MIDTERM Flashcards
(426 cards)
1
Q
Bilateral symmetry is in what % of RA patients?
A
80%
2
Q
What is juxta-articular osteopenia due to?
A
Hyperemia, disuse, and steroid therapy may lead to generalized form
3
Q
Uniform loss of joint space is associated with what?
A
Collagenase/chemical destruction RA
4
Q
Bare area bone destruction is what?
A
Marginal (rat bite) erosions
5
Q
What is Pannus?
A
granulation tissue made up of new capillary growth and fibroblasts that grows into the joint
6
Q
What can be infrequent, solid, or laminated in RA?
A
Juxta articular periostitis
7
Q
What can deformity of RA be due to?
A
joint destruction, ligament laxity, and stenosing tenosynovitis
8
Q
What is stenosing tenosynovitis?
A
Tendon sheaths scar, shrink, and pull
9
Q
What are the areas of foot and hand affected by RA?
A
forefoot, MTP joints, PIP joints possible, dorsal dislocation on MTP, fibular dislocation on digits (Lanois deformity)
10
Q
Primary DJD does not care about ____ but likes ______ ?
A
MCP, but does like DIP and PIP joints
11
Q
RA likes ____ and does not involve ____ ?
A
Likes MCPs, and does not involve DIP joints (besides thumb) and entire wrist
12
Q
What tendon does RA like?
A
the extensor carpi ulnaris tendon that runs right along side the ulnar styloid process, common for patients to complain of this before they get soft tissue swelling
13
Q
Does RA create radial or ulnar deviation?
A
ulnar
14
Q
Describe the Boutonniere hand deformity:
A
“BEFE”
boutonniere, extend DIP, flex PIP, extend MCP
Fingers are STUCK
15
Q
Describe the “swan neck” hand deformity:
A
“FEF”
(Flex DIP, extend PIP, flex MCP)
16
Q
Describe the Mallet finger RA:
A
DIP joint hyperflexion
17
Q
What is the sign of RA that combines different hand deformities?
A
Arthritis Mutilans
- boutonniere
- swan neck
- mallet finger
- zig zag, ulnar deviation
(looks like your hand is in a blender)
18
Q
What is the zig zag look associated with RA?
A
Radial carpal deviation with ulnar deviation
19
Q
What are the exceptions of the hand deformities in RA?
A
Doesn’t like 2-5th DIP joints, but every other joint in upper extremity is fair game
20
Q
What is rheumatoid’s primary focus?
A
Synovial Membrane
21
Q
What is a deposition of immune complexes involving multiple systems?
A
Systemic Lupus Erythematous (SLE)
22
Q
When does System Lupus Erythematous (SLE) occur?
A
Female childbearing years
48/100,000
23
Q
What areas does SLE affect?
A
Skin and joints very common, kidney is severe
24
Q
The butterfly rash is prevelant in how many percent of patients, and what disease is it involved with?
A
SLE and 40%
25
What are the symptoms of SLE?
90% joint symptoms, pain, swelling, and stiffness
26
How is the joint ivolvment in SLE?
Mile with little destruction, that's why a lot of SLE deformities are reversible
27
What would you radiographically see on SLE?
Osteopenia, tuft resorption, and calcinosis
28
What are the corticosteroid changes that occur within SLE?
It is called, **_Corticosteroid Osteopothay_**, and one would see osteopenia, fractures, and AVN. Bone changes occur because of the steroid use
29
What are the early symptoms of SLE?
Chronic, episodic pain, stiffness, and soft tissue swelling
30
What is PSS?
**_P_**rogressive **_S**_ystemic _**S_**clerosis
31
What is PSS main target?
(Scleroderma) Subcutaneous connective tissue
32
What is the main age group and gender of PSS?
Females 30-50 y.o.
33
What systems are affected by PSS?
systemic inflammatory then scarring disorder, skin, lungs, GI tract, heart, kidneys, MSK
34
90% of scleroderma patients have ______ ?
Raynaud's
35
What does "CREST" stand for? What disease is it associated with?
**_Progressive Systemic Sclerosis_**
* **C**alcinosis
* **R**aynauds
* **E**sophagus
* **S**cleroderma
* **T**eleangiectasia
36
Describe the Calcinosis portion of CREST in PSS:
Calcinosis Cutis, Circumscripta, and Universalis
37
Calcinosis Circumscripta pic:
38
Calcinosis Universalis pic
39
What are the components associated with the Esophagus in CREST (PSS)?
GERD is common, and there is difficulty swallowing
40
scleroderma x ray pic
41
Describe "Teleangiectasia" (CRES**_T_**) associated with PSS:
Localized areas of redness
42
What's the most common area of damage for PSS?
Hands, feet, and face
43
What happens to the skin during PSS?
It begins to tighten due to scarring
44
What type of arthritis is associated with PSS?
"Non-erosive arthritis"
45
Selective destruction of _____ is common in PSS?
1st MCC (base of thumb-trapezium) is distinctive
46
Tuft Resorption is associated with what?
(PSS) scleroderma is the default condition that causes this
47
What is the origin of Dermatomyositis/Polymyositis?
It is unknown
48
What is more common, Dermatomyositis or Polymyositis?
Dermatomyositis
49
What is dermatomyositis?
Dermatomyositis is an uncommon inflammatory disease marked by muscle weakness and a distinctive skin rash. Likely **_autoimmune_**
* Muscle fascial inflammation
50
Dermatomyositis may occur _____ ?
secondary to neoplasm of lung, prostate, female pelvic organs, breast, and GI
51
What are the key features of Dermatomyositis?
* Non - suppurative inflammation of skeletal muscle with
* Weakness
* Erythematous skin rash
52
What does the inflammation of Dermatomyositis lead to?
Eventual scarring of fascia and subsequent calcinosis universalis
53
Is there tuft resorption with Dermatomyositis?
YES, there is "non destructive small joint inflammation with tuft resorption"
54
The articular of Dermatomyositis resembles what?
PSS and SLE
55
What is Mixed Connective Tissue Disorder described as?
MCTD is characterized by overlapping clinical features of PSS, SLE, DM and possibly RA
56
What is common with Mixed Connective Tissue Disorder?
Arthropathy consisting of arthralgia and arthritis is common in the small joints of the hand, foot, and wrist
57
What is Jaccoud's Arthropathy?
1867, Infrequent, deforming, non-erosive hand and foot arthropathy
* Originally subsequent to rheumatic fever (from systemic strept)
58
What are the deformities of Jaccoud's Arthropathy?
* Ulnar deviation with flexion
* Boutonniere and swan neck
59
KNOW THIS PIC :
60
What is the history of Sjogren's Syndrome?
1930, A Swedish Opthalmomologist described a patient with low secretions from lacrimal and parotid glands
61
What is Sjogren's syndrome due to?
Lymphocytic accumulation in and obstructing exocrine glands
* Can be ***primary*** or ***secondary***
62
Sjogren's Syndrome is most common in \_\_\_\_\_
Females 40-50 year old
63
What does Sjogren's Syndrome cause?
* Keratoconjunctivitis sicca (dry eyes), xerostomia (dry mouth), as well as other areas of dryness (nose, skin, and vaginal)
64
What is the 3rd most common rheumatic autoimmune disorder next to RA and SLE?
Sjorgren's syndrome
65
What is the clinical triad of Sjogren's syndrome?
