CM3 (C5)

Fracture complications

• Pseudarthrosis

• Infection 

• Arthrosis

• Perifocl ossification

• Callus

  • Delayed 

  • Abnormal

  • Hypertrophic

Fracture Healing

CALLUS GENESIS

• Fibrino-proteic (1st 7 days)

• Provisional fibrous (7-16 days)

• Raw bone ( from day 16)

• Definitive (6-12 maths)

Rx

• Definitive: normal bone structure

• Raw: NO structure

  • visible after 20-60 days 

Rx assessment of Fr (peculiar types)

According to AGE

• Children

  • greenstick

  • buckled (impacted)

  • epiphyseal loosening

• Elderly: OP

Skin status: closed / open 

Rx assessment of Fr alignment (dislocation)

• Lateral

• Angulation

• Rotation

• Longitudinal (along the bone axis)

  • Distancing

  • Intermission

  • AScent (straddling)

Rx assessment Fr appearance and course

APPEARANCE

• Fissure (subtle)

• Complete (total disruption)

• Incomplete (ONLY one cortical disrupted)

 

COURSE (single or multiple)

• Transverse (diaphysis)

• Oblique (bending)

• Helical (torsion)

• Cominuted

• Layered

Rx assessment of Fr location

• Short 

• Flat

• Long

  • Metaphysis

  • Diaphysis

  • Epiphysis (intra / extra articular)

 

Rx assessment of Fractures

• Loc (anatomic)

• Extent

• Type (complete / incomplete)

• Course (carry): fr line VS bone long axis

• Aligment bone fragments (annulation, rotation, ascent, spacing)

• Special types

• Skin

• Assoc lesions (Fr + luxation / spacing)

Fractures Classif

1. Mechanism

   • direct (direct blow or bone allusion due to ligamental traction)

   • indirect (bending, torsion, traction, suqatting-crush)

2. Terrain

   • commo,, trivial

   • stress (fatigue)- long term microtrauma

   • PATHO- on preexisting bone lesion

Diastasis def 

Luxation of synarthroses 

Luxation def

Complete loss of contact between joints surfaces 

 + subluxation 

Fracture def

Disruption of bone continuity, installed abruptly, as a csq of trauma

 + incomplete fracture 

MSK Trauma Rof of Imaging 

• Positive Dg + lesion type

• Monitoring + Dg complications 

METHODS

• CT (complex fractures)

• Conventional Xray

• Nuclear Medecine (sometimes)

• Arthrography

• Angiography (concomitant vascular involvement)

• MRI (soft tissue, bone concussion)

Thigh Rhabdmiosarcoma

Meniscal tear

Achille's tendon rupture

Rupture of cruciate ligaments 

Periarthrisits, intraarticlar chondromatosis 

Spondylolisthesis + Spondylolysis 

Knee 

Gonarthrosis 

 

Hip

Coxarthrosis

Hand

Polyarthrosis (DIPh, Trapezo MC1)

Difference Osteophyte Syndesmophyte

Spondylosis

• Osteophytosis

  • any segment, at 1st horizontal, then vertical

  • McNab Osteophyte

• Discarthosis 

  • narrowing, bulging, vacuum phenomen

  • OS

  • Intraspongious hernias (schoolroom nodules)

  • Disk calcification

Spine 

• Spondylotis 

• Arthrosis of small posterior joints

• Spondylarthrosis

• Uncarthrosis

Arthrosis Rx

GENERAL Rx signs

• Joint space narrowing (even or uneven)

• Subchondral OS

• Subchondral cysts

• Osteophytes

Technique: 2 views AP + prophyle

 

CHANGES

• Joint space narrowing : slow, expressed in %

• Osteophytes: marginal, subcartilaginous

• Subchondral OS & subuxation

• Synovitis: joint effusion (US, MRI)

Pathology of Arthrosis

• Cartilage changes (thinning)

• Sbchondral bone sclerosis 

• OP

• Osteophytes (chondro-synovial junction)

• Subchondral cyts

• Narrowing of joint space but NEVER disappearance 

 

Arthrosis NEVER produces bone ankylosis

There is NO relation between Rx changes and clinical symptoms 

Degenerative Articular Changes (ARTHROSIS)

Heterogenous group of disease, joint changes due to a joint cartilage degeneration (aging) & consecutive subchondral bone changes (affecting the whole joint)

 

Other names: osteoarthritis, osteoarthritis, deforming arthrosis

 

Based on:

• Joint cartilage thinning

• Consecutive change of bone surface

• OSteophytes

• Joint deformity

 

The most fq arthropathy (primary and secondary)

Etio: multifactorial

• Genetic / Habitus

• Endocrine

• Nutritional / Metabolic

• Mechanic

• Age 

GOUT Imaging recommendations

• Rx

• Soft tissue masss, NO tophi => MRI

GOUT Imagistics

Rx (N in first year)

• Cartilage destruction (advanced stage)

• Tophi

  • Density, sometimes calcified, eccentric, NOT necessary with neighboring joint changes

  • RARELY intraosseous calcification

• Circumscribed erosions + sclerotic margins

  • Juxtaarticular, often intraarticular 

MR

• Effusion: hypoT1, hyperT2

• Edema: soft tissue / bone

• Tophi: intermediate homogenous T1

• Synovial panus: hypoT1, hypoT2, peripheral enhancement 

Gout Dg Clues

• Dense tophi, erosiosn

• LOC

  • MTPh 1

  • Lower extremities > up

  • Small joints > large

  • Any loc

  • Oligo, BUT may be polyarticular, asymmetric

Gout CharaK

• Synovial

• Idiopthic, familial 

• Hyperuricemia => uric acid deposits on soft tissues => cartilage, bone => inflammation, destruction

  • Primary: acute attack

  • Chronic: gouty tophi 

GOUT

Epidemio: <5% of hyperuricemia pts, 5% of arthritis pts

 

Age: 30-60 yrs

 

M:F = 20:1

 

Predispo F: metabolic syndrome => obesity, HBP, diabetes,  endstage renal D+, alcohol, diuretics 

AS Dg recommendations 

• Early: MRI (detect early infection)

• Late / advanced: Rx

  • Sacroilic Rx= business card of AS patient

• Complication or trauma: CT, MRI

Enthesopathy AS = spicules, brush 

• Tendon insetion

• Iliac crest

• Grater trochanter

• Ischiatic tubeerosity 

• Calcanean enthesitis 

Spine AS

• Shiny corners

• Square vertebrae

• Syndesmophites 

• Bamboo stick

• Calcifications

  • Interspinate

  • Yellow lig (tram line)

Sacroiliitis AS

• Bilat, symmetrical

• Subchondral OS

• Erosions + false widening 

• Bone bridges, narrowing

• Fusion : ankylosis

ARA  Dg  criteria AS

• Lumbar pain > 3 maths, NOT eased by resting

• Pain + stiffness in chest 

• Limmited breathing movements

• Limited spinal mobility 

• Iritis

• Sacroileitis Rx

• Syndesmophytes Rx

AS Dg

Dg: syndesmophyes + bilat sacroilitis

 

LOC

• SI joints (synovial part inf 1/2-1/3)

• Large proximal joints : hips, shoulder

• Spine (DL)

  • Anterior margins

  • Anterior fibers of fibrous ring

AS

Inflammatory arthropathy & enthesopathy located mainly in the axial skeleton

HLA-B27

 

Incidence: 0,1 % pop (15-30 y) - B:F = 2,5-5 : 1

 

CLINIC

• Persistent, progressive

• Nocturnal

• Bilat

• Sensitivity on local pressure

• LATE: wolf neck, skier position and stepping 

 

OBJECTIVE SIGNS

• Occipital : wall dist

• Finger : ground dist

• Schober Test

• Ches expansion

Rheumatoid Arthritis Dg

Rx = business card of RA patients 

• RM (early US)

• Follow up

  • US + Doppler, contrast (synovitis, effusion)

  • RX (MR) = erosions

EXTRA articular changes

• rheumatoid lung

• rheumatoid lung nodules

• pleuraal effusion

• pericarditis

RA MRI

• Panusul

• Effusion

• Bone edema

• Erosions

• Cysts

• Tendons + contrast

RA US

• Small fluid effusion of joints

• Panus

• Erosions

• Rheumatoid nodules

RA

CharaK RA hands

• Focal soft tissue swelling

  •  early=> MCPh, PIPh, ulnar styloid

• OP

  • early=> juxtaarticular, band

  • late=> diffuse

• Erosions

  • early=> decreased cortical differentiation (dot dash pattern)

  • marginal = moue ears at basis of the phalanges

  • subchondral=> pen in cup, destruction of ulna, carpal bones

• Cartilage destruction

  • early false increased of joint space (effusion)

