59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
59 y/o male with ulnar sided wrist pain
TFC Tear
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Palmer classification for triangular fibrocartilage complex
abnormalities
Class 1: Traumatic
A - Central perforation
B - Ulnar avulsion
C - Distal avulsion
D - Radial avulsion with or without sigmoid notch fracture
Class 2: Degenerative (ulnocarpal abutment syndrome) stage
A - TFCC wear
B - TFCC wear with lunate and/or ulnar chondromalacia
C - TFCC perforation with lunate and/or ulnar chondromalacia
D - TFCC perforation with lunate and/or ulnar chondromalacia
and LT ligament perforation
E - TFCC perforation with lunate and/or ulnar
chondromalacia, LT ligament perforation, and ulnocarpal arthritis
30 y/o female with clinical hx of left-sided
trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided
trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided
trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided
trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided
trunk/thigh hypertrophy?
30 y/o female with clinical hx of left-sided
trunk/thigh hypertrophy?
Absent vs. Atrophic Piriformis muscle?
•
1)
Piriformis muscle might be absent and
there might be variations in origin and
insertion sites of some muscles and
their relation with regional nerves of
this region.
Bannister L, Berry M, Collins P, Dyson M, Dussek J : Muscles of the thigh and gluteal region. In. Williams P
(ed): GrayÕs Anatomy. 38 th ed. London: Churchill Livingstone, 1995 : 875-878
2) Lee CS, Tsai TL : The relation of the sciatic nerve to the piriformis muscle. Taiwan I Hsueh Hui Tsa Chih 1974;
73 : 75-80.
27 y/o male with twisting ankle injury while hiking
27 y/o male with twisting ankle injury while hiking
27 y/o male with twisting ankle injury while hiking
Achilles Avulsion
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Greek mythology relates that the legendary
warrior Achilles was made invincible by his
mother Thetis, who dipped him in the River
Styx while holding him by his heel. Because
his heel was never immersed, it remained
his one area of vulnerability. After the fall of
Troy, Achilles met his demise when he was
shot in the heel by Paris, whose arrow was
guided by the Greek god Apollo. This is the
derivation of the term "Achilles tendon."
Achilles Avulsion
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However, Achilles avulsion is considered
rare, usually occuring at the calc. tubercle.
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Possible causes:
• Traumatic dorsiflexion in maximally
plantar flexed foot
• Contraction of triceps surae during knee
extention in a sprint
• Direct blow
The heel of achilles: calcaneal avulsion fracture from a gunshot wound.
Cooper DE, Heckman JD Foot Ankle. 1989 Feb;9(4):204-6
34 y/o MLB pitcher with shoulder pain
34 y/o MLB pitcher with shoulder pain
34 y/o MLB pitcher with shoulder pain
34 y/o MLB pitcher with shoulder pain
Thrower’s Shoulder
Elbow pain
55 yr old man
pre
post
Elbow pain
55 yr old man
Bicipitoradial Bursa
Cubital Bursae
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bicipitoradial
bursa
interosseous
bursa
Bicipitoradial Bursitis: MR Imaging Findings in Eight Patients and Anatomic Data from Contrast
Material Opacification of Bursae Followed by Routine Radiography and MR Imaging in Cadavers1
Abdalla Y. Skaf, MD, Robert D. Boutin, MD, Robert Weiber M. Dantas, MD, Andrew W. Hooper, MD,
Claus Muhle, MD, David S. Chou, MD, Nittaya Lektrakul, MD, Debra J. Trudell, RA, Parviz Haghighi,
MD and Donald L. Resnick, MD 1
From the Departments of Radiology (A.Y.S., R.D.B., R.W.M.D., A.W.H., C.M., D.S.C., N.L., D.J.T., D.L.R.)
and Pathology (P.H.), Veterans Affairs Medical Center and University of California San Diego, 3350 La
Jolla Village Dr, San Diego, CA 92161.
Bicipitoradial Bursa
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reduces friction between the biceps
tendon and the radial tuberosity
Bursitis
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Repetitive mechanical trauma
Infection
Inflammatory arthropathy
Chemical synovitis
Bone proliferation
Elbow Pain
Torn Biceps
Tendon
Cubital Bursitis
Supinator
muscle edema
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Mass effect in the
cubital tunnel may
compress the
branches of the
radial nerve
Posterior Interosseous Nerve Syndrome
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Compression of the deep branch of
the radial nerve
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innervates multiple extensor muscles
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extensor indicis proprius, extensor digiti
quinti, extensor carpi ulnaris, abductor pollicis
longus, extensor pollicis brevis, and extensor
digitorum communis muscles
34 yo Hockey player
SLAP tear with possible extension into the SGHL
and MGHL
33 yo woman
33 yo woman
osteopenia, cartilage loss, and erosions, subluxation
Rheumatoid Arthritis
Same patient
OA pattern
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Superolateral joint
space narrowing
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Marginal
osteophytes
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Eburnation and
subchondral cystic
change
Why the early OA?
