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Today we are honored to welcome Dr. Donald Resnick for

0:45

a lecture our articular disorders of the peripheral skeleton with

0:48

an emphasis on morphology and Target sites at

0:51

the end of the lecture joined Dr. Resnick in a Q&A session

0:54

where he will address questions you may have from today's topic. Please remember

0:57

to use the Q&A feature to submit your questions and welcome to

1:00

as many as we can before our time is up. We are all so excited

1:03

to announce that Dr. Resnick will be back on MRI online virtual

1:06

stage in 2023 for a conference on MRI

1:09

of upper extremities. This will be September 10th through the

1:12

14th of 2023. He'll be joined by colleagues Dr.

1:15

Steven J pomerance and Dr. Christine Chung who

1:18

will present through targeted lectures and live scrolling case

1:21

reviews on shoulder elbow hand wrist finger

1:24

and nerve entrapment on MRI sign up

1:27

today for early bird pricing using the link posted in the

1:30

chat. We hope you'll join us with that being said we are ready to

1:33

begin today's lecture Dr. Resnick. Please take it

1:36

from here.

1:37

Okay, everybody. I'm back and it's a

1:40

privilege to be able to talk to you

1:43

today.

1:44

I'm doing so from my home in a

1:47

small City Del Mar, California, which is a little bit

1:50

outside of San Diego.

1:52

This is an exciting for me

1:55

because as you look at the title of this particular

1:58

talk, it gives me the opportunity not

2:01

to talk so much about MRI, but

2:04

to go back to my first love which is conventional radiography and

2:07

I'm going to use that technique as

2:10

we discuss articulate disorders of the peripheral skeleton

2:13

with an emphasis on morphology and

2:17

Target sites.

2:19

There are two general objectives to this particular. They're

2:22

Talk number one to review the characteristic morphologic

2:25

features of some of the important arthritic

2:28

disorders that affect the synovial joints

2:31

of the peripheral skeleton and number two

2:34

to review the distribution of articular disorders

2:37

in the hands and risks something that I call

2:40

the target area approach now we're

2:43

going to discuss only the hands and risks because of

2:46

the time limit today, but I would tell you the same Target area

2:49

approach is excellent for other regions

2:52

of the body.

2:56

One of the things to help you during this lecture is when you see these

2:59

yellow boxes, please pay attention diagnostic pearls

3:02

will appear in that. So

3:05

if you doze off just wake up when you see Yellow

3:08

Boxes and read the material that is present within

3:11

them.

3:12

We're going to start by talking about morphology and I've

3:15

listed here what I call the Magnificent Seven morphologic

3:18

features that allow you to diagnose

3:21

articular diseases. I called

3:24

them The Magnificent Seven because they

3:27

were famous movies that use that particular title

3:30

as I illustrate on the left.

3:33

You will note on this particular slide. I'm

3:36

highlighting four of those Magnificent Seven

3:39

morphologic features and it will be those

3:42

four that I will cover over the next few minutes.

3:46

The first of the four morphologic features that

3:49

is important to understand the presence of

3:52

bone erosions.

3:54

On your right I'm showing you a typical synovium line

3:57

joint with two bones separated by

4:00

a joint cavity. The ends of the bones are covered

4:03

by cartilage here in blue, which in most

4:06

areas of the body is Highland cartilage not federal

4:09

cartilage surrounding the joint cavity is

4:12

a fibrous capsule the inner margin of

4:15

which represents the synovial membrane, which

4:18

is shown in red Ivan large one particular area

4:21

of that drawing over on your left the

4:24

point out that at the edges or margins of

4:27

the joint shown here by the blue arrow.

4:30

There is synovium in red that

4:33

is a budding bone with our

4:36

protective cartilage. So if you have a process with

4:39

synovitis, one of the ways that we would see that

4:42

on the radiograph or on any Imaging

4:45

technique would be the presence of marginal erosion.

4:48

You may not know which particular disease

4:51

is present. It could be rheumatoid arthritis.

4:55

It could be a spondylorthy. It could be septic arthritis,

4:58

but you've taken one step toward accurate diagnosis,

5:01

you know, the pathology in fact

5:04

is cinnabitus.

5:06

so here we look at a typical example of

5:09

marginal erosion in the classic disease rheumatoid

5:12

arthritis early on your in the

5:15

center image and a later finding here

5:18

the right in this

5:21

particular example, you can see that there is a bit

5:24

of joint space now in there was soft issue swelling not

5:27

well displayed here but a emphasizing the

5:30

marginal erosions shown here the extend over

5:33

a longer distance on the proximal bone that

5:36

makes up the articulation but often appear more

5:39

discreet on the distal bone here at approximal

5:42

interphalangeal joint on your

5:45

right in a different person or later stage of

5:48

rheumatoid arthritis and you'll know in fact in

5:51

the yellow box to four classic radiographic features

5:54

of rheumatoid erosions that

5:57

tend to be marginal soft tissue swelling

6:00

about the joint fuse or form in nature join

6:03

space now that occurs early and is

6:06

Use and osteopenia probably osteoporosis

6:09

in a very articular location.

6:12

Typical Target site a

6:15

proximal interphalangeal joint.

6:18

Here we're comparing the marginal erosions of rheumatoid arthritis

6:21

on your left with two other processes where

6:24

the erosions look a bit different.

6:27

the first of these is gout

6:30

in gout we have both intro-articular and power

6:33

articular erosions and the

6:36

erosions occur very slowly. So they're often surrounded

6:39

by aerotic margin as indicated here

6:42

marginal erosions may occur, but

6:45

they're not a classic feature of the disease. You can

6:48

also appreciate that there is disease at

6:51

the metatarsal phalangeal joint.

6:54

And in hyperparathyroidism, which will cover also a

6:57

little bit later in this lecture. Although we know

7:00

in fact that there is some periosteo resorption

7:03

among there are also is subchondral resorption

7:06

of bone and you can get these subconsual cystic

7:09

areas with indistinct bone surfaces,

7:12

very typical of hyperparathyroidism.

7:17

The second morphologic feature that we will cover

7:20

is joint space now in rheumatoid

7:23

arthritis. Typically what we see is Palace

7:26

or inflammatory synovial tissue that

7:29

grows over the surface of articular cartilage.

7:33

Through a process of enzymatic degradation of

7:36

cartilage rapid early joint space

7:39

losses seemed typically diffusely distributed

7:42

in enjoyment.

