The Musculoskeletal System
Common Problems in Ambulatory Care Medicine
A dr Z Lecture
on common traumatic and non-traumatic conditions of the musculoskeletal system in primary care practice…
With a little help…
• From a noted BONE expert
dr Z’s secret formula for success in radiology
• Know what to order
• Know what an optimal imaging series is and accept no less
• Know a good image from a poor one and accept only the good
…and…
• Read by check list
• Know the common lesions
• Know the commonly MISSED lesions
The Musculoskeletal System
• Soft tissues: muscles, ligaments, tendons, bursae, skin and subcutaneous tissue
• Joints: capsule, synovium, articular cartilage
• Bones: cortex, cancelleous, medullary canal
A case-based overview
• Upper extremity
• Lower extremity
• Spine
• Pelvis
But first…
Some general Musculoskeletal imaging principles
Bones: components
• Epiphysis• Physis (growth plate)• Metaphysis• Diaphysis• Apophysis
Joints: components
• Fibrous capsule• Synovial lining• Articular cartilage• Subchondral bone
Some Fracture Terminology
• Nondisplaced
• Displaced
• Comminuted
• Angulated
• Articular: fracture extends to a joint
• Pathologic: fracture through a focal lesion
• Stress: repetitive microtrauma, fatigue and insufficiency types
Osteolytic Patterns
Geographic
Motheaten
Permeative
Osteolytic Patterns
• These refer to degree of aggression of a bone destroying lesion
• Geographic least, motheaten intermediate, permeative most aggressive
• Usually, but not always, refers to neoplasm or infection
The Upper Extremity
• Shoulder
• Humerus
• Elbow
• Forearm
• Wrist
• Hand
The Shoulder
The Case
• 25 y/o female• Sudden onset pain and
loss of ROM after a fall on the shoulder while playing basketball
Anterior Dislocation
• Very common injury• Can be associated with
humerus head and glenoid rim fractures
• Rx: Closed reduction• If repetitive,
stabilization surgery
The Case
• 60 y/o female• Chronic shoulder pain
and limited ROM, increasing over 10 years
• No trauma
Rotator Cuff Disease
• AKA: impingement syndrome
• This is Phase Three: end stage; complete loss of rotator cuff stabilization
• Rx: Symptomatic, PT
The Elbow
The Case
• 55 y/o female• Fell on outstretched
arm at work• Pain and tenderness of
elbow
Radius Head Fracture
• Note: abnormal fat pads=hemarthrosis
• Common injury• Most are treated with
sling and PT and back to full activity in 3 weeks
The Wrist
The Case
• 55y/o female• Fall on outstretched
hand at work (again)• Pain in wrist and
“Snuff Box” tenderness
Scaphoid Fracture
• Risk of AVN• Immobilize in thumb
spica cast for 6 weeks• If fracture uncertain,
immobilize and repeat films in one week
• Oh: What else is fractured?
Answer
• Capitate
• Distal radius
The Case
• 51 y/o female• 20 year hx hand pain,
swelling, erythema• Both hands
symmetrically involved
Rheumatoid Arthritis
• Very common• Females more than
males• Inflammatory arthritis,
Rh factor seropositive• Rx: Several classes of
drugs (DMARDs, steroids), surgery
The Case
• 80 y/o female• 10 year hx hand pain• Both hands involved,
but dominate hand worse
Osteoarthritis
• Extremely common • Middle aged and
elderly• A mechanical wear
and tear arthritis• Rx: symptomatic
The Finger
The Case
• 25 y/o female• Hyperflexed DIP joint
playing basketball• Pain, tenderness and
inability to extend DIP joint
Mallet or “Baseball” finger
• An injury of the extensor tendon and fracture of dorsal base of distal phalanx
• Caused by hyperflexion of DIP
• Rx: Usually splint 4-6 wks, occasionally pin
The Case
• 60 y/o female• Nicked thumb while
cutting vegetables• One week later,
developed erythema, swelling and pain at IP joint
Osteomyelitis
• Both the bone and joint are involved in this bacterial infection
• The destructive process has crossed the joint, typical of infections
The Spine
• Cervical
• Thoracic
• Lumbar
• Sacral/coccygeal
Cervical Spine
• Plain film
• MRI
The Case
• 55 y/o male smoker• Carcinoma of the right
lung, treated by lobectomy surgery
• One year later, insidious onset of neck pain not relieved by rest
Lateral Cervical Spine Film
• Where is the abnormality?
