Imaging Rheumatoid Arthritis - Lieberman's eRadiology Learning Sites

Aimee Shu
Gillian Lieberman, MD
Imaging Rheumatoid Arthritis
April 2002
Aimee Shu, Harvard Medical School, Year III
Gillian Lieberman, MD

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Aimee Shu
Gillian Lieberman, MD
Meet Ms. M
50-year old female
22-year history of seronegative
rheumatoid arthritis (RA)
Followed at BIDMC rheumatology
department
Films from 1981 - present in BIDMC Film
Library
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Aimee Shu
Gillian Lieberman, MD
Ms. M’s RA at a Glance
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Age 28: trouble opening jars, episodic swelling of hands
Principle sites: hands, wrists, feet
Initially, rapid bony changes
Developed osteoporosis
Past DMARDs*: azathioprine, hydroxychloroquine, gold
Present drugs: leflunomide, prednisone, piroxicam
Disease now relatively stable
Left wrist continues to give her most trouble
*DMARD = disease-modifying anti-rheumatic drug
Netter, The Ciba Collection of Medical Illustrations
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Aimee Shu
Gillian Lieberman, MD
Rheumatoid Arthritis: Definition
Chronic, inflammatory, systemic disease
Etiology unknown
Prominent characteristic = symmetric
polyarthritis
Extra-articular manifestations in 20% of
patients
Variable presentation at onset
Variable clinical features
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synovium
Aimee Shu
Gillian Lieberman, MD
Diarthrodial
cartilage
Marginal areas—where synovium
directly touches bone (without
cartilage in between)—are
designated with small black arrows.
Resnick & Niwayama, Diagnosis of Bone and Joint Disorders
Joint Anatomy
fibrous
capsule
Cross section through
cadaveric MCP joint
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Aimee Shu
Gillian Lieberman, MD
Joint Pathology: Progressive Stages
Synovitis pannus* joint destruction
Pannus = granulation tissue
Netter, The Ciba Collection of Medical Illustrations
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acute synovitis
continued synovitis,
pannus formation,
cartilage destruction,
mild osteoporosis
fibrous ankylosis,
subsidence of
inflammation
bony ankylosis,
advanced osteoporosis
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Aimee Shu
Gillian Lieberman, MD
American College of Rheumatology Criteria for RA
4 of the following 7:
– Morning stiffness
– Arthritis of > 3 joint areas
– Arthritis of hand joints
– Symmetric arthritis
– Rheumatoid nodules
– Serum rheumatoid factor
– Radiographic changes
Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association
1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315-24.
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Aimee Shu
Gillian Lieberman, MD
Rheumatoid Arthritis: Epidemiology
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1.0% of Americans
2.5 female : 1 male
Onset between ages 25-50
Peak incidence between ages 40-50
Associated with certain HLA-DR
haplotypes
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Aimee Shu
Gillian Lieberman, MD
Agenda
Broad overview of systemic manifestations
Focus on Ms. M
Focus on imaging hand pathology
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conventional radiography
MRI
Brief visit to Ms. T
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Aimee Shu
Gillian Lieberman, MD
Articular
Areas of joint involvement
Klippel, John, Primer on the Rheumatic
Diseases, 2 nd ed, 1997.
