Arthitis Xray

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

 

Bone in Bone

Infection

 

Caffey's

 

Diaphyseal dysplasia

 

Pyknodysostosis

 

FHO

 

 

 

Charcot Joints

SAD SLIPS

 

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

 

 

Chondrocalcinosis

WHIP A DOG

 

Wilson's

Haemochromatosis

Idiopathic

Pseudogout, pernicious anaemia

 

Amyloid, acromegaly

 

Diabetes

Ochronosis

Gout

 

 

 

Deformity

6 Causes of Joint Deformity

 

Skin contracture - burn

 

Fascial contracture - Dupuytren

 

Muscle contracture - Volkmann's

 

Muscle imbalance - asymmetric paralysis

 

Joint instability - ACL rupture

 

Joint destruction - RA

 

6 Causes of Bone Deformity

 

Congenital disorder - Pseudoarthrosis

 

Soft bone - Rickets, osteomalacia, OI

 

Dysplasia - Hereditary Multiple Exostosis

 

Physeal injury

 

Malunion

 

Paget's

 

 

 

 

Failed Surgery

 

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

 

 

 

 

Gait

STRAWS

 

Short

Trendelenberg

Rigid

Antalgic

Weak

Spastic

 

 

 

 

General Osteopenia

Primary

 

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

 

Secondary / DDD NICE

 

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

 

 

 

Generalised Sclerosis

VD FROM PA

 

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

 

 

 

 

 

 

Inflammatory Arthritis

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

 

 

 

Local Osteopaenia

TO DROP BART

 

Transient Osteoporosis of Hip

Osteolytic Tumour

Disuse

RA

Osteomyelitis

Paget's

Burns

AVN

RSD

TB

 

 

 

Nonunion

Patient Factors

 

Patient factors

- age

- nutrition / catabolic states

- anaemia

- smoking

- alcohol

- DM

- immunocomprimise

- non compliance       

 

Pharmacological agents

- steroids

- cytotoxics

- ciproflaxacin

- NSAIDS

 

DXRT

 

Injury factors

     

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

     

Surgeon factors

 

Distraction of fracture

Inadequate stability with excessive movement

Excessive stability

Extensive approach with vascular compromise

No axial load

 

 

 

 

     

Periosteal Reaction

I BIT NOAH CNS

 

Infection

     

Blood

- Haemophilia

- DVT

 

Inflammatory arthritis

 

Trauma

 

Neoplasia

 

Osteoarthropathy Hypertrophic

 

A Vitaminosis

 

Hypophosphatasia / Hyperthyroidism

 

Caffey's/ Child Abuse

 

NF

 

Scurvy

 

 

 

 

Peripheral Neuropathy

Idiopathic ~ 50%

 

Congenital

 

HMSN

Friedrich's Ataxia

 

Acquired

 

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

 

 

 

 

 

Soft Tissue Calcification

Metastatic

 

Hypercalcaemia

- primary HPTH

- secondary HPTH

- malignancy (production of PTH like proteins)

- Vit D intoxication

- Milk Alkali Syndrome

- Sarcoidosis

     

Dystrophic

 

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

 

Metatarsalgia

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

 

 

 

AVN Hip

AS IT GRIPS 3Cs

 

Alcohol

Steroids

 

Idiopathic

Trauma

 

Gout, Gauchers

Rheumatoid / radiation

Infection / increased lipids / inflammatory arteritis

Pancreatitis / pregnancy

SLE / sickle cell / smoking

 

CRF / chemotherapy / Cassion's disease

 

 

 

 

 

Cavovarus Foot

2. Neuromuscular

 

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

 

2. Congenital

 

Congenital cavus foot

Residual clubfoot

Arthrogryposis

 

3. Traumatic

 

Residual of Compartment Syndrome

Crush injury to lower extremity

Severe burn

Malunion of fractured foot

 

4. Degenerative / Inflammation

 

OA / RA of hindfoot

 

5. Idiopathic

 

