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235 Cards in this Set

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McCune Albright is a form of ? and is seen mostly in ?
fibrous dysplasia
females
describe fibrous dysplasia
8-14 yo
M more than female except MA
Cherubism
Coast of MAINE
asymptomatic
cherubism
familial fibrous dysplasia of jaw
radio features fibrous dysplasia
skeletal lesions not prestent at birth. Occur several years before puberty
Radiolucent
Loculated (undulated endosteal areas)
LONG LESION IN A LONG BONE
Trabeculated
Ground glass - smoky
wiped out trabeculae
Fibrous dysplasia almost never affects the ______, different from Pagets
epiphyses
appearance of fibrous dysplasia margins
thick, sclerotic margins
loculated (soap bubble)
classic matrix? = GROUND GLASS
Bony expansion
Endosteal thinning
SHEPARDS CROOK deformity
classic appearance for fibrous dysplasia?
RIND of sclerosis
SHEPARD'S CROOK
GROUND GLASS appearance
=
fibrous dysplasia
Where is the RIND of sclerosis most common in fibrous dysplasia?
femur
deformity of hip in long lesion of long bone as coxa vara is
fibrous dysplasia

*Shepard's crook deformity, ground glass appearance with expansion of bone, rind of sclerosis and loculated (soap bubble)
fibrous dysplasia d/dx
Paget's, Eosinophilic granuloma, ABC or simple bone cyst (unicameral) and osteosarcoma

(sclerosis and ground glass and soap bubble/locular and irregular cortex, respectively)
What gives fibrous dysplasia away?
EXPANSION OF BONE
types of fibrous dysplasia
mono-ostotic

poly-ostotic
McCune-Albright syndrome
females
PRECOCIOUS puberty
POLYostotic
skin pigmentation
radio presentation of MC-Albright
same as fibrous dysplasia because it is a subtype:

ground glass, loculated, sclerosed cortices, long lesion in a long bone
Synonym for Neurofibromatosis - Type !
Von Reckilinghausen's disease
What did Rocky Dennis have
polyostotic fibrous dysplasia (lionitis form)- remember FD is BONE EXPANSION.
It was the pressure on his brain that gave him all those headaches and finally killed him.
Two types of neurofibromatosis but we are talking about?
Von Recklinghausen's disease (type I)

Dysplasia: true benign, rarely malignant Chromosome 17. Irregular immature collagen and muscles or bone (NEUROECTODERMAL AND MESODERMAL tissues).

Skin and Brain features
Classic triad of neurofibromatosis type 1
Coast of CALIFORNIA (smoother cafe au lait spots)
Fibroma molluscum
Osseous deformities
NEurofibromatosis description
M -f
Cafe au lait spots (50%)
Fibroma molluscum
Elephantiasis
Focal gigantism
Spinal involvement (Kypohoscoliosis) = MOST COMMON BONY ABNORMALITY + atlantoaxial subluxation
How many cafe au lait spots make neurofibromatosis? What are the outgrowths of the skin called?
more than 3

FIBROMA MOLLUSCUM

*much thicker skin can be present as well
Classic spine of NF type 1
KYPHOscoliosis
SCALLOPING of POSTERIOR vertebral bodies, pedicles or borders of IVF and ribs
Neurofibromatosis is MOST COMMON disease that enlarges the IVF
Intrathoracic MENINGEOCELES
Twisted RIBBON ribs
Pseudoarthosis of TIBIA
Multiple NON-ossifying FIBROMAS (eccentric, soap bubble, patients over 10 years of age)
what grow all over Neurofibromatosis type 1 patients?
Multiple NON-ossifying FIBROMAS (eccentric, soap bubble, patients over 10 years of age)
Wide IVF cause?
Neurofibromatosis type 1

COMMON disease that enlarges the IVF. Can have symptoms of neurological deficits. MULTIPLE NON-OSSIFYING FIBROMAS
multiple non ossifying fibromas
eccentric soap-bubble lesions all over the body in a child under 10 = neurofibromatosis type 1
Child in office with persistent knee pain displays multiple soap bubble lesions in femur and tibia?
non ossifying fibromas of neurofibromatosis type 1. Send child out = no contact sports because trabecular pattern destroyed.
When 50% of the medullary space is involved in NF, what is the fracture risk?
50%
Brain NF?
skull changes
PLEXIFORM NEUROFIBROMATOSIS
UNIFOCAL LANGERHANS CELL HISTIOCYTOSIS
(old name is Eosinophilic Granuloma - a complete misnomer - but taught in this class anyway)
Histiocytosis X (old name)

Part of specturm of Langerhan's cell histiocytosis - the UNIFOCAL part

Abnormal proliferation of histiocytes (also an outdated term - means activated DENDRITES & MACROPHAGES)
Disorder of immune regulation
http://en.wikipedia.org/wiki/Langerhans_cell_histiocytosis
It is a monostotic or polystotic disease with no extraskeletal involvement. This differentiates _____________________ from other forms of Langerhans Cell Histiocytosis. The most-frequently seen symptom in both unifocal and multifocal disease is painful ________swelling. The _____is most frequently affected, followed by...
Unifocal LCH, also called eosinophilic granuloma (an older term which is now known to be a misnomer), is a slowly-progressing disease characterized by an expanding proliferation of Langerhans cells in various bones. It is a monostotic or polystotic disease with no extraskeletal involvement. This differentiates eosinophilic granuloma from other forms of Langerhans Cell Histiocytosis (Letterer-Siwe or Hand-Schüller-Christian variant.
Bone: The most-frequently seen symptom in both unifocal and multifocal disease is painful bone swelling. The skull is most frequently affected, followed by the long bones of the upper extremities and flat bones. Infiltration in hands and feet is unusual. Osteolytic lesions can lead to pathological fractures.
types of Langerhans cells histiocytosis?
Letterer-Siwe or Hand-Schüller-Christian or Eosinophilic Granuloma/Unifocal LCH/Histiocytosis X
etiology of EG
macrophages chew up body and then stop - sometimes the organ can grow back to normal function if happens young in life
EG represents ___% of all Langerhan's histocytosis?
70
Radiographic appearance of EG
RADIOLUCENT
round oval
sharp borders
LAMINATED spiculated

