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207 Cards in this Set

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Anatomical Components of the Skeletal System
1. Tissue types
2. Cells
3. Covering
4. Layers
5. Parts
6. Development
Tissue Types
The skeletal system is composed primarily of two highly specialized tissue types: bone and cartilage
Cells in Bone
Osteoblasts build bone up. Osteoclasts break bone down.
Covering of Bone
A fibrous membrane called the periosteum covers the outer surfaces of bone except at joint surfaces where articular cartilage covers the bone and acts as a protective cushion. The medullary cavity is lined by an inner membrane called the endosteum.
Layers or Types of Bone
Outer layer - compact bone which is a matrix of complex structural units called "haversian systems".
Inner layer - Cancellous (spongy) bone which is a weblike arrangement of marrow-filled spaces separated by thin processes of bone called trabeculae.
Parts of Bone
Parts of a long bone - diaphysis, metaphysis, epiphysis
Development of Bone
Matrix Bones - Bone consists of an organic matrix in which inorganic salts (calcium and phosphate) are deposited.
Long Bones - The cartilage between the metaphysis and the epiphysis ossifies during growth and fuses.
Development of Bone - Osteoclasts and Osteoblasts
Osteoclasts enlarge the diameter of hte medullary cavity by removing bone from the diaphysis walls. Osteoblasts from the periosteum produce new bone around the outer circumference.
Bone Age
Skeletal bone age is determined using the Greulich and Pyle radiographic atlas.
Essentials for Obtaining Quality Radiographs of Bone
1. Proper patient positioning
2. Correct alignment of the tube, the body part, and the image receptor
3. exposure factors chosen to produce optimal contrast and visiblility of detail taking into account disease processes and how they affect the absorption of bone.
Alternative Modalities for Imaging the Skeletal System
MRI - movement of hyrdogen
- Bones end up lookign black - MRI is good at looking at cartilage and ligaments.
CT - Good for evaluation of normal fractures because we can get that third dimension
Nuc Med - We see increased vascular flow ("hot spots") that indicate cancer or very fine fractures that may not be seen on x-ray.
X-Ray Penetrability Aspects of Disease Processes
Pathology that increase bone density - sclerosis, marble bone, paget's disease - require an increase in technique.
Pathology that decrease bone density - carcinoma, gout, arthritis, metastasis, osteoporosis, osteomalacia - need to decrease technique.
Congenital/Hereditary Skeletal Abnormalities
An abnormality in the skeletal system that is present at birth and/or is inherited.
Congenital Disease - Vertebral Anomalies
Transitional Vertebra - Most frequently occur at the lumbosacral junction and contain expanded transverse processes.
Rudimentary Ribs - extra ribs seen at the thracolumbar junction or at the seventh cervical vertebra.
Problems Caused by Vertebral Abnormalities
Transitional Vertebra - extra sacral vertebra can make uneven weight distribution and nerve impingement at the SI Joints.
Rudimentary Ribs - can cause psoas muscle issues if they are fractured.
Hemivertebra - this half vertebra can create an unusual curvature and formation of the spine.
Treatment of Vertebral Abnormalities
Most go unnoticed, but if they do cause problems such as compressing nerves or arteries, then surgical removal is the treatment.
Congenital Disease - Spina Bifida Occulta
Non-fusion of spinous process area.
- Is a neural tube defect caused by insufficiencies of folic acid (vitamin B9) in pregnancy.
- Occulta means "hidden" so there is no external evidence/demonstration of symptoms for the most part.
- If anything, you may see a little tuft of hair on the back and it can cause unusual stress on the lamina.
Spina Bifida Occulta Radiographic Appearance
It will look like there is a missing "owl nose" on an AP lumbar spine.
Congenital Disease - Spina Bifida (Meningocele or Myelomeningocele)
Meningocele - meninges coming out in a little sac
Myelomeningocele - meninges plus nerve cells/spinal cord contents coming out into little sac.
Spina Bifida Complications
Can become an intracranial pressure concern due to CSF in the sac which can lead to excessive CSF = hydrocephalis. Can also see clubfeet, gait disturbances, and bladder incontinence, and neurologic deficits at and below the site of protrusion.
Chiari Malformation
Is a complication of spina bifida that almost all patients that have myelomeningocele have. The Chiari II malformation is a caudal displacement of posterior fossa structures through the foramen magnum and into the cervical canal. This puts excess fluid and pressure on the medulla causing respiratory problems.
Radiographic Appearance of Spina Bifida
Large bony defects - absence of the laminae and increased interpedicular distance. The herniated spinal contents are seen as a soft tissue mass posterior to the spine.
Treatment of Spina Bifida
Prenatal prevention with taking folic acid is best. Spina bifida occulta and meningoceles usually require no treatment. Myelomeningocele requires surgical repair and shunting.
Congenital Disease - Hip Dysplasia (Dislocation)
Incomplete acetabulum formation caused by physiologic and mechancial factors.
- As the baby gets bigger, there is less space for amniotic fluid which creates excessive pressure around the hips of the baby. This can cause avascular necrosis and/or loosening of the joint due to lengthening of ligaments and tendons.
Hip Dysplasia Signs and Symptoms
Hip may pop and click when the leg is flexed and abducted. Early identification is best.
Hip Dysplasia Radiographic Appearance
AP image appears almost normal with only a slightly larger joint space. On lateral, the hip is usually dislocated superiorly and posteriorly.
Hip Dysplasia Treatment
Immobilization of the femoral head. A SPICA cast is used to realign and hold the femoral head in place.
