Table of contents :

• definitions
• rheumatology (from the Greek "rhêuma" = flow, as pain usually migrates)
• ostealgia / ostalgia : pain in a bone or in the bones
• osteoneuralgia : neuralgia of a bone
• fusion : the formation of an ankylosis / arthrokleisis : immobility and consolidation of a joint due to disease, injury, or surgical procedure

Aetiology :
• injury
• disease
• surgery (arthrodesis / artificial ankylosis)
• extracapsular ankylosis : ankylosis due to rigidity of structures exterior to the joint capsule.
• intracapsular ankylosis : obliteration of joint motion due to disease, injury, or surgical procedure within the joint capsule.
• false, fibrous or spurious ankylosis : reduced mobility of a joint due to proliferation of fibrous tissue
• bony or true ankylosis : the union of the bones of a joint by proliferation of bone cells, resulting in complete immobility
• cricoarytenoid joint ankylosis : fixation of the cricoarytenoid joint due to inflammation; characterized by hoarseness, cough, and difficulty in expectoration.
• stapedial ankylosis : fixation of the footplate of the stapes in otosclerosis, causing a conductive hearing loss.
• deformities and malformations : permanent, not self-correctable (avoid overtreatment !) morphological alterations causing functional (antalgic or anatomical) or aesthetic (absolute or subjective) impairment.
• clear deformities : detected at inspection, comparing to normal hemisoma
• occult deformities : detected only when the disease is already known or when we are looking for it
• functional capacity evaluation : a 1 day test (6 hrs) to determine what patient can do (lift/bend/twist/etc.)
• osteopathies : any disease of a bone
• hereditary bone dysplasia : a heterogeneous group of more than 80 distinct skeletal disorders associated with abnormalities in the size, shape, and proportions of the limbs, trunk, and skull, often resulting in short, disproportionate stature.
• bone infarct : an area of bone tissue which has become necrotic as a result of loss of its arterial blood supply.
• hemihypertrophy / Curtius' syndrome / isolated hemihyperplasia : hypertrophy of one side of the entire body or a portion of one side of the body, as of the face
• complex hemihyperplasia : involvement of half of the body (at least 1 arm and 1 leg); affected parts may be contralateral or ipsilateral
• simple hemihyperplasia is involvement of a single limb
• hemifacial hyperplasia : involvement of one side of the face
• achondroplasia / osteosclerosis congenita : a hereditary, congenital disturbance of epiphyseal chondroblastic growth and maturation, causing inadequate enchondral bone formation and resulting in a peculiar form of dwarfism with short limbs, normal trunk, small face, low nose, normal vault, lordosis, and trident hand, macrocephaly, sometimes hydrocephalus
• chondroectodermal dysplasia / Ellis-van Creveld syndrome : achondroplasia occurring in association with defective development of skin, hair, and teeth, polydactyly, and defect of the cardiac septum
Therapy : targeted overexpression of CNP in chondrocytes counteracts dwarfism in a mouse model of achondroplasia with activated FGFR-3 in the cartilage. CNP prevents the shortening of achondroplastic bones by correcting the decreased ECM synthesis in the growth plate through inhibition of the MAPK pathway of FGF signaling. CNP has no effect on the STAT-1 pathway of FGF signaling that mediates the decreased proliferation and the delayed differentiation of achondroplastic chondrocytes.
• dyschondroplasia / chondrodysplasia : formerly, a general term encompassing both enchondromatosis and exostosis, which has caused some synonyms of one disorder to become incorrectly associated with the other disorder
• thanatophoric dysplasia : a uniformly fatal type of skeletal dysplasia presenting as extreme shortening of limbs, thoracic cage deformity, and relative cephalomegaly.
• Looser-Milkman syndrome : a generalized bone disease marked by multiple transparent stripes of absorption in the long and flat bones
• Bruck's disease : a condition marked by deformity of bones, multiple fractures, ankylosis of joints, and atrophy of muscles
• osteodysplasty : abnormal development of bone.
• osteodysplasty of Melnick and Needles : a hereditary disorder, transmitted as an autosomal dominant trait, in which there are severe congenital bone abnormalities manifested by striking facies (exophthalmos, full cheeks, micrognathia, and malalignment of the teeth), flaring of the metaphyses of long bones, S -like curvature of the leg bones, irregular constrictions in the ribs, and sclerosis of the base of the skull.
• diaphyseal dysplasia / diaphyseal sclerosis / Engelmann's disease : a condition characterized by thickening of the cortex of the mid-shaft area of the long bones, progressing toward the epiphyses, the thickening sometimes occurring also in the flat bones; excessive growth in length of bones of the extremities usually results in abnormal stature
• metaphyseal dysplasia / Pyle's disease : a disturbance in enchondral bone growth, failure of modeling causing the ends of the shafts to remain larger than normal in circumference
• epiphyseal dysplasia (ED) : faulty growth and ossification of the epiphyses, with radiographically apparent stippling and decreased stature, not associated with thyroid disease
• dysplasia epiphysealis hemimelica / tarsoepiphyseal aclasis / Trevor's disease : a rare condition characterized by swellings in the extremities, usually on the inner and outer aspects of the ankles and knees, made up of bone covered with epiphyseal cartilage, and leading to limitation of motion of the joints
• dysplasia epiphysealis multiplex / dysostosis enchondralis epiphysaria / multiple epiphyseal dysplasia (MED) : a developmental abnormality of various epiphyses, which appear late and are mottled, flattened, fragmented, and usually hypoplastic; the digits are short and thick, with blunt ends, and stature may be diminished owing to flattening deformities at the hips, knees, and ankles
• dysplasia epiphysealis punctata / chondrodystrophia calcificans congenita / chondrodystrophia congenita punctata / chondrodystrophia fetalis calcificans / Conradi's disease or syndrome / hypoplastic fetal chondrodystrophy / stippled epiphyses : a heterogeneous group of bone dysplasias, the common characteristic of which is stippling of the epiphyses in infancy. The group includes :
• a severe autosomal recessive form (rhizomelic dwarfism)
• an autosomal dominant form (Conradi-Hünermann syndrome)
• a milder X-linked form
• tall stature : height > 97th percentile for that population
• short stature / dwarfism : compared to a well-nourished, genetically relevant population, short stature is defined as standing height > 2 standard deviations below the mean (or below the 2.5th percentile) for gender

Epidemiology : by definition, 2.5% of the population is short.
Aetiology :
• endocrine aetiology
• GH deficiency (GHD)
• essential or harmonic dwarfism (possible familiarity, growth velocity > 25th percentile (1-4 cm/yr), delayed bone age, possible neonatal hypoglycemia, defects of median line, prognosis depends on therapy)
• adult GH deficiency (AGHD)
• psychosocial deprivation (eventually hyperphagia, behavioural disorders, improvement by improving environment)
• hypothyroidism
• Cushing's syndrome
• hypogonadism after age 10-11
• genetic aetiology
• normal variants :
• genetic or familial short stature : bone age (BA) appropriate for chronologic age (CA), normal growth velocity, and predicted adult height (PAH) appropriate to the familial pattern, no clinical or biochemical alterations, growth velocity > 25th percentile (> 4 cm/yr)
• constitutional delay of growth and development : familial pattern, delayed bone age (BA), normal growth velocity but reduced spurt, and predicted adult height (PAH) appropriate to the familial pattern, no clinical or biochemical alterations. Final height is normal. Patients with constitutional delay typically have a first-degree or second-degree relative with constitutional delay (eg, menarche reached when older than 15 y, adult height attained in male relatives when older than 18 y).
• genetic diseases :
• Turner syndrome
• idiopathic familial short stature : SHOX gene mutations (2.4% of idiopathic short stature) : changes in spontaneous secretion and resistance to GH
• IGF-1 gene mutation
• IGF-1 receptor gene mutation
• insulin receptor gene mutations (leprechaunism)
• Shwachman-Diamond syndrome
• Rubinstein-Taybi syndrome
• Aarskog-Scott syndrome
• chromosomal aneuploidies
• Leri-Weil dyschondrosteosis (LWD), including Langer mesomyelic dysplasia and Madelung deformity, normal GH levels : SHOX gene mutations
• achondroplasia
• Down syndrome (trisomy 21)
• dysmorphic syndromes
• Noonan syndrome 1
• Prader-Willi syndrome (PWS)
• PHPIA / McCune-Albright hereditary osteodystrophy
• intrauterine aetiology
• growth retardation
• small for gestational age (SGA) fetus (birth weight and/or length < mean - 2 standard deviations for gestational age) : 10-15% of SGA fetuses lack the compensatory growth in the first 2-3 years of life and have a final stature < mean - 2 standard deviations; maternal, placental, and fetal anomalies
• Silver-Russel syndrome (SRS) : intrauterine growth delay, relative macrocephalia, small and triangular face, asymmetry
• nutritional (weight is often more compromised than height)
• inadequate nutrition
• starvation
• anorexia
• mineral and/or vitamin deficiencies : rickets
• nutrient loss :
• malabsorption (inflammatory bowel diseases (IBDs), celiac disease (sometimes the only sign of CD : 8.1% of children with short stature is IgG⁺, 2.8% IgA⁺, and 2.5% EMA⁺; gluten-free diet for > 6 months normalize GH levels)
• chronic vomiting (gastrointestinal obstructions, esophageal achalasia, electrolyte alterations, endocranial hypertension)
• dysmetabolism
• uncontrolled diabetes mellitus (high HbA_1c, hepatomegaly)
• hyperthyroidism
• chronic diseases (weight is often more compromised than height)
• lung diseases
• cystic fibrosis
• severe asthma
• chronic obstructive pulmonary diseases (COPD)
• restrictive lung disease
• hypoxemia
• heart disease (always associated with other symptoms & signs!)
• congestive heart failure
• low cardiac output states
• precocious puberty
• renal disease
• chronic renal failure
• renal tubular acidosis
Pathogenesis : according to Kalberg infancy, childhood, puberty (ICP) model, nutrition is the most important growth factor during infancy, GH during childhood and sex steroids and GH during puberty
Laboratory examinations :
• auxological clinical examination
• anamnesis
• auxology
• objective examination :
• morphological evaluation
• dismorphic nots
• evaluation of bone age
• laboratory examination
• psychoscial evaluation (separation, deaths, birth of siblings, school failure, growth at lactation)
• dysostosis : defective ossification; defect in the normal ossification of fetal cartilages.
• hypostosis : deficient development of bone.
• hyperostosis : increase of bone mass per unit of volume, hypertrophy of bone; exostosis
• cleidocranial dysostosis or dysplasia : a rare autosomal dominant condition in which there is defective ossification of the cranial bones, with large fontanels and delayed closing of the sutures; complete or partial absence of the clavicles, so that the shoulders may be brought together, or nearly together, in front; wide pubic symphysis; short middle phalanges of the fifth fingers; and dental and vertebral anomalies.
• craniofacial dysostosis (CFD) / Crouzon's disease : an autosomal dominant disorder characterized by acrocephaly, exophthalmos, hypertelorism, strabismus, parrot-beaked nose, and hypoplastic maxilla with relative mandibular prognathism.
• craniosynostos type 1 (including oxycephaly)
• dysostosis enchondralis epiphysaria / dysplasia epiphysealis multiplex.
• mandibulofacial dysostosis : a hereditary disorder occurring in 2 forms
• complete form (Franceschetti's syndrome) is autosomal dominant and consists of antimongoloid slant of the palpebral fissures, coloboma of the lower lid, micrognathia, hypoplasia of the zygomatic arches, and microtia.
• incomplete form (Treacher Collins syndrome) consists of the same anomalies in less pronounced degree; it occurs sporadically and autosomal dominance is suspected.
• mandibulofacial dysostosis with epibulbar dermoids / oculoauriculovertebral dysplasia
• metaphyseal chondrodysplasia or dysostosis / Jansen's disease : a skeletal abnormality in which the epiphyses are normal, or nearly so, and the metaphyseal tissues are replaced by masses of cartilage, producing interference with enchondral bone formation, and expansion and thinning of the metaphyseal cortices.
• dysostosis multiplex : a term for the widespread skeletal manifestations typical of the mucopolysaccharidoses
• Nager's acrofacial dysostosis : a congenital condition in which mandibulofacial dysostosis is associated with limb deformities consisting of absence of the radius, radioulnar synostosis, and hypoplasia or absence of the thumbs.
• oral-facial-digital syndrome (OFD)
• type I / orodigitofacial dysostosis : a male-lethal X-linked dominant disorder characterized by camptodactyly, polydactyly, and syndactyly; by cranial, facial, lingual, and dental anomalies; and by mental retardation, familial trembling, alopecia, and seborrhea of the face and milia.
• type II / Mohr syndrome : an autosomal recessive disorder characterized by brachydactyly, clinodactyly, polydactyly, syndactyly, and bilateral hallucal polysyndactyly; by cranial, facial, lingual, palatal, and mandibular anomalies; and by episodic neuromuscular disturbances
• type III : an autosomal recessive disorder characterized by postaxial hexadactyly of the hands and feet, by ocular, lingual, and dental anomalies, and by profound mental retardation
• postaxial acrofacial dysostosis / Miller syndrome : a syndrome of extensive facial and limb defects, characterized by malar hypoplasia, downslanting palpebral fissures, micrognathia, cleft lip and palate, cup-shaped ears, lower lid ectropion, postaxial limb deficiencies, and syndactyly. Less frequently present are heart defects and hearing loss. The syndrome is probably an autosomal recessive trait.
• megalomelia / macromelia : abnormal largeness of a limb or limbs
• peromelia : congenital deformity of the limbs.
• peromelus : a fetus with malformed limbs.
• sclerodactyly : localized scleroderma of the digits, as in acrosclerosis
• perodactylus : a fetus with deformity of fingers or toes, or both, especially absence of one or more digits.
• tridactylism : the condition of having 3 digits on the hands or feet.
• tetradactyly : the condition of having 4 digits on the hand or foot
• hexadactyly : the occurrence of 6 digits on one hand or foot.
• triphalangism : the presence of 3 phalanges in the longitudinal axis of a digit normally composed of only 2.
• ectromelia : gross hypoplasia or aplasia of one or more long bones of one or more limbs; the term includes
• amelia : congenital absence of a limb or limbs
• meromelia : congenital absence of any part of a limb
• adactyly / adactylia / adactylism : a developmental anomaly characterized by the absence of digits on the hand or foot.
• hemimelia : a developmental anomaly characterized by absence of all or part of the distal half of a limb
• radial hemimelia : hemimelia of the upper limb in which the radial side is absent.
• ulnar hemimelia : hemimelia of the upper limb in which the ulnar side is absent
• fibular hemimelia : hemimelia of the lower limb in which the fibular side is absent.
• tibial hemimelia : hemimelia of the lower limb in which the tibial side is absent.
• phocomelia : a type of meromelia characterized by absence of the proximal portion of a limb or limbs, the hands or feet being attached to the trunk of the body by a single small, irregularly shaped bone

Aetiology : thalidomide use in pregnants
• alterations of bone structure and density
• bone rarefaction
• osteohalisteresis : loss or deficiency of the mineral elements of bones with relative increase of organic component
• halisteresis : osteomalacia; a loss or lack of the lime salts (calcium) of bone.
• halisteresis cerea : waxy softening of the bones.
• rickets : decrease of mineral matrix in childhood

Epidemiology : prevalence = Algeria (35.45% in 1963 => 18.7% in 1984/85), Italy (9.3% in 1972 => 4.3% in 1986/90), USA (20% in 1938 => <5% in 1988), UK (13% in 1944 => 30% in 1973 => 6% in 1982), INndia (20% in 1966/73), China (18% in n1980 => 11% in 1983), Ethiopia (30% in 1965), Finland (16% in 1981), France (10-40% in 1963/69 => 1.3-1.7% in  1983/84 => 0.5-2.6% in 1986), Bangladesh, Near East (e.g. Saudi Arabia (> 30% in 1988), due to genetic predisposition)
Aetiology : hypovitaminosis 1a,25-(OH)₂-vitamin D₃
Symptoms & signs :
• head
• caput quadratum
• delayed closure of an abnormously wide fontanelle
• craniotabes
• hypoplasia of enamel
• anemia
• decreased body growth
• chest
• rachitic beads
• Harrison's groove : a horizontal depression along the lower border of the thorax, corresponding to the costal insertion of the diaphragm, whose traction deforms the chest
• abdomen
• Lucas' sign : distention of the abdomen in the early stages of rickets
• hypotonia => umbilical hernia due to laxity of rectus abdominis muscles
• scoliosis or kyphosis
• lower limb
• coxa vara
• genu varus
• genu valgus
• rachitic ankles
• rachitic bracelet : lack of cartilage mineralization causes enlargement of space between metaphysis and epiphyses
Laboratory examinations :
• increased thickness of metaphysis
• irregular temporary calcification line
• cup-shaped extravasation of the metaphysary side of diaphysis
• delayed and irregular appearance of ossification nuclei
• Quant's sign : a T -shaped depression in the occipital bone, sometimes seen in rickets.
• osteomalacia : inadequate or delayed mineralization of osteoid in mature cortical and spongy bone; it is the adult equivalent of rickets and accompanies that disorder in children. The etiology of osteomalacia and its clinical and biochemical manifestations are as described for rickets

Aetiology :
• chronic acidosis
• renal tubular osteomalacia : osteomalacia occurring as a consequence of acidosis and hypercalciuria, resulting from inability to produce an acid urine or ammonia because of deficient activity of the renal tubules.
• chronic hypocalcemia
• senile osteomalacia : softening of bones in old age due to vitamin D deficiency.
• chronic hypophosphatemia
• antacid-induced osteomalacia : osteomalacia in which low dietary phosphorus intake coupled to excessive, chronic consumption of aluminum hydroxide–containing antacids leads to phosphate depletion, characterized by hypophosphatemia, nephrolithiasis, anorexia, muscle weakness, and bone loss.
• oncogenic or oncogenous osteomalacia / tumour-induced osteomalacia (TIO) : osteomalacia occurring in association with usually benign mesenchymal neoplasms. The tumors appear to produce a substance that impairs renal tubular functions such as phosphate transport and hydroxylation of 25-hydroxyvitamin D; hypophosphatemia secondary to reduced renal resorption of phosphate is a major cause of the bone disease
• primary mineralization disorders
• hereditary : hypophosphatasia
• acquired : etidronate sodium
• fast bone neoformation with or without a corresponding defect in bone reabsorption
• post-surgical period in hyperparathyroidism with cystic fibrous osteitis
• osteopetrosis / Albers-Schönberg or marble bones disease / ivory bones
• matrix synthesis deficiency : fibrogenesis imperfecta ossium
• other forms
• magnesium-dependent conditions
• axial osteomalacia
• parenteral feeding
• aluminum poisoning
• anticonvulsant osteomalacia : osteomalacia occurring in anticonvulsant rickets of children or anticonvulsant rickets occurring in adults
• familial hypophosphatemic osteomalacia : osteomalacia occurring in familial hypophosphatemic rickets
• puerperal osteomalacia : osteomalacia occurring as a consequence of exhaustion of skeletal stores of calcium and phosphorus by repeated pregnancies and lactation.
Laboratory examinations :
• deformations
• pathologic fractures
• decreased total bone mass (reduction of bone mass per volume unit) with normal ratio between organic and mineralized components

Epidemiology : expecially frequent in women after menopause.
Aetiology :
• primary
• type I or postmenopausal osteoporosis (higher prevalence) : that occurring in women within 3 to 20 years after menopause (6 times more frequently than in men), affecting trabecular bone more than cortical bone, and manifested mainly by vertebral fractures of the painful crush type, hip fracture, Colles' fracture, and increased tooth loss.

Pathogenesis : decreased estrogenincretion => decreased TGF-b and IGF-1, decreased OPG-L secretion, increased OAF, decreased 1a-hydroxyase activity => decreased 1a,25-(OH)₂-vitamin D₃ synthesis => decreased intestinal Ca²⁺ absorption => hypercalcemia and hypocalciuria => decreased PTH. Low BMI is a risk factor as adipocytes convert adrenal androstenedione to estrogens and weight stimulates bone turnover.
Replacement therapy :
• postmenopausal women, who typically consume 600 mg of elemental calcium per day, should increase their calcium intake to 1200 mg per day (Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes: for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, D.C.: National Academy Press, 1997)
• 800-1000 IU of 1a,25-(OH)₂-vitamin D₃ per day — the amount the average postmenopausal woman needs to raise her serum 25-hydroxyvitamin D level to that needed to lower the risk of fracture (> 75 nmol/l or > 30 ng/ml)^{ref1, ref2} and to maximize intestinal absorption of calcium^ref for optimal bone health and the prevention of cancer^ref
• SERMs
• PTH (daily injections, builds new bone; rat trial has shown potential risk of bone cancer)
• type II or senile osteoporosis : that occurring in men and women over 70 (male-to-female ratio = 1:2), manifested mainly by femur neck and vertebral fractures of the painless multiple wedge type leading to dorsal kyphosis.

Pathogenesis : 5-10 years after menopause, decreased activity of renal 1a-hydroxylase => decreased 1a,25-(OH)₂-vitamin D₃ synthesis => decreased intestinal Ca²⁺ absorption => hypocalcemia => increased [PTH]_plasma => increased activity of osteoclasts uncompensated by decresed activity of osteoblasts
• juvenile idiopathic osteoporosis
• secondary
• genetic diseases
• osteogenesis imperfecta congenita (OIC)
• VDR SNPs (B and b alleles)
• hematological diseases
• thalassemias
• lymphomas
• adult survivors of solid paediatric cancers
• radiotherapy
• allogeneic bone-marrow transplantation (BMT) : during the first 6 months after the graft, related to treatment of graft versus host disease (GVHD) with glucocorticoids and cyclosporine A, and the increase in bone marrow IL-6, which is a potent stimulator of bone resorption in vivo.
• hypothyroidism
• anorexia nervosa
• gastrectomy
• osteoporosis of disuse : decrease in bone substance as a result of lack of re-formation of laminae in the absence of functional stress that ordinarily leads to their replacement in new stress lines (e.g. Preiser's disease)
• Sudeck-Leriche syndrome : post-traumatic osteoporosis associated with vasospasm.
• erosive arthritis
• osteoporosis of disuse : decrease in bone substance as a result of lack of re-formation of laminae in the absence of functional stress that ordinarily leads to their replacement in new stress lines.
• immobilization
• living in low-pressure environments (eg astronauts)
• low sunlight exposure
• low Ca²⁺ intake
• cigarette smoking
• osteolytic bone metastases
• ethanol
• estrogen deficiency
• late menarche
• secondary amenorrhoea
• menopause praecox
• drugs
• GR agonists increase OPG-L secretion and decrease OPG secretion
• T₃
• thiazide diuretics
• heparin
• phenytoin
• methotrexate
Pathogenesis : local (e.g. Sudeck algodystrophy / reflex sympathetic dystrophy (RSD)) or systemic bone mass reduction with microarchitectural alterations but without alterations in the normal (mineral matrix):(organic matrix):(cell) ratio (65:33:2). Overexertion of the hematopoietic system resulting from constant excessive need for blood cell production could play an important role in the etiology of osteoporosis. It is generally accepted that the development of osteoporosis in postmenopausal women is due to the reduction of estrogen level. However a most striking observation is the fact that in the male organism, which has never been protected by high levels of estrogen, osteoporosis in senescence is significantly less frequent then in the female organism, which has been protected by estrogens for at least 35 years. Healthy women loose about 70ml of blood every month, which adds up to some 850ml per year and approximately 30l over the 35 years of their reproductive life. Blood loss intensifies hematopoiesis by increasing the level of hematopoietic growth factors while, at the same time, stimulating proliferation of osteogenic progenitor cells. Osteogenic activity has, indeed, been detected in the blood of bled animals. The chain of events that converts continuous requiremental pressure on hematopoiesis into development of osteoporosis may be formulated as follows: on the one hand, blood loss creates developmental pressure on the hematopoietic system, augments production of hematopoietic growth factors with subsequent intensified proliferation of hematopoietic progenitor cells, increases the number of hematopoietic cells including osteoclasts, thus intensifying resorption of bone tissue and extension of hematopoietic territories. On the other hand, blood loss leads to stimulation of bone development, extensive proliferation of osteogenic progenitor cells resulting in increased numbers of osteoblasts, followed by new bone formation and, at the same time, increased production and maturation of osteoclasts which then enter the cycle of bone resorption. The bone resorption process itself is characterized by the release of bone morphogenic proteins that induce proliferation of osteogenic cells and subsequent production of osteoclasts that in their turn enter the cycle of bone resorption. Important evidence supporting the substantial role of hematopoietic insufficiency in the development of osteoporosis comes from the field of clinical hematology: hematological diseases accompanied by chronic anemia, such as beta thalassemia major, sickle cell anemia, chronic hemolytic anemia, pernicious anemia, etc., are also characterized by the concomitant development of osteoporosis. Patients suffering from hemophilia tend to develop osteoporosis as well^ref.
Symptoms & signs : only from fractures
• lifetime fracture risk after age 50 : 13.1 % males; 39.7 % females
• femural fractures : 6% males; 17.5 % females.
• vertebral fracture : 5% males; 15.6 % females. Pain is absent while resting, upright or seated (no compression symptoms due to reduced bone tissue and marrow) and appears only during flexoextension maneuvers. Fractures below T12 cause retroperitoneal hematoma => ileus. Pain at downward manual pressure over shoulders while patient is seated. Curved back and decreased heigth
• dowager's hump : popular name for dorsal kyphosis caused by multiple wedge fractures of the thoracic vertebrae seen in osteoporosis.
Therapy : three-point corset, percutaneous vertebroplasty
• Colles' fracture : 2.5 % males ; 16% females
• humeral fracture
• rib fracture
Laboratory examinations : instrumental
• radiography :
• morphological alterations
• compact bone : reduced thickness
• cancellous bone : reduced number of trabecular with compensatory enlargement of remaining trabeculae
• decreased horizontal trabeculae
• increased vertical trabeculae
• empty box
• biconcave vertebrae
• wedge vertebrae
• sandwich vertebrae
Vertebral static histomorphometry measures anterior, intermediate and posterior height of a vertebra and uses rates between these values to define morphological alterations.
• bone densitometry : decrease of bone mineral density (BMD) => increased radiotransparence measured with ...
• single-energy X-ray absorptiometry (SXA)
• dual-energy X-ray absorptiometry (DXA / DEXA) at L1-L4 and left hip (neck, trochanter, intertrochanter region)
• T-score : number of standard deviations from the average value of healthy young individuals of the same gender. WHO staging, 1994 :
• -1 < T < 2.5 => osteopenia (RR for fractures = 2-5)
• T < 2.5 => osteoporosis (RR for fractures > 5)
• severe osteoporosis if fracture(s) already occured (RR for further fractures > 10)
• Z-score : number of standard deviations from the average value of individuals of the same gender and with same age
• single photon absorptiometry (SPA)
• dual photon absorptiometry (DPA)
• quantitative computed tomography (QCT)
• peripheral quantitative computed tomography (pQCT)
• quantitative ultrasound (QUS)
• (SOS-BUA)
• bone fractures
• bone metastases
• regional bone mass reduction
• metabolic
• ESR
• CBC
• protidogram
• [total Ca²⁺, P, AlkP, creatinine]_plasma
• [Ca²⁺]_urine
• unbound [Ca²⁺]_plasma
• [PTH, estrogen, T₃]_plasma
• 25-OH-vitamin D₃
• medullary FNAB
• bone biopsy
• Ca²⁺ metabolism markers
• markers of bone formation
• measured in serum
• markers of cell activation
• total and bone-specific isozyme of AlkP
• osteocalcin / bone Gla protein (BGP)
• markers of organic matrix deposition
• carboxy-terminal propeptide of type I procollagen (PICP)
• markers of bone breakdown
• measured in serum
• marker of cell activation
• TRAP
• markers of organic matrix deposition
• carboxy-terminal telopeptide of type I collagen (ICTP)
• cross-linked C-telopeptides (S-CTx) CrossLaps (measured in bone collagen equivalent (BCE))
• cross-linked N-telopeptides (NTx) CrossLaps (measured in bone collagen equivalent (BCE))
• pyridinoline (PYD)
• deoxypyridinoline (DPD)
• measured in urine
• Ca²⁺ / creatinine ratio in 24 hrs
• Hpr
• Hly glycosides
• pyridinoline (PYD)
• deoxypyridinoline (DPD)
• carboxy-terminal telopeptide of type I collagen (ICTP)
• cross-linked C-telopeptides (U-CTx) CrossLaps (measured in bone collagen equivalent (BCE))
Therapy :
• Ca²⁺
• hormone replacement therapy
• calcitonin
• vitamin D₃
• VDR agonists
• xenobiotics
• bisphosphonates
• bone-forming agents
• distal convoluted tubule diuretics
• weight-bearing exercise (such as brisk walking)
• synthetic mimetics of collagenous ECMs : synthetic poly(ethylene glycol) (PEG)–based hydrogels as cell-ingrowth matrices for in situ bone regeneration. These networks contain a combination of pendant oligopeptide ligands for cell adhesion (RGDSP) and substrates for matrix metalloproteinase (MMP) as linkers between PEG chains. Primary human fibroblasts were shown to migrate within these matrices by integrin- and MMP-dependent mechanisms. Gels used to deliver recombinant human bone morphogenetic protein-2 (rhBMP-2) to the site of critical- sized defects in rat crania were completely infiltrated by cells and were remodeled into bony tissue within 5 weeks. Bone regeneration was dependent on the proteolytic sensitivity of the matrices and their architecture. The cell-mediated proteolytic invasiveness of the gels and entrapment of rhBMP-2 resulted in efficient and highly localized bone regeneration.
Prevention
Web resources : Usenet sci.med.diseases.osteoporosis
• osteoporomalacia : osteoporosis + osteomalacia. Common in elderlies due to concurrent senile osteoporosis and decreased synthesis of 1,25-(OH)₂-vitamin D₃.
• osteolysis : dissolution of bone; applied especially to the removal or loss of the calcium of bone.

