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Flashcards in Christman chapter 19 Deck (116):
1

Causes of Monoarticular joint disease (7)

OCTOPIS

-Osteonecrosis
-Crystal induced
-Trauma
-Osteochondroma
-Pigmented villonodular synovitis
-Infectious disease (septic arthritis)
-Systematic disease (RA, psoriatic arthritis, reactive arthritis)

2

Causes of polyarticular joint disease (2 categories)

Inflammatory causes:
-Chronic tophaceous gout
-Rheumatoid arthritis
-Seronegative spondyloarthritis
-----psoriatic arthritis
-----ankylosing spondylitis
-----Reactive arthritis

Noninflammatory:
-primary OA
-Charcot arthropathy
-Pigmented villonodular synovitis

3

Categories of joint disease:underlying pathology (2)

Degenerative and inflammatory

4

Degenerative joint disease: another word for it

osteoarthritis

5

Inflammatory: 4 types

-Rheumatoid arthritis
-Seronegative:
---Psoriatic arthritis
---reactive arthritis
---ankylosing spondylitis
-Septic arthritis
-Metabolic
---gouty arthritis
---pyrophosphate arthropathy

6

Categories of joint disease : based on radiographic features (2)

-hypertrophic joint disease: subchondral sclerosis and osteophyte formation at the joint margin

-Atrophic joint disease: loss of bone substance through erosion and joint space narrowing

7

Hypertrophic joint disease (2)

-osteoarthritis
-
Detritus arthritis
---tarsus and midfoot charcot arthropathy
---posttraumatic arthritis

8

Atrophic joint disease (5)

-Rheumatoid arthritis

-Seronegative spondyloarthritis
---psoriatic arthritis
---ankylosing spondylitis
---reactive arthritis

-Septic arthritis

-Forefoot charcot osteoarthropathy

-Lumpy-bumpy
---gouty arthritis
---multiple reticulohistiocytosis
---pigmented villonodular synovitis

9

Primary radiographic changes (4)

-Osteophyte
-Erosion
-Subchondral resorption
-Arthritis mutilans

10

Osteophyte: definition and examples

Definition:
-a spur at the margin of a joint
-also known as dorsal flag, lipping and beaking

Pathognomonic of OA

11

Erosion: definition and examples

Definition:
-a localized wearing away of bone that begins along its outer surfaace
-Primary feature of all joint disorders affecting the foot except for OA

Examples:
-Rheumatoid arthritis

-Seronegative spondyloarthritis
---psoriatic arthritis
---ankylosing spondylitis
---reactive arthritis

-gouty arthritis

12

Subchondral resorption: definition and examples

Examples:
-Charcot arthropathy
-Septic arthritic

13

Arthritis Mutilans: definition and examples

Definition:
-erosions that involve both margins

-Most commonly called the "pencil-in-cup"

Examples:
-Psoriatic arthritis
-Charcot neuropathic osteo
-Rheumatoid arthritis (5th MPJ)

14

Bone producing secondary radiographic findings (5)

-Diffuse sclerosis

-periostitis

-Whiskering

-Ivory Phalanx

-Overhanging margin of bone

15

Diffuse sclerosis: association?

association with the repair and remodeling phase of Carcot arthropathy

16

Periostitis:association?

associated with seronegative arthritis, septic arthritis, and forefoot Charcot arthropathy

17

Whiskering: association?

Seen with psoriatic arthritis

18

Ivory phalanx: association?

associated with psoriatic arthritis

19

Overhanging margin of bone: association

associated with gouty arthritis

20

Secondary radiographic findings that result in joint space alteration (2 categories)

Even joint space narrowing:
---inflammatory arthritis

Uneven joint space narrowing:
---OA/trauma

21

Osteoarthritis:
-Joints to be worried about (5)

-Hallux interphalangeal

-First MPJ

-Second met cuneiform

-Intermediate naviculocuneiform

-Talonavicular

22

OA Radiographic features: 6

-Primary finding is osteophyte

-uneven joint space narrowing

-subchondral sclerosis (eburnation)

