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PATH FINAL > MSK PATH > Flashcards

MSK PATH Flashcards

1
Q

What can ABC arise from ?

A

2/3 Primary

1/3 Secondary
**- GCT
- Chondroblastoma
- NOF
- Osteoblastoma
- Fibrous Dysplasia
**

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2
Q

What malignant lesions have ABC components ?

A
  • Osteosarcoma
  • Chondrosarcoma
  • MFH

A

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3
Q

ABC microscopics ?

A
  • Plump fibroblasts
  • Multinucleated Osteoclast-like giant cells
  • Reactive woven bone
  • “Blue cone” - cartilage like matrix
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4
Q

ABC prognosis

A
  • Non-malignant
  • Recurrence rate 20-30% (if incomplete resection)
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5
Q

Most common causes of AVN

A
  • Trauma (most common): due to vascular occlusion
  • Steroids (next common)
  • Sickle cell
  • Alcohol
  • Infection
  • Pancreatitis
  • Gauchers
  • Caissons
  • Bisphosphonate for the jaw!
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6
Q

Chondrosarcoma can arise from ?

A
  • Enchondroma
  • Osteochondroma
  • Pagets
  • Fibrous dysplasia
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7
Q

Types of Chondrosarcoma

A
  • Conventional (90%)
  • Clear cell: special – only originates in epiphyses of tubular long bones
  • Mesenchymal
  • De-differentiated
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8
Q

Chondrosarcoma histologically graded based on ?

A
  • nuclear size, hyperchromasia, and cellularity.

Histologic grade is most important predictor for prognosis

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9
Q

Associated syndromes of Chondrosarcoma

A
  • Maffuci
  • Ollier
  • Multiple Hereditary Exostosis
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10
Q

Pathology findings of Ewings

A
  • Small round blue cell tumor
  • Recurrent t(11;22) (q24;q12) chromosomal translocation.
  • EWS/ETS gene fusion.
  • Homer-wright pseudorosettes indicates neuroectodermal differentiation (PNET)**

–> also found in pPNET, Askin tumour, and neuroepithelioma

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11
Q

Clinical presentation of Ewing sarcoma

A
  • Pain (most common)
  • Fever
  • Raised ESR, LDH
  • Femur shaft most common site
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12
Q

Which site of Ewing sarcoma will mets most commonly ?

A
  • Pelvis (mets most common compared to extremities) - mets very important prognostic factor
  • Spine is the most common BONE site to mets
  • Lung most common site of mets
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13
Q

Which site of Ewing sarcoma has the best prognosis ?

A
  • Spinal Ewing (best prognosis site)
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14
Q

Monostotic FD vs Polyostotic FD

A

Monostotic
- Adolsecent and stops growing with skeletal maturity
- Frequently asymptomatic
- Proximal Femur (most common site)
- Leg-length differences and impingement or nerve compression syndromes

Polyostotic
- Younger age and causes problem in adulthood
- Rarely sarcomatous transformation
- Craniofacial, Skull base and mandible (most common site)
- Unilateral and monomelic: one limb
- Femur most common

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15
Q

Pathophysiology of FD

A
  • GNAS1 mutation
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16
Q

What are the associated syndromes of FD

A

McCune Albright
- endocrinopathy: precocious puberty
- polyostotic fibrous dysplasia: more severe than in sporadic cases**
- ‘café au lait’ spots

Mazabraud syndrome
- fibrous dysplasia and intramuscular myxomas

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17
Q

GCT most common site

A
  • Distal femur Epiphysis*
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18
Q

GCT consists of what cells

A
  • Non-neoplastic osteoclasts* (majority of cells)
  • Neoplastic cells (minority of cells - high RANK-L)
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19
Q

Epidemiology of GCT ?

A
  • F (slightly more common)
  • M (more common in malignant GCT)
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20
Q

GCT associations

A
  • Pagets
  • Gorlin-Goltz
  • Jaffe-Campanacci
  • Phaeochromocytoma-paraganglioma and giant cell tumour syndrome
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21
Q

Recurrence rate of GCT ?

A

40-60% recur locally

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22
Q

Prognosis of GCT mets ?

A
  • lungs mets (4%)
  • rarely fatal
  • can regress spontaneously
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23
Q

Classifications of Gout ?

A

Primary (95%)
- Enzyme defect: abnormalities in purine metabolism
- reduced renal excretion of urate (90%)

Seconcary (5%)
- Secondary to increased serum uric acid levels resulting from associated disorder
- Leukemia, neoplasm, lymphoproliferative disease, end-stage renal disease, drugs (diuretics, ethanol, cytotoxics)
- Congenital: Lesch-Nyhan

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24
Q

Aetiology of Gout

A

Undersecretion of Uric acid by kidneys (90%)
- CKD
- HTN
- Hyperparathyroidism
- Drugs (frusemide, thiaizde, diuretics)
- Lead poisoning (saturnine gout)
- Obesity

Overproduction of Uric acid (10%)
- Myeloproliferative disorders
- Haemolysis
- Extreme exercise
- Lesch-Nyhan syndrome

Gout uncommon in premenopausal woman due to estradiol having urate lowering effect

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25
Q

Most common organism in Osteomyelitis due to Sickle cell disease ?

