Artropathies: what can be seen in hands?

Transcription

1 Artropathies: what can be seen in hands? Poster No.: C-2452 Congress: ECR 2015 Type: Educational Exhibit Authors: B. M. Torres Rodrigues, J. C. Ruivo Rodrigues, C. Albuquerque, D. Silva; Viseu/PT Keywords: Extremities, Musculoskeletal system, Conventional radiography, Diagnostic procedure, Education and training DOI: /ecr2015/C-2452 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 53

2 Learning objectives - To describe the imaging findings on radiography of the articular diseases affecting hands. - To discuss the diferencial characteristics of the inflammatory and degenerative conditions. Page 2 of 53

3 Background Radiography is a common technique used to evaluation of arthritis. There are a wide variety of pattens of disease with an important overlap of features. We focused on the radiologic features of arthritis that affects hands and wrists. Page 3 of 53

4 Findings and procedure details Osteoarthritis Osteoarthritis (OA), or degenerative joint disease (DJD) is the most common arthropathy. It results of articular cartilage damage from repetitive microtrauma that occurs throughout life. However genetic, hereditary, nutritional, metabolic, preexisting articular disease and body habitus factors may contribute. OA involves the distal interphalangeal (DIP) joints and proximal interphalangeal (PIP) joints with relative sparing of the metacarpophalangeal (MCP) joints. The first carpometacarpal joint (rhizarthrosis) and the joint between the trapezium and the scaphoid are the sites involved in the wrist (Fig. 1, 2, 4 and 5). The hallmarks of OA are asymmetric joint space narrowing, bone sclerosis, ostheophytosis and subchondral cysts, or geodes. However, joint space narrowing of the interphalangeal (IP) and MCP joints may be symmetric (Fig. 2, 4 and 5). The soft tissue swelling around the DIP joints associated with osteophyte formation is called a Herberden node and around the PIP joints is called a Bouchard node (Fig. 3). Marginal osteophytes is used to detect OA while joint space narrowing, bone sclerosis and subchondral cysts are used to assess severity. Page 4 of 53

5 Fig. 1: Osteoarthritis. Posteroanterior (PA) view of the hands shows the distribution of OA. There are involvement of the IP joints and of the base of the first metacarpal. References: - Viseu/PT Page 5 of 53

6 Fig. 2: Osteoarthritis. PA view of the IP joints showing joint space narrowing, sclerosis and osteophytes. References: - Viseu/PT Page 6 of 53

7 Fig. 3: Osteoarthritis. PA view of the second and third finger with a Herberden node (yellow circle). References: - Viseu/PT Page 7 of 53

8 Fig. 4: Osteoarthritis. PA view of the wrist showing rhizarthrosis with loss of joint space, sclerosis and subchondral cyst (arrow) between the base of the first metacarpal and the trapezium. References: - Viseu/PT Page 8 of 53

9 Fig. 5: Osteoarthritis. PA view of the wrist showing OA space joint narrowing between the base of the first metacarpal and the trapezium and between the trapezium and the scaphoid. There is subchondral sclerosis and osteophyte formation (arrow). References: - Viseu/PT Erosive osteoarthritis Erosive osteoarthritis (EOA) is considered a subset of OA characterized by intermittent and inflammatory episodes and progressive joint damage. It has an estimated prevalence of 5-15% of those with symptomatic hand OA and occurs in postmenopausal women. It has the same distribution as primary OA with involvement of the DIP and PIP joints and the base of the thumb. Presentation is typically bilateral and symmetrical, with DIP joints more frequently affected, usually the second and third DIP joints followed by the fourth and fifth DIP joints. It is distinguished from OA bacause it has an inflammatory component with erosive disease that can result in ankylosis. The characteristic radiographic feature is a central erosion that produces two convexities of the joint surface like the wings of a seagull (Fig. 6). Page 9 of 53

