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X-rays show lucency of the ossification front in juveniles. In older people, the lesion typically appears as an area of osteosclerotic bone with a radiolucent line between the osteochondral defect and the epiphysis. The visibility of the lesion depends on its location and on the amount of knee flexion used. Harding described the lateral X-ray as a method to identify the site of an OCD lesion.
Magnetic resonance imaging (MRI) is useful for staging OCD lesions, evaluating the integrity of the joint surface, and distinguishing normal variants of bone formation from OCD by showing bone and cartilage edema in the area of the irregularity. MRI provides information regarding features of the articular cartilage and bone under the cartilage, including edema, fractures, fluid interfaces, articular surface integrity, and fragment displacement. A low T1 and high T2 signal at the fragment interface is seen in active lesions. This indicates an unstable lesion or recent microfractures. While MRI and arthroscopy have a close correlation, X-ray films tend to be less inductive of similar MRI results.
Computed tomography (CT) scans and Technetium-99m bone scans are also sometimes used to monitor the progress of treatment. Unlike plain radiographs (X-rays), CT scans and MRI scans can show the exact location and extent of the lesion. Technetium bone scans can detect regional blood flow and the amount of osseous uptake. Both of these seem to be closely correlated to the potential for healing in the fragment.
Physical examination often begins with examination of the patient's gait. In OCD of the knee, people may walk with the involved leg externally rotated in an attempt to avoid tibial spine impingement on the lateral aspect of the medial condyle of the femur.
Next, the examining physician may check for weakness of the quadriceps. This examination may reveal fluid in the joint, tenderness, and crepitus. The Wilson test is also useful in locating OCD lesions of the femoral condyle. The test is performed by slowly extending the knee from 90 degrees, maintaining internal rotation. Pain at 30 degrees of flexion and relief with tibial external rotation is indicative of OCD.
Physical examination of a patient with ankle OCD often returns symptoms of joint effusion, crepitus, and diffuse or localized tenderness. Examination often reveals symptoms of generalized joint pain, swelling, and times with limited range of motion. Some with loose body lesions may report catching, locking, or both. The possibility of microtrauma emphasizes a need for evaluation of biomechanical forces at the knee in a physical examination. As a result, the alignment and rotation of all major joints in the affected extremity is common, as are extrinsic and intrinsic abnormalities concerning the affected joint, including laxity.
The classic diagnostic technique is with appropriate X-rays and hip scoring tests. These should be done at an appropriate age, and perhaps repeated at adulthood - if done too young they will not show anything. Since the condition is to a large degree inherited, the hip scores of parents should be professionally checked before buying a pup, and the hip scores of dogs should be checked before relying upon them for breeding. Despite the fact that the condition is inherited, it can occasionally arise even to animals with impeccably hip scored parents.
In diagnosing suspected dysplasia, the x-ray to evaluate the internal state of the joints is usually combined with a study of the animal and how it moves, to confirm whether its quality of life is being affected. Evidence of lameness or abnormal hip or spine use, difficulty or reduced movement when running or navigating steps, are all evidence of a problem. Both aspects have to be taken into account since there can be serious pain with little X-ray evidence.
It is also common to X-ray the spine and legs, as well as the hips, where dysplasia is suspected, since soft tissues can be affected by the extra strain of a dysplastic hip, or there may be other undetected factors such as neurological issues (e.g. nerve damage) involved.
There are several standardized systems for categorising dysplasia, set out by respective reputable bodies (Orthopedic Foundation for Animals/OFA, PennHIP, British Veterinary Association/BVA). Some of these tests require manipulation of the hip joint into standard positions, in order to reveal their condition on an X-ray.
The following conditions can give symptoms very similar to hip dysplasia, and should be ruled out during diagnosis:
- Cauda equina syndrome (i.e. lower back problems)
- Cranial (anterior) cruciate ligament tears
- Other rear limb arthritic conditions
- Osteochondritis dissecans and elbow dysplasia in the forelimbs are difficult to diagnose as the animal may only exhibit an unusual gait, and may be masked by, or misdiagnosed as, hip dysplasia.
A dog may misuse its rear legs, or adapt its gait, to compensate for pain in the "forelimbs", notably osteoarthritis, osteochondritis (OCD) or shoulder or elbow dysplasia, as well as pain in the hocks and stifles or spinal issues. It is important to rule out other joint and bodily issues before concluding that only hip dysplasia is present. Even if some hip dysplasia is present, it is possible for other conditions to co-exist or be masked by it.
