1	Joint diseases OSCE Review
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9	Approach to differential diagnosis Sutton’s law: “that is where the money is” DJD/DDD, RA, CPPD and DISH Law of parsimony One diagnosis cannot always explain everything Demographic information Prevalence in age, gender, etc.
10	Approach to differential diagnosis Radiographic hallmarks Osteophytes, erosions Real estate: location, location, location Pattern approach Know where to look Know what affects where ABCDS of joint diseases Alignment Bone Cartilage Distribution Soft Tissue
11	DJD
12	Degenerative Joint Disease Primary Osteoarthritis No evidence of underlying etiology Secondary Osteoarthritis Abnormal forces including obesity, trauma, and joint deformity. Pre-existing cartilage pathology such as rheumatoid arthritis, fractures and meniscal damage. Collapse of subchondral bone, such as avascular necrosis and osteoporosis.
13	DJD-risk factors systemic & local risk factors age- DJD w/ age gender- females DJD of hands, knees obesity- DJD of knees & hips trauma- most significant local factor physical activity- DJD w/ high impact
14	General Radiology Features asymmetric loss of joint space osteophytes enthesopathy subchondral sclerosis subchondral cysts intrarticular loose bodies ankylosis (rare) subluxation
15	Joint misalignment degeneration leads to joint laxity muscle tension and gravity may cause misalignment redistribution of forces leads to bone deformity
16	Degenerative joint disease
17	Degeneration- hands common, especially among middle-aged postmenopausal women enlarged soft tissue nodes of DIPs (Heberden’s nodes) and PIPs (Bouchard’s nodes)
18	Radiology of the Hands Target Locations.... distal interphalangeal joints proximal interphalangeal joints 1st metacarpal-carpal joints
19	Synoviochondrometaplasia
20	Synovial Osteochondrometaplasia multiple intra-articular loose bodies synovial tissue metaplasia that produces cartilaginous masses may ultimately ossify to become visible radiographically common in the knee and are also seen about the hip, ankle, shoulder and wrist. "joint mice", with joint locking.
21	RSDS
22	Reflex sympathetic dystrophy syndrome Clinical pain vasomotor disturbances trophic skin changes skin atrophy pigmentation abnormalities Synonyms causalgia, Sudeck's atrophy or osteodystrophy, shoulder-hand syndrome
23	Etiology theory lesion or injury painful impulses travel to the spinal cord, "internuncial pool" reflexes provoked efferent pathways to the peripheral nerves
24	Imaging too nonspecific to make the diagnosis in the absence of clinical information soft tissue swelling regional osteoporosis aggressive and severe significant juxtaarticular osteoporosis generally a unilateral process entire extremity osteoporosis may be patchy joints are usually maintained radionuclide imaging shows increased uptake of tracer in the articular regions
25	Gout
26	Gout A sodium urate induced arthropathy (a metobolic joint dz) disorder of purine metabolism principally males chronic hyperuricemia renal disease red, swollen and extremely painful joints
27	Radiology of Gout tophi - soft tissue nodules adjacent to the joint tophi may contain amorphous calcification para-articular erosion with sclerosis and "overhanging edge" sign often only seen after chronic years of disease
28	Gout
29	HADD
30	Hydroxyapatite Deposition Disease (HADD) Commonly seen about the: shoulder, elbow, wrist, hip, knee, ankle, spine Other names include: calcifying tendinitis and bursitis peritendinitis calcarea MC in the supraspinatus tendon
31	Case 7
32	Rheumatoid arthritis (RA) MC inflammatory arthritis (1-2%) marked by inflammatory, hyperplastic synovitis (pannus) F>M, 1:2-7; usually 20-50 yoa >60 years, F=M elevated ESR 70 to 80% +RA factor (5% in general pop) +ESR, +ANA
33	RA-radiographic progression Periarticular soft tissue swelling juxtaarticular osteoporosis, later generalized narrowed joint spaces, symmetrical loss erosions, beginning in bare areas subchondral geodes joint deformity due to conn. tissue laxity secondary OA, possible ankylosis pattern of involvement in hands: PIP, MCP jts
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35	RA Cervical Spine more common than other axial sites 50% of patients within 10 yrs atlantoaxial subluxations dens erosion apophyseal joint disease
36	Odontoid erosions Synovial joints: 1. Between dens and anterior arch 2. Between the dens and transverse ligament 3. At the tip of dens
37	Lupus
38	Systemic Lupus Erythematosis rheumatoid type (seropositive) female, 9F:1M; MC among those 20-40 yoa ESR elevated, ANA positive Marked subluxation although the joints integrity is relatively normal butterfly rash
39	SLE-distribution hands- MCP and PIP usually affected ligament laxity results in reversible nonerosive ulnar deviation of digits (classic & <50% of patients) swan-neck & boutenniere deformity spine- ADI (8.5%)
40	Scleroderma
41	Scleroderma Progressive Systemic Sclerosis Of unknown etiology. Causes small vessel disease and fibrosis in multiple organ systems. Scleroderma is the cutaneous manifestation of the disease. 3F:1M ratio 20 to 50 years hands- soft tissue atrophy, osseous resorption (acro-osteolysis), & subcutaneous calcification RF positive
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43	Diffuse Idiopathic Skeletal Hyperostosis very common, MC males over 50 incidence among diabetics: 13-49%, in general population (8-20%) neck stiffness, dysphagia in 20% exuberant proliferation of bone at osseous sites of ligament and tendon attachments (enthesopathy) spinal and extraspinal sites most marked along the anterior longitudinal ligament (ALL) of the middle & lower thoracic, upper lumbar, and lower cervical regions
44	Radiology of DISH Multiple levels of flowing ossification involving the anterior vertebral body margins with ankylosis ...... an enthesopathy. Preservation of disc height (minimal evidence of disc disease) Absence of sacroiliitis (excludes ankylosing spondylitis)
45	OPLL
46	Ossification of the Posterior Longitudinal Ligament Sometimes found in conjunction with DISH, but is also seen as an distinct entity. present in 40-50% of DISH patients X-ray- linear radiodense strip along posterior vertebral body margins, usually in cervical spine can result in loss of the sagittal diameter of the spinal canal, with resultant myelopathy.