Usually pure cavus = calcaneocavus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic Lateral Ankle Pain

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

 

 

 

 

 

 

 

 

Hallux Valgus

Extrinsic

 

Shoe Wearing

 

Intrinsic

 

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

 

 

 

 

Hip Arthritis

Primary          

 

Secondary

 

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

 

 

 

       

Knee Loose Body

Osteochondral fracture

OA / cartilage fragments

Synovial chondromatosis

Meniscus Tear

ACL Stump

 

 

Knee Pain

Medial

 

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  

 

Lateral

 

Extra-articular

 

ITB

             

Intra-articular

 

Lateral meniscus tear

Discoid meniscus

                    

Anterior

 

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       

           

Hip

 

 

 

Mass Behind Knee

DDx

 

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

 

 

 

Painful TKA

Knee Pain

 

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

 

Referred Pain

 

Hip 

Back 

      

Expectation/Result mismatch 

 

Unrealistic expectations 

Secondary gain issues 

Psychiatric disorders and depression 

 

 

Pes Planus

Congenital

 

Flexible

 

Physiologic (painless / painful)

Ligamentous laxity (DIAL HOME CS)

 

Rigid

 

CVT

Tarsal Coalition

Skewfoot

 

Acquired

 

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

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protusio Acetabuli

Primary

 

Otto's Disease

- bilateral 1/3

- middle aged females

- pain & decreased ROM early

- coxa vara & OA common

 

 

Secondary / PROFSHAMN

 

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

 

 

Snapping Hip

Intra-articular Structures

 

Labrum

Ligamentum teres

Loose Bodies

Synovial chondromatosis

Osteocartilaginous exostoses

 

Extra-articular Structures

 

Fascia lata on greater trochanter (common)

Iliopsoas on lesser trochanter / iliopectineal eminence

Long head biceps femoris over ischial tuberosity

Iliofemoral ligament over femoral head

 

 

 

Tibialis Post Dysfunction

Associations

      

Hypertension

Prior surgery

Obesity

Steroids

Trauma

Diabetes

     

Inflammatory

 

RA

Seronegative

 

Other

 

Hypermobile flatfoot

 

 

 

 

Abnormal Physis

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 (2^o spongiosa abnormal development)

 

 

 

 

Adolescent Knee Pain

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           

 

 

 

 

 

 

 

 

 

Brachial Plexus Injury

Clavicle / Humeral Fracture

- should feel fracture / crepitus

 

Arthrogryposis

- no elbow crease

 

Monoplegic CP

 

Causes SUFE

Mechanical

 

Anatomical

- increased retroversion

- increased physeal angulation

 

Increased weight

- overweight immature males

 

Tall children at end of growth spurt

 

Biochemical

 

Hypothyroidism

 

Hypogonadism, panhypopituitarism, pituitary tumours

 

Acromegaly

 

Hyperparathyroidism

 

Rickets / renal osteodystrohy

 

Iatrogenic - GH, chemotherapy, XRT

 

Genetic

 

Klinefelter’s, Downs, Marfan's

 

 

 

 

Congenital Sclerosis

MD COP MOOO

 

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)

 

 

 

Coxa Vara

ACDC

 

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

 

 

 

Erlenmeyer Flask

TOM & GLEN

 

Thalassemia

Osteopetrosis

Metaphyseal Chondrodysplasia

Mastocytosis

Pyle’s (metaphyseal dysplasia)

 

Gaucher’s

Lead poisoning

Enchondroma --> Ollier’s & Maffucci’s

NF

 

 

 

Frayed Metaphysis

Definition

 

Deficiency of calcification in zone of provisional calcification physis

- requires vit D / C
- gives metaphyseal cupping

 

MMM RASH = Syphilis & Rubella

 

Metaphyseal Chondrodysplasia

Metaphyseal Dysplasia / Pyles disease

MPS

 

Rickets

Achondroplasia

Scurvy

Hypophosphatasia

 

