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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“