nbs xray part 4 x ray tough, NBCE Part 4 Xray

Seropositive Arthritis

"RSSS"= Rheumatoid arthritis, Sjogren's, Scleroderma, Systemic Lupus Erythematosis (SLE); All RA Latex (+)

Giant cell tumor 4 keys

"Soap bubble" in distal femur/proximal tibia (1. Metaphysis to epiphysis to 2.adjacent joint )filled with giant cells and neoplastic mononuclear cells 3. eccentric, 4. no sclerosis, 50% knee, 20-40 F, years of progression biopsy, bone scan, orthopedic surgery or radiation therapy

Limbus Bone lumbar lower corner/ cervical upper corner

(small ossicles at anterior corner of vertebral bodies, often caused by herniation of nuclear material) VS avulsion, teardrop fx -->acute

*Lumbar Gravity Line* 1) aka 2) landmarks 3) positives

*1* AKA Ferguson's line *2* Landmarks: vertical line is drawn through the center of the L3 vertebral body. *3* The line should intersect the sacral base if the line is anterior to the sacrum it is a possible hyperlordosis if the line is posterior to the sacrum it is a possible hypolordosis.

*Femoral Angle* 1) aka 2) landmarks 3) recorded findings

*1* AKA Mikulicz's angle. *2* Landmarks: two lines are drawn through and parallel to the mid-axis of the femoral shaft and the femoral neck. *3* Normal angle is 120-130 degrees, less than 120 degrees is termed coxa vara greater than 130 degrees is termed coxa valga.

*Lumbosacral angle* 1) aka 2) landmarks 3) normal angle 4) average angle

*1* AKA sacral base angle, Ferguson's angle. *2* Landmarks: oblique line drawn through and parallel to the sacral base, horizontal line parallel to the bottom edge of the film. *3* Normal angle is 26-57 degrees *4* average is 41 degrees.

Stress lines of Cervical Spine 1) landmarks 2) Flexion should ____ 3) extension should ____ 4) may be altered by ____

*1* Landmarks lines grawn at the posterior bodies of C2 and C7. *2* Flexion should intersect at C5/6, *3* extension should intersect at C4/5. *4* May be altered by muscle spasm, joint fixation, or disc degeneration.

ADI *Atlantodental Interspace* 1) landmarks 2) If the line measures ore than 3 mm in an adult or 5 mm in a child this indicates _____

*1* Landmarks: A line is drawn from the C1 anterior tubercle to the odontoid. *2* If the line measures ore than 3 mm in an adult or 5 mm in a child this indicates transverse ligament rupture or instability which may be due to trauma, Downs syndrome, or inflammatory arthritis. RA

*Hadley's S Curve* 1) landmark 2) positive

*1* Landmarks: a curvilinear line is drawn along the inferior aspect of the TP, the inferior articular process, and through the joint space to the superior articular process of the vertebra below. *2* The line should result in a smooth "S" shaped curve. An interruption in the S curve indicates a subluxation or facet imbrication

*Klein's Line* 1) landmark 2) positive

*1* Landmarks: a line is drawn along the outer margin of the femoral neck. *2* The femoral head should intersect the line. Failure to intersect the line indicates a slipped capital femoral epiphysis. This is the best line of mensuration for SCFE.

*Kohler's Line* protrusio acetabuli.

*1* Landmarks: a line is drawn along the pelvic inlet to the outer aspect of the obturator foramen. *2* If the acetabular floor crosses the line, this indicates

*Macrae's line* 1) landmarks 2) if the occipital bone is above the line, this indicates _____

*1* Landmarks: a line is drawn from the anterior foramen magnum (basion) to the posterior foramen magnum (opisthion). *2* If the occipital bone is above the line, this indicates basilar impression

*McGregor's line* 1) landmarks 2) If the odontoid is more than 8 mm above the line in males or more than 10 mm above the line in females this indicates _____

*1* Landmarks: a line is drawn from the hard palate to the base of the occiput. *2* If the odontoid is more than 8 mm above the line in males or more than 10 mm above the line in females this indicates basilar impression. $$$ This is the most accurate line to evaluate for basilar impression.

*Chamberlain's line* 1) landmarks 2) If the odontoid is greater than 7 mm above the line this indicates _____

*1* Landmarks: a line is drawn from the hard palate to the opishition (posterior foramen magnum). *2* If the odontoid is greater than 7 mm above the line this indicates basilar impression

*Macnab's Line* 1) landmarks 2) positive

*1* Landmarks: a line is drawn parallel and through the inferior end plate. *2* If the line intersect the superior articular process of the vertebra below, extension malposition or facet imbrication is suspected

*Skinner's Line* 1) landmarks 2) positive

*1* Landmarks: a line is drawn through and parallel to the femoral shaft, a perpendicular line is drawn tangential to the tip of the greater trochanter. *2* The fovea capitus should lie above or at the level of the trochanter line. If the fovea capitus falls below this line it indicates fracture or coxa vara.

Eisenstein's Method for Sagittal Canal Measurement 1) landmark 2) <15mm = ____

*1* Landmarks: a line is drawn to connect the tips of the superior and inferior articular processes. The distance to the posterior body margin at the midpoint is measured. *2* If the measurement is less than 15 mm, indicates spinal canal stenosis

*Shenton's Line* 1) landmark 2) positives

*1* Landmarks: a smooth curvilinear line is drawn along the inferior femoral neck to the superior aspect of the obturator foramen. *2* An interrupted, discontinuous line indicates a dislocation, neck fracture, or slipped capital femoral epiphysis

*Iliofemoral Line* 1) landmarks 2) positive

*1* Landmarks: a smooth curvilinear line is drawn along the outer ilium, across the joint and onto the femoral neck. *2* Bilateral asymmetry indicates a slipped femoral capital epiphysis, dislocation, fracture, or dysplasia.

*Sacral inclination* 1) landmarks 2) normal angle 3) average angle

*1* Landmarks: a tangential line is drawn parallel and through the posterior margin of S1 and a vertical line is draw intersecting the sacral line. *2* Normal angle is 30-72 degrees, *3* average angle is 46 degrees.

Prevertebral soft tissues (PLT) 1) landmarks 2) if positive it is indicative of _____ 3) Retropharyngeal (C2-4) > _____ 4) Retrolaryngeal (C5) > _____ 5) Retrotracheal (C6-7) > ______

*1* Landmarks: anterior vertebral bodies to posterior margin of air shadow of the pharynx, larynx, and trachea. *2* indicative of a soft tissue mass such as a tumor, infection, or hematoma. *3* If the retropharyngeal is greater than 7mm *4* retrolaryngeal is greater than 14 mm *5* the retrotracheal space is greater than 22 mm

*Basilar angle* 1) Landmarks 2) if > 152 it is indicative of ___

*1* Landmarks: line drawn from the nasion to the center of the sella turcica, a line is drawn from the basion (anterior foramen magnum) to the center of the sella turcica. *2* If the angle is greater than 152 degrees it is indicative of platybasia which may be associated with basilar impression

*Posterior cervical line* 1) landmarks 2) Discontinuous line may indicate _____

*1* Landmarks: lines drawn at each spinolaminar junction should form a smooth arc-like curve. *2* Discontinuous line may indicate A to P vertebral malposition such as anterolisthesis or retrolisthesis

*George's line* 1) landmarks 2) Discontinuous line may indicate ____

*1* Landmarks: posterior body margins are checked for alignment with what should be a smooth, continuous line. *2* Discontinuous line may indicate A to P vertebral malposition such as anterolisthesis or retrolisthesis.