7:44

The example I show you here is in fact

7:47

the need and I'm showing you in a classic case of

7:50

rheumatoid arthritis of the knee. There is fairly symmetrical

7:53

disease in the medial

7:56

and lateral femoral tibial compartments with

7:59

diffuse loss of joint space. We can see the same

8:02

features here on a fluid sensitive Mr. Image

8:05

with the reactive marrow edema

8:08

appearing bright on this particular image.

8:12

Now, let's look at the situation with gout because

8:15

it is different.

8:17

In gouty arthritis the urate crystals and carried

8:20

to the synovial membrane by the bloodstream.

8:23

During an acute attack of gout those crystals

8:26

are shed into the joint cavity then owing

8:29

to the succulents of articulate cartilage

8:32

erosion of cartilage and Bone may

8:35

occur.

8:36

But typically about the areas of erosion

8:39

there is relatively normal articular

8:42

cartilage. So with surprising

8:45

then in doubt when you see large erosions

8:48

that you may also see a joint space

8:51

that may not be narrowed at all or in this

8:54

case slightly narrow. That is a feature. We typically

8:57

do not see in rheumatoid arthritis.

9:01

Now diffuse loss of joint space joint space now is

9:04

also seen early in pyogenic arthritis and

9:07

I pick a very very good example this being

9:10

the glenohumeral joint here also

9:13

the panus grows off over the surface of

9:16

articulate the cartilage. So rapid loss of

9:19

joint spaces seen. I love this particular image because

9:22

there's something else very important shown in

9:25

this case. Not only the marginal erosions

9:28

of bone, but you'll know the elevated position

9:31

of the humeral head with respect to the glenoid and

9:34

the narrowing of the economial distance.

9:37

You see what happens with septic or

9:40

fighters of the gummy will joint

9:43

The rotator cuff may be destroyed by that panace and

9:46

then the panace the infective

9:49

palace reaches the Bursa and extends even

9:52

in some cases into the acromiocubicular joint.

9:55

Now that's important to know because we always think

9:58

of septic arthritis as a monoarticular

10:01

process, which it typically is but in

10:04

certain locations such as the glenemal joint

10:07

it may then extend into a second joint

10:10

particularly the acromial convicta the

10:13

joint

10:14

Now let's look at the pictures on

10:17

the right. I'm showing you an example of tuberculus arthritis

10:20

by diagram and a case

10:23

in the air in this particular type of arthritis and

10:26

in granular sorethritis in general

10:29

such as fungal disease, the panus

10:32

can grow between cartilage and subcondral

10:35

Bone. So in tuberculosis and

10:38

fungal related arthritis, you can get large

10:41

erosions of bone with relative preservation of

10:44

joint space.

10:48

We're going to move on and talk about bone proliferation and

10:51

show you various patterns of bone proliferation that

10:54

occur within articular diseases.

10:58

The first of these is gout and when we have gouty deposits,

11:01

we call them profile and those toeflies slowly

11:05

grow into the adjacent bone the bone

11:08

reacts to it by sending out a linear or curvilinear

11:11

ledge of bone known as

11:14

the overhanging margin or ledge sign

11:17

of gout.

11:19

This can simulate an osteophyte but

11:22

tends to occur at a distance from The Joint in

11:25

some instances a very classic example

11:28

of the overhanging margin or

11:31

ledge of gout.

11:33

Now another disorders there are different patterns of

11:36

bone response and psoriasis. Okay

11:39

in common with the other sponsor orthopathies

11:42

bone proliferation that

11:45

initially is ill-defined is evident

11:48

shown in this case. We call this whiskerin.

11:52

And in osteoarthrosis particularly of the

11:55

inflammatory type we get a combination of

11:58

bone outgrowth known as osteophytes

12:01

combined with Central collapse mechanical

12:04

collapse of bone the Gold Wing

12:07

appearance, which is typical of inflammatory osteoarthritis.

12:12

Perhaps the most famous pattern of bone proliferation

12:15

is known as osteophytosis. Now,

12:18

there are two basic types of osteophytes depending

12:22

upon their position some are

12:25

at the edge of the joint marginal osteophied summer located.

12:28

Centrally. I'm going to use this example to illustrate

12:31

marginal osteoparts. Of course, this

12:34

is a hip and in a hip the stress is

12:37

related here super early and laterally

12:40

so in the region of stress, we get joint

12:43

space now and Bones sclerosis and subchondral cysts.

12:47

The axial and medial aspect of the femoral

12:50

head are not distressed regions. So the cartilage

12:53

is Left Behind the osteophyte develops

12:56

owing to a process known as

12:59

endochondral bone formation cartilage laying

13:02

down bone. And as that

13:05

cartilage lays down bone. The original zone of

13:08

calcified cartilage is Left Behind as

13:11

a curval linear line telling you that

13:14

there is an osteopath here in a

13:17

specimen. I'm showing you again the original zone of calcified cartilage

13:20

and the osteophytes and on

13:23

the specimen radiograph those same features are present. So,

13:26

please look for that osteophyte

13:29

and the original zone of calcified cartilage

13:32

that is buried as the ostify girls.

13:36

Now in some instances of osteoarthrosis islands

13:39

of cartilage are left behind centrally

13:42

and because of that endochondral bone

13:45

formation will lead to button-like Expressions

13:48

shown here that are Central osteophytes. These

13:51

can simulate into articular

13:54

bodies, but they are connected to the Bone and

13:57

are not free within the joint cavity Central

14:00

osteopaths.

14:03

Another pattern of bone proliferation that I mentioned

14:06

earlier is this whiskering or ill-defined bone

14:09

proliferation seen in psoriasis reactive

14:12

arthritis and rarely in peripheral

14:15

joint disease of Ankylosing Spondylitis here.

14:18

You can appreciate capsular attachment

14:21

bone proliferation. This is

14:24

emphasis to remind

14:27

you and emphasis is a site of tendon ligament or

14:30

capsular attachment of our own and fascitis

14:33

is inflammation at that site and

14:36

here we can see the inflammatory reaction has

14:39

produces ill-defined regions of

14:42

bone proliferation.

14:44

Over time these may become better defined but

14:47

note how widespread they are in this

14:50

particular example. So psoriatic arthritis

14:53

with whispering

14:56

this is also a beautiful case showing you emphasis.

15:00

With bone proliferation as well

15:03

as Maryl edema on the Mr. Images

15:06

as you see before you so this

15:09

is classic bundle orthopathy usually psoriatic

15:12

arthritis within this emphasis

15:15

and Bone whispering.

