OA
- subchondral sclerosis, cysts, joint space narrowing, osteophytes
RA
- generalised osteopaenia
- marginal joint erosions due to synovial proliferation & pannus
- soft tissue swelling
- joint space narrowing
Psoriatic arthropathy
- distal arthritis with affected DIPJs
- periarticular erosions
- affects wrists severely
Gout
- erosions due to tophi
- punched out erosions, periarticular
- overhanging sclerotic margin
- no osteopaenia c.f. to RA
Infection
Caffey's
Diaphyseal dysplasia
Pyknodysostosis
FHO
Spina Bifida
Alcoholism
DM
- most common cause
Syphilis
- Tabes dorsalis
Leprosy
- most common UL
Indifference to pain (congenital)
Peripheral nerve lesions
Syringomyelia 20-40%
- number 1 cause in upper limb
Wilson's
Haemochromatosis
Idiopathic
Pseudogout, pernicious anaemia
Amyloid, acromegaly
Diabetes
Ochronosis
Gout
Skin contracture - burn
Fascial contracture - Dupuytren
Muscle contracture - Volkmann's
Muscle imbalance - asymmetric paralysis
Joint instability - ACL rupture
Joint destruction - RA
Congenital disorder - Pseudoarthrosis
Soft bone - Rickets, osteomalacia, OI
Dysplasia - Hereditary Multiple Exostosis
Physeal injury
Malunion
Paget's
1. Diagnosis incorrect
- other local (intra-articular eg meniscal tear)
- referred (hip or spinal pathology)
2. Right diagnosis but wrong surgery
- osteotomy for advanced OA
3. Right surgery performed inadequately
- poorly performed - inadequate fixation for osteotomy
- incomplete - didn't address all pathology / incomplete correction of deformity
4. Recognized complication of well performed surgery
5. Well performed surgery with inadequate rehabilitation
- patient motivation
- wrong rehab
- right rehab done poorly
6. Progression of pathology or disease process
- progression of OA after osteotomy
Short
Trendelenberg
Rigid
Antalgic
Weak
Spastic
Type 1
- postmenopausal
- high turnover / osteoclast mediated
- F x 6
Type 2
- age-related / senile
- low turnover / osteoblast mediated
- F x 2
Can have both
Disuse
- prolonged bed rest
- inactivity
- paralysis
- space travel
Diet
- low Ca, vit C
- anorexia nervosa
Drugs
- heparin
- methotrexate
- ethanol
- steroids
Neoplasms
- metastatic disease
- myeloma
- lymphoma
- leukemia
- mastocytosis
Idiopathic
- adolescent (10-18yrs)
- middle-age men
Chronic Illness
- RA
- cirrhosis
- sarcoidosis
- renal tubular acidosis
Endocrine Abnormalities
- pituitary hypersecretion
- adrenal cortex excess
- ovary- oestrogen deficiency
- testis - testosterone deficiency
- hyperparathyroidism
- hyperthyroidism
- hypophosphatasia
Vitamin D Intoxication
Diaphyseal Dysplasia / Englemann's
Fluorosis
Renal Osteodystrophy
- secondary hyperparathyroidism
- rugger jersey spine
Osteopetrosis
Osteopoikilosis (= spotted bones)
Myelosclerosis
Metastasis - prostate / breast
Malignancy - Lymphoma
Mastocytosis
Melorheostosis - candle bones
Metaphyseal dysplasia
Paget's
Pyknodysostosis
AVN / Sickle Cell
RA
Sero-ve Spondyloarthropathies
- Rieter's
- Ankylosing spondylitis
- Psoriatic
- Enteropathic (IBD)
Crystal Arthropathies
- Gout
- CPPD
- HADD
Ochronosis / Haemachromatosis
CT Diseases
- JCA
- SLE
- Sarcoid
- CREST - scleroderma
PVNS
Haemophilia
Septic arthritis
Polymyalgia Rheumatica
Transient Osteoporosis of Hip
Osteolytic Tumour
Disuse
RA
Osteomyelitis
Paget's
Burns
AVN
RSD
TB
Patient factors
- age
- nutrition / catabolic states
- anaemia
- smoking
- alcohol
- DM
- immunocomprimise
- non compliance
Pharmacological agents
- steroids
- cytotoxics
- ciproflaxacin
- NSAIDS
DXRT
Injury
- open fracture
- significant soft tissue trauma
- soft tissue interposition
- poor vascularity
- infection
- pathological fracture
- malignant tissue
- osteoporosis
Fracture pattern
- intact fellow bone
- excessive bone loss
- segmental injury
- comminution
- displacement
- synovial fluid
Distraction of fracture
Inadequate stability with excessive movement
Excessive stability
Extensive approach with vascular compromise
No axial load
Infection
Blood
- Haemophilia
- DVT
Inflammatory arthritis
Trauma
Neoplasia
Osteoarthropathy Hypertrophic
A Vitaminosis
Hypophosphatasia / Hyperthyroidism
Caffey's/ Child Abuse
NF
Scurvy
Idiopathic ~ 50%
HMSN
Friedrich's Ataxia
Trauma
Infection
- Leprosy
- TB
- Syphilis
Tumour
- Malignancy
- Myeloma
- Polycythemia rubra vera
Inflammatory
- GBS
- SLE
- RA
- Sarcoid
- PAN
Metabolic
- DM
- CRF
- Chronic liver disease
- Amyloid
- B1 / B6 / B12
- Thiamine
