Arthropathies/Connective Tissue Diseases

Madhura A. Desai

Jeffrey J. Peterson

Thomas H. Berquist

▪ RHEUMATOID ARTHRITIS

KEY FACTS

Clinical:
- Rheumatoid arthritis (RA) affects 1% to 2% of the general population with permanent deformity and disability in 10% to 20%.
Age: 25 to 55 years
Sex: Females outnumber males in the ratio 3:1.
Diagnostic clinical criteria of the American Rheumatism Association are as follows:
- Morning stiffness lasting 1 hour before improvement
- Soft tissue swelling of three or more joint areas noted on physical examination
- Swelling of wrists, metacarpophalangeal joints, and proximal interphalangeal (PIP) joints
- Symmetric swelling
- Rheumatoid nodules
- Positive rheumatoid factor
- Radiographic erosions with or without juxta-articular osteopenia in hand, wrist, or both
Criteria 1 to 4 must be present for 6 weeks. If four or more criteria are present, the criteria are 91% to 94% sensitive and 89% specific for RA.
Laboratory findings: positive rheumatoid factor, elevated erythrocyte sedimentation rate
Distribution: hands and wrists, feet, knees, shoulders, hips, elbows, and cervical spine
Radiographic features: characterized by bilateral symmetric involvement, osteopenia, and an absence of reparative bone or osteophyte formation
- Early:
  - Soft tissue swelling around involved joints
  - Juxta-articular osteopenia
  - Subtle marginal bone erosions
- Late:
  - Osteopenia (diffuse)
  - Joint space narrowing
  - Obvious erosions
  - Joint subluxations
  - Soft tissue atrophy
  - Rheumatoid nodules
Magnetic resonance imaging (MRI) often features marginal bone erosions, osseous and soft tissue edema, and synovitis.
Cervical spine: Atlantoaxial disease is most common and can include laxity of the transverse ligament and vertical subluxation of the dens.

FIGURE 12-1. Early rheumatoid arthritis (RA). Hand radiograph shows early periarticular osteopenia with focal soft tissue swelling about the second metacarpophalangeal (MCP) joint with early erosive marginal erosions (arrow).

FIGURE 12-2. Advanced rheumatoid arthritis (RA). Hand radiograph (A) depicts osteopenia with marked joint space narrowing and erosion with subluxation predominately involving the metacarpophalangeal (MCP) joints. Lateral (B) and anteroposterior (AP) (C) views of the elbow demonstrate with marked erosive changes at the distal humerus, proximal radius, and proximal ulna which contribute to joint space widening and deformity.

FIGURE 12-3. Early rheumatoid arthritis (RA). Coronal T1-weighted magnetic resonance (MR) (A) of the wrist demonstrates low intensity erosion at the ulnar styloid (arrowhead), a common location for early erosions. Coronal fat-saturated T2-weighted MR (B) shows mild edema at the ulnar styloid (arrowhead) with tenosynovitis of the adjacent extensor carpi ulnaris tendon (arrows), manifest by tendon thickening, increased internal signal, and complex fluid about the tendon.

FIGURE 12-4. Carpal rheumatoid arthritis (RA). Extensive erosive changes with loss of joint space at the proximal carpus, distal radius, and ulna (A). Coronal fat-saturated proton density magnetic resonance (MR) (B) better demonstrates osseous edema and surrounding soft tissue edema and synovitis.

SUGGESTED READING

Brower AC, Flemming DJ. Arthritis in Black and White. 3rd ed. Philadelphia: Elsevier/Saunders; 2012:170-199.

Farrant JM, Grainger AJ, O’Connor PJ. Advanced imaging in rheumatoid arthritis. Part 2: erosions. Skeletal Radiol. 2007;36(5):381-389.

Farrant JM, O’Connor PJ, Grainger AJ. Advanced imaging in rheumatoid arthritis. Part 1: synovitis. Skeletal Radiol. 2007;36(4):269-279.

Sommer OJ, Kladosek A, Weiler V, et al. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation, and clinical implications. Radiographics. 2005;25(2):381-398.

▪ PSORIATIC ARTHRITIS

KEY FACTS

Clinical:
- Psoriatic arthritis occurs in 2% to 6% of patients with psoriasis, and may precede or coincide with skin manifestations. Psoriatic arthritis comprises approximately 5% of patients with polyarthropathy.
Age: 25 to 55 years
Sex: No sex predilection
Distribution: hands, feet, sacroiliac joints (50%), and spine, in order of decreasing frequency
Laboratory findings: negative rheumatoid factor, elevated erythrocyte sedimentation rate, human leukocyte antigen (HLA)-B27 antigen often positive
Imaging features:
- Bilateral, but asymmetric involvement
- Fusiform (entire digit) soft tissue swelling
- Normal bone density (no osteopenia)
- Marked joint space narrowing
- “Pencil in cup” erosions
- Bone proliferation
- In the hands and feet, distal joint involvement (distal and PIP joints) is more common with psoriatic arthritis than proximal joints involvement (carpal and metacarpal joints), which is more commonly seen with RA.