1. Keratoconjunctivitis sicca
2. Xerostomaia
3. Autoimmune rheumatoid type disorder usually RA but can be SLE or PSS
66
Describe Juvenile chronic Arthritis:
Juvenile onset adult type RA (Rh factor +)
* Rheumatoid in a child under the age 16
67
What are the radiologic signs in Juvenile Chronic Arthritis, (Juvenile onset adult type RA) Rh factor + ?
* Bilateral symmetry
* Starts in **_hands_** and moves toward axial skeleton
* Longer term = Worse it gets
68
What are the 3 Juvenile chronic Arthritis subcategories?
1. Juvenile Onset Adult type RA (Rh factor + )
2. Still's Disease (Rh factor - )
3. Juvenile Onset Rheumatoid variant disease
69
What are the main characteristics of Still's Disease?
* Classic systemic form
* Polyarticular form
* Pauci - or monoarticular form - only have it in one joint or 2/3 but WON'T have a widespread form
70
Still's disease is Rh +
t/f ?
FALSE (negatron)
71
Describe Juvenile onset Rheumatoid variant disease:
HLA-27 spondyloarthropathies, and Rheumatoid variants can **_Uncommonly_** happen in children
72
Juvenile onset adult type RA (Rh factor +), Still's Disease (Rh factor - ), and Juvenile onset Rheumatoid variant disease are all _____ ?
Inflammatory arthritis
73
What is a bone infarct?
Ischemic death of the cellular elements of the bone and marrow
74
What does a bone infarct refer to?
Lesions occurring in the metaphysis and diaphysis of bone
75
Lesions in the epiphysis are called what?
Avascular Necrosis
76
What are the 3 classifications of Osteonecrosis?
1. Bone ends children
2. Bone ends adults
3. Metaphysis and Diaphysis
77
In osteonecrosis, bone ends in children are called what?
Epiphyseal ischemic necrosis, ***_femoral_*** ***_head_*** is the most common location
78
What is adult osteonecrosis?
Chandler's Disease
79
What is osteonecrosis in children?
Legg-Calves - Perthes disease, femoral head is the most common location
80
What is it called when osteonecrosis is found in the metaphysis and diaphysis?
**Medullary infarction**
81
What is the normal cause of osteonecrosis in the metaphysis and diaphysis?
It can be idiopathic or secondary to a number of conditions that reduce blood supply to the bone such as an intraluminal abnormality, extrinsic compression or combo of both
82
Osteonecrosis can be ____ or \_\_\_\_\_
**Idiopathic** or **Secondary**
83
Osteonecrosis can be idiopathic or secondary to a number of conditions that reduce blood supply to bone, what are they?
* Intraluminal abnormality
* An extrinsic compression
* Combo of both
84
What does therapeutic radiation do in regards to Osteonecrosis?
Inflames the walls of arteries, narrows the lumen, and causes obstruction
85
Children usually develop ostenecrosis through \_\_\_\_
TRAUMA
86
What is the "gold standard" for detection of Osteonecrosis?
MRI
87
What plays a major role in diagnosing osteonecrosis at a young age?
CT scans, MRI, and bone scans, but if we see it on plain film, this means it is far along in its stages
88
AVN shows up how on a bone scan?
COLD AREA
89
What is the most common hematological condition of the skeleton?
AVN
90
What is AVN predisposed to?
Areas of tenuous blood supply with poor collateral circulation, that's why the femoral head is the most common area - it gets most of its blood from one blood vessel (lateral peripheral artery)
91
Under the category of external vessel compression in osteonecrosis, what are the 3 subcategories?
infection, gaucher’s disease, hyperlipidemia
92
What is Gaucher's disease?
Lipid storage disease, genetic disorder, accumulation of abnormal fatty material that accumulates in macrophages.
* Cells accumulate in marrow -- creates pressure --- squishes vessels
93
What could cause external vessel compression?
**Hyperlipidemia**
94
Vessel wall disorders in the etiology of AVN is due to what?
Therapeutic levels of radiation used to treat cancers, it inflames blood vessels and narrows lumen
95
Under etiologies of AVN, Thrombo-embolic disorders are classified as:
1. Alcoholism
2. Sickle-cell
3. Caisson's disease
96
Why would alcoholism cause a thrombo-embolic disorder?
Causes pancreatitis, fatty embolism in the blood, and is one of the MORE COMMON causes of AVN
* typically ***_BILATERAL_*** (long term alcoholics)
97
How would sickle cell cause a thrombo embolism?
Widespread AVN in femoral heads, humeral heads, etc. You can get an embolism in the kidneys or lungs
98
What is Caisson's disease?
* This could cause a nitrogen gas embolism
* "Diver's disease"
* Rapid decompression in aircraft can cause it
* Tends to involve in ***_HUMERAL HEADS_***
99
Describe what corticosteroid use can do:
Prednisone for a period of time to treat rheumatoid type arthritis can cause AVN
100
\_\_\_\_\_\_\_ with prednisone leads to AVN?
LUPUS
101
What is the pneumonic for etiology list?
**_PLASTIC RAGS_**
102
Etiology of AVN - **Pancreatitis**:
_Pregnancy_, late stage pregnancy - particularly develop AVN in left hip
103
Patient with Cushing's syndrome may develop AVN, t/f?
TRUE
104
What is the "I" in PLASTIC RAGS pneumonic?
_**IDIOPATHIC\*\*\*\***_
- One of the more common ones, aka ***_"SPONTANEOUS AVN"_***
105
What is the "C" in PLASTIC RAGS?
Caisson's, rapid decompression, nitrogen embolism
106
What is the "A" in PLASTIC RAGS?
**Amyloidosis**:
* Metabolic Arthritic disorders (lumpy bumpy)
* Amyloid - abnormal protein material
* Amyloid accumulating in bone marrow causes compression
107
What is the "G" in PLASTIC RAGS?
**Gaucher's**
"Hematological disorder"
108
What would you see in the epiphyseal findings of osteonecrosis?
* Deep dull joint pain, exacerbated by activity
* Limp waddling gait
109
What would you notice with the medullary portion of bone in Osteonecrosis?
Medullary infarct typically asymptomatic
110
What is a _**bolded\*\***_ finding of ostenecrosis?
_**Osteochondritis Dissecans\*\***_ may cause joint locking
111
What are common locations of Osteochondritis Dissecans?
Knee and ankle
112
What are the main points of Osteochondritis Dissecans?
* Specific, focal subchondral AVN
* Does not involve entire epiphyseal area -- right up at articular surface
* Usually due to trauma
* Late teens, early adults
* Subchondral piece of cartilage that falls into joint (***joint*** **_mouse_**)
* Get secondary DJD from it
113
What are the 4 stages of Osteonecrosis?
1. **Avascular**
2. **Revascularization**
3. **Repair - Reossification**
4. **Deformity - Healed**
114
During the Avascular stage of AVN, what would you see?
* Joint effusion -- especially at the hip
* Push the femur slightly lateral - increase medial joint space
115
How does the bone look during the Avascular stage of Osteonecrosis?
**_Normal_**, no radiographic changes
116
What can be a precursor to AVN?
TOH
117
What would describe, Avascular event has occured but has not started to heal yet?
**Avascular** stage of Osteonecrosis
118
What are the 3 stages to the principles of Infarction?
**_• Stage 1:_** cessation of intracellular metabolic activity at a
chemical level.
_**• Stage 2**:_ alteration or interruption of intracellular enzyme
systems
**_• Stage 3:_** disruption or dissolution of intracellular nuclear
and cytoplasmic ultrastructure. Irreversible.
119
Adults rarely get beyond what stage of AVN?
