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Musculoskeletal MUSCULOSKELETAL Dr. Dean Bruce University of Alberta DISCLOSURES… Member of the Royal College Examination Committee in Diagnostic Radiology. Lectures given to the Workman’s Compensation Board and Siemens MRI Symposium. Learning Objectives 1. Better understand Bone and Soft Tissue Tumors through individual cases. 2. Assess Internal Derangement of Joints through individual cases. 3. Improve your CanMEDS roles as a Scholar and Collaborator CASES 19 year old male Foot pain while running 1 Axial STIR Axial T1 Sagittal T1 22 year old male 2 months of elbow pain 2 Sagittal T1 Sagittal PD FS Coronal STIR Sagittal CT Recon Axial CT 9 year old male Growing ankle mass 3 Sagittal STIR Sagittal T1 AXIAL T2 52 year old female Slowly growing painless lump in triceps 4 Coronal T1 Coronal STIR COR T1 FS + GAD Ultrasound CASE REVIEW Case 1: DIFFUSE PIGMENTED VILLONODULAR SYNOVITIS (PVNS) OF CALCANEOCUBOID JOINT 1 Axial STIR Axial T1 Sagittal T1 1 Key Points NOTABLE: Mono-articular benign neoplasm, which is treated by synovectomy, but high-recurrence rates (50%) CLASSIC DESCRIPTOR: Low T1 and T2 lobulated tissue throughout the joint, with blooming on the gradient sequences due to hemosiderin PEARL: Almost never calcifies Cystic bone changes are usually in small joints Preserved joint space until late Case 1: PVNS of Calcaneocuboid Joint Companion Case – PVNS Wrist Coronal T2 Coronal GRE T2 Coronal T1 1 Differential Diagnosis 1. Amyloid Arthropathy a. Multiple joints (Systemic) 2. Chronic Hemorrhagic Effusions a. Rheumatoid arthritis b. Hemophilia c. Intra-articular Hemangioma, Sarcoma (very rare) 3. Synovial Chondromatosis a. Round or ovoid lesion, usually with calcification 4. Indolent Infection e.g. TB Case 1: PVNS of Calcaneocuboid Joint Companion Case Synovial Osteochondromatosis Axial T1 Axial PD FS Case 2: INTRA-ARTICULAR OSTEOID OSTEOMA 2 Sagittal T1 Sagittal PD FS Coronal STIR Sagittal CT Recon Axial CT 2 Key Points NOTABLE: Night pain - relieved by Aspirin CLASSIC DESCRIPTOR: CT shows a round low-attenuation nidus, with possible central mineralization, and variable surrounding sclerosis PEARL: Intra-articular lesions have no surrounding sclerosis - There is no inner periosteum (cabrium) within a joint Case2: INTRA-ARTICULAR OSTEOID OSTEOMA 2 Differential Diagnosis INTRA-ARTICULAR OSTEOID OSTEOMA 1. Osteoblastoma > 2 cm 2. Septic arthritis 3. Chronic inflammatory arthritis Case2: INTRA-ARTICULAR OSTEOID OSTEOMA Companion Case – Fibular Osteoid osteoma Axial T1 Axial STIR 2 Differential Diagnosis CLASSIC OSTEOID OSTEOMA 1. Osteoblastoma > 2cm 2. Langerhans Cell Histiocytosis (EG) 3. Brodie’s Abscess 4. Intracortical Hemangioma – no edema 5. Stress Fracture - linear Case 2: INTRA-ARTICULAR OSTEOID OSTEOMA Treatment Conservative – NSAIDS Surgical resection Radiofrequency Ablation Case 3: ANEURYSMAL BONE CYST 3 Sagittal STIR Sagittal T1 AXIAL T2 3 Key Points NOTABLE: Thought to be post traumatic (12-18 months after) Vascular tissue lined cystic lesion CLASSIC DESCRIPTOR: Expansile radiolucent bone lesion within the metaphysis, with multiple septa “soap bubble appearance”. MRI demonstrates a multi-cystic lesion with fluid/ fluid