Diagnostics - Exam 2

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216 Terms

1
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Anti-nuclear antibody (ANA)

SLE, connective tissue disease

autoimmune conditions: rheumatoid arthritis and thyroid disease

sensitive but not specific

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ANA is measured through

indirect immunofluorescence as a titer

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ANA is clinically significant when

greater than or equal to 1:160

1:40 seen in some healthy people

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ANA patterns

nuclear fluorescence under microscopy

certain patterns are associated with specific diseases

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Anti-Dsdna & anti-Sm antibodies

ordered when ANA is positive and concern for lupus

Dsdna - positive in 70-80% of lupus; high levels are associated with lupus nephritis and predictive of lupus flare

Smith - 30% associated with lupus

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Serum complement levels (C3 + C4)

low levels in increased activity of disease with SLE, systemic vasculitis, cryoglobulinemia

increased consumption due to complement activation

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Sjrogrens antibodies

Anti-SSA(Ro) and anti-SSB(La)

SSA positive in 75% of Sjrogrens and 40% of SLE

SSB positive in 40-50% of Sjrogrens and 15% of SLE

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Anti-scleroderma antibodies

anti-centromere ab and anti-topoisomerase ab

anti-centromere - seen in limited scleroderma (CREST syndrome)

anti-topoisomerase ab (Scl-70) - seen in systemic sclerosis/scleroderma / higher risk of severe lung disease

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ESR

indirect measurement of alterations in acute-phase reactants and quantitative immunoglobulins

non-specific

high levels caused by rheumatologic (connective tissue disease, giant cell arteritis, polymyalgia rheumatic, inflammatory arthritis) or malignancy

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CRP

pentameric protein present in trace concentrations in everyone

more specific than ESR - measures specific acute phase reactant

high levels suggest underlying bacterial infection

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Rheumatoid factor

50-80% sensitive for RA

positive from chronic immune stimulation

can be caused by chronic disease (hepatitis and pulmonary disease), lupus, systemic sclerosis, Sjrogrens, polymyositis, sarcoidosis, neoplasms, infections, cryoglobulinemia

can also be seen in normal individuals at lower titer

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HLA-B27

seen in seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis), IBD, or reactive arthritis

if positive, increased risk of ankylosing spondylitis

helpful in patients with inflammatory back pain

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Uric acid

end product of degradation of purines

target in gout is less than 6

may be falsely low in flare

could be asymptomatic hyperuricemia

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Synovial fluid

ultrafiltrate of plasma found in joints to allow for friction-free movement

excess can accumulate as result of noninflammatory, inflammatory or septic processes

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Joint aspirations are assessed for

synovial fluid cell count, Gram stain, & culture - infections

presence of crystals - crystalline arthropathy

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Arthrocentesis indications

removal from fluid from a swollen, inflamed joint

suspicion for septic arthritis

excessive joint fluid removal to improve ROM and patient comfort

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Arthrocentesis contraindications

active cellulitis or abscess overlying the joint

caution if INR is greater than 3

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Major determinant of clarity and color of arthrocentesis is the

cell count

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Noninflammatory fluid

low cell count and clear

ex. OA

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Inflammatory arthritis fluid

higher cell count and translucent-yellow

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Rice bodies in fluid

free-floating aggregates of tissue --> RA, SLE, septic arthritis

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Milky white fluid

large quantities of urate crystals in acute gout

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Normal synovial fluid has less than ____ WBC

200

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WBC in non-inflammatory vs inflammatory

< 2000 in noninflammatory

> 2000 in inflammatory

> 50,000 in septic arthritis or gout if crystalline

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Crystal analysis of synovial fluid

performed on a wet mount under polarized light

yellow or blue - birefringent material

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Crystals that are yellow when oriented parallel and blue when perpendicular

negatively birefringent - gout

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Crystals that are blue when oriented parallel and yellow when perpendicular

positively birefringent - pseudogout or inflammatory joint disease, hemarthrosis, trauma, pancreatitis

