Orthopedics/Musculoskeletal Flashcards
What percentage of back pain resolves on its own?
90% resolve in 6 weeks, <5% become chronic
What is the pathophysiology of a pinched nerve (radiculopathy)?
When the inner core (nucleus pulposus) of the intervertebral disc bulges out through the outer layer of ligaments that surround the disc (annulus fibrosis). This tear in the annulus fibrosis causes pain in the back at the point of herniation. If the protruding disc presses on a spinal nerve, the pain may spread to the area of the body that is served by that nerve.
What are the stages of nuclear herniation?
Nuclear herniation, disc protrusion, nuclear extrusion and nuclear sequestration
What is the etiology of back pain?
Mechanical (98%):
- Sprain (ligament), strain (muscle), facet joint degeneration (OA), disc degeneration/herniation, spinal stenosis (e.g. spondylosis), spondylolisthesis, compression fracture
Non-Mechanical (2%):
- Surgical Emergencies: cauda equina syndrome), AAA (pulsatile abdominal mass)
- Medical Conditions:
- Neoplastic (primary, metastatic, multiple myeloma)
- Infectious (osteomyelitis, TB)
- Metabolic (osteoporosis, osteomalacia, Paget’s disease)
- Rheumatologic (ankylosing spondylitis, polymyalgia rheumatica)
- Referred pain (perforated ulcer, pancreatitis, pyelonephritis, ectopic pregnancy, herpes zoster)
What time period is acute back pain?
Acute: <4wks
What time period is sub-acute back pain?
Subacute: 4-12wks
What time period is chronic back pain?
Chronic: >12 wks
Herniated disc is unlikely in a _____ as the nucleus pulposus is already _____, thus commoner in younger people. Older people can still have pinched nerves but different process - smaller joint spaces
50+ yo
Fibrotic
When discs protrude at a level, they often compress the spinal nerve root (has dorsal and ventral root) of the segment _____!
Below
For instance if you have an L4/L5 nerve root disc herniation, you can affect the L4 root which is in that area, but often affects the L5 one. Why? The intervertebral foramina are pretty big in the lumbar region (small in the cervical region). But the nerve root is up really high in the foramen, above the disc. If the disc pushes out, it is likely to spare the nerve root because the root will be above, but instead it will push against the level below
What are the red flags of acute lower back pain?
B: owel or bladder dysfunction; sudden onset (Emergency, refer w/n hours)
A: nestheia (saddle) (Emergency, refer w/n hours)
C: onstitutional symptoms, weight loss, hx of cancer, fever (Urgent, refer w/n 24-48 hours)
K-(C): hronic disease, severe, constant or worsening pain (PM or supine) (Urgent, refer w/n 24-48 hours)
P: aresthesia (Urgent, refer w/n 24-48 hours)
A: ge > 50 (Soon, refer w/n weeks) + mild trauma (Urgent, refer w/n 24-48 hours)
I: V drug use/infection (Urgent, refer w/n 24-48 hours)
N: euromotor deficits (Urgent, refer w/n 24-48 hours)
What are the yellow flags of acute lower back pain?
Belief that pain and activity are harmful, sickness behaviours (extended rest), low/negative mood, social withdrawal, treatment expectations that do not fit best practice, problems with claim/compensation, history of back pain/time-off/other claims, problems at work, poor job satisfaction, heavy work, unsociable hours (shift work), overprotective family or lack of support
Clinical features of cauda equina syndrome and features on physical exam?
Pain is usually the first symptom of cord compression, but motor (lower extremity weakness, areflexia, decreased anal tone) and sensory findings (saddle anesthesia). Fecal incontinence, urinary retention are often late findings
Clinical features of infectious back pain and features on physical exam?
Long use of corticosteroids; Unexplained fever, malaise; IV drug use, Recent spinal injection or epidural catheter placement. The pain is not relieved with rest and is provoked by weight bearing. On examination there will be focal tenderness at the involved spinous process.
Clinical features of cancer for back pain and features on physical exam?
Hx of Ca + new back pain; Unexplained weight loss; Duration > 6wks; Age >70. Focal tenderness at the involved vertebrae
In patients with a history of cancer, sudden, severe pain raises concern for ______?
Pathologic fracture.
What is pinched nerve (radiculopathy)?
Pressure or impingement on nerve roots in spinal canal
Clinical features of vertebral compression fracture and features on physical exam?
Acute onset of localized back pain which may be incapacitating - worse with flexion and often point tenderness on palpation. There may be no history of preceding trauma
What is sciatica?
Sciatica is a nonspecific term used to describe a variety of leg or back symptoms. Usually, sciatica refers to a sharp or burning pain radiating down from the buttock along the course of the sciatic nerve (the posterior or lateral aspect of the leg, usually to the foot or ankle).
