2nd half of Arthritis Lecture (slide 56 on)

Question 1

Calcium Deposition Diseases: -calcium can be deposited in joint _____

Answer 1

soft tissues in a number of entities

Question 2

Calcium Deposition Diseases: -Calcification can be in:

Answer 2

articular cartilage, menisci, tendons, soft tissues, and bursae

Question 3

**Chondrocalcinosis is technically the term for a condition of calcification of soft tissue articular structures as seen on imaging studies, calcifications seen in _____

Answer 3

cartilage, menisci, cruciate ligaments, and synovium with calcium compound crystals.

Question 4

Chondrocalcinosis is found in a number of disease processes including: (hint: there’s a lot)

Answer 4

Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPDCDD is sometimes called Chondrocalcinosis and Pseudogout!!), Pseudogout, Tophaceous Pseudogout, Osteoarthritis, Familial CPPDDD, Basic Calcium Phosphate Crystal Deposition Disease, gout, hyperparathyroidism, hemochromatosis, hypophosphatasia, hypomagnesemia, ochronosis, Wilson’s Disease, acromegaly and entities mimicking rheumatoid arthritis, osteoarthritis and neuropathic arthropathy.

Question 5

Calcium Pyrophosphate Dihydrate Crystal Deposition occurs in a number of disease entities, including the following:

Answer 5

Pseudogout, Tophaceous Pseudogout, Familial Calcium Pyrophosphate Dihydrate Deposition, and Osteoarthritis, pseudoosteoarthritis, pseudorheumatoid arthritis, and pseudoneuropathic arthropathy. (notes: just know that calcium will deposit into soft tissue, BUT there are also disease processes that deposit calcium into the joints)

Question 6

Chondrocalcinosis is the condition of ______ _____ _____ calcifications as seen on medical imaging studies.

Answer 6

articular soft tissue

Question 7

Calcium Pyrophosphate Dihydrate crystals are deposited in ______

Answer 7

articular soft tissues in a number of disease entities –>Need a joint aspiration to determine

Question 8

Pseudogout is one of several disease entities in which calcium pyrophosphate dihydrate crystals are deposited in the _______

Answer 8

articular soft tissues

Question 9

_______ is the MC of the calcium deposition arthropathies

Answer 9

pseudogout -The source of confusion: Pseudogout is also known as Calcium Pyrophosphate Deposition Disease, Calcium Pyrophosphate Dihydrate Deposition Disease, and Chondrocalcinosis, and some include it in a separate category as one of the CPPD Disease

Question 10

Pseudogout: -is a disease of _____ -symptoms? -____ deposits cause an inflammatory gout-like process

Answer 10

-It is a disease of aging -It may be asymptomatic -Synovial (and fibrous and hyaline articular cartilage) Calcium Pyrophosphate crystal deposits cause an inflammatory gout like process

Question 11

Gout itself is the accumulation of:

Answer 11

articular monosodium urate monohydrate crystals

Question 12

Calcium Deposition – Chondrocalcinosis

Answer 12

note yellow arrows (Ca 2+ deposition)

Question 13

Calcium Deposition – ChondrocalcinosisCPPDD

Answer 13

-**Note evidence of laxity of scapholunate ligament

Question 14

Avascular Necrosis=Osteonecrosis aka Aseptic Necrosis: -usually seen in the _____ -how common?

Answer 14

-**femoral head -Increasingly common, accounts for 10% of Total Hip Replacements

Question 15

Femoral Head is an end organ system with poor collateral circulation. Compromise of the arterial supply, especially the _____ _____ artery, causes ischemia.

Answer 15

**medial circumflex artery

Question 16

Femoral head avascular necrosis can be seen 2/2: (lots of things)

Answer 16

-Trauma -Vasculitis -Vasospasm–>decompression -Circulating microemboli: –Hemoglobinopathies (Sickle Cell Disease) –Fat emboli –Hypercoagulable States –Decompression Sickness -Steroid Therapy -Alcoholism -Pancreatitis -Dialysis

Question 17

Normal Hip: Normally there are thickened and prominent _______ seen in the Femoral Head. Maximal strength with minimal mass in response to _______

Answer 17

*trabeculae -mechanical stress.

