High-Resolution Radiographs of the Hand

Giuseppe Guglielmi ∙ Wilfred C.G. Peh ∙ Mario Cammisa

High-Resolution Radiographs of the Hand

Giuseppe Guglielmi Wilfred C. G. Peh Mario Cammisa

High-Resolution Radiographs of the Hand With 213 Figures

123

Giuseppe Guglielmi, MD Professor of Radiology University of Foggia Viale L. Pinto, 1 71100 Foggia Scientific Institute Hospital San Giovanni Rotondo Italy

Wilfred C. G. Peh, MBBS, MD, FRCP, FRCR Clinical Professor and Senior Consultant Department of Diagnostic Radiology Alexandra Road 378 Alexandra Road Singapore 159964 Republic of Singapore Mario Cammisa, MD Professor Emeritus of Radiology Via Acherusio, 32 00199 Roma Italy

ISBN 978-3-540-79479-0

e-ISBN 978-3-540-79480-6

DOI 10.1007/978-3-540-79480-6 Library of Congress Control Number: 2008928137 © 2009 Springer-Verlag Berlin Heidelberg This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, eStudio Calamar, Spain Production & Typesetting: le-tex publishing services oHG, Leipzig, Germany Printed on acid-free paper 987654321 springer.com

This book is dedicated to our families. Their continuous love, support, and inspiration to us are much appreciated.

Foreword  I

Plain radiography is still alive. In many institutions, including ours, conventional radiography has been replaced by digital systems including imaging-plate-based computed radiography and flat-panel detector-based digital radiography. Even for the education of radiation technologists, conventional film-screen radiography has been de-emphasized, and their education is concentrated on digital systems. Spatial resolution of a conventional system is still far better than the current digital systems, although the dynamic range is wider in the latter system. Industrial film radiography with small grain size and direct exposure has an even higher resolution, and such highresolution systems are something we lost in the transition from the conventional system to the current PACS-friendly system. I am pleased to know that Giuseppe Guglielmi and Wilfred Peh have published this textbook of high-resolution hand radiographs that cannot be obtained with any other techniques. Radiography has always been the most important modality in the evaluation of the hand, and, moreover, high-resolution industrial films are extremely effective in the evaluation of the hand, particularly for assessing subtle erosions. Hands are not just one of the peripheries of the human body. They reflect conditions of the whole human body. Not only the metabolic status, but also many congenital disorders are manifested in the hand. Radiographic findings of the hand are often specific, and contribute to the diagnoses a great deal. There have been several publications concerning the radiology of the hand, and they have been well accepted. I congratulate Giuseppe Guglielmi, Wilfred Peh and Mario Cammisa for accomplishing this important task. I hope this work is accepted widely by those who are interested in musculoskeletal imaging. May 2008, Morioka, Japan Professor Shigeru Ehara, MD President of the Asian Musculoskeletal Society (AMS)

Foreword  II

Imagine the ultimate charts of the most important photographs of humankind! The photograph of the hand of Mrs. Roentgen by means of X-rays will surely be in the “Top 10.” The discovery of “X-rays” by Conrad Roentgen marked a rarely paralleled breakthrough in the diagnosis of normal and pathologic conditions. The use of X-rays has brought to light numerous new pathologies. This is particularly true for the diagnostic evaluation of the hand, although the thin soft tissue covering of the hand allows relatively easy clinical examination of this anatomic area. In the last 30 years, diagnostic imaging of the hand has changed dramatically. New modalities such as bone scintigraphy and crosssectional imaging (CT, MRI, sonography) have evolved. At the same time tremendous progress has been made in therapeutic options, mainly due to microsurgical techniques. We have learned more about the pathophysiology and biomechanics of the wrist. The enthusiasm provoked by this progress may tempt the inexperienced medical community to underestimate the value of X-rays in the diagnosis of numerous conditions in the hand. At such a time a book against the trend is more than necessary. The authors and the publisher are to be congratulated for presenting at the right time a book of high aesthetic and didactic quality about a seemingly “old-fashioned” topic. It is a sign of deep understanding and knowledge to underline the enormous validity of X-rays in the diagnostic workup of local and systemic disease in the hand. We have to understand that for the majority of pathologic conditions, cross-sectional imaging and scintigraphic techniques complete the technically perfect radiograph of the hand—and not vice versa. It is to the great merit of Giuseppe Guglielmi, Wilfred Peh and Mario Cammisa that they illustrate the tremendous diagnostic



Foreword  II

potential of X-rays at the right time. There is a saying “an image tells more than thousand words.” The authors have followed this principle with great success. They have to be thanked for the investment of time and energy that a project such as this requires. June 2008, Augsburg, Germany Professor Klaus Bohndorf, MD President of the International Skeletal Society

X

Foreword  III

Despite sophisticated imaging methods developed in the hundred years since the discovery of X-rays, plain radiography is still the primary method of choice in the evaluation of skeletal system diseases. In most systemic diseases, pathologic changes develop in the bone and soft tissues of the hand and wrist, whose images can be taken easily and at low cost. Diseases originating from bone can also cause radiological changes in the hand and wrist. Using the appropriate technique and position in radiological evaluations of pathological conditions involving the hand and wrist is essential for proper diagnosis. In this atlas, diseases leading to pathological changes in the hand and wrist, normal radiological images taken in different stages of disease and variants are displayed in detail using high-resolution industrial radiographs. The authors demonstrate how it is still important to use analogue technique imaging for fine details in the assessment of small bone structures. The information provided for each example will help the reader remember the images related to each disease, and the atlas will be an important source not only for radiologists but also for rheumatologists, orthopedists, hand surgeons and their residents. I would like to congratulate Giuseppe Guglielmi, Wilfred Peh and Mario Cammisa, the authors of the book, for their meticulous work. We are grateful for the time and enthusiasm they gave to this effort. June 2008, Izmir, Turkey

Professor Remide Arkun, MD President of European Society of Musculoskeletal Radiology (ESSR)

Preface

The hand, the first human part ever studied with X-rays, may be the primary clue to underlying systemic disease. In many instances, the findings on the radiograph of the hand may be pathognomonic of the disease. As the early stages of a disease usually begin with the involvement of a small area of tissue, the early diagnosis of pathologic conditions by means of radiographs requires the detection of minute changes. The challenge is therefore to produce X-ray images of findings much finer than those observable by the naked eye on conventional radiographs. This requirement is met by using highresolution industrial radiographs. High-resolution industrial radiographs are able to optimize the maximum amount of information in order to provide the best prognosis and facilitate management. There are conditions which require a higher X-ray dose to provide sufficient details in the image for a successful diagnosis. Mammography, oncology, and orthopedics are examples where there is a delicate balance of dose versus image quality. This atlas aims to illustrate various systemic as well as localized diseases that manifest themselves on radiographs of the hand and wrist and which need very detailed images in order to arrive at the diagnosis of the disease process. Sometimes, there are limitations in the radiologic diagnosis and, therefore, clinical, laboratory, and additional radiographic examinations are needed. However, satisfactory differential diagnosis can often be arrived at, even with a single radiographic finding, especially if the radiographic image is of excellent quality. This work is meant to be an atlas—not a text book—and therefore the illustrations are large and the written text is kept to a minimum. Each illustration is supplied with a description and, for the convenience of the reader, a supplementary reference list is presented at the end of the book. July 2008 Giuseppe Guglielmi Wilfred C. G. Peh Mario Cammisa

Acknowledgements

A very special thanks must go to Mark Kirk, HCIS Consultant, Carestream Health Italia for his contribution in writing the chapter on industrial radiographs.

Contents

1

High-Resolution Industrial Radiographs: An Introduction Historical Context  2 Industrial Film Performance Results  3

2

Normal Hand and Variant s

2.1

Standard Projections  10

2.2

Normal Child  12

2.3

Normal Teenager  14

2.4

Variants  16

3

Soft Tissue Lesion s

3.1

Chondrocalcinosis  26

3.2

Extraskeletal Chondroma  28

3.3

Joint Contractures  30

3.4

Metastatic Soft Tissue Calcification  31

3.5

Soft Tissue Edema  32

3.6

Vascular Calcification  34

4

Soft Tissue Lesions Involving Bone

4.1

Extraskeletal Chondroma  38

4.2

Gout  40

4.3

Scleroderma  42

5

Cortical and Periosteal Lesions

5.1

Epidermoid Cyst  46

5.2

Osteochondroma  48

5.3

Osteoid Osteoma  50

5.4

Osteoporosis  52



Contents 5.5

Periosteal Enchondroma  54

5.6

Periostitis Ossificans  56

5.7

Renal Osteodystrophy: Subperiosteal Resorption  60

5.8

Renal Osteodystrophy: Severe  62

6

Articular Lesion s

6.1

Gout  66

6.2

Juvenile Chronic Arthritis  68

6.3

Multicentric Reticulohistiocytosis  70

6.4

Osteoarthritis  72

6.5

Osteoarthritis: Early  77

6.6

Osteoarthritis: Erosive  80

6.7

Osteoarthritis: Loose Body  84

6.8

Osteoarthritis: Primary  86

6.9

Osteoarthritis: Severe  89

6.10

Osteoarthritis: Thumb  92

6.11

Osteoarthritis: Ulnar Styloid  94

6.12

Psoriasis  96

6.13

Pyrophosphate Arthropathy  100

6.14

Rheumatoid Arthritis: Carpal  102

6.15

Rheumatoid Arthritis: Early  104

6.16

Rheumatoid Arthritis: Moderate  106

6.17

Rheumatoid Arthritis: Severe  110

6.18

Systemic Lupus Erythematosus  112

7

Associated Articular and Soft Tissue Lesions

7.1

Amyloidosis and Renal Osteodystrophy  116

7.2

Calcium Pyrophosphate Dihydrate Deposition Disease  118

7.3

Vascular Calcification and Renal Osteodystrophy  120

8

Bone Lesion s

8.1

Generalized  124

8.2

Multiple  138

8.3

Solitary  148

Bibliography  Subject Index 

XVIII

169 171

1

High-Resolution Industrial Radiographs: An Introduction

Historical Context Industrial Film Per formance Results

1

1

High-Resolution Industrial Radiographs: An Introduction

Historical Context The historical development of radiology has been driven by the need to provide the most accurate diagnosis of the patient’s ailment, using the technique that gives the greatest amount of information in order to provide the best prognosis and resulting management plan. Technology suppliers have worked diligently with radiologists to provide better technology to match the improvements made in radiology techniques. This cooperation with radiologists and technologists, working together to help patients, has occurred on virtually a daily basis. The early radiographic films were very similar to industrial radiographs. They both used small crystals to absorb the direct X-ray exposure to give excellent image quality. A high dose, with manual processing, was used. Companies such as Kodak led the way to develop materials that could reduce the dose. • 1960s  Kodak developed blue emitting screens to reduce the dose by 50%. • 1970s  3M developed green Trimax screens to reduce the dose by another 50%. • 1980s  Kodak developed T Grain technology for faster automatic processing and higher image quality. • 1990s  Kodak developed InSIGHT dedicated thoracic films. • 1990s  With mammography films, there were massive improvements in film structure and emulsion technology to improve dose and image quality. The original equipment manufacturers (OEMs) made massive strides in new digital technology, improving: • Computed tomography (CT) scanners • Magnetic resonance (MR) imaging scanners • Positron emission tomography (PET) scanners • Computed radiography • Digital radiography • Picture archiving and communication systems (PACS) This mixture of techniques and technology has benefited numerous patients, leading to successful clinical outcomes. There exist ailments that require a higher X-ray dose to provide sufficient details in the image for a successful diagnosis. Mammography and oncology are

2

1

High-Resolution Industrial Radiographs: An Introduction

examples in which this delicate balance of dose versus image quality is required in order to make the right diagnosis. Orthopedics is another area where some ailments require very special imaging techniques to be able to make the right diagnosis. This book is dedicated to describing the techniques and applications required for the minority of patients who need very detailed images of the hand for the diagnosis of disease.

Industrial Film Performance Results Many papers in the radiologic literature have defined how to obtain optimal, high-resolution images of bone structures. Using highquality, fine phosphor crystals in the analog radiographic screens, coupled with a radiographic film having an intrinsic high contrast, has been recommended. This combination permits the reduction of granularity in the radiographic image, which, if not controlled, would negatively impact any resolution of fine details in the image. This particular type of examination demands an extremely high definition combined with high contrast, which can be achieved by using two different technical solutions: 1. A double-sided film, normally used in industrial applications, containing a high quantity of very fine silver halide crystals with a very narrow distribution profile. This creates, after processing, a high contrast image with a high resolution. The film is directly exposed in its light-safe container, in direct contact with the element being X-rayed. 2. A film/screen combination based on mammography film with its corresponding mammography screen exposed using X-ray techniques more normally seen in dedicated mammography examinations. The two systems were compared using the following parameters: • Dose and contrast (measured based on ISO 9236-1) • Modulation transfer function (MTF) (measured based on ISO 9236-2) The processing condition optimization study of the two systems was done using a manual and an automatic process. The two systems were evaluated in an automatic process, using a dedicated mammography processor with dedicated mammography processing chemi-

3

1

High-Resolution Industrial Radiographs: An Introduction

cals, while the manual process was reserved for the X-OMAT industrial film.

