骨科學(xué)教學(xué)課件：Chronic Arthropathies

ChronicArthropathiesRheumatoidArthritis(RA)AnkylosingSpondylitis(AS)Osteoarthritis(OA)RheumatoidArthritis(RA)permanentdeformityanddisabilityin10%to20%patientsPositiverheumatoidfactor

Age:25to55yearsSex:Femalesoutnumbermales3:1Distribution:PIPjoint,metacarpophalangealjoint,wrist,metatarsophalangeal(MTP)joint,ankles,knees,shoulders,and,toalesserextent,hips,andspine(asymmetricpolyarthropathy)Inflammatoryarthritides.Highlightsofthemorphologyanddistributionofarthriticlesionsintheinflammatoryarthritides.RadiographicfeaturesEarlySofttissueswellingaroundinvolvedjointsJuxta-articularosteopeniaSubtlemarginalboneerosionsLateOsteopenia(diffuse)JointspacenarrowingObviouserosionsJointsubluxationsSofttissueatrophyRheumatoidnodules

typicalerosionsofthesmalljointsTypicalerosionsinthebareareasareseeninthis55-year-oldwomanwithrheumatoidarthritis.Notealsoperiarticularosteoporosisandsoft-tissueswelling.(above)a59-year-oldwomanshowstheswan-neckdeformityofthesecondthroughfifthfingers.Notetheflexioninthedistalinterphalangealjointsandtheextensionintheproximalinterphalangealjoints,thehallmarksofthisabnormalitya51-year-oldwomanshowssubluxationinthemetacarpophalangealjointsresultinginulnardeviationofthefingersandradialdeviationintheradiocarpalarticulations.Notealsoankylosisofthemidcarpalarticulationsoftherighthanda52-year-oldwomanwithrheumatoidarthritisaffectingseveraljointsshowtricompartmentalinvolvement.Notetheperiarticularosteoporosis,jointeffusion,andlackofosteophytosis.

a72-year-oldmanwithadvancedrheumatoidarthritisshowsupwardmigrationofthehumeralheadsecondarytorotatorcufftear,acommoncomplicationofrheumatoidchangesintheshoulderjoint.Notethecharacteristictaperederosionofthedistalendoftheclavicle,erosionsofthehumeralhead,andthesubstantialdegreeofperiarticularosteoporosis

a52-year-oldwomanwithadvancedrheumatoidarthritisshowserosivechangesoftheapophysealjoints.Inaddition,noteosteoporosis,erosionoftheodontoid,erosionsatthediskovertebraljunctions,andwhittlingofthespinousprocessesA52-year-oldwomanwithadvancedrheumatoidarthritispresentedwithchronicneckpain,weaknessoftheupperlimbs,numbnessinbothhands,andoccasionaldyspneaandcardiacarrhythmia.AsagittalSET1WMRimageshowsinflammatorypannuserodingodontoid(arrow),andcranialsettlingwithcephaladmigrationofC-2impingingonthemedullaoblongata(openarrow).RheumatoidnodulosisRA(early)RA(early)RA(early)RA(early)RA(early)RA(early)RheumatoidosteitisAnkylosingSpondylitis(AS)Aninflammatoryconditionthataffectsprimarilytheaxialskeleton.youngmaleswhopresentwithlow-backpain.Age:15to35yearsSex:Malesoutnumberfemales4:1to10:1.Distribution:sacroiliacjoints,spine(lumbartocervical),hips,knees,shoulders.Peripheraljointsofhandsandfeetlesscommon.

HLA-B27antigenfrequentlypositive

ImagingfeaturesSacroilitis(mostbilateralsymmetricinvolvement)

Erosion(moresevereontheiliacside)SubchondralsclerosisPseudowideningofjointspaceOsseousbridgingAnkylosisASASFusionoftheSacroiliac(SI)JointsinAnkylosingSpondylitis.BilateralcompletefusionoftheSIjointsinthispatientwithankylosingspondylitismakestheSIjointstotallyindistinguishable.(leftfig.)Bilateralsymmetricsacroiliacjointsclerosisanderosions(rightfig.)Bilateralsymmetricobliterationofthesacroiliacjointswithprominentsyndesmophytesinthelowerlumbarspine

Ankylosisofjoint

Inthespine

Squaringoftheanteriorborderofthelowerthoracicandlumbarvertebrae(earlyradiographicfeature)Syndesmophytesbridgingthevertebralbodies(verticalorientation)Paravertebralossifications

“bamboo”spine

(A)Lateralradiographofthecervicalspineina53-year-oldmanwithadvancedankylosingspondylitisshowsanteriorsyndesmophytesbridgingthevertebralbodiesandposteriorfusionoftheapophysealjoints,togetherwithparavertebralossifications,producinga“bamboo-spine”appearance.Thesamephenomenonisseenontheanteroposterior(B)andlateral(C)radiographsofthelumbosacralspine.Noteontheanteroposteriorviewthefusionofthesacroiliacjointsandtheinvolvementofbothhipjoints,whichshowaxialmigrationofthefemoralheadssimilartothatseeninrheumatoidarthritis.(D)Sagittalproton-densityMRIshowsanteriorsyndesmophytes,calcificationoftheposteriorlongitudinalligament,andpreservationoftheintervertebraldisksAdvancedankylosingspondylitisofthespine

(A)Lateraland(B)APradiographsofthelumbarspineshowthatthesyndesmophyteshavematuredtoproducetheclassic‘bamboospine’.

(C)MRshowsthesquaringofthevertebralbodies,calcificationoftheanteriorlongitudinalligament,andincreasedsignalintheanterioraspectsofthediscs.

ASAS(Bamboo)AS(Bamboo)AS(Bamboo)AS(Bamboo)Osteoarthritisthemostcommonarthropathyandincreasesinincidencewithagemayoccurafterotherarthropathies(secondaryOAs).Degenerativejointdiseasemaybegenetic,ortheresultofage,occupation,ormultiplefactors.Patientspresentwithpainandswellingintheinvolvedjoints.Age:morethan50yearsold(primaryOAs)Sex:nosexpredilectionDistribution:hands(DIPandPIPjoints),feet,knees,andhips.DDxImagingfeatures:Asymmetricjointspacenarrowing(weight-bearingsite)SubchondralsclerosisSubchondralcystsOsteophyteformationSubluxations(lessdramaticthanRA)Unilateralorbilateralinvolvement,butasymmetricBothjointsdemonstratejointspacenarrowing,subchondralsclerosis,andosteophytosis,whicharehallmarksofDJD.Pre