Lecture 1Wednesday, May 14, 20089:31 AM Key to colors/notations

Green highlighted words and phrases represent definitionsYellow highlighted words and phrases represent things Dr. Kuhn emphasized or which seem key to learningA small pen to the left of something (typically a chart) indicates the information is important

Pre test

1. Provide a definition for CTA computerized imaging modality utilizing attenuating X-rays and simultaneous motion of the tube and scintillator to produce a 3-dimensional, variable slice, image of the part imaged

a. Examples of proper useTrauma situations, measurements of anatomical size, enhanced soft tissue resolution over plain film

b. Examples of weaknesses of the toolStarburst artifact of occipital bone, difficulty with imaging near metal implants, high radiation dose, doesn't demonstrate physiology

2. Provide a definition for MRiA computerized imaging modality utilizing induced precession and radio frequency output to produce a 3-dimensional, variable slice, image of the part imaged

a. Examples of proper useSoft tissue imaging, central canal imaging, neural imaging, skeletal survey for tumors, physiology

b. Examples of weaknesses of the toolClaustrophobia, metal implants, expenses, time of exposure

3. List several other imaging toolsDiagnostic ultrasoundBone scan (SPECT)MRAFMRiMyelogramTomogram

4. Define the following and give examples:a. Congenital anomaly=a lesion that an individual is born with

Straight back syndrome, Os Odontoidium (now thought as non-union fracture)b. Normal variant=a different than 'normal' presentation but with no clinical significancec. Dysplasia=congenital anomaly with multiple systems involved, typically has similar risk profile

5. What is the classification system used for soft tissue calcification  Physiological Dystrophic Metastatic

Serum calcium Normal Normal Abnormal (high)

Tissue calcium Normal Abnormal Normal

Examples Thyroid cartilageStylohyoid ligamentArcuate Foramen

Calcific tendonitisCalcific bursitisMyositis Officans

HyperparathyroidismLytic MetastasisMultiple Myeloma

  

Lecture 2Monday, May 19, 200810:16 AM Arthritis 4 categories of arthritis

Degenerative-DJDInflammatory-RAMetabolic-GoutSeptic joint/Septic arthritide

Terms

Enthesis= musculotendonous attachment of Sharpe's fibersMonoarticular=1 jointPolyarticular=4+ jointsPauciarticular=2-3 jointsOsteophyte=accessory boney growth adjacent to the joint (periarticular)Syndesmophyte=calcification of outer annular fibersSeronegative=no chemical marker within the blood

Poster children

Degenerative-DJD/OAClinical features

Local inflammation is presentMorning stiffness in affected jointsReduced range of motionSwelling of afflicted jointOsteophytic changeMonoarticularChanges in soft tissue contour

Lab findingsNo prominent findings (seronegative)No change in ESR (Eosinophil Sedimentation Rate)Biopsy abnormality

Thinner corticesLowered MMP (methylmetalo protease)Activation of cytokines (pathologic)]

Radiographic findingsDecreased joint space in asymmetric patter(medial worst) owing from decreased articular cartilageSubchondral sclerosis=whitening/thickening of cortical bone underneath articular cartilage

(due to increased stress input from decreased articular cartilage)OsteophytesGeode/subchondral cyst formation (can be synovial fluid or blood or both)

Most commonly seen in large joints (hips, knee, shoulders)Inflammatory-RA

System inflammation is presentMetabolic-GoutSeptic joint/Septic arthritide

  

Lecture 3Wednesday, May 21, 20089:19 AM Continued from last lecture DJD=gradual loss of articular cartilage, combined w/ thickening of the subchondral bone; bony outgrowths at the joint margins, and nonspecific synovial inflammation Poster children

Degenerative-DJD/OAClinical features

Local inflammation is presentMorning stiffness in affected jointsReduced range of motionSwelling of afflicted jointOsteophytic changeMonoarticularChanges in soft tissue contour

Lab findingsNo prominent findings (seronegative)No change in ESR (Eosinophil Sedimentation Rate)Biopsy abnormality

Thinner corticesLowered MMP (methylmetalo protease)Activation of cytokines (pathologic)]

Radiographic findingsDecreased joint space in asymmetric patter(medial worst) owing from decreased articular cartilageSubchondral sclerosis=whitening/thickening of cortical bone underneath articular cartilage

(due to increased stress input from decreased articular cartilage)OsteophytesGeode/subchondral cyst formation (can be synovial fluid or blood or both)

Most commonly seen in large joints (hips, knee, shoulders)

Inflammatory-Rheumatoid ArthritisClinical presentation

System inflammation is presentUlnar deviation of MP joints of handsDecreased and painful movementsLots of soft tissue swellingPolyarticular processAlso present in the C-spine, hips, knees, elbowsPannus formationDestruction of the soft tissue surfaces leading to ulnar deviationUsually bilateralSymmetrical joint space narrowing (w/in same joint)Don't mess with when flared up

RA Produces highest number of ankylosis in the handsALL Inflammatory arthritides present danger of ADI instabilityAnkylosis may produce lack of joint motion in all inflammatory arthritidesHyperemia (increased periarticular blood flow) may erode bone and produce osteopeniaLab findings

Positive rheumatoid factor (usually present)Increased ESRC-reactive protein

Radiographic findingsUlnar deviation1st thing seen: Decreased joint space (symmetrically)Swelling of MP, PIP joints (Bouchard's nodes)No swelling of DIP!!!Periarticular soft tissue swellingPeriarticular osteoporosis Rat bite lesions (produced by pressure erosion and pannus formation)

Metabolic-Gout (will be CPPD)Clinical presentation

Older men predominantlyPredominance of the heels, big toe, thumbAbnormal soft tissue (sticking out), pannusChanges made to the underlying boneNo initial changes in joint spacing/bone makeupPain and redness in area of swelling

Lab findingsTissue/suction biopsyIncreased ESRBlood/urine may be normal or abnormal

Radiographic findingsNo bone changes seen but adjacent soft tissue may calcify (dystrophic)

