1
Q
Examples of monoarticular joint diseases (6)
A
- Trauma
- infection
- crystal deposition (gout, CPPD)
- Rheumatoid -monoarthritis
- PVNS
2
Q
Examples of polyarticular inflammatory diseases
A
- OA
- RA
- Seronegatives
- Charcot
- Chronic gout
- reticular histiocytosis
3
Q
Degenerative joint disease
A
Osteoarthritis
4
Q
Inflammatory joint disease
A
- Rheumatoid arthritis
- Seronegative arthritis
- Psoriatic arthritis
- Reiters disease
- Ankylosing spondylitis
- Septic arthritis
5
Q
Metabolic joint diseases
A
Gouty arthritis
6
Q
Hypertrophic joint diseases
A
Means more bone growth
- osteoarthritis
- Detritus arthritis (post-traumatic arthritis and Charcot)
7
Q
Atrophic joint diseases
A
means loss of bone growth… Primarily by erosion
- inflammatory arthritities
- forefoot charcot
8
Q
Osteophyte formation found in:
A
osteoarthritis
9
Q
Definition of erosion, and different presentations
A
- bare areas
- pannus, dot-dash and skipping
10
Q
Bone erosion a primary feature in what?
A
Bone erosion is a primary feature of all joint disorders except OA, Charcot and Septic arthritis
11
Q
Subchondral resorption is a primary finding in what?
A
Charcot and septic arthritis
12
Q
Arthritis mutilans definition and where is it found
A
Definition: erosions that involve both margins of any MPJ, or interphalangeal joint
-psoriatic, RA and Charcot
13
Q
Predominant feature of hypertrophic joint disease
A
bone production
14
Q
Characteristic radiographic findings of OA
A
-osteophytosis and subchondral sclerosis (eburnation)
15
Q
Periostosis is found in what ?
A
inflammatory processes
16
Q
What are the characteristic radiographic findings of seronegative arthritis
A
- periostitis
- whiskering
- cortical and trabecular thickening
17
Q
Type of joint space seen in OA:
A
assymmetrical joint space narrowing
18
Q
Type of joint space seen in RA
A
symmetrical narrowing
19
Q
type of joint space seen in psoriatic
A
widening
20
Q
Type of joint space seen in gout
A
normal joint space
21
Q
Underlying biochemistry changes seen in Gout
A
- Calcifications
- Martel’s sign
- increased monosodium rate crystals that precipitate and are found periarticular next to erosions
- negatively birefringent crystals
22
Q
Underlying biochemistry changes seen in pseudogout
A
- calcium pyrophosphate deposition disease
- chondrocalcinosis
- cartilage will calcify
- – joint surfaces will have parallel calcifications
- —hyaline cartilage calcifies
- Will see positively birefringent rhomboids
23
Q
Underlying biochemistry changes seen in hydroxyapatite crystal deposition disease
A
Will find extra-articular calcification that will be within joint capsule or found within a tendon or bursae
24
Q
Osteoarthritis: target joint
A
First MPJ
25
Rheumatoid arthritis: target joints
-less MPJ's and hallux IPJ
26
Psoriatic arthritis: target joints
Lesser MPJ's and IPJ's (really varies )
27
Gouty arthritis: target joints
first MPJ
28
Neuropathic arthropathy: target joints
Tarsometatarsal joints
29
Osteoarthritis: bone production
Osteophyte and subchondral sclerosis
30
Rheumatoid arthritis: bone production
NONE
31
Psoariatic arthritis: bone production
occasionally
- periostitis
- whiskering
- Ivory phalanx
32
Gouty arthritis: bone production
overhanging edge
-----Martel's sign
33
Neuropathic arthropathy: bone production
Diffuse sclerosis
34
Osteoarthritis : erosions
NONE
---some of the subchondral bone cyst may mimic erosion
35
Rheumatoid arthritis: erosions
medial aspects
36
Psoriatic arthritis: erosions
Medial/lateral/central
37
Gouty arthritis: erosions
medial (more common)
-can also have lateral margins
38
Neuropathic arthropathy: erosions
subchondral resorption
39
Osteoarthritis: joint spacing
Nonuniform narrowing
40
Rheumatoid arthritis: joint spacing
uniform narrowing
41
psoriatic arthritis: joint spacing
widening (relative)
42
Gouty arthritis: joint spacing
normal
43
neuropathic arthropathy: joint spacing
Narrowing or relative widening
44
Osteoarthritis:soft tissue swelling
NONE
45
rheumatoid arthritis: soft tissue swelling
not significant
46
Psoriatic arthritis: soft tissue swelling
diffuse: sausage toe
47
Gouty arthritis: Soft tissue swelling
Lumpy-bumpy
48
Neuropathic arthropathy: soft tissue swelling
diffuse
49
Osteoarthitis: soft tissue calcification/ossification
Losse osseous body (joint mouse)
50
Rheumatoid: soft tissue calcification/Ossification
