The case: Transient patellar dislocation.
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Adult↗
Biomedical subjects
Murali Sundaram
Publications and source records attributed to Murali Sundaram.
Ewing's sarcoma of the humerus mimicking fibrous dysplasia on imaging and biological behavior.
We present the case of a 12-year-old girl who presented with a pathological fracture through a benign-appearing osteolytic lesion that was presumed to represent fibrous dysplasia. The fracture healed, and over the next 2.5 years there was further refracturing and healing with progressive osteolysis. A biopsy was performed and revealed Ewing's sarcoma. The disease was locally controlled by neoadjuvant chemotherapy and radiation therapy. The patient is disease free with excellent function 6 years following the discovery of the lesion. We illustrate and discuss the sequence of events.
Antineoplastic Agents↗
Chondroblastoma of the hands and feet.
OBJECTIVE: To review the imaging findings, age and gender distribution of chondroblastoma of the hands and feet. DESIGN AND PATIENTS: Twenty-five cases of pathologically proven chondroblastoma of the hands and feet were reviewed. Available imaging modalities included radiographs (n=24), CT (n=3), MRI (n=5), and radionuclide bone scintigraphy (n=1). The following imaging features for each case were tabulated: location, presence of sclerotic margin, calcification, expansion, presence of fluid/fluid levels on cross-sectional imaging and surrounding edema on MRI. The images were evaluated for skeletal maturity using closure of the physeal plate in the region as a standard. RESULTS: The average age at time of diagnosis was 23 years (range 7-57 years). Eighty-four percent (n=21) of the patients were skeletally mature. Males (20 of 25) outnumbered females by a ratio of 5:1. The bones of the foot accounted for 22 cases: calcaneus (n=8), talus (n=8), metatarsals (n=3), and the cuboid (n=3). The bones of the hand accounted for three cases: phalanx (n=1), triquetrum (n=1), and a metacarpal (n=1). Radiographically all lesions were osteolytic with identifiable calcification in 54% (13 of 24). Fluid/fluid levels were seen in four of five cases on MRI. Edema on MR images was seen in 40% (2 of 5). The size of the lesions ranged from 2 to 41 cm(2). CONCLUSION: Chondroblastomas of the hands and feet share many of the radiographic characteristics seen in the long bones, but manifest in skeletally mature patients with a higher male to female ratio than in long bone chondroblastoma. Talar and calcaneal lesions were encountered only in males. Chondroblastoma of the wrist and hand appears to be exceptionally rare.
Adolescent↗
Primary Ewing's sarcoma of the vertebral column.
OBJECTIVE: To determine the demographics, imaging findings, clinical symptoms, and prognosis of primary vertebral Ewing's sarcoma (PVES). DESIGN: A retrospective review of medical records and radiological studies of patients diagnosed with PVES from 1936 through 2001 in our institution and Department of Pathology consultation files was undertaken. Metastatic and soft tissue Ewing's sarcoma cases were excluded. RESULTS: From a total of 1,277 cases of Ewing's sarcoma, 125 (9.8%) had a primary vertebral origin. There were 48 females and 76 males. Patient ages ranged from 4 to 54 (mean 19.3, standard deviation 10.7, median 16) years. Vertebral column distribution was four cervical (3.2%), 13 thoracic (10.5%), 31 lumbar (25%), and 67 sacrum (53.2%). More than one vertebral segment was involved in ten cases (8%). Satisfactory imaging studies were available in 51 patients: 49 radiographs, 27 computerized tomography (CT), and 23 magnetic resonance imaging (MRI) studies. The majority of tumors were lytic (93%). Three cases were mixed lytic and sclerotic (6%) and one sclerotic. In the nonsacral spine, the majority of lesions (12/20) involved the posterior elements with extension into the vertebral body. Five cases were centered in the vertebral body with extension into the posterior elements. Two cases were limited to the posterior elements, and one case solely involved the vertebral body. Ala was the most frequently affected site in the sacrum (18/26). Spinal canal invasion was frequent (91%). Detailed clinical information was available in 53 patients. Duration of symptoms ranged from 1 to 30 (mean 7) months. Local pain was the first symptom and seen in all cases. Neurological deficits were present in 21 (40%) cases. All patients received radiation in various dosages; 70% additionally received chemotherapy. Twenty-five patients had surgery, and two patients received bone marrow transplantation. Forty-five patients had follow-up; the five-year disease-free survival probability is 0.53. Disease-free survival probabilities are 0.60 for sacral tumors and 0.45 for nonsacral tumors. CONCLUSION: PVES is an uncommon tumor, usually seen in the second decade of life (mean age 19.3 years) with a male predilection (62%). An aggressive osteolytic lesion, particularly in the sacrum, should raise suspicion for this tumor in adolescents. Prognosis was similar in sacral and nonsacral tumors.
