Part 3 board review (pt. 5)

Primary cancer

aka sarcoma

pain early

periosteal reaction

biopsy and hypercalcemia

Multiple Myeloma

older, cold bone scan

primary bone cancer

no periosteal reaction

raindrop skull

blood, bone, protein problem

bence jones proteinuria

increased ESR, IgG, A-G reversal

Osteosarcoma

young (knee)

old (pagets stage IV)

blastic or lytic

periosteal reactions

secondary cancer

aka mets (bone scan)

veins of batson

rare in extremities

no periosteal reaction

Differentiate spinal mets → Lytic

has a moth eaten or permeative appearance, winking pedicle, vertebral body collapse

Differentiate spinal mets → Blastic

causes an ivory white vertebra with a chalky appearance or cotton balls

Epiphyseal tumors (subarticular)

chondroblastoma (before 20)

giant cell (quasi-malignant) (after 20)

Diaphyseal tumors

ewing’s sarcoma (children)

multiple myeloma (adults)

Giant cell arteritis complication (aka temporal arteritis)

blindness

most common benign bone tumor of the hand

enchondroma

most common benign bone tumor of the spine

hemangioma

most common benign tumor of the body

osteochondroma

most common malignancy of body

lytic mets

most common primary malignancy of bone

Multiple myeloma

most common fracture

clavicle fracture

most common skin cancer

basal cell carcinoma

most common bone cancer

lytic mets

giant cell tumor complication

cancer → quasi malignant

OA (non-inflammatory)

>40 y/o

normal labs

weight bearing joints

S/S in the morning, stiffness, crepitus, loss of extension

x-ray: asymmetrical, spurs, decreased joint space, subchondral cysts

RA (inflammatory)

female 20-40 y/o, male >40 y/o

labs = RA and FANA

wrists, symmetrical involvement of the appendicular small joints and cervical spine

prolonged morning stiffness, swollen hot joints, joint deformity, ulnar deviation (swan and boutonniere)

rat bite erosions, subchondral cyst, localized osteoporosis, fibrosis

Gout (inflammatory, podegra)

male >45 y/o

joint aspiration, UA and uric acid

podegra, great toe, elbow, hands and feet

episode caused by purine foods, night pain, hot swollen joints, fever, tophi

asymmetrical, overhanging edge sign (messy)

CPPD (inflammatory)

both over 50 y/o

joint aspiration and UA

knee

episodes

joint calcinosis

AS (inflammatory, aka marie strumpell aka bamboo)

males 10-30 y/o (90%)

HLA-B27, ESR

SI joints, spine, rib joints

morning stiffness, LBP, dyspnea, aortic calcification

syndesmophytes, dagger, trolley and carrot fracture

Enteropathic

young

HLA-B27, ESR

SI joint and spine

GI disease

syndesmophytes

Scleroderma (inflammatory) (PSS → progressive systemic sclerosis)

females 30-50 y/o

FANA, RA, RNA

hands, systemic (vascular and fibrotic changes in skin and organs)

tight shiny skin, CREST sign, progressive dysphagia

distal tuft erosion, acroosteolysis

Psoriatic (inflammatory)

both 20-50 y/o

HLA-B27

DIPS, hands and feet, SI and spine

skin rashes (extensors), pitted nails, mimics RA

syndesmophytes, distal tuft erosions, large joint and asymmetrical

SLE (inflammatory)

females (90%)

LE, FANA, RA, Coombs, + DNA

Systemic, hands and feet

fever, raynauds, photosensitive

Jaccoud’s, no xray destruction

Reiter’s (reactive, inflammatory)

males 20-40 y/o

HLA-B27, ESR, culture

feet, SI, spine, heel spur

conjunctivitis, urethritis, arthritis

syndesmophytes. asymmetrical, large joint destruction

DISH (non-inflammatory)

males >50y/o

HLA-B8, FBS (DM)

cervical and thoracics

dysphagia

thick flowing hyperostosis (ALL)

