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48M Feelings of ankle instability

48M Feelings of ankle instability. MOCK ORAL BOARDS 2005 GENERAL RADIOLOGY Don Fleischli, M.D., M.B.A. Associate Clinical Professor, U.C.S.D. School of Medicine Assistant Professor of Radiology & Radiological Sciences, U.S.U.H.S. GENERAL SUGGESTIONS. What is the exam? What are the findings?

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48M Feelings of ankle instability

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  1. 48MFeelings of ankle instability

  2. MOCK ORAL BOARDS 2005GENERAL RADIOLOGYDon Fleischli, M.D., M.B.A.Associate Clinical Professor, U.C.S.D. School of MedicineAssistant Professor of Radiology & Radiological Sciences, U.S.U.H.S.

  3. GENERAL SUGGESTIONS • What is the exam? What are the findings? • You have seen one like this in your review! • Obvious findings - long DDX or detailed discussion? • Aunt Minnie? It looks like…but could be…. • Corner of film type trick that looks normal? • Have a script in mind so when your mind goes blank… • Usually you get no history until you ask • Don’t ask until you have run through your script • An example of a category script…don’t step INIT • Infection…bacterial, viral, fungus, immune sys… • Neoplasm…benign, malignant, pseudotumor… • Inflammation…arthritis, collagen vasc, drugs… • Trauma/Other…extrinsic, mechanical, rupt, vasc…

  4. GENERAL SUGGESTIONS • Pick a category and pursue it until exhausted or the examiner directs you away from it • Don’t jump to another category quickly, it may take you down the wrong path…“this could be tumor…” • When exhausted go to other categories, say “this looks inflammatory but could be trauma or infection or neoplasitic…”; “I would recommend…” • Couch your discussion in terms of assumed clinical findings…“if this pt is immune compromised I would consider…if not I would consider” • Start by stating the obvious category and diagnosis • Don’t mumble/shout/run on/interrupt/joke/ask for Dx • If examiners says “is there anything else you would consider”…go back to INIT then ask for more history…or mercy

  5. ACTUAL SCORE SHEET FROM ABR • Case # • -- - + ++ +++ • Observation • Synthesis/Imp • Management • 68 69 70 71 72 •  Score

  6. CASE #1

  7. CASE #1

  8. CASE #1 - DISCUSSION • Findings • Multiple erosions/uniform joint space narrowing • Ulnar styloid erosions; pisoform/triquetrum early • Subluxations; mention SLE best seen in Norgaard view • Osteoporosis; juxta-articular>>diffuse • Little fusiform soft tissue swelling; early sign • Bilateral symmetrical • No swan neck and boutonniere deformities distal phalanges • Differential Diagnosis Infection • Differential Diagnosis Neoplasm

  9. CASE #1 - DISCUSSION • Differential Diagnosis Inflammation • Rheumatoid Arthritis • HLA-B27 Arthropathies-mineralization-bone formation • Erosive Osteoarthritis-1st CMC and DIPs, central seagulls • Gout-no overhanging edges with sclerosis • Differential Diagnosis Trauma/Other • This does not look like primary or secondary OA • Diagnosis: Rheumatoid Arthritis (advanced) • Short Read: • Discuss types of erosions in other arthritis • Bare area of joint within capsule not covered by cartilage • Lack of bone formation seen in Psoriatic, not in DIPs • Ankylosis of carpals but not distal to them

  10. CASE #4

  11. CASE #4

  12. CASE #4 - DISCUSSION • Findings • Calcified stone in distal left ureter • Scattered calcifications in soft tissues • Typical ovoid elongated calcifications in muscles • Differential Diagnosis Infection/Inflammation • Cysticercosis with calcified left ureteral calculus • Trichinosis cysts are tiny, round, punctate (mammo) • Guinea worm dz, Echinococcosis, Sarcosporidosis, Loiasis also have soft tissue calcification • Dermatomyositis and other collagen vascular dz

  13. CASE #4 - DISCUSSION • Differential Diagnosis Neoplasm • Differential Diagnosis Trauma/Other • Myositis ossificans • Vascular calcifications • Diagnosis: Cysticercosis & ureteral calculus • Short Read: • Taenia solium (helminth)=pork tape worm (cestode) • Humans are the only definitive host of adult worm in the intestine; hog and human are intermediate hosts • Larval form in muscles and viscera >>die>>Ca++

