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What is the term used to describe softening of bone?
- Osteomalacia, "adult rickets."
- A lack of Ca++ deposited into the osteoid matrix.
True or false; osteomalacia is characterized by decreased quantity of bone.
False: Osteomalacia is characterized by a decrease in QUALITY of bone.
Name the 5 radiographic findings associated with Osteomalacia.
- 1. Decreased bone density: low bone mineral content.
- 2. Mottled trabecular pattern: disorganized, holes.
- 3. Loss of cortical definition: thinner.
- 4. Pseudo fractures: insufficiency fractures.
- 5. Deformities.
What are 3 a/k/a's for Pseudo Fractures associated with Osteomalacia?
- 1. Looser lines.
- 2. Milkman's Syndrome.
- 3. Umbau Zones.
Where is the most common site for "Looser Lines" in regards to Osteomalacia?
- At the femoral necks.
- Bilateral & symmetrical.
- Other locations:
- Pubic & ischial rami.
- Axillary border of scapula.
Name 4 deformities associated with Osteomalacia:
- 1. Weight-bearing bones.
- 2. Protusio-acetabuli: femoral necks burst through acetabulum... uni or bilateral, also common with RA.
- 3. Bowing of femur, tibia.
- 4. Kyphoscoliosis: abnormal curvature of the spine in both a coronal and sagittal plane.
What is the childhood equivalent of osteomalacia?
- Rickets: Vit D, Ca++, P deficiencies.
- 6-12 months old.
- Rare in first world countries.
Soft tissue swellings around growth plates are associated with which pathology?
- Secondary to hypertrophied cartilage.
Which pathology is associated with a "Rachitic Rosary Sign?"
- Rachitis Rosary: anterior rib cage presents with costocondral bumps.
How can you tell radiographically if a patient has healed from Rickets?
An opaque metaphyseal line is visualized.
True or false; in regards to growth plate changes associated with Rickets, bone cells grow to rapidly and are unable to calcify.
False: cartilage cells grow normally, but fail to calcify.
Name 3 radiographic findings associated with Rickets.
- 1. Widened growth plate of long bones.
- 2. Paintbrush metaphysis: irregular, frayed, & cupped metaphyseal margin.
- 3. Lack of zone of provisional calcification (until healing).
- Bowing deformities.
- Decreased bone length.
- Pseudo- fractures.
- Rachitic Rosary.
Rachitic bone = increased lucency/osteopenia.
Name 2 a/k/a's for Scurvy.
- 1. Barlow's Disease: Infentile scurvy.
- 2. Hypovitaminosis C.
What are the 3 main functions of Vitamin C (ascorbic acid)?
- 1. Forms collagen.
- 2. Forms osteoid matrix.
- 3. Forms endothelial linings.
Which age group is most commonly associated with Scurvy?
Babies, 8-14 months due to improper milk feedings.
Which pathology is associated with spontaneous hemorrhages?
Scurvy, due to capillary fragility.
Cutaneous petechiae, bleeding gums, melena, joint swelling, irritability, pain, & frog leg position are associated with which pathology?
What are the 5
main radiographic findings associated with Scurvy
- 1. White Line of Frankel: dense zone of provisional cancification resulting from a delayed conversion to bone.
- 2. Wimberger's Sign: ring epiphysis.
- 3. Corner Sign: Suggestive of subphyseal infarctions.
- 4. Pelken's Spurs: at the edges of the metaphsis, marginal spur formations.
- 5. Trummerfeld Zones: scorbutic zone... a transverse band of radiolucency beneath the dense zone of provisional calcification
- Subperiosteal hemorrhage.
- Scorbutic rosary.
Which hormone is associated with acromegaly?
- Growth hormone due to an anterior pituitary adenoma.
- Results in the activation of bone growth & irregular thickening of the cortex.
What are the 4 clinical findings associated with Acromegaly?
Patients are predisposed to degenerative changes.
- 1. Thick heel pad.
- 2. Skull & facial changes.
- 3. Large hands & tufts.
- 4. Increased ADI space.
Hyperparathyroidism is associated with over releasing of PTH. What kind of hormone is PTH?
Osteoclastic: removes bone tissue.
What are the 3 type of HPT?
