OITE 2010 DISEASES
Ortho Diseases3. A 32-year-old man has had a 2-year history of  left groin pain. Radiographs, MRI scans, and a  biopsy spe...
3A     3B
3C
3D
3E
3F
Ortho Diseases3. A 32-year-old man has had a 2-year history of  left groin pain. Radiographs, MRI scans, and a  biopsy spe...
Clear Cell Chondrosarcoma• Rare variant of chondrosarcoma(2% of all  chondrosarcoma, 0.2% of biopsy-analyzed  primary bone...
• XR: expansile radiolucent bony lesion, absence of any  periosteal reaction and absence of soft tissue mass +/-  calcific...
Recommended Reading:• Seo SW, Remotti F, Lee FYI. Chondrosarcoma  of bone. In: Schwartz HS, ed. Orthopaedic  Knowledge Upd...
Ortho Diseases4. When patients with rheumatoid arthritis are  being treated with the disease-modifyingantirheumatic drug a...
Ortho Diseases4. When patients with rheumatoid arthritis are  being treated with the disease-modifyingantirheumatic drug a...
Adalimumab (Humira)• Mechanism: TNF α Inhibitor• TNFα - highly inflammatory macrophage-derived  cytokine, plays a critical...
Recommended reading:• Shojania K, Esdaile JM, Gredanus N. Arthritis.  In: Vaccaro AR, ed. Orthopaedic Knowledge  Update 8....
Ortho Diseases21. Which of the following is a recognized  complication of extra-articular  corticosteroid injections?1- Ac...
Ortho Diseases21. Which of the following is a recognized  complication of extra-articular  corticosteroid injections?1- Ac...
Fat Atrophy• More common with less soluble agents  (eg. Triamcinilone)• Effects can last >6mo• Other side effects steroid ...
Recommended Reading/References:• Cole BJ, Schumacher HR Jr. Injectable  corticosteroids in modern practice. J Am Acad  Ort...
Ortho Diseases24.Figures 24a through 24c show the radiographs  and CT scan of a 7-year-old girl who has had  mild discomfo...
24A      24B
24C
Ortho Diseases24.Figures 24a through 24c show the radiographs  and CT scan of a 7-year-old girl who has had  mild discomfo...
Ossifying Fibroma• Typically occurs in the jaw bone, only rarely in long bones where they  have been termed Osteofibrous d...
Pathoogy:•loose, often storiform fibrousbackground containing spiculesof woven bony trabeculae thatare lined by a layer of...
• Consider open biopsy even if radiographically  c/w OFD as could be early AD lesion.• Treatment controversial  – Traditio...
Recommended Reading:• Pitcher JD Jr, Weber KL. Benign fibrous and  histiocytic lesions. In: Schwartz HS, ed.  Orthopaedic ...
Ortho Diseases32. A 24-year-old woman reports a 4-month history  of knee pain. Radiographs, an MRI scan, and  biopsy speci...
32A      32B
32C
32D      32E
Ortho Diseases32. A 24-year-old woman reports a 4-month history  of knee pain. Radiographs, an MRI scan, and  biopsy speci...
Osteosarcoma• Most common bone sarcoma• Peak incident 2nd decade, assoc w/ peak growth• Most commonly occurs at sites of r...
• MRI: demonstrates extent of tumor  invasion of the surrounding soft tissues,  neurovascular involvement, extent of bone ...
Osteosarcoma Subtypes• Conventional: most common, 1st/2nd decade. High grade,  originating from intramedullary cavity.• Te...
• Tx: multidisciplinary.• Low grade or parosteal: Wide surgical resection.• High grade lesions or mets: pre-op chemo, wide...
Recommended Reading:• Damron TA. Orthopaedic Surgery Essentials,  Oncology and Basic Science. Philadelphia, PA:  Lippincot...
Ortho Diseases45.A 13-year-old boy has had right knee pain for  the past 4 months. Radiographs, bone scan, CT  scan, and b...
3A 45A         3B       45B
3C45C
45D
45E
Ortho Diseases45.A 13-year-old boy has had right knee pain for  the past 4 months. Radiographs, bone scan, CT  scan, and b...
Chondroblastoma• Benign neoplasm primarily affecting patients 10-  25 years old with a male predominance of 2:1• Most comm...
• Microscopically, there are sheets of  chondroblasts with background of  chondroid matrix. Calcification is present  givi...
Recommended Reading- Damron TA. Orthopaedic Surgery Essentials,  Oncology and Basic Science. Philadelphia, PA:  Lippincott...
Ortho Diseases57. Optimal management of osteoporosis diagnosed after a   hip fracture includes1- urgent medical consultati...
Ortho Diseases57. Optimal management of osteoporosis diagnosed after a   hip fracture includes1- urgent medical consultati...
• Hip, wrist, vertebral fractures in the elderly from low  energy mechanisms are termed fragility fractures as the  forces...
Recommended reading:- Miki RA, Oetgen ME, Kirk J, Insogna KL,  Lindskog DM. Orthopaedic management  improves the rate of e...
Ortho Diseases67. Which of the following diagnostic  modalities is most useful for the diagnosis  of proximal thigh deep v...
Ortho Diseases67. Which of the following diagnostic  modalities is most useful for the diagnosis  of proximal thigh deep v...
Deep vein thrombosis• 80-90% occur in operated limb• Peak incidence is 4 days after surgery and minimal after  day 17.• Cl...
Recommended Reading/References:- Conduah AH, Lieberman JR. Thromboembolism and   pulmonary distress in the setting of orth...
Ortho Diseases78.Paget’s disease of bone results from a defect in  which of the following processes?1- Bone resorption2- B...
Ortho Diseases78.Paget’s disease of bone results from a defect in  which of the following processes?1- Bone resorption2- B...
Paget disease•   Disorder of unregulated bone turnover. Excessive osteoclastic    resorption is followed by increased oste...
Recommended Reading/References:- Zuscik MJ, Drissi MH, Chen D, Rosier RN. Molecular and   cell biology in orthopaedics. In...
Ortho Diseases87.A 19-year-old college football player has had  suprapubic pain for the past 4 months. A  radiograph and C...
87A32A        32B
87B      87C
Ortho Diseases87.A 19-year-old college football player has had  suprapubic pain for the past 4 months. A  radiograph and C...
Osteitis Pubis• Painful, noninfectious, inflammatory condition involving  the pubic bone, symphysis and surrouding structu...
Recommended Reading/References:- Sekiya JK, Gibbs AE. Groin and pelvis injuries:   In: Kibler WB, ed. Orthopaedic Knowledg...
Question 104Paget’s disease is best characterized as increased boneturnover that results:1- from a sequenced missense gene...
Question 104Paget’s disease is best characterized as increased boneturnover that results:1- from a sequenced missense gene...
Question 104•   Paget’s disease - common geriatric problem, occurring in 3% to 4% of the    population over 50 years of ag...
Question 104Type I Collagen                  - Metabolic bone markers                  relating type I collagen           ...
ReferencesMurray MA. Bone metabolism and metabolic bone disease. In: Vaccaro AR, ed.Orthopaedic Knowledge Update 8. Rosemo...
Question 112A 7-year-old girl has activity-related leg pain.Radiographs and biopsy specimens are seen inFigures 112a throu...
