P2.4 - Approach to Arthritis Degenerative Disorders

Degenerative

ID type of arthritis

Inflammatory

ID type of arthritis

Osteoarthritis

Inflammation of the bone and joint

Rheumatoid arthritis with secondary osteoarthritis (aka inflammatory arthritis with secondary degeneration)

The radiographic features here are consistent with which process?

Arthritis

_____ is the foremost crippler in the USA

Articular disease

- Costs >$14 billion annually (CDC - 128 billion for AORC)

- Affects 1/7 people

X-ray

_____ evaluation is usually the first and most extensively used method of evaluation for articular disease

Fibrous

_____ joints:

- Cranial sutures

- Syndesmoses (tibia-fibula, radius-ulna)

Cartilaginous

_____ joints:

- Symphysis pubis

- Intervertebral discs

- Manubriosternal joint

Synovial

_____ joints:

- Facet joints

- SI joints

- Hips

- Knees

- Shoulders

- Fingers

Intracapsular

With synovial joints, there is no periosteum found around the _____ cortices

Periosteal response

Because there is no periosteum found in the intracapsular cortices of synovial joints, there is a lack of _____ in this area

Uniform

_____ loss of joint space (inflammatory)

Non-uniform

_____ loss of joint space (degenerative)

- Soft tissue swelling

- Uniform loss of joint space

- Bone erosions

- Juxta-articular osteoporosis

- Occasional periostitis (adjacent metaphysis)

State the radiographic features of inflammatory arthritis

- Pannus

- Bare area

Erosive changes from _____ formation affecting the _____

Metabolic joint disease

Relative preservation of joint space with well-marginated erosions away from the joint

Degenerative joint disease (DJD)

_____ is the most common articular affliction

Progressive, non-inflammatory

Degenerative joint disease is a _____ disease

Primary

_____ osteoarthritis:

- No known or proven factors

Secondary

_____ osteoarthritis:

- Known precipitating factors:

• Trauma

• Congenital anomalies

• Crystal deposition disease

Poor

A _____ correlation exists among the extent of radiologic changes and clinical signs and symptoms of degenerative joint disease

- Weight-bearing joints of the spine, hips, and knees

- AC joint

- First MTP

- First metacarpal-trapezium

- Distal interphalangeal joint (DIP) of the hands

- Any joint may be affected if conditions are right

State the common locations affected by degenerative joint disease

- M>F

- >45 y.o.

State the clinical features of degenerative joint disease

- Insidious onset of intermittent achy pain, stiffness, and swelling

- Stiffness typically occurs with rest, particularly in the morning

• Gradually disappearing with activity (<30 mins)

Explain the symptomatology of degenerative joint disease

- Osteophytes

- Non-uniform joint space loss

- Subchondral sclerosis

- Subchondral cysts

- Subluxation

- Unilateral or bilateral

State the radiographic findings of osteoarthrosis

Asymmetric

_____ distribution of osteoarthritis

Non-uniform

Degenerative _____ loss of joint space

Uniform

Inflammatory _____ loss of joint space

Osteophytes

Bone spurs

Subchondral sclerosis

Increased density of bone just deep to articular surface

Subchondral cysts

Fluid-filled sacs in subchondral bone

Intra-articular loose bodies

ID radiographic feature of osteoarthrosis

Articular deformity

Due to repetitive stress and trabecular remodeling, fracture, or collapse

Lateral listhesis

ID type of joint alignment change

Retrolisthesis

ID type of joint alignment change

- C5-C7

- T2-T5, T10-T12

- L4-S1

- Discovertebral

- Uncovertebral

- Apophyseal

- Costovertebral

State the target sites of degenerative spine disease

- Loss of disc height

- Osteophytosis

- Endplate sclerosis

- Vacuum cleft

State the radiographic features of degeneration of the intervertebral disc

Lower cervical spine

Degeneration of intervertebral discs is usually worse in the _____

Facet joint osteoarthrosis

ID type of degenerative spine disease

Facet hypertrophy

- Enlargement of facet joints

- May be the result of the body responding to degenerative disease

Uncovertebral osteoarthrosis

ID type of degenerative spine disease

C5-C6

Which levels are you expecting uncinate hypertrophy to be on the AP lower cervical?

Cervical spondylosis: foraminal encroachment

ID type of degenerative spine disease

Cervical spondylotic myelopathy and radiculopathy

ID type of degenerative spine disease

Intercalary bone

Calcification within the annular fibers

- A sign of degenerative disc disease

Limbus bone

- Not an intercalary ossicle

- Notice the parent site

Atlantoaxial osteoarthrosis

ID type of degenerative spine disease

- Osteophytes

- Sclerosis

- Subluxation

State the radiographic features of apophyseal joints in degenerative cervical spine disease

- Osteophytes

- Foraminal encroachment

State the radiographic features of uncovertebral joints in degenerative cervical spine disease

- Decreased height

- Osteophytes

- Vacuum

- Canal stenosis

- Ligament calcification

State the radiographic features of discovertebral joints in degenerative cervical spine disease

Spondylosis and senile kyphosis

ID type of degenerative spine disease in the thoracic spine

Costovertebral arthrosis

ID type of degenerative spine disease in the thoracic spine

- Osteophytes

- Sclerosis

- Subluxation

State the radiographic features of apophyseal joints in degenerative thoracic spine disease

- Osteophytes

• Unilateral

• Right side

State the radiographic features of costovertebral joints in degenerative thoracic spine disease

