Complete EBM Objectives Flashcards
What are the four monoarticular inflammatory diseases?
POGS Psoriasis Osteoarthritis Gout Scleroderma
What are the four polyarticular inflammatory diseases?
LARP Lupus Amyloidosis Rheumatoid Arthritis Psoriatic arthritis
What are four examples of non-inflammatory joint diseases?
Septic Arthritis
Rheumatoid Arthritis
Gout
Osteoarthritis
What characterizes degenerative joint disease?
The breakdown of joint cartilage and underlying bone.
Will have pain, stiffness and swelling with decreased ROM.
Herberdene nodes and bouchard nodes will be appreciated.
What are the six inflammatory joint diseases?
"PISSSR" Psoriatic arthritis IBD Still's disease Scleroderma SLE RA
Will have stiffness, pain, swelling, restricted motion and reduced strength.
What are the 5 metabolic joint diseases?
POOOCh Paget's Osteoperosis Osteomalacia/rickets Osteitis fibrosa cystica Charcot
What are the four hypertrophic joint diseases?
Scleroderma
Osteoarthritis
Charcot
Gout
Characterized by increased deposition of bone at the joints.
What disease state is pathomnemonic for osteophytes?
Osteo arthritis/ Degenerative joint disease.
Look for assymetrical joint space narrowing as well as detritus and subchondral sclerosis/ geode.
What disease state is noted by the appearance of erosions?
Rheumatoid arthritis!
Differentiate from psoriatic arthritis by seeing extraarticular erosions and osteopenia adjacent to the joint.
Joint space narrowing will also be symetric.
What disease state is noted by subchodral resorption?
Seen extremely commonly in septic joint and charcot.
In septic joint you will laso have osteolysis and sequestra.
In charcot look for the generalized sclerosis and detritis or arthritis mutilans.
How can you differentiate between Charcot and septic joint?
In septic joint you will laso have osteolysis and sequestra.
In charcot look for the generalized sclerosis and detritis or arthritis mutilans.
How can you differentiate between rheumatoid arthritis and psoriatic?
Rheumatoid:
Extra articular erosions.
Osteopenia adjacent to the joint
Enthesopathy/ Bywaters
Psoriatic: Periostitis whiskering Ivory Phalanx Sausage digit **Osteolysis at distal phalanx
Which two pathologies can cause arthritis mutilans?
Charcot
Rheumatoid arthritis
Psoriatic arthritis can cause it too!
What is eburnation?
Eburnation is subchondral sclerosis. Seen most commonly near the area of joint space narrowing on the concave side of the joint.
Most commonly seen in osteoarthritis.
What is whiskering?
Variation of periostitis radiating away from the bone margin.
Most commonly seen in psoriatic arthritis
What is ivory phalanx?
A form of periositis
There is increased density of distal phalanx relativee to the normal bone density.
Also seen in psoriatic arthritis.
What is Martels sign?
A form of periostitis seen with gout.
Overhanging margin of new bone seen at the erosion.
Monosodium urate crystals will be present.
What’s the difference between chondrocalcinosis and hydroxy appatite deposition.
Chondrocalcinosus will result in calcified cartilage and is known as pseudo gout.
hydroxy appatite deposition disease is characterized by joint widening on both sides of the joint.
Is gout distributed symetrically?
No!
Tophi are typicall assymetric in distribution.
The monosodium urate crystals are deposited into the joint capsule, synovium, cartilage, subchondral bone, and periarticular tissues.
Unlike RA, psoriatic arthritis does not have….
Juxta-articular osteopenia.
You see an arthritity with non uniform joint space narrowing, osteophytes and eburnation?
Osteoarthritis.
Important to note the OA does not have erosions.
Just look for Geodes.
What joint space narrowing pattern does psoriatic arthritis follow?
Uniform narrowing!
Which joints are targeted by charcot?
Metatarsal-tarsal
Not seen in intertarsal joints typically.