Endocrine
- hypothyroid
Drugs and Toxins
- Alcohol
- Lead
- Phenytoin
- Metronidazole
- Nitrofurantoin
- Vincristine
Hypercalcaemia
- primary HPTH
- secondary HPTH
- malignancy (production of PTH like proteins)
- Vit D intoxication
- Milk Alkali Syndrome
- Sarcoidosis
Myositis ossificans progressive / MO / HO
Haematoma
Trauma
Burns
Tumoral calcinosis - produces large lobulated mass; high recurrence rate
Atherosclerosis, thrombi
Synovial sarcoma / Chondrosarcoma / Haemangioma
Dermatomyositis
Infection (TB, Infected lymph nodes)
Parasites
Fat necrosis
Scleroderma
Transfer metatarsalgia
- clawing
- RA
- short 1st MT with uncovering second
- splayed / wide first ray
Great toe
- hallux rigidus
- hallux valgus
- sesamoiditis
Lesser toes
- Morton's neuroma
- Frieberg's
- stress fracture
- plantar keratosis / plantar wart
Alcohol
Steroids
Idiopathic
Trauma
Gout, Gauchers
Rheumatoid / radiation
Infection / increased lipids / inflammatory arteritis
Pancreatitis / pregnancy
SLE / sickle cell / smoking
CRF / chemotherapy / Cassion's disease
A) Central
Primary cerebellar disease
Cerebral Palsy
Hydrocephalus
CVA
B) Spinal cord
Friedreich's Ataxia
- absent ankle jerks & balance
Spinal dysraphism / spina bifida
Diastematomyelia
Syringomyelia
Spinal Cord tumours
CMT Type 2 (degenerative of spinal axons)
C) Anterior horn cell
Polio
SMA
D) Peripheral nerves (+roots)
CMT Type 1
- demyelinating peripheral neuropathy
Polyneuritis
E) Muscle Disease
Muscular Dystrophy
Congenital cavus foot
Residual clubfoot
Arthrogryposis
Residual of Compartment Syndrome
Crush injury to lower extremity
Severe burn
Malunion of fractured foot
OA / RA of hindfoot
Usually pure cavus = calcaneocavus
Bone
- talus OCD
- lateral process talus fracture
- anterior process fracture calcaneum
- stress fracture calcaneum
- tarsal coalition
Ligament injury
- syndesmotic injury / high ankle sprain
- peroneal tendonitis / subluxation / dislocation
- sinus tarsi syndrome / chronic injury interosseous TC ligament
- recurrent instability / chronic lateral ligament injury
- lateral gutter fibrosis / Bassett's ligament
Joint
- OA / degeneration
- RA / inflammatory condition
- cavo-varus deformity
Other
Infection
Tumour
Shoe Wearing
Hereditary
- generalised ligamentous laxity
- metatarsus primus varus
- hypermobile TMT
- joint configurations: oblique TMT / DMAA
- long or short first metatarsal
Acquired
- second toe amputation
- RA
- short achilles tendon
- valgus knee
- neurological conditions
- flatfoot
Trauma
- fracture
- dislocation
Infection
Tumour
Inflammatory
- RA
- seronegative (RAPE - Reiter's, AS, Psoriasis, Enteropathic)
- CT disorders (SLE, sarcoidosis, JCA)
Metabolic
- gout, pseudogout, HADD
- hemochromatosis, ochronosis
- Paget's
Developmental
- DDH, Perthe's, SUFE
Dysplasia
Vascular
- haemophilia
- AVN
Synovial
- PVNS, chondromatosis
Osteochondral fracture
OA / cartilage fragments
Synovial chondromatosis
Meniscus Tear
ACL Stump
Extra-articular
Bursitis (pes anserinus / semimembranosus)
Medial gastrocnemius strain/tear
VMO avulsion
Infrapatellar branch saphenous nerve entrapment
Subcutaneous trauma / infection
Intra-articular
Soft tissue
- MCL / medial meniscal tear or cyst / MPFL rupture / synovitis
Bone
- AVN / OA / RA / fracture / OCD / infection / tumour
Synovium
- PVNS, synovial chondromatosis. lipoma arborescens
RA , seronegative inflammatory conditions
Gout / Pseudogout
Extra-articular
ITB
Intra-articular
Lateral meniscus tear
Discoid meniscus
Trauma
Fracture / bipartite patella
Quads / patella rupture
Overuse
- quads / patella tendinitis / jumper's knee
- bursitis
- ITB syndrome
- quads / patellar tendon rupture
Hoffa's syndrome / fat pad impingement
PFJ OA
PFJ dysplasia
- LPPS / patella tilt
- patella instability
- CMP
- patella alta / baja
PCL Insufficiency
Paediatric
- traction apophysitis
Baker's Cyst
Popliteal Anerysm
Soft tissue sarcoma
Osteosarcoma / Parosteal OS
Hemangioma / AVM
Note:
Always do xray for calcification
A Bakers cyst / aneurysm can be calcified
Infection
Prosthetic loosening and failure
PF tracking problems
Instability
Component overhang / Recurrent intra-articular soft-tissue impingement
Bursitis-tendinitis
- pes anserine bursitis
- patellar tendinitis
- popliteal tendinitis
CRPS
Persistent crystalline deposition
- gout
- CPPD disease
Vascular problems
- vascular claudication
- thrombophlebitis / DVT
Hip
Back