Question 18

Normal Hip MR: note _____

Answer 18

*symmetry

Question 19

Avascular Necrosis: -imaging findings?

Answer 19

-Note mild osteoarthritis characterized by joint space narrowing, periarticular sclerosis and osteophytosis. -Note superimposed flattening of the femoral head indicating osteonecrosis with subchrondral fracture and buckling of the underlying trabeculae -Note: distorted trabeculae and collapse of subchondral bone

Question 20

Describe Avascular Necrosis in the scaphoid bone -This is seen with which demographic?

Answer 20

-Similar phenomenon occurs in Scaphoid bone with compromised circulation -Seen with: alcoholism, steroids, Bends, arterial embolism/thrombosis, & Sickle Cell Anemia.

Question 21

Avascular necrosis: -describe the circulation to the femoral head -Tx?

Answer 21

The blood supply to the Femoral head is primarily via the *Medial circumflex femoral artery, and to a lesser extent the *Lateral Circumflex artery. -There is also blood flow via the artery to the Ligamentum teres (a branch of the Obturator artery) -Compromise to this latter artery can also lead to Avascular Necrosis of the Femoral Head –tx of AVN–> replace the femoral head usually since you usually lose integrity of articular surfaces

Question 22

Neuropathic ArthropathyCharcot’s Joint: describe this condition

-risk factors? (which Pt demographic)

Answer 22

=loss of deep sensation and proprioception–>leads to recurrent trauma and progressive destruction, degeneration, and disorganization of the joint. (they have repeated

• Also to be considered is neuromediated vascular reflex causing hyperemia and bone resorption.
• Diabetes, trauma, steroids, alcoholism, neurological and spinal disorders

Question 23

Neuropathic ArthropathyCharcot’s Joint: -signs?

Answer 23

Joint effusions, destruction of articular surfaces, bone fragmentation, subluxation, osteophytosis, sclerosis

Question 24

Neuropathic joint

Answer 24

Question 25

Neuropathic Joint: associated tabes doralis (Tabes dorsalis is a slow degeneration of the nerve cells and nerve fibers that carry sensory information to the brain. The degenerating nerves are in the dorsal columns of the spinal cord) and also seen in Leprosy.

Answer 25

Tabes dorsalis: dorsal column spinal disease 2/2 tertiary sphyillis)

Question 26

Neuropathic Joint: in DM

Answer 26

Diabetes: Note the degenerative arthritis in Ist MTP joint Note destructive changes in the tarsal bones

Question 27

Ankylosing Spondylitis=

Answer 27

=Inflammation of multiple articular and para-articular sites -Spondylitis is related to the spine, ankylosing means fusion -An enthesopathy, an inflammatory process of the attachments to bone of the ligaments, tendons, and joint capsules with subsequent calcification and ossification and ankylosis.

Question 28

Ankylosing Spondylitis:

Answer 28

add image —>On the left note sacroiliitis with subchondral sclerosis and erosions. This will progress to what is seen on the right, fusion of the sacroiliac joints

(image is what is seen after disease has progressed)

Question 29

Ankylosing Spondylitis: note the ossification of ligaments bridging vertebral bodies ( syndesmophytes) and ______

Answer 29

facet joint fusion

Question 30

Anklosing Spondylitis: key findings on Xray is ____ spine

Answer 30

*“bamboo spine” Bamboo Spine= Solid ankylosis of facet joints and syndesmophytosis of entire spine ligamentous structures (KNOW!)

