SlideShare a Scribd company logo
38 DAVID SUTTON
DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL
• Fig. 38.1 Rheumatoid arthritis. Bilateral changes are fairly symmetrical. Soft-tissue swelling
is demonstrated, especially over the ulnar styloids. Erosions are demonstrated at the
carpus, distal radius and ulna, with joint space narrowing and collapse of bone.
Metacarpophalangeal erosions are also seen associated with joint space narrowing. There is
a swan-neck deformity of the right fifth distal interphalangeal joint.
• Fig. 38.2
Retrocalcaneal
bursitis in association
with thickening of the
tendo Achilles and a
retrocalcaneal
erosion. A soft-tissue
mass is demonstrated
in the angle normally
filled by fat between
the insertion of the
tendon and the upper
calcaneus.
• Fig. 38.3 Rheumatoid arthritis. (A) The initial radiograph shows a hint
of early trabecular loss around the proximal interphalangeal joint of a
finger with preservation of the joint space and early marginal cortical
loss at the base of the middle phalanx. (B) The subsequent radiograph
shows established erosive change in the area of ill-defined
demineralisation in association with joint space narrowing. (Courtesy
of Dr. A. Larsen, Oslo.)
• Fig. 38.4 Terminal
phalangeal sclerosis in
rheumatoid arthritis.
Obliteration of the
medullary cavity of the
distal phalanges is
demonstrated in this
patient. The new bone
is very dense and well
defined. The change is
especially marked at
the little and ring
fingers.
• Fig. 38.5 Progressive narrowing of a joint in rheumatoid arthritis.
(A) Y ear 1. The metacarpophalangeal joint looks normal. (B) Y ear
3. There is narrowing of the metacarpophalangeal joint of the index
finger with associated local soft-tissue swelling. Erosive change is
demonstrated at the metacarpal head. (C) Y ear 4. Little change
over the year. (D) Y ear 13. On this late film the soft tissues remain
thickened. The joint space is obliterated. Erosive change is
demonstrated, especially at the metacarpal head. There is ulnar
drift.
• Fig. 38.6 Gross
rheumatoid arthritis
at the carpus with
ulnar deviation,
subluxation and joint
narrowing at the
metacarpophalangeal
joints. Boutonniere
deformities are
present at the index
and little fingers.
• Fig. 38.7 Rheumatoid
arthritis with narrowing
of the
metatarsophalangeal
joint of the great toe and
a fine periostitis on the
adjacent shafts (arrows).
• Fig. 38.8 Rheumatoid
arthritis. A lateral view
of the heel shows
irregular erosive change
along the base of the
heel in association with
a small plantar spur.
Erosive change is also
demonstrated
posteriorly at the
insertion of the tendo
Achillis.
• Fig. 38.9 Rheumatoid arthritis. (A) The initial radiograph shows
demineralisation of bone at the second and third metacarpals heads with
preservation of local joint spaces. (B) The second film shows that the areas
of demineralisation at the second metacarpal head hid erosions. The
erosions are marginal. The joint space narrows slightly.
• Fig. 38.10 Rheumatoid
arthritis. Marked soft-
tissue swelling is
demonstrated over the
ulnar aspect of the
carpus in association with
erosion at the distal ulna
and the related carpal
bones. The joint space
between the carpus and
the ulna is narrowed.
• Fig. 38.11
Rheumatoid arthritis
very pronounced
destructive changes
in the tarsus and in
metatarsal heads.
• Fig. 38.12 Rheumatoid arthritis. Progressive films
taken over 6 years, showing marginal erosions and
joint space narrowing followed by collapse of articular
surfaces. A small geode is demonstrated in the
proximal phalenx of the third ray.
• Fig. 38.13 Geodes in rheumatoid arthritis. There is
joint space narrowing. Osteoporosis is demonstrated.
An effusion is present. There are large distal femoral
geodes which reach the patellofemoral articulation.
• Fig: 38.14 Rheumatoid arthritis – extreme
protrusio with medial migration and erosion
of the femoral heads. Compare this with Fig:
38.72 (protrusio in osteoarthritis)
• Fig. 38.15 Rheumatoid arthritis of the elbow
showing marked resorption of all the articular
surfaces with marginal erosions, especially
well at the radial neck and trochlea.
• Fig. 38.16 Rheumatoid arthritis-widening of
the acromioclavicular joint. Erosion of the
third and fourth ribs superiorly is also seen in
this condition.
• Fig. 38.17 Rheumatoid arthritis of the cervical spine. (A) The plain
film shows subluxation of C1 and loss of the odontoid peg. The disc
spaces from C3 down are narrowed and the end-plates irregular
and eroded. Fusion is demonstrated at C5/6 and C7/T1 levels. There
is no soft-tissue swelling, but deformity results from the forward
subluxation of C1 upon C2. (B) In the same patient the sagittal T,-
weighted MR sequence demonstrates that the odontoid peg is no
longer visible. End-plate irregularity is again demonstrated with
narrowing of disc spaces.
• Fig. 38.18 Rheumatoid
arthritis of cervical spine-
tomographic section
showing erosions of the
left atlanto-axial
articulation. Similar
changes affect the right
side and also the occipito-
atlanto joints and the
odontoid peg.
• Fig. 38.19 Rheumatoid arthritis. (A) Erosions and
upward subluxation of the humeral head. (B)
Arthrogram showing numerous 'millet seeds' floating
freely within the joint. There is also a rotator cuff tear.
• Fig. 38.20 Baker's cyst. (A) Sagittal fat-suppression (left) and axial T
1 - weighted gradient-echo (right) MR sequences. The sagittal
image demonstrates a well-defined and intact Baker's cyst posterior
to the knee joint in this child. The axial image shows the medial
situation of the Baker's cyst and demonstrates its origin between
the tendons of the medial gastrocnemius head and distal
semimembranosus muscles.
• Fig. 38.20 Baker's cyst. (B) T1- and T 2-
weighted MR images showing a posteriorly
situated cyst, seen to contain debris. The leak
disrupts the adjacent musculature.
• Fig. 38.21 Rheumatoid
arthritis. (A) Whole-body
radioisotope scan showing
areas of increase in uptake in
the neck, both shoulder
joints, the elbow joints, the
left hip, both knees and
ankles in a patient with
rheumatoid disease. The
distribution of disease is
shown, but the changes on
this scan are not specific.
(Courtesy of Dr A. Hilson.) (B)
Localised images of the
hands showing changes of a
more specific distribution.
(Courtesy of Dr A. Saifuddin.)
• Fig. 38.21 Rheumatoid
arthritis.(B) Localised
images of the hands
showing changes of a
more specific
distribution. (Courtesy
of Dr A. Saifuddin.)
• Fig. 38.22 Sagittal scan of metacarpophalangeal joint affected by
rheumatoid arthritis. The irregular echogenic margin of an erosion
(e) is shown in the distal high echogenic cortical margin of the head
of the second metacarpal (M) with adjacent low echogenic synovial
proliferation (S) and anechoic fluid (f). The fibrillar extensor tendon
(T) and echogenic cortex of proximal phalanx (P) and
metacarpophalangeal joint (jt) are shown.
• Fig. 38.23 Coronal scan of lateral meniscal tear. Echogenic margin
of lateral femoral condyle (F) and tibial plateau (T), intermediate
lower echogenicity of meniscus (M) with torn fragment (*), areas of
anechoic fluid of the meniscal cyst (Cy) arising from the tear.
• Fig. 38.24 Longitudinal scan of synovial thickening around
the lateral mid foot. Echogenic margins of the calcaneum
(C) and cuboid (Cu). Irregular margin of cuboid representing
erosion (e). Synovial thickening (black S) of intermediate
echogenicity around peroneus brevis tendon (T) which has
a bright fibrillar structure. Irregular fingers of synovium
(white S) associated with calcaneocuboid joint with
associated anechoic synovial fluid and low echogenicity (f).
• Fig 38.25 Transverse scan through olecranon bursa.
Deep to the skin (sk) and subcutaneous fat (ft), an
anechoic fluid-filled bursa (B) is shown with echogenic
foci within, these representing loose bodies (lb)
adjacent to the echogenic cortical margin of the
olecranon (0).
• Fig. 38.26 Longitudinal scan of the normal
Achilles tendon. Echogenic fibrillar structure of
the tendon, with bright linear echogenicity of the
paratenon (arrows) and anisotropic effect of
tendon fibrils (tailed arrows) as they curve into
the insertion point in the calcaneum (C). Karger's
fat pad (Kf) is of low heterogeneous echogenicity.
• Fig. 38.27 (A) Longitudinal scans of the Achilles tendon. On the left,
normal tendon (T), Karger's fat pad (Kf) and insertion of tendon into
calcaneum (C). On the right the tendon (T) is swollen and has focal low
echogenicity near the insertion into the calcaneum (C) consistent with
focal tendonosis. A small area of low echogenicity deep to the tendon (r) is
a retrocalcaneal bursa. Also, note the increased echogenicity of Karger's
fat pad on the right associated with the inflammatory change. (B)
Transverse scans of the Achilles tendon. On the left normal tendon (T) and
on the right the focal area of tendonosis (T) in the medial aspect of the
tendon.
• Fig. 38.28 Longitudinal scan of partial tear in the
distal Achilles tendon (T) where torn fibrils of the
tendon extend into a liquefied anechoic
haematoma Jr) adjacent to insertion in
calcaneum (C).
• Fig. 38.29 (A) Transverse scan through the bicipital
groove of the humerus (H), which contains a normal
brightly echogenic long head of biceps tendon (t)
surrounded by low echogenic synovial thickening (s).
(B) Longitudinal scan through the long head of biceps
(LHB) surrounded by anechoic fluid (F) and synovial
thickening (S).
• Fig. 38.30 Coronal scan through the shoulder showing the
tip of the acromion (Ac) casting acoustic shadow, the layers
of tissue superficial to the supraspinatus tendon (ss) as it
inserts into the greater tuberosity of the humerus (H),
namely: skin (sk), fat (ft), deltoid muscle (dt) and a large
subacromion subdeltoid bursa (B) of hypoechogenicity, the
cause of the patient's symptoms.
• Fig. 38.31 'Jumper's knee'. (A) Longitudinal scan. A focal central tendonosis of the
patella tendon (Pt) at the proximal insertion in the lower pole of the patella (P).
