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Rheumatoid Arthritis of Shoulder and Elbow

 




Definition 

Chronic progressive systemic inflammatory disease in which joints are primary target


 

IMAGING

Purely erosive arthropathy

Uniform cartilage narrowing

Osteoporosis

 

Glenohumeral joint

Uniform cartilage narrowing

Erosions

Largest and earliest at margin (junction of cartilage covered humeral head and greater tuberosity)

Eventually, erosions uniformly involve humeral head and glenoid

End-stage destruction of entire head and glenoid

Subchondral cysts may be large, but underlying osteoporosis may mask their size

Elevation of humeral head due to RCT With chronicity, head seems to articulate with underside of acromion, molding acromion into

concavity

Hatchet-like mechanical erosion at medial surgical neck of humerus

Due to chronic elevation of humeral head and consequent rubbing of osteoporotic humeral neck against inferior glenoid

Increases risk of insufficiency fracture across surgical neck

Swelling of joint may be prominent due to decompression of synovial fluid through RCT into subacromial/subdeltoid bursa

 

Elbow joint

Effusion (elevated anterior and posterior fat pads)

Swelling about joint

Over olecranon: Olecranon bursitis common in RA

Elsewhere due to decompression of synovial fluid through capsule or into bicipital radial bursa

Erosions uniform throughout joint

Equally involving capitellum, trochlea, ulna, radial head/neck

End-stage uniform destruction of osseous structures

 

MR in RA

Thickened, low signal, avidly enhancing pannus and synovium

Low signal rice bodies within effusion

Subchondral marrow edema

RCT, partial or complete

Decompression of synovial effusion well seen

 

DIAGNOSTIC CHECKLIST

Other causes of synovitis, especially infection if Monoarticular

 

 


 


AP radiograph shows erosions of the distal end of the clavicle as well as at the coracoclavicular ligament insertion site of the clavicle , typical sites of erosions in rheumatoid arthritis (RA).

 

 






 Coronal graphic shows advanced RA of the shoulder. Thickened synovium lining the capsule is distended by effusion. Cartilage is thinned uniformly. Large marginal erosions are seen where bone is not covered by cartilage, and smaller subchondral erosions are present. Marrow edema and rotator cuff tear complete the picture.

 

 






 Axial bone CT demonstrates the typical uniform glenohumeral cartilage loss that is seen in RA, along with humeral head erosions and subchondral cysts.

 




 



Coronal bone CT shows marginal erosion at the humeral head . The head is subluxated superiorly secondary to chronic rotator cuff tear. This results in a mechanical erosion of the osteoporotic bone at the surgical neck of the humerus ; this puts the patient at additional risk of fracture.

 






AP radiograph shows a case of severe, long-term RA, with erosions of the clavicle, glenoid, and humeral head.

 

 





Coronal PD FS MR shows the retracted infraspinatus tendon , part of the chronic rotator cuff tear that is usually seen with advanced RA. There is mild edema in the humeral head. The glenohumeral joint is distended, and low signal synovitis fills the axillary bursa and extends across the rotator cuff tear into the subacromial bursa . Note the humeral head elevation.

 

 





 Coronal T1WI MR shows typical findings of RA in the shoulder. There are low signal subchondral cysts, as well as a marginal erosion of the humeral head .

 

 




 Axial PD FSE FS MR in the same patient shows subchondral cysts as well as a marginal erosion . Note the thin and disrupted subscapularis tendon , with fluid seen both in the glenohumeral joint and subdeltoid bursa. It seems remarkable that the radiograph in this case appeared normal.

 

 





 AP radiograph in a patient with RA shows only osteopenia and a small marginal erosion . The osteopenia seen on radiographs in patients with RA often disguises the full extent of erosive disease and subchondral cysts.

 

 







 Coronal T2WI FS MR in the same patient shows tremendous synovitis in both the glenohumeral joint  and subacromial/subdeltoid bursa . The diffuse nodular low signal masses within the fluid are synovitis.

 





 Sagittal T2WI FS MR in the same patient emphasizes the tremendous synovitis in both the glenohumeral joint and subacromial/subdeltoid bursa . Both the synovitis and extent of subchondral cysts extending down the marrow are well depicted.

 




Axial PD FS MR in the same patient shows the size of the erosions . It is quite remarkable that the radiographs showed only osteopenia and a small erosion, even in retrospect. This humeral metadiaphysis is at risk for fracture.

 

 




Coronal T1 FS postcontrast MR in the same patient confirms that the marrow abnormality represents erosions and subchondral cysts, with low signal fluid surrounded by enhancing synovitis . A rotator cuff tear is seen as well, with retraction of supraspinatus .



 


Lateral radiograph of the elbow shows diffuse osteopenia and soft tissue swelling over the olecranon . The location is typical for olecranon bursitis, secondary to RA in this case.

 





Anteroposterior radiograph shows a classic case of severe and long-term RA. There is symmetric erosive disease of the distal humerus, proximal radius, and proximal ulna, along with osteopenia.

 

 




 Lateral radiograph confirms the erosions, as well as a mechanical erosion at the proximal shaft of the ulna where the remnant of radial head has been rubbing. The symmetry of the process and purely erosive nature make the diagnosis RA.

 





 AP radiograph shows extensive uniform thinning of cartilage throughout the elbow and subchondral erosions at the coronoid . There is extensive soft tissue swelling and diffuse osteopenia. No productive change is seen; the findings are typical of RA.

 





Sagittal T2FS MR in the same case of RA shows complete loss of cartilage and thinning of cortex at the capitellum . The fluid is all contained within an extremely distended joint and contains low signal material that has been termed rice bodies.

 






 AP radiograph shows a lateral soft tissue mass but no other abnormalities in a patient with RA.

 




Axial PD FS MR performed to evaluate the soft tissue mass in the same patient shows synovitis and fluid surrounding the radial neck. There is a thin neck of fluid extending from the joint effusion to the mass . This proves that the mass is simply fluid from the joint, which has decompressed into the soft tissues laterally, as happens in restricted joints with active synovitis.

 





Sagittal T2WI MR shows bicipital radial bursitis related to RA. Lobular-enhancing synovitis is seen in the bicipital radial bursa around the biceps tendon . Fluid and synovitis are also seen in the elbow joint .



 



Sagittal T2WI MR in a patient with RA shows joint destruction, large effusion, and abnormal bone marrow signal . These findings could be due simply to advanced RA, but infection must be considered and was proved surgically.

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