Ortho Flashcards
Axillary nerve,
Motor, sensory, root
M: deltoid, teres minor, triceps long head
S: lateral upper arm
R: C5, C6
Musculocutaneous nerve
Motor, sensory, root
M: biceps, brachialis
S: lateral forearm
R: C5, C6
Median nerve
Motor, sensory, root
M: Wrist flexor, Wrist abductor, flexion of 1,2,3 digits
S: palmar thumb to radial half of 4th digit. Dorsal tips of digit 1 to radial half of digit 4 OK sign (AIN)
C6, C7
Ulnar nerve
Motor, sensory, root
M: wrist flexor, wrist adductor, Flexion of 4th, 5th digit
S: medial palm, dorsum of hand, 5 th digit and medial half of 4th digit
Spread fingers
R: C8, T1
Radial nerve
Motor, sensory, root
M: triceps (medial/lateral heads). Wrist, thumb, finger extensors
S: lateral dorsum of hand. Medial upper forearm. Thumbs up (PIN)
R: C5, C6,C7, C8
Tibial nerve
Motor, sensory, root
M: ankle plantar flexion, knee flexion, great toe flexion
S: sole of foot
R: L5, S1
Superficial peroneal nerve
Motor, sensory, root
M: ankle eversion
S: dorsum of foot
R: L5, S1
Deep peroneal
Motor, sensory, root
M: Ankle dorsiflexion and eversion
S: 1st web space
R: L5-S1
Sural nerve
Motor, sensory, root
M: -
S: lateral foot
R: S1, S2
Saphenous nerve
Motor, sensory, root
M: -
S: anteromedial ankle
R: L3, L4
Signs suggestive for open fx
Continuous bleeding from puncture site
Fat droplets in blood
Angulation in transverse fx
< 30°
Angulation in oblique fx
30-60°
Fx description
- Name of injured bone
- Integrity of skin/soft tissue
- Location in bone
- Orientation/pattern
- Alignment
Indications for open reduction
Non-union
Open fx
Neurovascular compromise
Displaced intraarticular
Salter-Haris 3,4,5
Polytrauma
Failed close reduction
Not able to cast or apply traction due to site
Pathologic fx
Potential for improved function with ORIF
Evaluation of fx healing
No longer tender on palpation/ stressing
Xray: teabecula cross fx site, visible callus
Normal healing time course of fx
0-3 wk: hematoma, macrophages
3-6 wk: osteoclasts remove sharp edges. Callus forms
6-12 wk: Bone forms within the callus, bridging fragments
6-12 mo: cortical gap bridged by bone
1-2 y: normal architecture achieved through remodeling
CRPS/RSD clinic
Exaggerated response to an insult
Hyperalgesia
Allodynia
Autonomic dysfunction:
Temperature asymmetry
Mottling
Hair/nail changes
Swimmer’s view Xray
Helps to see C7-T1 junction
Controversial Initial Mx if open fx
1st generation cephalo or clinda. Upon arrival until 24 h after each debridement.
Culture from: delayed injury (>24 h), infected injury
Debridement of open fx ASAP
Wound closure: within 7 d ( after soft tissue stabilization and all non-viable tissue removal
Negative pressure wound therapy: decreases infection rate
Initial Mx of open fx
ABC, primary survey
Removal of obvious foreign material
Irrigate with NS
Cover with sterile dressing
Immediate IV AB
Tetanus
Reduce and splint fx
NPO and prepare for OR:
Blood work, consent, ECG, CXR
Operative irrigation and debridement within 6-8 h
Wound left open to drain OR vacuum-assisted closure dressing
Re-examine + irrigation + debridement in 48 h
AB for open fx
If < 10 cm: Cefazolin for 3 d Or Quinolone (if penicillin allergy) Or Vanco (if MRSA positive)
If > 10 cm:
Cefazolin + Genta for 3 d
+ penicillin if soil contamination (clostridium)
Time of muscle necrosis in compartment syndrome
4-6 h
First symptom of compartment syndrome
Pain out of proportion to injury
The most sensitive sign of compartment syndrome
Pain with passive stretch
Inv for compartment syndrome
A clinical diagnosis
Don’t wait for five Ps
If child or if unconscious:
Compartment pressure monitoring with catheter AFTER clinical diagnosis is made
Normal: 0
Elevated: 30 or higher
Treatment of compartment syndrome
Non-operative:
Remove constrictive dressings, Elevate limb at the level of the heart
Operative:
Urgent fasciotomy
48-72 h post-op: wound closure +/-necrotic tissue debridement
Volkmann’c contracture
Complication of compartment syndrome: ischemic necrosis of muscles followed by secondary fibrosis and finally calcification. especially following supracondylar fracture of humerus
The most common cause/ mechanism of spread of osteomyelitis
S. Aureus
Hematogenous
Plain film of osteomyelitis
Soft tissue swelling
Lytic bone destruction (after 10-12 d)
Periosteal reaction (after 10-12 d)
Inv for osteomyelitis
CBC, diff
ESR, CRP
B/C
Aspirate culture/bone Bx
Tx of acute osteomyelitis
IV AB 4-6 wk
+/- surgery (abscess, significant involvement)
Hardware removal
Tx of chronic osteomyelitis
Surgical debridement
AB: systemic (IV) and local
Most common cause of septic arthritis in adults
S. Aureus
If prior joint replacement: consider Staph coagulase negative
If newborn or sexually active adult: N. Gonorrhea
The most common route: hematogenous
Inv for septic joint
Xray ESR, CRP WBC B/C Joint aspirate
Joint aspirate in septic arthritis
Cloudy Yellow WBC > 50,000 PMN > 90% Protein > 4.4 mg/dL Glucose < 60% of blood No crystal Positive Gram stain
Tx of septic arthritis
IV AB
joint aspiration (if early Dx and superficial joint)
Arthroscopic/open irrigation, irrigation and drainage, decompression
Most common joint in infective arthritis
Knee > hip > elbow > ankle> sternoclavicular joint
Plain film of septic joint
Day 0-3:
Normal
+/- soft tissue swelling, joint space widening
Day 4-6:
Joint space narrowing, destruction of cartilage
Monitoring response of septic joint to treatment by
CRP
Shoulder passive ROM
Abduction 180° Flexion 180° Extension 45° Addiction 45° Internal rotation T4 External rotation 40-45°
Most common type of shoulder dislocation
Anterior
Mechanism of anterior shoulder dislocation
Abducted arm is externally rotated/extended
Or
Blow to posterior shoulder
Symptoms of anterior shoulder dislocation
Arm slightly abducted and externally rotated.
