Noninflammatory Joint Pathologies Flashcards
1
Q
What is joint degeneration?
A
A disease in which the function or structure of the affected tissues or organs changes for worse over time
2
Q
Joint degeneration is driven by ___
A
the mechanical wear of joints
3
Q
Joint degeneration is characterized by ___
A
progressive destruction of articular cartilage at synovial joints
4
Q
Is joint degeneration inflammatory?
A
No
5
Q
What is the most common joint problem in humans?
A
Joint degeneration
6
Q
Primary joint degeneration is an ___-related pathology
A
age
7
Q
What genetic mutation related to cartilage may cause joint degeneration?
A
Mutations in type II collagen gene (COL2A1)
8
Q
___% of 75-79 years of age are affected by joint degeneration
A
85%
9
Q
Before age 45, joint degeneration is more common in ___
A
men
10
Q
After age 55, joint degeneration is more common in ___
A
women
11
Q
What is secondary joint degeneration?
A
Due to an underlying cause
12
Q
What are some etiologic factors of joint degeneration?
A
- Increased unit load
- Disruption of water bonding (decreased resilience)
- Subchondral stiffening
- Biochemical changes
13
Q
Which biochemical changes are etiologic factors for joint degeneration?
A
- Decreased proteoglycans
- Glycosaminoglycan chain length reduced
- Increased fibrillin
- Increased water binding
- Collagenase present
14
Q
How does bone respond to early joint degeneration?
A
Reparative response
15
Q
With joint degeneration, ___ and ___ will progressively decrease
microscopic concepts
A
matrix synthesis and cellular replication
16
Q
When during joint degeneration might you see reactive inflammation?
A
Later disease
17
Q
With reactive inflammation later in joint degeneration, local increases in ___ and ___ induce an increase in nitric oxide and PGE2
A
IL-1b and TNF-a
18
Q
With reactive inflammation later in joint degeneration, local increases in IL-1b and TNF-a induce an increase in ___ and ___.
A
nitric oxide and PGE2
19
Q
The beginning of joint degeneration pathogenesis involves a decrease in ___ leading to an increase in ___
microscopic concepts
A
decrease in proteoglycan synthesis leading to an increase in chondrocyte death
20
Q
In the pathogenesis of joint degeneration, what is the result of decreased proteoglycan synthesis and increased chondrocyte death?
A
Fibrillation or cracking in the surface layers of the articular cartilage
21
Q
In the pathogenesis of joint degeneration, what are the immediate consequences of fibrillation propagation?
A
- Synovial fluid fills defects, increasing fissuring
- Pieces of cartilage may break off
22
Q
In the pathogenesis of joint degeneration, fibrillation propagation may eventually crack across the tide mark.
What are the histological events that occur at this point?
A
- Neovascularization/angiogenesis
- Osteoclast activity increases (subchondral resorption)
- Osteoblast activity increases (subchondral sclerosing)
- Fibrocartilage forms
23
Q
In the pathogenesis of joint degeneration, fibrocartilage forms to fill cracks across the tide mark.
What happens if that fibrocartilage plug breaks down?
A
- Exposes subchondral bone to mechanical erosion
- Eburnation
- Subchondral sclerosing
24
Q
In the pathogenesis of joint degeneration, the fibrocartilage plug made to fill cracks can break down and become eburnated bone.
What if eburnated bone cracks?
A
- Cracks fill with synovial fluid
- Subchondral cysts form and may increase in size
25
What are three consequences of haphazard remodeling associated with joint degeneration?
1. Osteophytes (bone spurs)
2. Subchondral sclerosis (joint stiffening, increased bone mass)
3. Subchondral bone cysts
26
With joint degeneration, where are osteophytes most likely to develop?
Joint margins
27
Which joints are capable of degenerating?
Any and all
28
Which joints most commonly degenerate?
Hands, knees, hips, cervical and lumbar spine
29
How do degenerated joints appear externally?
May be enlarged (and tender)
30
How does joint degeneration feel upon palpation?
May have crepitus
31
What are Heberden nodes?
Nodes at distal interphalangeal joint seen in joint degeneration of hands
32
What are Bouchard nodes?
Nodes at proximal interphalangeal joint seen in joint degeneration of hands
33
With joint degeneration, a patient might have ___ pain following ___ and relieved by ___
patient might have **deep achy** pain following **activity** and relieved by **rest**
34
When joint degeneration comes with pain, this is generally a sign of ___
significant joint destruction
35
What are some clinical manifestations of joint degeneration?
* Deep achy pain following activity and relieved by rest
* Short term stiffness in the morning or after inactivity
* Functional limitations in affected joints
36
What are some physical/functional limitations in joints affected by degeneration?
* Intra-articular loose bodies
* Large osteophytes
* Loss of congruity in joint surfaces
* Muscle contractures or decreased muscle mass
37
What are six radiographic findings in joint degeneration?
1. Non-uniform loss of joint space
2. Subchondral sclerosis
3. Osteophyte formation
4. Subchondral cysts
5. Chondral/osteochondral loose bodies (joint mice)
6. Subluxation
38
Disc degeneration is also known as ___
degenerative disc disease, discogenic spondylosis
39
What are two tissue based pathologies of disc degeneration?
