Week 6 Flashcards
Plain films of the pelvis usually include what view?
AP view
What is the shape of the male pelvis?
Male pelvis has a triangular (android) shape
What is the shape of the female pelvis?
Female pelvis has a rounded (ovoid) shape
Why shouldn’t the SI view of the pelvis be ordered often?
Due to the increase of radiation exposure
What are the special views of the pelvis to order in the case of a trauma, when there is a suspicion of a Fx?
- Inlet view: defines AP translation
* Outlet view: defines cephalad/ caudad translation
What is the best secondary image of choice when a xray doesn’t show a fx when we suspect there is one and why?
CT, it defines osseous anatomy extremely well
How much space between the pubis is considered as abnormal?
Widening of the symphysis pubis > 1 cm
True or False
The pelvis is a ring and fractures usually occur in more than one area
True, the pelvis is a ring and fractures usually occur in more than one area
What can pelvis FX’s lead to?
- Pelvic hematomas
* Possible urethral and bladder injuries.
What is the criteria for determining the presence of a pelvis fx?
- Age: > 3 yrs
- No impairment of consciousness
- No other major distracting injuries
- No complaint of pelvic pain
- No signs of fracture on inspection
- Painless compression of iliac or pubic symphysis
- Pain free hip rotation and flexion
What does it mean when a pt meets all the criterias for a pelvic fx?
The likelihood of a pelvic fx is zero. If only one is not met, then you can’t completely rule out a fx
What is paget’s disease?
A benign lesion of the pelvis, characterized by increased sclerosis and enlargement of the entire right hemi-pelvis.
What are the malignant tumors that affect children and adults in the pelvis?
- Child – Ewing’s sarcoma
- Adult – chondrosarcomas
Metastasis are also common
What is the presentation of a child with a pelvic stress fx?
• History of overuse • Relief w non-weight bearing • Insidious in nature • Local pain, tenderness, swelling • Typical site in the pelvis is the pubic ramus
How is a pelvic stress fx diagnosed?
Bone scan is diagnostic early
What are some of the things that a pt with a pelvic stress fx will complain of?
- Change in work out activity
* Increases with WB activity and relieves with a rest period
Why would the xray of a pelvic stress fx be read as normal?
It takes a period of time for a stress fx to show up on normal imaging
___ is a typical site of a pelvic stress fx
The left inferior pubic ramus is a typical site of a pelvic stress fx
What are the types of pelvic stress FXs?
- When abnormal stresses are put on normal bone
* When normal stresses are put on abnormal bone, and are considered insufficiency fractures
What is the honda sign indicative of on a radiograph of the pelvis?
A sacral insufficiency fx
What radiograph views is usually ordered of the hip?
AP view and “frog leg” view
abducted
Why may the hip axial lateral view be ordered?
If the normal AP or frog leg view don’t allow adequate visualization of the femoral neck
What is the most common hip dislocation?
Posterior dislocation
What is the usual cause of a hip dislocation?
The result of MVA’s
What are the high yield areas to examine for hip trauma?
- Widening of joint space
- Femoral neck or intertrochanteric fractures
- Pelvis or acetabular fractures
In what direction does the femoral head displace in an anterior dislocation?
Head displaced inferiorly and medially.
What are the most common hip FX?
- Fx’s of the femoral neck
* Fx’s of the intertrochanteric region
What is a fx of the femoral neck often due to?
Often due to osteoporosis
True or False
Stress fx’s of the femoral neck may appear sclerotic
True, Stress fx’s of the femoral neck may appear sclerotic
What is a fx of the intertrochanteric region often due to?
Often due to trauma
What is the best way to evaluate a nondisplaced hip fx?
A MRI
___ is the most common cause of chronic hip pain.
Osteoarthritis is the most common cause of chronic hip pain.
In what direction does the femoral head displace in an posterior dislocation?
Superior and lateral to the acetabulum.
What is the presentation of an intertrochanteric region fx?
Shortened leg with internal rotation
What is the pt presentation of hip OA?
Patient presents with pain and loss of mobility, starting with internal rotation
What do DJD changes of the hip include?
- Joint space narrowing
- Subchondral cysts
- Sclerotic/white looking borders
- Osteophytes.
The Altman criteria has 2 test cluster and is used to classify hip OA. What are the components of test cluster 1?