Malformation of Hands and Feet
- Syndactyly - Fused phalanges
- Polydactyly - Many phalanges
- Clubfoot - Feet are turned in and upwards.
***All three can be hereditary and/or congenital. If it is bilateral it is usually hereditary and if it is unilateral it is usually congenital.
Syndactyly and Polydactyly
Harder to separate or remove these than it might seem because vasculature, nerves, tendons, and ligaments are involved.
Clubfoot
The turn in and up of the feet makes ligaments inside shorter and outside longer so it is harder to fix than "pigeon-toes". It takes a long process of braces to realign.
Hereditary Disease - Osteopetrosis (Marble Bone)
Heriditary dysplasia inc which failure of the resorptive mechanism of calcified cartilage interferes with the normal replacement of bone. This prevents the bone marrow from forming so that bones become very brittle and stress fractures occur often.
-ie...osteoclasts do not reabsorb and osteoblasts are at a normal rate so broken down bone in medullary cavity is not being reabsorbed and there is not enough room for bone marrow formation.
Osteopetrosis Affects
- It really is "soft" bone
- Shortened life expectancy (8-10 yrs)
- Insufficient RBC's so anemic
- Insufficient WBC's so immunocompromised
- Brittle bones
- Craniotubular - causes pinching of nerves (palsy) in face and blindness due to pinching of optic nerve.
Osteopetrosis Radiographic Appearance
Symmetric, generalized increase in bone density. Must increase exposure factors to compensate for increase in bone formation. Image may appear blurred due to structural changes.
Osteopetrosis Treatment
- Give parathyroid hormone to stimulate reabsorption of bone.
- Give blood transfusions and bone marrow transplants.
THERE IS NOT effective treatment at this point.
Hereditary Disease - Osteogenesis Imperfecta
Inappropriate formation of collagen in bones making bones brittle and VERY easy to break.
Osteogenesis Imperfecta Signs and Symptoms
- Multiple fractures (can be mistaken for child abuse so important to know history)
- Blue tint in sclera of eyes
- Hairline fractures often cause unusual reformation of bone seen as growth defects externally
- Most severe cases usually die at birth due to the curshing of the skeletal system in the birth canal.
Osteogenesis Imperfecta Radiographic Appearance
Repeated fractures due to severe osteoporosis at different stages of healing and that heal with exuberant callus formation (can simulate a malignant tumor) causing bizarre deformities. Must lower technique to account for bone loss.
- In the skull it may present as wide sutures with multiple accessory bones within the sutures called wormian bones.
Osteogenesis Imperfecta Treatment
- Extendable rods for support
- Medications to decrease osteoclastic breakdown so osteoblasts have time to build up
- Education and safety measures to decrease fractures
Heriditary Disease - Achondroplasia
Means "without cartilage formation"
- The most common form of dwarfism and is hereditary in the dominant gene.
- They have normal matrix bone formation but abnormal long bone formation because the epiphyseal plates have no cartilage to grow and expand.
Achondroplasia Signs and Symptoms
Short limbs with normal trunk length, large head with frontal bulging, saddle nose, jutting jaw, and prominent buttocks.
- Causes inproprotionate weight distribution on legs causing knee, feet, and hip problems and may cause gait and balance issues. Hygiene issues can also occur due to short arm length.
Achondroplasia Radiographic Appearance
- Progressive narrowing of the interpedicular distances from above downward
- Scalloping of the posterior margins of the lumbar vertebral bodies
- Short, thick long bones with widened metaphysis
Achondroplasia Treatment
No cure. Treatment is just education, exercise and diet to ease pressure and gait issues.
Craniosynostosis
means "skull fused unusually"
Is the unusual (premature) closing of sutures in the head. Not supposed to close for 18-21 mos. This is closing prior to that so brain starts pushing out of other places.
Craniosynostosis Complications
Pressure on one side can cause squeezing of ventricles leading to hydrocephalus - use shunt to drain.
Craniosynostosis Treatment
No treatment other than surgical intervention. They have to open the sutures back up.
Anencephaly
means "no brain"
A neural tube defect where there is no skull to protect the brain from amniotic fluid which leads to no brain because the acidic amniotic fluid will eat it away. Child will have a brain stem and spinal cord but will live only a short time.
Anencephaly Treatment
No cure. Can be seen in utero. Only treatment is preventative - folic acid!
Metabolic Bone Diseases
Biochemical disease processes caused by problems with metabolic processes in the body such as absorption of nutrients or cell functionality.
Metabolic Bone Disease - Osteoporosis
Cortical edge thinning caused by osteoclasts breaking down bone normally but osteoblasts not bringing in new bone formation consistantly to match osteoclast breakdown. This creates a wider medullary cavity decreasing cortical edges.
Osteoporosis Radiographic Appearance
The ability to differentiate from one bone to the next is lost due to loss of cortical edges (Most evident in the spine and pelvis). As the bone density decreases, the cortex appears as a relatively dense and prominent thin line looking like a "picture frame" surrounding the bone.
- May also see a spotty loss of density.
Osteoporosis Causes
- Vitamin D Deficiency
- Calcium Absorption deficiency
- Decrease in metabolic rate
- Menopause (loss of estrogen)
- Decrease in activity
Imaging modalities to See Osteoporosis
Since there must be a 30% decrease in bone matrix density to visualize it on an x-ray, osteoporosis is better seen on quantitative CT and/or DEXA scan (dual-energy x-ray absorptiometry) which provide data that measure bone mineral content.