**EXPANSILE bone lesions** key characteristic

Path frx
Moth eaten, permeative
Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X
Beveled uneven edge/hole within a hole appearance - big holes in the skulls of children that look like bleeding gunshot wounds from the skin. See wikipedia.

Sequestrum - button sequestrum
mandible
of
Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X
floating teeth appearance
Vertebral

Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X
vertebra plana
COIN ON EDGE******* vertebra
silver vertebra
BENIGN lesions that can look aggressive *********
Benign but looks aggressive:
looks like osteosarcoma, Ewing's or acute osteomyelitis BUT consider ESO GRAN, GIANT CELL or ANEURSYMAL BONE CYST, or OSTEOBLASTOMA as benign

Benign lesions that can look aggressive on an xray in young individuals
Irregular bony destruction wi/ destroyed cortex, medullary space when macrophages chewing them up?
Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X:

VERTEBRA PLANA or COIN ON EDGE/END appearance d/t chewing macrophages is CLASSIC board question radiologic appearance
If EG occurs in very young, patients can regrow easily up to ___% of vertebral body height
75

When immune sys deficiency stops (crazy ass macrophages) BUT patient can die if all over body. PAINFUL
battle cry**
Mets! Myeloma! Lymphoma! A

Ewings, Acute osteomyelitis! C
Tumors reside or starting in epiphysis** C.A.G.E. epiphysis
Chondroblastoma (epiphysis or apophysis) -In children, it is the most common epiphyseal tumor. a CODMAN's tumor.

ABC

Giant Cell tumor

Enchondroma - An Enchondroma is a cartilage cyst found in the bone marrow. The bones most often involved with this benign tumor are the miniature long bones of the hands and feet. It may, however, also involve other bones such as the femur, humerus, or tibia. While it may affect an individual at any age, it is most common between the ages of 10 to 20 years. Ollier's dz (many) and Mafucci's (many plus angiomas) two types of enchondroma states.
Musculoskeletal infection:
ACUTE suppurative (pyogenic) osteomyelitis
BRODIES abcess
SEPTIC arth
CHRONIC osteomyelitis
DIABETIC osteomyelitis and SEPTIC arthritis
NON suppurative osteomyelitis (TB and syphilis)
Acute Suppurative Osteomyelitis predisposed population?
ASO pop predisposed:
immunocompromised, alcoholic, newborn, IV drug abuser, diabetics, hemodialysis, post surgical (7-10% hospital acquired infections), hemodialysis, severe anemia (sickle cells)
ASO organisms:
STAPH aureus 90%
E. coli
H. Influenzae
Klebsiella (lung fields - invasive)
STREP B
osteomyelitis
INfection of MEDULLARY SPACE:
Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone, myelo- meaning marrow, and -itis meaning inflammation) simply means an infection of the bone or bone marrow.[1] It can be usefully subclassified on the basis of the causative organism (pyogenic bacteria or mycobacteria), the route, duration and anatomic location of the infection.
osteitis?
Infection of CORTEX/CORTICAL BONE
Disc-itis
infection of the disc
ASO pathways of SPREAD

Tubercular osteomyelitis of the spine was so common before the initiation of effective antitubercular therapy, it acquired a special name, Pott's disease.
1. HEMATOGENOUS = MOST COMMON
2. Contiguous
3. Direct implantation
4. Postoperative
ASO clinical features
Progressive PAIN in doubling intensity in less than one week in most patients. Pt starts to take large doses of painkillers.
CELLULITIS (redness ar extremity, swelling)
M : F ratio 2:1
Ages 2-12 year (MOST COMMON).
In children, the long bones are usually affected. In adults, the vertebrae and the pelvis are most commonly affected.
ASO
Bloodstream-sourced osteomyelitis is seen most frequently in children, and nearly 90% of cases are caused by Staphylococcus aureus
Acute Suppurative Osteomyelitis
Acute osteomyelitis almost invariably occurs in children. When adults are affected, it may be because of compromised host resistance due to debilitation, intravenous drug abuse, infectious root-canaled teeth, or other disease or drugs (e.g., immunosuppressive therapy).
ASO
Progressive PAIN in doubling intensity in less than one week in most patients. Pt starts to take large doses of painkillers. CELLULITIS (redness ar extremity, swelling)

ulcer
radiograph ASO

(remember this thing doubles in pain in one week)
Early: soft tissue swelling
bone destruction
Periosteal rx
Diagnosis of osteomyelitis is often based on radiologic results showing a lytic center with a ring of sclerosis.[wiki]
***Latent period for onset of radiographic findings: Extremities: 7-10 days, SPINE: 21 days (3 wks)
ASO finding almost always early sign
soft tissue swelling on xray

cortical bone destruction

sometimes periosteal rx

bone marrow edema
ASO later signs ***boards In Secret Closed Sessions...