Unrealistic expectations
Secondary gain issues
Psychiatric disorders and depression
Flexible
Physiologic (painless / painful)
Ligamentous laxity (DIAL HOME CS)
Rigid
CVT
Tarsal Coalition
Skewfoot
Tendon
Tibialis posterior tendon dysfunction
Tight T achilles
Ligament
Rupture of spring ligament
Rupture of plantar fascia (including iatrogenic)
Bone
Fracture (talus / calcaneus / lis franc)
Tumour - OO/ABC/UBC
RA midfoot
OA hind/midfoot
Charcot (SADSLIPS)
Sinus Tarsi Syndrome
Neuromuscular
CP
Spinal dysraphism (SB)
Polio
MND
Compensatory
Genu valgum
Internal tibial torsion
Otto's Disease
- bilateral 1/3
- middle aged females
- pain & decreased ROM early
- coxa vara & OA common
Paget's
RA / Radiation
Osteomalacia / OI
Fracture - Central Dislocation
Septic arthritis especially TB
Hemiarthroplasty or bipolar
Ankylosing Spondylitis / Reiter's
Marfan's syndrome / Ehler Danlos / Stickler
Malignancy
Neurofibromatosis
Labrum
Ligamentum teres
Loose Bodies
Synovial chondromatosis
Osteocartilaginous exostoses
Fascia lata on greater trochanter (common)
Iliopsoas on lesser trochanter / iliopectineal eminence
Long head biceps femoris over ischial tuberosity
Iliofemoral ligament over femoral head
Hypertension
Prior surgery
Obesity
Steroids
Trauma
Diabetes
RA
Seronegative
Hypermobile flatfoot
Trauma
- growth arrest line
Infection
Tumor
- leukemia
- neuroblastoma
Metabolic
- rickets (calcifiable matrix is formed, but matrix doesn’t calcify due to lack of available mineral)
- scurvy (metaphyseal disarray / calcified cartilage persists into metaphysis / very little osteoid)
Drugs & toxins
- lead
- pamidronate
Dysplasia
- achondroplasia
- OI (2o spongiosa abnormal development)
Hip
Trauma
- fracture, OCD
- ligamentous injury / ACL
- meniscal injury
- tendonitis / patella
- bursitis
- apophysitis / OSD
- PJF tilt / instability / chondromalacia
Infection
Tumour
Inflammatory
- rheumatoid
- seronegative
- CT disorder
Synovial
- PVNS, chondromatosis
Congenital
- discoid meniscus
- plica
Clavicle / Humeral Fracture
- should feel fracture / crepitus
Arthrogryposis
- no elbow crease
Monoplegic CP
Anatomical
- increased retroversion
- increased physeal angulation
Increased weight
- overweight immature males
Tall children at end of growth spurt
Hypothyroidism
Hypogonadism, panhypopituitarism, pituitary tumours
Acromegaly
Hyperparathyroidism
Rickets / renal osteodystrohy
Iatrogenic - GH, chemotherapy, XRT
Klinefelter’s, Downs, Marfan's
Metaphyseal Dysplasia (Pyles Disease )
Diaphyseal dysplasia (Engleman’s)
Caffeys' / Infantile Cortical Hyperostosis
Osteoarthropathy / Familial Hypertrophic
Pyknodysostosis
Melorheostosis / Mastocytosis / Myelosclerosis
Osteopathia striata
Osteopetrosis
Osteopoikilosis (bone islands)
Acquired
Rickets / renal osteodystrophy / hyperparathyroidism
Perthes disease
Infection
Trauma with early closure physis
Tumour
SUFE
Congenital
Infantile / developmental
- Hofmeister 1894
- progressive disorder that develops in early childhood
- due to limb bud abnormality
- Y deformity in metaphysis
PFFD / congenital short femur / bowed femur
- not congenital really infantile
- as appears after birth
Dysplasia
MED / SED
Achondroplasia
Cleidocranial dysostosis
Fibrous dysplasia
Cretinism
Thalassemia
Osteopetrosis
Metaphyseal Chondrodysplasia
Mastocytosis
Pyle’s (metaphyseal dysplasia)
Gaucher’s
Lead poisoning
Enchondroma --> Ollier’s & Maffucci’s
NF
Deficiency of calcification in zone of provisional calcification physis
- requires vit D / C
- gives metaphyseal cupping
Metaphyseal Chondrodysplasia
Metaphyseal Dysplasia / Pyles disease
MPS
Rickets
Achondroplasia
Scurvy
Hypophosphatasia
Congenital Infection - Syphilis & Rubella
Physiological valgus
- up to 8 years
- treat > 8 years and > 15˚
Trauma - physeal injury / proximal tibial metaphyseal fracture
Infection
JRA
Posteromedial Bowing
Anteromedial Bowing - fibular hemimelia
Skeletal Dysplasia - MED / Morquio / Pseudoachondroplasia
Neuromuscular - CP / polio
Congenital - dislocation of the patella / hypoplasia of LFC
Rickets / Renal osteodystrophy
OI
Physiological genu varum
- < 2 years
Lateral Bowing
Blount’s
Ricket’s / Renal Osteodystrophy
Physeal injury
- trauma
- tumor
- infection
JRA
Skeletal dysplasia
- achondroplasia
- metaphyseal chondrodysplasia
- Ollier’s / maffuci’s
- Focal fibrocartilagenous dysplasia
OI
Anterolateral Bowing / pseudoarthrosis
Trauma / ORIF
Infections
Chemotherapy
