Di Imaging I - Exam 3 (Spinal RA, Seropositive, Systemic Diseases)

RA in the Cervical spine will impact about 50% of RA patients within ______ of diagnosis

10 years

RA of the Cervical spine findings

atlantoaxial subluxations (AADI >3 mm, PADI <14 mm)

atlantoaxial impaction

odontoid erosions (whittled dens)

subaxial subluxations (canal <14 mm)

apophyseal joint disease

spinous process erosions

osteopenia

Which of the findings of cervical RA is the MC to cause neurological symptoms

atlantoaxial impaction

Odontoid erosions can occur in what three different synovial joints

btw dens and anterior arch (AADI)

btw dens and transverse ligament

tip of dens

What two diseases does this pt have

OA + RA

What two image studies should be perfomed to evaluate the AADI movement

flexion and extension

The AADI should not exceed ____ in an adult

3mm

A wider AADI (due to erosions caused by pannus) is bad b/c

space available for cord (SAC) is decreased → posterior cord compression

If erosions of bone is seen, it has already gotten through

ligaments and soft tissues

What finding of cervical RA is in this image

Occ-C1 and C1-2 facet erosions

What finding of cervical RA is in this image

basilar invagination

What are four other reasons why a pt could have a wider AADI

congenital anomaly

narrowing PADI

fracture of C1 (at least 2 in ring)

inflammation or degenerative

Juvenile Chronic Arthritis (juvenile idiopathic arthritis) onset

before 16 yo

Which type of JCA is most common

seronegative - polyarticular in females

JCA (Juvenile Chronic Arthritis) is a _____ disease (lymph, spleen, liver, heart)

systemic

Polyarticular form of JCA

bilateral and symmetrical involvement

mild fever

lymphadenopathy

rash

JCA (Juvenile Chronic Arthritis) radiolgy findings

soft tissue swelling (bare areas)

osteopenia (pannus dec bone density)

JSN

articular erosions

malalignments/subluxations (growth disruptions, periostitis (mouse ears), ankylosis)

JCA locations

hands - periostitis and shortening

knee - ballooning of metaphysis

hip - acetabular protrusion

cervical spine - erosions, posterior joint ankylosis

Balooning represents large epiphysis with a constricted appearance of the

metaphysis and diaphysis

What finding of JCA is found in this image

periostitis

• children have loosley attached periosteum

This young female presented with stiffness and pain in both wrists, limitation of movement in both wrists (esp. right side), what diagnosis would you give her

JCA

What JCA two radiological findings are in this image

osteopenia

ballooning - enlargement of distal femoral epiphysis

This adult patient who had JCA presents what findings

hypoplastic bodies (didn’t fully develop)

ankylosed facets

This pt has what two diseases

OA + JCA (more clinically significant)

Systematic lupus erythematosus (SLE)

generalized connective tissue disorder involving multiple organs

seropositive

20-40 yo females

ANA positive

90% of SLE pt have articular symptoms regardless of

radiographic evidence (symp well before radiographic findings)

The MC and serious consequences of SLE involve the

kidneys - nephropathy and renal failure

raynaud phenomenon

SLE findings

hands, wrists, shoulders, knees, feet

bilateral and symmetrical

widened AADI

joint swelling and pain

soft tissue calcifications

non-erosive

subluxed joint can be temporarily manually reduced

SLE is commonly treated with

corticosteroids (on/off to reduced risk of avascular necrosis/osteonecrosis)

Fibrinoid necrosis in tissues due to SLE cause

synovitis, vasculitis, pleuritis, pericarditis, nephritis

SLE in hands

MCP and PIP joints

ligament laxity → ulnar and fibular deviation

swan neck deformity (unopposed flexion)

boutonneire deformity (unopposed extension)

What disease does this pt have

SLE

What findings of SLE does this x-ray show

ulnar deviation (NO erosions)

osteopenia

SLE + increased risk of clots + Tx of corticosteroids =

increased risk of avascular necrosis

Jaccoud Arthropathy

follows rheumatic fever (hx of strep)

associated with multiple connective tissue disorders

Jaccoud arthropathy is a radiographic mimic of

SLE (non-erosive, ulnar deviation, fibular deviation, swan neck, boutonniere)

