Arthritis Flashcards
Categories of arthritis
degenerative, inflammatory, crystal deposition, hematologic, metabolic
OA hallmarks
asymmetric joints space narrowing, subchondral sclerosis, osteophytosis, subchondral cysts, lack of periarticular osteopenia
? extensive subchondral cystic changes
consider CPPD as well as OA
distribution of OA hand
DIP, PIP, 1st CMC (commonly 2nd DIP)
Heberden vs Bouchard nodule?
soft tissue swelling around H - DIP; B - PIP
Best view for joint space narrowing shoulder?
Grashey view, oblique posterior in external rotation
distribution OA foot?
MTP, hallux rigidus with dorsal osteophytes; dorsal beaking of talonavicular joint
OA knee?
tricompartmental joint space narrowing (mostly medial compartment), osteophytes
OA hip?
superolateral migration of hip, less so medial migration
RA hip space narrowing?
axial migration –> protrusio deformity
Kummel disease?
gas from vertebral body compression fracture (osteonecrosis), different from vacuum phenomenon
DISH diagnosis
4 vertebral levels of anterior bridging osteophytes; exuberant osteophytosis; associated with ossification of PLL
OA of SI joint?
inferior portion of SI joint (synovial joint); superior part is syndesmotic joint
Erosive OA hands?
same as OA (DIP, CMC thumb, PIP); characteristic gull wing appearance of DIP joint (central erosion, marginal osteophytes)
RA overview
RF+; antibody directed against IgG which targets synovium and causes symmetric joint pain, swelling, morning stiffness
RA involvement
hands/wrist first, feet; advanced cases cervical spine, knees, shoulders, hips
Hallmark of RA
marginal erosions, soft tissue swelling, diffuse/symmetric joint space narrowing, periarticular osteopniea, joint subluxations
RA hands?
MCP, PIP, carpal articulations; DIP SPARED!
typically radial aspect of 2nd/3rd MCP, ulnar styloid
Boutonnier, Swan neck deformity?
Boutonniere: PIP flex, DIP hyperextension
Swan: PIP hyperextension, DIP flex
Late stage RA?
anklysosis/fibroosseous joint fusion of wrist
JIA can also cause carpal ankylosis
RA feet?
MTP of forefoot and talocalcaneonavicular joint in midfoot
RA hip?
protruso deformity; 3 mm male, 6mm female medial deviation of femoral beyond ischial line
RA knee?
all three joints + superimposed OA possible
RA spine?
cervical spine; no bone production but C1-C2 subluxation, osteopenia, erosions of odontoid, facets, vertebral endplates, spinous processes
RA shoulder
high riding shoulder; chronic rotator cuff tears; erosions on lateral aspect of humeral heads
penciling of distal clavicle
Seronegative spondylopathy
HLA-B27 +
PAIR
psoriatic, ankylosing spondylitis, inflamatory bowl disease associated arthropathy, reactive arthritis/Reiters arthropathy
Hallmark of spondyloarthropathies
sacroilitis of the inferior SI joint
- Symmetric: IBD, Ankylosing
- Assymetric: Psoratic, reactive
Unilateral sacroilitis can also be caused by septic arthritis
Types of IBD associated sacroilitis
UC, Crohn, Whipple, status post gastric bypass
AS associations
young men with HLA B27, pulmonary fibrosis (upper lobe predominant), aortitis, cardiac conduction defects
ankspond early findings, late
SI joint: symmetric erosions, widening, sclerosis
Lumbar to cervical
Romanus leisons: erosions of vertebral body endplates (enthesitis) inflammation of ligaments at attachment of annulus fibrosus
Shiny corners: clerosis of romanus lesions
Squaring of vertebral disc margins
Delicate syndesmophytes which then bridge to form bamboo spine
Andersson lesion
pseudoarthrosis in completely ankylosed spine
Psoriatic arthritis classic location
HANDS HANDS HANDS
Psoriatic arthritis presentation
hand involvement, hx of skin psoriasis; normal mineralization; asymmetric SI joint involvement
Hallmark psoriatic arthritis
sausage digit soft tissue swelling
pencil in cup erosions at the DIP
telescoping digits or main en lorgnette (opera glass hand) deformity
fluffy periostitis and ill defined erosions
psoriatic arthritis in the foot
great toe IP/MTP joints; “ivory phalanx” with otosclerosis
plantar calcaneal spur with periosteal reaction
psoriatic arthritis in spine
coarse bony bridging sometimes indistinguishable from reactive arthropathy
Reactive arthropathy common location
FEET FEET FEET
calcaneus; posterior-superior aspect of calcaneus with erosions (bursitis) and achilles tendinitis
Hallmarks of reactive arthropathy
soft tissue swelling, joint space loss, aggressive marginal erosions, juxta-articular osteopenia
reactive arhtropathy in the hands
interphalangeal joints and MTP with erosions and diaphyseal periostitis
SLE joints
subluxations of MCP/PIP, reducible
Jaccoud arthropathy
secondary to rheumatic fever?
type III ypersensitivity
Scleroderma affects first?