levels PEARL: 1/3 (35%) are secondary, so give GAD and look for soft tissue components Case 3: Aneurysmal Bone Cyst Treat by Curettage and Bone Packing 3 Differential Diagnosis SECONDARY ABC 1. Giant Cell Tumor- most common 2. Chondroblastoma 3. Chondromyxoid fibroma 4. Osteoblastoma 5. Fibrous dysplasia 6. Telangiectatic Osteosarcoma 7. Brown Tumor Case 3: Aneurysmal Bone Cyst Case 4: INTRA-MUSCULAR MYXOMA 4 Coronal T1 Coronal STIR Coronal T1 FS + GAD Ultrasound 4 Key Points NOTABLE: Solitary, painless, slowly growing mass 82% Intramuscular Benign – curative with complete excision CLASSIC DESCRIPTOR: Cyst like (low T1 and High T2) mass with thin subtle septa and a peri-tumoral rind of fat. Variable enhancement PEARL: Multiple myxomas are almost always associated with fibrous dysplasia of bone (Mazabraud Syndrome) Case 4: INTRA-MUSCULAR MYXOMA 4 Differential Diagnosis 1. Myxoid Liposarcoma 2. Myxoid Neurofibroma 3. Soft Tissue Ganglion a. Can look like a cyst without GAD or Ultrasound Case 4: INTRA-MUSCULAR MYXOMA Companion Case – Intramuscular Myxoid Liposarcoma Coronal STIR Coronal T1 Companion Case – Intramuscular Myxoid Liposarcoma Axial T2 Axial T1 FS Axial T1 FS + GAD CASES 30 year old female Slowly enlarging left hip mass Remote injury 5 Coronal T1 Axial T1 Axial STIR Axial GRE T2 30 year old male FOOSH, R/O Fracture 6 • M • M 84 year old female Slowly enlarging calf mass 7 Coronal T1 Coronal T1 FS + GAD Sagittal T2 Sagittal T1 FS 50 year old male Chronic hand pain 8 CASE REVIEW Case 5: MOREL-LAVALLEE LESION 5 Coronal T1 Axial T1 Axial STIR Axial GRE T2 5 Key Points NOTABLE: Closed de-gloving injury Slowly enlarging hemolymph fluid collection CLASSIC DESCRIPTOR: Chronic hematoma, with a pseudocapsule, centered in the deep fascial planes PEARL: Bright T1 signal fluid, with lobules of fat necrosis Classic location near the hip Case 5: MOREL-LAVALLEE LESION Case 6: BENNETT FRACTURE 6 • M Coronal STIR Coronal MEDIC 3D 6 Key Points NOTABLE: Most frequent thumb fracture CLASSIC DESCRIPTOR: Single intra-articular fracture at base of first metacarpal, with malalignment PEARL: Early diagnosis and treatment are vital - Delayed diagnosis can lead to instability and early arthritis - Call Clinician Case 6: BENNETT FRACTURE Bennett Fracture 6 Differential Diagnosis 1. Rolando Fracture a. Comminuted b. Intra-articular c. Worse prognosis Presentation Title - Subtitle Case 7: DE-DIFFERENTIATED CHONDROSARCOMA 7 Coronal T1 Coronal T1 FS + GAD Sagittal T2 Sagittal T1 FS 7 Key Points NOTABLE: Pain 10% of chondrosarcomas are de-differentiated 50-60 years old (Osteosarcoma – 20-30 years old) CLASSIC DESCRIPTOR: Medullary based lesion with “ring and arc” calcifications, which destroys the adjacent cortex with adjacent periostitis PEARL: 1. Cortical destruction, periostitis, and a soft tissue component are suggestive features 2. Deep endosteal scalloping (>2/3 of cortical thickness) - Endosteal scalloping and cortical expansion are normal for finger enchondromas Case 7: DE-DIFFERENTIATED CHONDROSARCOMA 7 Differential Diagnosis 1. Other sarcomas e.g. Fibrosarcoma, MFH 2. Collision Lymphoma 3. Collision Metastases 4. Collision Multiple Myeloma Case 7: DE-DIFFERENTIATED CHONDROSARCOMA Case 8: GOUT 8 8 