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MC bacteria in septic arthritis

staph aureus

strep pyogenes

strep pneumonia

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Classes of synovial fluid

1 - noninflammatory

2 - inflammatory

3 - septic

4 - hemorrhagic

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Fluoroscopy

continuous XR

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Desired structure in imaging should be closer to plate or source of XR?

plate - so spinal imaging is best with AP

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MRI time

20-30 minutes - not used typically in emergent settings except something like cauda equina

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Dual energy XR (DEXA)

low dose XR with 2 different energies that attenuate differently in bone and soft tissue

allows for calculation of bone mass density

typically looks at lumbar spine and proximal femur

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Positron emission tomography (PET)

uses radioactive tracer to evaluate metabolic activity

evaluates cancer mets earlier than CT/MRI

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Osteoporosis imaging

DEXA

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Osteoarthritis imaging

XR with Rosenberg view or sunrise view

<p>XR with Rosenberg view or sunrise view</p>
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Sunrise view

knowt flashcard image
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Osteoarthritis radiographic findings

joint space narrowing - medial compartment MC

osteophyte formation

subchondral sclerosis

cyst formation

bone attrition (flattening)

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Pseudogout on imaging

calcium pyrophosphate dehydrate deposition (CPDD) - may mimic OA - differentiated bc isolated or disproportionate patellofemoral OA with chondrocalcinosis

<p>calcium pyrophosphate dehydrate deposition (CPDD) - may mimic OA - differentiated bc isolated or disproportionate patellofemoral OA with chondrocalcinosis</p>
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Early RA on imaging

MRI or US with synovial proliferation or bony erosions in both MRI and US

<p>MRI or US with synovial proliferation or bony erosions in both MRI and US</p>
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Late RA on imaging

symmetric polyarthropathy with joint space narrowing

involves distal radioulnar, radiocarpal, intercarpal, carpometacarpal, and metacarpophalangeal articulations

distal IP joints are spared

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Gout on imaging

soft tissue swelling

XR with soft tissue calcification, tophi, cortical erosions and irregularity, juxta-articular erosions with sclerotic rims and overhanging margins, preservation of mineralization and joint space

MRI can detect smaller tophi and earlier disease

CT not preferred but can be used

<p>soft tissue swelling</p><p>XR with soft tissue calcification, tophi, cortical erosions and irregularity, juxta-articular erosions with sclerotic rims and overhanging margins, preservation of mineralization and joint space</p><p>MRI can detect smaller tophi and earlier disease</p><p>CT not preferred but can be used</p>
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Osteomyelitis on imaging

infection of bone

radiographs + MRI w/ contrast

bone marrow edema with decreased bone marrow signal (same or lower signal than muscle --> diagnostic)

soft tissue swelling

ulcers, sinus tracts, abscesses, and necrosis

<p>infection of bone</p><p>radiographs + MRI w/ contrast</p><p>bone marrow edema with decreased bone marrow signal (same or lower signal than muscle --&gt; diagnostic)</p><p>soft tissue swelling</p><p>ulcers, sinus tracts, abscesses, and necrosis</p>
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Pigmented villonodular synovitis (PVS)

inflammatory vs neoplastic process of knee

painful joint swelling and decreased ROM

radiograph with large joint effusion or intra-articular soft tissue mass

well defined erosions with preservation of joint space

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Systematic review of images in trauma

Adequate and Aligned

Bones

Cartilage and joints

Soft tissues and spacing

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Open vs closed fracture

open = break in the skin

closed = skin intact

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Midshaft of the bone

diaphysis

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Distal end of bone

metaphysis and epiphysis with physis (growth plate) between in kids

<p>metaphysis and epiphysis with physis (growth plate) between in kids</p>
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How to note joint involvement in fracture imaging

intra vs extra-articular +/- displaced

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Type 1 intra-articular fracture

nondisplaced

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Type 2 intra-articular fracture

single displaced fracture plane

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Type 3 intra-articular fracture

2 displaced fracture planes

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Type 4 intra-articular fracture

highly comminuted

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Types of fractures

knowt flashcard image
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Orientation of fracture

knowt flashcard image
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In displacement, describe the displacement of the proximal or distal fragment?