* Spondylosis deformans
* Intervertebral osteochondrosis
40
Spondylosis deformans involves ___ degeneration of the disc
annular
41
Intervertebral osteochondrosis involves ___ degeneration of the disc
nuclear
42
How much disc space is lost with spondylosis deformans?
Minimal loss
43
How much disc space is lost with intervertebral osteochondrosis?
Prominent loss
44
How many osteophytes are expected in spondylosis deformans?
Prominent osteophytes
45
How many osteophytes are expected in intervertebral osteochondrosis?
Minimal osteophytes
46
In spondylosis deformans, there are ___ clefts
annular vacuum
47
In intervertebral osteochondrosis, there is ___ phenomenon
nuclear vacuum
48
What is chondromalacia?
Softening and breakdown of cartilage, a subcategory of joint degeneration
49
Chondromalacia commonly occurs after ___
long periods of immobility or inactivity
50
All synovial joint degeneration will have what effect on cartilage?
Cartilage softening
| chondromalacia
51
Who does chondromalacia patellae affect?
Younger population
52
What is a better diagnosis than chondromalacia patellae?
Patellofemoral pain syndrome
53
The following are clinical manifestations of which pathology?
* Dull, aching anterior knee pain and stiffness
* Grinding sensation with knee flexion
Chondromalacia patellae
54
What are the clinical manifestations of chondromalacia patellae?
* Dull, aching anterior knee pain and stiffness
* Grinding sensation with knee flexion
55
What increases symptoms of chondromalacia patellae?
* Going down stairs
* Running down hill
* Squatting
* Standing after periods of sitting
56
What are possible treatments for chondromalacia?
* Rest
* Alterations in exercise
* Adequate pre-exercise warming up and flexibility
* Weight loss
* Supportive devices
* NSAIDs
57
When the force or stress placed on a joint exceeds the ___, the joint may undergo deterioration of the articular cartilage
cartilage unit load
58
In the pathogenesis of joint degeneration, a fibrocartilaginous plug will begin to form when ___
damage crosses the tide mark
59
What is DISH?
Diffuse idiopathic skeletal hyperostosis aka Forestiere's disease (out-dated)
60
What is the etiology of DISH?
What is the general age range of patients with DISH?
Unknown etiology
Generally in patients over age of 50
61
How common is DISH in each sex?
Very common: 25% in men over 50; 15% of women over 50
62
What is the main concept of diffuse idiopathic skeletal hyperostosis (DISH)?
**Hypertrophy** and **ossification** of the **anterior longitudinal ligament**
63
If a patient has flowing hyperostosis of the anterior longitudinal ligament involving 4 or more adjacent segments, what condition do they have?
Diffuse idiopathic skeletal hyperostosis (DISH)
64
#DISH
What is an enthesis?
What is an enthesophyte?
**Enthesis**: insertion of tendon or ligament into bone
**Enthesophyte**: bone growth at the site enthesis
65
Up to 50% of patients with DISH will have ___
ossification of the **posterior longitudinal ligament**
66
The following are all pathologic features of which condition?
* Flowing hyperostosis of the ALL
* Extensive enthesophyte formation
* Additional ossification of the PLL
Diffuse idiopathic skeletal hyperostosis (DISH)
67
What are the pathologic features of DISH?
* Flowing hyperostosis of the ALL
* Extensive enthesophyte formation
* Additional ossification of the PLL
68
What are the clinical features of DISH?
* Can be clinically silent
* Can restrict AROM/PROM; full range to complete ankylosis
* Back/neck achy pain, stiffness
* Increased thoracic kyphosis
* Associated with insulin resistance/diabetes mellitus
69
What is the theory behind the association between insulin resistance/diabetes mellitus and DISH?
Pituitary dysfunction
70
#DISH
Ankylosis increases possibility of ___
spinal fracture
71
The following are all radiographic features of which pathology?
* Flowing ossification of ALL
* Lower thoracic spine predominantly affected
* Enthesopathy
Diffuse idiopathic skeletal hyperostosis (DISH)
72
How is DISH differentially diagnosed from seronegative spondyloarthropathies?
DISH has preservation of SI joint and facet joints
73
What are some areas DISH may cause enthesopathy besides the spine?
* Nuchal bones (nuchal ligament)
* Achilles and plantar enthesophytes
* Pelvic enthesophytes
74
50% of those with DISH have OPLL
Can OPLL be a stand alone condition?
Yes
75
Japanese spine disease is the old term for ___
ossification of the posterior longitudinal ligament (OPLL)
76
Which age group sees OPLL?
Those over 50 (degenerative condition)
77
What is the diagnostic criteria for DISH?
Must involve 4 or more adjacent segments
78
OPLL does not have to involve DISH (or ALL)
Does OPLL have to involve 4 segments?
No
79
If a patient has the following, what is their condition?
* Hyperostosis of the PLL
* Commonly in the cervical spine (can be any spinal region)
* Central canal stenosis
Ossification of the posterior longitudinal ligament (OPLL)
80
What are some pathologic features of OPLL?
