Home / X-ray + ECG +CT / X-Ray

Joint X-ray

Protocols

Acromegaly:

Image

Fig-a: Acromegaly Hand

Image

Fig-B: Acromegaly Hand

X-ray -A finding: X-ray of left hand AP view showing:

  • • Hand is enlarged with increased soft-tissue shadow.
  • • There is enlargement of bones, widening of joint space and tufting of terminal phalanges.

X-ray -B finding: 

X-ray of both hands AP view showing:

  • • Hands are enlarged with increased soft-tissue shadow.
  • • There is enlargement of bones, widening of joint space and tufting of few terminal phalanges.

Diagnosis: Acromegaly.



  1. Q: What else do you want to examine in this patient clinically?
  2. A: I want to examine the skull, face, eye (to see bitemporal hemianopia) and
  3. other parts of the body (usually enlarged). Also I want to examine the skin, blood
  4. pressure and voice of the patient (which is husky, cavernous voice).
  1. Q: What are the findings in hands in acromegaly?
  2. A: As follows:
    • • Both hands are large, warm and sweaty, doughy feeling, spade-like fingers.
    • • Carpal tunnel syndrome (if asked to examine the hands, always test for it).
    • • Clubbing involving all the fingers is present.
    • Image

Fig-D: 

X-ray of both feet, lateral view, showing increase in the heel pad thickness (heel pad sign).

      • Q: What is ‘heel pad sign’?
      • A: It is a radiological sign, measured on lateral plain X-ray of the non-weight-bearing foot.
      • It is measured from the lowest point of the calcaneal tuberosity to the lowest margin of
      • soft tissue. Normally, in males up to 21.5 mm and in females 18 mm. If 25 mm, highly suggestive.
      • Q: Mention one single investigation.
      • A: CT scan or MRI of the skull (MRI is more preferable).
      • Q: How to confirm acromegaly?
      • A: GTT with simultaneous measurement of GH (more diagnostic). Normally during GTT,
      • there is suppression of GH level. But in case of acromegaly, there is failure of suppression of GH; rather there may be paradoxical rise of GH.
      • Q: What are the signs of active acromegaly?
      • A: Signs of activities are progressive increase in body size, excessive sweating, increasing
      • visual field defect, large skin tags (molluscum fibrosum), presence of glycosuria (DM), hypertension, progressive headache and enlarging thyroid.
      • Q: What are the long-term complications of acromegaly?
      • A: Increased incidence of large bowel carcinoma and increased atherosclerosis.

X-ray Rickets:

Image

X-ray -A finding: 

X-ray of both hands AP view showing:

  • • Widening, splaying, cupping and irregularity of metaphysis (arrow below).
  • • Distance between the epiphysis and the metaphysis is increased (zone of provisional calcification is lost; arrow above).
Diagnosis: Rickets.
  1. Q: Why are there cupping and splaying?
  2. A: Cupping and splaying are due to weight bearing and stress of uncalcified bone. In rickets, there is lack
  3. of mineralization of growth plate in the developing bone (so, lack of calcification of osteoid).
  1. Q: Why is this not scurvy?
  2. A: Because in scurvy findings are:
    • • Epiphysis is small, ring shaped and sharply marginated (Wimberger’s sign).
    • • Zone of provisional calcification at the growing metaphysis is dense, giving a white line (Frankel’s line).
    • • Beneath this, a lucent zone due to lack of mineralization of osteoid (Trümmerfeld zone). This area is prone
    • to fracture which is seen at the corner, giving rise to spur (Pelkan’s spur).
    • • Subperiosteal haemorrhage may be seen and there may be new bone formation.

