* cor t1 sag pd * 47f 5y increasing stiffness and decreased rom. initial presentation 4
TRANSCRIPT
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Cor T1 Sag PD
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47F 5Y increasing stiffness and decreased ROM. Initial
presentation
4
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Ankylosing SpondylitisDagger signBilateral hip inflammatory arthritis
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Ankylosing Spondylitis
• Young white men
• When fuse posteriorly, may spare anterior
• Scalloping of Cx spine
• Dagger + Bamboo = Tram tracks
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19M increasing mass on hand, refused treatment
3
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Osteosarcoma
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• Most common primary malignant bone tumor in young adults and children
• Second to MM in older
• Osteoid immature bone
• Bimodal
• Close to knee, away from elbow
• Young-cylindrical, Old-flat
Osteosarcoma
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25M with wrist pain
3
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Osteopoikilosis
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Osteopoikilosis
• Juxtaarticular bone islands
• ?AD, M>F, asymptomatic
• Ovoid 2-10mm
• Benign sclerosing bone dysplasia
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95 M pain R hip
4
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Cor T1
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Cor STIR
Pagets diseasePathological FxAsterix enhancement
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Pagets disease
• O. deformans
• 3% >40, northern latitudes, >M
• Lytic, vascular fibrous connective tissue
• Inactive, decreased turnover with sclerosis
• Mixed, common, both together
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40M painful knee
4
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Cor T1
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Sag PD
B thalassemia intermedia
*
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• Major-Homozygous-Cooley anaemia
• lack of B
• Italian and Greek
• Skull, hair on end, widened diploic
• Porosis, thin cortex, Erlenmyer flask
• Arthropathy
B thalassemia
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23M knee pain
1
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Distal MCL injury
*
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• Ossification points to joint
• MHE points away from joint
Distal MCL injury
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Sag T1
Sag PDFS
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Sag T1
Sag PDFS
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C5
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50M heel pain
2
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Sag T1
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Sag PDFS
*
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Involuting lipoma
• Any age, equal sex
• Calcaneus>Femur>Tibia>Fibula
• Can have central dystrophic calcification
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13F painful footNo trauma
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Sag T1
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Sag PDFS
*
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57ML hip pain
3
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Sandwich vertebraeOsteopetrosis
*
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Osteopetrosis
• Marble bone, Defective osteoclasts
• AR, Infantile, Systemic, Leukaemia
• AD, Adult, Fxs, anaemia, CN palsy
• Sclerotic, peri and endosteal
• Erlenmyer flask
• Bone in bone, sandwich vertebrae
• Calvaria and mandible spared
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Variable patients Same condition
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*
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Pseudohypoparathyroidism
• X-linked, renal and skeletal resistance to PTH
• Short, retarded,
• Decreased Ca, normal/increased PTH
• Brachydactyly 1,4,5 MC
• Ca basal ganglia, skin, SubQ
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Variable patients Same condition
8
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Dermatomyositis
• Damaged chondroitin sulfate
• Atrophy, oedema, necrosis of muscle
• 30-60, F>M
• Calcification extremities and girdles
• Pointing of tufts
• Ass. Malignancy, lung, kidney, ovary, breast
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35M with recent traumaFlex / Ext
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C5
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C5
C6
C6 Fx subluxation
*
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Signs of instability
• Spinous process fanning
• Widening of disk space
• Horizontal displacement >3.5mm
• Angulation >11 degrees
• Disruption of facets
• Multiple fractures at one level
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*
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*
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*
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10M painful neck
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Transient disc calcification of children
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• Painful
• Pain lasts weeks
• Calcification lasts months
• Adjacent vertebrae flattened
Transient disc calcification of children
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28F pain in lumbar region
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Anterior limbus with instability*
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Limbus Vertebrae
• More often anterior and superior
• More significant posterior
• Disc herniates through ring apophysis
• Commonest lower lumbar
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37F acute torticollis, stiffness and shortness of breath
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Fibrodysplasia ossificans progressiva*
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• MOP / Stone man
• Rare, AD, sporadic
• Presents in childhood
• Stiffness, Heterotopic ossification
• Malformed fingers and toes
• Bone morphogenic protein (BMP) signaling pathway problem
Fibrodysplasia ossificans progressiva
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48M joint pains and dark pigmentation on ears
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Alkaptonuria
*
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Alkaptonuria / Ochronosis
• Absence of homogentisic acid oxidase
• Pigmentation
• Arthropathy
• Osteoporotic with dense disc calcification
• Larger joints show DJD
