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  1. Radiological features of Osteoarthritis/Degenerative arthritis
    1. Joint space narrowing
    2. Subchondral sclerosis/eburnation
    3. Central and peripheral osteophytosis including tibial spiking in knees
    4. Subarticular cyst or Geode formation
    5. Loose bodies
    6. Joint deformities
    7. Heberden’s nodes at DIP and Bouchard’s nodes at PIP joints.Q
  2. Rheumatoid Arthritis
    1. Table 321-1 Classification Criteria for Rheumatoid Arthritis (Ref: H-18th edition, Pg-2745, table 321.1)              

a. Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle)   0
  2–10 large joints 1  
  1–3 small joints (MCP, PIP, Thumb IP, MTP, wrists) 2  
  4–10 small joints 3  
  >10 joints (at least 1 small joint) 5  
b. Serology Negative RF and negative ACPA   0
  Low-positive RF or low-positive anti-CCP    
  antibodies (3 times ULN) 2  
  High-positive RF or high-positive anti-CCP    
  antibodies (>3 times ULN) 3  
c. Acute-phase reactants Normal CRP and normal ESR 0  
  Abnormal CRP or abnormal ESR   1
d. Duration of symptoms <6 weeks 0  
  ³6 weeks   1

Note: Criteria a–d must be present for at least 6 weeks. Criteria b–e must be observed by a

