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MSK Adult Flashcards

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1
Q

What is the differential diagnosis (Ddx) for diaphyseal lesions in young patients?

A

Osteoid osteoma, enchondroma, simple bone cyst, fibrous dysplasia, adamantinoma, Ewing sarcoma, LCH

LCH refers to Langerhans cell histiocytosis.

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2
Q

What is the differential diagnosis (Ddx) for diaphyseal lesions in adult patients?

A

Metastasis, myeloma/plasmacytoma, lymphoma, osteomyelitis, bone infarct, Brown tumour

Brown tumour is associated with hyperparathyroidism.

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3
Q

What is the nuclear medicine finding characteristic of osteoid osteoma?

A

Double density sign

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4
Q

What are the three concentric parts of the pathology of osteoid osteoma?

A

1 - nidus, 2 - fibrovascular rim, 3 - surrounding reactive sclerosis

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5
Q

What are the management options for osteoid osteoma?

A

NSAIDs, RFA, cryoablation, core drill excision, high intensity focused ultrasound, laser photocoagulation, surgical resection

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6
Q

What is the differential diagnosis (Ddx) for metaphyseal lesions in young patients?

A

Cortical desmoid, osteoblastoma, osteosarcoma, enchondroma, chondrosarcoma, ABC, UBC, NOF, chondromyxoid fibroma, desmoplastic fibroma, osteomyelitis

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7
Q

What is the differential diagnosis (Ddx) for spinal tumors in osteoblastoma?

A

Osteoid osteoma, osteochondroma, GCT, ABC, LCH, haemangioma, lymphoma, sarcoma, chordoma, mets, multiple myeloma

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8
Q

What is the management for osteoblastoma?

A

Curettage +/- cryotherapy, cauterisation, en bloc surgical excision with pre-operative embolisation

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9
Q

What is the differential diagnosis (Ddx) for epiphyseal lesions in young patients?

A

Chondroblastoma, ABC, osteomyelitis

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10
Q

What are the epiphyseal equivalents for chondroblastoma?

A

Calcaneus, patella, carpals, greater/lesser trochanters, apophysis

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11
Q

What is the management approach for chondroblastoma?

A

Curettage and packing, RFA may be used

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12
Q

What is the differential diagnosis (Ddx) for exophytic lesions in osteochondroma?

A

BPOP, juxtacortical chondroma/chondrosarcoma, desmoid, surface osteosarcoma, osteoma, melorrheostosis

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13
Q

What are the associations with osteochondroma?

A

Hereditary multiple exostosis, Trevor disease

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14
Q

What is the incidence of malignant transformation in solitary versus hereditary osteochondroma?

A

1% if solitary, 5-25% if hereditary

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15
Q

What are the complications associated with osteochondroma?

A

Neurovascular impingement, spinal cord compression, bursitis, OA, fracture, pain

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16
Q

What are the features of sarcomatous degeneration in osteochondroma?

A

Growth, cortical destruction, pain, soft tissue mass, cartilage cap >1.5cm

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17
Q

What are the associations with enchondroma?

A

Ollier, Maffucci (haemangiomas)

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18
Q

How can you distinguish between an enchondroma and low-grade chondrosarcoma?

A

Chondrosarcomas are typically >5-6cm, cortical breach, deep endosteal scalloping, soft tissue component, bone scan uptake, outside hands and feet

Particularly in spine/pelvis/ribs, often a middle-aged patient presenting with pain.

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19
Q

What is the differential diagnosis (Ddx) for expansile lytic lesions?

A

Chondroblastoma, ABC, NOF in young; mets, plasmacytoma, GCT, brown tumour in adults

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20
Q

What is the pathology of giant cell tumor (GCT)?

A

Occurs at the metaphyseal side of growth plate in a skeletally mature patient, overexpression of RANK/RANKL by stromal cells leading to hyperproliferation of osteoclast-like giant cells

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21
Q

What is the management for giant cell tumor (GCT)?

