Fake tumors in adolescents: MRI findings of lower limb apophysitis

Transcription

1 Fake tumors in adolescents: MRI findings of lower limb apophysitis Poster No.: C-2166 Congress: ECR 2010 Type: Educational Exhibit Topic: Musculoskeletal Authors: A. Salvador, C. Jimenez, J. Arnaiz, T. Piedra, A. García Bolado, E. Yllera; Santander/ES Keywords: Apophysis, Epiphiseal plate, Osgood Schlatter DOI: /ecr2010/C-2166 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 43

2 Learning objectives To describe the physiopathology of apophysitis. To review the imaging features of apophysitis with special emphasis on MRI. To discuss the differential diagnosis of apophysitis. Background ANATOMY Epiphyses and epiphyseal plates are vital structures in the bone development. Epiphyses are only present in children, adolescents and young adults (most epiphyses are closed by age of 20 years). Epiphyseal plate is two to five times weaker than the surrounding fibrous structures (ligaments,tendons and articular capsule) in childrens and adolescents. Page 2 of 43

3 As the child grow old, the epiphyseal plate ossifies and becomes stronger. There are two types of epiphysis: Traction and Pressure epiphysis. PRESSURE EPIPHYSIS: o Located at the end of a long bone. o Subject to pressures transmitted through the joint of which it is a part. o Responsible for the longitudinal growth and circunferential remodelling of long bones. TRACTION EPIPHYSIS (APOPHISIS): o Site of origin or insertion of major muscles or muscles group. o Site of attachment of tendons at long bones. TYPES OF EPIPHYSEAL LESIONS The Epiphyseal plate is two to five times weaker than the surrounding fibrous tissue in childrens and adolescents; consequently, a force causing a ligamentous or tendinous tears in adults, is likely to cause and epiphyseal plate or apophysis lesion in growing children. teaching point. Lesions that involve pressure apophysis are separation across the epiphyseal plate, which is usually produced by direct blow to the joint area (eg, Salter Harris lesion) (This is not the subject of study of our educational exhibit). Page 3 of 43

4 There are Two types of lesions that involve traction epiphysis (apophysis): Separation across the epiphyseal plate, which is usually produced by a strong muscular contraction (acute avulsion fracture of apophysis)(. (This is not the subject of study of our educational exhibit). Traumatic apophisitis, which is usually caused by strong, repetitive contraction of a muscle attached to a traction apophysis. (This is the subject of study of our educational exhibit). PHISIOPATHOLOGY Repetitive contraction over a muscle or muscle group in adult can lead to tendinous lesion or tear. In the growing child, epiphyseal plate of apophysis are weaker than the tendon (two to five times weaker). Thus, participation in vigorous activities increases increases the risk of acute and chronic apophyseal injuries rather than injury to the stronger adjacent muscle, tendon, or ligament, especially at times of growth acceleration. Overuse injury to a tissue results from repetitive sumaximal loading. Overuse injury in apophysis consists on distraction from chronic and repetitive musculotendinous pull. With sufficient recovery, the tissue adapts to the demand and is able to undergo further loading without injury. Page 4 of 43

5 Histological findings are described as increased osteoblastic activity, edema, and poliferation of benign spindle cells and small vessels in the intertrabecular spaces. Minimal inflammatory cell infiltration. Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN APOPHYSITIS OVERVIEW Page 5 of 43

6 Apophysitis are more common en active childs and young athletes. Different sports apply forces to specific apophysis: Upper limb apophysis: Swimming and throwing sports. Lower limb apophysis: Sports involving running and sudden changes of direction). Epiphyseal injuries are common during the period of rapid growth ( years in girls and years in boys. Osteomyelitis and metabolic diseases such as scurvy, rickets, and endocrine imbalance increase vulnerability to epiphysieal injuries. teaching point. Apophysitis occurs most often in the calcaneus and tibial tubercle. CLINICAL FINDINGS Signs and sympoms to look for are deformity (lump), swelling and pain at the affected apophysis. Pain will be present over the apophysis than over the nearby fibrous strucures, but sympoms can be vague or referred elsewhere Isometric contraction of muscles attached to apophysis will produce pain at the apophyseal location. Page 6 of 43

7 Clinical onset is usually gradual, the signs and sympoms worsen as the child continues exercise aggravating the condition. Symptoms can subside with 2-3 days of rest, so the child returns to exercise. This creates a failure to arrest this condition,and can result in chronic inflammation. TREATMENT Conservative therapy is the treatment of choice. Reduction of the frequency and intensity of exercise, activity modification and analysis of sporting techniques ( in the case of athletes). Physiscal theraphy-rehabilitation: Graduated rehabilitation program comprising strengthening and flexibility exercises is recommended. Control of pain and swelling with non steroideal antiflammatory drugs (NSAIDS). Prevention is essential. Prevention of excessive muscular activity particularly in context of highly competitive sport. Excellent prognosis. a beningh and self-limited Page 7 of 43

