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Flashcards in MSK Deck (320):
1

Mach effect. Describe

- optical phenomenon
- inbuilt edge enhancement mechanism of retina
- via lateral inhibition of retina

2

Lotteo ossicles. Describe.

Lanula
- distal to ulna styloid in TFCC

Os styloidium
- dorsal 2nd, 3rd MC

Os triangulare
- more radial then lanula

Os trapezium secundarum
- volar of trapezium


Os epilunate
- dorsal of lunate

Os hamuli propium
- volar aspect of hamulus

3

List fracture mimickers and fractures of the 5th metatarsus

Os peroneum
- in fibulas longus

Os versalium
- in fibularis brevis

Apophpysis

Avulsion fracture
- fracture of the peroneus braves insertion
- most common

Johns fracture
- diametaphysis
- often have non-union 30-50%
- 2nd most common

Stress fracture
- metaphysics
- 3rd most common

4

Nutrient foramen.

1) How to differentiate from fractures
2) what kind of bones has it?

1)
- well corticated
- lucent line passing into medulla

2) all long bones
- humorous 1 - 2
- radius 1 normally
- ulna 1 -3
- femur 1 -9
- tibia 1 : posterior
- fibula 1-3
- phalanges 1 -2

5

Bone island

1) define
2) imaging
3) ddx
4) what is multiple bone island

1)
- aka exostosis
- compact bone in medulla (cancellous bone)

2)
CT
- fades into surrounding bone (brush-like border)
- no aggressive features

- MR: low signal on all sequence
- STIR : can have high signal mimicking tumour

- bone scan: may have increased uptake

3) ddx
- sclerotic met
-> more polyostic
-> bone scan not helpful (increased
-> may require biopsy

- ossified NOF
- osteoma: normally paranasal sinus
- osteoid osteoma


4) osteopoikilosis

6

Vertebral segmentation and fusion anomaly, and failure of formation

1) define
2) location, type of abnormalities
3) imaging
4) ddx

1)
- vertebral anomaly due to failure of normal segmentation, fusion, or abnormal development

2)
- lumbar > cervical > thoracic

Types
- hemivertebrae : failure of development of lateral half of vertebral body
- butterfly vertebrae : failure of development of central of vertebral body (persistent notochord tissue) -> thus failure of fusion
- block vertebrae : deformed fused vertebrae, fused posterior element, ribs

- Partial formation failure : wedge vertebrae
- complete formation failure: aplasia, hemivertebrae, butterfly vertebrae

3)
- sharply angulated scoliosis with abnormal fused vertebra
- single -> multiple level

4) ddx
- junvenile chronic arthritis : unable to differentiate. Need clinical history
- infection (discitis) with subsequent fusion
- ank spondylitis
- surgical fusion

5) associaion
- Klippel feil : cervical fusion (anterior/posterior element), occipitalisation of atlas Sprengel deformity, omovertebral bone, spina bifida, hemivertebrae
-> congenital spinal malformation
-> no obvious etiology
-> could be familial

7

Transitional vertebrae

1) define

1) abnormality occurring at the spinal junctions.
- vertebrae has indistinct feature of the adjacent vertebral segment
- can become symptomatic (thoracic outlet obstruction)

2)
Atlantoaxial
- atlanto-occipital assimilation
- occipital vertebrae

Cervicothoracic junction
- cervical rib

Thoracolumbar
- 13th rib arising from T13 or L1

Lumbosacral
- lumbrolisation of sacrum
- sacralisation of lumbar spine

8

Cleft epiphysis

1) define
2) ddx

1)
- normal variant of epiphysis
- a cleft that runs through epiphysis
- normally 1st toe proximal phalanx involved
- any epiphysis can be involved

2) ddx
- fracture : f/u imaging will show callous

9

epiphysis fusion date

1) CRMTOL

2) wrist ossification dates

1)
- capitalum
- radial head
- medial epicondyle
- trochlea
- olecranon
- lateral epicondyle

2) wrist
- capitate 1 mth
- hamate 2 mth
- triquetrum 2 year
- lunate 2
- scaphoid 4
- trapezium 4
- trapezoid 4
- pisiform 8

10

Vacuum phenomenon

1) define
2) cause

1)
- accumulation of nitrogen
- in the clef of the intervertebral disc
- or between the disc and vertebrae

2) cause
- degeneration
- osteomyelitis
- schmorl node
- osteonecrosis (Kummell disease)

11

Growth arrest line

1) define

2) path

3) ddx

1) alternating transverse sclerotic metaphyseal line

2) due to stress during bone development

3) bisphosphate therapy for osteogenesis imperfect

12

Carpal coalition

1) where is it most common
2) how often?
3) cause
4) fusion types
5) associated syndrome

1)
- lunate triquetrum
- capitate hamate

2)
- 0.1% caucasian american
- 1.5% african american

3)
- inherited
- inflammatory arthropathy (RA, seronegative arthropathy)

4) fusion type
- osseous : synostosis
- cartilage : synchondrosis
- fibrous : syndesmosis

5) association
- Holt-Oram : AD syndrome.
- Turner

13

Tarsal coalition

1) types and signs
2) exam pearl
3) describe change with severe talocalcaneal coalition
4) symptoms

1)
- talocalcaneal
-> inverted C sign
-> talar beaking
2 types
- intraarticular : involving the medial facet
- extraarticular : posterior to the medial facet

- calcaneonavicular
-> ant-eater sign
-> reverse ant-eater sign

Joint involved
- broad joint morphology
- irregular surface if fibrous union
- joint orientation may be altered

2)
- 25% bilateral
- check contralateral foot

3) extensive coalition
- develops ball and socket joint at the tibiotalar joint to provide more universal motion -> talus becomes rounded

4) symptoms
- pain
- ball and socket joint
- secondary OA
- tarsal tunnel syndrome
- peroneal tendon spasm
- pes planus

14

Bone marrow types

1) general marrow content
2) red marrow
3) yellow marrow
4) where does marrow conversion (red to yellow)
5) how to differentiate between red marrow and malignancy (met)

1)
- haematopoietic cells
- fat
- stroma
- vessels

2) more haematopoeitic cells
- high T1, T2
- high STIR (compared to yellow marrow but still have some fat sat)

3) more fat
- high T1, T2
- STIR - fat sat
(follows subcutaneous fat)

4) red to yellow
- phalanges
- then femur/humerous

5)
- both red marrow and malignancy is low on T1
- out of phase : red marrow still has some fat and will have signal drop in out of phase. Met doesn't have drop out.

15

Os acetabuli

1) define

2) association

1)
- may be unfused secondary ossification centre of acetabulum

- some think it's now post-traumatic

2) association
- FAI
- hip dysplasia
- osteochondritis dissecans

16

Hyperostosis frontalis interna

1) define
2) what is morgagni syndrome
3) ddx

1) benign bony proliferation from the inner table of frontal bone
- may extend to parietal bone

2) morgagni syndrome
- hyperostosis frontalis interna
- obesity
- hirsutism

3) ddx
- pagets
- fibrous dysplasia
- sclerotic met
- meningioma

17

Pneumatisation of paranasal sinus variation

1) normal pneumatisation
2) arrested pneumatisation

1) over expansion of the paranasal sinus cavities.
- thinning of bone
- clinical significance for surgery

2) arrested pneumatisation
- sphenoid sinus affected often
- developmental abnormality
- nuclear mechanism
- CT: non-expansile lesion with curvilinear calcification and sclerotic margin posterior to sphenoid
- MR : internal fat

18

Intracranial calcification

list the causes

- normal (before 9 yo is abnormal)
-> pineal
-> choroid
-> basal gangla
-> falx, dura, tentorium
-> petroclinoid ligament
-> superior sagital sinus
-> dentate nucleus

- age related

- vascular
-> AVM
-> Sturge-Weber syndrome
-> VHL syndrome

- infection
-> neurocysticercosis
-> TB
-> TORHC

- toxins (CO, drugs, methane)

- metabolic
-> hypoparathyroidism
-> pseudohypoparathyroidism

- mitochondrial disorder

- radiation

19

Pseudosubluxation

1) define
2) what is Swischuk's line

1) physiological occurence in paediatric population
- C2 move anterior to C3

2) Swischuk's line
- spinolaminar line
- if C2 is off by > 2mm = true subluxation

20

Notocord

1) define
2) where is the remnants
3) what is chordoma
4) other residual notochord

1)
- primitive cell line
- earliest fetal axial skeleton
- from Rathke's pouch to coccyx

2)
- remnant normally in midline

3)
- malignant tumour arising from notochord remnants

4)
- nucleus pulposus
- Thornwaldt cyst

can also seen in
- sphenoid occipital synchondrosis
- sacrococcygeal regions

21

Scoliosis

1) define
2) cause

1) lateral curvature of spine with cobb angle > 10 degrees

2) cause

- infection
- trauma

- congenital
-> skeletal dysplasia
-> connective tissue disorder : Marfan, Elher danlos
-> NF1
-> segmentation anomalies

- degenerative

- vertebral fusion anomalies

- spinal dysraphism

22

Fibrous cortical defect

1) define
2) imaging
3) ddx

1) benign bone lesion
- histologically same as NOF
- < 3ccm in size

2) imaging
- diametaphyseal junction
- distal femur
- proximal or distal tibia

Xray
- lucent intracortical defect
- sclerotic rim
- no medulla involvement
- no aggressive features

Eventually ossifies

3) ddx
- NOF : if larger
- infection, EG
- osteoid osteoma

23

Anterior angulation of coccyx

1) types

2) ddx

3) symptoms
4) treatment

1)
1 - coccyx pointing forward and inferiorly (70%)
2- coccyx pointing straight foward
3 - coccyx sharply angulated at C1/2 or C2/3
4 - anterior subluxation of coccyx at sacrococcygeal level (or C1/2)

2)
- trauma/fracture

3)
- type 1 can get idiopathic pain

4) surgical removal

24

Physeal scar

1) define

1) normal appearance of a fused physis after growth cessation

2) radiological
- transverse sclerotic line at the region of previous physis

25

Transverse metaphyseal line ddx

PRINCES

- poison (lead, mercury)
- rickets
- infection (torch)
- normal : neoplastic (leukaemia, lymphoma)
- congenital syphilis
- endocrine (hypothyroidism)
- sickle cell, survey, syphilis

26

Bipartite patella

1) define
2) location
3) ddx
4) management

1) anatomical variation
- unfused patella accessory ossification centre
- 2% of populiation
- bilat 43%
- male > female

2)
type 1 : inferior pole 1%
type 2 : lateral pole 25%
type 3 : superolateral portion most common 75%

3) ddx
- fracture : with bipartite patella normally there is more bone (due to the presence of accessory ossification centre) compared with fracture (normal amount of patellar bone)

4) may need surgery if pain

27

Glenoid labrum variation

1) buford complex
2) sublabral sulcus on MRI
3) sublabral foramen on coronal imaging
4) labral attachment type
5) bicep labral complex

1) buford complex
- congenital labrum variant
-> Anterior superior labrum absent in 1-3 o'clock direction
- middle GHL thickened and
-> originates from superior labrum at the base of the biceps tendon + cross subscapularis tendon to insert on the humerus
- 1.5%

2) sublabral sulcus
- biceps tendon (black)
- superior labral sulcus (white)
- superior labrum (black)
- superior sublabral sulcus ( white)
- glenoid

3) sublabral foramen
- poorly attached anterior superior part of the labrum to the glenoid cartilage

4) labral attachment type
A - small cleft between labrum and underlying glenoid cartilage (meniscoidal)
B - labrum firmly attaches to glenoid articular cartilage

5) bicep labral complex
type 1 - firmly attach to glenoid
type 2 - small superior sublabral sulcus between bicep/labrum and underlying glenoid
type 3 - large superior sublabral sulcus between biceps/labrum and underlying glenoid (meniscoidal type)

28

Limbus vertebrae

1) define
2) imaging
3) ddx

1)
- herniation of nucleus pulposus through the vertebral body and ring apophysis

2)
- lumbar
- anterior superior corner
- well corticated

3) ddx
- fracture (limbus, teardrop)
- degeneration
- infection

29

Schmorl's node

1) define
2) what is it associated with ?
3) imaging

1)
- aka: intravertebral disc herniation
- herniation of nucleus pulposus through vertebral body endplate
- into adjacent vertebrae

2) one of the diagnostic criteria for Scheuermann disease

3) imaging
- inferior endplate thoracic or lumbar vertebrae
- sclerotic margin
- MRI: same signal as adjacent disc

30

Conjoined nerve root

1) define
2) ddx
3) symptom

1)
- enlarged nerve root sheath containing 2 nerve roots
- normally subsequently split at the lateral recess level
- each nerve then normally exit through their respective foramen
- L5/S1 common

2) ddx
- nerve sheath tumour
- disc herniation

3)
- normally asymptomatic
- may have radiulopathy

31

filum fibrolipoma

1) define
2) imaging
3) ddx
4) clinical
5) PEARL

1)
- aka : fatty filum terminale
- fat in otherwise normal filum

2)
- linear fat within filum terminale
--normally dorsal sac

- no mass effect
- no tethered cord appearance
-> normal conus position
-> no dysraphism

3) ddx
- intraspinal lipoma: larger > 5mm, thickening of filum > 2mm, low lying conus
- tethered cord: thick filum, indistinct conus termination
- lipomyelocele : dorsal dysraphism

4) asymptomatic
- 4-6% of patient

5) PEARL
- symptomatic = suggest lipoma - asymptomatic = fatty hilum

32

Spinal lipoma

1) define
2) imaging
3) ddx

1) lipoma
- intradural lipoma that is separated from the subcutaneous fat

types
- associated with cord (intradural) or
- terminal lipoma ( associated with filum)


2) imaging
- intradural : invaginate into cord
- terminal lipoma: mass +/- posterior dysraphism

3) ddx
- filum fibrolipoma : smaller, no mass effect
- lipomyelocele: neural placode contact subcutaneous fat. Lies within the spinal canal. No ventral CSF expansion.
- lipomyelomeningocele : near placode contact subcutaneous fat. Lies outside of spinal canal. Ventral CSF expansion
- meningocele : CSF sac protrusion through dorsal defect
- dermoid

33

Tethered cord

1) define
2) imaging

1) imaging and symptoms associated with a low lying conus
- which is tethered by short, thick filum terminale

2) imaging
- conus below L2
- tethered thick filum
- associated abnormality
-> fibrolipoma, lipoma
-> dysraphism
-> segmentation/fusion abnormality
-> lack of motion of the conus

34

Ventriculus terminalis

1) define
2) imaging
3) ddx

1)
- aka: terminal ventricle (5th ventricle)
- CSF filled cavity of conus medullar is filled by ependymal cell

2) imaging
- cystic dilatation the conus terminals
- no cord signal abnormality or enhancement

3) ddx
- transient dilatation of central canal
- hydrosyringomyelia
- neoplasm :
-myelomalacia : previous trauma. Seen atrophy.

35

Accessory soles muscle

1) imaging

1) imaging: increased well defined soft tissue in Kager fat pad
- normally no clinical relevance

36

Low solar musculcutaneous junction

1) is there any difference?

2) surgical implication

1) there is considerable anatomical variation for the musculotendinous junction level

2) surgical implication for
- repair
- planning of reconstructive surgery using soleus muscle flap

37

Standard shoulder view.
List function for imaging below:

- AP external rotation
- AP internal rotatin
- True anatomical AP (Grashay)
- axial view:
- outlet view :

- AP external rotation : for GT
- AP internal rotation : for letter tubercle and good for hill sach.
- True anatomical AP : for GH joint space
- axial view : superior inferior view
- outlet view : like lateral view by with 15 degree angulation. For impingement.

38

Clavicle standard view:
List the function for:

- AP
- AP cephalid angulation

- AP: entire length of clavicle

- AP caphalad : straighten out clavicle. For occult fracture

39

Westpoint view. What is it and what is it used for?

- similar view to axial view of the shoulder (supero inferior)
- best for imaging inferior glenoid
- via projecting away the coracoid.

40

Rotator cuff impingement

1) aka
2) define
3) imaging
4) ddx
5) exam PEARL

1) subacromial impingement

2)
- clinical syndrome
- rubbing of subacromial bursa and supraspinatous by
- acromium, coracoid and humerous

3) imaging
- AC joint ostephyte
- os acromiale
- hooked acromium
- large lateral extension of acronym +/- lateral acromial tilt
- decreased acromiohumeral joint distance < 7mm

MR
- tendinitis
- bursitis
- rotator uff tear
- thickening of coracoacromial tendon

4) DDX

Intrinsic cause fo tendinopathy/rotator cuff tear
- ischemia, myxoid degeneration, microtrauma

Internal impingement
- fraying and tearing of posterior superior labrum

Secondary impingement
- due to instability
- normal coracoacromial arch

Subcoracoid impingement
- decreased distance between coracoid and humorous lesser tubercle
- compress subscapularis tendon

5)
- this is a clinical diagnosis

41

Internal impingement

1) aka
2) imaging

1)
- posterior superior glenoid impingement
- abduction and external rotation (pitcher)
- clinical diagnosis

2) imaging
- posterior superior labral fraying/tear (SLAP tear if severe)
- thick posterior capsule, posterior band of IGHL
- posterior superior rotator cuff injury
- loosened anterior capsule
- greater humeral head cyst/notch

3) mechanism
- throwing action (abduction and external rotation) -> greater tuberosity hitting posteriorsupesior glenoid

42

Subcoracoid impingement

1) define

2) imaging

1)
- shoulder impingement type
- due to narrowing of coracohumeral distance < 10mm

2) imaging
- decreased coracohumeral distance < 10mm
- sub scapular tendinitis/tear
- long head of biceps
- middle GHL involvement

43

Clavicle fracture

1) location
2) fracture displacement pattern
3) associated injury
4) Neer classification

1) medial 1/3

2) anteroinferior displacement of lateral fragment ( coracoclavicular ligament)
- superior displacement of medial fragment ( no coracoclavicular ligament ) = unstable

3) associated injury
- rib
- pneumothorax
- AC separation
- SC injury
- subclavian vessel, brachial plexus injury

4) Neer classification
- type 1 : between AC joint and CC ligament -> no displacement of medial fragment, stable

- type 2 : unstable
-> metal to CC ligament or
-> rupture of CC ligament

44

Sternoclavicular joint trauma

1) imaging
2) anterior vs posterior
3) exam Pearl
4) ddx

1)
- abnormal position of medial clavicle related to manubrium

2)
- Anterior dislocation : medial clavicle anterosuperior to manubrium
- more common

- posterior dislocation:
medial clavicle posteriorsupesior to manubrium
- damage mediastinal structure.
- life threatening-> need CTA

3) exam PEARL
- high force trauma -> potential life threatening.
- need urgent CTA to assess underlying vascular injury

4) ddx
- atraumatic cause -> ligamentous laxity with raising arm over head

45

Humeral fracture

1) describe neer classification

1)
location
- head
- surgical neck
- greater tuberosity
- lesser tuberosity

Amount of displacement
- > 1 cm displacement
- > 45 degree angulation

Neer classification
1- fracture but no displacement
2 - 1 displaced fragment
3 - 2 displaced fragment
4 - 3 displaced fragment

46

Coracoid fracture

1) association, is it common? and which ones?
2) classification
3) ddx

1)
- yes
- acromium, clavicle, scapula
- humeral head dislocation

2)
type 1
- base fracture
- proximal to the coracoclavicular ligament

Type 2
- tip fracture
- distal to coracoclavicular ligament

3) ddx
- physics :
-> tip of coracoid fuse at 18-25 yo
-> base of coracoid fuse at 14-16 yo

47

Scapula fracture

1) define
2) association
3) location/classification

1)
- uncommon shoulder fracture (3%)
- often associated other injuries due to high impact injury

2)
- clavicle
- humeral
- rib
- pneumothorax
- sternum,
- spine
- brachial plexus

3)
- intra-articular fracture
- extra-articular fracture
- coracoid process
- acromial fracture

48

Shoulder dislocation

1) write note for anterior dislocation

2) posterior dislocation

3)

1)
- more common (95%)
- anterior inferior displacement
- bankart : anterior inferior glenoid (bony or cartilaginous)
- Hill-sach lesion: posterolateral glenoid head (contusion or impaction)
- associated injury
-> anterior band IGHL tear
-> rotator cuff tear
-> greater tuberosity avulsion
- PEARL: west point view of the shoulder demonstrate glenoid fracture well

2)
- less common
- cause : seizure, electrocution, FOOSH

- imaging:
-> light bulb sign (internal rotation due to pull from subscapularis)
-> trough sign (reverse Hill- Sachs - anteromedial humorous impact on posterior glenoid)
- loss of congruity between glenoid and glenoid head
- posterior bankart

Associated injury
- reverse bankart lesion
- posterior labrocapsular periosteal sleeve avulsion
- posterior GHL tear
- posterior humeral avulsion GHL

49

List the types of anterior glenoid labrum injury

1) normal variant
2) injuries
3) what are these associated with
4) PEARL for exam

1)
- sublabral recess : recess inferior to the anterior superior labrum (bicep, superior labral sulcus, labrum, superior sublabral sulcus, glenoid)

- sublabral foramen : defect where the anterior superior labrum doesn't attack to underlying glenoid firmly)

2)
- bankart :
-> torn labrum + periosteum

- bony bankart:
-> torn labrum + periosteum
-> with underlying osteochondral injury of glenoid rim

- Perthes lesion: (unstable)
-> anterior inferior labrum tear (minimally displaced)
-> still attached to the periosteum
-> periosteum is intact but lifted

ALPSA (stable)
- aka: anterior labroligamentous periosteal sleeve avulsion
- similar to perthes but
- labrum displace inferior medially

-GLAD : (stable)
-> aka: glenolabral articular disruption
-> define:
- anterior inferior labral partial tear + glenoid articular cartilage injury
- periosteum is intact
-> mechanism: forced adduction
-> PEARL: imaging defect often parallel glenoid surface

HAGL
- more inferior
- avulsion of IGHL from humeral insertion

BHAGL
- avulsion of IGHL and bony avulsion from its humeral attachment

3) anterior shoulder dislocation

4)
- if you see a Hill-sach
- check the labrum for above

50

OA

1) define

1) degenerative joint disease
- loss of articular cartilage
- hypertrophic bone changes

2) imaging
- subchondral sclerosis, cyst
- osteophyte
- loss of joint space

3)
shoulder
- inferior medial glenoid osteophyte common
- ddx:
-> rotator cuff: cause 2ndary OA
-> HADD : milwaukee shoulder
-> infection

Elbow
- ddx :
-> JIA : enlarged radial head, epiphysis. More synovitis. Erosion, lose body, cartilage loss.
-> haemophilia: similar to above

Hand:
- DIP > PIP > 1st CMC and STTJ
- erosive OA : central gullwing erosion
- ddx :
-> psoriasis: acroosteolysis, DIP, PIP. Erosion, periostitis, swelling (sausage finger)
-> multi centric reticulohistiocytosis: acroosteolysis, DIP > PIP. Erosion. soft tissue nodule (no sausage finger)
-> Adult still's disease

Hip
- weight bearing surface articular cartilage loss
- calcar buttressing (medial femoral neck thickening/osteophyte)
- lateral femoral neck thickening/osteophyte
- superomedial displacement 80%
- medial displacement (protrusio) 20%
- rapidly progressive osteoarthritis (hatchet deformity) : well demarcated femoral neck defect. Femoral head destroyed. DDX infection, neurogenic

Knee
- medial compartment > lateral
- varus > valgus deformity
- look for other changes: meniscus, cartilage, subchondral bone edema, ligament ( cruciate, collateral)

Spine:
- anterior/lateral osteophytes
- facet arthropathy
- uncovertebral joint osteophytes
- Baastrup disease : spinous process friction and osteophytosis, degeneration, cyst formation (interspinous bursitis)

51

Rheumatoid

1) define

2) imaging

3) path
4) steps

1)
- BILATERAL SYMMETRICAL EROSION, OSTEOPENIA, SUBLUXATION, SWELLING, SUBCHONDRAL CYST
- chronic inflammatory erosive arthritis
- involve several joints
- characterised by erosion and cartilage destruction

2) SEOSSS
General
- bilateral symmetric
nodule
- erosion
- osteopenia
- subluxation
- swelling : effusion, rheumatoid
- subchondral cyst

MR:
- concentric cartilage loss/thinning
- erosion
- subchondral edema
- effusion
- pannus, rice bodies
- synovitis
- torn ligament

Pannus: low T1, heterogenous T2. Avidly enhances.

