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.

• 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.

• 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.