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1986-1987 Mini Pathria Michael Zlatkin Richard (Rick) G Stiles.

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Presentation on theme: "1986-1987 Mini Pathria Michael Zlatkin Richard (Rick) G Stiles."— Presentation transcript:

1 1986-1987 Mini Pathria Michael Zlatkin Richard (Rick) G Stiles

2 Mini Pathria Middle-aged male Hx of recent knee trauma

3 Case 1 Middle-aged male Hx of recent knee trauma

4 Radiographs

5 Sagittal

6 Coronal

7 Axial

8 Thigh

9 Differential diagnosis Neurofibromatosis Melorheostosis with soft tissue component

10 Neurofibromatosis Further history obtained Skin nodules Neurofibromas on cranial CT 7 years previously (not acoustic neuroma)

11 Case 2 Middle-aged female with thigh mass

12 Radiographs

13 Coronal

14 MR

15 Follow-up Mass biopsied, benign plexiform neurofibroma Patient developed hip pain

16 Hip MR

17 Neurofibromatosis Plexiform neurofibroma at biopsy No evidence of malignancy

18 Case 3 40 year old male with slowly growing painless mass

19 Plexiform neurofibroma

20 Specific finding for NF1 (peripheral form) 5% of patients with NF1 Approximately 5- 10% degenerate to neurosarcoma courtesy of Mark Murphey, AFIP

21 Neurofibroma Localized Diffuse Plexiform Well-defined Bag of worms Infiltrating

22 Elephantiasis neurofibromatosa Diffuse form of plexiform neurofibroma Overgrowth of epidermal and subcutaneous tissue Wrinkled and pendulous appearance

23 Michael B. Zlatkin and Alfredo Arraut NMSI 27 year old male involved in a motor vehicle accident



26 Findings Subscapularis tendon is avulsed with bone from the lesser tuberosity Humeral avulsion of the anterior band of the glenohumeral ligament (HAGL) Middle glenohumeral ligament and possibly the superior glenohumral ligament may be avulsed as well Possible reverse Hill-Sachs lesion

27 Subscap Rupture and HAGL (BHAGL) Rupture of the subscapularis tendon uncommon but can be seen in younger patients injured by forced external rotation or extension of a partially abducted arm Tears occur near insertion on the lesser tub. May occur at sup margin, where tendon may be weakened by degeneration Avulsion fracture of the lesser tuberosity may occur, and is displaced medially and inferiorly Subscapularis avulsions are also associated with injury to the anterior capsule and glenohumeral ligaments (HAGL) When the AIGHL avulses a fragment of bone from the humerus, the lesion is known as a bony HAGL, or BHAGL ? With MGHL and SGHL torn = Super BHAGL

28 Michael B. Zlatkin and Alfredo Arraut NMSI 17 year old male with bony growth on the dorsum of hand



31 Findings Bone prominence on the dorsum of the hand between the trapezoid, capitate, and bases of the 2 nd and 3 rd metacarpals Associated with base of 3 rd metacarpal, but no marrow continuity with it Sclerosis and cystic change at junction with 3 rd metacarpal base

32 Carpal Boss Bone protuberance on dorsum of the hand Degenerative osteophyte or os styloideum Located between trapezoid, capitate, and base of 2 nd and 3 rd metacarpals Most often fused to a metacarpal base, but rarely (2%) can be completely isolated Symptoms caused by degeneration, formation of ganglion or bursa, or snapping of an extensor tendon moving over it

33 Carpal Boss Can be demonstrated on lateral radiograph with hand flexed and supinated 30-40 degrees; best seen with mild ulnar deviation Alternatively can image with CT or MR MR can demonstrate marrow edema in the carpal boss and surrounding soft tissue changes

34 Carpal Boss – Companion Case Carpal boss fused to base of third metacarpal with edema in overlying soft tissues

35 Carpal Boss - Companion Case Carpal boss fused to third metacarpal with fracture at its base

36 Carpal Boss – Companion Case Surface rendering of carpal boss with fracture at its base

37 Michael B. Zlatkin and Alfredo Arraut NMSI 33 year old professional hockey player with pain in the flank after practice



40 Findings Partial thickness tear of the internal oblique muscle belly proximally, with surrounding edema and hematoma Fluid tracking between internal and external obliques Feathery pattern of edema at the more distal aspect of the internal oblique

41 Side Strain Uncommon sporting injury presenting with pain and tenderness over anterolateral and posterolateral lower ribcage Associated with cricket, golf, and ice hockey – eccentric contraction of trunk muscles Partial or complete tear of lateral abdominal wall musculature (internal oblique > external oblique > transversus abdominis) May also see avulsion at the muscular origins from the lower ribs Recovery takes 6-10 weeks. Full recovery is the norm

42 Michael B. Zlatkin and Alfredo Arraut NMSI 19 year old injured while pitching, now has valgus instability of elbow on exam


44 Findings Thickened ulnar collateral ligament (UCL) with increased intrasubstance signal distally and at its midportion, indicating partial thickness tear No complete disruption Edema in the adjacent flexor/pronator musculature Reactive marrow edema in the sublime tubercle

45 UCL Partial Tear Most often injured in overhand throwing athletes, especially baseball pitchers Pitching causes valgus stress on the elbow that can injure the UCL MR arthrogram reportedly higher sensitivity than conventional MR for partial thickness tears MR findings – thickening/irregularity/laxity of the ligament, edema in adjacent soft tissues T sign – pathognomonic sign of contrast extending into a partial thickness tear, giving a sideways “T” shaped appearance Tears tend to occur more distally in younger pitchers, more proximally in older pitchers

46 Michael B. Zlatkin and Alfredo Arraut NMSI 16 year old pitcher with elbow pain


48 Findings Delayed union of the olecranon apophysis Persistent widening of physis with surrounding edema consistent with stress injury/stress fracture

49 Olecranon Stress Fracture/Apophysitis May occur in young throwing athletes and gymnasts due to repetitive microtrauma Present with pain localized to the tip of the olecranon Imaging shows a widened physis or open physis after expected age of closure, and stress related edema Normal fusion occurs at age 12-15, comparison to contralateral side may help

50 Michael B. Zlatkin and Alfredo Arraut NMSI 24 year old male with shoulder pain and suspected rotator cuff tear after fall on outstretched hand


52 Findings Avulsion fracture of the greater tuberosity, with a small fracture fragment retracted medially with a torn supraspinatus tendon Associated marrow edema

53 Greater Tuberosity Avulsion Fracture RCT uncommon in younger patients Usually occurs after trauma, may be concomitant fx Great tub fx’s may be difficult to distinguish from RCT clinically. May be radiographically occult if non-displ MR useful in differentiating contusion/nondisplaced fracture from RCT Concomitant rotator cuff tears not common in nondisplaced fractures, but more common in more severe injuries with avulsions/displaced fractures

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