Radiology of Joint Disease · ©Ken L Schreibman, PhD/MD 2/3/15 Radiology of Joint Disease page 1...
Transcript of Radiology of Joint Disease · ©Ken L Schreibman, PhD/MD 2/3/15 Radiology of Joint Disease page 1...
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 1 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
1 of 94
Ken Schreibman, PhD/MD, FACRUniversity of Wisconsin - MadisonProfessor, Musculoskeletal Section9 Faculty, 5 Fellows
My Practical Approach to ArthritisRadiology of Joint Disease is HardIt took me 10 years to begin to understand itAnother 10 years to figure out how to teach itMay not be possible to teach in one hour
Ordered list of 5 most common arthropathiesCan download PowerPoints & handouts
for this and all my lectures
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
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FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
Sharp Erosions withoverhanging edges
Resembles OAChondrocalcinosis
Pencil-in-CupSausage Digit
My Ordered ListIs it…
OA?
EOA?
RA?
Gout?
CPPD?
Psoriatic?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
RandomFavors Toes (1st)
Unusual distribution for OAFavors Patella-Femoral
Hands, Feet, SpineSI Joints (Asymmetric)
Topics
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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Prevalence of ArthritisArthritis is one of the
most prevalent chronic health problems
The nation’s leading cause of disabilityCosts US economy
$128 billion annually
US Adult Population
≈ 225 Million
20%(46M)
Diagnosedwith Arthritis
Adults >65 yo50% have Arthritis
2005(most recent
available data)arthritis.org
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
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>100 conditions affect joints*RA:1.3M‡=3% all arthritisDecreased from 2.1M (5%) 1995
Gout:3M†=7% all arthritis Increased from 2.1M (5%) 1995
CPPD:?No prevalence data
Seronegative Spondylarthritides:up to 2.4M‡ (5%)
Prevalence of ArthritisPrevalence of Types of Arthritis
*arthritis.org
2005(most recent
available data)
46 MillionDiagnosed
with Arthritis…
OA = 27M†
(59% of allArthritis)
and those of uswho look at joints
suspect OA ismore like
> 80%†ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35‡ARTHRITIS&RHEUMATISM,2008,v58,n1,p15-25
RA
Gout
CPPD
SNSA
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Arthritis is Ancient: Gout“king of diseases and disease of kings”
2600BC (Egypt): Described in the great toe400BC (Greece): Hippocrates wrote about it1599 Shakespeare
(Henry IV, Part 2) Falstaff:“A pox of this gout! or a gout of this pox! for the one or the other plays the rogue with my great toe.”
1799 James Gillray(British caricaturist):
wikipedia.org© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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4500BC (Tennessee)Native American skeletal
1661JacobJordaens(Flemish Baroquepainter)
The Familyof the Artist
Arthritis is Ancient: RA
wikipedia.org
MCPs
PIPs
Rheumatoid Nodules
wikipedia.org
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page 2 of 16Radiology of Joint DiseaseMy Practical Approach
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150,000,000BC (late Jurassic period)Osteophytes have been found in fossils of:Toe of Allosaurus fragilis*TMJ of Pliosaurus brachyspondylus**
Arthritis is Ancient: OA
*wikipedia.org
wikipedia.org
**Palaeontology 2012 May 16
Harvard Museum of Comparative Zoology
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Old Diseases = Old Names (misnomers)“Osteoarthritis”Osteo=“Bone”… but it’s not disease of boneitis=“inflamed”… but it’s not inflammatory disease
“Rheumatoid” Arthritis“resembles Rheumatic Fever”…
but it has nothing to do with rheumatic fever (not caused by Streptococcus pyogenes)
“Gout” vs “Pseudo-gout”Radiographically, these look nothing like each other
CDC Public Health Image Library
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Old Diseases = Old Names (misnomers)“Reiter’s Disease”1942:HansConradJuliusReiterInflammatory arthritisEye inflammation (conjunctivitis or uveitis)Urethritis in men or cervicitis in womanReiter was a Nazi
