Lab: Joint Disease 1 Flashcards
non-inflammatory joint disease
Increased fibrillation and chondrocyte necrosis can be due to damage to the cartilage.
What is the general cause of this damage?
Excessive unit loads on articular cartilage
Does an excessive unit load on articular cartilage lead to inflammatory or non-inflammatory joint changes?
Non-inflammatory
Degenerative joint disease is also known as ___
osteoarthritis
Degenerative joint disease/osteoarthritis is common in which joints?
Weight bearing/excessive unit loads
DJD/osteoarthritis
What are four examples of the damage to articular cartilage with progressive deterioration?
- Narrowing of joint space
- Subchondral sclerosing (purple)
- Subchondral cysts (red)
- Osteophytes (blue)
Is degenerative joint disease unilateral or bilateral?
Can be either
Is degenerative joint disease symmetrical or asymmetrical?
Asymmetrical
What are some clinical manifestations of degenerative joint disease?
- Unilateral or bilateral and asymmetrical
- Crepitus
- Heberden nodes
- Swelling, stiffness, pain
- Inflammation from cartilage damage
What can predispose an individual to early or more severe degenerative joint disease?
- Excessive unit loads on articular cartilage
- Injury to supportive joint structures
- Altered gait
- Pathologic changes to biomechanical properties of bone at joint (Acromegaly, Paget disease)
What is the term for the softening and breakdown of knee cartilage found in younger adults?
Chondromalacia patellae
A young adult patient reports anterior knee pain and stiffness. They have worse symptoms when going down stairs, running down a hill, squatting, or standing after sitting.
Which joint disease is this most consistent with?
Chondromalacia patellae
What might aggravate symptoms of anterior knee pain and stiffness with chondromalacia patella?
- Going down stairs
- Running down hill
- Squatting
- Standing after sitting
What are four pathologies associated with neuropathic arthropathy (Charcot joint)?
- Diabetes mellitis
- Syphilis
- Syringomyelia
- Peripheral nerve trauma
What is neuropathic arthropathy?
Severe and rapid degenerative joint disease secondary to a neurological issue
bone injury and eventually inflammation and destruction of joint
If a patient has diabetes mellitus, where are they most likely to experience neuropathic arthropathy?
Feet and ankles
If a patient has syringomyelia, where are they most likely to experience neuropathic arthropathy?
Shoulder and upper extremity
If a patient has neurosyphilis, where are they most likely to experience neuropathic arthropathy?
Knee
If a patient has a spinal cord injury, where are they most likely to experience neuropathic arthropathy?
Spine
Is neuropathic arthropathy typically unilateral or bilateral?
Unilateral
Progressive articular and subchondral bone destruction with neuropathic arthropathy are accelerated by ___
absence of pain and proprioception
degenerative joint disease
What are the “6 D’s” describing degenerative changes?
- Distension
- Density (subchondral sclerosing)
- Debris
- Dislocation
- Disorganization
- Destruction
What is tenosynovitis?
Inflammation of the tendon sheath
What are the features of non-infectious tenosynovitis?
- Inflammation leads to increased fibrin thickening of synovial fluid
- Increase in friction between tendon sheath and tendon
What are the features of infectious tenosynovitis?
- Bacterial infection affects sheath
- Purulent exudate present
- Necrosis of tendon sheath, tendon, and other structures
What is occurring at the arrow labeled 1?
What is occuring at the other label?
At label 1: early cracking and fibrillation of cartilage
At the other arrow: synovial fluid is leaking into cracks
degenerative joint disease
What part of the pathogenesis of DJD is depicted in this image?
What factors contribute to the death of chondrocytes that initiate this event?
Early in pathogenesis:
- Decreased proteoglycans, decreased glycosaminoglycan chain length, increased fibrillin, increased H2O bonding, collagenase present
- Fibrillation in surface articular cartilage
- Fibrillation propagation (synovial fluid fills and increases fissures, pieces of cartilage break off)
The blood vessel shown penetrating into the damaged area here is an important part of the pathogenesis of DJD.
What is the process of new vessel formation called?
Angiogenesis
Given that this is DJD what is displayed by label 2?
Label 3?
