Mskl 303 Notes

7/24/2019 Mskl 303 Notes

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Orthopedic Anatomy 20.11.2014 18:14

Anterior inferior glenohumeral ligament – most important stabilizing

shoulder joint

We always define a dislocation by the position of a distal part – humerus

is the distal part, if humerus is more anterior, it is anterior dislocation

Bankart lesion – tear of the anterior inferior

Tuberosity (tubercle) in humerus – two important lines are anatomical

and surgical neck lines. In anatomical neck fractures, blood supply could

be impaired.

Path of radial nerve, behind humerus, entrapment possible in shaft

fracture

Lateral ulnar collateral ligament – clinical importance

Annular radial ligament holds radial head in the place

Scaphoid fractures cannot heal easilyCapitatum is biggest – lunate is also important

Brachial plexus C4-T1

Innervation of trapezius – CN XI

Quadrangular space – humerus, long head of triceps, teres major –

axillary N & circumflex humeral artery

Triangular interval – radial N and deep brachial artery

Triangular space – circumflex scapular artery

Posterior interosseus nerve – continuation of radial nerve, before enteringsupinator canal and becomes this nerve

Anterior interosseous nerve – median nerve – pinch test if +, it’s palsy

Ulnar nerve innervates flexor carpi ulnaris , flexor digiotum profundus 4,5

Adductor pollicis is a thenar muscle but innervated by ulnar nerve –

Froment test check for ulnar nerve

Cubital tunnel in the inner side

De Quervain tenosynovitis – BELA (EXTENSOR BREVIS – ABDUCTOR

LONGUS)

CLINICAL EXAMINATION OF MUSCULOSKELETAL SYSTEM

Symptoms: pain, swelling, deformity, referred pain

Orthopedics: inspection -> palpation -> movement -> stressing

Epolette sign in anterior shoulder dislocation*

Valgus – lateral movement / varus – medial movement

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Feel warmth before pressure with the same hand, the same part

MRC Scale

Define the deformity – angular, contractures, spasticity

Contracture- wolkman ischemic contracture in the image below

Hamilton’s ruler sign

For thr first 90* scapula doesn’t move in shoulder joint abduction

It is a combination of scapula thoracic and glenohumeral movement

2:1 ratio: after 90* for every 1*, 1* ST and 1* GH

carrying angle of elbow

Ulna is the pivot point, radius turns

Erb duchenne – tear of c5-c6 biceps&deltoid& rotator cuff do not work

Klumpke palsy- claw hand, ulnar nerve is more involved –c7-t1

Thoracolumbar spine - straight leg test show irritation for sciatic nerve –the patient tends to bend the knee to relieve the stress on the nerve,

tenderness, back pain sciatica/sciatalgia means the irritation, may be due

to lumber hernia or compression

80% of bending movement from lumbar and rotation from thoracal

vertebrae due to facet joints

Memorize 234: patellar reflex L3,L4

Ober testTrandelenburg test

Knee inspection: deformity – knocked knee/bowl legs/valgus

Medial joint space, medial meniscus, medial collateral ligament, pes

ansenius – gracilis, sortorius, semitendinosus

ACL- anterior drawing test

Medial collateral ligament – is stretched in valgus test

Lateral collateral ligament – is stretched in varus test

When knee is extended fully in these tests, you would lock cruciate lig

and you would have stability // collateral lig torn is only measured when

you bend the knee 20*

Lachmann test

Ankle inspection – hemosiderin causes ecchymosis

Palpation is according to Ottawa rule: press on medial malleolus, lateral

malleolus, base of 5th metatarsal if painful, take x-ray!!!

Dorsiflexion stretches calcaneofibular lig

Plantarflexion CF is lost, ATF is assessed only

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3-4 toe – Morton neuroma

2nd toe – malleo in distal and hammer toe

Thomas test

Pediatric Examination

Screening examination & focused examination

Compare the level of shoulder in front of a window- level of light passing

History taking

In-toeing: içe basma, very common in babies & toddlers,

Femoral antetorsion – internal rotation of femurAngular problems – last normal position 5-7* of valgus, varus is present

