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235 Cards in this Set
- Front
- Back
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McCune Albright is a form of ? and is seen mostly in ?
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fibrous dysplasia
females |
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describe fibrous dysplasia
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8-14 yo
M more than female except MA Cherubism Coast of MAINE asymptomatic |
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cherubism
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familial fibrous dysplasia of jaw
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radio features fibrous dysplasia
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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 |
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Fibrous dysplasia almost never affects the ______, different from Pagets
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epiphyses
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appearance of fibrous dysplasia margins
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thick, sclerotic margins
loculated (soap bubble) classic matrix? = GROUND GLASS Bony expansion Endosteal thinning SHEPARDS CROOK deformity |
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classic appearance for fibrous dysplasia?
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RIND of sclerosis
SHEPARD'S CROOK GROUND GLASS appearance = fibrous dysplasia |
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Where is the RIND of sclerosis most common in fibrous dysplasia?
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femur
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deformity of hip in long lesion of long bone as coxa vara is
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fibrous dysplasia
*Shepard's crook deformity, ground glass appearance with expansion of bone, rind of sclerosis and loculated (soap bubble) |
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fibrous dysplasia d/dx
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Paget's, Eosinophilic granuloma, ABC or simple bone cyst (unicameral) and osteosarcoma
(sclerosis and ground glass and soap bubble/locular and irregular cortex, respectively) |
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What gives fibrous dysplasia away?
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EXPANSION OF BONE
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types of fibrous dysplasia
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mono-ostotic
poly-ostotic |
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McCune-Albright syndrome
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females
PRECOCIOUS puberty POLYostotic skin pigmentation |
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radio presentation of MC-Albright
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same as fibrous dysplasia because it is a subtype:
ground glass, loculated, sclerosed cortices, long lesion in a long bone |
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Synonym for Neurofibromatosis - Type !
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Von Reckilinghausen's disease
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What did Rocky Dennis have
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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. |
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Two types of neurofibromatosis but we are talking about?
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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 |
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Classic triad of neurofibromatosis type 1
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Coast of CALIFORNIA (smoother cafe au lait spots)
Fibroma molluscum Osseous deformities |
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NEurofibromatosis description
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M -f
Cafe au lait spots (50%) Fibroma molluscum Elephantiasis Focal gigantism Spinal involvement (Kypohoscoliosis) = MOST COMMON BONY ABNORMALITY + atlantoaxial subluxation |
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How many cafe au lait spots make neurofibromatosis? What are the outgrowths of the skin called?
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more than 3
FIBROMA MOLLUSCUM *much thicker skin can be present as well |
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Classic spine of NF type 1
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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) |
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what grow all over Neurofibromatosis type 1 patients?
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Multiple NON-ossifying FIBROMAS (eccentric, soap bubble, patients over 10 years of age)
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Wide IVF cause?
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Neurofibromatosis type 1
COMMON disease that enlarges the IVF. Can have symptoms of neurological deficits. MULTIPLE NON-OSSIFYING FIBROMAS |
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multiple non ossifying fibromas
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eccentric soap-bubble lesions all over the body in a child under 10 = neurofibromatosis type 1
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Child in office with persistent knee pain displays multiple soap bubble lesions in femur and tibia?
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non ossifying fibromas of neurofibromatosis type 1. Send child out = no contact sports because trabecular pattern destroyed.
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When 50% of the medullary space is involved in NF, what is the fracture risk?
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50%
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Brain NF?
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skull changes
PLEXIFORM NEUROFIBROMATOSIS |
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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 |
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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...
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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. |
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types of Langerhans cells histiocytosis?
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Letterer-Siwe or Hand-Schüller-Christian or Eosinophilic Granuloma/Unifocal LCH/Histiocytosis X
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etiology of EG
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macrophages chew up body and then stop - sometimes the organ can grow back to normal function if happens young in life
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EG represents ___% of all Langerhan's histocytosis?
