48M Feelings of ankle instability. Dr. Tudor H. Hughes M.D., FRCR Department of Radiology University of California School of Medicine San Diego, California

48MFeelings of ankle instability

Dr. Tudor H. Hughes M.D., FRCR

Department of Radiology

University of California School of Medicine

San Diego, California

MOCK ORAL BOARDS 2005MOCK ORAL BOARDS 2005GENERAL RADIOLOGY

Don Fleischli, M.D., M.B.A.

Associate Clinical Professor, U.C.S.D. School of Medicine

Assistant Professor of Radiology & Radiological

Sciences, U.S.U.H.S.

GENERAL SUGGESTIONS• What is the exam? What are the findings?• You have seen one like this in your review!

• Obvious findings - long DDX or detailed discussion?• Aunt Minnie? It looks like…but could be….• Corner of film type trick that looks normal?

• Have a script in mind so when your mind goes blank…• Usually you get no history until you ask• Don’t ask until you have run through your script

• An example of a category script…don’t step INIT• Infection…bacterial, viral, fungus, immune sys…• Neoplasm…benign, malignant, pseudotumor…• Inflammation…arthritis, collagen vasc, drugs…• Trauma/Other…extrinsic, mechanical, rupt, vasc…

GENERAL SUGGESTIONS• Pick a category and pursue it until exhausted or the

examiner directs you away from it• Don’t jump to another category quickly, it may take

you down the wrong path…“this could be tumor…”• When exhausted go to other categories, say “this

looks inflammatory but could be trauma or infection or neoplasitic…”; “I would recommend…”

• Couch your discussion in terms of assumed clinical findings…“if this pt is immune compromised I would consider…if not I would consider”

• Start by stating the obvious category and diagnosis• Don’t mumble/shout/run on/interrupt/joke/ask for Dx• If examiners says “is there anything else you would

consider”…go back to INIT then ask for more history…or mercy

ACTUAL SCORE SHEET FROM ABR

• Case # • -- - +

++ +++• Observation• Synthesis/Imp• Management• 68 69 70

71 72• Score

CASE #1

CASE #1

CASE #1 - DISCUSSION

• Findings• Multiple erosions/uniform joint space narrowing• Ulnar styloid erosions; pisoform/triquetrum early• Subluxations; mention SLE best seen in Norgaard view• Osteoporosis; juxta-articular>>diffuse• Little fusiform soft tissue swelling; early sign• Bilateral symmetrical• No swan neck and boutonniere deformities distal

phalanges

• Differential Diagnosis Infection• Differential Diagnosis Neoplasm


• Differential Diagnosis Inflammation• Rheumatoid Arthritis• HLA-B27 Arthropathies-mineralization-bone formation• Erosive Osteoarthritis-1st CMC and DIPs, central seagulls• Gout-no overhanging edges with sclerosis

• Differential Diagnosis Trauma/Other• This does not look like primary or secondary OA

• Diagnosis: Rheumatoid Arthritis (advanced)• Short Read:

• Discuss types of erosions in other arthritis• Bare area of joint within capsule not covered by cartilage• Lack of bone formation seen in Psoriatic, not in DIPs• Ankylosis of carpals but not distal to them

CASE #4

CASE #4


• Findings• Calcified stone in distal left ureter• Scattered calcifications in soft tissues• Typical ovoid elongated calcifications in muscles

• Differential Diagnosis Infection/Inflammation• Cysticercosis with calcified left ureteral calculus• Trichinosis cysts are tiny, round, punctate (mammo)• Guinea worm dz, Echinococcosis, Sarcosporidosis,

Loiasis also have soft tissue calcification• Dermatomyositis and other collagen vascular dz


• Differential Diagnosis Neoplasm• Differential Diagnosis Trauma/Other

• Myositis ossificans• Vascular calcifications

• Diagnosis: Cysticercosis & ureteral calculus• Short Read:

• Taenia solium (helminth)=pork tape worm (cestode)• Humans are the only definitive host of adult worm in the

intestine; hog and human are intermediate hosts• Larval form in muscles and viscera >>die>>Ca++