distal (medially or laterally)

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Soft tissue and joint spaces

effusion or soft tissue swelling or gas

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Boxer's fracture

punching wall or other object

seen on XR

fracture of mid-diaphysis of 4th and/or 5th metacarpal

<p>punching wall or other object</p><p>seen on XR</p><p>fracture of mid-diaphysis of 4th and/or 5th metacarpal</p>
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Stress injury/fractures

focal pain in athlete with repetitive stress/loading of bone

commonly proximal tibia

diagnosed with XR and then MRI for prognosis

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Classification of stress fractures

fatigue fracture - abnormal activity on normal bone (excessive running)

insufficiency fracture - normal activity on abnormal bone (walking but osteoporotic)

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Insufficiency fracture of knee on imaging

subtle impression along medial femoral condyle

if delayed - subchondral lucency that process to flattening and collapse of articular surface

late findings - degenerative changes

MRI - extensive bone marrow edema (usually in medial femoral condyle)

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Soft tissue foreign body imaging

US - limited to visualization of radiopaque foreign bodies

posterior acoustic shadowing on radiograph with surrounding area of hypoechoic granulation tissue, edema, or hemorrhage

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Pseudo subluxation of spine

neck pain often s/p MVA

may be anatomic variant in adolescents due to ligamentous laxity

seen on XR with subluxation of vertebral body that would be accentuated with flexion

<p>neck pain often s/p MVA</p><p>may be anatomic variant in adolescents due to ligamentous laxity</p><p>seen on XR with subluxation of vertebral body that would be accentuated with flexion</p>
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Glenohumeral dislocation

shoulder deformity after FOOSH

arm abducted and held in ER

seen on XR with axillary or scapular "Y" view

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Glenohumeral dislocation on imaging

humeral head displaced medially and inferiorly in relation to glenoid fossa

inferior to coracoid process

Bankart lesion - fx of anteroinferior glenoid rim seen on CT or MRI

<p>humeral head displaced medially and inferiorly in relation to glenoid fossa</p><p>inferior to coracoid process</p><p>Bankart lesion - fx of anteroinferior glenoid rim seen on CT or MRI</p>
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Acute rotator cuff tear

persistent shoulder pain that's worse with overhead activity

seen on XR, MRI, or US with inferior osteophytes at AC joint and cephalad migration of humeral head

<p>persistent shoulder pain that's worse with overhead activity</p><p>seen on XR, MRI, or US with inferior osteophytes at AC joint and cephalad migration of humeral head</p>
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US findings that may mimic rotator cuff tear

tendinosis

calcific tendonitis

adhesive capsulitis

subacromial/subdeltoid bursitis

greater tuberosity fracture

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Colles fracture

FOOSH with extended wrist

pain of distal radius/wrist

radiographic findings - volar fracture angulation with dorsal proximal displacement or "dinner fork" deformity

<p>FOOSH with extended wrist</p><p>pain of distal radius/wrist</p><p>radiographic findings - volar fracture angulation with dorsal proximal displacement or "dinner fork" deformity</p>
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Smith fracture (reverse Colles)

FOOSH with flexed wrist

pain of distal radius/wrist

may be extra-articular, intraarticular or part of fracture-dislocation of wrist

radiographic findings: dorsal fracture of distal radius with hand and wrist displaced volarly

<p>FOOSH with flexed wrist</p><p>pain of distal radius/wrist</p><p>may be extra-articular, intraarticular or part of fracture-dislocation of wrist</p><p>radiographic findings: dorsal fracture of distal radius with hand and wrist displaced volarly</p>
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Galeazzi fracture

pain and tenderness along shaft of radius that typically requires ORIF

radiographic findings: isolated fracture along the length of radius with or without associated ulnar fracture

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Monteggia fracture

FOOSH

required ORIF

radiographic findings: fracture at proximal 1/3 of ulnar with anterior dislocation of radial head

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Scaphoid fracture

FOOSH and tenderness over anatomical snuff box

vascular supply of scaphoid bone is distal to proximal

1/3 of fractures of middle scaphoid develop avascular necrosis

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Scaphoid fracture radiographic findings

subtle!