How to differentiate SLE from Jaccoud

SLE first thought from findings…but Jaccound will have a hx of cardiac issues

Scleroderma (progressive systemic sclerosis - PSS)

generalized systemic inflammatory connective tissue disorder of skin, lungs, GI, kidneys, MSK system

seropositive

What is the MC finding of scleroderma (PSS)

small vessel calcifications

Scleroderma (PSS) skin findings progression

1) edema

2) induration/hardening (Hidebound)

3) atrophy

sometimes raynaud pheomenon too

MC organ involvement of scleroderma besides the skin

esophagus dilate and reduced mobility (dysphagia and heartburn)

bowels slow down (constipation and impaction)

CREST syndrome fo scleroderma

Calcinosis (of soft tissues)

Raynaud phenomenon

Esophageal dysmobility

Sclerodactyly (contracture)

Telangiectasia (dilated subdermal blood vessels)

Scleroderma (PSS) in hands

osseous resorption of distal tufts/ungual tufts (acral osteolysis)

flexion contractures

What x-ray finding is present in this pt with Scleroderma (PSS)

acral osteolysis

soft tissue calcifications (calcinosis)

Other causes of acro-osteolysis

burns, frostbite, electric shock, syringomyelia, diabetes

raynaud, sarcoidosis, hyperparathyroidism, leprosy, lesch-nyhan

How to differentiate scleroderma from other causes

just acral osteolysis = think of other causes

soft tissue calcification + acral osteolysis = scleroderma

What are some ddx for clavicle erosions

hyperparathyroidism

RA

post-traumatic osteolysis

scleroderma

ankylosing spondylitis

Osteopenia

broad, all-encompassing term describing increased radiolucency of bone

generalized loss

a FINDING (not dx)

If the cause of bone density loss is osteoporosis, use the term

osteoporosis (radiolucency)

• generalized loss of bone quantity

• regional loss of bone quantity

• localized loss of bone quantity

If the cause of bone density loss is NOT osteoporosis, use the term

osteopenia

Hormones and nutrients inhibiting bone production

parathyroid hormone (PTH) *Primary bone absorption*

cortisol

Max bone density in males vs females

Males = 40-50

Females = 35

Non-modifiable osteoporosis risks

>70

asian and caucasian

early onset of menopause

thin build frames

Chances of hip fractures (femoral neck) in women ____ every 5 years after 60yo

double

Primary osteoporosis

Age related (senile) osteoporosis

Post-menopausal osteoporosis (dec estrogen)

Transient or regional osteoporosis (cast/immobilized)

Secondary osteoporosis

coricosteroids

malignancy

infection

Complex regional pain syndrome (CRPS)

You wouldn’t take an ___ if you want to confirm a diagnosis of osteopenia

x-ray (require 30-50% loss before able to see)

Bone scan

evaluate degree the tissues absorb the radiotracer

technetium is absorbed by cells immediately, soft tissues, bone (3hrs)

increased uptake in areas more metabolically active (ANYWHERE)

The Bone scan is a sensitive exam for bone activity, but not a

specific exam

DEXA T scores

T score: amount of bone you have compared w/young adult of same gender with peak bone mass

• -1.1 to -2.4 = osteopenia

• < -2.5 = osteoporosis

DEXA Z scores

Z score: amount of bone you have compared w/other people your age of same size and gender

• abnormally high or low require further tests

T score predicts fracture risk by saying for every -1 SD, the fracture risk

doubles

Orientation of trabeculae

1* = weight bearing (vertical)

2* = stability (horizontal)

3* = tertiary (crisscross)

Bone resorption ordered 3→2→1 (vertical only left)

Osteopenia radiographic findings

cortical thinning (pencil thin)

vertical trabeculae/struts

altered VB shape

There is a normal less dense area within the femoral neck known as

Wards triangle

A compression fracture occurs in a pt with

non-altered bone density

A pathological fracture occurs in a pt with

altered bone density

Fracture shapes of osteoporosis

wedge-shaped

endplate concavity

codfish vertebra deformity (biconcave compression fx)

schmorl nodes

What type of fracture due to osteoporosis is shown in the image

codfish vertebra deformity (biconcave compression fx)

What is a DDX of codfish vertebra deformity

nuclear impressions (nucleus pulposus of IVD)

This patient has hyperparathyroidism which has caused ______ and fractures that made the VB to be smaller than the IVDs

osteopenia

A single vertebra with accentuated vertical trabeculae is a characteristic finding of a benign tumor-like condition of dilated capillaries

hemangioma

Pathological fractures

metastasis (lytic)

multiple myeloma

osteoporosis

eosinophilic granuloma (pediatrics)

