Lec 7. Skeletal System Inflammatory +Metabolic Diseases PDF

King Khalid University College of Applied Medical Sciences Department of Radiological sciences Course Title :Radiographic Image Interpretation Course No. RAD 439 Credit Hour 2 Prerequisite RAD 313...

King Khalid University College of Applied Medical Sciences Department of Radiological sciences Course Title :Radiographic Image Interpretation Course No. RAD 439 Credit Hour 2 Prerequisite RAD 313 Musculoskeletal Lecture inflammatory disease.analysis  Lecture contents 1-Inflammatory and degenerative conditions  Bursitis  Tendinitis  Arthritis Osteoarthritis (“DJD” – degenerative joint disease) Rheumatoid arthritis (one of many “autoimmune” Arthritis) 2.Gout  A-Useful Definitions Arthralgia: Joint pain Arthritis: Joint inflammation or damage Acute: Onset < 6 weeks ago. Chronic: Onset > 6 weeks ago. Monoarticular: Affecting one joint.  Definitions Oligoarticular: Affecting 2-3 joints. Polyarticular: Affecting > 3 joints. Additive: Sequential joint involvement. Intermittent: On again, off again. Migratory: Arthritis moves from one joint to another.  Definitions Myopathy Any disease of muscle. Myalgia Muscle Pain. Myositis Inflammation of Muscle.  -1-Bursitis 1. Bursitis: inflammation of a bursa, typically one in the knee, elbow or shoulder. Description: Swelling of the bursa (a fluid-filled sac around joint ) called “water on the knee” (Bursae, are small, jelly-like sacs that are located throughout the body contain a small amount of fluid, and are positioned between bones and soft tissues, acting as cushions to help the reduce friction). 2. Symptoms: Swelling, Pain when pressure applied, stiffness. 3. Caused by inflammation of the synovial membrane. 4. Diagnosis: Physical Exam, Medical History, Draw Bursa Fluid for testing.  1-Bursitis :Clinical presentation  Patients with bursitis have a history that may include the following:  Localized tenderness  Decreased range of motion or pain with movement  Erythema (reddening of the skin) or edema  History of repetitive movement  History of inflammatory disease (eg, rheumatoid arthritis)  History of trauma Swelling associated with elbow bursitis.  2-Tendinitis  Inflammation of a tendon, most commonly from overuse but also from infection or rheumatic disease.(tendon connects muscle to bone). Symptoms:  gradually increasing pain, sore to touch (painful sensitive tender), swelling, stiffness Risk Factors:  repetitive tasks Diagnosis:  Physical Exam, Medical/ Activity History, MRI, X-Rays  Arthritis is an inflammation of the joint  Very painful, most crippling (motionless, not moving) disease in US (United States)  Symptoms include :-pain, stiffness and swelling of the joint.  Depending on the type of arthritis, changes in the joint structure can occur.  Types of Arthritis 3-1-Osteoarthritis (OA) – joint breaks down over time because of wear and tear  85% of people with arthritis have OA  affects hyaline cartilage  cartilage softens and breaks down  Bones thicken where cartilage breaks down; extra bone is made called bone spurs and restricts joint movement  OA:DEFINITION  Osteoarthritis OA is degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints. characterized by  Bbreakdown of articular cartilage and proliferative changes of surrounding bones  Is the most common joint disease  OA of the knee joint is found in 70% of the population over 60 years of age  Radiological evidence of OA can be found in over 90 % of the population  3-1-Osteoarthritis Diagnosis: Physical Exam, X-Rays, Blood Tests Risk Factors: Age, Gender (female), previous joint injuries, obesity, weak thigh muscles (for knee), contracting gout, rheumatoid arthritis  3-1-Osteoarthritis (OA) Symptoms 1.Pain in joint 2.Swelling 3.Stiffness 4.Deformity 5.Decreased range of motion (limited motion) 6.Instability 7.Loss of function 8. tenderness  Types of Arthritis - Rheumatoid arthritis (RA) – a more severe type of inflammation - RA is an autoimmune disease; the body attacks its own tissue and destroys it - Synovial membranes swell and release bad cells that release chemicals that destroy tissue. - As cartilage is destroyed, scar tissue form and connects the bones -Cartilage then turns into bones creating deformed joints  3-2-Rheumatoid Arthritis  Description:  Inflames Synovial Membranes in joint  Abnormal Immune System Activity  Synovial Tissue Thickens  Causes ongoing inflammation and cartilage breakdown 3-2-Epidemiology  Prevalence 1%  Women > Men  Incidence Ages 30-60 years  Genetics 4% inheritance  3-2.Rheumatoid Arthritis  Symptoms:  Pain, stiffness, swelling in joints of hands, wrists, elbows, feet, ankles, knees, and neck  Diagnosis:  joint examination, medical history, several tests  Risk Factors:  Age, Gender (female), genetic susceptibility, smoking  Rheumatoid Factor(RF) Rheumatoid factor is an antibody that is detectable in the blood of approximately 