-geode with sclerotic margins (subchondral cyst)

-Detritus

23

OA: targets what column

Targets the medial column especially the first MPJ

24

Rheumatoid arthritis classification criteria

-Joint involvement
-Serology
-Acute phase reactants
-Duration of symptoms

25

RA: first joint to be affected

5th MPJ is the first

26

Classic presentation of Rheumatoid Arthritis (5)

-Bilateral and symmetric

-Medial erosions at the 1st through 4th ray

-Lateral erosion of the 5th

-Uniform joint space narrowing at affected joints

-Fibular deviation

27

More specific presentations for RA

-increased soft tissue density and volume

-joint space widening (initially)

-Para-articular osteopenia

-Geode

-Erosion (medial sides except for lateral at the 5th)

-Joint space narrowing (to end with)

-Digital misalignment

-Ankylosis

28

Psoriatic arthritis:clinical presentations (5)

-predominant distal interphalangeal joint involvement

-Assymetric MPJ involvement with associated swelling (sausage toe)

-Spondylitis

-Arthritis mutilans

-Psoriatic onychopachydermoperiostitis

29

Psoriatic arthritis: radiographic changes(7)

-Primary: erosion/arthritis mutilans

-Periostitis (adjacent to affected joint line)

-Whiskering/ Ivory phalanx

-Sausage toe

-Acro-osteolysis

-Lack of juxta-articular osteopenia

-Enthesitis

30

Reactive arthritis: what causes it (2)

Shigella/ Chlamydia

31

Reactive arthritis: radiographic features (4)

-Primary finding: erosion

-Joint space narrowing and widening

-Sausage toe

-Periostitis adjacent to affected joint

32

Gouty arthritis: stages (3)

1) asymptomatic hyperuricemia

2) acute intermittent gout

3) advanced (chronic tophaceous) gout

33

Gouty arthritis:radiographic features (5)

-Primary finding: erosion which tends to be periarticular withan overhanging margin (Martel sign)

-Normal joint space

-Soft tissue mass (tophus)

-Rarefaction in bone occurs secondary to intraosseous tophus

-Occasional calcification of tophus

34

Charcot osteoarthropathy: Characterized by?

characterized by early inflammation and affects the bones and joints

35

Charcot osteoarthropathy (classification)

Eichenholz
1) Development

2)Coalescence

3) Reconstruction phase

36

Charcot osteoarthropathy (three target areas)

According to Cofeld

1) MPJ's

2)Tarsometatarsal joint

3) Combination of: Talonavicular, Naviculocuneiform, and intercuneiform

37

Unique presentation of Forefoot charcot osteoarthropathy (2)

Subchondral resorption or arthritis mutilans

Periostitis

38

Unique presentation of rearfoot charcot osteoarthopathy (3)

- subchondral resorption

-loss of joint apposition (subluxation/dislocation)

-Detritus

39

Unique presentation of septic arthritis

-Primary finding is subchondral resorption

-Joint space widening

-Will progress to osteolysis

40

What pathology results in:
Regional osteopenia (2)

-Disuse and immobilization

-Complex regional pain syndrome

41

What pathology results in generalized osteopenia (5)

-Osteoporosis

-Osteomalacia

-Hypophosphatasia

-Hyperparathyroidism

-Renal osteodystrophy

42

What pathology results in: epiphyseal region abnormality (2)

-Scurvy

-Rickets

43

What pathology results in: altered bone architecture (4)

-Paget disease

-fibrous dysplasia

-sickle cell anemia

-thalesemia

44

What pathology results in: altered bone form (7)

-acromegaly

-gigantism

-hereditary multiple exostoses

-echondromatosis

-osteogenesis imperfecta

-hypoparathyroidism

-Albright hereditary osteodystrophy

45

What pathology results in: generalized sclerosis (7)