There is increase in the echogenicity of the related Hoffa's fat pad (Hf) adjacent to
the area of swelling and low echogenicity in the patella tendon on the left
compared to the normal tendon on the right. Arrowheads indicate the paratenon.
(B) Transverse scan showing the patella tendon between *. On the left the central
focal area of swelling and low echogenicity can be compared to the wide thin high
echogenicity of the normal tendon on the right.
• Fig. 38.32 (A) Longitudinal scan through diffuse/global patella
tendonosis; the patella tendon (Pt) on the right is swollen and of
generally low echogenicity compared to the normal tendon on the
left. (B) Transverse scan through diffuse/global patella tendonosis,
showing the patella tendon between * on the right being diffusely
swollen compared to Fig. 38.31B and the normal tendon on the left
(P) = patella
• Fig. 38.33 Transverse scan through Baker's cyst,
an anechoic collection of fluid (Cy). This is a
bursa communicating with the knee joint sited
behind the medial femoral condyle (F), the neck
of the cyst has formed between the medial head
of gastrocnemius (G) and the semimembranosus
tendon (S)
• Fig. 38.34 Ruptured Baker's cyst. (A) Longitudinal scan of the ruptured
Baker's cyst (Cy) posterior to the medial femoral condyle (F) and
gastrocnemius muscle (G) with a mixture of anechoic synovial fluid and
synovial thickening and debris extending into the cystic cavity which may
relate to haemorrhage. The tapered inferior end of the cyst indicates that
there has been rupture. (B) Longitudinal scan of the tip of the ruptured
cyst (Cy); the streaks of low echogenicity extending into the muscle (sy)
represent
• Fig. 38.35 Longitudinal scan of lower leg and a
muscle tear (tr) associated with liquefied
haematoma (fl) just below the skin (sk). In
comparison with Fig. 38.34B, the area of low
echogenicity is more heterogeneous and has a
more irregular contour than the muscle oedema.
Note normal muscle (Ms)
• Fig. 38.36 Rheumatoid arthritis at MRI. (A) Coronal T,-weighted
sequence. (B) Coronal fat-suppression images. There is a large
effusion in the shoulder joint and in the subacromial bursa. There is
upward subluxation of the humeral head but the rotator cuff
tendon is in part intact. Erosive changes are demonstrated in the
humeral head with the appropriate signal change. (C) A more
anterior scan shows the distended subacromial bursa containing
numerous loose bodies. See also Fig. 38.19.
• Fig. 38.37 Pannus in rheumatoid arthritis.
Thickened synovium demonstrated (A) pre- and
(B) post-gadolinium enhancement. The effusion
exhibits a low signal, while the surrounding area
of bright signal (arrow) represents hypertrophic
vascular synovium. (Courtesy of Dr G. Clunie, UCL
Hospitals.)
• Fig. 38.38 Rheumatoid arthritis at MRI (corona)
(A) and sagittal (B) T 2 -weighted sequences).
There is loss of meniscal and articular cartilage,
irregularity of articular surfaces and subchondral
cysts filled with fluid. There is also debris within
the joint.
• Fig. 38.39 Retrocalcaneal bursitis with an
erosion. The tendo Achilles is thickened distally;
the bone is eroded at its insertion and there is
also an erosion on the upper aspect of the
calcaneus assosiated with local bursitis.
• Fig. 38.40 (A) Sagittal CT reconstruction showing odontoid
peg erosion and separation of the space between the peg
and arch. There is a soft-tissue mass interposed between
the two structures. The peg is upwardly subluxated.
(Courtesy of Dr J. Stevens.) (B) CT radiculography in
rheumatoid arthritis. The odontoid peg is eroded and
separated from the arch of the atlas by a soft-tissue mass.
(Courtesy of Dr J. Stevens.)
• Fig. 38.41 Rheumatoid
arthritis at MR scanning. (A)
T,-weighted axial image. (B)
T,-weighted sagittal image. A
soft-tissue mass is seen in the
region of the eroded odontoid
peg and this indents the cord.
Note distal changes at all
levels in the cervical spine
• Fig. 38.42 juvenile
chronic arthritis.
Accelerated skeletal
maturity with
modelling
abnormalities of the
carpal bones and
osteoporosis.
• Fig. 38.43 Juvenile
chronic arthritis.
Monarticular
arthritis with soft-
tissue swelling,
osteoporosis and
overgrowth of the
epiphyses at the
right knee. Normal
left knee.
• Fig. 38.44 Juvenile
chronic arthritis.
There is overgrowth
the epiphyses around
the knee with
associated soft-tissue
swelling. The tibial
epiphysis in particular
shows a rather square
shape with marked
angulation of its
margins, which never
occurs in the normal.
• Fig. 38.45 Juvenile chronic arthritis. (A) The early
radiograph in this some patient shows hypoplasia of
the vertebral bodies and a widened cervical canal. (B)
Subsequently the vertebral bodies and facet ioints
ankylose, with failure of development.
• Fig. 38.46 The relationship between the different manifestations of
arthritis is shown, together with the appropriate tissue markers.
(Courtesy of Dr D. A. Brewerton.)
• Fig. 38.47 Psoriasis.
Soft-tissue swelling is
seen over the great toe
and the erosions at the
bases of the distal
phalanges are on the
articular, rather than
the periarticular,
surface, producing a
'gull's wing‘appearance.
• Fig. 38.48 Psoriasis. The distal
interphalangeal joints are involved
in this condition. Bone density is
often preserved. Erosions proceed
along the bases of the distal
phalanges and there is splaying of
bone locally. Despite the erosive
change, the joints may be
increased in width or, alternatively,
fused. These changes are totally
unlike those seen in rheumatoid
arthritis both in appearance and
distribution. There is also a
neurotrophic change at the distal
and middle phalanges, with
longitudinal and concentric bone
resorption, producing a 'licked
candy stick' appearance.
• Fig. 38.49 A ' sausage digit'
in psoriatic arthritis. There
is soft tissue swelling.
Periostitis is demonstrated.
The bone shows an
apparent increase in
density.
• Fig. 38.50 Psoriatic
spondylitis. Non-marginal
vertical floating
syndesmophytes are
more typical of psoriasis
and are less often seen in
ankylosing spondylitis.
• Fig. 38.51 Reiter's syndrome-
acute form, showing marked
osteoporosis and periosteal
reaction (arrows).
• Fig. 38.52 Reiter's
syndrome.
Periostitis and
erosive changes on
the plantar and
posterior aspects of
the calcaneus and of
the distal tibia.
• Fig. 38.53 (A,B,C)
Reiter's syndrome. The
three radiographs
taken over a 12-year
period demonstrate
the progression of a
unilateral sacroiliitis.
• Fig. 38.54 Ankylosing spondylitis-early. (A)
Serrated margins of sacroiliac joints and
periarticular sclerosis.
• Fig. 38.54 Ankylosing spondylitis- early (B) CT
scanning demonstrates bilateral sacroiliitis.
• Fig. 38.55 Ankylosing
spondylitis. Increase
in uptake is
demonstrated at both
sacroiliac joints,
greater on the right, in
this posterior scan.
(Courtesy of Dr A.
Hilson.)
• Fig. 38.56
Ankylosing
spondylitis. Discal
narrowing and
adjacent erosions
heal with prolific
new bone formation.
Sclerosis and
vertebral squaring
result.
• Fig. 38.57 Ankylosing
spondylitis. (A) Squaring
of vertebral bodies is
demonstrated, much of
which is due to ossification
in the line of the anterior
longitudinal ligament.
Longstanding fusion has
resulted in calcification of
the discal nucleus. There is
also quite marked
ankylosis of the posterior
spinal elements. (B) A T2 -
weighted MR sequence
showing vertebral
squaring with fusion
across the narrowed
intervertebral discs. There
is prominence both of the
anterior and posterior
longitudinal ligaments,
which may relate to
ligamentous ossification.
• Fig. 38.58 Ankylosing spondylitis-'bamboo spine' with marginal
syndesmophytes
• Fig. 38.59 Cervical spine in ankylosing spondylitis, with fractures through
the C4/5 and C5/6 discs.
• Fig. 38.60 Ankylosing spondylitis (Andersson lesion). End-
plate irregularity is demonstrated together with reactive
sclerosis in the underlying bone in this patient with
ankylosing spondylitis. There is also instability at this level.
• Fig. 38.61 Ankylosing spondylitis-note bony
ankylosis across joint cartilage. Irregularity of
the surface of the ischium is also shown.
• Fig. 38.62 Senile
ankylosing
hyperostosis-this is an
extreme example of
this common lesion. A
tremendous amount of
new bone has formed.
The outlines of the
original vertebral bodies
and disc spaces are
preserved.
• Fig. 38.63 Diffuse idiopathic skeletal hyperostosis. The
plain radiograph of this patient demonstrates new
bone formation at the iliac crests and ischia as well as
fusion of the sacroiliac joints superiorly. There is also
faget's disease in the right femur.
• Fig. 38.64 Diffuse idiopathic skeletal
hyperostosis. The CT scan shows that the
joint spaces are still patent but there is
ankylosis anteriorly.
• Fig. 38.65 Diffuse idiopathic skeletal hyperostosis with
ossification of the posterior longitudinal ligament. New
bone is seen anteriorly on this cervical vertebral body and
posteriorly in the canal along the line of the posterior
• Fig. 38.66 (A) The initial radiograph shows lateral migration of the
femoral head with obliteration of the superior joint space. There is
accretion of new bone medially within the joint. (B) The subsequent
radiograph shows collapse of the femoral head and of the
acetabulum. There is now more new bone both on the femoral
head and on the acetabulum medially. A new joint space often
results. Buttressing of the medial cortex of the femoral neck (the
calcar) is a common finding in degenerative disease of the hip.
• Fig. 38.67 (A,B,C) Patterns of degeneration
(see text). Key: Grey = cartilage; black =
cortex; stripes = medulla. (D) Reduplication
with new bone laid down on the articular
surface.
Eburnation Reduplication
• Fig. 38.67 (D)
Reduplication with
new bone laid
down on the
articular surface.
• Fig. 38.68 (A) CT scan of osteoarthritis
showing new bone formation within the
acetabulum and cyst formation at the
articular surface. (B) Osteoarthritis
demonstrated at MRI: sagittal STIR (fat
suppression) sequence showing loss of
joint space, subarticular cyst formation
in the tibia with oedema of the
periarticular soft tissues, as well as an
effusion in the joint.
