MSK Interesting Cases
MeetingCarita Tsoi
21.05.2020
1. MH Ho 63/F• PMH
• Graves Disease
• CA uterus with TAHBSO in 2008
• "E" adm x left hip and inner thigh pain for 1 week
• No recent injury
• P/E:• Tenderness over left inner thigh
• Left groin, hip, GT area non-tender
• Axial loading, pelvic rocking –ve
• No deformity
26.12.2019
PATIENT TRANSFERRED TO TPH FOR REHAB AND
DISCHARGED.
ARRANGED MRI FOR SUSPECTED LABRAL
TEAR
10.1.2020
History clarified
• Patient fell from 2 steps of stairs with left hip pain since 6/2019
• On and off left groin and left SI joint pain since then
31.1.2020
Osteoporotic insufficiency fracture
• Vertebral fractures• Very common
• Marrow oedema is limited to the vertebral body; extension of abnormal signal into the pedicles suggests an underlying lesion
• Sacrum• Honda sign
• Neck of femur
• Pubic rami
2. SC Chan 58/F
• PMH• CA ovary and corpus resection in 2014
• Presented with massive PE on Innohep since then
• Surveillance CT 9/2015: Soft tissue density nodules in subcutaneous fat of anterior abdominal wall are non-specific
• DDx
• Post-operative granulation tissue / fat necrosis
• Vasculitis
• Metastatic nodules
USG-guided FNAC 15/1/2016
Another USG abdominal wall arranged
Interval reduction in sizes in CT on 7/2016 and 5/2018 but increase in number and size in 8/2019
FNA result
Negative for malignant cells Reactive soft tissue
DDx: small hematoma or granulomata
Multiple hypoechoic lesions in the subcutaneous fat of anterior abdominal wall
USG 16/3/2020
Areas of moderate subcutaneous fat atrophy with discrete nodules
Moderate subcutaneous fat hyperaemia
Delayed hypersensitivity reaction to subcutaneous heparin injections
• Erythematous, infiltrated plaques at injection sites
• Confirmed by challenge tests
3. SY Li 63/M
Retired fireman. PMH: Pernicious anemia
Right distal arm swelling since 9 months ago
Hx of minor contusion during soccer game in late 2019
Progressive swelling of right arm esp in recent 3 months
Right arm not painful
No fever or systemic symptoms
12.3.2020
Septal and peripheral rim-like enhancement corresponding to fibrovascular septation between lobules of hyaline cartilage
26.3.2020
Permeative lytic
destructive
Endosteal scalloping
Cortical thickening and
remodelling
Periosteal reaction
Cortical thickening and remodelling
Periosteal reaction
Intralesional calcifications
Chondrosarcoma
• Hyaline cartilage• High water content
• High T2 signal
• Ring and arc calcifications
• Endosteal scalloping affecting more than two-thirds of the cortical thickness
4. F Shum, 72/M
• DM HT, CAD PCI 2017, TIA
• ESRF on PD since 2017
PMH
• Neck pain for 2 months
• Numbness over 4 limbs, bil shoulders, upper chest & back
• 4 limbs weakness for 2-3 weeks with difficulty walking.
• No back pain /bowel symptoms/ fever / night sweats
• Developed AROU with Foley inserted
• Sensation: Decreased light touch & pinprick sensation over C4 dermatome
Cervical myelopathy
14.4.2020
Vertebral body reabsorption, spondylolisthesis, angular kyphus at C4/5 Severe cord compression and cystic myelomalaciaPrevertebral fluid
16.4.2020
Companion Case 57/F YH, Chan. ESRF on HD
Amyloid Spondyloarthropathy
• Skeletal manifestation of amyloidosis esp on HD
• X-ray and CT• Sclerosis, erosion and cyst formation in adjacent endplates in single or multiple levels• Vertebral body collapse• +/- disc space narrowing.
• MRI• Amyloid deposits are typically hypointense on T1WI and T2WI• Increased intensity on T2-weighted images may be seen,less prominent
than expected in spondylodiscitis.• Variable enhancement.
• DDx• Low grade infection
• Soft tissue mass / collection
5. PK Luk, 49/F
• GPH
• c/o right hip pain for 1-2 month in 2013
• Some dull pain on prn analgesic
• One episode of severe right hip pain and dizziness and attended AED
2.5.2013
Focal areas of
cortical and
subcortical
thickening and
sclerosis
7.5.2013
2014 2015 2016
• Claimed progressive increase in right hip stiffness esp with decrease in flexion ROM in 2020
• Inflammatory type of pain
• Relieved by exercise
2014 2020 2020
Mild interval increase in extent of known melorheostosis
2014 2020
New partly calcified outgrowth at the right
anterior acetabulum into the anterior right hip joint space. Arranged biopsy
Melorheostosis
• Incidental findings or present as joint contracture or pain in adults
• Patterns• Classic
• Periosteal cortical thickening
• Endosteal thickening is also seen in many cases
• Dripping wax appearance: thick undulating ridges of bone
• Osteoma-like• Myositis ossificans-like• Osteopathia striata-like
Associations
• Sclerodermic skin changes: thickening and fibrosis of overlying skin
• Hyperpigmentation of overlying skin
• Muscle atrophy
• Vascular tumours and malformations
• Other tumours• e.g. osteosarcoma and malignant fibrous histiocytoma
6. YN, Wong 56/F
PMH
• SLE
• Gout
C/O swelling over right bicep
Previous fall with injury to right arm
USG arm
Left humerus
SHBSHBLHB
LHB
Right
humerus
USG arm
LeftRight
Ruptured long head of biceps tendon
• Trauma-related injury involves the distal part, which is rare and seen in young people.
• Degenerative causes involve the proximal part of the tendon.
• Radiological findings• Absence of the tendon
• Fluid-filled tendon sheath
• Muscle oedema and atrophy
7. YC Cheung, 35/F
PMH: Left calf adenocytic carcinoma excision in 2016
Left thigh recurrence with excision in 31/3/2020
c/o progressive swelling over the left anterior thigh at the surgical scar right after operation
USG left thigh
27.4.2020
MRI Left thigh
28.4.2020
USG-guided aspiration29/4/2020
500mL yellowish clear fluid
Negative for malignant cells. Lymphocytes seen
Lymphocele
• Thin-walled simple fluid collections with minimal wall enhancement
8. YM, Lam 33/F
• GPH
• Right thumb injury during ski
• No deformity or dislocation
18.2.2020
USG: nodular lesion at dorsal ulnar side of MCPJ
4.3.2020
MRI: UCL avulsed from phalangeal attachment.Nodular low signal lesion overlying adductor aponeurosis is retracted = End of displaced torn ligament
5.3.2020
Ulnar Collateral Ligament tear• Normally, the ulnar collateral
ligament lies deep to the adductor pollicis tendon.
• Stener lesion is slippage of the torn end of the ulnar collateral ligament superficial to the adductor aponeurosis / adductor pollicis muscle
• Interposition of the adductor pollicis muscle between the ulnar collateral ligament and the MCP joint.
• Prevents healing and is an indication for surgical repair.
Stener lesion
• Proximal retraction of the ligament fibres which looks like a small mass displaced superficial to the adductor aponeurosis
• Gives the yo-yo on a string appearance both on ultrasound and MRI images• "yo-yo" represents the torn UCL which has curled back
• "string" is the aponeurosis of the adductor pollicis muscle.
Companion case52/M
R thumb injury
motorcyclist
slipped with immediate
pain
9. DG, Leovigilda Santiago 47/F
Appendicitis with appendicectomy done
Admitted for left hip pain with fever in 10/2019
WCC and CRP raised
Sudden onset
Faint calcification at the tendon insertion of the left gluteus medius and minimus at the greater trochanter.
Linear calcification along the left piriformis muscle
21.10.2019
Moderate oedema present in the left gluteus medius, minimus, piriformis extending to the greater trochanter
24.10.2019
Corresponding enhancement
Acute calcific tendinitis
• Calcific tendinitis is caused by deposit of calcium hydroxyapatite crystals in periarticular muscle attachments.
• Reported at different anatomical sites• most commonly around the shoulder, Achilles tendon, quadriceps,
gastrocnemius and adductor tendons.
• Calcification with trochanteric bursitis is well describe
• Gluteus medius calcific tendinitis is an uncommon clinical condition.
• Treatment usually involves analgesia, nonsteroidal anti-inflammatory drugs and local steroid injections.
Preliminary findings of use of dual energy CT for detection
of bone marrow edema
Dual-energy CT virtual non-calcium imaging for detection of traumatic bone marrow edema
Tube voltages were set at 100 kVp and 140 kVp using tin filter
Generates color-coded virtual non-calcium overlay image
The depiction of bone bruises at computed tomography (CT) is impeded by the overlying trabecular bone
Subtract calcium from cancellous bone, allowing bone marrow assessment