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1

what is this condition?

oseomyelitis

2

what are the arrows pointing to?

sequestrum = island of dead bone

3

what is noteable in the long bone?

involucrum = thick layer of periosteal new bone that forms around sequestrom

4

what is the opening from the bone to the skin called that may show up in this patient?

cloaca = opening in an involucrum that drains pus and debris out of infected bone

via sinus tract

5

patient presents with pain and swelling at joint
fever, chills
suspected infection

what do they probably have?

suppurative (pyogenic) osteomyelitis

photo: same patient, repeat xrays

6

what are these called?

7

what condition is this?

osteomyelitis

8

what is the left? what is the right

left: acute osteomyelitis

right: chronic osteomyelitis

9

what is this?

brodie abscess

10

what is this condition?

septic arthritis?

11

what is noted by the arrow here?

loss of joint space

12

what should be the ratio of the femoral-acetabular joint?

1:1:2

13

what is this?

septic arthritis

- marked and rapid joint space loss

- motheated or permeative destruction, complete resorption of articular end

- laminated periosteal response

- osseous or fibrous ankylosis

14

joint space loss

bone destruction

rapid over several weeks

what do you think this is?

septic arthritis

NOTE: upper extremity is uncommon

15

what is noted here?

what condition is this?

severe disc space narrowing
endplate destruction (hazy, irregular)

Condition: Spondylodiscitis

infection involving disc and adjacent vertebral body

16

what patient usually gets this?

younger and older patients usually get spondylodiscitis

17

patients with this condition usually present with what?

spondylodiscitis = back pain

less often fever

18

what is the MC level(s) for spondylodiscitis?

single 65%

multiple contiguous 20%

19

what is this?

spondylodiscitis

20

how is this spread?

spondylodiscitis

hematogenously

21

what kind of deformity is this?

what kind of disease is this?

gibbus deformity

a form of structural kyphosis found typically in upper lumbar and lower throacic vertebra where 1+ adjacent vertebrae become wedged. most offten develops in children as a result of spinal TB and is the result of collapse of vertebral bodies.

pott disease

form of TB that occurs outside lungs and seen in vertebra

22

what ___% of TB is skeletal TB?

25-60% has Potts disease

slower than pyogenic spondylitis. lower thoracic and upper lumbar. begins at endplate. disc space loss is the earliest radiographic sign. lytic destruction 2-5 months.

23

what condition is this?

describe it

tubercular spondylitis, Pott's disease

decreased disc space. loss of cervical curve. ??

24

what is this imaging modality?

what is this condition? why?

MRI and T1 weighted CSF/bone is dark and fat appears bright

tubercular spondylitis "Pott's Disease"; ???

25

patient presents with insidious onsent of aching pain, stiffness, swelling, no lab changes.

Observation of crepitus, decreased ROM, palpable excrescences and adjacent mm atrophy.

what condition is this?

degenerative joint disease AKA osteoarthritis

MC joint disease and leading cause of disability

stiffness after rest that decreases with ~30 minutes of activity 

26

name the radiographic findings of DJD

non-uniform joint space loss

osteophytes

suchondral sclerosis

subchondral cysts (geodes)

joint subluxation

intra-articular loos bodies

27

what is this?

DJD

28

what is this condition?

DJD

29

what is noted here?

uncovertebral joints
Small synovial articulations situated b/w the five lower cervical vertebral bodies. They are located anteromedially to the mixed nerve root and posteromedially to the vertebral artery, vein, and sympathetics as these pass through the vertebral foramen.

usually associated with IVD DJD

sharpening of uncinates first, then hypertrophic changes

30

what condition is this?

DJD

31

what condition is noted here?

DJD

32

what is noted here?

neurologic compromise 2˚ to DJD

33

what is this condition?

are patients asymptomatic / symptomatic?

Baastrup syndrome

"kissing spine" syndrome

associated with excessive lordosis and DDD

Both asymtpomatic and symptomatic patients

34

what is noted by the yellow?

subchondral cyst AKA geode

geographic, osteolytic lesion

35

what is noted by the green arrow?

decreased joint space

subchondral sclerosis

36

what condition is this?