A
  • Salmonella
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26
Q

Most common organism in Osteomyelitis due to IVDU ?

A
  • E-Coli, Steph aureus (most common overall)
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27
Q

OM locations in:
Neonates
Children
Adults

A

Neonates
- Epiphysis

Children
- Metaphysis

Adult
- Epiphysis

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28
Q

Most common location of OM ?

A
  • Lower limb medulla (most common)*
  • Vertebra: Lumbar > Thoracic > Cervical
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29
Q

Complications of OM

A
  • develops into SCC (Marjolin Ulcer)
  • secondary sarcoma (eg. osteosarcoma) rare
  • secondary amyloidosis
  • pathological fracture
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30
Q

Primary vs Secondary causes of Osteoporosis

A

Primary
- Post menopausal
- Senile
- Idiopathic

Secondary
- Hyperparathyroidism
- Multiple Myeloma
- Malabsoprtion, Malnutrition
- Chemotherapy, Steroids
- Immobilisation

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31
Q

2 Variants of Osteoporosis

A

Low turnover variant
- Elderly with low functioning osteoblasts

High turnover variant
- Post menopausal
- Reduced estrogen stimulates osteoclasts by increasing RANK-L

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32
Q

Osteosarcoma Epidemiology

A
  • <25 yo (mostly)
  • Seen in older patients if secondary to a pre-existing lesion
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33
Q

Secondary Osteosarcomas arise from ?

A
  • Bone infarct
  • Infection
  • Osteoblastoma
  • Osteochondroma
  • Paget disease
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34
Q

Osteosarcoma associations

A
  • Paget disease
  • Retinoblastoma
  • Li-Fraumeni syndrome
  • Irradiation
  • Rothmund-Thomson syndrome
  • Fibrous Dysplasia (rare)
  • Mazabraud syndrome (rare)
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35
Q

Classification of Osteosarcoma

A

Intramedullary/Central (80%)
- Conventional (80%): osteoblastic type (most common)
- Telangiectatic
- Small cell
- Low grade central

Surface
- Periosteal
- Parosteal

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36
Q

Most common mets site for Osteosarcoma

A
  • Lung > Bone and Nodes
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37
Q

Epidemiology of Paget disease

A
  • Caucasian
  • > 55yo (90%)
  • M > F
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38
Q

Paget disease Polyostotic or Monostotic more common

A

Polyostotic more common

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39
Q

Paget clinical presentation

A
  • Asymptomatic when diagnosed, usually incidental (majority)
  • high ALP with normal Ca and PO4
  • Bone pain (most common symptom)
  • Bone deformity: Kyphosis, Protrusio, Bowing*, spinal stenosis, big skull, hearing loss, fracture
  • high output cardiac failure (rare)
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40
Q

Pathophysio of Paget

A
  • a disease of OSTEOCLASTS*
  • associated with PARAMYXOVIRUS
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41
Q

Lab markers of Paget disease

A
  • High ALP
  • Normal Ca and Phosphorus
  • High urine Hydroxyproline
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42
Q

Which type Osteogenesis is lethal ?

A
  • Type 2 (death in utero)
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43
Q

Clinical features of Osteogenesis imperfecta by type

A

Type 1 and 3:
- blue sclera
- hearing impairment

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44
Q

RA epidemiology

A
  • 1% in developed country
  • Female (3x)
  • peak 20-50
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45
Q

Pathophysiology of RA

A
  • T-helper cell activate macrophages
  • TNF and IL-2* stimulates synovial cells to release proteases to break down hyaline cartilage
  • RANK-L activates to stimualte bone resoprtion
  • ** Fibrinoid necrosis = immune complex (antigen-antibody) deposition in vessels walls
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46
Q

Extra-articular involvements of RA

A
  • Skin RA nodules
  • lung necrobiotic nodules
  • vasculitis
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47
Q

RA lab findings ?

