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Core > MSK: Arthritis > Flashcards

MSK: Arthritis Flashcards

1
Q

What are the major categories of arthritis?

A
  • Degenerative
  • Inflammatory
  • Metabolic
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2
Q

What are the major types of degenerative arthritis?

A
  • Osteoarthritis
  • Neuropathic joint
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3
Q

What are the major types of inflammatory arthritis?

A
  • Erosive arthritis (inflammatory osteoarthritis)
  • Rheumatoid arthritis
  • Rheumatoid variants
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4
Q

What are the “rheumatoid variants”?

A
  • Psoriatic arthritis
  • Reactive arthritis (i.e. Reiter’s syndrome)
  • Ankylosing spondylitis
  • IBD-related arthritis
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5
Q

What are the major types of metabolic arthritis?

A
  • Gout
  • CPPD (calcium pyrophosphate deposition disease)
  • Hemochromatosis
  • Milwaukee shoulder
  • Hyperparathyroidism
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6
Q
A

Think neuropathic joint

Note: “Surgical like margins” of degenerative changes are really only seen in neuropathic joints.

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7
Q
A

Charcot foot, consistent with neuropathic degenerative changes (common in diabetic neuropathy)

Note: “Rocker-bottom deformity” of the mid foot due to collapse of the longitudinal arch.

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8
Q

What features should make you think osteomyelitis rather than neuropathic degeneration when looking at a diabetic foot radiograph?

A
  • Presence of an ulcer or sinus tract
  • Location at pressure points (e.g. metatarsal heads, interphalangeal joints, or posterior plantar aspect of the calcaneus)

Note: Diabetic neuropathic changes (Charcot foot) mostly involves the midfoot.

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9
Q
A

Gullwing deformity, suggestive of erosive osteoarthritis

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10
Q

Which joints are most classically involved in erosive osteoarthritis?

A

The distal interphalangeal joints

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11
Q

What are the classic general imaging features of rheumatoid arthritis?

A
  • Marginal erosions
  • Uniform joint space narrowing
  • Soft tissue swelling
  • Osteoporosis
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12
Q

Which joints are classically involved in rheumatoid arthritis?

A

Metacarpophalangeal joints, with relative sparing of the 1st MCP joint (usually bilateral and symmetric)

Note: RA usually spares the DIP joints (which can help differentiate it from erosive osteoarthritis).

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13
Q

What is the first spot to show rheumatoid arthritis changes in the feet?

A

The 5th metatarsal head

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14
Q

Isolated degenerative changes of the first CMC joint…

A

Think osteoarthritis

Note: Rheumatoid and psoriatic arthritis often involve the carpal joints, but these usually spare the first CMC joint until late in the disease.

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15
Q

Rheumatoid arthritis, splenomegaly, and neutropenia…

A

Felty syndrome

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16
Q

Rheumatoid arthritis and pneumoconiosis…

A

Caplan syndrome

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17
Q

How can you differentiate osteoarthritis from rheumatoid arthritis in the hip?

A

The distribution of degenerative changes will be more vertical/horizontal in osteoarthritis

Rheumatoid arthritis mostly affects the superomedial joint space

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18
Q

Which hip is more likely osteoarthritis?

A

B (vertical forces narrowing the superior joint space)

Note: In A, there is more narrowing of the superomedial joint space, more suggestive of rheumatoid arthritis.

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19
Q

What percentage of pts with psoriasis get psoriatic arthritis?

A

30%

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20
Q

Which comes first: skin findings or psoriatic arthritis?

A

Skin findings (90%)

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21
Q

Which joints are most commonly affected in psoriatic arthritis?

A

Hand joints (mostly interphalangeal joints with relative sparing of the MCP joints)

Note: Feet and SI joints are also commonly involved.

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22
Q

Which portion of a DIP joint is usually involved first in psoriatic arthritis?

A

The joint margins

Note: The central joint is usually the last to go, which is what creates the pencil-in-cup deformity.

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23
Q
A

Psoriatic arthritis

Note: Pencil-in-cup deformity and sausage digits.

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24
Q

DIP joint degenerative changes with “fuzzy appearance” to the bone around the joint…

A

Think psoriatic arthritis

Note: The fuzzy appearance is due to bone proliferation.

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25
Q

Hand arthritis with sausage digits…

A

Think psoriatic arthritis (due to soft tissue swelling involving an entire finger)

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26
Q
A

Ivory phalanx, consistent with psoriatic arthritis

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27
Q
A

Pencil-in-cup deformity, consistent with psoriatic arthritis

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28
Q

Arrows

A

Finger ankylosis, which can be seen in psoriatic arthritis and erosive osteoarthritis

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29
Q
A

“Mouse ear” erosions with bony proliferation, consistent with psoriatic arthritis

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30
Q
A

Acroosteolysis

Note: This can be seen in psoriatic arthritis and other diseases.

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31
Q
A

Arthritis mutilans (when severe bone resorption leads to soft tissue telescoping/collapse)

Note: This can be seen in severe rheumatoid and severe psoriatic arthritis.

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32
Q

Does psoriatic arthritis tend to be symmetric or asymmetric?

