59 y/o male with ulnar sided wrist pain

59 y/o male with ulnar sided wrist pain







TFC Tear

• Palmer classification for triangular fibrocartilage complex abnormalities

Class 1: Traumatic • A - Central perforation • B - Ulnar avulsion • C - Distal avulsion • D - Radial avulsion with or without sigmoid notch fracture

Class 2: Degenerative (ulnocarpal abutment syndrome) stage • A - TFCC wear • B - TFCC wear with lunate and/or ulnar chondromalacia • C - TFCC perforation with lunate and/or ulnar chondromalacia • D - TFCC perforation with lunate and/or ulnar chondromalacia

and LT ligament perforation • E - TFCC perforation with lunate and/or ulnar chondromalacia,

LT ligament perforation, and ulnocarpal arthritis

30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?






Absent vs. Atrophic Piriformis muscle?

• Piriformis muscle might be absent and there might be variations in origin and insertion sites of some muscles and their relation with regional nerves of this region.

1) Bannister L, Berry M, Collins P, Dyson M, Dussek J : Muscles of the thigh and gluteal region. In. Williams P (ed): GrayÕs Anatomy. 38 th ed. London: Churchill Livingstone, 1995 : 875-878

2) Lee CS, Tsai TL : The relation of the sciatic nerve to the piriformis muscle. Taiwan I Hsueh Hui Tsa Chih 1974; 73 : 75-80.

27 y/o male with twisting ankle injury while hiking



Achilles Avulsion

• Greek mythology relates that the legendary warrior Achilles was made invincible by his mother Thetis, who dipped him in the River Styx while holding him by his heel. Because his heel was never immersed, it remained his one area of vulnerability. After the fall of Troy, Achilles met his demise when he was shot in the heel by Paris, whose arrow was guided by the Greek god Apollo. This is the derivation of the term "Achilles tendon."

Achilles Avulsion

• However, Achilles avulsion is considered rare, usually occuring at the calc. tubercle.

• Possible causes:• Traumatic dorsiflexion in maximally

plantar flexed foot• Contraction of triceps surae during knee

extention in a sprint• Direct blow

The heel of achilles: calcaneal avulsion fracture from a gunshot wound.

Cooper DE, Heckman JD Foot Ankle. 1989 Feb;9(4):204-6

34 y/o MLB pitcher with shoulder pain




Thrower’s Shoulder

Elbow pain 55 yr old man

pre post

Elbow pain 55 yr old man

Bicipitoradial Bursa

Cubital Bursae

• bicipitoradial bursa

• interosseous bursa

Bicipitoradial Bursitis: MR Imaging Findings in Eight Patients and Anatomic Data from Contrast Material Opacification of Bursae Followed by Routine Radiography and MR Imaging in Cadavers1

Abdalla Y. Skaf, MD, Robert D. Boutin, MD, Robert Weiber M. Dantas, MD, Andrew W. Hooper, MD, Claus Muhle, MD, David S. Chou, MD, Nittaya Lektrakul, MD, Debra J. Trudell, RA, Parviz Haghighi, MD and Donald L. Resnick, MD 1

From the Departments of Radiology (A.Y.S., R.D.B., R.W.M.D., A.W.H., C.M., D.S.C., N.L., D.J.T., D.L.R.) and Pathology (P.H.), Veterans Affairs Medical Center and University of California San Diego, 3350 La Jolla Village Dr, San Diego, CA 92161.

Bicipitoradial Bursa

• reduces friction between the biceps tendon and the radial tuberosity

• Bursitis• Repetitive mechanical trauma• Infection• Inflammatory arthropathy• Chemical synovitis• Bone proliferation

Elbow Pain

Torn Biceps Tendon

Cubital Bursitis

Supinator muscle edema

• Mass effect in the cubital tunnel may compress the branches of the radial nerve

Posterior Interosseous Nerve Syndrome

• Compression of the deep branch of the radial nerve

• innervates multiple extensor muscles• extensor indicis proprius, extensor digiti

quinti, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, and extensor digitorum communis muscles

34 yo Hockey player

SLAP tear with possible extension into the SGHL and MGHL

33 yo woman

osteopenia, cartilage loss, and erosions, subluxation

Rheumatoid Arthritis

33 yo woman

Same patient

OA pattern

• Superolateral joint space narrowing

• Marginal osteophytes

• Eburnation and subchondral cystic change

Why the early OA?

Femoral Acetabular Impingment?Crystal deposition disorders?

19 yr old Marine with new onset difficulty performing pull-ups

19 yr old Marine with new onset difficulty performing pull-ups

Suprascapular Nerve Entrapment

• At suprascapular notch, will involve both the supra- and infraspinatus muscles

• At the spinoglenoid notch, involves only the infraspinatus

• Most common cause is a ganglion cyst from a superior labral tear

36 year old man with arm and hand numbness for one day

36 year old man with arm and hand numbness for one day

• Patchy scattered foci and muscular edema

• Considerations• Parsonage Turner

syndrome• Quadrilateral space

syndrome

Post op day 1 from ventral hernia repair

• Other considerations

• Positioning neuropathy

T2 T1-PRE POST

T2 T1 PRE T1 POST

SOFT TISSUE MASS: VOLAR DISTAL PHALANX

• Ganglion cyst 50% to 70%

• Hemangioma/vascular malformation

• Giant cell tumor

• Glomus tumor

• Mucoid (epidermoid) cyst

• Epidermoid

• Nerve sheath tumor

Benign tumors of fibrous tissue origin

• Nodular fasciitis

• Neurofibroma

• Schwannoma

• Fibrous histiocytoma

• Fibroma/ fibromatosis

Nodular fasciitis

• Most common soft tissue lesion originating from fibrous tissue

• 50% arise in the upper extremity, m/c volar forearm

• Present as a rapidly growing mass

Enzinger FM, Weiss SW. Soft tissue tumors. St Louis: Mosby, 1995.

Nodular fasciitis

• Histologically often misdiagnosed because of its rapid growth, increased cellularity and mitotic activity

Nodular fasciitis

• Thee subtypes• Subcutaneous

• Subcutanous nodule

• Intramuscular• Large, deep, mimics a soft tissue malignancy

• Intermuscular• Irregular/ stellate appearance, mimics

inflammatory lesion

MR characteristics

• Variable depending on the amount of collagen, cellularity, and mucin.

• Subcutaneous lesions to occur in younger patients and exhibit myxoid histology and increased T2 signal.

Wang et al., Nodular fasciitis: correlation of MRI findings and histopathology.Skeletal Radiol. 2002 Mar;31(3):155-61.

Axial T1 FS

Axial T1 FS/Gd

Axial T2 FS

Axial T1

69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.

Cor T2 FS Cor T1 FS/Gd


Sag T1


Sag T1


Sag T1


Sag T1 FS/Gd


Sag T1 FS/Gd


Sag T1 FS/Gd


Gout

• MRI of Tophi• Low on T1WI• On T2WI usually variable but contain low-

signal regions• High signal on post Gd

Yu et al, MR imaging of tophaceous gout. AJR Am J Roentgenol. Yu et al, MR imaging of tophaceous gout. AJR Am J Roentgenol. 1997 Feb;168(2):523-7.1997 Feb;168(2):523-7.

Weishaupt et al, MR imaging of inflammatory joint diseases of the Weishaupt et al, MR imaging of inflammatory joint diseases of the foot and ankle.foot and ankle.Skeletal Radiol. 1999 Dec;28(12):663-9. Skeletal Radiol. 1999 Dec;28(12):663-9.

Axial T1

Axial T1FS/Gd

20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and

wrist.

Axial T2 FS


wrist.


wrist.


wrist.


wrist.


wrist.


wrist.

Chronic Infection and Synovial Hypertrophy

• D.Dx.• Fungus• TB ( Mycobacterium marinum)

Mycobacterium Infection

Recurrent Mycobacterium marinum tenosynovitis of the wrist mimicking extraarticular synovial chondromatosis on MR images.Lee EY, Rubin DA, Brown DM.

Skeletal Radiol. 2004 Jul;33(7):405-8. Epub 2004 May 04.

Horseshoe AbscessDiagnosis of Bone and Joint Disorders, Resnick

Hand – Pathways of infection, pg 2399

Tenosynovitis caused by atypical mycobacterial infections may produce rice bodies within affected tendon sheaths.

…. the flexor tendons within the carpal tunnel in which the rice bodies were mistaken for synovial chondromatosis on MR images

21yo F with hand pain. History of bilateral THA and TKA.






Juvenile Chronic Arthritis

Portrait of a Youth

Botticelli, 1483

Juvenile –onset adult type RA

• Female

• >10yrs

• Polyarticular

• Possible subQ nodules and vasculitis

• Seropostive for RA

Diagnosis of Bone and Joint Disorders, 3rd ed. D Resnick, editor. W.B. Saunders Co., Philadelphia, 1995.


• MCP and IP joints of hand

• Wrist

• Knee

• MTP and IP joints of foot

• Cervical spine

• Hip

• Shoulder


• Soft tissue swelling• Osteoporosis• Periostitis• Erosions, especially in the absence of joint

space loss• Possible joint space loss• Atlanto Axial Subluxation• Epiphyseal compression fractures• Joint Subluxation• Growth disturbances

73 y.o F with wrist pain and stiffness



Rheumatiod Arthritis vs Psoraisis

Interesting Wrist Case

• Dorsal Midcarpal Instability

• Carpal Instability Non Dissociative (CIND)

UCSD Bone Conference

June 3, 2005

Jeremy Kuniyoshi

57 yo M with increasing thigh mass X 2-3 months

Further Hx:

Infected hematoma post cath many yrs ago

On anticoag for prosthetic valves (INR 1.6)



17964259.jpg

SAG STIR COR T1

AX PD FS

17964259.jpg

T1 POST

T1 FS POST AX T1 POST

T1 FS POST


Surgical Pathology Report:

Fibrous Capsule with areas of granulation tissue, multinucleated giant cells, areas of necrosis, and hemorrhage with clot c/w pseudoaneurysm

Fig. 1A–C MRI of the left knee.

A Coronalinversion recovery (TR 2000 / TE 18 /TI 150) image shows a large ovoid masswithin the popliteal fossa, which is predominantlyof high signal intensity. There is noedema in the adjacent muscles.

B Sagittalgradient echo (TR 500/TE 16/flip angle30°) image shows multiple low-signal fociwithin the mass consistent with calcifications.Note also the mass merging with themassively dilated popliteal vein behind thedistal femur (arrows). The uniform highsignal within the dilated vein is typical ofslow venous flow.

C Axial T2-weighted(TR 2000/TE 80) image shows intimate relationshipof the mass to the popliteal arteryand vein (arrow), interposed between themass and the tibial plateau, although no directcommunication could be identified

Fig. 2A, B Digital subtraction angiogram of the left leg. A Arterial phase oblique image of the popliteal artery demonstrates a direct communication between the lumen of the artery and the mass (arrow), consistent with a pseudoaneurysm. B Late venous phase image shows large slow-flow venous channels (arrowheads) within the mass, draining into the enlarged popliteal vein (arrows)

Popliteal vascular malformation simulating a soft tissue sarcoma

Wambeek N, Munk PL, O'Connell JX, Lee MJ, Masri BA. Skeletal Radiol 1999;28(9):532-5.

51 yo M with R Shoulder pain s/p humeral head replacement

10-28-03 4-25-04 HHR Converted to TSA


5-12-04 Glenoid component well located 6-23-04 Glenoid component dislocated


6-2-05

Total Shoulder Arthroplasty: Glenoid Component

- indications are controversial;

- this needs to be performed prior to insertion of the humeral component;

- increased glenoid loosening rates from eccentric loading & excessive glenoid wear can be expected with w/ rotator cuff arthropathy

Glenoid loosening:

- radiolucencies around the glenoid component will eventually be seen in 60% of patients;

- some authors note that in many cases radiographs may fail to show loosening because the radiographic beam is not perpendicular to the bone-component interface;

From: http://www.wheelessonline.com/ortho/total_shoulder_arthroplasty_glenoid_component

http://www.wheelessonline.com/ortho/rotator_cuff_tears

http://www.wheelessonline.com/ortho/total_shoulder_arthroplasty_glenoid_component

http://www.wheelessonline.com/image3/i1/glnd3.jpg



http://www.wheelessonline.com/images/tssr24.jpg

http://www.wheelessonline.com/images/tssr26.jpg




Conversion of painful hemiarthroplasty to total shoulder arthroplasty: Long-term resultsRaymond M. Carroll, MD, Rolando Izquierdo, MD, Michael Vazquez, MD, Theodore A. Blaine, MD, William N. Levine, MD, and Louis U. Bigliani, MD, New York, NY

“revision of a failed HHR to a TSA is a salvage procedure whose results are inferior to those of primary TSA…”

From: J Shoulder Elbow Surg Nov/Dec 2004




27yo man with palpable nodules in foot





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59 y/o male with ulnar sided wrist pain