Question 112A 7-year-old girl has activity-related leg pain.Radiographs and biopsy specimens are seen inFigures 112a throu...
Question 112•   A few fun facts about                                      There is no intralesional                      ...
References•   Pitcher JD Jr, Weber KL. Benign fibrous and histiocytic lesions. In: Schwartz    HS, ed. Orthopaedic Knowled...
Question 131Patients with multiple hereditary exostosis have a greaterrisk of the development of what kind of mesenchymalt...
Question 131Patients with multiple hereditary exostosis have a greaterrisk of the development of what kind of mesenchymalt...
Question 131•   Hereditary multiple exostoses (HME)     –   an autosomal dominant condition,         mutation of tumor sup...
Question 131•   Weber KL, O’Connor MI. Benign cartilage tumors. In: Schwartz HS, ed.    Orthopaedic Knowledge Update: Musc...
Question 150A 60-year-old patient who has diabetes mellitus withperipheral neuropathy has a plantar ulcer on the plantarsu...
Question 150A 60-year-old patient who has diabetes mellitus withperipheral neuropathy has a plantar ulcer on the plantarsu...
Question 150•   Key is recognizing that limited dorsiflexion has been implicated as a    contributing factor to excessive ...
Question 150•   Lin SS, Lee TH, Wapner KL. Plantar forefoot ulceration with equinus    deformity of the ankle in diabetic ...
Question 171Figures 171a through 171g show the radiographs, MRIscans, and biopsy specimens of a 9-year-old girl who report...
Question 171Figures 171a through 171g show the radiographs, MRIscans, and biopsy specimens of a 9-year-old girl who report...
Question 171•   Ewing’s Sarcoma Clinical Features:     –   Second most common bone tumor         (after osteosarcoma) occu...
Question 171373 patients in theIntergroup Ewing’s Sarcoma    Study 7299, common    radiographic findingsIncluded:1. poor m...
Question 171•   On pathology: small    round uniform cells with    high nucleus-    tocytoplasmic ratio and    grow in den...
Question 171•   Patterson FR, Basra SK. Ewing’s sarcoma. In: Schwartz HS, ed.    Orthopaedic Knowledge Update: Musculoskel...
204. A 26-year-old woman has had wrist pain for thepast 3 weeks. Radiographs and an MRI scan are seen inFigures 204a throu...
204A
204B
204C
204D
204E
204. A 26-year-old woman has had wrist pain for thepast 3 weeks. Radiographs and an MRI scan are seen inFigures 204a throu...
Giant cell tumors are commonly seen in the knee (50%), distal radius (as in this case), andproximal humerus. They are more...
References204.Mirra JM. Bone Tumors. Philadelphia, PA: Lea and Febiger;1989:941-1022.McDonald DJ, Weber KL. Giant cell tum...
224. Figures 224a and 224b show the radiographs of a40-year-old woman with a familial history of ‘higharches’ with weaknes...
224A
224B
224. Figures 224a and 224b show the radiographs of a40-year-old woman with a familial history of ‘higharches’ with weaknes...
High longitudinal arches, or pes cavus, occur frequently in neurologicaldisorders such as Charcot-Marie-Tooth. Weakness an...
References224.Alexander IJ, Johnson KA. Assessment and management of pescavus in Charcot-Marie-Tooth disease. Clin Orthop ...
241. Figure 241 shows the radiograph of a 40-year-oldman who reports a 1-year history of forefoot pain andswelling. Examin...
241
241. Figure 241 shows the radiograph of a 40-year-oldman who reports a 1-year history of forefoot pain andswelling. Examin...
Psoriatic arthritis is an seronegative spondyloarthropathy thataffects 10-30% of people with psoriasis. Classic findingsin...
References241.Berberian WS, Najarian RG. Midfoot and forefoot arthritis andhallux rigidus. In: Pinzur MS ed. Orthopaedic K...
253. A 43-year-old woman who is right-hand dominant fellonto her outstretched arm while rollerblading 1 day ago.She report...
253. A 43-year-old woman who is right-hand dominant fellonto her outstretched arm while rollerblading 1 day ago.She report...
Type 1 complex regional pain syndrome (CRPS), formerly known as reflex sympatheticdystrophy, is characterized by pain, swe...
References253.Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Canvitamin C prevent complex regional pain syndrome...
263. The antirheumatic drug anakinra’s mode of action isvia inhibition of which of the following?1-   IL-12-   IL-63-   Rh...
263. The antirheumatic drug anakinra’s mode of action isvia inhibition of which of the following?1-   IL-12-   IL-63-   Rh...
Anakinra (brand name Kineret) is a competitive inhibitor of theinterleukin-1 receptor. It is a approved for treatment of R...
References263.Shojania K, Esdaile JM, Greidanus N. Arthritis. In: Vaccaro AR, ed.Orthopaedic Knowledge Update 8. Rosemont,...
275. A 10-year-old girl has a painful right tibial tubercle.She has swelling but no fever. Figures 275a through275e show A...
275A
275B
275C
275D
275E
275F
275. A 10-year-old girl has a painful right tibial tubercle.She has swelling but no fever. Figures 275a through275e show A...
Eosinophilic granuloma is a form of Langerhans Cell Histiocysosis (Histiocytosis X). It is acondition that mimics primary ...
References275.Mirra JM. Bone Tumors. Philadelphia, PA: Lea and Febiger;1989:1022-1045.Pitcher JD, Weber KL. Benign fibrous...
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Oite 2010 disease

  1. 1. OITE 2010 DISEASES
  2. 2. Ortho Diseases3. A 32-year-old man has had a 2-year history of left groin pain. Radiographs, MRI scans, and a biopsy specimen are seen in Figures 3a through 3f. What is the most likely diagnosis?1- Enchondroma2- Chondroblastoma3- Giant cell tumor4- Osteonecrosis5- Clear cell chondrosarcoma
  3. 3. 3A 3B
  4. 4. 3C
  5. 5. 3D
  6. 6. 3E
  7. 7. 3F
  8. 8. Ortho Diseases3. A 32-year-old man has had a 2-year history of left groin pain. Radiographs, MRI scans, and a biopsy specimen are seen in Figures 3a through 3f. What is the most likely diagnosis?1- Enchondroma2- Chondroblastoma3- Giant cell tumor4- Osteonecrosis5- Clear cell chondrosarcoma
  9. 9. Clear Cell Chondrosarcoma• Rare variant of chondrosarcoma(2% of all chondrosarcoma, 0.2% of biopsy-analyzed primary bone tumors)• Usually low grade, slow growing, infrequent metastases, but frequent local recurrence• Male:Female 1.3:1• most commonly proximal humerus or femur (75%). 15% around the knee(distal femur and proximal tibia). In about 10%, the lesion has been noted in the skull, spine, ribs, pelvis,ulna or phalanges.• Epiphyseal +/- extension into metaphysis.• young adults, 20- 50 yo
  10. 10. • XR: expansile radiolucent bony lesion, absence of any periosteal reaction and absence of soft tissue mass +/- calcifications• MR: Well demarcated, T1 -relatively homogeneous low to intermediate signal intensity, T2- heterogeneous high signal intensity• Path: large round-to-oval tumor cells w/ distinct borders, abundant clear cytoplasm and a centrally located round nucleus. Typically see woven bone trabeculae within the microlobules or scattered between sheets of tumour cells. Giant cells present.• S-100 positive• Tx: operative resection with a wide margin.References:SPRINGFIELD DS, GEBHARDT MC, MCGUIRE MH: Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Chondrosarcoma: a Review. J. Bone Joint Surg. Am., Jan 1996; 78: 141 - 9.AYOUB KS, GRIMER RJ, CARTER SR, MANGHAM DC, DAVIES AM, TILLMAN RM:. Clear cell chondrosarcoma of bone. Sarcoma (1999) 3, 115-119.Itälä A; Leerapun T, Inwards C, Collins M, Scully SP: An Institutional Review of Clear Cell Chondrosarcoma. Clin Orthopaedics and Related Research Number 440, pp. 209–212
  11. 11. Recommended Reading:• Seo SW, Remotti F, Lee FYI. Chondrosarcoma of bone. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:185-195.• Damron TA. Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:201.
