DI II Final Flashcards
List the three presentations/types of osteoporosis.
Generalized – age related, post-menopausal, steroid induced, heparin induced, multiple myeloma, metastasis, hyperparathyroidism, scurvy, osteomalacia, rickets, sickle cell, osteogenesis imperfecta
Regional – disuse/immobilization, RSD
Localized – infection, inflammatory arthritis, neoplasm
What is the most common cause of generalized osteoporosis?
Old age - post-menopausal
What is the standard modality to quantify bone mineral density?
Dual Energy Xray Absorptiometry (DXA)
What causes rickets?
Systemic skeletal disorder due to deficiency in Vit D from:
- lack of dietary intake
- lack of natural light exposure
- renal osteodystophy (renal rickets) - chronic kidney dz
- renal tubular defect - failure to resorb phosphate
What causes osteomalacia?
Lack of osteoid mineralization leading to generalized bone softening
What causes rickets? What are the classic radiographic features?
Generalized osteopenia due to primary vit D deficiency
Coarse trabecular changes Widened growth plates Rachitic (costal) rosary Absent zone of provisional calcification Frayed 'paintbrush' and cupped metaphyses
What causes scurvy?
AKA “Barlow’s Disease”
Caused by Vit C deficiency
depresses intrercellular substance formation, especially in CT, cartilage, and bone
What are the classic radiographic features of scurvy?
Combination of abnormalities occuring at the growing ends of long bones
- osteoporosis
- dense zones of provisional - calcification (white line of frankel)
- Ring epiphysis (Wimberger’s sign)
- Pelken’s spurs
- Scorbutic zone (trummerfeld zone)
- Superperiosteal hemorrhage
What are the classic radiographic features of hyperparathyroidism in the spine, skull, and hand?
Spin - osteopenia, trabecular accentuation, end plate concavities, ‘rugger jersey’ spine, widened SIJs
Skull - ‘salt and pepper’ resorption of lamina dura
Hand - subperiosteal resorption, radial margins of the proximal and middle phalanges of the 2nd/3rd digits with acroosteolyisis
What are the face, skull, and foot changes seen with acromegaly?
Face - prominent forehead, thickened tongue
Skull - sella tursica enlargement (pituitary neoplasm), sinus overgrowth, malocclusion, widened mandibular angle
Hand - widened shafts, bony protuberances, enlarged distal tufts (‘spade-like’) and widened joint spaces (cartilage overgrowth), widened heal pad
What osseous changed might long term corticosteroid use cause?
Osteonecrosis (avascular necrosis) - rapid bone turnover
“H” shaped vertebra is classical 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 anemia?
Bone changes are due to marrow hyperplasia, ischemia, and necrosis
- generalized osteoporisis
- thin cortices
- coarse trabeculae
- large vascular channels
- widened medullary cavity
- growth deformities
- epiphyseal ischemic necrosis
- medullary infarcts
- secondary salmonella 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 (enlarged epiphysis, widened intercondylar notch, and scquared inferior patella)
Ankle (tibiotalar slant deformity)
Elbow
Also, Pseudotumors – destructive intraosseous hemorrhages – most commonly occur in femur and pelvis
What is a common DDX when encountering hemophilic arthropathy of the knee?
childhood RA
List some common sites for AVN/osteonecrosis?
Femoral head (leff-calve-perthes) Knee (SONK) Carpal lunate (Keinboch's)
List 5 typical causes of AVN/osteonecrosis?
Trauma Hemoglobinopathy Caison's disease Corticosteroid use Radiation Collagen disease Alcoholism Gaucher's disease Pancreatitis Gout
Which arthritis demonstrates non-uniform joint space narrowing, osteophytes, subchondral sclerosism and subchondral cysts?
DJD - osteoarthritis
Which condition presents with a triangular sclerosis at the iliac portion of the lower SIJ?
Osteitis condensans ilii
- predominantly women of childbearing age
Is osteitis condensans ilii more commonly unilateral or bilateral?
Bilateral
IS osteitis condensans ilii more common in males or females?
Females (childbearing age)
Osteitis pubis is commonly associated with which medical procedure?
surgery near pubic symphysis
What is the difference between marginal and non-marginal syndesmophytes?
Marginal syndesmophytes (intervertebral bony bony bridges) are delicate and symmetric, more commonly seen in ankylosing spondylitis.
