Describing radiological findings of rheumatic disease in conventional radiography

1. Conventional Radiography
in
Rheumatic Diseases
Dr. Mazen Al Zo’ubi

2. Content Layout
• Radiographic features of rheumatoid
arthritis
• Radiographic features of psoriatic
arthritis
• Radiographic features of crystalline
arthropathies
• Other syndromes commonly seen in
rheumatology.

3. Radiographic features of RA/ Early manifestations
• Periarticular soft tissue swelling
• Periarticular osteopenia
• Marginal erosions – begin at “bare areas” – intercapsular articular margins,
usually at the ulnar styloid, MCP 2 and 3, and the fifth MTP before other
areas are affected

4. Radiographic
features of RA/
Late
manifestations
• Diffuse osteopenia
• Joint space narrowing
• Erosions at both proximal and distal
phalanges
• Ulnar deviation
• Joint subluxation and dislocation with
characteristic deformities
• Ankylosis (of joints – most often
carpals and tarsals
• Secondary osteoarthritic changes

5. Early rheumatoid arthritis
• Primarily periarticular osteopenia;
diffuse joint space narrowing; early
marginal erosive changes most
evident at right second and third and
left fourth and fifth MCP and carpal
bones

6. Advanced rheumatoid arthritis
• Diffuse osteopenia; marked joint space
narrowing; erosive changes at PIPs, MCPs,
radiocarpal, and intercarpal joints at both
proximal and distal phalanges.

7. Rheumatoid arthritis with chronic deformities
• Diffuse osteopenia; subluxation and ulnar
dislocation of the second through fifth MCP
joints as sequelae of erosive disease.
Windswept deformity – symmetric
ulnar subluxations and dislocations
of the MCP and PIP joints

8. Bilateral Protrusio Acetabuli deformity
• Rheumatoid arthritis
• Ankylosing spondylitis
• Paget’s disease
• Marfan’s syndrome
• Osteomalacia
• Metastatic disease

9. Rheumatoid arthritis
affecting the hips
Continued marked diffuse osteopenia;
concentric decrease in hip joint space and
symmetric cartilage loss; axial migration of
the femoral head with resultant acetabular
remodeling resulting in protrusio acetabuli
deformity; femoral head shows small
erosions

10. Cervical spine involvement in rheumatoid arthritis
• Facet erosions
• Cranial settling
• C1–C2 subluxation

11. Cranial Settling
• The rheumatoid pannus induces bony
erosion and destruction of the C1/C2
facets and the stabilizing articulations.
• As a result, the skull “settles” on to the
spinal column and the odontoid
migrates superiorly into the foramen
magnum, leading to compression of the
spinal cord and brainstem between the
odontoid and the skull.
• An atlantoaxial distance greater than 4-
5 mm, as demonstrated by lateral
radiographs, is indicative of AAI.
• Another marker of instability in the
anteroposterior (AP) plane is
displacement of 3.5 mm in flexion-
extension films.

12. Cranial Settling

13. Radiographic features of psoriatic arthritis
There are five patterns of psoriatic arthritis:
• “Classic” form primarily involving the distal joints of hands and feet
• Symmetric arthritis that mimics RA (but is RF negative)
• Asymmetric arthritis with sausage digits
• Spondylitis with peripheral arthritis
• Arthritis mutilans – a severe, deforming, and destructive arthritis.

14. Psoriatic arthritis in the hands
Asymmetric joint involvement; erosive changes
in left MCP 2, 3, 4; erosive and proliferative
changes in right PIP 3; milder DIP involvement
evident in left DIP 2 and right DIP 2 and 3; mild
soft tissue swelling of entire left second digit
consistent with dactylitis.

15. Enthesophytes at sites of enthesopathy
Plantar calcaneal enthesophyte

16. Psoriatic arthritis in the foot
Complete erosion of the articular surface at MTP 3;
great toe with early pencil in cup deformity at the IP
joint: destruction and resorption of the middle phalanx
with bony proliferation at the distal phalangeal base;
generalized soft tissue swelling consistent with
dactylitis.

