mskl 303 notes
TRANSCRIPT
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 1/33
Orthopedic Anatomy 20.11.2014 18:14
Anterior inferior glenohumeral ligament – most important stabilizing
shoulder joint
We always define a dislocation by the position of a distal part – humerus
is the distal part, if humerus is more anterior, it is anterior dislocation
Bankart lesion – tear of the anterior inferior
Tuberosity (tubercle) in humerus – two important lines are anatomical
and surgical neck lines. In anatomical neck fractures, blood supply could
be impaired.
Path of radial nerve, behind humerus, entrapment possible in shaft
fracture
Lateral ulnar collateral ligament – clinical importance
Annular radial ligament holds radial head in the place
Scaphoid fractures cannot heal easilyCapitatum is biggest – lunate is also important
Brachial plexus C4-T1
Innervation of trapezius – CN XI
Quadrangular space – humerus, long head of triceps, teres major –
axillary N & circumflex humeral artery
Triangular interval – radial N and deep brachial artery
Triangular space – circumflex scapular artery
Posterior interosseus nerve – continuation of radial nerve, before enteringsupinator canal and becomes this nerve
Anterior interosseous nerve – median nerve – pinch test if +, it’s palsy
Ulnar nerve innervates flexor carpi ulnaris , flexor digiotum profundus 4,5
Adductor pollicis is a thenar muscle but innervated by ulnar nerve –
Froment test check for ulnar nerve
Cubital tunnel in the inner side
De Quervain tenosynovitis – BELA (EXTENSOR BREVIS – ABDUCTOR
LONGUS)
CLINICAL EXAMINATION OF MUSCULOSKELETAL SYSTEM
Symptoms: pain, swelling, deformity, referred pain
Orthopedics: inspection -> palpation -> movement -> stressing
Epolette sign in anterior shoulder dislocation*
Valgus – lateral movement / varus – medial movement
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 2/33
Feel warmth before pressure with the same hand, the same part
MRC Scale
Define the deformity – angular, contractures, spasticity
Contracture- wolkman ischemic contracture in the image below
Hamilton’s ruler sign
For thr first 90* scapula doesn’t move in shoulder joint abduction
It is a combination of scapula thoracic and glenohumeral movement
2:1 ratio: after 90* for every 1*, 1* ST and 1* GH
carrying angle of elbow
Ulna is the pivot point, radius turns
Erb duchenne – tear of c5-c6 biceps&deltoid& rotator cuff do not work
Klumpke palsy- claw hand, ulnar nerve is more involved –c7-t1
Thoracolumbar spine - straight leg test show irritation for sciatic nerve –the patient tends to bend the knee to relieve the stress on the nerve,
tenderness, back pain sciatica/sciatalgia means the irritation, may be due
to lumber hernia or compression
80% of bending movement from lumbar and rotation from thoracal
vertebrae due to facet joints
Memorize 234: patellar reflex L3,L4
Ober testTrandelenburg test
Knee inspection: deformity – knocked knee/bowl legs/valgus
Medial joint space, medial meniscus, medial collateral ligament, pes
ansenius – gracilis, sortorius, semitendinosus
ACL- anterior drawing test
Medial collateral ligament – is stretched in valgus test
Lateral collateral ligament – is stretched in varus test
When knee is extended fully in these tests, you would lock cruciate lig
and you would have stability // collateral lig torn is only measured when
you bend the knee 20*
Lachmann test
Ankle inspection – hemosiderin causes ecchymosis
Palpation is according to Ottawa rule: press on medial malleolus, lateral
malleolus, base of 5th metatarsal if painful, take x-ray!!!