Radiotherapy
Burns
Immobilisation
Hemi-hypertrophy or atrophy
Idiopathic
Klippel-Trenaunay-Weber syndrome
Proteus syndrome
Beckwith-Weiderman syndrome
Russel-Silver syndrome (atrophy)
Skeletal dysplasia
Chondrodysplasia punctata
Ollier’s / Maffuci’s
Multiple hereditary exostoses
NF
Fibrous dysplasia
Neurological
Closed HI
Polio
Spina bifida
CP
Spinal dysraphism / tumour / injury
Peripheral nerve injury
Tumour / trauma / infection / radiotherapy physis
Hip
- PFFD
- Coxa vara
- SUFE
- DDH
- Perthe’s
- Tom Smith septic arthritis
Femur
- congenitally short femur
Leg
- fibula hemimelia
- tibial hemimelia
- bowing
Foot
- CTEV
Down’s Syndrome
Idiopathic (familial)
Achondroplasia
Larsen’s Syndrome
Homocystinuria
Osteogenesis imperfecta
Marfan’s Syndrome
Ehlers Danlos
Congenital contractural arachnodactyly (Marfans variant)
Sticklers
Accidental injury
NAI
OI
Rickets
Juvenile osteoporosis
Leukaemia
Caffey’s
Osteopetrosis
Fibrous Dysplasia
Homocystinuria
Congenital syphilis
Congenital indifference to pain
Muscles
- polymyositis / Muscular Dystrophy
Peripheral Nerves
- GB / CMT
Anterior Horn Cells
- SMA / Polio / Motor Neurone Disease
Cord
- Motor Neurone Disease
- Syrinx
Motor Cortex
- CVA / CP / Tumour
Peripheral
- diabetes
- alcohol
- acromegaly
- amyloidosis
- chronic demyelinating polyradiculopathy
Sensory Cortex
- CVA
Peripheral Nerves
- CMT/ PN
- nerve entrapment
Cord
- syrinx
- tumour
- dysraphism
- infarct
- fracture / trauma
- Friedrich’s
Central
- MS / CVA / CP
Cerebellar
- Friedrich's ~ LMN
- CVA ~ UMN
Flexible
- compensatory - tight T achilles / out-toeing / genu valgum
- physiological
Rigid
- CVT / tarsal coalition / skewfoot
Trauma
- midfoot fracture / Lisfranc / rupture spring ligament / rupture plantar fascia
Neuromuscular
- CP, spina bifida, polio
Skeletal Dysplasias / MAD KEN LOOT
- Achondroplasia / Down's
- Marfans / Ehler Danlos / Larsens
Congenital
- rare
- anterior or posterior
- lateral uncommon
Trauma / Missed Monteggia
Osteochondroma
PFA
- usually symmetrical
- resolve by 8
- consider CP
ITT
- may be asymmetrical
- usually resolves
Metatarsus adductus
- no treatment required
Metatarsus primus varus
Skewfoot
ETT
- asymmetrical
SUFE
Failure formation (unilateral bar / block)
Failure segmentation (wedge, hemivertebrae)
CP
SB
Muscular dystrophy
Young SCI
NF
Achondroplasia
OI (basilar invagination)
Marfan’s
Irradiation
SED (atlanto-occipital)
Risks of progression
- MR Sex MAP
Chondromalacia punctae
OI
MED / SED
Metaphyseal Dysplasia
Mucopolysaccharidases
Osteopetrosis
NF
Hypophosphataemia
Exostosis
Achondroplasia
Diaphyseal Dysplasia / Diastrophic Dysplasia
Fibrous Dysplasia
Ollier’s (multiple enchondromas)
Epiphyseal fragmentation
MED
Osteopoikilosis
Chondrodysplasia Punctata
Hypothyroidism - Cretinism
AVN / Sickle cell / Gauchers
SED
Morquio
Sickle Cell
Gaucher's
Warfarin
Downs syndrome
Lateral
- normal variant
- resolves
Posteromedial
- packaging variant
- usually resolves
- may need osteotomy about 2 - 3 if persists
Anteromedial
- fibular hemimelia
Anterolateral
- tibial hemimelia
- tibial pseudoarthrosis
Normal til age 3
- child can actively heel walk
Fixed equinus – CTEV / arthrogryposis
Short / tight T Achilles
SOL in calf
CP
Spinal dysraphism / tethered cord
DMD– Duchenne / Gower’s
CMT
Real - unilateral
Apparent - knee or hip deformity
Cretanism
Pyknodysostosis
Osteogenesis Imperfecta
Rickets in healing phase
Kinky hair syndrome of Menke
Cliedocranial Dysplasia
Hypophosphatasia (also hypothyroidism)
Otopalatodigital syndrome
Primary Acroosteolysis, Pachydermoperiostosis
Syndromes and Chromosome disorder; esp 21
Protrusio PROFSHAMMN
Charcot joints SAD SLIPS
Chondrocalcinosis WHIP A DOG
AVN AS IT GRIPS 3C
Gen Lig Lax DIAL HOME CS
Coxa vara ACDC
Waddell’s DR TOS
Basilar Impression SAD MAN BOOK
Schmorl’s SHOOT
Spondylolithesis DID TIP
Radial N Compression FREAS
Skeletal Dysplasia COMMON HEAD FOG
Sieve TITIMENDVISC
Lucent Lesions FOG MACHINES
Diaphyseal lesions HALFEE
CI Limb Salvage PIN LEG
Female Tumours JIHAD GAL
Sclerotic Cortical OOPS
Sclerotic Lesions VINDICATE
Osteoporosis DDD NICE
Scoliosis Progression MR SEX MAP
Urogenital system - tumour / stones
Gastrointestinal system
Vascular system - AAA
Trauma
- fracture, HNP, facet dislocation
Infection
- vertebral osteomyelitis, TB
Tumour
- benign / OO / OB / ABC / Giant cell
- primary malignant / Ewing's / OS / Lymphoma
- secondary malignant / metastasis / MM
