10 most interesting Xray cases for the month January 2024 at Osmania general hospitals,Hyderabad

1. X-RAY INTERESTING
CASES(JAN 2024)
Presenter: Dr. Keerthi Reddy A (JR-2)
Moderator: Dr. Sushma Chary Mam (Asst. Prof)
25/1/2024
Osmania General hospital

2. E/o longitudinally oval shaped radiodense lesion
noted at the level of origin of lateral collateral
ligament from lateral femoral condyle
S/o - LATERAL COLLATERAL LIGAMENT
CALCIFICATION
DD- LCL Avulsion fracture
Case 1- Plain AP radiograph of B/L knee joints of 34/M

3. ● Anatomy of LCL /FCL
● Origin- originates within an osseous
depression slightly posterosuperior to the
lateral femoral epicondyle and inserts onto the
anterolateral fibular head
● ***The biceps femoris tendon (BFT) and lateral collateral ligament (LCL) in the
knee were formerly known to form a conjoined tendon at the fibular attachment site.
However, the BFT and LCL are attached into the fibular head in various patterns.
● Its average length is ~50 mm and is more
commonly cord-like than band-like.
● Unlike the medial collateral ligament, it is not
attached to the knee capsule or lateral
meniscus and as such, is more flexible and
less susceptible to injury.

4. ● Non traumatic acute knee pain due to LCL calcification is rare phenomenon.
● The pathogenesis of calcific deposits in the LCL remains unclear, and different theories have
been proposed.
● Calcific deposits should be differentiated from insertional calcific deposits, which is believed to be
a degenerative process
● Arthroscopic intra-articular removal of the calcific deposits, which caused bone edema of the
lateral femoral condyle, was successfully performed
(A)Coronal PD w MR showing a
dark signal lesion at the femoral
insertion portion of the lateral
collateral ligament (LCL).
(B) coronal, fat-suppressed, T2W
MR image revealed multi-lobulated
dark signal lesion and soft tissue
edema, suggesting calcific
tendinitis of the LCL.
Bone marrow edema is associated
with subchondral erosion in the
lateral femoral condyle.

5. Named fractures around knee joint
avulsion of the medial collateral ligament,
origin of MCL avulsion fracture: Stieda fracture
insertion of deep fibers: reverse Segond fracture
avulsion of the lateral collateral ligament:
origin of LCL: above popliteal groove
conjoined tendon: fibular head below the tip, biceps femoris and insertion of LCL avulsion
fracture
arcuate ligament complex avulsion fracture (arcuate sign)
Segond fracture: The classical appearance of a Segond fracture is that of a curvilinear or
elliptic bone fragment projected parallel to the lateral aspect of the tibial plateau. avulsion
of the middle third of the lateral capsular ligaments ,the iliotibial band and anterior oblique
band of the fibular collateral ligament
iliotibial band avulsion fracture: Gerdy tubercle

7. Case 2-Plain AP and lateral radiograph of Left forearm and wrist joint of 29/F
E/o marked ulnar tilt of the radiocarpal
articulation, anterolateral bowing of
the radius and the distal ulna also
appears dysmorphic.
Probable causes for dysmorphic ulna
- post traumatic, surgically resected

8. ● This case highlights what actually defines the Madelung
deformity
● Although the post-traumatic healing process of this patient
resulted in some features reminiscent of Madelung deformity,
many other features are absent, and this results in a sort of
"pseudo" Madelung.
● In particular, the marked shortening of the distal ulna is not
typical of Madelung deformity.
● in order to diagnose a post-traumatic Madelung deformity, the
ulna should be distal to the medial distal radius(positive ulnar
variance) and the distal ulna should be dorsally subluxed.
● So the diagnosis of this case is pseudo Madelung deformity

9. Madelung deformity
● bowing of the radial shaft with increased interosseous space and dorsal subluxation of the distal
radioulnar joint.
● This deformity is due to premature closure or defective development of the ulnar third of the distal
physis of the radius.
Causes: HITDOC
H: Hurler syndrome
I: infection-
T: trauma-trauma to the growth plate, e.g. Salter-Harris fracture (type V
D: dyschondrosteosis (Leri-Weill syndrome: an autosomal dominant dyschondrosteosis (a form of
mesomelic dwarfism))
O: osteochondroma (multiple hereditary exostoses)
C: congenital, does not usually manifest until 10-14 years of age e.g. Turner syndrome

