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- Trochanteric bursitis
- Fibrous Dysplasia
- Specific Findings/Manifestations
Acute Knee Pain [AIM]Causes: see acute arthritis Strategy: use Ottawa rules to determine need to r/o fracture with plain film; XR can comment on OA (34% will have OA) Ottawa knee rules: injury due to trauma, age > 55, tenderness at head of fibula or patella, inability to bear weight for 4 steps, inability to flex knee to 90 degrees If history suggests ligament or meniscus tear, exam is 80-90% sensitive and specific Lachman test better than anterior drawer sign / Pivot test / McMurray test [diagram of maneuvers] Plain films improves sensitivity but not specificity Bursitis Trochanteric bursitisLateral hip and thigh pain with tenderness over trochanter / pain with abduction of hips against resistance Bone Fractures types complete, incomplete, comminuted (splintered), compression, transverse, closed, open pathologic (site of pre-existing disease) healing inflammatory - hematoma, inflammatory cells, soft tissue callus at 1 week reparative -osteoblasts deposit woven bone, cartilage envelopes fracture site by week 2-3 remodeling - ossification of cartilage, bony callus bridge, further mineralization Compression Factures (of vertebrae) ?usually do not cause radicular pain Plain Radiography / characteristics of common bone problems Osteomyelitis – end plate bony erosions which cross disk space (tumors do not usu. cross disk space) Hyperparathyroidism – subperiosteal resorption Myeloma – osteopenia and lytic lesions RA – erosions of bone cortex and cartilage in joint spaces Ankylosing spondylitis – squaring of vertebral bodies Bone Malformations Osteopetrosis (Albers-Schonberg Disease) osteoclast dysfunction / thickening of cortex, narrowing of marrow (marble bones) / brittle, fracture easily / autosomal recessive (AR) worst of 4 forms / fractures, anemia, hydrocephaly in utero widened metaphyses and diaphyses Achondroplasia AD or new mutation (80%) / paternal effect / premature ossification of epiphyseal growth plate normal health, intelligence / associated with platybasia, which results in obstructive hydrocephalus and increased ICP / compression of nerve roots
deficiency in normal type I collagen / thin, brittle bones / blue sclera (choroid), abnormal joints, ligaments, teeth, skin, deafness (ossicles) OI congenita (severe, neonatal disease, fatal) / heterogeneous inheritance OI tarda (compatible w/ life) / AD inheritance Paget’s disease (osteogenesis deformans) disorder of bone remodeling / more bone, worse quality / older males / usually polyostotic axial skeleton / viral etiology? Pathology: osteoclasts in Howship’s lacunae in early lytic lesions, mosaic pattern of new bone
idiopathic cortical hyperostosis / no good treatment Osteonecrosis (avascular necrosis) Common causes: idiopathic, fracture, steroids Pathology: subchondral infarcts, triangular wedge-shaped necrotic segment, microinfarct (no osteocytes in lacunae), overlying articular cartilage viable (nourished by synovium) Diagnosis: MRI gold standard (detects lesions in ischemic stage), CT 2nd choice, plain films only positive after infarction occurs, bone scan positive after infarction Note: a form of reversible AVN (pre-AVN if you will) can look just like classic AVN on MRI (not sure what difference this will make in management) Legg-Calve-Perth’s avascular necrosis of femoral head / 2-12 yrs, males > females 4:1 / usually painless limp Treatment: medical management 1st or surgery if discovered late or treatment failure Osgood-Schlatter’s Inflammation of insertion of patellar tendon / rest and decreased physical activity Fibrous DysplasiaMore in females / 20s and 30s / 80% monostotic / ribs, tibia (20%), femur, mandible or maxilla / often with multiple skeletal lesions Treatment prevents progression and/or fracture McCune-Albright syndrome (Albright’s hereditary osteodystrophy) Polyostotic fibrous dysplasia, multiple large pigmented nevi (usually on one side of trunk), precocious puberty (more in females), associated with pheochromocytoma Mazabraud’s syndrome Osteoporosis [annals] reduction in mineralization, bone mass / increased resorption, decreased deposition / primary (age, 14% of white women; 3-5% of white men develop osteoporosis in lifetime) Secondary causes: endocrine (gonadal deficiency, hyperprolactinemia), steroids, hyperthyroid, hyperparathyroid, renal osteodystrophy, vitamin C and D deficiency or malabsorption), drugs (cyclosporine, antiepileptics, heparin, GnRH) Risk Factors: maternal fracture (1.8), hyperthyroidism (1.7), anticonvulsants (2.0), BMD abnormal by 1 SD (1.6), any previous