Arthritis Flashcards
1
Q
Degenerative Arthritis Types
A
- Increased bone/calcifications
- Degenerative joint disease
- DISH
- Synoviochondraplasia
- Neurotrophic arthropathy
- Erosive arthritis
2
Q
Inflmmatory Arthritis Types
A
- Bone erosions and soft tissue swelling
- Rheumatoid arthritis
- Psoriatric arthritis
- Reactive arthritis
- Ankylosing spondylitis
- Osteitis condensans ilii
- Osteitis pubis
3
Q
Metabolic Arthritis Types
A
- Soft tissue masses within periarticular soft tissue
- may be calcified
- Relative preservation of the joint space
- May have inflammatory changes
- May have secondary degenerative changes
Gout, CPPD, HADD
4
Q
Infectious Arthritis Types
A
- Soft tissue swelling
- Joint and bone destruction
- More agressive and progressive than other forms of arthritis
Septic arthritis
5
Q
Arthritis Flow Chart
A
6
Q
Axial Skeleton Arthritis
A
- Most common
- DJD
- Less common
- DISH
- RA
- Ankylosing spondylitis
- Psoriatric arthritis
- Osteitis condensans ilii
- Osteitis pubis
- Rare
- Reactive arthritis
- Infective
7
Q
Appendicular Skeleton Arthritis
A
- Most common
- DJD
- Less common
- RA
- Psoriatric
- Gout
- CPPD
- HADD
- Synoviochondrometaplasia
- Rare
- Neurotrophic
- Erosive osteoarthritis
- Reactive arthritis
- Infection
8
Q
Degenerative Arthritis
A
DJD
- Osteoarhritis
- Most common form of arthritis
- Small joints of hands, larger weight bearing joints (spine, knee, hip)
- May affect any joint
- Often disparity between clinical and radiographic features
Clinical Features
- >40 yrs (often >60yrs)
- Inc males 45 yrs, primary osteoarthritis
- Insidious onset, intermittent exacerbations
- Aching pain, stiffness (am), swelling
- Joint crepitus
- Decreased motion
- May have inflammatory episodes
Pathogenesis
- Cartilage destruction and reactive changes in surrounding tissues
- Cartilage metaplasia at joint margins and capsular insertion stress resulting in bone remodelling
- Augmentation of subchondral bone structural capacity
- Synovial fluid intrusion into subchondral bone through weakened cartilage and cortical microfractures
Pathologic and Radiographic Features
- Cartilage destruction and reactive change in surrounding tissues
- Loss of joint space
- Asymetrical pattern
- Cartilage metaplasia at joint margins and capsular insertion stress
- Osteophytes
- Remodeling of bone - continuation of bone not calcifications
- Augmentation of subchondral bone structural capacity
- Subchondral sclerosis
- Synovial fluid intrusion into subchondral bone through weakened cartilage and cortical microfractures
- Subchondral geodes and cysts
- Secondary changes
- Intraarticular loose bodies (joint mice), intraarticular deformity: joint subluxation
- Possible joint fusion at end range
9
Q
Kellgren-Lawrence Grading Scale
A
- Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
- Grade 2: definite osteophytes, definite narrowing of joint space
- Grade 3: moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour
- Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour
10
Q
DJD Hip
A
- Asymmetrical loss of joint space
- Upward and outward migration of femoral head
- Medial or central joint space loss less common
- Synovial subchondral cyst-like formation (geode or Egger’s cyst)
- Sclerosis
- Osteophytes
- Buttressing of medial femoral neck
- Lack of internal rotation
- Secondary changes
11
Q
DJD Knee
A
- Loss of joint space
- Medial most common, lateral joint space, patellofemoral joint less common
- Subchondral sclerosis
- More pronounced on tibia
- Osteophytes
- Loose bodies/calcifications
- Subluxation (genu vara)
12
Q
DJD AC Joint
A
13
Q
DJD 1st Metatarsal Phalangeal
A
- Hallux rigidus
- Sclerosis
- Joint space loss
- Osteophyte formation
- Osseous bunion
- Subluxation
14
Q
DJD 1st Carpometacarpal Joint
A
- Sclerosis and loss of joint space
- Lateral subluxation
- Also sclerosis and loss of joint space in scaphoidtrapezoid/trapezium joints