A

Curettage with local adjuvants, en bloc resection, thermocoagulation, cryotherapy

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22
Q

What is the differential diagnosis (Ddx) for rib lesions?

A

Fibrous dysplasia, ABC, metastasis/multiple myeloma, enchondroma

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23
Q

What percentage of ABCs are secondary?

A

1/3rd

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24
Q

What is the difference between unicameral bone cyst (UBC) and aneurysmal bone cyst (ABC)?

A

UBC: fallen fragment sign, central, thin sclerotic margin; ABC: eccentric, no margin

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25
What is the differential diagnosis (Ddx) for wide thick ribs?
Fibrous dysplasia, healed fractures, thalassaemia, Paget, TS, achondroplasia, mucopolysaccharidoses
26
What are the polyostotic syndromes associated with fibrous dysplasia?
McCune Albright, Mazabraud
27
What is the pathology of fibrous dysplasia?
Developmental anomaly where osteoblasts fail to develop, marrow replaced by fibro-osseous tissue
28
What are the markers for fibrous dysplasia?
Elevated ALP
29
What are the complications of fibrous dysplasia?
Malignant degeneration in <1% (in Mazabraud) into osteosarcoma, fibrosarcoma, UPS, chondrosarcoma
30
What is the differential diagnosis (Ddx) for lucent lesions with sclerotic margins?
Bubbly lesions (ABC, fibrous dysplasia, NOF, UBC), chondroblastoma, osteoblastoma, Brodie's abscess, interosseous lipoma, chondromyxoid fibroma, liposclerosing myxofibrous tumour
31
What are the associations with non-ossifying fibroma?
Jaffe-Campanacci syndrome, NF1, cafe au lait spots, mental retardation, hypogonadism
32
What is the finding associated with bone infarct?
Double line sign - T2 hyperintense inner ring of granulation tissue and hypointense outer ring of sclerosis
33
What is the differential diagnosis (Ddx) for aggressive bone lesions?
Ewing, osteomyelitis, LCH, lymphoma/leukaemia, metastasis
34
What is the primary age group for osteosarcoma?
10-20 years (75% before 20 years)
35
What is the management for osteosarcoma?
CT/MRI/bone scan for staging, look for skip lesions, tertiary referral for biopsy
36
What are the associations with osteosarcoma?
Retinoblastoma, Li-Fraumeni, radiation, Paget
37
What are the subtypes of osteosarcoma?
Conventional, surface, telangiectatic
38
What is the age group for chondrosarcoma?
50-70 years
39
What are the subtypes of chondrosarcoma?
Conventional, dedifferentiated, myxoid, clear cell, mesenchymal
40
What are the primary cancers for lytic bone metastases?
Renal, lung, thyroid, melanoma
41
What are the primary cancers for sclerotic bone metastases?
Prostate, breast, TCC, carcinoid, GIT
42
How would you perform a bone biopsy?
Consent, sedation, lignocaine, 18G coaxial if cortex breached, 16G bone drill if cortex intact
43
What is the differential diagnosis (Ddx) for sacral lesions in multiple myeloma?
Plasmacytoma, GCT, ABC, mets, chordoma, neurogenic tumour
44
What are the lab findings in multiple myeloma?
Monoclonal gammopathy, Bence Jones protein, hypercalcaemia, decreased/normal ALP
45
What are the complications of spinal radiotherapy in multiple myeloma?
Radiation myelopathy, osteosarcoma, osteopenia, fractures
46
What is the most sensitive MRI sequence for osteomyelitis/septic arthritis?
T1
47
What are the common organisms causing osteomyelitis/septic arthritis?
Staph aureus, E. coli, pseudomonas, klebsiella, salmonella, H. influenzae
48
What radiotracer is used in bone scans for osteomyelitis?
Tc99m HDP or MDP
49
What are the types of sarcomas?
Undifferentiated pleomorphic sarcoma, liposarcoma, rhabdomyosarcoma, leiomyosarcoma, synovial sarcoma, malignant peripheral nerve sheath tumour, extraskeletal osteo/chondrosarcoma
