DI II Final

Question 1

List the three presentations/types of osteoporosis.

Answer 1

Generalized – age related, post-menopausal, steroid induced, heparin induced, multiple myeloma, metastasis, hyperparathyroidism, scurvy, osteomalacia, rickets, sickle cell, osteogenesis imperfecta

Regional – disuse/immobilization, RSD

Localized – infection, inflammatory arthritis, neoplasm

Question 2

What is the most common cause of generalized osteoporosis?

Answer 2

Old age - post-menopausal

Question 3

What is the standard modality to quantify bone mineral density?

Answer 3

Dual Energy Xray Absorptiometry (DXA)

Question 4

What causes rickets?

Answer 4

Systemic skeletal disorder due to deficiency in Vit D from:

• lack of dietary intake
• lack of natural light exposure
• renal osteodystophy (renal rickets) - chronic kidney dz
• renal tubular defect - failure to resorb phosphate

Question 5

What causes osteomalacia?

Answer 5

Lack of osteoid mineralization leading to generalized bone softening

Question 6

What causes rickets? What are the classic radiographic features?

Answer 6

Generalized osteopenia due to primary vit D deficiency

Coarse trabecular changes
Widened growth plates
Rachitic (costal) rosary
Absent zone of provisional calcification
Frayed 'paintbrush' and cupped metaphyses

Question 7

What causes scurvy?

Answer 7

AKA “Barlow’s Disease”
Caused by Vit C deficiency
depresses intrercellular substance formation, especially in CT, cartilage, and bone

Question 8

What are the classic radiographic features of scurvy?

Answer 8

Combination of abnormalities occuring at the growing ends of long bones

• osteoporosis
• dense zones of provisional - calcification (white line of frankel)
• Ring epiphysis (Wimberger’s sign)
• Pelken’s spurs
• Scorbutic zone (trummerfeld zone)
• Superperiosteal hemorrhage

Question 9

What are the classic radiographic features of hyperparathyroidism in the spine, skull, and hand?

Answer 9

Spin - osteopenia, trabecular accentuation, end plate concavities, ‘rugger jersey’ spine, widened SIJs

Skull - ‘salt and pepper’ resorption of lamina dura

Hand - subperiosteal resorption, radial margins of the proximal and middle phalanges of the 2nd/3rd digits with acroosteolyisis

Question 10

What are the face, skull, and foot changes seen with acromegaly?

Answer 10

Face - prominent forehead, thickened tongue

Skull - sella tursica enlargement (pituitary neoplasm), sinus overgrowth, malocclusion, widened mandibular angle

Hand - widened shafts, bony protuberances, enlarged distal tufts (‘spade-like’) and widened joint spaces (cartilage overgrowth), widened heal pad

Question 11

What osseous changed might long term corticosteroid use cause?

Answer 11

Osteonecrosis (avascular necrosis) - rapid bone turnover

Question 12

“H” shaped vertebra is classical seen in what condition?

Answer 12

Sickle Cell Anemia
(caused by osteoporosis of vertebral bodies – deformed at end plates with central depression due to hypoplasia of central portion of vertebrae)

Question 13

What are some complications to the skeleton secondary to sickle cell anemia?

Answer 13

Bone changes are due to marrow hyperplasia, ischemia, and necrosis

• generalized osteoporisis
• thin cortices
• coarse trabeculae
• large vascular channels
• widened medullary cavity
• growth deformities
• epiphyseal ischemic necrosis
• medullary infarcts
• secondary salmonella osteomyelitis
• vertebral body collapse
• posterior mediastinal extramedullary hematopoiesis

Question 14

Which anemia tends to result in ‘honeycomb’ trabecular patterns?

Answer 14

Thalassemia

Question 15

Hemophilic arthropathy typically occurs in which joints?

Answer 15

Knee (enlarged epiphysis, widened intercondylar notch, and scquared inferior patella)
Ankle (tibiotalar slant deformity)
Elbow
Also, Pseudotumors – destructive intraosseous hemorrhages – most commonly occur in femur and pelvis

Question 16

What is a common DDX when encountering hemophilic arthropathy of the knee?

