Exam 2: [Diseases, Deformities & Signs] Flashcards
1
Q
DJD is generally characterized by:
A
1) bone proliferation
2) asymmetrical non-uniform joint space loss
3) locations of weight bearing/high use
2
Q
Hip DJD: Radiographic Features
A
1) non-uniform joint space loss
2) Circumferential (collar) Osteophytes
3) Cortical buttressing
4) Subchondral Cysts & Subchondral Sclerosis
5) Superior migration of femoral head
6) Intra-articular loose bodies
3
Q
Advanced Hip DJD can lead to
A
Malum Coxae Senilis
4
Q
Knee DJD: Radiographic Features
A
1) Joint space loss (M -> L -> patellofemoral)
2) Patellofemoral involvement
3) Loose bodies (joint mice)
5
Q
Patellofemoral involvement in Knee DJD…
A
Without substantial findings in other compartments should raise suspicion of Pyrophosphate (CPPD) arthropathy
6
Q
Ankle DJD: Occurs…
A
Secondary too trauma, occupational or activity stressors
7
Q
Ankle DJD: Calcaneal Enthesophytes
A
Are unrelated to joint degeneration (even though frequently present)
8
Q
Foot DJD: MC Location
A
1st MCP Joint
9
Q
Foot DJD is associated w/
A
Bunion Formation
10
Q
What is a Bunion?
A
Hyperostosis on medial aspect of 1st metatarsal head
11
Q
Shoulder DJD: MC vs. Uncommon Sites
A
MC: AC Joint
Uncommon: GH Joint
12
Q
GH Joint DJD
A
Should consider Pyrophosphate (CPPD) arthropathy in a sense of:
1) trauma
2) altered biomechanics (rot cuff tendinopathy)
13
Q
Elbow DJD: Occurs…
A
Secondary to trauma, occupational or activity based stressors
14
Q
Elbow DJD: Features
A
- Loose Bodies (joint mice)
- Triceps Enthesophyte may accompany
15
Q
Wrist DJD: Areas Affected
A
- 1st Carpometacarpal Joint (trapezium/metacarpal)
- Trapezium/Scaphoid Joint
- Radiocarpal Joint
16
Q
Wrist DJD: Occurs…
A
Secondary to trauma, occupational or activity based stressors OR altered biomechanics
17
Q
Altered biomechanics preceding Wrist DJD:
A
- Carpal instability syndromes
- Ulnar variance
18
Q
Hand DJD: MC Location
A
Interphalangela joints (DIPs & PIPs)
19
Q
Hand DJD: Occurs…
A
Secondary to trauma, occupational or activity based stressors
20
Q
Hand DJD: Clinical Feature***
A
Heberden (DIPs) & Bouchard (PIPs) Nodes
21
Q
DISH: a.k.a.
A
Forestier’s Disease
22
Q
DISH: Features***
A
- Spondylosis Hyperostotica
- Spondylitis Ossificans Ligamentosa
- (Senile) ankylosing Hyperostosis of the spine
- Juxta-Articular ossification of vertebral ligaments
23
Q
DISH: What is it?
A
Skeletal disorder characterized by ligamentous calcification & ossification
24
Q
DISH: most prominent location
A
In the Spine involving the Anterior Longitudinal Ligament (ALL)
25
DISH: Population Affected
Males slightly > Females
> 50 years old
26
DISH: Signs & Symptoms
1) Asymptomatic
2) Loss of Lordosis/Increased Kyphosis
3) Pain & Stiffness
4) Dysphagia
5) Joint Pain
6) Tendon Pain
7) Synovitis
27
DISH & Diabetes
Adult-Onset Diabetes seen in 13-32% of people with DISH
HLA-B8 positive = 40%
28
DISH diff Dx from IVOC Includes:
- preservation of disc height
- absence of DDD signs (vacuum phenomenon & vertebral body marginal sclerosis)
29
DISH diff Dx from AS Includes:
- Absence of facet joint ankylosis
- SI Joint erosion, sclerosis or intra-articular osseous fusion
30
Strict Dx Criteria for DISH:
1) anterolateral ossification in 4 cont. vertebra
2) relative preservation of disc height
3) absence of facet joint ankylosis
31
DISH: MC site
On the right in T Spine (T7-T11)
32
DISH: Additional Features
1) bumpy ant. Spinal contour
2) discal extensions
3) vertical shadow between ossified ligament & vertebral body
33
DISH: MC other Skeletal Sites
Pelvis
Patella
Calcaneus
Foot
Elbow
34
DISH is associated w/…
OPLL
35
OPLL: a.k.a.
