Transcript Infection of bone,joint and soft tissue

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)
Acute Purulent Osteomyelitis
• clinical symptom：
• pathology：metaphysis－cortex of bone－
subperiosteum abscess
－medullary cavity of bone－
sequestrum(死骨）－plerosis(修复)
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）
Acute Purulent Osteomyelitis
• CT：It is better than X-ray plain
film.
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.
急
性
化
脓
性
骨
髓
炎
Acute Purulent Osteomyelitis
双侧胫骨骨髓炎
Both tibiae acute purulent osteomyelitis
胫骨中下段感染
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.
Chronic Purulent
Osteomyelitis(慢性骨髓炎)
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
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
Brodie abscess of bone
慢性局限性骨髓炎
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.
化
脓
性
关
节
炎
Pyogenic Arthritis
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
Tuberculosis of Bone
• CT：
– TB of bone：destruction of bone,
sediment sequestrum, soft tissue
swelling
– TB of spine: bone destruction,
sequestrum, cold abscess
• MRI：
– TB of spine
TB of spine
脊柱结核
Tuberculosis of Joint
–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
关节结核(TB of joint)
infection of soft tissue
• CT：hyperemia, edema, abscess
• MRI：it is best for making
early diagnosis in infection
of soft tissue
膝前皮下软组织脓肿
Arthritis
Definition
l
Disease that affects bones on both sides
of the joint space and
l
Narrows the space in between them
Classification
l
Hypertrophic
n
Hallmarks
l
l
l
Infectious
n
Hallmark
l
l
Bone production
Sclerosis
Destruction of articular cortex
Erosive
n
Hallmark
l
Erosions
Hypertrophic Arthritis
l
l
Degenerative arthritis
n
Primary
n
Secondary
Charcot arthropathy
1º Degenerative Arthritis
l
Intrinsic degeneration of articular cartilage
l
Excessive wear and tear
n
Most commonly hips and knees
n
Less commonly shoulders and elbows
1º DJD of knees affects medial,
weight-bearing surface
1º DJD of hips affects superior,
weight-bearing surface
1º Degenerative Arthritis
Hands
l
Not due to mechanical stress
l
F:M 10:1
l
Most often involves DIP joints
l
n
Sclerosis
n
Marginal osteophyte formation
1st MCP joint of thumb
n
1º DJD of Hands
2º Degenerative Arthritis
l
Another process destroys articular
cartilage
l
Degenerative changes supervene
l
How to recognize
n
Atypical locations (CPPD and knee)
n
Atypical appearance (Marked DJD of 1 hip)
n
Atypical age (DJD in 20 year-old)
2º Degenerative Arthritis
Causes
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Trauma
l
Infection
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Avascular necrosis
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CPPD
l
RA
l
Hemophilia
2º Degenerative Arthritis
More Causes
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Hemochromatosis
l
Acromegaly
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Ochronosis
l
Wilson's Disease
l
Bottom line: Any arthritis can end as
DJD
R3
2º DJD of right ankle following fracture
Calcium Pyrophosphate
Deposition Disease (CPPD)
n
May be idiopathic or associated with
l
Hyperparathyroidism, hemochromatosis
n
Symmetric involvement: knees (most
common), wrists, MCPs
n
Sudden onset of pain and fever
n
Clinically
l
Tender, swollen, red, LOM
CPPD
Findings
n
l
Calcification of articular cartilage
l
Knee, hip, shoulder
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Triangular fibrocartilage of ulna
l
Symphysis
n
Large subchondral cysts
n
Preferential involvement of femeropatellar compartment
Chondrocalcinosis
Hypertrophic Arthritis
Classification
l
l
Degenerative arthritis
n
Primary
n
Secondary
Charcot arthropathy
Charcot’s Arthropathy
General
l
Disturbance in sensation leads to multiple
microfractures
l
Pain sensation intact from muscles and
soft tissue
l
Causes
n
Shoulders – syrinx, spinal tumor
n
Hips – tertiary syphilis, diabetes
n
Feet – diabetes
Charcot’s Arthropathy
Findings
l
X-ray findings
n
Fragmentation
n
Soft tissue swelling
n
Destruction of joint
n
Sclerosis
n
Osteophytosis
Charcot’s Knees-Diabetes
Charcot’s Shoulder - Syrinx
Charcot’s Arthropathy of Foot - Diabetes
Classification
l
Hypertrophic
n
Hallmarks
l
Bone production