15:19

We're going to move on to the final morphologic feature that

15:22

is really helpful in trying to

15:25

figure out what type of articular disease is present

15:28

and that is interarticular periarticular calcification

15:32

or ossification.

15:36

The first disorder that I'm showing you is known as idiopathic or

15:39

primary synovial osteochondromatosis or

15:43

chondromatosis. And what occurs here

15:46

is a metaplasia of the synovial lining into

15:49

cartilage nodules that may subsequently

15:52

calcify and ossify this

15:55

process is monoorticular most commonly

15:58

seen in the knee. Although I show you an example

16:01

in the elbow the body's tend

16:04

to be many in number almost too many

16:07

to count and the body's in most cases tend to

16:10

be of equal size or almost equal size distributed

16:13

throughout the joint. Here's another

16:16

example in this case involvement of the

16:19

Glen you'll join

16:21

you'll note the bodies here Many Many Bodies distributed

16:24

throughout the joint of approximately equal

16:27

size. At least most of them are of

16:30

equal size.

16:32

Now that is primary synovial normatosis, and

16:36

that has to be differentiated from another problem,

16:39

which is secondary synovialsis any

16:43

disease process?

16:46

That leads to disintegration of the

16:49

articular surface and I've listed some here can

16:52

lead to the presence of interarticular bodies

16:55

shown in this example in the

16:58

knee in a patient with osteoporosis.

17:01

Typically, the bodies are fewer in number of

17:04

variable size and not distributed equally

17:07

throughout the joint and the underlying

17:10

disease should be readily apparent those

17:13

features differ from the features of primary

17:16

synovialasticenormatosis.

17:20

Here's an example rheumatoid arthritis were

17:23

fairly symmetrical medial and lateral femoral

17:26

tibial compartment involvement the arrow

17:29

pointing to an intro articular body

17:32

related to disintegration of

17:35

the articular surface.

17:39

my favorite disease

17:41

of arthritis is this one calcium pyrophosphate dihydrate

17:44

Crystal deposition disease.

17:48

It's a long name and maybe some of you don't mention

17:51

it because it is so long, but I can tell

17:54

you with the exception of osteoarthrosis.

17:57

This is the most common particular disorder

18:00

that we see radiographically.

18:04

And there are a number of findings. I'm going to stress pyrophosphatically arthropathy

18:07

a little bit later in this talk. But

18:10

right now, let me just stress the calcification.

18:14

The typical location of calcification related to pyrophosphate

18:17

Crystal deposition is within Highland

18:20

cartilage or fibrocartilage shown

18:23

beautifully in this example, but

18:26

I would remind you that the same

18:29

crystals can be deposited elsewhere in the

18:32

synovian in the joint capsule in

18:35

tendons and ligaments and in soft tissue. So please

18:38

do not think of this as a disease that

18:41

leads only to control calcinosis. It

18:44

does more than that. Yes, it calcifies

18:47

cartilage but a calcifies a lot

18:50

of other tissues as well. Look at

18:53

this example in a cadaver.

18:56

You're looking at a coronal section of the wrist. We

18:59

can see the involvement of the cartilage within the

19:02

Triangular fibrocartilage of the wrist. And here's

19:05

what that looks like. But look at the ligament.

19:08

A calcification these are pyrophosphate crystals

19:11

in the stateful loonate and lunotrigoquietro interosseus

19:15

ligaments, and you can see

19:18

a little bit of calcification of articular cartilage as

19:21

well.

19:23

Another example cadavers showing you

19:26

the pyrophosphate crystal deposition within the

19:29

skateful lunate interosseous ligament within

19:32

the transverse carpal ligament in the

19:35

region of the carpal tunnel and here involving capsule

19:38

and synovium of a metacarpal

19:41

phalangeal joint with erosion of the

19:44

subjacent bone.

19:47

When we think of calcification of tendons, we

19:50

typically think of calcium hydroxyapatide Crystal

19:53

deposition disease now, I

19:56

want to remind you that that's not the only Crystal there

19:59

are other calcium phosphate crystals that

20:02

do produce calcific tendonitis. We see

20:05

this most commonly as you know in the shoulder we

20:08

see it in any of the tendons of the

20:11

rotator cuff but is shown here the most common site

20:14

is in the supraspinatus tendon and

20:17

typically

20:19

The calcification occurs at the footprint where the

20:22

tendon attaches to bone.

20:25

The pattern of calcification varies, but if it

20:28

is discrete and well-defined the

20:31

patient who has this may be totally asymptomatic. So

20:35

stationary well-defined calcification

20:38

related to hydroxyapatite deposition

20:42

can be totally asymptomatic.

20:47

What makes it symptomatic is when it moves and

20:50

it can move in three different directions. The

20:53

first is it can move superficially.

20:57

Being present beneath the floor of the Bursar or

21:00

actually being extruded into the Versa right?

21:03

Here's an example. This was calcification

21:06

within the subscapularis tendon a

21:09

coronal fluid sensitive sequence. This

21:12

calcium has now been extruded and you

21:15

can see the inflammatory reaction the second

21:18

direction in which the calcium may move

21:21

is in fact medially along delaminated

21:24

tears of the adjacent tendon.

21:27

This can be very symptomatic. Here's a

21:30

beautiful example showing you my grading calcification

21:33

in a delaminated tear of

21:36

the infraspinatus.

21:38

And the third direction in which the calcium May

21:41

migrate is downward into the bone. Here's an

21:44

example showing you that with the inflammatory reaction.

21:47

This can simulate tumor unless

21:50

you appreciate those calcium outside of

21:53

the bone as well.

21:57

Tumor like deposits of calcification around joints

22:00

known as tumoral calcinosis. This

22:03

can relate to a number of

22:06

rare disorders hereditary disorders,

22:09

but more commonly it relates

22:12

to an underlying disorder of

22:15

which two are most important. One of

22:18

these is college and vascular disease particularly

22:21

square or Derma here is tumoral

22:24

calcinosis involving joints.

22:29

related to hydroxyapatite in Scleroderma

22:32

and the second

22:35

cause of tumoral calcinosis is chronic renal

22:38

disease as shown in this example with multiple

22:41

sites of calcium hydroxyapatite Crystal

22:44

deposition.

22:48

Okay, that's part one of this lecture. We're now going to

22:51

move on to the Target area approach. We're

22:54

going to look at the distribution of articular disorders

22:57

in the hands and in the wrist.