Dorsiflexion stretches calcaneofibular lig
Plantarflexion CF is lost, ATF is assessed only
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 3/33
3-4 toe – Morton neuroma
2nd toe – malleo in distal and hammer toe
Thomas test
Pediatric Examination
Screening examination & focused examination
Compare the level of shoulder in front of a window- level of light passing
History taking
In-toeing: içe basma, very common in babies & toddlers,
Femoral antetorsion – internal rotation of femurAngular problems – last normal position 5-7* of valgus, varus is present
in infants
Osteoclasis – breaking the bone
Flexible flatfoot – tibialis posterior will pull to give the arc of the foot,
Clubfoot – immediate serial casting for treatment
Osteoporotic fractures
Trabecular bone is mainly in ends of the bone
Post-meopausal type I
Vit D deficiency, steroid use, H+ pump inhibitors – risk factors for OP
Distal radius fracture at 50s – yellow alarm – femoral neck fracture 70s
Anti resorptive agent- bisphosphonate – atypical fractures may occur
CASE-1
71 F – acute back pain
steroid use for SLE since 2006
lateral x ray of low back – to evaluate height of vertebrae
MRI needed to detect whether it is a new fracture or an old one
Always count from sacrum – compression fractures of L1,L2,L3
Vertebroplasty – noninvasive, cement is injected
CASE-2
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 4/33
CASE-3
Hospice – risk for osteoporosis due to sedentary lifestyle
Screw may be a solution – but correct treatment would be bedrest,
vertebroplasty
T2 MRI –bright region in vertebrae- bleeding in trabecular bone, new
fracture, patient underwent percutaneous vertebroplasty
Pilon tibia – comminuted fracture of ankle, sagittal CT section, intra
articular fracture after simple ankle sprain, smoking was a predisposing
factor, surgical treatment of plate and screws
Patient with rheumatoid disease, heavy smoking habit – think ofosteroporosis!
Tibial plato has a compression – more clearly on CT scan, plate and
screws
Consider osteoporosis in elderly – in the treatment – consult
endocrinologist and physiotherapist to promote healing and prevent
future fractures
Metabolic disease – PTH stimulates osteoblasts
2 questions from this part
Fractures and Dislocations
Opacity – compression fracture
Pain – swelling – deformity – loss of function are cardinal symptoms of
fracture
Hip fracture – external rotation of the lower limb
Swelling: hematoma, edema, effusion (in the joint space)
Movement and stressing is not done in the diagnosis of shoulder; look and
palpate, never stress!
Internal bleeding – excessive swelling in closed fractures
Fascia limits muscle – muscle depends on it for strength
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 5/33
In the case of bleeding, the compartments in the leg are not enlarged due
to restriction and pressure exerted by fascia
Artery keeps bringing blood, vein closes completely in critical point, tissue
is congested, intratissue pressure is increased, necrosis occurs –
compartment syndrome
Subluxation – partial dislocation
March fracture in metatarsal bones
Greenstick fracture in children – break it again willingly for healing
Impacte- içiçe geçmi! kırık
Comporession – calcaneous
Avulsion – touch base of metatarsal V – peroneus brevis attaches to it
If more than 30*, it is oblique fracture
Repeat xray after one week in scaphoid fracture due to resorption
2nd metatarsal takes the most load in walking – hairline fracture
Open fractures – Gustilo Classification
Type I: less than 1 cmType II: >1 cm , extensive soft tissue damage
Type III: periosteal splitting, exposure of bone
Axillary artery can be entrapped between bone fragments
Bone fractures in children
Thicker periosteum is an advantage, increased remodeling, presence of
physis
In trabecular bone, no osteon
Bionet position – remodeling within 6 months
Conservative treatment – usually no surgery
Do not confuse physis with fractures
Children grow from knee, shoulder and wrist 70-80% - clinical relevance
is that if you have a fracture around these regions, high potential for
remodeling
For the elbow, this is not the case, healing is not very good .
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 6/33
Bone activity is high in children and adolescents, bone tumors are more
frequent, around knee, shoulder.
CAPITELLUM -3
INT EPICONDYLE -6
TROCHLEA - 9
EXT EPICONDYLE -12
Little leager – medial epicondyle traction injury
Toddlers fracture – very subtle, blurry opacity sometimes seen as healing
Monteggia: proximal ulna fracture with radial head dislocation
Galeazzi: fracture of radius, dislocation of distal radioulnar joint
Torus fracture: impaction
After 12 years of age, physis close from median to lateral and this takes 2
years, tf ligament pulling in severe ankle sprain may cause tillaux fracture
Lateral part of distal tibial epiphysis
Nursemaid’s elbow: elastic fixation of elbow, painful pronation position
Unable to supinate
Gently pull, turn outward, flex it , click sound will be heard when radial
head sits in place, wait for 10 min to assess again
Calcaneocuboid and talonavicular articulations in feet
Case 6: 5th phalanx, epiphyseal type II fracture
Torus fracture xray!!!
