1
Q
What is TR (time repition) in MRI pulse sequence?
A
Time between each RF pulse, varies from 500msec to 4000msec
2
Q
What is TE (time echo)?
A
Time each RF to listening for signal generated by patient varies from < 40msec to 100msec>
3
Q
What determine the type of image created?
A
TR and TE times
Time Repetition
Time Echo
4
Q
T1 in MRI (Time 1) main characteristics
A
- Weighted image with short TR (500msec) and short TE (40msec)
- Water is dark (CSF, edema, synovial fluid - NOT water in fat)
5
Q
What does the pathology look like on a T1 film?
A
Usually dark on T1 due to edema (most pathologies have edema with water)
6
Q
T2 MRI main characteristics:`
A
Weighted image - long TR (1500-4000msec)
- Long TE (80-100msec)
- Water is BRIGHT
7
Q
T2 allows what?
A
System to go back to neutral state
- Listened long enough for echo signal, so now we see water that looks brighter, and can now see edema
8
Q
what color is bone marrow on T2 MRI?
A
Gray
9
Q
What does fat look like on MRI?
A
It re-aligns quickly and appears as bright white on MRI
- Fatty tumors, subcutaneous fat, yellow marrow
10
Q
Contrast in MRI (signal intensity) is related to ____ ?
A
How tightly bound water is to time
11
Q
Describe the Hydrogen properties in MRI contrast formation?
A
Hydrogen is more loosely bound in fat than water substance like CSF; re-aligns faster in fat than CSF
12
Q
Spin-echo flip angle?
A
90 degrees
13
Q
Gradient echo flip angle:
A
< 90 degrees
14
Q
SE T1: (Fat color)
A
- Fat image
- Structures containing fat appear brighter/whiter (bone marrow, subcutaneous fat);
15
Q
SE T1: (Water containing) -
A
- Edema, neoplasm, inflammation, CSF, large amounts of Fe) appears DARK
* long TR, short TE
16
Q
SE T1 is standard or not?
A
Standard
17
Q
SE T2 first echo:
A
Proton density, good anatomical detail, has properties of both T1 and T2
- Not done anymore
18
Q
SE T2 second echo water image (loosely bound)?
A
Loosely bound water (neoplasms, edema, inflammation, healthy nucleus puposus, CSF) appear bright/white
19
Q
What is the appearance/what does it detect of tightly bound or low water content on SE T2 second echo?
A
Ligaments, menisci, tendons, calcium, sclerosis, cortical bone or large amounts of Fe appear dark/black
20
Q
Main charac. of SE T2 second echo?
A
- Classic Image
- Standard
- MRI is the ONLY one that can see water in an IVD
21
Q
FSE, fast spin echo:
A
Multiple echoes/TR, faster exam time, good in neuroimaging especially spine myelographic images
- Very sensitive to EDEMA
22
Q
Gradient Echo:
A
Fast MRI using short TR and TE with (flip angle)
- >90 degrees
- Provides a T2 image in less time, but does sacrifice some signal
- Terms: GRE, GRASS, FLASH, FISP, MPGR, SPGR
23
Q
Fat Suppression:
A
Technique that suppresses signal from fat, making small areas of pathology (often appearing bright because of edema) more evident and increasing the overall sensitivity of the exam, usually accomplished
(STIR)
- VERY SENSITIVE TO WATER
24
Q
Techniques providing function information:
A
Kinematic (kMRI) functional joint movement
25
MRA is used to ____ ?
image **_VASCULAR_** flow
26
Diffusion MRI does what?
Reveals disturbances of fluid restriction as seen in stroke
27
MR spectroscopy can display what?
Concentration of biochemical metabolites
28
Functional MRI (fMRI) does what?
Displays changes in oxygen concentration associated with neural activation, and provides high resolution imaging of the brain
29
What can upright MRI reveal?
Weight bearing (kMRI) can reveal pathologies that may be missed (canal stenosis, transitional motion, & disc lesion)
30
WHat is the most important clinical indication to use an MRI?
Suspicion of C, T, or L spine disc disease
_***\*\* MRI IS THE GOLD STANDARD OF DISC PATHOLOGY***_
* IS THERE A **MASS**?
31
Suspicion of what would be a good reason to send out for an MRI?
**_Central canal, foramina, or lateral recess stenosis_**
**SPinal CORD pathology - MYELOMALACIA**
32
What is a congenital disorder that would be of good use for an MRI?
Arnold Chiarimalformation (herniation of cerebellum through foramen magnum) syringomyelia
33
What would be some good things to evaluate using MRI?
* **Bone marrow infiltration**
* Primary bone neoplasms (benign and malignant)
* Suspected failed back syndrome - Gd DTPA
34
What is a red flag, and would suggest getting an MRI?
FAILURE TO IMPROVE with TREATMENT
Persistent bone pain with malignant history
35
SHould a patient have painful scoliosis?
NO
80% is not painful
36
What's the biggest MRI contraindication?
1st trimester pregnancy
37
What is something in the body that would cause a contraindication of MRI?
Ferromagnetic artifacts
* aneurysm clips, intraocular foreign bodies (welders), permanent eyeliner, subcutaneous metal shards and shrapnel
38
Cardiac Pacemakers/defibrallators/implanted neurotransmitters (TENS) unit would mark a red flag for what?
MRI
39
T1 film
40
T2 film
41
WHen does bone marrow change on bone pathology?
FIRST
42
STIR VS FAT SUPRESSION
43
MRI cervical spine, sagittal T1 and T2
44
pic of herniated discs
45
disc herniations can be:
Soft discs, herniation without surrounding osteophytosis, can be acute, subacute or chronic
46
Herniated disc
47
Contained central protrusion
48
What would Cauda Equina Syndrome present as?
1. _**Saddle Parestesia or anesthesia\*\***_
2. _**Bowel and Bladder distrubances\*\***_
3. Lower extremity motor weakness and sensory deficits
4. Reduced or absent lower external reflexes
5. Low back pain
6. Uni or bi lateral sciatica
_**\*\*\*IMMEDIATE REFERRAL\*\*\*\***_
49
What is this?
Synovial Cyst
50
What are characteristics of synovial cyst?
