TheMusculoskeletalSystem

CommonProblems
in

AmbulatoryCareMedicine
AnAdventureinImaging

AdrZpresentation
Commonnontraumaticand
traumaticconditionsofthe
MusculoskeletalSystem
in
AmbulatoryCareMedicine
Docendodiscimus
Senecasaidthat
Inthe21stcentury,Radiologyiswhereitsat!
Isaidthat

MS3,AA,NP201415

ABigPawProduction

Inassociationwith

PetitPawPresents

FuzzyPawFeatures

And

AndTheAdorableAssociates
CanineContributionsfromour
OPTOMISTICOSTEOLOGIST:
Hiya!BONESarereally,really
BONES
interestingandalsovery
YUMMY!CanIhavethemwhen
YUMMY
weredone?

Written,editedandcritically
criticizedbyourFANTASTIC
FELINE:
Salve,andyouaremostwelcome
toMYBenevolentBountiful
MY
BuonAvventuraofBONES.
BONES.

Andnow,anImportantMessage

BroughttoyoubyBigPawsOfficialSpokesdog.
Hi!ImNonobaddog.Nicetomeetya!
Nonobaddog.

ConflictofInterest
Ihavenofinancialrelationshipsorsupportfrom
commercialintereststodisclose.

Andnow,basicconceptsof
MSKImaging

TheMSKImagingConcepts
InAmbulatoryCaremusculoskeletal
problems,wealmostalwaysstartwith
aConventionalRadiologySeries(also
calledCR,plainfilms,xrays).

TheCRseriesconsistsof:

Alljoints:AP,lateral,oblique(wristhasanadditional
scaphoidview)
Longbones:APandlateral
Spine:APandlateral(occasionallyobliques)
Pelvis:AP

TheMSKImagingConcepts
IfCRdoesnotresolvethemanagementquestion,we
proceedtoadvancedimaging.
CT:Excellentforhardtoseeareaslikepelvis,scapulaandsacrum,andforcorticalbonelesions;
tumormatrix,andcalcifications
MRI:Excellentforsofttissueevaluation,marrowlesions,jointdetail,neuraltissue
Ultrasound(forsomesofttissuesandjoints),andNuclearMedicine(SPECTbonescansand
PET,mainlyformalignancy)arealsousefulinselectiveclinicalsituations.

Theadvancedimagingmodalityonechooses
thereforedependsuponthespecificsofthecase.

Andnow:SomebasicconceptsofAnatomyand
PathologyoftheMusculoskeletalSystem

TheMusculoskeletalSystem
Anatomicallyconsistsof:
Softtissues:muscle,ligament,tendon,
bursa,skinandsubcutaneoustissue
Joints:capsule,synovium,meniscus,
articularcartilage,jointcavity
Intervertebraldisc
Bones:Periosteum,corticalbone,
cancellousbone,medullarycavity

AnatomyofaBone:Adult

Diaphysis
Metaphysis
Epiphysis
Apophysis

Corticalbone
Cancellousbone
Periosteum

AnatomyofaBone:Child:more
elastic

Diaphysis
Metaphysis
Apophysis
PHYSIS(growthplate)
Epiphysis

AnatomyofaJoint

Fibrouscapsule
Synoviallining
Articularcartilage
Subchondralbone
Jointcavity**

Pathologyofthemusculoskeletalsystem
Pathology
Manydifferenttypesofpathologicallesions
canaffectthebonesandsofttissuesofthe
MSK:
Trauma
Neoplasm
Infection
Metabolic
Congenital/developmental

Trauma
Fractures:thingstoconsider

Displacement
Angulation
Overriding
Distraction
Impaction
Comminution
Jointinvolvement
Openorclosed
Neurovascularinjury
Pathologicfractures(afracturethrough

Stressfractures(repetitivemicrotrauma)

adiscretebonelesion)

Fractures:thingstoconsider
Nondisplaced

Overriding

Displaced
Comminuted:morethan
2parts
Angulated

Distracted:pulled
apart
Impacted:smushed
together

Fractures:thingstoconsider

Articular:fracturethatextendsintoajoint
Open:skinoverlyingthefractureisnotintact
Pathologic:fracturethroughafocallesion
Stress:repetitivemicrotrauma;fatiguetype(abnormal
stressonnormalbone)andinsufficiencytype(normalstresson
abnormalbone,usuallyosteoporosis)

Malunion:heals,butnotinanatomicposition
Delayedornonunion:takestoolongtoheal,or
doesnthealatall

PediatricMSKInjuries
Pediatricorthopedicinjuriescanbeidenticalto
thoseinadults,especiallyinolderchildrenand
adolescents.However,therearethreetypesof
MSKinjuriesthatareexclusivelyseeninthe
pediatricpopulation,especiallyinyounger
children:
Tensioninjuries:abendingforceperpendicularto
Tensioninjuries
thelongaxisofthebone
Compressioninjuries:acompressionforcealong
Compressioninjuries
thelongaxisofabone(frequently,FOOSH)
Growthplatephysisinjuries
Growthplatephysisinjuries (SalterHarris)

Pediatrics:TensionInjuries
Common,especiallyoftheshaftsof
theradiusandulnafromafall
ontheoutstretchedarm..
Tensioninjuriesarea
continuum:theinjuryis
directlyproportionaltothe
amountofFORCE:
amountofFORCE
Elasticdeformity
Plasticdeformity
Incompleteofgreenstick
fracture
Completefracture
Theyareusuallytreatedwithcast
immobilizationfor6weeks.