Aetiology :
• infection
• inflammation
• endocrine disease
• osteitis fibrosa cystica of hyperparathyroidism
• cancer
• intra-osseous meningiomas
• osteolytic bone metastases
• multiple myeloma
• thalassemia (punched-out lesions of the skull)
• familial expansile osteolysis (FEO) is a rare syndrome involving most of the peripheral skeleton and the skull which was observed world-wide in only 3 kinships and in 2 unrelated American individuals^ref
• Gorham-Stout syndrome / massive osteolysis of Gorham / disappearing bone disease / vanishing bone disease / phantom bone disease is a rare condition of unknown aetiology that is thought to result from a localised endothelial proliferation of lymphatic vessels resulting in destruction and absorption of bone. It was first reported by Jackson in 1838 in a 12-year-old boy with complete osteolysis of the humerus (Jackson JBS. A boneless arm. Boston Med Surg J1838; 18 :368 –369). In 1955, Gorham and Stout further characterized the main pathologic features of this rare disease as nonmalignant intraosseous proliferation of hemangiomatous or lymphangiomatous tissue that caused massive osteolysis (Gorham LW, Stout AP. Massive osteolysis (acute spontaneous absorption of bone, phantom bone, disappearing bone): its relation to hemangiomatosis. J Bone Joint Surg Am1955; 37 :985 –1044). Noncranial imaging features of Gorham disease at conventional radiography, CT, MR, and scintigraphy have been reported elsewhere in the literature^{ref1, ref2, ref3, ref4, ref5} (Donald Rresnick. Osteolysis and chondrolysis. In: Resnick D, ed. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia: WB Saunders;2002 :4928 –4931; Igel BJ, Shah H, Williamson MR, Sell JJ. Gorham’s syndrome: correlative imaging using nuclear medicine, plain film, and 3-D CT. Clin Nucl Med1994; 11 :1017 –1019), and most of the cases failed to show the vasculature entity of the lesion, an important pathologic feature of the disease^{ref1, ref2, ref3, ref4}. Moreover, because of a lack of specific findings on conventional images, including those of conventional radiography and CT, the diagnosis of Gorham disease with skull involvement can be difficult. Other diseases such as Paget disease and metastases may have similar appearance. In this report, we present the unique MR imaging findings of a pathologically proved case of Gorham disease of the cranial vault. The syndrome is rarely seen in the facial skeleton and has a variable prognosis. Many treatments have been advocated but only surgery and radiotherapy have had some success^{ref1, ref2}.
• osteosclerosis / osteofibrosis : increased bone mineralization, leading to hardening or abnormal density of bone
• centrosclerosis / centro-osteosclerosis : the filling of the marrow cavity of a bone with osseous material
Aetiology :
• metabolic, toxic or traumatic osteopathies
• endocrinopathies
• primary hyperparathyroidism
• hypothyroidism
• acromegaly
• radiation osteitis
• chemical intoxications
• osteofluorosis : skeletal changes, usually consisting of osteomalacia and osteosclerosis, caused by fluorosis
• elementary phosphorus
• berillium
• arsenic
• lead
• bismuth
• vitamin A
• eburnation : the conversion of a bone into an ivory-like mass. In osteoarthritis, the thinning and loss of the articular cartilage resulting in exposure of the subchondral bone, which becomes denser and the surface of which becomes worn and polished
• localized osteosclerosis associated with condensing osteitis
• osteosclerotic phase of Paget bone disease
• neoplastic addensing osteopathies : osteosclerosis associated with carcinomatous metastases, malignant lymphoma, hematological diseases (myeloproliferative diseases, sickle cell anemia (SCA), leukemia, multiple myeloma, systemic mastocytosis)
• congenital addensing osteopathies
• osteosclerosis due to erythroblastosis fetalis
• osteopetrosis / Albers-Schönberg or marble bones disease / ivory bones / osteosclerosis fragilis : a rare genetic disease characterized by abnormally dense bone, due to defective resorption of immature bone. It occurs as :
• severe autosomal recessive form occurring in utero, infancy, or childhood. The proliferation of bone obliterates the marrow cavity, causing anemia and hepatosplenomegaly, and narrowing the foramina of the skull, causing compression of cranial nerves, which may result in deafness and blindness
• with infantile neuroaxonal dystrophy
• benign autosomal dominant form occurring in adolescence or adulthood
• type I
• type II : normal serum calcium, phosphorus, alkaline phosphatase, and creatinine levels. Bone radiology demonstrates osteosclerosis primarily involving the axial and appendicular skeleton. A plain radiograph of the spine shows end-plate thickening and sclerosis producing the classic "sandwich vertebra" appearance^ref.
• mild autosomal recessive form
• osteopetrosis with renal tubular acidosis / Guibaud-Vainsel syndrome
• lethal osteopetrosis
• ectodermal dysplasia, anhydrotic, with immunodeficiency, osteopetrosis, and lymphedema (OL-EDA-ID)
• hyperostosis corticalis generalisata, benign form of worth, with torus palatinus / hyperphosphatasemia tarda / van Buchem's syndrome : an autosomal recessive disorder, characterized principally by osteosclerosis of the skull, mandible, clavicles, ribs, and diaphyses of long bones, associated with elevated blood alkaline phosphatase; beginning during puberty, it sometimes leads to optic atrophy and perceptive deafness due to nerve pressure exerted by thickening of the base of the skull.
• high bone mass
Bone fractures are common in all forms
• diseases of uncertain classification
• pyknodysostosis : an autosomal recessive symptom complex consisting of dwarfism, osteopetrosis, partial agenesis of terminal digits of hands and feet, cranial anomalies, frontal and occipital bossing, and hypoplasia of the angle of the mandible.
• allelic loss-of-function mutation in LEMD3 / MAN1, which encodes an inner nuclear membrane protein that antagonizes both BMP and activin-TGF receptor–activated Smads during embryogenesis
• Buschke-Ollendorff syndrome (BOS)
• osteopoikilosis / osteitis condensans generalisata / osteopecilia / osteosclerosis fragilis generalisata :  an autosomal dominant trait in which there are multiple sclerotic foci in the ends of long bones and scattered stippling in round and flat bones, usually without symptoms and diagnosed fortuitously by x-ray examination.
• melorheostosis : a form of hyperostosis (rheostosis / flowing hyperostosis) or osteosclerosis extending in a linear track through one of the long bones of an extremity, and consisting of proliferated ivory-like new bone
• osteomyelosclerosis / myelosclerosis / osteosclerosis myelofibrosis : obliteration of the normal marrow cavity by small spicules of bone; the pathogenesis may be similar to that of myelofibrosis
• Camurati-Engelmann disease (CED) / progressive diaphyseal dysplasia (PDP)
• type I

Aetiology : domain-specific mutations in TGF-b₁
• type II
• infantile cortical hyperostosis / Caffey's disease : a disease of young infants characterized by soft tissue swellings over the affected bones, fever, and irritability, and marked by periods of remission and exacerbation
• hyperphosphatasemia : high levels of alkaline phosphatase in the blood
• hyperostosis corticalis deformans juvenilis / juvenile Paget disease / chronic congenital idiopathic hyperphosphatasemia / familial osteoectasia

Aetiology : an autosomal recessive disorder due to mutations in osteoprotegerin (OPG)
Symptoms & signs : beginning in childhood and marked by multiple fractures and bowing of all extremities
Laboratory examinations : thickening of the frontal, parietal, and occipital bones, osteoporosis, and by elevated concentrations of serum alkaline phosphatase and of urinary hydroxyproline
Therapy : recombinant osteoprotegerin^ref
• mixed lesions
• osteonecrosis / avascular or ischemic necrosis of bone : necrosis of bone in areas with at risk circulation due to obstruction of its blood supply

Aetiology :
• septic osteonecrosis : osteomyelitis
• aseptic osteonecrosis :
• idiopathic osteonecrosis
• idiopathic infantile osteonecrosis (osteochondritis)
• idiopathic juvenile osteonecrosis
• idiopathic adult osteonecrosis
• post-trauma osteonecrosis
• ischemic osteonecrosis
• physical agents
• folgoration
• radiations
• toxic agents
• GR agonists
• SARS coronavirus (?)
• ethanol
• long-term bisphosphonate therapy => osteonecrosis of the jaw (ONJ) (the bone tissue in the jaw fails to heal after minor trauma such as a tooth extraction, causing the bone to be exposed. The exposure can eventually lead to infection and fracture and may require long-term antibiotic therapy or surgery to remove the dying bone tissue)^ref
• osteochondritis dissecans
Laboratory examinations : radiological diagnosis only after 8 months

	first phase	hyperemia and cellular infiltrate that replaces fatty tissue in epiphyseal trabeculae seen only at MRI
	first-second phase	demarcation line and hyperemic wall around the necrotic area
	second-phase	crescent line, fibrosis => thickening of the demarcation line
	third phase	collapse, arthrosis (treated with arthroprosthesis)

Complications :
• sequestrum : a piece of dead cortical bone that has become separated during the process of necrosis from the sound bone and persists into an abscess.
• primary sequestrum : a sequestrum that is entirely detached.
• secondary sequestrum : a sequestrum that is partially detached and may be pushed into place.
• tertiary sequestrum : a sequestrum that is separated by only a slight dividing line and remains in its place.
Therapy : sequestrectomy / sequestrotomy : the surgical removal of a sequestrum
• osteodystrophy : defective bone formation

Aetiology :
• primary hyperparathyroidism
• fibrous dysplasia of bone / fibrous osteitis : a disease of bone marked by thinning of the cortex and replacement of bone marrow by gritty fibrous tissue containing bony spicules, producing pain, disability, and gradually increasing deformity. 2 types or stages are distinguished :
• osteitis fibrosa localisata / monostotic fibrous dysplasia : fibrous dysplasia of bone involving only one bone (rarely a vertebra)
• osteitis fibrosa disseminata / polyostotic fibrous dysplasia : a later stage of fibrous dysplasia of bone in which several or many bones are involved; when associated with skin and endocrine disorders, it is known as PHPIA / McCune-Albright hereditary osteodystrophy
• Jaffe-Lichtenstein disease / cystic osteofibromatosis / juvenile fibrous osteitis : a form of polyostotic fibrous dysplasia characterized by an enlarged medullary cavity with a thin cortex, which is filled with fibrous tissue (fibroma)
• renal osteodystrophy : a condition resulting from chronic kidney disease, characterized by impaired renal function, hyperphosphoremia with hypocalcemia or normal calcemia, and stimulation of parathyroid function. Bone disease includes a variable mixture of osteitis fibrosa cystica, osteomalacia, osteoporosis(subperiosteal bone reabsorption ("scratches") due to secondary hyperparathyroidism), and sometimes osteosclerosis (brown tumors are areas of hyperplasia and require differential diagnosis from osteoclastoma and aneurysmal bone cyst). Onset is usually in childhood, resulting in renal dwarfism.
• Paget's disease of bone / osteitis deformans (Paget J. On a form of chronic inflammation of bones (osteitis deformans). Med-Chirurgic.Transact.London 60:37-63 (1877))

Pathogenesis : increased bone turnover (repeated episodes of increased bone resorption followed by excessive attempts at repair), resulting in weakened deformed bones of increased mass.
Symptoms & signs : bowing of long bones and deformation of flat bones; pain and pathologic fractures are associated. When it affects the bones of the skull, deafness may result
Localizations :
• monostotic Paget's disease
• segmentary Paget's disease
• polyostotic Paget's disease
• lumbar rachid-pelvis-femur-tibia
• skull-jaw-humerus-sternum
• scapular limb-girdle-forearm-feet
Laboratory examinations : increased density due to increased trabecular and cortical density with anarchic, foggy (mosaic-like) structure due to overlap, with preserved architecture. Bone volume is increased (differential diagnosis with osteoblastic metastases, expecially from breast carcinoma in dorsal rachid)
Therapy : a single infusion of zoledronic acid produces more rapid, more complete, and more sustained responses in Paget's disease than does daily treatment with risedronate^ref
• osteitis : inflammation of a bone, involving the haversian spaces, canals, and their branches, and generally the medullary cavity, and marked by enlargement of the bone, tenderness, and a dull, aching pain
• panosteitis / panostitis : inflammation of every part of a bone.
• osteitis albuminosa : osteitis with accumulation of a sticky, albuminous liquid.
• caseous osteitis : tuberculous caries of bone.
• central osteitis / endosteitis : inflammation of the endosteum
• cortical osteitis / periostitis : inflammation of the periosteum. The condition is generally chronic, and is marked by tenderness and swelling of the bone and an aching pain. Acute periostitis is due to infection, is characterized by diffuse suppuration, severe pain, and constitutional symptoms, and usually results in necrosis.
• periostitis albuminosa / albuminous periostitis / serous abscess / periosteal gangrene : a form accompanied by the exudation of a clear, albuminous liquid into a flattened cavity beneath the periosteum
• diffuse periostitis : a noncircumscribed periostitis of the long bones.
• hemorrhagic periostitis : a form in which blood is extravasated beneath the periosteum.
• periostitis hyperplastica / hypertrophic pulmonary osteoarthropathy / secondary hyperplastic osteitis
• periostitis interna cranii / external pachymeningitis : inflammation of the outer layers of the dura
• precocious periostitis : syphilitic osteoperiostitis (Treponema pallidum subsp. pallidum) occurring as an early symptom.
• chronic osteitis : central caries or bone abscess; often due to tuberculosis, sometimes syphilis (Treponema pallidum subsp. pallidum)
• malakoplakia of bone^ref
• osteitis condensans ilii : a condition marked by an area of dense sclerosis on the iliac side of the sacroiliac joint.
• osteitis fibrosa cystica generalisata / von Recklinghausen's disease / osteitis fibrosa osteoplastica / parathyroid osteitis / osteodystrophia cystica / osteodystrophia fibrosa : rarefying osteitis with fibrous degeneration and formation of cysts, and with the presence of fibrous nodules on the affected bones; it is due to marked osteoclastic activity secondary to hyperparathyroidism
• osteitis fragilitans / osteogenesis imperfecta congenita (OIC)
• osteitis carnosa, fungosa, or granulosa : chronic osteitis in which the haversian canals are dilated and filled with granulation tissue.
• gummatous osteitis : a chronic form associated with syphilis (Treponema pallidum subsp. pallidum)
• osteitis pubis : sclerosis of the pubic bones, in the region of the symphysis, usually observed as an incidental finding in radiography of the pelvis
• rarefying osteitis : a bone disease in which the inorganic matter is lessened and the hard bone becomes cancellated.
• vascular osteitis : rarefying osteitis in which the spaces formed become occupied by blood vessels.
• subchondral osteitis
• metaphysitis : inflammation of the metaphysis of a long bone.
• diaphysitis : inflammation of a diaphysis
• tuberculous diaphysitis : inflammation involving intermediate segments of the shafts of long bones, caused by Mycobacterium tuberculosis
• osteomyelitis / acute, carious or necrotic osteitis / suppurative periosteitis / bone abscess : inflammation of bone caused by infection, usually by a pyogenic organism, although any infectious agent may be involved. It may remain localized or may spread through the bone to involve the marrow, cortex, cancellous tissue, and periosteum.
• acute hematogenous osteomyelitis : osteomyelitis resulting from localization of blood-borne bacteria in bone, usually seen in the long bones of children following blunt trauma or adjacent infection. When it spreads to the joints it is known as septic or bacterial arthritis.
• subperiosteal abscess : a bone abscess situated just below the periosteum.
• Brodie's abscess : a roughly spherical region of bone destruction, filled with pus or connective tissue, usually found in the metaphyseal region of long bones
• Staphylococcus aureus
• Staphylococcus epidermidis
• Mycobacterium tuberculosis
• Brucella melitensis
• salmonella osteomyelitis : osteomyelitis due to Salmonella spp.; it occurs more frequently than normal in sickle cell anemia (SCA)
• typhoid osteomyelitis : a type of osteomyelitis that usually occurs in the late convalescent stage of typhoid fever
• osteomyelitis variolosa : osteomyelitis due to, or occurring as a complication of, smallpox
Laboratory examinations : => cancellous bone (hyperemia/edema (demineralization) and ischemia (osteonecrosis => sequestrum)) => endosteum => cortical bone => periosteum (subperiosteal abscess) => soft points (fistulae and abscesses); fever, increased ESR, neutrophilic leukocytosis
• chronic osteomyelitis
• conchiolin osteomyelitis : a condition seen in workers in mother-of-pearl, probably due to the inhaled dust being deposited in the bone marrow
• diffuse sclerosing osteomyelitis : chronic diffuse inflammatory response of bone to low-grade infection, with inflammatory cell infiltrate, fibrous replacement of marrow, and dense sclerotic masses of trabecular bone. Neutrophils, plasma cells, and focal osteoblasts may be present. Oral lesions occur predominantly in the mandible of older persons and are often sequelae of chronic periodontal disease.
• focal sclerosing osteomyelitis / condensing, formative or productive osteitis / osteitis ossificans : chronic confined inflammatory response of bone to low-grade infection, with formation of dense trabecular bony masses with little interstitial marrow tissue. It occurs particularly in the mandible of children and young adults, adjacent to the apex of a tooth with long-term pulpitis
• primary chronic sclerosing nonsuppurative osteomyelitis / Garré's osteomyelitis, osteitis, or disease / chronic nonsuppurative osteitis / proliferative periostitis / periostitis ossificans : chronic idiopathic osteomyelitis involving the long bones, particularly the tibia and femur, and characterized by a diffuse inflammatory reaction, increased density and spindle-shaped sclerotic thickening of the cortex, and an absence of suppuration. A distinctive type of chronic osteomyelitis associated with gross thickening of the periosteum of the bones (onion skinning) and peripheral reactive bone formation resulting from mild irritation or infections. The condition is seen exclusively in children or young adults. Mandible is more often affected than the maxilla. Clinically it manifests as bony hard, non-tender swelling which is slowly progressive and associated with painful carious tooth^ref.
• ostempyesis : suppuration within a bone.
• syphilitic abscess : one occurring in the bones during tertiary syphilis (Treponema pallidum subsp. pallidum)
Laboratory examinations : Pott's puffy tumor (a circumscribed area of edema surrounding lesions of osteomyelitis of the skull)
• osteanabrosis : atrophy of bone.
• osteectopia / osteectopy : displacement of a bone.
• osteoanagenesis / osteanagenesis : regeneration of bone
• osteoanesthesia : the insensitiveness of bone
• osteoaneurysm : aneurysm in a bone
• osteophlebitis : inflammation of the veins of a bone
• osteothrombosis : thrombosis of the veins of a bone
• osteothrombophlebitis : inflammation extended through intact bone by a progressive thrombophlebitis of small venules, such as sometimes occurs in the mastoid bone.
• osteocachexia : cachexia due to chronic bone disease; also chronic disease of bone
• osteocampsia / osteocampsis : curvature or bending of a bone, as in rickets
• osteoectasia : bowing of the bones.
• osteocele : bony tumor of the testis or scrotum; a hernia containing bone
• osteochondropathy : any morbid condition affecting both bone and cartilage, or marked by abnormal enchondral ossification
• polyglucose (dextran) sulfate–induced osteochondropathy : an experimentally produced disorder of enchondral ossification characterized by a deficient formation of bone matrix in the metaphyses of long bones
• osteoclasia : the absorption and destruction of bone tissue.
• osteodiastasis : the separation of 2 adjacent bones
• osteopathia striata : multiple condensations of cancellous bone beginning at the epiphyseal line and extending into the diaphysis, an abnormality seen only on radiographic examination.
• alimentary or hunger osteopathy : disturbances of the skeletal system observed in famine areas, characterized by a reduction in the amount of normally calcified bone, and attributed to dietary deficiencies and associated hormonal dysfunction.
• myelogenic osteopathy : any bone disease due to the impaired relation between the medullary and osseous tissues.
• osteophyte / osteophyma : a bony excrescence or osseous outgrowth
• osteophytosis : a condition characterized by the formation of osteophytes.
Aetiology :
• in rachid dehydratation => reduced thickness of intervertebral disk => pulpy mass stirs annulus fibrosus => stirring of tendon insertion => traction of longitudinal ligament => bone neoformation having a transverse extension
• in articular capsules stirred by effusion
• in other locations : in osteogenic peripheral areas to redistribute loads over articular cartilage
• syndesmophyte : an osseous excrescence, or bony outgrowth, from a ligament, arising from the annulus fibrosus and having a vertical extension in the rachid
• osteotylus : the callus enclosing the end of a broken bone
• osteosynovitis : synovitis together with osteitis of the neighboring bones.
• osteolathyrism : a skeletal disorder produced in laboratory animals by diets containing the sweet pea (Lathyrus odoratus) or its active principle, b-aminopropionitrile, or other aminonitriles. Characterized, in rats, by hernias, dissecting aortic aneurysms, lameness of the hind legs, exostoses, and kyphoscoliosis and other skeletal deformities, apparently as the result of defective aging of collagen tissue.
• osteohydatidosis : hydatid disease of bone
• arthropathies => articular rheumatisms (pain during both active and passive movements)
• monoarticular arthropathies
• oligoarticular or pauciarticular arthropathies (2-3 joints)
• polyarticular arthropathies (> 3 joints)
• hemarthrus : hemorrhage in a joint

Aetiology : hemophilia
• calculous concretion / articular or joint calculus / chalk stone : a deposit in a joint; it is usually composed of sodium urate, sometimes of calcium urate
• psychogenous rheumatism
• reflex sympathetic dystrophy (RSD) / algodystrophy
The structure which is initially affected may be :
• articular cartilage : degenerative rheumatisms : osteoarthrosis

Epidemiology :  female:male ratio 2:1
• primary osteoarthrosis (average onset at age 45-55)
• senile osteoarthrosis (> 65 yy)
Aetiology :
• primitive idiopathic osteoarthrosis
• localized
• hand arthrosis
• foot arthrosis
• gonarthrosis
• coxarthrosis
• vertebral spine arthrosis
• glenohumeral arthrosis
• acromioclavicular arthrosis
• tibiotarsal arthrosis
• sacroiliac arthrosis
• temporomandibular joint (TMJ) dysfunction
• generalized (> 3 abovementioned joints according to Kellgren-Moore criteria)
• secondary to
• trauma
• acute trauma
• chronic trauma
• occupational trauma
• sport
• knee and ankle in footballers
• thumb in cricket players
• hip in Zulu dancer
• congenital developmental disorders
• congenital hip (acetabular) dysplasia / subluxation
• osteochondrosis / epiphyseal ischemic necrosis : a disease of the growth or ossification centers in children that begins as a degeneration or osteonecrosis followed by regeneration or recalcification.

Epidemiology : 1.7%
Symptoms : pain
It may affect :
• articular or epiphysary forms (target growing nuclei)
• vertebrae : Scheuermann's disease / vertebral epiphysitis / kyphosis dorsalis juvenilis
• ilium
• epiphysiolysis capitis femoris / slipped femoral capital epiphyses
• capitular epiphysis (head) of the femur : Legg-Calvé-Perthes disease / Waldenström's disease / coxa plana / pseudocoxalgia
• Kohler's second disease
• extraarticular or apophysary forms (target entheses)
• capitellum of the humerus : Panner's disease
• tuberosity of the tibia : Osgood-Schlatter syndrome / apophysitis tibialis adolescentium
• medial condyle of the tibia : osteochondrosis deformans tibiae / Blount's disease / nonrachitic bowleg / tibia vara
• calcaneus (os calcis) : calcaneal apophysitis / Sever-Haglund disease
• navicular (tarsal scaphoid) : tarsal scaphoiditis / Kohler bone disease
• lunate (semilunar) bone : Kienböck's disease / lunatomalacia
• head of the second metatarsal bone : Freiberg's disease or infraction
• metabolic disorders
• alcaptonuria
• hemochromatosis
• Wilson disease
• Gaucher disease
• endocrine disorders
• acromegaly
• hyperparathyroidism
• diabetes mellitus
• dyslipidemias and obesity
• hypothyroidism
• calcium depots-associated diseases
• chondrocalcinosis
• calcium hydroxyapatite crystals
• osteopathies or arthropathies
• localized :
• fractures
• aseptic necrosis
• septic arthritis
• gout
• diffuse :
• Paget's disease of bone / osteitis deformans
• arthritides
• rheumatoid arthritis
• osteopetrosis
• osteochondritis
• neurogenic or neuropathic arthritis or arthropathy / Charcot's arthropathy, disease or joint : chronic progressive degeneration of the stress-bearing portion of a joint, with bizarre hypertrophic changes at the periphery. Loss of sensation leads to relaxation of supporting structures and chronic instability of the joint
• diabetes mellitus (0.5%), including Lisfranc fracture/luxation of tarsometatarsal joints
• dorsal tabes (knees, hips, and ankles)
• myelomeningocoele
• syringomyelia (shoulders, elbows, and wrists)
• amyloidosis
• leprosy
• congenital pain unsensitivity
• Charcot-Marie-Tooth (CMT) peroneal muscular atrophy
• endemic arthrosis
• Kashin-Bek (Kaschin-Beck) disease (KBD) / osteoarthritis deformans endemica : a slowly progressive, chronic, disabling, degenerative disease of the peripheral joints and spine, which principally occurs in children and is endemic in eastern Siberia, northern China (Tibet), and Korea

Aetiology :
• selenium deficiency
• high concentration of organic matter (mainly fulvic acid) in drinking water
• ingestion of cereal grains infected with Fusarium sporotrichiella
• Mseleni disease : Mseleni in Northern Zululand is a remote geographically isolated improverished district in which about 2,000 persons suffer from a crippling joint disease similar to dysplasia epiphysealis multiplex and spondyloepiphyseal dysplasia. 11% of the men and 39% of the women in young adult life are seriously disabled and, with concurrent osteoarthritis, 90% of the population are grossly incapacitated in old age
• Handigodu disease in Karnataka India : hips are destroyed in 80% of cases in the acute form of this disease which is brought on by environmental factors related to subtropical climate, low animal protein intake and intake of a variety of possibly toxic products of vegetable origin
• other diseases
• hemophilias
• hemoglobinopathies
• sickle cell anemia (SCA) dactylytis
• articular effusions during sickle cell anemia (SCA) crises
• osteomyelitis
• bone infarction
• osteonecrosis
• bone alterations secondary to medullary hyperplasia
• septic arthritis
• gouty arthritis
• decompression syndrome
• freezing disease
• drugs
• quinidine
• amphotericine B
• rifampin
• fluoroquinolones
• acyclovir
• cimetidine
• IFNs
• IL-2
• vaccines
Pathogenesis : asymmetric decrease of chondroblasts and amorphous substance with increase in KS / CS and CS IV / CS VI rates, sometimes arthritis (oedema of synovial membrane, angioneogenesis, fibrin depots, fibrosis of capsulae and tendons). Repair occurs along wrong gravity lines => osteophytes.
Symptoms : arthralgia (gonalgia, coxalgia) worsening under effort, improving when resting (on the contrary of arthritis), lasting < 1 hr
Laboratory examinations : X-rays shows decreased intraarticular space, osteophytes, calcifications of vertebral annulus => syndesmophytes.
Therapy :
• glucosamine sulfate
• hyaluronic acid
• synovial membrane : inflammatory rheumatisms :
• osteoarthritis / arthritis / degenerative or hypertrophic arthritis / degenerative joint disease : a noninflammatory degenerative joint disease seen mainly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain, usually after prolonged activity, and stiffness, particularly in the morning or with inactivity
• acroarthritis : arthritis affecting the extremities
Epidemiology : affecting over 5% of adults (at some degree, about 80% of people aged > 65 years). Women are more seriously affected than men.
Aetiology : a polymorphism in the aspartic acid (D) repeat (D14 allele) of asporin is more common in hip and knee osteoarthritis patients. Asporin suppresses TGF-b-mediated expression of the genes aggrecan (AGC1) and type II collagen (COL2A1) and reduced proteoglycan accumulation in an in vitro model of chondrogenesis. The effect on TGF-b activity is allele-specific, with the D14 allele resulting in greater inhibition than other alleles. In vitro binding assays showed a direct interaction between asporin and TGF-b^ref. ASPN belongs to a family of leucine-rich repeat (LRR) proteins associated with the cartilage matrix. The name asporin reflects the unique aspartate-rich N terminus and the overall similarity to decorin^{ref1, ref2}. Mice defective for aggrecanase / ADAMTS5 are resistant to osteoarthritis^{ref1, ref2}
Therapy :
• exercise and strength training for knee OA (< 5000 dollars/QALY)
• knee bracing
• paracetamol is the most appropriate first-line analgesic
• NSAIDs may be used as second-line analgesia on an as-needed basis (including continuous use), but must be used with caution
• CSI are used if there are risk factors for upper-gastrointestinal complications, but only after considering cardiovascular risk.
• complementary and alternative medicine (CAM) therapies
• acupuncture
• homeopathy
• phytotherapy
• selected nutritional supplements / nutraceuticals : there is little scientific evidence at the cellular and molecular levels to explain their mechanisms of action
• fish oils (e.g. cod liver oil) : gamma linolenic acid (GLA)
• capsaicin
• green tea
• S-adenosyl methionine (SAMe) has a "slower onset of action" than does celecoxib, but the 2 treatments are equally efficacious^ref
• chondroitin sulphate
• glucosamine sulfate is a safe and effective over-the-counter symptomatic relief for patients with osteoarthritis of the knee in short-term clinical trials. In addition, glucosamine has shown promising results in modifying the progression of arthritis over a 3-year period. In animal models of sponge granuloma, Kaolin arthritis and adjuant arthritis, glucosamine hydrochloride inhibits granulation, delays immunoreactivity, immunological-reactive arthritis in daily doses of 0.25-0.75 g/kg BW orally and vascular oozing, tissue swelling and cell isolating in daily doses of 0.5-1.5 g/kg BW orally, indicating that it might have a preventive and therapeutic effect on osteoarthritis^ref. Glucosamine occurs naturally in all human tissues. It stimulates the synthesis of glycosaminoglycan, proteoglycan and hyaluronic acid, although the precise mechanism of action remains to be established. In 2 large randomised, double-blind, multicentre studies in patients with osteoarthritis, oral or intramuscular glucosamine sulphate for 4-6 weeks was associated with a greater decrease in symptom severity (as assessed by the Lequesne index) than placebo. In addition, there was a greater proportion of responders (defined as patients with a >or=3-point reduction in the Lequesne index, along with a positive overall assessment by the investigator) at the end of the treatment period with glucosamine than with placebo. In 2 large 4-week trials, oral glucosamine produced similar improvements to ibuprofen in the Lequesne index in one study and in articular pain scores in the other study. In a smaller 8-week comparative trial, oral glucosamine therapy achieved a significantly greater improvement in articular pain score than ibuprofen, and the investigators rated treatment efficacy as 'good' in a significantly greater proportion of glucosamine than ibuprofen recipients. In comparison with piroxicam, glucosamine significantly improved arthritic symptoms after 12 weeks of therapy and remained effective 8 weeks after treatment was discontinued. Beneficial effects of long-term oral glucosamine therapy in preventing joint space narrowing and improving symptoms were shown in 2 3-year placebo-controlled trials in a total of 414 patients with osteoarthritis. Statistically significant differences favouring glucosamine were noted in the per-protocol and intention-to-treat analyses for the primary endpoints for both joint structural changes and symptom modification. Glucosamine has a tolerability profile similar to that of placebo and is better tolerated than ibuprofen or piroxicam. In particular, glucosamine recipients had a markedly lower incidence of gastrointestinal disturbances than those receiving ibuprofen. Other adverse events reported in both glucosamine and ibuprofen recipients were pruritus or skin reactions, flushing and fatigue. In general, a lower incidence of withdrawal from clinical trials was reported for glucosamine recipients than either ibuprofen or piroxicam recipients^ref.
• intra-articular therapies are used when others have failed. Corticosteroids and hyaluronic acid are the most frequently used intra-articular therapies in osteoarthritis. Other intra-articular substances such as orgotein, radiation synovectomy, dextrose prolotherapy, silicone, saline lavage, saline injection without lavage, analgesic agents, NSAIDs, glucosamine, somatostatin, sodium pentosan polysulfate (SPS), chloroquine, mucopolysaccharide polysulfuric acid ester, lactic acid solution, and thiotepa cytostatica have been investigated as potentially therapeutic in the treatment of arthritic joints. Despite the lack of strong, convincing, and reproducible evidence that any of the intra-articular therapies significantly alters the progression of osteoarthritis, corticosteroids and hyaluronic acid are widely used in patients who have failed other therapeutic modalities for lack of efficacy or toxicity. As a practical approach for a knee with effusion, steroid injections should be considered while the presence of symptomatic "dry" knees may favour the hyaluronic acid approach. The virtual absence of serious side effects, coupled with the perceived benefits, make these approaches attractive^ref.
• total hip replacement (THR) and total knee replacement (TKR) surgery were the most effective treatments and also highly cost-effective, at estimated cost per quality-adjusted life-year (QALY) of 7500 dollars for THR and 10000 dollars for TKR (best estimate)
Web resources :
• NIH Osteoarthritis
• Arthritis Foundation
• Brodie's disease : chronic synovitis, especially of the knee, with a pulpy degeneration of the parts affected
• autoimmune spondyloarthritis
• connective tissue diseases (CTD)-associated rheumatism
• hypertrophic osteoarthropathy (HOA)
• primary or idiopathic HOA / pachydermoperiosteosis (PDP) / Touraine-Solente-Golé syndrome
• secondary HOA
• lung diseases (hypertrophic pulmonary osteoarthropathy / hyperplastic osteoarthritis / acropachy / Marie-Bamberger disease or syndrome : symmetrical osteitis of the 4 limbs, chiefly localized to the phalanges and the terminal epiphyses of the long bones of the forearm and leg, sometimes extending to the proximal ends of the limbs and the flat bones, and accompanied by a dorsal kyphosis and some affection of the joints
• primitive or metastatic pulmonary carcinoma
• mesothelioma
• bronchiectasia
• lung abscess
• pleural empyema
• chronic interstitial pneumonia
• cystic fibrosis
• chronic obstructive pulmonary diseases (COPD)
• sarcoidosis
• gastrointestinal diseases
• esophageal carcinoma
• hepatocellular carcinoma (HCC)
• liver cirrhosis
• celiac disease
• inflammatory bowel diseases (IBDs)
• colorectal carcinoma (CRC)
• cardiovascular diseases
• congenital cyanogenous cardiopathies with right => left shunt :  megakaryocytes are not fragmented in pulmonary circles and can reach endothelial cells of limb extremities, where they release PDGF, stimulating proliferation of connective tissue and periosteal tissue.
• subacute bacterial endocarditis
• infectious arterial transplantations [monolateral]
• aorta aneurysms [bilateral in lower limbs]
• limb arteries aneurysms [monolateral]
• patent ductus arterious (PDA) [bilateral in lower limbs]
• bilateral arterovenous fistulae in lower limb extremities [monolateral]
• primary hyperparathyroidism
• thyroideal acropachy : Graves' disease
Pathogenesis : large platelets accumulate in distal extremities => release of FGF => excess skin and bone proliferation at distal extremity
Symptoms & signs : often asymptomatic, deep bone pain at distal extremities (usually legs), enlargement of the terminal phalanges, thickening of the joint surfaces, digital clubbing / digital hippocratism, bone thickening of wrists and ankles
• septic arthritis : from direct inoculation (infiltrations, ...), contiguity (osteomyelitis, skin abscesses), or hematogenous spread
• acute monoarthritis
• virus
• mumps virus
• Bacteria (pyoarthritis)
• Staphylococcus aureus (expecially in patients with rheumatoid arthritis, due to rupture of rheumatoid nodules and ulcers)
• Staphylococcus epidermidis (after prosthesis insertion of arthroscopy)
• Pseudomonas aeruginosa (in intravenous drug addicted)
• Mycoplasma arthritidis (in patients with primitive immunoglobulin deficits)
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Neisseria gonorrhoeae
• Kingella kingae
• Pasteurella multocida
• anaerobic bacteria from human bites or diffusion from intrabdominal abscesses or decubitus ulcers
• Fungi
• Candida spp.
• chronic monoarthritis
• Bacteria
• Mycobacterium tuberculosis (tuberculous arthritis; when chronic a.k.a. white tumor)
• Mycobacterium marinum
• Mycobacterium avium-intracellulare
• Mycobacterium terrae
• Mycobacterium kansasi
• Mycobacterium fortuitum
• Mycobacterium chelonae
• Mycobacterium haemophilum
• Borrelia burgdorferi
• Treponema pallidum subsp. pallidum
• Nocardia spp.
• Brucella spp.
• Fungi
• Candida spp.
• Ajellomyces capsulatus
• Ajellomyces dermatidis
• Sporothrix schenkii
• Coccidioides immitis
• Aspergillus spp.
• Cryptococcus neoformans
• Pseudoallescheria boydii
• Protozoa
• Cryptosporidium parvum
• Giardia lamblia
• helminths
• Echinococcus granulosus
• Filarioidea
• Strongyloides stercoralis
• Dracunculus medinensis
• acute polyarthritis
• viruses
• HBV
• parvovirus B₁₉
• HIV-1
• HTLV-1
• rubella virus
• mumps virus
• Barmah Forest virus (BFV)
• Chikungunya virus
• Mayaro virus
• O'nyong-nyong virus
• Ross River virus
• LCMV
• enteroviruses
• echoviruses
• Bacteria
• Neisseria meningitidis
• Neisseria gonorrhoeae (70% all septic arthritides in patients with age < 40)
• Fungi
• Candida spp.
• sarcoidosis
• oral contraceptives
• idiopathic
Risk factors : immune deficiencies, intravenous drug addiction, prostheses
Diagnosis : culture of synovial exudate
Therapy : i.v. 3^rd generation cephalosporin, arthrotomy, passive joint movement
Pathogenesis : imbalance of extracellular proteolytic enzymes and their endogenous tissue inhibitors. Metalloproteinases called 'aggrecanases' that cleave the Glu³⁷³-Ala³⁷⁴ bond of the aggrecan core protein play a key role in the early stages of cartilage destruction in rheumatoid arthritis and in osteoarthritis. 3 members of the ADAMTS family of proteinases, ADAMTS-1, ADAMTS-4 and ADAMTS-5, have been identified as aggrecanases. MMPs, which are also found in arthritic joints, cleave aggrecans, but at a distinct site from the aggrecanases (i.e. Asn³⁴¹-Phe³⁴²). TNF-a and C₂-ceramide induce a degradative pathway in cartilage mediated via activation of PKR by PKR-activating protein (PACT) / PRKRA^ref
Symptoms : arthralgia improving under effort, worsening when resting, lasting > 1 hr
Web resources :
• Arthritis at CDC
• Arthritis care
• Associations
• Arthritis Foundation
• The Arthritis Society
• Journals
• Arthritis Research [free at PubMed Central (PMC)
• dysmetabolic rheumatisms
• gouty arthritis