80% of adults with rheumatoid arthritis The "normal" range (or negative test result) for rheumatoid factor is less than 14 IU/ml (IU/ml: international units per milliliter)  Table 1 Radiographic methods most frequently used for assessing early rheumatoid arthritis. Radiographic methods Advantages Disadvantages Conventional radiography - Low cost - Two dimensional representation of - Wide availability and easy access a three-dimensional lesion - Standardization available -Ionizing radiation - Easy reproducibility (copied) - Insufficient to assess soft tissues - Valid assessment methods - ACR criteria (American college of radiology) - Allows some differential diagnoses Ultrasonography - Non-invasive method - Depends on the examiner - Relatively low cost - Difficult objective documentation - No ionizing radiation - Low reproducibility - Detection of inflammatory and - No standardization destructive changes - Difficult visualization of some - Allows assessing several joints joints (wrists) -Can guide diagnostic interventions, such - Questionable prognostic value as biopsies -- In association with Doppler allows detecting synovitis Magnetic resonance imaging -Safe method - High costs -No ionizing radiation - Limited availability of the - High sensitivity equipment -Assessment of all structures affected - MRI exams require extended -  3.Psoriatic Arthritis:  Psoriatic arthritis is a form of arthritis that affects some people who have psoriasis Deformities in Psoriatic arthritis  Pencil and cup – end of bone looks like it has been through a pencil sharpener, bone becomes cupped.  Complete destruction of bone (arthritis mutilans) Psoriatic (skin disease marked by red, itchy, scaly patch.  Other joint disorders :gout Disorder of urine metabolism characterized  Tends to run in families, by hyperuricaemia & recurrent attacks of  affects more men than women acute arthritis.  M:F = 20:1 is a disease where uric acid (waste product)  occurs in the big toe. accumulates in the blood and forms crystals  Most joint affect: Smaller bones of that are needle-shape in the soft tissues the feet surrounding the joint Hyperuricemia: is an abnormally high level of uric acid in the blood. CRYSTAL DEPOSITION DISEASE  gouty arthritis symptoms The first symptom of gouty arthritis is typically the sudden onset of a hot, redness, tenderness swollen, stiff, painful joint. Complications of gout (long term) Renal stones  Gout: Risk factors 1) obesity 2) Hyperuricemia (is an abnormally high level of uric acid in the blood). 3) alcohol intake 4) chemotherapy 5) Medications 6) Hyperparathyroidism Gout investigations A. Laboratory: 1. Hyperuricemia 2. Leukocytosis (Leukocytosis: an increase in the number of white cells in the blood, especially during an infection) 3. Increased ESR 4. Synovial Fluid - B.X-ray:  Metabolic bone disease  Is an umbrella term referring to abnormalities of bones caused by a broad spectrum of disorders.  Affects the skeleton in one of two ways: there is either too much or too little calcified bone.  The latter change, which comprises the majority of metabolic bone disease, is due either to a decrease in the amount of bone formed, or to excessive resorption of bone.  Most commonly these disorders are caused by abnormalities of minerals such as calcium, phosphorus, magnesium or vitamin D leading to dramatic clinical disorders that are commonly reversible once the underlying defect has been treated  Conditions considered to be metabolic bone disorders A. Osteoporosis B. Osteomalacia (adults) &Rickets (children) C. Paget’s Disease  A-OSTEOPOROSIS DEFINITION A skeletal disease characterized by low bone mass and deterioration of the microarchitecture of bone tissue with a consequent increase in bone weakness and susceptibility to low trauma fractures.  Osteoporosis Bone-thinning disease afflicting  50% of women over age 65  20% of men over age 70 Disease makes bones fragile and bones can easily fracture Estrogen aids in health and normal density of a female skeleton Localized Generalized Regionalized Osteoporosis Osteoporosis Osteoporosis- - Focal losses of bone - Bone density is decreased - Loss of bone density density affecting in the majority of confined (limited) to a small area of bone. the skeleton, especially in region or segment of the axial components of the the body, such as an spine, pelvis, and proximal entire limb or portion of - Usually it is due to long bones. a limb. local disease such - Most common type[Eg- - Most typical example is as inflammatory arthritis, neoplasm, postmenopausal and senile the osteoporosis or infection. osteoporosis. that occurs after immobilization of a limb in case of fracture.  Role of diagnostic imaging  Two principal aims:  Identify the presence of osteoporosis.  Quantify bone mass with use of:  Qualitative(conventional radiography)  Quantitative (densitometry) methods.  