Diagnosis of osteomyelitis is often based on radiologic results showing a lytic center with a ring of sclerosis.[wiki]
IN-VOLUCRUM formation - envelope of new periosteal bone surrounding infection

SE-QUESTRUM formation - portion of infection necroses so body creates area of central calcification

CL-OACA formation - Opening from diseased bone to soft tissues

S-INUS tract= opening from soft tissue to HOLLOW viscerals (GI tract, eg.) or OUTSIDE skin/surface
ASO xray finding

Diagnosis of osteomyelitis is often based on radiologic results showing a lytic center with a ring of sclerosis
painful hip: proximal diaphysis focal, small area of radiolucency in medullary space. Keep looking! Even if xray normal, go to MRI or CT.
Faint lucency of medullary space
ASO involucrum appearance
CHILDREN!!! most common = involucrum

massive periosteal bone formation surrounding infected site

prominent uptake on bone scan (technetium 99 or gallium scan for WBC proliferation)
ASO sequestrum
NECROTIC = sequestrum

anterior metaphysis of femur necrotic foci
cortex or medullary space
ASO proximal humerus description
MOTH EATEN - permeative, purely lytic = acute osteomyelitis bone infection with S. aureus (usually)

permeative pattern of bone destruction involving proximial metaphysis and diaphysis wi/ cortical destruction or violation. Suggestion of sclerosis although purely lytic. Aggressive.

Could be Ewings, osteosarc or Hodgkin's lymphoma
ACUTE osteomyelitis is typically _______. (sclerotic or lytic?)
LYTIC (destroys)

vs chronic that starts to sclerose
Hematogenous spread of infection at lumbar spreads to bone via
Batson's venous plexus
Suppurative spinal osteomyelitis

*affects the _____ in children and the _____ of vertebral body in adults
aka infectious spondylodiscitis


children = DISC
adult = CORNER of vertebral body
3 wk radio latent period
STAPH
WEird looking schmorl's node losing endplate collapsing disc and destroying ligaments is
suppurative spinal osteodiscitis
SSO features radio
postop spines
see notes for other 5
ACUTE Suppurative spinal osteomyelitis radiograph
narrowing of L3-L4 disc space
Integrity of endplates? losing cortex - cortical bone should ALWAYS be visible, even through gas bubble. Here, it is not.
Both endplates destroyed - infection of disc
Entire vertebral bodies often bright
approx 6 weeks.
CHRONIC suppurative osteomyelitis
destructive
soft tissue involvement all over
low signal on bone segments
Chronic SOM destroys adjacent levels so we know it is not multiple myeloma. Why?
INFECTION crosses tissues - STAPH aureus!!!

Narrowed disc space
High signal intensity
Endplates gone - lose the corner of the vertebral body, then it's an INFECTION
Lots of bright spots
Abcess
SOM treatment and prognosis {race against destruction}
Refer OUT - need antibiotics w/ culture to determine infectious pathogen

Brace (spine)
Surgical debridement late
Prognosis GOOD if diagnosed EARLY
Abcesses requiring surgery?
Abcesses that are still active an not healing need to be DRAINED if > 2-3 cm.

Why don't they go away with antibiotics? No blood supply?
Where a joint has reduced ROM ie due to bracing, in one month will display histological changes such as
fusion - osteoblasts are present
Brodie's abcess
*suppurative infection of bone w/ a NIDUS greater than 2cm - lots of SCLEROSIS

A Brodie abscess is a SUBACUTE OSTEOMYELITIS, which may persist for years before converting to a frank osteomyelitis. Classically, this may present after conversion as a draining abscess extending from the tibia out through the shin.

Most frequent causative organism is Staphylococcus aureus.
Most common loc for Brodie's abcess
tibia
radius

Most Frequent Sites [wiki]
Usually occurs at the metaphysis of long bones. Distal tibia, proximal tibia, distal femur, proximal or distal fibula, and distal radius.
Brodies' population
Males w/ Staph aureus

Localized pain, often nocturnal, alleviated by aspirin. Often mimics the symptoms of Osteoid osteoma, which is typically < 1 cm diameter.
Osteoid osteoma size
less than 1 cm
Brodie's abcess size
bigger than 2 cm
radiolucent center NIDUS
d/dx Brodies and osteoid osteoma
DIAPHYSIS and CORTICAL w/ solid periosteal bone rx, < 1cm= OO

METAPHYSIS and INTERMEDULLARY Tibia or Distal radius, > 2cm = BRODIES

BOTH = Localized pain, often nocturnal, alleviated by aspirin.
Brodies can have irregular margins w/ intracapsular and not much sclerosis. When lots of sclerosis?
Extracapsular w/ regular margins
Osteomyelitis CAN cross the growth plate but is usually the __________ factor for it.
limiting
Focal area of progression or extension into the epiphysis w/ cystic lesion w/ small amt of edema in surrounding marrow. Distal femur. Abnormal signal of epiphysis.
BRODIE's ABCESS of Tibia

Faint sclerotic lesion
Epiphyseal (ENDS of long bones)
Cannot d/dx from OO unless > 2cm
DIstal radius
ABCESS AT END
DIstal radius
minimal sclerosis
BRODIEs abcess of distal radius
Cannot d/dx from OO unless >2cm
Brodie's is Bigger
SEPTIC arthritis description verbal
infections progress FAST - pus inside joint but minimal radiographic changes.
PAINFUL
Big joint SINGLE joint involvement
SEPTIC arthritis notes description
SINGLE joint involvement