Question 31

Ankylosing Spondylitis: -The rigidity and loss of flexibility of the spine in Ankylosing Spondylitis makes it more vulnerable to:

Answer 31

fracture and resultant neurological injury

Question 32

Reactive Arthritis–Reiter’s Syndrome: -describe? -associated with which antigen? -it’s a type of seronegative ______

Answer 32

=an arthritis complicating an infection elsewhere in the body and no organism can be cultured from the affected joint. -Associated with positive Histocompatibility Antigen called the Human Leukocye Antigen **HLA-B27 -*A type of seronegative (for rheumatoid factor) spondyloarthropathy

Question 33

Reactive ArthritisReiter’s Syndrome: can be triggered by?

Answer 33

by bacterial pathogens related to dysentery and STDs, especially Chlamydia, also

“cant see–conjunctivitis, cant climb a tree- arthritis, urethritis-cant pee”

Question 34

Reiter Syndrome is arthritis, conjunctivitis (or uveitis), and ______

Answer 34

urethritis

Question 35

Reactive Arthritis can be mono or ____

Answer 35

poly arthropathic

Question 36

Reactive arthritis: imaging study

Answer 36

add image findings: -Severe erosive changes on Left with subluxations -Small erosions in First MC heads with subluxations

(image shows severe erosive changes)

Question 37

Pigmented Villonodular Synovitis= is a benign, _______ disorder of:

Answer 37

=Benign, proliferative disorder of thickened synovium with villous and nodular proliferation -**Nodular intra-articular masses= KEY finding

Question 38

Complex Regional Pain Syndromeformally called________

Answer 38

Reflex Sympathetic Dystrophy

Question 39

Complex Regional Pain Syndrome: -describe -related to? -Sx? -Plain films show _____

Answer 39

• Incompletely understood, over-response of the body to an external stimulus, usually trauma
• increased blood flow causes demineralization
• Possibly related to efferent sympathetic nervous system over- activity or abnormal neurological activity of central cord or peripheral neurons.
• Sx: Pt presents with characterized by pain and vasomotor disturbances with hyperemia and swelling.

Dx: Radionuclide 3 phase

-Plain films usually show osteopenia and swelling.

Question 40

Complex Regional Pain Syndrome: test of choice is 3 phase _____

Answer 40

*three phase Radionuclide Bone Image (RNBI)

Question 41

Complex Regional Pain Syndromeformally called Reflex Sympathetic Dystrophy: -Describe each phase of the 3 phase RNBI

Answer 41

Phase 1: gives information about blood flow perfusion and shows diffuse increased activity.

Phase 2: gives info about relative vascularity (blood pool) and shows diffuse increased activity also.

Phase 3: gives info about the bones themselves and shows increased activity

Question 42

Hemophilia= articular changes are 2/2 _____

Answer 42

-recurrent hemorrhages into the joints. -The effects are secondary to direct chemical effects of blood on the synovium, cartilage, and bone causing joint destruction.

Question 43

Hemophilia: imaging findings? -what is the KEY finding?

Answer 43

joint effusion, periarticular osteoporosis, irregular subchondral bone and **subchondral cysts, cartilage erosion -**There is hemosiderin deposition.

Question 44

Hemophilia: MC involved joint?

Answer 44

**Knee MC involved.

Question 45

Hemophilia: imaging study

Answer 45

Note hemarthrosis, eroded cartilage, subchondral cysts and hemosiderin deposition

Question 46

Spondylolysis = -MC seen at which level?

Answer 46

-Spondy (spine) and lysis (unbind)= is a defect in the pars interarticularis of a vertebral body. -Can be congenital or acquired -Can be unilateral or bilateral -**Most commonly seen at the L5 level

Question 47

Spondylolysis is the most common cause of low back pain in ______

Answer 47

adolescents –> Occurs in 8-14% of adolescent athletes

Question 48

Spondylolisthesis =

Answer 48

Spondy (spine) and listhesis (slipping) -Of those with Spondylolyis, 15-25% will develop spondylolisthesis.

Question 49

ON THE OBLIQUE FILM, THE NECK OF THE SCOTTY DOG IS THE _______

Answer 49

PARS INTERARTICULARIS **Spondylolysis – No neck Scotty Dog (L4-L5) (KNOW!!)