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Imaging Rheumatoid Arthritis


monoarticular polyarticular

trauma inflammatory degenerative metabolic

infection deposition
rhematoid rheumatoid
gout types variants OA Gout
pseudogout Amyloidosis
RA ankylosing
Reiters syndrome
psoriatic arthritis

Radiographic findings rarely

pathognomonic for arthritides Must use
radiographic findings in conjuction with
clinical presentation

Hand Anatomy Review

DIP joint
PIP joint MCP
bones =
in tendons;
# variable
in between
Conventional Radiography of Hands
Bone mineralization
Soft tissue
PA and oblique views
low dose radiation for hands, therefore
serial studies are relatively safe
Rheumatoid Arthritis
Imaging in RA

Diagnosis usually made by plain film confirmation of:

Osteopenia - a demineralization of the bone - is the result of increased blood flow,
due to inflammation, which washes out the calcium.
o Early on in the inflammatory process,only the periarticular portion of the bones are
o Over time, the inflammatory pain causes disuse of affected joints leading to
generalized osteopenia of whole bones.
Uniform joint space narrowing - a feature which helps differentiate RA from OA.
Marginal erosions at bare areas where synovium lies on bone
Subluxation due to ligamentous or capsular laxity
Imaging Modalities
Conventional radiography
Magnetic resonance imaging (MRI)
Bone densitometry (DEXA)
Evaluate osteoporosis
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
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
Articular Manifestations
Symmetrical involvement,
listed from most least
commonly affected
Hands, wrists
Feet, ankles
Cervical spine

Areas of joint involvement

Diarthrodial Joint Anatomy


Marginal areaswhere synovium
Cross section through
directly touches bone (without
cadaveric MCP joint
cartilage in between)are
designated with small black arrows.
Joint Pathology: Progressive Stages
Synovitis pannus* joint destruction
Pannus = granulation tissue

1. acute synovitis
2. continued synovitis,
pannus formation,
cartilage destruction,
mild osteoporosis
3. fibrous ankylosis,
subsidence of
4. bony ankylosis,
advanced osteoporosis
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
ulnar deviation
Boutonnire deformities
Neuropathy, e.g. carpal tunnel syndrome

Dorsoplantar views of both feet show an asymmetric arthritis involving the great toes
predominantly as well as other joints. This arthritis is characterized by well
marginated erosions, a large area of soft tissue swelling related to tophus, with
relative preservation of the joint space given the amount of periarticular erosion
present. The findings are typical of gout, which spares the joint space itself until late
in the disease. The erosions with their overhanging edges have been called "Mickey
Mouse ears" or "cookie cutter" type erosions.
RA of the Hands

f one metacarpal phalangeal joint (MCP) is involved with rheumatoid arthritis, then
typically all of the joints are involved. In this image we see that every MCP joint is
affected. The DIP (distal interphalangeal) joints are relatively spared. This patient has
also developed ligamentous abnormalities due to RA. A radial deviation of the carpus
and ulnar deviation of the digits give the hands a characteristic zig-zag pattern.

erosions (arrows) are noted in the periarticular areas of the toes in this patient with
rheumatoid arthritis
multiple erosions and marked joint space narrowing are noted in a pancarpal
distribution in this patient with rheumatoid arthritis
RA of the Hips

This is an image of advanced RA in the hips. At first glance, the plain film resembles
OA but note the joints are narrowed symetrically unlike OA. There exists, however,
some subchondral sclerosis due to intervening secondary OA. The hips look like
they will migrate right into the middle of the pelvis this is called protrusio acetabulae.
Differential Diagnoses
Feature Also seen in
Carpal erosions Gout
Ulnar deviation & volar SLE, Jaccouds syndrome
subluxation of proximal 2 to rheumatic fever
Narrow joint space Osteoarthritis
Bony destruction Sarcoid
(punched-out lesion)
Swell, erode, cyst Psoriatic arthritis

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
Radiological Evidence of Degenerative Joint Disease

Primary osteoarthritis - most common in the older age group as

the result of wear and tear on articular cartilage over time.
Secondary osteoarthritis - results from a previous process that
damaged cartilage such as trauma, or inflammatory arthritis.

