DI 2- Final Flashcards
List the three presentations/types of osteoporosis.
o Generalized (Senile/Postmenopausal)
o Regional—dt disuse/immobilization, reflex sympathetic dystrophy (RSD)
o Localized-dt infx, inflammatory arthritis, neoplasm
How does generalized osteoporosis present?
- ↑ bone radiolucency
- cortical thinning; “pencil thin” cortices & endplates
- endplates very radiopaque
- altered trabeculae patterns: no horizontal lines; accentuated vertical trabeculae = “pseudohemangiomatous”
- “Pancake” and anteriorly wedged vertebrae
- Biconcave endplates
- Isolated end plate infarction
- Schmorl’s nodes
How does regional osteoporosis present?
- Acute, Painful: progressive pain, swelling, atrophy
- Usu develops in one area distal to trauma site
- Osseous hyperemia dt neurovascular imbalance
- Patchy, mottled
- Metaphyseal localization
- No joint dz
What is the most common cause of generalized osteoporosis?
o Age o ↓ Estrogen (F > 60, pm) o ↓ Androgen (M) o ↓ intake Vit D and Ca o lack of weight-bearing exercise
What is the standard imaging modality to quantify bone mineral density?
o DEXA (dual energy x-ray absortiometry)
What causes rickets and osteomalacia? 2 forms of rickets?
o ↓ Vit D, mb dt malabsorption
o Osteomalacia: also abN Ca and PO4 metabolism, dietary deficiency, renal dz
o renal osteodystrophy w chronic renal dz
o renal tubular defect (don’t reabsorb phosphate)
What are the classic radiographic features of rickets?
- Generalized osteopenia (bowed appearence)
- Coarse trabecular changes
- Wide growth plates (tall, thick; feels thicker on palp, swollen)
- Rachitic Rosary (bead-like, on sternum)
- no zone of provisional calcification
- Frayed “paintbrush” (growth plate margn) and cupped metaphyses
What causes scurvy and what are the classic radiographic features?
↓ Vit C
o White Line of Frankel – dense zone of provisional calcification, @ metaphysis
o ring epiphysis (Wimberger’s sign)
o Pelken’s spurs, @ metaphysis
o scorbutic zone (Trummerfeld zone)
o subperiosteal hemorrhages dt vascular fragility
What are the classic radiographic features of hyperparathyroidism in the spine, skull, and hand?
- Hand: Subperiosteal resorption, Radial margins of proximal and middle phalanges of digits 2-3 w acroosteolysis (jagged edge)
- Skull: “Salt and pepper” resorption of lamina dura
- Spine: Osteopenia, Trabecula accentuation, End plate concavities, “Rugger Jersey” spine (thick cortical area), Wide SIJs
What are the face, skull, and foot changes seen with acromegaly?
- Face: prominent forehead, Sinus overgrowth, Wide mandibular angle (prognathism)
- Skull: large Sella turcica dt pituitary neoplasm; Sinus overgrowth, Malocclusion
- Foot: heel pad > 20 mm (1 in)
What osseous changes might long term corticosteroids cause?
- Osteoporosis of Cushing’s dz: Thin cortices, ↓density, deformities; Biconcave end plate
- Osteonecrosis: femoral & humeral heads; distal femur and talus; “Intravertebral vacuum cleft sign”: Gas in vertebra, avascular necrosis → vertebrae collapse
The “H”-shaped vertebra is classically seen in what condition?
Sickle Cell Anemia: vertebral bodies are osteoperotic; deformities at endplates (“step off”, “fish vertebrae”, “H” vertebrae, w central depression (hypoplasia of central portion of vertebrae)
What are some complications to the skeleton secondary to sickle cell anemia?
bone changes dt marrow hyperplasia, ischemia, necrosis
• Generalized osteoporosis (marrow hyperplasia)- Thin cortices
• Coarse trabeculae, esp in axial skeleton
• Large vascular channels
• Wide medullary cavity
• Epiphyseal ischemic necrosis
• Medullary infarcts (metaphysis or diaphysis)
• 2nd salmonella or staph aureus osteomyelitis
• Vertebral body collapse
• Posterior mediastinal extramedullary hematopoiesis
Which anemia tends to result in “honeycomb” trabecular patterns?