What diagnosis does this pediatric patient have

Eosinophilic granuloma

Disuse osteoporosis findings

diffuse osteopenia of that region

lucent bands of osteopenia proximal to physeal line

subchondral lucency

uniform/spotty demineralization (spotty carpals)

What radiographic findings of Disuse osteoporosis are found in this image

diffuse osteopenia

uniform/spotty demineralization (spotty carpals)

Complex regional pain syndrome (CRPS) osteoporosis

neuropathic pain disorder

allodynia (nerve related pain), hyperalgesia (sensitive to stimuli), sudomotor and vasomotor abnormalities, trophic changes

soft tissue swelling

regional osteoporosis

Complex regional pain syndrome (CRPS) osteoporosis types

Type 1 - absence of nerve trauma

Type 2 - occurs in the setting of known nerve trauma

**Follows a regional distribution

What type of secondary osteoporosis does this pt have

CRPS osteoporosis

Transient Osteoporosis of the hip (TOH)

MC in young adults 20-40 and pregnancy (3rd tri)

MC in men bilaterally

MC in left hip in women

self-limiting over 3-12 months

Transient Osteoporosis of the hip (TOH) findings

periarticular osteopenia w/preserved joint spaces

bone scan - increased uptake of radiotracer (hot spots)

MRI (T2) - diffuse bone marrow edema

An accurate diagnosis of Transient Osteoporosis of the hip (TOH) requires what imaging type

MRI

**sensitive to fluid accumulation

What type of secondary osteoporosis does this pt have

Transient Osteoporosis of the hip (TOH)

Osteomalacia (malacia = softening)

diminished bone QUALITY due to lack of calcium salt deposits

abnormal ratio of osteoid to mineralized bone

Osteomalacia findings

osteopenia

coarsened trabeculae

medial looser zones (pseudofractures) *late sign*

horizontal osteoid lines

basilar invagination

acetabular protrusion

What is required in order to definitively diagnose osteomalacia

bone biopsy

What finding is seen in this image of a pt with Osteomalacia

medial looser lines/zones at most weight bearing part of femoral neck

**Note: we don’t get fractures ½ into bone!!

What radiographic finding of Osteomalacia can be found in RA too

acetabular protrusion (BUT with erosions in RA!!)

Rickets (pediatric osteomalacia)

decreased quantity of calcified osteoid

delayed skeletal maturation (small stature)

soft tissue edema near open ossification centers

Rickets findings

physeal/growth plate appearance

“fraying”

• reduced mineralization of cartilage

• cartilage overgrowth

• bowing deformities

• widening/splaying at physes

• rachitic rosary in ribs

Rickets findings are common in which type of bones

long bones!

• ribs

• femur, humerus, tibia, ulna, radius

What radiographic finding is in this image of Rickets

Rachitic rosary

What radiographic finding is in this image of Rickets

Widening/splaying at physes (splayed and frayed)

What two radiographic findings are in this image of Rickets

splayed metaphyses (fraying and sclerosis)

bowing deformities (genu varus)

Osteomalacia and Rickets are caused by what deficiencies

vitamin D, calcium, and/or phosphate deficiencies

Scurvy (Barlow disease)

vitamin C deficiency

infants that were fed pasteurized/boiled milk (infantile scurvy)

Scurvy (Barlow disease) findings

petechiae, bleeding gums, hematuria

joint edema and pain (frog leg position relieves pain)

mimics non-accidental trauma (abuse)

cartilage is slow to grow BUT mineralizes

osteopenia

Scurvy (Barlow disease) radiographic findings

widened metaphyses (splaying and fraying)

sclerotic/dense zones of provisional calcification (ZPC)

• white line of frankel

radiolucent band adjacent to ZPC

• scorbutic zone/trummerfeld zone

beak-like metaphyseal outgrowths at right angles to diaphyseal shafts

• pelken spurs

dense sclerosis around epiphyses w/lucent centers

• wimberger ring sign

irregular metaphyseal margins

• corner sign

What radiographic finding of Scurvy is in the blue box

wimberger sign (ringed epiphysis)

What two radiographic findings of Scurvy are in the yellow box

pelkin spurs

corner signs