MSK Interesting Cases. Dr Yap Sheau Huey

Transcription

1 MSK Interesting Cases Dr Yap Sheau Huey

2 Case 1: History 41 y.o man, surf skier C/o pain over anterior left 5 th to 8 th ribs. Worse after sport activity.

3 Chest Radiograph

4 US Periostitis and early callus formation

5 US Periostitis and early callus formation

6 Hypoechoic rim of periostitis surrounding the affected rib

7 Juxtacortical hyperemia

8 US Report Healing stress fracture of left 6 th rib in the anterior axillary line.

9 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

10 Case 2 Madam SKT 61 y.o lady H/O bilateral hip AVN? Idiopathic cause H/O bilateral Total Hip Replacement in 2006

11 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.

12 Clinical Impression: Rt hip pain post THR- TRO iliopsoas impingement

13 Ultrasound Images

14 CT

15

16

17 Ultrasound Guided Diagnostic Injection Of LA ( mixture of lignocaine & marcaine)

18 Post Injection Immediate pain relief Conclusion: Iliopsoas impingement post THR due to femoral bony proliferation

19 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.

20 Clinical assessment Diagnosis 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.

21 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.

22 US (4/5/2017) Severe swelling of pect major: features of myositis

23

24 MRI (12/5/2017) T1W STIR

25 MRI Post Contrast

26 During F/U on 28/5/2017 Clinically mass is smaller in size after steroid treatment. Diagnosis: radiation recall

27 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

28 Radiological Findings US/CT: MRI: Non specific soft tissue swelling High signal intensity of the muscles, fascial or subcutaneous tissue involved. Some reported rim enhancement of the muscle Treatment: Steroid/Anti-inflammatory drugs.

29 Case 4: History Mr LSP 28 y.o man Presented with trigger finger of the right index finger.

30 Plain XR 2010

31 XR 2017

32 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.

33 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

34 Radiographs - post separation of syndactyly Soft tissue thickening. Broadening and splaying of the phalanges of middle and ring fingers.

35 MRI (30/5/2014) Enlarged median nerve with fat deposition in btw nerve fascicles.

36 MRI Report Soft tissue and bony hypertrophy of middle and ring finger Enlargement of median nerve and ulnar nerve ( lesser degree).

37 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.

38 Complication: Cosmetic Degenerative joint disease Neurovascular compression Carpal tunnel syndrome

39 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

40 MRI (7/4/2017) STIR Coronal

41 TSFS

42 T1FS Post Contrast

43 Plain Film (11/5/2017)

44 US ( 11/5/2017)

45 Ultrasound guided biopsy done on 11 th May 2017 HPE shows: benign muscle with focal fibrosis, regeneration, fibrosing granulation tissue, and rare foci of ossification. Diagnosis: Myositis ossificans

46 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

47 Plain Radiograph ( 27/6/2016)

48 MRI ( 2/7/2016) T2W Heterogeneous lesion in distal brachialis muscle

49 STIR

50 T1FS Post Contrast

51 US (11/7/2016)

52 CT (11/7/2016)

53 Plain Radiograph (25/8/2016)

54 Biopsy (10/8/2016) HPE:benign skeletal muscle with significant fibrosis and ossifications. Diagnosis: myositis ossificans

55 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.

56 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.

57 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.

58 THANK YOU!