What are the causes of spinal stenosis?
Spondylosis (degenerative arthritis affecting the spine), spondylolistheses (slipping of a vertebra in relation to the one below), and thickening of the ligamentum flavum
What is spinal stenosis?
Narrowing of the spinal canal by a piece of bone
Over 90 percent are ______ radiculopathies.
Over 90 percent are L5 and S1 radiculopathies
Risk factors for osteoporotic fracture include _____ and _____.
Advanced age and chronic glucocorticoid use
What are the causes of pinched nerve (radiculopathy)?
Causes: herniated disc, degenerative disc disease, bone spurs/osteophytes, spinal stenosis.
_____ is a hallmark of lumbar spinal stenosis
Neurogenic claudication
What are the symptoms of spinal stenosis?
Ambulation-induced (walking, standing or extension) pain localized to the calf and distal lower extremity resolving with sitting or leaning forward
Clinical features of ankylosing spondylitis and associated features?
Morning stiffness; Improves with exercise; Younger age males, pain at night. Associated with uveitis and colitis
Clinical features of lumbosacral muscle strains/sprains and features on physical exam?
Often following isolated traumatic incidents or repetitive overuse; pain worse with movement, relieved by rest; examination may reveal restricted range of motion, muscle tenderness, or trigger points
Clinical features of lumbar spondylosis?
More common in persons older than 40 years; pain may be present in or radiate from the hips; pain is worse with activity; pain may worsen with lumbar spine extension or rotation
Clinical features of osteoarthritis and in which age group does it commonly present in?
Low back pain may be a symptom of osteoarthritis of the facet joints spine. Patients may also complain of hip pain, either from osteoarthritis of the hip or referred pain from the spine. Osteoarthritis most commonly presents in patients over the age of 40. Pain is typically exacerbated by activity and relieved by rest
______ may contribute to the severity symptoms of low back pain or may be a cause of nonorganic back pain
Psychologic distress (eg, depression or somatization)
What is spondylolysis and activities that can cause it?
Break in the pars interarticularis, (scotty dog has a ring around his neck), typically stress fracture, pain with activities involving lumbar extension - weightlifting, gymnastics. Pain in young adolescent athletes
What should be asked on history for back pain?
o OPQRST
o Back/Buttock dominant vs leg dominant
o Constant vs intermittent pain
o What increases your typical pain?
▪ Flexion (possibly extension) – disc pain
▪ Extension only – facet joint pain
▪ All movements (improved with rest) – compressed nerve pain
▪ Walking or standing (relieved with sitting or flexion) – spinal stenosis
o Red Flags – bowel or bladder incontinence
o Medications
Indications for Lumbar Xray
▪ No improvement after 6 wk ▪ Fever >38oC ▪ Unexplained weight loss ▪ Prolonged corticosteroid use ▪ Significant trauma ▪ Progressive neurological deficit ▪ Suspicion of ankylosing spondylitis ▪ History of cancer (rule out metastases) ▪ Alcohol/drug abuse (increased risk of osteomyelitis, trauma, fracture)
Work up for back pain?
Work-Up: plain films not recommended in initial evaluation
o If Infection/Cancer Suspected: CBC, CRP
o If Neuro Deficits Worsening or Infection/Cancer Suspected: consider CT or MRI
What are the special tests that can be done for back pain?
▪ Straight leg raise ▪ Crossed straight leg raise ▪ Femoral stretch test ▪ FABER ▪ Thomas ▪ Romberg ▪ Schober
What are the symptoms of benign back pain?
Benign Back Pain: moderate, dull, aching, worse with movement or cough
What vascular emergencies should you rule out for acute back pain?
Aortic dissection, AAA, PE, MI, retroperitoneal bleed
What are the causes of spinal emergencies?
Osteomyelitis, cauda equina, epidural abscess or hematoma
How do you evaluate risk for fracture/infection/cancer/vascular causes of acute back pain?
Osteoporosis, age, IV drug user, recent spinal intervention, immunosuppression, cardiac risk factors
What are the physical exam
o Inspection: curvature, posture, gait
o Palpation: bony deformities/spine for bony tenderness, paraspinal muscle bulk/tenderness, trigger points
o Percussion: of spine to elicit pain due to fracture or infection
o Move: ROM and peripheral pulses
o Neuro Exam: for L4/L5/S1 helps determine level of spinal involvement (power, reflexes, sensation)
o Other Exam: precordial, respiratory, abdominal and neurological exams guided by history
o Special Tests
What is straight leg raise and what does it help diagnose?
