MSK Interesting Case (21 September 2017) Dr Yap Sheau Huey · 2020. 5. 18. · Narrowing of...
Transcript of MSK Interesting Case (21 September 2017) Dr Yap Sheau Huey · 2020. 5. 18. · Narrowing of...
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MSK Interesting Case (21st September 2017)
Dr Yap Sheau Huey
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Case 1
3 y.o boy
Bilateral thumbs IPJ flexion deformity ~ a few months.
O/E: full active flexion, active extension ~20 degree
Passive ~ fully extends
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Ultrasound
RT FPL
LT FPL
Normal adult
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RT LT
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Pediatric Trigger Thumb
Abnormal/fixed flexion of the thumb or snapping movement across IPJ.
Etiology: unknown
3 in 1000 within 1st year of life. Bilateral in 25%.
Pathophysiology:
FPL thickening (dt abnormal collagen degeneration & synovial proliferation)
Causing disruption of normal tendon gliding
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Presented with fixed flexion of thumb IPJ.
May have prominent FPL nodule ( Notta's node).
Prognosis:
30-60% resolve spontaneously before 2 y.o.
<10% resolve after 2 y.o.
Treatment: conservative or A1 pulley release.
US post resolution
Enlarged FPL persist, but gliding improve, dt local anatomy change and A1 pulley accommodated FPL.
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Case 2
68 y.o lady
4 months ago, admitted for Gullain-barre syndrome with limb weakness and required ventilator support.
Recently, c/o painful left shoulder.
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XR 25/5/2017
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22/7/2017
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CT
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Case 3
40 y.o man, recreational football player.
Right distal posterior calf swelling ~10years.
No distal neurovascular deficit.
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Radiograph (2.5.2017)
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CT
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MRI
STIR
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Histopathology
Lamellar bone with necrotic material and blood clot.
No malignant cells.
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Myositis Ossificans
An inflammatory pseudotumour
Radiographic appearances change with time.
Most important diagnostic feature:
zoning pattern of peripheral maturation.
Ossification is peripheral & centripetal.
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Early phase
Soft tissue mass, periosteal reaction,
Extensive muscle edema
Subacute phase
Mature phase
Rim/peripheral calcification or with crenated outlined, separation of mass from cortex
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Case 4
33 y.o lady, Down Syndrome
Progressive weakness of both lower limb in the past few years.
Deteriorate from walking independently to walking with walking frame.
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XR
Neutral Extension Flexion
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CT
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Atlanto-axial Subluxation and Os Odontoideum in Down Syndrome
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Case 5
6 y.o. Boy, Down Syndrome.
Presented with weakness of all the 4 limbs after a car ride ( sleeping with neck flexion for about 2 hours).
Symptoms improved after 1 week but recurred later on.
No history of trauma.
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XR
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CT
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MRI
Narrowing of cranio-cervical junction with cord compression and myelomalacia
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Discussion
Atlantoaxial instability affects 10-20% of Down Syndrome (DS) patients.
Mostly asymptomatic.
Symptoms due to spinal cord compression.
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Os Odontoideum Well-corticated ossific density along the
superior margin of a relatively hypoplastic/foreshortened base of dens.
Orthotopic/dystopic
orthotopic: normal position with a wide gap between C2 and os odontoideum ( gap above superior articular facet).
A dystopic ossicle may be fixed to the clivus or to the anterior ring of the atlas.
Commonly associated with antlanto-axial instability.
Associated with
Hypetrophied and rounded anterior arch of C1
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Case 6
71 y.o man
T1a right vocal cord carcinoma in 2003.
Elevated ALP during medical check up.
Otherwise, symptomatic.
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BONE SCAN
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XR
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CT
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Diagnosis: Paget disease
3-4% of individual >40 y.o ( in US, Europe, rare in Asia, Africa).
Causes: unknown.
3 phases: lytic; mixed and blastic phases.
Radiographic appearance dt:
Abnormal osseous resorption & apposition within periosteal & endosteal cortex.
Produces disorganized new bone.
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Case 7
63 y.o man.
C/O left shoulder swelling for 3 months.
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Severe RC arthropathy
Large RC
tear
Superior
migration
Cartilage
thinning
Humeral head
wears down
AC joint capsule
↓↓
GH joint fluid
leaks thro’
AC joint
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Rotator cuff arthropathy:
Geyser phenomenon
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CASE 8
54 y.o lady
C/O left lateral ankle pain.
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US
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CT
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Chopart Joint
AKA midtarsal, transverse tarsal joint.
Calcaneocuboid & talocalcaneonavicular joints.
MR Imaging of Midfoot Including Chopart and Lisfranc Complexes. Rosenberg et al.
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MR Imaging of Midfoot Including Chopart and Lisfranc Complexes. Rosenberg et al.
Chopart Joint is stabilized by:- spring ligament- bifurcate lig- short & long plantar lig- dorsal calcaneocuboid lig- dorsal talonavicular lig
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Chopart Joint injuries
Pure ligamentous injury → small avulsion fractures → rare fracture dislocation
Can be missed upto 40% of cases.
Midfoot avulsion fracture:
Low-energy trauma, more in women dt wearing high heel.
Ankle inversion injury
20% with LCL sprain
Dailymail.co.uk
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MR Imaging of Midfoot Including Chopart and Lisfranc Complexes. Rosenberg et al.
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Case 9
8 y.o girl
Presented with left thigh swelling for 1-2 years.
Progressive enlarging
No neurological sign.
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MRI
Extensive venous malformation from mid thigh to mid leg, involving subcutaneous fat and muscle
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MRV shows- lateral vein at lateral upper leg, knee and lower thigh
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Case 10
2 year old girl
Vascular birth mark & right thigh swelling since birth.
Progressive enlargement of right lower limb since birth.
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Severe venolymphatic vascular malformation of right lower limb, involving subcutaneous, intermuscular and intramuscular.
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Dilated subcutaneous vein. Presence of lateral and sciatic vein draining to internal iliac vein.
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Klippel Trenaunay Syndrome
Congenital malformation syndrome
Unknown cause
Characterized by:
vascular malformation
capillary malformation/port-wine stain;
venous malformation/varicosity (persistent embryonic vein: lateral marginal vein-most common)
Soft tissue or bony hypertrophy of extremities.
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Hyung et al. Clinical Experience of the Klippel-Trenaunay Syndrome
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THANK YOU!