Pediatrics:TensionInjuries
TheinjuriesareacontinuumdependentupontheamountofFORCE.

Elasticdeformity

Plasticdeformityorbowing:
staysthatway

Incompleteorgreenstickfracture

Completefracture

Pediatrics:Compressioninjuries:
morecommonb/cpplextends
outextremitiestocatchafall.
Torusorbucklefracture
Common,especiallyofthe
distalradiusfromafallon
theoutstretchedhand.
Canbesubtle.Lookforany
corticalmarginconvexity.
Treatedwithcast
immobilizationfor6
weeks.

Pediatrics:GrowthPlateInjuries
SalterHarrisClassification

Common.Arms,legs,pelvis.
AllSalterHarrisinjuriesinvolve
anunfusedgrowthplate
(physis)inanimmature
skeleton.
TypesofSalterHarrisinjuries:
SHIPhysisinjuryonly,nondisplaced to
completelydisplaced
SHIIPhysisinjuryandmetaphysis
fracture
SHIIIPhysisinjuryandepiphysis
fracture
SHIVPhysisinjuryandbothmetaphysis and
epiphysisfractures
SHVPhysiscrushinjury

AllSHtypescandisruptbonegrowthduetothephysis
injury;SHVhastheworstprognosis.
SHIIIandIVcanalsodisruptjointcartilage,causing
secondaryosteoarthritis.

Pediatrics:GrowthPlateInjuries
SalterHarrisClassification
Normal

III

IV

II

DislocationsEmergency
Dislocationsarecommonin
adultsandchildren.They
mayoccurwithorwithout
fractures.
Theyarealwaysan
emergency,andmustbe
emergency,
reduced(relocated)assoon
aspossibleinorderto
minimizefurthercapsule
andligamentdamage,and
AVN.
Usuallyobvious,theycan
occasionallybesubtle.

AGeneralRuleforringbones
Twobonesthataretightlyboundat
proximalanddistaljoints,
mainlythetibiafibulaand
radiusulna,formanelongated
ringlikesemirigidstructure.
Ifoneboneisforeshortenedbya
bendingdeformityorfracture
withdisplacement,angulation
oroverriding,thentheother
bonemustfractureorbendto
accommodatethelossof
length,oreithertheproximalor
distaljointmustdislocate.

BoneLesions
Osteolytic:boneisdestroyed(metastaticbreast
cancer)darkboneistakenaway.
Osteoblastic:abnormalboneisproduced
(prostate)lightb/cboneisadded
Mixed:thereisbonedestructionandthe
productionofabnormalbone

Bonedestruction:
Osteolyticpatterns

Theosteolyticpatterns
correlatewiththe
aggressivenessof
aggressiveness
abonedestroyinglesion,
notaspecific
pathologicprocess:
Geographic:least
Motheaten:intermediate
Permeative:mostaggressive

Geographic:
least
aggressive
distinctsharply
definedmargins

Motheaten:
intermed
aggresive

marginsarenotwelldefined

Permeative:
Most
aggressive

veryindistinctmargins

Bonedestruction:
Osteolyticpatterns

Geographic:leastaggressive

Motheaten:intermediate

Permeative:most

Bonedestruction:
Osteolyticpathology

Manydifferentpathologicalprocessescan
causeanosteolyticlesion,butmostoften
theyaredueto:
Neoplasmorneoplasmlikelesions,benign
ormalignant(metastaticorprimary)
Osteomyelitis,acuteinfectionsofbones
causedbybacteriaorfungi
Lesscommonetiologies
Boneinfarcts(early)
Radiationtherapy(early)
Fractures(acuteandofunusualconfiguration)
Severaluncommonandrarebonediseasesincluding
congenital/developmentalandmetabolicdisorders(eg
hyperparathyroidism,Gauchersdisease)

Permeativeosteolyticpattern

Osteoblasticlesions
Osteoblasticlesionscauseproduction
ofabnormalbone.Theyoccurwith
severaltypesofboneproducing
diseases.Theyaresometimes
referredtoasscleroticlesions.
Osteoblasticlesions;themost
commonetiologies:
Neoplasmandneoplasmlike,
benignandmalignant(metastases
andprimary)
Osteomyelitis,chronicinfectionsof
bonecausedbybacteriaandfungi
Lesscommonetiologies
Boneinfarcts(late)
Radiationtherapy(late)
Fractures(healing)
Severaluncommonandrarebonediseases{eg
Pagetsdisease(latephase),renalosteodystrophy,
myelosclerosis}

Osteoblasticpattern:Osteoblasticmetastasiswith
pathologicvertebralcompressionfracture

Periostealreactions
Thenormalperiosteumisnotvisible.With
pathologicprocesses,theperiosteummay
thickenandcalcify,andsobecomevisible
onCR.Ittakesatleast10daysbeforethe
periosteumbecomesvisibleonCR,less
onCT,muchlessonMRI.Thereactionis
oftennonspecific,butthepatterntype
usuallyindicateswhethertheconditionis
activeorindolent.Laminatedorsunburst
indicateactivediseases,thickandfused
withthecortexindicateindolent
conditions.
Etiology:
Malignantbonetumors(osteosarcomaand
Ewingstumor,forexample)