- 1. Primary HPT: due to hypercalcemia or pituitary adenoma.
- 2. Secondary HPT: complication of renal disease.
- 3. Tertiary HPT: dialysis patients.
True or false: HPT results in the formation of kidney stones.
- Females 30-50 yo.
- Weakness, lethargy, polydipsia, polyuria.
- Calculus formation in kidneys.
HPT results in hyper-excretion of which two substances?
- 1. Calcium.
- 2. Phosphorus.
What is considered to be the Hallmark sign of HPT?
Subperiosteal bone resorption
of the outer cortex, @ ligament & tendon insertion points.
- =Brown tumors: cyst-like destructive bone lesions.
- osteoclastic giant cells.
Where is subperiosteal resorption associated with HPT visible radiographically?
- Radial margins of the middle & proximal phalanges: digits 2 & 3.
- "Shame shame!"
- Medial metaphysis of the humerus & tibia.
- Undersurface of the distal clavicle.
Which pathology is associated with a lace-like appearance of external bone surfaces?
- Lace-like appearance: outer cortical erosions, irregular, frayed.
Subarticular bone resorption associated with HPT is most commonly found where?
- Symphysis pubis.
- Widens joint space.
Salt & Pepper skull, Brown tumors, chondrocalcinosis, subperiosteal resportion, Rugger Jersey Spine, & osteolysis are common radiographic findings associated with which pathology?
HYPOparathyroidism results from accidental removal of the parathyroid glands during thyroid surgery. What are the 4 radiographic findings?
- 1. Osteosclereosis.
- 2. Calvarial thickening.
- 3. Hypoplastic dentition.
- 4. Basal ganglia calcification.
What are the 3 differential diagnosises for Osteosclerosis?
- 1. Osteoblastic metastatic disease.
- 2. Paget's Disease.
- 3. Sickle cell anemia.
Is pseuohypoparathyroidism similar to hypoparathyroidism?
Yes, similar symptoms, but additionally includes: characteristic dwarfism, obesity, round face, bradydactyly, abnormal teeth, mental retardation, impaired taste & smell.
Which pathology is associated with a positive metacarpal sign
- Sibbling has PHP (pseudo-hypo-parathyroidism).
Anatomy of joints:
- 1. Fibrous joints: sutures, tib/fib, radius/ulna.
- 2. Cartilage joints: IVD, symphysis pubis.
- 3. Synovial joints: SI-joint, digits, knees.
Is the joint capsule visualized radiographically with synovial joints?
What are 4 signs of inflammatory radiographic findings?
- 1. Soft tissue swelling.
- 2. Uniform loss of joint space.
- 3. Bone erosions.
- 4. Juxta-articular osteoporosis.
RA, Psoriasis, Ankylosing Spondylitis, & Reiter's Syndrome are associated with which type of arthritic disorders?
- Ankylosing spondylitis
- Reiter's syndrome
What are the 4 characteristics for degenerative arthritic disorders?
- 1. Non-uniform loss of joint space.
- 2. Osteophytes.
- 3. Subchondral sclerosis.
- 4. Subchondral cysts (geodes).
Name 3 characteristics for metabolic arthritic disorders, such as Gout.
- 1. Periarticular soft tissue masses.
- 2. Well-marginated bone lesions.
- 3. Preservation of joint space.
*degenerative & inflammatory may overlap.*
What is an a/k/a for DJD?
- Osteoarthritis (OA): most common joint pathology.
- Small joints of hands.
- Larger weight-bearing joints.
Which form of DJD (OA) is idiopathic?
Primary DJD: 5th-6th decade, weight bearing joints.
Secondary DJD: known factor or event is cause... 2nd-6th decade.
Subchondral cyst formation:
- Weakness of joint cartilage & cortical microfractures
- Synovial fluid enters subchondral bone (subarticular)
- Subchondral cysts (a/k/a: Geodes).
8 radiographic findings of DJD:
- 1. Asymmetrical distribution.
- 2. Non-uniform loss of joint space.
- 3. Osteophytes.
- 4. Subchondral sclerosis: increased bone formation around joint space.
- 5. Subchondral cysts.
- 6. Intra-articular loose bodies.
- 7. Articular deformities.
- 8. Joint subluxation.
