Oite 2010 disease

Ortho Diseases

3. 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- Enchondroma
2- Chondroblastoma
3- Giant cell tumor
4- Osteonecrosis
5- Clear cell chondrosarcoma

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

• 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

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.

Ortho Diseases

4. When patients with rheumatoid arthritis are
being treated with the disease-modifying
antirheumatic drug adalimumab, what is the
optimal time for surgical intervention?
1- Immediately after infusion
2- Approximately 10 days after injection
3- Only after a year of continuous therapy
4- When drug levels are at their highest
5- When the pharmacokinetic levels reach
equilibrium

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 days
References:
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

Recommended reading:
• Shojania K, Esdaile JM, Gredanus N. Arthritis.
In: Vaccaro AR, ed. Orthopaedic Knowledge
Update 8. Rosemont, IL: American Academy of
• 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.

Ortho Diseases

21. Which of the following is a recognized
complication of extra-articular
corticosteroid injections?
1- Acne
2- Depression
3- Fat atrophy
4- Hypogonadism
5- Manic episode

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.

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.

Ortho Diseases

24.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- Chondroblastoma
2- Ewing’s sarcoma
3- Ossifying fibroma
4- Aneurysmal bone cyst
5- Parosteal osteosarcoma

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.

Pathoogy:
•loose, often storiform fibrous
background containing spicules
of woven bony trabeculae that
are lined by a layer of
osteoblasts.
•Osteoblastic rimming
differentiates from fibrous
dysplasia.
•Devoid of devoid of epithelial
differentiation, which
differentiates fro AD

DDX: Adamantinoma(AD), fibrous dysplasia, nonossifying fibroma, UBC,
ABC, chondromyxoid fibroma, Langerhans cell histiocytosis (ie, eosinophilic
granuloma), osteomyelitis, osteosarcoma, chondrosarcoma,
hemangioendothelioma, angiosarcoma, and metastatic carcinoma

• 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.

• 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,
Lippincott Williams & Wilkins; 2008:156-158.

Ortho Diseases

32. 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- Chondrosarcoma
3- Giant cell tumor
4- Periosteal chondroma
5- Conventional osteosarcoma

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.

• 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

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.

• 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
rate
Messerschmitt PT, Garcia RM, Abdul-karim FW, Greenfield EM, Getty P. Osteosarcoma. JAAOS Aug
2009; 17:515-527

• Damron TA. Orthopaedic Surgery Essentials,
• 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.

Ortho Diseases
45.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- Osteomyelitis
2- Chondroblastoma
4- Eosinophilic granuloma

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.

• 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.

Recommended Reading
- Damron TA. Orthopaedic Surgery Essentials,
- 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:

Ortho Diseases

57. Optimal management of osteoporosis diagnosed after a
hip fracture includes
1- 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.

• 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 al's 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.

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.

Ortho Diseases
67. Which of the following diagnostic
modalities is most useful for the diagnosis
of proximal thigh deep venous
thrombosis?
1- D-dimer assay
2- Physical examination
3- Venous ultrasonography
4- Computed tomography
5- Impedance plethysmography

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

- 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
- 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.

Ortho Diseases

78.
Paget’s disease of bone results from a defect in
which of the following processes?
1- Bone resorption
2- Bone regeneration
3- Osteodifferentation
4- Matrix maturation and mineralization
5- Coupling of bone formation and resorption

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.

- 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.

Ortho Diseases
87.
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 strain
2- Osteoid osteoma
3- Chronic pelvic instability
4- Stress fracture
5- Osteitis pubis

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.

- 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.

Question 104
Paget’s disease is best characterized as increased bone
turnover 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 necessitate
advanced imaging.
5- in increased urinary N-telopeptide and alpha-C-
telopeptide.

Question 104
Paget’s disease is best characterized as increased bone
turnover 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 necessitate
advanced imaging.
5- in increased urinary N-telopeptide and alpha-C-
telopeptide.

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.

Question 104
Type 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

References
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.

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.

Question 112
A 7-year-old girl has activity-related leg pain.
Radiographs and biopsy specimens are seen in
Figures 112a through 112d. What is the most likely
diagnosis?