Septic joint/Septic arthritide

Clinical presentationLots of swelling/painIf younger person they got sick quicklyIf older person they took a while to developDestruction of both joint surfaces will occur in chronic conditionsHot, red, swollen, tender jointsPrevious URTI, recent UTI, or recent skin infection

Lab findingsWBC elevationESR elevation when large joints are involved

Core of ESR measures stability of blood poolIf sampled infectious organism may be present

Radiographic findingsSymmetrical destruction of joint spaceCortical damage

Watch what separates from arthritide Degenerative category

DJD=gradual loss of articular cartilage, combined w/ thickening of the subchondral bone; bony outgrowths at the joint margins, and nonspecific synovial inflammation

GeneralsMost common joint disorder in the worldStriking age correlation

1/3 of all 65 year olds affectedMore common in men vs women younger than 50 (post traumatic/wear and tear)More common in women vs men older than 50 (hormonal changes)

Predilection for weight bearing joins of the lower extremity, cervical and lumbar spine, and some joints of the hand

EtiologyKnown local factors associated with secondary DJD

WeightInjury

OccupationalRecreational

Skeletal anomaliesQuadriceps strengthKnown systemic factors

Reduction in estrogen levelsGenetic susceptibilityLow vitamin D and C intake

Crystal deposition diseasesHemophiliaPaget'sMost sero - and sero + arthritides

Stages (3)Phase I: Edema and microcracks (enchondral tissue)

Edema of the extracellular matrix, cartilage loses its smooth aspect, and microcracks appearThere is focal loss of chondrocytes, alternating with areas of chondrocytes proliferation

Phase II: Fissuring and pittingThe microcracks deepen in the direction of the forces of tangential cutting and along fibrils of collagenClusters of chondrocytes appear around these clefts and at the surface

Phase III: ErosionFissures cause fragmentation of cartilage to detachThese loose fragments cause the local inflammationThis form of inflammation is much more limited than the typical RASubchondral microcysts form (may develop into geodes later)

PathogenesisThe physiologic homeostasis of normal articular cartilage is driven by chondrocytes, which synthesize collagens, proteoglycans, and proteinasesDJD results from failure by chondrocytes to synthesize good quality matrixThis abnormal chondrocytes synthesis is the result of tissue activation by cytokines, lipid mediators (mainly prostaglandins) free radicals (NO, H2O2) and constituents of the matrix itself, such as fibronectin fragmentsActivated chondrocytes become capable of producing proinflammatory mediators Certain proteinases are involved in the destruction of cartilage

Matrix metalloprotienases (MMPs) are the most potentThe MMPs are held in check by Tissue Inhibitor MetalloProteinases (TIMPs)As long as the MMPs and TIMPs are in balance no degradation occursThe enzyme, aggrecanase, plays a major role in the degradation of the matrix

Although DJD is classified as non-inflammatory arthritis, inflammatory cytokines may stimulate chondrocytes to release cartilage-degrading enzymesLipid mediators, eicosanoids, can activate chondrocytes to increase synthesis of MMPs ,tipping the balance towards degradation Nitric Oxide plays an uncertain role in DJD

Some studies suggest an ability to induce "DJD, while other studies suggest some protection of the cartilage"

Degenerative

Inflammatory-RA

Metabolic-Gout

Septic

DJD

  Lecture 4Wednesday, May 28, 20089:14 AM Frequency of Arthritis on radiographs (how often you will see stuff on films)

Weekly Monthly Yearly

DJD Ankylosing spondylitisCPPDDISHOsteitis Condensans Ilii (OCI)Psoriatic arthritisRASynoviochondrometaplasia

Gout infectionLupusReiter's syndromeScleroderma

Age of onset Arthritis

0-20 years 20-40 year old 40+ years

JRA (Juvenile Rheumatoid Arthritis)/JCA (Juvenile Chronic Arthritis)May be seropositive or seronegative

Ankylosing spondylitisOsteitis Condensans Ilii (OCI)LupusReiter's syndrome/Reactive arthritisPsoriatic arthritisSclerodermaSynoviochondrometaplasia

DJDDISHGoutHypertrophic osteoarthropathyPseudogout (CPPD)

Arthopathies associated with distinct sex predilection

Male Female

Ankylosing spondylitisGoutHypertrophic osteoarthropathyReiter's syndrome/Reactive arthritisSecondary OA

JRA/JCALupusOCIPrimary OARheumatoid ArthritisScleroderma

Reminders of Categories of joints

FibrousStressed Syndesmosis found in Running sports, martial arts, springboard divers

Cartilage joint (disc)Not compartmentalized like always depictedDiscogram does show NP in disc

Synovial jointsVariety of arthritides

FIBROUS CARTILAGINOUS SYNOVIAL

Cranial suturesSyndesmosis (tib/fib, radius/ulna)

Symphysis pubisIVDSternal Angle of LewisSternoclavicularAcromioclavicularJoint Capsules

FingersToesKneesHipsApophyseal jointsSI joints

DJD

Predominates in the spine and in large weight bearing jointsIncomplete understanding of DJDAppears to be an end pointNeed to de-emphasize the -itis (as in arthritis)Local inflammatory reactions Film: Lower Cervical AP

Common radiographic findingsDecreased disc spaceSubchondral sclerosis should be seen

Sharpening/thickening of uncovertebral joints (1st stage of degenerative stage of Uncovertebral Arthrosis)Remodeling of lateral margin due to altered alignment

Film: Oblique Cervical

Common radiographic findingsShows anterior-lateral osteophytesWatch for

Abnormal IVF (oval with concave edges)Uncovertebral encroachment

Positioning is very important (may appear to have smaller IVFs but may not)

Film: Lateral CervicalCommon radiographic findings

Look at disc spacing (should be even posterior and anterior)Watch posterior elements for sclerosis/thickeningExamine the anterior body and posterior elements for osteophytes

Pt asks "How did my neck get like that?"

