Ortho 251 Notes

ORTHOPEDICS

TRAUMA STRAIN An injury of the musculo-tendinous unit. Grade1 (mild): non-traumatic tightening, pain on stretching. Grade 2 (moderate): + pop/snap with spasm. Grade 3 (severe): dramatic, often with audible snap/pop, then pain. SPRAIN A ligament injury. Ligaments stabilize joints by preventing abnormal motion. Grade 1: no laxity and good end point. Grade 2: laxity, but good end point. Grade 3: no end point, needs referral for repair within 5 days. Can evaluate with stress radiographs. Rehab with isometric exercises that are begun immediately. Goal is to re-establish strength and motion while protect from re-injury. Treatment of Strain/ Sprains: NSAIDs, consider muscle relaxer. “PRICEMS” Protection (padding and changes in technique to avoid further injury. Rest. Ice. Compression. Elevation. Modalities (U/S, electrical stimulation, heat)/ Meds (NSAIDs, steroid injections). Support (braces). Rehab to re-establish both strength and flexibility together. FRACTURE Fracture- soft tissue injury complicated by a break in the bone Nomenclature: Fracture, [closed/open], [completeness], [configuration], [displacement], [location], [laterality] I. Closed / Open – not seen radiologically a. Closed – intact skin over fracture b. Open – soft tissue injury in the region of the fracture with exposure to the external environment How to detect an open fracture: 1. bleeding is not proportional to the size of the wound (bleeding from the marrow) 2. wound is over the fracture 3. bone seen 4. presence of fat globules Gustilo Classification of Open Fractures Type Definition Bacteria Management I Skin opening 1cm, extensive tissue damage, Gram (+) & (-) Debridement + Cefazolin + Gentamicin flaps, or avulsion IIIA Extensive soft tissue laceration, adequate bone Gram (+), (-), & Debridement + Cefazolin + Gentamicin + coverage anaerobes Penicillin G IIIB Extensive soft tissue injusty with periosteal Gram (+), (-), & Debridement + Cefazolin + Gentamicin + stripping and bone exposure anaerobes Penicillin G IIIC Vascular injury requiring repair Gram (+), (-), & Debridement + Cefazolin + Gentamicin + anaerobes Penicillin G + Vascular repair Sample Chart Entry NPO now D5NR 1L X 8 ATS 3000 Units IM ( ) ANST & TeAna 0.5mL IM Cefazolin 1g IV LD ( ) ANST, then 1g IV q8 thereafter Gentamicin 240mg IV OD Penicillin G 4 Million Units LD ( ) ANST then 4 M units IV q6 thereafter OR Scheduling [Debridement, Vascular repair] II. Completeness a. Complete – break in 4 cortices in at least 2 views (AP and lateral) b. Incomplete III. Configuration a. Transverse – fracture line perpendicular to long axis of bone; caused by tapping injury b. oblique – fracture line creates an oblique angle with long axis of bone; moment force c. spiral – rotational / torsional stress; e.g. child abuse

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d. segmental – in different parts of the bone e. comminuted - >2 breaks in part of the bone f. torus – axial loading / compression. Usually in children: perosteum not broken, “buckle fracture” g. longitudinal h. green stick fracture with plastic deformity – less than 3 cortices are affected;bend in the long bone Type Bone Involvement Other Description Management I Transverse physis In young children, growth arrest is Closed reduction / GA Cast immobilization II Through physis & unlikely, results in malalignment metaphysis III Through physis & Intraarticular Open reduction and fixation to align growth plate epiphysis IV Through physis, Results in migration & growth arrest metaphysic & epiphysis V Crush injury of the physis Growth arrest, usually not identified earlier, with ↑ complication rate, VI Injury to perichondrium Bridging / Angular deformity cartilaginous growth plate heals ~50% of the time “SALTER”: S=Slide,straight through the growth plate, Type 1, A= above, Type 2, L= Low to the growth plate, Type 3, T= Through the growth plate above and below, Type 4, ER= Erasing the growth plate, Type 5