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70
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Radiographic appearance of EG
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RADIOLUCENT
round oval sharp borders LAMINATED spiculated **EXPANSILE bone lesions** key characteristic Path frx Moth eaten, permeative |
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Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X
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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 |
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mandible
of Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X |
floating teeth appearance
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Vertebral
Eosinophilic Granulomatosis/Unifocal Langerhan's Cell Histiocytosis/Histiocytosis X |
vertebra plana
COIN ON EDGE******* vertebra silver vertebra |
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BENIGN lesions that can look aggressive *********
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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 |
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Irregular bony destruction wi/ destroyed cortex, medullary space when macrophages chewing them up?
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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 |
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If EG occurs in very young, patients can regrow easily up to ___% of vertebral body height
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75
When immune sys deficiency stops (crazy ass macrophages) BUT patient can die if all over body. PAINFUL |
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battle cry**
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Mets! Myeloma! Lymphoma! A
Ewings, Acute osteomyelitis! C |
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Tumors reside or starting in epiphysis** C.A.G.E. epiphysis
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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. |
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Musculoskeletal infection:
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ACUTE suppurative (pyogenic) osteomyelitis
BRODIES abcess SEPTIC arth CHRONIC osteomyelitis DIABETIC osteomyelitis and SEPTIC arthritis NON suppurative osteomyelitis (TB and syphilis) |
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Acute Suppurative Osteomyelitis predisposed population?
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ASO pop predisposed:
immunocompromised, alcoholic, newborn, IV drug abuser, diabetics, hemodialysis, post surgical (7-10% hospital acquired infections), hemodialysis, severe anemia (sickle cells) |
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ASO organisms:
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STAPH aureus 90%
E. coli H. Influenzae Klebsiella (lung fields - invasive) STREP B |
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osteomyelitis
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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. |
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osteitis?
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Infection of CORTEX/CORTICAL BONE
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Disc-itis
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infection of the disc
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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 |
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ASO clinical features
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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. |
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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). |
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ASO
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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 |
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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) |
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ASO finding almost always early sign
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soft tissue swelling on xray
cortical bone destruction sometimes periosteal rx bone marrow edema |
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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 |
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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 |
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ASO involucrum appearance
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CHILDREN!!! most common = involucrum
massive periosteal bone formation surrounding infected site prominent uptake on bone scan (technetium 99 or gallium scan for WBC proliferation) |
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ASO sequestrum
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NECROTIC = sequestrum
anterior metaphysis of femur necrotic foci cortex or medullary space |
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ASO proximal humerus description
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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 |
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ACUTE osteomyelitis is typically _______. (sclerotic or lytic?)
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LYTIC (destroys)
vs chronic that starts to sclerose |
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Hematogenous spread of infection at lumbar spreads to bone via
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Batson's venous plexus
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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 |
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WEird looking schmorl's node losing endplate collapsing disc and destroying ligaments is
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suppurative spinal osteodiscitis
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SSO features radio
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postop spines
see notes for other 5 |
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ACUTE Suppurative spinal osteomyelitis radiograph
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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. |
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CHRONIC suppurative osteomyelitis
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destructive
soft tissue involvement all over low signal on bone segments |
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Chronic SOM destroys adjacent levels so we know it is not multiple myeloma. Why?
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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 |
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SOM treatment and prognosis {race against destruction}
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Refer OUT - need antibiotics w/ culture to determine infectious pathogen
Brace (spine) Surgical debridement late Prognosis GOOD if diagnosed EARLY |
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Abcesses requiring surgery?
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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? |
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Where a joint has reduced ROM ie due to bracing, in one month will display histological changes such as
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fusion - osteoblasts are present
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Brodie's abcess
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*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. |
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Most common loc for Brodie's abcess
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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. |
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Brodies' population
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Males w/ Staph aureus
Localized pain, often nocturnal, alleviated by aspirin. Often mimics the symptoms of Osteoid osteoma, which is typically < 1 cm diameter. |
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Osteoid osteoma size
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less than 1 cm
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Brodie's abcess size
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bigger than 2 cm
radiolucent center NIDUS |
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d/dx Brodies and osteoid osteoma
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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. |
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Brodies can have irregular margins w/ intracapsular and not much sclerosis. When lots of sclerosis?
