Imaging Rheumatoid Arthritis - Lieberman's eRadiology Learning Sites
Imaging Rheumatoid Arthritis - Lieberman's eRadiology Learning Sites
Imaging Rheumatoid Arthritis - Lieberman's eRadiology Learning Sites
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Aimee Shu<br />
Gillian Lieberman, MD<br />
<strong>Imaging</strong> <strong>Rheumatoid</strong> <strong>Arthritis</strong><br />
April 2002<br />
Aimee Shu, Harvard Medical School, Year III<br />
Gillian Lieberman, MD
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Meet Ms. M<br />
50-year old female<br />
22-year history of seronegative<br />
rheumatoid arthritis (RA)<br />
Followed at BIDMC rheumatology<br />
department<br />
Films from 1981 - present in BIDMC Film<br />
Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M’s RA at a Glance<br />
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Age 28: trouble opening jars, episodic swelling of hands<br />
Principle sites: hands, wrists, feet<br />
Initially, rapid bony changes<br />
Developed osteoporosis<br />
Past DMARDs*: azathioprine, hydroxychloroquine, gold<br />
Present drugs: leflunomide, prednisone, piroxicam<br />
Disease now relatively stable<br />
Left wrist continues to give her most trouble<br />
*DMARD = disease-modifying anti-rheumatic drug<br />
Netter, The Ciba Collection of Medical Illustrations<br />
3
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Aimee Shu<br />
Gillian Lieberman, MD<br />
<strong>Rheumatoid</strong> <strong>Arthritis</strong>: Definition<br />
Chronic, inflammatory, systemic disease<br />
Etiology unknown<br />
Prominent characteristic = symmetric<br />
polyarthritis<br />
Extra-articular manifestations in 20% of<br />
patients<br />
Variable presentation at onset<br />
Variable clinical features<br />
4
synovium<br />
Aimee Shu<br />
Gillian Lieberman, MD<br />
Diarthrodial<br />
cartilage<br />
Marginal areas—where synovium<br />
directly touches bone (without<br />
cartilage in between)—are<br />
designated with small black arrows.<br />
Resnick & Niwayama, Diagnosis of Bone and Joint Disorders<br />
Joint Anatomy<br />
fibrous<br />
capsule<br />
Cross section through<br />
cadaveric MCP joint<br />
5
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Joint Pathology: Progressive Stages<br />
Synovitis pannus* joint destruction<br />
Pannus = granulation tissue<br />
Netter, The Ciba Collection of Medical Illustrations<br />
1.<br />
2.<br />
3.<br />
4.<br />
acute synovitis<br />
continued synovitis,<br />
pannus formation,<br />
cartilage destruction,<br />
mild osteoporosis<br />
fibrous ankylosis,<br />
subsidence of<br />
inflammation<br />
bony ankylosis,<br />
advanced osteoporosis<br />
6
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Aimee Shu<br />
Gillian Lieberman, MD<br />
American College of Rheumatology Criteria for RA<br />
4 of the following 7:<br />
– Morning stiffness<br />
– <strong>Arthritis</strong> of > 3 joint areas<br />
– <strong>Arthritis</strong> of hand joints<br />
– Symmetric arthritis<br />
– <strong>Rheumatoid</strong> nodules<br />
– Serum rheumatoid factor<br />
– Radiographic changes<br />
Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association<br />
1987 revised criteria for the classification of rheumatoid arthritis. <strong>Arthritis</strong> Rheum 1988;31:315-24.<br />
7
Aimee Shu<br />
Gillian Lieberman, MD<br />
<strong>Rheumatoid</strong> <strong>Arthritis</strong>: Epidemiology<br />
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1.0% of Americans<br />
2.5 female : 1 male<br />
Onset between ages 25-50<br />
Peak incidence between ages 40-50<br />
Associated with certain HLA-DR<br />
haplotypes<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Agenda<br />
Broad overview of systemic manifestations<br />
Focus on Ms. M<br />
Focus on imaging hand pathology<br />
–<br />
–<br />
