adiology of hand in systemic diseases ppt

1. RADIOLOGY OF HAND-
MIRROR OF VARIOUS
SYSTEMIC DISEASES
Dr DINESH
RADIOLOGY RESIDENT
GMC SRIKAKULAM

2.  Several systemic diseases manifest on the
radiographs of hand.
 Conventional radiographs of hand are
excellent source of information in most of the
systemic diseases
 The diagnosis can be clinched on a single
hand radiograph if characteristic findings are
present.

3. Common indications
 Evaluation of the bone age and
 Trauma
 Systemic hematologic and
 Metabolic conditions.
 Radiologists interpreting the hand radiograph
can make the diagnosis or direct appropriate
investigations for diagnosis.

4. Anatomy

5. FEATURES USED FOR
DIAGNOSIS
 EROSIONS
 BONE PRODUCTION
 DISTRIBUTION
 SOFT TISSUE SWELLING
 PATTERN

6. Congenital/Developmental
 Osteopetrosis
 rare hereditary and familial bone abnormality
characterized by defective osteoclast function.
 Bone remodelling is impaired -thick but
structurally weak and brittle.
 generalized increase in bone density with
obliteration of normal trabecular pattern
 Marrow is encroached upon and extra-
medullary hematopoiesis occurs.

9. Pyknodysostosis
 a rare autosomal recessive disorder
 increased bone density with preservation of
medullary canal –no anemia
 dwarfism and skeletal fragility.

10. i
Hand radiograph shows dense sclerotic
bones with acro-osteolysis.

11. Radiograph shows generalized increase
in bone density with
preservation of medullary canals and
acro-osteolysis

13. Marfan’s Syndrome
 an autosomal dominant entity , affect the body’s
connective tissue.
three systems: skeletal, ocular and cardiovascular.(aortic
aneurysm)
 The elongation of tubular bones ,most marked in distal
portion of the extremities-the phalanges, metacarpals
and metatarsals without an increase in width
 long, slender and gracile-arachnodactyly or spider-like
fingers.
 Radiographically, the metacarpal index is abnormal(8.8 for
males or 8.4 for females)
 the skull reveals dolichocephaly. individuals are taller

14. Arachnodactyly in a 16-year-old
girl. Radiograph shows a
metacarpal index of approximately
9.5.
The tubular bones of the hands
(Metacarpals and phalanges) are long,
slender and gracile – Arachnodactyly or
spider-like fingers

15. METAPHYSEAL DYSPLASIAS
 ACHONDROPLASIA
Rhizomelic dwarfism with normal trunk, large head, and
midface hypoplasia
Mc nonlethal skeletal dysplasia
○ Findings are evident at birth
PATHOLOGY
 Form of chondrodysplasia – Failure of conversion of
cartilage to bone

16. Hands
Trident hand with short, broad,
splayed and cone-shaped
phalanges and shortened
metacarpals

17. Hand radiograph shows approximation of second and
third digits and also the fourth and fifth digits forming the
trident hand appearance.
Tubular bones are short and show coned phalanges.

18. Pseudoachondroplasia
 autosomal dominant manner.
 It is a form of short-limb dwarfism.
 diagnosis is made 2-3 years of age.
 the trunk appears long with lumbar lordosis and
rhizomelic shortening of the limbs.
 Pseudoachondroplasia have normal head size
and facial features.
 Radiographic changes include shortening of
tubular bones, flaring of metaphyses, variable
epiphyseal maldevelopment and some degree of
vertebral end-plate malformation

19.  four yr old boy
 Short metacarpals with metaphyseal cupping
 short and stubby phalangeal bones
 delayed ossification of the small and irregular carpal bones

20. Chondrodysplasia punctata,
brachytelephalangic
subtype (CDP-BT)
 rare congenital disorders caused by peroxisomal
dysfunction.
 -erratic cartilage calcification within apophyses and
epiphyses,
 carpal and tarsal bones, vertebrae and cartilages of the
trachea and bronchi.
 types of chondrodysplasia punctata include autosomal-
dominant (non-rhizomelic, non-lethal)
 autosomal-recessive (rhizomelic, lethal type) and rare x-
linked dominant and recessive forms.

21.  short triangular-shaped distal phalanges suggestive of
brachytelephalangy.
 The fifth middle phalanx is small with clinodactyly.
 The metacarpals are relatively small.