Osteoporosis Treatment
- Vitamin D
- Weight bearing exercises
- Diet
- Meds to stimulate thyroid (Boniva)
- Severe cases - kyphoplasty or vertebroplasty to prevent vertebral collapse.
Metabolic Bone Disease - Osteomalacia/Rickets
Osteomalacia is insufficient mineralization of the adult skeleton.
Rickets is the childhood version where calcification of the growing skeletal elements is defective because of a deficiency of Vitamin D in the diet or lack of exposure to UV radiation.
Osteomalacia/Rickets Causes
Vitamin D Deficiency and/or lack of UV radiation.
Osteomalacia/Rickets Radiographic Appearance
Causes weak bones and appears as a loss of bone density because of the presence of nonmineralized osteoid. Cortical edges may stand out due to thinning, like osteoporosis, but unlike osteoporosis, they are indistinct or blurry. Due to softening of bones, bowing can occur in long bones.
Osteomalacia/Rickets Treatment
Doses of Vitamin D with calcium supplements.
Metabolic Bone Disease - Gout
A disorder in the metabolism of purine in which an increase in the blood level of uric acid leads to teh deposition of uric acid crystals in the joints, cartilage, and kidney. This causes irritation of the synovial membranes which in turn can cause degredation of bone ends.
Gout Radiographic Appearance
It is most commonly seen in the 1st metatarsophalangeal joint. It is usually seen as soft tissue density that can obscure bone density and look like cysts with overhanging edges called "rat bite" erosions.
- May see stones on abdominal x-rays
Other Tests to Identify Gout
- MRI can be used to visualize
- Test w/BUN since urea is a waste product which should be taken out in the kidneys. If it is high, this is not happening.
Common Sites of Gout
- 1st MTP Joint
- ear
- olecranon bursa
- achilles tendon insertion
Gout Treatment
- Antihyperuricemic medications which decrease protein metabolism or increase kidney function
Metabolic Bone Disease - Paget's Disease
Also called Osteitis Deformans (Unusual formation of bone).
A progressive disorder that is the destruction of bone followed by a reparative process that results in weakened, deformed, and thickened bony structures that tend to fracture easily. The bone breaks down and the osteoclasts come in to rebuild, but there is insufficient mineralization causing "soft" bone.
Paget's Disease Common Sites and Imaging
Mostly affects the pelvis, femurs, skull, tibias, vertebrae, clavicles, and ribs.
- Best demonstrated on a radionuclide bone scan.
Paget's Disease Radiographic Appearance
Mottled "cotton-wool" appearance - looks like "hairs" on the bone due to irregular islands of sclerosis and cortical thickening.
Paget's Disease Complications
Is unequal deterioration.
- Downward thrust of the heavy head on the softened bone of the skull base may compress the brainstem and cause numerous cranial nerve deficits.
- Expansion and distortion of softened vertebral bodies may compress the spinal cord.
- Multiple arteriovenous malformations in pagetoid bone may result in high-output cardiac failure.
- in 1% there can be development of osteosarcoma.
Paget's Disease Treatment
There is no known ideology so there is no curative treatment. It affects people in the 30-50 age range mostly.
Treatment is palliative - anti-inflammatories, pain meds, stabilizers such as spints.
Metabolic Bone Disease - Acromegaly
Growth hormone is produced beyond puberty, after the growth plates have fused. This can be caused by pituitary issues since it is released by the pituitary or with hypothalmus issues since it tells the pituitary when to release it.
Acromegaly Complications and Radiographic Appearance
- Leads to abnormally long bones and then matrix bones and soft tissues expand and increase in thickness after puberty.
- We have typically less than 23mm of soft tissue in hands and feet. In Acromegaly, the tissues in hands and feet is really thick.
Acromegaly Treatment
- May irradiate pituitary to try and slow down growth hormone.
- May remove tumors from pituitary if they are there.
- May give hormone suppressing drugs.
Neoplastic Bone Disease
An abnormal new growth of tissue. Can be benign or malignant.
Diagnosis of Neoplastic Bone Disease
Viewed on CT, Tomography, X-rays, and Nuclear Medicine Imaging but diagnosed through Biopsy to see if it is benign or malignant.
Defining Factors of Benign VS Malignant Tumors
1. Age - of individual and clinical indications
2. Pattern - well-defined borders, diffuse, symmetrical, localized, etc...
3. Location - In periosteum, endosteum, etc...
4. Position - Surrounding tissue, affected VS unaffected areas.
Benign Tumors of Bone - Osteochondroma (Exostosis)
Is unusual growth outside bone - originates in structures with cartilaginous areas sucha s metaphysis/epiphysis.
- Usually grow from the metaphysis outward and grow away from the joints.
Osteochondroma Complications
- Only real issue is pressure
- Extra bone may just irritate unless it gets hit and broken then it can become embedded in muscular structures.
Osteochondroma Treatment
Men are 3X as likely to have osteochondromas.
- Even if they are taken out they usually come back so often, unless there is an irritation or pain issue, they are left alone.
- can be found in long bones and matrix bones.
Benign Bone Tumors - Osteoclastomas (Giant Cell Tumors)
Sometimes called Soap-Bubble Tumors due to how they look on Radiographs, these are benign tumors but they can turn malignant.
- they are caused by enlarged osteoclasts so they are found in the medullary cavity
- can be a complication of Paget's disease
Giant Cell Tumors Complications and Common Sites
- The expansion of the medullary cavity deteriorates the cortical bone and causes major pressure.
- Can reoccur, even if removed.