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Extracapsular w/ regular margins
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Osteomyelitis CAN cross the growth plate but is usually the __________ factor for it.
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limiting
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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.
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BRODIE's ABCESS of Tibia
Faint sclerotic lesion Epiphyseal (ENDS of long bones) Cannot d/dx from OO unless > 2cm DIstal radius |
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ABCESS AT END
DIstal radius minimal sclerosis |
BRODIEs abcess of distal radius
Cannot d/dx from OO unless >2cm Brodie's is Bigger |
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SEPTIC arthritis description verbal
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infections progress FAST - pus inside joint but minimal radiographic changes.
PAINFUL Big joint SINGLE joint involvement |
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SEPTIC arthritis notes description
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SINGLE joint involvement
HEMATOGENOUS or DIRECT IMPLANTATION *****MONOARTICULAR***** (single/unilateral presentation) STAPH AUREUS (Most common) |
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Could resemble rheumatoid arth but septic is ________ in presentation
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unilateral
*rheum is multiple bilateral while septic is monarthrotic/unilateral |
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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
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Imaging of septic arth
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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 |
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First radiographic finding of septic arth?
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***JOINT EFFUSION****
loss of fat planes X-rays - may not be helpful early, but may show subtle increase in joint space tissue swelling.wiki |
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If septic is suppurative, what happens to joint space?
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****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) |
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Suppurative infections like staph
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erode joint surface and cartilage and collapse the joint every time
ie, septic arthritis from dirty needle |
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Septic loss of _____________ white line
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SUBCHONDRAL
(septic arthritis and brodies abcess both caused by staph aureus) |
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(septic arthritis and brodies abcess both caused by __________)
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staph aureus
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Septic arthritis in HIP = capsular tissue attaches to intertrochanteric ridge so osteomyelitis of femoral neck invades/destroys cortex causing
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septic arthritis, because of large capsule
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Pattern of septic radiograph
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MOTH-eaten
PERMEATIVE |
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Late presentation septic arthritis does eventually ______ the joint.
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FUSE
(bony ankylosis) |
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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****** |
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CLASSIC sign of infection of radiograph
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NO FAT PLANE
(tumors displace but infections OBLITERATE FAT PLANES, ie septic arthritis) |
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Radio hip R hip single view septic arthritis shows no _______ of the acetabulum. It has been destroyed.
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no cortex due to infection
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Radio lumbopelvic showing Posterior Superior dislocation of hip
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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 |
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Septic not only affects hips but ______, ie animal bites, human bites or redundant work or fist fights
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HANDS
breaking hand skin on another person's mouth can commonly affect carpal joints of hands via SEPTIC ARTHRITIS |
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Osteopenia
Hyperemia Joint destruction Late stage ankylosis like inflammatory arthritides |
SEPTIC arthritis
Periarticular osteopenia |
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Radio of lateral ankle
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Fusion of calcaneus and talus, no joints left w/ cuboids, navicular, etc.
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IV drug users w/ septic arthritis?
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PSEUDOMONAS infection of ****S**** joints:
spine sternoclavicular j sacroiliac j symphysis pubis j Say acromioclavicular (AC) j ;-) |
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Cause of septic arthritis?