Adolescent↗
Radiographic differentiation of enchondroma from low-grade chondrosarcoma in the fibula.
To evaluate demographic and radiographic features that may differentiate between enchondroma and low-grade chondrosarcoma of the fibula. The radiographs of ninety-three histologically-confirmed cartilaginous tumors of the fibula were retrospectively reviewed along with demographic information as to patient age and gender. Fifty-four enchondromas and thirty-nine low-grade chondrosarcomas were included in the study. Multiple previously-established radiographic features distinguishing enchondroma from chondrosarcoma were evaluated in each fibular tumor in a consensus manner by two experienced, board-certified and fellowship-trained musculoskeletal radiologists. Five radiographic features were shown to statistically favor chondrosarcoma over enchondroma in the fibula. These were soft-tissue mass ( p<0.0001), periosteal reaction ( p=0.008), cortical disruption in the juxta-articular fibula ( p=0.0133), cortical thickening ( p=0.032), and tumor size greater than 4 cm ( p=0.0046). No statistically-significant demographic differences were found between patients with enchondroma and chondrosarcoma of the fibula. When two or more of the identified features of malignancy are identified in the same patient, chondrosarcoma is 2.4 times more likely than in those patients exhibiting none of the features of malignancy. Soft-tissue mass, periosteal reaction, cortical disruption in the juxta-articular fibula, cortical thickening, and tumor size greater than 4 cm indicate chondrosarcoma over enchondroma of the fibula. Radiographs demonstrating more than one of the identified malignant features are more likely to be due to chondrosarcoma than radiographs demonstrating none or only one of the identified features. No unique malignant features of chondrosarcoma in the fibula were observed when compared to previous descriptions of these tumors in the long and short tubular bones of the appendicular skeleton.
Adolescent↗
Imaging features of low-grade central osteosarcoma of the long bones and pelvis.
PURPOSE: To determine the age and gender distribution and imaging features of low-grade central osteosarcoma (LGCOS) of the long bones and pelvis and to discuss our findings in the context of lesions for which LGCOS has been mistaken. MATERIALS AND METHODS: We reviewed 99 cases of LGCOS collected between 1919 and 2002 from our institution and pathology consultation files. Adequate imaging was available in 70 cases (36 radiographs only, 17 radiographs/CT, 12 radiographs/MRI, 2 radiographs/CT/MRI, 2 CT only, 1 MRI only, 5 bone scans). RESULTS: Patient average age was 30.1+/-14.2 years, with a slight female predominance. The femur and tibia were the most common long bones involved (29 and 20 each) with the majority of these tumors arising around the knee, followed by the fibula, radius, humerus and ulna (four, three, two and one case each). Flat bones were involved in six cases (three pelvis, one rib, two scapulae). Short tubular bones were involved in five cases (two metatarsal, two phalanges, one clavicle). The lesion extended to the end of the affected long bone in 22 of 59 cases. Lesions were large at presentation (mean 7.9+/-4.6 cm, range 2-24). Four radiographic patterns were identified: lytic with varying amounts of thick and coarse trabeculation ( n=22), predominantly lytic with few thin, incomplete trabecula ( n=21), densely sclerotic ( n=17) and mixed lytic and sclerotic ( n=10). Lesions were benign-appearing overall with focally aggressive features. CT or MRI demonstrated cortical breech or extension into the soft tissues in all cases. CONCLUSIONS: LGCOS has a variable appearance on radiographs. A frequent pattern is a slow-growing large intracompartmental fibro-osseous lesion with varying amounts of septal ossification associated with focal areas of aggression. A homogeneously sclerotic pattern was also noted. Imaging with CT or MRI was helpful in every instance in our series in identifying areas of soft tissue extension or cortical disruption suggestive of a low-grade malignancy.
Adult↗
Primary vertebral osteosarcoma: imaging findings.