BONE HEALING
Type I - bone
Type II – nucleus pulposus, articular cartilage
Type III- healing tissue, scar tissue
First thing after a fracture: blood and inflammation
1. reactive phase for 3-7 days, for all tissues ligaments, tendons, muscle,
bone, bleeding to promote healing,
2. repair phase 3 weeks
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 7/33
3. remodeling phase at the end of 3 week, most tissues roughly healed, 3
wks to 6 mo bone remodeled
if possible, natural healing is the best way
If periosteum incompletely torn, external callus formation
In the joints, we need 1* healing, anatomical reduction, direct osteonal
healing, we want a smooth joint surface, 1* healing required for intra
articular fractures
In 2* healing, bone tips are not together, open wound heals in this way
For shaft fractures, 2* healing is accepted.
The only tissue that heals with its original tissue is bone. Bone heals with
bone, but tendon, muscle, ligaments heal with scar tissue.
Direct osteonal healing vs. enchondral healing
Osteosynthesis
Internal fixation: fixing with a medical device
Intraarticular joint needs absolute stability, anatomical reduction which is
the perfect alignment
Shaft fx – functional reduction – it provides a good position for
functioning
Cortical screw – holds the bones by the frequent teeth
We put the plates at the tension site
Cancellous bone screws for compression and fixation
Hip fracture: naling or screwing make osteosynthesis or hip replacement
surgery by prosthesis. Nailing is preferred, it will healing with bone.
Intramedullary nails would impair endosteal healing
Kirscher Wires !n tension band wiring
Schanz screws or pins in external fixation
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 8/33
Case1 – minimal material, this is not a stable fixation with wires. Since it
involves the joint, anatomic reduction is a must. You can see a callus but
this is not preferred. Tried to be fixed with plaques in second picture.
Hematoma after open surgery is a source of infection, drain after surgery
Schanz screw and bone cement – segmental bone excision and replaced
by cement in the case of osteomyelitis to eradicate infection
CRP, acute phase reactants controlled, if normal, cement removed and
biological reconstruction may be performed or segment sliding
Osteomyelitis
1.Acute hematogenous osteomyelitis
2. Subacute hematogenous osteomyelitis
3. Chronic osteomyelitis
venous sinusoids in metaphysis, in bacteremia septic emboli sits there
due to slow circulation and there are less phagocytic activity and oxygen
acute starts in metaphyseal regionbefore age 2, physical vessels are open so metaphysical infection can
spread to epiphysis
after 2 age, physis is a barrier to infection
the most common cause is bacteremia
sequestrum: dead bone found in chronic osteomyelitis
involucrum: bone tries to encover dead bone
diagnosis: acute phase reactants increase also in rheumatoid diseases
all of lab tests can be normal in newborn!! Newborn sometimes do not
have fever after infection.
Axial mrı best technique
Bone scan not very specific
US – for soft tissue abscess, subperiosteal abscess can be aspirated
Cortical destruction or cortical degeneration, take biopsy inside the bone
Abscess – debridement
The most common cause is S. aureus in all patients with sickle cell
anemia and the disease increase the risk of salmonella infection
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 9/33
Before 2 years, vessels are open infection can spread to epiphysis, septic
arthiritis
After 12 years – epiphysis closes, cartilage barrier is not enough,
infections can spread, again septic arthiritis may occur
Subacute osteomyelitis – history more then 10 days, some sign on XR,
incidious onset
Acute osteomyelitis – nothing on plain xray, history less than 10 days,
more obvious symptoms
Chronic: sequestrum, invalucrum, debridement of necrotic tissue
Brodies abscess – lytic lesion, radioluscent
Ewing sarcoma
Eosinophylic granuloma
Leukemia
Involvement of bone infection, common before 2 years or after 12 years
epiphysis septic arthritis
Limping adult ( From signs to diagnosis)
Neurological or musculoskeletal
Stance 60% swing 40%
Energy conservation:
Pelvic tilt
Pelvic rotation
Lateral shift
Stride length between 2 heel strikes of the same leg
Step length
Antalgic gait – very short stance phase on affected side, showing pain
Abductor lurch – gluteus medius weakness PAINFUL
TRANDELENBURG NO PAIN
Abnormal calcification of plantar fascia attaching to calcaneus – topuk
dikeni/ epin calcanei – tiptoeing, pain on the heel
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 10/33
Patients with femoral palsy, will knock their knee as they cannot extend
knee
Foot slap gait – weak ankle dorsiflexion, yeri tokatlayarak yürüme
