Final Flashcards
List the three presentations/types of osteoporosis
- Generalized (Senile/Postmenopausal)
- Regional
- Localized
List the characteristics of Generalized Osteoporosis (Senile/Postmenopausal)
• increased bone radiolucency
• cortical thinning; “pencil thin” cortices & endplates
• endplates look very white compared to radiolucent vertebrae
• altered trabeculae patterns
1. horizontal lines disappear
2. accentuated vertical trabeculae = “pseudohemangiomatous” appearance
• “Pancake” and anteriorly wedged vertebrae
• Bioconcave endplates
• Isolated end plate infarction
• Schmorl’s nodes (intrabody discal herniations)
List the characteristics of Regional Osteoporosis
dt disuse/immobilization, reflex sympathetic dystrophy
- Acute & Painful: progressive pain, swelling and atrophy
- Usually develops in one area distal to trauma site
- Osseous hyperemia dt neurovascular imbalance
- Patchy, mottled
- Metaphyseal localization
- No joint dz
Cause of Localized Osteoporosis
dt infection, inflammatory arthritis, neoplasm
What is the most common cause of generalized osteoporosis?
o Age
The leading cause of osteoporosis is a lack of certain hormones, particularly estrogen in women and androgen in men. Women, especially those older than 60 years, are frequently diagnosed with the disease. Menopause brings lower estrogen levels and increases a woman’s risk for osteoporosis. Other factors that may contribute to bone loss in this age group include inadequate intake of calcium and vitamin D, lack of weight-bearing exercise, and other age-related changes in endocrine functions (in addition to lack of estrogen).
What is the standard imaging modality to quantify bone mineral density?
DXA (DEXA/dual energy x-ray absortiometry)
What causes rickets and osteomalacia?
Primarily due to a deficiency in vitamin D, which may be dt malabsorption
Osteomalacia also involves abN levels of calcium and phosphorus metabolism, and also may be dt dietary deficiency, renal dz, and a small group of miscellaneous dz
Note that rickets has two other forms: renal osteodystrophy with chronic
renal disase, and renal tubular defect (a failure to reabsorb phosphate in urine, so it doesn’t become mineralized in the bone).
What are the classic radiographic features of rickets?
- Generalized osteopenia (bowed appearence)
- Coarse trabecular changes
- Widened growth plates (tall, thick; with palpation feels thicker, swollen up)
- Rachitic Rosary (rosary – bead appearance; sternum looks like line of beads)
- Absent zone of provisional calcification
- Frayed “paintbrush” (edge margin close to growth plate) and cupped metaphyses
What causes scurvy and what are the classic radiographic features?
o Vitamin C def.
o Radiographic features
• White Line of Frankel – dense zone of provisional calcification - @ end of metaphysis – (vs. frayedpaintbrush w/ Rickets)
• ring epiphysis (Wimberger’s sign)
• Pelken’s spurs—a spur at the end of the bone (outcropping of BN @ metaphysis)
• scorbutic zone (Trummerfeld zone)
• subperiosteal hemorrhages dt def. of intercellular cement which in turn promotes vascular fragility
What are the classic radiographic features of hyperparathyroidism in the spine, skull, and hand?
• Spine
o Subperiosteal resorption
• Hand – Radial margins of the proximal and middle phalanges of 2nd and 3rd digits with acroosteolysis (appears as a jagged edge)
• Skull
o “Salt and pepper” resorption of lamina dura
• Hand
o Osteopenia
o Trabecula accentuation
o End plate concavities
o “Rugger Jersey” spine (thick cortical area)
o Widened sacroiliac joints
What are the face, skull, and foot changes seen with acromegaly?
- Face:
- prominent forehead
- Sinus overgrowth
- Widened mandibular angle (prognathism)
- Skull
- Sella turcica enlargement dt pituitary neoplasm
- Sinus overgrowth
- Malocclusion
- Foot: heel pad greater than 20 mm (about 1 inch)
What osseous changes might long term corticosteroids cause?
• Osteoporosis of Cushing’s dz
o Cortices wll be thinned, density diminished, deformities
o Bioconcave end plate configurations
• Osteonecrosis
o In femoral & humeral heads; in distal femor and talus
o “Intravertebral vacuum cleft sign”; Gas in the vertebra with avascular necrosis leading to collapse of the vertebae
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?
The bone changes dt marrow hyperplasia, ischemia and necrosis.
• Generalized osteoporosis (marrow hyperplasia)
o Thin cortices
• Coarse trabeculae, especially in axial skeleton
• Large vascular channels
• Widened medullary cavity
• Epiphyseal ischemic necrosis
• Medullary infarcts (metaphysic or diaphysis)
• Secondary 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, and elbow (bilateral and symmetrical)
What is a common differential diagnosis when encountering hemophilic arthopathy?
Rheumatoid arthritis
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?
• bilat & symmetric sclerosis (the text says asymmetric (364)
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 the pubic symphysis→ usu fr operations on the lower urinary tract (suprapubic or retropubic prostatectomies)
What is the difference b/w marginal & non-marginal syndesmophytes?