1- Unicameral bone cyst
2- Nonossifying fibroma
3- Osteofibrous dysplasia
4- Giant cell tumor

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

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.

Question 131
Patients with multiple hereditary exostosis have a greater
risk of the development of what kind of mesenchymal
tumor?

1- Hemangioma
2- Enchondroma
3- Chondrosarcoma
4- Chondroblastoma
5- Extra-abdominal desmoid

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

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.
Philadelphia, PA: Lippincott Williams & Wilkins; 2008:133.

Question 150
A 60-year-old patient who has diabetes mellitus with
peripheral neuropathy has a plantar ulcer on the plantar
surface 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 neutral
and 15° of plantar flexion. Which of the following treatments
offers the lowest recurrence rate of ulceration?

1- Early débridement and excision of the metatarsal head
2- Second ray resection
3- IV antibiotics with ulcer débridement
4- Total contact casting
5- Total contact casting with gastrocnemius recession

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)

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.

Question 171
Figures 171a through 171g show the radiographs, MRI
scans, and biopsy specimens of a 9-year-old girl who reports
right elbow pain that is worse at night. What is most likely
diagnosis?

2- Osteomyelitis
3- Giant cell tumor

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)

Question 171
373 patients in the
Intergroup Ewing’s Sarcoma
Study 7299, common
radiographic findings
Included:
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%)

Question 171

• On pathology: small
round uniform cells with
high nucleus-
tocytoplasmic ratio and
grow in dense, solid
sheets

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.
Philadelphia, PA: Lippincott Williams & Wilkins; 2008:187-191.

204. A 26-year-old woman has had wrist pain for the
past 3 weeks. Radiographs and an MRI scan are seen in
Figures 204a through 204d. A biopsy specimen is seen
in Figure 204e. What is the most likely diagnosis?

1- Osteosarcoma
2- Giant cell tumor
3- Large cell lymphoma
4- Metasatatic carcinoma
5- Nonossifying fibroma

Giant cell tumors are commonly seen in the knee (50%), distal radius (as in this case), and
proximal humerus. They are more common in females. Radiographically, they are seen as
well circumscribed purely lytic lesions. Pathology shows sheets of multi-nucleated giant
cells.

-Osteosarcoma commonly occurs about the knee, proximal humerus, proximal femur and
pelvis of children and young adults. Radiographs show poorly defined bone forming lesions
with both bone destruction and formation. Path demonstrates lacelike mineralizing osteoid
surrounding atypical osteoblasts.
-Lymphoma is most frequently seen in the knee, pelvis, proximal femur, and vetebra, and
can occur in all ages. Lymphoma of bone is typically diffuse large B-cell type. Xrays show
poorly circumscribed lytic lesions. Path shows marrow replacement by a uniform
population of lymphoid cells.
-Metastatic disease is the most common lesion seen in older patients, particularly over the
age 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 and
proximal 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 lucent
lesion that is metaphyseal, eccentric, and surrounded by a sclerotic rim. Histology shows a
whorled pattern of fibroblastic cells with giant cells.

References

204.

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.

224. Figures 224a and 224b show the radiographs of a
40-year-old woman with a familial history of ‘high
arches’ with weakness and feelings of lateral ankle
instability. Significant contribution to the development
of this deformity comes from which of the following?

1- Hindfoot arthritis
2- Deltoid insufficiency
3- Contracture of the gastrocsoleus complex
4- Atrophy of the peroneus brevis muscle
5- Weakness of the posterior tibialis muscle

224. Figures 224a and 224b show the radiographs of a
40-year-old woman with a familial history of ‘high
arches’ with weakness and feelings of lateral ankle
instability. Significant contribution to the development
of this deformity comes from which of the following?