10 Fig. 6: Erosive osteoarthritis. PA view of the hands showing involvement of the DIP and PIP joints and the base of the thumb. There are osteophyte formation, erosions with the appearance of a seagull and ankylosis of the third PIP joint. References: - Viseu/PT Septic arthritis Septic arthritis is characterized by inflammation limited to a single joint but multiple joints are involved in about 20% of cases. The cause is usually hematogeneous seeding with staphylococcal and streptococcal microrganisms being the most common agents. The radiographic features are those of an inflammatory arthritis: periarticular osteopenia, uniform joint space narrowing, soft tissue swelling and bone erosions (Fig. 7). Initially, bone erosions may not be evident and the joint space may be widened owing to the effusion. Page 10 of 53

11 Fig. 7: Septic athritis. PA (a) and oblique (b) radiographs shows joint space narrowing, soft-tissue swelling and bone erosion (arrow). References: - Viseu/PT Rheumatoid arthritis Rheumatoid arthritis is most common in women between 30 and 60 years. There are serologic markers like rheumatoid factor and antibodies to cyclic citrullinated peptide that indicate the diagnosis. In the hands, there are involvement of the MCP, PIP, midcarpal, radiocarpal and distal radioulnar joints with predilection for the ulnar styloid process. Involvement is usually bilateral and fairly symmetric (Fig. 8). Page 11 of 53

12 Radiographic features includes periarticular osteopenia, uniform joint space loss, bone erosions and soft-tissue swelling (Fig. 9 and 10). Joint subluxation and subchondral cysts may be seen because of the chronic nature of disease. Ulnar deviation occurs at the MCP joints (Fig. 11). Hyperextension at the PIP joints with flexion at the DIP joints results in a swan neck deformity. Flexion at the PIP joints and hyperextension at the DIP joints results in a boutounnière deformity (Fig. 12). Radiographs of the hands are used to help in early diagnosis and to assess for disease progression. The proximal distribution and lack of bone proliferation suggests rheumatoid arthritis. The first erosive changes occur before there is loss of joint space. Erosive disease is an indication of the aggressiveness of the arthropathy. Fig. 8: Rheumatoid arthritis. PA views of the hands shows bilateral and symmetric involvement of the PIP joints, MCP joints and carpal bones. References: - Viseu/PT Page 12 of 53

13 Fig. 9: Rheumatoid arthritis. PA radiograph of the hand shows early changes of the MCP joints: marginal erosions (arrows). References: - Viseu/PT Page 13 of 53

14 Fig. 10: Rheumatoid arthritis. PA view of the wrist shows diffuse loss of joint spaces and erosions in a pancarpal distribution. References: - Viseu/PT Page 14 of 53

15 Fig. 11: Rheumatoid arthritis. PA view of the hands showing late changes with involvement of the PIP joints, MCP joints and the carpals joints as a unit. There is diffuse osteoporosis and severe erosion. In the right hand, the proximal phalanges are subluxating ulnarly relative to the metacarpal heads. References: - Viseu/PT Page 15 of 53

16 Fig. 12: Rheumatoid arthritis. Boutounnière deformity of the fifth finger (a) and swan neck deformity of the fourth and fifth fingers (b). References: - Viseu/PT Seronegative spondyloarthropathies Psoriatic arthritis Psoriatic arthritis occurs in 5-8% of patients with severe and londstanding psoriatic skin disease. However, the artropathy may coincide with or antedate the appearance of skin disease. It has a distal distribution and may be unilateral or bilateral, symmetric or assymmetric. There are signs of an inflammatory arthritis (fusiforme soft tissue swelling, joint space lose and erosions) with bone proliferation, periostitis and enthesitis. Normal mineralization Page 16 of 53

17 is usually maintained even in the presence of severe erosive disease. Involvement of several joints in a single digit with soft tissues swelling produces the "sausage digit" appearance. The bone proliferation produces an irregular and indistinct appearance to the marginal bone, the "fuzzy" or "whiskering" appearance (Fig. 13). The bone destruction may take the appearance of a "pencil and cup" (Fig. 14). The most significant difference with rheumatoid arthritis is the presence of bone proliferation. Fig. 13: Psoriatic arthritis. PA radiographs of fingers demonstrating marginal bone erosions with adjacent irregular bone proliferation and periostitis. There is soft tissue swelling. References: - Viseu/PT Page 17 of 53