Epidemiology : more common in men than in women, whose age of onset is older than men
Aetiology : hyperuricemia
Pathogenesis : hyperuricemia causes precipitation of monosodium urate crystals in synovial fluid, creating crystals (tophic concretion / tophus : a chalky deposit of sodium urate occurring in gout; tophi form most often around joints in cartilage, bone, bursae, and subcutaneous tissue and in the external ear, producing a chronic, foreign-body inflammatory response). Androgens reduces uric acid elimination and increase its synthesis, so that normal uric acid plasma level in fertile females is < 6 mg / dL, while in males it is < 7 mg / dL : under the same muscular mass no difference exists before puberty or after menopause.
Symptoms & signs :
• acute phase : fever and morning monoarthritis, usually beginning in big toe (podagra : due to trauma lower temperature and pH during night-time) > metatarsophalangeal joint (70%), fingers, wrists, ankles, knees, and shoulders (omagra) lasting 6-10 days, and tendinitis (tenontagra)
• chronic phase : tophi in periarticular and subcutaneous tissues (extensory surfaces of elbows and fingers, anterior region of knees, Achilles tendons and ears)
Laboratory examinations :
• neutrophilic leukocytosis
• [urate]_plasma (33% have normal values due to inflammatory response or uricuric action of antiinflammatory drugs !)
• [urate]_urine / 24 hours
• pseudouridine excretion : increased excretion of pseudouridine in the urine of gouty patients, the significance of which remains to be established; a greater turnover of some forms of RNA has been suggested, possibly adding to the hyperuricemia of gout.
• negative birefringent urate crystals with polarized light microscopy on synovial exudate
Therapy : as for hyperuricemia
• microcrystal arthritides
• calcium pyrophosphate deposition disease (CPDD) : an acute or chronic inflammatory arthropathy caused by deposition of calcium pyrophosphate dihydrate (CPPD) crystals(Ca₃(PO₄)₂) in the joints and characterized by chondrocalcinosis and the presence of the crystals in synovial fluid. Clinically, it may resemble numerous connective tissue diseases, including osteoarthritis, rheumatoid arthritis, and gout, or it may be asymptomatic. Acute attacks are sometimes called pseudogout

Aetiology :
• most commonly idiopathic
• aging
• associated diseases :
• hyperthyroidism
• hemochromatosis
• hypophosphatemia (expecially hyperparathyroidism)
• hypomagnesemia
• chronic tophaceous gout
• post-meniscectomy pseudogout
• epiphysary dysplasia
• hereditary
Laboratory examinations : slight positive birefringent crystals under polarized light microscopy.
• calcium apatite deposition disease : any acute or chronic connective tissue disorder marked by deposition of hydroxyapatite crystals in one or more joints or bursae; such deposition may be primary or it may be secondary to other disorders such as chronic renal failure

Aetiology :
• aging
• osteoarthrosis
• hemarthrus (Milwaukee shoulder)
• degenerative arthropathy
• bursitis
• tendinitis
• tumoral calcinosis
• associated diseases
• hyperparathyroidism
• milk-alkali syndrome
• chronic renal failure / long-term hemodialysis
• CTDs
• SSc
• CREST syndrome
• SLE
• heterotopic calcification following severe neurological lesions
• stroke
• medullary injuries
• heredity
• arthritis
• bursitis
• tumoral calcinosis
• progressive ossifying fibrodysplasia
• calcium oxalate crystals

Aetiology :
• primary
• secondary to end-stage renal disease (ESRD) : vitamin C dietary supplements are converted to oxalate, which cannot be removed by hemodialysis
• arthrifluent abscess : a wandering abscess which has its point of origin in a diseased joint
• joint mouse : one of the portions of the fringes in the synovial membrane of joints in osteoarthritis which are changed into cartilage and become free in the joints
• arthrolith : a calculous deposit in a joint
• arthrophyte : an abnormal growth in a joint cavity
• Birkett's synovial hernia : protrusion of the inner lining membrane through the stratum fibrosum of a joint capsule
Laboratory examinations :
• clincal-radiological criteria for differential diagnosis :
• asymmetry
• localization of joints and involved parts (periphery, pits)
• lack of elementary lesions

	arthritis	arthrosis
tumefaction of soft tissues. It is assessed with echography or MRI > conventional X-rays (arthrography is no longer used)	yes : subcutaneous edema and effusion/hypertrophy of synovial membrane => increased density of periarticular soft tissues; spindle, nodular, enlengthened morphology with net or confused borders	no
osteoporosis	yes : flogosis => hyperemia => demineralization (this is not osteoporosis of disuse !)	no
reduced articular space seen with X-rays (water content is seen with MRI; echography is useful only in knee after extensive enxtension)	diffuse (effusion, enzymes)	focal
erosions	synovial flogosis => osteolysis => marginal erosions (in bone areas not covered by the more resistant articular cartilage)	cartilage degeneration => osteolysis => central erosions. Pressure allows enzymes to penetrate into subchondral bone
bone neoformation	spondylosis subchondral sclerosis enthesopathies periosteal calcifications	osteophytes
endo- or paraarticular calcifications	deposits in seronegative spondyloarthropathies (interapophysary joints, sacroiliitis, syndesmophytes => ankylosis)	yes
modification of joint relationships	soft tissue laxity	deformity  luxations and subluxations disaxing protrusion

• features of elementary lesions
• spondylitis
• diseases in other organs
• synovianalysis (the laboratory examination of joint fluid (synovia))
Web resources :
• American College of Rheumatology
• Pediatric rheumatology
• The Pediatric Rheumatology Home Page
• Rheumatology resources
• Diagnostic criteria for the rheumatic diseases
• Merck Manual - Disorders of joints and connective tissue
• Associations
• European Association of Rheumatology (EULAR)
• Journals
• British Journal of Rheumatology
• Rheumatology
• periarticular diseases
• Jeanselme's nodules / juxta-articular nodules : gummata of tertiary syphilis and of nonvenereal treponemal diseases, located on joint capsules, bursae, or tendon sheaths
• bursitis : inflammation of a bursa, occasionally accompanied by a calcific deposit in the underlying tendon; the most common site is the subacromial or subdeltoid bursa
• septic bursitis : that caused by infection, usually the result of bacterial inoculation due to trauma
• Verneuil's disease : syphilitic disease of the bursae.
Localizations :
• scapulohumeral bursitis
• radiohumeral bursitis
• olecranon bursitis
• trochanteric bursitis
• ischiogluteal bursitis
• popliteal bursitis / Baker's cyst
• prepatellar bursitis
• anserine bursitis
• achillobursitis / superficial calcaneal bursitis
• retrocalcaneal bursitis
• calcaneal apophysitis (Sever-Haglund disease)
• tendineal lesions
• peritendinitis / peritenonitis / peritenontitis / tenosynovitis / tenosynitis / tendinous synovitis / tendosynovitis / tendovaginitis / tenovaginitis / tenontothecitis : inflammation of a tendon sheath (peritenonium)
• tenosynovitis acuta purulenta : tenosynovitis with pus formation.
• adhesive tenosynovitis : tenosynovitis in which the tendons become bound in an inflammatory mass.
• gonococcic tenosynovitis / gonorrheal tenosynovitis : tenosynovitis due to metastatic gonococcal infection.
• tenosynovitis hypertrophica : a condition marked by swellings along the tendons and their sheaths.
• tenosynovitis serosa chronica : tenosynovitis with serous effusion.
• tuberculous tenosynovitis : chronic tuberculous infection of tendon sheaths and bursae.
• tenosynovitis granulosa : tuberculosis of tendon sheaths, which become filled with granulation tissue.
• (pigmented) villonodular tenosynovitis : a condition characterized by exaggerated proliferation of synovial membrane cells, producing a solid tumorlike mass, commonly occurring in periarticular soft tissues and less frequently in joints.
• villous tenosynovitis : chronic infection of tendon sheaths and bursa, with proliferation of villous projections from the surface of the membranes
• peritendinitis calcarea : a painful condition marked by calcareous deposits in tendons and in peritendinous, capsular, and ligamentous tissues.
• peritendinitis crepitans / tenosynovitis crepitans : a form accompanied by a crackling sound in the soft tissues on movement.
• peritendinitis serosa / ganglion : a benign cystic tumor occurring on an aponeurosis or tendon, as in the wrist or dorsum of the foot; it consists of a thin fibrous capsule enclosing a clear mucinous fluid
Localizations :
• Achilles' tendinitis
• pubalgia
Laboratory examinations : none detected X-ray, MRI, or echography
Therapy :
• rest
• antiiflammatory drugs
• tendinitis / tendonitis / tenonitis / tenontitis : inflammation of tendons and of tendon-muscle attachments
• tendinitis ossificans traumatica : a condition in which areas of ossification develop in tendons as a result of trauma
• osteodesmosis / ossidesmosis : ossification of tendon
• melon-seed body : any of a class of small fibrous masses sometimes occurring in the joints and in cysts of the tendon sheaths
• oryzoid or rice bodies / corpora oryzoidea : small bodies resembling grains of rice which form in the tendons of joints and in the fluid of hygroma
• thecal abscess : one arising in an tendon sheath.
• tendinosis : degeneration of a tendon

Localizations :
• palmar aponeurosis :
• plantar aponeurosis : Ledderhouse syndrome
Symptoms & signs : pain
Laboratory examinations : hypertrophy => calcific tendinosis detected at Rx, MRI, or echography
Therapy : tendineal split (longitudinal cuts) to clear calcium depots => vascular trauma => fibrous repair
• tendon rupture
• pulled tendon : disruption of the fibers attaching a muscle to its point of origin, occurring as the result of unusual muscular effort
• riders' tendon : injury to the adductor tendons of the thigh incurred in horseback riding.
Laboratory examinations : echography, MRI
Therapy :
• immobilization
• terminoterminal tenorrhaphy
• capsuloligamentous lesions
• capsulitis : inflammation of articular capsule
• adhesive bursitis or capsulitis / frozen shoulder : adhesive inflammation between the joint capsule and the peripheral articular cartilage of the shoulder with obliteration of the subdeltoid bursa, characterized by painful shoulder of gradual onset, with increasing pain, stiffness, and limitation of motion
Localizations : shoulder instability
• syndesmitis : inflammation of a ligament or ligaments
• syndesmectopia : unusual situation of a ligament
• subaponeurotic abscess : one beneath an aponeurosis or fascia
• subfascial abscess : one beneath a fascia
• subgaleal abscess : one under the galea aponeurotica
• chondropathies
• chondrocalcinosis : the presence of calcium salts, especially calcium pyrophosphate, in the cartilaginous structures of one or more joints
• asbestos transformation : the deposition of extraneous fibers in hyaline cartilage, which gives it a silky, glossy appearance
• chondritis : inflammation of cartilage.
• relapsing polychondritis
• Morquio's syndrome / MPS IV / osteochondrodysplasia / eccentrochondroplasia / eccentro-osteochondrodysplasia / osteochondrodystrophia deformans
• osteochondritis : inflammation of both bone and cartilage.
• osteochondritis dissecans / osteochondrolysis : osteochondritis resulting in the splitting of pieces of cartilage into the joint, particularly the knee joint or shoulder joint.
• osteochondritis necroticans
• Wegner's disease : osteochondritic separation of the epiphyses in hereditary syphilis
Localizations :
• osteochondritis ischiopubica
• Fleischner's disease
• calcaneal osteochondritis / Haglund's disease
• juvenile deforming metatarsophalangeal osteochondritis / Köhler's bone disease
• Thiemann's disease / familial osteoarthropathy of fingers : familial avascular necrosis of the phalangeal epiphysis, beginning in childhood or adolescence and resulting in deformity of the interphalangeal joints. Similar lesions may occur in the great toes and first tarsometatarsal joints, in which case the disorder is known as osteochondritis ossis metacarpi et metatarsi
• chondromalacia : softening of the articular cartilage, most frequently in the patella.
• chondromalacia fetalis : a condition in which the limbs of the stillborn fetus are soft and pliable due to softening of the epiphyseal cartilage.
• chondromalacia patellae : pain and crepitus over the anterior aspect of the knee, particularly in flexion, with softening of the cartilage on the articular surface of the patella and, in later stages, effusion.
Web resources : Chondromalacia
• traumatic lesions
• avulsion : the ripping or tearing away of a part either accidentally or surgically
• distortion : the state of being temporarily twisted out of a natural or normal shape or position.
• distraction : a form of dislocation in which the joint surfaces have been separated without rupture of their binding ligaments and without displacement.
• luxation / dislocation : the permanent displacement of a bone
• incomplete or partial dislocation / subluxation : a slight displacement
• complete dislocation : one which completely separates the surfaces of a joint
• complicated dislocation : one which is associated with other important injuries
• simple or closed dislocation : one in which the joint is not penetrated by a wound
• compound or open dislocation : one in which the joint communicates with the external air
• intrauterine dislocation : one which occurs to the fetus in utero
• congenital dislocation : one which exists from or before birth
• consecutive dislocation : one in which the luxated bone has changed its position since its first displacement
• divergent dislocation : one in which the ulna and radius are dislocated separately
• fracture dislocation : dislocation complicated by fracture of, or adjacent to, a joint
• habitual dislocation : one which often recurs after replacement
• recent dislocation : one in which there is no complicating inflammation
• old dislocation : a dislocation in which inflammatory or fibrotic changes have occurred
• pathologic dislocation : one which results from paralysis, synovitis, infection, or other disease
• primitive dislocation : one in which the bones remain as originally displaced
• traumatic dislocation : one due to an injury or to violence.
• bone fractures : a break or rupture in a bone
• pseudofracture : a condition seen in a radiograph of a bone as a thickening of the periosteum and formation of new bone over what looks like an incomplete fracture.
• fracture-dislocation : a fracture of a bone near a joint, also involving dislocation.
Aetiology :
• direct fracture : a fracture at the point of injury.
• pathologic, secondary or spontaneous fracture : one due to weakening of the bone structure by pathologic processes, such as neoplasia, osteomalacia, osteomyelitis, and other diseases
• agenetic fracture : spontaneous fracture due to osteogenesis imperfecta congenita (OIC)
• atrophic fracture : a spontaneous fracture resulting from atrophy of the bone
• dyscrasic fracture : fracture due to weakening of the bone from debilitating disease.
• endocrine fracture : fracture of a bone weakened by an endocrine disorder such as hyperparathyroidism.
• inflammatory fracture : fracture of a bone weakened by inflammatory disease
• pressure fracture,   one caused by pressure on the bone from an adjoining neoplasia.
• neoplastic fracture : fracture due to weakening of the bone as a result of a malignant process
• neurogenic fracture : fracture due to weakening of the bone as a result of dorsal tabes, paresis, etc
• trophic fracture : one due to a trophic (nutritional) disturbance
• Chester's disease : xanthomatosis of the long bones with spontaneous fractures.
• traumatic fracture
• buttonhole or perforating fracture : fracture in which the bone is perforated by a missile
• surgical fracture / osteoclasis : the surgical fracture or refracture of bones.
• stress, fatigue or march fracture : a fracture caused by unusual or repeated stress on a bone, such as with soldiers or athletes
• insufficiency fracture : a stress fracture that occurs during normal stress on a bone of abnormally decreased density
Laboratory examinations : Looser's transformation zones (dark lines seen on radiographs of bones, thought to represent pathological healing phases of fatigue fractures occurring in certain bone diseases)
• indirect fracture : a fracture at a point distant from the site of injury.
Localization :
• epiphyseal detachment or fracture : fracture at the point of union of an epiphysis with the shaft of a bone
• Salter-Harris fracture : an epiphyseal fracture in children that involves the epiphyseal growth plate
• (intra)-articular or joint fracture : a fracture of the joint surface of a bone
• extraarticular fracture
• periarticular fracture : a fracture extending close to, but not into, a joint.
• intracapsular fracture : one within the capsule of a joint.
Fractures of the epiphysis and growth plate are more common in boys, and are usually seen either in infancy or between the ages of 10 and 12.
Salter and Harris classification :
• grade I fracture is a slipped epiphysis. This type of injury usually occurs in infants but is also seen at puberty as a slipped femoral epiphysis. This type of injury seldom results in any serious problem.
• grade II fracture occurs along the epiphyseal plate but branches into the shaft. The detached fragment of bone consists of the epiphysis plus a triangular fragment of the shaft. A alter-Harris II fracture is the most common type of epiphyseal injury, occurs in older children and seldom results in abnormal growth
• grade III fracture occurs along part of the epiphyseal plate and then cuts into the epiphysis. The result is detachment of part of the epiphysis from the shaft. The fracture extends into the joint. In order to prevent abnormal growth, accurate reduction is required to restore the joint surface.
• grade IV fracture occurs through the shaft, the epiphyseal plate, the epiphysis and into the joint. The detached pieces of bone consists of a fragments of the shaft, epiphyseal plate and epiphysis. There is disruption of the growth plate and the articular surface.
• grade V fracture is compression damage to a portion of the growth plate. The crushed epiphysis stops growing; this is not easy to detect acutely, but results in severe deformity in the long-term. This injury carries the worst prognosis of any of the epiphyseal injuries, usually causing partial or complete cessation of growth.

• metaphyseal fracture
• apophyseal or diaphyseal fracture : one in which a small smear fragment or a bony prominence is torn from the bone
• subcapital fracture : fracture of a bone just below its head, especially an intracapsular fracture of the neck of the femur at the junction of the head and neck.
Number of interruptions :
• unifocal fracture
• multiple fracture : a variety in which there are 2 or more lines of fracture of the same bone not communicating with each other.
• bifocal, double or segmental fracture : fracture of a bone in 2 places
• trifocal fracture
• ....
Pathogenesis :
• flexion fracture
• sprain fracture : the separation of a tendon or ligament from its insertion, taking with it a piece of bone.
• torsion or spiral fracture : one in which the bone has been twisted apart
• compression fracture : one produced by compression, as of a vertebra
• axial compression or burst fracture : fracture of a vertebra by excessive vertical force, so that pieces of it move out in horizontal directions, often injuring the spinal cord; it usually occurs in the thoracic or lumbar region as a result of flexion
• avulsion fracture : an indirect fracture caused by avulsion or pull of a ligament.
• dislocation fracture : fracture of a bone near an articulation with concomitant dislocation of that joint
• fracture en coin : a V-shaped fracture
• fracture en rave : a fracture in which the break is transverse at the surface, but not within.
• fissure or fissured fracture : a crack extending from a surface into, but not through, a long bone
• resecting fracture : a fracture in which a piece of the bone is removed by violence, as by a bullet
• stellate fracture : a fracture with a central point of injury, from which radiate numerous fissures.
Integrity of covering skin :
• closed, simple or subcutaneous fracture : a fracture that does not produce an open wound in the skin
• complex simple fracture : a closed fracture in which there is considerable injury to adjacent soft tissues
• open or compound fracture : one in which there is an external wound leading to the break of the bone
Grading :
• complete fracture : one in which the bone is entirely broken across.
• loose fracture : a fracture in which the bone is completely broken so that the broken ends have free play
• linear fracture : a fracture extending along the length of a bone
• longitudinal fracture : a break in a bone extending in a longitudinal direction.
• transverse fracture : a fracture at right angles to the axis of the bone.
• oblique fracture : fracture in which the break extends in an oblique direction
• complex fracture
• spiroid fracture
• comminuted fracture / thrypsis : one in which the bone is splintered or crushed
• butterfly fracture : a comminuted fracture in which there are 2 fragments on each side of a main fragment, somewhat resembling the wings of a butterfly.
• splintered fracture : a type of comminuted fracture in which the bone is splintered into thin, sharp fragments.
• incomplete fracture : one which does not entirely destroy the continuity of the bone.
• intraperiosteal fracture : a fracture without rupture of the periosteum
• subperiosteal fracture : a crack through a bone without alteration in its alignment or contour, the supposition being that the periosteum is not broken
• infraction : incomplete fracture of a bone without displacement of the fragments.
• greenstick, hickory-stick, willow or interperiosteal fracture : fracture in which one side of a bone is broken, the other being bent; an infraction
• capillary fracture : a fracture that appears in the radiograph as a fine hairlike line, the segments of bone not being separated; sometimes seen in fractures of the skull.
• lead pipe fracture : fracture in which the cortex of the bone is slightly compressed and bulges on one side with a slight crack on the opposite side of the bone
Fragment displacement : fragments have to be surgically ablated when intraarticular
• fat pad sign : distention and displacement of the fat adjacent to a joint capsule, usually in the elbow or knee, visible on a radiograph when the joint is flexed; a sign of a fracture within the joint that involves little or no bone displacement.
• decompound fracture
• with transverse displacement of fracture fragments (ad latus)
• with longitudinal displacement (ad longitudinem)
• with angular displacement (ad axim)
• with rotatory displacement (ad peripheriam)
• compound fracture
• impacted fracture : fracture in which one fragment is firmly driven into the other
Symptoms & signs :
• crepitation
• antalgic posture / praeternatural movements
• post-traumatic deformities
• pain exacerbated by deep palpation or percussion
• ecchymoses
• tumefaction
• functional impotence
• Hueter's sign : the absence of the transmission of osseous vibration in cases of fracture with fibrous material interposed between the fragments.
Laboratory examinations :
• X-rays
• CT : only ...
• when conventional X-rays has doubtful results or not concordant with clinical picture
• in complex fractures which require surgery
• for correct localization of intraarticular fragments
• when soft tissue involvement is suspected
• MRI : only in ...
• vertebral fractures
• infectious complications
Therapy :
• reduction
• closed reduction : the repositioning of a fractured bone without open surgery.
• open reduction : providing access to a fracture for purposes of anatomic approximation by cutting tissue or surrounding bone.
• Trueta treatment : immediate treatment of fractures as follows: (1) adopt surgical treatment as soon as possible; (2) thoroughly wash wound and entire limb with water, soap, and a nail brush, shave hair, paint surrounding skin with weak alcoholic solution of iodine, avoiding the wound; (3) débride wound; (4) open neighboring cellular spaces and remove hematomas; (5) remove completely denuded or displaced bone fragments and all foreign matter; (6) reduce fracture; (7) dress wound with sterile gauze and immobilize with plaster, including two adjacent joints if possible; (8) give injection of tetanus antitoxin.
• Orr treatment : treatment of compound fractures and osteomyelitis by débridement of the wound, alignment of fracture, drainage with petrolatum gauze, and immobilization of limb in a plaster cast which is left on until the wound discharge has softened the plaster.
• bone plate : a metal bar with perforations for the insertion of screws, used to immobilize fractured segments.
• plasters
creeping substitution of bone : the formation of new bone on the surfaces of necrotic trabeculae by osteoblasts, occurring after the revascularization of an area that has been disrupted by fracture, as at the head of the femur after fracture of the neck has disrupted the blood supply to the head of the bone
Complications (long bones > flat bones > short bones) :
• acute complications
• vascular complications => ischemic bone necrosis => wet gangrene within 24-36 hrs

Pathogenesis :
• direct mechanical damage : a fragment recides a vessel fundamental for bone perfusion (rare, only in open fractures)
• reflexed mechanical damage : subfascial hematoma (up to 1.5 L) => compression of nerves and vessels

Therapy : extended fasciotomy to evacuate hematoma => thrombendoarteriectomy => terminoterminal biological bypass
• peripheral nerve complications
• radial nerve in humeral fractures

Therapy :
• endomedullary osteosynthesis
• neurorrhaphy using internal saphenous nerve as donor and fibrin glue
• acute osteomyelitis
• traumatic osteomyelitis (in open fractures)
• iatrogenic osteomyelitis (post-therapeutical reduction)
Therapy : antimicrobial therapyab initio
• acute pelvis

Aetiology :
• pelvis unhinging
• pelvis crushing
• complete craniocaudal unhinging
Signs : anemia within 4-5 days
Therapy : surgery or external fixation
• chronic complications
• chronic osteomyelitis : relapsing poussées for all life
• pseudoarthrosis (lack of healing within 6 months)
• atrophic pseudoarthrosis : fracture endings are subtle and porous

Therapy : autologous bone transplantation from iliac wing
• hypertrophic pseudoarthrosis / elephant pad arthrosis : malunion of hypertrophic fracture ends

Therapy : perforation of cortical bone to increase regenerative potential
• ankylosis
• secondary arthrosis (conflicts)
• aseptic epiphysary necrosis (usually at femur head)

Aetiology :
• in youngs : femur luxation or luxation fracture lacerates articular capsule, including the circumflexed artery which vascularize femural head => fracture doesn't heal within 8-10 months

Therapy : multiple forage of femural head, arthrodesis
• in elderlies : impaired synovial liquid efflux => inhibition of osseous callus formation => pseudoarthrosis and ischemic bone necrosis

Therapy : arthroplasty
Laboratory examinations : Rx => MRI
• Chester's disease : xanthomatosis of the long bones with spontaneous fractures.
• bone heteroplasias : the replacement of normal by abnormal tissue; malposition of normal cells
• osteocystoma : a bone cyst.
• subchondral or ganglionic cyst : a bone cyst within the fused epiphysis beneath the articular plate; it is lined with a membrane (probably modified synovia) which contains a mucinous material
• pseudocysts / adventitious or false cysts : an abnormal or dilated cavity resembling a true cyst but not lined with epithelium; usually not growing
• aneurysmal bone cyst : a benign, rapidly growing, osteolytic lesion usually occurring in childhood or adolescence; it may be primary or secondary to an existing lesion and is characterized by blood-filled, often large, cystic spaces lined by bony or fibrous septa that contain osteoid and multinucleated giant cells.

