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#2 BOARDS > Radiology 1 > Flashcards

Radiology 1 Flashcards

1
Q

What is a normal synovial fluid analysis?

A
  • Color: Clear and colorless
  • Clarity: Transparent
  • Viscosity: High (high viscosity due to presence of hyaluronan)
  • Mucin clot: Stable (forms from hyluronate-protein complex)
  • ***WBC: <200/mm³
  • ***Differential: <25% PMNs
  • ***Culture: Negative
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2
Q

What is a Baker’s cyst?

A
  • A cyst located in the popliteal region (AKA popliteal cyst)
  • Arthritis, cartilage tear or other knee joint pathologies lead to excessive production of synovial fluid and therefore cyst formation
  • Causes swelling, pain with full knee extension or flexion, activity, etc.
  • Treated by treating the underlying knee pathology causing excessive synovial fluid production
  • From overuse from medial head of gastrocnemius and semimembranosus
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3
Q

Why obtain a chest film?

A
  • Rule out rheumatoid arthritis lung changes

- Rule out sarcoidosis of the lung

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4
Q

Monarticular joint diseases

A

Inflammatory
o Infectious (septic arthritis)
o Crystal induced (gout, pyrophosphate arthropathy, hydroxyapatite)
o Systemic disease with monoarticular involvement (RA, psoriatic, reactive arthritis)

Mechanical/infiltrative (non-inflammatory)
o Trauma
o Osteonecrosis
o Benign tumor (pigmented villonodular synovitis, osteochondroma)

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5
Q

Polyarticular joint diseases

A

Inflammatory
o Rheumatoid arthritis
o Seronegative spondyloarthritis (psoriatic, ankylosing, reactive)
o Chronic tophaceous gout

Non-inflammatory
o Primary osteoarthritis
o Charcot neuropathic osteoarthropathy
o Pigmented villonodular synovitis (midfoot)

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6
Q

Categories of joint diseases

A
  • Degenerative
  • Inflammatory
  • Metabolic

NOTE: This is a categorization system of arthritis that is based on the underlying pathologic process - it unfortunately does not include Charcot

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7
Q

Degenerative joint disease

A

Osteoarthritis

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8
Q

Inflammatory joint diseases

A

o Rheumatoid arthritis
o Seronegative spondyloarthritis (psoriatic, reactive, ankylosing)
o Septic arthritis

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9
Q

Metabolic joint diseases

A

o Gouty arthritis

o Pyrophosphate arthropathy

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10
Q

Hypertrophic vs atrophic joint diseases

A

o Hypertrophic and atrophic radiographic features can be used to distinguish between osteoarthritis and rheumatoid arthritis
o Hypertrophic joint disease features bone overgrowth and enlargement with the characteristic finding of subchondral sclerosis and osteophyte formation
o Detritus arthritis is a type of hypertrophic joint disease and includes disorders with fragmentation in addition to exaggerated hypertrophic features
o Atrophic joint disease features loss of bone substance, primarily through erosions and joint space narrowing, with or without periarticular osteoporosis
o A subgroup of atrophic joint disease is “lumpy-bumpy” joint disease which features adjacent soft tissue masses and the preservation of the joint space

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11
Q

Hypertrophic joint diseases

A 
o	Osteoarthritis (PRMIARY) 
o	Detritus arthritis (tarsus and midfoot Charcot, post-traumatic arthritis)
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12
Q

Atrophic joint disease

A

o Rheumatoid arthritis
o Seronegative spondyloarthritis (psoriatic, ankylosing, reactive)
o Septic arthritis
o Forefoot Charcot
o Lumpy-bumpy joint disease (gouty arthritis, multiple reticulohistocytosis, pigmented villonodular synovitis)

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13
Q

Osteophyte

A
  • An osteophyte is a spur at the margin of a joint
  • AKA dorsal flag (along first met head), lipping (if at both sides of joint) and beaking (talar head)
  • Note that a talar beak may not actually be an osteophyte due to its location (ridge is normally phone here)
  • ***Presence of an osteophyte is pathognomonic of osteoarthritis
  • Degeneration of cartilage, causing excess pressure on subchondral bone
  • SUBCHONDRAL bone is what forms osteophytes
  • Many of these arthritis types will start out as inflammatory, destroy cartilage, then DJD will take over
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14
Q

Osseous erosion

A
  • Osseous erosion is a localized wearing away of bone that begins along its outer surface
  • There are differing appearances of osseous erosion with is helpful when determining pathology
  • ***It is the primary feature of all joint disorders affecting the foot except osteoarthritis, Charcot and septic arthritis
  • EVERYTHING ELSE will have an erosion – KNOW THIS
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15
Q