DJD

37

which side is the lesion? and what is noted? what condition is it?

right side (reading left)

decreased superrior joint space, sclerosis, osteophytes

hip DJD

38

what is noted here?

sclerosis

osteophytes

knee DJD

39

what is this?

knee DJD

medial > lateral compartment changes

osteophytes, cysts, sclerosis and sharpening of tibial spines

osteochondral bodies are common

40

what is noted here? what sign is visible?

osteophytes at superiro and inferior poles

"tooth sign"

Patellofemoral DJD

41

what is this condition?

who woudl you refer this to?

patellofemoral DJD

surgeon to replace knee

42

what is this?

DJD

43

what is noted here?

non uniform joint space, soft tissue bump/nodule, osteophytes

MC DJD in in the DIPs

inflammatory at the PIPs

44

what is green?

what is blue?

Green: heberden nodes

Blue: bouchard nodes

45

what is this?

wrist DJD

osteophyte, sclerosis to name a few

46

what is visible here? what is the condition?

DJD

sclerosis

subluxation

loose body

47

what is noted here?

what view is this?

osteophyte

greater tuberosity

shoulder DJD

view: external rotation of shoulder

48

what is this? 

treatment?

shoulder DJD

Tx: maint/ restore mobility (CMT, STM, rehab), nutritional support, NSAIDS, surgery may eventually be needed to replace joint

uncommon sites of DJD: ankle, GH, elbow, wrist (except 1st ray), MCP

if seen here, suspect 2˚ DJD

49

what condition is this?

who gets it?

erosive OA

females 30-50 yo

features of DJD and inflammatory arthritis. bilateral DIP and PIP involvement

50

what is noted by the blue?

green?

blue: "gull wing" sign

(severe DJD plus erosions = "gull wing" sign)

green: fused joint

51

what is this sign?

what is this condition?

"gull wing" sign

erosive osteoarthritis

52

what is condition?

what is the most involved part of the body?

DISH: Diffuse Idiopathic Skeletal Hyperostosis

Spinal and extraspinal ligaments and tendinous calcification and ossification. Especially ALL. 

Thick, flowing hyperostosis anterior to the spine of 4 contiguous levels.

**NOTE: NORMAL disc spaces

53

what is this?

what is the most prominent Hx suggesting this conditoin?

DISH

Hx: stiffness

54

what is the different between DISH, DDD, AS, Psoriatic/Reactive?

DISH

  1. ossification: thick flowing at mid-body
  2. IVD: maintained
  3. Other: extraspinal enthesophytes

DDD

  1. non-marginal "claw"
  2. decreased
  3. --

AS

  1. thin, marginal
  2. maint or "ballooned"
  3. SI fusion early

P/R

  1. thick, non marginal
  2. maint
  3. some enthesopathy

55

What is this?

DISH extraspinal stuff

red and yellow arrows: rought areas of mm attachments

blue arrow: iliolumbar ligament calcification

56

what is this? what percent of these are associated with DISH?

what are the arrows noting in the images?

waht is the best imaging modality?

Ossification of Posterior Longitudinal Ligaments (OPLL) 85% associated with DISH, though it can be independent of DISH

Ossified PLL - may produce myelopathy

best imaging: CT, though MRI is still good

NOTE: 2 segments with DISH on the xray, however technically need 4 contiguous segments 

57

what is this condition?

tx?

OPLL

tx: no specific. symptom-based, palliative. monitor for signs of central stenosis. conservative or surgical treatment for stenosis.

58

what is this conditoin?

6 Ds

Neuropathic arthropathy AKA Charcot joint

Distended
Dislocation
Disorganization
Density increase
Destruction
Debris

59

patient presents with swollen, deformed joint. insidious painless onset. signs of peripheral neuropathy.

what is it?

neuropathic arthropathy AKA Charcot joint

similar to DJD but more rapid, more severe

60

what is this?

synovial chondromatosis

AKA osteochondromatosis, synoviochondrometaplasia

Pathology: metaplastic changes in synovium produce cartilaginous bodies that may (or may not) calcify or ossify

61

what is this?

who gets it?

most common location?

synovial chondromatosis

20-50 yo and M:F 3:1

MC location: elbow, hip 20%

DDX:

  1. osteochondritis dissecans = single osteochondral body + defect in host bone
  2. ossicles 2˚ to DJD
  3. neuropathic arthropathy AKA charcot joint
  4. pigmented villonodular synovitis (PVNS)
  5. normal sesamoids

62

what is this?

what is the MC inflammatory arthritis?