What occurs at the joint space with neuropathic osteo-arthropathy?
Increased joint space due to subchondral resorption.
What exactly is osteopenia?
Decreased bone density with cortical bone thinning.
Bone will appear mottled, or moth eaten with loss of bone density.
What exactly is osteoperosis?
Bone is normal but the ammount of bone per unit volume is decreased.
Seen most commonly in cancellous bones due to metabolic issues!!
What are the radiographic pearls of osteoporosis?
Endosteal resorption
Subperiosteal resorption
Will have loss of secondary trabeculae!! Leads to primary trabeculations in the long axis of the bone.
What is osteomalacia?
Excessive ammounts of uncalcified osteoid.
Vitamin D deficiency in adults!
Osteomalacia within children is known as?
Rickets!!
What are the two radiographic pearls of osteomalacia?
Looser’s lines: Lucency perpendicular to the cortex (inner border) leading to pseudo fractures.
Bowing of the long bones.
What is hypophosphatemia?
Reduced levels of alkaline phosphatase!
What are the radiographic pearls for hypophosphatasia?
Chondrocalcinosis articularis
You will have loosers lines similar to osteomalacia however it will be found on the outer cortex of long bone.
What is primary hyperparathyroidism?
Excessive PTH secretion due to a Parathyroid tumor.
Will lead to hypercalcemia.
What is Secondary hyperparathyroidism?
Excessive PTH secretion due to low calcium levels.
An example of this would be vitamin D deficiency.
What is tertiary hyperparathyroidism?
Excessive PTH secretion due to hyperplasia of the parathyroid glands and loss of response to serum calcium levels.
Will see this in patient with chronic renal failure!!!
What effect does elevated PTH have on the bone?
Causes excessive resorption of the bone!
Leads to extremely high levels of blood calcium levels and deminished bone strength.
What are the radiographic pearls of hyperparathyroidism?
Subperisteal bone resorption
Browns tumors (lytic lesions)
Histopathologically you will have fibrous tissue replacing bone.
Also associated with hyperuricemia and overt gout.
Which form of hyperparathyroidism will you see excessive soft tissue calcification?
Secondary hyperparathyroidism.
What occurs in hypoparathyroidism?
Loss of the parathyroid due to surgical excision or autoimmune disorder.
Will result in osteosclerosis of bones and soft tissue calcification.
What is pseudohypoprathyroidism?
Tissue is resistant to PTH but PTH levels are high.
Injection of PTH will fail to result in phosphatemuria.
Pseudohypoparathyroidism is a condition associated primarily with resistance to the parathyroid hormone. Those with the condition have a low serum calcium and high phosphate, but the parathyroid hormone level (PTH) is appropriately high (due to the low level of calcium in the blood).
What is pseudopseudohypoparathyroidism?
Inherited disorder in which the patient is biochemically normal but appears like he has pseudohypoparathyroidism.
Calcium levels are normal!!
Considered albrights hereditary osteodystrophy.
What is renal osteodystrophy?
Patients with chronic renal failure.
Seen in adults on hemodialysis.
How will the bone appear in patients with osteodystrophy?
Areas of increased and decreased bone turnover.
Results in disturbances of calcium regulating hormones, vitamin D and PTH metabolism.
What is evelated in renal osteodystrophy?
Chronic kidney disease causes hyperphosphatemia directly and indirectly causing increased PTH stimulating osteoclast activity.
What feature stands out radiographically with renal osteodystrophy?
Will appear very similar to hyperparathyroidism and osteoperosis/osteomalacia.
however there will be excessive calcification of soft tissues and vessels.
what are the radiographic signs of scurvy?
In addults you may lead to blood supplies dieng off secondary to loss of Vit C. Leads to infarctions.
In children you’ll have…
The scurvy line: Transverse line of sclerosis in metaphyseal region.
Pelkan sign: Small beak-like outgrowth of bone on metaphysis.
Periostitis along entire length of bone.