- Decreased height

- Osteophytes

- Vacuum

- Kyphosis

State the radiographic features of discovertebral joints in degenerative thoracic spine disease

Facet joint osteoarthrosis

ID type of degenerative spine disease in the lumbar spine

- L4-L5 and L5-S1 MC sites

- L4-L5 disc normally tallest

- Osteophytes

- Sclerosis

- Narrowing

- Vacuum phenomenon

State the radiographic features of degenerative lumbar disc disease

Degenerative disc disease

ID type of degenerative spine disease in the lumbar spine

Vacuum phenomena

ID feature of degenerative lumbar spine disease

- Osteophytes

- Sclerosis

- Subluxation

- Decreased space

- Instability: degenerative spondylolisthesis

State the radiographic features of apophyseal joints in degenerative lumbar spine disease

- Decreased height

- Osteophytes

- Vacuum

- Body sclerosis

- Stenosis

- Subluxation

State the radiographic features of discovertebral joints in degenerative lumbar spine disease

- Stenosis

- Instability

- Degenerative spondylolisthesis

- Degenerative scoliosis

- Baastrup's disease

- Vertebral body sclerosis

State the complications of lumbar spine degenerative disease

Spinal stenosis

ID complication of degenerative lumbar spine disease

Degenerative spondylolisthesis

ID complication of degenerative lumbar spine disease

Degenerative scoliosis

ID complication of degenerative lumbar spine disease

Baastrup's disease

ID complication of degenerative lumbar spine disease

Kissing spine syndrome

Another term for Baastrup's disease

Extension

_____ is more painful for patients with Baastrup's disease

Degenerative sclerosis

ID complication of degenerative lumbar spine disease

SI joint degeneration

ID complication of degenerative lumbar spine disease

Superior

With osteoarthrosis of the hip joint, the _____ joint space is most commonly involved

- Superior migration of femoral head

"Collar"

What is the term for the circumferential osteophytes in osteoarthrosis of the hip joint?

Hip replacement surgery

What is the treatment for osteoarthrosis of the hip joint?

Medial

With osteoarthrosis of the knee joint, the _____ tibiofemoral joint is more commonly affected

Tibial spines

With osteoarthrosis of the knee joint, osteophytes are seen on the _____

- Subchondral cysts

- Sclerosis

- Genu varum

State the other radiographic features of osteoarthrosis of the knee joint

- AP weight-bearing view

- Tunnel view

What views do we need to see osteoarthrosis of the knee joint?

Patellar tooth sign (enthesophyte)

ID radiographic feature of osteoarthrosis of the knee joint

Trauma

Osteoarthosis of the ankle is rare except after _____

Enthesophyte

With osteoarthrosis of the ankle, an _____ can be seen in the calcaneus

- 1st MTP

- Bunion

• Hallux valgus

State the clinical features of osteoarthrosis of the foot

Uncommon

Osteoarthrosis of the shoulder is _____

- AC joint (MC)

- Glenohumeral joint

• Rare

- Trauma

- Occupational or activity-based stressors

- Altered biomechanics (rotator cuff tendinopathy)

What is osteoarthrosis of the shoulder secondary to?

- Calcified cartilaginous fragments (joint mice) frequently seen

- Triceps enthesophyte may accompany it

State the radiographic features of osteoarthrosis of the elbow

- Trauma

- Occupational or activity-based stressors

What is osteoarthrosis of the elbow secondary to?

1st metacarpal-trapezium joint

State the common location of osteoarthrosis of the wrist

Trauma

What is osteoarthrosis of the wrist secondary to?

Heberden's nodes

With osteoarthrosis of the hand, what radiographic feature is present in the distal interphalangeal joints?

Bouchard's nodes

With osteoarthrosis of the hand, what radiographic feature is present in the proximal interphalangeal joints?

- Middle-aged females

- Inflammatory variant of osteoarthritis

- Symmetric

- DIPs and PIPs

- Normal labs

- Pain, edema, redness

- Residual deformities

- Chronic progressive changes

State the clinical features of erosive osteoarthritis

- Osteophytosis

- Subchondral sclerosis

- Loss of joint space

State the degenerative joint disease-like changes seen with erosive osteoarthritis

- Erosions (including central area)

- Periostitis

- Ankylosis

State the inflammatory-like changes seen with erosive osteoarthritis

Gull wing deformity

ID radiographic feature of erosive osteoarthritis

- Ligamentous calcification and ossification

- Most prominent in the spine, involving the anterior longitudinal ligament (ALL)

State the radiographic features of diffuse idiopathic skeletal hyperostosis (DISH)

- 25% of men over 50 y.o.

- 15% of women over 50 y.o.

State the epidemiology of diffuse idiopathic skeletal hyperostosis (DISH)

- Mild low back pain and stiffness

- Dysphagia

- Ossification of the posterior longitudinal ligament

- 20% have diabetes mellitus

State the clinical features of diffuse idiopathic skeletal hyperostosis (DISH)

- T7-T11 MC

- Cervical

- Thoracic

- Lumbar

- Extraspinal enthesophytes

- Ligament ossification

State the target sites of diffuse idiopathic skeletal hyperostosis (DISH)

- Flowing hyperostosis

- Preservation of disc spaces

- 4 contiguous segments

- Absence of facet ankylosis

- No sacroiliac involvement

State the criteria for diffuse idiopathic skeletal hyperostosis (DISH)

Ossification of the posterior longitudinal ligament (OPLL)

ID complication of diffuse idiopathic skeletal hyperostosis (DISH)