carpal instability in rheumatoid arthritis calcium ... · the pattern of carpal instability (see...

Annals of the Rheumatic Diseases, 1977, 36, 311-318

Carpal instability in rheumatoid arthritis andcalcium pyrophosphate deposition diseasePathogenesis and roentgen appearance

D. RESNICK AND G. NIWAYAMA

From the Departments of Radiology and Pathology, Veterans Administration and University Hospitals, SanDiego, California, USA

SUMMARY The roentgen appearance and pathogenesis of carpal instability are described in an

evaluation of patients and cadavers with rheumatoid arthritis and calcium pyrophosphate depositiondisease. Dorsiflexion (16 %) and palmar flexion (8 %) instability occurs in rheumatoid arthritis,particularly in patients with moderate to advanced disease. Navicular-lunate dissociation frequentlyaccompanies dorsiflexion instability and results from involvement of the interosseous ligamentbetween the two bones by rheumatoid pannus. Carpal instability and navicular-lunate dissociationalso accompany pyrophosphate arthropathy, resulting from calcific deposition and cystic degenera-tion of ligamentous structures.

Deformity and malalignment in rheumatoid arthritismay be produced by incongruity in apposingcartilaginous and bony surfaces, capsular andligamentous laxity, and muscle and tendon im-balance. Although these deformities occur mostfrequently about digital articulations, they are alsocommon in the wrist (Martel, 1964; Straub andRanawat, 1969; Collins et al., 1972; Resnick, 1976).In this latter location subluxations of the distal ulnaand radiocarpal joint are well recognized: intercarpalmalalignment, although not infrequent, has receivedlittle attention.

Recently Linscheid et al. (1972) classified mal-position of the carpal bones after trauma as palmarflexion and dorsiflexion carpal instability, properlyfocusing attention not on a single bone, the carpalnavicular, but rather on the relative position ofseveral bones, the radius, navicular, and lunate.These same patterns of wrist instability can berecognized in patients with rheumatoid arthritis.

This report (a) re-emphasizes both the normalstable pattern of the carpal bones and patterns ofcarpal instability which can be recognized duringradiographic evaluation of the wrist; (b) determinesthe incidence of such carpal instability in patients

Accepted for publication October 3, 1976Correspondence to Dr. D. Resnick, Department of Radi-ology, Veterans Administration Hospital, 3350 La JollaVillage Drive, San Diego, California 92161, USA

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with rheumatoid arthritis; (c) shows that suchinstability occurs not only in rheumatoid arthritisbut additionally in calcium pyrophosphate depositiondisease (CPPD); and (d) compares the pathogenesisand roentgen appearance of carpal instability inboth arthritic disorders.

Material and methods

The records and radiographs of 75 patients withclassical or definite rheumatoid arthritis by thecriteria of the American Rheumatism Associationwere chosen at randon from the files of the Universityand Veterans Administration Hospitals, San Diego.Most patients had moderate to advanced disease andconsiderable deformity. Many had multiple radio-graphic examinations over a period of several years.24 patients were eliminated as hand and wrist radio-graphs were considered suboptimal for evaluation.The remaining 51 patients had adequate roentgeno-graphic evaluation of their wrists, which includedradiographs in the frontal, lateral, and obliqueprojections. The pattern of carpal instability (seebelow), the position of the remaining carpal bones,and the presence of increased intercarpal space ordissociation were recorded.

Additional examples of carpal instability wereselected from 85 patients with CPPD. All haddefinite (31) or probable (54) disease based upon

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312 Resnick, Niwayama

criteria set forth by McCarty (1972). Skeletalabnormalities in these patients have been reportedpreviously in detail (Resnick et al., 1976).

Pathological examination of the wrist in 5rheumatoid cadavers and 5 cadavers with CPPDwas used to show the pathogenesis of these deformi-ties. This examination included whole and sectionalgross pathology and radiography, and microscopicalevaluation of 10 ,um sections which had been doubleembedded with 4% celloidin in methyl benzoate andparaffin. Macerated specimens using commercialbleach were also studied.

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Normal wrist alignment

In a posteroanterior radiograph of the wrist inneutral position (without ulnar or radial deviation)the radius articulates with the navicular and approxi-mately half of the lunate (Fig. la). A certain degreeof radial deviation at the wrist is normal. This can bedetermined by measuring the obtuse angle createdby the intersection of two co-ordinates, one alongthe longitudinal axis of the second metacarpal and a

second co-ordinate drawn from the tip of the radialstyloid to its ulnar limit. This normal value of radialdeviation is 1120 (92°-127°) (Resnick, 1976). Thespace between adjacent carpal bones is approximatelyequal throughout the wrist.