Head of the Reich Health OfficeWidely considered expert on vaccinesImplicated in experimenting with typhus on
Buchenwald concentration camp internees
1945: Interrogated in Nuremberg; released 19472009: Disease renamed “Reactive Arthritis”Seminars in Arthritis and Rheumatism
2003, Feb, vol 32, No 4 © 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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BONE
White Line =Cortical Bone
Gray Fill =Trabecular Bone
(Cancellus)
BONE
BONE
BONE
BONE
PowerPoint Model: BonePowerPoint Model: JointJoint: 2 bones meetBones flair out at endsMetaphysis
Can see on radiographs:Trabecular boneCortical boneJoint space between bones
Black rectangle = Radiograph
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PowerPoint Model: Joint
R,S 14yoM
BONE
BONE Cortex
Trabecular
JointSpace
UnfusedGrowthPlates
Knee RadiographAP view
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PowerPoint Model: JointStuff inside joints we
can’t see on radiographs:CartilageArticularHyaline [Gr] “resembling glass”
SynoviumNormally very thin (1-3 cells)
Synovial fluidNormally just wetting amount
BONE
BONE
This is too much fluid (i.e. Effusion)
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Joint Disease = Cartilage DamageImaging joint disease =
“seeing cartilage”RadiographsCan’t see cartilage directlyWe see it indirectly by
looking at joint space widthArthrogram-CTInject contrast into joint,
then do a CT scanMultiplanar reformat
BONE
BONE
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Arthrogram - CTBONE
BONE
R,S 14yoM
Knee RadiographAP view
Knee Arthrogram-CTCoronal Reformat
Cortex
Intra-ArticularContrast
Trabecular
Cartilage is dark tissue between white cortex and white contrast
Kind of like an Oreo:Dark Cookie=CartilageLight Cream=Contrast
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Joint Disease = Cartilage DamageImaging joint disease =
“seeing cartilage”RadiographsWe see it indirectly by
looking at joint space widthArthrogram-CTInject contrast into joint MRI!Can see cartilage directlyWithout injecting contrast
BONE
BONE
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MRIBONE
BONE
R,S 14yoM
Knee MRI CoronalPD fat-suppressed
Knee MRI CoronalCartilage Sensitive
Articular (hyaline) cartilage: light gray
Meniscal (fibro-cartilage): black
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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5 Most Common ArthropathiesIs it…
OA?
EOA?
RA?
Gout?
CPPD?
Psoriatic?
Features Distribution
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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Osteoarthritis (OA)THE most common
joint diseaseAt least 60% of ALL
arthritis is OA…In my experience it’s
more like 80-90%Primary OAEffects specific joints
Secondary OACan effect any joint
“Osteoarthrosis”
46 MillionDiagnosed
with Arthritis…
OA = 27M†
(59% of allArthritis)
2005(most recent
available data)†ARTHRITIS&RHEUMATISM,2008,v58,n1,p26-35
and those of uswho look at joints
suspect OA ismore like
> 80%
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
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RA
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OA = Disease of Hyaline CartilageArticular hyaline cartilage
is the diseased tissueLoss of hyaline cartilageProximal&Distal articular surfaces
Non-Uniforme.g. Knee: Medial > Lateral
Progressive – worsens with time
Non-Uniform joint narrowing Asymmetrice.g. Dominant hand > other hand
BONE
to OA
BONE
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OA: Knees
M,G 46yoM
Knee RadiographRIGHT - AP view
Knee RadiographLEFT- AP view
Features OANon-Uniform joint narrowingMedial compartment > Lateral
Asymmetric (here L > R)
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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OA = Bone Producing DiseaseIn OA, joints make boneSub-cortical sclerosisArticular cortex thickensStress response?