• Fig. 38.69
Osteoarthritis. (A) Right
shoulder arthrogram.
There is irregularity of
the synovium and
numerous loose bodies
are demonstrated
within the joint space.
There is also a small
rotator cuff tear.
• Fig. 38.69 Osteoarthritis. (B) MRI demonstrates
degenerative changes of the knee with an
effusion, loss of the medial meniscus, marginal
osteophytosis and a large loose body lying
medially within the joint.
• Fig. 38.70 (A,B) Osteoarthritis of the ankle. Articular irregularity with
synovial thickening and effusions as well as synovial diverticula are
demonstrated. Loss of articular cartilage is seen and erosive changes are
demonstrated, especially on the upper surface of the talus. Osteophytes
are demonstrated at the malleoli .There is a very large anterior alar
osteophyte associated with local synovial proliferation, seen on sagittal
images.
• Fig. 38.70 (A,B) Osteoarthritis
of the ankle. Articular
irregularity with synovial
thickening and effusions as well
as synovial diverticula are
demonstrated. Loss of articular
cartilage is seen and erosive
changes are demonstrated,
especially on the upper surface
of the talus. Osteophytes are
demonstrated at the malleoli
.There is a very large anterior
alar osteophyte associated with
local synovial proliferation,
seen on sagittal images.
• Fig. 38.71 Loss of
the femoral head
and deepening of
the acetabulum
may be the end-
stage of
osteoarthritis.
• Fig. 38.72 Patterns of osteoarthritis. (A) Superior migration of the
femoral head. There is new bone on the medial aspect of the
acetabulum. (B) Osteoarthritis associated with protrusio acetabuli.
(C) Migration of the femoral head is in a superomedial direction.
• Fig. 38.73 (A) Osteoarthritis of the shoulder-note excavation of the upper
part of the anatomical neck with local sclerosis, and cysts seen en face
(arrow). (B) Widespread abnormalities are present on this coronal image
of the shoulder. There is degeneration with an effusion around the
acromioclavicular joint, a subacromial bursitis and considerable thickening
of the rotator cuff, which shows a cyst in its body. In addition, there is a
distal tendinitis associated with an erosion of the greater tuberosity.
• Fig. 38.74 Osteoarthritis of
the shoulder, classic type-loss
of joint space, eburnation,
cyst formation and
osteophytosis shown.
• Fig. 38.75 Osteoarthritis
of patellofemoral joint.
There is a groove on the
lower anterior part of
the femoral shaft
(arrow).
• Fig. 38.76
Osteoarthritis. A
degenerate and torn
medial meniscus is
associated with marginal
osteophytosis and a
subarticular cyst in the
tibia. In addition, there
is spiking of the tibial
spines and at the
intercondylar notch. An
effusion is also present.
• Fig. 38.77 Severe osteoarthritis
of the carpometacarpal joint of
the thumb.
• Fig. 38.78 Osteoarthritis.
joint narrowing and
osteophyte formation,
with broadening of the
joint underlying the
Heberden's nodes.
• Fig. 38.79 Erosive
osteoarthritis of the
interphalangeal
joints. Appearance
of destruction
around some
proximal and distal
interphalangeal
joints.
• Fig. 38.80 Early cervicalspondylosis . (A) The plain film shows slinght loss
of normal curve centered around the C5/6 disc which is also minimally
narrowed. There are no osteophytes as yet. (B) MR scan confirms the
minimal loss of the height of this disc. There is no loss of signal and no
dorsal protrusion of discal material. (C) A discogram confirms the
presence of an annular tear with substantial leak of contrast.
• Fig. 38.80 Early cervicalspondylosis . (D) cervical spondylosis in a
more advanced form. The MR scan is abnormal with anterior
discal bulging and marginal osteophytosis at C4/C5 and C5/C6
levels. (E) In the discogram of the same patient anterior and
posterior annular tears are demonstrated with dorsal bulging. The
anterior annular tears shown to extend to the osteophytes.
• Fig. 38.81 Cervical spondylosis. (A) There is early narrowing of the C5/6
disc and the beginnings of anterior osteophytosis. (B) Disc degeneration is
now pronounced, with both anterior and posterior osteophytes.
• Fig. 38.82 Oblique
projection of cervical spine
showing large osteophytic
protrusions into the C5/6
intervertebral foramen
(arrow).
• Fig. 38.83 MRI of the
cervical spine. Dorsal
osteophytosis and distal
protrusion indent the
thecal sac and cervical
cord.
• Fig. 38.84 (A) The facet joints are no longer
symmetrical and show features of degeneration. (B)
The CT scan shows gross new bone formation around
narrowed facet joints. There is marked bony
encroachment upon the exit foramina, especially the
left. Gas is seen in the disc (vacuum phenomenon).
• Fig. 38.85 Lumbar spondylosis. There is distal narrowing and a vacuum
phenomenon is present in the degenerative discs. Marginal osteophytes
are present. Inferiorly the facet joints show features of degeneration and,
with the increase in lordosis, the spinous processes are in contact.
• Fig. 38.86 (A) Simultaneous discography and radiculography demonstrate
a torn annulus, through which contrast medium escapes and impinges
upon the opacified theca. (B) The CT scan shows, in the axial plane, the
site of the annular tear and the displacement of the nucleus. Indentation
of the opacified thecal sac is demonstrated.
• Fig. 38.87 Lumbar degeneration. (A) The L5/S1 disc is
clearly grossly abnormal showing loss of height and signal,
together with a dorsal distal protrusion. At L4/5 there is
early loss of signal. (B) The discogram at L4/5 shows an
essentially normal nucleus, but there is a fine annular tear
which is associated with a bulge. No extraneous leak. This
injection was extremely painful.
• Fig. 38.88 The HIZ T2-
weighted MR sequence
showing the posterior
high-intensity zone.
• Fig. 38.89 (A,B) MRI and discography
demonstrate a dorsal distal protrusion with
narrowing of the canal at that level.
• Fig. 38.90 Gout-erosion on
the medial part of the first
metacarpal extends away
from the joint surface.
• Fig. 38.91 Very advanced gout. Note eccentric
soft-tissue swellings, intraosseous tophi
extending to bone ends and lack of
osteoporosis.
• Fig. 38.92 Gout-large
calcified tophi in
olecranon bursa.
• Fig. 38.93 Hypertrophic
osteoarthropathy-exuberant
periosteal reaction of the
radius and ulna. In this
patient, changes in the
bones of the hands were
minimal.
• Fig. 38.94
Hypertrophic
osteoarthropathy
secondary to
pulmonary neoplasm.
• Fig. 38.95 Hypertrophic osteoarthropathy.
Generalised and symmetrical diffuse increase
in uptake is associated with thickening of the
bony image at isotope scanning.
• Fig. 38.96
Scleroderma.
Contractures result
in pressure
resorption of bone
at metacarpal
necks. Para-
articular
calcification is
prominent, as is
distal phalangeal
sclerosis.
• Fig. 38.97 Discoid meniscus. (A) The
plain film shows dishing of the lateral
tibial plateau. (B) Arthrography. The
meniscus extends medially to the
midline of the joint and has a bulbous
internal aspect. (C) The MR scan shows
the same external contour of the
meniscus as the arthrogram but shows
cystic degeneration within the structure
of the meniscus. Note also the increase
in signal at the metaphysis-a normal
feature.
• Fig. 38.98 Double-contrast arthrography of
the knee showing total peripheral
detachment.
• Fig. 38.99 Sagittal
T,-weighted image
of the knee. The
medial meniscus is
torn. There is a
large Baker's cyst
which contains
loose bodies.
• Fig. 38.100
Classification of
meniscal change at
MRI from normal to
tear , according to
mink et al. (1993)
• Fig. 38.101 Tear of the
posterior horn of the
medial meniscus
associated with a tibial
cyst. Peripheral
meniscal cysts
originating from
degenerate menisci are
seen on sagittal, axial
and coronal images at
MR scanning.
• Fig. 38.102 (A,B) A
medially directed cyst
related to an abnormal
posterior horn is shown
in coronal, axial (A) and
sagittal (B) images. The
cyst is palpable beneath
the skin and serial
images track its
communication to the
interior of
• Fig. 38.102 (A,B) A
medially directed cyst
related to an
abnormal posterior
horn is shown in
coronal, axial (A) and
sagittal (B) images.
The cyst is palpable
beneath the skin and
serial images track its
communication to the
interior of
• Fig: 18.103 A disrupted
posterior cruciate ligament
surrounded by effusion.
• Fig. 38.104 Sagittal T,-
weighted MR sequence
of the knee showing an
irregular and ruptured
anterior cruciate
ligament (arrow)
• Fig. 38.105 Coronal T2-
weighted image of the
knee demonstrates a
tear of the medial
collateral ligament.
• Fig. 38.106 Bone bruising
in the medial femoral
condyle well
demonstrated on a
sagittal fat-suppression
image of the knee.
• Fig. 38.107 Rupture of a
Baker's cyst is
demonstrated. This is
probably chronic, as the
cavity in the calf has a
smooth margin. (Courtesy
of Dr A. R. Taylor.)
• Fig. 38.108 Radioisotope bone scan (SPECT) of
the knee shows focal areas of increase in uptake
(arrows) at sites of proven abnormality of the
menisci. (Courtesy of Dr I. Fogelman.)
• Fig. 38.109 A normal
shoulder arthrogram
showing the extent of
the glenohumeral
synovium. There is no
contrast beneath the
acromion. The synovial
reflection around the
long head of biceps
tendon is shown.
• Fig. 38.110 A rupture
of the rotator cuff is
seen at shoulder
arthrography, with
contrast medium
filling the
subacromial space.
38  DAVID SUTTON PICTURES  DISEASES OF JOINT
• Fig. 38.112 A
subacromial osteophyte
is associated with local
tendinitis (T,- and T 2-
weightings).
• Fig. 38.113 Total rotator cuff tear with
retraction. Axial CT of the shoulder
demonstrates an anterior labral tear.
• Fig. 38.114 A tear of the labrum glenoidale
anteriorly shown at MR scanning. Fluid provides
the contrast medium on the T1 -weighted image.