Rice body : low T1 (detached synovium)

Synovitis: inflamed synovium, low signal, enhance. Distended capsule with low signal debris within capsule

Spine:
- thinning of dens
- dens erosion
- increased predental space
- basilar impression
- PEARL: flexion/extension lateral x-ray to evaluate stability.
- DDX:
-> seronegative arthritis: check SI joint
-> CPPD : has calcium (RA never has calcium)
- JIA: vertebral body fusion. Facet erosion


Mandible
- pencil thin condyle
- MRI: intermediate signal pannus
- ddx:
-> OA : can mix with RA. Subchondral sclerosis differs.
-> JIA : mandibular hypoplasia. Fusion of cervical spine
-> psoriasis: hx. less destruction then RA.

Wrist/hand
- > MCP > PIP
- wrist (DRUJ, RCJ, ICJ)
Late:
- 1st CMC in very late stage
- pencil in a cup deformity
Subluxation:
- z shaped deformity
- boutonnière
- swan neck
- MCP volar subluxation or ulnar deviation
- volar subluxation of carpus on radius
MR:
- subluxation - tenosynovitis
- swelling - effusion
- erosion
- pannus : thick nodular, low T1. surrounding effusion.
- marrow edema
DDX:
- SLE : reducible deformity. Nonerosive. Prominent tenosynovitis.
- Erosive OA : OA distribution
- Psoriasis: fluffy periostitis. DIP > PIP
- Hyperparathyroidism: acroosteolysis, subperiosteal erosion, brown's tumour
- multi centric reticulohistiocytosis: acroosteolysis, DIP erosion, soft tissue nodules.

Clavicle:
- erosion on both side of joint
- erosion at coracoclavicular ligament insertion

Glenoid
- erosion
- uniform decreased joint space
- large subchondral cyst
- rotator cuff tear
- can have complete erosion of humeral head
- synovitis : low signal with debris. Enhance
- subacromial, sub deltoid synovitis
- exam case: symmetrical bilateral pencil deformity of the humeral head and clavicular/acromial joint
- ddx: infection, neuropathic joint (normally unilateral), CPPD milwaukee shoulder

Hip
- bilateral symmetrical erosion, osteopenia, protrusion (subluxation)
- insufficiency fracture : femoral head, neck, weight bearing acetabulum
- soft tissue in iliopsoas bursa : characteristic of fluid decompressing into iliopsoas bursa
- tendinitis, ruptured tendon : gluteus
- swelling, erosion,
- NOTE: CALCAR BUTTRESSING IN RA -> SECONDARY OA

3)
- idiopathic, probable autoimmune
- genetic component
- histology:
-> synovitis
-> thickened synovium = pannus
-> rice body : detached synovial villi

Feet: 5TH METATARSUS
- location: MTP (5th), posterior calcanea tubercle, mid foot, tibiotalar joint
- symmetrical erosion, osteopneia
- swelling/effusion: MTP, tibiotalar
- calcanea erosion : ddx chronic reactive arhtirits, psoriasis ( these have fluffy periostitis - i.e erosion + periosteal bone formation)

4) steps
- synovitis -> effusion -> pannus formation/juxta-articular osteopenia -> marginal erosion -> subchondral erosion -> pencil in a cup deformity

52

Septic arthritis

1) define
2) distribution
3) imaging
4) ddx
5) organism
6) PEARL

1) infection within joint space

2) distribution
- most common: knee
- children: hip
- HIV/diabetes : SI, sternoclavicular

3) imaging
- early: normal
- 1st sign: joint effusion

- destruction of cartilage, bone
- marginal erosion
- osteoporosis
- sclerotic bone reaction : if bacterial
- TB/funga: little bony reaction

MR:
- bone edema
- effusion
- surrounding soft tissue enhancement
- post contrast: bone enhancement, synovial thickening, occasional surrounding pus

4) ddx
- inflammatory arthritis
- viral (toxic) synovitis: need aspiration to differentiate.

5) organism
- s. aureus : most common
- strep pneumonia, groupB strep, ecoli
- mycobacterium, psedomonus (IVDU)

6) PEARL
- hip aspiration if clinical suspicion if imaging equivocal

53

Osteomyelitis

1) define
2) organism
3) location
4) location via age
5) imaging
6) subacute brodie's abscess
7) complication

1)
- bony infection

2) organism
- staph aureus : most common
- ecoli, pseudomonas, kelbisella (IVDU)
- salmonella : sickle cell disease
- haemophiliac, group b strep : neonate

3)
- lower limb
- vertebrae
- radial styloid
- SI joint

4) location
- neonate: epiphysis, metaphysis
- child: metaphysis
- adult : epiphysis and subchondral region

5) imaging
- lytic bony lesion
- ill circumscribed
- cortical breach
- periostitis : thickening vs aggressive cowman's triangle

6) Subacute Brodie abscess:
- Sequestration: calcification within a
- cloaca: opening to a brodie's abscess
- involucrum : thick periosteal new bone surrounding sequestrum

7)
- spreading infection
- pathological fracture
- sinus tract
- secondary sarcoma : rare

8) ddx
- neurogenic joint: sinus tract (infection), bony debris (neurogenic joint)
- tumour :
-> children: ewing, met ((neuroblastoma), EG
-> adult: met, myeloma, lymphoma

54

Psoriasis

1) define
2) imaging
3) ddx
4) is oligo or polyarticular more common?
5) PEARL

1) seronegative spondyloarthropathy
- arthritis precedes skin change by 2 years in 15%

2) FEP ENAA!!!
- fluffy periostitis (erosion/periostitis)
- enthesitis
- no osteoperosis
- ankylosis
- acroostelytis

HAND
- dip, pip
- fluffy periostitis
- swelling, erosion, ankylosis, periostitis
- acro-osteolysis
- arthritis mutilans, pencil in cup, telescoping, sausage finger
- ddx:

Sacroiilitis
- 35% of patient
- asymmetrical

Spondylitis
- 30%
- asymmetrical bulky anterior osteophyte

Foot
- enthesitis (inflammation at tendon insertion)
- achilles tendinitis
- retrocalcaneal bursitis
- joint effusion, synovitis

Other joints may be involved but uncommon
- erosions

3) ddx
- reactive arthritis: similar

Hand ddx
- reactive arthritis: more often lower limb
- erosive OA : no periostitis, acro-osteolytis. Involves 1st CMC and STTJ (only in OA)
- RA: MCP more often. No periostitis

4)
- oligoarticular > poly

5) rapid development of skin psoriasis could be associated with HIV

55

Synovial chondromatosis

1) define
2) imaging
3) ddx
4) location

1)
- benign neoplasm
- synovial proliferation of cartilage or osseous bodies
- in joint, bursa or tenosynovial structure

2) imaging
- multiple round bodies of similar size.
- variable calcification (85% calcify)
- erosion not uncommon

xray
- may show monoarticular erosion and osteopenia : exam pearl -> ddx of erosive arthropathy, infection or underlying synovial pathology. Need MR for further diagnosis

MR (required for diagnosis)
- variable signal of round bodies
- most low T1, high t2
- low T2 if calcify
- can have bone formation (outer cortical bone signal, inner marrow signal)

3)
ddx
- synovial chondrosarcoma: may not be differentiated by imaging. Snowstorm appearance of calcified cartilage
- PVNS: low T1, T2, bloom
- secondary synovial osteochondromatisis: underlying OA with multiple variable size loose body.

4) knee (50-60 %) > hip > shoulder > elbow
- popliteal
- ilipsoas bursa
- subacromial bursa

56

PVNS

1) define
2) location
3) imaging
4) ddx
5) exam pearl

1) low grade aggressive neoplasm
- GCT of tendon sheath : histologically similar

2) knee, hip, elbow, shoulder

3) imaging
x-ray
- large effusion
- erosion 50%
- large subchondral cyst sometimes

MR:
- intra/extraarticular
- effusion
- low T1, T2, bloom
- intense heterogenous enhancement (not required for diagnosis)

4) ddx
- intra-articular nodular synovitis
- : low T1, T2. Punched out lesion. No bloom.
- amyloid: Low t1, t2. enhance. No bloom.
- haemophilia : effusion, low T1, T2 synovial proliferation, enhancement, bloom, erosion of surrounding bone (all similar to PVNS). Look for enlarged epiphysis
- synovial chondromatosis: use Xray for calcified bodies. Can see mass. Ask for Gradient image (no blooming)

5) if see low T1, T2 signal mass in joint -> could be PVNS, gout, amyloid, haemophilia -> ask for x-ray to check calcified bodies -> ask for gradient (then check the epiphysis for no enlargement to rule out

57

CPPD

1) define
- cppd
- chonedrocalcinosis

2) location

1)
- CPPD : arthropathy secondary to deposition of CPPD in joint
- chonedrocalcinosis: crystal within articular cartilage

2)
- chonedrocalcinosis : knee > symphysis pubis > wrist > hip > shoulder > elbow

- arthropathy : knee > hand > shoulder

- knee: more patellofemoral space invovement
- wrist : slap
- spine: dens erosion and calcification . ddx RA (no calcification). Calcification (HADD)

3) DO CHESS

- DJD in odd position
- chondrocalcinosis
- hook like osteophyte
- erosion (early stage)
- subchondral cyst
- SLAC wrist

MR:
- chonedrocalcinosis signal is variable on T1 and fluid sensitive sequence

3) ddx
- infection : need aspiration
- haemachromatosis
-> primary: HFE gene. increased gut reabsorption of iron.
-> secondary: increased transfusion, iron ingestion, alcohol.
- RA

58

Gout

1) define
2) types
3) imaging
4) ddx
5) PEARL

1)
- type of crystalline arthropathy
- sodium monourate crystal deposit in joint
- 1st MTP

2)
primary
- over production of sodium monourate
- decreased renal secretion

secondary
- CRF, tumour or dialysis

3) PONT
- punched out erosion
- overhanging sclerotic edge
- no osteoperosis
- tophi

MR: low T1, T2, no bloom

4) on MR
Synovial pathology
- PVNS
- primary osteochondromatosis

Other arthritis
- amyloid: Low t1, t2, enhance. No bloom. erosion.
- RA:
- haemophilia : bloom. erosion

5) gout can look like anything

59

Amyloid

1) define
2) types
3) imaging
4) ddx

1) deposition of non-soluble protein

2)
AL
- monoclonal proliferation of plasma cell -> amyloid L production
- 15% of Multiple myeloma have AL

AA
- inflammation -> liver release of AA

Hereditory
- gene mutation

Dialysis related
- accumulation of B2 microglobulin

3) imaging
MR - low t1, t2, no bloom. enhancement. erosion.

4) ddx :
- synovial pathology
- other arthritis

60

Sternoclavicular hyperostosis

1) define
2) association SAPHO

1) enlargement of
- sternum, clavicle
- sometimes 1st, 2nd costocondral junction

2) association with SAPHO syndrmoe
- synovitis
- acne
- pustulosis
- hyperostosis
- osteitis

61

Adhesive capsulitis

1) define
2) imaging
3) age
4) ddx

1)
- aka frozen shoulder
- fibrotic shoudler with decreased movement

2) imaging
- thickening, fibrous tissue involving
-> rotator cuff recess, - thick coracohumeral ligament
-> anterior capsule (subcoracoid region)
-> axillary pouch inferiorly

3) 50 yo lady

4) ddx
- DJD shoulder
- calcific tendinopathy
- impingement : pain with impingement test. NOT A RADIOLOGY DIAGNOSIS

62

SLAP tear

1) list all types
2) ddx

1)
Type 1
- superior labrum fraying
- bicep anchor stable
- common 20%
- the only slap tear that has conservative management.

Type 2 :
- superior labrum longitudinal tear
- bicep anchor unstable
- most common
- imaging:
-> high signal extending laterally in superior labrum or
-> widening of high signal > 2mm in superior labrum

- double oreo cookie sign:
-> 2 high density lines in the sueprior labrum
-> superior line : SLAP 2 tear
-> dark labrum in between
-> inferior line : superior sublabral recess

Type 3:
- superior labrum full width tear (bucket handle)

Type 4
- superior labrum longitudinal tear extending into bicept root (bicep high signal or torn)

2) ddx
- superior sublabral recess: sometimes impossible to differentiate.
- normal sulcus between bicep and labrum.

63

Shoulder instability

1) define

2) name the stabilisers

3) type of soulder instability

- TUBS
- AMBRI

4) most common cause

1)
- tendency for shoulder to sublux/dislocation
- due to loss of stabiliser

2) stabiliser
Anatomical
- glenoid
- labrum
- ligaments
- capsule
- coracoacrominal arch
- negative adhesive forces

Dynamic
- rotator cuff
- bicep long tendon

3)
Anterior:
- aka TUBS (traumatic)
- traumatic unidirectional dislocation with Bankart requiring surgery
- due to previous anterior dislocation
- surgical repair normally

Posterior:
- rare
- due to previous posterior dislocation
- surgical repair normally

Multidirectional:
- aka : AMBRI (atraumatic multidirectional bilateral that responds to rehabilitation, occasional inferior capsular shift)

Superior (microinstability):
- often associated with multidirectional

4) most common cause
- labral tear
- capsular laxity
- GHL tear
- glenoid #

64

Paralabral cyst of the shoulder

1) define

1)
- cyst around labrum
- unknown aetiology
- can ompress suprascapular or axillary nerve

2) location
- posterior superior most common

65

HADD

1) define

2)
- monoarticular vs poly articuarlar??
- location?

3) imaging
4) ddx
5) exam pearl

1)
- disease associated with hydroxyapatite deposition
- calcific tenditis and bursitis

2)
- mono
- shoulder (70%) > hip
- > spine > elbow/knee/wrist/ankle

3) imaging (xray to locate calcification)
- calcification in tendon or bursa (best) : low signal, bloom
- can erode bone surface
- tendon enlargement
- bone marrow edema
- milwakee shoulder -> destruction of shoulder joint.

4) ddx for low intensity soft tissue/tendon thickening
- fibrous tissue
- tumour
- calcium deposit
-> dystrophic calcification ( connective tissue disease, hyperparathyroidism)
-> metastatic calcification (dialysis)

4) exam PEARL
-ASK FOR XRAY if given MR first

5) typical exam case
- Milwakee shoulder
- calcified tendinitis of longus colli

66

Rotator cuff tendinopathy

1) define

1)
- aka : rotator cuff impingement syndrome

2) imaging
MR
- thickened swollen rotator cuff tendon on T2

Ultrasound
- swollen tendon : hypo echoic region within tendon (relative to deltoid mm)
- thick tendon
- loss of normal fibrillar pattern in normal tendon

3) cause
Extrinsic cause
- subacromial /subcoracoid impingement

Intrinsic cause
- age
- trauma
- decreased vascularity
- mucoid /eosinophilic degeneration

4) ddx
- tear/cleft/fissure within the tendon (some consider spectrum of rotator cuff tendinopathy)
- HADD
- rotator cuff tear: normally supraspinatous
- magic angle: increased signal BUT NO TENDON THICKENING

67

Bicep tendinopathy

1) imaging
2) ddx
3) cause
4) pearl

1) imaging
MR: thickened swollen bicep tendon

U/S: hypo echoic thickened tendon
- tender on probing

2) ddx
- bicep partial tear: high signal extend to ligament surface
- magic angle artefact

3) cause
- a/w rotator cuff tear or impingement syndrome 95%

4) Exam pearl: look for rotator cuff tendinopathy

68

Subscapularis tear

1) imaging
2) cause
3) ddx

1)
- normally in cranial portion of tendon 2cm short of lesser tuberosity
- often associated with medially displaced bicep tendon

2) cause
- rotator cuff tear (supraspinatous)
- trauma
- subcoracoid impingement

3) ddx
- subscapularis tendinopathy : high signal within tendon (no extension to the surface of tendon)
- rotator interval tear : bicep pully and anterior supraspinatous tear
- subcoracoid impingement

69

Bicep tendon dislocation

1) define subluxation
2) define dislocation
3) exam spill

1) bicep tendon perched on lesser tuberosoity

2) bicep tendon displaced medially

3) association
- rotator cuff tear
- rotator cuff interval tear : subscapularis, anterior suprasinatous and bicep pully (coracohumeral and superior GHL)

3) exam spill
- bicep is dislocation -> i'd like to check the rotator cuff

70

bone infarct/AVN

1) define
2) iamging
3) cause
4) ddx

1)
- bone infarct: osteonecrosis in the bone marrow

- AVN: osteonecrosis in the subchondral location

2) imaging
- serpininous sclerosis with central lucency
- double line on T2 MR: inner bright, outer low

- other appearance:
-> mixed sclerosis/lucency
-> sclerotic lesion with scattered calcification

3) cause
- plastic rags
- sickle cell and steroid high risk factor

4) ddx
- enchondroma
- bone island

5) compication
- pleomorphic undifferentiated sarcoma (most common soft tissue sarcoma)

6) exam case
- hip with bilat femoral AVN (mixed sclerosis and lucency). Surgical clip and pelvic kidney
- H-shaped vertebrae in sickle cell anaemia
- Muller Weiss syndrome: bilateral navicular AVN due to stress fracture (in adult)
- Kohler : navicular AVN in childhood

7) ficat arlect
- 1 : ostepenia
- 2 : mixed osteopenia, sclerosis
- 3 : subchondral lucency
- 4: end stage DJD

71

Clavicular osteolysis post trauma

1) cause
2) imaging
3) ddx of distal clavicular lysis

1) cause
- trauma
- repeated lifting post trauma

2)
- clavicle erosion
- spare acromium

3) ddx of distal clavicular lysis
- infection
- trauma
- erosive arthropathy: RA
- collagen vascular disease: look for subcutaneous calcification
- hyperparathyroidism

72

Suprascapular nerve palsy

1) location of impingement
2) imaging
3) ddx

1) location of impingement
- supra scapular notch : supra and infraspinatous denervation
- spinoglenoid notch: infraspinatous only
- cause: paralabral cyst, venous dilated vessel, scar, trauma, mass

2) imaging
- look for impingement
- mm denervation: high muscle signal (first), then fatty degeneration

3) ddx
- cervical radiculopathy
- parsonage-turner (brachial neuritis) : supra/infaspinatous > teres minor, deltoid
- tumour
- rotator cuff tear

73

shoulder implant complication

1) types

1) type
- total shoulder arthroplasty:

- hemiarthroplasty:

- reverse shoulder arthropathy: severe rotator cuff tear
-> glenosphere
-> metaglene: polyethylene cup
- ALWAYS COMPARE MEDIAL EDGE OF METAGLEN TO THE LATERAL BORDER OF SCAPULA : SHOULD ALIGN

2)
- infection
- loosening
- dislocation
- fracture (prosthesis, surrounding bone)
- particle disease: wear of the polyethylene

74

osteochondral lesion

1) define
2) cause
3) classification
4) location

1)
- articular damage with underlying subchondral injury

2) cause
- osteochondral dissecans (repeated micro trauma))
- AVN
- surgery
- macrotrauma

3) classification
- 1 : cartilage only (but mr show subchondral bone edema)
- 2: subchondral bone (A: edema, B: no edema)
- 3 : cleft
- 4 : loose body
- 5 : DJD

4) location
- femoral condyle (medial)
- humeral head
- humeral capitalum (panner disease)
- talus

75

Acromial apophysitis

1) define

1) MRI finding
- inflammation of unfused acromial apophysis
- especially in throwing sport

76

scapulothoracic bursitis

1) where is scapulothoracic bursa

1)
- superior medial scapula
- inferior medial scapula

77

Axillary nerve palsy/quadrilaterla space syndrome

1) boundary
2) muscle affected

1) boundary
- teres minor, major
- tricep and humorous

2) muscle affected
- teres minor
- deltoid

78

Cubital tunnel

1) state boundaries
2) content

1) space between medial epicondyle and olecranon


- roof :
1) cubital tunnel retinaculum (band of osbourne). From medial epicondyle -> olecranon
2) ancones epitrochlearis

- medial : medial epicondyle
- lateral: olecranon
- floor : elbow joint capsule

2) content
- ulnar nerve
- superior ulnar collateral artery
- fat

79

Terrible triad of elbow

1) define

1)
- posterior elbow dislocation
- coracoid fracture
- radial head fracture

80

Elbow fracture: brief notes

1) supracondylar fracture/ transcondylar fracture

2) epicondyle fracture (avulsion)

3) lateral condylar

4) intercondylar fracture

1)
- def: above the condyles in distal humorous
- transcondylar fracture: name for the same fracture in children
-> complication:
- need surgery due to high risk of neuromuscular injury (anterior interosseous median > ulnar, radial nerve).
-> Vascular injury, spasm, thrombus, rupture.
- > other fracture : olecranon, medial epicondyle, distal radius
- PEARL: if suspicious reimage in 1-2 week

2)
- def: fracture of the ossification centre (medial or lateral)
- epicondyle is responsible for tendon attachment -> i.e can be avulsed
- medial epicondyle : most common and is displaced. Common exam question
- lateral epicondyle : less common. Avulsion fracture (increased lateral displacement of lateral condyle is common exam case). Requires surgery.