Answer 16

childhood RA

Question 17

List some common sites for AVN/osteonecrosis?

Answer 17

Femoral head (leff-calve-perthes)
Knee (SONK)
Carpal lunate (Keinboch's)

Question 18

List 5 typical causes of AVN/osteonecrosis?

Answer 18

Trauma
Hemoglobinopathy
Caison's disease
Corticosteroid use
Radiation
Collagen disease
Alcoholism
Gaucher's disease
Pancreatitis
Gout

Question 19

Which arthritis demonstrates non-uniform joint space narrowing, osteophytes, subchondral sclerosism and subchondral cysts?

Answer 19

DJD - osteoarthritis

Question 20

Which condition presents with a triangular sclerosis at the iliac portion of the lower SIJ?

Answer 20

Osteitis condensans ilii

- predominantly women of childbearing age

Question 21

Is osteitis condensans ilii more commonly unilateral or bilateral?

Answer 21

Bilateral

Question 22

IS osteitis condensans ilii more common in males or females?

Answer 22

Females (childbearing age)

Question 23

Osteitis pubis is commonly associated with which medical procedure?

Answer 23

surgery near pubic symphysis

Question 24

What is the difference between marginal and non-marginal syndesmophytes?

Answer 24

Marginal syndesmophytes (intervertebral bony bony bridges) are delicate and symmetric, more commonly seen in ankylosing spondylitis.

Non-marginal syndesmophytes are bulky and discontinuous, more commonly in reactive arthritis and DISH.

Question 25

Which spinal arthritides have marginal vs. non-marginal syndesmophytes?

Answer 25

Marginal – (thin) ankylosing spondylitis | Non-marginal – (coarse) psoriatic/reactive arthritis, Reiter's syndrome

Question 26

What systemic condition is commonly found in patients with diffuse idiopathic skeletal hyperostosis?

Answer 26

Diabetes

Question 27

Dysphagia is common in which arthritis condition? Why?

Answer 27

Diffuse idiopathic skeletal hyperosteosis (DISH) | Decreased lordosis and increased kyphosis

Question 28

What part of the spine is DISH most commonly found?

Answer 28

Thoracisc spine, lower cervical, upper lumbar, superior SIJ

Question 29

List the radiographic findings of neurotrophic arthropathy.

Answer 29

``` 6 "D"s Distended joint Density increased Debris Dislocation Disorganization Destruction ```

Question 30

Which conditions may result in neurotrophic arthropathy?

Answer 30

``` diabetes alcoolism tabes dorsalis paralysis syringomyelia ```

Question 31

What is synoviochondrometaplasia?

Answer 31

aka synovial chondromatosis or osteochrondromatosis metaplastic changes in synovium produce cartilaginous bodies that may or may not calcify/ossify and may or may not be free within joint capsule

Question 32

Name the common sites of involvement of RA in the hand and wrist.

