radiology of hand in systemic diseases ppt

adiology of hand in systemic diseases ppt

1. RADIOLOGY OF HAND-MIRROR OF VARIOUS SYSTEMIC DISEASES Dr DINESH RADIOLOGY RESIDENT GMC SRIKAKULAM

2. Several systemic diseases manifest on the radiographs of hand. Conventional radiographs of hand are excellent source of information in most of the systemic diseases The diagnosis can be clinched on a single hand radiograph if characteristic findings are present.

3. Common indications Evaluation of the bone age and Trauma Systemic hematologic and Metabolic conditions. Radiologists interpreting the hand radiograph can make the diagnosis or direct appropriate investigations for diagnosis.

4. A natomy

5. FEATURES USED FOR DIAGNOSIS EROSIONS BONE PRODUCTION DISTRIBUTION SOFT TISSUE SWELLING PATTERN

6. Congenital/Developmental Osteopetrosis rare hereditary and familial bone abnormality characterized by defective osteoclast function . Bone remodelling is impaired -thick but structurally weak and brittle. generalized increase in bone density with obliteration of normal trabecular pattern Marrow is encroached upon and extra- medullary hematopoiesis occurs.

7. Pyknodysostosis a rare autosomal recessive disorder increased bone density with preservation of medullary canal –no anemia dwarfism and skeletal fragility .

8. i Hand radiograph shows dense sclerotic bones with acro-osteolysis .

9. Radiograph shows generalized increase in bone density with preservation of medullary canals and acro-osteolysis

10. Marfan’s Syndrome an autosomal dominant entity , affect the body’s connective tissue. three systems: skeletal, ocular and cardiovascular .( aortic aneurysm) The elongation of tubular bones ,most marked in distal portion of the extremities-the phalanges, metacarpals and metatarsals without an increase in width long , slender and gracile-arachnodactyly or spider-like fingers . Radiographically , the metacarpal index is abnormal( 8.8 f or males or 8.4 for females) the skull reveals dolichocephaly . individuals are taller

11. Arachnodactyly in a 16-year-old girl. Radiograph shows a metacarpal index of approximately 9.5. The tubular bones of the hands (Metacarpals and phalanges) are long, slender and gracile – Arachnodactyly or spider-like fingers

12. METAPHYSEAL DYSPLASIAS ACHONDROPLASIA Rhizomelic dwarfism with normal trunk , large head, and midface hypoplasia Mc nonlethal skeletal dysplasia ○ Findings are evident at birth PATHOLOGY Form of chondrodysplasia – Failure of conversion of cartilage to bone

13. H ands Trident hand with short, broad, splayed and cone-shaped phalanges and shortened metacarpals

14. Hand radiograph shows approximation of second and third digits and also the fourth and fifth digits forming the trident hand appearance . Tubular bones are short and show coned phalanges .

15. Pseudoachondroplasia autosomal dominant manner . It is a form of short-limb dwarfism. diagnosis is made 2-3 years of age . the trunk appears long with lumbar lordosis and rhizomelic shortening of the limbs. Pseudoachondroplasia have normal head size and facial features. Radiographic changes include shortening of tubular bones, flaring of metaphyses , variable epiphyseal maldevelopment and some degree of vertebral end-plate malformation

16.   four yr old boy Short metacarpals with metaphyseal cupping short and stubby phalangeal bones delayed ossification of the small and irregular carpal bones

17. Chondrodysplasia punctata , brachytelephalangic subtype ( CDP-BT) rare congenital disorders caused by peroxisomal dysfunction . -erratic cartilage calcification within apophyses and epiphyses, carpal and tarsal bones, vertebrae and cartilages of the trachea and bronchi. types of chondrodysplasia punctata include autosomal -dominant (non- rhizomelic , non-lethal) autosomal -recessive ( rhizomelic , lethal type) and rare x-linked dominant and recessive forms .

18. short triangular-shaped distal phalanges suggestive of brachytelephalangy . The fifth middle phalanx is small with clinodactyly . The metacarpals are relatively small.