conventional radiography<br />
MRI<br />
Brief visit to Ms. T<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Articular<br />
Areas of joint involvement<br />
Klippel, John, Primer on the Rheumatic<br />
Diseases, 2 nd ed, 1997.<br />
Manifestations<br />
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Symmetrical involvement,<br />
listed from most least<br />
commonly affected<br />
Hands, wrists<br />
Feet, ankles<br />
Knees<br />
Hips<br />
Cervical spine<br />
Shoulders<br />
Elbows<br />
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Image from:<br />
Aimee Shu<br />
Gillian Lieberman, MD<br />
Hands & Wrists<br />
Almost always affected in RA<br />
MCPs, PIPs swollen and/or deformed<br />
DIPs spared<br />
Ulnar deviation at MCP<br />
Radial deviation at the carpals<br />
Swan-neck deformities<br />
Boutonnière deformities<br />
Neuropathy, e.g. carpal tunnel syndrome<br />
ulnar deviation<br />
Eric A. Brandser on Virtual Hospital site, http://www.vh.org/Providers/Lectures/icmrad/skeletal/Parts/RAHands.html<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Extra-Articular<br />
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Nodules<br />
Vasculitis<br />
<strong>Rheumatoid</strong> factor =<br />
anti-IgG antibodies<br />
Ocular:<br />
keratoconjunctivitis<br />
sicca, scleritis<br />
Manifestations<br />
Nodular episcleritis<br />
Radiograph showing<br />
right lung nodule<br />
Netter, The Ciba Collection of Medical Illustrations<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Extra-articular<br />
manifestations<br />
•Pulmonary: interstitial lung disease,<br />
pleural effusion<br />
•Cardiac: pericardial effusion,<br />
pericarditis<br />
•Subcutaneous nodules over knuckles<br />
•3 rd<br />
•Ulnar<br />
phalange: swan-neck deformity<br />
deviation<br />
•Muscle atrophy<br />
•Subcutaneous nodules in olecranon<br />
bursa and just distal to olecranon<br />
process<br />
Netter, The Ciba Collection of Medical Illustrations<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
<strong>Imaging</strong> Modalities<br />
Conventional radiography<br />
Magnetic resonance imaging (MRI)<br />
Bone densitometry (DEXA)<br />
– Evaluate osteoporosis<br />
Ultrasound<br />
– Not often used for RA in US; more often in Europe<br />
Computed tomagraphy<br />
– Only as adjunct; not as primary modality<br />
Bone scintigraphy<br />
–<br />
–<br />
Confirm disease presence<br />
Evaluate disease distribution & activity<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Role of <strong>Imaging</strong> in RA<br />
Assist in diagnosis<br />
–<br />
Early & aggressive treatment is now the<br />
standard of care<br />
Track disease progression<br />
Evaluate response to treatment<br />
Classify disease severity for<br />
research/clinical trials<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Characteristic Changes on Plain Film<br />
Individual findings are non-specific<br />
–<br />
since synovium<br />
reacts in limited # of ways<br />
But patterns and combinations of findings<br />
can suggest RA<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Characteristic Changes on Plain Film<br />
Soft tissue changes<br />
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–<br />
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Early swelling<br />
Later atrophy<br />
Periarticular fat displacement (large joints)<br />
Cartilage changes<br />
–<br />
Joint space wide narrow wide<br />
•<br />
Secondary to inflammation, cartilage destruction,<br />
ligamentous laxity, respectively<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Characteristic Changes on Plain Film<br />
Bony changes<br />
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Marginal bony erosion: periarticular “bare” areas<br />
Subchondral cyst formation<br />
Juxta-articular osteopenia generalized osteopenia<br />