CASE #5

CASE #5

CASE #5


• Findings• Complex vertical fx probably stable• Interpedicular distance wider than above or below• Posterior superior corner fragment>>spinal canal• Posterior ligaments and bones intact• L-2; typically 67% T-12, L-1, L-2 junction stable to mobile

• Differential Diagnosis Infection• Differential Diagnosis Neoplasm• Differential Diagnosis Inflammation


• Differential Diagnosis Trauma/Other• Simple wedge fracture in osteoporosis (insuff) or normal bone• Burst fracture is vertical (ant/mid column); stable or unstable• Chance fracture (lapbelt only) is horizontal; no anterior

column compression like burst fx; bone/ST; stable or unstable• Flexion distraction injury; combination of both; ant column +

• Diagnosis: Burst fracture• Short Read:

• Three columns (Denis); CT for middle and posterior columns• Simple wedge anterior column only…mechanism of injury• Anterior/middle columns in 85%; 25% middle column miss• Posterior column and/or ligaments involved on CT=unstable• CT the night of injury then MR the next day for ligaments• Unstable (two columns + ligs)>>further neurological injury

CASE #6

CASE #6

CASE #6


• Findings• Chondrocalcinosis both hips• Protrusio acetabuli with uniform joint space narrowing


• CPPD crystal deposition disease• Gout (if chondrocalcinosis it is not CA++ urate but CPPD)• Pseudogout


• Differential Diagnosis Trauma/Other• Chronic trauma>>DJD with chondrocalcinosis

• Diagnosis: CPPD “pseudo-rheumatoid arthritis”• Short Read:

• Calcium PyroPhosphate Dihydrate (CPPD) deposition dz• Chondrocalcinosis with secondary DJD• May be aggressive and look like neuropathic joint• May look like RA “pseudo-rheumatoid” but no erosions vs

true RA with erosions and CPPD; unusual secondary OA• Diagnosis by CPPD crystal identification• Knees, hands, hips, shoulder, elbow; need two areas for

DX• Arthropathy of CPPD resembles secondary OA usually

CASE #15

CASE #15

CASE #15


• Findings• Erosions with overhanging edge, sclerotic cortical rims• Normal mineralization, joint spaces preserved• Look for faint soft tissue calcification=tophus


• Gout (if chondrocalcinosis they also have CPPD)• Rheumatoid arthritis• Osteoarthritis • HLA-B27 arthropathies


• Differential Diagnosis Trauma/Other• Diagnosis: Gout• Short Read:

• M:F=20:1, elevated uric acid, monosodium urate monohydrate deposits (tophi) which may calcify and be seen on films

• Many diseases cause elevated uric acid (myeloproliferative)• Uncommon before age 20 yrs, oldest recognized arthropathy• Must have untreated disease for years to see changes on films• Feet (1st MTP), hands, elbow, wrist, knee, shoulder, hip, SI Jnt• Asymmetrical polyarticular distribution, indolent, remodeling• Secondary gout with increase production or diminished excrete of

uric acid usually have no radiographic changes

CASE #16


• Findings• Bubbly lesion with fracture no periostitis; chondroid matrix

• Differential Diagnosis Infection• Osteomyelitis (bacterial or fungus)

• Differential Diagnosis Neoplasm• Enchondroma• FOGMACHINES or FEGNOMASHIC for benign cystic lesion• Chondroid matrix=popcorn, speckle, swirled, punctate Ca++• Osteoid matrix=denser, cloud-like, mashed potatoes Ca++• Zone of transition=narrow benign, wide malignant; slow

growth time to retreat in orderly manner; rapid permeative• Periostitis may be benign (benign lesion) or aggressive

(either)


• Differential Diagnosis Inflammation• Differential Diagnosis Trauma/Other

• Healing displaced fracture

• Diagnosis: Enchondroma with Fracture• Short Read:

• Most common lesion of phalanges, diaphyseal, lytic, expansile, thin sclerotic rim, may not have chondroid matrix in hand

