Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2603_Библиотеки_им_академика_М_И_Перельмана
.pdf
238
https://t.me/medicina_free
Chapter 6 · Rheumatology
Rapid destructive osteoarthritis ( Postel ’ s osteoarthritis ) is
an uncommon type of hip OA where destruction of the bone
and cartilage occurs within a matter of weeks to months. e
cause of this disorder is unknown. Cases might be seen with
disorders like ochronosis, hemochromatosis, and druginduced arthropathy (especially indomethacin). Patients are
usually women presenting with severe progressive pain classically in a single hip joint.
Signs on Plain Radiographs and MRI
5 The radiological hallmarks for OA are its four main
6
signs: narrowing of joint space, bone sclerosis,
subchondral cysts, and osteophytes formation
(
. Fig. 6.5.1 ).
5 Normal bone density (no osteoporosis)
differentiates OA from rheumatoid arthritis which
is characteristically associated with osteoporosis of
the affected joint due to hyperemia and synovial
inflammation.
5 Subchondral cysts ( geodes ) are seen as cystic
lesions located below the articular cartilage. On
MRI, the cysts show fluid signal intensity on T2W
images (high signal) (
5 Heberden ’ s nodes are osteophytes that are seen at
the DIP joints. They are commonly seen in primary
OA, mainly in the index and the middle fingers
(
. Fig. 6.5.3 ).
5 Bouchard ’ s nodes are osteophytes that are seen at
the PIP joints (
5 Ganglion cyst formation is a myxoid, tumorlike, cystic
lesion that is surrounded by dense connective tissue
and fi lled with gelatinous material. It is typically
located in the epiphysis of long bones. Ganglion
cysts are typically round or tubular, unilocular or
multilocular lesions with often sharply defi ned
internal septa (
enhancement following contrast injection. Ganglion
cysts can be found juxta-articular, intraosseus, and
periosteal in location. Sometimes they are diffi cult to
diff erentiate from synovial cysts based on imaging
alone.
5 Gullwing sign describes wavy contours of the base
of the distal phalanx resembling the wings of a
seagull due to small osteophytes formation on
both sides of the articular surface.
. Fig. 6.5.2 ).
. Fig. 6.5.3 ).
. Fig. 6.5.4 ). They may show rim
. Fig. 6.5.1 Plain shoulder radiograph shows the classical
signs of OA: narrowing of the joint space, sclerosis of the
humeral head and the glenoid fossa, and osteophyte formation
at the base of the humeral head ( arrow )
5 Thumb - base osteoarthritis ( rhizarthrosis ) is OA that
occurs at the trapeziometacarpal joint and the
trapeziometacarpal joint of the thumb (
5 Central erosions of the interphalangeal joints
(characteristic of erosive arthritis).
5 Hallux rigidus is a term used to describe OA of the
fi rst metatarsophalangeal joint (the big toe). The
appearance of accentuated transverse skin crease
overlying the big toe at the DIP joint is commonly
associated with hallux rigidus (
5 I n rapid destructive osteoarthritis , the radiographic
features may mimic osteonecrosis of the hip joint.
Septic arthritis must be excluded by synovial fl uid
aspiration before diagnosing rapid erosive OA.
5 In OA of the hip joint, superior migration of the
femoral head may occur (
. Fig. 6.5.6 ).
. Fig. 6.5.7 ) .
. Fig. 6.5.5 ).
6.5 · Osteoarthritis
https://t.me/medicina_free
ab
239
6
. Fig. 6.5.2 Plain knee radiograph ( a ) and coronal T1W knee MRI of the same patient shows subchondral cysts ( black arrowheads ) and
marginal osteophyte ( b ) in the lateral tibial plateau ( white arrows )
. Fig. 6.5.3 Plain radiograph of the fi nger shows both
Heberden’s node ( arrow ) and Bouchard’s node ( arrowhead )
240
https://t.me/medicina_free
Chapter 6 · Rheumatology
ab
6
. Fig. 6.5.4 Sagittal ( a ) and axial ( b ) PD knee MRI shows juxta-articular intraosseous ganglion cysts formation in the posterior part of
the tibia with bone marrow edema due to knee OA ( arrowheads ). A small Baker cyst can be seen as a secondary fi nding ( arrow )
. Fig. 6.5.6 An illustration demonstrates hallux rigidus with its
accentuated transverse skin crease
. Fig. 6.5.5 Plain radiograph of the hand shows OA of the
base of the thumb ( arrow )
6.6 · Psoriasis and Psoriatic Arthritis
https://t.me/medicina_free
. Fig. 6.5.7 Anteroposterior plain radiograph of the pelvis
shows severe OA of the left hip joint with superior displacement
of the femoral head. Notice the total right hip joint replacement
due to previous OA of the right hip joint
Further Reading
Beaman FD, etal. MR imaging of cysts, ganglia, and bursae
about the knee. Radiol Clin North Am. 2007b;45:969–82.