Can have them with no symptoms, no way to see on plain film, and complication of facet DJD
51
What are the main points of an annular tear?
* POSTERIOR anular fibers
* clincially significant
* Pain generator due to nociceptors
* CAN MANAGE chiropractically
52
Clinical Significance of Modic Changes:
**_Type 1:_** Represents marrow edema. Painful! Associated with an acute process. Converts to
**_Type 2:_** Represents fatty degneration of subchondral marrow. Associated with a chronic process
**_Type 3:_** Correlate with extensive bony sclerosis on plain radiographs
53
Describe fatty infiltration of spinal musculature:
* Semispinalis cervicis or lumbar multifidus
* Strongly associated with LBP
* Is an indicator for spine stabilization exercises
* Responds favorably to neuromusculoskeletal rehab and therapy exercises
54
WHat is Tarlov's Cyst?
* Perineural cyst - fluid filled meningeal dilation of the nerve root sheath
* up to 9% of pop.
* Usually asymptomatic
* 20% do have symptoms --\> if it expands
* May need drainage
55
Levoscoliosis =
Wrong way
Convex Left \> 15 degrees may indicate interspinal pathology
56
What is pictured?
Arnold Chiari
57
What is a descriptive term for **decreased bone density?**
**_Osteopenia_**
58
Is, "osteopenia" a precise diagnosis?
NO
59
When does osteopenia occur?
When bone resporption exceeds bone formation regardless of specific pathogenesis
60
What are the major causes of diffuse osteopenia:
* Osteoporosis
* Osteomalacia/Rickets
* Hyperparathyroidism
* Neoplasm
61
What is an osteoprogenitor cell?
Originates from the marrow stem cells, develop into osteoblasts
62
What is an osteoblast?
Produces osteoid (soft material) 90-95% collagen, remainder is ground substance (mucopolysaccharides); numerous and large in growing skeleton
* Decrease in # and size at maturity
63
What is an osteocyte?
Arise from osteoblasts that become entrapped in their own osteoid, maintain the integrity of the bone around them
MATURE BONE CELLS
64
What are inactive cells?
inacive/dormant osteoblasts
65
What are osteoclasts?
Bone resorptive cells, derived from hematopoetic monocyte lineage
66
for normal bone density, Osteoblastic activity should =
Osteoclastic activity
67
what is the process in getting to a mature Osteocyte?
1. Marrow stem cell
2. Osteoblast - produces osteoid
3. Osteoid is mineralized by Calcium Hydroxyapatite
4. Osteocyte is formed
68
bone resorption
69
Water is responsible for _____ % of wet weight of bone?
20
70
Cellular components make up a ____ fraction of bone weight?
**TINY**
71
What is the remaining organic matrix/osteoid?
* **(90% collagen) and 10% mucopolysaccharides account for 30% by _dry_ weight**
* **The inorganic material accounts for 70% of osseous tissue by _dry_ weight**
72
Bone quality ratio aka
_***MATRIX vs. MINERAL RATIO\*\*\****_
73
Organic matrix/osteoid is _____ , remaining _______ is what?
1. 90% collagen
2. Remaining 10% is mucopolysaccharide material (ground substance)
74
Inorganic material exists as what?
**_Calcium Hydroxyapatite_**
## Footnote
* It is destributed regularly along the length of collagen fibrils surrounded by ground substance
* ***Ca10(PO4)6OH2***
75
What does the skeleton do in relation to calcium?
***Contains 99% of the body's calcium and serves as the reservoir for maintenance of serum calcium; normally 10mg/dL \*\*\*\****
76
70% of plasma calcium is believed to be maintained by?
A continuous exchange of calcium ions between bone and extracellular fluid
77
What is defined as producing an inward flux of calcium from extracellular fluid?
Hypocalcemia
78
if 70% of plasma calcium is an exchange between bone and ECF, whats the remaining 30%?
Mediated by the actions of the parathyroid hormone and other hormones
79
The process of resorption and formation occur ______ ?
Continuosuly in normal bone and are related to the function of osteoclasts and osteoblasts, whose function must remain in balance
80
Osteoclasts exists where?
In pits on bone surface called resorption bays or Howship's lacuae
81
What are the osteoclasts main function?
Secrete acid to breakdown hydroxyapatite, and collagenase to break down osteoid
* May secrete substances to attract and promote function of osteoblasts
82
What is the key production of osteoblasts?
Produce osteoid/matrix which is then mineralized by calcium hydroxyapatite
* Scurvy can actually impede the osteoblasts ability to produce osteoid/matrix
83
What is the substance capable of directly or indirectly stimulating osteoclasts or increasing formation of new osteoclasts?
**PTH**, active metabolites of **Vit. D**, Prostaglandin E2, Thyroid hormone, Heparin
84
Is calcitonin inhibiting or excitatory when it comes to osteoclasts?
Inhibitory
85
What is osteoporosis characterized as?
Qualitatively normal, but quantitatively deficient bone
86
What is the **_MOST FREQUENT BONE DISEASE IN HUMANS?_**
**_OSTEOPOROSIS_**
87
What is associated with **decreasing osteoblastic function with age?**
Osteoporosis
88
When is osteoporosis radiographically significant?
when **_30-50%_** bone loss (spine closer to 50)
89
Where is osteoporosis predominant?
**Axial** **Skeleton**
90
Is osteoporosis bone softening?
NO
91
What is Osteomalacia defined as?
Pathology, **inadequate mineralization of osteoid**
Immature cortical and spongy bone (osteomalacia) and interruption of orderly development and mineralization of physis (rickets)
92
What is related to the ***_deficiency of calcium, Vit D, or phosphorus?_***
Osteomalacia
93
Is Osteomalacia a quality or quantity problem?
Quality, its bone SOFTENING
94
pic of Vit D process in body
95
What are the deficiencies of osteomalacia related to?
1. Dietary
2. Liver Disease
3. GI disease
4. **RENAL DISEASE\*\*\* (with loss of phosphorus)**
5. Sunlight def.
96
Osteoid is a soft material and gains it's hardness by adding what?
Calcium and minerals
97
Hyperparathyroidism accelerates what?
