MSK Interesting Cases Dr Yap Sheau Huey · Discussion Incidence is 4.3%. Clinically, patient c/o...

MSK Interesting Cases

Dr Yap Sheau Huey

Case 1: History

41 y.o man, surf skier

C/o pain over anterior left 5th to 8th ribs.

Worse after sport activity.

Chest Radiograph

US

Periostitis and early callus formation

US

Periostitis and early callus formation

Hypoechoic rim of periostitis surrounding the affected rib

Juxtacortical hyperemia

US Report

Healing stress fracture of left 6th rib in the anterior axillary line.

Discussion

US is useful in early detection of stress fracture & monitor healing process.

In stress fracture:

Grey-scale US:

Thicken periosteum

Cortical disruption

Surrounding soft tissue edema

Doppler: hypereamia at fracture site

Case 2

Madam SKT

61 y.o lady

H/O bilateral hip AVN ? Idiopathic cause

H/O bilateral Total Hip Replacement in 2006

C/O right hip pain since early 2017

Mechanical pain, difficult in climbing up stairs

Walk with stick

O/E:

ROM: Reduced Rt hip flexion,

Pain worse on active flexion.

Clinical Impression:

Rt hip pain post THR- TRO iliopsoas impingement

Ultrasound Images

CT

Ultrasound Guided Diagnostic Injection Of LA ( mixture of

lignocaine & marcaine)

Post Injection

Immediate pain relief

Conclusion:

Iliopsoas impingement post THR due to femoral bony proliferation

Discussion Incidence is 4.3%.

Clinically, patient c/o groin pain during activities with active hip flexion.

Common causes:

Acetabular fixation screw penetrating inner table of ilium

Oversize /malposition of acetabular component

Collar of femoral stem.

This patient, the impingement is resulting from bony proliferation from femur: rare.

Diagnosis

Clinical assessment

Plain radiograph and CT :

To look for the size and position of the acetabular component.

US

Assessment of iliopsoas tendon.

US guided diagnostic local anesthetic injection.

Case 3

Mr LY, 58 y.o man

Stage IV Right Lung SqCC

H/O palliative chest radiotherapy in Dec 2016

Chemotherapy with gemcitabine since Jan 2017

Until pt developed anterior chest wall mass in April 2017.

US (4/5/2017)

Severe swelling of pect major: features of myositis

MRI (12/5/2017)

T1W STIR

MRI Post Contrast

During F/U on 28/5/2017

Clinically mass is smaller in size after steroid treatment.

Diagnosis: radiation recall

Radiation Recall

Rare phenomenon

Acute inflammation triggered by subsequent chemotherapy in previously radiated tissue.

Weeks to years after radiotherapy

Common feature: acute dermatitis,

Myositis is a rarer form.

Most common reported drug: gemcitabine

Clinical Sx: Muscle pain & swelling

Radiological Findings

US/CT:

Non specific soft tissue swelling

MRI:

High signal intensity of the muscles, fascial or subcutaneous tissue involved.

Some reported rim enhancement of the muscle

Treatment:

Steroid/Anti-inflammatory drugs.

Case 4: History

Mr LSP 28 y.o man

Presented with trigger finger of the right index finger.

Plain XR 2010

XR 2017

Case 5 : History

7 y.o boy

No family history of congenital malformation

Noted to have left hand malformation since birth

No neurocutaneous stigmata/capillary hemangioma.

Left Hand Radiograph ( 26/11/2009) – at 3 months old

Syndactyly of middle and ring finger with bony fusion of distal phalanx.Broadening of all the phalanges of middle finger.Soft tissue thickening of middle and ring finger

Radiographs - post separation of syndactyly

Soft tissue thickening.Broadening and splaying of the phalanges of middle and ring fingers.

MRI (30/5/2014)

Enlarged median nerve with fat deposition in btw nerve fascicles.

MRI Report

Soft tissue and bony hypertrophy of middle and ring finger

Enlargement of median nerve and ulnar nerve ( lesser degree).

Macrodystrophia Lipomatosa (MDL)

Non-hereditary congenital developmental anomaly.

Associate with:

Syndactyly, clinodactyly, polydactyly

Localized gigantism

overgrowth of all mesenchymal elements, disproportionate increased in fibroadipose tissue.

Usually unilateral, frequently in the distribution of median & plantar nerve.

Growth ceases after puberty.

Complication:

Cosmetic

Degenerative joint disease

Neurovascular compression

Carpal tunnel syndrome

Case 6

Madam LSM 51 y.o lady

C/O left thigh mass for 10 days, a/w pain

Static in size

Denied h/o trauma

O/E firm mass, 5x10cm.

INR, ESR, CRP normal

MRI (7/4/2017)

STIR Coronal

TSFS

T1FS Post Contrast

Plain Film (11/5/2017)

US ( 11/5/2017)

Ultrasound guided biopsy done on 11th May 2017

HPE shows: benign muscle with focal fibrosis, regeneration, fibrosing granulation tissue, and rare foci of ossification.

Diagnosis: Myositis ossificans

Case 7

Mr CKH

68 y/o man

C/O left elbow mass for 2 weeks

Deny h/o trauma or injury.

No constitutional Sx

O/E:

3x3cm firm mass overlying left medial epicondyle, non tender

Plain Radiograph ( 27/6/2016)

MRI ( 2/7/2016) T2W

Heterogeneous lesion in distal brachialis muscle

STIR

T1FS Post Contrast

US (11/7/2016)

CT (11/7/2016)

Plain Radiograph (25/8/2016)

Biopsy (10/8/2016)

HPE:benign skeletal muscle with significant fibrosis and ossifications.

Diagnosis: myositis ossificans

Myositis Ossificans(MO)

An inflammatory pseudotumour

Clinically: inflammatory, rapid growing painful mass.

Radiographic appearances change with time.

It passes 3 characteristic phases → Zone phenomenon.

Ossification is peripheral & centripetal.

Acute phase ( 1 week)

Myxoid matrix, fibroblast ( pseudofibrosarcoma)

Subacute phase ( upto 2 weeks )

Osteoblasts with osteoid matrix (pseudoosteosarcoma)

Maturation phase ( starts btw 2 – 5 weeks)

Bone production at periphery of the lesion.

Biopsy can be performed after maturation phase.

Imaging

Xray:

Early stage: normal

Later: ossification surrounding clear area

CT:

More sensitive than Xray

US:

Can demonstrate zonal phenomenon earlier.

MRI:

Acute phase: diffuse/annular enhancement

Subacute: hypointense rim in all sequences

Presence of muscle fibers within lesion.

THANK YOU!