8 After 2-6 months under conservative theraphy, the sympoms usually disappear. Surgical theraphy is only indicated in patients with certain apophysitis (eg, Osgood Schlatter disease) and chronic persistent sympoms ( eg, ossicle excision). Page 8 of 43

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11 Images for this section: Page 11 of 43

12 Fig. 1 Page 12 of 43

13 Imaging findings OR Procedure details RADIOGRAPHS Radiographs are nonspecific and inconclusive: Apophysis may appear normal or may reveal irregularity and fragmentation of the margin. Osteoporotic patches, sclerosis and mild widening of the involved apophyseal area can be also found Generally is not neccesary to obtain radiographs in patients with clinical findings of apophysitis. Radiographs are obtained in order to exlude other conditions (fracture, tumors, osteomyelytis),in patients who have atypical features or absence of recovery with conventional therapy. ULTRASONOGRAPHY Nonspecific findings. Page 13 of 43

14 Apophysis is seen as a heterogeneous vascularized mass at the site of apophysis. Ultrasonography findings may simulate appearance of soft tissue sarcoma. teaching point. NUCLEAR SCINTIGRAPHY Nonspecific findings. Increased radiotracer uptake in the apophysis on blood pool and delayed images. This technique has been used when the clinical findings are atypical and radiography is unrevealing. MRI Apophysis enlargement/widening (site of muscle insertion). Page 14 of 43

15 Discrete or absent epiphiseal plate separation (markedly hyperintense on T2) T2 Hyperintensity in apophysis, subyacent bone and fibrous periapophyseal structures ( tendon, ligaments, capsule, bursae). T2WI hypersignal of epiphyseal plate. T1 hypointensity in apophysis and subyacent bone. Contrast enhancement of apophysis, epiphyseal plate, subyacent bone and surrounding soft tissue structures. MRI can be used to identify or confirm a diagnosis, usually after radiography has been performed. Or after sonographic suspiction of soft tissue sarcoma. ILIAC CREST APOPHYSITIS Page 15 of 43

16 Iliac crest apophysis remains cartilaginous until adolescence. Fusion of the ossified apophysis to the iliac bone begins around the age of 15 but can still occur up to the age of 25 years The iliac crest is the site of origin of insertion of the external and internal abdominal oblique muscles, transverse abdominis muscle, gluteus medius muscle and the tensor fascia latae. Fig.: 9 year old girl, presenting Pain over the iliac crest. Page 16 of 43

17 References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN ANTERIOR SUPERIOR ILIAC CREST APOPHYSITIS Discrete separation and inflammation of the traction epiphysisis at the attachement of the sartorius muscle sartorius and tensor fascia lata (anterior superior iliac spine). Page 17 of 43

18 Groin pain mimcking athletic pubalgia Pain at the anterior superior iliac spine. During active flexion and external rotation of the hip, the pain increases. Frequent in child that practice sports that involves kicking (soccer). Page 18 of 43

19 Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN ISCHIAL TUBEROSITY APOPHYSITIS Painful inflammation of the ischial tuberosity, particularly in physically active growing children. Caused by repetitive microtrauma to the ischial tuberosity apophysis induced by the hamstring muscles contraction. Page 19 of 43

20 Commonly seen in activities that involve distance running and dancers. Dull pain in hip aggraved by activity Examination may reveal tenderness on over compression of ischial tuberosity and while isometric contraction of hamstring muscles. Page 20 of 43

21 Fig.: 4 year old boy presenting insidious pain (4weeks) in the anterior side of the right thigh and right knee. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN Page 21 of 43

22 Fig.: 11 year old boy active player of basketball, presenting insidious and invalidating pain References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN Page 22 of 43

23 Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN GREAT TROCHANTER APOPHYSITIS Greater trochanter apophysis develops between2 and 5 years, with fusion between the ages of 16 and 18 years; It provides attachment for gluteus medius and minimus. Page 23 of 43

24 Fig.: 2 years,4 months old girl presenting pain (2 weeks) in left hip and gait disturbance. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN Page 24 of 43

25 Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN OSGOOD SCHLATTER DISEASE Traction apophysistis of the proximal tibial tubercle at the insertion of the patellar tendon. Page 25 of 43