HEMATOGENOUS or DIRECT IMPLANTATION

*****MONOARTICULAR***** (single/unilateral presentation)

STAPH AUREUS (Most common)
Could resemble rheumatoid arth but septic is ________ in presentation
unilateral

*rheum is multiple bilateral while septic is monarthrotic/unilateral
Clinical Features septic arthritis

The usual etiology of septic arthritis is bacterial, but viral, mycobacterial, and fungal[3] arthritis occur occasionally. A broader term is "infectious arthritis", which describes arthritis caused by any infectious organism.[4] Viruses can cause arthritis,[5] but it can be hard to determine if the arthritis is directly due to the virus or if the arthritis is reactive.[6]

Septic/suppurative arthritis and "bacterial arthritis" are sometimes considered equivalent, but there are exceptions. For example, Borrelia burgdorferi can cause infectious arthritis, but is not associated with suppurative arthritis.[wiki]
Septic arthritis should be considered whenever one is assessing a patient with rapid onset of joint pain. Usually only one joint is affected (monoarthritis) however in seeding arthritis, several joints can be affected simultaneously; this is especially the case when the infection is caused by staphylococcus or gonococcus bacteria. Pain can be significant with any movement, therefore, patient will refuse to use extremity and prefers to hold joint rigidly. May have associated swelling, redness & warmth, often absent for deep joints such as hips & shoulders
Imaging of septic arth
KNEE and HIP (mc)

HAND - human bite fights/punches
Prominent JOINT EFFUSION distorts FAT FOLDS
Rapid LOSS of joint space unless non-suppurative, ie TB
LOSS of subchondral white line
MOTHEATEN
Late appearance: bone ANKYLOSIS
MONOARTICULAR
First radiographic finding of septic arth?
***JOINT EFFUSION****
loss of fat planes

X-rays - may not be helpful early, but may show subtle increase in joint space tissue swelling.wiki
If septic is suppurative, what happens to joint space?
****RAPID LOSS OF JOINT SPACE*****

vs. non-suppurative which preserve joint space until late into dz (d/dx) ex. TB or fungal infections and spirochete (syphillis)
Suppurative infections like staph
erode joint surface and cartilage and collapse the joint every time

ie, septic arthritis from dirty needle
Septic loss of _____________ white line
SUBCHONDRAL

(septic arthritis and brodies abcess both caused by staph aureus)
(septic arthritis and brodies abcess both caused by __________)
staph aureus
Septic arthritis in HIP = capsular tissue attaches to intertrochanteric ridge so osteomyelitis of femoral neck invades/destroys cortex causing
septic arthritis, because of large capsule
Pattern of septic radiograph
MOTH-eaten

PERMEATIVE
Late presentation septic arthritis does eventually ______ the joint.
FUSE

(bony ankylosis)
Radiolucency on septic arthritis hip

*think FAT PLANES
GLUTEUS MEDIUS FAT PLANE on LATERAL side of femoral neck ******

ILIOPSOAS FAT PLANE on MEDIAL side of femoral neck*****

Inside of pelvic bowl OBTURATOR internus FAT PLANE******
CLASSIC sign of infection of radiograph
NO FAT PLANE

(tumors displace but infections OBLITERATE FAT PLANES, ie septic arthritis)
Radio hip R hip single view septic arthritis shows no _______ of the acetabulum. It has been destroyed.
no cortex due to infection
Radio lumbopelvic showing Posterior Superior dislocation of hip
Septic arthritis: loss of fat planes and normal cortex of acetabulum. Changes in soft tissue w/ lots of swelling.

not RA because unilateral but infection is most likely dx
Septic not only affects hips but ______, ie animal bites, human bites or redundant work or fist fights
HANDS

breaking hand skin on another person's mouth can commonly affect carpal joints of hands via SEPTIC ARTHRITIS
Osteopenia
Hyperemia
Joint destruction
Late stage ankylosis like inflammatory arthritides
SEPTIC arthritis
Periarticular osteopenia
Radio of lateral ankle
Fusion of calcaneus and talus, no joints left w/ cuboids, navicular, etc.
IV drug users w/ septic arthritis?
PSEUDOMONAS infection of ****S**** joints:
spine
sternoclavicular j
sacroiliac j
symphysis pubis j
Say acromioclavicular (AC) j ;-)
Cause of septic arthritis?
STAPH & PSEUDOMONAS

*don't forget pseudomonas of dirty needles for septic infection
Septic arthritis intravenous drug abusers cervical spine
RETROTRACHEAL space too wide at C5-C6

Cortex of inferior endplate 5 and superior 6 showing reduced Interdiscal space. Any neurologica sx= go to MRI
Chronic osteomyelitis general considerations
UNRESOLVED osteomyelitis
SCLEROSIS (healing)
CORTICAL thickening
PERIOSTEAL NEW bone formation (chronic)
OSSEOUS DESTRUCTION
SEQUESTRUM
MALIGNANT DEGENERATION = fibrosarcoma, squamous cell carcinoma (Marjoilin's ulcer)
Chronic osteomyelitis MALIGNANT DEGENERATION in adults (kids have acute osteomyelits) can morph into:
1. FIBROSARCOMA

2. SQUAMOUS CELL CARCINOMA >> Marjolin's Ulcer [occur at site of skin ulcer more often/ abnormal dysplastic cells]
commonly dev. from ULCER (eruptive volcano CLOACA)
MARJOLIN'S ULCER into SQUAMOUS CELL CARCINOMA

assoc. with CHRONIC OSTEOMYELITIS
anterior forearm radio chronic osteomyelitis
LOTS OF NEW BONE W/ AN ULCER
SCEROSIS