OSTEOPHYTES!Bony spurs from jointsCan occur either after the
joint is narrowed…or before the joint narrows
to OA
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Osteophytes: Knees
P,C 67yoF
Knee RadiographAP view
Knee RadiographLateral view
MedialCompartment
LateralCompartment Patella-
FemoralCompartment
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Let’s Talk about “Phyte Club”Suffix phyte: “abnormal growth”3 Types of phytes:Osteophytes
@ Joints
Enthesophytes@ Ligament/Tendon
insertions
Syndesmophytes@ Disks (Annulus Fibrosis)
doddleme.com© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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EnthesophytesEnthesophytes are… nothingBone spurs at ligament/tendon insertionsNot osteophytes (which occur at joints)Not pathologyCommon in calcaneus “Heel spurs”Not plantar fasciitis
PHYTECLUB
L,E 62yoF@ plantar fascia
@ Achilles tendon insertion
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OsteophytesOccur at Joints in DJD
(Degenerative Joint Disease)Extend from joint edges
Occur at Disks in DDD (Degenerative Disk Disease)Extend from vertebral
bodies corners In DDD disk bulges outwardOsteophytes extend out
around bulging disk
Extend horizontallyTypically extend anteriorly
Body
Body
Nucleus
Body
Body
NucleusAnnulus
PowerPoint Model: Spine
PHYTECLUB
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Spine: Osteophytes Horizontal
Body
Body
PowerPoint Model: Spine
D,R 66yoM
Lumbar SpineLateral view
PHYTECLUB
L3
L4
L5
S1
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Osteophytes vs SyndesmophytesWhile OsteophytesExtend horizontally from
corners of vertebral body
SyndesmophytesExtend vertically along
Annulus FibrosusThinCover multiple levelsCervicalThoracicLumbar
Body
Body
NucleusAnnulus
PowerPoint Model: Spine
PHYTECLUB
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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Syndesmophytes Vertical
Body
Body
Nucleus
PHYTECLUB
W,D 52yoM
Thoracic SpineLateral view Extend vertically
along Annulus Fibrosus
Thin Cover multiple
levelsCervicalThoracicLumbar
Lumbar SpineLateral view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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Syndesmophytes Vertical PHYTECLUB
W,D 52yoM
Royal Botanical GardenKandy, Sri Lanka 2005
Lumbar SpineLateral view
Lumbar SpineAP view
FusedSI
Joints
“Bamboo Spine”
AnkylosingSpondylitis
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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FeaturesNon-uniform joint
space narrowingOsteophytes!
My Ordered ListIs it…
OA?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
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Distribution: OASpineLower
Cervical SpineC5-C6
Lower Lumbar SpineL4-L5
Andreas Vesalius: “De humani corporis fabrica”1543 p.163
J,W 48yoF
C1
C2
C3
C4
C5
C6
C7
Cervical SpineLateral view
F,D 34yoF
L5
L4
L3
L2
L1
Lumbar SpineLateral view
“VacuumDisk”
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Distribution: OALower ExtremityCommon in the HipCommon in the KneeUncommon in the AnkleNot simply due to weightbearing
Common 1st MTP Joint
Andreas Vesalius: “De humani corporis fabrica”1543 p.163
D,M 52yoF
FootAP view
FootLateral view
O-phyte “Hallux Limitus”“Hallux Rigidus”aka “OA”
Non-uniform narrowingOsteophytes
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PelvisAP view
OA: HipsNon-uniform narrowingHip: Superior weightbearing surface
PowerPoint Model: Hip
Acetabulum
FemoralHead
to OA
OAK,K 44yoM
Symptomaticside
Asymptomaticside
Asymmetry: to OA
Normal width
NarrowedSuperiorly
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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OA: HipsNon-uniform narrowingHip: Superior weightbearing surface
Asymmetry ProgressiveWorsens over time
to OA
to OA
K,K 44yoM
2 years earlier 2 months later
TotalHip
ProsthesisNarrowedSuperiorly
Normal width
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OA: HipsNon-uniform narrowingHip: Superior weightbearing surface
Asymmetry ProgressiveWorsens over time
Osteophytes?Often not seen on AP viewBest seen on frog-leg view
to OA
to OA
to OA
mi9.com
What’s a frog-leg view?
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Pelvis RadiographsLying on x-ray tableNot weight-bearingUnlike knees&feet which
should be done standingCassette slides into “Bucky Grid”Minimize x-ray scatterDr Gustav Bucky
(9/3/1880-2/19/1963)
1913: Moving grid(Berlin)
X-raycassette
Tray
Marty age 15
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AP Pelvis
X-R
AYS
Internally Rotated
Head
GreaterTrochanter
LesserTrochanter
APview ofFemurs
Hip joint width
B,A 16yoF© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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Frog Leg Lateral
X-R
AYS
B,A 16yoF
Externally Rotated
Lateralview ofFemurs
GT
LT
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PelvisAP view
Osteophytes: HipsSuperior narrowingAsymmetryOsteophytes?None on AP
R,C 81yoF
Right HipFrog-leg view
Osteophyte!