Automatic Processing Conditions • Developer temperature = 34°C • Total processing time (dry to dry): –– Min-R EV mammography film = 120 s –– X-OMAT MA industrial film = 270 s

Manual Processing Conditions • Developer temperature = 32°C • Variable treatment time in the processing bath = 3–5 min • Fixed treatment time in the processing bath = 1 min

Fig. 1  Sensitometric curve comparison using automatic processing conditions

4

1

High-Resolution Industrial Radiographs: An Introduction 5

4.5

OPTICAL DENSITY

4 3.5

AUTOMATIC PROCESSING MANUAL PROCESSING

3 2.5 2 1.5 1 0.5

4

3 3. 2 3. 4 3. 6 3. 8

1 1. 2 1. 4 1. 6 1. 8 2 2. 2 2. 4 2. 6 2. 8

0. 2 0. 4 0. 6 0. 8

0

0

LOG RELATIVE EXPOSURE

Fig. 2  Sensitometric curve effects of automatic versus manual processing of X-OMAT MA film

5 4.5 4

5 Minutes 4 Minutes 3 Minutes

OPTICAL DENSITY

3.5 3 2.5 2 1.5 1 0.5

4

2 3. 4 3. 6 3. 8

3.

3

2 2. 2 2. 4 2. 6 2. 8

1. 2 1. 4 1. 6 1. 8

1

8 0.

0 0. 2 0. 4 0 .6

0

LOG RELATVE EXPOSURE

Fig. 3  Sensitometric effect of varying manual processing time of X-OMAT MA film

5

1

High-Resolution Industrial Radiographs: An Introduction

Interpretation of Results Figures 1–3 demonstrate that by increasing the manual processing time, the average contrast increases to achieve a maximum of 3.30. There is also a slight increase in sensitivity as the processing lengthens, corresponding to a lower patient dose. In manual processing, the use of a hardener-free developer, such as Kodak LE Plus Developer, is strongly suggested as it permits a more even and rapid development process to be obtained.

Contrast and Dose The two systems under consideration were exposed using a GE Mammograph SENOGRAPHE DMR and a plastic step-wedge, with 12 steps to validate the dose received at 28 Kv. The following systems were exposed: 1. Kodak X-OMAT MA industrial film / direct exposure 2. Kodak Min-R EV mammography film / Kodak Min EV150 screen Exposure technique: • 28 Kv, 160 mA, ddf 60 cm • 28 Kv, 12 mA, ddf 60 cm The automatic processing times were varied, based on the chemical and physical characteristics of the two films evaluated. The results indicated significant differences in the speed of the systems and the contrast of the resulting images.

Kodak X-OMAT MA Film The direct exposure achieved an average contrast value at 3.30 that may be considered as the optimum value to permit the visualization of fine bone structure. A critical parameter is to be able to see dense bone structure that absorbs significant quantities of the X-rays. This is the toe contrast value, which in this system has a value of 1.45 that permits very small variations in X-ray absorption to be seen with different gray levels. This results in a greater capability to diagnose details in the area of low optical density in the radiographic image.

6

1

High-Resolution Industrial Radiographs: An Introduction

Kodak Min-R EV Film /  Kodak Mammography EV150 Screen The film-screen system delivered an average contrast of 4.52, giving significant advantages in the appropriate mammography examinations done with this system, while in the diagnosis of fine bone structure, the extremely high contrast negatively affects the perception of the image by increasing the perception of the granularity of the image. Combined with this, the toe contrast gave a value of 2.04, which reduces the ability to perceive small changes in gray levels in the areas of underexposure, predominantly of dense bone structures. One significant advantage of this system is that the patient exposure dose is drastically reduced, compared to the direct exposure system.

Modulation Transfer Function (MTF) The MTF measurement was based on a target of parallel X-rayopaque and X-ray-transparent layers. The variable frequency of fine lead strips is the basis of this target. As the frequency of the lead strips increases, the spaces between the maximum density areas decreases (Dmax areas correspond to strips of X-ray-transparent materials) and the spaces between the strips of minimum density increase (Dmin areas correspond to strips of lead in the target). The higher frequency corresponds to an increased difficulty in being able to distinguish areas of rapid changes in the light and dark strips. The study of the MTF helps in defining the ability of the radiographic system to differentiate the smallest anatomic detail with diagnostic confidence. A higher MTF value corresponds to a higher diagnostic quality of the radiographic image. The direct exposure, without using phosphor screens, of X-OMAT MA gave a higher MTF compared to the dedicated mammography system, Min-R EV/ EV150, using phosphor screens, which despite having very fine grain X-ray phosphors, compromised the sharpness of the resulting images (Fig. 4).

7

1

High-Resolution Industrial Radiographs: An Introduction

1.2

1

0.8

Min R EV / MIN R 150 Screen 0.6

X OMAT MA

0.4

0.2

0

0

1

2

3

4

5

6

7

8

9 10 11 12 13 14 15 16 17 18 19 20

Spatial Frequency in Object Plane (cycles/mm)

Fig. 4  Modular transfer function comparison of systems

Conclusions The improvements in digital technology are proving to be of significant benefit to patient care in terms of lower dose and improved manipulation of data for more effective image diagnosis. The work developed here demonstrates clearly that, in the orthopedic assessment of small bone structures, there exists a need for a level of extremely high image quality for very specific ailments, where the dose is a secondary concern. The clarity of details in the image permits an accurate diagnosis and hence permits a relevant patient management plan. Over the last ten years, digital imaging has made outstanding improvements to patient care. The use of alternative analog techniques, which can still offer considerable patient care, will be superseded by digital imaging in the near future. Today, the crossroads has been reached, such that analog techniques are still part of the weaponry that radiologists can use for the niche cases in which digital imaging has still yet to offer a complete solution.

8

2

Normal Hand and Variants

2.1

Standard Projections

2.2

Normal Child

2.3

Normal Teenager

2.4 Variants

9

2

2.1

Normal Hand and Variants

Standard Projections

The standard radiographic projections in the study of the hand are: posteroanterior (PA), lateral, semipronated oblique, and semisupinated oblique. Most specific projections which can be added in particular clinical cases are PA with ulnar deviation and/or cephalad tube angle, complete three-views, carpal tunnel projection, externally rotated oblique, internally rotated oblique, anterior-posterior (AP) or PA of thumb, PA with valgus stress, and contralateral comparison. For most patients with trauma of the hand, wrist, or both, radiographs provide adequate diagnostic information and guidance for the treating physician. In most patients with suspected distal radius fractures, a three-view radiographic examination (PA, lateral, and 45-degree semipronated oblique) suffices, while a recent study suggests that the routine addition of a fourth projection—a semisupinated oblique projection—would increase the yield for distal radius fractures, which may be visible only on this fourth view. The diagnosis of distal radioulnar joint (DRUJ) subluxation is problematic. The symptoms and physical findings are often nonspecific, and the condition is difficult to confirm radiographically. An additional fourth radiographic projection—an elongated PA view with approximately 30 degrees of cephalad beam angulation and the wrist positioned in 10–15 degrees of ulnar deviation—is recommended as a routine whenever there is clinical suspicion of a scaphoid fracture. Compared with the scaphoid, the diagnosis of other carpal bone injuries is less problematic. In specific circumstances, however, supplemental studies in addition to the standard wrist examination are useful. Pisiform fractures are best seen on semisupinated AP or carpal tunnel projections, which project the pisiform volar to the rest of the carpus. The same projections may also demonstrate fractures involving the hook of the hamate that are not visible on the standard radiographs. Most fractures of the thumb will be visible on a two-view radiographic examination, although there is a slight increase in diagnostic yield with the addition of an oblique projection. The standard PA projections are nicely illustrated in both hands of an adult (Figures a, b).

10

2

Normal Hand and Variants

11

2

Normal Hand and Variants

2.2

Normal Child

Radiographs of the child’s hand and wrist are notoriously difficult to interpret due to the extent of nonossified cartilage in the immature hand. The center of ossification of the capitate is the first to appear radiologically at 3–4 months after birth, closely followed by the hamate, the triquetrum at 2–3 years, the lunate at 4 years, the scaphoid (where ossification begins distally) at 4–5 years, the trapezium at 5 years, the trapezoid at 6 years, and the pisiform at 9 years. The ossification centers appear in the carpus in anticlockwise fashion (when looking at the dorsum of the right wrist). The epiphyses of the phalanges and the thumb metacarpal are situated at their bases, whereas those of the other metacarpals lie distally. Occasionally there are anomalies such as an extra basal epiphysis of the index metacarpal. These features are nicely illustrated in the hands of two children (Figures a–d).

12

2

Normal Hand and Variants

13

2

2.3

Normal Hand and Variants

Normal Teenager

Three main groups of bones constitute the skeleton of the hand. From proximal to distal, these include the carpal bones, metacarpal bones, and the phalanges. Additionally, the hand also contains some small bony structures termed sesamoid bones. Sesamoid bones may be found on the palmar surface of the hand. The two commonest are in the tendons of the thumb in the two heads of the flexor pollicis brevis at the metacarpophalangeal joint. The other sesamoid bones of the hand are usually found at the metacarpophalangeal portion of the volar plate. The hand contains eight carpal bones made up of two rows of four bones each. From lateral to medial, the proximal row consists of the scaphoid, lunate, triquetrum, and pisiform bones. In the same order, the distal row consists of the trapezium, trapezoid, capitate, and hamate bones. The anterolateral margins of the scaphoid and trapezium elevate and protrude forward to make an attachment site for the flexor retinaculum. The hamate bone has a bony hook volarly, and the pisiform stands on the triquetrum; thus, these two protrusions provide the medial attachment side for the flexor retinaculum. The distal row of the carpal bones joins to the metacarpal bones to form the carpometacarpal joint. The carpus is cartilaginous at birth. The capitate begins to ossify during the first year, and the others begin to ossify at intervals thereafter until the 12th year, when all bones are ossified. The hand has five metacarpal bones. From proximal to distal, each has a base, a shaft, and a head. The first metacarpal bone constitutes the skeleton of the thumb and is the shortest and most mobile. It is in contact with the trapezium proximally. The other four metacarpals contact with the trapezoid, capitate, and hamate, with articulations at the lateral-medial surfaces of metacarpal bones. The heads of the metacarpal bones, which form the knuckles, articulate with the proximal phalanges. The shaft of each metacarpal bone is slightly concave forward and is triangular in transverse section, with medial, lateral, and posterior surfaces. The hand has 14 phalanges. Each finger contains three phalanges, while each thumb only has two phalanges. These features are nicely illustrated in both hands of a teenager (Figures a, b).

14

2

Normal Hand and Variants

15

2

Normal Hand and Variants

2.4

Variants

2.4.1

Carpal Fusion

This congenital anomaly may occur either as an isolated finding or as part of a syndrome. In general, the isolated form occurs between bones on the same carpal row, and bones on different rows are involved in syndromes. The lunatotriquetral form is the most common form of this anomaly, involving about 0.1% of Caucasian Americans and about 1.6% of African Americans. The lunatotriquetral form of this anomaly has little or no clinical significance, and has very little effect on wrist motion. The second most common type of this anomaly is the capitate-hamate form. Other forms are much rarer and include trapezium-trapezoid, capitate-trapezoid, pisiformhamate, and others. The term “carpal fusion” does not make sense, since that would imply that the two bones were once apart. However, it should be noted that there are indeed acquired forms of carpal fusion, including surgical fusion, prior trauma, and inflammatory disease such as rheumatoid arthritis. In the right clinical setting, these causes should be considered. Radiographic appearances of carpal fusion is present in diverse forms, for example: bones may be completely united or partially so with a notch present, or there may be narrowing of joint space. Scaphotrapeziotrapezoid fusion is seen as union of the scaphoid, trapezium, and trapezoid. These features are nicely illustrated in both hands of an adult with bilateral tricarpal fusion (Figures a–d).

16

2

Normal Hand and Variants

17

2

Normal Hand and Variants

2.4.2

Clinodactyly

The term clinodactyly is used to describe a bending or curvature deformity of the finger which occurs in the plane of the hand. Clinodactyly is typically caused by abnormal growth and development of the small bones of the finger (the phalanges). In many cases, there may be abnormal shape or orientation of the growth plate. Rather than growing perpendicular to the axis of the finger, these bones may deviate in their direction of growth, resulting in trapezoidal or triangular-shaped bones (the so-called delta phalanx). This can cause a shift in the alignment of the finger joints. Clinodactyly is estimated to be present in approximately 10% of the general population to varying degrees. It tends to be present more commonly in males and usually affects the small finger. Bilateral involvement is common. Clinodactyly can be an inherited condition and may present as part of an associated syndrome. A significant percentage of patients with Down syndrome, for example, have clinodactyly. Clinodactyly is seen as permanent medial or lateral deflection of the fingers, producing a curved deformity. These features are nicely illustrated in both hands of an adult with bilateral clinodactyly of the little fingers (Figures a–d).

