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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!
