Don's gem's Nov-Dec 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                  

December 21st 2001

1. Benign fibrous histiocytoma can be a pedunculated superficial ST mass.  1/3 multiple. Enhance.  Younger age group.  Occasionally degenerate to MFH.  DDx plantar fibroma.  Related to dermatofibroma protuberance at the elbow.

2. The GLAD lesion (glenoid labrum articular disruption) is an anterior inferior articular cartilage disruption.  There is no associated instability.  The Anterior band of the IGHL is intact.

3. Treatment for patella dislocation includes; tibial tubercle transfer, repair of the medial patella retinaculum and vastus medialis exerecises.  When considering fractures associated with patella dislocation, avulsions have less oedema than impactions.  A fracture at the apex of the patella is likely a shear injury.  A fracture of the lateral femoral condyle laterally is due to compression.  Dislocations occur between 0 and 30 degrees flexion.

4. Tibial plateau fractures are classified by the Schatzker classificaion.   1. lateral split. 2. split with depression.  3. pure lateral depression.  4. pure medial depression.  5. bicondylar.  6. split extends to metadiaphyseal region.  Type 2 most commonly associated with MCL inj.  Type 4 most commonly associated with MM injuries.   MR is better than CT for the accompanying ST injuries, but CT has higher resolution for the fracture fragments.  2mm max articular displacement in center of excellence and 4mm in country practice.

5. Knee injected contrast anterior to the patella or tendon is compatible with full thickness patella or quads rupture.

6. Knee OCD is commonest on the lateral aspect of the medial femoral condyle.  M>F. Adolescents. ? trauma.  Autosomal dominant.  IA Gd better than T2.  Rx Children conservatively, adults aggressively.  Drill to encourage new cell growth in kids.  Allograft for adults. 

7. Best sequence to assess bony bridging of the physis is FSE FS T2.

8. If there is mid foot collapse with a  torn TP tendon then there is also a stretched spring ligament, particularly the horizontal component.

9. The SMUNT proceedure is a submuscular ulna nerve transpostion.  This is used for ulna nerve entrapment at the elbow.  They take down the common flexor origin, transpose the nerve and then reattach the tendon.


November 16th

1. End stage shoulder consider:  Renal failure with amyloid (low T2 masses), all crystals increased in renal failure (CPPD, HA, Urate), cuff arthropathy, neuropathic.

2. The reason for an MRI part of the preoperative planning for shoulder arthropathy is principally to assess the rotator cuff.  A total shoulder replacement requires an intact rotator cuff and good bone stock of the glenoid.  A hemiarthroplasty needs an intact subscapularis.  Therefore, even if the X-rays show a longstanding full thickness supraspinatus tear, the MRI is useful to assess if a hemiarthroplasty is still possible.  If the glenoid is retroverted, it is possible to angle the replacement humeral head to accomadate.

3. Bone oedema of an injury lasts approx. 2 months.

4. A prominent ligament of Wrisberg can mimic an intact PCL when the PCL is in fact torn.

5. The plantar fascia attaches to the medial calcaneus and has 5 bundles and medial, middle and lateral cords.  Plantar fibromas are more common medially and enhance.

6. A reason not to inject around the plantar fascia with steroids for facittis is that it can cause heel pad atrophy.

7. SLAP:

    1 Undersurface fraying, questionable significance in the elderly.

    2 Biceps anchor detached

    3 Bucket handle tear of superior labrum

    4 Bucket handle tear of superior labrum with tear extending longitudinally into biceps tendon

    5 Labral detachment extends anteriorly below 3 O'clock, often 12-6 O'clock

    6 Radial tear or flap displaced (ie like parrot beak meniscus)

    7 Tear extends into MGHL

    8 Posterior extension to below 9 O'clock

    9 Anterior and Posterior complete

    10 Extends into rotator interval to include the SGHL

8. Hypoplastic glenoid or dentate glenoid predisposes to premature OA.  It is principally the inferior 2/3 of the glenoid that is affected.

9. A complete tear of the tibialis anterior tendon often retracts to the level of the extensor retinaculum, and produces a mass like pseudo tumour.


November 2nd

1. The major bundles of the ACL are anteromedial and posterolateral.

2. A ganglion cyst adjacent to the ACL is a good indicator of a previous partial tear.

3. When performing an MRI arthrogram of the knee, put an ACE bandage around the suprapatella soft tissues.

4. Rapidly destructive hip disease is usually elderly women. ? ischsemic, ? analgesic NSAIDs, ? radiation.  DDx: Infection, neuropathic, crystals; CPPD or HA (Milwaukee hip).

5. Suprascapular cyst denervation produces high signal in supra and infra spinatus muscles.

6. The posterolateral tibia on the lateral view is flatter than the posteromedial.

7. Semimembranous tendon has 5 arms: Direct, anterior, capsule, meniscus and deep to MCL.

8. When assessing posteromedial tibial plateau high signal and possible ACL tear, there is more signal from an impaction injury than an avulsion injury.

9. ACL tears can be either anteromedial rotation of the tibia or anterolateral rotation of the tibia, and rarely straight anterior translation.  Anteromedial is the O'Donogue terrible triad of ACL, MCL and medial meniscus, and anterolateral is ACL and segond Fx with a positive pivot shift.

10. There are 6 dorsal compartments at the wrist:


Intersection syndrome occurs as the 1st and 2nd compartments cross, with symptoms 4cms proximal to the wrist, and is seen in oarsmen and canoeists.  The Bugaboo wrist is due to the crossing of the 2nd and 3rd compartments.

11. A dislocating biceps will present with clicking and a feeling of instability.

12.  The tibial arm of semimembranous extends medially around the proximal tibia.

13. Lipoma arborescens may be primary or secondary.  Secondary to RhA or trauma and tend to be associated with more inflammation of the fat.


Scripps November 1st

1. Fibrous dysplasia will have varying bone density.

2. Although lupus is usually a non erosive deforming arthropathy, there is a cystic type involving the carpals and metacarpals.  Also consider the collagen vascular overlap syndrome with features of RhA combined with either lupus, scleroderma or polymyositis, or mixed connective tissue dissease.

3. Plantar fibromatosis predominates on the medial aspect of the foot.  They all enhance.

4. If knee arthrography is performed in the presence of a quadriceps rupture, contrast may pass into the superficial prepatella bursa.  Also have a wrinkled patella tendon.  Consider hyperparathyroidism, steroids and lupus as underlying causes.