Generalised This may be due to steroids or limitation of movement due to pain, or muscle wasting, and occurs later in the course of the disease.
As in rotator cuff tears allow upward subluxation of the eroded humeral head. Gross rheumatoid arthritis with ulnar deviation, subluxation and joint narrowing at the metacarpophalangeal joints. Boutonniere deformities are present at the index and little fingers
Progressiv ejoint space narrowing
Erosiins typically appear lateral side of 5th metatarsal but the medial side of others. Fig very pronounced destructive changes in tarsus and in metatarsal heads
Pannus is an abnormal layer of fibrovascular tissue or granulation tissue. Geodes in rheumatoid arthritis. There is joint space narrowi ng. Osteoporosis is demonstrated. An effusion is present. There are large distal femoral geodes which reach the patellofemoral articulation.
Caplan syndrome (also known as rheumatoid pneumoconiosis) is the combination of seropositive rheumatoid arthritis and a characteristic pattern of fibrosis. 5 - 50 mm well-defined nodules in the upper lung lobes / lung periphery. nodules may remain unchanged, multiply, calcify, or become thick walled cavities. background changes of pneumoconiosis may have an accompanying pleural effusion features often grow in short bursts
Fig 3 shows extensive pulmonary fibrosis with honey combing (rare more commonly assosciated with Progressive massive pulmonary fibrosis)
Mediastinal window image showing cavitatory lesions in bilateral upper lobes (arrows) with large fibrotic area in right upper lobe (arrow head) and few subpleural fibrotic lesions
MALAR RASH ALSO SEEN IN Pellagra, dermatomyositis, and Bloom Syndrome. This is due to the presence of two X chromosomes in the female as opposed to the one X chromosome present in males. The X chromosome carries immunological related genes, which can mutate and contribute to the onset of SLE. The Y chromosome has no identified mutations associated with autoimmune disease
the oblique radiograph of her left hand shows dislocation at the first carpometacarpal joint (arrow) and subluxations in the metacarpophalangeal joints of the index and middle fingers associated with swan-neck deformities
because the malalignments are flexible and are corrected by the pressure of the hand against the radiographic cassette
A 62-year-old woman presented with a 15-year history of systemic lupus erythematosus. Dorsovolar view of both hands shows severe deformities, subluxations, and articular erosions. Note the advanced (generalized ) osteoporosis secondary to disuse of the extremities and treatment with corticosteroids.
. Multiple soft tissue calcifications follow muscles planes of thigh There is significant osteoporosis.
Coronal T1-weighted image of the thighs showing fatty infiltration of the muscles caused by chronic myopathy
dilatation of distal 2/3 of the oesophagus 1 apparent shortening of length due to fibrosis Small bowel: uminal dilatation (can be massive) reduced peristalsis / delayed contrast transit. hidebound bowel sign (crowding of valvulae conniventes): thought to be pathognomonic of scleroderma sacculation (antimesenteric border, focal dilatations, pseudo-diverticula)
Septic arthritis of proximal interphalangeal joint of the fifth finger. Lupus patient with pain and focal increase in volume (A). Coronal and sagittal MRI T2-weighted images with fat suppression (B,C) demonstrating medullary edema in bone borders (black arrow on B) and strain caused by articular capsule fluid in the fifth finger proximal interphalangeal joint (white arrow on C). On the sagittal image, erosion of the corresponding proximal phalanx is also well characterized. Coronal, contrast-enhanced MRI T1-weighted image (D) demonstrating contrast enhancement surrounding the bone, synovia and soft tissues of this area.
Seropositive arthritis Rheumatoid and others
• RA FACTOR
• Anti-CCP antibodies
Rheumatology: Rheumatoid Arthritis; SLE; Sjogren’s; MCTD; Myositis;
Others: SABE; syphilis; Sarcoidosis; cirrhosis; Walden storm's macroglobulinemia;
RA factor is seen in 5-10% of normal population as well
Chronic systemic inflammatory disease
Affects many organs
Predominantly attacks the synovial tissues and joints.