X-rays may help visualize bone spurs, acromial anatomy and arthritis. Further, calcification in the subacromial space and rotator cuff may be revealed. Osteoarthritis of the acromioclavicular (AC) joint may co-exist and is usually demonstrated on radiographs.
MRI imagining can reveal fluid accumulation in the bursa and assess adjacent structures. In chronic cases caused by impingement tendinosis and tears in the rotator cuff may be revealed. At US, an abnormal bursa may show (1) fluid distension, (2) synovial proliferation, and/or (3) thickening of the bursal walls. In any case, the magnitude of pathological findings does not correlate with the magnitude of the symptoms.
In patients with bursitis who have rheumatoid arthritis, short term improvements are not taken as a sign of resolution and may require long term treatment to ensure recurrence is minimized. Joint contracture of the shoulder has also been found to be at a higher incidence in type two diabetics, which may lead to frozen shoulder (Donatelli, 2004).
DISH is diagnosed by findings on x-ray studies. Radiographs of the spine will show abnormal bone formation (ossification) along the anterior spinal ligament. The disc spaces, facet and sacroiliac joints remain unaffected. Diagnosis requires confluent ossification of at least four contiguous vertebral bodies. Classically, advanced disease may have "melted candle wax" appearance along the spine on radiographic studies. In some cases, DISH may be manifested as ossification of enthesis in other parts of the skeleton.
The calcification and ossification is most common on the right side of the spine. In people with dextrocardia and situs inversus this calcification occurs on the left side, which confirms the role of the descending thoracic aorta in preventing the physical manifestations of DISH on one side of the spine.
Treatment is frequently by means of removal of the loose bodies and of a partial or full synovectomy (removal of the synovium)
Full synovectomy is a moderately major operation and involves completely exposing the joint and removing the affected tissue. Partial synovectomy is normally done arthroscopically. Synovectomies are normally carried out by shaving the lining of the knee but there are other ways of achieving this by either freezing the synovium or by the use of radiation treatment.
The need for further procedures is greater than 25% although normally the frequency of the required removal of loose bodies is reduced by the previous synovectomy. There have been documented cases of malignant transformation however this is rare.
Whilst the condition can be described as a ‘benign growth’ it seldom affects more than one joint, and does not usually affect surrounding tissue.
Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures.
Strength in the core and legs is also important to posture, so physical training also helps to prevent GTPS. But it is equally important to avoid exercises that damage the hip.
Osteitis pubis may be diagnosed with an X-ray, where irregularity and widening of the pubic symphysis are hallmark findings. Similar change is also demonstrated with Computed Tomography (CT), but the multi-planar nature of CT has a higher sensitivity than conventional radiography. Though not well visualised on ultrasound (US), thickening of the superior joint capsule with cyst formation is a clue to the diagnosis, as well as secondary changes (i.e. tendinosis) of the adjacent adductor muscles - particularly the adductor longus and rectus abdominis. US is also useful for excluding a hernia, which may co-exist with osteitis pubis and warrant additional treatment.
Both US and CT may be used for injecting the pubic symphysis with corticosteroid as part of an athlete's treatment program. Magnetic resonance imaging combines the diagnostic advantages of CT and ultrasound, also shows bone marrow edema, and has the advantages of not being operator dependent (unlike US), nor using radiation (such as CT and X-rays). As such, MRI is the modality of choice for evaluation, diagnosis, and treatment planning.
Typically, radiographs are taken of the hip from the front (AP view), and side (lateral view). Frog leg views are to be avoided, as they may cause severe pain and further displace the fracture. In situations where a hip fracture is suspected but not obvious on x-ray, an MRI is the next test of choice. If an MRI is not available or the patient can not be placed into the scanner a CT may be used as a substitute. MRI sensitivity for radiographically occult fracture is greater than CT. Bone scan is another useful alternative however substantial drawbacks include decreased sensitivity, early false negative results, and decreased conspicuity of findings due to age related metabolic changes in the elderly.
As the patients most often require an operation, full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray.
Early treatment for mild cases of hallux rigidus may include prescription foot orthotics, shoe modifications (to take the pressure off the toe and/or facilitate walking), medications (anti-inflammatory drugs), injection therapy (corticosteroids to reduce inflammation and pain) and/or physical therapy.