• Fig. 38.115 Coronal oblique scan of a normal
supraspinatus tendon. The layers of tissue that
should be seen are: skin (sk), fat (ft), deltoid
muscle (dt), brightly echogenic supraspinatus
tendon (ss), low echogenic hyaline cartilage (hy),
high echogenicity of the cortex of the humerus
(H) and greater tuberosity (GT).
• Fig. 38.116 Coronal oblique scan of supraspinatus calcific
tendonosis. The supraspinatus tendon (ss) is of
heterogeneous low echogenicity with foci of high
echogenicity (arrowheads), some of which cast acoustic
shadow consistent with calcification. Skin (sk), fat (ft),
deltoid muscle (dt) And humeral head (H) are shown
• Fig. 38.117 Coronal
oblique scan of
supraspinatus full-
thickness tear. There is an
area of low echogenicity
between the two points
indicated (*), which
contains a mixture of low-
echogenic debris. Note
how the deltoid muscle
(dt) dips into the defect in
the supraspinatus tendon
(ss). GT = greater
tuberosity; H =humeral
head.
• Fig. 38.118 Coronal oblique (A) and axial (B) scans of
massive fullthickness rotator cuff tear. The skin (sk), fat (ft)
and deltoid muscle (dt) between the double-headed arrows
and synovium of subdeltoid bursa (br) are the only layers of
soft tissue seen between the subcutaneous fat and humeral
head (H). Note the irregularity of the humeral head contour
in B. Cr = coracoid process.
• Fig. 38.119 Axial scan showing the long head
of biceps (arrowheads) subluxed onto the
lesser tuberosity (LT), and an empty low
echogenic bicipital groove (BG), indicating tear
of the transverse humeral ligament.
38  DAVID SUTTON PICTURES  DISEASES OF JOINT
• Fig. 38.121 Total rupture of a thickened tendo
Achilles demonstrated at MRI. Fluid fills the
space between the retracted parts
• Fig. 38.122 Injection of the radiocarpal joint
space has demonstrated a tear of the
triangular cartilage and filling of the distal
radioulnar joint at arthrography.
• Fig. 38.123 MRI of the triangular cartilage.
There is bright signal within the bulk of the
triangular cartilage extending to its distal
surface.
• Fig. 38.124 Sagittal scan of a ganglion (Gg)
arising from an interphalangeal joint (IPJ). The
ganglion is anechoic consistent with being fluid
filled, and has a 'speech bubble' shape, the tail
extending between the phalanges (PH) into the
joint.
• Fig. 38.125 Loosening of
the hip prosthesis is
demonstrated at
arthrography. Contrast
medium surrounds the
acetabular component
and tracks down the
femoral stem. There is
also a defect in the bone
through which contrast
medium escapes into the
soft tissues.
• Fig. 38.126 Synovial tuberculosis. (A) The plain film
shows bone and cartilage destruction on both sides of
the joint. (B) The arthrogram shows gross irregular
synovial hypertrophy. The geode does not
• Fig. 38.127 Technetium bone scan. (A) Anterior scan
of pelvis. (B) Oblique scan of right hip. The prosthesis
can be seen as a defect on the scan and there is
increased uptake around it, especially at the femoral
component.
38  DAVID SUTTON PICTURES  DISEASES OF JOINT

More Related Content

PPTX
37 DAVID SUTTON PICTURES AVASCUALR NECROSIS
PPTX
44 DAVID SUTTON PICTURES SKELETAL TRAUMA REGIONAL
PPTX
40 DAVID SUTTON PICTURES TUMORS AND TUMORS LIKE CONDITIONS OF BONE II
PPTX
30 DAVID SUTTON PICTURES THE KIDNEY AND URETERS
PPTX
36 DAVID SUTTON PICTURES PERIOSTEAL REACTION BONE AND JOINT INFECTIONS: SARCOID
PPTX
54 DAVID SUTTON PICTURES NEURORADIOLOGY OF SPINE
PPTX
Spots with keys
PPTX
KEYS OF RADIOLOGY SPOTTERS GIT
37 DAVID SUTTON PICTURES AVASCUALR NECROSIS
44 DAVID SUTTON PICTURES SKELETAL TRAUMA REGIONAL
40 DAVID SUTTON PICTURES TUMORS AND TUMORS LIKE CONDITIONS OF BONE II
30 DAVID SUTTON PICTURES THE KIDNEY AND URETERS
36 DAVID SUTTON PICTURES PERIOSTEAL REACTION BONE AND JOINT INFECTIONS: SARCOID
54 DAVID SUTTON PICTURES NEURORADIOLOGY OF SPINE
Spots with keys
KEYS OF RADIOLOGY SPOTTERS GIT

What's hot (20)

PPTX
39 DAVID SUTTON PICTURES TUMORS AND TUMORS LIKE CONDITIONS OF BONE
PPTX
2 david sutton pictures
PPTX
1 david sutton pictures
PPTX
Presentation1.pptx. imaging of the cartilage.
PPTX
Biliary tract imaging final...........
PPTX
Presentation1, film readiing for barium studies.
PPTX
Ct mri urography
PPTX
Imaging of stomach
PPTX
Imaging of the large bowel
PPTX
Presentation1, radiological imaging of lateral hindfoot impingement.
PPTX
Presentation1, radiological imaging of anterior knee pain.
PPT
Pediatric urinary tract infection..the role of imaging
PPTX
SPOTTERS in radiology with explanations
PPTX
18 DAVID SUTTON PICTURES THE SALIVARY GLANDS PHARYNX AND ESOPHAGUS
PPTX
Barium swallow diseases
PPTX
Acute pancreatitis radiological approach
PPTX
21 DAVID SUTTON PICTURES THE LARGE BOWEL
PPT
Diagnostic Imaging of Spinal Infection & Inflammation
PPTX
Mri of knee
PPTX
Imaging of spleen ct and mri
39 DAVID SUTTON PICTURES TUMORS AND TUMORS LIKE CONDITIONS OF BONE
2 david sutton pictures
1 david sutton pictures
Presentation1.pptx. imaging of the cartilage.
Biliary tract imaging final...........
Presentation1, film readiing for barium studies.
Ct mri urography
Imaging of stomach
Imaging of the large bowel
Presentation1, radiological imaging of lateral hindfoot impingement.
Presentation1, radiological imaging of anterior knee pain.
Pediatric urinary tract infection..the role of imaging
SPOTTERS in radiology with explanations
18 DAVID SUTTON PICTURES THE SALIVARY GLANDS PHARYNX AND ESOPHAGUS
Barium swallow diseases
Acute pancreatitis radiological approach
21 DAVID SUTTON PICTURES THE LARGE BOWEL
Diagnostic Imaging of Spinal Infection & Inflammation
Mri of knee
Imaging of spleen ct and mri
Ad

Viewers also liked (20)

PDF
Vol 25 arthritis
PPTX
57 DAVID SUTTON PICTURES INTRACRANIAL LESIONS I
KEY
Direct MR Arthrography of Hip joint in Children for Acetabular Labrum- Techni...
PPTX
CONGENITAL HEART DISEASE
PPT
Arthrograms(3)
PPTX
35 DAVID SUTTON PICTURES THE CONGENITAL SKELETAL ANOMALIES: SKELETAL DYSPLAS...
PPTX
19 DAVID SUTTON PICTURES THE STOMACH AND DUODENUM
PPTX
25 DAVID SUTTON FRACTURE THE LIVER AND SPLEEN
PPT
Arthrograms Presentation
PPTX
15 DAVID SUTTON PICTURES Arteriography and Intervewntional Radiology
PPTX
28 DAVID SUTTON PICTURES THE PEDIATRIC ABDOMEN
PPTX
Presentation1.pptx, radiological imaging of bursae.
PPTX
PPTX
58 DAVID SUTTON PICTURES INTRACRANIAL LESIONS (2)
PPTX
26 DAVID SUTTON PICTURES THE PANCREAS
PDF
Uterine Tumours
PPT
MSK Imaging Guidelines
PPTX
MR Imaging of shoulder and knee joints
PPTX
Arthrography of the Shoulder, Ankle and Wrist.pptx
PPT
Digital fluoro
Vol 25 arthritis
57 DAVID SUTTON PICTURES INTRACRANIAL LESIONS I
Direct MR Arthrography of Hip joint in Children for Acetabular Labrum- Techni...
CONGENITAL HEART DISEASE
Arthrograms(3)
35 DAVID SUTTON PICTURES THE CONGENITAL SKELETAL ANOMALIES: SKELETAL DYSPLAS...
19 DAVID SUTTON PICTURES THE STOMACH AND DUODENUM
25 DAVID SUTTON FRACTURE THE LIVER AND SPLEEN
Arthrograms Presentation
15 DAVID SUTTON PICTURES Arteriography and Intervewntional Radiology
28 DAVID SUTTON PICTURES THE PEDIATRIC ABDOMEN
Presentation1.pptx, radiological imaging of bursae.
58 DAVID SUTTON PICTURES INTRACRANIAL LESIONS (2)
26 DAVID SUTTON PICTURES THE PANCREAS
Uterine Tumours
MSK Imaging Guidelines
MR Imaging of shoulder and knee joints
Arthrography of the Shoulder, Ankle and Wrist.pptx
Digital fluoro
Ad

Similar to 38 DAVID SUTTON PICTURES DISEASES OF JOINT (20)

PPTX
43 DAVID SUTTON PICTURES SKELETAL TRAUMA : GENERAL CONSIDERATION
PPTX
Presentation1 radiological film reading of wrist joint.
PPTX
Presentation1, radiological film reading of the sholder joint.
PPTX
51 DAVID SUTTON PICTURES THE ORBIT
PPTX
10 arthritides CLINICAL IMAGAGING AN ATLAS OF DIFFERENTIAL DAIGNOSIS EISENBERG
PPTX
Presentation1, radiological film reading of elbow joint.
PPTX
Presentation1.pptx. shoulder joint.
PPTX
48 DAVID SUTTON PICTURES THE SINUSES
PPTX
41 DAVID SUTTON PICTURES DISORDERS OF LYMPHORETICULAR SYSTEM AND HEMATOPOITIC...
PPTX
Presentation1, artifact and pitfalls of the knee, hip and ankle joints.