22. Sickle cell disease
 autosomal-recessive hemoglobinopathy
 caused by formation of a defective hemoglobin
called hemoglobin S (Hb S).
 Pathology -Bone infarcts in the diaphyses of
small tubular bones in the hands and feet
 Age (from 6 months to 3 years) are called
sickle cell dactylitis or hand-foot syndrome
 caused by the presence of red marrow in
these regions

23. Hand radiograph shows
cortical thickening, and metaphyseal
cupping involving the proximal phalanx of
the third digit.
Findings are in keeping with prior
infarction

24. Thalassemia
 hereditary disorders caused by genetic
deficiency in the synthesis of beta-globin
chains of hemoglobin.
 Excess unpaired alpha-chains aggregate to
form precipitates that cause hemolysis.
 Erythroid hyperplasia causes medullary
expansion within the bones. Extramedullary
hematopoiesis

25. Hand radiograph shows expansion,
groundglass appearance,
lace-like thin trabeculae and
thin cortex involving
predominantly metacarpals, in keeping with
medullary expansion

26.  Inflammatory joint disease
This is characterized by bone erosions,
osteopenia, soft-tissue swelling and uniform,
symmetric joint space loss.
Inflammation of a single joint should raise
concern for infection.

27. Infective/Inflammatory
Disorders.
 Tubercular Dactylitis/Spina Ventosa
 Dactylytis is an inflammatory disorder of the
digit (hand or foot)
 seronegative arthropathies-psoriatic
arthropathy and ankylosing spondylitis,
 sickle cell disease
 infectious conditions -tuberculosis and leprosy.
 Tuberculous dactylytis -as a painless swelling
in the hand or foot.

28.  Plain radiograph-
 diaphyseal lytic lesion, either round and cystic
with a variable amount of sclerosis and minimal
periostitis
 Sickle cell dactylytis may present silently or with a
painful bone crisis,
 radiographs in young children similarly show
diaphyseal lytic lesions within the tubular bones of
the hands or feet. Periostitis is uncommon.

29. Radiograph of the little finger of the right
hand -a rounded lucency in the proximal
phalanx of a child. There is minimal
periostitis.

30. Gout
 crystal deposition arthropathy caused by the
deposition of monosodium urate crystals
(tophi)
 Presentation -the acute phase with soft tissue
swelling and joint effusion.
 chronic tophaceous phase (6-12 years after
the initial attack) with eccentric asymmetrical
nodular tophi within the synovium and
subchondral bone.

31. Plain radiograph
 Bony erosions may be intra-articular, peri-
articular or distinct from the joint with a
rounded or ‘punched out’ appearance.
 The erosion margins are typically thin and
sclerotic with a raised, overhanging, cortical
lip, giving a ‘rat bite’ appearance.
 This characteristic late finding is caused by
peri-articular tophaceous nodules and erosion.
 osteopaenia is seen until late in the disease.

32. Radiograph of the index and middle finger
of the right hand showing
periarticular soft tissue swellings (arrows
A) and
eccentric ‘punched out’ lytic bone erosions
with thin sclerotic margins and overhanging
edges (arrows B).
There is preservation of the
interphalangeal joint spaces and absence
of periarticular demineralisation (features
that respectively help to differentiate gout
from psoriatic or rheumatoid arthropathy

33. Radiograph of right hand showing
erosions and punced out lesions

35. Rheumatoid arthritis
 chronic systemic connective tissue disease
principally involving synovial joints
 hands and wrists are a focal target area.
 Typical features -symmetrical,
 deforming polyarthropathy, -proximal joints:
 the distal radio-ulnar joint (especially the ulnar
styloid),
 radio-carpal, mid-carpal and the
metacarpophalangeal joints.
 Most patients have radiological evidence of
erosions by three years .

36. Right hand radiograph -proximal
osteoarthropathy and
ulnar subluxation of the 5th
metacarpophalangeal joint.
Peri-articular osteoporosis, marginal bone
erosions and subluxations.

37. Progressive narrowing of a joint in
rheumatoid arthritis.
(A) Y ear 1. The
metacarpophalangeal joint
looks normal.
(B) Y ear 3. There is
narrowing of the
metacarpophalangeal joint of the
index finger with associated
local soft-tissue swelling. Erosive
change is demonstrated at the
metacarpal head.
(C) Y ear 4. Little change over the
year.
(D) Y ear 13. On
this late film the soft tissues
remain thickened. The joint space
is obliterated.
Erosive change is demonstrated,
especially at the metacarpal head

38. Obliteration of the medullary cavity of the
distal phalanges .
The new bone is very dense and well
defined. The change is especially marked
at little and ring fingers.

39. Left wrist radiograph –
concentric joint space narrowing and
fusion of the carpal bones of the left
wrist (late signs).
changes in the ulna styloid and distal
radioulnar joint (early signs).

