Collection of orthopedic conditions

This article covers various orthopedic conditions, including orthopedic cysts, genu valgum and genu varum, and forearm fractures.

Myositis ossificans (heterotopic ossification) is a benign, heterotopic ossification of soft tissue and/or skeletal muscle that either occurs congenitally or, more commonly, following soft tissue or muscle injury

Localized course (myositis ossificans localisata)

• Etiology
  • Posttraumatic; : especially after implantation of an artificial hip joint or after blunt muscle trauma
  • Neurogenic: after nerve injuries, meningitis, and spinal cord injuries
  • Chronic degenerative disease (e.g., in ankylosing spondylitis)
  • Muscle overuse (e.g., in athletes)
• Clinical features: localized symptoms in the affected muscle/tissue (e.g., quadriceps femoris muscle, brachialis muscle)
  • Restriction of movement
  • Muscle stiffness
  • Pain, swelling
  • Palpable soft tissue mass
• Diagnostics
  • Soft tissue ossification is detectable on conventional x-ray.
  • Radiological findings: periosteal reaction with periarticular soft tissue calcifications (eggshell calcification)
  • Laboratory findings: ↑ alkaline phosphatase and ESR levels
  • Positive scintigraphy
  • Histology: zonal distribution of immature, proliferating fibroblasts that are surrounded by metaplastic trabecular bone
• Differential diagnosis: malignant bone tumors (e.g., sarcoma)
• Treatment: radiotherapy, possibly surgery
• Prophylactic measures against recurrence
  • Single dose radiotherapy recommended (possibly postoperative or preoperative)
  • Alternative: postoperative administration of NSAID (indomethacin)

Progressive generalized disease (myositis ossificans progressiva/fibrodysplasia ossificans progressiva)

• Etiology: extremely rare, autosomal dominant hereditary disease
• Pathophysiology: Fibrocytes produce bone tissue instead of scar tissue in all types of trauma.
• Clinical features
  • Generalized ossification mainly from cranial to caudal (life-threatening if the respiratory muscles are affected)
  • Malformation of toes is frequently observed at birth.
  • During the course of the disease, large, painful, well-vascularized swellings appear at various sites, which develop into bone tissue after regression.
• Treatment
  • No causal treatment
  • Symptomatic: NSAIDs, radiotherapy, possible surgical removal of individual lesions

References:^[1][2]

• Definition: a restriction in joint movement resulting from connective tissue fibrosis in the skin, fascia, muscles, and/or joint capsule adjacent to the affected joint
• Etiology
  • Prolonged immobilization, especially bed care patients
    • Hospitalization > 2 weeks (especially in the ICU)
    • Bed care in the domestic or nursing home setting
  • Chronic disease (e.g., rheumatoid arthritis, severe burn, stroke, multiple sclerosis)
  • Trauma (e.g., fractures, connective tissue injury)
  • Congenital disease (e.g., cerebral palsy)
• Clinical features
  • Decreased range of motion (ROM) of the affected joint
  • Pain when attempting to move or extend the joint
  • See also “Dupuytren contracture.”
• Diagnostics
  • Assessment of the ROM of the affected joint
  • Imaging (to detect connective tissue fibrosis)
• Treatment
  • Conservative therapy (e.g., physiotherapy)
  • Surgery

References:^[3]

• Definition: benign mucin-filled cyst that develops along tendons or joints and has no true epithelial lining
• Epidemiology: most common type of hand mass
• Location: : wrist and fingers (most common at the dorsal wrist)
• Pathophysiology: herniation of connective tissue; associated with repetitive trauma and mucoid degeneration of periarticular structures → sac that is lined with synovial cells and contains paucicellular connective tissue (typically mucin)
• Clinical features
  • Usually asymptomatic but can occasionally cause joint pain
  • Fluctuant, transilluminant swelling
  • Can lead to nerve compression, which may cause numbness, weakness, or tingling (e.g., Guyon tunnel syndrome)
• Differential diagnoses: epidermoid cysts, lipoma, rheumatoid nodules, infectious tenosynovitis, soft tissue tophus
• Treatment
  • Asymptomatic: observation (ganglion cysts often regress spontaneously)
  • Symptomatic: aspiration or surgical resection

References:^[4]