Differential diagnosis : brown tumors in renal osteodystrophy and osteoclastoma
• essential, juvenile, simple, solitary, traumatic or unicameral bone cyst : a unilocular, cystic, often asymptomatic bone lesion usually occurring in the long tubular bones of children and adolescents; it is hollow or fluid-filled, lacks an epithelial lining, and does not penetrate the cortex or extend into soft tissue. Its origin is debated, but it is postulated to occur secondary to traumatic hematoma formation => ischemia => medullary necrosis and intramedullary hematoma
• blood extravasation
• solid
• idiopathic (hollow)
• exostosis : a benign bony growth projecting outward from the surface of a bone
• exostosis bursata : an exostosis from the epiphyseal portion of a bone, consisting of bone and cartilaginous tissue covered by a connective-tissue capsule.
• multiple osteocartilaginous exostoses / hereditary deforming chondrodysplasia / diaphyseal aclasis / hereditary multiple exostoses : an autosomal dominant disorder characterized by exostoses near the extremities of diaphyses of long bones, which may be cartilaginous or osteocartilaginous growths; it is generally benign, although sarcomatous changes have occurred
• subungual exostosis : a cartilage-capped reactive bone spur occurring on the distal phalanx, usually of the great toe, particularly in women.
• Busquet's disease : exostoses on the dorsum of the foot due to osteoperiostitis of the metatarsal bones.
• osteochondroma / ecchondroma / ecchondrosis / osteocartilaginous exostosis : a hyperplastic growth of epiphyseal cartilage tissue consisting of adult bone capped by yet unossified cartilage projecting from the lateral contours of endochondral bones. The earlier in development was the hernia of the soft bone layer, the more distant from epiphysis is the ecchondroma (usually at metaphysis or metaphysis-epiphysis junction).
• fibrosing osteochondroma : a tumor containing the elements of osteoma, chondroma, and fibroma
• ecchondrosis physaliphora : gelatinous nodules of heterotopic notochordal tissue projecting from the clivus or dorsum sellae. True tumors (chordomas) may arise from these or from intraosseous remnants of the notochord
• osteochondromatosis / Ombrédanne's disease : a condition marked by the presence of multiple osteochondromas
• synovial osteochondromatosis : a rare condition in which cartilage bodies are formed in the synovial membrane of the joints, tendon sheaths, or bursae, later undergoing secondary calcification and ossification; some of the bodies may become detached and remain as viable, growing structures in the synovial spaces.
• Henderson-Jones disease : osteochondromatosis characterized by the presence of numerous cartilaginous foreign bodies in the joint cavity or in the bursa of a tendon sheath.
Epidemiology : onset at age 10-12
Symptoms & signs : painless (when diplacing muscles) or painful (when compressing nerves or blood vessels) tumefaction, sometimes evident on skin, usually in knee, ankle, shoulder
Laboratory examinations : metaphysary protrusion at Rx
Therapy : surgical ablation to prevent degeneration into osteosarcoma
Prognosis : self-limiting at the end of body growth (around age 25), when even the cartilaginous cap is mineralized, more than normal bone; if growth persists it is likely to have become a chondrosarcoma (2-3%; 25% in Ombrédanne's disease)
• skeletal neoplasms
• primitive tumors (50%, rare, more frequent among youngs)
• benign primitive tumors
• synovioma : a tumor of synovial membrane origin
• arising from cartilage tissue
• chondroblastoma / Codman's tumor : a usually benign tumor derived from immature conjugation cartilage cells, occurring primarily in the epiphyses of adolescents

Microscopic anatomy : fine, matrix-like calcifications arranged hexagonally, often resembling chicken wire, around closely packed cells => less fundamental substance than in chondroma, no reactive osteosclerosis, slow growth
Symptoms & signs : moderate pain. Pulmonary metastases in 1%.
Therapy : surgical ablation and bone prosthesis => high incidence of relapses due to lack of well-defined borders
• chondroma : a benign tumor or tumorlike growth of mature hyaline cartilage. It may remain centrally within the medullary cavity of long bones (enchondroma / true chondroma) or may develop beneath the periosteum but external to the cortex of a bone (juxtacortical or periosteal chondroma), and usually occurs in the small bones of the hands or feet, the femur, the humerus, or the ribs.
• fibroenchondroma : enchondroma containing fibrous elements.
• chondromatosis / Ollier syndrome : formation of multiple chondromas; evolution to chondrosarcoma is more common
• Kast's or Maffucci's syndrome : enchondromatosis associated with congenital multiple cutaneous or visceral cavernous hemangiomas
• synovial chondromatosis : formation of multiple intrasynovial nodules resembling osteochondromas, resulting from proliferative changes in the synovial linings of joints; as the disorder progresses, nodules increasingly forsake the intrasynovial areas for the joint cavities
Epidemiology : congenital but usually symptomatic in any age group (most commonly adolescents or young adults)
Microscopic anatomy : lobular mature cartilage (capsule-less)
Symptoms & signs : painless tumefaction, cortical osteolysis => pathologic fracture
Laboratory examinations : osteolysis at Rx
Therapy : surgical curettage followed by caustic injection and refilling with autologous bone transplantation
Prognosis : rare relapses
• arisig from bony tissue (5%)
• osteoma : a benign, slow-growing tumor composed of well-differentiated, densely sclerotic, compact bone, usually arising in membrane bones, particularly the skull and facial bones, and ribs.
• compact osteoma / ivory exostosis, osteoma or ivory-like tumor / osteoma durum or eburneum : a small, dense, compact tumor of mature lamellar bone with little medullary space, usually occurring in the craniofacial or nasal bones.
• osteoma medullare : an osteoma containing marrow spaces.
• osteoma spongiosum / spongy or trabecular osteoma : osteoma containing cancellated bone.
• exostosis cartilaginea : a variety of osteoma consisting of a layer of cartilage developing beneath the periosteum of a bone.
Aetiology : cavalryman's osteoma : osteoma at the insertion of the adductor femoris longus muscle.
Symptoms & signs : asymptomatic; exophytic osteomas of skull may cause focal seizures, limit cervical extension, or compression of arteries and nerves at foramen magnum (when involving occipital bone), diplopia, dysodontiasis, or sinusitis (when involving splanchnocranium)
Therapy : surgical ablation only if exophytic
• osteoid osteoma : a small, benign but painful, circumscribed tumor of spongy bone occurring especially in the long bones of the extremities and vertebrae

Epidemiology : onset at age 5-25, male-to-female ratio = 3:1
Macroscopic anatomy : hemorrhagic soft mass of a few mm consisting of osteoid and blood vessels, usually at the border between cortical and cancellous bone
Symptoms & signs : severe pain due to increased local prostaglandin incretion (expecially during bedtime; differential diagnosis with rheumatoid arthritis and osteomyelitis) exhacerbated by ethanol assumption
Laboratory examinations : osteolysis masked by surrounding reactive osteosclerosis (eburnization) at Rx, CT and MRI. Sometimes the centre of osteolytic area contains calcifications (target look)
Therapy : acetylsalicylic acid to control pain (ex adjuvantibus criterion), surgical radical ostectomy or CT-assisted thermoablation of the nidus
• osteoblastoma / giant osteoid osteoma : a benign, painful, rather vascular tumor of bone characterized by the formation of osteoid tissue and primitive bone, usually in long bones and vertebrae

Epidemiology : onset at age 10-35; male-to-female ratio = 1:1; rarer than osteoid osteoma
Microscopic anatomy : no reactive osteosclerosis => osteoporosis
Symptoms & signs : less painful => larger masses at diagnosis, pathologic fracture
• ossifying fibroma of bone : a benign, relatively slow-growing, central bone tumor, usually of the jaws, especially the mandible, which is composed of fibrous connective tissue within which bone is formed

Therapy : check-up every 1-2 years
• peripheral ossifying fibroma / epulis : a fibroma, usually of the gingiva, showing areas of calcification or ossification
• cemento-ossifying fibroma : ossifying fibroma, particularly when characterized by globular cementoid calcifications.
• arising from fibrous tissue
• desmoplastic fibroma : a rare, benign, fibrous, osteolytic neoplasm usually occurring in the mandible, in long tubular bones, or in the hip bone; it is characterized by abundant collagen formation and an absence of significant cellularity or pleomorphism.
• cementifying fibroma : a tumor usually occurring in the mandible of older persons and consisting of fibroblastic tissue containing masses of cementum-like tissue
• nonossifying or nonosteogenic fibroma / metaphyseal fibrous defect : an osteolytic, proliferative, sometimes painful lesion comprising a focus of fibrous tissue in the metaphyseal region of long bones, particularly of the lower extremities, usually occurring in late childhood or adolescence; it is similar to fibrous cortical defect but is generally larger and actively growing

Therapy : check-up
• chondromyxoid fibroma / chondromyxoma : a very rare, benign, slowly growing tumor of bone of chondroblastic origin, usually affecting the metaphyses of large long bones of the lower extremity; it is characterized by spindle and starred cells, chondroid, myxoid (aqueous) osteoid, and fibrous areas in a lobular pattern (similar to fibrocartilage) and often has a deceptively malignant histologic appearance resembling chondrosarcoma.

Symptoms & signs : pathologic fracture
Therapy : surgical ablation => high incidence of relapses due to lack of well-defined borders
• chondromyoma
• giant cell tumor of bone / osteoclastoma : despite large numbers of osteoclasts, stromal cells are the actually proliferating cell type. It is most commonly located at the distal end of femur.
• benign synovioma / nodular tenosynovitis / giant cell tumor of tendon sheath : a benign tumor-like lesion of tendon sheath origin forming a small, yellow, discrete nodule, most commonly of the wrist and fingers, or ankle and toes; the tissue is laden with lipophages and contains multinucleated giant cells. It is sometimes considered a variant or subtype of benign fibrous histiocytoma
Differential diagnosis : brown tumors in renal osteodystrophy and aneurysmal bone cyst
Prognosis : osteolysis may destroy an epiphysis (local malignity); pulmonary metastases after surgical resection
Therapy : surgical ablation and filling with polymethylacrylate; relapses are treated with large prostheses or amputation
• Herendeen phenomenon : rarely occurring rapid enlargement of a giant cell tumor of bone for several weeks to months after therapeutic irradiation of the lesion.
• angiomas

Laboratory examinations :
• intraosseous or paraosseous aneurysmal bone cysts in vertebral bodies give a palisade look at X-ray
• disappearing bone disease : gradual, but often complete, resorption of a bone or group of bones, which may be associated with multiple hemangiomas; it usually occurs in children or young adults, sometimes following trauma, but its etiology is unknown
Therapy : surgical ablation
• neurilemmoma
• lipoma
• malignant primitive tumors
• chondrosarcoma / sarcoenchondroma : a malignant tumor derived from cartilage cells or their precursors, but lacking direct osteoid formation; it occurs predominantly in the pelvis, femur, and shoulder girdle in middle-aged to older adults. It may be primary, arising from cartilage cells, or secondary to a pre-existing benign lesion.
• central chondrosarcoma : one developing in the interior of a bone; it usually presents with dull pain but a mass is rare.
• peripheral chondrosarcoma : that arising on the surface of a bone; it may be either primary or secondary to underlying neoplasms, which are usually benign cartilage tumors, and generally presents as a large mass.
• clear cell chondrosarcoma : a very rare form characterized by swollen, glycogen-rich clear cells, occurring usually in the femur, tibia, vertebrae, or pubis in adults; it is slow-growing and metastasizes only after multiple local recurrences.
• dedifferentiated chondrosarcoma : a rare, fast-growing, very aggressive form of chondrosarcoma that contains additional malignant mesenchymal elements, such as areas of fibrosarcoma or spindle cells.
• juxtacortical or periosteal chondrosarcoma : that arising in relation to the cortex of the periosteum, occurring on the surface of the bone, particularly the femur or humerus, usually in adults.
• mesenchymal chondrosarcoma : a rare, aggressive, malignant neoplasm composed of a small cell stroma containing islands of cartilaginous elements; it occurs primarily in flat bones, but also in soft tissue, and particularly in adolescents and young adults.
• osteochondrosarcoma : chondrosarcoma occurring in bone; used for those tumors including cartilaginous foci but not neoplastic foci of bone
• myxoid chondrosarcoma / chondromyxosarcoma
• chondrosarcomatosis : the formation of multiple chondrosarcomas
Prognosis : up to 3-4 kg, rare metastases, severe if vertebral localization, 5-6 years of survival after diagnosis
• osteosarcoma / osteogenic sarcoma : a malignant primary neoplasm of bone composed of a malignant connective tissue stroma with evidence of malignant, osteoid, bone, or cartilage formation. Classical osteosarcoma is a poorly differentiated tumor affecting mainly young adults, most often involving the long bones, and is classified as osteoblastic, chondroblastic, or fibroblastic sarcoma according to which histologic component predominates

Epidemiology : second onset peak around age 60
• extraosseous osteosarcoma : a rare neoplasm occurring in the soft tissues of the body, generally in the thighs, composed of sarcomatous tissue that produces malignant osteoid and bone; it is histologically identical to osteosarcoma occurring in bone.
• intraosseous osteosarcoma
• intracortical osteosarcoma : a rare form of osteosarcoma affecting mainly young adults, consisting of an osteolytic lesion confined within the cortex of a bone with a surrounding area of cortical sclerosis.
• parosteal or juxtacortical osteosarcoma / parosteal sarcoma : a variant of osteosarcoma consisting of a slowly growing tumor that arises from the cortex of a bone and grows outward, eventually surrounding the bone; it resembles cancellous bone and is characterized histologically by a fibrous stroma containing bony spicules and trabeculae. It affects adults in the second through fifth decades of life and is less malignant than classical osteosarcoma
• periosteal osteosarcoma : a variant of osteochondroma consisting of a soft, lobulated tumor arising from the periosteum of a long bone (usually the tibial shaft) and growing outward from the bone; histologically it is a chondroblastic osteosarcoma.

Laboratory examination : Codman's triangle : radiologic image described by the American radiologist Codman. A small radiolucent lesion with some evidence of basic spiculation. The cortex is characteristically intact with a "scooped out" appearance
• intraosseous low-grade osteosarcoma : a well-differentiated osteosarcoma of low malignancy arising within a bone, composed of spindle cells arranged in interlacing bundles separated by collagen fibers, with invasion of fatty marrow or extraosseous soft tissue.
• high-grade surface osteosarcoma : a highly malignant osteosarcoma histologically identical to classical osteosarcoma but located on the surface of a bone.
• osteosarcoma of jaw / gnathic osteosarcoma : a variant of osteosarcoma occurring in the mandible or maxilla, having a slightly older age of onset than classical osteosarcoma, with less tendency to metastasize than other osteosarcomas.
• multicentric osteosarcoma : the occurrence of osteosarcomas in more than one bone or in different sites on the same bone; lesions may be synchronous (sensu strictu) or metachronous (sensu latu).
• small-cell osteosarcoma : a variant of osteosarcoma resembling Ewing's sarcoma, composed of small round to spindle-shaped cells arranged in sheets or separated into lobules by fibrous septa, and having areas of osteoid and sometimes chondroid formation; called also polyhistiocytoma and multipotential primary sarcoma of bone.
• telangiectatic osteosarcoma : an aggressive, lytic form occurring as a soft, cystic tumor containing aneurysmally dilated blood-filled spaces lined by pleomorphic cells producing osteoid foci.
Symptoms & signs : Dupuytren's sign : a crackling sensation on pressure over a sarcomatous bone
• osteosarcomatosis / synchronous multicentric osteosarcoma : the simultaneous occurrence of multiple osteosarcomas.
Pathogenesis : TP53 mutations (but not amplification of MDM2 - an upstream inhibitor of p53) increase genomic instability^ref
Symptoms & signs : pulmonary metastases
• fibrosarcoma : a malignant tumor composed of cells and fibers derived from fibroblasts, which produce collagen but otherwise lack cellular differentiation; it is grossly grayish white and firm, invades locally, and metastasizes hematogenously. Several varieties occur:
• aggressive adult form
• rarely metastasizing infantile or congenital form
• inflammatory form
• postirradiation form
Symptoms & signs : pain, pathologic fracture
• Ewing's sarcoma or tumor (ET) : a highly malignant, metastatic, primitive SRBCT of bone, usually occurring in the diaphyses of long bones of limbs, ribs, and flat bones (pelvis) (Ewing J. Diffuse endothelioma of bone. Proc.NY.Pathol.Soc. 21:17-24 (1921))

Epidemiology : first year of age,  adolescence or after age 40
Miscroscopic anatomy : always classed as G4; saucerization of the cortex, patchy, permeative destruction, and often a large soft tissue mass (it is difficult to establish the origin); variable consistence due to regressive phenomena, gray-to-yellow collor (differential diagnosis with pus) or red color (due to hemorrhages). 2 cell types :
• large nucleus, diffuse chromatin, large cytoplasm with poorly defined borders
• small nucleus, dense chromatin, large cytoplasm with well-defined borders
Both cell types have PAS⁺ glycogen granules (seen as large perinuclear inclusions at TEM, which are lost in advanced stages.
Symptoms & signs : pain, swelling, leukocytosis, increased ESR, secondary anemia, local lymphadenopathy, fever (differential diagnosis with osteomyelitis), slimming, .
Prognosis : average life expectancy after diagnosis 6 months (maximum 12 months)
• reticulosarcoma / reticulum cell sarcoma
• malignant synovioma / synoviosarcoma / synovial sarcoma (SS) : a malignant neoplasm ccurring mainly in the synovial membrane of the joints and also in synovial cells of tendons and bursae of the extremities of young adults. Rare occurrence in the esophagus^ref
• poorly differentiated synovial sarcomas (PDSS) : epithelioid, spindle and Ewing sarcoma-like small round cells.
• angiosarcoma
• liposarcoma
Summary of anatomical locations :
• conjugation or epiphyseal cartilage / growth disk or plate : chondroblastoma
• metaphysis :
• osteochondroma
• chondromyxoid fibroma
• giant cell tumor
• osteosarcoma
• chondrosarcoma (few)
• diaphysis-metaphysis junction
• osteoid osteoma
• osteoblastoma
• diaphysis
• chondroma
• Ewing's sarcoma
• chondrosarcoma (most)
• bone metastases (50%, commonest in elderlies)
• osteoblastic metastases
• prostate carcinoma
Pathogenesis : urokinase system, which may have growth factor activity as well as enzymatic activity.
Therapy : ET₁ antagonists
• osteolytic metastases. Local bone destruction also occurs in patients with osteoblastic metastases and may precede or occur simultaneously with increased bone formation.
• follicular thyroid carcinoma
• breast carcinoma
• renal cell carcinoma
• bladder carcinoma
• lung carcinoma
• gastric carcinoid
• rectal carcinoid
• multiple myeloma / plasmacytoma
• melanoma
• contiguity metastases : uterine corpus carcinoma
Pathogenesis : bone provides chemotactic factors, adhesion factors, and growth factors (IGF-1, TGF-b) that allow the carcinoma cells to target and proliferate in the skeleton. The carcinoma cells reciprocate through production of osteoblastic and osteolytic factors (CCL-3 / MIP-1a, IL-6, PTHrp) => up-regulation of RANK-L on osteoclasts) that modulate bone remodeling. The carcinoma-induced osteolysis promotes release of the many growth factors within the bone extracellular matrix thus further enhancing the progression of the metastases. When tumors release abundant PTHrp into the circulation, this may act as an endocrine substance to produce generalized osteopenia and, ultimately, hypercalcemia. Osteomalacia may be a manifestation of tumors either through accelerated bone formation with insufficient mineralization or through the production of a phosphaturic substance.
Localizations : Deutschländer's disease : tumor of the metatarsal bones
Symptoms & signs : pain is due to direct or indirect stimulation, pathologic fractures, increased intramedullary pressure, radicular compression => diminished quality of life of the patient
Laboratory examinations : (eventually MRI for spinal cord metastases =>) bone scintigraphy (high sensitivity, poor specificity) =>
• normal => no further workup
• abnormal => X-rays =>
• normal => MRI / CT =>
• metastasis
• normal => biopsy
• abnormal =>
• metastasis
• benign lesion
Therapy :
• bisphosphonates inhibit both bone lesions and tumor cell burden in bone in experimental models of breast carcinoma metastasis
• palliative radionuclide therapy of painful bone metastases (RTBM)
• neutralizing antibodies or therapeutic vaccines to PTHrp, which inhibit PTHrp effects on osteoclastic bone resorption, also reduce osteolytic bone lesions and tumor burden in bone.
Prognosis : 5-yr OS
• multiple myeloma / plasmacytoma (10%)
• breast carcinoma (20%)
• prostate carcinoma (25%)
• lung carcinoma (5%)
• renal cell carcinoma (10%)
• follicular thyroid carcinoma (40%)
• melanoma (< 5%)
Web resources : Bone Metastasis
Laboratory examinations :
• [LDH]_plasma
• [AlkP]_plasma
• [paraproteins]_plasma
• [Ca]_plasma
• [phosphate]_plasma
• [PTH]_plasma
• [tumor markers]_plasma
• [Hpy]_urine
• ESR
• [CRP]_plasma
• [APP]_plasma
• X-ray
• CT
• MRI
• bone scintigraphy
• angiography
• biopsy (risk of spreading tumor cells)
TNM staging (modified from Enneking staging, 1980, adopted by Musculoskeletal Tumor Society (MSTS) :
• T1 : tumor < 8 cm in greatest dimension
• T2 : tumor > 8 cm in greatest dimension
• T3 : discontinuous tumors in the primary bone site
• M1a : lung
• M1b : other distant sites
AJCC stage grouping :
• stage IA :
• T1, G1, N0, M0
• T1, G2, N0, M0
• stage IB :
• T2, G1, N0, M0
• T2, G2, N0, M0
• stage IIA :
• T1, G3, N0, M0
• T1, G4, N0, M0
• stage IIB :
• T2, G3, N0, M0
• T2, G4, N0, M0
• stage III : T3, any G, N0, M0
• stage IVA : any T, any G, N1, M1a
• stage IVB : any T, any G, any N, M1b
Enneking (MSTS) stage groupings :
• stage IA : T1, G1, M0
• stage IB : T2, G1, M0
• stage IIA : T1, G2, M0
• stage IIB : T2, G2, M0
• stage IIIA : T1, any G, M1
• stage IIIB : T2, any G, M1
Differential diagnosis with osteomyelitis by lack of fever.
• diseases of head
• skull deformities
• congenital malformations of skull
• acrania : a developmental anomaly characterized by partial or complete absence of the skull (calvaria) due to anencephalia
• acraniate monster / acranius : a fetus exhibiting acrania
• cranium bifidum / cranioschisis : incomplete formation of the calvaria, with defective development of the brain and often an encephalocele or meningocele
• cranium bifidum occultum : congenital cleft of the calvaria without associated abnormality of the brain or meninges, detectable only radiographically
• clinocephaly : congenital flatness or concavity of the vertex of the head.
• acrobrachycephaly : a condition resulting from fusion of the coronal suture, causing abnormal shortening of the anteroposterior diameter of the skull.
• iniencephaly : a developmental anomaly characterized by enlargement of the foramen magnum and absence of the laminal and spinous processes of the cervical, dorsal, and sometimes lumbar vertebrae, with vertebrae reduced in number and irregularly fused, the brain and much of the spinal cord occupying a single cavity.
• plagiocephaly : an unsymmetrical and twisted condition of the head, resulting from irregular closure of the cranial sutures.
• strophocephaly : a developmental anomaly characterized by distortion of the head and face.
• perocephalus / strophocephalus : a fetus exhibiting strophocephaly.
• trigonocephaly / trigonocephalia : a deformity of the head characterized by sharp angulation ventrad of the squamous portion of the frontal bones at the site of the suture between them.
• leontiasis ossea / leontiasis ossium / megalocephaly : bilateral and symmetrical hypertrophy of the bones of the face and cranium, giving it a vaguely leonine appearance

Aetiology : hyperparathyroidism secondary to chronic renal failure
• tricephalus : a fetus having 3 heads.
• craniosynostosis / craniostosis : premature closure of the sutures of the skull, causing deformities such as
• oxycephaly / acrocephaly / hypsicephaly / turricephaly / steeple head or skull / tower head or skull : a condition in which the top of the head is pointed or conical owing to premature closure of the coronal and lambdoid sutures

Aetiology : congenital syphilis (Treponema pallidum subsp. pallidum)
• scaphocephaly / sagittal synostosis : a condition in which the skull is abnormally long and narrow, as a result of premature closure of the sagittal suture, with heavy centers of ossification in the line of the suture; usually accompanied by inflammation and atrophy of the optic papillae and by mental retardation
• craniostenosis : deformity of the skull caused by craniosynostosis, with consequent cessation of skull growth; the nature of the deformity depends on the sutures involved in the process
• kleeblattschädel syndrome : a congenital disorder, characterized by synostosis of multiple or all cranial sutures, hydrocephalus, and in some cases facial dysostosis and long bone anomalies.
• anteroposterior facial dysplasia : defective development resulting in abnormal anteroposterior relationship of the maxilla and mandible to each other or to the cranial base with secondary malocclusion
• craniodiaphyseal dysplasia : an autosomal recessive condition in which progressive cranial and facial hyperostosis results in significant distortion of the shape of the head
• craniometaphyseal dysplasia : metaphyseal dysplasia associated with overgrowth of the head bones, leontiasis ossea, and hypertelorism.
• ophthalmomandibulomelic (OMM) dysplasia or syndrome : an autosomal dominant syndrome consisting of blindness caused by corneal opacities, temporomandibular fusion, absent coronoid process, obtuse mandibular angle, radiohumeral and radioulnar dislocations, and aplasia of the lateral condyle of the humerus, radial head, and distal ulna
• craniofenestria : defective development of the calvaria of the fetal skull, with areas in which no bone is formed
• craniolacunia / lückenschädel : defective development of the calvaria of the fetal skull with depressed areas on the inner surfaces
• tribasilar synostosis : fusion in infancy of the three bones at the base of the skull, producing mental retardation.
The murine frontal bone derives entirely from the cranial neural crest (CNC) and consists of the calvarial (lateral) aspect that covers the frontal lobe of brain and the orbital aspect that forms the roof of bony orbit. TGFß and FGF signaling have important regulatory roles in postnatal calvarial development. Conditional inactivation of Tgfbr2 in the neural crest results in severe defects in calvarial development, although the cellular and molecular mechanisms by which TGFß signaling regulates the fate of CNC cells during frontal bone development remain unknown. TGFß IIR is required for proliferation of osteoprogenitor cells in the CNC-derived frontal bone anlagen. FGF acts downstream of TGFß signaling in regulating CNC cell proliferation, and exogenous FGF2 rescues the cell proliferation defect in the frontal primordium of Tgfbr2 mutant. Furthermore, the CNC-derived frontal primordium requires TGFß IIR to undergo terminal differentiation. However, this requirement is restricted to the developing calvarial aspect of the frontal bone, whereas the orbital aspect forms despite the ablation of Tgfbr2 gene, implying a differential requirement for TGFß signaling during the development of various regions of the frontal bone. TGFß-mediated FGF signaling cascade has biological significance in regulating frontal bone development, and TGFß functions as a morphogen in regulating the fate of the CNC-derived osteoblast and provides a model for investigating abnormal craniofacial development^ref
• macrognathia : a condition characterized by abnormally large jaws
• maxillary protrusion :
• bimaxillary protrusion : the projection of both the maxilla and the mandible beyond normal limits in relation to the cranial base
• bimaxillary dentoalveolar protrusion : the positioning of the entire dentition forward with respect to the facial profile
• prognathism / caput progeneum / exognathia / progenia/ prognathia : a condition marked by abnormal protrusion of the mandible
• underhung bite : a characteristic of mandibular prognathism in which the incisal edges of the mandibular anterior teeth extend labially to the incisal edges of the maxillary anterior teeth when the jaws are in habitual occlusion
Aetiology : acromegalic disease
Laboratory examinations : prognathometer
• micrognathia / bird-beak jaw / parrot jaw / micromandible / brachygnathia : abnormal smallness of the mandible

Aetiology :
• mandibulofacial dysostosis
• postaxial acrofacial dysostosis / Miller syndrome
• polyarticular Still disease
• retrognathia / retrognathism : retrusion of the mandible

Symptoms & signs : obstructive sleep apnea syndrome (OSAS)
• craniomalacia : abnormal softness of the skull.
• craniotabes : reduction in the mineralization of the skull, with abnormal softness of the bone, usually located in the occipital and parietal bones along the lambdoidal sutures.
• craniosclerosis : thickening of the bones of the skull.
• caput quadratum : a head deformity seen in rickets in which the eminences of the frontal and parietal bones form elevations (Olympic forehead) separated by depressions marking the lines of the cranial sutures
• osteoporosis circumscripta cranii / Schüller's disease : demineralization of the bones of the skull, characteristic of the destructive or osteolytic phase of Paget's disease
• hyperostosis cranii (HC) : hyperostosis involving the cranial bones

Classification of Moore :
• hyperostosis frontalis interna (HFI) / Morgagni-Stewart-Morel syndrome / endocraniosis (Morgagni's term in 1770) : bilateral thickening of the inner table of the frontal bone

Epidemiology : it most commonly affects women near menopause. While its magnitude of manifestation and frequency are much higher in females, HFI is not a purely female phenomenon. Males with hormonal disturbances such as atrophic testis were found to manifest HFI type D. HFI is associated with age insofar as it is much less frequent in females under 40 years of age. Prevalence = 0.8% of autopsies, mean age was 60 years. Although advanced cases of HFI (types C and D) have been observed in individuals as young as 40 years of age, it is more frequently found after age 60. The frequency of HFI type D will not increase from age 60. Type-predicted analysis by cohort reveals significant ethnic differences. Changes in African American (AA) females appear earlier in life and progress more rapidly than in European American (EA) females. Analysis of radiographs shows a discrepancy between the anatomic prevalence of HFI and its radiological recognition, which is very poor for mild cases. This apparently resulted in the misconceptions that HFI is entirely an old-age phenomenon, and that it is exclusively female. Surprisingly, this condition had a higher male prevalence in its rare archaeological records. This is again highlighted by the oldest known male European hyperostosis frontalis interna case in an adult Celtic from 100 BC, supporting earlier suggestions of the possible microevolution of human endocrine regulation, e.g. by sex steroids, and its pathoanatomical impact^ref.
Aetiology : prolonged estrogen stimulation or hypoandrogenism. Histological analysis shows that the inner table along with the closely attached dural layer play a major role in the osteogenesis of HFI. Contrary to previous models, no evidence for diploe or ectocranial plate involvement was found. Cadaver study suggests that the predilection for the frontal area may be related to an altered blood supply and/or vascular stretching^ref.
Symptoms & signs : several associations of symptoms (hypertrichosis, headache^{ref1, ref2, ref3, ref4}, obesity, transient monoparesis, abnormal vestibular function, neuropsychiatric symptoms and recurrent disc prolapse with absent right radial pulse ^ref), whose incidence varies according to the population studied, have been described. Age and gender appear to be linked with the preponderance of this condition, as does the presence of behavioral disturbances
Differential diagnosis : HFI should be recognized as a benign entity and distinguished from other disorders that involve the frontal skull bone, such as Paget's disease, acromegaly, and malignancy.
HFI is an independent condition, not a symptom of a more generalized syndrome as suggested in the past. It can appear in a variety of forms but each is the result of the same process and probably of the same etiology. Investigators' previous failure to recognize the mild stages of HFI (types A and B) as an early form of the general HFI process led to erroneous statistics and interpretations of observations. HFI should also be considered a phenomenon separate from HCI, HCD, and other endostoses, even when it appears in association with them. To avoid ambiguity and facilitate the description of cranial hyperostoses, uniform nomenclature (HFI, HCD) has been recommended. HFI is rarely seen in historic populations, regardless of geographical origin.
Therapy : surgical removal of hypertrophic frontal bone followed by dura and bone reconstruction^ref
• hemicraniosis : a condition marked by hyperostosis on one half of the cranium or face, with cerebral involvement. The condition is believed to be due to endothelioma of the dura
• hyperostosis frontoparietalis
• cranial vault hyperostosis
• hyperostosis cranialis diffusa (HCD)
• oral bone cysts : an abnormal closed cavity in the bone, lined by epithelium containing a liquid or semisolid homogeneous material with net borders, diameter > 1 mm and surrounding bone densities (differential diagnosis from periapical granuloma)
• true cysts : any cyst that is not a normal structure and is not formed by the dilatation of a passage or cavity. They have progressive course and secrete their content.