Osteoclastic activity
98
Describe primary HPT:
Increased production of parathormone by **glands**, usually benign adenoma = HYPERCALCEMIA
99
Describe Secondary HPT:
Abnormal stimulation of glands by sustained hypocalcemia: **Chronic renal disease**, GI malsorption,
* serum calcium - low, low normal and _phosphorus is elevated_
100
Describe Tertiary HPT:
In long standing HPT, parathyroid function may become autonomous, can be related to ectopic tissue, paraneoplastic syndrome, ***may have hypercalcemia***
* Can be from _external stimulus_, ext production of parathyroid hormone via tumor
101
What is the parathormone function (main):
**ULTIMATELY INCREASE SERUM CALCIUM**
102
Osteoblastic inhibition would be a characteristic of what?
Parathormone function
103
If serum calcium drops, what does parathormone do?
Parathyroid hormone increases serum calcium, it is a positive feedback
104
What are the 3 features in regards to the function of Parathyroid hormone function?
* Renal Conservation of calcium and inhibiton of phosphate resorption
* Renal stimulation of 1-alpha-hydroxylase causing increase formation of **_1,25 Vit. D_**
* Indirect effect on GI absorption of calcium
105
What is calcitonin secreted by?
The human parafollicular or C cells of the the human thyroid gland
106
What is calcitonin controlled by?
Serum calcium levels
107
What does calcitonin inhibit?
Bone calcium resorption by decreasing osteoclastic function and may lead to hypocalcemia and hypophosphatemia
* also inhibits GI calcium abosorption
108
What does calcitonin stimulate?
Osteoblastic activity
109
In regards to the kidney, what does calcitonin inhibit?
Renal tubular cell reabsorption of calcium
110
What is used to treat pagets disease?
**Calcitonin**, inhibits clastic activity
111
Where is osteoporosis most prevelant?
AXIAL SKELETON:
* Vertebral column
* Pelvis
* Ribs
* Sternum
112
What is the major cause of osteoporosis?
**_AGE RELATED CONDITIONS:_** Senile and postmenopausal states (by far most common and most often seen in clinical practice)
113
Describe the role of medications in regards to Osteoporosis:
**_Steroids_** (many pts; chronic use end up w/bone density issues), heparin
114
What are some endocrine states that would affect osteoporosis?
HPT, hyperthyroidism, Cushing's, acromegaly, pregnancy, diabetes mellitus, hypogonadism
115
What are some deficiency states that could affect osteoporosis?
**SCURVY\*\*\*,** malnutrition, calcium deficiency
116
Major causes of generalized osteoporosis:
* Age related
* medications
* endocrine states
* deficiency states
* alcoholism
* chronic liver disease
* anemic states
* osteogenesis imperfecta
* idiopathic condition
117
What would be the reason for localized osteoporosis?
**Immobilization** and disuse (fracture healing)
* Some degree of bone atrophy occurs; sustained Hyperemia in bone (too much blood flow in bone marrow) overstimulates osteoclasts
118
What is a VERY important reason for localized osteoporosis?
_**Complex regional pain syndrome \*\*\***_
Sympathetically mediated pain syndrome, RSDS
had FOOSH injury 3-4 months ago
119
What is a type of osteoporosis that would cause pain?
Transient regional (localized) osteoporosis
* Transient (temporary) osteoporosis of the hip (TOH)
* Commonly seen in men
* Regional Migratory Osteoporosis
120
what is pictured?
Complex Regional Pain Syndrome (CRPS) /Sympathetic Mediated Pain Syndrome (SMPS)
121
Describe the key points of Complex Regional Pain Syndrome (CRPS) / Sympathetic Mediated Pain Syndrome (SMPS):
* Typically follows trauma
* **VERY PAINFUL (suicidal type of pain)**
* Just around joints (r wrist; can also be rheumatoid, lupus, scleroderma, etc)
\*\*\* Common in WRIST
122
Transient Osteoporosis of the hip usually involves?
Healthy middle aged men, rarely women, but almost exclusively during the 3rd trimester of pregnancy or the immediate postpartum period
* Usually **_SINGLE HIP_**
123
Transient Osteoporosis of the hip is characterized by what?
**Acute disabling pain** in the hip and functional disability without a history of previous trauma
124
Histological exam of transient osteoporosis of the hip reveals what?
Focal areas of thin and disconnected bone trabeculae covered by osteoid and active osteoblasts, **active osteocytes** in the lacunae
125
what is this
TOH
Transient osteoporosis of the hip
* should clear up on its own
126
What are the key features of regional migratory osteoporosis?
RMO was discovered by Duncan et al
* Occurs in 5-41%
* It may occur in different or same joint in an unpredictable time interval after the onset of the first symptoms
* Can stay in left knee, jump to R knee, or diff joint
* The joint nearest to the diseased one is the next to be involved
127
?
RMO of the ankle
128
What is general slowing down of osteoblastic activity?
Osteoporosis
129
What is the etiology of osteoporosis?
multifactorial
130
When does the gradual loss of bone occur with osteoporosis?
Beginning in the 5th or 6th decade in men and 4th decade in women
* 40's and 50's in men
* 30's in women
131
\> 50 y/o men lose bone at ______ ?
.4 % a year
132
\> 35 y.o. women lose at _________ ?
**.75-1% increasing to 2-3% post menopause**
133
There is a significant loss of ____ bone in women who have osteoporosis?
Cortical
134
What disease may cause "fish vertebrae"?
Osteoporosis
135
Pic of osteoporosis byproducts
136
What type of bone is lost in osteoporosis?
Horizontal trabecular
137
When does the anterior wedge of osteoporosis normally occur?
Post Traumatic - Typically get with axial load trauma on normal bone. Edge anterior b/c vertebrae posterior is stronger
138
What is the worst sign when dealing with osteoporosis?
Losing posterior and ant. body height, commonly via Mets and Mult Myeloma
* MOST COMMON PATHOLOGICAL COLLAPSE
139
What can cause fish vertebrae?
Biconcave (both endplate compression)
**_- Osteoporosis_**
**_- Mult Myeloma_**
140
141
where are common fracture sites of osteoporosis?
142
what could this be?
**_Osteoporosis, but could be multiple myeloma or Mets_**
## Footnote
* Normally would have white cortex, grey medullary cavity, and very gray soft tissue
143
144
what is this?
145
Hemangioma is what?