Femoral Acetabular Impingment?
Crystal deposition disorders?
19 yr old Marine with new onset difficulty
performing pull-ups
19 yr old Marine with new onset difficulty
performing pull-ups
Suprascapular Nerve Entrapment
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At suprascapular notch, will involve
both the supra- and infraspinatus
muscles
At the spinoglenoid notch, involves
only the infraspinatus
Most common cause is a ganglion cyst
from a superior labral tear
36 year old man with arm and hand numbness for
one day
36 year old man with arm and hand numbness for
one day
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Patchy scattered
foci and muscular
edema
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Considerations
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Parsonage Turner
syndrome
Quadrilateral
space syndrome
Post op day 1 from ventral hernia repair
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Other
considerations
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Positioning
neuropathy
T2
T1-PRE
POST
T2
T1 PRE
T1 POST
SOFT TISSUE MASS: VOLAR DISTAL
PHALANX
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Ganglion cyst 50% to 70%
Hemangioma/vascular malformation
Giant cell tumor
Glomus tumor
Mucoid (epidermoid) cyst
Epidermoid
Nerve sheath tumor
Benign tumors of fibrous tissue origin
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Nodular fasciitis
Neurofibroma
Schwannoma
Fibrous histiocytoma
Fibroma/ fibromatosis
Nodular fasciitis
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Most common soft tissue lesion
originating from fibrous tissue
50% arise in the upper extremity, m/c
volar forearm
Present as a rapidly growing mass
Enzinger FM, Weiss SW. Soft tissue tumors. St Louis: Mosby, 1995.
Nodular fasciitis
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Histologically often misdiagnosed
because of its rapid growth, increased
cellularity and mitotic activity
Nodular fasciitis
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Thee subtypes
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Subcutaneous
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Intramuscular
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Subcutanous nodule
Large, deep, mimics a soft tissue malignancy
Intermuscular
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Irregular/ stellate appearance, mimics
inflammatory lesion
MR characteristics
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Variable depending on the amount of
collagen, cellularity, and mucin.
Subcutaneous lesions to occur in younger
patients and exhibit myxoid histology and
increased T2 signal.
Wang et al., Nodular fasciitis: correlation of MRI findings and histopathology.
Skeletal Radiol. 2002 Mar;31(3):155-61.
69 y.o. male with possible fracture of 1st proximal
Axial T1 FS
nd
phalanx and gout of 2 digit.
Axial T1
FS/Gd
Axial T2 FS
Axial T1
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Cor T2 FS
Cor T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Sag T1
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Sag T1
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Sag T1
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Sag T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Sag T1 FS/Gd
69 y.o. male with possible fracture of 1st proximal
phalanx and gout of 2nd digit.
Sag T1 FS/Gd
Gout
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MRI of Tophi
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Low on T1WI
On T2WI usually variable but contain lowsignal regions
High signal on post Gd
Yu et al, MR imaging of tophaceous gout. AJR Am J Roentgenol. 1997 Feb;168(2):523-7.
Weishaupt et al, MR imaging of inflammatory joint diseases of the foot and ankle.
Skeletal Radiol. 1999 Dec;28(12):663-9.
20 yo minor league baseball player with history of aspergillus
Axial
T1 Recurrent pain and swelling in the hand and
infection 1 yr
ago.
wrist.
Axial
T1FS/Gd
20 yo minor league baseball player with history of aspergillus
infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
Axial T2 FS
20 yo minor league baseball player with history of aspergillus
infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus
infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus
infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus
infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
20 yo minor league baseball player with history of aspergillus
infection 1 yr ago. Recurrent pain and swelling in the hand and
wrist.
Chronic Infection and Synovial Hypertrophy
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D.Dx.
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Fungus
TB ( Mycobacterium marinum)
Mycobacterium Infection
Recurrent Mycobacterium marinum tenosynovitis of the wrist
mimicking extraarticular synovial chondromatosis on MR images.
Lee EY, Rubin DA, Brown DM.
Skeletal Radiol. 2004 Jul;33(7):405-8. Epub 2004 May 04.
Tenosynovitis caused by atypical mycobacterial infections may
produce rice bodies within affected tendon sheaths.
…. the flexor tendons within the carpal tunnel in which the rice bodies
were mistaken for synovial chondromatosis on MR images
Horseshoe Abscess
Diagnosis of Bone and Joint Disorders, Resnick
Hand – Pathways of infection, pg 2399
21yo F with hand pain. History of bilateral THA
and TKA.
21yo F with hand pain. History of bilateral THA
and TKA.
21yo F with hand pain. History of bilateral THA
and TKA.
21yo F with hand pain. History of bilateral THA
and TKA.