-Osteopetrosis

-osteopoikilosis

-Melorheostosis

-osteopathia striata

-pyknoidysostosis

-fluorosis

-hypervitaminosis D

46

What pathology results in: Generalized periostitis (5)

-hypertrophic osteoarthropathy

-venous stasis

-hypervitaminosis A

-thyroid acropachy

-tuberous sclerosis

47

Osteopenia: when does it occur and when is it seen on x-rays

-occurs when bone resorption exceeds bone formation

-when 30-50% of bone mass is lost X-rays reveal osteopenia

48

Radiographic Patterns of chronic osteopenia (3)

-endosteal resorption

-intracortical tunneling

-subperiosteal resorption

Endosteal+subperiosteal resorption = cortical thinning

49

Primary radiographic feature of acute osteopenia

Primary radiographic feature is spotty loss of bone density

50

Definition of osteoporosis

progressive loss of bone mass due to increased resorption as well as decreased bone production.

-Results in normal bone composition but reduced amount of bone present per unit volume

51

Gold standard for detection of early osteoporosis

- DXA scan
---Dual x-ray absorptiometry

52

Differential diagnoses for generalized osteoporosis

ViNDICaTE

-Vascular: anemia

-Nutritional: scurvy, malnutrition, calcium deficiency

-Drugs: steroids and heparin

-Idiopathic

-Congenital: osteogenesis imperfecta

-Toxic: alcoholism, chronic liver disease, cirrhosis

-Endocrine/Metabolic

53

Radiographic features of chronic osteopenia (3)

-thinning of the cortices

-prominent primary trabeculations

-intracortical striations

54

Osteomalacia: histologic findings

Histological disorder with excessive amounts of uncalcified osteoid.

55

Osteomalacia: amount of time to osteoid synthesis

Normally: 5-10 days

With osteomalacia: 2-3 months

56

Radiographic sign AND other changes seen in osteomalacia

-Primary radiographic sign is osteopenia

-Bowing deformity of long tubular bones may occur

-Transversely oriented incomplete radiolucency (pseudofracture)

-Lucent line may be bordered by sclerosis and is located along compressive side of bone

-Looser zone found in inner cortex

57

Hypophosphatasia: definition of

characterized by reduced levels of alkaline phosphatase

58

Hypophosphatasia: radiographic presentations (5)

-bowing

-shortening of long tubular bones

-Osteochondral spurring

-Chondrocalcinosis articularis

-Looser zone seen on the outer cortex (tensile side)

59

Hyperparathyroidism: definition

refers to increaed levels of PTH which indirectly leads to increased osteoclastic activity and leads to removal of calcium from bone into blood

60

Definition of primary hyperparathyroidism

due to a parathyroid abnormality and leads to hypercalcemia.

-May be in response to low calcium levels as well.

-Associated with hyperuricemia and gout

-TUMOR

61

Definition of secondary hyperparathyroidism

various situations that cause Vitamin D deficiency

62

Definition of tertiary hyperparathyroidism

results from hyperplasia of the parathyroid glands and a loss of response to serum calcium levels

-dialysis patients

63

Hyperparathyroidism radiographic features (7)

-Primary is subperiosteal bone resorption

-periarticular resorption

-intracortical resorption

-endosteal resorption

-subchondral resorption

-entheseal resorption

-acral osteolysis

64

Hyperparathyroidism hisological features

fibrous tissue replaces bone that is removed in a process known as osteitis fibrosis cystica

65

Hyperparathyroidism: what may resemble metastatic lesions?

Brown tumors: geographic radiolucent lesions corresponding to hot spots within the same bone on bone scans

66

Renal osteodystrophy:

subtype of?