Benign bone tumor
146
?
147
?
148
Percutaneous Verebroplasty fixes what? (pic)
149
Due to percutaneous vertebroplasty, ant. wedge fracture possibly
**_(liquid cement shows up extremely white on X ray)_**
150
When does an insufficiency fracture occur?
When the elastic strength of the bones is not sufficient to withstand normal physiologic stress (type of stress fracture)
151
Simplistic def. of insufficiency fracture?
normal stress on abnormal bone
152
What is a major cause of an insufficiency fx?
Osteoporosis
153
Characteristically, what does an insufficiency fracture involve?
Weight-bearing bones of the lower extremity, **_often bilateral_**
154
What are 2 main places of insuf. fx?
**Sacrum and Pubic Rami**
## Footnote
(MICRO fractures in trabeculae)
155
Insufficiency fracture
156
?
Honda sign!
Insufficiency fx. (associated with osteoporosis)
157
What are the osteoporosis risk factors?
158
Osteoporosis is not \_\_\_\_\_
a direct calcium deficiency, but an osteoblastic deficiency
159
Calcium deficiency =
Osteomalacia
160
What is the most sensitive meausure of bone mineral density?
DEXA/DXA Scan
161
DEXA/DXA Scan is dual \_\_\_\_\_\_
X-ray Absorptiometry (DEXA/DXA)
162
What is the MAJOR feature of a DEXA/DXA scan?
Very sensitive scan to detect early bone (mineral) density loss (only thing we need to know about DEXA)
163
What is an aka for Hypovitaminosis C?
Scurvy/Barlow's Disease
164
What is Hypovitaminosis C associated with?
Long term deficiency of Vit C, seen predominantly in infants
* Children have specific and unique findings
* 90-95% of osteoid is collagen
* If it can't produce, they slow down bone production
165
What is Vit C essential for?
The formation of collagen, osteoid and endothelial linings - bleeding gums, muscles, soft tissues, cutaneous petechiae and hematuria
166
What is the main "Hallmark" in regards to hypovitaminosis (Scurvy/Barlow's disease)?
Spontaneous hemorrhage due to capillary fragility - bleeding in subperiosteum: Bone PAIN
167
Osteopenia is defined as:
Decreased osteoblastic function
168
T/F, you will have osteopenia with Hypovitaminosis C?
TRUE
169
An adult with Hypovitaminosis will present as similar to what disease?
Osteoporosis
170
What is subject to bleeding in Hypovitaminosis C?
**_Capillary Fragility_** is why you are susceptible to bleeding
171
Is Scurvy a mineralization disorder?
NO
172
What is the major sign in kids in regards to Scurvy
Trummerfield sign, band of radiolucency
173
Major radiographic signs of Scurvy?
174
What is a dense bright Zone of provisional mineralization (ZPM)?
White line of Frankel
175
What is a dense cortical margin of epiphysis with radiolucent center?
Wimberger's Ring
176
What is an irregular metaphyseal margin?
Corner (angle sign)
177
What is a Pelken's sign?
Bony protuberances at margin of ZPM
178
_**What is Trummerfield/Scorbutic zone? \*\*\***_
Radiolucent metaphyseal band directly beneath ZPM, due to defective bone formation --\> LEUKEMIA LINES
* *failure of normal bone formation*
179
?
180
3 big signs of Scurvy in CHILDREN?
1. Frankel
2. Trummerfield
3. Subperiosteal Hemorrhage
181
Define the name of Hypovitaminosis in adults and kids -
Kid = "Rickets"
Adult = "Osteomalacia"
182
What is the major takeaway from Osteomalacia?
It is based on a **_QUALITY_** deficiency, and there is an abundance of unmineralized osteoid, thus causing **_BONE SOFTENING_**
183
How does osteomalacia clinically present itself?
Muscle weakness and _bone pain_ on palation
* **_Deformities_** - Pelvis (sacrum could sink down into pelvis), femur (bows laterally), tibia, and spine (prone to compression fractures or scoliosis)
184
What are the main bone softening disorders?
Osteomalacia, Paget's, and Fibrous Dysplasia
185
Describe the bone ratio in osteomalacia :
The **ratio** of mineral to osteoid is **_defective_**; not enough mineral to put on osteoid; Too much unmineralized osteoid; **_BONE SOFTENING_** = bowing deformities
186
Osteomalacia can a lot of times occur due to:
Hypophasphotemia (renal disease), but can also be due to not enough Ca+
187
What are the radiographic features of Osteomalacia?
* Osteopenia
* Coarsened Trabecular pattern
* Pseudofractures
* Loss of cortical definition
188
Describe pseudofractures and their importance in bone softening disorders:
First described by Looser in 1930 and later by Milkman in 1934, they are defined as
* Little band of unmineralized osteoid
189
Pseudo fracures are only seen when?
BONE SOFTENING DISEASES
190
What are deformities of Osteomalacia?
Weight bearing bones; triradiate pelvis, acetabular protrusion, femoral and tibial bowing, kyphoscoliosis and endplate concavity, bell-shaped thorax
191
what are common locations for osteomalacia?
Femur, ribs, and pelvic rami
192
?
Rickets
193
194
195
What is a seam of unmineralized osteoid?
Pseudofracture
196
Where do pseudofractures occur?
Happens in ribs, boney pelvis, femur, but **_NOT SPINE_**
197
Pseudofractures almost always ____ ?
Perpendicular to cortex
198
Describe polyostotic Fibrous Dysplasia:
Not monostotic --\> polyostotic = multiple bones
199
What are the akas of Pseudofractures?
Looser's lines, Milkman's syndrome, increment fractures, osteoid seams, **_umbauzonen_** \*\*\*
200
What is pediatric osteomalacia with same etiologies, may begin as early as 6-12 months?
RICKETS
201
What is rickets defined as?
Renal tubular loss of phosphorus, not cured by administration of Vit D (resistant/refractory rickets) aka renal rickets (kidney losing phosphorus)
202
Renal Rickets + Secondary HPT =
Renal Osteodystrophy
203
What does Rickets clinically present with?
