William Martel

The Pattern of Bone Erosion in the Hand and Wrist in Rheumatoid Arthritis

Rheumatoid arthritis is a systemic disease of connective tissue affecting many organs and structures in addition to the bones and joints. Its outstanding clinical manifestation is a chronic deforming arthritis, particularly of the hands and wrists. The chief lesion is a proliferative synovitis, of both joints and tendon sheaths, with synovial inflammation and hyperplasia often developing into large nodular masses. Although much has been written about the general radiographic features of this disease (1–4), apparently little is known concerning the pathogenesis of the bone erosions. Vague references to “malignant synovitis” and “invasion by synovium” contribute little toward recognizing the factors involved in this process. The bone lesions in rheumatoid arthritis do not develop in a haphazard manner. Their pattern is in fact characteristic and predictable (5). In this study x-ray films of the hands and wrists of patients with rheumatoid arthritis were analyzed to define this pattern more precisely in term...

Tumoral calcinosis: radiologic-pathologic correlation

ObjectiveTumoral calcinosis is a frequently misdiagnosed disorder. This study details the radiologic and pathologic characteristics of tumoral calcinosis that distinguish it from most other entities.DesignRadiologic and pathologic findings, and medical records of 12 patients with tumoral calcinosis were reviewed and compared with equivalent information about 5 patients with other calcified lesions.PatientsThe 12 patients ranged in age from 15 months to 62 years. Six had idiopathic tumoral calcinosis and 6 had secondary tumoral calcinosis.Results and conclusionsA consistent radiologic finding for tumoral calcinosis was a dense calcified mass that was homogeneous except for a “chicken wire” pattern of lucencies, which correlated histologically with thin fibrous septae. Other characteristics of tumoral calcinosis included fluid-calcium levels, demonstrated in four patients, and smooth osseous erosions adjacent to the mass, demonstrated in three patients. Five cases of tumoral calcinosis were originally confused with other calcified lesions; however, the radiologic findings were characteristic of tumoral calcinosis in retrospect.

DISLOCATION OF THE ATLAS IN MONGOLISM: PRELIMINARY REPORT.

Anumber of roentgenographic manifestations of mongolism have already been described. Attention has been called to abnormalities of the cranial bones ((1, 3–5) and to characteristic features of the pelvis and hips (2). The purpose of this paper is to call attention to yet another finding, dislocation of the atlas, which appears to be significantly frequent in this disease. We recently observed such a dislocation in a ten-year-old mongoloid female who was referred to The University of Michigan Medical Center, Ann Arbor, Mich., because of accelerated skeletal maturation. The atlanto — odontoid distance measured 8 mm in the neutral position (Fig. 1). There were no symptoms or signs referable to the cervical spine and no history of trauma or other condition (8–10) which might explain this abnormality. It was therefore of interest to learn whether atlas dislocation was particularly common among mongoloid children. Method Cervical spine films of 18 mongoloids were obtained in neutral and flexion positions. Four ...

Pulmonary and pleural lesions in rheumatoid disease.

Pulmonary and pleural lesions are not uncommon in rheumatoid disease. Nonspecific pleuritis is a frequent finding at necropsy (1, 2), and rheumatoid nodules of the pleura have been observed (3–5). Such nodules have been described in the lungs of coal miners with rheumatoid disease (Caplans syndrome) (6–8) and in patients with other forms of pneumoconiosis (9–11). In addition, rheumatoid nodules have occasionally been reported in the lungs of patients who had not had such occupational exposures (12–15). In 1943 Ellman and Ball (16) called attention to diffuse pulmonary fibrosis at necropsy in two rheumatoid patients, and subsequently many similar cases were described. The recognition that clinical manifestations may occur with such pulmonary involvement led to the concept of the “rheumatoid lung syndrome.” This concept has not gained universal acceptance largely because of the nonspecificity of some of the pulmonary and pleural changes and the considerable variation in the type of involvement encountered....

The Overhanging Margin of Bone: A Roentgenologic Manifestation of Gout

Characteristic but not diagnostic of gout are “punched-out lytic lesions” of articular bone. Such erosions, appearing as sharply marginated lucent pockets or as discrete subchondral “pseudocysts” which seem unconnected to the joint, are commonly observed in rheumatoid arthritis and in other chronic joint diseases. There is a type of erosion, however, that is typical of gout and seems to be relatively rare in rheumatoid arthritis (1). The purpose of this communication is to describe this finding and emphasize its diagnostic value. Roentgenologic Description At the periphery of the erosion there is an elevated bone margin which appears to hang over the tophaceous nodule as though it were displaced by it (Figs. 1 and 2). This margin characteristically has a thin shell-like configuration and is continuous with the adjacent bone contour; its close relationship to a tophus is usually evident. This type of lesion is most commonly observed in the hand or foot. Comment In a retrospective review of the available ro...

