Approach to Radiographic

Analysis of Arthritic Changes in

the Hand
Prepared by : Dr. Mohammed Elshaer
Radiology Resident

Supervised by : Dr. Samer Hamad

Consultant Radiologist
• In general, the radiologic diagnosis of arthritis can be highly specific
and reliable when classic changes are present in the expected
distributions.

• A specific radiologic diagnosis is often possible.

• The clinical disease may precede radiologic abnormalities and vice

versa.
• Standard views should be obtained in at least two projections (AP,
lateral or oblique radiographs).

• Additional views may also be required for some joints.

• Bilateral radiographs should be obtained for comparison as they may

present additional helpful findings.
• PA view :
Demonstrates the metacarpals, phalanges, radius and ulna in the
natural anatomical position
Excellent view to inspect the metacarpals
Ideal for identifying early signs of rheumatoid arthritis and
osteoarthrosis
• Ball-catcher view (a.k.a. Nørgaard projection) :
Specialized view used to demonstrate the metacarpophalangeal
(MCP) joints, often requested in the context of rheumatoid arthritis
• The classic analysis of the imaging features of arthropathies involves
careful evaluation of several radiographic findings.

• These include the Alignment of the joint, the Bones, the Cartilage
spaces, the Distribution of involvement, Erosions and the Soft tissues
surrounding the joint.

• These points of analysis create the pneumonic ABCDE’S.

Radiographic Assessment
of Arthritis
 S - Soft Tissue Swelling
• Symmetrical Swelling Around an Involved Joint (Fusiform shape).
• Asymmetrical Swelling Around an Involved Joint.
• Diffuse Swelling of an Entire Digit (sausage digit).
• Lumpy, Bumpy Soft Tissue Swelling.
• X-ray examination shows soft tissue swelling around the affected
joints without any osseous changes.
• PA radiograph of the hand
showing sausage third digit in
psoriasis.
• Lumpy-bumpy soft-tissue swelling
(tophaceous gout).
• Soft tissue masses distributed asymmetrically
around the proximal and distal
interphalangeal joint of the second digit in
patient with gout.
 A - Alignment
• Alignment becomes abnormal when joint capsules or ligaments and tendons are
torn or lax.

• The normally balanced tension across joints becomes unbalanced.

• The result is deformity, subluxation, dislocation.

• It is important to review different views as reducible subluxations may be

reduced on the PA view.

• Classic deformities of the fingers include the swan neck and boutonnière
deformities of rheumatoid arthritis.
• Swan neck deformity showing
hyperextension at the PIP and
hyperflexion at the DIP.
• Boutonnière deformity showing
hyperflexion at the PIP and
hyperextension at the DIP.
• ulnar deviation (subluxation) of the
metacarpophalangeal joints in lupus
arthritis
 B - Bone
• Depending upon the arthropathy, the bones may become osteopenic,
or sclerotic.

Bone mineralization.
Bone formation.
 Bone Mineralization
• Overall mineralization is evaluated by the metacarpal index (MCI).

• The width of the midpoint of the second or third metacarpal is measured,

and the width of the combined cortex is determined at the same level.

• If cortical combined thickness is less than 50% of the width of the

diaphysis, then the bone is osteopenic.

• Normal mineralization is typical of every arthropathy except rheumatoid

arthritis.
• Shaft of the third metacarpal
demonstrating normal mineralization.

• At the line drawn on the diaphysis,

the sum of the two cortices equals
half the width of the shaft.
• Diffuse osteoporosis.
• At the line drawn on the
diaphysis of the third metacarpal,
the sum of the two cortices is
clearly less than half of the width
of the shaft.
 Bone Production
• There are two different kinds of bone production:

• One is bone production of enthesopathies.

Periosteal New Bone Formation.
Enthesophyte.

• The second form of bone production is a reparative response.