Thalassemia
Hemophilic arthropathy typically occurs in which joints?
Knee, ankle, elbow (BL, symmetrical)
What is a common ddx when encountering hemophilic arthopathy?
Rheumatoid arthritis
What are the 4 mc sites for aneurysm in the abdomen?
Aorta, Splanchnic (mb mc), Iliac, Femoral
Which condition demonstrates nonuniform joint space narrowing, osteophytes, subchondral sclerosis, & subchondral cysts?
DJD
Which condition presents with triangular sclerosis only at the iliac portion of the lower SI joint?
Osteitis Condensans Ilii
Is osteitis condensans ilii more commonly unilateral or bilat?
BL & symmetric sclerosis
Is osteitis condensans ilii more commonly found in males or females?
• predominantly women of childbearing age
Osteitis pubis is commonly associated with which medical procedure?
• surgery near pubic symphysis, usu lower urinary tract (suprapubic or retropubic prostatectomies)
What is the difference bw marginal & non-marginal syndesmophytes?
- Syndesmophyte= osseous excrescence attached to a ligament
- Non-Marginal Syndesmophytes: don’t come from corners
- Marginal syndesmophytes: ossification of outer annulus fibrosis → thick, vertical radiodense areas; connect adjacent vertebrae.
Which spinal arthritides have marginal vs non-marginal syndespmophytes?
- Marginal: ankylosing spondylitis (AS), bow outward slightly → “bamboo spine” dt extensive syndesmophytes (vs spondylophytes in DJD); AS & Enteropathic: continuous syndesmophytes
- Non-marginal: Psoriatic arthritis (esp at thoracolumbar jxn) & Reiters (=reactive arthritis, dt infx) (both tend to skip levels)
What systemic condition is commonly found in pts w diffuse idiopathic skeletal hyperostosis (DISH)?
- # 1 Osteoarthritis
- # 2 Diabetes
- Dyslipidemia
- Hyperuricemia
• Describe a cervical spine with DISH?
o large bridging anterior osteophytes from C2-T1
o Dense band of calcification along posterior aspect of vertebral bodies
o Mild disc space narrowing at C5-6 and C6-7, minimal narrowing at C3-4
o No evidence of facet joint fusion or narrowing.
Dysphagia is common in which arthritic condition & why?
DISH: spinal involovement, esp ALL & extraspinal ligamentous & tendonous calcification & ossification
• also PLL & Longus colli
• What is intervertebral disc degeneration?
- aka spondylosis
- Loss of disc height
- Osteophytes (spondylophytes (in spine))
- Endplate sclerosis
- Vacuum phenomenon (cleft) (sign of degeneration, lucency in disk)
- Retrolisthesis (MC cause is DJD)
- Central stenosis uncommon (MC cause is facet degeneration vs disk degeneration)
List the radiographic findings of Neuropathic Arthropathy:
6 D’s =pathognomonic 1. Distended Joint 2. Density ↑ of subchondral bone 3. Debris or loose bodies 4. Dislocation 5. Disorganization Joint 6. Destruction of articular cortex (also 3Ds = dislocation, destruction & degeneration)
Which conditions may result in neuropathic arthropathy?
- 2nd to loss of sensationand proprioception
- DM
- Alcoholism
- tabes dorsalis (syphilis breaks down body, lose reflexes)
- paralysis
- syringomyelia (esp UE): cavity inside canal filled w CSF
- Essentially severe, destructive DJD
What is synoviochondrometaplasia?