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6mMCalcareous nodules
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Idiopathic calcinosisuniversalis
*
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28BF mass in shoulder
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Idiopathic Tumoral Calcinosis
*
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*
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Ax PDFS Ax T1
*
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Cor T1
Cor T2
*
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*
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1518960
*
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Sag T1
*
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81M shoulder pain
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Chondrocalcinosis*
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Chondrocalcinosis
• CPPD
• Hyperparathyroidism
• Hemochromatosis
• Acromegaly
• Gout
• Wilsons disease
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45F swelling of arm with numbness of 2nd and 3rd fingers
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Ax PDFS Ax T1
Fibrolipomatous hamartoma of the median nervewith macrodystrophia lipomatosis*
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Fibrolipomatous hamartoma of the median nerve with macrodystrophia
lipomatosis• Nerve territory directed macrodactyly
• Localised form of gigantism
• Median or Plantar nerves
• Possible relation with neurofibromatosis
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35M8w post injury
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Cor T1
Cor T2
Post traumatic myositis ossificans
*
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Post traumatic myositsis ossificans
• 4/52 Faint peripheral Ca– Periosteal reaction
• 8/52 Circumscribed cortex– Central lacy pattern
• 5/12 Maturity• >6/12 Regression
– Separate from bone
• 1 year Usually disappears– Periosteal reaction remains
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25MBlocker
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Myositis ossificans*
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Sport related myositis ossificans
• Single direct blow
• Repeated minor trauma– Adductor longus-Rider’s bone– Brachialis-Fencer’s bone– Soleus-Dancer’s bone– Blocker’s arm
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48MAlcohol ++
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1518960
*
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Grading of AVNSteinberg modification of
Arlet/Ficat
• 0 - Abnormal MRI no symptoms
• 1 - Abnormal MRI, pain
• 2 - Mixed sclerosis and lucency on x-ray
• 3 - Subchondral collapse
• 4 - Marked collapse
• 5 - Secondary acetabular OA
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Causes of AVN• Trauma• Steroids• Alcohol• Pancreatitis• Protease inhibitors• Gauchers• Sickle cell• Caisson• Perthes / Idiopathic
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34MDeveloping lump anterior to knee
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Ax T1
Ax PDFS
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Sag T1*
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Soft tissue chondroma
• Rare
• 20-40Y
• Hands and feet
• Well demarcated and lobulated
• Curvilinear, ringlike or nodular calcification
• High signal T2
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PDFS
*
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*
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*
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1171948
*
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1999621*
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35M Knee injury
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PDFS
*
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ACL/MCL
• Empty lateral gutter
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86MStiffness and Locking
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Multiple bodies in Popliteal recess
• Primary V’s secondary osteochondromatosis
• Multiple similar size
• Origin
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62MFullness in suprapatella region
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*
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Body growing in joint
• Laminated
• Slow growing
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30MOutdoors man
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*
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Snake bite
• Venom not infection
• Due to proteases
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36MPrior trauma
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1171948
*
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Florid reactive periostitis
• BPOP
• Bizarre parosteal osteochondromatous proliferation
• Manifestation of PTMO in hands
• Periosteal proliferation > ST ossification
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50MTrauma
Whiplash injury
1
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1999621*
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Extension tear drop Fx
• Small fragment
• Usually more superior Cx spine
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0850849
1*
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*
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2W earlier 2W later
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1927160
*
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2001785
*
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36MTrauma 3Y ago
MVANow myelopathy
3
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2001176
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*
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Chronic non-union of C2 Fx
• Type 1 steep oblique– Due to alar ligament
• Type 2 neck of odontoid process– Prone to non-union
• Type 3 extends into body– Often heal with conservative Rx
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42MFall
1
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0850849
1*
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Anterior shoulder dislocation
• Hill Sach’s lesion (Hatchett )– Stryker view
• Bony or soft tissue Bankart– Westpoint view
• Posterior dislocation– Trough Fx– Bennet’s lesion
• Bony
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21MInjury weeks agoRecent surgery
1
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*
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Volkmann’s ischaemic contracture
• Soft tissue contractures– Volkmann’s– Burns– Neurologic conditions– RhA, SLE– Arthrogryposis multiplex congenita