In young patient, wi/o ulcer, would be acute osteomyelitis
DIABETES type II ulcers
DIABETIC OSTEOMYELITIS
Uncontrolled diabetes
Pressure sores but cannot feel d/t peripheral neuropathy

5th or 1st metatarsal phalangeal joints (MOST COMMON) or heel and both malleoli
Worst case scenario of diabetes osteomyelitis?
GAS GANGRENE

Subcutaneous, emphysema - air production. Mottled soft tissues; d/t puncture, pneumothorax, bugs like costridium difficile b/c produces GAS ergo gas gangrene)
TUBERCULOSIS can cause ______________ osteomyelitis.
NON-SUPPURATIVE
midfoot joint for diabetic neuropathy

surgery dev by Napoleon's battle surgeon
Lisfranc
tarsometatarsal (mid foot) joints

Dr. Frank worked for Napolean. Found way to amputate feet in less than one minute on battlefield. Cut entire tarsometatarsal joint then sew up skin immediately. Soldiers fared ok.
Variation of Lisfranc joint = CHOPART joint (injury)

http://www.learningradiology.com/archives06/COW%20217-Lisfranc%20fx/caseoftheweek217page.htm
Chopart joint

Chopart fracture-dislocation involves the midtarsal joints (talonavicular and calcaneocuboid joints)
Typically caused by falls from a height, motor vehicle accidents and severe twisting injuries such as can occur in basketball players who land on a plantar-flexed and inverted foot
Usually result from severe trauma
Most commonly, there is medial displacement of the distal fragments (80%)
The foot is displaced inward and upward
But displacement in other directions can occur
Gangrene (gas) looks like pesto. What disorder?
Diabetic osteomyelitis
TB description
enjoying comeback! Yay!

Immunocompromised
Nearly all US TB infections caused by inhalation of MYCOBACTERIUM tuberculosis
Primary stage TB
infects LUNGS
leads to GRANULOMATOUS rx
May stay silent for patient's lifetime
Secondary TB
POST primary stage
REACTIVATION of organism (mycobacterium tb)
Spreads to other organs and bone via HEMATOGENOUS (ie, POTTS dz)
General considerations of TB:
Most common ages of skeletal TB?
2-30 years of age
Rare in first year of life
Males over females
Sx of TB
Insidious onset of PAIN
Decreased ROM
FOCAL TENDERNESS
Large air filled cavities of TB lung fields
No bronchial margins
TB loves AIR
radiograph and MRI of TB lung fields
SECONDARY (post primary stage)
TB loves the __________ spine
THORACOLUMBAR = POTT'S dz
describe POTTS
50% spine
-TUberculosis spondtlitis - Pott's

30% hips
20% others
spinal involvement most common POTTs segment
L1

due to slow flowing blood
Pott's paraplegia = epidural involvement and compression of conus medullaris or cord itself
Imaging find of POTTS
Radiographically LATENT period! Characteristic of TB.

Starts at DISC OR DISCOVERTEBRAL JUNCTION, then spreads along ALL or PLL to involve adjacent segments (T12, 10 etc.) = SUBLIGAMENTOUS SPREAD

PRESERVES DISC SPACE UNTIL LATE into dz (unlike staph quick erosion)

ANTERIOR VERTEBRAL BODY

PSOAS and PARASPINAL MUSCULATURE
Late POTTS
pathological COMPRESSION FX

GIBBOUS DEFORMITY

PARAPLEGIA
Joint involvement elsewhere in TB is called _________ TRIAD
PHEMISTER'S TRIAD:
*************progressive, slow joint space narrowing *************
Juxta-articular osteoporosis
Peripheral erosions of articular surfaces
Prone to large suchondral cysts
PHEMISTER's
TB of other joints besides spine (which is Pott's)
Lateral cervical TB radiograph
anterior body of C2

retropharyngeal space is greater than 7cm
Lateral thoracic TB radiograph
tubercular spondylitis
DISC SPACES are RELATIVELY INTACT whereas w. staph would be intact + MULTIPLE SEGMENT involvement via spread along All or Pll.

GIBBOUS deformity

SUbchondral cysts and it's an Aunt Minne
AP thoracic TB view
what's wrong with soft tissues?
OUTWARD bulging of PARASPINAL STRIPE

Descending portion of thoracic aorta is not close to spine.
Abcess, infection spread along soft tissues in POSTERIOR MEDIASTINUM

MRI vs. plain film: NO SPINOUS PROCESSES [posterior elements] of L2. Hard call on the x-rays
SPINA VENTOSA
tuberculosis dactylitis
POTTS PUFFY TUMOR
TB of the skull (frontal bone) w/ scalp abcess
WEAVER'S BOTTOM
subgluteal infective bursitis with direct extension to ischium due to TB
hand AP for TB (tuberculous dactylitis) is also called?
Which digit?
Local or spread?
spina ventosa

first phalange of 3rd digit expansion

Localized
lateral skull for TB
Potts PUFFY TUMOR
R hip for TB
WEaver's bottom w/ ischial tuberosity and infective bursitis

Sclerosis
Lack of cortical density
Sclerosis means CHRONIC whereas acute is purely lytic
SYPHILLIS general consideration
Transmitted across PLACENTA

WIDESPREAD SYSTEMIC INF:
Hepatosplenomegaly, Jaundice, Rhinitis, Osseous lesions, Skin lesions, Adrenopathy, Hematological disturbances
TORCH mnemonic
Perinatal dxz that cross placenta from mother to child:

