Don's gem's Sept-Oct 01

The Wizard's potion

These are some of Don's interesting comments from the Friday morning case conferences.  Any errors in this section are solely the poor recording of otherwise accurate comments, due to the pressure of the quantity of interesting comments.  This section is updated weekly.

This section has outgrown it's page and been subdivided. Previous sections are linked below.

2001             July August September October November December
2002 Jan Feb March                  


October 26th

1. The medial patellofemoral ligament is a thickening of the retinaculum.


October 12th

1. Fibromatosis: Superficial, palmar and plantar.

                            Deep, Abdominal and extra abdominal.

Desmoid is an example of a deep extra abdominal tumour.  It is related to Gardener's syndrome.

2. Perthes is usually unilateral.  Bilateral, consider multiple epiphyseal dysplasia and sickle cell.

3. RhA has joint space narrowing equally at radioscaphoid and radiolunate unlike OA which predominates at the radioscaphoid joint.

4. Ulna drift of the phalanges is less common in Juvenile RhA because it is secondary to radial deviation at the wrist, which is less common due to early fusion.

5. Talonavicular joint most common midfoot joint involved in RhA.

6. The navicularcunneiform joint is a single joint.

7. May see new bone formation on the medial side of the medial malleolus in sero neg arthritis.

8. The Lisfranc ligament passes from the medial cunneiform to the base of the second MT.


September 28th

1. At the elbow the tendons tend to be injured laterally and the ligaments medially.

2. Multiple hereditary osteochondromatosis often causes a reversed Madelung.

3. The presence of a peroneus quartus or the peroneal calcaneal muscle is associated with a longitudinal split of peroneus brevis.

4. Congenital contractural arachnodactyly is due to a fibrillin 2 abnormality.  Marfan's is a type 1 fibrillin abnormality.


September 21st

1. ACL distal avulsion, look for trapped transverse meniscal ligament.

2. A displaced bucket handle tear can only relocate early, it then becomes fixed.  If one limb of a bucket handle tear is torn off, the tear is not reparable, only resectable.

3. Repairable menisci are the exception.

4. Red zone is likely less than 30%.

5. Isolated PCL tears are 30% of total.  Posterior displacement of tibia with knee flexed, ie dashboard.

6. Midsubstance PCL tears are poor to repair. Avulsion easier to repair.

7. PCL tears, check the posterolateral corner.  Also associated with a radial tear of the medial body and posterior horn tears of the lateral meniscus.

8. Myositis ossificans is suggested by a fusiform shape.

9. If a Hill Sach's engages the glenoid in external rotation with abduction, then a repair of the labrum is less likely to be successful.


Scripps September 20th

1. Inflammatory OA occurs in a background setting of OA. The erosions spare the edges.  May cause fusion.

2. DISH: 4 continuous vertebrae. The most sensitive extra axial sites of new  bone proliferation that indicate DISH are the lesser trochanter and outer margin of the acetabulum.

3. Chester Erdheim: Related to Langerhans histiocytosis.  Have retroperitoneal masses.  Spares the epiphyses.  Tends to be bilateral.  Flame shaped.

4. Tumoral calcinosis: Primary Idiopathic TC, Secondary; collagen vascular disease, CRF with dialysis, Milk alkali, hyper vit D.

5. Cement can tract into vein at time of TJR.

6. Paget's can extend from spine to ribs, but rare in ribs and fibula.

7. Haemosiderin in synovium. Low signal made lower by gradient echo imaging.  PVNS, haemophilia, synovial haemangioma.

8. If see high signal post medial superior to MCL at the knee, consider, posterior oblique ligament injury or isolated sekimembranous injury.

9. If there is a common flexor tendon injury at the elbow, always check the medial collateral ligament.


Navy September 19th 2001

1. Longus colli calcification can be associated with STS, pain, fever and rigidity.  It is due to calcium hydroxyappetite and disappears over months.

2. An os acetabuli is an ossicle in the anterior labrum and is often bilateral.

3. The acetabular rim syndrome can be due to crystals such as CPPD, HA, or labral tears or labral ganglion cysts.

4. Rapidly disolving joints: Idiopathic rapidly destructive (OA) hip disease.  ? neuropathic, ?Milwaukee hip, ? insufficiency Fx, ? massive osteonecrosis.

5. Rice bodies can be caused by RhA, TB, Non caseating granulomas.

6. Muscular sarcoid: 

    a. Asymptomatic

    b. Chronic myopathy with proximal wasting.

    c. Acute myositis.

    d. Nodular.  Stars and stripes granulomas.

        Low signal centre - fibrosis.

        High signal rim - inflammation

7. The accessory soleus attaches to the medial calcaneus.

8. Fibrosarcoma: 30-40Y, tubular bones, femur, 40% path Fx, have islands of necrosis, may occur in bone infarcts.

9. Osteolytic lesions with an Erlenmyer flask deformity, consider Gaucher's.  Cerebroside laden macrophages throughout.  Salmonella infection occasionally affects Gaucher's bones.

    1.5T       In phase multiple of 4.2

                    Out of phase multiple of 2.2

    No signal change = no fat.  ie Gaucher's

    Red marrow contains fat.  Infarcts can contain fat.

    Gaucher's can cause a soft tissue mass.  Subperiosteal hematoma represents active Gaucher's  and can lead to a bone crisis from increased pressure in bone.

10. Tumour can cross the knee in the cruciates.

11. Fluid fluid levels in bone: Telangiectatic osteosarcoma, ABC, GCT


September 14th 2001

1. Juvenile adamantinoma and fibrous dysplasia are related entities.

2. Sessile osteochondroma tend to be on the extensor suface.  At the knee they may interfere with patellofemoral movement.

3. Osteonecrosis of the foot is often steroid related, especially with SLE

4.  Mueller Weiss syndrome is spontaneous osteonecrosis of the navicular.  Comma shaped navicular with medial and dorsal displacement.  Usually obese.  20% stress Fx.

5. The accessory soleus when present usually attaches to the medial superior calcaneus.

6. Oedema of the posterior medial tibial plateau can be associated with a meniscal tear, but if there is also oedema of the femur consider semimembranous pathology.

7. Lytic lesions in children include, EG, infection, osteosarcoma, Ewings.  EG may have an onion skin periosteal reaction and marked oedema of the adjacent bone.  If the lesion looks bad, but the periosteal reaction looks mature, consider EG.

8. Finger pulleys. A1-5 and Cruciates C1-3.  Huk is the expert.  A2 and A4 are the important ones.  With FDP laceration can't make a fist

    MCPG A1 A2 C1 PIPJ A3 C2 A4 DIPJ C3 A5

9. With a solid bony coalition there can still be increased uptake.