A
  • Anti-CCP
  • RA
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48
Q

RA syndromes

A
  • Felty syndrome: RA + splenomegaly + neutropenia
  • Caplan syndrome: RA + pneumoconiosis
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49
Q

Treatment and prognosis of RA

A
  • 20% complete remission
  • TNF targeted drugs and Steroids

Complications
- Amyloidosis and opportunistic infection

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50
Q

Rickets and Osteomalacia pathophysio

A
  • defect in bone mineralization due to Vitamin-D deficiency or defect in metabolism
  • Reduced GI and renal absoprtion of calcium and phosphate
  • Increased PTH which increases calcium resorption in kidney, but this comes at the cost of losing
    phosphate
  • Reduced osteoblast stimulation
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51
Q

Clinical presentation of Rickets / Osteomalacia

A
  • Basilar invagination
  • Scoliosis
  • Acetabular protrusio
  • Leg bowing
  • Rachitic rosary ribs due to osteoid accumulation at costochondral junction
  • Looser zones are pseudofractures
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52
Q

Aetiology of Rickets / osteomalacia

A
  • Vit-D deficiency
  • Reduces Vit-D synthesis: renal failure, liver cirrhosis (liver converts vit D to soluable form)
  • Vit-D receptor defect
  • Phosphate metabolism defect: X-linked hypophosphatemia
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53
Q

MFH (pleomorphic undifferentiated sarcoma) Risk factors ?

A
  • Radiotherapy**
  • Arise from Paget disease**
  • can also arise from FD, GCT, enchondroma, OM, Osteonecrosis
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54
Q

MFH (pleomorphic undifferentiated sarcoma) imaging features ?

A
  • T2 dark to intermediate (half the time) - think about “fibrous” like scar
  • Spontaneous hemorrhage common “history is old lady stood up from chair ends with big proximal hematoma - under that hematoma is MFH
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55
Q

Synovial sarcoma mimic

A
  • Baker cyst: if it’s not located in its typical location / looks too complex or has flow in it, think synovial sarcoma*
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56
Q

3 imaging appearances of Synovial sarcoma

A

1) “triple sign”, high, medium and low signal all in same mass (prob in knee) on T2

2) “bowel of grapes” bunch of fluid-fluid level in a mass

3) xray with soft tissue component and calcifications (least likely way shown)

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57
Q

Clinical features of Synovial sarcoma

A
  • Most sarcomas don’t attack bones; Synovial sarcoma Can
  • Most sarcomas present as painless mass; Synovial sarcomas Hurt
  • Soft tissue calcifications + Bone erosion is highly suggestive
  • Slow growing, mislead people to think its benign
  • 90% have X-18 translocation
  • Most common malignancy in teens/young adults of the foot, ankle and lower extremity*
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58
Q

Earliest sign of Gout ?

A
  • Joint effusion
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59
Q

Myossitis Ossificans vs. Parosteal Osteosarcoma calcification pattern ?

A

Myossitis ossificans
- Ossifies from peripheral to central

Parosteal osteosarcoma
- Ossifies from central to peripheral

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60
Q

What happens to phosphate in Hyper PTH ?

A
  • “Phosphate retention”
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61
Q

What view to do for SLE hand ?

A

Norggard view
- Shows reversible ulnar deviation
- No articular erosions
- Show hands with ulnar deviation on Norggard view, but reduces on AP view (because hands are flat)
- The ligamentous laxity also increases risk of patellar dislocation

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62
Q

SLE hand DDx ?

A

Jaccoud’s Arthropathy
- very similar to SLE in the hand (ppl often say them together)
- History is Post Rheumatic Fever

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63
Q

JIA features

A
  • <16yo
  • carpals are jacked and ankylosed (premature fusion of growth plates)
  • Serology often negative (85%)
  • Enlargement of epiphysis in knees** (Epiphyseal overgrowth BUZZWORD)
  • Widened interocondylar notch (like hemophilia)
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64
Q

Amyloid Arthropathy features

A
  • Seen in dialysis patients after 10 years of treatment
  • Bilateral involvement of shoulders, hips, carpals, and knees (distribution key*)
  • Carpal tunnel syndrome common manifestation**
  • Joint space preserved until late***
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65
Q

What is the normal pattern of marrow conversion?

A
  • Epiphysis / apophysis > diaphysis > distal metaphysis > proximal metaphysis
  • Red marrow converts to Yellow marrow from distal to proximal
  • Adult has yellow marrow everywhere except axial skeleton and proximal metaphysis
  • Red marrow can be found in adult femoral head or humeral head as variant
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66
Q

Yellow marrow on MRI

A

T1 is money sequence: Yellow is bright, Red is darker than yellow (iso-intense to muscle almost)

Red marrow should never be darker than disk on T1

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67
Q

What is the normal pattern of REconversion of marrow ?

A
  • Occurs in reverse order:
  • Axial skeleton > peripheral
  • The last to go are distal long bones
  • Typically epiphysis are spared unless hematopoietic demand is very high*
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68
Q

How to differentiate Giant cell tumor of tendon sheath from a ganglion cyst on imaging ?

A

GCT of tendon sheath will
- show doppler flow
- T1 and T2 low to intermediate (c.f. ganglion cyst T2 hyperintense)
- Otherwise: Both can be non compressible, both can be homogeneous or heterogeneous
- GCT can mimic cancer on PET

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69
Q

Pathology marker of GCT of tendon sheath ?