*Slipped Capital Femoral Epiphysis* what is it?

*1* Most commonly seen in *boys age 10-16* *2* Salter Harris type I fracture when the femoral head slides inferior and medial, femoral neck slides superior and lateral. *3* Associated lines on radiographs include Klein's, Shenton's and Skinner's, the best is *Klein's* *4* Case managment: refer to orthopedist

*Ullman's Line* 1) landmark 2) +

*1* line drawn parallel thru the sacral base. Perpendicular line drawn from sacral promontory *2* l5 beyond perpendicular line = Spondylolisthesis

*o*steoblastoma (neck) *g*iant cell tumor (Epiphysis/Metaphysis) *a*neurysmal bone cyst( Diaphysis/Metaphysis)

*3 benign bone tumors that cause expansion of the neural arch*...

*Ankylosing Spondylitis* 4) SI joint signs

*4* SI joints there is bilateral joint fusion in later stages called ghost joints.

*Ankylosing Spondylitis* 5) spine signs

*5* In the spine *early on shiny corner sign* *later bilateral marginal syndesmophytes* *squaring of the vertebral bodies* *bamboo spine, dagger sign, trolley track sign, poker spine* Bilateral SI fusion (ghost jt)

Most common *patient demographic in scoliosis*

*Female between 13-19 years old*

*3* Need a biopsy to confirm with presence of *Reed Sternberg cells*

*Hodgkin's disease* 3) lab

Paget's disease of bone

*Increased Alkaline Phosphatase* Pathogenesis:Imbalance between osteoclast and osteoblasts function 3 Stages: 1. Osteoclastic 2. Mixed osteoblastic-osteoclastic 3. Osteoblastic Clinical features: Increasing hat size (skull commonly affected) High output Cardiac Failure (due to shunt formation from bone) Osteosarcoma (malignant tumor of osteoblasts 3rd stage) Pathology: Mosaic pattern of lamellar bone

*Ewing's Sarcoma*

*Onion skin periosteal reaction!* -Lytic, central and accompanied by endosteal scalloping @ diaphysis -Moth eaten mottled appearance + extension into soft tissue. metaphsis Osteosarcoma

Teenage, pain during exercise

*Osteochondroma* cartilage cap pedunculated (coat hanger exostosis/caulifflower like) or sessile

*Most common bone malignancy found in children*

*osteosarcoma* (cotton candy tumor)

Pyogenic osteomyelitis Vs Pott: T/L, multiple, skip lesion(spread underneath ligaments), extensive subligamentous spread; disc could be spared; well defined large paraspinal abscess with thin wall, might be calcification on CT

- a broad term that includes vertebral osteomyelitis, spondylodiskitis, and epidural abscess. IF TB—Pott UTI —-Gonorro M/C —-Strap aureus

30 F, fever, mid back pain, gibbus, lower limb weakness and paraplegia Pott disease / tuberculosis spondylitis

- back pain, gibbus deformity and possibly *compressive myelopathy* / *paraplegia, weakness - More Lower thoracic spine - Mantoux test/tuberculin skin test; ESR; Abscess sample biopsy, acid-fast bacilli(AFB) - Paraspinal abcess - MRI is the criterion gold standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissue and the spread of tuberculous debris

17/o girl, fever, back pain, Discitis/ spondylodiskitis —-infection eats from endplates and disc to adjacent endplates

- pediactic/>50 - back pain, less common fever, *endocardiatis, strap aureus/ IV drug use/ remote infection, DM, CA, TB - Infection: so ELEVATED ESR/CRP - Lumbar, 65% single level involvement - MRI: especially T2 hyperintensity in Psoas major

MVA, neck pain, rust sign? —FX Avulsion or Burst Burst fracture VS other types of compression fracture: posterior vertebral body cortex is intact widening of pedicle spaces —-VS butterfly vertebra/ chance fracture

- trauma, back pain + lower limbs neuroglical deficits (L1) - Occurs with AXIAL LOADING and causes the vertebral body of C3-C7 to shatter outward from the compressive force **C1 Jefferson - Disrupts the anterior longitudinal ligament: loss of Anterior vertebral height but always involves posterior vertebral cortex - CT and MRI for spinal cord contusion

RA at wrist knee cervical spine

---spotty carpals, erosion of styloid processes ---not much misalignment, uniform loss of joint spacesVS OA ---ADI-->MRI instead of FLEX/EXT

SLE - NON erosion VS RA

-MULTIPLE systems (women 15-40) -Diagnosis with ANA titer - 99% definitive -Rest and Avoid UV light -Encourage activity -->non erosive, Reducible, "ligament laxity" skin lesion, malar, pitting nails,

Scoliosis treatment. Cobb's angle

-focus of tx: determined based on magnitude of the curve and the degree of progression (Non structional: lessen curves when bending/Adam's ) -if the curve is not progressing, generally no formal action is taken -monitor, PT tx includes muscle strengthening and flexibility exercises, shoe lifts and bracing -a spinal orthosis/brace is often warranted with a curve that ranges between 25 and 40° -Surgical intervention > 40 degrees >50 pulmonary compromise

ADI & UCI

1. Down's syndrome- 20% of the time lack a transverse ligament, Down's is not an x-ray diagnosis, you diagnose that from clinical work. 2. Trauma 3. RA 4. AS or Marie Strumpel's disease, 5. Psoriatic Arthritis, 6. Reiter's syndrome Avoid flx/ext views if large neurological compromise, UCI—ER, MRI

What 3 primary benign tumors appear cartilaginous? MOST COMMON BENIGN TUMOR OF HANDS---encondroma

1. Enchondroma --systematic 2. Olliers 3. Maffuci's +hemagiomas/lymphangiomas

multiple myeloma ** skull: raindrop: MM Salt pepper: HPT Large cotton wool lesion: Paget skull

1. Most common primarily bone Malignancy in adults MOCEL 2. bone marrow cells (plasma cells that produce IgG).—> MRI great but bone scan usually cold 3. CRAB syndrome —CBC, serum protein electrophoresis (SPEP) , Bone panel, UA Hypercalcemia, reversed a/g, M spike, norm norm anemia, Kidney failure(increased Cr, BUN, protein BJ),

MVA—>Cervical avulusion fracture & spinal cord injury (Upper,c2 more hyperextensive; lower, 4-6, hyperflexional )

1. Weakness/paralysis below the level of injury, no pain and temp, autonomic dysfunction, but DCML/ propioception, vibration preserved —>anterior spinal cord syndrome (more common) 2. Ipsilateral loss of properioception and vibration(2 post vertebral artery) —posterior cord injury, rare 3. Central cord injury —most common! hyperextensive neck fx/ whiplash/spondlylosis in the old -lower motor neuron lesion in upper extremity, motor worse -upper motor neuron lesion in lower extremity -hand function last to come back if it does small lesion= bilateral loss of pain and temp at the level of injury "Cape" + Babinski

artheritis

1. degenerative, inflammatory, metabolic 2. may refer to rheumatologist ** Inflammatory arthritis also could be : arthritis deformans(PsA) enthesopathic arthropathy (AS) sacrolitis