Lack of bony response to overwhelming bone and joint<br />
destruction is characteristic of RA<br />
Subluxation & dislocation<br />
Flexion & extension contracture<br />
Ankylosis<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Hand<br />
Anatomy<br />
Review<br />
Normal hand<br />
radiograph<br />
BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Sesamoid<br />
bones =<br />
ovoid<br />
nodules<br />
embedded<br />
in tendons;<br />
# variable<br />
in between<br />
people<br />
Hand Anatomy Review<br />
DIP joint<br />
PIP joint MCP<br />
joint<br />
radius<br />
Wicke, Atlas of Radiologic Anatomy<br />
Carpal<br />
bones<br />
ulna<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
trapezium trapezoid capitate hamate<br />
Carpal<br />
Bones<br />
scaphoid lunate triquetral pisiform<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Conventional Radiography of Hands<br />
“ABC’S”<br />
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Alignment<br />
Bone mineralization<br />
Cartilage<br />
Soft tissue<br />
PA and oblique views<br />
low dose radiation for hands, therefore<br />
serial studies are relatively safe<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M’s Initial<br />
Presentation, Age 28<br />
1981, age 28, episodic pain &<br />
swelling<br />
Right lateral oblique view<br />
(“Zither player position”)<br />
Normal mineralization<br />
Normal joint space<br />
4th digit, middle phalanx: small<br />
cystic changes & minimal soft<br />
tissue swelling, consistent with<br />
“post-traumatic cyst”<br />
BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M’s Initial<br />
Presentation<br />
•1981, age 28<br />
•Left lateral oblique<br />
BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M, 1983, Age 30<br />
•Right AP<br />
(dorsopalmar) view<br />
•Changes since 1981<br />
•Erosions: 2nd metacarpal, 3rd PIP<br />
4 th<br />
DIP,<br />
•Soft tissue swelling<br />
•Consistent with RA<br />
BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M, 1983, Age 30<br />
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BIDMC Film Library<br />
Left AP view<br />
Erosions: 3rd PIPs<br />
Cyst: 1 st<br />
IP<br />
& 5 th<br />
Soft tissue swelling<br />
around PIPs, MCPs<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M, 1986,<br />
Age 33<br />
Right lateral<br />
oblique<br />
Disease<br />
progression<br />
Erosions: 2nd MCP, 3rd & 4th PIPs, 3rd DIP, 1st IP<br />
Decreased joint<br />
spaces<br />
BIDMC Film Library<br />
27
Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M’s RA Progresses, Right AP Views<br />
1988, Age 35<br />
BIDMC Film Library<br />
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↓joint space, new<br />
erosions: 3rd MCP,<br />
PIP, 5th PIP<br />
4 th<br />
Note 1st IP fused<br />
by screw<br />
Erosions: 2nd-5th MCPs, 4th-5th PIPs,<br />
DIPs<br />
4th-5 th<br />
Carpal cysts<br />
1995, Age 42<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M, Left<br />
Lateral Oblique,<br />
1995, Age 42<br />
•This view shows ulnar<br />
styloid erosion<br />
•2 nd<br />
MCP subluxation<br />
BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Advantages of MRI<br />
Better than conventional radiography at<br />
imaging soft tissue, marrow, & cartilage<br />
Multiplanar<br />
Can assess complications<br />
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Tendon tear or rupture<br />
Synovitis, tenosynovitis, bursitis<br />
Erosions, cysts, fibrocartilage degeneration<br />
May show erosions earlier than plain film<br />
Up & coming!<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Anatomy Pointers<br />
ulna<br />
radius<br />
MR (T2), Left wrist, Axial view. BIDMC Film Library<br />
Ms. M, 2002, Age 49<br />
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flexor<br />
retinaculum<br />
(Carpal tunnel)<br />
contains tendons<br />
and median nerve<br />
