Trauma and Orthopedic Surgery: PART VI Flashcards
Compression or irritation of a nerve root that manifests with pain, paresthesia, weakness, and/or hyporeflexia along the distribution of the nerve root.
Radiculopathy
Intervertebral disks usually protrude/herniate posterolaterally, through the __________________________
posterior longitudinal ligament which is thinner than the anterior longitudinal ligament.
Cervical radiculopathy that presents with sensory defects in the shoulder and nexk area. You may observe scapular winging for motor defects of the trapezius/serratus anterior
C3/C4 radiculopathy
Cervical radiculopathy that presents with sensory deficits in the anterior shoulder and motor deficiets in the biceps and deltoid. You may observe deminished biceps reflex.
C4/C5 radiculopathy
Cervical radiculopathy with sensory defecits from the upper lateral elbow over the radial forearm up to the thumb and radial side of index finger, Motor deficits in the biceps and wrist extensors. Deminished biceps and brachioradialis reflexes
c5/c6 radiculopathy
Cervical radiculopathy with sensory deficts Palmar: fingers II–IV (II ulnar half, III entirely, IV radial half), Dorsal: medial forearm up to fingers II–IV, motor deficits in triceps/wrist flexors/finger extensors, and reduction of triceps reflex.
c7 radiculopathy
Radiculopathy with sensory deficits in Fingers IV (ulnar half) and V, hypothenar eminence, and ulnar aspect of the distal forearm. Motor deficits in finger flexors.
C8 radiculopathy.
What physical exam maneuver do we use to assess/determine lumbosacral rasdiculopathy?
Straight leg raise
What spinal level: sensory to anterolateral area of the thigh
L2-L3
What spinal level: sensory to
Anterolateral thigh, area over the patella, medial aspect of the leg, medial malleolus
L3/L4
What spinal level: sensory to Lateral aspect of the thigh and knee, anterolateral aspect of the leg, dorsum of the foot, and the big toe
L4-L5
What spinal level: sensory to Posterior aspect of the thigh and leg , perineum, perianal
Posterior aspect of the thigh and leg (S2), perineum (S3–S4), perianal (S4)
Motor deficits w/ Tibialis anterior muscle (foot dorsiflexion): difficulty heel walking (foot drop)
Extensor hallucis longus muscle (first toe dorsiflexion) would suggest radiculopathy where?
L5
Peroneus longus and brevis muscle (foot eversion) and gastrocnemius muscle (foot plantarflexion): difficulty toe walking suggests radiculopathy where?
S1
________________________ is associated with a disruption of the vertebral ring and most commonly occurs at L5–S1. This form is most prevalent in children and adolescents and is often associated with repetitive hyperextension of the spine (e.g., in gymnasts).
Isthmic spondylolisthesis
__________________________occurs at L4–L5 and most commonly affects individuals over 50 years of age.
Degenerative spondylolisthesis occurs at L4–L5 and most commonly affects individuals over 50 years of age.
A seronegative spondyloarthropathy and a chronic inflammatory disease of the axial skeleton that leads to partial or complete fusion and rigidity of the spine. Males are disproportionately affected and > 90% of patients are positive for HLA-B27, which is a predisposing factor for the disease.
Ankylosing spondylitis (AS)
A specific allele of the class I major histocompatibility complex that is strongly associated with seronegative arthropathies (e.g., ankylosing spondylitis). This allele is present in 6% of the general population but in ~ 90% of patients with seronegative arthropathies.
HLA-B27
An inflammation of the enthesis (the point at which a tendon attaches to bone). Typically seen in patients with ankylosing spondylitis, psoriatic arthritis, enthesitis-associated juvenile idiopathic arthritis, or reactive arthritis.
Enthesitis
radiographic sign characterized by a radiodense line running through the center of vertebral bodies on spine x-ray. Caused by ossification of the spinal ligaments.
Dagger sign, seen in ankylosing spondylitis
What are some extraarticular manifestations of ankylosing spondylitis?
–anterior uveitis
–fatigue
–Restrictive pulmonary disease
—-Due to decreased mobility of the thoracic spine and costovertebral joints
–Gastrointestinal symptoms
–Aortic root inflammation and subsequent aortic valve insufficiency, atrioventricular blocks
How do we dx ankylosing spondylitis?
Initally with an X ray, you can get labs to look for CRP or ESR and HLA-B27 positive (not in ALL cases but..)
Criteria:
Lower back pain for > 3 months in patients < 45 years of age and one of the following:
Sacroiliitis confirmed on x-ray or MRI and ≥ 1 typical clinical or laboratory finding
A positive HLA-B27 test and ≥ 2 typical clinical or laboratory findings
NOTE that in labratory findings:
CRP and ESR are typically elevated.
HLA-B27: Positive in 90–95% of patients with axial spondyloarthritis
Autoantibodies (e.g., rheumatoid factor, antinuclear antibodies) are negative
A collection of bony growths or calcifications that can form in the annulus fibrosus or the spinal ligament. Etiologies include ankylosing spondylitis, reactive arthritis, and psoriatic arthritis.
Syndesmophytes
Syndesmophytes grow vertically, as opposed to osteophytes, which grow horizontally!
