Download - 59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
TFC Tear
• Palmer classification for triangular fibrocartilage complex abnormalities
Class 1: Traumatic • A - Central perforation • B - Ulnar avulsion • C - Distal avulsion • D - Radial avulsion with or without sigmoid notch fracture
Class 2: Degenerative (ulnocarpal abutment syndrome) stage • A - TFCC wear • B - TFCC wear with lunate and/or ulnar chondromalacia • C - TFCC perforation with lunate and/or ulnar chondromalacia • D - TFCC perforation with lunate and/or ulnar chondromalacia
and LT ligament perforation • E - TFCC perforation with lunate and/or ulnar chondromalacia,
LT ligament perforation, and ulnocarpal arthritis
30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided trunk/thigh hypertrophy?
Absent vs. Atrophic Piriformis muscle?
• Piriformis muscle might be absent and there might be variations in origin and insertion sites of some muscles and their relation with regional nerves of this region.
1) Bannister L, Berry M, Collins P, Dyson M, Dussek J : Muscles of the thigh and gluteal region. In. Williams P (ed): GrayÕs Anatomy. 38 th ed. London: Churchill Livingstone, 1995 : 875-878
2) Lee CS, Tsai TL : The relation of the sciatic nerve to the piriformis muscle. Taiwan I Hsueh Hui Tsa Chih 1974; 73 : 75-80.
27 y/o male with twisting ankle injury while hiking
27 y/o male with twisting ankle injury while hiking
27 y/o male with twisting ankle injury while hiking
Achilles Avulsion
• Greek mythology relates that the legendary warrior Achilles was made invincible by his mother Thetis, who dipped him in the River Styx while holding him by his heel. Because his heel was never immersed, it remained his one area of vulnerability. After the fall of Troy, Achilles met his demise when he was shot in the heel by Paris, whose arrow was guided by the Greek god Apollo. This is the derivation of the term "Achilles tendon."
Achilles Avulsion
• However, Achilles avulsion is considered rare, usually occuring at the calc. tubercle.
• Possible causes:• Traumatic dorsiflexion in maximally
plantar flexed foot• Contraction of triceps surae during knee
extention in a sprint• Direct blow
The heel of achilles: calcaneal avulsion fracture from a gunshot wound.
Cooper DE, Heckman JD Foot Ankle. 1989 Feb;9(4):204-6
34 y/o MLB pitcher with shoulder pain
34 y/o MLB pitcher with shoulder pain
34 y/o MLB pitcher with shoulder pain
34 y/o MLB pitcher with shoulder pain
Thrower’s Shoulder
Elbow pain 55 yr old man
pre post
Elbow pain 55 yr old man
Bicipitoradial Bursa
Cubital Bursae
• bicipitoradial bursa
• interosseous bursa
Bicipitoradial Bursitis: MR Imaging Findings in Eight Patients and Anatomic Data from Contrast Material Opacification of Bursae Followed by Routine Radiography and MR Imaging in Cadavers1
Abdalla Y. Skaf, MD, Robert D. Boutin, MD, Robert Weiber M. Dantas, MD, Andrew W. Hooper, MD, Claus Muhle, MD, David S. Chou, MD, Nittaya Lektrakul, MD, Debra J. Trudell, RA, Parviz Haghighi, MD and Donald L. Resnick, MD 1
From the Departments of Radiology (A.Y.S., R.D.B., R.W.M.D., A.W.H., C.M., D.S.C., N.L., D.J.T., D.L.R.) and Pathology (P.H.), Veterans Affairs Medical Center and University of California San Diego, 3350 La Jolla Village Dr, San Diego, CA 92161.
Bicipitoradial Bursa
• reduces friction between the biceps tendon and the radial tuberosity
• Bursitis• Repetitive mechanical trauma• Infection• Inflammatory arthropathy• Chemical synovitis• Bone proliferation
Elbow Pain
Torn Biceps Tendon
Cubital Bursitis
Supinator muscle edema
• Mass effect in the cubital tunnel may compress the branches of the radial nerve
Posterior Interosseous Nerve Syndrome
• Compression of the deep branch of the radial nerve
• innervates multiple extensor muscles• extensor indicis proprius, extensor digiti
quinti, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, and extensor digitorum communis muscles
34 yo Hockey player
SLAP tear with possible extension into the SGHL and MGHL
33 yo woman
osteopenia, cartilage loss, and erosions, subluxation
Rheumatoid Arthritis
33 yo woman
Same patient
OA pattern
• Superolateral joint space narrowing
• Marginal osteophytes
• Eburnation and subchondral cystic change
Why the early OA?
