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Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023
| Contributor Information
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Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Arthritic joint pains are common presenting complaints that can be difficult to distinguish from history and physical examination findings alone. Plain radiographs are extremely valuable in differentiating between the many forms of arthritis. Classic radiographic findings in the extremities for osteoarthritis (OA), psoriatic arthritis (PA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), gout, and pseudogout will be discussed. The classic "gull wing" deformity (arrow) of the distal interphalangeal joint (DIP) from advanced OA is shown.
Left image courtesy of Medscape; right image courtesy of Medscape / Bruce M Rothschild, MD.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
PA is a seronegative spondyloarthropathy caused by the macrophage-induced enzymatic breakdown of bone, tendons, and cartilage. As seen in the left-hand image, the classic findings of PA in the hands are soft-tissue swelling, joint-space loss (yellow arrow), bilateral asymmetric distribution, bone proliferation (green arrow), distal tuft resorption (white arrows), and marginal erosions (red arrow).[1] The soft-tissue swelling is severe, giving fingers a "sausagelike" appearance. Early erosions are common, and a classic feature of PA is the "pencil-in-cup" or "cup-in-saucer" appearance, in which the erosions become so severe that the proximal bone has been narrowed and appears to be resting in the shallow depression of the distal bone (blue arrow).[2]
In the right-hand image, the majority of the PA changes can be found in one digit. The third digit demonstrates distal phalangeal tuft resorption (white arrow), joint-space narrowing (yellow arrow), marginal erosions (red arrow), and bone proliferation (blue arrow). Erosive changes typically affect the hands before the feet and the DIP joints before the proximal joints of the fingers and wrist.[3]
Image courtesy of Medscape / Bruce M Rothschild, MD.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Radiographs of the pelvis in patients with PA show extensive erosion along the length of the sacroiliac (SI) joint without joint fusion. Initially shallow erosive changes and subchondral sclerosis occur, followed by progressive erosive changes and unequal joint-space widening.[1] Bony proliferation may also develop, leading to joint-space narrowing and ankyloses.[4]
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
AS is a seronegative arthritis that causes inflammatory enthesopathy.[5] Entheses are the bony attachments of ligaments, tendons, and joint capsules. Involvement of the SI joints is the hallmark of AS. Classically, there is initially symmetric bony erosion (yellow arrows), followed by subchondral sclerosis (iliac side), and eventually complete ankylosis (not shown). The disease involves both the true and the ligamentous SI joints. In some cases, the pubic symphysis may also be involved.
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
In the hips, AS presents with joint-space loss (white arrows), axial migration of the femoral head (yellow arrow), and osteophyte formation. The osteophytes typically form a ring or collar around the femoral head-neck junction (red arrow). In late disease, ankylosis of the joint may develop, accompanied by a loss of osteophytes and subsequent osteoporosis. Involvement of the hips is not usually the first presentation of AS, but it is more common in juvenile-onset disease. As many as 8% of patients with AS will require total hip replacement.[6]
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
RA is a systemic inflammatory disease of the synovial membrane that results in destruction of cartilage and bone.[7] It is classically symmetric and polyarticular in presentation. The earliest changes in RA are nonosseous, and magnetic resonance imaging (MRI) is the best modality for identifying hyperemia, synovitis, effusions, marrow edema, and subcortical cysts.[3] Although radiographs are less sensitive to early changes, they are more cost-effective and may provide the first sign of disease in patients who present with nonspecific findings. Early changes are soft-tissue swelling (white arrow), joint-space narrowing (blue arrow), and erosions of the proximal interphalangeal (PIP) joints (red arrows). The erosions first occur adjacent to the articular cartilage (periarticular erosions).
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
In late RA of the hands, articular damage leads to significant joint subluxation and malalignment. Classic findings are ulnar deviation of the fingers at the metacarpophalangeal (MCP) joints (white arrows). In the fingers, either swan-neck or boutonniere deformities may develop. A swan-neck deformity is extension of the PIP joint and flexion of the DIP joint, whereas a boutonniere deformity is flexion of the PIP joint and extension of the DIP joint. In very late RA, fusion or joint ankylosis may occur.
Images courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Similar changes are found in the wrist in patients with RA. The image on the left demonstrates multiple erosions of the carpal and metacarpal bones (white arrows). The image on the right, taken 18 months later, demonstrates worsened erosions (yellow arrows) and ankylosis of the carpal bones (red arrows). The carpal bones are often collectively affected as a unit, and their fusion is called carpal coalition.