3)
- define: intraarciular # lateral condyle. second most common paeds fracture
- common in children, but can occur in adult
- PEARL: shoulder articular condyle involvement -> assume lateral condyle fracture first

4) Intercondylar fracture
define: transverse horizontal supracondylar fracture with vertical intra-articular extension

81

capitalum fracture.

What to think about

- osteochondral injury
- in children = panner disease

82

Define:

Galeazzi
Monteggia
Nighstick

Essex-lopresti

Coronoid fracture
Olecranon fracture


Greenstick
plastic bowing fracture
buckle

Galeazzi : fracture of the radius and displaced distal ulna

Monteggia: fracture of the ulna with displaced radial head

Nighstcik: fracture of the mid diaphysis of the ulna normally due to direct blow. High rate of non-union

Essex-lopresti
- radial head fracture with distal ulnar dislocation

Coronoid fracture:
- often with posterior elbow dislocation (terrible triad)

Olecranon fracture:
- easy to see on lateral x-ray
- require ORIF due to tricep insertion

Greenstick: incomplete fracture of the young bone.
- Only breach of one cortical surface.

Plastic bowing fracture: incomplete fracture of young bone
- bowing of the long bone
- PEARL: look for bowing in apparently normal paeds msk x-ray. if see nothing ASK FOR ORTHOGONAL VIEW!!!! Radius common

buckle fracture: incomplete fracture in immature bone.


83

Checklist for paediatric elbow

1-4) check list
5) what fracture to look for

1) critoe

2) alignment:
- anterior humeral line/capitalum
- radius capitalum

3) bone

4) effusion

Fracture
- supracondylar
- lateral condylar
- medial epicondyle avulsion
- radial head dislocation (Monteggia)
- radial neck
- olecranon fracture : look for terrible triad (posterior elbow dislocation, coronoid fracture, radial neck fracture)

84

1) supinator fat pad sign suggest?

2) anterior fat pad

3) posterior fat pad

1)
- normally supinator fat pad is flat
- if raised = suspect radial neck fracture

2) anterior fat pad is normally flat and small

3) posterior fat pad is not normally seen
- if positive suggest intraarticular #

85

Os supratrochlear dorsale

1) define
2) ddx

1) accessory ossicle of elbow
- in olecranon fossa of humorous
- can cause pain -> surgical removal

2) ddx
- loose body : although treatment is the same
- osteochonral

86

Valgus extension overload

1) define
2) what injury

1) associated pitcher and throwing action

2)
- UCL tear
- capitalum osteochondral defect
- posterior elbow arthrosis . i.e. trochlear posterior bone bruise

87

Olecranon bursitis

1) imaging
2) ddx
3) cause

1) imaging
- fluid in subcutaneous tissue posterior to olecranon

2) ddx
- tricep tendinopathy
- neoplasm
- haematoma

3) cause
- infection
- trauma
- arthropathy
- tricep tendinopathy

88

Bicipital radial bursitis

1) define
2) imaging
3) ddx

1)
- bicep tendon does not have tendon sheath
- fluid around bicep tendon attachment or between radial head and bicep tendon = bicipital radial bursitis

2) fluid changes shape with pronation and supination

3)
- bicep tendinopathy/partial tear
- bicep rupture
- mass
-> neoplastic
- sarcoma
- peripheral NST
-> non-neoplastic
- haematoma
- ganglion cyst

89

Posterior elbow dislocation

1) mechanism
2) associated fracture
3) ligament injury
4) terrible triad

1) FOOSH with elbow in hyperextension

2) associated fracture
- medial humeral condyle >
- radial head neck >
- coronoid process (adult)
- bruising of posterior capitalum

3) Ligament injury
- radial and ulnar collateral both teared
- LUCL tear (most common)

Muscle injury
- tear of flexor and pronator teres proximally

Brachial artery injury (uncommon)

4) terrible triad -
= posterior dislocation
- coronoid fracture
- radial head fracture

90

Radial collateral ligament injury

1) what are the 2 components
2) imaging
3) ddx
4) clinical

1)
- radial collateral ligament
- lateral ulnar collateral liament

2) imaging
- MR arthropathy !!!
-> contrast extending through ligament
-> tear at origin > insertion

3) ddx
- lateral epicondylitis (tennis elbow)
- iatrogenic contrast extravasation

4) clinical
- less common then UCL injury
- often associated with elbow

91

Lateral ulnar collateral ligament

1) function
2) imaging
3) cause
4) grading posterolateral instability

1) posterolateral stability of the elbow (with the radial collateral ligament)

2) imaging
- proximal tear more common

3) cause
- trauma
- dislocation

4) grading posterolateral instability
1 - LUCL tear
2 - LUCL + RCL
3a - stage 2 + posterior UCL
3b - stage 2 + completely UCL
3 c - complete stripping of ligaments and tendon from distal humorous

92

ulnar collateral ligament injury (elbow)

1) which band is most important
2) MR arthrogram
3) ddx
4) cause
5) associated injury

1) anterior band

2) MR arthrogram
- contrast between ligament and muscle

3) ddx
- medial epicondylitis
- stress fracture of olecranon
- avulsion of sublime tubercle

4) cause
- throwing (valgus injury)
- dislocation

5) associated injury
-> LUCL, radial collateral ligament injury, radial head fracture, capitalum osteochondral defect/bruising
-> flexor digitorum superficialis tear
-> ulnar neuropathy

93

Elbow epicondylitis

1) medial epicondylitis aka
2) lateral epicondylitis aka

1) golfer's elbow

2) tennis elbow (more common) 20x more common then medial

3) imaging
Tendinosis /substance partial tear - intrinsic high t2 signal
- partial tear: high T2 signal extending to tendon surface

U/S
- thickening, hypo echoic, fibrillar disruption of tendon
- hyperaemia of tendon origin

94

Bicep tendon injury

1) location
2) best imaging

1)
- near or at radial tuberosity insertion

2) best imaging
- axial fat sat or T2 weighted sequence

3) PEARL :
check laceratus fibrosis (normally attach to the pronator teres)

95

Tricep tendon injury

1) at the attachment site what portion of tricep tendon attaches to the olecranon

2) cause

2) tricep tendon from long and lateral head
- tendon and muscle of medial head

2) cause
- trauma
- steroid, DMB, CRF, connective tissue disease

96

Brachialis tendon

1) possible presentation
2) if untreated?
3) PEARL

1) mass in the ante cubital fossa
- most are strain of muscles/myotedinous junction -> improve with rest

2) if untreated -> decreased elbow flexion strength

3) PEARL
- check for bicep injury

97

Hyperextension elbow injury

1) associated injuries
2) what type of athletes get this

1)
Bony
- loose body
- osteophyte

Soft tissue
- medial collateral ligament (50%)
- tricep tendinopathy
- ular neuritis
- effusion

2) goalkeepers

98

Ulnar neuropathy

1) at cubital fossa or guyon's canal

2) imaging
3) cause

1) at cubital fossa or guyon's canal
- 2nd most common nerve entrapment in the upper extremity (after carpal tunnel)

2)
- high nerve signal
- high signal of FCU and FDP (secondary sign)
- check band of osborne for irregularity = fibrosis
- check for ancones epitrochlearis (accessory muscle at the region of band of osborne - medial epicondyle to olecranon)

3) cause
- infection
- trauma
- bony abnormality (fracture, osteophyte, loose body)
- soft tissue (fibrosis of band of osborne, accessory ancones epitrochlearis)
- mass

99

Median nerve neuropathy

1) what syndromes are associated with median nerve neuropathy

2)

1)
- pronator syndrome: nerve trap between bicipital aponeurosis and pronator teres

- carpal tunnel : nerve entrapment at carpal tunnel
-> FDS tenosynovitis most common cause

2) ddx
- cervical radiulopathy
- tenosynovitis
- peripheral nerve sheath tumour

100

Synovial fringe syndrome

1) define

1) synovial thickening in the lateral elbow
- extends into the posterolateral radiocapitalar joint space

101

Functional view for wrist and carpal instability. describe

1) types
2) indication

Types
- ulnar deviation : increase scapholunate distance
- radial deviation: close scapholunate distance
- clenched fist : can increase scapholunate distance

Indication: Test scaphlounate instability

102

Special wrist views

Pisoquetral view
Carpal boss view

Pisotriquetral view
- looking at pisiform and triquetrium

Carpal boss view
- carpal boss = bony dorsal protuberance of the 2nd/3rd metacarpal base (OA spurr)
- 30-> 40 degree supination
- 20-30 degrees ulnar deviation

103

Scaphoid fracture

1) clinical
2) location, frequency and healing rate
3) imaging
4) outcome and complication
5) treatment and indication

1)
- FOOSH
-less likely to occur then colles #
- pain in anatomical snuff box

2) location
- waist 70% : 8-12 weeks healing
- proximal pole 20% : 6-8 weeks healing
- distal pole 10% ( most likely for AVN due to least blood supply) : 12-24 weeks healing

3) imaging
- fracture visualised
- increased scapholunate distance > 3mm (Terry thomas sign)
- AVN : 1st sign is increased sclerosis

4)
- healing : 90%
- delayed union : no healing > 4mth
- non-union : no healing > 6 month
- malunion: humpback deformity (volar angulation of the bony fragments -> creating a humpback)
- osteonecrosis: 15-30%
- SNAC: scaphoid non-union advanced collapse. Imaging of DJD at radioscaphoid joint, scaphoid capitate, lunocapitate joint. May need 4 corner fusion or proximal row capatectomy.
- SLAC: similar to SNAC.

5) treatment
Cast:
-> indication: stable mid/distal scaphoid
-> cast for 3-6 month

Surgical
- indication: unstable, displaced, delayed/non/malunion, osteonecrosis
- initial possibility:
-> K wire
-> compression screw
-> bone graft
-> vascularised bone graft

- salvage therapy
-> carpectomy
-> wrist fusion

104

Triquetral fracture

1) clinical

1) second most common after scaphoid fracture

2) Mechanis
- FOOSH in ulnar deviation

105

Thumb fractures

please list
1) intra-articular
2) extra-articular
3) ligamentous
-> skier's thumb (ulnar collateral ligament)
-> radial collateral ligament

1)
Bennet fracture/dislocation
- def: fracture base of thumb MCP, intraarticular, 2 part
-> 1st fracture articulate with trapezium
-> lateral (that articulates with the 1st MCP) displaced laterally by abductor pollicis longs
- forced abduction of 1st MCP
- tx: requires ORIF if displacement > 3mm

Rolando fracture
- def: fracture of base of thumb,
intraarticular, 3 part (communiuted bennet)
- needs ORIFF (unstable #)

2)
Pseudo-bennett fracture
- aka : epibasal thumb fracture
- proximal fracture of thumb MCP metaphysics
- tx: stable. mostly conservative

3) Gamekeepr thumb
- Skier thumb
- def: forced abduction of thumb -> ulnar collateral ligament of MCPJ tear
- increased risk of stener lesion
-> Adductor apnoneurosis caught in UCL - no healing (adductor is the string, retracted UCL is the yoyo pseudo mass)

4) radial collateral ligament injury
- can get stener like lesion ( abductor caught in torn LCL)


106

Volar plate injuries of finger

1) what are volar plate
2) injury

1)
- forms floor of PIP joint
- separate joint from flexor tendon sheath
- has próximal phalanx ligamentous origin, capsular insertion to middle phalanx

2) injury
- hyperextension causing injury to volar plate -> avulsion fracture of middle phalanx base

107

Metacarpal fracture/dislocation

1) list fracture types
2) which MC fracture are most common
3) Describe CMC fracture dislocation

1)
Thumb
- Bennet fracture
- Rolando fracture
- Epibasal fracture (pseudo- bennet)
- boxer fracture
- Fight bite: opponent's tooth breaks skin over MCP

2)
- 2nd MC head
- 5th MC neck
- 2nd MC shaft
- 1st MC and 5th MC base

2)
- disruption to the CMC alignment on frontal radiograph
- MC dorsal displacement (normally)

3) PEARL
- dorsal fracture of capitate or hamate : look for 4-5th CMC joint subluxation/dislocation

108

CMC fracture

1) imaging
2) which CMC is often dislocation
2) pearl

1)
- frontal x-ray: disruption to the CMC alignment

2) 5th (and often missed)
- see loss of CMC articulation
- base of 5th is out of alignment with the rest, and appears to articulate with the hamate hook

2) pearl
- fractured capitate/hamate -> look for CMC dislocation

109

Phalangeal fracture

1) how common
2)

1) less common then MC fractures

2) operation
- failure of reduction
- K-wires

110

Thumb MCP stress view

1) aka
2) what to do and what you will see if there is an injury

1) game keeper's stress view

2) abduction of thumb
-> show opening of opening of medial side of MCPJ . i.e tear of UCL of thumb MCPJ

111

Lunatomalacia

1) aka
2) patient type
3) causative factor
4) imaging
5) ddx

1) kienboch disease
- AVN of lunate

2) patient type
- young man with repeated lunate loading

3) causative factor
- negative ulnar variance

4) imaging
- flattening of lunate
- fragmentation
- sclerosis

MR
- low T1/T2 (sclerosis)
- edema in acute phase
- radial aspect of lunate

5) ddx
- ulnar impaction syndrome
-> a/w positive ulnar variance
-> sclerosis/edema at proximal ulna aspect of lunate

112

Stress fracture

1) define
- stress fracture
- insufficiency fracture
- stress reaction

1)
- stress fracture: increased stress on normal bone (young athlete, repeated movement)

- insufficiency fracture: normal stress on abnormal bone (osteoporosis, RA, steroids, joint prosthesis stress shielding)

- stress reaction: marrow edema with periosteal reaction without fracture.

2)
x-ray
- initial may be normal
- later: linear sclersis + periosteal reaction

MR:
- low signal fracture line with surrounding edema

3) location
- pelvis: sacrum, superior pubic rami
- femur : basicervical, medial cortex in proximal/midshaft, posterior cortex distal shaft
- tibia : anterior cortex (shin splint) Proximal 1/3 > distal > middle. posterior medial shaft
- fibula : proximal to lateral malleolus
- ankle: calcaneous (often vertical), navicular (often bilateral), talar neck
- foot : metatarsals (2nd/3rd)
- upper extremity/rib: uncommon
- spine: pars interarticularis defect

4) PEARL
- femoral head AVN vs insufficiency fracture
-> fracture : parallel joint surface
-> AVN : line curve away from joint surface

113

Hook of hamate fracture

1) complication?
2) shape of hand?

1) guyon's canal syndrome
- compress ulnar nerve (4th and 5th finger sensory loss), weakness in abduction, flexion, opposition of little finger, adduction)

2) ulnar claw (extension of MCP and flexion of PIP)

114

Distal radial growth plate

1) if injured what may result
2) imaging
3) bilateral? how often
4) cause

1) madelung deformity
- premature closure of distal radius epiphysis ulnar aspect.

2) deformity
- no ossification of ulnar 1/3 of radial epiphysis
- bowed radial shaft (dorsal, radial)
- exaggerated radial incline
- positive ulnar variance
- V shaped lunate
- V shaped proximal carpal row
- dorsal subluxation of distal radioulnar joint (ulna normally)
- carpus sublux palmar /ulnar direction

3) 50-66 % bilateral

4) cause
- trauma
- infection

- turner : short 4th MC

- Aneuploidy
-> Leri Well (mesmelic shortening)
-> achondroplasia

- Ollier disease
- HME
- Huler mucopolysaccharidosis
- nail patella syndrome

115

Scapholunate dissociation

1) define
2) cause
3) how is it associated with SLAC wrist
5) imaging

1) damage to the scapholunate interosseous ligament + other stabilisers
- implies carpal instability

2) trauma

3) leading cause of SLAC wrist
ddx: CPPD

4) scapholunate component
- dorsal (strongest)
- intermediate
- volar

5) imaging
scapholunate space > 4mm (terry thomas sign)
-> increased with
--> clenched fist view
--> PA with ulnar deviation

6) acute injury requires surgical repair

116

Pronator quadrates fat pad

1) what is it used for?

1) suggesting distal radius fracture

117

Scaphoid fat pad.

1) what is it?
2) how many fat pads
3) what does it imply

Loss of the fat planes x2 lateral to scaphoid -> suggest scaphoid fracture

from scaphoid to lateral
- RCL
- vein
- tendon
( fat pads in between above)

118

DISI

1) define
2) cause
3) xray

1)
- a type of wrist instability
- due to disruption of dorsal intercarpal ligament

2) cause
Wrist trauma (bony disi)
- scaphoid fracture
- distal radius fracture
- radius malunion

Scaphlolunate dissociation (ligamentous disci)

3) xray
Frontal : scaphoid appears triangular (normally trapezoid)

Lateral:
- dorsal tilt of lunate
-> increased scapholunate angle > 60 degrees
-> increased capitolunate angle > 30 degrees

119

Types of carpal instability

1) list cause of carpal instability

2) List and describe
- ligament injured
- imaging

1) cause of carpal instability
- scaphoid fracture
- distal radius fracture

2)

Scapholunate dissociation
- cause: damage to scapholunate ligament (dorsal, ventral, interosseous)
- scapholunate distance > 3mm.
- damage

DISI
- cause: damage to dorsal interosseous ligament
- imaging:
-> dorsal tilt of lunate
-> increased scapholunate angle > 60
-> increased capitolunate angle > 30
- more common then VISI

VISI
- cause: damage to ulnar aspect of wrist volar arcuate ligament (scaphocapitate, triquetrohamatecapitate)
- imaging: volar tilt of lunate
-> decreased scapholunate < 30
-> increased capitolunate > 30

Lunate dislocation
- uncommon
- imaging:
-> frontal: loss of galilu's arch. Lunate looks triangular.
-> lateral : lunate displace and rotate volarly
- mechanism: FOOSH

Perilunate dislocation
- dislocation of capitate relative to lunate.
- 60% a/w scaphoid fracture (transcaphoid perilunate dislocation)
- imaging: dorsal displacement of capitate (volar displacement is rare)
- complication: can lead to DISI, VISI, non-union

Midcarpal dislocation
- lunate sublimed from radius + capitate dislocated from lunate

120

TFCC (triangular fibrocartilage complex ) injury

1) TFCC anatomy

1)
- radial cartilage (central attachment) -> ulnar fovea and ulnar styloid (peripheral attachment)
+ dorsal/volar radioulnar ligament
+ ulnalunate, ulnotriquetral
+ meniscal homologue (fibrofatty tissue adjacent to styloid)
+ ECU

1) arthrogram for diagnosis
Contrast injected into radiocarpal joint first then :

- Partial tear : thinning/irregular TFCC contour
- full thickness: contrast extending from radoiocarpal join to 1) distal radioulnar joint (central tear) or 2) ulnar side soft tissue
- peripheral tear: detachment of styloid fascicle

121

Distal radioulnar joint instability
1) define

1) disruption of normal distal radioulnar alignent
- assess as if ulna is mobile structure

2) imaging direct signs
- ulnar head subluxation/dislocation
- widened DRUJ on PA or
- increased ulnar-radial overlap on PA

Indirect sign
- comminuted radial head fracture
- dorsal angulation of radius > 20 degrees
- shortening of radius > 5mm

122

Infectious tenosynovitis

1) imaging
2) cause
3) ddx
4) management

1)
x-ray
- swelling in tendon distribution

MR
- thickened, enhancing synovium
- fluid in tendon sheath

2) cause
- trauma/needle puncture

3) ddx
- inflammatory
- traumatic

4) need urgent treatment due to compartment syndrome

123

haemachromatosis

1) define
- haemachromatosis
- haemosiderosis
2) types
3) imaging
4) other organs involved
5) treatment

1)
Haemachromatosis
- condition characterised by iron overload

Haemosiderosis:
- accumulation of haemosiderin
- initially in the reticuloendothelial system -> then spill to organ organs

2) primary
- HFE gene mutation -> increased reabsorption from gut

Secondary
- causes of haemosiderosis
(usually chronic haemolytic anaemia)
- subsequent haemosiderosis from multiple blood transfusion