  12. 12. Ortho Diseases4. When patients with rheumatoid arthritis are being treated with the disease-modifyingantirheumatic drug adalimumab, what is the optimal time for surgical intervention?1- Immediately after infusion2- Approximately 10 days after injection3- Only after a year of continuous therapy4- When drug levels are at their highest5- When the pharmacokinetic levels reach equilibrium
  13. 13. Ortho Diseases4. When patients with rheumatoid arthritis are being treated with the disease-modifyingantirheumatic drug adalimumab, what is the optimal time for surgical intervention?1- Immediately after infusion2- Approximately 10 days after injection3- Only after a year of continuous therapy4- When drug levels are at their highest5- When the pharmacokinetic levels reach equilibrium
  14. 14. Adalimumab (Humira)• Mechanism: TNF α Inhibitor• TNFα - highly inflammatory macrophage-derived cytokine, plays a critical role in the joint destruction of patients with RA• TNF α Inhibitors provide symptomatic and functional improvement and slows radiographic progression of disease• Enhances the risk of infection with mycobacteria and other opportunistic microorganisms, as well as increasing risk of postoperative infections.• Half life 10-13.6 daysReferences:Giles JT, Bartlett SJ, Gelber AC, Nanda S, Fontaine K, Ruffing V, Bathon JM. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Rheum. 2006 Apr 15;55(2):333-7.Pfeiffer M, Koller M, Wnivernhaus A, Trieb K. A postoperative infectious complication in a patient with rheumatoid arthritis treated with adalimumab. Z Rheumatol 2006 Dec;65(8): 725-7
  15. 15. Recommended reading:• Shojania K, Esdaile JM, Gredanus N. Arthritis. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:234-239.• Giles JT, Bartlett SJ, Gelber AC, Nanda S, Fontaine K, Ruffing V, Bathon JM. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Rheum. 2006 Apr 15;55(2):333-7. PubMed PMID: 16583385.
  16. 16. Ortho Diseases21. Which of the following is a recognized complication of extra-articular corticosteroid injections?1- Acne2- Depression3- Fat atrophy4- Hypogonadism5- Manic episode
  17. 17. Ortho Diseases21. Which of the following is a recognized complication of extra-articular corticosteroid injections?1- Acne2- Depression3- Fat atrophy4- Hypogonadism5- Manic episode
  18. 18. Fat Atrophy• More common with less soluble agents (eg. Triamcinilone)• Effects can last >6mo• Other side effects steroid injections: Post- injectional flare (1-10%), facial flushing (15%, women>men), infection, sepsis, skin depigmentation, perilymphatic atrophy, hyperpigmentation,tendon rupture.
  19. 19. Recommended Reading/References:• Cole BJ, Schumacher HR Jr. Injectable corticosteroids in modern practice. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):37-46. Review. PubMed PMID: 15712981.• Kumar N, Newman RJ. Complications of intra- and peri-articular steroid injections. Br J Gen Pract. 1999 Jun;49(443):465-6. PubMed PMID: 10562748; PubMed Central PMCID: PMC1313446.
  20. 20. Ortho Diseases24.Figures 24a through 24c show the radiographs and CT scan of a 7-year-old girl who has had mild discomfort and a hard mass on the anterior tibia for 1 year. What is the most likely diagnosis?1- Chondroblastoma2- Ewing’s sarcoma3- Ossifying fibroma4- Aneurysmal bone cyst5- Parosteal osteosarcoma
  21. 21. 24A 24B
  22. 22. 24C
  23. 23. Ortho Diseases24.Figures 24a through 24c show the radiographs and CT scan of a 7-year-old girl who has had mild discomfort and a hard mass on the anterior tibia for 1 year. What is the most likely diagnosis?1- Chondroblastoma2- Ewing’s sarcoma3- Ossifying fibroma4- Aneurysmal bone cyst5- Parosteal osteosarcoma
  24. 24. Ossifying Fibroma• Typically occurs in the jaw bone, only rarely in long bones where they have been termed Osteofibrous dysplasia (OFD)• OFD:rare (0.2% all bone tumors), benign, self-limited fibroosseous lesion, usually in the diaphysis of the tibia but occasionally ipsilateral fibula is involved• First two decades of life• benign lesion that rarely progresses during childhood and never progresses after skeletal maturity• P/w lower leg swelling +/- pain, anterior bowing or path fx. Often incidental finding• XR: intracortical lytic lesion, well marginated and is often surrounded by a zone of sclerosis. Cortex may be expanded or thickened. Typically involves anterior cortex.• .CT can provide more information on the amount of cortical destruction and may reveal occult pathologic fracture• MRI can aid in diagnosis by identifying the lesion and assessing for extraosseous soft tissue or intramedullary extension. OFD generally contained within the cortex.
  25. 25. Pathoogy:•loose, often storiform fibrousbackground containing spiculesof woven bony trabeculae thatare lined by a layer ofosteoblasts.•Osteoblastic rimmingdifferentiates from fibrousdysplasia.•Devoid of devoid of epithelialdifferentiation, whichdifferentiates fro ADDDX: Adamantinoma(AD), fibrous dysplasia, nonossifying fibroma, UBC,ABC, chondromyxoid fibroma, Langerhans cell histiocytosis (ie, eosinophilicgranuloma), osteomyelitis, osteosarcoma, chondrosarcoma,hemangioendothelioma, angiosarcoma, and metastatic carcinoma
  26. 26. • Consider open biopsy even if radiographically c/w OFD as could be early AD lesion.• Treatment controversial – Traditionally tx with observation. Bracing may be attempted to minimize deformity and prevent fracture. Surgery reserved for extensive or deforming lesion, or path fx. – Some have recommended aggressive surgical approach with extraperiosteal resection in all cases. Advocates site sampling error in biopsy and theory that OFD could progress to AD References: Most MJ, Sim FH, Inwards CY Osteofibrous Dysplasia and Adamantinoma J. Am. Acad. Ortho. Surg., June 2010; 18: 358 - 366. Schoenecker PL, Swanson K, Sheridan JJ. Ossifying fibroma of the tibia. Report of a new case and review of the literature. JBJS 1981; 63:483-488.
  27. 27. Recommended Reading:• Pitcher JD Jr, Weber KL. Benign fibrous and histiocytic lesions. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:121-132.• Damron TA: Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:156-158.