23:01

This is my drawing of a hand and I haven't

23:04

redone it but somehow it didn't turn out. Well, the film

23:07

is wrong, but you can get an idea

23:10

of what joints we're dealing with. We're dealing with

23:13

the metacarpal theologial joints, the proximal interfalengeal

23:16

joints the distal interphalangeal

23:19

joints and the interphalangeal joint

23:22

of the thumb. These are the possible target areas

23:25

of a number of articulate diseases.

23:30

The first disease we're going to look at is rheumatoid arthritis

23:33

typically bilateral fairly symmetrical

23:36

more often in women than in men.

23:39

This particular drawing shows you the classic

23:42

distribution of the major abnormalities that

23:45

occur in the hand involvement of

23:48

the metacarpal phalangeal and proximal interphalangeal

23:51

joints as well as the interphalangeal joint

23:55

of the thumb.

23:56

Now when I was a resident, I was told you do

23:59

not get erosions of the distal interphalangeal joints

24:02

in rheumatoid. That is incorrect.

24:05

Erosions of the distal joints are

24:08

infrequent and small in size

24:11

when compared with the more proximal erosions. If

24:14

you want to know which joints are

24:17

the earliest to be involved. It's the ones in Orange the

24:20

second and third metacarpal phalangeal joint

24:23

and the third proximal interphalangeal joint.

24:28

You know already the four fundamental early features

24:31

of rheumatoid arthritis here again, you've

24:34

seen this example marginal erosions joint

24:37

space narrowing periarticular osteopenia

24:40

and not well shown in this image

24:43

soft tissue swelling about the involved joint a

24:46

proximal interphalangeal joint.

24:50

At the metacarpal phalangeal joints in rheumatoid

24:53

arthritis, the erosion's predominate on

24:56

the radial aspect of the metacarpal heads

24:59

as shown here. This is lucky for

25:02

us because normally there are ridges

25:05

on the owner side of the metacarpal head that

25:08

can cause problems. So I always look at the radio

25:11

aspect of the metacarpal has

25:15

let's now look at austrial courses and inflammatory osteoarthritis.

25:18

You can see here the

25:21

distribution is that of the interphalangeal joints

25:24

proximal and distal typically

25:27

seen in Middle aging elderly women

25:30

bilateral and fairly symmetrical.

25:34

So if you look at this example here in a cadaver,

25:37

this shows you the morphologic features and Target

25:40

sites of ordinary osteoporosis. These

25:44

are the interphalangeal joints. The

25:47

findings are marginal ostevice as

25:50

we talked about and a snug

25:53

fit of one bone with its neighboring bone.

25:56

They fit together like the pieces of a

25:59

puzzle. They interdigitate. This

26:02

is very very characteristic leading to

26:05

diffuse loss of joint space combined with

26:08

the peripheral osteopaths.

26:12

another example

26:14

showing you the closeout position of one bony

26:17

surface with its neighbor.

26:19

the marginal osteoporates the involvement of

26:22

the proximal and distal interferial joints

26:27

A metacarpal phalangeal joints in osteoarthrosis

26:30

minor changes develop and

26:33

the only one that you see frequently is shown here.

26:36

It is diffuse loss of joint space

26:39

at the metacarpal phalangeal joints.

26:42

So we have radiographic rules that we use.

26:46

And for radiographs shows erosions of

26:49

the metacarpal phalangeal joints. It's

26:52

not going to be osteoarthrosis. If a

26:55

radiograph shows large bone outgrowths or

26:58

osteophytes or Spurs particularly on the

27:01

metacarpal heads. It's not going to be osteoporosis is

27:04

going to be something else.

27:09

Inflammatory ostroarthritis is part of

27:12

the picture in some patients who have ordinary

27:15

Oscar orthosis. It's more of an

27:18

inflammatory process. So here's what you

27:21

see you see bilateral ordinary Australis

27:24

and then painted on a few

27:27

of the joints is a more aggressive process. Where

27:30

what will the alcohols are larger?

27:33

The degree of bone collapse is greater and

27:36

the degree of subluxation may be

27:39

more profound.

27:41

Now when you think of rheumatoid arthritis with subluxations, you

27:44

think a boutonniere and swan neck deformities

27:47

that is subluxation in a

27:50

dorsal volar Direction.

27:52

When you think about osterosis or inflammatory osteoarthritis

27:55

with deviations of

27:58

the fingers, typically, it's in a horizontal plane

28:01

radial or owner not dorsal

28:04

or more characteristically seen

28:07

in this example.

28:10

Now when patients with ordinary osterosis developed

28:13

inflammation in one or a

28:16

few joints inflammatory asteroidis is

28:19

the most likely diagnosis, but be

28:22

aware that secondary Crystal deposition may

28:25

occur in degenerative joints of

28:28

women involving the digits and

28:31

the type of crystal is highly variable pyrophosphate

28:34

basic calcium

28:37

phosphate calcium oxalate even rarely you

28:40

will see and then occasionally as shown

28:43

in this example secondary gout with monosodium

28:46

urate deposition within a

28:49

joint or multiple joints of

28:52

the fingers involve first in osteo or

28:55

forces so these patients will come in now with

28:58

inflammatory reaction involving one or several

29:01

of these interphalangeal joints.

29:06

Let's move on to psoriatic arthritis.

29:10

As opposed to the symmetry of rheumatoid psoriatic arthritis

29:14

may be asymmetrical more than

29:17

that.

29:18

It can be unilateral.

29:20

More than that, it can be ray-like in

29:23

distribution. Meaning it may involve multiple joints

29:26

in one or two fingers and

29:29

spare the others and psoriasis certainly

29:32

can produce significant erosions of distal interphalangeal

29:35

joints.

29:38

In addition emphasis and changes in the nail,

29:41

of course may be seen.

29:44

So here two examples of ray-like distribution

29:47

in psoriatic arthritis where multiple

29:50

joints of a single finger or in some

29:53

cases, maybe two fingers are involved.

29:56

Those changes include marginal erosion and

29:59

the bone perforation. I showed you this image before.

30:02

All right, a whiskering so

30:05

called whiskering and psoriatic arthritis.

30:09

Let's move on to calcium pyrophosphate Crystal

30:12

deposition disease. So let's go over the terminology

30:15

again for this disease.

30:18

Calcium pyrophosphate dihydrate cppd is

30:22

the causative crystal in this

30:25

disease.

30:26

Pseudogout is one pattern of

30:29

clinical presentation.

30:32

These are acute intermittent attacks of arthritis

30:35

that simulate gout but patients may

30:38

have pseudo-rheumatoid.

30:41

Pseudosteroarthrosis or even pseudo-nuropathic disease

30:45

as clinical presentations, but the

30:48

most common pattern we see is asymptomatic

30:51

involvement.

