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What are the characteristic radiographic findings in osteoarthritis?
Joint Space Narrowing
What disorder is associated with osteophytes but no joint space narrowing or sclerosis?
DISH (Diffuse Idiopathic Skeletal Hyperostosis)
What are the characteristic radiographic findings of rheumatoid arthritis?
Any synovial lined joint in the body:
Soft tissue swelling
Joint space narrowing
In what direction does the joint space narrowing occur in rheumatoid arthritis in the femoral head vs osteoarthritis
Rheumatoid arthritis - In an axial direction
Osteoarthritis - superior direction (towards weight bearing)
Syndesmophytes run vertically while osteophytes run horizontally
Which spondyloarthropathies tend to have syndesmophytes which are MARGINAL and SYMMETRIC?
Inflammatory Bowel Disease
Which spondyloarthopathies tend to have syndesmophytes which are NONMARGINAL and ASYMMETRIC?
Symmetric/bilateral SI joint involvement
Inflammatory Bowel Disease
Unilateral/asymmetric SI joint involvement
What is the classic pattern of arthropathy seen in psoriatic small joint involvement?
Soft tissue swelling
How long does it take for gout to manifest itself radiographically?
Takes 4 to 6 years for gout to cause radiographically evident disease
Erosions with SCLEROTIC margins
- Classic gout finding
What is the classic triad in CPPD (pseudogout)?
What are the classic locations for cartilage calcification (chondrocalcinosis)?
Knee (medial and lateral compartments)
Wrist (triangular fibrocartilage)
What is the differential for soft tissue calcification of the rotator cuff of the shoulder?
CHA (HAD) (Hydroxyapatite deposition)
What is the main difference between the joint destruction found in DJD versus CPPD (pseudogout)?
CPPD has a proclivity for the upper extremity
What disorders are highly associated with CPPD (pseudogout)?
What are the characteristic radiographic findings in collagen vascular diseases?
Soft tissue wasting
What types of hand findings are noted in patients with lupus (SLE)?
Severe ulnar deviation
What types of radiographic changes are found in hemachromatosis?
- Findings of DJD (joint space narrowing, sclerosis, osteophytes)
- CPPD (pseudogout)
What disease do these bony findings suggest?
"Squaring" of the metacarpal heads due to large osteophytes
What is the most commonly seen location of a Charcot joint?
First and second tarsometatarsal joint
What are the classic findings for Juvenile Rheumatoid arthritis and hemophilia?
Overgrowth of the ends of bones (epiphyseal enlargement)
What is the pathogenesis of synovial osteochondromatosis?
Metaplasia of the synovium with deposition of foci in joint cartilage
What is the difference in pathophysiology between primary and secondary synovial osteochondromatosis?
Secondary synovial osteochondromatosis - small bits of cartilage shed into joint at different times, grow as they are nourished by synovial fluid > loose bodies of different sizes
What is pigmented villonodular synovitis?
Chronic inflammation of the synovium that causes synovial proliferation
What is another consideration on the differential if the deposits of cartilate do not ossify in the joint?
Noncalcified synovial osteochondromatosis
Pigmented villonodular synovitis
What is the most reliable radiographic sign of a knee effusion?
Distance between suprapatellar fat pad and the anterior femoral fat pad (> 10 mm)
What are the radiographic stages of avascular necrosis?
1. Joint effusion
2. Patchy/mottled increase in density
3. Subchondral lucency along articular surface
4. Collapse of articular surface
What is a smaller and more focal form of avascular necrosis?
- Madelung deformity
- - Positive ulnar variance
- - Lateral/dorsal bowing of radius
Congenital or traumatic distubrance of distal ulnar side of epiphyseal growth plate leading to shortening of the radius and overgrowth of the ulna
What is the mnemonic for benign lytic bone lesions?