  28. 28. Ortho Diseases32. A 24-year-old woman reports a 4-month history of knee pain. Radiographs, an MRI scan, and biopsy specimens are seen in Figures 32a through 32e. What is the most likely diagnosis?1- Chondrosarcoma2- Ewing’s sarcoma3- Giant cell tumor4- Periosteal chondroma5- Conventional osteosarcoma
  29. 29. 32A 32B
  30. 30. 32C
  31. 31. 32D 32E
  32. 32. Ortho Diseases32. A 24-year-old woman reports a 4-month history of knee pain. Radiographs, an MRI scan, and biopsy specimens are seen in Figures 32a through 32e. What is the most likely diagnosis?1- Chondrosarcoma2- Ewing’s sarcoma3- Giant cell tumor4- Periosteal chondroma5- Conventional osteosarcoma
  33. 33. Osteosarcoma• Most common bone sarcoma• Peak incident 2nd decade, assoc w/ peak growth• Most commonly occurs at sites of rapid bone turnover (eg. the distal femur, prox tibia, and prox humerus). Less commonly occurs in the pelvis, the spine, and the craniofacial bones.• p/w pain, decreased ROM, mass, warmth or erythema, or path fx.• XR: aggressive bone lesion arising from the metaphysis distal femur, proximal tibia, or proximal humerus. Illdefined borders, osteoblastic and/or osteolytic features, and an associated soft-tissue mass.
  34. 34. • MRI: demonstrates extent of tumor invasion of the surrounding soft tissues, neurovascular involvement, extent of bone marrow replacement, and presence of discontinuous metastases (ie, skip lesions)• Biopsy• Path: malignant mesenchymal cells w/ pleomorphic nuclei and osteoid
  35. 35. Osteosarcoma Subtypes• Conventional: most common, 1st/2nd decade. High grade, originating from intramedullary cavity.• Telangiectatic osteosarcoma: <4%. Eccentric and osteolytic lesion, may resemble ABC. Composed of blood filled sinusoids, with high signal on T2.• Low Grade: 1-2%. 3rd/4th decade. Tumor may resemble fibrous dysplasia, but MRI shows cortical invasion.• Small Cell: 1.5%. Lytic areas and variable amount os sclerosis. Path small, round, malignant ells w/in osteoid matrix.• Parosteal: Arise surface, sparing intramedullary canal. Pead 3 rd decade. Females>males. Low grade, well=differentiated fibrowus stroma with osseous components.• Periosteal: 1-2%. More aggressive that paraosteal, Sunburst pattern or codman triangle commonly seen. Intermed grade tumor, mostly cartilaginous with areas of calcification.• High Grade: <1%. Surface tumor. High grade spindle cells, w/ atypia & varying amounts of osteoid.
  36. 36. • Tx: multidisciplinary.• Low grade or parosteal: Wide surgical resection.• High grade lesions or mets: pre-op chemo, wide surgical resection, post-op chemo• Commonly used chemo agents: doxorubicin, cisplatin, MTX, and ifosfamide• Without mets, 70% survival rate• With clinically detectable mets, 20-30% survival rateMesserschmitt PT, Garcia RM, Abdul-karim FW, Greenfield EM, Getty P. Osteosarcoma. JAAOS Aug 2009; 17:515-527
  37. 37. Recommended Reading:• Damron TA. Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:177-185.• Hornicek FJ. Osteosarcoma of bone. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:163-174.
  38. 38. Ortho Diseases45.A 13-year-old boy has had right knee pain for the past 4 months. Radiographs, bone scan, CT scan, and biopsy specimen are seen in Figures 45a through 45e. What is the most likely diagnosis?1- Osteomyelitis2- Chondroblastoma3- Ewing’s sarcoma4- Eosinophilic granuloma5- Aneurysmal bone cyst
  39. 39. 3A 45A 3B 45B
  40. 40. 3C45C
  41. 41. 45D
  42. 42. 45E
  43. 43. Ortho Diseases45.A 13-year-old boy has had right knee pain for the past 4 months. Radiographs, bone scan, CT scan, and biopsy specimen are seen in Figures 45a through 45e. What is the most likely diagnosis?1- Osteomyelitis2- Chondroblastoma3- Ewing’s sarcoma4- Eosinophilic granuloma5- Aneurysmal bone cyst
  44. 44. Chondroblastoma• Benign neoplasm primarily affecting patients 10- 25 years old with a male predominance of 2:1• Most common sites include distal femur, proximal tibia, proximal humerus although in older populations it tends to involve flat bones.• Characteristic radiographic findings include well- circumscribed lesions centered in an epiphysis of a long bone. In children, a well circumscribed epiphyseal lesion crossing an open growth plate is virtually diagnostic. There can be a surrounding rim of reactive bone and 30-50% will have some calcification evident on radiograph. Usually there is no soft tissue involvement.
  45. 45. • Microscopically, there are sheets of chondroblasts with background of chondroid matrix. Calcification is present giving a "chicken wire" appearance. Multinucleated giant cells are abundant.• In adults, differential diagnoses include giant cell tumors (no rim of sclerotic bone or calcification) and clear cell chondrosarcoma• Treatment includes extended curettage, bone grafting and/or bone cement.
  46. 46. Recommended Reading- Damron TA. Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:135-137.- Weber KL, O’Connor MI. Benign cartilage tumors. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:103-120.g:
  47. 47. Ortho Diseases57. Optimal management of osteoporosis diagnosed after a hip fracture includes1- urgent medical consultation.2- administration of bisphosphonates with follow-up as needed.3- referral to the patient’s primary care physician within a year of surgery.4- initiation of vitamin D and calcium supplementation with follow-up as needed.5- initial evaluation by the orthopaedic team with early postoperative referral to an osteoporosis clinic.
  48. 48. Ortho Diseases57. Optimal management of osteoporosis diagnosed after a hip fracture includes1- urgent medical consultation.2- administration of bisphosphonates with follow-up as needed.3- referral to the patient’s primary care physician within a year of surgery.4- initiation of vitamin D and calcium supplementation with follow-up as needed.5- initial evaluation by the orthopaedic team with early postoperative referral to an osteoporosis clinic.
  49. 49. • Hip, wrist, vertebral fractures in the elderly from low energy mechanisms are termed fragility fractures as the forces involved would not fracture healthy bone.• Miki et als paper in JBJS 2008 was a randomized control trial involving 62 patients with fragility hip fractures. Their mean age was 79.2. Each patient was assigned to either an intervention or a control group. Patients in the intervention group were worked up for osteoporosis, treated and followed closely in a specialized orthopaedic osteoporosis clinic. Patients in the control group was started on treatment and told to follow up with their primary care doctors.• The paper found that patients randomized to follow up in the specialized orthopaedic osteoporosis clinic had much a much high percentage of patients on osteoporotic medication and getting surveillance studies at 6 months as compared to the control group.
  50. 50. Recommended reading:- Miki RA, Oetgen ME, Kirk J, Insogna KL, Lindskog DM. Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial. J Bone Joint Surg Am. 2008 Nov;90(11):2346-53. PubMed PMID: 18978403.- Murray MA. Bone metabolism and metabolic bone disease. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:187- 196.
