Aimee Shu

Gillian Lieberman, MD
April 2002

Imaging Rheumatoid Arthritis

Aimee Shu, Harvard Medical School, Year III

Gillian Lieberman, MD
 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

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 Aimee Shu
Gillian Lieberman, MD

Ms. M’s RA at a Glance

Netter, The Ciba Collection of Medical Illustrations

• 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

*DMARD = disease-modifying anti-rheumatic drug

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 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
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 Aimee Shu
Gillian Lieberman, MD

Diarthrodial Joint Anatomy

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.
5
Resnick & Niwayama, Diagnosis of Bone and Joint Disorders
 Aimee Shu
Gillian Lieberman, MD

Joint Pathology: Progressive Stages

• Synovitis Æ pannus* Æ joint destruction
• Pannus = granulation tissue

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

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.

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 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

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 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

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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

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
• 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

13
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

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

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 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 Æ narrow Æ wide
• Secondary to inflammation, cartilage destruction,
ligamentous laxity, respectively

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 Aimee Shu
Gillian Lieberman, MD

Characteristic Changes on Plain Film

• 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

BIDMC Film Library

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 Aimee Shu
Gillian Lieberman, MD

Hand Anatomy Review

DIP joint
PIP joint MCP
joint
Sesamoid
bones =
ovoid
nodules
embedded
in tendons;
# variable
Carpal
in between
bones
people
radius
ulna

20
Wicke, Atlas of Radiologic Anatomy
 Aimee Shu
Gillian Lieberman, MD

trapezium trapezoid capitate hamate

Carpal
Bones

scaphoid lunate triquetral pisiform 21

 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

22
 Aimee Shu
Gillian Lieberman, MD

Ms. M’s Initial

Presentation, Age 28
• 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”

BIDMC Film Library 23

Aimee Shu
Gillian Lieberman, MD

Ms. M’s Initial

Presentation

•1981, age 28
•Left lateral oblique

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BIDMC Film Library
 Aimee Shu
Gillian Lieberman, MD

Ms. M, 1983, Age 30

•Right AP
(dorsopalmar) view
•Changes since 1981
•Erosions: 2nd
metacarpal, 3rd DIP,
4th PIP
•Soft tissue swelling
•Consistent with RA
BIDMC Film Library
25
Aimee Shu
Gillian Lieberman, MD
Ms. M, 1983, Age 30

• Left AP view
• Erosions: 3rd & 5th
PIPs
• Cyst: 1st IP
• Soft tissue swelling
around PIPs, MCPs

26
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

Ms. M’s RA Progresses, Right AP Views

• ↓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

1988, Age 35
1995, Age 42

28
BIDMC Film Library
 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 29

 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!
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 Aimee Shu

Ms. M, 2002, Age 49

Gillian Lieberman, MD

Anatomy Pointers • flexor

retinaculum
(Carpal tunnel)
contains tendons
and median nerve
radius • Tendon sheath
ulna normally
indistinct from
tendon (low
signal; dark in
this view)
31
MR (T2), Left wrist, Axial view. BIDMC Film Library
 Aimee Shu

Ms. M, 2002, Age 49

Gillian Lieberman, MD

Findings
• Tenosynovitis
– Extensor carpi
ulnaris tendon
– Flexor carpi radialis
tendon
• Synovial proliferation

MR (T2), Left Wrist Axial view. BIDMC Film Library

* Tenosynovitis = tendon sheath inflammation, seen in RA or

repetitive trauma. In contrast, tendonitis = tendon
32
inflammation, signal would be within tendon; seen with overuse
 Aimee Shu
Gillian Lieberman, MD

More proximally, flexor carpi radialis

appears normal

MR (T2), Left Wrist Axial view. BIDMC Film Library

33
Aimee Shu
Gillian Lieberman, MD

Extensor carpi ulnaris

http://www.rad.washington.edu/atlas/extensorcarpiulnaris.html
34
Aimee Shu
Gillian Lieberman, MD

Flexor carpi radialis

http://www.rad.washington.edu/atlas/flexorcarpiradialis.html

35
 MR Normal Wrist,
Aimee Shu
Gillian Lieberman, MD

Coronal View
3 important areas:
• triangular fibrocartilage
(TFC)
• scapholunate ligament (SL)
• lunotriquetra ligament (LT)

• These areas confer stability

• Commonly injured Æ pain

T2-weighted gradient echo. BIDMC Film Library 36

 Aimee Shu
Gillian Lieberman, MD

Ms. M: TFC Tear & SL Tear

Gap > 2 mm
indicates
SL tear

↑ signal =
TFC tear
* SL tear
nickname is “David
Letterman sign”
reminiscent of the
talk show host’s
gap teeth.

T2-weighted gradient echo. BIDMC Film Library

37
Aimee Shu
Gillian Lieberman, MD

Ms. M: Erosions on MRI

T2-weighted gradient echo. BIDMC Film Library

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 Aimee Shu
Gillian Lieberman, MD

Sagittal View of Normal TFC

Notice ample joint

triquetral
space between
ulna ulna and triquetral
bones

T1 MRI, left wrist. BIDMC Film Library

39
 Aimee Shu
Gillian Lieberman, MD

Ms. M: TFC Tear

Carpal
tunnel

ulna and triquetral

bones touch

T1 MRI, left wrist. BIDMC Film Library

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 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

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 Now Meet Ms. T
Aimee Shu
Gillian Lieberman, MD

62yo woman, h/o RA and 50 lb weight loss, right leg

shorter than left, inability to ambulate. Please
evaluate…
Acetabuli protrusio
into ilium
•hips involved in 50% RA
patients
• ↓ cartilage allows
femoral head to migrate
superomedially within
acetabulum
•more severe with time
BIDMC Film Library 42
 Aimee Shu
Gillian Lieberman, MD

Normal shoulder

BIDMC Film Library 43

 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 BIDMC Film Library
• humeral head migrates
proximally & superiorly 44
 Aimee Shu
Gillian Lieberman, MD

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

45
Aimee Shu
Gillian Lieberman, MD

Arthritides

• Radiographic findings rarely

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

46
 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

47
 Aimee Shu
Gillian Lieberman, MD

RA: Distinguishing Features

• Diffuse (vs. limited to juxta-articular)

osteoporosis
• Lack of new bone formation

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 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

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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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