- Benign; metaplasia of hyperplastic synovium to hyaline cartilage
- cartilage ossifies, detaches → loose bodies (any synovial jt)
- large wt-bearing jts, Knee MC, st BL
- Never in spine
- Radiographic: Mult radiodense loose bodies in jt capsule, LC tendon sheath or bursae; Pressure erosions, wide jt space,
- Sx: asx, pain, jt swell, stiff, “joint locking”, crepitus, effusion, reduced motion, 2nd DJD
Name the common sites of involvement of RA in the hand & wrist:
Hands: • MCP’s & PIP’s • marginal erosions (irregular, no sclerotic margin): radial margins of 2-3 MC head • spinde digit (soft tissue swelling) • Boutonniere (DIP extend, PIP flex) • Swan neck deformities (DIP flex, PIP extend) • Ulnar deviation at MCP jt Wrist: • Ulnar Styloid erosion • uniform loss of radiocarpal jt • erosions of triquetrum-pisiform • spotty carpal sign • pancarpal involvement • scapholunate dissociation
What is a marginal erosion?
irregular, no sclerotic margin (on sides of MC heads, esp radial)
• Marginal erosions: bare area; up to 1 yr; extend to central portions
• Erosions - gout
What is the significance of widening of the atlanto-dental interspace?
→ direct compress brainstem, neuro damage by excessive kyphosis
• C-spine (mc) involvement; few at T/L jxn
• dens erosions
• C1-C2 instability → neuro damage (enlarged; N < 3mm in adult, child <5); atlanto-axial subluxations
• Pseudobasilar invagination
• Facet involvement; stair-stepping (anterolisthesis; also in DJD)
• IVD involvement
Which conditions demonstrate laxity of the transverse ligament (of atlas)?
inflammatory arthirtides affect tendons & ligs, joint membranes like the degeneratives (enthesopathy)
- SLE, Down’s
- possible w RA
Is SI involvement common in RA?
No – if so, usu minimal sclerosis; UL or BL & asymmetric
Describe the radiographic difference b/w RA & Psoriatic Arthritis in the hand & wrist:
Psoriatic looks similar to RA w/o hyperemia
PA:
• DIP and PIP jts of hand
• Ray pattern: effects all jts of a single digit
• st swelling
• Fluffy periostitis
• “Pencil in cup” deformity
• marginal erosions and tapered bone ends
• Asymmetrical w uniform joint space loss
RA:
• MCP’s (Haygarth’s nodes) & PIP’s
• marginal erosions (irregular, no sceroltic margin, Rat bite lesion)
• radial margins of 2-3 MC head
• Boutonniere (DIP extend, PIP flex)
• Swan neck deformities (DIP flex, PIP extend)
• Lanois deformity
• Ulnar deviation at MCP joint
• BL and symmetrical, uniform joint space loss
• (mc Protusio Acetabuli in pelvis)
What is the gender incidence of the vertebral column & pelvis in ankylosing spondylitis?
o M:F 9:1 (of AS in general, including spine and pelvis)
o Onset 15-35
What are the 1st and 2nd sites of involvement of the vertebral column & pelvis in AS?
o 1st: Pelvis: iliac side & lower 2/3 (synovial portion) of SIJ; symmetrical
o 2nd: Spine (spondylitis): TL and LS (probably) jxns mc initial spinal sites
o as a rule, spondylitis develops after SI dz
Is SI involvement usu uni or bilat in AS?
bilateral and symmetrical
What condition demonstrates squaring of the vertebral body?
AS
What is the shiny corner sx?
- ↑ radiodensity of corners of vertebral body, related to osteitis
- reactive sclerosis in AS
- at anterior vertebral margins assoc w Romanus lesions w AS (Romanus = erosion at insertion of outer annulus fibrosus into anterior corners of vertebral bodies, in AS)
What is a “carrot stick” fracture?
fracture of an ankylosed segment in AS usu causes paralysis
Which condition demonstrates similar SIJ & vertebral column findings to AS?
Enteropathic Arthropathy, Ulcerative colitis, Crohn’s dz; Whipple’s dz, Salmonella, Shigella, Yersinia
Which 2 seronegative spondyloarthropathies demonstrate non-marginal syndesmophytes & peripheral arthritis?
Psoriatic & Reiters
Non-marginal syndesmophytes= thicker, not throughout spine like AS
Reversible deformities of the hand are seen in which condition?