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STAPH & PSEUDOMONAS
*don't forget pseudomonas of dirty needles for septic infection |
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Septic arthritis intravenous drug abusers cervical spine
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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 |
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Chronic osteomyelitis general considerations
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UNRESOLVED osteomyelitis
SCLEROSIS (healing) CORTICAL thickening PERIOSTEAL NEW bone formation (chronic) OSSEOUS DESTRUCTION SEQUESTRUM MALIGNANT DEGENERATION = fibrosarcoma, squamous cell carcinoma (Marjoilin's ulcer) |
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Chronic osteomyelitis MALIGNANT DEGENERATION in adults (kids have acute osteomyelits) can morph into:
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1. FIBROSARCOMA
2. SQUAMOUS CELL CARCINOMA >> Marjolin's Ulcer [occur at site of skin ulcer more often/ abnormal dysplastic cells] |
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commonly dev. from ULCER (eruptive volcano CLOACA)
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MARJOLIN'S ULCER into SQUAMOUS CELL CARCINOMA
assoc. with CHRONIC OSTEOMYELITIS |
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anterior forearm radio chronic osteomyelitis
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LOTS OF NEW BONE W/ AN ULCER
SCEROSIS In young patient, wi/o ulcer, would be acute osteomyelitis |
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DIABETES type II ulcers
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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 |
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Worst case scenario of diabetes osteomyelitis?
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GAS GANGRENE
Subcutaneous, emphysema - air production. Mottled soft tissues; d/t puncture, pneumothorax, bugs like costridium difficile b/c produces GAS ergo gas gangrene) |
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TUBERCULOSIS can cause ______________ osteomyelitis.
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NON-SUPPURATIVE
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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. |
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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 |
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Gangrene (gas) looks like pesto. What disorder?
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Diabetic osteomyelitis
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TB description
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enjoying comeback! Yay!
Immunocompromised Nearly all US TB infections caused by inhalation of MYCOBACTERIUM tuberculosis |
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Primary stage TB
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infects LUNGS
leads to GRANULOMATOUS rx May stay silent for patient's lifetime |
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Secondary TB
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POST primary stage
REACTIVATION of organism (mycobacterium tb) Spreads to other organs and bone via HEMATOGENOUS (ie, POTTS dz) |
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General considerations of TB:
Most common ages of skeletal TB? |
2-30 years of age
Rare in first year of life Males over females |
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Sx of TB
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Insidious onset of PAIN
Decreased ROM FOCAL TENDERNESS |
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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) |
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TB loves the __________ spine
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THORACOLUMBAR = POTT'S dz
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describe POTTS
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50% spine
-TUberculosis spondtlitis - Pott's 30% hips 20% others |
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spinal involvement most common POTTs segment
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L1
due to slow flowing blood Pott's paraplegia = epidural involvement and compression of conus medullaris or cord itself |
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Imaging find of POTTS
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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 |
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Late POTTS
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pathological COMPRESSION FX
GIBBOUS DEFORMITY PARAPLEGIA |
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Joint involvement elsewhere in TB is called _________ TRIAD
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PHEMISTER'S TRIAD:
*************progressive, slow joint space narrowing ************* Juxta-articular osteoporosis Peripheral erosions of articular surfaces Prone to large suchondral cysts |
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PHEMISTER's
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TB of other joints besides spine (which is Pott's)
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Lateral cervical TB radiograph
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anterior body of C2
retropharyngeal space is greater than 7cm |
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Lateral thoracic TB radiograph
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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 |
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AP thoracic TB view
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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 |
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SPINA VENTOSA
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tuberculosis dactylitis
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POTTS PUFFY TUMOR
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TB of the skull (frontal bone) w/ scalp abcess
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WEAVER'S BOTTOM
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subgluteal infective bursitis with direct extension to ischium due to TB
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hand AP for TB (tuberculous dactylitis) is also called?