in infants

Osteoclasis – breaking the bone

Flexible flatfoot – tibialis posterior will pull to give the arc of the foot,

Clubfoot – immediate serial casting for treatment

Osteoporotic fractures

Trabecular bone is mainly in ends of the bone

Post-meopausal type I

Vit D deficiency, steroid use, H+ pump inhibitors – risk factors for OP

Distal radius fracture at 50s – yellow alarm – femoral neck fracture 70s

Anti resorptive agent- bisphosphonate – atypical fractures may occur

CASE-1

71 F – acute back pain

steroid use for SLE since 2006

lateral x ray of low back – to evaluate height of vertebrae

MRI needed to detect whether it is a new fracture or an old one

Always count from sacrum – compression fractures of L1,L2,L3

Vertebroplasty – noninvasive, cement is injected

CASE-2

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CASE-3

Hospice – risk for osteoporosis due to sedentary lifestyle

Screw may be a solution – but correct treatment would be bedrest,

vertebroplasty

T2 MRI –bright region in vertebrae- bleeding in trabecular bone, new

fracture, patient underwent percutaneous vertebroplasty

Pilon tibia – comminuted fracture of ankle, sagittal CT section, intra

articular fracture after simple ankle sprain, smoking was a predisposing

factor, surgical treatment of plate and screws

Patient with rheumatoid disease, heavy smoking habit – think ofosteroporosis!

Tibial plato has a compression – more clearly on CT scan, plate and

screws

Consider osteoporosis in elderly – in the treatment – consult

endocrinologist and physiotherapist to promote healing and prevent

future fractures

Metabolic disease – PTH stimulates osteoblasts

2 questions from this part

Fractures and Dislocations

Opacity – compression fracture

Pain – swelling – deformity – loss of function are cardinal symptoms of

fracture

Hip fracture – external rotation of the lower limb

Swelling: hematoma, edema, effusion (in the joint space)

Movement and stressing is not done in the diagnosis of shoulder; look and

palpate, never stress!

Internal bleeding – excessive swelling in closed fractures

Fascia limits muscle – muscle depends on it for strength

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In the case of bleeding, the compartments in the leg are not enlarged due

to restriction and pressure exerted by fascia

Artery keeps bringing blood, vein closes completely in critical point, tissue

is congested, intratissue pressure is increased, necrosis occurs –

compartment syndrome

Subluxation – partial dislocation

March fracture in metatarsal bones

Greenstick fracture in children – break it again willingly for healing

Impacte- içiçe geçmi! kırık

Comporession – calcaneous

Avulsion – touch base of metatarsal V – peroneus brevis attaches to it

If more than 30*, it is oblique fracture

Repeat xray after one week in scaphoid fracture due to resorption

2nd metatarsal takes the most load in walking – hairline fracture

Open fractures – Gustilo Classification

Type I: less than 1 cmType II: >1 cm , extensive soft tissue damage

Type III: periosteal splitting, exposure of bone

Axillary artery can be entrapped between bone fragments

Bone fractures in children

Thicker periosteum is an advantage, increased remodeling, presence of

physis

In trabecular bone, no osteon

Bionet position – remodeling within 6 months

Conservative treatment – usually no surgery

Do not confuse physis with fractures

Children grow from knee, shoulder and wrist 70-80% - clinical relevance

is that if you have a fracture around these regions, high potential for

remodeling

For the elbow, this is not the case, healing is not very good .

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Bone activity is high in children and adolescents, bone tumors are more

frequent, around knee, shoulder.

CAPITELLUM -3

INT EPICONDYLE -6

TROCHLEA - 9

EXT EPICONDYLE -12

Little leager – medial epicondyle traction injury

Toddlers fracture – very subtle, blurry opacity sometimes seen as healing

Monteggia: proximal ulna fracture with radial head dislocation

Galeazzi: fracture of radius, dislocation of distal radioulnar joint

Torus fracture: impaction

After 12 years of age, physis close from median to lateral and this takes 2

years, tf ligament pulling in severe ankle sprain may cause tillaux fracture

Lateral part of distal tibial epiphysis

Nursemaid’s elbow: elastic fixation of elbow, painful pronation position

Unable to supinate

Gently pull, turn outward, flex it , click sound will be heard when radial

head sits in place, wait for 10 min to assess again

Calcaneocuboid and talonavicular articulations in feet

Case 6: 5th phalanx, epiphyseal type II fracture

Torus fracture xray!!!