Aetiology : supplemental gemmation
Pathogenesis : protein secretion induce osmotic water inflow
• dysembryogenetic cysts
• odontogenic cysts : one derived from epithelium, usually containing fluid or semisolid material, which develops during various stages of odontogenesis. Nearly all odontogenic cysts are enclosed within bone
• Gorlin's calcifying odontogenic cyst : a slow-growing benign neoplasm either in the mandible or in the gingiva, varying from solid to soft and cystlike; the center contains a layer resembling stellate reticulum, with ghost cells, some of which have dystrophic calcification
• dentigerous, follicular or pericoronal cyst / germinal follicle : a fluid-containing odontogenic cyst surrounding the crown of an unerupted tooth, usually involving the crowns of normal permanent teeth and arising from enamel organ. It is caused by inflammation and traumas, is not keratinized, and can degenerate into ameloblastoma.
• eruption cyst : a dentigerous cyst presenting as a dilatation of the follicular space about the crown of the erupting deciduous or permanent teeth in children, caused by the accumulation of tissue fluid or blood. Male-to-female ratio 2:1. Eruption hematomas can be differentiated from hemangiomas as they are not ischemizable with pressure.
• gingival cyst : an odontogenic cyst of the soft tissue of either the free or attached gingiva, presenting as a small, well-circumscribed, painless swelling, sometimes resembling a superficial mucocele
• childhood gingival cyst : self-limiting whitish nodules (2-3 mm) arising from rests of dental lamina
• Epstein's pearls : small whitish-yellow cysts (milia / whiteheads / closed comedones) on each side of the raphe of the hard palate of the newborn (they should be classified as fissural cysts)
• Bohn's nodules or pearls : inclusion cysts along the buccal and lingual aspects of the dental ridges and on the palate away from the raphe, found in newborn infants; considered to be remnants of mucous-gland tissue trapped during fetal development
• dentary lamina cysts in maxillary or mandibular alveolar crest
• adulthood gingival cyst : between lateral incisor and canine; none at X-ray; maxillary-to-mandibular ratio 2:1
• primordial cyst / keratocyst : a relatively uncommon type of odontogenic multilocular cyst that develops through cystic degeneration and liquefaction of the stellate reticulum in an enamel organ before any calcified enamel or dentin has been formed. Such cysts originate from supernumerary teeth, and are found in place of a tooth rather than being associated with one. Often associated with multiple nevi syndrome. Lack of sediments allows differential diagnosis with multicystic ameloblastoma. Pindborg classification : parakeratosis (83% : increased tendence to relapses), orthokeratosis (10%) or mixed cyst (7%).

Therapy : cystectomy
• inflammatory cysts :
• periodontal cyst : one in the periodontal ligament and adjacent structures
• radicular or periapical cyst : a periodontal cyst involving the apex of an erupted tooth, frequently a result of pulpitis
• apical cyst (55-65%) : an epithelium-lined cyst in the bone at the apex of a pulpless tooth following periodontitis of maxillary tooth

Pathogenesis : latency => deformation and a crackling sensation on pressure over sarcomatous bone (Dupuytren's sign) => fluctuation; impaired development and eruption of surrounding teeth
Therapy :
• in a deciduous tooth : extraction
• in a permanent tooth : endodonthic therapy or extraction
• lateral periodontal cyst : a cyst of the lateral periodontal membrane of an erupted tooth, usually occurring in the bicuspid region of the mandible
• residual cyst : a periodontal cyst that remains after or develops subsequent to tooth extraction
• nonodontogenic, inclusion or fissural cysts : one formed by the inclusion of a small portion of epithelium or mesothelium within connective tissue along a line of fusion of embryonic processes in splanchnocranium
• median anterior maxillary cyst / incisive canal cyst / nasopalatine duct cyst : an inclusion cyst of the maxilla which arises from proliferation of epithelial remnants of the nasopalatine duct
• incisive canal
• palatine papilla
• globulomaxillary cyst : an inclusion cyst of the maxillary bone, located in the globulomaxillary fissure, usually between the lateral incisor and cuspid teeth, which seldom presents any clinical manifestation
• median mandibular cyst : a rare inclusion cyst occurring in the midline of the mandible, believed to be caused by inclusion of the epithelium trapped in the central groove of the mandibular process, or by cystic degeneration of a supernumerary tooth germ.
• median palatal cyst : an inclusion cyst located in the midline of the hard palate between the lateral palatal processes
• nasoalveolar or nasolabial cyst : an inclusion cyst arising from epithelial remnants at the junction of the globular, lateral nasal, and maxillary processes, which clinically may cause a swelling in the mucolabial fold and in the floor of the nose and superficial erosion of the outer surface of the maxilla
• pseudocysts / adventitious or false cysts
• unicameral, simple or traumatic bone cyst / hemorrhagic or extravasation cyst
• aneurysmal bone cyst
• retention or secretory cysts : one caused by blockage of the excretory duct of a gland, so that glandular secretions are retained
• mucocele / mucus retention cyst : a mucus-containing retention cyst caused by blockage of a salivary gland duct, visible as a small nodule on the oral mucosa
• extravasation mucocele : mucus extravasation phenomenon is extravasation of mucus into the surrounding connective tissue from a damaged minor salivary gland excretory duct, followed by an inflammatory reaction leading to the formation of a pool of macrophages and mucin surrounded by a wall of granulation tissue; visible as a small nodule or vesicle on the oral mucosa.
• retention mucocele : from subocclusion of a lingual gland excretory duct
• ranula / sublingual cyst or ptyalocele : a form of retention cyst of the floor of the mouth, usually due to obstruction of the ducts of the submaxillary or sublingual glands, presenting a slowly enlarging painless deep burrowing mucocele of one side of the mouth
• plunging ranula : a rare type of ranula that has become invasive and penetrates into the mylohyoid muscle, the submental region, or the submandibular region
• mucous cyst : a retention cyst that contains mucus.
• oroantral communications : a communication connecting the oral cavity and the maxillary antrum due to lack of substance within the hard palate (expecially in elderies when the hard palate is thinned)

Epidemiology : males > females, onset at age 40-50
Aetiology :
• maxillary tooth extraction or avulsion (alveolar curettage, pulling of root into the sinus); more common in first molar > second molar > second premolar > first premolar > canine > third molar; more common in devitalized teeth than in vital teeth
• partial or total maxillectomy to treat carcinomas, sarcomas, epitheliomas, odontomas, ameloblastomas, or oral bone cysts
• traumas
• ballistic wounds
• car accidents
• sport traumas
• implantology
Pathogenesis : oroantral communication =oral epithelium invades the communication=> oroantral fistula (epithelial lining of both surfaces prevents closure) => marsupialization (replacement of respiratory epithelium with oral epithelium)
Grading :
• small fistula and with no chronic sinusitis
• intermediate fistula with penetration of foreign bodies in the sinus (root remnants, prostheses) => foreign body granulomas
• large fistula
Localization :
• vestibular communication / fistula
• alveolar communication / fistula
• minor
• major
• palatal communication / fistula
Symptoms & signs :
• rhinolalia
• Valsalva maneuver : with closed nose, air flows out of dental alveolum during expiration
• Glatzel test : place a glass near the extracted tooth
• in acute phase blood from maxillary sinus marks the glass during Valsalva maneuver
• in chronic phase warmed air from maxillary sinus opacizes a cooled glass during Valsalva maneuver
• sensation of water within nose after drinking : during swallowing tongue pull against palate
Laboratory examinations :
• X-ray
• antroscopy
• sinusal probe
Therapy :
• recovery of fragments within sinus
• conservative recovery
• aspiration
• curettage
• enter gauze into maxillary sinus from oral cavity and
• practice Valsalva maneuver before removing the gauze
• recall the gauze from meatus medium within the nose
• surgical recovery
• sinusitis => conservative therapy => antiinflammatory drugs
• induction of spontaneous closure of small fistulae : don't tampon the alveolus with cotton but use only fibrin bands to allow better coagulation
• plastic surgery in local anaesthesia
• closure of fistula with
• autologous mucous or mucoperiosteal layers from cheeks or palate
• bony closure after oral opening of maxillary sinus (Caldwell-Luc operation)
• insertion of artificial occlusors
• alveolectomy and suture of mucosa (eventually after incisions of surrounding mucosa to distend it)
• protect the closure with a resin cast for 15-20 days
Relapses are common due to misuse of cast and overpressure of tongue over communication.
Prognosis relates to diameter of fistula, duration of communication, and condition of antral mucosa
• temporomandibular dysfunction syndrome / Costen's syndrome : a complex of symptoms including partial deafness, stuffiness in the ears, tinnitus, clicking or snapping of the temporomandibular joint, dizziness, headache, and burning pain in the ear, throat, tongue, and nose. Some researchers question the anatomical and physiological justification for considering this a separate diagnostic entity

Epidemiology : adult females
Aetiology :
• odontopathies
• malocclusion (expecially iatrogenic; in babies it leads to deformity but not to TMJ dysfunction)
• edentulous
• temporomandibular joint (TMJ) arthropathies
• TMJ arthrosis

Symptoms & signs : burst sound
• TMJ articular disk displacement (the posterior region is the most vascularized and innervated one)
• anterior displacement during mandibular opening => opening block
• posterior displacement during mandibular opening => closure block
Symptoms & signs : snap sound during mandibular opening and closure
Therapy : deblocking maneuver
• myopathies
• jaw claudication : a complex of symptoms like those of intermittent claudication but seen in the muscles of mastication, occurring in giant cell arteritis (GCA).
• trismus / lockjaw : motor disturbance of the trigeminal nerve, especially spasm of the masticatory muscles, with difficulty in opening the mouth

Aetiology :
• Clostridium tetani
• strychnine poisoning
• muscular infiltration
• nasopharyngeal carcinoma
• clenching : the clamping and pressing of the jaws and teeth together in centric occlusion

Aetiology :
• mental effort
• physical effort (jumping, pushing or lifting a heavy object, performing a difficult task...)
• bruxism : involuntary, nonfunctional, rhythmic or spasmodic gnashing, grinding, and clenching of teeth (not including chewing movements of the mandible), usually during sleep, sometimes leading to occlusal trauma.
• centric bruxism / clamping habit / clenching habit : bruxism characterized by clenching in centric occlusion
• bruxomania : bruxism occurring in the daytime, usually performed unconsciously.
Aetiology :
• repressed aggression
• emotional tension
• anger
• fear
• frustration
• PCP
Symptoms & signs : limited mandibular excursions, spontaneous pain or pain evoked by palpation of elevator muscles (masseter and temporal muscles) and external auditory meatus, tinnitus, hearing loss, vertigo, headache, dental synalgias, ..
Laboratory examinations : X-ray to compares the 2 halves
Therapy : bite, relaxing gym for chewing muscles, psychoactive drugs
• jaw melanotic neuroectodermal tumor of infancy (MNTI)
• cranial fractures
• fracture by contrecoup : a fracture of the skull opposite to the site of impact.
• depressed fracture / depressed skull fracture : a fracture of the skull in which a fragment is depressed
• gutter fracture : a fracture of the skull in which the depression is long elliptic in form; often caused by a missile passing along the outside or grooving the inside of the skull
• ping-pong fracture / pond fracture : a type of depressed skull fracture usually seen in young children, resembling the indentation that can be produced with the finger in a ping-pong ball; when elevated it resumes and retains its normal position
• Battle's sign : discoloration over the skin of the mastoid region of the skull, in the line of the posterior auricular artery, the ecchymosis first appearing near the tip of the mastoid process; seen in fracture of the base of the skull.
• orbital fractures
• blow-out fracture : fracture of the orbital floor caused by a sudden increase of intraorbital pressure due to traumatic force; the orbital contents herniate into the maxillary sinus so that the inferior rectus or inferior oblique muscle may become incarcerated in the fracture site, producing diplopia on looking up; this may occur solely because of periorbital oedema and haemorrhage, possibly exerting pressure on the globe and resolving in several days (while entrapment diplopia remains). There are some other possible causes for eye motility disturbances after an orbital blow-out fracture, for example post-traumatic oculomotor nerve palsy, gross enophthalmos with posterior and inferior displacement of the eyeball, incarceration of orbital fat itself and scar formation. Sometimes only indirect signs of a blow-out fracture are present on conventional X-rays, consisting of soft tissue swelling over the inferior orbital rim and antral opacification. The presence of an opacified maxillary sinus can be misleading, as it can be due to inflammatory disease or haemosinus caused by a mucosal tear. Coronal CT clearly shows the actual fracture and the herniation of the orbital contents.
• impure type involves the rim, i.e., there is concomitant midfacial fracture.
• pure ethmoidal blow-out fractures : there is disruption of the orbital floor without involvement of the orbital rim. They are more rarely seen; entrapment of the medial rectus muscle is rare. Medial wall fracture can be inferred by the presence of orbital emphysema, developing after trauma when the patient blows his nose
• maxillofacial fractures
Aetiology :
• traumatic fracture
• car accidents (70%)
• work accidents
• sport accidents
• firearms
• pathologic fracture
• maxillary fractures
• partial fractures
• alveolar border
• maxillary tuberosity
• palatine arch
• apophysis
• anterior wall of maxillary sinus
• nasal fractures

Types :
• simple fracture of the nasal bones, most often just the tip
• lateral displacement of the nasal bones, often as a green stick fracture on one side and impaction on the other
• marked flattening of the nasal bridge with comminution of the bones or an accordian fracture displacement of the septum
Signs : comparison of the patient to his or her ID card or recent photo
Laboratory examinations : lateral X-ray of the nasal bone
Therapy :
• fracture reduction
• stable lateral displaced fractures can often be reduced without anesthesia by simple, quick, firm, thumb pressure on the convex side of the nose.
• when soft tissue swelling is marked, distorting the true alignment of the nasal bones, one may elect to wait 4-5 days for the swelling to recede before reduction. A compound fracture should be reduced within a few hours and then have a plastic-type laceration closure since reduction maneuvers usually tear out delicate sutures. Antibiotic coverage is recommended to prevent complications.
• anesthesia technique for reduction of nasal fractures.
• shrink the nasal mucosa with 1% Neo-Synephrine.
• use fresh cocaine from 1-5%, most common is 4% or plain 2-4% Xylocaine.
• moisten long, thin, cotton pledgets with cocaine, squeeze out the excess, and insert them into the superior and middle aspects of the nasal passages. They should touch the septum and turbinate mucosa beneath the nasal bones where reduction instruments are inserted. The sphenopalatine and long nasopalatine nerves may be blocked by applying anesthetic on a long applicator to the area of the sphenoid rostrum. The area can be reached by inserting the applicator back past the posterior tip of the middle turbinate. The ethmoid nerves may be blocked by applying anesthetic on an applicator inserted superiorly just exterior to the middle turbinate tip.
• local anesthesia, using 2% Xylocaine with epinephrine (dental syringe carpule), is obtained by inserting a long dental needle into the nasal vestibule just above the upper lateral cartilage at the limen nasi. Slide the needle is slid beneath the skin in the subcutaneous tissue but external to the nasal bones to the desired locations.
• infiltration sites are the glabella for the superior trochlear nerve, the inner canthus region for the ethmoid and the infratrochlear nerves. A more lateral reinsertion of the needle to the infraorbital notch will block the infraorbital nerve. Following an initial wheal, the needle is slowly withdrawn while injecting a tract of anesthesia. Repeat on each side.
• local anesthesia of the superior septum is obtained by injection of the septum just beneath the tip of the nasal bones and obtaining a "run" of the anesthesia beneath the mucoperichondrium. For the entire septum several anterior injections are required with the bevel toward the cartilage
• equipment for nasal fracture reduction
• elevator : most often used is the Sayer elevator. Others are flat scalpel handles or the Salinger reduction instrument
• Bayonet forceps
• Gelfoam pledgets
• half-inch vaseline-impregnated gauze, minimum of 2 tubes
• antibiotic ointment
• rubber finger cot
• quarter-inch regular or plastic tape
• malleable metal nasal splint
• nasal fracture reduction techniques
• septal fractures only
• grasp the septum between 2 fingers, pull forward up, and side to side, using a thumb or finger of the opposite hand to unbuckle a concavity.
• the nose is then packed (beware of toxic shock syndrome) on both sides to maintain a good alignment alone or against a stint.
• stints of dental wax or Teflon sheets can be used and held in position with through and through septal sutures.
• depressed nasal tip
• place a finger cot over the elevator and insert it in either nostril to just beneath the fracture. Using the fingers of the opposite hand to move and guide the fragment, lift the fragment with the elevator and slowly withdraw.
• place compressed Gelfoam beneath the fracture site on both sides. Selvage gauze anterior packing, external taping, and a metal splint offer the best results.
• lateral displaced or comminuted fracture.
• measure the distance externally from the nostril to the glabella on the elevator. Insert the elevator the measured length into the most open side of the nose.
• with a steady lift of the elevator, move the fracture further to the deviated side. Then move the nasal bones across the midline an equal distance to the opposite side; return the fragments to the midline. Some bleeding is expected, but in the majority of cases, Gelfoam is all that is required for control, and it helps prevent adhesions that may occur superiorly. External taping and metal protection aid in maintaining alignment.
• taping and splinting techniques
• apply benzoin solution to the forehead, nose, and cheek areas.
• if the nose is packed, the initial tape should run from one side to the other parallel with the dorsum across the packed nares. Do not pull tight, and allow for tissue swelling by cutting or pinching the tape at the tip.
• fixation of the nose is provided by an initial tape across the dorsum from cheek to cheek, then a crisscross taping from the forehead to the cheek on both sides. This may be weaved in with the dorsal tapes. If the nose is packed, be sure all of the tip is covered with tape to prevent swelling.
• a malleable aluminum splint is placed over the nasal taping and held in place by similar crisscross taping.
• for drainage, a folded 2 by 2-inch pad taped across the lower lip allows the patient to breathe and eat without interference.
• rhinoplasty
Errors in nasal fracture treatment :
• the doctor attempts to set a nose that was also fractured years previously, but the patient becomes aware of the old deformity only when the new trauma calls attention to it. (Check the patients ID card).
• X-rays reveal no fracture when one is present
• the doctor regards easy to reduce fractures too seriously, and severe fractures too lightly, leading to unnecessary anesthesia or poor reduction because of limited anesthesia.
• the doctor waits longer than 5-6 days to reduce; thereafter, reduction may be difficult.
• in addition, attempting to reduce a fracture in a grossly swollen nose may lead to insufficient reduction or poor alignment.
Laboratory examinations : anterior rhinoscopy in the 3 Grunwald-Lermoyex positions with
• frontal mirror
• Clar mirror
• photophore
• total fractures
• horizontal fractures
• Le Fort's fracture : bilateral horizontal fracture of the maxilla
• Le Fort I fracture / Guérin's fracture / horizontal maxillary fracture : a horizontal segmented fracture of the alveolar process of the maxilla, in which the teeth are usually contained in the detached portion of the bone (as a denture)
• Le Fort II fracture / pyramidal fracture (of maxilla) : unilateral or bilateral fracture of the maxilla, in which the body of the maxilla is separated from the facial skeleton and the separated portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the midline of the hard palate, through the floor of the orbit, and into the nasal cavity
• Le Fort III fracture / craniofacial disjunction / transverse facial fracture : a fracture in which the entire maxilla and one or more facial bones are completely separated from the craniofacial skeleton; such fractures are almost always accompanied by multiple fractures of the facial bones, and involves frontonasal suture, lacrimal bones, medial orbit wall, inferior orbitary fissure and frontozygomatic suture
• vertical fractures
• intermaxillary sagittal fracture
• double sagittal fracture
• other fractrures
• single fracture of zygomatic bone and/or zygomatic arc
• incisive bone
Symptoms : malocclusion or restriction of mandibular movement, flattening of the side of the face, a "black eye" which included ecchymosis and subconjunctival hemorrhage, anesthesia over the face supplied by the infraorbital nerve, or the more serious sign of diplopia.
Laboratory examinations : Waters, Caldwell, lateral, and submental vertex X-rays
Therapy : zygomatic arch fractures can be elevated under local anesthesia through a temporalis fascia approach or a buccal mucosa approach. All other fractures require more extensive open reduction, often with wire fixation or prosthetic support and protection requiring the assistance and training of an oral surgeon, otolaryngologist, or in the case of a true blow-out fracture, an ophthalmologist.
• mandibular fractures
• partial fractures
• fracture of alveolar border
• fracture of lower border
• fracture of mandibular angle
• total fractures
• midline fracture
• paramedian region fracture
• canine region fracture
• premolar region fracture

Prognosis :
• favorable fracture : from up to bottom coming from back to front => compound fracture
• unfavorable fracture : from bottom to up coming from back to front => dyslocation
• mandibular angle fracture

Aetiology : ameloblastoma
• coronoideal process fracture (due to contracture of temporal muscle insertion)
• condylar fracture (also indirect fracture from contralateral trauma; the condyle is a fragile region to prevent endocranial dyscharge)
Complications :
• ecchymoses
• teeth mobility
• malocclusion
• hemorrhages (lower alveolar vein and artery)
• paraesthesias and anaesthesias (lower alveolar nerve)
• otorrhage
• bilateral parasymphyseal fracture may lead to death by suffucation
Therapy : Borton's bandage
Objective examination : exclude orbitary fractures with palpation of ciliary arch (crepitation, pain, border irregularities if uncompound)
Therapy : maxillofacial surgery is delayed during emergencies to allow eventual vomiting and general anaesthesia via respiratory route
• invasive : osteosynthesis (metallic threads, plaque and screws, Kirschner wires)
• noninvasive : intermaxillary blockade (elastic closures => metallic grid for 15-30 days)
Endpoints :
• teeth protection
• occlusion
• aesthetic look
Contraindicated if : severe displacement, edentulous patient, alcoholism, cardiopathy, asthma, epilepsy
Recovery steps : hematoma (24-72 hrs) => fibrous repair (3 weeks) => bony repair
• vertebral column diseases / spondylopathy / rachiopathy : any disorder of the vertebrae
• vertebral column deformities
• congenital vertebral column malformations (Mac Ewen classification)
• rachischisis / schistorachis / spondyloschisis : congenital fissure of the vertebral column

Grading :
• rachischisis partialis / merorachischisis / mesorachischisis : fissure of a part of the vertebral column
• hemirachischisis : rachischisis without prolapse of the spinal cord.
• rachischisis totalis / holorachischisis : fissure of the entire vertebral column
Localization :
• rachischisis anterior
• spina bifida / rachischisis posterior : a congenital cleft of the spinal column with hernial protrusion of the meninges and sometimes the spinal cord
• zona dermatica : an elevation of thick skin around the protruding mass in spina bifida
• zona epithelioserosa : an area of membranous tissue inside the zona dermatica.
Pathogenesis : => myelomeningocoele, menigocoele or myelocystomeningocoele
Symptoms & signs : lumbosciatalgia, lumbar hypertrichosis over median line
Web resources :
• Spina bifida
• Spina bifida at CDC
Pathogenesis : area medullovasculosa (a median elongated area of vascular granulation-like tissue)
• diastematomyelia
• hemivertebra : a developmental anomaly characterized by incomplete development of one half of a vertebra
• vertebral synostosis : fusion of 2 or more contiguous vertebral bodies
• Klippel-Feil syndrome / congenital cervical synostosis / congenital brevicollis : condition characterized by shortness of the neck resulting from reduction in the number of cervical vertebrae or the fusion of multiple hemivertebrae into one osseous mass (synostosis); the hairline is low and motion of the neck is limited
• sacralization : anomalous fusion of L5 vertebra to S1 segment, so that the sacrum consists of 6 segments.
• hemisacralization : fusion of the L5 vertebra to S1 segment on only one side.
• Bertolotti's syndrome : sacralization of L5 (fusion of L5 vertebra and S1 segment) together with sciatica and scoliosis
• prespondylolisthesis : a congenital defect in the L5 vertebra consisting of a bilateral defect in the neural arches at the pedicles.
• (congenital) spondylolysis : dissolution of a vertebra; a condition marked by ...
• platyspondylia
• aplasia of the vertebral arch
• separation of the pars interarticularis
=> fracture at vertebral isthmus => "decapitated dog"-shaped vertebrae at Rx) => congenital or dysplastic spondylolisthesis (a defect in a vertebra between the pedicle and the lamina with forward displacement of the L5 on S1, common in babies practicing artistic gym), graded as
• I : displaced for 1/3 of S1 length
• II : displaced for 2/3 of S1 length
• III : completely displaced respect to S1
• IV : L5 spondyloptosis
• retrospondylolisthesis / retrolisthesis : posterior displacement of one vertebral body on the subjacent body
Symptoms & signs : pain over back, jutting out back, Ullmann's line (in cases of spondylolisthesis, a line extended upward at a right angle from the anterior edge of the first sacral vertebra to the superior surface of the sacrum will pass through the last lumbar vertebra)
Therapy : anterior and circumferential arthrodesis
• formation defects
• partial, unilateral formation => wedge-shaped vertebrae
• complete, unilateral => hemispondylia congenita
• segmentation defects
• unilateral => congenital bar
• bilateral => vertebral block
• mixed vertebral anomalies
• multiple anomalies
• costal fusion
• oculoauriculovertebral (OAV) dysplasia / Goldenhar's syndrome / mandibulofacial dysostosis with epibulbar dermoids : a congenital condition in which colobomas of the upper eyelid, epibulbar dermoids, bilateral accessory auricular appendages anterior to the ears, and vertebral anomalies are frequently associated with characteristic facies, consisting of asymmetry of the skull, prominent frontal bossing, low hairline, mandibular hypoplasia, low-set ears, and sometimes hemifacial microstomia
• spondyloepiphyseal dysplasia : hereditary dysplasia of the vertebrae and extremities resulting in dwarfism of the short-trunk type, often with shortened limbs due to epiphyseal abnormalities. In the delayed onset form, the principal feature is precocious osteoarthritis. There are several forms, including autosomal dominant, autosomal recessive, and X-linked forms, the dominant form often being associated with such ocular anomalies as myopia and detached retina.
• platyspondylia / platyspondylisis : congenital flattening of the vertebral bodies
• acquired deformities
• atlantoaxial subluxation : a complication of rheumatoid arthritis of the cervical spine; degeneration of the atlas (C1) and axis (C2) cause malalignment and cervical myelopathy.
• Grisel's syndrome : subluxation of the atlantoaxial joint after an upper respiratory tract infection or an adenoidectomy, usually seen in children.
• Bell-Dally dislocation : nontraumatic dislocation of the atlas
• tracheloschisis : congenital fissure of the neck
• scoliosis : an appreciable lateral deviation in the normally straight vertical line of the spine on a frontal plane

Aetiology :
• congenital
• congenital vertebral column malformations
• congenital hypotonia
• spinal muscular atrophy (SMA)
• Friedreich ataxia
• Marfan syndrome
• neurofibromatosis
• Ehlers-Danlos syndrome (EDS) / cutis hyperelastica
• osteogenesis imperfecta congenita (OIC)
• Down syndrome
• osseous dysplasia
• dwarfism
• tear of sternocleidomastoid muscle

Therapy : surgical correction at age 2
Therapy : Lorenz bed
• acquired
• idiopathic (85%)
• habit scoliosis : scoliosis due to improper posture
• static scoliosis : that which is due to difference in the length of the legs
• myopathic scoliosis
• paralytic scoliosis
• cerebral palsy
• muscular dystrophies
• polyomyelitis
• rheumatic scoliosis : that which is due to rheumatism of the dorsal muscles.
• sciatic scoliosis / Brissaud's scoliosis : a list of the lumbar part of the spine away from the affected side in sciatica
• osteopathic scoliosis : that which is caused by disease of the vertebrae
• inflammatory scoliosis : that which is due to vertebral disease
• osteochondrosis
• rickets (rachitic scoliosis)
• nephropathies
• thoracogenic scoliosis
• ocular scoliosis / ophthalmic scoliosis : scoliosis attributed to tilting of the head on account of astigmatism or muscle imbalance
• cicatricial scoliosis : that which is due to a cicatricial contraction following caries or necrosis
• coxitic scoliosis : scoliosis in the lumbar region caused by hip disease
• empyematic scoliosis : that which is caused by empyema
Epidemiology : female:male ratio 8:1
Symptoms & signs :
• primary curve (larger and less reducible angle)
• scolioses with single primary curve (70%)
• cervical scoliosis / torticollis / trachelocyllosis /scoliosis capitis / wryneck : a contracted state of the cervical muscles, producing twisting of the neck and an unnatural position of the head
• osseous torticollis
• atlas occipitalization
• hemispondylia
• Klippel-Feil syndrome / congenital cervical synostosis / congenital brevicollis
• Sprengel's deformity
Symptoms & signs : onset at age 10-20
• low hairline
• shortness of the neck
• articular levitation
• pain due to involvement of brachial plexus
Laboratory examinations : Rx
• reflex torticollis : torticollis caused by inflammation or suppuration in the neck, enlarged cervical lymph nodes, or tumor in the tonsil, neck, or pharynx.
• tonsillitis
• retropharyngeal abscess
• pimple in external auditory meatus
• odontopathies
• cervical lymphadenitis
• ocular torticollis : torticollis due to a
• high degree of astigmatism
• ocular muscle palsy.
• strabismus (disappearing with monocular vision)
• osteoarticular torticollis (rickets, arthritis, traumatic after rotatory luxation of atlas in babies with age 2-5, spondylitis, neoplasms)
• spurious torticollis : twisting or stiffness of the neck due to caries of the cervical vertebrae.
• intermittent, neurogenic or spasmodic torticollis : torticollis due to intermittent dystonia and spasms of neck muscles, particularly the sternocleidomastoid and trapezius muscles. The cause is unknown, although irritation of the accessory nerve has been implicated in some cases

nervous torticollis (paralysis, neuralgia, ischemia)
• labyrinthine torticollis : torticollis due to irritation of the semicircular canals on one side.
• dermatogenic torticollis : torticollis caused by contraction of the skin of the neck
• myogenic torticollis
• fixed torticollis : an unnatural position of the head due to actual and persistent organic muscular shortening
• hysterical torticollis : that of psychogenic origin
• mental torticollis : a form of tic, or habit spasm, in which there is spasmodic contraction of the neck muscles, producing deviation of the head. This deviation usually ceases when the patient lies down, or it may be controlled by slight pressure.
• symptomatic torticollis : stiffness of the neck due to spasm of the sternomastoid or adjacent muscles
• trachelism / trachelismus : spasm of the neck muscles; spasmodic retraction of the head in epilepsy
Symptoms & signs :
• compensation posture (higher contralateral shoulder) to keep eye axis horizontal
• Hoffmann's sign : the fingernail of the long finger is pinched and the examiner notes flexion of the distal phalanx of other digits
• cervicothoracic scoliosis (1%) : left convexity and thoracic and thoracolumbar compensation curves
• thoracic scoliosis (25%) : right convexity and lumbar compensation curve
• thoracolumbar scoliosis (19%) : right convexity and 2 compensation semicurves
• lumbar scoliosis (25%) : left convexity
• scolioses with double primary curve (30%)
• double thoracic curve between T1 and T6 and T6 and T12
• thoracic and thoracolumbar curves
• thoracic and lumbar curves (23%) : right thoracic and left lumbar convexity
• compensation (semi-)curve(s) (smaller and more reducible angle)
• monolateral gibbus / hump at back flexion when upright due to abnormal rotation of dorsal vertebrae
• costal gibbus (ribs on convex side undergo verticalization, while those on concave side undergo horizontalization) measured with gibbometer
• hatchet stroke : the triangle of the size (space between extended upper limb and thorax) is larger at the concave side, where psoas muscle is more retracted
• iliac crests are one in antiversion (posterior inferior iliac spine (3 fingers below posterior superior iliac spine) higher than anterior superior iliac spine => lordosis) and the other in retroversion (posterior inferior iliac spine lower than anterior superior iliac spine  => kyphosis)
Laboratory examinations : trapezoidal vertebral bodies at Rx
Grading :
• 0-20°  : mild
• 20-40° : intermediate
• 40-60° : major
• > 60° : severe
Prognosis : inversely related to age of onset; worses 0.5°/yr between age 20 and 45, 2°/yr after age 45 (menopause, ageing)
Therapy :
• minimal scolioses (angle < 20°) : Rx every 4-5 months (10% of scolioses have a progressive course); if evolutive => Risser jacket :  a combination of plaster, turnbuckles, and hinges, extending from the chin and occiput to one knee, sometimes including one arm as far as the elbow; used in scoliosis
• intermediate scolioses (40 < angle < 20°) : orthesis with Milwaukee brace carried up to end of growth (evaluated with growing of iliac growing nucleus)
• major scolioses (angle > 40°) : surgical spondylolisthesis and arthrodesis (contraindicated above L2 and in patients with diastematomyelia)
• Klapp's creeping treatment : treatment of scoliosis by having the patient creep about on the floor, with exaggerated movements of the spine
Web resources : Scoliosis Association (SAUK)
• kyphosis / hunchback : abnormally increased convexity in the curvature of the thoracic spine as viewed from the side