Muscle tetany, irritability, weakness, delayed bone development, small stature and bone deformities/bowing
* Enlargement around growth plates (trumpeting) and rib ends (rachitic rosary)
204
What is the most common cause of Rickets/Osteomalacia?\*\*\*\*
**_KIDNEY DISEASE_**
205
?
RICKETS
206
Rickets presents with loss of _____ ?
Zone of Proliferative Mineralization
207
Describe the mineral process of Rickets:
There is a ***_mineral deficiency_*** (calcium or phosphorus) - loss of ZPM & cant make bone after it
* **BONE SOFTENS**
* **CANT MAKE NEW BONE IF YOU DONT HAVE A ZONE**
208
What is the "hallmark" finding of Rickets?
Loss of ZPM (easier to see in big bones)
209
?
Trumpeting, associated with Rickets
210
?
Richatic Rosary
211
What is X linked Hypophosphatemia?
Genetically transmitted, X linked dominant trait
* **Renal tubular loss of phosphate, part of Fanconi Syndrome --\> _Resistant to Vit D administration (Not lack of Vit D intake)_**
212
What develops from X-linked Hypophosphatemia?
Childhood rickets develops, and patients are short, bowlegged and stocky
213
What happens in the adult skeleton from X-linked Hypophosphatemia?
**Develops osteosclerosis and enthesopathic paravertebral ligament.** Ossification may resemble AS or DISH
214
What is a clinical finding of X-linked Hypophosphatemia?
Decreased pedicle length, **lumbar spinal stenosis**
215
X-linked Hypophosphatemia is a type of \_\_\_\_
**Dwarfism**
216
X-linked Hypophosphatemia is a ______ of Osteomalacia?
Subtype (the phosphorus side of it)
217
What is Hypophosphatasia?
Rare genetic disorder related to **low serum alkaline phosphatase production by _osteoblasts_**
* This helps link collagen to osteoid (linkage disorder)
218
What "resembles rickets"?
Hypophospha**_TASIA_**
219
What are some clinical findings of Hypophosphatasia?
Peculiar radiolucent metaphyseal defects extending from the growth plate into the metaphysis
220
What are some changes that occur due to Hyperparathyroidism HPT?
Histopathologic changes consist of osteoclastic and osteocytic **bone resporption with fibrous tissue replacement** (osteoitis fibrosa cystica, Recklinghausen's disease of bone)
221
What are some major bone changes that occur from Hyperparathyroidism?\*\*\*\*\*\*
Osteopenia, accentuated trabecular pattern, loss of cortical definition, brown tumors and ***_the radiographic/pathologic hallmark - subperiosteal bone resporption_***
* Classic HPT finding = Pathognomonic
222
What body part do we need to see if we suspect HPT?
HANDS
223
is HPT a bone softening disorder?
no
224
What is actually occuring in HPT?
Clasts are working faster than blasts, the clasts take away both calcium and phosphorus (QUALITY prob.)
225
HPT female/male:
3:1 female:male, and
typical patient is 30-50 y.o.
226
Symptoms are usually related to ______ during HPT?
bone, renal, or GI
227
Physical indicators of HPT?
Weakness (hypercalcemia), lethargy, polydipsia, polyuria, renal calculi, and bone tenderness
228
Kidney loses calcium on a ______ in HPT?
Concentration basis
229
Parathyroid Hormone general overview:
* **Osteoclastic and osteocytic stimulation --\>** Increase calcium from bone
* **Osteoblastic inhibition**
* Renal Conservation of calcium and inhibition of Phosphate resorption
* Renal stimulation of 1-a-hydroxylase causing increase formation of 1,25 Vit D
* Indirect effect on GI absorption of calcium
230
Parathyroid hormone increases what?
Calcium and phosphorus out of the bone
231
Describe Primary HPT:
Direct gland involvment: adenoma 90%, carcinoma, hyperplasia, or ectopic tumors (3o).
* Renal function = Normal --\> **_HYPERCALCEMIA and HYPOPHOSPHATEMIA_**
232
Describe secondary HPT:
Sustained gland function from persistant **_hypocalcemia_** predominantly from RENAL DISEASE with loss of calcium and decrease Vit. D formation,
* less likely GI malsorption --\> low normal or **_HYPOCALCEMIA & HYPERPHOSPHATEMIA._**
233
In Secondary HPT, renal disease with hypocalcemia is associated with:
Soft tissue and vascular calcification and osteomalacia - Renal Osteodystrophy/uremic osteopathy (not rare)
234
In secondary HPT, renal disease + Hypocalcemia =
**Soft tissue & Vascular Calcification & Osteomalacia\*\***
235
Describe Tertiary HPT:
With chronic renal failure or malabsorption and long standing 2o who develop autonomous pathological function and **_HYPERCALCEMIA & HYPOPHOSPHATEMIA_**
* "can be due to corrected secondary HPT"
236
HPT bone changes:
**Diffuse Osteopenia and Localized Bone Resorption**
237
**_In HPT, Subperiosteal Bone Resorption_** can be _____ ?
Seen in many locations but hand, middle phalanges radial aspect 2nd-4th digits pathognomonic \*\*\*\*\* TEST
238
What happens with cortical bone during HPT?
**Intracortical bone resorption** within Haversion Canals linear striations
239
Describe **Endosteal bone resorption** within HPT?
Typically hands and other findings (know endosteal bone resorption happens with HPT)
240
Describe **Subchondral bone resorption** when it comes to HPT:
Common, SI, SC, AC, SP (symphysis pubis), and DV junction, can mimic inflammatory joint disease. SI joint sacroiliitis
## Footnote
**DRA** (dialysis related arthropathy)
**DRSA** (dialysis related spondyloarthropathy)
\* Typically related to secondary HPT
241
Describe **Trabecular bone resorption** in HPT bone changes:
Diffuse in skeleton, very prominent in cranium, causes very granular appearance of diploic space "salt and pepper" or "pepper pot skull"
242
Describe Subligamentous Bone resorption of HPT bone changes:
At entheses; trochanters, ischial and humeral tuberosities, elbow, calcaneus, inferior distal end of clavicle
243
Describe **brown tumor/osteoclastoma/Giant cell tumor** in regards to HPT bone changes:
Localized cyst like bone resorption containing fibrous tissue, giant cells and hemorrhages, "brown" color Histopathologic
244
Describe **Acro-osteolysis** in regards to HPT bone changes:
Distal tuft resorption, seen with many other conditions
245
?