**_Revascularization_** (2)
* Deformity happens in this stage, once you deform the bone and the adult secondary DJD happens faster than they can get through being healed
120
What happens to the bone during the Revascularization stage of AVN
(2)
* New osteoblasts/clasts
* Clasts take away the dead bone
* New vascular vessels/capillaries growing in the area - happens SLOWLY
121
What are the radiographic findings during Revascularization?
* Look more radiolucent because clasts take away dead bone
* Areas of increased bone density where blasts are building on dead trabeculae
* Intermixed pattern of density in the femoral head
122
What are the signs you'd see during Revascularization stage of AVN?
* **_Crescent sign_** - arc right under bone
* **_Snow cap_** - osteosclerosis of femoral head
* Fragmentation - well into second stage
* can become extremely fragmented in CHILDREN
123
What is the overall quantity/quality of bone during Revascularization stage of AVN?
Net reduction in bone --\> subchondral fracture
* Femoral head collapses
* **FLATTEN FEMORAL HEAD** - disrupt biomechanical integrity of articular cartilage --\> DJD
124
What happens during the Repair - Reossification stage of AVN?
* **_NEW BONE_** formation
* More bone seen on the previous x-ray
*\*\* Fast is 2 years, and has been known to take 8 years \*\**
125
Children need to be radiographed every _____ during Repair stage of AVN?
6 months
126
What is the last stage of AVN?
Deformity - Healed
127
What are the major findings in the last stage of AVN?
* Normal bone density but shape change
* Cox magna
* Cox Plana
* Reduced femoral neck angle
* Large greater trochanter
128
What will happen to children during the Deformity stage of AVN?
They will heal but they may get secondary DJD years later
129
What will the signal look like taking an MRI for AVN?
Loss of signal in the marrow on a T1 weighted scan
* T1 water is dark
130
Describe the epiphyseal on an MRI in AVN:
MRI are most sensitive, and it is often seen **bilateral**
* May demonstrate joint effusion
* GOLD STANDARD for early MRI imaging
131
What are the 4 main signs of AVN?
1. **SNOW CAP SIGN**
2. **CRESCENT/RIM SIGN**
3. **MUSHROOM Deformity**
4. **HANGING ROPE SIGN**
132
What can you also get from AVN (appears on X ray)?
**Geodes** - once you fracture articular surface, synovial fluid can leak down
133
Once the femoral head flattens in AVN it \_\_\_\_\_
PERMANENTLY Deformed
134
What would you think if you saw a bilateral case of AVN?
If it's bilateral it's probably not idiopathic - most likely **_alcohol_** or **_corticosteroids_** \*\*
* **Sickle cell** classically does it bilateral at multiple places
135
Adults typically don't make it past what stage of AVN?
REVASCULARIZATION
136
Healed AVN has what signs?
* Articular deformity
* Early OA
* Acetabular dysplasia, hanging rope
* Trochanteric overgrowth
* Mushroom cap deformity
137
Altered signal from fat and edema - ring of dark signal around the area of necrosis describes:
MRI findings of Osteonecrosis
138
What is a group of disorders that share certain features?
Osteochondroses
139
Osteochondroses has a predilection for what?
Immature skeleton
140
What does osteochondroses involve?
Involvement of the epiphysis, apophysis, oor epiphyseal equivalent
141
What are the radiographic pictures dominated by in Osteochondroses?
* Fragmentation
* Collapse
* Sclerosis
* Frequently, reossification with reconstruction of the osseous contour
142
Osteochondroses is more common in boys or girls?
BOYS
143
Legg Calves - Perthes discovered in 1910 affects patients from \_\_\_\_\_\_
4-8 years old, and is more common in boys (5:1)
- Bilateral in 10-20%
144
What are the clinical signs of Legg-Calve Perthes Disease?
* Limping
* Pain
* limiting movement (abduction and internal rotation) - or could be salter harris fracture
**_TRAUMA in 25% of cases_**
145
If parents smoke during pregnancy, it increase the risk of this disease in the child?
Legg Calve Perthe
146
What are the radiographic findings in Legg Calve Perthes disease?
* Soft tissue swelling
* Small epiphysis
* Lateral displacement of ossification center
* Flattening, fissuring, and fracture of the ossification center
* Intraepiphyseal gas
147
What is Waldenstrong's Radiographic Staging Initial stage?
* Increased head-socket distance (medial joint space widens)
* Subchondral plate thinning
* Dense epiphysis
148
What are the 5 stages of Waldenstrom's Radiographic Staging?
1. Initial
2. Fragmentation
3. Reparative
4. Growth
5. Definitive
149
What happens during the Fragmentation stage of Waldenstrom's?
* Subchondral fracture
* An inhomogenous dense epiphysis
* Porous appearance with metaphyseal cysts
150
What happens during the Reparative Stage of Waldenstrom's?
* Normal bone in areas of resorption and removal of sclerotic bone
* epiphysis has more homogenous appearance
151
What happens during the Growth stage of Waldenstrom's?
* Re-ossification
* Normal femoral shape approached
* Some degree of flattening does occur - earlier detection --\> less deformity
* Greater the deformity - higher chance of DJD
152
What happens during the Definitive stage during Waldenstrom's?
Final shape is determined with joint congruency or incongruency
153
Waldenstrom's Radiographic staging is under what category?
Legg-Calve Perthes Disease
154
What happens to the Metaphysis during Legg-Calves Perthes Disease?
* Metaphyseal cysts - frayed looking areas
* Widening and shortening of the femoral neck
155
Secondary OA is a problem in what?
Legg-Calve Perthe's Disease
156
What is the basic problem of Legg-Calve Perthes
basic problem is osteonecrosis with
structural failure of bone, fragility of blood
supply
157
What is Legg Calve Perthe's Disease different from?
```
diff. from hypothyroidism and other
avascular necrosis (ie, sickle cell)
```
158
How long does healing for Legg Calve Perthe's Disease last?
18 months
159
What are the main history components of Freidberg's Infarction?
* Affects children and adults
* Usually unilateral
* Woman 3 or 4:1
* Ages 13-18
160
What are the clinical findings of Freiberg's Infarction?
* Local pain and swelling
* Complain about MTP joint hurting
* Increased density, flattened
161
What does Freiberg's Infarction lead to?
DJD - Forefoot MTP joint most common place
- DJD is secondary in Freiberg's
162
What is the pathogenesis of Freiberg's Infarction?
pathogenesis is AVN secondary to
single or repeated trauma
163
Healed osteonecrosis pic
164
What is AVN in the scaphoid?
Preiser's Disease
165
What are the main points of Preiser's Disease?
* Scaphoid is most common carpal bone to fracture
* Sclerosis analagous to snowcap appearance in femoral head
* Eventually collapses like femoral head collapses
166
What usually happens secondary to fracture of scaphoid?
Preiser's Disease
167
Radial carpal DJD -- Secondary DJD describes what?
Preiser's Disease
168
What suggests AVN of tarsal navicular navicular?
Kohler's Disease
169
What are the main attributes of Kohler's disease?
* Boys 4 or 6:1
* 3-6 years old
170
What are the radiographic findings of Kohler's Disease?
* Radiographs reveal patchy increased density and fragmentation
* Local Pain, tenderness, and swelling
* Look a little osteosclerotic, maybe radiolucent in areas, flattened
171
What is AVN of the lunate?
Kienbock's Disease
172
What happens during "**Advanced Collapse**" of Kienbock's disease?