21yo F with hand pain. History of bilateral THA
and TKA.
21yo F with hand pain. History of bilateral THA
and TKA.
Juvenile Chronic Arthritis
Portrait of a Youth
Botticelli, 1483
Juvenile –onset adult type RA
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Female
>10yrs
Polyarticular
Possible subQ nodules and vasculitis
Seropostive for RA
Diagnosis of Bone and Joint Disorders, 3rd ed. D Resnick, editor. W.B. Saunders Co., Philadelphia, 1995.
Juvenile –onset adult type RA
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MCP and IP joints of hand
Wrist
Knee
MTP and IP joints of foot
Cervical spine
Hip
Shoulder
Juvenile –onset adult type RA
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Soft tissue swelling
Osteoporosis
Periostitis
Erosions, especially in the absence of joint
space loss
Possible joint space loss
Atlanto Axial Subluxation
Epiphyseal compression fractures
Joint Subluxation
Growth disturbances
73 y.o F with wrist pain and stiffness
73 y.o F with wrist pain and stiffness
73 y.o F with wrist pain and stiffness
Rheumatiod Arthritis vs Psoraisis
Interesting Wrist Case
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•
Dorsal Midcarpal Instability
Carpal Instability Non Dissociative
(CIND)
UCSD Bone Conference
June 3, 2005
Jeremy Kuniyoshi
57 yo M with increasing thigh mass X 2-3 months
Further Hx:
Infected hematoma post cath many yrs ago
On anticoag for prosthetic valves (INR 1.6)
57 yo M with increasing thigh mass X 2-3 months
57 yo M with increasing thigh mass X 2-3 months
17964259.jpg
COR T1
SAG STIR
AX PD FS
17964259.jpg
T1 POST
T1 FS POST
T1 FS POST
AX T1 POST
57 yo M with increasing thigh mass X 2-3 months
Surgical Pathology Report:
Fibrous Capsule with areas of
granulation tissue,
multinucleated giant cells,
areas of necrosis, and
hemorrhage with clot c/w
pseudoaneurysm
Popliteal vascular malformation simulating a soft tissue sarcoma
Wambeek N, Munk PL, O'Connell JX, Lee MJ, Masri BA. Skeletal Radiol 1999;28(9):532-5.
Fig. 1A–C MRI of the left knee.
A Coronal
inversion recovery (TR 2000 / TE 18 /
TI 150) image shows a large ovoid mass
within the popliteal fossa, which is predominantly
of high signal intensity. There is no
edema in the adjacent muscles.
B Sagittal
gradient echo (TR 500/TE 16/flip angle
30°) image shows multiple low-signal foci
within the mass consistent with calcifications.
Note also the mass merging with the
massively dilated popliteal vein behind the
distal femur (arrows). The uniform high
signal within the dilated vein is typical of
slow venous flow.
C Axial T2-weighted
(TR 2000/TE 80) image shows intimate
relationship
of the mass to the popliteal artery
and vein (arrow), interposed between the
mass and the tibial plateau, although no direct
communication could be identified
Fig. 2A, B Digital subtraction angiogram of the left leg. A Arterial phase oblique
image of the popliteal artery demonstrates a direct communication between the
lumen of the artery and the mass (arrow), consistent with a pseudoaneurysm. B
Late venous phase image shows large slow-flow venous channels (arrowheads)
within the mass, draining into the enlarged popliteal vein (arrows)
51 yo M with R Shoulder pain s/p humeral head replacement
10-28-03
4-25-04 HHR Converted to TSA
51 yo M with R Shoulder pain s/p humeral head replacement
5-12-04 Glenoid component well located
6-23-04 Glenoid component dislocated
51 yo M with R Shoulder pain s/p humeral head replacement
6-2-05
Total Shoulder Arthroplasty: Glenoid Component
- indications are controversial;
- this needs to be performed prior to insertion of the humeral component;
- increased glenoid loosening rates from eccentric loading & excessive glenoid
wear can be expected with w/ rotator cuff arthropathy
Glenoid loosening:
- radiolucencies around the glenoid
component will eventually be seen in 60% of
patients;
- some authors note that in many cases
radiographs may fail to show loosening because
the radiographic beam is not perpendicular to the
bone-component interface;
From: http://www.wheelessonline.com/ortho/total_shoulder_arthroplasty_glenoid_component
Conversion of painful hemiarthroplasty to total shoulder arthroplasty:
Long-term results
Raymond M. Carroll, MD, Rolando Izquierdo, MD, Michael Vazquez, MD, Theodore A. Blaine, MD,
William N. Levine, MD, and Louis U. Bigliani, MD, New York, NY
“revision of a failed HHR to a TSA is a salvage
procedure whose results are inferior to those
of primary TSA…”
From: J Shoulder Elbow Surg Nov/Dec 2004
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot
27yo man with palpable nodules in foot