Lecture Slides

Slide 1 ______Musculoskeletal Specialty Review ______

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Slide 2 ______

Musculoskeletal Specialty Review: ______Trauma & Tumors ______

Christopher Cerniglia, DO, MEng Chief, Division of Musculoskeletal Imaging Department of Radiology ______UMass Memorial Medical Center Program Director, Musculoskeletal Fellowship Associate Director, Radiology Residency Program University of Massachusetts Medical School

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Slide 3 ______Outline • Cases ______

• Trauma ______• Tumors

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______Slide 4 CASES ______

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4 June 2014 ______

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Slide 5 ______Case 1 • Hx: Trauma ______

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Slide 6 ______Case 1 ______

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______Slide 7 ______Question 1 ______

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Slide 8 ______Case 2 • Pain s/p trauma ______

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Slide 9 ______Case 2 ______

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______Slide 10 ______Question 2 ______

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Slide 11 ______Case 3 • Hx: Clip injury while playing football ______

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Slide 12 ______Case 3 ______

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______Slide 13 ______Question 3 ______

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Slide 14 ______Case 4 • Palpable Mass x 1 month ______

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Slide 15 ______Case 4 ______

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______Slide 16 ______Question 4 ______

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Slide 17 ______Case 5 • Slowly Enlarging Palpable Mass ______

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Slide 18 ______Case 5 ______

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______Slide 19 ______Question 5 ______

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Slide 20 ______Case 6 • Medial Volar Hand Mass ______

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Slide 21 ______Case 6 ______

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______Slide 22 ______Question 6 ______

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Slide 23 ______Case 7 • 51 year old female with several week history ______of knee pain.

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Slide 24 ______Case 7 ______

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______Slide 25 ______Question 7 ______

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Slide 26 ______Case 8 • 40 year old with right thigh pain ______

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Slide 27 ______Case 8 ______

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______Slide 28 ______Question 8 ______

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Slide 29 ______Trauma & Sports Injuries

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Slide 30 ______TRAUMA • Axial Trauma ______– Spine – Pelvis • Appendicular Trauma – Upper Extremity ______– Lower Extremity • Sequela & Complications ______

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______Slide 31 ______TRAUMA • Axial Trauma ______– Spine – Pelvis • Appendicular Trauma – Upper Extremity ______– Lower Extremity • Sequela & Complications ______

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Slide 32 ______SPINE

• Mechanism of injury – Flexion ______– Extension – Axial load/burst – Distraction – Translation • Fracture/ligament injury patterns ______• Column concept/stability – Cervical – Thoracic – Lumbar – Sacrum/coccyx ______

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Slide 33 ______

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______Slide 34 ______MECHANISM OF INJURY • Flexion/Extension ______– E.g. Teardrop Fx • Axial Load/Distraction – E.g. Compression Fx ______• Rotation • Translation • MIXED ______– E.g. Hangman (Distraction/Extension)

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Slide 35 ______FLEXION • Hyperflexion Sprain (Ant Subluxation) ______• Anterior Wedge Fx • Clay Shoveler’s Fx • B/L Interfacetal Dislocation ______• Flexion Teardrop Fx

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Slide 36 ______Anterior Wedge Fx ______

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• Loss of height of anterior vertebral • Anterior superior Fx of VB ______body • C/W Burst NO Vertical Fx Component • Buckled anterior cortex NO Post cortical Involvement

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______Slide 37 ______Seatbelt Fracture

• Secondary to hyperflexion at the ______waist : – Anterior compression of the vertebral body – Distraction of ______posterior elements and ligaments • Usually involves T12, L1, or L2 ______

7/1/2014 37 ______

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Slide 38 ______Bilateral Locked Facets

• There is hyperflexion, the spinous process is ______distracted, facets override, and the spine recoils • 50% vertebral body ______displacement anteriorly ______Unstable 7/1/2014 38 ______

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Slide 39 ______• Teardrop fragment Flexion Teardrop anterior vertebral body avulsion fracture ______• All ligaments are disrupted

• Posterior subluxation of vertebral body ______into the spinal canal often leads to Spinal cord compression

