Aimee Shu

Gillian Lieberman, MD

Imaging Rheumatoid Arthritis

Aimee Shu, Harvard Medical School, Year IIIGillian Lieberman, MD

April 2002

2

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

3

Aimee Shu

Gillian Lieberman, MD

Ms. M’s RA at a Glance

•

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

Netter, The Ciba Collection of Medical Illustrations

*DMARD = disease-modifying anti-rheumatic drug

4

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

5

Aimee Shu

Gillian Lieberman, MD

Diarthrodial

Joint Anatomy

Resnick

& Niwayama, Diagnosis of Bone and Joint Disorders

cartilage

fibrous capsule

synovium

Marginal areas—where synovium

directly touches bone (without cartilage in between)—are designated with small black arrows.

Cross section through cadaveric MCP joint

6

Aimee Shu

Gillian Lieberman, MD

Joint Pathology: Progressive Stages•

Synovitis pannus* joint destruction

•

Pannus

= granulation tissue

Netter, The Ciba Collection of Medical Illustrations

1.

acute synovitis2.

continued synovitis, pannus

formation, cartilage destruction, mild osteoporosis

3.

fibrous ankylosis, subsidence of inflammation

4.

bony ankylosis, advanced osteoporosis

7

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.

8

Aimee Shu

Gillian Lieberman, MD

Rheumatoid Arthritis: Epidemiology

•

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

9

Aimee Shu

Gillian Lieberman, MD

Agenda

•

Broad overview of systemic manifestations•

Focus on Ms. M

•

Focus on imaging hand pathology –

conventional radiography

–

MRI•

Brief visit to Ms. T

10

Aimee Shu

Gillian Lieberman, MD

Articular

Manifestations•

Symmetrical involvement, listed from most least commonly affected

•

Hands, wrists•

Feet, ankles

•

Knees•

Hips

•

Cervical spine•

Shoulders

•

Elbows

Klippel, John, Primer on the Rheumatic Diseases, 2nd

ed, 1997.

Areas of joint involvement

11

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 syndromeImage from:

Eric A. Brandser

on Virtual Hospital site, http://www.vh.org/Providers/Lectures/icmrad/skeletal/Parts/RAHands.html

ulnar

deviation

12

Aimee Shu

Gillian Lieberman, MD

Extra-Articular

Manifestations

•

Nodules•

Vasculitis

•

Rheumatoid factor = anti-IgG

antibodies

•

Ocular: keratoconjunctivitis

sicca, scleritis

Nodular episcleritis

Netter, The Ciba Collection of Medical Illustrations

Radiograph showing right lung nodule

13

Aimee Shu

Gillian Lieberman, MD

Extra-articular

manifestations

•Pulmonary: interstitial lung disease, pleural effusion•Cardiac: pericardial effusion, pericarditis

•Subcutaneous nodules over knuckles

•3rd

phalange: swan-neck deformity

•Ulnar

deviation

•Muscle atrophy

•Subcutaneous nodules in olecranon

bursa and just distal to olecranon

process

Netter, The Ciba Collection of Medical Illustrations

14

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–

Confirm disease presence

–

Evaluate disease distribution & activity

15

Aimee Shu

Gillian Lieberman, MD

Role of Imaging in RA

•

Assist in diagnosis –

Early & aggressive treatment is now the standard of care

•

Track disease progression•

Evaluate response to treatment

•

Classify disease severity for research/clinical trials

16

Aimee Shu

Gillian Lieberman, MD

Characteristic Changes on Plain Film

•

Individual findings are non-specific–

since synovium

reacts in limited # of ways

•

But patterns and combinations of findings can suggest RA

17

Aimee Shu

Gillian Lieberman, MD

Characteristic Changes on Plain Film

•

Soft tissue changes –

Early swelling

–

Later atrophy–

Periarticular

fat displacement (large joints)