PURPOSE: To evaluate patient age and sex and location and imaging appearances of primary vertebral osteosarcoma (PVOS) compared with histologic subtypes. MATERIALS AND METHODS: Retrospective review (1915-2001) of imaging findings in patients with histologically proved primary osteosarcoma of vertebral column was performed. Two radiologists in consensus reviewed findings for location, origin site, matrix pattern, and spinal canal invasion and compared them with histologic subtypes. Radiation-induced, Paget, metastatic, and multifocal osteosarcoma were excluded. RESULTS: Of 4,887 osteosarcoma cases, 198 (4%) were PVOS arising from vertebral column. There were 103 female and 95 male patients (age range, 8-80 years; median age, 34.5 years). Involvement included cervical (27 patients), thoracic (66 patients), lumbar (64 patients), and sacral (41 patients) spine. Adequate imaging findings were available in 69 patients, and involvement of two levels was seen in 12 (17%). In nonsacral spine, most tumors (44 cases) arose from posterior elements, with partial involvement of vertebral body. Lesions confined to vertebral body were less frequent (12 cases). Sacral tumors involved body and sacral ala. The most common histologic subtypes were osteoblastic (47 patients), chondroblastic (12 patients), telangiectatic (four patients), fibroblastic (four patients), small cell (one patient), and epithelioid (one patient). The majority (55 cases) demonstrated osteoid matrix mineralization; 17 showed marked mineralization. Five cases with marked mineralization were confined to vertebral body, with "ivory vertebra" appearance. Purely lytic pattern was seen in 14 (20%) cases. Lytic pattern was seen in four (100%) telangiectatic, three (75%) fibroblastic, three (25%) chondroblastic, three (6%) conventional osteoblastic, and one (100%) small-cell subtypes. Invasion of spinal canal was common (84% of cases). Appearance simulating osteoblastoma without soft-tissue mass was present (seven cases). Pathologic compression fractures were identified (seven patients). CONCLUSION: This study provides age and sex distribution and location and imaging features in a large series of PVOS.
Adolescent↗
Effect of granulocyte-stimulating factors on marrow of adult patients with musculoskeletal malignancies: incidence and MRI findings.
OBJECTIVE: Our goal was to determine the incidence and pattern of red marrow reconversion on MRI of adults receiving granulocyte-stimulating factors as part of their chemotherapy regimen for primary musculoskeletal neoplasms and correlate the changes with WBC counts. MATERIALS AND METHODS: Twenty-five adults with soft-tissue sarcomas (n = 15) or primary bone tumors (n = 10) who underwent chemotherapy that included granulocyte-stimulating factors formed the study group. Two radiologists retrospectively evaluated the MRI studies by consensus before and after therapy to determine the presence of changes consistent with red marrow reconversion. Changes were categorized by appearance on T1- and T2-weighted images for location, pattern, and extent of marrow involvement. WBC counts at the time of MRI were recorded. Records were examined for evidence of marrow-infiltrating tumors or metastases. RESULTS: Ten (40%) of the 25 patients underwent bone marrow changes consistent with red marrow reconversion. In seven (70%) of 10 patients, the changes were diffuse in visualized bones and simulated diffuse marrow-infiltrative tumor. In three (30%) of 10 patients, the changes were focal, simulating metastases. T2 signal prolongation was identified in the marrow reconversion in nine patients (90%), although all had shortened T1 signal. Four patients (40%) had elevated WBC counts at the time of the MRI after therapy, but all had shortened T1 signal. Four patients (40%) had elevated WBC counts at the time of the MRI after therapy, five (50%) had normal counts, and one (10%) had a below-normal count. No osseous metastases or marrow-infiltrating tumors were found during follow-up. CONCLUSION: Forty percent of patients showed marrow changes mimicking tumor on MRI that were attributable to red marrow reconversion, which correlated moderately with WBC response.
Adult↗
Radiologic case study. Gouty tophus involving the distal quadriceps tendon.
This case depicts an unusual presentation of gout, which could be mistaken for sarcoma. The radiographic and MRI findings suggest gout whereas the CT appearance is most specific. Therefore, CT should be considered when MRI demonstrates low to intermediate T2 signal in a heterogeneously enhancing soft-tissue mass around a joint, tendon, or bursa, especially when radiographs show adjacent erosion with a sclerotic margin. Gouty tophus is not excluded by a normal serum uric acid level. Computed tomography or ultrasound can be used to guide needle biopsy to provide diagnostic tissue.
Gout↗
Radiologic case study. Rheumatoid arthritis with rice bodies.
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Adult↗
Radiologic case study. Osteoid osteoma.
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Adult↗
What's your diagnosis: chronic displaced greater tuberosity fracture of the proximal humerus.
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Chronic Disease↗
Fibrous dysplasia with cartilaginous differentiation ("fibrocartilaginous dysplasia"): a review, with an illustrative case followed for 18 years.
A 21-year-old man with an 18-year history of progressive, and deforming, monomelic fibrous dysplasia with massive cartilaginous differentiation (fibrocartilaginous dysplasia) is described. A review is made of all prior reported examples of this entity in the English language medical literature. The radiologic and histologic differential diagnoses are described, distinguishing the lesion from chondrosarcoma and from fibrocartilaginous mesenchymoma.
Adult↗
Anterior rim tibial plateau fractures and posterolateral corner knee injury.