Answer 32

``` HAND Boutonniere - DIP extension/PIP flexion Swan neck - DIP flexion/PIP extension Ulnar deviation at MCP joint Radial deviation of carpals 'Zig-Zag' deformity (ulnar/radial deviation) ``` ``` WRIST earlier and more severe than hand changes ulnar styloid erosion uniform loss of radiocarpal joint erosion of triquetrum/pisiform 'spotty carpal' sign pancarpal involvement scaphoid/lunate dislocation ```

Question 33

What is a marginal erosion and what category of arthritis is it seen with?

Answer 33

Irregular erosion with no sclerotic margin | Associated with RA

Question 34

What is the significance of widening of the atlantodental interspace?

Answer 34

May create direct compression of the brainstem or cause neuro damage by excessive kyphosis C1-C2 instability Ligament may widen and rupture with inflammatory arthropathisees like RA, psoriatic arthritis, reiter's syndrome, and ankylosing spondylitis

Question 35

Which conditions demonstrate laxity of the transverse ligament?

Answer 35

SLE, Downs syndrome, possibly RA (uncommon)

Question 36

Is SI involvement common in RA?

Answer 36

No

Question 37

Describe radiographic differences between RA and psoriatic arthritis in the hand and wrist

Answer 37

Psoriatic – ray pattern – involvement of all 3 joints of a single digit (MCP, PIP, and DIP) RA – just MCPs and PIPs (no DIPs)

Question 38

What is the gender incidence of RA?

Answer 38

F:M 3:1 until age 40, then 1:1

Question 39

What is the first site of involvement of ankylosing spondylitists?

Answer 39

SI joint or thoracolumbar

Question 40

What is the second site of involvement with ankylosing spondylitis?

Answer 40

Spine - discovertebral joint erodes, sclerosis, and ossifies | Also apophyseal joints, interspinous ligamentsossification, costovertebral joints, and c-spine

Question 41

Is SI involvement in ankylosing spondylitis usually unilateral or bilateral?

Answer 41

Bilateral

Question 42

What is gender incidence of ankylosing spondylitis?

Answer 42

M:F - 9:1 | Usually onset at 15-35yrs

Question 43

Which condition demonstrates squaring of the vertebral body?

Answer 43

Ankylosing spondylitis

Question 44

What is the shiny corner sign?

Answer 44

Seen in ankylosing spondylitis | Erosion of outer fibers of annulus and ossification of vertebral body edge

Question 45

What is a carrot stick fracture?

Answer 45

Complication of ankylosing spondylitis | fracture of an alkylosed segment often causing paralysis

Question 46

Which condition demonstrates similar SIJ and vertebral findings to AS?

Answer 46

Enteropathic arthropathy – secondary to UC, crohn’s, whipples, salmonella, shigella, Yersinia

Question 47

Which 2 seronegative spondyloarthropathies demonstrate non-marginal syndesmophytes and peripheral arthritis?

Answer 47

Psoriatic and Reiter's

Question 48

Reversible deformities of the hand are seen in which condition?

Answer 48

SLE - ulnar deviation, but pt can overcome this with muscle contraction or pushing down on the table - ligaments are lax, but joints are not destroyed

Question 49

What is acro-osteolysis and which conditions demonstrate this finding?

Answer 49

Reabsorption of extremities | Seen in scleroderma, psoriatic arthritis, and SLE, and hyperparathyroid

Question 50

What is the overhanging margin sign and which condition is this seen in?

Answer 50

C-shaped erosion | Seen in Gout

Question 51

What structures are primarily involved in CPPD?

Answer 51

Knee - Most common site for radiographic and clinical findings, Suspect with isolated patellofemoral or tricompartmental involvement Wrist - triangular fibrocartilagae distal to ulnar styloid - Arthropathy at radiocarpal joint, Scapholunate dissociation, SLAC wrist Pubic symphysis

Question 52

What structures are primarily involved in HADD?

Answer 52

Shoulder and hip Usually single site of involvement Causes calcific tendinitis

Question 53

What is the most common source of osteoblastic metastatic carcinoma in adult females?

Answer 53

Breast (prostate, lung, kidney)

Question 54

List the three common causes of solitary sclerotic vertebral body/ivory vertebra.

Answer 54

IHOP Hodgkin’s lymphoma Paget’s disease

Question 55

Is it common to find a tumor involving a joint?

Answer 55

No

Question 56

Is multiple myeloma more common in vertebral body or neural arch?

Answer 56

Vertebral body

Question 57

What malignancy demonstrates a cold bone scan?

Answer 57

Multiple myeloma

Question 58

Which is the most dense primary malignant bone tumor?

Answer 58

Osteosarcoma (2nd most common bone neoplasm)

Question 59

What is the common age range of primary osteosarcoma?

Answer 59

10-25 yrs | in older pts, likely due to malignant degeneration of benign tumor

Question 60

What is the difference between sunburst and onion skin appearance?

Answer 60

Sunburst – lytic lesion of hemangioma in brain Onion skin – layered or laminated periosteal reaction created by several parallel concentric layers or lamellae of periosteal new bone – implies aggressive process seen in Ewings and osteosarcoma

Question 61

Which part of the long bone is commonly involved in osteosarcoma?

Answer 61

Metaphysis

Question 62

What is codman's triangle?

Answer 62

Triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone- seen with osteosarcomas

Question 63

Why is Ewing's sarcoma commonly found in the diaphysis of long bone?

Answer 63

It’s a marrow cell tumor – “round cell”

Question 64

What is a geographic lytic appearance and does it suggest more benign or aggressive neoplasms?

Answer 64

Geographic = Well defined margin; non-aggressive lesion

Question 65

What are the other two lytic appearances of tumors?

Answer 65

Geographic Motheaten Permeativ

Question 66

Which condition presents as a solitary exostosis that points away from the nearest joint?

Answer 66

Osteochondroma – most common benign bone tumor, usually asx but could impinge on things

Question 67

Compared the incidence of malignant transformation in osteochondroma and hereditary multiple exostosis.

Answer 67

Osteochondroma – malignant in 1% | Hereditary multiple exostosis – malignant in 20%

Question 68

What is a “corduroy vertebra”?

Answer 68

Lytic lesion with coarse vertical striations – seen in hemangioma

Question 69

Is spinal hemangioma commonly solitary or polyostotic?

Answer 69

Solitary

Question 70

Which is the most common benign bone tumor of the spine?

Answer 70

Hemangioma – mostly seen after age 40, mainly asx

Question 71

Is a bone island symptomatic?

Answer 71

No – cortical bone inside where medullary bone should be – does not happen in skull

Question 72

Which benign tumor classically demonstrates as pain worst at night and easily relieved by aspirin?

Answer 72

Osteoid osteoma

Question 73

Which part of the bone is usually involved with osteoid osteoma?

Answer 73

Cortical bone - usually proximal femur

Question 74

What is the appearance of the tumor matrix in enchondroma?

Answer 74

