joint disease

Typical Atypical >1joint 1jointThis is characterized by osteophytes and sub-
Osteoarthritis Osteoarthritis
chondral sclerosis with an asymmetric distribu-
Unusualdistribution Proximal Distal
severity,age Nobony +bony tion both when you compare left and right as
Infection
proliferation proliferation
→ well as within the joint itself. Usually it is typical
Trauma
osteoarthritis.
Typical Crystal-deposition Rheumatoid Seronegative When Rndings are atypical (unusual combina-
Osteoarthritis Neuropathic Arthritis Spondyloarthritis
Hemophilia tion of age, aTected joint and severity) think of
posttraumatic, CPPD, neuropathic or rare dis-
AxialSpA PeripheralSpAeases like hemophilic arthritis.
→
ModiRed from Jacobson, et al. Radiology 2008 (2)
Psoriaticarthritis
Ankylosing InJammatory
Reactivearthritis joint disease
Spondylitis
IBD-associated
This is characterized by bone erosions, os-
teopenia, soft-tissue swelling and uniform, sym-
metric joint space loss.
In^ammation of a single joint should raise con-
cern for infection.
Multiple symmetric joint in^ammation in a
proximal distribution in the hands or feet with-
out bone proliferation suggests rheumatoid
arthritis.
When the in^ammation is more in a distal dis-
tribution in the hands or feet with bone prolif-
eration it suggests a seronegative spondy-
loarthropathy (SpA).
SpA is a group of chronic in^ammatory dis-
eases associated with HLA-B27 (2).
Axial SpA - most commonly ankylosing
spondylitis - is located more in the axial skele-
ton.
Peripheral SpA - like psoriatic, reactive and IBD-
associated arthritis - is located more in the pe-
ripheral skeleton.
ABCDE-S

Joint diseases have variable manifestations with

an overlap of radiological features.
The ABCDE-S mnemonic is a helpful tool for a
systematic and complete radiological interpre-
tation and reporting.

We use the ABCDE-S, which stands for Articular,

Bone, Cartilage, Distribution, Extra's and Soft
tissue.
There are variants of this mnemonic. Some use
ABCDE for Alignment, Bone, Cartilage, Distrib-
ution and ETusion.

Articular - erosions

Marginal erosions
They occur at the bare area of the joint, where
the bone is not covered by articular cartilage.
They are typically seen in rheumatoid arthritis
(MCP-joints) and psoriatic arthritis (DIP).

Subchondral erosions
They occur at the subchondral bone plate of
the articular surfaces. They are a typical feature
of erosive osteoarthritis.

Gullwing deformity
In erosive osteoarthritis the combination of
central erosions and osteophytes results in a
gullwing deformity.

Pencil-in-cup deformity
In psoriatic arthritis the combination of mar-
ginal erosions and bone proliferation can result
in a pencil-in-cup deformity.

Peri- or juxtaarticular erosions.

Gout erosions are a bit more eccentric juxta-ar-
ticular located, where the joint capsule attaches
to the bone. They are most often seen in the
MTP1-joint.
 Typical examples of speciNc erosion pat-
terns

1. Rheumatoid arthritis.
Typical marginal erosions in MCP-joints.
2. Erosive osteoarthritis.
个 Subchondral erosions in DIP- and PIP-
joints. The concurrent formation of
1.RAmarginal 2.ErosiveOA 3.Gout
osteophytes results in a gull-wing
deformity.
3. Gout.
Eccentric erosion with an overhanging
edge. The sclerotic margin in this case
indicates chronic and indolent disease.
4. Infection.
Destructive changes with cartilage loss
and erosions.
4.Septicarthritis 5.Psoriatic 6.Sclerodermia 5. Psoriatic arthritis.
Bony erosions narrowed the end of the
proximal phalange as a “pencil”, which
rests in the “cup” formed by the expanded
base of the distal phalanx as a result of
bony proliferations.
6. Scleroderma.
And other multisystem disorders can
produce erosions at the distal tufts, this is
called acro-osteolysis.

Alignment

Some use the A of ABCDE-S for Alignment.

The problem however is that misalignment or
malalignment can be seen in all end-stage joint
diseases, whether it is degenerative or in^am-
matory.
Bone - formation

Bone formation or proliferation is seen in many

joint diseases and especially in osteoarthritis,
DISH and spondyloarthritis like ankylosing
spondylitis and psoriatic arthritis.
It is NOT present in the active phase of
rheumatoid arthritis.

Images
1. Osteophytes in osteoarthritis.
Bony proliferations, that develop at the
margins of a synovial joint secondary to
articular cartilage damage in
osteoarthritis.
2. Osteophytes in a patient with CPPD.
Notice the soft tissue calciRcations (circle).
3. Bony proliferations in Psoriatic arthritis.
Sometimes described as ^uTy periostitis
(arrowheads).
4. Spondylophytes
Osteophytes in the spine in spondylosis /
degenerative disease. Typical orientation
is horizontal / perpendicular to the
spine.
5. Syndesmophytes
Paravertebral ossiRcations in the
ligaments of the spine. Typical orientation
is vertical / parallel to the spine. This is
the hallmark of ankylosing spondylitis.
6. DISH
OssiRcation in the anterior longitudinal
ligament. These ossiRcations are more
bulky compared to ossiRcations in
ankylosing spondylitis.
 Bone - density

Bone density changes either present as os-

teopenia or as osteosclerosis.
Periarticular osteopenia (Rgure) is typically seen
in rheumatoid arthritis and not in osteoarthri-
tis. Peri-articular demineralization develops as a
result of the hyperemia of the in^amed synovi-
um and soft tissues.
Two examples of periarticular osteopenia in rheumatoid Subchondral sclerosis is typically seen in os-
arthritis. Click on image to enlarge.
teoarthritis. Also in patients with neuropathic
arthritis.

Images
Here two examples of periarticular osteopenia
in patients with rheumatoid arthritis.
The osteopenia can be very subtle.
It may help to play with the window width set-
tings (detail views in the center) or to look
through your eyelashes to see the osteopenia.

Cartilage

Degenerative diseases aTect the cartilage non-

uniformly or asymmetrically, since this is the
result of mechanical load, which is not evenly
distributed throughout the joint.

In^ammatory diseases aTect the cartilage uni-

formly, since the synovitis is present in the en-
tire joint.

1. Typical osteoarthritis with cartilage loss on

the medial side, subchondral sclerosis and
osteophytes.
2. There is uniform cartilage loss.
There are no osteophytes.
In such a case your Rrst thought should be
in^ammatory joint disease.

Click on image to enlarge.

Distribution

Understanding distribution patterns is a very

powerful tool, since most common
diseases (osteoarthritis, rheumatoid and psori-
atic arthritis) have distinctive patterns.
In the following chapters on the various joint
diseases, we will start each chapter with an il-
lustration of the distribution.

Distribution in the hands

Osteoarthritis is located in CMC1-, STT-
and DIP-joints.
Rheumatoid arthritis is located mainly in
the carpus and MCP- (and PIP-) joints.
Also, the processus styloideus ulna is an
often aTected area.
Psoriatic arthritis is located more distally
in PIP and DIP joints. In the wrist the STT
and triquetrohamate joints are common
locations aswell.

Extra Nndings

Serological tests can help when rheumatic dis-

eases are suspected.

A positive rheumatoid factor (RF) or anti-citrulli-

nated peptide (CCP) antibody test can support
the diagnosis when rheumatoid arthritis is sus-
pected.
A positive HLA-B27 test can aid establishing a
diagnosis of ankylosing spondylitis (AS).
NonspeciRc in^ammatory markers, including
the erythrocyte sedimentation rate (ESR) and
the C-reactive protein (CRP), are often elevated
in any in^ammatory disease.

However, immunologic tests are not always

helpful, since they have limited speciRcity.
Soft tissue

Soft tissue swelling and calciRcations are fre-

quently seen in arthritis and can help to narrow
the diTerential diagnosis.

