1. Infection of bone,joint and soft tissue
化脓性骨髓炎(purulent osteomyelitis)
金黄色葡萄球菌(staphylococcus aureus)
Infection pathway
血行感染(haematogenous spread)
直接延伸(direct extend)
开放性骨折(open fracture)

2. Acute Purulent Osteomyelitis
clinical symptom：
pathology：metaphysis－cortex of bone－subperiosteum abscess
－medullary cavity of bone－sequestrum(死骨）－plerosis(修复)

3. Acute Purulent Osteomyelitis
X-ray film：
Soft tissue
Muscle interspace clouding
Subcutaneous fat clouding
bone
Destruction of bone
Sequestrum(死骨)
Parallel periosteal proliferation(平行骨膜反应）

6. Acute Purulent Osteomyelitis
CT：It is better than X-ray plain film.

8. Acute Purulent Osteomyelitis
MRI：It is better than X-ray and CT. It can make early diagnosis, low signal in T1WI and high signal in T2WI. The wall of the abscess should be enhancement after injection of Gd-DTPA.

9. 急性化脓性骨髓炎
Acute Purulent Osteomyelitis

10. 双侧胫骨骨髓炎
Both tibiae acute purulent osteomyelitis

11. 胫骨中下段感染

12. Chronic Purulent Osteomyelitis
X-ray：bone hyperplasia or sclerosis, diaphysis asper(粗糙)，medullary cavity of bone narrow, destruction of bone, sequestrum
CT：similar to X-ray
MRI：hyperostosis osteosclerosis(骨质增生硬化),sequestrum and periosteal proliferation are low signal. MRI can show abscess cavity and fistula cannulas(瘘管) high signal.

14. Chronic Purulent Osteomyelitis(慢性骨髓炎)

15. 慢性硬化性骨髓炎 （Garre Osteomyelitis ）
Periosteal proliferation(骨膜增生)，cortex thickening， osteosclerosis， medullary cavity constriction or emphraxis(闭塞), no destruction and sequestrum

17. 慢性局限性骨髓炎 （Brodie abscess of bone）
Low toxicity(低毒性)pyogenic infection
Metaphysis(干骺端)
Light symptom
Round destruction surrounded by osteosclerosis

18. Brodie abscess of bone
慢性局限性骨髓炎

19. Pyogenic Arthritis
X-ray：articular capsule swelling, joint subluxation or dislocation，bone destruction(首先见于持重面），joint space constriction，even bone stiff(强直)
CT：similar to X-ray film
MRI：MRI can display synovitis, hydrarthrosis, destruction of articular cartilage. It is better than X-ray and CT.

21. 化脓性关节炎
Pyogenic Arthritis

22. Tuberculosis of Bone X-ray film
TB of Long bone: epiphysis and metaphysis osteoporosis and destruction, sediment sequestrum(泥沙样死骨)
TB of Diaphysis：metacarpal bone(掌骨), metatarsal bone(跖骨)destruction, “tambour” (骨“气鼓”征)
TB of Spine：collapse of vertebra，intervertebral space constriction, vertabral body confluence(融合)，cold abscess, calcification

27. Tuberculosis of Bone CT： MRI：
TB of bone：destruction of bone, sediment sequestrum, soft tissue swelling
TB of spine: bone destruction, sequestrum, cold abscess
MRI：
TB of spine

28. TB of spine
脊柱结核

30. Tuberculosis of Joint X-ray film CT similar to X-ray film
Soft tissue swelling，joint space constriction，articular bone destruction(首先见于非持重面）
Synovium TB of joint
CT similar to X-ray film
MRI hydrarthrosis, synovium swelling, articular cartilage and bone destruction, cold abscess

31. 关节结核(TB of joint)

37. infection of soft tissue
CT：hyperemia, edema, abscess
MRI：it is best for making early diagnosis in infection of soft tissue

38. 膝前皮下软组织脓肿

39. Arthritis

40. Definition
Disease that affects bones on both sides of the joint space and
Narrows the space in between them

41. Classification Hallmarks Hallmark Hypertrophic Bone production
Sclerosis
Infectious
Hallmark
Destruction of articular cortex
Erosive
Erosions

