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Gillian Lieberman, MD
April 2002
Meet Ms. M
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Aimee Shu
Gillian Lieberman, MD
fibrous
capsule
synovium
cartilage
Marginal areas—where synovium
Cross section through
directly touches bone (without
cadaveric MCP joint
cartilage in between)—are
designated with small black arrows.
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Resnick & Niwayama, Diagnosis of Bone and Joint Disorders
Aimee Shu
Gillian Lieberman, MD
1. acute synovitis
2. continued synovitis,
pannus formation,
cartilage destruction,
mild osteoporosis
3. fibrous ankylosis,
subsidence of
inflammation
Netter, The Ciba Collection of Medical Illustrations
4. bony ankylosis,
advanced osteoporosis
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Aimee Shu
Gillian Lieberman, MD
• 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.
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Aimee Shu
Gillian Lieberman, MD
• 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
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Aimee Shu
Gillian Lieberman, MD
Agenda
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Aimee Shu
Gillian Lieberman, MD
Articular Manifestations
• Symmetrical involvement,
listed from most Æ least
commonly affected
• Hands, wrists
• Feet, ankles
• Knees
• Hips
• Cervical spine
• Shoulders
• Elbows
Areas of joint involvement
Klippel, John, Primer on the Rheumatic
Diseases, 2nd ed, 1997. 10
Aimee Shu
Gillian Lieberman, MD
• Swan-neck deformities
ulnar deviation
• Boutonnière deformities
• Neuropathy, e.g. carpal tunnel syndrome
Image from:
Eric A. Brandser on Virtual Hospital site, http://www.vh.org/Providers/Lectures/icmrad/skeletal/Parts/RAHands.html
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Aimee Shu
Gillian Lieberman, MD
Extra-Articular Manifestations
• Nodules
• Vasculitis Nodular episcleritis
• Rheumatoid factor =
anti-IgG antibodies
• Ocular:
keratoconjunctivitis
sicca, scleritis
Radiograph showing
right lung nodule
Netter, The Ciba Collection of Medical Illustrations
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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
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Netter, The Ciba Collection of Medical Illustrations
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
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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
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Aimee Shu
Gillian Lieberman, MD
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Aimee Shu
Gillian Lieberman, MD
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Aimee Shu
Gillian Lieberman, MD
• Bony changes
– Marginal bony erosion: periarticular “bare” areas
– Subchondral cyst formation
– Juxta-articular osteopenia Æ generalized osteopenia
– Lack of bony response to overwhelming bone and joint
destruction is characteristic of RA
– Subluxation & dislocation
– Flexion & extension contracture
– Ankylosis
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Aimee Shu
Gillian Lieberman, MD
Hand
Anatomy
Review
Normal hand
radiograph
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Wicke, Atlas of Radiologic Anatomy
Aimee Shu
Gillian Lieberman, MD
Carpal
Bones
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Aimee Shu
Gillian Lieberman, MD
•1981, age 28
•Left lateral oblique
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BIDMC Film Library
Aimee Shu
Gillian Lieberman, MD
• Left AP view
• Erosions: 3rd & 5th
PIPs
• Cyst: 1st IP
• Soft tissue swelling
around PIPs, MCPs
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BIDMC Film Library
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 BIDMC Film Library
spaces 27
Aimee Shu
Gillian Lieberman, MD
1988, Age 35
1995, Age 42
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BIDMC Film Library
Aimee Shu
Gillian Lieberman, MD
Ms. M, Left
Lateral Oblique,
1995, Age 42
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!
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Aimee Shu
Findings
• Tenosynovitis
– Extensor carpi
ulnaris tendon
– Flexor carpi radialis
tendon
• Synovial proliferation
http://www.rad.washington.edu/atlas/extensorcarpiulnaris.html
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Aimee Shu
Gillian Lieberman, MD
http://www.rad.washington.edu/atlas/flexorcarpiradialis.html
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MR Normal Wrist,
Aimee Shu
Gillian Lieberman, MD
Coronal View
3 important areas:
• triangular fibrocartilage
(TFC)
• scapholunate ligament (SL)
• lunotriquetra ligament (LT)
↑ signal =
TFC tear
* SL tear
nickname is “David
Letterman sign”
reminiscent of the
talk show host’s
gap teeth.
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Aimee Shu
Gillian Lieberman, MD
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Aimee Shu
Gillian Lieberman, MD
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
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Now Meet Ms. T
Aimee Shu
Gillian Lieberman, MD
Normal shoulder
Arthritides
monoarticular polyarticular
• trauma
inflammatory degenerative metabolic
• infection deposition
rhematoid rheumatoid
• gout • OA
types variants • Gout
• pseudogout
• Amyloidosis
• RA • ankylosing
spondylitis
• SLE
• Reiter’s syndrome
• scleroderma
• psoriatic arthritis
• DM
• IBD
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Aimee Shu
Gillian Lieberman, MD
Arthritides
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Aimee Shu
Gillian Lieberman, MD
Differential Diagnoses
Feature Also seen in
Carpal erosions Gout
Ulnar deviation & volar SLE, Jaccoud’s syndrome
subluxation of proximal 2º to rheumatic fever
phalanges
Narrow joint space Osteoarthritis
Bony destruction Sarcoid
(“punched-out” lesion)
Swell, erode, cyst Psoriatic arthritis
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Aimee Shu
Gillian Lieberman, MD
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Aimee Shu
Gillian Lieberman, MD
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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.
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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
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