FIGURE 12-5. Psoriatic arthritis. Hand radiograph (A) shows proliferative changes and erosions at the second and third interphalangeal (IP) joints with fusiform enlargement of those digits. Classic “pencil in cup” erosion at the first metacarpophalangeal (MCP) joint. There is ankylosis across the fourth distal interphalangeal (DIP) joint. There is also loss of the carpal joint spaces. Radiograph of the feet (B) in the same patient demonstrates osteolysis and erosions involving the IP joints diffusely.

FIGURE 12-6. Psoriatic arthritis. Anteroposterior (AP) (A) and lateral (B) radiographs of the hand depict ankylosis of the fourth distal interphalangeal (DIP) joint (arrowhead) and “pencil in cup” erosions at the second DIP joint (arrow).

SUGGESTED READING

Bennett DL, Ohashi K, El-Khoury GY. Spondyloarthropathies: ankylosing spondylitis and psoriatic arthritis. Radiol Clin North Am. 2004;42(1):121-134.

Poggenborg RP, Østergaard M, Terslev L. Imaging in psoriatic arthritis. Rheum Dis Clin North Am. 2015;41(4):593-613.

Resnick D, Kransdorf MJ. Psoriatic arthritis. In: Resnick D, Kransdorf MJ, eds. Bone and Joint Imaging. 3rd ed. Philadelphia: Elsevier-Saunders; 2005:288-297.

▪ REACTIVE ARTHRITIS

KEY FACTS

Formerly known as Reiter syndrome
Clinical:
- Reactive arthritis is typically associated with conjunctivitis and urethritis. Patients may also have fever and weight loss. This triad is sexually transmitted. In females, the arthropathy is associated with dysentery.
Age: 15 to 35 years
Sex: most common in males
Distribution: feet, ankles, knees, and sacroiliac joints. Upper extremity involvement is uncommon.
Laboratory findings: HLA-B27 antigen positive in 75%
Imaging features:
- Bilateral asymmetric joint involvement
- Fusiform (entire digit) soft tissue swelling
- Joint space narrowing
- Bone proliferation
- Ill-defined erosions
- Normal mineralization

FIGURE 12-7. Reactive arthritis. Radiograph (A) in a patient with reactive arthritis shows proliferative changes and erosions (arrow) at the first interphalangeal (IP) joint with fusiform swelling of the great toe. Radiograph (B) in a different patient, the most notable proliferative and erosive changes are at the first, third, and fifth IP joints. There is ankylosis involving the proximal third phalanx. Mineralization is preserved.

FIGURE 12-8. Reactive arthritis involvement of the calcaneus. Irregular proliferative changes at the plantar aspect of the calcaneus in this patient with reactive arthritis.

SUGGESTED READING

Klecker RJ, Weissman BN. Imaging features of psoriatic arthritis and Reiter’s syndrome. Semin Musculoskelet Radiol. 2003;7(2):115-126.

▪ ANKYLOSING SPONDYLITIS

KEY FACTS

Clinical:
- Ankylosing spondylitis is an inflammatory condition that affects primarily the axial skeleton. Patients are typically young males who present with low-back pain. Patients may also have weight loss and low-grade fever.
Age: 15 to 35 years
Sex: Males outnumber females in the ratio 4:1 to 10:1.
Distribution: sacroiliac joints, spine (ascends from lumbar to cervical), hips, knees, shoulders. Peripheral joints of hands and feet are less commonly involved (seen in 10% of those with long-standing disease).
Laboratory findings: HLA-B27 antigen frequently positive, elevated erythrocyte sedimentation rate
Imaging features:
- Bony ankylosis of involved joints
- Bilateral symmetric involvement of sacroiliac joints
- Bone mineralization is normal early in the disease process but osteopenic after ankylosis
- Minimal erosive changes
- Patients are more susceptible to fractures after ankyloses, notably in the spine.

FIGURE 12-9. Ankylosing spondylitis. Radiograph (A) shows long-standing ankylosing spondylitis with symmetric sacroiliac (SI) joint ankylosis, syndesmophytes, and spinous ligament ossification. There are bilateral hip replacements. Axial (B) computed tomography (CT) shows symmetric ankylosis across bilateral sacroiliac joints.

FIGURE 12-10. Ankylosing spondylitis with shear fracture. Coronal (A) and lateral (B) computed tomography (CT) show ankylosis across the lower thoracic and lumbar spine. Shear fracture at L1-L2 is transfixed with hardware. Lucencies about the screws suggest loosening of the hardware.

FIGURE 12-11. Ankylosing spondylitis. Early syndesmophytes contribute to squaring of the vertebral bodies on this lateral computed tomography (CT). There are also shiny corners (arrows) at the vertebral body margins.

