Christman chapter 19 Flashcards
Causes of Monoarticular joint disease (7)
OCTOPIS
- Osteonecrosis
- Crystal induced
- Trauma
- Osteochondroma
- Pigmented villonodular synovitis
- Infectious disease (septic arthritis)
- Systematic disease (RA, psoriatic arthritis, reactive arthritis)
Causes of polyarticular joint disease (2 categories)
Inflammatory causes:
- Chronic tophaceous gout
- Rheumatoid arthritis
- Seronegative spondyloarthritis
- —-psoriatic arthritis
- —-ankylosing spondylitis
- —-Reactive arthritis
Noninflammatory:
- primary OA
- Charcot arthropathy
- Pigmented villonodular synovitis
Categories of joint disease:underlying pathology (2)
Degenerative and inflammatory
Degenerative joint disease: another word for it
osteoarthritis
Inflammatory: 4 types
- Rheumatoid arthritis
- Seronegative:
- –Psoriatic arthritis
- –reactive arthritis
- –ankylosing spondylitis
- Septic arthritis
- Metabolic
- –gouty arthritis
- –pyrophosphate arthropathy
Categories of joint disease : based on radiographic features (2)
- hypertrophic joint disease: subchondral sclerosis and osteophyte formation at the joint margin
- Atrophic joint disease: loss of bone substance through erosion and joint space narrowing
Hypertrophic joint disease (2)
-osteoarthritis - Detritus arthritis ---tarsus and midfoot charcot arthropathy ---posttraumatic arthritis
Atrophic joint disease (5)
-Rheumatoid arthritis
- Seronegative spondyloarthritis
- –psoriatic arthritis
- –ankylosing spondylitis
- –reactive arthritis
- Septic arthritis
- Forefoot charcot osteoarthropathy
- Lumpy-bumpy
- –gouty arthritis
- –multiple reticulohistiocytosis
- –pigmented villonodular synovitis
Primary radiographic changes (4)
- Osteophyte
- Erosion
- Subchondral resorption
- Arthritis mutilans
Osteophyte: definition and examples
Definition:
- a spur at the margin of a joint
- also known as dorsal flag, lipping and beaking
Pathognomonic of OA
Erosion: definition and examples
Definition:
- a localized wearing away of bone that begins along its outer surfaace
- Primary feature of all joint disorders affecting the foot except for OA
Examples:
-Rheumatoid arthritis
- Seronegative spondyloarthritis
- –psoriatic arthritis
- –ankylosing spondylitis
- –reactive arthritis
-gouty arthritis
Subchondral resorption: definition and examples
Examples:
- Charcot arthropathy
- Septic arthritic
Arthritis Mutilans: definition and examples
Definition:
-erosions that involve both margins
-Most commonly called the “pencil-in-cup”
Examples:
- Psoriatic arthritis
- Charcot neuropathic osteo
- Rheumatoid arthritis (5th MPJ)
Bone producing secondary radiographic findings (5)
- Diffuse sclerosis
- periostitis
- Whiskering
- Ivory Phalanx
- Overhanging margin of bone
Diffuse sclerosis: association?
association with the repair and remodeling phase of Carcot arthropathy
Periostitis:association?
associated with seronegative arthritis, septic arthritis, and forefoot Charcot arthropathy
Whiskering: association?
Seen with psoriatic arthritis
Ivory phalanx: association?
associated with psoriatic arthritis
Overhanging margin of bone: association
associated with gouty arthritis
Secondary radiographic findings that result in joint space alteration (2 categories)
Even joint space narrowing:
—inflammatory arthritis
Uneven joint space narrowing:
—OA/trauma
Osteoarthritis:
-Joints to be worried about (5)
- Hallux interphalangeal
- First MPJ
- Second met cuneiform
- Intermediate naviculocuneiform
- Talonavicular
OA Radiographic features: 6
- Primary finding is osteophyte
- uneven joint space narrowing
- subchondral sclerosis (eburnation)
- geode with sclerotic margins (subchondral cyst)
- Detritus
OA: targets what column
Targets the medial column especially the first MPJ
Rheumatoid arthritis classification criteria
- Joint involvement
- Serology
- Acute phase reactants
- Duration of symptoms
RA: first joint to be affected
5th MPJ is the first
Classic presentation of Rheumatoid Arthritis (5)
- Bilateral and symmetric
- Medial erosions at the 1st through 4th ray
- Lateral erosion of the 5th
- Uniform joint space narrowing at affected joints
- Fibular deviation
More specific presentations for RA
- increased soft tissue density and volume
- joint space widening (initially)
- Para-articular osteopenia
- Geode
- Erosion (medial sides except for lateral at the 5th)
- Joint space narrowing (to end with)
- Digital misalignment
- Ankylosis
Psoriatic arthritis:clinical presentations (5)
- predominant distal interphalangeal joint involvement
- Assymetric MPJ involvement with associated swelling (sausage toe)
- Spondylitis
- Arthritis mutilans
- Psoriatic onychopachydermoperiostitis
Psoriatic arthritis: radiographic changes(7)
- Primary: erosion/arthritis mutilans
- Periostitis (adjacent to affected joint line)
- Whiskering/ Ivory phalanx
- Sausage toe
- Acro-osteolysis
- Lack of juxta-articular osteopenia
- Enthesitis
Reactive arthritis: what causes it (2)
Shigella/ Chlamydia
Reactive arthritis: radiographic features (4)
- Primary finding: erosion
- Joint space narrowing and widening
- Sausage toe
- Periostitis adjacent to affected joint
Gouty arthritis: stages (3)
1) asymptomatic hyperuricemia
2) acute intermittent gout
3) advanced (chronic tophaceous) gout
Gouty arthritis:radiographic features (5)
- Primary finding: erosion which tends to be periarticular withan overhanging margin (Martel sign)
- Normal joint space
- Soft tissue mass (tophus)
- Rarefaction in bone occurs secondary to intraosseous tophus
- Occasional calcification of tophus
Charcot osteoarthropathy: Characterized by?