19. Sickle cell disease autosomal -recessive hemoglobinopathy caused by formation of a defective hemoglobin called hemoglobin S ( Hb S ). Pathology -Bone infarcts in the diaphyses of small tubular bones in the hands and feet A ge ( from 6 months to 3 years) are called sickle cell dactylitis or hand-foot syndrome caused by the presence of red marrow in these regions

20. Hand radiograph shows cortical thickening , and metaphyseal cupping involving the proximal phalanx of the third digit . Findings are in keeping with prior infarction

21. Thalassemia hereditary disorders caused by genetic deficiency in the synthesis of beta- globin chains of hemoglobin. Excess unpaired alpha-chains aggregate to form precipitates that cause hemolysis . Erythroid hyperplasia causes medullary expansion within the bones. Extramedullary hematopoiesis

22. Hand radiograph shows expansion , groundglass appearance, lace-like thin trabeculae and thin cortex involving predominantly metacarpals , in keeping with medullary expansion

23. Inflammatory joint disease This is characterized by bone erosions, osteopenia , soft-tissue swelling and uniform, symmetric joint space loss. Inflammation of a single joint should raise concern for infection.

24. Infective/Inflammatory Disorders. Tubercular Dactylitis / Spina Ventosa Dactylytis is an inflammatory disorder of the digit (hand or foot) seronegative arthropathies -psoriatic arthropathy and ankylosing spondylitis , sickle cell disease infectious conditions -tuberculosis and leprosy.   Tuberculous dactylytis -as a painless swelling in the hand or foot.

25. Plain radiograph- diaphyseal lytic lesion , either round and cystic with a variable amount of sclerosis and minimal periostitis Sickle cell dactylytis may present silently or with a painful bone crisis, radiographs in young children similarly show diaphyseal lytic lesions within the tubular bones of the hands or feet. Periostitis is uncommon .  

26. Radiograph of the little finger of the right hand -a rounded lucency in the proximal phalanx of a child. There is minimal periostitis .

27. Gout crystal deposition arthropathy caused by the deposition of monosodium urate crystals ( tophi ) Presentation -the acute phase with soft tissue swelling and joint effusion . chronic tophaceous phase (6-12 years after the initial attack) with eccentric asymmetrical nodular tophi within the synovium and subchondral bone.

28. Plain radiograph   Bony erosions may be intra- articular , peri-articular or distinct from the joint with a rounded or ‘punched out ’ appearance.  The erosion margins are typically thin and sclerotic with a raised, overhanging, cortical lip, giving a ‘rat bite’ appearance.  This characteristic late finding is caused by peri-articular tophaceous nodules and erosion.   osteopaenia is seen until late in the disease.

29.  Radiograph of the index and middle finger of the right hand showing periarticular soft tissue swellings (arrows A) and eccentric ‘punched out’ lytic bone erosions with thin sclerotic margins and overhanging edges (arrows B). There is preservation of the interphalangeal joint spaces and absence of periarticular demineralisation (features that respectively help to differentiate gout from psoriatic or rheumatoid arthropathy

30. Radiograph of right hand showing erosions and punced out lesions

31. Rheumatoid arthritis chronic systemic connective tissue disease principally involving synovial joints hands and wrists are a focal target area.   Typical features - symmetrical , deforming polyarthropathy , - proximal joints : the distal radio- ulnar joint (especially the ulnar styloid ), radio-carpal , mid-carpal and the metacarpophalangeal joints.   Most patients have radiological evidence of erosions by three years  .  

32. Right hand radiograph -proximal osteoarthropathy and ulnar subluxation of the 5 th metacarpophalangeal joint. Peri-articular osteoporosis, marginal bone erosions and subluxations .

33. Progressive narrowing of a joint in rheumatoid arthritis. Y ear 1. The metacarpophalangeal joint looks normal . (B) Y ear 3. There is narrowing of the metacarpophalangeal joint of the index finger with associated local soft-tissue swelling. Erosive change is demonstrated at the metacarpal head. ( C) Y ear 4. Little change over the year. ( D) Y ear 13. On this late film the soft tissues remain thickened. The joint space is obliterated. Erosive change is demonstrated, especially at the metacarpal head

34. Obliteration of the medullary cavity of the distal phalanges . The new bone is very dense and well defined. The change is especially marked at little and ring fingers.

35. Left wrist radiograph – concentric joint space narrowing and fusion of the carpal bones of the left wrist (late signs ). changes in the ulna styloid and distal radioulnar joint (early signs ).