  14. CASE #5

  15. CASE #5

  16. CASE #5

  17. CASE #5 - DISCUSSION • Findings • Complex vertical fx probably stable • Interpedicular distance wider than above or below • Posterior superior corner fragment>>spinal canal • Posterior ligaments and bones intact • L-2; typically 67% T-12, L-1, L-2 junction stable to mobile • Differential Diagnosis Infection • Differential Diagnosis Neoplasm • Differential Diagnosis Inflammation

  18. CASE #5 - DISCUSSION • Differential Diagnosis Trauma/Other • Simple wedge fracture in osteoporosis (insuff) or normal bone • Burst fracture is vertical (ant/mid column); stable or unstable • Chance fracture (lapbelt only) is horizontal; no anterior column compression like burst fx; bone/ST; stable or unstable • Flexion distraction injury; combination of both; ant column + • Diagnosis: Burst fracture • Short Read: • Three columns (Denis); CT for middle and posterior columns • Simple wedge anterior column only…mechanism of injury • Anterior/middle columns in 85%; 25% middle column miss • Posterior column and/or ligaments involved on CT=unstable • CT the night of injury then MR the next day for ligaments • Unstable (two columns + ligs)>>further neurological injury

  19. CASE #6

  20. CASE #6

  21. CASE #6

  22. CASE #6 - DISCUSSION • Findings • Chondrocalcinosis both hips • Protrusio acetabuli with uniform joint space narrowing • Differential Diagnosis Infection • Differential Diagnosis Neoplasm • Differential Diagnosis Inflammation • CPPD crystal deposition disease • Gout (if chondrocalcinosis it is not CA++ urate but CPPD) • Pseudogout

  23. CASE #6 - DISCUSSION • Differential Diagnosis Trauma/Other • Chronic trauma>>DJD with chondrocalcinosis • Diagnosis: CPPD “pseudo-rheumatoid arthritis” • Short Read: • Calcium PyroPhosphate Dihydrate (CPPD) deposition dz • Chondrocalcinosis with secondary DJD • May be aggressive and look like neuropathic joint • May look like RA “pseudo-rheumatoid” but no erosions vs true RA with erosions and CPPD; unusual secondary OA • Diagnosis by CPPD crystal identification • Knees, hands, hips, shoulder, elbow; need two areas for DX • Arthropathy of CPPD resembles secondary OA usually

  24. CASE #15

  25. CASE #15

  26. CASE #15

  27. CASE #15 - DISCUSSION • Findings • Erosions with overhanging edge, sclerotic cortical rims • Normal mineralization, joint spaces preserved • Look for faint soft tissue calcification=tophus • Differential Diagnosis Infection • Differential Diagnosis Neoplasm • Differential Diagnosis Inflammation • Gout (if chondrocalcinosis they also have CPPD) • Rheumatoid arthritis • Osteoarthritis • HLA-B27 arthropathies

  28. CASE #15 - DISCUSSION • Differential Diagnosis Trauma/Other • Diagnosis: Gout • Short Read: • M:F=20:1, elevated uric acid, monosodium urate monohydrate deposits (tophi) which may calcify and be seen on films • Many diseases cause elevated uric acid (myeloproliferative) • Uncommon before age 20 yrs, oldest recognized arthropathy • Must have untreated disease for years to see changes on films • Feet (1st MTP), hands, elbow, wrist, knee, shoulder, hip, SI Jnt • Asymmetrical polyarticular distribution, indolent, remodeling • Secondary gout with increase production or diminished excrete of uric acid usually have no radiographic changes

  29. CASE #16

  30. CASE #16 - DISCUSSION • Findings • Bubbly lesion with fracture no periostitis; chondroid matrix • Differential Diagnosis Infection • Osteomyelitis (bacterial or fungus) • Differential Diagnosis Neoplasm • Enchondroma • FOGMACHINES or FEGNOMASHIC for benign cystic lesion • Chondroid matrix=popcorn, speckle, swirled, punctate Ca++ • Osteoid matrix=denser, cloud-like, mashed potatoes Ca++ • Zone of transition=narrow benign, wide malignant; slow growth time to retreat in orderly manner; rapid permeative • Periostitis may be benign (benign lesion) or aggressive (either)

  31. CASE #16 - DISCUSSION • Differential Diagnosis Inflammation • Differential Diagnosis Trauma/Other • Healing displaced fracture • Diagnosis: Enchondroma with Fracture • Short Read: • Most common lesion of phalanges, diaphyseal, lytic, expansile, thin sclerotic rim, may not have chondroid matrix in hand • Ollier’s dz multiple unilateral, Maffucci syndrome multiple A/W hemangiomata more likely to degenerate into malignancy • Films underestimate true size; MR/CT better • Geographic lesions=those with distinct margin sclerotic or not