Congenital Infection - Syphilis & Rubella

 

 

 

Genu Valgum

Physiological

 

Physiological valgus

- up to 8 years

- treat > 8 years and > 15˚

 

Pathological

 

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

 

 

 

 

 

 

 

Genu Varum

Physiological

 

Physiological genu varum

- < 2 years

 

Lateral Bowing

 

Pathological

 

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

 

 

 

Growth Arrest

 

Trauma / ORIF

Infections

Chemotherapy

Radiotherapy

Burns

Immobilisation

 

 

LLD

General

 

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

 

Specific

 

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

 

Ligamentous Laxity

DIAL HOME CS

Down’s Syndrome

Idiopathic (familial)

Achondroplasia

Larsen’s Syndrome

 

Homocystinuria

Osteogenesis imperfecta

Marfan’s Syndrome

Ehlers Danlos

 

Congenital contractural arachnodactyly (Marfans variant)

Sticklers

 

Multiple Fractures

Accidental injury

NAI

OI

Rickets

Juvenile osteoporosis

Leukaemia

Caffey’s

 

Osteopetrosis

Fibrous Dysplasia

Homocystinuria

Congenital syphilis

Congenital indifference to pain

 

 

Neuromuscular Disease

Motor Only

 

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

           

Sensory Only

 

Peripheral

- diabetes

- alcohol

- acromegaly

- amyloidosis

- chronic demyelinating polyradiculopathy

 

Sensory Cortex

- CVA

           

Mixed Sensorimotor

 

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

 

 

 

 

 

 

Pes planus

Congenital

 

Flexible

- compensatory - tight T achilles / out-toeing / genu valgum

- physiological

 

Rigid

- CVT / tarsal coalition / skewfoot

 

Acquired

 

Trauma

- midfoot fracture / Lisfranc / rupture spring ligament / rupture plantar fascia

 

Neuromuscular

- CP, spina bifida, polio

 

 

 

 

 

 

Radial Head Dislocation

Congenital

 

Skeletal Dysplasias / MAD KEN LOOT               

- Achondroplasia / Down's

- Marfans / Ehler Danlos / Larsens

 

Congenital

- rare

- anterior or posterior

- lateral uncommon

 

Acquired

 

Trauma / Missed Monteggia

 

Osteochondroma

 

 

 

 

 

 

 

 

Rotational Profile

DDx In-toeing

 

PFA

- usually symmetrical

- resolve by 8

- consider CP

 

ITT

- may be asymmetrical

- usually resolves

 

Metatarsus adductus

- no treatment required

 

Metatarsus primus varus

 

Skewfoot

 

DDx Out-toeing

 

ETT

- asymmetrical

 

SUFE

 

 

 

 

 

 

Scoliosis

Congenital (VACTERL)

 

Failure formation (unilateral bar / block)

Failure segmentation (wedge, hemivertebrae)

 

NM

 

CP

SB

Muscular dystrophy

Young SCI

 

Other (NAOMI’S)

 

NF

Achondroplasia

OI (basilar invagination)

Marfan’s

Irradiation

SED (atlanto-occipital)

 

Adolescent Idiopathic

 

Risks of progression

- MR Sex MAP

 

 

 

 

Skeletal Dysplasia

COMMON HEAD FOG

 

Chondromalacia punctae

 

OI

 

MED / SED

Metaphyseal Dysplasia

Mucopolysaccharidases

Osteopetrosis

NF

 

Hypophosphataemia

Exostosis

Achondroplasia

Diaphyseal Dysplasia / Diastrophic Dysplasia

 

Fibrous Dysplasia

Ollier’s (multiple enchondromas)

 

 

 

 

 

 

Stippled Epiphysis

Definition

 

Epiphyseal fragmentation

 

MOCHAS MSG Warfarin 21

 

MED

Osteopoikilosis

Chondrodysplasia Punctata

Hypothyroidism - Cretinism

AVN / Sickle cell / Gauchers

SED

 