RA

it targets synovial tissues and joints, bilateral symmetry, progressive. affects 0.5-1% of the population.

affects articulations: wrist, hands, feet, shoulder, hip, knee, cervical spine

pathologic process: antigen-antibody complex depositive in synovium w/ resulting inflamm cascade. Synovial proliferation = pannus (hypertrophied vascular granulation tissue). Pannus erodes bone and articular cartilage.

63

what % of these patients get nodules?

20% rheumatoid nodules

64

what is this?

RA

- osseous erosion

- joint space loss

- bilateral symmetry

65

what is this?

Note: location

RA

Location: MCP and PIP. not DIPS

66

what is this?

RA

  • bilateral
  • wrist, mcp and pip involvement (NOT dip)

67

what is this?

Rheumatoid arthritis

  • bilateral erosions
  • no dip involvement 

68

yellow arrows

red arrows

yellow: boutonniere

red: hitchhiker thumb

69

?

swan neck

70

what is this?

RA wrist

common things seen:

  • tendinopathy is one of the earliest changes around wrist
  • ulnar and radial styloid erosion
  • "spotty carpal" sign
  • uniform loss of radiocarpal joint
  • scapholunate dissociation

71

what is this?

RA foot

  • deformities e.g. hallux valgus
  • poorly defined erosions at calcaneus

72

what is this?

how often is this location involved in this condition?

RA Spine

cervical spine involvement in 50-80%

  • C1-2 instability
  • facet and uncovertebral erosion
  • pseudobasilar invagination
  • canal stenosis possible d/t "stepladder" kyphotic changes

73

name them

a - typical SI joints

b - widening

c - sclerosing

d - ankylosing joints

74

what view is this?

lumbosacral spot view or L5-S1

75

what is this?

AS

  • sclerosis at SI joint

76

what is noted on the left?

what is this

  • ossification of outer annulus = thin, marginal sydesmophyte formation (bamboo spine) 
  • erosion (squaring of body)
  • reactive sclerosis (shiny corner sign)
  • late changes = ballooning of disc space

Ankylosing spondylosis

77

what is this?

AS

78

What is this sign?

squaring of the body is called?

what condition is this?

shiny corner sign

reactive sclerosis following inflammatory erosion

Romanus lesion

AS

79

what is this called?

what condition

dagger sign

AS

80

what is this called?

what condition

possibly trolley track

AS

81

82

what is this?

what is the treatment?

erosion > sclerosis > periosteal new bone ("whiskering")

enthesopathy (iliac crest, ischial tuberosities, femoral troch, SPs, calcaneus)

AS in peripheral joint

Treatment: pain control, maint mobility, prevent deformity, anti-inflammatories

83

involvement of all 3 joints in a single digit is called what? what condition does this suggest?

ray pattern

psoriatic arthritis

typically happens at DIPs and PIPs

84

what is this?

opera glass hand

psoriatic arthritis

85

what is this?

erosion, new bone growth

psoriatic arthritis

86

what is the yellow cirlce showing?

what condition?

pencil-in-cup deformity

psoriatic arthritis/ reactive (hard to tell the 2 apart)

87

Observe asymmetric, non-marinal syndesmophytes

Q: What condition might this be?

Q: DDX?

Q: if they were symmetrical and marginal syndesmophytes, Dx?

psoriatic

DDX: reactive

Dx: AS

88

what is this condition?

enthesopathy noted

Condition: psoriatic/reactive

Photo: normal 

89

what is this?

Reactive arthritis

  • osteopenia
  • erosions
  • enthesopathy

90

what is noted on the left radiograph?

what are the arrows noting on the right?

1 - asymmetrical mid-body to mid-body syndesmophyte

2 - bi sclerotic changes

psoriatic/reactive (asymmetrical SI DDX)

91

30 yo F, positive ANA, fever, joint pain, rash.

what is it?