1. Chondrocalcinosis is a descriptive term for

Rne calciRcations within a joint. Although
not very speciRc, CPPD is very likely when
chondrocalcinosis is located around the
TFCC, radiocarpal joint or within the knee
joint.
CPPD can cause SL dissociation (left
arrow).
2. Chondrocalcinosis in the knee joint.
3. Mild radiopaque nodular soft tissue
swelling next to the MTP1 joint is almost
pathognomonic for gout. Other typical
locations are tendon insertions around
the knee, for example the popliteus
tendon, or ^exor tendons in the ankle
joint.
4. Fusiform periarticular soft tissue swelling
is a common Rnding in psoriatic arthritis
and may involve the entire digit resulting
in dactylitis or a "sausage-digit". Notice the
pencil-in-cup deformity of the joint.
5. Coarse calciRcations in the subcutaneous
tissue surrounding distal ends of Rngers
or toes are very likely caused by
scleroderma.
6. Scleroderma
7. Heberden noduli, due to osteophytes in
osteoarthritis
8. Rheuma noduli. These soft tissue nodules
are too big for Heberden noduli and there
are no osteophytes.
9. Chondrocalcinosis in CPPD. Again, SL
dissociation is seen, with severe
secondary degeneration. This severe
degeneration is called a SLAC wrist, which
stands for Scaphoid Lunate Advanced
Collapse.

Osteoarthritis
Key Nndings
Non-uniform joint space narrowing with osteo-
phytes, most often in weight-bearing joints. No
erosions.

Clinical
Most common joint disease, incidence
increases with age.
Characterized by non-in^ammatory
destruction of cartilage.
Primary idiopathic and secondary form
(e.g., trauma, obesity)

Radiological Rndings
Articular: no erosions
Bone: no osteopenia. Productive changes
like osteophyte formation and
subchondral sclerosis.
Cartilage: non-uniform joint space
narrowing. Subchondral cyst formation
(geode).
Distribution: see illustration
Extra Rndings: subluxations associated
with hallux valgus or hallux rigidus
Soft tissue: Heberden‘s nodes in DIP-joints
or Bouchard’s node in PIP-joints.

Teaching point: Many arthropathies show sec-

ondary osteoarthritis in a later stage.

In the knee, osteoarthritis is classiRed by the

Kellgren and Lawrence classiRcation.
This classiRcation can be used when grading
degeneration in other joints, but it is primarily
designed for the knee.
A
Joint space narrowing of the 4th DIP joint (ar-
row) with osteophyte formation and subchon-
dral sclerosis.

B
Asymmetric joint space narrowing of the 2-5th
DIP joint with osteophyte formation, subchon-
dral sclerosis and slight ulnar deviation of the
3th DIP joint (arrow).
The PIP joints are also aTected, but less severe.

C
Slight narrowing of the cranial joint space of the
hip joint at the right side with osteophyte for-
mation and subchondral sclerosis (Kellgren-
Lawrence classiRcation grade 3).

D
Severe narrowing of the glenohumeral joint
space with osteophyte formation and subchon-
dral sclerosis (Kellgren-Lawrence classiRcation
grade 4).

E
Hip osteoarthritis
Severe non-uniform narrowing of the hip joint
with osteophyte formation, subchondral sclero-
sis and large cyst formation.
In these later stages, joint deformity with
broadening and deformation of the femoral
head can occur.

F
Knee osteoarthritis
Moderate to severe asymmetric narrowing of
the medial compartment of the femorotibial
joint space with osteophyte formation and sub-
chondral sclerosis (Kellgren-Lawrence classiRca-
tion grade 3-4).
G
CMC1 osteoarthritis
Non uniform joint space narrowing of the CMC
1 joint with osteophyte formation and subchon-
dral sclerosis.
There is a large subchonderal cyst in the base
of the Rrst metacarpal (white arrow).

H
STT osteoarthritis
Non uniform joint space narrowing of the
scaphotrapeziotrapezoid (STT) joint with osteo-
phyte formation and subchondral sclerosis.

This is a diTcult case.

Dominant Rnding is non-uniform joint space

narrowing in CMC and DIP joints. So this patient
has osteoarthritis. The severity of Rndings may
suggest erosive osteoarthritis.

However, there is also joint space narrowing of

the MCP joints and a possible erosion in the lu-
nate bone. Without abnormalities in the PIP
joints it is very unlikely that these abnormalities
are all due to osteoarthritis.

Most likely this patient has both rheumatoid

arthritis and osteoarthritis.

Rheumatoid Arthritis
Key Nndings
Symmetrical uniform cartilage damage with
marginal erosions predominantly in MCP-joints
and the carpus, not in DIP-joints. No bone pro-
liferation.

Clinical
Usually starts to develop between the
ages of 40 and 50.
RF and anti-CCP are most often positive.
Begins in the appendicular skeleton in a
symmetrical pattern.

Radiological Rndings
Articular: erosions, typically at the
marginal area i.e. bone not covered with
cartilage, deformities
Bone: periarticular osteopenia. No bone
production or proliferation in the active
phase.
Cartilage: uniform cartilage destruction.
Distribution: see illustration, symmetric
peripheral distribution.
Extra Rndings: autoimmune in^ammatory
disease that aTects many organs, such as
the lungs, skin, eyes or the heart.
Soft tissue: fusiform swelling, nodes,
deformity

Typical marginal erosions and joint space nar-

rowing of MCP 3-5.
Also note the uniform joint space narrowing of
the MCP joints.
The PIP-joints only show minimal joint space
narrowing.
 This is a case with end stage rheumatoid arthri-
tis with severe erosive changes and ligamen-
tous ruptures causing dislocation of the MCP
joints.

Scapholunate dissociation (white arrow) is a

common Rnding due to diTuse carpal in^am-
mation. Both the dissociation and in^ammation
can cause joint space narrowing in the radio-
carpal joint.

End stage Rheumatoid arthritis. Notice also the erosion in the distal ulna with
surrounding soft tissue swelling (blue arrow).

In this case of rheumatoid arthritis there are

marginal erosions adjacent to almost all MTP
joints (arrowheads).
The 5th MTP joint is most frequently involved in
rheumatoid arthritis.
When erosions are as severe as in this case, it
can look like pencil-in-cup deformity (white ar-
row) as is frequently seen in psoriatic arthritis.
However, the primarily aTected MTP joints dis-
tribution and less aTected interphalangeal
joints is the clue that this is a case of rheuma-
toid arthritis.

Rheumatoid arthritis in the feet

Rheumatoid nodules

Rheumatoid nodules are Rrm lumps that ap-

pear subcutaneously in up to 20% of patients
with rheumatoid arthritis.
These nodules usually occur adjacent to over-
exposed joints that are subject to trauma or
pressure, such as the Rngers joints and elbows.
Rheumatic nodule at the elbow
In this variant of rheumatoid arthritis, there are
often no joint abnormalities.

Images
Soft tissue mass (i.e., rheumatoid nodules) in
the subcutis at the dorsolateral side of the ole-
cranon.
 Atlanto-axial subluxation

The cervical spine is often aTected in rheuma-

toid arthritis and can present as atlantoaxial
instability, subaxial subluxation or basilar in-
vagination with cranial settling.
Cranial settling occurs when the dens extends
into the foramen magnum.

Atlanto-axial subluxation is an important and

potentially life threatening complication of
rheumatoid arthritis. It is deRned when the
Atlanto-axial subluxation due to rheumatoid arthritis of the space between the dens of C2 and the arch of
cervical spine the atlas exceeds more than 3 mm. It is caused
by in^ammatory ligamentous laxity.

Instability in this joint may result in numerous

neurological symptoms due to compression of
the spinal cord.

Images
In ^exion of the cervical spine there is widening
of the distance (14 mm) between the dens and
the posterior surface of the anterior atlas ring
(normal ≤3 mm).

Basilar invagination
Enable Scroll
Basilar invagination also called cranial settling
or basilar impression occurs in 5-10% of pa-
tients with cervical rheumatoid arthritis.

In basilar invagination the odontoid is prolaps-

ing into the foramen magnum limiting the
space for the spinal cord.