- Hip Pain
- Hip IR < 15
- Hip flexion < 115
The Altman criteria has 2 test cluster and is used to classify hip OA. What are the components of test cluster 2?
If hip IR > 15
• Painful w IR
• Age > 50 yrs
• Morning stiffness less than 60 minutes
What are the items on the CPR of a hip OA in individuals with unilateral hip pain?
- Patient reported squatting as an aggravating factor
- Flexion ROM caused lateral hip pain
- Scour test with adduction caused lateral or groin pain
- Extension ROM caused pain
- IR less ≤ 25°
What is the physical presentation of an aseptic necrosis of the hip?
Femoral head is flattened, irregular and sclerotic
What is the best way to visualize an aseptic necrosis of the hip?
MRI
What are some of the presentations/causes that will indicate that a patient has an aseptic necrosis of the hip?
- A nemia (sickle cell)
- S teroids
- E thanol (alcohol)
- P ancreatitis
- T rauma
- I diopathic
- C aisson’s disease
What is klein line?
A line drawn along superior border of the femoral neck,
should intersect with the femoral head (usually displaced in a SCFE)
What are the presentations of a femoral neck stress fx?
- History of overuse
- Relief w non-weight bearing
- Insidious in nature
- Local pain, tenderness, swelling
What are the types of femoral neck stress fx?
- Compression: fx of the medial side of the femoral neck
* Tension: fx of the lateral side of the femoral neck (more serious)
What can be used to diagnose an early femoral neck stress fx?
Bone scan
What is the gold standard for diagnosing a femoral neck stress fx and why?
MRI, because it is 100% sensitive and specific
Why is a tension(lateral) side femoral neck stress fx more serious?
They don’t heal very well, because bone ends are being pulled apart and not apart
What are the early signs of a stress reaction that might lead to a stress fx?
Increased uptake/a sclerotic line
What are the typical views of the femur?
AP view and lateral view.
True or False
The femur is prone to tumors – benign and malignant
True, The femur is prone to tumors – benign and malignant
What are the benign lesions found in the femur?
- Fibrous cortical defects
- Fibrous dysplasia
- Non-ossifying fibroma
What are the malignant lesions found in the femur?
- Chondrosarcoma
* Metastases
What are the characteristics of benign lesions found in the femur?
- Small
- No associated periosteal reaction
- Narrow transition zone between bone and lesion
- Thin, well defined sclerotic (white) margins
What type of cancers can produce a lytic lesion?
Breast and lung cancer
Lytic lesion w/o sclerotic margins is considered ___ until proven otherwise!
Lytic lesion w/o sclerotic margins is considered malignant until proven
otherwise!
What are the characteristics of malignant lesion: chondrosarcomas?
- Destructive in nature
- Vary in appearance
- Occur typically in the femur, pelvis and ribs.
A periosteal reaction can either be benign or malignant. Where are they typically found?
Typically in long bone
What are the causes of a periosteal reaction?
- Infections
- Osteomyelitis
- Ewings tumor- young patients 5- 20 years, diaphysis of long bone
- Osteogenic sarcoma- around a joint (knee)
- Sunburst pattern- think malignancy!
What are the presentations that is indicative of a stress fx?
- Pain w activity, relief w rest.
- Antalgic gait
- Pain increased w all ROM, FABERS, log rolling.
What is the AP view of the knee best for visualizing?
Joint space narrowing or calcification of the cartilage
What is the lateral view with partial flexion of the knee best for visualizing?
Patella and joint effusions
What is the sunrise or merchant view of the knee best for visualizing?
Relationship of the patella to the anterior femur or a retropatella image (done in prone)
What is the tunnel view of the knee best for visualizing?
Tibial spines and femoral condyles
What is the best way to visualize the ligaments, cartilage and tendons of the knee?
A MRI
What are the CPRs for the knee?
- Pittsburgh Knee rule (more sensitive than specific)
* Ottawa knee rule (more sensitive than specific)
What are the components of the Pittsburgh knee rule?
Blunt trauma or a fall as mechanism of injury plus either of the following:
• Age younger than 12 or older than 50 years
• Inability to walk 4 weight-bearing steps in the ED
According to the ottawa knee rules, what are the items that require a xray to be ordered?