In a lateral radiograph of the wrist in neutralposition (without dorsi or palmar flexion) a

continuous line can be drawn along the longitudinalaxes of the radius, lunate, capitate, and thirdmetacarpal (Fig. lb). A second line through thelongitudinal axis of the navicular produces an angle(navicular-lunate angle) of 30°-60° with the firstline (Linscheid et al., 1972). Navicular-lunate angles

Fig. 1 Normal and abnormal carpal alignment.(a) Posteroanterior radiograph ofa normal wrist. Thedistal radius articulates with the navicular and a portionof the lunate. Note that the space between carpal bonesis approximately equal throughout the wrist. (b) In thenormal wrist (centre) the longitudinal axis of the radius(R) is continuous with that of the lunate (L) andcapitate (C). The longitudinal axis of the navicular (N)creates an angle of 30606 with the longitudinal axesof the other bones. Dorsiflexion carpal instability (top)is characterized by dorsiflexion of the lunate and anincreased navicular-lunate angle. Palmar flexion carpalinstability (bottom) relates to palmar flexion of thelunate in relation to the longitudinal axes of theradius and capitate. (c) Navicular-lunate dissociation ischaracterized by an increased space between navicularand lunate (arrow) and a foreshortened navicularprofile related to palmar flexion of that bone.ij[! hI('u

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Carpal instability in rheumatoid arthritis and calcium pyrophsphate deposition disease 313

of greater or lesser magnitude suggest carpalinstability.Carpal alignment normally changes during radial

and ulnar deviation of the wrist. In radial deviationpalmar flexion of the proximal carpal row occursand the distal navicular rotates into the palm; duringulnar deviation the space between the navicular andlunate increases slightly and the navicular is exposedin full profile (Arkless, 1966).

Pattern of carpal instability

The pattern of carpal instability may be classified asin Fig. lb. (1) Dorsiflexion instability (DFI) inwhich the lunate is dorsiflexed and displaced in avolar direction with an associated vertical displace-ment of the navicular. This results in an increasednavicular-lunate angle and usually indicates adissociation between the two bones (Fig. 1c),

Fig. 2(a) FigJ. 2(b)

Fig. 2 Carpalinstability inrheumatoid arthritis.(a, b) Note progressivewidening of the spacebetween navicular andlunate (arrow) andproximal migration ofthe capitate (arrowheads) in a 6-monthperiod. Otherrheumatoidabnormalities includesoft tissue swelling,joint space narrowing,bony erosions, andincreasing space betweendistal radius and ulna.(c) On the lateralradiograph, dorsiflexionof the lunate (L) andan increasednavicular-lunate (N, L)angle are apparent.

Fig. 2(c)

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termed navicular-lunate dissociation (NLD). (2)Palmar flexion instability (PFI) in which the lunateis palmar flexed in relation to the longitudinal axesof the radius and capitate. NLD is absent.

Results

Ninety-six wrists in 51 patients (37 men, 14 women)with rheumatoid arthritis were evaluated. The meanage was 55 years, range 25-83 years. The durationof disease varied from 6 months to 37 years. DFIwas noted in 15 wrists (16%) and PFI in 8 wrists(8 %). Increased intercarpal space between thenavicular and lunate (NILD) unrelated to apposingerosive abnormalities was noted in 25 wrists (26 %);DFI was present in 10 of these wrists (40%) andPFI in 1 (4%) (Fig. 2).

In the 25 wrists with NLD, 23 had associatedmedial displacement and 11 associated volardisplacement of the radiocarpal joint. DFI wasevident in all cases of severe dissociation. Onepatient developed NLD after resection of the distalulna associated with severe medial and moderatevolar displacement at the radiocarpal joint. Manypatients had 'pseudo' NLD created by adjacenterosions of the two bones. In these patients, if onereconstructed the osseous outlines, the navicular andlunate appeared in normal position. Carpal collapsewith severe disorganization was noted in 8 wrists.Additional deformities in these rheumatoid wristsappear in Table 1 (Resnick, 1976).

