Rheumatoid Arthritis and Osteoporosis X-ray

X-Ray Findings in
Rheumatoid arthritis
and Osteoporosis
Dr. Hruthik Aradhya P R

Rheumatoid arthritis
Introduction:
● Rheumatoid arthritis (RA) is a common form of inflammatory
arthritis, occurring throughout the world and in all ethnic
groups.
● The prevalence of RA is approximately 0.8–1.0% in Europe and
the Indian subcontinent, with a female-to-male ratio of 3 : 1.
● The prevalence is lower in South-east Asia (0.4%).
● The highest prevalence in the world is in Pima Indians (5%)
Articular Manifestations:
Joints Involved:
● Small Joints: Metacarpophalangeal joints, proximal interphalangeal joints, and

metatarsophalangeal joints
● Large joints: Wrist, Knee, Elbow, ankles, hips and shoulder joints.
Hand and Wrist:
● Ulnar deviation- subluxation of MCP joints, with subluxation of proximal phalynx to volar
side of hand
● Swan Neck Deformity- Hyper extension of proximal interphalangeal joint with flexion of
distal interphalangeal joint
● Boutonniare deformity- Flexion of proximal interphalangeal joint and extension of distal
interphalangeal joint
● Gamekeepers thumb: Hyperextension of first interphalangeal joint and flexion of first
Metacarpophalangeal joint
● Z shaped deformity: Thumb flexes at Metacarpophalangeal joint and Hyperextension at
interphalangeal joint
Feet and Ankle:
● Broadening of forefoot- swelling of metatarsophalangeal joint

● Subluxation of toes at MTP joints
● Hallux valgus deformity
● Hammer toes
Larger Joints:
● Shoulder joint: Glenohumeral arthritis, rotator cuff fraying and rupture

Diagnostic criteria
X-Rays
Plain X-rays of the hands, wrist and feet are usually normal in early
RA but periarticular osteoporosis and marginal joint erosions may be
observed with more advanced disease.
The main indication for an X-ray is in the assessment of patients with

painful joints to determine whether significant structural damage has
occurred.
Patients who are suspected of having atlanto-axial disease should

have lateral X-rays taken in flexion and extension, and an MRI.
1. Advanced features of
rheumatoid arthritis, with
erosive subluxation most
marked of the MCP joints
with ulnar deviation.
Prominent degenerative
change is also seen at the
ulnar-carpal articulation.
Note also osteopaenia
particularly of the MCP
regions.
2. Typical changes of
rheumatoid arthritis of the
hands with prominent
metacarpophalangeal
osteopenia, erosions very
marked within the carpus
and radiocarpal/ulnocarpal
joints.
3. Rheumatoid arthritis
with distal clavicle
reabsorption.
4. Symmetrical significant joint spaces narrowing involves all
three joint compartments of both knees, namely both medial
and lateral tibiofemoral compartments as well as
patellofemoral compartment. Lateral tibiofemoral
compartments are more severely affected/narrowed.
Marginal bone erosions at the bilateral medial and lateral

femoral condyles of both knees.
5. In addition to the erosive
changes and periarticular
osteoporosis routinely seen
in rheumatoid arthritis, there
is an erosion of the radial
side of the distal radioulnar
joint; known as the "scallop
sign".
6.Yellow arrows indicate
Boutonierre deformity
Red arrow indicates

hitch-hiker thumb deformity
Red circle indicates key area of

affection of the intercarpal
spaces
7. Joint space narrowing and
marginal erosions at both
fifth metatarsophalangeal
joints.
8. Marginal erosions
involving the MTP joint of
the right little toe.
Associated periarticular
subchondral lucency.
Osteoporosis
Osteoporosis is the most common bone disease.
The defining feature of osteoporosis is reduced bone density,

which causes micro-architectural deterioration of bone tissue
and leads to an increased risk of fracture, in response to minor
trauma
Clinical features
Fragility fracture- Typical of osteoporosis
● Spine: Sudden severe back pain radiating to front suggesting