36. Gross rheumatoid arthritis at the carpus with ulnar deviation, subluxation and joint narrowing at the metacarpophalangeal joints .

37. Psoriatic arthritis common seronegative spondyloarthropathy which affects 20% of patients with psoriasis. characterised by -inflammatory arthritis, a predilection for the distal joints of the hands and feet. Erosions tend to occur at the margins of the distal interphalangeal -such that the terminal phalanx may sit at an angle resembling a pencil resting in a cup.   Bone proliferation is also a feature; periostitis -phalanges , bilateral and asymmetrical, associated with soft tissue swelling giving rise to the typical ‘ sausage digit ’ appearance. Occasionally acroosteolysis of the distal phalanx is also seen. Bone mineral density is preserved.

38. Right index finger radiograph shows distal interphalangeal joint erosion with characteristic ‘pencil in cup’ deformity, (ill-defined erosion with adjacent periosteal new bone formation ).

39. Left middle finger radiograph of the same patient shows distal interphalangeal joint erosion new bone formation at the distal phalanx (arrows). Soft tissue swelling of the digit ‘sausage digit’ is also noted.

40. Erosive osteoarthritis Key findings Arthropathy with the age of onset and distribution of osteoarthritis, with an inflammatory and erosive component. Clinical Inflammatory form of osteoarthritis of the hand Affects the DIP and PIP joints and the first carpometacarpal joint of the hand most frequently, just like osteoarthritis.

41. Radiological findings A rticular : joint space narrowing B one: sclerosis, productive bony changes with osteophyte formation, ankylosis C artilage: subchondral central erosions  D istribution: see illustration. Same distribution as with osteoarthritis, with a preference for the IP joints (DIP more than PIP) E xtra findings: occurs primarily in postmenopausal women S oft tissue: rheumatoid arthritis-like proliferative intra articular synovitis , soft tissue swelling around the joint

42. Erosive changes of PIP 2-5 and DIP 3-5. Typical gullwing deformity in DIP 3 (white arrow).

43. Ball catcher view of the hands in a patient with erosive osteoarthritis. There is bilateral extensive damage to the IP joints. .  

44. Dermatomyositis   autoimmune inflammatory myopathy , with diffuse nonsuppurative inflammation of striated muscle and skin. female m/c c/f -gradual onset muscle weakness, elevated muscle enzymes and elevated myositis -specific antibodies, (anti-Jo-1 ).   swelling of the distal joints of the hands

45. Radiographic features include cutaneous calcific deposits (40%), and rarely , acro-osteolysis (more common in scleroderma). The calcific deposits are usually more ‘ linear, reticular and lacy’, and more widespread than those seen in scleroderma (5).   found in the soft tissues of extremities as well as overlying large joints, chest and abdominal wall (especially in younger patients). Unlike scleroderma, osteopaenia is not a feature.  

46. Radiograph of the index finger of the right hand showing confluent digital soft tissue calcifications. No peri-articular erosions.

47. Endocrinal and nutritional/metabolic disorders . Acromegaly adulthood , excessive growth hormone secretion from a pituitary eosinophilic adenoma -growth of intramembranous bone tissue and subcutaneous hypertrophy. prominent in hands and feet ( Acral parts) from which the term acromegaly is derived. Heel pad thickness is greater than 20mm . A reliable indicator is the generalized increase in joint space width owing to cartilage overgrowth.

48.  Radiographs may reveal osseous enlargement , presenting with ‘ spade-like’ hands and widening of the terminal phalangeal tufts , giving an ‘arrow-head’ appearance  Other features in the hand may include prominent muscle attachments and widened joint spaces (due to cartilage hypertrophy ). Generalised osteoporosis and cystic changes in the carpal bones are also described.  

49. Radiograph of the left hand showing widening of the terminal phalangeal tufts with a ‘arrow-head’ appearance. The hand is enlarged and soft tissue swelling is noted

50. Hyperparathyroidism uncontrolled production of parathyroid hormone which usually leads to an increase in serum alkaline phosphatase and calcium and a decrease in serum phosphate. Bone pain and tenderness may be the presenting features . Hand radiographs often show osteopaenia and bone demineralisation . The most pathognomic finding however is subperiosteal bone resorption . -radial aspect of the middle phalanges of the index and middle fingers. Early findings are of proximal metaphyseal cortical irregularity. Chronic features include spiculated cortical scalloping (may involve the entire digit), acro-osteolysis in rare cases, lytic lesions caused by accumulations of osteoclastic giant cells known as ‘brown tumours .’