15
Q
DJD PIPs and DIPs
A
- Osteophytes
- Heberden’s nodes (DIP’s)
- Bouchard’s nodes (PIP’s)
- Primary DJD in fingers
- May appear more symmetrical as becomes widespread
16
Q
DJD Cervical Spine
A
DJD in the cervical spine is a can affect any of the joints:
- Intervertebral Discs
- Facet Joints
- Uncovertebral joints
Degenerative Disc Disease
- Radiographic Features
- Decreased disc height
- Osteophytes (circumferential, anterior and posterior)
- Endplate sclerosis
- Intercalary bone = calcification of the anterior annulus of disc
- Displacment (anterior, retro, laterolisthesis)
Facet Arthritis
- Radiographic Features
- Decreased joint space
- Subchondral sclerosis
- Osteophytes
- Possible antero/retrolisthesis
- AP projection shows sharp osteophytic projections and sclerosis through smooth articular pillar boarder
- IVF encroachment from osteophytes
- Facet hypertrophy
- Asymetrical
Uncovertebral Arthritis
- Radiographic Features
- Osteophytes over uncinate process
- Foraminal encroachment with possible nerve and artery interference
- Sharpening of tip of uncinate process (early), bulbous enlargment of uncinate process (late)
- Psuedofracture line across posterior margin of lower half of vertebral body (lateral projection)
- Hypertrophy of uncinate process
17
Q
DJD Thoracic Spine
A
Facet Arthritis
- Radiographic Features
- Decreased joint space
- Sclerosis
- May refer to low lumbar spine and iliac crest = Maignes Syndrome
Costovertebral/costotransverse arthritis
- Radiographic Features
- Lower thoracic segments
- May simulate upper gastrointestinal disease: Roberts syndrome
Degenerative Disc Disease
- Radiographic Features
- Mid-low thoracic spine
- Osteophytes (absence on left – aortic pulsations)
- Mild disc narrowing
- Minimal sclerosis
- Inc kyphosis
19
Q
Inflammatory Arthritis Pathogenesis
A
- Formation of synovitis (inflammation) within joint and oedema
- Soft tissue swelling
- Formation of pannus (granulation tissue)
- Destroys cartilage uniformly – symmetrical joint space loss
- Creates erosions in bone where not protected by cartilage – marginal erosions
21
Q
RA Wrist
A
- Bilateral and symmetrical
- 60% of cases have early prominence at wrist:
- Ulnar styloid erosion
- Carpal erosion and dislocation
22
Q
RA Hands
A
- Bilateral and symmetrical
- MCP erosion (rarely PIP and DIP erosion)
- Subluxations
- Swan neck deformity
- Extension PIP, flexion DIP
- Boutonnierre deformity
- Hitchhiker’s thumb
- Ulnar deviation
23
Q
RA Feet
A
- MTP marginal erosions
- Subluxations
24
Q
RA Elbow
A
- Erosions – tapering of ends of bones
25
Q
RA Knees
A
- Bilateral and symmetrical
- Symmetrical loss of joint space
- Subchondral cysts
- Juxta-articular osteopenia
26
Q
RA Hip
A
- Central loss of joint space
- Most common cause of bilateral protrusio acetabulae
27
Q
RA Shoulder
A
- Symmetrical loss of GH joint space
- Humeral erosions
- Subacromial bursa may be involved
- Distal clavicle erosions
28
Q
RA Spine
A
- Most commonly involves cervical spine
- 50-80% of cases • Contraindication due to instability
- Flexion cervical views
- Erosions of dens and atlantoaxial ligament insertions
- Facet joint erosions, subluxations (stepladder)
- May involve thoracolumbar region
- 5% of cases
- Discovertebral endplate irregularities, sclerosis, loss of disc height
- Resembles advanced DDD or infection
Radiographic Features
- Increased ADI
- Dens erosions
- Endplate erosions C3-C5
- Anterolesthesis C3 (Step ladder)
29
Q
Psoriatric Arthritis
A
- Psoriatic arthritis (PsA) is the second most common inflammatory arthropathy, after rheumatoid arthritis diagnosis, in early arthritis clinics.
- Most patients have established psoriasis, often for years, prior to the onset of joint pain and swelling; in addition, associated features of nail disease, dactylitis, enthesitis, spondylitis or uveitis may be present.