30:54

Control calcinosis means simply cartilage calcification

30:57

and in this disease may be fibrocortilage or

31:01

Highland cartilage. But as I mentioned earlier other

31:04

things calcify.

31:07

Capsule synovium tendons ligaments and

31:10

even large soft tissue deposits May

31:13

relate to pyrophosphate deposition. And

31:16

then finally and what is pertinent for

31:19

this part of the lecture pyrophosphate arthropathy, which

31:22

is structural joint damage that

31:25

morphologically can look like

31:28

osteoarthrosis.

31:30

What differs in its distribution in the

31:33

hand as shown here metacarpal phalangeal

31:37

joint involvement? Particularly the second

31:40

and third often bilateral is the classic distribution

31:43

of pyrophosphate orthopathy.

31:46

So let me show you an example. Now.

31:49

I will tell you in this case. The diagnosis

31:52

is made easier because of pyrophosphate

31:55

Crystal deposition within cartilage

31:58

and synovium here, but that may not

32:01

be present. So you have to consider the disease

32:04

based upon pyrophosphate orthopathy joint

32:07

space narrowing and even small

32:10

osteoporites and surface or regularity.

32:13

It doesn't look like what we see in Australia.

32:16

So if you see something like this

32:19

the differing in morphology involving

32:22

the second and third metacarpal

32:25

phalangeal joints with or

32:28

without the calcification consider.

32:32

pyrophosphate arthropathy and calcium

32:35

pyrophosphate disease

32:39

Now if they go into the literature you're going to find a long list of

32:42

disorders that have been associated with calcium pyrophosphate

32:45

Crystal deposition the ones

32:48

in yellow shown here are

32:51

the ones in which this Association appears to

32:55

be real the others we could argue about so primarily

32:58

or secondary hyperparathyroidism emochromatosis

33:01

gittleman syndrome

33:04

and hypophosphatasia come

33:07

to mind.

33:09

I'm showing you the arthropathy that occurs in hemochromatosis

33:12

typically in this disease

33:15

bilateral symmetrical abnormalities of

33:19

the metacarpal phalangeal joints are seen

33:22

similar to pyrophosphate disease.

33:25

But in this disease all of

33:28

the metacarpal phalangeal joints may be

33:31

involved. That's unusual.

33:34

with idiopathic pyrophosphate disease

33:37

there are other findings as well. So

33:40

here's a beautiful example of the arthropathy of

33:43

hemochromatosis.

33:45

Bilateral symmetrical disease involvement of

33:49

all of the metacarpal phalangeal joints and another

33:52

Finding shown by the arrows these beak

33:55

like osteophytes that occur

33:58

on the radial aspect of the metacarpal heads

34:01

a classic feature of hemochromatosis.

34:05

Calcification may or may not

34:08

be present and in some cases not in this

34:11

one osteopenia is also present.

34:15

Now let's look at this distribution or my diagram

34:18

is showing you monoarticular disease of a

34:21

metacarpal phalangeal joint the Third.

34:25

Now whenever I say monoarticular disease, you

34:28

should be thinking.

34:30

Septic arthritis wherever you see

34:33

it in any joint and this is

34:36

such a classic distribution. Here's what

34:39

it looks like joint space narrowing and

34:42

a marginal erosion mono articular

34:45

you think of septic arthritis and the mechanism you

34:48

probably know as well.

34:51

This is the fist fight and the bytes or

34:54

what happens in this is someone strikes the opponent in

34:57

the mouth with a fist.

35:00

And long after the supposed losers mandibular

35:04

fracture has healed.

35:07

The winner the supposed winner may have

35:10

a septic arthritis of the metacarpal phalangeal

35:13

joints because the tooth entered that

35:16

particular joint.

35:18

The diagnosis Made Easy in some

35:21

cases because the tooth is present about the infected

35:24

joint, but always think of this mechanism when

35:27

dealing with a monoarticular process particularly

35:30

of the third sometimes the second

35:33

or fourth metacarpal phalangeal joint.

35:38

Now let's look at another pattern of involvement and that is

35:41

predominant erosion of distal interphalangeal

35:44

joints, and I give you a list here

35:47

on the left of the disorders that I think of.

35:51

This is an example of gout and of course

35:54

probably other joints were involved in this case, but I'm

35:57

showing you the extent of involvement of a distal

36:00

interfalengeal joint. You'll know

36:03

the asymmetrical soft issue swelling the

36:06

well-defined erosions here the overhanging edge

36:09

or ledge all the features of gout and

36:12

I showed you this picture before this is

36:15

hyperparathyroidism with some control

36:18

and subperio resorption of

36:21

bone evolvement of interphalangeal joints

36:24

is rather common.

36:27

The complete our list of problems of

36:30

distal interphalangeal joints. I show you a case

36:33

of a rare disorder multi-centric reticular

36:36

historio cytosis. This is

36:39

also known as dermoid lipo orthosis.

36:42

It has a number of names. It's a

36:45

disease.

36:47

Of skin and bone. And in fact,

36:50

when you look at it the erosions in this disease tend

36:53

to be the sharpest of any erosion seen in

36:56

any type of articular disease.

37:00

To complete our story. I show you an example of thermal

37:03

injury specifically frostbite on

37:06

the right interphalangeal joint

37:10

involvement.

37:11

Even growth disturbance have been

37:14

some child may occur and one of the interesting things that

37:17

may help you is the relative sparing of

37:20

the thumb in frostbite because as

37:23

you are freezing you tend to protect the thumb within

37:26

the clinched this so this is an example

37:29

of soft frostbite.

37:33

In some disorders we see deforming non

37:36

erosive arthropathy. Meaning there are

37:39

a lot of deformities but we do not see erosion and

37:42

although there's a list of possibilities here.

37:45

The one that I would emphasize is SLE

37:48

these patients come in initially.

37:52

With reversible boutonniere and swan neck

37:55

deformities the PA radiograph may

37:58

look normal, but as the hand is lifted off, you will

38:01

see these deformities and erosions tend to

38:04

be absent later on these deformities

38:07

may become fixed.

38:10

We're going to finish up in the last 10 minutes

38:13

or so by talking about the risk.

38:17

Now this is a little bit complex, but my advice

38:20

to you.

38:22

Is that you should not be considering the wrist a

38:25

single joint?

38:26

Whether you are viewing conventional radiograph

38:29

ctmr orthograms, what have

38:32

you you should know that the wrist is composed with

38:35

this series of compartments. So

38:38

let's go over that Anatomy.