• Spinous Process Fx ______

Image: c/o Spencer B. Gay, MD Univ of Virginia Health System

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______Slide 40 ______EXTENSION • C1 anterior arch Avulsion Fx ______• C1 posterior arch Fx • Extension Teardrop Fx • Laminar Fx ______• Hangman’s Fx

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Slide 41 ______ANSWER 1 ______

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Slide 42 ______Hangman’s Fracture

• Extension & Distraction of C2 ______from MVA/Hanging • B/L C2 pars (common) or pedicle fx ______• Anterior sublux of C2 can occur • Ant Inf corner Fx C2 ______can occur (ALLig)

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______Slide 43 ______AXIAL LOAD • Jefferson Fx ______• Compression Fx

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Slide 44 ______Jefferson’s Fx ______

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Slide 45 ______

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______Slide 46 ______Jefferson Fx

• Fracture of C1 vertebra • Axial loading with neck extended ______• Transverse ligament integrety determines stability • Open mouth view- lateral masses of C1 align with lateral masses of C2 ______

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Slide 47 ______MIXED/OTHER • Unilateral Facet ______• Odontoid Fracture

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Slide 48 ______Unilateral Facet

• MIXED Severe flexion associated with rotation ______• Results in: – Rupture of Facet joint ligaments – Facet joint dislocation ______• 25 % anterior vertebral body displacement • “Bow tie” appearance on lateral radiograph ______

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______Slide 49 ______Unilateral Facet • MIXED Severe flexion associated with rotation ______• Results in: – Rupture of Facet joint ligaments – Facet joint dislocation ______• 25 % anterior vertebral body displacement • “Bow tie” appearance on lateral radiograph ______

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Slide 50 ______Unilateral Facet ______

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Slide 51 ______Odontoid Fx

• Type 1 – Fx upper dens ______– Rare

• Type 2 ______– Fx at base of dens

• Type 3 – Base and body of C2 ______

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______Slide 52 ______DISH/AS • Be careful with ______ankylotic and fused spine • Significant Injury with Minor Trauma ______

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Slide 53 ______

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Slide 54 ______TRAUMA • Axial Trauma ______– Spine – Pelvis • Appendicular Trauma – Upper Extremity ______– Lower Extremity • Sequela & Complications ______

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______Slide 55 ______Sacral Insufficiency Fracture ______

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Slide 56 ______Pelvic Fx

• Stable – Single break of ring ______• Unilateral Pubic Rami (PR) – Peripheral Fx • Avulsions – ASIS, AIIS, IT, Pubus • Unstable ______– 2 breaks in ring – Malgaigne: SI & Ipsilateral PR – Bucket: SI & Contralateral PR – Straddle: B/L Opterator ______Rings – Dislocation: SI and symphysis

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Slide 57 ______TRAUMA • Axial Trauma ______– Spine – Pelvis • Appendicular Trauma – Upper Extremity ______– Lower Extremity • Sequela & Complications ______

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______Slide 58 ______Upper Extremity Trauma • Clavicle & AC joint ______• Shoulder & GH joint • Elbow • Forearm ______• Wrist • Hand ______

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Slide 59 ______Clavicle and AC joint • Grades of acromioclavicular joint separation ______• Clavicle fracture • Sternoclavicular fracture / dislocation • Post-traumatic osteolysis ______

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Slide 60 ______AC Separation ______

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______Slide 61 ______Clavicle Fracture

• Nonunion and malunion greatest at ______central 1/3 of clavicle • Allman Classification ______

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Slide 62 ______SC Fracture/Dislocations • Direct Impact ______• Anterior MC • Posterior LC – Risk for vascular injury ______

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Slide 63 ______Post Traumatic Osteolysis

• Common repetitive trauma/overuse ______• Weightlifters • DDX: – B/L: ______Hyperparathyroidism/ RA/Scleroderma – U/L: Infection/Tumor/Surg ______ery

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______Slide 64 ______Upper Extremity Trauma • Clavicle & AC joint ______• Shoulder & GH joint • Elbow • Forearm ______• Wrist • Hand ______