Inflammatory
- RA
- seronegative
Metabolic
- gout / CPPD / onchronosis
Endocrine
- PTH
Neuromuscular
- spinal dysraphism
Degenerative
Dysplasia
- Achondroplasia, dysraphism
Congenital
- Scheurmann's
Waddell's Signs
3 or more to be significant
DR TOS
1 Distraction
- FLIP SLR (Sign 1)
2 Regional
- Non-anatomically numb or weak
- Esp Cogwheel Give Way
3 Tenderness
- Superficial "Pinch Test" (Sign 2)
- Non-anatomic
4 Over-Reaction
Collapse
Verbalisation
Sweating
5 Simulation
- Axial loading by head compress
(Sign 3)
- Passive Pelvic rotation (Sign 4)
2° Thoracic rotation
Successful Discectomy
6/6 Nachemson
1. Leg pain > back pain
2. Neurological symptoms dermatomal
3. Neurological signs dermatomal
4. Signs of nerve tension
5. Correlation with imaging
6. > 6 weeks
Achondroplasia
Hurler syndrome
Down syndrome
Cretins
NF
Morquoi syndrome
Pseudoachondroplasia
Spondylometaphyseal dysplasia of Kozolowski
2° laxity of transverse ligament
DIAL HOME CS
Trauma
Infection
- retropharyngeal abscess
- Grisel's syndrome
Inflammatory
- JRA
Congenital
- Down's syndrome - very common 15%
- Achondroplasia
- MPS & SED
- Os Odontoideum
Definition
- superior migration of odontoid into region of foramen magnum
Diagnosis
- Ranawat's < 13 mm (pedicle of C2 to line of axis)
- McGregor's > 4.5 (hard palate to base occiput)
- McCrae's - dens above line of foramen magnum
SED
Achondroplasia
Downs
Morquio
Atlas Hypoplasia
NF
Bifid posterior arch atlas
Occipitocervical synostosis
OI
Klippel Feil syndrome
JRA
Rickets
RA
Osteoblastic metastasis (prostate or breast)
Lymphoma
Paget's disease
Hemangioma
Osteopetrosis
Sickle cell disease
Myelosclerosis
Fluorosis
Carcinoid
Mastocytosis (very rare etiology for an ivory vertebra)
Postural
Scheuremann's
Ankylosing spondylitis
Osteoporotic fractures
TB
Iatrogenic - post laminectomy
Osteomalacia
Osteoporosis
Morquio's
Polio
Syrinx
SB
OI
SED
Achondroplasia
Congenital kyphosis
Spondylosis / spondylolisthesis
- most common cause
- adolescent playing sport
Scheuermann's kyphosis
- 1/3 of patients
HNP
- rare
Fracture
Apophyseal ring fracture
- traumatic fracture between vertebral body and cartilaginous ring
- apophysis displaced posteriorly with disc
- decompression if causes neurological symptoms
Discitis / Osteomyelitis
Tumour
- benign: OO / OB / ABC / giant cell tumour / EG
- malignant: Ewings / OS / chordoma / leukaemia
RA
Ankylosing spondylitis / other seronegative inflammatory conditions
Diastematomyelia
Juvenile Osteoporosis
EG
Ewing's
Lymphoma / leukaemia
Infection
ABC
Mets / myeloma
Metatropic dysplasia
OI
Morquio
Achondroplasia
SED
Fracture
- osteoporosis (JRA / JOP / homocystinuria / Gaucher's)
Benign tumour
- EG
- haemangioma
Malignant tumour
- Ewings / leukaemia / multiple myeloma / metastasis
Infection
Steroids / Cushings / Sickle Cell
Scheuermann's
Scheuermann's
Hyperparathyroidism
Osteoporosis
Osteomalacia
Trauma
Fibrous dysplasia
Osteopetrosis
Osteoblastic metastasis
Lymphoma
Infection
Sickle cell
Haemangioma
Pagets
Osteoblastoma
Osteoid Osteoma
Fluorosis
Compensatory
Hysterical
Irritative
Postural
Sciatic
Magnitude
Risser
Sex
Menarche
Age
Peak Height Velocity
Neurofibromatosis
Achondroplasia
OI
Marfan's
Irradiation
Achondroplasia
SED
Polynesians (trefoil)
Prematurity
Osteopetrosis
Degenerative discs
Spondylolisthesis
Kyphosis
Trauma
Iatrogenic
- post laminectomy
Miscellaneous
- Paget's
- AS
- DISH
- Fluorosis
Tumour
Dysplastic
- 20%
- abnormal L5 / S1
- around 6 years old
- tendency to worse slips
- worse symptoms as posterior elements move forwards
- may have SB occulta
- L5 kyphosis
- L5 nerve root
Isthmic
- 50%
- L5/S1
- adolescents
- L5 lordosis
- L5 nerve root
- may be acute / chronic / elongated and thinned
Degenerative
- facet joints
- L4/5
- slips limited to Grade II
Trauma
- fracture not of pars
- neural elements
Iatrogenic
- laminectomy
Pathological
- weak posterior elements
- OI, Larsen's, Marfans
Congenital vertebral anomaly
Cord tumour / fibrosis of SCM
Ocular dysfunction
HNP (number 1)
Trauma
- atlanto-axial rotatory displacement
- C1/2 fracture
Viral pharyngitis / Griesel's
Infection / discitis
Scar / burns
Muscle spasm
Trauma
Infection
- bacterial / viral / fungal
Tumour
- benign
- malignant - primary / secondary
Inflammatory
- RA
- seronegative / RAPE (Reiter's, Ankylosing spondylitis, Psoriasis, Enteropathic)
- CT (SLE / sarcoidosis / scleroderma)