****RA -->attack synovial fluid, leads to FUSION, PATTERN！！！（bil,sym, uniform） -->synovial fluid: wrist, MCP, PIP, HIP, C1C2 *2* Labs: *positive RA latex, positive ESR, positive FANA, positive CRP, normocytic normochromic anemia-aplastic anemia*. OA: overuse, non-uniform, sclerotic, Heberden nodes (OA and RA bouchards)

1. inflammation /synovitis 2. juxta-articular osteoporosis, subchondral cysts, erosion/rat bits/bare area 3. *symmetrical, uniform bilateral loss of joint space in the hands and hips* in the hands *Haygarth's nodes* are noted but the *dips are spared*. *** Swan neck (PIP hyper extension& DIP flexion) and Boutonniere deformity(just the opposite) 4. migration, deformity, fusion *Bilateral ulnar deviation, protrusio acetabulae (OttO's PELVIS)

*Paget's* *1* AKA *Osteitis Deformans* *2* Most commonly seen in *men over age 50* *3* Stage 1: *lytic* or destructive Stage 2: *mixed* or combined Stage 3: *Sclerotic*/ Stage 4: malignant degeneration to *osteosarcoma*

1. localized pain and tenderness 2. increased focal temperature due to hyperemia (due to hypervascularity) 3. increased bone size: historically changing hat size was a giveaway OR HA, Hearing loss bowing deformities kyphosis of the spine decreased range of motion signs and symptoms relating to complications (see below) MRI for stenosis, basilar invagination

What primary benign tumors have a bony appearance?

1.osteochondroma HME 2. Hemangioma 3.osteoid osteoma and osteblastoma 4. Bone islands

trauma RA secondary HPT

3 things that can cause osteolysis

-infection -fracture -legg calve perthes(2 yr process)

3 things they would time sequence

OS ODONTOIDEUM-chronic pain, if acute=think dens fracture -notice dens and anterior tubercule are basically touching, and anterior tubercle is round -they like the term 'molding' not union -need to check flex/ext films for slippage and cord compression

32 year old woman neck pain

-concavity of anterior VB-wasp waist -absent or remnant IVD aka hypoplastic disc -enlargemtn of IVF -fusion of postieor elements

4 findings of congenital block

-squared or rectangular VB -degenerated/obliterated disc -normal sized IVF, NO IVF on lateral cerviacal -no fusion of posteior elments, can be degenearted

4 findings of surgical block

Developmental dysplasia of hip DDH

<1 year -->ULTRASOUND diagnosed before walk congenital hip dysplasia small/absent of hip epiphysis (missing femur head) Surgery, plantar support

Brodie's Abscess (intraosseous abscess with subacute or chronic Pyogenic Osteomyelitis) A 7 year old girl presents with high fever, swelling and pain in the knee, that is worse at night and often wakes her up. Pain is relieved by aspirin.

A 7 year old girl presents with high fever, swelling and pain in the knee, that is worse at night and often wakes her up. Pain is relieved by aspirin. - boys, strap. aureus, localized nocturnal pain alleviated by aspirin - M/C: proximal/distal tibial metaphysis - oval radiolucency, >1cm, heavily reactive sclorosis rim, and a nidus/cloaca - BEST view CT ** VS osteoid osteoma, size <1cm, nidus central, femur neck/mid tibial diaphysis, NO FEVER —> percutaneous radiofrequency ablation under CT guidance/UC *** epiphyseal plate/growth plate: hyaline cartilage plate in the metaphysis

benign tumor in children

ABC SBC osteoid osteoma

grade 3

AC grade?

direct blow foosh

AC separation mechanism

*15 year old wakes up with low back pain

AKA Marie Stumpell. Seen most commonly in males *15-35 years old*

nuclear impression vs smorl's nodes(pencil tip)

AKA notochordal remnant, from disc and alar plate-CUPIDS BOW on xray(AP VIEW) YES STABLE ADJUSTABLE

bilateral symmetrical -up spine, around pelvic ring

AS SI jt is almost always_______And ______. It starts in SI jt and goes-> or->

HLA-b27 ESR RA ANA

AS labs

educate -adjust -brueggers excercise(respiratory adn posture) -NSAIDs

AS managment

-bamboo spine, squaring -syndesmphytes(thin, marginal) -dagger -railroad -trolley -shiny corner sign -Romanus lesion=intense Shiny corner

AS signs

osteonecrosis osteochondrosis ischemic necrosis avascular necrosis aseptic necrosis((1 side of jt), septic is both)

AVN aka

-brace, support, rest initially -heat with initial presentation

AVN management

legg calve perthes chandlers

AVN of femoral head child= adult=

*Osteochondritis dessicans*

AVN, knee locks out in extension, test is Wilson's sign

Facet tropism

Asymmetrical articular planes, most common at L5/S1 facet asymmetry (sagital and coronal )

Clay Shoveler's Fracture

Avulsion fracture of the spinous process in the lower cervical and upper thoracic region C7

RA of shoulder

BILateral symmetric GH and AC joints erosion rotator cuff rupture (supra)- axial migration of humeral head when deltoids are unopposed. ****AC separation: trauma, RA, secondary HPT

Enchondroma

Benign cartilaginous neoplasm found in intramedullary bone. Usually distal extremities.

Fracture

Boxer 2nd and 3rd bar room 5th metacarpal —most common fractured carpal bone

C4 C4

C5 nerve root =_____disc =_____IVF

jt aspiration -ra factor uric acid levels

CPPD labs

diabetes knee, wrist

CPPD usually linked with_______and a classic spot is in the ______

comminution(burst fx) -healing stages

CT is a common to evaluate ________and MRI for ______

lytic MM osteoperosis (this is Mets because the bone has been squirted out the front-extrusion)

Causes?

Dens Fracture Type 2 may also have: Spinal stenosis and myelopathy

Cervical myelopathy refers to a loss of function in the upper and lower extremities secondary to compression of the spinal cord. Cervical radiculopathy refers to a loss of function in a specific region within the upper extremity secondary to irritation and / or compression of a spinal nerve root in the neck.

*Systemic Lupus Erythematosis*

Child bearing age, woman, gets skin rashes and oral ulcers with sunlight, bilateral multiple joints stiffness and pain worsen in the morning

Jefferson fracture

Comminuted fracture of the ring of C1/ Burst fx, - odontoid view, lateral mass displacement, >6mm with ligamentous injury ** ADI <3MM; kids<5mm - MRI for pre vertebral hemorrhage. Spinal cord injure —ER for instability - Tx: hard collar immobilization or When unstable, HALO vest + internal fixation

Hemivertebra

Congenital malformation of spine in which only half of vertebral body develops scoliosis, count pedicles and ribs VS compression fx

Pedicle agenesis

Contralateral pedicle hypertrophy and sclerosis Vs PATHOLOGICAL: wicking owl

DDD-disc arthrosis->posterolisthesis DJD-facet arthrosis->anterolistehsis

DDD VS DJD

-US, CT -surgery and plantar support do to resulting short leg

DDH diagnosis and treatment

*Psoriatic Arthritis* NO pattern & NO osteoporosis VS RA Erosion, symmetrical joint space loss bulbous large unilateral non-marginal syndesmophtes --> VS AS

DIP joint involvement, pencil and cup rash w/ silvery scale on elbows and knees, pitting nails and swollen fingers

ankylosing hyperostosis -forestiers

DISH aka

endocrinologist -CT, MRI

DISH and OPLL management

bone scan (nuclear medicine test)

