Erosion or normal variant? 4-year MRI follow-up of the wrists in healthy children

Juvenile Idiopathic Arthritis and Spondylarthritis

Juvenile idiopathic arthritis (JIA) is a heterogeneous disorder affecting children < 16 years of age. The clinical heterogeneity translates to imaging, where no specific joint is affected. This article highlights a general imaging approach to JIA, using specific examples of the knee, hand, and wrist as the typical joints affected. We then focus on unique joints that are commonly affected by JIA: the temporomandibular joint, the joints of the upper cervical spine, and the sacroiliac joint. For these latter anatomical sites, regional anatomy and development, location-specific imaging considerations, and arthritis, treatment decision making, and potential differential considerations are reviewed. We highlight, where applicable, a multimodal approach to imaging using developed or developing standardized scoring systems.

Congenital and Traumatic Conditions of the Pediatric Hand: Overview for the Radiologist

Alignment, longitudinal growth, and function of the musculoskeletal unit of the pediatric hand is complex due to the combination of open growth plates, ossification variations, and their relationship with finger tendinous and ligamentous attachments. This review presents the basics of normal development, acquired and congenital variations, and traumatic conditions of the pediatric hand from the perspective of the pediatric musculoskeletal radiologist and hand surgeon. This multimodality imaging article focuses on non-oncologic and non-rheumatologic conditions of the pediatric hand, inclusive of fingers, thumb, and metacarpal bones.

Imaging in pediatric spondyloarthritis

PURPOSE OF REVIEW

Imaging is used in the diagnosis of peripheral and axial disease in juvenile spondyloarthritis (JSpA). Imaging of the joints and entheses in children and adolescents can be challenging for those unfamiliar with the appearance of the maturing skeleton. These differences are key for rheumatologists and radiologists to be aware of.

RECENT FINDINGS

In youth, skeletal variation during maturation makes the identification of arthritis, enthesitis, and sacroiliitis difficult. A great effort has been put forward to define imaging characteristics seen in healthy children in order to more accurately identify disease. Additionally, there are novel imaging modalities on the horizon that are promising to further differentiate normal physiologic changes versus disease.

SUMMARY

This review describes the current state of imaging, limitations, and future imaging modalities in youth, with key attention to differences in imaging interpretation of the peripheral joints, entheses, and sacroiliac joint in youth and adults.

Atlas of MRI findings of sacroiliitis in pediatric sacroiliac joints to accompany the updated preliminary OMERACT pediatric JAMRIS (Juvenile Idiopathic Arthritis MRI Score) scoring system: Part II: Structural damage lesions

Magnetic resonance imaging (MRI) is the imaging modality of choice for identifying sacroiliitis in juvenile idiopathic arthritis (JIA). Besides active lesions of sacroiliitis, of which bone marrow edema (BME) is the key feature, structural damage lesions can also be detected. Structural changes include erosion, sclerosis, fat lesion, backfill and ankylosis, and are more common at later stages. Systematic MRI assessment of inflammation and structural damage may aid in monitoring the course of the disease and evaluating treatment options. In this pictorial essay, we illustrate normal MRI findings and growth-related changes of the SIJ in the pediatric population, as well as the different MRI features of structural damage of sacroiliitis. This atlas can serve as a reference for assessing structural lesions of SIJ arthritis according to the updated preliminary JAMRIS (Juvenile Idiopathic Arthritis MRI Score) scoring system proposed by the MRI in JIA working group of Outcome Measures in Rheumatology and Clinical Trials (OMERACT). The atlas is intended to be read in conjunction with its companion Part 1, Active Lesions.

Whole-body magnetic resonance imaging in children - how and why? A systematic review

Whole-body magnetic resonance imaging (MRI) is increasingly being used for a number of indications. Our aim was to review and describe indications and scan protocols for diagnostic value of whole-body MRI for multifocal disease in children and adolescents, we conducted a systematic search in Medline, Embase and Cochrane for all published papers until November 2018. Relevant subject headings and free text words were used for the following concepts: 1) whole-body, 2) magnetic resonance imaging and 3) child and/or adolescent. Included were papers in English with a relevant study design that reported on the use and/or findings from whole-body MRI examinations in children and adolescents. This review includes 54 of 1,609 papers identified from literature searches. Chronic nonbacterial osteomyelitis, lymphoma and metastasis were the most frequent indications for performing a whole-body MRI. The typical protocol included a coronal STIR (short tau inversion recovery) sequence with or without a coronal T1-weighted sequence. Numerous studies lacked sufficient data for calculating images resolution and only a few studies reported the acquired voxel volume, making it impossible for others to reproduce the protocol/images. Only a minority of the included papers assessed reliability tests and none of the studies documented whether the use of whole-body MRI affected mortality and/or morbidity. Our systematic review confirms significant variability of technique and the lack of proven validity of MRI findings. The information could potentially be used to boost attempts towards standardization of technique, reporting and guidelines development.