What is an a/k/a for subchondral sclerosis?
Eburnation: seen where greatest cartilage is lost.
Subchondral cysts are __ - __ mm in diameter.
What is an a/k/a for intra-articular loose bodies?
- Joint mice: intra-articular accumulation of cartilage.
- MC = knee.
Name 2 a/k/a's for DJD of the hip?
- 1. Coxarthrosis.
- 2. Malum coxae senilis.
- =increased risk of osteoporosis.
- non-uniform loss of joint space = migration.
3 types of margination:
- 1. Superior: Waldenstrom Sign... MC = medial joint space widened.
- 2. Medial: displacement of femoral head medially = protrusio acetabuli.
- 3. Axial: superomedial displacement.
Where does buttressing take place?
- At the hip w/ DJD.
- Medial side.
- Altered joint mechanics.
Sharpening of the tibial eminences is characteristic for which pathology?
DJD of the knee.
Patellar tooth sign:
advanced patellofemoral degeneration.
Where is the pain with chondromalacia patella?
- Crepitus, buckling, locking, stiffness, swelling.
- "Movie sign."
- "Patella alta."
Tarsal beaks & heel spurs are associated with which pathology?
- DJD of the ankle & tarsal joints.
- Uncommon, due to previous trauma.
DJD of the foot is most common at which joint?
What is the most common joint associated with DJD of the shoulder?
GH-joint = previous trauma or cartilagenous disease.
- evaluate from inferior borders.
True or false: HADD affects any joint in the body.
False: HADD = tendons, bursae, ligaments.
Where is the most common location for HADD/DJD of the shoulder?
Supraspinatus tendon: insertion on greater tuberosity.
2nd MC: subacromial bursa.
___ = non-uniform loss of joint space.
DJD = non uniform loss of joint space.
Which disease is characterized as "lumpy bumpy?"
Metabolic deposition disease: gout, hyperlipidemia, etc.
What does HADD stand for?
isease: calcifying tendinitis & bursitis.
- MC = shoulder rotator cuff, followed by hip & upper cervical spine.
- Etiology unkown.
- Does not attach to cortex.
What does CPPD stand for?
- Calcium PyroPhosphate Dihydrate (Deposition Disease).
- "Pseudo Gout."
Which disease is the exception to the no erotions in RA rule?
Gull Wing's Sign is associated with EOA, and affects which joints?
- DIP joints.
- DJD changes with central. bone erosions.
- Main DDX = RA... but RA rarely involves the DIP joints.
- or Psoriatic arthritis: marginal erosions.
- 1. Autoimmune.
- 2. Attacks hands & feet first.
- 3. Moves proximal to distal.
- 4. Ulnar/fibular deviation will not correct with pressure.
- 5. Connective tissue disorder.
- 6. Etiology unkown.
- 7. Attacks synovial tissue.
- 8. Jelling phenomenon: morning joint stiffness.
- 9. Haygarth's Nodes: MCP joints.
RA + Leukopenia + Splenomegaly.
rough, grainy tissue that evolves cartilage.
RA findings: (frequently seen in the wrist first).
**DIP joints not involved**
- 1. Bilateral symmetrical.
- 2. Periarticular soft tissue swelling.
- 3. Juxt-articular osteoporosis.
- 4. Uniform loss of joint space.
- 5. Marginal erosions (rat bites).
- 6. Deformity.
- 7. Ankylosis: fusion/metacarpal joints.
- 8. Boutonniere deformity.
- 9. Swan neck deformity.
- 10. Zigzag deformity: digital ulnar deviation + carpal radial deviation.
Terry Thomas sign involves which 2 carpal bones?
Marginal erosions are medial with digits 1-4, digit 1 = MC.
Fifth metatarsal head = lateral.
What is the most common cause for bilateral protrusio acetabuli?
Which joint has a positive fat pad sign with RA?
What is the most frequent systemic autoimmune inflammatory disease affecting children?
JCA = Still's Disease.
Seronegative for RA factor.
Polyarticular disease is the most common form of JRA.
- Distal extremities & cervical spine.
- Simulates rheumatic fever.
- Bird like appearance.
- JRA/hand & foot: spares distal joints.
- Inferior pole of patella is squared.
SLE has _______ deformities.