Japanese Disease
36
OPLL: MC Location
C2-C4 (cervical spine)
37
OPLL: Signs
May have neuro or Myelopathy signs
38
Signs of Myelopathy in OPLL
[Insidious motor & sensory disturbances]
- Heavy legs
- inability to walk at a brisk pace
- deterioration of fine motor skills
- (I) shooting pains in arms/legs
[Pathological Reflex Findings]
39
OPLL: Radiographic features
- Dense, linear radiopaque strip 1-5mm thick
- parallel to vertebral body margins
- radiolucent zone between ligament & vertebral body may be seen
40
Ossification of _________ in OPLL Patients
Ligamenta Flava (7%)
41
Synovial Chondromatosis (SCM/SOC): What is it?
Meta plasma of synovial tissue into cartilage nodules that may calcify or ossify
42
Synovial Chondromatosis (SCM/SOC): Populations affected
20-50 year olds
Male 3:1
(Precipitated by trauma)
43
Synovial Chondromatosis (SCM/SOC): Clinical Presentation
- Insidious onset of pain
- Pain increase over time
- swelling
- Crepitus
- Joint locking
44
Synovial Chondromatosis (SCM/SOC): MC Locations
70% Knee
20% Hip
Elbow
Ankle
Shoulder
Wrist
45
Primary Synovial Chondromatosis (SCM/SOC): Cause
[Idiopathic]
- Spontaneous
- Maybe Microtrauma??
46
Secondary Synovial Chondromatosis (SCM/SOC): Cause
1) DJD
2) Neuropathic Joint Disease
3) Osteochondritis Dessicans
4) Osteochondral Fractures
5) Joint Dislocations
47
Synovial Chondromatosis (SCM/SOC): Pressure
Extrinsic pressure may cause bone erosions
48
Synovial Chondromatosis (SCM/SOC): Deformity
Apple Core deformity (femoral neck)
49
Diff Dx for Synovial Chondromatosis (SCM/SOC):
Pigmented Villonodular Synovitis
50
What is Pigmented Villonodular Synovitis?
[Mass-like synovial proliferation]
- can cause pressure erosions
[No loose body calcification/ossification]
51
Synovial Chondromatosis (SCM/SOC): Referral
Orthopedic
52
Synovial Chondromatosis (SCM/SOC): Further Imaging
MRI (to determine extent of loose body formation)
53
Synovial Chondromatosis (SCM/SOC): Contraindication to Adjust?
Absolute
54
What is Neuropathic Arthropathy?
Destructive Articular disease occurring secondary to a loss of joint proprioception & loss of pain sensation
55
What happens to the involved joint in Neuropathic Arthropathy
undergoes premature and excessive traumatic degeneration that leads to severe destruction and instability
56
Neuropathic Arthropathy: a.k.a.
Charcot Joint
57
Neuropathic Arthropathy: Secondary conditions
[may cause neurological deficits]
1) MC: Diabetes 35% (lower extremities)
2) Syringomyelia 25% (upper extremities)
3) Tabes Dorsalis 20% (L spine & lower ext.)
58
Causes of Neuropathic Arthropathy (9)
1) DM ( alcoholism)
2) Syringomyelia (uremia)
3) Tabes Dorsalis (amyloidosis)
4) spinal cord tumors (steroid injections)
5) meningomyelocele (pernicious anemia)
6) spinal cord compression (congenital insensitivity to pain)
7) peripheral nerve tumors (familial dysautonomia)
8) MS (hereditary neuropathy)
9) poliomyelitis (leprosy)
59
French Theory for Pathogenesis of Neuropathic Arthropathy
Joint changes are result of CNS trophic centers damage which control nutrition of bones & joints (vasomotor dysregulation)
60
German Theory for Pathogenesis of Neuropathic Arthropathy
Joint changes are cumulative effects of multiple unprotected mechanical micro traumatic events
61
What leads to disintegration in Neuropathic Arthropathy
Loss of Normal Neurological Function rendering a joint susceptible to pathological alterations
62
Six “D’s” of Hypertrophic Pattern in Neuropathic Arthropathy
Distended Joints
Dislocation
Disorganization
Density Increases
Debris Production
Destruction
63
Characteristics of Atrophic Neuropathic Arthropathy
- Lack’s the D’s
- Reabsorbed articular surface
- Tapered bone ends (licked candy stick)
64
Diff Dx & Treatment for Neuropathic Arthropathy
[Infection vs. aggressive neoplasm]
- immobilization/casting may slow healing
- managing underlying condition is crucial
65
Clinical presentation of Neuropathic Arthropathy
- Painless swelling
- deformity
- weakness
- instability
- crepitus
- “bag of bones”
66
What is Erosive Osteoarthritis (EOA)?
