Arthritis + X-rays Flashcards
Revise Image
Revise arthritic changes which may be seen in an X-ray
What are the 3 types of arthritis?
- Degenerative joint disease (osteoarthritis)
- Inflammatory arthritis
- Metabolic arthritis (gout)
List the 5 X-ray hallmarks of osteoarthritis (LOSS+)
- Loss of joint/articular space (asymmetrical)
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts (true cysts or pseudocysts)
- Lack of osteoporosis
Compare the 2 images
What is Inflammatory arthritis?
Joint inflammation caused by an overactive immune system
Comprised of RA, PA, EA?????
List 4 X-ray changes seen in inflammatory arthritis
- Unmarginated erosions
- Periarticular osteoporosis is common
- Soft tissue swelling
- Uniform loss of articular space
List 3 X-ray changes seen in Metabolic arthritis (gout)
- Lumpy bumpy soft tissue swelling
- Marginated bony erosions with
- Overhanging edges
List the early changes of OA
Disruption of the armour plate of the articular cartilage. Subsequently there is a progressive loss of macromolecular components from the ground substance, eventually exposing subchondral bone.
What are the 2 types of OA?
Compare these
Primary OA
- No underlying local etiological factors
- Abnormally high mechanical forces on normal joint
- Age related
Secondary OA
- Underlying etiological factors: CPPD
- Normal forces on abnormal joint
- Trauma, inflammatory arthritis, hemochromatosis, acromegaly, congenital hip dysplasia, osteonecrosis, loose bodies
List 2 keys features in a patient history that indicate OA
- Aggravated by joint use; relieved by rest
- Morning stiffness < 15 min
List 6 clinical examination findings indicative of OA
Explain various pathological changes of OA and link these to the disease stage and radiographic findings
Which compartment of the knee is most commonly affected by OA?
List 2 ‘knee-specific’ X-ray changes
Medial femorotibial compartment most commonly narrowed
- Osteochondral bodies
- Patellar tooth sign (enthesopathy at the patellar attachment of the quadriceps tendon)
What X-ray view of the knee is best to assess OA and why?
Weight-bearing views in order to correctly assess amount of joint space loss
List the 2 main causes of secondary OA in the knee
trauma and meniscectomy
What is shown on the image below?
Patellar tooth sign
List 3 hand changes indicative of OA
- Heberden’s nodes in DIP
- Bouchard’s nodes in PIP
- Asymmetrical peripheral involvement
Identify changes on both X-rays below - what condition is this?
OA
What is erosive osteoarthritis and who does it most commonly affect?
OA with superimposed inflammatory erosive changes
Characteristically affects middle-aged women
List 3 x-ray features of erosive OA
- Erosive and productive changes of DIP and PIP
- Gull-wing pattern: secondary to central erosions and marginal osteophytes
- Interphalangeal fusion may occur.
What are the 2 types of Inflammatory Arthritis?
- Autoimmune arthritis
- Seronegative spondylarthropathies
What is RA and is is more common in males or females?
RA is a chronic autoimmune multisystemic inflammatory disease which affects many organs but predominantly attacks the synovial tissues and joints
Female : male (3:1)
List 6 features of a patient history/exam/investigations indicative of RA
List the 2 main early radiographic changes of RA (incl which joints)
Early changes
- Periarticular soft tissue swelling (edema, synovial congestion)
- Periarticular osteoporosis in symmetrical distribution (hallmark)
Preferred sites of early involvement
- Hands: MCP joint
- Feet :MTP joint
Give the stages and pathology of RA
What is this X-ray indicative of?
List 5 hand changes indicative of RA
- MCP ulnar deviation
- Boutonniere deformity: hyperextension of DIP, flexion of PIP
- Swan-neck deformity: hyperextension of PIP, flexion of DIP
- Z-deformity of the thumb **
- Ulnar and radial styloid erosions are common
List x-ray changes indicative of RA in the following locations:
- Shoulder
- Hip
- Spine
What is scleroderma? (systemic sclerosis)
A group of rare diseases that involve the hardening and tightening of the skin and connective tissues
Manifests as soft tissue abnormalities in addition to erosive arthritis
List 4 radiographic features of Sceleroderma
- Soft tissue calcification
- Acro-osteolysis: tuft resorption results from pressure of tight and atrophic skin
- Soft tissue atrophy
- Erosive changes of DIP and PIP
Is arthrits seen in SLE, explain?
Non-erosive arthritis (in 90% of SLE) resulting from ligamentous laxity and joint deformity
Distribution is similar to that seen in RA
List 4 radiographic features of SLE
- Prominent subluxations of MCP
- Usually bilateral and symmetric
- No erosions
- Soft tissue swelling may be the only indicator
What is Psoriatic arthritis?
Uncommon disease involving synovium + ligamentous attachments with propensity for sacroiliitis/ spondylitis
Classified as seronegative spondyloarthropathy
Give the location/distribution of psoriatic arthritis?
Widely variable distribution + asymmetry with involvement of lower+ upper extremities
- Distinctive pattern: terminal interphalangeal joints
- Asymmetrical distribution
- Marginal erosions
What condition is frequently present in late stages of psoriatic arthritis
Osteoporosis
Give the radiological hand and foot changes seen in psoriatic arthritis
Target area: DIP, PIP, MCP
- “sausage digit” = soft-tissue swelling of entire digit
- destruction of distal interphalangeal joint
- “pencil-in-cup“ deformity
Give 3 radiological ‘axial skeleton’ findings of psoriatic arthritis
- “floating“ osteophyte= large bulky vertically oriented paravertebral soft-tissue ossification
- Sacroiliitis( 40%)= (most commonly) bilateral
- asymmetric sacroiliac joint affection
What is ankylosing spondylitis and who does it most commonly affect?