Stage 1 hallux rigidus involves some loss of range of motion of the big toe joint or first MTP joint and is often treated conservatively with prescription foot orthotics.
X-rays of the affected hip usually make the diagnosis obvious; AP (anteroposterior) and lateral views should be obtained.
Trochanteric fractures are subdivided into either intertrochanteric (between the greater and lesser trochanter) or pertrochanteric (through the trochanters) by the Müller AO Classification of fractures. Practically, the difference between these types is minor. The terms are often used synonymously. An "isolated trochanteric fracture" involves one of the trochanters without going through the anatomical axis of the femur, and may occur in young individuals due to forceful muscle contraction. Yet, an "isolated trochanteric fracture" may not be regarded as a true hip fracture because it is not cross-sectional.
A doctor may begin the diagnosis by asking the patient to stand on one leg and then the other, while observing the effect on the position of the hips. Palpating the hip and leg may reveal the location of the pain, and range-of-motion tests can help to identify its source.
X-rays, ultrasound and magnetic resonance imaging may reveal tears or swelling. But often these imaging tests do not reveal any obvious abnormality in patients with documented GTPS.
Diagnosis is confirmed by x-ray imaging. Displaced fractures are readily apparent. A non-displaced fracture can be difficult to identify and a fracture line may not be visible on the X-rays. However, the presence of a joint effusion is highly suggestive of a non-displaced fracture. Bleeding from the fracture expands the joint capsule and is visualized on the lateral view as a darker area anteriorly and posteriorly, and is known as the sail sign. Depending on the child's age, parts of the bone will still be developing and if not yet calcified, will not show up on the X-rays. At times, X-rays of the opposite elbow may be obtained for comparison. There are landmarks on the X-rays that can be used to assess displacement, including the "anterior humeral line", which is a line drawn down along the front of the humerus on the lateral view and it should pass through the middle third of the capitulum of the humerus.
Patients usually complain of pain in one joint, which persists for months, or even years, does not ease with exercise, steroid injection or heat treatment, shows nothing on X-ray, but shows a definite restriction of movement.
There are 3 defined stages to this disease:
- early: no loose bodies but active synovial disease;
- transitional: active synovial disease, and loose bodies;
- late: loose bodies but no synovial disease;
In the early stages of the disease it is often confused with tendinitis and/or arthritis. Once it reaches transitional the loose bodies become apparent with X-ray in greater than 70% of cases, with MRI often showing where xray fails. In experienced hands, US is also useful for the diagnosis.
In the disease, the thin flexible membrane of the synovium gradually forms blisters which calcify and enlarge. These nodules eventually break free and float around the joint space becoming larger – these add to the discomfort and stiffness of the joint.
The disease is rare and little known and there is currently no known cure. The affected tissue will show up as a semi-solid mass in a MRI scan, final diagnosis is usually confirmed by taking a biopsy.
Synovial chondromatosis occurs twice as commonly in males as females and usually in their forties. However, online communities for synovial chondromatosis patients have yielded a stark contrast, with equal representation from both genders and members diagnosed as young as late teenage/early 20s.
The disease generally affects only one of the larger weight bearing joints (hip, ankle, knee) – although the elbow, and wrist can also be affected. Rarely involves the temporal mandibular joint.
Manipulative physiotherapy, therapeutic exercises and chiropractic manipulative therapy shows beneficial results for decreasing pain and increasing spinal range of motion. As areas of the spine and tendons can become inflamed NSAIDs such as ibuprofen and Naproxen can be helpful in both relieving pain and inflammation associated with DISH. It is hoped that by minimizing inflammation in these areas, further calcification of tendons and ligaments of the spine leading to bony outgrowths (enthesophytes) will be prevented, although causative factors are still unknown.
Diagnosis should be based on the clinical and radiographic findings and a genetic analysis can be assessed.
"Baumann's angle", also known as the humeral-capitellar angle, is measured on an AP radiograph of the elbow between the long axis of the humerus and the growth plate of the lateral condyle.
Reported normal values for Baumann's angle range between 9 and 26° An angle of more than 10° is generally regarded as acceptable. When reducing paediatric supracondylar humerus fractures, a deviation of more than 5° from the contralateral side should not be accepted.
Alteration of Baumann angle: Baumann's angle is created by drawing a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image normal is 70-75 degrees, but best judge is a comparison of the contralateral side deviation of more than 5 degrees indicates coronal plane deformity and should not be accepted.