- Inflammatory variant of osteoarthropathy (DJD)
- Possible familial tendency
67
Clinical features of Erosive Osteoarthritis (EOA)
- Middle-aged Females (30s-40s)
- Pain, swelling & redness of joints
- chronic disease progression
68
Radiographic features of Erosive Osteoarthritis (EOA)
DJD changes w, osseous erosions, periostitis and ankylosis
(Spares ulnar aspect of the wrist)
69
Located MCly affected by Erosive Osteoarthritis (EOA)
1) DIPs & PIPs
2) MCPs & 1st carpometacarpal joint
70
Sign seen in Erosive Osteoarthritis (EOA)
Gull-Wing
71
Erosive Osteoarthritis (EOA): Referral
Rheumatology for NSAIDS & Physical Therapy
72
Target tissue in RA
Synovium
73
RA is the result of…
Abnormal cellular immune response to antigen in synovial membrane
74
RA immune response leads to..
Erosive Pannus
75
RA: Lab Analysis
RF: not sensitive or specific for RA
(Not a requirement)
Anti-CCP (cyclic citrullinated peptide) antibody
ACCP: not sensitive for RA
ACCP: SPECIFIC for RA
76
Diagnosis of RA
Established by the constellation of findings observed over a period of time
(NOT BY LABS OR IMAGING FINDINGS)
77
RA: Population Affected
Females 3:1 before 40 years old
20-60 year olds
78
JIA: Onset
Before 16 years old
79
RA: Onset
- Insidious
- may follow physical/emotional stress
80
RA: Symptoms
- Joint pain (tenderness, swelling, stiffness)
- Fusiform ST swelling
- Stiffness in the morning lasting > 2 hrs
81
MC Articular symptoms in RA
Begin in proximal interphalangeal joints & MCPs -> progress proximal
82
Clinical features of RA
Fatigue
Malaise
Generalized Muscle Weakness
Fever
Sjogren Syndrome: Xerostomia, Xerophthalamia, Xeroderma
(Dry mouth, dry eyes, dry skin)
Haygarth Nodes
Carpal Tunnel Syndroem
83
Xerophthalmia (dry eyes) condition seen in RA
Keratoconjunctivitis Sicca
84
RA Radiographic Features
- Bilateral & Symmetrical
- Periarticular Swelling
- Uniform Loss of Joint Space
- Marginal Erosions
- Juxta-Articular Osteopenia
- Large Pseudocysts
85
What is typically the 1st radiographic sign of RA?
Periarticular swelling
86
Deformities Seen in RA
Boutonnière Deformity
Hitchhiker Thumb
87
What is Boutenierre deformity?
Extension @ DIP, Flexion @ PIP
88
What is Hitchhiker Thumb?
Boutonnière of the thumb
Flexion of MCP, Extension of IP
89
RA: Target site of the wrist
Ulnar Styloid process
90
How much time before radiographic manifestations occur in RA?
3-6 months from onset
91
MC Location of Marginal Erosions in Hand RA
Radial aspect of 2nd & 3rd metacarpal heads and radial margins of proximal phalanges ends
92
Deformity in Foot RA
Lanois Deformity
93
X-Rays of RA Patients must include:
Standard series with Flexion View
94
Cervical Spine RA is associated w/
Pseudo-Basilar Invagination
95
Ligamentous Instability in Cervical Spine RA
- Atlantoaxial joint from destruction of transverse ligament
- widened ADI
96
MC alignment changes in Cervical Spine RA
C2-C4 Anterior Translation
97
Cervical Spine RA Lateral Cervical Appearance
Stepladder/Doorstep Appearance (multiple anterolisthesis)
98
Endplate erosions in Cervical Spine RA are MCly where?