- F - Fibrous dysplasia
- E - Enchondroma/Eosinophilic Granuloma
- G - Giant Cell Tumor
- N - Nonossifying Fibroma
- O - Osteoblastoma
- M - Metastatic disease
- A - Aneurysmal Bone Cyst
- S - Solitary Bone Cyst
- H - Hyperparathyroidism
- I - Infection
- C - Chondroblastoma/Chondromyxoid fibroma
How can one rule out fibrous dysplasia?
Fibrous dysplasia will not have periostitis
Fibrous dysplasia looks like almost anything
Often "ground glass" appearance
Where does one typically find fibrous dysplasia?
Pelvis (proximal femur invariably)
What else should you consider if you are considering fibrous dysplasia in the tibia?
Adamantinoma (malignant tumor)
What is the syndrome if one notes polyostotic (affecting more than one bone) lesions in conjunction with cafe au lait spots and precocious puberty?
What is the most common benign cystic lesion of the phalanges?
What are the typical findings in an enchondroma?
Calcified chondroid matrix (except in phalanges)
- Bone infarct -
- well defined, serpentiginous, densely sclerotic border
- No endosteal scalloping
How to differentiate enchondroma vs Chondrosarcoma?
Pain is more commonly associated with chondrosarcoma
What syndrome is associated with multiple enchondromas?
What syndrome is associated with multiple enchondromas and soft tissue hemangiomas?
What entities have been described to have bony sequestra?
What is the approximate age cutoff for patients with eosinophilic granuloma?
EG is much more rare in patients above 30
1. Closed epiphyses
2. Epiphyseal lesion abutting articular surface
3. Eccentric location
4. Sharp, non-sclerotic border
What is the difference between a fibrous cortical defect and a non-ossifying fibroma?
Fibrous cortical defects are typically shorter than 2 cm in length
What is the differential diagnosis for expansile, lytic lesions in posterior aspect of spine?
Aneurysmal Bone Cyst
What types of cancers can cause expansile, lytic metastases?
Aneurysmal bone cyst - multiple fluid-fluid levels
What is the typical age range of an aneurysmal bone cyst?
Less than 30 years old
Unicameral(solitary) bone cyst
Fallen fragment sign (from fracture)
- Central location
- Proximal humerus and femur often
Subperiosteal bone resorption - resorption of radial(lateral) aspects of proximal/middle phalanges (often 2nd/3rd)
Can also be seen in distal clavicles
What is the differential diagnosis for a lytic lesion in the EPIPHYSIS in a patient under age 30?
- 1. Infection (osteo)
- 2. Chondroblastoma
- 3. Giant Cell Tumor
What rare lesion can mimic a non-ossifying fibroma?
What disease is eosinophilic granuloma a benign form of?
Langerhans Cell Histiocytosis
How do thalassemias affect bone?
Cause extramedullary hematopoeisis > hairy skull, thickened bone
What is the mechanism of a Jefferson fracture?
Axial loan injury leading to burst fracture of C1 (atlas) ring
What is the most common type of dens fracture?
Type II - fracture through base of odontoid process
What can structures can be injured with an MVA in which the chin hits the dashboard and causes hyperextension?
Bilateral pars interarticularis fracture
What is the name of the fracture in which chin strikes dashboard leading to bilateral pars interarticularis fractures?
What structures can get injured with a hyperflexion injury?
Anterior compression fracture
Disruption of posterior ligament
What is the name of the fracture associated with severe hyperflexion injury?
Flexion teardrop fracture
What can be fractured with hyperflexion of the neck associated with shoveling against fixed resistance?
What is the fracture called in which the spinous process is fractured associated with hyperflexion of the neck during shoveling against fixed resistance?
Clay Shoveler's fracture
What is the difference in mechanism between unilateral and bilateral facet joint dislocations?
Unilateral - rotational injury
Bilateral - extreme hyperflexion
What fracture can occur a motor vehicle accident in which someone's back hyperflexes with a lap belt in place?