The following sections cover a variety of orthopedic conditions involving the lower extremities, including:

• Greater trochanteric pain syndrome
• Pes anserinus pain syndrome
• Meniscal cyst
• Genu valgum
• Genu varum
• Tarsal tunnel syndrome
• Heel pad syndrome

• Definition: lateral hip pain caused by tendinopathy of the gluteus medius or minimus
• Etiology: : gluteus medius or gluteus minimus muscle tendinopathy
  • Involvement of the trochanteric bursa is possible, although rare.
  • May also be associated with snapping hip (coxa saltans) or trauma
• Clinical features
  • Common cause of lateral hip pain
  • Pain is usually localized to the greater trochanter at the proximal end of the femur.
  • Tenderness to palpation over the greater trochanter
  • Pain is triggered by resisting active abduction or standing only on the affected leg.
• Diagnostics
  • Usually, clinical diagnosis is sufficient.
  • Imaging may be indicated if the diagnosis is unclear, if underlying pathology is suspected, or in cases that do not respond to initial treatment. ^[5]
    • X-ray: used to rule out other causes of hip pain (e.g., osteoarthritis, femoral neck fracture)
    • Ultrasound: may show thickening of the iliotibial band, tendinosis of the gluteal muscles, and/or trochanteric bursitis ^[6]
    • MRI: to evaluate for an underlying pathology or prior to surgery
• Treatment ^[5]
  • Mainly conservative
    • Physical therapy and relative rest
    • Oral NSAIDs or glucocorticoid injections for pain/discomfort
    • Management of comorbidities, including back pain, obesity, and leg length discrepancy
  • In refractory cases; (without improvement after > 12 months of conservative management), surgery is indicated (e.g., bursectomy). ^[7]

• Definition: a condition characterized by pain and tenderness at the anteromedial aspect of the knee
• Components: each of these can be present to varying degrees depending on the patient
  • Tendinopathy of the pes anserinus
  • Pes anserine bursitis
• Risk factors
  • Female sex
  • Type 2 diabetes mellitus
  • Obesity
  • Osteoarthritis of the knee
  • Knee arthritis, knee deformities (e.g., knee valgus; , knee varus)
• Clinical features
  • Pain on the medial aspect of the knee when rising from a seated position, ascending or descending stairs, and/or sitting with legs crossed
  • Worsening of pain at night
  • Tenderness over the upper medial tibia ^[8]
• Diagnostics
  • Clinical diagnosis
  • Physical examination: assessment of knee alignment, pes anserinus insertion site, pain or tenderness during knee flexion and extension
    • No pain on passive external rotation or valgus stress
    • Usually no joint instability or swelling
  • Imaging
    • AP x-ray of the knee: rule out underlying osteoarthritis and stress fractures
    • Knee ultrasound or MRI: indicated in patients with local inflammation and/or induration to rule out other diagnoses (e.g., tumors, meniscal tears, osteonecrosis) that cannot be diagnosed on x-ray
• Differential diagnosis
  • Tibial stress fracture
  • Medial meniscus injury
• Treatment
  • Rest (e.g., avoidance of high or heavy-impact activities), application of ice to the knee
  • NSAIDs
  • Physical therapy: quadriceps-strengthening exercises
  • Weight loss in patients with obesity
  • Soft knee brace
  • Steroid injections: indicated in patients with refractory symptoms, severe pain, or nocturnal pain

• Definition: a collection of synovial fluid in or around the meniscus
• Etiology: secondary to a meniscal tear → synovial fluid becomes encysted
• Clinical features
  • Pain and swelling
  • Decreased range of motion of the knee
  • Chronic meniscal tears → locking (decreased extension of the knee) and popping (knee joint laxity)
• Diagnostics
  • Clinical diagnosis
  • MRI can aid in management if surgical intervention is indicated.
• Treatment ^[9]
  • Conservative management with rest, pain control, and crutches
  • Surgical intervention is indicated in refractory cases that do not respond to conservative management, or if there are mechanical symptoms (locking, popping) or tears in an avascular zone.