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Slide 65 ______Shoulder

• Anatomic vs. surgical neck humerus • Rotator cuff tear fracture • Labral injury • Greater tuberosity humerus fracture – Patterns of instability ______• Scapular fracture – SLAP tear – Body • Proximal biceps tear or dislocation – Glenoid • Impingement syndrome • Dislocations – Anterior – Anterior – Posterior • (a) Hill Sachs fracture – Coracoid • (b) Bankart fracture • ______• (c) Recurrence Adhesive capsulitis – Posterior • (a) Reverse Bankart • (b) Neurovascular injuries – Other • Inferior • scapulothoracic dissociation* ______

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Slide 66 ______

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______Slide 67 ______Greater Tuberosity Fx • Post dislocation ______• Avulsion fractures of RTC ______

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Slide 68 ______Anterior Dislocation ______

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Slide 69 ______Anterior Dislocation

Hill-Sachs Deformity Bankart Lesion ______

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______Slide 70 ______Anterior Dislocation

• Indirect force from – abduction, ______– external rotation and – extension • Best demonstrated on ______AP internal rotation view • Recurrence is common after first dislocation ______

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Slide 71 ______Posterior Dislocation

• Direct or Indirect force a/w seizures or ______electrical shock • Fixed Internal Rotation • No overlap of humerus ______• + Rim Sign • +/- Trough Sign • +/- Reverse Bankart ______

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Slide 72 ______Inferior Dislocation • Luxatio Erecta ______• Risk of injury to: – Ax artery – Brachial Plexus – Rotator Cuff ______

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______Slide 73 ______Pseudo-dislocation • Inferior and lateral displacement of humeral ______head due to hemarthrosis

• Often occurs in fractures of the humeral head or neck ______

• NOT a true dislocation ______

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Slide 74 ______RTC • SS, IS, TM = GT ______• SubS = LT • AH interval <6mm Chronic RCT ______

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Slide 75 ______

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______Slide 76 ______FT Supraspinatus Ter ______

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Slide 77 ______FT Tear Junctional Fibers SS-IS ______

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Slide 78 ______Labral Injuries ______

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______Slide 79 ______Labral Injuries SLAP ______• Type I Fraying • Type II Tear SL • Type III bucket ______handle of SL • Type IV Tear SL w/biceps involvment ______

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Slide 80 ______Prox Biceps Tear/Dislocation • A/W Labral tear ______• Often degenerative in etiology c/w distal biceps often traumatic ______

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Slide 81 ______Impingement • Suprascapular Notch ______• Spinoglenoid Notch • Quadrilateral Space Syndrome ______

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______Slide 82 ______Quadrilateral Space Syndrome ______

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Slide 83 ______Adhesive Capsulitis • Acute/Subacute phase ______

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PD FSE w/wo FS

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Slide 84 ______Adhesive Capsulitis • Chronic phase ______

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______Slide 85 ______Upper Extremity Trauma • Clavicle & AC joint ______• Shoulder & GH joint • Elbow • Forearm ______• Wrist • Hand ______

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Slide 86 ______Elbow

• Radial head fracture • Fracture/dislocation ______• Humeral condyle fractures • Extensor tendinosis (tennis elbow/lateral epicondylitis) • Flexor tendinosis (pitcher’s elbow/medial epicondylitis) ______• Ulnar collateral ligament tear • Radial collateral ligament tear • Biceps avulsion • Triceps avulsion ______

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Slide 87 ______Radial Head/Neck Fx ______

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______Slide 88 ______Posterior Elbow Dislocation ______

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Slide 89 ______Lateral Epicondylitis ______

______• Tennis Elbow • Degeneration and Tearing of CET (ECU, EDC, and ECRB) ______• Overuse injury

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Slide 90 ______RCL tear ______

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______Slide 91 ______RCL Tear ______

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Slide 92 ______UCL tear ______

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Slide 93 ______Biceps Tendon Tear ______

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______Slide 94 ______

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Slide 95 ______Post Tendon Repair ______

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Slide 96 ______Upper Extremity Trauma • Clavicle & AC joint ______• Shoulder & GH joint • Elbow • Forearm ______• Wrist • Hand ______

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______Slide 97 ______Forearm • Galeazzi fracture/dislocation ______• Monteggia fracture/dislocation • Isolated ulna (nightstick) fracture ______

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Slide 98 ______Galeazzi fracture-dislocation ______

