X-Ray Case Studies
Jim Messerly D.O.
Case #1 History
 17 year-old female
ballet dancer with
snapping sensation
along the medial
aspect of her right
knee when extending
her right knee during
jumps.
Case #1 Physical Exam
 Physical exam showed
no evidence of effusion.
There was full range of
motion of the right knee
with reproducible
popping of the posterior
medial hamstring with
flexion and extension
which was minimally
painful. No joint line
tenderness. McMurray’s
testing was negative.
Case #1 X-Rays
Case #1 X-Rays
Case #1 Diagnosis ?
A.
B.
C.
D.
Stress fracture
Osteoid Osteoma
Osteochondroma
Osteosarcoma
Osteochondroma
 Most common benign tumor of bone.
 Outgrowth of bone usually located in the
metaphysis projecting away from the
joint.
 Malignant transformation rare except in
Hereditary Multiple Exostosis (HME).
 Usually left alone unless interferes with
surrounding muscles, tendons or nerves
or interferes with activity- then can be
resected.
Case #2 History
 16 year-old male football
player who developed
sudden onset of severe
left shoulder pain while
reaching with his left
upper extremity during a
football drill. There was
no contact. He
complained of pain in the
posterior aspect of his
left shoulder and
proximal left arm. He
was evaluated by an
athletic trainer and was
placed in a sling.
Case #2 Physical Exam
 The patient was in obvious
discomfort due to his left
shoulder pain. There was a
questionable left shoulder
effusion. Active flexion and
abduction were limited to only
15° because of severe pain.
There was severe pain with
any attempts of resisted
internal or external rotation of
the left shoulder.
Case #2 X-rays
Case #2 X-rays
Case #2 Diagnosis?
A.
B.
C.
D.
Aneurysmal Bone Cyst
Metastatic lesion
Fibrous Dysplasia
Unicameral Bone Cyst
Unicameral Bone Cyst
 Usually found in the proximal humerus, but
also can be found in the proximal femur or
calcaneus.
 X-rays show well-defined lytic lesion with thin
sclerotic margin with no periosteal reaction.
 Pathologic fracture may allow healing of cyst.
 Injection of steroid, bone marrow,
demineralized bone or surgical treatment may
be needed.
Case #3 History
 16-year-old male with 6-9
month history of right elbow
pain and lack of full extension.
The patient is a snowmobile
racer and wondered if he may
have injured the right elbow
during one of his many wipe
outs during snowmobile
races. Three days prior, he
was lifting a heavy box and
had a forceful extension of his
left elbow with associated
increased pain and some
swelling.
Case #3 Physical Exam
 There was a
moderate right elbow
effusion. Range of
motion was 40° to
105° with pain at end
range motion.
Moderate tenderness
of the medial joint
line. Ligaments were
stable with some
pain with valgus
stress.
Case #3 X-rays
Case #3 X-Rays
Case #3 MRI
Case #3 Diagnosis?
A.
B.
C.
D.
Osteoid Osteoma
Fibrous Dysplasia
Aneurysmal Bone Cyst
Chondrosarcoma
Aneurysmal Bone Cyst
 Usually located in long bones or spine in
patients less than age 20.
 X-rays show eccentrically located metaphyseal
lytic lesion.
 Typical complaints are swelling and pain which
usually follows an injury.
 Biopsy is frequently required to rule out
malignant lesion.
 Treatment is by curettage with bone grafting.
Case #4
 20 year-old college
female with anterior right
leg pain for the past five
months. The patient had
been using the Stair
Master and jogging for
up to an hour a day
during the summer.
When her college
classes started in the
fall, she continued to
workout in spite of the
pain, but had been off
running for the past two
weeks without
improvement of her pain.
Case #4 Physical Exam
 There was mild firm
swelling over the anterior
aspect of the distal third
of the right tibial shaft.
Moderate tenderness to
palpation and
percussion. Full range
of motion of the right
knee and ankle. Arches
of the feet were
minimally pronated.
Case #4 X-Rays
Case #4 X-Rays
Case #4 CT Scan
Case #4 Diagnosis ?
A.
B.
C.
D.
Osteoid Osteoma
Fibrous Cortical Defect
Healing Stress Fracture
Hemangioma
Osteoid Osteoma
 Frequently causes deep aching pain
which is worse at night.
 Pain is frequently relieved by
aspirin/NSAIDs.
 X-ray/CT shows radiolucent nidus
surrounded by reactive sclerotic bone.