  51. 51. Ortho Diseases67. Which of the following diagnostic modalities is most useful for the diagnosis of proximal thigh deep venous thrombosis?1- D-dimer assay2- Physical examination3- Venous ultrasonography4- Computed tomography5- Impedance plethysmography
  52. 52. Ortho Diseases67. Which of the following diagnostic modalities is most useful for the diagnosis of proximal thigh deep venous thrombosis?1- D-dimer assay2- Physical examination3- Venous ultrasonography4- Computed tomography5- Impedance plethysmography
  53. 53. Deep vein thrombosis• 80-90% occur in operated limb• Peak incidence is 4 days after surgery and minimal after day 17.• Clinical diagnosis of pain, tenderness, positive Homan sign, swelling, erythema, low grade fever is absent in 50% of patients• Venography is still considered most sensitive and specific test for calf and thigh DVTs but is costly, invasive, poses risk of contrast allergy or inducing thrombosis• Ultrasound has a sensitivity of 79%, specificity of 98% and accuracy of 97% compared to venography but is not as useful in the diagnosis of calf and pelvic thrombi
  54. 54. Recommended Reading/References:- Conduah AH, Lieberman JR. Thromboembolism and pulmonary distress in the setting of orthopaedic surgery. In: Einhorn TA, O’Keefe, RJ, Buckwalter JA, eds. Orthopaedic Basic Science: Foundations of Clinical Practice, 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:105-113.- Haut ER, Chang DC, Pierce CA, Colantuoni E, Efron DT, Haider AH, Cornwell EE 3rd, Pronovost PJ. Predictors of posttraumatic deep vein thrombosis (DVT): hospital practice versus patient factors-an analysis of the National Trauma Data Bank (NTDB). J Trauma. 2009 Apr;66(4):994-9; discussion 999-1001. PubMed PMID: 19359905.
  55. 55. Ortho Diseases78.Paget’s disease of bone results from a defect in which of the following processes?1- Bone resorption2- Bone regeneration3- Osteodifferentation4- Matrix maturation and mineralization5- Coupling of bone formation and resorption
  56. 56. Ortho Diseases78.Paget’s disease of bone results from a defect in which of the following processes?1- Bone resorption2- Bone regeneration3- Osteodifferentation4- Matrix maturation and mineralization5- Coupling of bone formation and resorption
  57. 57. Paget disease• Disorder of unregulated bone turnover. Excessive osteoclastic resorption is followed by increased osteoblastic activity. An early lytic phase is followed by excessive bone production with cortical and trabecular thickening.• More common in people over 55 years old of Anglo-Saxon descent.• Radiographic findings vary based on the stage of the disease. In the lytic phase, the bone can take on a "blade of grass" or "flame" appearance at the end of the bone extending to the diaphysis. Later on, the bone is sclerotic with thickened cortices and trabeculae. Bone scans can be hot. MRI is used to differentiate between malignancy with the marrow in Paget disease appearing normal.• Paget is managed medically with NSAIDs, calcitonin and bisphosphonates.• Alkaline phosphatase levels and urine pyridinium cross-links is used to monitor disease activity.• ~1% of patients with Paget disease develop a sarcoma, usually osteosarcoma.
  58. 58. Recommended Reading/References:- Zuscik MJ, Drissi MH, Chen D, Rosier RN. Molecular and cell biology in orthopaedics. In: Einhorn TA, O’Keefe RJ, Buckwalter JA, eds. Orthopaedic Basic Science: Foundations of Clinical Practice, 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:3- 24.- Miller JD, McCreadie BR, Alford AI, Hankenson KD, Goldstein SA. Form and function of bone. In: Einhorn TA, O’Keefe RJ, Buckwalter JA, eds. Orthopaedic Basic Science: Foundations of Clinical Practice, 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:129-159.
  59. 59. Ortho Diseases87.A 19-year-old college football player has had suprapubic pain for the past 4 months. A radiograph and CT scans are show in Figures 87a through 87c. What is the most likely diagnosis?1- Chronic adductor strain2- Osteoid osteoma3- Chronic pelvic instability4- Stress fracture5- Osteitis pubis
  60. 60. 87A32A 32B
  61. 61. 87B 87C
  62. 62. Ortho Diseases87.A 19-year-old college football player has had suprapubic pain for the past 4 months. A radiograph and CT scans are show in Figures 87a through 87c. What is the most likely diagnosis?1- Chronic adductor strain2- Osteoid osteoma3- Chronic pelvic instability4- Stress fracture5- Osteitis pubis
  63. 63. Osteitis Pubis• Painful, noninfectious, inflammatory condition involving the pubic bone, symphysis and surrouding structures.• Associated with urological/gynecological surgery and athletes.• Gradual onset of pain in the pubic region is the primary symptom and pain may be severe enough to limit ambulation.• Radiographic changes include symmetrical bone resorption at the medial ends of the pubic bones, widening of the pubic symphysis, and rarefaction or sclerosis along the pubic rami.• Usually self limiting and treatment includes rest, anti- inflammatory medication. If symptoms persist, corticosteroid injections and wedge resection of the symphysis pubis may be necessary.
  64. 64. Recommended Reading/References:- Sekiya JK, Gibbs AE. Groin and pelvis injuries: In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:83-90.- Nuccion SL, Hunter DM, Finerman GAM. Hip and pelvis: adult. In: DeLee JC, Drez D Jr, Miller MD, eds. DeLee and Drez’s Orthopaedic Sports Medicine, 2nd ed. Philadelphia, PA: WB Saunders; 2003:1448.
  65. 65. Question 104Paget’s disease is best characterized as increased boneturnover that results:1- from a sequenced missense genetic mutation.2- from an autosomal-recessive inheritance pattern.3- in significant deformity but is rarely painful.4- in subtle radiographic findings that necessitateadvanced imaging.5- in increased urinary N-telopeptide and alpha-C-telopeptide.
  66. 66. Question 104Paget’s disease is best characterized as increased boneturnover that results:1- from a sequenced missense genetic mutation.2- from an autosomal-recessive inheritance pattern.3- in significant deformity but is rarely painful.4- in subtle radiographic findings that necessitateadvanced imaging.5- in increased urinary N-telopeptide and alpha-C-telopeptide.
  67. 67. Question 104• Paget’s disease - common geriatric problem, occurring in 3% to 4% of the population over 50 years of age• Increased bone resorption leads to a compensatory increase in bone formation. The overall rate of bone remodeling is accelerated, resulting in a predominance of highly vascular bone that is structurally weak and prone to deformities and pathologic fractures• The measurement of serum alkaline phosphatase activity is a good initial biochemical test for Paget’s disease. But, can be elevated in other diseases as well• Most sensitive test is urinary N-telopeptide and alpha-C-telopeptide.
  68. 68. Question 104Type I Collagen - Metabolic bone markers relating type I collagen degradation products provide important information on Paget’s - urinary N-telopeptide (NTX) and alpha-C- telopeptide (CTX) for bone resorption have emerged as the most sensitive ones
  69. 69. ReferencesMurray MA. Bone metabolism and metabolic bone disease. In: Vaccaro AR, ed.Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy ofOrthopaedic Surgeons; 2005:187- 196.Delmas PD. Biochemical markers of bone turnover in Paget’s disease of bone.J Bone Miner Res. 1999 Oct;14 Suppl 2:66-9. Review. PubMed PMID:10510216.