  32. CASE #17

  33. CASE #17

  34. CASE #17 - DISCUSSION • Findings • Cocktail hot dogs or sausages (soft tissue swelling beyond joint) • Normal mineralization • Bone proliferation=hypertrophic bone at ligament attachments • Differential Diagnosis Infection • Osteomyelitis • Differential Diagnosis Neoplasm • Differential Diagnosis Inflammation • Psoriatic arthritis • Rheumatoid arthritis, Reiter’s dz, HLA-B27 arthropathies • Osteoarthritis • Gout, amyloid, sarcoid

  35. CASE #17 - DISCUSSION • Differential Diagnosis Trauma/Other • Fracture or soft tissue hemorrhage and periostitis • Exostosis • Diagnosis: Psoriatic Arthritis • Short Read: • Erosions and bone formation (DDX RA) • Mouse ear hypertrophy next to marginal erosion • Pencil in cup central erosions (late) may widen joint • Soft tissue swelling beyond joints, normal mineral • 1)DIP/PIP joints involved, 2)rays 1-3 all joints, 3)like RA but DIP, bone prolif, normal mineralization • Feet more than hands; bilateral asymmetrical; Achilles and plantar aponeurosis bone proliferation

  36. CASE #22

  37. CASE #22

  38. CASE #22

  39. CASE #22

  40. CASE #22

  41. CASE #22 - DISCUSSION • Findings • Periosteal new bone 3rd metacarpal • Sclerosis (not quite bubbly) • Bubbly/lytic/sclerotic process distal left clavicle • Positive three phase bone scan in above and spine • Chest shown no coin lesion or cavity • Differential Diagnosis Infection • Cocci osteomyelitis • TB or fungus, pseudomonas (addicts), salmonella (sickle cell) • Differential Diagnosis Neoplasm • FOGMACHINES/FEGNOMASHIC • Lymphoma, leukemia, mets, multifocal osteogenic sarcoma

  42. CASE #22 - DISCUSSION • Differential Diagnosis Inflammation • Differential Diagnosis Trauma/Other • Fracture with healing • FEGNOMASHIC/FOGMACHINES • Diagnosis: Cocci Osteomyeltis • Short Read: • Brodie abscess subacute or chronic osteomyeltis • Involucrum is a shell of periosteal reactive bone formation surrounding infected bone (sequestrum) • Sequestrum is a segment of necrotic bone with organisms separated from viable bone by granulation tissue • Cloaca are holes in involucrum through which pus extrudes • MRI low signal dark on T1, high signal bright on T2

  43. CASE #23

  44. CASE #23

  45. CASE #23

  46. CASE #23

  47. CASE #23 - DISCUSSION • Findings • Bilateral symmetrical , postage stamp edge erosions, sclerosis • No squaring of T12/L1 vert bodies, ivory corner, no ankylosis • Normal mineralization, no syndesmophytes • Differential Diagnosis Infection • Septic arthritis (bacterial, fungal, TB) • Differential Diagnosis Neoplasm • Differential Diagnosis Inflammation • Ankylosing spondylitis • IBD, Psoriatic, Reiter’s, RA, CPPD, Gout, OCI

  48. CASE #23 - DISCUSSION • Differential Diagnosis Trauma/Other • Post traumatic secondary OA • Diagnosis: Ankylosing Spondylitis • Short Read: • Least erosive most ossifying of all inflammatory arthropathies • RF neg; HLA-B27 antigen positive in many especially caucas • Fibrocartilage (1 mm) iliac first, Hyaline (3-5 mm) sacral later • Anteroinferior half to 2/3 is a true synovial joint; posterosuper half to 1/3 is a cleft between bones with ligs (no cartilage) • DDX 1) width of joint space 2) presence and type of erosions 3) presence and type of sclerosis 4) presence and type of bony bridging 5)distribution of above changes • Septic unilateral; AS, IBD, CPPD, OCI bilateral symmetrical; Psoriatic, Reiter’s, Gout, OA bilateral asymmetrical

  49. CASE #29

  50. CASE #29 - DISCUSSION • Findings • Fragmentation of tibial tuberosity, soft tissue swelling • Thickened patellar tendon indistinct posterior margin • Differential Diagnosis Infection • Osteomyelitis (stretch) • Differential Diagnosis Neoplasm • Differential Diagnosis Inflammation • Apophysitis tibial tubercle • Differential Diagnosis Trauma/Other • Osgood-Schlatter disease

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