Inability to internally rotate
Squared off shoulder
Positive apprehension test
Positive relocation test
Positive sulcus sign
Axillary/ musculocutaneous nerve malfunctions
Imaging in anterior shoulder dislocation
Axillary view: humeral head is anterior
Trans-scapular Y view: humeral head anterior to the centre of Mercedes-Benz sign
AP view: subcoracoid lie of humeral head
Hill-Sachs lesion: compression fx of posterior humeral head
Bony Bankart lesion: avulsion of anterior glenoid acetabulum
Tx of anterior shoulder dislocation
Close reduction
Post-reduction Xray
Post-reduction NVS check
Sling 3 wk (avoid abduction and external rotation)
Shoulder rehabilitation
Mechanism for posterior shoulder dislocation
Adducted, internally rotated, flexed arm
Epileptic seizure
Electrocution
EtOH
Blow to anterior shoulder
FOOSH
Clinic of posterior shoulder dislocation
Arm: held in internal rotation and adduction
External rotation blocked
Anterior shoulder flattening
Prominent coracoid
Palpable mass posterior to shoulder
Positive posterior apprehension test: only used to test recurrent posterior instability and NOT ACUTE INJURY
Axillary/ musculocutaneous nerves dysfunction
Radiology of posterior shoulder dislocation
Axillary view: humoral head posterior
Trans-scapular Y view: head posterior to centre of Mercedes-Benz
AP view: partial vacancy of glenoid fossa.
> 6mm space between anterior glenoid rim and humeral head (positive rim sign).
Light bulb sign
Reverse Hill-Sachs lesion (anterior humeral head)
Reverse bony Bankart: avulsion of the posterior glenoid labrum
Tx of posterior shoulder dislocation
Close reduction
Post-reduction Xray and NVS
Sling in abduction and external rotation x3 wk
Shoulder rehabilitation
Recurrence rate in shoulder dislocation
Depends on age of first dislocation
More if age <20 yr
Complications of shoulder dislocation
Rotator cuff/ capsular/ labar tear
Shoulder stiffness
Axillary nerve/artery, brachial plexus injury
Most common complication: recurrent dislocation
Rotator cuff nerve supply
Teres minor: axillary
All others: suprascapular nerve
Function of rotator cuff muscles
Supraspinatus: abduction
Infraspinatus: external rotation
Teres minor: external rotation
Subscapularis: internal rotation
Rotator cuff examinati
Passive movements permitted
Pain worse with active movements, esp overhead
Weakness and loss of ROM, esp between 90-130°
Tenderness over greater tuberosity
R/O biceps tendoniosis
Inv for rotator cuff disease
X-ray: AP view: high riding humerus indicative of large tear
MRI +/- arthrogram( geyser sign)
Arthrogram: can assess full thickness tear
Tx of rotator cuff disease
If mild or mod: PT, NSAID, +/- IACS
If severe or refractory to 2-3 mo PT and 1-2 IACS: arthroscopic/ open surgical repair
Tests for supraspinatus
Jobe’s test
Lift-off or belly press test
Tests for infraspinatus and teres minor
Posterior cuff test
Rotator cuff impingement tests
Neer’s test:
Passive shoulder flexion. Pain between 130-170°
Hawkins-Kennedy Test:
Shoulder flexion to 90° and passive internal rotation. Pain suggests impingement
Test for rotator cuff tendinopathy
Painful arc test:
Pt actively abducts shoulder. Pain with abduction > 90°
Speed’s test
Apply pressure to the forearm when arm is in forward flexion (90°) with elbow fully extended.
If pain in bicipital groove = biceps tendon pathology
Test with greatest specificity and sensitivity for rotator cuff disease
Painful arc test
O’Brien’s test
SLAP lesion
Forward flexion of arm to 90°, while keeping arm extended, arm adducted to 10-15°. Internally rotate the arm so thumb is facing down. Apply downward force. Repeat test while externally rotated.
Pain or clicking in glenohumsral joint in internal but not external rotation = glenohumeral labral tears (superior labral tear from anterior to posterior)
AC joint injury mechanism
Fall onto shoulder with adducted arm
Clinic of AC injury
Tenderness
Pain with adduction
Step deformity on AC (if dislocated)
Limited ROM
Inv of AC injury
Xray: bilateral AP, axillary view, Zanca view
Tx of AC injury
Sling 1-3 wk, ice, analgesia, early ROM and rehabilitation
Surgery if complete tear + displacement
Most common fx site in clavicle
Middle third
Mechanism of clavicular fx
Fall on shoulder
FOOSH
Direct trauma
Inv for clavicle fx
NVS of entire upper arm
Xray
CT: if medial physeal fx, sternoclavicular injury
Tx of clavicle fx
Medial and middle third:
Sling 1-2 wk
Early ROM and strengthening
If > 2cm shortened: ORIF
Distal third:
Undisplaced: sling 1-2 wk
Displaced: ORIF
Complications of clavicular fx
Cosmetic bump Shoulder stiffness Weakness with repetitive activity Pmeumothorax Brachial plexus injury (esp with proximal third fx) Subclavian vessel injury
Pt with arm clasped to chest
Clavicular fx
Course of adhesive capsulitis
Progressive pain and stiffness
Spontaneous resolution after 18 mo
Freezing phase, frozen phase, thawing phase
Mechanism of frozen shoulder
Primary:
Associated with DM
Secondary: Prolonged immobilization most significant) CRPS/RDS MI Stroke Shoulder trauma AI disease Hyperthyroidism Cervical disc disease Poorer outcome
F> M
Age > 49
Inv for adhesive capsulitis
Xray: Nl or bone demineralization
Tx of frozen shoulder
Freezing phase:
Active and passive ROM
NSAID and IACS to manage pain
Thawing phase:
Manipulation under anesthesia
Early PT
Arthroscopy for debridement/decompression
Clinic of frozen shoulder
Gradual onset
Diffuse shoulder pain
Pain worse at night, prevents sleeping on affected side
Decreased active and passive ROM
Increased stiffness as pain subsides :stiffness continues for 6-12 mo after pain has disappeared
Proximal humerus fx mechanism
Young: high energy trauma
Elderly: FOOSH
Inv for proximal humeral fx
Axillary nerve
Xray
CT: to evaluate articular involvement and fx displacement
Tx for proxima humerus fx
Treat osteoporosis
If non-displaced: broad arm sling immobilization. Begin ROM within 14 d.