Clinical presentations range from chronic

headaches, limited neck motion to acute neuro-
logic deterioration (spinal cord and brain stem
compression, which can lead to paralysis or
even death if the neck is moved in certain posi-
tions).

Images
Scroll through the CT-images.
There is upward migration of the odontoid
process into the occipital foramen.
Juvenile Rheumatoid Arthritis

Key Nndings
Polyarthritis in the pediatric population with
variable manifestations and radiographic Rnd-
ings.

Clinical
It starts before the age of 16 years.
Usually located in the larger joints.
Joint changes are distinct from adult RA, howev-
er the distribution can be similar.

Radiological Rndings
Articular: erosions are late manifestations
Bone: osteopenia, bone oedema,
periosteal reaction. growth disturbances:
epiphyseal overgrowth, early growth plate
closure, contractions and ankylosis
Cartilage: cartilage destruction and
erosions are late manifestations
Distribution: see illustration
Extra Rndings: stills, uveitis, tendinitis,
bursitis.
Soft tissue: swelling, deformity

Juvenile rheumatoid arthritis is a diagnosis of

exclusion, when in^ammatory changes do not
match other in^ammatory diseases.

Juvenile rheumatoid arthritis is also called juve-

nile idiopathic arthritis.

Image
Typical ankylosis of the carpal bones.
Periarticular osteopenia
 In this patient with juvenile rheumatoid arthritis
there are multiple erosions in the carpus and in
the base of the metacarpal bones.
DiTuse joint space narrowing is present.

Continue with the MR of this patient.

MR-Rndings:
Enable Scroll
DiTuse eTusion in all wrist joints.
DiTuse bone marrow edema in all carpal
bones.
Erosions, for example in scaphoid, capitate and
hamate.
Destruction of joint space and cartilage, most
striking in STT and CMC4/5.

Two patients with juvenile rheumatoid arthritis

A. Multiple erosions aTecting the carpal bones

and MCP joints. Collapse of the scaphoid and
lunate bone.

B. Adult with a history of juvenile arthritis. Ab-

normal bone length due to premature growth
plate closure and epiphyseal overgrowth. Se-
vere joint malalignment.

Juvenile arthritis Both cases show periarticular osteopenia.

Large erosions of the humerus, glenoid and
acromion in a patient with juvenile idiopatic
arthritis.

Erosions and joint space narrowing of the right

hip joint in a patient with juvenile idiopatic
arthritis.

Erosive osteoarthritis
 Key Nndings
Arthropathy with the age of onset and distribu-
tion of osteoarthritis, with an in^ammatory and
erosive component.

Clinical
In^ammatory form of osteoarthritis of the
hand
ATects the DIP and PIP joints and the Rrst
carpometacarpal joint of the hand most
frequently, just like osteoarthritis.
The combination of osteofyt formation
(like osteoarthritis) and central erosions,
which causes a characteristic biconcave
articular surface, is called the gullwing or
seagull deformity. It can look like a pencil-
in-cup deformity.

Radiological Rndings
Articular: joint space narrowing
Bone: sclerosis, productive bony changes
with osteophyte formation, ankylosis
Cartilage: subchondral central erosions
Distribution: see illustration. Same
distribution as with osteoarthritis, with a
preference for the IP joints (DIP more than
PIP)
Extra Rndings: occurs primarily in
postmenopausal women
Soft tissue: rheumatoid arthritis-like
proliferative intra articular synovitis, soft
tissue swelling around the joint

A
Erosive changes of PIP 2-5 and DIP 3-5.
Typical gullwing deformity in DIP 3 (white ar-
row).
Ankylosing of PIP 4 (yellow arrow), which occurs
in a late phase of the disease.

B
Joint space narrowing with central erosions.
Gullwing deformity of PIP 2-4, DIP 2 and CMC-1
joint.
Ankylosing of DIP 3. Medial deviation of PIP 2.
Erosive osteoarthritis in two patients
Ball catcher view of the hands in a patient with
erosive osteoarthritis.

There is bilateral extensive damage to the IP

joints.
Note the symmetrical distribution and sparing
of the MCP joints.

Typical gull-wing appearance of the DIP-joints,

also known as seagull erosions or sawtooth ap-
pearance.
This is classically seen in erosive osteoarthritis,
but has also been reported in psoriatic and
rheumatoid arthritis.

Septic arthritis
 Key Nndings
Rapid destruction of one joint with extensive
erosions and eTusion.

Clinical
Septic arthritis, also called infectious arthritis, is
usually an acute mono-arthritis.
It is secondary to bacteremia, local spread of
infection or a complication of surgery or injec-
tion.
Septic arthritis leads to rapid joint destruction
and requires prompt aspiration or drainage.
Septic arthritis

Radiological Rndings
Articular: joint eTusion sometimes with
gas. thickened synovium, erosions.
Bone: Early stage (after a few days): juxta-
articular osteoporosis, followed by
erosion and joint space narrowing.
Adjacent bone marrow edema. End-stage:
ankylosing and sclerosis.
Cartilage: Late cartilage destruction
Distribution: mono-arthritis. Most
common in knees in adults and knees or
hips in children (most common in infants
up to 12 months).
Extra Rndings: fever, bacteria in synovial
^uid.
Soft tissue: erythema, warmth and
swelling. MRI shows thickened enhancing
synovium. Outpouching of the synovium
and microabscesses can be seen.

Images
A. Soft tissue calciRcations in the rotator cuT.
Patient got a subacromial injection for relief of
symptoms.
B. After corticosteroid injection severe cartilage
loss in the glenohumeral joint and bone de-
struction of the humeral head occured. This
was the result of a septic arthritis, which is a
rare complication of injection.
Septic arthritis of the PIP 3-joint.
There is enormous soft tissue swelling of the
3rd Rnger.
There are extensive erosions of the joint with
some small bone fragments.

Infectious arthritis as a compllication of a Rn-

gertip abscess.

The Rndings are:

Soft tissue swelling
Erosions and joint space narrowing of the
DIP-joint.
The subchondral sclerosis and osteophyte
formation are caused by secondary
osteoarthritis.

This radiograph of the pelvis is of a patient with

tuberculous arthritis of the left hip joint.

There is subtle joint space narrowing with some

subchondral sclerosis of the left hip.
These radiographic Rndings are nonspeciRc and
most likely would be the result of osteoarthri-
tis..

Continue with the MRI...

 Much to everyone's surprise there were multi-
Enable Scroll ple abscesses.
When abscess formation is this extensive and
the clinical Rndings are minimal, always think of
tuberculous arthritis.

The diagnosis of tuberculous arthritis was

made by joint aspiration.

Spondyloarthritis - SpA

Spondyloarthritis (SpA) comprises a group of

in^ammatory diseases of the joints and spine,
with various clinical manifestations.

There have some key features in common, in-

cluding:
joint in^ammation, especially SI joints
enthesitis, especially of the lumbar spine
HLA-B27 genetic factor association
Rheumatoid factor negative (seronegative)

Spondyloarthritis can further be divided into an

axial and a peripheral type.
Ankylosing spondylitis is the most common axi-
al type and the prototypical type of spondy-
loarthritis.
The most common peripheral types are psoriat-
ic arthritis, reactive arthritis and enteropathic
arthritis (associated with in^ammatory bowel
diseases).
ClassiRcation criteria for SpA from the Assess-
ment of SpondyloArthritis International Society
(ASAS) are:

≥3 months of back pain and age of onset ≤

45 years
and sacroiliitis on imaging plus ≥1 clinical
feature
or HLA-B27+ plus 2 other clinical features

The clinical features of spondyloarthritis are

listed in the table.

Ankylosing Spondylitis

Key Nndings
Axial arthropathy, with enthesitis (edema, shiny
corners), syndesmophytes and sacro-iliitis.

Clinical
SigniRcant back pain, morning stiTness and dis-
ability.
The onset is in the 3rd and 4th decade and the
prevalence is about 1%.
Ankylosing Spondylitis is the prototypical type
of seronegative, axial SpA and primarily aTects
the spine and SI-joints although other joints like
shoulders, hips, ribs, heels and small joints of
the hands and feet can become involved.

