NERRS MSK 2012 answers

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  • 1. Dr. Steve Sharatz
  • 2. 36 year old man presents to the ED with non-traumatic severe right hip pain
  • 3. T1 STIR
  • 4. Post contrast T1 W FS
  • 5. They decide to get radiographs after the MRI
  • 6. Calcific Tendinitis (resorptive phase)• Key points: – Calcium hydroxyapatite crystals in tendons – Common cause of joint pain (shoulder, hips) – 4 phases: formative, calcific, resorptive, reparative – Resorptive phase can mimic infection or tumor – Radiographs helpful to identify the faint calcifications – Ill-defined calcifications more symptomatic Siegel, Wu et al. CARJ 2009. 60; 263-272
  • 7. Calcific Tendinitis (resorptive phase)• DDx – Calcific tendinitis – Greater trochanteric bursitis – Gluteal tendon avulsion – Myositis – Infection (abscess)
  • 8. Dr. Akira Murakami
  • 9. 40 year old man with back pain and “bloating”
  • 10. T1 STIR
  • 11. Post contrast T1 W FS
  • 12. Osteochondroma• Key points: – Common benign bone tumor – Due to displacement of growth plate cartilage to the metaphysis – Points away from the joint – Marrow and cortex are contiguous with the host bone – Cartilaginous cap that shrinks with ageMurphey et al. Radiographics 2000; 20:1407-1434
  • 13. Osteochondroma• Key points: – Clinical issues • Mass affect on adjacent tissue (bursitis, joint immobility, nerve compression, pseudoaneurysms) • Thicken cartilaginous cap (> 2cm in adults) associated with transformation to chondrosarcoma – DDX • Osteochondroma • Myositis ossificans • Parosteal osteosarcoma • Surface chondrosarcoma • Nora’s lesion (BPOP)
  • 14. Osteochondroma (with malignant transformation)
  • 15. Osteochondroma
  • 16. Dr. Manjiri Didolkar
  • 17. 58 year old woman with difficultywalking up stairs and hypercalcemia
  • 18. 2 months later, develops hand pain
  • 19. T1 T2 fat sat T2 fat sat
  • 20. Sarcoidosis – Key points • Granulomatous disease of unknown cause • Non-caseating granulomas affecting multiple organ systems (lungs, lymph nodes, skin, eyes, MSK system) • Sarcoid myositis: – Muscle involvement is common(50-80%) but rarely symptomatic (1-2%) – Presents with muscle weakness and pain – 3 subtypes: nodular, acute myositis, chronic myopathy – Diagnosed by muscle bx and treated with steroidsVardhanabhuti et al. Clin Radiol 2012. 67;263-276
  • 21. Sarcoidosis – Key points• Bone and Joint involvement: – Can involve small and large bones – “Lacy pattern” of osteolysis in digits with “sausage-like” dactylitis of the fingers on radiographs – MRI can have variable appearance (round, “starry sky pattern”, infiltrative); Low T1 and high T2/STIR
  • 22. Muscle Edema DDx • Diffuse: – Polymyositis/dermatomyositis – Viral myositis – Inclusion body myositis – Medication induced (AZT, statins, ampho B) • Focal: – Trauma (strain, contusion) -Denervation – Necrotizing fasciitis -Radiation – Diabetic muscle infarction -Tumor – Compartment syndromeMcmahon, Wu, et al. AJR 2010. 194(4):W284-92
  • 23. Muscle Edema DDx • Multifocal (Nodular): – Delayed onset muscle soreness (DOMS) – Pyomyositis – Sarcoid myopathy – Denervation – MetastasesMcmahon, Wu, et al. AJR 2010. 194(4):W284-92
  • 24. Dr. Stacy Smith
  • 25. 44 year old woman with right buttock “lump” and “tingling down my legs”
  • 26. T1 WMR images
  • 27. T1 T2 STIRPostContrastT1 fat sat(Ax, Sag)
  • 28. Lipomatosis of Nerve• AKA: fibrolipomatosis hamartoma• Anomalous growth of fibrofatty tissue within a nerve causing fusiform enlargement• Histological changes within the nerve are identical to macrodystrophia lipomatosa• Unknown cause, however, may be due to irritation or compression of nerve• 80% in median nerve (carpal tunnel) and ulnar nerve (cubital tunnel)• Enlarging mass with or without motor/sensory deficits• Imaging findings are pathognomonic and treated with decompression as surgical excision can cause more nerve damage
  • 29. Desmoid Tumor• Bland benign fibrous T1 neoplasm• Infiltrative, firm lesions• Can distort tissues, cause pain and have high recurrence rates• Due to fibrous content, Low T2 on T1 AND T2 and enhance• Can have spiculated irregular borders• Treatment with surgery, NSAIDS, radiation• Association Gardner’s syn T1 FS – GI adenomatous polyps, post osteomas, desmoids; AD
  • 30. Lipomatosis of Nerve
  • 31. Lipomatosis of Nerve
  • 32. Dr. Levon Nazarian
  • 33. 23 year old man from Cape Cod with severalyears of progressive ankle pain and swelling
  • 34. T1 T2
  • 35. Post Contrast T1 fat sat
  • 36. Additional History• At time of biopsy, patient recalled stepping on a horseshoe crab when 8 years old. Had to have tail remove from his foot in the emergency room
  • 37. Foreign Body Pseudotumor (Horseshoe crab tail tip)• Penetrating trauma is common cause of pseudotumors in bone• Often in hands and feet with thorns and wood splinters the most common foreign bodies• Can take a long time to show symptoms• Smooth bony remodeling (as in this case) indicative of a slow indolent process• Often surrounded by fluid or granulation tissue (bright and T2/STIR and enhancement)• Clinical history crucial in making diagnosis!!
  • 38. Foreign Body Pseudotumor• DDX: – Foreign body pseudotumor – Myositis ossificans – Intraosseous lipoma (from plain film) – Synovial sarcoma – Vascular malformation
  • 39. Foreign Body Pseudotumor
  • 40. Thank You!