The most commonly involved joints in primary osteoarthritis


Distal interphalangeal joints

First carpometacarpal joint
Weight bearing joints: spine, hips, knees
Imaging of degenerative joint disease

1. Diagnosis by plain films includes identification of :

Asymmetric joint space narrowing

Osteophytes-bony spurs
Degenerative cysts
Sclerosis of subchondral bone

2. CT or MRI are also useful on certain occasions

General Considerations
Most common form of arthritis
Accounts for more functional limitation, work
loss and physical disability than any other
chronic disease
Cost approaches 2-3% of GNP in developed
Prevalence in the US estimated to increase by
66 - 100% by the 2020
Menu of Imaging Studies

Plain Radiography

Magnetic resonance imaging (MRI)

Musculoskeletal Ultrasound (MSUS)

Plain Radiography: Knee

Narrowing of medial

and lateral compartment

Subchondral sclerosis

Subchondral cysts

Marginal Osteophytosis
Plain Radiography: Hand
Narrowing of DIP and
PIP joints compared to
MCP joints

Subchondral sclerosis of
DIP, PIP and 1st CMC
OA of the Hip

This is an image of DJD or OA of the hip which should be differentiated from

Rheumatoid Arthritis (RA). Note the joint space is almost completely obliterated. There is
still a hint of joint space medially but the superior portion is completely destroyed. The
supralateral aspects are going to be affected most because the weight is transfered
through the roof of the acetabulum. Note the sclerosis and oseophyte formation (arrow).
OA of the Fingers

This is an image of DJD or OA of the finger joints. Note the narrowing of the joint
spaces and the increased density around the joints due to the subchondral sclerosis
(black arrows). There are also a few osteophytes (white arrow).
OA of the Knee

These are plain film images of a right knee with narrowing of the medial compartment
and a widening of the lateral compartment. There are also a number of osteophytes
and a large subchondral cyst where the bones have been rubbing on each other.
erosions (arrows) are noted at the articular margins of the tibia in this patient with
juvenile chronic arthritis
OA of the Spine

The left image is OA of the spine with resulting scoliosis. Note the asymmetric disk
space as well as the large osteophytes which develop in attempt to bear some of the
weight of the body (arrow). The right image is a photo of a gross spine from another
patient with OA of the spine. Note the the large bulky osteophytes and subchondral
sclerosis of the abnormal disk as compared to the normal disk above (arrow).
Ankylosing Spondylitis

AP radiograph of the pelvis shows classic changes of ankylosing spondylitis. Note that
the sacroiliac joints are obliterated bilaterally with osseous fusion. In addition, there is
joint space narrowing of both hips, concentric in nature, which is similar to rheumatoid
arthritis in the distribution of joint destruction. However, note that there is extensive
sclerosis of both the femur and the acetabulum as while as large collar osteophytes.
This differs significantly from rheumatoid arthritis. Inflammatory sclerotic changes of the
large bones are common in patients with ankylosing spondylitis
Progression of Sacroiliitis in Ankylosing Spondylitis

n AP radiograph of the pelvis from 1975 shows that the sacroiliac joints are normal
radiographically. A subsequent radiograph in 1981 shows that there is irregularity of
the sacroiliac joints, more so on the iliac side of the joint. This is due to the fact that
the cartilage thickness of the ilium is less than that of the sacrum and hence bone
erosions appear first on the iliac side. A follow-up radiograph in 1982 demonstrates
that both the sacral and iliac sides of both sacroiliac joints show conspicuous
erosion and sclerosis. The findings are characteristic of the symmetric seronegative
spondylarthropathies, including ankylosing spondylitis and arthritis associated with
inflammatory bowel disease.
Ankylosing Spondylitis
of the Spine

AP and lateral views of the lumbosacral spine show classic changes of ankylosing
spondylitis. Note bilateral symmetric sacroiliac erosive changes with sclerosis.
Characteristically, delicate vertical syndesmophytes bridge multiple vertebra causing
a "bamboo spine". On the lateral view, annular calcification is noted causing the
appearance of squared vertebral bodies
Calcaneal Spur
An ossification and calcification resulting from traction of plantar fascia upon
the periosteum (covering of bone) of the inferior surface of the calcaneum