Non-marginal syndesmophytes are bulky and discontinuous, more commonly in reactive arthritis and DISH.
Which spinal arthritides have marginal vs. non-marginal syndesmophytes?
Marginal – (thin) ankylosing spondylitis
Non-marginal – (coarse) psoriatic/reactive arthritis, Reiter’s syndrome
What systemic condition is commonly found in patients with diffuse idiopathic skeletal hyperostosis?
Diabetes
Dysphagia is common in which arthritis condition? Why?
Diffuse idiopathic skeletal hyperosteosis (DISH)
Decreased lordosis and increased kyphosis
What part of the spine is DISH most commonly found?
Thoracisc spine, lower cervical, upper lumbar, superior SIJ
List the radiographic findings of neurotrophic arthropathy.
6 "D"s Distended joint Density increased Debris Dislocation Disorganization Destruction
Which conditions may result in neurotrophic arthropathy?
diabetes alcoolism tabes dorsalis paralysis syringomyelia
What is synoviochondrometaplasia?
aka synovial chondromatosis or osteochrondromatosis
metaplastic changes in synovium produce cartilaginous bodies that may or may not calcify/ossify and may or may not be free within joint capsule
Name the common sites of involvement of RA in the hand and wrist.
HAND Boutonniere - DIP extension/PIP flexion Swan neck - DIP flexion/PIP extension Ulnar deviation at MCP joint Radial deviation of carpals 'Zig-Zag' deformity (ulnar/radial deviation)
WRIST earlier and more severe than hand changes ulnar styloid erosion uniform loss of radiocarpal joint erosion of triquetrum/pisiform 'spotty carpal' sign pancarpal involvement scaphoid/lunate dislocation
What is a marginal erosion and what category of arthritis is it seen with?
Irregular erosion with no sclerotic margin
Associated with RA
What is the significance of widening of the atlantodental interspace?
May create direct compression of the brainstem or cause neuro damage by excessive kyphosis
C1-C2 instability
Ligament may widen and rupture with inflammatory arthropathisees like RA, psoriatic arthritis, reiter’s syndrome, and ankylosing spondylitis
Which conditions demonstrate laxity of the transverse ligament?
SLE, Downs syndrome, possibly RA (uncommon)
Is SI involvement common in RA?
No
Describe radiographic differences between RA and psoriatic arthritis in the hand and wrist
Psoriatic – ray pattern – involvement of all 3 joints of a single digit (MCP, PIP, and DIP)
RA – just MCPs and PIPs (no DIPs)
What is the gender incidence of RA?
F:M 3:1 until age 40, then 1:1
What is the first site of involvement of ankylosing spondylitists?
SI joint or thoracolumbar
What is the second site of involvement with ankylosing spondylitis?
Spine - discovertebral joint erodes, sclerosis, and ossifies
Also apophyseal joints, interspinous ligamentsossification, costovertebral joints, and c-spine
Is SI involvement in ankylosing spondylitis usually unilateral or bilateral?
Bilateral
What is gender incidence of ankylosing spondylitis?
M:F - 9:1
Usually onset at 15-35yrs
Which condition demonstrates squaring of the vertebral body?
Ankylosing spondylitis
What is the shiny corner sign?
Seen in ankylosing spondylitis
Erosion of outer fibers of annulus and ossification of vertebral body edge
What is a carrot stick fracture?
Complication of ankylosing spondylitis
fracture of an alkylosed segment often causing paralysis
Which condition demonstrates similar SIJ and vertebral findings to AS?
Enteropathic arthropathy – secondary to UC, crohn’s, whipples, salmonella, shigella, Yersinia
Which 2 seronegative spondyloarthropathies demonstrate non-marginal syndesmophytes and peripheral arthritis?
Psoriatic and Reiter’s
Reversible deformities of the hand are seen in which condition?
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 demonstrate this finding?
Reabsorption of extremities
Seen in scleroderma, psoriatic arthritis, and SLE, and hyperparathyroid
What is the overhanging margin sign and which condition is this seen in?
C-shaped erosion
Seen in Gout
What structures are primarily involved in CPPD?
Knee - Most common site for radiographic and clinical findings, Suspect with isolated patellofemoral or tricompartmental involvement
Wrist - triangular fibrocartilagae distal to ulnar styloid - Arthropathy at radiocarpal joint, Scapholunate dissociation, SLAC wrist
Pubic symphysis
What structures are primarily involved in HADD?