Improper wear and tearThe body's process of stabilization of a joint not moving/functioning properly Couch potato story

Large group of patients split in half (homogenized except for activity level)People that are less active get more DJD and wear faster than active group

Rat StudyGenetically identical rats at different agesOlder versions have synovial fluid removed and stuck into younger versionsControls and young versions dissected and experimental rats had local subchondral sclerosis and osteophyte growth after short periods of time

Film: Lower CervicalTypically not symmetricalThis particular film shows uncovertebral hypertrophy (previous "T-bone" style accident)

Film: Proton Density MR imagePosterior vertebral bodies have osteophytic growths

Film: CT Bone window

Shows osteophytes in posterolateral margin of the vertebral bodyFilm: Lateral Cervical

Routinely we will see major changes and alterations in osteophytic growth and/or alterations in lordosis/motion planes

Film: Lateral ThoracicTrue retrolisthesisFacet degeneration definitely presentLoss of disc spaceHuge osteophytesLimited segmental motion

Film: AP LumbarMassive osteophytes on left connecting L5-S1 on leftNone to little segmental motion (can't claim fusion unless we see trabecular fibers bridging the former joint space)May have hook shaped osteophytes between segments

Film: Lateral LumbarVacuum phenomenon=tearing of annular fibers leading to opening of space and pulling of gas out of solution after the NP dissolvesVacuum cleft=marginal disruption of outer annular fibers (may be trauma related or related to degenerative changes)

Hahn's fissure=midline artery supply and vein drain for vertebral body (shows up on MR)Lower Cervical AP (DJD)

Oblique Cervical (DJD)

Lateral Cervical (DJD)

 

Proton Density MR vs T1 MR (DJD)

Lateral Thoracic (DJD)

AP Lumbar (DJD)

Vacuum Cleft

Lecture 5Monday, June 02, 200810:16 AM DJD

SpondylolisthesisAnterolisthesis

Spondylolysis=fracture acting as causative agent for anterolisthesisSpect or MR scans become indicated if modified Stork Test is positive (localizes pain to one area)

Stork Test/Modified Stork Test=Gillet's TestFacet degeneration=alternative causative agent for anterolisthesisOblique film will allow classification easily (check for pars break)Examine the cortical lines to evaluate for fractureSubchondral sclerosis will compromise the joint space

Film: CT Myelogram-demonstrating neuritis (shown in class)

Shows bone window but cord appears as white dot and cauda equina appears as black dot w/ white border (nerve root inflammation will appear as blurriness)The nerve root sitting against a facet osteophyte is the likely cause of the neuritis (nerve root inflammation) and would benefit quite nicely from adjustment

Film: Plain film showing L-T scoliosisOnly able to offer relief careDo not try to correct the curve because it isn't going anywhere (in DJD patients)Wolf's law and other models show this to be the case

Special featuresDirectly posterior jetting of annular fibers of disc

Herniation=NP stays connected to AF but pushes out on Annulus FibrosusSequestration=a free floating fragment of NP not attached to Annulus Fibrosus

Hemispherical Spondylosclerosis=half circle of lucency at anterior margin of vertebral bodyShows the body's response to the increase in anterior stressMost commonly seen on lateral view

SI DJDWill have consistent cortical margin vs a tumor which would not

Sacro-Coccygeal jointDJD may show up here as well

DISH=Diffuse Idiopathic SkeletalHyperostosis

May occur at same time as DJD

Anterolisthesis (DJD)

CT Myelogram Bone window-not showing neuritis!

L-T Scoliosis (DJD)

What comes up when Google Image Searching Hemispherical Spondylosclerosis?

Dr. Kettner and nothing else! Lecture 6Wednesday, June 04, 20089:17 AM DJD Film: AP Shoulder plain film

Typically onset is predicated by trauma and related irregular contour (thru avascular necrosis or frank damage)Acromio-humeral space is supposed to be non-articular (but supraspinatus lives here)

Point of opposition of rotator cuff group and deltoidPrior avascular necrosis plays an important role in progression (person will feel better prior to actual bone remodeling) Ball and socket joints (especially hip) socket joint surface shapes the 'ball' surfaceIncremental loading is better than jumping up and walking after non load bearing period of recoveryIf person is less than 60 years old and has DJD present then you can't assume 'normal use' was the cause

Film: CT of chest showing Sternoclavicular DJD

May project over lung on plain film

Film: plain film AP PelvisHip is #1 site of DJD in weight bearing jointsKnee is #2 site of DJD in weight bearing jointsDecreased joint spaceSubchondral sclerosisOsteophytic change occurs after the decreased joint spaceSubchondral cyst is more likely to be seen in the acetabulum than the femoral headFrog leg view may show more osteophytes that are not available on the AP viewOsteophytes may appear as a single hook but because we are only seeing along one angle we may actually be viewing a rounded ridge

Film: Lateral Knee plain filmMay show exaggerated superior pole of patella (owing from increased traction forces)Dystrophic calcification w/in patellar bursa, calcific bursitis (not shown but would be in the superior tendon of the patella)

Film: Tunnel viewMay show wasting of the tibial eminence (which could lead to lateral translation during ambulation)May have bones appearing osteopenic

Film: Sunrise viewHook (osteophyte) may encroach upon cartilage surfacesDystrophic calcific tendonitis may involve calcification of Sharpe's fibers leading to an irregular border of the anterior surface of the patella

DISH=Diffuse Idiopathic Skeletal Hyperostosis (aka Forestier's Disease)If present in the Cervical spine may present w/ difficulty swallowing

Dysphasia occurs in 1/5 of those w/ DISHWhile there is calcification of the ALL it doesn't always alter ROMHypertrophy does not become a problem unless the PLL is involved40% incidence of co-presence of Diabetes Mellitus patients4 continuous segments with smooth and flowing ligamentous hypertrophy and ossification required for DISH diagnosisWill not get a cavitation (adjusting will feel boggy)Predominates T6-11, mid cervicals to CT junction, L3-S1

Film: Cervical Lateral plain filmMajor hypertrophy and calcification of the ALLDisc space remains preservedNo subchondral sclerosis present

Flam shaped SyndesmophyteHas 3 differentials

DISH (Dx by eliminating other disorders)Twin pair=different conditions but look THE SAME on film

Reactive arthritis (Reiter's)Psoriatic arthropathy (must have psoriasis lesions)

Reiter's disease pneumonicCan't see=ConjunctivitisCan 't pee=UrethritisCan't dance w/ me