Harris-Park growth arrest line – seen on late radiography of minor injuries, transversely oriented IV. Displacement a. displaced - < 50% cortical contact b. minimally displaced c. undisplaced V. Location a. anatomic: proximal third, middle third, distal third b. physiologic: epiphysis, physis, metaphysic, diaphysis VI. Laterality – left or right, not seen radiologically Supracondylar Fractures a. Extension – anterior fracture b. Flexion – posterior fracture When fracture is undisplaced, there is bleeding which accumulates within the periosteum Fat pad sign – fat / marked lucency detected anterior &/or posterior to paper-thin bone (between coronoid & olecranon fossae); indicative of a fracture Gartland classification of supracondylar fractures Type Description Management I Incomplete & undisplaced Arm sling or LAPS II Complete & undisplaced, intact Closed reduction +/- pinning, LAPS periosteum A. with rotatory component B. without rotatory component III Complete & displaced Open / closed reduction with pinning on lateral side or open fracture site with Xpinning Garden classification of Femoral Neck Fractures I – impaction II – complete, undisplaced III – complete, displaced without contiguous trabeculations IV – complete, displaced with contiguous trabeculations Lange-Hansen Classification (Initial position – direction of injury) a. supination – adduction b. pronation – abduction c. supination – external rotation d. pronation – external rotation Forearm Fractures Colle – distal radius, dorsal Smith – distal radius, volar

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Barton – fracture/dislocation or subluxation in which the rim of the distal radius, dorsally or volarly, is displaced with the hand & carpus Chauffeur – fracture radial styloid Monteggia – proximal half of ulnar shaft & dislocation of radial head Galeazzi - dislocation of distal radioulnar joint Nightstick Fracture - fracture of ulnar diaphysis alone from a direct blow Management of Fractures A. Casting / Splinting Immobilize one joint above & one joint below Deforming forces in radio-ulnar fractures (fractures of necessity – operate because closed reduction wont work) Location Deforming Forces Cast in Proximal third Supinator Supinated position Middle third Supinator + pronator teres Neutral (“raise your hand” position) Distal third Supinator + pronator teres + pronator Pronated position quadratus B. Debridement – 4Cs of proper debridement 1. color – beefy red 2. consistency – firm 3. contractility 4. capacity of bleed C. Reduction – should hold ragments in place 1. Closed reduction (under vocal anesthetic) 2. Open reduction a. Plating – more rigid, load sparing: plates carries axial load, sparing the bone → leads to delayed healing b. Intramedullary (IM) nailing w/ or w/o screws Nailing – more stable & better biomechanically, load sharing: nail shares load with bone → better healing; enhances blood supply by centripetal circulation Screws – prevents rotation & tilting of nail; bone closer to joint is cancellous, hence requiring screws with bigger threads c. External fixation – preferred if with open wound & infected d. Pinning – also in closed reduction Acceptable reduction of supracondylar fractures: a. anterior humeral line should bisect or lie posterior to the capitulum b. intact figure of eight c. >30° angel of capitellum with humeral line at lateral view d. angle between humeral line & base of humerus (Bowman’s angle) 82° ± 5° at AP view D. Correction of malrotation – with regard to radial fractures, check the following: a. radial styloid should be in the same plane as the radial tuberosity, but on opposite directions b. proper interdigitation at the fracture site c. no difference in the diameters of the apposed bone d. presence of the radial bow Fracture Healing Requires 8-12 weeks of healing Stages: a. Inflammatory – 1-5 days b. Proliferative – 5 days to 2 weeks c. Remodelling – 2 weeks to 6 months Motion in joints squeezes synovial fluid during flexion Pt should do partial weight bearing activities after 1 day of open reduction if the pt is stable. Weight bearing is important in bone formation because disuse can lead toosteoporosis. Long bone fractures predispose pt to fat embolism Tibia has poor capacity to heal because it is subcutaneous with high chances of malunion Full weight bearing started at 6 weeks specially if patient is young Possible complications a. Limb length discrepancy b. Malunion (Fx not in the right position) c. Non-union (not healed at the specified amount of time) Hypertrophic – ends of bone are broad Atrophic – ends of bone are sharp e.g. penciling d. Post-traumatic arthritis e. Fat embolism (in long bone fractures → may present as dyspnea) Golden period of surgical intervention Open long hand injury – within 6-8 hours Hand injury – within 12 hours Tendon repair – within 10-14 days