Metabolic
- osteoporosis / osteomalaciae / rickets
- gout / pseudogout / HADD
- haemochromatosis / ochronosis
Endocrine
- DM
- thyroid / parathyroid
- Paget's
Neuromuscular
- SB, CP, Muscular dystrophy
- Charcot
Dysplasia
- OI, Achondroplasia, MED, SED, Metaphyseal, Diaphyseal
- multiple exostosis
- multiple enchondromatosis
Degenerative
- primary or secondary OA
Developmental
- SUFE, Perthe's, DDH
Drugs / Toxins
- alcohol, medications
Vascular
- AVN
- Hemophilia
Idiopathic / Iatrogenic
Synovial
- PVNS, chondromatosis
Sychiatric
Congenital
- Marfans / Ehler Danlos / Downs / NF
1-5 Years
Osteomyelitis
Metastatic neuroblastoma
Leukaemia
Eosinophilic granuloma
Unicameral bone cyst
6-18 years
Unicameral bone cyst
ABC
Non-ossifying fibroma
Ewings
Osteomyelitis
Osteosarcoma
Enchondroma
Chondroblastoma (epiphyseal)
Chondromyxoid fibroma
Osteoblastoma
Fibrous dysplasia
19-40 years
Ewings
Adamantinoma
GCT (epiphyseal)
Osteosarcoma (rare)
(OB, CMF, Enchondroma)
> 40 years
Metastatic disease (polyostotic)
Multiple Myeloma
Chondrosarcoma
MFH / fibrosarcoma
Brown tumor (polyostotic)
Neuroblastoma
- sarcoma of nervous system
- usually <10y
- most common in ANS / adrenal medulla
Wilm's tumour
- nephroblastoma
- similar appearance to rhabdosarcoma
Fibrous Dysplasia
ABC
Giant Cell tumour
Simple bone cyst
Geographic
Least aggressive
- usually indicative of slow growing lesion
- usually seen in benign tumours
- may be myeloma / mets / OM
Narrow transition from normal to abnormal bone
- Margin of the lesion is well defined
- margin is easily separated from surrounding bone
- margin may be smooth / irregular, sclerotic / non sclerotic
Moth-eaten
More aggressive
- characteristic of more rapidly growing lesion
- seen in malignant bone tumours & osteomyelitis
Wider zone of transition from normal to abnormal
- less well defined lesional margin
Permeative
Aggressive bone lesion with rapid growth potential
- malignant tumours such as Ewing's
Wide zone of transition
- lesion is poorly demarcated
- not easily separated from surrounding N bone
In general 1° malignant tumours are larger than benign tumours
- may be >5cm when first discovered
Benign lesions grow slowly or not at all
- plasma cell cytomas may occas be slow
- benign tumours occas are fast
Slowly growing lesions can have associated sclerotic reactive margin
Calcification
- usually central
- may be ring-like, flocculent, fleck-like
DDx
- chondromas, chondroblastoma, chondrosarcoma, chondromyxoid fibroma
- synovial sarcoma
- occasionally seen in ewings (rare)
- hemangioma
Neoplastic Bone
- osteosarcomas, ossifying fibromas, osteomas, osteoblastomas
Ground Glass
- fibrous dysplasia
If lesion erodes endosteal surface
- new bone tends to be laid down on periosteal surface and the bone widens
Non aggressive
- may not provoke an endosteal reaction
Enchondroma / chondrosarcoma
- can lead to endosteal scalloping & new periosteal bone may be laid down
ABC
- can expand the cortex rapidly
Malignant tumours
- can expand through cortex and lift periosteum
Periosteal reaction
- slow growing tumour can evoke a periosteal response
- can get buttress at junction of normal & expanded bone
Onion skin pattern
- Ewing's
- multiple layers of periosteal new bone formation
Codman's triangle
- OS, Ewing's, infection
- lifting of periosteum at edge of lesion with bone formation
Sunburst pattern
- OS
- rays of periosteal bone formation radiating away from the bone
Primary malignant bone neoplasm
Metastasis
Infection
Central
- enchondroma, simple bone cyst
Eccentric
- GCT, OS, chondrosarcoma, fibrosarcoma, chondromyxoid fibroma, ABC
Cortical
- Nonossifying fibromas, osteoid osteomas, intracortical OS
Juxtacortical
- osteochondromas, parosteal OS
Position in Longitudinal Plane
Epiphyseal
Child
- chondroblastoma until proven otherwise
- consider OM, EG
Adult
- GCT
- arises in metaphysis but quickly penetrates closed physis into epiphysis
- consider clear cell chondrosarcoma, ganglion, eosinophilic granuloma, chondromyxoid sarcoma
- child - chondroblastoma
Metaphyseal
- NOF
- UBC
- osteochondroma
- brodie's abscess
- OS
- CS
Diaphysis
- Ewings
- UBC
- ABC
- enchondroma
- OB
- fibrous dysplasia
Age of malignant osseous lesions
< 1
- metastatic neuroblastoma
1 - 30
- OS
- Ewing's
30 - 60
- CS
- 1° lymphoma
- MFH
> 50
- metastatic disease
- multiple myeloma
Polyostotic versus Monostotic
Non-aggressive polyostotic lesions
