DI 2 Final Flashcards
what are the three presentations/ types of osteoporosis
- Generalized
- Regional
- Localized
What are the risks of generalized osteoporosis
- Age related
- Post menopausal
- Steroid and heparin induced
- Multiple myeloma
- Metastasis
- Hyperparathyroidism
- Scurvy
- Osteomalacia
- Rickets
- Sickle cell anemia
- Osteogenesis imperfect
what is the cause of regional osteoporosis
dt disuse, immobilization, RSD (reflex sympathetic dystrophy)
What is the cause of localized osteoporosis
dt tissue inflamation arthritis neoplasm
what is the most common cause of generalized osteoporosis
increasing age
What is the standard imaging modality to quantify bone mineral density?
DEXA scan (dual energy x-ray absorptiometry)
Osteomalacia
lack of osteoid mineralization leading to generalized bone softening, bones lack a proper amount of calcium
Rickets
- osteomalacia in kids
-systemic skeletal disorder dt
deficiency primarily of vit D
What are the classic radiographic features of rickets
- Generalized osteopenia
- Coarse trabecular changes
- Widened growth plates
- Rachitic (costal) rosary
- Absent zone of provisional calcification - ( frayed ‘paintbrush’ and cupped metaphases)
What causes scurvy and
- Scurvy: depressed intercellular substance formation, esp. in connective tissue, cartilage and bone
- cause by Vit C deficiency
What are the radiographic features of scurvy
- Few in adults – often just osteopenia
- A combo of abnormalities occurring at the growing ends of long bones
- Osteoporosis
- Dense zone of provisional calcification (White Line of Frankel)
- Ring epiphysis (Wimberger’s sign) circular, opaque shadow surrounding epiphyseal centers of ossification
- Pelkan spurs – lateral growth of metaphysial calcification zone creates beak appearance
- Scorbutic zone (Trummerfeld zone) – lucent band beneath white band of frankel
- Subperiosteal hemorrhages (due to deficiency of intercellular cement which in turn promotes vascular fragility)
What are the classic radiographic features of hyperparathyroidism in the Hand
- Subperiosteal resorption (hallmark feature)
- Radial margins of the proximal and middle phalanges of the 2nd and 3rd digits with acroosteolysis
What are the classic radiographic features of hyperparathyroidism in the Skull
- “salt and pepper”
- resorption of lamina dura
What are the classic radiographic features of hyperparathyroidism in the Spine
- Osteopenia
- Trabecular accentuation
- End plate concavities
- “rugger jersey” spine
- widened SI joints
What are the face, skull, and foot changes seen with acromegaly?
- d.t pituitary eosinophilic adenoma secreting GH after the plates have fused
- XS production of GH prior to the closure of the long bone growth centers = gigantism
Face:
- Prominent forehead
- Thickened tongue
Skull:
- Sella turcica enlargement (dt pituitary neoplasm)
- Sinus overgrowth
- Malocclusion
- Widened mandibular angle (prognathism)
Foot:
- Heel pad greater than 20 mm (approx. 1 inch)
what osseous changes might long term corticosteroids cause
cushings Dz and steroid induced osteonecrosis
- both d.t XS glucocorticoid release by the adrenal cortex
Osteoporosis of cushings disease
- Cortices are thinned, density diminished and deformities evident
- Biconcave end plate configurations (differentiates from old age osteoporosis)
Osteonecrosis/ avascular necrosis Dt glucocorticoids
Seen in femoral and humeral heads, distal femoraknee) and talus
Intravertebral vacuum cleft sign dt glucocorticoids
d.t collapse of a vertebral body following steroid medication from ischemic necrosis looks like a compression fx with wedging anteriorly and vacuum of air inside vertebral body
The ‘H’ shaped vertebra is classically seen in what condition
- Sickle Cell Anemia
(caused by osteoporosis of vertebral bodies – deformed at end plates with central depression due to hypoplasia of central portion of vertebrae)
What are some complications to the skeleton secondary to Sickle cell
- Bone marrow hyperplasia, ischemia and necrosis
- Osteopenia/osteoperosis due to marrow hyperplasia
- Osteomyelitis – caused by salmonella in sickle cell anemia, destroys vertebrae (hematogenous spread)
- Thin cortices (increased radiolucency)
- Coarse trabeculae (esp in axial skeleton)
- Large vascular channels
- Widened medullary cavity due to marrow hyperplasia
- Growth deformities
- Epiphyseal ischemia necrosis = osteonecrosis = avascular necrosis
- Medullary infarcts (metaphysis or diaphysis)
- Vertebral body collapse
- Posterior mediastinal extramedullary hematopoiesis (blood forming a mass next to the vertebral bodies in the T spine – may look like a lung tumor on xray)
Which anemia tends to result in ‘honeycomb’ trabecular patterns?