Subchondral Bone.
Osteophytes.
• Periosteal reaction in psoriatic arthritis
(arrows)
• Subchondral sclerosis and
joint space narrowing
between the trapezium,
trapezoid, and distal
navicular bones in a
patient with osteoarthritis.
• Lateral view of a finger showing
osteophytes extending proximally at the
DIP and PIP joints in a patient with
osteoarthritis.
 C - Cartilage
• Cartilage space.
• Calcifications.
 Cartilage Space
• Cartilage space.
• The ends of the articulating bones, that is, the joint surfaces, are covered with hyaline
articular cartilage.

• Hyaline cartilage destruction causes joint space narrowing.

• In inflammatory arthritis, pannus produces proteolytic enzymes and interferes with

nutrient diffusion, causing uniform cartilage loss throughout the joint.

• In noninflammatory arthritis, especially osteoarthritis, cartilage loss occurs along lines of

force and thus tends to be asymmetrically greater at load-bearing surfaces.
•
• Uniform Narrowing
All of the arthropathies except for osteoarthritis produce uniform narrowing of
the joint space.
This includes the inflammatory arthropathies that erode the cartilage and all
other arthropathies that deposit extra substance into the cartilage (i.e., the
crystalline arthropathies).

• Nonuniform Narrowing
Nonuniform narrowing of the joint space is typical of osteoarthritis and erosive
osteoarthritis.

Some arthritides (gout) are associated with preservation of articular cartilage, at

least until late in the disease.
• Nonuniform narrowing of the PIP and
DIP joints in patient with osteoarthritis.
• Uniform narrowing of the MCP
joints in rheumatoid arthritis.
 Calcification
• Soft Tissue Calcification.
When the urate crystals of gout deposit in the soft tissues to form a
tophus, calcium is precipitated with the urate crystals to varying
degrees.

• Cartilage Calcification (Chondrocalcinosis).

Calcium pyrophosphate dihydrate crystals (CPPD) deposit in hyaline
and fibrous cartilage, producing a radiographic picture of calcified
cartilage.
• Calcification in a soft tissue mass or
tophus surrounding the second and
third PIP joints. Less dense tophi in the
volar soft tissues of the thumb.
• Calcification in the
triangular fibrocartilage
of the wrist (arrow).
 E - Erosions
• Erosion is focal subcortical loss of bone.

• Erosions are classified as central, marginal and peri-articular.

• Depending upon the underlying condition, the types of erosions and

the severity with which they affect the joint vary in appearance and
provide another clue to diagnosis.
• DIP joint. Bare areas (in black).
• A, Marginal erosions.
• B, Subchondral erosions.
• Marginal erosions resembling
mouse ears in the DIP joint of a
patient with psoriatic arthritis.
• Central erosion create a seagull
appearance of the second and the
third DIP in a patient with erosive
osteoarthritis.
• PA radiograph of the foot showing
periarticular erosions of the distal
first metatarsal secondary to gout.
Note the clasp shape appearance to
this erosion and the Granger
overhanging edge (arrow).
 D - Distribution of involvement
• Narrowing the differential down within the class of arthropathies
requires an additional piece of information, the distribution of joints
affected.

• Different arthropathies have predilections to involve different joints.

Intimate knowledge of these predilections is useful for making a
diagnosis.
• Outlined here is the characteristic distribution within the digits.
• I. DIP and PIP involvement
A. Osteoarthritis - osteophytes without erosions
B. Erosive osteoarthritis - osteophytes and erosion
C. Psoriatic arthritis - erosion without osteophytes

• II. MCP and PIP involvement

A. Rheumatoid arthritis - erosions without new bone formation; spares the
DIPs
B. Psoriatic arthritis, reactive arthritis, ankylosing spondylitis - erosions and
new bone formation; will involve DIPs
• III. MCP involvement
A. Inflammatory arthropathies - erosions
B. CPPD - osteophytes

• IV. Random involvement

A. Gout
 Erosive Seronegative
Osteoarthritis
osteoarthritis arthritis

Rheumatoid CPPD Gout

arthritis arthropathy arthropathy