Posterior 2/3rds of endplate
99
Consequences of Cervical Spine RA
- Osteopenia w/ 5+ yrs of corticosteroid use
- compression fractures
- “sharpened pencil” spinous processes
100
Hip RA: Features
- Axial migration
- Protrusio Acetabuli
- Erosions, Pseudocysts, Osteoporosis, ostenecrosis
101
RA is the MC cause of…
Bilateral Protusio Acetabuli
102
Elbow RA: Radiographic features
-Posterior Fat Pad in the absence of trauma should suspect RA or Infection
103
Heart RA
- Cardiomegaly
- Pericarditis
104
Lung RA
- Nodular Densities
- Diffuse basilar interstitial pattern
105
RA + Pneumoconiosis =
Caplan Syndrome
106
RA + leukopenia and splenomegaly =
Felty Syndrome
107
RA: Referral
Rheumatology
108
RA: Treatment
- DMARDs: anti-rheumatic drug
- MC: Mathotrexate
- Anti-inflammatory Diet
- PACE exercise
109
Juvenile Idiopathic Arthritis (JIA): Clinical Features
- Females
- Peak @ 2-5 and 9-12 years old
- Fever, Rash, Lymphadenopathy, Iridocyclitis, Hypoplastic Mandible
110
Juvenile Idiopathic Arthritis (JIA): Target Sites
- C Spine
- Hands/Wrists
- Feet
- Knees
- Hips
111
Juvenile Idiopathic Arthritis (JIA): Referral, Labs to run, Contraindication?
Rheumatology
CBC w/ differential & arthritis panel
Contraindication of involved joints
112
What does “Seronegative Spondyloarthropathies” Mean?
“Seronegative”: rheumatoid factor negative
“Spondyloarthropathies”: affect joints, especially the spine
113
Seronegative Spondyloarthropathies:
[PEAR]
1) Psoriatic Arthritis
2) Enteropathic Arthritis
3) Ankylosing Spondylitis
4) Reactive Arthritis
114
Ankylosing Spondylitis (AS): what is it?
Chronic INFLAMMATORY disorder of unknown cause
115
Ankylosing Spondylitis (AS): a.k.a.
Marie-Strumpell’s disease
116
Ankylosing Spondylitis (AS): Pathogenesis***
- Inflammatory
- Autoimmune
- HLA-B27 (90% test +)
117
Ankylosing Spondylitis (AS): Target Sites
[Sharpey’s Fibers]
118
Ankylosing Spondylitis (AS): Pathological Features in Synovial Joints
Synovial Joint proliferation -> Pannus -> Subchondral Bone Erosions -> Cartilage & Bone transformation -> osseous ankylosis
119
Ankylosing Spondylitis (AS): Pathological Features in Fibrous Joints
Subchondral bone inflammation & granulation -> erosions -> fibrous ossification -> bony ankylosis
120
Ankylosing Spondylitis (AS): Pathological Features in Entheses Joints
Erosive changes @ bone-ligament junction (Sharpey’s fibers) -> repair by bony deposition -> bony spicules (spur-like)
121
Ankylosing Spondylitis (AS): Population Affected
15-35 years old
Males
White (4) to Black (1)
122
When to consider Ankylosing Spondylitis (AS)
- insidious back pain & stiffness
- younger than 40
- symptoms for > 3 months
- increased symptoms in morning/inactivity
- improvement w/ exercise
- presence of iritis
123
Ankylosing Spondylitis (AS): Symptoms
Local pain/tenderness of SI Joints
Sciatica Pain
124
Ankylosing Spondylitis (AS): Extraskeletal Features
- Unilateral Iritis
- Heart & Lung changes
125
Ankylosing Spondylitis (AS): Hallmark Joint Involved
SI Joints (bilateral & Symmetric)
126
Stage 1 Ankylosing Spondylitis (AS)
Pseudo-widening of joint space
127
Stage 2 Ankylosing Spondylitis (AS)
[Erosive & sclerotic changes]
- Rosary bead appearance/postage stamp
- triangular sclerosis
128
Stage 3 Ankylosing Spondylitis (AS)
[Ankylosis]
- Ghost Joint (synovial)
- Star Sign (fibrous/syndesmotic)
129
Important Early feature of Ankylosing Spondylitis (AS)
Osteitis
130
What is Osteitis?
[Romanus Lesion the “shiny corner” sign]
Focal destructive areas along anterior margin of discovertebral junction @ superior and inferior vertebral bodies
131
What comes secondary to remodeling a Romanus Lesion in Ankylosing Spondylitis (AS)?