Scoliosis

right convexity is most common

thoracolumbar region of adolescent girls

adam’s test is used to determine whether it is structural or functional

risser’s sign and wrist x-ray can determine bony maturation

protocol for right convexity = 0-20 degrees → adjust, 20-40 degrees = bracing, >40 degrees = surgery, >50 degrees = cardiopulmonary compromise

protocol for left thoraco scoliosis = cardiologist

causes of scoliosis

hemivertebrae = structural

neurofibromatosi = kyphoscoliosis

idiopathic = spina bifida, QL spasm, etc

Retro-pharyngeal space

<7

Retro-laryngeal space

<14

Retro-tracheal space

<22

ADI

child: <5

Adult <3

Myelopathy

cord, UMNL, CNS

Upper cervical (ADI), RA

lower cervical (canal stenosis), OA

complete clonus and pathological reflexes

lhermitte’s (perform actively!)

MRI, EMG, and SSEP (somatosensory evoked potential)

Xray: flex and ext views

Radiculopathy

root/number

LMNL, PNS

IVF and lateral recess, C5-T1, L4-S1 (Everything)

Spinal lateral flexion and extension, rotation towards side of lesion, radiating pain

myotome, dermatome, and DTRs

Cervical compression, shoulder depressor, kemps, SLR, WLR

EMG, xray (IVF), disc = MRI

Neuropathy

peripheral/name

LMNL, PNS

extremities → brachial plexus and sciatica

distal to site of entrapment (Adjacent), burning (causalgia)

several muscles in compartment, pure patch

otho exam varies

NCV and EMG

Complete Neurological evaluation

Mental status, CN

reflexes (4 kinds)

motor evaluation

sensory evaluation

coordination (cerebellum)

Radiculopathy (nerve roots)

muscle → myotome

Reflex → DTR

Sensory → dermatome

Cerebellum

charcot’s triad → Speech, intention tremor, nystagmus

responsibility = motor, coordination, speech, gait

tests: heel to shin, diadochokinesia (dyssynergia), finger to nose

disease: alcoholism, MS, motor ataxia

Posterior columns

Charcot’s joints

cuneatus = upper extremity

gracilis = lower extremity

responsible for sensory (2 point discrimination, vibration, position sense)

Tests: romberg’s, 2 pins, 128 tuning fork, toe placement

Disease: PLS, MS, syphilis, DM, sensory ataxia

Extra-pyramidal

responsible for postue

test = gait

disease = parkinsons

Lateral spinal-thalamic

pseudo charcot’s joint

responsible for sensory (temperature and pain)

test = hot and cold test tube

disease = syringomyelia (bilateral loss of pain and temp, shawl like)

Corticospinal tract (pyramidal lesions)

responsible for motor and voluntary motor

tests = muscle tests, mensuration, DTR

Disease = UMNL (before anterior cell), LMNL anterior cell to periphery

UMNL (need 3)

spastic paralysis

increased DTRs

present pathological reflexes

clonus present

hypertrophy

absent fasciculations

absent superficial reflexes

CNS bilateral (Co-Care)

LMNL

flaccid paralysis

Decreased DTRs

Absent pathological reflexes

absent clonus

atrophy

fasciculations present

absent superficial reflexes

Muscular dystrophy

affects lower body 1st → not going up stairs → calves enlarged

young boys, muscle destruction, pseudohypertrophy, waddling gait

gower’s sign, albuminuria, creatinuria

ALS

ALS ←→ CTE

UMNL, LMNL, and bulbar palsy

starts in intrinsic muscles in hand, older males, 5 year terminal

Myasthenia gravis (CN muscles)

myoneural junction, autoimmune

diplopia, swallowing, fatigue, shoulders and head

intermittent (naps, sleeps, rest), tensilon test

Cerebral palsy

non-progressive motor disorder occurs at birth due to anoxia, scissor gait

Parkinsonism (paralysis agitans)

basal ganglia lesion, substantia nigra, extrapyramidal

resting tremor (pill rolling)

blank stare, oily, diminished swing

festinating gait

Guillain Barre

rapidly ascending paralysis (post viral polyneuropathy)

Brown sequard’s (trauma and tumors)

hemi-sections of spinal cord with ipsilateral loss of motor and paresthesia, and contralateral loss of pain and temp