18 Fig. 14: Psoriatic arthritis. PA view of the hands shows involvement of IP joints and carpal joints. There is pencil and cup erosions (yellow circles) and ankylosis. References: - Viseu/PT Reactive arthritis Reactive arthritis, also called Reiter syndrome, is a sterile inflammatory arthritis that follows an infection at a different site, usually enteric or urogenital. Urethrithis and conjunctivitis and seropositivity for the HLA-B27 antigen are associated. Affects young men aged between years. Radiographic features are similar to those of psoriatic arthritis (joint inflammation, bone proliferation, periostitis and enthesitis) with a distribution uni or bilateral, symmetric or assymetric. The PIP joints are more frequently involved than the DIP or MCP joints. Sausage digit and pencil and cup deformities may also occur. Juvenile idiophatic arthritis Page 18 of 53

19 Juvenile idiophatic arthritis includes juvenile-onset ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, juvenile-onset adult-type rheumatoid arthritis and Still s disease (seronegative chronic arthritis). Except for Still's disease, they tend to occur in older children and are similiar to their adult counterpart. Juvenile-onset adult-type rheumatoid arthritis differs from adult rheumatoid arthritis because periostitis is frequent in the metaphyses of the falanges and metacarpals and there is significant erosive disease without joint space loss. Still disease has three subtypes: systemic disease with little to no radiographic articular changes, polyarticular disease with less severe systemic manifestations and pauciarticular or monoarticular disease with infrequent systemic manifestations. It has a bilateral and symmetrical distribution in polyarticular disease and involve the DIP joints as well as the PIP joints and MCP joints. Wrist is more commonly involved than hand. Radiographic features includes periarticular soft-tissue swelling and osteoporosis. Periostitis along the metaphysis and diaphysis may be present. There is overgrowth and ballooning of the epiphyses and premature fusion of the growth plates leads to brachydactyly. However, erosive disease is usually absent and joint space is preserved. Crystal deposition disease Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease may cause chondrocalcinosis and calcification of the synovium, joint capsule, tendons and ligaments. It typically affects the middle-aged and eldery populations. Radiographic findings are similar to those of OA but they are atypical because of joint distribution usually confined to the MCP joints, extensive subchondral cyst formation and associated calcium deposition. CPPD arthropathy characteristically involves the radiocarpal joint of the wrist and the second and third MCP joints of the hand. Chondrocalcinosis of the triangular fibrocartilage is commom and calcium deposition in the intrinsic carpal ligaments, specially the lunotriquetral ligament, and joint capsules may also occur (Fig. 15 and 16). There is joint space narrowing, suchondral bone formation and variable osteophyte formation. Page 19 of 53

20 Fig. 15: Calcium pyrophosphate dihydrate crystal deposition disease. PA radiograph of the wrist showing chondrocalcinosis in the triangular fibrocartilage and lunotriquetral joint (yellow circle). References: - Viseu/PT Page 20 of 53

21 Fig. 16: Calcium pyrophosphate dihydrate crystal deposition disease. PA radiograph of the hand shows capsular calcification (arrow). References: - Viseu/PT Gout Gout arthritis is caused by deposition of monosodium urate crystals and occurs predominantly in males. Page 21 of 53

22 It has an asymmetrical polyarticular distribuiton (Fig. 17). In early disease, radiographs may be normal or show peri-articular soft tissue or joint effusion in an acute flare. Radiographic features includes characteristic erosions that may be both intra or extraarticular with sclerotic margins and overhanging edges that produce a punched-out appearance. Periarticular osteopenia is absent and joint space narrowing is a relatively late feature as well as ankylosis and subluxation. There is marked soft-tissue swelling from gouty tophus deposition. Tophi may be observed as asymmetrical, lobulated softtissue masses with or without calcifications, usually in the periarticular area along the extensor surface of bone. Marked bone destruction occurs in severe cases with substancial soft-tissue swelling (Fig. 18 and 19). Fig. 17: Gout. PA view of hands shows erosions and tophi with asymmetrical distribution. Mineralization is maintained. References: - Viseu/PT Page 22 of 53

23 Fig. 18: Gout. PA radiograph of the fingers shows periarticular soft tissue swelling and erosions. References: - Viseu/PT Page 23 of 53