41. Gross rheumatoid arthritis at the carpus
with ulnar deviation,
subluxation and joint narrowing at the
metacarpophalangeal joints.

43. Psoriatic arthritis
 common seronegative spondyloarthropathy which affects
20% of patients with psoriasis.
 characterised by -inflammatory arthritis, a predilection for the
distal joints of the hands and feet.
 Erosions tend to occur at the margins of the distal
interphalangeal -such that the terminal phalanx may sit at an
angle resembling a pencil resting in a cup.
 Bone proliferation is also a feature;
 periostitis -phalanges, bilateral and asymmetrical, associated
with soft tissue swelling giving rise to the typical ‘sausage
digit’ appearance.
 Occasionally acroosteolysis of the distal phalanx is also
seen. Bone mineral density is preserved.

44.  Right index finger radiograph shows
 distal interphalangeal joint erosion with
characteristic ‘pencil in cup’ deformity, (ill-
defined erosion with adjacent periosteal
new bone formation).

45. Left middle finger radiograph of the same
patient shows
distal interphalangeal joint erosion
new bone formation at the distal phalanx
(arrows).
Soft tissue swelling of the digit ‘sausage
digit’ is also noted.

46. Erosive osteoarthritis
 Key findings
Arthropathy with the age of onset and
distribution of osteoarthritis, with an
inflammatory and erosive component.
 Clinical
 Inflammatory form of osteoarthritis of the hand
 Affects the DIP and PIP joints and the first
carpometacarpal joint of the hand most
frequently, just like osteoarthritis.

47.  Radiological findings
 Articular: joint space narrowing
 Bone: sclerosis, productive bony changes with
osteophyte formation, ankylosis
 Cartilage: subchondral central erosions
 Distribution: see illustration. Same distribution as with
osteoarthritis, with a preference for the IP joints (DIP
more than PIP)
 Extra findings: occurs primarily in postmenopausal
women
 Soft tissue: rheumatoid arthritis-like proliferative intra
articular synovitis, soft tissue swelling around the joint

48. Erosive changes of PIP 2-5 and DIP 3-
5.
Typical gullwing deformity in DIP 3
(white arrow).

49. Ball catcher view of the hands in a patient
with erosive osteoarthritis.
There is bilateral extensive damage to the
IP joints.
.

50. Dermatomyositis
 autoimmune inflammatory myopathy, with
diffuse nonsuppurative inflammation of striated
muscle and skin.
 female m/c
 c/f -gradual onset muscle weakness, elevated
muscle enzymes and elevated myositis-
specific antibodies, (anti-Jo-1).
 swelling of the distal joints of the hands

51.  Radiographic features include
 cutaneous calcific deposits (40%), and
 rarely, acro-osteolysis (more common in
scleroderma).
 The calcific deposits are usually more ‘linear,
reticular and lacy’, and more widespread than
those seen in scleroderma (5).
 found in the soft tissues of extremities as well as
overlying large joints, chest and abdominal wall
(especially in younger patients).
 Unlike scleroderma, osteopaenia is not a feature.


52. Radiograph of the index finger of the right
hand showing confluent digital soft tissue
calcifications. No peri-articular erosions.

53. Endocrinal and nutritional/metabolic
disorders.
 Acromegaly
 adulthood, excessive growth hormone secretion
from a pituitary eosinophilic adenoma -growth of
intramembranous bone tissue and subcutaneous
hypertrophy.
 prominent in hands and feet (Acral parts) from
which the term acromegaly is derived.
 Heel pad thickness is greater than 20mm.
 A reliable indicator is the generalized increase in
joint space width owing to cartilage overgrowth.

54.  Radiographs may reveal osseous enlargement,
 presenting with ‘spade-like’ hands and
 widening of the terminal phalangeal tufts, giving
an ‘arrow-head’ appearance
 Other features in the hand may include prominent
muscle attachments and widened joint spaces
(due to cartilage hypertrophy).
 Generalised osteoporosis and cystic changes in
the carpal bones are also described.


55. Radiograph of the left hand showing
widening of the terminal phalangeal tufts
with a ‘arrow-head’ appearance.
The hand is enlarged and soft tissue
swelling is noted

56. Hyperparathyroidism
 uncontrolled production of parathyroid hormone which usually leads
to an increase in serum alkaline phosphatase and calcium and a
decrease in serum phosphate.
 Bone pain and tenderness may be the presenting features.
 Hand radiographs often show osteopaenia and bone
demineralisation.
 The most pathognomic finding however is subperiosteal bone
resorption. -radial aspect of the middle phalanges of the index and
middle fingers.
 Early findings are of proximal metaphyseal cortical irregularity.
 Chronic features include spiculated cortical scalloping (may involve
the entire digit),
 acro-osteolysis
 in rare cases, lytic lesions caused by accumulations of osteoclastic
giant cells known as ‘brown tumours.’