17. Telescoping digits
Marked bone erosion and resorption has
obliterated the articular surfaces, resulting in
complete loss of left PIPs 2–5 and right PIPs 2,
4, 5; clinically this manifests as telescoping
digits and arthritis mutilans from psoriatic
arthritis.

18. RA vs PSA
PSA RA
Symmetric joint
involvement
No Yes
Juxta-articular
osteopenia
No Yes
DIP involvement Yes No
Wrist involvement Rare Common
Dactylitis Yes No
Periostitis Yes No
Enthesophytes Yes No
Subchondral cysts Rare Common

19. Radiographic features of ankylosing spondylitis
• Mixed erosive and productive arthritis
• Involves primarily the axial skeleton and may involve the large proximal
joints
• Sacroiliac joint involvement is a hallmark of the disease, more prominently
on the inferior, iliac side of the joint (the synovial portion) in early disease
but later involving the entire joint
• Sacroiliitis in AS is typically bilateral and symmetric. Unilateral or
asymmetric sacroiliitis is more consistent with RA, psoriatic arthritis, or
reactive arthritis.

20. Radiographic features of ankylosing spondylitis
• The superior pole of the sacroiliac joint is made primarily of ligaments that
can form bridging enthesophytes
• Bridging enthesophytes can also be seen in:
• DISH
• Chronic reactive arthritis
• Psoriatic arthritis
• Vitamin D toxicity

21. Early vertebral involvement
Lateral film shows squaring of the
vertebral bodies; later finding of
irregular new bone formation is
evident at the corners of some more
inferior vertebral bodies. Two
vertical syndesmophytes are also
evident.

22. Advanced ankylosing
spondylitis
Sacroilitis and bamboo spine. Complete SI joint fusion and
advanced AS; fusion of the lumbar vertebral bodies;
vertical syndesmophytes are continuous throughout the
lumbar spine, giving the characteristic bamboo spine
appearance; fusion of the intraspinous ligament is also
evident, known as the “dagger sign”.

23. Cervical spine manifestations of
AS
C1 vertebral body erosion causing cranial settling and loss
of axial supporting structures; the superior portion of C2
(dens) migrates upward to breach the foramen magnum,
resulting in basilar invagination (BI) and placing the
patient at risk for lower brainstem compression or
atlantoaxial subluxation (AAS) and cord compression;
fusion of the posterior laminae and mild squaring of the
vertebral bodies are also evident.

24. Radiographic
findings in
crystalline
arthropathies/
Gout
• Feet are most involved; primarily the first
MTP, but also other MTPs, IP joints, and
tarsal bones
• Erosions in gout are typically well defined,
with sclerotic margins leading to a “punched
out” appearance on plain films
• Overhanging edges are also evident from
new bone formation

25. Erosive gout
Erosion at the fifth metacarpal head
with overhanging edges; overlying
soft tissue swelling; relative
preservation of the joint space; soft
tissue calcification of the tophus;
bone density is maintained

26. Longstanding gout in the foot
Destruction of the first MTP and proximal aspect of the proximal phalanx of
the great toe is seen; cloud-like calcification and tophi around the first MTP
and posterior aspect of the calcaneus are evident; punched out erosions of
the dorsal aspect of the talar and navicular bones and a large bony erosion at
the posterior aspect of the calcaneus are evident.

27. Advanced tophaceous gout
Advanced tophaceous arthritis
with near total osteolysis of
most of the right carpal bones
and heavy tophus burden,
especially over PIPs.

28. Radiographic findings in crystalline arthropathies/
Calcium pyrophosphate disease
• Typical finding is chondrocalcinosis, or calcium deposition in cartilage, synovium,
or joint capsule
• Typical sites of involvement include the menisci of the knees, triangular
fibrocartilage (TFC) of the wrist, proximal joints of the hand, pubic symphysis,
acetabular labrum, and annular ligament of the spine
• Can be seen in association with hemochromatosis; the presence of hook
osteophytes and osteoarthritis of MCPs 2 and 3 with chondrocalcinosis

29. Bilateral knee
CPPD
Chondrocalcinosis seen as a linear density within menisci
of knees bilaterally; note bilateral bony erosions of the
lateral femoral condyles that may mimic gout, but
represent CPPD in this bilateral, symmetric distribution
and clinical setting.