BONE HEALING

Type I - bone

Type II – nucleus pulposus, articular cartilage

Type III- healing tissue, scar tissue

First thing after a fracture: blood and inflammation

1. reactive phase for 3-7 days, for all tissues ligaments, tendons, muscle,

bone, bleeding to promote healing,

2. repair phase 3 weeks

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3. remodeling phase at the end of 3 week, most tissues roughly healed, 3

wks to 6 mo bone remodeled

if possible, natural healing is the best way

If periosteum incompletely torn, external callus formation

In the joints, we need 1* healing, anatomical reduction, direct osteonal

healing, we want a smooth joint surface, 1* healing required for intra

articular fractures

In 2* healing, bone tips are not together, open wound heals in this way

For shaft fractures, 2* healing is accepted.

The only tissue that heals with its original tissue is bone. Bone heals with

bone, but tendon, muscle, ligaments heal with scar tissue.

Direct osteonal healing vs. enchondral healing

Osteosynthesis

Internal fixation: fixing with a medical device

Intraarticular joint needs absolute stability, anatomical reduction which is

the perfect alignment

Shaft fx – functional reduction – it provides a good position for

functioning

Cortical screw – holds the bones by the frequent teeth

We put the plates at the tension site

Cancellous bone screws for compression and fixation

Hip fracture: naling or screwing make osteosynthesis or hip replacement

surgery by prosthesis. Nailing is preferred, it will healing with bone.

Intramedullary nails would impair endosteal healing

Kirscher Wires !n tension band wiring

Schanz screws or pins in external fixation

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Case1 – minimal material, this is not a stable fixation with wires. Since it

involves the joint, anatomic reduction is a must. You can see a callus but

this is not preferred. Tried to be fixed with plaques in second picture.

Hematoma after open surgery is a source of infection, drain after surgery

Schanz screw and bone cement – segmental bone excision and replaced

by cement in the case of osteomyelitis to eradicate infection

CRP, acute phase reactants controlled, if normal, cement removed and

biological reconstruction may be performed or segment sliding

Osteomyelitis

1.Acute hematogenous osteomyelitis

2. Subacute hematogenous osteomyelitis

3. Chronic osteomyelitis

venous sinusoids in metaphysis, in bacteremia septic emboli sits there

due to slow circulation and there are less phagocytic activity and oxygen

acute starts in metaphyseal regionbefore age 2, physical vessels are open so metaphysical infection can

spread to epiphysis

after 2 age, physis is a barrier to infection

the most common cause is bacteremia

sequestrum: dead bone found in chronic osteomyelitis

involucrum: bone tries to encover dead bone

diagnosis: acute phase reactants increase also in rheumatoid diseases

all of lab tests can be normal in newborn!! Newborn sometimes do not

have fever after infection.

Axial mrı best technique

Bone scan not very specific

US – for soft tissue abscess, subperiosteal abscess can be aspirated

Cortical destruction or cortical degeneration, take biopsy inside the bone

Abscess – debridement

The most common cause is S. aureus in all patients with sickle cell

anemia and the disease increase the risk of salmonella infection

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Before 2 years, vessels are open infection can spread to epiphysis, septic

arthiritis

After 12 years – epiphysis closes, cartilage barrier is not enough,

infections can spread, again septic arthiritis may occur

Subacute osteomyelitis – history more then 10 days, some sign on XR,

incidious onset

Acute osteomyelitis – nothing on plain xray, history less than 10 days,

more obvious symptoms

Chronic: sequestrum, invalucrum, debridement of necrotic tissue

Brodies abscess – lytic lesion, radioluscent

Ewing sarcoma

Eosinophylic granuloma

Leukemia

Involvement of bone infection, common before 2 years or after 12 years

epiphysis septic arthritis

Limping adult ( From signs to diagnosis)

Neurological or musculoskeletal

Stance 60% swing 40%

Energy conservation:

Pelvic tilt

Pelvic rotation

Lateral shift

Stride length between 2 heel strikes of the same leg

Step length

Antalgic gait – very short stance phase on affected side, showing pain

Abductor lurch – gluteus medius weakness PAINFUL

TRANDELENBURG NO PAIN

Abnormal calcification of plantar fascia attaching to calcaneus – topuk

dikeni/ epin calcanei – tiptoeing, pain on the heel

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Patients with femoral palsy, will knock their knee as they cannot extend

knee

Foot slap gait – weak ankle dorsiflexion, yeri tokatlayarak yürüme

Hallux rigidus – cannot extend the metatarsophalangeal joint of hallux,

step length shortened

Anklosis – fusion of joint

Back knee gait – quadriceps weakness

Gluteus medius gait – tries to have central point of mass to the affected

side

OA – sclerosis, bone formation unlike osteoporosis

Cruris Fracture

Sural N – sense for lateral foot

Dorsalis pedis and tibialis posterior pulses

Tibia fracture – high energy trauma, assess consciousness

Undress the patients limbs

Active bleeding – never put tourniquet, PUT STERILE PAD FOR PRESURE

Yaraya distalden bastırınca kanama duruyorsa venous, proximalden

bastırınca duruyorsa arterial agırlıklı kanama olur

Open fracture – fascia torn so low risk of compartment syndrome

Once you have paralysis – it is too late to decompress the tissues, muscle

underwent necrosis so fasciotomy is too late, you only have 6 hrs ot one

day at most

Pain, pallor, pulselessnesss, paresthesia

Watch for abnormal pain - remember compartment syndrome

Ischemic contracture of Volkmann – frequent complication of arterialinjury after elbow fractures

If you do not feel your sole, tibial nerve is gone, indication for limb

amputation

Sural nerve – lateral side of foot

Toddlers fracture – usually missed

Torus – soft periosteal thickness

Maison nevue – medial malleolus & fibular neck fracture – may occur after

severe sprain

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Cyanosis – there might be hematoma – not compartment syndrome

Dizin üstündeki bacak venleri

Sudek atropfisi – osteoporosis occurs, rigid joints later period

Bone – tendon – arter but if too much ischemia, arteria may be scheduled

before tendons

Dislocation of shoulder ( From signs to diagnosis)

Inferior glenohumeral ligament

Cyst in scapular notch – suprascapular nerve

90% anterior dislocation of the shoulder

is there any previous dislocation?

Look – feel – neurovascular examination

Brachial plexus is stretched in dislocation, most common axillary N. injury

Too see if contract deltoid muscle, if there is sensation loss around lateral

part of deltoidTransthoracic and AP xray because patient cannot abduct for axillary

position

Bankart lesion – anterior dislocation tears capsule attached to labrum

After 1st dislocation, 95% patients have this lesion, this does not heal

anatomically. MRI is the best

Hillsacks lesion, impression or compression fracture of the posterior part

of humerl head. CT is the bestDue to these lesions, one dislocation may lead to another in the future

Abduction ext rotation – shoulder dislocation

Shoulder Examination

Palpate bony prominences AC, SC, tuberosity, biceps tendon, coracoid

process,

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Internal rotation level according to thumbs reaching which spinal levels

Knee Examination

Medial side tenderness on medial meniscus, MCL, bony edema or

osteoarthritis

compare quadriceps

Patella for fluid in the joint

Flex 15-20* before examination of mcl, lcl

Lachmann test for cruciate ligaments

US, MRI

Ayak ice veya dısa basarken diz ustune cokturme testi

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20.11.2014 18:14

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20.11.2014 18:14

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Osteoporosis 20.11.2014 18:14

most common bone disorder

low bone mass & micro architectural deterioration

mineral matrix ratio is normal, lab values are normal

lifetime risk at the age of 50

peak bone mass: Amount of bony tissue at the end of skeletal maturation

type I collagen (94%) in osteoid

Osteoporosis in trabecular bone: hard outer layer is compact bone,

spongy inner bone is cancellous bone, which makes 80% turnover media

Most commonly in vertebra and the hip bones. More bone loss occurs at

trabecular areas.

Vertebral fractures are seen most common, 50% trabecular bone content

Postmenopausal osteoporosis – type I

Hormonal changes increases rankl production, bone loss 1% per yearClinical manifestations: silent until fracture

Fragility fracture definition

Vertabra, hip, wrist, shoulder fractures

Once a vertebral fracture occurs, risk increases x5

Hip fracture- 20% risk of death within a year

Diagnosis: BMD

Biochemical markers not diagnostic but to follow up

Many drugs are anti resorptiveAntigravity exercise – walking is the best for osteoporosis

Women >65 age should be checked for screening

-2.5 SD means osteoporosis

>3% needs treatment

>20% severe osteoporosis

farx tool by who

Hip fractures

X3 more remodeling active unit in trabecular bone

Loss of height of 4 cm within a year – check for osteoporosis

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Hand Examination 20.11.2014 18:14

Allen test – look at refilling speed when releasing one artery

If one of them is slow, note it.

