Skeletal Radiol (1992) 21:515-517
Skeletal Radiology
Superolateral erosions of the humeral head in chronic inflammatory arthropathies Juan C. Babini, Simon E. Gusis, Silvia M. Babini, and Jos6 A. Maldonado Cocco Rheumatology Department, Instituto Nacional de Rehabilitacion, Buenos Aires, Argentina
Abstract. Erosive lesions o n the s u p e r o l a t e r a l a s p e c t o f the h u m e r a l h e a d were studied in 127 p a t i e n t s with chronic inflammatory arthropathies including rheumatoid arthritis (RA), juvenile rheumatoid arthritis (JRA), a n k y l o s i n g s p o n d y l i t i s (AS), a n d p s o r i a t i c a r t h r o p a t h y (PA), as well as in a c o n t r o l g r o u p o f 53 p a t i e n t s with n o n - i n f l a m m a t o r y s h o u l d e r j o i n t disease. S u p e r o l a t e r a l e r o s i o n s were f o u n d in 39 o u t o f 127 p a t i e n t s (31%), c o m p r i s i n g ]1/56 R A cases (20%), 2 2 / 5 0 J R A cases (44%), 4/9 cases o f A S ( 4 4 % ) , a n d 2/12 cases o f P A (17%), b u t were a b s e n t in n o n - i n f l a m m a t o r y disorders. Two m o r p h o l o g i c a l l y distinct types o f e r o s i o n s were observed, an extensive one, p r e s e n t in all o f the i n f l a m m a t o r y c o n d i t i o n s studied, a n d a c i r c u m s c r i b e d one occurring p r e d o m i n a n t l y in J R A patients.
Key words: S h o u l d e r j o i n t - R a d i o l o g y C h r o n i c a r t h r o p a t h i e s - Juvenile r h e u m a t o i d a r t h r i t i s - E r o s i o n s
T h e s h o u l d e r j o i n t is often i n v o l v e d in c h r o n i c i n f l a m m a t o r y a r t h r o p a t h i e s , at times p r e s e n t i n g b o n e e r o s i o n s w h i c h h a v e n o t yet been fully c h a r a c t e r i z e d . In 1980, R o s e n [18] d e s c r i b e d an erosive s h o u l d e r lesion l o c a t e d in the s u p e r o l a t e r a l region o f the h u m e r a l head, w h i c h he c o n s i d e r e d t y p i c a l o f a n k y l o s i n g s p o n d y l i t i s (AS), b u t which was o c c a s i o n a l l y p r e s e n t in j u v e n i l e r h e u m a t o i d a r t h r i t i s ( J R A ) . U s u a l l y bilateral, the lesion d e s t r o y s the g r e a t e r t u b e r o s i t y a n d n e i g h b o u r i n g b o n e areas. T h e p u r p o s e o f the p r e s e n t s t u d y was to e v a l u a t e the p r e v a l e n c e a n d clinical significance o f erosive lesions o f the s u p e r o l a t e r a l r e g i o n o f the h u m e r a l h e a d in c h r o n ic i n f l a m m a t o r y arthritis. Correspondence to: Dr. Jos~ A. Maldonado Cocco, Seccidn Reumatologia, Instituto Nacional de Rehabilitacidn, Echeverria 955, 1428-Buenos Aires, Argentina
Materials and methods A prospective radiological study of the glenohumeral joint was carried out in 180patients presenting clinical manifestations of shoulder involvement in the form of pain and/or of limitation movement lasting for over 6 months. The population consisted of 56 patients with rheumatoid arthritis (RA) [17], 50 with JRA [4], 12 with psoriatic arthropathy (PA) [3], and 9 with AS [2]. A consecutive group of 53 patients with miscellaneous non-inflammatory conditions of the soft tissue of the shoulder joint (bicipital tenosynovitis, supraspinatus calcification, tendinitis, subacromial bursitis, and adhesive capsulitis) were similarly studied as a control group. In order to evaluate the glenohumeral joint superimposition of structures, a standardized radiological study of both schoulders was performed [8]. Briefly, the patient was seated facing the beam but rotated to form a 40~ angle between the coronal plane of the examined shoulder and the film; the beam was angulated caudally by 15~ Interpretation of the X-rays was carried out independently by two of the authors, who were unaware of diagnosis in each case. Special attention was paid to erosive lesions located on the superolateral aspect of the humeral head. No notice was taken of minor cystic defects sometimes present even in non-inflammatory soft tissue conditions of the shoulder joint. All patients received a Full clinical examination in which the duration and features of shoulder involvement were specially considered. Statistical significance of results was evaluated by means of the Student t and Z2 tests [1].