thalassemia
Hemophilic arthropathy is typical in which joints
- Knee, ankle, elbow (bilateral and symmetrical) – all weight bearing joints
- Knee will show enlarged epiphyses, widened intercondylar notch, squared inferior patella
- Ankle may show tibiotalar slant deformity
- Pseudotumors – destructive intraosseous hemorrhages – most commonly occur in femur and pelvis
What is a common ddx when encountering hemophilic arthropathy of the knee ( hint: think childhood arthritis)
Juvenile RA
List some common sites for avascular necrosis/ osteonecrosis
- epiphyses ( may remain clinically silent until articular collapse) - esp femoral head
- metaphases/diaphysis- usu completely asx
- conditions leading to Avas necrosis
What are some conditions that lead to avascular necrosis
- Legg-Calve-Perthes Disease: avasc necrosis of femoral head
- SONK = spontaneous osteonecrosis of the knee (collapse of articular surface)
- Keinboch’s Disease = avascular necrosis of the carpal lunate
- Osteochondritis Dissecans = in adolescence, small segment of subchondral bone undergoes ischemic necrosis secondary to trauma or primary vascular occlusion (most common in knee or ankle)
List 5 typical causes of avascular necrosis/ osteonecrosis
- Trauma
- Hemoglobinopathy
- Caisons disease (the Bends)
- Corticosteroids
- Collagen disease
- Radiation
- Alcoholism
- Gaucher’s disease
- Pancreatitis
- Gout
Which common arthritis demonstrates non-uniform joint space narrowing, osteophytes, subchondral sclerosis and subcentral cysts
Degenerative Joint Disease (most common joint disease)
(Also will see asymmetric distribution, joint subluxation, articular surface deformity, and intraarticular osteochondral bodies)
Which condition presents with a triangular sclerosis at the iliac portion of the lower sacroiliac joint?
Osteitis Condensans Ilii
Is osteitis condensans ilii more commonly unilateral or bilateral?
bilat
Is osteitis condensans ilii more commonly found in males or females?
females ( childbearing ge)
Osteitis pubis is commonly associated with which medical procedure?
Surgeries near the pubic symphysis
Osteitis pubis = inflammation of the pubic symphysis
- What is the difference between marginal and non-marginal syndesmophytes?
Syndesmophyte = osseous excrescence attached to a ligament
Non-marginal: don’t come from the corners
Marginal: ossification of outer annulus fibrosis leading to thick, vertical radiodense areas – connect adjacent vertebrae
Which spinal arthritides have marginal vs. non-marginal syndesmophytes?
Marginal: Ankylosing Spondylitis: bamboo spine, formed from extensive syndesmophwytes
Non-marginal: Psoriatic arthritis (at thoracolumbar jxn), Reiter’s syndrome syndesmophytes skip levels with these two conditions
What systemic condition is commonly found in patients with diffuse idiopathic skeletal hyperostosis?
Diabetes (up to 50% of pts with DISH)
Dysphagia is common in which arthritic condition and why?
DISH – dysphagia due to spinal involvement, tendenous and extraspinal ligamentous calcification and ossification creates stiffness and difficulty swallowing
What part of the spine is DISH most commonly found?
Thoracic, lower cervical, upper lumbar
List the radiographic findings of neurotrophic arthropathy.
6 D’s
Distended joint Density increase Debris Dislocation Disorganization Destruction
Which conditions may result in neurotrophic arthropathy?
- Diabetes
- Alcoholism
- Tabes dorsalis (complication of syphilis leading to muscle weakness/paresthesia)
- Paralysis
- Syringomyelia (damage to spinal cord dt formation of fluid-filled area within cord)
What is synoviochondrometaplasia?