• Definition: valgus (lateral) misalignment of the knee, resulting in a knocked knee deformity
• Etiology
  • Physiological
    • Normal at 2–5 years of age
    • Associated with normal stature, bilateral symmetry, and no clinical symptoms
  • Pathological: post-traumatic; (e.g., distal femoral fracture), metabolic disorders; (e.g., rickets; , mucopolysaccharidosis), skeletal dysplasias, or neoplasms
• Clinical features of pathological valgus
  • Unilateral valgus that is progressive (after 4–5 years of age) or persistent (after 7 years of age)
  • Severe valgus
  • Gait abnormalities and congenital flat feet
  • Features suggestive of an underlying disease (e.g., unilateral deformity, short stature, fever, knee or foot pain, abnormal swelling)
• Diagnostics: if pathological valgus is suspected, imaging and/or metabolic evaluation to determine underlying disease
• Treatment
  • Physiological valgus may improve by the age of 7 years and should be managed with close observation and reassurance.
  • Medical treatment of the underlying pathology
  • For persistent symptoms in patients older than 10 years, surgery is indicated.

• Definition: varus (medial) misalignment of the knee, resulting in a bowleg deformity
• Epidemiology: common in children
• Etiology
  • Physiological
    • Normal at birth
    • Associated with normal stature, bilateral symmetry, and no clinical symptoms
  • Pathologic varus: result of Blount disease, metabolic disorders (e.g., rickets; ), skeletal dysplasias, or neoplasms
• Clinical features of pathological varus
  • Bowing that is progressive or persistent (after 3 years of age)
  • Severe bowing
  • Gait abnormalities
  • Features suggestive of an underlying disease (e.g., unilateral deformity, short stature, fever, knee or foot pain, abnormal swelling)
• Diagnostics: if pathological varus is suspected, imaging and/or metabolic evaluation to determine underlying disease
• Treatment
  • Physiological varus usually improves by 24 months and should be followed by close observation.
  • Treatment of the underlying pathology
  • For persistent symptoms; that do not respond to medical management, surgery is indicated.

• Definition: peripheral neuropathy caused by chronic or acute compression of the tibial nerve by the flexor retinaculum of the foot at the medial ankle
• Etiology
  • Trauma (most common): fracture or sprain of the ankle (talus, calcaneus, medial malleolus)
  • Rheumatoid arthritis
  • Bone spurs, tumors, cysts, nerve ganglions
• Clinical features
  • Symptoms develop in areas innervated by the tibial nerve (distal to the medial malleolus):
    • Neuropathic pain and paresthesia in the heel, sole of the foot, and first three toes
    • Weakness and atrophy of intrinsic foot muscles (severe cases)
  • Symptoms worsen with walking, prolonged standing, and at night
• Diagnostics
  • Usually a clinical diagnosis
    • Positive Tinel sign: radiating paresthesia triggered by tapping the flexor retinaculum posterior to the medial malleolus
    • Pain upon foot dorsiflexion with eversion
    • Diminished sensation on the plantar area of the foot
  • Nerve conduction studies: slow conduction velocity in the medial and lateral plantar nerves
• Treatment
  • Initially conservative
    • Rest, NSAIDs, physiotherapy, use of orthotic shoes
    • Corticosteroid injection (if no improvement)
  • Surgery
    • Indications: lack of response to conservative treatment or documented entrapment of the tibial nerve
    • Procedure: Division of the flexor retinaculum of the foot to decompress the tibial nerve

Reference: ^[10]

• Definition: a condition characterized by damage to the fatty and fibrous tissue in the heel
• Etiology: typically caused by inflammation but can also be due to damage or atrophy of the heel pad
  • Acute trauma
  • Repetitive overload (e.g., running, prolonged standing or walking)
• Risk factors
  • Age (usually > 40 years old)
  • Corticosteroid injections
  • Improper footwear
  • Cavus feet
  • BMI > 30
• Clinical features
  • Deep, mid-heel pain that increases with activity and when walking on hard surfaces
  • Tenderness in the mid-portion of the heel
• Diagnostics
  • Clinical diagnosis
  • Imaging (x-ray, ultrasound) may be indicated if the diagnosis is unclear.
• Differential diagnosis
  • Plantar fasciitis
  • Calcaneal stress fracture
• Treatment: mainly conservative
  • Rest (decrease/avoid pressure to the affected area)
  • Ice packs
  • Oral NSAIDs for pain
  • Heel taping
  • Heel pads or cups
  • Use of proper footwear