• How would you describe it?
Sagittal MRI
• Where is the osseous abnormality?
• What other structures are involved?
• What is the diagnosis?
Metastasis to Cervical Spine
• Hematogenous spread to spine from the primary carcinoma
• The tumor extends from bone into the spinal canal and compresses the spinal cord.
Thoracic Spine
The Case
• 91 y/o female• Insidious onset mid
back pain• Increasing kyphosis• No trauma
Osteoporosis
• With multiple insufficiency fractures
• RX: Pain control, biphosphonates
• Common conditon, underdiagnosed & undertreated, can cause severe disability
Lumbar Spine
The Case
• 18 y/o female• Insidious onset low
back pain after 3 months of weight lifting
• No trauma
Stress Fracture of the Pars
• SPONDYLOLYSIS:
spondylo=spine
lysis=a defect, break, disruption
The break is of the pars, the bone bridge between the sup and inf facets
Spondylolysis
• Most often due to fatigue stress fracture
• Young gymnasts, hurdlers, weight lifters, cheerleaders are at risk
• If bilateral, the vertebral body can slip
Spondylolisthesis
Spondylolisthesis
spondylo=spine
listhesis=slipping, displacement
With high grade slipping, surgical fusion is considered
The Case
• 34 y/o male• 10 years of
progressive low back pain and restricted ROM
• No trauma
Ankylosing spondylitis
• There is calcification of all ligaments (syndesmophytes) and complete destruction and fusion (ankylosis) of both sacro-iliac joints
• Seronegative, HLA B27 positive inflammatory arthritis
The Pelvis
Normal Pelvis
The Case
• 85 y/o male• Insidious onset of pain
in right pelvis at rest, over 10 days
• No trauma• No history of
malignancy
Paget’s Disease
• Increased density and thickening of right hemipelvis
• Disease of unknown etiology with ‘hot’, mixed and ‘cold’ phases
Why the onset of pain?
• Notice the fracture of the right medial acetabulum margin
• The fractures associated with Paget’s are often incomplete and due to repetitive microtrauma
Paget’s Disease
• Usually asymptomatic• Complications include
pathologic fracture, pain, nerve encroachment, high output heart failure, malignant transformation
The Lower Extremity
• Hip
• Femur
• Knee
• Lower leg
• Ankle
• Foot
The Knee
The Case
• 34 y/o female• “Clipped” on lateral
knee while playing with nephews
• Tender lateral margin• Positive “drawer sign”
Segond Fracture
• An avulsion fracture caused by tension on lateral capsular lig.
• 95% association with ACL tear, as common mechanism
The Ankle
The Case
• 40 y/o female• Inverted ankle on
stairs• Tenderness lateral
malleolus• Can ambulate but with
severe pain
Fracture of Distal Fibula
• Fracture of lateral malleolus below the joint (Weber A)
• Stable, so treated by cast for 6 weeks
The Foot
• “Now you’re talking MY language!”
Sorry: The HUMAN Foot
The Case
• 23 y/o female• Training for LA
Marathon• Insidious onset of heel
pain
Radiograph: Negative
Diagnosis
• Plantar fasciitis?• Rx: Orthotics, ice,
reduce mileage• No improvement next
2 weeks• So, repeat radiograph
Stress Fracture
• Fatigue fracture: Abnormal stress on normal bone
• Radiographs usually negative for first 2-3 weeks
• Often initially thought to be plantar fasciitis
The Case
• 30 y/0 female• Inverted ankle and
foot after stepping on toy
• Pain and tenderness over base of the fifth metatarsal
Fracture of the Base of the Fifth Metatarsal (Jones)
• Inversion puts tension on the peroneous brevis muscle tendon
• This causes a transverse force, fracturing the 5th MT base
• Can be “Dancer’s” or “Jones” type
The Case
• 55 y/o male • Type I diabetes 30 yrs• Painless swelling of
foot 2 months• No trauma
Neuropathic Joint Disease
Charcot joints with destruction, disintegration, debris, density, distension
Due to loss of sensation from peripheral neuropathy, vascular insufficiency and poor healing
Happy OSSEOUS Imaging!
…and I hope you like BONES as much as I do!
Goodbye…
Copyright 2005
Michael Zucker, MD
Top Related