30. Chondrocalcinosis
in the wrist
TFC chondrocalcinosis; large
subchondral cystic changes in the
ulnar styloid.

31. Advanced CPPD of the hand
Multiple cystic lucencies throughout the carpal
bones, distal radius, and distal ulna bilaterally;
complete loss of the normal radiocarpal joint
space. Loss of joint space at the right second
and third MCP joints with large hook-like
osteophytes and subchondral cyst formation
which can suggest hemochromatosis

32. Radiographic
features of diffuse
idiopathic skeletal
hyperostosis (DISH)
• Typically involves the thoracic spine
most commonly, followed by cervical
and lumbar spine involvement
• Ossification of the anterior longitudinal
ligament results in thick, bulky, flowing
syndesmophytes that can be confused
with those seen in ankylosing
spondylitis
• Sacroiliac joint involvement may be
seen, in which the superior
(ligamentous) pole of the sacroiliac joint
exhibits ossification and fusion, while
the inferior (synovial) pole is typically
normal

33. Early DISH in the lower
thoracic spine
Early development of ossification of the anterior
longitudinal ligament along the anterolateral
aspect of the spine over four levels. Unlike in AS,
ossification in DISH is not continuous and is not
associated with loss of disc height or squaring of
the vertebral bodies

34. DISH in the lumbar spine
• Dense, bulky ossification of the anterior longitudinal
ligament over four contiguous segments. Note continued
preserved disc height and lack of squaring of vertebral
bodies

35. DISH in the cervical spine
Ossification of both the anterior and posterior
longitudinal ligaments, which can be seen in up
to 50% of patients with DISH. Bulky ossification
may cause significant esophageal impingement
during swallowing, if anterior, or cervical spinal
cord compression, if posterior.

36. Differentiating
ankylosing
spondylitis and
DISH
AS DISH
SI joint
involvement
Primarily
inferior
(synovial)
portion
Primarily
superior
(ligamentous
) portion
Continuous
spine
involvement
without skip
areas
Yes No
ALL
ossification
Thin,
delicate
Thick, bulky
Shiny
corner sign
Yes No
Squaring of
vertebral
bodies
Yes No

37. Radiographic
features of
sarcoidosis
• About 10% of patients with sarcoidosis
exhibit bone or joint involvement
• Bone or joint involvement with
sarcoidosis in the absence of chest x-ray
findings consistent with sarcoidosis is
exceedingly rare
• Typical joint and bone involvement
shows “lacy,” reticular lytic lesions in the
middle or distal phalanges of the fingers
• These areas represent areas of
granulomatous infiltration of the
medullary cavity of the bone
• Sclerosis of articular surfaces may also
occur
• Pathologic fractures at sites of lesions are
common

38. Sarcoidosis in the hand.
Typical lacy lytic lesions in the middle and
distal phalanges, most notably in the second,
third, and fifth digits. Accompanying soft
tissue swelling can mimic dactylitis and in
these cases spondyloarthropathy must also
be on the differential diagnosis list. There is
a pathologic fracture of the third digit due to
granulomatous infiltration.