Horizontal splitting of posterior elements extending anteriorly
What is the difference between spondylolysis and spondylolisthesis?
Spondylolysis - defect or fracture of pars interarticularis
Spondylolisthesis - Anterior displacement of the involved vertebral body with respect to inferior vertebral body
What is grade II spondylolisthesis?
Displacement of 25 to 50% of the vertebral body's AP dimension
Marked ulnar subluxation at MCP joints
What is the major complication of multiple hereditary exostoses?
What are the characteristic imaging findings in multiple hereditary exostoses?
Widening of metaphyses
Sessile or pedunculated exostoses
What are characteristic MSK findings of neurofibromatosis type I?
- S-shaped scoliosis
- Posterior vertebral body scalloping
- Ribbon Ribs
- Severe bowign
What is the primary defect in osteopetrosis?
Defective osteoclast activity
Sever disease - Inflammation/sclerosis of calcaneal apophyses
Often seen in young children (jumping) and is self limited
What is the difference between lunate and perilunate dislocation?
Perilunate dislocation > lunate maintains normal position with respect to distal radius
What is the difference between a trans-scaphoid perilunate dislocation and a perilunate dislocation?
Transcaphoid perilunate dislocation > includes fracture of the scaphoid
What are the most common tarsal bone coalitions?
Calcaneus and navicular (most common)
Talus and calcaneus
What nerves and muslces are typically involved in Parsonage-Turner syndrome?
- Supraspinatus and infraspinatus
What nerves and muscles are involved with quadrilateral space syndrome?
Deltoid and teres minor
- Do not conform to prosthesis
- No associated sclerotic reaction
Double PCL sign - band anterior to intact PCL
Suggests bucket handle meniscal tear
Lytic lesion, sclerotic, scalloped
Myositis Ossificans - peripheral calcifications in patient with history of trauma
What is the difference between gigantism and acromegaly?
Gigantism - stimulation of endochondral ossification before growth plate closure
Acromegaly - growth hormone hypersecretion in the skeletally mature patient leading to intramembranous bone formation resulting in periosteal new bone formation and widening of osseous structures
Blount disease - lack of growth of the medial proximal tibial physis
What is typically the first ligament to be injured in an ankle inversion?
Anterior talofibular ligament (ATFL)
Tug lesion - minimal smooth periosteal thickening at medial aspect of distal femur (most likely secondary to vastus medialis insertion)
Humeral pseudocyst - area of decreased cancellous bone in the greater tuberosity due to disuse or osteoporosis
Not a lytic lesion
Supracondylar process of the humerus
Accessory ossification center at superolateral aspect of patella
Unrecognized fracture through growth plate before age 6 - lack of fusion of dens
Abnormal mobility of the dens with respect to C2
Dysplasia Epiphysealis Hemimelica (Trevor's disease)
Osteochondromas arising from the epiphysis
What is the differential diagnosis for a cystic lesion of the TERMINAL phalanx?
Epidermal inclusion cyst (associated with history of trauma)
Teenager pitcher with shoulder pain
- Little league shoulder - Salter 1 injury with widened proximal humeral lateral physis
Where do labral variants tend to occur?
- At the 11 to 3 o'clock position -
- Sublabral foramen
- Sublabral recess
- Buford complex
Luxatio erecta (inferior shoulder dislocation)
Arm appears held upward or behind head in fixed abduction.
Macrodystrophia lipomatosa - localized form of giantism
Usually affects 2nd or 3rd digit of hand or foot
Peroneus brevis split tear
C-shaped appearance around peroneus longus
Nail patella syndrome (Fong disease)
Iliotibial band syndrome
Ill-defined signal abnormality interposed between the iliotibial band and femoral condyle (low T1, high T2)
Jumper's knee -
Injury of proximal patellar tendon where it inserts onto inferior pole of the patella
- Pediatric form - similar to:
- Sinding-Larsen-Johansson disease
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