The aim of this study was to review MRI findings of clinically suspected posterolateral corner knee injuries and their associated internal derangements. Sixteen knees in 15 patients who had evidence of a posterolateral corner knee injury on the physical exam underwent MRI to evaluate the posterolateral corner of the knee and to look for associated injuries. Two musculoskeletal radiologists reviewed the scans. Surgery was performed on 10 of the knees. Tibial plateau fractures were present in 6 knees; 5 of the fractures were anteromedial rim tibial plateau fractures. The popliteus muscle was injured in 13 knees and the biceps femoris in 6 knees. The lateral collateral ligament was ruptured in 12 knees. The posterior cruciate ligament was completely ruptured in 7 knees and avulsed from its tibial attachment in 1 knee. Eleven knees had a complete anterior cruciate ligament rupture. The anterior cruciate ligament was edematous without complete disruption of all fibers in 3 knees. There was excellent correlation between the MRI results and operative results in regard to the presence of a posterolateral corner injury of the knee (9 of the 10 knees had a posterolateral corner injury). In our study MRI readily detected posterolateral corner injuries. Posterolateral corner injuries of the knee are frequently associated with a variety of significant injuries, including cruciate ligament tears, meniscus tears, and fractures. Fractures of the peripheral anteromedial tibial plateau are not common; however, given their relatively common occurrence in this study, they may be an indicator of a posterolateral corner injury to the knee.
Journal Article↗
Mycobacterium marinum infections of the distal upper extremities: clinical course and imaging findings in two cases with delayed diagnosis.
Mycobacterium marinum infections cause tenosynovitis of the distal upper extremities and develop as a consequence of skin abrasions acquired in contaminated water. We report on two patients whose MR imaging studies showed tenosynovitis of the distal upper extremity secondary to M. marinum. In one patient sequential MR imaging showed development of bony erosions. Appropriate treatment was delayed in both patients because the diagnosis was not considered. We report on and discuss the clinical course and MR imaging findings in two patients with M. marinum infection.
Adult↗
The distal semimembranosus complex: normal MR anatomy, variants, biomechanics and pathology.
OBJECTIVE: To describe the normal MR anatomy and variations of the distal semimembranosus tendinous arms and the posterior oblique ligament as seen in the three orthogonal planes, to review the biomechanics of this complex and to illustrate pathologic examples. RESULTS AND CONCLUSION: The distal semimembranosus tendon divides into five tendinous arms named the anterior, direct, capsular, inferior and the oblique popliteal ligament. These arms intertwine with the branches of the posterior oblique ligament in the posterior medial aspect of the knee, providing stability. This tendon-ligamentous complex also acts synergistically with the popliteus muscle and actively pulls the posterior horn of the medial meniscus during knee flexion. Pathologic conditions involving this complex include complete and partial tears, insertional tendinosis, avulsion fractures and bursitis.
Biomechanical Phenomena↗
Apparent cellulitis with a prolonged APTT. Activated partial thromboplastin time.
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Adult↗
Solid variant of aneurysmal bone cysts in long tubular bones: giant cell reparative granuloma.
OBJECTIVE: The purpose of this study was to determine the age distribution, location, and imaging features of histologically proven solid variants of aneurysmal bone cysts in long tubular bones. MATERIALS AND METHODS: We performed a retrospective review of imaging studies of histologically proven solid aneurysmal bone cysts in long bones between 1961 and 2001. There were 30 cases comprising 29 radiographic, six CT, and eight MR imaging examinations. The lesions were evaluated for bone involved, location within a long bone, matrix, size, soft-tissue mass, and MR imaging characteristics. The imaging findings were correlated with the histologic findings. RESULTS: The patients were 17 females and 13 males ranging in age from 2 to 58 years (mean, 18 years). The bones involved were the femur (n = 10), the ulna (n = 7), the tibia (n = 7), the humerus (n = 2), the radius (n = 2), and the fibula (n = 2). The lesions were five juxtaarticular, 13 metaphyseal, one diametaphyseal, and 11 diaphyseal. The location was eccentric in 20 cases, of which two were intracortical and two periosteal, and central in 10. Lesion size varied between 1 and 7 cm. Thirty-three percent of lesions were nonaneurysmal. Four lesions were mineralized. A soft-tissue mass was present in four cases. Four lesions showed a permeative-lytic pattern simulating a malignant process. Unusual findings included periosteal reaction and development of a solid aneurysmal bone cyst in a preexisting fracture. MR imaging showed solid elements in all cases and pronounced edema in 50% of cases. CONCLUSION: Solid aneurysmal bone cyst is a reactive nonneoplastic bone lesion with varied imaging characteristics; one third of lesions are nonaneurysmal.
Adolescent↗