NarrowedSuperiorly
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PelvisAP view
Sub-Cortical Sclerosis: Hips
R,C 81yoF
“Isn’t thissub-corticalsclerosis?”
Not sub-cortical sclerosis
Normal appearance of acetabular roof
sourcil: [Fr] “eyebrow”
blogburo247.ru
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Sub-Cortical Sclerosis: Hips
R,C 81yoF
This is sub-cortical sclerosis! This isn’t a French
model’s eyebrow
This looks more like this guy’s
eyebrow…flickr.com
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OA
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EOA
RA
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Distribution: OAUpper ExtremityUncommon in the Shoulder1º OA spares glenohumeral joint2º OA from trauma, rotator cuff tear
D,H 63yoM
ShoulderOblique view
Severe osteoarthritic narrowing GH jt
Complete loss of acromial-humeral
space =Chronic rotator
cuff tear
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OA
Phytes
EOA
RA
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Distribution: OAUpper ExtremityUncommon in the Shoulder1º OA spares glenohumeral joint2º OA from trauma, rotator cuff tearVery common acromioclavicular jt.Narrows w/age usually not symptomatic
Uncommon in the ElbowHand/WristCommon at the Thumb baseSTT & CMC (Spares rest of wrist)
Common at the PIPs & DIPs(Spares MCPs)
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OA: HandsNarrows DIPs & PIPsNon-uniform narrowingSub-cortical sclerosis
S,H 73yoF
Left HandPA view
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OA: HandsNarrows DIPs & PIPsNon-uniform narrowingSub-cortical sclerosis
Spares MCPsNarrows Thumb BaseThumb CMC jointSpares the other CMCs
Scaphoid-Trapezoid-Trapezium jtSpares other intercarpal jtsSpares radiocarpal joint
S,H 73yoF
Left HandPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
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OA
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OA: HandsSymmetry?Has similar
distribution in both hands
One hand (dominant) usually more severely involvedHere right
thumb > leftS,H 73yoF
Left HandPA view
Right HandPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
47 of 94
Osteophytes: HandsBest seen on lateral
C,C 76yoF
HandPA view
HandLateral view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
48 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
My Ordered ListIs it…
OA?
EOA?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 9 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
49 of 94
Erosive OsteoarthritisOccurs in women>50As does conventional OA
Involves DIPs (PIPs)
As does conventional OA
“Gullwing Erosions”
T,M 64yoF
Left HandPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
50 of 94
Erosive OsteoarthritisLeft HandPA view
Right HandPA view
Symmetry
T,M 64yoF
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
51 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
My Ordered ListIs it…
OA?
EOA?
RA?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
52 of 94
RA = Disease of SynoviumNormal synovium is very thin 1-3 cells thick
RA synovium hypertrophies 8-10 cells thick “Pannus”Contains increased blood vesselsIncreased blood flow (hyperemia)
Contains inflammatory cellsIncluding osteoclasts
Causes EROSIONSCartilageBone
BONE
BONE
hopkins-arthritis.org
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
53 of 94
RA = Disease of SynoviumInflamed pannus effects the articular cartilage uniformlyUniform cartilage lossUniform joint narrowingSynovial osteoclasts erode cortical boneCentral erosionsMarginal erosionsPannus tends to heap up at
margins of joint capsule
BONE
BONE
BONE
BONE
to RA
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
54 of 94
RA = Disease of SynoviumSynovial hyperemia causes bone resorption, bone lossWithin the joint capsule“Peri-articular osteopenia”This is subtle on radiographsRadiographic technique dependent
May not even be present on pts treated with Bisphosphonates to prevent loss of bone mass
Cortical thinning causes bone bowing/deformity
BONE
BONE
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 10 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
55 of 94
OA vs RADisease of
Cartilage
NonuniformNarrowing
Produces boneSubcortical
SclerosisOsteophytes
BONE
BONE
Disease of Synovium
UniformNarrowing
Resorbs bonePeriarticular
OsteopeniaErosions
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
56 of 94
OA vs RADisease of
Cartilage
NonuniformNarrowing
Produces boneSubcortical
SclerosisOsteophytes
Disease of Synovium
UniformNarrowing
Resorbs bonePeriarticular
OsteopeniaErosions
H,A 51yoFV,D 50yoF
KneeAP view
KneeAP view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
57 of 94
RA: Marginal Erosions
A,F 69yoF
Left HandPA view
Right HandPA view
Mirror ImageSymmetry
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
58 of 94
RA: Erosions
T,H M
MarginalErosions
CentralErosions
HandPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
59 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
My Ordered ListIs it…
OA?