Manifestations
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Symmetrical involvement,
listed from most least
commonly affected
Hands, wrists
Feet, ankles
Knees
Hips
Cervical spine
Shoulders
Elbows
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Image from:
Aimee Shu
Gillian Lieberman, MD
Hands & Wrists
Almost always affected in RA
MCPs, PIPs swollen and/or deformed
DIPs spared
Ulnar deviation at MCP
Radial deviation at the carpals
Swan-neck deformities
Boutonnière deformities
Neuropathy, e.g. carpal tunnel syndrome
ulnar deviation
Eric A. Brandser on Virtual Hospital site, http://www.vh.org/Providers/Lectures/icmrad/skeletal/Parts/RAHands.html
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Aimee Shu
Gillian Lieberman, MD
Extra-Articular
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Nodules
Vasculitis
Rheumatoid factor =
anti-IgG antibodies
Ocular:
keratoconjunctivitis
sicca, scleritis
Manifestations
Nodular episcleritis
Radiograph showing
right lung nodule
Netter, The Ciba Collection of Medical Illustrations
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Aimee Shu
Gillian Lieberman, MD
Extra-articular
manifestations
•Pulmonary: interstitial lung disease,
pleural effusion
•Cardiac: pericardial effusion,
pericarditis
•Subcutaneous nodules over knuckles
•3 rd
•Ulnar
phalange: swan-neck deformity
deviation
•Muscle atrophy
•Subcutaneous nodules in olecranon
bursa and just distal to olecranon
process
Netter, The Ciba Collection of Medical Illustrations
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Aimee Shu
Gillian Lieberman, MD
Imaging Modalities
Conventional radiography
Magnetic resonance imaging (MRI)
Bone densitometry (DEXA)
– Evaluate osteoporosis
Ultrasound
– Not often used for RA in US; more often in Europe
Computed tomagraphy
– Only as adjunct; not as primary modality
Bone scintigraphy
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Confirm disease presence
Evaluate disease distribution & activity
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Aimee Shu
Gillian Lieberman, MD
Role of Imaging in RA
Assist in diagnosis
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Early & aggressive treatment is now the
standard of care
Track disease progression
Evaluate response to treatment
Classify disease severity for
research/clinical trials
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Aimee Shu
Gillian Lieberman, MD
Characteristic Changes on Plain Film
Individual findings are non-specific
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since synovium
reacts in limited # of ways
But patterns and combinations of findings
can suggest RA
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Aimee Shu
Gillian Lieberman, MD
Characteristic Changes on Plain Film
Soft tissue changes
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Early swelling
Later atrophy
Periarticular fat displacement (large joints)
Cartilage changes
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Joint space wide narrow wide
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Secondary to inflammation, cartilage destruction,
ligamentous laxity, respectively
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Aimee Shu
Gillian Lieberman, MD
Characteristic Changes on Plain Film
Bony changes
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Marginal bony erosion: periarticular “bare” areas
Subchondral cyst formation
Juxta-articular osteopenia generalized osteopenia
Lack of bony response to overwhelming bone and joint
destruction is characteristic of RA
Subluxation & dislocation
Flexion & extension contracture
Ankylosis
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Aimee Shu
Gillian Lieberman, MD
Hand
Anatomy
Review
Normal hand
radiograph
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Sesamoid
bones =
ovoid
nodules
embedded
in tendons;
# variable
in between
people
Hand Anatomy Review
DIP joint
PIP joint MCP
joint
radius
Wicke, Atlas of Radiologic Anatomy
Carpal
bones
ulna
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Aimee Shu
Gillian Lieberman, MD
trapezium trapezoid capitate hamate
Carpal
Bones
scaphoid lunate triquetral pisiform
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Aimee Shu
Gillian Lieberman, MD
Conventional Radiography of Hands
“ABC’S”
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Alignment
Bone mineralization
Cartilage
Soft tissue
PA and oblique views
low dose radiation for hands, therefore
serial studies are relatively safe
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Aimee Shu
Gillian Lieberman, MD
Ms. M’s Initial
Presentation, Age 28
1981, age 28, episodic pain &
swelling
Right lateral oblique view
(“Zither player position”)
Normal mineralization
Normal joint space
4th digit, middle phalanx: small
cystic changes & minimal soft
tissue swelling, consistent with
“post-traumatic cyst”
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Ms. M’s Initial
Presentation
•1981, age 28
•Left lateral oblique
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Ms. M, 1983, Age 30
•Right AP
(dorsopalmar) view
•Changes since 1981
•Erosions: 2nd metacarpal, 3rd PIP
4 th
DIP,
•Soft tissue swelling
•Consistent with RA
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Ms. M, 1983, Age 30
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BIDMC Film Library
Left AP view
Erosions: 3rd PIPs
Cyst: 1 st
IP
& 5 th
Soft tissue swelling
around PIPs, MCPs
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Aimee Shu
Gillian Lieberman, MD
Ms. M, 1986,
Age 33
Right lateral
oblique
Disease
progression
Erosions: 2nd MCP, 3rd & 4th PIPs, 3rd DIP, 1st IP
Decreased joint
spaces
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Ms. M’s RA Progresses, Right AP Views
1988, Age 35
BIDMC Film Library
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↓joint space, new
erosions: 3rd MCP,
PIP, 5th PIP
4 th
Note 1st IP fused
by screw
Erosions: 2nd-5th MCPs, 4th-5th PIPs,
DIPs
4th-5 th
Carpal cysts
1995, Age 42
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Aimee Shu
Gillian Lieberman, MD
Ms. M, Left
Lateral Oblique,
1995, Age 42
•This view shows ulnar
styloid erosion
•2 nd
MCP subluxation
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Advantages of MRI
Better than conventional radiography at
imaging soft tissue, marrow, & cartilage
Multiplanar
Can assess complications
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Tendon tear or rupture
Synovitis, tenosynovitis, bursitis
Erosions, cysts, fibrocartilage degeneration
May show erosions earlier than plain film
Up & coming!