Which digit? Local or spread? |
spina ventosa
first phalange of 3rd digit expansion Localized |
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lateral skull for TB
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Potts PUFFY TUMOR
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R hip for TB
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WEaver's bottom w/ ischial tuberosity and infective bursitis
Sclerosis Lack of cortical density Sclerosis means CHRONIC whereas acute is purely lytic |
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SYPHILLIS general consideration
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Transmitted across PLACENTA
WIDESPREAD SYSTEMIC INF: Hepatosplenomegaly, Jaundice, Rhinitis, Osseous lesions, Skin lesions, Adrenopathy, Hematological disturbances |
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TORCH mnemonic
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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 |
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ACQUIRED syphillis
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SKELETAL involvement w/ tertiary syphillis infection
<10% w/ syphillis PERIOSTITIS (solid or laminated) SKULL (frontal bone) CLAVICLE TIBIA |
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CONGENITAL syphilis:
______ shaped teeth/ _______ teeth ________'s joints |
PEG SHAPED/HUTCHINSON'S TEETH
CLUTTON'S JOINTS (bilateral knee swelling from congenital syphillis infection) |
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3 phases of syphillis bone
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Metaphysitis
Periostitis Osteitis = SABER SHIN deformity |
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WIMBERGER'S sign
makes a kid whimper when he walks |
METAPHYSEAL-itis (inflammation) of syphillis
errosive defects of *MEDIAL* TIBIA |
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SABER SHIN deformity
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OSTEITIS of syphillis
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lab quiz on normal and normal variants of spine and extremities - next week includes tumors
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quiz tmrw
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Vascular imaging MRI - what's wrong w/ this?
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GEOGRAPHIC PATTERNS OF BONE INFARCTS!
SERPIGINOUS (SERPENTLIKE) UNDULATING MARGINS ISLANDS ON A MAP |
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Most common malignant disease of childhood
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Leukemia
*bone marrow and blood disease of PROLIFERATING WHITE CELLS |
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Halmarks of Leukemia on radiograph
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Osteopenia
RADIOLUCENT METAPHYSEAL BANDS @ growth plates |
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Osteonecrosis at EPIPHYSIS
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Avascular necrosis (AVN)
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Osteonecrosis @ METAPHYSIS/DIAPHYSIS
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Bone infarct
*at the epiphysis, it's an AVN. At the metaphysis, it's a bone infarct |
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Origin of Osteonecrosis
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Reduction/obliteration of blood supply to bone = most commonly from outside compressing artery
*leads to death of osseous structures via blockage/thrombus/emboli/vasculitis |
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PLASTIC RAGS
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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 |
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Neimann-Pick disease
*an accumulation of ________ all over the body |
sphengomyelin
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PLASTIC RAGS is mnemonic for _____
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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 |
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Can be non-specific, depending on location and etiology. Latent period of weeks to years
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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 |
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Unilateral assoc. disorders of AVN
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Surgery
Spontaneous Trauma Infection Gout |
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AVN bilateral assoc. disorders
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Alcoholism
Corticosteroids (RA, SLE) Spontaneous Aterioscleroisis Caisson Cushings dz Hemoglobinopathy Hemophilia |
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sx of AVN
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PAIN
Antalgia Painful ROM Muscle atrophy |
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1st phase AVN
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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 |
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2nd phase AVN
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Subchondral cysts
Sclerosis (BITE SIGN, SNOW CAP SIGN) Subchondral fracture (CRESCENT SIGN) Collapse/flattening of articular surface (no longer smooth and round!) Fragmentation |
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3rd phase AVN
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Repair and remodeling
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Crescent sign
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A radiolucent band paralleling subchondral bone that IS a true fracture.
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OCD
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Spontaneous osteonecrosis of the knee (pretty much)
Osteochondritis Dessicans |
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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 |
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OCD
Patient age? Which side of femoral condyle affected? |
YOUNGER patient
Change in LATERAL aspect of MEDIAL femoral condyle |
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Pain from OCD
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Edema!!