- Common Sites - distal femur and proximal tib/fib
- increased incidence in Chinese population
Giant Cell Tumors Treatment
50% are benign and 50% are malignant so it is best to remove these at the early stages even if it may reoccur so it doesn't become malignant. This is especially important since they are slow growing unless they become malignant at which point they metastasize quickly.
Treatment is removal and stabilizing devices.
Benign Bone Tumors - Osteoma
Where two pieces of bone come together and then instead of stopping they continue to grow.
Osteoma Complications
Typically these are not a problem until they start causing functional issues. For instance, one filling up the sinuses would cause sinus pressure. If one is in the jaw, it could cause trouble eating. One behind the eye could put pressure on the optic nerve causing visual problems.
Osteoma Radiographic Appearance
Well-cicumscribed, extremely dense, round lesions that are less than 2cm in diameter. Most occur in the femur and tibia and originate from osteoblastic cells. Sometimes best seen on overexposed films or CT.
Osteoma Bone Islands
Bone islands are still osteomas, they are just osteoclastic breakdown that is not reabsorbed and becomes calcified.
Osteoma Treatment
Surgical excision if it is causing pain or pressure issues.
Bone Cysts
Can be simple, multiloculated, or aneurysmal.
- A collection of serous fluid inside a well-delineated area. Can be in areas of trauma, after an infection, etc...
Common sites of Bone Cysts
A simple bone cyst is most often found in the proximal humerus or femur at the metaphysis.
Radiographic Appearance of Bone Cysts
Simple cysts look like expansile lucent lesions with a thin rim of sclerosis.
Aneurysmal cysts look like a pronounced ballooning with thinned cortex (internal separations)
Bone Cyst Treatments
Simple and Multiloculated - Drain to remove fluid and then put bone graft/chips inside to regenerate bone. In multiloculated tney may do surgery to remove insides due to compartments and then put in bone chips.
Aneurysmal cysts - Due to the vasculature structures in these cysts, they may do a CT to determine if they are just fluid filled or vasculature. If there is vasculature, they do not want to biopsy because this could cause hemorrhage. They will then surgically drain.
Benign VS Malignant Appearances on Radiographs
Benign bone neoplasms generally displace soft tissue, whereas malignant bone tumors produce true soft tissue swelling. When there is bone expansion, an intact cortex with a sclerotic margin (ie. well defined border) usually indicates a benign lesion. Malignant bone lesions generally cause cortical bone erosion that has a poorly defined or absent margin and extends into the soft tissue through spiculations.
Malignant Bone Tumors - Osteogenic Sarcoma (or Osteosarcoma)
Starts in the bone and is found in the connective tissue (ie. bone, ligament, or tendon). Causes a complete deterioration of the bone and inflammation of tissue.
Osteosarcoma Radiographic Appearance
Often looks "starburst" in appearance and seems to completely obscure bone but really is completely eating away at bone and causing inflammation in surrounding tissue.
- On a nuc med study it looks like asymmetry with greater uptake of nucleide in affected area.
Osteosarcoma Common Sites
50% are associated with the knee joint/distal femur. It is often found in young people (under 20) in the metaphyseal area.
Osteosarcoma Treatment
Amputation is the only treatment. This is because it is in the bone marrow area so it is highly likely to metastasize. Then treated with radiation and chemotherapy.
Osteosarcoma Signs and Symptoms
Initial complaints are usually local pain and swelling, followed by fever, weight loss, and secondary anemia.
Osteosarcoma Prognosis
Usually fatal but about 30% of patients are cured after receiving chemotherapy.
Malignant Bone Tumors - Ewing's Sarcoma
Starts in the medullary cavity of long bones and deteriorates entire bone. Tumor cells invade the cortical bone and spread into the soft tissue.
Ewing's Sarcoma Signs and Symptoms
Local pain for several months that persistently increases in severity and may have a tender soft tissue mass. Patients may also have malaise, appear sick, and have fever and leukocytosis.
Ewing's Sarcoma Radiographic Appearance
An ill-defined permeative area of bone destruction involving a large central portion of the shaft of a long bone with layered periosteal reaction (called "onion-skin" appearance)
Ewing's Sarcoma Stats
Who: Osteogenic tumor affecting young people (5-15 years old). More commonly affects males than females
What: Deteriorates entire bone by starting in the medullary cavity and eating its way out!
Where: Progresses rapidly and has a high potential for metastasis if not found quickly. Due to this they will do a nuc med scan to identify sites.
Ewing's Sarcoma Treatment
Amputation and chemo. There is a 75% 5-yr survival rate with chemo after amputation because they have identified the cell type and the chemo that best affects it.
Malignant Bone Tumor - Multiple Myeloma
Means "Many Marrow Tumors"
Is a disseminated malignancy of plasma cells that may be associated with bone destruction, bone marrow failure, hyper calcemia, renal failure, and recurrent infections. It attacks the intermedullary canal of the diaphysis through abnormal proliferation of one particular antibody.
How Multiple Myeloma is identified
It is identified by protein in the urine called Bence Jones which is caused by the breakdown of antibodies. It can also create high levels of calcium in the vasculature causing deterioration of the kidneys.
MGUS
Multiple Myeloma is progressive . First you can have MGUS (multiple gammaglobulin of unknown significance) which you can live with your whole life and have no problems until/unless it progresses and passes the threshold into stage1 multiple myeloma.
Multiple Myeloma Common Sites
Since this bone destruction is attributed to the proliferation of plasma cells distributed through the bone marrow, the flat bones containing red marrow are most affected - vertebrae, skull, ribs, and pelvis.