* Very negative ulnar deviation
* Very flattened lunate - almost looks like a crescent sign
173
Describe the "ulnar variance" associated with Kienbock's disease:
* Patients that have negative ulnar variance have an increased risk of lunate AVN -- causes excessive stress load on proximal carpal load
* Patients should be followed
174
What leads to DJD and decreased wrist function?
Kienbock's Disease
175
What are the main attributes of Vertebral body AVN?
* May occur with corticosteroids, compression fracture, or osteoporosis
* **_"Intravertebral Vacuum_**
176
What are the radiograhic findings of Vertebral body AVN?
* Radiolucency in vertebral body (almost looks like gas)
* **_FLATTENING_**
177
Aka for vertebral body AVN?
Kummel - Verneuli's Disease
178
What represents a focal subchondral infarction of sub-articular bone?
Osteochondritis Dissecans
179
Describe what happens during Osteochondritis Dissecans:
The necrotic bone may become a free floating fragment separated from the parent bone
* **_JOINT MOUSE:_** Damages hyaline cartilage and causes secondary DJD
180
What case attributes are associated with Osteochondritis Dissecans?
* Often associated with trauma
* Seen in young individuals
* Complain about joint pain
181
What is the most common place for Osteochondritis Dissecans?
Knee is a common place, more common is **_lateral portion of medial femoral condyle_**
182
Medullary Necrosis affects, ?
Large Tubular Bones
- Tibia, Fibula, humerus, femur
183
What are the main characteristics of Medullary Necrosis?
* Medullary infarcts
* Faint rim of calcification outlining area
* Usually found by accident -- traumatic determinism (x-ray after trauma and find this)
* Can disappear overtime (go through all the stages to heal)
* **NO SYMPTOMS**
184
What classification is Medullary Necrosis in?
3rd in classification
* Bone-ends children
* Bone - ends adults
* Everywhere else (diaphysis & metaphysis)
185
What are the radiographic signs of medullary necrosis?
* Snake like appearance in medullary cavity (twisted appearance)
* One of the benign cartilage tumors (**_enchondroma_**) is in the differential with this -- looks familiar
186
What are the first few main points of Osteomyelitis?
* Early diagnosis is intrinsic to appropriate therapy (antibiotics) being instituted
* Often a high index of clinical suspicion is required rather than reliance on radiographic changes
* Relatively short time frame for symptomatology
187
most of the time, the infections of osteomyelitis are \_\_\_\_\_\_
secondary
188
What is Cellulitis?
Infection of skin, subcutaneous fat, or connective tissue (tendons/ligaments/muscle)
189
What is Osteomyelitis?
Infection of Bone (marrow spaces)
190
What is Septic Arthritis?
Infection of joint (synovial tissue, articular surfaces)
191
What is osteotitis?
Inflammatory condition usually confined to cortex
192
What type of bacteria destroys joints very quickly?
Staph Aureus
193
What are the "at risk groups" of osteomyelitis?
* Immunosuppressed
* Diabetics
* Post surgical
* Vascular insufficiency
* Sickle Cell anemia
* IV drug Users (pseudomonas aeruginosa)
194
Explain Intravenous drug users in regards to Osteomyelitis:
"Mainliners Syndrome"
* **_S JOINTS_**
* **__**spine - discovertebral
* sacroiliacs
* symphysis pubis
* sternoclavicular
- ALL ARE **_AXIAL_** JOINTS \*\*\*\*
195
What are the categories under Osteonecrosis?
* Osteochondroses
* Legg-Calve Perthes Disease
* Freiberg's Infarction
* Preiser's Disease
* Kohler's Disease
* Kienbock's Disease
* Vertebral Body AVN
* Osteochondritis Dissecans
* Medullary Necrosis
196
What are the categories of Osteomyelitis?
* Acute
* Subacute
* Chronic
197
What are the clinical features of acute osteomyelitis?
* Edema
* Lymphadenopathy
* Warm Skin
* Cellulitis
* Joint Pain
- Happens within 2 weeks of disease onset
198
Subacute Osteomyelitis develops \_\_\_\_\_
Within one to several months
199
Chronic Osteomyelitis develops \_\_\_\_\_
After several months
200
What are the classifications of Osteomyelitis?
* **Suppurative**
* **Non-Suppurative**
* **Syphilitic (lues) - Teponema Pallidum**
201
What are the aerobes associated with Osteomyelitis?
* **Myobacterium Tuberculosis\*\*\*\***
* Neisseria Gonorrhea
* Pseudomonas
* Fungus
202
What are the anaerobic or faculative anaerobes associated with Osteomyelitis?
_**\*\*\*\*Staphylococcus Aureus\*\*\*\* (MOST COMMON)**_
* Streptococcus Pyogens
* Treponema Palladium
203
What is under the suppurative classification of Osteomyelitis?
* Bone marrow infection by (pyogenic) non-tubercular organism (anything but TB)
* Staylococcus aureus 90%
* Haemophilus Influenza
* Streptococcus Pneumonia
* E. Coli
* Pseudomonas
* IV drug abuse
* Mainliners Syndrome
* Axial Joints
* S joints
204
What's under the Non-suppurative category of Osteomyelitis?
* Mycobacterium tuberculosis
* Granulomatous
* Fungal Infections
* Blastomycosis - regional fungal infection
205
What's under the Syphilitic (lues) teponema pallidum?
- Congenital
- Acquired
206
What is the Route of Contamination in Osteomyelitis?
Osseous and articular contamination by 4 principle mechanisms
207
What are the 4 principle mechanisms of contamination in osteomyelitis?
1. Hematogenous spread of infection - via bloodstream
2. Spread from a contiguous source - cutaneous, sinus, and dental infections
3. Direct Implantation - Penetrating injuries, particularly in the feet
4. Postoperative Infection - contamination of surgical sites
208
What are the clinical characteristics of Osteomyelitis?
* Most often between 2-12
* 3:1 male dominance
* Boys have greater tendency to do things that make them vulnerable
* Large tubular bones of extremities (metaphysis and richly vascularized)
* Femur
* Tibia
* Humerus
* Radius
209
What are the Radiographic Findings associated with Osteomyelitis?
1. Moth eaten ostelysis
2. Periosteal reaction (involucrum - very substantial, mature, solid layer of bone around host bone)
3. Cloaca
4. Sequestra
5. Marjolin's Ulcer
210
What is the "Cloaca" associated with the Radiographic finding of Osteomyelitis?
* Hole through cortex and periosteal bone
* Allows exudate out into the soft tissue
211
What is "sequestra" associated with radiographic findings of Osteomyelitis?
Segments of necrotic bone separated from living bone by granulation tissue
212
What is Marjolin's Ulcer associated with Osteomyelitis radiographic findings?
Epidermoid carcinoma occuring at a sinus tract
- Rare finding after 20-30 years with chronic disease
213
How long does it take to see Radiographic evidence of Osteomyelitis?
10-14 days
214
What is Brodie's Abscess?
Low grade infection usually seen in children, may **_MIMIC_** osteoid osteoma
215
What are the main points of Septic Arthritis?
* May occur secondary to subarticular osteomyelitis or direct inoculation
* Usually monoarticular
* Spinal Involvement with TB frequently multi-disc level
* Only 10% of skeletal infectious disease will be spinal
216
What is Tom Smith Arthritis?
* Spread of metaphyseal osteomyelitis to the adjacent joint when the metaphysis is intrascapular
* Proximal and Distal femur and humerus as well as tibia
217
What are the modes of infection occuring in Osteomyelitis?
* Trauma/post - surgical
* UTI - particularly bad for getting it into the spine
* Pneumonia
* Skin (open wound or cellulitis)
218
What are the most common locations of Osteomyelitis?
