DI 2 FINAL (Arthritides)

Question 1

Which common arthritis demonstrates non-uniform joint space narrowing, osteophytes, subchondral sclerosis and subchondral cysts?

Answer 1

Degenerative Joint Disease (most common joint disease)
(Also will see asymmetric distribution, joint subluxation, articular surface deformity, and intraarticular osteochondral bodies)

Question 2

Which condition presents with a triangular sclerosis at the iliac portion of the lower sacroiliac joint?

Answer 2

Osteitis Condensans Ilii

Question 3

Is osteitis condensans ilii more commonly unilateral or bilateral?

Answer 3

Bilateral

Question 4

Is osteitis condensans ilii more commonly found in males or females?

Answer 4

Females Child bearing age

Question 5

Osteitis pubis is commonly associated with which medical procedure?

Answer 5

Surgeries near the pubic symphysis

Osteitis pubis = inflammation of the pubic symphysis

Question 6

What is the difference between marginal and non-marginal syndesmophytes?

Answer 6

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

Question 7

Marginal syndesmophytes seen in ankylosing spondylitisWhich spinal arthritides have marginal vs. non-marginal syndesmophytes?

Answer 7

Marginal: Ankylosing Spondylitis: bamboo spine, formed from extensive syndesmophytes

Non-marginal: Psoriatic arthritis (at thoracolumbar jxn), Reiter’s syndrome  syndesmophytes skip levels with these two conditions

Question 8

What systemic condition is commonly found in patients with (DISH) Diffuse idiopathic skeletal hyperostosis?

Answer 8

Diabetes (up to 50% of pts with DISH)

Question 9

Dysphagia is common in which arthritic condition and why?

Answer 9

DISH – dysphagia due to spinal involvement, tendenous and extraspinal ligamentous calcification and ossification creates stiffness and difficulty swallowing

Question 10

What part of the spine is DISH most commonly found?

Answer 10

Thoracic, lower cervical, upper lumbar

Question 11

List the radiographic findings of neurotrophic arthropathy.

6D’s

Answer 11

Distended joint
Density increase
Debris
Dislocation
Disorganization
Destruction

Question 12

Which conditions may result in neurotrophic arthropathy?

Answer 12

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)

Question 13

What is synoviochondrometaplasia?

Answer 13

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 

Question 14

Name the common sites of involvement of rheumatoid arthritis in the hand and wrist.

Answer 14

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

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

Question 15

What is a marginal erosion and what category of arthritis is it seen with?

Answer 15

Seen in rheumatoid arthritis, especially in the radial margins of the 2nd and 3rd MC heads
Progressive marginal erosions

Irregular
Progressive marginal erosions erosion with no sclerotic margin

Question 16

What is the significance of widening of the atlantodental interspace?
Seen in R.A.:

Answer 16

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

Question 17

Which conditions demonstrate laxity of the transverse ligament?

Answer 17

SLE, Down’s syndrome, possible with RA (but uncommon): The inflammatory arthridities tend to affect the tendons and ligaments rather than joint membranes

Question 18

Is sacroiliac involvement common in rheumatoid arthritis?

Answer 18

No – if so, minimal sclerosis, unilateral or bilateral asymmetric

Question 19

Describe the radiographic difference between rheumatoid arthritis and psoriatic arthritis in the hand & wrist.

*Psoriatic Arthritis

Answer 19

Psoriatic Arthritis
HAND:
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)

IN GENERAL:
Asymmetric
Soft tissue swelling
No osteopenia (unlike RA)
Erosions
Fluffy periostitis
Narrowed or widened jt spaces
ankylosis

Question 20

Describe the radiographic difference between rheumatoid arthritis and psoriatic arthritis in the hand & wrist.

*rheumatoid arthritis

Answer 20

Rheumatoid Arthritis
HAND:
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
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

Question 21

What is the gender incidence of rheumatoid arthritis?

Answer 21

F:M 3:1 until age 40, then 1:1

Question 22

What is the first site of involvement with ankylosing spondylitis?

Answer 22

SI joint or thoracolumbar ->
-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

Question 23

What is the second site of involvement with ankylosing spondylitis?

Answer 23

Spine – disco vertebral joint (outer fibers of annulus erode->  sclerose->  ossify)
Also apophyseal joints, interspinous ligament ossification, costovertebral joints, cervical spine involved

Question 24

Is sacroiliac involvement usually unilateral or bilateral in ankylosing spondylitis?

Answer 24

bilateral

Question 25

What is the gender incidence of ankylosing spondylitis?

Answer 25

Younger males (15-35 years): M:F 9:1

Question 26

Which condition demonstrates squaring of the vertebral body?

Answer 26

Ankylosing spondylitis

Question 27

What is the shiny corner sign?

Answer 27

Increased radiodensity of vertebral body related to osteitis (in AS)

Question 28

What is a “carrot stick” fracture?

Answer 28

A complication of ankylosing spondylitis, a fracture of an alkylosed segment of vertebrae, usually causing paralysis 

Question 29

Which condition demonstrates similar sacroiliac joint and vertebral column findings to ankylosing spondylitis?

Answer 29

Enteropathic arthropathy, secondary to ulcerative colitis, crohn’s dz, whipple’s dz, salmonella, shigella, Yersinia

Question 30

Which two seronegative spondyloarthropathies demonstrate non-marginal syndesmophytes and peripheral arthritis?

Answer 30

Psoriatic and Reiters

Non-marginal syndesmophytes = thicker, not throughout the spine like in AS

Question 31

Reversible deformities of the hand are seen in which condition?

Answer 31

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

Question 32

What is acro-osteolysis and which conditions demonstrates this finding?

Answer 32

 resorption of the extremities (ie, distal phalanx “tufts”)

seen in scleroderma, psoriatic, SLE, hyperparathyroid

Question 33

What is the overhanging margin sign and which condition is this seen in?

Answer 33

Pathognomonic finding in Gout, a C-shaped erosion that sticks out 

Question 34

What structures are primarily involved in CPPD?

Answer 34

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

Question 35

What structures are primarily involved in HADD?

Answer 35

HADD = Hydroxyapatite deposition disease
Common at shoulder and hip
Usually a single site of involvement
Causes calcific tendinitis (bursae, ligament, capsule)