Radiological
Shiny corners of vertebral bodies
Bamboo spine
Sacro-iliitis
 Enthesitis
In^ammation of the enthesis is one of the hall-
marks of SpA.
The earliest sign of ankylosing spondylitis is
edema at the enthesis, which is only visible on
MRI (white arrow).
In a later stage sclerosis will present as shiny
corners on X-rays or CT.
Finally syndesmophytes are formed along these
enthesis (see next images).

Images
Early stage ankylosing spondylitis Three diTerent patients with typical features of
early stage ankylosing spondylitis:
1. Shiny corners of the anterior border of
vertebrae where the enthesis is located.
Squaring of the vertebral bodies is seen.
2. Another patient with squaring and shiny
corners of the vertebral bodies on CT.
3. This patient has edema at the enthesis of
vertebral bodies, visible on sag STIR.

Syndesmophytes
These images show syndesmophytes in the
lumbar spine and ossiRcation of the paraspinal
ligaments.
When these syndesmophytes fuse, this pro-
duces the typical “bamboo spine” appearance.

Also note the ossiRcation of the intervertebral

disc and ankylosis of the facet joints.

Syndesmophytes have a typically vertical orien-

tation.
Ankylosing spondylitis Bridging and fusing is quite common.
As a result the spine looses its ^exibility and
can easily fracture even after a minor trauma.
 Bamboo spine
Bamboo spine in ankylosing spondylitis.
Fusion of the lumbar spine by syndesmophytes
and ossiRcation of the paraspinal ligaments.
Notice the ligamentous calciRcation (arrow).

A rigid bamboo spine is prone to hyperexten-

sion fractures, even after mild trauma.
Always have a high suspicion of these fractures
in a rigid spine!

A bamboo spine often begins at the lumbar lev-

el and can ascend up to the cervical spine.
Notice the squaring of the vertebral bodies (ar-
row).

Ankylosing spondylitis of the cervical spine

Dagger sign

The radiopaque central line on frontal radi-

ographs of the spine due to ossiRcation of the
interspinous ligaments, known as the “dagger
sign”, is a radiographic feature of ankylosing
spondylitis.
Also note the complete fusion of the SI-joints.
 Sacro-iliitis

An important hallmark of SpA is sacro-iliitis.

It starts with in^ammation, which is visible on
MRI as edema, with or without erosions (visible
on MRI and conventional imaging).
Later on you will see fatty metaplasia on MRI or
Sacroiliitis in ankylosing spondylitis
sclerosis alongside the SI-joints on radi-
ographs.
In the end stage there is ankylosis of the SI-
joints.

X-ray
Bilateral subchondral sclerosis and erosions of
the sacroiliac (SI) joints caused by sacro-iliitis.

MRI
T1W post contrast MR of the same patient
shows an irregular contour of the SI-joints
caused by erosions.
There is enhancement in the subchondral bone
and bone marrow edema.
There is no joint eTusion.

I.V. contrast does not necessarily have to be

used for the diagnosis of sacro-iliitis.

Scroll through the MR-images and compare

Enable Scroll with the Rndings on the X-ray (last image).
 DiTerential Diagnosis of sacro-iliitis:
1. Osteoarthritis: bilateral subchondral
sclerosis without erosions of the SI-joints.
2. Osteitis condensans Ilii: bilateral
triangular shaped sclerosis of the ilium
adjacent to the SI-joint.

The diagnosis of sacro-iliitis can be challenging

based on these X rays alone. It can be helpful to
include an X-LWK or other investigation to be-
come more certain.

Late stage sacro-iliitis with ankylosis of the SI-

joints.

The Hatchet sign is a circumscribed erosion of

the lateral-dorsal aspect of the humeral head
leading to a hatchet-shaped deformity.
A hatchet is a small axe.

This deformity is typical for ankylosing spondy-

larthritis.

Hatchet lesion. Ankylosing spondylitis of the humeral head

 Hatchet sign versus avascular necrosis

The hatchet sign diTers from the deformity

seen in avascular necrosis, where there is pro-
gressive collapse of the articular surface of the
humeral head.

Avascular necrosis of the humeral head

Milwaukee shoulder
A rare shoulder arthropathy that can simulate
the hatchet shoulder is the Milwaukee shoulder
syndrome.
It is characterized by rupture of the rotator cuT
and large joint and bursal eTusions with depo-
sition of hydroxyapatite crystals leading to
rapid destruction of the glenohumeral joint.

Image
Severe destruction of the humeral head
with cephalic migration and erosions of the
Milwaukee shoulder syndrome
acromion indicating total cuT rupture.
In the Milwaukee shoulder syndrome, symp-
toms are often much milder than imaging sug-
gests.
In this case, there was no attempt to diag-
nose calcium hydroxyapatite crystals in the syn-
ovium.
Based on clinical and radiographic Rndings, Mil-
waukee shoulder syndrome was diagnosed.
 Ankylosis of the hip joints with joint space nar-
rowing in a patient with ankylosing spondylitis.
There is also ankylosis of the sacroiliac joints.

Ankylosis of the hip joints

Psoriatic arthritis
Key Nndings
Erosions and bone proliferation predominantly
in a distal distribution, presenting most often as
a typical pathognomonical pattern, but some-
times as a confusing subtype (see diTerential
diagnosis).

Clinical
Psoriatic arthritis is a peripheral type of
spondyloarthritis and presents as a peripheral
arthritis with or without sacroiliitis and
spondylitis.
It frequently is preceded by psoriasis of the
skin, but can occur without skin disease in up to
20% of patients.
Enthesopathy is common.
The hands are most commonly involved fol-
lowed by the feet. Other locations are the
spine, sacroiliac joints and less frequently knee,
elbow, ankle and shoulder.

Radiological Rndings
Articular: small marginal bone erosions,
arthritis mutilans with acro-osteolysis and
pencil-in-cup deformities, joint
subluxation, interphalangeal ankylosis,
sacroiliitis (frequently asymmetrical).
Bone: bone productive changes,
periostitis, Ivory phalanx (distal phalanx
dig 1), spondylitis (asymmetrical
paravertebral ossiRcations).
Cartilage: joint space narrowing
Distribution: see illustration, asymmetric
and predominantly peripheral.
Extra Rndings: skin lesions, telescoping
Rngers.
Soft tissue: Enthesitis, dactylitis (sausage
digit), onycholysis (the nail separates from
the skin).

DiTerential Diagnosis
Rheumatoid arthritis, erosive osteoarthritis, re-
active arthritis
 There are Rve subtypes of psoriatic arthritis.

Due to these diTerent patterns, the diagnosis

of psoriatic arthritis can sometimes be chal-
lenging.

Sausage digits

Typical appearance of dactylitis “sausage digits”

with soft tissue swelling and pencil-in-cup de-
formity of DIP 1-2 and 5 of the left hand in a pa-
tient with psoriatc arthritis.
Notice that the MCP joints are not involved (un-
like in RA).

Sausage digits and pencil in cup deformity in Psoriatic

arthritis

Progressive psoriatic arthritis

1. The picture on the left shows marginal

erosions (black arrow) and subtle bone
formation (blue arrow) of the IP joint.
2. Later on, it progresses to the typical
pencil-in-cup deformation.

The distribution and the bone formation makes

the diagnosis of rheumatoid arthritis unlikely.
Psoriatic arthritis

The marginal erosions and the absence of DIP

involvement in other joints makes the diagnosis
of erosive osteoarthritis unlikely, although pen-
cil-in-cup can look like the gullwing deformity in
erosive osteoarthritis.
 Pencil in cup deformity

A. Pencil in cup deformity of 1st and 5th toe.

B. Acro-osteolysis with resorption of the termi-
nal tuft of digits 2-4 and 5.
There are erosions in MTP 2 and 3.

Psoriatic arthritis

Periostitis in psoriatic arthritis

This is a patient with psoriatic arthritis.