• Ollier’s dz multiple unilateral, Maffucci syndrome multiple A/W hemangiomata more likely to degenerate into malignancy

• Films underestimate true size; MR/CT better• Geographic lesions=those with distinct margin sclerotic or

not

CASE #17

CASE #17


• Findings• Cocktail hot dogs or sausages (soft tissue swelling beyond

joint)• Normal mineralization• Bone proliferation=hypertrophic bone at ligament

attachments

• Differential Diagnosis Infection• Osteomyelitis

• Differential Diagnosis Neoplasm• Differential Diagnosis Inflammation

• Psoriatic arthritis• Rheumatoid arthritis, Reiter’s dz, HLA-B27 arthropathies• Osteoarthritis• Gout, amyloid, sarcoid


• Differential Diagnosis Trauma/Other• Fracture or soft tissue hemorrhage and periostitis• Exostosis

• Diagnosis: Psoriatic Arthritis• Short Read:

• Erosions and bone formation (DDX RA)• Mouse ear hypertrophy next to marginal erosion• Pencil in cup central erosions (late) may widen joint• Soft tissue swelling beyond joints, normal mineral• 1)DIP/PIP joints involved, 2)rays 1-3 all joints, 3)like RA

but DIP, bone prolif, normal mineralization• Feet more than hands; bilateral asymmetrical; Achilles

and plantar aponeurosis bone proliferation

CASE #22

CASE #22

CASE #22

CASE #22

CASE #22


• Findings• Periosteal new bone 3rd metacarpal• Sclerosis (not quite bubbly)• Bubbly/lytic/sclerotic process distal left clavicle• Positive three phase bone scan in above and spine• Chest shown no coin lesion or cavity

• Differential Diagnosis Infection• Cocci osteomyelitis• TB or fungus, pseudomonas (addicts), salmonella (sickle

cell)

• Differential Diagnosis Neoplasm• FOGMACHINES/FEGNOMASHIC• Lymphoma, leukemia, mets, multifocal osteogenic

sarcoma



• Fracture with healing• FEGNOMASHIC/FOGMACHINES

• Diagnosis: Cocci Osteomyeltis• Short Read:

• Brodie abscess subacute or chronic osteomyeltis• Involucrum is a shell of periosteal reactive bone formation

surrounding infected bone (sequestrum)• Sequestrum is a segment of necrotic bone with organisms

separated from viable bone by granulation tissue• Cloaca are holes in involucrum through which pus

extrudes• MRI low signal dark on T1, high signal bright on T2

CASE #23

CASE #23

CASE #23

CASE #23


• Findings• Bilateral symmetrical , postage stamp edge erosions,

sclerosis• No squaring of T12/L1 vert bodies, ivory corner, no

ankylosis• Normal mineralization, no syndesmophytes

• Differential Diagnosis Infection• Septic arthritis (bacterial, fungal, TB)


• Ankylosing spondylitis• IBD, Psoriatic, Reiter’s, RA, CPPD, Gout, OCI


• Differential Diagnosis Trauma/Other• Post traumatic secondary OA

• Diagnosis: Ankylosing Spondylitis• Short Read:

• Least erosive most ossifying of all inflammatory arthropathies• RF neg; HLA-B27 antigen positive in many especially caucas• Fibrocartilage (1 mm) iliac first, Hyaline (3-5 mm) sacral later• Anteroinferior half to 2/3 is a true synovial joint; posterosuper

half to 1/3 is a cleft between bones with ligs (no cartilage)• DDX 1) width of joint space 2) presence and type of erosions

3) presence and type of sclerosis 4) presence and type of bony bridging 5)distribution of above changes

• Septic unilateral; AS, IBD, CPPD, OCI bilateral symmetrical; Psoriatic, Reiter’s, Gout, OA bilateral asymmetrical

CASE #29


• Findings• Fragmentation of tibial tuberosity, soft tissue swelling• Thickened patellar tendon indistinct posterior margin

• Differential Diagnosis Infection• Osteomyelitis (stretch)