Systemic Lupus Erythematosus (SLE)

Joint manifestations:

  • 80% patients
  • Bilateral, symmetric
  • Hand, knee, wrist, shoulder
  • Pain, stiffness, swelling
  • Transient, reversible deformities
  • Soft tissue calcifications
  • Osteoporosis (juxta-articular)
  • Osteonecrosis (due to steroid use)
  • No erosions

92

40 yo F, edema, induration, atrophy of skin.

what is this?

Scleroderma AKA systemic sclerosis

Generalized, systemic, inflammatory CT disease associated w/ CREST syndrome. Involves skin, lungs, GI tract, heart, kidneys, MSK system.

radiographic findings: acro-osteolysis (ungual tuft) and soft tissue calcifications

93

predominantly women, childbearing age. asymptomatic but sometimes chronic LBP and stiffness. SI motion may be altered.

what condition is this?

describe the findings

Osteitis Condensans Ilii (OCI)

radiographic findings:

  • bi symmetric triangle-shaped areas of sclerosis on iliac side of lower SIJ
  • complete regression may occur over years
  • no joint abnormalities (NO widening, narrowing, erosion)
  • similar process may affect medial clavicle

94

patient presents with severe pain that subsides over 1-2 years.

what is this?

what are the radiographic findings?

Osteitis Pubis

Radiographic findings:

  • bilateral, symmetric invovlement of both sides of symphysis
  • irregular joint margin
  • reactive sclerosis
  • widened joint space

95

following brochogenic carcinoma... what is this?

what is the associated triad?

Hypertrophic osteoarthropathy

Triad:

  1. digital clubbing
  2. symmetric arthritis
  3. periosteal reaction

96

what is the arrow on the distal tibia pointing to?

what is the arrow on the chest xray pointing to?

what condition is this?

periosteal response

bronchogenic carcinoma (likely)

hypertrophic osteoarthropathy

97

what is this?

MC in what pop?

what are the 5 stages of this disease

MC Locations?

Gout

Population: M:F >40yo

5 stages of Gout:
asymptomatic, acute, intercritical, chronic, gouty neuropathy

Locations: 1st MTP, hand + wrist, knee, elbow, SI, spine

98

what is this?

Calcium Pyrophosphate Dihydrate (CPPD)

Crystal Deposition Disease

Radiographic features

  • chondrocalcinosis
    • hyaline: parallel to cortex, thin, linear
    • fibrous: thick, irregular, poorly defined

99

56 YO F. Chronic bi knee and shoulder pain

what is it?

how do you make a definitive Dx?

Calcium Pyrophosphate Dihydrate (CPPD)

Dx: aspiration of synovial fluid demonstrates crystals

100

what is this called?

what is the condition?

SLAC wrist

ScaphoLunate Advanced Collapse - MC degenerative arthritis of wrist. Hallmark is collapse on radial side of wrist.

Pyrophosphate arthropathy

101

what is this?

where is the MC location for this?

pyrophosphate arthropathy

photo shows SLAC wrist

MC Locations:

  • Knee: 
    • MC site for radiographic + clinic findings
    • suspect w/ isolated patellofemoral or tricompartmental involvement
  • Wrist:
    • arthropathy at radiocarpal joint
    • scapholunate dissociation
    • SLAC wrist (scapholunate advanced collapse)

102

what is this?

ddx?

chondrocalcinosis affecting menisci

Pyrophosphate arthropathy (can occur with or without chondrocalcinosis)

DDX: primary DJD

  • unusual joint or joint compartment involvement
  • prominent cysts
  • severe changes
  • variable osteophyte formation

103

what is this?

MC locations?

Hydroxyapatite Deposition Disease (HADD)

Locations: shoulder, hip

Radiographic:

  • calcification near insertion of tendon
  • linear or round / oval / globular
  • usually homogenous, well-defined; less at early stages
  • calcification may change or disappear over time
  • US is more sensitive to early calcification

104

39 yo M presented in ED w/ 3-day Hx of throat pain and stiff neck. Radiographs were performed.

What is the condition?

Phases?

Hydroxyapetite Deposition Disease (HADD)

Phases: precalcific, calcific/formative, resorptive, post-calcific