Morquio

Sickle Cell

Gaucher's

 

Warfarin

 

Downs syndrome

 

 

 

 

 

 

 

 

 

 

 

Tibial Bowing

4 types

 

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

 

 

 

Toe Walking

1.  Habitual

 

Normal til age 3

- child can actively heel walk

 

2.  Structural

 

Fixed equinus – CTEV / arthrogryposis

Short / tight T Achilles

SOL in calf

 

3.  Neuromuscular

 

CP

Spinal dysraphism / tethered cord

DMD– Duchenne / Gower’s

CMT

 

4.  Short leg

 

Real - unilateral

Apparent - knee or hip deformity

 

 

 

Wormian Bones

Cretin PORK CHOPS

 

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

 

 

 

 

Adult Back Pain / Sciatica

Extrinsic lesions

 

Urogenital system - tumour / stones

 

Gastrointestinal system

 

Vascular system - AAA

 

Intrinsic lesions

 

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

Anterior Vertebral Beaking

Lower third

 

Achondroplasia

Hurler syndrome

Down syndrome

Cretins

NF

 

Central

 

Morquoi syndrome

Pseudoachondroplasia

Spondylometaphyseal dysplasia of Kozolowski

 

Atlantoaxial Instability

Primary

 

2° laxity of transverse ligament

 

DIAL HOME CS

 

Secondary 

 

Trauma

 

Infection  

- retropharyngeal abscess

- Grisel's syndrome

 

Inflammatory

- JRA

 

Congenital

- Down's syndrome - very common 15%

- Achondroplasia

- MPS & SED

- Os Odontoideum

 

 

 

 

 

Basilar Invagination

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

 

Congenital / SAD MAN BOOK

 

SED

Achondroplasia

Downs

 

Morquio

Atlas Hypoplasia

NF   

 

Bifid posterior arch atlas

Occipitocervical synostosis

OI

Klippel Feil syndrome  

     

Acquired

 

JRA

Rickets

RA

     

 

 

Ivory Vertebra

Common

 

Osteoblastic metastasis (prostate or breast)

Lymphoma

Paget's disease

Hemangioma

 

Uncommon

 

Osteopetrosis

Sickle cell disease

Myelosclerosis

Fluorosis

Carcinoid

Mastocytosis (very rare etiology for an ivory vertebra)

 

 

 

Kyphosis

Common

 

Postural

Scheuremann's

Ankylosing spondylitis

Osteoporotic fractures

TB

Iatrogenic - post laminectomy

 

Metabolic

 

Osteomalacia

Osteoporosis

Morquio's

 

Neuromuscular

 

Polio

Syrinx

SB

 

Congenital

 

OI

SED

Achondroplasia

Congenital kyphosis

 

 

 

Paediatric Back Pain

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

 

 

 

 

 

 

 

 

 

Platyspondyly

Vertebroplanar

 

 

EG

Ewing's

Lymphoma / leukaemia

Infection

ABC

Mets / myeloma

 

Congenital

 

Metatropic dysplasia

OI

Morquio

Achondroplasia

SED

 

Acquired

 

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

 

 

 

Schmorl Node

SHOOT

 

Scheuermann's

Hyperparathyroidism

Osteoporosis

Osteomalacia

Trauma

 

 

Sclerotic Vertebrae

Fibrous dysplasia

Osteopetrosis

Osteoblastic metastasis

Lymphoma

Infection

Sickle cell

Haemangioma

 

Pagets

Osteoblastoma

Osteoid Osteoma

Fluorosis

 

Scoliosis

Non structural scoliosis / CHIPS

 

Compensatory

Hysterical

Irritative

Postural

Sciatic

 

Risk of Progression / MR Sex MAP

 

Magnitude

Risser

Sex

Menarche

Age

Peak Height Velocity

 

Other causes / NAOMI

 

Neurofibromatosis

Achondroplasia

OI

Marfan's

Irradiation

 

 

 

Spinal Stenosis

Congenital

 