18

2

Normal Hand and Variants

19

2

Normal Hand and Variants

2.4.3

Sesamoids

Sesamoid bones are small rounded masses embedded in certain tendons and usually related to joint surfaces. Their functions probably are to modify pressure, to diminish friction, and occasionally to alter the direction of a muscle pull. That they are not developed to meet certain physical requirements in the adult is evidenced by the fact that they are present as cartilaginous nodules in the fetus, and in greater numbers than in the adult. They must be regarded as integral parts of the skeleton phylogenetically inherited. In the upper extremity, the sesamoid bones of the joints are found only on the palmar surface of the hand. Two sesamoids, of which the medial is the larger, are constant at the metacarpophalangeal joint of the thumb; one is frequently present in the corresponding joint of the little finger, and one (or two) in the same joint of the index finger. Sesamoid bones are also found occasionally at the metacarpophalangeal joints of the middle and ring fingers, at the interphalangeal joint of the thumb and at the distal interphalangeal joint of the index finger. Sesamoid bones are seen as rounded corticated ossicles at the palmar aspect of the metacarpal heads. These features are nicely illustrated in both hands of an adult with multiple bilateral sesamoids of the thumb, and index, middle, and little fingers (Figures a–d).

20

2

Normal Hand and Variants

21

2

Normal Hand and Variants

2.4.4

Ulnar Styloid Ossicle

The accessory ulnar styloid process is an uncommon variant in the wrist. It is a bony protuberance at the dorsum of the base of the second or third metacarpal that may or may not be fused. Overlying the carpometacarpal joint, this accessory ossification in some cases may be degenerative, not congenital, in origin. Although it can be asymptomatic, when traumatized, it can be responsible for pain in the ulnar border of the wrist. Identification of this variation is of importance because the injury may occur as a result of chronic repetitious trauma and the ossicle may easily be mistaken for a fracture. These features are nicely illustrated in the hands of two adults with an ulnar styloid ossicle (Figures a–d).

22

2

Normal Hand and Variants

23

3

Soft Tissue Lesions

3.1

Chondrocalcinosis

3.2

Extraskeletal Chondroma

3.3

Joint Contractures

3.4 Metastatic Soft Tissue Calcification 3.5

Soft Tissue Edema

3.6 Vascular Calcification

25

3

3.1

Soft Tissue Lesions

Chondrocalcinosis

Chondrocalcinosis refers to the radiographic finding of calcification in hyaline and/or fibrocartilage. It may be caused by several different disorders, such as calcium pyrophosphate dihydrate deposition disease (CPPD), hyperparathyroidism, hemochromatosis, hypophosphatemia, acromegaly, gout, Wilson’s disease, and alkaptonuria. The clinical manifestations of CPPD are varied, and are due to precipitation of calcium pyrophosphate dihydrate crystals in the connective tissues. CPPD is a polyarticular disorder, although it can initially be monarticular. Patients usually present with painful inflammation in one or more joints. Chondrocalcinosis is seen as calcifications of both the fibrocartilage as well as articular hyaline cartilage. These features are nicely illustrated in the hands of an adult with bilateral triangular cartilage calcifications (Figures a–c).

26

3

Soft Tissue Lesions

27

3

3.2

Soft Tissue Lesions

Extraskeletal Chondroma

Extraskeletal chondroma is a rare benign cartilaginous tumor that is most frequently seen in the soft tissues of the hands and feet. This lesion usually presents in adults aged between 30 and 60 years. Histologically, it is a well-circumscribed multinodular tumor that consists of mature hyaline cartilage, with areas of vascular interlobular connective tissue. Calcification is a late feature, and is more prominent in the center than the periphery of the tumor. Extraskeletal chondroma is seen as a soft tissue mass with scattered calcified foci. These features are nicely illustrated in the hand of an adult with an extraskeletal chondroma of the little finger (Figures a, b). On magnetic resonance imaging, a predominantly hyperintense signal indicative of a chondromatous lesion is present.

28

3

Soft Tissue Lesions

29

3

3.3

Soft Tissue Lesions

Joint Contractures

Joint contractures may be due to a variety of causes such as Dupuytren’s contracture, burns, Volkmann’s ischemic contracture, Parkinson’s disease, and even congenital disorders such as arthrogryposis multiplex congenita. Also known as claw hand, Dupuytren’s contracture causes flexion deformities of the fingers, most often affecting the ring or little finger. The cause is unknown. It occurs most often in middle-aged white men and is genetic. The palmar fascia thickens and becomes nodular, producing progressive flexion contractures of the fingers. Treatment may be non-surgical or surgical, depending on how advanced the contractures are. These features are nicely illustrated in the hand of an adult with flexion contractures of the fingers (Figure a).

30

3

3.4

Soft Tissue Lesions

Metastatic Soft Tissue Calcification

Also known as calcific pseudogout, metastatic calcifications are seen in patients undergoing hemodialysis for chronic renal failure. These patients often present with painless hard soft tissue swellings on the hand. Clinically, these calcifications may mimic the tophi of urate arthropathy, although they tend to be denser. Other causes of soft tissue calcifications of the digits include primary hypercalcemia and collagen diseases such as scleroderma and polymyositis. Metastatic calcifications are seen as areas of amorphous soft tissue density in the soft tissues of the hand. These features are nicely illustrated in the hand of an adult undergoing hemodialysis for chronic renal failure (Figure a). Bony changes of renal osteodystrophy should also be looked for.

31

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3.5

Soft Tissue Lesions

Soft Tissue Edema

Soft tissue edema may be due to a variety of causes, including infection, trauma, myxedema, and peripheral edema due to a variety of conditions such as cardiac failure and renal failure. Soft tissue thickening may be caused by other etiologies such as acromegaly and obesity. It is useful to correlate radiographic findings with clinical features. Soft tissue edema is seen as diffuse thickening of the soft tissues, often with patchy areas of increased radiolucency. These features are nicely illustrated in the hand of an adult with chronic renal failure. This patient also has bony features of secondary hyperparathyroidism due to renal osteodystrophy (Figures a, b).

32

3

Soft Tissue Lesions

33

3

3.6

Soft Tissue Lesions

Vascular Calcification

Calcification of the arteries may be due to a variety of causes. These include diabetes mellitus, hyperparathyroidism, atheroma, aneurysm, vitamin D intoxication, Werner’s syndrome, and Mönckeberg’s medial calcific sclerosis. Arterial calcification in diabetes mellitus more commonly occurs in the lower limbs. Arterial calcification is more common in secondary than in primary hyperparathyroidism. Arterial calcification is easily detected as linear and curvilinear calcifications in the walls of arteries located in known anatomic locations. These features are nicely illustrated in the hand of an adult with extensive arterial calcifications of the palm and digits (Figures a, b).

34

3

Soft Tissue Lesions

35

4

Soft Tissue Lesions Involving Bone

4.1

Extraskeletal Chondroma

4.2 Gout 4.3 Scleroderma

37

4

4.1

Soft Tissue Lesions Involving Bone

Extraskeletal Chondroma

Extraskeletal chondroma is a rare benign cartilaginous tumor that is most frequently seen in the soft tissues of the hands and feet. The diagnostic criteria for this tumor include its extraskeletal location and noninvolvement of the cortical bone or medullary cavity. Involvement of adjacent bone is therefore a very rare and confusing feature, particularly as radiographically and histologically extraskeletal chondromas may mimic chondrosarcoma. Extraskeletal chondroma is seen as a soft tissue mass with scattered calcified foci. There is osteolytic scalloping of the adjacent metacarpal with sclerotic margins. These features are nicely illustrated in the hand of an adult with an extraskeletal chondroma involving the adjacent metacarpal (Figures a, b).

38

4

Soft Tissue Lesions Involving Bone

39

4

4.2

Soft Tissue Lesions Involving Bone

Gout

Gout is caused by monosodium urate monohydrate or uric acid crystal deposition. In the majority of patients it is idiopathic, but this condition may be associated with many other disorders such as chronic renal disease, drugs, and myeloproliferative disorders. Gout can be divided into three stages, of which chronic tophaceous gout is one of the stages where eccentric, asymmetric nodular deposits of calcium urate are found in the soft tissues. Calcification is rare. These tophaceous deposits may produce bony erosions which may be intra-articular or periarticular. Erosions are round or oval, with their long axes in line with the bone. Erosions may have an overhanging lip and a sclerotic margin. If involving a joint, the joint space is preserved until late in the disease, as is bone density. Chronic tophaceous gout is seen as a soft tissue mass that produces erosions in the adjacent bones that are well defined, with sclerotic margins and overhanging edges. These features are nicely illustrated in the index finger of an adult with gout (Figures a, b).

40

4

Soft Tissue Lesions Involving Bone

41

4

4.3

Soft Tissue Lesions Involving Bone

Scleroderma

Scleroderma is a multisystem connective tissue disorder characterized by excessive deposits of collagen in the skin and other organs. There are various forms and manifestations, with the generalized type being fulminating and potentially fatal. When it affects the skin, patients present with hardening of the skin and associated scarring, initially over the fingers. There may be subcutaneous calcifications, especially in the fingertips and over bony prominences. Eventually, about half of the patients have articular involvement, with the fingers and wrist being among the commonly affected sites. Terminal phalangeal resorption is associated with soft tissue atrophy. Erosions of the distal interphalangeal, first carpometacarpal, and metacarpophalangeal joints may be present. Scleroderma is seen as soft tissue atrophy associated with resorption of the tufts of the distal phalanges of multiple fingers. These features are nicely illustrated in both hands of an adult with scleroderma (Figures a–c).

42

4

Soft Tissue Lesions Involving Bone

43

5

Cortical and Periosteal Lesions

5.1

Epidermoid Cyst

5.2

Osteochondroma

5.3

Osteoid Osteoma

5.4 Osteoporosis 5.5 Periosteal Enchondroma 5.6 Periostitis Ossificans 5.7

Renal Osteodystrophy: Subperiosteal Resorption

5.8 Renal Osteodystrophy: Severe

45

5

Cortical and Periosteal Lesions

5.1

Epidermoid Cyst

An epidermoid bone cyst is an uncommon lesion that occurs almost solely in the distal phalanges or the skull and presents as a lytic lesion or a pseudotumor. These cysts usually appear in patients, mainly men, between the ages of 25 and 50 years. They are benign lesions with a satisfactory outcome after excision. An epidermoid cyst is regarded as a traumatic or an iatrogenic lesion and can be clinically and radiologically deceptive. Initial differential diagnoses include osteomyelitis, enchondroma, gout, and simple bone cyst. Epidermoid cyst is seen as a well-defined osteolytic, radiolucent lesion with sclerotic margin involving the phalanx. It causes bone expansion and cortical thinning, with or without soft tissue swelling, and often shows spotty calcification. These features are nicely illustrated in the hand of an adult with epidermoid cyst (Figures a, b).

46

5

Cortical and Periosteal Lesions

47

5

5.2

Cortical and Periosteal Lesions

Osteochondroma

Osteochondroma is a cartilage-covered bony excrescence (exostosis) that arises from the surface of a bone. It is the most common bone tumor in children. It may be solitary or multiple, and may arise spontaneously or as a result of previous osseous trauma. It arises from tubular bones and is metaphyseal in location. The radiographic appearances of an osteochondroma are those of a pedunculated or sessile bony excrescence with well-defined margins. In adults, the cartilage cap often contains flecks of calcification. Osteochondromas arise from the surface of the bones and contain spongiosa and cortex that appear continuous with the parent bone. Osteochondroma is seen as a well-defined, pedunculated bone outgrowth that is continuous with the parent bone. These features are nicely illustrated in the hand of an adult with an osteochondroma of the metacarpal of the little finger (Figures a, b).