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Radiographs are important in differentiating RA from other sources of knee pain. On radiographs, the knees of patients with RA show uniform joint-space loss (yellow arrows) without osteophytosis, unlike the medial compartment preference of OA. Baker's cysts (arrowhead) are also frequently identified. For further evaluation of the knee, MRI is best at evaluating the extent of marrow edema, articular surface injury, and associated soft-tissue injuries to the muscles, tendons, and cartilage.[8]
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
OA is the most common arthropathy seen in general practice. Primary OA is idiopathic, unlike secondary OA, which develops from another predisposing condition (eg, trauma). OA of the fingers involves the DIP and PIP joints. The classic findings are joint-space narrowing (white arrow), osteophyte formation (yellow arrow), subchondral sclerosis, subchondral cyst formation, and, in more advanced cases, central erosions (blue arrow). The joint involvement may be highly asymmetric. Soft-tissue swelling due to dorsal osteophyte formation may be found around an involved joint; this is termed a Heberden node when around the DIP joint and a Bouchard node when around the PIP joint.
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Primary OA of the wrist predominately involves the first carpometacarpal (CMC) joint and the scaphoid-trapezium articulation. Involvement of other joints should raise suspicion for another arthritic process. The image shown demonstrates significant joint-space narrowing with sclerosis of the trapezium-scaphoid and trapezoid-scaphoid articulations (white arrows). The scaphoid (blue asterisk), trapezium (red asterisk), and trapezoid (yellow asterisk) are labeled. MRI of the wrist is the most sensitive imaging modality for the detection of synovitis, bone-marrow edema, and early erosions, especially in the setting of negative radiographs.[9]
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Primary OA of the hips is a genetic disease most common in patients with European ancestry.[10] It predominantly involves narrowing of the superior aspect of the joint, which leads to superior migration of the femoral head within the acetabulum and associated subchondral sclerosis (yellow arrow). The direction of femoral head migration is an important factor differentiating among the arthritic mechanisms. With increasing stress, the femoral head may become flattened and eventually collapse. Osteophytes may often be found on the lateral border of the acetabulum and along the femoral head. Osteoarthritic pseudocysts in the acetabulum are termed Egger cysts. Although primary OA is classically bilateral, posttraumatic OA may present as a unilateral finding.
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
In the knees, primary OA predominantly involves the medial tibiofemoral and patellofemoral compartments. The asymmetric medial joint-space loss causes a varus deformity on standing radiographs. Classically, a large osteophyte forms on the medial tibial articular margin. Subchondral sclerosis and cyst formation may also occur.
A lateral radiograph of the knee is shown demonstrating significant OA of the patellofemoral compartment. Prominent osteophytes (white arrows) and joint-space narrowing (red arrow) are visible. Large ossified intra-articular loose bodies are also incidentally present (blue arrow).
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Gout is a peripheral arthritis caused by the deposition of sodium urate crystals (tophi) in the soft tissues,[11] most commonly in the hands and feet. Urate crystals are not radiopaque, but calcium will often precipitate with the urate crystals, producing a cloudy opacity. Other classic radiographic findings in gout are punched-out erosions (white arrow), asymmetric joint swelling (yellow arrow), and joint cysts.[12] These erosions often have sclerotic borders with overhanging edges of cortex. Joint-space destruction (red arrow) is a late finding, along with subluxation and joint deformity.
Clinically, gout initially affects the first metatarsophalangeal (MTP) joint of the foot. The tophus may lead not only to joint-space destruction but also to a hallux valgus deformity. It must not be mistaken for a bunion. Punched-out erosions in the foot may be extensive.
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Calcium pyrophosphate deposition (CPPD) disease is an arthritis caused by the deposition of calcium pyrophosphate crystals in the connective tissues (pseudogout). The classic findings are chondrocalcinosis, subchondral sclerosis, and subchondral cysts (red arrow) and are often indistinguishable from those of acute gouty arthritis or septic arthritis.[13] In the hands, the chondrocalcinosis is most commonly found in the triangular fibrocartilage (yellow arrow) and between the scaphoid and the lunate (white arrow). Scaphoid-lunate calcification may lead to joint laxity and disruption of the scapholunate ligament with widening of the scapholunate interval (blue arrow).
Image courtesy of Medscape.
Can't-Miss Radiographic Changes in Rheumatologic Disease
Lars Grimm, MD, MHS | August 21, 2023 | Contributor Information
Chondrocalcinosis is a disease of the elderly, but prevalence estimates are largely based on radiographically detected chondrocalcinosis rather than crystal aspirates.[14] The knee is the joint most commonly involved in CPPD disease. In the image shown, chondrocalcinosis of the meniscal (white arrow) and hyaline cartilage is readily visible. Narrowing of the patellofemoral space with sparing of the tibiofemoral components is a common finding. Previous trauma, including iatrogenic injury, is a strong risk factor for CPPD disease.
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Contributor Information
Author
Lars Grimm, MD, MHS
Clinical Associate
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial
relationships.
Editor
Jose Varghese, MD
Associate Professor
Boston University School of Medicine
Boston, Massachusetts
Disclosure: Jose Varghese, MD, has disclosed no relevant financial
relationships.
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References
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