MSK Interesting Cases Dr Yap Sheau Huey · Discussion Incidence is 4.3%. Clinically, patient c/o...
Transcript of MSK Interesting Cases Dr Yap Sheau Huey · Discussion Incidence is 4.3%. Clinically, patient c/o...
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MSK Interesting Cases
Dr Yap Sheau Huey
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Case 1: History
41 y.o man, surf skier
C/o pain over anterior left 5th to 8th ribs.
Worse after sport activity.
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Chest Radiograph
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US
Periostitis and early callus formation
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US
Periostitis and early callus formation
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Hypoechoic rim of periostitis surrounding the affected rib
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Juxtacortical hyperemia
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US Report
Healing stress fracture of left 6th rib in the anterior axillary line.
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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
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Case 2
Madam SKT
61 y.o lady
H/O bilateral hip AVN ? Idiopathic cause
H/O bilateral Total Hip Replacement in 2006
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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.
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Clinical Impression:
Rt hip pain post THR- TRO iliopsoas impingement
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Ultrasound Images
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CT
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Ultrasound Guided Diagnostic Injection Of LA ( mixture of
lignocaine & marcaine)
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Post Injection
Immediate pain relief
Conclusion:
Iliopsoas impingement post THR due to femoral bony proliferation
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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.
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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.
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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.
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US (4/5/2017)
Severe swelling of pect major: features of myositis
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MRI (12/5/2017)
T1W STIR
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MRI Post Contrast
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During F/U on 28/5/2017
Clinically mass is smaller in size after steroid treatment.
Diagnosis: radiation recall
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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
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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.
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Case 4: History
Mr LSP 28 y.o man
Presented with trigger finger of the right index finger.
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Plain XR 2010
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XR 2017
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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.
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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
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Radiographs - post separation of syndactyly
Soft tissue thickening.Broadening and splaying of the phalanges of middle and ring fingers.
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MRI (30/5/2014)
Enlarged median nerve with fat deposition in btw nerve fascicles.
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MRI Report
Soft tissue and bony hypertrophy of middle and ring finger
Enlargement of median nerve and ulnar nerve ( lesser degree).
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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.
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Complication:
Cosmetic
Degenerative joint disease
Neurovascular compression
Carpal tunnel syndrome
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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
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MRI (7/4/2017)
STIR Coronal
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TSFS
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T1FS Post Contrast
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Plain Film (11/5/2017)
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US ( 11/5/2017)
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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
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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
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Plain Radiograph ( 27/6/2016)
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MRI ( 2/7/2016) T2W
Heterogeneous lesion in distal brachialis muscle
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STIR
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T1FS Post Contrast
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US (11/7/2016)
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CT (11/7/2016)
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Plain Radiograph (25/8/2016)
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Biopsy (10/8/2016)
HPE:benign skeletal muscle with significant fibrosis and ossifications.
Diagnosis: myositis ossificans
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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.
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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.
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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.
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THANK YOU!