- Age 55 or older
- Isolated tenderness over the patella
- Tenderness over the fibula head
- Unable to flex > 90 degs
- Unable to weight bear immediately, or in the emergency room 4 steps
What are the symptoms of knee osteoarthritis?
- Pain with motion
- Limited ROM
- Redness
- Swelling or visible deformity
What are the xray findings of knee osteoarthritis?
- Joint space narrowing
- Sclerosis
- Osteophytes
What may happen to the cartilage in the presence of osteoarthritis?
The cartilage may become calcified and break off resulting in loose bodies in the joint
___ is the calcification of the articular cartilage
Chondrocalcinosis is the calcification of the articular cartilage
What are the types fx of the knee?
- Patella fractures
* Fractures of the tibia, fibula, and femur
____ is a normal variant of the knee that may appear to be a fracture
Bipartate patella is a normal variant of the knee that may appear to be a fracture
What is the best view for a tibial plateau fx?
An AP view
If the films of a tibial plateau fx is negative and a fx is still suspected, what is indicated?
A MRI is indicated
What is a segond fracture?
A cortical avulsion fx off the proximal lateral tibia, just distal to the tibial plateau at the sit of insertion of the middle third f the lateral capsular ligament(LCL) resulting from excessive IR and varus stress
What is the imaging view for a segond fracture?
A MRI
What is osteochondritis dessicans?
Lesion involving both bone and hyaline cartilage
What does an osteochondritis dessicans cause?
Causes 50% of loose bodies in the knee
What are the causes of osteochondritis dessicans?
- Traumatic
- Ischemic
- Abnormal ossification centers
- Genetic or combination
What is a loose body?
A piece of bone or cartilage caused by trauma that is within the joint and causes locking or swelling, pain and decreased function
What is a fabella?
A variant of the sesamoid bone and is typically causes no pain and functional problem. They are smooth and often teardrop shaped
What do we see in the radiograph of a knee with chondrocalcinosis?
- The meniscus shows signs of calcification
* Cloudy lines in the joint line where the meniscus line.
What do we find upon the physical examination of a pt with a patellar fx?
- Gross effusion and edema
- Exquisite tenderness over he fx site
- Significant quad inhibition
What part of the knee does an osteochondritis dessicans lesion usually affect?
Weight-bearing surfaces of the medial femoral condyle
___ is the major cause of loose bodies in the knee
Osteochondritis dessicans is the major cause of loose bodies in the knee
What are the typical signs of osteochondritis dessicans lesions?
Persistent effusion and locking of the joint
Why might osteochondritis dessicans go undiagnosed initially?
Cartilage can not be visualized on a xray
If an 11-15 year old boy complains of activity related anterior knee pain, and he points to his tibial tuberosity, what should be your number 1 differential diagnosis?
Osgood-Schlatter disease
What are the characteristics of Osgood-Schlatter disease?
- AKA tibial tubercle apophysitis
- More in boys than girls
- Usually self limiting, and will cure with rest
___ is an analogous condition to Osgood-Schlatter disease and involves the patellar tendon and the lower margin of the patella, instead of the upper margin of the tibia
Sinding-Larsen-Johansson syndrome is an analogous condition to Osgood-Schlatter disease and involves the patellar tendon and the lower margin of the patella, instead of the upper margin of the tibia
What are the imaging views for the foot and ankle?
- AP view
- Lateral view
- Oblique
- Mortise view(only for the ankle)
What does ankle effusion on a radiograph appear as?
An anterior fat line in front of the joint space on the lateral view
What does the most common ankle fx involve?
Lateral or medial malleolus
According to the ottawa ankle rules, when should an ankle xray be ordered?
Pain in malleolar zone AND any of the following:
• Bone tenderness in posterior half of distal tibia or fibula (or tip of medial or lateral malleolus)
• Unable to bear weight for 4 steps immediately after injury and during exam
According to the ottawa foot rules, when should a foot xray be ordered?
Pain in midfoot zone AND any of the following:
• Bone tenderness over navicular or base of 5th MT
• Unable to bear weight for 4 steps immediately after injury or during exam
What are the psychometrics for the ottawa ankle and foot rules?
100% sensitive for malleolar and midfoot FXs
What are the characteristics of the mortise view of the ankle?
- Modified AP view: foot and leg are internally rotated 15-30 degs
- Enables viewing of mortise and distal tibiofibular joint
How does the danis-weber classification system for the ankle classifies fractures?