Label 2: deep crack across tide mark with underlying neovascularization
Label 3: fibrocartilage plug
degenerative joint disease
What occurs as a consequence of this crack crossing the tide mark?
- Angiogenesis
- Increased osteoclastic activity (subchondral resorption)
- Decreased osteoblastic activity (subchondral sclerosis)
- Fibrocartilage forms
degenerative joint disease
Which tissue layers are damaged in this image?
- Articular (hyaline) cartilage (tangential, transitional, radial zones)
- Tide mark
- Calcified zone (cartilage)
- Subchondral bone plate
degenerative joint disease
What is the reparative structure that fills the area of destroyed chondrocytes?
What tissue layer must be damaged before this structure is created?
Fibrocartilage plug: damage has passed tide mark into calcified cartilage
degenerative joint disease
What terminology describes the thickened bone in the image on the right?
Subchondral sclerosis
degenerative joint disease
What term is used to describe the necrosis of osteocytes and polished appearance of bone caused by the mechanical wear of bone-on-bone friction once articular cartilage is lost (label 4)?
Eburnation
degenerative joint disease
What is the synovial fluid filled structure shown (label 5)?
Subchondral bone cyst
degenerative joint disease
Label the following in this image:
1.
2.
3.
1: Eburnation
2: Subchondral bone cyst
3: Intact hyaline cartilage (healthy)
Your new patient is a 55-year-old male factory worker. He reports pain in his left shoulder and low back. He broke his right radius playing baseball when he was 12 years old, but continued to play for decades. He had a heart attack recently and his left interventricular artery was stented. His heart attack inspired him to start trying to lose weight. His back pain has lasted for years, but eases when he comes home from work. His shoulder has been more concerning. It gives a little trouble all day, but is worse in the morning and after a long day at work.
What are three pathological features seen in this radiograph of his shoulder?
- Subchondral sclerosing (articular part of humeral head and glenoid fossa)
- Decreased joint space (articular cartilage reduced)
- Osteophytes
degenerative joint disease
What cellular events could explain the radiolucent areas on the humeral head?
What is the term for these lesions?
- Fibrillation
- Synovial fluid fills cracks
- Increased osteoclastic activity (subchondral resorption)
- Decreased osteoblastic activity
Led to subchondral bone cysts
degenerative joint disease
What is the term for the projections extending from the inferior portion of the humeral head?
What type of cells comprise these structures?
Where are they generally found in the joint?
Osteophytes: composed of osteoblasts, generally found at joint margins
degenerative joint disease
What is subchondral sclerosing?
Does it appear radiopaque or radiolucent?
Thickening and hardening of subchondral bone in response to stress
Appears radiopaque
Your new patient is a 55-year-old male factory worker. He reports pain in his left shoulder and low back. He broke his right radius playing baseball when he was 12 years old, but continued to play for decades. He had a heart attack recently and his left interventricular artery was stented. His heart attack inspired him to start trying to lose weight. His back pain has lasted for years, but eases when he comes home from work. His shoulder has been more concerning. It gives a little trouble all day, but is worse in the morning and after a long day at work.
What is the term for the changes seen at the intervertebral joint margins of his cervical spine?
Spondylophytes
degenerative joint disease
Is degenerative joint disease/osteoarthritis inflammatory?
Etiology is non-inflammatory, but pathogenesis includes inflammation
Your new patient is a 55-year-old male factory worker. He reports pain in his left shoulder and low back. He broke his right radius playing baseball when he was 12 years old, but continued to play for decades. He had a heart attack recently and his left interventricular artery was stented. His heart attack inspired him to start trying to lose weight. His back pain has lasted for years, but eases when he comes home from work. His shoulder has been more concerning. It gives a little trouble all day, but is worse in the morning and after a long day at work.
Would you expect to see the same level of degeneration in his right shoulder as is seen in his left shoulder radiograph here?
No, the left arm has been through more stress
The following are all changes featured in what joint pathology?
- Non-uniform decreased joint space
- Subchondral sclerosis
- Osteophytes and spondylophytes
- Subchondral cysts
- Chondral/subchondral loose bodies (joint mice)
Degenerative joint disease/osteoarthritis
The following are all changes seen in what joint pathology?