Types of osseous erosion

A
  • Bare area
  • Pannus
  • Dot-dash, skipping
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16
Q

Bare area

A
  • Bare area: the bony surface covered by only periosteum or perichondrium between where the cartilage ends and the joint capsule inserts, which is in contact with the synovium and its fluid
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17
Q

Pannus

A
  • Pannus: inflamed synovium, which invades the bare area, making the outer margin of subchondral bone disappear on radiograph
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18
Q

Dot-dash or skipping

A
  • Dot-dash, skipping or skip-appearance: the subtle early disappearance of the outer margin of subchondral bone seen with pannus
  • Eventually the localized loss of marginal bone (decreased density) of an inflamed synovium leads to an ill-defined and irregular appearance of the bone, days to weeks after onset of symptoms
  • Well-defined erosion occurs several months to years after onset of symptoms
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19
Q

Subchondral resorption

A
  • Subchondral bone plate: the thin white line at an articular margin where the cartilage ends and bone begins, which is normally well defined on x-ray
  • KNOW THE DIFFERENCE&raquo_space;> Subchondral resorption involves the central part of the joint whereas erosions are marginal
  • It is the primary radiographic feature of septic arthritis and Charcot neuropathic osteoarthropathy
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20
Q

Arthritis mutilans

A
  • Erosions involve both margins (medial and lateral) of any MPJs or IPJs as well as the proximal phalangeal base
  • AKA resorptive arthropathy
  • Characterized by concentric bone resorption and primary joint destruction (osteolysis)
  • The resorption can extend to include the metadiaphyseal cortex, which is referred to as “pencil-in-cup” deformity
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21
Q

Pencil-in-cup deformity

A
  • Traditionally associated with psoriatic arthritis, however forefoot Charcot and, to a lesser extent, RA of the 5th MPJ  KNOW ALL OF THESE
    o RA affects the 5th MPJ always
    o Erosions of RA typically initially occur MEDIALLY on the joint, except for the 5th joint where they occur LATERALLY
    o **    THIS HAS BEEN TESTED ON BOARDS    *
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22
Q

Bone production: secondary radiographic findings

A
  • Includes subchondral sclerosis (eburnation), periostitis, “whiskering”, “ivory phalanx” and Martel’s sign
  • Secondary radiographic findings, including bone production, can further narrow down differential diagnosis
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23
Q

Subchondral sclerosis (eburnation)

A
  • DJD sclerosis occurs centrally in the joint and…
    o On the concave phalanx in the first MPJ
    o On the concave navicular side of these joints
  • ***Forces on the head of the first metatarsal causes bone thickening and strengthening, therefore damage to the base of the proximal phalanx, not the head of the first met
  • Ill-defined increased density found in periarticular bone, commonly associated with post-traumatic osteoarthritis***
  • Diffuse sclerosis involving an entire bone is associated with the repair and remodeling phases of ***Charcot neuropathic osteoarthropathy in the tarsus
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24
Q

Periostitis

A
  • The presence of periostitis near the metaphysis of a symptomatic MPJ or IPJ is highly suggestive of seronegative arthritis***
  • The periostitis is short lived (few weeks) before it becomes continuous with the bony margin
  • Can also be seen with septic arthritis and forefoot Charcot neuropathic osteoarthropathy
25
Q

Whiskering

A
  • Whiskering is a variation of periostitis seen particularly with psoriatic arthritis***
  • Whiskering has a speculated appearance radiating away from the bone margin
  • It characteristically involves the hallux, but can also involve the lesser digits
  • Frequently accompanied by ill-defined bony sclerosis
  • Whiskering appears to represent concomitant new bone formation and erosion of capsule and ligaments
26
Q

Ivory phalanx

A

KNOW THIS

  • When the distal phalanx of a digit is affected, it becomes sclerotic relative to normal bone density and is known as an ivory phalanx
  • It is also associated with psoriatic arthritis***
27
Q

Overhanging margin of bone (Martel sign)

A
  • The well-defined erosion of chronic gouty arthritis*** occasionally leads to an overhanging margin of bone where there is new bone formed at the margin of erosion
  • It seems as if the body is responding to the presence of tophi by attempting to encapsulate or wall it off
28
Q

Joint space narrowing

A

o Uniform: Seen in inflammatory arthritis (rheumatoid)
o Non-uniform: Seen in degenerative arthritis (osteoarthritis), post-traumatic arthritis and septic arthritis
o Ankylosis (end stage): Seen in seronegative spondyloarthritis (IPJ) and midfoot rheumatoid arthritis