10. Case 3 - Plain AP radiograph of Rt shoulder with rt arm of 16/F
(skeletally immature patient)
Probable dx- Simple bone cyst in a skeletally immature patient
E/o central expansile radiolucent lesion with
thin sclerotic rim with narrow zone of transition
noted in the proximal diaphysis of rt humerus,
with cortical thinning, no periosteal reaction and
no adjacent soft tissue swelling

11. DD for radiolucent lesions
Mnemonic FEGNOMASHIC
F: fibrous dysplasia (FD) or fibrous cortical defect (FCD)
E: enchondroma or eosinophilic granuloma (EG)
G: giant cell tumor (GCT) or geode
N: non-ossifying fibroma (NOF)
O: osteoblastoma
M: metastasis(es)/myeloma
A: aneurysmal bone cyst (ABC)
S: simple (unicameral) bone cyst
H: hyperparathyroidism (brown tumor)
I: infection (osteomyelitis) or infarction (bone infarction)/intraosseous lipoma
C: chondroblastoma or chondromyxoid fibroma
E/o well defined longitudinally oval
ground glass matrix lesion with mildly
thick sclerotic rim noted in
metaphysis of rt femur with no
cortical thinning nor periosteal
reaction-s/o fibrous dysplasia

13. Case 4- Plain PA CHEST radiograph of 20/M
● E/o round thin walled radiolucent lesion
noted in the upper zone of left
lung-probably pneumatocoele
● With dilated bronchi few are tramlines
(non tapering airway) signet ring
opacities,probably post infective
pneumatocole
● Post traumatic pneumatocele results
when a lung laceration, a cut or tear in
the lung tissue, fills with air. A rupture of
a small airway creates the air-filled
cavity

14. Two months after initial examination of an infant, the
airspace opacities have resolved and thin-walled cystic
spaces have developed bi-basally, consistent with post
pneumonic pneumatoceles.
Other 44 yr old male’s CT showing incidentally
detected lung cyst

15. A cyst is any round circumscribed space that is surrounded by an epithelial
or fibrous outer wall of variable thickness. On CT, cysts appear as lucent
or low attenuation parenchymal lesions with a well-defined interface with
normal lung.

16. ● There are several specific types of thin-walled cystic spaces in the lungs:
bleb: pleural/subpleural, ≤1-2 cm diameter
bulla: pleural/subpleural, ≥1-2 cm diameter
honeycombing: subpleural stacks of cysts, typically 3-10 mm diameter with walls 1-3 mm in thickness
pneumatocele: usually transient cystic airspace within the lung, usually due to pneumonia or trauma
● There are several mimics of pulmonary cysts:
pulmonary cavity: surrounded by mass, nodule, or consolidation, creating wall thickness >2-4 mm
emphysema: lucencies without wall and with central vessel
cystic bronchiectasis: contiguous with other airways
occasionally lung cancer may appear as thin walled cystic lung cancer

17. E/o multiple punctate calcifications noted in the epiphyseal regions of appendicular skeleton
before the appearance of ossification centres s/o- chrondrodysplasia punctata
Case 5- Plain AP Chest with both upper limbs and pelvis with both lower
limbs radiograph of 2month old male

18. ● Chondrodysplasia punctate: Rare congenital skeletal dysplasia with
many clinical and inheritance variants
● Broadly divided into rhizomelic(lethal) and non-rhizomelic(
Conradi-Hunermann syndrome)
○ Clinically, the babies with this disorder may have dysmorphic
feature in the form of
○ prominent forehead,
○ saddle nose with anteverted nares,hypertelorism, cataracts,
○ excematous dermatitis with hyperkeratosis and erythema of skin in
infancy,
○ short stature, kyphoscoliosis, contractures of elbows, knees and
hips.
● A hallmark in plain X-ray films of Chondrodysplasia Punctata is ‘coronal
clefting’ of the vertebral bodies.
● This is due to abnormal development and fusion at the two ossification
centres at each vertebral body preventing the formation of a normal
rectangular block of vertebra. This results in vertebrae with a gap in the
body