Osteomyelitis
Fractures,healingphase
Severaluncommonandrareconditions(eg
VitaminCdeficiency)

ClinicalSituationsthatare
ORTHOPEDICEMERGENCIES
Source:AndrewSchwartz,MD,UCLAOrthopedicSurgery

CasesyoumustimmediatelyrefertoanOrthopedicSurgeon:
Compound/openfractures.Iftheskinoverafractureisnotintact,evenifitisa
Compound/openfractures
smalllacerationorasmallpuncturewound,youmustassumeitisanopen
fracture,andthereforearouteformicroorganismstoreachtheboneand
causeinfection..Thewoundwillneedurgentirrigationanddebridementinthe
ORandantibioticsstartedwithin6hoursafterinjury.
Compartmentsyndrome.Duetoeithervenousoutflowobstructionfromatight
Compartmentsyndrome
castordressing,orduetotheinflowofedemaorhemorrhagefromsofttissue
injury.Muscleandnervedeathwilloccurwithin8hoursifthecompartmentis
notsurgicallydecompressedbyORfasciotomy.
Openjointinjury.IfthereisajointinjuryandairinthejointisseenonCR,or
Openjointinjury
thereisadeepappearinglacerationorpuncturewoundoftheskinoverlying
thejointwithnoassociatedadjacentfracture,orthereisanyskindisruption
withafractureintheproximityofthejoint,thejointisatriskforinfectionand
mustbeexploredandirrigatedintheORandantibioticsstartedwithin6
hours.

ClinicalSituationsthatare
ORTHOPEDICEMERGENCIES
CasesyoumustimmediatelyrefertoanOrthopedicSurgeon:
Caudaequinasyndrome.Syndromeiscausedbytrauma,infection,tumor,
Caudaequinasyndrome.
congenitaldeformityorstenosisduetodegenerativespondylosisorothercauses,
whichinvolvesthecaudaequinaandresultsinalowermotorneurondeficit.
Presentationcanincludelowbackpain,saddleanesthesia,bowelorbladder
dysfunction,lowerextremitypain,lowerextremitymotororsensorychanges.
Symptoms/signsvaryfromsubtletomarked.Emergencyevaluationisindicated.
Treatmentdependsuponthecauseandthedegreeofneurologicalimpairment.
Hipjointdislocation.Thisisdramaticandsoyouareunlikelytoencounteritinan
Hipjointdislocation.
outpatientsetting,butitisincludedforcompleteness.Thereisa6hourwindow
beforepermanentdamageoccurstothebloodsupplyofthefemurhead
(avascularnecrosis/AVN).Prolongeddislocationcanalsopermanentlyinjurethe
sciaticnervebycompressingit.
Anyjointdislocation:Alldislocationsmustbereduced(relocated)assoonas
Anyjointdislocation
possibletoavoidfurtherdamagetothejointstructures,ligaments,tendons,and
adjacentbones(ieAVN).Ifyouarenottrainedtodothereductionthenreferto
orthopedicsurgeryimmediately.

OK,thatwasntsobad.
Andnow.
letsbringonthe
Bones!
Bones!
(andtheotherMSKstuff,too!)

DogintheHat

ThisisaCaseBasedPresentation
Upperextremity
Spine
Lowerextremity

Therearetwelvecasestotal

TheUpperExtremity
ShouldertoShoulder
AllThingsWrist
ManoaMano

TheFirstCase
40y/ofemale.Avidtennis
player.
Chronicshoulderpainand
limitedROM,increasing
over10years
Notrauma
CRshoulderserieswas
obtained.HereistheAP
view:

OK,howaboutacloser
look

Diagnosis?

Whatsthis?

RotatorCuffDisease

AKA:impingementsyndrome
ThisisPhaseThreeorEnd
Stage:completelossofrotator
cuffstabilization.Notethe
narrowacromionhumerus
spaceandcalcifiedrotatorcuff
tendonremnant(calcific
tendonopathy).Advancedrotator
cuffdiseasecandamagethearticular
hyalinecartilageoftheadjacentjoint
andleadtosecondaryosteoarthritis..

Calcifictendonopathywithchronicrotatorcufftearis
sometimescalledMilwaukeeshoulder.

Rx:Symptomatic,PT

ShoulderConditions
inCommunityClinicalPractice
Impingementsyndrome
Rotatorcuffdisease
Calcificbursitis
Adhesivecapsulitis
SLAPlesions
Bicepstendonosis
Osteoarthritis
Rheumatoidandotherinflammatory
arthritis
CPPDcrystaldepositiondisease
(Pseudogout)

Fracturesanddislocations
Infectionandneoplasm
Radiculopathyfromcervicalspine
disease

TheCase

20y/ofemale
FellonoutstretchedhandPatienthas
pain,butthinkssheonlysprained*
herwrist.(sprainedconcernsthe
ligament)
However,onyourexam,youfind
SnuffBoxtenderness.scaphoid
fractureuntilprovenotherwise
So,youorderaCRwristseries.
LookattheCRobliqueview.Isthe
patientcorrect:isitonlyasprain*?

*Asprainisatearofaligamentandcanhave
sprain
consequencesthatrangefromminortovery
major.

