Missed MSK Diagnoses

Indications

Interpretation

Commonly missed diagnosis in musculoskeletal conditions

Department of Diagnostic RadiologyDivision of Neuro- & MSK Radiology with Imaging CAD LabMedical University of Vienna

Franz Kainberger

To recognise the importance of insufficient consideration of clinical information

To stress the importance of a systematic approach to the interpretation of imaging, particularly radiographs

To learn about the differential diagnosis between stress injuries, inflammatory processes, necrosis and tumors – exclusive soft tissue tumors

Objectives

Commonly missed diagnosis in musculoskeletal conditions

Part 1: STRESS, REPETITIVE TRAUMA, ARTHRITIS

What is “common”?The majority of the selected cases are from primary imaging centers.

USMLE-style questions

(1) infection (referring physician‘s diagnosis)

(2) pubic stress reaction (radiologist‘s diagnosis)

(3) Reiter‘s disease (reactive arthritis) or other rheumatologic disorder

Your diagnosis, please – VOTE NOW

Groin pain in athletes

adolescent semi-professional male soccer player

• during training, groin pain on his right side since a few days

• feels exhausted• projection radiographs: normal

(1) - correct: pubic osteomyelitis

Blood cultures (results sent a few days after MRI) were positive for staphylococcus aureus.

• osteomyelitis of the pubis is a rare, but nevertheless classical infective location of bone infection.

• most common complaint in both infection and inflammation: pain under load, local or pseudoradicular

• Biochemistry: normal or slightly inflammatory in osteitis pubis, frankly inflammatory in osteomyelitis.

control after 5 weeks

similar case in an adolescent male

(2) - incorrect: pubic stress reaction

Osteitis pubis is a noninfective inflammation of the symphysis pubis

• after urological or gynaecological procedures, • associated with overuse or trauma

Pauli S et al. Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature. Br J Sports Med 2002; 36: 71–73

(3) - incorrect: rheumatologic disorder

The best fitting rheumatic disease would be chronic recurrent multifokal osteomyelitis (CRMO).

Average age 8.3 years (range, 2.5–24 ys).

Principally in every bone.

Soft tissue involvement in this case does not fit to this diagnosis.

Khanna G et al. Imaging of chronic recurrent multifocal osteomyelitis.2009 Jul-Aug;29(4):1159-77

Teaching point: Top DDx in groin pain in athletes

5 – 18 % of all athletic injuries, predominantly kicking sports1/3 of soccer players will develop groin pain.

• traumatic injury to the adductor and rectus abdominis muscles

• osteitis pubis• insufficiency fractures of the pelvis, • posterior inguinal wall deficiency,

hernias („sportsman‘s hernia“)• osteomyelitis pubis

Koulouris G. Imaging Review of Groin Pain in Elite Athletes: An Anatomic Approach to Imaging Findings. AJR 2008; 191:962–972

adductor edema due to horse riding

adductor longus

gracilis

pectineus

Interlude – your diagnosis, please

Matterhorn (Switzerland) in the cloud

Matterhorn from Wikipedia

Wrist pain

60 ys old female with left-sided wrist pain, no trauma

(1) normal (radiologist‘s diagnosis)

(2) late onset rheumatoid arthritis (referring physician‘s diagnosis)

(3) De Quervain‘s disease

(4) psoriatic arthopathy

Your diagnosis, please – VOTE NOW

(3) - correct: De Quervain‘s tendovaginitis

Overuse of the tendons of the first dorsal compartment of the wrist; diagnosed by a specific provocative test (Finkelstein test)

This patient was left-handed.

First dorsal wrist compartment

One of the tendons within the first dorsal wrist compartment are from the

(1)Extensor pollicis longus

(2)Extensor carpi radialis longus

(3)Flexor carpi radialis

(4)Abductor pollicis longus

(5)Adductor pollicis

adductor pollicis longus tendonextensor pollicis brevis tendon

extensor pollicis longus tendonCorrect: (4)

Your answer, please – VOTE NOW

(1) - incorrect: normal radiograph

Soft tissue involvement is a very important indicator of stress reactions, inflammation, trauma, or neoplasm.

Sausage finger (right thumb) PVNS RA with extensor carpi ulnaris tendovaginitis

(2) - incorrect: Late onset rheumatoid arthritis (LORA)

Abnormalities in RA are typically located on ulnar side, radial side involvement is unusual.

Rheumatoid ArthritisThe 4 common disease entities of the handa – osteoarthritis b – rheumatoid arthritisc – pyrophosphate arthropathyd – psoriatic arthropathy

Early arthritis – a commonly missed diagnosis

(4) - incorrect: psoriatic arthropathy

periosteal appositions

Teaching point: radial-sided wrist pain

• De Quervain's tendovaginitis: Synonyms: housewife‘s thumb, oarsman‘s wrist, washer woman‘s sprain

• Repetitive activities leading to increased friction

• Gender: female : male = 8-10 : 1• Top DDx:

- Intersection syndrome (proximal)- Wartenberg‘s syndrome (irritation of superficial branch of radial nerve)

Image gallery

Interlude – your diagnosis, please

Synovial thickening & knee effusion formed as Venetian carnival mask

Atlantodental destruction

66 ys male with marked restriction of neck motion and radiological report of rheumatoid arthritis. All other joints were normal. No trauma.

(1)Rheumatoid arthritis

(2)Ankylosing spondylitis

(3)Dens pseudarthrosis

(4)Pyrophosphate arthropathy (CPPD)

Your diagnosis, please – VOTE NOW

(4) correct: Pyrophosphate arthropathy

crowned dens

Synonyms: CPPD - calcium pyrophosphate deposition disease, chondrocalcinosis

other patient

Goto S et al. Crowned Dens syndrome. JBJS Am 2007 Dec;89(12):2732-6

(1) incorrect: Rheumatoid arthritis

• Dens destruction without other joint involvement is unusual

• CPPD (synonyms: Pseudo-gout, Pseudo-RA) is an important DDx of RA

• Pseudobasilar impression• Rheumatic stepladder

(2) incorrect: Ankylosing spondylitis

• Dens destruction in ankylosing spondylitis is rare

Teaching point: Pyrophosphate arthropathy = Pseudo-gout = Pseudo-RA

Bathing LadiesAuguste Renoir, 1919

Interlude – your diagnosis, please

Specific low back pain

33 ys female after breast carcinoma a few years ago. Now low back pain with bilateral extension. A previous MRI 6 months before was normal.

(1)metastasis

(2)osteoporosis

(3)stress fracture

(4)sacroiliitis

Your diagnosis, please – VOTE NOW

• sacral stress fractures30 – 40 casuistic publications, females mostly involved: extensive running, basket & volley ball, aerobics

Major NM, Helms CA. AJR 2000: 174: 727

Shah MK, Stewart GW. Spine. 2002:

15;:E104

White JH et al. Clin Radiol. 2003:58:914

• SI-joint overuseoften combined with leg-length differences and/or piriformis syndrome:rowers, cross-country skiers

Brolinson PG et al. Curr Sports Med Rep

2003;

(3) correct: stress fracture

Recently, the patient had bought a puppy-dog carrying it regularly up and down from her 4th floor appartment (without lift).

MRI one year later normal

(2) incorrect: osteoporosis

Sacral insufficiency fractures: common in•patients with low bone mineral density•after irradiation

78 ys female after colonic carcinoma

(4) incorrect: sacroiliitis

Distinctive sign: the „varigated picture“ (Dihlmann):erosion + sclerosis + ankylosis occur synchronously

endstage ankylosis

Sacroiliitis – yes or no?

27 ys male with low back pain during night. HLA-B27 positive. Projection radiograph of lumbar spine and pelvis was reported normal.What is your next step in the imaging workup?

Your diagnosis, please – VOTE NOW

(1) angulated views of SI-joints(2) MRI(3) CT(4) Bone scan

(2) correct: MRI

Diagnosis of ankylosing spondylitis

The mean duration from the first onset of symptoms until the definite diagnosis of ankylosing spondylitis is

(1)2 ys

(2)4.5 ys

(3)7 ys

(4)9 ys

Your diagnosis, please – VOTE NOW

(3) Correct

Feldtkeller E. [Age at disease onset and delayed diagnosis of spondyloarthropathies] Z Rheumatol 99 Feb;58(1):21-30.

It may be anticipated that the majority of these patients undergoes imaging which is reported as being normal.

Interlude – your diagnosis, please

Wladimir Mihailowitsch BECHTEREW (1857 – 1927), russian psychiatrist and neurologist. He diagnosed Stalin with “grave paranoia.” Later that day Prof. Bekhterev suddenly died.

60 ys female with swelling of her elbow. No detailed history.

(1)Vascular malformation or other soft tissue tumor

(2)Synovial chondromatosis

(3)Tendon rupture

Elbow swellingT1 axial + CE

Your diagnosis, please – VOTE NOW

(3) Correct: rupture of distal biceps tendon

ulnaradius

bicipito-radial bursitis

68 ys male, enthusiastic tennis player, now painfully impaired elbow flexion after skiing.

(1) incorrect: vascular malformation

• The typical location and configuration strongly suggest biceps tendon rupture with pseudotumorous configuration.

• AVMs occur in children and adolescents.

tendon inserts both at radius and in muscle fascia

(2) incorrect: synovial chondromatosis

Teaching point:Pseudotumors of the MSK-system

• Fat pad necrosis after minor trauma• Foreign body reaction• Chronic hematoma• Morel-Lavallée lesion• Inflammatory pseudotumor after

tendon rupture• Myositis ossificans (subacute phase)• Pseudoaneurysm• Tumorous calcinosis

rectus femoris rupture

Interlude – your diagnosis, please

Budapest

Painful greater toe

tall young lady, long periods of standing and walking with high heeled shoes in her profession

(1)fractured sesamoid

(2)OA of greater toe

(3)gout

Your diagnosis, please

Sesamoiditis – an underdiagnosed entity

• medial sesamoid is in 14% of foot MRIs abnormal.

• common observation in diabetics• typical disease in racehorses

Sesamoid stress fracture in a ballet dancer

Kulemann V et al. Abnormal findings in hallucal sesamoids on MR imaging. Europ J Radiol (in press)

• Stress fractures of 1st metatarsal are rare.• „Sesamoiditis“ is more common and at

least in part due to mechanical stress• Specific sports related overuse in soccer

players and dancers along the course of the flexor hallucis longus tendon including os trigonum.

Teaching point: 1st ray stress reactions – a kinetic chain

Stress reaction MT I

Os trigonum stress fracture in a soccer player

Os trigonum stress reaction in a balletteuse

flexor hallucis longus tendon

33 ys male with painful greater toe during walking

55 ys male after wrist injury with dorsiflexion

• diffuse wrist pain• projection radiographs

(including scaphoid series ) were normal

Occult fracture

Your diagnosis, please

(1) Scaphoid fracture

(2) other fracture

(3) no fracture, but posttraumatic synovitis

(4) two fractures

Correct (5): scaphoid fracture and hamulus fracture

normal hamulus for comparison

• Incidence of hamulus fractures: 1 %• Findings: Dislocation of hamulus, fracture line,

edema• Etiology: high-energy trauma with dorsiflexion

(ball catching) of closed fist in ulnarduction

Yalcinkaya M et al., A rare wrist injury: simultaneous fractures of the hamate body and scaphoid waist. Orthopedics. 2009 Aug;32(8).

R. Schedl (contemporary Austrian expressionist): „In the same boat“