Arthritis

Question 1

5 broad categories of arthritis

Answer 1

1. Degenerative )OA)
2. inflammatory (RA, spondyloarthropathy, JIA)
3. Crystal deposition (Gout, CPPD, HADD)
4. hematologic
5. metabolic

Question 2

radiographic hallmarks of OA

Answer 2

Asymmetical joint space narrowing

sclerosis of subchondral bone

osteophytosis

subchondral cystic change

lack of periarticular osteopenia

Question 3

OA in hand

1. Distribution in hand

Answer 3

1. DIPs (2nd dip is most common). 1st CMC, PIPs.

Unlike RA, MCPs not usually involved

2. Heberden node - soft tissue swelling around DIP

Bouchard node: swelling around PIP

Question 4

1. OA in shoulder - which view is best?
2. OA in foot (which 2 joints)

Answer 4

1. Grashey, shows loss of joint space
2. 1st MTP - Hallux Rigidus.

talonavicular joint - dorsal beaking

Question 5

OA in knee - tends to be bilateral

1. Which compartment is most involved
2. Which view is best for assessment of joint narrowing?

Answer 5

1. asymmetric involvement of medial tibiofemoral comp.
2. Standing weight bearing views.

Question 6

OA in hip - tends to be bilateral

1. Direction of femoral head migration?

Answer 6

1. Femoral head migration is usually superiolateral, and less often medial. (axial migration is seen inRA)

Question 7

Degenerative chane in spine - Vertebral body-disc articulations are cartilagenous joints

1. What are 3 parts of intervertebral disck?
2. Which joints in spine get OA (aka, which joints are synovail)
3. findings of DDD
4. Vacuum phenomenon vs. Kummel disease
5. Complications of DDD

Answer 7

1. Annulus fibrosis, nucleuous pulposis, cartilagenous endplates
2. facet, atlanto-axial, uncovertebral, costovertebral, inferior inferior sacroiliac
3. Dessication, disc endplate sclerosis, osteophytosis.
4. Vacuum phenomenon. Gas in Disc, pathognomonic of DDD. Kummel: Gas in vertebral body. compression fracture - representing necrosis.
5. Spinal stenosis, nf stenosis, spondylolisthesis.

Question 8

DISH - Diffuse idiopathic skeletal hyperostosis

1. Describe
2. A/w what?

Answer 8

1. Exuberant osteophytes - at least 4 vertebral bodies.Normal disc spaces and SI joint.
2. Ossification of posterior longitudinal ligament.

Question 9

OA at the SI joint. Which area is affected?

Answer 9

Only inferior portion is effected because that is the synovial portion.

The upper 1/3 is syndesmotic ligament

Question 10

Erosive OA

1. clinical findings and demograpics
2. Findings

Answer 10

1. erroisve changes and swelling in hand. Occurs in elderly women
2. swelling and erosions. Only in the hand. Distribution of OA

Central erosions = gullwing sign

Question 11

RA

1. Which joints are involved
2. radiographic hallmarks (5)
3. Explain Marginal erosions and ‘bare areas”

Answer 11

1. First foot and hands, then Cervical spine, knees, shoulders, and hips.
2. marginal erosions (bare areas), soft tissue swelling, diffuse, symmetric joint space narrowing, periarticular osteopenia, joint subluxations
3. Marginal erosions explanation: They occur because at the “bare areas” there is synovium directly on bone with no cartilage protection. Therefore, the inflammatory process eats the bone which is not protected by overlying articular cartilage

Question 12

1. RA in the hand/wrist.
2. Earlierst radiographic sign?
3. where are first erosions typically
4. Late disease has bony ankylosis, irriducible ulnar deviation, and swan neck/boutiers. What is difference between swan neck and Boutiers

Answer 12

1. MCPs, PIPs, carpal articulations. DIPs are usually spared.
2. Articular soft tissue swelling. Periarticuluar osteopenia (synovitis and hyperemia)
3. radial aspects of 2nd and 3rd metacarpal heads. bases of proximal phalanges, and ulnar styloid.
4. Swan neck has DIP flexion

Question 13

1. RA in foot: Which joints are involved?
2. RA in hip. Name of severe deformity in hip
3. RA in knee

Answer 13

1. MtP, talocalcaneonavicular
2. Symmetric acetabular cartilage loss, axial migration of femoral head

Protrusio deformity is severe axial migration: >3mm medial deviation of femoral head beyond ilioischial line in males and >6mm in females

3. All 3 joint compartments involved. Erosions not as prominent as you would think.

Question 14

RA in spine - mostly cervical spine. Osteopenia, erosions of odontoid, facet joints, vertebral endplates, spinous process.

1. Characteristic finding

Answer 14

1. atlantoaxial subluxation (most commonly anterior, but can be any direction)

Anterior: Laxity of transverse ligament. >2.5mm ADI

Vertical: results from facet erosion and collapse. Protrosion of odontoid through foramen magnum.