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Fx RADIUS with Dislocation at DRUJ. Galeazzi fractures have a peak incidence of 9-12 years of age. ______

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Slide 99 ______Monteggia fracture-dislocation

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• Fracture of the ulna diaphysis & dislocation of radial head

• Detect Ulnar Fx -> Look to radial head – can miss disloc ______

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______Slide 100 ______Night Stick Fracture

Isolated ulnar shaft fracture ______

Most commonly a/w self defense against blunt trauma ______Force is to the medial forearm as the arm is used to shield head and body ______

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Slide 101 ______Essex-Lopresti Fracture

• Comminuted fracture of ______the radial head

• Dislocation of the DRUJ ______

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Slide 102 ______Buckle and Greenstick Fractures

• Distal radius Buckle (Torus) fractures very ______common injuries in children. ______• Quick to heal

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______Slide 103 ______Forearm • Galeazzi fracture/dislocation ______• Monteggia fracture/dislocation • Isolated ulna (nightstick) fracture ______

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Slide 104 ______Upper Extremity Trauma • Clavicle & AC joint ______• Shoulder & GH joint • Elbow • Forearm ______• Wrist • Hand ______

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Slide 105 ______Wrist

• Colles fracture • Ligament tears • Smith fracture – Interosseous ligaments ______• Radial styloid fracture – Triangular fibrocartilage complex • Isolated carpal bone fracture – Extrinsic ligaments – Scaphoid fracture • Chronic carpal instability • Significance of blood supply • Osteonecrosis – Dorsal intercalated segment • Non-union instability ______– Triquetral fracture – Volar intercalated segment instability – Hamate fracture – Scapholunate advanced – Other collapse • Complex carpal bone injuries • Distal radioulnar joint injury – Perilunate dislocation • Carpal tunnel syndrome – Lunate dislocation • Ulnar impaction syndrome ______

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______Slide 106 ______Colles Fracture

• MC Fx distal radius. • Transverse Fx of ______distal radial metaphysis • Dorsal angulation and displacement of the distal ______fragment. • Typically produced by a fall on an outstretched hand, with the wrist ______dorsiflexed.

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Slide 107 ______Smith Fracture

• Reverse Colles fracture with fracture of the ______metaphysis and volar angulation of the distal fracture fragment.

• Younger patients results ______from extensive traumatic forces on the volar flexed wrist. ______• Volar comminution is common.

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Slide 108 ______Smith Fracture

• Type 1: Horizontal Fx line ______• Type 2: Oblique Fx line

• Type 3: Intra-articular oblique (Reverse Bartons) ______

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______Slide 109 ______Chauffeur Fracture

• Chauffeur aka Hutchinson or Backfire fracture consists of an oblique, intraarticular fracture of the distal radius ______involving the radial styloid. Displaced fracture fragments indicates disruption of intercarpal ligaments. • • The name originates from documented injuries while ______cranking backfiring automobile starters in the early 20th century. This fracture is classically a shearing force transmitted through the scaphoid or scapholunate interval. ______

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Slide 110 ______Chauffeur Fracture Intra-articular fracture of the distal radius involving the ______radial styloid.

Displaced fracture fragments indicates disruption of ______intercarpal ligaments

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Slide 111 ______Scaphoid Fracture • Most common carpal fracture • At risk of AVN, especially at ______proximal pole

• 65%: waist • 15%: proximal pole ______• 10%: distal body • 8%: volar tuberosity • 2%: through the distal articular surface ______

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______Slide 112 ______Scaphoid Fracture ______

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Slide 113 ______Lunate Fracture ______

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Slide 114 ______Triquetral Fracture

• Common at dorsal surface ______

• Avulsions from ligamentous attachments ______

• Dorsal avulsion best detected on a lateral ______projection

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______Slide 115 ______Hamate Fractures ______

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______BODY HOOK

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Slide 116 ______Hamate Hook Fracture ______

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Slide 117 ______Other Carpal Fracture

• Capitate fx = rare; high suspicion • Trapezoid are rare due to stabilization from its ______articulations, and may be associated with a dislocation of the second metacarpal. • Pisiform (sesamoid bone) within FCU tendon and injury often occurs in the setting of direct trauma. ______– vertical, – transverse – or a compressive ______