NONE
51
Psoriatic arthritis: soft tissue calcification/ ossification
None
52
Gouty arthriti: soft tissue calcification/ ossification
small, punctate calcifications
53
Neuropathyic arthropathy : soft tissue calcification/ ossification
fragmentation of bon
54
Osteoarthritis: positional deformity
associated with hallux abductovalgus
55
Rheumatoid arthritis: positional deformity
deviation of toes laterally; subluxation
56
Psoriatic arthritis: positional deformity
nothing specific
57
Gouty arthritis: positional deformity
NO
58
Neuropathic arthropathy: positional deformity
subluxation/dislocation
59
Osteoarthritis: bilateral symmetry
no
60
Rheumatoid arthritis: bilateral symmetry
YES
61
Psoriatic arthritis: bilateral symmetry
NO
62
Gouty arthritis: bilateral symmetry
NO
63
Neuropathic arthropathy: bilateral symmetry
NO
64
RA: will it exhibit juxta-articular osteopenia
yes
65
psoriatic arthritis: will it exhibit juxta-articular osteopenia
NO
66
Define osteopenia
Non specific radiographic finding of decreaed bone density
67
Define osteoporosis
metabolic disease where amount of bone present per unit volume is reduced but composition is normal
68
Define osteomalacia
metabolic disease of increased amount of uncalcified osteoid found on histology
69
X-ray findings of chronic osteopenia (3)
- cortical thinning by endosteal/subperiosteal resorption
- increased primary trabeculations
- intracortical tunneling
70
X-ray findings for acute osteopenia
spotty or regional osteoporotic from disuse
71
X-ray findings for general osteoporosis (3)
- prominent primary trabeculations
- cortical thinning
- cortical tunneling
72
X-ray findings for osteomalacia (5)
- Bowing deformity of long tubular bones
- Transverse incomplete radiolucency (milkman fracture)
- bordered by sclerosis on the compressive side/medial side/inner side of bone
- Widening of the physis (paint brush appearance)
- Cupping and widening of the metaphysis
73
Etiology of hypophosphatasia
reduced levels of alkaline phosphatase in serum, bone and other tissues due to mutations in tissue non-specific
74
X-ray findings of hypophosphatasia (4)
- bowing and shortening of long tubular bones
- Osteochondral spurring
- Chondrocalcinosis aricularis
- losser zone (outer cortex/ tension side)
75
Hyperparathyroid etiology
increased levels of parathyroid hormone= increased osteoclastic activity= removal of calcium from bone which then enters the blood
76
Hyperparathyroid: 3 forms
1) Primary- due to tumor which results in hypercalcemia and vitamin D deficiency.... assciated with hyperuricemia and overt gout
3) tertiary- hyperplasia of parathyroid glands and a loss of response to serum calcium levels. Occurs in chronic renal failure
77
Hyperparathyroid readiographic findings (4)
- subperiosteal resorption
- Other sites of bone resorption (periarticular, intracortical, endosteal, subchondral and entheseal)
- Acral Osteolysis
- Radiolucent lesions: hot spots-brown tumors
78
Hypoparathyroidism- what do you see in the digits
brachymetaphalangea
79
Renal osteodystrophy etiology
- seen in chronic renal failure
| - Chronic kidney disease= hyperphosphatemia= increase in PTH= osteoclastic activity
80
Renal osteodystrophy: X-ray findings
calcifications of soft tissue and vessels
81
Etiology of Rickets
vitamin D deficiency or hypophosphatemia during open growth plate stages
82
Etiology of Scurvy
deficiency of Vitamin C
83
X-ray findings of Rickets (5)
- osteopenia
- bowing deformity of long tubular bones
- widening of the physis
- decreased density at the zone of provisional calcification (fraying/paint brush appearance)
- widening/cupping of the metaphysis
84
X-ray findings of scurvy
-in the metaphysis (4)
- White line of scurvy: increased density bordering the growth plate (sclerotic)
- transverse line of decreased density adjacent to the line of increased density on its metaphyseal side
- Scurvy line: radiolucent
- Radiolucency at margins of metaphysis or epiphysis
85
X-ray findings of scurvy
-in the epiphysis
-outer shell of increased density surrounding a central lucency dye to atrophy of central spongiasa, sclerotic ring around epiphysis
86
X-ray findings of scurvy
-periosteal
- bleeding found under the periosteum that may elevate along the long axis of the bone
87
Identify the type of osteoporosis/osteopenia seen in a patient who is immobilized in a cast for 8 weeks.