T – Toxoplasmosis / Toxoplasma gondii
O – Other infections (see below)
R – Rubella
C – Cytomegalovirus
H – Herpes simplex virus-2
ACQUIRED syphillis
SKELETAL involvement w/ tertiary syphillis infection

<10% w/ syphillis

PERIOSTITIS (solid or laminated)
SKULL (frontal bone)
CLAVICLE
TIBIA
CONGENITAL syphilis:

______ shaped teeth/ _______ teeth
________'s joints
PEG SHAPED/HUTCHINSON'S TEETH

CLUTTON'S JOINTS (bilateral knee swelling from congenital syphillis infection)
3 phases of syphillis bone
Metaphysitis
Periostitis
Osteitis = SABER SHIN deformity
WIMBERGER'S sign

makes a kid whimper when he walks
METAPHYSEAL-itis (inflammation) of syphillis

errosive defects of *MEDIAL* TIBIA
SABER SHIN deformity
OSTEITIS of syphillis
lab quiz on normal and normal variants of spine and extremities - next week includes tumors
quiz tmrw
Vascular imaging MRI - what's wrong w/ this?
GEOGRAPHIC PATTERNS OF BONE INFARCTS!

SERPIGINOUS (SERPENTLIKE) UNDULATING MARGINS

ISLANDS ON A MAP
Most common malignant disease of childhood
Leukemia

*bone marrow and blood disease of PROLIFERATING WHITE CELLS
Halmarks of Leukemia on radiograph
Osteopenia
RADIOLUCENT METAPHYSEAL BANDS @ growth plates
Osteonecrosis at EPIPHYSIS
Avascular necrosis (AVN)
Osteonecrosis @ METAPHYSIS/DIAPHYSIS
Bone infarct

*at the epiphysis, it's an AVN. At the metaphysis, it's a bone infarct
Origin of Osteonecrosis
Reduction/obliteration of blood supply to bone = most commonly from outside compressing artery

*leads to death of osseous structures via blockage/thrombus/emboli/vasculitis
PLASTIC RAGS
mnemonic for AVN reasons:

P : pancreatitis
L : lupus
A : alcohol
S : steroids
T : trauma
I : idiopathic, infection
C : caisson disease, collagen vascular disease

R : radiation, rheumatoid arthritis
A : amyloid
G : Gaucher disease
S ; sickle cell disease
Neimann-Pick disease

*an accumulation of ________ all over the body
sphengomyelin
PLASTIC RAGS is mnemonic for _____
AVascular Necrosis

P : pancreatitis
L : lupus
A : alcohol
S : steroids
T : trauma
I : idiopathic, infection
C : caisson disease, collagen vascular disease

R : radiation, rheumatoid arthritis
A : amyloid
G : Gaucher disease
S ; sickle cell disease
Can be non-specific, depending on location and etiology. Latent period of weeks to years
AVN - PLASTIC RAGS

P : pancreatitis
L : lupus
A : alcohol
S : steroids
T : trauma
I : idiopathic, infection
C : caisson disease, collagen vascular disease

R : radiation, rheumatoid arthritis
A : amyloid
G : Gaucher disease
S ; sickle cell disease
Unilateral assoc. disorders of AVN
Surgery
Spontaneous
Trauma
Infection
Gout
AVN bilateral assoc. disorders
Alcoholism
Corticosteroids (RA, SLE)
Spontaneous
Aterioscleroisis
Caisson
Cushings dz
Hemoglobinopathy
Hemophilia
sx of AVN
PAIN
Antalgia
Painful ROM
Muscle atrophy
1st phase AVN
AVASCULAR phase I:

1. WALDEN-STROOM sign - increase in medial aspect of joint space >11 mm or measures more than
2. SIGN OF JOINT EFFUSION IN HIP. Femoroacectabular space bigger than 11mm or 2mm bigger than other side, along w/ fat planes disappearing (3) displacement of hip
3. Capsular swelling
2nd phase AVN
Subchondral cysts
Sclerosis (BITE SIGN, SNOW CAP SIGN)
Subchondral fracture (CRESCENT SIGN)
Collapse/flattening of articular surface (no longer smooth and round!)
Fragmentation
3rd phase AVN
Repair and remodeling
Crescent sign
A radiolucent band paralleling subchondral bone that IS a true fracture.
OCD
Spontaneous osteonecrosis of the knee (pretty much)

Osteochondritis Dessicans
SONK

older or younger
body part
medial or lateral
equivalent in the other population
OLDER patient
Subarticular Osteonecrosis of the KNee (instead of OCD) MEDIAL weight bearing surface
OCD

Patient age?
Which side of femoral condyle affected?
YOUNGER patient
Change in LATERAL aspect of MEDIAL femoral condyle
Pain from OCD
Edema!!

osteochondral loose bodies like Panner's disease of capitulum (AVN - osteonecosis of capitulum w/ OCD of radial head = what you have!)
Bone Infarct
looks like a starburst cloud in the middle of along bone

enchondroma or low grade sarcoma d/dx. Need bone scan. Cartilage on MRI won't be bright except at periphery.