Sclerosis
Infectious
l
l
n
Hallmark
l
l
Destruction of articular cortex
Erosive
n
Hallmark
l
Erosions
Infectious Arthritis
l
More common in adults
n
Usually from local trauma-surgery or accident
n
Children get osteomyelitis
l
Destruction of articular cartilage & cortex
l
Tends to affect one joint (DDx from gout)
n
Fingers from human bites
n
Feet from diabetes
n
Hips from THRs
Normal joint
Normal articular cortex
Infectious Arthritis
Causes
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Usually staph - “early” destruction of articular
cortex
n
l
TB spreads via bloodstream from lung
n
More protracted course
In children, spine most common; in adults, knee
n
Severe osteoporosis
n
l
Rapid course (unlike most arthritides)
Healing with ankylosis common in both
Acetabular white line
R3
Septic arthritis of hip with pathologic
fracture
Normal hip
Septic arthritis of toe
TB septic arthritis over 1 year
Classification
Erosive Arthritis
l
Hypertrophic
n
Hallmarks
Bone production
l Sclerosis
Infectious
l
l
n
Hallmark
l
l
Destruction of articular cortex
Erosive
n
Hallmark
l
Erosions
Erosive Arthritis
General
l
Synovial proliferation (pannus formation)
l
Inflammation
l
Erosions seen in small joints (hands)
better than large (hips)
n
Destroy portion of cortex
Erosive Arthritis
Types
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Rheumatoid arthritis
l
Gout
l
Hemophilia
l
Erosive osteoarthritis
l
Rheumatoid variants
n
Psoriatic arthritis
n
Reiter's
n
Ankylosing spondylitis
n
Inflammatory bowel disease
Erosive Arthritis
More Types
n
Connective tissue disease
l
Scleroderma
l
SLE
Jaccoud's arthropathy
Sarcoidosis
l
l
n
Rare
l
Amyloid
Rheumatoid Arthritis
General
l
Bilaterally symmetrical
n
Earliest change: STS MCP, PIP, ulnar styloid
l
Radiocarpal jt most commonly narrowed
l
Periarticular demineralization
l
Begins MCP jts of 1st and 2nd fingers
l
Large joints usually no erosions
Rheumatoid Arthritis
General
l
Can lead to 2º DJD
n
n
Marked narrowing of joint space with intact articular cortex,
think of RA
l
Little or no sclerosis
l
Especially, hips and knees
RA of Hips – Marked narrowing, little
sclerosis
R3
RA Hands
RA usually
involves 5th
MT-P joint
first
RA of Foot
Gout
General
l
Long latent period between onset of
symptoms and bone changes
l
Asymmetric and monoarticular
l
More common in males
l
Most common at 1st MT-P joint
l
Tophi rarely calcify
l
Olecranon bursitis is common
Gout
Findings
l
Juxta-articular erosions
n
Sharply marginated with sclerotic rims
n
Overhanging edges (rat-bites)
l
No joint space narrowing until later
l
Little or no osteoporosis
l
Soft tissue swelling
l
Tophi not calcified
R3
Gout
R3
Gout
Erosive Osteoarthritis
l
Post-menopausal females
l
Changes like DJD but with marked
inflammation and erosions
l
IP joints of hands and carpal-MCP joint of
thumb
l
DDx: Psoriasis (skin changes)
Erosive Osteoarthritis
Erosive Osteoarthritis
Ankylosing Spondylitis
l
l
l
HLA-B27 positive
B/L SI arthritis
n
l
Squaring of vertebral bodies
l
Bamboo-spine from continuous
syndesmophytes
l
Peripheral large joint erosive arthritis
Ankylosing Spondylitis
Overview
l
Hypertrophic
n
n
l
Degenerative Arthritis
l
Primary
l
Secondary
Charcot Arthropathy
Infectious
n
Pyogenic
n
Tuberculous
Overview
l
Erosive
n
RA
n
Gout
n
Hemophilia
n
Erosive osteoarthritis
n
Psoriatic arthritis
n
Reiter’s Syndrome
n
Ankylosing Spondylitis
n
Chronic Arthritis
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（-）
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
Rheumatoid Arthritis RA
MRI
• synovitis early manifestation
• Bone erosion pannus (血管翳) ,
granulation tissue(肉芽组织)
• Soft tissue lesion
Enhancement scan
• Synovium enhancement
• 5-10 minuts After Gd-DTPA
injection
• Dynamical enhancement
MRI clinical application
• Earlier diagnosis
• Progress evaluation
• Effect evaluation
Rheumatoid Arthritis RA
Rheumatoid Arthritis
Rheumatoid Arthritis RA
Rheumatoid Arthritis RA
平扫
增强
Bone erosion
Subchondral cysts and bone erosions
SE
STIR
SE C+
Carpal canal(腕管) syndrome
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
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）
关节软骨变薄
关节软骨消失
关
节
软
骨
肿
胀
退行性骨关节病
退行性骨关节病
图示：颈椎退行性变