Barrel-Shaped vertebra
132
Radiographic feature of Spinal Ankylosing Spondylitis (AS)
Thin Marginal Syndesmophytes
133
Bamboo Spine in Ankylosing Spondylitis (AS)
Fusion from marginal Syndesmophytes
134
Railroad sign in Ankylosing Spondylitis (AS):
Ossification in facet joint capsules
135
Dagger sign in Ankylosing Spondylitis (AS):
Isolated ossification of supraspinous & interspinous ligaments
136
Trolley track sign in Ankylosing Spondylitis (AS):
Ossification within facet joint capsules, ligamentum flavum, interspinous ligaments
137
Anderson lesion in Ankylosing Spondylitis (AS):
Poorly defined endplate secondary to fracture through a previously ankylosed segment
138
Ankylosing Spondylitis (AS): Lab Findings
RF(-): Seronegative
Elevated ESR and CRP
HLA B27 (-): not specific, but sensitive
139
Ankylosing Spondylitis (AS): Referral
Rheumatology
140
Ankylosing Spondylitis (AS): Treatment
- DMARDs, NSAIDS, Analgesics
- Maintian joint mobility
- Anti Inflammatory diet/ supplements
141
What is Enteropathic Arthritis (EOA)?
Disease of GI origin w/ articular abnormalities
142
2 MC GI Diseases in Enteropathic Arthritis (EOA)
Ulcerative Colitis & Regional Enteritis (Crohn’s)
143
Other Related Conditions to Enteropathic Arthritis (EOA)
1) Whipple Disease
2) Salmonella, Shingella, Yersinia
3) Intestinal By-Pass
4) Hepatitis
5) Pacreatic Disease
144
Enteropathic Arthritis (EOA): Clinical Features w/ Ulcerative Colitis
1) Malaise
2) Anorexia
3) Weight Loss
4) Abdominal Pain
5) Change in Stool
145
Enteropathic Arthritis (EOA): Radiographic Changes
Same as AS
146
When findings of AS/Enteropathic are seen…
(In the absence of clinical Hx)
The diff Dx is: (in this order)
1) AS
2) Enteropathic Arthritis
147
Psoriatic Arthritis: What is it?
Skin disorder associated w/ erosive arthropathy
148
Psoriatic Arthritis: Population Affected
20-50 years old
Male = Female
149
Most significant Physical Correlation in Psoriatic Arthritis:
Nail Involvement (Nail Changes)
150
Psoriatic Arthritis: Location
- Interphalangeal Joints
- MCP & MTP Joints
- Calcaneus
- SI Joints
- Spine
151
Psoriatic Arthritis: Early Involvement characterized by…
DIP Joint: redness, swelling & pain
Whole digit = Sausage digit
152
Earliest Radiographic sign of Psoriatic Arthritis
Soft Tissue Swelling
153
Immune reaction in Psoriatic Arthritis
[similar to RA]
Proliferation Synovitis -> Pannus -> cartilage & bone erosions -> narrowed joints
154
Psoriatic Arthritis: Periosteal Reaction
Periostitis adjacent to erosions (not seen in RA)
155
Psoriatic Arthritis: Radiographic Features
- Asymmetric
- Uniform loss of joint space (large joints)
- widened joint space from erosions & fibrous deposition (small joints)
- Complete ankylosis common
156
What helps differentiate an RA diagnosis from a Psoriatic Arthritis diagnosis?