Straight leg raise (positive if pain at <70 degrees and aggravated by ankle dorsiflexion) = (+)Sciatica
What is the femoral stretch test and what does it help diagnose?
Femoral stretch test (patient prone, knee flexed, examiner extends hip) to diagnose L4 radiculopathy
What is FABER and what does it help diagnose?
FABER (Flex, abduct, externally rotate knee)
SI joint pain– osteoarthritis
What is crossed straight leg raise?
Crossed straight leg raise (raising of uninvolved leg elicits pain in leg with sciatica), more specific than straight leg raise
What is the Thomas test and what does it help diagnose?
Hand under lumbar spine, flex opposite knee, observe angle between femur and table
Angle >0 – Flexed hip contracture
What is the Romberg test and what does it help diagnose?
Patient stands feet together, arms outstretched at 90, eyes closed
Loss of balance - Pathology of dorsal columns or vestibular system
What is the Schober test and what does it help diagnose?
Mark 5cm below and 10cm above L5, patient bends forward, measure distance between marks
Distance increase <5cm - Muscle tightness, ankolyosing spondyitis, scoliosis
Management of chronic back pain (>12wks since onset)?
▪ Rx: physical or therapeutic exercise
▪ Analgesics: acetaminophen, NSAIDs (consider PPI), low dose TCAs (amitriptyline), short term cyclobenzaprine PRN
▪ Referral Options: community based rehab or self-management/CBT
▪ Additional Options: progressive muscle relaxation, acupuncture, massage, TENS, aqua therapy, yoga
Management of moderate to severe chronic back pain (>12wks since onset)?
Opioids, multidisciplinary chronic pain program, epidural steroids (short term relief of radicular pain), prolotherapy, facet joint injections, surgery(?)
Management of spinal infection?
Early IV antibiotics and ID consultation
Management of lumbosacral strain + disc herniation?
Analgesia and continue daily activities as much as tolerated; discuss red flags and organize follow-up
▪ Discectomy (removal of part of disc that is compressing nerve)
▪ Disc prosthesis occasionally used (newer procedure, beneficial in younger more active patients)
▪ Epidural Injection
Management of cauda equine syndrome?
Dexamethasone + lumbosacral MRI + early neurosurgical consultation
Management of acute back pain (<12wks since onset)?
▪ Education: low back pain typically resolves within a few weeks (70% in 2 weeks, 90% in 6 weeks)
▪ Rx: alternating cold and heat, continue activities as tolerated; encourage early return to work, physical activity and/or exercise
▪ Analgesics: acetaminophen > NSAIDS, short course muscle relaxants, short-acting opioids (rarely), spinal traction
▪ Follow-up in 1-6 weeks
▪ Consider Referral: physical therapist, chiropractor, physiatrist, spinal surgeon (if unresolving radicular symptoms), multidisciplinary pain program (if not returning to work)
Definition of monoarthritis?
1 joint involved
Definition of oligoarthritis?
2-4 joints involved
Definition of polyarthritis?
> 5 joints involved
The spondyloarthropathies are classically ____, whereas rheumatoid arthritis (RA) is usually ____.
Oligoarticular
Polyarticular
Polyarticular/Oligoarticular DDx
- Mechanical: OA
- Inflammatory
- Infections
- Endocrine/metabolic: hypo/hyperthyroidism, hyperparathyroidism, hemochromatosis, Wilson’s disease
- Malignancies: acute leukemia
- Sarcoidosis: lofgren’s syndrome
- Familial mediterranean fever
- Polymyalgia rheumatica
- Mucocutaneous disorders: dermatomyositis, erythema nodosum, erythema multiforme, pyo derma gangrenosum, pustular psoriasis
Inflammatory etiology of polyarticular/oligoarticular disease?
- Rheumatoid arthritis
- Spondyloarthropathies - psoriatic arthritis, enteric arthritis, reactive arthritis, AS
- Crystal induced: gout, pseudogout
- Connective tissue diseases – SLE, Sjogrens, myositis
- Vasculitis: polymyalgia rheumatica, wegener’s Granulomatosis, behcet’s disease, still’s disease
Infectious etiology of polyarticular/oligoarticular disease?
- Bacterial: septic (gonococci) – usually monoarticular, meningococci, endocarditis, lyme disease, whipple’s disease, mycobacteria
- Viral: parvovirus, rubella, hbv, hcv, hiv, ebv
- Fungal
- Post-infectious/reactive: enteric infections, genitourinary infections, rheumatic fever, inflammatory bowel disease
Red flags for polyarticular/oligoarticular disease?
Abnormal vitals, symptoms > 6 weeks, immunocompromised, rapid onset/progression, STI/IVDU, non-weight bearing, constitutional symptoms
Questions asked on HPI for polyarticular/oligoarticular disease?