Hallux rigidus – cannot extend the metatarsophalangeal joint of hallux,
step length shortened
Anklosis – fusion of joint
Back knee gait – quadriceps weakness
Gluteus medius gait – tries to have central point of mass to the affected
side
OA – sclerosis, bone formation unlike osteoporosis
Cruris Fracture
Sural N – sense for lateral foot
Dorsalis pedis and tibialis posterior pulses
Tibia fracture – high energy trauma, assess consciousness
Undress the patients limbs
Active bleeding – never put tourniquet, PUT STERILE PAD FOR PRESURE
Yaraya distalden bastırınca kanama duruyorsa venous, proximalden
bastırınca duruyorsa arterial agırlıklı kanama olur
Open fracture – fascia torn so low risk of compartment syndrome
Once you have paralysis – it is too late to decompress the tissues, muscle
underwent necrosis so fasciotomy is too late, you only have 6 hrs ot one
day at most
Pain, pallor, pulselessnesss, paresthesia
Watch for abnormal pain - remember compartment syndrome
Ischemic contracture of Volkmann – frequent complication of arterialinjury after elbow fractures
If you do not feel your sole, tibial nerve is gone, indication for limb
amputation
Sural nerve – lateral side of foot
Toddlers fracture – usually missed
Torus – soft periosteal thickness
Maison nevue – medial malleolus & fibular neck fracture – may occur after
severe sprain
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 11/33
Cyanosis – there might be hematoma – not compartment syndrome
Dizin üstündeki bacak venleri
Sudek atropfisi – osteoporosis occurs, rigid joints later period
Bone – tendon – arter but if too much ischemia, arteria may be scheduled
before tendons
Dislocation of shoulder ( From signs to diagnosis)
Inferior glenohumeral ligament
Cyst in scapular notch – suprascapular nerve
90% anterior dislocation of the shoulder
is there any previous dislocation?
Look – feel – neurovascular examination
Brachial plexus is stretched in dislocation, most common axillary N. injury
Too see if contract deltoid muscle, if there is sensation loss around lateral
part of deltoidTransthoracic and AP xray because patient cannot abduct for axillary
position
Bankart lesion – anterior dislocation tears capsule attached to labrum
After 1st dislocation, 95% patients have this lesion, this does not heal
anatomically. MRI is the best
Hillsacks lesion, impression or compression fracture of the posterior part
of humerl head. CT is the bestDue to these lesions, one dislocation may lead to another in the future
Abduction ext rotation – shoulder dislocation
Shoulder Examination
Palpate bony prominences AC, SC, tuberosity, biceps tendon, coracoid
process,
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 12/33
Internal rotation level according to thumbs reaching which spinal levels
Knee Examination
Medial side tenderness on medial meniscus, MCL, bony edema or
osteoarthritis
compare quadriceps
Patella for fluid in the joint
Flex 15-20* before examination of mcl, lcl
Lachmann test for cruciate ligaments
US, MRI
Ayak ice veya dısa basarken diz ustune cokturme testi
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 13/33
20.11.2014 18:14
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 14/33
20.11.2014 18:14
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 15/33
Osteoporosis 20.11.2014 18:14
most common bone disorder
low bone mass & micro architectural deterioration
mineral matrix ratio is normal, lab values are normal
lifetime risk at the age of 50
peak bone mass: Amount of bony tissue at the end of skeletal maturation
type I collagen (94%) in osteoid
Osteoporosis in trabecular bone: hard outer layer is compact bone,
spongy inner bone is cancellous bone, which makes 80% turnover media
Most commonly in vertebra and the hip bones. More bone loss occurs at
trabecular areas.
Vertebral fractures are seen most common, 50% trabecular bone content
Postmenopausal osteoporosis – type I
Hormonal changes increases rankl production, bone loss 1% per yearClinical manifestations: silent until fracture
Fragility fracture definition
Vertabra, hip, wrist, shoulder fractures
Once a vertebral fracture occurs, risk increases x5
Hip fracture- 20% risk of death within a year
Diagnosis: BMD
Biochemical markers not diagnostic but to follow up
Many drugs are anti resorptiveAntigravity exercise – walking is the best for osteoporosis
Women >65 age should be checked for screening
-2.5 SD means osteoporosis
>3% needs treatment
>20% severe osteoporosis
farx tool by who
Hip fractures
X3 more remodeling active unit in trabecular bone
Loss of height of 4 cm within a year – check for osteoporosis
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 16/33
Hand Examination 20.11.2014 18:14
Allen test – look at refilling speed when releasing one artery
If one of them is slow, note it.