Achondroplasia

SED

Polynesians (trefoil)

Prematurity

Osteopetrosis

 

Acquired

 

Degenerative discs

 

Spondylolisthesis

 

Kyphosis

 

Trauma

 

Iatrogenic

- post laminectomy

 

Miscellaneous

- Paget's

- AS

- DISH

- Fluorosis

 

Tumour

 

 

 

 

Spondylolithesis

DID TIP

 

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

 

 

 

 

Wry Neck / Torticollis

Congenital

 

Congenital vertebral anomaly

Cord tumour / fibrosis of SCM

Ocular dysfunction

 

Acquired

 

HNP (number 1)

 

Trauma

- atlanto-axial rotatory displacement

- C1/2 fracture

 

Viral pharyngitis / Griesel's

 

Infection / discitis

 

Scar / burns

 

Muscle spasm

 

 

 

 

 

Age Prediction

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

 

 

Bone Multiloculated Defect

Fibrous Dysplasia

ABC

Giant Cell tumour

Simple bone cyst

 

 

 

Bone Tumour X-rays

1.  Pattern of bone destruction

 

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

 

2.  Size

 

In general 1° malignant tumours are larger than benign tumours

- may be >5cm when first discovered

 

3.  Growth rate

 

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

 

4.  Visible tumour matrix

 

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

 

5.  Cortical erosion

 

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

 

6.  Periosteal response

 

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

 

7.  Soft Tissue Mass

 

Primary malignant bone neoplasm

Metastasis

Infection

 

8.  Position in Transverse Plane

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

Diaphyseal Lesions

HALFEE

 

Histiocytoma (MFH)

Adamantinoma     

Lymphoma

Fibrous dysplasia

Ewing's

EG

 

 

Epiphyseal Lesions

 

Giant Cell

Chondroblastoma

Clear Cell Chondrosarcoma

PVNS

Infection

Telangiectic Osteosarcoma

 

Enchondroma

Brodie's Abscess

ABC

Geode

Trevor's Disease

Foot Soft Tissue

Malignant

 

Melanoma - most common

Synovial Sarcoma

 

Benign

 

Ganglion

Giant Cell Tumour Tendon Sheath

PVNS

Plantar fibromatosis / fibroma

Lipoma

AVM

NF / Schwannoma

Hemangioma

Glomus Tumour

 

 

 

 

 

Limb Salvage Contra-indications

PIN LEG

 

Pathological fracture

Infection

N/V involvement

 

LLD > 6-8cm

Extensive muscle involvement

Good biopsy (actually poor biopsy)

 

 

Lymphatic Spreading MSK Tumors

Synovial sarcoma

Epithelioid sarcoma

Clear cell sarcoma (melanoma of soft tissue)

 

 

 

Lytic Lesions Sclerotic Rim

Brodies abscess

Simple bone cyst

Enchondroma

Chondroblastoma

Fibrous dysplasia

Benign fibrous histiocytoma

NOF

 

 

 

Male vs Female

Tumours with Female  Prevalence

 

JIHAD GAL

 

Juxtacortical Osteosarcoma

Intraosseous Hemangioma

Haemangioma

ABC

Desmoid Tumours

 

Giant Cell Tumour

Ganglions

Albrights (Fibrous dysplasia / Café au Lait / Precocious puberty)

Leiomyosarcoma

 

Male = Female Prevalence

 

Enostosis

Osteoma

Fibrosarcoma of bone

Enchondroma

Myositis ossificans progressiva

Lipomas

Fibrosarcoma

Neurosarcoma

Haemagioendothelioma

Haemangiopericytoma

 

 

 

 

Polyostotic

Non-aggressive

 

Fibrous dysplasia

Paget's disease

Histiocytosis

Multiple exostosis

Multiple enchondromatosis

 

Aggressive

 

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

 

 

 

Sclerotic Bone Lesions

VINDICATE

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sclerotic Cortical Lesion

OOOPS

 