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COMPARTMENT SYNDROME Sx’s usually begin within a few hours of injury, may be delayed up to 64 hrs (6 P’s) a. Pulselessness (unreliable pulses, late sign) b. Pain (with passive stretching is an early sign, yet diminishes secondary to pressure ischemia) c. Pallor (if any arterial injury or in affected compartment) d. Paresthesias (discomfort out of proportion to injury and unrelenting, late sign) e. Paralysis (secondary to ischemia, late sign) f. Poikilothermy Causes: a. ↓ compartment size (crush, closure of fascial defect, application of exessive traction to fractured limb) b. ↑ contents (swelling, bleeding, extensive use of muscles in sz/ exercise/ tetany/ eclampsia, burns, venous obstruction) c. Externally applied pressure (tight cast/ dressing, lying on limb, pneumatic anti-shock garment, congenital bands) Leg a. Anterior – tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tersius. Deep peroneal nerve sensory loss at 1st web space. Weakness of toe extensors, tibialis anterior. Pain on passive toe flexion. b. Lateral – peroneus longus, peroneus brevis. Pain of active or passive eversion and inversion of the foot, superficial peroneal nerve (hypesthesia of lateral foot). c. Superficial Posterior – gastrocnemius, soleus. Weakened soleus/ gastroc, pain with foot dorsiflexion. d. Deep Posterior – tibialis posterior, flexor digitorum longus, flexor hallucis longus, poplitus. Posterior tibial nerve sensory loss (plantar surface), weakness of toe flexors and tibialis posterior. Pain on passive toe extension. Upper arm: a. Flexor/ Anterior Compartment – sensory loss of ulnar & median nerves, weak biceps and distal flexors, pain on passive elbow extension. b. Extensor/ Posterior – sensory loss of radial nerve (dorsum of hand), weakened triceps and forearm extensors. Pain with passive elbow flexion. Forearm: a. Dorsal Compartment – weakened digital extensors, pain of passive digital flexion. 1. Abductor pollicis longus (APOL) Extensor pollicis brevis (EPB) 2. Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) 3. Extensor pollicis longus (EPL) 4. Extensor digitorum communis (EDC) Extensor indicis proprious (EIP) 5. Extensor digiti minimi (EDM) 6. Extensor carpi ulnaris (ECU) b. Volar Compartment – sensory loss of ulnar/ median nerves (palm of hand), weakened digital flexors, pain on digital extension. Compartment Pressures: normal: 30mmHg or MAPCP check pressures. Fasciotomy if >30-40mmHg or if pressure 20mmHg below DBP or worsening clinical signs. If 6 hours) 1* Pulse reduced or absent but perfusion normal 2 Pulseless; paresthesias, diminished capillary refill 3* Cool, paralyzed, insensate, numb Shock 0 Systolic BP always > 90 mm Hg 1 Hypotensive but responsive to fluid challenge 2 Hypotensive not responsive to fluid challenge Age (years) 0 50 0-6 Probable viable limb, > 6 Increased risk of amputation