47	Atrophic neuropathic arthropathy
48	Neuropathic arthropathy (Charcot joints) joint abnormalities secondary to impaired pain perception or proprioception distribution is usually monoarticular and depends on underlying abnormality two categories based on imaging Hypertrophic- bone forming Atrophic- resorptive
49	Neurotrophic- clinical Suspected in patients with a painful swollen joint, neurological disorder, and radiographic evidence of bone destruction weightbearing joints- hypertrophic non-weightbearing joints- atrophic decreased pain sensation and proprioception 30% will have pain making diagnosis difficult swollen unstable joint DDx from infection, advanced DJD, or CPPD
50	Etiologies congenital indifference to pain alcoholism diabetes syphilis syringomyelia trauma steroids leprosy
51	Case 14
52	Osteitis condensans illi
53	Osteitis Condensans ilii MC in women than men etiology unknown: theories: stress across the SI joint hypervascularity of pregnancy triangular radiodensities on illium side of SI joint, usually bilateral. the SI joint itself is usually normal
54	Early AS
55	Ankylosing spondylitis (AS) MC seronegative spondyloarthropathy affect 0.1-0.2% 1:1 to 1:10 female to male ratio 90% positive HLA-B27 (6-8% in general population) Axial: SI and spine Appendicular: proximal large joints of extremities (rhizomelic) Enthesis (attachment of ligaments and tendons to bone)
56	Enthesis
57	Sacroiliac involvement Classic initial site of skeletal involvement hazy loss of subchondral (cortical) definition erosions and joint space widening fusion 50% will progress to fusion
58	Management management is aimed at a long-term plan to prevent, decrease, or delay joint and postural deformities NSAIDS to limit joint inflammation and pain
59	AVN
60	AVN Osteonecrosis can be idiopathic or secondary to a number of conditions that reduce blood supply to the bone such as an intraluminal abnormality, an extrinsic compression, or a combination of both. CT scans, MRIs, and bone scans play a significant role in diagnosing the disease at an early stage to reduce the number and/or severity of complications and morbidity associated with the disease. MC cause adults: corticosteroids MC cause in kids: idiopathic
61	Plain film-AVN no radiographic evidence early in the disease, first finding is osteopenia, followed by fissures, sclerosis, and fragmentation subchondral fractures heals with articular deformity leading to DJD MRI and bone scan are more sensitive
62	Why is this not just DJD?
63	Calcium Pyrophosphate Deposition Disease Arthropathy characterized by intra-articular deposition of calcium pyrophosphate crystals. Synonyms: CPPD pseudogout chondrocalcinosis symptoms before age 50 are uncommon
64	Radiology of CPPD radiographic evidence of chondrocalcinosis of hyaline or fibrocartilage (linear radiodensities) common sites include the knee (menisci), wrist, MCPs, and symphysis pubis less common in capsule, tendons, and ligaments intraarticular deposits of CPPD may degrade cartilage cause severe joint degeneration
65	DJD
66	Uncinate hypertrophy (DJD)
67	Bouttonnière / Swan neck
68	Osteomyelitis
69	Carpal coalition
70	Sacroilitis
71	Gout
72	Pelligrini-Stieda (HADD)
73	Bilateral DJD (hip)
74	Synoviochondrometaplasia
75	DJD primary and secondary
76	Osteitis condensans ilii
77	CPPD and DJD
78	Synoviochodrometaplasia
79	Neuropathic arthropathy
80	Healed AVN
81	Hemivertebra
82	OCI
83	DJD and patella removal
84	AS ?