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Flashcards in Arthritis Deck (35)
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1

Degenerative Arthritis Types 

  • Increased bone/calcifications 
    • Degenerative joint disease 
    • DISH
    • Synoviochondraplasia 
    • Neurotrophic arthropathy 
    • Erosive arthritis 

2

Inflmmatory Arthritis Types 

  • Bone erosions and soft tissue swelling 
    • Rheumatoid arthritis 
    • Psoriatric arthritis 
    • Reactive arthritis 
    • Ankylosing spondylitis 
    • Osteitis condensans ilii 
    • Osteitis pubis 

3

Metabolic Arthritis Types 

  • Soft tissue masses within periarticular soft tissue 
    • may be calcified 
  • Relative preservation of the joint space 
  • May have inflammatory changes 
  • May have secondary degenerative changes 

 

Gout, CPPD, HADD

4

Infectious Arthritis Types 

  • Soft tissue swelling 
  • Joint and bone destruction 
  • More agressive and progressive than other forms of arthritis 

Septic arthritis 

5

Arthritis Flow Chart 

6

Axial Skeleton Arthritis 

  • Most common 
    • DJD
  • Less common 
    • DISH
    • RA
    • Ankylosing spondylitis 
    • Psoriatric arthritis 
    • Osteitis condensans ilii
    • Osteitis pubis 
  • Rare 
    • Reactive arthritis 
    • Infective 

7

Appendicular Skeleton Arthritis

  • Most common 
    • DJD
  • Less common 
    • RA
    • Psoriatric 
    • Gout 
    • CPPD
    • HADD
    • Synoviochondrometaplasia 
  • Rare 
    • Neurotrophic 
    • Erosive osteoarthritis 
    • Reactive arthritis 
    • Infection 

 

8

Degenerative Arthritis 

DJD

  • Osteoarhritis 
  • Most common form of arthritis 
  • Small joints of hands, larger weight bearing joints (spine, knee, hip)
  • May affect any joint
  • Often disparity between clinical and radiographic features

Clinical Features 

  •  >40 yrs (often >60yrs)
  • Inc males 45 yrs, primary osteoarthritis
  •  Insidious onset, intermittent exacerbations
  • Aching pain, stiffness (am), swelling
  • Joint crepitus
  • Decreased motion
  • May have inflammatory episodes

Pathogenesis 

  • Cartilage destruction and reactive changes in surrounding tissues
  • Cartilage metaplasia at joint margins and capsular insertion stress resulting in bone remodelling
  • Augmentation of subchondral bone structural capacity
  • Synovial fluid intrusion into subchondral bone through weakened cartilage and cortical microfractures

Pathologic and Radiographic Features 

  • Cartilage destruction and reactive change in surrounding tissues 
    • Loss of joint space 
    • Asymetrical pattern 
  • Cartilage metaplasia at joint margins and capsular insertion stress 
    • Osteophytes 
    • Remodeling of bone - continuation of bone not calcifications 
  • Augmentation of subchondral bone structural capacity 
    • Subchondral sclerosis 
  • Synovial fluid intrusion into subchondral bone through weakened cartilage and cortical microfractures 
    • Subchondral geodes and cysts 
  • Secondary changes 
    • Intraarticular loose bodies (joint mice), intraarticular deformity: joint subluxation 
    • Possible joint fusion at end range 

9

Kellgren-Lawrence Grading Scale

  •  Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
  • Grade 2: definite osteophytes, definite narrowing of joint space
  • Grade 3: moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour
  • Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour

10

DJD Hip

  • Asymmetrical loss of joint space
  • Upward and outward migration of femoral head
  • Medial or central joint space loss less common
  • Synovial subchondral cyst-like formation (geode or Egger’s cyst)
  • Sclerosis
  • Osteophytes
  • Buttressing of medial femoral neck
  • Lack of internal rotation
  • Secondary changes