A bony outgrowth that can occur in inflamed or degenerating joints (e.g., from osteoarthritis, rheumatoid arthritis, joint ligament injury, ankylosing spondylitis). Can be asymptomatic or cause pain, joint deformity, tendinitis, restriction of joint movement, or compression of adjacent nerves. Visible on imaging as bony projections or spurs along the joint line.
Osteophyte
Syndesmophytes grow vertically, as opposed to osteophytes, which grow horizontally!
How do we treat anylosing spondylitis?
Supportive therapy: Provide regular physical therapy to maintain range of motion and posture
Pharmacological therapy:
First-line pharmacotherapy in most patients: NSAIDs
Second-line : TNF-α inhibitors (e.g., etanercept, adalimumab)
Spurling test
A maneuver used to test for cervical spine radiculopathy. Performed by extending and rotating the neck to the side of the pain and applying downward pressure to the head. The test is positive if the limb pain/paresthesia can be reproduced.
A localized infection in the epidural space surrounding the spine that can lead to spinal compression, thrombosis of nearby veins, and interruption of blood supply. Clinical symptoms include fever, malaise, and point tenderness. Neurologic deficits can also occur.
Spinal epidural abscess
Spinal epidural abscess: first test, first treatment
first test is MRI then we do empiric antibiotics and we may end up needing surgical drainage and decompression
Emergent ____________________________ is indicated for patients with neurologic deficits from spinal cord compression due to malignancy.
high-dose intravenous corticosteroid therapy (e.g., with dexamethasone)
Soap bubble appearance–> this is likely an osteolytic lesion like a giant cell tumor (osteoclastoma)
This is an osteochondroma (cartilaginous exostosis) , typically located in metaphysis of long bones
Enchondroma
benign tumor arising from hyaline cartilage, Usually found in medulla of the long bones of the hands and feet (most often the metacarpals of the hand and phalanges of the fingers)
This is most likely…
An enchondroma
Clinical features: Located in metaphysis and diaphysis of long bones, intense pain that worsens at night. Pain is responsive to NSAIDs (e.g., ibuprofen, aspirin)
Diagnostics
X-ray or CT: radiolucent core (osteoid), surrounded by perifocal sclerosis (nidus)
Osteoid Osteoma
extracolonic manifestation of familial adenomatous polyposis (FAP) that includes osteomas of the skull or mandible, hypertrophy of the retinal pigment epithelium, adrenal adenomas, desmoid tumors, dental abnormalities, and cutaneous lesions
Gardner syndrome
Solitary, generally single-chambered bone cysts
Unicameral bone cyst
Mostly septated, blood-filled cysts
Aneurysmal bone cyst
How does an Aneurysmal bone cyst look like on xray
X-ray: osteolytic lesion with definite margins; usually located in the metaphysis
Lytic lesion consisting of Langerhans and immune cells. May manifest with rash and recurrent otitis media with mastoid swelling.
Langerhans cell histiocytosis
benign, developmental disorder of bone that causes normal skeletal tissue to be replaced by fibrous tissue
fibrous dysplasia
A genetic syndrome caused by a mosaic mutation in G-protein signaling and subsequent continuous stimulation of endocrine functions. Typical features include precocious puberty, café-au-lait spots, polyostotic fibrous dysplasia, and endocrine abnormalities (e.g., Cushing syndrome, acromegaly, thyrotoxicosis).
McCune albright syndrome
Syndrome associated with Polyostotic fibrous dysplasia
mccune albright syndrome
The most common primary bone tumors are
osteosarcomas, Ewing sarcomas, and chondrosarcomas
A malignant bone-forming tumor that arises from bone mesenchymal tissue and typically occurs in the metaphysis of long bones.
Osteosarcoma
sunburst pattern on x-ray
osteosarcoma
A malignant bone tumor that arises from neuroectodermal tissue. Typically occurs in flat bones (e.g., ilium, scapula) or in the diaphysis of long bones.
Ewing sarcoma
A heterogeneous group of malignant tumors that arise from cartilaginous tissue and typically occur in patients > 50 years old. Usually occur in the pelvis, ribs, and metaphyses of long bones.
chondrosarcoma
translocations of the EWSR1 gene (chromosome 22) (Chromosomal translocation t(11;22); fusion protein EWS-FLI1)
ewing sarcoma
malignant, osteoid, and bone-forming tumor arising from mesenchymal stem cells (osteoblasts)
Osteosarcoma
a malignant tumor arising from mesenchymal cells that produce cartilage
chondrosarcoma
Osteolysis with a moth-eaten appearance on xray or ct
chondrosarcoma
A type of aggressive periosteal reaction in which a ridge of subperiosteal new bone is raised by an underlying tumor. Most commonly seen in patients with_______________-
an osteosarcoma
The presence of a bony hard, nontender mass in the midline of the hard palate is consistent with ___________
torus palatinus
_________________________is the imaging modality of choice for suspected vertebral bone metastasis, even in patients without neurologic findings (e.g., bowel or bladder incontinence, weakness, or sensory loss).
Contrast-enhanced MRI of the spine