3) imaging
- arthropathy in 25-50%
- 2nd, 3rd, then all MCP
- similar to CPPD appearance
-> DO CHESS
-> hook like osteophyte bigger then CPPD
-> subchondral cyst and sclerosis
-> chonedrocalcinosis
(YOUNGER population for haemachromatosis)

4) other organs
- liver: periobular hepatocytes, fibrosis -> cirrhosis
- pancreas
- cardiomyopathy, arrythmia
- skin pigmentation

5) treatment
Primary : phlebotomy

Secondary and haemosiderosis : iron chelation therapy

124

Chronic regional pain syndrome

1) aka
2) types
3) imaging
4) ddx
5) exam pearl

1)
- reflex sympathetic dystrophy
- sudeck dystrophy

Characterised by
- diffuse persistent pain in the extremities, associated with
-> vasomotor change
-> skin change
-> decreased joint mobility

2) types
- 1 : no detectable nerve lesion
- 2 : detectable nerve lesion

3) imaging
- regional osteoporosis
- soft tissue trophic change

MR
- skin thickening
- soft tissue edema
- subchondral patchy marrow edema

Bone scan
- increase in all phase
- increased periarticular uptake distal to injury

4) ddx
- senile osteoporosis : more diffuse
- disuse osteoporosis: bone can demonstrates increased proximal uptake
- diffuse marrow infiltration
- normal patchy marrow

5) PEARL
- exam: correlate with history

125

Ulnar impingement syndrome

1) define
2) imaging

1) cause: NEGATIVE ulnar variance ( vs ulnar impaction syndrome )
- normally due to surgical resection of distal ulna (due to trauma, RA, Madelung deformity)

2) imaging
- short ulna
- ulna impinges on radius (subchondral sclerosis, bone edema). Erosion in late stage


126

Hamate lunate impingement

1) define
2) imaging

1)
- uncommon cause of ulna side wrist pain
- cause: abnormal lunate morphology (distal lunate medial facet that articulates with the hamate)
-> causes repeated impaction
-> DJD

2J) iamging
- edema at the proximal end of hamate that articulates with the lunate

127

Scleroderma (hand)

1) define
2) imaging
3) exam case

1) connective tissue disease of unknown cause
- causes widespread systemic fibrosis

2) imaging :
Best:
- severe resorption of CMC with radial subluxation !!!
- SOFT TISSUE CALCIFICATION

Bone:
- acro-osteolysis
- erosion
- osteoporosis
- point space narrowing

Soft tissue:
- subcutaneous calcification ( can be extensive)
- periarticular calcification
- finger atrophy
- flexion contractors

3)
- extensive soft tissue calcificatifon + acro-osteolysis

128

SLE hand manifestation

1) SLE definition
2) hand imaging
3) ddx

1) autoimmune condition with multi system involvement
- may be classified as vasculitis

2) hand
- jaccoud's arthropathy : ulnar subluxation of 2-5 MCP.
- no erosion
- may have hook erosion

3) DDX
- RA: has erosion

129

Acromegaly/Gigantism

1) define
- acromegaly
- gigantism
- hypopituitism

2) imaging
- acromegaly
- hypopituitarism

1)
- acromegaly: onset of disease after physeal closure
- gigantism: before physeal closure

2)
Imaging
Acromegaly:
Skull:
- cranial thickening, enlarged protruberance
- enlarged sella
- enlarged sinuses

Hand:
- spade like terminal tuft
- increased joint space (i.e at MCP)
- soft tissue enlargement
- DJD (i.e at DIP)

OVERGROWTH OF SOFT TISSUE!!

Hypopituitarism
- delayed skeletal maturaiton
-> late appearing epiphyses
-> late fusion physes
-> slow growth rate

130

De Quervain tenosynovitis

1) define
2) imaging
3) management

1) stenosing tenosynovitis involving the first extensor compartment (APL and EPB)

2)
x--ray
- soft tissue swelling over radial styloid
- radial styloid cortical erosion, sclerosis, periosteal reaction

U/S
- tendon enlargement
- tendon oedema (hypo echoic)
- loss of fibrillar tendon pattern
- peritendinous fluid
- periteidnous vascularity

MR
Tenosynovitis
- increased fluid
- debris within sheath (iso T1)
- thick retinaculum
- peritendinous edema
- peritendinous contrast enhancement

Tendinosis
- enlarged tendon
- high signal T1, T2 within tendon

Longitudinal tendon tear
- high linear signal within tendon
- APL often

3)
Management
- conservative
- steroid injection (50% effective)
- surgical decompression

131

ECU tenosynovitis/tendinosis

1) cause

1)
- RA
- athlete (trauma) - rowing, golf

132

FDP injury

1) describe injury for

A) avulsion fracture
B) tendon tear
C) tendinopathy/intrasubstance tear
D) Pully injury
E) Jersey finger
F) Trigger finger

2) mechanism

A)
- avulsion at FDP insertion (aka Jersey finger): distal phalanx base avulsion dorsally
- mechanism: forceful hypertension
- ring finger most involved
Type 1 : retract to palm
Type 2 : retract to A2 pully
Type 3 : bony fragment distal to A4 (minimal retraction)

B) retraction of tendon

c) high T1 and T2 signal

d) Pulley injury
- A2 most common.
-> partial tear : thickening of pulley with bowstring
-> complete tear: bowstring of tendon during flexion

E) Jersey finger
- disruption of FDP at the volar insertion +/- avulsion

F) Trigger finger
- A1 pulley thickening
+/- tendinopathy/tenosynovitis

133

Ganglial cyst

1) define
2) imaging
3) ddx
4) PEARL

1) cyst arising from tendon or capsular tear
- filled with mucoid material
- pseudo capsule

2) imaging
- mjultiloculated cystic structure
- associated capsule or tendon tear
- rim enhancement

3) ddx
- GCT of tendon sheath
- periperal nerve sheath tumour

4) PEARL
- look for a tear in capsule or tendon if see a ganglion cyst

134

Carpal boss

1) define
2) component
3) complication

1)
- hypertrophied bony protruberance from 2nd/3rd metacarpal base dorsally

2)
- DJD
- os styloidum
- bony protruberance at 2nd/3rd metacarpal base
- enlarged carpus (i.e trapezoid)

3)
- can produce a ganglion
- inflammed bursa
- extendon tendor tenosynovitis

135

Carpal tunnel

1) define
2) imaging
3) clinical

1) median nerve compression at wrist

2) imaging
- median nerve swelling proximal to carpal tunnel
- median nerve flattening in carpal tunnel
- flexor retinaculum thickening
- abnormal signal within LOAF

3) clinical
- pain/paraesthesia 1-3 digit, and radial aspect 4th digit

136

Ulnar tunnel

1) define
2) imaging

1) aka : guyon's canal syndrome
- ulnar nerve compression at wrist

2) imaging
- ulnar nerve focal/diffuse swelling
- high intraneural signal

137

Watertenberg syndrome

1) define
2) imaging
3) clinical

1) entrapmetn of superficial branch of radial nerve at wrist

2) imaging
- look for a mass in the area of superficial nerve branch distribution
- or hx of extrinsic compression

3) paesthesia/pain dorsal aspect of 1 st webspace

138

Hypothenar hammer syndrome

1) define
2) imaging

1)
- ulnar artery superficial palmar arch injury
- a/w pseudoaneurysm : saccular vascular dilatation (disruption of intima and media) contained by adventitia
- via repeated trauma

2) imaging
- complete ulnar artery occlusion, narrowing
- corckscrew contour of ulnar artery
+/- aneurysm
+/- distal embolic occlusion

139

Buerger disease

1) aka
2) imaging
3) ddx

1)
- aka: thromboangiitis obliterans
- a type of arteritis that occurs in young smoker
- chronic, non-atherosclerotic inflammatory thrombotic arteritis

2) imaging
- extensive arterial occlusive disease
- corkscrew collateral vessels
- > 1 limb normally
- Lower limb > upper limb

3) ddx
- atherosclerosis
- connective tissue tissue (corkscrew vessel as well)
(SLE, sleroderma, dermatomyositis, mixed CTD, CREST, RA)

140

Disruption of pelvic ring

1) define
2) define anterior and posterior ring
3) what makes diruption unstable
4) what fracture/change suggest what ligamentous injury
5) best clue
6) types

1)
- fracture or ligamentous disruption of the pelvis
- normally anterior and posterior ring involved

2) ischial spine separates anterior/posterior

3) ligamentous instability

4)
- L5 transverse process # - disruption to iliolumbar ligament
- widened pubic symphysis > 2.5cm - partial SIJ disruption
- widen anterior and posterior SIJ - all SIJ ligament diruption
- widening of anterior SIJ - only anterior SI disruption

5) best clue: fracture and displacement of anterior and posterior pelvic ring

6) cause: high energy trauam
A) anterior posterior compression:
- mechanism: compression fracture, getting hit front on by car
-> anterior injury: sagitally orientated pubic rami fracture or pubic symphysis disruption
-> posterior injury: vertically orientated fracture of sacrum or posterior ilium, or SI joint disruption

b) Lateral compression
- most common
- mchanism: getting hip by car side one
-> anterior injury: corona, oblique or transverse pubic bone fracture
-> posterior :
LC 1 : impaction (buckle) of sacrum
LC 2: posterior SIJ widening or crescent fracture dislocation of SIJ
LC 3 : ipsilateral compression, contralateral APC injury
- can a/w transverse acetabular fracture (Winswept)

C) vertical shear (VS) : imaging the same as APC
- mechanism: fall from height
-> anterior injury: sagitally orientated pubic rami fracture or pubic symphysis disruption
-> posterior injury: vertically orientated fracture of sacrum or posterior ilium, or SI joint disruption

To differentiate APC from VS
- APC normally has similar iliac crest height
- VS : normally one hemipelvis is elevated

141

sacral fracture

1) classification (Denis)

1) grading is from lateral to medial
- zone 1 : lateral to sacral foramen (6%)
- zone 2 : transforaminal (28%)
- zone 3 : medial to sacral foramen (56%)

142

Acetabular fracture types (Judet-Lteournel classification)

1) list the types
2) associated fractures
3) anterior column line on x-ray
4) posterior coulmn line on x-ray
5) medial wall on x-ray
6) PEARL
7) describe Judet views

1)
- anterior column : ASIS to inferior pubic rami. Coronally orientated
- posterior column : greater sciatic foramen to inferior pubic rami. Coronally orientated
- posterior wall
- anterior wall
- transverse: sagitally orientated

2)
- T type
- transverse / posterior wall
- posterior column / posterior wall
- anterior column / posterior hemitransverse : posterior hemitransverse arise at the level of the acetabulum
- both columns : posterior column fracture arise above the acetabulum.

3) iliopectineal line

4) ilioischial line

5) tear drop

6) Pearl
- column fracture: coronoally orientated fracture
- anterior column: iliopectineal line disruption
- posterior column: ilioischial line disruption
- both column: both disruptied. spurr sign
- transverse fracture : both disrupted. Sagittally orientated fracture. No obsturator ring fracture.
- T type: both disrupted. Obturator ring fracture

7)
- Iliac oblique (external oblique)
-> turn towards side of abnormality
-> for anterior wall, posterior column

- obturator oblique (internal oblique)
-> turn away from side of abnormality
-> for anterior column, posterior wall

143

Pubic rami fracture

-unilateral could be from mild trauma
- non-specific symptoms
- paitent may or maynot weight bear
- female > male

144

Apophyseal avulsion fracture

1) age
2) region of avulsion
3) management
4) EXAM PEARL

1) 14-25 yo. Physically active young adult.
- kicking sport implicated

2)
- iliac crest: anterior abdominal wall muscle/tensor fascia lata (1%)
- ASIS: sartorius/tensor fascia lata (3rd - 19%)
- AIIS: rectus femoris (2nd - 22%)
- greater trochanter: gluteus medius, minimus
- lesser trochanter: ilipsoas
- ischia tuberosity: hamstring (most common)
- body/inferior pubic ramus: adductors, gracilis (1%)

3) management: conservative normally.

4) PEARL
- iliposoas avulsion at lesser trochanter is SO RARE IN ADULT -> METASTASIS UNTIL PROVEN OTHERWISE

145

Pelvic apophysitis

1) define
2) location

1) accessory of centre ossification inflammation

2) location : exactly similar to apophyseal avulsion location

146

Sacral insufficiency fracture fracture

1) define
2) imaging

1)
- insufficiency fracture
- most due to osteoperosis

2) imaging
- fracture with sclerosis parallel sacroiliac joint

- MR : edema within 18 days of symptoms
- nuclear med : Honda sign 20-40%

147

Thigh splint

1) aka and define
2) imaging

1)
aka - adductor insertion avulsion syndrome
- avulsion injury of the adductor muscle insertion medial femoral proximal /mid diaphysis

2)
- proximal /mid medial femoral high soft tissue signal
- bone marrow edema at the adductor insertion

148

Osteitis pubis

1) define
2) imaging
3) ddx
4) cause

1) inflammation of the pubic symphysis

2) imaging
- x-ray ; joint irregularity, sclerosis, erosive change, finally ankylosis (think of SI joint)

- MR: bone/soft tissue edema

3) ddx
- infection
- hyperparathyroidism : bone resorption

4) cause
- pregnancy , childbirth
- high level of activity
- trauma
- previous urological surgery
- seronegative spondyloarthropathy

149

Hip dislocation

1) which one is more common?
2) imaging
3) clinical management
4) complication
5) exam pearl

1) posterior 90%

2) imaging
- loss of alignment
- a/w fracture of head, neck, acetabular fracture
- air bubble within joint space -> in post reduced hip

Posterior:
- smaller femoral head compared to contralateral side
- a/w posterior acetabular wall fracture
- location: obturator, iliac

Anterior view:
- head bigger then other side

3)
- reduce < 6 hr to avoid osteonecrosis of femoral head

4) complication
- DJD
- ostenecrosis
- chronic instability

5) ask for a lateral

150

Intraarticular loose body

1) cause
2) can they move

1)
- DJD
- osteochondral defect
- trauma/fracture/surgery
- neuropathic joint

synovial pathology
- PVNS
- synovial osteochondromatosis

2) sometimes

3) pain

4) imaging
- xray
- MR
- CT less common??

151

Hip intraairticular loose body

1) define
- chondral/osteochondral injury
- delamination

2) best sequence to see acetabular cartilage

3) how many slice of cartilage defect needs to be seen to be confident with diagnosis

4) ddx
5) path

1) chondral or osteochondral injury (osteochondritis dessicans of hip)
- normally only cartilage (no bone injury)

delamination: cartilage partly detached from underlying bone: unstable flap -> can eventually completely detach.

2)sagittal

3) at least 2 slices :
- 2 slices on 1 plan or
- 1 slice on 2 plans

4)
- labral tear: contrast in labrum, or between labrum and underlying cartilage
- DJD: acetabular roof and posterior acetabular rim often.
- inflammatory arthritis

5) path
- cause: FAI, hip dislocation, impaction injury
- a/w labral tear

152

Femoral neck fracture

1) types
2) what happen if you can't see on x-ray
3) garden classification
4) which garden classification is associated with AVN

1)
- subcapital : between head and neck
- transcervical
- basicervical
- vertically orientated: superolateral to inferomedial

2) MR

3)
1 - incomplete lateral with valgus impaction
2 - complete non-displaced
3 - complete mild varus angulation
4 - completely displaced

4) 3- 4

4)
- osteoid osteoma : in young patient with bony cortical sclerosis and pain.

5) complication
- osteonecrosis
- malunion
- delayed union
- non-union

153

Intertrochanteric fracture

1) define
2) define reverse intertrochanter
3) classification
4)

1) femoral fracture
- extending from greater to lesser trochanter

2) fracture from above lesser trochanter and head inferolateral to subtrochanteric regionj

3) imaging
- usually displaced + varus angulation

3) classification
- 2 part : single fracture, no displacement
- 3 part - greater or lesser trochanter form separate fragment
- 4 part - greater and lesser trochanteric fragment

4) consider metastasis until proven otherwise

154

Transient osteoperosis of the hip

1) define
2) imaging
3) ddx
4) clinical
- management
- patient group
- outcome
5) define regional migratory osteoperosis
6) WHEN TO CONSIDER

1)
- self limiting
- idiopathic condition of the hip
- can cause hip pain
- ? early reversal stage of AVN

2)
xray
- can be normal
- subchondral cortical loss of femoral head neck : pathognomonic
- osteopneia
- joint effusion
- preserved joint space

MR
- femoral head, neck > intertrochanteric edema

Nuc Med
- increased homogenous uptake in femoral neck

3) ddx
- early AVN : has curvilinear low signal line on T2 and post contrast T1
-> enhancement in transient osteoperosis
-> no enhancement in AVN

- septic arthritis
- sudeck dystrophy

4)
management
- protected weight bearing
- pain control

patient group
- pregnant lady
- middle age man 40-50 yo

outcome
- resolve in 6-8 month

5) when it resolves then subsequently involve
- other hip or
- other joints

6) femoral head neck edema with no fracture line
- small surrounding effusion

155

AVN of hip

1) imaging
2) cause
3) ddx
4) fiat and arlet staging

1)
- early : patchy sclerosis of femoral head
- late : DJD, loose body, collapse

MR:
- double line sign

T1 +
- early : decreased enhancement
- late : no enhancement (no viable cell and vascularity)

2)
- trauma
- STEROIDS!!!
- perthes: children
and plastic rags

3) ddx (time and f/u scan to differentiate)
- Transient osteoperosis of hip
- infection
- neoplasm

4)
- 1: osteopenia (MR edema)
- 2 : mixed osteopenia /sclerosis (geographic defect)
- 3 : subchondral lucency (crescent sign) (same as plan radiograph)
- 4 : DJD, loose fragment, collapse

156

Sacroiliitis

1) unilateral ddx
2) bilateral ddx

1)
- infection: IVDU, HIV, diabetes
- psoarisis, chronic reactive arthritis
- OA (mimic)
- early ankylosing spondylitis, enteric arthropathy
- RA, gout

2)
- ankylosing spondylitis
- enteric arthropathy
- psoariasis, chronic reactive arthropathy

157

Acetabular labral injury

1) includes?
2) imaging
- what modality
- commonest location
- tear =
- myxoid degeneration
- OA change
- posterior dislocation change
3) what does paralabral cyst suggest?
4) what does isolated anterior (2-3 o'clock) labral tear suggest?
5) pathological cause

1) tear, avulsion, detachment

2) imaging modality
- MR arthrogram best
-> location: anterior superior undersurface

Tear =
-> contrast extending into labrum -> diastasic between labrum and acetabulum
-> detachment of labrum
-> loss of triangular morphology (suggest)

Myxoid degeneration
-> intrinsic high signal

- in OA : superior undersurface
- in posterior dislocation: posterior labrum

Morphology
- fraying
- incomplete/complete tear
- bucket handle tear
- detachment

3)
- paralabral cyst -> raise suspicion of tear

4) ilipsoas impingement

5) pathology
- FAI (cam, pincer - coxa profunda)
- DJD
- DDH
- trauma

158

coxa profunda vs protrusio.
Define

Coxa profunda
- acetabular fossa medial to the ilioischial line
-> could be in normal patient or in FAI (pincer type)

Protrusio
- femoral head medial to the ilioischial line

159

Hip chondrolysis

1) define
2) cause
3) imaging
4) complication

1) diffuse cartilage loss in femoral head and acetabulum
- rapidly progression

2)
- SUFE
- trauma/toxin

3) imaging
- narrowing of joint space > 50% or > 3mm then the other joint
- erosion, periarticular osteoperosis sometimes

4) complication
- fibrous ankylosis

160

Ilipsoas bursitis

1) cause
2) imaging

1)
- infection
- trauma/surgery
- arthropathy (OA, RA, CPPD)
- snapping ilipsoas tendon

2) thin fluid collection along line of the ilipsoas tendon
- content : homogenous or heterogenous

161

Snapping hip syndrome

1) define
2) cause
3) imaging
4) management

1) painful snapping, popping or clicking with hip motion
- muscles /tendon rubs against underlying bony protruberance during hip movement

2) cause
- External: iliotibial band/gluteus maximus popping over greater trochanter
- Internal: iliapsoas kinks against the pelvic bone (iliopectineal region). Medial fibre of iliacus rubs against the ilipsoas tendon.
- Intraarticular: labral tear, intar-articular bodies, ligamentous teres injury

i.e. combination of anatomical variation + overuse

3) imaging
- external: peritendinous high signal around greater trochaner
- internal: peritendinous high signal around ilipsoas tendon(normally region of iliopectineal line)
- intra-articular: any internal deranagement causing abnormal motion of intra-articular structures (MR arthrography)

Confirm diagnosis by : dynamic ultrasound

162

Infective bursitis

1) cause
2) imaging
3) ddx

1) cause
- direct innoculation : olecranon, prepatellar
- extension from infected prosthesis

2) ring enhancing bursa with surrounding edema
- synovial thickening

3) ddx
- inflammatory ( arthropathy, erosive, crystalline)
- trauma
- synovial lesion (chondromatosis)

163

Complication of paraplegia.

Please list

- decubitus ulcer

- infection/osteomyelitis

- heterotopic ossification
-> 16-53%
-> periarticular
-> peripheral ossification
-> especially around spastic joint > flaccid
-> imaging :
- 0-2 weeks : soft tissue mass
- 3-4 weeks : amorphous bone density. Periosteal reaction
- 6-8 weeks : Peripheral calcified/mineralised rim
- 5-6 month = Peripheral bony rim. Decreased central attenuation (cystic)
-> ddx :
- osteosarcoma

- osteoperosis :
-> may be aggressive, moth eaten appearance
-> DDX : infiltrative disease

- neuropathic joint
-> spine often
-> below level of fixation
-> ddx: discitis (has surrounding soft tissue stranding and chnge)

- SCC

- cartilage atrophy
-> decreased synovial fluid production
-> SI joint abnormal in 61% of patient

164

DISH

1) define
2) imaging
3) ddx
4) cause
5) complication
6) assocation!!