HPI:
- Timing of onset (acute vs chronic) – symmetric vs asymmetric
- Jt swelling, jt pain, decreased ROM
- Hx of joint trauma
- Identify involved joints
- Features of RA or OA
- Reactive arthritis symptoms - rash, conjunctivitis, urethritis/cervicitis
Lofgren syndrome triad?
Triad: bilateral ankle swelling, erythema nodosum, hilar lymphadenopathy
Possible skin and nails findings on physical exam for polyarticular/oligoarticular disease?
- Rashes: pustular lesions (disseminated gonococcal infection), erythema migrans (Lyme), erythema nodosum (IBD, sarcoidosis), psoriasis/nail pitting/onycholysis
- Tophi (gout)
- Lesions on glans penis (reactive arthritis)
Investigations for polyarticular/oligoarticular disease?
- Labs
- CBCd – may have anemia of chronic disease, leukocytosis/leukopenia, thrombocytosis/thrombocytopenia
- Electrolytes, Cr, CRP* (main one), liver enzymes, urinalysis, serum urate
- If Suspected RA: RF (>20), anti-CCP
- If suspected connective tissue disorder: ANA, anti-dsDNA, C3/C4, urine protein-Cr ratio, CK
- If suspected seronegative spondyloarthropathy: HLA-B27
- If suspected vasculitis: ANCA, anti-GBM - Arthrocentesis
- Xray
What should you send the synovial fluid for in an arthrocentesis
Complete cell count + differential, gram stain, culture, crystals (gold standard)
Synovial fluid findings for OA?
- Cell count = 200-2000
- Polys = <25%
- Crystals = occasional CPPD (calcium pyrophosphate disease) - Pseudogout, can calcify cartilage
be aging - Gm stain and culture = negative
Synovial fluid findings for inflammatory arthritis?
- Cell count = 2,000-50,000
- Polys = >50%
- Crystals = none
- Gm stain and culture = negative
Synovial fluid findings for septic arthritis?
- Cell count = >50,000
- Polys = >75%
- Crystals = none
- Gm stain and culture = positive
Inflammatory arthritis symptoms?
- Pain at rest, relieved by gentle motion
- Morning stiffness >1 h
- Warmth, swelling, erythema
- Malalignment/deformity (late finding)
- Extra-articular manifestations
- Nighttime awakening due to pain
Degenerative arthritis symptoms?
- Pain with motion, relieved by rest
- Morning stiffness <1/2 h
- Joint instability, buckling, locking
- Bony enlargement, malalignment/deformity (late finding)
- Evening/end of day pain
Seronegative spondyloarthropathies Ddx?
- Psoriatic arthritis
- Enteric arthritis
- Ankylosing spondylitis
- Reactive arthritis
- Undifferentiated
Clinical features of seronegative spondyloarthropathies
- SPONDYLOARTHROPATHY spondylitis, sacroiliitis, morning stiffness >30 min
- OLIGOARTHRITIS asymmetric, dactylitis, usually larger joints, lower extremities (exception: PsA)
- ENTHESOPATHY inflammation at the sites of insertion of ligaments, tendons, joint capsule, and fascia to bone, with both destruction and new bone formation. This results in Achilles tendonitis, plantar fasciitis, tenosynovitis, and dactylitis/sausage fingers
Extraarticular changes of seronegative spondyloarthropathies
Nail pitting, onycholysis, psoriasis, tenosynovitis, dactylitis, synovitis, acute uveitis, aortic regurgitation, apical pulmonary fibrosis, chin to chest distance, occiput to wall distance, decreased chest expansion, cauda equine compression, and enthesitis (costochondritis, patellar and Achilles tendonitis, plantar fasciitis).
Serology HLA B27 ____, rheumatoid factor ____ (hence, why they are called seronegative spondyloarthropathies).
Positive
Negative
Back exam for seronegative spondyloarthropathies?
- INSPECTION swelling, erythema, atrophy, scars, and loss of thoracic kyphosis and cervical/lumbar lordosis
- RANGE OF MOTION check gait and flexion, extension, lateral bending, rotation
- PALPATION tenderness over spinous processes and sacroiliac joints
- SPECIAL TESTS Schober’s test (place mark 5 cm below and mark 10 cm above the spine at level of PSIS/L5 with patient standing. A distance increase of <5 cm [<2 in.] between the marks with the patient bending forward suggests limited lumbar flexion), finger to floor distance, occiput to wall distance. Perform FABER test (SI joint stability) and straight leg raising test (sciatica)
Clinical features/physical exam findings of ankylosing spondylitis?