* Knee
* Hip
* Ankle
* Shoulder
* Spine
* Venous Stasis and Gravity
219
What are the 4 Radiographic Stages?
1. **Latent (Hidden) stage 1-10 days**
1. No radiographic findings
2. **Early Stage days 10-21 days**
1. Decreased bone density and soft tissue
2. Periarticular Osteopenia - characteristic of RA
3. **Middle Stages - weeks**
1. ****Moth eaten destruction and periosteal reaction (solid)
2. Lytic moth eaten destruction may cross anatomical barriers
4. **Late Stage - months**
1. ****Involucrum, sequestrum, cloaca
2. Solid Periosteal Reaction - parallel to periosteal layer of bone
220
What stage of osteomyelitis would you see moth eaten destruction and periosteal reaction?
Middle stage
221
What is sequestrum?
Chalk, white area representing dead bone
222
What is the vocabulary associated with Involucrum of Osteomyelitis?
* Bony collar
* Continuation of periosteal response
* will eventually represent the new periosteum
* **_Cloaca_**: Drainging sinus, more common with chronic disease
223
What are the characteristics of arthritides?
* Degenerative and Inflammatory
* ***_INFLAMMATORY_***:
* Soft tissue swelling
* osteoporosis
* erosions
* Septic arthritis
224
What are common themese within Septic Arthritis?
* Joint infection
* MC in joints in which the capsules covers metaphysis
* Joint capsule infected first
* Completely eliminates both sides of the joint
225
What are the radiographic features of Septic Arthritis?
* Joint effusion
* Juxtaarticular Osteoporosis
* Erosions
* Joint space loss
* Lytic destruction that crosses the joint space
***_Tumors respect joints, INFECTIONS DONT!_***
226
Describe **Infectious Spondylodiscitis**:
Infection that gets into the disc and starts at the end plates
* Both suppurative and non-suppurative can do this
227
Pediatric patient with disc space loss =
INFECTION
228
What would give you the idea that you're seeing infection vs. DJD?
Destruction on both sides of disc level with disc narrowing and prevertebral swelling - think infectious
229
What "favors" TB?
Gibbus - hyperkyphosis with an angle
230
DJD is the most common reason for having joint space narrowing but it does not \_\_\_\_\_\_\_
DESTROY end plates,
**_INFECTION DESTROYS END PLATES_**
231
Metastasis can completely destroy the vertebral bodies, but \_\_\_\_\_
NOT touch the discs
232
What does TB destroy?
More of the front of the vertebral body - segment begins to flex forward
233
How much bone loss do you need for it to be detected on plain film?
30-70%
234
What imaging is more detailed, and more sensitive?
Computed Tomography
235
Tuberculosis is simply \_\_\_\_\_\_
Non suppurative Osteomyelitis
236
What is the most common cause of infection related death world wide?
Tuberculosis with 15 million people infected in the USA
237
What are the clinical features of Tuberculosis?
* Respiratory symptoms
* _**Pulmonary infection first (PRIMARY TB)\*\***_
* In an immunocompetent person, TB is asymptomatic _98_% of the time
238
What happens with the pulmonary infection in Tuberculosis?
Spreads through lymphatics and vascular system - _**lymphohemotogenous dissemination - secondary TB\*\*\***_
* Can embed organisms in bone marrow and spine
239
What is gohn's tubercle?
Localized embedded areas of tubercular bascillus organisms that are walled off and contained
240
What are the symptoms of Tuberculosis?
* Respiratory symptoms
* Weight loss
* night sweats
* vague joint/back pain
* persistently elevated ESR
241
What does TB really like?
The **_spine_** and joints - more so than suppurative
242
What is spinal tuberculosis?
**POTTS DISEASE**
243
What's the most common place for TB?
SPINE
244
What are the radiographic features of TB?
* similar to osteomyelitis in the spine, but:
* Multiple levels
* Paraspinal cold abscesses with Ca2+
* Subligamentous spread to multiple vertebrla bodies
* Spreads under **ALL**
245
Explain the "Paraspinal cold abscesses with Ca2+" in the Radiographic features of TB:
* New capillary growth with fibroblasts oozing from infectious site - granulation tissue can occur around the vertebra
* Below diaphragm in lumbar area - granulation runs down psoas muscle - psoas abscesses
* Calcifies because it scars
246
What are the most common places for TB?
Spine, hips, and knees
247
What is TB joint infection
Tuberculosis septic arthritis
248
What will you see with Tuberculosis septic arthritis - TB joint infection?
* **_PHEMISTER'S TRIAD_**
* Juxtaarticular osteoporosis (osteopenia)
* Marginal erosions
* Slow joint space loss (uniform)
* **_SCROFULA_** - associated with TB - cervical lymphadenitis
* Cervical lymph nodes enlarged
249
Osteitis Deformans =
**_Paget's Disease_**
250
What is Paget's Disease?
Very common _bone softening_ disease - many asymptomatic early in disease; progress with pain, bowing and enlargement with possible neurological complications (especially if it involves the spine)
251
Where is Paget's most common?
Great Britain and descendants
* About 5% of the world (1 in 20)
* Uncommon in Asia and Africa
* In US slightly higher incidence the further north you go
252
What is the etiology of Paget's?
Undetermined, current thought is the **latent Virus**
253
Describe the bone in Paget's:
Bone is extrememly vascular - tremendously high increase in blood flow
* This can overload the heart - high cardiac output --\> lead to heart failure
254
What does the lab report of Paget's Disease look like?
* Serum alkaline phosphatase - indication of liver activity and osteoblastic activity
* Urinary and serum hydroxyproline - from collagen breakdown
255
Describe the simple definition in early stage of Paget's:
Bone/osteoclastic resorption - where you will find hydroxyproline
256
Describe what simply happens in 2nd stage of Paget's in regards to the lab findings:
Bone productive - high osteoblastic activity - significant elevation of alkaline phosphatase (20 x's normal level)
257
Patient with Paget's disease frequently have \_\_\_\_\_\_
both stages going on at the same time - may see increase in both labs
258
Where is Paget's most common?
Big Tubular bones, pelvis, spine, and cranial vault
259
What is a distinguishing characteristic of Paget's?
Can jump over joints and involve the bones on the other side of the joint - typically subarticular (goes right up to the bone end)
* Can also cause deformity of the subarticular bone - impact the integrity of the cartilage of the joint - secondary DJD
260
Is there periosteal involvment in Paget's?
NO
261
What is the age group of Paget's ?
\> 40 years old
262
What are the stages of Paget's?
**_4 stages_**
1. **Stage 1 - Osteoclastic Resorpiton**
2. **Stage 2 - Bone Productive - mixed stage, biphastic stage**
3. **Stage 3 - Osteosclerotic stage**
4. **Stage 4 - Malignant Degeneration**
263
What happens during the 1st stage of Paget's?
* Seen with areas of radiolucency
* Lytic Phase - radiographic findings depend on if it is a long bone or flat bone
264
Describe the tubular component of Paget's in regards to the 1st stage:
Tubular - progresses proximal to distal, or distal to proximal
* Will have an area of radiolucency in a V shape ("blade of grass" or "candle flame") or oblique line
265
What happens to the skull in paget's?
_***1st stage\*\****_
* Skull/flat bone - large well-defined geographic area of radiolucency "osteoporosis circumscripta"
* IN SKULL ONLY
266
What are some features of Stage 2 Paget's?