  70. 70. Question 112A 7-year-old girl has activity-related leg pain.Radiographs and biopsy specimens are seen inFigures 112a through 112d. What is the most likelydiagnosis?1- Unicameral bone cyst2- Nonossifying fibroma3- Osteofibrous dysplasia4- Giant cell tumor5- Eosinophilic granuloma
  71. 71. Question 112A 7-year-old girl has activity-related leg pain.Radiographs and biopsy specimens are seen inFigures 112a through 112d. What is the most likelydiagnosis?1- Unicameral bone cyst2- Nonossifying fibroma3- Osteofibrous dysplasia4- Giant cell tumor5- Eosinophilic granuloma
  72. 72. Question 112• A few fun facts about There is no intralesional Most commonly nonossifying fibromas: matrix mineralization, but located in the distal nonossifying fibromas can – Most common fibrous lesion femoral metaphysis, have an internal “bubbly” in children and adolescents followed by the appearance that is created proximal and distal by thin, white septae – Radiolucent, eccentric, tibial metaphyses. resulting from ridging of the cortically based lesions cortex – Most undergo spontaneous regression, usually starting at the end of adolescence and disappear by age 20 to 25 years. Distinct, sclerotic margins often with scalloping
  73. 73. References• Pitcher JD Jr, Weber KL. Benign fibrous and histiocytic lesions. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:121-132.• Damron TA. Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:149-151.
  74. 74. Question 131Patients with multiple hereditary exostosis have a greaterrisk of the development of what kind of mesenchymaltumor?1- Hemangioma2- Enchondroma3- Chondrosarcoma4- Chondroblastoma5- Extra-abdominal desmoid
  75. 75. Question 131Patients with multiple hereditary exostosis have a greaterrisk of the development of what kind of mesenchymaltumor?1- Hemangioma2- Enchondroma3- Chondrosarcoma4- Chondroblastoma5- Extra-abdominal desmoid
  76. 76. Question 131• Hereditary multiple exostoses (HME) – an autosomal dominant condition, mutation of tumor suppressor genes EXT1 or EXT2 – prevalence 1/50,000• Enlargement of exostoses rarely continues beyond skeletal maturity• Presence of an enlarging mass in an adult patient with HME should raise concerns about malignant transformation• 5% of cases go on to malignant transformation – Most commonly chondrosarcoma – Lesions arising from the pelvic and shoulder girdles are more likely to undergo sarcomatous transformation Erlenmeyer flask deformity of HME
  77. 77. Question 131• Weber KL, O’Connor MI. Benign cartilage tumors. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:103-120.• Damron TA. Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:133.
  78. 78. Question 150A 60-year-old patient who has diabetes mellitus withperipheral neuropathy has a plantar ulcer on the plantarsurface of the second metatarsophalangeal joint.Examination reveals no fluctuance or purulent drainage,pulses are palpable, and the ulcer does not involve bone.Range of motion of the ankle reveals dorsiflexion to neutraland 15° of plantar flexion. Which of the following treatmentsoffers the lowest recurrence rate of ulceration?1- Early débridement and excision of the metatarsal head2- Second ray resection3- IV antibiotics with ulcer débridement4- Total contact casting5- Total contact casting with gastrocnemius recession
  79. 79. Question 150A 60-year-old patient who has diabetes mellitus withperipheral neuropathy has a plantar ulcer on the plantarsurface of the second metatarsophalangeal joint.Examination reveals no fluctuance or purulent drainage,pulses are palpable, and the ulcer does not involve bone.Range of motion of the ankle reveals dorsiflexion to neutraland 15° of plantar flexion. Which of the following treatmentsoffers the lowest recurrence rate of ulceration?1- Early débridement and excision of the metatarsal head2- Second ray resection3- IV antibiotics with ulcer débridement4- Total contact casting5- Total contact casting with gastrocnemius recession
  80. 80. Question 150• Key is recognizing that limited dorsiflexion has been implicated as a contributing factor to excessive plantar pressures and forefoot skin breakdown leading to recurrence• Mueller et al: – Randomized clinical trial involving 64 DM pts with plantar foot ulcers – TCC vs TCC with percutaneous Achilles lengthening TCC TCC with Achilles lengthening Initial healing 88% 100% (p>0.05) Recurrence < 7 months 59% 15% (p=0.001) Recurrence 2 years 81% 38% (p=0.002)
  81. 81. Question 150• Lin SS, Lee TH, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-Achilles lengthening and total contact casting. Orthopedics. 1996 May;19(5):465-75. PubMed PMID: 8727341.• Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003 Aug;85-A(8):1436-45. PubMed PMID: 12925622.
  82. 82. Question 171Figures 171a through 171g show the radiographs, MRIscans, and biopsy specimens of a 9-year-old girl who reportsright elbow pain that is worse at night. What is most likelydiagnosis?1- Ewing’s sarcoma2- Osteomyelitis3- Giant cell tumor4- Aneurysmal bone cyst5- Eosinophilic granuloma
  83. 83. Question 171Figures 171a through 171g show the radiographs, MRIscans, and biopsy specimens of a 9-year-old girl who reportsright elbow pain that is worse at night. What is most likelydiagnosis?1- Ewing’s sarcoma2- Osteomyelitis3- Giant cell tumor4- Aneurysmal bone cyst5- Eosinophilic granuloma
  84. 84. Question 171• Ewing’s Sarcoma Clinical Features: – Second most common bone tumor (after osteosarcoma) occurring in children – t(11;22)(q24;q12) – Most common presenting symptoms of ES are pain, swelling, and a mass – 20% have fever• Radiographic Features on X-ray: – Location: 50/50 flat bones vs. long bones – Long bones: typically at metadiaphysis (58.7%) or diaphysis (35.4%) – Typically, ES appears as an ill-defined, permeative, mottled, or focally motheaten, destructive intramedullary lesion. – Periosteal reaction, with a laminated or “onion skin” appearance (a prominent multilayered reaction)
  85. 85. Question 171373 patients in theIntergroup Ewing’s Sarcoma Study 7299, common radiographic findingsIncluded:1. poor margination (ie, indistinct lesion borders 96%)2. soft-tissue component (80.4%)3. permeative component (76.1%)4. laminated periosteal reaction (56.6%)5. sclerotic component (39.7%)
  86. 86. Question 171• On pathology: small round uniform cells with high nucleus- tocytoplasmic ratio and grow in dense, solid sheets
  87. 87. Question 171• Patterson FR, Basra SK. Ewing’s sarcoma. In: Schwartz HS, ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:175-183.• Damron TA. Orthopaedic Surgery Essentials, Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:187-191.