Charcot marie tooth (peroneal disease)

characterized by calf weakness and sensory loss, steppage gait

Cord compression (UMNL)

causes upper and lower extremity symptoms neurologically

myelopathy

Cauda Equina (lumbars)

radiculopathy

S2-S4 bowel and bladder control (nerve root compression - LMNL)

CVA (hemiplegia)

spares forehead

short or long duration

prognosis after 2 years

Syringomyelia

fluid filled cavitation that expands and puts pressure on the lateral spinothalamic tract (most often)

cervical spine region, pain and temperature loss in a shawl or capelike distribution

PLS (combined systems disease)

stomach gastritis leads to anemia which leads to PLS (B12)

paresthesia, weakness, pain and temperature loss, progressive neurological deficits

Schilling’s Test (B12), reticulocytosis

MS

demyelination of the cord (plaques form)

diplopia, intention tremors, speech, incontinence, exacerbation and remissions, Lhermitte’s test

Charcot’s triad (cerebellum)

MRI, CSF evaluation, eye exam, EMG

heat and humidity flare

Subclavian steal

TIA, reversal of blood flow

stenosis of subclavian

wallenburg syndrome

post trauma (TIA)

Barre lieou’s

post trauma (mimics meniere’s)

BPV (benign paroxysmal positional vertigo)

post trauma, fatigable dizziness

Meniere’s AKA Endolyphatic hydrops

tinnitus, vertigo, transient deafness

no trauma

Horner’s syndrome

Interruption of sympathetics to the face causing anhydrosis, ptosis and miosis

causes: TOS, pancoast syndrome, whiplash, birth

Pancoast syndrome

metastasis

TOS (neuropathy)

horner’s syndrome

Festination gait

AKA shuffling, mincing, propulsion = parkinson’s

Motor ataxia (aka staggering)

cerebellum

Sensory ataxia (slappage gait)

posterior columns

Steppage (L4)

foot drop, toe drag, foot slap

tibialis anterior

Gluteus medius lurch (L5)

lateral sway over the weight bearing leg

Gluteus maximus lurch (S1)

AP sway (leans back during mid stance)

Circumduction gait

CVA, weak quadriceps (unilateral)

Scissor gait

cerebral palsy, adductor spasm

Waddling gait

MD, clumsy and weak

Normal gait =

Heel strike → mid-stance → toe-off → accelerate → mid swing → decelerate

C2

scalp

C3

nape of neck

T2

axilla

T4

nipple

T7

xiphoid

T10

umbilicus

L1

inguinal ligament and oblique upper thigh

L2

oblique middle thigh

L3

knee

L4

medial leg

L5

dorsum of foot

S1

little toe

S2

posterior thigh

S2-S4

bull’s eye

Nerve level: C5

Vertebral Disc: C4, IVF: C4

Myotome → arm abduction (biceps)

dermatome: lateral arm

DTR: biceps

Nerve level: C6

Vertebral disc: C5, IVF: C5

Myotome: Wrist extension (bicep)

Dermatome: lateral forearm (first 2 digits)

DTR: brachioradialis

Nerve level: C7

Vertebral disc: C6, IVF: C6

Myotome: wrist flexion, finger extension

dermatome: middle finger

DTR: triceps

Nerve level: C8

Vertebral disc: C7, IVF:C7

Myotome: finger flexion

dermatome: medial forearm, last 2 digits

no DTR

Nerve level: T1

Vertebral disc: T1, IVF: T1

Myotome: interossei

dermatome: medial elbow

No DTR

Nerve level: L4

vertebral Disc: L3, IVF, L4

myotome: tibialis anterior (heel walk/foot drop)

dermatome: medial leg, ankle

DTR: patellar

nerve level: L5

vertebral disc: L4, IVF, L5

Myotome: Gluteus medius, extensor hallucis longs (heel walk)

dermatome: Lateral leg, dorsum of foot

DTR: posterior tibial, and medial hamstring

Nerve level: S1

Vertebral Disc: L5, IVF: S1 foramen

Myotome: peroneus longs and brevis, gluteus maximus, gastroc and soleus (toe walk)

Dermatome: posterior leg, lateral foot and plantar foot

DTR: achilles