Lack of Osteopenia
157
Sign seen in Periostitis with Psoriatic Arthritis
Mouse ear Sign
158
Deformities seen in Psoriatic Arthritis:
- Pencil in Cup
- Opera Glass Hand
- Arthritis Multilans
- Ray Pattern
- Acro-Osteolysis
- Calcaneal Erosions
- Ivory Phalanx
159
MC Joints affected by Psoriatic Arthritis:
DIP & PIP
(MCP & wrists are usually spared)
160
What is “Ray Pattern”
DIP, PIP and MCP involvement of the same digit
(Diagnostic sign of Psoriatic Arthritis)
161
Psoriatic Arthritis: Calcaneal Effects
Calcaneal erosions & Periostitis at the Achilles and Plantar Ligament Insertions
162
Calcaneal erosions & Periostitis at the Achilles and Plantar Ligament Insertions in Psoriatic Arthritis is due to
Infection of Clamydia
163
Sacroiliac Psoriatic Arthritis:
MC: Bilateral asymmetric
30-50% of patients w/ Psoriatic Arthritis:
164
Spinal Psoriatic Arthritis: Features
1) Non-Marginal Syndesmophytes
2) Atlantoaxial Subluxation
3) Discovertebral Erosions
4) Sparing of Facets
165
MC Location & Involvement of Non-Marginal Syndesmophytes in Psoriatic Arthritis:
(T11-L3)
- Ossification initially lateral & separate from vertebral body
- eventually involves adjacent vertebral body & annulus fibers
166
Cervical Spine Psoriatic Arthritis: Features
- C-Spine involved in 35-75% of psoriatic arthritis patients
- Narrowing/fusion of facets
167
Psoriatic Arthritis: Referral
Rheumatology
168
Psoriatic Arthritis: Skin Disease Treatments
Topical emollients & keratolytic agents
169
Psoriatic Arthritis: Joint Disease Treatments
NSAIDS, DMARDs, Methotrexate, corticosteroid injections, Surgery
170
Psoriatic Arthritis: general treatments
- Anti-inflammatory diet
- exercise
171
Reactive Arthritis: formerly known as
Reiter’s Syndrome
172
Reactive Arthritis: Clinical Triad
1) Conjunctivitis (cant see)
2) Urethritis (cant pee)
3) polyarthritis (cant dance with me)
173
Reactive Arthritis: Population Affected
MC INflammatory Polyarthritis affecting Young Men
MALES
18-40 years old
174
Reactive Arthritis: 2 Modes of Onset
MC: Venereal (Chlamydia Trachomatis)
Enteric (shigella, salmonella, yersinia)
175
Reactive Arthritis: Location of skin lesions
MC on soles of feet & palms
176
Up to 30% of Reactive Arthritis patients may develop:
Keratoderma Blennorrhagia
177
Other lesions seen in Reactive Arthritis:
- Genitals
- Oral mucosa
- Tongue
- Hard Palate
178
Reactive Arthritis: Clinical Features
- asymmetrical in the lower extremity
- shows up 1-3 weeks after urethritis or diarrhea
179
Reactive Arthritis: MC Location
- MTP Joints
- IP Joints of the foot
- Calcaneus
- Ankle & Knee
180
Reactive Arthritis: Foot & Ankle Radiographic Features
- ST Swelling
- Mariginal Erosions
- Osteoporosis & Linear or Fluffy Periostitis
181
What is Lanois Deformity?
Dorsal subluxation of the MTP joints and Fibular Deviation of the digits
182
Pain in Reactive Arthritis:
- Heel Pain & tenderness
- Located posteriorly in the retro Calcaneal bursa or Achilles
- Located Inferiorly at attachment of aponeurosis on plantar surface
183
Calcaneal Sign in Reactive Arthritis:
Lover’s Heel
184
Other Radiographic Features of Reactive Arthritis:
[Similar to AS & PsA]
- Periostitis & Spine changes mimic (PsA)
- Enthesis changes mimic all seronegative spondyloarthropathies
185
Where are changes most apparent in Reactive Arthritis?
Lower Extremity & are Asymmetrical
186
SIJ Reactive Arthritis: Features
MC: Sacroilitis
MC: Bilateral, asymmetrical
187
Spine Reactive Arthritis: Features
- Isolated to lower T spine and upper L spine
- 15% non-marginal syndesmophytes
- Atlantoaxial instability in < 2% of cases
188
Reactive Arthritis: Referral
Rheumatology
189
Reactive Arthritis: Treatment
- NSAIDs, DMARDS
- anti inflammatory diet
- exercise
190
What is Gout?