The lateral radiograph is the best view for visualization of this condition, the spurs
are frequently bilateral and may be asymptomatic, most centres image both sides.
chondrocalcinosis is seen in both the fibrocartilage of the menisci and in the
hyaline articular cartilage of this knee.
a gouty erosion (arrow) is noted along the medial margin of the first metatarsal head in
this patient with gout -- relative sparing of the articular cartilage is also noted
Pattern Approach

typical distribution of arthritis in the hands

joint compartments of the wrist

CMC (first carpometacarpal), CCMC (common carpometacarpal),

ST (scaphotrapezial), MC (midcarpal), RC (radiocarpal),
and DRUJ (distal radioulnar joint)
typical distribution of arthritis in the wrists
typical distribution of arthritis in the knees

typical distribution of arthritis in the hips

bridging osteophytes in the spine of a patient with degenerative disk disease
syndesmophytes (arrows) in the spine of a patient with ankylosing spondylitis

Age Group Age of Onset Disorder

Juvenile chronic arthritis

Young (< 20 years) < 20 years
Septic arthritis

Ankylosing spondylitis
onset 15 - 35 years

Middle (> 20 years) Young adults Enteropathic arthropathies

Rheumatoid arthritis
25 - 55 years
Psoriatic arthritis

Older patients (> 55 years) > 55 years DISH
Arthropathies with Male Predominance

Disorder male:female ratio

Ankylosing spondylitis 4:1 to 10:1

Psoriatic 2:1 to 3:1, but controversial

Reiter's 5:1 to 50:1

Gout 20:1

DISH 3:2

CPPD 1:1

Primary osteoarthritis
(< 45 years)

Enteropathic arthropathy

Ulcerative colitis 4:1

Crohn's disease 1:1

Arthropathies with Female Predominance

Disorder female:male ratio

Rheumatoid Arthritis 2:1 to 3:1

Primary osteoarthritis
(> 45 years)

CPPD 1:1

Radiographs of the cervical spine (two projections): Ligament calcification is visible at

the ventral and lateral contours of the vertebral bodies (arrow), producing the well-
known bamboo spine. The intervertebral spaces are normal. (=> picture)

Radiographs of the thoracic spine (two projections): The spinous processes are
connected by ligament calcifications (arrows). (=> picture)

Radiographs of the lumbar spine (two projections): The facet joints are destroyed by
the inflammation, the joint spaces are narrowed, partially ankylotized (arrow) and
calcified ligament bridges are present (double arrow).
Rheumatoid arthritis

Radiograph of the hand: Inflammatory

disease of the wrist and the interphalangeal
joints. Swelling around the affected joints
and osteoporosis are visible. Marginal
erosions are present in the distal part of the
ulna and the radius, with additional small
lytic lesions of the ulna. The interphalangeal
joint spaces are narrowed, marginal
erosions are present (arrow). A subluxation
of the distal phalanx of the thumb is visible
(double arrow).
Tuberculotic arthritis

PA hip radiograph: The joint space of the left hip can not be recognized.
The femoral head is completely destroyed.
Tuberculotic block vertebra

Radiographs of the lumbar spine (two projection): The erosion of adjacent vertebral
bodies and the destruction of the disc resulted in a block vertebra
Soft Tissue Calcifications
Patient with dystrophic calcification in the Achilles tendon due to recurrent trauma
and tendinitis.
Patient with multiple bilateral phleboliths in the pelvic veins.

Patient with multiple bilateral phleboliths in the pelvic veins.

Patient with multiple "rice-grain" calcifications in muscles about knees due to
66 year old male with scleroderma, exhibiting acroosteolysis, skin atrophy over
fingertips and calcinosis cutis.
46 year old female with dermatomyositis and extensive soft tissue calcifications
about the knee.

