Category: Musculoskeletal cases

Musculoskeletal #45

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Clinical Data

40-year-old female:
with chronic medial side knee pain.

What abnormality is present?

Pellegrini-Stieda lesion


There is an ossified lesion adjacent to medial femoral condyle, at the insertion of medial collateral ligament (MCL).

MCL fibers are intact.

No signs of osteoarthritis.

Slight degenerative changes within the body of medial meniscus.

Explanation:

Pellegrini-Stieda lesions are defined as post-traumatic ossifications of the medial collateral ligament (MCL) at or near its proximal insertion on the medial femoral condyle.
Pellegrini-Stieda disease (or syndrome) is defined as the combination of the radiographic findings and concomitant medial knee joint pain or restricted range of motion.

Musculoskeletal #44

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Clinical Data

39-year-old male:

  • With wrist trauma

Wrist X-ray AP projection
Wrist X-ray lateral projection
Which is the diagnosis?

  • Undisplaced scaphoid fracture

  • Acute boxer’s fracture

  • Dorsal avulsion fracture of the triquetrum

  • No abnormality

Which is the diagnosis?

  • Undisplaced scaphoid fracture – FALSE

  • Acute boxer’s fracture – FALSE

  • Dorsal avulsion fracture of the triquetrum (Red arrow) – TRUE

  • No abnormality – FALSE

    Explanation:

    • Notice also the dorsal soft tissue swelling with air lucencies (Located inside the orange line).




    Triquetral fractures:

    • Second most common carpal bone fracture (after the scaphoid)

    • Fall onto an outstretched hand in ulnar deviation and carpal extension or direct blow to the dorsum of the hand (latter in this case)

    • Almost always dorsal avulsion type

    • Usually only seen on lateral radiographs with the classic “pooping duck” sign




Musculoskeletal #43

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Clinical Data

32-year-old male:

  • After fall from about 1 meter high

  • Felt a snap in his knee

  • Instability







What are the findings on the radiograph?

  • Deep lateral notch (sulcus) sign on lateral projection

  • Suprapatellar effusion

What’s the next best step and why?

  • MRI of the knee, due to high index of suspicion for ACL tear










What is the final diagnosis?

    Full-thickness ACL tear

    • Patient had additional abnormalities of the knee not shown.


Image 1
Right

Image 2
(Almost) Normal left for comparison

Musculoskeletal #42

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Clinical Data

55-year-old female:

  • With trauma

  • Painful elbow after a fall from height

  • Supination and pronation painful



What’s the radiological sign visible on the radiograph?

Capitellum fracture

The case represents a classic capitellum fracture, with a mildly displaced fragment on the lateral projection, which can easily be missed if one is not familiar with the double-arc sign.

Musculoskeletal #41

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45-year-old female with forefoot pain:

What is the pathology located?

Where is the pathology located?

D3/D4 intermetatarsal space

Describe the pathology. Can you name it?

T1- and T2-hypointense soft tissue mass located in D3/D4 intermetatarsal space – Morton neuroma.

References:

Morton neuroma is a result of a compressive neuropathy of the forefoot interdigital nerve. The most common location for interdigital neuromas are between the 3rd and 4th metatarsal heads. Most patients with Morton neuroma have a good recovery with non-surgical treatment. 

Munir U, Tafti D, Morgan S. Morton Neuroma. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470249/

Musculoskeletal #40

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85-year-old patient:
– with long-standing left hip pain
– X-rays requested

Showing images from an MRI

T2W Fat Sat
T1W

What is the most likely diagnosis?

What is the most likely diagnosis?

Marked collapse of the articular surface of the left femoral head, along with fragmentation, indicative of osteonecrosis
Secondary dvanced degenerative changes in the hip joint

Reference: Mont MA et al: Nontraumatic osteonecrosis of the femoral head: where do we stand today? A 5-year update. J Bone Joint Surg Am. 102(12):1084-99, 2020

Musculoskeletal #38

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15-year-old patient with left hip pain:
– X-rays requested

What is the next step?

What is the next step?

MRI

T1W
T2W Fat Sat
What is the most likely diagnosis?

What is the most likely diagnosis?

Femoral stress fracture

MRI findings linear low-signal pattern on the medial aspect of the femoral neck, accompanied by bone marrow oedema
Surrounding cortical thickening and solid periosteal reaction

Reference: Shelat NH et al: Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 36:138-46, 2016

Musculoskeletal #36

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35-year-old patient:
– With persistent right hip pain
– Pain exacerbated by abduction/external rotation
– MRI arthrogram requested

Showing images from an MR-arthrography:

What are the findings?

What are the findings?

There is a complete tear in the anterosuperior labrum, located around the 2 o’clock position.

Reference: Schmaranzer F et al: Diagnostic performance of direct traction MR arthrography of the hip: detection of chondral and labral lesions with arthroscopic comparison. Eur Radiol. 25(6):1721-30, 2014

Musculoskeletal #35

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52-year-old patient:
·With chronic right hip pain

MRI findings:

T1W
T1W
T2W Fat Sat
T2W Fat Sat
T2W Fat Sat
What is the underlying reason for the alterations observed in the bone marrow?

What is the underlying reason for the alterations observed in the bone marrow?

– A subchondral insufficiency fracture accompanied by bone marrow edema is noted
– The presence of additional bone marrow edema in the right femoral neck, particularly in the anterolateral region, is likely indicative of an insufficiency response
– Complete cartilage damage is observed

Pelvic insufficiency fractures

-Pelvic insufficiency fractures typically manifest in the lateral aspect of the femoral neck, while stress fractures tend to occur on the medial aspect

-Additionally, damage to the articular surface can result from cartilage loss, a condition distinct from osteonecrosis

Reference: Peh WC et al: Imaging of pelvic insufficiency fractures. Radiographics. 16(2):335-48, 1996