- Spinal findings in up to 50% of patients with skin disease
Clinical Features
- 20-50 yrs
- Early: DIP/PIP swelling, redness, pain, sausage digit
- Inc ESR, negative rheumatoid factor, 30-75% have HLA-B27 antigen
- Pathologic features similar to RA
Radiographic Findings
- Asymmetric nonmarginal syndesmophytes
- Thoracolumbar most common
- Paravertebral ossifications
- Coarse, irregular, mid vertebral body to mid vertebral body
- Complete/incomplete/floating
- Atlantoaxial subluxation (increased ADI)
- Sparing of facet joints (except cervical spine)
- Sacroiliac joint involved in up to 50%
- Unilateral or bilateral asymmetric sacroiliitis
- Synovitis and oedema
- Soft tissue swelling
- No hyperaemia in bone
- Normal bone density
- Pannus eroding bare areas
- Marginal erosions and tapered bone ends
- Pencil in cup deformity
- Healing periosteal response stimulated
- Fluffy juxtaarticular periostitis
- Mouse ears
- Narrowed or widened joint space
- Pannus fibrosis
- Fibrotic and eventual bony ankylosis
- Arthritis mutilans
Distribution
- DIP, PIP hands and feet
- May have ray pattern and include MCP
- Knee
- Sacroiliac joint
- Thoracolumbar spine
- Cervical spine
- Hip
- Shoulder
30
Q
DISH
A
- Diffuse Idiopathic Skeletal Hyperostosis
- Forrestier’s disease
- Characterised by ligamentous calcification and ossification
- Most prominent in anterior longitudinal ligament of spine
- 12% of middle aged and elderly people
Distribution
- Spine
- C4-C7
- T7-T11: majority of hyperostosis on right
- L1-L3
- SI Joint: ossification of ligamentous portion, sparing of synovial joint
- Extraspinal sites
- 30% of patients with spinal DISH
- Most common at pelvis, patella, calcaneus, foot, elbow
- Calcification of ligamentous/tendinous insertions – enthesial changes/enthesopathy
Clinical Features
- 40-60 yrs
- Broad spectrum of presentations
- Asymptomatic – similar to DJD
- Morning stiffness, low-grade spinal musculoskeletal pain
- Facet joints spared: spinal movement relatively maintained despite anterior ossification
- Increased kyphosis, decreased lordosis
- 20% have dysphagia
- 20% have ossification of the posterior longitudinal ligament (OPLL) leading to spinal stenosis
- Associated with increased incidence diabetes
- Can progress to ankylosis
- May be complicated by carrot stick fracture
- 90% in lower cervical spine
- Neurological compromise - quadriplegia
Pathogenesis
- Exaggerated response to form bone to unidentified stimuli
- Calcification followed by ossification of ALL (arrowheads)
- Begins midpoint of vertebral body and extends to bridge IVD space
- Early: deep fibres of ALL uninvolved – lucency between calcification and vertebral body (arrows)
- Late: deep fibres calcify and blurs with anterior vertebral body
- May progress to fusion of vertebral bodies
Radiographic Features
- Flowing calcification/ossification of ALL of at least 4 contiguous vertebral bodies
- Dripping candle wax
- Flame-shaped osteophytes
- Flowing hyperostosis
- Relative preservation of disc height
- No osteophytic change or subchondral sclerosis
- No ankylosis of facet joints
- DJD can occur concurrently
- Carrot Stick fracture when ankylosis occurs
31
Q
Synovial osteochrondromatosis
A
- Synovial osteochrondromatosis; synoviochrondrometaplasia
- 30-50 yrs, males 3:1
- Knee (70%), hip, elbow, ankle, shoulder, wrist
- Insidious onset of mild pain, intermittent swelling, decreased motion, crepitus
- Acute exacerbation of pain, swelling, joint locking
May be primary or secondary to DJD; may promote DJD
Pathogenesis
- Synovial tissue undergoes metaplastic transformation
- Produce foci of cartilage
- May calcify/ossify
Radiographic Features
- Multiple loose bodies, 1-20mm
- Rare degeneration into a chondrosarcoma
32
Q
Neuropathic Arthropathy
A
- Loss of joint proprioception and pain sensation
- Diabetes, syphilis, alcoholism, syringomyelia
- Neurologic signs: altered gait, loss of deep reflexes, pain insensitivity