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Aimee Shu
Gillian Lieberman, MD
Anatomy Pointers
ulna
radius
MR (T2), Left wrist, Axial view. BIDMC Film Library
Ms. M, 2002, Age 49
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flexor
retinaculum
(Carpal tunnel)
contains tendons
and median nerve
Tendon sheath
normally
indistinct from
tendon (low
signal; dark in
this view)
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Aimee Shu
Gillian Lieberman, MD
Findings
MR (T2), Left Wrist Axial view. BIDMC Film Library
* Tenosynovitis = tendon sheath inflammation, seen in RA or
repetitive trauma. In contrast, tendonitis = tendon
inflammation, signal would be within tendon; seen with overuse
Ms. M, 2002, Age 49
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Tenosynovitis
– Extensor carpi
ulnaris tendon
– Flexor carpi radialis
tendon
Synovial proliferation
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Aimee Shu
Gillian Lieberman, MD
More proximally, flexor carpi
appears normal
MR (T2), Left Wrist Axial view. BIDMC Film Library
radialis
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Aimee Shu
Gillian Lieberman, MD
Extensor carpi
http://www.rad.washington.edu/atlas/extensorcarpiulnaris.html
ulnaris
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Aimee Shu
Gillian Lieberman, MD
Flexor carpi
radialis
http://www.rad.washington.edu/atlas/flexorcarpiradialis.html
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Aimee Shu
Gillian Lieberman, MD MR Normal Wrist,
Coronal View
3 important areas:
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triangular fibrocartilage
(TFC)
scapholunate
lunotriquetra
ligament (SL)
ligament (LT)
• These areas confer stability
• Commonly injured pain
T2-weighted gradient echo. BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
↑ signal =
TFC tear
Ms. M: TFC Tear & SL Tear
T2-weighted gradient echo. BIDMC Film Library
Gap > 2 mm
indicates
SL tear
* SL tear
nickname is “David
Letterman sign”
reminiscent of the
talk show host’s
gap teeth.
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Aimee Shu
Gillian Lieberman, MD
Ms. M: Erosions on MRI
T2-weighted gradient echo. BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Sagittal
triquetral
ulna
T1 MRI, left wrist. BIDMC Film Library
View of Normal TFC
Notice ample joint
space between
ulna and triquetral
bones
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Aimee Shu
Gillian Lieberman, MD
Ms. M: TFC Tear
ulna and triquetral
bones touch
T1 MRI, left wrist. BIDMC Film Library
Carpal
tunnel
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Aimee Shu
Gillian Lieberman, MD
What is This Bulge on Ms. M?
T2 MRI, left wrist. BIDMC Film Library
No, it is not
her thumb…
…It is a vitamin
E tablet to
mark the area
of her pain!