characterized by early inflammation and affects the bones and joints
Charcot osteoarthropathy (classification)
Eichenholz
1) Development
2) Coalescence
3) Reconstruction phase
Charcot osteoarthropathy (three target areas)
According to Cofeld
1) MPJ’s
2) Tarsometatarsal joint
3) Combination of: Talonavicular, Naviculocuneiform, and intercuneiform
Unique presentation of Forefoot charcot osteoarthropathy (2)
Subchondral resorption or arthritis mutilans
Periostitis
Unique presentation of rearfoot charcot osteoarthopathy (3)
- subchondral resorption
- loss of joint apposition (subluxation/dislocation)
- Detritus
Unique presentation of septic arthritis
- Primary finding is subchondral resorption
- Joint space widening
- Will progress to osteolysis
What pathology results in: Regional osteopenia (2)
- Disuse and immobilization
- Complex regional pain syndrome
What pathology results in generalized osteopenia (5)
- Osteoporosis
- Osteomalacia
- Hypophosphatasia
- Hyperparathyroidism
- Renal osteodystrophy
What pathology results in: epiphyseal region abnormality (2)
- Scurvy
- Rickets
What pathology results in: altered bone architecture (4)
- Paget disease
- fibrous dysplasia
- sickle cell anemia
- thalesemia
What pathology results in: altered bone form (7)
- acromegaly
- gigantism
- hereditary multiple exostoses
- echondromatosis
- osteogenesis imperfecta
- hypoparathyroidism
- Albright hereditary osteodystrophy
What pathology results in: generalized sclerosis (7)
- Osteopetrosis
- osteopoikilosis
- Melorheostosis
- osteopathia striata
- pyknoidysostosis
- fluorosis
- hypervitaminosis D
What pathology results in: Generalized periostitis (5)
- hypertrophic osteoarthropathy
- venous stasis
- hypervitaminosis A
- thyroid acropachy
- tuberous sclerosis
Osteopenia: when does it occur and when is it seen on x-rays
- occurs when bone resorption exceeds bone formation
- when 30-50% of bone mass is lost X-rays reveal osteopenia
Radiographic Patterns of chronic osteopenia (3)
- endosteal resorption
- intracortical tunneling
- subperiosteal resorption
Endosteal+subperiosteal resorption = cortical thinning
Primary radiographic feature of acute osteopenia
Primary radiographic feature is spotty loss of bone density
Definition of osteoporosis
progressive loss of bone mass due to increased resorption as well as decreased bone production.
-Results in normal bone composition but reduced amount of bone present per unit volume
Gold standard for detection of early osteoporosis
- DXA scan
- –Dual x-ray absorptiometry
Differential diagnoses for generalized osteoporosis
ViNDICaTE
- Vascular: anemia
- Nutritional: scurvy, malnutrition, calcium deficiency
- Drugs: steroids and heparin
- Idiopathic
- Congenital: osteogenesis imperfecta
- Toxic: alcoholism, chronic liver disease, cirrhosis
- Endocrine/Metabolic
Radiographic features of chronic osteopenia (3)
- thinning of the cortices
- prominent primary trabeculations
- intracortical striations
Osteomalacia: histologic findings
Histological disorder with excessive amounts of uncalcified osteoid.