Subperiosteal bone resorption associated with HPT
* **Acro**-**osteolysis** --\> TUFTS (tuft resorption)
246
**Subperiosteal bone resorption**
NOT pathognomonic in this location
247
?
248
?
249
?
250
?
Salt and pepper skull
251
?
252
?
253
254
?
255
What is common in Primary HPT?
Brown Tumor and Chondrocalcinosis
256
What is rare in primary HPT?
Osteosclerosis and Periostitis
257
What is common in Secondary HPT?
Osteosclerosis and Periostitis
258
What is rare in Secondary HPT?
Brown tumor and Chondrocalcinosis
259
Additional findings of renal osteodystrophy are observed _____ ?
In association with Secondary HPT, including rickets, osteomalacia, and soft tissue and vascular calcification
260
What is renal osteodystrophy?
Renal disease leading to secondary HPT will push patient into rickets/osteomalacia if hypocalcemic
* Renal Disease + Secondary HPT = RICKETS
261
What is termed renal osteodystrophy/uremic osteopathy?
Comibnation of secondary HPT + osteomalacia + soft tissue and vascular calcification
262
**_Osteosclerosis_** is more commonly seen in _____ ?
**RO** and predominates in the axial skeleton (rugger jersey spine)
263
?
264
DRSA =
Dialysis Related Spondylo-Arthropathy
265
Renal failure patients treated with hemodialysis will have \_\_\_\_\_
**Resolution of RO bone changes**
266
Dialysis resolves what?
RO bone changes
267
Normally after 3-5 years of dialysis, what happens?
**Cervical spine involved is MC**
268
What occurs during DRSA?
Narrowing of disc height, subchondral cysts, endplate erosions, collapse, erosions of contiguous vertebral bodies, facet erosion, spondylolisthesis, peridiscal calcification\*\*\*\*
* Calcification in subcutaneous regions
269
Hypoparathyroidism is acquired or genetic?
Acquired
270
Deficiency of Parathyroid hormone is most commonly from what?
***Excision or trauma to the parathyroid gland during thyroidectomies***
271
What are the 2 main things that occur during Hypoparathyroidism?
**_HYPOCALCEMIA & HYPERPHOSPHATEMIA_**
272
What are some underlying physical changes of Hypoparathyroidism?
**_Bone osteosclerosis (mc)_**, thickening of cranial vault bones, calcification of **basal ganglia**, rarely choroid plexus and cerebellum\*\*\*
test
273
What is happneing within the spine during Hypoparathyroidism?
Rare spine changes of pain, **stiffness with calcification of ALL and posterior spinal ligaments**, resembling DISH
274
Is hypoparathyroidism acquired? expand on it:
YES it is acquired
* Has Ca and P levels like Secondary HPT
* Osteosclerosis like Secondary HPT
275
?
Hypoparathyroidism
276
PHP stands for what?
Pseudohypoparathyroidism
277
PHP is an \_\_\_
**_End - organ resistance to parathormone_**
278
PHP main features:
X-linked dominant and more common in females
* **_MAJOR DIFFERENCE:_*****Genetic***, unlike hypoparathyroidism (which is acquired)
* End/Target-Organ restance to PTH
279
In PHP, what conditions would you see?
**_Hypocalcemia_**, hyperphosphatemia and basal ganglia & soft tissue calcification
280
What is another major difference between PHP and HPT (hypo)?
Characteristic somatotype:
**Short stature, obesity, round face, and brachydactyly (short fingers and toes)**
* Tend to be mentally challenged
_\*\*\* all above is PHP_
281
What does PPHP stand for?
Pseudopseudohypoparathyroidism
282
Describe PPHP:
Normocalcemic form of PHP, same somatotype
* Also _GENETIC_
* Do not have a problem with PTH --\> "false PHP"
283
What is the major difference between PHP and PPHP?
PPHP is **_NORMOCALCEMIA & NORMOPHOSPHATEMIA_**
* Also has Basal Ganglia & Soft tissue calcification
* Both may occur in the same family --\> STOP PROCREATING
284
Neoplasm is described as what?
Widespread marrow infiltration with cancer cells **_(inhibits osteoblastic activity_**) and results in loss of bone density
285
Neoplasm is often accompanied with what?
Other radiographic or clinical findings (punched out)
286
Patients will be ____ in regards to a neoplasm?
ANEMIC
287
What is associated with Neoplasm?
Multiple Myeloma, leukemia in children, and lymphoma (non-Hodgkins) can cause diffuse osteopenia
288
**_Osteoporosis review:_**
Reduced bone mass of normal quality; related to imbalance between osteoclastic and osteoblastic activity favoring osteoclastic resorption; serum calcium, phosphorus and alkaline phosphatase typically normal; generalized osteopenia with fractures frequent
289
**_Osteomalacia/Rickets review:_**
Related to deficiency of calcium, Vit D or phosphorus with multitude of causes including dietary deficiency, malabsorption, liver disease and renal disease; abundance of unmineralized osteoid resulting in bone softening disease and osteopenia including pseudofractures; rickets in the child with radiographic findings including loss of zone of provisional calcification
290
Hypophasphatemia Review:
Renal disease acquired or genetic resulting in Ph deficiency and leading to osteomalacia/rickets (Vit D resistant osteomalacia/rickets)
291
**_Hyperparathyroidism Review:_**
* Primary - Related to parathyroid tumor or hyperplasia
* Secondary - Related to renal disease or GI malabsorption
* Tertiary - Related to ectopic autonomous functioning tissue or chronic secondary HPT
Radiographic findings of HPT related to increased osteoclastic activity with localized resorption including subperiosteal at middle phalanges pathognomonic
292
**_Hypoparathyroidism Review:_**
Acquired related to accidental removal/damge to parathyroid glands during thyroid surgery, radiation, infection, carcinoma; hypocalcemia and hyperphosphatemia; radiographic finding is osteosclerosis as well as calvarial thickening and hypoplastic dentition, may be associated with extensive calcification of spinal ligaments and basal ganglia calcification
293
**_Pseudohypoparathyroidism PHP review:_**
PHP is a genetic disorder related to end organ resistance to parathyroid hromone with normal parathyroid hormone production; characteristic somatotype of short stature, obesity, round face, brachydactyly, abnormal dentition and mental retardation;
**Radiographic findings:** similar to hypoparathyroidism; hypocalcemia and hyperphosphatemia
294
**_Pseudopseudohypoparathyroidism PPHP review:_**
Genetic disorder similar to PHP and frequently a sibling of; is the normal calcium and phosphorus version of PHP; produce and respond to parathyroid hormone; same somatotype and radiographic findings
295
**_Hypophosphatemia Review:_**
Congenital abnormality related to decreased alkaline phosphatase production by osteoblasts resulting in findings similar to rickets; radiolucent metaphyseal defects
296
**_Hypovitaminosis C Scurvy review:_**
Deficiency of Vit C resulting in decreased abilitiy to produce collagen with inadequate osteoid formation; is a form of osteoporosis; adult form identical to adult osteoporosis; childhood form changes at the bone and are characteristic with proper names
297
Arthritic disorder affects 1 in \_\_\_\_
7
298
What are the most prevelant types of arthritis:
* DJD
* RA
* SLE = systemic lupus
* PA = psoriatic arthritis
* AS = Ankylosing spondylitis
* Gout
* JRA = Juvenile rheumatoid arthritis
* PSS = Progressive Systemic Sclerosis (scleroderma)
299
What remains the primary method of initial imaging in arthritic disorder?