Osteophyte on calcaneus (lover's heel)Polyarticular arthritisFluid filled pustules on soles of feet

Beuboitis/balanitis=inflammation of glans penis (a classical feature of Reiter's)

Types of osteophytes/Diff Dx

Osteophyte Features Disorder/Diff Dx

Claw osteophytes Associated w/ disc degeneration DJD

Traction spurs Parallel endplate DJD

Flowing exuberant ossification

Along ALL, PLL DISH

Syndesmophytes Ossification of the annulus fibrosus. Pencil thin Paravertebral ossification (Marginal)

Ankylosing spondylitis, Enteropathic arthritis

Paravertebral ossification

Ossification of connective tissue separated from edge of the vertebral body (C shaped, comma shaped, stuck on, non marginal)

Reiter's Syndrome, Psoriatic Arthropathy

AP Shoulder plain film

CT Sternoclavicular DJD

AP Pelvis plain film

Lateral Knee plain film

Cervical Lateral plain film

Lecture 7Monday, June 09, 200810:15 AM 

DISHDiff Dx tree (MUCHO IMPORTANO!!!)

Osteophyte?Yes->

Hands?Yes->Erosive Arthritis (Gullwing deformity DIP/PIP)No->DJD. Now claw or traction?

No->Flowing/exuberant->DISHConform to ALL pathway->DISHMaintenance of disc space->DISH Pencil thin marginal->Enteropathic Arthritis (GI issues w/ spinal arthopathies as a secondary component) or Ankylosing Spondylitis

GI Issues?Yes->Enteropathic ArthritisNo->Ankylosing Spondylitis

C-shaped non marginal->Reiter's, psoriatic arthropathy

Skin Lesions (past/present)?Yes->PsoriaticNo->Reiter's

Urethritis, Conjunctivitis, Polyarthritis?Yes->Reiter'sNo->Psoriatic

Flamed shape Syndesmophyte->DISH, Psoriatic, or Reiter'sHLA 8 may be elevated in some DISH patients

Half of DISH patients may have PLL thickening (C and T spine predominate) with some portion having calcification of the PLL also

Discogenic spondylosis (aka spondylosis)=DJD of the spineCheck Sign=visible sign of endplate fracture (looks like V entering into the vertebra from above)

Calcification of ligaments may also show up more in DISH patients

Film: Bone Window CT of C-spineSoft tissue window of CT of C-spineShowing ossification of PLL and the location of the cord is alteredA surgeon should be consulted if the cord is impacted by the PLL hypertrophy

Erosive Osteoarthritis (EOA)=inflammatory variant of DJD involving the IP joints of the handsSometimes thought like an RA presentation (but not)Typically B/L presentationSwelling of the digits (DIP/PIP)Classically a hand disease w/ priority given to the DIP (Distal InterPhalangeal joints)Gullwing Deformity=classic sign of EOA where a down sweep and up sweep down sweep appears across the DIPs1st metacarpal-carpal joint is decreased w/ osteophytic growth (just like DJD) is not needed to confirm diagnosis but will aid as a sign (2nd most common finding)

PLL HypertrophyPlain Film (DISH)

CT Bone Window (DISH)PLL hypertrophy/ossification

Erosive Osteoarthritis (Gullwing Deformity)

Lecture 8Wednesday, June 11, 20089:14 AM Table 10.24 diagnostic criteria for RA

Physical1. Morning stiffness2. Pain on motion or tenderness in at least 1 joint3. Soft tissue swelling or joint effusion in at least 1 joint4. Swelling of at least 1 other joint (w/in 3 months)5. Bilateral, symmetrical, and simultaneous joint swelling (except DIP)6. Subcutaneous nodules-boney protuberances (extensor surfaces), justaarticular

Laboratory7. Positive sheep agglutination test (Rh Factor)8. Poor mucin precipitate from synovial fluid (have to aspirate from joint)9. Synovium-at least three of (have to open joint to perform)

a. Marked villous hypertrophyb. Superficial synovial cell proliferationc. Marked inflammatory cell infiltrate fibrin depositiond. Foci of cell necrosis

10. Nodules-granulomas with central necrosis, proliferated fixed cells, peripheral fibrosis, and chronic inflammatory cell infiltrate

11. Typical changes-uniform joint space loss, marginal erosions, etc. (radiographic)Classification

Classic >7 criteria (w/ swelling for > 6 months)Definite >5 criteria (w/ continuous joint symptoms >6 weeks)Probable >3 criteria (w/ continuous joint symptoms) (4-6 weeks)Possible at least 2 of stiffness, pain, welling, nodules, elevated ESR or CRP, or iritis, with joint symptoms for at least 3 weeks

Drawings of joints

Early pathologic change includes proliferation of pannusBone erosion is a later change (predominately occurring at 'bare area' distal to joint but near the articular cartilage)

Table 10.26 pathologic-radiologic correlation in RA

Pathologic features (physical stuff) Radiologic features (seen on film)

Synovial edema and effusion Periarticular soft tissue swelling

Rheumatoid nodule Subcutaneous soft tissue mass

Cartilage destruction by pannus Uniform loss of joint space

Pannus eroding in the "bare area" Marginal erosion

Intra-osseous pannus and synovial fluid intrusions Subchondral bone cysts

Inflammatory hyperemia Juxta-articular osteoporosis

Periostitis Juxta-articular periosteal new bone (linear)

Fibrous tissue metaplasia Ankylosis

Capsule and ligamentous laxity, tendon rupture Deformity

Film: Left hand showing RA hand with cylastic implant (appears like soft tissue mass)

Implant requires 8-10 hours to applyImplant appears w/ soft tissue contrast and level

Film: B/l hands showing MCP joint and Carpal coalitionCarpal coalition=fusion of the carpal bones (ankylosis)Pencil in cup appearance=head of metacarpal gets thinned and pushes into the phalanx

Film: lateral cervical spine (zoomed to atlantodental interspace)1/5 of all RA patients develop ADI instabilityPannus formation and granulation tissue decreases the integrity of the Cruciate ligamentSafe to x-ray yearly to check progressMay actively translate during flexion/extension views

