Trauma and Orthopedic Surgery: PART VI

Question 1

Compression or irritation of a nerve root that manifests with pain, paresthesia, weakness, and/or hyporeflexia along the distribution of the nerve root.

Answer 1

Radiculopathy

Question 2

Intervertebral disks usually protrude/herniate posterolaterally, through the __________________________

Answer 2

posterior longitudinal ligament which is thinner than the anterior longitudinal ligament.

Question 3

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

Answer 3

C3/C4 radiculopathy

Question 4

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.

Answer 4

C4/C5 radiculopathy

Question 5

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

Answer 5

c5/c6 radiculopathy

Question 6

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.

Answer 6

c7 radiculopathy

Question 7

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.

Answer 7

C8 radiculopathy.

Question 8

What physical exam maneuver do we use to assess/determine lumbosacral rasdiculopathy?

Answer 8

Straight leg raise

Question 9

What spinal level: sensory to anterolateral area of the thigh

Answer 9

L2-L3

Question 10

What spinal level: sensory to
Anterolateral thigh, area over the patella, medial aspect of the leg, medial malleolus

Answer 10

L3/L4

Question 11

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

Answer 11

L4-L5

Question 12

What spinal level: sensory to Posterior aspect of the thigh and leg , perineum, perianal

Answer 12

Posterior aspect of the thigh and leg (S2), perineum (S3–S4), perianal (S4)

Question 13

Motor deficits w/ Tibialis anterior muscle (foot dorsiflexion): difficulty heel walking (foot drop)
Extensor hallucis longus muscle (first toe dorsiflexion) would suggest radiculopathy where?

Answer 13

L5

Question 14

Peroneus longus and brevis muscle (foot eversion) and gastrocnemius muscle (foot plantarflexion): difficulty toe walking suggests radiculopathy where?

Answer 14

S1

Question 15

________________________ 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).

Answer 15

Isthmic spondylolisthesis

Question 16

__________________________occurs at L4–L5 and most commonly affects individuals over 50 years of age.

Answer 16

Degenerative spondylolisthesis occurs at L4–L5 and most commonly affects individuals over 50 years of age.

Question 17

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.

Answer 17

Ankylosing spondylitis (AS)

Question 18

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.

Answer 18

HLA-B27

Question 19

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.

Answer 19

Enthesitis

Question 20

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.

Answer 20

Dagger sign, seen in ankylosing spondylitis

Question 21

What are some extraarticular manifestations of ankylosing spondylitis?

Answer 21

–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

Question 22

How do we dx ankylosing spondylitis?

Answer 22

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

Question 23

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.

Answer 23

Syndesmophytes

Syndesmophytes grow vertically, as opposed to osteophytes, which grow horizontally!

Question 24

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.

Answer 24

Osteophyte

Syndesmophytes grow vertically, as opposed to osteophytes, which grow horizontally!

Question 25

How do we treat anylosing spondylitis?

Answer 25

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)

Question 26

Spurling test

Answer 26

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.

Question 27

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.

Answer 27

Spinal epidural abscess

Question 28

Spinal epidural abscess: first test, first treatment

Answer 28

first test is MRI then we do empiric antibiotics and we may end up needing surgical drainage and decompression

Question 29

Emergent ____________________________ is indicated for patients with neurologic deficits from spinal cord compression due to malignancy.

Answer 29

high-dose intravenous corticosteroid therapy (e.g., with dexamethasone)

Question 30

Answer 30

Soap bubble appearance–> this is likely an osteolytic lesion like a giant cell tumor (osteoclastoma)

Question 31

Answer 31

This is an osteochondroma (cartilaginous exostosis) , typically located in metaphysis of long bones

Question 32

Enchondroma

Answer 32

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)

Question 33

This is most likely…

Answer 33

An enchondroma

Question 34

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)

Answer 34

Osteoid Osteoma

Question 35

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

Answer 35

Gardner syndrome

Question 36

Solitary, generally single-chambered bone cysts

Answer 36

Unicameral bone cyst

Question 37

Mostly septated, blood-filled cysts

Answer 37

Aneurysmal bone cyst

Question 38

How does an Aneurysmal bone cyst look like on xray

Answer 38

X-ray: osteolytic lesion with definite margins; usually located in the metaphysis

Question 39

Lytic lesion consisting of Langerhans and immune cells. May manifest with rash and recurrent otitis media with mastoid swelling.

Answer 39

Langerhans cell histiocytosis

Question 40

benign, developmental disorder of bone that causes normal skeletal tissue to be replaced by fibrous tissue

Answer 40

fibrous dysplasia

Question 41

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).

Answer 41

McCune albright syndrome

Question 42

Syndrome associated with Polyostotic fibrous dysplasia

Answer 42

mccune albright syndrome

Question 43

The most common primary bone tumors are

Answer 43

osteosarcomas, Ewing sarcomas, and chondrosarcomas

Question 44

A malignant bone-forming tumor that arises from bone mesenchymal tissue and typically occurs in the metaphysis of long bones.

Answer 44

Osteosarcoma

Question 45

sunburst pattern on x-ray

Answer 45

osteosarcoma

Question 46

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.

Answer 46

Ewing sarcoma

Question 47

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.

Answer 47

chondrosarcoma

Question 48

translocations of the EWSR1 gene (chromosome 22) (Chromosomal translocation t(11;22); fusion protein EWS-FLI1)

Answer 48

ewing sarcoma

Question 49

malignant, osteoid, and bone-forming tumor arising from mesenchymal stem cells (osteoblasts)

Answer 49

Osteosarcoma

Question 50

a malignant tumor arising from mesenchymal cells that produce cartilage

Answer 50

chondrosarcoma

Question 51

Osteolysis with a moth-eaten appearance on xray or ct

Answer 51

chondrosarcoma

Question 52

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_______________-

Answer 52

an osteosarcoma

Question 53

The presence of a bony hard, nontender mass in the midline of the hard palate is consistent with ___________

Answer 53

torus palatinus

Question 54

_________________________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).

Answer 54

Contrast-enhanced MRI of the spine