Radiographic features

subtype of hyperparathyroidism

-will see a lot of soft tissue calcifications

67

Ricket's: reason for pathology

-failure of osteoid to calcify in a growing person

68

Ricket's radiologic signs (4)

-widening of the physis

-decreased density at the zone of provisional calcification

-Fraying and paint-brush appearance at the zone of provisional calcification

-widening and cupping of the metaphysis

69

Scurvy: causes

Insufficient dietary vitamin C intake

70

Scurvy: radiographic characteristics at the metaphysis (3)

- White line of scurvy: increased density bordering the growth plate

-Scurvy line: transverse line of decreased density by the metaphyseal line

-Small beak-like outgrowths of the zone of provisional calcification along its margins

71

Scurvy: radiographic characteristics at the epiphysis (just 1)

Epiphysis appears as an eggshell appearance: appears as an outer shell of increased density surrounding a central lucency.

72

Scurvy: 2 more radiographic changes

- Coroners sign

-Extensive periostitis may be seen along the entire length of bone

73

Acromegaly cause

Increase in GH and IGF 1

-most commonly due to a pituitary adenoma

74

Acromegaly: radiographic changes (4)

-Very thick heel pad >25mm

-Met shafts thickened, enthuses and spurring

75

Acromegaly arthropathy

resembles osteoarthritis and may find osteophytes, eburnation, subchondral geode, joint space narrowing

76

Osteochondromatosis: what is it?

It is a skeletal dysplasia resulting from disturbances in chondroid production resulting in heterotropic proliferation of epiphyseal chondroblasts

77

Osteochondromatosis: radiographic finding

Exostosis is found adjacent to the metaphysis and is attached to the bone by a stalk or pedicle

78

Echondromatosis (Ollier disease): what is it?

abnormality is due to multiple benign cartilage tumors within bone

79

What is Maffucci syndrome

name given to multiple enchondromas associated with hemangiomas

80

Echondromatosis radiographic findings?

geographic destructive (lucent lesion)

81

Osteogenesis imperfecta what is it

-result of abnormal metaphyseal and periosteal ossification caused by deficient osteoid disease

-referred to as brittle bone disease

82

Osteogenesis imperfecta (four types)

-Type I: most common, mild form that demonstrates fractures with no dwarfing.

-Type II: neonatal and lethal

-Type III: rare and demonstrates dwarfing and extremely fragile bone

Type IV: variable findings

83

Osteogenesis imperfecta : -Referred to as?

-due to:

-Radiographic findings

- Referred to as brittle bone disease

-due to deficient osteoid production

-Radiographically will see -diffuse osteopenia

-diminished bone girth

-flared metaphyses which give Erlenmeyer flask deformity

84

Hypoparathyroidism

-cause

-resulting findings

-radiographic findings

-caused by deficient or absent PTH, and is due to surgical exicision of all parathyroid tissue

-Results in hypocalcemia, hyperphosphatemia and hypercalciuria

Radiographic findings: osteosclerosis of bones and soft tissue calcification

Pathognomonic: brachymetaphalangea (shortened and widened out)

85

Albright hereditary osteodystrophy

-what is it

-Features

-Radiographic findings

-PTH resistant hypocalcemia and hyperphosphatemia along with an unusual constellation of developmental and skeletal defects

-features: short stature, round face, brachydactyly, obesity,

-radiographically: short mets and phalanges, exostoses, widening bones

86

Paget disease: osteitis deformans

-occurence

-marked by what bony changes

-associated with elevated serum?

-second most common aging bone disorder

-blade of grass
-flame appearance
-Sabre shins
-cortical thickening

-associated with elevated serum ALP and hydroxyproline

87

Paget disease

-marked by?

-abnormal serum levels

-Radiographic changes

-Marked by excessive and abnormal remodeling of bone

-Serum ALP and hydroxyproline become elevated

-Radiographic changes:
Lucent wedge, blade of grass appearance, flame appearance.

----Sabre shins
----Cortical thickening

88

Paget disease: earliest imaging modality

bone scintigraphy demonstrates increaed uptake of radionuclide before radiographic changes found

-CT better to visualize trabecular thickening.