"SERPIGINOUS AREA OF CALCIFICATION IN CENTRAL PORTION OF RED MARROW"
"SERPIGINOUS AREA OF CALCIFICATION IN CENTRAL PORTION OF RED MARROW"
BONE INFARCT

*can be GEOGRAPHIC PATTERN, too
GEOGRAPHIC PATTERN and ______ are classic for bone infarct
SERPIGINOUS
Where is BONE INFARCT
METAPHYSEAL/DIAPHYSEAL
D/DX BONE INFARCT
Low grade CHONDROSARCOMA (esp if over 40), ENCHONDROMA
***RADIOLOGICAL features of AVN
FRAGMENTATION
SCLEROSIS
ARTICULAR COLLAPSE
Osteochondroses
A group of EPIEPHYSEAL/APOPHYSEAL conditions characterized by:
FRAGMENTATION
SCLEROSIS
IRREGULAR ARTICULAR SURFACES

*just like AVN
Osteochondroses:

Some are real ___________
Some are ___________ deformities
Some are __________ variations
AVN
POST-TRAUMATIC
DEVELOPMENTAL
LEG-CALVE-PERTHES disease
AVN of FEMORAL CAPITAL EPIPHYSIS
aka: coxa plana

Flattened femoral head
Mushroom appearance
AFFECTS CHILDREN
changes shape and morphology of femoral head forever
Legg -Calve -Perthe's dz

Children
Flattening of epiphysis
**Waldenstroom sign
Painful limp
Trendelenburg sign
**Flat femoral head w/ crescent sign
CARTILAGE NOT AFFECTED
Flattened and sclerotic femoral head
Legg Calve Perthe's

can be bilateral or unilateral
Sharp angulation = coxa VERA deformity of femoral neck
Femoral head overgrows, creating MUSHROOM deformity
Early imaging finding of LCF=P
ST swelling
WIDE medial joint space (WALDENSTROOM SIGN)
SMALL femoral head
EPIPHYSEAL FRAGMENTATION
SCLEROSIS
CRESCENT SIGN
if someone has hip pain, first view
AP pelvis
Late Imaging of LCP
MUSHROOM DEFORMITY (femoral head continues to grow)
Subchondral cysts
WIDE, SHORT FEMORAL NECK
Coxa vara, coxa magna, coxa plana
SAGGING ROPE SIGN (overgrowth of femoral head leads to sclerotic line along intertrochanteric line)
ENLARGED GREATER TROCHANTER
FLATTENED FEMORAL HEAD
Degenerative changes = osteoarthritis
Sagging rope sign
Leg Calve Perthe late imaging finding

*w/ mushroom deformity
FREIBERG'S FUNKY FOOT
True AVN of head of 2nd metatarsal (sometimes 3rd)

RESULT OF HIGH HEELED SHOES IN TEENS (skeletally immature)
Freiberg's
Flattening
Fragmentation
Sclerosis
KIENBOCK'S DISEASE
True AVN of LUNATE

LUNATOMALACIA**
Excessive stress on lunate carpal of wrist especially in pts w/ NEGATIVE ULNAR VARIANCE
NEGATIVE ULNAR VARIANCE
Kienbock's disease = LUNATE sclerosis and becomes TRIANGULAR SHAPE

No normal roundness of inferior surface
Post-traumatic apophysitits
Osgood-Schlatter's
Panner's
OSGOOD SCHLATTERS
HYPEREXTENSION ACTIVITIES (soccer, running, kicking)
that causes SWELLING and FRAGMENTATION of tibial apophysis
Normal to have a fragmented tibial apophysis but abnormal to have?
Swelling

Swelling!! = Osgood Schlatters
Fragmented only = Tendinosis of patellar ligament
SCHEUERMANN'S DZ

Juvenile kyphosis
Vertebral epiphysitis
JUVENILE KHYPOSIS
Postraumatic entity:
MANY SCHMORL'S NODES
IRREGULAR ENDPLATES
ANTERIOR WEDGING OF VERTEBRAL BODIES by 5degrees at 3-4 contiguous levels\
INCREASED KYPHOSIS
Vertebral endplates of thoracic spine are often irregular so don't immediately label Scheuermann's dz.
Overcalling SD on everyone w/ irregular endplates is wrong.
Need anterior wedging and Schmorl's nodes
SINDING-LARSEN JOHANSEN

Scarlett Johansen fell on her knees
It's distal patellar apophysitis I sees!
SAME as Osgood Schlatters but on other side of patella

DISTAL PATELLAR APHOPHYSISTIS
KUMMEL'S DISEASE

Kummel's Vacuum!
true AVN of VERTEBRAL BODY itself

SCLEROSIS
COLLAPSE OF VERTEBRAL BODY
***INTRABODY VACUUM PHENOMENON inside vertebral body
Intrabody vacuum phenomenon
KUMMEL'S

due to TRAUMA
develop AVN of vertebral body during healing
"I heard a snap in my spine!"
KUMMEL'S DISEASE

Vacuums in a snap!
VAN NECK's disease
Normal irregular growth at the ischiopubic synchondrosis

I f you spend too much time necking, you may get a growth just above your pubic bones
tell tale sign of Kummel's dz
VACUUM inside the vertebral body

(vacuum phenomenon)
ISCHIOPUBIC SYNCHONDROSIS
VAN NECK's disease - you get it if you neck too much

*completely asymptomatic
NORMAL variant
BLOUNT'S BABY DISEASE

Blount's bowing baby
true AVN of MEDIAL EPIPHYSIS of of TIBIA

Infantile tibia vara
BOWING (bi or unilateral)
Length discrepancy of lower limbs
CHANDLER'S DZ
AVN of the HIP IN ADULTS

same as Leg Calve Perthes in children
SPONTANEOUS
Most common location of AVN
FEMORAL HEAD
Signs of AVN
Sclerosis
Collapse/flattening of articular surface
Fragmentation
Epiphysis/apophysis osteochondrosis
AVN of Hip in adults
CHANDLER's