Detect osteoblatic response —> arthritis, bone tumor***EXCEPT FOR MM, Mets(primarily to detect the spread), bone infection, bone trauma and stress fracture, AVN " Hot spots". *** FOR METS: vertebral body + PEDICLE VS f-18 PET/CT for Mets: detect metabolic activity of tumor cells + SPECT =3D

Diffuse Idopathic Skeletal (EXOSTOSIS)Hyperostosis

Diabetic >50 white male 4 contigous segs, ossification of ALL (MID BODY TO MID BODY = non-marginal, bulbous, candle wax, ) trouble swallowing due to calcification of ALL associated with DM (2-hr postprandial, urinalysis), increased appetite, thirst, urination --> DISC, FACET FINE * OPLL only Japanese disease--canal stenosis OALL & OPLL still DISH

DIPS and PIPs seagull

Erosive OA aka kellegren

Butterfly vertebra VS hemivertebra

Failure of the center of the vertebral BODY to ossify properly (stable, no canal stenosis) LOOK AT THE VERTEBRA UP AND DOWN

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Forrestier's disease; age, > 50+, trouble swallowing due to calcification of ALL associated with DM (2-hr postprandial, urinalysis), increased appetite, thirst, urination

Bennett's fracture

Fracture at base of first metacarpal

monoarticular, globular -only place they show it is in the shoulder

HADD aka calcific tendonitis is typically__________, only place they show it is _______

*Osteopoikilosis*

Hereditary, asymptomatic disorder. Multiple small (3 to 10 mm) sclerotic bony densities. Primarily involves ends of long bones and pelvis. May mimic diffuse osteoblastic metastases. HX, PSA, prostate/ Breast, mammogram this shows us blastic mets

1) *Risser's sign*- iliac crest lateral to medial, *fuses medial to lateral* 2) *Wrist films*- best way to monitor 3) *Tanner's sign*- determining maturity by *secondary sex characteristics*

How do you *monitor scoliosis?*

Osteitis Condensans Ilii (ilium side of SIJ's stress hypertrophy)

Hx is key: assoc with mechanical stress Multiparous female ----condensation of the ILIUM side of SIJ Sacrum & SI are clear associated with childbirth, especially twins + Hyperostosis triangularis ilii pain w/walking, stiff SI jt tests No lab, self limit

japanese disease -can have DISH+japanese disease

IF ossification of PLL without DISH=

*H*odgkins lymphoma — age, ant scallop *o*steo*blastic* mets — hx *P*aget's disease — picture frame, larger

Ivory vertebra

SBO of S1 + L5 Megaspinous =

Knife clasp Syndrome canal stenosis, radiculopathy follow the sacrum base

L3 L4

L4 nerve root =_______disc =_______IVF

Canal/Body Ratio explain the process

Landmarks: four lines are drawn, *A* interpedicular distance *B* sagittal canal dimension (Eisenstein's Method) *C* transverse body dimension *D* sagittal body dimension. The ratio should be 1x2/3x4, the higher the ratio, the smaller the canal. If less than 1:6 at L3, L4, or 1:6.5 at L5 indicates canal stenosis.

Lumbosacral Disc Angle

Landmarks: lines are drawn parallel and through the inferior end plate of L5 and the superior end plate of S1. Normal is 10-15 degrees.

*Boehler's Angle* 1) landmark 2) positive calcaneal fx, /dysplastic

Landmarks: the three highest points on the superior aspect of the calcaneus are connected with two lines. If the resultant angle is less than 28 degrees this indicates calcaneal fracture or dysplastic calcaneus, the angle should be 28-40 degrees.

Diagnosed by 5 Hereditary multiple exostosis is multiple osteochondromas

Large mess, maybe painful, bursa may form pistol grip femur, MRI for neuro-vascular involvement or malignancy

Gibbus deformity

Lateral: SHARP angle in the spine that can be seen with the naked eye. --> Anterior aspect of vertebral body has either been compressed TB & Pott, infectious, trauma

achondroplasia /skeletal dysplasia Kid shorter than average, waddling gait, back pain ***pistol grip deformity HME(masses); Dwarf or achondroplasia; SCFE

Long bones stop growing in childhood--- most common form of dwarfism; Normal torso, short limbs Failure of cartilage growth in metaphysis plevis tilt-->champagne glass pelvis bullet shaped vertebra W. SPINAL STENOSIS，lamminectomy, CES, upper cervical cord compression, early OA

Brown tumor of hyperparathyroidism

Lytic bone lesion that develops with persistent hyperparathyroidism that gets its color from abundant hemorrhage and hemosiderin within the lesion

persistent spinous process apophysis

M/C @C7 also in lumbar old trauma might be related/ DJD

65 M, chronic severe back pain, kidney failure,

MM

-cold bone scan -MRI -M spike -bence joines -increased creatinine and BUN -hyperuricemia -reversed A/G

MM labs and imaging

Aneurysmal Bone Cyst (ABC)

Metaphyseal/Diaphyseal(long bone, 40/40 arm/leg). Eccentric location on bone. "blister of bone", <20... "fallen fragment sign" & thicker margin vs GCT acute, painful, rapid increase in intensity, trauma related, UBC is the same but centrally located GCT is 20-40, meta to epi to joint, expansile, bubbly, No Sclerosis, years progression

Sudden mid back pain, severe, localized, kyphosis so AGE? Spinal Compression Fx VS severe osteomylitis/discits : infection eats everything discitis & osteomyolitis. —->SPECT SCAN & ER for IV Vs osteolytic Mets and fracture: age, lung hx, cancer (PET for B/M, show metabolic pattern; CT + SPECT shows blood flow and surgical plan; Bone scan for other sites )

Most commonly of the lumbar or thoracic region. Commonly caused by "osteoporosis". — Old(osteoprosis) pain, loss of mobility, Kyphosis &loss of height(vertebral>20%), fall on the buttock/ pressure from normal activities - Midline back pain- axial and not radiating. Aching or stabbing. May be severely painful or painless. Can have a sudden onset. Pain is worse when standing, walking, bending or twisting and slightly relieved by lying down. Loss of height. Pain is intense and more localized than a herniated disc. - cortical breaking/ Impaction of trabeculae, signs of FX; Or, consider chronic —> MRI look for edema - Non- surgical: observation and bracing; bisphophonates; - Surgical vertebroplasty

Hereditary Multiple Exostosis (HME)

Multiple Osteochondromas multiple hard painless bumps near the joints, knee and shoulder usually; pain with activities; widening of femur heads

Ollier's disease

Multiple enchondromas generally presenting in childhood. Generaly asymptomatic. Ollier's + soft tissue hemangiomas= Maffucci's syndrome

spina bifida occulta

Neural tube defect/vertical cleft (not a butterfly body) characterized by a dimple or patch of hair over the vertebral defect MC C1/S1 butterfly vertebra: AP view, look at the vertebrae up and down

Lupus hands

Non erosive, reducible joint deformity due to ligament laxity , JOINT SPACE SPARED VS RA Connective tissue disease

Multiple joints TRASHER:

OA RA PsA

-joints that you beat up -wrist->MCPS->PIPS->DIPS -random

OA attacks= RA attacks= Psoriatic attacks=

decreased jt space -poor apposition=bad position -subchondral sclerosis -subchondral cysts -osteophytes -joint fragments=jt mice

OA in ext findings

RA-becasue there are no helmet heads and because its bilateral and symmetrical -notice juxtarticular osteoperosis on esp PIP joints on right pic -OA and psoriatic is random, RA is pattern based

OA or RA

RA-glob in wrist, widdled down styloid process, OA would add bone

OA or RA?