  1. The plain X-ray film joint changes of RA include:
    1. Soft tissue changes
    2. Osteoporosis (Juxtaarticular/ juxtaepiphyseal)…..earliest
    3. Joint space changes and alignment deformities
    4. Periostitis
    5. Bone erosions (no erosions in SLE)Q
    6. Secondary Osteoarthritis
  2. Juvenile Rheumatoid Arthritis/Still’s Disease
    Radiological features:
    1. Soft tissue swelling
    2. Synovitis with joint effusion
    3. Osteopenia
    4. Epiphyseal overgrowth (due to chronic Synovitis and hyperaemia)
    5. Cartilage loss, loss of joint space and bone erosions (late features)
    6. Ankylosis and deformities
    7. Early closure of epiphyseal plate may occur resulting in growth disturbances
    8. Atlanto-axial dislocation
    9. In hands: florid periosteal reaction along the metacarpal and phalangeal shafts, loss of joint space, fine erosions and ankylosis.
  1. Psoriatic arthritis
    1. Types:
      1. True psoriatic arthritis (31%)
      2. Psoriatic arthritis resembling RA (38%)
      3. Concomitant RA with psoriatic arthritis (31%)
    2. Radiological features:
      1. Asymmetrical involvement
      2. Ray distribution (all '3' joints of single ray involved; DIP, PIP, and MCP)
      3. QSausage digits
      4. Absence of osteoporosis
      5. Sparing of joint space (early)
      6. QErosions at DIP (Gull wing appearance)
      7. ‘Cup-like’ erosions
      8. Fluffy periosteal reaction
      9. Productive bone changes (periosteal reaction and Proliferative new bone formation)
      10. ‘Mouse ear’ sign (joints flanked by fluffy new bone formation)
      11. Q'Pensile in cup' or 'pestle in mortar' deformity
      12. Q‘Opera glass' or ‘Main-en-lorgnette' deformity or 'telescoping'
      13. Tapering of proximal phalanges
      14. Acroosteolysis
      15. QIvory phalanx
      16. No ulnar deviation
      17. Fibular digital deviation
      18. Sharply demarcated adjacent bony surface (pathognomonic)
      19. Spontaneous joint fusion
      20. Destruction of IP joints of hands and feet with abnormal widening of joint space
      21. Neurotrophic changes at DIP joints with 'licked candy' appearance
      22. QArthritis mutilans
      23. QThimble pitting of nails
  2. Ankylosing spondylitis (Marie-Strumplle disease or Bechterew disease)
    1. QBamboo-spine (knobby spine, poker back or universal syndesmophytosis) is a characteristic feature of it.
    2. Syndesmophytes are gracile ossifications of the outer fibers of annulus fibrosus. They are marginal, delicate, vertically oriented, extending from edge or margin of one vertebral body to that of others.
    3. Syndesmophytes should be differentiated from the parasyndesmophytes or the paravertebral ossifications seen in psoriatic arthritis or Reiter's disease by which although vertically oriented are thicker, denser, non marginal extending from mid-body to mid-body, larger, coarse and may affect any part of spine to start with, without proper order.
    4. Other diagnostic radiological features of Ankylosing spondylitis are:
      1. Bilateral symmetrical Sacroilitis (most specific)
      2. Enthesitis (earliest pathological change)
      3. Uncommon involvement of small joints of hand and feet.
  1. GOUT
    It is a metabolic disorder characterized by hyperuricemia and deposition of positively birefringent monosodium urate (msu) crystals in the form of tophi in periarticular soft tissues including synovium, articular cartilage, joint capsule, ligaments, bursae and even intraosseously.
    Primary gout occurs due to enzyme hgptrase deficiency or increased pprp synthatase activity or it can be idiopathic (99%).
    1. Complete hgprtase deficiency = lysch nyhen syndrome (gout + self mutilation + mental retardation).
    2. Partial hgptrase deficiency = kelly-segmiller syndrome (gout with nephritis)
    3. Secondarygout is seen in myeloproliferative disorders, blood dyscrasias, von gierke disease, crf, drugs, etc.
Clinical stages include:
  1. Asymptomatic hyperuricemia (levels of uric acid correlate with the symptoms)
  2. Acute gouty arthritis—no distinct radiological features except for joint effusion (earliest sign), soft tissue swelling and rarely erosions.
  3. Chronic tophaceous gout-characterized by radiological features like:
    1. Absence of osteoporosis
    2. Absence of joint space involvement (until late in disease)
    3. Gouty tophi
    4. Eccentric non-periarticular erosions with sclerotic rim
    5. An "overhanging" bony edge along the bony contour (hallmark)
    6. Chondrocalcinosis
    7. Elbow= olecranon bursa 'rising sun' sign
    8. Knee = pseudotumor
    9. Punched out bony lesions
    10. Intervertebral disc calcification
    11. Aural calcification
    CPPD arthropathy may be asymptomatic, acute, subacute, or chronic or cause acute synovitis superimposed on chronically involved joints.
    1. Other clinical manifestations of cppd deposition include
      1. Induction or enhancement of peculiar forms of osteoarthritis;
      2. Induction of severe destructive disease that may radiographically mimic
      3. Neuropathic arthritis
      4. Production of symmetric proliferative synovitis, clinically similar to rheumatoid arthritis and frequently seen in familial forms with early onset;
      5. Intervertebral disk and ligament calcification with restriction of spine mobility, mimicking ankylosing spondylitis (also seen in hereditary forms); and rarely spinal stenosis (most commonly seen in the elderly).
      6. The knee is the joint most frequently affected in cppd6 arthropathy. Other sites include the wrist, shoulder, ankle, elbow, and hands. 
      7. Rarely, the temporomandibular joint and ligamentum flavum of the spinal canal are involved.
      8. If radiographs reveal punctate and/or linear radiodense deposits in fibrocartilaginous joint menisci or articular hyaline cartilage (chondrocalcinosis), the diagnostic certainty of cppd is further enhanced.
      9. Definitive diagnosis requires demonstration of typical crystals in synovial fluid or articular tissue.
      10. In the absence of joint effusion or indications to obtain a synovial biopsy, chondrocalcinosis is presumptive of cppd deposition. One exception is chondrocalcinosis due to caox7 in some patients with chronic renal failure.
  2. Paget’s disease of bones
    Paget’s disease is a chronic skeletal disease characterized by disordered and exaggerated bone remodeling, affecting order individuals.
    Sites: (usually polyostotic and asymmetric) pelvis > lumbar spine > thoracic spine > proximal femur > calvarium > scapula > distal femur > proximal tibia > proximal humerus.
    1. Radiological features:
      1. Skull:
        1. Widened diploic spaces
        2. Osteoporosis circumscripta
        3. "Cotton wool" appearance (mixed lytic and blastic pattern of thickened calvarium) and
        4. Basilar impression
      2. Long bones:
        "candle flame"/"blade of grass" lysis originating in subarticular site
      3. Spine:
        1. "picture-frame" vertebra,
        2. "bone with bone" appearance
        3. "ivory" vertebra
        4. Ossification of spinal ligaments
Signs and symptoms
Paget's disease of bone affects each person differently. Most people with paget's disease have no symptoms. When symptoms do occur, they typically present in specific areas affected by the disease, although they may be widespread. Affected areas may include:
  1. Bones. Pain in the affected bones is the most common symptom of paget's disease of bone
  2. Joints. Paget's disease may damage the cartilage lining the joints near your affected bones. This wear and tear often leads to osteoarthritis in the affected joints.
  3.  Nerves. Enlarged bones can compress the spinal cord or the nerves exiting the brain and spinal cord. The location of the pain caused by nerve compression depends on the nerve that's affected. Pressure on a nerve can also cause numbness, tingling, weakness, hearing loss and double vision
Paget’s Disease Or Osteitis Deformans Is Characterized By Disordered And Exaggerated Bone Remodeling With Features Like
  1. Widening Of Diploic Space Of Skull With 'Cotton-Wool' Appearance,
  2. Osteoporosis Circumscipta,
  3. Candle-Flame Or Blade Of Grass Lysis Of Diaphysis Of Long Bone (Fissure Fracture),
  4. Bubbly Destruction Of Small/Flat Bones And
  5. Picture Frame And Ivory Vertebra.
Extra Edge
  1. QRotator cuff tears are best diagnosed by  MRI.
  2. QMRI is the most sensitive modality for detection of early osteonecrosis, before femoral head cortical collapse.
  3. A meniscal tear is best diagnosed on MRI by identifying increased internal meniscal signal intensity that extends to the articular surface.
  4. There is high association between Segond fracture and anterior cruciate ligament (ACL) tear and meniscal injury.
  5. When you see a fracture of the medial malleolus, do not forget to look at the proximal fibula for Maisonneuve fracture.
  6. After the Achilles tendon, the next most likely ankle tendon to tear is the posterior tibial tendon (PTT).
  7. The anterior talofibular ligament, part of the lateral ligamentous complex, is the most commonly sprained and torn ankle ligament. 