- Regional osteoporosis with spotty osteopenia
- multiple radiolucent spots.
- Transverse bands of decreased desnity and subperiosteal resorption
88
Define and describe the etiology in acromegaly
- There is an increased GH and IGF-1 production.
- this results in increased osteoblast proliferation.
- There is an initial increased bone formation followed by an increased bone resorption
89
X-ray findings in acromegaly
- high levels of osteoporosis.
- Increased bone turnover and appendicular cortical bone mass
- Heel pad thickness increased >25mm
- Joint space is widened due to cartilage thickening
- bone is more prominent, met heads and distal phalanx ungal tuberosities are enlarged
- met shafts are thickened
- spurring at entheses
90
Osteogenesis imperfecta aka brittle bone disease: etiology
- abnormal metaphyseal and periosteal ossification caused by deficient osteoid production
- abnormal maturation of collagen in mineralized and nonmineralized tisseus
91
X-ray findings in osteogenesis imperfecta (3)
- Diffuse osteopenia, diminished bone girth, flared metaphyses
- Complication: fractures
- Bottom of metaphyses flares out (Erlenmeyer flask deformity)
92
Describe the X-ray changes of Paget's disease (osteitis deformans)
- Excessive and abnormal remodeling of bone
- Tibia has anterior bowing (sabre-shin deformity)
- Flame lesions (radiolucent)
- Blades of grass
93
Diseases that present with generalized sclerosis (5)
- osteopetrosis
- melorheostosis
- osteopoikilosis
- osteopathia striata
- pyknodysostosis
94
X-ray findings with osteopetrosis (2)
bone in bone
-erlenmeyer flask
95
X-ray findings in melorheostosis (2)
candle wax
hyperostosis
96
X-ray findings in osteopoikilosis
multiple bone islands
97
X-ray findings osteopathia striata
striations parallel to the long axis
98
X-ray findings for pyknodyostosis (3)
- acral osteolysis
- narrowing of medullary canal
- sclerosis
99
What x-ray finding is found with fluorosis
generalized sclerosis
100
What x-ray finding is found with hypervitaminosis D
generalized sclerosis
101
What is metastatic calcification and provide examples of it (2)
- Results from disturbances in calcium or phosphorus metabolism
- occurs in hyperparathyroidism and renal osteodystrophy
102
What is generalized calcinosis and provide example of it (1)
- Presents as calcium deposition in the skin or subq in the presence of normal calcium metabolism.
- tumoral calcinosis is an example
103
What is Dystrophic calcification and provide examples (2)
- calcium is deposited in damaged or devitalized tissue in the absence of abnormal calcium metabolism
- tumors or trauma are n exmple
104
What is Myositis ossificans circumscripta
develops in sites of trauma
attaches to cortex of bone and radiographically it looks like a form of osteogenic sarcoma
105
Histologically what is the difference between myositis ossificans circumscripta and osteogenic sarcoma
- Myositis ossificans circumscripta has bone formation beginning in the periphery
- Sarcoma bone production appears in the center of tumor
106
Dexa: what does it tell you?
Dexa is the gold standard for measuring bone mineral density.
- does so through T-score measurements
107
VFA and IVA what does it tell you
Will tell you if there is an old fracture of the vertebra.