Discussion

Intercarpal instability is a recognized complicationafter wrist trauma. Although similar instabilityoccurs in rheumatoid arthritis, most reports of thelatter disease stress malalignment of the distal ulnaand radiocarpal joint. The normal concavity of the

Table 1 Rheumatoid attitudes and deformities

Attitude or deformity No. ofhandsor wrists

RadiocarpalRadial deviation 95Ulnar deviation IMedial displacement 59Volar displacement 27IntercarpalDorsiflexion carpal instability 15Palmar flexion carpal instability 8Inferior radioulnarDiastasis 27Dorsal ulnar subluxation 51MetacarpophalangealUlnar deviation 45Radial deviation 1Volar subluxation 29

radiocarpal joint is disrupted by destruction of thetriangular fibrocartilage and dorsal subluxation ofthe distal ulna. This results in medial andvolar displacement of the proximal carpal row.Exaggerated radial deviation at the radiocarpaljoint becomes apparent and may be associated withulnar deviation at the metacarpophalangeal jointsproducing the 'zig-zag' deformity of the rheumatoidhand (Stack and Vaughan-Jackson, 1971; Resnick,1976). Abnormal motion at the radiocarpal jointmay produce sclerosis and osseous debris (Arkless,1966, 1967; Resnick and Gmelich, 1975).

Intercarpal instability in rheumatoid arthritisconsists of both PFI and DFI. In our series the latterwas more frequent. PFI apparently results as theproximal carpal row migrates in an ulnar and volardirection along the inclined articular surface of thedistal radius. Palmar flexion of both navicular andlunate occurs and the navicular appears fore-shortened on frontal radiographs (Linscheid, 1969;Linscheid et al., 1972; Pekin and Zvaifler, 1963).The exact aetiology of DFI is unknown but may berelated to disruption of the navicular-lunate

Fig. 3 Cadaver with rheumatoid arthritis. (a) Radiographofa coronal section of the wrist shows navicular-lunatedissociation (arrow). Note joint space narrowing anderosive abnormalities. (b) Photograph of thecorresponding specimen, the increased space betweennavicular and lunate (black arrow) can be seen. Pannusis covering the navicular-lunate interosseous ligamentandproducing fibrous ankylosis of the joint (whitearrows). (c) Photomicrograph (x 4) ofa coronal sectionof the wrist, extensive synovial inflamnmation hasresulted in pannus-covered ligaments and cartilage at theradial aspect of the radiocarpal joint (arrows). Note themedial displacement of the navicular (N) and lunate (L)in relation to the distal radius (R).

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Carpal instability in rheumatoid arthritis and cakcium pyrophosphate deposition disease 315

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ligament and the distal attachment of the palmarradiocarpal ligament. These alterations result in anincreased angle between the longitudinal axes of thenavicular and lunate, and NLD. Our pathologicalstudies confirm the presence of synovial inflamma-tion with pannus covering these ligaments, resultingin weakening and disruption (Fig. 3).The incidence of NLD in our rheumatoid wrists

was 26%. Arkless (1966, 1967) used cineradiographyto evaluate wrist motion and noted that the lunatefailed to return to its supraradial position in ulnar

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deviation in 58 of 110 rheumatoid wrists. Separationbetween navicular and lunate was apparent in 50%of these wrists. Other series report a slightly lowerincidence of NLD and note additional sites ofintercarpal dissociation (Collins et al., 1972).DFJ and NLD occur in other arthritides. They

frequently appear in the wrist arthropathy of CPPDassociated with radiocarpal joint space narrowing,sclerosis, osteophytosis, and subchondral cystsprefeiring the navicular, lunate, and capitate(Resnick et al., 1976) (Fig. 4). Chondrocalcinosis

Fig. 4 Carpal instability in cakcium pyrophosphatedeposition disease (CPPD). (a) An increased spacebetween navicular and lunate has resultedfrom proximalmigration of the navicular with narrowing of theradiocarpal joint (arrow) and distal migration of thelunate with narrowing of the midcarpal joint (arrowhead).Calcification within the wrist is present but poorlyidentified. (b) More severe changes have resulted inseparation of navicular (arrow) and lunate (arrowhead).Sclerosis, osteophytosis, subchondral cyst formation,and calcification are apparent. (c) Photograph ofamacerated wrist specimen from a cadaver with CPPD,note the disruption of the interosseous ligamentbetween navicular and lunate (arrow) producing a gapbetween the two bones. Calcification of cartilage andsynovia (arrowhead) can be seen. (d) The correspondingphotomicrograph (x 4) shows the navicular-lunate (N-L)dissociation related to disruption of the interosseousligament (arrows). The radius (R) is indicated.