Corrà T, etal. Ochronotic arthropathy: rapid destructive hip
osteoarthritis associated with metabolic disease. Clin
Rheumatol. 1995;14:474–7.
Gupta KB, etal. Radiographic evaluation of osteoarthritis.
Radiol Clin North Am. 2004;42:11–41.
Kijowski R, etal. Correlation between radiographic ndings
of osteoarthritis and arthroscopic ndings of articular
cartilage degeneration within the patellofemoral joint.
Skeletal Radiol. 2006;35:895–902.
eiler R, etal. Reduced vitamin A tolerance in a hyperlipid-
emia patient with rapid destructive and hyperostotic
osteoarthritis of the hip. Clin Rheumatol. 1994;13:293–8.
Weiss E, etal. Osteoarthritis revisited: a contemporary review
of aetiology. Int J Osteoarchaeol. 2007;17:437–50.
6.6 Psoriasis and Psoriatic Arthritis
Psoriasis is an idiopathic genetic, multifactorial disease characterized by the formation of large, sharply de ned, sliver- white
scaly cutaneous plaques on the extensor surfaces of the knees
and elbows, genitalia, scalp, and lumbosacral area. Psoriasis
comes from the Greek word “spora,” which means itch.
Psoriasis can present as erythematous plaques (psoriasis
vulgaris) or pustules (psoriasis pustulosa). e psoriatic skin
lesions are characterized by hyperproliferation of the epidermal keratinocytes, and in ammatory cell cutaneous in ltration in which neutrophils and lymphocytes predominate. e
earliest psoriatic lesion is an erythematous papule surmounted by a ne scale and is characteristically sharply
demarcated from surrounding normal skin. If the scale of
psoriasis is li ed, multiple, minute areas of bleeding will form
( Auspitz sign ).
Predisposing factors of psoriasis include emotional
trauma, infections (e.g., β-hemolytic streptococci), sunlight,
hormonal changes (e.g., pregnancy), medications (e.g., antimalaria drugs), and cigarette smoking. Many patients experience worsening symptoms in winter. Köbner ’ s phenomenon is
241
a term used to describe the formation of psoriatic lesions in
an area of previous trauma. Inverse psoriasis is a term used to
describe a condition in which the psoriasis involves the exor
surfaces rather than the extensor surfaces.
Psoriatic arthritis ( PsA ) is an in ammatory, rheumatoid
factor-negative arthritis that is associated with psoriasis. PsA is
found in 5–7 % of patients with psoriasis. PsA can occur in up
to 40 % of severe psoriasis cases. Up to 60 % of PsA patients are
HLA-B27 positive, and they are young adults aged 35–55 years.
Skin psoriasis precedes PsA in 70 % of cases and occurs
concomitantly with PsA in 15 % of cases. However, PsA may
precede psoriasis skin lesions in 10–30 % of cases.
PsA is characterized by bone erosions with new bone formation, which is the most distinguishing character of PsA di erentiating it from other seronegative spondyloarthritis disorders.
PsA is characterized by the formation of periostitis, enthesitis,
and distal joint distribution in the extremities. Moreover, PsA
arthritis can be symmetrical mimicking rheumatoid arthritis
and asymmetrical, a ecting the axial skeleton, mimicking ankylosing spondylitis. Because of these reasons, the history of psoriasis plus the absence of serological tests for rheumatoid factor
are essential criteria to establish the diagnosis of PsA.
Hyperuricemia may be found in association with PsA as
a result of increased purine metabolism due to high cell turnover. However, gout arthropathy is rarely developed in association with PsA.
Enthesitis is the in ammation at the site of attachment of
a tendon or a ligament to the joint capsule (e.g., plantal fasciitis). e concept of an “enthesis organ” states that the enthesis together with the adjacent brocartilage, periosteum,
synovial, and bursal membrane should be viewed as a unique
“organ.” PsA is considered as a disease a ecting the enthesis
organ, unlike rheumatoid arthritis which is a disease essentially a ecting the synovium. Entheses may be brous
(located at the metaphyses or diaphyses of long bones) or
brocartilaginous (located at the apophyses and epiphyses of
long bones). Both types are found in the spine.