A positive finding on VFA and IFA will trump the results of a DXA scan
108
Specifics about T scores
Definition
Units
Ranges
Definition: your bone density compared with what is normally expected in a healthy adult of your sex.
Measured in units of standard deviations that your bone density is above or below the average
Range:
-1 and above: bone density is considered normal
--1: -2.5: sign of osteopenia, a condition in which bone density is below normal and may lead to osteoporosis
--2.5 and below: bone density indicates osteoporosis
109
What age range are T-scores useful in?
Postmenopausal women and men over 50
110
Z- scores
Definition and range
Number of standard deviations above or below what's normally expected for someone of your age, sex, weight, and ethnic or racial origin
- If Z-score is -2 or lower, it may suggest that something other than aging is causing abnormal bone loss.
111
What age range is z-score useful in
Z-scores are useful in premenopausal women and men under age of 50
112
FRAX score: when should you consider treatment
Patient should receive treatment:
If low bone mass... T-score between -1 and -2.5 at the femoral neck or spine.
- 10-year probability of a hip fracture at >3%
- 10 year probability of a major osteoporosis related fracture >20%
113
What are the factors that go into calculating FRAX score
- Age
- Height
- Weight
- BMD- femoral neck and spine
- Smoking
- Alcohol
- Glucocorticoid
- RA
- Spine fracture
- Family history
- Gender
- Ethnicity
114
How much bone loss occurs with every change in SD of the T-score
For every 1 standard deviation away from normal bone, patient will have 10% less bone density
115
Non-pharmaceutical types of therapy that should be used to treat osteoporosis (2)
- Behavioral changes (smoking, alcohol consumption and diet changes)
- exercise: weight training
116
OTC drugs that should be used to treat osteoporosis
Calcium: 1000-1200mgs daily
Vitamin D:800-1000 International units daily
117
Bisphosphonates
- MOA
- Biggest side effect to look out for
How to prevent against side effects
MOA- inhibits bone reabsorption.
Side effect: can cause a typical femur fracture and osteonecrosis of the jaw with long term use
Also watch out for GI symptoms such as GERD.
Take the medications in the morning before food with a glass of water and upright for 30 minutes.
Avoid in people with chronic kidney disease
Take a drug holiday!!!
118
What are the 4 big bisphosphonates and administration
- Alendronate (Fosamax): oral
- Risedronate (Actonel, Atelvia): oral
- Ibandronate (Boniva): oral
- Zolendronic acid (Reclast): IV
119
Hormonal therapy that can be used in patients with osteoporosis
Estrogen can be used in postmenopausal women.
However there is an increased risk of breast, ovarian, and uterine cancers.
120
Raloxifene (Evista) MOA and are there risks to consider?
Evista mimics estrogen's beneficial effects on bone density in postmenopausal women.
- Is not associated with the cancer risks that are seen in regular estrogen.
121
Denosumab (Prolia)
- MOA
- Comparison to bisphosphonates
- Administration
Inhibits bone resorption by neutralizing RANKL
- compared with bisphosphonates denosumab produces similar or better bone density results and reduces the chance of all types of fractures
- Delivered via a shot under the skin every 6 months
122
Teriparatide (Forteo)
- MOA
- Comparison with parathyroid
- Administration and length of time
Builds bone
- powerful drug similar to parathyroid hormone and stimulates new bone growth.
- Given by daily injections under the skin, and after 2 years of treatment with teriparatide another osteoporosis drug is taken to maintain new bone growth.
123
Wilson-Katz classification used for?
Stress fractures
124
Wilson-Katz type I
WIll see a radiolucent fracture line.
No evidence of endosteal callus or periosteal reaction.
_ similar to a jones fracture presentation
125
Wilson-Katz type II
Will see a focal sclerotic line and endosteal callus
- will only occur in cancellous bone
- Will see white line everywhere but shaft
126
Wilson-Katz type III
Periosteal reaction and external callus seen.
- Will visualize a callus lump here
- Mainly seen on shaft and subjected to more movement and irritate periosteum
127
Wilson-Katz type IV
combination of all types: I,II,III.