- Fibrous dysplasia
- Paget's disease
- Histiocytosis
- Multiple exostosis
- Multiple enchondromatosis
Aggressive polyostotic lesions
- metastases
- Multiple myeloma
- Primary bone tumor with osseous metastases
- An aggressive phase of Paget's disease
- Multifocal osteomyelitis
- Aggressive histiocytosis
- Multifocal vascular bone tumors
Metastasis
Solitary
- rare
- thyroid
- kidney
Appearance
- moth eaten
- wide zone of transition
- no sclerotic rim
Purely lytic
- lung
- breast
- kidney
- thyroid
- GI
- neuroblastoma
Blastic
- prostate
- breast
- bladder
- lung
Mixed
- breast
- prostate
- lung
Histiocytoma (MFH)
Adamantinoma
Lymphoma
Fibrous dysplasia
Ewing's
EG
Giant Cell
Chondroblastoma
Clear Cell Chondrosarcoma
PVNS
Infection
Telangiectic Osteosarcoma
Enchondroma
Brodie's Abscess
ABC
Geode
Trevor's Disease
Melanoma - most common
Synovial Sarcoma
Ganglion
Giant Cell Tumour Tendon Sheath
PVNS
Plantar fibromatosis / fibroma
Lipoma
AVM
NF / Schwannoma
Hemangioma
Glomus Tumour
Pathological fracture
Infection
N/V involvement
LLD > 6-8cm
Extensive muscle involvement
Good biopsy (actually poor biopsy)
Synovial sarcoma
Epithelioid sarcoma
Clear cell sarcoma (melanoma of soft tissue)
Brodies abscess
Simple bone cyst
Enchondroma
Chondroblastoma
Fibrous dysplasia
Benign fibrous histiocytoma
NOF
Juxtacortical Osteosarcoma
Intraosseous Hemangioma
Haemangioma
ABC
Desmoid Tumours
Giant Cell Tumour
Ganglions
Albrights (Fibrous dysplasia / Café au Lait / Precocious puberty)
Leiomyosarcoma
Enostosis
Osteoma
Fibrosarcoma of bone
Enchondroma
Myositis ossificans progressiva
Lipomas
Fibrosarcoma
Neurosarcoma
Haemagioendothelioma
Haemangiopericytoma
Fibrous dysplasia
Paget's disease
Histiocytosis
Multiple exostosis
Multiple enchondromatosis
Osseous metastases
Multiple myeloma
Primary bone tumor with osseous metastases
An aggressive phase of Paget's disease
Multifocal osteomyelitis
Aggressive histiocytosis
Multifocal vascular bone tumours
Vascular
- hemangiomas / AVN
Infection
Neoplasm
Primary - Osteoma / OO / OB / OS
Secondary - lymphoma, blastic metastatic - prostate, breast, lung
Drugs
- vitamin D, fluoride
Inflammatory
- SAPHO
Congenital/Cartilage
- enchondroma / osteochondroma / bone islands
- bone infarct
- osteopetrosis
Autoimmune
Trauma
- stress fracture
Endocrine
- Paget's disease, hyperparathyroidism
OO
Osteoma
Osteomyelitis
Parosteal OS
Stress Fracture
Ewing's / PNET
Small cell Osteosarcoma
Embyronal Rhabdomyosarcoma
Metastatic Neuroblastoma
Myeloma
Small cell Lung Ca
Lymphoma
Mesenchymal Chondrosarcoma
Soft Tissue Sarcoma
Hemangioma
Chondromatosis
Myositis Ossificans / Heterotropic Ossification
Calcified Lymph node
Aneurysm
OS / CS
Vascular - hemangioma, AVM, lymphangioma, glomus
Neurogenic - NF, schwannoma
Muscular - leiomyoma
Fibroblastic - desmoid tumour, fibromatosis
Fat - Lipoma
Cyst - Simple cyst
Synovium - PVNS / synovial chondromatosis
Bone - MO
Other - FB
Malignancy - sarcoma
Fibrous Dysplasia, Fibrosarcoma
Osteoblastoma/ Osteoid Osteoma / Osteosarcoma
Giant Cell Tumour
Malignancy / Mets / Myeloma
Primary
- Ewing's, Osteosarcoma, Chondrosarcoma
- Myeloma
Secondary
- Metastasis
- leukaemia, lymphoma
ABC / Adamantinoma
Cartilage
- enchondroma, osteochondroma
- Chondroblastoma
- Chondromyxoid Fibroma
Hemangioma / Hyperparathyroidism / Haemophilia / Histiocytoma
Infection / Intra-osseous ganglion/ Lipoma/fibroma
Non-Ossifying Fibroma / NF
Eosinophilic Granuloma
Simple Bone Cyst / synovial condition (PVNS)
Posterior elements
- Osteoid Osteoma
- Osteoblastoma
- ABC
Anterior
- Giant Cell tumour
- EG
- Hemangioma
Primary
- Chordoma
- Ewings
- Osteosarcoma
- Chondrosarcoma
- Multiple myeloma
Secondary
- Lymphoma / Leukaemia
- metastasis
Posterior elements
- OO, OB
- ABC
Vertebral body
- Giant cell
- Hemangioma
Sacrum
- chordoma
- Ewings
Child
- EG
- Ewing's
- Leukaemia / lymphoma
Adult
- mets
- MM
- hemangioma
- leukaemia / lymphoma
Absorption of distal tuft of phalanx
Psoriasis
Scleroderma / Raynauds
Frostbite
Hyperparathyroidism
Diabetes
Vasculitis
Leprosy
RA rarely
Gout
1. Trauma
- blunt trauma
- anterior shoulder dislocation
- proximal humeral fracture
2. Iatrogenic
- deltoid splitting approach
- deltopectoral approach
3. Quadrangular space syndrome
- pain in abduction and ER
- diagnose on dynamic angiogram
4. Parsonage Turner syndrome
- brachial neuritis
- can rarely affect AXN in isolation