51. Radiograph of the index finger of the right hand showing subperiosteal bone resorption of the radial aspect of the entire digit but particularly affecting the middle phalanx.

52. Radiograph of the middle finger showing more developed features of hyperparathyroidism including acro-osteolysis coarse spiculated cortical reaction (B ). This involves the entire digit but is more marked on the radial aspect.

53. Radiograph showing subperiosteal resorption of the radial margins of the proximal and middle phalanges of the second and third digits . Central, slightly expansile , septated , lytic lesion is seen in proximal end of the fifth metacarpal (Brown tumour )

54. Thyroid acropachy Acropachy (‘thickening of the extremities’) occurs as one of the extra-thyroid manifestations of auto-immune thyroid disease. Graves ’ disease, Hashimoto’s thyroiditis .   seen in patients treated with radioiodine ablation for hyperthyroidism-common in smokers.

55. Solid periosteal new bone formation usually bilateral, relatively symmetric and painless, and involves the diaphyseal tubular bones of the hands and feet. 

56.  Radiograph of the right hand showing thick ‘feathery’ periosteal reaction of the index and middle fingers. The mid-portions of the diaphyses are typically affected.

57. Rickets- vitamin D deficiency decreased mineralization at the growth plate resulting in growth retardation and delayed skeletal maturation . Defective mineralization of trabecular bone is called osteomalacia . Rickets can only be seen in children before closure of growth plates, while osteomalacia can occur at any age

58. Radiological features -widening , cupping and fraying of metaphyses , craniotabes bowing of long bones, genu valgum , scoliosis, triradiatepelvis , rachitic rosary and periosteal reaction. Knees, wristsmand ankles are affected predominantly.

59. Hand radiograph shows widening, cupping, and fraying of distal metaphyses of the ulna and radius. There is reduction in bone density with prominence of trabeculae and thinning of cortex. Findings are typical for rickets. Follow-up radiograph 3 weeks after initiation of vitamin D therapy shows dense metaphyseal band of provisional zone of calcification (arrows), suggestive of healing rickets

60. M iscellaneous Hypertrophic Osteoarthropathy triad of digital clubbing, symmetric arthritis and periostitis -visceral disorder, usually intrathoracic in location. MC males in 4th-6th decades. MC is hypertrophic pulmonary osteoarthropathy (HPOA), a paraneoplastic syndrome secondary to carcinoma of the lung Radiographs show bilateral, symmetric, linear periostitis (most common in the tibia, fibula, radius and ulna), joint effusions, digital clubbing visible as a bulbous enlargement of the distal fingertips

61. Radiograph of the ring finger of the left hand widespread irregular periosteal proliferation of the phalanges (arrows ). There is cortical thickening without narrowing of the medulla . .

62. Radiograph of the right thumb shows smooth laminar periosteal proliferation of the proximal metacarpal (arrows ). Mc site of hand involvement is the ulnar aspect, peri-metaphyseal region of the proximal phalanx.

63. Scleroderma (or Progressive Systemic Sclerosis multi-system connective tissue disorder of unknown aetiology . Musculoskeletal symptoms -fatigue and myalgia accompanying arthralgia . hand radiographs will show absorption of the distal phalangeal tuft ( acro-osteolysis ). The result is thinning of the bone distally. Peri-articular osteopaenia and erosions are typical.   Subcutaneous calcifications are also seen, particularly on the extensor surfaces of the hands.

64.  Radiograph of the radial aspect of the right hand shows acro-osteolysis of the phalangeal tufts (arrow A), and soft tissue calcifications (arrow B). There is peri-articular osteopaenia . Additionally, erosions are commonly seen at the interphalangeal and metacarpophalangeal joints.

65. references RADIOLOGY OF HAND-MIRROR OF VARIOUS SYSTEMIC DISEASES Sadashiva Gowda H1 Twenty classic hand radiographs that lead to diagnosis Govind B. Chavhan & Elka Miller & Erika H. Mann . Sutton

66. Thank you