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Radiodiagnosis Cirriculum > MSK > Flashcards

Flashcards in MSK Deck (132):
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

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

1)
- vertebral anomaly due to failure of normal segmentation

2)
- lumbar > cervical > thoracic

Types
- hemivertebrae :
- butterfly vertebrae : failure of fusion of lateral half of vertebral body
- block vertebrae : deformed fused vertebrae, fused posterior element, ribs

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, Sprengel deformity, spina bifida, hemivertebrae

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

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

2)
- 25% bilateral
- check contralateral foot

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

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

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

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

- 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 endplate
- beneath the 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: 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

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 prudential 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,

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

Psoariasis

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) FEENA!!!
- fluffy periostitis (erosion/periostitis)
- enthesitis
- erosion
- 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

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

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.

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) type of soulder instability

- TUBS
- AMBRI

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

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

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

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 pads 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

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

- carpal tunnel : nerve entrapment at carpal tunnel

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 : posterior cortex (shin splint)
- fibula : proximal to lateral malleolus
- ankle: calcareous, navicular (often bilateral)
- foot : metatarsals (2nd/3rd)
- upper extremity/rib: uncommon

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

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

3) imaging
- regional osteoporosis
- soft tissue trophic change

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

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)

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