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Diffuse Idiopathic Skeletal Hyperostosis: Musculoskeletal Manifestations

Belanger, Theodore A. MD; Rowe, Dale E. MD

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Journal of the American Academy of Orthopaedic Surgeons: July 2001 - Volume 9 - Issue 4 - p 258-267
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Abstract

In 1950, Forestier and Rotes-Querol described a disorder characterized by spinal stiffness, osteophytosis, and “flowing” new-bone formation about the thoracic spine. They termed it “senile ankylosing hyperostosis” and distinguished it from ankylosing spondylitis. They documented clinical and radiographic findings in a series of 200 patients, as well as descriptions of pathologic specimens. Over the years, Forestier and various other authors have described numerous extraspinal findings. The condition is a systemic bone-forming diathesis with primary spinal and various extraspinal clinical and radiographic findings.1

During this evolution of understanding, the disorder has been given many labels. These include ankylosing hyperostosis, Forestier's disease, generalized juxta-articular ossification of vertebral ligaments, and spondylosis hyperostotica. The most descriptive and inclusive term, and the one used in the most recent literature, is diffuse idiopathic skeletal hyperostosis (DISH), which was introduced by Resnick.1,2

In an effort to understand the etiology of DISH, investigators have sought relationships with other syndromes. Historically, both rheumatoid arthritis and ankylosing spondylitis were thought to be related to DISH. Because the type of newbone formation observed in DISH resembles that which occurs in several seronegative spondyloarthropathies, attempts have also been made to establish an association to HLA-B27; however, no convincing evidence of such an association exists. Some endocrine and metabolic syndromes, such as acromegaly and hypervitaminosis A, can also produce hyperostosis resembling that seen in DISH. Increased prevalences of diabetes mellitus, glucose intolerance, hyperuricemia, and dyslipidemia have been associated with DISH.3 HLA-B8 is common among patients with both DISH and diabetes mellitus.2 Despite the many similarities to other syndromes that cause osseous outgrowths or ankylosis, convincing evidence linking DISH to other systemic disorders is lacking, and the cause remains unknown.2,4–6

Prevalence

Diffuse idiopathic skeletal hyperostosis is a common disease, which is most prevalent in persons over 50 years of age. In an autopsy series, Boachie-Adjei and Bullough7 reported that 28% of the spines of subjects with an average age of 65 years had evidence of DISH. Mata and coworkers4,8 documented a frequency of 2.5% to 10% in persons over age 70, with a slight male predominance. Other authors have stated that the prevalence is as high as 15% in women and 25% in men over age 50, and 26% in women and 28% in men over 80.9,10 Resnick and Niwayama2 postulated that the disorder may begin between the ages of 20 and 40 years but requires several decades to become mature enough to meet diagnostic criteria. They also noted no difference in frequency of the disease between black and white persons.

Clinical Presentation

The usual presentation is a middleaged or older patient with chronic mild pain in the middle to lower back, spinal stiffness, and the typical radiographic changes in the thoracic spine. Tendinitis may also be present in any location, but most often in the Achilles tendon. Dysphagia secondary to large cervical osteophytes is an occasional complication of DISH.4,11–15 Overall, clinical findings are mild in comparison to the dramatic radiographic findings. The minimal pain experienced by some patients may be a consequence of the relative stabilization of spinal segments through ankylosis. In fact, many patients are asymptomatic, and DISH is discovered incidentally.

Spinal Manifestations

Diffuse idiopathic skeletal hyperostosis is predominantly a radiographic diagnosis with three major diagnostic criteria, as outlined by Forestier and refined by Resnick and Niwayama2 (Table 1). The first criterion, flowing ossification along the anterolateral borders of at least four contiguous spinal segments, is the essence of DISH. The other two criteria, absence of degenerative changes and sclerosis or ankylosis of facet or sacroiliac joints, serve to eliminate the spondylosis of degenerative spinal disorders and ankylosing spondylitis as alternative diagnoses.

