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58 Cards in this Set
- Front
- Back
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NAME THE 4 CATEGORIES OF ARTHRITIS
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DEGENERATIVE
INFLAMMATORY METABOLIC SEPTIC |
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KEY CLINICAL FEATURES OF DEGENERATIVE ARTHRITIS
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ASYMMETRIC JOINT SPACE NARROWING
*"THE MOST WEIGHT BEARING ASPECT GOES 1ST" MORNING STIFFNESS PAIN & SWELL OSTEOPHYTIC CHANGES CHANGES IN TISSUE CONTOUR REDUCED ROM (ASYMMETRIC) |
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KEY LAB FINDINGS FOR DEGENERATIVE ARTHRITIS
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SERONEGATIVE -- NO PROMINENT FINDINGS
BIOPSY ABNORMALITY -- THINNER CORTICES, LOWER MMP, ACTIVATION OF CYTOKINES. |
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KEY RADIOGRAPHIC FEATURES OF DEGENERATIVE ARTHRITIS
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DECREASED JT SPACE ASYMMETRICALLY
SUBCHONDRAL SCLEROSIS OSTEOPHYTES SUBCHONDRAL CYSTS/GEODES |
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KEY CLINICAL FEATURES OF INFLAMMATORY ARTHRITIS
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SYSTEMIC INFLAMMATION
ULNAR DEVIATION OF MP JOINTS OF HANDS POLYARTICULAR PROCESS ANKYLOSING PANNUS FORMATION DECREASED & PAINFUL ROM |
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KEY LAB FINDINGS FOR INFLAMMATORY ARTHRITIS
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POSITIVE Rf
INCREASED ESR C REACTIVE PROTEIN |
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KEY RADIOGRAPHIC FEATURES OF INFLAMMATORY ARTHRITIS
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ULNAR DEVIATION
SYMMETRIC DECREASE IN JOINT SPACE (PAN COMPARTMENTAL NARROWING)!!!!!! BOUCHARDS NODES (NO SWELLING OF DIP JTS!!) INCREASED RISK OF ADI INSTABILITY (1/5 PTS WITH RA SHOW ADI INSTABILITY) PERIARTICULAR SOFT TISSUE SWELLING PERIARTICULAR OSTEOPOROSIS |
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CLINICAL FINDINGS OF DEGENERATIVE ARTHRITIS
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Local inflammation is present
Morning stiffness in affected joints Reduced range of motion Swelling of afflicted joint Osteophytic change Monoarticular Changes in soft tissue contour |
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LAB FINDINGS OF DEGENERATIVE ARTHRITIS
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No prominent findings (seronegative)
No change in ESR (Eosinophil Sedimentation Rate) Biopsy abnormality Thinner cortices Lowered MMP (methylmetalo protease) Activation of cytokines (pathologic)] |
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RADIOGRAPHIC FINDINGS IN DEGENERATIVE ARTHRITIS
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Decreased joint space in asymmetric pattern(medial worst) owing from decreased articular cartilage
Subchondral sclerosis=whitening/thickening of cortical bone underneath articular cartilage (due to increased stress input from decreased articular cartilage) Osteophytes Geode/subchondral cyst formation (can be synovial fluid or blood or both) Most commonly seen in large joints (hips, knee, shoulders) |
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POSTERCHILD OF DEGEN ARTHRITIS
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DJD/OA
gradual loss of articular cartilage, combined w/ thickening of the subchondral bone; bony outgrowths at the joint margins, and nonspecific synovial inflammation |
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CLINICAL PRESENTATION OF METABOLIC ARTHRITIS
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Older men predominantly
Predominance of the heels, big toe, thumb Abnormal soft tissue (sticking out), pannus Changes made to the underlying bone No initial changes in joint spacing/bone makeup Pain and redness in area of swelling |
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LAB FINDINGS OF METABOLIC ARTHRITIS
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Tissue/suction biopsy
Increased ESR Blood/urine may be normal or abnormal |
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RADIOGRAPHIC FINDINGS IN METABOLIC ARTHRITIS
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No bone changes seen but adjacent soft tissue may calcify (dystrophic)
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CLINICAL FINDINGS IN SEPTIC ARTHRITIS
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Lots of swelling/pain