1) flowing osteophyte bridging 4 vertebral body
- with ossification of tendon and ligaments

2) imaging
- flowing osteophyte bridging 4 vertebral body
- normal disc space
- thoracic
+/- PLL ossification

Can get sclerosis of
- SI joint (superior nonsynovial portion)
-> synovial portion remains normal
- pubic symphysis

3) ddx:
- spondylosis : other spondylotic change
- seronegative spondyloarthropathy : osteoperosis change!!
- retinoid related degenerative change

4) cause unknown
- often incidental finding

5) carrot stick #

6) ossification of PLL
- 50% of DISH patient has OPLL
- 44% of OPLL have DISH

7) RULE OF THUMB CALLING DISH OR OPLL
- anterior flowing osteophyte in thoracic vertebrae = DISH
- posterior flowing osteophyte in cervical vertebrae = OPLL

165

Adductor compartment injury

1) what types are there?
2) differential

1)
- tendo sprain
- tendon partial/complete tear
- avulsion injury
- hypoxic tendinopathy (all low signal)

2) rectus abdominus/adductor aponeurosis tear (sport hernia)

166

Quadriceps injury

1) most common location
2) imaging
3) severity of injury
4) cause

1)
- vastus intermedius
- at or just proximal to patellar tendon insertion

2) imaging
- partial or complete tear
- thinning of qadudricep
- patella baja
- bony avulsion may occur

3) severity of injury
- tendinopathy
- partial tear
- complete tear
- muscular injury

4)
- trauma
- steroid
- chronic renal failure
- RA

167

Quadricep injury

1) which one ?
2) describe normal quadricep tendon slip.

1) vastus intermedius most often
- normally at or just proximal to the patella insertion

2) 3 slips of normal quadricep tendon
- anterior: rectus femoris
- middle: medias and lateralis
- deep: intermedius

3) injury type
- tendinosis : thickening and abnormal signal
- partial tear
- complete tear
- avulsion from patella attachment

168

Hamstring injury

1) where can it occur
2) describe ischial tuberosity tendon
3) what is hamstring injury associated with

1)
- origin at ischial tuberosity
- and everywhere else

2)
- anterior: semimembranosis
- posterior : conjoint tendon (semimembranosus and bicep femoris long head)

3) sciatic nerve injury

169

Muscle wasting

1) imaging
2) cause

1)
- muscle replaced by fat
-> high T1, T2, fat sat
-> high T2 = ongoing denervation or inflammation

2) cause
-assess distribution, history to differentiate cause

- post op : clue - surgical clips
- immobilisation - focus to diffuse. starts 10 days post immobilisation
- injury (tendon) : complete tear (gleteus minimus)
- injury (spinal cord) : decrease muscle bulk within 6 weeks
- injury (nerve) : differentiate by nerve distribution. Subacute have increased fluid signal depspite fatty infiltration
- injury (muscle) : compartment syndrome, trauma, diabetes myonecrosis)
- diabetes : combination of neuropathy, muscle infarction, infection, fracture
- age related

Others:
- NF1 : neuropathy
- malnutrition
- Cushings
- muscular dystrophy : extensive fatty infiltration
- Charcot- marie tooth : hereditary motor sensory neuropathy
- amyotrophic lateral sclerosis: adult onset motor neuron disease
- brain high T2 from corona radiation -> brain stem corticospinal tract
- Gullain- Barre syndrome: thick enhancing nerve root. Full recovery

170

Myositis ossificans

1) define
2) stage
3) location
4) PEARL

1) heterotypic bone, cartilaginous formation in soft tissue
- benign, self limiting

2) stage
- 0-2 : soft tissue mass, ill defined plan
- 2 -4 : amorphous bone, periosteal reaction (most confusing stage)
- 4-8 weeks: peripheral calcification
- 2-6 month: peripheral ossification, central cyst sometimes
- > 7 month: decrease size

3) location: area prone to trauma
- anterolateral thigh
- adductor of thigh (horse riders)
- antecubital fossa : post elbow dislocation
- shoulder/elbow : burnt patient
- pelvis/hip ; spinal cord/brain injury

4) PEARL
- if suspicious -> correlate with history of trauma
- avoid biopsy first
- follow up scan
- discuss at orthopaedic, oncology meeting

171

Cellulitis

1) define
2) imaging
3) ddx
4) PEARL

1) acute infection of dermis and subcutaneous tissue
- epidermis not involved

2)
U/S
- early : thickening, increased echogenic SC tissue
- late: fluid in SC tissue (cobblestone appearance)

CT:
- differentiate superficial and deep infection
- skin thickening, septation of SC fat, thickening of superficial fascia
- +/- abscess, osteomyelitis
- gas

MR
- osteomyelitis: confluent T1 marrow signal ( if patchy - more likely to be bony reaction rather then osteomyelitis)

3) DDX
- tumour : obliterates fat plan
- necrotising fasciitis
- charcoat joint
- infected bursa

4) PEARL:
Celluitis/soft tissue infection will OBLITERATE FAT PLAN NORMALLY

172

hematoma

1) imaging
2) ddx
3) PEARL

1)
CT
- isodense to muscle
- acute : hyperdense, no enhancement
- fluid fluid level : hematocrits level

MR
- complete and variable
- less predictable then intracranial haemorrhage
- most : high T1, T2, heterogenous
- acute: low T1, T2 normally...um..
- chronic: low haemosiderin. often have peripheral enhancement = soft tissue reaction

2) ddx
- solid tumour : central aspect of hematoma enhances
- muscle infarct
- ganglion cyst

3) PEARL
- check hx of trauma, anticoagulation
- unexplained spontaneous bleed -> LOOK FOR UNDERLYING TUMOUR

173

Peripheral nerve sheath tumour

1) define
2) imaging
3) type
4) ddx
5) path
6) PEARL

1) group of disease
- benign and malignant neoplasm of the peripheral nerve

2) imaging
- mass associated with peripheral nerve
- Low T1, PD
- high T2, STIR
- avid enhancement
- denervation of

3) types
- schannoma: Round. eccentric to nerve. less malignant degeneration
- neurofibroma : Target sign (central low T2 signal dot). Cord like centred on nerve. more like to have malignant degeneration.
- plexiform neurofibroma : branching lobulated mass
- MPNST: anything

4) ddx
- traumatic neuroma : hx of trauma. Bulbous nerve at site of trauma with enhancement
- haemangioma : enlarged vessel. Have draining vein
- neuritis : general nerve enlargement, long segment enhancement
- cyst

5) path
- 5 -13 % of NF1 degeneration into MPNST

6) PEARL: ALWAYS GIVE CONTRAST TO DIFFERENTIATE FROM CYST

174

Femoral nerve injury

1) describe brief anatomy
2) cause
3) imaging

1)
- arise from posterior L2-4
- deep to psoas
- exit lateral border of psoas
- go in between ilipsoas groove (lateral to psoas)
- under inguinal ligament
- femoral triangle (lateral to femoral artery)
- divides into superficial and deep branch by lateral circumflex femoral artery

2) cause
- ischaemia
- trauma, compression, stretch
- compression by extrinsic

3)
- nerve enlargement and high T2 signal
- location:
-> psoas muscle body
-> ilipsoas groove
-> femoral canal

- quadricep atrophy with high T2

175

Necrotising fasciitis

1) define
2) imaging
3) ddx
4) PEARL

1)
- aggressive rapidly progressive infection
- tracks along superficial and deep fascia plan
- cause necrosis by microvascular occlusion

2) imaging
- dissection gas or fluid spreading along superficial /deep fascial plan. (especially in the absence of trauma)
- High fluid signal along fascial plan
- subcutaneous edema
- fascial thickening
- peripheral enhancement only - suggest necrosis

3) ddx
- cellulitis
- non-necrotising fasciitis
- compartment syndrome

4) PEARL
- in the absence of trauma, gas dissection = pathognomonic
- imaging should not delay scan
- it is a clinical diagnosis

176

Myonecrosis

1) define
2) cause

1) infarct of muscle

2) cause
- idiopathic
- sickle cell
- diabetes

- infection, ischaemia
- trauma
- rhabdomyalisis

177

Diabetic myonecrosis

1) define
2) location
3) imaging
4) cause
5) treatment
6) ddx

1) myonecrosis due to chronic uncontrolled diabetes

2) location
- quadricep
- hip adductors
- hamstrings

3) imaging
- CT: muscle enlargement, decreased attenuation

- MR: non-specific

4) cause
- unknonwn

5) treatment
- conservative

6) ddx
- infection
- malignancy

178

Inflammatory myopathy

1) define
2) imaging
3) ddx
4) association
5) PEARL

1)
- autoimmune inflammatory muscular condition
- increased CK
- includes polymyositis, dermatomyositis

2) imaging
- bilateral symmetric, high T2, enhance
- early : proximal lower extremities (vastus!!!)
- late: upper limb, neck, pharynx

x-ray
- soft tissue calcification (20-50%) !!! Surrounds muscle on CT.
- sheet like
- osteopenia, osteonecrosis: from steroids

3) ddx
- infection
- diabetes myonecrosis

4) association
- connective tissue disease : SLE, sjogre, scleroderma, MCTD

5) always remember to ask for x-ray to check for calcification

179

Nerve entrapment

Describe

1) Obturator neuropathy
2) sciatic nerve
3) neuralgia paresthetica
4) sportman's hernia

1) obturator neuropathy
- nerve root lies in the adductor compartment
- anterior division: between pectinous, adductor longus and brevis
- posterior division: between adductor brevis and magnus

2) sciatic nerve
- exit via greater sciatic foramen -> then inferior to piriformis
- supplies : AT, peroneus longs and brevis
- a/w : hamstring rupture

3) meralgia paresthetica
- cause: lateral femoral cutaneous
- neuropathic pain proximal lateral thigh
- entrapment at : inguinal ligament at ASIS as nerve penetrates fascia

4) sportman's hernia
- injury to rectus abdomens adductor longs aponeurosis

180

Hip implant

1) correct position
2) complication

1)
- lateral openin40 +/- 10 degrees
- ante version of 15 degrees

2) complication
- infection
- fracture (bone, implant)
- loosening
- particle disease
- polyethylene cup wear

181

Hip arthrodesis

1) define
2) indication
3) imaging

1) fusion of hip
- for end stage hip disease
- patient not indicated for joint replacement

2) indication
- contraindication for hip replacement
-> not enough bone
-> failure

3) imaging
- no joint space
- surrounding rigid fixation

182

Intramedullary rod/nail

1) indication
2) does it allow early weight bearing
3) complication

1) for long bone fracture
- femur, tibia

2) share load, allow early weight bearing

3) complication
- fat embolism
- nonunion, malunion, delayed union
- infection
- rod migration -> to joint -> pain

183

Fracture healing

1) define
- clinical union
- radiological union
- delayed union
- non-union
- malunion

2) imaging
- 1st sign of healing
- hypertrophic nonunion
- atrophic nonion

3) what does failure of fixation of union imply

4) pathological steps

1) define
- clinical union : bone growth across fracture, allowing restoration of function
- radiological union : ossified callous bridge fracture line (callous at or near same density to bone)
- delayed union : lack of clinical/radiological union within expected timeframe, but appropriate care may lead to ultimate union
- non-union : failure of mature bone to bridge the fracture
- malunion: bone healing in abnormal alignment

2) imaging
- 1st sign of healing : blurring of fracture margin
- healing requires callous to bridge the fracture
- hypertrophic nonunion : large amount of callous without fracture bridging
- atrophic nonion : no callous develops

3) incomplete/non-union

4) path steps
- fracture ->
- haematoma
- granulation tissue
- callous formation
- mature bone

184

Patella fracture

1) types
- fracture
- osteochondral injury
- patella sleeve

2) imaging
3) what is insall-Salvati ratio, patella alta and baja

1)
- transverse midportion of patella 50-60%
- comminuted 30%
- longitudinal 15%
- marginal avulsion (superior or inferior)

- osteochondral injury
-> a/w transient lateral patella dislocation

- patellar sleeve (paeds)
-> avulsion injury of patella in skeletal immature patient
-> imaging: small bone fragment with large unossified epiphyseal cartilage avulsed
-> inferior pole : more common, by patella tendon
-> superior pole:
-> most common patellar fracture < 16 yo

2) MR needed for
- osteochondral injury
- patella sleeve avulsion (cartilage)

3)
- insall salvati ratio :
-> patella tendon / patella
-> normal 0.8 - 1.2

-patella alta > 1.2
- patella baja < 0.8

185

Knee injury bruising pattern

Describe
- pivot shift
- dashboard
- clip
- hyperextension
- lateral patellar dislocation

Pivot shift
- mechanism: valgus force on external rotated flexed knee
- bone bruise : posterolateral tibial plateau, posterolateral femoral condyle
- ACL injury

Dashboard
- mechanism: anterior force on flexed knee
- bruise: posterior patella, anterior tibia
- PCL injury

Clip
- mechanism: valgus force on flexed knee
- bruise: lateral femoral condyle, lateral tibial plateau
- MCL injury

Hyperextension
- bruise: anterior tibial plateau, anterior femoral condyle
- ACL, PCL, meniscus +/- dislocation

Lateral patellar dislocation
- bruise : medial patella, lateral femoral condyle
- Medial retinaculum, medial patellofemoral ligament injury
+/- medial patellotibial ligament injury

186

Bone scan for fracture

1) sensitivity for acute fracture at
- 1 day
- 3 days
- 1 week

2) nuclear medicine finding

1) sensitivity for acute fracture at
- 1 day :80%
- 3 days : 95%
- 1 week : 98%

2) positive on all phase

187

Fracture of fibular head

1) arcuate sign

1) bony fragment superior to the fibula head

2) damage to posterolateral complex
- bicep tendon
- LCL (fibular portion)

3) a/w
- cruciate ligament injury
- meniscal injury
- bone edema

188

SONK (spontaneous osteonecrosis of the knee)

1) define
2) imaging
3) path

1)
- osteochodnritis of knee in older age group

2) imaging
- similar to osteochondritis dessicans
- imaging does not look like a bone infarct

3) path
- no predisposing cause
- maybe due to subchondral insufficiency fracture

189

ACL injury

1) x-ray sign
2) association
3) mechanism
4) management

1) x-ray
- segond fracture
- deep sulcus sign (deepening of the anterinferior lateral femoral condyle -via pivot shift injury = impaction injury)
- anteriorly displaced tibia

MR
- bone bruise: posterolateral tibial plateau, lateral femoral condyle (terminal sulcus region)

2) association
- meniscal tear
- iliotibial band, LCL injury (segond)
- posterolateral corner injury

3) Pivot shift
- knee flexed and externally rotated -> additional valgus force

4)
- conservative : low grade partial tear (< 25% cross section of ligament)

190

PCL tear

1) mechanism
2) imaging

1) mechanism
- dashboard
- fall on flexed knee

2) imaging

xray
- avulsion/fracture of the posterior tibial plateau on x-ray

mr
- bone bruise: posterior patella, anterior tibia
- intrasubstance tear
- partial tear
- complete tear
- location: genu most often (horizontal and vertical less)

191

Lateral collateral ligament complex

1) what consist of lateral collateral ligaments?
2) what are posterolateral corner ligaments then??
3) imaging
4) association

1) Lateral collateral ligament complex
- ITB
- FCL (LCL fibular portion)
- bicep femoris
- anterolateral ligament (LCL tibial portion): attaches to lateral rim of tibia
- lateral joint capsule

2) posterolateral corner (Arcuate ligament complex)
- bicep femoris + FCL (some author includes these)
-> popliteus ligament
-> popliteus muscle and tendon/aponeurosis
-> arcuate ligament
-> popliteal fibular ligament
-> fabellofibular ligament

3) imaging
- arcuate sign (fibular head avulsion - bicep femurs and FCL involved)
- sigond (ITB, LCL tibial portion, bicep femoris sometimes)

4) association
- ACL injury!!! especially with segond fracture

192

Tibial plateau classification

1) schatzker classification
2) which ones are high energy

1
- lateral split
- no depression

2 -
- lateral split
- depression

3
- lateral depression

4
- medial split
+/- depression

5
- medial and lateral split

6
- medial and lateral split
+ diametaphyseal fracture
+ displacement

2) 4-6

193

Femoral condylar fracture

1) list the types

1) think of elbow
- supracondylar
- condylar (lateral or medial)
- intercondylar (T or Y)

194

Meniscal tear

1) list types
a - describe
b - imaging
c - location
d - clinical

1)
Radial tear: (lateral meniscus)
a - vertical, perpendicular to long axis of meniscus
b - coronal best :
-> ghost meniscus on 1 slice or
-> abrupt shortening of meniscus
- sagital : gap sign
- axial : can see the radial tear sometimes
c - lateral meniscus : anterior horn and body junction
- medial less common: posterior horn

Longitudinal tear (medial meniscus)
a - vertical, along long axis of meniscus
c- medial meniscus, posterior horn, outer 1/3 (red zone)
d - bucket handle if displaced.
- repair recommended
- often a/w ACL injury

Bucket handle tear
a - vertical longitudinal tear with mesial displacement of the central fragment into intercondylar notch
- the segment maintains anterior and posterior connection with the peripheral segment
b - double PCL sign sometimes
c - medial meniscus
d - need urgent surgery
e - ddx : flap tear - completely displaced fragment

Horizontal tear (medial or lateral)
a - horizontally orientated tear
- from free edge and extend peripherally
b - a/w parameniscal cyst, intrameniscal cyst
- a/w DJD
- may have displaced inferior fragment -> can go into medial or lateral gutter
c - medial or lateral meniscus posterior horn
d - repair for large flap/displacement

Horizontal flap tear
a - horizontal tear + displaced flap

Complex meniscal tear
- tear in more then 1 plan

195

Posterolateral corner injury

1) define
2) ligament group
- from deep to superficial
3) imaging
4) association
5) mechanism

1) injury to ligamentous structure that stabilise the posterolateral corner of knee

2)
- FCL, bicep (some author excludes these)
- arcuate ligament
- popliteal ligament
- popliteus muscle/tendon /aponeurosis
- popliteal fibular ligament
- fabellofibular ligament

deep to superficial
- popliteus tendon
- arcuate
- FCL
- fabellofibular
- bicep femoris

3) imaging
- arcuate sign
- anterior medial femoral condyle + medial tibial bone bruise

4) a/w
- cruciate ligament injury
- meniscus injury

5) mechanism
- anteromedial, varus force to tibia

196

Patella tendon injury

1) list all types
- patellar tendinopathy
- partial/complete tear
- Osgood Schlatter
- Sinding-Larsen Johansson

2) location of injury
- in sport
- in medical conditions

1)
Patella tendinopathy
- thick tendon, heterogenous signal

Tear
- partial
- full : patella alta

Osgood-Schlatter
- thick distal tendon
- high T2
- enlarged, irregular tibial tubercle
- chronic injury -> can cause tibial tuberosity avulsion fracture

Sinding-Larsen Johansson
- overuse injury at the superior patella tendon attachment site
- at its inferior pole
- adult form of Sinding-Larsen-Johanson

Jumpers knee
- adult form of Sinding-Larsen-Johanson

2) location
- normally proximal 1/3 with sport
- if others : consider DM, steroids, other medical disease

197

Segond fracture

1) define
2) imaigng
3) tendon injury

1) avulsion fracture of knee
- involving lateral aspect of tibial plateau
- high involvement with ACL injury and medial meniscus
- mechanism: contentious. As opposed to normal valgus force,segond may have varus force with knee internal rotation

2) imaging
- lateral capsular sign

3)
- ITB, Anterolateral ligament
- sometimes FCL, BF
- ACL

198

Reverse segond fracture

1) define
2) imaging
3) association

1) avulsion fracture of knee
- MCL deep fibre injury
- high risk of PCL injury
- mechanism: knee in external rotation with valgus force

2) imaging
- elliptic bone from medial articular surface proximal tibia

3) a/w
- medial meniscus
- PCL tear

199

Medial retinacular patella avulsion

1) association
2) imaging

1) association
- lateral patellar dislocation

2)
- medial retinaculum avulsion
- bone bruise : medial patella, lateral fibula

3) normally at
- patella insertion (50%)
- femoral insertion (25%)

200

Knee ossicle. Describe

- fabella

Fabella
- ossicle in lateral gastrocnemius (sometimes medial)
- 20% of population

201

Discoid meniscus

1) define
2) lateral or medial more often
3) imaging
4) symptoms

1)
- congenital abnormality large meniscus
- due to failure of resorption of the central element
- can be complete or partial
- increased risk of meniscal tear

2) lateral > medial

3) coronal imaging best
- meniscus extends to central portion in the mid condylar portion > 50% of tibial surface

4) symptoms
- pain, clikcing
- 5% population
- 20% bilateral

202

Meniscal/parameniscal cyst

1) define

1)
- synovium filled cyst lesions
- a/w meniscal tear
- horizontal meniscal tear often

203

Popliteus tendon injury

1) association

1) often associated with posterolateral corner injury

204

Iliotibial band syndrome

1) define
2) imaging

1)
- chronic friction injury of the ITB rubbing against the lateral femoral condyle

2) imaging
- thickenig of the ITB
- fluid between ITB and lateral femoral condyle

205

ITB avulsion

1) association

segond fracture

206

DDX of cyst in the knee

- meniscal cyst : look for meniscal tear
- ganglion cyst : ACL , PCL, Hoffa fat pad, intraosseous
- popliteal cyst : posteriorly between semimembranosus and medial gastrocnemius
- knee joint effusion

207

Ganglia of knee

Describe
- ACL/PCL ganglion
- intraosseous

Cruciate ligament ganglion
- rare
- ganglion cyst of the knee
- may be due to ACL /PCL mucoid degeneration
- a/w joint capsule/tendon tear/defect

Intraosseous
- benign cyst in the bone often at epiphysis
- no DJD
- MR: cyst. No solid portion