Magnetic resonance imaging of knee hyaline cartilage and intraarticular pathology.

Injuries to the hyaline cartilage of the knee joint are difficult to diagnose without invasive techniques. Even though these defects may be the most important prog nostic factors in assessing knee joint injury, they are usually not diagnosed until arthrotomy or arthroscopy. Once injuries to hyaline cartilage are found and/or treated, no technique exists to follow these over time. Plain radiographs, arthrograms, and even computed tomography fail to detail most hyaline cartilage defects. We used magnetic resonance imaging (MRI) to eval uate five fresh frozen cadaver limbs and 10 patients whose pathology was known from arthrotomy or ar throscopic examination. Using a 0.35 Tesla supercon ducting magnet and spin-echo imaging technique with a head coil, we found that intraarticular fluid or air helped to delineate hyaline cartilage pathology. The multiplane capability of MRI proved to be excellent in detailing small (3 mm or more) defects on the femoral condyles and patellar surface. Cruciate ligaments were best visualized on sagittal oblique projections while meniscal pathology was best seen on true sagittal and coronal projections. MRI shows great promise in providing a noninvasive technique of evaluating hyaline cartilage defects, their response to treatment, and detailed anatomical infor mation about cruciate ligaments and menisci.

MR evaluation of liver iron overload

Children and young adults with hemolytic anemias requiring frequent transfusions develop increased liver iron content. We evaluated 15 chronically transfused children with sickle cell disease to determine whether spin-echo magnetic resonance (MR) imaging was useful in assessing the degree of iron overload. Quantitative MR parameters were correlated with liver biopsy iron determinations and serum ferritin levels. The best predictor of liver iron was the ratio of the intensities between the liver and paraspinal musculature on somewhat T1 weighted sequence (repetition time 0.5 s, echo time 28 ms). R2 = 0.58. Magnetic resonance was able to separate those patients with liver iron levels >100 μg/mg (intensity ratio ∼0.4). from those with levels <100 μg/mg (intensity ratios near I). However. MR was unable to quantitate liver iron in patients with values ranging from 100 to 400 μg/mg since similar intensity ratios were present in this range. Thus. MR provides a qualitative rather than quantitative assessment of liver iron overload.

Isotretinoin therapy is associated with early skeletal radiographic changes

Eight patients with disorders of keratinization (six with ichthyosis, one with Dariers disease, and one with palmar-plantar keratoderma) were treated with isotretinoin for 9 months (1 patient) to 1 year (7 patients). The patients ranged from 5 to 26 years of age. The average isotretinoin dose was 2 mg/kg/day (range, 1.0-2.9 mg/kg/day). Radiographic skeletal surveys were performed prior to therapy, and after 6 months and 1 year of therapy. After 1 year of isotretinoin treatment, six of the eight patients had small but unequivocal skeletal hyperostoses. Five of the patients had multiple hyperostoses. While only two patients were judged to have hyperostoses after 6 months of isotretinoin therapy during prospective evaluation, retrospective comparison with the radiographs obtained after 1 year revealed skeletal hyperostoses after 6 months of treatment in an additional three patients. Between 6 months and 1 year of therapy, some of the hyperostoses remained unchanged while others had progressed. In three patients, hyperostoses were seen at 12 months that were not detectable at 6 months. Based on this prospective study of skeletal changes during isotretinoin therapy, we recommend that patients taking high doses of isotretinoin for long periods be monitored radiographically.

Magnetic resonance imaging appearance of the muscles in childhood dermatomyositis

Documentation of muscle involvement in a child thought to have dermatomyositis may require the performance of invasive procedures such as electromyography and/or muscle biopsy. We describe four patients with dermatomyositis in whom magnetic resonance imaging (MRI) demonstrated the muscle involvement. The involved muscles had increased signal intensity on the T2-weighted images (SE 2500/80) and normal appearance on the T1-weighted images (SE 600/20). The involvement of the muscles was not uniform. There was good correlation between the distribution of muscle involvement by MRI and functional testing. Follow-up MRI scans in patients with favorable outcome demonstrated that the affected muscles had returned to normal signal intensity. Although the MRI findings are not specific, in the proper clinical context they may be helpful in establishing the diagnosis of dermatomyositis. MRI may also be used in establishing an appropriate muscle biopsy site. In addition, MRI may be used for monitoring the progress of the disease.

Lymphofollicular Synovitis with Osteoid Osteoma

Five cases of intra-articular osteoid osteoma occurring in the hip and elbow have been reviewed. Certain features not generally associated with this lesion are emphasized. These include: uniform narrowing of the interosseous space, subperiosteal bone apposition involving the affected bone as well as adjacent bones, and lymphofollicular inflammation in the adjacent soft tissues. The latter feature appears to be a consistent finding in intra-articular osteoid osteoma and was not a feature of the synovitis associated with other types of intra-articular mass lesions.