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Aimee Shu
Gillian Lieberman, MD Now Meet Ms. T
62yo woman, h/o RA and 50 lb weight loss, right leg
shorter than left, inability to ambulate. Please
evaluate…
Acetabuli
into ilium
BIDMC Film Library
protrusio
•hips involved in 50% RA
patients
• ↓ cartilage allows
femoral head to migrate
superomedially within
acetabulum
•more severe with time
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Aimee Shu
Gillian Lieberman, MD
BIDMC Film Library
Normal shoulder
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Aimee Shu
Gillian Lieberman, MD
Ms. T’s Shoulder
Findings on Ms. T:
erosions, fusions,
superior subluxation
Shoulders involved in
50% RA patients
Narrowing of all
compartments of
shoulder
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glenohumeral
acromiohumeral
acromioclavicular
humeral head migrates
proximally & superiorly
BIDMC Film Library
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Aimee Shu
Gillian Lieberman, MD
Arthritides
monoarticular polyarticular
trauma
infection
gout
pseudogout
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rhematoid
types
RA
SLE
scleroderma
DM
inflammatory degenerative metabolic
deposition
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rheumatoid
variants
ankylosing
spondylitis
Reiter’s syndrome
psoriatic arthritis
IBD
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OA
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Gout
Amyloidosis
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Aimee Shu
Gillian Lieberman, MD
Arthritides
Radiographic findings rarely
pathognomonic for arthritides
Must use radiographic findings in
conjuction with clinical presentation
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Aimee Shu
Gillian Lieberman, MD
Differential Diagnoses
Feature Also seen in
Carpal erosions Gout
Ulnar deviation & volar SLE, Jaccoud’s syndrome
subluxation of proximal
phalanges
2º to rheumatic fever
Narrow joint space Osteoarthritis
Bony destruction
(“punched-out” lesion)
Sarcoid
Swell, erode, cyst Psoriatic arthritis
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Aimee Shu
Gillian Lieberman, MD
RA: Distinguishing Features
Diffuse (vs. limited to juxta-articular)
osteoporosis
Lack of new bone formation
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Aimee Shu
Gillian Lieberman, MD
Summary: Key Points
Conventional radiography and MRI are especially
useful in imaging RA
Chronic, progressive changes are evident in the
hands and wrists
Characteristic changes on plain film include bony
erosions, joint space narrowing, & osteoporosis
On MRI: tenosynovitis, synovial proliferation,
cartilage tear, tendon rupture
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Aimee Shu
Gillian Lieberman, MD
References
American College of Radiology Film Library
Britton, Cynthia A. and Mary Chester Wasko, “Rheumatoid Arthritis,” Seminars in Roentgenology
31 (3): 198-207, July 1996.
Brower, Anne C., Arthritis in Black and White, 2nd ed., W.B. Saunders, 1997.
Edeiken, Roentgen Diagnosis of Diseases of Bone, 3rd ed., 1981.
Forrester, D.M. and J.C. Brown, The Radiology of Joint Disease, 3rd ed., W.B. Saunders, 1987.
Grassi, Walter, Rossella De Angelis, Gianni Lamanna, and Claudio Cervini, “The Clinical Features of
Rheumatoid Arthritis,” European Journal of Radiology 27:S18-24, 1998.
Klippel, John H., Primer on Rheumatic Diseases, 2nd ed., 1997.
Netter, Frank H., The Ciba Collection of Medical Illustrations, Volume 8: Musculoskeletal System,
Part II: Developmental Disorders, Tumors, Rheumatic Diseases, and Joint Replacement, CIBA-
GEIGY, 1990.
Reid, Graham, and John M. Esdaile, “Rheumatology: Getting the Most Out of Radiology,” Canadian
Medical Association Journal 162(9):1318-1325, May 2000.
Resnick & Niwayama, Diagnosis of Bone and Joint Disorders, 2nd ed., W.B. Saunders, 1988.
Stoller, David W., “The Wrist,” Seminars in Roentgenology 30 (3): 265-276, July 1995.
Taveras & Ferrucci, Radiology, J.B. Lippincott Co., 1991.
Wicke, Lothar, Atlas of Radiologic Anatomy, 5th English ed., 1994
Winalski, Carl S., William E. Palmer, Danieal I. Rosenthal, and Barbara N. Weissman, “Magnetic
Resonance Imaging of Rheumatoid Arthritis,” Radiologic Clinics of North America 34 (2): 243-
248, March 1996.
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Aimee Shu
Gillian Lieberman, MD
Acknowledgements
Gillian Lieberman, MD, Radiology Course
Director, BIDMC
Pamela Lepkowski, Student Coordinator, BIDMC
Daniel Saurborn, MD, Resident in Radiology,
BIDMC
Daniel Lim, MD, Radiology Staff, BIDMC
Larry Barbaras and Cara Lyn D’amour,
Webmasters, BIDMC
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