SLE; may have ulnar deviation, like RA, but pt can overcome w/ mm contraction or pushing hand down onto a table, etc
o No erosions of the hand
o SLE reversible b/c ligs are lax, but jts not destroyed; not reversible with RA, etc
What is acro-osteolysis & which condition demonstrates this finding?
resorbtion of the extremities (ie: distal phalanx) in psoriatic arthritis
What is the overhanging margin sign & which condition is this seen in?
Pathognomonic for Gout = sclerotic margin outside jt capsule
What structures are primarily involved in CPPD (calcium pyrophosphate dehydrate crystal deposition disease)?
- fibrous & hyaline cartilage of knee, wrist, pubic symphysis
- Fibrous: in meniscus, triangular shape
- wrist and ulna: thick, irregular, mb poorly defined menisci, triangular cartilage
- pubic symphysis, annulus fibrosis
- Hyaline (end of bones): parallel to cortex, thin, linear
What structures are primarily involved in HADD (hydroxyapatite deposition dz)?
o Shoulder & Hip MC; calcification near insertion of a tendon
o MC spot = supraspinatous tendon or bursa
What is the most common source of osteoblastic metastatic carcinoma in adult females?
Breast CA
List the three common causes of solitary sclerotic vertebral body.
Aka Ivory Vertebra
1- Hodgkin’s Lymphoma (anterior body scalloping)
2- Osteoblastic metastastic, MC
3- Paget’s Dz (cortical thickening and expansion)
Hint: Can’t differentiate end plates
Is it common to find a tumor involving a joint?
NO. if jt involved, think arthritic dz before tumor
Is multiple myeloma more common in the vertebral body or neural arch?
o MC vertebral body
o lateral lumbar: shows deformity of L4 vertebral body dt plasmacytoma (solitary myeloma)
What malignancy demonstrates as a cold bone scan?
Multiple myeloma
Cold =looks normal
= ddx from mets
Which is the most dense primary malignant bone tumor?
• Multiple myeloma, Osteosarcoma 2nd, Condrosarcoma 3rd (kid), Ewing’s 4th (kid)
What is the common age range of primary osteosarcoma?
o 10-25 75%
o Older, 2nd peak: likely dt malignant degeneration of benign process
What is the difference between sunburst and onion skin appearance?
o Sunburst = periosteal “spokes of a wheel” pattern; bad news; Sunburst: skull lesions (hemagiomas) often round or oval; lytic w striations in “sunburst” or “spoked wheel” pattern; characteristic of osteosarcoma;
o Onion skin (aka hair-on-end)= layered or laminated periosteal rxn, several parallel concentric layers periosteal new bone; benign or malig; most characteristic of Ewing’s tumor (Ewing’s sarcoma), or in osteosarcoma, acute, osteomyelitis, stress fractures, eosinophilic granuloma in very young
Which part of the bone is commonly involved in osteosarcoma?
Metaphysis of long bone – esp distal femur, proximal tibia, proximal humerus (around knee mc)
What is Codman’s triangle?
- Periosteal bone formation mb interrupted or incompletely cover surface of a lesion; periosteum lifts off cortex (osteosarcomas)
- Triangle, several layers of periosteal rxn at lesion margin of the lesion
- used to be pathognomonic of bone sarcomas, but also in osteomyelitis
- usu free of tumor; should be avoided as a site of bx
Why is Ewing’s sarcoma commonly found in the diaphysis of long bone?
o arises from red BM, mainly in diaphysis, closely related to reticulum cell sarcoma
o Mimics radiographic appearance of “round cell” tumors, leukemia & metastatic neuroblastoma
What is geographic appearance?
Geographic Lytic appearance – Geographic = well-defined margins, benign, non-aggressive lesion
Which condition presents with solitary exostosis that points away from the nearest joint?
Osteochondroma (supercondylar process points toward elbow joint)
What is the radiographic difference in appearance between osteochondroma and a benign solitary expansile osteolysis (= ABC)?