A

Asymmetric

Note: This can help distinguish it from rheumatoid arthritis, which tends to be symmetric.

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33
Q

Psoriatic and reactive arthritis are both associated with…

A

HLA-B27

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34
Q

Urethritis, conjunctivitis, and arthritis…

A

Reactive arthritis (classic triad)

Note: “Can’t see, can’t pee, can’t climb a tree.”

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35
Q

Classic radiographic appearance of reactive arthritis

A

Very similar to psoriatic arthritis, but rarely involves the hands (reactive arthritis tends to affect things below the waist, e.g. foot joints)

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36
Q
A

Think early ankylosing sponylitis

Note: “Shiny corners.”

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37
Q
A

Ankylosing spondylitis

Note: This is the “bamboo spine.”

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38
Q

What is usually the first site to be involved in ankylosing spondylitis?

A

The sacroiliac joint (symmetric involvement)

Note: The joint actually widens before it narrows.

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39
Q

Next step: Pt with known ankylosing spondylitis has minor trauma to the back

A

Whole spine CT (bamboo spines are very susceptible to fracture)

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40
Q

What is the most common site of peripheral skeleton involvement in ankylosing spondylitis?

A

Hips (followed by shoulders)

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41
Q

Pts with ankylosing spondylitis are at a high risk for ______ after hip arthroplasty

A

Heterotopic ossification

Note: This is why these pts often get postoperative low dose radiation and NSAIDs (as prophylaxis against heterotypic ossification).

42
Q

Bamboo spine with normal sacroiliac joints…

A

Its not ankylosing spondylitis (which virtually always involves the SI joints first)

43
Q

What percentage of pts with IBD get enteropathic arthritis?

A

20%

44
Q

What are the two main manifestations of enteropathic arthritis?

A
  • Axial arthritis (favoring the SI joints and spine)
  • Peripheral arthritis (which usually varies depending on the severity of the bowel disease)
45
Q
A

Symmetric sacroiliitis, think ankylosing spondylitis or enteropathic arthritis

46
Q

Differential for bilateral sacroiliitis

A

PAIR:

  • Psoriatic arthritis
  • Ankylosing spondylitis
  • IBD arthritis
  • Reactive arthritis

Note: PaiR (psoriatic/reactive tend to be asymmetric) and pAIr (ankylosing and IBD tend to be symmetric).

47
Q

Unilateral sacroiliitis…

A

Think infection (e.g. pyogenic, tuberculous, brucellosis)

Note: Psoriatic and reactive arthritis tend to be bilateral (but asymmetric).

48
Q

Gout is most common in what pt population?

A

Males over age 40 (think red meat eaters)

49
Q

Pathophysiology of gout

A

Uric acid crystal deposition in and around the joints

50
Q

Most common location for gout

A

First MTP joint

51
Q

Earliest sign of gout

A

Joint effusion

52
Q

Classic imaging findings for gout

A
  • Juxtaarticular erosions (sparing the joint space until late in the disease)
  • Punched out lytic lesions with overhanging edges
  • Soft tissue tophi (usually enhances)
53
Q
A

Dense soft tissue swelling around the first MTP joint, think Gout

54
Q
A

Gout

55
Q

What are the 5 entities that can have a similar appearance to gouty arthritis?

A

CRASH:

  • Cystic rheumatoid arthritis
  • Reticular histiocytosis
  • Amyloid
  • Sarcoid
  • Hyperlipidemia

Note: Gouty appearance is much more rare with these than with actual gout.

56
Q

Calcium pyrophosphate deposition disease and synovitis…

A

Pseudogout

57
Q

Classic imaging feature of CPPD

A

Chondrocalcinosis (especially of the triangular fibrocartilage)

Note: Hemochromatosis can also appear this way.

58
Q

Degenerative changes in the shoulder…

A

Think CPPD (unless there is a reason to develop osteoarthritis)

Note: Degenerative changes in an uncommon joint is a common feature of CPPD.

59
Q

What is the most common location for CPPD arthropathy?

A

The knee

60
Q

Isolated degenerative changes at the STT (scaphotrapeziotrapezoid) joint…

A

Think CPPD

Note: Consider CPPD when you find degenerative changes in atypical, non-weight bearing joints.

61
Q

What is the pathophysiology of chondrocalcinosis in hemochromatosis?

A

Calcium pyrophosphate deposition (same as for CPPD)

62
Q

Does hemochromatosis arthritis get better after treating the hemochromatosis?

A

No

63
Q
A

Hemochromatosis arthropathy

Note: Uniform MCP joint narrowing favors hemochromatosis. CPPD would look very similar, but the index/middle fingers tend to be more prominently involved than other MCP joints.

64
Q
A

Think Milwaukee shoulder (destruction of the humeral head from hydroxyapatite deposition)

Note: Can appear similar to a neuropathic shoulder, but shouldn’t have the same “surgical margins.”

65
Q

Milwaukee shoulder is more common in what pt population?

A

Older females with a history of prior shoulder trauma

66
Q

Subperiosteal bone resorption on the radial aspect of the 2nd and 3rd fingers…

A

Think hyperparathyroidism

67
Q
A

Subperiosteal bone resorption, think hyperparathyroidism

68
Q
A

Terminal tuft erosions

Note: This can be seen in hyperparathyroidism.