Osteomalacia: amount of time to osteoid synthesis
Normally: 5-10 days
With osteomalacia: 2-3 months
Radiographic sign AND other changes seen in osteomalacia
- Primary radiographic sign is osteopenia
- Bowing deformity of long tubular bones may occur
- Transversely oriented incomplete radiolucency (pseudofracture)
- Lucent line may be bordered by sclerosis and is located along compressive side of bone
- Looser zone found in inner cortex
Hypophosphatasia: definition of
characterized by reduced levels of alkaline phosphatase
Hypophosphatasia: radiographic presentations (5)
- bowing
- shortening of long tubular bones
- Osteochondral spurring
- Chondrocalcinosis articularis
- Looser zone seen on the outer cortex (tensile side)
Hyperparathyroidism: definition
refers to increaed levels of PTH which indirectly leads to increased osteoclastic activity and leads to removal of calcium from bone into blood
Definition of primary hyperparathyroidism
due to a parathyroid abnormality and leads to hypercalcemia.
- May be in response to low calcium levels as well.
- Associated with hyperuricemia and gout
- TUMOR
Definition of secondary hyperparathyroidism
various situations that cause Vitamin D deficiency
Definition of tertiary hyperparathyroidism
results from hyperplasia of the parathyroid glands and a loss of response to serum calcium levels
-dialysis patients
Hyperparathyroidism radiographic features (7)
- Primary is subperiosteal bone resorption
- periarticular resorption
- intracortical resorption
- endosteal resorption
- subchondral resorption
- entheseal resorption
- acral osteolysis
Hyperparathyroidism hisological features
fibrous tissue replaces bone that is removed in a process known as osteitis fibrosis cystica
Hyperparathyroidism: what may resemble metastatic lesions?
Brown tumors: geographic radiolucent lesions corresponding to hot spots within the same bone on bone scans
Renal osteodystrophy:
subtype of?
Radiographic features
subtype of hyperparathyroidism
-will see a lot of soft tissue calcifications
Ricket’s: reason for pathology
-failure of osteoid to calcify in a growing person
Ricket’s radiologic signs (4)
- widening of the physis
- decreased density at the zone of provisional calcification
- Fraying and paint-brush appearance at the zone of provisional calcification
- widening and cupping of the metaphysis
Scurvy: causes
Insufficient dietary vitamin C intake
Scurvy: radiographic characteristics at the metaphysis (3)
- White line of scurvy: increased density bordering the growth plate
- Scurvy line: transverse line of decreased density by the metaphyseal line
- Small beak-like outgrowths of the zone of provisional calcification along its margins
Scurvy: radiographic characteristics at the epiphysis (just 1)
Epiphysis appears as an eggshell appearance: appears as an outer shell of increased density surrounding a central lucency.
Scurvy: 2 more radiographic changes
- Coroners sign
- Extensive periostitis may be seen along the entire length of bone
Acromegaly cause
Increase in GH and IGF 1
-most commonly due to a pituitary adenoma
Acromegaly: radiographic changes (4)
- Very thick heel pad >25mm
- Met shafts thickened, enthuses and spurring
Acromegaly arthropathy
resembles osteoarthritis and may find osteophytes, eburnation, subchondral geode, joint space narrowing
Osteochondromatosis: what is it?
It is a skeletal dysplasia resulting from disturbances in chondroid production resulting in heterotropic proliferation of epiphyseal chondroblasts
Osteochondromatosis: radiographic finding
Exostosis is found adjacent to the metaphysis and is attached to the bone by a stalk or pedicle
Echondromatosis (Ollier disease): what is it?
abnormality is due to multiple benign cartilage tumors within bone
What is Maffucci syndrome
name given to multiple enchondromas associated with hemangiomas
Echondromatosis radiographic findings?
geographic destructive (lucent lesion)
Osteogenesis imperfecta what is it
- result of abnormal metaphyseal and periosteal ossification caused by deficient osteoid disease
- referred to as brittle bone disease
Osteogenesis imperfecta (four types)
- Type I: most common, mild form that demonstrates fractures with no dwarfing.
- Type II: neonatal and lethal
- Type III: rare and demonstrates dwarfing and extremely fragile bone
Type IV: variable findings
Osteogenesis imperfecta : -Referred to as?
- due to:
- Radiographic findings
- Referred to as brittle bone disease
- due to deficient osteoid production
- Radiographically will see -diffuse osteopenia
- diminished bone girth
- flared metaphyses which give Erlenmeyer flask deformity
Hypoparathyroidism
- cause
- resulting findings
- radiographic findings
- caused by deficient or absent PTH, and is due to surgical exicision of all parathyroid tissue
- Results in hypocalcemia, hyperphosphatemia and hypercalciuria
Radiographic findings: osteosclerosis of bones and soft tissue calcification
Pathognomonic: brachymetaphalangea (shortened and widened out)
Albright hereditary osteodystrophy
- what is it
- Features
- Radiographic findings
- PTH resistant hypocalcemia and hyperphosphatemia along with an unusual constellation of developmental and skeletal defects
- features: short stature, round face, brachydactyly, obesity,
- radiographically: short mets and phalanges, exostoses, widening bones
Paget disease: osteitis deformans
- occurence
- marked by what bony changes
- associated with elevated serum?