M:F = 1:3
Clinincally Low-grade fever, fatigue, weight loss, muscle soreness, and
Symmetric peripheral joint pain and swelling, particularly of the hands
Typically involves small joints : metatarsophalangeal and
metacarpo-phalangeal and carpal joints (very often SYMMETRICAL
Axial skeleton involvement n advanced stages
CLINICAL DIAGNOSTIC CRITERIA
American College of Rheumatology revised criteria require that 4 out of 7 of the
following are present 4:
1. morning stiffness lasting at least 1 hour before maximal improvement
2. soft tissue swelling of 3 or more joints observed by a physician
3. swelling of the proximal interphalangeal, metacarpophalangeal, or wrist
4. symmetric swelling
5. rheumatoid nodules
6. the presence of rheumatoid factor; and
7. radiographic erosions and/or periarticular osteopenia in hand and/or
SOFT TISSUE CHANGES
More clinical exam than radiological finding
Swelling due to
1. oedema of peri- articular tissues
2. synovial inflammation in bursae, joint spaces and along tendon
3. Joint distension increased synovial fluid.
Hands: most commonly seen fusiform swelling
ulnar styloid (invl of ext carpi ulnaris tendon)
radial styloid (invl of radiocarpal synocial hypertrophy)
Similar fusiform swelling can be found in the 1st and
5th metatarsal heads
At the Achilles tendon insertion
When synovitis thickens the bursa ,
oedema obliterates the local fat and
blurs out margins of the tendon
Note : the swelling is symmetric but if a
rheumatoid nodule Is present at the
swelling it may appear eccentric
(as in olecranon)
Assessment of osteoporosis depends in part on film quality, and
comparison between normal and abnormal joints in the same
Interpretation is subjective and changes arc seen only after loss of
25-50% of mineral density
1. Late/Generalised ( steroid and limitation of movement)
2. Early/ Localized (synovial inflammation and hyperaemia)
In menopausal women , generalized osteoporosis masks the
osteoporotic changes due to RA
Generalised or solitary sclerosis one or more distal phalanges is an
Terminal phalangeal sclerosis
New bone with no ,medullary cavity .
JOINT SPACE CHANGES
EARLY WIDENING due to synovial hypertrophy and Effusion
LATER NARROWING of joint space due to cartilage destruction
Allignment abnormalities at joint due to weakening of capsule
Leads to tendon rupture or improper muscle action
The boutonniere deformity results from proximal interphalangeal
joint flexion and distal intcrphalangeal joint extension
swan-neck deformity proximal interphalangeal joint extension
and distal interphalangeal joint flexion.
The boutonniere deformity is the more common.
Z-deformity radial deviation at the wrist;
ulnar deviation of the digits, and often palmar subluxation of the
Synovitis of the metacarpophalangeal joint.
Longitudinal high-resolution (10.5-MHz) sonogram shows thickened
synovial tissue (arrows).
Coronal contrast- enhanced fat-
saturated T1-weighted MR image shows
hyperenhancement of small joints in
the hand (arrows), a finding that
reflects hyperemic synovial tissue.
Erosions (arrowheads) and thickened,
intensely enhancing synovium are seen
at the fifth metacarpophalangeal joint
Most important diagnostic feature
Incidence rises with duration progresses (<40% at
3months to 90-95% at 10years )
Peri-articular erosion starts in the bare area
1. Carpal erosions occur extensively.
2. Ulnar and radial styloid
3. Proximal compartment of distal radioulnar joint.
4. Fusion is inevitable especially in CARPAL joints
1. Earlier seen in feet most often 5th metacarpo-
2. Apart from posterior and inferior surfaces of
3. CALCANEUM tarsal erosion are uncommon
4. (Tarsal erosion is seen commonly in sero-negative)
Local Demeneralisation progressive resorption
of Sub-cortical Bone Pannus sread
Destruction of articular cartilage
Once destroyed the articular cartilage rarely
reforns on helaing
Erosive changes are less common in larger joints
but bone destruction Is more
intraosseous defects-cysts (Geodes) are seen 3 –
4 cm or more in diameter.
A. Diagram. Three sites for potential erosions to occur are shown.
B. Erosions. Note the erosion from the extensor carpi ulnaris (rat bite
lesion) (arrow) and prestyloid recess (arrowhead). Note the adjacent
erosion on the triquetral bone (crossed arrow).
C. Erosions. Note the three sites of ulnar erosion: extensor carpi
ulnaris (arrow), prestyloid recess (arrowhead), and radioulnar
articulation (crossed arrow). Observe the adjacent soft tissue swelling
RHEUMATOID ARTHRITIS: FEET
A. Diagram, Marginal Erosions. Target sites for marginal erosions lie
on the medial surfaces of the metatarsal heads, except for the fifth
metatarsal where early erosions can occur on the lateral side.
B. PA Foot. Typical radiographic depiction of the locational
predominance on the medial metatarsal surfaces, except at the fifth.