Sinus tarsi syndrome may occur in patients with PsA. e
sinus tarsi is a bony compartment bounded by the talus, the
calcaneus, the talonavicular, and posterior subtalar joints and
is continuous with the tarsal canal medially. e sinus tarsi
contain fat, nerve endings, vessels, and ligaments (cervical
and interosseous ligaments). Sinus tarsi syndrome is a clinical condition characterized by pain and paresthesia in the
lateral side of the ankle. e causes of sinus tarsi syndrome
include hemorrhage or in ammation of the synovial recesses
of the sinus tarsi. Other causes include ganglion cyst formation within the sinus tarsi.
D i ff erential Diagnoses and Related Diseases
SAPHO syndrome is a disease characterized by S ynovitis,
A cne, P ustulosis of the palmar and plantar skin surface (pso-
riasis vulgaris), H yperostosis of bones (e.g., sternoclavicular
joint), and O stitis. SAPHO syndrome can occur with PsA in
2 % of cases.
6
242
https://t.me/medicina_free
Chapter 6 · Rheumatology
Signs on Radiographs (In General, the Radiographic
Features Are Either Erosive or Proliferative Changes)
5 Osteoporosis is mild or absent in spite of severe
bone erosions. Erosions typically start at the
margins and then progress toward the center.
5 Bone erosions start from the periphery of the joint
and extend to the articular surface. The distal
interphalangeal joints (DIPJs) of the hands and feet
are commonly affected.
5 The sacroiliac joint is affected in a unilateral or
bilateral pattern (sacroiliitis occurs in up to 40 %).
6
5 Periosteal reaction is seen at the affected bones as
fuzzy appearance, which is characteristic for the
bony proliferation associated with psoriatic
arthritis (
5 Sausage fingers or toes are soft-tissue swelling of
the affected fingers or toes due to tenosynovitis. It
is seen in 40 % of psoriatic patients (
5 Ivory phalanx is a characteristic lesion of PsA that
most often occurs in the distal phalanx of the great
toe. It is seen as a dense appearance of the distal
interphalangeal joint due to sclerosis plus
periosteal and endosteal new bone formation.
5 Pencil and cup deformity is seen in a severe form of
marginal erosion, with one end of the joint
forming the cup and the other a pencil that
projects into this cup. It is mostly seen in the DIP
joints of the fingers. The pencil tip is represented
. Fig. 6.6.1 ).
. Fig. 6.6.2 ).
by the distal end of the metatarsal or metacarpal
bone with the cup represented by the eroded
articular surface of the opposing phalanx.
5 Non - marginal bridging is seen in the axial skeleton
as excess bone formation that usually begins
toward the vertebral bodies and curves upward. In
contrast, syndesmophytes in ankylosing
spondylitis begin at the corner of the vertebral
body and extend vertically.
. Fig. 6.6.1 Plain radiograph of the distal fi ngers in a patient
with psoriasis shows narrowing of the DIP joints and marginal
new bone formation ( arrowheads )
. Fig. 6.6.2 Plain radiograph of the fi ngers in a patient with
psoriasis shows soft-tissue swelling ( arrowheads ) of the PIP
joints (sausage fi ngers)
6.6 · Psoriasis and Psoriatic Arthritis
https://t.me/medicina_free
243
6
Signs on MRI
5 Tenosynovitis is defined as high T2 signal intensity
surrounding a low T2 intensity tendon (
5 In the foot, PsA can develop Achilles tendinitis, which
is seen as thickened Achilles’ tendon with high signal
intensity within the tendon (
5 Plantal fasciitis is seen as a T2 high signal intensity at
the site where the plantar fascia is inserted into the
calcaneus (enthesitis) (
5 In sinus tarsi syndrome, there are low T1 and high T2
signal intensities within the sinus tarsi, with or
without loss of the cervical or the interosseous
ligaments (
a
. Figs. 6.6.3 and 6.6.4 ) .
. Fig. 6.6.3 ).
. Fig. 6.6.3 ).
. Fig. 6.6.3 ).