Painful arthropathy associated w/ hyperuricemia and secondary precipitation of sodium mono rate crystals in and around articulations
191
Gout: Population Affected
Males
> 40 years old
192
In Primary Gout, Hyperuricemia results from:
- Overproduction
- lack of excretion (enzyme defect)
193
In Secondary Gout, Hyperuricemia results from:
- Other disorders/diseases
- drug interactions
(Causing overproduction/under excretion)
(Renal dysfunction os a common cause)
194
Acute Gouty Arthritis
- 60% on 1st MTP Joint
- swollen, red, hot BUT DRY
- responds immediately to colchicine treatment
195
Polyarticular Gouty Arthiritis
- Multiple attacks leads to poly articular involvement
- radiographic changes are now visible
- eventually, recovery becomes incomplete
196
Chronic Tophaceous Gout
- Follows numerous attacks (10-12 years)
- Urate crystals deposit in several locations
- Tophi contents have consistency of thick toothpaste
197
Urate Crystal Deposition in Gout Occurs in:
- Articular Cartilage
- Subchondral Bone
- Synovial membrane
- Capsular/Periarticular tissues
198
Pathological Features in Articular Tissues with Gout:
Crystal deposition -> inflammatory response -> Pannus -> cartilage breakdown & erosions
199
Pathological Features in Periarticular Tissues with Gout:
Develop Tophi -> non-marginal pressure -> bone erosions
200
Periarticular tissue affected by Gout
Bursae
Tendon Sheaths
Ligaments
Subcutaneous Tissues
201
Radiographic features of Gout:
- ST changes
- Preservation of joint spaces
- Uniform loss of Joint Space (in late disease)
- Erosions
- Periosteal new bone formation
- secondary DJD
- Chondrocalcinosis (5%)
202
3 types of Bone Erosions in Gout:
1) Marginal
2) Periarticular
3) Intraosseous
203
Marginal Erosions in GHout:
Due to pannus within joint
204
Periarticular Erosions in Gout:
[Due to pressure erosions (tophus)]
- Eccentric
- Metaphyseal/Diaphyseal
- Sclerotic margin w/ protruding lip of bone (overhanging margin)
205
Intraosseous Erosions in Gout:
Due to Tophi build up within bone
206
Lab findings in Gout
- Hyperuricemia (absolute finding)
- Should be performed prior to imaging
207
Gout: Treatment
- Moist Heat
- NSAIDs
- Colchicine
- Allopurinol
208
How does Allopurinol work in treating Gout?
Decreases Uric acid formation & purine synthesis through xanthine oxidase
209
How does Colchicine work in treating Gout?
Inhibits Uric acid deposition
210
What is Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD)?
Articular disease characterized by production of gout like symptoms (pseudo-gout) in the presence of CPPD crystals
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD): Main Radiographic Finding
Chondrocalcinosis (involves hyaline and/or Fibrocartilage)
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD): Lab Findings
Normal except Increased ESR
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What reveals CPPD Crystals?
Joint Aspiration
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD) may occur secondary to…
- Hyperparathyroidism
- Hemochromatosis
- DM
- Gout
- etc.
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD) triggers what?
Acute Synovitis (pain, swelling, redness of joint)
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD) DOES NOT Trigger what?
Pannus formation or Tophi
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD) Leads to…
Rapid & Extensive degradation of cartilage -> DJD
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD): Common Locations
- Knee Meniscus
- Symphysis Pubis
- Triangular Fibrocartilage of wrist
- annulus fibrosis
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD): Associated w/ what syndrome
Crowned Dens Syndrome
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Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD): Radiographic Features
- Unusual articular/intra-articular distribution
- Prominent Subchondral cysts
- Subchondral bone changes
- may have osteophytes
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Hydroxyapatite Deposition Disease (HADD): What is it?
Deposition of calcium hydroxyapatite within tendon, bursa or other Periarticular ST’s
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Hydroxyapatite Deposition Disease (HADD): May cause…
Tendinitis
Bursitis
Joint Pain
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Hydroxyapatite Deposition Disease (HADD): Population affected
40-70 year olds
M = F
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Hydroxyapatite Deposition Disease (HADD): Symptoms
Pain
Tenderness
Localized Swelling
Decreased ROM
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Hydroxyapatite Deposition Disease (HADD): Radiographic Features
- Tendon calcification
- round/oval with clear margins (globular)
- “veil-like”
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Hydroxyapatite Deposition Disease (HADD): MC Location
Shoulder
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Hydroxyapatite Deposition Disease (HADD): Other Locations
Hip or Longus Colli Muscle Tendon
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Hydroxyapatite Deposition Disease (HADD): Effect of Physiotherapy
Calcification may dissapear
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Progressive Systemic Sclerosis (PSS): a.k.a.’s
Scleroderma
Systemic Sclerosis
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What is Progressive Systemic Sclerosis (PSS)?