  88. 88. 204. A 26-year-old woman has had wrist pain for thepast 3 weeks. Radiographs and an MRI scan are seen inFigures 204a through 204d. A biopsy specimen is seenin Figure 204e. What is the most likely diagnosis?1- Osteosarcoma2- Giant cell tumor3- Large cell lymphoma4- Metasatatic carcinoma5- Nonossifying fibroma
  89. 89. 204A
  90. 90. 204B
  91. 91. 204C
  92. 92. 204D
  93. 93. 204E
  94. 94. 204. A 26-year-old woman has had wrist pain for thepast 3 weeks. Radiographs and an MRI scan are seen inFigures 204a through 204d. A biopsy specimen is seenin Figure 204e. What is the most likely diagnosis?1- Osteosarcoma2- Giant cell tumor3- Large cell lymphoma4- Metasatatic carcinoma5- Nonossifying fibroma
  95. 95. Giant cell tumors are commonly seen in the knee (50%), distal radius (as in this case), andproximal humerus. They are more common in females. Radiographically, they are seen aswell circumscribed purely lytic lesions. Pathology shows sheets of multi-nucleated giantcells.-Osteosarcoma commonly occurs about the knee, proximal humerus, proximal femur andpelvis of children and young adults. Radiographs show poorly defined bone forming lesionswith both bone destruction and formation. Path demonstrates lacelike mineralizing osteoidsurrounding atypical osteoblasts.-Lymphoma is most frequently seen in the knee, pelvis, proximal femur, and vetebra, andcan occur in all ages. Lymphoma of bone is typically diffuse large B-cell type. Xrays showpoorly circumscribed lytic lesions. Path shows marrow replacement by a uniformpopulation of lymphoid cells.-Metastatic disease is the most common lesion seen in older patients, particularly over theage of 40. Most common carcinomas to metastisize to bone are breast, lung, prostate,kidney and thyroid. Most common locations are the pelvis, vertebral bodies, ribs andproximal limb girdles. Radiographs can show lytic, mixed, or purely sclerotic lesions.-Nonossifying fibroma is a benign lesion most common seen in the distal femur, distal tibia,and proximal tibia of young patients. Characteristic radiographic appearance is a lucentlesion that is metaphyseal, eccentric, and surrounded by a sclerotic rim. Histology shows awhorled pattern of fibroblastic cells with giant cells.
  96. 96. References204.Mirra JM. Bone Tumors. Philadelphia, PA: Lea and Febiger;1989:941-1022.McDonald DJ, Weber KL. Giant cell tumor of bone. In: Schwartz HS,ed. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2.Rosemont, IL: American Academy of Orthopaedic Surgeons;2007:133-140.
  97. 97. 224. Figures 224a and 224b show the radiographs of a40-year-old woman with a familial history of ‘higharches’ with weakness and feelings of lateral ankleinstability. Significant contribution to the developmentof this deformity comes from which of the following?1- Hindfoot arthritis2- Deltoid insufficiency3- Contracture of the gastrocsoleus complex4- Atrophy of the peroneus brevis muscle5- Weakness of the posterior tibialis muscle
  98. 98. 224A
  99. 99. 224B
  100. 100. 224. Figures 224a and 224b show the radiographs of a40-year-old woman with a familial history of ‘higharches’ with weakness and feelings of lateral ankleinstability. Significant contribution to the developmentof this deformity comes from which of the following?1- Hindfoot arthritis2- Deltoid insufficiency3- Contracture of the gastrocsoleus complex4- Atrophy of the peroneus brevis muscle 5-Weakness of the posterior tibialis muscle
  101. 101. High longitudinal arches, or pes cavus, occur frequently in neurologicaldisorders such as Charcot-Marie-Tooth. Weakness and atrophy of thetibialis anterior, extensor hallucis longus and the peroneus brevis are foundin pes cavus. This leads to an imbalance in the plantar and dorisiflexors, aswell as invertors and evertors of the foot and produces plantarflexion of thefirst ray, hindfoot varus, and the cavus malalignment.Patients tend to complain of painful calluses under the first and fifthmetatarsals and the medial heel.The Coleman block test is important in determining the flexibility of thehindfoot varus. This is important in determining treatment.Work up should include a family history and neuro exam, as well as EMG toevaluate for neuromuscular disorders.Unilateral or asymmetric deformity can result from cerebral palsy, spinalcord tumors, or a tethered cord.Bilateral deformity can be caused by muscular dystrophy, cerebral palsy,CMT, Friedreich’s Ataxia, Polio, or be idiopathic.
  102. 102. References224.Alexander IJ, Johnson KA. Assessment and management of pescavus in Charcot-Marie-Tooth disease. Clin Orthop Relat Res. 1989Sep;(246):273-81. PubMed PMID: 2766615.Paulos L, Coleman SS, Samuelson KM. Pes cavovarus. Review of asurgical approach using selective soft-tissue procedures. J Bone JointSurg Am. 1980 Sep;62(6):942-53. PubMed PMID: 7430182.
  103. 103. 241. Figure 241 shows the radiograph of a 40-year-oldman who reports a 1-year history of forefoot pain andswelling. Examination reveals synovitis and pitting of thenails. What is the most likely diagnosis?1- Gout2- Hallux rigidus3- Reiter’s syndrome4- Psoriatic arthritis5- Rheumatoid arthritis
  104. 104. 241
  105. 105. 241. Figure 241 shows the radiograph of a 40-year-oldman who reports a 1-year history of forefoot pain andswelling. Examination reveals synovitis and pitting of thenails. What is the most likely diagnosis?1- Gout2- Hallux rigidus3- Reiter’s syndrome4- Psoriatic arthritis5- Rheumatoid arthritis
  106. 106. Psoriatic arthritis is an seronegative spondyloarthropathy thataffects 10-30% of people with psoriasis. Classic findingsinclude inflammatory arthritis of distal joints, sausage digits(dactylitis), changes in the nails (pitting, onycholysis,keratosis), pain the in the feet and ankles, and pain in thesacrum. Periarticular erosions can lead to the classic “pencil-in-cup” sign on xrays.-Gout tends to affect the 1st MTP joint (50-75% initial cases).Characteristic radiographic signs are inordinate soft tissueenlargement and bony erosions on both sides of the joint.-Hallux rigidus, or stiff big toe, is a degenerative condition thataffects the MTP joint.-Reiter’s Syndrome (Reactive arthritis) is an autoimmunephenomena that can develop after bacterial infection(Chlamydia, Salmonella, Shigella, etc). Characterized by triadof inflammatory arthritis of large joints, inflammation of theeyes (conjuctivitis or uveitis) and urethritis (“can’t pee, can’tsee, can’t climb a tree”).-RA affects the forefoot > midfoot/hindfoot. Also tends topredominantly affect the MTP joint.
  107. 107. References241.Berberian WS, Najarian RG. Midfoot and forefoot arthritis andhallux rigidus. In: Pinzur MS ed. Orthopaedic Knowledge Update:Foot and Ankle 4. Rosemont, IL; American Academy ofOrthopaedic Surgeons; 2008:201-214.Shurnas PS, Coughlin MJ. Arthritic conditions of the foot. In:Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot andAnkle, 8th ed. Philadelphia, PA: Mosby Elsevier; 2007: 856-863.
