Arthritis Flashcards

Question

RA Knees

Answer 1

* Bilateral and symmetrical * Symmetrical loss of joint space * Subchondral cysts * Juxta-articular osteopenia

Answer 2

* Central loss of joint space * Most common cause of bilateral protrusio acetabulae

Answer 3

* Symmetrical loss of GH joint space * Humeral erosions * Subacromial bursa may be involved * Distal clavicle erosions

Answer 4

* 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)

Answer 5

* 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

Answer 6

* 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

Answer 7

* 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

Answer 8

* 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

Answer 9

* Inflammatory variant of DJD * 40-60 yrs, females 12:1 * Symmetric, episodic and acute inflammation of DIPs, PIPs and 1^st 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

Answer 10

* 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