-May see dreaded black line. Inability to heal
128
AP X-ray signs of a Lisfranc injury
Lateral step-off at the second tarsometatarsal joint is accepted as the most common and reliably detected abnormality seen in Lisfranc injuries with diastasis of 2 mm or more indicating instability
129
Lateral X-ray signs of a Lisfranc injury
there should be no step-off at the dorsal margins of the tarsometatarsal joints
-Plantar surface of the medial cuneiform should project dorsal to the plantar aspect of M5
130
Oblique X-ray signs of a Lisfranc injury
the lateral margins of C2-M2 and C3-M3 should align
131
Hardcastle classification for Lisfranc injury (5)
Type A: Total incongruity, with mets 1-5 medially or laterally displaced
Type B1: Partial incongruity with Medial dislocation of the 1st Met cuneifrom, and no displacement of the rest of the forefoot
Type B2: Partial incongruity, but lateral dislocation of the all mets 2-5 or some of them.
Type C1: divergent
Partial displacement with 1st travelling medial and some of 2-5 travelling lateral
Type C2: Total displacement with 1st going medially and all 2-5 going laterally
132
Nunley classification for Lisfranc injury (3)
Stage 1: sprain- looks normal on x-ray with <2mm of displacement and arch height remains unchanged. SURGERY
Stage 2: 2-5mm diastasis on AP x-ray between first and second and arch height remains unchanged. SURGERY
Stage 3: 2-5mm of displacement loss of arch height and SURGERY
133
Tc99 carrier molecule and sites of uptake
-Methylene diphosphate. taken up by hydroxyapetite crystal laid down by osteoblast
134
Ceretec/ Tc99 HMPAO carrier molecule and sites of uptake
carrier molecule is WBC and will lay down at acute osteomyelitis
135
Te99 Sulfur colloid carrier molecule and sites of uptake
taken up by macrophage, reticular endothelial cells in bone marrow.
136
Indium 111 uptake
acute inflammation (acute charcot and acute cellulitis)
137
What Disease processes result in acryl osteolysis (4)
- psoriatic arthritis
- Hyperparathyroidism
- Pyknodysostosis
- Pulmonary hypertrophic osteoarthropathy
138
What disease processes result in Erlenmeyer Flask deformity (3)
- osteopetrosis
- Thalassemia
- osteogenesis imperfecta
139
What disease processes result in dachtylitis (3)
- psoriatic arthritis
- sickle cell anemia
- Pulmonary hypertrophic osteoarthropathy
140
Arendt Grade I Navicular stress fracture will show:
X-ray
Bone scan
MRI
What is the treatment
X-ray will be normal findings
Bone scan will have poorly defined area of increased activity
MRI will have positive results on STIR
To treat: 3 week rest
141
Arendt Grade II Navicular stress fracture will show:
X-ray
Bone scan
MRI
What is the treatment
X- ray: Normal findings
Bone scan: More intense but still poorly defined
MRI: will have positive STIR and T-2 weighted images
To treat will do 3-6 weeks resting
142
Arendt Grade III Navicular stress fracture will show:
X-ray
Bone scan
MRI
What is the treatment
X-ray will show discrete line with discrete periosteal reaction
Bone scan: sharply marginated area of increased activity
MRI: positive T1 and T2 weighted images but without definite cortical break
To treat: 12-16 weeks of rest
143
Arendt Grade IV Navicular stress fracture will show:
X-ray
Bone scan
MRI
What is the treatment
X-ray: fracture or periosteal reaction
Bone scan: more intense transcortical localized uptake
MRI: postive T1 and T2 weighted images of the fracture line
Treatment: >16 weeks rest
144
Saxena Type 1
How to treat
CT shows a fracture line through the dorsum of the navicular
TX: NWB 6 weeks followed by gradual weightbearing in a boot for 2-6 weeks.
145
Saxena Type 2
How to treat
CT shows a fracture line from the dorsum of the navicular into the body
TX: ORIF
146
Saxena Type 3
How to treat
CT shows a fracture line through both cortices of the navicular (dorsal and plantar)
TX: ORIF
147
Saxena type .5
Stress reaction, MRI will show a reaction
148
Torg recommended what treatment plan for Navicular stress fracture
NWB cast for 6-8 weeks followed by gradual weightbearing in a boot for 2-6 weeks
149
- Length of time till bone stress reaction on MRI for stress fracture
- Length of time until fracture line is seen on a stress fracture
- 5-6 weeks
| - 6-weeks
Mahoney EBM
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