Various modalities include  CONVENTIONAL RADIOGRAPHY – Qualitative evaluation.  Dual - Energy x-ray absorptiometry (DEXA) and quantitative CT - quantify bone mineral content assess bone loss.  Morphometry Assessment of presence of fractures.  ULTRA SONOGRAPHY - provides important information about bone properties.  HIGH-RESOLUTION MRI - improved assessment of the bone micro-architecture.  Conventional radiography  Able To Detect Bone Loss Only. Main Radiographic Features Are-  Increased Radiolucency.  Cortical Thinning.  Altered Trabecular (cancellous bon) Patterns.  Fracture Deformity.  Conventional radiography  Radiologic appearance stay the same whatever the cause.  Most common modality to diagnose osteoporosis.  Drawback: Not sensitive to soft tissue evaluation  Not sensitive to early changes  Start picking up bone loss at 30 % and more.  Clinical manifestations osteoporosis.  Compression fractures are the hallmark of osteoporosis  Other than spine, common sites affected are - femoral neck intertrochanteric region, distal radius, tibia  Of all osteoporotic fractures, hip fractures cause the greatest morbidity and mortality  Etiology of osteoporosis  A. Congenital Disorders  B. Idiopathic  C. Nutritional Disturbances  D. Endocrinopathy  E.Renal Osteodystrophy (Decalcification of bone or abnormal bone development due to Chronic KIDNEY DISEASES).  F. Immobilization  G. Bone Marrow Replacement (A bone marrow transplant is a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells).  H. Drug Therapy  I Radiation Therapy  J. Localized Osteoporosis  Osteoporosis symptoms and problems Osteoporosis usually develops slowly over several years, without any symptoms. Symptoms : Back pain mainly Problems: after bone density loss, the following may happen a)Fractures b)Loss of height, c)a stooping (bent forward)  Osteomalacia (Soft Bone)  Osteomalacia is softening of the bones, typically through a deficiency of vitamin D or calcium, or because of overactive resorption of calcium from the bone as a result of hyperparathyroidism.  Osteomalacia in children is known as rickets.  The most common cause of the disease is a deficiency in vitamin D Which is normally obtained from the diet and/or from sunlight exposure.  Rickets  a disease of children caused by vitamin D deficiency, characterized by imperfect calcification, softening, and distortion of the bones typically resulting in bow legs.  most commonly in children 6-24 months of age  Rickets and Osteomalacia basic disorder, occurring in children and adults respectively. The pathological changes result from 1. an interruption of development and, in particular, mineralization of the growth plate in the developing skeleton, 2. lack of mineralization of osteoid in the mature skeleton. They occur as a result of a lack of the actions of vitamin D, which in turn may be due to: Dietary lack, lack of production by the body. Failure of absorption or defective metabolism.  Osteomalacia and Rickets causes and risk factors I. (primary) POST MENOPOSAL & SENILE - stop of estrogen or androgen - bad nutritional habits during productive years (15-45yr) - low calcium content food & phosphorous - smoking, alcohol consumption (soda drinks). - genetics II.Secondary : 1.medications: heparin use chemotherapy (anticoagulant) 2.Immobilisation  Signs and symptoms of Osteomalacia Steomalacia symptoms: Steomalacia symptoms early stage.  Delayed formation of teeth  Bone aches and pains or  Delayed growth tenderness (Transparency)  Loss of height  Muscle weakness and decreased  Stress #s. muscle strength  dental deformities  RICKETS CLINICAL FEATURE 1. Tetany (involuntary contraction of muscles). 2. Convulsions. 3. Failure to growth. 4. Restlessness or anxiety  Rickets complication If left untreated, rickets may lead to: Failure to grow Abnormally curved spine Skeletal deformities Dental defects  Rickets, Osteomalacia :investigation 1.Blood Tests Shows  Calcium Reduced,  Phosphate reduced  Alkaline Phosphatase increased  Urinary excretion of calcium diminished 2- X ray  Paget’s Disease  Paget's disease of bone is a chronic disease of elderly people characterized by deterioration of bone tissue, especially in the spine, skull, or pelvis, sometimes causing severe pain. Cause : unknown -The excessive breakdown and disordered of bone tissue causes affected bone enlarged, crisp (weaken and breakage), resulting in pain, misshapen bones, fractures, and arthritis in the joints near the affected bones. Paget's disease typically is localized, affecting just one or a few bones, as opposed to osteoporosis, for example, which usually affects all the bones in the body.  Assignment write about Bone density measurements techniques Explain all radiological modalities about: 1- technique 2- Usefulness 3- Advantages & disadvantages Reference: Textbook of Radiology and Imaging - David Sutton 7ed volume 2 Note Results must be submitted before the next lecture