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may or may not be apparent (Resnick and Utsinger,1974). The abnormal separation between thenavicular and lunate in this condition is oftendistinctive. As the radiocarpal joint space narrows,the navicular moves proximally becoming impactedin the articular surface of the distal radius; as themidcarpal joint space narrows, the lunate movesdistally becoming intimate with the capitate. A'step-off' between navicular and lunate becomesapparent. This pattern of NLD, although notinvariably present, differs from that occurring in therheumatoid wrist.Examination of the pathological alterations

accompanying NLD in CPPD also indicateschanges distinct from those in the rheumatoid wrist(Table 2). Cystic degeneration and calcific depositionare apparent within the interosseous ligamentbetween navicular and lunate. Ligament laxity anddisruption become apparent. Cartilage fibrillationand erosion, and subchondral sclerosis and cystformation are associated findings.

Table 2

Location Pathological abnormali- Pathological abnormali-ties in rheumatoid ties in CPPDarthritis

Cartilage Pannus destruction, Fibrillation, erosion,replacement with denudation, calcificgranulation tissue deposition

Subchondral bone Pannus extension with Bony eburnation, cysts,cysts, erosions osteophytosis

Synovium Inflammation, hyper- Cartilaginous andtrophy, cellular osseous debris withinfiltration local inflammatory

change, calcificdeposition

Intra-articular Pannus invasion and Calcific deposition andligaments destruction cystic degeneration

Supported in part by VA Hospital grant no. 7406.D.R. is a Picker Scholar, James Picker Foundation.

References

Arkless, R. (1966). Cineradiography in normal and abnormalwrists. American Journal of Roentgenology, 96, 837-844.

Arkless, R. (1967). Rheumatoid wrists: cineradiography.Radiology, 88, 543-549.

Collins, L. C., Lidsky, M. D., Sharp, J. T., and Moreland, J.(1972). Malposition of carpal bones in rheumatoidarthritis. Radiology, 103, 95-98.

Linscheid, R. L. (1969). The mechanical factors affectingdeformity at the wrist in rheumatoid arthritis. Journal ofBone and Joint Surgery, 51A, 790.

Linscheid, R. L., Dobyns, J. H., Beabout, J. W., and Bryan,R. S. (1972). Traumatic instability of the wrist. Diagnosis,classification and pathomechanics. Journal of Bone andJoint Surgery, 54A, 1612-1632.

McCarty, D. J., Jr. (1972). Pseudogout; articular chondro-calcinosis. Calcium pyrophosphate crystal depositiondisease. Arthritis and Allied Conditions: a Textbook ofRheamatology, 8th ed., pp. 1140-1160. Ed. by J. L.Hollander. Lea and Febiger, Philadelphia.

Martel, W. (1964) The pattern of rheumatoid arthritis in thehand and wrist. Radiologic Clinics of North America, 2,221-234.

Pekin, T. J., Jr., and Zvaifler, N. J. (1963). Navicular displace-ment in rheumatoid arthritis: its recognition and signifi-cance. (Abst.) Arthritis and Rheumatism, 6, 292.

Resnick, D. (1976). Inter-relationships between radiocarpaland metacarpophalangeal joint deformities in rheumatoidarthritis. Journal of Canadian Association of Radiology, 27,29-36.

Resnick, D., and Gmelich, J. T. (1975). Bone fragmentationin the rheumatoid wrist: radiographic and pathologicconsiderations. Radiology, 114, 315-321.

Resnick, D., and Utsinger, P. D. (1974). Thewristarthropathyof 'pseudogout' occurring with and without chondro-calcinosis. Radiology, 113, 633-641.

Resnick, D., Niwayama, G., Goergen, T. G., Utsinger, P. D.,and Shapiro, R. F. (1976). Clinical, radiographic andpathologic abnormalities in calcium pyrophosphatedihydrate deposition disease (CPPD): an analysis of 85patients. Radiology, 22, 1-15.

Stack, H. G., and Vaughan-Jackson, 0. J. (1971). Thezig-zag deformity in the rheumatoid hand. Hand, 3, 62-67.

Straub, L. R., and Ranawat, C. S. (1969). The wrist inrheumatoid arthritis. Surgical treatment and results.Journal of Bone and Joint Surgery, 51A, 1-20.

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carpal instability in rheumatoid arthritis calcium ... · the pattern of carpal instability (see...

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