Syndesmophyte – An osseous excrescence attached to a ligament
• Non-Marginal Syndesmophytes – don’t come from corners
o Psoriatic (esp at thoracolumbar jxn) & Reiters
o the syndesmophytes tend to skip levels w/ psoriatic & reiters
• Marginal syndesmophytes – ossification of outer annulus fibrosis leading to thick, vertical radiodense areas; They connect adjacent vertebrae. In AS, they bow outward slightly, giving the spine the bamboo stick appearance
(vs the spondylophytes found in DJD)
• AS (bamboo spine – formed fr extensive syndesmophytes)
• AS & Enteropathic the syndesmophytes tend to be continuous
Which spinal arthritides have marginal vs non-marginal syndespmophytes?
- Marginal: AS
* Non-marginal: Psoriatic Arthritis, Reiter’s syndrome
What systemic condition is commonly found in pts w/ diffuse idiopathic skeletal hyperostosis (DISH)?
• Diabetes
• Dyslipidemia
• Hyperuricemia
x-ray of cervical spine reveals large bridging anterior osteophytes from the level of C2 to the upper thoracic spine (yellow arrow). Additionally, a dense band of calcification is noted along the posterior aspect of the vertebral bodies. (red arrow) Mild disc space narrowing is noted at C5-6 and C6-7, with minimal narrowing at C3-4. There is no evidence of facet joint fusion or narrowing.
Dysphagia is common in which arthritic condition & why?
DISH – spinal involovment, esp ALL, & extraspinal ligamentous & tendonous calcification & ossification – much trouble swallowing if involves ALL (note: this condition has relative maintenance of the disc height and absence of posterior joint fusion or sacroiliitis; there is also ossification of the PLL)
• Ekatrina also found
• Hydroxyapatite deposition disease
• Calcific tendinitis (bursae, ligament, capsule)
• Longus colli
• anterior to C2 and C3 bodies, inferior to anterior tubercle of C1
• RPI (retro-pharangeal interphase) may increase
• Self-limiting (transient)
• Acutely symptomatic
• Pain, stiffness, muscle spasm, painful dysphagia
• Acute onset, increase over 2-5 days, gradually resolve over 1-2 weeks; radiographic findings resolve
• Similar process occurs in IVD (intervertebral disc) of children
INTERVERTEBRAL DISC DEGENERATION
• a.k.a. 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 Neurotrophic Arthropathy:
• joint changes that occur secondary to loss of sensation • Hypertrophic Type: the 6 D’s: 1. Distended Joint 2. Density Increase of subchondral bone 3. Debris or loose bodies 4. Dislocation 5. Disorganization Joint 6. Destruction of articular cortex (there is also the abbreviated 3Ds dislocation, destruction & degeneration)
• Atrophic type: Atrophic – resorbtion
- complete resorption of articulating bone end, leaving a sharp transverse demarcation at the metadiaphysis which has been likened to surgical amputation (often in the proximal humerus)
- tapers the bone end to a sharp pencil point
Which conditions may result in neurotrophic arthropathy:
- These stem from impaired pain perceptions or proprioception with repeated unrecognized trauma
- DM
- Alcoholism
- tabes dorsalis (results from syphilis slow breakdown of all or part of the body and the progressive loss of reflexes)
- paralysis
- syringomyelia (esp UE) – cavity inside canal filled w/ CSF
- Essentially severe, destructive DJD
What is synoviochondrometaplasia?
• A benign disorder marked by metaplasia of hyperplastic synovium to hyaline cartilage
• The hyaline cartilage calcifies or ossifies and detaches from the synovium to form loose bodies (<2-3 cm in diameter) within the joint, tendon sheath, or bursae in which it forms
• Involves large wt-bearing joints
• Most common in knee; occasionally bilateral
• Never in the spine
• Radiographically
o Multiple radiodense loose bodies in the joint capsule, less commonly a tendon sheath or bursae
o Pressure erosions, widened joint space, and secondary degeneration
• Sx: intermittent pain, joint swelling, stiffness, and episodes of “joint locking”
Name the commone sites of involvment of RA in the hand & wrist:
Hands: • MCP’s & PIP’s; marginal erosions (irregular, no sceroltic margin) • radial margins of 2nd & 3rd MC head • Boutonniere (DIP extend, PIP flex) • Swan neck deformities (DIP flex, PIP extend) • Ulnar deviation at MCP joint Wrist: • Ulnar Styloid erosion • uniform loss of radiocarpal joint • erosions of triquetrum-pisiform • spotty carpal sign • pancarpal involvement • scapholunate dissociation
What is a marginal erosion?
irregular, no sclerotic margin (on sides of metacarpal heads – radial sides more)
• 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?
Text pg. 478: “can lead to direct compression of the brainstem or cause neurological damage by excessive kyphosis
• Cervical (MC) spine involvement in 50-80%; few at T/L junction
• Odontoid/dens erosions
• C1-C2 instability → neurologic damage (enlarged; N <5 in child); atlanto-axial subluxations
• Pseudobasilar invagination
• Facet involvement; stair-stepping (anterior-lysthesis; can get with DJD as well)
• IVD involvement
Which conditions demonstrate laxity of the transverse ligament?
The inflammatory arthirtides tend to affect tendons & ligaments rather than joint membranes as with the degeneratives (enthesophy)
→possible w/ RA (but uncommon), ????
- SLE, Down’s syndrome