Wiberger sign: Epiphysis has an outer shell if increased density with central lucency.
Corner’s Sign: Radiolucency on the edge of the metaphysis.
Frankel’s Line: White line of scurvy on fibula.
What is Rickets and how does it show on X-ray?
Vitamin D deficiency in children.
will have excessive amounts of uncalcified osteoid.
Bowing of long bones
Loosers zones on inner border of bone
Widened physis
Widened and cupped metaphysis
Irregular physeal margins “Paint brushing”
If the loosers lines are present, think of hypophosphatasia.
What is the type of osteoperosis/osteopenia seen in a patient who is immobilized in a cast for 8 weeks?
Regional osteoperosis!
Progressive loss of bone mass nothing is physically wrong with the bone.
Considered normal after immobilization.
What X-ray changes are seen in Paget’s disease?
Osteitis Deformans will show:
Remodeling of bone with increased bone production.
Increased alkaline phosphatase and hydroxyproline.
X-rays will show blade of grass/flame shaped lesions.
Saber shin deformities.
Sclerotic cortical thickening.
What X-ray changes are seen in osteopetrosis?
Bone within bone/ stone bone.
Diffuse bone sclerosis
Earle Meyer Flask Deformity
What X-ray changes are seen in melorheostosis?
Candle Wax Disease
Looks like wax flowing down side of candle.
What X-ray changes are seen with osteopoikilosis?
Numerous small, well defined and homogenous circular foci called “Bone island’s”
What X-ray changes are seen in osteopathia striata?
Linear regular bands of increased density extending from metaphysis to diaphysis
What X-ray changes are seen in pynknodyostosis?
Shortened lmbs with generalized osteosclerosis.
Acral osteolysis
Dense brittle bones
What is metastatic calcification?
A disturbance in calcium/ phosphate metabolism leading to deposition of calcium in NORMAL tissue.
ABNORMAL METABOLISM IN NORMAL TISSUES
Examples: Hyperparathyroidism Hypoparathyroidism Renal osteodystrophy Hypervitaminosis D Sarcoidosis
What is generalized calcinosis?
Calcium deposition in the skin and subQ tissue with NORMAL CALCIUM METABOLISM deposited into ABNORMAL TISSUES
Examples: Scleroderma/dermatomyositis.
What is dystrophic calcification?
Calcium is being deposited into damage or devitalizd tissues in the absence of metabolic derangement.
NORMAL METABILISM IN DAMAGED SOFT TISSUE.
ex: Phleboliths, arterial calcification, artherosclerosis.
What are the radiographic signs of myositis ossificans circumscripta?
Caused by localized trauma resulting in a zoning phenomenon.
Soft tissue swelling leading to ill-defined calcific densities and eventaul ossification.
What is DEXA used for?
Low does X-rays with two energy peaks.
One absorbed by tissue one by bone do determine bone mineral density.
What is VFA used for?
Thoracic and lumbar fractures.
Prior fracture shows as squashed down verebrae anteriorly.
What is IVA used for?
Rapid assessment of the vertebral fractures.
What does the T-score look at?
Compares you to a young adult (30 y/o) of same gender with peak bone mass.
What is a normal T score?
Greater than -1.0
What T score is related to osteopenia?
-1.0 to -2.5
What T score is related to osteoperosis?
Less than -2.5
Each standard deviation results in 10% decreased bone density.
What does the DEXA Z score test?
Tests the ammount of bone that you have compared to other people at your same age group, size, and gender.
Used in young men and premenopausal women.
What is the FRAX score?
Fracture risk calculator estimating the 10 year fracture risk for post-menopausal women and men 45+.
What is the dosage of calcium for osteroporosis?
1000-1500 mg/day
Its in the form of calcium citrate.
What is the dosage for vitamin D?
1000-2000 iu/day
Each 100 iu raises the blood 1 ng/mL.
50,000 iu causes hypervitaminosis D!
What are Bisphosphonates used for?