- Spondylitis, sacroiliitis, morning stiffness, and arthritis of the hips, knees, shoulders, and occasionally peripheral joints.
- Loss of lumbar lordosis and thoracic kyphosis with significant decreased range of motion and chest expansion
- Positive Schober’s test and occiput to wall test.
Extraarticular manifestations of ankylosing spondylitis?
Extraarticular manifestations include anterior uveitis, C1-2 subluxation, restrictive lung disease, aortic regurgitation, conduction abnormalities, and secondary amyloidosis.
Imaging findings of ankylosing spondylitis?
Imaging reveals bamboo spine (syndesmophytes), shiny corners (squaring and increased density anteriorly of vertebral bodies), and whiskering (new bone and osteitis at tendon and ligament insertions)
• Large joints: synovitis indistinguishable from RA
• Spine: enthesitis: inflammation visualized as bone marrow edema at entry of ligaments into bone. (not synovitis here)
New York diagnostic criteria for ankylosing spondylitis?
- CLINICAL CRITERIA low back pain and morning stiffness of >3 months, limitation of motion of the lumbar spine in both the sagittal and frontal planes, and limitation of chest expansion (<2.5 cm [1 in.])
- RADIOLOGIC CRITERIA sacroiliitis with more than minimum abnormality bilaterally or unequivocal abnormality unilaterally
- DIAGNOSIS one clinical plus one radiologic criterion = definite AS; three clinical criteria or one radiologic criterion only = probable AS
Treatment of ankylosing spondylitis?
Aggressive NSAID (indomethacin) and exercise, TNF-inhibitors
Clinical features of reactive arthritis?
- <5 joints involved, proximal and distal, asymmetric, other systems include urethritis, dysentery, skin, eye
- Spondylitis, sacroiliitis, morning stiffness, lower limb arthritis (asymmetric oligoarthritis of lower limbs), and enthesitis (Achilles tendonitis, plantar fasciitis, chest wall changes, and sausage fingers/toes).
Pathophysiology of reactive arthritis?
Preceding/ongoing infectious disorders such as urethritis (Chlamydia), diarrhea (Shigella, Salmonella, Campylobacter, Yersinia) or HIV, usually within 6 weeks.
Physical exam findings of reactive arthritis?
- Genital lesions (circinate balanitis with shallow painless ulcers on the glans or urethral meatus, urethritis, prostatitis)
- Skin lesions (keratoderma blennorrhagica with vesicles that progress to macules, papules and nodules on palms and soles)
- Eye lesions (conjunctivitis, iritis [acute, unilateral, photophobia, pain, redness, impaired vision])
- Bowel inflammation (acute enterocolitis, chronic ileocolitis)
- Cardiac abnormalities (aortic regurgitation, conduction abnormalities).
Imaging findings of reactive arthritis?
Plain film reveals fluffy erosions, periosteal spurs, and asymmetric syndesmophytes
Reactive arthritis triad?
- “can’t see, can’t pee, can’t climb a tree”–> conjunctivitis, urethritis/cervicitis, arthritis
- Urethritis (chlamydia) or dysentery (SEXCY) followed by arthritis, conjunctivitis, painless oral ulcers and typical skin lesions (balanitis, keratoderma)
Treatment of reactive arthritis?
NSAIDs, sulfasalazine, anti-TNF agents, methotrexate, azathioprine, leflunomide
Ddx for musculoskeletal lump/mass?
- Soft tissue
- Benign (e.g., lipoma)
- Malignant (e.g., leiomyosarcoma) - Bone (e.g., cyst)
- Benign (e.g., cyst)
- Malignant (e.g., Ewing sarcoma) - Non-neoplastic
- Infectious (e.g., osteomyelitis)
- Traumatic (e.g., hematoma)
- Inflammatory (e.g., rheumatoid nodules, tendonitis)
What should be asked on history for musculoskeletal lump/mass?
- Lump: Onset, recent changes (size, colour, rapid growth), provoking factors, trauma (hematoma), cut (abscess), warmth, pain
- Systemic: fever, night sweats, weight loss, fatigue
- PMHx: previous malignancy, illnesses
- FHx: cancers in family
- Meds:
- Social: smoking, alcohol intake
Physical exam for musculoskeletal lump/mass?
- Inspection: location, appearance, SEADS
- Palpation: temp, tenderness, consistency (soft, rubbery, firm, stony hard, or nodular, lobulated), contour (irregular), surface (smooth, rough, irregular), depth, size, pulsation
- Tethered to skin (mobile or fixed), muscle or tendon involvement
- Special tests: transilluminability - should be done in a darkened room, with pen torch directly on lump. Fluid-filled lumps like cysts or hydrocele are transilluminable, while solid lumps are not.