48

5

Cortical and Periosteal Lesions

49

5

5.3

Cortical and Periosteal Lesions

Osteoid Osteoma

Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. The tumor is usually smaller than 1.5 cm in diameter. Osteoid osteoma can occur in any bone, but in approximately two-thirds, of patients the appendicular skeleton is involved. The skull and facial bones are involved exceptionally. The classic presentation is that of focal bone pain at the site of the tumor. The condition worsens at night and increases with activity, and it is dramatically relieved with small doses of aspirin. The lesion initially appears as a small sclerotic bone island within a circular lucent defect. This central nidus is seldom larger than 1.5 cm in diameter, and it may be associated with considerable overlying cortical and endosteal bone sclerosis. The radiographic appearances of an osteoid osteoma are those of a circular or an ovoid lucent defect, usually smaller than 1.5 cm in diameter, that is associated with a variable degree of cortical and endosteal sclerosis. In subarticular and intracapsular tumors, reactive sclerosis may be absent or minimal. Intra-articular tumors may show joint effusion associated with the premature loss of cartilage. Osteoarthrosis affects approximately half of patients with intra-articular tumors. Rarely, regional osteoporosis affects patients, presumably as a result of disuse. Osteoid osteoma is seen as an ovoid osteolytic lesion with prominent adjacent cortical and endosteal sclerosis. These features are nicely illustrated in the hand of an adult with osteoid osteoma of the proximal phalanx of the middle finger (Figures a, b).

50

5

Cortical and Periosteal Lesions

51

5

5.4

Cortical and Periosteal Lesions

Osteoporosis

Osteoporosis is defined as a progressive systemic skeletal disorder characterized by low bone mineral density (BMD), deterioration of the microarchitecture of bone tissue, and susceptibility to fracture. Osteoporosis can be subdivided into three types: (1) involutional, or primary, osteoporosis in which no underlying cause can be identified; (2) secondary osteoporosis in which the underlying cause (e.g., steroid use) is known; and (3) rare forms of the disease, such as juvenile, pregnancy-related, and postpartum osteoporosis. Involutional osteoporosis develops from excessive age-related bone loss. The pathogenesis of osteoporosis is multifactorial. Two types of osteoporosis can be distinguished in aging women: (1) postmenopausal osteoporosis and (2) age-related osteoporosis. Type I osteoporosis is characterized by increased bone resorption due to osteoclastic activity and is related to estrogen deficiency. Vertebral crush fractures and fractures of the distal radius (Colles’ fractures) are the main complications. Age-related osteoporosis occurs when there is excessive bone loss manifested after age 70 years in both women and men and is associated with a steady, 1–2% loss of cortical and trabecular bone mass each year. Hip and vertebral fractures are most common in this type of osteoporosis. Radiographs are relatively insensitive for demonstrating osteoporosis. At least 30% of the bone mass must be lost before it is recognized. The most characteristic radiographic feature in the hand is the cortical narrowing in the second metacarpal bone, which is an expression of endosteal resorption. Osteoporosis begins at the endosteal surface with irregularities and indentations in the early stage and progressive cortical thickness reduction, with consequent medullar widening, in later stages. Background metacarpal index (MCI), measured from hand radiographs as the ratio between combined cortical thickness and bone diameter, has been suggested for assessment of bone mass and risk of osteoporotic fracture. Osteoporosis is seen as diffuse generalized osteopenia with extensive endosteal resorption. These features are nicely illustrated in both hands of an adult with osteoporosis (Figures a–c).

52

5

Cortical and Periosteal Lesions

53

5

5.5

Cortical and Periosteal Lesions

Periosteal Enchondroma

Enchondromas are benign cartilaginous neoplasms that are usually due to solitary ectopic hyaline cartilage rests within intramedullary bone. The primary significant factors of enchondroma are related to its complications, most notably pathologic fracture, and a small incidence of malignant transformation, which may be associated with pathologic fracture. It has a predilection for the small bones of the hands and feet, where most of these lesions occur. Of these, half are in the proximal phalanx, followed in frequency by the metacarpal and middle phalanx and, lastly, by the distal phalanges and carpal bones. Low-grade chondrosarcoma may be indistinguishable from enchondroma; however, in most cases, chondrosarcoma has certain imaging features that are indicative of its aggressive behavior. Cortical breakthrough, soft tissue mass, and scalloping of the cortex are three features that are described more frequently in chondrosarcoma. In contrast to enchondromas which occur within the medullary cavity, periosteal enchondromas arise at the surface of the bone. These patients usually present with mild pain and the feeling of a mass. The lesion has a characteristic radiographic appearance, resting in a saucer-shaped depression, with cortical thickening at the base of the lesion. Periosteal enchondroma is seen as a well-defined osteolytic lesion that arises from the bone surface, with thickened cortex at the base of the lesion. These features are nicely illustrated in the thumb of a child with a periosteal enchondroma (Figures a, b).

54

5

Cortical and Periosteal Lesions

55

5

5.6

Cortical and Periosteal Lesions

Periostitis Ossificans

Periosteal lesions arise from the periosteum or soft tissue in the immediate proximity of the cortex of a bone. Periosteal lesions can be predominantly bony, fibroblastic, cartilaginous, or myxoid and can be classified into four groups: (1) predominantly bony and fibroblastic (periostitis ossificans, parosteal fasciitis, periosteal osteoid osteoma, osteoblastoma, parosteal fibrosarcoma, parosteal osteosarcoma, and high-grade surface osteosarcoma); (2) cartilaginous lesions (osteochondroma, osteochondromatosis, and chondromatous transformation of osteochondromatosis); (3) predominantly cartilaginous to myxoid lesions (parosteal chondroma, myxoma, and malignant parosteal chondrosarcoma); and (4) miscellaneous rarities (parosteal lipoma, ganglion, and glomus). Periostitis ossificans encompasses those reparative and injuryrelated lesions of the periosteum unassociated with bone fracture. The reaction in the periosteum consequent to fracture, however, can be identical to those of periostitis ossificans. The radiographic features are quite variable and can be similar to those seen in malignant tumors. Most lesions are eccentrically longitudinal with a prominent Codman’s triangle, and sometimes are bilateral. In the early stages of development periostitis ossificans may show eccentric “onion skinning.” The lesions usually comprise a mixture of slightly hypercellular fibroblastic tissue with “injury-type” capillaries. All cases involve osteoid and/or woven bone to a variable degree. In some cases cartilage is seen and the peripheral osseous tissues are more mature than those in the central regions. Sometimes focal sheets of immature osteoid are set in a cellular stroma and it could be mistaken for osteosarcoma. These features are nicely illustrated in the hands of adults with periostitis ossificans (Figures a–g).

56

5

Cortical and Periosteal Lesions

57

5

58

Cortical and Periosteal Lesions

5

5.7

Cortical and Periosteal Lesions

Renal Osteodystrophy: Subperiosteal Resorption

Subperiosteal resorption is virtually pathognomonic of hyperparathyroidism. The radiographic appearance has been described as an irregularity of the normal cortical margin, which may progress to areas of scalloping and speculation. The earliest involvement is often seen along the radial aspects of the middle phalanges of the index and middle fingers, beginning in the proximal metaphyseal region. The terminal tufts also demonstrate subperiosteal resorption, seen initially as a loss of the cortical line. Subperiosteal resorption shows an irregular surface of the periosteal bone, which can create a false appearance of periosteal reaction (pseudoperiostitis). These features are nicely illustrated in hands of adults with subperiosteal resorption due to renal osteodystrophy (Figures a–f).

60

5

Cortical and Periosteal Lesions

61

5

5.8

Cortical and Periosteal Lesions

Renal Osteodystrophy: Severe

Renal osteodystrophy is a term describing a constellation of musculoskeletal abnormalities that occur in association with chronic renal failure, including secondary hyperparathyroidism, osteosclerosis, osteoporosis, osteomalacia, and soft tissue and vascular calcifications. The changes observed depend on the degree to which bone responds to parathyroid hormone. If the bone responds with an increased activity of osteoclasts and osteocytes, the result is bone resorption. If parathyroid hormone levels are mildly elevated over a long period of time, its effect on bone tends to be anabolic. These effects include excessive maturation of osteoblasts leading to new bone formation and increased laying down of osteoid. Radiographic findings of renal osteodystrophy include osseous resorption, periosteal reaction, soft tissue calcification, osteopenia, and fracture. Bone resorption is typically classified as subchondral, trabecular, endosteal, intracortical, subperiosteal, subligamentous, and subtendinous. Involvement of the hands by subchondral resorption typically occurs along distal interphalangeal joints and the first carpometacarpal joints. The periosteal reaction is seen as a linear new bone paralleling the cortical surface; it can be laminated and is also separated from the cortex by a radiolucent zone. Tumoral calcinosis typically is periarticular and appears as a cloudlike, dense area that may be quite large. These features are nicely illustrated in both hands of an adult with severe renal osteodystrophy (Figures a–d).

62

5

Cortical and Periosteal Lesions

63

6

Articular Lesions

6.1

Gout

6.2 Juvenile Chronic Arthritis 6.3 Multicentric Reticulohistiocytosis 6.4 Osteoarthritis 6.5 Osteoarthritis: Early 6.6 Osteoarthritis: Erosive 6.7 Osteoarthritis: Loose Body 6.8 Osteoarthritis: Primary 6.9 Osteoarthritis: Severe 6.10 Osteoarthritis: Thumb 6.11 Osteoarthritis: Ulnar Styloid 6.12 Psoriasis 6.13 Pyrophosphate Arthropathy 6.14 Rheumatoid Arthritis: Carpal 6.15 Rheumatoid Arthritis: Early 6.16 Rheumatoid Arthritis: Moderate 6.17 Rheumatoid Arthritis: Severe 6.18 Systemic Lupus Erythematosus

65

6

Articular Lesions

6.1

Gout

Gout is defined as a peripheral arthritis that results from the deposition of sodium urate crystals in one or more joints. Although gout has many contributing factors, two main processes are involved in its development: the overproduction and the underexcretion of uric acid. A variety of conditions, including renal disease, have been implicated as causes of gout, but the vast majority of cases are idiopathic. Podagra, or pain in the first metatarsophalangeal joint, is the classic presentation of gout. In general, the symptoms of gout suddenly appear at night and occur in men with hyperuricemia who are aged 30–60 years. In the early phase of gout, the clinical findings are limited to the soft tissues, of which an asymmetric swelling around the affected joint is typical. Another finding that may be evident is edema of the soft tissues around the joints. In a patient who has had multiple episodes of gouty arthritis in the same joint, a cloudy area of increased opacity may be seen on radiographs. In the intermediate phase of gout, the earliest bony changes manifest, most commonly appearing initially in the first metatarsophalangeal joint area. These changes generally appear outside the joint or are in the juxta-articular area and are often described as punched-out lesions. Such lesions can progress to become sclerotic as they increase in size. In severe cases of intermediate-phase gout, fractures may be present in the affected areas. In late-phase gout, the hallmark findings are numerous interosseous tophi. Another change that is evident on radiographs is joint space narrowing, which can be severe and symptomatic. Marked deformities and subluxation may also be noted in affected areas, as well as calcium deposits in the soft tissues. These features are nicely illustrated in both hands of an adult with gout (Figures a–d).

66

6

Articular Lesions

67

6

6.2

Articular Lesions

Juvenile Chronic Arthritis

Juvenile chronic arthritis (JCA) is part of a group of systemic inflammatory disorders affecting children below the age of 16 years. Three major subsets have been described: (1) pauciarticular onset, with four or less than four joints involved; (2) polyarticular onset, with more than four joints involved; and (3) systemic onset, with fever, rash, and arthritis. Pauciarticular and polyarticular JCA tend to affect girls more often than boys. Systemic-onset disease occurs with equal frequency in boys and girls. The cause of the arthritis is largely unknown, but several predisposing factors are identified. A possible infectious etiology has been considered for a variety of arthritic conditions and clusters of patients, frequently following viral epidemics, are identified episodically. Among the radiographic findings are loss of joint space, bone erosions, periostitis, intra-articular bone ankylosis, epiphyseal compression fractures, subluxation or dislocation, and growth disturbances. Abnormalities occur most commonly in the hand, wrist, foot, knee, hip, cervical spine, mandible, and temporomandibular joint. Features of JCA that allow differentiation from the adult type of rheumatoid arthritis include: predilection for large joints rather than small ones, propensity for producing joint contractures and muscle wasting, and association with significant extra-articular manifestations. Among the radiographic abnormalities associated with JCA are soft tissue swelling, osteopenia (sometimes with growth recovery lines), joint space diminution, bone erosion, periostitis, growth disturbances, epiphyseal compression fractures, joint subluxation, and soft tissue calcification. The early features are nicely illustrated in both hands of a boy with juvenile chronic arthritis (Figures a–d).

68

6

Articular Lesions

69

6

6.3

Articular Lesions

Multicentric Reticulohistiocytosis

Multicentric reticulohistiocytosis is a rare systemic disease with proliferation of histiocytes which leads to destructive polyarthritis and skin lesions. Target areas of the hands primarily involve the interphalangeal joints, especially at the distal interphalangeal joints. The metacarpophalangeal joints and carpal bones are involved less frequently. Symmetric well-circumscribed marginal erosions are seen at the involved articular surfaces. Uncalcified soft tissue nodules and the absence of periarticular osteoporosis are additional radiographic features of multicentric reticulohistiocytosis. Severe progression of the disease can lead to extensive osseous resorption with foreshortening of the fingers and telescoping digits. Radiographic findings in multicentric reticulohistiocytosis are different than those in rheumatoid arthritis since there is involvement of the joints distally. Multicentric reticulohistiocytosis can also be differentiated from other arthritides due to the absence of juxtaarticular osteoporosis and periosteal reaction. The erosive patterns seen in gout and psoriatic arthritis are unlike multicentric reticulohistiocytosis due to their asymmetric distribution. Furthermore, calcified soft tissue nodules and overhanging edges are findings in gout which are not seen in multicentric reticulohistiocytosis. These features are nicely illustrated in both hands of an adult with multicentric reticulohistiocytosis (Figures a–d).