PPTX
32 DAVID SUTTON PICTURES THE MALE GENITILIA AND URETHRA
PPTX
shoulder pathologies MRI: basic anatomy and MRI scans
PPTX
x ray diagnostics of fractures and dislocations.pptx
PPTX
20 neoplastic lesions of vertebrae on magnetic resonance
PPTX
Mri shoulder joint with common pathologies
PPTX
Presentation1 Short cases MD..pptx
PPTX
Presentation1.pptx mri of elbow joint
PPTX
Patello femoral joint - MRI
PPTX
Patello femoral jt.
PPTX
Presentation1, radiological film reading of the ankle joint.
43 DAVID SUTTON PICTURES SKELETAL TRAUMA : GENERAL CONSIDERATION
Presentation1 radiological film reading of wrist joint.
Presentation1, radiological film reading of the sholder joint.
51 DAVID SUTTON PICTURES THE ORBIT
10 arthritides CLINICAL IMAGAGING AN ATLAS OF DIFFERENTIAL DAIGNOSIS EISENBERG
Presentation1, radiological film reading of elbow joint.
Presentation1.pptx. shoulder joint.
48 DAVID SUTTON PICTURES THE SINUSES
41 DAVID SUTTON PICTURES DISORDERS OF LYMPHORETICULAR SYSTEM AND HEMATOPOITIC...
Presentation1, artifact and pitfalls of the knee, hip and ankle joints.
32 DAVID SUTTON PICTURES THE MALE GENITILIA AND URETHRA
shoulder pathologies MRI: basic anatomy and MRI scans
x ray diagnostics of fractures and dislocations.pptx
20 neoplastic lesions of vertebrae on magnetic resonance
Mri shoulder joint with common pathologies
Presentation1 Short cases MD..pptx
Presentation1.pptx mri of elbow joint
Patello femoral joint - MRI
Patello femoral jt.
Presentation1, radiological film reading of the ankle joint.

More from Dr. Muhammad Bin Zulfiqar (20)

PPTX
Dislocations of joint. Joint Dislocation
PPTX
Role of color doppler ultrasound in rvhtn
PPTX
Bone age assessment
PPTX
Role of medical imaging in developemental dysplasia of Hip Dr muhammad Bin Zu...
PPTX
Trauma axial skeleton Dr. Muhammad Bin Zulfiqar
PPTX
21 non ischaemic acquired Dr.Muhammad Bin Zulfiqar
PPTX
Mri anatomy of knee Dr. Muhammad Bin Zulfiqar
PPTX
20 congenital heart disease Dr. Muhammmad Bin Zulfiqar
PPTX
An approach to cardiac xray Dr. Muhammad Bin Zulfiqar
PPTX
19 cardiac anatomy and Imaging techniques Dr. Muhammad Bin Zulfiqar
PPTX
Pediatric brain tumors Dr. Muhammad Bin Zulfiqar
PPTX
Prostate Biopsy--New Emerging Trends, Dr. Muhammad Bin Zulfiqar
PPTX
Eponymous fractures name Dr. muhammad Bin Zulfiqar
PPTX
18 Airspace Diseases Dr. Muhammad Bin Zulfiqar
PPTX
17 Thoracic Trauma and Related Topics
PPTX
Basic approach to brain CT Dr. Muhammad Bin Zulfiqar
PPTX
16 High Resolution Computed Tomography of Interstitial and Occupational Lung ...
PPTX
15 Pulmonary Neoplasms Dr. Muhammad Bin Zulfiqar
PPTX
Ultrasound of spinal cord in neonates Dr. Muhammad Bin Zulfiqar
PPTX
Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar
Dislocations of joint. Joint Dislocation
Role of color doppler ultrasound in rvhtn
Bone age assessment
Role of medical imaging in developemental dysplasia of Hip Dr muhammad Bin Zu...
Trauma axial skeleton Dr. Muhammad Bin Zulfiqar
21 non ischaemic acquired Dr.Muhammad Bin Zulfiqar
Mri anatomy of knee Dr. Muhammad Bin Zulfiqar
20 congenital heart disease Dr. Muhammmad Bin Zulfiqar
An approach to cardiac xray Dr. Muhammad Bin Zulfiqar
19 cardiac anatomy and Imaging techniques Dr. Muhammad Bin Zulfiqar
Pediatric brain tumors Dr. Muhammad Bin Zulfiqar
Prostate Biopsy--New Emerging Trends, Dr. Muhammad Bin Zulfiqar
Eponymous fractures name Dr. muhammad Bin Zulfiqar
18 Airspace Diseases Dr. Muhammad Bin Zulfiqar
17 Thoracic Trauma and Related Topics
Basic approach to brain CT Dr. Muhammad Bin Zulfiqar
16 High Resolution Computed Tomography of Interstitial and Occupational Lung ...
15 Pulmonary Neoplasms Dr. Muhammad Bin Zulfiqar
Ultrasound of spinal cord in neonates Dr. Muhammad Bin Zulfiqar
Intervention radiology— an introduction Dr. Muhammad Bin Zulfiqar

Recently uploaded (20)

PDF
HVAC Specification 2024 according to central public works department
PPTX
Chinmaya Tiranga Azadi Quiz (Class 7-8 )
PDF
BP 704 T. NOVEL DRUG DELIVERY SYSTEMS (UNIT 2).pdf
PPTX
Computer Architecture Input Output Memory.pptx
PDF
Vision Prelims GS PYQ Analysis 2011-2022 www.upscpdf.com.pdf
PDF
Paper A Mock Exam 9_ Attempt review.pdf.
PDF
ChatGPT for Dummies - Pam Baker Ccesa007.pdf
PDF
Environmental Education MCQ BD2EE - Share Source.pdf
PDF
Trump Administration's workforce development strategy
PDF
IGGE1 Understanding the Self1234567891011
PPTX
Share_Module_2_Power_conflict_and_negotiation.pptx
PDF
advance database management system book.pdf
PDF
David L Page_DCI Research Study Journey_how Methodology can inform one's prac...
PPTX
CHAPTER IV. MAN AND BIOSPHERE AND ITS TOTALITY.pptx
PPTX
ELIAS-SEZIURE AND EPilepsy semmioan session.pptx
PDF
My India Quiz Book_20210205121199924.pdf
PDF
International_Financial_Reporting_Standa.pdf
PPTX
A powerpoint presentation on the Revised K-10 Science Shaping Paper
PDF
Hazard Identification & Risk Assessment .pdf
PDF
A GUIDE TO GENETICS FOR UNDERGRADUATE MEDICAL STUDENTS
HVAC Specification 2024 according to central public works department
Chinmaya Tiranga Azadi Quiz (Class 7-8 )
BP 704 T. NOVEL DRUG DELIVERY SYSTEMS (UNIT 2).pdf
Computer Architecture Input Output Memory.pptx
Vision Prelims GS PYQ Analysis 2011-2022 www.upscpdf.com.pdf
Paper A Mock Exam 9_ Attempt review.pdf.
ChatGPT for Dummies - Pam Baker Ccesa007.pdf
Environmental Education MCQ BD2EE - Share Source.pdf
Trump Administration's workforce development strategy
IGGE1 Understanding the Self1234567891011
Share_Module_2_Power_conflict_and_negotiation.pptx
advance database management system book.pdf
David L Page_DCI Research Study Journey_how Methodology can inform one's prac...
CHAPTER IV. MAN AND BIOSPHERE AND ITS TOTALITY.pptx
ELIAS-SEZIURE AND EPilepsy semmioan session.pptx
My India Quiz Book_20210205121199924.pdf
International_Financial_Reporting_Standa.pdf
A powerpoint presentation on the Revised K-10 Science Shaping Paper
Hazard Identification & Risk Assessment .pdf
A GUIDE TO GENETICS FOR UNDERGRADUATE MEDICAL STUDENTS

38 DAVID SUTTON PICTURES DISEASES OF JOINT

  • 2. DAVID SUTTON PICTURES DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL
  • 3. • Fig. 38.1 Rheumatoid arthritis. Bilateral changes are fairly symmetrical. Soft-tissue swelling is demonstrated, especially over the ulnar styloids. Erosions are demonstrated at the carpus, distal radius and ulna, with joint space narrowing and collapse of bone. Metacarpophalangeal erosions are also seen associated with joint space narrowing. There is a swan-neck deformity of the right fifth distal interphalangeal joint.
  • 4. • Fig. 38.2 Retrocalcaneal bursitis in association with thickening of the tendo Achilles and a retrocalcaneal erosion. A soft-tissue mass is demonstrated in the angle normally filled by fat between the insertion of the tendon and the upper calcaneus.
  • 5. • Fig. 38.3 Rheumatoid arthritis. (A) The initial radiograph shows a hint of early trabecular loss around the proximal interphalangeal joint of a finger with preservation of the joint space and early marginal cortical loss at the base of the middle phalanx. (B) The subsequent radiograph shows established erosive change in the area of ill-defined demineralisation in association with joint space narrowing. (Courtesy of Dr. A. Larsen, Oslo.)
  • 6. • Fig. 38.4 Terminal phalangeal sclerosis in rheumatoid arthritis. Obliteration of the medullary cavity of the distal phalanges is demonstrated in this patient. The new bone is very dense and well defined. The change is especially marked at the little and ring fingers.
  • 7. • Fig. 38.5 Progressive narrowing of a joint in rheumatoid arthritis. (A) Y ear 1. The metacarpophalangeal joint looks normal. (B) Y ear 3. There is narrowing of the metacarpophalangeal joint of the index finger with associated local soft-tissue swelling. Erosive change is demonstrated at the metacarpal head. (C) Y ear 4. Little change over the year. (D) Y ear 13. On this late film the soft tissues remain thickened. The joint space is obliterated. Erosive change is demonstrated, especially at the metacarpal head. There is ulnar drift.
  • 8. • Fig. 38.6 Gross rheumatoid arthritis at the carpus with ulnar deviation, subluxation and joint narrowing at the metacarpophalangeal joints. Boutonniere deformities are present at the index and little fingers.
  • 9. • Fig. 38.7 Rheumatoid arthritis with narrowing of the metatarsophalangeal joint of the great toe and a fine periostitis on the adjacent shafts (arrows).
  • 10. • Fig. 38.8 Rheumatoid arthritis. A lateral view of the heel shows irregular erosive change along the base of the heel in association with a small plantar spur. Erosive change is also demonstrated posteriorly at the insertion of the tendo Achillis.