Femoral Acetabular Impingment?Crystal deposition disorders?
19 yr old Marine with new onset difficulty performing pull-ups
19 yr old Marine with new onset difficulty performing pull-ups
Suprascapular Nerve Entrapment
• At suprascapular notch, will involve both the supra- and infraspinatus muscles
• At the spinoglenoid notch, involves only the infraspinatus
• Most common cause is a ganglion cyst from a superior labral tear
36 year old man with arm and hand numbness for one day
36 year old man with arm and hand numbness for one day
• Patchy scattered foci and muscular edema
• Considerations• Parsonage Turner
syndrome• Quadrilateral space
syndrome
Post op day 1 from ventral hernia repair
• Other considerations
• Positioning neuropathy
T2 T1-PRE POST
T2 T1 PRE T1 POST
SOFT TISSUE MASS: VOLAR DISTAL PHALANX
• Ganglion cyst 50% to 70%
• Hemangioma/vascular malformation
• Giant cell tumor
• Glomus tumor
• Mucoid (epidermoid) cyst
• Epidermoid
• Nerve sheath tumor
Benign tumors of fibrous tissue origin
• Nodular fasciitis
• Neurofibroma
• Schwannoma
• Fibrous histiocytoma
• Fibroma/ fibromatosis
Nodular fasciitis
• Most common soft tissue lesion originating from fibrous tissue
• 50% arise in the upper extremity, m/c volar forearm
• Present as a rapidly growing mass
Enzinger FM, Weiss SW. Soft tissue tumors. St Louis: Mosby, 1995.
Nodular fasciitis
• Histologically often misdiagnosed because of its rapid growth, increased cellularity and mitotic activity
Nodular fasciitis
• Thee subtypes• Subcutaneous
• Subcutanous nodule
• Intramuscular• Large, deep, mimics a soft tissue malignancy
• Intermuscular• Irregular/ stellate appearance, mimics
inflammatory lesion
MR characteristics
• Variable depending on the amount of collagen, cellularity, and mucin.
• Subcutaneous lesions to occur in younger patients and exhibit myxoid histology and increased T2 signal.
Wang et al., Nodular fasciitis: correlation of MRI findings and histopathology.Skeletal Radiol. 2002 Mar;31(3):155-61.
Axial T1 FS
Axial T1 FS/Gd
Axial T2 FS
Axial T1
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Cor T2 FS Cor T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Sag T1
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Sag T1
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Sag T1
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Sag T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Sag T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Sag T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal phalanx and gout of 2nd digit.
Gout
• MRI of Tophi• Low on T1WI• On T2WI usually variable but contain low-
signal regions• High signal on post Gd
Yu et al, MR imaging of tophaceous gout. AJR Am J Roentgenol. Yu et al, MR imaging of tophaceous gout. AJR Am J Roentgenol. 1997 Feb;168(2):523-7.1997 Feb;168(2):523-7.
Weishaupt et al, MR imaging of inflammatory joint diseases of the Weishaupt et al, MR imaging of inflammatory joint diseases of the foot and ankle.foot and ankle.Skeletal Radiol. 1999 Dec;28(12):663-9. Skeletal Radiol. 1999 Dec;28(12):663-9.
Axial T1
Axial T1FS/Gd
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
Axial T2 FS
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
Chronic Infection and Synovial Hypertrophy
• D.Dx.• Fungus• TB ( Mycobacterium marinum)
Mycobacterium Infection
Recurrent Mycobacterium marinum tenosynovitis of the wrist mimicking extraarticular synovial chondromatosis on MR images.Lee EY, Rubin DA, Brown DM.
Skeletal Radiol. 2004 Jul;33(7):405-8. Epub 2004 May 04.
Horseshoe AbscessDiagnosis of Bone and Joint Disorders, Resnick
Hand – Pathways of infection, pg 2399
Tenosynovitis caused by atypical mycobacterial infections may produce rice bodies within affected tendon sheaths.
…. the flexor tendons within the carpal tunnel in which the rice bodies were mistaken for synovial chondromatosis on MR images
21yo F with hand pain. History of bilateral THA and TKA.
21yo F with hand pain. History of bilateral THA and TKA.
21yo F with hand pain. History of bilateral THA and TKA.
21yo F with hand pain. History of bilateral THA and TKA.
21yo F with hand pain. History of bilateral THA and TKA.
21yo F with hand pain. History of bilateral THA and TKA.