A
  • CSF-1 hyperexpression
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70
Q

“popeye” bulge in the arm

A

Biceps tendon tear

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71
Q

RF factors + or - in JIA ?

A

RF usually negative and ANA usually positive (Robbins)

RF 20-30% positive and ANA 40% positive. If RF + then anti CCP + (StatDx)

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72
Q

Nodular fasciitis location ?

A
  • Volar aspect of the forearm** (c.f. Palmar fibromatosis aka. Dupytrens contracture seen in PALMAR hand, Female) - most common
  • The lower extremity, and the chest and back.
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73
Q

Nodular fascitis clinical presentation ?

A
  • typically manifests as a rapidly growing mass
  • The lesions tend to be small (<4 cm).
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74
Q

Nodular fascitis causes ?

A
  • Trauma
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75
Q

Dupuytren contracture, also called Viking disease, or palmar fibromatosis
- epi

A
  • European Male
  • 65 yo
76
Q

Dupuytren contracture (Palmar fibromatosis)
- location ?

A
  • flexor tendons of superficial fascia of the palm
  • lesions can be bilateral in about half of cases
  • the 4th ray is typically involved
77
Q

SLE diagnostic criteria ?

A
  • Non-erosive arthritis
  • Malar rash
  • Discoid rash
  • Oral ulcers
  • Pericarditis / Pleuritis
  • Photosensitivity
  • Seizures
  • Proteinuria
78
Q

Chondrosarcoma mostly low or high grade ?

A
  • Low grade and rarely mets
79
Q

Location of Bone Adamantinoma

A

The occurrence is almost exclusively confined to the tibial diaphysis

80
Q

Bone Adamantinoma appearance ?

A
  • Multilocular or slightly expansile osteolytic cortical lesion
  • NO periosteal reaction
81
Q

Looser zone’s usually uni or bilateral

A
  • Bilateral
  • Not related to stress (abnormal bone - insufficiency fracture)
82
Q

Chondrosarcoma arises from where most commonly ?

A
  • predominantly arises in the axial skeleton (pelvis, shoulder, ribs)
  • peripheral involvement is rare.
  • Clear cell variants can occur in epiphysis of long bones.
83
Q

Chondrosarcoma histo apperance ?

A

Chicken wire calcification

84
Q

Synovial sarcoma does not originate from what cell

A
  • morphologic features are inconsistent with an origin from synoviocytes
85
Q

Synovial epi

A

young adults
15-40yo

86
Q

CPPD secondary causes

A

haemochromatosis

hyperparathyroidism

hypothyroidism

hypomagnesaemia

previous joint injury

ochronosis

87
Q

What can compress causing popliteal entrapment syndrome

A
  • medial head of gastrocnemius or less commonly with popliteus or fibrous bands.
88
Q

Popliteal entrapment most common presentation ?

A
  • Most Asymptomatic
  • When symptomatic, cause claudication (cured with the release of the popliteal artery)
  • Chronic repeated arterial compression can lead to acute thrombus formation and presentation with acute limb-threatening ischaemia in those with poorly developed collateral vessels.
89
Q

Popliteal entrapment usually unilateral or bilateral ?

A
  • Bilateral (2/3)
90
Q

Morton Neuroma epi ?

A
  • Women +++
91
Q

Morton neuroma vs Intermetatarsal bursa/bursitis

A

Morton neuroma
- Non-compressible
- Dumbbell shape
- T1/T2 low

Intermetatarsal bursa/bursitis
- Compressible
- Extruding out in between the metatarsal bones on the plantar aspect of the foot

92
Q

ACL tear associations

A
  • O’Donoghue unhappy triad
  • Segond fracture
  • Posteromedial corner injury of the knee
  • Meniscocapsular separation
93
Q

Distal femoral metaphyseal irregularity (cortical desmoid)
- epi
- clinical
- appearance ?

A
  • present in adolescents (10-15 years of age).
  • may present with pain

Appearance
- saucer-shaped radiolucent cortical irregularity involving the posteromedial aspect of the distal femoral metaphysis at the attachment of the adductor magnus tendon. The lesion lacks an outer margin.

94
Q

JIA features and epidemiology

A

Epi
- F
- RF+ somtimes
- Still disease: Spiking fevers

Features
- Osteopenia
- Erosions
- Epiphyseal overgrowth “ballooning” and joint subluxation
- Atlantoaxial dislocation
- Hepatosplenomegaly
- Pericardial, Pleural effusion
- Knee: Widened intercondylar notch, Rice bodies

95
Q

US findings of De Quervain tenosynovitis

A

oedematous tendon thickening of APL and EPB at the level of the radial styloid (compare with the contralateral side)

increased fluid within the first DORSAL extensor tendon compartment tendon sheath*

thickening of overlying retinaculum and the synovial sheath

peritendinous subcutaneous oedema resulting in a hypoechoic halo sign

peritendinous subcutaneous hyperaemia on Doppler imaging

96
Q

What effects prognosis of healing of De Quervain Tenosynovitis ?