-flex ext films -MRI for cord -maybe neuro consult

OS odointeum manage

shoulder dislocation

OT: ROM (avoid combined ABD & ER w/ ant dislocation, pain mgmt, strengthen rotator cuff AC 3MM; AH 8mm

Sacralization of L5 (LSTV)

One or both TP of L5 become fused to the sacrum. batwing TP； LBP with DDD and DJD, spinal stenosis

Brim sign in the pelvis or blade of grass in the femur

Orthopedist for support and brace Oncologist for tx -pagets

reiters-cant see, cant pee cant dance with me

PA and reiters look similar in spine so you need to understand which parts each disease affects

-re-exam with film every 6 months -adjustmetns when non acute -monitor skin lesions -NSAIDs, anti-rheumatoid

PA managemnt

AS -symmetrical

PA mimics _______in the SI joints, except it will probably not be ___________

*Type V*/ Pathological Spondylolisthesis

Paget's

no no yes yes

Pain? persistent apophysis limbus bone avulsion frx clay shovelers fx

Osteoid Osteoma Nocturnal leg pain in kids: growth pain/ osteoid osteoma/ Brodie's

Painful sclerotic cortical lesion with lucent centered nidus, <1 cm, alleviated by aspirin. Occurs in patients younger than 30. Nidus is surgically removed or thermally ablated. May mimic osteomyelitis. Bone scan double-density sign versus photopenic area for osteomyelitis.

*Enteropathic Arthropathy*

Patient has sever GI pain

AC joint sprain

Piano Key Sign, Sulcus Sign, Shear Test, Compression need 2 sides / weighted X-ray

*Hyperparathyroidism* *1* Seen in females 30-50 years old, *2* over activity of the parathyroid gland causes *calcium to increase in the blood and phosphorus to decrease* *3* On radiograph see *renal calculi*, brown tumors (central geographic osteopenia in bones) *salt and pepper skull, and rugger-jersey spine* less well defined edge to sclerosis than sandwich vert from osteopetrosis, pagets= picture frame *4*Labs show *increased alkaline phosphatase*

Primary —parathyroid tumor secondary—- renal

RA -symmetrical soft tissue swelling -multi jts, if single jt=gout -juxtarticular osteoperosis=osteoperosis in bone nearest jt space bone looks cracked->rat bite erosions->uniform jt space narrowing->jt deformity->fusion

RA

ADI-widdling of dens

RA in neck MC affects

RA factor esr CRP ANA ACPA

RA labs

-can adjust if stable -deitary changes -refer if MRI if needed

RA management

osteoid osteoma

Radiolucent lesion in cortex of proximal femur/long bones. nidus + slcerosis rim, eccentric, lytic, in the cortex ***nocturnal pain/ pain worse at nigh, relieved by aspirin ** the mcc of painful scoliosis in adolescent (l>c>t>s)

males -mid 30's cant pee, cant see, cant dance with me

Reiters aka reactive arthritis

30-50 -female of child bearing age -malar rash, jt deformities in 90%

SLE Age: Gender Clinical:

ANA RA factor metabolic panel

SLE labs

internist

SLE referral

wrists, MCPs, PIPs -jt spaces

SLE targets the___________and the ______Are spared

NSAIDS corticosteroids sunscreen

SLE treatment

small muscle-vessels, GI, esophagus(raynauds, esophageal lesions, calcinosis) CREST

Scleroderma is _______calcification

Non-ossifying fibroma

Sclerotic border Eccentric in location Like the knee NOT common in kids that have not started walking (but are common in kids) Will spontaneously regress, usually asymptomatic When small <2 cm call these fibrous cortical defects/FCD (chewed gum, in cortical, eccentric ) Wastebasket term for both of these is fibroxanthoma

Nuchal Bone

Solitary or multiple calcified of nuchal liga. aka persistent spinous process apophysis

true

T/F cervical ribs are aysmptomatic

*Calcium Pyrophosphate Dihydrate Crystal Deposition Disease* 1)*1* AKA CPPD, Pseudogout. *2* Characterized by thin linear calcification parallel to the articular cortex within the joint space. *3* When it affects cartilage it is called chondrocalcinosis *4* Most commonly seen in the knee.

To confirm joint aspiration Exercise, mobilization, NSAIDs Comanagment of HPT, DM, Heart disease

metastasis-ivory vertebrae tests?

UA bone panel bone scan reproductive eval if female

HLA-B27. Association?

UCRAPE ulcertic colitis crohn +PEAR

Hangman's fracture

Unstable, serious fracture of pedicab/ posterior elements /neural arch of C2 usually with C2 anterolisthesis on C3. Caused by hyperextension and distraction (head against dashboard).

*Multiple Myeloma* and *lytic metastasis*

What *two conditions make bone dark* on x-ray?

*Fibrous dysplasia* *Paget's disease*

What *two conditions that cause bone deformities*?

Psoriatic Arthritis and Reiter's Arthritis (picture is Psoriatic) PEAR

What condition(s) cause *non-marginal syndesmophytes*? 韧带骨赘 bil marginal syndesmophytes -->E A

*Osteosarcoma, Fibrosarcoma, and Chondrosarcoma* DDx by age of patient- osteosarcoma occurs under age 30

What conditions can cause *spiculated or sunburst periosteal reaction*

*Paget's* disease *Ankylosing Spondylitis*

What two conditions cause *squaring off of vertebral bodies*?

psoriatiac(trashes all joints) and reiters -enteropathic arthropathy and AS

Which seronegative arthorpathies cause thick bulky calcifiers, which are thin calcifier

hemangioma

a benign tumor made up of newly formed blood vessels—-Vertebral hemangiomas are the most common benign vertebral neoplasm 1. classic "corduroy cloth" or "jail bar" appearance 2. Axial CT will show a "polka-dotted" or "salt and pepper" appearance due to the thickened vertebral trabeculea 3. Accentuated trabeculae since small chance of fx, 1) *referral to orthopedist* 2) *adjust to tolerance* 3) *continue ADL's as normal*

Disc Herniation with Radiculopathy cervical above; lumbar below

a herniation of the L4-5 disc compresses the L5 nerve root

giant cell, osteochondroma -lymphomas

adults benign malignant

ESR RA factor ANA HLA-b27

arthritides lab studies

-degenerative-secondary -inflammatory/conn tissue-seropositive(RA, SLE, jaccouds, scleroderma), seronegative(psoriatic, AS, reiters, enteropathic(PEAR)) -metabolic-gout, cppd, hadd, ochronosis

arthritis classifications

psoriatic sometimes RA

arthritis mutilans is describing

-aseptic-only 1 side not getting blood supply, not infection -septic-both side of joint are eroded, from infection

aseptic(AVN) vs septic(infection)

SBC-- Unicameral bone cyst/simple bone cyst -central -90% humerus and knee -diaphysis

asymptomatic; cone appearance; fallen fragment sign; serous fluid filled cyst with fibrous lining-->CENTRIC

spondylolisthesis ullman;s line used @L5; M/C @L5 Isthmic

back pain; L5 weakness. claudication, radiating pain

-category of infection -may mimic osteoid osteoma -radiolucent nidus surrounding reactive sclerosis

brodies abscess

Posterior Ponticle ---chronic neck pain, HA

calcification of the **oblique atlanto-occipital ligament aka: arcuate foramen (foramen arcuate atlantis, ponticulus posticus or posterior ponticle, or Kimerle anomaly The atlantic portion (V3) of the vertebral arteries pass through this foramen.---avoid rotation when adjustment