24 Fig. 19: Gout. PA view of the fingers shows soft tissue masses representing tophi and extensive involvement of the bone by erosions with sclerotic borders and overhanging edges. References: - Viseu/PT Hemochromatosis Primary hemochromatosis is an inherited disease classically seen in male between 40 and 60 years old that leads to iron deposition in body. Joint disease and chondrocalcinosis are common in hemochromatosis and can be the presenting feature. In hemochromatosis, there is extensive involvement of the second through fifth metacarpophalangeal joints, specially of the second and third MCP joints. It has a bilateral symmetrical distribuiton. There are uniform loss of the joint space with subchondral sclerosis and small subchondral cysts. There are a characteristic metacarpal radial Page 24 of 53

25 hooklike or drooping osteophytes (Fig. 20). There may be flattening or collapse of the heads of the metacarpals. The interphalangeal joints are usually spared. In wrists, there is involvement of carpometacaral, midcarpal and the first carpometacarpal compartments with sparing of the radiocarpal compartment. Fig. 20: Hemochromatosis. PA hand radiograph shows osteoarthritis which is most marked at the MCP joints and hooklike osteophytes (arrows). References: - Viseu/PT Systemic lupus erythematosus Systemic lupus erythematous (SLE) is a connective disorder predominantly affecting women of chilbearing age. Page 25 of 53

26 Joint space narrowing and erosions are not frequent in SLE. The most commom finding is the presence of reducible MCP joint subluxation identified on oblique radiographs (Fig. 21). Periarticular osteopenia and soft-tissue swelling may be seen. Fig. 21: Systemic Lupus Erythematosus. PA view of the hands shows juxta-articular osteoporosis and subluxation of the MCP joints. There is no evidence of erosive disease. References: - Viseu/PT Scleroderma Systemic sclerosis is commonly associated with joint disease. Radiographic features include resorption of soft tissue of the fingertip with or without subcutaneous calcification. There may be erosion of the distal tuft (acroosteolysis) and erosive disease can be seen also in the interphalangeal joints and carpometacarpal joint (Fig. 22 and 23). Page 26 of 53

27 Fig. 22: Scleroderma. PA view of the hands. Osteoporosis, soft tissue wasting and acroosteolysis are present. References: - Viseu/PT Page 27 of 53

28 Fig. 23: Scleroderma. (a) PA view of second and third fingers shows atrophy of distal soft tissues and erosive changes of the distal tuft. (b) PA view of hand shows more advanced erosive changes with amputation of the distal second, third and fifth fingers. References: - Viseu/PT Page 28 of 53

29 Images for this section: Fig. 1: Osteoarthritis. Posteroanterior (PA) view of the hands shows the distribution of OA. There are involvement of the IP joints and of the base of the first metacarpal. - Viseu/PT Page 29 of 53

30 Fig. 2: Osteoarthritis. PA view of the IP joints showing joint space narrowing, sclerosis and osteophytes. - Viseu/PT Page 30 of 53

31 Fig. 3: Osteoarthritis. PA view of the second and third finger with a Herberden node (yellow circle). - Viseu/PT Page 31 of 53

32 Fig. 4: Osteoarthritis. PA view of the wrist showing rhizarthrosis with loss of joint space, sclerosis and subchondral cyst (arrow) between the base of the first metacarpal and the trapezium. - Viseu/PT Page 32 of 53

33 Fig. 5: Osteoarthritis. PA view of the wrist showing OA space joint narrowing between the base of the first metacarpal and the trapezium and between the trapezium and the scaphoid. There is subchondral sclerosis and osteophyte formation (arrow). - Viseu/PT Page 33 of 53

34 Fig. 6: Erosive osteoarthritis. PA view of the hands showing involvement of the DIP and PIP joints and the base of the thumb. There are osteophyte formation, erosions with the appearance of a seagull and ankylosis of the third PIP joint. - Viseu/PT Page 34 of 53

35 Fig. 7: Septic athritis. PA (a) and oblique (b) radiographs shows joint space narrowing, soft-tissue swelling and bone erosion (arrow). - Viseu/PT Page 35 of 53