42. Hypertrophic Arthritis
Degenerative arthritis
Primary
Secondary
Charcot arthropathy

43. 1º Degenerative Arthritis
Intrinsic degeneration of articular cartilage
Excessive wear and tear
Most commonly hips and knees
Less commonly shoulders and elbows

44. 1º DJD of knees affects medial, weight-bearing surface
1º DJD of hips affects superior, weight-bearing surface

45. 1º Degenerative Arthritis Hands
Not due to mechanical stress
F:M 10:1
Most often involves DIP joints
Sclerosis
Marginal osteophyte formation
1st MCP joint of thumb

46. 1º DJD of Hands

47. 2º Degenerative Arthritis
Another process destroys articular cartilage
Degenerative changes supervene
How to recognize
Atypical locations (CPPD and knee)
Atypical appearance (Marked DJD of 1 hip)
Atypical age (DJD in 20 year-old)

48. 2º Degenerative Arthritis Causes
Trauma
Infection
Avascular necrosis
CPPD RA
Hemophilia

49. 2º Degenerative Arthritis More Causes
Hemochromatosis
Acromegaly
Ochronosis
Wilson's Disease
Bottom line: Any arthritis can end as DJD

50. 2º DJD of right ankle following fracture

51. Calcium Pyrophosphate Deposition Disease (CPPD)
May be idiopathic or associated with
Hyperparathyroidism, hemochromatosis
Symmetric involvement: knees (most common), wrists, MCPs
Sudden onset of pain and fever
Clinically
Tender, swollen, red, LOM

52. CPPD Findings Calcification of articular cartilage
Knee, hip, shoulder
Triangular fibrocartilage of ulna
Symphysis
Large subchondral cysts
Preferential involvement of femero-patellar compartment

53. Chondrocalcinosis

54. Hypertrophic Arthritis Classification
Degenerative arthritis
Primary
Secondary
Charcot arthropathy

55. Charcot’s Arthropathy General
Disturbance in sensation leads to multiple microfractures
Pain sensation intact from muscles and soft tissue
Causes
Shoulders – syrinx, spinal tumor
Hips – tertiary syphilis, diabetes
Feet – diabetes

56. Charcot’s Arthropathy Findings
X-ray findings
Fragmentation
Soft tissue swelling
Destruction of joint
Sclerosis
Osteophytosis

57. Charcot’s Knees-Diabetes

58. Charcot’s Shoulder - Syrinx

59. Charcot’s Arthropathy of Foot - Diabetes

60. Classification Hallmarks Hallmark Hypertrophic Bone production
Sclerosis
Infectious
Hallmark
Destruction of articular cortex
Erosive
Erosions

61. Infectious Arthritis More common in adults
Usually from local trauma-surgery or accident
Children get osteomyelitis
Destruction of articular cartilage & cortex
Tends to affect one joint (DDx from gout)
Fingers from human bites
Feet from diabetes
Hips from THRs

62. Normal articular cortex
Normal joint
Normal articular cortex

63. Infectious Arthritis Causes
Usually staph - “early” destruction of articular cortex
Rapid course (unlike most arthritides)
TB spreads via bloodstream from lung
More protracted course
In children, spine most common; in adults, knee
Severe osteoporosis
Healing with ankylosis common in both

64. Septic arthritis of hip with pathologic fracture
Acetabular white line R3
Septic arthritis of hip with pathologic fracture
Normal hip

65. Septic arthritis of toe

66. TB septic arthritis over 1 year

67. Classification Erosive Arthritis
Hypertrophic
Hallmarks
Bone production
Sclerosis
Infectious
Hallmark
Destruction of articular cortex
Erosive
Erosions

68. Erosive Arthritis General
Synovial proliferation (pannus formation)
Inflammation
Erosions seen in small joints (hands) better than large (hips)
Destroy portion of cortex

69. Erosive Arthritis Types
Rheumatoid arthritis
Gout
Hemophilia
Erosive osteoarthritis
Rheumatoid variants
Psoriatic arthritis
Reiter's
Ankylosing spondylitis
Inflammatory bowel disease

70. Erosive Arthritis More Types
Connective tissue disease
Scleroderma
SLE
Jaccoud's arthropathy
Sarcoidosis
Rare
Amyloid