All AVN's of hip have a special named sign: DOUBLE LINE SIGN on MRI
***************************************
High signal intensity on T2 w/ low signal right next to it
AVN of talus

a Dias on a Dome
DIAZ's TALAR DOME AVN

Multiple fragmentation
DIAZ's disease
AVN of TALUS
HAAS' Easter eggs are Humorous
HAAS' HUMERAL HEAD AVN

Superior migration of humeral head w/ fragmentation and sclerosis (normal humeral-acromial distance is 7-11 but if decreased, usually rotator cuff tear). First 10 deg. of abduction is supraspinatus, then deltoid 80 deg.. If supraspinatus torn, deltoid unopposed and results in superior traction and reduction in acromial distance.
KOHLER'S DISEASE

Navigate through a Kohl's store
NAVICULAR of foot Avascular Necrosis
PRIESER'S DZ
Proximal pole of SCAPHOID of wrist Avascular Necrosis

*usually the waist of scaphoid is fx; proximal pole is what makes this different
*Young adult, FOOSH
*Cause: non-displaced OCCULT fracture
PANNER'S DISEASE
CAPITULUM OF HUMERUS Avascular Necrosis

*not OCD - occurs after trauma and only affects surface of capitulum. 3rd most common place after knee and talar dome.

Panner's is entire capitulum - sclerosis, fragmentation, flattening (looks like crescent sign)
fragmented capitulum
Panner's disease of capitulum of humerus

*Displaced POSTERIOR FAT PAD - problem
SEVER'S DISEASE

Johnnie Sever kept pitching the ball and finally hurt his heel
CALCANEAL APOPHYSIS avascular necrosis
Sever's disease or calcaneal apophysitis is the most common, cause of heel pain in the growing athlete and is due to overuse and repetitive microtrauma of growth plates of the calcaneus in the heel. It occurs in children ages 7 to 15, with the majority of patients presenting between 10 and 14 years of age. It is in relation to Osgood-Schlatter disease which affects the knee rather than the heel/ankle.
Vascular Disorders include
Monkenberg's MEdial sclerosis
Atherosclerosis
Aortic aneurysm
Vertebral artery disorders
Pheboliths
MONKENBERG'S
MEDIAL SCEROSIS

Monks wear a tunic
TUNICA MEDIA sclerosis of artery

*Does NOT narrow the lumen but DOES HARDEN THE ARTERIES
Hyperparathyroidism/SLE/Diabetes Mellitus all neurovascular disorders
Seeing floculation all along wall of artery on radiograph
Monkenberg's medial sclerosis

Medial sclerosis

Hyperparathyroidism/SLE/Diabetes m.
ATHEROSCLEROSIS main cause
systemic hypertension

*MOST COMMON degenerative arterial dz
*Intimal and subintimal layers
Layer of arteries affected by atherosclerosis
INTIMA and subintimal layers
Atherosclerosis on radiograph
Calcification of some of the plaques. Evaluate how much Ca+ present around heart, but poor correlation and % of narrowing around other arteries (aorta, iliac, subclavian, carotid, femoral and coronary)
There is a good correlation between amount of _________________ calcification and risk of stroke (atherosclerosis). *****************
ABDOMINAL AORTA CALCIFICATION and risk of stroke *******************
AAA
Abdominal Aortic Aneurysm

*Normal 3.0 cm vs. > 3.5 cm/3.8 cm go to ER!!
*Refer for ULTRASONIC DOPPLER imaging
AAA is a ____________to adjusting.
contraindication
Average age and gender of AAA
male over 50
Lifestyle of AAA patient
high BP
smoker
high cholesterol
obesity
emphysema
genetic factors, MALE
Percentage of AAA that are SILENT
50%
Presentation of AAA patient
LBP or testicular pain (testicular artery ischemia)
Emergency presentation of AAA patient
Diaphoresis (sweating) all over body
Rigid abdomen w/ PULSATIONS
Back/groin pain
Shock, Rapid heart rate
Anxiety, clammy skin
Send an AAA patient out for
DOPPLER ULTRASOUND
How accurate is abdominal palpation of AAA?
48%

(37% detected w/ x-ray)
Average rupture time of AAA
75% within 5 years
Best view for AAA -don't miss it!
curvilinear lines next to TP's
On CT, can see false lumen (dissected) around true lumen
AAA
Every time you see a mass in a kidney, always consider
renal cell carcinoma

*consider it, but don't freak out. Contrast fluid collects in kidney. Calcific 'tumors' are extremely common in middle aged persons. Ask a radiologist to read the film for you.
AAA tx
Endovascular STENT

Vascular GRAFT (Dacron)
VBA is commonly clinically ______-
silent
Complications of VBA
STROKE

*intramural hemorrhage leads to vascular occlusion and thrombus formation

**extramural hemorrhage and brain stem infarct

***death
Imaging of VBA
MRI & angiography
MRI of VBA
Should always be able to see a FLOW VOID (darkness in lumen that indicates there IS blood flow in vertebral artery)
Phelboliths are usually seen
below the ischial spines of the pubic bowl
IF there is some movement of the phebolith, then consider
a mass in the pelvic area that is a kidney stone, pushed away
Injection granulomas vs. pheboliths in mm.
necrosis of fat in gluteal mm calcified vs.

INTRAMUSCULAR HEMANGIOMAS everywhere = MAFUCCI'S syndrome