11

DJD Knee 

  • Loss of joint space
    • Medial most common, lateral joint space, patellofemoral joint less common
  • Subchondral sclerosis
  • More pronounced on tibia
  • Osteophytes
  • Loose bodies/calcifications
  • Subluxation (genu vara)

12

DJD AC Joint 

13

DJD 1st Metatarsal Phalangeal 

  • Hallux rigidus
  • Sclerosis
  • Joint space loss
  • Osteophyte formation
  •  Osseous bunion
  • Subluxation

14

DJD 1st Carpometacarpal Joint 

  • Sclerosis and loss of joint space
  • Lateral subluxation
  • Also sclerosis and loss of joint space in scaphoidtrapezoid/trapezium joints

15

DJD PIPs and DIPs

  • Osteophytes
  • Heberden’s nodes (DIP’s)
  • Bouchard’s nodes (PIP’s)
  • Primary DJD in fingers
  • May appear more symmetrical as becomes widespread

16

DJD Cervical Spine 

DJD in the cervical spine is a can affect any of the joints:

  • Intervertebral Discs 
  • Facet Joints 
  • Uncovertebral joints 

Degenerative Disc Disease 

  • Radiographic Features 
    • Decreased disc height 
    • Osteophytes (circumferential, anterior and posterior)
    • Endplate sclerosis 
    • Intercalary bone = calcification of the anterior annulus of disc 
    • Displacment (anterior, retro, laterolisthesis)

Facet Arthritis 

  • Radiographic Features 
    • Decreased joint space 
    • Subchondral sclerosis 
    • Osteophytes 
    • Possible antero/retrolisthesis 
    • AP projection shows sharp osteophytic projections and sclerosis through smooth articular pillar boarder 
    • IVF encroachment from osteophytes 
    • Facet hypertrophy 
    • Asymetrical 

Uncovertebral Arthritis 

  • Radiographic Features 
    • Osteophytes over uncinate process 
    • Foraminal encroachment with possible nerve and artery interference 
    • Sharpening of tip of uncinate process (early), bulbous enlargment of uncinate process (late)
    • Psuedofracture line across posterior margin of lower half of vertebral body (lateral projection)
    • Hypertrophy of uncinate process 

17

DJD Thoracic Spine 

Facet Arthritis 

  • Radiographic Features 
    • Decreased joint space
    • Sclerosis 
    • May refer to low lumbar spine and iliac crest = Maignes Syndrome 

Costovertebral/costotransverse arthritis​

  • Radiographic Features 
    • Lower thoracic segments
    •  May simulate upper gastrointestinal disease: Roberts syndrome

Degenerative Disc Disease 

  • Radiographic Features 
    • Mid-low thoracic spine
    • Osteophytes (absence on left – aortic pulsations)
    • Mild disc narrowing
    • Minimal sclerosis
    • Inc kyphosis

18

DJD Lumbar Spine 

Degnerative Disc Disease 

  • Radiographic Features 
    • L4-L5 most common 
    • Early: retrolisthesis, anterior/lateral osteophytes, vacuum phenomenon (nitrogen accumulation in fissured disc)
    • Late: claw/bridging osteophytes, decreased disc height, subluxations
    • Lateral best view for diagnosis, AP for lateral osteophytes
    • Vacumm Phenomenon = Nitrogen accumulation in fissured disc 
    • Hemispherical spondylosclerosis 

Facet Arthritis 

  • Radiographic Features 
    • L4 and L5 most common
    • Loss of joint space • Sclerosis
    • Osteophytes
    • Subluxation (esp anterolisthesis)
    • AP: decreased joint space, sclerosis
    • Lateral: sclerosis, anterolisthesis/retrolisthesis (may need flexion/extension views)
    • Oblique: decreased joint space, sclerosis, osteophytes

Degenerative Spondylolisthesis 

  • Radiographic Features 
    • Most common at L4
    • No pars defects
    • > 50yrs
    • Predominantly female (6:1)
    • Disc space narrowing
    • Facet sclerosis
    • Change in pedicle/facet angle

19

Inflammatory Arthritis Pathogenesis 

  • Formation of synovitis (inflammation) within joint and oedema
  • Soft tissue swelling
  •  Formation of pannus (granulation tissue)
  • Destroys cartilage uniformly – symmetrical joint space loss
  • Creates erosions in bone where not protected by cartilage – marginal erosions

 

20

Rhuematoid Arthritis 

RA is a connective tisue disorder that affects the synovial joints within the body creating an inflmmatory repsonse, the body then attacks and breaks down these joints. 