LHermitte's sign=electric shocks down both arms (think central canal stenosis)If patient has this then do NOT manipulate

Film: AP pelvisBilateral involvement at the acetabulum (symmetric involvement)

Left femur head representing Protrusio Acetabuli (no teardrop space)Both spaces show no joint spaceDecreased bone density is seen alsoCan't be DJD because it is B/l symmetrical and there are NO osteophytes present

Film: B/l kneesSymmetrical decreased joint space seen on both lateral and medial surfacesReduced cortical space (almost 0) vs medullary portion

Film: lateral knee Arthrogram

Contrast has leaked into Baker's CystBaker's Cyst=represents defect in the capsule allowing herniation of synovial lining beyond its normal chamber (usually contains synovial fluid). Commonly seen w/ RA but may be caused by other conditions

Film: PA chestPleural Interstitial fibrosis-associated finding w/ RA due to it being a systemic condition

Film: Left hand showing ulnar deviation (RA)

Carpal Coalition (RA)

Film: lateral cervical spine (increased ADI)

AP Pelvis (RA)

Baker's Cyst (RA)Lateral Knee Plain film

Lecture 9Monday, June 16, 200810:14 AM Juvenile Chronic Arthritis

Formerly Juvenile Rheumatoid ArthritisFilm: Lateral Cervical

Fusion of posterior elements w/ no facet joint seen b/t 2,3,4Anomalous IVFs (shouldn't be seen here)Thin/tall vertebral bodiesADI instability presentDx: sero + JCA

Inflammatory arthritides most common type to produce ankylosisPremature maturation=early closure of the growth platesTypical cutoff age is 14 y/o but may occur as late as 20 y/oFilm: bilateral AP foot view

Dx: Seronegative JCA (Still's disease)Bilateral but not symmetrical

Always do flexion/extension views on JCA patients to document stability/instabilityFilm: AP Pelvis

Joint replacement of hip on right side w/ slipped capitis femoral epiphysis on leftEnlarged obturator foramen bilaterally due to reduced growth inferior and superior pubic rami

Film: 2 views of left handShowing severe ulnar deviationDegradation of carpals is nearly complete w/ no spacing seenDx: seronegative JCAPencil in a cup appearance of metacarpals and proximal end of phalanx

Ankylosing SpondylitisRailroad track sign=Vertically oriented white lines overlying the pedicle area

Ossification of interpedicle ligaments and ligamentum flavumPencil thin ossification of outer annular fibersGhost joint=No spacing seen of the SI joint (but present on CT)Disuse osteoporosis of vertebral bodies leading to carrying of weight on calcified soft tissuesAssociated w/ HLA-B27 genetic profileFilm: AP Pelvis

Dagger Sign=ossification of interspinous and supraspinatus ligamentSI joints are visualized better but with greater degree of osteoporosis

Progression typicallySITLLumbarCTThoracicCervicals

Equal distribution in men and womenMore prone to fracture (also in unusual locations)

Midvertebral fractureDisc space fracture

Carrot stick fracture=unusual fracture seen in Ankylosing SpondylitisVery common to see dystrophic calcification of ligamentsSyndesmophyte=Calcification of outer annular fibers

Will end up carrying the weight instead of the bodies/posterior elements

Dagger Sign

AP Pelvis w/ replaced right femoral head (JCA)

Slipped Femoral Capitis Epiphysis (JCA)

Ankylosing Spondylitis

Railroad Track Sign

 

Ghost Joint

Lecture 10Wednesday, June 18, 20089:20 AM Ankylosing Spondylitis

Trolley Track Sign=a combination of Railroad sign and Dagger SignStar Sign=pattern made by ossification of soft tissues at top of SI joint in AS#1 cause of death in AS=SuicideDisc ballooning=unrestricted imbibition of NP w/ water increasing its dimension (leading to weakening of cortical margin of vertebral body and deep depressions into the vertebral body possibly both superior and inferior)

May lead to disc calcificationDisc calcification=dystrophic calcification of the disc starting w/ the outer annular fibersIn patients w/ involvement of any sort flexion/extension views are needed to rule in ADI stabilityOrder of progression of AS

Romanus lesion=next step after sacroiliits (then shiny corner sign consisting of focal sclerosis)Shiny corner sign (Romanus lesion)=vertebral body “squaring” with anterior vertebral body corner reactive Osteitis seen on lateral radiographs

Bridging syndesmophyte (calcification of outer annular fibers)Classic presentation

B/l sacroiliitsTL junction40% more problematic inflammatory bowel diseaseHLA B27 from lab testsIf no HLA B27 then check ESR (for Enteropathic Arthritis)

Psoriatic ArthritisPictures of surface lesions of psoriasis10-30% of those with surface lesions will get joint problemsProduces highest percentage of ankylosis in handsFilm: B/l hands

Pencil in cup deformity seen

DIP joint is affected=Psoriatic ArthritisCarpal coalition presentWill be SeronegativeBilateral and symmetrical=inflammatoryMutilatingDistribution (complete=Ray's Sign)Ray's Sign=complete distribution to all 5 rays (fingers)

Tends to produce normal densityGreater mutilating ability than RA

Greater percentage will have ankylosisIf present in hands (or other small joints) Reiter's must be left outPreservation of bone density (vs RA which does not preserve bone density)Degree of involvement of surface lesions on body does not correlate w/ psoriatic arthropathy100% of people w/ psoriatic arthropathy does have history of skin lesionsMay produce sacroilitis Film: AP Pelvis

Right Femur has moved superior thru softened bonePubic symphysis is bridged along superior portion

Film: Lumbar AP viewStuck on, non-marginal density seen

Radiologic changes in the SI joints w/ Ankylosing spondylitisGeneral

Bilateral, symmetricIliac side is more extensively involvedInitially involves lower 2/3 of joint

Early "sacroiliitis"Articular erosions (Rosary bead)Diminished joint spaceLoss of articular cortex definition (pseudowidening)Patchy reactive sclerosisSubchondral osteoporosis

LateBony ankylosisGeneralized osteoporosis-disappearance of reactive sclerosis"Ghost" joint margin"Star" sign

Reactive Arthritis (formerly Reiter's Syndrome)