* Repair stage that comes behind
* Osteoid is poor quality (lot of fibrous tissue)
* Accentuate the bone cortex and thicken the trabeculae - increase bone density and increase size
267
What stage do most patient's stay in Paget's?
**_STAGE 2_**
268
What will happen to the bone during Paget's?
* Sclerosis and lucency
* Trabecular and cortical thickening
* Bone enlargment - bone may lose vertical height (due to softening) but gain horizontal size
269
What appearance will the Paget's skull present with during stage 2?
* Skull is cotton wool appearance - fluffy, non homogenous look
* will cause enlargment of head
* often spares facial bones
270
What will the spine present with during Paget's in the 2nd stage?
Vertebral body "picture frame" - name for cortical thickening - best illustrated in the lumbar layer
* May see ivory vertebral body
* Can extend posterior
271
What is your differential diagnosis for ivory vertebra?
Pagets, blastic mets, lymphoma (Hodgkins)
272
What is a "sign" in stage 2 of Paget's?
"Brim/rim" sign - cortical thickening along the inside bony pelvic margin
\* Bony enlargment in the spine can cause the neurological symptoms
273
Describe Stage 3 of Paget's:
* Bone becomes homogenously osteosclerotic looking
* Cannot distinguish trabeculae from cortex
274
Describe stage 4 of Paget's:
Most people do not get to this stage, and bone becomes very painful
275
What can you use to diagnose Paget's?
* Radiographs
* Bone scan can find areas of involvment
* CT/MRI can asses for complications
276
What are the complications of Paget's?
* Osseous Deformity
* Fractures
* Neurologic Symptoms
* Arthropathy (secondary DJD)
* Neoplasm (4th stage)\*\*\*
KNOW THIS \*\*\*\*
277
What are the "Osseous deformities associated with Paget's?"
* Due to bone softening
* Bowing common
* Acetabular protrusion with positive Kohler's line
* Basilar Invagination
* Saber - shin deformity - bowing of tibia
278
What type of fractures do you see in Paget's?
**_Pseudofractures_**: Thin lines of radiolucency from unmineralized osteoid associated from softening
279
Describe pseudofractures in Paget's:
* Can become true fractures
* typical in femur, humerus, and pelvis
* **_AKA_**: osteoid seam, Milkman's syndrome, increment fracture, Looser's lines, umbazone
280
What is a Banan fracture in Paget's?
Usually through a pseudofracture in big tubular bones, horizontal/transverse fracture
* **_SPINE CAN HAVE COMPRESSION FRACTURES_**
281
Describe Neoplasm symptoms in Paget's:
* Sacromatous transformation that are most often lytic (only about 1% of patients)
* Occur in OLDER patients (55-80 y.o.)
* May have soft tissue mass develop around it
282
What are common sites of neoplasms?
FEMUR, pelvis, humerus
(UNCOMMON in spine)
283
Osteosarcom neoplasm %
50-55%
284
Fibrosarcoma neoplasm %
20-25%
285
Chondrosarcoma neoplasm %
10%
286
What is a neoplasm?
Abnormal cellular growth that can be benign or malignant
* **Malignant**: Ability to metastasize/spread
* ***Benign***: Does not metastasize, but this does not mean insignificant
287
Any cell found in bone can produce \_\_\_\_\_\_
a tumor
\* Subdivided by what type of cell it comes from
288
If a tumor originates in bone it is called a \_\_\_\_\_
primary bone tumor
289
What is a secondary bone tumor basic definition?
Starts somewhere else and metastasizes to bone
290
What is a tumor like lesion?
Lesions that radiographically appear as tumors but are not histo-pathologically classified as a tumor - usually produce geographic radiolucency
291
Primary bone tumors, benign category:
1. Osteoma - **_MOST COMMON_**, intramembranous bone tumor, dont hurt
2. Osteoid Osteoma - not as common, ***HURT***
3. Osteoblastoma - _RARE_, but half occur in spine
292
Malignant bone tumr =
Osteosarcoma
293
Describe conventional osteosarcomas:
Most of these are central sclerotic (about 75%) originate from inside the bone and loves the distal femoral metaphysis
* **72% (over 2/3 of all osteosarcomas)**
294
What is multifocal Osteosarcomatosis?
Most often in children in first decade, nearly always fatal
295
Osteosarcoma can be from post therapeutic radiation, t/f
true
296
What type of malignant bone tumor is extremely vascular?
Telangiectatic
297
What type of tumor can become an ostoesarcoma?
Dedifferentiated chondrosarcoma
298
What osteosarcoma originates in the soft tissue attached to the bone?
Extraskeletal Osteosarcoma
299
What are 2 of the most common benign bone tumors?
Chondroma and Solitary Osteochondroma - asymptomatic
300
What is a tumor of the cortical bone?
Chondroma, and it is a common benign
301
What is a benign bone tumor that is inside the bone?
Enchondroma
302
Is osteochondroma benign or malignant?
Benign
303
What is a fibromyxoid chondroma?
Tumor made of fibrous mucus cartilage
* Dominant content is cartilage
* Loves the **_TIBIA_** - rare to be anywhere else
**_BENIGN_**
304
What is a chondroblastoma?
High concentration found in the epiphysis - where chondroblasts are located - may spread into rest of bone
BENIGN\*\*
305
What are the 3 Malignant cartilage Tumors?
* Primary Chondrosarcoma
* Secondary Chondrosarcoma
* Clear cell chondrosarcoma
306
What is primary chondrosarcoma?
Didn't require anything else for it to be there, it originates by itself
307
What is secondary chondrosarcoma?
From a preexisting benign tumor that malignantly degenerate - can be multiple
* **Central** secondary chondrosarcoma - From ENCHONDROMA, central is inside the bone in medullary cavity or cortex
* **Peripheral** - OSTEOCHONDROMA - located external to the bone, looks like a trunk/stalk of broccoli coming off
308
Central secondary chondrosarcoma comes from \_\_\_\_\_
Enchondroma
309
Peripheral secondary chondrosarcoma comes from _____ ?
Osteochondroma
310
What is clear cell chondrosarcoma?
Usually near a joint, mistaken for chondroblastoma
311
What is one of the more common bone tumors?
Giant cell tumor of bone/osteoclastoma
312
What are the characteristics of Giant cell tumor?
* Classically expansile soap bubble lesion
* about 1 in 5 are malignant
* "Quasi - malignant" can go either way - **_80% malignant_**
313
Where do giant cell tumors most likey occur?
At the knee (HURT)
314
Marrow tumors, aka:
round cell tumors
315
What is the common theme with marrow tumors (round cell tumors)?
_**Occur in diaphysis and are all MALGINANT AND DESTRUCTIVE \*\*\*\*\*\***_
316
Ewings Sarcoma is in what category?
Marrow tumor (round cell tumor)
* Classically gives laminated periosteal reaction
* moth eaten appearance
* big tubular bone in young children
317
What is the most common primary bone malignancy in first decade (peak in teenagers)?
**_EWINGS SARCOMA_**
* dont confuse Leukemia, which is the most common _malignancy_ in the first decade
318
What category is Non-Hodgkin Lymphoma under? (NHL)
Marrow tumor (round cell tumor: malignant)
319
What is the most common primary bone malignancy?
_**Multiple Myeloma\*\*\*\* TEST**_
320
Where would you see true punched out lesions?
Multiple Myeloma
321
Explain Myelomatosis:
Form of multiple myeloma:
* Produces osteopenia, looks like osteoporosis - will also have weakness and fatigue due to anemia - radiographically will look the same
322
What will plasmacytoma have?