1- Hindfoot arthritis
2- Deltoid insufficiency
3- Contracture of the gastrocsoleus complex
4- Atrophy of the peroneus brevis muscle 5-
Weakness of the posterior tibialis muscle

High longitudinal arches, or pes cavus, occur frequently in neurological
disorders such as Charcot-Marie-Tooth. Weakness and atrophy of the
tibialis anterior, extensor hallucis longus and the peroneus brevis are found
in pes cavus. This leads to an imbalance in the plantar and dorisiflexors, as
well as invertors and evertors of the foot and produces plantarflexion of the
first ray, hindfoot varus, and the cavus malalignment.
Patients tend to complain of painful calluses under the first and fifth
metatarsals and the medial heel.
The Coleman block test is important in determining the flexibility of the
hindfoot varus. This is important in determining treatment.
Work up should include a family history and neuro exam, as well as EMG to
evaluate for neuromuscular disorders.
Unilateral or asymmetric deformity can result from cerebral palsy, spinal
cord tumors, or a tethered cord.
Bilateral deformity can be caused by muscular dystrophy, cerebral palsy,
CMT, Friedreich’s Ataxia, Polio, or be idiopathic.

References

224.

Alexander IJ, Johnson KA. Assessment and management of pes
cavus in Charcot-Marie-Tooth disease. Clin Orthop Relat Res. 1989
Sep;(246):273-81. PubMed PMID: 2766615.

Paulos L, Coleman SS, Samuelson KM. Pes cavovarus. Review of a
surgical approach using selective soft-tissue procedures. J Bone Joint
Surg Am. 1980 Sep;62(6):942-53. PubMed PMID: 7430182.

241. Figure 241 shows the radiograph of a 40-year-old
man who reports a 1-year history of forefoot pain and
swelling. Examination reveals synovitis and pitting of the
nails. What is the most likely diagnosis?

1- Gout
2- Hallux rigidus
3- Reiter’s syndrome
4- Psoriatic arthritis
5- Rheumatoid arthritis

Psoriatic arthritis is an seronegative spondyloarthropathy that
affects 10-30% of people with psoriasis. Classic findings
include 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 the
sacrum. 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 tissue
enlargement and bony erosions on both sides of the joint.
-Hallux rigidus, or stiff big toe, is a degenerative condition that
affects the MTP joint.
-Reiter’s Syndrome (Reactive arthritis) is an autoimmune
phenomena that can develop after bacterial infection
(Chlamydia, Salmonella, Shigella, etc). Characterized by triad
of inflammatory arthritis of large joints, inflammation of the
eyes (conjuctivitis or uveitis) and urethritis (“can’t pee, can’t
see, can’t climb a tree”).
-RA affects the forefoot > midfoot/hindfoot. Also tends to
predominantly affect the MTP joint.

References

241.

Berberian WS, Najarian RG. Midfoot and forefoot arthritis and
hallux rigidus. In: Pinzur MS ed. Orthopaedic Knowledge Update:
Foot and Ankle 4. Rosemont, IL; American Academy of

Shurnas PS, Coughlin MJ. Arthritic conditions of the foot. In:
Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and
Ankle, 8th ed. Philadelphia, PA: Mosby Elsevier; 2007: 856-863.

253. A 43-year-old woman who is right-hand dominant fell
onto her outstretched arm while rollerblading 1 day ago.
She reports a painful wrist. Examination reveals swelling and
tenderness dorsally. Radiographs reveal a nondisplaced
transverse fracture of the distal radius. She is placed in a
short arm cast. What can be done to reduce the risk of type
1 complex regional pain syndrome?
1- Transcutaneous electrical nerve stimulation
2- Occupational therapy treatment for finger dexterity
3- Strict elevation above the heart for 72 hours
4- Alpha adrenergic blockers for 2 weeks after injury
5- Daily oral vitamin C for 2 months

253. A 43-year-old woman who is right-hand dominant fell
onto her outstretched arm while rollerblading 1 day ago.
She reports a painful wrist. Examination reveals swelling and
tenderness dorsally. Radiographs reveal a nondisplaced
transverse fracture of the distal radius. She is placed in a
short arm cast. What can be done to reduce the risk of type
1 complex regional pain syndrome?