Patient with CPPD (calcium pyrophosphate dyhidrate depostition) and

chondrocalcinosis of hyaline articular cartilage and meniscal fibrocartilage of knee

Patient with a large focus of calcific tendinitis in the supraspinatus tendon

Child with conventional intramedullary osteosarcoma of distal femur with large soft
tissue mass exhibiting classic osteoid matrix. However, an osteosarcoma arising from
the soft tissues or metastatic to soft tissue would appear much the same as this mass.
Causes of Solid Periosteal Reaction
benign neoplasms
osteoid osteoma
eosinophilic granuloma
hypertrophic pulmonary osteoarthropathy
deep venous thrombosis (lower extremity)

Causes of Aggressive Periosteal Reaction

malignant neoplasms
Osteosarcoma of the distal femur, demonstating dense tumor bone formation and
a sunburst pattern of periosteal reaction.
Lucent Lesions of Bone
Differential Diagnosis of Solitary Lucent Bone Lesions

Fibrous Dysplasia
Giant Cell Tumor
Metastasis / Myeloma
Aneurysmal Bone Cyst
Chondroblastoma / Chondromyxoid Fibroma
Hyperparathyroidism (brown tumors) / Hemangioma
Non-ossifying Fibroma
Eosinophilic Granuloma / Enchondroma
Solitary Bone Cyst
Differential Diagnosis of Multiple Lucent Bone Lesions

Fibrous Dysplasia
Metastasis / Myeloma
Hyperparathyroidism (brown tumors) / Hemangioma
Eosinophilic Granuloma / Enchondroma


Age vs. Malignant Tumor Type

AGE (years) TUMOR

1 neuroblastoma

1 - 10 Ewing's of tubular bones

10 - 30 osteosarcoma, Ewing's of flat bones

reticulum cell sarcoma (Primary histiocytic lymphoma),

30 - 40 fibrosarcoma, parosteal osteosarcoma, malignant giant cell
tumor, lymphoma

40 + metastatic carcinoma, multiple myeloma, chondrosarcoma

English Doctor Talk

Short fingers Brachydactyly

Too many fingers Polydactyly

Two or more fingers are fused together Syndactyly

Contractures of fingers Camptodactyly

Inclined fingers, usually fifth Clinodactyly

Long, spider-like fingers Arachnodactyly


AP view of the legs: Short, thickened bones, widening of the epiphyseal plates

AP view of the lower extremity: The bones of the

lower extremity are definitely shorter, strongly
deformed. Cupped metaphyseal bone margins,
widened metaphysis and irregular contours are
apparent (arrow).

AP view of the pelvis and the bones: Short, curved, deformed femurs. Signs of
earlier fractures in the middle third of the bones (arrows).

Radiograph of the hip (AP view): The joint space is significantly narrowed on the left
side. The joint surfaces are sclerotic, irregular, subchondral pseudo-cysts are visible
in the femoral head. Acetabular new-bone formation (osteophytosis) is present
False joint

AP humerus radiograph: In the middle third of the humerus, the broken ends are scraped off
and between them a false joint of 0.5 cm can be seen (arrow); the periosteal callus does not
reduce the broken ends.

Radiograph of the right leg (two projections):

The metaphysis of the fibula is strongly widened (below the epiphyseal plate). A multi-
compartmental structure with low calcium content and narrow compacta are visible in the
inflated bone (arrow).
Osteogenesis imperfecta

Radiograph of the leg (two projections):

Curved, thin bones with diminished bone density (arrows) and fracture of the middle
third of the tibia (double arrow) are visible.

Skull radiograph (two projections): Left side picture: In the latero-lateral radiograph air can
be seen in the lateral ventricle (arrow). Right side picture: Face-up radiograph: In the picture
made with a horizontal beam direction, free air can be observed behind the frontal bone

Latero-lateral conventional tomogram of the skull:

Dense bone mass is present in the inner and outer laminas of the frontal bone (arrows).

AP radiograph of the thigh:

Abnormal bone structure of the right femur, crumbling of the distal metaphysis (arrow).
Irregular bone compacta, periosteal reaction in the proximal part (double arrow).
Osteomyelitis, late stage

AP view of left leg:

The bone density is increased, the compacta is thickened on the boundary between the distal
and middle third of the tibia. A transparent cavity has developed in the bone marrow with small
dense bone fragments (arrow). Late stage of osteomyelitis, the sclerotic involucrum and the
sequester are typical.
Localized, magnified radiograph: The sclerotic involucrum and the sequester are better seen.
Osteoplastic metastasis (prostate cancer)

AP radiograph of the pelvis and the lumbar spine: Multiple circumscribed hyperdense lesions
are visible in the lumbar vertebrae and the pelvic bones.