Geographic soap bubble lesion
323
What is "extra osseous" ?
Branch of multiple myeloma
* Mass in nasal pharynx (difficulty breathing), very uncommon
324
What is under the Benign Vascular and Connective Tissue tumor?
**_Hemangioma_** - produces localized coarsening of the trabecular pattern
325
What is the "Malignant vascular tumor?'
Fibrosarcoma
326
What is the notochord remnant tumor?
Chordoma - most often found in Clivus, C2, sacro-coccygeal, will cross the joint
327
What are secondary tumors?
Metastatic tumors in bone
328
Vast majority of secondary tumors are \_\_\_\_\_
**Hematogenous**
329
Osteolytic mets is a \_\_\_\_\_
secondary tumor
330
What has 75% occurence %, osteolytic mets or osteoblastic mets?
Osteolytic
331
What are the key points of osteolytic mets?
* Destroys by physical bulk and restricting osteoblasts
* 80% of metastasis found in spine, ribs and pelvis with another 10% found in cranium
* Rarely go beyond the elbow and knee
332
What accelerates osteoblasts?
Osteoblastic mets
333
Pic of mixed mets
334
What is in the "Tumor Like" category?
* Not exhaustive list
* **Fibrous dysplasia** - as common as Paget's
335
How can tumors be classified?
* They can be classified by location of where they originate - most often from the **metaphysis**
336
If a tumor is most likely benign, what will it's characteristics be?
* Almost always originate before age of 30 (with exception of giant cell tumor 20-40 years old)
KNOW THIS\*\*\*
337
What are the top "Malignant Tumors" ?
MOCEF - top 5 primary malignant
1. Multiple Myeloma: **Over 40**
2. Osteosarcoma: **under 30**
3. Chondrosarcoma: **40 - 60**
4. Ewing's: **Under 40**
5. Fibrosarcoma: **30 - 60**
338
Primary Bone Tumors:
* Bone Forming Tumors
* Cartilage Forming Tumors
* Giant Cell Tumor of Bone/Osteoclastoma
* Marrow Tumors (Round Cell Tumors)
* Vascular and Connective Tissue Tumors
* Notochord Remnant Tumor
339
What are the Bone forming primary bone tumors?
* **_Benign_**
* Osteoma
* Osteoid Osteoma
* Osteoblastoma
* **_Malignant - Osteosarcomas_**
* Conventional Osteosarcoma
* 72% central
* 75% sclerotic
* 25% lytic
* Parosteal Os 4%
* Periosteal Os 1%
* Multifocal Os/osteosarcomatosis 1%
* Osteosarcoma of Jaw - 6%
* Post Radiation Os - 4%
* Os in Paget's disease - 3%
* Os Degeneration from benign condition - 1%
* Telangiectatic Os - 3%
* Dedifferentiated Chondrosarcoma - 3%
* Extraskeletal Os. \< 1%
340
What are the Benign Cartilage Forming Tumors?
* Benign
* Chodnroma/Enchondroma
* Solitary Osteochondroma
* Chondromyxoid Fibroma/Fibromyxoid Chondroma
* Chondroblastoma
341
What are the malignant Cartilage forming tumors?
Malignant
* Primary Chondrosarcoma - arise de novo
* Secondary Chondrosarcoma - from preexisting benign tumor
* Central - From enchondroma
* Peripheral - From Osteochondroma
* Clear cell chondrosarcoma - mistaken form chondroblastoma, low grade
* Extra Skeletal - Rare
342
What are the marrow tumors (round cell tumors?)
* Ewing's Sarcoma
* NHL (non hodgkin lymphoma) of bone/reticulum cell sarcoma
* Multiple Myeloma
343
What are the branches of multiple myeloma?
* Classical MM
* Myelomatosis
* Plasmacytoma
* Extra Osseous MM
344
Vascular and Connective Tissue tumors are in what category, what are their subcategories?
It is in the category of "primary bone tumor"
* Benign - Hemangioma
* Malignant - Fibrosarcoma
345
Metastatic Tumors in bone - most common skeletal malginancy
* Osteolytic Mets
* Osteoblastic Mets
* Mixed Mets
346
Tumor Like Conditions:
PRIMARY BONE TUMORS
* Solitary bone cyst/Unicameral bone cyst
* Aneurysmal bone cyst
* Fibrous Cortical defect and nonossifying fibroma
* Fibrous Dysplasia
* Brown Tumor of hyperparathyroidism
* Pseudotumors of Hemophilia
* Large Arthritic Cysts/Geode
347
If it's a benign tumor they overwhelmingly originate when?
Before the Age of 30
348
If a tumor is asymptomatic and benign, it may not show till \_\_\_\_
age 50
349
When does Giant cell tumor usually occur?
20-40 this is an exception
350
Metastisis happens how?
Through Vascular system
351
Big 6 strongest potential to spread?
1. Breast - females 70%
2. Lung - 25%
3. Prostate - Males 60%
4. Kidney
5. Ewing's
6. Neuroblastoma
\*\*\* Breast, lung, prostate, and kidney account for 80%
352
Where does lytic Mets come from?
Physical bulk - pressure from the tumor taking up space which impedes the osteoblasts
* More common (75% of metastasis destroys)
353
Approximately 80% of all osseous metastases will be found \_\_\_\_\_
In the axial skeleton
* 28% ribs
* 39% vertebra
* 13% bony pelvis
10 % of skeletal metastasis will be found in the cranium
10% extremities
354
Is Enostosis primary or secondary bone tumor?
Primary
AKA BONE ISLAND
355
What is enostosis classified as?
Tumorlike, usually an incidental finding, and is asymptomatic
356
What are the characteristics of Enostosis?
* Rare in children
* Osteosclerotic bone lesion
* Can be considered a hamartoma (benign tumor that is multicellular and has all the cells of the host tissue)
357
Where is the location of Enostosis?
Intramedullary Location - usually up against inner surface of cortex
* Composed of normal appearing compact lamellar bone with haversian canals
* Blends with surround trabecular bone creating irregular margin
358
What is the radiological appearance of Enostosis
* Round to oval (.2 - 2 cm) osteoblastic area
* Epiphyseal or metaphyseal
* Bone scan NORMAL
95 % no need for further radiologic evaluation
359
WHat is the differential diagnosis for Enostosis?
Osteoblastic Mets, osteoma, osteoid osteoma, low grade osteosarcoma
360
Osteoblastic mets \_\_\_\_
HURTS
361
low grade osteosarcoma is \_\_\_\_
PAINFUL
362
When would you take a biopsy of Enostosis?
Increase in size of 25% in 6 months
363
Bony pelivs is a common site to see \_\_\_\_
enostosis
364
Giant bone island is a \_\_\_\_\_
Enostosis that is \> 2-3 cm in size
More likely to have increased activity on bone scan
365
What are the possible diseases related to Enostosis?
* Osteopoikilosis
* Osteopathia Striata
* Melorheostosis
366
Osteopoikilosis =
Periarticular bone islands
367
Osteopathia Striata =
Lesions are more elongated in periarticular pattern, Vooerheve disease, fan-like bands in flat bones
368
What are the 3 common characteristics of Melorheostosis?
* Osteosclerotic bone disorder
* Often symptomatic (pain, decreased ROM, contractures, limb swelling, bowing)
* Scleroderma - like skin lesions over osseous changes
369
What is the radiology of Melorheostosis?
o Osseous excrescences often exuberant and lobulated along bone surface
o Single limb—more common lower extremity
o Also endosteal involvement may extend into marrow space
o Intense activity on bone scan
o Long drippy bone island
370
Benign Bone forming:
OSTEOMA
OSTEOID OSTEOMA
OSTEOBLASTOMA
371
Osteoma aka:
Ivory Exostosis
372
What is a benign, slow growing hamartomatous lesion composed of well differentiated mature bone?