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ADULT CHRONIC OSTEOMYELITIS Mostly hematogenous vs. direct spread Locus of minora resistencia – blood goes to the area of low resistance Acute - ~2 weeks; presents as pain, fever, malaise Chronic - ~6 weeks; sudden drop of pressure, decreased pain, fever, malaise.Do serieal ESR (sEnsitive – measures inflammation not infection) & CRP (sPecific) monitoring Etiology: Staphylococcus aureus most common organism in all age patients (90%). Direct trauma: Staph, Strep; Trauma to foot through shoe: P. aeruginosa; Hematogenous: Strep pneumo, H. influ type B, Hgb SS: Salmonella Risks: smoking, DM, extremes of age , chronic hypoxia, immune def, malignancy, malnutrition, RF, liver failure, alcohol abuse, corticosteroid therapy, arteritis, chronic lymphedema, extensive scarring, radiation fibrosis, venous stasis, major vessel compromise. S/s: warmth, swelling, pain, +fever, dec ROM, limp, h/o trauma. Draining sinus, open wound. Continuous bone pain, point tenderness and well-localized. +Pain at infection site with percussion of the bone away from the area of tenderness. Possible sympathetic effusion. Pathophysiology: Stasis ↓ Accumulation ↓ Acute Increase in pressure → gets walled off (radio-opaque) → abscess ↓ Rupture of cortex (cloaca) ↓ Periosteum (sudden drop of pressure, decreased pain) ↓ Sequestrum (dead bone with infection that is devoid of blood supply) ↓ Involucrum (shell of new bone formed by the peiostum that surrounds the sequestrum ↓ Draining sinus Types Type 1 (medullary): limited to the endosteum. Most hematogenous cases. Tx: Abx alone effective in 85%, if recalcitrant, then to surgery. Often can tx for 2-4weeks with PO Quinolones unless a child (need initial IV Abx). Type 2 (superficial): involves the bone surface. Decubital ulcers, venous stasis sores, skin breakdown (burns, trauma). Can progress to Type 3&4 in compromised host. Type 3: localized, but have medullary and superficial characteristic resulting in full thickness cortical sequestration, which requires removal of the nidus. Type 4: diffuse with unstable bone/limb. Often from infected nonunion, endoprosthetic infection, chronic sepsis, or progression of other types. SEPTIC ARTHRITIS Pus would adhere to the cartilage Emergency Endotoxins released by bacteria causes the inflammation Gold standard for diadnosis: Arthrocentesis (+) result in Gram staining Treatment: Debridment (joint kept in fixation, very sever pain in any movement within any range); for TB arthritis: fusion, splint, antiKochs NEOPLASMS Principal Questions 1. Where is the mass? 2. What is the size of the mass? Compare the lesion relative to the size of the affected bone 3. What is the tumor doing to the bone? Lytic, sclerotic, blastic 4. What is the bone doing to the tumor? Margins Permeative – ill-defined bordersl aggressive Geographic – bone walls off the tumor; slow-growing 5. What is the matrix? Osteoid – radiologically: cloudlike or ill-defined amorphous densities with haphazard mineralization. This pattern is seen in osteosarcoma. Mature osteoid, or organized bone, shows more orderly, trabecular pattern of ossification. This is characteristic of the benign bone-forming lesions such as osteoblastoma. Mixed Chondroid - Radiologically, it is usually easier to recognize cartilage as opposed to osteoid by the presence of focal stippled or flocculent densities, or in lobulated areas as rings or arcs of calcifications. They are best demonstrated by CT. Whatever the pattern, it only suggests the histologic nature of the tissue (cartilage) but does not reliably differentiate between benign and malignant processes. 6. Is there a cortical break? If with soft tissue injury, then there is cortical break 7. Is there soft tissue involvement?

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Features of aggressive tumours • Cellular atypia • Frequent mitoses • Extensive necrosis • Significant vascularity • Small amounts of immature matrix Grade (assessment of biological aggressiveness) G0 Histologically benign (well differentiated and low cell to matrix ratio). May be latent , active or aggressive benign lesions G1 Low grade malignant (few mitoses, moderate differentiation and local spread only) G2 High grade malignancy (frequent mitoses, poorly differentiated and frequent mitoses) Site (anatomic setting of the lesion) T0 Confined within its capsule (does not extend beyond the bounds of the compartment of origin, may be distorted but remains intact) T1 Extra capsular extension but contained within the anatomic compartment (eg cortical bone, joint capsule or fascia) T2 Extending beyond compartmental barriers (spreads beyond fascial plane without longitudinal containment) Metastasis (nodal or blood borne tumour spread) M0 No evidence of regional or distant metastases M1 Regional or distant metastases evident Age Most common benign lesions Most common malignant tumors 0 - 10

simple bone cyst, eosinophilic granuloma

10 - 20

non-ossifying fibroma, fibrous dysplasia, simple bone cyst, aneurysmal bone cyst, osteochondroma (exostosis), osteoid osteoma, osteoblastoma, chondroblastoma, chondromyxoid fibroma enchondroma, giant cell tumor

20 - 40 40 & above

Osteoma

Ewing's sarcoma, leukemic involvement, metastatic neuroblastoma osteosarcoma, Ewing's sarcoma, adamantinoma

chondrosarcoma metastatic tumors, myeloma, leukemic involvement, chondrosarcoma, osteosarcoma (Paget's associated), MFH, chordoma