Metaplastic changes in synovium produce cartilaginous bodies
These bodies may or may not ossify or calcify
They also may or may not be free within joint capsule
Name the common sites of involvement of rheumatoid arthritis in the hand
Hands: MCPs, PIPs (not DIPs)
• spindle digit (soft tissue swelling)
• marginal erosions (irregular with no sclerotic margin) especially of the 2nd and 3rd metacarpal head
Hand Deformities:
• Boutonniere – DIP extension, PIP flexion
• Swan neck – Dip flexion, PIP extension
• Ulnar deviation at MCP joint
• Radial deviation of carpals
• Zig-zag deformity – ulnar deviation and radial deviation
Name the common sites of involvement of rheumatoid arthritis in the wrist.
often occurs earlier and more severe than hand changes • ulnar styloid erosion • uniform loss of radiocarpal joint • erosions at triquetrum-pisiform • “spotty carpal” sign • pancarpal involvement • scapholunate dissociation
What is a marginal erosion and what category of arthritis is it seen with?
- Seen in rheumatoid arthritis, especially in the radial margins of the 2nd and 3rd MC heads
- Irregular erosion with no sclerotic margin
What is the significance of widening of the atlantodental interspace?
Seen in R.A.:
• can create direct compression of the brainstem or cause neurological damage by creating excessive kyphosis
• can create C1-C2 instability neurological damage, atlanto-axial subluxations
can get anterior-lysthesis if facet involvement: stair-stepping
Which conditions demonstrate laxity of the transverse ligament?
SLE, Down’s syndrome, possible with RA (but uncommon): The inflammatory arthridities tend to affect the tendons and ligaments rather than joint membranes
Is sacroiliac involvement common in rheumatoid arthritis?
No – if so, minimal sclerosis, unilateral or bilateral asymmetric
describe how psoriatic arthritis effects the hands
- DIPs and PIPs
- All three joints in a single digit involved = “ray pattern”
- Pencil-in-cup deformity (narrowing/tapering of middle bone like a pencil, with cup shaped distortion in end bone)
- Asymmetric
- Pseudowidening
- Osseous fusion
- Acro-osteolysis (see question 31)
How does Psoriatic arthritis effect the body in general
• Asymmetric • Soft tissue swelling • No osteopenia (unlike RA) • Erosions • Fluffy periostitis • Narrowed or widened jt spaces ankylosis
How for RA Fx the hands
- MCPs and PIPs (not DIPs)
- Soft tissue swelling (spindle digit)
- Marginal erosions (irregular with no sclerotic margins)
- Radial margins of 2nd and 3rd MC head eroded
- Boutonniere – DIP ext, PIP flex
- Swan neck – DIP flex, PIP ext
- Ulnar deviation at MCP
- Radial deviation of carpals
- “Zigzag” deformity: ulnar + radial deviation
How does RA affect the Wrist
• often earlier and more severe than hand changes • ulnar styloid erosion • uniform loss of radiocarpal joint • erosions at triquetrum-pisiform • “spotty carpal” sign • pancarpal involvement scapholunate dissociation
What is the incidence of RA
F:M 3:1 until 40, then 1:1
What is the first site of involvement with ankylosing spondylitis
- most classic finding
- bilateral, symmetric
- changes more prominent on iliac side and lower 2/3
- pseudowidening erosions (“rosary bead” appearance) reactive sclerosis ankylosis (average 14 years)
- approximately ½ ankylosis
- similar changes occur at pubic symphysis
What is the second site of involvement with ankylosing spondylitis
Spine – discovertebral joint (outer fibers of annulus erode sclerose ossify)
Also apophyseal joints, interspinous ligament ossification, costovertebral joints, cervical spine involved
Is SI invoement usually unilateral or bilateral in ankylosing spondylitis
bilateral
What isteh incidence of ankylosing spondylitis
younger males (15-35) M:F 9-1
Which condition demonstrates acquiring of the vertebral body?
ankylosing spondylitis
What is the shiny corner sign
increased radio density of vertebral body related to osteitis in (AS)
What is a carrot stick fracture?
A complication of ankylosing spondylitis, a fracture of an alkylosed segment of vertebrae, usually causing paralysis
Which condition demonstrates similar sacroiliac joint and vertebral column findings to ankylosing spondylitis?
Enteropathic arthropathy, secondary to ulcerative colitis, crohn’s dz, whipple’s dz, salmonella, shigella, Yersinia\
Which two seronegative spondyloarthropathies demonstrated non-marginal syndesmophwytes and peripheral arthritis
Psoriatic and Reiters
Non- marginal syndesmophytes= thicker, not throughout the spine like in AS
Reversible deformities of the hand are seen in which condition?