70

6

Articular Lesions

71

6

6.4

Articular Lesions

Osteoarthritis

Osteoarthritis, also known as degenerative joint disease, is a process of progressive deterioration of articular cartilage and formation of new bone (osteophytes) at the joint surface. Primary osteoarthritis is age related and associated with repetitive and/or high mechanical stress on a normal joint. Secondary osteoarthritis is due to an underlying cause such as trauma, inflammatory, metabolic, developmental, or connective tissue disease. Osteoarthritis of the hands typically targets the proximal interphalangeal (PIP), distal interphalangeal (DIP), scaphotrapeziotrapezoid, and the first carpometacarpal joints. The knee, hip, spinal, and first metatarsophalangeal joints are other areas which are commonly involved. Additional joints can be affected in cases of secondary osteoarthritis. Affected joint spaces are narrowed with reactive subchondral sclerosis (eburnation). Other classic radiographic findings include osteophytes and subchondral cysts. Heberden’s nodes at the DIP joints and Bouchard’s nodes at the PIP joints of the hands are areas of osteophyte formation and soft tissue swelling associated with osteoarthritis. Intra-articular loose bodies can also sometimes be seen. These features are nicely illustrated in the hands of adults with osteoarthritis (Figures a–l).

72

6

Articular Lesions

73

6

74

Articular Lesions

6

Articular Lesions

75

6

76

Articular Lesions

6

6.5

Articular Lesions

Osteoarthritis: Early

Patients with early osteoarthritis often do not show any kind of radiographic changes. Thus, relying only on radiographs to determine this condition, especially in patients with early or mild osteoarthritis, can result in a false-negative diagnosis. Using the clinical presentation (signs and symptoms) along with imaging findings will likely improve the diagnosis of osteoarthritis of the hand. Microscopically, flaking and fibrillations develop along the normally smooth articular cartilage surface. The loss of cartilage results in the loss of the joint space. Progressive erosion of the damaged cartilage occurs until the underlying bone is exposed. With the onset of osteoarthritis, the articular cartilage loses its smooth texture and becomes coarsened. This change leads to a sharp increase in frictional forces. Subsequently, cracks and tears, which lead to cartilage softening and flaking, are noted histologically. The net loss of articular cartilage appears as a reduction of the joint space on radiographs. These features are nicely illustrated in both hands of an adult with early osteoarthritis (Figures a–e).

77

6

78

Articular Lesions

6

Articular Lesions

79

6

6.6

Articular Lesions

Osteoarthritis: Erosive

Erosive osteoarthritis is a disease entity which is most common in middle-aged females. The disease is characterized by acute articular attacks resembling rheumatoid arthritis, although other peripheral joints are unaffected and the serologic tests for rheumatoid factor are negative. The onset of the disease may be abrupt as with painful nodules identified along the distal and proximal interphalangeal joints in association with edema and tenderness. The distribution of the disease is symmetric with the interphalangeal articulations most commonly involved. The course of the disease is quite variable. The radiographic findings are characterized by the combination of features suggestive of osteoarthritis as well as findings suggestive of rheumatoid arthritis, i.e., consisting of both bony proliferation and erosion. There will typically be joint space narrowing as well as associated subchondral sclerosis and osteophytosis. In contradistinction to osteoarthritis, erosions are a common manifestation of erosive (inflammatory) osteoarthritis. The erosions most commonly begin in the central portion of the articulation which differs from the marginal erosions seen in rheumatoid arthritis. Central erosions are characteristic of erosive osteoarthritis. These are sharply marginated and located primarily within the interphalangeal joints. In severe cases, there may be bony ankylosis at the interphalangeal joints. Occasionally, erosive osteoarthritis may be mistaken for psoriatic arthritis. In contrast to erosive osteoarthritis, psoriasis demonstrates no osteophyte formation. Less commonly involved joints include the metacarpophalangeal and first carpometacarpal articulations. These features are nicely illustrated in the hands of two adults with erosive osteoarthritis (Figures a–e).

80

6

Articular Lesions

81

6

82

Articular Lesions

6

6.7

Articular Lesions

Osteoarthritis: Loose Body

A loose body is a free-floating piece of bone, cartilage, or a foreign object in a joint and can be a rather frequent complication of osteoarthritis. Loose bodies can be classified into several categories: osteocartilaginous, hyaline cartilaginous, and fibrous cartilaginous. The radiographic findings depend on the degree of calcification within the body. Osteocartilaginous loose bodies are composed of bone and cartilage and are thus detectable radiographically because of the osseous component. A purely cartilaginous or a fibrous cartilaginous loose body create no radiographic abnormalities, whereas one containing calcified cartilage and bone may be visible on the radiograph. These features are nicely illustrated in both hands of an adult with loose body (Figures a–d).

84

6

Articular Lesions

85

6

6.8

Articular Lesions

Osteoarthritis: Primary

Historically, osteoarthritis has been divided into primary and secondary forms, although this division is somewhat artificial. The definition of primary osteoarthritis is nebulous. In the broadest sense of the term, primary osteoarthritis is an idiopathic phenomenon occurring in previously intact joints, with no apparent initiating factor. Primary osteoarthritis is related to the ageing process and typically occurs in older individuals. Some clinicians limit primary osteoarthritis to the joints of the hands (specifically the distal interphalangeal joints, proximal interphalangeal joints, and joints at the base of the thumb), whereas others include the knees, hips, spine (apophyseal articulations), and hands as potential sites of involvement. Primary osteoarthritis of the hands typically targets the PIP, DIP, scaphotrapeziotrapezoid, and the first carpometacarpal joints. Affected joint spaces are narrowed with reactive subchondral sclerosis (eburnation). Other classic radiographic findings include osteophytes and subchondral cysts. Heberden’s nodes at the DIP joints and Bouchard’s nodes at the PIP joints of the hands are areas of osteophyte formation and soft tissue swelling associated with osteoarthritis. These features are nicely illustrated in both hands of an adult with primary osteoarthritis (Figures a–f).

86

6

Articular Lesions

87

6

88

Articular Lesions

6

6.9

Articular Lesions

Osteoarthritis: Severe

In advanced stages of osteoarthritis, several complications can appear, such as subluxation and skewing of the joint space as a consequence of an asymmetric joint space narrowing, interphalangeal joint fibrous ankylosis, para-articular osseous ankylosis as a consequence of large osteophytes which can simulate an intra-articular osseous fusion, intra-articular loose bodies as a consequence of transchondral fractures, cartilage destruction, or synovial meta­ plasia. These features are nicely illustrated in both hands of an adult with severe osteoarthritis (Figures a–d).

89

6

90

Articular Lesions

6

Articular Lesions

91

6

Articular Lesions

6.10

Osteoarthritis: Thumb

Osteoarthritis of the base of the thumb is a very common condition, particularly in postmenopausal women. Although about 30% of postmenopausal women have radiographic changes of arthritis, the majority have no or only minor symptoms. Symptomatic osteoarthritis is confirmed by careful physical examination and radiologic assessment. The radiologic appearance enables classification into four stages of increasing severity: grade 0 indicates no osteoarthritis; grade 1 shows minimal osteophytes and possible cyst formation (doubtful osteoarthritis); grade 2 shows definite osteophytes and possible cyst formation (minimal osteoarthritis); grade 3 shows moderate osteophytes, narrowing of the joint space, subchondral sclerosis, and deformity of the bone ends (moderate osteoarthritis); and grade 4 shows large osteophytes, severe sclerosis, and narrowing of the joint space (severe osteoarthritis). These features are nicely illustrated in the hands of two adults with osteoarthritis of the thumb (Figures a–d).

92

6

Articular Lesions

93

6

Articular Lesions

6.11

Osteoarthritis: Ulnar Styloid

Ulnar styloid osteoarthritis is infrequent and is most often a consequence of scaphoid lesions, fractures, ulnar styloid luxation or subluxation, or lunate osteonecrosis (Kienböck’s disease). Classic radiographic findings are articular space narrowing, sclerosis, cysts, and osteophytes. These features are nicely illustrated in both hands of an adult with ulnar styloid osteoarthritis (Figures a, b).

94

6

Articular Lesions

95

6

Articular Lesions

6.12

Psoriasis

Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong genetic basis characterized by red plaques distributed over extensor body surfaces and the scalp. Psoriatic arthritis (PA) is a specific type of arthritis that has been diagnosed in approximately 23% of those who have psoriasis. This condition appears about 10 years after the first signs of psoriasis occur, but in about 1 of 7 people with PA, arthritis symptoms occur before any skin lesions appear. PA most commonly involves the small joints of the hands and feet, especially the DIP joints. At times, the spine is involved as well. In some cases, it is hard to distinguish PA from other types of arthritis, such as rheumatoid arthritis and Reiter syndrome. In the fingers, the main patterns of the extrasynovial changes are capsular enthesophytes, juxta-articular periosteal reaction, enthesopathy at the site of deep flexor tendon insertion on the distal phalanx, subcutaneous soft tissue thickening of the finger pad, subcutaneous soft tissue thickening of the entire finger, no or minimal juxta-articular osteoporosis, and bony proliferation near joints and ligament and/or tendon insertion sites. There are bone erosions beginning in the periarticular region and progressing to more central areas, symmetric destruction of the DIP with bony ankylosis, resorption of terminal phalangeal tufts (i.e., the morningstar appearance), periostitis along the shaft of a bone, often accompanied by soft tissue swelling, ivory phalanx, destruction/resorption of the interphalangeal joint of the first toe with periosteal reaction, and bony proliferation at the distal phalangeal base. There may be diffuse soft tissue swelling of an entire digit (i.e., sausage digit) with generalized symmetric joint involvement. These features are nicely illustrated in both hands of an adult with psoriatic arthritis of the hand (Figures a–e).

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Articular Lesions

6.13

Pyrophosphate Arthropathy

Calcium pyrophosphate dihydrate deposition disease (CPPD) is a metabolic arthropathy resulting from the deposition of calcium pyrophosphate dihydrate in and around joints, especially in articular and fibrocartilage. Although CPPD is often asymptomatic, with only radiographic changes (i.e., chondrocalcinosis), various clinical manifestations may occur, including acute (pseudogout) and chronic arthritis. The knees, wrists, and hips are the most commonly affected joints and women have a slightly higher incidence than men. Although the exact mechanism for the development of CPPD remains unknown, increased adenosine triphosphate breakdown with resultant increased inorganic pyrophosphate in the joints occurs as a result of aging, genetic factors, or both. Calcium deposition is often seen at the triangular fibrocartilage of the wrist. Subchondral sclerosis, joint space narrowing, subchondral cyst formation which may be quite large, and intra-articular bodies from subchondral osseous collapse and fragmentation are all findings that can be seen in patients with CPPD. These radiographic abnormalities are most common at the radiocarpal articulation and at the second and third metacarpophalangeal joints. Additionally, there may be a shift in the normal alignment of the scaphoid and lunate and narrowing at the midcarpal compartment. These features are nicely illustrated in the hands of two adults with pyrophosphate arthropathy (Figures a–d).

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Articular Lesions

6.14

Rheumatoid Arthritis: Carpal

Rheumatoid arthritis is a systemic inflammatory disease that results in cartilage and bone destruction. Rheumatoid arthritis is characterized by a typical pattern and distribution of synovial joint involvement. Disorganization of the joint leads to deformities and loss of function. There is diffuse cartilage loss and erosion of bone and cartilage. It starts in the synovial membrane, with the initial processes of edema, neovascularization, and hyperplasia of the synovial lining. Proliferation of synoviocytes and macrophages causes thickening of the synovial lining and, together with lymphocytes, plasma cells, and mast cells, develops into pannus. In the hands, the metacarpophalangeal (MCP), PIP, and thumb interphalangeal (IP) joints are most frequently involved. The DIP joints are involved only in the presence of a coexisting MCP or PIP disease. Tenosynovitis of the flexor tendons causes a reduction in finger flexion and grip strength. Nodular thickening in the tendon sheath may also produce a trigger finger. In the wrist, the early stages of rheumatoid arthritis cause tenosynovitis of the extensor tendons, causing swelling over the distal wrist. The ulnar styloid may become tender, which indicates inflammatory synovitis. The distal end of the ulna tends to subluxate dorsally, and the carpal bones subluxate anteriorly to the distal radius and ulna. Tendinous involvement of rheumatoid arthritis may result in rupture of the tendon, causing increased disability. If significant involvement of the scapholunate joint is present, laxity or rupture may cause rotatory subluxation of the scaphoid. These features are nicely illustrated in both hands of an adult with advanced carpal rheumatoid arthritis (Figures a–c).