- Non-uniform decreased joint space
- Subchondral cysts
- Chondral/subchondral loose bodies (joint mice)
- Intra-articular loose bodies
- Subluxation
Degenerative joint disease/osteoarthritis
The following are all changes seen in what joint pathology?
- Non-uniform decreased joint space
- Subchondral/chondral loose bodies (joint mice)
- Subluxation
- Loss of congruity in joint space
- Muscle contractures or decreased muscle mass
Degenerative joint disease/osteoarthritis
Your new patient is a 55-year-old male factory worker. He reports pain in his left shoulder and low back. He broke his right radius playing baseball when he was 12 years old, but continued to play for decades. He had a heart attack recently and his left interventricular artery was stented. His heart attack inspired him to start trying to lose weight. His back pain has lasted for years, but eases when he comes home from work. His shoulder has been more concerning. It gives a little trouble all day, but is worse in the morning and after a long day at work.
What treatment should be recommended for this patient?
- Over the counter pain relievers
- Exercise, weight loss
- Support devices (ie. shoe inserts)
- Heat and cold therapy
- Complementary therapy
- Surgery
degenerative joint disease
A 23-year-old female patient recently suffered a complete, non-comminuted fracture to her right tibia and was in a cast for several months with restricted activity. The cast was removed three months ago and she began jogging again. It was difficult at first, and recently, she has noticed her knee feel stiff and achy almost all the time. She stopped taking stairs because it makes it worse. Radiographs of both knees appear unremarkable.
Based on this case presentation what would the most likely differential diagnosis be?
Chondromalacia patellae (patellofemoral pain syndrome)
A 23-year-old female patient recently suffered a complete, non-comminuted fracture to her right tibia and was in a cast for several months with restricted activity. The cast was removed three months ago and she began jogging again. It was difficult at first, and recently, she has noticed her knee feel stiff and achy almost all the time. She stopped taking stairs because it makes it worse. Radiographs of both knees appear unremarkable.
What would your next step be to confirm a diagnosis?
Functional and orthopedic testing, eventually a referral
chondromalacia patellae
A 23-year-old female patient recently suffered a complete, non-comminuted fracture to her right tibia and was in a cast for several months with restricted activity. The cast was removed three months ago and she began jogging again. It was difficult at first, and recently, she has noticed her knee feel stiff and achy almost all the time. She stopped taking stairs because it makes it worse. Radiographs of both knees appear unremarkable.
What cellular changes could you expect to see at her knee joints?
Which part of the joint will primarily be affected?
Cartilage softening, swelling, and edema
Primarily in anterior knee
chondromalacia patellae
A 23-year-old female patient recently suffered a complete, non-comminuted fracture to her right tibia and was in a cast for several months with restricted activity. The cast was removed three months ago and she began jogging again. It was difficult at first, and recently, she has noticed her knee feel stiff and achy almost all the time. She stopped taking stairs because it makes it worse. Radiographs of both knees appear unremarkable.
Based on your differential diagnosis, what would your treatment recommendation be for this patient?
- Rest (take on exervise progressively)
- Alter exercise (adequate warmup and stretching)
- Weight loss
- Support devices
- NSAIDs
chondromalacia patellae
A 60-year-old male comes to you for back pain. He has a pronounced slapping or stomping gait. He thinks he hurt his back lifting boxes. He was diagnosed with diabetes mellitus at the age of 16 years, broke three ribs in a car accident when he was 31, and has been suffering from depression, preventing him from much activity. He also admits he hasn’t been eating as healthy or taking he diabetes medication as well as he should.
What is indicated by this patient’s altered gait?
Some type of neuropathic condition
A 60-year-old male comes to you for back pain. He has a pronounced slapping or stomping gait. He thinks he hurt his back lifting boxes. He was diagnosed with diabetes mellitus at the age of 16 years, broke three ribs in a car accident when he was 31, and has been suffering from depression, preventing him from much activity. He also admits he hasn’t been eating as healthy or taking he diabetes medication as well as he should.
He has reduced sensation in his foot. You order a radiograph.
What evidence is there for joint destruction in this radiograph?