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______Slide 118 Pisiform Fracture ______

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Slide 119 ______Answer 2 ______

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Slide 120 ______Carpal Arcs ______

Arc 3

Arc 2

Arc 1 ______

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______Slide 121 Perilunate injury: Greater and Lesser ______Arcs • Perilunate dislocation (lesser arc injury) is a pure ligamentous disruption around the lunate. ______• Perilunate dislocation with associated fracture of one or more bones around the lunate (scaphoid, trapezium, capitate, hamate, or triquetrum) is called a greater arc injury. ______• Perilunate injuries result from high-energy wrist hyperextension, typically falls from a height, motor vehicle collisions, or sports-related injuries. ______

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Slide 122 Perilunate injury: Greater and Lesser ______Arcs • Lesser Arc injuries (ligamentous) ______– Scapholunate – Perilunate – Midcarpal ______2 – Lunate 3 1 4 • Greater Arc injuries (ligamentous with adjacent fractures) ______

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Slide 123 Lesser Arc Injury ______Stage I: Scapholunate Dissociation ______

2 3 1 ______4

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______Slide 124 Lesser Arc Injury ______Stage II: Perilunate ______

2 ______2 3 3 1 1 4 4 ______

Stage 2 lesser arc with associated Normal fractures/greater arc disrpution Comparison ______

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Slide 125 ______Trans Styloid Perilunate Dislocation ______

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Slide 126 Lesser Arc Injury ______Stage III: Midcarpal ______

2 2 ______1 3 3 4 1 4

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______Slide 127 Lesser Arc Injury ______Stage IV: Lunate ______

2 ______3 1 4

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Slide 128 Stage IV: Trans-Scaphoid ______Lunate Dislocation ______

2 ______3 1 4

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Slide 129 ______SLAC Wrist ______

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______Slide 130 ______SLAC: Watson Classification

• Stage I Arthritis between scaphoid ______and radial styloid • Stage II Arthritis between scaphoid and entire scaphoid ______facet of the radius • Stage III Arthritis between capitate and lunate ______

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Slide 131 ______Wrist

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Slide 132 ______Upper Extremity Trauma • Clavicle & AC joint ______• Shoulder & GH joint • Elbow • Forearm ______• Wrist • Hand ______

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______Slide 133 ______Hand

• Phalanx fracture / dislocation – Intra vs. extra articular ______– Volar plate fracture – Tuft fracture • Metacarpal fracture – Bennett vs. Rolando fracture – Boxer fracture • Carpometacarpal dislocation ______• Tendon injuries • Pulley injuries • Capsular and collateral ligament injuries – Gamekeeper (skier) thumb – Metacarpophalangeal joint ______

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Slide 134 ______

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Slide 135 ______TRAUMA • Axial Trauma ______– Spine – Pelvis • Appendicular Trauma – Upper Extremity ______– Lower Extremity • Sequela & Complications ______

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______Slide 136 ______Lower Extremity Trauma • Hip ______• Femur • Knee • Ankle ______• Foot

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Slide 137 ______Hip & Femur • Acetabular fracture - fracture patterns ______• Hip dislocation - risk of osteonecrosis • Femoral neck fracture • Intertrochanteric fracture ______• Femoral head fracture • Labral injury ______

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Slide 138 ______Lower Extremity Trauma • Hip ______• Femur • Knee • Ankle ______• Foot

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______Slide 139 ______Patellar Fx post Dislocation ______

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Slide 140 ______Patellar Dislocation ______

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Slide 141 ______Discoid LM ______

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______Slide 142 ______Bucket Handle ______

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Slide 143 ______Radial Tear ______

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Slide 144 ______Horizontal Oblique Tear ______

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______Slide 145 ______Parrot-beak ______

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Slide 146 ______IT Band Syndrome ______

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Slide 147 ______Displaced Meniscal Fragments • Anterior Flipped LM ______

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______Slide 148 ______Answer 3 ______