69
Q
A

Rib notching

Note: This can be seen in hyperparathyroidism.

70
Q

What is the cause of rib notching, rugger jersey spine, and subperiosteal bone resorption in hyperparathyroidism?

A

Phosphate retention

71
Q

Severe arthritis in the bilateral hands…

A

Rheumatoid arthritis

Note: Atlantoaxial instability can occur in rheumatoid arthritis.

72
Q
A

Marginal erosions favoring the 4th/5th MCP joints, think rheumatoid arthritis

73
Q

What should you decide first when looking at complicated hand arthritis radiographs?

A

Is it inflammatory arthritis (symmetric joint space narrowing OR erosions)

OR

Degenerative (asymmetric joint space narrowing OR osteophytes)

74
Q

Differential for degenerative changes in an atypical joint or at an atypical age

A
  • Post traumatic
  • Gout or CPPD
  • Hemophilia
  • Neuropathic (if severe or surgical margins)
75
Q

Bulky osteophytes sparing the disc space…

A

Think DISH

76
Q

Flowing syndesmophytes…

A

Think ankylosing spondylitis (i.e. bamboo spine)

77
Q

Focal lateral paravertebral ossification/bridging lateral osteophyte…

A

Think ossification of annulus fibrosis in psoriatic arthritis

78
Q
A

Cervical spine fusion, think congenital (Klippel-Feil) or juvenile rheumatoid arthritis

79
Q
A

Erosion of the odontoid process, think CPPD or rheumatoid arthritis

80
Q
A

Severe cervical kyphosis, think NF1

81
Q

Classic imaging appearance of DISH

A

Ossification of the anterior longitudinal ligament involving at least 4 levels with relative sparing of the disc space AND no sacroiliitis (helps distinguish from ankylosing spondylitis)

82
Q
A

Ossification of the posterior longitudinal ligament, which can lead to spinal canal stenosis (especially in the cervical spine)

83
Q

Ossification of the posterior longitudinal ligament is associated with…

A
  • DISH
  • Ossification of the ligamentum flavum
  • Ankylosing spondylitis
84
Q

Ossification of the posterior longitudinal ligament is most common in the _____ spine

A

Cervical

Note: This is not good because this is also where it is most likely to cause spinal stenosis/cord injury.

85
Q

Pt with end stage renal disease

A

Think destructive spondyloarthropathy

Note: This is associated with pts on dialysis for at least 2 years due to amyloid deposition (it looks like bad degenerative changes or CPPD).

86
Q
A

Think SLE

Note: This is the “swan neck” deformity.

87
Q
A

Think SLE

Note: Reversible ulnar deviation.

88
Q

Classic imaging findings of SLE on hand radiographs

A

Reducible joint deformities/subluxations without erosions

89
Q

Pts with SLE have an increased risk of _____ dislocations due to ligamentous laxity

A

Patella dislocations

90
Q

History of rheumatic fever

A

Jaccoud’s arthropathy

Note: Non-erosive arthropahty with ulnar deviation of the 2nd-5th fingers at the MCP joints with a history of rheumatoid arthritis.

91
Q

Anti-ribonucleoprotein (anti-RNP) positive

A

Mixed connective tissue disease

92
Q

By definition, juvenile idiopathic arthritis starts before age…

A

16

93
Q

14 y/o

A

Juvenile idiopathic arthritis

Note: Carpal ankylosis and periarticular osteopenia in a pt younger than 16 y/o.

94
Q

Does serology help when considering juvenile idiopathic arthritis?

A

Only in ruling out other diseases (JIA is serology negative 85% of the time)

95
Q

32 y/o with long standing history of arthritis

A

Juvenile idiopathic arthritis (chronic)

Note: Epiphyseal overgrowth and severe joint malalignment with a history of arthritis in youth.

96
Q

Classic imaging features of juvenile idiopathic arthritis

A
  • Carpal ankylosis (due to premature fusion of growth plates)
  • Epiphyseal overgrowth
  • Widened intercondylar notch in the knee
97
Q
A

Widening of the intercondylar notch, think hemophilia or juvenile idiopathic arthritis

98
Q

Carpal tunnel syndrome in a pt on dialysis…

A

Think amyloid arthropathy

99
Q

Amyloid arthropathy is seen in what pt population?

A

Pts on dialysis for at least 5 years (80% prevalent in pts on dialysis for more than 10 years)

Note: It can also be seen in pts with long-standing chronic inflammation (e.g. rheumatoid arthritis).

100
Q

Severe destructive arthritis involving the bilateral shoulders, hips, carpals, and knees…

A

Think amyloid arthropathy (pt likely on dialysis or with long-standing RA)

101
Q

Widening of the joint space in an adult hip…

A

Think pituitary gigantism

Note: This is due to the formation of enchondral bone at existing chondrites-osseous junctions.

102
Q
A

Think pituitary gigantism

Note: Widening of the hip joint space with epiphyseal necrosis (occurs in gigantism due to the cartilage outgrowing its blood supply).

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