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Articular Lesions

6.15

Rheumatoid Arthritis: Early

Usually, the earliest sign of rheumatoid arthritis is a periarticular soft tissue swelling with a fusiform appearance. Normal fat planes may be obliterated, which occurs as a result of joint effusion, edema, and tenosynovitis. Juxta-articular osteopenia is another early sign, particularly during the acute inflammatory stage. Initially, joint spaces in the small joints of the hands show widening as a result of effusion; however, with cartilage destruction, joint spaces narrow. Erosions usually begin at the bare area of the joint not covered by cartilage, such as the intracapsular articular margins. Marginal erosions occur as a result of direct mechanical action of the hypertrophied synovium and granulation tissue. These features are nicely illustrated in hands of two adults with early rheumatoid arthritis (Figures a–d).

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6.16

Rheumatoid Arthritis: Moderate

As rheumatoid arthritis progresses, its characteristic deformities become apparent. These include ulnar deviation of the fingers at the MCP joints, progressive subluxation of the MCP joints with or without the presence of bony erosions in the joints, with the proximal phalanx slipping to the volar side of the metacarpal heads, hyperextension of the PIP joint with flexion of the DIP joint (swanneck deformity), flexion of the PIP joint with hyperextension of the DIP joint (boutonnière/button-hole deformity), Z-shaped deformity of the thumb from subluxation of the first MCP joint and compensatory hyperextension of the IP joint, and drooping of the ring and little fingers resulting from rupture of the extensor tendons at the point of crossing the inflamed, eroded ulnar styloid. Osteopenia subsequently becomes more generalized as the disease progresses. These features are nicely illustrated in both hands of an adult with moderate rheumatoid arthritis (Figures a–f).

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Articular Lesions

6.17

Rheumatoid Arthritis: Severe

Fusion or joint ankylosis is common in the later stages of rheumatoid arthritis. Fusion usually takes place in a deformed or malaligned position. This further reduces the functionality of the hand and affects independence in the activities of daily living. In the end stage, extensive erosions may combine to result in resorption and tapering of the ends of the bones. These features are nicely illustrated in the hands of two adults with severe rheumatoid arthritis (Figures a–c).

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6.18

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic, multifaceted, autoimmune disorder that involves multisystem microvascular inflammation with the generation of autoantibodies and can affect every organ system of the body. SLE is protean in its manifestations and follows a relapsing and remitting course. SLE occurs predominantly in women of childbearing age, suggesting a role for hormonal factors in the pathogenesis of the disease. Its presentation and course is highly variable, ranging from indolent to fulminant, and includes nonspecific signs (e.g., fatigue, fever), musculoskeletal manifestations of small joints of the hands, wrists, and knees (arthralgia, myalgia, and arthritis represent the most common presenting symptoms in SLE), cutaneous, renal, pulmonary gastrointestinal, or neuropsychiatric manifestations. Jaccoud’s arthropathy is the term for the nonerosive, deforming synovitis of the hand, predominantly of the metacarpophalangeal and proximal interphalangeal joints due to chronic arthritis and tendonitis that develops in 10% of patients with SLE. This may mimic rheumatoid arthritis, with ulnar deviation and phalangeal subluxations. Radiographically, this synovitis can be differentiated from the synovitis in rheumatoid arthritis by the absence of typical erosions though the formation of “hooks” may occur. Ulnar drift with subluxation of metacarpophalangeal joints is often the first sign, whereas “swan neck,” boutonnière deformities, and Z deformities may occur at a later stage. These features are nicely illustrated in both hands of an adult with SLE (Figures a, b).

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Associated Articular and Soft Tissue Lesions

7.1

Amyloidosis and Renal Osteodystrophy

7.2

Calcium Pyrophosphate Dihydrate Deposition Disease

7.3

Vascular Calcification and Renal Osteodystrophy

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Associated Articular and Soft Tissue Lesions

Amyloidosis and Renal Osteodystrophy

Secondary amyloidosis complicates numerous chronic diseases, including chronic renal failure. In chronic renal failure, amyloid deposition consists of β2-microglobulin, which is different from other types of amyloid. It is a 100-amino acid protein existing on cell surfaces as the light chain of the class I major histocompatibility antigens. Amyloidosis in chronic renal failure may result from repeated antigenic stimulation primarily related to long-term hemodialysis. There are many areas of deposition, including bone, tenosynovium, vertebral disk, articular cartilage and capsule, ligament, and muscle. Carpal tunnel syndrome is recognized as a complication of chronic renal failure, particularly in patients who undergo long-term hemodialysis, occurring in 2–3.1% of patients. The prevalence increases with the duration of hemodialysis, and, unlike carpal tunnel syndrome due to other causes, there is an equal sex distribution and lack of prevalence involving the dominant hand. One suggested cause is venous stasis and edema due to presence of the fistula for treatment; however, amyloid deposition in the tenosynovial tissue of the carpal tunnel likely plays a primary role in compression of the median nerve. Amyloid may also be responsible for small carpal and phalangeal radiolucent areas (hemodialysis cysts), most commonly seen in the scaphoid, lunate, and capitate. These cysts may enlarge with longterm hemodialysis. Typical radiographic features of amyloidosis include osteopenia, focal medullary lytic lesions with endosteal scalloping, pathologic fractures, soft tissue masses that may cause extrinsic osseous erosion, and occasionally extensive joint destruction. These features are nicely illustrated in both hands of an adult with amyloidosis and renal osteodystrophy (Figures a–d).

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7.2

Associated Articular and Soft Tissue Lesions

Calcium Pyrophosphate Dihydrate Deposition Disease

Calcium pyrophosphate dihydrate deposition disease (CPPD) is slightly more prevalent in men. Chondrocalcinosis results in deposition of calcium pyrophosphate dihydrate crystals in cartilage. The clinical term pseudogout denotes symptomatic acute attacks that present in a similar fashion to gouty or infectious arthritic attacks. CPPD is associated with certain metabolic disorders such as hyperparathyroidism, hemochromatosis, hypothyroidism, hypomagnesemia, and hypophosphatasia. The most commonly affected area of the wrist is at the articulation of the distal radius and proximal carpal row. There is a strong propensity of CPPD for the second and third metacarpophalangeal joints. Changes at the interphalangeal joints and other metacarpophalangeal articulations occur much less frequently and to a much lesser degree. Calcium deposition is often seen at the triangular fibrocartilage of the wrist. Subchondral sclerosis, joint space narrowing, subchondral cyst formations which may be quite large, and intra-articular bodies from subchondral osseous collapse and fragmentation are all findings which can be seen in patients with CPPD. These radiographic abnormalities are most common at the radiocarpal articulation and at the second and third metacarpophalangeal joints. Additionally, there may be a shift in the normal alignment of the scaphoid and lunate and narrowing at the midcarpal compartment. CPPD causes destruction of cartilage which can lead to radiographic findings similar to osteoarthritis. Sites of involvement are useful for differentiating CPPD and osteoarthritis since the radiocarpal compartment of the wrist is not a common location for osteoarthritis. Lack of an erosive process at the MCP joint differentiates CPPD crystal deposition disease from rheumatoid arthritis. Greater propensity for the MCP joints (also commonly includes the fourth and the fifth) with medial beak-like osteophytosis at the metacarpal heads and more widespread involvement of the carpal bones may help to differentiate hemochromatosis from idiopathic CPPD disease. These features are nicely illustrated in both hands of an adult with CPPD (Figures a–d).

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7.3

Associated Articular and Soft Tissue Lesions

Vascular Calcification and Renal Osteodystrophy

Factors that contribute to soft tissue calcification in patients with renal osteodystrophy include hypercalcemia, local tissue damage and alkalosis (precipitation of calcium salts), and, most importantly, an increase in the calcium-phosphorus product in the extracellular fluid. Calcifications can be seen in ocular tissues, arteries, subcutaneous and periarticular soft tissues, and viscera. Different chemical types of calcifications are seen at various sites. Subcutaneous, periarticular, and vascular calcifications consist of hydroxyapatite material. Visceral calcification is more amorphous, with a higher magnesium concentration. Patients may be asymptomatic; however, pain and limitation of motion can be caused by an associated aseptic inflammatory response in the surrounding tenosynovial tissue. Periarticular calcifications are multifocal, frequently symmetric, and can extend into the adjacent joint. Radiographically, these appear as discrete, cloudlike, dense areas that may be quite large around the phalangeal joints, wrists, elbows, shoulders, hips, knees, and ankles. These calcifications are also seen in tenosynovial tissue and can cause pressure erosions on adjacent bone, predisposing the bone to fracture. The chalky fluid or paste-like material may demonstrate fluid-fluid levels as seen in tumoral calcinosis. Arterial calcifications typically occur in the medial and intimal elastic tissues, giving a pipe-stem appearance without prominent luminal involvement. This calcification, when extensive, can make shunt or fistula formation for hemodialysis surgically difficult. Vascular deposits are often initially seen in the dorsal artery of the foot and are also frequent in the forearm, wrist, and hand in patients older than 40 years who have chronic renal failure. Arterial calcification is rare in children. Some investigators have described a second type of arterial calcification in chronic renal failure, with nodular calcification leading to luminal encroachment. This may result in vascular obstruction with cardiac failure, skin ulceration, and gangrene. Calcification in aneurysms at shunt sites and digital clubbing related to anoxia distal to the hemodialysis fistulae may be seen. These features are nicely illustrated in both hands of an adult with vascular calcification in renal osteodystrophy (Figures a–d).

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Associated Articular and Soft Tissue Lesions

8

Bone Lesions

8.1

Generalized

8.2 Multiple 8.3 Solitary

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8.1

Generalized

8.1.1

Acromegaly

Acromegaly results from the effects of excessive growth hormone on the mature skeleton, and is usually due to an adenoma of the anterior lobe of the pituitary gland, although gland hyperplasia may also be a cause. The excess growth hormone produces overgrowth of all tissues, including bone, cartilage, and soft tissue. In the hand, there is widening of the tufts of the distal phalanges, with bony spurs on the side, producing a “spade-like” appearance. Marginal spurs develop at the bases of the distal phalanges, which typically point distally, in contrast to osteophytes. There may be widening of the phalangeal and metacarpal heads and bases. The sesamoids of the thumbs may be enlarged. There may be cortical thickening of the metacarpal shafts. Generalized thickening of the soft tissues of the fingers may be seen. These features are nicely illustrated in both hands of an adult with acromegaly (Figures a–d). Other features include widening of the joint space due to articular cartilage hypertrophy, cystic changes in the carpal bones, and osteoporosis. Premature osteoarthritis may develop.

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8.1.2

Osteoporosis

Osteoporosis results from a diminished quantity of normal bone. It manifests radiographically as osteopenia or reduced bone density. It is frequently seen in elderly women, with an incidence of over 30% in women aged over 65 years. There are numerous causes of osteoporosis, which may be broadly divided into endocrine, disuse, iatrogenic, deficiency states, congenital, and idiopathic. The bony changes are due to increased osteoclastic resorption. Generalized osteopenia is present. There is thinning of the cortices (“pencil line” appearance), with intracortical and endosteal resorption. There is relative accentuation of the primary trabeculae (trabecular coarsening) because of resorption of the secondary trabeculae. These features are nicely illustrated in the hand of an adult with osteoporosis (Figures a–d). Complications include an increased incidence of fractures, but these typically occur in weight-bearing bones. There may, however, be delayed fracture healing with poor callus formation.

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Bone Lesions

8.1.3

Renal Osteodystrophy

Renal osteodystrophy is caused by renal glomerular disease. In adults, it consists of a combination of osteomalacia, secondary hyperparathyroidism, and osteosclerosis. Secondary hyperparathyroidism results from parathyroid hyperplasia due to end-organ resistance to parathyroid hormone. It induces increased osteoclastic activity which may produce subperiosteal and tuft resorption. In the hands, the changes are mainly due to secondary hyperparathyroidism, together with soft tissue calcification. The hallmark of hyperparathyroidism is subperiosteal bone resorption, which typically affects the radial side of the middle phalanx of the middle finger. In more advanced disease, there is terminal phalangeal resorption. Other changes include diffuse cortical tunneling, brown tumor, and marginal joint erosions, predominantly at the distal interphalangeal joint. Calcifications may affect soft tissues such as the arteries, tendons, and ligaments. Secondary hyperparathyroidism is seen as radial-sided subperiosteal resorption of the phalanges and diffuse cortical tunneling. These features are nicely illustrated in the hands of an adult with renal osteodystrophy (Figures a–d).