The noncontrast radiograph
300
What are synovial joints characterized by?
Joint capsule:
* **2 layers: Outer fibrous & Inner Synovial**
* Articular/Hyaline cartilage, synovial membrane, synovial fluid, (anatomical) joint space (not radiographic space)
301
Describe the synovial membrane:
Loose vascular connective tissue - secretes synovial fluid (blood plasma and mucoid substance) lubrication and nutrition; "bare area" --\> major role in inflammatory
**_(no role in degnerative)_**
302
Describe the articular cartilage:
Hyaline is most common intraarticular cartilage and consists of chondrocytes embedded in a matrix of collagen fibrils and ground substance (mucopolysaccharide chondroitin sulfate concentrated in water)
303
Describe the subchondral bone plate:
Thin cortex and underlying cancellous trabeculae, abundant blood supply
304
What is the bare area?
NO periosteum, no articular cartilage; btwn end of synovial membrane & articular cartilage
305
What are the 2 branches of arthritis?
Mono and Poly arthritis
306
What are the categories under monarthritis?
* Traumatic
* Infectious
* Crystal induced (gout and psedo gout)
* Rheumatoid
307
What are the 4 categories under polyarthritis?
1. Inflammatory Joint Disease
2. Degenerative Joint Disease
3. Metabolic Deposition Disease
4. Hematological Disease
308
What is under inflammatory Joint disease?
Painful Soft tissue swelling of joints
309
What are the 2 subtypes of Inflammatory joint disease?
310
What are under Rheumatoid types?
311
What are under Rheumatoid Variants?
312
What is under DJD?
313
What goes under Metabolic Deposition disease?
314
What goes under Hematological?
315
Describe the Important Arthritis Chart as best you can:
316
What are the only 2 types of arthritis in human beings?
Mechanical or Inflammatory
317
Mechanical arthritis =
Osteophytes
318
Inflammatory arthritis =
Erosions
319
All arthritis destroys what?
Articular Cartilage
320
Gout starts where?
Single joint, nomally the big toe
321
Metabolic Deposition Disease =
Accumulation of normal or abnormal metabolic biproducts in or around the joint
322
Trauma: Bleed into joint ---\>
Inflammatory
323
Describe the Rheumatoid factor in Polyarthritis:
IgM is reactive to IgG (serological blood test)
* Rheumatoid types are autoimmune diseases, antigen-antibody reactions, IgM reacting to **altered** IgG
324
What is the major key point of Rheumatoid?\*\*\*
It is the *ONLY* one that is **_PRIMARY_** to the **_JOINT_** --\> Main target is **_SYNOVIAL MEMBRANE_** ---\> Worst of the group
325
HLA-B27 (+) / Rheumatoid (-) ---\>
**Rheumatoid Variants (P.A.I.R)**
326
HLA-B27 (-) / Rheumatoid (+) --\>
**Rheumatoid Types (R.S.P.D.T/V.)**
327
In lupus, what is the "Secondary" target?
Synovial Membrane
328
What is Reiter's Syndrome aka?
Reactive Arthritis Syndrome
329
Describe Psoriatic Arthritis:
Very Specific and common inflammatory, non-rheumatoid arthritis
330
What can IBD patients develop?
**Ankylosing Spondylitis** that can act like **rheumatoid** **arthritis**
331
What is "_Primary_" DJD?
(common joints; Spine) nothing else has happened to the joint
332
What is the _secondary_ DJD?
Joints involved where we don't expect to see it, unpredictable joints (uncommon joints, any joint), and clinically we know something else has happened to that joint
333
Bony enlargements come from _____ ?
Bony enlargements from DJD come from osteophytes
334
Describe Metabolic Deposition Disease:
Accumulation of normal (uric acid --\> Gout) or abnormal (amyloids --\> amyloidosis)
Metabolic byproducts --\> Creating "lumps and bumps" around a joint
335
What is amyloid?
Abnormal Proteinacious material/metabolic byproduct
336
In Metabolic Deposition Disease, describe uric acid:
Normal metabolic byproduct
MBB has amyloid and uric acid : gout
337
All arthritis \_\_\_\_\_\_\_
Enlarges the joint
338
THERE ARE ONLY 2 TYPES of ARTHRITIS IN HUMANS:
**_Joint Degenerates or Joint is INFLAMED_**
339
What are the 4 things that inflame joints?
1. Immune complexes
2. Metabolic Byproducts
3. Organisms
4. Blood (Toxic/Inflammatory if outside of vascular system)
340
All arthritis does one thing, what is it?
Desroys articular cartilage and narrows radiographic joint space
* Radiographic joint space = bone-bone
341
DJD is _______ whereas Inflammatory is \_\_\_\_\_\_\_?