•

Cartilage changes–

Joint space wide narrow wide•

Secondary to inflammation, cartilage destruction, ligamentous

laxity, respectively

18

Aimee Shu

Gillian Lieberman, MD

Characteristic Changes on Plain Film

•

Bony changes –

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

19

Aimee Shu

Gillian Lieberman, MD

Hand Anatomy Review

Normal hand radiograph

BIDMC Film Library

20

Aimee Shu

Gillian Lieberman, MD

Hand Anatomy Review

Wicke, Atlas of Radiologic Anatomy

Sesamoid

bones = ovoid

nodules embedded in tendons; # variable in between

people

DIP joint

PIP joint MCP joint

Carpal bones

radiusulna

21

Aimee Shu

Gillian Lieberman, MD

Carpal Bones

scaphoid lunate pisiformtriquetral

trapezium trapezoid capitate hamate

22

Aimee Shu

Gillian Lieberman, MD

Conventional Radiography of Hands

•

“ABC’S”–

Alignment

–

Bone mineralization–

Cartilage

–

Soft tissue •

PA and oblique views

•

low dose radiation for hands, therefore serial studies are relatively safe

23

Aimee Shu

Gillian Lieberman, MD

Ms. M’s Initial Presentation, Age 28

BIDMC Film Library

•

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”

24

Aimee Shu

Gillian Lieberman, MD

Ms. M’s Initial Presentation

BIDMC Film Library

•1981, age 28

•Left lateral oblique

25

Aimee Shu

Gillian Lieberman, MD

Ms. M, 1983, Age 30

BIDMC Film Library

•Right AP (dorsopalmar) view

•Changes since 1981

•Erosions: 2nd metacarpal, 3rd

DIP,

4th

PIP

•Soft tissue swelling

•Consistent with RA

26

Aimee Shu

Gillian Lieberman, MD Ms. M, 1983, Age 30

BIDMC Film Library

•

Left AP view

•

Erosions: 3rd

& 5th PIPs

•

Cyst: 1st

IP

•

Soft tissue swelling around PIPs, MCPs

27

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

28

Aimee Shu

Gillian Lieberman, MD

Ms. M’s RA Progresses, Right AP Views

1988, Age 351995, Age 42

• ↓joint space, new erosions: 3rd

MCP, 4th

PIP, 5th

PIP

•

Note 1st

IP fused by screw

•

Erosions: 2nd-5th

MCPs, 4th-5th

PIPs, 4th-5th

DIPs

•

Carpal cysts

BIDMC Film Library

29

Aimee Shu

Gillian Lieberman, MD

Ms. M, Left Lateral Oblique,

1995, Age 42

•This view shows ulnar styloid

erosion

•2nd

MCP subluxation

BIDMC Film Library

30

Aimee Shu

Gillian Lieberman, MD

Advantages of MRI•

Better than conventional radiography at imaging soft tissue, marrow, & cartilage

•

Multiplanar•

Can assess complications–

Tendon tear or rupture

–

Synovitis, tenosynovitis, bursitis–

Erosions, cysts, fibrocartilage

degeneration

•

May show erosions earlier than plain film•

Up & coming!

31

Aimee Shu

Gillian Lieberman, MD Ms. M, 2002, Age 49

•

flexor retinaculum

(Carpal tunnel) contains tendons

and median nerve•

Tendon sheath normally indistinct from tendon (low signal; dark in this view)

MR (T2), Left wrist, Axial view. BIDMC Film Library

Anatomy Pointers

radiusulna

32

Aimee Shu

Gillian Lieberman, MD Ms. M, 2002, Age 49

•

Tenosynovitis–

Extensor carpi

ulnaris

tendon–

Flexor carpi

radialis

tendon•

Synovial proliferation

* Tenosynovitis

= tendon sheath inflammation, seen in RA or repetitive trauma. In contrast, tendonitis