Goniometer for flexion,extension, ulnar/radial deviation
Ulnar & radial collateral ligaments on MCP joints
Know the tendons and muscles
FDS for PIP joint flexion
FDP for DIP joint flexion
Thenar muscles: abductor pollicis brevis, flexor pollicis brevis, opponens
brevis
Hand posture maneuver
Swan neck: overextension of PIP, flexion of DIP
Wrist drop: radial nerve palsy
Interosseus – ulnar nervePhalen test for carpal tunnel syndrome
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 17/33
RADIOLOGY 20.11.2014 18:14
Fractures& Dislocations Radiologic Perspective
Systematic checklist:
1.patient and image data
2. bone and joint alignment
3. joint spacing
4. cortical outline – important for trauma cases
5. bone texture
6. soft tissue
tibial plateau fraction – if too much depression, operation would be
needed
toddler fractures are examples of spiral fracturesmultidirectional fractures usually on calcaneus
communited fracture – check vascular damage
Avulsion fracture –
Epiphysis fractures important in children type II 75% involves proximal
part of epiphysis/ type V hard to detect in radiology, physis line
compressed in axial injuries, worst prognosis, if doubt, observe edema on
the bone by MRI
Diasthasis – usually two points in pelvisUnunited fractrues – in scaphoid, important complication, avascular
necrosis, proximal part malnutrition at first
Sudeck atrophy – reflex sympathic atrophy, due to trauma, immobility,
causing pain, heat, erythema due to stimulation of sympathetic system
but not proved, osteoporosis can be seen
No sclerosis in fracture lines
Growth plates, 2* ossification centers have their own cortex
Anterior fat pad – hypodense in xray
High atomic number molecules are hyperdense
Fat – water – muscle – bone
Fat pad elevated in fractures
http://www.radiologymasterclass.co.uk
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 18/33
Radiology In Low-back Pain
3 categories of patients: nonspecific LBP, assn. with spinal stenosis or
assn. with tumors, infections
high risk of infection: ESR, leukocytes lab results give clue
chronic steroid use – osteoporosis
Radiology of Bone Tumors
Simple bone cystic central – aneurysmal bone cyst is eccentric
Metastasis very common in bone tumors1* bone tumors exclude metastasis
epiphysis should be closed for giant cell tumor
osteoid osteoma – nidus, near periosteum
enchondroma – popcorn shaped calcifications
enchondroma can be low grade sarcoma if size is getting large
fibrous cortical defect is developmental mineralization disorder
non ossifying fibroma metaphysis of long bones
osteo chondroma – exocytosis, cartilage cap, if cartilage gets thicker itcan be chondrosarcoma, cartilage checked with MRI
osteomsarcoma – ill defined, codman triangle
abc- honeycomb appereance, MRI shows fluid fluid level
in older age group, malignant tumors dominate
enchondroma most important
infection can mimic malignant tumor – keep in mind
geode degenerative disease – synovial fluid gets into bone cyst, articular
surface
FEEHMMI – multifocal lesions
Neuroblastoma, retinoblastoma, lymphoma can cause metastasis in
childhood, ewing can be multifocal
Calcaneus – simple bone cyst, intraosseus bone cyst are seen common
Lytic lesion with sclerotic margin
Moth eaten – malignant with lamellated periosteal rxn onion skin
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 19/33
Permeative pattern – malignant
Fibroxhantoma – nof and fibrous cortical defect
Osteoblastoma in vertebra, osteoid osteoma in diaphysis
Sclerotic metastasis in men – prostate should be thought
Parosteal osteosarcoma – behind distal femur and in older ages
Radiology of musculuskeletal infections
Osteomyelitis – oyun çocukları ve erkek M/F=3
Diabetic foot
Mostly btw 2-12CT – vertebra tuberculosis or abscess biopsy
Brodie’s abscess – density is higher compared to tumors, pus containing
material
Garre can become osteosarcoma
Potts disease vs. brucella
pyogenic spondylitis – iatrogenic,after surgey
septic arthritis – monoarthricular
toxic synovitis – clinical info needed, joint fluid aspiration
Imaging in arthritis
Periarticularosteopenia – eklemin çevresindeki kemikler shafta gore daha
radioluscent
Inflammatory arthritis – cartilage cap protects