Diagnostics 1. ESR – sensitive measure of inflammation; goes up later, decreases in 2-3 weeks but does not decrease with improvement of infection 2. CRP – specific measure of acute inflammation; peaks in 2-3 days, decreases in 10 days with resolution of inflammation 3. Alkaline phosphatase – measure of bone formation, significant if 3-4X elevated 4. MRI – important for staging 5. Bone scan or skeletal survey for metastasis 6. Biopsy – aspiration, tru-cut, open Therapeutics 1. Excision of mass a. Intralesional - leaves macroscopic tumour, not therapeutic; within the bounds of the mass, for benign lesions, curette the mass b. Marginal – through the reactive zone pseudo-capsule of tumour, residual extensions or satellites, controls non-invasive benign tumours c. Wide - excise tumour, reactive zone and cuff of normal tissue, skip lesions left; with 2-3 cm cuff of normal tissue d. Radical - removal of entire compartment or compartments, distant metastases left; disarticulation 2. Limb salvage – involves excision & reconstruction (autograft, allograft, isograft, xenograft) 3. Amputation 4. Post-op chemotherapy – methotrexate, doxorubicin, cisplatin OSTEOSARCOMA Primary tumor arising from bone and producing bone with variants depending on the appearance of the prominent cell type Male : Female 2:1 Peak incidence 10 - 20 years, with a second peak at 50 - 70 years (80% less than 30 and those more than 40 years usually secondary to Pagets) Commonly seen at the axial skeleton – proximal to the knees and elbow joints Location: Distal femur (32%), proximal tibia (16%), proximal humerus Codman’s triangle, sunburst pattern EWING’S SARCOMA Lytic lesion with calcified periosteal layering (“onion skin”) TKO: Twenty years or younger, Knee, Onion Skin MULTIPLE MYELOMA Most common primary malignant bone tumor METASTASIS Usual primaries: Breast in women, lung, thyroid, prostate, kidney

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FEMORAL NECK FRACTURES Usually in the elderly Parts of the femur – from proximal to distal 1. femoral head 2. femoral neck a. subcapital b. transcervical c. basicervical – if fractured, has best prognosis 3. greater trochanter 4. lesser trochanter 5. subtrochanteric area (5cm below the superior margin of the lesser trochanter) isthmus – narrowest portion of the femoral canal intertrochanteric fracture – extracapsular femoral neck fracture – intracapsular test for pelvic obliquity – TLL and ALL Synovial Ring Blood Supply 1. medial circumflex artery (from deep femoral artery) 2. lateral circumflex artery (from deep femoral artery) 3. medial epiphyseal artery – supplies inferior part of femoral head 4. lateral epiphyseal artery – supplies superior & anterior part of femoral head Management • Apply traction then pinning if 80 y.o. • May save femoral head by using pins / screws / plates / bone cement / antibiotic-laden spacer (40g bone cement: 2.4g heatstable and water-soluble antibiotic) • Replacement: a. Total hip arthroplasty – replace head & acetabulum b. Partial hip arthroplasty – replace head only Complications: avascular necrosis, poor healing, non-union OSTEOPOROSIS • Seen as radiolucency with thinning out of the cortices Medical treatment 1. Calcium supplements 2. Estrogen – prevents bone resorption of calcium by osteoblastic stimulation 3. Low-dose parathyroid hormone – induces negative feedback (↑ transfer of calcium from bone to blood) to restimulate bone formation PATHOLOGIC FRACTURE • Caused by normal stresses applied to normal bone; with predisposing factor • CRP, ESR, Alk phos

PEDIATRICS Difference between pediatric & adult patients • Bone still growing in children • In children, ligaments are stronger than bones • Children have hyperlaxity of joints • For elbow injuries: elbow dislocation in adults, supracondylar in children Pediatric Milestones 4 months turn around 6 months crawl 9-10 months stand on their own 12 months first step, broad-based gait Closure of Physis in Different Bones C Capitellum 2 y.o. R Radial head 4 y.o. I Internal epicondyle 6 y.o. T Trochlea 8 y.o. O Olecranon 10 y.o. E External epicondyle 12 y.o. Collagen Type I – skin, tendon, ligaments & bone Collagen Type II – Hyaline cartilage