• Apophysitis tibial tubercle

• Differential Diagnosis Trauma/Other• Osgood-Schlatter disease


• Diagnosis: Osgood Schlatter Disease• Short Read:

• Due to repetitive micro trauma involving patellar tendon• Apophysitis lower pole patella=jumper’s knee (Sinding-

Larsen-Johansson disease)• Apophysitis tibial tubercle=Osgood Schlatter Dz• Normal pt can have multiple centers of ossification in both

tibial tuberosity & lower pole patella>>DDX no pain or STS• Combined clinical and Radiologic diagnosis• Ultrasound may show above findings• MRI>>edema & abnormal signal in tendon, fragmentation

TT

CASE #31

CASE #31


• Findings• Soft tissue calcifications• Atrophic tapering of distal phalanges• Major erosions and minor subluxations• Osteoporosis and soft tissue swelling, joint space

narrowing• DIP, PIP, MCP, Carpal, Radius/Ulna involvement


• Rheumatoid Arthritis• Scleroderma, dermatomyositis, polymyositis, Systemic

Lupus Erythematosis


• Differential Diagnosis Trauma/Other• Superimposed DJD

• Diagnosis: Mixed Connective Tissue Disease• Short Read:

• Originally RA with SLE and Scleroderma• Now may be RA with Polymyositis, SLE,

Dermatomyositis, Scleroderma• Defined serologically plus x-ray changes since connective

tissue diseases overlap• Very high titers of circulating antinuclear antibody to a

nuclear ribonucleoprotein antigen

CASE #35

CASE #35

CASE #35


• Findings• Lateral femoral notch deeper than 1.5 mm• Hemarthrosis or effusion• ACL gone, kissing contusions

• Differential Diagnosis Infection• Differential Diagnosis Neoplasm• Differential Diagnosis Inflammation• Differential Diagnosis Trauma/Other

• Medial and lateral femoral condylar notches seen in lateral• Internal derangement, meniscal tear, ACL tear• Chondral/Subchondral fracture


• Diagnosis: Positive Lateral Condylar Notch Sign• Short Read:

• Deeper than 1.5 mm (1.2 mm + 2 SD per Resnick)• A/W anterior cruciate ligament tear, hemarthrosis• Kissing contusions lat fem condyle>>lat tib plateau

CASE #37

CASE #37

CASE #37


• Findings• Erosions with overhanging edge, sclerotic cortical rims• Normal mineralization, joint spaces preserved• Look for faint soft tissue calcification=tophus


• Gout (if chondrocalcinosis they also have CPPD)• Rheumatoid arthritis• HLA-B27 arthropathies


• Differential Diagnosis Trauma/Other• Secondary OA

• Diagnosis: Gout• Short Read:

• M:F=20:1, elevated uric acid, monosodium urate monohydrate deposits (tophi) which may calcify and be seen on films

• Many diseases cause elevated uric acid (myeloproliferative)• Uncommon before age 20 yrs, oldest recognized arthropathy• Must have untreated disease for years to see changes on films• Feet (1st MTP), hands, elbow, wrist, knee, shoulder, hip, SI Jnt• Asymmetrical polyarticular distribution, indolent, remodeling• Secondary gout with increase production or diminished excrete

of uric acid usually have no radiographic changes

CASE #38

CASE #38


• Findings• Periarticular STS, juxta-articular osteoporosis, narrowing

of DIP/PIP/MCP joints; MCP subluxations; growth deformity rather than erosive dz dominant like adult RA

• Overgrowth/ballooning of MC head epiph & premature fusion, flattening of heads & cupping of prox pahalanges, short MCs

• Ankylosis of irregularly shaped carpals; wrists more involved than hands; erosions and sclerosis of carpals and ulnar styloids

• Differential Diagnosis Infection• Differential Diagnosis Neoplasm


• Differential Diagnosis Inflammation• Juvenile RA (JRA) or Juvenile Chronic Arthritis (JCA)

• Differential Diagnosis Trauma/Other• Diagnosis: Juvenile Chronic Arthritis (JRA) Still’s