EOA?
RA?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
60 of 94
Distribution: OA vs RABig JointsHipsKneesAnklesShouldersElbowsSpineC1-C2HandsAll the MCP jtsEntire Wrist
Andreas Vesalius: “De humani corporis fabrica”1543 p.164
OA RA
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 11 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
61 of 94
OA vs RA: HipsAlso, since
with RA there is
bone loss/ resorption, there can
be thinning of medial
acetabular wall…
PowerPoint Model: Hip
Acetabulum
FemoralHead
OA
Non-uniform cartilage loss
Superior Narrowing
PowerPoint Model: Hip
Acetabulum
FemoralHead
UNIFORM cartilage loss
MEDIAL Narrowing
RA
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
62 of 94
RA: Hips
H,K 51yoM
MEDIAL NarrowingMirror Image Symmetry
ThinnedMedial
AcetabularWalls
PelvisAP view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
63 of 94
Protrusio AcetabuliThe degree of bone loss in RA can be so great that the medial acetabular wall not only thins, it protrudes into the pelvis…
PelvisAP view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
64 of 94
Distribution OA vs RA: HandsOADIPsPIPsThumb
baseCMCSTT
SparesMCPsRest
of the wrist
Z,S 26yoFS,H 73yoF
HandPA view
HandPA view RA
MCPsEntire
wristDRUJ
SparesDIPsPIPs
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
65 of 94
RA: Ligamentous LaxityParticularly in the handMCPsWristThe bones drift in the
ULNAR direction
I,I 60yoF
“Ulnar deviation”
of the MCPs
HandPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
66 of 94
Normally, lunate sits½ over radius and
½ over ulna
RA: Ligamentous LaxityParticularly in the handMCPsWristThe bones drift in the
ULNAR direction
R,T 47yoF
Right HandPA view
Left HandPA view
“Ulnar translocation of the carpus”
RadiusUlna
L
Lunate drifted towards ulna
Lunate drifted towards ulna
L
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 12 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
67 of 94
RA: Ligamentous Laxity
O,J 42yoF
C1
C2
C3
C4
C5
C6
C7
Cervical SpineLateral view
EXTENSION
Cervical SpineLateral view
FLEXION
C1C2
C3
C4
C5
C6
C7
C1
C2
C1 C2
C1-C2Instability
10mm!
Normal < 3mm © 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
68 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
My Ordered ListIs it…
OA?
EOA?
RA?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
OA looks nothing like RA!OA has osteophytesNot everything with
osteophytes is OA
RA has erosionsNot everything with
erosions is RA
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
69 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
Sharp Erosions withoverhanging edges
Resembles OAChondrocalcinosis
My Ordered ListIs it…
OA?
EOA?
RA?
Gout?
CPPD?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
RandomFavors Toes (1st)
Unusual distribution for OAFavors Patella-Femoral
Radiographically, Gout & CPPD look very different!