  • Selectively targets synovial tissue: joints, tendons, bursae
  • Bilateral, symmetrical, progressive
  • Other body systems may be involved: heart, lungs, blood vessels, nerves, eyes

Clinical Features 

  • 20-60 yrs
  • Increased females 3:1 20-40yrs, equal >40yrs
  •  Insidious onset articular pain, swelling, tenderness, stiffness (am),
  • Bilateral and symmetrical
  • Fatigue, malaise, muscle weakness, fever
  • Rheumatoid nodules (20%) elbows, knees, ankles, hands, sacrum
  • Laboratory: anaemia, inc ESR, CRP, rheumatoid factor (70%)
  • Periods of remission and exacerbation
  • Gradual progression of deformity and disability

Radiographic Features 

  • Acute synovitis with oedema
    • Periarticular soft tissue swelling
  • Synovial proliferation forming pannus (vascular granulation tissue)
  • Juxtaarticular hyperaemia
    • Juxtaarticular osteoporosis
  • Pannus destruction of cartilage
    • Uniform loss of joint space
  • Pannus eroding bare area
    •  Marginal erosions
  • Pannus intrusion into marrow spaces
    • Subchondral cysts
  • Secondary changes
    •  Joint deformity, Joint destruction, ligamentous laxity, altered muscles
    •  Fibrosis of pannus filling joint cavity - fibrous ankylosis (possibly bony ankylosis)
    • Secondary degenerative changes

Distribution 

  • Wrist/Hand to MCP
  • Ankle/Feet to MTP
  • Elbow • Knee
  • Glenohumeral
  •  Hip
  • Bilateral and symmetrical

21

RA Wrist 

  • Bilateral and symmetrical
  •  60% of cases have early prominence at wrist: 
  • Ulnar styloid erosion
  • Carpal erosion and dislocation

22

RA Hands 

  • Bilateral and symmetrical
  • MCP erosion (rarely PIP and DIP erosion)
  • Subluxations
  • Swan neck deformity
    • Extension PIP, flexion DIP
  • Boutonnierre deformity
  • Hitchhiker’s thumb
  •  Ulnar deviation 

23

RA Feet 

  • MTP marginal erosions
  •  Subluxations

24

RA Elbow 

  • Erosions – tapering of ends of bones

25

RA Knees 

  • Bilateral and symmetrical
  • Symmetrical loss of joint space
  •  Subchondral cysts
  • Juxta-articular osteopenia

26

RA Hip

  • Central loss of joint space
  • Most common cause of bilateral protrusio acetabulae

27

RA Shoulder 

  • Symmetrical loss of GH joint space
  • Humeral erosions
  • Subacromial bursa may be involved
  • Distal clavicle erosions

28

RA Spine 

  • Most commonly involves cervical spine
    • 50-80% of cases • Contraindication due to instability
    • Flexion cervical views
    •  Erosions of dens and atlantoaxial ligament insertions
    •  Facet joint erosions, subluxations (stepladder)
  • May involve thoracolumbar region
    • 5% of cases
    • Discovertebral endplate irregularities, sclerosis, loss of disc height
    •  Resembles advanced DDD or infection

Radiographic Features 

  • Increased ADI 
  • Dens erosions 
  • Endplate erosions C3-C5 
  • Anterolesthesis C3 (Step ladder)