Osteochondroma
• Bony exostosis: cortex continuous with host bone; normal trabeculae
• pedunculated or sessile (asymmetric widening)
• Cartilaginous cap may calcify
• Projects away from joint
Benign Solitary expansile osteolysis (= aneurismal bone cyst)
• Expansile & very large
• Lytic & separated
• very thin cortex
• Only tumor that crosses growth plate (metaphysis to epiphysis)
Compare the incidence of malignant transformation in osteochondroma and hereditary multiple exostosis.
Osteochondroma: 1%
HME: 20%
What is a corduroy vertebra?
= lytic lesion w coarse vertical striations
• usu only at 1-2 vertebral bodies (osteoporosis mb many levels)
• occurs with hemangiomas (may look like Paget’s dz, osteoporosis)
Is spinal hemangioma commonly solitary or polyostotic?
Solitary
Which is the most common benign bone tumor of the spine?
Hemangioma (osteochondroma for entire body)
Is a bone island (endostoma) symptomatic?
No. usu asx; any bone except skull
Which condition demonstrates pain worst at night and easily relieved by aspirin?
Osteoid Osteoma (benign)
Which part of the bone is usually involved with osteoid osteoma?
- Can occur in any bone, mc cortices
- MC proximal diaphysis and metaphysis
- Subperiosteal: 50% in femur (esp proximal) and tibia, 20% phalanges; 10% spine (mostly neural arch)
What is the appearance of the tumor matrix in enchondroma?
(= cartilage cyst in BM) Geographic lytic o Expansile o stippled matrix calcification (calc in 50%) o Thinned cortex, endosteal scalloping o Metaphyseal- diaphyseal o Most central o No periosteal rxn, no soft tissue mass o MC mini long bones of hands, feet
Why is it common to observe a short limb with enchondroma?
The masses increase in size as the child grows, along with asymmetrical shortening of a limb
What is multiple enchondromatosis called?
Ollier’s Dz (& Maffucci’s syndrome but also has soft tissue hemangiomas/phleboliths)
What is the most common location of fibrous cortical defect?
o Lower extremity (90% in tibia or fibula) o Humerus o Ribs o Ilium Usu in cortex
What is a fallen fragment sign?
- 2/3 of simple bone cysts undergo pathologic fractures
- piece of bone seen on Xray below the pathologic fracture
- piece of cortex falls into cyst (if it doesn’t fall = trap door sign)
Which benign bone tumor is named according to its appearance rather than its histological composition?
ANEURYSMAL BONE CYST
• Cystic, blood filled cavity; “aneurysmal” in appearance
Described the radiographic difference between an enchondroma, simple bone cyst, aneurysmal bone cyst and osteochondroma.
- Endochondroma: Small round, central, geographic lytic
- Simple Bone Cyst: central, expansile, subepiphyseal, osteolytic; “fallen fragment” sign
- Aneurysmal bone cyst: Osteolytic, “soap bubble”; expansile cortex w thinning; blood filled
- Osteochondroma: Sessile or pedunculated; “coat hanger” exostosis or cartilage “cauliflower cap”; lateral growth plate; points away from jt
Is giant cell tumor painful?
yes
Is Paget’s disease monostotic or polyostotic?
• Polyostotic (= more than one bone involved)
List the radiographic features of Paget’s disease in a long bone
Plain film usu dx; bone scan can identify additional sites
o or bone density
o coarse (thick, less distinct) trabeculae
o thick cortex (less distinct)
o bone expansion
o subarticular extension
o pseudo-fractures (ie stress fractures thru bone)
o deformities
o Femur and tiba: blade of grass or candle frame appearance; V lesion; saber shin deformity; shepard’s crook (thick, bowing femur)
o What is the most common organism responsible for bone and joint infection?
• Staphylococcus aureus
o What terms are used to describe bone and joint infections?
o Osteomyelitis: • Suppurative (90% staph aureus) • Nonsuppuratie (TB) & arthritis: T & L; TB spondylitis (Pott’s dz); TB arthritis • Syphilitic (treponema pallidu) • Mycotic: fungus