fingertips –> atrophy of distal soft tissue
acroosteolysis
Ddx for acroosteolysis
collagen vascular diseases like scleroderma, neuropathy, polyvinyl chloride exposure, thermal injury, hyperparathyroidism, Hajdu-Cheney
polymyositis/dermatomyositis hallamrks
soft tissue calcifications,
calcium hydroxyapatitie deposition disease (HADD)
calcific tendinitis of periarticular tissues; NOT IN JOINT!
most common location HADD
shoulder, supraspinatus tendon
also seen in longus colli
Milwaukee shoulder– intraarticular variant
CPDD
intraarticular deposition of CPPD crystals which are positively birefringemnt
Manifestations of CPPD
pseudogout, pseudoosteoarthritis, pseudorehumatoid, pseudoneurpathic
Age of CPPD, associations
> 50, hemochromatosis/hyperparathyroidism, hypophosphatasi
Hallmarks CPPD
chondrocalcinosis (calcification of hyaline/meniscal cartilage)
Locations for CPPD in the wrist
trangular fibrocartilage complex (TFCC) –> SLAC
SLAC is also seen in RA or trauma
CPPD in knee
patellofemoral compartment isolated is highly suspicious with prominent subchondral cristals
CPPD hand
2nd and 3rd MCP with hooklike or drooping osteophytes from radial aspect of metacarpal heads
similar to hemochromatosis
Gout cause
sodium urate deposition in joints
excess uric acid (renal isufficiency)
Birifringency of gout
negative
Common locations/presentation
Great toe
overhanging margins, soft tissue gouty tophy; joint space preserved
Cause of hemochromatosis arthropathy
deposition of iron and CPPD crystals in joints
Hemochromatosis presentation
bronze pigmentation, diabetes, cirrhosis, CHF, arthropathy; autosomal recess
Location for hemochromatosis arthropathy
MCP joints with hook like osteophytes at metacarpal heads; involves all MCPs unlike CPPD which is usually 2nd/3rd MCP heads
Acromegaly presentation
beak like osteophytes of carpal heads; spade like enlargement of tufts
early: widening of joint spaces
later: secondary OA with space narrowing
Causes of amyloid arthropathy
primary: monoclonal plasma cell dyscrasia; infiltration by beta pleated sheets of amino acids
secondary: chronic inflammation/infection
other: beta 2 microglobulin accomulation on chronic HD
What is the shoulder pad sign?
bulky soft tissue noduels in shoulder superimposed on atrophic shoulder muscles ; characteristic of amyloidosis
Alkaptonuria –> ochronosis
intervertebral disc calcifications with disc narrowing
alkaptonuria: defective homogentistic acid oxidase; black urine when oxidized
Multicentric reticulohistiocytosis
lipid laden macrophages deposited in soft tissue/periarticular tendons –> soft tissue nodules, erosions, sclerotic margins
Distribution multicentric reticulohistiocytosis
DIP symmetrically; soft tissue nodules; preserved bone; can cause arthritis mutilans
Types of hemophilic arthropathy
A: factor VIII
B/Christmas dx: factor IX
Hallmark hemophilic arthropathy
hemarthrosis –> synovial hypertrophy/hyperemia –> epiphyseal enlargement/fusion
nees, elbows, ankles
enlarged radial head/widened trochlear notch
squaring of patella and widened intercondylar notch
hemophilic arthropathy can look like?
JIA
still disease
variant of JIA; systemic disorder in kids <5; acute febrile illness, rash, adenopathy, pericarditis, mild arthralgias
hallmarks of JIA
abnormal bone length (hyperemia), epiphyseal enlargement/ballooning of ends of bones; premature skeletal maturation/physeal fusion; brachydactyly
Ddx for cervical spine ankylosis
Klippel Feil and JIA
Charcot joint
neuropathic arthropathy; fragmentation of bone/cartilage; painful swollen joint
Causes of charcot joint
diabetes (ankle/foot); syringomyelia (upper extreity), alcohol abuse, amyloid, spinal tumors, syphilis/leprosy
Forms of neuropathic arthropathy
hypertrophic and atrophic
Hallmarks of hypertrophic
anarchy in joint: destruction, dislocation, debris, disorganizaiton, no demineralization
Hallmarks of atrophic form
shoulder; resorption of humeral head/surgical like margins
bone hallmarks of sarcoid
lace like lytic lesions of middle/distal phalanges; polyarthritis
ABCDEs of arthritis
alignment, bone mineral density/bone creation, calcification/cartilage spaces, distribution, erosions, soft tisssue swelling
Reducible vs nonreducible subluxations; dislocations?
reducible: SLE, Jaccoud
Nonreducible: rheumatoid –> dislocations
Diffuse osteopenia arthropathy?
RA
periarticular osteopenia
RA, early inflammatory arthritis
osteophytes arthropathy
OA, CPPD, hemochromatosis
periosteal bone formation, arthropathy?
psoriatic arthritis, reactive arthropathy
bone ankylosis in wrist/cervical spine?
JIA
ankylosis of DIPs
psoriatic arthritis
ankylosis of wrist?
JIA, advanced RA