- Regional LN exam, neuro exam
What should you comment on an Xray of a musculoskeletal lump/mass?
- Internal calcification may be signs of a vascular tumour, heterotopic ossification, or rare forms of sarcoma.
- Advanced imaging including MRI may demonstrate signs of malignancy or aggressive masses.
- Large size (>5cm).
- Deep.
- Heterogeneous.
- Incorporating the neurovascular bundle.
Treatment of musculoskeletal lump/mass?
- Infection should be treated with irrigation & debridement and antibiotics
- Most benign masses may be excised in symptomatic
- Most malignant masses benefit from radiation treatment followed by wide resection
What is a lipoma?
Single or multiple non-tender subcutaneous tumours that are soft and mobile
_____ tumours to bone are much more common than primary bone tumours, particularly if age >40 yr
Metastatic
Pathophysiology of a lipoma?
Adipocytes enclosed in a fibrous capsule
Investigations for a lipoma?
Biopsy only if atypical features (painful, rapid growth, firm)
Management of a lipoma?
Reassurance, excision or liposuction only if desired for cosmetic purposes
Clinical features of bone tumors?
- Malignant (primary or metastasis): local pain and swelling (weeks to months), worse on exertion and at night, soft tissue mass
- Benign: usually asymptomatic
- Minor trauma often initiating event that calls attention to lesion
Xray findings of bone tumors?
- Lytic, lucent, sclerotic bone
- Involvement of cortex, medulla, soft tissue
- Radiolucent, radiopaque, or calcified matrix
- Periosteal reaction
- Permeative margins
- Pathological fracture
- Soft tissue swelling
Red flags of bone tumors?
- Persistent skeletal pain
- Localized tenderness
- Spontaneous fracture
- Enlarging mass/soft tissue swelling
Ddx of benign active bone tumors?
- Bone-Forming Tumors
- Osteoid Osteoma - Fibrous Lesions
- Fibrous Cortical Defect
- Osteochondroma
- Enchondroma - Cystic Lesions
- Unicameral/Solitary Bone Cyst
What is an osteoid osteoma?
Bone tumour arising from osteoblasts
When and where do osteoid osteoma typically occur?
- Peak incidence in 2nd and 3rd decades, M:F=2:1
- Proximal femur and tibia diaphysis most common locations
- Not known to metastasize
Radiographic findings of osteoid osteoma?
Small, round radiolucent nidus (<1.5cm) surrounded by dense sclerotic bone (“bull’s-eye”)
Symptoms of osteoid osteoma?
Produces severe intermittent pain from prostaglandin secretion and COX1/2 expression, mostly at night (diurnal prostaglandin production), thus is characteristically relieved by NSAIDs
Treatment of osteoid osteoma?
NSAIDs for night pain; surgical resection of nidus; ablation of the small radiolucent zone with percutaneous radiofrequency energy
Most common benign bone tumour in children, typically asymptomatic and an incidental finding
Fibrous Cortical Defect i.e.non-ossifying fibroma, fibrous bone lesion
What are fibrous cortical defects?
These lesions are developmental defects in which parts of bone that normally ossify are instead filled with fibrous tissue
Location of fibrous cortical defects?
Femur and proximal tibia most common locations, 50% of patients have multiple defects that are usually bilateral, symmetrical, metaphysis
Radiographic findings of fibrous cortical defects?
Diagnostic, radiolucent metaphyseal eccentric ‘bubbly’ lytic lesion near physis; thin, smooth/lobulated, well-defined sclerotic margin
Treatment of fibrous cortical defects?
Most lesions resolve spontaneously
What is an osteochondroma?
- Cartilage capped bony tumour
- Most common of all benign bone tumours: 45%
What are the two types of osteochondroma?
Sessile (broad based and increased risk of malignant degeneration) vs. pedunculated (narrow stalk)
Location of osteochondroma?
Metaphysis of long bone near tendon attachment sites (usually distal femur, proximal tibia, or proximal humerus)
Radiographic findings of osteochondroma?
Cartilage-capped bony spur on surface of bone (“mushroom” on x-ray)
Treatment of osteochondroma?
Typically observation; surgical excision if symptomatic (compressing nerve/vessel)
What is an enchondroma?
Benign cartilaginous growth, an abnormality of chondroblasts, develops in medullary cavity
Where do enchondromas occur?
60% occur in the small tubular bones of the hand and foot; others in femur, humerus, ribs
Pain in absence of pathologic fracture is an important clue for malignant degeneration to _____ for suspected enchondroma?
Chondrosarcoma
Radiographic finding of enchondromas?
- Single/multiple enlarged rarefied areas in tubular bones
- Lytic lesion with sharp margination and irregular central calcification (stippled/punctate/popcorn appearance)
Treatment of enchondromas?