89

Pathognomonic signs of Paget

bone enlargement, cortical and trabecular thickening

90

Anemia: change in bone and change in soft tissue

- cause sclerotic lesions in bone

-soft tissue:dachtyly

91

Thalassemia

will see the Erlenmeyer flask deformity in bone

92

Osteopetrosis: other synonyms for this

stone bone, and marble bone disease

93

Lower limb deformities seen with osteopetrosis (4)

coxa vara
-genu valgum
-genu varum
-clubfoot

94

Radiographic presentation in osteopetrosis (3)

-diffuse bone sclerosis: known as "bone within a bone"

-Transverse band of sclerosis

-Erlenmeyer flask deformity

95

Radiographic presentation seen in Melorheostosis

-flowing hyperostosis along the cortex of tubular bone

-Candle wax disease

96

Osteopoikilosis radiographic presentation

-multiple bone islands

---also known as enostosis

97

Osteopathia striata radiographic findings

-linear and regular fine bands of increased and decreased density that extend from the metaphysis

98

Pyknodysostosis radiographic findings

recurrent fractures and dwarfism

-acryl osteolysis

99

Hypervitaminosis A, Hypervitaminosis D, fluorosis common findings

will cause excessive bone formation

100

Venous stasis insufficiency 2 characteristic findings

-indurated cellulitis

-periostitis

101

Pulmonary hypertrophic osteoarthropathy findings (4)

-dactylitis

-periostitis

-clubbing of the fingernails

-acryl osteolysis

102

Tuberous sclerosis: triad, and soft tissue finding

-mental retardation

-hamartomas

-epilepsy

soft tissue: periungual fibromas

103

Metabolic disorders that result in periostitis (5)

-hypervitaminosis A

-hyperthyroidism

-tuberous sclerosis

-venous stasis

-pulmonary hypertrophic osteoarthropathy

104

Metastatic soft tissue calcification:definition and example

-the soft tissue is normal, but the bone metabolism is abnormal

-seen in renal osteodystrophy

105

Generalized soft tissue calcification: definition and example

-Soft tissue is normal and the bone metabolism is normal

-seen in tumoral calcinosis

106

Tumoral calcinosis definition and testing

-soft tissue calcification that usually occurs on the dorsum of the foot over the extensor tendons.

-Must biopsy

107

Dystrophic calcification definition and areas it is usually seen in

-soft tissue metabolism is abnormal, but bone metabolism is normal

-Seen in:
---plantar fasciitis
---Achilles tendinitis
---Monckeberg's : medial calcific sclerosis seen in diabetic vessel calcification of the tunica media
---Fleboliths in venous stasis
--- Atherosclerotic plaques

108

What is Monckeberg's

medial calcific sclerosis of the tunica media of blood vessels that occurs with Diabetics

109

What are Fleboliths

they are calcifications of the surrounding soft tissue seen in venous stasis

110

Example of heterotopic calcification:

Myositis ossificans in tendon or muscle

111

How to histologically differentiate myositis ossificans from osteogenic sarcoma

-Myositis ossificans circumscripta: osteoid production occurs in the periphery of the bone mass

-Osteogenic sarcoma: osteoid production begins in the center of the bone mass.

112

Which disease processes exhibit dachtylitis (3)

-psoriatic arthritis

-sickle cell disease

-pulmonary hypertrophic osteoarthropathy

113

Diseases that result in acryl osteolysis (4)

-Psoriatic arthritis

-hyperparathyroidism

-Pyknodysostoss

-Pulmonary hypertrophic osteoarthropathy

114

Diseases that result Erlenmeyer flask deformity (3)

-Osteogenesis imperfecta(brittle bone disease)

-Thalassemia

-Osteopetrosis (marble bone disease)

115

Charcot Classification (zones)

Sanders and Frykberg

116

Sanders and Frykberg Classification (5 zones)

- Zone 1: Distal and proximal interphalangeal joints and MPJ's

-Zone 2: Tarsometatarsal joints ( Lisfranc)

-Zone 3: Naviculo-cuneiform joints, talonavicular and calcaneocuboid

-Zone 4: Ankle joint and subtalar joint

Zone 5: Calcaneus