Extra Edge

Measurement Of Bone Mass

  1. Several noninvasive techniques are now available for estimating skeletal mass or density. These include dual-energy x-ray absorptiometry (DXA), single-energy x-ray absorptiometry (SXA), quantitative CT, and ultrasound.
  2. DXA is a highly accurate x-ray technique that has become the standard for measuring bone density in most centers.
  3. Though it can be used for measurements of any skeletal site, clinical determinations are usually made of the lumbar spine and hip.
  4. Portable DXA machines have been developed that measure the heel (calcaneus), forearm (radius and ulna), or finger (phalanges). DXA can also be used to measure body composition. In the DXA technique, two x-ray energies are used to estimate the area of mineralized tissue, and the mineral content is divided by the area, which partially corrects for body size. However, this correction is only partial since DXA is a two-dimensional scanning technique and cannot estimate the depths or posteroanterior length of the bone. Thus, small people tend to have lower-than-average bone mineral density (BMD).
  5. Bone spurs, which are frequent in osteoarthritis, tend to falsely increase bone density of the spine and are a particular problem in measuring the spine of older individuals. Because DXA instrumentation is provided by several different manufacturers, the output varies in absolute terms.
  6. Consequently, it has become standard practice to relate the results to "normal" values using T-scores, which compare individual results to those in a young population that is matched for race and gender.
  7. Z-scores compare individual results to those of an age-matched population that is also matched for race and gender. Thus, a 60-year-old woman with a Z-score of1 (1 SD below mean for age) has a T-score of2.5 (2.5 SD below mean for a young control group) A T-score below2.5 in the lumbar spine, femoral neck, or total hip is taken as a diagnosis of osteoporosis.

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