Observation with serial x-rays; surgical curettage if symptomatic or lesion grows
Most common cystic lesion; serous fluid-filled lesion
Unicameral/Solitary Bone Cyst
In unicameral/solitary bone cyst the cortex thins and predisposes the area to a ____
Buckle-like pathologic fracture
Most common location of unicameral/solitary bone cyst
Proximal humerus and femur most common
Symptoms of unicameral/solitary bone cyst
Asymptomatic, or local pain; complete pathological fracture (50% of presentations) or incidental detection
Radiographic findings of unicameral/solitary bone cyst
Lytic translucent area on metaphyseal side of growth plate, cortex thinned/expanded; well-defined lesion
Treatment of unicameral/solitary bone cyst?
Aspiration followed by steroid injection; curettage ¬ ± bone graft indicated if re-fracture likely
When do giant cell tumours/aneurysmal bone cyst/osteoblastomas occur?
Affects patients of skeletal maturity, peak 3rd decade
Location of osteoblastoma?
Found in the distal femur, proximal tibia, distal radius, sacrum, tarsal bones, spine
Radiographic findings of giant cell tumors?
Eccentric lytic lesions in epiphyses adjacent to subchondral bone; may break through cortex; T2 MRI enhances fluid within lesion (hyper-intense signal)
Radiographic findings of aneurysmal bone cyst?
- Either solid with fibrous/granular tissue, or blood-filled
- Expanded with honeycomb shape
Symptoms of giant cell tumours/aneurysmal bone cyst/osteoblastomas?
Local tenderness and swelling, pain may be progressive (giant cell tumours), ± symptoms of nerve root compression (osteoblastoma)
Treatment of giant cell tumours/aneurysmal bone cyst/osteoblastomas?
- Intralesional curettage + bone graft or cement
- Wide local excision of expendable bones
Radiographic findings of osteoblastoma
Often nonspecific; calcified central nidus (>2 cm) with radiolucent halo and sclerosis
Ddx of malignant bone tumors?
- Osteosarcoma
- Chondrosarcoma
- Ewing’s Sarcoma
- Multiple Myeloma
- Metastatic bone cancer
Most frequently diagnosed in 2nd decade of life (60%), 2nd most common primary malignancy in adults
Osteosarcoma
Ask about history of what if suspecting osteosarcoma?
History of Paget’s disease (elderly patients), previous radiation treatment
Location for osteosarcoma
Predilection for sites of rapid growth: distal femur (45%), proximal tibia (20%), and proximal humerus (15%)
Radiographic findings of osteosarcoma
- characteristic periosteal reaction: Codman’s triangle or “sunburst” spicule formation (tumour extension into periosteum)
- destructive lesion in metaphysis may cross epiphyseal plate
Management of osteosarcoma?
Complete resection (limb salvage, rarely amputation), neo-adjuvant chemo; bone scan- rule out skeletal metastases, CT chest - rule out pulmonary metastases
Symptoms of osteosarcoma
Painful symptoms: progressive pain, night pain, poorly defined swelling, decreased ROM
What is primary chondrosarcoma?
Primary (2/3 cases): previous normal bone, patient >40 yr; expands into cortex to cause pain, pathological fracture
What is secondary chondrosarcoma?
Malignant degeneration of pre-existing cartilage tumour such as enchondroma or osteochondroma. Age range 25-45 yr, better prognosis than primary chondrosarcoma
Symptoms of chondrosarcoma?
Progressive pain, uncommonly palpable mass
Radiographic findings of chondrosarcoma?
In medullary cavity, irregular “popcorn” calcification
Treatment of chondrosarcoma?
Unresponsive to chemotherapy, treat with aggressive surgical resection + reconstruction; regular follow-up X-rays of resection site and chest
What is Ewing’s sarcoma?
- Malignant, small round cell sarcoma
- Most occur between 5-25 yr old
Radiographic findings of Ewing’s sarcoma?
Presents with pain, mild fever, erythema, and swelling; anemia, increased WBC, ESR, LDH (mimics an infection)
Signs/symptoms of Ewing’s sarcoma?
Moth-eaten appearance with periosteal lamellated pattern (“onion-skinning”) in metaphyses of long bone with diaphyseal extension
Treatment of Ewing’s sarcoma?
Resection, chemotherapy, radiation
What is multiple myeloma?