Current status of MR imaging of juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic arthropathy in the pediatric population. Although the diagnosis is essentially clinical for many affected joints, MR imaging has become an important tool for the assessment of joints that are difficult to evaluate clinically, such as temporomandibular and sacroiliac joints, and for screening of inflammatory changes in the entire body by whole body MRI (WBMRI) assessment. The utilization of MR imaging is challenging in the pediatric population given the need for discrimination between pathological and physiological changes in the growing skeleton. Several multicentric multidisciplinary organizations have made major efforts over the past decades to standardize, quantify, and validate scoring systems to measure joint changes both cross-sectionally and longitudinally according to rigorous methodological standards. In this paper, we (1) discuss current trends for the diagnosis and management of JIA, (2) review challenges for detecting real pathological changes in growing joints, (3) summarize the current status of standardization of MRI protocols for data acquisition and the quantification of joint pathology in JIA by means of scoring systems, and (4) outline novel MR imaging techniques for the evaluation of anatomy and function of joints in JIA. Optimizing the role of MRI as a robust biomarker and outcome measure remains a priority of future research in this field.

Exploring contrast-enhanced MRI findings of the clinically non-inflamed symptomatic pediatric wrist

BACKGROUND

Knowledge of the synovial and tenosynovial appearance of the clinically non-arthritic symptomatic juvenile wrist using contrast-enhanced magnetic resonance imaging (MRI) is sparse.

OBJECTIVES

To analyze contrast-enhanced MRI findings of the clinically non-inflamed symptomatic pediatric wrist, focusing on the enhancing synovial and tenosynovial membrane. To evaluate the coexistent presence of (teno)synovial enhancement, joint fluid, bony depressions and medullary changes suggestive of bone marrow edema.

MATERIALS AND METHODS

We included 20 children (15 girls; age range: 7.5-17.6 years) who underwent contrast-enhanced MRI of the wrist, based on initial clinical indication, and eventually turned out to be unaffected by arthritic or orthopedic disorders. Various imaging characteristics of the synovium, tenosynovium, joint fluid, bone tissue and bone marrow were evaluated using existing MRI scoring systems.

RESULTS

In 3/20 (15%) children, mild or moderate-severe synovial enhancement was observed and 2/20 (10%) children showed mild tenosynovial enhancement/thickening. Joint fluid (11/20 children; 55%), bony depressions (20/20 children; 100%) and medullary changes suggestive of bone marrow edema (6/20; 30%) were found in a substantial percentage of children. The most frequently observed combination of coexisting imaging characteristics was bony depressions with ≥2 mm joint fluid, which was found in 7/20 (35%) children. Simultaneous presence of synovial and tenosynovial enhancement/thickening, bony depressions and medullary changes suggestive of bone marrow edema was observed in one child.

CONCLUSION

Several juvenile idiopathic arthritis-relevant MRI characteristics can be observed in the clinically non-inflamed symptomatic pediatric wrist.

No radiographic wrist damage after treatment to target in recent-onset juvenile idiopathic arthritis

BACKGROUND

To evaluate radiographic progression of patients with new-onset juvenile idiopathic arthritis (JIA) in response to an early, tightly-controlled, treatment-to-target.

METHODS

Patients with JIA participating in the BeSt-for-Kids-study, randomized to 3 treatment strategy arms, were eligible if at least 1 conventional wrist-radiograph was available. Bone damage as reflected by carpal length was assessed using the Poznanski-score. The BoneXpert-method was used to determine the Bone Age (BA, > 5 years) and bone mineral density (BMD) of the wrist. These scores were evaluated over time and compared between the treatment arms and mean JADAS10-score using linear mixed models corrected for age and symptom duration.