Posterior: usually due to odontoid erosion or odontoid fracture.

Question 15

1. RA in shoulder - characteristic finding. Where do erosions occur?

RA can involve elbow in 1/3 of patients.

Answer 15

1. chronic rotator cuff tears - high riding humerus.

Erosions occur at latera aspect of humeral heads, AC joints. Erosions may lead to penciling of distal clavicle

Question 16

Seronegative Spondyloarthropathies - by definition RF negative. Usually HLA B27 positive

1. Name the 4, Which are symmetric vs. asymmetric
2. Which portion of the SI joint is involved?

Septic joint - unilateral

Answer 16

1. Ankylosing Spondylitis and IBD associated (symmetric)

Reiter’s and psoriatic (asymmetric)

2. Inferior portion is synovial

Question 17

1. IBD - what causes it?

Answer 17

1. UC, Crohn disease, Whipple disease, s/p gastric bypass

Question 18

Ankylosing Spondylitis - young men w/ HLA B27, back stiffness

1. Associations (3)
2. Earliest radiographic sign?
3. Sequence of findings in spine (ascends from lumbar to cervical)
4. Andersson lesion

Answer 18

1. Pulm fibrosis (upper lobes), aortitis, cardiac conduction
2. symmetric erosions, widening, sclerosis of SI
3. Romanus - erosions of anterior superior or inferior edges of vertebral endplate, causted by enesthesis (inflammation of of annulus fibrosus)

Shiny corners - sclerosis of romanus

Squaring - bone loss

Delicate syndesmophytes - bony bridgening, bamboo spine

4. Pseudoarthrosis occuring in a compleely ankylosed spine

Question 19

Psoriatic arthritis

1. Most commonly affects what?
2. 2 contrasts from RA
3. Name of severe form of arthritis effecting hands?
4. Radiographic hallmark?
5. fancy name for “telescoping digits?’
6. PA in foot
7. PA in spine

Answer 19

1. Hand. Can affect any joint in hand
2. mineralization is presevered. Fusiform swelling (opposed to articular swelling)
3. Arthritis mutilans
4. Fusiform swelling of entire digit producing sausage digit. Pencil incup erosions
5. Main-en-lorgnette (pera glass hand
6. Great toe and MTP most commonly affected.

Ivory phalynx and osteosclerosis.

Plantar calcaneal spur

7. coarse bony bridging.

Question 20

Reactive Arthropathy - PA of the feet

1. Caused by what?
2. radiographic findings?
3. Calcaneus findings
4. Findings in hands and spine

Answer 20

1. diarrhea, urethritis, cervicitis. Usually asymmetric
2. diffuse sweling, joint space loss, marginal erosions, juxta-articular osteopenia
3. erosions, enthesophytes, and fluffy periosteal reaction in calcaneous. Secondary achilles tendinitis is posible.
4. hands; IP and MTPs. In spine, coarse bony bridging, like PA.

Question 21

Connective tissue disorders of joints (4)

Answer 21

1. SLE, Jaccoud, scleroderma, polymyositis/dermatomyositis.

Question 22

1. SLE joints - key radiographic abnormality. Best view?
2. What is a similar disease to SLE of joints, but different name?

Answer 22

1. Reducible subluxations of MCPs and PIPs. Alighnment may be normal when hands are compessed against radiographic plate, and become apparent on Nogarrd (ballcatcher’s) or oblique views.
2. Jaccoud arthropathy

Question 23

1. Scleroderma key findings

Answer 23

1. Calcifications of soft tissues. Acro-osteolysis, peri-articular calcifications

Question 24

Acroosteolysis Ddx (6)

Answer 24

Collagen vascular disease

Neuropathy

Polyvinyl chloride exposure

thermal injury (in frostbite, thumb may be spared due to clenched fist.

Hperparathyroidism

Hajdu-Cheney - rare autosomal cominant syndrome - shoft stature, craniofacial changes.

Question 25

Entity: Intramuscular and subcutaneous calcifications

Answer 25

Polymositis and dermatomyositis - Periarticular osteopenia may also be present

Question 26

1. CPPD stands for what? 2. Microscopic appearance? 3. Hallmark? 4. Common locations 5. Complication

Answer 26

1. Calcium pyrophosphate dihydrate deposition disease 2. rhomboid crystals - positively birefringent 3. Chondrocalcinosis (calcification of hyaline cartilage) 4. TFCC, radiocarpal joint, knee, MCPs of hand 5. Scapholunate advanced disease (SLAC Wrist) - proximal micration of capitate b/w the dissociated scaphoid/lunate (SLAC can also ben seen in RA and trauma)

Question 27

Name the arthritis; patellofemoral degenration, prominent subcondral cysts in effected joints

Answer 27

CPPD

Question 28

1. HADD - full name, nickname 2. Where does it deposit? Most common tendon involved 3. variant that can mimic prevertebral abscess 4. Severe intra-articular shoulder variant

Answer 28

1. Calcium Hydroxyapatite deposition disease, AKA calcific tendinitis 2. Deposition of calcium in tendons. Supraspinatous is most affeced 3. HADD of prevertebral longus muscle; neck pain, odonophagia, fever, prevertebral effusion. 4. Milwaukee shoulder. Rapid destruction of rotator cuff, glenohueral joint.