Proliferation of neoplastic plasma cells
Most common primary malignant tumour of bone in adults
Multiple myeloma
Treatment of multiple myeloma
Chemotherapy, bisphosphonates, radiation,s surgery for symptomatic lesions or impending fractures - debulking, internal fixation
Diagnosis of multiple myeloma
- serum/urine immunoelectrophoresis (monoclonal gammopathy)
- CT-guided biopsy of lytic lesions at multiple bony sites
Radiographic findings of multiple myeloma
Multiple, “punched-out” well-demarcated lesions, no surrounding sclerosis, marked bone expansion
Signs and symptoms of multiple myeloma
Localized bone pain (cardinal early symptom), compression/pathological fractures, renal failure, nephritis, high incidence of infections (e.g. pyelonephritis/pneumonia), systemic (weakness, weight loss, anorexia)
Labs for multiple myeloma
Anemia, thrombocytopenia, increased ESR, hypercalcemia, increased Cr
Risk factors for neck pain?
- Non-modifiable: F, middle-age, occupation, more children
- Modifiable: smoking/enviro tobacco, inactivity, occupational.
- Others: psychology (depression, anxiety, poor coping skills), trauma (TBI)
Etiology of neck pain
- Mechanical – strain, whiplash, DDD, OA
- Traumatic – fracture, ligamentous
- Neurological – stenosis, radiculopathy, myelopathy
- Inflammatory – RA, PMR
- Infectious, malignant, metabolic
Investigations for neck pain
- X-ray – In the absence of red flags - imaging is not necessary in patients with mild acute or chronic neck pain that does not limit or interrupt daily activities, does not affect performance of occupation, and is easily ignored when distracted
- MRI - should be performed urgently in patients suspected of having an infection, malignancy, or spinal cord compression
- Infection: White blood cell (WBC) count, CRP, imaging (usually MRI or CT), and culture of infected tissue
Treatment for neck pain
- Spinal Manipulation – short term evidence that it is helpful
- Acupuncture – good for muscle based pain
- Massage – superior to no treatment
- Exercise Therapy – strong evidence
- Surgery – Used for radiculopathy, NOT neck pain
Questions to ask on history for neck pain
- OPQRST - changes in position, weight bearing, and time of day (eg, at night, when awakening), previous problems
- Stiffness, numbness, paresthesias, weakness, concussion (WAD)
Physical exam for neck pain
- Spinal examination: visible deformity, area of erythema, or vesicular rash,
- Neuro: muscle strength, sensory, reflex and gait testing, and evaluation for upper motor neuron signs
- Neck: range of motion (rotation and lateral flexion), palpation of the trapezius and paraspinal muscles
Symptoms of C4 radiculopathy
Pain in the lower neck and trapezius area with paresthesias involving the lower neck and upper shoulder girdle
Symptoms of C5 radiculopathy
- Pain in neck, shoulder, and dorsal forearm with paresthesias and numbness involving the dorsal arm
- Weakness of deltoid, biceps, rotator cuff
- Decrease in the biceps reflex
Symptoms of C6 radiculopathy
- Pain in the trapezius ridge and tip of the shoulder, often radiating to the thumb and index finger, with paresthesias and numbness in the same areas
- Weakness of the wrist extensors
- Decreased brachioradialis reflexes
Symptoms of C7 radiculopathy
- Pain, paresthesias, and numbness in the shoulder blade and axilla, radiating to the long and ring fingers
- Weakness of triceps
- Decreased triceps brachii reflex
Red flags for neck pain?
- Neck pain associated with lower extremity weakness, gait or coordination difficulties, and/or bladder or bowel dysfunction
- A shock-like paresthesia occurring with neck flexion (Lhermitte’s sign)
- Fever
- Unexplained weight loss
- Headache, vision changes
- Anterior neck pain
Definition of whiplash associated disorders?
Whiplash injury is defined as neck injury resulting from an acceleration-deceleration mechanism that causes sudden extension and flexion of the neck
Symptoms of whiplash associated disorders?
- Neck pain and stiffness which may present immediately after the injury or may be delayed for several days
- Associated WAD symptoms: tinnitus, headache, dizziness, memory loss, TMJ pain.
Classification of whiplash associated disorders?
- Grade 0: no complaints about neck, no physical signs. Treat: reassure.
- Grade 1: pain/stiffness or tenderness only, full ROM (no physical signs). Treat: pain relief.
- Grade 2: pain/stiffness or tenderness, MSK SIGNS on physical exam (ROM, tenderness). Treat: prompt investigation.
- Grade 3: neck complaints with NEURO SIGNS on physical exam – reflexes, weakness, numbness. Treat: prompt investigation.
- Grade 4: neck complaint with fracture/dislocation. Treat: prompt investigation.
What should you include in the description of fractures?
- Site
- Open vs. closed
- Length
- Articular
- Rotation
- Translation
- Alignment/Angulation
- Type e.g. Salter-Harris, etc.