Symptoms & signs due to compensatory curves : lumbago, kyphosis in C7 (trachelokyphosis / trachelocyrtosis) or T12-L1 => compensatory cervical (=> dizziness, headache) and lumbar (worsen pregnancy) lordoses
Laboratory examinations : wedge-shaped vertebrae
Varieties :
• asthenic curved back : it disappear in self-correction tests and doesn't need treatment (common in tall patients)
• osteochondrotic curved back / Scheuermann's disease or kyphosis / kyphosis dorsalis juvenilis /  juvenile kyphosis : osteochondrosis of vertebral epiphyses

Therapy :
• if kyphosis > 10° per vertebra or > 30° in 3 contiguous vertebrae => antigravitary Milwaukee brace up to resolution (it may take up to 2 yrs) + physiotherapy
• vertebral bodies osteotomy and anterior arthrodesis
• kyphoscoliosis : backward and lateral curvature of the spinal column

Symptoms & signs : restrictive pulmonary syndrome
• lordosis / hollow back / saddle back / swayback : abnormal increase in the anterior concavity in the curvature of the lumbar and cervical spine as viewed from the side
• lordoscoliosis : lordosis complicated with scoliosis
• straight back syndrome : a skeletal deformity characterized by loss of the anterior concavity of the vertebral column in the upper thoracic region, with consequent reduction in the anteroposterior diameter of the thorax and compression of the heart between the dorsal spine and the sternum.
• senile ankylosing hyperostosis of spine : a disorder of the elderly characterized by large osteophytes that bridge vertebrae and, in association with calcified ligaments, may resemble ankylosing spondylitis
• Schanz's syndrome : a series of symptoms indicating spinal weakness, consisting of a sense of fatigue, pain on pressure over the spinous processes, pain on lying prone, and indications of spinal curvature.
• Rust's syndrome : stiff neck, stiff carriage of the head, with the necessity of grasping the head with both hands in lying down or rising up from a horizontal posture, occurring in tuberculosis, cancer, fracture of the spine, rheumatic or arthritic processes, or syphilitic periostitis.
• Neri's sign : with the patient standing, forward bending of the trunk will cause flexion of the knee on the affected side in lumbosacral and iliosacral lesions.
• Mennell's sign : an examining thumb is placed over the posterosuperior spine of the sacrum and then made to slide, first outward and then inward. If on pressure over the former point tenderness is detected, it is due to a sensitive deposit in the structures of the gluteal aspect of the posterosuperior spine. If the tenderness is over the inner point, it is probable that the superior ligaments of the sacroiliac joint are strained and sensitive. If the tenderness is increased by pressure backward on the anterosuperior aspect of the ilium and decreased by pulling forward the crest from behind, this is positive proof that it is caused by the sensitive ligaments.
• Soto-Hall sign : with the patient flat on his back, on flexion of the spine beginning at the neck and going downward, pain will be felt at the site of the lesion in back abnormalities
• spondylodynia / spondylalgia : pain in a vertebra
• Brodie's disease : hysterical pseudofracture of the spine
• vertebral fractures
• Jefferson's fracture : fracture of the atlas (first cervical vertebra)
• hangman's fracture : fracture through the pedicles of the axis (C2) with or without subluxation of the second cervical vertebra on the third
• Chance fracture / seat belt fracture : horizontal splitting of the neural arch and body of a vertebra, usually in the lumbar region, caused by a flexion-distraction force
• sagittal slice fracture : fracture of a vertebra breaking it in an oblique direction; the spinal column above is displaced horizontally, usually causing paraplegia
Aetiology :
• osteoporosis
• neoplasm
• trauma
• flexion fracture
• extension fracture : detachment of anterior angle of vertebral body due ligament traction, fracture of laminae
• compression fracture
• wedge-compression fracture : compression fracture of only the anterior part of a vertebra, leaving a wedge-shaped vertebra
• spondylomalacia : softening of vertebrae.
• spondylomalacia traumatica / traumatic spondylopathy :Kümmell-Verneuil disease or spondylitis / post-traumatic spondylitis : compression fracture of vertebra; a complex of symptoms coming on in a few weeks after spinal injury, and consisting of pain in the spine, intercostal neuralgia, motor disturbances of the legs, and a gibbus of the spine which is painful on pressure and easily reduced by extension
• rotation fracture
• spinal cord disease
Morphology :
• collapse :
• angular or concave
• diffuse or focal
• posterior limiting plate
• posterior arc
• paravertebral tissues
• spinal cord
• intersomatic disk
Laboratory examinations : conventional X-ray => CT. MRI (GRE sequences for trabecular bone; SE and fat-suppression sequences for bone marrow) is used only if a spinal cord injury is suspected and it has prognostic value by assessing the completeness of resection (if partial => decompression by extended laminectomy, which anyway worsen rachid stability; if total => only stabilization to allow upright posture) and post-traumatic hematomyelia (deoxyhemoglobin in T2wi)
• degenerative diseases
• discal degeneration
• spondylosis : general term for degenerative changes of  due to osteoarthritis.
• spondylosis uncovertebralis : cervical spondylosis affecting the uncinate process of a vertebra.
Localizations :
• cervical spondylosis : degenerative joint disease affecting the cervical vertebrae, intervertebral disks, and surrounding ligaments and connective tissue, sometimes with pain or paresthesia radiating down the arms as a result of pressure on the nerve roots.
• lumbar spondylosis : degenerative joint disease affecting the lumbar vertebrae and intervertebral disks, causing pain and stiffness, sometimes with sciatic radiation due to nerve root pressure by associated protruding disks or osteophytes.
Symptoms & signs : spinal cord compression
Laboratory examinations : X-rays, CT, myelography, myelo-CT, and MRI (degenerative spondylolisthesis)
• acquired spondylolisthesis : luxation or forward displacement (olisthy) of one vertebra over another, usually of L5over the body of S1, or of L4 over L5, usually due to a developmental defect in the pars interarticularis. More common in obese elderlies with hypotrophy of paraspinal muscles
• pathological spondylolisthesis : that due to alterations in the structure of the pedicle, the pars articularis, or the articular processes caused by bone disease
• degenerative spondylolisthesis : that caused by long-standing instability due to progressive degeneration of the spinal joints, usually accompanied by rotation of the affected disk
• traumatic spondylolisthesis : that due to acute fracture of the facets, pedicle, or lamina, rather than of the pars interarticularis.
• isthmic spondylolisthesis : that accompanied by a lesion of the pars interarticularis, divided into 3 subtypes on the basis of the type of lesion:
• lytic (stress fracture of the pars interarticularis)
• elongated (elongation of the pars interarticularis due to continuous cracking and healing)
• acute fracture
• vertebral spine arthrosis / spondyloarthrosis (expecially cervical and lumbar vertebrae)

Epidemiology : adults
Aetiology : lordosis appearing in species with upright posture
• interapophysary arthrosis
• discoarthrosis
• osteophytosic spondylosis
• Forestier's disease / diffuse idiopathic skeletal hyperostosis (DISH) : hyperostosis of the anterolateral vertebral column, especially in the thoracic region.

Epidemiology : males after age 40
Symptoms & signs : morning pain
Laboratory examinations : CT scan
• synovial cysts
• vertebral canal stenosis due to somatic osteophytes

Symptoms & signs : spinal cord compression when above L1
Laboratory examinations : MRI
• herniation of intervertebral disk / herniated, protruded, or ruptured disk / herniated nucleus pulposus : protrusion of the nucleus pulposus (whose hydratation status directly relates with invasiveness and inversely relates with patient's age) of an intervertebral disk through anulus fibrosus and posterior longitudinal ligament, which may impinge on nerve roots

Aetiology :
• trauma (post-traumatic hernia)
Types : Schmorl body : a portion of the nucleus pulposus that has protruded into an adjoining vertebra.
• median hernias => compression of dural sac => compression of bone marrow
• lateral hernias => compression of nerve roots
Localization :
• disk herniation between L2 and L4 => compression of femoral nerve (sensory and motor symptoms)
• disk herniation between L2 and L3 (impairing L3 root) => pain at anteromedial region of thigh and medial region of knee and motor impairment of vastus medialis, rectus (=> impaired patellar reflex) and adductor muscles (impaired thigh adduction when an abducing force is applied while patient is seated ; adductor reflex by distending tendon at femural condylus)
• disk herniation between L3 and L4 (impairing L4 root) => pain at anteromedial region of leg and motor impairment of tensor fascia lata, femural quadriceps and anterior tibial muscles (Dandy sign)

Symptoms & signs :
• pain at lumbosacral region irradiated along areas innervated by crural nerve
• positive Wassermann sign
• negative Lasègue sign
• disk herniation between L4 and S1
• disk herniation between L4 and L5
• disk herniation between L5 and S1
Topographical classification :
• posterolateral hernia (60-70%)
• posteromedial hernia
• central hernia
Invasiveness staging :
• contained hernia
• protrused hernia
• expulsed or migrated hernia : free to move in intervertebral canal
Symptoms & signs :
• sensory impairment =>
• compression of L4 root (rare) => pain in lateral thigh, medial leg and big toe
• compression of L5 root => pain in lateral leg and medial foot
• compression of S1 root => pain in posterior buttock, thigh, leg and lateral foot
Pain is exacerbated by walking (disk claudicatio intermittens needs differential diagnosis with vascular claudicatio due to arterious or venous failure in lower limbs) or elevation of 20 kg with extended forearms. Negative Wassermann sign, positive Lasègue sign.
• motor impairment
• compression of L4 root (rare) => eventual paresis of tibilais anterior muscle
• compression of L5 root => common toe extensor and lateral peroneal muscles
• compression of S1 root => triceps surae muscle
• patient can't walk over toetips
• Dandy sign : weak dorsal flexion of the foot when a force opposes the movement
• Waddell test : the patient is tested for appropriateness of response to tenderness, axial loading, rotation, straight leg raising in the seated position, regional disturbances and overreaction. Inappropriate responses in 3 of the 5 areas is very suggestive of functional overlay in patients with back problems.
• Gaenslen's sign : with the patient on his back on a table, the knee and hip of one leg are held in a flexed position by the patient, while the other leg, hanging over the edge of the table is pressed down by the examiner to produce hyperextension of the hip
• straight leg raising : with the knee extended and the patient supine or seated, the hip is flexed (with the leg straight) causing pain in the sciatic nerve distribution
Laboratory examinations : Schmorl's nodule (a nodule seen in radiographs of the spine, due to prolapse of a nucleus pulposus into an adjoining vertebra)
Therapy : Kambin's triangular working zone : a triangular space free of significant vascular and neural structures that allows safe access to a lumbar disk in microdiskectomy; it is bounded anteriorly by the spinal nerve, inferiorly by the upper rim of the next lower vertebral plate, and posteriorly by the lateral edge of the superior articular process.
• disc sequestration : complete separation of disc material with rupture through posterior longitudinal ligament into the epidural space; free fragment herniation findings: migration superiorly/inferiorly with compression of nerve roots above/below the level of herniation, disc material noted > 9 mm from disc space.

Differential diagnosis :
• postoperative scarring (retraction of thecal sac to the site of surgery)
• epidural abscess/tumour
• conjoined nerve root: 2 nerve roots arising simultaneously from the thecal sac
• normal variant in 1-3%
• inflammatory diseases
• spondylitis / rachitis : inflammation of the vertebrae

Aetiology :
• ankylosing spondylitis (AS)
• hypertrophic spondylitis : spondylitis with evidence of hypertrophic changes in the vertebrae.
• spondylitis infectiosa : inflammation of the vertebrae caused by a specific pathogen.
• spondylitis tuberculosa / tuberculous spondylitis / tuberculosis of the spine / spinal tuberculosis / David's or Pott's disease : osteitis or caries of the vertebrae, usually occurring as a complication of tuberculosis of the lungs; it is marked by stiffness of the vertebral column, pain on motion, tenderness on pressure, prominence of certain of the vertebral spines, and occasionally abdominal pain, abscess formation, and paralysis
• malum vertebrale suboccipitale : tuberculosis of the atlas and axis.
• Pott's abscess : one associated with tuberculosis of the spine
• Pott's triad : paraplegia, pain and gibbus
• Anghelescu's sign : inability to bend the spine while lying on the back so as to rest on the head and heels alone, seen in tuberculosis of the vertebrae
• spondylitis typhosa : inflammation of the vertebrae following typhoid fever
• muscular spondylitis : a morbid condition of the spine resulting from muscular weakness and not a true inflammation.
• traumatic spondylitis : spondylitis occurring as a result of injury to the vertebrae.
Laboratory examinations : vertebra plana (a condition of spondylitis in which the body of the vertebra is reduced to a sclerotic disk; often due to eosinophilic granuloma)
• spondylopyosis : suppuration of a vertebra or of vertebrae.
• intervertebral discitis / diskitis : inflammation of an intervertebral disk

Epidemiology : in babies, when the disk is still vascularized => haematogenous infection
• spondylodiscitis : spondylitis (the involvement of the disk-vertebral junction allows differential diagnosis with metastases, tumor and osteomyelitis, which arise in cancellous bone) + intervertebral discitis;

Aetiology :
• contiguity infection from haematogenous spondylitis in elderlies (when the disk is no longer vascularized)
• iatrogenic infection during diskal hernia surgery
• Staphylococcus aureus
• viridans streptococci
• Streptococcusanginosus
• Streptococcus mitis
• Streptococcussanguis
• Brucella melitensis
Complications : epidural abscess => spinal cord compression
Laboratory examinations :
• MRI : paravertebral spindle due to flogosis of soft tissues
• X-rays : latency > 10 days; edema within cancellous bone and caries in upper and lower vertebral body borders
• bone scintigraphy : poor specificity
• CT : poor spatiality and specificity
• sacralgia : pain in the sacrum.
• scimitar sacrum : a congenitally deformed sacrum shaped like a scimitar, usually accompanied by other defects such as anorectal malformations or neural anomalies.
• tilted sacrum : a condition marked by separation of the sacroiliac joint and forward displacement of the sacrum.
• sacroiliitis : inflammation (arthritis) in the sacroiliac joint

Aetiology :
• spondyloarthropathies
• juvenile spondyloarthopathy / seronegative arthritis enthesitis (SEA) syndrome
• psoriatic arthritis (PsA)
• IBD-associated arthritis
• ankylosing  spondylitis (AS)
• reactive arthritides
• spondylo-enteroarthritides
• Whipple disease / intestinal lipodystrophy
Symptoms & signs : sacralgia evoked by ...
• Erichsen's test (iliac compression test) : the examiner sharply presses the iliac crests toward each other  when patients lies on a side : pain is felt in sacroiliac disease but not in hip disease.
• pressure over anterosuperior iliac spines when patient lies in bed
• body rotation when leg are crossed
• Mennell's sign : the examiner places a thumb over the posterior superior iliac spine and applies pressure outward and then inward. Pain experienced during this procedure indicates sensitive ligaments related to the sacroiliac joints.
• neoplastic diseases :
• intradural neoplasms
• extradural neoplasms
• primary neoplasms
• benign tumors
• osteoid osteoma
• osteoblastoma (most commonly in posterior arch)
• osteochondroma
• giant cell tumor
• chondromyxoid fibroma
• hemangiomas
• aneurysmal bone cysts
• eosinophilic granuloma
• malignant tumors
• osteosarcoma
• chondrosarcoma
• fibrosarcoma
• angiosarcoma
• Ewing's sarcoma
• multiple myeloma
• multiple myeloma
• metastases
• prostate carcinoma
• breast carcinoma
• lung carcinoma
• hourglass tumor : a spinal tumor made up of intradural and extradural masses joined by a narrow pedicle passing through an enlarged intervertebral foramen.
Laboratory examinations :
• bone scintigraphy is very sensitive (except than for plasmocytoma) but aspecific
• CT : the vertebral peduncle is very vascularized and so more often involved in metastatic localizations (on the contrary osteoporotic pathologic fractures usually involve the vertebral body)
• MRI to study :
• bone marrow : an hematopoietic reservoir, lack of captation in T1wi means fatty tissue has beenn replaced by water of other cell types
• spinal cord compression : when occuring it can be treated with
• orthesis
• CT-assisted vertebroplasty
• prosthetic vertebrectomy
• extramedullary tumors are out of BBB and captate more contrast agent
• Rust's phenomenon : in caries or cancer of the upper cervical vertebrae, the patient supports his head with his hands when rising from or assuming a lying position
• Amoss' sign : in painful flexure of the spine, the patient, when rising to a sitting posture from lying in bed, does so by supporting himself with his hands placed far behind him in the bed.
Laboratory examinations :
• analogic or digital conventional X-ray allows study of bone morphology (e.g. in fractures)
• spinal CT with 2D post-processing allows finer study of bone morphology
• MRI for vertebral bone marrow, spinal cord and surrounding soft tissues (intervertebral disks, ligaments, muscles, blood vessels, ..) (direct multiplanar acquisition)
• thoracic cage diseases

Epidemiology : affect about 1% of the population
• congenital malformations of the thoracic cage
• apleuria : absence of ribs
• thoracoschisis / schistothorax / schizothorax : congenital fissure of the thorax, which may result in herniation of lung tissue
• partal thoracoschisis : involving manubrium and body
• complete sternal schisis : involving also the xyphoid process

a cleft in the inferior part of the sternum : Cantrell's pentalogy / pentalogy of Cantrell
• asphyxiating thoracic dystrophy (ATD) / Jeune's syndrome / thoracic-pelvic-phalangeal dystrophy : a congenital hereditary syndrome transmitted as an autosomal recessive trait, characterized by chondrodystrophy of the rib cage that usually causes asphyxia early in the newborn period, in association with defects of the phalanges and pelvis, and renal insufficiency. Other clinical manifestations include cystic lesions of the pancreas and retinal abnormalities. Hepatic abnormalities have been described both clinically and at autopsy, but the pathogenesis of the liver disease is not clear (progressive portal hypertension ?)
• pectus carinatum / chicken breast / pigeon breast or chest / keeled chest : a condition of the chest in which the sternum is prominent
• expecially in the upper part : chondrogladiolar variant
• expecially in the lower part : chondroxyphoid or xiphisternal variant
Aetiology :
• obstruction of infantile respiration
• Currarino-Silverman syndrome : premature obliteration of the sternal sutures with synostosis as well as a protruding manubrium, causing pectus carinatum; other abnormalities may also be present such as hyperostosis of ribs or hypotrophy of the anterior diaphragm
• rickets
Therapy : surgery is required only for aesthetic reasons; Chen procedure gives permanent correction
• pectus excavatum (PE) / foveated or funnel chest / funnel breast / pectus recurvatum / koilosternia / trichterbrust / sternal lordosis : a chest in which there is a funnel-shaped depression in the middle of the anterior thoracic wall, with the deepest part in the sternum

Epidemiology : 1 in every 400 births, with males afflicted 5 times more often than females
Aetiology :
• combination of subcortical/subependymal heterotopia, corpus callosum dysgenesis, craniofacial dysmorphism, severe eye abnormalities, and growth-mental retardation
• Catel-Manzke syndrome without cleft palate or cardiac abnormalities : mild facial dysmorphism, bilateral brachydactyly and ulnar deviation of both index fingers
• Teebi hypertelorism syndrome
• X-linked syndrome with agenesis of the corpus callosum, mental retardation, coloboma, micrognathia
• spinal muscular atrophy type 1
• Noonan syndrome
• Marfan syndrome
Pathogenesis : disturbances in endochondral ossification and growth of costal cartilage seem to be more probable cause of the deformities than diaphragm underdevelopment.
Symptoms & signs : usually recognized in infancy, becomes much more severe during adolescent growth years, and remains constant throughout adult life. Symptoms are infrequent during early childhood, but become increasingly severe during adolescent years with circulatory-respiratory malfunctions (easy fatigability, dyspnea with mild exertion, decreased endurance, pain in the anterior chest, and tachycardia. The heart is deviated into the left chest to varying degrees causing reduction in stroke volume and cardiac output. Pulmonary expansion is confined, causing a restrictive defect. Also right bundle branch block, sinus bradycardia, left atrial enlargement and right atrial dilatation => true physiologic impairment and reduced exercise capacity, predominantly due to impaired cardiovascular performance rather than ventilatory limitation. Impairment is not explained by physical deconditioning), cosmetic defects => psychical problems.
Associated anomalies : scoliosis, clubfoot, syndactilia, Klippel-Feil syndrome,
Therapy : correction is permanent in 90% cases providing that they were performed in patients aged 12-16. When patients were at the age 6-10, recurrence of the deformity occurrs in 37% of cases.  Repair of congenital defects of the sternum in adults can be performed safely with low morbidity and no mortality. Long-term results are excellent with requirement for reoperation rare.
• a variety of open surgery techniques
• transsternal traction in the classical Ravistch-Garnier procedure(usually performed after the age of 8 years. The optimal age for repair is between 12 and 16 years. Repair can be performed on adults with similar good results. Recent modifications in the Ravitch technique remove minimal cartilage and routinely use a temporary internal support bar for 6 months. Operation rarely takes more than 3 hours, and hospitalization rarely exceeds 3 days. Pain is mild and complications are rare, with 97% of patients experiencing a good to excellent result)
• sternochondroplasty by raising with osteosynthesis by slide fastener-handle of Martin-Borrelly
• custom-made silicone elastomer prothesis which are deeply placed, behind muscle and aponevroses
• minimally invasive repair of pectus excavatum (MIRPE) : Nuss modified correction employing videothoracoscopic extrapleural insertion of a substernal stabilizing Walter Lorenz pectus bar (as well as utilizing the pectus bar stabilizer that provides more rigid fixation of the strut) avoids cartilage resection and takes less operating time, but is associated with more severe pain, a higher complication rate, with the bar remaining for 2 or more years, considerably reduces the time of hospitalisation but requires one more hospitalisation to remove the bar. It was originally developed only for children and is based on the fact that the growing chest wall is still flexible. This technique is less applicable to older patients and those with asymmetric deformities.

Side effects :
• postpericardiotomy syndrome resolved with intravenous methylprednisolone
• acquired thoracic scoliosis following
Web resources :
• Pectus info pages
• Pectus excavatum information site
• barrel-shaped thorax / barrel chest : a rounded, bulging chest with abnormal increase in the anteroposterior diameter, showing little movement on respiration; seen in pulmonary emphysema and in kyphosis.
• Peyrot's thorax : a chest that is obliquely oval; seen in large pleural effusions.
• pyriform thorax : a pear-shaped thorax, large above, small below.
• cobbler's chest : a chest showing a sinking in at the lower end of the sternum.
• rib fractures
• flail chest (FC) / volet costal : one whose wall moves paradoxically with respiration (paradoxal inspiration (re-entry of thoracic wall) and expiration (expansion of thoracic wall)), occurring in an area where 4 or more ribs are fractured in at least 2 locations. Air flows from the normal area to the injured area, which is ventilated only during expiration, when air has already lost its content of O₂. Patients often have an underlying pulmonary contusion which is underestimated by the initial chest x-ray. Respiratory failure in these patients may not be immediate, and frequent reevaluation is warranted. It is as a marker of high kinetic energy absorption, resulting in life-threatening thoracic as well as nonthoracic injuries^ref. These patients are at high risk for pneumonia and adult respiratory distress syndrome, which adds substantially to their morbidity and mortality rates.
• stove-in chest : a rare form of flail chest in which there is collapse of a segment of the chest wall, associated with a high immediate mortality. Early ventilatory support, despite good gas exchange, may have closed down the pleural space prevented the empyema. Prophylactic ventilation and possibly surgical stabilisation of the chest wall should be considered early in the course of admission, even when the conventional parameters to indicate ventilation are not met.
Therapy : operative stabilization (OS) of chest wall should be considered when extensive FC occurs, particularly for patients with severe pulmonary and myocardial contusion : open reduction and osteosynthesis (ASIF reconstruction plates or isoelastic rip clamps) of the chest wall. In severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal pneumatic stabilization. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. On the contrary, multiple ribs fractures and flail chest without major pulmonary contusion are managed with regional analgesia allowing effective physiotherapy and avoiding the infectious complications related to prolonged mechanical ventilation.
• alar, flat or pterygoid chest : deformity of the chest in which it is flattened from front to back
• paralytic chest : a long and narrow chest with emaciation so that the ribs stand out sharply under the skin.
• tetrahedron chest : a chest that suggests a solid with 4 sides, each an equilateral triangle, the chest projecting in a peak between the nipples
• pectus arcuatum : mixed type
• Tietze syndrome / costal chondritis : idiopathic painful nonsuppurative swellings of one or more costal cartilages, especially of the second rib; the anterior chest pain may mimic that of coronary artery disease
• rachitic beads : a series of palpable or visible prominences at the points where the ribs join their cartilages; seen in certain cases of rickets due to lack of mineralization of costochondral joint
• scorbutic beads : a series of visible prominences at the costochondral joints, sometimes seen in children with scurvy
• thoracic cage cancers :
• osteochondroma
• shoulder diseases (on the contrary of hip, glenoideal cavity doesn't cover whole humural head and hence most diseases come from dysfunctions of soft containment structures)
• obstetric shoulder lesions
• osseous traumas
• articular distorsions

Aetiology : forceps use
Laboratory examinations : Rx
Prognosis : rapid self-recovery with restitutio ad integrum
• fractures
• clavicular fracture (provoked to allow exit of macrosomic fetuses, cephalic fetuses (5 every 100,000) or podalic fetuses (160 every 100,000))
• fracture of intermediate third of humerus
Prognosis : restitutio ad integrum within 2-4 weeks
• humeral chondroepiphysary detachment (fracture at metaphysis, a locus minoris resistentiae)

Therapy : immobilization in extrarotation
Symptoms & signs : brachial plexopathy, contracture of scapular limb-girdle, intrarotated, adduced, and pronated forearm
Laboratory examinations : echography (epiphysis cannot be detected at X-rays in any case)
Prognosis : stiffness of scapular limb-girdle
• obstetric brachial plexus palsy

Aetiology :
• maternal factors
• pelvic vicia
• oligohydramnios
• precipitating carriage
• foetal factors
• macrosomia
• amniotic adherences
• funicular dystocia
• anomalous foetus presentation
Pathogenesis : monolateral brachial plexopathy
• Sunderland (prognostic) grading :
• 1 : neuroapraxia; subperinevrial hematoma, edema at traction zone, spontaneous recovery within 4-5 weeks
• 2 : axonotmesis, spontaneous recovery within 4-5 months
• 3 : axonotmesis with endoneural cylinders
• 4 : perineurial rupture => anarchic regeneration => recovery with co-contractions or simultaneous contractions
• 5 : neurotmesis, no recovery
Symptoms & signs :
• flaccid palsy, pronated forearm, white limb due to sympathetic disturbances
• superior palsy (Erb-Duchenne type) : lesions from C5 to C6 => impaired deltoid, pectoral, biceps, and extrarotator muscles => extended, prone and intrarotated limb, but good finger motility
• inferior palsy (Dejerine-Klumpke type) : lesions from C7 to T1 => impaired radial nerve => immobile hand
• Bernard-Horner syndrome : enophthalmus, palpebral ptosis, slight elevation of the lower lid, miosis, narrowing of the palpebral fissure, and anhidrosis and flushing of the affected side of the face; caused by a brain stem lesion on the ipsilateral side that interrupts descending cervical orthosympathetic nerves
• total palsy : lesion extended from C5 to T1
Laboratory examinations : scapular girdle, cervical spine and diaphragm Rx, EMG before day 20
Therapy :
• physiotherapy : temporanoeus immobilization in abduction and extrarotation and passive mobilization of elbow and fingers to prevent capsulo-ligamentous retractions
• osteotomy
• arthrodesis
• capsulotomy
• tenotomy
• tendineal transpositions
Prevention : caesarean delivery
• Sprengel's deformity : congenital elevation of the scapula, due to failure of descent of the scapula to its normal thoracic position during fetal life
• omagra : gout in the shoulder.
• omalgia / omodynia  : pain in the shoulder.
• omarthritis : inflammation of the shoulder joint.
• shoulder arthrosis (10%)
• painful arc syndrome : shoulder pain occurring at a particular portion of the arc described when the arm is abducted from the side to the fully raised position, as in inflammation of the tendons of the supraspinatus muscle.
• supraspinatus syndrome : tenderness over the supraspinatus tendon, a painful arc on movement of the arm, and a reversal of scapulohumeral rhythm.
• scapulocostal syndrome : pain in the superior or posterior aspect of the shoulder girdle, radiating to contiguous regions, as a result of long-standing alteration of the relationship of the scapula and the posterior thoracic wall
• subcoracoid dislocation : a type of dislocation of the head of the humerus
• subglenoid dislocation : a type of dislocation of the head of the humerus
• subspinous dislocation : dislocation of the head of the humerus into the space below the spine of the scapula
• Comolli's sign : a sign of scapular fracture consisting of the appearance in the scapular region, shortly after the accident, of a triangular swelling reproducing the shape of the body of the scapula.
• Codman's sign : in rupture of the supraspinatus tendon, the arm can be passively abducted without pain, but when support of the arm is removed and the deltoid contracts suddenly, pain occurs again
• Bryant's sign : lowering of the axillary folds in dislocation of the shoulder
• rotator cuff tear

Signs : supraspinous isolation : weakness of abduction of the shoulder is tested by abducting and forward flexing the arm with the forearms in internal rotation. This isolates the supraspinatus muscle, the most common ares of weakness in a rotator cuff tear. Joint fluid that tracks from the glenohumeral joint, through a rotator-cuff tear, and into the acromioclavicular joint, can form a cyst above the joint^ref.
• shoulder instability
• Traumatic, Unidirectional instability and Bankart lesion which often requires Surgery (TUBS)

Pathogenesis :
• humeral avulsion of the glenohumeral ligament (HAGL) lesion
• Hill-Sachs lesion : compression fracture of the posteromedial humeral head, sometimes occurring with anterior dislocation of the shoulder, caused by impaction of the soft base of humeral head on the anterior relatively hard anterior rim of the glenoid fossa
• Bankart lesion : avulsion of the anterior glenoid labrum following anterior dislocation of the shoulder (at hour 3-6 of left glena and hour 6-9 in right glena) => air enters
• anterior labrum periostal sleeve avulsion (ALPSA)
• bony Bankart lesion / inverted pear : both cercinal and bony detachment
Symptoms & signs :
• apprehension test : pain or fear at passive abduction and extrarotation
• relocation test :
• O'Brien test :
• sulcus sign : distal arm retraction creates a sulcus between acromion and humeral head
Therapy : arthroscopic surgery
• acquired instability overstress which often requires surgery (AIOS)

Aetiology :
• fall with abduced arm => tear in longer end of biceps muscle => superior labrum anterior to posterior (SLAP) lesion

Snyder staging (1991) :
• I
• II
• III
• IV
• overstress of extrarotatory cuff (supraspinous, subspinous, and little round muscle) in javelottists, volleyball players. Enthesitis => stenosis of anterior circumflexed artery => ischaemic necrosis of supraspinous muscle (80% of onsets)
Therapy :
• immobilization
• physiokinesitherapy
• arthroscopic surgery
• Atraumatic, Multidirectional, Bilateral instability that often responds to Rehabilitation, but in case of surgery Inferior capsular shift is indicated (AMBRI)

Therapy : rehabilitation, training, surgery
Web resources : Arthroscopic findings in shoulder instability by Alessandro Castagna , M.D.
• subacromial impingement syndrome (90%) : the progressive pathologic changes resulting from mechanical encroachment of the acromion, coracoacromial ligament, coracoid process, or acromioclavicular joint on the rotator cuff, including reversible edema and hemorrhage, fibrosis, tendinitis, pain, bone spur formation, and tendon rupture.

