Osteoporosis Of Elbow

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The shoulder has three different joints: the gle-nohumeral joint, the acromioclavicular joint, and the coracoclavicular joint. The last of these is a variant joint between the coracoid process and conoid process of the clavicle. Furnished with a bursa it is the site of coracoclavicular ligament attachment, and its prevalence is 0.8% (Gumina et al. 2002).

Rheumatoid arthritis is common in the first two joints, but is rare in the last whose existence itself is rare (Lehtinen et al. 1999). Topographically, the superolateral aspect of the humeral head (Babini et al. 1992) and the region between the head and greater tuberosity of the humerus are the favorite sites of erosion and cystic formation. Pinhole scintigraphy provides useful diagnostic information, particularly in the early phase. Patients with acute synovitis show intense uptake in the periarticular bones that are osteopenic; for example, in the lateral end of the clavicle and the tip of the acromion when the acromioclavicular joint is affected (Fig. 10.18). The articular space appears widened or unchanged at this time. The severity of osteopenia strongly parallels the intensity of tracer uptake. In classical rheumatoid arthritis the acromioclavicular and glenohumeral joints are involved in symmetrical fashion (Fig. 10.19). More often than not the acromioclavicular

Osteoporosis Elbow

Fig. 10.17A, B Chronic active rheumatoid arthritis of the elbow. A Anteroposterior radiograph of the left elbow in a 67-year-old female shows diffuse osteoporosis with accentuated cortical lines (upper four arrows olecranon, lower pair of arrows radioulnar joint). B Anterior pinhole scan reveals tracer diffusely accumulated in the whole elbow including the olecranon fossa and notch (OF), coronoid fossa (CF), radial fossa (RF), trochlear notch (TB), and proximal radioulnar joint (RUJ). The eccentric uptake is considered to indicate erosions in the periarticular bones that are exposed by pannus

Fig. 10.17A, B Chronic active rheumatoid arthritis of the elbow. A Anteroposterior radiograph of the left elbow in a 67-year-old female shows diffuse osteoporosis with accentuated cortical lines (upper four arrows olecranon, lower pair of arrows radioulnar joint). B Anterior pinhole scan reveals tracer diffusely accumulated in the whole elbow including the olecranon fossa and notch (OF), coronoid fossa (CF), radial fossa (RF), trochlear notch (TB), and proximal radioulnar joint (RUJ). The eccentric uptake is considered to indicate erosions in the periarticular bones that are exposed by pannus

Joint Pannus

Fig. 10.18A, B Intense tracer uptake in the periarticular bones of the acromioclavicular joint in acute rheumatoid synovitis. A Anterior pinhole scintigraph of the right shoulder in a 29-year-old man with rheumatoid synovitis delineates extremely intense tracer uptake in the lateral clavicular end (cl) and the acromial tip (ap). The joint space appears fallaciously narrowed due to intense uptake (arrows). B Anteroposterior radiograph shows severe porosis in the bones about the acromioclavicular joint (arrows) and widening of the joint space due to effusion (arrowheads). Observe the intimate correlation between the scintigraphic and radiographic alterations of osteoporosis

Fig. 10.20A, B Rheumatoid arthritis in the coracoid process and coracoclavicular joint. A Anterior pinhole scan of the left shoulder in a 51-year-old male shows increased tracer uptake in the coracoid process (C), conoid tubercle (arrow) and acromioclavicular joints (A). B An-teroposterior radiograph reveals regional osteoporosis and a small erosion in the acromion (arrowhead). No radiographic change is seen in the conoid tubercle (?)

Fig. 10.19 Symmetrical involvement of both shoulders in rheumatoid arthritis. Anterior pinhole scintigraph of both shoulders (separate acquisitions) in a 55-year-old woman with established rheumatoid arthritis shows diffuse and patchy tracer uptake in the bones about the gle-nohumeral and acromioclavicular joints. Note nearly perfect symmetry (ap acromion process, cp coracoid process, ghj glenohumeral joint)

Osteitis Pubis
B
Boil Shoulder Bones

Fig. 10.21A, B Intense tracer uptake in rheumatoid subchondral cyst. A Anterior pinhole scintigraph of the right shoulder in a 53-year-old woman with rheumatoid intraosseous cysts in the humeral head shows patchy, intense tracer uptake in the base of the greater tuberosity (black arrow) and the inferomedial aspect of the humeral head (open arrow). The coracoid process (cp) and the lateral clavicular end (arrowheads) also concentrate some tracer. (Evaluation of the coracoid process uptake requires much caution because it concentrates tracer intensely in the normal state.) B Anteroposterior radiograph shows intraosseous cystic changes in the base of the greater tuberosity and the inferomedial aspect of the humeral head (arrowheads). The lateral end of the clavicle appears eroded

Fig. 10.21A, B Intense tracer uptake in rheumatoid subchondral cyst. A Anterior pinhole scintigraph of the right shoulder in a 53-year-old woman with rheumatoid intraosseous cysts in the humeral head shows patchy, intense tracer uptake in the base of the greater tuberosity (black arrow) and the inferomedial aspect of the humeral head (open arrow). The coracoid process (cp) and the lateral clavicular end (arrowheads) also concentrate some tracer. (Evaluation of the coracoid process uptake requires much caution because it concentrates tracer intensely in the normal state.) B Anteroposterior radiograph shows intraosseous cystic changes in the base of the greater tuberosity and the inferomedial aspect of the humeral head (arrowheads). The lateral end of the clavicle appears eroded

Inferomedial Aspect Humeral Head

Fig. 10.22 Photopenic representation of large rheumatoid bone cyst. A Anterior pinhole scintigraph of the right humerus in a 43-year-old woman with a large intraosse-ous rheumatoid cyst shows a rectangular "cold" defect surrounded by markedly increased tracer uptake in the neck (open arrows). B Lateral radiograph demonstrates a cystic bone defect in the greater tuberosity (arrowheads)

Fig. 10.22 Photopenic representation of large rheumatoid bone cyst. A Anterior pinhole scintigraph of the right humerus in a 43-year-old woman with a large intraosse-ous rheumatoid cyst shows a rectangular "cold" defect surrounded by markedly increased tracer uptake in the neck (open arrows). B Lateral radiograph demonstrates a cystic bone defect in the greater tuberosity (arrowheads)

joint and the coracoid process physiologically accumulate tracer, confusing the diagnosis. Therefore, it is mandatory to individually examine whether increased uptake is symptomatic or not. The case presented in Fig. 10.20 manifests as increased tracer uptake in the acromio-clavicular joint, the conoid tubercle, and the coracoid process. All were painful and considered to be related to rheumatoid arthritis. Radiography showed focal erosion at the top of the acromion with osteopenia in the regional bones.

With the destruction of articular cartilages and subchondral bones, the joints become narrowed and eventually closed with ankylosis. Small cysts are indicated by patchy uptake located within the subchondral cancellous bone (Fig. 10.21) and when a cyst is large enough it is shown as a photon defect (Fig. 10.22).

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