SUGGESTED READING

Brower AC, Flemming DJ. Arthritis in Black and White. 3rd ed. Philadelphia: Elsevier/Saunders; 2012:226-242.

Hermann KG, Althoff CE, Schneider U, et al. Spinal changes in patients with spondyloarthritis: comparison of MR imaging and radiographic appearances. Radiographics. 2005;25(3):559-569; discussion 569-570.

Lacout A, Rousselin B, Pelage JP. CT and MRI of spine and sacroiliac involvement in spondyloarthropathy. Am J Roentgenol. 2008;191(4):1016-1023.

Navallas M, Ares J, Beltrán B, et al. Sacroiliitis associated with axial spondyloarthropathy: new concepts and latest trends. Radiographics. 2013;33(4):933-956.

Vinson EN, Major NM. MR imaging of ankylosing spondylitis. Semin Musculoskelet Radiol. 2003;7(2):103-113.

▪ OSTEOARTHRITIS

KEY FACTS

Clinical:
- Osteoarthritis is the most common arthropathy and increases in incidence with age. Osteoarthritis may occur after other arthropathies (secondary osteoarthritis). Degenerative joint disease may be genetic, the result of advancing age or occupational activity, or multifactorial. Patients present with pain and swelling in the involved joints.
Age: More than 50 years
Sex: No sex predilection
Distribution: hands (distal interphalangeal and PIP joints, thumb base), feet, knees, and hips. Elbows and shoulders less commonly involved.
Laboratory findings: None
Imaging features:
- Asymmetric joint space narrowing (uniform joint space narrowing in secondary osteoarthritis)
- Subchondral sclerosis
- Subchondral cysts
- Osteophyte formation
- Subluxations (less dramatic than RA)
- Unilateral or bilateral involvement, but asymmetric
- Absence of erosions
Erosive osteoarthritis is closely related to primary osteoarthritis but occurs primarily in postmenopausal females with an inflammatory component superimposed on osteoarthritic changes. Distribution in the hand is similar to that of primary osteoarthritis.

FIGURE 12-12. Osteoarthritis. Posteroanterior (PA) view of the hand and wrist demonstrates the typical distal interphalangeal (DIP) and proximal interphalangeal (PIP) joint involvement with joint space narrowing and osteophyte formation. As in this patient, osteoarthritis commonly also involves the first metacarpophalangeal (MCP) joint and the scaphoid-trapezio-trapezium joints.

FIGURE 12-13. Osteoarthritis. Anteroposterior (AP) view of the hips with asymmetric osteoarthritic involvement. There is severe joint space narrowing on the left with sclerosis, osteophyte formation, and development of subchondral cysts. Milder joint space narrowing is seen on the right.

FIGURE 12-14. Osteoarthritis. Standing view of the knees demonstrating typical medial compartment narrowing and osteophyte formation.

FIGURE 12-15. Erosive osteoarthritis. Asymmetric joint space narrowing, erosions, osteophytes, and soft tissue swelling involving the third distal interphalangeal (DIP) and fourth proximal interphalangeal (PIP) joints in a postmenopausal woman. There is no demineralization.

SUGGESTED READING

Brower AC, Flemming DJ. Arthritis in Black and White. 3rd ed. Philadelphia: Elsevier/Saunders; 2012:243-260.

Greenspan A. Erosive osteoarthritis. Semin Musculoskelet Radiol. 2003;7(2):155-159.

Gupta KB, Duryea J, Weissman BN. Radiographic evaluation of osteoarthritis. Radiol Clin North Am. 2004;42(1):11-41.

Jacobson JA, Girish G, Jiang Y, et al. Radiographic evaluation of arthritis: degenerative joint disease and variations. Radiology. 2008;248(3):737-747.

Smith D, Braunstein EM, Brandt KD, et al. A radiographic comparison of erosive osteoarthritis and idiopathic nodular osteoarthritis. J Rheumatol. 1992;19:896-904.

▪ ENTERIC ARTHROPATHIES

KEY FACTS

Clinical:
- Arthropathies may accompany enteric conditions, such as Crohn disease, ulcerative colitis, and Whipple disease. Findings may be similar radiographically to ankylosing spondylitis. Incidence of sacroiliitis associated with these conditions varies from 2% to 26%.
Age: 20 to 40 years
Sex: No sex predilection
Distribution: sacroiliac joints, spine, hips, knee; peripheral joints less common
Laboratory findings: HLA-B27 antigen positive in approximately 90%
Imaging features:
- Bilateral sacroiliac joint involvement
- Spondylitis similar to ankylosing spondylitis
- Peripheral joint swelling and osteopenia
- Joint space narrowing and erosions rare

FIGURE 12-16. Enteric arthropathy. Coronal (A) and axial (B) computed tomography (CT) bone kernel images demonstrate symmetric sacroiliitis with bilateral erosive and sclerotic changes in this patient with inflammatory bowel disease. Axial (C) image through the abdomen demonstrates wall thickening involving the descending colon (arrow) with stranding in the surrounding fat.

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