IsthisanegativeXray:i.e.fractureno.sprainyes?

NO!ItisaPositivexray:i.e.,fractureyes,
Positive
sprainno!
Shehasascaphoidfracture!

Rx:Immobilizeinthumbspica
castfor6weeks
Riskofdelayedornonunion,
andespeciallyofAVNofthe
proximalpolewithsecondary
osteoarthritisandchronicwrist
instability;Thesearevery
seriouscomplications,so,ifa
scaphoidfractureisuncertain,
immobilizethewristandrepeat
theCRinoneweek.
Oh:Arethereanyother
fractures?(Dontfallintothe
SearchSatisfactiontrap!)

Yes!Shealsohas

Acapitatefracture
Adistalradiusfracture

Mostscaphoidfracturesarevisible
onthefirstCR.However,a
significantminorityarevery
subtleoroccult.Thesescaphoid
fracturesusuallybecome
visibleonCRwithin2weeks.
But,ifyouneededtoknowNOW
whetherornotthescaphoid
wasfractured,andtheCRwas
equivocalornegative,what
wouldyouorder?

MRIGoldstandard
MRIisabout100%sensitiveand
specificforscaphoidfracturesandis
positiveveryearly(minutestoafew
hoursafterthefall).So,essentially,
apositiveMRIrulesinanda
rulesin
negativeMRIrulesoutascaphoid
rulesout
fracture.Butitisexpensiveandnot
alwaysreadilyavailable.MDCT
maysoonbesensitiveenoughtouse
insteadofMRI.
.
Mostofthetimewerelyonrigid
immobilizationbyathumbspica
splintandaoneweekfollowup
evaluationinuncertaincases.
Occasionally,asecondfollowupat
twoweeksisneedediftheCR
findingsarenotdefinitivebut
symptomsarestillpresent.

SCAPHOID
Fracture

MRIcoronalwrist.POSITIVE

TheCase

52y/ofemale
12yearhxofflareupsofhand
pain,jointswelling(especially
PIPs),erythema,andheat.Joint
painandstiffnessarepresenton
awakeningandlastseveralhoursa
day,andaremoderatelysevere.
Shehasafternoonfatigueand
occasionallyfever,andingeneral
feelssick.Shehasnotedsome
softsubcutaneousnodulesonthe
dorsumofherhands.
Bothhandsaresymmetrically
involved.
CRhandserieswasveryabnormal.
HereistheAPview:

DIAGNOSIS?

RheumatoidArthritis

Averycommondisease(1%ofpopulation);females
morethanmales(2.5:1).Onsetatanyagebutmost
commonly3055years.
RAisasystemicInflammatoryArthritis,
rheumatoidfactor(RF)positive.Inadditiontojoint
involvement,therecanbeskin,eye,andcardio
thoraciclesions,vasculitisandanemia.
Multipleerosions(usuallymarginal),perijoint
osteoporosis,andmarkeduniformjointspace
narrowinganddestructionwithlittlebonerepairare
present,especiallyPIP,MCP,intercarpals,spine,SIjoints.
Rx:Severalclassesofdrugs(DMARDs,steroids),
surgery

WhataretheothermembersoftheRFseropositivearthropathy
group?

TheSeropositiveArthropathies
Rheumatoidarthritis.RAcaninvolveanyjoint,largeorsmall,buthandsaremost
common

Systemiclupuserythematosus.MSKinvolvementismainlyligamentouslaxity
causingjointdeformities.TherearemanyotherorgansystemsinvolvedinSLE,
especiallykidneys,thorax,andbrain

Systemicsclerosis(scleroderma)
andCREST:AcroosteolyticdestructionoffingertipsandcalcinosismostcommonMSK
findings.TheGItractisinvolvedfrrequently,especiallyesophagus.

Dermatomyositis
Polymyositis
PolyarticularsubtypeofJuvenileIdiopathicArthritis (alsocalled
ChronicJuvenileArthritis,formerlyknownasJuvenileRheumatoidArthritis)

PolyarticularsubtypeofJuvenilaRA

JuvenileIdiopathicArthritis*
Inflammatoryarthritiswithonsetunderage18(butusually
muchyounger),withthreemajorsubtypes:
Pauciarticular:60%.HLAB27positive.Similartoadult
ankylosingspondylitisandpsoriaticarthritis
Polyarticular:20%.RheumatoidFactorIgMpositive.Similarto
adultrheumatoidarthritis
SystemicJCA:20%.Fever,rash,lymphadenopathy,
hepatosplenomegaly,pleuraleffusions,acutelunglesions,
pulmonaryfibrosis,pericarditis,myocarditis.
*.AlsocalledChronicJuvenileArthritis;formerlycalledJuvenileRheumatoidArthritis

TheCase
76y/ofemale
10yearhxhandpainCOOLand
HARD.NOTWARMAND
PUFFY
Shehassomestiffnesson
awakeningandafterprolonged
rest,butitresolvesin15minutes.
Herjointshurtwithsomenormal
activities.However,exceptfor
herjointsymptoms,shefeels
well.
Bothhandsinvolved,but
dominanthandisworse.
AroutineCRhandseries
providesthediagnosis.Hereis
theAPview:

Diagnosis?

