1. Case Report Submitted by: Eric Hames, MS IV Faculty reviewer:
Radiological Category:
Musculoskeletal
Principal Modality:
X-ray
Case Report
Submitted by:
Eric Hames, MS IV
Faculty reviewer:
Sandra Oldham, M.D.
Date accepted:
August 27th, 2014

2. Case History
26 year old male with chronic joint pain in his left elbow and right ankle. No history of trauma or injury to joints. Otherwise feeling well.

3. X-ray of Left Elbow – 3 viewsAP
Oblique

4. X-ray of Left Elbow – 3 views

5. X-ray of Left Elbow – 3 views
Lateral View

6. X-ray of Right Ankle– 3 views
AP View
Lateral View

7. X-ray of Right Ankle – 3 views
AP Oblique Internally Rotated (Mortise View)

8. X-ray of Right Ankle – 3 views
AP Oblique Internally Rotated (Mortise View)

9. Diagnosis? Reactive arthritis (Reiter’s Syndrome) Rheumatoid arthritis
Osteoarthritis
CPPD arthropathy
Psoriatic arthritis
Infectious arthritis
Hemophilic arthropathy
Ankylosing Spondylitis

10. Findings and Differentials
Left Elbow: Progressive joint space narrowing of the humeroradial and humeroulnar joint. Sclerosis and subchondral cyst formation is also apparent. No acute fractures. No excessive fluid or soft tissue abnormality. Right Ankle: Extensive joint space narrowing of the tibiotalar joint. Sclerosis and subchondral cyst formation is also apparent. No acute fractures.
Differentials:
Hemophilic arthropathy
Reactive arthritis (Reiter’s Syndrome)
Rheumatoid arthritis

11. Discussion Reactive arthritis (Reiter’s Syndrome)
An asymmetric oligoarthritis that usually presents one to four weeks following an infection from elsewhere in the body.
Multiple pathogens can be causative, including Chlamydia, Yersinia, Salmonella, Shigella, and Campylobacter.
Microorganisms from infection are not recovered from the joint
Can also be associated with with urethritis and conjunctivitis (Rarely)
HLA-B27 is identified in ~80% of patients
Typically follows a self-limited course, with resolution of symptoms by 3-12 months, however approximately 15-30% of patients with Reactive Arthritis develop a long-term, sometimes destructive, arthritis.
Distal lower-extremity involvement (MTP>>calcaneus>ankle>knee) is more common than upper-extremity involvement. Sacroiliac involvement can also be observed.
27-year-old man shows erosions in all the left metatarsophalangeal (MTP) joints with subluxation and valgus deformity of most of the toes. Smaller erosions in the four and fifth MTP joints of the right foot are also shown.

12. Discussion Rheumatoid arthritis
A type of erosive arthritis that is more common in females, with females being affected approximately three times more often than men.
Rheumatoid factor is present in approximately 80% of patients with RA; these patients usually have more severe disease features.
Frequently involves proximal joints of the hands and wrists
Is usually bilateral and symmetrical
Early radiographic findings are soft tissue swelling and periarticular osteopenia
Later radiographic findings include ulnar deviation of the fingers, subluxation of the MCP joints, and deformities of the fingers (swan-neck and boutonniere deformities).

13. Discussion Hemophilic Arthropathy Disease progression
Hemophilia is an X-linked recessive bleeding disorder. It is caused by a deficiency in either coagulation factor VIII in Hemophilia A (classic hemophilia) or factor IX in Hemophilia B (Christmas disease).
The worldwide prevalence of Hemophilia A is 1 in 5000 males and for Hemophilia B is 1 in 30,000 males. Although it is an X-linked disorder, up to a third of all cases are a result of spontaneous mutations of the factor VIII and factor IX clotting genes, resulting in no prior family history.
Disease progression
In the acute setting of a hemarthrosis, the joint is swollen, painful, and warm, with decreased range of motion. Treatment consists of factor replacement and rest, returning to normal over the course of days to weeks.
Subacute arthropathy ensues after a critical threshold of synovitis develops after repeated hemarthroses. The resulting synovial hyperplasia results in more bleeds and worsening joint deterioration.
At the chronic stage, bony changes develop with subchondral cysts, cartilage loss from lack of support for the articular surface, and sclerosis.

14. Discussion Pathophysiology
Recurrent hemorrhage into the joint leads to hemosiderin deposition, which has a direct degenerative toxic effect on the cartilage. Hemosiderin also stimulates synovial hypertrophy and inflammation, and repeated synovitis also leads to the progressive destruction of cartilage and subchondral bone.
Intra-articular bleeds usually involve the hinge joints (knee, elbow, or ankle). These ‘hinge’ joints may be more vulnerable to hemarthrosis because of their relatively larger synovial content when compared with shoulder or hip joints.

15. Discussion Radiographic Evaluation
With X-ray, two classification systems have been developed to help grade the severity of joint disease in Hemophilic Arthropathy.
The Arnold-Hilgartner system is a progressive scale for the assessment of Hemophilic Arthropathy.
The Pettersson score is an additive scale from 1 to 13, with a score of 13 indicating a totally destroyed joint.

16. Discussion 10

17. Discussion Radiographic Evaluation cont.
MRI has recently gained more popularity in evaluating patients with Hemophilic Arthropathy.
It is much better at evaluating the early stages of the arthropathy, such as synovial hyperplasia, localization of the bleeding site, evaluation of cartilage loss, and follow-up of prescribed treatment.
The Denver MRI Scale has been developed as a way of staging the degree of Hemophilic Arthropathy.

18. Discussion Radiographic Evaulation cont.
Large white arrow shows a large effusion in the suprapatellar bursa
Small white arrows show areas of mild synovial hyperplasia.
sagittal gradient echo MRI

19. Advanced Hemophilic Arthropathy
Diagnosis
Advanced Hemophilic Arthropathy

20. References
Adams, Julie E. "Hemophilic Arthropathy of the Elbow." Hand Clinics 27.2 (2011): Cross, Susan, Sujit Vaidya, and Nicos Fotiadis. “Hemophilic Arthropathy: A Review of Imaging and Staging.” Seminars in Ultrasound, CT, and MRI 34 (2013): Herring, William. Learning Radiology: Recognizing the Basics. Philadelphia: Mosby Elsevier, Print. Kilcoyne, Ray F., and Rachelle Nuss. "Radiological Evaluation of Hemophilic Arthropathy." Seminars in Thrombosis and Hemostasis 29.1 (2003): Luck, James V., and Mauricio Silva. "Hemophilic Arthropathy." Journal of American Academy Orthopedic Surgeons 12 (2004):