. Fig. 6.6.3 Sagittal STIR ankle MR illustration demonstrates
types of foot pathologies seen in psoriatic arthritis: ( 1 ) synovitis,
( 2 ) sinus tarsi syndrome, ( 3 ) tenosynovitis, ( 4 ) Achilles
peritendinitis, ( 5 ) Achilles tendonitis, ( 6 ) retrocalcaneal bursitis,
and ( 7 ) plantar fasciitis
b
. Fig. 6.6.4 Sagittal T1W ( a ) and STIR ( b ) ankle MRI of a patient with chronic sinus tarsi syndrome show mild hyperintense signal within
the sinus tarsi with disruption of the interosseous ligament ( arrowhead )
244
https://t.me/medicina_free
Chapter 6 · Rheumatology
Further Reading
Baden HP, etal. Psoriasis. Dis Mon. 1973;19:1–45.
Bellet JS, etal. Intertriginous pustular psoriasis. J Am Acad
Dermatol. 2009;60:679–83.
Benjamin M, etal. Magnetic resonance imaging of entheses.
Part 1. Clin Radiol. 2008;63:691–703.
Herbst RA, et al. Guttate psoriasis triggered by perianal
streptococcal dermatitis in a four-year-old boy. J Am Acad
Dermatol. 2000;42:885–7.
Jacobson JA, et al. Radiographic evaluation of arthritis:
in ammatory conditions. Radiology. 2008b;248:378–89.
Jiaravuthisan MM, et al. Psoriasis of the nail: anatomy,
6
pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol. 2007;57:1–27.
Lee Bennett D, et al. Spondyloarthropathies: ankylosing
spondulitis and psoriatic arthritis. Radiol Clin North Am.
2004b;42:121–34.
Leung YY, etal. Psoriatic arthritis as a distinct disease entity.
J Postgrad Med. 2007;53:63–71.
Prasad PVS, etal. A clinical study of psoriatic arthropathy.
Indian J Dermatol Venerol Leprol. 2007;73:166–70.
Tan AL. Imaging of seronegative spondyloarthritis. Best
Pract Res Clin Rheumatol. 2008;22:1045–59.
Vun YY, etal. Generalized pustular psoriasis of pregnancy
treated with narrowband UVB and topical steroids. J Am
Acad Dermatol. 2006;54:S28–30.
Zelickson BD, etal. Generalized pustular psoriasis in child-
hood. Report of thirteen cases. J Am Acad Dermatol.
1991;24:186–94.
Zuhal Erdem C, etal. MR imaging features of foot involvement
in patients with psoriasis. Eur J Radiol. 2008;67:521–5.
6.7 Baastrup’s Disease (Spinout Process
Impingement Syndrome)
Baastrup’s disease (BD) is a pathological condition characterized by close approximation and contact of adjacent spinout
processes, an appearance known as “kissing spines,” leading
to reactive bone and cartilage formation in the spinous processes, causing sclerosis, enlargement, and attening of the
involved spines, with calci cation of the interspinous and
supraspinous ligaments (. Fig. 6.7.1 ).
. Fig. 6.7.1 An illustration of the thoracic vertebrae demonstrates
the gross appearance of the kissing spines and the calcifi cation of the
interspinous and supraspinous ligaments in Baastrup’s disease
BD most commonly occurs in the lumbar spines. Cervical spines can be a ected rarely. Patients typically present
with back pain exacerbated on spine extension, which is
relieved by exion. e pain arises due to irritation of the
periosteum or adventitial bursae between abutting spinous
processes.
6.7 · Baastrup’s Disease (Spinout Process Impingement Syndrome)
https://t.me/medicina_free
Signs on Plain Radiograph
There is close approximation of the spinous processes with sclerosis, osteophytes formation, and hyperlordosis (Fig. 6.7.2 ).
245
6
. Fig. 6.7.2 Lateral and anteroposterior plain radiograph of the vertebral column in the thoracolumbar region shows fl attened spinous
processes of the lumbar vertebrae with sclerosis and close approximation ( arrowheads ), typical fi ndings in Baastrup’s disease of the spines
Signs on MRI
There is approximation of the spinous processes, usually
in the lumbar spines. Bone marrow edema is often seen
in active disease, typically located in the spinous
processes.
Further Reading
Hui C, etal. Two unusual presentations of Baastrup’s disease.
Clin Radiol. 2007;62:495–7.
Lin E. Baastrup’s disease (kissing spine) demonstrated by
FDG/PET CT.Skeletal Radiol. 2008;37:173–5.
Pinto PS, et al. Spinous process fracture associated with
Baastrup disease. J Clin Imaging. 2004;28:219–22.