Aetiology : tennis players, dolphin swimmers, baseball players, water-polo players
• acromion morphology (Biglioni-Morrison classification)
• I : flat acromion (less predisposed)
• II : curved acromion
• III : hooked acromion (more predisposed)
• calcific tendinopathy
• subacromial or subdeltoid bursitis
• os acromiale : a movable joint between the spine of the scapula and the epiphysis of the acromion.
• preacromion
• mesoacromion
• metaacromion
• basiacromion
Pathogenesis : rising of humeral head and greater than normal acromion (often containing osteophytes) => impaired tendons of rotator cuff => subacromial bursitis and oedema (scapulohumeral bursitis / calcific bursitis or tendinitis : inflammation and calcification of the subacromial or subdeltoid bursitis, resulting in pain, tenderness, and limitation of motion in the shoulder) => subacromial fibrosis => subluxation => sporadic or relapsing luxations, antalgic stiffness (differential diagnosis with Sudeck algodystrophy / reflex sympathetic dystrophy (RSD), adhesive capsulitis, and stiffness secondary to trauma-induced fibrosis of soft tissues)
Symptoms & signs :
• pain at
• arm abduction between
• 70-140° = cuff lesion (Snyder classification) :
• articular lesion
• bursal lesion
• normal
• fibrillation < 1 cm
• fibrillation < 2 cm
• fibrillation and fragmentation < 3 cm
• severe partial lesion
• complete lesion => deficiency of arm abduction up to 40°
• small rupture
• rupture < 2 cm with no rectraction
• rupture < 3-4 cm with minimal retraction
• massive rupture with retraction and degeneration (not repairable)
• 140-180° : acromioclavicular disease (normal rotator cuff)
• 70-180° : cuff lesion + acromioclavicular disease
• palpation of greater humeral tuberosity
• Neer test / impingement test : the shoulder is forcefully abducted causing the greater tuberosity to press against the undersurface of the acromion
• Hawkins test : the shoulder is forcefully abducted and internally rotated causing the greater tuberosity to press against the coracoacromial ligament
• Gerber test : causing the greater tuberosity to press against the coracoid process
• Yacun test : the elbow is  subacromion clavear
• Jobe test : the arm is lifted, abduced and internally rotated to assay strength of supraspinatus muscle
• the arm is adduced at 90° and externally rotated to assay strength of infraspinatus and teres minus muscles
• lift-off test assays strength of subscapularis muscle
• Yergason test : arm is adduced at 90° and forearm is lifted with palm down to assess strength of longer end of biceps brachii muscle
• retroposition test assays strength of longer end of biceps brachii muscle
• Speed's test : arm is adduced at 90° and forearm is lifted with palm up to assess strength of longer end of biceps brachii muscle
• Dawbarn's sign : in acute subacromial bursitis, when the arm hangs by the side palpation over the bursa causes pain, but when the arm is abducted this pain disappears.
Pain is exacerbated during bed-time, by warm and cold environments, and reduced by ice, NSAIDs, and movement
• crackles ("clock-clock sign")
• Popeye syndrome : detachment of longer end of biceps muscle
• local erythema and warm skin
• asymmetric joint
Laboratory examinations (useful for differential diagnosis from cervical disk hernia, shoulder-hand syndrome, superior cervical strict syndrome, neoplasms and infections) :
• Rx
• standard anteroposterior
• Neer projection
• echography
• CT
• MRI
• with contrast enhancement medium
Therapy :
• acute pain
• cold
• NSAIDs (they cannot used chronically as they damage intraarticular cartilage)
• subacromial infiltrations of local anaesthetics (ex adjuvantibus criterion) and cortisone
• immobility
• subacute pain
• passive (massotherapy : transverse deep massage) => active assisted kinesitherapy
• NSAIDs
• subacromial infiltrations of local anaesthetics (ex adjuvantibus criterion) and cortisone
• chronic pain :
• arthroscopic acromioplasty (lying on contralateral side and with arm abduced by 45° with opposing a force of 5-10 kg) cuts coracoacromial ligament. Mini-open requires a cut of 3-4 cm only.
• laser therapy, spasmolytic electrotherapy, US and massage to treat antalgic spasm
Post-operatory follow-up : immobilization in abduction for
• 28 days if rotator cuff lesion
• 7-10 days if acromioplasty, bursectomy, mini-Humford
• shoulder luxation : usually anterior

Complications : injury of circumflex nerve
Laboratory examinations : Hamilton's test : when the shoulder joint is luxated, a rule or straight rod applied to the humerus can be made to touch the outer condyle and the acromion at the same time.
Therapy : Brickner position : a position for treating shoulder disability, secured by tying the patient's wrist to the head of the bed with his arm supported on a pillow and raising the head of the bed; thus traction with abduction and external rotation is obtained.
• diseases of humerus
• perobrachius : a fetus with deformed arms.
• tribrachia : a developmental anomaly characterized by tripling of an arm.
• Panner's disease : osteochondrosis of the capitellum of the humerus
• humeral fractures
• cleavage fracture : shelling off of cartilage with a small fragment of bone from the upper surface of the capitellum humeri.
• condylar fracture : fracture of the humerus in which a small fragment including the condyle is separated from the inner or outer aspect of the bone
• extracapsular fracture : a fracture of the humerus or femur outside of the capsule
• grenade-thrower's fracture : fracture of the humerus caused by muscular contraction, as in throwing a grenade
Complications : radial nerve injury in middle third fractures
Therapy : Jones' position : acute flexion of the forearm for the treatment of fracture of the internal condyle of the humerus.
• elbow diseases
• cubitus varus : carrying angle decreased.
• cubitus valgus : carrying angle increased

Aetiology : Turner syndrome
• epicondylitis : inflammation of the epicondyle or of the tissues adjoining the epicondyle of the humerus.
• lateral epicondylitis / tennis elbow / external humeral epicondylitis / radiohumeral bursitis or epicondylitis : a painful condition localized to the outer aspect of the elbow, due to inflammation or irritation of the extensor tendon attachment to the lateral humeral condyle

Laboratory examinations : Mills' test : with the wrist and fingers fully flexed and the forearm pronated, complete extension of the elbow is painful
• medial epicondylitis :
• golfer's elbow : pain due to medial epicondylitis, the lesion being in the origin of the flexor muscles.
• little leaguer's elbow : medial epicondylitis of the elbow due to repeated stress on the flexor muscles of the forearm, a frequent problem of adolescent ballplayers.
• olecranon bursitis: inflammation and enlargement of the bursa over the olecranon
• miners' elbow : enlargement of the bursa over the point of the elbow (olecranon bursitis) caused by resting the weight of the body on the elbow as in mining.
• baseball pitchers' elbow : a disorder of the elbow in baseball pitchers due to a piece of cartilage or bone torn from the head of the radius
• nursemaids' or pulled elbow / Goyrand's injury / Malgaigne's luxation : subluxation of the head of the radius distally under the annular ligament, produced by sudden traction on the hand with the elbow extended and the forearm pronated
• elbow fracture : complicated by calcifications and articular stiffness
• olecranon fracture : complicated by ulnary nerve injury
• forearm diseases
• triantebrachia : a developmental anomaly characterized by tripling of the forearm
• radioulnar synostosis : bony fusion of the proximal ends of the radius and ulna
• ulnar fractures
• Monteggia's fracture : fracture in the proximal half of the shaft of the ulna, with dislocation of the head of the radius. Sometimes called parry fracture because it is often caused by attempts to fend off blows with the forearm
• radial fractures
• Barton's fracture : fracture of the distal end of the radius into the wrist joint
• chisel fracture : oblique detachment of a piece from the head of the radius
• Colles' fracture : fracture of the lower end of the radius in which the lower fragment is displaced posteriorly. A reverse Colles' fracture / Smith's fracture is one in which the lower fragment is displaced anteriorly. Silver-fork fracture is a name sometimes given to Colles' fracture because of the shape of the deformity that it causes

Aetiology : postmenopausal osteoporosis
Symptoms & signs : Maisonneuve's sign : marked hyperextensibility of the hand
Therapy : external reduction => plaster
• Galeazzi's or Dupuytren's fracture : fracture of the radius above the wrist combined with dislocation of the distal end of the ulna
• Moore's fracture : fracture of the lower end of the radius with dislocation of the head of the ulna and imprisonment of the styloid process beneath the annular ligaments
• Skillern's fracture : complete fracture of the lower third of the radius with greenstick fracture of the lower third of the ulna
Symptoms & signs : Laugier's sign :  a condition in which the styloid process of the radius and of the ulna are on the same level; seen in fracture of the lower part of the radius.
• hand diseases
• congenital malformations of hand
• perobrachius : a fetus with deformed arms.
• tricheiria : a developmental anomaly characterized by tripling of a hand
• congenital clubhand or club hand / talipomanus : a deformity of the hand due to congenital absence of the radius or ulna in which the hand is twisted out of shape or position
• radial clubhand / manus valga : the most common type of clubhand in which the hand is deflected toward the radial side; when the hand is held in the anatomic position it is known as manus valga and when it is held in the opposite direction as manus vara
• ulnar clubhand / manus vara : clubhand in which the hand is deflected toward the ulnar side; when the hand is held in the anatomic position it is known as manus vara and when it is held in the opposite direction as manus valga
• ectrodactyly / ectrodactylism / ectrodactylia : congenital absence of a digit or part of a digit

Aetiology : ectrodactily, ectodermal dysplasia, and cleft lip/palate (EEC) syndrome
• 1
• 2
• arachnodactyly / acromacria / dolichostenomelia / spider finger : a condition characterized by abnormal length and slenderness of the fingers

Aetiology :
• congenital contractural arachnodactyly (CCA) : a form of hereditary bone dysplasia
• Marfan's syndrome
• multiple endocrine neoplasia (MEN) IIB / III / Wagenmann-Froboese syndrome / ganglioneuromatosis of the alimentary tract
• Achard's syndrome : arachnodactyly associated with receding mandible and joint laxity limited to the hands and feet.
• bifid thumb : a deformed thumb in which the distal phalanx is divided or bifurcated.
• manus varus : deviation to the thumb-side of the hand
• manus valgus : deviation to the little-finger side of the hand
• ape hand : a hand with the thumb permanently extended.
• benediction hand / preacher's hand  : a hand in which the ring and little fingers are flexed; there is weakness of abduction and adduction of the index and middle fingers but they can be extended normally, and the thumb remains normal; seen in ulnar paralysis and syringomyelia.
• claw hand / clawhand
• cleft hand / lobster-claw hand or deformity / split hand / split-hand deformity / main fourchée :  a congenital anomaly of the hand in which the division between the fingers extends into the metacarpus; often there are just two large digits, one on either side of the cleft
• dead hand : an occupational disorder seen sometimes in those who use vibratory tools, and apparently caused by the multitude of concussions. The hands are painful and dark blue in color, but blanch on exposure to cold.
• drop hand / wristdrop :
• flat hand / manus plana :
• frozen hand : stiffness of the hand resulting from edema accompanying trauma.
• Marinesco's succulent hand / main succulente and Marinesco's sign : a soft, swollen, cyanotic, and cold hand caused by thickening and edema of the subcutaneous tissues; seen in syringomyelia
• mirror hands : an anomaly in which there are two crude hands growing from a common wrist.
• mitten hand : a hand in which several fingers are fused together and have a common nail.
• monkey hand / main en singe / monkey paw : a condition in which the thumb lies in adduction and extension and cannot be opposed so as to touch the tips of the other fingers, because of thenar muscle weakness, sometimes caused by lesions of the median nerve
• obstetrician's hand : the contraction of the hand in tetany, flexed at the wrist with fingers at the metacarpophalangeal joints but extended at the interphalangeal joints, the thumb being strongly flexed into the palm; so called because of a dubious resemblance to the position assumed by the hand of the obstetrician when examining the vagina.
• opera-glass hand : a pawlike hand marked by telescoping of the fingers caused by absorption of the phalanges; occurs in chronic arthritis.
• phantom hand : a paresthetic feeling as if the hand were still present after amputation.
• skeleton hand / main en squelette : a hand markedly atrophied and held in a position of extension: seen in progressive muscular atrophy
• spade hand : the thick square hand of myxedema and acromegaly.
• trident hand : the characteristic hand of achondroplasia: the fingers are relatively of the same length, and there is a peculiar separation of the second and third fingers at the second phalangeal joint, causing the fingers to spread out.
• writing hand : a peculiar position of the hand in which the hand appears poised for writing; seen in paralysis agitans.
• diseases of wrist
• SLAC wrist : a wrist affected by scapholunate advanced collapse (SLAC) : a common form of arthritic degeneration of the wrist, with gradual loss of ligamentous support due to chronic malalignment of the scaphoid bone, resulting in a rotational deformity
• tennis wrist : tenovaginitis of the tendons of the wrist in tennis players.
• wristdrop / carpoptosis / drop hand : a condition resulting from paralysis of the extensor muscles of the hand and fingers
• De Quervain tenosynovitis stenosans / tendinitis stenosans / stenosing tendinitis : a painful condition of the wrist, marked by thickening and narrowing of the tendon sheath of the extensor brevis and abductor longus pollicis

Symptoms & signs : Finkelstein's test (with the thumb inside the palm, the wrist and hand are ulnarly deviated, causing pain in the abductor tendons of the thumb at the radial styloid)
• carpal tunnel syndrome (CTS)
• Gubler's tumor : a tumor on the back of the wrist, with paralysis of the extensors of the hand, in cases of lead poisoning.
• Dupuytren's contracture : shortening, thickening, and fibrosis of the palmar fascia, producing a flexion deformity of a finger; sometimes associated with long-standing epilepsy. Applied also to flexion deformity of a toe caused by involvement of the plantar fascia.
• tennis thumb : tendinitis with calcification in the flexor pollicis longus, resulting from repeated friction experienced in playing tennis.
• pouce flottant [Fr. “floating thumb (great toe)”] : a deformity of the thumb or great toe associated with a number of congenital anomalies and with microvascular and plastic surgery
• Preiser's disease : osteoporosis and atrophy of the carpal scaphoid due to trauma or a fracture which has not been kept immobilized.
• Kienböck's disease / lunatomalacia : slowly progressive osteochondrosis of the semilunar (carpal lunate) bone; it may affect other bones of the wrist
• Kienböck's dislocation : isolated dislocation of the semilunar bone
• Fleischner's disease : osteochondritis affecting the middle phalanges of the hand.
• tendineal injuries
• Kanavel's sign : a point of maximum tenderness in the palm 1 inch proximal to the base of the little finger in infection of tendon sheath
• extensory tendons
• at the level of distal interphalangeal (DIP) joint => mallet finger / baseball finger / dropped finger

Aetiology :
• cut
• trauma (Segond)
Therapy to prevent swan neck deformity :
• pull-out suture allows healing and scaring
• Stack splint
• interphalangeal osteoarthritis : a localized form of arthritis involving the finger joints, characterized by the formation of nodosities (Bouchard's nodes and Heberden's nodes) and degenerative changes with intermittent inflammatory episodes, and leading eventually to deformities and ankyloses.

Signs :
• distal interphalangeal joints : erosive arthrosis or protuberances of bases of terminal phalanges => painless Heberden's nodules
• proximal interphalangeal joints : erosive arthrosis or Bouchard's nodules
• trapetiometacarpal joint (rhizoarthrosis) => squaring of toe basis => loss of motility and keeping force
• hand fractures
• carpal fractures
• de Quervain's fracture : fracture of the navicular bone together with a volar luxation of the lunate bone
• metacarpal fractures
• Bennett's fracture : a fracture of the base of the first metacarpal bone running into the carpometacarpal joint and complicated by subluxation
• boxer's fracture : fracture of the metacarpal neck with volar displacement of the metacarpal head caused by striking a hard object with the closed fist
• phalangeal fractures
• bursting fracture / tuft fracture : a comminuted fracture of the distal phalanx
• radial deviation or drift : a hand deformity sometimes seen in rheumatoid arthritis, in which the fingers are displaced to the radial side. Arthritic hands may be splinted into this position to counteract ulnar deviation
• ulnar deviation or drift deformity : a hand deformity, seen in chronic rheumatoid arthritis and systemic lupus erythematosus (SLE), in which the swelling of the metacarpophalangeal joints causes the fingers to become displaced to the ulnar side
• bacinus diseases
• ilial fractures
• Duverney's fracture : fracture of the ilium just below the anterior superior spine
• sprinter's fracture : fracture of the anterior superior or of the anterior inferior spine of the ilium, a fragment of the bone being pulled off by muscular violence, as at the start of a sprint
• osteochondritis ischiopubica : a condition observed in the radiograph, consisting of granular-looking bodies at the junction of the ischium and os pubis in children.
• Coopernail's sign : ecchymosis on the perineum and scrotum or labia: a sign of fracture of the pelvis.
• hip diseases
• protrusio acetabuli / intrapelvic protrusion / arthrokatadysis / Otto's disease : a sinking in or subsidence of the floor of the acetabulum with protrusion of the femoral head through it (intrapelvic protrusion) resulting in limitation of movement of the hip joint
• open pubic arch : a congenital anomaly in which the pubic arch is not fused, the bodies of the pubic bones being spread apart.
• congenital hip (acetabular) dysplasia (CHD) / subluxation

Epidemiology : incidence = 1.5 per 1,000 births; female-to-male ratio = 8:1. The left hip is twice as often involved as the right and bilateral dislocation occurs in > 25% of affected children. CHD is more frequently encountered in Caucasians than in Negroes. CHD is very common in Mediterranean (higher in females from Alpes; rare in Sardinia)  and Scandinavian countries but is almost unknown in China, possibly due to the Chinese custom of carrying the infant on the mother's back with the child's hips flexed and abducted.
Aetiology :
• polygenic inheritance (30%)
• oligohydramnios
• pelvic presentation
• ligament weakness
Symptoms & signs : bilateral in 50% of cases
• staging :
• CHD generally refers to delayed or defective development of the hip joint leading to a deranged articular relationship between an abnormal acetabulum and a deformed proximal end of the femur. This condition is considered a precursor of the clinical entities of
• asymptomatic preluxation (within month 10, before the baby walks; if treated, 97% have restitutio ad integrum)
• asymptomatic subluxation of the hip, there is an abnormal relationship between the femoral head and acetabulum, but the two are in contact
• luxation / dislocation is associated with a complete loss of contact of the femoral head with the acetabular cartilage
• ab initio or embryonary luxation
• afterload luxation (after age 1, when baby walks; if treated 50-55% have restitutio ad integrum)
• inveterated luxation (after age 3-4, no restitutio ad integrum)
• coxarthrosis (after age 15)
• Ortolani's "jerk" sign / "clunk of entry" or reduction sign : the presence of a palpable click in and out as the hip is reduced by abduction and dislocated by adduction within month 2-3 of life
• Barlow's click, sign or test / "clunk of exit" or dislocation sign
• Allis' or Galeazzi's sign : apparent shortening of the femur, lower position of knee of the affected side when knees and hips are flexed at right angles with the patient lying on a flat table, due to location of femoral head posterior to acetabulum in this position;
• Savariaud sign
• Dupuytren or pump sign : a free up-and-down movement of the head of the femur, telescoping or pistoning action of thighs, due to lack of containment of femoral head with acetabulum
• Trelat or square sign
• asymmetries (if monolateral)
• trochanters
• increase in depth or asymmetry of the inguinal or thigh skinfolds
• Trendelenburg's sign or test : the patient standing erect with back to examiner is told to lift one leg and then the other. When weight is supported by the affected limb, the pelvis on the healthy side falls instead of rising. A positive test indicates gluteus medius weakness or a dislocated hip => monopodalic walking
• limb dysmetria (shortening of one leg)
• extrarotated lower limbs (aspecific marker for many hip lesions)
• limited abduction of the flexed hip, due to shortening and contraction of the hip adductors;
• waddling type of gait
• talipes equinovarus (12%)
• meningocoele (1.5%)
Laboratory examinations :
• echography (screening within month 2) is innocuous and allows Graff staging :
• I : normal
• II : risky
• III : mild dysplasia
• IV : severe dysplasia
• X-rays : unfortunately, the femoral head and acetabulum in the newborn cannot be assessed by direct visualization, since the femoral head is not ossified and is a cartilaginous body which is not visualized on plain films. The ossification center for the femoral head generally appears between 3-6 months; a delay in its appearance is an indication of congenital hip dysplasia. The neck of the femur is used for ascertaining the relationship between the acetabulum and the femoral head until the ossification center appears. The measurement used to evaluate the relationship of the femoral head and acetabulum include :
• inclination angle (angle between femural neck and femural diaphysis) > 125° (varism)
• declination angle (angle between femural neck and femural condyles) < 10° (antiversion)
• Hilgenreiner or Y-line is a line drawn through the superior part of the triradiate cartilage. In normal infants, the distance represented by a line (ab) perpendicular to the Y-line at the most proximal point of the femoral neck should be equal on both sides of the pelvis, as should the distance represented by a line (bc) drawn coincident with the Y-line medially to the acetabular floor. In infants age 6-7 months, the mean value for the distance (ab) has been determined to be 19.3 mm +/- 1.5 mm; for the distance (bc), 18.2 mm +/- 1.4 mm
• Putti's triad
• diastasis and supero-lateral migration (instead of usual infero-medial) of growing nucleus of femoral head
• Paci-Lorenz sign
• acetabular angle or index is an angle formed by a line drawn tangent to the acetabular roof ("escaping roof") from point (c) at the acetabular floor on the Y-line = 25-29°. In babies with CHD it is > 25°
• hypoplasia of growing nucleus in capital femoral epiphysis
• Shenton-Menard line is an arc running through the medial aspect of the femoral neck at the superior  border of the obturator foramen. It should be smooth and unbroken.
• Perkins-Ombredanne line is drawn perpendicular to the Y-line, through the most lateral edge of the ossified acetabular cartilage, which actually corresponds to the anteroinferior iliac spine in normal newborns and infants, the medial aspect of the femoral neck or the ossified capital femoral epiphysis falls in the lower inner quadrant. The appearance of either of these structures in the lower outer or upper outer quadrant indicates subluxation or dislocation of the hip.
• Andren-von Rosen line, which is obtained with at least 45 degrees of hip abduction and internal rotation, is drawn along the longitudinal axis of the femoral shaft
• in normal hips, it intersects the pelvis at the upper edge of the acetabulum.
• in subluxation or dislocation of the hip, the line bisects or falls above the anteorsuperior iliac spine.

Therapy :
• conservative, especially if diagnosed early. The most common technique is to reduce the dislocation of the femoral head by means of a flexion/abduction maneuver, for a sufficient period of time to permit proper growth of the head and acetabulum, which in turn assures a congruent and stable hip joint. This technique is usually performed on patients in the very early stages of CHD and in infants < 2 years of age; which include splinting, with a Frejka pillow splint or Pavlik harness. Colonna or Buck's skin traction is used in children 2 to 12 years of age, with a well-padded spica cast applied simultaneously to the unaffected side.
• orthosis with retractors
• Putti's retractor
• Millgram retractor
• Hohmann's retractor
• if the conservative approach fails, or the child is too old, or the deformities are too advanced, surgical management is indicated. There are several surgical techniques currently in use for treating CHD, the most popular being the
• Salter osteotomy of the innominate bone, which may be combined with simultaneous derotation varus osteotomy of the femoral neck. The key to preventing significant deformities and future arthrosis of the hip is to diagnose CHD early, before the child begins to walk, when conservative care is most effective, and before the femoral head has completely ossified.
• Lorenz-Paci operation : reduction of the dislocation, and keeping the head of the femur fixed against the rudimentary acetabulum until a socket is formed
• capsular arthroplasty : correction of dislocation or deformation of the hip by soft tissue manipulation, curetting of the acetabulum, and muscle transfer but without osteotomy
• hip osteochondrosis / Legg-Calvé-Perthes disease

Epidemiology : male:female ratio 3:1, onset :
• age 5-8 : early
• age 10-15 : late
Laboratory examinations : Rx shows the status of the ossification nucleus ... :
• hypotrophy
• displaced
• fissured / fragmented
• compression
..., edema at tendon insertion, hydrarthrus, osteonecrosis, osteoid repair ("tigrization") and ossification
Therapy to prevent destruction of femur head :
• Thomas orthosis
• pelvimalleolar plaster
• osteotomy
• adductors tenotomy
• epiphysiolysis capitis femoris / slipped femoral capital epiphyses
• coxitis / coxarthritis / coxarthria : inflammation of the hip joint
• coxitis fugax : a transient benign coxitis.
• senile coxitis : degenerative arthritis of the hip joint.
• coxodynia / coxalgia : pain in the hip
• paracoxalgia : a condition marked by pain simulating that of coxitis.
• coxarthrocace : fungus disease of the hip joint
• coxarthrosis : degenerative joint disease or osteoarthritis of the hip joint
• eccentric (superior) arthrosis
• concentric (axial, medial) arthrosis
• diffuse (coxae senilis)
Signs :
• genu varus or genu valgus
• Jansen's test (the patient is asked to cross his legs at a point just above the ankle. This motion is impossible when osteoarthritis of the hip is present)
• Patrick's test : with the patient supine, the thigh and knee are flexed on the affected side and the external malleolus is placed over the patella of the opposite leg to make a figure 4; the flexed knee is then depressed, and if pain is produced thereby arthritis of the hip is indicated. When the test is performed in a healthy individual or in one with sciatica, pain is not produced. Discomfort is elicited in hip disorders, also in lesions of the sacroiliac ligaments at the site involved. Patrick called this test fabere sign, from the initial letters of movements that are necessary to elicit it, namely, flexion, abduction, external rotation, and extension.
Therapy : drugs & physiotherapy => hip prosthesis
• hip-joint disease / coxalgia / coxarthropathy / coxotuberculosis : tuberculosis of the hip joint.
• flexion contracture

Signs : Thomas test : with the patient supine, the opposite hip from that to be tested is flexed maximally. With the opposite leg held on the chest, the degree of flexion found in the hip to be tested is low (Thomas' sign)
• trochanteric bursitis: inflammation of a trochanteric bursa with pain on the lateral part of the hip and thigh
• ischiogluteal bursitis: inflammation of the bursa over the ischial tuberosity, characterized by sudden onset of excruciating pain over the center of the buttock and down the back of the leg
• Hefke-Turner obturator sign : a widening and change in contour of the normal obturator x-ray shadow, indicative of pathologic condition of the hip joint
• hip luxation : posterior luxation may cause sciatic nerve palsy
• diseases of thigh
• coxa valga : deformity of the hip in which the angle formed by the axis of the head and the neck of the femur and the axis of its shaft is materially increased.
• coxa adducta, flexa or vara : deformity of the hip in which the angle formed by the axis of the head and neck of the femur and the axis of its shaft is materially decreased
• coxa vara luxans : fissure of the neck of the femur with dislocation of the head developing from coxa vara.
• coxa plana : head of the femur is flattened due to osteochondrosis of the capitular epiphysis of the femur
• coxa magna : a condition marked by broadening of the head and neck of the femur.
• Ehlers-Danlos syndrome (EDS) / cutis hyperelastica
• osteogenesis imperfecta congenita (OIC)
• Monteggia's dislocation : dislocation of the hip joint in which the head of the femur is near the anterosuperior spine of the ilium
• femural fractures
• basal neck fracture : fracture of the neck of the femur at its junction with the trochanteric region
• bucket-handle fracture : a tear in the semilunar cartilage, along the middle portion, leaving a loop of cartilage lying in the intercondylar notch
• extracapsular fracture : a fracture of the femur outside of the capsule
• pertrochanteric fracture : fracture of the femur passing through the great trochanter
• pillion fracture : a fracture of the lower end of the femur occurring when the knee of a person riding pillion on a motorcycle is struck in a collision; it is a T -shaped fracture with displacement of the condyles behind the femoral shaft
• Stieda's fracture : fracture of the internal condyle of the femur
• supracondylar fracture : fracture of the humerus in which the line of fracture is through the lower end of the shaft of the humerus
• transcervical fracture : fracture through the neck of the femur
• transcondylar fracture / diacondylar fracture : fracture of the humerus in which the line of fracture is at the level of the condyles, traverses the fossae, and is in part within the capsule of the joint
Aetiology :
• trauma (expecially neck fractures)
• osteolytic bone metastases (expecially diaphysary fractures)
Symptoms & signs : limb extrarotation, inguinal pain (extended down to knee if obturator nerve compression occurs) exacerbated by intrarotation maneuvers, functional impotence, ecchymosis in lateral fractures coming out of articular capsule
• Ludloff's sign : swelling and ecchymosis at the base of Scarpa's triangle together with inability to raise the thigh when in a sitting posture, a sign of traumatic separation of the epiphysis of the greater trochanter.
• Langoria's sign : relaxation of the extensor muscles of the thigh; a symptom of intracapsular fracture of the femur.
• Desault's sign : a sign of intracapsular fracture of the femur, consisting of alteration of the arc described by rotation of the great trochanter, which normally describes the segment of a circle, but in this fracture rotates only as the apex of the femur as it rotates about its own axis.
• Cleeman's sign : creasing of the skin just above the patella, indicative of fracture of the femur with overriding of fragments
• Allis' sign : relaxation of the fascia between the crest of the ilium and the greater trochanter: a sign of fracture of the neck of the femur.
Complications : medial beck fractures are at higher risk of avascular necrosis
Therapy :
• surgical reduction
• prostethic replacement in adults for neck fractures

• knee diseases
• genu recurvatum : beck-knee or hyperextension
• badger leg : inequality in the length of the legs
• genu valgum / gonycrotesis / baker leg : X-shaped limbs, knock-knee. Physiological valgism is just 7-8° (2-3 fingers)
• genu varum / gonyectyposis / bandy leg / bow leg : bow-leg, curvated limbs
• gonocampsis : permanent flexion of the knee
• plica syndrome : pain, tenderness, crepitus, and swelling of the knee joint, sometimes accompanied by weakness or locking of the joint, caused by fibrosis and calcification of the synovial plicae, usually the mediopatellar plica.
• Köhler-Pellegrini-Stieda disease : a condition characterized by a semilunar bony formation (calcification) in the upper portion of the medial collateral ligament of the knee, due to traumatism, findings initially described by Pellegrini and Stieda in the early 1900s^ref

Therapy : local corticosteroid injection and range-of-motion exercises
• Hoffa's disease : traumatic proliferation of fatty tissue (solitary lipoma) in the knee joint.
• bayonet leg : uncorrected backward displacement of the bones of the leg at the knee, followed by ankylosis at the joint
• tears of ligaments

Grading :
• I : laxity < 5 mm; rupture in < 33% of fibers
• II : defibred, laxity of 5-10 mm, rupture in > 50% of fibers
• III : complete fiber rupture; laxity > 10 mm
Localizations :
• ligament injuries
• collateral ligament tears
• cruciate ligament tears
• anterior cruciate ligament (ACL) tear