-second most common aging bone disorder
- blade of grass
- flame appearance
- Sabre shins
- cortical thickening
-associated with elevated serum ALP and hydroxyproline
Paget disease
- marked by?
- abnormal serum levels
- Radiographic changes
- Marked by excessive and abnormal remodeling of bone
- Serum ALP and hydroxyproline become elevated
-Radiographic changes:
Lucent wedge, blade of grass appearance, flame appearance.
- —Sabre shins
- —Cortical thickening
Paget disease: earliest imaging modality
bone scintigraphy demonstrates increaed uptake of radionuclide before radiographic changes found
-CT better to visualize trabecular thickening.
Pathognomonic signs of Paget
bone enlargement, cortical and trabecular thickening
Anemia: change in bone and change in soft tissue
- cause sclerotic lesions in bone
- soft tissue:dachtyly
Thalassemia
will see the Erlenmeyer flask deformity in bone
Osteopetrosis: other synonyms for this
stone bone, and marble bone disease
Lower limb deformities seen with osteopetrosis (4)
coxa vara
- genu valgum
- genu varum
- clubfoot
Radiographic presentation in osteopetrosis (3)
- diffuse bone sclerosis: known as “bone within a bone”
- Transverse band of sclerosis
- Erlenmeyer flask deformity
Radiographic presentation seen in Melorheostosis
- flowing hyperostosis along the cortex of tubular bone
- Candle wax disease
Osteopoikilosis radiographic presentation
-multiple bone islands
—also known as enostosis
Osteopathia striata radiographic findings
-linear and regular fine bands of increased and decreased density that extend from the metaphysis
Pyknodysostosis radiographic findings
recurrent fractures and dwarfism
-acryl osteolysis
Hypervitaminosis A, Hypervitaminosis D, fluorosis common findings
will cause excessive bone formation
Venous stasis insufficiency 2 characteristic findings
- indurated cellulitis
- periostitis
Pulmonary hypertrophic osteoarthropathy findings (4)
- dactylitis
- periostitis
- clubbing of the fingernails
- acryl osteolysis
Tuberous sclerosis: triad, and soft tissue finding
- mental retardation
- hamartomas
- epilepsy
soft tissue: periungual fibromas
Metabolic disorders that result in periostitis (5)
- hypervitaminosis A
- hyperthyroidism
- tuberous sclerosis
- venous stasis
- pulmonary hypertrophic osteoarthropathy
Metastatic soft tissue calcification:definition and example
- the soft tissue is normal, but the bone metabolism is abnormal
- seen in renal osteodystrophy
Generalized soft tissue calcification: definition and example
- Soft tissue is normal and the bone metabolism is normal
- seen in tumoral calcinosis
Tumoral calcinosis definition and testing
- soft tissue calcification that usually occurs on the dorsum of the foot over the extensor tendons.
- Must biopsy
Dystrophic calcification definition and areas it is usually seen in
-soft tissue metabolism is abnormal, but bone metabolism is normal
- Seen in:
- –plantar fasciitis
- –Achilles tendinitis
- –Monckeberg’s : medial calcific sclerosis seen in diabetic vessel calcification of the tunica media
- –Fleboliths in venous stasis
- – Atherosclerotic plaques
What is Monckeberg’s
medial calcific sclerosis of the tunica media of blood vessels that occurs with Diabetics
What are Fleboliths
they are calcifications of the surrounding soft tissue seen in venous stasis
Example of heterotopic calcification:
Myositis ossificans in tendon or muscle
How to histologically differentiate myositis ossificans from osteogenic sarcoma
- Myositis ossificans circumscripta: osteoid production occurs in the periphery of the bone mass
- Osteogenic sarcoma: osteoid production begins in the center of the bone mass.
Which disease processes exhibit dachtylitis (3)
- psoriatic arthritis
- sickle cell disease
- pulmonary hypertrophic osteoarthropathy
Diseases that result in acryl osteolysis (4)
- Psoriatic arthritis
- hyperparathyroidism
- Pyknodysostoss
- Pulmonary hypertrophic osteoarthropathy
Diseases that result Erlenmeyer flask deformity (3)
- Osteogenesis imperfecta(brittle bone disease)
- Thalassemia
- Osteopetrosis (marble bone disease)
Charcot Classification (zones)
Sanders and Frykberg
Sanders and Frykberg Classification (5 zones)
- Zone 1: Distal and proximal interphalangeal joints and MPJ’s
- Zone 2: Tarsometatarsal joints ( Lisfranc)
- Zone 3: Naviculo-cuneiform joints, talonavicular and calcaneocuboid
- Zone 4: Ankle joint and subtalar joint
Zone 5: Calcaneus