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Slide 149 ______ACL ______

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Slide 150 ______Knee

• Femoral condyle fracture • Ligament injury • Tibial plateau fracture – Anterior cruciate • Knee dislocation – Posterior cruciate ______• Patella fracture – Medial collateral – Lateral collateral • Patella dislocation • Extensor mechanism injury • Meniscal injury – Quadriceps tear – Bucket handle tear – Patellar tendon (ligament) tear – Parrot-beak tear – Retinaculum injury – Horizontal oblique tear • Posterolateral corner injury – Horizontal cleavage tear – Popliteus muscle/tendon – Vertical longitudinal tear – Arcuate ligament* ______– Radial tear – Popliteofibular ligament* – Complex tear – Fabellofibular ligament* – Root tear – Meniscocapsular separation • Articular cartilage injury – Fraying and degeneration • Overuse injuries – Displaced fragments – Plica syndrome – Meniscal cyst – Iliotibial band friction syndrome – Pes anserine bursitis ______

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______Slide 151 ______Lower Extremity Trauma • Hip ______• Femur • Knee • Ankle ______• Foot

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Slide 152 ______Ankle Foot

• Mechanisms of injury • Calcaneal fracture - anterior • Pilon fracture process fracture ______• Tilleaux fracture • Fifth metatarsal base • Maisonneuve fracture fracture • • Ligament injury Metatarsal fracture – Anterior talofibular ligament • Lisfranc fracture/dislocation – Deltoid ligament • Phalanx fracture ______– Syndesmotic/anterior • Cuboid fracture tibiofibular ligament • Navicular fracture • Talar fracture – Dome fracture – Neck fracture – Lateral process fracture ______

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Slide 153 ______Lisfranc ______

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______Slide 154 ______TRAUMA • Axial Trauma ______– Spine – Pelvis • Appendicular Trauma – Upper Extremity ______– Lower Extremity • Complications ______

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Slide 155 ______FRACTURE COMPLICATIONS

IMMEDIATE DELAYED • Hemorrhage/Epidural • Malunion ______Hematoma • Nonunion • Fat Embolism • Premature physeal • Acute Ischemia closure • Spinal Cord Injury • Osteonecrosis – Femoral head ______– Scaphoid proximal pole – Talar dome • Infection • Arthritis ______

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Slide 156 ______

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______Slide 157 ______AVN scaphoid • Post fracture ______• AVN of scaphoid without prior fx: – Preiser Dz • DDx fx nonunion without avn ______• Typically prox pole waist fx and nonunion • T1C+ indicates viable marrow ______

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Slide 158 ______Osteonecrosis • Femoral Head ______• Scaphoid • Talar dome ______

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Slide 159 ______

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______Slide 160 ______OTHER TRAUMA

• Stress injuries (bone and • Soft tissue injuries soft tissue) – Grades of muscle tear ______– Mechanisms – Grades of ligament tear – Pathophysiology – Myositis ossificans – Epidemiology • Thermal trauma – Imaging diagnosis – Burns ______– Implications for treatment – Cold injury • Repetitive trauma – Tendinosis – Enthesophytes – Other ______

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Slide 161 ______Answer 4 ______

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Slide 162 ______

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______Slide 163 ______

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Slide 164 ______Tenosynovitis 2nd EC ______

______• EXTENSOR CARPI RADIALIS LONGUS AND BREVIS TENOSYNOVITIS ______

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Slide 165 ______

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______Slide 166 ______BREAK ______

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• End Part 1: Trauma ______• Begin Part 2: Tumor after the break

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Slide 167 ______Tumors • Insert Picture ______

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Slide 168 ______Answer 5 ______

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______Slide 169 ______

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Slide 170 ______Answer 6 ______

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Slide 171 ______Answer 7 ______

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______Slide 172 ______Answer 8 ______

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Slide 173 ______EG ______

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Slide 174 ______BONE • Clinical: Age & Symptoms ______• Tumor Location • Tumor Matrix • Tumor Aggressiveness ______

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______Slide 175 ______PEARLS: AGE

• AGE < 30 • AGE > 40 – Infection – Mets ______– EG – Myeloma – ABC – Infection – NOF ______– Chondroblastoma – UBC ______

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Slide 176 ______PEARLS: Symptoms

• PAINLESS – FD ______– Enchondroma – NOF – UBC ______

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Slide 177 ______PEARLS: Location