If younger person they got sick quickly If older person they took a while to develop Destruction of both joint surfaces will occur in chronic conditions Hot, red, swollen, tender joints Previous URTI, recent UTI, or recent skin infection |
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LAB FINDINGS IN SEPTIC ARTHRITIS
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WBC elevation
ESR elevation when large joints are involved Core of ESR measures stability of blood pool If sampled infectious organism may be present |
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RADIOGRAPHIC FINDINGS IN SEPTIC ARTHRITIS
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Symmetrical destruction of joint space
Cortical damage |
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IMPORTANT GENERAL FACTS ABOUT DEGENERATIVE ARTHRITIS (5)
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Most common joint disorder in the world
1/3 of all 65 year olds affected More common in men vs women younger than 50 (post traumatic/wear and tear) More common in women vs men older than 50 (hormonal changes) Predilection for weight bearing joins of the lower extremity, cervical and lumbar spine, and some joints of the hand |
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PHASE I OF DEGENERATIVE ARTHRITIS
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Phase I: Edema and microcracks (enchondral tissue). Edema of the extracellular matrix, cartilage loses its smooth aspect, and microcracks appear
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PHASE II OF DEGENERATIVE ARTHRITIS
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Phase II: Fissuring and pitting. microcracks deepen. Clusters of chondrocytes appear around these clefts and at the surface
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PHASE III OF DEGENERATIVE ARTHRITIS
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Phase III: Erosion
Fissures cause fragmentation of cartilage to detach. These loose fragments cause the local inflammation (much more limited than the typical RA) Subchondral microcysts form (may develop into geodes later) |
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PATHOGENESIS OF DEGENERATIVE ARTHRITIS
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homeostasis of normal cartilage is driven by chondrocytes, which synthesize collagens, proteoglycans, and proteinases
DJD results from failure by chondrocytes to synthesize good quality matrix This abnormal chondrocytes synthesis is the result of tissue activation by cytokines, prostaglandins,free radicals, and fibronectin fragments Activated chondrocytes become capable of producing proinflammatory mediators Certain proteinases are involved in the destruction of cartilage: Matrix metalloprotienases (MMPs) = most potent The MMPs are held in check by Tissue Inhibitor MetalloProteinases (TIMPs) As long as the MMPs and TIMPs are in balance no degradation occurs |
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ARTHROPATHIES MORE COMMONLY ASSOCIATED WITH MALES
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Ankylosing spondylitis
Gout Hypertrophic osteoarthropathy Reiter's syndrome/Reactive arthritis Secondary OA |
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ARTHROPATHIES MORE COMMONLY ASSOCIATED WITH FEMALES
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JRA/JCA
Lupus OCI Primary OA Rheumatoid Arthritis Scleroderma |
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Common A-P C/S
Radiographic Findings of DJD |
Decreased disc space
Subchondral sclerosis should be seen Sharpening/thickening of uncovertebral joints (1st stage of degenerative stage of Uncovertebral Arthrosis) Remodeling of lateral margin due to altered alignment |
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Common Oblique C/S
Radiographic Findings of DJD |
Shows anterior-lateral osteophytes
Watch for Abnormal IVF (oval with concave edges) Uncovertebral encroachment Positioning is very important (may appear to have smaller IVFs but may not) |
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Common lateral C/S
Radiographic Findings of DJD |
Look at disc spacing (should be even posterior and anterior)
Watch posterior elements for sclerosis/thickening Examine the anterior body and posterior elements for osteophytes |
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Common lateral L/S
Radiographic Findings of DJD |
Vacuum phenomenon=tearing of annular fibers leading to opening of space and pulling of gas out of solution after the NP dissolves