Systemic Inflammatory collagen vascular disorder (skin, lungs, GIT, Heart, kidneys & MSK)
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Progressive Systemic Sclerosis (PSS): Population Affected
30-50 year old Females
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Progressive Systemic Sclerosis (PSS): Most Unique Features
Edema -> Induration -> Atrophy
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Progressive Systemic Sclerosis (PSS): Symptoms
- Peripheral Pain & Swelling
- Raynaud Phenomenon
- Thickening of Skin
- Mouse-Like Fascies
- Esophagus Dilation (GERD)
- Decreased Bowel Function
- Pleural/Pericardial Effusion
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Progressive Systemic Sclerosis (PSS): Crest Syndrome
- Calcinosis
- Raynaud Phenomenon
- Esophageal Motility Issues
- Skin/Subcutaneous Calcification
- Telangiectasia
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Progressive Systemic Sclerosis (PSS): Pathological Changes
- ST Changes (atrophy or calcifications)
- Osseous changes (acro-osteolysis)
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Progressive Systemic Sclerosis (PSS): MC Site & Features
[Hand]
- ST retraction, tapered fingers
- acro-osteolysis
- calcinosis cutis
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Progressive Systemic Sclerosis (PSS): Referrals
[Rheumatology]
- Dermatologist, Pulmonologist, Nephrologist, astroenterologist, Cardiologist, Orthopedic Surgeon
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Progressive Systemic Sclerosis (PSS): Medications
Corticosteroids and DMARDs
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Systemic Lupus Erythematous (SLE): What is it?
- CT disorder with multi-organ involvement
- chronic w/ acute exacerbations
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Systemic Lupus Erythematous (SLE): Population Affected
20-40 year old Females
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Systemic Lupus Erythematous (SLE): Clinical Features
- Fever & Malaise
- Anorexia, Weight loss
- Skin Rash
- Arthralgia (pain, swelling, stiffness)
- Hypermobility
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Systemic Lupus Erythematous (SLE): Lab Findings
Elevated ESR
+ ANA
LE Cell
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Rash seen in Systemic Lupus Erythematous (SLE)
Malar Rash on Face (40%)
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Systemic Lupus Erythematous (SLE): Systemic features
Kidney: renal failure
Heart: pericarditis
Lungs: interstitial disease
Raynaud phenomenon
Arthropathy** (up to 90%)
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Systemic Lupus Erythematous (SLE): Radiographic features
- Bilateral, symmetric
- reversible deformities
- no joint space loss/erosions
- Tuft reabsorption
- ST atrophy & calcifications
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Systemic Lupus Erythematous (SLE): Complications of Steroid Treatments
1) Osteoporosis
2) Osteonecrosis
3) Spinal fracture
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Systemic Lupus Erythematous (SLE): Referral
[Rheumatologist]
- cardiologist, pulmonologist, nephrologist, PCP
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Systemic Lupus Erythematous (SLE): Treatment
Immunosuppressants & Corticosteroids
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Osteitis Condensans Ilii (OCI): What is it?
Isolated, Non-erosive sacroiliac arthropathy that mimics features of stress fracture
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Osteitis Condensans Ilii (OCI): Population affected & Cause
20-40 year old women
Unknown cause
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Osteitis Condensans Ilii (OCI): Theory for cause
Hormonal & secondary mechanical stresses related to pregnancy or menstrual cycle
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Osteitis Condensans Ilii (OCI): Radiographic features
- Bilateral & symmetrical triangular sclerosis of iliac portion of SI Joints
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Osteitis Condensans Ilii (OCI): If reaction is suspected treat with…
[as appropriate]
- Adjustment
- PT
- Exercise
- Nutrition
- Education
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Osteitis Pubis: What is it?
Painful condition of the pubic symphysis
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Causes of Osteitis Pubis
- Childbirth
- Pelvic Surgeries
- Athletic Injuries
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Osteitis Pubis: Clinical Features
- Local pain/tenderness
- Muscle spasms
- Unstable gait
- “groin-burning”
- Audible “click” w/ some activities
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Osteitis Pubis: Radiographic features
- bilateral & symmetrical
- irregular bone margins
- Subchondral sclerosis
- moth-eaten type of osteoporosis
- widening of joint space
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Osteitis Pubis: Looks identical to…
Infection
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Osteitis Pubis: May lead to…
Long term joint irregularity, instability & ankylosis
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Osteitis Pubis: Treatment Options
- Adjustment
- Referral if needed
- remove from sport (if related)
- strengthen & condition are a must
- focus on balance & core strength exercises
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Osteitis Pubis: Must rule out what?
Infection