Results O f the 127 p a t i e n t s with c h r o n i c i n f l a m m a t o r y a r t h r o pathies, 39 ( 3 1 % ) h a d erosive lesions in the s u p e r o l a t e r a l region o f the h u m e r a l h e a d , b i l a t e r a l in 20 cases a n d u n i l a t e r a l in 19. O f the 39 p a t i e n t s with erosions, l l ( 2 0 % ) were R A cases, 22 ( 4 4 % ) were J R A , 2 ( 1 7 % ) were P A a n d 4 ( 4 4 % ) were AS. N o n e o f the 53 p a t i e n t s in the c o n t r o l g r o u p s h o w e d erosive lesions. O n a n a l y s i n g the s a m p l e a c c o r d i n g to the n u m b e r o f X - r a y s studied, o u t o f a t o t a l o f 254 s h o u l d e r s with c h r o n i c i n f l a m m a t o r y arthritis, erosive lesions were f o u n d in 59 (23%), c o m p r i s i n g 16 s h o u l d e r s in R A p a 9 1992 International Skeletal Society
516
J.C. Babini et al. : Humeral erosions in chronic arthropathies
Table 1. Incidence of erosive lesions in the superolateral region of the humeral head in 127 cases of chronic inflammatory shoulder joint disease Disease
No. of shoulders
No. of shoulders with erosions
Incidence (%)
Rheumatoid arthritis Juvenile rheumatoid arthritis Psoriatic arthropathy Ankylosing spondylitis
112 100
16 33
14 33
24 18
3 7
13 39
Total
254
59
23
Fig. 1. Erosive lesion classified as extensive, with destruction of the greater tuberosity and neighbouring bone Fig. 2. Erosive lesion classified as circumscribed, having sharp borders and located within the greater tuberosity
Table 2. Patient age and duration of clinical involvement in 254 shoulders with chronic inflammatory joint disease Disease
Rheumatoid arthritis Juvenile rheumatoid arthritis Psoriatic arthropathy Ankylosing spondylitis
Patients age (years)
Total duration (years)
With erosions (years)
Without erosions (years)
Mean
Range
Mean
Range
Mean
Range
Mean
Range
48.9 15.6 46.4 31.8
22-76 6-42 8 64 17-52
8.0 7.0 5.0 4.8
0.5-41 0.5-27 0.5-21 0.5-10
8.4 6.7 17.6 7.2
0.5-25 0.5-26 11-21 0.5-10
7.7 7.0 3.0 3.0
0.5-41 0.5-27 0.5-21' I 5
*p
Skeletal Radiology
Superolateral erosions of the humeral head in chronic inflammatory arthropathies Juan C. Babini, Simon E. Gusis, Silvia M. Babini, and Jos6 A. Maldonado Cocco Rheumatology Department, Instituto Nacional de Rehabilitacion, Buenos Aires, Argentina
Abstract. Erosive lesions o n the s u p e r o l a t e r a l a s p e c t o f the h u m e r a l h e a d were studied in 127 p a t i e n t s with chronic inflammatory arthropathies including rheumatoid arthritis (RA), juvenile rheumatoid arthritis (JRA), a n k y l o s i n g s p o n d y l i t i s (AS), a n d p s o r i a t i c a r t h r o p a t h y (PA), as well as in a c o n t r o l g r o u p o f 53 p a t i e n t s with n o n - i n f l a m m a t o r y s h o u l d e r j o i n t disease. S u p e r o l a t e r a l e r o s i o n s were f o u n d in 39 o u t o f 127 p a t i e n t s (31%), c o m p r i s i n g ]1/56 R A cases (20%), 2 2 / 5 0 J R A cases (44%), 4/9 cases o f A S ( 4 4 % ) , a n d 2/12 cases o f P A (17%), b u t were a b s e n t in n o n - i n f l a m m a t o r y disorders. Two m o r p h o l o g i c a l l y distinct types o f e r o s i o n s were observed, an extensive one, p r e s e n t in all o f the i n f l a m m a t o r y c o n d i t i o n s studied, a n d a c i r c u m s c r i b e d one occurring p r e d o m i n a n t l y in J R A patients.