If minimally displaced (most common): close reduction, sling 2wk, gentle ROM
If anatomic neck fx, displaced, dislocated glenohumeral joint: ORIF, +/- arthroplasty
Complications of proximal humeral fx
AVN (esp if anatomical neck fx)
Nerve palsy
Malunion
Post-traumatic arthritis
Humeral shaft fx mechanism
Young: high energy
Elderly: low energy: FOOSH, twisting, mets
Inv for humeral shaft fx
Radial nerve
Brachial artery
Xray
Tx of humerus shaft fx
Generally non-operatively
+/- reduction. Can accept deformity
Hanging cast, collar and cuff sling immobilization
After swelling subsides, Samiento functional brace, then ROM
Surgery if:
Pathological fx, floating elbow
ORIF: plating, IM rod, external fixation
If radial nerve palsy in humeral shaft fx
Recovery expected within 3-4 mo
Otherwise: EMG
Other complications: non-union, decreased ROM, compartment syndrome
Distal humeral fx mechanism
Young. High energy
Elderly: FOOSH
Inv for distal humeral fx
Assess brachial artery
Xray
CT: when suspecting shear fx of capitulum/trochlea
Tx of distal humeral fx
Goal: restore ROM 30-130° flexion
Cast immobilization
Surgical if:
Displaced
Supracondylar
Bicolumnar
Closed reduction+ percutaneous pinning, ORIF, +/- total elbow arthroplasty
Supracodylar fx mechanism
FOOSH
Most common in children around 7 yr
Inv in suprachondylar fx
Median nerve (esp AIN)
Radial nerve
Radial artery
Xray: disruption if anterior humeral line. Fat pad sign
Tx of suprachondylar fx
If non-displaced:
Long arm plaster slab in 90° flexion x 3 wk
surgery: percutaneous pinning, ORIF in adults if: Displaced Vascular injury Open fx Unacceptable angulation
Complications of suprachondylar fx
Stiffness (most common) Brachial artery injury Median, ulnar nerve injury Compartment syndrom Malalignment Cubitus varus
Radial head fx mechanism
Common in young adults
FOOSH
Inv of radial head fx
Xray: enlarged anterior fat pad (sail sign)
Presence of posterior fat pad
Tx of radial head fx
If comminuted: excision and prosthesis
If displaced: ORIF
If non-displaced: elbow slab or sling x 3-5 d with early ROM
Complications of radial head fx
Myositis issificans
Recurrent instability ( if MCL injured and head excised)
Do not immobilize elbow more than
2-3 wk
Olecranon fx mechanism
Direct trauma
Fall onto elbow
FOOSH
Inv for olecranon fx
X ray
Tx of olecranon fx
If non-displaced (< 2mm, stable):
Cast, 3 wk (elbow 90°) then gentle ROM
If displaced: ORIF, early ROM if stable
Elbow dislocation mechanism
hyperextension (via FOOSH)
Or
Vulgar/supination stress during elbow flexion
Monteggia: radial head dislocated. Ulna remains
Inv for elbow dislocation
Xray
Radial/ ulnar arteries
Brachial artery
Median, ulnar nerves
Tx of elbow dislocation
Close reduction, Parvin’s method
Then long arm splint, forearm in neutral rotation, elbow 90°
Early ROM (<2wk)
ORIF if:
Complex dislocation
Persistent instability after close reduction
Complications of elbow disloction
Stiffness
Intraarticular loose body
NVS injury
Rasial head fx
Recurrent instability
Tennis elbow
Lateral epicondylitis
Common extensor tendon
Golfer’s elbow
Medial epicondylitis
Common flexor tendon
Course of epicondylitis
Self limited, but may take 6-18 mo to resolve
Tx of epicondylits
Rest Ice NSAID Brace, strap PT, stretching, strengthening CS injection
Operation if:
Failed 6-12 mo conservative therapy
Release of common tendon
Radius and ulna shaft fx mechanism
High energy
Usually accompanied by displacement
Inv for radius/ulna shaft fx
Xray
CT if close to joint
Tx of ulna/radius shaft fx
Goal: anatomic reduction
ORIF with plate and screws
Poor results for close reduction (except in children)
Complications of forearm fx
Soft tissue contracture resulting in limited forearm rotation
Monteggia fx
Fx of proximal ulna with dislocation of radial head. Proximal radioulnar joint injury
Children: more common and better prognosis
Mechanism: direct blow. Hyperpronation. Fall on hyperextended elbow
Inv for monteggia
Xray
PIN injury
Tx if monteggia
Adults:
ORIF of ulna, indirect reduction/ORIF of radius
Early post-op ROM if stable. If not, 6 wk immobilization
Children:
Attempt close reduction and immobilization
Complications of monteggia
PIN: mist common nerve injury
Radial head instability
Radioulnar synostosis
Tx of PIN injury
Observe for 3 mo
Nightstick fx
Isolated ulna fx, without radial head dislocation
Tx of nightstick fx
If non-dislocated:
Below elbow cast x 10d, then brace
ORIF: if displaced, angulation
Galeazzi fx
Fx of distal radial shaft, disruption of distal radioulnar joint
Mechanism: FOOSH
Inv: Xray
Tx of Galeazzi fx
All ORIF
If DRUJ stable and reducible:
Splint x 10-14 d, early ROM
If DRUJ unstable:
Pinning, ORIF. Long arm cast x6 wk
Most common wrist fx in women > 40
Colles’ fx (dinner fork deformity)
FOOSH
transverse distal radius fx with dorsal displacement +/- ulnar styloid fx
Inv: Xray
Tx of colles’ fx
Goal: restore radial height, radial inclination, volar tilt, DRUJ stability, forearm rotation
Closed reduction:
- Traction with extension
- Traction with ulnar deviation
- Pronation, flexion
Then dorsal slab, below elbow cast for 5-6 wk
Xray: 1 wk, 3 wk, at cessation of immobilization
Repeat reduction if necessary
Operative if:
Failed closed reduction, loss of reduction
Smith fx
Volar displacement of distal radius
Mechanism: fall onto the back of the flexed hand
Inv: Xray
Tx: ORIF
If poor candid for surgery, attempt closed reduction
Long arm cast in suppination x 6 wk
Complications of wrist fx
Poor grip strength Stiffness Radial shortening Compartment syndrome EPL rupture Acute CTS Venous block CRPS/RSD
Scaphoid fx examination
Pain with resisted pronation
Pain with long axis compression into scaphoid
Snuff box tenderness
Scaphoid fx inv
Xray
AP, Lat, scaphoid view (wrist extension and ulnar deviation)
+/- CT, MRI
Rarely bone scan
If suspicion of scaphoid fx
If negative Xray: treat as if positive
Repeat Xray 2 wk later. If still negative: CT or MRI
Tx of scaphoid fx
Non displaced: long arm thumb spica cast x 4wk.