Note the phalangeal fibular deviation. (Lanois deformity)
Coronal contrast-enhanced fat-
saturated T1-weighted MR image
shows synovitis of the second and
third metacarpophalangeal joints. A
subcortical cyst (arrowhead) is seen
near the bare area
This type of lesion is called a pre-
erosion or subcortical erosion
MR image shows a small effusion of
the third metacarpophalangeal
Local periosteal reactions occur either along the
midshaft of a phalanx or metacarpal as a reaction to
local tendinitis, at the metaphysis near a joint
affected by synovitis.
Such changes are less common in rheumatoid arthritis
than in the seronegative arthropathies
SECONDARY OA CHANGES
Seen in Weight bearing joints
Its seen at Hip joints commonly.
Superimposes the undetected RA
ASYMMETRY IS KEY IN DIAGNOSIS
Reactive sclerosis and new bone formation in
osteoarthritis is not marked
INVOLVEMENT OF AXIAL SKELETON
C1 /C2 JOINT
Osteoporosis with disc narrowing
Little new bone formation
Erosions of facet joints result in Subluxation
Commonly seen in the synovial joint between the odontoid
peg and arch of atlas
potentiated by laxity of ligaments around the peg.
Separation in flexion of more than 2.5 mm in adults or 5
mm in children is held to be abnormal.
30% of patients with chronic rheumatoid arthritis and is
best seen in flexion.
The eroded odontoid may also fracture
Resorption of hone at non-articular surfaces occurs in the
cervical spine at the spinous processes, which become
short, sharp and tapered in patients with chronic disease
the translocation of
odontoid into and beyond
the foramen magnum
(arrows) owing to erosion
and destruction of the upper
two cervical vertebrae
Sacro iliac Joint
Changes are less common and less severe
than Spinal changes
More common in seronegative disease but
may he seen in up to 30% of those with
Seen more in women
Usually unilateral and involving the lower
two thirds of the joint; erosions present
but no sclerosis; rarely, ankylosis.
Shoulder joint changes
Uniform loss of glenohumeral
joint space, marginal
erosions (particularly at the
superior lateral portion of
the humerus), humerus often
tapered distal clavicle,
Hip joint changes
RHEUMATOID ARTHRITIS: PROTRUSIO
A. AP Hip Unilateral. Observe the
symmetric loss of joint space and
axial migration of the femoral head,
creating a protrusio acetabuli
B. AP Pelvis Bilateral. Note the
uniform loss of joint space, small
femoral heads, and protrusio
acetabuli, characteristic of long-
standing rheumatoid arthritis.
Note: The most common cause for
bilateral protrusio acetabuli in the
adult is rheumatoid arthritis
Knee joint changes
A. Uniform Loss of Joint Space. Despite the loss of joint space, the distinct
absence of subchondral sclerosis and diffuse osteopenia.
B. Suprapatellar Effusion. Observe the bulging soft tissue density owing to
effusion (arrows). A patellar erosion can also be appreciated.
C. Baker’s Cyst. Note that on arthrography the extent of the cyst is defined
extending into the popliteal space (arrows). Observe the rupture and dissection of
the rheumatoid cyst into the posterior calf.
Whole-body radioisotope scan showing areas of
increase in uptake in the neck, both shoulder
joints, the elbow joints, the left hip, both
knees and ankles
The distribution of disease is shown, but the
changes on this scan are not specific.
1. accelerated coronary artery and cerebrovascular atherosclerosis which
contribute significantly to the excess mortality of RA
3. vasculitis : occurs more commonly with severe erosive disease, rheumatoid
nodules, high RF titres.
• rheumatoid nodules are usually seen in pressure areas : elbows, occiput,
lumbosacral3. They generally occur in RF positive patients 9.
1. keratoconjunctivitis sicca
Respiratory system: parenchymal or pleural diseases ;
manifests as pleural thickening or Effusion, ground glass opacities
Bronchiolitis , bronchienctasis (advanced stages), nodules – cavitation is seen
Caplan syndrome (also known as rheumatoid
pneumoconiosis) is the combination of seropositive
rheumatoid arthritis and a characteristic pattern
5 - 50 mm well-defined nodules in the upper lung
lobes / lung periphery.
nodules may remain unchanged, multiply, calcify,
or become thick walled cavities.
background changes of pneumoconiosis
may have an accompanying pleural effusion
chronic, inflammatory, connective tissue
disorder of unknown cause
Common in young females
Classical Butterfly Rash over face.
SLE, like many autoimmune diseases, affects
females more frequently than males, at a rate
of almost 9 to 1.
