Rice bodies are fibrous bodies that macroscopically resemble grains of rice. They may uncommonly occur as a
complication of inflammatory arthritides but may create diagnostic confusion when the patient has no underlying
inflammatory disease. The combined use of ultrasound, magnetic resonance imaging (MRI) and plain film
makes it possible to reach a correct diagnosis. We describe a patient with a chronic monoarthritis of unknown
aetiology who presented with rice bodies in the right elbow joint demonstrated on MRI.http://www.charpublications.co.za/C_JournalsORTH.as

Suleman, Farhana Ebrahim

Velleman, Mark D.

UPSpace at the University of Pretoria

Intra-articular rice bodies: Imaging for persistent joint painDr FE Suleman MBChB(Natal), FCRad(D)(SA), MMedRad(D)(Medunsa)Department of Radiology, University of PretoriaDr MD Velleman MBChB(UP), FCRad(D)(SA), MMedRad(D)(UP)Little Company of Mary Medical Centre, PretoriaReprint requests:Dr FE Suleman PO Box 13044Laudium 0037Tel: 0027833020295Fax: 002786639874Email: fesuleman@gmail.comARTICLEPage 80 /  SA ORTHOPAEDIC JOURNAL Summer 2011 | Vol 10 • No 4 ARTICLEAbstractRice bodies are fibrous bodies that macroscopically resemble grains of rice. They may uncommonly occur as acomplication of inflammatory arthritides but may create diagnostic confusion when the patient has no underly-ing inflammatory disease. The combined use of ultrasound, magnetic resonance imaging (MRI) and plain filmmakes it possible to reach a correct diagnosis. We describe a patient with a chronic monoarthritis of unknownaetiology who presented with rice bodies in the right elbow joint demonstrated on MRI.Key words: rice bodies, synovitis, arthritis, elbow, MRI, ultrasoundIntroductionChronically inflamed joints with proliferation and hyper-trophy of the synovium may occasionally be complicatedby rice bodies. Rice bodies were originally described inassociation with tuberculous arthritis but are now mostfrequently seen in patients with rheumatoid arthritis1although any inflammatory arthropathy may predispose apatient to this complication. We describe a patient with achronic monoarthritis of unknown aetiology who present-ed with rice bodies in the right elbow joint.Case reportA 43-year-old female patient was referred to theRadiology Department with right elbow pain. She had noevidence of underlying rheumatoid arthritis. Plain radi-ographs of the elbow were within normal limits (Figure1). Ultrasound demonstrated a posterior joint effusionwith echogenic material (Figure 2). The rest of the struc-tures around the joint were within normal limits. Thepatient was treated conservatively but three months laterfailed to show any response to treatment. Figure 1. Lateral radiograph of the rightelbow joint is within normal limitsSAOJ Summer 2011_Orthopaedics Vol3 No4  2011/11/27  7:16 PM  Page 80ARTICLE SA ORTHOPAEDIC JOURNAL Summer 2011 | Vol 10 • No 4 /  Page 81The patient was then referred for MRI which demonstrat-ed a joint effusion with synovial hypertrophy, prolifera-tion and multiple loose nodular bodies that werehypointense on fat-suppressed proton density weightedimaging (Figures 3a and b). No specific blooming-typeartefact was noted on the gradient echo study (Figure 4).Other than mild changes suggesting a lateral epicondyli-tis, no other abnormalities were seen.The diagnosis of synovitis with rice body formation wasconfirmed at arthroscopy. Fluid from the joint space wassent for microscopy and culture and the results were neg-ative for all organisms including acid-fast bacilli. Allinflammatory markers were negative.The patient’s symptoms settled post-operatively and shemade an uneventful recovery. Six months later no recur-rence was noted.DiscussionSeveral theories exist as to the aetiology of rice body for-mation but the definite cause remains unclear.2 It is asso-ciated with synovial proliferation and hypertrophy in thejoint space and it has been suggested that synovial cellsundergo infarction and are shed into the joint where theybecome encased by fibronectin over time.2 Another theo-ry simply suggests that fibrin accumulates in the villousstructures of the hypertrophied synovium causing them toelongate and snap off.3Rice bodies are an uncommon phenomenon that occursmost commonly in patients with rheumatoid arthritis butare also known to occur in patients with tuberculousarthritis or rarely in the absence of underlying systemicdisorders.1 The clinical relevance lies in the fact that fib-rin is a known irritant and therefore rice bodies have beenimplicated as a stimulus for continuing synovial inflam-mation.3 Their removal therefore produces clinicalimprovement and in cases where no underlying diseaseprocess such as systemic arthropathy is present, surgerycan result in complete resolution of symptoms.2 Imaginghelps in diagnosis as well as in surgical planning.The important differential diagnoses that need to beexcluded in patients with rice bodies are synovial chon-dromatosis and pigmented villonodular synovitis.1-5 Plain radiographs of the affected joints may be normalfor both rice bodies and early phases of synovial