  108. 108. 253. A 43-year-old woman who is right-hand dominant fellonto her outstretched arm while rollerblading 1 day ago.She reports a painful wrist. Examination reveals swelling andtenderness dorsally. Radiographs reveal a nondisplacedtransverse fracture of the distal radius. She is placed in ashort arm cast. What can be done to reduce the risk of type1 complex regional pain syndrome?1- Transcutaneous electrical nerve stimulation2- Occupational therapy treatment for finger dexterity3- Strict elevation above the heart for 72 hours4- Alpha adrenergic blockers for 2 weeks after injury5- Daily oral vitamin C for 2 months
  109. 109. 253. A 43-year-old woman who is right-hand dominant fellonto her outstretched arm while rollerblading 1 day ago.She reports a painful wrist. Examination reveals swelling andtenderness dorsally. Radiographs reveal a nondisplacedtransverse fracture of the distal radius. She is placed in ashort arm cast. What can be done to reduce the risk of type1 complex regional pain syndrome?1- Transcutaneous electrical nerve stimulation2- Occupational therapy treatment for finger dexterity3- Strict elevation above the heart for 72 hours4- Alpha adrenergic blockers for 2 weeks after injury5- Daily oral vitamin C for 2 months
  110. 110. Type 1 complex regional pain syndrome (CRPS), formerly known as reflex sympatheticdystrophy, is characterized by pain, swelling and changes in the skin in the absence of anidentifiable nerve lesion. Type II, or causalgia, by comparison is a result of a nerve injury.Classically, patients are thought to progress through three stages of disease (although theymay be more accurately thought of as three distinct types of the disease):1 - severe burning pain, redness, warmth, hyperhydrosis, muscle spasm, rapid hair and nailgrowth, and vasospasm2 - intense pain, hard edema, muscle and skin atrophy3 - irreversible skin changes (cool, glossy, dry skin), unyielding pain, marked muscle atrophyand stiffness/joint contracturesIncidence of CRPS is higher in women, upper extremity>lower extremity. There is nocorrelation with age. Common in distal radius fracturesVitamin C has been been shown to have a protective effect against CRPS. A randomizedclinical trial published in JBJS in 2007 showed a decrease in the incidence of complex regionalpain syndrome following distal radius fracture, with a recommended dosing of 500mg dailyfor 50 days. Across the treatment dosages, there was a prevalence of CRPS in the treatmentgroup of 2.4% (8 of 328 patients) vs. 10.1% (10 of 99 patient) of those given placebo(p=0.002).Treatments for CRPS include:NSAIDs, centrally acting analgesics (cymbalta, neurontin, amitryptilene, etc), vasodilators,steroids, transcutaneous electrical stimulation, neurolysis. Treatments are typically moreeffective the earlier in the disease process they are initiated.
  111. 111. References253.Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Canvitamin C prevent complex regional pain syndrome in patients withwrist fractures? A randomized, controlled, multicenter dose-responsestudy. J Bone Joint Surg Am. 2007 Jul;89(7):1424-31. PubMedPMID: 17606778.Zollinger PE, Tuinebreijer WE, Kreis RW, Breederveld RS. Effect ofvitamin C on frequency of reflex sympathetic dystrophy in wristfractures: a randomised trial. Lancet. 1999 Dec 11;354(9195):2025-8.PubMed PMID: 10636366.
  112. 112. 263. The antirheumatic drug anakinra’s mode of action isvia inhibition of which of the following?1- IL-12- IL-63- Rheumatoid factor4- Leukocyte production5- TNF-α
  113. 113. 263. The antirheumatic drug anakinra’s mode of action isvia inhibition of which of the following?1- IL-12- IL-63- Rheumatoid factor4- Leukocyte production5- TNF-α
  114. 114. Anakinra (brand name Kineret) is a competitive inhibitor of theinterleukin-1 receptor. It is a approved for treatment of RA inpatients with moderate or severe disease who have had aninadequate response to other disease-modifying antirheumaticdrugs (DMARDs). By blocking IL-1, it prevents the inflammatoryand immunologic effects of this mediator.It is administered as a subcutaneous injection daily, typically for 24weeks. It can not be co-administered with TNF-a inhibitors, andno head-to-head studies comparing the two have been performed.Can be given in with methotrexate.Common side effects include infections (40%, 2% severe), nausea,diarrhea and GI upset, pain and erythema at injection site (70%),and a decrease in neutrophil count (8%).
  115. 115. References263.Shojania K, Esdaile JM, Greidanus N. Arthritis. In: Vaccaro AR, ed.Orthopaedic Knowledge Update 8. Rosemont, IL: AmericanAcademy of Orthopaedic Surgeons; 2005:234-239.Kalliolias GD, Liossis SN. The future of the IL-1 receptor antagonistanakinra: from rheumatoid arthritis to adult-onset Still’s disease andsystemic-onset juvenile idiopathic arthritis. Expert Opin InvestigDrugs. 2008 Mar;17(3):349-59. Review. PubMed PMID: 18321234.
  116. 116. 275. A 10-year-old girl has a painful right tibial tubercle.She has swelling but no fever. Figures 275a through275e show AP and lateral radiographs, CT scans, and anMRI scan. Figure 275f shows a biopsy specimen. Whatis the most likely diagnosis?1- Healing fracture2- Adamantinoma3- Ewing’s sarcoma4- Chondroblastoma5- Eosinophilic granuloma
  117. 117. 275A
  118. 118. 275B
  119. 119. 275C
  120. 120. 275D
  121. 121. 275E
  122. 122. 275F
  123. 123. 275. A 10-year-old girl has a painful right tibial tubercle.She has swelling but no fever. Figures 275a through275e show AP and lateral radiographs, CT scans, and anMRI scan. Figure 275f shows a biopsy specimen. Whatis the most likely diagnosis?1- Healing fracture2- Adamantinoma3- Ewing’s sarcoma4- Chondroblastoma5- Eosinophilic granuloma
  124. 124. Eosinophilic granuloma is a form of Langerhans Cell Histiocysosis (Histiocytosis X). It is acondition that mimics primary bone neoplasm. Presents with pain and swelling and any bonecan be involved. Most frequently, a single bone is involved, but multiple bones can be affected.Radiographs will show a highly destructive lesion with well defined margins. Histology showscharacteristic proliferating eosinophilic Langerhans cells, as well as multiple bilobedeosinophils with bright eosinophilic cytoplasm. It is commonly a self-limiting process, althoughlow dose radiation, or curettage with bone grafting when articular surface is at risk orfracture is imminent are options.-Adamantinoma is a rare neoplasm of young adults found most frequently in the tibia, but thefibula, femur, ulna and radius are infrequently involved. Radiographs shows multiple “bubbly”sharply circumscribed lucent defects of different sizes, with sclerotic bone between.-Ewing’s Sarcoma is a small round cell sarcoma of children and young adults. Most commonlyfound in pelvis, distal femur, proximal tibia, femoral diaphysis, and proximal humerus. Xraysdemontrate a large destructive lesion that may be purely lytic or have variable amounts ofreactive new bone formation. May have characteristic “onion skin” appearance caused byperiosteum lifted off in multiple layers.- Chondroblastoma is a benign cartilage tumor found in young patients with open physes.Most common locations are the distal femur, proximal tibia and proximal humerus.Radiographs show a central region of bone destruction separated from the medullary cavityby a rim of sclerotic bone. Histo shows chondroblasts and scattered multinucleated giantcells.
  125. 125. References275.Mirra JM. Bone Tumors. Philadelphia, PA: Lea and Febiger;1989:1022-1045.Pitcher JD, Weber KL. Benign fibrous and histiocytic lesions. In:Schwartz HS, ed. Orthopaedic Knowledge Update: MusculoskeletalTumors 2. Rosemont, IL: American Academy of OrthopaedicSurgeons; 2007:121-132.
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