19. Warfarin embryopathy
Zellwager syndrome(cerebrohepato renal syndrome)
Hallmark is severe hypotonia
Moreover, the calcific stippling in Zellweger Syndrome
preferentially involves the knees and patella unlike the
generalised distribution of stippling seen in CDP.
Other conditions with stippling of the epiphyses

20. E/o elevation of left hemi
diaphragm with smooth
contour-s/o diaphragmatic
palsy
(traumatic/iatrogenic)
Case 6- Plain Frontal chest radiograph of 32/M

21. Causes of unilateral elevated diaphragm include
Causes above the diaphragm Diaphragmatic causes Causes below the diaphragm
1. Phrenic nerve palsy—smooth
hemidiaphragm. No movement on
respiration. Paradoxical movement on
sniffing. The mediastinum is usually
central. The cause may be evident on the
X-ray
2. Lung collapse.
3. Pleural disease—e.g. old haemothorax,
empyema
4. Splinting of the diaphragm—due to pain
associated with rib fractures, pleurisy or
subphrenic abscess.
5. Hemiplegia—upper motor neuron
lesion, e.g. stroke.
1.Eventration—left >
right
2. Herniation
1.Subphrenic inflammation—e.g.
subphrenic abscess, hepatic or
splenic abscess, pancreatitis.
2. Marked hepatomegaly or
splenomegaly—e.g. extensive
liver metastases.
3. Gaseous distension of the
stomach or splenic flexure—left
side only. May be transient.

22. ● Abnormal contour of the diaphragm with no
disruption to diaphragmatic continuity
● Typically affects only affected segment of the
hemidiaphragm compared to paralysis/
weakness where the entire diaphragm is
typically affected
● Congenital or acquired , occurs due to
incomplete muscularisation of diaphragm with a
thin membranous sheet.
Diaphragmatic eventeration
Diaphragmatic paralysis
elevation of left hemi diaphragm with smooth
contour
Probably due to Traumatic/iatrogenic C-spine
injury in this case as there is E/O pedicle screw
fixation of C5 and C4(may be)

23. malignancy mediastinal tumors or neck malignancy
bronchogenic carcinoma
pulmonary metastases
trauma and
iatrogenic
penetrating injury
chiropractic manipulation
postoperative: especially cardiac: up to 10% of cases
Forceps delivery of newborn
central venous catheters
direct trauma
compression by hematoma
Interscalene brachial plexus nerve blocks
incidence reduced with ultrasound guidance and use of
lower volumes of local anesthetic
inflammation pneumonia
empyema
pleurisy
herpes zoster infection
neuromuscular
diseases
Parsonage-Turner syndrome
CIDP
direct
compression
aortic aneurysm
cervical osteophytes

24. Case 7- Plain AP radiograph of right and left upper limbs of 1/M
E/o absence of radius on both
sides, thumb on right side,
hypoplasia of thumb on left
side,short right humerus -s/o radial
dysplasia

25. ● Congenital difference occurring in a longitudinal direction resulting in radial deviation of wrist (due
to lack of support to carpal bones and poorly functioning/abnormally inserted muscles)and
shortening of forearm
● Although B/L , it is often assymetric
● Incidence 1:30000 to 1:100000
● More often a Sporadic mutation rather than an inherited condition
● Can be Isolated or associated with other defects such as
○ VACTERL
○ HOLT-Oram syndrome(atrial and digital dysplasia / cardiac limb syndrome) - ASD and
absent radial bone in the forearm
○ Fanconi anemia-Bone marrow failure, AML, solid tumors and developmental abnormalities
-abnormal thumb, absent radii,short stature, abnormal facial features and kidneys)
○ TAR syndrome( Thrombocytopenia with absent radius but preservation of thumb also
cardiac abnormalities and dysmorphic features)
○ Other possible causes are
○ an injury to the apical ectodermal ridge during upper limb development,[2] intrauterine
compression,
○ maternal drug use (thalidomide)

27. E/o upward shift of right femur
with pseudoarticulation of femoral
head with iliac bone, deformed
flattened small femoral head,
acetabular dysplasia, in keeping
with long standing DDH causing
secondary limb shortening , s/o
neglected ddh
Case 8-Plain AP Pelvis with B/L hip joints radiograph of 7/M