Osteoperosis
Inhibits enzymes using pyrophosphate preventing resorption of bone.
Long term will result in atypical femoral fractures, osteonecrosis of jaw, GERD.
When is bisphosphonates contraindicated?
Kidney disease
What is Teriparatide used for?
Synthetic PTH to stimulate bone formation.
Contraindicated in things that can increase risk of osteosarcoma.
Administered subque daily for 2 years.
What is the use of Raloxifene?
SERMS that acts to modulate estrogen receptors
What is the use of Denosumab?
Inhibits maturation of pre-osteoclasts by inhibiting RANKL
Contraindicated in hypocalcemia.
What is calcitonin used for?
Inhibits osteoclasts
Administered intranasaly only used for bone pain.
Describe a type 1 wilson katz classification?
fracture line with no evidence of endosteal callous or periosteal reaction.
At the base of teh 5th met it is a jones fx.
Describe a type 2 Wilson-Katz classification?
Focal sclerotic line and endosteal callus.
Seen in cancellous bone body of the calcaneus and proximal/distal tib/fib
Describe a type 3 Wilson-Katz classification?
Periosteal reaction and external callus.
Cortical bone: shaft of long bones.
Describe a type 4 Wilson-Katz classification?
Mixed combination of II/III
Dreaded black line that is unable to heal.
What is Fleck’s Sign seen on X-ray?
Avulsion fracture of 2nd metatarsal base within the first intermetatarsal space.
Seen in lis franc injuries.
In a lis franc injury the medial border of the 2nd met will not be continuous with?
The intermediate cuneiform.
What is seen in AP stress abduction in lis franc injuries?
Step off from the second metatarsal and intermediate cuneiform medial borders.
What is seen in the AP stress adduction in lis franc injuries?
1st ray moves medially from the second ray resulting in a large gap between cuneiforms called diastasis.
The medial border of the 4th met should be continuou with… in an Medial oblique X-ray if there is no lis franc injury.
Medial border of the 4th met should be continuous with the medial border of the cuboid.
The lateral border of the third met should be continuous with the … if there is no lis franc injury on the Medial Oblique ray.
Lateral border of the third met should be continuous with lateral border of the lateral cuneiform.
What is a Hardcastle Type A injury?
Homolateral or homomedial (metatarsal displacement in lis franc injury)
What is a Hardcastle Type B injury?
Partial incongruity in which not all metatarsals are displaced in the sam direction.
What is a Hardcastle Type C injury?
Divergent lis franc injury.
First met medially dislocated 2-5 mets are partially or completely laterally dislocated.
What is a Nunley Stage 1 injury?
A lis franc ligament sprain.
Normal AP and lateral WB X-ray
Positive bone scan.
What is a Nunley Stage 2 injury?
Lis franc ligament rupture
2-5 mm diastasis on AP WB X-ray normal lateral X-ray.
Positive bone scan
What is a Nunley Stage 3 injury?
Ligamentous rupture of Lis Franc
2-5 mm diastasis on AP n
Loss of arch height on lateral
Positive Bone scan
Describe Te99 carrier molecule and its site of uptake
Binds to hydroxyapatite in bone
Taken up in sites of bone turnover such as fractures, charcot, osteomyelitis where there is osteoclast activity.
Describe Te99 - Sulfur colloid carrier molecule and its site of uptake.
Binds to reticuloendothelial cells in the bone marrow and neutrophil production.
Useful to see if bone changes are due to infection or infarction (osteo vs charcot)
Describe Te99 - HMPAO Carrier molecule and its site of uptake
Binds to leukocytes used to determine inflammation and infection.
Describe IN111 carrier molecule and its site of uptake
Binds to WBC membranes
Used in post-op fever to determine osteomyelitis, diabetic foot infections, or graft infection.
Identify the phase of a Te99-MDP bone scan by film only.
Phase 1: Alot of pictures
Phase 2: No distinct bone margins.
Phase 3: Distinct bone margins.