Disease (seronegative)• Short Read:

• Used to lump all under JRA; may not be able to differentiate one from the other at a specific time within course of dz >JCA

• JCA=juvenile onset ank spondy, psoriatic arthritis of IBD, juvenile onset adult type (seropositive) RA, Still’s dz=seroneg JCA

• Still’s dz makes up about 70% of JCA, occurs at younger age during growth while others act more like their adult counterparts

CASE #41

CASE #41

CASE #41


• Findings• Erosions both humeri• Tapering & erosions of clavicles• Interstitial process in lungs• Advance RA both feet

• Differential Diagnosis Infection• Viral pneumonia (stretch)

• Differential Diagnosis Neoplasm• Lymphangitic metastasis (stretch)


• Differential Diagnosis Inflammation• Rheumatoid Arthritis• Collagen vascular disease

• Differential Diagnosis Trauma/Other• Diagnosis: Advanced Rheumatoid Arthritis• Short Read:

• Corner of film trick• If the findings you found aren’t enough keep looking

CASE #43

CASE #43

CASE #43

CASE #43


• Findings• Subtle sclerosis on compressive side of femoral neck• Positive bone scan femoral neck• Positive MRI femoral neck (T1 dark, T2 bright)

• Differential Diagnosis Infection• Osteomyelitis

• Differential Diagnosis Neoplasm• Osteoid osteoma• Metastasis, lymphoma

• Differential Diagnosis Inflammation


• Differential Diagnosis Trauma/Other• Stress fracture• Traumatic fracture• Pitt’s pit (synovial herniation pit)

• Diagnosis: Stress fracture L femoral neck• Short Read:

• Fatigue fx: normal bone with repetitive excess muscular forces

• Insufficiency fx: bone that lost elasticity with normal forces• Peds=rickets, osteomalacia, ost imperfecta, osteopetrosis,

scurvy; osteoclastic activity outpaces osteoblastic activity• Tibia, metatarsal, femur, rare in upper extremity• Splint and rest before fracture becomes complete

CASE #46

Abdominal PainAbdominal Pain

CASE #46

CASE #46

CASE #46

CASE #46

CASE #46

CASE #46


• Findings• Differential Diagnosis Infection• Differential Diagnosis Neoplasm



• Diagnosis: Intra-osseous Lipoma and Arcuate Ligaments of Levator Ani

• Short Read:• Rare; may be intraosseous, intracortical, parosteal• Esp long tubular bones fibula, femur (intertroch), tibia, calcaneous• Well circumscribed lytic thin sclerotic rim with fat and CA++• Appearance varies with degree of involution & necrosis (Stage 1-3)• DDX=fibrous dysp, abc, simple cyst, infarct, chondroid matrix

tumors, liposclerosing myxofibrous tumor (>>sarcoma 10-16%)

CASE #47

CASE #47

CASE #47


• Rheumatoid Lung with effusion

Interstitial Process Acronym(Michael D’Alessandro & Jeffrey Galvin)

Sarcoid

Histiocytosis X

Idiopathic pulmonary fibrosis (UIP), Infection (viral, DIP)

Tumor (lymphangitic), TB

Failure (interstitial pulm edema)

Asbestosis and other dusts (silica, coal, pneumoconiosis)

Collagen vascular disease (Wegener’s/Lupus/RA)

Environmental, Ex Alrg Alv=org & inorg hypersens

Drugs (chemoRx, antibio, amiodarone, contrast, O2)

CASE #65

CASE #65

CASE #65

CASE #65 DISCUSSION

• Lung transplant (host vs graft?) for bronchiectasis

• Insufficiency fractures on steroids• Keep an open mind for a case you may

never have seen

CASE #66

CASE #66

CASE #66

CASE #66

CASE #66 DISCUSSION

• Posterior mediastinal Neurofibroma

Documents

48M Feelings of ankle instability. Dr. Tudor H. Hughes M.D., FRCR Department of Radiology University of California School of Medicine San Diego, California