Produces pustule like surface lesions on the soles of the feet or palms of the handsWill be different types of lesion than psoriasis

Spine and big jointsUrethritis, conjunctivitis, balanitis, calcaneal spur (also at Achilles' insertion spur)Will have non-osteophyte

No disc problemNon C-shaped but marginal

Film: AP pelvisPubic symphysis narrowed w/ adjacent osteophyte like boneErosion of inferior margin of pubic bones

Table from Yochum and RoweRadiologic Diff Dx of SI disease

Disease Bilateral symmetric Bilateral asymmetric Uni-lateral

Ankylosing Spondylitis +++ + (early) +(early)

DISH + (upper joint)  

Enteropathic sacroilitis +++    

Gouty arthritis + + +

Hyperparathyroidism +++    

Infection     +++

Osteitis Condensans ilii (Pregnant female)

+++ + +

Osteoarthritis (DJD)   + +++

Psoriatic spondylitis + +++ ++

Reiter's Syndrome ++ ++ +++

Rheumatoid arthritis   + +++

SI Disease Diff Dx

Bilateral SymmetricalAnkylosing Spondylitis

Increasing stiffness w/ agingDagger SignRailroad/Trolley signStar signOsteopenia of vertebral bodiesBridging syndesmophytes

Enteropathic Arthritis

GI disturbances (past/present)Hyperparathyroidism

Low levels of Parathormone in circulationOsteopenia

Osteitis Condensans IliiPost-multi parity female

Bilateral AsymmetricalPsoriatic Arthritis

Focal/global skin lesions (past/present)Unilateral

DJDOsteophytesSubchondral sclerosisSubchondral cystsAsymmetrical (across joint) space lossAsymmetrical distributionSero -

Reiter'sConjunctivitisUrethritisCalcaneal spur

Often asymptomaticSero -

RheumatoidSero +Likely hand involvement Uniform joint space lossMorning stiffnessPannus formationLots of soft tissue swelling

InfectionInfective agent within joint capsule

Ankylosing spondylitisDagger Sign

Star Sign

Shiny Corner Sign

 B/L hand view w/ Psoriatic Arthritis

Reactive Arthritis

 Lecture 11Monday, June 23, 200810:18 AMTable 10.53 Diff Dx of Psoriatic arthritis

Feature Psoriatic Arthritis Reiter's Syndrome Rheumatoid Arthritis Ankylosing Spondylitis

Distribution

Upper extremity hand +++DIP/PIP

--

+++MCP/Wrist

+

Lower extremity +++ +++ +++ -

SI ++ ++ + +++

B/l ++ ++ (asymmetric) + +++

U/l ++ +++ +++ +

Spine ++ + +++ (cervical) +++

Key Signs

Osteoporosis   + +++ +++

Joint space +++ (widening) + (narrowing) +++ (narrowing) ++ (narrowing)

Ankylosis ++ - + +++

Periostitis +++ (fluffy) +++ (fluffy) + (linear) +++ (fluffy)

Tuft resorption +++ - - -

Soft tissue swelling ++ ++ +++ +

Laboratory

ESR + ++ +++ +++

RA Factor   - +++ -

HLA-B27 60% 75% 8% (normal) 90%

ScaleRare -Occurs +

More common++Very common +++

Dystrophic calcificationCalcific tendonitis/HADD (Hydroxy-Apatite Deposition Disease)

Film: AP and oblique foot (unilateral)Concretion of Peroneus longus tendon (dystrophic calcification)Will occur due to change in pH and may lead to spontaneous ruptureLikely suffered several inversion injuriesLooks similar to Os Peronei but won't be palpableComposed of HADTx: ultrasound

Film: AP ShoulderShowing calcific tendonitis of the supraspinatus where it attaches to the greater tubercle of the humerusChanges in pH due to blood-flow changes w/in the bursa cause precipitation to occur

Metabolic arthritide Gout

Tophi=uric acid crystal accumulation on the pinna of the earSodium monourate=uric acid crystalsBig toe is major spot where Gout shows upBone changes created due to pannus formation began under deposition of uric acid crystalsOverhang sign=overhanging of one bone upon an adjacent boneTypically not seen on radiographs now due to early treatment

Calcific Tendonitis (Shoulder)

Tophi of ear (Gout)

Overhang sign

Lecture 12Wednesday, June 25, 20089:18 AM Continuing metabolic arthritide

GoutMetabolic arthritideAberration of purine pathway->uremia->(Uric acid crystal deposition)Transient processDeposition occurs in smaller vessels w/ slower flowBreak in lesion=classic radiographic sign of Gout producing Overhang SignAvascular necrosis due to blood vessel impactionNot a tremendous risk to the kidneysFilm: B/l foot AP film

Overhang sign presentMucho soft tissue swelling (may make you think infection)

Film: B/l hand AP filmLots of small depositions in the phalangesDystrophic soft tissue calcificationTophaceous Gout=metabolic arthritic disorder producing soft tissue calcification after uric acid deposition

No organizationFilm: Lateral knee

Lucency seen in proximal tibial shaftInitial Diff Dx: cyst, enchondroma, Giant Cell tumorCT of same patient shows very sclerotic margin (slow onset)Biopsy shows uric acid crystalsDx: Intraosseous Gout

CPPD (Calcium PyroPhosphate Dihydrate Deposition)Will likely become the poster-child for metabolic disorders later Joint space is NOT blackSome Calcium pyrophosphate deposition in the joint spaceFilm: AP knee

Lines or triangles seen b/t articular cartilagesFilm: AP shoulder

What appears to be thickened cortical margin but upon closer inspection is not connected to cortical margin

Homogentisic acid (aka: Alkaptonuria/ochronosis)Dermatology Slide: Ear

Darkening skin in superior pinna of earDarkened skin on cheekBlackening due to oxidized homogentisic acid

Pt is missing enzyme: homogentisic acid oxidaseTakes long time to develop in the body (genetic disorder)Onset around age 30Lab finding: urine will turn black if left exposed to airNo osteophytes normal corticesNo bony hypertrophy, no subchondral sclerosisFilm: AP lumbar