fracture (1.5), caffeine (1.2) Diagnosis: all women > 65 or fracture < 65 yrs should have bone mineral density testing (BMD) / Dexa scans Z score compares same age, T score compares to young, adult normal (T scores more useful; osteoporosis = T score < (-) 2.5 SD; every 1 SD below mean doubles fracture risk) / note: alkaline phosphatase mildly elevated in presence of healing fracture Ddx: osteomalacia, Paget’s, osteomyelitis, malignancy Treatment: underlying cause and PBP’s / current thinking is not to use estrogens for prevention of osteoporosis because cardiovascular risks outweigh benefits; only use estrogen for severe, persistent symptoms (see Women’s Health Initiative) / can leave on HRT if already on (and no proven CV disease) / postmenopausal women should receive 1500 mg daily calcium (1000 mg if on HRT; most diets only provide 600-700mg) or 400-800 IU vitamin D or a bisphosphonates (decrease incidence of fractures 30-50%) / premenopausal need 100-200 mg/d calcium Hip (see below for more) risk varies more epidemiologically than other / 17% women > 50 yrs / 6% men / happens from falls / initial mortality may be increased up to 10% in 1st yr, then about 50% will not be able to ambulate, then up to 33% become dependent on living Spine 2-3x increase risk > 60 yrs in women / 16% lifetime risk / steroids, lack of estrogen / from normal activities / 66% go undiagnosed / up to 50 yrs, men just as high risk (risk factors include cigarettes, smoking, trauma, Tb, peptic ulcer) Wrist mostly peri/post-menopausal women Osteomalacia and rickets inadequate mineralization / vitamin D deficiency, hypocalcemia and hypophosphatemia / rickets (children): craniotabes (thinning) and frontal bossing, rachitic rosary (costochondral bulging), enlarged wrists and ankles, pigeon breast, lumbar lordosis / osteomalacia (adults): aches and pains / Looser’s zones, Milkman’s fractures (bilateral, symmetrical, right angles) / abundant osteoid (non-mineralized) on uncalcified cartilage / loss of bone density, cortical thickness Osteomyelitis (see other) Hip Fractures women > men Average mortality 4% / average 1 year mortality 20% Diagnosis: regular AP lateral X-rays (Johnson and Judet views) / CT scan / MRI Femoral neck fractures – graded as Garden I-IV scale Faster operation (if needed) leads to better outcome (operate < 6-12 hrs if possible) / AP view with internal rotation may be helpful for diagnosis Trochanteric fractures if < 1 cm displacement (and no tendency to more displacement), bedrest with early WBAT is an option / if > 1 cm displacement, consider reduction and internal fixation (younger, active) versus conservative management (older, less active) Intertrochanteric fractures – more in elderly women high morbidity, mortality (worse if not operated on) / presentation usually leg is shortened, externally rotated initial evaluation be sure to assess and consider other concomitant damage to joints (pelvis will be fractured in 10%), nerve damage (can be caused by expanding hematoma; peroneal nerve distribution most sensitive and common neurologic finding is weakness in the extensor hallucis longus muscle, signifying a sciatic nerve injury), acute blood loss, vascular damage, AND why the patient may have fallen (cardiac arrhythmia, etc.) prophylactic antibiotics are indicated for all open fractures and for patients being prepared for immediate internal fixation (cefazolin) / if moderate contamination, an associated laceration greater than 1 cm, or if soft tissue injury is extensive, a loading dose of an aminoglycoside should be added to the cephalosporin / a penicillin should be added for clostridial coverage if the injury occurs in an environment that is highly contaminated (proper abx leads to 44% decrease in post-operative infections. complications: avascular necrosis (20% in high-risk subgroups), complications associated with operative delay include recurrent hip dislocations, post-traumatic arthritis, myositis ossificans and aseptic necrosis (8% in anterior fracture dislocations, and 10-20% in posterior fracture dislocations) Other Bone Disorders Scoliosis adolescent females > males / 20% with positive family history Slipped capital femoral epiphyses 20% with referred knee pain (can be misleading) / occurs in pubescent males, happens gradually, can be bilateral / Treatment: surgical with pinning Villonodular synovitis (benign neoplasms) aggregates of polyhedral cells, hemosiderin, foam cells, giant cells, zones of sclerosis Treatment: surgery if possible, usually difficult to excise