OO

Osteoma

Osteomyelitis

Parosteal OS

Stress Fracture

 

 

 

Small Round Cell Tumors of Bone

Ewing's / PNET

Small cell Osteosarcoma

Embyronal Rhabdomyosarcoma

Metastatic Neuroblastoma

Myeloma

Small cell Lung Ca     

Lymphoma

Mesenchymal Chondrosarcoma

 

 

 

Soft tissue Calcification

Soft Tissue Sarcoma

Hemangioma

Chondromatosis

Myositis Ossificans / Heterotropic Ossification

Calcified Lymph node

Aneurysm

OS / CS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soft tissue mass

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

 

 

 

 

 

 

 

 

Solitary Lucency

FOG MACHINES

 

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)

 

 

 

 

Spinal Tumours

Benign

 

Posterior elements

- Osteoid Osteoma

- Osteoblastoma

- ABC

 

Anterior

- Giant Cell tumour

- EG

- Hemangioma

 

Malignant

 

Primary

- Chordoma

- Ewings

- Osteosarcoma

- Chondrosarcoma

- Multiple myeloma

 

Secondary

- Lymphoma / Leukaemia

- metastasis

 

DDx by Site

 

Posterior elements

- OO, OB

- ABC

 

Vertebral body

- Giant cell

- Hemangioma

 

Sacrum

- chordoma

- Ewings

 

 

 

 

Vertebroplanar

Child

- EG

- Ewing's

- Leukaemia / lymphoma

 

Adult

- mets

- MM

- hemangioma

- leukaemia / lymphoma

 

 

 

Acro-osteolysis

Definition

 

Absorption of distal tuft of phalanx

 

DDx

 

Psoriasis

Scleroderma / Raynauds

Frostbite

Hyperparathyroidism

Diabetes

Vasculitis

Leprosy

RA rarely

Gout

 

 

Axillary Nerve Palsy

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

 

 

 

 

DIPJ OA

DDx

 

 

OA

Psoriasis

CREST (scleroderma)

 

RA (rare form)

Other seronegative arthropathies

Hyperparathyroidism

Reactive arthropathy

Gout

 

Dropped finger RA

Definition

 

Unable to extend finger in RA

 

Causes

 

Extensor tendon rupture

MCPJ dislocation

Dislocation extensor tendons

PIN palsy (loss of extension wrist and thumb)

Locked trigger finger

 

 

 

Lateral Elbow Pain

Intra-articular

 

Humeroradial OA

Capitellar OCD

RA

 

Extra-articular

 

Lateral epicondylitis

Posterolateral instability

Radial Tunnel Syndrome / Supinator Syndrome

Radiculopathy

 

 

 

Median Nerve Compression

Sites

 

Above elbow

- ligament of Struthers

 

Forearm

- bicipital aponeurosis

- pronator teres

- FDS

- fascial bands

- vascular sheaths

- accessory muscles

 

Carpal tunnel

 

 

Palmar Lump

EGG HAND – FLAG’M

 

Epidermoid inclusion cyst

Ganglion

GCT of tendon sheath

 

Haemangioma

Abscess

Neurilemoma / Neurofibroma

Dupytrens

 

FB granuloma

Lipoma

AVM / Aneurysm

Gout

 

Malignancy

- fibrosarcoma

- synovial sarcoma

- MFH

 

 

Radial Nerve Compression

FREAS

 

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

 

Radial Nerve Injury

 

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

 

 

 

 

Radial Wrist Pain

DOG WRIST RIFT

 

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

Scapula Winging

Primary            

 

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

 

Secondary            

 

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

 

Voluntary

 

Rare

 

 

 

 

Short Metacarpal Metatarsal

TAMP

 

Turner's syndrome

Aperts syndrome

Myositis ossificans progressiva

Pseudohypoparathyroidism

 

 

 

Swan Neck Finger Deformity

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)

 

 

Ulna Nerve Compression

Sites of Compression

 

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

 

 

 

Ulna Wrist Pain

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