Multi-level degeneration and major sclerosis (S1-L4)DJD in wrong age and wrong distribution

Film: Lateral ThoracicNormal cortices but calcification of disc spaces

HADD (Calcific tendonitis)Film: AP and oblique foot (unilateral)

Concretion of Peroneus longus tendon Dystrophic calcification=occurs due to change in pH and may lead to spontaneous ruptureLikely suffered several inversion injuriesLooks similar to Os Peronei but won't be palpableComposed of HADD (Hydroxy-Apatite Deposition Disease)Tx: ultrasound

Film: AP ShoulderShowing calcific tendonitis of the supraspinatus where it attaches to the greater tubercle of the humerusChanges in pH due to blood-flow changes w/in the bursa

OCI (Osteitis Condensans Ilii)

10:1 Women: menBrought on by multiple full term pregnanciesBright triangle of sclerosis along iliac margin of SI jointFilm: AP Pelvis

Classic bright triangle of sclerosis in ilii Hypertrophic Pulmonary OsteoArthropathy (HPOA)

Looking at the trabecular bone, then cortico-trabecular interaction, cortical bone then we see some of the periosteal tissue (periosteal reaction)Typically due to either reduction of lung function or metastatic bone disease Solid periosteal reaction is presentIf no lung disease present HOA (Hypertrophic OsteoArthropathy)is presentClubbing will be present

MiscScleroderma

CREST SyndromeCalcinosis (calcium deposits, usually on fingers)Raynaud phenomenon (Red, White, Blue fingers)Esophageal dysmotility (inability to swallow)Sclerodactyly (tapering deformity of bones, seen on X-ray)Telangiectasia (red spots seen on fingers/mouth)

Difficulty protruding tongue

Difficulty opening mouthTruncated=retraction of skin at fingertipsReduction of blood flow to and from the distal extremities due to aberrant connective tissue depositionAcroosteolysis=consumption of distal portion bones w/in extremities

Systemic Lupus Erythematosus (SLE)Changes soft tissues not boneSmall joint diseaseAppears like RA but pt will be able to flatten hand to film (Reversible Subluxation)

Break in=something breaking into the bone (pannus). Will carry a solid cortical marginOsteopoikilosis=polka dots w/in boneSynoviochondrometaplasia=metaplasia of synovial cells into cartilage (and later bone) within the joint capsule but outside the cortical bone

Typically affects only 1 joint at a timeAppears as polka dots (joint mice) outside the cortical bone and within the synovial capsuleIntracapsular and extra corticalJoint will 'lock' (due to 'joint mice)Tunnel view is best to view joint miceLoose chondral bodies w/in joint at to predispose to DJDPressure erosion of nearby bones may occur (may produce Apple Core Deformity)

Dystrophic calcification of the glenoid labrumPigmented Villonodular Synovitis=villous tissue hypertrophies to produce synovial fluid they attract hemosiderin

Apple Core Deformity=pressure erosion of bone Break In Lesion (Gout)

Tophaceous Gout

CPPD AP Knee

Alkaptonuria

 

 

 HADD (Calcific Tendonitis)

Osteitis Condensans Ilii

Hypertrophic Pulmonary OsteoArthropathy

Scleroderma

Systemic Lupus Erythematous (SLE)

Osteopoikilosis

Synoviochondrometaplasia

Pigmented Villonodular Synovitis

 Lecture 13Monday, June 30, 200810:17 AM Arthritides of the Axial and Appendicular SkeletonDr. Bonic DC RT® 25 cases w/ arthritides then normal w/ abnormal Case 1

DISHDish space/Z joint preservedExuberant hyperostosis on 4 continuous levelsPLL may ossify

Case 2

RhAADI enlarged (3 mm+)Disruption of spinolaminar lineOsteopeniaB/l symmetricalTypically shows

Uniform joint space narrowingMarginal erosionsDeformitiesAtlantodental instabilityProtrusio acetabuliOsteopeniaRotator cuff tears

Case 3DJD

IVD narrowingOsteophytesUncovertebral and Z joint arthrosis/sclerosis (may narrow IVF)

Case 4JRA

Atlantodental instabilityApophyseal ankylosisHypoplasia of vertebral bodies and discsOsteopenia

Case 5Ossification of PLL (DISH)

May compromise spinal canalCase 6

Ankylosing SpondylitisThin, marginal syndesmophyteAnkylosis of apophyseal jointsDecreased lordosis and marked anterior head carriage often seenADI instability likelyCarrot stick pathologic fracturesSpinous process erosion

Case 7Infectious discitis

Widened retropharyngeal and retrotracheal soft tissuesCortical destructionIVD narrowing

Case 8Ankylosing spondylitis

Thin, marginal syndesmophytes'Bamboo spine''Trolley track spine'IVD calcificationDagger sign=interspinous calcification

Case 9Reiter's

Non-marginal syndesmophytesCan't pee, can't see, can't climb a treePolyarthritis

Lover's heel

Non marginal syndesmophytesB/l sacroiliitis

UrethritisConjunctivitis

Case 10Apophyseal Joint Arthrosis

Hypertrophy and arthrosis of Z-jointsMay change in pedicle-facet angle leading to non Lytic/fracture Spondylolisthesis

Case 11Discogenic spondylosis (DJD)

IVD narrowingOsteophytosisDiscovaccum phenomenon

Case 12Villonodular

B/l sacroiliitisMay fuse SI jointsWill then ascend into lumbar spine

Case 13Psoriatic arthritis

Psoriatic skin lesionsNon-symmetricalErosive changes, widening of SICommon=SI, hands (DIP), feet (DIP), spine

Case 14Rheumatoid arthritis

Carpal fusionB/l symmetricalMCP deviation to ulnar sideSwan neck deformity (Boutonniere deformity)=flexion deformity of PIP, extension deformity of DIP

Marginal erosionCase 15

Psoriatic arthritisMCP intact (rules out RhA)Fusiform swellingPredominately affects DIPPencil in cup deformity

Case 16

GoutSodium monourate (uric acid) crystal depositionMetabolicMarginal erosions, IntraosseousOverhang signUnilateralDistribution is definitiveTophi, bone erosions (long standing only), normal bone density seen