29
Q

Normal joint space

A

o Seen in gouty arthritis

30
Q

Joint space widening

A

o Uniform: Early inflammatory arthritis (with acute synovitis)
o Non-uniform: Early psoriatic arthritis (extensive erosion with fibrous tissue deposition

31
Q

Generalized soft tissue edema

A

o Not associated with any type of arthritis
o Associated with cardiac disease, acromegaly, cellulitis, venous insufficient, lymphedema
o When present in a patient with arthritis, it is secondary to another disease process

32
Q

Regional soft tissue edema

A

o Edema confined to a small segment of the body (i.e. entire digit = sausage toe)
o Associated with acute septic arthritis, seronegative arthritis (sausage toe), acute gouty arthritis or Charcot of the midfoot (could also be diffuse)

33
Q

Local soft tissue edema

A

o Joint effusion is edema associated with synovitis which appears as increased soft-tissue density on x-ray – this is highly associated with inflammatory joint disease (rheumatoid or seronegative spondyloarthritis)
o The synovitis of post-traumatic arthritis can appear identical to that of an inflammatory joint disease on radiographs

34
Q

Soft tissue masses

A
  • Tohpi in gout
  • RA nodules
  • Pigmented vilonodular synovitis (PVNS)
35
Q

Tophi in gout

A

o Well-defined masses that are found adjacent to joints or at extra-articular sites
o Occasionally exhibit calcification and are distributed asymmetrically in the foot

36
Q

RA nodules

A

o Seldom found in the foot, but when found may be radiographically indistinguishable from gouty tophus, except there is rarely calcification of RA nodules

37
Q

Pigmented vilonodular synovitis (PVNS)

A

o A PVNS is an example of a soft tissue tumor that manifests in a periarticular location and causes articular erosions (located adjacent to the soft tissue mass)
o Usually monoarticular, but can be seen as polyarticular in the midfoot

38
Q

Soft tissue calcifications

A
  • Gout
  • Pseudo gout
  • Hydroxyapatitie
39
Q

Gout

A

o Monosodium urate crystals may be deposited in the joint capsule, synovium, cartilage, subchondral bone or periarticular tissues
o Visualization of calcified crystals is easiest to see in the periarticular soft tissues
o A collection of MSU crystals is called a tophus, which is occasionally seen with chronic tophaceous gout
o Calcification of a periarticular soft tissue mass situated adjacent to erosion is highly suggestive of gouty arthritis
o Small, punctate calcifications are seen

40
Q

Pseuodogout

A

Calcium pyrophosphate dehydrate (CPPD) = PSEUDOGOUT
o CPPD deposition disease radiographic features include joint space narrowing, subchondral sclerosis and loose osseous bodies
o Calcifications can occur in articular and periarticular soft tissues
o Large calcifications seen in chondrocalcinosis are primarily CPPD crystals
o Seen in MPJ, tarsal joints (mostly talonavicular) and ankle
o ***Likes to calcify cartilage

41
Q

Hydroxyapatite crystal deposition disease (HADD)

A 
Hydroxyapatite crystal deposition disease (HADD) 
o	AKA calcifying tendonitis 
o	Hydroxyapatite (HA) crystals 
o	The clinical course may mimic single-joint symptoms of gout or pseudogout 
o	Round or oval calcifications are found within the course of a tendon
o	Linear or punctate calcifications are found along the margins of affected joints 
o	Can also see large, amorphous calcifications adjacent to a joint
42
Q

Detritus

A
  • AKA loose osseous bodies or “joint mice”
  • Detritus vary considerably in size/architecture
  • Occasionally seen in osteoarthritic joints or when trauma causes osteophytes or subchondral bone with overlying cartilage to break off
  • Bone fragments can float or become wedged in the joint or synovium and tend to enlarge over time
  • Large osseous fragments in the midfoot and tarsal joints are suggestive of either post-traumatic arthritis or Charcot
43
Q

Geode

A
  • AKA subchondral bone cyst or pseudocyst
  • Since the term cyst implies an epithelial-lined cavitary lesion, the term geode is used
  • It is a subarticular area of rarefaction, usually presenting as a geographic lytic lesion
  • Seen in osteoarthritis, rheumatoid arthritis, osteonecrosis and CPPD disease***
    o He likes to think of a geode as a sign of DJD or osteoarthritis – bone rubbing on bone
  • May mimic erosion, especially along medial 1st met head
    o Radiolucent, but sometimes a sclerotic rim
44
Q