Vacuum cleft=marginal disruption of outer annular fibers (may be trauma related or related to degenerative changes) Hahn's fissure=midline artery supply and vein drain for vertebral body (shows up on MR) |
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Anterolisthesis
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Spondylolysis=fracture acting as causative agent for anterolisthesis
Spect or MR scans become indicated if modified Stork Test is positive (localizes pain to one area) Stork Test/Modified Stork Test=Gillet's Test Facet degeneration=alternative causative agent for anterolisthesis Examine the cortical lines to evaluate for fracture Subchondral sclerosis will compromise the joint space |
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Destruction of the IVD
with DJD |
Herniation=NP stays connected to AF but pushes out on Annulus Fibrosus
Sequestration=a free floating fragment of NP not attached to Annulus Fibrosus Hemispherical Spondylosclerosis=half circle of lucency at anterior margin of vertebral body |
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DISH=Diffuse Idiopathic Skeletal Hyperostosis
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aka Forestier's Disease
May occur with DJD While there is calcification of the ALL it doesn't always alter ROM Hypertrophy does not become a problem unless the PLL is involved 40% incidence of co-presence of Diabetes Mellitus patients 4 continuous segments with smooth and flowing ligamentous hypertrophy and ossification required for DISH diagnosis Will not get a cavitation (adjusting will feel boggy) Predominates T6-11, mid cervicals to CT junction, L3-S1 If present in C/S - may present w/ dysphagea |
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Common Radiographic Findings
Of the AP Pelvis in DJD |
Hip is #1 site of DJD in weight bearing joints
Knee is #2 site of DJD in weight bearing joints Decreased joint space Subchondral sclerosis Osteophytic change occurs after the decreased joint space Subchondral cyst is more likely to be seen in the acetabulum than the femoral head Frog leg view may show more osteophytes that are not available on the AP view Osteophytes may appear as a single hook but because we are only seeing along one angle we may actually be viewing a rounded ridge |
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Flame shaped Syndesmophyte
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Has 3 differentials
DISH (Dx by eliminating other disorders) Twin pair=different conditions but look THE SAME on film Reactive arthritis (Reiter's) Psoriatic arthropathy (must have psoriasis lesions) |
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Reiter’s Disease
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Can't see=Conjunctivitis
Can 't pee=Urethritis Can't dance w/ me Osteophyte on calcaneus (lover's heel) Polyarticular arthritis Fluid filled pustules on soles of feet Beuboitis/balanitis=inflammation of glans penis (a classical feature of Reiter's) |
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Physical Diagnostic Criterial for RA
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Physical
1. Morning stiffness 2. Pain on motion or tenderness in at least 1 joint 3. Soft tissue swelling or joint effusion in at least 1 joint 4. Swelling of at least 1 other joint (w/in 3 months) 5. Bilateral, symmetrical, and simultaneous joint swelling (except DIP) 6. Subcutaneous nodules-boney protuberances (extensor surfaces), justaarticular |
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Laboratory Diagnostic Criteria for RA
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7. Positive sheep agglutination test (Rh Factor)
8. Poor mucin precipitate from synovial fluid (have to aspirate from joint) 9. Synovium-at least three of (have to open joint to perform) a. Marked villous hypertrophy b. Superficial synovial cell proliferation c. Marked inflammatory cell infiltrate fibrin deposition d. Foci of cell necrosis 10. Nodules-granulomas with central necrosis, proliferated fixed cells, peripheral fibrosis, and chronic inflammatory cell infiltrate 11. Typical changes-uniform joint space loss, marginal erosions, etc. (radiographic) |
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AS Classic Presentation
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B/l sacroiliits
TL junction 40% more problematic inflammatory bowel disease HLA B27 from lab tests If no HLA B27 then check ESR (for Enteropathic Arthritis) |
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Radiologic changes in the SI joints
w/ Ankylosing spondylitis |
General