50
What are the histological subtypes of undifferentiated pleomorphic sarcoma (UPS)?
Storiform-pleomorphic, myxoid, inflammatory, giant cell, angiomatoid
51
What is the management approach for sarcoma?
Stage, orthopaedic/sarcoma MDT to plan biopsy tract
52
What is the differential diagnosis (Ddx) for soft tissue calcification?
Vascular, metabolic, autoimmune, neoplasm, previous trauma
53
What are the histopathological stages of myositis ossificans?
1st month - granulation tissue, 2nd month - mineralised osteoid, 3rd month - mature lamellar bone
54
What is the histological zonal organization in myositis ossificans?
Peripheral mature lamellar bone, intermediate osteoid region, central immature non-ossified fibroblasts
55
What is the difference between calcification and ossification?
Calcification = calcium salts buildup; ossification = laying down new bone material
56
What is metaplasia?
Change of one mature/differentiated cell type to another differentiated cell type
57
What should you do if a GP asks to biopsy myositis ossificans?
Don't biopsy; it will look like osteosarcoma
58
What is the epidemiology of elastofibroma dorsi?
65-70yo women
59
Which is more common in elastofibroma dorsi, unilateral or bilateral?
Unilateral (70%)
60
What are the types of fibromatosis?
Palmar, plantar, knuckle pads, lipofibromatosis, desmoid, aggressive fibromatosis, Peyronie disease
61
What is the pathology of fibrolipomatous hamartoma?
Hamartomatous overgrowth of mature fat & fibroblasts within epineurium
62
Where else in the body can hamartomas occur?
Bronchial, pulmonary, cardiac, hepatic, biliary, spleen, hypothalamus, subependymal, GIT polyps, breast
63
What is the epidemiology of erosive OA?
More common in postmenopausal women; non-erosive OA is more common in men <50 and women >50.
64
What are the findings associated with RA?
Marginal erosions, pencil-in-cup deformity, proximal symmetrical joint space narrowing, fusiform soft tissue swelling, juxta-articular osteopenia, swan neck, Boutonniere, ulnar deviation, subcutaneous nodules, rice bodies.
65
What is the differential diagnosis (Ddx) for RA?
* Psoriasis * Erosive OA * Reactive arthritis (more in feet than hands)
66
What is the pathology of RA?
Chronic autoimmune disorder with inflammation of synovium, dense inflammatory infiltrate forming a pannus, increased osteoclast activity leading to periarticular erosions, eventual ankylosis.
67
What are the markers for RA?
* RF * Anti-CCP
68
What are the extraskeletal manifestations of RA?
* Skin (nodules) * Lungs (nodules, ILD) * Vasculitis * Felty syndrome (splenomegaly, neutropenia) * Caplan syndrome (pneumoconiosis)
69
What is the ball-catcher view used for in RA?
To detect early RA changes in radial aspects of base of phalanges, triquetrum, pisiform.
70
What are the findings associated with psoriasis?
* Pencil in cup * Periostitis * Dactylitis * Acro-osteolysis * Arthritis mutilans * Ivory phalanx * Sacroilitis
71
What are the other seronegative spondyloarthropathies?
* Reactive arthritis * Enteric arthritis * Ankylosing spondylitis
72
What is the differential diagnosis for arthritis with periosteal reaction in psoriasis?
* Reactive arthritis * Septic arthritis * JIA
73
What percentage of patients with psoriasis develop arthritis?
25%; skin changes precede arthritis in 65%.
74
What would you write on the pathology form if you performed a joint aspiration for gout?
MCS + crystals.
75
What are the microscopy findings in gout?
Monosodium urate crystals - needle-shaped, negatively birefringent on polarized light.
76
What are the risk factors for gout?