38:41

Here's my drawing and then here.

38:44

I'm showing you kind of a condensed drawing and

38:47

here is a category coronal section. The

38:50

major joint of the wrist is the radial

38:53

carpal joint.

38:56

C-shape separating the distal radius from

38:59

the proximal Corporal row.

39:01

A second joint is the inferior or

39:04

distal radioma joint shown here here

39:07

and here separated in

39:10

many of us from the radio carpal compartment

39:13

by the Triangular fibrocartilage complex of

39:17

the wrist.

39:18

A third joint is the pisiform triquel

39:21

compartment and I'll talk

39:24

about that at the very end. Here's what it looks like.

39:28

Then we deal with the fourth compartment which is the mid

39:31

carpal compartment shown here and here

39:34

and here separating the

39:37

proximal and distal carpal rows.

39:40

And for my drawing I'm gonna separate out the

39:43

try-scape portion of the mid-corpal compartment.

39:48

Finally more distally. We have a common carpal metacarpal

39:51

compartment. You can see it here with

39:54

its intermetic carpal extensions and a

39:57

separate first carpal metacarpal compartment

40:00

that does not communicate with the

40:03

other carpal metacropyl joints. Now the

40:06

reason this is important is when we

40:09

look at the differential diagnosis as we're going to

40:12

do in the next few minutes when we look at it for arthritis.

40:15

What I simply do in my mind is figure out

40:18

which compartments are involved and once I've done

40:21

that.

40:22

I've narrowed down the differential diagnosis. All

40:25

right, because certain diseases affect certain

40:28

compartments of the list and others different compartments.

40:31

So let's look at this.

40:34

Pattern one will be early pan compartmental

40:37

involvement of the rift and the

40:40

classic disease that does this is rheumatoid arthritis

40:43

to show you an example. This is

40:46

from a cadaver years ago. I'm showing you

40:49

a coronal section photograph and

40:52

radiograph and the arrows are playing to all of

40:55

the disease involving radio carpal distal

40:58

radio in the mid carpool and maybe a little bit

41:01

of relative sparing of the common carpal

41:04

metacarpal compartment up at the top but this

41:07

in rumatoid pan compartmental

41:10

involvement occurs early on

41:13

Here's an example pan compartmental disease

41:16

may be in this case. Also not so severe in

41:19

the common carpal medical compartment, but

41:22

in all of the other compartments classic for

41:25

rheumatoid.

41:27

Now if you're really good at this.

41:29

If you have a lot of experience with arthritis, you recognize that

41:32

sometimes you can diagnose rheumatoid,

41:35

even at an earlier stage. We're only

41:38

one or two compartments are involved. So

41:41

we'll call this pattern 1A with early

41:44

involvement of the radio carpal and distal

41:47

radio in the joint and you'll remember that typically

41:50

you see that's as manifestations about

41:53

the distal ulna

41:55

Now this is an interesting erosion here. This

41:58

in fact is an erosion involving the

42:01

almost thyroid related to radial carpal

42:04

joint involvement and the

42:07

radial carpal compartment. There is a diverticulum known

42:10

as the priestyroid recess that extends

42:13

over toward the only thyroid and maybe

42:16

become abnormal very very early on

42:19

in rheumatoid producing those tip erosions.

42:22

So yes, very early on these

42:25

may be the only two compartments involved but soon

42:28

pan compartmental involvement. Here's another

42:31

example, look at the changes about the distal

42:34

owner. All right, so radio carpal inferior

42:37

compartment involvement, there's

42:40

even Tino's in a virus involving the

42:43

extensor carpial Narrows tendon sheet,

42:46

but soon in rheumatoid, the rule that we use is

42:49

pan compartmental involvement. Now, you

42:52

can see the other diseases that are in the differential.

42:56

But I love this rule probably one of my favorite rules

42:59

helps me so often if you

43:02

have a process that is pan compartmental generally

43:05

asymmetrical but Pan compartmental

43:08

and the largest erosions are

43:11

about the common carpal metacarpal joint

43:14

involving the metacarpal bases. It is much more

43:17

likely gout than it is

43:20

rheumatoid arthritis. And by the way, the same rule

43:23

works for the foot involvement of the bases of the

43:26

metatarsals classic for gout in

43:29

the midfoot. So, please remember that rule.

43:33

And septic arthritis to fuse pan compartmental involvement

43:36

tends to occur relatively early,

43:39

although in some cases the first carpal metacarpal

43:42

joint may be spare.

43:46

The second pattern that I would emphasize is

43:49

the involvement of the radial aspect of the risk specifically

43:52

the first carpal metacarpal joint

43:55

and the try-scapi area of

43:58

the mid carpal joint. When I see involvement there.

44:01

These are the two diseases that I consider.

44:05

In this case, we're seeing combined first carpal metacarpal

44:08

and triscaping involvement. But in

44:11

some cases just this joint may be

44:14

involved and rarely an osteoarthrosis. Just

44:17

this joint may be involved. All right,

44:20

so this is osteoporosis.

44:23

Now let's look at calcium pyrophosphate disease

44:26

with pyrophosphate orthopathy because the

44:29

distribution is distinctive involvement

44:32

predominantly of the radial carpal

44:35

compartment of the risk and the

44:38

mid-carpal compartment. So look at this example, and

44:41

I would admit in this particular example, there

44:44

is chondro calcinosis to

44:47

help you. I'm going to show you another example where

44:50

that's not present. You'll know the involvement

44:53

of the radio carpal compartment more than that

44:56

narrowing between the radius and skateboard

44:59

excavation and deepening of

45:02

the skateboarding fossa of the

45:05

distal radius narrowing between the lunate

45:08

capitate and hamate with disorganization owing

45:11

to abnormal tilting of

45:14

the lunates. Those are the characteristics of

45:17

pyrophosphate orthopathy. Here's another

45:20

example, it looks the same except

45:23

there's no calcification. So if

45:26

you see this appearance bilateral fairly symmetrical

45:30

in an older person man, or

45:33

woman, please think of pyrophosphate arthropathy

45:36

whether or not

45:39

You see the calcification? All

45:42

right.

45:44

Now there are a couple other disorders. I put in here just for

45:47

completeness sake these are post-traumatic abnormalities.

45:50

They tend to occur in

45:53

persons of all ages often young people and they are

45:56

more often unilateral than bilateral. The first

45:59

of these is known as the slack risk apollonate

46:02

Advanced collapse. You can see the

46:05

same sort of pattern. We saw when calcium pyrophosphate

46:08

disease shown on the right, right and

46:11

this relates to Progressive scaffold Looney.