Goniometer for flexion,extension, ulnar/radial deviation

Ulnar & radial collateral ligaments on MCP joints

Know the tendons and muscles

FDS for PIP joint flexion

FDP for DIP joint flexion

Thenar muscles: abductor pollicis brevis, flexor pollicis brevis, opponens

brevis

Hand posture maneuver

Swan neck: overextension of PIP, flexion of DIP

Wrist drop: radial nerve palsy

Interosseus – ulnar nervePhalen test for carpal tunnel syndrome

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RADIOLOGY 20.11.2014 18:14

Fractures& Dislocations Radiologic Perspective

Systematic checklist:

1.patient and image data

2. bone and joint alignment

3. joint spacing

4. cortical outline – important for trauma cases

5. bone texture

6. soft tissue

tibial plateau fraction – if too much depression, operation would be

needed

toddler fractures are examples of spiral fracturesmultidirectional fractures usually on calcaneus

communited fracture – check vascular damage

Avulsion fracture –

Epiphysis fractures important in children type II 75% involves proximal

part of epiphysis/ type V hard to detect in radiology, physis line

compressed in axial injuries, worst prognosis, if doubt, observe edema on

the bone by MRI

Diasthasis – usually two points in pelvisUnunited fractrues – in scaphoid, important complication, avascular

necrosis, proximal part malnutrition at first

Sudeck atrophy – reflex sympathic atrophy, due to trauma, immobility,

causing pain, heat, erythema due to stimulation of sympathetic system

but not proved, osteoporosis can be seen

No sclerosis in fracture lines

Growth plates, 2* ossification centers have their own cortex

Anterior fat pad – hypodense in xray

High atomic number molecules are hyperdense

Fat – water – muscle – bone

Fat pad elevated in fractures

http://www.radiologymasterclass.co.uk

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Radiology In Low-back Pain

3 categories of patients: nonspecific LBP, assn. with spinal stenosis or

assn. with tumors, infections

high risk of infection: ESR, leukocytes lab results give clue

chronic steroid use – osteoporosis

Radiology of Bone Tumors

Simple bone cystic central – aneurysmal bone cyst is eccentric

Metastasis very common in bone tumors1* bone tumors exclude metastasis

epiphysis should be closed for giant cell tumor

osteoid osteoma – nidus, near periosteum

enchondroma – popcorn shaped calcifications

enchondroma can be low grade sarcoma if size is getting large

fibrous cortical defect is developmental mineralization disorder

non ossifying fibroma metaphysis of long bones

osteo chondroma – exocytosis, cartilage cap, if cartilage gets thicker itcan be chondrosarcoma, cartilage checked with MRI

osteomsarcoma – ill defined, codman triangle

abc- honeycomb appereance, MRI shows fluid fluid level

in older age group, malignant tumors dominate

enchondroma most important

infection can mimic malignant tumor – keep in mind

geode degenerative disease – synovial fluid gets into bone cyst, articular

surface

FEEHMMI – multifocal lesions

Neuroblastoma, retinoblastoma, lymphoma can cause metastasis in

childhood, ewing can be multifocal

Calcaneus – simple bone cyst, intraosseus bone cyst are seen common

Lytic lesion with sclerotic margin

Moth eaten – malignant with lamellated periosteal rxn onion skin

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Permeative pattern – malignant