Key words: S h o u l d e r j o i n t - R a d i o l o g y C h r o n i c a r t h r o p a t h i e s - Juvenile r h e u m a t o i d a r t h r i t i s - E r o s i o n s
T h e s h o u l d e r j o i n t is often i n v o l v e d in c h r o n i c i n f l a m m a t o r y a r t h r o p a t h i e s , at times p r e s e n t i n g b o n e e r o s i o n s w h i c h h a v e n o t yet been fully c h a r a c t e r i z e d . In 1980, R o s e n [18] d e s c r i b e d an erosive s h o u l d e r lesion l o c a t e d in the s u p e r o l a t e r a l region o f the h u m e r a l head, w h i c h he c o n s i d e r e d t y p i c a l o f a n k y l o s i n g s p o n d y l i t i s (AS), b u t which was o c c a s i o n a l l y p r e s e n t in j u v e n i l e r h e u m a t o i d a r t h r i t i s ( J R A ) . U s u a l l y bilateral, the lesion d e s t r o y s the g r e a t e r t u b e r o s i t y a n d n e i g h b o u r i n g b o n e areas. T h e p u r p o s e o f the p r e s e n t s t u d y was to e v a l u a t e the p r e v a l e n c e a n d clinical significance o f erosive lesions o f the s u p e r o l a t e r a l r e g i o n o f the h u m e r a l h e a d in c h r o n ic i n f l a m m a t o r y arthritis. Correspondence to: Dr. Jos~ A. Maldonado Cocco, Seccidn Reumatologia, Instituto Nacional de Rehabilitacidn, Echeverria 955, 1428-Buenos Aires, Argentina
Materials and methods A prospective radiological study of the glenohumeral joint was carried out in 180patients presenting clinical manifestations of shoulder involvement in the form of pain and/or of limitation movement lasting for over 6 months. The population consisted of 56 patients with rheumatoid arthritis (RA) [17], 50 with JRA [4], 12 with psoriatic arthropathy (PA) [3], and 9 with AS [2]. A consecutive group of 53 patients with miscellaneous non-inflammatory conditions of the soft tissue of the shoulder joint (bicipital tenosynovitis, supraspinatus calcification, tendinitis, subacromial bursitis, and adhesive capsulitis) were similarly studied as a control group. In order to evaluate the glenohumeral joint superimposition of structures, a standardized radiological study of both schoulders was performed [8]. Briefly, the patient was seated facing the beam but rotated to form a 40~ angle between the coronal plane of the examined shoulder and the film; the beam was angulated caudally by 15~ Interpretation of the X-rays was carried out independently by two of the authors, who were unaware of diagnosis in each case. Special attention was paid to erosive lesions located on the superolateral aspect of the humeral head. No notice was taken of minor cystic defects sometimes present even in non-inflammatory soft tissue conditions of the shoulder joint. All patients received a Full clinical examination in which the duration and features of shoulder involvement were specially considered. Statistical significance of results was evaluated by means of the Student t and Z2 tests [1].
Results O f the 127 p a t i e n t s with c h r o n i c i n f l a m m a t o r y a r t h r o pathies, 39 ( 3 1 % ) h a d erosive lesions in the s u p e r o l a t e r a l region o f the h u m e r a l h e a d , b i l a t e r a l in 20 cases a n d u n i l a t e r a l in 19. O f the 39 p a t i e n t s with erosions, l l ( 2 0 % ) were R A cases, 22 ( 4 4 % ) were J R A , 2 ( 1 7 % ) were P A a n d 4 ( 4 4 % ) were AS. N o n e o f the 53 p a t i e n t s in the c o n t r o l g r o u p s h o w e d erosive lesions. O n a n a l y s i n g the s a m p l e a c c o r d i n g to the n u m b e r o f X - r a y s studied, o u t o f a t o t a l o f 254 s h o u l d e r s with c h r o n i c i n f l a m m a t o r y arthritis, erosive lesions were f o u n d in 59 (23%), c o m p r i s i n g 16 s h o u l d e r s in R A p a 9 1992 International Skeletal Society
516
J.C. Babini et al. : Humeral erosions in chronic arthropathies
Table 1. Incidence of erosive lesions in the superolateral region of the humeral head in 127 cases of chronic inflammatory shoulder joint disease Disease
No. of shoulders
No. of shoulders with erosions
Incidence (%)
Rheumatoid arthritis Juvenile rheumatoid arthritis Psoriatic arthropathy Ankylosing spondylitis
112 100
16 33
14 33
24 18
3 7
13 39
Total
254
59
23
Fig. 1. Erosive lesion classified as extensive, with destruction of the greater tuberosity and neighbouring bone Fig. 2. Erosive lesion classified as circumscribed, having sharp borders and located within the greater tuberosity
Table 2. Patient age and duration of clinical involvement in 254 shoulders with chronic inflammatory joint disease Disease
Rheumatoid arthritis Juvenile rheumatoid arthritis Psoriatic arthropathy Ankylosing spondylitis
Patients age (years)
Total duration (years)
With erosions (years)
Without erosions (years)
Mean
Range
Mean
Range
Mean
Range
Mean
Range
48.9 15.6 46.4 31.8
22-76 6-42 8 64 17-52
8.0 7.0 5.0 4.8
0.5-41 0.5-27 0.5-21 0.5-10
8.4 6.7 17.6 7.2
0.5-25 0.5-26 11-21 0.5-10
7.7 7.0 3.0 3.0
0.5-41 0.5-27 0.5-21' I 5
*p
