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Rheumatoid Arthritis of Wrist and Hand


Radiographic Findings

Hand and foot have earliest involvement; watch for subtle changes

Focal soft tissue swelling may be clue to underlying bone involvement

Especially about MCP, PIP, ulnar styloid



Early: Juxtaarticular

Later: Diffuse



Earliest pattern is loss of cortical distinctness, followed by dot-dash pattern of cortical loss

Marginal erosions tend to be early in portion of bone, which is within capsule but not covered by cartilage

Mouse ears appearance at base of phalanges

Ulnar and radial styloid processes

Direct subchondral erosions

Late severe destruction of osseous structures

May give pencil-in-cup appearance in phalanges

May destroy distal ulna or proximal carpal row


Cartilage destruction

Initial radiographs may make joint space appear wide due to distension from effusion

Cartilage thinning and narrowing of joint are uniform


Subchondral cysts frequent finding in RA but nonspecific


Ulnar styloid may show capping: Only site of productive change in RA


Malalignment due to ligament/tendon disruption


Ulnar translocation (carpals subluxate ulnarly such that lunate mostly articulates with ulna)

Volar subluxation of carpus on radius

Scapholunate dissociation

Volar or dorsal intercalated segmental instability (VISI or DISI)


Ulnar drift at MCPs

Volar subluxation of MCPs

Hitchhiker's thumb

"Boutonnière" (hyperflexion PIP, hyperextension DIP) and "swan neck" (hyperextension PIP, hyperflexion DIP) deformities


CT Findings

Mirror radiographic findings; rarely used except in postoperative evaluation


MR Findings


Low signal effusion, erosions

Fluid-sensitive sequences

High signal effusion, erosions, subchondral cysts

High signal tenosynovitis

Pannus: Thick, nodular, low signal synovium outlined by effusion

Marrow edema: Subchondral high signal


Thickened, avidly enhancing synovium outlines low signal effusion and erosions

Tenosynovitis: Enhancement of involved tendons

Median nerve may enhance if impinged by tenosynovitis

in carpal tunnel


Ultrasonographic Findings

Excellent for early effusions in small joints

Tenosynovitis: Hyperechoic

Tendon rupture: Direct visualization

Color Doppler evaluates hypervascularity

Rheumatoid nodule: Homogeneous hypoechoic mass


Imaging Recommendations

Best imaging tool

Initial imaging is radiograph

If negative, US or MR useful to detect early disease

Excellent for detection, but not prognostic for individual

Following therapy (generally drug studies)

US with Doppler good for effusions, inflammation

MR best for following early erosions


Protocol advice

Radiographs: PA and open-book view (Norgard)

Open-book view helpful to identify early MCP, triquetral, and pisiform erosions

If carpal alignment evaluation is required, true lateral view should be added

Half dose contrast at 3T MR sufficient for assessing synovitis/tenosynovitis in early RA




RA in 1% of worldwide population

5% in some Native American populations

Female > male (3:1)

Carpus involved in 80% patients with RA

MCPs involved in 85% patients with RA

Hand PIP involved in 75% patients with RA



Earliest RA may be monostotic or asymmetric

Must differentiate from septic joint

Use sites of focal soft tissue swelling to guide you to subtle osseous findings on radiograph

Watch for cortical indistinctness and dot-dash pattern for earliest radiographic signs of erosion




PA graphic of a PIP joint shows progressive destruction of the joint.

(A) is normal, with intact cortex, cartilage, bone density, and capsule.

(B) shows early disease, with only synovitis and effusion.

(C) shows juxtaarticular osteopenia, with cortex becoming indistinct, the dotdash pattern.

(D) shows thinning of cartilage and marginal erosions in the portion of bone which is intracapsular but not protected by cartilage.

(E) shows progression of osteopenia and subchondral erosions extending through cartilage defects.

(F) shows arthritis mutilans, with pencil-in-cup deformity, seen in end-stage disease.

Longitudinal color Doppler ultrasound shows typical tenosynovitis with marked increase in vascularity, indicating hyperemia . There is also synovial thickening and hyperemia of the palmar aspect of the joint capsule , indicating joint synovitis. This proved to be early RA, normal on radiograph.


 Axial T2WI FS MR shows high signal tenosynovitis surrounding normal extensor and flexor tendons and synovitis in the DRUJ . There are no erosions; radiograph was normal.



Coronal T1WI MR, obtained in a patient with a new onset of unilateral joint pain and swelling, shows the MC heads with marginal erosions . These erosions were not visible on radiograph.



 Coronal T2WI FS MR in the same patient shows involvement beyond the MCPs. The carpal bones, radiocarpal joint, and DRUJ show similar findings of effusion and both marginal and subchondral erosions. The distribution and pattern of erosive disease is typical of RA.



 PA radiograph in a patient with new-onset hand pain and swelling shows swelling at the MCPs  and PIPs .There is no focal osteoporosis or erosion, but distension of MCPs 2 and 3 is seen . This is due to synovitis and effusion, very early radiographic signs of RA.



 PA radiograph shows juxtaarticular osteopenia and cartilage narrowing at the MCPs . Cortical indistinctness on the MC heads is the dot-dash pattern, indicating early erosive change.




PA radiograph shows a typical case of marginal erosions in RA . These are seen early in the erosive process, occurring in bone that is intracapsular but not protected by cartilage. This is the region of bone that is most vulnerable to the inflammatory process.



 PA radiograph in a patient with early RA shows that the bone density is normal. The only involved joint is a PIP , showing erosion and severe cartilage damage. Remember that early erosions in RA are as likely to involve the PIP as the MCP.



 PA radiograph shows a nodule , which causes scalloping of underlying bone . Note the decreased cartilage width at the 2nd MCP, along with the marginal erosion of the MC head . The appearance and distribution is typical for RA with a rheumatoid nodule.



PA radiograph in a 48- year-old man shows severe rapid-onset osteopenia in a band-like pattern of the distal radius as well as soft tissue swelling and likely erosion at the ulnar styloid .



Coronal T1 MR arthrogram of the same patient shows edema and erosions of the ulnar styloid and triquetrum . In addition, there is disruption of the scapholunate ligament .



Coronal T2 FS MR in the same patient confirms the erosions in the ulnar styloid, triquetrum, and demonstrates another in the scaphoid . Note the mild thinning of cartilage at the radioscaphoid joint , with other cartilage appearing normal. This patient's erosions are more extensive than suspected on radiograph.



 PA radiograph shows normal bone density and only a single MCP with soft tissue swelling and single associated erosion . This is the only radiographic sign of RA in this young woman.



PA radiograph in a patient with early RA shows radiocarpal joint narrowing, as well as ulnar translation of the entire carpus . Note that the majority of the lunate overlies the ulna, confirming that translation.



 PA radiograph in a middle-aged man with joint pain shows only soft tissue swelling near the ulnar styloid. This should suggest early RA.


 In the same patient, an indirect T2 C+ FS MR arthrogram shows ulnar sided tenosynovitis and small ulnar styloid erosion with extensive edema. There is also scapholunate ligament disruption .


Axial PD C+ FS MR in the same patient, through the distal carpus, shows more extensive erosion of the distal ulna than was suspected on the coronal.


PA radiograph demonstrates severe osteopenia with arthritis mutilans. The erosions are so severe that "pencil-in-cup" morphology is seen in multiple joints . Although arthritis mutilans is a hallmark for psoriatic arthritis, it is also seen in any severe inflammatory arthropathy, including RA.


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