  • destruction & narrowing of joint space

• Subchondral cysts

• Malalignement

  • carpal: ulnar deviation and scaphoid luxation

  • fingers: MCPh, ulnar deviation, subluxation

RA Patholoy

• Papilomatous synovial hypertrophy

• Panus

• Cartilagee destruction

• Bone destruction 

• Luxation / subluxation 

• Ankylosis

• Inner organ disease

RA hand joints 

Dg CLUES

• Purely erosive 

• OP

• Joint alignement changes

 

LOC

• Classic: symétrie (+ unilateral in early stages)

• Early: MCPh, distal RU, RC

• Late: PIPh, IC

• Almost NEVER involved DIPh

ARA positive Dg criteria RA

• Morning stiffness

• Pain upon movement or pressure (at least 1 joint)

• Joint swelling > 6 wks

• Swelling of another joint < 3 mths

• Bilateral swelling MCPh, PIPh, MTF, NOT DIPh

• Subcutaneous rheumatoid nodules

• typical RX changes

• Positive rheumatoid factor 

• Pathology= rheumatoid nodules

Rheumatoid Arthritis (RA)

Chronic inflammation disease primary involving the small joints of extremities

 

• 1% of the population (F:M= 3:1)

• Joints involved: MCF 85%, carpal 80% and PIPh 75%

Septic Arthritis US

• Small fluid effusions 

• Thickened synovial membrane + Doppler signal in acute phase 

• US guided joint punctures (Dg, therapeutic)

Septic Arthritis (Pseudomonas)

Septic Arthritis MRI

Within 24 hrs from onset

 

• T1: subchondral hyposignal on both bones

• Fluid sensitive sequences: hypersignal fluid in joint, surrounding edema

• Post contrast: 

  • Synovial enhancement

  • Subchondral enhancement

  • Soft tissue abscess

Septic Arthritis CT

Rarely used / same as Xray

Guided puncture

Septic Arthritis Rx

Normal Rx

• Intraarticular effusion 

• Periarticular OP

• Joint space narrowing

• Blurred cortical bone

• Subcondral bone destruction

• Erosion + osteomyelitis

• Ankylosis (rare)

Septic Arthritis

• Agent: Staph

• Seeding: hematoG, direct and contiguity

• Predispo F:

  • local: RA, arthrosis, trauma, microcristal arthritis, neurotropathy

  • general: hémopathies, DM, cancer, chronic renal failure, immune deficit, drug abuse

• Loc: any joints

  • more fq= hip (kids), knee (adults) and SI or sternoclavicular in DM, HIV and drug abuse

Ankylosis

Disappearance of joint space => bone fusion across a joint

 

ONLY  produced by arthritis

NEVER produced by arthrosis

Osteomyelitis Complication

• Septic Arthritis

• PATHO fractures with PATHO healing

• Limb deformity (shortening / lengthening)

Osteomyelitis (peculiar- bone whitlow= infection of the soft tissue of the fingers)

• Soft tissue swelling

• Surface osteolysis

• NO periostosis

EVO (complication)

• Septic arthritis 

• PATHO fracture with PATHO healing

• Limb deformity (shortening / lengthening)

Chronic Osteomyelitis MRI

• Active foci

• Abscess

• Fibrosis

• Sequestration

• Soft tissue abscess

CharaK Osteomyelitis 

• Chronic, evolution in bursts

• Single bone, single place 

• Involves etaphyses an diaphyssis NOT epiphysis NOR joints

Xray CharaK

• Bone sequestration

• Osteosclerosis

• Periostosis

• Hyperostosis

MRI Osteomyelitis 

• Paraosseous hyperT2 (soft tissue edema)

• In bone marrow : hypoT1 and hyperT2

• Increased Ga Uptake

Osteomyelitis (nelaton in 1844)

• Agent: Staph Aureus (75%) or streptococci & other germs

• Contamination

  • Hematogenous

  • Contiguity

  • Direct seeding: accidental & iatrogenous

• Affecting: any age, more fq in children M/F=3/1

 

• Slow emergence

  • at 24-48h: increased soft tissue opacity and thinning if adipose tisse

  • at 7-10 d: OP, foci of Osteolysis and thinning blade shaped periostosis (3-6 wks)

Chronic Osteomyelitis CT

• Sequestration

• Cortcal thinnign

• Fistulae (fistulography)

• Soft tissue absecess (+ contrast)

US Osteoyelitis (7,5-10 MHz)

• Edema

• Periosseous abscess (transonic)

• Periostosis (irregular bone surface)