Progressive Systemic Sclerosis (Scleroderma)

calcifying skin& smooth muscles -->vessels &GI NOT JOINTS CREST calcinosis, raynaud's, dysphagia, sclerodactly, telangiectasia Chest films, CT, upper GI study, exercise, PT, diet

-ABC, SBC, osteoid osteoma -osteosarcoma, ewings

children tumors benign malignant

epiphyeal or bone end tumors

chondrobalstoma(under 20) giant cell tumor(over 20)

50-70(old)

chondrosarcoma age range

osteomyelitis-fever, staph, wound, DM, can be anywhere ewings-fever, children only, starts in diaphysis

chronic osteomyelitis vs ewings

left=compensated=s Curve middle=compesated=s curve right=uncompensated=C curve

compensated or uncompensated

bankhart frx torn labrum/slap lesion hill sachs deformity

complications of AI dislocation

Torus fracture

cortex buckles but does not break

surgical/acquired blocked vertebra(such as discitis)

degenerated disc & IVF *** OA doesn't fuse joint C2/C3

Legg-Calve-Perthes Disease

degeneration of femoral epiphysis due to AVN . disease is self limiting and has 4 phases: condensation, fragmentation, re-ossification and remodeling. presents with pain, decreased ROM, antalgic gait, positive Trendelenburg sign. primary treatment focus is to relieve pain and maintain femoral head in proper region

geographic

describe?

motheaten punched out rain drop

describe?

permeative

describe?

right left=BAD, send to cardiologist

dextro= levo=

NOOO -increased ADI

do we do flex/ext films on downs syndrome

spinal bifida occulta C1 LATERAL view

double shadow around SP

Fibrous cortical defect/non-ossifying fibroma

eccentric, radiolucent, geographyic __>3cm , scallop: NOF

crohns ulcerative coliits

enteropathic arthritis includes

AS -PA -inflammatory bowel

enteropathic arthritis mimics______in the spine/SI joints and less often mimics_______in appendages. Pt will have have _______flare ups

medications -stool stransplant -bowel resections -jt mobilization

enteropathic arthtis treatment

AS

enthesopathic arthropathy=

Spina Bifida Oculta

failure of vertebrae to fuse

stable=weber A unstable=weber b, Weber c=very unstable

fibular fx below talur dome= above talur dome=

OA -disc narrowing -anteiror osteophytes -retrolisthesis

findings

Salter Harris fracture

fracture through any open growth plate *type I:* horizontal through growth plate *type II:*growth plate and metaphysis *type III:* growth plate and epiphysis *type IV:* growth plate, metaphysis, and epiphysis *type V:* compression deformity of growth plate

look at ribs, if ribs are pointing all over the place know its structural, and if hemivertebrae are present left= middle right

functional or structural

adult benign

giant cell osteochondroma

sharp angle from collased vertebrae

gibbus

uricemia

gout is associated with hyper_______

-blood urate -hyperuricemia -monosodium urate crystals(aspiration)

gout labs

-anti-inflammatory -lifestyle modifications-meats, seafood, alcohol

gout management

-overhanging edge sign -tophus -soft tissue swelling, lumpy-bumpy -assymetrical side of joint -juxtarticular(outside the jt)

gout signs

PANNUS(hyperplastic synovitis)->symmetrical jt space loss -attacks hands and feet -swan neck(flexion of DIP) -boutiner deformtion(flexion of PIP) -ulnar deviation

hallmark of RA

fracture central canal stenosis

hemangioma concerns

myositis ossificans -post traumatic change to muscle -leave it alone -MC in biceps, quad

heterotopic bone formation aka

OA

his trick round joints with helmet head=

be acute pain, hemi would have scoliosis

how to differentiate hemivertebra from compression fracture

Chance fracture

hyper-flexion fracture, lumbar, 3 column(body, facet, sp) involved MRI/ ER —> unstable, intraabdominal injury like pancreas • MOI: seen in car accidents when only a lap belt is used

anomaly

hyperplasia aka

not adjust -canal stenosis

if PLL is ossified you probably should___________becuase of possible _________

colles fracture

if broken wrist and hand portion goes posterior=

RA -if unilateral=psoriatic

if there is bilateral and ulnar deviation

-mediastinal widening -ivory white Vertebrae

in a lymphoma pt they will probably also show a film of a ______or a ________

Osteomyelitis

infection has no boundary if you see it on xray: osteomyelitis & discitis

early-no radiographic findings middle-cortical disrpution, periosteal reaction, ischemic necrosis of bone late-sequestra of bone with involcrum development

infection stages*****

infection: skin bone joint

infection: cellulitis osteomyelitis septic arthritis

rheumatic fever -SLE -MCPs

jaccouds arthropathy is a post___________complication and mimics________in the hands except for it is only at the ______

low posteior hairline, decreased ROM, short webbed neck -check GU, GI and cardiopulmonary

klippel feil classic triad -need to check

kyphosis+scoliosis=dont adjust

kyphoscoliosis

S curve --> compensated C curve uncompensated rotatory ? --->look at Pedicles

larger cobb's one is major

Cobb's Method of Scoliosis Evaluation

locate the superior and inferior extremes of scoliosis draw a parallel line through the superior end plate of the extreme superior vertebra and through the inferior end plate of the extreme inferior vertebra. Intersecting perpendicular lines are drawn and the angle is measured. This is the preferred method of scoliosis evaluation

Risser-Ferguson Method of Scoliosis Evaluation

locate the superior and inferior extremes of scoliosis and apical segment. Diagonal lines are drawn to locate the center of the vertebral bodies. Two lines are drawn connecting the center of the apical segment with each end vertebra and the resultant angle is measured. A method of evaluating scoliosis, the values obtained in this method are 25% below those found using the Cobb method.

*Ankylosing Spondylitis* ***PEAR EA marginal syn AS: just calcify ligaments/enthesis E: + Crohn/UC (bowel) Reiter ： UNILATERAL +FOOT PsA VS AS look at spine (PsA irregular)

low back pain + morning stiffness, + starts in the SI joints -->pelvic rim, T12.L1, -->cervical spine, posterior joints fusion BIL symmetrical fusion of SIJ \Spine: thin bilateral marginal syndesmophytes -->bamboo spine -->shiny corners and squared verteberae(AS doesnt attack disc) **railroad sign: post facet joints fusion + dagger sign: fusion of supraspinous ligament = Trolley track Associated with iritis/uveitis. Orthos include chest expansion(Bruegge's exericse), foresters bowstring, and Lewin's supine, as well as Amoss. Have difficulty sitting from laying supine.