208

Meniscal ossicle

1) define

1) bon in the meniscus

2)
x-ray
- well corticated
- triangular or ovoid

MR
- follow normal marrow signal
+/- meniscal injury

3) DDx
- loose body
- osteophyte
- CPPD

4) path
- probably due to previous meniscal trauma

209

Meniscocapsular separation

1) define
2) where does it occur normally?
3) imaging

1) meniscus separate from its capsular attachment

2) medial meniscus posterior horn

3) imaging
- meniscocapsular interval > 5mm
- fluid posterior to the posterior horn of the medial meniscus
- irregularity of the meniscus
+/- meniscal tear
+/- MCL tear
+/- other ligament tear

210

Ligamentum mucosum

1) what is it?
2) issue

1)
- aka: infra patella plica
- anatomical variant (enlarged synovial fold)
- remnant of synovial septum
- from anterior intercondylar notch -> through Hoffa's fat pad -> inferior pole of patella

2) can be thickened

211

Fong disease (nail patella syndrome)

1) aka
2) define /imaging
3) ddx
4) association

1) iliac horn syndrome

2) define
- AD condition with
-> iliac horns
-> horizontal acetabulum
-> no /hypopastic patella
-> no/hypoplastic radial head
-> hypoplastic changes of shoulder/hip
-> talipes equinovarus
-> nail deformities

3) ddx
- no differential with nail dysplasia and patella abnormality

4) association
- skeletal abnormalities (as above)
- nail deformity
- renal disease
- glaucoma

212

Excessive lateral pressure syndrome

1) define and aka

1)
- aka: patella compression syndrome
- lateral tilt of patella without lateral translation
- common cause of anterior knee pain

2) path
- imbalance between medial and lateral stabiliser
-> lax medial stabiliser and /or
-> increased tightening of the lateral stabiliser

213

Hoffa's fat pad impingement syndrome

1) aka and define
2) imaging

1)
- aka: patellar tendon lateral femoral condyle friction syndrome
- i.e patella tendon rubs against lateral femoral condyle
- cause impingement of superolateral Hoffa fat pad

2) imaging
- high signal in the superolateral Hoffa fat pad
+/- lateral patella subluxation
+/- patella alta

214

Patella instability

1) define
2) name the stabilisers of patella
3) most common abnormality
4) others

1)
- clinical syndrome
- with morphologic abnormality of the patellofemoral joint
- increased risk of patella lateral dislocation

2) stabilisers of patella
- active : extensor muscles
- passive: bone ligament

3) most common abnormality
- trochlear dysplasia :
-> crossing sign: trochlea line rise above condyle on lateral x-ray
-> double contour sign: medial femoral condyle very small on lateral x-ray (see 2 condylar lines)
-> shallow trochlea

- patella alta
- lateralised tibial tuberosity

4) others
- vastus medialis haemorrhag injury
- medial patellofemoral ligament tear
- medial retinaculum injury
- knee effusion
- bone contusion : patella and lateral femoral condyle
- loose body
- osteochondral defect of patella

215

Plica syndrome of the knee

1) what is synovial plicae
2) location
3) MR

1) folds of synovium

2) define:
- syndrome where there are synovial plicae
- can cause knee pain

2) Location
- medial patella (most common)
- suprapatella
- infra patella plica (ligamentum mucosum)
- lateral patella plica (rare < 1 %)

3) MR
- plicae: low t1, t2
- can cause chondromalacia patella

216

Politeal cyst

1) location
2) ddx
3) complication

1) between semimembranosus and medial gastrocnemius
- always communicate with knee joint

2) ddx
- semimembranosus/ tibial collateral ligament bursitis (more medial)
- ganglion cyst
- synovial cyst
- popliteal aneurysm

3) complication
- haemorrhage
- infection
- intraarticular bodies/debri
- rupture
- dissection of cyst away from normal location
- intramuscular dissection

217

Tennis leg

1) aka

1) medial gastrocnemius myotendinous junction tear
+- planters tendon rupture

2) imaging
- fluid deep to medial meniscus, superficial to soles
- disrupted muscle + edema
- plantaris tendon torn

3) complication
- compartment syndrome

218

Proximal tibiofibular joint and proximal fibula fracture

1) pearl/check
2) imaging PEARL to confirm dislocation on x-ray

1)
- if fibula head #
-> look for tibial plateau fracture

- fibular shaft #
-> image ankle
-> rule out maisonneuve injury

- fibular styloid avulsion
-> i.e arcuate sign
-> MR if suspicious of posterolaterla corner injury, ACL injury

- if unsure -> compare to contralateral side

- dislocation -> nearly always associated with posterolateral corner injury

2) x-ray for suspect dislocation
- AP: fibular head does not/or minimally overlap lateral tibia
- anterolateral dislocation most common
- lateral : fibula significantly overlaps the tibia (normally fibula shoulder be posterior to tibia)

219

Knee burisits

1) describe
- prepatella
- pretibial

Prepatellar
- well defined mass anterior o patella

Pretibial (infra patellar)
- anterior to distally patella tendon
- surrounding edema
+/- patella tendinopathy

Pes anserinus
- fluid between pes anserinus tendon and MCL/semimembranosus/tibia
- ddx:
-> popliteal cyst
-> semimembranosus tibial collateral ligament bursitis
-> tenosynovitis of pes anserinus
-> parameniscal cyst

220

Lipoma aborescens

1) define
2) region involved
3) association
4) imaging

1)
- rare
- affect synovial lining of joint/bursa
- fatty tissue deposition -> looks like frond
- suprapatellar bursa often

2) joint involved
- supra patella bursa (most common)
- hip, shoulder, wrist
- tendon sheath

3) association
- joint effusion
- DJD
- meniscal tear

4) imaging
CT
- low density intra-articular mass
- effusion

MRI
- fat containing mass in synovium
- frond like

221

Haemophilia

1) define
2) location
3) imaging
4) ddx
5) path

1) X-linked recessive bleeding disorder
- A: factor 8 deficiency
- B : factor 9 (Christmas disease)

2) location of arthropathy
- knee > elbow > ankle > hip

Pseudotumour
- soft tissue > bone

Intraosseous pseudotumour
- femur > pelvis > tibia > small bones of hand > calcaneous

3)
- DJD
- epiphyseal overgrowth
- large intercondylar notch
- effusion
- bleeding : haemosiderin

4) DDX
- JIA: no blooming
- PVNS: no enlarged epiphysis. More focal and nodular.

5)
path
- recurrent bleeding -> hyperaemia -> epiphyseal overgrowth
- hypertrophy /inflammation of synovium -> cartilage, bone damage

Pseudotumour
- recurrent extra-articular haemorrhage

222

Ankle ligament. List

1) lateral ligament complex

2) deltoid ligament

3) distal tibiotibular syndesmosis

1)
- ATFL
- PTFL
- CFL

2) deltoid ligament
- superficial
-> poseterior superficial tibiotalar ligament
-> tibionavicular
-> tibiocalcaneal
-> tibia spring ligament

- deep
- anterior tibiotalar ligament
-> posterior deep tibiotalar ligament

3) complex fibrous joint of multiple ligaments
- anterior inferior tibiofibular
- posterior inferior tibiofibular
- transverse ligament
- interosseous ligament

223

Weber ankle classificiation

A
- below talar dome
- tibiofibular syndesmosis and deltoid intact
- usually stable

B
- at the talar dome
- tibiofibular syndesmosis usually intact
- deltoid may be torn
- variable stability

C
- above talar dome
- disruption to tibiofibular syndesmosis and deltoid injury
- unstable: requires ORIF

224

Talar neck fracture

1) describe Hawkin classification

1 - nondisplaced

2- displaced
- subluxation/dislocation subtalar joint
- ankle joint normal

3- displaced
- abnormal subtler and ankle joint

225

Calcaneal fracture

1) types
- which is more common? intra or extra

2) classification for extra-articular fracture

3) intraarticular classification. What is it called?
How?

1) intraarticular vs extra-articular
Intraarticular 75%

2) Extraarticular 25%
A : - anterior calcaneal process
B - medial sustantaculum tali (medial)
- trochlea process (lateral)
C - posterior tuberosity
- calcanea tuberosity avulsion

3) Sander classification
- classification depends on
-> degree of articular displacement > 2mm
-> number of fracture line that runs through the posterior facet

1 - no # depression

2a - # pass lateral aspect of posterior facet
2b - # pass central aspect
2c - medial aspect
(- may have accessory # not involving the articular surface)

3ab - 2 #, lateral and central
3ac - 2#, lateral and medial
3bc - 2#, medial and central
(- normally depression between the # line
- may have accessory # not involving the articular surface)

226

Ankle injury

1) describe
- lateral (inversion) instability
- medial (eversion) instability
- rotational instability
- subtalar instability

lateral (inversion) instability
- ATFL, CFL injury
+/- PTFL
- varus tilt of the talus

medial (eversion) instability
- deltoid ligament injury
- vagus tilt of talus
- widening of medial ankle gutter

rotational instability
- medial and lateral ligament injury

subtalar instability
- hindfoot valgus (abduction of calcaneus, increased talocalcaneal angle)
- pes pplanus
- CFL injury
+/- cervical ligament/interosseous ligament injury (talocalcaneal ligaments)

227

Subtalar dislocation

1) define
2) imaging
3) complication

1)
- simultaneous dislocation of
-> talonavicular
-> talocalcaneal joint
- no simultaneous tibiotalar or talar neck fracture

2) imaging
- medial dislocation of foot 75%
-> lateral X-ray: talar head superior to navicular

- lateral dislocation of foot
-> lateral x-ray: talar head at or below navicular

3) complication
- DJD
- chronic regional pain syndrome
- chronic subtalar instability
- talar AVN

228

Syndesmosis in jury of ankle

1) aka
2) imaging
3) association

1) high ankle sprain

2) imaging
xray
- < 1mm overlap of tibia/fibula on AP and mortice view
- weight bearing view/stress view : syndesmosis widening

MR
- tear/laxity of distal tibiofibular ligament (anterior and posterior)
- fluid in sydesmosis
- widening syndemosis

3) a/w
- maisonneuve #
- malleolar #
- talar dome osteochoondral injury
- deltoid ligament tear

229

Chopart #

1) define
2) aka

1)
- fracture/dislocation of chopart joint (talonavicular, calcaneocuboidal)
- # of calcareous, navicular, cuboid

2) mid tarsal joint #/dislocation

230

Lis franc ligament injury

1) where is lis franc ligament ?
2) lisfranc ligament injury
3) ddx
4) describe lis franc ligament

1) medial cuneiform 2nd metatarsus base

2) Lisfranc injury
- isolated lisfranc ligament injury
- no disruption to entire TMT joint
- lateral view: dorsal 2nd metatarsus should line with mid cuneiform
- stress view important
- MRI coronal best

3) ddx
- lisfranc dislocation: more extensive, involving additional TMT
- neuropathic joint

4) lis franc ligament
- consists of 3 bands of ligament
-> dorsal, interosseous, plantar
- from medial cuneiform 2nd metatarsus base
- unstable if > 2 torn

231

Lisfranc Fracture- dislocation

1) define
2) association
3) ddx
4) cause

1)
- abnormal TMT alignment
- homovergent: all MT displaced laterally
- divergent : 1st MT displace medially, rest laterally

2) association
- # MT, cuneiform, cuboid

3) ddx
- Lisfranc ligament injury
- chopart dislocaiton
- neuropathic joint

4) cause
- MVA, industrial accident

232

Distal tibial growth plate fracture

1) salter harris type 1
2) tillaux #
3) triplane #

1)
- salter harris type 1
- subtle
- displacement/widening of physis
- soft tissue swelling

2)
- salter harris type 3 #
- involving lateral tibia
- reason: medial distal tibial plate fuse earlier then lateral -> stops medial propagation of #

3) triplane
- salter harris type 4
- sagittal # through epiphysis
- horizontal # through physis
- coronal # through metaphysis

233

Ankle impingement

1) define

2)
Describe. cause for
- anterolateral
- anterior
- anteromedial
- posterolateral
- posterior
- posteromedial

1) restriction of ankle movement

2)
- anterolateral
-> tear of anterior tibiofibular ligament and talofibular ligament
-> triangular lesion in anterolateral recess

- anterior
-> anterior oesophyte from tibia or talus

- anteromedial
-> tear of anterior tiotalar ligament (deep portion of deltoid)

- posterolateral
-> tear of posterior tibiofibular ligament

- posterior
-> os trigonum
-> bone edema
-> posterior talar osteochondral defect
-> posterior synovitis
-> accessory flexor muscle
-> achilles tendinopathy

- posteromedial
-> scar tissue, synovitis

234

Lauge-Hansen ankle # classification

1) describe

1)
- based on mechanism of injury

- 2 word descriptor for each type of #
-> 1st : force acting on talus
-> 2nd : position of foot at time of injury

- 4 main # type

supination adduction
Supination external rotation
Pronation abduction
pronation external rotation

Note:
supination = inversion, adduction, plantar flexion
Pronation = eversion, abduction, dorsiflexion

235

Haglund syndrome

1) define haglund deformity
2) defin haglund syndrome

3) imaging

1)
- enlaged posterior calcaneal process

2) Haglund triad =
= haglund deformity
- achilles tendinopathy
- retrocalcaneal bursitis.

3_ imaging
- soft tissue thickening of the retrocalceanal bursa (preachilles) region
- thickened achilles tendon soft tissue shadow
- bony prominence at posterior calcaneal process superiorly

MR
- Haglund triad

236

Tibialis posterior tear/tendinopathy

1) where ?
2) imaging for
- tendinopathy
- tenosynovitis
- acute partial tear
- chronic partial tear
- chronic full thickness tear
3) association
4) complication

1) normally horizontal portion > 1cm away from navicular
- normal navicular is x 2 size of FDL

2)
Tendinopathy
- high signal. No fluid signal
- tendon enlargement.

Tenosynovitis
- fluid in tendon sheath (normally no fluid at all)

Acute partial:
- enlarged tendon
- fluid between tear

Chronic partial tear
- focal atrophy /thinning of tendon
- partial tear

Complete chronic tear
- tendon retract into calve

3) association
- type 2 accessory navicular
- RA
- pes planus

4) complication
- pes planus
- pronation of foot
- OA

237

Plantar fasciits and fibromatosis
Describe.

1) plantar fasciitis
2) fibromatosis

1) Plantar fasciitis

- define: thickened plantar fascial insertion at medial calcaneous. Often with calcaneal spur
- cause:. microtrauma
- imaging: enlarged tendon, hypoechoic, peritendinous fluid. Undrerlying calcaneal spur.
- thickness > 4mm
- bilateral 1/3
- clincial: pain at medial calcaneous plantar aspect.


2) fibromatosis
- define: nodular fibrous thickening of the plantar fasia
- cause: unknown
- imaging: fusiform nodular thickening of plantar fascia. Away from calcaneal insertion. hypoechoic/isoechoic. variable posterior acoustic changes.
- bilateral 1/3
- clinical: no pain. nodules at sole of foot.

238

Os tibiale externum (aka accessory navicular)

1) what tendon attaches here
2 types
3) clinical. Os naviculare syndrome - what is it?

1) tibialis posterior

2) types
type 1 : 30%
- 2-3 sesamoid bone in distal tibialis posterior tendon

type 2 : 55%
- 55% of accessory navicular
- triangular/heart shaped
- connected to navicular by fibrocartilage or hyaline cartilage

Type 3 :
- fused type 2
- especially prominent navicular

3)
- can cause os naviculare syndrome
-> type 2 naviculare causing pain from movement between os and navicular bone.

239

FHL impingement

1) cause
2) imaaging

1)
- large os trigonum
- large posterior process
- # of posterior talus

2) imaging
- FHL normally has fluid in tendon
- tenosynovitis - irregular tendon sheath, may enlarge
- tear ; FHL tendon retraced to calve

240

Peroneus tendon tendinopathy

1) describe
- tendinopathy
- tenosynovitis
- stenosing tenosynovitis
- split tear
- partial tear
- complete tear

- tendinopathy : high signal, but less then fluid on fluid sensitive sequence

- tenosynovitis : fluid in sheath, irregular sheath

- stenosing tenosynovitis : no fluid in the sheath but has pain.

- split tear : longitudinal etear

- partial tear : tendon thinned. Split tear is also partial tear. More common then complete tear. Peroneus brevis common.

- complete tear

241

Extensor tendon tear of ankle

1) is it rare

1) yes

242

Fracture of metatarsus

1) list the # of 5th metarsus
2) list the order of # in metatarsus
3) ddx
4) what # pattern normally
5) which ones are often involved with stress #

1)
- avulsion #
- Johns : diametaphysis
- stress: at diaphysis

2) 5 > 3 > 2 > 1 > 4

3) ddx
- os versalium : at 5th metatarsus base
- os perineum : at cuboidcuneiform level or just distal
- apophysis of 5th metatarsus

4)
- transverse or short oblique

5) 2nd/3rd

243

Toe # and dislocation

1) how to distinguish sesamoid # from bipartite sesamoid

2) MTP joint dislocation
- cause
- direction

3) interphalangeal joint dislocation

4) PEARL

1) CT OR MR

2)
- cause
-> traumatic : crush, stubbed toe (tip of toe impaction against wall)
-> chronic insufficiency of plantar plate
-> stress # : sesamoid often

- direction: dorsal or lateral dislocation

3) dorsal

4) PEARL
- toe # often missed because this is not a search pattern
- salter harris 1 # of toe can be an open #

244

Sinus tarsi syndrome

1) define and list cause
2) imaging for each cause
3) list ligament from medial to lateral in sinus tarsi
4) which one is most often teared

1)
- pain in the hind foot
- due to abnormal tissue/mass filling sinus tarsi
- trauma with fluid
- ganglion
- inflammatory arthritis

2) imaging
- trauma with fluid
-> bone edema
-> irregularity of the ligament
-> ligament tear

- ganglion
-> fluid filled cyst

- inflammatory arthritis
-> fluid and bone erosion

3) list ligament from medial to lateral in sinus tarsi
- interosseous
- cervical
- extensor retinaculum

4) cervical > extensor retinaculum

245

Tarsal tunnel syndrome

1) define
2) imaging
3) cause and imaging
4) ddx

1) tibial nerve impingement in tarsal tunnel

2) imaging
- denervation of intrinsic foot muscle
-> high signal initially
-> then fat atrophy

3) cause and imaging

-> venous varices: serpantine large vessels in tarsal tunnel

- Trauma
-> ganglion (tendon/capsule rupture)
-> scar
-> osseous impingement (trauma, subtalar coalition)

Tumour
-> nerve sheath tumour

4)
- plantar fasciitis
- radiculopathy of L5/S1
- diabetic neuropathy : also intrinsic muscles affected

246

Avulsion # of talus posteromedial tubercle

1) association
2) complication
3) management

1)
- avulsion of posterior talofibular ligament (of deltoid ligament)

2) complication
- FHL impingement between bone fragment

3) conservative

247

MTP ligament injury

1) list the types
2) what is plantar plate

1) Turf toe
- 1st MTP plantar plate injury
- via severe dorsiflexion
- allows unrestricted movement of 1st MTP

2nd MTP plantar plate injury
- cause:
-> nontraumatic (more common) via transfer of stress from 1st to 2nd toe
-> traumatic

Traumatic hallux valgus
- abduction injury

Traumatic LCL injury
- adduction injury

Sandtoe
- hyeprflexion injury
- damage to dorsal ligamentous complex

2) plantar plate
- thick ligament structure over plantar MTP joint capsule
- stabiliser of MTP

3) imaging
- stress view/weightbearing view show deviation of toe away from side of injury

3) ddx
- OA
- morton neuroma
- inter metatarsal bursitis
- Freiberg infarction

248

Toe deformity

1) hammertoe
2) mallet toe

1)
- flexion deformity at PIP joint
-> cause: RA, neuromuscular condition ( stroke, Charcot-Marie-Tooth disease)

2) flexion deformity at DIP jont

249

Sesamoiditis

1) which is commonly involved
2) cause

1) first toe medial or lateral sesamoid

2) cause
- OA
- stress reaction
- fracture

- and any other cause
-> infection
-> trauma/tendon injury/plantar plate tear
-> tumour: GCT
-> autoimmune arthritis/crystalline arthritis

250

Hallux valgus

1) define
2) metatarsus primus varus
3) imaging
4) treatment

1)
- fixed abduction of the 1st MTP
- normally due to metatarsus primus varus

2)
- fixed abduction of the 1st metatarsus
- with increased first /second metatarsus angle

3) imaging
- Metatarsophalayngeal angle > 15
- 1st / 2nd inter metatarsal angle > 9 degrees

4) treatment
- scarf osteomyelitis

251

Hallux rigidus

1) aka
2) imaging

1)
- osteoarthritis of 1st MTP
- with decreased motion
- 2nd most common disabling deformity after hallux valgus

2) imaging grade (increasing severity of osteoarthritis)
1 - mild/moderate osteophyte with good joint space
2 - moderate osteophyte, joint space narrowing, subchondral sclerosis
3 - marked osteophyte, no joint space, subchondral cyst

252

Freiberg infraction

1) define
2) imaging
3) ddx

1) AVN or osteochondral fracture of 2nd, 3rd metatarsus head

2) imaging
- flattened metatarsus head
- sclerotic head
- mottled sclerosis and lucency in shaft
- late finding: fragmentation

3) ddx
- plantar plate rupture
- morton neuroma
- intermetatarsus bursitis

253

Mueller Weiss syndrome

1) define
2) imaging

1) AVN of navicular in adult

2) imaging
- common shaped deformity ( collapse of lateral part of bone)
- medial or dorsal protrusion of navicular

254

Bunionette

1) define
2) is it more common then 1st metatarsus bunion
3) cause
4) association
5) treatment

