Ankle and Tarsus

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Rheumatoid arthritic involvement of the ankle and tarsus may be generalized or limited to one or a few joints. Normally, the larger joints of the ankle, the talus, and the calcaneus are readily discerned by radiography and pinhole scintigraphy (Chap. 4). These larger joints are also clearly visible in the early inflammatory phase

Fig. 10.27A, B Delimitation of tracer uptake by physeal cartilages in rheumatoid digits and sesamoidal rheumatoid arthritis. A Dorsal pinhole scintigraph of the right forefoot in a 14-year-old girl with juvenile rheumatoid arthritis reveals very intense, expansile tracer uptake in the periarticular bones of all five metatarsophalangeal joints, except for the fifth which was inadequately imaged due to its peripheral location (arrowheads). Physeal growth cartilages clearly delimit the abnormal tracer uptake in the metatarsal heads (gc), and the first metatarsal sesamoids reveal increased tracer uptake (ss). B Dorso-plantar radiograph reveals periarticular soft-tissue swelling, porosis, and joint space narrowing (arrows)

Fig. 10.27A, B Delimitation of tracer uptake by physeal cartilages in rheumatoid digits and sesamoidal rheumatoid arthritis. A Dorsal pinhole scintigraph of the right forefoot in a 14-year-old girl with juvenile rheumatoid arthritis reveals very intense, expansile tracer uptake in the periarticular bones of all five metatarsophalangeal joints, except for the fifth which was inadequately imaged due to its peripheral location (arrowheads). Physeal growth cartilages clearly delimit the abnormal tracer uptake in the metatarsal heads (gc), and the first metatarsal sesamoids reveal increased tracer uptake (ss). B Dorso-plantar radiograph reveals periarticular soft-tissue swelling, porosis, and joint space narrowing (arrows)

Ankle Arthritis Swollen

Fig. 10.28A, B Inflammatory rheumatoid arthritis in the ankle. A Anteroposterior radiograph of the right ankle in a 5-year-old female shows marked swelling of the periarticular soft tissues (white arrows) with well visualized articular space (open arrows). B Anterior pinhole scan reveals diffusely increased tracer uptake but with well-discernible articular space (open arrows)

Fig. 10.28A, B Inflammatory rheumatoid arthritis in the ankle. A Anteroposterior radiograph of the right ankle in a 5-year-old female shows marked swelling of the periarticular soft tissues (white arrows) with well visualized articular space (open arrows). B Anterior pinhole scan reveals diffusely increased tracer uptake but with well-discernible articular space (open arrows)

Articular Space

Fig. 10.30A, B Difference between pinhole scan features of rheumatoid arthritis and osteoarthritis. A Lateral pinhole scan of the left midfoot in a 57-year-old female shows intense tracer uptake diffusely obliterating the small narrowed intertarsal joints (open arrows) (T talus, C cuneiform, Q cuboid). B Lateral radiograph reveals markedly narrowed intertarsal articular spaces with eburnation and porosis

Fig. 10.29A, B Radiographically visible small joints become obliterated by tracer uptake in rheumatoid arthritis. A Lateral radiograph of the left foot shows diffuse porosis with narrowed intertarsal joints (T talus, N navicular, C cuboid). There is an erosion at the plantar aspect of fifth metatarsal (arrowhead). B Lateral pinhole scan reveals intense tracer uptake in the intertarsal joints and fifth metatarsal erosion (arrowhead). Note clear visualization of rheumatoid plantar fasciitis and associated edema in adiposofibrous tissue (small arrows) that are attached to the calcaneal tuberosity (large arrow)

Fig. 10.30A, B Difference between pinhole scan features of rheumatoid arthritis and osteoarthritis. A Lateral pinhole scan of the left midfoot in a 57-year-old female shows intense tracer uptake diffusely obliterating the small narrowed intertarsal joints (open arrows) (T talus, C cuneiform, Q cuboid). B Lateral radiograph reveals markedly narrowed intertarsal articular spaces with eburnation and porosis of rheumatoid arthritis (Fig. 10.28). However, the smaller intertarsal joints are visualized only on radiographs, and they are not visible on pinhole scans because tracer uptake easily obliterates inflamed joints (Fig. 10.29).

As pointed out by Calabro (1962), the mid-foot rheumatoid arthritis characteristically involves the talocrural joint (Fig. 10.28) and the talocalcaneal and talonavicular joints (Fig. 10.29). Plantar fasciitis with the swelling of the adiposofibrous tissues may accompany tarsal rheumatoid arthritis, showing band-like uptake in the sole (Fig. 10.29B). Unlike seronegative spondyloarthropathies, rheumatoid arthritis affects the calcaneus less commonly. In

Seronegative Spondyloarthropathy

Fig. 10.31 "Wrapped bone" sign of acute rheumatoid synovitis in the knee. Anterior pinhole scintigraph of the left knee in a 35-year-old woman with acute rheumatoid sy-novitis delineates the classic linear tracer accumulation in the entire subchondral bones, giving rise to the "wrapped bone" sign (arrowheads). The patella (P) is also involved

Fig. 10.31 "Wrapped bone" sign of acute rheumatoid synovitis in the knee. Anterior pinhole scintigraph of the left knee in a 35-year-old woman with acute rheumatoid sy-novitis delineates the classic linear tracer accumulation in the entire subchondral bones, giving rise to the "wrapped bone" sign (arrowheads). The patella (P) is also involved the late stage the ankle and intertarsal and tar-sometatarsal joints are closed due to ankylosis, forming a solid block of bones and joints with markedly increased tracer uptake.

Diagnostically, it is helpful to remember that the pinhole scintigraphic features of uncomplicated rheumatoid arthritis differ from those of osteoarthritis. Indeed, uptake is diffuse in the former (Figs. 10.29 and 10.30), whereas it is discrete in the latter (Figs. 9.4 and 9.5).

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