All 6 D’s:
- Distension
- Dislocation
- Disorganization
- Density (subchondral sclerosing)
- Debris
- Destruction
hypertrophic neuropathic arthropathy (Charcot joint)
A 60-year-old male comes to you for back pain. He has a pronounced slapping or stomping gait. He thinks he hurt his back lifting boxes. He was diagnosed with diabetes mellitus at the age of 16 years, broke three ribs in a car accident when he was 31, and has been suffering from depression, preventing him from much activity. He also admits he hasn’t been eating as healthy or taking he diabetes medication as well as he should.
He has reduced sensation in his foot. You order a radiograph.
What does the destruction of this joint indicate about his pain?
What does this mean for the surrounding soft tissues?
Absence of pain and proprioception leads to altered joint biomechanics and gait, as well as soft tissue swelling, enlarging the joint
hypertrophic neuropathic arthropathy (Charcot joint)
A 60-year-old male comes to you for back pain. He has a pronounced slapping or stomping gait. He thinks he hurt his back lifting boxes. He was diagnosed with diabetes mellitus at the age of 16 years, broke three ribs in a car accident when he was 31, and has been suffering from depression, preventing him from much activity. He also admits he hasn’t been eating as healthy or taking he diabetes medication as well as he should.
He has reduced sensation in his foot. You order a radiograph.
Is the etiology of this joint destruction inflammatory or non-inflammatory?
Non-inflammatory
hypertrophic neuropathic arthropathy (Charcot joint)
What is the clinical presentation of neuropathic arthropathy?
- Non-inflammatory: due to underlying neurological condition
- Destruction is rapid and severe
- Painless instability
- Joint enlargement/swelling and warmth
- Abnormal joint mechanics
- “Bag of bones”, surgically amputated appearance
A 36-year-old female presents with pain and stiffness in her right thumb. It’s worse when she is working and causing her problems in her mail sorting job with the USPS. She has some swelling and tenderness in the area. Pain is reproducible when you ask her to abduct her right thumb. She has no other complaints or previous conditions.
What is the most likely cause/pathology?
De Quervain’s tenosynovitis (subacute)
inflamed abductor pollicis longus tendon
A 36-year-old female presents with pain and stiffness in her right thumb. It’s worse when she is working and causing her problems in her mail sorting job with the USPS. She has some swelling and tenderness in the area. Pain is reproducible when you ask her to abduct her right thumb. She has no other complaints or previous conditions.
What sort of treatment recommendations would you make?
Splint, NSAIDs, corticosteroids, surgery
de Quervain’s tenosynovitis
avoid anti-inflammatory drugs
A 70-year-old patient presents with pain, swelling, and obvious deformities of both hands. This is their radiograph.
Note the subluxation of the metacarpophalangeal joints.
What types of changes to the bone are indicated at the purple arrows?
Are these effects bilateral?
“Rat bite” lesions (marginal erosions), osteolytic lesions at the joint margins (juxta-articular)
Seen bilaterally and symmetrically
rheumatoid arthritis
A 70-year-old patient presents with pain, swelling, and obvious deformities of both hands. This is their radiograph.
Note the subluxation of the metacarpophalangeal joints.
Is this pattern of injury consistent with a non-inflammatory condition?
What pathology is likely present?
No, this is rheumatoid arthritis which is inflammatory
What is generally the etiology of non-inflammatory joint pathology?
Etiology of inflammatory?
Non-inflammatory: biomechanical wear and tear
Inflammatory: autoimmune
What is the nature of primary bone changes in non-inflammatory joint pathology?
What nature in inflammatory?
Non-inflammatory: mixed osteolytic and osteoblastic
Inflammatory: very osteolytic
Are non-inflammatory joint pathologies typically bilateral/symmetrical?
Are inflammatory pathologies?
Non-inflammatory: typically not symmetrical
Inflammatory: bilateral and symmetrical
What are generally the symptoms of a non-inflammatory joint pathology?
- Stiffness with activity
- Dull pain
- Worse with long inactivity (morning, long standing)
- Worse over time
What are generally the symptoms of an inflammatory joint pathology?
- More constant pain
- Exacerbation remission pattern
- Cardinal signs of inflammation
What are the ESR/CRP lab results for non-inflammatory versus inflammatory joint pathologies?
Non-inflammatory: normal, may elevate later if inflammation results
Inflammatory: increased