Key Points NOTABLE: Classic Podagra – Great Toe involvement CLASSIC DESCRIPTOR: Well-defined erosions with “overhanging” edges and preserved adjacent joint space. Dense adjacent soft tissue tophi. PEARL: Tophi are dense on CT (HU 160) and X-rays due to uric acid Case 8: GOUT 8 Differential Diagnosis 1. Psoriasis 2. Tophaceous Pseudo-gout 3. Indolent infection 4. Amyloid 5. PVNS Case 8: GOUT Companion Case of gout Sagittal T2 FS Sagittal PD Axial T2 FS Axial T1 FS Axial T1 FS + GAD 8 Key Points • Gout loves the quadriceps and popliteus tendons in the knee • Dual energy CT • Two scans (80 and 140 kv) • Use the difference to differentiate between urate and calcium • Can use instead of biopsy Case 8: GOUT CASES 17 year old male Leg pain 9 Coronal T1 Sagittal STIR Sagittal T2 Coronal T1 FS + GAD 26 year old male Shin pain 10 T1 T2 FS T1 FS T1 FS + GAD 58 year old female Hand pain 11 14 year old male Ankle twisting injury 12 CASE REVIEW Case 9: FIBROUS DYSPLASIA 9 Coronal T1 Sagittal STIR Sagittal T2 Coronal T1 FS + GAD 9 Key Points NOTABLE: Developmental abnormality due to the proliferation of fibroblasts CLASSIC DESCRIPTOR: Expansile medullary based diaphyseal lesion with ground glass matrix and a thin sclerotic margin PEARL: Causes bowing (Shepherd’s Crook Deformity of femur) McCune-Albright syndrome 1. Polyostotic fibrous dysplasia 2. Café au lait spots 3. Precocious puberty Case 9: FIBROUS DYSPLASIA 9 Differential Diagnosis NONE Case 9: FIBROUS DYSPLASIA Shepherd’s Crook Deformity Case 10: ADAMANTINOMA 10 T1 T2 FS T1 FS T1 FS + GAD 10 Key Points NOTABLE: Very rare, low grade sarcoma CLASSIC DESCRIPTOR: Well-demarcated multi-loculated lesion in anterior tibial cortex, with anterior bowing and no periostitis PEARL: Almost exclusively in the anterior tibial cortex Need Biopsy to diagnose (looks identical to osteofibrous dysplasia) Case 10: ADAMANTINOMA 10 Differential Diagnosis 1. Adamantinoma (23 years) 2. Osteofibrous Dysplasia (12.9 years) 3. EG 4. Chronic Cortical Osteitis (Garre’s) Case 10: ADAMANTINOMA Companion Case - 10 y.o with Osteofibrous Dysplasia Case 11: SCLERODERMA, WITH ACRO-OSTEOLYSIS 11 11 Key Points NOTABLE: Systemic Auto-immune disorder CLASSIC DESCRIPTOR: Diffuse acro-osteolysis with atrophic overlying skin and an inflammatory arthropathy PEARL: CREST SYNDROME 1. Calcinosis 2. Raynaud's Syndrome 3. Esophageal Dysmotility 4. Sclerodactyly 5. Telangiectasia Case 11: SCLERODERMA, WITH ACRO-OSTEOLYSIS Companion Case – Scleroderma Calcinosis and Acro-osteolysis 11 Differential Diagnosis for Acro-osteolysis • Band like – Polyvinyl Chloride – Hadju-Cheney – Hyperparathyroidism • Peripheral Ischemia – Frostbite – Burns – Raynaud’s – Meningococcemia • Neuropathy – Congenital insensitivity to pain – Diabetes – Leprosy • Collagen Vascular Disease – Psoriasis – Scleroderma • Snake or Scorpion venom Case 11: SCLERODERMA, WITH ACRO-OSTEOLYSIS Case 12: TRIPLANE FRACTURE 12 12 Key Points NOTABLE: Occurs only at adolescence, due to fusion of medial growth plate first (Kump’s Bump) CLASSIC DESCRIPTOR: Coronal fracture of metaphysis and sagittal fracture of epiphysis PEARL: Need CT to look for displacement Case 12: TRIPLANE FRACTURE
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