Multiple Myeloma Signs and Symptoms
5 Cardinal Signs of CA, bone pain, more prone to infection
Multiple Myeloma Treatment
Early Stage Treatment - pain meds, blood transfusions, iron supplements (NO anti-inflammatories)
Stage 3-4 Treatment - Chemo (not given until this point because it can kick cells into "overdrive"), bone marrow transplant.
Multiple Myeloma Prognosis
Mostly affects those ages 40-70. Prognosis is grim with most dying within 3-4 years.
Multiple Myeloma Radiographic Appearance
Looks like multiple "punched out" osteolytic lesions scattered throughout the skeletal system. Looks like bone is broken down and "patchy".
Methods of Metastasis
The most common malignant bone tumors which spread by means of the bloodstream or lymphatic vessels or by direct extension.
Common types of cancer known for Bony Metastasis
The most common primary tumors are carcinomas of the breast, lung, prostate, kidney, and thyroid. The favorite sites of metastatic spread are bones containing red marrow such as the spine, pelvis, ribs, skull, and upper ends of the humerus and femur.
Screening for Metastasis
The best screening exam for the detection of asymptomatic skeletal metastases is teh radionuclide bone scan or the PET scan because too much bone must be lost to be seen on regular x-ray. X-ray is then used to examine only those areas that show up on the PET scan as hot spots to further help in diagnosis. Bone destruction by metastasis and associated extension of tumor in the adjacent soft tissues can be well demonstrated on CT and MRI.
Types of Metastases
Ostyeolytic, Osteoblastic (or sclerotic), and Mixed
Osteolytic Metastases
Osteolytic metastases cause destruction w/out accompanying bone proliferation. They develop from tumor embolic deposits in the medullary canal and eventually extend to destroy cortical bone.
Osteolytic Metastases Radiographic Appearance
The margins of the lucent lesions are irregular and poorly defined, rarely sharp and smooth.
Y + ?
3
YA YE YO
Osteoblastic Metastases
Generally considered evidence of slow growth in a neoplasm that has allowed time for a proliferation of reactive bone. In men osteoblastic mets are usually from a carcinoma of the prostate gland and in women of the breast.
Osteoblastic Metastases Radiographic Appearance
These lesions initially appear as ill-defined areas of increased density that may progress to complete loss of normal bony architecture. They may vary from small, isolated round foci of sclerotic density to a diffuse sclerosis involving most or all of a bone.
Mixed Metastases
The combination of destruction and sclerosis in the affected bone causing to have a mottle appearance with intermixed areas of lucency and increased density.
Metastases Treatment
Radiopharmaceuticals to reduce bone pain, radiation and chemotherapy. Must treat the type of cells so must know origin of first tumor. Prognosis is poor.
Arthritis
Arthritis is joint inflammation. It can be Inflammatory (rheumatoid) where the inflammation of the joint is causing the issues or it can be degenerative (osteoarthritis) where the work of the bones leads to degeneration which then causes the inflammation.
Acute (Infectious) Arthritis
Pyogenic arthritis caused by an infection such as staph, strep, or gonococcal bacteria. It must be identified and resolved quickly or it can cause destruction of bone ends.
- S/S - fever, pain, swelling, and redness
- Treatment - IV antibiotics, aspiration
Diagnosis of Arthritis
Typically arthritis is diagnosed by the signs and symptoms and by the different appearances on x-ray. They may aspirate to look at cells.
Rheumatoid Arthritis
Autoimmune disease that attacks the synovial membranes causing deterioration of bone ends due to inflammed joint cells releasing lytic enzymes.
Characteristics of Rheumatoid Arthritis
- Chronic Inflammation
- Overgrowth (Pannus) - thickened granulation tissue that covers "like a sheet".
- Fibrous Ankylosis
- Ankylosis
***Causes fibrosis and thickening of synovial membranes
Common Sites of Rheumatoid Arthritis
Typically it affects the distal joints of the phalanges and then moves up the extremities since it is systemic.
Cause of Rheumatoid Arthritis
Autoimmune disease so it is "anti-self". The antibody that is usually anti-self in this case is IgG.
- Usually occurs in those over 40
- Like all autoimmune diseases it has periods of exacerbation and remission
Treatment of Rheumatoid Arthritis
Steroids (anti-inflammatory) to reduce the production of the inflammatory cells causing problems. The problem is these decrease the immune system.
- May use supportive devices
- May do surgical intervention for realignment
Juvenile Rheumatoid Arthritis
Called "Stills Disease"
- Has no known etiology
- Is not as global an effect as adult onset, but is just as deteriorating.
- May grow out of it by 15-16 years old
- Can lead to Ankylosing Spondylitis
Ankylosing Spondylitis
Called Marie-Strumpell Disease
- Is a continuation of rheumatoid arthritis
- Usually starts in the sacral joints and can spread to the SI joints
- Is a complete fusion of joint spaces in the spinal column.
- Creates a "bamboo spine" look on xray.
- Difficult to have normal daily activity because it can cause complications with respiratory and cardiovascular issues
- Treatment is surgical intervention
Radiographic Appearance of Rheumatoid Arthritis
Soft tissue swelling, narrowing of the joint space, subluxation, poorly defined edges without a sclerotic rim.
-May also be viewed on CT.
Radiographic Appearance of Ankylosing Spondylitis
Almost always begins in the SI joints and is symmetric in involvement. Will see blurring of the articular margins and patchy sclerosis leading to narrowing of the joint space. Later manifestation is "bamboo spine".