Osteoarthritis

Osteophytes,sclerosis,non
uniformjointspacenarrowing
anddegenerativecystsare
classicforOA.
OAisextremelycommon,
especiallyinmiddleagedand
elderlypatients.
OAisamechanicalwearand
teararthritis,usuallyprimary

butdoesoccursecondarytootherconditions
thatdamagethearticularhyalinecartilage
(infection,AVN,trauma,CPPDandgout,
impingement,etc.)

Rx:symptomatic

TheSpine
Cervical
Thoracic
Lumbar
Sacral

TheCase

55y/omalesmokerwithcarcinomaofthe
rightlung,treatedbyrightupper
lobectomy.HereishispreoperativeCR
PAchest.
Oneyearlater,hadinsidiousonsetofneck
painnotrelievedbyrestorconventional
analgesics.Painawakenshimatnight.
Begantonoticeweaknessandparesthesias
inhisextremities.
AnemergentCRcervicalspineserieswas
obtained.LetslookattheCRcervical
spinelateralview:

Whatsgoingonhere?
Letsdoamagnifiedview.

ThemagnifiedCRview

TheemergentCervicalSpineCRshowsa
highlysignificantabnormality.
WhereintheCervical
Where
Spineisthe
abnormalitylocated?
Howwouldyou
How
describeit?

LateralCervicalSpineCR
Thereisadestructive
osteolyticlesionofC4
osteolyticlesion
andC5,involvingthe
bodyandneuralarch.
Whatimagingwouldyou
ordernext?Whendo
youwantitdone?

YouwantanEmergentCervicalSpineMRI.
HereistheSagittal.
Whattypeofabnormalityis
this?bigmasscompressingthe
cord,anddeviatingposteriorly
Whatstructuresareinvolved,
directlyandindirectly?
Whatisthemostlikelyexact
diagnosis?
Emergentsurgical
decompression,IVsteroidsand
radiosensitivethencanstart
radiating

Lungcancermetastasistothe
CervicalSpine
Thereisanosteolyticmasslesion
ofthecervicalspine.
Ithasextendedfromthevertebra
intothespinalcanalasasoft
tissuemass,andiscompressing
thespinalcord.
Diagnosis:
Diagnosis: Hematogenousspread
ofcarcinomaofthelungtothe
spinewithspinalcord
compression.

Isthisanemergency?

YES!
Spinalcordcompressionis
alwaysaclinical
emergency,requiring
emergentimaging,most
oftenbyMRI,followed
byemergenttreatment.

CausesofSpinalCordCompression
Thecausesofspinal
cordcompression:

Trauma(hematoma,bonefragments,
traumaticHNP)

Neoplasm(especiallythyroid,breast,

lung,kidney,prostate,lymphoma,multiple
myeloma)

Abscess(pyogenic,tuberculosis)
Herniateddisc/HNP(non
traumatic)

NEOPLASMand
SpinalCordCompression
Emergencytreatment:

Corticosteroids(I.V.followedbyoralhigh
dosedexamethasone)
Andoneofthefollowing:
Surgicaldecompression(laminectomy,
fusion,andtumormassdebulking)
especiallyifspinalinstabilitypresent
or
Surgicaldecompressionfollowedby
radiationtherapy
or

Radiationtherapyalone
Treatmentdependsonthespecificcancerandits

radiosensitivity,theextentofneurologic
impairment,priortreatment,theoverall
conditionofthepatientandtheprognosisof
thecancer.Chemotherapymaybeaddedasan
adjunct.Ingeneral,survivalisapproximately3
monthsbutneurologicfunction(qualityoflife)
isusuallyimprovedbyaggressivetherapy.

TheCase
Active81y/ofemale
Insidiousonsetof
localizedmidbackpain.
Increasingkyphosis.
Notrauma.Nohistoryof
malignancy.
WeorderaCRthoracic
spineseries.Lookatthe
lateralimage.Whatis
yourdiagnosis?

Closeuplateralviewmidthoracicspine

OsteoporosisandCompressionFractures
Osteoporosisispresent,with
Osteoporosis
multiplecompression
insufficiencyfractures(a
formofStressFracturecausedby
repetitivemicrotraumaofnormal
everydayactivitiesonweakenedbone).

Commoncondition,under
diagnosed,undertreated.Itcan
causeseveredisabilityand
indirectlycancausedeath(i.e.
hipfracturecomplications).
RX:Bisphosphonates,vitaminD,
calcium,paincontrol
medication,kyphoplastyfor
severeintractablepain.

Osteoporosis
Osteoporosisismost
commonlypost
menopausal(female
estrogendecline)or
senile(maletestosterone
decline),andsoismost
commonlyacondition
thataffectstheelderly.

Osteoporosisinpatients
whoarenotelderly
not
Osteoporosiscanoccurinyoungandmiddleaged
people,andifso,asearchforanunderlyingdisease
orconditionisindicated.
Osteoporosismaypresentwithastressfractureinayoung
athlete,oftenafemalewithsecondaryamenorrhea.It
mayalsobesecondarytoaseriousendocrinedisorder
oramalignancy,orbeiatrogenic..
Herearethemajorspecificcausesofosteoporosis:
Corticosteroids,chemotherapy,antigoagulants,
anticonvulsants,hormonedeprivationtherapy,
hyperthyroidism,malabsorptionsyndromes,diabetes,
eatingdisorders,secondaryamenorrhea,
hyperparathyroidism,adrenalorpituitarydisease
causingincreasedglucocorticoidproduction,disuse,
multiplemyeloma,rheumatoidarthritis,cysticfibrosis,
calciumdeficiency,smokingandalcohol.Sincewe
startedtestingforVitaminDlevels,wearefindinga
significantnumberofpeoplewhoareVitaminD
insufficientordeficient,aconditionwhichcan
predisposetoosteoporosis.