sacralization= L5 segment shows characteristics of sacral segment lumbarization=sacrum takes on lumbar characteristics

lumbarization vs sacralization

geographic lesion

lytic mets cant create________, MM can

Osteoblastoma

m/c seen in neural arch—TP/SP , expansile, Age 10-30 M/C cause of adolescent painful scoliosis CT for bony extent MRI for Nerve involvement, surgery maybe

lymphoma thyroid tumor

mediastinal widening -no anterior medistinum space =

gout CPPD HADD ochronosis

metabolic arthits aka crystal-induced arthritides

serum calcium alk phosph in blastic mets -chest films for lung metastasis -radionuclide(bone scan) -MRI, CT -PET scan(soft tissue cancer)

mets labs

VS: Scheuermann's Disease Juvenile disc disease/ juvenile postural syndrome

multiple level avascular necrosis" of the cartilage ring of the vertebral body/endplates may progress into: wedged shape, kyphosis, multiple schmorl's nodes noticed, Irregular endplates, loss of disc height aka osteochondritis Junvenile discogenic disease -->brace, PT/exercise, lifestyle, NSAIDs

epiphysis location tumors

multiple myeloma ewing lymphoma

Missing pedicle, >50 back pain, non responsive, multiple myeloma vs Mets look at pedicle

multiple punched out lesions "plasma cell" MM wicking owl— mets raindrop —MM

degeneratino, neuropathy(DM, alcoholism), corticosteroids -debris, distention, density, degeneration, deformity, dislocation

neurogenic jt causes: signs:

neurotrophic jt -charcots joint

neurogenic jt aka

nuclear impression takes up whole endplate, schmorls is only anteiror 1/3 of endplate

nucleur impression vs schmorls node lateral view

flexion and extension -neuro involvement

occipitlization need to take_________views to check________

phenylalanine and tyrosine=homogentistic acid -alkaptonuria=dark urine(black) -white discs, black piss

ochronosis involves

-not many benign malignant- mets, MM, osteosarcoma

old benign malignant

Mc in multiparous femalies -traingular shaped iliac based sclerosis -usually bilateral -self limiting

osteitis condensans Illii

DJD spondylosis deformans

osteoarthriits aka

Kid, bone pain, non responsive, sun burst

osteosarcoma

-knee -humerus(shoulder)

osteosarcoma common places in body

osteochondroma

pedunculated/ sessile calcific

sarcoma -osteosarcoma, chondrosarcoma, ewings sarcoma

periosteal reaction you need to think

SCFE achondroplastic dwarf hereditary multi exostosis

pistol grip deformity is caused by

atlanto-occipital ligament

posteior ponticle is calcification/ossification of the_______

*Neurofibromatosis* aka von recklinghaus disease

present with plexiform neurofibromas, optic tumors, 6 or more cafe au lait spots, skeletal abnormalities, axillary freckles

salt and pepper skull

primary hyperparathyroidism

MOCEL MM osteosarcoma chondrosarcoma ewings lymphoma

primary malignant tumors of bone

-erosions -symmetircal jt space narrowing -eventual ankylosis

psoriatiac arthritis demonstrates

dermatomal psoriasis and soemthimes arthritis

psoriatic arthritis will develop ________

-sausage digit -ray pattern -mouse ears-fluffy, disorganized -pencil and cup

psoriatic arthtis findings

-lateral displacement of proximal femur -small or absent femoral epiphysis -increased acetabular angle

puttis triad for dysplasia of hip

TIPS:

read the history could be normal choose DDX, complications, refer/management, lab

-likes lower ext -random distribution(like PA)

reiters arthritis findiings

HLA-B27 ESR RA factor STD screen UA

reiters lab

Klippel-Feil Syndrome

related w. Sprengel deformity (hypoplastic, elevated scapula). Omovertebral bone. Fused cervical vertebrae. Hemivertebrae. Kyphoscoliosis. Rib anomalies. a short neck, low hairline, and restricted neck motion --> complete PE for CP, GI, GU... FLX/EXT VIEWS; MRI

retro-VB going backward due to disc spondyl-VB going forward(anteriolisthesis) due to facet (always compare to one below, if L2 is farther back than L3, L2 has slipped backward not L3 forward)

retrolisthesis vs spondylosisthesis

inflammatory arthritis or infection

sacroilitis=

juvenile disc disease -can be in thoracic AND lumbars

schuermans aka

progressive systemic sclerosis -30-60 -female

scleroderma aka______ age: gender:

ESR RA factor ANA capillary refill time

scleroderma labs

Chest films and Ct -upper GI contrast -diet, exercise

scleroderma management

ungual tuft resporption -soft tissue atrophy -skin calcifications(globs) -calcified vessels(linear)

scleroderma xray findings

psoriatic enteropathic AS Reiters (thats a negative on PEARs)

seronegative

RA Juvenile RA SLE jaccouds scleroderma (IM positive he Sucked some RJ)

seropositive

xray flex ext films bone scan spect MRI (almost anything)

spondylo diagnosis

isthmic-young, degenerative- traumatic-traumatic incident

spondylo types

structural curve remains with bending, functioal does not

structural scoliosis vs functional

supp-MC due to staph, IV drug user->discitis->carditis(tricuspid) non supp-TB, coccidiomycosis, blastomycosis

suppurative forms vs non suppurative forms

osteochondroma

the most common benign bone tumor. The femur and the tibia are most frequently involved. exostosis, outgrowth of epiphyseal plate pain with activities, young 10-30 could have numbness, fracture, or change in blood flow

Meyerding's Grading Method of Spondyllolisthesis

the sacral base is divided into quarters and the relative position of the posterior inferior aspect of L5 is made. Determines the degree of anterolisthesis

rheumatoid arthritis

transverse ligament, FLX/EXT view; not stable, no adjustment

ewings MM

tumors in diaphisis

chondroblastoma(under 20, growth plate evident) SO SO RARE giant cell(over 20)

tumors in epiphysis or end of bone

mostly normal cella turcia

unless: visual disturbance/bitemporal hemianopsia (bilateral loss outer visual fiels)

trauma hyperparathyroidism(kidney stone) RA(always bilateral)

what causes widening of AC jt

MRI -CT is just for finding fracture

what imaging for watching clay shovelers healing

DISH -ligament calcification -normal georges -DO NOT CALL these osteophytes, cant pick syndesmophytes because those go with PEAR family, not spondylophytes becuse that DDD

what is it

rheumatoid arthitis-osteopenia downs syndrome -increased ADI upon flexion -icnreased ADI -order an MRI

what is it

*Blastic Metastasis* *1* Over *40 years old* *2* *ivory* vertebrae, no cortical thickening or bone enlargement. *Snowball* lesions *3* *prastatic carcinoma* (Left image) *4* Labs: increased *alkaline phosphatase* *5* Special test: *bone scan* which will be hot or positive.

what is it?

*Chordoma* 1) demo 2) mc location 3) 2nd mc location 4) what is it

what is it?

*Congenital Hip Dysplasia* *1* Most commonly found in babies. *2* *Putti's triad*: hypolastic femoral head, shallow acetabular shelf, femoral head outside of acetabulum. *3* Orthopedic exams include telescoping, Ortolani's, Barlow's and Allis', best is *Ortolani's*. *4* Not always bilateral involvement.

what is it?

*Degenerative Joint Disease* 1) *1* AKA Osteoarthritis; non-inflammatory *2* most commonly involves the weight bearing joints. *3* The most common location in the extremities is the hip. in the spine is C5/6 *4* The affected joint(s) usually stiffen with rest and improve with activity. *5* Complications include spinal stenosis and IVF encroachment, the most commonly affected joint in the spine is C5/6. *6* In the spine characterized by IVD narrowing, osteophytes, endplate sclerosis or eburnation. *7* In the hand characterized by Heberden's DIP nodes, decreased joint space with sclerosis, asymmetrical distribution, and non-uniform loss of space. *8* In the hip characterized by decreased superolateral joint space with sclerosis. *9* In the knee characterized by decreased medial joint space with lateral space preserved. *10* Adjusting helps, heat feels good, these patients are worse in cold weather and with lack of movement. Smaller and whiter joint space

what is it?