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40MKnown medical condition
Recent trauma
2
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2W earlier 2W later
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2003485
2W later*
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Hemophilic pseudotumor
• Uncommon manifestation of Hemophilia
• Femur > Pelvis > Tibia > Small bones of hands and feet
• Intraosseous or subperiosteal
• Lytic, expansile, can look aggressive, ST mass
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75FLifelong limp
1
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1927160
*
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DDHAdults
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DDHInfants
• Acetabular angle
• Lateral shift
• Superior shift
• Shenton’s
• Perkin’s
• Hilgenreiner’s
• Center Edge
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40MWaterskier
1
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2001785
*
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Old ischial avulsion
• Avulse bone < 25Y
• Waterskier, Hurdler, Sprinter
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1806380
*
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2003226*
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1995690
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54FFall
2
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1777100
*
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Transverse Patella FX
• Direct or indirect
• Transverse 70%, indirect
• Longitudinal, stellate or comminuted
• Bipartite - superolateral
• Dorsal defect - superolateral– Direct
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63FLongstanding decrease ROM
1
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1806380
*
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Chronic anterior shoulder dislocation, with neoglenoid
• Failure to diagnose
• May have increased ROM
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19FSlowly growing (1Y) lump on
thigh
3
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1998078
*
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Alveolar Soft Part Sarcoma
• Malignant granular cell myoblastoma
• Young adult females
• Thigh muscles
• Slow growth, calcifcation, invade bone
• Metastasizes late
• Vascular, may have flow voids
• Path - similar to paraganglioma
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19FMVA
20032261
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2003226*
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Odontoid Fx
• Type 1 - Steep oblique– Sometimes tip Fx also called type 1
• Type 2 - Neck– Prone to non-union
• Type 3 - Involves body– Usually heal conservatively
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65MNeck pain
Myelopathy
19956903
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1995690
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1995690
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1995690
**
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CPPD arthropathy
• Deposited in transverse ligament
• Associated – Tumor like masses may compress cord– Atlanto axial subluxation – Spontaneous odontoid Fx
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35MDeformity
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Maffucci syndrome
• Multiple enchondromas
• ST Hemangiomas
• Malignant potential close to 100%– Olliers enchondromatosis 25-30%
• Developmental, not hereditary
• Growth deformities
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12MDeformity
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Noonans
• Short Metacarpal– Idiopathic– Post trauma
• Iatrogenic, Fx, Growth plate inj, Thermal, Electrical
– Turners, 4th +/- 3rd or 5th – Pseudo- and pseudopseudohypoparathyroidism
• 4th and 5th
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14MDeformity
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Carpal osteolysis
• Onset childhood
• Carpals, Tarsals, elbows
• Associated nephropathy
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29FFOOSH
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Scaphoid Fx on lateral view
• Many scaphoid fractures are best seen on lateral
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68MWrist instability
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VISI
• Suggests lunotriquetral ligament tear
• DISI- scapholunate ligament tear
• Angle between scaphoid and lunate < 30
• Pie shaped lunate
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33FNo history of trauma
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Keinbocks
• Ulna minus
• Trauma
• Osteonecrosis
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45FHand pain
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Acroosteolysis• Tuft
– CVD- Scleroderma, CREST, Raynauds– Psoriasis– Neuropathic
• DM, Leprosy, Myelomeningocele, Syrinx, Cong indifference to pain (Leesch Nyan)
– Trauma• Thermal, Burns, frostbite electrical
– Hyperparathyroidism– Epidermolysis bullosa– Porphyria, Subungal exostosis, – Snake and scorpion venom– Phenytoin toxicity in infants
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40MKnife injury
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Flexor tendon lacerationDisplaced sesamoid
• Sesamoid useful marker of tendon
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*
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*
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*
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*
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20MHurt hand catching ball
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Dislocations
• Need 2 views for trauma
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22FDeformity
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Boutonnierre
• Rupture of middle slip of extensor tendon as it passes over PIPJ
• Lateral slips migrate volarly
• Occasionally avulsion
• Needs early Dx
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76FRhA
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*
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Cranial Settling
• Atlantoaxial settling
• Erosion of lateral masses
• Different from basilar invagination
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57MBilateral shoulder pain
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*
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DDx• Unilateral
– Amyloid, TB
• Bilateral– Crystal
– Occupational OA
– Syrinx - neuropathic
– Previous inflammatory arthritis• Clavicles normal
– Hemophilia
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24MFOOSH