Geodes in OA

A
  • Osteoarthritis: subchondral geode w/ sclerotic margin, due to bone contusion/synovial intrusion
45
Q

Geodes in RA

A
  • RA: identical to an osteoarthritic geode, but lacks sclerotic margin, likely formed by pannus invading the subchondral bone
46
Q

Geodes in CPPD

A
  • CPPD: similar to osteoarthritis, except geode may be bigger, same mechanism as osteoarthritis
47
Q

Geodes in osteonecrosis

A
  • Osteonecrosis: forms from osteoclastic resorption of necrotic bone, may be surrounding sclerosis
48
Q

Gouty arthritis changes

A
  • Gout: MSU crystals deposit in soft tissue and bone when chronic tophaceous gout is present, early sign is that multiple areas of bone loss (rarefaction) will be present with absence of erosion
49
Q

Alignment abnormalities, including subluxation and dislocation

A
  • Fibular deviation of digits, especially the hallux, is seen in rheumatoid arthritis***
  • Generally does not involve 5th digit, likely due to shoe gear preventing lateral deviation
  • Erosion may or may not accompany fibular deviation of the digits
  • Hallux abductovalgus and lesser toe deformities are non-specific and seen in the absence of RA
  • Subluxation and dislocation are seen in the rheumatoid forefoot, especially the lesser MPJs, where the digits dislocate superiorly and are superimposed on the proximal phalanx base, potentially making the metatarsal head appear ankylosed in an AP image
50
Q

Extra-articular erosions, including RA and seronegative arthropathies

A
  • Erosions can be found at distant sites from involved joints in rheumatoid arthritis** and seronegative arthropathies (including psoriasis) **, commonly in the calcaneus
  • The site at the calcaneus that is most frequently affected is the posterosuperior aspect at the bursal projection, where the bursa lies over the bone and the bursa is lined by synovium and the bursal projection is covered with cartilage
  • Bursitis in RA or seronegative arthropathies frequently cause rarefaction and erosion of the calcaneus, which can sometimes be bounded by sclerosis
51
Q

Enthesopathy

A
  • Enthesopathy represents an alteration at any ligamentous or tendinous attachment to bone and may present as a spur formation, erosion or a combination of these
  • Enthesopathy is associated with many joint disorders and commonly affects the inferior calcaneal tuberosities and the posterior calcaneus (5th met tuberosity is infrequently affected)
52
Q

Enthesopathy in DJD and RA

A
  • ***DJD and RA: usually well-defined (unless early on in process) with degenerative spurs appearing pointed or hook-shaped
53
Q

Enthesopathy in seronegative arthropathies

A
  • ***Seronegative arthropathies: calcaneal spurs tend to be large and irregular with ill-defined erosions accompanying these spurs
54
Q

Enthesopathy in gout

A
  • ***Gout: Inferior calcaneal spurs can be seen with gout, but are smaller and ill-defined
  • Enthesopathy are common in INFLAMMATORY diseases
55
Q

RA: Why do we see marginal, not central bone destruction?

A
  • Bone with cartilage is protected from pannus formation (think of pannus as a destructive fluid)
  • RA is a disease of synovium, which does not attach to cartilage
56
Q

4 seronegative spondyloarthropathies

A

o Psoriatic arthritis
o Ankylosing spondylitis
o Reactive arthritis
o Enteropathic arthritis

57
Q

Seronegative spondyloarthropathies - common clinical and radiographic features

A

o Histocompatibility antigen HLAB27
o Peripheral arthritis of the foot that is oligoarticular and asymmetric
o Possibility of sacroiliitis (SI joint inflammation), spondylitis (vertebral inflammation), enthesitis (tendon, ligament or joint capsule insertion inflammation) and uveilitis (uvea inflammation)
o Predominant symptoms are chronic low back pain and or peripheral arthritis
o Erosion will often have new bone proliferation adjacent to it, unlike RA
o Pathogenic hallmark of seronegative spondyloarthritis is enthesitis, inflammation at enthuses, which is where soft tissue structures (ligament, tendon) insert onto bone
o This is why erosion along inferior calcaneus with associated new bone proliferation is particularly suggestive of seronegative spondyloarthropathies

58
Q

Bywater sign

A

o When there is an extraarticular erosion at the insertion of the Achilles tendon
o Suggests that the entheseopathy is part of an inflammatory arthropathy condition
o Since the bursa is filled with synovial fluid, the bursa will be involved

59
Q

Psoriatic vs RA

A
  • Psoriatic will never have periarticular osteopenia
  • This is included in our notes since it is in Christman text and is true in most cases
  • There are exceptions to this rule

#2 BOARDS (14 decks)

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