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Information

Differential Diagnosis of Musculoskeletal Disorders

1. Trauma, hemophilia
2. Infection
3. Inflammatory:arthritis
4. Neoplasm
5. Congenital:physiologic in newborn
6. Metabolic:hypertrophic osteoarthropathy, thyroid acropachy, hypervitaminosis A
7. Vascular:venous stasis

Solid Periosteal Reaction!!navigator!!

= reaction to periosteal irritant

  • even + uniform thickness >1 mm
  • persistent + unchanged for weeks

Patterns:

  1. thin: eosinophilic granuloma; osteoid osteoma
  2. dense undulating: vascular disease
  3. thin undulating: pulmonary osteoarthropathy
  4. dense elliptical: osteoid osteoma; long-standing malignant disease (with destruction)
  5. cloaking: storage disease; chronic infection

Interrupted Periosteal Reaction!!navigator!!

= pleomorphic, rapidly progressing process undergoing constant change

  1. buttressing = periosteal bone formation merges with underlying cortex: eosinophilic granuloma
  2. laminated = “onion skin”: acute osteomyelitis; malignant tumor (osteosarcoma, Ewing sarcoma)
  3. radiating spicules = “sunburst”: osteosarcoma; Ewing sarcoma; chondrosarcoma; fibrosarcoma; leukemia; metastasis; acute osteomyelitis
  4. perpendicular spicules = “hair-on-end”: Ewing sarcoma
  5. amorphous: malignancy (deposits may represent extension of tumor / periosteal response); osteosarcoma
  6. Codman triangle: hemorrhage; malignancy (osteosarcoma, Ewing sarcoma); acute osteomyelitis; fracture [Ernest Armory Codman (1869–1940), orthopedic surgeon at Massachusetts General Hospital, Harvard Medical School]

Symmetric Periosteal Reaction in Adulthood!!navigator!!

  1. Venous stasis (lower extremity)
  2. Hypertrophic osteoarthropathy
  3. Pachydermoperiostosis
  4. Thyroid acropachy
  5. Fluorosis
  6. Rheumatoid arthritis
  7. Psoriatic arthritis
  8. Reiter syndrome
  9. Idiopathic-degenerative

Periosteal Reaction in Childhood!!navigator!!

  1. benign
    1. Physiologic (up to 35%): symmetric involvement of diaphyses during first 1–6 months of life
    2. Nonaccidental trauma = battered child syndrome
    3. Infantile cortical hyperostosis: <6 months of age
    4. Hypervitaminosis A
    5. Scurvy
    6. Osteogenesis imperfecta
    7. Congenital syphilis
  2. malignant
    1. Multicentric osteosarcoma
    2. Metastases from neuroblastoma + retinoblastoma
    3. Acute leukemia

mnemonic: PERIOSTEAL SOCKS

  • Physiologic, Prostaglandin
  • Eosinophilic granuloma
  • Rickets
  • Infantile cortical hyperostosis
  • Osteomyelitis
  • Scurvy
  • Trauma
  • Ewing sarcoma
  • A-hypervitaminosis
  • Leukemia + neuroblastoma
  • Syphilis
  • Osteosarcoma
  • Child abuse
  • Kinky hair syndrome
  • Sickle cell disease

Periosteal Reaction in Infant!!navigator!!

› before 6 months of age

  1. Infantile cortical hyperostosis
  2. Physiologic
  3. Extracorporeal membrane oxygenation

› after 6 months of age

  1. Hypervitaminosis A
  2. Scurvy
  3. Rickets

› anytime during infancy

  1. Nonaccidental trauma
  2. Syphilis
  3. Metastatic neuroblastoma / leukemia
  4. Prostaglandin therapy: within 40 days
  5. Sickle cell dactylitis

DDx: motion artifact

Enthesopathy!!navigator!!

[en, Greek = in; thesis, Greek = position]

Enthesis = osseous attachment of tendon composed of 4 zones, ie, tendon itself + unmineralized fibrocartilage + mineralized fibrocartilage + bone

Cause:

  1. Degenerative disorder
  2. Seronegative arthropathies: ankylosing spondylitis, Reiter disease, psoriatic arthritis
  3. Diffuse idiopathic skeletal hyperostosis
  4. Acromegaly
  5. Rheumatoid arthritis (occasionally)

Location: at site of tendon + ligament attachment

  • bone proliferation (enthesophyte)
  • calcification of tendon + ligament
  • erosion

Outline