Table 1
Table 1:
Diagnostic Criteria for DISH 2

In practice, some patients present with involvement of fewer than four contiguous vertebrae. Exclusion of these patients is arbitrary, to avoid confusion of DISH with other syndromes. In fact, patients with DISH can have few radiographically evident spinal manifestations and varying degrees of extraspinal symptoms and findings.1,2

Thoracic Spine

The axial manifestations of DISH are the most frequent and characteristic, forming the basis of the diagnosis and offering an explanation for most patient complaints. The thoracic spine is the most commonly involved segment, often in isolation. Pain can be present in other areas of the spine, with isolated radiographic changes in the thorax, particularly from T7 to T11.2 Thus, a high index of suspicion must be maintained, with a low threshold for imaging the thoracic spine, even in patients with primarily lumbar or cervical complaints. Thoracic myelopathy has been reported, but is a rare manifestation of DISH.16,17

Radiographic imaging of the thoracic spine in the anteroposterior (AP) and lateral planes commonly reveals large syndesmophytes and flowing, laminated new-bone formation along the anterolateral margins of vertebral bodies, often continuing across the disk spaces (Fig. 1). The syndesmophytes project horizontally from the vertebral bodies with the classic appearance of flowing candle wax, becoming confluent to form an extra-articular ankylosis. They should be distinguished from the vertically oriented “bamboo spine” outgrowths that form an intra-articular ankylosis in ankylosing spondylitis. The syndesmophytes of DISH usually appear much more prominent on the right side of the thoracic spine, whereas they are commonly symmetrical in the cervical and lumbar spine. This is postulated to be due to a protective effect afforded by the pulsatile aorta on the left side of the thoracic vertebrae. Patients with DISH and situs inversus show ossification mainly on the left side of the thoracic spine.2,18

Figure 1
Figure 1:
AP (A) and lateral (B) thoracic spine radiographs of a 60-year-old woman show typical findings of DISH. Note the right-sided, nonmarginal syndesmophytes; the absence of disk-space narrowing; and the well-preserved bone density.

Ligamentous calcification may be as thick as 2 cm in some instances. Hyperostosis of posterior elements is rare, although hyperostosis of costovertebral joints may be present. Osteopenia, which is commonly seen in ankylosing spondylitis, is not typically profound in DISH. In fact, the radiodensity may appear excessive in relation to patient age. Facet articulations and disk spaces are generally preserved. The presence of significant degenerative changes, such as facet hypertrophy and disk-space narrowing, should cast doubt on the diagnosis of DISH. Technetium bone scanning can show increased uptake in areas of involvement, which may be confused with evidence of metastatic disease.19

Patients with diffuse complaints of back, neck, or extremity pain and/or stiffness that is worse in the morning or evening and is aggravated by cold weather may have objective radiographic findings limited to the thoracic spine that are visualized on thoracic spine films or chest radiographs.20 Often, these patients have undergone extensive workup or even surgery on the lumbar spine without a diagnosis of DISH having been established. The presence of such back complaints, even with other findings in the lumbar spine, warrants at least one set of radiographs of the thoracic spine to rule out the presence of DISH. This may alert the physician that a lumbar or cervical fusion is not likely to ameliorate all of the patient's axial symptoms. However, the presence of DISH is not a contraindication to an appropriate procedure for stenosis, instability, painful degenerative spondylosis, disk herniation, or other cervical and lumbar disorders.

Cervical Spine

Involvement of the cervical spine is less frequent than involvement of the lumbar or thoracic spine, although it is by no means rare.9 Pain and stiffness of the neck may be prominent symptoms and are occasionally the presenting complaints. Radiographic findings are most common in the lower segments and less prevalent at the more cephalad levels. Ossification and loss of elasticity occur along the anterior paravertebral tissues, such as the anterior longitudinal ligament. Cervical hyperostosis may be seen to be as much as 12 mm thick on a lateral radiograph.2 Syndesmophytes occur symmetrically along the anterolateral vertebral bodies. Ankylosis of vertebral bodies occurs with secondary ankylosis of apophyseal and uncovertebral joints, as distinguished from ankylosing spondylitis, which often fuses across these joints primarily. Ligamentum flavum hypertrophy, dystrophic calcification of spinal ligaments (including ossification of the posterior longitudinal ligament), and mild cervical kyphosis can occur, occasionally resulting in cervical spinal stenosis and myelopathy.2,9,21

Diffuse idiopathic skeletal hyperostosis of the cervical spine can also cause complications with adjacent soft-tissue structures when large osseous excrescences are present. Dysphagia is often the result of large cervical syndesmophytes, which are present in as many as 28% of patients with DISH.2,11,13–15 Hoarseness, sleep apnea, and difficulty with intubation have all been reported to be consequences of cervical DISH.2,22,23

If syndesmophytes are impinging on anterior structures, surgical resection can be palliative.13–15 In cases of multilevel cervical stenosis and myelopathy with preserved lordosis, laminoplasty or laminectomy may be indicated. In other cases, anterior decompression and stabilization may be necessary.

Lumbar Spine

Radiographic changes are common in the lumbar spine, resembling those in the thoracic spine without the predilection for rightsided involvement (Fig. 2). However, patients often complain of low back pain or stiffness without the presence of changes on lumbar radiographs. Radiographic evidence of DISH in the lumbar spine is most frequently seen in the upper levels and is less common caudally.

Figure 2
Figure 2:
AP (A) and lateral (B) lumbar spine radiographs of a 72-year-old man. Note the nonbridging, nonmarginal syndesmophytes; preservation of facet joints and disk spaces; and postoperative changes at L5-S1. The typical flowing ossification was also apparent along the anterolateral margins of the lower thoracic vertebrae. AP (C) and lateral (D) right elbow radiographs of the same patient show diffuse changes. He had no history of trauma, infection, or surgery affecting the elbow and had only minimally painful stiffness. On the AP view, note the preservation of joint space, with flowing ossification along the medial edge of the coronoid process. The lateral view shows large enthesophytes projecting proximally from the coronoid, olecranon, and trochlea, as well as small osteophytes projecting distally from the radial head.

Vertebral hyperostosis may be as much as 2 cm thick. Interspinous ligament calcification may also be seen. Degenerative changes such as disk-space narrowing and facetjoint sclerosis and narrowing, which are not considered typical of DISH, are common between the fourth lumbar and first sacral vertebrae. This is probably related to the normal stress imposed on the lumbosacral area, exacerbated by a stiff spine superiorly. These degenerative changes may have been treated surgically before recognition of DISH (Fig. 3, A). Hypertrophy and ossification of the ligamentum flavum and hyperostosis of posterior spinal elements, especially around the facet joints, may result in symptomatic stenosis of the spinal canal.2,24,25 Significant compression of the inferior vena cava due to large anterior lumbar osseous excrescences has been reported.26

Figure 3 A,
Figure 3 A,:
Lateral radiograph of the lower lumbar spine of a 60-year-old man treated with posterior intertransverse spinal fusion for postlaminectomy spondylolisthesis at L3-4 shows impressive syndesmophyte formation related to DISH. Note the absence of disk-space narrowing at L4-5 and L5-S1 and the presence of the large osseous excrescence. The patient also had classic changes in the thoracic spine and pelvis. B, AP radiograph of the pelvis of the same patient shows ossification of the sacrotuberous ligaments (arrows) with sparing of the sacrospinous ligaments, which is a pathognomonic finding in DISH. “Whiskering” of the iliac wings and ischial tuberosities and subtle osteophytosis about the pubic symphysis and superior acetabula with preservation of the sacroiliac joints are also common.

Traumatic Changes

Patients with DISH are at high risk for fracture and instability from even minor trauma. Fractures of the spine in patients with DISH are often characterized by a delay in diagnosis and a high rate of immediate and delayed neurologic consequences. The increased incidence of fracture instability in these patients is a consequence of ankylosis of the vertebral segments proximal and distal to the fracture, which creates increased lever arms that can cause displacement of the spine even in low-energy injuries.27–29 They occur in the middle or at the ends of ankylosed segments, as in ankylosing spondylitis. Hyperextension injuries are frequent, involving either disk disruption or fracture through the middle of a vertebral body.27,28 Patients with DISH, neck pain, and a history of trauma must be carefully evaluated for occult fracture with computed tomography (CT) or magnetic resonance (MR) imaging.

In the cervical spine, the changes in canal diameter, alignment, and mobility of motion segments not only cause neck pain and stiffness but put patients with DISH at risk for severe neurologic injury. As in the thoracic spine, hyperextension injuries are common. Odontoid fractures and atlantoaxial subluxation have been reported in association with DISH, but are not considered typical findings.30 Even minor trauma can result in cervical fracture, with a high incidence of associated neurologic injury and mortality.9 Unfortunately, the diagnosis of the fracture is often delayed and may not be made until a neurologic deficit occurs.9

Treatment of fractures is similar to that of patients with other ankylosing conditions. The physician must consider the additional instability caused by poor ligament integrity and increased lever arms. It is important to note that the degree of instability is likely to be underrepresented on radiographs. A thorough understanding of the pathophysiology of DISH is necessary to be able to adequately interpret radiographs of these patients and to accurately project their clinical course and risk. Better understanding of the injury may be obtained through CT or MR imaging with multiplanar reconstructions.

Cervical traction may result in excessive distraction due to the lack of ligamentous structures and should be used cautiously. The use of open reduction and internal fixation is recommended to prevent progression and delayed neurologic compromise (Fig. 4). Instrumentation must be of sufficient length to counteract the increased deforming forces acting at the fracture site. Given that preoperatively the spine is relatively stiff and multiple articulations may have to be fused, increasing the length of instrumentation does not necessarily sacrifice mobile motion segments. Anterior decompression and strut grafting may be required if ventral compression is present; this should be augmented with posterior stabilization. In a series of 20 patients with cervical fractures and DISH, the mortality of those treated surgically was 15%, compared with 67% for those treated nonoperatively.9

Figure 4 A,
Figure 4 A,:
Supine lateral radiograph of a 76-year-old man who fell at home demonstrates a benign-appearing fracture of the C5 vertebral body (arrow). Large anterior bridging osteophytes from C4 to C7 are present. B, Patient was immobilized in a cervicothoracic brace. When upright, he complained of severe neck pain and bilateral C6 radiculopathy, which resolved when he was supine. This upright lateral radiograph shows increased kyphosis and subluxation of the C5-6 facets to the perched position (arrow). C, Axial CT scan of C5-6 demonstrates vertebral body fracture and fracture of the lateral mass of C6 (arrows). D, Postoperative lateral radiograph following posterior stabilization and fusion with AO instrumentation (an off-label use of this device). E, Postoperative anteroposterior radiograph.

Extraspinal Manifestations

Although Forestier's initial description of DISH commented on occasional extraspinal manifestations, many subsequent authors have since delineated findings that range from rare to commonplace. In particular, tendinitis and enthesophytes (osseous outgrowths at the sites of attachment of tendon, ligament, or capsule to bone) are very common findings. Many joints can be affected, and some patients have diffuse, vague aching similar to that which occurs with polymyalgia rheumatica.2 Subtle periostitis at the site of ligament or tendon insertion is often seen. Each anatomic location has characteristic findings associated with DISH, which are usually bilateral and symmetrical.1

Pelvis

The most characteristic findings in the pelvis are enthesophytes involving the iliac wing and ischial tuberosity and calcification of the sacrotuberous and iliolumbar ligaments (Fig. 3, B).31 Periarticular osteophytes about the hip, sacroiliac joints, and symphysis pubis can often be found.1 The osseous excrescences are similar in appearance to those seen in the spine. Intra-articular or para-articular ankylosis rarely occurs about a joint. Bone proliferation (“whiskering”) can be seen at sites of ligament and tendon attachment. Bone erosions in the sacroiliac joints and at the sites of ligament attachment, commonly seen in ankylosing spondylitis and other disorders, are generally absent in DISH. While abnormalities of the sacroiliac joints generally exclude the diagnosis of DISH, bridging or nonbridging osteophytes about the sacroiliac joint have been reported in patients with DISH.32 With the exception of the symptomatic hip, most pelvic findings do not require surgical intervention.

Hip

Hip involvement is variable, with some patients having few or no pathologic changes in the hip. Those with signs and symptoms may have periarticular bone proliferation with an intact joint space (Fig. 5), hyperostosis with a narrowed joint space, or osteonecrosis.2 It has not been determined which of these findings are related to DISH and which are agerelated.

Figure 5
Figure 5:
AP (A) and frog-leg lateral (B) radiographs of the right hip of a 51-year-old man with DISH diagnosed on chest radiographs. He presented with right hip discomfort and stiffness that had developed over many years. Note the profound periarticular hyperostosis and relative preservation of the hip joint space. At the time of total hip arthroplasty, these osteophytes were found to be intra-articular, encroaching on the lesser trochanter, and impinging on the superior acetabular rim.

Patients with DISH and a severely symptomatic degenerative hip may require total hip arthroplasty. These patients may be at increased risk for heterotopic ossification.2,33–35 It has been suggested that this could be prevented by preoperative irradiation33 or by the use of warfarin in the postoperative period.34 The use of indomethacin, aspirin, subcutaneous heparin, and low-molecularweight heparin in this setting has not been investigated.

The clinical significance of heterotopic ossification in patients with DISH after total hip arthroplasty is debated. Guillemin et al34 retrospectively reviewed the data on 67 patients after total hip arthroplasty, 16 of whom had DISH. That study showed a higher incidence of heterotopic ossification in patients with DISH than in those without DISH (56% [9 of 16] vs 22% [11 of 51]). The incidence of heterotopic ossification was less in patients treated with anti-vitamin K drugs (e.g., warfarin) for 3 months postoperatively than in those treated with subcutaneous heparin over the same period (17% [5 of 29] vs 39% [15 of 38]).

Fahrer et al35 reported on a series of 204 patients who underwent total hip arthroplasty, 38 of whom had DISH. Postoperative ossification developed in 30% of the DISH patients, compared with 10% of those without DISH. The authors found low frequencies of significant pain (10%) and functional limitation (26% with less than 70 degrees of hip motion) as a result of ossification and did not feel that prophylaxis was justified.

Knee

Resnick et al1,2 reported that patients with DISH have a 29% prevalence of knee changes, compared with 5% of control subjects. Tendinous ossification can occur in association with the quadriceps mechanism, with patellar hyperostosis including large osseous excrescences on the poles. A prominent tibial spine is very common. An increased incidence of symptomatic osteoarthritis of the knee has not been observed.

Foot and Ankle

At least 70% of DISH patients have manifestations involving the foot and ankle.2,36 Any bone in the foot may exhibit hyperostosis. The numerous sites of ligament and tendon attachment make the foot particularly prone to spur formation. Calcaneal spurs are common, occurring in as many as 76% of patients, compared with 19% of control subjects.2,36 The cortex of the calcaneus may be thickened. Calcification of the Achilles tendon or plantar fascia may be seen, with or without associated symptoms of Achilles tendinitis or plantar fasciitis. Heel pain occurs in an estimated 23% of patients with DISH, occasionally as the presenting symptom. Garber and Silver36 suggested that the presence of large calcaneal spurs in the setting of Achilles tendinitis or plantar fasciitis should lead one to consider DISH as an underlying diagnosis. Enthesophytes may also be seen on the dorsal talus (talar beaking), medial navicular, lateral and plantar cuboid, and the base of the fifth metatarsal.1

Shoulder

Irregular osseous excrescences can occur at the deltoid tubercle, as well as in the greater and lesser tuberosities. Hyperostosis can be seen in the inferior glenoid and distal clavicle, as well as at the sites of attachment of the coracoclavicular ligaments.1 These changes are variably associated with pain, stiffness, and loss of motion. Primary shoulder osteoarthrosis is relatively uncommon; therefore, a symptomatic patient should be assessed with careful attention to the history and physical examination, which may reveal diffuse complaints that suggest DISH.

Treatment for DISH of the shoulder is largely symptomatic and may include activity modification, nonsteroidal anti-inflammatory medication, and/or physical therapy. Surgery is rarely necessary, and it is often difficult to justify it solely on the basis of manifestations of DISH.

Elbow

Spurs on the olecranon are frequent findings in DISH (Fig. 2, C and D). In one study,2 they were noted in 48% of patients with DISH, compared with 10% of control subjects. Hyperostosis can occur along the distal medial humerus. Patients with enthesophytes are frequently symptomatic,2 although the clinical relevance of radiographically evident elbow hyperostosis has been challenged.37 Irregularities of the proximal radioulnar joint and epicondylitis can be seen as well. These entities are generally treated nonoperatively.

Hand and Wrist

Cortical thickening may be seen in the tubular bones, as well as hyperostosis and spur formation in periarticular sites, such as the metacarpal heads. The distal phalangeal tufts may appear pointed (“arrowheading”).38 Soft-tissue and cartilage hypertrophy are present in acromegaly but not in DISH. An increased incidence of osteoarthrosis of the hand, especially in the interphalangeal joints, has been suggested. Irregularities at the insertion sites for the interosseous membrane and in the distal radioulnar joint are occasionally seen.

Diagnosis

The differential diagnosis of back pain and spondylophytosis includes a large number of disorders (Table 2).2 A careful history delineating the nature and location of back pain is necessary. Back pain that is severe or acute in onset is not likely to be related solely to DISH. The presence of extraspinal musculoskeletal symptoms should be sought.

Table 2
Table 2:
Differential Diagnosis of Back Pain and Spondylophytosis

There are no diagnostic laboratory findings, but evaluation may exclude other potential diagnoses. The erythrocyte sedimentation rate and C-reactive protein, rheumatoid factor, and antinuclear antibody levels are typically normal.

If DISH is suspected in an adult, the thoracic spine should be evaluated radiographically to establish the diagnosis. Chest radiographs are adequate as screening tests for DISH.20 The lumbar spine is usually evaluated radiographically, as this is the most common area of complaint. Including the sacroiliac joints on these films can be helpful in ruling out other entities, such as seronegative spondyloarthropathies. Other sites of pain should be imaged with plain radiography, especially the heel, elbow, sacroiliac joints, and cervical spine. In nontraumatic situations, bone scans are not often helpful and can falsely give the appearance of multiple periarticular metastases.

The recognition of DISH can be useful to patients by reassuring them that they have an objectively identifiable disorder that explains their symptoms. These patients have frequently been told that they have arthritis and often feel that they are not being taken seriously. A simple radiograph of the thoracic spine or the chest may validate their complaints and help direct therapy, which often establishes a good relationship between patient and physician.

Once the diagnosis of DISH has been established, important associated sequelae must be identified or ruled out. Neck discomfort after even minor trauma to the cervical spine needs to be aggressively evaluated with radiographs supplemented by CT, myelography with CT, or MR imaging. Suspected spinal stenosis at all levels deserves a similarly aggressive approach.

Dysphagia may warrant evaluation with cervical spine radiographs and a swallowing study. Consultation with an otorhinolaryngologist or a gastroenterologist may be appropriate to ensure that the dysphagia is truly related to an osteophyte rather than a tumor or other process. Endoscopy may be indicated in such cases.

Treatment

The treatment of DISH predominantly involves nonoperative measures with occasional surgical intervention for specific sequelae. For patients with isolated back pain or enthesopathies, activity modification, physical therapy, corset or brace wear, nonsteroidal antiinflammatory medications, and bisphosphonate therapy are the mainstays of treatment, but the efficacy of these modalities is not well established.

Generally, surgery is not indicated for DISH in the absence of some other diagnosis, such as fracture, stenosis, tumor, infection, or painful deformity. Fortunately, debilitating pain is rare in the absence of neurologic or visceral impingement, probably because bony ankylosis prevents painful motion. The joint reconstruction surgeon should be aware of the increased risk of heterotopic ossification after total hip arthroplasty; prophylaxis may be appropriate.

Summary

Diffuse idiopathic skeletal hyperostosis is a very common, often occult bone-forming diathesis with many musculoskeletal manifestations. The diagnosis is based on the presence of flowing ossification along the anterolateral aspects of at least four vertebrae, typically in the thoracic spine. There must be an absence of changes characteristic of degenerative spondylosis or spondyloarthropathies, such as ankylosing spondylitis. A diagnosis of DISH should be suspected in adult patients who present with back pain and spinal stiffness. Radiographic evaluation of the thoracic spine must be performed, even if pain is localized to the lumbar or cervical areas. All other areas of musculoskeletal pain should be evaluated radiographically, looking for hyperostosis or enthesopathy.

Awareness of DISH can have important implications. In addition to suggesting therapeutic measures, establishing the diagnosis serves to reassure the patient that his or her symptoms are related to an objectively identifiable condition, which can establish trust between physician and patient. Furthermore, it may alert the surgeon to look for certain associated problems, such as dysphagia, cervical myelopathy, spinal fracture, lumbar stenosis, heterotopic ossification, and enthesopathy, that often require surgical intervention.

The manifestations of DISH are numerous and vary among patients. Awareness of the disorder and a high index of suspicion can add a great deal to the clinical acumen of practitioners of nearly every orthopaedic subspecialty. This sensitization, perhaps coupled with only a chest radiograph, often allows a correct diagnosis, allaying the frustrations of delayed (or absent) diagnosis and occasionally identifying and preventing a serious sequela.

References

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© 2001 by American Academy of Orthopaedic Surgeons