RA factor , ANA
Unlike rheumatoid arthritis, lupus arthritis is
less disabling <10% lupus arthritis will develop
deformities of the hands and feet
present with a symmetrical peripheral
Soft tissues swelling with calcification around
joints and in blood vessels
Erosion is minimal and usually does not cause
severe destruction of the joints.
Most deformities as in swan neck , ulnar
deviation are reversible and arise due to tendon
or ligament laxity
Avascular necrosis is common
In lateral radiograph
1. Mal-alignments, most commonly at the
metacarpo-phalangeal and proximal
inter-phalangeal joints of the fingers and the
1. metacarpophalangeal and the interphalangeal
joints of the thumb
Note : in an AP view most of the time these will be
less apparent ….?
Calcinosis Interstitialis Universalis
Degeneration of collagen tissue
diffuse subcutaneous plaques or nodules of calcium or
reticular calcification often with overlying ulceration.
In addition with progression, calcified masses or sheets
of calcium and phosphate metabolism.
Seen in quadriceps, deltoid , calf muscles , elbows, kness,
hands, abdominal wall, chest wall
Pointing and resorption of terminal tufts
Bone erosions are not a feature of these diseases.
Progressive disease is invariably fatal
High incidence of malignancy is seen
Polymyositis (PM) refers a rare autoimmune (at
times considered paraneoplastic) inflammatory
myositis. It is considered a form of idiopathic
The condition is closely related to
dermatomyositis and the term “polymyositis” is
applied when the condition spares the skin.
Progressive systemic sclerosis
CREST SYNDROME (
Raynauds phenomenon : episodes of intermittent pallor of the fingers and toes
on exposure to cold, secondary to vasoconstriction of the small blood vessels)
Esophageal abnormalities: dilatation and hypoperistalsis
30% to 40% of patients have a positive serologic test for rheumatoid factor
and a positive antinuclear antibody (ANA) test.
Progressive systemic sclerosis
1. acro-osteolysis (resorption of the distal phalanges)
2. periarticular osteoporosis
3. joint space narrowing
Soft tissue changes
1. subcutaneous and periarticular calcification
2. atrophy especially at tips of fingers
3. With retraction of skin
4. flexion contractures
Other less common documented musculoskeletal
1. rib resorption, mandibular angle resorption, radius and
2. terminal phalangeal sclerosis
Corroborative findings are seen in the
gastrointestinal tract, where dilatation of
the esophagus and small bowel
Pseudo diverticula of colon is also seen
Either UIP or NSIP pattern
Most predominant feature will be fibrosis
early stages may show ground glass
later stages may show honeycombing and
evidence of lung volume loss
lung bases and sub-pleural regions
typically involved 4
cysts may be present measuring 1-5cm in
pleural effusions are usually not a
ESOPHAGEAL DILATATION IS
MIXED CONNECTIVE TISSUE DISEASE
Overlap syndrome ( mix of Rheumatoid arthritis,
dermatomyositis, SLE, Progressive systemic sclerosis)
The distribution may mimic rheumatoid arthritis, but
distal interphalangeal joints may be affected and the
peripheral arthropathy may be asymmetrical.
Osteoporosis (JUXTA ARTICULAR)
Soft tissue swelling and Joint space narrowing.
Erosive changes are not frequent as in RA
Distal phalanges show soft tissue loss, distal tuft bone
resorption and calcification is feature of Progressive
Chronic Autoimmune disease
Primarily affect Salivary and lacrimal glands resulting in XEROSTOMIA and
Secondary Sjogren’s seen most commonly in people with diagnosed with RA
As a single entity sjogren’s doesn’t involve the joints.
But definitely aggravates the primary Rheumatologic Arthropathy therby
increasing the Morbidity and Mortality
This condition is characterized by subluxation of
metacarpophalangeal joints, “swan-neck” and Boutonniere
deformities, besides “Z” deformity of thumb
CAN also occur in shoulder, knee and joints of feet.
Hidebound bowel sign
The hidebound bowel sign refers to an appearance on a barium study of the
small bowel in patients with scleroderma. The sign describes the narrow
separation between the valvulae conniventes which are of normal thickness
despite dilatation of the bowel lumen.
Although the term hidebound is used specifically to describe scleroderma, the
same appearance can be present in sprue. Stack of coins is an alternate
descriptive term that can be used for both conditions.
case of persistent monoarticular
Because of the chronic use of corticoids in such patients, the signs and
symptoms of infection are frequently masked and the process generally
presents a chronic and indolent course.
In, the absence of a clinical response to the therapy with corticoids or other
immunosuppressive drugs should raise the suspicion of an underlying