Signs :
• knee anterior drawer test :
• Lachman test : with the knee flexed 10-20°, the distal femur is stabilized with the non-dominant hand and the proximal tibia is pulled forward by grasping slightly below popliteal space with the dominant hand, causing excessive motion of the tibia anteriorly
• pivot shift phenomenon, sign or test / MacIntosh test : with the knee held at 20° flexion and in neutral rotation and with the muscles relaxed (which lets the femur drop down if the anterior cruciate ligament is torn), a slight valgus or axial force is applied to the knee (push from lateral side); subluxation or reduction of the tibia occurs if the anterior cruciate ligament is torn (the joint "clunks" in and out of place at 30° knee flexion)
• posterior cruciate ligament (PCL) tear

Epidemiology : uncommon
Signs :
• PCL sulcus test : patient sits with knees flexed at 90° with legs hanging freely over edge of exam table; the examiner palpates area between tibial plateau and femur and senses  widened space
• PCL sag test : patient supine as if sitting in a horizontal chair with thighs at 90° and knees at 90°; the examiner supports legs by holding ankles and observe increased sag as tibial plateau sinks below patella
• knee posterior drawer test : excessive movement with the knee flexed approximately 90° and the proximal tibia is pushed posteriorly
• meniscal injuries
• congenital discoid (lateral) meniscus : a semilunar lateral meniscus of the knee that has been transformed into a thickened, irregular discoid mass as a result of excess motion of the meniscus, which in turn results from congenital absence of attachment of the posterior horn of the meniscus to the tibial plateau. The excess motion also causes a clicking sound on flexion and extension of the knee. Occasionally, a discoid medial meniscus is observed
• lateral meniscus tear
• medial meniscus tear
Signs :
• joint effusion
• hyperflexion
• hyperdistension
• McMurray's test : the patient lies supine with knee flexed to 45° and hip flexed to 45°, the examiner holds ankle with one hand and knee with the other hand. He assesses for "click" suggesting meniscus relocation by applying valgus stress to flexed knee, externally rotating leg (toes point outward), and slowly extending the knee while still in valgus
• Apley's compression test / grinding test : patient lies prone on examining table with the testing leg flexed to 90°; the examiner leans on patient's foot, applying pressure to heel (compresses tibia into femur) and rotate tibia internally and externally on femur
• Bounce test
33% is associated with anterior cruciate ligament (ACL) tear
Laboratory examinations : MRI => CT, knee X-ray
Therapy :
• for grade I lesions : rest, ice, and NSAIDs
• for grade II lesions : knee brace for 14 days
• for grade III lesions : surgery
• Volkmann's subluxation : a type of tuberculous arthritis marked by flexion contracture of the knee, external rotation of the leg, genu valgus, and bending of the upper third of the tibia.
• Larsen-Johansson disease : pain and tenderness over the lower pole of the patella, often accompanied by inflammation, with radiographic evidence of a secondary ossification center in the lower pole of the patella.
• popliteal bursitis / Baker's cyst : a swelling behind the knee, caused by escape of synovial fluid which then becomes enclosed in a sac or membrane
• prepatellar bursitis / housemaid's knee : inflammation of the bursa in front of the patella, with fluid accumulating within it
• dislocation of the patella

Signs : patellar apprehension test : with the knee slightly flexed, the examiner attempts to push the patella(knee cap) in a lateral direction. Patients will become very apprehensive at this point and attempt to stop the examiner from completing the test.
• chondromalacia of the patella

Signs : quadriceps inhibition test : pressure is placed over the superior aspect of the patella and the patient is asked to perform a straight leg raising maneuver, causing pain and grinding
• rotatory instability of the knee

Signs : Slocum test : with the knee flexed approximately 90°, the foot is placed in both internal and external rotation for separate tests. The proximal tibia is then pulled forward. Excessive anterior motion of the tibia indicates , either anteromedial or anterolateral, depending upon the direction of rotation of the foot.
• gonarthritis : inflammation of a knee or knee joint.
• gonarthromeningitis : inflammation of the synovial membrane of the knee joint.
• gonitis / goneitis : inflammation of the knee
• fungous gonitis : inflammation of the knee joint in which the capsule is diffusely thickened.
• gonitis tuberculosa : tuberculosis of the knee joint
Therapy : glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain^ref
• gonarthrosis : arthritic affection of the knee joint, due to degeneration or trauma => genu varus or genu valgus
• medial compartment
• lateral compartment
• femororotuleal arthrosis
Therapy : drugs & physiotherapy => knee prosthesis
• gonyoncus / gonatocele : tumor of the knee
• gonarthrocace : white swelling of the knee, produced by tuberculous arthritis.
• gonyocele : synovitis or tuberculous arthritis of the knee.
• anserine bursitis : inflammation of the anserine bursa with pain on the medial side of the knee, sometimes seen after jogging or other heavy knee exercise and in heavy individuals with genu valgus
• parameniscitis : inflammation of the parameniscus
• knee distortion

Therapy : arthrocentesis, immobilization with plaster
• leg diseases
• apophysitis tibialis adolescentium / Osgood-Schlatter syndrome

Epidemiology : male:female ratio 10:1, onset at age 12-14
osteochondrosis of the tuberosity of the tibia targeting enthesis of patellar tendon
Therapy : plaster to prevent tendineal detachment
• osteochondrosis deformans tibiae / Blount's disease / nonrachitic bowleg / tibia vara : medial angulation of the tibia in the metaphyseal region, due to a growth disturbance of the medial aspect of the proximal tibial epiphysis; there are both infantile and adolescent types
• tibial fractures
• bumper fracture : fracture of one or both legs immediately below the knee caused by an automobile bumper, often involving the tibial plateau.
• Gosselin's fracture : a V-shaped fracture of the distal end of the tibia, extending into the ankle joint
• paratrooper fracture : fracture of the posterior articular margin of the tibia and/or of the internal or external malleolus
• pilon fracture : comminuted fracture of the inferior articular surface of the tibia and the malleoli, caused by axial compression of the ankle joint
• Wagstaffe's fracture : separation of the internal malleolus.
• Segond fracture : avulsion fracture of the tibial attachment of the iliotibial band
• trimalleolar fracture : fracture of the medial and lateral malleoli and the posterior tip of the tibia.
• Tillaux fracture : vertical fracture of the distal lateral margin of the tibia
• triplane fracture :  fracture of the distal lateral tibia occurring in 3 planes: sagittally through the epiphysis, horizontally through the physis, and coronally through the metaphysis.
• fibular fractures
• Maisonneuve fracture : spiral fracture of the neck of the fibula, associated with disruption of the tibiofibular syndesmosis
• Pott's or Dupuytren's fracture : fracture of the lower part of the fibula, with serious injury of the lower tibial articulation, usually a chipping off of a portion of the medial malleolus, or rupture of the medial ligament

Symptoms & signs : Keen's sign : increased diameter of the leg at the malleoli
• bimalleolar fracture

Therapy : surgical stabilization
• Nélaton's dislocation : dislocation of the ankle in which the talus is forced up between the end of the tibia and the fibula
• foot diseases
• congenital malformations of foot
• macropodia / megalopodia : excessive size of the feet
• tetrapus : a human fetus having 4 feet
• pes adductus : a deformed foot in which the anterior part is displaced so that it lies medially to the vertical axis of the leg
• pes pronatus : a deformed foot in which the outer border of the anterior part is higher than the inner border
• pes supinatus : a deformed foot in which the inner border of the anterior part is higher than the outer borde
• cyllosis : clubfoot or similar deformity of the foot or leg.
• congenital clubfoot / talipes / reel foot : a congenital deformity of the foot, which is twisted out of shape or position


• talipes calcaneus : a deformity in which the foot is dorsiflexed through tibioperoneoastragaleal joint
• talipes equinus : a deformity in which the foot is plantar flexed through tibioperoneoastragaleal joint, causing the person to walk on the toes without touching the heel.
• talipes varus : a deformity of the foot in which the heel is turned inward from the midline of the leg through mediotarsal Chopard's joint.
• talipes valgus : a deformity of the foot in which the heel is turned outward from the midline of the leg through mediotarsal Chopard's joint
• talipes cavus / hollow foot / cavus foot : exaggerated height of the longitudinal arch of the foot
• varus hollow (clinical form I)
• valgus hollow (clinical form II)
• pseudo-hollow (clinical form III)
Aetiology :
• congenital (< 1%)
• acquired
• neurological causes (90%) : however it has been found that in infancy, patients with either of these diseases may have an extreme pes valgoplanus
• CMT disease
• Friedreich's hereditary ataxia (Friedreich's foot : pes cavus, with hyperextension of the toes)
• multiple symmetric lipomatosis (MSL)
• split-cord malformations (SCM)
• Roussy-Levy syndrome / hereditary areflexic dystasia
• adrenomyeloneuropathy, an adult form of adrenoleukodystrophy
• Dejerine-Sottas disease (DSD)
• idiopathic (10%)
Pathogenesis : common deviation dynamics, the consequence of shortening of the sural-Achilles-calcaneoplantar system. Metatarsalgia often precedes deformation of the front of the foot. Talalgia is linked to excess traction or to a conflict between the heel and the back of the shoe
Evolution :
• distoproximal : griffe => lack of equilibrium, metatarsalgia with effusion
• intermediodistoproximal
• proximodistal (posterior hollow foot)
Laboratory examinations : Rx : longitudinal Costa-Bertani angle (calcaneal pedix - pedix of astragaloscaphoideal joint - pedix of first metatarsal head) < 100°
Therapy :
• plantar orthoses, eventually toe orthoses and orthopedic shoes which correct a dynamic hollow foot
• when surgery is used in the adult, it is generally not to correct excess cavus but to correct problems of the front of the foot such as hallux valgus, involvement of the second metatarsal bone (??), or toenails.
• pes planus / flatfoot / flat foot / platypodia : a condition in which one or more of the arches of the foot have been lowered and flattened out

Aetiology :
• primitive / congenital
• formation anomalies
• ventral astragalus
• hypoplasia of tibialis posterior muscle
• anomaly of peroneus brevis muscle
• developmental anomalies
• tarsal dysmetria (calcaneal foot is shorter than astragalic - medial- foot)
• tarsal synostosis between astragalus and calcaneus impairs pronosupination movements
• impaired talipes migration
• secondary to
• rheumatoid arthritis
• trauma
• neurological causes
• weak ligaments (sometimes accessory tarsal scaphoid causes weakness of posterior tibial tendon)
• spastic / myopathic causes
• adulthood degenerative form
Symptoms / signs :
• podogram (a print of, or an outline tracing of, the sole of the foot), graded as follows
• 1 : lateral isthmus < 1/3 of anterior heel (normally it should be < 1/3)
• weak foot : an early stage of flatfoot
Therapy : plantar orthesis lead to restitutio ad integrum in 50% and improvement in 40% of cases, while 10% need surgery
• 2 : quasi-total fulcrum
• 3 : total fulcrum
• 4 : as above + medial extroflexion due to displaced astragalus head

Therapy : surgery at age 10-11 (when foot is still growing)
• arthorisis / arthroereisis : a wedge is placed in tarsal sinus to reduce movement of astragalocalcaneal joint
• exosenotarsal arthrorisis (polylactic acid)
• endosenotarsal arthorisis (screw)
• arthrodesis with Grice operation
• osteotomy
• Helbing's sign : medialward curving of the Achilles tendon as viewed from behind
Laboratory examinations : Rx : longitudinal Costa-Bertani angle (calcaneal pedix - pedix of astragaloscaphoideal joint - pedix of first metatarsal head) > 120°
Prognosis : self-limiting in 50% if untreated
• talipes calcaneocavus : a deformity in which the anterior part of the foot is elevated and the longitudinal arch of the foot is abnormally high.
• talipes calcaneovalgus : a deformity of the foot in which the heel is turned outward from the midline of the body and the anterior part of the foot is elevated.
• talipes calcaneovarus : a deformity of the foot in which the heel is turned toward the midline of the body and the anterior part is elevated.
• talipes valgus pronatus : pronation through subastragaleal or astragalocalcaneal joint

Therapy : plaster for 2 weeks
• talipes cavovalgus : a deformity in which the longitudinal arch of the foot is abnormally high, and the heel is turned outward from the midline of the body.
• talipes cavovarus : a deformity of the foot in which the longitudinal arch is abnormally high and the heel is turned inward from the midline of the leg.
• talipes equinovalgus : a deformity of the foot in which the heel is elevated and turned outward from the midline of the body.
• talipes equinovarus supinatus : a deformity of the foot in which the heel is turned inward from the midline of the leg and the foot is plantar flexed. This is associated with the raising of the inner border of the foot (supination) and displacement of the anterior part of the foot so that it lies medially to the vertical axis of the leg (adduction). With this type of foot the arch is higher (cavus) and the foot is in equinus (plantar flexion). This is a typical clubfoot

Therapy : manipulations (not to correct equinism as we could risk to create a boat-shaped foot !), hypercorrecting plaster for 1-3 weeks, Z-shaped tenotomy to lengthen Achilles' tendon and new plaster to block the joint in the corrected position for 6 months, followed by maintenance therapy with manipulations and positioning plasters.
• Denis Browne splint
• talipes planovalgus : a deformity of the foot in which the heel is turned outward from the midline of the leg and the outer border of the anterior part of the foot is higher than the inner border. This results in a lowering of the longitudinal arch. The condition may be congenital and permanent, or it may be spasmodic as a result of reflex spasm of the muscles controlling the foot.
• metatarsovarus pes / metatarsus varus / pigeon-toes

Symptoms & signs : forefoot varism (through Lisfranc joint), C-shaped foot with medial deviation
Therapy :
• Codivilla operation (unmodified since 1906, lenghtens Achilles' tendon, median tendons, tibialis posterior tendon, medial big toe flexor tendon, common toe flexor tendon), followed by plaster containment therapy
• Bebax orthosis
• metatarsus adductocavus : a deformity of the foot in which metatarsus adductus is associated with pes cavus.
• metatarsus adductus : a congenital deformity of the foot in which the fore part of the foot deviates toward the midline.
• metatarsus varus : a congenital deformity of the foot in which its inner border is off the ground with the sole turned inward, the patient walking on the outer border of the foot.
• metatarsus adductovarus : a deformity of the foot in which metatarsus adductus is associated with metatarsus varus.
• metatarsus atavicus : abnormal shortness of the first metatarsal bone.
• metatarsus brevis : a condition in which the first metatarsal bone is shorter than normal and often abducted.
• metatarsus latus / broad foot / spread foot : a broadened foot due to spreading of the anterior part of the foot resulting from separation of the heads of the metatarsal bones from each other
• metatarsus primus varus : angulation of the first metatarsal bone toward the midline of the body, producing an angle sometimes of 20° or more between its base and that of the second metatarsal bone.
• cleft foot / split-foot deformity : a congenitally deformed foot in which the division between the third and fourth toes extends into the metatarsal region, often with ectrodactyly
• deformities of toes other than big toe
• symphalangia : congenital end-to-end fusion of contiguous phalanges of a digit, usually associated with other deformity of the hand or foot
• numeric anomalies (embrionary noxa)
• polydactyly (often bilateral and involving also hands, sometimes associated with tibial hypoplasia or infant thoracic dystrophy)
• distal phalangeal polydactyly
• intermediate phalangeal polydactyly
• proximal phalangeal polydactyly
• metatarsal polydactyly
• tarsal polydactyly
• Morand's foot : a foot having 8 toes
• oligodactyly (lack or 1 or more toes)
• transverse dysmelia
• longitudinal dysmelia if associated with lack of corresponding metatarsal bones
• monodactyly : a developmental anomaly characterized by the presence of only one digit on a hand or foot.
• adactyly (lack of all toes; rare condition associated to other systemic malformations)
• syndactyly (partial or total; if also in hand it is a.k.a. Gruber syndrome)
• cutaneous syndactyly
• fibrous syndactyly
• osseous syndactyly
• spatula foot : a foot in which several toes are fused together
• amniotic constricting band syndrome / amniotic deformities, adhesion, mutilation (ADAM) complex
• metric anomalies (foetal noxa)
• macrodactyly / digital gigantism (usually in big toe or second toe; requires destruction of bone growing nucleus due to cancerous evolution)
• arachnodactyly / acromacria / dolichostenomelia / spider finger : a condition characterized by abnormal length and slenderness of the fingers and toes

Aetiology :
• congenital contractural arachnodactyly (CCA) : a form of hereditary bone dysplasia
• Marfan's syndrome
• Achard's syndrome : arachnodactyly associated with receding mandible and joint laxity limited to the hands and feet.
• microdactyly / digital hypoplasia / brachyphalangia (isolated or associated with corresponding metatarsal hypoplasia)
• brachytelephalangia
• brachymesophalangia
• brachybasophalangia
• retracted toe due to corresponding brachymetatarsia
• axial anomalies (foetal  noxa)
• on a sagittal plan
• camptodactyly / mallet toe
• proximal camptodactyly : flexion of proximal interphalangeal joint
• distal camptodactyly : flexion of distal interphalangeal joint
• griffe : axial deviation on sagittal plan due to hyperextension of metatarsophalangeal joint and flexion of proximal interphalangeal joint (usually involving more toes and bilateral, associated with metatarsal equinism and systemic neuromuscular diseases)

Aetiology : neuralgia due to impaired equilibrium of flexor muscles
• tarsal tunnel syndrome (TTS)
• on a horizontal plan
• clinodactyly (usually in third finger, associated with Down syndrome) : axial deviation on horizontal plan
• clinophalangia (usually in distal phalanx of third finger)
• divergent toes (usually between big toe and second toe)
• fifth toe hyperadduced over forth toe
• combined anomalies
• sag foot : sagging of the arch of the foot.
• Köhler's bone disease / tarsal scaphoiditis / epiphysitis juvenilis / osteoarthrosis juvenilis / os naviculare pedis retardatum : osteochondrosis of the tarsal navicular bone in children

Epidemiology : male:female ratio 8-9:1, onset at age 3-7, monolateral (90%) or noncontemporaneously bilateral (10%)
• acquired deformities
• metric anomalies
• macrodactyly / digital gigantism => metatarsophalangeal monstruosity

Aetiology :
• arterovenous fistulae
• angiomas
• lymphomas
• Köhler's second disease / juvenile deforming metatarsophalangeal osteochondritis : changes about its articular head, characterized by pain in the second metatarsophalangeal joint on walking or standing

Epidemiology : male:female ratio 1:8, onset at age 12-15.
Pathogenesis : osteochondrosis due to high-heeled shoes
Therapy : plantars => metatarsal osteotomy
• axial anomalies
• on sagittal plan
• camptodactyly or mallet toe
• proximal camptodactyly : flexion of proximal interphalangeal joints (usually in second toe)

Aetiology :
• rheumatoid arthritis
• psoriatic arthritis
• distal camptodactyly : flexion of distal interphalangeal joints (usually in second toe)

Aetiology :
• degenerative and/or inflammatory diseases
• hook toe : flexion of both proximal and distal interphalangeal joints

Aetiology :
• neuromuscular diseases
• swan-neck toe : flexion of metatarsophalangeal joint, hyperextension of proximal interphalangeal joint and flexion of distal interphalangeal joint

Aetiology :
• rheumatoid arthritis
• griffe : axial deviation on sagittal plan due to hyperextension of metatarsophalangeal joint and flexion of proximal interphalangeal joint

Grading :
• functional / unstructured : viewable only while walking
• structured : not passively reducible
Aetiology :
• hollow foot
• polyomyelitis
• post-traumatic fibrosis
• on horizontal plan
• clinodactyly

Aetiology :
• degenerative or inflammatory diseases
• ex vacuo phenomenon after amputation of an adjacent toe
• second toe over big toe (usually hallux valgus)
• fifth toe hyperadduced over forth toe
• divergent toes

Aetiology :
• rheumatoid arthritis
• bursitis
• interdigital neuromas
• on 2 plans : fifth toe varus due to valgism of fifth metatarsal bone (sometimes associated to hallux valgus)
• combined anomalies
• mixed deformities : congenital malformations + acquired deformities
• Busquet's disease : exostoses on the dorsum of the foot due to osteoperiostitis of the metatarsal bones
• painful diseases
• plantar aponeurositis

Aetiology :
• abnormal sollecitations
• Ledderhouse syndrome : painful aponeurotic nodules

Therapy : aponeurosis ablation through incision practiced between calcaneus and first metatarsal head, followed by plaster for 15 days
• calcaneal spur : a bone excrescence on the lower surface of the calcaneus which frequently causes pain on walking.

Symptoms & signs : evokes pain by distending plantar aponeurosis
• tendon diseaes
• tibialis posterios tendinosis : decreased tendon resistance => compensatory tendineal hypertrophy => atrophy of deep tendineal regions => spontaneous tendon rupture

Therapy : scarification parallel to tendon fibers allows vascularization of deep regions
• Achilles calcaneal tendinitis

Aetiology :
• fluoroquinolones
• psoriatic arthritis
• peritendinitis : sensitive fibers innervate peritenonium / tendovaginal sheath
• peroneal tendineal luxation : due to post-traumatic retinacular weakness => relapsing luxation => secondary arthrosis
• calcaneal apophysitis (Sever-Haglund disease) : bursitisin the region of the Achilles tendon.

Epidemiology : male:female ratio 6-7:1, onset at age 8-13, monolateral (73%) or bilateral (27%).
Therapy : plasters, discharging  plantars
• ligament diseases
• acute diseases : distortion traumas during supination or pronation
• syndesmitis metatarsea / march tumor : inflammation of the metatarsal ligaments occurring during strenuous marches
Therapy : immobilization
• chronic diseases : from neglected acute diseases

Therapy : surgical ligament replacement
• nerve diseases
• canalicular syndromes / nerve entrapping syndromes => nerve degeneration
• Morton's neuroma
• trauma => vacuolar degeneration of the nerve
• articular diseases
• Lisfranc's dislocation : dislocation of the forefoot at the tarsometatarsal joints
• Smith's dislocation : upward and backward dislocation of the metatarsals and the medial cuneiform bone
• chondral detachment into articular cavity

Therapy : fragment removal and recreation of chondral integrity
• Strunsky's sign : a sign for detecting lesions of the anterior arch of the foot. The examiner grasps the toes and flexes them suddenly. This procedure is painless in the normal foot, but causes pain if there is inflammation of the anterior arch.
• foot osteoarthrosis
• localized :

Aetiology : Sudeck algodystrophy / reflex sympathetic dystrophy (RSD)
Therapy : peripheral analgesics
• generalized
• big toe valgism
• big toe stiffness
• mallet toes
• subastragalic (talonavicular) arthrosis
• output of chronic deformities
• hallux dolorosus : painful condition of the great toe usually associated with flatfoot.
• hallux malleus : hammer toe of the hallux.
• hallux flexus or rigidus : painful flexion deformity of the great toe in which there is limitation of motion at the metatarsophalangeal joint.
• hallux varus : angulation of the great toe toward the midline of the body, or away from the other toes.
• hallux valgus : angulation of the great toe away from the midline of the body, or toward the other toes; the great toe may ride under or over the other toes.Pain is due to big toe impingement with shoes. Big toe deviates > 15° from metatarsal axis and nail is prone.
• bunion : abnormal prominence of the inner aspect of the first metatarsal head, accompanied by bursal formation and resulting in a lateral or valgus displacement of the great toe.
• bunionette / tailor's bunion : enlargement of the lateral aspect of the fifth metatarsal head
• taut foot : a shortening and contraction of the calf muscles and plantar flexors of the foot, due to high-heeled shoes.
• stiff big toe / hallux limitus

Aetiology :
• structural anomalies
• metatarsus primus elevatus
• hypermobility of first metatarsal bone
• biomechanical anomalies
• retraction of flexor muscles
• excessive tension of plantar aponeurosis
• malfuctioning of peroneous longus mucle
• degenerative joint disease
• trauma
• post-surgery complications
Pathogenesis : degeneration of first metatarsophalangeal joint
Symptoms & signs : impaired normal dorsal flexion (80°) and plantar flexion (40°). Upwarding big toe while walking.
• biomechanical metatarsalgia : pain and tenderness in the metatarsal region.

Aetiology :
• distrectual metatarsalgia (noxa acting on metatarsal bone)
• skeletal diseases :
• distal dysmetrias

Therapy :
• draw back of metarsal heads via distal metaphysary osteotomy
• V-shaped osteotomy of metatarsal basis with ablation of bone mass
• shortness of first metatarsal bone in patient with hallux valgus

Therapy : semicircular osteotomy of metatarsal basis
• consolidated fractures
• articular diseases at tarsometatarsal Lisfranc joint

Therapy : V-shaped osteotomy of metatarsal basis without ablation of bone mass
• ligamentous diseases
• weak ligaments at tarsometatarsal Lisfranc joint
• weak transverse intermetatarsal joint

Therapy : intermetatarsal neoligamentoplasty
• noxa acting in a place other than metatarsal bone
• proximal metatarsalgia => talipes equinovarus or talipes equinovalgus
• malformative diseases

Therapy : osteotomy to correct calcaneal varism
• neurological diseases (flexor muscles prevalence)

Therapy : enlengthnment of flexor muscles tendons at retromalleolar cavity
• distal metatarsalgia :
• failure of distal phalanx extensor, and proximal phalanx flexor muscles

Therapy : arthrodesis of proximal interphalangeal joints
• failure of interosseous muscles

Therapy : transposition of superficial flexor muscles
• posterior tibial neuritis in tarsal tunnel syndrome (TTS)

Therapy : surgical lysis of posterior tibial nerve and terminal branches
Pathogenesis : shift of forefoot from a variable charge to a constant charge
Symptoms & signs : head metatarsalgia (usually second metatarsophalangeal joint) => griffe => dorsal luxation, plantar hyperkeratosis at overcharged areas
Laboratory examinations : Morton's test : in metatarsalgia, transverse pressure across the heads of the metatarsals causes a sharp pain, especially between the second and third metatarsals.
Therapy : ad hoc orthotic plantars with appropriate metatarsal discharges
• Kohler's second disease
• bone diseases
• accessory tarsal scaphoid => pain is due to impingement with shoe
• Hawkins sign : in fractures of the talar neck, a radiolucent zone beneath the subchondral plate of the head of the talus, indicative of disuse osteoporosis; its absence reflects increased risk of talar avascular necrosis
• MacLean-Maxwell disease : a chronic condition of the calcaneus marked by enlargement of its posterior third and attended by pain on pressure
• Morton's syndrome : a congenital insufficiency of the first metatarsal segment of the foot, characterized by metatarsalgia due to shortening or relaxation of the part.
• tarsal fractures
• Shepherd's fracture : fracture of the astragalus, with detachment of the outer protecting edge
• metatarsal fractures
• Jones fracture : diaphyseal fracture of the fifth metatarsal
• forced foot : a painful swelling of the feet of soldiers after forced marches, due to fracture of a metatarsal bone.
• march foot : painful swelling of the forefoot, often associated with fracture of one of the metatarsal bones, following excessive foot strain
• stress microfracture => onion-shaped metatarsus
• osseous callus around traumatized metatarsal bones due to repair after repeated traumas
• Sudeck algodystrophy / reflex sympathetic dystrophy (RSD)
• osteochondritis necroticans : a condition marked by necrosis and destruction in the cartilage of the sesamoid bone of the great toe.
• foot osteochondrosis:
• navicular (tarsal scaphoid) osteochondrosis :
• Freiberg's disease or infraction : osteochondrosis of the head of the second metatarsal bone
• cutaneous diseases
• Achilles bursitis / achillobursitis / superficial calcaneal bursitis : inflammation and thickening of the bursae about the Achilles tendon, especially of the bursa in front of it
• retrocalcaneal bursitis / achillodynia : pain in the Achilles tendon
• subcutaneous cysts => pain is due to impingement with shoe

Therapy : surgical ablation
• athlete's foot / tinea pedis
• Hong Kong foot
• mossy foot : chromoblastomycosis involving the foot
• ungueal diseases
• systemic diseases
• vascular foot
• diabetic foot in patients with diabetes mellitus
• burning feet : burning sensations in the soles of the feet; there are many causes such as the hyperalgesia of diabetes, alcoholism, or toxicity.
Osteomyelitis complicates up to 33% of diabetic foot infections, is often due to direct contamination from a soft-tissue lesion, and represents a clinical challenge. Early diagnosis is important since antibiotic therapy can be curative and may prevent amputation. The present study assessed the role of PET/CT using ¹⁸F-FDG for the diagnosis of diabetic foot osteomyelitis. 14 diabetic patients (10 men and 4 women; age range, 29-70 y) with 18 clinically suspected sites of infection underwent PET/CT after the injection of 185-370 MBq of ¹⁸F-FDG for suspected osteomyelitis complicating diabetic foot disease. PET, CT, and hybrid images were independently evaluated for the diagnosis and localization of an infectious process. Additional data provided by PET/CT for localization of infection in the bone or soft tissues were recorded. The final diagnosis was based on histopathologic findings and bacteriologic assays obtained at surgery or at clinical and imaging follow-up. ET detected 14 foci of increased ¹⁸F-FDG uptake suspected as infection in 10 patients. PET/CT correctly localized 8 foci in 4 patients to bone, indicating osteomyelitis. PET/CT correctly excluded osteomyelitis in 5 foci in 5 patients, with the abnormal ¹⁸F-FDG uptake limited to infected soft tissues only. One site of mildly increased focal ¹⁸F-FDG uptake was localized by PET/CT to diabetic osteoarthropathy changes demonstrated on CT. 4 patients showed no abnormally increased ¹⁸F-FDG uptake and no further evidence of an infectious process on clinical and imaging follow-up. ¹⁸F-FDG PET can be used for diagnosis of diabetes-related infection. The precise anatomic localization of increased ¹⁸F-FDG uptake provided by PET/CT enables accurate differentiation between osteomyelitis and soft-tissue infection^ref.
• neurological foot
• tabetic foot : the flat, distorted foot seen in tabes, and due to disease of the tarsus.
• Charcot's foot : the deformed foot seen in tabetic arthropathy
• dangle foot / drop foot / footdrop : dropping of the foot from a peroneal or tibial nerve lesion that causes paralysis of the anterior muscles of the leg
• dermatological foot
• rheumatological foot
• podagra : gout in the foot
• Laboratory examinations :
• X-rays always image skeleton, and sometimes also muscles
• determination of skeletal age (SA) (as opposed to chronological age (CA)) is conventionally practiced on left hand
• atlas system (for males and females) with a gap of 1.5-2 years between standard values
• Greulich-Pyle (GP) atlas
• apperance of ossification nuclei
• Béclard's nucleus : a vascular lentil-shaped center of ossification seen in the cartilage of the lower epiphysis of the femur since pregnancy month 6-7 (used for differential diagnosis between abortion and infanticide)
• indicators of maturity
• diaphysis/epiphysis fusion

• Tanner-Whitehouse II (TWII)
• radius, ulna, and short bones (TWII RUS) method

• computer aided skeletal age scores (CASAS)
• CT has higher contrast resolution for soft tissue, but lower spatial resolution, the tomographic effect is useful for bone with complex morphology, the contrast agent is used to characterize tumours; post-processing and parametric analysis are additional tools
• echography is an easy, immediate, and low-cost tool for multiplanar imaging of soft tissues (ECD is also used to image vascularization)
• MRI : higher contrast resolution, higher panoramicity and innocuity than radiological techniques
• Web resources
• Associations (see also Italian associations) :
• Bibliography :
• Orthopaedic Research Society (ORS)
• Wheeless' Textbook of Orthopaedics
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
• dmoz Open Directory Project (ODP) : Osteopathy
• Usenet sci.med.orthopedics