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Congenital – abrupt disruption in embryonal development Developmental – partial disruption; progressive defect O’Rahilly 1. Terminal – distal parts, e.g. aphalangia 2. Intercalary – before the distal, e.g. phocomelia (“flipper limbs” 3. Para-axial – 2-bone portions, as in radio-ulna, congenital absence of the tibia Most common – polydactyly, syndactyly Growth plates A. Physis – horizontal, stress-riser B. Epiphysis – spiral Epiphyseal Growth Plate 1. Zone of reserve cartilage - Typical hyaline cartilage with chondrocytes Cartilage would store lipid (proteoglycans) Lysosomal storage Gaucher’s disease 2. Zone of proliferation - Cartilage cells undergo successive mitotic divisions to form columns of chrondocytes Matrix: Inorganic (calcium hydroxyapatite) and Organic (Collagen – tensile strength, Proteoglycans – compressive strength) Longitudinal growth 3. Zone of maturation - Cell division stopped, chondrocytes increase in size 4. Zone of hypertrophy – Chondrocytes greatly enlarged and vacuolated; Matrix becomes calcified Cartilage → Bone Cartilage would store lipid (proteoglycans) a. Zone of provisional calcification b. Zone of cartilage degeneration – chondrocytes degenerate & lacunae of calcified matrix invaded by ostogenic cells & capillaries Fractures which are absolute indications of surgery for children 1. Supracondylar 2. Medial condyle 3. Lateral condyle 4. Medial head 5. Femoral neck CLUB FOOT Talipes equinovarus Clubfoot can be classified as (1) postural or positional or (2) fixed or rigid. Postural or positional clubfeet are not true clubfeet. Fixed or rigid clubfeet are either flexible (ie, correctable without surgery) or resistant (ie, require surgical release). Measurement Normal Foot Clubfoot Tibiocalcaneal angle 60-90° on lateral view >90° (hindfoot equinus) on lateral view get x-rays. Check AP of thoracolumbar spine. Use Cobb method (draw lines parallel to the two most angled vertebra and drop a perpendicular, measure the angle at the intersection) to measure magnitude. 2-3% of pop has a curve of 10 deg. LOW-BACK PAIN Types: 1. Discogenic back pain – herniation of nucleus pulposus 2. Radicular – nerve root irritated, (+) straight lef test 3. Referred – may be secondary to UTI, PID, aortic aneurysm, infection , hip arthritis Management 1. Conservative – NSAIDs, bed rest for 1-2 days, physical therapy 2. Surgical – Laminectomy, Laminotomy CLAUDICATION Neurogenic Claudication (Lumbar Spinal Stenosis) Vascular (Intermittent) Claudication Most in elderly (60-70yo) with severe DJD-osteophytes (usually Due to ischemia in exercising muscles. Pain is sclerotomal at L4-5 or L3-4), bulging annuli decrease the cross-sectional (vascular supply distribution), occurs with a fixed amount of area of spinal canal → spinal stenosis → leg pain with activity, may occur with standing alone → resolves almost commonly bilateral sciatic, insidious onset neuro deficit immediately with rest. Not improved with grocery shopping with (dermatomal weak/ numb). Worse with any activity that cart Vs shopping mall (neurogenic claudication is). extends the spine, walking down-hills, variable amount of Atherosclerotic dz of iliofemoral vessels, often with impotence, walking, prolonged stand, back extension, lift/bend, cough. dystrophic skin changes (nail atrophy, alopecia), foot pallor, Able to walk longer at grocery store Vs mall, can lean on cart decreased pulses, arterial bruits. Check: ABI and Doppler if suspect. and flex spine. SPONDYLOSIS Non specific degenerative process of the spine, in cervical region it is synonymous with stenosis. Usually seen in age >50, presents as dull nagging LBP, morning stiffness, worse with activity, relief with gentle exercise, hydrotherapy. All movements restricted. Tends to cause spinal stenosis with neurogenic claudication. Tx: analgesics, exercise, TENS.

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SPONDYLOLISTHESIS Anterior subluxation of one vertebral body on another, usually L5 on S1. Grade 1-4 (50, AM stiffness, worse with activity, Dec ROM. Tx: NSAIDs, exercise, hydrotherapy, TENS, acupuncture. LBP In Children: Age 10yo: spondylolysis, spondylolisthesis, Schaumanns dz, overuse, postural, HNP, tumor/infection, spinal dysraphism. NEOPLASM • Spine metastasis – most common CA of the spine • Faster progression of symptoms means worse prognosis Signs & symptoms: 1. night pain 2. instability of spine – most painful 3. stretch of the periosteum 4. motor weakness, then sensory loss, then bladder & bowel incontinence Radiologic features 1. collapse of the vertebral body – requires 30-50% destruction before this is detected radiographically 2. owl wink sign – destruction of the pedicle, usually seen posteriorly Indications for surgery 1. Rapid onset that you can decompress right away a. anterior decompression – preferred b. posterior decompression with instrumentation c. laminotomy / laminectomy – not indicated for unstable spine 2. Intractable pain 3. Impending fracture

References: Class 2005. Orthopedics Reviewer. DeMyer, W. Technique of the Neurologic Examination eMedicine Ryu, R. Orthopedics. http://www.wheelessonline.com http://www.umdnj.edu/tutorweb/pdf/bone_tumors.pdf

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