* Hyperuricaemia * Male * >40 years old * Alcohol * Obesity * Dehydration * Diuretics * Malignancy
77
What is the pathology of gout?
Hyperuricaemia due to abnormal purine metabolism or reduced excretion, or from secondary disorders (neoplasm, lymphoproliferative disease, ESRF, drugs).
78
What is the physics of dual energy CT?
Uses two separate x-ray photon energy spectra offset at 90 degrees to separate materials based on different attenuation properties.
79
What are the common locations for chondrocalcinosis in CPPD?
* Knee (medial meniscus, patellofemoral joint) * Wrist (TFCC, lunotriquetral ligament) * Pubic symphysis * Spine (crowned dens, intervertebral discs)
80
What are the microscopy findings in CPPD?
Calcium pyrophosphate dihydrate - rhomboid-shaped, weakly positively birefringent on polarized light.
81
What are the causes of CPPD?
* Idiopathic * Hereditary (AD) * Haemochromatosis * Hyperparathyroidism
82
What are the common locations for HADD (calcific tendinitis)?
* Shoulder * Gluteus medius tendon * Rectus femoris tendon * Longus colli
83
What is the treatment for calcific tendinitis in HADD?
Barbotage.
84
What are the differential diagnoses for femoral notch enlargement in haemophilic arthropathy?
* JIA * RA * Psoriatic arthritis * Postoperative * PVNS
85
What are the subtypes of haemophilia?
* Haemophilia A (factor 8 deficiency) * Haemophilia B (factor 9 deficiency) * Haemophilia C (factor 11 deficiency)
86
What are the nuclear medicine findings in complex regional pain syndrome?
Diffuse uptake, hot on all 3 phases.
87
What are the findings associated with hyperparathyroidism?
* Subperiosteal bone resorption * Floating teeth * Distal clavicular erosion * Sacroiliac/pubic symphysis erosion * Acro-osteolysis * Rugger jersey spine * Osteopenia * Brown tumour * Salt and pepper skull * Looser zones * Chondrocalcinosis * Superior/inferior rib notching * Superscan
88
What is the differential diagnosis for acro-osteolysis in hyperparathyroidism?
* Psoriasis * Thermal injury * Diabetic neuropathy * Scleroderma * Raynaud's * PVC exposure
89
What is the differential diagnosis for superscan in hyperparathyroidism?
* Diffuse mets * Myelofibrosis * Leukaemia/lymphoma
90
How can you confirm a brown tumour in hyperparathyroidism?
Intense uptake on bone scan.
91
What are the causes of hyperparathyroidism?
* Primary (parathyroid hyperplasia/adenoma) * Secondary (renal osteodystrophy, vitamin D deficiency) * Tertiary
92
What is the pathology of hyperparathyroidism?
Increased PTH leads to increased calcium resorption in kidneys and increased release of calcium from bones.
93
What are the normal bone mineral density scores?
T-score: osteopenia is between -1 and -2.5, osteoporosis is less than -2.5.
94
How do you differentiate Paget's disease from blastic mets of the skull?
Paget's disease demonstrates cortical thickening.
95
What is the pathology of Paget's disease?
Lytic (osteoclast), intermediate (osteoclasts/osteoblasts), sclerotic (osteoblasts); polyostotic in 85%.
96
What are the biochemical markers for Paget's disease?
* Elevated serum ALP * Elevated urine hydroxyproline * Normal calcium/phosphate levels
97
What are the complications of Paget's disease?
* Local (deformity, fracture, 1% risk of osteosarcoma) * Systemic (high output cardiac failure, hyperparathyroidism, extramedullary haematopoiesis)
98
What is the differential diagnosis for symmetrical periosteal reaction in hypertrophic osteoarthropathy?
* Paraneoplastic * Chronic venous insufficiency * Pachydermoperiostosis * Thyroid acropachy * Hypervitaminosis A
99
What are the nuclear medicine findings in hypertrophic osteoarthropathy?
Diffuse linear periosteal uptake.
100
What diseases are associated with hypertrophic osteoarthropathy?