Fibroxhantoma – nof and fibrous cortical defect

Osteoblastoma in vertebra, osteoid osteoma in diaphysis

Sclerotic metastasis in men – prostate should be thought

Parosteal osteosarcoma – behind distal femur and in older ages

Radiology of musculuskeletal infections

Osteomyelitis – oyun çocukları ve erkek M/F=3

Diabetic foot

Mostly btw 2-12CT – vertebra tuberculosis or abscess biopsy

Brodie’s abscess – density is higher compared to tumors, pus containing

material

Garre can become osteosarcoma

Potts disease vs. brucella

pyogenic spondylitis – iatrogenic,after surgey

septic arthritis – monoarthricular

toxic synovitis – clinical info needed, joint fluid aspiration

Imaging in arthritis

Periarticularosteopenia – eklemin çevresindeki kemikler shafta gore daha

radioluscent

Inflammatory arthritis – cartilage cap protects

Seronegative arthritis – rheumatoid factor is negative

Ankylosing spondylitis- male, HLAB27 positive

Medial side of knee, peak point of acetabulum, thumb are the most

common sites,

RA – uniform eklem daralması

No synovium in IV disc – eklimi tutmaz atlanoaxiali tutar

AS- mri diagnosis

Reiter syndrome – triad may involve enteritis, more in male due to more

common seen gonococcal urethritis, common in Achilles tendon

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Psoaris – erosive, pencil in the cup

Ivory phalanx – diffuse sclerosis in patients with skin lesions

Asymmetric osteophytes in vertebrae

Gout- tophi in bursa

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Sports traumatology 20.11.2014 18:14

Tendon injury

Exertional compartment syndrome: muscle hypertrophy

Do not move the casualty immediately, call medical service

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Population health 20.11.2014 18:14

Airway, breathe, circulating blood - abc for critical situation

OPQRST – complaining pain – onset, presentation/provocation, quality,

radiation, severity on a scale, time

Chest pain –

Risk factors for CAD: dm2, smoking, hypertension, HLD

Family history is the greatest risk

Check for depressed/suicidal

S1 – pulmonary valves open

S2 – valves close, end of systole

S3 – anytime the musculature gets stiff

Chf – listening lungs filled with fluid, blood cant leave the lung, high

pressure gradient causes pulmonary edema

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Musculoskeletal Tumors 20.11.2014 18:14

Most common in young patients

Early diagnosis is crucial

Night pain in children 10-25 – osteoid osteoma

Check for lymph nodes

Planning the biopsy approach

X-ray: lateral and AP

Benign tumors have sclerotic margin, grow slowly

Onion skin – ewing sarcoma

Sunburst – osteosarcoma

Codman triangle – osteosarcoma

MRI- soft tissue, bone marrow detailed information to evaluate tumors

Scintigraphy - bone metastasis

Malignant tumor: first save lives then extremities, wide resection andthen reconstruction

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20.11.2014 18:14

Instability is the major cause of local back pain

First examination – flex the back then extend and if there is pain in

extension – catch sign

Lumbar extension sign

Nerve root is irritated by PG,PLA2, LT, HA

Outer fibers of annulus fibrosus have nociceptors

If you have pain in lateral and backward extension -> facet joint pain

Lumbar canal stenosis – snoop test – as the patient walks, there are more

narrowing and neural ischemia, patient bends forward to relieve the pain

and tingling

Grade 4 spondylolisthesis – treated with surgery always

Ligamentum flavum hypertrophy, multisegmented degenerated disc cannarrow the spinal canal

Below 20 – inflammatory LBP / after 55 - malign disease

Lung, breast, prostate cancers and multiple myeloma metastasize to bone

Sıj pain – referred pain always above the knee

Line on crista iliaca – L4 level

Ankylosing spindylitis – abnormal pelvic lumber rhythm, no motion on

lumbar region while bending forward

Trandelenburg test, gillet test: finger should go upSLRT – positive if pain occurs at 40*

Ext halluces longus – strength test for L5 root

Ankle dorsiflexors – tibialis anterior

Cervical spinal stenosis

Scheurmann disease – vertebra takes a wedge shape, kyphosis

Qprst for pain evaluation

Check for red flags

Case-1

Step sign – when you palpate spinal processes, there is a gap true mostly

in obese people, spondylolisthesis

Shortening of walking distance, forward bending relieves pain, step sign

positive,

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If there was diabetes, polyneuropathy would occur

Diagnosis: lumbar cana stenosis

Investigation: MRI

She is obese, protruded abdomen -> spondylolisthesis

Management: diet, lumbar & abdominal support, exercise,follow up

surgery if needed

Case-2

SIJ pain increases while sitting, bending forward

Young patient, morning stiffness – spondylitis

Gillet +, stiff back -> restricted lumbar ROM

Ankylosing spondylitis

Case-3

Protection of the back, educating patient, exercise

Disc rupture

Physical therapy

Disc Hernia

Posterolateral side – most common protrusion due to weakness ofposterior lateral ligament