  • 11. • Fig. 38.9 Rheumatoid arthritis. (A) The initial radiograph shows demineralisation of bone at the second and third metacarpals heads with preservation of local joint spaces. (B) The second film shows that the areas of demineralisation at the second metacarpal head hid erosions. The erosions are marginal. The joint space narrows slightly.
  • 12. • Fig. 38.10 Rheumatoid arthritis. Marked soft- tissue swelling is demonstrated over the ulnar aspect of the carpus in association with erosion at the distal ulna and the related carpal bones. The joint space between the carpus and the ulna is narrowed.
  • 13. • Fig. 38.11 Rheumatoid arthritis very pronounced destructive changes in the tarsus and in metatarsal heads.
  • 14. • Fig. 38.12 Rheumatoid arthritis. Progressive films taken over 6 years, showing marginal erosions and joint space narrowing followed by collapse of articular surfaces. A small geode is demonstrated in the proximal phalenx of the third ray.
  • 15. • Fig. 38.13 Geodes in rheumatoid arthritis. There is joint space narrowing. Osteoporosis is demonstrated. An effusion is present. There are large distal femoral geodes which reach the patellofemoral articulation.
  • 16. • Fig: 38.14 Rheumatoid arthritis – extreme protrusio with medial migration and erosion of the femoral heads. Compare this with Fig: 38.72 (protrusio in osteoarthritis)
  • 17. • Fig. 38.15 Rheumatoid arthritis of the elbow showing marked resorption of all the articular surfaces with marginal erosions, especially well at the radial neck and trochlea.
  • 18. • Fig. 38.16 Rheumatoid arthritis-widening of the acromioclavicular joint. Erosion of the third and fourth ribs superiorly is also seen in this condition.
  • 19. • Fig. 38.17 Rheumatoid arthritis of the cervical spine. (A) The plain film shows subluxation of C1 and loss of the odontoid peg. The disc spaces from C3 down are narrowed and the end-plates irregular and eroded. Fusion is demonstrated at C5/6 and C7/T1 levels. There is no soft-tissue swelling, but deformity results from the forward subluxation of C1 upon C2. (B) In the same patient the sagittal T,- weighted MR sequence demonstrates that the odontoid peg is no longer visible. End-plate irregularity is again demonstrated with narrowing of disc spaces.
  • 20. • Fig. 38.18 Rheumatoid arthritis of cervical spine- tomographic section showing erosions of the left atlanto-axial articulation. Similar changes affect the right side and also the occipito- atlanto joints and the odontoid peg.
  • 21. • Fig. 38.19 Rheumatoid arthritis. (A) Erosions and upward subluxation of the humeral head. (B) Arthrogram showing numerous 'millet seeds' floating freely within the joint. There is also a rotator cuff tear.
  • 22. • Fig. 38.20 Baker's cyst. (A) Sagittal fat-suppression (left) and axial T 1 - weighted gradient-echo (right) MR sequences. The sagittal image demonstrates a well-defined and intact Baker's cyst posterior to the knee joint in this child. The axial image shows the medial situation of the Baker's cyst and demonstrates its origin between the tendons of the medial gastrocnemius head and distal semimembranosus muscles.
  • 23. • Fig. 38.20 Baker's cyst. (B) T1- and T 2- weighted MR images showing a posteriorly situated cyst, seen to contain debris. The leak disrupts the adjacent musculature.
  • 24. • Fig. 38.21 Rheumatoid arthritis. (A) Whole-body radioisotope scan showing areas of increase in uptake in the neck, both shoulder joints, the elbow joints, the left hip, both knees and ankles in a patient with rheumatoid disease. The distribution of disease is shown, but the changes on this scan are not specific. (Courtesy of Dr A. Hilson.) (B) Localised images of the hands showing changes of a more specific distribution. (Courtesy of Dr A. Saifuddin.)
  • 25. • Fig. 38.21 Rheumatoid arthritis.(B) Localised images of the hands showing changes of a more specific distribution. (Courtesy of Dr A. Saifuddin.)
  • 26. • Fig. 38.22 Sagittal scan of metacarpophalangeal joint affected by rheumatoid arthritis. The irregular echogenic margin of an erosion (e) is shown in the distal high echogenic cortical margin of the head of the second metacarpal (M) with adjacent low echogenic synovial proliferation (S) and anechoic fluid (f). The fibrillar extensor tendon (T) and echogenic cortex of proximal phalanx (P) and metacarpophalangeal joint (jt) are shown.
  • 27. • Fig. 38.23 Coronal scan of lateral meniscal tear. Echogenic margin of lateral femoral condyle (F) and tibial plateau (T), intermediate lower echogenicity of meniscus (M) with torn fragment (*), areas of anechoic fluid of the meniscal cyst (Cy) arising from the tear.
  • 28. • Fig. 38.24 Longitudinal scan of synovial thickening around the lateral mid foot. Echogenic margins of the calcaneum (C) and cuboid (Cu). Irregular margin of cuboid representing erosion (e). Synovial thickening (black S) of intermediate echogenicity around peroneus brevis tendon (T) which has a bright fibrillar structure. Irregular fingers of synovium (white S) associated with calcaneocuboid joint with associated anechoic synovial fluid and low echogenicity (f).
  • 29. • Fig 38.25 Transverse scan through olecranon bursa. Deep to the skin (sk) and subcutaneous fat (ft), an anechoic fluid-filled bursa (B) is shown with echogenic foci within, these representing loose bodies (lb) adjacent to the echogenic cortical margin of the olecranon (0).
  • 30. • Fig. 38.26 Longitudinal scan of the normal Achilles tendon. Echogenic fibrillar structure of the tendon, with bright linear echogenicity of the paratenon (arrows) and anisotropic effect of tendon fibrils (tailed arrows) as they curve into the insertion point in the calcaneum (C). Karger's fat pad (Kf) is of low heterogeneous echogenicity.
  • 31. • Fig. 38.27 (A) Longitudinal scans of the Achilles tendon. On the left, normal tendon (T), Karger's fat pad (Kf) and insertion of tendon into calcaneum (C). On the right the tendon (T) is swollen and has focal low echogenicity near the insertion into the calcaneum (C) consistent with focal tendonosis. A small area of low echogenicity deep to the tendon (r) is a retrocalcaneal bursa. Also, note the increased echogenicity of Karger's fat pad on the right associated with the inflammatory change. (B) Transverse scans of the Achilles tendon. On the left normal tendon (T) and on the right the focal area of tendonosis (T) in the medial aspect of the tendon.
  • 32. • Fig. 38.28 Longitudinal scan of partial tear in the distal Achilles tendon (T) where torn fibrils of the tendon extend into a liquefied anechoic haematoma Jr) adjacent to insertion in calcaneum (C).
  • 33. • Fig. 38.29 (A) Transverse scan through the bicipital groove of the humerus (H), which contains a normal brightly echogenic long head of biceps tendon (t) surrounded by low echogenic synovial thickening (s). (B) Longitudinal scan through the long head of biceps (LHB) surrounded by anechoic fluid (F) and synovial thickening (S).
  • 34. • Fig. 38.30 Coronal scan through the shoulder showing the tip of the acromion (Ac) casting acoustic shadow, the layers of tissue superficial to the supraspinatus tendon (ss) as it inserts into the greater tuberosity of the humerus (H), namely: skin (sk), fat (ft), deltoid muscle (dt) and a large subacromion subdeltoid bursa (B) of hypoechogenicity, the cause of the patient's symptoms.
  • 35. • Fig. 38.31 'Jumper's knee'. (A) Longitudinal scan. A focal central tendonosis of the patella tendon (Pt) at the proximal insertion in the lower pole of the patella (P). There is increase in the echogenicity of the related Hoffa's fat pad (Hf) adjacent to the area of swelling and low echogenicity in the patella tendon on the left compared to the normal tendon on the right. Arrowheads indicate the paratenon. (B) Transverse scan showing the patella tendon between *. On the left the central focal area of swelling and low echogenicity can be compared to the wide thin high echogenicity of the normal tendon on the right.
  • 36. • Fig. 38.32 (A) Longitudinal scan through diffuse/global patella tendonosis; the patella tendon (Pt) on the right is swollen and of generally low echogenicity compared to the normal tendon on the left. (B) Transverse scan through diffuse/global patella tendonosis, showing the patella tendon between * on the right being diffusely swollen compared to Fig. 38.31B and the normal tendon on the left (P) = patella
  • 37. • Fig. 38.33 Transverse scan through Baker's cyst, an anechoic collection of fluid (Cy). This is a bursa communicating with the knee joint sited behind the medial femoral condyle (F), the neck of the cyst has formed between the medial head of gastrocnemius (G) and the semimembranosus tendon (S)
  • 38. • Fig. 38.34 Ruptured Baker's cyst. (A) Longitudinal scan of the ruptured Baker's cyst (Cy) posterior to the medial femoral condyle (F) and gastrocnemius muscle (G) with a mixture of anechoic synovial fluid and synovial thickening and debris extending into the cystic cavity which may relate to haemorrhage. The tapered inferior end of the cyst indicates that there has been rupture. (B) Longitudinal scan of the tip of the ruptured cyst (Cy); the streaks of low echogenicity extending into the muscle (sy) represent
  • 39. • Fig. 38.35 Longitudinal scan of lower leg and a muscle tear (tr) associated with liquefied haematoma (fl) just below the skin (sk). In comparison with Fig. 38.34B, the area of low echogenicity is more heterogeneous and has a more irregular contour than the muscle oedema. Note normal muscle (Ms)
  • 40. • Fig. 38.36 Rheumatoid arthritis at MRI. (A) Coronal T,-weighted sequence. (B) Coronal fat-suppression images. There is a large effusion in the shoulder joint and in the subacromial bursa. There is upward subluxation of the humeral head but the rotator cuff tendon is in part intact. Erosive changes are demonstrated in the humeral head with the appropriate signal change. (C) A more anterior scan shows the distended subacromial bursa containing numerous loose bodies. See also Fig. 38.19.
  • 41. • Fig. 38.37 Pannus in rheumatoid arthritis. Thickened synovium demonstrated (A) pre- and (B) post-gadolinium enhancement. The effusion exhibits a low signal, while the surrounding area of bright signal (arrow) represents hypertrophic vascular synovium. (Courtesy of Dr G. Clunie, UCL Hospitals.)