39. Radiographic
features of septic
arthropathy
• Initial radiographs of septic arthritis
may only show effusion and soft tissue
swelling, with hazy articular surfaces
• More chronic infections will show
joint space narrowing, periarticular
osteoporosis, and adjacent bone,
cartilage, and soft tissue destruction
with sclerotic margins
• Depending on the organism, gas or
fluid collections may be present
• Septic arthropathy may be
distinguished from gout by the level of
surrounding soft tissue destruction and
tendency for the arthritis to spread
extensively across joint spaces

40. Septic arthropathy of the
great toe.
Note the extensive inflammation on both
sides of the involved joint spaces

41. Radiographic
features of
Neuropathic
arthropathy (Charcot
joint)
• Diabetes: associated with Lisfranc
injury, in which the tarsal bones are
displaced from the tarsus (midfoot) due
to repetitive subclinical trauma
• Syringomyelia: associated with
neuropathic shoulder primarily
• Spinal cord injury: typical joint
involved depends on the level of spinal
cord injury
• Chronic alcoholism: typically involves
the foot and/or the knee
• Syphilis: typically involves the knee

42. Charcot of the foot
Classic midfoot bony and ligamentous destruction
consistent with Lisfranc deformity, a specific form of
neuropathic arthropathy. Lisfranc deformity involves
ligamentous destruction of the midfoot leading to
lateral displacement of digits 2–5; clinically this
manifests as lateral deviation of digits 2–5 away from
the great toe. Note normal bone density and bony
debris in the midfoot.

43. Radiographic features of Paget’s disease of the bone
• Three phases of disease:
1. Osteolytic phase: osteoclastic bone resorption
2. Mixed lytic and blastic phase: osteoblasts are activated to counteract
osteoclast activities
3. Sclerotic phase

44. Radiogra
phic
features
of Paget’s
disease of
the bone
• Most common areas of involvement include
the pelvis, followed by hips and tibia,
lumbar spine and sacrum, skull, and
shoulder
• Disorganized bone resorption causes typical
radiographic findings of cortical and
trabecular bone thickening and bone
expansion
• Later lytic and blastic activity causes a
classic “cotton wool” appearance to the
cranial skull

45. Paget’s disease in the left hip
Bone expansion and cortical bone thickening along the
femur. Brim sign is evident (thickening of the
iliopectineal line from body of pubic symphysis
towards acetabulum), which is pathognomonic for
Paget’s disease. There is mosaic appearance of femoral
head and adjacent ilium, due to thickened trabecular
pattern and bony cortices.

46. Radiographic features of avascular necrosis (AVN)
• Initial signs of AVN include sclerosis of the femoral head; however it may take
months for this to be evident on plain film
• Over time, a “crescent sign” develops – essentially a linear subchondral fracture
at the area of sclerosis
• Late findings include collapse of the femoral head with secondary osteoarthritis

47. Crescent sign in hip
AVN without
collapse.

48. AVN of the hip with
collapse of the femoral
head and secondary
osteoarthritis.

49. Radiographic
features of
osteoarthritis
• Cartilage damage results in inadequate
cushioning of adjacent subchondral bone
and joint space narrowing, resulting in
adaptive changes such as osteophyte
formation, fibrosis, and sclerosis, as well
as joint malalignment and subchondral
cyst formation
• Bone density is normal
• Joint space loss is non-uniform and
asymmetric
• Erosive osteoarthritis is a subset of
osteoarthritis, most commonly seen in the
DIPs and PIPs of the hands in
postmenopausal women
• In erosive osteoarthritis, centrally located
erosions develop, with more marginal
osteophytes, creating a characteristic
“gull wing” across the articular surface

50. Osteoarthritis of the knee
• Osteophytes, medial compartment
narrowing, and increased height of the tibial
spines, consistent with osteoarthritis.
• Subchondral sclerosis is also evident at the
distal femur and proximal tibia, otherwise
there is normal bone density

51. Osteoarthritis of the
hands
Symmetric joint involvement is evident
with osteoarthritic changes notable in DIP,
PIP, and first CMC joints of both hands.
Proliferative osteophyte changes at the
first CMC joints are classic for
osteoarthritis and correlate clinically with
“squaring” of the first CMC on physical
exam. Subchondral cysts and sclerotic
articular margins are evident in the IP
joints of both hands, most notably the left
second and third PIPs, the right second
and fourth PIPs, and the right third DIP.
The sclerotic margin in the right second
PIP demonstrates the classic “gull wing”
deformity consistent with erosive
osteoarthritis. Note that the bone density
throughout the hands is relatively normal.