Until recently, there was no specific treatment for osteitis pubis. To treat the pain and inflammation caused by osteitis pubis, antiinflammatory medication, stretching, and strengthening of the stabilizing muscles are often prescribed. In Argentina, Topol et al. have studied the use of glucose and lidocaine injections ("prolotherapy", or regenerative injection therapy) in an attempt to restart the healing process and generate new connective tissue in 72 athletes with chronic groin/abdominal pain who had failed a conservative treatment trial. The treatment consisted of monthly injections to ligament attachments on the pubis. Their pain had lasted an average of 11 months, ranging from 3–60 months. The average number of treatments received was 3, ranging from 1–6. Their pain improved by 82%. Six athletes did not improve, and the remaining 66 returned to unrestricted sport in an average of 3 months.
Surgical intervention - such as wedge resection of the pubis symphysis - is sometimes attempted in severe cases, but its success rate is not high, and the surgery itself may lead to later pelvic problems.
The Australian Football League has taken some steps to reduce the incidence of osteitis pubis, in particular recommending that clubs restrict the amount of bodybuilding which young players are required to carry out, and in general reducing the physical demands on players before their bodies mature.
Osteitis pubis, if not treated early and correctly, can more often than not end a sporting individuals career, or give them an uncertain playing future.
In most people, ligaments (which are the tissues that connect bones to each other) are naturally tight in such a way that the joints are restricted to 'normal' ranges of motion. This creates normal joint stability. If muscular control does not compensate for ligamentous laxity, joint instability may result. The trait is almost certainly hereditary, and is usually something the affected person would just be aware of, rather than a serious medical condition. However, if there is widespread laxity of other connective tissue, then this may be a sign of Ehlers-Danlos syndrome.
Ligamentous laxity may also result from injury, such as from a vehicle accident. It can result from whiplash and be overlooked for years by doctors who are not looking for it, despite the chronic pain that accompanies the resultant spinal instability. Ligamentous laxity will show up on an upright magnetic resonance imaging (MRI), the only kind of MRI that will show soft tissue damage. It can be seen in standing stress radiographs in flexion, extension, and neutral views as well, and also digital motion X-ray, or DMX.
An advantage to having lax ligaments and joints is the ability to withstand pain from hyperextension; however, this is also a disadvantage as a lack of perceived pain can prevent a person from removing the ligament from insult, leading to ligament damage. This can also lead to death if you tear the wrong ligament. People with hypermobile joints (or "double-jointed" people), almost by definition, have lax ligaments.
Anterior-posterior (AP) X-rays of the pelvis, AP and lateral views of the femur (knee included) are ordered for diagnosis. The size of the head of the femur is then compared across both sides of the pelvis. The affected femoral head will appear larger if the dislocation is anterior, and smaller if posterior. A CT scan may also be ordered to clarify the fracture pattern.
Those who have loose ligaments in the legs and feet often mistakenly assume that they have flat feet. While their feet have an arch when not supporting weight, when stood upon, the arch will flatten. This is because the loose ligaments cannot support the arch in the way that they should. This can make walking and standing painful and tiring.
Pain will usually occur in the feet and lower legs, but can also spread to the back due to abnormal standing and walking habits. Wearing shoes that have good arch support can help minimize the discomfort. The underlying problem, however, is not solved by wearing shoes with arch supports or worsened by wearing shoes without arch support. There is currently no cure for the condition.
In addition, people with ligamentous laxity often have clumsy or deliberate gaits, owing to the body having to overcompensate for the greater amount of energy required to offset the weakened ligaments. The feet may be spread apart at a wide angle, and the knees may flex backwards slightly after each stride.
Those who have this disease may experience sprained ankles more frequently than other people.
This condition is usually curable with appropriate treatment, or sometimes it heals spontaneously. If it is painless, there is little cause for concern.
Correcting any contributing biomechanical abnormalities and stretching tightened muscles, such as the iliopsoas muscle or iliotibial band, is the goal of treatment to prevent recurrence.
Referral to an appropriate professional for an accurate diagnosis is necessary if self treatment is not successful or the injury is interfering with normal activities. Medical treatment of the condition requires determination of the underlying pathology and tailoring therapy to the cause. The examiner may check muscle-tendon length and strength, perform joint mobility testing, and palpate the affected hip over the greater trochanter for lateral symptoms during an activity such as walking.