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Bone Lesions

8.1.4

Rickets

Rickets can be regarded as osteomalacia occurring during endochondral bone growth, resulting in an increased amount of uncalcified osteoid in an immature skeleton. There are numerous causes of rickets, and these can be broadly divided into abnormalities in vitamin D metabolism, abnormalities in phosphate metabolism, and calcium deficiency. Rickets can also be classified into several types, such as primary vitamin D deficiency rickets, gastrointestinal absorption, primary hypophosphatasia, and renal failure. Affected patients typically manifest between 4 and 18 months of age. The bony changes are prominently seen at the growing ends of the bone. The growth plates are widened, with fraying, splaying, and cupping of the metaphysis which is of reduced bone density. There is often a thin bony spur extending from the metaphysis to surround the uncalcified physis. The cortex may be indistinct because of uncalcified subperiosteal osteoid. These features are nicely illustrated in the hand of a child with rickets (Figure a). Complications include retarded bone maturation and growth, diaphyseal bowing, and fractures.

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8.1.5

Thalassemia Major

Also known as Cooley anemia, Mediterranean anemia, and hereditary leptocytosis, thalassemia major is an inherited hemoglobinopathy where there is decreased synthesis of the β-chains of hemoglobin. Thalassemia major results from a homozygous defect and is therefore inherited from both parents. This disease manifests in early infancy. The bony changes in thalassemia major are more severe than in thalassemia minor. Initially, both axial and appendicular skeleton are affected but after puberty, changes are more prominent in the axial skeleton, reflecting the regression of the red-marrow-containing areas with skeletal maturation. There is marrow hyperplasia, resulting in radiographic appearances of bony expansion, cortical thinning, and osteoporosis. In the peripheral skeleton, the earliest changes are seen in the small bones of the hands and feet, starting from 6 months of age. There is widening of the bone medulla with thinning of the cortices. Osteoporosis is manifested as osteopenia and generalized trabecular coarsening. These features are nicely illustrated in both hands of a child with thalassemia major (Figures a, b). Potential complications include growth disturbances due to premature physeal fusion and pathologic fractures.

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Bone Lesions

8.2

Multiple

8.2.1

Acro-osteolysis

Acro-osteolysis refers to lytic destruction of the distal phalanges. The midportion of the distal phalanx may be affected. This may be an occupational hazard of polyvinyl chloride tank cleaners or be due to hyperparathyroidism or acro-osteolysis of the Hajdu–Cheney syndrome. The last condition is a familial disorder of unknown etiology in which affected patients have pseudoclubbing of the fingers and toes, and multiple skeletal anomalies. The more typical form of acro-osteolysis affects the tufts of the terminal phalanges. Causes are numerous and include diverse ones such as scleroderma, Raynaud’s disease, psoriasis, epidermolysis bullosa, neuropathic diseases, and thermal injuries. Typically, there is osteolytic destruction of the phalanges, no periosteal reaction, and the epiphyses are affected only at a late stage. These features affecting the middle three digits are nicely illustrated in the hand of an adult with acro-osteolysis (Figure a).

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8.2.2

Enchondromatosis

Also known as Ollier’s disease, dyschondroplasia, or multiple enchondromata, enchondromatosis is a condition where there is nonhereditary failure of cartilage ossification. Patients usually present in early childhood with hand and foot deformity, or limb shortening. The lesions are predominantly unilateral with a monomelic distribution. Lesions may be localized, regional, or generalized. Enchondromatosis is seen as rounded or columnar osteolytic lesions that extend from the physis to the diaphysis of long bones. Being cartilaginous lesions, there may be associated punctuate calcifications within. In the small bones of the hands, these lesions tend to be aggressively deforming and proliferate. These features are nicely illustrated in both hands of an adult with enchondromatosis (Figures a–d). The most important complication is sarcomatous transformation which occurs in 25–50% of cases. Osteosarcoma develops in young adults while chondrosarcoma develops in older patients. Other complications include pathologic fractures, growth disturbance leading to shortened bones, and bowing deformities.

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8.2.3

Geodes

Also known as subchondral cysts, subarticular pseudocysts, and necrotic pseudocysts, geodes are usually seen as well-defined osteolytic lesions. They are caused by bone necrosis which allows pressure-induced passage of synovial fluid into subchondral bone. These lesions are commonly seen in synovial inflammation. The causes of geodes include osteoarthritis, rheumatoid arthritis, osteonecrosis, and calcium pyrophosphate dihydrate deposition disease (CPPD). Geodes appear as well-defined rounded osteolytic lesions with marginal sclerosis, and are located subchondrally. They usually range from 2 to 35 mm in size. They may sometimes become large and expanded, particularly in CPPD. These features are nicely illustrated in the carpal bones of the hand of an adult with geodes (Figures a, b). Geodes should be differentiated from other well-defined osteolytic lesions such as Brodie’s abscess, simple bone cyst, enchondroma, fibrous dysplasia, giant cell tumor, pigmented villonodular synovitis, metastases, and intraosseous ganglion.

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8.2.4

Melorheostosis

Melorheostosis is a non-hereditary disease of unknown etiology. It is often an incidental finding, with a slow chronic course in adults and a rapid progression in children. Patients may present with severe pain, limitation of joint movement, scleroderma-like skin thickening, and muscle atrophy. The condition is segmental and usually unilateral. The diaphyses of at least two adjacent long bones are usually affected (monomelic distribution) in a dermatomic distribution (following the spinal sensory dermatomes). There is cortical thickening due to periosteal and endosteal new bone formation, with one side of the bone being more involved. The lesions typically extend across joints. Affected bones are usually enlarged. This pattern of hyperostosis has been described as a “candle wax dripping” appearance. These features affecting the phalanges and metacarpal of the ring finger, hamate, triquetrum, and ulna are nicely illustrated in the hand of an adult with melorheostosis (Figures a, b). Melorheostosis may be associated with musculoskeletal conditions such as osteopoikilosis, osteopathia striata, and vascular and lymphatic malformations. Joint fusion may occur with joint crossing.

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Bone Lesions

8.2.5

Sarcoidosis

Sarcoidosis is a multisystemic granulomatous disorder of unknown etiology. It may affect the lymph nodes, lungs, skin, eye, liver, gastrointestinal tract, and central nervous system. Bone involvement is present in up to 20% of patients. Patients may have a transient, symmetric arthropathy. The hands and feet are the most commonly affected bones. In the hands, a reticulated “lace-like” trabecular pattern in the middle and distal phalanges and the metacarpals is typically seen. These changes are initially at the metaphysis, and eventually involve the entire bone. There are often well-defined lytic areas of different sizes (pseudocysts). Periosteal new bone formation with endosteal sclerosis may occur. There may also be adjacent soft tissue swelling (dactylitis). Skin lesions (lupus pernio) accompany bone lesions. These features affecting the third to fifth digits are nicely illustrated in both hands of an adult with sarcoidosis (Figures a, b). Other changes include distal phalangeal and subperiosteal bone resorption, terminal phalangeal sclerosis, and enlarged nutrient foramina in the phalanges. There may be soft tissue calcification due to hypercalcemia in 30% of patients.

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Bone Lesions

8.3

Solitary

8.3.1

Bone Island

Also known as enostosis, compact island, focal sclerosis, and calcified medullary defect, a bone island represents a zone of compacted trabeculae of mature lamellar bone. It is asymptomatic and may present at any age. This benign lesion may grow in children. Common locations are the pelvis, ribs, femur, humerus, and phalanges. A bone island is seen as a round, well-defined, solitary osteosclerotic lesion that is usually less than 2 cm in diameter. It may have “brush” border margins that are sharply demarcated with thorny radiations. These features are nicely illustrated in the distal phalanx of the index finger of the hand of an adult with a bone island (Figures a, b). Bone islands may show increased uptake on bone scintigraphy. Although some bone islands may show slow growth, others may regress in size or disappear.

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Bone Lesions

8.3.2

Brown Tumor

Also known as osteoclastoma, brown tumor is due to increased osteoclastic resorption of bone resulting from hyperparathyroidism. This lesion is more frequent in primary hyperparathyroidism. Patients may present with bone pain and tenderness at the site of the brown tumor, or with a pathologic fracture. The most common location is the mandible, followed by pelvis, rib, and femur. In about 3% of patients, a brown tumor is the solitary skeletal sign of hyperparathyroidism. A brown tumor is seen as a well-defined, osteolytic lesion, with or without marginal sclerosis. It may sometimes be expansile with cortical breakthrough. These features are nicely illustrated in the lunate of the hand of an adult with a brown tumor (Figures a, b). In the fingers, a brown tumor may cause destruction of the midportion of the distal phalanges, with a telescoping deformity. On bone scintigraphy, there is increased uptake in brown tumors.

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Bone Lesions

8.3.3

Enchondroma

Enchondroma is a benign cartilaginous growth that arises in the medullary cavity of bones that are preformed in cartilage. It affects patients aged 10–30 years old. Patients are usually asymptomatic, although some may present with a painless swelling. Histologically, this tumor is comprised of lobules of hyaline cartilage. It is the most common tumor found in the small bones of the hands and feet, with 50% occurring at these sites. This tumor is typically located centrally in the diaphysis, with epiphyseal involvement only after physeal closure. It is seen as a well-defined osteolytic lesion with a thin sclerotic rim. It is often expanded with endosteal scalloping but the cortex is usually preserved. It may be multilocular in long bones. These features are nicely illustrated in the hand of an adult with an enchondroma (Figures a, b). Complications include pathologic fracture and malignant transformation. Multiple enchondromas may be part of a syndrome such as Ollier’s disease (enchondromatosis) and Maffucci’s syndrome (enchondromatosis and hemangiomata).

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Bone Lesions

8.3.4

Enchondroma with Calcification

Enchondroma is a benign cartilaginous growth that arises in the medullary cavity of bones that are preformed in cartilage. It is the most common tumor found in the small bones of the hands and feet. It is seen as a well-defined osteolytic lesion with a thin sclerotic rim. It is often expanded with endosteal scalloping but with cortical preservation. Internally, a ground glass appearance is present and if calcifications are present they may be punctuate, stippled, flocculent, or have a “rings and arcs” pattern. These various features are nicely illustrated in the hand of an adult with enchondroma (Figures a, b). The differential diagnosis of calcium- or bone-containing osteolytic lesions includes bone tumors such as breast metastases, chondrosarcoma, osteoid osteoma, osteoblastoma, osteogenic sarcoma, and fibrosarcoma, as well as other lesions such as fibrous dysplasia, eosinophilic granuloma, osteomyelitis, and osteoporosis circumscripta.

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Bone Lesions

8.3.5

Enchondroma in Children

Enchondroma is a benign cartilaginous growth that arises in the medullary cavity of bones, and may present in children. It is the most common tumor found in the small bones of the hands and feet. This tumor is seen as a well-defined osteolytic lesion with a thin sclerotic rim. It is often expanded with endosteal scalloping but the cortex is usually preserved. It may be multilocular in long bones. Internally, a ground glass appearance is present and calcifications if present, are an important diagnostic finding. These features are nicely illustrated in the hand of a child with enchondroma (Figures a, b). Other possible causes of solitary osteolytic bone lesions in children include: simple bone cyst (rare in the hand and usually more radiolucent), fibrous dysplasia (rare in the hand and typically polyostotic), chondroblastoma (rare in the hand and the location is epiphyseal), eosinophilic granuloma (rare in the hand with multisystemic involvement), and osteomyelitis (aggressive pattern of destruction).

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Bone Lesions

8.3.6

Geode

Also known as subchondral cyst, subarticular pseudocyst, and necrotic pseudocyst, a geode is usually seen as a well-defined osteolytic lesion. It is a benign lesion caused by bone necrosis which allows pressure-induced passage of synovial fluid into subchondral bone, and is associated with disorders such as osteoarthritis, rheumatoid arthritis, osteonecrosis, and calcium pyrophosphate dihydrate deposition disease (CPPD). A geode appears as a well-defined, rounded osteolytic lesion with marginal sclerosis. It is located subchondrally. These features are nicely illustrated in the scaphoid of the hand of an adult with a geode (Figures a, b). A solitary geode needs to be differentiated from other subarticular osteolytic lesions. The erosions of rheumatoid arthritis usually do not have a sclerotic margin, are initially located periarticularly near the joint capsular insertion, and are associated with juxta-articular osteoporosis. CPPD lesions are usually larger, with more collapse of and fragmentation of the articular surface. Gouty erosions have overhanging edges and adjacent soft tissue masses. Bony tumors such as aneurysmal bone cyst, giant cell tumor, and chondroblastoma are solitary. Aneurysmal bone cyst is typically expansile, while giant cell tumor is characteristically eccentrically located. Chondroblastoma is located in the epiphysis in children and is rare in the hands. Pigmented villonodular synovitis is seen as a soft tissue mass around a joint, with cyst-like bone defects and well-defined sclerotic margins.