26 Caused by repetitive microtrauma to the apophysis with repetitive strain and chronic avulsion of the tibial tubercle Generally occurs in children aged 9-14 years of age who have undergone a rapid growth spurt. Traditionally more common in boys, it is becoming more common in girls as their sports participation increases, Commonly seen in activities that involves running, cutting and jumping (basketball, soccer, gumnastics, ballet,etc.) 25-50%bilateral Examination may reveal tenderness and soft-tissue or bony prominence of the tibial tubercle, pain may be reptroduced by isometric contraction of quadriceps. Pain that persists after the closurer of the growth plate may be related to a residual ossicle. Excision of this ossicle can be curative. Page 26 of 43

27 Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN SINDIG-LARSEN-JOHANSONN Traction apophysistis at the inferior pole of the patella,at the insertion of the patellar tendon. Characterized by pain and swelling at the inferior pole of the patella, the point of insertion of the patellar tendon. Page 27 of 43

28 Generally occurs in boys aged 9-11 years. Apophysitis with repetitive strain and chronic avulsion of the inferior pole of the patella. Commonly seen in activities that involves running, cutting and jumping (basketball, soccer, gymnastics, ballet,etc.). Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN CALCANEAL APOPHYSITIS (SEVER'S DISEASE) Page 28 of 43

29 Painful inflammation fo the calcaneal apophysis. Most common cause of heel pain in athletes from 5 until 11 years of age. Caused by repetitive microtrauma to the weaker structure of the apophysis induced by the pull of the Achilles tendon on its insertion. Commonly seen in activities that involves running (basketball, soccer, track,etc.) Dull pain in the poasterior aspect of the heel agravated by activity 60% bilateral. Page 29 of 43

30 Fig. References: A. Salvador; Radiology, Hospital Universitario Marqués de Valdecilla, Santander, SPAIN COMMON PITFALL IN DIAGNOSING APOPHYSITIS The apophysitis MRI findings consistent with increase of signal intensity on T2 and contrast enhancement of soft tissue/bone, has led to soft tissue sarcoma diagnosis and biopsy in some cases. We should not misinterpret the apophyseal widening as a tumoral mass. Page 30 of 43

31 If radiologist is aware of this entity the MRI findings allows a straight-forward diagnosis, even in cases of uncommon location of apophysitis (eg,great trochanter). DIAGNOSIS As we have described, apophysitis share common physiopathology, ethiology origin as well as clinical behaviour, prognosis and management. Apophyisitis share morphologic and signal characteristics that allow precise and straight diagnosis On the other hand, the lack of imaging reports and its relatively rareness in the current MRI examination,and the similar imaging behaviour in MRI can lead to the mistaking diagnosis of soft tissue/ bone tumor, leading to unneccesary biopsy. Key features to remember: - Child-adolescent patient, - Characteristic location of the lesion (apophysis), Page 31 of 43

32 - Typical MRI pattern: Apophysis enlargement/widening (site of muscle insertion). Discrete or absent epiphiseal plate separation (markedly hyperintense on T2). T2 Hyperintensity in apophysis, subyacent bone and fibrous periapophyseal structures ( tendon, ligaments, capsule, bursae). T2WI hyperintensity of epiphyseal plate. T1 hypointensity in apophysis and subyacent bone. Contrast enhancement of apophysis, epiphyseal plate, subyacent bone and surrounding soft tissue. Images for this section: Page 32 of 43

33 Fig. 1: 9 year old girl, presenting Pain over the iliac crest. Page 33 of 43

34 Fig. 2 Page 34 of 43

35 Fig. 3: 4 year old boy presenting insidious pain (4weeks) in the anterior side of the right thigh and right knee. Page 35 of 43

36 Fig. 4 Page 36 of 43

37 Fig. 5: 11 year old boy active player of basketball, presenting insidious and invalidating pain Page 37 of 43

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39 Fig. 7: 2 years,4 months old girl presenting pain (2 weeks) in left hip and gait disturbance. Page 39 of 43

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42 Fig. 11 Page 42 of 43

43 Conclusion Apophysitis are common pathologyes in different location that share physiopathology, clincal, hystology, and common characteristics in MRI. Radiologists showld be aware of this entity in order to a void misdiagnosis as sarcoma or infection Understanding the physiopathology of apophysitis is essential for a precise diagnosis on MRI. Accurate identification of key MRI features of this entity may prevent misdiagnosis and inappropriate management of apophysitis. Personal Information References Kose O. Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children? Skeletal Radiol Aug 12. Yamamoto T, Akisue T, Nakatani T, Kawamoto T, Hitora T, Marui T, Kurosaka M. Apophysitis of the ischial tuberosity mimicking a neoplasm on magnetic resonance imaging. Skeletal Radiol Dec;33(12): Epub 2004 Jun 15. Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries. Am Fam Physician Mar 15;73(6): Review. Page 43 of 43