osteochondral loose bodies like Panner's disease of capitulum (AVN - osteonecosis of capitulum w/ OCD of radial head = what you have!) |
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Bone Infarct
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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" |
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"SERPIGINOUS AREA OF CALCIFICATION IN CENTRAL PORTION OF RED MARROW"
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BONE INFARCT
*can be GEOGRAPHIC PATTERN, too |
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GEOGRAPHIC PATTERN and ______ are classic for bone infarct
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SERPIGINOUS
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Where is BONE INFARCT
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METAPHYSEAL/DIAPHYSEAL
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D/DX BONE INFARCT
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Low grade CHONDROSARCOMA (esp if over 40), ENCHONDROMA
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***RADIOLOGICAL features of AVN
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FRAGMENTATION
SCLEROSIS ARTICULAR COLLAPSE |
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Osteochondroses
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A group of EPIEPHYSEAL/APOPHYSEAL conditions characterized by:
FRAGMENTATION SCLEROSIS IRREGULAR ARTICULAR SURFACES *just like AVN |
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Osteochondroses:
Some are real ___________ Some are ___________ deformities Some are __________ variations |
AVN
POST-TRAUMATIC DEVELOPMENTAL |
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LEG-CALVE-PERTHES disease
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AVN of FEMORAL CAPITAL EPIPHYSIS
aka: coxa plana Flattened femoral head Mushroom appearance AFFECTS CHILDREN |
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changes shape and morphology of femoral head forever
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Legg -Calve -Perthe's dz
Children Flattening of epiphysis **Waldenstroom sign Painful limp Trendelenburg sign **Flat femoral head w/ crescent sign CARTILAGE NOT AFFECTED |
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Flattened and sclerotic femoral head
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Legg Calve Perthe's
can be bilateral or unilateral Sharp angulation = coxa VERA deformity of femoral neck Femoral head overgrows, creating MUSHROOM deformity |
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Early imaging finding of LCF=P
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ST swelling
WIDE medial joint space (WALDENSTROOM SIGN) SMALL femoral head EPIPHYSEAL FRAGMENTATION SCLEROSIS CRESCENT SIGN |
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if someone has hip pain, first view
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AP pelvis
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Late Imaging of LCP
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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 |
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Sagging rope sign
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Leg Calve Perthe late imaging finding
*w/ mushroom deformity |
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FREIBERG'S FUNKY FOOT
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True AVN of head of 2nd metatarsal (sometimes 3rd)
RESULT OF HIGH HEELED SHOES IN TEENS (skeletally immature) |
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Freiberg's
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Flattening
Fragmentation Sclerosis |
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KIENBOCK'S DISEASE
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True AVN of LUNATE
LUNATOMALACIA** Excessive stress on lunate carpal of wrist especially in pts w/ NEGATIVE ULNAR VARIANCE |
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NEGATIVE ULNAR VARIANCE
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Kienbock's disease = LUNATE sclerosis and becomes TRIANGULAR SHAPE
No normal roundness of inferior surface |
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Post-traumatic apophysitits
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Osgood-Schlatter's
Panner's |
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OSGOOD SCHLATTERS
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HYPEREXTENSION ACTIVITIES (soccer, running, kicking)
that causes SWELLING and FRAGMENTATION of tibial apophysis |
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Normal to have a fragmented tibial apophysis but abnormal to have?
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Swelling
Swelling!! = Osgood Schlatters Fragmented only = Tendinosis of patellar ligament |
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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 |
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Vertebral endplates of thoracic spine are often irregular so don't immediately label Scheuermann's dz.
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Overcalling SD on everyone w/ irregular endplates is wrong.
Need anterior wedging and Schmorl's nodes |
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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 |
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KUMMEL'S DISEASE
Kummel's Vacuum! |
true AVN of VERTEBRAL BODY itself
SCLEROSIS COLLAPSE OF VERTEBRAL BODY ***INTRABODY VACUUM PHENOMENON inside vertebral body |
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Intrabody vacuum phenomenon
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KUMMEL'S
due to TRAUMA develop AVN of vertebral body during healing |
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"I heard a snap in my spine!"