- Joint:
- Painless instability, enlargement, crepitus
Distribution
- Hypertrophic
- Lumbar spine
- Knee
- Hip
- Foot
- Atrophic
- Shoulder
- Elbow
- Wrist
Pathogenesis
- Lack of joint sensation and proprioception
- Ineffective protective neurologic mechanisms
- Premature and excessive traumatic degenerative changes
- Hypertrophic (increased bone) or atrophic (decreased bone) changes
Radiographic Features
- Hypertrophic Six D’s
- Distended joint
- Density increase
- Debris production
- Dislocation
- Disorganisation
- Destruction
- Atrophic
- May follow hypertrophic or occur independently
- Resorbed articular surface
- Tapered bone ends: licked candy stick
33
Q
Erosive Arthritis
A
- Inflammatory variant of DJD
- 40-60 yrs, females 12:1
- Symmetric, episodic and acute inflammation of DIPs, PIPs and 1st CMC joints in hands
- 15% develop rheumatoid arthritis
- Nonuniform joint space loss, osteophytes, sclerosis
- Central articular erosions on distal joint surface (gullwings), at least 2 on separate interphalangeal joints; periostitis; ankylosis
34
Q
Ankylosing Spondylitis
A
- Chronic inflammatory disorder of the spine
- Bony ankylosis (fusion)
- Ligamentous calcification
- Enthesopathy
- Disorder of ligament/tendon attachments to bone
- Unknown aetiology
Clinical Features
- 15-35 yrs, males 4-15:1
- Initial diagnosis hard due to non-specific symptoms
- Lumbosacral aching and stiffness, into buttocks and thighs, variable intensity and distribution (>3 months)
- Pain maximal am and om, generally eases with activity
- Eye, vascular, pulmonary, gastrointestinal and genitourinary symptoms possible
- Increased ESR, HLA-B27 in 90%, seronegative
- Diagnostic criteria
- Sacroiliitis on radiography (usually bilarteral)
- At least 1 of the following:
- low back pain and stiffness for >3 months, improving with activity
- limited movement of the lumbar spine
- reduced chest expansion
Pathogenesis
- Synovial joints
- Synovial inflammation producing pannus formation
- Subchondral erosion
- Fibrosis and interarticular osseous ankylosis
- Entheses
- Inflammation (bone erosion at ligament/tendon insertion)
- Repair of erosion (new bone projects away from surface in spurlike bone spicules
Radiographic Features
- Sacroiliitis
- Hallmark of AS: symmetrical, bilateral sacroiliitis
Grade 1 = Pseudo widening of joint space
- Loss of articular cortical bone form subchondral osteoporosis
- Suspicious changes, not definitive
Grade 2 = Erosive and sclerotic changes
- Irregular joint margin, rosary bead sign
- Reactive sclerosis, especially in ilium
- Small localised areas of erosions or sclerosis; normal joint space width
Grade 3 = Erosive and sclerotic changes
- Irregular joint margin, rosary bead sign
- Reactive sclerosis, especially ilium
- Definite changes of erosions, sclerosis, narrowing or partial fusion
Grade 4 = Ankylosis
- Takes 7-23 yrs from onset
- Ghost sign: anterior joint cortex visible through fusion
- Star sign: triangular ossification of fused upper joint space
- Ankylosing Spondylitis
Spine
- 60% initiate at the thoracolumbar junction
- Discovertebral junction (entheses)
- Remanus lesion: erosion on corner of vertebral body
- Vertebral body squaring
- Shiny corner sign: reactive sclerosis
- Marginal syndesmophytes: calcification of outer disc annulus
- Bamboo/Poker spine: ankylosis b symmetrical marginal syndesmophytes
- Vertebral osteoporosis
- Eventual ossification of disc spaces
- May get pathological carrot stick fracture
- Dagger sign: ossification of interspinous and supraspinous ligaments
- Erosions, sclerosis, loss of joint space of facet joints
- Trolley track sign: ossification of joint capsule, ligamentum flavum and interspinous ligaments on AP
Peripheral Joints
- Occurs in 50% of cases
- Hips, shoulders, heels most commonly
- Bilateral, symmetric
- Synovial and enthesial changes
- Ligament calcification