A

In ~10% of patients, there is an intertendinous septum between APL and EPB.

The absence of a septum is associated with very high rates (almost 100%) of complete symptom resolution with conservative management.

Presence of a septum increases the likelihood that surgical management will be required.

97
Q

De Quervain Tenosynovitis Epi

A

middle aged FEMALE!

98
Q

Intersection syndrome imaging

A
  • Overuse tenosynovitis that occurs around the intersection of the
  • first extensor compartment = APL and EPB (abductor pollicis longus and extensor pollicis brevis)

AND

  • second extensor compartment = ECRL and ECRB (extensor carpi radialis longus and extensor carpi radialis brevis) within the forearm.
  • It occurs proximal to the location of the more common condition De Quervain tenosynovitis.
99
Q

What are the common median nerve entrapment syndromes

A
  • carpal tunnel syndrome
  • anterior interosseous nerve syndrome
  • pronator teres syndrome.
100
Q

Carpal tunnel syndrome US findings

A
  • palmar bowing of the flexor retinaculum (>2 mm beyond a line connecting the pisiform and the scaphoid)
  • distal flattening of the nerve
  • enlargement of the nerve proximal to the flexor retinaculum
101
Q

What structure is NOT in the carpal tunnel

A

Flexor carpi radialis* (FCR)

  • contains FDS, FPL, FDP, median nerve
102
Q

Causes of Carpal tunnel syndrome

A

a decrease in the size of the carpal tunnel caused by such conditions as:

  • mechanical overuse (considered the most common association)
  • osteoarthritis
  • trauma
  • acromegaly

disease states leading to change of carpal tunnel contents:
- ganglion cysts, primary nerve sheath tumours
- deposition of foreign material, e.g. amyloid
- synovial hypertrophy in rheumatoid arthritis
- bifid median nerve due to increased cross-sectional area

103
Q

Quadrangular space syndrome involves what

A
  • neurovascular compression syndrome of the posterior humeral circumflex artery (PHCA) and/or the axillary nerve or one of its major branches in the quadrangular space.
  • atrophy of the teres minor and/or deltoid muscles
104
Q

The “bow-stringing” of the flexor tendons of the hand

A

Flexor annular pulley tears

105
Q

Little Leaguer’s elbow features

A

Valgus stress leads to:

  • medial epicondyle apophysitis
  • osteochondritis dissecans (OCD) of the capitellum
  • Panner disease: benign self-limiting osteochondrosis of the capitellum secondary ossification centre in patients <12 years
  • traction apophysitis of the olecranon
106
Q

Tarsal tunnel syndrome

A

Entrapment neuropathy (tunnel syndrome) of the (posterior) tibial nerve or of its branches within the tarsal tunnel (medial)

This condition is analogous to carpal tunnel syndrome.

107
Q

Bucket handle tear more common Medial or lateral meniscus ?

A

Medial > lateral meniscus

108
Q

Ankylosing spondylitis
- first manifestation ?

A
  • sacroiliitis is usually the first manifestation
  • affects big and small joints of hands
  • secondary amyloidosis (rare)
109
Q

Kummel disease ?

A

AVN vertebra

110
Q

Mueller-Weiss disease ?

A

Navicular AVN

111
Q

ABC primary or secondary more common ?

A

Primary (MAJORITY)
- arise de novo

112
Q

Ameloblastoma clinical presentation vs OKC ?

A

Ameloblastoma
- PAINLESS
- loose teeth, Poorly healing tooth extraction
- Can arise from Dentigerous cyst (Asymptomatic)

OKC
- PAIN
- Jaw swelling

113
Q

Ewing arise from cortex or medulla

A

Typically in medullary cavity with invasion of the Haversian system

114
Q

Ewing sarcoma genetic mutation common ?

A

Nearly all Ewing family of tumours have EWS/ETS gene fusion.

115
Q

Ewing & PNET are considered as 2 variants of the same tumour
- with what phenotype ?

A
  • Neural phenotype

Ewing
- undifferentiated

PNET
- Neural differentiated
- Presence of Homer-Wright rosettes indicates neural differentiation (PNET).

116
Q

Is pathological fracture common in EWING ?

A

UNCOMMON

117
Q

Ewing complication ?

A

Treatment-related secondary malignancies 🡪 2% get leukemia or myelodysplastic syndrome. Median 3 years post-treatment.

Cumulative risk of 20% at 20 years for 2nd bone sarcoma.

Growth cessation, limb length discrepancy.

Radiation osteonecrosis.

118
Q

GCT associations ?