* Lung cancer * Osteosarcoma mets * Mesothelioma * Solitary fibrous tumour * IBD * Coeliac * Lymphoma
101
What is the normal atlantodental interval in atlantoaxial subluxation?
<3mm in adults, <5mm in children.
102
What are the normal basion-dens and basion-axial intervals in adults?
BDI >10mm, BAI >12mm.
103
What are the associations of atlantoaxial subluxation?
* T21 * Morquio * OI * Marfan * NF1 * Arthritis (RA, PA, reactive, AS, SLE) * CPPD * HADD * Trauma * Surgery * Retropharyngeal abscess
104
What are the causes of retro-odontoid pseudotumour?
* Trauma * RA * CPPD * HADD * Gout * Amyloid * Tenosynovial GCT * OPLL
105
What are the subtypes of dens fracture?
* Type 1 - upper (potentially unstable) * Type 2 - base (unstable, high risk of non-union) * Type 3 - lateral masses (best prognosis)
106
What are the differences between flexion and extension teardrop fractures?
Flexion: mid/lower cervical spine, severe flexion/compression forces, unstable. Extension: upper spine (C2), hyperextension injury, stable in flexion, unstable in extension.
107
What are the X-ray findings in Chance fracture?
Empty vertebral body sign, widened interpedicular distance/interspinous spaces.
108
What are the associations of Chance fracture?
Duodenal/pancreatic injury.
109
How would you perform a perineural injection for disc sequestration?
Plan approach, consent, prone in CT, sterile technique, 9cm 22G spinal needle into perineural space, confirm position with 1mL contrast, inject mixture of dexamethasone + bupivacaine.
110
What organisms are commonly associated with spondylodiscitis?
* S aureus (60%) * Strep viridans (IVDU) * E coli * TB * Fungal
111
What is the difference between Pott disease and conventional discitis?
Pott disease is subligamentous beneath anterior longitudinal ligament, involves multiple non-contiguous levels, disc space preservation.
112
How often do TB discitis patients get chest manifestations?
50%.
113
What is the differential diagnosis for gibbus deformity?
* Mucopolysaccharoidosis * Apert * Achondroplasia * Compression fracture * TB * Scheuermann disease
114
What is the management for spondylodiscitis?
Drain any collection, IV antibiotics (targeted to MCS).
115
What is the difference between syndesmophytes and osteophytes in ankylosing spondylitis?
Syndesmophytes involve a spinal ligament or annulus fibrosis; osteophytes occur at the synovial margins of vertebral bodies.
116
What are the associations of ankylosing spondylitis?
* Anterior uveitis * Psoriasis * IBD * Upper lobe ILD * Aortitis
117
What is the differential diagnosis for sacroilitis?
* Bilateral symmetrical (IBD, AS, RA) * Asymmetrical (psoriasis, reactive, gout, OA) * Unilateral (infective, SAPHO)
118
What is the epidemiology of ossification of the PLL?
Elderly Asian (Japanese) males.
119
What are the associations of ossification of the PLL?
* DISH * Ossification of the ligamentum flavum * Ankylosing spondylitis
120
What are the complications of ossification of the PLL?
* Canal stenosis * Ligamentous/cord injury * Fractures * Cord/anterior horn compression and motor neuropathy
121
What is the differential diagnosis for sternocostal changes in SAPHO?
* CRMO * Osteomyelitis
122
What is the differential diagnosis for ivory vertebra in SAPHO?
* Paget * Mets * Infection * Haemangioma * Lymphoma
123
What does SAPHO stand for?
Synovitis, acne, pustulosis, hyperostosis, osteitis.
124
What is the nuclear medicine finding in SAPHO?
Bull's head sign.
125
What is the pathology of SAPHO?
Due to propionibacterium acnes, causing costoclavicular ligament ossification and sternoclavicular joint arthropathy.

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