Give its onset and presentation
Autoimmune disease of unknown etiology primarily affecting axial skeleton (a/w HLA-B27)
- Age: 15-35 years
- M:F = 10 : 1
Insidious onset of low back pain + stiffness
Ankylosing spondylitis is associated with what 3 conditions?
- Ulcerative colitis, regional enteritis
- Iritis in 25%
- Aortic insufficiency + AV conduction defect
What locations does ankylosing spondylitis primarily affect?
- Axial skeleton: sacroiliac joints, thoracolumbar + lumbosacral junctions
- Peripheral skeleton (10 -20%): sternal joint, symphysis pubis, hip, glenohumeral joint
- Tendinous insertions in pelvis+ proximal femur
What is the hallmark of ankylosing spondylitis?
Sacroiliac joint involvement!
List 3 radiographic changes seen in the sacroiliac joint/ symphysis pubis in ankylosing spondylitis
- Initially sclerosis of joint margins primarily on iliac side
- bilateral + symmetric late in disease
- may be unilateral+ asymmetric early in disease
- Later irregularities + widening of joint (cartilage destruction)
- Bony fusion
List 4 radiographic changes seen in the spine in ankylosing spondylitis
Revise x-ray’s of ankylosing spondylitis
Gout is cause by a derangement of _______ metabolism
State who is most commonly affected - M/F and age?
purine
>40 years; males
List the 3 main manifestations of gout
- Hyperuricemia
- Deposition of crystals in synovial fluid
- Recurrent episodes of arthritis
Compare primary vs secondary gout
Primary (90% - M:F = 20:1;) ➞ overproduction of uric acid due to inborn error of metabolism
Secondary (10%) rarely radiographically apparent disease ➞ due to Increased turnover of nucleic acids due to:
- Myeloproliferative disorders+ sequelae of their treatment (lymphoma, multiplemyeloma)
- Blood dyscrasias: chronic haemolysis
Give the 5 clinical stages in chronologic order of gout
- asymptomatic hyperuricemia
- acute gouty arthritis
- chronic tophaceous gout
- gouty nephropathy / nephrolithiasis
- acute urate nephropathy
State the following about acute gouty arthritis:
- precipitated by?
- number of joints involved
- prognosis
Precipitated by: trauma, surgery, alcohol
Joints: Polyarticular (10%): any joint may be affected
Prognosis; usually self-limited (pain resolving within a few hours / days) without treatment
What is Chronic tophaceous gout?
Multiple large urate deposits in intra-articular, extra-articular, intraosseous location
State the distirbution/pattern about chronic tophaceous gout?
- Distribution: symmetric polyarticular disease (resembling rheumatoid arthritis),
- Asymmetric polyarticular disease, monoarticular disease
????????
Compare acute gouty arthrits vs chronic tophaceous gout
CPG has more severe prolonged attacks and may ulcerate expressing whitish chalky material
Where does gout most commonly affect?
1st MTP joint most common = podagra
> ankles > heels > wrists etc… see slide
Involvement of hip + spine is rare. Can also affect bones, tendon, bursa, bones
Give 2 radiological soft tissues changes seen in gout
- Eccentric juxta articular lobulated soft-tissue masses (hand, foot, ankle, elbow, knee)
- Bilateral effusion of bursae olecrani (characteristic), prepatellar bursa
Give 2 radiological joint changes seen in gout
- Joint effusion (earliest sign)
- Periarticular swelling (in acute monoarticular gout)
- Preservation of joint space until late in disease
- Cartilage destruction (late in course of disease)
Radiologically, how can we differentiate gout from RA?
Absence of periarticular demineralization (due to short duration of attacks)
Give 3 radiological joint changes seen in gout
- “punched-out” lytic bone lesion + sclerosis of margin ➞ “mouse/rat bite” from erosion of long- standing soft-tissue tophus
- “overhanging margin” ➞ elevated osseous spicule separating tophaceous nodule from adjacent erosion (intra- and extraarticular) (HALLMARK)
- Proliferative bone changes
What is neuropathic arthropathy (charcot joint)?
Traumatic arthritis due associated with loss of sensation + proprioception of affected limb
Give the pathogenesis of neuropathic arthropathy
- Decreased pain sensation produces repetitive trauma
- Sympathetic dysfunction results in local hyperemia + bone resorption
List 4 causes of neuopathic osteoarthropathy (there is heaps!)
Give some typical history, examination and investigation findings of neuropathic osteoarthropathy
What are the 6 D’s of neuropathic osteoarthropathy?
- Dense subchondral bone (sclerosis)
- Degeneration (attempted repair by osteophytes)
- Destruction of articular cortex (sharp margins, resemble surgical amputation)
- Deformity (“pencil point” deformity of metatarsal heads)
- Debris (loose bodies)
- Dislocation (non-traumatic) subluxation of joints (laxity of periarticular soft tissues) progressive rapid resorption
What is Primary Synovial Osteochondromatosis and how is it characterised?
A benign self-limiting mono-articular disorder which involves the synovium
Characterized by proliferation + metaplastic transformation of the synovium with formation of multiple intrasynovial osteocartilaginous nodules
Which age and gender are most commonly affected by Synovial Osteochondromatosis?
Presents in 3rd-5th decade of life
M:F = 2-4:1
Where does Synovial Osteochondromatosis most commonly affect?
What is seen radiographically?
Knee is most common >50%
Other sites: joint/ tendons heath/ ganglion/ bursa
Seen as multiple calcified/ossified loose bodies in a single joint (size of nodules varies between a few mm to several cm)