A
  • Radiation.
  • Associated with Paget disease (can be multiple)
  • Gorlin-Gotz syndrome
119
Q

GCT aetiology ?

A

Telomeric association is most frequent chromosomal abnormality.

Mononuclear cells express RANKL → stimulation of formation and maturation of osteoclasts.

120
Q

How many % of GCT have ABC components ?

A

15% have focal ABC components

121
Q

Recurrence rate of GCT post curretage ?

A

40-60% recur locally following curettage – need WLE.

122
Q

GCT pulmonary mets % ?

A

Pulmonary metastases in 5-10%

Malignant transformation: 5-10%.

123
Q

Multiple myeloma clinical presentations

A
  • Renal Failure: urate nephropathy, amyloidosis (AL), Hypercalcemia
  • Recurrent Bacterial infection
  • Neurological manifestations: Due to hypercalcemia*
  • Pathological fracture
124
Q

Multiple Myeloma: Can you always detect abnormal immunoglobulin (paraproteinaemia), light chains (part of Ig) or Bence-Jones proteins in urine (free Ig light chains) ?

A
  • NO, 1% are non-secretors
125
Q

Enchondroma most common site ?

A
  • Metaphysis
  • Proximal phalanx
126
Q

Enchondromatosis inheritance ?

A
  • Sporadic (mafucci, ollier)
127
Q

Enchondroma microscopy ?

A
  • hyaline cartilage
128
Q

Liposarcoma most common site ?

A
  • Subcutaneous tissue of thigh
129
Q

Liposarcoma most common subtype ?

A
  • Well-differentiated subtype*
130
Q

Localised tenosynovial giant cell tumour most common site, ddx ?

A
  • Fingers close to a tendon sheath or interphalangeal joint
  • Extra-articular (more common) vs intra-articular
  • Solitary, subcutaneous soft tissue nodules, with low T1 and T2 signal and moderate enhancement.

DDx
- Tendon sheath fibroma: no blooming on T2* sequences

131
Q

Pilon fracture definition

A
  • Fracture involves the tibial plafond and the distal tibial articular surface
  • Associated fractures of the fibula can be evident, with or without ankle dislocation
132
Q

Ankylosing spondylotis associations

A

anterior uveitis (most common)

psoariasis

IBD

Interstitial lung disease

133
Q

Colles fracture

Smiths fracture

Barton fracture

A

Colles fracture
- Extra articular distal radial fracture
- Dorsal angulation

Smiths fracture
- Extra articular distal radial fracture
- Volar angulation

Barton fracture (dorsal or volar)
- Intra-articular distal radial fracture

134
Q

DISI imaging finding

A

Dorsal tilt of the lunate with both of the following present:

  • scapholunate angle >60º: a sign of scapholunate ligament dissociation
  • capitolunate angle >30º: the capitate is displaced posteriorly compared to the distal radius
135
Q

2 types of charcot joint ?

A

Atrophic form
- most common form
- occurs earlier
- has an acute progression
- characterised by reabsorption of the ends of the affected bone
- joint destruction with resorption of fragments
- an absence of osteosclerosis and osteophytes
- mainly occurs in non-weight-bearing joints of the upper limb

Hypertrophic form
- only sensory nerves affected
- slow progression
- joint destruction with periarticular debris/bone fragmentation
- initially widened then narrowed joint space
- presence of osteosclerosis and osteophytes
- absence of osteoporosis (unless the joint is infected)

136
Q

Causes of Charcoit joint ?

A
  • Diabetes mellitus (Foot and ankle)
  • Syringomyelia (Shoulder)
  • Neurosyphylis / Tabes dorsalis (Knee)
  • Traumatic spinal cord injury (Spine)
137
Q

What’s cubital tunnel syndrome ?

A

Ulnar nerve neuropathy due to pathological compression of the ulnar nerve in the cubital tunnel

138
Q

Boundaries of cubital tunnel ?

A

Roof
- retinaculum
- aconeus (when present)

lateral
- olecranon process

medial
- medial epicondyle

floor
- elbow joint capsule

139
Q

Causes of cubital tunnel syndrome

A
  • Overuse
  • Extrinsic compression from Ganglino, Aconeus, Osteochondroma
  • Subluxation / Dislocation of ulnar nerve from congenital laxity in fobrous tissue
140
Q

In distal biceps tendon tear, where does it attach ?

A

Distal Attachment
- Radial tuberosity

Proximal Attachment
- Superior glenoid
- Coracoid process

Image
- Tear of the distal biceps tendon with retraction
- Fluid/hematoma fills the gap site

141
Q

Quadrilateral space syndrome is due to compression of what artery and nerve ?

A

Artery
- Posterior humeral circumflex artery

Nerve
- Axillary nerve

142
Q

Quadrilateral syndrome causes and association ?

