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