  • 42. • Fig. 38.38 Rheumatoid arthritis at MRI (corona) (A) and sagittal (B) T 2 -weighted sequences). There is loss of meniscal and articular cartilage, irregularity of articular surfaces and subchondral cysts filled with fluid. There is also debris within the joint.
  • 43. • Fig. 38.39 Retrocalcaneal bursitis with an erosion. The tendo Achilles is thickened distally; the bone is eroded at its insertion and there is also an erosion on the upper aspect of the calcaneus assosiated with local bursitis.
  • 44. • Fig. 38.40 (A) Sagittal CT reconstruction showing odontoid peg erosion and separation of the space between the peg and arch. There is a soft-tissue mass interposed between the two structures. The peg is upwardly subluxated. (Courtesy of Dr J. Stevens.) (B) CT radiculography in rheumatoid arthritis. The odontoid peg is eroded and separated from the arch of the atlas by a soft-tissue mass. (Courtesy of Dr J. Stevens.)
  • 45. • Fig. 38.41 Rheumatoid arthritis at MR scanning. (A) T,-weighted axial image. (B) T,-weighted sagittal image. A soft-tissue mass is seen in the region of the eroded odontoid peg and this indents the cord. Note distal changes at all levels in the cervical spine
  • 46. • Fig. 38.42 juvenile chronic arthritis. Accelerated skeletal maturity with modelling abnormalities of the carpal bones and osteoporosis.
  • 47. • Fig. 38.43 Juvenile chronic arthritis. Monarticular arthritis with soft- tissue swelling, osteoporosis and overgrowth of the epiphyses at the right knee. Normal left knee.
  • 48. • Fig. 38.44 Juvenile chronic arthritis. There is overgrowth the epiphyses around the knee with associated soft-tissue swelling. The tibial epiphysis in particular shows a rather square shape with marked angulation of its margins, which never occurs in the normal.
  • 49. • Fig. 38.45 Juvenile chronic arthritis. (A) The early radiograph in this some patient shows hypoplasia of the vertebral bodies and a widened cervical canal. (B) Subsequently the vertebral bodies and facet ioints ankylose, with failure of development.
  • 50. • Fig. 38.46 The relationship between the different manifestations of arthritis is shown, together with the appropriate tissue markers. (Courtesy of Dr D. A. Brewerton.)
  • 51. • Fig. 38.47 Psoriasis. Soft-tissue swelling is seen over the great toe and the erosions at the bases of the distal phalanges are on the articular, rather than the periarticular, surface, producing a 'gull's wing‘appearance.
  • 52. • Fig. 38.48 Psoriasis. The distal interphalangeal joints are involved in this condition. Bone density is often preserved. Erosions proceed along the bases of the distal phalanges and there is splaying of bone locally. Despite the erosive change, the joints may be increased in width or, alternatively, fused. These changes are totally unlike those seen in rheumatoid arthritis both in appearance and distribution. There is also a neurotrophic change at the distal and middle phalanges, with longitudinal and concentric bone resorption, producing a 'licked candy stick' appearance.
  • 53. • Fig. 38.49 A ' sausage digit' in psoriatic arthritis. There is soft tissue swelling. Periostitis is demonstrated. The bone shows an apparent increase in density.
  • 54. • Fig. 38.50 Psoriatic spondylitis. Non-marginal vertical floating syndesmophytes are more typical of psoriasis and are less often seen in ankylosing spondylitis.
  • 55. • Fig. 38.51 Reiter's syndrome- acute form, showing marked osteoporosis and periosteal reaction (arrows).
  • 56. • Fig. 38.52 Reiter's syndrome. Periostitis and erosive changes on the plantar and posterior aspects of the calcaneus and of the distal tibia.
  • 57. • Fig. 38.53 (A,B,C) Reiter's syndrome. The three radiographs taken over a 12-year period demonstrate the progression of a unilateral sacroiliitis.
  • 58. • Fig. 38.54 Ankylosing spondylitis-early. (A) Serrated margins of sacroiliac joints and periarticular sclerosis.
  • 59. • Fig. 38.54 Ankylosing spondylitis- early (B) CT scanning demonstrates bilateral sacroiliitis.
  • 60. • Fig. 38.55 Ankylosing spondylitis. Increase in uptake is demonstrated at both sacroiliac joints, greater on the right, in this posterior scan. (Courtesy of Dr A. Hilson.)
  • 61. • Fig. 38.56 Ankylosing spondylitis. Discal narrowing and adjacent erosions heal with prolific new bone formation. Sclerosis and vertebral squaring result.
  • 62. • Fig. 38.57 Ankylosing spondylitis. (A) Squaring of vertebral bodies is demonstrated, much of which is due to ossification in the line of the anterior longitudinal ligament. Longstanding fusion has resulted in calcification of the discal nucleus. There is also quite marked ankylosis of the posterior spinal elements. (B) A T2 - weighted MR sequence showing vertebral squaring with fusion across the narrowed intervertebral discs. There is prominence both of the anterior and posterior longitudinal ligaments, which may relate to ligamentous ossification.
  • 63. • Fig. 38.58 Ankylosing spondylitis-'bamboo spine' with marginal syndesmophytes • Fig. 38.59 Cervical spine in ankylosing spondylitis, with fractures through the C4/5 and C5/6 discs.
  • 64. • Fig. 38.60 Ankylosing spondylitis (Andersson lesion). End- plate irregularity is demonstrated together with reactive sclerosis in the underlying bone in this patient with ankylosing spondylitis. There is also instability at this level.
  • 65. • Fig. 38.61 Ankylosing spondylitis-note bony ankylosis across joint cartilage. Irregularity of the surface of the ischium is also shown.
  • 66. • Fig. 38.62 Senile ankylosing hyperostosis-this is an extreme example of this common lesion. A tremendous amount of new bone has formed. The outlines of the original vertebral bodies and disc spaces are preserved.
  • 67. • Fig. 38.63 Diffuse idiopathic skeletal hyperostosis. The plain radiograph of this patient demonstrates new bone formation at the iliac crests and ischia as well as fusion of the sacroiliac joints superiorly. There is also faget's disease in the right femur.
  • 68. • Fig. 38.64 Diffuse idiopathic skeletal hyperostosis. The CT scan shows that the joint spaces are still patent but there is ankylosis anteriorly.
  • 69. • Fig. 38.65 Diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament. New bone is seen anteriorly on this cervical vertebral body and posteriorly in the canal along the line of the posterior
  • 70. • Fig. 38.66 (A) The initial radiograph shows lateral migration of the femoral head with obliteration of the superior joint space. There is accretion of new bone medially within the joint. (B) The subsequent radiograph shows collapse of the femoral head and of the acetabulum. There is now more new bone both on the femoral head and on the acetabulum medially. A new joint space often results. Buttressing of the medial cortex of the femoral neck (the calcar) is a common finding in degenerative disease of the hip.
  • 71. • Fig. 38.67 (A,B,C) Patterns of degeneration (see text). Key: Grey = cartilage; black = cortex; stripes = medulla. (D) Reduplication with new bone laid down on the articular surface. Eburnation Reduplication
  • 72. • Fig. 38.67 (D) Reduplication with new bone laid down on the articular surface.
  • 73. • Fig. 38.68 (A) CT scan of osteoarthritis showing new bone formation within the acetabulum and cyst formation at the articular surface. (B) Osteoarthritis demonstrated at MRI: sagittal STIR (fat suppression) sequence showing loss of joint space, subarticular cyst formation in the tibia with oedema of the periarticular soft tissues, as well as an effusion in the joint.
  • 74. • Fig. 38.69 Osteoarthritis. (A) Right shoulder arthrogram. There is irregularity of the synovium and numerous loose bodies are demonstrated within the joint space. There is also a small rotator cuff tear.
  • 75. • Fig. 38.69 Osteoarthritis. (B) MRI demonstrates degenerative changes of the knee with an effusion, loss of the medial meniscus, marginal osteophytosis and a large loose body lying medially within the joint.
  • 76. • Fig. 38.70 (A,B) Osteoarthritis of the ankle. Articular irregularity with synovial thickening and effusions as well as synovial diverticula are demonstrated. Loss of articular cartilage is seen and erosive changes are demonstrated, especially on the upper surface of the talus. Osteophytes are demonstrated at the malleoli .There is a very large anterior alar osteophyte associated with local synovial proliferation, seen on sagittal images.
  • 77. • Fig. 38.70 (A,B) Osteoarthritis of the ankle. Articular irregularity with synovial thickening and effusions as well as synovial diverticula are demonstrated. Loss of articular cartilage is seen and erosive changes are demonstrated, especially on the upper surface of the talus. Osteophytes are demonstrated at the malleoli .There is a very large anterior alar osteophyte associated with local synovial proliferation, seen on sagittal images.
  • 78. • Fig. 38.71 Loss of the femoral head and deepening of the acetabulum may be the end- stage of osteoarthritis.
  • 79. • Fig. 38.72 Patterns of osteoarthritis. (A) Superior migration of the femoral head. There is new bone on the medial aspect of the acetabulum. (B) Osteoarthritis associated with protrusio acetabuli. (C) Migration of the femoral head is in a superomedial direction.
  • 80. • Fig. 38.73 (A) Osteoarthritis of the shoulder-note excavation of the upper part of the anatomical neck with local sclerosis, and cysts seen en face (arrow). (B) Widespread abnormalities are present on this coronal image of the shoulder. There is degeneration with an effusion around the acromioclavicular joint, a subacromial bursitis and considerable thickening of the rotator cuff, which shows a cyst in its body. In addition, there is a distal tendinitis associated with an erosion of the greater tuberosity.
  • 81. • Fig. 38.74 Osteoarthritis of the shoulder, classic type-loss of joint space, eburnation, cyst formation and osteophytosis shown.
  • 82. • Fig. 38.75 Osteoarthritis of patellofemoral joint. There is a groove on the lower anterior part of the femoral shaft (arrow).
  • 83. • Fig. 38.76 Osteoarthritis. A degenerate and torn medial meniscus is associated with marginal osteophytosis and a subarticular cyst in the tibia. In addition, there is spiking of the tibial spines and at the intercondylar notch. An effusion is also present.