 Treatment- Waiting, Radiofrequency
ablation or excision.
Case #5 History
 13-year-old male with
one-year history of
thoracic spine pain
which had been
worsening over the past
two months. Severe
night pain. The patient
had been unable to
participate in basketball
because of his pain.
Chiropractic care was
not helpful for his pain.
Previous x-rays had
shown evidence of a
moderate thoracic spine
scoliosis.
Case #5 Physical Exam
 Moderate right-sided
thoracic spine scoliosis.
Moderate tenderness on
palpation from T6 to T10.
Minimal restriction with
flexion and extension of
the thoracic spine.
Lower extremity
neurological exam was
unremarkable.
Case #5 X-Rays
Case #5 MRI
Case #5 CT Sagittal
Case #5 CT Axial
Case #5 Diagnosis?
A.
B.
C.
D.
Osteoid Osteoma
Osteoblastoma
Giant Cell Tumor
Hemangioma
Osteoid Osteoma
 Small round focus-nidus
 Radiofrequency ablation is difficult when
in the spine and resection may be best
approach.
Case #6 History
 17-year-old male with
complaint of right knee pain
which had been present for
the past 4-5 months. He
noted some right knee pain
after playing basketball during
the summer. He denied
catching, locking or giving
way. There was no significant
swelling. He had been
treating with physical therapy
without significant
improvement. He was
currently participating on the
curling team.
Case #6 Physical Exam
 No evidence of right
knee effusion. Mild soft
tissue swelling in the
region of the proximal
tibia both medially and
laterally with mild
tenderness on palpation.
Mild generalized knee
pain with forced
extension. There was full
flexion without pain.
Ligaments were stable.
Mild lateral joint line
tenderness. McMurray’s
testing was negative.
Case #6 X-Rays
Case #6 X-Rays
Case #6 X-Rays
Case #6 MRI
Case #6 Diagnosis?
A.
B.
C.
D.
Stress fracture
Osteosarcoma
Chondrosarcoma
I’m not sure, but it sure looks bad
Osteosarcoma
 Most common malignant bone tumor in
the pediatric population.
 Most common location is in the tibia,
femur or humerus.
 Frequently causes bone pain.
 X-rays frequently show combined lytic
and sclerotic changes.
 Treatment involves chemotherapy,
possible radiation followed by surgery.
Case #7 History
 60 year-old female with
complaint of right knee
pain which was worse
over the past few weeks
when she tried to
increase her walking
activities. She described
anterior medial and
lateral right knee pain.
Her pain was worse with
prolonged standing,
driving or when walking
stairs. There was no
catching, locking or
giving way. No swelling.
Case #7 Physical Exam
 There was a trace
effusion of the right
knee. There was full
range of motion with
moderate patella
crepitus. Mild
patellar facet
tenderness to
palpation. Ligaments
were stable. Mild
medial joint line
tenderness.
Case #7 X-Rays
Case #7 X-Rays
Case #7 X-Rays
Case #7 Diagnosis?
A.
B.
C.
D.
Stress fracture
Osteosarcoma
Enchondroma
Mild to moderate patellofemoral
osteoarthritis with patellofemoral pain
Enchondroma
 Benign cartilage lesion centrally located
within bones that can occur at any age.
 Usually asymptomatic.
 Frequently found in the bones of the
hand.
 X-ray follow-up recommended to
document stability because occasionally
difficult to distinguish enchondroma from
low-grade chondrosarcoma
Chondrosarcoma
Case #8 History and Exam
 History: 27 year-old
female with complaint of
left knee pain and
swelling for two months.
No history of injury. She
describes lateral left
knee pain with
associated near giving
way episodes. She
frequently limps because
of her left knee pain.
She denies fevers, chills
or night sweats.
 Exam: The patient does
walk with a limp favoring
her left knee. There was
a trace effusion of the
left knee. Mild anterior
lateral left knee pain with
full flexion. Ligaments
were stable. Moderate
lateral joint line
tenderness which was
worse with McMurray
testing.
Case #8 X-Rays
Case #8 X-Rays
Case #8 X-Rays
Case #8 MRI
Case #8 MRI
Case #8 Diagnosis?
A.
B.
C.
D.
Stress fracture
Fibrous cortical defect
Giant cell tumor
I don’t know, but it sure looks bad
I don’t know, but is sure
looks bad
 Referred to university center
 Biopsy shows leiomyosarcoma
 Treated with resection and knee
replacement surgery
Thank you