Radiology Presentation

henryfordwestbloomfield.com

51 year old With joint pain

Radiology Presentation

Jacob Miller, MSIV

Wayne State University School of Medicine

January 28, 2009


Symptoms

• 51 yo F with pain in b/l wrists, hands, and Rt

shoulder


• Joint space narrowing

at the radiocarpal,

and ulnar carpal,

carpocarpal, CMC

joint spaces

• Ankylosis of the

carpals

• Lucencies in the

carpal bones

• No fx, dislocation or

deviation


• Joint space narrowing

at the radiocarpal,

and ulnar carpal,

carpocarpal, CMC

joint spaces

• Ankylosis of the

carpals

• Lucencies within the

carpal bones

• Slight ulnar deviation

of MF PIP and RF MCP


• Erosion of

humerus at

anatomic neck

• Degenerative

changes at AC

joint


Differential Diagnosis

• RA

• OA

• Psoriatic arthritis

• Gout

• SLE

• Sjogren’s

• Reiter’s


RA Facts

• 0.5‐1% globally

• Female predominance

– 12.0–24.5 males and 23.9–54.0 females per

100,000 people

• peak age of onset lies between the ages of 45

and 65 years

• 70% of RA patients express HLA‐DR4


ACR RA Classification Tree


RA Criteria

• 4 out of following are present for > 6 weeks

– morning stiffness > 1 hour

– Involvement of >3 of the following joints

• PIP, MCP, wrist, elbow, knee, ankle and MTP

– Arthritis of wrist, MCP or PIP joint

– Presence of rhematoid nodules

– Positive serum rheumatoid factor

– Erosions or bony decalcification on radiograph


Pathophysiology

• Disease of synovium and adjacent tendon sheaths

– leads to hyperemia and pain

• Spreads to adjacent bone, tendons, capsules and ligaments

during progression of disease

• Synovial hyperplasia mediated by cytokines

– TNFα, IL‐1

• Macrophages, fibroblasts and lymphocytes invade synovial

tissue

• Metalloproteinases breakdown articular cartilage and bone


Imaging

• MR is best modality to diagnose early disease

– Before bony changes occur

– T1‐weighted sequence with and without contrast

– T2‐weighted sequence

– Cartilage specific sequence

• Usually symptomatic joints and those usually

involved in RA

– Hands, wrists


• T1‐weighted,

contrast enhanced

• Increased signal in

small joints

indicative of

hyperemia of

synovial tissue


• High res sonogram

of MCP

• Synovial thickening


Early Radiographic Findings

• Pararticular osteoporosis

– Increased bone lucency

– Due to osteoclastic activation

• Deterioration and lucency of subchondral end

plate


• Bone lucency at

PIP, MCP, CMC

and radiocarpal

joints


Late RA Radiographic Findings

• Joint space narrowing

• Subcortical cysts

• Erosions

• Destruction of periarticular soft tissue

structures

• Subluxation of joints

• Ulnar deviation


• Radiograph of advanced RA

• Narrow joint space

• Destruction of multiple

joints

• Subluxation and deviation of

RF and SF


References

• Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism

Association 1987 revised criteria for the classification of rheumatoid

arthritis. Arthritis Rheum 1988; 31:315–324.

• Gabriel SE. The epidemiology of rheumatoid arthritis. Rheum Dis Clin

North Am 2001; 27:269–282.

• Novelline R. Squires Fundamentals of Radiology. Harvard University Press;

6 edition (March 30, 2004)

• Sommer OJ, Kladosek A, Weiler V, Heinz C, Boeck M, Stiskal M.

Rheumatoid Arthritis: A Practical Guide to State‐of‐the‐Art Imaging, Image

Interpretation, and Clinical Implications. RadioGraphics 2005;25:381‐398.

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