Tendon sheath<br />
normally<br />
indistinct from<br />
tendon (low<br />
signal; dark in<br />
this view)<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Findings<br />
MR (T2), Left Wrist Axial view. BIDMC Film Library<br />
* Tenosynovitis = tendon sheath inflammation, seen in RA or<br />
repetitive trauma. In contrast, tendonitis = tendon<br />
inflammation, signal would be within tendon; seen with overuse<br />
Ms. M, 2002, Age 49<br />
•<br />
•<br />
Tenosynovitis<br />
– Extensor carpi<br />
ulnaris tendon<br />
– Flexor carpi radialis<br />
tendon<br />
Synovial proliferation<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
More proximally, flexor carpi<br />
appears normal<br />
MR (T2), Left Wrist Axial view. BIDMC Film Library<br />
radialis<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Extensor carpi<br />
http://www.rad.washington.edu/atlas/extensorcarpiulnaris.html<br />
ulnaris<br />
34
Aimee Shu<br />
Gillian Lieberman, MD<br />
Flexor carpi<br />
radialis<br />
http://www.rad.washington.edu/atlas/flexorcarpiradialis.html<br />
35
Aimee Shu<br />
Gillian Lieberman, MD MR Normal Wrist,<br />
Coronal View<br />
3 important areas:<br />
•<br />
•<br />
•<br />
triangular fibrocartilage<br />
(TFC)<br />
scapholunate<br />
lunotriquetra<br />
ligament (SL)<br />
ligament (LT)<br />
• These areas confer stability<br />
• Commonly injured pain<br />
T2-weighted gradient echo. BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
↑ signal =<br />
TFC tear<br />
Ms. M: TFC Tear & SL Tear<br />
T2-weighted gradient echo. BIDMC Film Library<br />
Gap > 2 mm<br />
indicates<br />
SL tear<br />
* SL tear<br />
nickname is “David<br />
Letterman sign”<br />
reminiscent of the<br />
talk show host’s<br />
gap teeth.<br />
37
Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M: Erosions on MRI<br />
T2-weighted gradient echo. BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Sagittal<br />
triquetral<br />
ulna<br />
T1 MRI, left wrist. BIDMC Film Library<br />
View of Normal TFC<br />
Notice ample joint<br />
space between<br />
ulna and triquetral<br />
bones<br />
39
Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. M: TFC Tear<br />
ulna and triquetral<br />
bones touch<br />
T1 MRI, left wrist. BIDMC Film Library<br />
Carpal<br />
tunnel<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
What is This Bulge on Ms. M?<br />
T2 MRI, left wrist. BIDMC Film Library<br />
No, it is not<br />
her thumb…<br />
…It is a vitamin<br />
E tablet to<br />
mark the area<br />
of her pain!<br />
41
Aimee Shu<br />
Gillian Lieberman, MD Now Meet Ms. T<br />
62yo woman, h/o RA and 50 lb weight loss, right leg<br />
shorter than left, inability to ambulate. Please<br />
evaluate…<br />
Acetabuli<br />
into ilium<br />
BIDMC Film Library<br />
protrusio<br />
•hips involved in 50% RA<br />
patients<br />
• ↓ cartilage allows<br />
femoral head to migrate<br />
superomedially within<br />
acetabulum<br />
•more severe with time<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
BIDMC Film Library<br />
Normal shoulder<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Ms. T’s Shoulder<br />
Findings on Ms. T:<br />
erosions, fusions,<br />
superior subluxation<br />
Shoulders involved in<br />
50% RA patients<br />
Narrowing of all<br />
compartments of<br />
shoulder<br />
–<br />
–<br />
–<br />
glenohumeral<br />
acromiohumeral<br />
acromioclavicular<br />
humeral head migrates<br />
proximally & superiorly<br />
BIDMC Film Library<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Arthritides<br />
monoarticular polyarticular<br />
trauma<br />
infection<br />
gout<br />
pseudogout<br />
•<br />
•<br />
•<br />
•<br />
rhematoid<br />
types<br />
RA<br />
SLE<br />
scleroderma<br />
DM<br />
inflammatory degenerative metabolic<br />
deposition<br />
•<br />
•<br />
•<br />
•<br />