Then short arm cast until radiographic evidence of healing (2-3 mo)
If displaced: ORIF
The most common complication of scaphoid bone fracture
Nonunion/malunion (use bone graft)
others:
AVN of proximal fragment (if fx through proximal third)
Delayed union (recommend surgical fixation)
Scaphoid nonunion advanced collapse and arthritis
Special testing for cervical radiculopathy
Compression test:
Pressure on head worsens radicular pain
Distraction test:
Traction on head relieves symptoms
Valsalva test:
Increases symptoms
C5 motor, sensory, reflex function
S: axillary nerve (patch over lateral deltoid)
M: deltoid, biceps, wrist extension
R: biceps
C6 motor, sensory, reflex function
M: biceps, brachioradialis
S: thumb
R: biceps, brachioradialis
C7 motor, sensory, reflex function
M: triceps, wrist flexion, finger extension
S: index, middle finger
R: triceps
C8 motor, sensory, reflex function
M: interossei, digital flexors
S: ring and little fingers
R: finger jerk
Abnormal findings on cervical Xray
Lateral:
Translation if vertebra body > 3.5 mm
Angulation between adjacent vertebral bodies > 11°
Anterior soft tissue space > 3 mm at C3 or > 8-10 mm at C4
Special tests for thoracolumbar spine
SLR (pain in 30-70°)
Lasegue maneuver: dorsiflexion of leg during SLR brings makes symptoms worse, or brings on symptoms in less elevation
Femoral stretch test: pt prone, flex knee, extend hip results in pain in anterior thigh
L4 motor, sensory, reflex
M: quadriceps,
S: medial malleolus
R: patellar
Screen: squat and rise
Test: femoral stretch
L5 motor, sensory, reflex
M: extensor hallucis longus, gluteus medius (hip abduction), tibialis anterior (ankle inversion + dorsiflexion)
S: 1st dorsal webspace, lateral leg
R: medial hamstring
Screen: heel walking
Test: SLR
S1 motor, sensory, reflex
M: peroneus longus/brevis (ankle eversion), gastrocnemius/soleus (plantar flexion)
S: lateral foot
Degenerative disc disease symptoms
Axial back pain
Pain worse with axial loading and flexion
Negative SLR
Inv for degenerative disc disease
Xray
MRI
Provocative discography
Change in alignment of facet joints
Osteophyte formation
Tx of degenerative disc disease
Staying active with modified activity
Back strengthening
NSAIDs
Operative: rare: decompression, fusion
Clinic of spinal stenosis
+/- bilateral back and leg pain
Neurogenic claudication: Worse with standing, exercise. Walking distance variable. Alleviation with flexion, sitting, lying down. Relief in 10 min
+/- motor weakness
Normal back flexion
Difficulty back extension
Positive SLR
Pain not worse with valsalva
SLR in spinal stenosis
Positive
Inv for spinal stenosis
Gold std : CT myelography
CT/MRI
Tx of spinal stenosis
Vigorous PT:
Flexion exercise
Stretch/strength exercise
NSAID
epidural CS
Decompressive surgery if:
Non-operTive failure > 6 mo
Relief time in neurogenic claudication
10 min
2 min in vascular claudication
Mechanical back pain clinical features
Not due to prolapsed disc or any other clearly defined pathology
Dull backache
Aggravated by activity and prolonged standing
Morning stiffness
No neurologic sign
Tx of mechanical back pain
PT
Analgesic
Resolves in 4-6 wk or becomes chronic
Most common location for disc herniation
L5-S1 > L4-5 > L3-4
Features of disc herniation
Back dominant pain (central herniation)
Or
Leg dominant pain (lateral herniation)
Muscle spasm
Loss of lumbar lordosis
Tenderness between spinous processes at affected level
Cauda equina syndrome in 1-10%
Disc herniation tests
Positive: SLR Contralateral SLR Lasegue Bowstring
Disc herniation investigation
Xray
MRI
Post-void residual volume (to check for urinary retention)
If PVR > 100 ml, suspicious for cauda equina
Tx of disc herniation
Extension protocol
NSAID
Surgery if:
progressive neurological deficit
Failure of symptoms to resolve within 3 mo
Cauda equina
Neurogenic claudication is worse by
Position
Vascular claudication is worse by
Exercise
Prognosis of disc herniation
90% improve within 3 mo
Mechanical back pain, disc origin
Pattern 1
Aggravated with flexion
Gradual onset
Long duration
Treatment: exercise, relief of strain
Mechanical back pain Facet origin (pattern 2)
Worse with extension, standing, walking
More sudden onset
Shorter duration (days, weeks)
Tx: exercise, relief of strain
Low back pain with direct nerve root compression, root compression
(Pattern 3)
Dominant in leg
Worse with flexion
Acute onset
Short episodes (attacks taking minutes)
Tx: relief of strain, exercise, surgical decompression if progressive/severe
Back pain with direct nerve root compression, spinal stenosis (pattern 4)
Leg dominant
Worse with exercise, extension, walking, standing
Cngenital or acquired
Acute or chronic Hx
Tx: relief of strain, exercise, surgical decompression if progressive/severe deficit
Defect in spondylolysis
Pars interarticularis
No movement if vertebral body
Most common symptoms of sciatica
Leg dominant pain Constant Burning Radiates down leg +/- foot Most common cause= disc herniation
Features of spondylolysis
Activity related back pain
Pain worse with unilateral extension (Michelis’ test)
Inv for spondylolysis
Oblique Xray:
Collar break in scottie dog’s neck
Bone scan
CT
Tx of spondylolystesis
Activity restriction
Brace
Stretching exercise
Adult isthmic spondylolisthesis
Defect in pars interarticularis with forward slippage of one vertebra on another
L5-S1> L4-5
Congenital or acquired, teratogenic, traumatic