Myelopathy – 1st motor neuron cord pressure

Radiculopathy – 2nd motor neuron signs, exiting root compressed

Conus medullaris syndrome – 1st motor neuron

Cauda equine syndrome – 2nd motor neuron

ALS ust extremite 2. Motor neuron, alt extremite 1. Motor neuron

bulguları

Vertebral fractures

Spontaneous fracture – osteoporosis

Intense pain, may compress medulla spinalis, compression facture

Atlas fracture – diving, elevator accidents

Odontoid – C2 dens fracture open mouth xray AP

C2 axis fracture – extreme extansion

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Edema – upwards medulla oblongata affects respiratory and cardiac

arrest or c4 phrenic nerve – teardrop fracture anterior corpus fracture

Burst fracture – decreased height, communiuted violent trauma

differentiate from compression fracture, which is due to minor trauma or

osteoporosis

Case discussion

Case-1

52 F LBP, R leg pain and numbness

Osteoid arthritis

Leading cause of disability in elderly

Valgus knees and flexed knees in standing – knee OA

Only rectus femoris is biarticular – football player muscle, they are

operated in meniscus lesions

Snapping hip – sound when ext rotation of the hip joint

Evaluation of OA

Kellfren Lawrence radiologicalWomac-functionale-

Osteonecrosis – overuse syndrome in young people, divers,

Drug response of patients- esp to analgesics and steroids – chromosome

p??

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Scoliosis & Kyphosis 20.11.2014 18:14

Cervical lordosis – 3 mo

Thoracic kyphosis – 6 mo

Lumbar lordosis – 14-16 mo

If the skeletal of the child is mature, the curves are determined. Scoliotic

curves will change magnitude if it can grow further

Riser 0-5 degress of skeletal maturity

Cobb angle measurement – magnitude of scoliotic curve

VACTERL – assn. of congenital anomalies

scoliosis - >10* cobb angle

side of convexity determines L or R

rib humpsyringomyelea

Limping child

In painful limb, stance phase is shorter in anthalgic gait

Steppage gate – you lift your foot higher, foot drop

Trandelenburg gait – pelvis falls to the unaffected side, hip abductor

efficiency, assn. in DDHInsertion and origin distance decreases in hip dislocation as greater

trochanter goes proximally – malfunction of hip abductors

Risk factor slide is very important

Breech positioning more or equal to 34 wk gestation – if hip comes first

Galeazzi test – the thigh is shorter

Trandelenburg gait is different from the test – trunk shifts, pelvis shifts,

waddling gait if the problem is bilateral – these are present in walking age

Skin fold, bartholoni, ortholani, galeazzi sign – present in the new boneHip ultrasonography – until 6 mo then pelvis xray 4-6 mo

Closed/opened reduction – opening or no opening the capsule of the hip

joint

Pavlik harness 0-4 mo keeping hips in physiological position

Reducible hip is Ortholani positive

Leggs calve perthes disease

Decreased internal rotation of the hip joint

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Neuro-muscular diseases

GMFCS classification system

Spastic diplegic patient –

Biarticular muscle – psoas, hamstrings, gastrocnemius

Spina bifida

Lowest functioning level by myelomeningocele is

Birth defect –

Chiari II – hydrocephalus

Arthrogryposis – contractures at 2 or more joints, normal intelligence

Progressive neuromuscular diseases

Duchenne muscular dystrophy – dystropin is absentSpinal Muscular Atrophy – survival motor neuron gene 1 is absent, there

are 3 types

Poliomyelitis – prevention steps started in 1990s but increased due to

immigration, infection and destruction of anterior horn, no sensory

changes

Congenital deformities of the musculoskeletal system

Deformation due to mechanical forces are reversible

Dysplasia, deformation, malformation, disruption

Sequence: pattern of multiple defect derived from single known or

presumed structural defect

Syndrome: pattern of multiple defects related but not representing a

single sequence

Preaxial (lateral part of hand, medial part of foot) and post axial terms

clubfoot: CAVE

rhizomelia, mesomelia, acromelia

proximal inbtw tip of the long limb are deficient

achondroplasia is rhizomelia type?