Seronegative arthritis – rheumatoid factor is negative
Ankylosing spondylitis- male, HLAB27 positive
Medial side of knee, peak point of acetabulum, thumb are the most
common sites,
RA – uniform eklem daralması
No synovium in IV disc – eklimi tutmaz atlanoaxiali tutar
AS- mri diagnosis
Reiter syndrome – triad may involve enteritis, more in male due to more
common seen gonococcal urethritis, common in Achilles tendon
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 20/33
Psoaris – erosive, pencil in the cup
Ivory phalanx – diffuse sclerosis in patients with skin lesions
Asymmetric osteophytes in vertebrae
Gout- tophi in bursa
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 21/33
Sports traumatology 20.11.2014 18:14
Tendon injury
Exertional compartment syndrome: muscle hypertrophy
Do not move the casualty immediately, call medical service
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 22/33
Population health 20.11.2014 18:14
Airway, breathe, circulating blood - abc for critical situation
OPQRST – complaining pain – onset, presentation/provocation, quality,
radiation, severity on a scale, time
Chest pain –
Risk factors for CAD: dm2, smoking, hypertension, HLD
Family history is the greatest risk
Check for depressed/suicidal
S1 – pulmonary valves open
S2 – valves close, end of systole
S3 – anytime the musculature gets stiff
Chf – listening lungs filled with fluid, blood cant leave the lung, high
pressure gradient causes pulmonary edema
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 23/33
Musculoskeletal Tumors 20.11.2014 18:14
Most common in young patients
Early diagnosis is crucial
Night pain in children 10-25 – osteoid osteoma
Check for lymph nodes
Planning the biopsy approach
X-ray: lateral and AP
Benign tumors have sclerotic margin, grow slowly
Onion skin – ewing sarcoma
Sunburst – osteosarcoma
Codman triangle – osteosarcoma
MRI- soft tissue, bone marrow detailed information to evaluate tumors
Scintigraphy - bone metastasis
Malignant tumor: first save lives then extremities, wide resection andthen reconstruction
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 24/33
20.11.2014 18:14
Instability is the major cause of local back pain
First examination – flex the back then extend and if there is pain in
extension – catch sign
Lumbar extension sign
Nerve root is irritated by PG,PLA2, LT, HA
Outer fibers of annulus fibrosus have nociceptors
If you have pain in lateral and backward extension -> facet joint pain
Lumbar canal stenosis – snoop test – as the patient walks, there are more
narrowing and neural ischemia, patient bends forward to relieve the pain
and tingling
Grade 4 spondylolisthesis – treated with surgery always
Ligamentum flavum hypertrophy, multisegmented degenerated disc cannarrow the spinal canal
Below 20 – inflammatory LBP / after 55 - malign disease
Lung, breast, prostate cancers and multiple myeloma metastasize to bone
Sıj pain – referred pain always above the knee
Line on crista iliaca – L4 level
Ankylosing spindylitis – abnormal pelvic lumber rhythm, no motion on
lumbar region while bending forward
Trandelenburg test, gillet test: finger should go upSLRT – positive if pain occurs at 40*
Ext halluces longus – strength test for L5 root
Ankle dorsiflexors – tibialis anterior
Cervical spinal stenosis
Scheurmann disease – vertebra takes a wedge shape, kyphosis
Qprst for pain evaluation
Check for red flags
Case-1
Step sign – when you palpate spinal processes, there is a gap true mostly
in obese people, spondylolisthesis
Shortening of walking distance, forward bending relieves pain, step sign
positive,
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 25/33
If there was diabetes, polyneuropathy would occur
Diagnosis: lumbar cana stenosis
Investigation: MRI
She is obese, protruded abdomen -> spondylolisthesis
Management: diet, lumbar & abdominal support, exercise,follow up
surgery if needed
Case-2
SIJ pain increases while sitting, bending forward
Young patient, morning stiffness – spondylitis
Gillet +, stiff back -> restricted lumbar ROM
Ankylosing spondylitis
Case-3
Protection of the back, educating patient, exercise
Disc rupture
Physical therapy
Disc Hernia