1- Transcutaneous electrical nerve stimulation
2- Occupational therapy treatment for finger dexterity
3- Strict elevation above the heart for 72 hours
4- Alpha adrenergic blockers for 2 weeks after injury
5- Daily oral vitamin C for 2 months

Type 1 complex regional pain syndrome (CRPS), formerly known as reflex sympathetic
dystrophy, is characterized by pain, swelling and changes in the skin in the absence of an
identifiable 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 they
may be more accurately thought of as three distinct types of the disease):
1 - severe burning pain, redness, warmth, hyperhydrosis, muscle spasm, rapid hair and nail
growth, and vasospasm
2 - intense pain, hard edema, muscle and skin atrophy
3 - irreversible skin changes (cool, glossy, dry skin), unyielding pain, marked muscle atrophy
and stiffness/joint contractures

Incidence of CRPS is higher in women, upper extremity>lower extremity. There is no
correlation with age. Common in distal radius fractures

Vitamin C has been been shown to have a protective effect against CRPS. A randomized
clinical trial published in JBJS in 2007 showed a decrease in the incidence of complex regional
pain syndrome following distal radius fracture, with a recommended dosing of 500mg daily
for 50 days. Across the treatment dosages, there was a prevalence of CRPS in the treatment
group 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 more
effective the earlier in the disease process they are initiated.

References

253.

Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can
vitamin C prevent complex regional pain syndrome in patients with
wrist fractures? A randomized, controlled, multicenter dose-response
study. J Bone Joint Surg Am. 2007 Jul;89(7):1424-31. PubMed
PMID: 17606778.

Zollinger PE, Tuinebreijer WE, Kreis RW, Breederveld RS. Effect of
vitamin C on frequency of reflex sympathetic dystrophy in wrist
fractures: a randomised trial. Lancet. 1999 Dec 11;354(9195):2025-8.
PubMed PMID: 10636366.

263. The antirheumatic drug anakinra’s mode of action is
via inhibition of which of the following?

1- IL-1
2- IL-6
3- Rheumatoid factor
4- Leukocyte production
5- TNF-α

Anakinra (brand name Kineret) is a competitive inhibitor of the
interleukin-1 receptor. It is a approved for treatment of RA in
patients with moderate or severe disease who have had an
inadequate response to other disease-modifying antirheumatic
drugs (DMARDs). By blocking IL-1, it prevents the inflammatory
and immunologic effects of this mediator.
It is administered as a subcutaneous injection daily, typically for 24
weeks. It can not be co-administered with TNF-a inhibitors, and
no 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%).

References

263.

Shojania K, Esdaile JM, Greidanus N. Arthritis. In: Vaccaro AR, ed.
Orthopaedic Knowledge Update 8. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2005:234-239.

Kalliolias GD, Liossis SN. The future of the IL-1 receptor antagonist
anakinra: from rheumatoid arthritis to adult-onset Still’s disease and
systemic-onset juvenile idiopathic arthritis. Expert Opin Investig
Drugs. 2008 Mar;17(3):349-59. Review. PubMed PMID: 18321234.

275. A 10-year-old girl has a painful right tibial tubercle.
She has swelling but no fever. Figures 275a through
275e show AP and lateral radiographs, CT scans, and an
MRI scan. Figure 275f shows a biopsy specimen. What
is the most likely diagnosis?

1- Healing fracture
2- Adamantinoma
4- Chondroblastoma

Eosinophilic granuloma is a form of Langerhans Cell Histiocysosis (Histiocytosis X). It is a
condition that mimics primary bone neoplasm. Presents with pain and swelling and any bone
can 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 shows
characteristic proliferating eosinophilic Langerhans cells, as well as multiple bilobed
eosinophils with bright eosinophilic cytoplasm. It is commonly a self-limiting process, although
low dose radiation, or curettage with bone grafting when articular surface is at risk or
fracture is imminent are options.

-Adamantinoma is a rare neoplasm of young adults found most frequently in the tibia, but the
fibula, 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 commonly
found in pelvis, distal femur, proximal tibia, femoral diaphysis, and proximal humerus. Xrays
demontrate a large destructive lesion that may be purely lytic or have variable amounts of
reactive new bone formation. May have characteristic “onion skin” appearance caused by
periosteum 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 cavity
by a rim of sclerotic bone. Histo shows chondroblasts and scattered multinucleated giant
cells.

References

275.

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: Musculoskeletal
Tumors 2. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2007:121-132.

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