A

Quadrilateral space
- Mass (Ganglion cyst, Paralabral cyst)
- FIbrous band
- Large osteophyte

High association
- Rotator cuff tears (LOOK FOR THIS)

143
Q

Bufford complex ?

A
  • Anterosuperior labrum absent
  • Cord-like middle glenohumeral ligament simulating an anterior labral tear
144
Q

Greater trochanter avulsion fracture what muscles ?

A

Gluteal medius and minimus

145
Q

Describe Hangman’s fracture

A
  • Fracture of the bilateral C2 pars interarticularis
146
Q

Classification of Hangman’s fracture ?

A

Levine and Edwards classification

Type 1: C2/3 antero-posterior translation <3mm (stable)

Type 2: C2/3 antero-posterior translation >3mm, posterior longitudinal ligament disrupted (unstable)

Type 3: C2/3 bilateral facet joint dislocation (need surgery)

147
Q

Hangman fracture complication ?

A
  • Vertebral artery injury
147
Q

Klippel-Feil syndrome findings

A
  • Cervical vertebral fusion
  • Antero-posterior vertebral body narrowing
  • Sprengel deformity
  • Scoliosis
  • Hemivertebra
148
Q

Klippel-Feil syndrome association

A
  • Chiari 1 Malformation
  • Cord abnormalities from disc herniation
  • Renal agenesis
  • Scoliosis
149
Q

Secondary causes of CPPD

A
  • Hemochromatosis
  • Hyperparathyroidism
  • Hypothyroidism
  • Hypomagnesemia
150
Q

Tarsal tunnel causes ?

A
  • idiopathic (most common)
  • ganglion cysts
  • calcaneal fracture
  • acessory abductor hallucis longus
  • schwannoma, lipoma
  • pes planus
  • hind foot valgus
151
Q

Procedural steps for shoulder arthrogram

A

Position patient for desired approach
Sterilely prepare/drape skin
20-gauge needle easier to use than 22-gauge in large or muscular patients
Keep needle perpendicular to table at chosen entry site
Advance needle to humeral head
Ease pressure; inject under intermittent fluoroscopy
Joint capsule often very firm; may be mistaken by inexperienced operator for bone
Anticipate needle hitting dense capsule before bone
When on capsule, advance needle with short, rapid push beyond capsule
Avoid performing this maneuver aggressively; will embed needle in cartilage/bone
Perform test injection with lidocaine
Needle likely in joint if low resistance to injection

*Needle must be lateral to labrum
Avoids injecting labrum, which mimics tear

*Contrast should flow away from needle tip
Contrast pooling at needle tip indicates malposition

152
Q

Where should you expect contrast to be seen in shoulder arthrogram?

A
  • Biceps tendon sheath (communicates with glenohuemral joint)
  • Contrast does NOT extend into subdeltoid or subacromial bursa, which would be superior and lateral to the humeral head
153
Q

Medial tibial stress syndrome (Shin splints)
- bone scan appearance vs. stress fracture ?

A
  • Normal appearances on the arterial and blood pool phases but longitudinal uptake on the delayed images. (cf. stress fracture which will show early phase uptake)
  • MRI still more sensitive
154
Q

Medial tibial stress syndrome imaging findings

A

MRI is the most sensitive radiological examination (~88%) for medial tibial stress syndrome.

It may demonstrate a spectrum of findings ranging from normal to periosteal fluid and marrow oedema in medial tibial stress syndrome to a complete stress fracture 5. The medial cortex (+/- posterior cortex) is most commonly affected

155
Q

Tear of the ulnar collateral ligament detaches from where ?

A
  • Sublime tubercle of the ulna
156
Q

Medial epicondylitis findings

A
  • Thickening and increased signal intensity on both T1 and T2 weighted sequences of the common flexor tendon
  • Soft tissue oedema around the common flexor tendon (i.e. peritendonitis)
  • Bone marrow oedema in the medial epicondyle
  • Muscle atrophy may occur in longstanding cases
157
Q

What are the 3 components of scapholunate ligament ?

A

Dorsal component
- strongest, most important

Intermediate component
- primarly made of cartilage

Volar component
- 1 mm in thickness

158
Q

Scapholunate dissociation association

A
  • Distal radius fracture, in particular of the radial styloid, in 40%
  • Widened scapholunate interval >4 mm on PA view
159
Q

Ulnar impaction syndrome definition

A
  • Painful degenerative wrist condition caused by the ulnar head impacting upon the ulnar-sided carpus with the injury to the triangular fibrocartilage complex (TFCC).
  • Differentiation from ulnar impingement syndrome is critical, which is due to a shortened ulna that abuts and causes radial remodelling.
160
Q

What predisposes one to Ulnar impaction syndrome ?

A
  • Positive ulnar variance
161
Q

Shin splint (stress injury) grading system

A
162
Q

Types of coalition

A

Osseous
Fibrous
Cartilaginous
Mixed

163
Q

Adhesive capsulitis features ?

A
164
Q

Hamstring muscle includes ?

A

Biceps femoris
Semimembranosus
Semitendinosis

165
Q

Ulnar collateral ligament consists of what 3 bundles, which one prone to injury

A

Anterior, posterior and transverse

Anterior bundle most prone to injury during valgus stress (little league elbow)

166
Q

ACJ dislocation grading

A

ROCKWOOD Classification
Type 2
- inferior border of clavicle not elevated beyond superior border of acromion
- ACJ ligament torn

Type 3
- Inferior border of clavicle elevated beyond superior border of acromion
- Coracoclavicular ligaments torn
- ACJ ligament torn

Type 4
- all of the above
- Clavicle displaces into trapezius*

167
Q

ACJ dislocation causes

A

SHIRT

Scleroderma
Hyperparathyroidism
Infection
Rheumatoid arthritis
Trauma

168
Q

Boutonniere deformity
Mallet finger

Volar plate avulsion
Jersey finger

A

Middle phalanx dorsal avulsion
Distal phalanx dorsal avulsion

Middle phalanx volar avulsion
Distal phalanx volar avulsion

169
Q

Esophageal web associations ?

A

Plummer-Vinson syndrome

Graft vs Host

GORD

Radiation

170
Q

Esophageal web arises from where most common?

A

Cervical esophagus near cricopharyngeus
- arise from anterior wall and never posterior

171
Q

Esophageal web treatment

A

An oesophageal web may indicate an oesophagus at higher risk of upper oesophageal and hypopharyngeal carcinoma.

  • Balloon dilatation
172
Q

Schatzki B ring vs Esophageal web

A

Schatzki B ring
- at the GEJ, hence squamous cell epithelium above the ring and columnar epithelium below (vs. Web is all esophageal epithelium)
- Assocated with hiatal hernia

173
Q

What’s Seymour fracture ? What’s clinically important about it?

A

Subtype of Mallet finger
- Distal phalanx physeal fracture that has an associated nail bed injury commonly with ungual subluxation.

Prone to
- delayed union, malunion and non-union, in addition to assessment for radiographic changes of osteomyelitis**

174
Q

Describe Maisoneuve fracture

A
  • Proximal fibula fracture
  • Widening of the ankle mortise on x-ray, often comprising ligamentous injury (distal tibiofibular syndesmosis, deltoid ligament)
  • Medial malleolus fracture
175
Q

Atlanto-occipital dissociation features

A

Basion-dens interval (BDI) >10 mm in adults

Basion-axial interval (BAI) >12 mm in adults

Powers ratio >1 (insensitive to a vertical distraction injury or posterior dissociation)

Atlantodental interval (ADI):
>3 mm in adult males
>2.5 mm in adult females

176
Q

Atlanto-occipital joint held together by what structures ?

A
  • Tectorial Membrane
  • Alar ligament
177
Q

Define Jefferson fracture

A
  • Burst Fracture of the anterior and posterior arch of C1
178
Q

Jefferon fracture management ?

A

If transverse atlantal ligament is intact (no widening of the atlantodental interval or intact ligament visualised on MRI) = CONSERVATIVE (hard collar immobilisation).

If the ligament is through to be disrupted, the fractures are considered unstable = MORE AGGRESSIVE TREATMENT

179
Q

Posterior sternoclavicular joint dislocation associations

A
  • Brachial plexus injury
  • Subclavian vascular injury
  • Haemothorax
  • Pneumothorax
  • Esophageal injury
  • Thoracic outlet syndrome

*Anterior dislocation more common

180
Q

What affects prognosis of scaphoid fracture ?

A

Location:
- Proximal pole worst

Vertically orientated fracture line

Fragment displacement >1mm

Ligamentous instability: increased scapholunate angle: i.e. >60º or radiolunate or capitolunate angle >15º

181
Q

Scaphoid fracture complications

A
  1. Non-union
  2. SLAC wrist
  3. SNAC wrist
  4. Osteonecrosis
182
Q

Why is it important to differentiate Pseudo-Bennett from Bennett and Rolando fracture ?

A

It is important to distinguish them from intra-articular fractures (e.g. Bennett fracture-dislocation or Rolando fracture), which are usually unstable and require surgery.

183
Q

Lunate osteonecrosis
- If lunate collapse, radioscaphoid angle <60, what stage is this ?

A

3

184
Q

What are other views to do to evaluate for Femoral-acetabular impingement ?

A

Dunn views, cross-table lateral, frog-leg lateral or Meyer lateral for the assessment of the femoral head-neck junction

185
Q

Complications of femoral-acetabular impingement ?

A

labral tear

chondrolabral separation

chondral injury e.g. carpet lesion

osteoarthritis of the hip

PATH FINAL (12 decks)

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