It uses the position of the level of the fibular fracture in its relationship to its height at the ankle joint
What are the components of the danis-weber classification system?
- Weber A: fracture below the ankle joint
- Weber B: fx at level of the joint, with the tibiofibular ligaments usually intact
- Weber C: fx above the joint level which tears the syndesmotic ligaments
How does the lauge hansen classification describe a fracture?
The 1st word describes the position of the foot, the 2nd word describes the motion of the foot (talus) with respect to the leg.
Types: supination-adduction or pronation-abduction
What is a stage 1 supination-adduction fx, according to the lauge hansen classification?
Transverse fx of lateral malleolus, at or below the level of anterio talo-fibular ligament or a tear of lateral collateral ligament structures with the anterior talofibular ligament disrupted most often and frequently the calcaneofibular ligament being torn
What is a stage 2 supination-adduction fx, according to the lauge hansen classification?
Oblique fx of medial malleolus
What is the most common lauge hansen classification fx?
Supination- external rotation
What is a stage 1 supination-external rotation fx, according to the lauge hansen classification?
Rupture of anterior inferior tibiofibular ligament
What is a stage 2 supination-external rotation fx, according to the lauge hansen classification?
Oblique fx or spiral fx of the lateral malleolus
What is a stage 3 supination-external rotation fx, according to the lauge hansen classification?
Rupture of post tibiofibular ligament or fx of posterior malleiolus of the tibia
What is a stage 1 supination-external rotation fx, according to the lauge hansen classification?
Transverse(sometimes oblique) fx of the medial malleolus
What is a stage 1 pronation-abduction fx, according to the lauge hansen classification?
Rupture of the deltoid ligament or transverse fx of the medial malleolus
What is a stage 2 pronation-abduction fx, according to the lauge hansen classification?
Rupture of the anterior and posterior inferior tibiofibular ligament or bony avulsion
What is a stage 3 pronation-abduction fx, according to the lauge hansen classification?
Oblique fx of the fibula at the level of the syndesmosis
What is a stage 1 pronation-external rotation fx, according to the lauge hansen classification?
Rupture of the deltoid ligament or transverse fx of the medial malleolus
What is a stage 2 pronation-external rotation fx, according to the lauge hansen classification?
Rupture of the anterior inferior tibiotalofibular ligaments or bony avulsion
What is a stage 3 pronation-external rotation fx, according to the lauge hansen classification?
Spiral/oblique fx of the fibula above the level of the syndesmosis
What is a stage 4 pronation-external rotation fx, according to the lauge hansen classification?
Rupture of the posterior inferior tibiofibular ligament or fx of the posterior malleolus
What is a stage 1 pronation-dorsiflexion fx, according to the lauge hansen classification?
Fx of the medial malleolus
What is a stage 2 pronation-dorsiflexion fx, according to the lauge hansen classification?
Fx of the anterior lip of the tibia
What is a stage 3 pronation-dorsiflexion fx, according to the lauge hansen classification?
Fx of the supramalleolar aspect of the fibula
What is a stage 4 pronation-dorsiflexion fx, according to the lauge hansen classification?
Rupture of the posterior inferior tibiofibular ligament of fx of the posterio malleolus
What is a maisonneuve fx?
A fx at the ankle that results from an ER force to the ankle with transmission of the force through the interosseous membrane, exiting through a proximal fibular fx
What are some associated lesion of an ankle fx?
• Osteochondral defect commonly at the medial dome
Why is a surgery used for a jones fx?
It is a water shed area, meaning that it has less blood circulation. Usually at the base of the 5th MT
What is a Lisfranc fx?
Fx of the 2nd, 3rd, 4th, ad 5th MT with lateral dislocation
___ is considered to be a hallmark sign of a lisfranc injury
Medial plantar bruising is considered to be a hallmark sign of a lisfranc injury
What is a march fx?
A stress fx of the 2nd, 3rd, or 4th MT
What structure is involved in gout?
The 1st MCP joint
What is a periosteal reaction?
Thickening of the periosteum, which appears white on a xray
When do we see bone and joint infections?
Seen in normal ealing fx, osteomyelitis, benign and malignant tumors
What type of periosteal reaction is worrisome for malignancy?
A radiating periosteal reaction(sun-burst)