1) bony prominence at lateral 5th metatarsus head

2) yes

3) cause
- narrow/consrictive footwear

4) association
- varus deformity of 5th MTP

5) tx
- conservative
- wide shoes
- orthotics

255

Os intermetatarseum

1) location
2) types

1)
- 1st/2nd metatarsus base
- 4th /5th base
- metatarsus head sometimes

2) types
- free standing
- articulating: synovial joint formation with 1st or 2nd metatarsus, or medial cuneiform
- fused : bony projection in 1st/2nd inter metatarsal space

256

Diabetic foot

1) complications

1)
SOFT TISSUE:
- soft tissue : ulceration, cellulitis, abscess
- gas gangrene

MUSCLE:
- diabetic myopathy

BONES:
- osteomyelitis
- insufficiency fracture
-> tarsus, metatarsus
-> calcareous (parallel posterior process vertically and displace superiorly)

JOINT:
- charcot joint
-> Lisfranc > chop art/midfoot > forefoot

257

Chronic reactive arthritis
aka reiter syndrome

1) define
2) imaging
3) ddx
4) exam pearl

1)
- seronegative arthropathy
- triad of uveitis, urethritis, arthritis
- < 33% displace full triad

2) imaging

erosion, enthesitis, periostitis

- CALCANEOUS!!!
-> early : posterior tubercle deossification
-> later : posterior tubercle erosion, enthesitis at achilles tendon insertion
-> plantar enthesopathy and plantar fasciitis
( however other seronegative arthropathy and RA can cause this too)

- medial malleolus enthesopathy

- digits
-> sausage digit (periostitis and soft tissue swelling), periostitis, erosion

- sacroilitis
-> unilateral or
-> bilateral asymmetrical sacroilitis

- bulky paravertebral asymmetric ossification

3) ddx
- psoriasis : hand > feet
- RA : similar MTP and posterior calcanea tubercle change
-> no periostitis, osteophyte
- ank spons/inflammatory bowel disease : peripheral disease involve hip, shoulder, knee

4) note
- all spondyloarthropathy can exhibit a mixture of
-> erosion and bone formation (periostitis) at different stage of disease
- all spondyloarthropathy can progress onto AS

258

NF1

1) define
2) list all the changes
3) chromosome

1) phacomatosis

- NF1 mutation
- earlier onset then NF2

2) clinically
- lisch nodules
- peri-oral freckling
- axillary tags
- neurofibroma
- plexiform neurofibroma

Head/neck
- bupthalmos
- sphenoid wing dysplasia

Head
- optic nerve glioma
- pilocytic astrocytoma
- brainstem glioma
- spinal astrocytoma
- FASI (iso to high T1. high T2 = water. If in thalamus may be a/w cognitive impairment)
- moya moya

spinal
- kyphoscoliosis
- astrocytoma
- neurofibroma

chest
- neurofibroma
- lateral meningocele

Breast
- peri-areolar neurofibromas

MSK
- enlargement of neural foramen
- posterior vertebral scalloping
- gracile rib
- rib notching
- tibial pseudoarthrosis
- NOF

Abdo
- pheochromocytoma
- wilms
- RCC, angiomyolipoma, rhabdomyosarcoma
- leiomyosarcoma, leiomyoma
- carcinoid
- ganglioglioma

3) NF1 gene
- chromosome 22q12

259

NF2

1) define

1) familial cancer syndrome
- meningioma
- schwannoma
- ependymoma

2)
- bilateral vestibular schwannoma best clue
- meningioma 50%
- ependymoma 6%

3) path
- NF2 gene mutation ( 22q12)

260

Scoliosis

1) define
2) cause

1) lateral curvature of spine > 10 degrees
- returns to midline at end of curve

2) cause

- idiopathic : no known cause. Thoracic dextroscoliosis most common. Onset young (infantile < 4, juvenile 4-9, adolescent > 10). Increased growth during growth spurt.

- infection : gibbous deformity (i.e short acute band)

- trauma, tumour

Congenital:
- neuromuscular: due to neurologic (cerebral palsy) or myopathic disease (muscular dystrophy). Long single thoracolumbar scoliosis.
- syndrome: NF1, osteogenesis imperfecta, Ehlers-Danlos
- congenital : secondary to vertebral fusion, segmentation anomalies (hemivertebrae, butterfly, fused). a/w Klippel-Feil syndrome (segmentation anomalies) and VACTERL

- degenerative

261

Scheuermann disease

1) aka
2) define
3) imaging
4) path
5) management

1) juvenile kyphosis

2) common condition
- cause kyphosis of thoracic or thoracolumbar spine
- 5% of population

Type 1 - thoracic spine (75%)
Type 2 - thoracolumbar

3) imaging
- thoracic spine kyphosis > 40 degrees
- thoracolumbar > 30 degrees
and
- > 3 vertebral anterior wedging

Association
- schomrl's node
- limbus vertebrae
- endplate irregularity (via disc invagination)
- narrow disc space

4) path
- AVN of ring apophysis

5) management
< 50 - conservative
50-70 - brace
> 75 - surgery

262

Diastematomyelia

1) define
2) imaging
3) ddx
4) types

1) split cord malformation
- division of cord into 2 hemicord
- normally fuse proximal and distally
- a/w bony or fibrous spur
- a/w vertebral segmentation anomalies

2) imaging
-xray : can have widening of canal with central spur

3) ddx
- duplicated spinal cord : each has own grey and white matter. Some consider a severe form of diastematomyelia

4)
1 - separate dural sac : fibrous or osseous spur. symptomatic
2 - single dural sac - fibrous band. normally asymptomatic

263

Partial vertebral duplication

1) define
2) imaging
3) ddx
4) path
5) clinical

1) partial duplication of vertebral column
- > 1 supernumerary hemivertebrae

2) imaging
- atypical scoliosis (sharply angulated, single curve)
- 1 or more extra hemivertebrae (exactly look like hemivertebrae)

3) ddx
- butterfly vertebrae
- vertebral fracture

4) abnormal vertebral ossification -> hemivertebrae

5) clinical
- asymptomatic or
- neuromuscular scoliosis
- respiratory failure

264

Spinal stenosis

1) cause
- list them

1)
- congenital
-> congenital stenosis due to short thick pedicle
- small central canal
- may not have symptoms until superimposed with degeneration (acquired spinal stenosis)

- acquired. i.e (spondylosis)
-> normal pedicle length
-> i.e DJD (spondylolithesis, facet arthropathy, disc herniation, thickened ligamentous flavum)

- achondroplasia

- mucopolysaccharidoses

265

Marfan and Ehler-danlos

1) define
2) imaging
3) differentiator between marfan and ED
4) PEARL

1) hereditary connective tissue disorder

2)
- arachnodactylyl (finger/toe lengthening)
- ligament laxity
- joint dislocation (patella, hip, mandible)
- scoliosis
- posterior vertebral scalloping
- chest : ectus excavatum or carinatum

3) differentiator by soft tissue
- Marfan : skin thin, muscle atrophy, little fat. Aortic dissection. Lens dislocation
- ED : subcutaneous calcification (fat necrosis) + heterotrophic ossification. Skin fragility

4) PEARL
- think of Marfan or ED in arachnodactylyl

266

Achondroplasia

1) define
2) imaging finding
3) ddx

1) most common cause of rhizomelic dwarfism

2)
Skull
- enlarged
- narrow cervicomedullary junction
- verticalised straight sinus
- vertebral invagination
- platysbasia

Spine
- posterior vertebral scalloping
- short pedicle
- decrease interpedicular distance towards lower level of vertebral spine
- platyspondylyl
- kyphoscoliosis

Short rib

Pelvis
- squared iliac wing
- horizontal acetabular roof
- short sacrosciatic notch

Rhizomelic dwarfism

3)
- thanaophoric dysplasia
-> severe platyspondylyl, bell shaped thorax, lethal dwarfism
-> cloverleaf skull, telephone receiver femur
- osteogenesis imperfecta

267

Osteogenesis imperfecta

1) define
2) types
3) imaging
4) path
5) ddx

1) collagen type 1 disorder

2) type
- 1 : classic. blue sclera. denting-genesis imperfecta
- 2 : perinatally leath
- 3 : progress. lethal in childhood
- 4 : similar to classic, without blue sclera

3) imaging
OSTEOPEROSIS!!!!

Skull
- wormian bone
- basilar invagination
- platysbasia
- delayed ossification (ddx hypophospataemia)
- thin skull : can be compressed by ultrasound transducer

Rib
- ribbon ribs, beaded appearance
- small chest

Spine
- kyphoscoliosis
- platyspondyly
- posterior vertebral scalloping

Hip
- coxa varus
- enthesopathy at ASIS, AIIS with bone formation

Bone
- normal length gracile bone (type 1, 4)
- callous -> crumped appearance, shortened (in type 2 , 3 )
- gracile bone : bone slender then usual
- osteoperosis
- subperiosteal haemorrhage!!!!!
- zebra line :bisphosphonate use

4) path
- abnormal type 1 collagen synthesis
- COL1A1 or COL 1A2 mutation (chromosome 17 and 7 respectively)
- AD transmission

5)
- hypophosphataemia : no calvarial ossification
- achondroplasia/thanatophoric dysplasia

268

Posterior element incomplete fusion

1) define
2) ddx
3) cause
4) clnical

1) incomplete fusion of the spinous process/lamina
- no underlying neural or dural abnormality
- no underlying fatty tissue
- old term: spinal bifida occult

2) ddx
- closed spinal dysraphism
- surgical laminectomy defect

3) cause
- unknown

4)
- normal incidental
- rarely neurological significance
-MR best for evaluation, but low yield if absence of neurological deficit

269

sacrococcygeal teratoma

1) define
2) imaging
3) ddx
4) path
5) in utero complication
6) types

1)
- congenital sacral tumour
- consist 3 germ cell layers

2) imaging
- large heterogenous sacral mass in infant
- calcification, solid, cyst, fat, bone, hair, teeth, cartilage
- avid enhancement

3) ddx
- anterior sacral meningocele : cystic mass. No solid component. No enhancement. Enlarge with valsalva.
- dermoid : fat, calcium. smaller more homogenous then sacral teratoma
- exophytic rhabdomyosarcoma : aggressive tumour. No calcium, fat, bone, hair.
- chordoma: mixed solid cystic sacral mass. age 50-60. High T2. Invade bone

4) path
- arise from toitopotential cells at caudal spine

5) in utero complication
- polyhydramnios
- high output cardiac failure
- hepatomegaly
- placentomegaly

6) types (ATLMAN classification)
- 1 : external (47%) - best diagnosis
- 2 : half external and internal
- 3 mostly abdo/pelvi
- 4 : entirely internal (10%) - worst prognosis

270

Anterior sacral meningocele

1) define
2) imaging
3) ddx
4) association

1) sacral meninges herniate anteriorly into pelvis
- by erosion or hypplasia or the vertebrae (sacrum/coccyx)

2) imaging
- presacral cyst
- continuous with thecae sac through anterior osseous defect

3) ddx
- sacrococcygeal teratoma
- sacral chordoma
- neurenteric cyst
- ovarian cyst
- cystic neuroblastoma

4) association
- currarino triad
-> sacral agenesis/hypoplaslia (caudal regression syndrome)
-> presacral lesion (epidermoid/dermoid tumour)
-> anorectal anomalies

271

Dural dysplasia

1) aka. define
2) ddx
3) cause
4) path
5) clinical

6) list the 3 causes of posterior vertebral scalloping

1)
- aka: dural ectasia
- enlarged dural sac with posterior vertebral scalloping
- enlarged central canal

2) ddx
- spinal tumour (ependymoma, astrocytoma, NST)
- syrinx
- congenital vertebral dysplasia (achondroplasia, mucopolysaccharidosis, osteogenesis imperfecta)
- cauda equina syndrome of ankylosing spondylitis

3) causes of dural ectasia
- NF1
- Marfan, ED

4) path
- AD for NF1, marfan, ED

association
- lateral /lumbar meningocele
- anterior sacral meningocele
- joint hypermobility
- kyphoscoliosis
- lens abnormality
- aneurysm
- aortic dissection

5) clincial
- back pain
+/- radiculopathy

6)
a) dural ectasia
- NF1
- Marfan, ED
- homocystinuria :congenital disorder of metabolism. Imaging: ectopic lentil, seizure, scoliosis, pectus excavatum, long limb. thromboembolism. DDX marfans

b) increased spinal canal pressure
- ependymoma, astrocytoma, nerve sheath tumour
- syrinx

c) congenital skeletal dysplasia
- achondroplasia
- mucopolysaccharidosis
- osteogenesis imperfecta


272

Mucopolysaccharidoses

1) define
2) imaging
3) ddx
4) types
5) AD or AR

1)
- inherited metabolic disorder
- single gene defect
- causing cellular accumulation of glycosaminoglycans
-> damage to multiple organs

2) imaging
Skull:
- J shaped sella

Hand:
- fan shaped 2-5 metacarpal (constriction at base)

Spine:
- platyspondyly : L1 most often
- hypoplasia of L1 with anterior beak
- posterior vertebral scalloping

Rib:
- oar-shaped rib : narrowing at vertebral end, broadening at sternal end!!!! (specific)

Pelvis:
- narrow elongated ilium.
- steep acetabular angle

MR:
- dural thickening -> cervical myelopathy

3) ddx
- achondroplasia : narrowing of interpedicular distance from L1-5 on AP

4) types
- Hurler
- Hunter
- Morquio

5) autosomal recessive

273

Osteopetrosis

1) define
2) imaging
3) ddx
4) types
5) cause of death in infantile form

1)
- uncommon hereditary disorder
- abnormal osteoclast malfunction
- accumulation of dense weak bone

2) imaging
- bone in bone deformity
- erlenmeyer flask deformity
- alternating metaphyseal band
- sandwich vertebrae
- skull thickening

Nuc med: superscan

3) ddx
- pycnodysostosis: short stature, acro-osteolysis, delayed cranial suture closure, obtuse mandibular angle
- mastocytosis

4) types
- infantile : AR. whole skull involvement. Diffuse skeleton.

- adult type 1 : AD. cranial vault. No cranial base involvement.

- adult type 2 : AD. cranial base involvement. Sandwich spine.

5) cause of death in infantile form
- marrow failure
- kinking at corticomedullary junction

274

Ochronosis

1) define
2) imaging
3) ddx

1)
- abnormal pigmentation of soft tissue (ear, sclera - blue grey)
- due to alkaptonuria
-> due to deficiency of homogentisic acid oxidase

2) imaging
Disc/spine:
- disc calcification/ossification (nucleus purposes)
- disc narrowing/vacuum
- endplate sclerosis, but underlying bone osteoporotic
- some osteophyte
- osteoperosis!!!

i.e spondylosis
+ central disc calcification
+ osteoperosis

Joint:
- SI joint calcification
- pubic symphysis calcification
- DJD : narrowing, osteophyte loose body, subchondral cyst
- tendon calcification/ossification

3) ddx
- DJD
- trauma: post op
- ankylosing spondylitis: has other associated findings

- CPPD, haemachromatosis, hypervitaminosis D : annulus fibrosis
- JIA
- amyloidosis

275

Caudal regression syndrome

1) define
2) types and imaging
3) ddx
4) association

1)
- spectrum of abnormality a/w
- hypoplasia or agnesis of the coccyx, sacrum and the lumbar spine

2) types
group 1 - distal spinal cord hypoplasia, sacral agenesis

group 2 - tethered cord, less severe sacral abnormality

- tombstone iliac bone closely opposed due to absence of sacrum

3) ddx
- tethered cord
- spinal dysraphism

4) association
- VACTERL
- currarino triad:

276

Neurenteric cyst

1) define
2) imaging
3) location
4) ddx
5) path

1)
- intraspinal cyst lined by enteric mucosa

2) imaging
- intraspinal cyst

+ vertebral abnormalities
-> vertebral segmentation fusion anomalies
-> persistent canal of Kovalevsky: midline circular vertebral defect

+/- mediastinal /abdominal cyst
+/- connecting fistula

3) location
- thoracic > cervical > lumbar spine > intracranial/basilar cisterne

4) ddx
- arachnoid cyst
- epidermoid cyst

5) path
- subgroup of split notochord syndrome (Klippel-Feil, VACTERAL, OEIS)

277

Morton neuroma

1) define
2) imaging
3) location
4) cause
5) clinical

1) fibrosis of plantar digital nerve

2) imaging
- well demarcated fusiform soft tissue mass
- unifocal, unilateral
- plantar aspect
- between metatarsus

MR:low T1, high T2, or iso fotr both
variable enhancement

US: ovoid mass, variable echogenicity
+- vascularity

3) location
- between 3-4 metatarsal
> 2-3 metatarsal
- plantar aspect

4) cause
- ill fitting shoes
- hindfoot valgus
- intermetatarsal bursitis

5) clincial
- female
- focal tenderness but no palpable mass

278

Discitis / osteoomyelitis / septic facet joint

1) define
2) imaging
3) imaging facet septic arthritis
4) ddx
5) organism
6) patient group

1)
- discitis: infection of interertebral disc
- osteomyelitis : infection of the bone
- septic arthritis

2) imaging discitis / osteomyelitis
x-ray
- disc destruction
- endplate irregularity
- laterally displaced paravertebral strip
- gibbous deformity, kyphosis

CT
- similar with xray
- paravertebral mass

MR
- low T1, high t2 bone
- enhancing disc and vertebral body. high T2
- paravertebral soft tissue swelling, pus

3) imaging
- effusion
- erosion
- joint destruction
- surrounding soft tissue swelling, abscess

4) ddx
- erosive or crystalline arthropathy
- amyloid deposition in dialysis
- neurogenic charcoat joint

5) organism
- staph aureus

6) 1st peak in children
- later in adult

279

Epidural abscess

1) how to differentiate between phlegmon and abscess

2) how to tell pus from fat
3) how to tell epidural vs subdural
4) what does post treatment persistent epidural enhancement mean
5) organism

1)
- phlegmon: homogenous or heterogenous enhancement

- abscess: rim enhancement

2) how to tell pus from fat
- fat sat image

3) how to tell epidural vs subdural
- fat sat image

4) what does post treatment persistent epidural enhancement mean
- probably granulation tissue/fibrosis
- follow up CRP/ESR to check

5)
- staph (most common)
- TB!!! (second)

6) ddx
- haematoma: may have fine enhancement
- met : soft tissue mass. diffuse enhancement
- disc : mild peripheral enhancement
- lipomatosis : fat sat

280

Spinal subdural abscess

1) define
2) imaging
3) ddx

1) pus between dural and arachnoid in the spinal canal

2) imaging
- Best: ring enhancing intradural extra medullar collection, outlined by fat and CSF on axial imaging!!!

- thoracolumbar most common
- use axial imaging and fat sat to confirm intradural region

3) ddx
- epidural abscess
-> normally a/w discitis/osteomyelitis
- subdural haematoma : trauma, or LP

281

TB osteomyelitis/discitis

1) main differentiator
2) imaging
3) spread by
4) ddx
5) pearl

1) disc may be preserved

2) imaging
Early sign
- reduction of vertebral height
- irregularity of anterosuperior plate

- gibbous deformity: collapse of vertebral body
- ivory vertebrae : with reossification
- vertebrae plana

- sub ligamentous spread: multipel vertebral bodies involved with no disc involvement

- paraspinal calcification/psoas calcification

- intence pachymeningitis of spinal canal

3) spread by
- haematogenous : venous plexus of batson
- sub ligamentous spread along ALL

4) ddx
- other cause of osteomyelitis
-> pyogenic
-> fungal
- met

- Brucellosis!!! : granulomatous osteomyelitis, difficult to distinguish from TB. both AFB.

5) can often cause large paraspinous collection without pain

282

pseudomeningocele

1) define
2) ddx
3) clinical

1) spinal fluid collection
- outside of dural sac, not lined by meninges
- continuous with dura
- normally in setting of trauma or surgery

2) ddx
- abscess
- haematoma
- extradural meningeal cyst
- meningocele (NF1 , marfan)
- plexiform neurofibroma

3)
- asymptomatic or
- a/w intracranial hypotension

283

Bone graft complication in spine

1)
- graft migration, can cause
-> hardware malalignment
-> neurological deficit
-> infection
-> instability

- graft failure
-> non-union
-> malunion

Others
- infection
- haematoma
- CSF leak (pseudomeningocele)
- heterotopic bone formation at region of interpedicular screw -> neural compromise

284

Name the hyperflexion spine injury types.

- wedge compression
1) is it considered a single column?
2) where?
3) cause
4) difference compared to burst

- Clayshoveler's #
5) define

- flexion tearedrop
6) describe, cause, symptom, imaging

- unilateral/bilateral # dislocation/fracture

- acute disc protrusion

1) yes (posterior vertebral body cortex intact)
2) thoracolumbar normally
3) cause: flexion or axial loading
4) difference compared to burst : 2 column # (posterior vertebral body also #)

5) spinous process # of lower cervical vertebrae
- normally C7

6) severe axial/flexion injury
- indicate severe ligamentous instability, C4-6 normally
- anterior cord syndrome -> quadriplegia common
- imaging: anterior inferior teardrop, retropulsion, PLL injury, ligamentous flavum, interspinous

285

Jefferson #

1) define
2) mechanism
3) a/w
4) management

1) burst # of C1

2) mechanism
- axial loading (diving into water)
-> occipital condyle driving into atlax

3) a/w
- 50% with other c-spine injury
- 33% with C2 injury
- 25-50% concurrent head injury
- vertebral artery injury
+/- ligamentous injury

4) management
- conservative : if no ligament injury or displacement
- may have surgery if ligament injury or displacement.