RESULTS

In 60 patients, 252 radiographs were analysed. Baseline age and symptom duration were different between the arms. No difference in comparison to the healthy reference population was found at baseline for the Poznanski-score (IQR varying from - 0,82; 0.68), nor for BA (varying from - 0.88 to 0.74). Baseline BMD was statistically significantly lower in arm 3 (initial treatment with etanercept and methotrexate) (- 1.48; - 0.68) compared to arm 1 (- 0.84; - 0.04) and arm 2 (- 0.93; 0.15). After treatment to target inactive disease, the Poznanski-scores and the BA remained clinically unchanged, while the BMD in arm 3 improved (p < 0.05 vs arm 1).

CONCLUSIONS

Recent-onset JIA patients, treated-to-target aimed at inactive disease, showed no signs of radiographic wrist damage (Poznanski-score, BA or BMD) either at baseline or at follow-up, irrespective of treatment arm. A lower BMD at baseline in arm 3, initially treated with methotrexate and etanercept, improved significantly after treatment.

TRIAL REGISTRATION

NTR, NL1504 (NTR1574). Registered 01-06-2009.

Consider the wrist: a retrospective study on pediatric connective tissue disease with MRI

The aim of this study is to describe the clinical characteristics and MRI findings of the wrist in a cohort of children suffering from connective tissue disease with musculoskeletal involvement. Ten patients with pediatric connective tissue disease [median age 14.7 years (IQR 12.7-16.6 years), 70% female] were identified from a large MRI database. Clinical findings during the disease course were retrospectively obtained from patient charts and findings at the time of MRI were prospectively registered in the MRI database. MRI wrist datasets were evaluated by three readers in consensus for synovitis, tenosynovitis, bone marrow changes, bone erosions and myositis. Patients suffered from connective tissue disease with clinical overlap of subtypes systemic lupus erythematosus, Sjögren syndrome and dermatomyositis. Median onset of disease was at 12.3 years (IQR 7.8-14.8 years). Clinical arthritis activity was scored low (median visual analogue scale physician 19, IQR 7-31). Notwithstanding, extensive inflammatory abnormalities such as synovitis and tenosynovitis were found in the wrist of 7/10 patients. Osteochondral involvement was detected in 3/10 patients. In a small cohort of children with connective tissue disease and musculoskeletal symptoms, severe inflammatory abnormalities of the involved wrist were present in the MRI, while clinical disease scores suggested mild disease activity. Therefore, clinicians should consider the wrist as vulnerable for joint damage and can add MRI as a helpful tool in the management of patients with pediatric connective tissue disease and musculoskeletal involvement.

Reliability of ultrasonography to detect inflammatory lesions and structural damage in juvenile idiopathic arthritis

BACKGROUND

Musculoskeletal Ultrasonography (MSUS) is an important tool for the clinical assessment in Juvenile Idiopathic Arthritis (JIA). The objective of this study was to evaluate the reliability of MSUS to detect elementary lesions: synovitis, tenosynovitis, cartilage damage and bone erosions in the wrist and metacarpal (MCP) joints of patients with JIA.

METHODS

Thirty children in various subgroups of JIA according to ILAR criteria, were included in this cross-sectional study. Clinical data including painful, swollen and limited joints were recorded. Five rheumatologist ultrasonographers, blinded to the clinical evaluation, evaluated the presence of elementary lesions in the wrist and MCP 2 and 3 joints bilaterally. The synovitis was graded in B-Mode and Power Doppler (PD). In addition to descriptive statistics intra- and inter-observer reliability was calculated using Cohen's kappa according to Landis and Koch.

RESULTS

US detected more synovitis than the clinical examination (62% vs 28%, 30% vs 23% and 22% vs 17% in the wrist, second and third MCP joints respectively). The intra-observer concordance for synovitis in all joints was excellent in B-Mode (k 0.84 .63-1.0 p = 0.001), except for MCP 2, where it was good (0.61, IC 95% .34-89, p = 0.001). For both modalities (PD, B-Mode) tenosynovitis, cartilage damage and bone erosions it was also excellent. Regarding synovitis grading the concordance was excellent for all grades (0.83-1.0, IC 95% 0.51.1.0, p = 0.001), except for grade 1 where it was good (0.61, IC 95% 0.43-.83, p = 0.001). Reliability inter-observer for grayscale synovitis (0.67-0.95, IC 95% 0.67-1.0, p = 0.001), tenosynovitis grayscale (0.89, IC 95% 0.78-0.99, p.001), damage cartilage (0.89, IC 95% 0.78-0.99, p = 0.001), PD (0.66, IC 95% 0.39-1.0, p = 0.001). The concordance for grading synovitis was excellent, but for grayscale grade 1 and 2 (.66, IC 95% .53-.74, p = 0.007) and PD grade 1 and 2 (0.63, IC 95% .58-.91, p = 004) was good.