Latero-lateral radiograph of the lumbar spine:

The vertebral bodies are compressed. The mineralization of bones is diffusely decreased.
Concave endplates, ventral narrowing of the vertebral bodies is visible.

AP view of the right shoulder and humerus

Large inhomogenous sclerotic mass is present around the humerus in the proximal third of the
upper arm. Periosteal reaction (Codman-triangle) is visible in the distal part of the tumor

CT examination:

Unenhanced axial scans: Pathological involvement of the bone is depicted in the upper image
(soft tissue window). Lower image: the tumor extends into the bone marrow (bone window).
Plasmacytoma (Multiple myeloma)

Latero-lateral radiograph of the skull: Well-defined osteolytic areas are visible in the
bone of the calvaria (classical 'raindrop' lesions) (arrows).
Chondroma (periosteal)
Periosteal chondroma a chondroma that develops from periosteum or periosteal
connective tissue.

Consists of small surface mass ( < 3 cm) &

appears as radiolucent oval or oblong defect
on periphery of underlying cortex;
The lesion is underlined by a thin, distinct
cortical reaction, has little or no calcification.
(in contrast to chondrosarcoma),
occassionally there is intralesional
calcifications minimal periosteal reaction.

achondroplasty; osteosclerosis congenita; Parrot's disease (2);

a type of chondrodystrophy characterized by an abnormality of
conversion of cartilage into bone, predominantly affecting the
epiphyses of long bones in which epiphysial growth is retarded
and ceases early, resulting in dwarfism apparent at birth, with
short extremities, but normal trunk; the head is frequently
enlarged, with flattened nose, due to midfacial hypoplasia;
autosomal dominant inheritance.

Short bowed wide bones with expanded ends

Increased bone density

Characteristic cupping of metaphases

Incomplete glenoid fossa and acetabulum

Wide joint spaces

adamantinoma of long bones,a rare tumor of limb bones,
usually the tibia, that microscopically resembles an
ameloblastoma; the histogenesis is uncertain.

Adamantinoma appears as an eccentric, well-circumscribed,

and lytic lesion on plain x-ray. The lesion usually has several
lytic defects separated by sclerotic bone which gives a "soap-
bubble" appearance. There is cortical thinning but little
periosteal reaction. The lesion may break through the cortex
and extend into soft tissue.

The differential diagnosis radiologically includes osteofibrous

dysplasia, fibrous dysplasia, ABC, chondromyxoid fibroma and
chondrosarcoma .
Aneurysmal Bone Cyst

aneurysmal bone cyst, benign bone aneurysm; a solitary benign osteolytic lesion
expanding a long bone or within a vertebra, consisting of blood-filled spaces, and
separated by fibrous tissue containing multinucleated giant cells; such cyst's
cause swelling, pain, and tenderness.
-Radiolucent lesion w/ expanded cortex arising in medullary canal of metaphysis,
aneurysmal expanded appearance of cortex is contained by periosteum & thin
shell of bone;
Marked cortical thinning and erosion and periosteal elevation;
Lesion rarely penetrates the articular surface or growth plate;

Radiographic differential diagnosis includes:

simple bone cyst
giant cell tumor of bone
telangiectatic osteosarcoma
Ankylosing Spondylitis

ankylosing spondylitis, Marie-Strmpell disease; rheumatoid spondylitis; arthritis of

the spine, resembling rheumatoid arthritis, that may progress to bony ankylosis with
lipping of vertebral margins; the disease is more common in the male often with the
rheumatoid factor absent and the HLA antigen present.

Radiographic Appearance

Anteroposterior Pelvis XRay

Usually sufficient as only XRay confirmation
Reveals Bilateral and symmetric sacroiliitis

Spine XRay other findings

Bony sclerosis appears as squaring of vertebrae
Syndesmophytes between vertebrae
Classic "Bamboo" spine (<10%) appearance

Special XRay views

Ferguson's View (specialized sacroiliac view)

Other studies with limited indications

Bone Scan
CT or MRI spine
Ankylosing Spondylitis