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8.3.7

Giant Cell Tumor

Also known as osteoclastoma, giant cell tumor is a bone tumor that is characterized histologically by the presence of multinucleated giant cells within fibroid stroma. It comprises 4% of primary bone tumors and 21% of benign bone tumors. The vast majority of these tumors present in patients aged 20–40 years, with 1.7–3% presenting before epiphyseal fusion. Eighty-five percent of giant cell tumors occur in the long bones, particularly around the knee and the wrist. Giant cell tumors typically involve the epiphysis and metaphysis, i.e., are subarticular in location. They are seen as solitary, expanded, osteolytic lesions that are eccentrically located. There are often prominent peripheral trabeculae without tumor matrix calcification. These features are nicely illustrated in the hand of an adult with giant cell tumor (Figures a, b). These tumors may break through the cortex, with soft tissue invasion in 25% and pathologic fracture in 5% of cases. Fifteen percent are malignant within the first 5 years, with metastases to the lungs.

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8.3.8

Hemangioma

Hemangioma of bone is a rare benign disorder that may occur in bone or soft tissues. Histologically, they consist of abnormal vascular channels interspersed in fatty matrix. Most of these lesions are asymptomatic and are usually slow-growing. The age of presentation is 10–50 years. Most hemangiomas of bone are found in the ribs, spine, or skull. The hand bones are a rare site. Hemangiomas are seen as osteolytic lesions with vertically orientated internal ridges that represent thickened trabeculae. There may be bony expansion and extraosseous extension. These features are nicely illustrated in the hand of an adult with bone hemangioma (Figures a, b).

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8.3.9

Metastasis

Metastases to bone are 15–100 times more common than primary bone tumors. If the primary is known, the most frequent metastases arise from the breast (35%), prostate (30%), lung (10%), and kidney (5%). Solitary metastasis is relatively uncommon, comprising only 7% of solitary bone lesions. Metastases usually occur in red-marrowcontaining bone, reflecting its typical distribution in adults (spine, skull, pelvis, ribs, and proximal ends of humerus and femur). Metastases to the hands and feet are rare, with 50% arising from bronchial carcinoma. Metastases may be osteolytic, osteosclerotic, or mixed. They may sometimes be expansile or permeative. Osteosclerotic metastases imply a slow-growing tumor. The most frequent primaries causing osteosclerotic metastases are the prostate (men) and breast (women). Others include bronchus, brain (medulloblastoma), bowel (carcinoid), and bladder. The margins of a metastasis may be ill-defined, with destruction of the adjacent cortex. Metastases rarely cross the joint space. These features are nicely illustrated in the hand of an adult with metastasis from bronchial carcinoma (Figures a, b).

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8.3.10 Paget’s Disease Also known as osteitis deformans, Paget’s disease is a multifocal chronic disease characterized by abnormal bone remodeling. It is thought to have a viral etiology. There is increased bone resorption and bone formation, with newly formed bone having a disorganized pattern causing deformity. Paget’s disease is usually asymptomatic, with patients presenting with deformity or fractures. It is rare in patients below 40 years of age, with an incidence of 10% in those older than 85 years in the West. The disease has a predominantly axial distribution, most frequently affecting the pelvis, spine, skull, proximal femur, and scapula. Distribution is usually asymmetric and polyostotic. Monostotic disease occurs in approximately 10–20% of cases. The three phases of the disease are the osteolytic (or active) phase, quiescent (or inactive) phase, and the mixed pattern (with both osteolysis and sclerosis). Monostotic involvement of the tubular bones of the hand is uncommon. In the inactive phase, there is sclerosis due to coarsened, thickened trabeculae. The thickened trabeculae are typically arranged in a striated orientation. The cortex is thickened, with encroachment into the medullary cavity. The epiphyseal region, extending subarticularly, is almost always involved. The affected bone is enlarged. These features are nicely illustrated in the hand of an adult with Paget’s disease (Figures a, b). The most important complication is sarcomatous transformation, which occurs in 1% of patients. The incidence increases to 5–10% if there is widespread involvement. Other complications include bowing due to bone softening, pathologic fractures, and osteomyelitis.

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Bibliography

Bourjat P (1987) Radiology of the hand. Springer, Berlin Byrne JJ (1959) The hand: its anatomy and disease. Thomas, Springfield Castriota-Scanderberg A, Dallapiccola B (2005) Abnormal skeletal phenotypes. From simple signs to complex diagnoses. Springer, Berlin Chapman S, Nakielny R (1984) Aids to radiological differential diagnosis. Bailliere’s Tindall, London Dahnert W (1993) Radiology review manual, 2nd edn. Williams & Wilkins, Baltimore Gerber LH, Espinoza LR (eds) (1985) Psoriatic arthritis. Grune & Stratton, Orlando Gilani S, Wignall BK (1995) Teaching atlas of hand radiology. Saunders, London Gilula LA, Yin Y (1996) Imaging of the wrist and hand. Saunders, Philadelphia Guglielmi G, Van Kuijk C, Genant HK (eds) (2001) Fundamentals of hand and wrist imaging. Springer, Berlin Jacobs P (1975) Atlas of hand radiographs. Miller & Medcalf, London Keats TE (1996) Atlas of normal roentgen variants that may simulate disease, 6th edn. Mosby, St Louis Kricun ME, Edeiken J (1973) Roentgenologic atlas of the hand and wrist in systemic disease. Williams & Wilkins, Baltimore Schmidt H, Freyschmidt J (1993) Kohler and Zimmer’s borderlands of normal and early pathologic findings in skeletal radiography, 4th edn. Thieme, Stuttgart Takahashi S, Sakuma S (1975) Magnification radiography. Springer, Berlin

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Subject Index

A

C

acromegaly  26, 32, 124 acro-osteolysis  138 alkalosis  120 alkaptonuria  26 amyloidosis  116 aneurysm  34 aneurysmal bone cyst  158 ankylosis  89 arterial calcification  34 arthralgia  112 arthritis  100, 112 –– gouty  66 arthrogryposis multiplex congenita  30 atheroma  34

calcification of the arteries  34 calcific pseudogout  31 calcified medullary defect  148 calcium –– deficiency  134 –– deposition  100, 118 –– pyrophosphate dihydrate deposition disease (CPPD)  26, 100, 118, 158 candle wax dripping  144 cardiac failure  32 carpal bone, hand of normal teenager  14 carpal fusion  16 carpal tunnel projection  10 carpal tunnel syndrome  116 cartilaginous tumor  28 chondroblastoma  158 chondrocalcinosis  26, 100, 118 chondroma, extraskeletal  28, 38 chondrosarcoma  38, 54, 140 chronic renal failure  116 claw hand  30 clinodactyly  18 Codman’s triangle  56 compact island  148 contrast  6

B BMD see bone mineral density bone –– island  148 –– mineral density (BMD)  52 –– resorption  62 –– tumor, in children  48 Bouchard’s nodes  72, 86 boutonnière/button-hole deformity  106 brown tumor  150

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Subject Index

cooley anemia  136 cortical bone sclerosis  50

growth plate, abnormal shape  18

D

Hajdu–Cheney syndrome  138 hardener-free developer  6 Heberden’s nodes  72, 86 hemangioma  162 hemochromatosis  26, 118 hemodialysis  31, 116 hemoglobinopathy  136 hereditary leptocytosis  136 hip fracture  52 hyaline cartilage  26 hypercalcemia  31, 120 hyperostosis  144 hyperparathyroidism  26, 34, 60, 62, 118, 130, 150 hyperuricemia  66 hypomagnesemia  118 hypophosphatasia  118 hypophosphatemia  26 hypothyroidism  118

dactylitis  146 degenerative joint disease  72 see also osteoarthritis delta phalanx  18 diabetes mellitus  34 distal radioulnar joint (DRUJ)  10 dose  6 Down syndrome  18 Dupuytren’s contracture  30 dyschondroplasia  140

E eburnation  72, 86 enchondroma  46, 152 –– in children  156 –– periosteal  54 –– with calcification  154 enchondromatosis  140 endosteal bone sclerosis  50 enostosis  148 enthesopathy  96 epidermoid bone cyst  46 erosive osteoarthritis  80 estrogen deficiency  52 exostosis  48 extraskeletal chondroma  28, 38

F fibroid stroma  160 film-screen system  7 focal sclerosis  148

G geode  142, 158 giant cell tumor  158, 160 gland hyperplasia  124 gout  26, 40, 46, 66 growth hormone  124

172

H

I industrial radiograph  2

J Jaccoud’s arthropathy  112 JCA see juvenile chronic arthritis joint –– ankylosis  110 –– contracture  30 juvenile chronic arthritis (JCA)  68 juxta-articular osteopenia  104

K Kienböck’s disease  94

L loose body  84 loss of articular cartilage  77 lupus pernio  146

 

Subject Index

M macrophage –– proliferation  102 Maffucci’s syndrome  152 mammography  2, 3 –– EV150 screen  7 –– Kodak  7 mediterranean anemia  136 medulloblastoma  164 melorheostosis  144 metacarpal bone, hand of normal teenager  14 metacarpal index (MCI)  52 metastases to bone  164 metastatic calcification  31 modulation transfer function (MTF)  3, 7 Mönckeberg’s medial calcific sclerosis  34 monosodium urate monohydrate deposition  40 monostotic disease  166 multicentric reticulohistiocytosis  70 multiple enchondromata  140 myalgia  112 myeloproliferative disorder  40 myxedema  32

N necrotic pseudocyst  142, 158

O obesity  32 Ollier’s disease  140, 152 oncology  2 original equipment manufacturer (OEM)  2 orthopedics  3 osseous trauma  48 osteitis deforman  166 osteoarthritis  72, 118 –– early  77 –– erosive  80 –– loose body  84 –– of the base of the thumb  92 –– primary form  86

–– severe  89 –– ulnar styloid  94 osteoarthrosis  50 osteochondroma  48 osteoclastoma  150, 160 osteodystrophy  60 –– renal  62, 130 osteoid osteoma  50 osteolysis  166 osteomalacia  62, 130, 134 osteomyelitis  46 osteopenia  52, 106, 126 osteophytes  72, 92 osteophytosis  80 osteoporosis  50, 52, 62, 126 osteosarcoma  56, 140 osteosclerosis  62, 130 osteosclerotic metastases  164

P Paget’s disease  166 parathyroid –– hormone  62 –– hyperplasia  130 Parkinson’s disease  30 periosteal –– enchondroma  54 –– lesion  56 periostitis ossifican  56 peripheral arthritis  66 phosphate metabolism  134 phosphor crystal  3 podagra  66 polyarthritis  70 polymyositis  31 processing condition –– automatic  4 –– manual  4 pseudoclubbing  138 pseudocyst  146 pseudogout  100, 118

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Subject Index

pseudoperiostitis  60 psoriasis  96 psoriatic arthritis (PA)  80, 96 punched-out lesion  66 pyrophosphate arthropathy  100

R radiographic/radiography –– child’s hand and wrist  12 –– film  3 –– hand of normal teenager  14 –– image  3 –– standard projection of the hand  10 radiology, historical development  2 Reiter syndrome  96 renal –– disease  40 –– failure  32 –– glomerular disease  130 –– osteodystrophy  31, 60, 62, 116, 120, 130 reticulohistiocytosis, multicentric  70 rheumatoid arthritis  16, 68, 80, 96, 102, 158 –– early signs  104 –– moderate form  106 –– severe form  110 rickets  134

S sarcoidosis  146 scaphoid fracture  10 scaphotrapeziotrapezoid fusion  16 scleroderma  31, 42 sclerosis  166 sensitometric curve  4 sesamoid bone  20 –– hand of normal teenager  14 skin lesion  70 SLE see systemic lupus erythematosus small bone structure  8 soft tissue –– atrophy  42

174

–– calcification  120 –– edema  32 subarticular pseudocyst  142, 158 subchondral –– cyst  142, 158 –– sclerosis  80 subperiosteal resorption  60 swan-neck deformity  106 synovial inflammation  142 synoviocyte proliferation  102 synovitis  112 systemic lupus erythematosus (SLE)  112

T tenosynovitis  102 thalassemia major  136 toe contrast  7 –– value  6 tophaceous deposit  40 trabecular coarsening  126 trauma –– hand  10 –– wrist  10 tumoral calcinosis  120

U ulnar styloid ossicle  22 uric acid –– crystal deposition  40 –– overproduction and underexcretion  66

V vascular calcification  120 vertebral fracture  52 vitamin D –– intoxication  34 –– metabolism  134 Volkmann’s ischemic contracture  30

 

Subject Index

W

X

Werner’s syndrome  34 Wilson’s disease  26 wrist, ulnar styloid process ––   22

X-OMAT industrial film  4, 5, 6

Z z-shaped deformity  106

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