Notice the subtle periostitis of the distal pha-
lanx of dig 1 on the right (arrowhead).
There are small erosions of the tuft of dig 2 and
3 on the left (white arrows).

Psoriatic arthritis

Reactive arthritis

Clinical
Reactive arthritis is a sterile arthritis following
soon after an infection elsewhere in the body,
usually of genitourinary or enteric origin.
It is caused by a cross-reaction of the antigen
reaction to bacteria as well as synovial tissue.
Classically patients present with conjunctivitis
and urethritis, leading to the triad: can't see,
can't pee and can't bend the knee.

Radiological Rndings
Articular: in later disease ill-deRned
erosions like psoriatic arthritis (typically
calcaneus is involved)
Bone: Bone proliferation but also juxta-
articular osteoporosis and
enthesopathy/enthesitis
Cartilage: uniform joint space narrowing.
Distribution: asymmetric, see illustration
Extra Rndings: usually triggered by a
preceding infection
Soft tissue: swelling soft tissue (also
sausage digit)
This patient suTered from an episode of
campylobacter gastroenteritis.
After a few weeks clinical symptoms of arthritis
emerged.

Image
On the right there are erosions at the base of
the 3rd proximal phalanx and at the head of
the 5th proximal phalanx (white arrowheads).
On the left there is an erosion at the base of
the 3rd proximal phalanx and lytic changes of
the head of the 1st proximal phalanx (yellow
arrowheads).

Based on the aspeciRc imaging Rndings alone, it

is discult to diagnose reactive arthritis.
The preceding infection makes it more likely.

DiEuse Idiopathic Skeletal

Hyperostosis
Key Nndings
Bulky spondylophytes, over more than 4 con-
tiguous levels, located at the right side of the
lower thoracic vertebrae.

Clinical

DiTuse Idiopathic Skeletal Hyperostosis (DISH)

is also known as Forestier’s disease. Most often
asymptomatic.
It is characterized by bony proliferation at
tendinous and ligamentous insertion of the
spine and pelvis mostly aTecting elderly individ-
uals.

Radiological Rndings
Articular: no erosions
Bone: CalciRcation or ossiRcation of the
anterior longitudinal ligament, paraspinal
connective tissue and annulus Rbrosis
over a region of at least four contiguous
vertebral bodies. These are of typical
'bulky' appearance.
Usually they are located on the right side,
since pulsations of the aorta prevent
spondylophytes from forming.
Enthesopathy of the pelvis (e.g. iliac crest,
ischial tuberosities, greater trochanters)
Cartilage: Typically preservation of disc
height without profound degenerative
disc disease.
Distribution: The lower thoracic spine is
most frequently aTected. Usually there is
no involvement of synovial lower part of
the sacroiliac joint, although ossiRcation
of ligamentous upper part of the SI joint
can occur.
Extra Rndings: Prone to severe fracture
after minor trauma.
Soft tissue: increased susceptibility to
fractures

Teaching point
In daily practice, it is the classic diTerential di-
agnosis of ankylosing spondylitis, especially in
early stages of both diseases.
Teach yourself the diTerences between the two
(see below).
 DISH should not be confused with the Rndings
of a bamboo spine, which is the hallmark of
ankylosing spondylitis.

Image
Bamboo spine: fusion of the lumbar spine
by subtle syndesmophytes and
ossiRcation of the paraspinal ligaments.
DISH: bulky ossiRcation and calciRcation of
the anterior longitudinal ligament and the
paraspinal connective tissue over more
than 4 contiguous levels. Typically
preservation of disc height without
profound degenerative disc disease.

DISH Other causes of ligamentous ossiRcation in the

spine are severe osteoarthritis, and less likely:
vitamin A toxicity and ^uorosis.

Image of another patient with DISH.

There is enthesopathy of the iliac crest, ischial
tuberosities and greater trochanters.

The lower part of the SI joint is normal (unlike

ankylosing spondylitis).
OssiRcation of the ligaments in the upper part
of the SI joint is present.

Image
Typical ossiRcation and calciRcation of the ante-
rior and paraspinal ligament and connective
tissue over more than 4 contiguous levels.
Large ossiRcations of the anterior longitudinal
ligament.
There is some non-typical narrowing of facet
joints.
No sign of degenerative disc disease.
Ankylosis due to DISH and ankylosing spondyli-
tis can result in a rigid spinal column. Then, the
spine is prone to fracture after even mild trivial
trauma. These fractures are most often hyper-
extension fractures.

This patient had a minor trauma, which howev-

er resulted in an unstable hyperextension frac-
ture with neurological complications.

Teaching point: you should always have a high

suspicion of hyperextension fractures in pa-
tients with rigid spine due to DISH and ankylos-
ing spondylitis.

Gout
Key Nndings
Tophi with juxtaarticular erosions at the cap-
sule insertion of a joint, typically MTP1, in pa-
tients with risk factors like diabetes and kidney
disease

Clinical
Gout is an in^ammatory arthropathy caused by
the deposition of sodium urate crystals in joints
and periarticular soft tissues and tendons. The
Rrst MTP joint is most often aTected (podagra).
Classically the diagnosis is made clinically, sup-
ported by joint aspiration.

Radiological Rndings
Articular: “punched out “ erosions >5 mm,
that spare part of the joint with an
overhanging edge of new bone.
Bone: bone mineralization is normal.
Chondrocalcinosis or osteonecrosis can
occur.
Cartilage: joint eTusion (earliest sign),
preservation of joint space
Distribution: see illustration, there is a
predilection for peripheral joints. Most
often it has an asymmetric, random
distribution.
Extra Rndings: usually male,
hyperuricemia
Soft tissue: tophi: pathognomonic,
eccentric nodular soft tissue swelling due
to crystal deposition around the joints is
common. These may be hyperdens due to
the crystals and may calcify. Olecranon
and prepatellar bursitis.
Late stage of Gout

Characteristic radiologic changes in the chronic

stage of gout.
Typically well-deRned “punched-out” eccentric
erosions with sclerotic margins in a marginal
and juxta-articular distribution.
These erosions have overhanging edges called
rat bite erosions.
There is preservation of joint spaces.

Periarticular hyperdense soft tissue swelling

due to tophi as a result of crystal depositions
(pathognomonic).
These are located in the ligamentous structures
around the joints.

Typical involvement of the 1st MTP joint with

punched-out erosion.
The soft tissue swelling represents a tophus.

The dislocation is not a common Rnding in

gout, but in this case the result of the erosions
and ligamentous injury.
 Soft tissue density

Typical dense soft tissue swelling surrounding

the 1st MTP joints bilateral.
Juxta-articular erosions at the medial side of
the distal MT, which have sclerotic margins.
They are most notably on the right side (ar-
row).

Continue with the Dual Energy CT...

Dual Energy CT of the same patient with gout

showing the urate crystal depositions.

In this 3D reconstruction the crystal depositions

are color coded green and can be seen sur-
rounding the MTP joints and at the insertion of
the right achilles tendon (arrow).
The green pixels in the nail beds of digitus 1
and 5 on the left are artifacts caused by keratin
in thickened nails.

Dual Energy CT is a noninvasive method of

urate crystal detection that can make joint aspi-
ration unnecessary.
Dual Energy CT simultaneously scans the sub-
ject at two diTerent energy levels.
Because urate crystals show diTerent attenua-
tion at these energy levels, the crystals can easi-
ly be identiRed with high accuracy.

Dual Energy CT in a patient with gout and urate crystal

depositions
Another case with typical gout tophi and jux-
taarticular erosions on plain Rlms.

Dual Energy CT shows gout attenuation in

MTP1, MTP2 and interphalangeal joints of the
3rd digit.

DECT is useful for the diagnosis when Rndings

are not so typical.
It is also very useful to show the extent of dis-
ease.

In this case, a bone tumor was suspected.

There are deRnitely some Rndings that could
support the diagnosis of an osteosarcoma of
chondrosarcoma.

However, this was proven to be gout.

Continue with the DECT images...