• Epiphysis – Infection ______– GCT – Chondroblastoma ______– Infection – Geode – Mets/Infiltrative – CCC ______

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______Slide 178 ______PEARLS: Symptoms

• PAINLESS – FD ______– Enchondroma – NOF – UBC ______

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Slide 179 ______RADIOGRAPHS Lodwick • IA Geographic – Well defined Classification – Sclerotic Rim – Intact Cortex • IB Geographic ______– Well defined – Non-sclerotic rim – Thinning of Cortex • IC Geographic – Ill defined ______– Non-sclerotic rim – Penetration /Destruction of Cortex • II Moth-eaten – Lamellar/Onion-skin Rxn. • III Moth-eaten and permeative ______– Destruction – Radial/Spicular rxn

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Slide 180 ______Lodwick ______

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______Slide 181 ______CT/MRI - Bone • CT: ______– Matrix characterization • MRI: – Assessing the response to treatment – Postchemotherapeutic MRI signal–intensity ______changes – Detecting recurrence ______

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Slide 182 ______PEARLS: Multiple Osseous Lesions • METS ______• Myloma • EG • FD ______• Enchondromas • Brown Tumers ______

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Slide 183 ______Bone: BENIGN

• Cartilaginous • Vascular – Enchondroma – Hemangioma - Multiple (Osler-Weber- Rendu) • Multiple (Ollier disease) – Hemophilic pseudotumor • Maffucci syndrome – Lymphangioma ______– Osteochondroma - Multiple hereditary exostoses – Glomus tumor – Chondromyxoid Fibroma – Chondroblastoma – Hemangiopericytoma* – Chondroma - Periosteal (surface, juxtacortical) – Gorham disease* • Fibrous • Other – Fibroxanthoma (non-ossifying fibroma) – Unicameral bone cyst (simple bone cyst) • Fibrous cortical defect – Aneurysmal bone cyst • Benign fibrous histiocytoma • (a) Primary – Fibrous dysplasia - McCune-Albright • (b) Secondary ______– Chondromyxoid fibroma – Giant cell tumor of bone – Desmoplastic fibroma – Langerhans cell histiocytosis (eosinophilic – Osteofibrous dysplasia (ossifying fibroma)* granuloma) • Osteogenic – Chordoma – Enostosis (bone island) - Multiple – Intraosseous ganglion – Osteoma - Multiple – Reactive lesions – Osteoid osteoma • Giant cell reparative granuloma – Osteoblastoma • Bizarre parosteal osseous proliferation (BPOP)* ______• Lipoid • Epidermoid inclusion cyst – Lipoma – Liposclerosing myxofibrous tumor (LSMFT)*

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______Slide 184 ______Enchondroma ______

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Slide 185 ______MHE ______

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Slide 186 ______Periosteal Chondroma ______

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______Slide 187 ______Periosteal Chondroma ______

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Slide 188 ______Periosteal Chondroma ______

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Slide 189 ______

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______Slide 190 ______

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Slide 191 ______

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Slide 192 ______Osteoid Osteoma ______

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______Slide 193 ______Surface Osteoma ______

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Slide 194 ______

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Slide 195 ______

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______Slide 196 ______

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Slide 197 ______

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Slide 198 ______EG ______

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______Slide 199 ______Bone: BENIGN

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Slide 200 ______Bone: MALIGNANT

• Cartilaginous - Chondrosarcoma • Vascular – Central – Angiosarcoma – Peripheral – Hemangioendothelioma ______– Dedifferentiated – Mesenchymal • Other – Clear cell – Chordoma – Multiple myeloma (plasmacytoma) • Fibrous – Ewing sarcoma – Fibrosarcoma – Primitive neuroectodermal tumor – Malignant fibrous histiocytoma (PNET) – Adamantinoma ______• Osteogenic - Osteosarcoma – Lymphoma – – Conventional Leukemia • chloroma – Surface • Periosteal • Parosteal SECONDARY • High grade surface • Radiation – Telangiectatic • Pagets ______– Low grade central • Metastatic

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Slide 203 ______Bone: MALIGNANT