CONCLUSIONS

The intra- and inter-observer reliability of MSUS for inflammatory and structural lesions is good to excellent for the wrist and MCP in patients with JIA.

Current status of wrist imaging in juvenile idiopathic arthritis

Wrist involvement occurs in about one-quarter of patients diagnosed with juvenile idiopathic arthritis (JIA), increasing to 40% 5 years after diagnosis. The imaging appearances, both for active inflammation and permanent change, differ from those seen in adult rheumatoid arthritis; therefore, a child-specific approach is crucial for correct assessment. In this review article, we provide an update on the current status for imaging wrist JIA, with a focus on evidence-based practice.

Imaging in juvenile idiopathic arthritis - international initiatives and ongoing work

Imaging is increasingly being integrated into clinical practice to improve diagnosis, disease control and outcome in children with juvenile idiopathic arthritis. Over the last decades several international groups have been launched to standardize and validate different imaging techniques. To enhance transparency and facilitate collaboration, we present an overview of ongoing initiatives.

Ultrasound imaging of synovial inflammation in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common rheumatic entity of childhood. The hallmark feature of all subtypes is joint inflammation. Imaging is used to evaluate the extent and severity of inflammation, degree of joint damage and response to treatment, which in turn impacts patient management. Ultrasound has become a useful adjunct to clinical examination because it shows promise in evaluating clinical and subclinical inflammation (synovitis, enthesitis) as well as cartilage and bone erosive changes. However more collaborative research is needed to help define the normal appearance of the growing skeleton, clarify the significance of subclinical findings and develop useful definitions, imaging protocols and scoring systems of disease.

Juvenile idiopathic arthritis: what is the utility of ultrasound?

Juvenile idiopathic arthritis (JIA) is a heterogeneous condition and an important cause of acquired disability in children. Evidence supports early treatment to prevent future complications. This relies on prompt diagnosis, achieved by a high index of clinical suspicion and supportive evidence, including the detection of joint and or tendon inflammation. Ultrasound is a readily accessible, well-tolerated, safe and accurate modality for assessing joints and the surrounding soft tissues. It can also be used to guide therapy into those joints and tendon sheaths resistant to systemic treatments. Ultrasound imaging is highly operator dependent, and the developing skeleton poses unique challenges in interpretation with sonographic findings that can mimic pathology and vice versa. Ultrasound technology has been rapidly improving and is more accessible than ever before. In this article, we review the normal appearances, highlight potential pitfalls and present the key pathological findings commonly seen in JIA.

Joint Fluid, Bone Marrow Edemalike Changes, and Ganglion Cysts in the Pediatric Wrist: Features That May Mimic Pathologic Abnormalities-Follow-Up of a Healthy Cohort

OBJECTIVE

The presence of findings at wrist MRI that may mimic disease is a diagnostic problem. The purpose of this study is to examine the occurrence of bone marrow changes resembling edema, joint fluid, and ganglion cysts over time, in a cohort of healthy children.

MATERIALS AND METHODS

Seventy-four of 89 healthy children included in a study of normal MRI findings of the wrists were reexamined after a period of 4 years, using the same 1.5-T MRI technique-namely, a coronal T1-weighted and a T2-weighted fat-saturated sequence. A history of handedness, diseases, and sports activity was noted.

RESULTS

Bone marrow edema or edemalike changes were seen in 29 of 74 (39.2%) wrists in 2013 as compared with 35 of 72 (48.6%) wrists in 2009 (p = 0.153), all in different locations. Changes were found in central parts of the bone, on both sides of a joint, or near bony depressions. Fifty percent of all subjects had at least one fluid pocket greater than or equal to 2 mm. The location was unchanged in 47% of the joints. In 24% of the individuals, at least one ganglion cyst was seen. Six ganglion cysts present on the first scan were not seen on the follow-up scan, and 11 new ganglion cysts had appeared.

CONCLUSION

Awareness of normal MRI appearances of the growing skeleton is crucial when interpreting MRI of children, and such findings must not be interpreted as pathologic abnormalities.