5. Nerve compression from mass effect
- tumour / aneurysm
OA
Psoriasis
CREST (scleroderma)
RA (rare form)
Other seronegative arthropathies
Hyperparathyroidism
Reactive arthropathy
Gout
Unable to extend finger in RA
Extensor tendon rupture
MCPJ dislocation
Dislocation extensor tendons
PIN palsy (loss of extension wrist and thumb)
Locked trigger finger
Humeroradial OA
Capitellar OCD
RA
Lateral epicondylitis
Posterolateral instability
Radial Tunnel Syndrome / Supinator Syndrome
Radiculopathy
Above elbow
- ligament of Struthers
Forearm
- bicipital aponeurosis
- pronator teres
- FDS
- fascial bands
- vascular sheaths
- accessory muscles
Carpal tunnel
Epidermoid inclusion cyst
Ganglion
GCT of tendon sheath
Haemangioma
Abscess
Neurilemoma / Neurofibroma
Dupytrens
FB granuloma
Lipoma
AVM / Aneurysm
Gout
Malignancy
- fibrosarcoma
- synovial sarcoma
- MFH
Fibrous bands
- level of radio-capitellar joint
Recurrent leash of Henry
- radial recurrent artery
- vessels to mobile wad
ECRB
- fibrous margin
Arcade of Frohse
- free fibrous proximal edge Supinator (superficial belly)
- most common site of compression
- always release
Supinator distal edge
- occasional cause
- always decompress to here
Brachial Plexus injury
Neurofibroma
Humeral shaft injury
- Holstein Lewis
- long spiral fracture where nerve can get caught
Monteggia fracture
Iatrogenic
- radial plate or removal
- ORIF radial head or neck fracture
Radial Tunnel compression
PIN syndrome
- RA, ganglion
De Quervain tenosynovitis
OA Base thumb / STT
G Ganglion - volar
W Wartenberg's syndrome (compression superficial branch radial nerve)
R Radial artery thrombosis
I Intersection syndrome (ECRL/B crossed by APL & EPB)
S Scaphoid fracture / non-union / SL instability / SLAC wrist
T Tumour
R RA - more common ulna
I Infection
F FCR synovitis
T CTS
Due to ST articulation disorder
1. Neurological
A. Spinal accessory nerve / Trapezius palsy
- iatrogenic (lymph node biopsy)
- stab wound
B. Long thoracic nerve / Serratus anterior palsy
- iatrogenic (mastectomy)
- trauma
- repetitive microtrauma / swimming
C. Dorsal scapular nerve / Rhomboids palsy (rare)
2. Osseous
Osteochondromas
Fracture Malunions
3. Soft Tissue
Muscular origin
- traumatic ruptures of Serratus Anterior
- iatrogenic / thoracotomy
Due to GHJ articulation disorders
A. Erb’s palsy
- compensatory for IR contracture
B. Deltoid fibrosis
- injury or repeated IM injections
C. Painful conditions
- i.e. RC tear, fracture, impingement
- compensatory
Rare
Turner's syndrome
Aperts syndrome
Myositis ossificans progressiva
Pseudohypoparathyroidism
RA
Tight intrinsics in CP / CVA
Laxity volar plate / patients with ligamentous laxity
P2 fracture malunited in extension
Mallet injury
Volar plate tear
Secondary to FDS sacrifice (volar plate attenuates)
Proximal
Arcade of Struthers
- thick myofascial band, 1.5-2cm wide
- present in 70%
- 8cm proximal to medial epicondyle
- from medial head of triceps to medial intermuscular septum, superficial to nerve
Medial intermuscular septum
- with subluxation, nerve may impinge on it
Medial head of triceps
- hypertrophied (body builders)
Medial epicondyle
Tardy ulna nerve palsy / cubitus valgus
- compression due to valgus deformity of the bone
- previous supracondylar / lateral condyle fracture
Cubital tunnel / Osbourne's ligament
Anatomy
- walls are humeral & ulna heads of FCU
- floor is MCL
- roof is Osbourne's fascia (continuation of fibro-aponurotic covering of epicondylar groove)
Nerve compression
- occurs in flexion as Osbourne's fascia tightens
- MCL bulges out and tunnel becomes flattened ellipse
FCU
Nerve passes intramuscular for ~5cm
- penetrates fascial layer to lie on FDP
- proximal and distal compression possible
Other
A. Lesions in the groove
- medial epicondyle fracture / arthritic spurs / HO
- lipomas / ganglia / osteochondromas / synovitis / rheumatoid nodule
- infection (TB, leprosy) /bleeding (haemophilia)
B. Conditions outside the groove
- external compression
- anomalous anconeus muscle
C. Subluxation / Dislocation from the groove
- laxity / traumatic tear of fibro-aponurotic roof
DRUJ
- dislocation
- subluxation
- arthritis
TFCC
- degeneration
- tears
Kienbock's
Fracture
- ulna styloid fracture
- carpal fracture / hook of hamate
Ulnocarpal abutment
Pisiform
- OA
- subluxation
LT instability
ECU
- subluxation and rupture
- tendonitis (+/- calcific)
Infection
Tumour
Ganglion