  • 84. • Fig. 38.77 Severe osteoarthritis of the carpometacarpal joint of the thumb.
  • 85. • Fig. 38.78 Osteoarthritis. joint narrowing and osteophyte formation, with broadening of the joint underlying the Heberden's nodes.
  • 86. • Fig. 38.79 Erosive osteoarthritis of the interphalangeal joints. Appearance of destruction around some proximal and distal interphalangeal joints.
  • 87. • Fig. 38.80 Early cervicalspondylosis . (A) The plain film shows slinght loss of normal curve centered around the C5/6 disc which is also minimally narrowed. There are no osteophytes as yet. (B) MR scan confirms the minimal loss of the height of this disc. There is no loss of signal and no dorsal protrusion of discal material. (C) A discogram confirms the presence of an annular tear with substantial leak of contrast.
  • 88. • Fig. 38.80 Early cervicalspondylosis . (D) cervical spondylosis in a more advanced form. The MR scan is abnormal with anterior discal bulging and marginal osteophytosis at C4/C5 and C5/C6 levels. (E) In the discogram of the same patient anterior and posterior annular tears are demonstrated with dorsal bulging. The anterior annular tears shown to extend to the osteophytes.
  • 89. • Fig. 38.81 Cervical spondylosis. (A) There is early narrowing of the C5/6 disc and the beginnings of anterior osteophytosis. (B) Disc degeneration is now pronounced, with both anterior and posterior osteophytes.
  • 90. • Fig. 38.82 Oblique projection of cervical spine showing large osteophytic protrusions into the C5/6 intervertebral foramen (arrow).
  • 91. • Fig. 38.83 MRI of the cervical spine. Dorsal osteophytosis and distal protrusion indent the thecal sac and cervical cord.
  • 92. • Fig. 38.84 (A) The facet joints are no longer symmetrical and show features of degeneration. (B) The CT scan shows gross new bone formation around narrowed facet joints. There is marked bony encroachment upon the exit foramina, especially the left. Gas is seen in the disc (vacuum phenomenon).
  • 93. • Fig. 38.85 Lumbar spondylosis. There is distal narrowing and a vacuum phenomenon is present in the degenerative discs. Marginal osteophytes are present. Inferiorly the facet joints show features of degeneration and, with the increase in lordosis, the spinous processes are in contact.
  • 94. • Fig. 38.86 (A) Simultaneous discography and radiculography demonstrate a torn annulus, through which contrast medium escapes and impinges upon the opacified theca. (B) The CT scan shows, in the axial plane, the site of the annular tear and the displacement of the nucleus. Indentation of the opacified thecal sac is demonstrated.
  • 95. • Fig. 38.87 Lumbar degeneration. (A) The L5/S1 disc is clearly grossly abnormal showing loss of height and signal, together with a dorsal distal protrusion. At L4/5 there is early loss of signal. (B) The discogram at L4/5 shows an essentially normal nucleus, but there is a fine annular tear which is associated with a bulge. No extraneous leak. This injection was extremely painful.
  • 96. • Fig. 38.88 The HIZ T2- weighted MR sequence showing the posterior high-intensity zone.
  • 97. • Fig. 38.89 (A,B) MRI and discography demonstrate a dorsal distal protrusion with narrowing of the canal at that level.
  • 98. • Fig. 38.90 Gout-erosion on the medial part of the first metacarpal extends away from the joint surface.
  • 99. • Fig. 38.91 Very advanced gout. Note eccentric soft-tissue swellings, intraosseous tophi extending to bone ends and lack of osteoporosis.
  • 100. • Fig. 38.92 Gout-large calcified tophi in olecranon bursa.
  • 101. • Fig. 38.93 Hypertrophic osteoarthropathy-exuberant periosteal reaction of the radius and ulna. In this patient, changes in the bones of the hands were minimal.
  • 103. • Fig. 38.95 Hypertrophic osteoarthropathy. Generalised and symmetrical diffuse increase in uptake is associated with thickening of the bony image at isotope scanning.
  • 104. • Fig. 38.96 Scleroderma. Contractures result in pressure resorption of bone at metacarpal necks. Para- articular calcification is prominent, as is distal phalangeal sclerosis.
  • 105. • Fig. 38.97 Discoid meniscus. (A) The plain film shows dishing of the lateral tibial plateau. (B) Arthrography. The meniscus extends medially to the midline of the joint and has a bulbous internal aspect. (C) The MR scan shows the same external contour of the meniscus as the arthrogram but shows cystic degeneration within the structure of the meniscus. Note also the increase in signal at the metaphysis-a normal feature.
  • 106. • Fig. 38.98 Double-contrast arthrography of the knee showing total peripheral detachment.
  • 107. • Fig. 38.99 Sagittal T,-weighted image of the knee. The medial meniscus is torn. There is a large Baker's cyst which contains loose bodies.
  • 108. • Fig. 38.100 Classification of meniscal change at MRI from normal to tear , according to mink et al. (1993)
  • 109. • Fig. 38.101 Tear of the posterior horn of the medial meniscus associated with a tibial cyst. Peripheral meniscal cysts originating from degenerate menisci are seen on sagittal, axial and coronal images at MR scanning.
  • 110. • Fig. 38.102 (A,B) A medially directed cyst related to an abnormal posterior horn is shown in coronal, axial (A) and sagittal (B) images. The cyst is palpable beneath the skin and serial images track its communication to the interior of
  • 111. • Fig. 38.102 (A,B) A medially directed cyst related to an abnormal posterior horn is shown in coronal, axial (A) and sagittal (B) images. The cyst is palpable beneath the skin and serial images track its communication to the interior of
  • 112. • Fig: 18.103 A disrupted posterior cruciate ligament surrounded by effusion.
  • 113. • Fig. 38.104 Sagittal T,- weighted MR sequence of the knee showing an irregular and ruptured anterior cruciate ligament (arrow)
  • 114. • Fig. 38.105 Coronal T2- weighted image of the knee demonstrates a tear of the medial collateral ligament.
  • 115. • Fig. 38.106 Bone bruising in the medial femoral condyle well demonstrated on a sagittal fat-suppression image of the knee.
  • 116. • Fig. 38.107 Rupture of a Baker's cyst is demonstrated. This is probably chronic, as the cavity in the calf has a smooth margin. (Courtesy of Dr A. R. Taylor.)
  • 117. • Fig. 38.108 Radioisotope bone scan (SPECT) of the knee shows focal areas of increase in uptake (arrows) at sites of proven abnormality of the menisci. (Courtesy of Dr I. Fogelman.)
  • 118. • Fig. 38.109 A normal shoulder arthrogram showing the extent of the glenohumeral synovium. There is no contrast beneath the acromion. The synovial reflection around the long head of biceps tendon is shown.
  • 119. • Fig. 38.110 A rupture of the rotator cuff is seen at shoulder arthrography, with contrast medium filling the subacromial space.
  • 121. • Fig. 38.112 A subacromial osteophyte is associated with local tendinitis (T,- and T 2- weightings).
  • 122. • Fig. 38.113 Total rotator cuff tear with retraction. Axial CT of the shoulder demonstrates an anterior labral tear.
  • 123. • Fig. 38.114 A tear of the labrum glenoidale anteriorly shown at MR scanning. Fluid provides the contrast medium on the T1 -weighted image.
  • 124. • Fig. 38.115 Coronal oblique scan of a normal supraspinatus tendon. The layers of tissue that should be seen are: skin (sk), fat (ft), deltoid muscle (dt), brightly echogenic supraspinatus tendon (ss), low echogenic hyaline cartilage (hy), high echogenicity of the cortex of the humerus (H) and greater tuberosity (GT).
  • 125. • Fig. 38.116 Coronal oblique scan of supraspinatus calcific tendonosis. The supraspinatus tendon (ss) is of heterogeneous low echogenicity with foci of high echogenicity (arrowheads), some of which cast acoustic shadow consistent with calcification. Skin (sk), fat (ft), deltoid muscle (dt) And humeral head (H) are shown
  • 126. • Fig. 38.117 Coronal oblique scan of supraspinatus full- thickness tear. There is an area of low echogenicity between the two points indicated (*), which contains a mixture of low- echogenic debris. Note how the deltoid muscle (dt) dips into the defect in the supraspinatus tendon (ss). GT = greater tuberosity; H =humeral head.
  • 127. • Fig. 38.118 Coronal oblique (A) and axial (B) scans of massive fullthickness rotator cuff tear. The skin (sk), fat (ft) and deltoid muscle (dt) between the double-headed arrows and synovium of subdeltoid bursa (br) are the only layers of soft tissue seen between the subcutaneous fat and humeral head (H). Note the irregularity of the humeral head contour in B. Cr = coracoid process.
  • 128. • Fig. 38.119 Axial scan showing the long head of biceps (arrowheads) subluxed onto the lesser tuberosity (LT), and an empty low echogenic bicipital groove (BG), indicating tear of the transverse humeral ligament.
  • 130. • Fig. 38.121 Total rupture of a thickened tendo Achilles demonstrated at MRI. Fluid fills the space between the retracted parts
  • 131. • Fig. 38.122 Injection of the radiocarpal joint space has demonstrated a tear of the triangular cartilage and filling of the distal radioulnar joint at arthrography.
  • 132. • Fig. 38.123 MRI of the triangular cartilage. There is bright signal within the bulk of the triangular cartilage extending to its distal surface.
  • 133. • Fig. 38.124 Sagittal scan of a ganglion (Gg) arising from an interphalangeal joint (IPJ). The ganglion is anechoic consistent with being fluid filled, and has a 'speech bubble' shape, the tail extending between the phalanges (PH) into the joint.
  • 134. • Fig. 38.125 Loosening of the hip prosthesis is demonstrated at arthrography. Contrast medium surrounds the acetabular component and tracks down the femoral stem. There is also a defect in the bone through which contrast medium escapes into the soft tissues.
  • 135. • Fig. 38.126 Synovial tuberculosis. (A) The plain film shows bone and cartilage destruction on both sides of the joint. (B) The arthrogram shows gross irregular synovial hypertrophy. The geode does not
  • 136. • Fig. 38.127 Technetium bone scan. (A) Anterior scan of pelvis. (B) Oblique scan of right hip. The prosthesis can be seen as a defect on the scan and there is increased uptake around it, especially at the femoral component.