Osteoporosis:diagnosis
DEXAscanning

DEXAisDualEnergyXrayAbsorptiometry,alowenergyXraydeterminationofBoneMass
Density(BMD).ThehipistheusualDEXAtargetandtheBMDisreportedasTscore
(comparedtoanormal30yearoldreference)andZscore(comparedtoanagematched
mean).
TheW.H.O.definitionsarebasedonBoneMassDensity(BMD):
Normal:within1StandardDeviationofthemean(thereference30yearold)
Osteopenia:12.5SDbelowthemean
Osteoporosis:morethan2.5SDbelowthemean
Severeosteoporosis:morethan2.5SDbelowthemeanwithahistoryofosteoporosis
relatedfractures
Thepointofscreeningosteoporosis:istopreventfracture.Wanttopreventhipfracturebecause
itendsindepentliving.50%wontliveindependently,and25%willdiewithtin11.5years.

TheCase

35y/omalephysician
10yearsofprogressiveback
painandrestrictedROM.
Symptomsstartedinthesacral
areabuthaveover10years
graduallyinvolvedtheentire
lumbarandthelowerthoracic
spine.
Notrauma.Nohistoryof
malignancy.Noinvolvementof
handsorfeet,eyesorGUtract.
AroutineCRlumbarspineseries
wasordered.HereistheAP
view.Whatisyourdiagnosis?

DIAGNOSIS?

LumbosacralspineAPview

AnkylosingSpondylitis
Thepatienthasthe
classicradiology
bamboospineand
theobliterationofthe
sacroiliacjointsof
advancedankylosing
spondylitis.

AnkylosingSpondylitis
Thereiscalcification
(syndesmophytes)ofallofthe
lumbosacralspineligaments,(i.e.
bamboospine)andcomplete
destructionandfusion(ankylosis)
ofbothsacroiliacjoints.
ASisaseronegativeHLAB27
positiveinflammatoryarthropathy.
Itismorecommoninmales,and
usuallybeginsinyoungadultlife.

WhatarethemembersofthisRFnegative
HLAB27positiveinflammatoryarthritis
group?

Seronegative
Spondyloarthropathies
Ankylosingspondylitis:themostcommon
memberofthisgroup.AlwaysinvolvestheSI
jointsandspine,mayinvolvehipsand
shoulderjoints,rarelyinvolvesthelungs,heart
andaorta
Psoriaticarthritis.MSKisinvolvedin5%of
cases,mainlyhandsandfeet(DIPjointsand
digittufts),andthespineandSIjoints
Reactivearthritis:spineandSIjointsandmainly
feet,especiallyheel.Etiology:26week
delayedreactiontochlamydiaor
shigella/salmonellainfections.
IBDrelatedarthritis:usuallySIjointsonly
PauciarticularsubtypeofIdiopathicJuvenile
Arthritis(alsocalledChronicJuvenile
Arthritis,formerlyknownasJuvenile
RheumatoidArthritis)

LowBackPain
LBPisverycommonfromtheteenage
yearstooldage.Over90%ofthe
populationwillexperienceatleast
oneepisodeofsignificantLBP.
TherearemanycausesofLBP:
Inayoungerpersonwithinsidiousonset
ofLBP,themostcommoncauseis
selflimitedmusclestrain,butalways
consideranklylosingspondylitisand
theotherseronegatives,
spondylolysisandspondylolisthesis,
andherniatedintervertebraldisk.
Inanolderperson,considermalignancy,
degenerativespondylosisandfacet
osteoarthritisandspinalstenosis.
Atanyage,considerboneordisc
infection.

TheCase
A50y/omalewithverysevere
coronaryarterydiseaseandend
stagecongestiveheartfailurewitha
VADhadasuccessfulheart
transplant.Heisonposttransplant
immunesuppressiontherapy.
Threemonthslater,hedeveloped
insidiousonsetoflowbackpain
andparaspinalmusclespasm.On
physicalexamination,hehad
localizedmidlinelowerspinal
columnpointtenderness.
Hehasnodefinitefeveror
leukocytosis.
NextistheCRlateralofhislower
lumbarspine:

VentricularAssistDevice(VAD)

Whatisyourdiagnosis?osteolyticlesionof
bothendplate.motheaten.Narrowdisc.:Canbe
abscess,neoplasm

Osteomyelitisanddiscitis
Therearemotheatenosteolyticlesionsof
twoadjacentlumbarvertebraewithloss
ofthediscspace(malignancyislesslikelyto

crossadiscspaceorjointthaninfection.Infections
crossjointspacesearly.Neoplasmsdontcrossearly
ornotatall).

Thispatientisathighriskforinfection
becauseofimmunesuppressiontherapy.
Ahighindexofsuspicionisneeded,as
immunesuppressingmedicationscan
mutethesymptomsandmaskfeverand
leukocytosis.Also,theinfecting
organismmaybeatypicaloropportunistic
andsodifficulttodetectoridentifyinthe
laboratory.