46:15

And ligament problems and other ligament

46:18

problems in the risk, usually following an

46:21

injury. And then the other disorder is known

46:24

as the snack wrist scaphoid non-union Advanced

46:27

collapse typically related to a non-union

46:30

fracture of the skateboard and then

46:33

over time involvement of the radial carpal compartment

46:36

particularly, the the distal radius

46:39

and the distal fragment of the

46:42

scaphoid combined with mid carpool

46:45

disease, but these tend to have occur in

46:48

younger people with a history of injury and

46:51

tend to be unilateral if it's an

46:54

older person no injury bilateral this pattern

46:57

without or with the calcification, please

47:00

think of pyrophosphate or a

47:03

properly

47:04

The complete our story of the risk just a few

47:07

other examples. If you have a disorder that's involving

47:10

mainly the mid-carpal compartment

47:13

and the common carpal metacarpal compartment

47:16

such that the carpal bones appear to

47:19

be get grouped together as you can see here

47:22

migrating towards the metacarpals with

47:25

relative sparing of the radial carpal

47:28

compartment. You should think of juvenile idiopathic arthritis

47:31

what we used to call juvenile rheumatoid or

47:34

adult onset Still's disease.

47:39

If you have isolated involvement of the first

47:42

carpal metacarpal compartment. Yes, it

47:45

can be australosis. But also it may

47:48

represent Scleroderma. Here's an example

47:51

of Scleroderma with abnormality of that

47:54

compartment. There was also changes in the phalangies some

47:57

of those were post-operative changes, but classic

48:00

resorption of bone in the

48:03

phalanges. This is not common but

48:06

very distinctive in scleroderma.

48:10

Here's another example and in this particular case involvement

48:13

of the first carpal metacarpal compartment and widespread

48:16

hydroxyapatide Crystal

48:19

deposition in a patient with scleroderm.

48:23

And then finally in with this

48:26

region, if you have isolated involvement

48:29

of the tri-scafee portion

48:32

of the mid carpool compartment. Yes, it can

48:35

be osteoarthrosis. But the other disorder to

48:38

think about is calcium pyrophosphate disease

48:41

and here you can see a little bit of control stenosis

48:44

in this example.

48:48

In the last couple of slides. Let me just quickly touch

48:51

upon the price reform tricho joint or

48:54

compartment This Is A sagittal section

48:57

and a categoric wrist is show you the volar surface

49:01

of the triquiture and the dorsal surface of the price

49:04

of warm. This is a synovial line joint and

49:07

I would remind you.

49:09

That this can be a large joint cavity

49:12

with very prominent distal and

49:15

proximal recesses and that explains why the

49:18

Pisa form will move considerably normally with

49:22

respect to the trichum As you move your

49:25

risk. There are a number of diseases that

49:28

can involve this joint and dominate in

49:31

this joints. Here's an example of osteoarthrosis patient

49:35

who had Volaris pain. No, by the

49:38

way, the migration of the price of form with

49:41

respect to the triques and that is normal. All

49:44

right, and the changes of osteoporosis with

49:47

an intra particular body in the joint and

49:50

then many years ago. We wrote an article on

49:53

involvement of this joint in rheumatoid. You're

49:56

looking at images from that article here,

49:59

you can get isolated involvement rarely in

50:02

roomatory involving the price of form trike,

50:05

which will joint with classic cinematitis.

50:08

All right, by the way, this was a radio carpal orthogram.

50:11

And normally that compartment can communicate

50:14

with the pisiform triquetral compartment

50:17

and the histologic features shown here.

50:21

So what I've tried to do in my allotted period of

50:24

time is to go over with you this particular talk

50:27

related to the diagnosis of

50:30

articular disease. We've reviewed

50:33

some of the very important morphologic features

50:36

that are encountered in

50:39

some of these rheumatologic diseases, and I

50:42

introduced you to the Target area approach. We

50:45

applied it only to two regions in this talk the

50:48

hands and the wrist, but it works elsewhere as well. I know

50:51

we may have a chance now to answer some

50:55

questions, but I'm also providing you with my email. I'm

50:58

very good at answering emails. So if

51:01

you do have any questions, you can just send them

51:04

to me, but thank you very much

51:07

for your attention.

51:11

Perfect. That was a great lecture today Dr. Resnick. We always appreciate when you're

51:14

with us. There is a few we have a few questions in that Q

51:17

and A feature if you don't mind opening that up, okay?

51:21

All right.

51:23

How do you differentiate synovial chondromatosis from

51:26

Rice bodies? Well, I

51:29

think it can be very difficult on Mr. But

51:32

not on Plain film because rice

51:35

bodies typically do not calcify or

51:38

ossify. So if you're lucky and you're dealing with

51:41

osteochondromatosis, you can differentiate them

51:44

from Rice bodies, but it can be very difficult. I think

51:47

on MRI the rice

51:50

bodies typically are of low signal. They're very

51:53

well defined. They simulate the signal of cartilage. And

51:56

so I think sometimes that is

51:59

a difficult differential and by the way the rice bodies occur

52:02

with chronic synovitis and rheumatoid and

52:05

tuberculosis and a number of other disorders

52:08

as well.

52:10

What are the changes in ligaments in rheumatoid arthritis

52:13

or many years ago? We did a study looking at

52:16

the distribution of

52:19

contrast in patients who had

52:22

rheumatoid arthritis to see how often the contrast

52:25

ran from the radio carpal compartment

52:28

into the mid carpal or distal radio on

52:31

the compartments and we were surprised by how

52:34

frequently those ligaments were injured. So when

52:37

you have synovitis, you can certainly you

52:40

can certainly have involvement

52:43

of the ligaments. Can you

52:46

show the first Slide the approach? I'm

52:49

not quite sure.

52:51

Well, let me come back. Let me answer the other ones first and I

52:54

Gathering want me to open up my

52:57

My talk again. Anyway, please explain

53:00

Target area in the Foot and Ankle.

53:03

I can't explain that in a short the

53:06

answer but I

53:09

would tell you particularly in the foot the distribution of

53:12

rheumatoid arthritis the erosions predominate

53:15

in the metatarsal phalangeal joints

53:18

when you're dealing with fondle arthropathy such

53:21

as psoriasis and reactive arthritis.