DJD is mechanical stress across a joint (macro/microtrauma) and Inflammatory is chemical (typical lytic enzymes, collagenase --\> Produced by synovial membrane due to being inflammed)
342
Inflammation is to ______ what _______ are to Degeneration ? \*\*\*\*\*
**EROSION, OSTEOPHYTES**
343
Relative frequency of arthritis, Weekly:
DJD
344
Relative frequency of Arthritis, Monthly:
CPPD, RA, AS, PA, SCM (Joint mice)- Synovial Chondrometaplasia, DISH, OCI (OsteitisCondens)
345
Relative Frequency of Arthritis, Yearly:
Gout, Infection RAS, Lupus, PSS (scleroderma)
346
What are the ABCS of Anatomic - Radiographic Correlation?
* **_A - Articular Alignment_**, adjacent bony relationships across the joint
* **_B - Bone_**, for joint evaluation, focus on the subchondral bone
* **_C - Cartilage_**, not visible but the space occupied is
* All arthritic diseases destroy articular cartilage and narrow the radiographic joint space
* **_S - Soft Tissues_**, periarticular soft tissues often enlarged by bone or soft tissue swelling
347
Describe **DJD**:
* Progressive, non-inflammatory joint disease characterized by degenerative pathologic changes to articular cartilage and its related components
* Non-Uniform loss of joint space, Asymmetrical, Osteophytes, Mechanical Problem
348
What are some findings of DJD?
Small joints of hands and feet as well as large weight bearing joint typically involved **(spine also involved)**
349
Describe the etiology of DJD:
Exact etiology unkown, although pathologic sequence of change is well known
350
What is the most common encountered Joint Disorder?
**DJD**
351
Describe X ray findings and clinical findings:
* Great disparity between radiographic findings and clinical presentation in any given patient
* Just because X ray looks bad, it doesn't mean the patient has symptoms
352
Describe the symptoms of DJD:
* Onset insidious with episodic moderate aching pain, stiffness and periarticular soft tissue swelling
* Can be via inflammatory around joint, but _NOT IN THE JOINT_
353
Stifness with prolonged inactivity, gradually decreasing with activity and returning with fatigue describes symptoms of \_\_\_\_
DJD
354
Repetitive movements or recurrent chronic injury, first thoughts would be \_\_\_\_
DJD
355
What lab values would DJD present with?
**_NORMAL LABS_**, no inflammatory or serological markers
356
Periarticular swelling, soft tissue inflammatory episode (increase pain) -
DJD
357
Once DJD is initiated it is :
**IRREVERSIBLE** (can be slowed down though)
358
what is the actual process of DJD ?
"Trigger" is likely from abnormal mechanical forces across the joint that injure or kill chondrocytes with resulting loss of the surrounding matrix/chondroitin sulfate and destruction of collagen fibers
* Macrotrauma
* Rep. microtrauma
359
Where does DJD begin?
At cartilage surface and extends toward subchondral bone - **progressive asymmetrical joint space narrowing \*\***
360
Describe the subchondral findings of DJD:
* Subchondral new bone due to cartilage loss (OSTEOPHYTES), subchondral synovial fluid intrusion - GEODES (subchondral cysts --\> related to arthritic disease --\> classic in DJD)
* Subchondral Sclerosis (ONLY DJD, NOT in inflammatory)
361
WHat is a hole in a rock?
GEODE
362
What are osteophytes?
The classic radiographic finding and lead to bony enlargement of the joint - visible in superficial joints
\*\* CLASSIC finding in DJD
363
How do osteophytes develop?
From the articular margin due to combination of cartilage metaplasia and increase capsular insertion stress
364
Osteophytes are bony with ____ ,
* Cortex, and unattached margin is **capped with layer of cartilage**
* Osteophytes have cartilage caps
* Doesn't make a difference in extremities (hip, joint, knee, PIP, etc.)
* Makes a big difference in spine
365
Osteophytes only occur in \_\_\_\_\_
DJD
366
?
DJD
367
DJD is symmetrical or Asymmetric?
ASYMMETRIC
368
Inflammatory is almost always _____ ?
Symmetrical
369
4 main DJD radiographic findings: \*\*\*\*
1. Non uniform loss of joint space - fundamental
2. Osteophyte formation - Classic finding
3. Subchondral sclerosis/eburnation - variable
4. Subchondral cysts/geodes - variable
\* Hips will have larger geodes than smaller joints
370
Intra articular loose bodies are found in what disease? WHat are they?
Joint Mice, found in DJD, loose ossicles in the joint, SCM (synvoial chondrometaplasia) --\> Cartilage pieces produced by synovial membrane)
371
Geodes can weaken \_\_\_\_\_
Subchondral bone
372
What is an articular deformity and what is it associated with?
Collapse of subchondral bone associated with DJD --\> linked with Geodes
373
?
DJD
374
?
Heberdene's Nodes (DIP)
Boucharde's Nodes (PIP)
DJD
375
?
376
DJD primary joints in hand:
* DIP, PIP & 1st MCP occ. Scaphotrapezium
* Not primary in MCP
* **Writst: Radioscaphoid = primary; Radiolunate = _SECONDARY_**
377
DJD Primary Joints, Shoulder:
GH, AC
378
What are common PRIMARY areas of DJD?
* **HAND**
* **SHOULDER**
* **SPINE**
* **KNEE**
* **FOOT - DIP, PIP and 1st MTP**
379
What are secondary DJD?
* **HIP**
* **ELBOW**
* **ANKLE**
**\*\* MOST COMMONLY SEEN IN POST MENOPAUSAL WOMEN**
380
?
DJD
381
?
382
?
DJD
383
?
384
?
385
What is CPPD?
Calcium Pyrophosphate Deposition DIsease
* Common Metabolic Disease
* Causes Pseudogout
386
?
DJD, GH
387
388
?
DJD
389
The bigger the joint,
The smaller the osteophytic bone
390
If we see a geode, how do we differentiate this?
* Is it next to a DJD (asymetrical joint space)
* Is it up against the subchondral bone plate
391
?
392
?
DJD
393
What is the #1 cause of secondary DJD, and also common to cause primary?
Avascular Necrosis **AVN**
394
?
Probably due to AVN in DJD
395
?
Bilateral DJD
396
397
?
Patella femoral DJD
398
?
399
?
400
5 SKEL RAD A
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