Rheumatoid arthritis

Wrist involvement in rheumatoid arthritis characteristically affects the carpus and the
metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints. Joint effusion, edema, and
tenosynovitis may be responsible for soft-tissue swelling. Swan-neck and boutonniere deformities are
common, and, in advanced disease, there are subluxations, dislocations, ulnar deviation in the MP joints,
and radial deviation in the radiocarpal articulation. Destructive changes include "main en lorgnette" (i.e.,
telescoping of the fingers), ulnar erosions, SL dissociation, and distal radioulnar joint incongruity.
Gadolinium contrast MR imaging can be used to selectively enhance pannus tissue in synovitis involving
the DRUJ; the ulnar styloid process; the radiocarpal, intercarpal, and MP joints; and the flexor and
extensor tendons. When periarticular enhancement on MR of the wrist or metacarpophalangeal and
proximal interphalangeal joints of the hand was used as a criterion for the diagnosis of early stage
rheumatoid arthritis, sensitivity was 100%, specificity 73%, and accuracy 89%. Coronal fat-suppressed
gadolinium-enhanced T1-weighted images of the wrist and hand can be used to evaluate periarticular
synovial inflammation as well as subchondral bone marrow edema. Synovial involvement of ligamentous
structures frequently affects the ulnolunate and ulnotriquetral ligaments, the TFCC, the distal radioulnar
joint, the ulnocarpal meniscus homologue, the ulnar collateral ligament, the RSC ligament, the RSL, the
LRL, and the SRL. The differential diagnosis of rupture of the extensor tendon at the wrist includes MP
synovitis, posterior interosseous nerve palsy from rheumatoid disease of the elbow, and extensor tendon
pathology overlying the metacarpal heads. With MR, it is possible to identify rupture of the extensor
pollicis longus tendon, which may be difficult to assess clinically if the function of the thumb is intact. MR
also allows identification of pannus involving the dorsal tendon sheaths and extensor tendons and
effusion of the six extensor tendon compartments. Triangular fibrocartilage tears, dorsal displacement of
the ulna, carpal tunnel pathology, and SL dissociation are also assessed on routine coronal, axial, and
sagittal studies.