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Bone and Joint Test #2


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What is the primary site of pathology in someone with Ankylosing Spondylitis?
The primary site is the insertion of ligaments and capsules into bone (enthesopathy).
What is a late spinal complication that rarely occurs in patients with ankylosing spondylitis.

Bamboo Spine - See image
What three areas of the body are typical locations for ankylosing spondylitis?

SI joints
Ankylosing spondylit is a disease of bilateral asymmetry. True or false?
False. Ankylosing spondylitis is a bilateral symmetrical pathology.
What is the "hallmark" pathological location of ankylosing spondylitis?
The SI Joints
In ankylosing spondylitis, what five things occur at the SI joints?
1. The lower 2/3 of the joint is effected.
2. The iliac side is effected more than the sacral side
3. There is a loss of joint definitition (pseudowidening)
4. There is joint erosion and reactive sclerosis
5. Bony ankylosis (fusion) occurs
In the spine, ankylosing spondylitis typically affects what parts of the spine?
The thoracic and lumbar regions
In the spine, vertical bridging occurs. What are these called?
Ankylosing Spondylitis: In the spine, vertical bridging occurs. What are these called?
Ankylosing Spondylitis: What 7 things would you find on an x-ray?
1. sydesmophytes
2. bamboo spine
3. erosions
4. sclerosis
5. loss of joint space at appophyseal and costovertebral joints
6. preservation of disc space
7. Sacroiliitis
Ankylosing Spondylitis: If you were to take a Lab, what would you find?
+ HLA-B27 in 90-95% of patients
- Rheumatoid Factor
+ Erythrocyte Sedimentation Rate (ESR)
Ankylosing Spondylitis Clinical Features:
What areas of the body might an AS patient feel pain?
1. low back
2. buttock
Ankylosing Spondylitis:
Does exercise diminish or exacerbate the pain?
It diminishes the pain and is improved with exercise.
Chronic prostatitis does not occur in 80% of patients with ankylosing spondylitis. True or False?
False. Chronic prostatitis does occur in 80% of patients.
Loss of lumbar lordisis and increased dorsal kyphosis are often found in patiens with ankylosing spondylitis. True or False?
What specifically should chiropractors look out for with a patient with AS?
Spontaneous Atlantoaxial subluxation
What other two joint pathologies are similar to AS?
What are the clinical features of the skin in a patient with psoriatic arthritis?
1. Erythematous patches covered with silvery scales
2. Auspitz Sign - removal of scales results in pinpoint bleeding
3. On the elbow, knee, scalp, back
What are the clinical features of the nails in a patient with psoriatic arthritis?
1. Thimble pitting, thickening, discoloration, separation
2. Found in up to 40% of patients
What joints are effected by psoriatic arthritis?
MTP (Metatarsophylangeal)
MCP (Metacarpophylangeal)