Posterolateral side – most common protrusion due to weakness ofposterior lateral ligament
Myelopathy – 1st motor neuron cord pressure
Radiculopathy – 2nd motor neuron signs, exiting root compressed
Conus medullaris syndrome – 1st motor neuron
Cauda equine syndrome – 2nd motor neuron
ALS ust extremite 2. Motor neuron, alt extremite 1. Motor neuron
bulguları
Vertebral fractures
Spontaneous fracture – osteoporosis
Intense pain, may compress medulla spinalis, compression facture
Atlas fracture – diving, elevator accidents
Odontoid – C2 dens fracture open mouth xray AP
C2 axis fracture – extreme extansion
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 26/33
Edema – upwards medulla oblongata affects respiratory and cardiac
arrest or c4 phrenic nerve – teardrop fracture anterior corpus fracture
Burst fracture – decreased height, communiuted violent trauma
differentiate from compression fracture, which is due to minor trauma or
osteoporosis
Case discussion
Case-1
52 F LBP, R leg pain and numbness
Osteoid arthritis
Leading cause of disability in elderly
Valgus knees and flexed knees in standing – knee OA
Only rectus femoris is biarticular – football player muscle, they are
operated in meniscus lesions
Snapping hip – sound when ext rotation of the hip joint
Evaluation of OA
Kellfren Lawrence radiologicalWomac-functionale-
Osteonecrosis – overuse syndrome in young people, divers,
Drug response of patients- esp to analgesics and steroids – chromosome
p??
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 27/33
Scoliosis & Kyphosis 20.11.2014 18:14
Cervical lordosis – 3 mo
Thoracic kyphosis – 6 mo
Lumbar lordosis – 14-16 mo
If the skeletal of the child is mature, the curves are determined. Scoliotic
curves will change magnitude if it can grow further
Riser 0-5 degress of skeletal maturity
Cobb angle measurement – magnitude of scoliotic curve
VACTERL – assn. of congenital anomalies
scoliosis - >10* cobb angle
side of convexity determines L or R
rib humpsyringomyelea
Limping child
In painful limb, stance phase is shorter in anthalgic gait
Steppage gate – you lift your foot higher, foot drop
Trandelenburg gait – pelvis falls to the unaffected side, hip abductor
efficiency, assn. in DDHInsertion and origin distance decreases in hip dislocation as greater
trochanter goes proximally – malfunction of hip abductors
Risk factor slide is very important
Breech positioning more or equal to 34 wk gestation – if hip comes first
Galeazzi test – the thigh is shorter
Trandelenburg gait is different from the test – trunk shifts, pelvis shifts,
waddling gait if the problem is bilateral – these are present in walking age
Skin fold, bartholoni, ortholani, galeazzi sign – present in the new boneHip ultrasonography – until 6 mo then pelvis xray 4-6 mo
Closed/opened reduction – opening or no opening the capsule of the hip
joint
Pavlik harness 0-4 mo keeping hips in physiological position
Reducible hip is Ortholani positive
Leggs calve perthes disease
Decreased internal rotation of the hip joint
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 28/33
Neuro-muscular diseases
GMFCS classification system
Spastic diplegic patient –
Biarticular muscle – psoas, hamstrings, gastrocnemius
Spina bifida
Lowest functioning level by myelomeningocele is
Birth defect –
Chiari II – hydrocephalus
Arthrogryposis – contractures at 2 or more joints, normal intelligence
Progressive neuromuscular diseases
Duchenne muscular dystrophy – dystropin is absentSpinal Muscular Atrophy – survival motor neuron gene 1 is absent, there
are 3 types
Poliomyelitis – prevention steps started in 1990s but increased due to
immigration, infection and destruction of anterior horn, no sensory
changes
Congenital deformities of the musculoskeletal system
Deformation due to mechanical forces are reversible
Dysplasia, deformation, malformation, disruption
Sequence: pattern of multiple defect derived from single known or
presumed structural defect
Syndrome: pattern of multiple defects related but not representing a
single sequence
Preaxial (lateral part of hand, medial part of foot) and post axial terms
clubfoot: CAVE
rhizomelia, mesomelia, acromelia
proximal inbtw tip of the long limb are deficient
achondroplasia is rhizomelia type?