- Systemic Lupus Erythematous (SLE)
- ulnar deviation, but pt can overcome this with muscle contraction or pushing down on the table
- ligaments are lax, but joints are not destroyed
What is acro-osteolysis and which conditions demonstrates this finding?
resorption of the extremities (ie, distal phalanx “tufts”)
seen in scleroderma, psoriatic, SLE, hyperparathyroid
What is the overhanging margin sign and which condition is this seen in ?
Pathognomonic finding in Gout, a C-shaped erosion that sticks out
What structures are primarily involved in CPPD?
CPPD = Calcium pyrophosphate dihydrate crystal deposition dz)
- wrist, triangular fibrocartilage distal to ulnar styloid
- knee, meniscus
- pubic symphysis
- involves calcification of cartilage chondrocalcinosis in intermediate layer
- fibrous & hyaline cartilage
- fibrous in meniscus and triangle
- hyaline at end of bones: calcification parallel to cortex, thin, linear
• AKA pseudogout
• onset after 30, peaks at 60
• Dx’ed by aspiration of synovial fluid
What structures are primarily involved in HADD?
HADD = Hydroxyapatite deposition disease
Common at shoulder and hip
Usually a single site of involvement
Causes calcific tendinitis (bursae, ligament, capsule)
What is the most common source of osteoblastic metastatic carcinoma in adult females?
breast cancer
List the 3 common causes of solitary sclerotic vertebral body/ ivory vertebra
Hodgkin’s lymphoma (anterior scalloping)
Osteoblastic mets
Paget’s disease – cortical thickening and expansion
“hop”
Is it common to find a tumor involving a joint
nope
Is multiple myeloma more common in a vertebral body of neural arch?
vertebral body
What malignancy demonstrated as a cold bone scan
multiple myeloma
Which is the most dense (white on x-ray) primary malignant bone tumor?
Osteosarcoma (2nd most common primary malignant bone neoplasm
What is the common age range of primary osteosarcoma
10-25 years old
- in older pts, likely dt malignant degeneration of benign process
What is the difference between sunburst and onion skin appearance?
Sunburst – seen in hemangioma, lytic skull lesions with striations in a “sunburst” or “spoked wheel” pattern
Onion skin
- layered or laminated periosteal rxn created by several parallel concentric layers or lamellae of periosteal new bone
- implies a more aggressive process, but can be dt both benign and malignant conditions
- most characteristic of Ewing’s sarcoma but could be found in osteosarcoma, osteomyelitis, stress fxs, eosinophilic granulomas in very young pts
Which part of the long bone is commonly involved in osteosarcoma?
Metaphysis – especially in distal femur, proximal tibia and proximal humerus
What is codman’s triangle?
When the periosteum lifts off of the cortex, creating triangular layers that form at the margin of the lesion, often in osteosarcomas (also seen in osteomyelitis)
the triangle itself is usu tumor free
Why is Ewing’s sarcoma commonly found in the diaphysis of long bone?
Why is Ewing’s sarcoma commonly found in the diaphysis of long bone?
• What is a geographic lytic appearance and does it suggest more benign or aggressive neoplasms?
What are the other two lytic appearances of tumors?
- Geographic lytic appearance = confined to a relatively specific area that is more or less easily defined, more likely to be benign (see left)
- Moth eaten and
Permeative
Which condition presents as a solitary exostosis that points away from the nearest joint?
Osteochondroma
Compare the incidence of malignant transformation in osteochondroma and hereditary multiple exostosis.
Osteochondroma: malignant degeneration in 1% (solitary)
Hereditary Multiple Exostosis: 20% malignant degeneration
What is a “corduroy vertebra”?
Corduroy cloth appearance of vertebrae, seen in hemangioma due to lytic lesions with coarse vertical striations
Is spinal hemangioma commonly solitary or polyostotic?