Osteomyelitisanddiscitis
AlwaysconsiderMSKinfection
(bone,joint,disc)inhighrisk
patients:

Postorganandbonemarrowtransplant
HIV/AIDS
IVdrugusers(includingrecreationaluse)
Corticosteroidtherapy
DMARDstheapyforinflammatoryarthritis
Recenttraveltoareasendemicfor
bone/joint/discseekingorganisms
Postsurgeryandpostinvasiveprocedures
forbone,jointandspineconditions
Andconsiderinfectioninanyonewith
anyone
recentonsetofanacutemono
articularinflammatoryarthritis.

TheCase
An80y/omantrippedona
rugathishome.
Heimmediatelyexperienced
moderatelyseverepainin
hislefthipandhehada
significantlimp,butwas
abletobearweight.
Thenextmorning,hewentto
seehisphysicianwho
obtainedthisAPCRhip:

Diagnosis?DoMRI(wontmiss
fractures)

Uncertain!
Thefemurneckdoesnot
lookquitenormalbut
thediagnosisof
fractureisuncertain.
However,inviewofthe
historyandsymptoms,
thephysicianis
concernedabouta
subtlehipfracture.
So,sheorderswhat?

???

AnMRI:whichshowswhat?
whiteisfatsignal.Badsideisleft
sideedemaandhemorrhage

Adefinitefemurneckfracture!
MRIisfarmoresensitiveandspecificthan
CRandshouldalwaysbeperformed
immediatelyifhipfractureisa
considerationandCRisnotdefinitively
positiveforfracture.Inthenearfuture,new

MDCTscannersmayallowaccurateCTdiagnosisof
occulthipfracture.

AlmostALLhipfracturesneedemergent
surgery,thetypeofproceduredependent
uponthelocationandamountof
displacementofthefracture.
Displacedhipfracturedisruptsbloodsupply
tothehead

TheLowerExtremity
EveryKneeMustBend
AstheAnkleTurns
HeeltoToe

TheCase
19y/ofemale
Clipped(valgusforce)
onlateralsideoftheknee
whileplayingtouch
football
Tenderlateraljointmargin
Negativedrawersign
(whatdoesthatmean?)

AnemergentCRknee
serieswasobtained.It
wasnegative.So,whatdo
wedonow?

HowaboutanMRI?
Thisisasagittalimage.
Whatdoyousee?

anterior

posterior

ThereisaTearofthe
LateralMeniscus
TheMRIshowsatearofthelateral
meniscus.Thistearisoftheposterior
hornofthelateralmeniscus,whichis
fairlycommon.Themostcommontearisofthe

posteriorhornofthemedialmeniscus.
Meniscustearsareverycommoninyoungathletes.
Theyareusuallyunilateral,buttheotherknee
maybeinjuredatafuturetime.
Plainfilmsareoflimitedvalueindiagnosingatear,but
areusefulinrulingoutabonefracture.MRIis
theimagingmodalityofchoiceformeniscus
evaluation.

Managementoflateralandmedial
meniscustears:
Observation(ifasmalltear)
Suturerepair
Partialmeniscectomy

Completemeniscectomy(rarelynecessary)

Lateral
meniscus
tear

MoreonMeniscusTears
Ifsurgeryisneeded,many
OrthopedicSurgeons
woulddoarthroscopic
repairofthemeniscus,
andsoonerratherthan
later.Notrepairingsignificant

meniscustearscanleadto
secondaryosteoarthritisofthe
knee,andultimatelytheneedfor
kneejointreplacement.
Athoroughevaluationoftheknee
mustbemadepriortosurgeryas
otherstructuresmaybeinjuredalso
andinneedofrepair:ACL,PCL,
MCL,LCL,theothermeniscus.

Lateral
meniscus
tear

TheCase
18y/ofemalestudent
Invertedherankleonthe
dormstairs
Shecanambulatebutshe
isinalotofpain.
Thereispointtenderness
overthelateralmalleolus.
ACRseriesistherefore
indicated(wewilldiscusswhya
littlelater).HereistheAP
viewfromthatseries.
Whatarethefindings?

Letslookcloser
atthisarea

Hereisamagnifiedviewofthe
LateralMalleolus

Diagnosis?

FractureoftheDistalFibula

Thisinversioninjury,themost
commonmechanisminmost
anklefractures,hascauseda
fractureofthelateralmalleolus
ofthefibula,belowthejoint.
Thisisaclosed(skinover
fractureintact)WeberAtype.
Weberclassificationdepends
onthelocationofthedistal
fibulafracture,andlocationof
thefibularfracture
determinessurgicalvsnon
surgicalmanagement.

FractureofDistalFibula

WeberA(belowjoint):stable,
sotreatedbycastfor6weeks.

MostWeberAfracturesdoverywellwitha
castfor6weeks.Complicationssuchas
osteomyelitisandavascularnecrosisarevery
rareintheseclosedfractures(ieskinintact
overthefracture),asopposedtoanopen
fracturewheretheoverlyingskinisdisrupted
allowingbacteriatocontaminatethe
fracturedboneandtheadjacentjoint.

WeberB(atjoint)andWeberC
(abovejoint):considered
unstableandusuallytreated
surgicallybyORIF(openreduction
internalfixation).

