Musculoskeletal #10 – Flashcard

29-year-old long-distance athlete presenting with 3 weeks of sciatica associated with an increase of running training loads

What do you see?

Click here to see the answer

IMAGING FINDINGS:

Unilateral sacral bone edema T2W, STIR hyperintensity associated with hypointense fracture line

DIAGNOSIS:

Fatigue stress fracture

TEACHING POINTS:

The sacrum is a frequent site for stress fractures
They can be related to overload occurring in a healthy bone as in this case, or related to osteoporosis (insufficiency stress fractures) in which cases they tend to be bilateral and “h- shaped”

Musculoskeletal #4 – Long case

Regarding the following X-Ray:

Frontal x-ray of the right hand

Where is the lesion?

Metaphysis of the base of the fourth middle phalanx.

What are the radiological characteristics/findings?

Expansile lytic lesion (bubbly appearance) with narrow zone of transition, no cortical break through, and no soft-tissue component.

What is the differential diagnosis?

Enchondroma: Enchondromas have variable imaging appearances but are typically lytic lesions with non-aggressive features. They could show chondroid calcifications (rings and arcs calcification). But in the hands and feet they are typically purely lytic with no matrix.
Eosinophilic granuloma: It mainly involves the diaphysis and does not cross the growth plates. It appears as punched out lytic lesions without sclerotic rim.  Imaging appearance in the long bones depends on the phase of the disease which is imaged. It can look aggressive in the initial phase. In the healing phase it can show solid benign periosteal reaction.
Fibrous dysplasia.Usually shows ground-glass matrix but may be completely lucent or sclerotic. Well-circumscribed lesions with no periosteal reaction may lead to premature fusion of growth plates leading to short stature in the lower limbs and bowing deformities (Shepherd’s Crook deformity of the femoral neck)

What is the most likely diagnosis?

Diagnosis: Enchondroma

Regarding the diagnosis…

What are the associated syndromes with multiple enchondromas?

Ollier disease: multiple enchondromas are usually  confined to one side of the body and limited to the limbs. There is increased risk of chondrosarcoma 

Maffucci syndrome: multiple enchondromas with soft-tissue haemangiomas

Emergency #14 – Flashcard

18-years-old male:
* Rigid abdomen and generalised tenderness
* Pain lower abdomen
* CRP 250

What do you see? Perforated appendicitis? What is your diagnosis?

Diagnosis Perforated sigmoid diverticulitis (Hinchey 3 or 4, peritonitis)

> Mesenterial fatty infiltration, free air bubbled outside bowel lumen.
> Also subdiaphragmal free air and free fluid.
> Notice enlarged reactive lymph nodes and peritoneal thickening and enhancement, indicative of peritonitis.
> Patient was operated, free faeces was found in the abdomen.

Hinchey classification of acute diverticulitis:
* Stage 1a: phlegmon
* Stage 1b: diverticulitis with pericolic or mesenteric abscess
* Stage 2: diverticulitis with walled off pelvic abscess
* Stage 3: diverticulitis with generalised purulent peritonitis
* Stage 4: diverticulitis with generalised faecal peritonitis