57. Radiograph of the index finger of the right
hand showing
subperiosteal bone resorption of the radial
aspect of the entire digit but particularly
affecting the middle phalanx.

58. Radiograph of the middle finger showing
more developed features of
hyperparathyroidism including acro-
osteolysis
coarse spiculated cortical reaction (B). This
involves the entire digit but is more marked
on the radial aspect.

59. Radiograph showing
subperiosteal
resorption of the radial margins
of the proximal
and middle phalanges of the
second and third digits.
Central, slightly expansile,
septated,
lytic lesion is seen in proximal
end of the fifth metacarpal
(Brown tumour)

60. Thyroid acropachy
 Acropachy (‘thickening of the extremities’)
occurs as one of the extra-thyroid
manifestations of auto-immune thyroid
disease.
 Graves’ disease, Hashimoto’s thyroiditis .
 seen in patients treated with radioiodine
ablation for hyperthyroidism-common in
smokers.

61.  Solid periosteal new bone formation usually
bilateral, relatively symmetric and painless,
and involves the diaphyseal tubular bones of
the hands and feet.

62. Radiograph of the right hand showing
thick ‘feathery’ periosteal reaction of the
index and middle fingers.
The mid-portions of the diaphyses are
typically affected.

63. Rickets- vitamin D deficiency
 decreased mineralization at the growth plate
resulting in growth retardation and delayed
skeletal maturation.
 Defective mineralization of trabecular bone is
called osteomalacia.
 Rickets can only be seen in children before
closure of growth plates, while osteomalacia
can occur at any age

64.  Radiological features -widening, cupping and
fraying of metaphyses, craniotabes
 bowing of long bones, genu valgum, scoliosis,
triradiatepelvis, rachitic rosary and periosteal
reaction. Knees, wristsmand ankles are
affected predominantly.

65.  Hand radiograph shows
widening, cupping, and
 fraying of distal metaphyses of
the ulna and radius.
 There is reduction in bone
density with prominence of
trabeculae and thinning of cortex.
 Findings are typical for rickets.
Follow-up radiograph 3 weeks after
initiation of
vitamin D therapy shows dense
metaphyseal band of provisional zone
of calcification (arrows), suggestive of
healing rickets

66. Miscellaneous
 Hypertrophic Osteoarthropathy
 triad of digital clubbing, symmetric arthritis and
periostitis -visceral disorder, usually intrathoracic
in location.
 MC males in 4th-6th decades.
 MC is hypertrophic pulmonary osteoarthropathy
(HPOA), a paraneoplastic syndrome secondary to
carcinoma of the lung
 Radiographs show bilateral, symmetric, linear
periostitis (most common in the tibia, fibula, radius
and ulna), joint effusions, digital clubbing visible
as a bulbous enlargement of the distal fingertips

67. Radiograph of the ring finger of the left
hand
widespread irregular periosteal proliferation
of the phalanges (arrows).
There is cortical thickening without
narrowing of the medulla.
.

68. Radiograph of the right thumb shows
smooth laminar periosteal
proliferation of the proximal
metacarpal (arrows).
Mc site of hand involvement is the
ulnar aspect, peri-metaphyseal region
of the proximal phalanx.

69. Scleroderma (or Progressive
Systemic Sclerosis
 multi-system connective tissue disorder of
unknown aetiology.
 Musculoskeletal symptoms -fatigue and myalgia
accompanying arthralgia.
 hand radiographs will show absorption of the
distal phalangeal tuft (acro-osteolysis).
 The result is thinning of the bone distally. Peri-
articular osteopaenia and erosions are typical.
 Subcutaneous calcifications are also seen,
particularly on the extensor surfaces of the hands.

70. Radiograph of the radial aspect of the right
hand shows acro-osteolysis of the
phalangeal tufts (arrow A), and soft tissue
calcifications (arrow B).
There is peri-articular osteopaenia.
Additionally, erosions are commonly seen
at the interphalangeal and
metacarpophalangeal joints.

71. references
 RADIOLOGY OF HAND-MIRROR OF
VARIOUS SYSTEMIC DISEASES Sadashiva
Gowda H1
 Twenty classic hand radiographs that lead to
diagnosis Govind B. Chavhan & Elka Miller &
Erika H. Mann .
 Sutton

72.  Thank you