Anterolateral bowing – neurofibromatosis
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 29/33
Px picture – fibular hemimalia, post axial longitudinal limb deficiency,
anteromedial bowing
Posteromedial deformity improves itself, leaving a limb discrepancy
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 30/33
Nuclear Medicine 20.11.2014 18:14
bone scintigraphy – low specificity
lytic metastasis to vertebra – prostate cancer
radiotracers not very important – for scintigraphy, diphosphanate is used
tracer detects new bone formation
diphosphosphanate replaces PO4 in HAP
Fluoride replaces hydroxide ion
Not in direct contact of capillaries and osteoid surface, large ECF in bone
3-phase bone scan: 1st phase vascular supply, 2nd blood in soft tissue, 3rd
phase osteoblastic activity
scintigraphy and ct at the same time
lesions with osteoclastic are difficult to detect – multiple myeloma, renal
cell carcinoma, lymphoma, leukemia, thyroid cancer
super scan – drug spread to all metastases, no sign of kidneyF18 pet ct volume rendered
MRI 1* dor osteosarcoma evaluation
Typical osteoid osteoma, sclerotic center well vascularity called nidus as
an intense point, new bone formation area in later stage
If no osteoblastic activity seen in scinitgrapy, benign tumor
Enchondroma is not diagnosed, just confirmed and checked for polyostotic
lesions
Septic thrombi or infiltration prevents good perfusion to the bone, traceruptake may decrease – do not crossover osteomyelitis!
To see soft tissue infection, mark leukocytes
If no sign on leukocyte labeling, no infection
Shin splints – no sign on medulla
Fracture – medulla involved
Paget disease – all parts of the bone is effected, well vascularized
1* hyperparathyroidism – 2.5 cm PTH adenoma
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 31/33
Osteomyelitis20.11.2014 18:14
1. hematogenous= usually microbial
microvasculature can be inadequate
complication of UTI, GI infections like appendicitis
2. contiguous spread , may be poly-microbial
3. direct inoculation trauma&surgery
acute OM prior to sequestra development
S. aureus most common pathogen – cover this in empiric treatment
Gram – bacteria like Pseudomonas more common in immunosuppressed
patients – diabetes px
Sickle cell anemia – salmonella infection
Tuberculous- thoracic vertebrae on mri
Pyogenic – hx of spinal surgery
Slime formation – more invasive bacteria on catheters S. epidermidis
Treatment – cephazoline for Methilicilin sensitive SA , vancomycin for
MRSA
Quinolones, cephalosporins, rifampin important and potent for biofilm
forming bacteria like brucella and tuberculosis infections
At least 6 wks of treatment
Radiology and esr, crp lab test follow up
Acute phase at least in one month
Osteomyelitis and septic arthritis case discussions
Case 1
Above 50.000 mg/dl WBC, septic
In synovial fluid, Bacterial infection gets glucose gets lower
Debridement and empirical antibiotic treatment
Culture (–) due to prior antibiotic use
Case 2
Osteomyelitis – soft tissue involvement, may be long term infection
Surgery, antibiotic cement
Case 3
Iatrogenic infection
Soft tissue abscess on US or not much on CT
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 32/33
Scintigraphy may be preferred
Arthroplasty infection – scintigraphy positive
Acute phase – not radiography dependent, follow the steps although
normal
HIP Prosthesis
Arthroprosthesis is joint replacement– endoprosthesis
For today – spine body possible
Not working joint – stiff and painful hip
Narrowing of joint space, sclerosis, subchondral cyst, osteophyte
41y F both femoral heads are dislocated, DDH, Trandelenburg sign
partial hip arthroplasty – the stem is fixed with cement or cement is not
used but a special design of prosthesis so that bone would grow into the
material to fix it
postpone the surgery because it should be renewed after
in cartilage defect – limited surface replacement
chndroblast replacement if less than 2 cm^2
Knee
Hinge joint,
Degenerative arthritis needs surgery
Polyethylene is radioluscent
Deformity is corrected, goal is pain free movement for daily activity
Shoulder: reverse arthroplasty, they don’t need rotator cuff,
Total elbow prosthesis, hip fractures may need arthroplasty but very rare
in knee and elbow
Arthrodesis – eklemleri kaynatma, we can fuse the ankle joint but another
solution total ankle arthroplasty
7/24/2019 Mskl 303 Notes
http://slidepdf.com/reader/full/mskl-303-notes 33/33
20.11.2014 18:14