chon-dromatosis. Late phases of synovial chondromatosis willdemonstrate calcified bodies within the joint space.Ultrasound for all three possibilities in the differentialdiagnosis will demonstrate an effusion with loose bodiesor a complex mass. In calcified synovial chondromatosis,posterior acoustic shadowing may be noted.1,5 Figure 2. Transverse ultrasound of the posterior right elbow joint shows a complexeffusionFigure 4. Gradient echo sagittal image of theright elbow does not demonstrate any‘blooming’ artefactFigure 3a and b. Fat-suppressed proton density coronal and sagittal views of the right elbow demonstrate a joint effusion with multiplehypointense loose bodies within itIn cases where no underlying disease process such as systemic arthropathy is present, surgery can result in complete resolution of symptomsSAOJ Summer 2011_Orthopaedics Vol3 No4  2011/11/27  7:16 PM  Page 81Page 82 /  SA ORTHOPAEDIC JOURNAL Summer 2011 | Vol 10 • No 4 ARTICLEMRI produces the most characteristic findings of allimaging modalities. Rice bodies appear as hypointenseloose bodies on all sequences on MRI with the low signalon T2-weighted and proton density-weighted imaging,making it possible to restrict the diagnosis.1,2,5 Uncalcifiedbodies of synovial chondromatosis have a high signal onT2-weighted images (making them difficult to visualise)and while this may change to low signal when the loosebodies calcify, the calcified bodies are then visible onplain film, allowing the diagnosis to be made.1,5 The lackof susceptibility artefact in rice bodies on gradient echosequences helps to distinguish them from pigmented vil-lonodular synovitis.5 ConclusionThe diagnosis of rice bodies may be delayed or missed,especially in patients who lack a relevant history or clini-cal findings typical of underlying systemic arthropathies.It should be an important consideration in patients whosejoint symptoms persist despite treatment, as their pres-ence provides an irritant within the joint that prevents res-olution on medical therapy alone. Imaging plays a vitalrole in making a definitive diagnosis and advanced imag-ing such as MRI must be considered in the presence ofnormal radiographs.No benefits of any form have been received from a com-mercial party related directly or indirectly to the subjectof this article. The content of this article is the sole workof the authors.References1. Rapitz JM, Martin SM, Vilamajo IR, Pons JT, Androver PA.Subacromial bursitis with rice bodies. Journal ofOrthopaedics 2007;4(4). 2. Matsumoto K, Fujita K, Fujioka H, Matsushima S, Kouso K,Yamaguchi S, Kurosaka M, Yoshiya S. Massive nonspecificolecranon bursitis with multiple rice bodies. J ShoulderElbow Surg 2004;13:680-83.3. Reid HS, McNally E, Carr A. Soft tissue mass around theshoulder. Ann Rheum Dis 1998;57:6-8.4. Chen A, Wong L, Sheu C, Chen B. Distinguishing multiplerice body formation in chronic subacromial subdeltoid bur-sitis from synovial chondromatosis. Skeletal Radiol2002;31:119-21.5. Spence LD, Adams J, Gibbons D, Mason MD, Eustace S.Rice body formation in bicipito-radial bursitis: ultrasound,CT and MRI findings. Skeletal Radiol 1998;27:30-32.• SAOJInternational centre for training in external fixation and limb reconstruction techniquesDr Birkholtz’s practice in Pretoria has been identified as an international centre for training in external fixationand limb reconstruction techniques.The centre of excellence comprises a multi-disciplinary team dedicated to quality care for patients requiringthese demanding procedures.The efforts of the team were recently rewarded when two companies set up training opportunities in the practice. Smith and Nephew have been running a very successful Visiting Surgeons Programme in the practicesince February 2010. This entails a week-long intensive hands-on learning experience, comprising a mix of teaching, discussion, workshops and clinical activities like ward rounds, theatre sessions and outpatient clinicsin the unit. The focus of this programme is on the Taylor Spatial Frame, a very advanced hexapod-based circular external fixator, and its application in trauma and post-traumatic reconstruction. This programme hasdrawn surgeons from as far afield as the United States, Sweden, Lithuania and Iran.Recently, a second educational event has become available in the unit in the form of a week-long OrthofixReconstructive Surgery Observership (ORSO). The ORSO also is open to surgeons from across the globe andaffords training and practical experience in the use of the LRS monolateral rail fixator as well as the TrueLok circular fixator. Contact detailsAny surgeons who are interested in attending one of these events can contact the relevant company or alternatively the Clinical Practice Manager, Dr Marie-Marí Alberts, at m2@internext.co.za.SAOJ Summer 2011_Orthopaedics Vol3 No4  2011/11/28  12:49 PM  Page 82

Intra-articular rice bodies : imaging for persistent joint pain

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Intra-articular rice bodies : imaging for persistent joint pain

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