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*
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Trans scaphoid/triquetrumperilunate Fx dislocation
• Pie shaped lunate
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31MBlow to flexed thumb
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*
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Rolando Fx
• Axial blow
• More difficult to anatomically reduce
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March 01
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*
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*
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*
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57MRight hip pain
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March 01
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May 01
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Dec 02
*
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Hepatic metastases
• Rare to bone
• Similar to other hypervascular mets
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50MMVA
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Anterior hip dislocation
• 5% of hip dislocations
• Can have associated impaction injuries
• Leg externally rotated
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32MBilateral chronic hip pain
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*
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Perthes
• White boys
• 4-7y
• Younger onset – better outcome
• DDx for bilateral– MED, Morquios, SCD, Gauchers, – Hypothyroid, CDP, Warfarin embryopathy
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17FMechanical symptoms
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*
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Osteochondroma
• Point away from joint
• Cartilage cap is hyaline
• Cap thickness > 1cm concerning
• Pain important to dx malignancy
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75MKnee locking
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*
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Primary synovialosteochondromatosis
• Metaplasia of synovium
• May not be visible on X-ray
• Primary similar size
• Synovial hemangiomas have lucent centers
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55M1Y post trauma
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*
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Dystrophic calcificationin Quadriceps tear
• Calcification– Metastatic– Dystrophic– Tumoral
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Left Right
*
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46MPrevious trauma
Chronic bowel problems
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*
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Hypertrophic Osteoarthropathy
• Pulmonary– CA bronchus, Lymphoma, Abscess, Bronchiectasis,
Metastases
• Pleural– LFTP (highest association), Mesothelioma
• Cardiovascular– CCHD
• GI– UC, Crohns, Dysentry, Lymphoma, Whipples, Coeliac,
Cirrhosis, Nasopharnygeal CA, Juvenile polyposis
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16MSlowly increasing pain in tibia
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T1FSGd
*
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Osteosarcoma
• Conventional
• Telangiectatic
• Parosteal
• Periosteal
• Multicentric
• Soft tissue
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14MPain with running
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1m later
*
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Stress Fracture
• Fatigue
• Insufficiency
• Pathologic
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54MTwisting injury
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*
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Maisonneuve Fx
• Transverse fracture of medial malleolus without distal fibula Fx, ask for proximal fibula
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31FArthritis
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Left
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Left Right
*
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RhA noeostosis
• Reiters is more plantar and less symmetric
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53MPain lower back
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Ankylosing Spondylitis
• Enthesopathy
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*
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42FFoot stiffness
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Compartment syndromeossification
• Extensive sheet like ossification
• Dystrophic
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24FFall
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Fracture blisters
• DDx pseudoaneurysm
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8MSwelling of toe
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Digital fibroma
• Recurring digital fibroma of infancy
• Can become large
• Painless
• Fingers and toes
• DDx– Enchondroma, Epidermoid inclusion, Digital
fibroma, Subungal lesions, Glomus
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Melorrheostosis
• A benign sclerosing bone dysplasia
• Osteopathia striata
• Osteopoikilosis
• Dripping candle wax
• Sclerotomes
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43MTrauma
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Osteoma (Ivory)
• Gardeners syndrome– Adenomatous polyps, Dental lesions, ST
tumors, osteomas
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67FLump
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Fibrous Dysplasia
• Common
• Hamartomatous fibro-osseous metaplasia
• 70% monoostotic
• Polyostotic tends to be unilateral
• Usually expansile
• Shepherds crook, ground glass
• Any bone, but spine unusual
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33MTackled at rugby
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Anterior dislocationHill sachs
Bony Bankart• Stryker for Hill Sachs
• Westpoint for bony Bankart
• Can occur after one dislocation
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56FLump and pain
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GCT
• Multinucleated giant cells in fibroid stroma
• Knee, distal radius, proximal humerus
• Lytic, subarticular, narrow zone of transition without sclerosis
• Can look aggressive
• After epiphyseal fusion
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42MMechanical symptoms
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*
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Sessile osteochondroma
• Anterior at knee
• Also have mechanical symptoms