246
https://t.me/medicina_free
Chapter 6 · Rheumatology
6.8 Scheuermann’s Disease (Juvenile
Kyphosis Dorsalis)
multiple end plate irregularities due to nucleus pulposus
extrusion.
Although the etiology of SD is unknown, Scheuermann
Scheuermann’s disease (SD) is a disease characterized by
juvenile thoracic kyphosis with minimal deformity and few
clinical symptoms (. Fig. 6.8.1 ). e disease has an autoso-
mal dominant pattern of inheritance, with an incidence of
1 % of population.
e normal disk space is composed of two end plates,
central nucleus pulposus, and an outer annulus brous tissue
(annulus brosus) surrounding the nucleus pulposus. Due to
age process or repetitive trauma, the nucleus pulposus loses
6
its watery content, and the annulus brosus develops cracks
and ssures. When this occurs, the nucleus pulposus extrudes
through the annulus brosus ssures. Extrusion of the
nucleus pulposus into the vertebral end plates results in
proposed that the kyphosis resulted from avascular necrosis
of the vertebral body’s apophysis ring, but it is now generally
believed to be a form of disk degeneration. Ky p ho si s is a term
used to describe posterior convex curvature of the spine.
Normal vertebral kyphosis is located in the cervicolumbar
areas and does not exceed 25–45°. Any kyphosis exceeding
this range is considered pathologic. Kyphosis is classi ed
into:
– Arcuate kyphosis : kyphosis with long arc. is type is seen
in SD, osteoporosis, and ankylosing spondylitis.
– Angular kyphosis : kyphosis with short arc. is type is
seen in vertebral pathologic or compressive fractures, and
spondylitis.
Schmorl’s node and limbus vertebra, while extrusion through
the annulus brosus results in disk degenerative disease (disk
hernia). Schmorl’s node is nucleus pulposus extrusion into the
end plates and then into the vertebral body. In contrast, lim-
bus vertebra is extrusion of the nucleus pulposus below the
ring apophysis, separating it from the body of the vertebra.
SD is characterized by the presence of Schmorl’s node and
SD can be associated with scoliosis in 15 % of cases.
Scoliosis is de ned as an abnormal lateral curvature of the
vertebral column. It can be classi ed into:
– Rotoscoliosis : scoliosis with rotation of the vertebra in the
axial plane (
. Fig. 6.8.2 )
– Kyphoscoliosis : scoliosis plus kyphosis
– S - shaped scoliosis : double lateral deviation of the vertebral
column (. Fig. 6.8.3 )
. Fig. 6.8.1 An illustration demonstrates thoracic kyphosis in a
young patient with Scheuermann’s disease (SD)
. Fig. 6.8.2 A plain abdominal radiograph of a patient shows right
rotoscoliosis
6.8 · Scheuermann’s Disease (Juvenile Kyphosis Dorsalis)
https://t.me/medicina_free
Signs on Radiographs, CT, and MRI
5 Increased thoracic kyphosis with compensatory
lumbar hyperlordosis (
5 Wedging of at least three consecutive vertebrae
(>5°) with end plate irregularities (
5 End plate irregularities, loss of disk space height,
and Schmorl nodes. Schmorl node is defined as
localized depression of the superior or inferior end
plates >3 mm in diameter (
5 Limbus vertebra is visualized as separation of the
ring apophysis from the vertebral body (
5 Scoliosis in 15 % of cases.
. Fig. 6.8.4 ).
. Fig. 6.8.4 ).
. Fig. 6.8.5 ).
247
. Fig. 6.8.6 ).
6
. Fig. 6.8.3 A plain abdominal radiograph of a patient with Marfan’s
syndrome shows right S-shaped scoliosis
– C - shaped scoliosis : single lateral curve of the vertebral
column
Neurological symptoms of SD are rare in general and
usually arise due to spinal cord compression. ere are three
types of neural compression reported in SD:
– Extradural spinal cyst
– Compression of the cord at the apex of the kyphos
– Disk hernia at the apex of the kyphos
Criteria for Scheuermann’s Disease
Diagnosis
– More than 5° of wedging of at least three adjacent verte-
brae at the apex of the kyphosis
– End plate irregularities
– A thoracic kyphosis of more than 45°
. Fig. 6.8.4 Lateral plain radiograph of the thoracic spine of
an 18-year-old girl with SD shows marked thoracic kyphosis
with wedging of more than three adjacent vertebrae
Соседние файлы в папке Библиотека им академика М.И. Перельмана