Juvenile Chronic Arthritis
Portrait of a Youth
Botticelli, 1483
Juvenile –onset adult type RA
• Female
• >10yrs
• Polyarticular
• Possible subQ nodules and vasculitis
• Seropostive for RA
Diagnosis of Bone and Joint Disorders, 3rd ed. D Resnick, editor. W.B. Saunders Co., Philadelphia, 1995.
Juvenile –onset adult type RA
• MCP and IP joints of hand
• Wrist
• Knee
• MTP and IP joints of foot
• Cervical spine
• Hip
• Shoulder
Juvenile –onset adult type RA
• Soft tissue swelling• Osteoporosis• Periostitis• Erosions, especially in the absence of joint
space loss• Possible joint space loss• Atlanto Axial Subluxation• Epiphyseal compression fractures• Joint Subluxation• Growth disturbances
73 y.o F with wrist pain and stiffness
73 y.o F with wrist pain and stiffness
73 y.o F with wrist pain and stiffness
Rheumatiod Arthritis vs Psoraisis
Interesting Wrist Case
• Dorsal Midcarpal Instability
• Carpal Instability Non Dissociative (CIND)
UCSD Bone Conference
June 3, 2005
Jeremy Kuniyoshi
57 yo M with increasing thigh mass X 2-3 months
Further Hx:
Infected hematoma post cath many yrs ago
On anticoag for prosthetic valves (INR 1.6)
57 yo M with increasing thigh mass X 2-3 months
57 yo M with increasing thigh mass X 2-3 months
17964259.jpg
SAG STIR COR T1
AX PD FS
17964259.jpg
T1 POST
T1 FS POST AX T1 POST
T1 FS POST
57 yo M with increasing thigh mass X 2-3 months
Surgical Pathology Report:
Fibrous Capsule with areas of granulation tissue, multinucleated giant cells, areas of necrosis, and hemorrhage with clot c/w pseudoaneurysm
Fig. 1A–C MRI of the left knee.
A Coronalinversion recovery (TR 2000 / TE 18 /TI 150) image shows a large ovoid masswithin the popliteal fossa, which is predominantlyof high signal intensity. There is noedema in the adjacent muscles.
B Sagittalgradient echo (TR 500/TE 16/flip angle30°) image shows multiple low-signal fociwithin the mass consistent with calcifications.Note also the mass merging with themassively dilated popliteal vein behind thedistal femur (arrows). The uniform highsignal within the dilated vein is typical ofslow venous flow.
C Axial T2-weighted(TR 2000/TE 80) image shows intimate relationshipof the mass to the popliteal arteryand vein (arrow), interposed between themass and the tibial plateau, although no directcommunication could be identified
Fig. 2A, B Digital subtraction angiogram of the left leg. A Arterial phase oblique image of the popliteal artery demonstrates a direct communication between the lumen of the artery and the mass (arrow), consistent with a pseudoaneurysm. B Late venous phase image shows large slow-flow venous channels (arrowheads) within the mass, draining into the enlarged popliteal vein (arrows)
Popliteal vascular malformation simulating a soft tissue sarcoma
Wambeek N, Munk PL, O'Connell JX, Lee MJ, Masri BA. Skeletal Radiol 1999;28(9):532-5.
51 yo M with R Shoulder pain s/p humeral head replacement
10-28-03 4-25-04 HHR Converted to TSA
51 yo M with R Shoulder pain s/p humeral head replacement
5-12-04 Glenoid component well located 6-23-04 Glenoid component dislocated
51 yo M with R Shoulder pain s/p humeral head replacement
6-2-05
Total Shoulder Arthroplasty: Glenoid Component
- indications are controversial;
- this needs to be performed prior to insertion of the humeral component;
- increased glenoid loosening rates from eccentric loading & excessive glenoid wear can be expected with w/ rotator cuff arthropathy
Glenoid loosening:
- radiolucencies around the glenoid component will eventually be seen in 60% of patients;
- some authors note that in many cases radiographs may fail to show loosening because the radiographic beam is not perpendicular to the bone-component interface;
From: http://www.wheelessonline.com/ortho/total_shoulder_arthroplasty_glenoid_component
Conversion of painful hemiarthroplasty to total shoulder arthroplasty: Long-term resultsRaymond M. Carroll, MD, Rolando Izquierdo, MD, Michael Vazquez, MD, Theodore A. Blaine, MD, William N. Levine, MD, and Louis U. Bigliani, MD, New York, NY
“revision of a failed HHR to a TSA is a salvage procedure whose results are inferior to those of primary TSA…”
From: J Shoulder Elbow Surg Nov/Dec 2004
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot