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FIGURE1-16.RadiographicpresentationPsoriasis.APradiographoftherightfootinthispatientwithahistoryof

psoriasisdemonstrateserosionsofthebasesofproximalphalangesof2ndto4thdigits,andoftheinterphalangeal jointsofalldigits,consistentwithaninflammatoryarthritissuchaspsoriaticarthritis.

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FIGURE1-17.X-rayandMRdemonstrationofRA.A:FrontalradiographoftheleftfootinapatientwithRA

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demonstratesperiarticularosteoporosisandtheclassicerosionsofthemetatarsalheadofthe5thdigitandbony destructionoftheproximalarticularsurfaceoftheproximalphalanxofthe5thdigit,representativeofRA.B:Coronal fastspinechoMRimagesoftheleftforefootdemonstrateuniformcartilagewearinthe5thMTPjointwith characteristicerosionsattheheadofthe5thmetatarsalandsubchondralcysts.

RICKETS

Rickets is a disorder of childhood characterized by decreased physeal mineralization and delayed endochondral ossification, resulting in disordered growth at the growth plates.

Although manyconditions cancause rickets, nutritional ricketsaccounts for themajorityof cases and arises from vitamin D deficiency.34 Rickets may not be radiographically evident

earlyinthediseasecourse,ormaybeassociatedwithonlysubtlediffusedemineralizationof theosseousstructures.35Classicrachiticfindingsappearlaterinthecourseofthediseaseand are most evident in rapidly growing bones.35 In the lower extremity, the distal femur and proximal and distal tibia are most affected.35 Findings include bowing of the long bones, commonlyresultingingenuvarus,metaphysealflaring andcupping,andphysealwidening.

Theedgesofthemetaphysesmayappearfrayed.35Insufficiencyfracturescanoccurinmobile childrenwithradiographicallyevidentrickets(Fig.1-18).

SARCOIDOSIS

Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by noncaseating granuloma formation. Although sarcoidosis most commonly manifests with thoracicinvolvement,anyorgansystemcanbeaffected,andskeletalinvolvementisreported

in5%to10%ofpatients.37Skeletalinvolvementisvariableandoftenasymptomatic.38When symptomatic,patientsmostfrequentlypresentwithinflammatoryarthralgia.37Sarcoidosiscan

affectlongandsmallbonesthroughoutthebody,withthephalangesofthehandsandfeetmost commonlyinvolved,usuallyinabilateraldistribution.38Radiographsoftheaffectedjointsare oftenunremarkable.37X-rayfindingsarealacelikepatternofosteolysis,classicallyseeninthe digitsofthehand,

37,38

andwithsimilarmanifestationswhenthefootisinvolved.Radiolucent

cysticlesionsandosteoporosismayalsooccur.

37,39

Pathologicfracturescanoccurinregions

of extensive cortical destruction.38 When arthralgia, erythema nodosum, and mediastinal lymphadenopathy are present together, they form the triad known as Löfgren syndrome, a

manifestationofsarcoidosisthatgenerallyresolvesspontaneously(Fig.1-19).

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FIGURE1-18.RadiographicpresentationRickets.Frontalviewoftheanklesdemonstratessymmetricwidening

ofthetibialandfibularphysiswithirregularfrayingofthephysealmargins.

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FIGURE1-19.RadiographicpresentationSarcoid.AP(A)andoblique(B)radiographsoftherighthandandright

foot(C)demonstratelacelikelesionsinthephalanges,metacarpals,andmetatarsalswithbonydestruction,cortical scalloping,jointdestruction,anddislocation.

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heumaticdiseasesandotherinflammatorydisordersofthelowerextremityareseenless

commonly than mechanical conditions andlocal injuries. But because all inflammatory disorders may present in a similar fashion and because some have the potential to cause permanent damage without appropriate therapy, one must always be on the alert for their presence. Inflammatory disorders can be grouped into several categories: autoimmune, crystalline,andinfectious(Table2-1).Ingeneral,theseconditionsaresystemicand,therefore, may involve the upper extremities and spine as well as organ systems outside of the musculoskeletal.Indeed,thepatternofjointinvolvementcombinedwithassociatedsymptoms (e.g., rash, oral ulcers, inflammation of the eye, interstitial lung disease) may be the most importantcluestoidentifyasystemicillness.Somesystemicillnessestendtofavorthelower extremities such as gout, spondyloarthropathy, Lyme disease, and sarcoidosis (Lofgren syndrome), but they all will often involve other body regions. Therefore, itis importantto always perform a careful history and physical examination when inflammatory disease is suspected.

SPECIALCONSIDERATIONSINTHEAPPROACHTO POTENTIALINFLAMMATORYDISEASE

UrgentandEmergentConditions

Failuretorecognizecertainconditionsmayleadtoirreversiblemorbidityormortality.These includesepticmonoarthritis,systemicsepsis,osteomyelitis,compartmentsyndrome,cellulitis, deep venous thrombosis (DVT), ischemia or infarction due to embolus, thrombosis or vasospasm,fracture, spinal cordcompression,mononeuritis multiplex,andvasculitis (Table

2-2). The followingfeatures of the history andexam, thoughfrequentlynonspecific, can be

helpfultodirectonetowardmoreurgenttesting.

1,2

InabilitytoBearWeight

Theinabilitytobearweightonajointraisessuspicionoffracture,asepticjoint/prosthesis,or

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Table2-1.

Table2-2.

gout.Usually,ahistoryoftraumawillpromptworkupforfracture;however,inpatientswith osteoporosis,fracturesmayoccurwithminimaltrauma.Riskfactorsforosteoporosisinclude being postmenopausal, prior or current use of corticosteroids, smoking, low body mass, a personal history of fracture, a family history of hip fracture, inflammatory disease such as

rheumatoidarthritis,excessivealcoholintake,andlowvitaminD.3Furthermore,spontaneous fracturesmayoccurinpatientswithanunderlyingtumoror,inrareinstances,inpatientstaking

bisphosphonates.

ListofInflammatoryDisordersoftheLowerExtremity

Autoimmune

Rheumatoidarthritis

Spondyloarthropathy

Ankylosingspondylitis

Psoriaticarthritis

Reactivearthritis

Enteropathicarthritis(associatedwithinflammatoryboweldisease)

SAPHO(synovitis,acne,pustulosis,hyperostosis,osteitis)

Sarcoidosis

Systemiclupuserythematosus

Inflammatorymyopathy:especiallyantisynthetasesyndrome

Crystalline

Gout(monosodiumurate)

Pseudogout(calciumpyrophosphate)

Basiccalciumphosphatedeposition

Infectious

Lymedisease

Parvovirus

Gonococcus

Poststreptococcalreactivearthritisandrheumaticfever

Alfavirusessuchaschikungunya

Tuberculosis(directseedingofjointsorreactive)

Fungal

Urgent/EmergentConditions

Septicmonoarthritis

Systemicsepsis

Osteomyelitis

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