With these DECT images, nobody was in doubt

anymore.
Punched out erosions

In this case there is a classical punched out ero-

sion of the MCP3 joint with an overhanging
edge (arrow).

The borders of the erosions in gout can be scle-

rotic because of the indolence of the process,
creating a punched-out or “mouse bitten” ap-
pearance.

CalciNed tophi

The images show extensive tophi around the

knee joint in a patient with gout (arrowheads).
In the knee, these locations (insertion popliteus
tendon, insertion quadriceps tendon, insertion
MCL) are very typical.
There is mild joint eTusion.
The joint space narrowing is likely due to sec-
ondary osteoarthritis.

When in doubt, think gout

This is a discult case.

Small bilateral erosions of the PIP joints on
both sides are seen.
The arrowheads show that the erosions are
more juxtaarticular in this patient that proved
to have gout.

Based on the distribution, rheumatoid arthritis

and psoriatic arthritis would have been an op-
tion.
However then the erosions would have been
more marginally located.
Also, the MCPs are spared, making the diagno-
sis of rheumatoid arthritis less likely.
Soft tissue swelling

This case is also challenging.

Multipele joint are aTected, but there is no typi-
cal distribution.

The only thing that these joints have in com-

mon is the surrounding hyperdense soft tissue
swelling.
This was due to gout tophi.

CPPD
Key Nndings
Fine chondrocalcinosis located at the TFCC or
menisceal tissue in the knee.

Clinical
Calcium Pyrophosphate Deposition (CPPD) is an
in^ammatory joint disease caused by deposi-
tion of calcium pyrophosphate dihydrate crys-
tals into the synovial ^uid, synovial lining and
articular cartilage.

Some terms regarding CPPD can be a bit con-

fusing:
1. Chondrocalcinosis
Descriptive term when Rne calciRcations
in cartilage are present, most often used
when CPPD is the cause. However,
chondrocalcinosis is not an exclusive
feature of CPPD and can also be seen in
severe osteoarthritis.
Most patients are clinically asymptomatic.
2. Pyrophosphate arthropathy
Distinctive arthropathy of CPPD, which is
similar to osteoarthritis, but with a funny
distribution.
There is chondrocalcinosis and large
chondral cysts, that can simulate a
osteolytic neoplasm.
3. Pseudogout
Acute joint in^ammation due to CPPD. It is
called pseudogout because clinically it can
look like gout.

Radiological Rndings
Articular: no erosions
Bone: subcortical cyst formation
Cartilage: joint space narrowing
Distribution: see illustration, symmetrical.
Extra Rndings: no
Soft tissue: chondrocalcinosis, especially
along the cartilage. The TFCC and knee
joints are preferred spots.
Two patients with typical CPPD.

A. There is cartilage loss in many joints and

chondrocalcinosis in:
CMC1 (white arrow)
MCP joints (arrowhead)
TFCC (asterix)

B. This patient had an acute joint in^ammation.

Chondrocalcinosis in the radiocarpal joint and
the TFCC (black arrows) is seen, almost pathog-
nomonical for CPPD. There is scapholunate dis-
sociation, which can be seen in CPPD, but also
in rheumatoid arthritis or posttraumatic.

This sudden attack is called pseudogout, be-

cause it can simulate the in^ammation and in-
tense pain of a gout attack.

Chondrocalcinosis in CPPD

There are faint calciRcations of the cartilage

and meniscus both on the right side (white ar-
row) as well as on the left side (black arrows).
These can be caused by CPPD, but may be seen
in other conditions as well, such as gout or os-
teoarthritis.

Also note the joint space narrowing and mild

osteophyte formation.
CPPD has many features similar to osteoarthri-
tis.

There is a well-circumscribed coarse calciRca-

tion adjacent to the 4th DIP joint. This does not
look like CPPD and scleroderma would have
been more likely.

However, aspiration revealed typical CPPD crys-

tal depositions.

As in other arthropathies, atypical presenta-

tions of CPPD are possible, but fortunately less
common.
Scleroderma

Key Nndings
Soft tissue calciRcations and acro-osteolysis

Clinical
Scleroderma (systemic sclerosis) is an autoim-
mune connective tissue disease and is charac-
terized by microvascular obliteration and scle-
rosis of the skin and internal organs.
The clinical hallmark of the disease is the ap-
pearance of taut tethering of the skin.
Clinically evident arthritis occurs in up to 65% of
patients, and it may be one of the earliest mani-
festations of scleroderma.

There is a limited and a multisystem variant.

CREST syndrome is a common type of limited
scleroderma (skin calcinosis, Raynaud’s phe-
nomenon, esophageal dysmotility, sclerodactyly
and telangiectasia).
The systemic variant can aTect virtually every
organ system or can be localized.

Radiological Rndings
Articular: erosions, pencil-in-cup
deformity, resorption of the 1st CMC joint
with radial subluxation.
Bone: acral osteolysis (resorption of the
distal phalanges), periarticular osteopenia.
Cartilage: joint space narrowing
Distribution: see illustration, symmetric
Extra Rndings: scleroderma has a lot of
other organ manifestations like
pulmonary and abdominal organ
manifestations.
Soft tissue: skin thickening, cutaneous
calciRcations (often at mechanically
exposed locations), acral soft tissue
necrosis.
Soft tissue calciNcations

Extensive soft tissue calciRcations in the distal

phalanges in a patient with scleroderma.
Notice the calciRcations next to the distal ulna
(arrow).
There are no signs of cartilage damage.

The pathophysiology of the calcium deposits is

not well understood.
It occurs in tissues that are under chronic
stress, such as local trauma or damage associ-
ated with an underlying in^ammatory process.
It is usually more abundant in the dominant
hand.
When these Rndings are present, the diagnosis
is usually straight forward.

Subtle, but coarse soft tissue calciRcations at

the most distal part of the Rnger in a patient
with scleroderma.

No acro-osteolysis or other signs are seen.

Acro-osteolysis in Scleroderma

Severe acro-osteolysis of the Rnger tips of dig 1-

3 in a patient with scleroderma (arrows). Notice
the lysis of the soft tissues distally.

Acro-osteolysis is a radiographic Rnding which

refers to bone destruction of the distal pha-
langes and occurs in 6–65% of patients with
scleroderma.
Vascular alterations and reduced capillary den-
sity impair tissue oxygenation and the resulting
hypoxia may contribute to osteoclast activa-
tion.

There is a wide variety of diseases that can

cause acro-osteolysis including psoriatic arthri-
tis, infection, raynaud disease and thermal trau-
ma.

A. Subcutaneous and periarticular calciRcations

in the foot of a patient with scleroderma.
There is also a hallux valgus deformity, which is
not caused by scleroderma.

B. Subcutaneous calciRcations near the elbow

in a patient with scleroderma.
These subcutaneous calciRcations often form at
pressure points.

Systemic lupus
erythematosus
 Key Nndings
Abnormal joint alignment without erosions.
Avascular necrosis.

Clinical
SLE is a generalized autoimmune connective
tissue disease.
Essentially any organ system can be aTected
with systemic (weakness, malaise, fever), muco-
cutaneous (typical butter^y rash on the face),
renal and neurological symptoms.

Radiological Rndings
Articular: no erosions
Bone: periarticular osteoporosis
Cartilage: normal joint spaces
Distribution: see illustration, symmetric
distribution
Extra Rndings: avascular necrosis
Soft tissue: reducible deformities like
swan neck and boutonniere deformities.
Soft tissue swelling. CalciRcations in the
subcutaneous and deep soft tissues may
be seen, most often around small joints.

Z-thumbs and swan neck Rngers in a patient

with SLE.
The deformities are thought to be a conse-
quence of low-grade in^ammation of the syn-
ovial membrane and capsule resulting in liga-
mentous laxity and muscular contracture.

SLE: Z-thumbs and swan neck Rngers

Swan neck deformity

Here another example with extensive align-

ment deformities without erosions or signs of
cartilage damage in a patient with SLE.

Another patient with a swan neck deformity.