Osteoma
373
What is the defect in Osteoma?
One resorption or formation during skeletal maturation
374
What does osteoma arises beneath?
Endosteum from inner surface of cortex
375
What causes surrounding reactive bone formation in Osteomas?
Elevation of periosteum from underlying bone
376
Osteoma is a bone of \_\_\_\_\_
Intramembranous origin
377
Extracranial Osteoms -
.03% of bone biopsied primary bone lesions
378
Paranasal sinus osteomas -
.4%
Most have a osteosclerotic lesion in a frontal or ethmoid lesion
379
What are the associated abnormailities with Osteoma?
* Gardner's Syndrome
* Mutation of Adenmatous Polyposis Coli Gene (5q21)
* Multiple osteomas, intestinal polypsos, soft tissue desmoid tumors
* Bone lesions may precede intestinal polyposis
380
Describe Gardner's Syndrome in Osteoma:
* Autosomal Dominant
* Syndrome of hamartomatous tumors in different locations
* One of the key findings - osteomas
* Will develop color cancer (precursor to colon cancer)
381
In osteoma, most just have \_\_\_\_
single solitary osteoma
382
What are the clinical issues associated with Osteoma?
* Small lesions usually asymptomatic
* Project away from cortical surface
* Palpable enlarging osseous mass
383
What is the nasal issue with Osteoma?
* Large oseomain paranasal sinus may obstruct nasal ducts
* Can erode wall of cranial fossa and dura
* Can cause mucocele, sinusitis, headache, pain
384
What can osteoma tumors near orbit cause?
Cause exopthalmosis, double vision, vision loss
385
What about the Hx of Osteoma:
* Found before 30 but can be seen anytime
* EQUAL GENDER
* No malginant potential
386
What looks identical to bone island but has different location?
Osteoma
387
What does Osteoma look like radiographically?
(first 3)
* Well defined round dense sclerotic lesion attach to underlying bone
* Vast majority in frontal and ethmoid sinus
* DENSE ivory like sclerotic mass
388
What does Osteoma look like radiographically?
(last 3)
* No satellite lesions
* Low signal on MRI
* Plain film is good to see them
389
OSTEOID OSTEOMA: main characteristics
* Painful!
* Produce dense periosteal reaction
* Can regress spontaneously - infarction
* Local swelling and point tenderness
390
What is Osteoid Osteoma characterized by?
Nidus less than 1 cm of osteoid/woven bone is vascular tissue surrounded by zone of reactive sclerosis
391
What is elevated in Osteoid Osteoma?
Prostaglandin E2 elevated 100-1000 times within Nidus (pain and vasodilation)
392
Describe the nidus in Osteoid osteoma:
Radiolucent and is the actual tumor
393
Pain is worse at night with what tumor?
Osteoid Osteoma
394
Whats the origin of Osteoid Osteoma?
Unknown, inflammatory, traumatic, vascular, viral
395
What is a distinguishing characteristic of Osteoid Osteoma?
These can produce a painful scoliosis, and they happen in the spine (lean into a legion)
396
Osteoid Osteoma is more common in \_\_\_\_\_\_
males 2-3:1
397
What are the first 4 radiological features of Osteoid Osteoma?
* Long bones are common
* Metaphysis/Diaphysis
* Phalanges of hands and feet
* Spine (10%)
* Posterior Elements 90% - posterior arch lamina
* Vertebral body 10%
398
What are the last 5-6 radiological features of osteoid osteoma?
* Cortical: 70-80%
* Radiolucent Nidus \< 1.5 cm with surrounding dense sclerosis
* Periosteal reaction may be present
* Medullary: 25%
* CT - well defined, round oval nidus surrounded by sclerosis
* MRI - T1 WI nidus isointense to muscle
399
What does osteoid osteoma look like on bone scan?
lights up
(will have a solid dense periosteal reaction)
400
OSTEOBLASTOMA aka:
Giant osteoid osteoma, osteogenic fibroma
401
What is Osteoblastoma characterized by?
* Production of osteoid and woven bone
* Lesion \> 1.5 cm
* Histology similar to osteoid osteoma
402
What are the %'s associated with Osteoblastoma?
\< 1% of primary bone tumors
3% benign bone tumor
403
Describe Osteoblastoma:
* Circumscribed mass, often surrounded by shell of cortical bone or periosteum
* Sharp interphase between lesion and cancellous bone
404
What does the nidus look like in Osteoblastoma?
* 2-10 cm, friable, deep red (highly vascular)
* Very vascular connective tissue stroma with interconnecting trabecular bone
405
What are the symptoms of osteoblastoma?
* Dull, localized pain of insidious onset
* Pain rarely interferes with sleep
* Localized swelling, tenderness, and decreased ROM
* Doesnt respond well to aspirin
406
Osteoblastoma originates \_\_\_\_
under 30
407
Osteoblastoma gender pref.
2-3:1 in males
408
WHat can Ostoeblastoma have?
Foci of aggressive stage 3 lesion (prone to aneurysmal bone cysts formation)
RECURRENCE AFTER resection = 10-25%
409
In aggressive osteoblastoma, the recurrence is ____ %
50
410
First 4 things of Osteoblastoma (radiology):
* 30-50% SPINAL
* Posterior elements --\> 60% spinous, transverse process, pedicle
* Posterior elements with extension into vertebral body 25%
* Vertebral body 15%
* Long bones, 30% originate in metaphysis
411
What are the 5-8 radiographic features of Osteoblastoma?
* Hands and feet 15%
* Skull and Jaw 15%
* Pelvis 5%
* Expansile, lytic circumscribed lesion
* Reactive sclerosis 60%
412
Last radiologic features of Osteoblastoma:
* CAN rapidly increase in size
* Secondary aneurysmal bone cyst (ABC): 16% can look exactly the same
* NECT: Expansile, lytic lesion with or without matrix mineralization
* Can be purely radiolucent inside, speckled (inside matrix), or sclerotic looking
***_KEY IS EXPANSION_***
413
MALIGNANT PRIMARY BONE TUMORS:
Osteosarcoma, aka Osteogenic Osteosarcoma
414
What is the main definition of Osteosarcoma?
Malignant tumor with ability to produce osteoid directly from neoplastic cells
415
Talk about the growth rate of Osteosarcoma:
Frequency of tumor occurence corresponds to greatest growth rate during adolescence
416
What is chemically happening in osteosarcoma?
Overexpression of P-glycogen in OGS cells with propensity for metastasis and rx failure
alteration in Rb genes in OGS
417
Think of osteosarcoma as \_\_\_\_
osteoblastic malignant tumor
418
Periosteal reaction of osteosarcoma =
Spiculated
419
2nd primary bone tumor is \_\_\_\_
Osteosarcoma (MOCEF)
420
When does osteosarcoma peak?
teens
421
Where is the most common location for osteosarcoma?
Distal femoral metaphysis
422
Osteosarcomatosis survival:
Change low
423
Where will osteosarcoma metastasize to?
LUNG
424
Osteosarcoma has a majority of unknown origin, primary, but secondary to predisposing factors are:
* Paget's Disease (4th stage)
* Bone infarction
* Radiation
425
What is the most common malignant primary bone tumor in young adults and children?
Osteosarcoma
426