36 Fig. 8: Rheumatoid arthritis. PA views of the hands shows bilateral and symmetric involvement of the PIP joints, MCP joints and carpal bones. - Viseu/PT Page 36 of 53

37 Fig. 9: Rheumatoid arthritis. PA radiograph of the hand shows early changes of the MCP joints: marginal erosions (arrows). - Viseu/PT Page 37 of 53

38 Fig. 10: Rheumatoid arthritis. PA view of the wrist shows diffuse loss of joint spaces and erosions in a pancarpal distribution. - Viseu/PT Page 38 of 53

39 Fig. 11: Rheumatoid arthritis. PA view of the hands showing late changes with involvement of the PIP joints, MCP joints and the carpals joints as a unit. There is diffuse osteoporosis and severe erosion. In the right hand, the proximal phalanges are subluxating ulnarly relative to the metacarpal heads. - Viseu/PT Page 39 of 53

40 Fig. 12: Rheumatoid arthritis. Boutounnière deformity of the fifth finger (a) and swan neck deformity of the fourth and fifth fingers (b). - Viseu/PT Page 40 of 53

41 Fig. 13: Psoriatic arthritis. PA radiographs of fingers demonstrating marginal bone erosions with adjacent irregular bone proliferation and periostitis. There is soft tissue swelling. - Viseu/PT Page 41 of 53

42 Fig. 14: Psoriatic arthritis. PA view of the hands shows involvement of IP joints and carpal joints. There is pencil and cup erosions (yellow circles) and ankylosis. - Viseu/PT Page 42 of 53

43 Fig. 15: Calcium pyrophosphate dihydrate crystal deposition disease. PA radiograph of the wrist showing chondrocalcinosis in the triangular fibrocartilage and lunotriquetral joint (yellow circle). - Viseu/PT Page 43 of 53

44 Fig. 16: Calcium pyrophosphate dihydrate crystal deposition disease. PA radiograph of the hand shows capsular calcification (arrow). - Viseu/PT Page 44 of 53

45 Fig. 17: Gout. PA view of hands shows erosions and tophi with asymmetrical distribution. Mineralization is maintained. - Viseu/PT Page 45 of 53

46 Fig. 18: Gout. PA radiograph of the fingers shows periarticular soft tissue swelling and erosions. - Viseu/PT Page 46 of 53

47 Fig. 19: Gout. PA view of the fingers shows soft tissue masses representing tophi and extensive involvement of the bone by erosions with sclerotic borders and overhanging edges. - Viseu/PT Page 47 of 53

48 Fig. 20: Hemochromatosis. PA hand radiograph shows osteoarthritis which is most marked at the MCP joints and hooklike osteophytes (arrows). - Viseu/PT Page 48 of 53

49 Fig. 21: Systemic Lupus Erythematosus. PA view of the hands shows juxta-articular osteoporosis and subluxation of the MCP joints. There is no evidence of erosive disease. - Viseu/PT Page 49 of 53

50 Fig. 22: Scleroderma. PA view of the hands. Osteoporosis, soft tissue wasting and acroosteolysis are present. - Viseu/PT Page 50 of 53

51 Fig. 23: Scleroderma. (a) PA view of second and third fingers shows atrophy of distal soft tissues and erosive changes of the distal tuft. (b) PA view of hand shows more advanced erosive changes with amputation of the distal second, third and fifth fingers. - Viseu/PT Page 51 of 53

52 Conclusion The majority of arthropaties are easily identified by their effects on the hands. The radiologist should be familiar with the radiographic features of common arthritis to provide a correct diagnosis. Page 52 of 53

53 References 1. Jacobson J; Girish G; Jiang Y; Sabb B. Radiographic evaluation of arthritis: degenerative joint disease and variations. Radiology 2008 Sep;248(3): Jacobson J; Girish G; Jiang Y; Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology 2008 Aug;248(2): Brower A; Flemming D. Arthritis in black and white. Elsevier Saunders. Philadelphia rd edition. 4. Dalbeth N; Doyle A J. Imaging of gout - An overview. Best Practice & Research Clinical Rheumatologu 26(2012) Page 53 of 53