Usually this is reversible in the early stage of
the disease.

Avascular necrosis

Avascular necrosis is a frequent complication in

SLE in up to 15% of patients.
The femoral head and tibial plateau are the
most involved sites, but other sites may be af-
fected.
SLE patients with bone pain should be suspect
of having avascular necrosis.
Avascular necrosis in SLE can occur even in the
absence of steroid use.

Images
Increased density in the distal femur in a guir-
lande-like pattern, representing avascular
necrosis in a patient with SLE.
A. Subluxation of the 1st MCP joint without ero-
sions in a patient with SLE. This is not typical for
SLE and can be seen in other forms of arthritis
like for instance osteoarthritis.

B. SLE of the shoulder. Collapse of the humeral

head with some loose bony fragments due to
avascular necrosis. Both steroid therapy and
SLE are associated with an increased risk of
avascular necrosis.

Sarcoid
Key Nndings
Lace-like granuloma lesions in the bone

Clinical
Sarcoidosis is a multisystem disorder of un-
known etiology characterized by the formation
of in^ammatory non-caseating granulomas.
Musculoskeletal manifestations of sarcoidosis
occur in about 20% of patients with sarcoidosis
and include joint involvement, bone lesions,
and muscular disease.
Primary skeletal involvement without other or-
gan involvement is extremely rare. Usually
arthritis is seen early in the course of sarcoid
disease, chronic sarcoid arthritis is rare.
The most frequent musculoskeletal manifesta-
tion of sarcoidosis is an acute arthritis that oc-
curs as part of Löfgren’s syndrome character-
ized by the combination of erythema nodosum,
bilateral hilar adenopathy, polyarthritis, and
constitutional symptoms.

Radiological Rndings
Articular: erosions
Bone: sarcoid bone lesions can be
permeative or “moth-eaten”, lytic or
sclerotic. These lesions are very
distinctive.
Cartilage: joint space narrowing is
unusual.
Distribution: Typically there is multiple
joint involvement with symmetric
distribution, see illustration.
Extra Rndings: There are a wide range of
manifestations and thereby also many
clinical and radiographic manifestations.
Soft tissue: dactylitis, myopathy.
Lace-like granulomas

Multiple bone lesions in a patient with sarcoid.

The osteolytic lesions are quite typical and de-
scribed as having a lace-like or trabecular pat-
tern.
Once you have seen this, you will recognize it in
other cases.

The image shows an osteolytic lesion in the dis-

tal radius (blue arrow) with trabecular and corti-
cal bone destruction in a patient with sarcoid.

There is osseous destruction on both sides of

the interphalangeal joint of the Rrst digit with
extraosseous extension of granulomatous tis-
sue (black arrow).

Amyloidosis
Clinical
Amyloidosis is a systemic disease in which nor-
mally soluble proteins (amyloid) are deposited
as an insoluble proteinaceous material in the
extracellular spaces.
Amyloid is often deposited into the heart, kid-
ney, gastrointestinal tract and nervous systems.
The secondary form of amyloidosis is associat-
ed with diseases such as multiple myeloma, he-
modialysis, RA and chronic infection.
Musculoskeletal manifestations are most often
depositions in periarticular tendons and cap-
sule.
Amyloid arthropathy is extremely rare and only
5-13% of patients have bone or joint involve-
ment.

Radiological Rndings
Articular: erosions in a late stage of
disease
Bone: subchondral cysts
Cartilage: joint space widening in early
stages due to intra-articular amyloid
deposition
Distribution: symmetric, in shoulders and
wrist.
Extra Rndings:
Soft tissue: purulent synovial ^uid and
bulky soft tissue nodules

Amyloidosis is very discult to diagnose on con-

ventional imaging alone, MR is more useful for
the diagnosis.
 T2W series of a patient with amyloid arthropa-
Enable Scroll thy of the shoulder joint.

The Rndings are:

Large intra-articular swelling caused by
the deposition of hypointens amyloid.
Spread to the subacromial and
subscapular space.
Large erosions of the humeral head.

This soft tissue swelling should not be mistaken

for rice bodies as seen in rheumatoid arthritis.

Neuropathic arthropathy
Clinical
Neuropathic arthropathy also known as Char-
cot arthropathy is a progressive destructive
joint disorder in patients with peripheral neu-
ropathy with loss of pain sensation and propri-
oception in the foot, ankle or hands.
Patients may experience fractures and disloca-
tions of bones and joints with minimal or no
known trauma.
The most common cause is diabetes mellitus,
which typically aTects the tarsal and tarso-
metatarsal joints. Arterial wall calciRcation is
commonly seen in these patients. Other causes
are tabes dorsalis (tertiary syphilis), sy-
ringomyelia, leprosy and CPPD.

Radiological Rndings
Articular: no erosios
Bone: early phase consists of
in^ammation and osteopenia. Finally joint
destruction with loose bodies,
fragmentation and insusciency fractures.
When Charcot is treated and becomes
less active, bone will coalescense with
formation of osteophytes and bony
proliferations.
Cartilage: joint space narrowing and
ankylosis
Distribution: frequently asymmetric.
Extra Rndings: neuropathy and
vasculopathy.
Soft tissue: soft tissue swelling. Severe
joint malalignment leading to rocker-
bottem deformity.
These radiographs are of two diTerent patients
with diabetes and neuropathic arthropathy.

A. Destruction of the tarsometatarsal joints

with periarticular lucencies.

B. Typical radiological changes in the foot of a

diabetic patient. There is lateral subluxation of
the TMT joints (Lisfranc dislocation).

The changes in bone and joints itself may mimic

severe osteoarthritis, severe in^ammation or
septic arthritis.
The key in this case is the clinical history with
the presence of diabetic neuropathy.

Rocker bottom deformity

On this weight-bearing lateral view the disloca-
tion in the TMT joints is even better visible.

For a more detailed explanation of diabetes-re-

lated foot problems go to MRI examination of
the diabetic foot.

Diabetic Hand Syndrome

The diabetic hand syndrome is the inability to
use the hand due to contractures and stiTness.
It can aTect the proximal and distal IP and
MCP-joints and is often painless.
Prolonged hyperglycemia is thought to result in
the accumulation of advanced glycation end
products (AGEs).
These AGEs can break down collagen and de-
posit abnormal amounts of collagen in connec-
tive tissue around the joints, resulting in stiTen-
ing and hardening of the joints and the skin.

Images
Destruction of the CMC-1 and all DIP-joints.
Erosions and bone destruction adjacent to the
IP1, DIP 2-5 and PIP 4-5.
There is subluxation of PIP 4-5 and DIP 2-5.
Notice the extensive vascular calciRcations in a
patient with Diabetes Mellitus type 2.
The hand of this patient with neuropathy shows
a status after removal of the trapezium (arrow).
There is destruction of all DIP joints and ero-
sions adjacent to the PIP and MCP joints.
There are erosions and bone destruction adja-
cent to the IP1, the DIP and PIP and MCP joints.
There is subluxation and dislocation of DIP 2, 4
and 5 and PIP 2-4.

Hemophilic arthropathy
Key Nndings
Extensive Rndings that look like osteoarthritis,
but in an unusual distribution or pattern.

Clinical
Hemophilia is an inherited coagulation bleeding
disorder which is mainly X-linked recessive and
therefore occurs almost exclusively in males.
About 50% of the hemophilia patients develop
haemophilic arthropathy.
This results from recurrent hemarthrosis, which
leads to synovial hyperplasia, chronic in^am-
mation, Rbrosis, and hemosiderosis.
It is frequently mono- or oligoarticular.
Early prophylaxis with coagulation factors con-
siderably reduces the musculoskeletal compli-
cations.

Radiological Rndings
Articular: erosions and eventually joint
destruction
Bone: subchondral bone cyst formation,
osteoporosis (mostly periarticular due to
hyperemia), ankylosis in late stage
Cartilage: joint space narrowing and
destruction in late stage of disease
Distribution: hemarthrosis aTects large
joints and is frequently mono- or
oligoarticular, see illustration
Extra Rndings: growth abnormalities
Soft tissue: soft tissue swelling due to joint
swelling or extra-articular hemorrhage.