286

List the hyperextension cervical injury

- C1 anterior arch avulsion
- C1 posterior arch #
- C2 dens #
- C2 hangman #
- hyperextension tear drop
- hyperextension dislocation
- laminar #
- central cord syndrome

287

Hangman #

1) define
2) mechanism
3) imaging
4) management

1) # of C2 pars
2) hyperextension /distraction
injury

3) imaging
- bilateral pedicle, lamina # of C2
- C2/3 anterolithesis
- vertebral artery injury

4) typically surgery

288

Atlantoaxial rotary fixation

1) define
2) imaging
3) cause
4) clinical

1)
- disorder of C1/2 alignment
- causing impaired rotation of neck

2) imaging (Felding and Hawkins)
- type 1 : rotary fixation. No anterior displacement (< 3mm)
- type 2 : anterior displacement of atlas from dens (3-5mm). transverse ligament injury
- type 3 : anterior displacement > 5mm . Transverse and alar ligament injury.
- type 4 : posterior displacement of atlas on dens.

3) cause
- trauma
- surgery
- infection (Grisel syndrome)

4) clinical
- fixed rotated and flexed neck
- painful torticollis (if attempt to reduce/correct)

289

Uncovertebral joint

1) aka
2) which vertebrae
3) degeneration complication

1) Luschka's joint
- at lateral vertebral body
- limit lateral movement
- forms anterior border of intervertebral foramen

2) C3-7

3) posterior osteophyte can cause nerve root /vertebral arteryimpingement

290

Burst #

1) define
2) ddx
3) MUST REMEMBER

1)
- axial loading injury
- normally at thoracolumbar junction
- involve anterior and posterior vertebral body
+/- retropulsion
+/- vertically orientated posterior element #
+- widening

2) ddx
- compression : posterior cortex intact
- chance : horizontal posterior element #, separation of facet joints (distraction force)
- pathological #

3)
- VERTICALLY ORIENTATED POSTERIOR ELEMENT #####!!!

291

lumbar CHANCE #

1) define
2) imaging
3) ddx

1)
- flexion distraction injury (seatbelt)
-> compression to anterior column
-> distraction of mddle/posterior column
-> T11-L3 normally (thoracolumbar junction)

2) imaging
- wedge anterior vertebra body
- posterior column
-> horizontal #
-> separation of facet joints
-> increased interspinous ligament
-> ligament injury on MR

3) DDX
- shear injury : transverse shearing force. Horizontal # of 3 column with displacement.
- distraction injury : all 3 columns disrupted.
- burst : anterior and posterior column + retropulsion
- traumatic compression/anterior wedge # anterior column compression. Intact posterior vertebral body wall.

292

Transvserse process #

1) define
2) complication

1)
- common sequale of trauma
- minor and stable normally
- strongly a/w other injuries.

2) complication
- cervical : if extension to transverse foramen -> vertebral artery injury

293

Posterior apophyseal ring fracture

1) what is ring apophysis
2) mechanism, location
3) imaging

1)
- part of the vertebral body
- at the corners of the vertebrae. connected to the vertebral body by a thin cartilage that only calcifies at 18 yo (before then it is a weak point)
i.e. apophyseal ring -> cartilage growth plate -> endplate -> vertebral body
- connects to annulus fibrosis (via sharpy's fibre)

2) imaging
- normally in lumbar spine
- in immature skeleton
- repeated trauma can cause disc herniation here (think of mechanism similar to limbus)

3) CT
- bone fragment displace posterior to endplate
-> rectangular or arc shape
- posterior endplate defect
- disc herniation

MR:
- defect in the endplate
- with disc herniation

294

vertebral body osteonecrosis

1) aka
2) define
3) imaging

1) Kummell disease

2) define
- AVN and collapse of vertebral body

3) imaging
- sclerotic and collapsed vertebral body
- horizontal vacuum cleft and fluid (non-specific)

295

Spondylolysis

1) define
2) imaging
3) ddx
4) clinical

1) defect in pars interarticularis
- via repetitive stress injury
( pars is junction of pedicle, lamina and facets)

2) imaging
- L5 most common
- scottie dog on oblique view

3) ddx
- trauma
- facet arthropathy
- infection
- tumour

4) clinical
- 6-8 % general population
- 10-20 years often
- conservative management for grade 1-2 spondylolithesis

296

Sacroiilitis

1) unilateral ddx
2) bilateral assymetric ddx
3) bilateral symmetric ddx
4) x-ray grading

1) unilateral ddx
- INFECTION! (risk : IVDU, HIV, DM)
- psoarisis
- reiter arthropathy
- ank spond,
- RA
- OA
- Gout

2) bilateral assymetric ddx
- reiter, psoriasis
- ank spond, enteric
- others: OA, gout, JIA, RA)

3) bilateral symmetric ddx
- ank spond, enteric
- psoriasis, reiter (late)
- mimic: OA, DISH, osteitis condensans

4) x-ray grading
1 - indistinct SIJ
2- some erosion, sclerosis
3- more erosion, sclerosis
4- ankylosis

297

Stress fracture of spinous process

1) which ones?
2) what activity?

1) c6- T2

2) shovelling

298

Lumbosacral pseudoarthrosis

1) aka

1) sacralisation of L5 (type 2 castellvi classification)

type 1 - enlarged and dysplastic transverse process ??

type 2 - pseudoarticulation of enlarged transverse process and sacrum
- incomplete lumbarisation/sacrolisation

type 3- transverse process fuse with sacrum (complete sacralisation or lumbrolisation)

type 4 - don't worry about this
( type 2 on one side, type 3 on the other)

299

Degenerative joint disease nonmenclature

define
(from radiopedia)

- desiccation

- bulge
- herniation
- sequestration

Localisation
- central
- paracentral/subarticular/lateral recess
- foraminal
- extraforaminal/far lateral disc
- anterior

- dessication:
-> nucleus pulposus glycosaminoglycans replaced with fibrocartilage
-> low T2 disc, with no more low signal midline cleft

- annular fissure
-> fissure within the annulus fibrosis
-> region of high T2 signal in the annulus (normally low signal)

- bulge:
-> circumference: involve entire disc
-> asymmetric : > 25% of circumference (i.e > 90 degrees)

- herniation: disc herniation < 25% of circumference

- protrusion: herniation
-> dome smaller then neck

- extrusion: type of herniation
-> dome bigger then neck

- sequestration: disc migration extruded disc material away disc.
-> no contact with adjacent disc

300

Degenerative endplate changes

1) aka

2) list

3) ddx

1) modic changes

2)
- type 1 : low t1, high t2 (edema)
- type 2 : high t1 and t2 (transformation to yellow)
- type 3 : low t1, t2 (sclerosis)

3) ddx
- infection: low t1 change. endplate destruction. high t2 disc.
- seronegative discitis (anderson lesion - hemispheric low t1 high t2 endplate change)
- haemodialysis spondyloarthropathy : low t1 endplate (appear similar to infection)

301

Spondylolithesis cause

1) cause
2) possible imaging sign
3) complication of treatment
4) benefit of surgery

1) (same cause for instability)
- degeneration (facet arthropathy)
- pars defect : bilateral 80%
- post surgery / trauma
- dysplastic
- tumour

2) napolean's hat sign (inverted napolean hat) on AP pelvis

3) treatment will cause 9.2% complication rate
-> i.e higher grade of spondylolithesis

4)
- but improves spinal canal stenossi

302

Spine instability

1) define
2) cause

1)
- decreased spine stiffness
- causing increased/exaggerated motion
- with pain and deformity

2) cause (same as cause of sondylolithesis)
- degeneration (facet arthropathy)
- pars defect : bilateral 80%
- post surgery / trauma
- dysplastic
- tumour

303

Spondylosis

1) list the changes
2) SI OA changes

1)
- anterior osteophyte
- decreased disc space
- ligament flavum thickening
- PLL ossification
- Baarstrap
- uncovertebral arthropathy
- facet arthropathy

2) SI OA changes
- could be linear sclerosis
- or ROUND sclerosis
- superior OSTEOPHYTE!!!

304

Epidural lipomatosis

1) define
2) location
3) ddx

1) excessive intraspinal fat
- cause cord comrpession

2) location
- thoracic > lumbar

3) ddx
- epidural haematoma
- angiolipoma : enhance
- epidural met: enhance
- abscess: ring enhance

305

Facet synovial cyst

1) define
2) imaging
3) ddx
4) clinical
5) mechanism

1) degenerative cyst secondary to facet degeneration

2) imaging
- posterolateral extradural cyst, communicates with facet joint
- communicates with dura
- lumbar 90%

3) ddx
- ganglion cyst : from ligament flavum. Difficult to distinguish by imaging
- disc fragment
- nerve sheath tumour : enhance
- septic arthritis/abscess: inflammatory markers. ring enhancement, significant surrounding edema.

4) clinical
- pain
- radiculopathy

5) path
- facet degneration
-> fluid accumulation
-> synovial proliferation
-> cyst formation

306

Ankylosing spondylitis

1) define
2) imaging
3) ddx
4) path
5) clinical

1) seronegative inflammatory arthropathy
- predilection for axial skeleton

2) imaging

OSTEOPENIA!!

Spine:
- bamboo spine
- squaring vertebra
- flowing syndesmophyte
- dagger spine
- romanus body
- shinning corner
- anderson lesion : same as romanus but centred on endplate -> contribute to vertebral fusion

SI : symmetrical sacroiilitis

Early sign
- enthesopathy (early sign) : pubic symphysis enthesitis
- romanus lesion (low t1, high t2)

3) ddx
- inflammatory bowel arthropathy : exactly the same as any spond
- psoriasis or reiter: bulky asymmetric syndesmophyte, bilateral asymmetric sacroiilitis, hand /feet, no osteoperosis
- OA : osteophyte arises away from the disc

4) path
- HLA B27 association
- native american
- syndesmophyte : form from annulus fibrosis
- Aetiology
-> genetic predisposition +
-> environmental stimulating factor / arthriogen.
-> Autoantibodies.

5) clinical (most common)
- low back pain, stiffness
-assymetric oligoarticular peripheral disease
- young man 15-30 yo

307

Inflammatory bowel disease arthritis

1) define
2) imaging
3) differentiators
4) Pearl !!!

1) seronegative spondyloarthroapthy
- inflammatory erosive arthropathy a/w inflammatory bowel disease

2) imaging
- identical to ank spond
- early enthesitis
- proximal joint affected (erosive and periostitis)
- peripherall joint polyarthropathy but normally no bony change
- osteoperosis late

3) helpful differnetiators
- bowel surgery evidence (colostomy, staple line, ileostomy)
- AVN femoral head : steroid use

4) pearl
- if consider FAI in young patient --> always check SI joint to make sure no abnormality

-> consider patient with enteric arthropathy in patient with
- ank spond _ bowel surgery

308

Sacroiilitis , septic arthritis

1) tell me about it

- Top differential in unilateral sacroiilitis
- others: psoriasis, reactive arthropathy, OA, ank spondylitis, RA

- consider in IVDU, HIV DM

309

Neuropathic joint

1) define
2) IMAGING
3) spine charcoat vs osteomyelitis
4) location and cause
5) ddxlower

1)
- severe , rapidly destructive joint process
- ethology often suggested by location

2)
- distension
- dislocation/disorganisation
- destruction
- debri
- density

3)
spine charcoat vs osteomyelitis
Following makes charcot more likely :
- debri
- dislocation/subluxation
- vacuum disc
- facet involvement
-> NEED ASPIRATION

4) location and cause
- syrinx: shoulder, wrist
- syphilis: spine, knee , lower limb (hip, ankle, knee)
- DM: hand, feet
- spinal cord injury: spine (more distal then site of injury -> no protection)

others:
- congenital insensity to pain
- neurological : charcot-Marie-Tooth
- intra-articular steroid : knee
- alcoholism: knee

5) DDX
- osteomyelitis: sinus tract, abscess, more confluent bone marrow abnormal signal (low t1, high T2), less debri
- spine disciitis: both can have paraspinal collection, endplate destruction, debris, subluxation.


310

Ossification of ligamentum flavum

1) where?
2) imaging
3) clinical
4) association

1) thoracic > cervical

2) imaging
- sagittal: ossification anterior to the facet joint

MR: low signal anterior to facet joint

3) clinical
- japanese , asian
- ethology: unknown
- can cause cord compression/

4) association
- ossification of PLL

311

HME

1) define
2) imaging, location
3) ddx
4) path
5) pearl

1) hereditary condition of multiple osteochondroma

2) imaging
- exostoes growing away from mjoint
- sessile > pedunculate

MR:
- cartilage overlying < 1cm (low t1, high T2, thin enhancement over the fibrocartilaginous cap [fibrovascular tissue]).

Metaphyseal flaring : can mimi

Location:
- metaphysics of tubular bone
- femur , tip, fib, humerus, forearm (prox/distal)
- pelvis (ilium, pubis, ischium)
- ribs (costovertebral, costochondral junctions)
- spine 27% involved

OFTEN BILATERALLY SYMMETRIC

3) ddx
- chondrosarcoma:
-> most important to differentiate
-> if continue growth, pain, pathological fracture, new lucency, bone breach, soft tissue mass

- metaphyseal flaring ddx
-> chong

4) path
- AD 90
- 1-3 % chondrosarcoma transformation

5) OFTEN BUT NOT ALWAYS BILATERAL SYMMETRIC


312

Enchondroma

1) define
2) imaging
3) ddx
4) path
5) management
6) pearl

1) benign tumour (2nd most common type)
- hyaline cartilage origin
- in medullary bone

2) imaging
- hand /feet 50%
-> expansile lucent lesion
-> a/w pathological #

- long bone
-> femur, tibia, fibula, humerus
-> central distribution
-> metaphysis
-> non-aggressive
-> could be expansile
-> ring and arc/flocculant/punctate
-> non-sclerotic margin

- if endosteal scalloping -> SUSPECT CHONDROSARCOMA TRANSFORMATION

- enchondroma protubérance :
-> exophytic mass with cortical breach
-> benign

MR:
- lobulated low T1, high T2.
- matrix with low signal
- peripheral septal enhancement

3) ddx
Small tubular bone ddx : SBC, ABC, GCT

Large long bone ddx:
- chondrosarcoma : extensive endosteal scalloping, other aggressive features, change in chondroid matrix on f/u films!!!!
- GCT: entirely lytic, more confluent on MR signal

4)
- etiology uncertain
- 5- 80 yo (30 -50 common)
- 2nd most common benign tumour of bone

5) management
-small lesion : may monitor
- large lesion + symptom : discuss at orthopaedic meeting -> marginal/wide excision -> check histo
-> if benign : no f/u
-> if chondrosarc -> should be curative but f/u as per orthopaedic sarcoma protocol

6) change in appearance of lesion -> suspect chondrosarcoma!!!

313

Ollier disease

1) define

2) imaging
3) ddx

1) multiple enchondromas with chondroicd matrix
- but is actually a bone dysplasia (not simple multiple enchondromas)

2) imaging
- multilobulated expansile metaphyseal lytic lesions with chondroid matrix or
- could be central lytic nonexpansile, but demarcated by chondroid calcification
- sclerotic margin
- matrix : popcorn, arcs
- streaky sclerotic lines in lucent lesion appearance in long bone

- growth deformity: short stature, made lung, limb length discrepancy
- don't involve facet, skull

3) ddx
- enchondromatosis: confined to hand (rarely feet). normal height
- maffucci: enchondromatosis + soft tissue haemangiomas
- fibrous dysplasia : diaphysial
lesion. No chondroid matrix. Facial involvement.

314

Maffucci syndrome

1) define
2) imaging, distribution
3) ddx
4) clinical

1) enchondromatosis with soft tissue haemangioma

2) imaging and distribution
- distribution asymmetric 50%
- 50% unilateral
- upper extremity

- typical appearance of enchondroma
- soft tissue haemangiomas : fat, flow void (soft tissue or muscle)
-> phleboliths

3) ddx
- enchondromatosis
- ollier disease

4) clinical
- sporadic nonfamilial
- < 160 cases in the world

315

achondroplasia

1) define
2) list abnormalities
3) ddx
4) gene abnormality

1)
- most common non-lethal short limb skeletal dysplasia
- rhizomelic

2)


head
- large skull
- small craniocervical junction
- platysbasia
- vertebral invagination
- vertical straight sinus

face
- midface hypoplasia
- small/no nasal bone
- dental abnoramlities

spine (differentiator from others!)
- progressive narrowing interpedicular distance !!!
- short pedicles
- platyspondyly
- decreased AP distance
- posterior vertebral scalloping
- bullet shaped vertebrae

Pelvis
- short iliac bone
- short sacroiliac notch
- flat acetabular angle
- champagne glass pelvic cavity
- short femoral neck

hand
- trident hand
- brachydactyly

femur/leg
- short humerus, femur
- coxa valga or varus
- metaphyseal flaring

3) ddx
- thanatophoric dysplasia
-> lethal at birth
- osteogenesis imperfecta: no progressive narrowing of pedicles

4) FGFR gene 3 mutation
- AD
- 1/15-40 k

316

Dystrophic calcification ddx

vascular : venous inssuficiency

infection : granulomatous parasitic, cysticercosis

Tumour:
- osteosarcoma
- synovial sarcoma!!!
- osteoma
- tumour necrosis

trauma
- heterotrophic ossificaiton

autoimmune:
- CTD : SLE, scleroderma, dermatomyositis

drugs
- vitamin D
- milk-alkali syndrome

317

Melorheostosis

1) define
2) imaging
3) ddx
4) clinical
5) association

1) idiopathic nonheriditory condition
- aka leri disease
- with flowing periosteal hyperostosis

2) imaging
- linear and round/lobulated sclerosis
- follow dermatomal pattern
- periosteal hyperostosis
- endosteal hyeprostosis
-> dripping wax pattern

3) ddx
- other dysplasia

4)
- usually incidental
- early adulthood/teenagers
- tx: bisphosphate for pain

5) association
- vascular tumour : haemangioima
- AVM
- glomus

318

Intersex state / disorder of gender development

1) define
2) types

1) condition where there is atypical development of
- chromosomal
- gondal or
- anatomical sex

2) types
female pseudohermatphroditism
- 46 xx
- 2 ovaries
- some virilisation

male pseudohermaphroditism
- 46 xy
- 2 testis
- less virilisation
- i.e androgen insensitivie syndrome

true hermaphroditism

gondal dysgenesis

319

Leiomyoma

1) define
2) imaging
3) ddx
4) types of degeneration
5) complication
6) treatment
7) uterine artery embolisation pre and post imaging

1) benign uterine smooth muscle cell tumour

2)
- large well defined myometrial mass
- uterus enlarged
- bridging vessel sign:

location
- intrauterine :
-> submucosal : 5%. Sessile/pedunculated. Can prolapse into cervix.
-> intramural : most ocmmon
-> subserosal : pedunculated or sessile. Not covered fully by myometrium. Can grow into broad ligament. Bridging vessel sign : vessel/pedicle connecting fibroid to uterus.

- extrauerine : tubal, ovarian, broad ligament, cervical

U/S
- TA for large fibroid. TV beetter spatial resolution.
- hypoechoic
- shadow
- echogenic component : suggest heterogenity (? air) - suggest degeneration.

sonohysterogram:

NECT: iosintence

CECT: homogenous enhancement

MR : low t1, t2.
- contrast not needed to make diagnosis

3) ddx
- polyp
- adenomyoma : MR: enlarged junctional zone with cysts (high t1, T2 signal). lesion is intermediate signal. U/S: thickening of posterior wall of uterus, blurring of endometrial myometrial itnerphase, cysts. Less mass effect (more of a enlarged uterine wall).
- ovarian fibroma : lack of briding vessel differentiate from subserosal fibroid.

4) type of degeneration
- red : high t1 (venous thrombosis)
- cystic : high T2
- hyaline : low T2
- myxoid : enhance
- sarcomatous 0.2-0.3%

5) complication
- pain : by degeneration
- pedunculated : can tort, infarct
- infection
- dysmenorrhea : when co-exist with pelvic inflammatory disease
- infertility : controversial
- problem during gestation: spontaneous abortion, preterm labour, placenta praevia, malpresentation
- placental abruption : highest when in subplacental region
- sarcomatous

6) treatment
- medical : GHRH analogue. Regrow with cessation.
- myomectomy : for those wanting to maintain fertility.
- uterine artery embolisation : majority with improved symptoms.
- hysterectomy is definitive: leiomyoma is leading cause of surgery in woman.

7) uterine artery embolisation
Pre-op MR : assess for contraindication
- nonviable : (degree of enhancement)
- stalk < 2cm : risk of necrosis
- size > 20cm
- submucosal leiomyoma : size/diameter and endometrial interface
- adenomyosis : affect clinical success of embolisation
- ovarian vessel parasitisation

Post-op MR
- may not need if asymptomatic
- assess viability: normally less enhancing (infarcted)
- haemorrhage, small amount of gas, liquefaction, calcification!!!
- parasitised vessel : to assess if repeat embolisation is needed

320

Adenomyosis

1) define
2) imaging
3) ddx
4) path
5) clinical
6) management

1) presence of endometrium in tne myometrium
- associated SM hypertrophy

2) imaging
- assymetric thickening posterior > anterior
- smooth uterine contour
- no focal mass
- subendometrial cysts
- linear striation : radiating from endomtrial into myometrium.

MR:
- blurring thickened junctional zone > 12mm
- increased T1, T2 foci
(best performed late prolferative -early seretroy phase): can be cysts or fingerlike projection extending from endometrium to the myometrium

Hysterosalpingography:
- irregular uterine cavity
- multiple subendometrial cysts

3) ddx
- fibroid
- menstrual and early prolfierative phase : pseudothickening of junctional zone on MR
- endometrial cystic glandular hypertrophy
- myometrial hypertrophy

4) path
- stratum basale of endometrium migrate into myometrium
- unknown etiology
- probable : tamoxifen, brith trauma

5) clinical
- signs: pain, dysmehorrhea, menorrhagia
- clinical: 90% multiparous women
- 50-60 yo

6) management:
- hysterectomy definitive
- conservative NSAID for pain
- hormone : not as effective then endometriosis
- surgery: endometrial ablation, myometrial exision, uterine artery embolisation