Radiographic Assessment of Arthritis: A Pictorial Review Poster No.:

C-0065

Congress:

ECR 2011

Type:

Educational Exhibit

Authors:

J. Acosta Batlle , S. Hernandez Muñiz , B. Palomino Aguado , M.

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D. Lopez Parra , M. perez de las vacas , J. C. Albillos Merino ; 1

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28702/ES, san sebastian de los reyes/ES, madrid, España/ES,

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Madrid/ES, San Sebastian de los Reyes, Ma/ES

Keywords:

Musculoskeletal joint, Plain radiographic studies

DOI:

10.1594/ecr2011/C-0065

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Learning objectives To provide an educational and pictorial review of the peripheral arthritis based on radiological imaging features (plain radiography/MRI/US), emphasizing its anatomical distribution.

Background The correct diagnosis of peripheral arthritis is based on numerous factors, including clinical features (age and sex of the patient, duration of symptoms, clinical appearance of involved joint or joints), presence or absence of associated diseases (skin disease, uveitis, conjunctivitis, urethritis), laboratory values (rheumatoid factor, serum uric acid, markers for inflammation), and various imaging features. The key to reading arthritis radiographs is to have an organized approach that dissects the radiographic finding into manageable components. Radiographic diagnosis of arthritis is based on regional and global joint assessment. Almost all arthritic processes have a preferential joint distribution, as well as a specific distribution within a joint. Another important parameter in the evaluation of an arthritic process is the determination of whether it is primarily erosive, productive of bone or mixed. Rheumatoid arthritis is an example of a purely erosive arthritic process. Osteoarthritis is at the other end of the spectrum, with productive rather than erosive manifestations. Most of the other arthropathies generally fall between the erosive and productive ends of the spectrum, often demonstrating both erosive and productive changes.

Imaging findings OR Procedure details Radiographs represent the mainstay for diagnosis and follow-up of joint damage, although magnetic resonance imaging (MRI) and ultrasound (US) can be useful evaluation tools, especially in the early stages of disease.

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Many imaging features have to be systematically assessed to establish a correct diagnosis: 1. Distribution (Fig. 1) on page 4: 1.

1. 2. 3. 4. 5.

a. Monoarticular, oligoarticular, or polyarticular b. Symmetrical or asymmetrical c. Proximal or distal d. Associated axial involvement e. Associated enthesis involvement

Arthritis may be monoarticular (one joint involved), oligoarticular(just a few joints), or polyarticular (multiple joints). Polyarticular disease virtually excludes infection. Monoarticular and oligoarticular involvement is unusual for rheumatoid arthritis (RA), but is more typical of seronegative arthritis, infection, pigmented villonodular synovitis, synovial chondromatosis, crystal deposition disease, and hemophilic arthropathy. Arthritis may be symmetric vs. asymmetric. Symmetry favors RA and CPPD disease. Asymmetry is seen in osteoarthritis, seronegative spondyloarthropathies, and gout. Reactive arthritis and psoriasis are often polyarticular and involve entire rays. In the hands and feet, proximal disease favours RA and crystal deposition diseases. Distal and first-ray disease favours osteoarthritis. Either pattern can be seen with seronegative arthritis. Distal inflammatory disease favours seronegative arthritis. Some arthritides may primarily involve the axial skeleton. Spondyloarthropathy means arthritis with spine involvement. 2. Soft tissue swelling (Fig.2) on page 5 1.

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a. Fusiform (symmetrical around the joint) This is the pattern most associated with rheumatoid arthritis and septic arthritis. 1. b. Diffuse ("sausage digit") • This pattern is most typical of psoriatic arthritis and reactive arthritis. 1. c. Lumpy, bumpy • Tophaceous deposits in gout tend to be eccentric. Thus, soft tissue swelling due to gout tens to be asymmetric and lumpy-bumpy in appearance 3. Joint space change (Fig.3) on page 6, (Fig.4) on page 7 1. . Widening 2. b. Uniform narrowing

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Inflammatory arthritis and crystal deposition disease often result in uniform joint space loss. 1. c. Asymmetrical narrowing • Osteoarthritis tends to be asymmetrically greater at load-bearing surfaces 1. d. Ankilosis • It is associated with ankylosing spondylitis, late-stage juvenile rheumatoid arthritis, reactive arthritis, psoriatic arthritis and rheumatoid arthritis. Ankilosis distal to wrist is most likely in seronegative spondyloarthropathy, trauma, and infection. 1. e. Normal 4. Bone erosion (Fig.5) on page 8 1. a. Marginal • It occurs in inflammatory arthritis 1. b. Nonmarginal • These erosions are associated with crystal deposition diseases 1. c. Subchondral 2. d. None 5. Bone production (Fig.6) on page 9, (Fig.7) on page 10 1. . Reparative response • "Whiskering" /"brush stroke" erosions • Overhanging edge of the cortex • Subchondral sclerosis • Osteophytes 6. Calcification (Fig.8) on page 11 1. a. Periarticular 2. b. Chondrocalcinosis 7. Subchondral cyst 8. Mineralization (Fig.9) on page 12 1. a. Periarticular osteoporosis 2. b. Diffuse osteoporosis 3. c. Normal

Images for this section:

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Conclusion The accurate diagnosis of peripheral arthritis is based on clinical features, presence or absence of associated diseases, laboratory values and imaging features. Radiographs represent the mainstay for diagnosis, although MRI and US are useful in the early stages of disease.

Personal Information [email protected]

References Aurea VR. Monoarticular arthritis. Radiol Clin North Am 2004. 42(1):135-150. Bennett DL. Spondyloarthropathies: Ankylosing Spondylitis and psoriatic arthritis. Radiol Clin North Am 2004. 42(1):121-134. Bolster MB. Rheumatoid arthritis. Imaging of the musculoskeletal system. Elsevier Saunders 2008. Vol II. Pag 1100-1112. Brower AC. Arthritis: in Black and White. Hardcover. Second edition 1996. Greenspan A. Erosive osteoarthritis. Semin Musculoskelet Radiol. 2003. 7(2):155-159. Gupta KB. Radiographic evaluation of the osteoarthritis. Radiol Clin North Am 2004. 42(1):11-42. Johnson K. Juvenile idiopathic arthritis. Imaging of the musculoskeletal system. Elsevier Saunders 2008. Vol II. Pag 1165-1171. Klecker RJ, Weissman BN. Imaging features of psoriatic arthritis and Reiter´s syndrome. Semin Musculoskelet Radiol 2003. 7(2):115-126.

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Manaster BJ, May DA, Disler DG. Musculoskeletal Imaging. The requisites. Mosby Elsevier. Third edition, 2007 Monu JUV. Gout: A clinical and radiologic review. Radiol Clin North Am 2004. 42(1):169-184. Steinbach LS. Calcium Pyrophosphate Dihydrate and calcium hydroxyapatite crystal deposition diseases: Imaging perspectives. Radiol Clin North Am 2004. 42(1):185-206. Tehranzadeh J. Advanced imaging of early rheumatoid arthritis. Radiol Clin North Am 2004. 42(1):89-108.

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