of compression fracture
● Proximal femur : Common in elderly, occur by falling on their
side or back
● Wrist: Colles’ fracture due to fall on our stretched arm
X-Rays and DXA
Substantial amount of bone loss (30%) is required for detection

osteoporosis on plain X-ray
Estimation of bone mineral density (BMD) has a key role in the diagnosis
and management of osteoporosis and is best made using dual X-ray
absorptiometry (DXA)
Principle of DXA: Calcium in bone attenuates passage of X-rays through

the tissue in proportion to the amount of mineral present; the more bone
mineral present, the higher the BMD value.
Bone density measurements are often presented as T-scores, which
measure of the number of standard deviations by which the patient’s
BMD value differs from that in a young healthy control.
Osteoporosis is defined in postmenopausal women and men of more

than 50 years old by a T-score of 2.5 or below (shaded red in the figure)
Osteopenia is diagnosedwhen the T-score lies between −1.0 and −2.5

(shaded pink).
BMD values above −1.0 and below +2.5 are considered normal
(yellow/green), whereas values above +2.5 indicate high bone mass, the
most common cause being OA.
Aortic calcification, vertebral fractures, degenerative disc disease must

be ruled out as they can artefactually raise BMD results
X-ray - Osteoporosis
Severe uneven decreased
bone density with cortical
thinning. Widespread areas
of lucency in both lower
limbs are present
Multiple biconcave,
wedge-shaped or flat
vertebrae of the thoracic and
lumbar spine resulting from
earlier fractures in severe
osteoporosis.
Fractures associated with
osteoporosis
A. X-ray wrist
B. X-ray vertebrae
C. X-ray shoulder joint
D. X-ray Hip
PA Spine
● BMD for L2-L4 is 0.89 g/cm2

● T-score: -2.5 Age Matched
● Z-score: -1.7
Left Proximal femur
● BMD for the total hip site is 0.70 g/cm2

● T-score: -2.6
● Age Matched Z-score: -1.6
REFERANCES
● Davidson’s principles and practice of medicine Edition 24

● Radiopedia- Rheumatoid arthritis (musculoskeletal manifestations)
○ Accessed on 21st May 2023 at
https://radiopaedia.org/articles/rheumatoid-arthritis-musculoskel
etal-manifestations-2?lang=gb#search for X-ray images
● Radiopedia- Osteoporosis
○ Accessed on 21st May 2023 at
https://radiopaedia.org/articles/osteoporosis-3#article-images for
X-ray images
THANK YOU

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X-Ray Findings in

Dr. Hruthik Aradhya P R

● Small Joints: Metacarpophalangeal joints, proximal interphalangeal joints, and

Hand and Wrist:

Feet and Ankle:

● Broadening of forefoot- swelling of metatarsophalangeal joint

● Shoulder joint: Glenohumeral arthritis, rotator cuff fraying and rupture

The main indication for an X-ray is in the assessment of patients with

Patients who are suspected of having atlanto-axial disease should

Marginal bone erosions at the bilateral medial and lateral

Red arrow indicates

Red circle indicates key area of

Osteoporosis is the most common bone disease.

The deﬁning feature of osteoporosis is reduced bone density,

Fragility fracture- Typical of osteoporosis

● Spine: Sudden severe back pain radiating to front suggesting

Substantial amount of bone loss (30%) is required for detection

Principle of DXA: Calcium in bone attenuates passage of X-rays through

Osteoporosis is deﬁned in postmenopausal women and men of more

Osteopenia is diagnosedwhen the T-score lies between −1.0 and −2.5

Aortic calciﬁcation, vertebral fractures, degenerative disc disease must

● BMD for L2-L4 is 0.89 g/cm2

Left Proximal femur

● BMD for the total hip site is 0.70 g/cm2

● Davidson’s principles and practice of medicine Edition 24

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