rheumatoid<br />
variants<br />
ankylosing<br />
spondylitis<br />
Reiter’s syndrome<br />
psoriatic arthritis<br />
IBD<br />
•<br />
OA<br />
•<br />
•<br />
Gout<br />
Amyloidosis<br />
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Arthritides<br />
Radiographic findings rarely<br />
pathognomonic for arthritides<br />
Must use radiographic findings in<br />
conjuction with clinical presentation<br />
46
Aimee Shu<br />
Gillian Lieberman, MD<br />
Differential Diagnoses<br />
Feature Also seen in<br />
Carpal erosions Gout<br />
Ulnar deviation & volar SLE, Jaccoud’s syndrome<br />
subluxation of proximal<br />
phalanges<br />
2º to rheumatic fever<br />
Narrow joint space Osteoarthritis<br />
Bony destruction<br />
(“punched-out” lesion)<br />
Sarcoid<br />
Swell, erode, cyst Psoriatic arthritis<br />
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•<br />
Aimee Shu<br />
Gillian Lieberman, MD<br />
RA: Distinguishing Features<br />
Diffuse (vs. limited to juxta-articular)<br />
osteoporosis<br />
Lack of new bone formation<br />
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•<br />
Aimee Shu<br />
Gillian Lieberman, MD<br />
Summary: Key Points<br />
Conventional radiography and MRI are especially<br />
useful in imaging RA<br />
Chronic, progressive changes are evident in the<br />
hands and wrists<br />
Characteristic changes on plain film include bony<br />
erosions, joint space narrowing, & osteoporosis<br />
On MRI: tenosynovitis, synovial proliferation,<br />
cartilage tear, tendon rupture<br />
49
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Aimee Shu<br />
Gillian Lieberman, MD<br />
References<br />
American College of Radiology Film Library<br />
Britton, Cynthia A. and Mary Chester Wasko, “<strong>Rheumatoid</strong> <strong>Arthritis</strong>,” Seminars in Roentgenology<br />
31 (3): 198-207, July 1996.<br />
Brower, Anne C., <strong>Arthritis</strong> in Black and White, 2nd ed., W.B. Saunders, 1997.<br />
Edeiken, Roentgen Diagnosis of Diseases of Bone, 3rd ed., 1981.<br />
Forrester, D.M. and J.C. Brown, The Radiology of Joint Disease, 3rd ed., W.B. Saunders, 1987.<br />
Grassi, Walter, Rossella De Angelis, Gianni Lamanna, and Claudio Cervini, “The Clinical Features of<br />
<strong>Rheumatoid</strong> <strong>Arthritis</strong>,” European Journal of Radiology 27:S18-24, 1998.<br />
Klippel, John H., Primer on Rheumatic Diseases, 2nd ed., 1997.<br />
Netter, Frank H., The Ciba Collection of Medical Illustrations, Volume 8: Musculoskeletal System,<br />
Part II: Developmental Disorders, Tumors, Rheumatic Diseases, and Joint Replacement, CIBA-<br />
GEIGY, 1990.<br />
Reid, Graham, and John M. Esdaile, “Rheumatology: Getting the Most Out of Radiology,” Canadian<br />
Medical Association Journal 162(9):1318-1325, May 2000.<br />
Resnick & Niwayama, Diagnosis of Bone and Joint Disorders, 2nd ed., W.B. Saunders, 1988.<br />
Stoller, David W., “The Wrist,” Seminars in Roentgenology 30 (3): 265-276, July 1995.<br />
Taveras & Ferrucci, Radiology, J.B. Lippincott Co., 1991.<br />
Wicke, Lothar, Atlas of Radiologic Anatomy, 5th English ed., 1994<br />
Winalski, Carl S., William E. Palmer, Danieal I. Rosenthal, and Barbara N. Weissman, “Magnetic<br />
Resonance <strong>Imaging</strong> of <strong>Rheumatoid</strong> <strong>Arthritis</strong>,” Radiologic Clinics of North America 34 (2): 243-<br />
248, March 1996.<br />
50
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Aimee Shu<br />
Gillian Lieberman, MD<br />
Acknowledgements<br />
Gillian Lieberman, MD, Radiology Course<br />
Director, BIDMC<br />
Pamela Lepkowski, Student Coordinator, BIDMC<br />
Daniel Saurborn, MD, Resident in Radiology,<br />
BIDMC<br />
Daniel Lim, MD, Radiology Staff, BIDMC<br />
Larry Barbaras and Cara Lyn D’amour,<br />
Webmasters, BIDMC<br />
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