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