Osteoarthritis
Degenerative Joint Disease where there is deterioration of joint cartilage first and then the inflammation comes from the cartilage rubbing against the bone in chronic work of the joint.
- Can be caused by excessive weight or repeat actions.
Radiographic Appearance of Osteoarthritis
Leads to sclerosing (hardening) of the bone ends and joint spaces. This presents as a fuzzy appearance of bones on a radiograph and sclerosing of bone ends leads to spurring which is not seen in rheumatoid arthritis.
Osteoarthritis Treatment
Is treated by NSAIDS and then if surgical intervention is needed, it is treated with abrasion where they clean the area off and roughen it up so it will regenerate cartilage with rest of the joint. It requires a change in LIFESTYLE.
Cardinal Signs of Osteoarthritis
Nodes.
- Nodes in the PIP joints are called Bouchard's Nodes.
- Nodes in the DIP joints are Heberden's Nodes.
Inflammatory Disorders of Connective Tissue
Bursitis - Inflammation of the bursae - small fluid filled sacs located near the joints that reduce the friction caused by movement.
- Caused by repeat movements, rheumatoid arthritis, gout, or infection.
- Not usually seen on plain radiographs, but can be seen on Ultrasound.
- Can further lead to tendonitis
Radiographic Appearance of Bursitis and Tendonitis
Deposition of calcification in tendons, seen most often in the shoulder joint. The calcium deposits may vary in size and shape. The bursa may also be demonstrated on US having ill-defined margins.
Treatment of Bursitis and Tendonitis
Heat, rest, and immobilization. NSAIDS to reduce inflammation and relieve pain. Corticosteroid injections in severe cases.
Osteomyelitis
Inflammation of the bone and bone marrow. Can be acute or chronic.
Acute Osteomyelitis
Abscess under the periosteum which causes bone necrosis within 24-48 hours. This causes ulceration in the medullary cavity. Patients will have fever, pain, and heat in area.
Radiographic Appearance of Acute Osteomylelitis
- A clear sign is a Brodie's abscess where you have a central radiopaque area surrounded by radiolucent area outside the opaque area that is part of the affected area as well.
- Will show as inflammation in the soft tissue and an opaque area in the bone.
Chronic Osteomyelitis
Is deterioration due to bacteria but then osteoblasts lay down new growth trapping bacteria. Has two parts:
- Sequestrum - Infected tissue or fluid
- Involucrum - New bone growth containing the bacteria in the bone - creates long term infection in the medullary cavity and outside the bone.
Suspceptability to Chronic Osteomyelitis
Since it is bacterial, it does not just stay in the bone, but proliferates into tissue as well and eats away at both. Diabetics are highly susceptible to this disease which leads to gangrene.
Treatment of Osteomyelitis
- IV antibiotics
- Debridement - take out affected tissue and replace with bone graft.
- May amputate to avoid spread.
Radiographic Appearance of Chronic Osteomyelitis
Localized, deep soft tissue swelling adjacent to the metaphysis of long bones. The inflammation causes displacement or obliteration of the normal fat planesadjacent to and between the deep muscle bundles. In bone it will look like lucency and then a ragged moth-eaten appearance. CT, MRI, and Ultrasound can all help in diagnosing Osteomyelitis.
Tuberculosis of the Skeletal System
In the skeletal system, TB is called Pott's Disease.
Chronic Inflammation from secondary outbreak where tuberculin bacteria breaks out of lesions and goes to highly vascular areas such as the hips, knees, and spine. It deteriorates structures, both skeletal and soft tissue.
Complications of TB of the Skeletal System
Often associated with a paravertebral abscess, it causes a narrowing of the intervertebral disc spaces and then infection spreads to vertebral body and causes bone destruction. This can cause deficits in the nervous system and lead to paralysis.
Radiographic Appearance of TB of the Skeletal System
Varies greatly from honeycomb-like areas of destruction to well-circumscribed or completely diffuse. Appear as lytic processes with minimal or no periosteal reaction. Best seen using other imaging modalities such as CT, MRI, and bone scans.
Treatement of TB of the Skeletal System
Antibiotics and anti-tuberculin medications, supportive devices.
Fractures
A discontinuity of bone caused by a mechanical force. The rad will discuss where it is located, how much of surrounding areas are affected, joints affected, and type of fracture.
Diagnosis of Fractures
Requires a good history of what happened, a clinical assessment from the referring physician including limitations to ROM, swelling, etc..., and x-rays that are at least 90° to each other.
Types of Fractures
1. Open/Closed - Open is bony protrusion outside skin and closed is contained within the body.
2. Complete/Incomplete - Full discontinuity of bone or only partial
3. Displaced/Nondisplaced - Is the bone aligned or not. Refers to the distal piece of the bone in relation to the proximal segment.
Compound Fracture
Means the same as open - breaks through the skin.
Impacted Fracture
The shaft is impacted into the head of the long bone - most commonly seen in humerus or femur.
Compression Fracture
Different from impacted only in that it is not in long bones. Is usually found in vertebrae and affects anterior vertebral bodies mostly causing a wedging or "pie-shaping" of the vertebra.
Directional Fractures
1. Transverse - Starts on one side and travels across the shaft of the long bone transversely. Usually results from a direct blow.
2. Oblique - Fracture at an oblique angle to the shaft of the long bone. Usually results from angulation and compression forces.
3. Spiral - encircles the shaft of a long bone and is generally longer than an oblique fracture. Caused by torsional forces.