Classic presentation is in one large joint and in 1-2 intephalangeal joints (dactylitis or "sausage digit"
If you were to look on an x-ray, what would you see in a patient with psoriatic arthritis?
1. soft tissue swelling
2. Erosions and bone proliferation
3. "Pencil in Cup" erosion
4. Periostitis with "fluffy" new bone
5. Ankylosis in interphalangeal joints
6. SI joint involvement in 30-50% of patients
7. in the spine >> syndesmophytes
If you were to do a Lab on someone with psoriatic arthritis, what would you find?
Increased erythrocyte sedimentation rate (ESR)
- Rheumatoid Factor
+ HLA-B27
In Reiter's Syndrome, what are the three parts of the triad?
1. Conjunctivitis
2. Urethritis
3. Arthritis
What is the age range of someone with Reiter's Sydrome?
20-40 years of age
What is the etiology of Reiter's Syndrome (e.g, how do you get it?)
It has a venereal origin, and the urethritis comes 7-14 days after sexual intercourse
A patient with Reiter's Syndrome displays what arthritic characteristics?
Asymmetric involvement
Polyarticular synovitis
If you were to look at a patient x-ray with Reiter's Syndrome, what would you see?
The interphalangeal joint of the big toe would show:
1. soft tissue swelling
2. uniform loss of joint space
3. Marginal erosions
4. Periostitis with fluffy new bone
What is "Lover's Heel?"
It is a pathological condition associated with Reiter's Syndrome, and presents with soft tissue swelling, erosions, fluffy periostitis at the insertion of the Achilles and plantar tendons
In Reiter's sydrome, what other significant joint is involved?
The SI joint in 50% of patients
If Reiter's Syndrome was found in the spine of a patient, what would you see on x-ray?
If you were to do a Lab on someone with Reiter's Sydrome, what would you find?
Increased erythrocyte sedimentation rate
- Rheumatoid Factor
+ HLA-B27
How would you treat a patient with Reiter's Syndrome?
Treat the venereal disease
A group of GI tract disorders causes what named pathology in joints?
Enteropathic Arthropathy
What are the two GI disorders associated with Enteropathic Arthropathy?
1. Ulcerative Colitis
2. Regional Enteritis (Crohn's Disease)
In enteropathic arthropathy, the inflammed bowels cause what symptoms?
1. Chronic Diarrhea
2. abdominal pain
3. fever
4. anorexia
5. weight loss
What happens to 15% of patients with GI disorders?
They develop arthritis
What are the typical arthritic locations of patients with enteropathic arthropathy?
1. Knees
2. Ankles
3. Elbows
4. Wrists
5. SI joints (identical to AS)
If you were to do a Lab on someone with enteropathic arthropathy, what would you find?
+ HLA-B27
- Rheumatoid Factor
What similarities do ankylosing spondylitis, psoriatic arthritis, Reiter's Syndrome, and enteropathic arthropathy have?
1. patients < 40 years old
2. Low back pain
3. sydesmophytes
4. bilateral pathology
5. bone erosion and reactive sclerosis
6. SI joint involvement (sacroiliitis)
7. + HLA-B27
What is the physiological problem that occurs with Gout?
There is a defect in purine metabolism, which results in hyperuricemia, which results in monosodium urate crystals into the joints.
What gender is most susceptible, and what percentage?
95% of patients are male
What is the etiology of gout?
It is an unknown biochemical defect that causes hyperuricemia
What are the four stages of gout? Describe each.
1. Asymptomatic hyperuricemia
2. Acute Gouty arthritis - formation of monosodium urate crystals in joint fluid and synovial membrane >> acute inflammatory synotivits

3. Chronic gouty arthritis - precipitation of urates into synovial linings. Synovial proliferation and pannus formation. Destruction of cartilage and erosion of bone

4. Tophus formation - local accumulation of monosodium urate crystals surrounded my intense inflammation.
What are the clinical findings in a person with gout?
1. Sudden onset of excruciating pain and tenderness with swelling in peripheral joints.

2. 85% of patients affected at metatarsophalangeal joint.

3. Possible chills and fever

4. Possible immediate past history of emotional or physical stress, alcohol or food.

5. Women can develop gout post menopause
What are the chronic clinical findings assciated with gout?
1. Decreased ROM

2. Joint damage upon x-ray

3. Tophi deposit in avascular soft tissue (pinna of ear, elbows, knees, fingers, toes.
What is the pathognomic lesion of gout?
Tophus formation
If you were to look at an x-ray in a person with gout, what might you find?
Marginal and periarticular bone erosions. Soft tophi tissue.
If you were going to do a lab on a person with gout, what might you find?
Monosodium urate crystals in the synovial fluid.
What treatment is associated with gout?
2. Allopurinol - inhibits formation of uric acid
3. Colchicine/Indicine - slows cell division and reduces pain and swelling
What are the other (aka's) names for calcium pyrophosphate dihydrate crytal deposition disease?
CPPD, pseudogout, chondrocalcinosis
What is the pathological physiology of CPPD?
Inflammation of a joint caused by the deposition of CPPD crystals into joint tissue.
When CPPD crytals deposit into joint tissue what damage occurs?
degeneration of cartilage and loss of joint space.

inflammation of synovium

What clinical findings are found in a person with CPPD?
Acute - Similar to gout; hot, swollen, tender joints (pseudogout)

Chronic - similar to DJD, bony swelling, crepitus, stiffness

Can also be asymptomatic
If you were viewing an x-ray in someone with gout, what might you see?
chondrocalcinosis - calcification of articular cartilage, esp. in the knees

loss of joint space

subchondral sclerosis



How can you differentiate CPPD from DJD?
A lab would identify calcium pyrophosphate dihydrate crytals in the tissues.
What is the treatment for CPPD?

Drain synovial fluid

Generally an excellent prognosis

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