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KUMMEL'S DISEASE
Vacuums in a snap! |
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VAN NECK's disease
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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 |
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tell tale sign of Kummel's dz
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VACUUM inside the vertebral body
(vacuum phenomenon) |
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ISCHIOPUBIC SYNCHONDROSIS
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VAN NECK's disease - you get it if you neck too much
*completely asymptomatic NORMAL variant |
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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 |
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CHANDLER'S DZ
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AVN of the HIP IN ADULTS
same as Leg Calve Perthes in children SPONTANEOUS |
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Most common location of AVN
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FEMORAL HEAD
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Signs of AVN
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Sclerosis
Collapse/flattening of articular surface Fragmentation Epiphysis/apophysis osteochondrosis |
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AVN of Hip in adults
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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 |
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AVN of talus
a Dias on a Dome |
DIAZ's TALAR DOME AVN
Multiple fragmentation |
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DIAZ's disease
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AVN of TALUS
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HAAS' Easter eggs are Humorous
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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. |
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KOHLER'S DISEASE
Navigate through a Kohl's store |
NAVICULAR of foot Avascular Necrosis
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PRIESER'S DZ
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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 |
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PANNER'S DISEASE
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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) |
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fragmented capitulum
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Panner's disease of capitulum of humerus
*Displaced POSTERIOR FAT PAD - problem |
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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. |
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Vascular Disorders include
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Monkenberg's MEdial sclerosis
Atherosclerosis Aortic aneurysm Vertebral artery disorders Pheboliths |
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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 |
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Seeing floculation all along wall of artery on radiograph
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Monkenberg's medial sclerosis
Medial sclerosis Hyperparathyroidism/SLE/Diabetes m. |
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ATHEROSCLEROSIS main cause
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systemic hypertension
*MOST COMMON degenerative arterial dz *Intimal and subintimal layers |
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Layer of arteries affected by atherosclerosis
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INTIMA and subintimal layers
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Atherosclerosis on radiograph
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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)
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There is a good correlation between amount of _________________ calcification and risk of stroke (atherosclerosis). *****************
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ABDOMINAL AORTA CALCIFICATION and risk of stroke *******************
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AAA
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Abdominal Aortic Aneurysm
*Normal 3.0 cm vs. > 3.5 cm/3.8 cm go to ER!! *Refer for ULTRASONIC DOPPLER imaging |
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AAA is a ____________to adjusting.
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contraindication
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Average age and gender of AAA
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male over 50
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Lifestyle of AAA patient
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high BP
smoker high cholesterol obesity emphysema genetic factors, MALE |
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Percentage of AAA that are SILENT
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50%
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Presentation of AAA patient
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LBP or testicular pain (testicular artery ischemia)
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Emergency presentation of AAA patient
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Diaphoresis (sweating) all over body
Rigid abdomen w/ PULSATIONS Back/groin pain Shock, Rapid heart rate Anxiety, clammy skin |
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Send an AAA patient out for
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DOPPLER ULTRASOUND
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How accurate is abdominal palpation of AAA?
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48%
(37% detected w/ x-ray) |
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Average rupture time of AAA
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75% within 5 years
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Best view for AAA -don't miss it!
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curvilinear lines next to TP's
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On CT, can see false lumen (dissected) around true lumen
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AAA
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Every time you see a mass in a kidney, always consider
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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. |
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AAA tx
|
Endovascular STENT
Vascular GRAFT (Dacron) |
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VBA is commonly clinically ______-
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silent
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Complications of VBA
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STROKE
*intramural hemorrhage leads to vascular occlusion and thrombus formation **extramural hemorrhage and brain stem infarct ***death |
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Imaging of VBA
|
MRI & angiography
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MRI of VBA
|
Should always be able to see a FLOW VOID (darkness in lumen that indicates there IS blood flow in vertebral artery)
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Phelboliths are usually seen
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below the ischial spines of the pubic bowl
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IF there is some movement of the phebolith, then consider
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a mass in the pelvic area that is a kidney stone, pushed away
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Injection granulomas vs. pheboliths in mm.
|
necrosis of fat in gluteal mm calcified vs.
INTRAMUSCULAR HEMANGIOMAS everywhere = MAFUCCI'S syndrome |