Comminuted Fracture
Has at least 3 fragments of bone instead of just proximal and distal segments there is at least one extra piece. Multiple fragments is called a "splinter" comminuted fracture.
Butterfly Fracture
A comminuted fracture where there is an elongated triangular fragment of cortical bone detached from the two other larger fragments of bone.
Greenstick Fracture
An incomplete fracture with the opposite cortext intact. Found almost exclusively in infants and children due to teh softness of their cancellous bone because of collagen in bones.
Torus Fracture
Also called a "buckle" fracture.
A fracture where the cortical edges buckle out due to blunt force. Usually in children. Treatment is immobility.
Avulsion Fracture
Small bone fragments that have torn off the bone due to ligament stress and/or detachment. Often seen in the ankle.
Stress Fracture
The response of bone to repeated stresses applied over time on a long bone. Seen often in metatarsals. You may have to send them to Nuc med to locate these and then you may only see the periosteal callus (calcification) 6 weeks later where it has tried to heal.
Longitudinal Fracture
Seen in long bones only, in the shaft. Is a fracture that travels along the length of the long bone.
Fracture Healing
The radiographic evidence of fracture healing is a continuous external bridge of callus (calcification) that extends across the line of fracture and unites the fracture fragments.
The healing process consists of:
- Embryonic process
- clot formation
- osteoblasts come in to rebuild bone
- A provisional callus is formed to protect the bone during reformation
- A bony callus is formed by osteoblastic rebuilding and total healing is accomplished.
Fracture Treatment
Closed reduction - Bones do not have to be realigned completely, they just have to be touching and muscles, tendons, and ligaments will help to realign. Done without surgical intervention.
Open reduction - surgical intervention to realign bones.
External Fixation - use of splints or casts externally to support bone.
Internal Fixation - Use of metal plates, screws, rods, etc.. placed inside bone to support.
Complications of Healing Fractures
- Delayed Union - includes malunion and nonunion
- Soft Tissue Trauma - such as nerve damage or damage to ligaments/tendons/bursa, etc...
- Muscular Ossification
Malunion Complication
When the pieces of the bone are touching but did not align properly. Leads to impairment of normal function or a cosmetic appearance that may require surgical intervention.
Nonunion Complication
Fracture healing process completely stops and the fragments remain ununited even with prolonged immobilization. Can lead to avascular necrosis.
Delayed Union
Any fracture that takes longer to heal than the average fracture of that anatomic region. May result from infection, inadequate immobilization, limited blood supply, or loss of bone at fracture site.
Pathologic Fracture
A fracture caused by a decrease in bony integrity due to a disease process. The most common underlying cause is metastic malignancy or multiple myeloma. In children it is seen with osteogenesis imperfecta, osteopetrosis, or nutritional deficiencies. Can also occur with benign process that weaken bone such as cysts or fibrous dysplasia.
Most Common Sites of Pathologic Fracture
Spine, femur, and humerus since this is where metastatic disease is most common.
Battered Child Syndrome
Is multiple, repeated, physically induced injuries in young children caused by parent or guardian. They look for fractures in areas not typically affected by normal childhood play. These fractures are often seen at the epiphyseal plates where there is lots of cartilage making it hard to fracture. They look for sclerosing and multiple fractures in varying stages of healing.
How to Diagnose Battered Child Syndrome
You MUST get a good history to make sure it is not osteogenesis imperfecta. The history often does not match the injury and the injuries are often in places where the bones do not normally break without a direct blow such as the ribs, scapula, sternum, spine, or lateral ends of clavicles.
Common Fractures
- Colle's Fracture
- Boxer's Fracture
- Monteggia Fracture
- Pott's Fracture
- Jones' Fracture
- Bi-malleolar and Tri-malleolar fractures
Colle's Fracture
Also called "silver fork deformity"
- Posterior displacement of the distal end of the radius due to transverse fracture often including an avulsion fracture of the ulna. Often caused by a fall on the outstretched hand.
Boxer's Fracture
A transverse fracture of the neck of the 5th metacarpal with palmar angulation of the distal fragment. Typically the result of punching something or someone.
Monteggia Fracture
An isolated fracture of the proximal 1/3 of the shaft of the ulna with a related anterior dislocation of the radial head. Often caused by compression force on forearm.
Pott's Fracture
Fracture of the fibular malleoli with dislocation of the distal end of the tibia.
Jones' Fracture
Transverse fracture of the base of the 5th metatarsal. This is an avulsion fracture due to the twisting of the ankle with plantar flexion and inversion such as happens when stepping off of a curb incorrectly.
Bi-Malleolar Fracture
A fracure of both malleoli. Due to the twisting that causes these fractures, the fracture on one side is transverse and the other side is oblique or spiral.
Tri-Malleolar Fracture
Is a fracture of both malleoli and the posterior lip of the tibia. Usually represent fracture dislocations.
Fractures/Dislocations of the Spine
- Jefferson Fracture
- Hangman's Fracture
- Clay Shoveler's Fracture
- Seat Belt Fracture
Jefferson Fracture
A comminuted fracture of C1 where the anterior and posterior rings are both fractured. Since it affects both anterior and posterior columns, this is an unstable fracture.
- It causes fragments that can go into the spinal canal and can also be associated with fractures of the dens.
Causes and Appearance of Jefferson Fracture
Most often caused by a diving accident into a pool where the head is compressed or a car accident.
On an AP view the lateral masses will not line up. On a cross-sectional view you will see both fractures.
Hangman's Fracture
Is a fracture of the arch of C2 in the regions of the pedicles. It can result in complete separation of the vertebral body from the posterior arch.