Teaching point: when Rndings look like os-

teoarthritis, but in an odd presentation or dis-
tribution, think hemophilic arthropathy.
 This patient has a history of hemophilia and
repetitive hemarthros.

Images
Distention of the suprapatellar recess of the
right knee due to hemarthrosis (black arrow).
There is narrowing of the medial joint space
caused by cartilage destruction and secondary
osteoarthritis (white arrow).
Hemophilic arthropathy of the right knee (Arnold-
Hilgartner classiRcation: Stage III) Subchondral bone cyst formation underneath
the intercondylar eminence.
No erosions.

The Arnold-Hilgartner classiRcation is a plain

radiograph grading system for haemophilic
arthropathy of the knee.

This patient has a history of repetitive

hemarthrosis caused by a vascular malforma-
tion (not visible on plain radiography).

Images
The image of the right knee shows joint space
narrowing, subchondral cysts formation and
erosions of the medial and lateral tibial plateau.
Normal left knee joint for comparison.
 This patient has a long term history of repeti-
tive hemarthrosis as a result of hemophilia.

Images
A slightly widened intercondylar notch on the
left hand side, which can also be found in juve-
nile rheumatoid arthritis and tuberculous
arthropathy.
Bulbous femoral condyles with ^attened condy-
lar surfaces.
The congruent bony deformation on the left
hand side can also be seen in tuberculous
arthropathy.

This is stage V Arnold-Hilgartner classiRcation

hemophilic arthropathy. with severe joint space
narrowing, subchondral cyst formation and ero-
sive destruction.

This image is of a patient with hemophilia and

recurrent hemarthrosis of the shoulder joint.

There are features of secondary osteoarthritis

with subchondral sclerosis and osteophyte for-
mation at both sides of the glenohumeral joint.
In general hemophilic arthropathy has similari-
ties with osteoarthritis.
However, the presence of erosions, extensive
subchondral bone cyst formation and the histo-
Hemophilic arthropathy of the shoulder ry of recurrent hemarthrosis are distinguishing
features in favor of hemophilic arthropathy.

Image of the ankle of a patient with hemophilia.

The Rndings are:

extensive symmetrical joint space loss,
subchondral bone cyst formation
erosive changes

Hemophilic arthropathy of the ankle

 End Stage hemophilic arthropathy

The Rndings are:

symmetric joint space narrowing
joint eTusion
subchondral cyst formation
secondary osteoarthritis with osteophytes

Although the Rndings itself are not that speciRc,

you can see the resemblance between all of the
above cases.
Hemophilic arthropathy

CRMO - chronic recurrent

multifocal osteomyelitis
Key Nndings
Multifocal areas of sterile bone in^ammation

Clinical
Chronic Recurrent Multifocal Osteomyelitis
(CRMO) is an uncommon autoin^ammatory dis-
order of the bone of children and young adults
that is characterized by nonbacterial os-
teomyelitis.
Patients present with episodic multifocal bone
pain secondary to sterile osseous in^ammation.
The disease has a relapsing and remitting
course. The cause of CRMO is unclear. The diag-
nosis is made by exclusion, and the main caus-
es to be excluded are neoplasms and infec-
tions.
It is sometimes diagnosed along with in^amma-
tory bowel disease or psoriasis and there
seems to be a genetic component.
CRMO is comparable to SAPHO in adults.

Radiological Rndings
Articular: no abnormal Rndings.
Bone: Rrst lytic lesions and bone edema,
later progressive sclerotic lesions in
metaphysis. Also periostitis.
Cartilage: no abnormal Rndings
Distribution: see illustration, often
symmetrical and multifocal. Typically
medial clavicles and tibia are involved.
Other common sites are rib, mandible,
pelvis and vertebral bodies.
Extra Rndings: occurs in children and
adolescents with an average age of onset
of 7-14 and a female to male ratio of
approximately 2:1.
Soft tissue: edema in soft tissue around
the CRMO.

Cortical thickening, sclerosis and bone enlarge-

ment of the diaphysis and metaphysis of the
right clavicle and the metaphysis of the left
clavicle.
SPECT-CT and Bone scintigraphy of the same
patient. Abnormal tracer uptake in correspond-
ing areas, re^ecting increased bone turnover.

X-ray of a patient with CRMO with pain on the

left side.

There is subcortical osteolysis lateral in the

proximal femur (arrow)

The MRI (axial and coronal T1 TSE FS with con-

trast) shows a region of bone and soft tissue
enhancement.
This was due to non-infectious osteomyelitis
with extra osseous extension.

There is also a small CRMO location visible in

the dorsal aspect of the trochanter major on
the right.

Multiple CRMO locations

This patient has locations in the humeral head

and proximal diaphysis and in the coracoid on
the right and the distal tibia on both sides.

SAPHO syndrome
Clinical
SAPHO syndrome (synovitis, acne, pustulosis,
hyperostosis, and osteitis) is an uncommon in-
^ammatory disorder of bone, joints and skin.
The pathogenesis of SAPHO syndrome is not
well understood.
It is sometimes described as an autoin^amma-
tory disorder.
The pediatric counterpart of the disease is
known as CRMO.

Radiological Rndings
Articular: joint erosions and erosion at the
vertebral body corners.
Bone:
Osteitis (bone in^ammation), seen as
sclerosis of the medullary cavity and bone
marrow edema.
Hyperostosis (excessive bone growth),
seen as cortical thickening, formation of
osteophytes, paravertebral ossiRcation
and ankylosis.
Osteolysis is also a common Rnding and
may lead to vertebral body collapse.
Cartilage: joint space narrowing is present
Distribution: asymmetric, anterior chest
wall is the most common site of
involvement, see illustration.
Extra Rndings: Usually seen in an average
age of 30 to 50 years with a female
predominance.
Soft tissue: Acne and pustulosis of palms
and soles, although skin and
osteoarticular manifestations do not
necessarily coexist.

Teaching point: the degree of in^ammation

determines the type of bone abnormalities. Os-
teolysis will occur when there is extensive in-
^ammation. Increase of bone activity and scle-
rosis will occur when there is less in^amma-
tion.
 Patient with SAPHO syndrome with:
osteïtis of corpus and manubrium sterni
and sclerotic thoracic vertebral bodies,
some endplate erosions and
paravertebral syndesmophyte formation
(left, sag CT)
increased bone turonver (middle, bone
scintigraphy)
sclerosis in manubrium sterni (right, axial
CT)

Hyperostosis in SAPHO

This patient has extensive hyperostosis of the

medial side of the clavicles on both sides.

CT of the same patient.

There is extensive hyperostosis of the medial
side of the clavicles and sternum.
Ankylosis of the sternoclavicular and of the Rrst
and second sternocostal joints.

ABCDE-S overview

In this table the key Rndings of the various joint

diseases are summarized according to the
ABCDE-S mnemonic.

Click on the image for a larger view.

1. A Systematic Approach to Radiographic Evaluation of Arthritis of the Hand and Wrist

by Matthew Kluckman, Stephanie Bernard and Liem Bui-MansReld.
 Contemporary Diagnostic Radiology Volume 44 May 31 2021
2. Radiographic Evaluation of Arthritis: In^ammatory Conditions
by Jon A. Jacobson, Gandikota Girish, Yebin Jiang, Donald Resnick
Radiology 2008. august Pages:378–389.
3. Seronegative Spondyloarthropathy
by Rouhin Sen, Amandeep Goyal and John A. Hurley.
StatPearls Publishing; 2022 Jan-.
4. A Comprehensive Guide on Arthritis imaging
by L. Jans L and M. Chen
Published 2021.
5. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess
spondyloarthritis
by J Sieper, M Rudwaleit, X Baraliakos, J Brandt, J Braun, R Burgos-Vargas, M Dougados, K-G Hermann, R Lan-
dewé, W Maksymowych and D van der Heijde
Ann Rheum Dis 2009;68;ii1-ii44
6.

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