Bilateral, symmetric Iliac side is more extensively involved Initially involves lower 2/3 of joint Early "sacroiliitis" Articular erosions (Rosary bead) Diminished joint space Loss of articular cortex definition (pseudowidening) Patchy reactive sclerosis Subchondral osteoporosis Late Bony ankylosis Generalized osteoporosis-disappearance of reactive sclerosis "Ghost" joint margin "Star" sign |
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Hypertrophic joint disease
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Characterized by 6 Ds/(BNSLOT)
Debris (from destruction) Density (subchondral intensity increase) Destruction Dislocation (or feels like it/to much motion) Disorganization Distension Occurs in weight bearing joints |
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REVIEW ANATOMIC CLASSIFICATION OF JOINTS
1- FIBROUS 2- CARTILAGINOUS 3- SYNOVIAL |
1- CRANIAL SUTURES; SYNDESMOSES
2- SYMPHYSIS PUBIS, IVD, MANUBRIOSTERNAL JXN 3- FINGERS, TOES, KNEES, HIPS, APOPHYSEAL JT, SACROILIAC JT |
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OUTER ANNULAR FIBERS OF THE DISC CONSIST PRIMARILY OF _____ AND INSERT BY WAY OF ______ INTO THE VERTEBRAL BODY MARGIN
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COLLAGEN
SHARPEY'S FIBERS |
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ENTHESIS
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TRANSITION ZONE B/W BONE & LIGAMENT OR TENDON
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RAD FEATURES OF JT DISEASE
SYMMETRY |
INFLAM- SYMMETRIC
DEGEN- ASYMM MET- ASYMM |
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RAD FEATURES OF JT DISEASE
JTS INVOLVED |
INFLAM- POLYARTICULAR
DEGEN- MONO MET- MONO OR PAUCI (2-4) |
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RAD FEATURES OF JT DISEASE
ALIGNMENT |
INFLAM- ABN
DEG- ABN MET- NORM |
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RAD FEATURES OF JT DISEASE
BONE DENSITY |
INFLAM- DEC
DEG- NORMAL OR INCREASED MET- NORMAL |
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RAD FEATURES OF JT DISEASE
EROSIONS |
INFLAM- POORLY DEFINED
DEG- ABSENT MET- SHARPLY DEFINED |
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RAD FEATURES OF JT DISEASE
OSTEOPHYTES |
INFLAM- ABSENT
DEG- PRESENT MET- ABSENT |
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RAD FEATURES OF JT DISEASE
PERIOSTITIS |
INFLAM- PRESENT
DEG- ABSENT MET- ABSENT |
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in the lumbar spine, up to ____% of asymptomatic individuals have disc abnormalities shown by mri
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50%
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young adult male with bilateral loss of SI joint definition suggests
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ankylosing spondylitis
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RA, JRA, Reiter's, and AS are all associated with _________
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Atlanto-Axial instability
(measure ADI, & posterior cervical lines) |
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characteristics of osteophytes
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- distinct bony cortex
- normal internal trabecular architecture - distal unattached surface has cartilage (analogous to long bone growth plate)-->contributing to progressive growth of the osteophyte |
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one of the best views to see degeneration of the hip joint
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frog leg
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DJD of the cervical spine
(rad features) |
C5-C6
apophyseal joints - osteophytes, sclerosis, sublux lushka- osteophytes, foraminal encroachment ivd- decrease height, vacuum phen, osteophytes, canal stenosis |
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DJD thoracic spine
(rad features) |
T6-T12
costovertebral joints- osteophytes ivd- decrease height, osteophytes (unilateral, only on the right side) kyphosis |
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DJD lumbar spine
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L4-L5$$
apophyseal- decrease space, sclerosis, osteophytes, sublux IVD- decrease height, vacuum phen, osteophytes, canal stenosis, body sclerosis |
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3 interpretations of vacuum phenomenon
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1- reliable sign for excluding infection
2- indicates degenerative disc 3- indicates that intersegmental motion is occurring |