29

Psoriatric Arthritis 

  • Psoriatic arthritis (PsA) is the second most common inflammatory arthropathy, after rheumatoid arthritis diagnosis, in early arthritis clinics.
  • Most patients have established psoriasis, often for years, prior to the onset of joint pain and swelling; in addition, associated features of nail disease, dactylitis, enthesitis, spondylitis or uveitis may be present. 
  • Spinal findings in up to 50% of patients with skin disease

Clinical Features 

  • 20-50 yrs
  • Early: DIP/PIP swelling, redness, pain, sausage digit
  •  Inc ESR, negative rheumatoid factor, 30-75% have HLA-B27 antigen
  • Pathologic features similar to RA

Radiographic Findings 

  • Asymmetric nonmarginal syndesmophytes
  • Thoracolumbar most common
  • Paravertebral ossifications
  • Coarse, irregular, mid vertebral body to mid vertebral body
  • Complete/incomplete/floating
  • Atlantoaxial subluxation (increased ADI)
  • Sparing of facet joints (except cervical spine)
  • Sacroiliac joint involved in up to 50%
    • Unilateral or bilateral asymmetric sacroiliitis
  • Synovitis and oedema
    •  Soft tissue swelling
  • No hyperaemia in bone
    • Normal bone density
  •  Pannus eroding bare areas
    •  Marginal erosions and tapered bone ends
    • Pencil in cup deformity
  •  Healing periosteal response stimulated
    • Fluffy juxtaarticular periostitis
    • Mouse ears
  • Narrowed or widened joint space
  • Pannus fibrosis
    • Fibrotic and eventual bony ankylosis
    • Arthritis mutilans

Distribution 

  • DIP, PIP hands and feet
    • May have ray pattern and include MCP
  • Knee
  • Sacroiliac joint
  • Thoracolumbar spine
  • Cervical spine
  • Hip
  • Shoulder

30

DISH 

  • Diffuse Idiopathic Skeletal Hyperostosis
  •  Forrestier’s disease
  • Characterised by ligamentous calcification and ossification
  • Most prominent in anterior longitudinal ligament of spine
  • 12% of middle aged and elderly people

Distribution 

  •  Spine
    •  C4-C7
    • T7-T11: majority of hyperostosis on right
    • L1-L3
    •  SI Joint: ossification of ligamentous portion, sparing of synovial joint
    •  Extraspinal sites
    • 30% of patients with spinal DISH
    •  Most common at pelvis, patella, calcaneus, foot, elbow
    • Calcification of ligamentous/tendinous insertions – enthesial changes/enthesopathy

Clinical Features 

  •  40-60 yrs
  • Broad spectrum of presentations
    •  Asymptomatic – similar to DJD
    • Morning stiffness, low-grade spinal musculoskeletal pain
  • Facet joints spared: spinal movement relatively maintained despite anterior ossification
  •  Increased kyphosis, decreased lordosis
  •  20% have dysphagia
  •  20% have ossification of the posterior longitudinal ligament (OPLL) leading to spinal stenosis
  • Associated with increased incidence diabetes
  •  Can progress to ankylosis
  •  May be complicated by carrot stick fracture
  •  90% in lower cervical spine
  •  Neurological compromise - quadriplegia

Pathogenesis 

  • Exaggerated response to form bone to unidentified stimuli
  • Calcification followed by ossification of ALL (arrowheads)
  • Begins midpoint of vertebral body and extends to bridge IVD space 
  •  Early: deep fibres of ALL uninvolved – lucency between calcification and vertebral body (arrows)
  •  Late: deep fibres calcify and blurs with anterior vertebral body
  • May progress to fusion of vertebral bodies

Radiographic Features 

  • Flowing calcification/ossification of ALL of at least 4 contiguous vertebral bodies
    • Dripping candle wax
    •  Flame-shaped osteophytes
    •  Flowing hyperostosis
  •  Relative preservation of disc height
  •  No osteophytic change or subchondral sclerosis
  • No ankylosis of facet joints
  •  DJD can occur concurrently
  • Carrot Stick fracture when ankylosis occurs