28. 16/F
Neglected DDH will result in osteonecrosis of femoral and acetabular bones by
repeated pressure stress unless treated in early childhood.
66/F

30. E/o resorption of distal half of
the terminal phalanx of the left
index finger -
s/o acroosteolysis(likely post
traumatic)
Case 9-Plain PA radiograph of b/l hands of 32/M

31. Variants
● Longitudinal -terminal tuft
● Transverse- linear bone resorption of mid shaft of the phalanx also known as band acrosteolysis
Inflammatory conditions
scleroderma
Raynaud disease
psoriatic arthritis
juvenile idiopathic
arthritis
reactive arthritis
hyperparathyroidism
drugs-
phenytoin (occurs in
infants of epileptic
mothers treated with
phenytoin)
ergot poisoning/abuse
Snake and scorpion
venom
Peripheral neuropathy
e.g. leprosy,diabetes,
congenital insensitivity to
pain
Injury—
Trauma
thermal injury
extreme cold: frostbite
extreme heat: burns,
electricity
Other skin conditions
dermatomyositis
pityriasis rubra pilaris
epidermolysis bullosa
porphyria
pachydermoperiostosis
sarcoidosis

32. 1. Midshaft resorption (band acro-osteolysis)
○ polyvinyl chloride exposure
○ primary acro-osteolysis: Hajdu-Cheney syndrome(ass. with acroosteolysis ,osteoporosis and
bone deformities)
○ hyperparathyroidism (also causes terminal tuft resorption)
○ scleroderma (also causes terminal tuft resorption)
○ idiopathic non-familial acro-osteolysis
○ pyknodysostosis (also causes terminal tuft hypoplasia)
○ biomechanical in guitar players
Single digit
○ epidermal inclusion cyst
○ glomus tumor of digit

33. generalised osteopaenia
subperiosteal bone
resorption
acro-osteolysis
S/o hyperparathyroidism
Soft tissue
calcification and
acro-osteolysis in
keeping with
scleroderma. Resorption of phalanges of the
hands of a 52 yr old male with
H/O PVC exposure

34. E/o
Case 10 - Plain lateral knee radiograph of 40/F
E/o patch of sclerosis with internal lucencies is present in the
proximal tibial metaphysis. It has a narrow zone of transition
and geographic margins. Findings are in keeping with a
medullary bone infarct.
Bone infarct -osteonecrosis within the metaphysis or diaphysis
of a bone, as a result of ischemia, which can lead to the
destruction of bony architecture, pain, and loss of function
Close DD - Enchondroma

35. The classic description is of medullary lesion of
sheet-like central lucency surrounded by
shell-like sclerosis with a serpiginous border.
Discrete calcification and periostitis may also
be seen.

36. General causes of osteonecrosis include
trauma
caisson disease
hemoglobinopathies, e.g. sickle cell disease 2
radiotherapy
connective tissue disorders
renal transplantation
corticosteroid excess (both endogenous and exogenous)
pancreatitis
gout
Gaucher disease
alcohol
Behçet disease 9
******This list applies to both bone infarct and subchondral osteonecrosis. Some conditions are more likely to
lead to one over the other: sickle cell disease and Gaucher disease very commonly cause bone infarcts and
less commonly cause subchondral osteonecrosis.

37. Enchondroma bone infarct Grade1 chondrosarcoma
benign findings include typical chondroid
matrix mineralization, in stipples or arcs and
rings, evenly distributed throughout a small
(less than 3-5 cm) metaphyseal lesion with
no aggressive features.
There should be no endosteal scalloping,
no cortical breaks, no periosteal reaction or
soft tissue mass. Such a lesion should be
reported as an enchondroma with no further
workup require
A cartilage lesion is more likely to be
malignant when initial x-rays show deep
or. extensive endosteal scalloping, when
there is cortical destruction or periosteal
reaction or when there is an obvious soft
tissue mass
If the features are not diagnostic, one should
carefully examine the subchondral regions for
findings that might indicate additional areas
of osteonecrosis (CT imaging will show the
typical peripheral mineralization. Usually the
internal marrow fat is visible in an area of
infarcted bone as opposed to internal
cartilage matrix mineralization or soft tissue
with an enchondroma.

38. THANK YOU