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
70 of 94
Crystal Deposition ArthropathiesThree crystals can deposit in joints:Hydroxyapatite: Usually in shoulders (calcific tendonitis/bursitis)
Uric acid (monosodium urate): “Gout”Calcium pyrophosphate dihydrate: “Pseudogout”
microscopyu.com
Uric acid
BirefringenceNeedlesStronglyNegative
CPPD
BirefringenceRhomboidsWeaklyPositivediseaseaday.com ard.bmj.com
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
71 of 94
GoutJoint fills with crystals
While these destroy cartilage,Presence of crystals in the
joint PRESERVES joint widthCrystals erode cortex slowlyTakes 6-10 years to see erosions
Erosions are sharply definedWell-corticated marginsOverhanging edges“Rat-bite”
Calcified soft tissue tophi are rare
BONE
BONE
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
72 of 94
Gout: Favors Toes (1st)
BONE
BONE
D,W 80yoM
Classic gout erosion
1st toeSharp marginOverhanging
edges
Marginal erosions
Diff Dx:GoutRA
FootAP view
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 13 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
73 of 94
Gout: Favors Toes (1st)Erosions can be quite
small……or
totally erode
phalangesR,B 30yoM
FootAP view
M,B 78yoM
FootAP view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
74 of 94
Gout: Random Distribution
A,J 66yoM
FootAP view
HandPA view
Classic “rat-bite” erosion1st toeSharp marginOverhanging
edges
Same “rat-bite”
erosion
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
75 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
Sharp Erosions withoverhanging edges
Resembles OAChondrocalcinosis
My Ordered ListIs it…
OA?
EOA?
RA?
Gout?
CPPD?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
RandomFavors Toes (1st)
Unusual distribution for OAFavors Patella-Femoral
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
76 of 94
Chondrocalcinosis“Cartilage calcified”Can be subtle…Sometimes obviousCommon sites:KneePubic symphysisWristTFC (Triangular
fibrocartilage)
H,W 63yoM
KneeAP view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
77 of 94
Chondrocalcinosis“Cartilage calcified”Can be subtleSometimes obviousCommon sites:KneePubic symphysisWristTFC (Triangular
fibrocartilage)Not all chondrocalcinosis = CPPD
M,Y 76yoF
TFC
Lunate-TriquetrumJoint
WristPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
78 of 94
Clues to CPPD:1)Chondrocalcinosis2)Distribution unusual
for OA
CPPD: WristWrist
PA view
TFC
TFC
HandPA view
M,Y 76yoF
NarrowingSTT &Thumb CMC(Typical for OA)
Spared DIPs & PIPs
(Somewhat atypical for OA)
Narrowed MCPs(Atypical for OA)Typical for CPPD!
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 14 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
79 of 94
CPPD: Knees
B,L 70yoF
Bilateral KneesAP view
Bilateral KneesSunrise view
Chondrocalcinosis
Lateral compartment narrowed > Medial
Atypical for OA
Patellofemoral compartments narrowed >> MedialAtypical for OA, …but typical for CPPD!
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
80 of 94
CPPD SLAC WristScapho-Lunate Advanced Collapse
Loss of the S-L ligament DiastasisCapitate then
descends downbetween S & LCausing entire
wrist to collapse“CPPD is one of
the major causesof SLAC*”
*Radiology 1990;177: 459-461
W,M 88yoF
LS
TFC
C
WristPA view
F,C 58yoM
LS
C
WristPA view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
81 of 94
FeaturesNon-uniform joint
space narrowingOsteophytes!
Gullwing Erosions
Uniform narrowingMarginal Erosions!
Sharp Erosions withoverhanging edges
Resembles OAChondrocalcinosis
Pencil-in-CupSausage Digit
My Ordered ListIs it…
OA?
EOA?
RA?
Gout?
CPPD?
Psoriatic?
DistributionHips, Knees, 1st MTPL4-5, C5-6DIPs, PIP, Thumb base
DIPs (Symmetric)Women > 50yo
MCPs, Carpus, C1-2Big Joints (Symmetric)
RandomFavors Toes (1st)
Unusual distribution for OAFavors Patella-Femoral
Hands, Feet, SpineSI Joints (Asymmetric)
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
82 of 94
PsoriasisPsoriasis is the most
prevalent autoimmune disease in the US
7.5 million Americans (2% of population)125 million worldwide (2-3% of population)Up to 30% develop psoriatic arthritis15% the arthritis precedes the skin disease
psoriasis.orgPlaque Psoriasis Guttate Psoriasis Inverse Psoriasis Pustular Psoriasis Erythrodermic
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
83 of 94
Psoriatic Arthritis: 5 TypesSymmetric Like RA; milder, less deformity.