C
B
A

TheanswertothequestionWHYdoweneed
imaginginthiscase:

TheOTTAWARules

TheOttawaRulesweredevelopedtodeterminewhichpatientswould
benefitfromimaging;thatis,thosethathaveahighprobabilityofa
significantfracture.Ifapatientfailsoneormoreoftherules,they
needimaging.
Unabletotake5unaidedstepsatsceneandinoffice
Pointtendernessofeithermalleolus,talus,orbaseof5 thmetatarsal
TheOttawaRulesarenotvalidforpatientsunder18years,andininjuries
morethan12daysold.Thenegativepredictivevalueisabout95%,
butthepositivepredictivevalueisconsiderablylower.

ThePenultimateCase
(andalsothenexttothelastone)

A30y/oU.S.Marine
GunnerySergeantwas
trainingfortheMarine
CorpsMarathon.
Shedevelopedinsidious
onsetofheelpain.

Oneweeklatershegoeson
SickCallandseesthe
PharmacistMate.
Letslistenin:

SemperFi

AtSickCall
PhM:OK,Gunny.
Fromthesoundofit,it
lookslikeyourground
poundinghascaused
plantarfasciitis.But
plantarfasciitis
waitone.Iwanttosee
somerayssolets
OscarMiketothe
ShadowGazer.

TheShadowGazercallstheRays#1

CRlateral

BackatSickCall
PhM:Raysare#1A
OK,Gunny.Youre
goodtogo.Imcalling
itplantarfasciitis.
Restit.Iceit.Wrapit.
ButStayFrosty.Ifits
notbetterinaweek,
RTB.Copythat?
GySgt:Roger.Solid
copyonall,Doc.

RTB:atSickCallagain
Butoneweeklaterthepainismuch
worse.
TheGunnyreturnstoSickCallandDoc
reexaminestheGunnyssoreheel.
ShouldDocrepeattheCR?Wouldit
changemanagement?Whatwouldyou
expecttoseeonCRinplantar
fasciitis?Isthereanotherdiagnostic
possibilitywhereasecondXray
mightaltermanagement?

DocdoesrepeattheCR.
IstheresomethingnewontherepeatXray?

TherepeatCR:2weeksafteronsetofheelpain

ComparethetwoCRs:Diagnosis?
calcaneousfracture
TheinitialCR

TherepeatCR

CalcaneusStressFracture

Fatiguefracture:fromrepetitive
microtrauma,abnormalstressonnormal
bone.
Calcaneusstressfracturesareofteninitially
thoughttobeplantarfasciitisclinically.
Instressfractures,radiographsareusually
negativefor23weeksafterpainonset.
However,CRsarealwaysnegativeinplantar
fasciitisunlessitischronicandareactiveheel
spurforms.
Therefore,alwaysrepeattheCRin12weeks
ifyouarepresumptivelytreatingplantar
fasciitisandthereisnoimprovement.Itmay
beastressfracture,andthetreatmentis
different.
Rx:Restrictedactivity68weeks,often
withoutweightbearing.Occasionally,acast.
And,ofcourse,nomarathon.

Oh,andonemoresubtlecase!

Diagnosis?Anddonttrythisathome!

Nailgunmisadventure!

Andnow,aMovieQuoteQuiz!!!

MainlySciFi,frommainlymovies.Oboy,isthisgreat?(Yes,andalsoahiddenmoviequote.)

TheQUIZ!!!
(Beep)No,Idontthinkhelikesyouatall(Beep)No,Idont
likeyoueither.
ShesaReplicant,isntshe?
WearereceivingadistresscallfromtheUSSKobayashiMaru.
Hesrightaboutthe9000Serieshavingaperfectoperational
record.Theydo.Imsorry,Dave.
Firstcharacter:Canarobotwriteasymphony?Canarobot
turnacanvasintoamasterpiece?Secondcharacter:Can
you?
Houstonintheblind.I,RyanStone,amthesolesurvivorofthe
STS157.
Wearenoodlefolk.Brothrunsthroughourveins.

TheQUIZAnswers!!!
(Beep)No,Idontthinkhelikesyouatall.(Beep)No,Idontlikeyou
either.StarWars:EpisodeIVANewHope
ShesaReplicant,isntshe?BladeRunner
WearereceivingadistresscallfromtheUSSKobayashiMaru.Star
TrekII:TheWrathofKhan
Hesrightaboutthe9000Serieshavingaperfectoperationalrecord,
Theydo.Imsorry,Dave.2001:ASpaceOdyssey
Firstcharacter:Canarobotwriteasymphony?Canarobotturna
canvasintoamasterpiece?Secondcharacter:Canyou?I,Robot
Houstonintheblind.I,RyanStone,amthesolesurvivoroftheSTS
157.Gravity
Wearenoodlefolk.Brothrunsthroughourveins.KungFuPanda

Andsofinally
WEAREDONE!

Farewell,andHappy
OSSEOUSImaging!
AndIhopenowyoulikeBONES
asmuchasIdo!Yummmy!
I

AndIhopetoseeyouallagainat
anotherofMYpertinent,
practicalandperspicacious
presentations.

Goodbye
Untilnexttime
Copyright2014
MichaelZucker,MD
Sigratiascupitis,canemconsequimini.
Cicerosaidthat(maybe)