Features of spondylolisthesis
Low back pain radiating to buttocks
Relieved with sitting
Neurogenic claudication
L5 radiculopathy
May present as cauda equina
Inv for spondylolisthesis
Xray
MRI
Tx of spondylolisthesis
Activity restriction
Bracing
NSAID
IF intractable pain, > 50% operation:
Operation: decompression, spinal fusion
Mechanism of pelvic injury
Young: high energy trauma
Elderly: fall from standing height, low energy trauma
Inv for pelvic fx
Xray
CT (posterior pelvic injury, acetabular fx)
Assess GU injury (considered open fx)
Tear drop displacement in pelvic Xray
Acetabular fx
Tx of pelvic fx
ABCDE IV fluid/blood Pelvic binder/sheeting External fixation vs emergent angiography/embolization \+/- laparotomy (if FAST/DPL + )
If stable fx:
Protected weight bearing
ORIF if:
Unstable pelvic ring injury
Disruption of anterior and posterior SI ligament
Symphysis diasthasis > 2.5 cm
Vertical instability of the posterior pelvis
Open fx
Complications of pelvis fx
Hemorrhage Injury to rectum/UG Obstetrical dificulties Sexual, voiding dysfunction Persistent SI joint pain Hip arthritis with acetabular fx High risk of DVT
Best time to reduce hip dislocation
Within 6 h (to decrease AVN)
Mx of hip dislocation
ABC
NVS
reduction within 6 h
Hip precautions (no extreme flexion, adduction, internal or external rotation): avoid flexing > 90° or crossing legs for 6 wk
Anterior hip dislocation mechanism
Posteriorly directed blow to knee, with hip widely abducted
Symptoms of ant. Hip dislocation
Shortened, abducted, externally rotated limb
Tx of anterior hip dislocation
Closed reduction
Post reduction CT
Posterior hip dislocation mechanism
Severe force to knee with hip flexed and adducted
Features of Posterior hip dislocation
Shortened
Adducted
Internally rotated
Posterior hip dislocation Tx
Close reduction
ORIF if:
Unstable, intraarticular fragments, posterior wall fx,
Associated femoral neck fx, ipsilateral displacement
Post-reduction CT
If unstable reduction, put in traction x 4-6 wk
Rochester method
To reduce Posterior hip dislocation:
Supine
Hip and knee flexed
Traction, internal rotation, then external rotation
hip dislocation complications
OA AVN Fx of femoral head, neck, shaft Sciatic nerve palsy HO DVT/PE
Clinic of hip fx
Unable to bear weight
Leg: shortened, externally rotated
Painful ROM
Femoral neck (subcapital) fx Tx
ORIF +/- total/hemi hip arthroplasty in elderly
Intertrochanteric hip fx
Closed reduction under fluoroscopy,
Then dynamic hip screw or IM nail
Subtrochanteric hip fx Tx
Close/open under fluoroscopy, then plate or IM
DVT prophylaxis for hip fx
LMWH on admission
Do not give <12 h before surgery
AVN etiologies
Femoral neck fx, chronic CS, SCFE, Legg-Calvé-Perthes, SLE, RA
Pain reduction for hip fx
Nerve blockade seems effective
Preoperative traction seems to not reduce acute pain
First motion lost in hip arthritis
Internal rotation
Features of hip arthritis
Pain (groin, medial thigh)
Pain better with rest: OA
morning stiffness > 1h, multiple joint swelling, hand nodules: RA
Decreased ROM (first internal rotation)
Crepitus
Effusion
Fixed flexion contracture
Trendelenburg sign
Inv for hip arthritis
Xray
ANA, RF
Tx of hip arthritis
Weight reduction, activity modification, PT, analgesics, walking aids
If advanced disease: operative
Complications of arthroplasty
Component loosening Dislocation HO VTE infection NVS injury Limb length discrepancy
Xray of hip RA
Osteopenia
Erosions
Joint space narrowing
Subchondral cysts
Xray of hip OA
Joint space narrowing
Subchondral cysts
Subchondral sclerosis
Osteophytes
DVT prophylaxis in elective THA
Continue 10-35 d post-operative
Fondaparinox
LMWH
Warfarin
Fx caused by bisphosphonate use
Femoral diaphysis fx
Femoral diaphysis fx mechanism
High energy
Children: low energy (spiral)
Pathologic:
Malignancy, osteoporosis, bisphosphonate
Femoral diaphysial fx clinic and inv
Shortened, Externally rotated leg (if displaced)
Inability to bear wt
Often open
Inv:
Xray
Tx of femoral diaphysial fx
If non-displaced: long leg cast
ORIF with IM nail
External fixator if: unstable pt, open fx, highly vascular area
Plate and screw: for open growth plate
Early mobilization and strengthening
Complications of femoral diaphysial injury
Blood loss
Fat embolism
Extensive soft tissue damage
Ipsilateral hip dislocation/fx
Nerve injury
Mechanism, clinic, inv for distal femoral fx
High energy
Pain, effusion, NVS deficit
Xray, CT, Angio if diminished pulses
Tx of distal femoral fx
If non-displaced and extraarticular: hinged knee brace
If displaced, intraarticular, non-union: ORIF
Early mobilization and strengthening
Complications of distal femoral fx
Femoral/popliteal artery injury
Nerve injury
Extensive soft tissue injury
Angulation deformities
DDx of knee locking
Torn meniscus
Loose bode in joint
Pseudo-locking:
Effusion
Muscle spasm
Arthritis
Painful clicking
Torn meniscus
DDx of knee giving away
Torn meniscus
Torn cruciate ligament
Patellar dislocation
Anterior and posterior drawer sign
Knee 90° flexed
If able to sublux tibia anteriorly: torn ACL
If able to sublux tibia posteriorly: torn PCL
Lachman test
Knee 10-20° flexed
Torn ACL
more reliable than anterior drawer test
Pivot shift sign
Torn ACL
Reverse picot shift test
Torn PCL
Posterior sag sign
Torn PCL
Flex knees and hips to 90°
Collateral ligament stress test
Opening felt on MCL or LCL while applying valgus and varus stress on knee respectively.