* Idiopathic
* Hyperostosis of the PLL
* Most common in cervical spine (can be any spinal region)
* Central canal stenosis
81
What are some clinical features of OPLL?
* Can be clinically silent
* Back/neck achy pain, stiffness
* Can restrict AROM/PROM
* Symptoms of central canal stenosis
* Can lead to myelopathy
82
What is the treatment for OPLL?
Surgical decompression
83
DISH most commonly presents in ___ vertebrae
OPLL most commonly presents in ___ vertebrae
DISH: **lower thoracic**
OPLL: **cervical**
84
What are radiographic features of OPLL?
* Hyperostosis of the PLL (can be more than 5-8mm thick)
* Parallels the posterior vertebral body margin
* Most common in cervical spine (but can be anywhere)
85
Synoviochondrometaplasia is also known as ___
synovial osteochondromatosis, synovial chondromatosis
86
What is synoviochondrometaplasia?
Creation of osteochondral loose bodies inside the joint capsule
87
What is the condition that involves creation of osteochondral loose bodies inside the joint capsule?
Synoviochondrometaplasia
88
Which form of synoviochondrometaplasia is primary?
Which form is secondary?
Idiopathic = primary
Degenerative = secondary
89
What are pathologic features of primary (idiopathic) synoviochondrometaplasia affecting the synovium?
* Synovium undergoes metaplasia (forms exuberant synovial villi)
* Ends of villi form cartilage bodies (eventually can ossify and/or break free)
90
What are the pathologic features of secondary (degenerative) synoviochondrometaplasia?
| pathogenesis
* Degeneration results in cartilage flaking off
* Flakes of cartilage act as an accretion site and continue to grow (can eventually ossify)
91
What are some symptoms known as clinical features of synoviochondrometaplasia?
* Joint pain
* Swelling
* Crepitus
* Locking
92
What are some locations known as clinical features of synoviochondrometaplasia?
* Knee (70%)
* Hip
* Shoulder
* Elbow
* Ankle
* Wrist
93
What are the radiographic features of primary SCM?
* Loose bodies tend to have similar size and shape (only seen if ossified)
* None-mild degenerative change (early in disease)
* 1-100s of loose bodies
94
What are the radiographic features of secondary SCM?
* Loose bodies tend to have different size and shape (only seen if ossified)
* Pre-existing moderate to severe degenerative change
* 1-10 loose bodies
95
What is the treatment for primary SCM?
* Loose body resection
* Partial or complete synovectomy
96
What is the treatment for secondary SCM?
* Conservative management
* NSAIDs
* Arthroscopic removal of loose bodies
97
Charcot joint is an old term for which pathology?
Neuropathic arthropathy (NA)
98
What is neuropathic arthropathy?
Progressive joint destruction secondary to a neurological disorder
99
#NA
What are some examples of peripheral neuropathies?
* Diabetes mellitus
* Alcoholism
* Multiple sclerosis
* Charcot-Marie-tooth disease
100
#NA
What is an example of a central motor abnormality?
Neurosyphilis
101
Which neurological disorders may cause neuropathic arthropathy?
* Peripheral neuropathies
* Central motor abnormalities
* Syringomyelia
* Iatrogenic cases
102
Which joints are most commonly affected by neuropathic arthropathy?
Weight bearing joints:
* Lumbar spine
* Knee
* Foot/ankle
103
#NA
Which joints are most commonly affected by syringomyelia?
Shoulder and upper extremity joints
104
What are the two forms of neuropathic arthropathy?
Hypertrophic and atrophic
105
What is hypertrophic neuropathic arthropathy?
What accelerates this?
Rapid and severe form of secondary joint degeneration
Progressive articular and subchondral bone destruction is accelerated by absence of pain and proprioception
106
What is atrophic neuropathic arthropathy?
How does it appear?
Resorption of bone
Tapered bone ends, missing parts (atrophy of the bones)
107
Which gaits may present with neuropathic arthropathy?
Slapping or stomping
108
What are clinical manifestations of neuropathic arthropathy?
* Pain insensitivity
* Joint enlargement/swelling with warmth
* Crepitus
* Symptoms worsen over weeks, months, or years
* Bag of bone appearance
* Surgically amputated appearance
109
If a patient presents with the following, what pathology is present?
* Pain insensitivity
* Joint enlargement/swelling with warmth
* Painless insensitivity
* Crepitus
* Symptoms worsen over weeks, months, or years
* **Bag of bone appearance**
* Surgically amputated appearance
Neuropathic arthropathy
110
What are the 6 Ds (3 Di and 3 De) of hypertrophic NA radiographic presentation?
* Distension
* Dislocation
* Disorganization
* Density (subchondral sclerosing)
* Debris
* Destruction
111
How does atrophic NA present radiographically?
* Tapered distal margins of bones (licked candy stick appearance)
* Surgically amputated appearance
112
What is the most common cause of neuropathic arthropathy?
Diabetes mellitus
113
What is the most clinically significant component of synoviochondrometaplasia?
Loose bodies in joints
114
What is the clinical significance of OPLL?
May cause radiculopathy or compression of a nerve root