single or multiple, diffuse involvement, red-brown projections giant cell tumor of tendon sheath (localized tenosynovitis) small, discrete nodule Bone Cancer mets most common form: BLT2KP lung > breast (lytic) > prostate (blastic) > testes, kidney primary malignant: OS, malignant fibrous histiocytoma, adamantinoma, chordoma Osteochondroma most common primary bone lesion / young males / sessile or stalked / cartilage cap / usually stops growing as bones mature Chondroma single or multiple (Olier’s Disease, Maffucci’s syndrome) / short bones of hands, feet / radiolucent / lobulated, hypercellular, disorganized / focal calcification w/in lesion / self-limited disease Chondrosarcoma (good prognosis) proliferation of malignant cartilage / older males / axial skeleton / surgery only useful option Osteoid osteoma very common / young males / < 2 cm growth / appendicular skeleton / produces pain at night (relieved by aspirin) / radiolucent lesion surround by reactive bone formation / surgical removal 25% relapse due to poor nidus locating by surgeon
pre-op and post-op chemotherapy / arm, leg bones (mostly in metaphysis of long bones, usually near knee) produces bone, cartilage, spindle cells / osteoblastic response and large, adjacent soft-tissue mass / cortical destruction with extension in soft tissues (Codman’s triangle) Course: usually have mets Parosteal osteosarcoma (POS) (excellent prognosis) young, early middle age, women / long bones / radiolucent ‘string sign’ along cortex / spindle cells produce well-formed bone Ewing’s sarcoma (variable prognosis) Pathology: PAS+ cytoplasm / small cell neoplasia / unknown histiogenesis very young, males, lower extremities / flat bones or diaphysis of long bones (not usually in metaphysis) Radiology: moth-eaten intramedullary pattern (permeative appearance), ‘onion skin’ periosteal reactive bone Treatment: still evolving Fibrous cortical defect very common / young, males, long bones Radiology: metaphysis, sub-cortical, soap bubbles, sclerosis at interface spindle cells, foamy macrophages, hemosiderin, chronic infiltrate / self-limiting at skeletal maturity Fibrous dysplasia very common / single, multiple / young, localization random Radiology: radiopaque, ‘shepherd’s crook’ of proximal femur / spindle, cells, woven bone, lack of osteoblastic rimming, Chinese character appearance / no treatment unless symptomatic / excellent prognosis Malignant fibrous histiocytoma (poor prognosis) similar demographics to OS / Radiology: metaphysis, destructive, radiolucent / anaplastic spindle cells, storiform pattern / treatment same and prognosis slightly worse than OS Giant cell tumor of bone benign but aggressive local tumor / young, wide distribution / hemorrhage / surgery when possible / extended curettage (experimental) or resection / prosthesis / 98% monostotic radiation contraindicated (secondary sarcomas) Adamantinoma (good prognosis) primary malignant bone tumor / young males, tibia/fibula / Radiology: may be multifocal (observe carefully) / epithelial or endothelial proliferation / complete surgical extirpation Chordoma malignant bone tumor arising from notochord / 40s to 60s / males / physaliferous cells in acid mucoid background / surgery and post-op radiation survival: sacral 60% (fair) 5 yr, cervical (horrible) 50% 5 yr 0% 8 yr
Treatment: usually cured by excision Unsorted Baker’s cyst can mimic phlebitis 1) swollen calf 2) extrinsic venous compression / diagnose with MRI / usually self-limited (ruptures, causes pain/swelling) then goes away / may recur Pre and Post Op (specific to ortho) Total hip – warfarin started pre-operatively, goal INR 2.0-2.5 Dermatology Drug Reactions Eczematous diseases atopic dermatitis, seborrheic dermatitis, contact dermatitis, other eczematous Fungal Infections Papulosquamous Disease psoriasis, lichen planus, lichen simplex, pityriasis rosea Epidermal Tumors benign, pre-malignant, malignant Dermal Tumors benign dermal tumors, hemangiomas, Kaposi’s sarcoma Melanocytic Tumors benign, pre-malignant, melanoma Acne vulgaris Vesiculobullous Intraepidermal Subepidermal I urticaria, atopic dermatitis II pemphigus, pemphigoid, herpes gestationis, epidermolysis bullosa III erythema multiforme (drug eruptions), dermatitis herpetiformis Leukocytoclastic vasculitis Congenital Skin Disorders Pediatric Skin Conditions ETN, PN, salmon patch, milia Dermis [infinite pics] Dermnet good site // lots of pics Specific Findings/ManifestationsPruritis Treatment: atarax and doxepin are best / sarna is also good / avoid benadryl (because it’s actually not good for itching), avoid benzocaine (lidocaine is better), avoid topical neomycin (frequently causes irritation) Download 3.95 Mb. Share with your friends:
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