splint anyone with suspected scaphoid fx

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Slipped capital femoral epiphysis (SCFE)

atraumatic fracture with posterior and medial displacement of proximal femoral epiphysis (in relation to metaphysis)

adolescent with limping gait +/- growth spurt, overweight, or increased activity

XR with frog leg view

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Slipped capital femoral epiphysis (SCFE) on imaging

widening of physis

medial displacement of epiphysis on lateral view

Lines of Klein - superior edge of femoral neck

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Patellar fracture

knee pain following blunt trauma

XR with merchant/sunrise view

<p>knee pain following blunt trauma</p><p>XR with merchant/sunrise view</p>
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Tibial plateau fracture

severe knee pain, inability to bear weight, large knee joint effusion

seen on XR with oblique view

CT or MRI for further eval

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Tibial plateau fracture on imaging

lipohemoarthrosis with intraarticular fractures

<p>lipohemoarthrosis with intraarticular fractures</p>
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Tibial plateau fracture - Schatzker classification

knowt flashcard image
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ACL tear

injury with deceleration, twisting, or jumping

XR to r/o fx and MRI for fx

joint effusion, Segond fracture (avulsion fx secondary to ACL tear) and deep lateral femoral notch sign

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Calcaneus fracture

axial loading after jumping or falling

XR with Harris view: lucent line, loss of height of central calcaneus, increase in Bohler's angle, and/or decrease in critical angle of Gissane

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Plantar fasciitis

heel pain with first steps of day and after sitting for extended periods

sharp pain with palpation of medial plantar calcaneal region

discomfort in proximal plantar heel on passive ankle dorsiflexion

commonly co-occur with calcaneal spurs

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Bone sarcoma - solid

intact cortex with solid, continuous overlying bone formation

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Bone sarcoma - unilamellated

slow growing lesion contained by bone

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Bone sarcoma - multilamellated

waxing and waning, bone continually tries to contain lesion "onionskin"

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Bone sarcoma - spiculated

most aggressive - highly suggestive of malignancy "hair on end" or "sunburst"

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Bone sarcoma - Condman triangle

elevation of periosteum away from cortex

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Bone sarcoma - buttress

beaklike new bone formation

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Bone sarcoma - cortex or patterns of bone destruction

IA - well defined with sclerosis

IB - well defined without sclerosis

IC - ill defined

moth-eaten

permeative

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Giant cell tumor of bone

XR: geographic bone destruction with well-defined margins, often IB or IC patterns

located in metaphysis with extension into diaphysis

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Enchodroma

may be found incidentally on imaging

imaging of choice: MRI

found in long bones with mineralization in form of dots, rings, or arcs

may be radiolucent in short tubular bones of hands and feet

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Incidental cystic bone lesion

atraumatic pain

seen on XR: well defined borders of lesion and adjacent bone, evaluate for pathologic fracture

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Osteoid sarcoma

benign, bone producing sarcoma

nocturnal pain relieved with aspirin

imaging of choice CT: small cortical lucency surrounded by sclerosis involving one side of diaphysis

subtypes classified by location in bone: cortical, medullary, and subperiosteal

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Multiple myeloma

bone pain, pathologic fracture

abnormal labs with anemia, hypercalcemia, renal insufficiency

radiograph: multiple lytic foci with round, punched out areas of bone destruction uniform in size

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Padget disease

chronic skeletal disorder characterized by focal resorption of bone followed by disorderly bone formation and abnormal bone remodeling

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Padget disease - lytic stage

osteolysis in epiphysis extending to metaphysis and then diaphysis

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Padget disease - mixed stage

advanced osteolysis with thickening of bone trabeculae and cortex

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Padget disease - blastic stage

osteosclerosis with high concern for insufficiency fractures

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Myositis ossificans

benign, self-limiting, nonneoplastic response to injury

mature bone develops within the injury in about 2 months

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Osteochrondroma

palpable hard mass in extremity

XR: bony protrusion with contiguous marrow and cortex to underlying normal bone