Anterolateral bowing – neurofibromatosis

7/24/2019 Mskl 303 Notes


Px picture – fibular hemimalia, post axial longitudinal limb deficiency,

anteromedial bowing

Posteromedial deformity improves itself, leaving a limb discrepancy

7/24/2019 Mskl 303 Notes


Nuclear Medicine 20.11.2014 18:14

bone scintigraphy – low specificity

lytic metastasis to vertebra – prostate cancer

radiotracers not very important – for scintigraphy, diphosphanate is used

tracer detects new bone formation

diphosphosphanate replaces PO4 in HAP

Fluoride replaces hydroxide ion

Not in direct contact of capillaries and osteoid surface, large ECF in bone

3-phase bone scan: 1st phase vascular supply, 2nd blood in soft tissue, 3rd

phase osteoblastic activity

scintigraphy and ct at the same time

lesions with osteoclastic are difficult to detect – multiple myeloma, renal

cell carcinoma, lymphoma, leukemia, thyroid cancer

super scan – drug spread to all metastases, no sign of kidneyF18 pet ct volume rendered

MRI 1* dor osteosarcoma evaluation

Typical osteoid osteoma, sclerotic center well vascularity called nidus as

an intense point, new bone formation area in later stage

If no osteoblastic activity seen in scinitgrapy, benign tumor

Enchondroma is not diagnosed, just confirmed and checked for polyostotic

lesions

Septic thrombi or infiltration prevents good perfusion to the bone, traceruptake may decrease – do not crossover osteomyelitis!

To see soft tissue infection, mark leukocytes

If no sign on leukocyte labeling, no infection

Shin splints – no sign on medulla

Fracture – medulla involved

Paget disease – all parts of the bone is effected, well vascularized

1* hyperparathyroidism – 2.5 cm PTH adenoma

7/24/2019 Mskl 303 Notes


Osteomyelitis20.11.2014 18:14

1. hematogenous= usually microbial

microvasculature can be inadequate

complication of UTI, GI infections like appendicitis

2. contiguous spread , may be poly-microbial

3. direct inoculation trauma&surgery

acute OM prior to sequestra development

S. aureus most common pathogen – cover this in empiric treatment

Gram – bacteria like Pseudomonas more common in immunosuppressed

patients – diabetes px

Sickle cell anemia – salmonella infection

Tuberculous- thoracic vertebrae on mri

Pyogenic – hx of spinal surgery

Slime formation – more invasive bacteria on catheters S. epidermidis

Treatment – cephazoline for Methilicilin sensitive SA , vancomycin for

MRSA

Quinolones, cephalosporins, rifampin important and potent for biofilm

forming bacteria like brucella and tuberculosis infections

At least 6 wks of treatment

Radiology and esr, crp lab test follow up

Acute phase at least in one month

Osteomyelitis and septic arthritis case discussions

Case 1

Above 50.000 mg/dl WBC, septic

In synovial fluid, Bacterial infection gets glucose gets lower

Debridement and empirical antibiotic treatment

Culture (–) due to prior antibiotic use

Case 2

Osteomyelitis – soft tissue involvement, may be long term infection

Surgery, antibiotic cement

Case 3

Iatrogenic infection

Soft tissue abscess on US or not much on CT

7/24/2019 Mskl 303 Notes


Scintigraphy may be preferred

Arthroplasty infection – scintigraphy positive

Acute phase – not radiography dependent, follow the steps although

normal

HIP Prosthesis

Arthroprosthesis is joint replacement– endoprosthesis

For today – spine body possible

Not working joint – stiff and painful hip

Narrowing of joint space, sclerosis, subchondral cyst, osteophyte

41y F both femoral heads are dislocated, DDH, Trandelenburg sign

partial hip arthroplasty – the stem is fixed with cement or cement is not

used but a special design of prosthesis so that bone would grow into the

material to fix it

postpone the surgery because it should be renewed after

in cartilage defect – limited surface replacement

chndroblast replacement if less than 2 cm^2

Knee

Hinge joint,

Degenerative arthritis needs surgery

Polyethylene is radioluscent

Deformity is corrected, goal is pain free movement for daily activity

Shoulder: reverse arthroplasty, they don’t need rotator cuff,

Total elbow prosthesis, hip fractures may need arthroplasty but very rare

in knee and elbow

Arthrodesis – eklemleri kaynatma, we can fuse the ankle joint but another

solution total ankle arthroplasty

7/24/2019 Mskl 303 Notes


20.11.2014 18:14

Documents

Mskl 303 Notes