Question 29

Gout - takes 20 years for uric acid to build before symptoms 1. microscopic appearance 2. Most common joint 3. Radiogrpahic hallmarks 4. How do joint spaces look?

Answer 29

1. needle like - negatively birofringent 2. Great toe 3. Sharply marginated erosions. Overhanging margins. Soft tissue gouty tophi 4. Joint spaces are well preserved (they are just crystals. They don't destry the cartilage)

Question 30

Hemochromatosis arthropathy - deposition of iron and calcium pyrophosphate dihidrate crystals 1. Typical location in hand 2. Typical look of osteophytes

Answer 30

1. MCP joints in hand (may involve all MCPs, unlike CPPD) 2. Hook-like osteophytes

Question 31

metabolic, hematologic, and other arthropathies

Answer 31

Hemochromatosis, acromegaly, amyloid arthropathy, ochronosis (alkaptonuria), multicentric reticulohistiocytosis, hemophilic arthropathy, JIA, Charcot joint, sarcoidosis

Question 32

1. Acromegaly findings

Answer 32

1. Joints widened in early disease due to cartilage hypertrophy. Later there is osteoarthritis with space narrowing. Beak like osteophytes of metacarpal head ans spade like enlargement of terminal tufts are characteristic.

Question 33

Name the entity: bulky soft tissue noduels in the shoulder, supoerimposed on atrophic shoulder muscles

Answer 33

Shoulder pad sign - amyloid arthropathy Imaging findings of amyloid arthorpathy are nonspecific but soft tissue nodules and erosions may be present.

Question 34

Aunt Minnie

Answer 34

Ochronosis (alkaptonuria) Intervertebral disc calcs at every level w/ disc space narrowing. Defect in homogentisic acid oxidase - causing homogentisic acid polymers to accumulate in visceral organs.

Question 35

Entity: Well defined erosion affecting DIPs symmetrically. Soft tissue nodules

Answer 35

Multicentric reticulocytosis Lipid laden macrophages are doposited in soft tisssues and periarticular tendons forming skin nodules and erosions. Can have rapid joint destruction (arthritis mutilnans appearance)

Question 36

hemophilic arthropathy 1. Most common locations 2. Findings in elbow and knee 3. Other findings 4. Psuedotumor hemophilia

Answer 36

1. Knees, elbows, ankles 2. hyperemia can cause epiphyseal enlargement and early fusion. (At the elbow, this is an enlarged radial head and widened trochlear notch. At the knee this is squaring of th epatella and widened intertrochlear notch. 3. increased soft tissue density around joints. Joint space narrowing 4. Benign lesion caused by recurrent intraosseous or subperiosteal bleeding. Caues bony scalloping and pressure erosion, often w/ an associated soft tissue mass

Question 37

Juvenile idiopathic arthritis (children under 16) Can be mono, pauci-articular, or polyarticular 1. Which joints are effected? 2. What is a variant of JIA? 3. radiographic hallmarks of JIA hand knee (similar to hemophilia) Elbow (similar to hemophilia)

Answer 37

1. In mono and pauci-articular, its big joints (knees, elbows, ankles wrists). In Poly ist all those plus hands, feet, cervical spine. 2. Still disease (systemic disorder affecting children younger than 5, febrile illness, rash, adenopathy, pericarditis, mild arthralgias. 3. abnormal bone length or morhphology in skeletally immature patient. In hand, premature fusion of growth plate may cause brachydactaly. Knee: widened intercondylar notch, metaphyseal flaring, uniform joint space narrowing. Elbow: enlargement of radial head and trochlear notch, uniform cartilage space hips; symmetrical cartilage space narrowing, protrusio deformity (like RA). gracile appearance of femoral shaft is

Question 38

Neuropathic arthopaty (Charcot joint) - Normal clinical presentation is painless swollen joint 1. Causes 2. 2 variants

Answer 38

1. any process that effects sensory nerves: syringomyelia, diabetes, chronic alcohol abuse, amyloid, spinal tumors, syphilis or leprosy 2. hypertrophic (more common) - anarchy of the joint. atrophic - occurs mor commonly in shoulder. classic radiographic appearance of humeral head resorption.

Question 39

Name the entity 1. manifestations in bone

Answer 39

1. lace-like or punched out lytic lesions in middle or distal phalanges. May also manifest as acute or chronic polyarthritis.

Question 40

Answer 40

Question 41

Answer 41