PRIMARY • Vascular • Cartilaginous - Chondrosarcoma – Angiosarcoma – Central – Hemangioendothelioma ______– Peripheral – Dedifferentiated • Other – Mesenchymal – Chordoma – Clear cell – Multiple myeloma (plasmacytoma) – Ewing sarcoma • Fibrous – Primitive neuroectodermal tumor – Fibrosarcoma (PNET) – ______– Malignant fibrous histiocytoma Adamantinoma – Lymphoma – Leukemia • Osteogenic - Osteosarcoma • Chloroma – Conventional – Surface SECONDARY • Periosteal • Parosteal • Radiation • High grade surface • Pagets ______– Telangiectatic • Metastatic – Low grade central

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Slide 204 ______SOFT TISSUE ______

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______Slide 205 ______Soft Tissue: BENIGN

• Fibrous • Lipoid – Fibroma – Lipoma – Fibromatosis – Angiolipoma ______– Desmoid – Hibernoma – Elastofibroma – Lipoblastoma • Neural • Muscle – Neurofibroma – Rhabdomyoma – Schwannoma – Leiomyoma – Neurofibromatosis • Dermal/subcutaneous – Neuroma – Sebaceous cyst – Lipomatosis of nerve (fibrolipomatous – Dermatofibroma hamartoma) – Granuloma annulare ______– Post-resection neuroma – Granular cell tumor* – Morton neuroma • Other • Cartilaginous - soft tissue chondroma – Myxoma • Vascular – Giant cell tumor of tendon sheath – Hemangioma – Pigmented villonodular synovitis – Hemangioendothelioma – Ganglion – Glomus tumor – Vascular malformations ______– Lymphangioma

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Slide 206 ______Desmoid Tumor ______

______• Plantar Fibromatosis ______

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Slide 207 ______Elastofibroma ______

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Slide 209 ______Neuroma ______

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Slide 210 ______Atypical Lipoma ______

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______Slide 211 ______Epidermal Cyst ______

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Slide 215 ______Soft Tissue: BENIGN

• Fibrous • Lipoid – Fibroma – Lipoma – Fibromatosis – Angiolipoma ______– Desmoid – Hibernoma – Elastofibroma – Lipoblastoma • Neural • Muscle – Neurofibroma – Rhabdomyoma – Schwannoma – Leiomyoma – Neurofibromatosis • Dermal/subcutaneous – Neuroma – Sebaceous cyst / Epidermoid cyst – Lipomatosis of nerve (fibrolipomatous – Dermatofibroma hamartoma) – Granuloma annulare ______– Post-resection neuroma – Granular cell tumor* – Morton neuroma • Other • Cartilaginous - soft tissue chondroma – Myxoma • Vascular – Giant cell tumor of tendon sheath – Hemangioma – Pigmented villonodular synovitis – Hemangioendothelioma – Ganglion – Glomus tumor – Vascular malformations ______– Lymphangioma

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Slide 216 ______Soft Tissue: MALIGNANT

PRIMARY SECONDARY • Fibrosarcoma • Metastasis ______• Malignant fibrous histiocytoma • Leukemia (high-grade undifferentiated • Lymphoma pleomorphic sarcoma) • Soft tissue extension of bone • Synovial sarcoma lesion • Rhabdomyosarcoma • Malignant peripheral nerve ______sheath tumor • Liposarcoma – (a) Myxoid – (b) Well-differentiated – (c) Dedifferentiated • Melanoma ______

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______Slide 217 ______High Grade Sarcoma ______

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Slide 218 Synovial ______Sarcoma ______

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______Slide 220 ______Lymphoma ______

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Slide 221 ______Soft Tissue: MALIGNANT

• Fibrosarcoma • Metastasis • Malignant fibrous histiocytoma (high- • Leukemia grade undifferentiated pleomorphic • Lymphoma ______sarcoma) • Soft t • Synovial sarcoma • Rhabdomyosarcoma • Malignant peripheral nerve sheath tumor • Epithelioid sarcoma* • Liposarcoma – (a) Myxoid – (b) Well-differentiated ______– (c) Dedifferentiated • Dermatofibrosarcoma protuberans* • Alveolar soft part sarcoma* • Myxofibrosarcoma* • Soft tissue osteosarcoma* • Kaposi sarcoma* • Melanoma ______

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______Thank You ______Contact/Questions: [email protected] ______

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