Image

X-ray -C findings: 

X-ray of leg including knee and ankle joint showing:

  • • Widening, splaying, cupping and irregularity of metaphysis.
  • • Distance between epiphysis and metaphysis is increased (zone of provisional calcification is lost).
  • • Bowing of tibia and fibula.
  • • There is osteopenia.
  1. Q: What are the presentations of rickets?
  2. A: Depends on the age of the patient:

In infants and early childhood:

  1. 1. Restlessness, fretful, pale and flabby muscles
  2. 2. Delayed milestones of development (failure to crawl, sit, stand, walk)
  3. 3. Delayed tooth eruption
  4. 4. Early signs are:
    • • Craniotabes (small unossified area in skull)
    • • Enlarged epiphysis (at the lower end of radius)
    • • Swelling of costochondral junction (rickety rosary)
    • • Frontal and parietal bossing
    • • Delayed closure of anterior fontanelle

In older children:

  • • Retardation of growth.
  • • Bony deformity (bowing of legs, knock knee).
  • • Chest deformity (kyphoscoliosis, pectus excavatum, pigeon chest).
  • • Pelvic deformity (in females: difficulty during childbirth occurs in later life).
  • • Epiphysis is enlarged.


X-ray Osteomalacia:

Image



X-ray G& H Findings: 

X-ray of dorsal vertebra showing generalized osteopenia with biconcave shape of the body of vertebra giving rise to fish mouth appearance.

Diagnosis: Osteomalacia.

  1. Q: Define osteomalacia and osteoporosis.
  2. A: As follows:
    • • OsteomalaciA: It is a metabolic bone disease, characterized by softening of the bone due to deficiency
    • of vitamin D, resulting in inadequate mineralization of osteoid tissue. The ratio of osteoid tissue to calcium
    • and phosphate is increased (there is low calcium, low phosphate and increased osteoid tissue; alkaline phosphatase is high).
    • • Osteoporosis: It is defined as ‘reduction of bone mass per unit volume’. Ratio of osteoid tissue to
    • calcium and phosphate is normal (calcium, phosphate and alkaline phosphatase are normal).



X-ray Rheumatoid hand:

Image


X-ray -A FINDINGS: 

X-ray of both hands AP view showing:

  • • Periarticular osteopenia in metacarpophalangeal and proximal interphalangeal joints
  • • Reduction of joint space of all the PIP joints of both hands
  • • Ulnar deviation of both hands with ankylosis of carpal bones

Diagnosis: Rheumatoid arthritis.

  1. Q: Which joint is spared in rheumatoid arthritis?
  2. A: Distal interphalangeal (DIP) joints.
  1. Q: Can DIP joint be involved in rheumatoid arthritis?
  2. A: Usually no DIP joint involvement. But may be involved, if secondary osteoarthritis.
  1. Q: What are the deformities of the hand in rheumatoid arthritis?
  2. A: As follows:
    • • PIP: Boutonniere deformity
    • • DIP: Swan neck deformity
    • • Thumb: ‘Z’ deformity
    • • Ulnar deviation, dorsal subluxation of ulna at the carpal joint and arthritis mutilans
  • Image

X-ray -C findings :

X-ray of both hands AP view showing:

  • • Reduction of all joint spaces and disorganization of all PIP joints of both hands
  • • Reduction of all the joint spaces and also periarticular osteopenia involving metacarpophalangeal and wrist joints of both hands
  • • Ulnar deviation of both hands
  • • ‘Z’ deformity of thumb

  1. Q: What is the type of arthritis in RA?
  2. A: Inflammatory type.
  1. Q: What is boutonniere deformity?
  2. A: Fixed flexion of PIP joint and extension of DIP joint.
  1. Q: What is the mechanism?
  2. A: Due to chronic synovitis of PIP joint, central slip of extensor tendon ruptures, causing protrusion of the joint between two lateral slips of extensor tendon.
  1. Q: Why is it called boutonniere?
  2. A: Due to rupture of central slip of extensor tendon, it looks like a gap of buttonhole.
  1. Q: Why radial deviation?
  2. A: Weakness of extensor carpi ulnaris leads to radial deviation at wrist, as carpal bone rotates.
  1. Q: What is swan neck deformity? What is the mechanism?
  2. A: Fixed flexion of distal interphalangeal joints (DIP) and extension of proximal interphalangeal joints (PIP), reverse of boutonniere.

Image

  1. X-ray finding :

  2. X-ray of right foot AP view showing:

    • • Multiple erosions of bones of metatarsophalangeal joints.
    • • There are also subluxations and dislocations of metatarsophalangeal joints and 4th proximal interphalangeal joint.