Shoulder and hip
Usually single site of involvement
Causes calcific tendinitis
What is the most common source of osteoblastic metastatic carcinoma in adult females?
Breast (prostate, lung, kidney)
List the three common causes of solitary sclerotic vertebral body/ivory vertebra.
IHOP
Hodgkin’s lymphoma
Paget’s disease
Is it common to find a tumor involving a joint?
No
Is multiple myeloma more common in vertebral body or neural arch?
Vertebral body
What malignancy demonstrates a cold bone scan?
Multiple myeloma
Which is the most dense primary malignant bone tumor?
Osteosarcoma (2nd most common bone neoplasm)
What is the common age range of primary osteosarcoma?
10-25 yrs
in older pts, likely due to malignant degeneration of benign tumor
What is the difference between sunburst and onion skin appearance?
Sunburst – lytic lesion of hemangioma in brain
Onion skin – layered or laminated periosteal reaction created by several parallel concentric layers or lamellae of periosteal new bone – implies aggressive process
seen in Ewings and osteosarcoma
Which part of the long bone is commonly involved in osteosarcoma?
Metaphysis
What is codman’s triangle?
Triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone- seen with osteosarcomas
Why is Ewing’s sarcoma commonly found in the diaphysis of long bone?
It’s a marrow cell tumor – “round cell”
What is a geographic lytic appearance and does it suggest more benign or aggressive neoplasms?
Geographic = Well defined margin; non-aggressive lesion
What are the other two lytic appearances of tumors?
Geographic
Motheaten
Permeativ
Which condition presents as a solitary exostosis that points away from the nearest joint?
Osteochondroma – most common benign bone tumor, usually asx but could impinge on things
Compared the incidence of malignant transformation in osteochondroma and hereditary multiple exostosis.
Osteochondroma – malignant in 1%
Hereditary multiple exostosis – malignant in 20%
What is a “corduroy vertebra”?
Lytic lesion with coarse vertical striations – seen in hemangioma
Is spinal hemangioma commonly solitary or polyostotic?
Solitary
Which is the most common benign bone tumor of the spine?
Hemangioma – mostly seen after age 40, mainly asx
Is a bone island symptomatic?
No – cortical bone inside where medullary bone should be – does not happen in skull
Which benign tumor classically demonstrates as pain worst at night and easily relieved by aspirin?
Osteoid osteoma
Which part of the bone is usually involved with osteoid osteoma?
Cortical bone - usually proximal femur
What is the appearance of the tumor matrix in enchondroma?
- second most common benign tumor, most common in hands and feet Geographic lytic Expansile Thinned cortex, endosteal scalloping Metaphyseal-diaphyseal Most central Calcification in 50% No periosteal reaction; no soft tissue mass - look like chondrosarcoma, but painless
What is multiple enchondromatosis called?
Ollier’s disease – higher chance of malignancy
What is the most common location of fibrous cortical defect?
lower extremity (90% in tibia or fibula) and humerus; ribs, ilium
What is a fallen fragment sign associated with?
Simple bone cyst – sign seen with fracture – associated with pathological fractures
- piece of cortex breaks off
Which benign bone tumor is named according to its appearance rather than its histological composition?
Aneurysmal bone cyst – young age, painful, look aggressive but benign – most common posterior arch
Described the radiographic difference between an enchondroma, simple bone cyst, aneurysmal bone cyst and osteochondroma.
Enchondroma • Geographic lytic • Expansile • Thinned cortex, endosteal scalloping • Metaphyseal-diaphyseal • Most central • Calcification in 50% • No periosteal reaction; no soft tissue mass
Simple bone cyst
• Geographic; lytic; maybe loculated
• Broad based at physis, narrows toward diaphysis
• Bone expansion, but not beyond physis diameter
• “Fallen fragment” sign with fracture
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?
Intermittent aching pain, usually around knee
“quasimalignant” – 20%
- Is Paget’s disease monostotic or polyostotic?
Usually polyostotic
Most commonly seen in older pts, >55
- List the radiographic features of Paget’s disease in a long bone such as the femur or tibia.
Blade of grass or candle flame appearance – V lesion
Thickened bones