``` - second most common benign tumor, most common in hands and feet Geographic lytic Expansile Thinned cortex, endosteal scalloping Metaphyseal-diaphyseal Most central Calcification in 50% No periosteal reaction; no soft tissue mass - look like chondrosarcoma, but painless ```

Question 75

What is multiple enchondromatosis called?

Answer 75

Ollier’s disease – higher chance of malignancy

Question 76

What is the most common location of fibrous cortical defect?

Answer 76

lower extremity (90% in tibia or fibula) and humerus; ribs, ilium

Question 77

What is a fallen fragment sign associated with?

Answer 77

Simple bone cyst – sign seen with fracture – associated with pathological fractures - piece of cortex breaks off

Question 78

Which benign bone tumor is named according to its appearance rather than its histological composition?

Answer 78

Aneurysmal bone cyst – young age, painful, look aggressive but benign – most common posterior arch

Question 79

Described the radiographic difference between an enchondroma, simple bone cyst, aneurysmal bone cyst and osteochondroma.

Answer 79

``` Enchondroma • Geographic lytic • Expansile • Thinned cortex, endosteal scalloping • Metaphyseal-diaphyseal • Most central • Calcification in 50% • No periosteal reaction; no soft tissue mass ``` Simple bone cyst • Geographic; lytic; maybe loculated • Broad based at physis, narrows toward diaphysis • Bone expansion, but not beyond physis diameter • “Fallen fragment” sign with fracture ``` Aneurysmal bone cyst • Expansile • Lytic, septated • Eccentric • Markedly thinned cortex • Metaphyseal, may extend to epiphysis (only benign tumor to cross growth plate) • Periosteal response more common ``` ``` Osteochondroma • Bony exostosis: cortex continuous with host bone; normal trabeculae • Cartilaginous cap may calcify • Project away from joint • Sessile produces asymmetric widening ```

Question 80

80. Is giant cell tumor painful? Is it malignant?

Answer 80

Intermittent aching pain, usually around knee | “quasimalignant” – 20%

Question 81

81. Is Paget's disease monostotic or polyostotic?

Answer 81

Usually polyostotic | Most commonly seen in older pts, >55

Question 82

82. List the radiographic features of Paget's disease in a long bone such as the femur or tibia.

Answer 82

Blade of grass or candle flame appearance – V lesion | Thickened bones