= tendon inflammation, signal would be within tendon; seen with overuse

MR (T2), Left Wrist Axial view. BIDMC Film Library

Findings

33

Aimee Shu

Gillian Lieberman, MD

More proximally, flexor carpi

radialis appears normal

MR (T2), Left Wrist Axial view. BIDMC Film Library

34

Aimee Shu

Gillian Lieberman, MD

Extensor carpi

ulnaris

http://www.rad.washington.edu/atlas/extensorcarpiulnaris.html

35

Aimee Shu

Gillian Lieberman, MD

Flexor carpi

radialis

http://www.rad.washington.edu/atlas/flexorcarpiradialis.html

36

Aimee Shu

Gillian Lieberman, MD MR Normal Wrist, Coronal View

3 important areas:•

triangular fibrocartilage

(TFC)

•

scapholunate

ligament (SL)

•

lunotriquetra

ligament (LT)

T2-weighted gradient echo. BIDMC Film Library

• These areas confer stability

• Commonly injured pain

37

Aimee Shu

Gillian Lieberman, MD

Ms. M: TFC Tear & SL Tear

* SL tear nickname is “David Letterman sign” reminiscent of the talk show host’s gap teeth.

T2-weighted gradient echo. BIDMC Film Library

↑

signal = TFC tear

Gap > 2 mm indicates SL tear

38

Aimee Shu

Gillian Lieberman, MD

Ms. M: Erosions on MRI

T2-weighted gradient echo. BIDMC Film Library

39

Aimee Shu

Gillian Lieberman, MD

Sagittal

View of Normal TFC

T1 MRI, left wrist. BIDMC Film Library

Notice ample joint space between ulna and triquetral

bonesulna

triquetral

40

Aimee Shu

Gillian Lieberman, MD

Ms. M: TFC Tear

ulna and triquetral bones touch

Carpal tunnel

T1 MRI, left wrist. BIDMC Film Library

41

Aimee Shu

Gillian Lieberman, MD

What is This Bulge on Ms. M?

No, it is not her thumb…

…It is a vitamin E tablet to mark the area of her pain!

T2 MRI, left wrist. BIDMC Film Library

42

Aimee Shu

Gillian Lieberman, MD Now Meet Ms. T62yo woman, h/o

RA and 50 lb weight loss, right leg

shorter than left, inability to ambulate. Please evaluate…

Acetabuli

protrusio into ilium

BIDMC Film Library

•hips involved in 50% RA patients

•

↓

cartilage allows femoral head to migrate superomedially

within

acetabulum

•more severe with time

43

Aimee Shu

Gillian Lieberman, MD

Normal shoulder

BIDMC Film Library

44

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–

glenohumeral

–

acromiohumeral–

acromioclavicular

•

humeral head migrates proximally & superiorly

BIDMC Film Library

45

Aimee Shu

Gillian Lieberman, MD

Arthritides

monoarticular polyarticular

•

trauma

•

infection

•

gout

•

pseudogout

inflammatory degenerative metabolic deposition

rhematoid

types

rheumatoid variants •

OA

•

RA

•

SLE

•

scleroderma

•

DM

•

ankylosing

spondylitis

•

Reiter’s syndrome

•

psoriatic arthritis

•

IBD

•

Gout

•

Amyloidosis

46

Aimee Shu

Gillian Lieberman, MD

Arthritides

•

Radiographic findings rarely pathognomonic

for arthritides

•

Must use radiographic findings in conjuction

with clinical presentation

47

Aimee Shu

Gillian Lieberman, MD

Differential DiagnosesFeature Also seen inCarpal erosions GoutUlnar

deviation & volar

subluxation

of proximal phalanges

SLE, Jaccoud’s

syndrome 2º to rheumatic fever

Narrow joint space OsteoarthritisBony destruction (“punched-out” lesion)

Sarcoid

Swell, erode, cyst Psoriatic arthritis

48

Aimee Shu

Gillian Lieberman, MD

RA: Distinguishing Features

•

Diffuse (vs. limited to juxta-articular) osteoporosis

•

Lack of new bone formation

49

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

50

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.

51

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