71. Rheumatoid Arthritis General
Bilaterally symmetrical
Earliest change: STS MCP, PIP, ulnar styloid
Radiocarpal jt most commonly narrowed
Periarticular demineralization
Begins MCP jts of 1st and 2nd fingers
Large joints usually no erosions

72. Rheumatoid Arthritis General
Can lead to 2º DJD
Marked narrowing of joint space with intact articular cortex, think of RA
Little or no sclerosis
Especially, hips and knees

73. RA of Hips – Marked narrowing, little sclerosis

74. R3
RA Hands

75. RA usually involves 5th MT-P joint first
RA of Foot

76. Gout General
Long latent period between onset of symptoms and bone changes
Asymmetric and monoarticular
More common in males
Most common at 1st MT-P joint
Tophi rarely calcify
Olecranon bursitis is common

77. Gout Findings Juxta-articular erosions
Sharply marginated with sclerotic rims
Overhanging edges (rat-bites)
No joint space narrowing until later
Little or no osteoporosis
Soft tissue swelling
Tophi not calcified

78. R3
Gout

79. R3
Gout

80. Erosive Osteoarthritis
Post-menopausal females
Changes like DJD but with marked inflammation and erosions
IP joints of hands and carpal-MCP joint of thumb
DDx: Psoriasis (skin changes)

81. Erosive Osteoarthritis

82. Erosive Osteoarthritis

83. Ankylosing Spondylitis
HLA-B27 positive
B/L SI arthritis
Squaring of vertebral bodies
Bamboo-spine from continuous syndesmophytes
Peripheral large joint erosive arthritis

84. Ankylosing Spondylitis

85. Overview Hypertrophic Infectious Primary Secondary
Degenerative Arthritis
Primary
Secondary
Charcot Arthropathy
Infectious
Pyogenic
Tuberculous

86. Overview Erosive RA Gout Hemophilia Erosive osteoarthritis
Psoriatic arthritis
Reiter’s Syndrome
Ankylosing Spondylitis

92. Chronic Arthritis

93. Rheumatoid Arthritis RA
Multilation disease(致残性疾病)
Symmetric chronic polyarthropathy
Incidence rate is about 1%
Episode(发病) age: 40-70
F/M: 2-3/1
Small joints: hand, wrist, foot
PIP，MCP（+）DIP（-）

94. Rheumatoid Arthritis RA
X-ray plain film：
Symmetrical fusiform(梭形) soft tissue swelling
Joint space: widening----narrowing
Bone matrix erosion in border of articular suface
Articular suface clouding，subchondral cysts
Regional (periarticular) osteoporosis(骨质疏松)
Amyotrophy(肌肉萎缩)，joint deformaton，fibrosum stiff，dislocation or subluxation

95. Rheumatoid Arthritis RA

96. MRI synovitis early manifestation Soft tissue lesion
Bone erosion pannus (血管翳) , granulation tissue(肉芽组织)
Soft tissue lesion

97. Enhancement scan Synovium enhancement
5-10 minuts After Gd-DTPA injection
Dynamical enhancement

98. MRI clinical application
Earlier diagnosis
Progress evaluation
Effect evaluation

99. Rheumatoid Arthritis RA

100. Rheumatoid Arthritis

101. Rheumatoid Arthritis RA

102. Rheumatoid Arthritis RA平扫 增强

103. Bone erosion

104. Subchondral cysts and bone erosionsSE
STIR
SE C+

105. Carpal canal(腕管) syndrome

106. ankylosing spondylitis (强直性脊柱炎)
X-ray：sacroiliitis(骶髂关节炎), small arthritis, ligament calcification “bamboo spine”
CT and MRI: similar to X-ray appearance

107. Degenerative Osteoarthropathy
X-ray film：irregular joint space narrowing，marginal osteophytes(骨赘),subchondral cysts, joint corpus liberum(游离体)
Spine degenerative osteoarthropathy：include disc degeneration, apophyseal joint osteoarthritis, spondylosis(关节强直）

109. 关节软骨消失
关节软骨变薄
关节软骨肿胀

110. 退行性骨关节病

111. 退行性骨关节病

112. 图示：颈椎退行性变