*Diffuse Idiopathic Skeletal Hyperostosis* *1* AKA DISH, Forestier's Disease, Anklylosing Hyperostosis. *2* Most commonly seen in *males over the age of 40* *3* present with complaint of neck stiffness or pain on swallowing. *4* There is an association with diabetes mellitus. *5* Can cause ossification of the posterior longitudinal ligament. But always ALL *6* Radiographic findings include flowing hyperostosis, candle wax drippings, anterior bridging, 3+ contiguous segments involved, with the disc space preserved. *7* Labs involved are fasting glucose (best) and glucose tolerance (most specific) both are for diabetes.

what is it?

*Enostoma* aka bone island multiple called osteopoikilosis 1) what is it 2) what does it look like

what is it?

*Ewing's Sarcoma*

what is it?

*Fibrous Dysplasia* Softens bone with rom of dense sclerosis Shepard's hook-Cox's varus with bowing

what is it?

*Gout* *1* Most commonly seen in *males over the age of 40* *2* symptoms are caused by an *overproduction of uric acid*. Joints affected are extremely painful, red, hot, and swollen, usually monoarticular with the *3* most common site at the *MTP of the big toe* (Podagra), or can affect multiple joints with no discernable distribution pattern; goes to the coldest areas first. *4* On radiographs may see *overhanging margin, juxta-articular erosions after both joints are affected, and tophi crystals* may be visible. Bone destruction occurs before joint space decreases. *5* Labs include increased *uric acid, +ESR* *6* Special test is *joint aspiration*. Pharmacology/drugs when acute Colchicine, when chronic Allopurinol. *7* Foods high in purines like red meat, red wine, beer, pork, and aged cheeses raise uric acid levels. *8* Case management: dietary changes and pure cherry juice.

what is it?

*Hodgkin's disease* Compression fx& stenosis Extremities: lytic diaphysus (mimics Ewing sarcoma, so another round cell lesion) *2* On x-ray see i*vory vertebrae with anterior body scalloping* *unilateral hilar lymphadenopathy* seen on PA chest view

what is it?

*Hydroxyapatite Deposition Disease* *1* AKA HADD *2* Most commonly affects the shoulder joint *3* characterized by round or oval calcifications near the insertion of a bursa or tendon.

what is it?

*Legg Calve Perthe's* *1* AVN of the femoral epiphysis in a child *2* most commonly found in boys *between age 4-9* *3* Radiographic signs include *fragmentation of the femoral head called crescent sign*, flattening of the femoral head, increased white density of the femoral head called snow capped appearance, increased joint space. When healed the femoral head has a mushroom capped appearance. *4* There are no labs. special test is a bone scan or MRI. *5* Requires referral to an orthopedist for an "A" brace

what is it?

*Lytic Metastasis* 1) demographic 2) clinical signs ---------------------------- *1* patient *over 40* *2* recent *unexplained weight loss and skeletal pain that is worse at night* unresponsive * Lab is *alkaline phosphatase* levels which will be elevated and hypercalcimia

what is it?

*Multiple Myeloma* Can cause *pathological collapse of the vertebra*-loss of posterior and anterior body height called *vertebra plana*- pedicles are spared.

what is it?

*Neurogenic Arthopathy* *1* AKA Charcot's Joint. *2* Secondary to impaired sensory function in joints seen with diabetes, tabes dorsalis, syphilis, syringomyelia, leprosy, alcoholic neuropathies, and corticosteroid use. *3* 6 D's characterize what is most commonly seen in weight bearing joints: distension density of subchondral sclerosis debris within joint dislocation disorganization destruction of bone.

what is it?

*Protrusio Acetabuli* ---------------------------- *1* Axial migration of femoral head with uniform loss of joint space. *2* Unilateral causes are Paget's, Osteomalacia, RA, and trauma. *3* Bilaterally most often occurs with Rheumatoid Arthritis resulting in Otto's Pelvis. Also seen in osteoporosis, osteomalacia, Paget's, trauma, and idiopathic causes. *4* The most common cause is trauma *5* second is corticosteroid use, *6* third is genetic/hereditary trait. *7* On radiograph see obliteration of Kohler's teardrop.

what is it?

*Reiter's or Reactive Arthritis* 1) *1* "can't see, can't pee, can't dance with me, can't climb a tree" *2* affects males *20-30 +/- a few years* *3* Urethritis, conjunctivitis, arthritis, caused by Chlamydia. See calcaneal spur (lover's heel), fluffy periostitis, non-marginal syndesmophytes in the spine. *4* Labs show positive *HLA B27, ESR, and positive Chlamydia* culture.

what is it?

*Scleroderma* ------ *1* AKA Progressive Systemic Sclerosis *2* commonly seen in *females 30-50 years old* *3* associated with *erosions of the distal tufts of the phalange* (also called auto-amputation or *acro-osteolysis*), associated with *CREST syndrome*- calcinosis, Raynaud's phenomenon, esophogeal dysfunction, sclerodactyly (skin harden), telangiectasias (red broken vessels visible). *4* Labs include *+FANA, +RA latex* (in 30% of cases)

what is it?

*Septic Arthritis* *1* AKA Infective arthritis, infective spondylitis, discitis, osteomyelitis, Pott's disease. *2* Patient presents with a *fever, chills, possible history of trauma/surgery and a warm, tender, red, and swollen joint*. *3* Lab: *WBC count* *4* Case management: refer to *ER for IV antibiotics*

what is it?

*Synoviochondrometaplasia* aka joint mice 1) Most common joint affected is the knee results in multiple loose bodies within the joint that are round or ovoid in shape

what is it?

*Systemic Lupus Erythematosis* *3* Can cause *ulnar deviation of the phalanges with no joint destruction* and positive rebound effect. *4* Labs include *+LE prep, +FANA, +RA latex, +ESR, leukopenia, throbocytopenia, anti-DNA* *5* Comanage with a *rheumatologist*, case management: *chiropractic care, avoid sunlight, and ADLs* to tolerance

what is it?

Maffucci Syndrome

what is it?

Olliers

what is it?

enchondroma

what is it?

-intracapsular injury from radial head fx if adult, supracondylar fx if child, notice fat pad is seen(sail sign) -mechanism=FOOSH

what is it? mechanism?

*Chondrosarcoma/Fibrosarcoma* 1) demo 2) signs

what is it? elderly, malignant, long bones look similar to enchondroma

*Fibrous Dysplasia* 3) causes deformity such as *saber shin tibia* and *shephard's crook femur*

what specific signs

*Fibrous Dysplasia* 4) ground glass appearance*, called Mccune albright sydrome if *cafe au lait spots* too, have a coast of maine appearance- dark pigmented non elevated macules with irregular borders

what specific signs

MRI

what study would you do to track stages of healing for bone fractures

PLL -ALL is also calcified but not invading space

whats invading

disc

whats invading

short pedicles -young person, low back pain, pain down legs

whats invading

-facet arthrosis

whats invading space

OA RA Psoriatic

which 3 cause multiple jt damage in hands and feet(start with this list)

Basilar impression

~ Dens protrudes above the FM ~ (+) McGregor's line ~ (+) Chamberlain's line seen in softening of the occipital bone: RA trauma, infection, tumor MRI; NO adjustment ** bone softening seen in: Paget's, osteomalacia