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 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