Asymmetric “Sausage digit”. Usually mild.
psoriasis.org L,J 65yoF
Left HandPA view
3 Clues to PA:1) “Sausage” digit2) “Pencil-in-cup” erosion3) Unilateral SI-itis
Sausage Digit
Right HandPA view
0Sausage digit is not a tasty meat product*0Finger or toe swells
from tip to base0Shaped like a
cocktail sausage*voices.yahoo.com
Pencilin
cuperosion
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
84 of 94
Symmetric arthritis Like RA; milder, less deformity.
Asymmetric arthritis “Sausage digit”. Usually mild.
DIP (5%) Like OA; nail changes.
Arthritis mutilans (5%)Hands/feet.
Spondylitis (5%)Stiff spine, SIs; extremities.
Psoriatic Arthritis: 5 Types
psoriasis.org B,R 53yoF
Arthritismutilans
HandPA view
Pencil-in-Cuperosion
Clue to PA
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 15 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
85 of 94
4 Seronegative Spondyloarthropathies“Seronegative”: RF factor neg.
“Spondylo”: Effects spine
All 4 cause sacroiliitisPsoriatic arthritis &
“reactive arthritis”Unilateral, asymmetric
Ankylosing spondylitis & inflammatory bowel diseaseBilateral, symmetric fusion (ankylosis)
Crohn's DiseaseAbdomenAP view
Resectionterminal
ilium
Ankylosis SIs Bilateral Symmetric
M,P 32yoF© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
86 of 94
How Ordered List Helps Me Is this OA?No 1st MTP osteophytes
Is this RA?Not uniform narrowingNot all MTP, no osteopenia
Is this Gout?Maybe… not 1st toe
Is this CPPD?No chondrocalcinosis
Could this be PA?Do we have SI images?
S,E 36yoM
PelvisAP view
Normal IndistinctSclerotic
UnilateralSacroiliitis
PsoriaticArthritis!
FootOblique
view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
87 of 94
What to Order WhenAlways start with
radiographsLeast expensive
imaging studyWell shows results of
joint disease:Narrowing & alignmentOsteophytes & erosions
Useful for following course of disease
H,B 69yoF
HandPA view
“r/o RA”
Run eyes around wrist:No Narrowing
Run eyes along MCPs:Only 1 MCP is narrowed
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
88 of 94
Radiograph 1 year later
HandPA view
Radiographs: Disease Progression
H,B 69yoF
Only 1 MCP is narrowed Disease progression, now with 4 MCPs narrowed
HandPA view
“r/o RA”
Radiograph 2 years later
Further disease progression, now with ulnar deviation MCPs
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
89 of 94
Advanced Imaging StudiesMRI with IV
contrastWell shows
hypervascular pannusNormal synovium
does not enhance
Useful for diagnosing early RA
L,L 43yoF
HandPA view
Coronal MR HandT1 FatSat post IV contrast
Negative(even in
retrospect)
Enhancing pannus
Enhancing carpal bones
Developing erosions
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
90 of 94
Advanced Imaging StudiesDual-Energy CT (coming soon…)Specific for uric
acid crystals in gout
RadioGraphics 2011;31:1365–1375
©Ken L Schreibman, PhD/MD 2/3/15 www.schreibman.info
page 16 of 16Radiology of Joint DiseaseMy Practical Approach
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
91 of 94
Advanced Imaging StudiesFluoroscopic guided
joint injectionsUseful to prove which
joint is symptomaticWith steroids can yield
long-term reliefCan inject any joint:Hips, Knees, ShouldersFacets, AC, SIPubic symphysisAnkle, Subtalar joint
A,S 64yoF
Subtalar joint injectionLateral view
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
92 of 94
Any Final Questions?
morbidanatomy.blogspot.com
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
93 of 94
Final Exam Is this OA?No. Erosions, not phytes.
Is this RA?Does involves MTPs…Has marginal erosions…
Is this Gout?Not random enough.
Is this CPPD?No chondrocalcinosis.
Could this be PA?Pencil-in-cup erosion!
FootAP view
N,C 57yoF
PsoriaticArthritis!
© 2015 Ken L Schreibman, PhD/MDwww.schreibman.info
Radiology of Joint Disease My Practical Approach
Prevalence/HxJoint AnatomyOrdered List
OA
Phytes
EOA
RA
Gout
CPPD
PA
WOW
94 of 94
Thank you!
media.photobucket.com