Case 17Scleroderma

Soft tissue changesTapered conical fingertips, retraction of tip (truncation), soft tissue calcification

Resorption of distal tufts (Acroosteolysis)Normal joints

Case 18Synoviochondrometaplasia

Benign arthropathy3-5th decadeCalcific loose bodies outside joint capsule (joint mice)May produce erosions on the bone

Case 19Neuropathic Arthropathy (Joint Disease)

6 D's "Bens lot", "De, De, De, Dis, Dis, Dis"DebrisDensityDestructionDislocationDisorganizationDistension

Case 20Pigmented villonodular synovitis

Usually affects 1 jointEffusion'Apple core deformity' secondary to extrinsic erosions

Case 21HADD (calcific bursitis/tendonitis)

Calcification of tendons, bursas, capsulesHydroxyAppatite Deposition diseaseShoulder, hip, spine

Case 22CPPD

Calcium PyroPhosphate Dihydrate depositionHot tender swollen jointsKnee, wristPyrophosphate arthropathy may be seen

Atypical locationSubchondral cystsDestruction changes in listSlac risk (scapholunate advance collapse)

Case 23Juvenile Chronic Arthritis (formerly Juvenile Rheumatoid Arthritis)

Hyperemia seen

Accelerated growth in epiphysis leads to ballooningOsteopenia seenSoft tissue swellingUniformed joint space narrowingAnkylosis possibleLinear Periostitis

Case 24Systemic Lupus Erythematosus

Deforming arthropathy w/out permanent changes (Reversible Subluxation) Swann neck deformityAffects many systemRash, Arthralgia

Case 25Primary OsteoArthritis

Peripheral erosions of distal phalanx 'Gull wing Sign'OsteophytosisNon-uniform joint space lossAnkylosisSubchondral sclerosis

  

Lecture 14Wednesday, July 02, 20089:16 AM Neurotrophic joint disease

Not only do we have the kind we normally think about but there is finer proprioception within joints (keeping the cartilage from banging together)Damage results from loss of proprioception functionMay be associated w/ diabetic neuropathyHypertrophic joint disease

Characterized by 6 Ds/(BNSLOT)Debris (from destruction)Density (subchondral intensity increase)DestructionDislocation (or feels like it/to much motion)DisorganizationDistension

Occurs in weight bearing jointsCase: 52 year old woman w/ diabetic neuropathy

Calcaneus is pretty destroyedTalus is almost totally missingThis patient walked in, felt the joint was unstable

Atrophic Joint DiseaseSmall non-weight bearing jointsSurgically amputed appearance or Candy lick appearanceCandy lick appearance=smooth cortical bone and worn down to a fine point

3 causesDiabetes MellitusTabes dorsalis=a slow degeneration of the nerve cells and nerve fibers that carry sensory information to the brainSyringomyelia

Typically occurs in the shoulderC-spine surgeryDue to formation of Syrinx w/in cordSyrinx=CSF cyst w/in spinal cord

Enteropathic ArthritisActs as a complication to Chron's or Ulcerative ColitisRadiographic twin for Ankylosing Spondylitis

Distinguish by history (will have GI issues) and HLA B27 (will not be present in EA but will be in AS)Predict as male

Atrophic Neurotrophic Joint Disease

Syrinx/Syringomyelia

Enteropathic Arthritis

 Lecture 15Monday, July 07, 200810:15 AM Video of Dr. Gross (guy w/ Ankylosing Spondylitis)

Defect on 6th chromosome creating an abnormal charge potential in collagen strandsThis happens all over the bodySigns of collage disruption=idiopathic sore throats, recurrent bladder infections, eye irritationOnset of signs occur in the twentiesHLA-B27 is positive only after pubertyGait=shuffle w/ arms extended posteriorly as balance/pain reliefPrimary causes of death

Suicide

Congestive heart failureHypertension->strokeFracture, dislocation of C/S following MVARenal failure typically liked to medical complicationsAcute liver failureSecondary leukemia associated w/ radiation therapySurgical complications

Traditional medical treatmentsNSAIDsMuscle relaxantsAnti-depressants-you still feel the pain but don't give a damnBlood thinnersPain killersJoint replacements as indicated

Alternative therapy optionsRegularly scheduled chiropractic careNutritional supportStrength and mobility exercises (pain can't hit a moving target)Emotional support groups and professional counselingLifestyle assistance devices and optionsMassage therapy for pain control and flexibility

Dr. Stan's Nutritional programAscorbic acid: 10-15 grams/day (gradual delivery)Beta glucans: yeast derived immune support 600 mg dailyA high quality multivitamin/multimineral baseHyaluronic acid: 150 mg natural anti-inflammatoryExtremely limited refined carbohydrates-raw fruits and vegetables preferred-avoidance of processed foodsModerately limited meat and animal products1-2 gallons of water per day (80% compliance is acceptable)Fiber, fiber, more fiber

Dr. Stan's Lifestyle ModificationsDressing successfully (simple modifications to make getting dressed a little easierGadgets galore (walking sticks, arm extenders)

Make list of things that you would do if you didn't have AS (then show them how they can do these things)

Exercise for the unique physique (swimming and aerobic workouts)Not accepting limitations (find out goals and help them accomplish those goals)Staying motivated (realize that AS isn't the end of the world)

Other problems to considerNumber of joints replacedAge of onset (often mis-diagnosed)The support systemThe level of progressionThe emotional supportOther health complicationsComplications from medications

DrStan@naturalhealingpower.com

  ListsSunday, July 06, 2008

3:55 PM Degenerative Arthritides

DJDErosive ArthritisDISHOPLLNeurotrophic ArthropathySynoviochondrometaplasia

InflammatoryRheumatoid ArthritisJuvenile Chronic Arthritis (Juvenile Rheumatoid Arthritis)Reactive Arthritis (Reiter's)Ankylosing Spondylitis

PsoriaticEnteropathic ArthritisSystemic Lupus ErythematosusScleroderma Osteitis Condensans IliiHypertrophic Osteoarthropathy

MetabolicGoutCPPDDHADDOchronosisPigmented Villonodular Synovitis