53:24

What we used to call writers syndrome. You may get

53:27

metatarsal phalangeal joint involvement, but

53:30

you also may get radiographically evident interval

53:33

and Geo and joy, so I think that can

53:36

certainly help you in gout you

53:39

can get involvement of the great toe and any of the other articulations,

53:42

but it tends to be asymmetrical or

53:45

even unilateral in some cases.

53:48

How often does the

53:51

common carpal metacarpal joint space communicate physiologically

53:54

with the mid-corp very often? I

53:57

would say in the vast majority of cases. If

54:00

you get contrast material or synovial tissue

54:03

in the mid-carb OR

54:06

compartment it will then be able to extend into

54:09

the common carpal medical compartment. All

54:12

right, so that is a normal.

54:14

Pathway that exists in most of

54:17

us. So therefore cinnabitus involving

54:20

the mid-carville compartment could extend into

54:23

the common carpal metacarpal compartment.

54:26

How do I differentiate rheumatoid arthritis of

54:29

the dens from tuberculosis? Well, if

54:32

you know the anatomy of the dens, you will recognize

54:35

that there are two synovial joints with fancy names

54:38

a median answer in a

54:41

median posterior linoxial joint. They hug the

54:44

odontoid process in rheumatoid arthritis, you

54:47

get synovitis often of both leading to

54:50

erosion and patterns of subluxation. I

54:53

haven't seen too many examples of tuberculosis isolated

54:56

to those joints, but they I

54:59

imagine they can occur one of the most common

55:02

articular disorders that involves those joints is

55:05

calcium pyrophosphate disease where

55:08

you get heavy calcification around the odontoid

55:11

process. So be aware that that's is

55:14

a disease that can involve that region.

55:18

How do yeah, I'm looking. Let me see

55:21

looking for a reason some part periosteo absorption and

55:24

hyperparathyroidism is always a radial side

55:27

of the fallonies. There have

55:30

been a lot of articles that have addressed that years and years

55:33

ago. Some people thought that perhaps it was

55:36

the apposition of the thumb with the radial aspect

55:39

of the phalanges that explain that I don't

55:42

have a good reason for that, but it

55:45

would be a good place to do some research.

55:49

How do you differentiate woven bone and lamelo bone

55:52

on radiographs? It's much easier done

55:55

histologically than it is radiographically.

55:59

We've had a recent cases of microgiotic disease

56:02

and two kids.

56:05

I'm not sure. I I think that

56:08

that entity and I have to look this

56:11

up is was originally described in Israel and

56:14

then in the Middle East and it led to

56:17

a lot of geodes insists and there

56:20

was some relationship to Thermal injury, but frankly, I

56:23

don't remember enough about that disease, so I

56:26

can't answer that question.

56:30

Um, oh, yeah gal. This is interesting and cppd deposits

56:33

in cartilage are quite

56:36

similar by Imaging ultrasound and x-ray as

56:39

I understand it. I'm very poor in

56:42

ultrasenography and admit it what you get

56:45

in gout is icing surface Crystal

56:48

deposition. And I think that said to

56:51

be a very distinctive feature on ultrasound and

56:54

gout and not what you see with calcium pyrophosphate

56:57

disease.

56:59

overlap of early rheumatoid cppd hemochromatosis

57:05

the I guess your indicating. Can

57:08

I tell them apart the typical

57:11

features with cppv and hemochromis are

57:14

joint space narrowing not erosions

57:17

on the radial aspect of the metacarpal head.

57:20

So that's how I would tell them apart.

57:24

And what are your standard playing film image views for

57:27

Rheumatology work?

57:29

typically

57:31

We include PA oblique and

57:34

lateral radiographs of the risk. Now. I must admitted

57:37

some of our hospitals we would like to

57:41

get both risks together limiting the

57:44

the amount of radiographs that

57:47

we are taking but we do rely typically on three

57:50

views. We do not typically get that semi-supinated old

57:53

like you

57:55

And I guess there for the

57:58

person wanted to see that slide send me an

58:01

email and I will send you that slide. Okay, that's

58:04

the easiest way to to do that.

58:07

Any others here on maybe?

58:10

Okay, second and third mCP or owner styloid

58:13

tritium price of one first involved

58:16

in rheumatoid. I would say far most frequently

58:19

the earliest erosions in

58:22

rheumatoid are the second and third NCP and third

58:25

pip joints and that only in rare cases.

58:28

Do you see involvement of high perform Troy

58:31

creature compartment? We described a

58:34

few cases not many in that article. I reference radio

58:37

skateboard excavation.

58:40

Uh, this is

58:43

interesting radio skateboard excavation does

58:46

occur with injury, but

58:49

widening of the space between the scaphoid and

58:52

lunate requires more than disruption

58:55

of the stateful loonate interosseous

58:58

ligament in order to get that and to

59:01

go on to the mechanical erosion of

59:04

the radio carpal compartment other ligaments extrinsic

59:07

ligaments of the risk may

59:10

be involved. So, let me

59:14

see are there any symptoms and premedications for

59:17

cppd? So let me give you the the good

59:20

news and the bad news, you know

59:23

here at UCSD through the

59:26

years. We've done a lot of Imaging pathologic correlation.

59:29

We've had access to cadivaric or

59:32

cadavers and catever specimens

59:35

and most of those were derived from patients

59:38

who were elderly at the time.

59:40

It and I have been amazed how often when

59:43

you section joints of derived from

59:46

elderly persons. When you go ahead and

59:49

section them. There is almost always pyrophosphate Crystal

59:52

deposition. So there is what

59:55

sounds like the bad news almost all of you listening to

59:58

this now. I can tell you we'll get

60:01

calcium pyrophosphate Crystal deposits

60:04

in and around joints if you live long enough

60:07

The good news is in most of you

60:10

they will be asymptomatic. All right, and so

60:13

although you will have calcification. Generally

60:16

you're not going to have significant symptoms related to

60:19

that early symptoms of

60:22

cppd as I indicated. Most people are asymptomatic.

60:25

Some have pseudo gout

60:28

attacks. Some have pseudo-rheumatoid attacks some

60:31

have neuropathic like findings in

60:34

the joint. So it's very very variable.

60:38

And maybe I got to the end of these. I'm not I'm not

60:41

sure. All right any others you could go ahead and

60:44

send me you know the email me as

60:47

they say. I'm very good at answering those emails

60:50

unless I get hundreds of them, but please do

60:53

that.

60:54

Okay, and I guess Ashley you want

60:57

to come out and just do a quick sign off. Just want to say thank you,

61:00

Dr. Resnick. We always appreciate when you are on with us at MRI online

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Yeah. Thank you everybody for tuning in.