Causes and Appearance of Hangman's Fracture
Seen most often with MVA when people are hung up by the seatbelt. Also seen with any type of hanging trauma.
On a radiograph it will be seen as anterior subluxation of the 2nd cervical vertebra over the 3rd. Fracture may be seen on radiograph.
Clay Shoveler's Fracture
An avulsion fracture of the spinous process (most often the 7th cervical vertebrae). Caused when the muscles move suddenly over the spinous process and fracture it.
Demonstrated on a radiograph as a double shadow of the spinous process on an AP due to caudal displacement. Hard to see on a lateral due to shoulders getting in the way sometimes.
Seat Belt Fracture
A transverse fracture of the lumbar vertebra. The horizontal fracture of the vertebral body extends to involve some or all of the posterior elements (a somewhat contra-coup fracture in the lamina).
Caused by the lap belt and the significant visceral injuries caused by a lap belt in a MVA.
Intervertebral Disk Herniation
Can be ruptured or bulging.
Ruptured - the annulus fibrosis has a fracture so the nucleus pulposus is leaking out.
Bulging - the annulus fibrosis is intact so the nucleus pulposus is simply bulging.
Common Sites of Intervertebral Disk Herniation
L4-L5 and L5-S1 are the most common but other sites include C5-C6 and C6-C7 and T9-T12. Causes pressure, pain against the nerves and spinal cord and may require surgical resection and fusion to eliminate pressure.
Radiographic Appearance of Intervertebral Disk Herniation
Narrowing of the intervertebral disk spaces with hypertrophic spur formation, bony sclerosis, spurs, and lucencies over disks. These are nonspecific findings and CT, MRI, or myelography are required to diagnose.
Fibrous Dysplasia
An abnormal amount of fibrous tissue in the medullary cavity. The fibrous tissue excess leads to breaking down of cortical areas and "bowing" of bones. It also affects the surrounding tissues.
- Has an unknown etiology. If multiple bones are involved though it is usually an endocrine disorder.
Fibrous Dysplasia Patients, Appearance, and Treatment
- Affects mostly children and females.
- Will appear as well-defined lucencies in medullary cavity with a ground-glass appearance.
- Treatment is completely palliative - anti-inflammatories, pain meds, stabilizers, and surgery.
Scoliosis
Abnormal curvature of the spine.
- Levoscoliosis is displacement to the left
- Dextroscoliosis is displacement to the right
- Rotoscoliosis is displacement with abnormal rotation of the spine.
Causes of Scoliosis
- Functional
- Structural (hemivertebra, segmental bar (fusion of vertebral column), congenital
- Osteopathic - disease processes
- Neuropathic - problem with innervation of muscles
- Myopathic - Muscular deficits
- Idiopathic - no known cause
***Any abnormal curvature can lead to respiratory problems due to displacement of thoracic viscera/cavity.
Treatment of Scoliosis
To realign spine they may insert Harrington Rods. These correct the curvature of the spine and relieve the pressure on the thoracic cavity.
Kyphosis
Abnormal anterior bending of the thoracic vertebra. Commonly congenital, postural, or osteoporotic. Treatment is corrective surgery.
Spondylolysis and Spondylolisthesis
Spondylolysis is a defect in the pars interarticularis between the superior and inferior articular processes of a vertebra. Most commonly affects the 5th lumbar vertebra. Spondylolysis is the term for this defect without displacement. Spondylolisthesis is the term for this defect with an anterior displacement of the vertebra over the inferior vertebra.
Causes and Grading of Spondylolysis and Spondylolisthesis
Often it is caused by jarring sports.
Spondylolisthesis will be graded by severity with a grade of 1 meaning there is only 1/4 displacement of the vertebral body and a grade of 4 being complete vertebral body anterior displacement.
Radiographic Appearance of Spondylolysis/Spondylolisthesis
On a lateral projection Spondylolisthesis will be seen as the displacement of one vertabra over an inferior vertebra. If there is no displacement, then spondylolysis will require an oblique projection of the lumbar spine in order to see the lucency in the pars interarticularis.
Treament of Spondylolysis/Spondylolisthesis
Vertebral fusion using hardware or using bone chips and a cage.
Ischemic Necrosis of Bone
A devascularization of the bone due to loss of blood supply. This is often seen in the femoral head or the scaffoid of the wrist due to singular vascular feeds to those areas so if the vascular feed is cut off, there is no other blood supply. Caused by thrombosis, vasculitis, disease in surrounding bone, repeated trauma.
Diseases Associated with Avascular Necrosis
- Legg-Calve Perthes Disease
- Osgood Schlatter's Disease
- Kohler's Disease
- Kienbrock's Disease
Legg-Calve Perthes Disease
Congenital hip dysplasia that creates a deterioration of the proximal femur. Can be corrected with realignment surgically. Seen on radiograph as lytic and sclerotic areas of severe flattening of the femoral head. This appears as an arclike radiolucent cortical band called the "crescent sign".
Osgood-Schlatter's Disease
This is a tearing away of the ligament from the anterior tuberosity of the tibia which leads to avascularization. It is common in kids due to activies and is seen on radiographs as an incomplete separation of the tibial tuberosity from the tibia.
Kohler's Disease
Devascularization of the tarsal scaffoid. This causes pain, swelling, and decreased ROM. Has an unknown etiology so there is no way to prevent it, but it may be due to trauma.
Kienbock's Disease
Devascularization of the lunate which leads to deterioration of the carpal bones due to the inflammatory cells.