Solitary
Which is the most common benign bone tumor of the spine?
hemangioma
hemangioma
- age 40 and up
- usually asx – can have pain or muscle spasm occasionally
- neurological compromise due to ballooning of vertebral body, extension of tumor into central canal, pathologic fx, hemorrhage
- 75% found in spine and skull
- usually in vertebral body, 10-15% into arch
- usually solitary
- body expansion is rare
bone island
AKA: Enostoma
- Usually asymptomatic
- Occurs in pelvis, sacrum, proximal femur, and any bone except skull
- compact lamellar bone in spongiosa
- can look like blastic mets on an xray
Which benign tumor classically demonstrates as pain worst at night and easily relieved by aspirin?
- pain refers to nearby joint
- usually in kids
- can cause painful, rigid scoliosis
- can occur in any bone (50% in femur and tibia, 20% phalanges, 10% spine)
- tends to be in cortex of bone
Which part of the bone is usually involved with osteoid osteoma?
cortex, will see increased opacity on X-ray, actual lesion is lucent ( but usu
What is the appearance of the tumor metric in enchondroma?
Cartilaginous lesion inside the cartilage • thinned cortex • endosteal scalloping • stippled calcification Asx, but can cause pathologic fx Age 10-30 Can happen in any bone with cartilage Most common tumor of phalanges Can potentially transform to chondrosarcoma (think pain – if no pain, likely benign)
what is multiple endochromatosis called
2 types:
- Ollier’s Disease
- usually unilateral, monomelic (may cause growth change, shortened limb)
- malignant transformation rate 25-50% - Maffucci’s syndrome
- soft tissue hemangioma
- phleboliths
- greater risk of malignant transformation than Ollier’s
What is the most common location of fibrous cortical defect?
In cortex of bone in lower extremity: tibia or fibula, also humerus, ribs, ilium
2-8 years old
What is a fallen fragment sign also with?
Simple bone cyst
What is a fallen fragment
piece of cortex falls off into cyst and sinks to bottom
Which benign bone tumor is named according to its appearance rather than its histological composition?
Aneurysmal Bone Cyst – cystic, blood filled cavity, “aneurysmal” dt appearance
Describe the radiographic difference between an enchondroma, simple bone cyst, aneurysmal bone cyst and osteochondroma.
see def
Endocondroma
- Geographic lytic
- Expansile
- Thinned cortex, endosteal scalloping
- Metaphyseal-diaphyseal
- Most central
- Calcification in 50%
- No periosteal rxn, no soft tissue mass
Simple bone cyst
- Ages 3-4
- Asx
- 2/3 undergo pathologic fx
- fluid-filled cyst
- 75% in proximal humerus or femur
- “fallen fragment” sign with fracture – piece of cortex falls into cyst and sinks to bottom of it
Aneurysmal bone cyst
• expansile • lytic, septated • eccentric • markedly thinned cortex • metaphyseal, may extend to epiphysis (only benign tumor to cross growth plate) periosteal response more common
Osteochondroma
• bony exostosis: cortex continuous with host bone; normal trabeculae
• cartilaginous cap may calcify
• project away from joint
• sessile produces asymmetric widening
• Is giant cell tumor painful? Is it malignant?
Painful
“quasimalignant” – 20% malignant, 80% benign
Is page’s disease monostotic or polyostotic
polyostotic ( Rt side more common than LF)
List the radiographic features of Paget’s disease in a long bone such as the femur or tibia.
In Long bones – thickened cortex, bowing deformities (saber shin = shin that looks like a curved sword), shephard’s crook deformity = thickening of cortex plus bowing, blade of grass (candle flame or V-shape) – looks like cut piece of grass or tip of flame (lytic appearance)
Radiographic findings in skull- pagets
• osteoporosis circumscripta (circumscribed, outlined lytic area ), cotton wool appearance (spots all over skull)
Radiographic findings in jaw, spine, pubic bone- pagets
- increased size
- Ivory vertebrae, picture frame vertebra ( thickened cortex)
- unilateral “brim sign”- thicker on one side than the other
Pagets Dz in general - radiographic sx
- increased or decreased bone density
- coarsened less distinct, trabeculae
- thickened cortex (less distinct)
- bone expansion
- subarticular extension
- pseudofractures (similar to insufficiency stress fx)
- deformities (like bowing)
- pathologic fx (mild trauma cuases bone to break)
Pagets dz general info
- rare before age 40, usually over 55
- mostly asx, found incidentally on xray of low back
- most common sx: dull, boring pain
- temperature of involved area may increase
- see enlargement of bone – causes mass effect on surrounding structures
- can have heart problems bc vascular lesions – cause heart to work harder
