msk interesting cases meeting
TRANSCRIPT
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MSK Interesting Cases
MeetingCarita Tsoi
21.05.2020
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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
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26.12.2019
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PATIENT TRANSFERRED TO TPH FOR REHAB AND
DISCHARGED.
ARRANGED MRI FOR SUSPECTED LABRAL
TEAR
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10.1.2020
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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
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31.1.2020
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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
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2. SC Chan 58/F
• PMH• CA ovary and corpus resection in 2014
• Presented with massive PE on Innohep since then
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• 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
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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
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USG 16/3/2020
Areas of moderate subcutaneous fat atrophy with discrete nodules
Moderate subcutaneous fat hyperaemia
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Delayed hypersensitivity reaction to subcutaneous heparin injections
• Erythematous, infiltrated plaques at injection sites
• Confirmed by challenge tests
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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
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12.3.2020
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Septal and peripheral rim-like enhancement corresponding to fibrovascular septation between lobules of hyaline cartilage
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26.3.2020
Permeative lytic
destructive
Endosteal scalloping
Cortical thickening and
remodelling
Periosteal reaction
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Cortical thickening and remodelling
Periosteal reaction
Intralesional calcifications
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Chondrosarcoma
• Hyaline cartilage• High water content
• High T2 signal
• Ring and arc calcifications
• Endosteal scalloping affecting more than two-thirds of the cortical thickness
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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
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14.4.2020
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Vertebral body reabsorption, spondylolisthesis, angular kyphus at C4/5 Severe cord compression and cystic myelomalaciaPrevertebral fluid
16.4.2020
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Companion Case 57/F YH, Chan. ESRF on HD
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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
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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
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2.5.2013
Focal areas of
cortical and
subcortical
thickening and
sclerosis
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7.5.2013
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2014 2015 2016
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• Claimed progressive increase in right hip stiffness esp with decrease in flexion ROM in 2020
• Inflammatory type of pain
• Relieved by exercise
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2014 2020 2020
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Mild interval increase in extent of known melorheostosis
2014 2020
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New partly calcified outgrowth at the right
anterior acetabulum into the anterior right hip joint space. Arranged biopsy
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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
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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
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6. YN, Wong 56/F
PMH
• SLE
• Gout
C/O swelling over right bicep
Previous fall with injury to right arm
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USG arm
Left humerus
SHBSHBLHB
LHB
Right
humerus
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USG arm
LeftRight
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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
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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
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USG left thigh
27.4.2020
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MRI Left thigh
28.4.2020
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USG-guided aspiration29/4/2020
500mL yellowish clear fluid
Negative for malignant cells. Lymphocytes seen
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Lymphocele
• Thin-walled simple fluid collections with minimal wall enhancement
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8. YM, Lam 33/F
• GPH
• Right thumb injury during ski
• No deformity or dislocation
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18.2.2020
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USG: nodular lesion at dorsal ulnar side of MCPJ
4.3.2020
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MRI: UCL avulsed from phalangeal attachment.Nodular low signal lesion overlying adductor aponeurosis is retracted = End of displaced torn ligament
5.3.2020
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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.
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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.
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Companion case52/M
R thumb injury
motorcyclist
slipped with immediate
pain
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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
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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
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Moderate oedema present in the left gluteus medius, minimus, piriformis extending to the greater trochanter
24.10.2019
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Corresponding enhancement
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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.
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Preliminary findings of use of dual energy CT for detection
of bone marrow edema
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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
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