Showing MCL or LCL damage
Thessaly test
Meniscal teat
Pt stands on one leg, flexes knee to 20°, rotates femur on tibia medially and laterally
Discomfort in medial or lateral joint line = meniscal tear
Tests for meniscal tear
Joint line tenderness
Crouch compression test (pain with squatting)
McMurray test:
Lateral meniscus tear: internally rotate foot, varus stress, extend knee
Medial meniscus tear: externally rotate foot, valgus stress, extend knee
Painful Pop/click: torn meniscus
Indications for Xray in acute knee injury
Age> 55
Tenderness at fibula head
Isolated tenderness of patellainability to flex to 9°
Inability to bear wt immediately and in ER
Torn ACL exam
Effusion
Posterolateral joint lime tenderness
Positive anterior drawer
Positive lachmann
Pivot shift
Tx of torn ACL
If stable knee with minimal functional impairment:
2-4 wk immobilization. Early ROM and strengthening
If high demand lifestyle: ligament reconstruction
PCL tear exam
Cannot descend stairs
Pain with pushoff
Effusion
Anteromedial joint line tenderness
Positive posterior drawer
Reverse pivot shift
Tx if torn PCL
Unstable knee, young person, high demand: ligament reconstruction
Inv for collateral ligament tear
Xray
MRI
Tx of collateral ligament injury
If partial tear:
Immobilization 2-4 wk
Early ROM and strengthening
If complete tear:
Immobilization at 30° flexion
Multiple ligamentus injuries:
Operative
Pain in partial vs complete ligamentous tear
Pain more severe in partial tear
Medial vs lateral meniscus tear
Medial > lateral
Hemarthrosis in meniscus tear
Insidious (after 24-48 h)
Inv in meniscus tear
MRI
arthroscopy
Tx of meniscus tear
If not locked:
Non-operative ( ROM, NSAID, strengthening)
If locked or failed above measures: Arthroscopic repair (if peripheral longitudinal tear with good vascular response), partial meniscectomy (if complex, degenerative, radial tear)
RFs for quadriceps/patellar tendon rupture
Obesity DM RA SLE Steroid use RF on Dialysis
Mechanism of patellar/quadriceps tendon rupture
Forceful contraction of quadriceps while attempting to stop
Inv for quadriceps/patellar rupture
Unable to do SLR (if complete rupture)
Knee Xray (to exclude patella fx)
MRI (to distinguish between complete/partial rupture)
Lateral view: Patella alta (patellar tendon rupture) Patella baja (quadriceps tendon rupture)
Tx of patellar/quadriceps tendon rupture
If incomplete:
Immobilization in brace
If complete/loss of extensor mechanism:
Early surgical repair (<6 wk)
Inv for dislocated knee
Xray
ABI (<0.9 abn)
Arteriogram/ CT angio if abnormal vascular exam
Tx of knee dislocation
Urgent closed reduction
Assess: peroneal nerve, tibial artery, ligaments
If vascular injury: emergent operative repair
If open fx/dislocation: emergent OR
non-reducible: emergent OR
Compartment syndrome: emergent OR
Knee immobilization x 6-8 wk
Complications of knee dislocation
Popliteal artery injury
Peroneal nerve injury
Capsular tear
Chronic instability, stiffness, post traumatic arthritis
Patellar fx inv
Xray
Tx of patellar fx
Non-displaced: Straight leg immobilization, 1-4 wk with hinged knee brace. Wt bearing as tolerated Progress in flexion after 2-3 wk PT
Operative if:
Displaced > 2mm
Comminuted
Disrupted extensor mechanism
Complications of patellar fx
Symptomatic wiring Loss of reduction Osteonecrosis (proximal) Hardware failure Knee stiffness Nonunion Infection
RFs for patellar dislocation
Young, female Obesity High-riding patella Genu valgus Q angle > 20° Shallow intercondylar groove Weak vastus medialis Tight lateral retinaculum Ligamentous laxity
Patellar dislocation features
Knee catches/gives way with walking
Severe anteromedial pain/tenderness from rupture of capsule
Positive patellar apprehension test
Recurrent. Self reducing.
Weak knee extension/ inability to extend unless patella reduced
Concomitant MCL injury
Increase Q angle
J sign
Inv for patellar dislocation
Xray
Check for medial patella and lateral femoral condyle fx
Tx of patellar dislocation
NSAID Activity modification Physical therapy Short-term immobilization, then 6 wk controlled motion Progressive wt bearing Isometric quadriceps strengthening
Operative if: Recurrent Loose bodies present Surgical tightening of medial capsule Release if lateral retinaculum Tibial tuberosity transfer Proximal tibial osteotomy
RFs fir patellofemoral syndrome
Malalignment (Genu valgus, Q > 20°) Post-trauma Deformity of patella or femoral groove Recurrent dislocations Ligamentous laxity Excessive knee strain
Mechanism of chondromalacia patellae
Softening, erosion, fragmentation of articular cartilage.
Predominantly medial aspect of patella.
Common in active young females
Symptoms of patellofemural syndrome
Deep, aching anterior knee pain.
Pain exacerbated by prolonged sitting (theatre sign), strenuous athletic activity, stair climbing, squatting, kneeling
Insidious onset
Vague
Instability, pseudolocking
Pain with extension against resistance through terminal 30-40°
Pain with compression of patella with knee ROM
Palpable crepitus
NO/MINIMAL SWELLING
Inv for patellofemural syndrome
Xray
CT
MRI: best to assess articular cartilage
Tx of chondromalacia patellae
Rest Rehabilitation Non-impact activities NSAID PT: vastus medialis and core strengthening
Operative: If failed non-operative treatment Tibial tubercle elevation Arthroscopic shaving/debridement Lateral release of retinaculum
Tibial plateau fx mechanism
Varus/valgus load +/- axial loading
Lateral > bicondylar > medial
Inv for tibial plateau fx
Xray
CT
ABI
Complications of tibial plateau fx
Ligamentous injuries Meniscal lesion AVN infection OA Compartment syndrome
Tx if tibia plateau depression
If depression < 3mm or varus/valgus instability < 15°:
Straight leg immobilization 4-6 wk, with progressive ROM Wt bearing
If depression > 3mm or significant varus/valgus instability > 15°:
ORIF (often with graft)
Tibial shaft fx mechanism
Low energy torsional
High energy
Inv: Xray
Tibial shaft fx Tx
If closed and minimally displaced or adequately reduced:
Long leg cast 8-12 wk, tgen functional brace
If open or displaced:
ORIF
+ AB, I&D, vascular coverage of open fx defect
Tibial shaft fx complications
High incidence of:
NVS injury
Compartment syndrome
Poor soft tissue coverage
Tx of ankle fx
If non-displaced, no history of dislocation:
Below knee cast, non weight bearing
Operative if: Any fx-dislocation Trimalleolar Talar tilt > 10° Open fx Open joint injury Medial clear space on Xray greater than superior clear space
Complication of ankle fx
High incidence of arthritis
Talar fx mechanism
Axial loading
Hyperdorsiflexion
Most common site: neck
Complication of talar fx
High risk of AVN if displaced
Inv for talar fx
Xray
CT
MRI (to define extent of AVN)
Tx of talar fx
If non-displaced:
NWB, below knee cast x 6wk
ORIF if:
Displaced
Calcaneal fx mechanism
High energy axial load
Calcaneal fx inv
Calcaneal fx of other side
Compression fx of thoracic and lumbar spine
Xray (oblique view is mandatory)
Gold std: CT
Tx of calcaneal fx
NWB cast x 3 mo, early ROM
Close vs open reduction controversial
Achilles tendonitis mechanism
Activity
Poor-fitting footware
+/- heel bumps (retrocalcaneal bursitis)
Inv for achilles tendonitis
Xray (lateral: bone spurs, calcification)
U/S
MRI
Tx of achilles tendonitis
Rest
NSAID
Shoewear modification
Main stay of non-operative treatment: heel sleeves and pads
Gentle gastrocnemius-soleus stretching
Eccentric training with physical therapy
Deep tissue calf massage
Shockwave therapy in chronic tendonitis
Forbidden treatment in achilles tendonitis
Steroid injection
Achilles tendon rupture mechanism
Loading activity
Stop and go sports
Chronic tendonitis
Steroid injection
Thompson test
Prone
Squeeze calf
If no passive plantarflexion= rupture
Achilles rupture inv
Xray
U/S
MRI (partial vs complete)
Tx for achilles rupture
If low athletic demand or elderly:
Non operative. Cast in plantar flexion x 8-12 wk
If high athletic demand:
Surgical repair, then cast in plantar flexion x 6-8 wk
Surgical repair reduces risk of rerupture
Plantar fasciitis definition (heal spur syndrome)
Inflammation of plantar aponeurosis at calcaneal origin
Plantar fasciitis associations
Athletes
Obesity
DM
Seronegative, seropositive arthritis
Mechanism of plantar fasciitis
Repetitive strain injury causing microtears and inflammation of plantar fascia
Nerve injury in achilles rupture
Sural
Clinical features of plantar fasciitis
Insidious onset of heel pain
Pain when getting out of bed
Stiffness
Intense pain when walking from rest
Pain subsides as patient continues to walk
Pain worse at the end of day with prolonged standing
Swelling/tenderness over soal
Greatest at medial calcaneal tubercle and 1-2 cm distal along plantar fascia
Pain with toe dorsiflexion
Inv for plantar fasciitis
Xray
Often there is bony exostosis
Spur is secondary to inflammation (not the cause of pain)
Tx of plantar fasciitis
1st line:
Pain control, stretching programs
Rest Ice NSAIDs Steroid injection PT Orthotics with heel cup
Surgical release of fascia if failed non-operative treatment
Bunion associations
Poor fitting footwear (high heel, narrow toe box)
Hereditary (70%)
10 x more frequent in women
Features of bunion
Painful bursa over medial eminence of 1st MT head
Pronation of great toe
Numbness over medial aspect of great toe
Toe deviation angle > 15°
Inv for bunion
Xray
Tx of bunion
Indications: painful (corn, bunion), overriding 2nd toe
1st line: properly fitted shoes and toe spacer
Operative:
Goal: to restore normal anatomy.
Osteotomy with realignment of 1st MTP
Arthrodesis
Foot stress fxs
Midshaft 5th metatars
Shaft 2nd, 3rd metatars
Tx of avulsion of base of 5th metatars
ORIF if displaced
Tx of march fx (shaft of 2nd, 3rd fx)
Symptomatic
Tx of 5th metatars midshaft fx
NWB BK cast x 6wk
ORIF if athlete
1st metatars fx Tx
If displaced:ORIF
if non-displaced: 3 wk NWB BK cast then walking cast
Lisfranc fx
Tarso-metatarsal fx-dislocation
Most common fx site in children
Distal radius
2nd: phalanges
Fxs in children suspicious of abuse
Hallmark: metaphyseal corner fx
Femur fx < 1yr
Humeral shaft < 3 yr
Sternal fx
Posterior rib fx
Spinous process fx
Most common site of stress fx
Tibia
Dx of stress fx
Localized pain and tenderness
Xray may not show fx for 2 wk
Bone scan positive in 12-15 d
Tx of stress fx
Rest (from strenuous activity)
Salter-Harris type I fx Tx
Closed reduction and cast immobilization
Exception: SCFE which requires ORIF
Salter-Harris type II Tx
Closed reduction and cast
If failure: ORIF
Salter-Harris type III Tx
ORIF
Avoid fixation across growth plate
Salter-Harris type IV Tx
Closed reduction and cast if anatomic
Otherwise: ORIF
Salter-Harris type V Tx
No specific Tx
Most common adolescent hip disorder
SCFE
RFs for SCFE
Male
Obesity (#1 factor)
Hypothyroid (risk of bilateral involvement)
AD
Black
Trauma (acute slip)
(Sex hormone secretion which stabilizes physis, not yet begun)
Clinical features of SCFE
Acute: sudden severe pain with limp
Chronic: groin/anterior thigh pain, knee pain. Positive trendelenburg on affected side
Tender over joint capsule
Restricted: internal rotation, abduction, flexion (whitman sign: obligatory external rotation during passive hip flexion)
Inv for SCFE
Xray ( including frog leg)
Disruption of Klein line
Tx of SCFE
If mild-moderate slip:
Stabilize physis with pins in current position
If severe slip:
ORIF
Or
Pin physis without reduction, osteotomy after epiphyseal fusion
Complications of SCPE
AVN
Chondrolysis
Pin penetration
Premature OA
Loss of ROM
Most common orthopedic disorder in children
Developmental dysplasia of the hip
If painful DDH
Suspect septic dislocation
Tests for DDH
Limited abduction of the flexed hip
Barlow
Ortolani
Galeazzi (> 1yr)
Trendelenburg test and gait (> 2y)
Predisposing factors to DDH
Female FHx Frank breech First born Left hip
Inv for DDH
U/S in first few month
Xray at 4-6 mo
Tx of DDH
0-6 mo: reduce hip with Pavlic harness (maintains abduction and flexion
6-18 mo: reduction under GA, hip spica cast 2-3 mo (if pavlic fails)
> 18 mo: open reduction, pelvic/femoral osteotomy
Complications of DDH
Inadequate reduction
Stiffness
Redislocation
AVN
Legg-Calvé-Perthes (coxa plana)
AVN of femoral head
Idiopathic
4-8 y
M>F
Associations of Legg-Calvé-Perthes (coxa plana)
FHx LBW Abn pregnancy/delivery ADHD Delayed bone age Second hand smoke Asian Inuit Central European
Legg-Calvé-Perthes (coxa plana) symptoms
Antalgic or Trendelenburg gait
+/- pain
Intermittent hip/knee/groin/thigh pain
Flexion contracture
Decreased internal rotation
Decreased abduction of hip
Limb length discrepancy
Legg-Calvé-Perthes (coxa plana) inv
Xray (including frog leg)
May be negative early
If high index of suspicion, bone scan/MRI
Tx of Legg-Calvé-Perthes (coxa plana)
Goal: preserve ROM and keep femoral head contained in acetabulum
Non-operative: PT, brace in flexion and abduction x2-3 mo
Operative:
Femoral or pelvic osteotomy (> 8y or severe)
Who has better prognosis in Legg-Calvé-Perthes (coxa plana)
Male
<6 yr
< 50% of femoral head involved
Abduction > 30°
Complications of Legg-Calvé-Perthes (coxa plana)
Early OA
Decreased ROM
Osgood Schlatter (tibial tubercle apophysitis
Inflammation of patellar ligament at insertion point on tibial tuberosity
M> F
Boys 12-15y
Girls 8-12y
Mechanism: repetitive tensile stress, causing minimal avulsions and the inflammation
Osgood Schlatter symptoms
Tender lump on tuberosity
Pain on resisted leg extension
Anterior knee pain, exacerbated by jumping, kneeling, relieved by rest
Mist common in adolescent athletes (jumping, sprinting)
Inv for Osgood Schlatter
Xray: fragmentation of tibial tubercle
+/- ossicle in patellar tendon
Osgood Schlatter Tx
Benign Self limited (does not resolve until growth halts)
Restrict activities (cycling, basketball)
NSAIDs
Rest
Flexibility, isometric stretch exercise
Casting if no resolution
If refractory: ossicle excision (if skeletally mature)
Congenital talipes equinovarus
M: more common
F: more severe
CAVE: Midfoot Cavus Forefoot Adductus Hindfoot Varus Hindfoot Equinus
Talar neck medial and plantar deviated
Calcaneus: varus, medially rotated
Navicular and cuboid: medially displaced
Inv for talipes equinovarus
DDH
Knee deformities
Back dysraphism
Tx of club foot
Ponseti technique
Correct deformities in CAVE order
Change strapping/cast q1-2 wk
If refractory, surgical release (delayed until 3-4mo)
Scoliosis
F> M
F: more severe
10-14 y
Most common cause of scoliosis
Idiopathic
Inv for scoliosis
Xray (3foot standing. AP. Lateral)
+/- Associated kyphosis
Cobb angle
Tx of scoliosis
Based on Cobb’s angle
<25° : observe with serial radiographs
> 25° or progressive: bracing (do not reverse deformity, but halt/slow progression)
> 45° or cosmetically unacceptable or respiratory problem: surgical correction
Benign bone lesion on Xray
No periosteal reaction
Thick endosteal reaction
Well developed bone formation
Intraosseous and even calcification
Malignant bone lesions on Xray
Acute periosteal reaction:
Codman’s triangle
Onion skin
Sunburst
Broad border between lesion and normal bone
Varied bone formation
Extraosseous and irregular calcification
Inv for bone tumor
Xray Blood work including liver enzymes CT bone scan Bone Bx MRI
Red flags in bone pain
Persistent pain
Localized tenderness
Spontaneous fx
Enlarging mass/soft tissue swelling
Osteoid osteoma
Osteoblasts
M>F
Proximal femur, tibia diaphysis
Radiolucent nidus, surrounded by dense sclerotic bone (bull’s eyes)
Severe intermittent pain, mostly at night
Tx: NSAIDs, surgical resection
Fibrous cortical defect (non ossifying fibroma)
Children
Asymptomatic
M> F
Femur, proximal tibia
Xray of fibrous cortical defect
Metaphyseal eccentric, bubbly lytic lesion
Near physis
Margin: thin, smooth, lobulated, well defined, sclerotic
Tx of fibrous cortical defect
Resolves spontaneously
Most common bone tumor in children
fibrous cortical defect (35%)
Osteochondroma
2nd and 3rd decades
M>F
Painless slowgrowing mass
Most common benign tumor
Pdunculated or sessile (risk of malignant transformation)
Distal femur, proximal tibia, proximal humerus (metaphysis, near tendon attachment)
Risk of malignant degeneration if multiple
Xray of osteochondroma
Mushroom
Tx of osteochondroma
Observation
Excision if symptomatic
Howlong does osteochondroma grow
Until skeletal maturity
Enchondroma
Hyaline cartilage
Asymptomatic
2nd-3rd decades
Chondroblast
In medullary cavity
Single/multiple
Most common sites for enchondroma
Small tubular bones of hand and foot
Others: femur, humerus, ribs
Enchondroma Xray
Rarefied area
Lytic
Sharp margins
Irregular central calcification (stippled/punctate/popcorn)
1-2% malignant degeneration to chondrosarcoma (pain without fx)
Tx of enchondroma
Serial Xray
If symptom/grow: curretage
Solitary bone cyst
Children, young adults (1st 2 decades)
M>F
Proximal humerus
Distal Femur
Xray of solitary bone cyst
Lytic/translucent
Metaphyseal side of growth plate
Thinned cortex
Expanded cortex
Well defined
Tx of bone cyst
Aspiration, steroid injection
Curettage +/- bone graft
Giant cell tumor
Peak 3rd decade
Skeletal maturity
Xray: eccentric, lytic, epiphysis, adjacent to subchondral bone
Enhanced on T2 MRI
3% pulmonary mets
Osteoblastoma
3rd decade
Skeletal maturity
Distal femur, proximal tibia, distal radius, sacrum, tarsal bones, spine
Xray: non-specific, calcified central nidus, radiolucent halo, sclerosis
Aneurusmal bone cyst
Solid with fibrous/granular tissue or blood filled
Cray: Expanded with honeycomb shape
Tx of benign aggressive bone tumors
Gian cell tumor
Osteoblastoma
Aneurysmal bone cyst
Tx: curettage + bone graft or cement
Wide local excision of expandable bones
Most common age group for osteosarcoma
2nd decade
Sites of osteosarcoma
Distal femor, proximal tibia, proximal humerus
Predisposing factors for osteosarcoma
Paget (elderly)
RT
Xray of osteosarcoma
Codman’s triangle
Sunburst
May cross epiphyseal plate
Tx of osteosarcoma
Complete resection (limb salvage)
Neoadjuvant chemo
Bone scan (R/O mets)
CT (R/O mets)
Chondrosarcoma
Primary (2/3) > 40 yr
Or
Secondary (from osteochondroma or enchondroma) 25-45 yr
Xray of chondrosarcoma
Popcorn calcification in medullary cavity
Tx of chondrosarcoma
Aggressive surgical resection + reconstruction
Regular F/U Xrays: chest. Excision site.
Ewing sarcoma
5-25 yr
Small round cells
Florid periosteal reaction
Metaphysis of long bones, diaphysial extension
Mets frequent
Inv in ewing sarcoma
Fever
Increased WBC, ESR, LDH
Xray: moth-eaten. Periosteal lamellated pattern
Tx of Ewing
Resection, chemo, RT
Most common primary malignant bone tumor in adults
MM
> 40
M> F
African-Americans
Xray of MM
Multiple punched out, welldemarkated lesions
No surrounding sclerosis
Inv
Xray
CT guided Bx
Ca
ESR
Cr
CBC
SPEP/UPEP
Tx of MM
Chemo
Bisphosphonate
RT
Surgery (impending fx, symptomatic lesion)
Most common cause of bone lesion in adults age > 40
Mets (2/3 breast, prostate)
Inv in bone mets
Bone scan
MRI for spine
Tx of bone mets
Pain control
Bisphosphonates
Surgery ( if impending fx)
Prevention of heterotopic ossification
Misoprostol + indomethacin
