The Teaching Files: Musculoskeletal PDF
Preview The Teaching Files: Musculoskeletal
1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 THe TeAcHinG FileS: MuSculoSKeleTAl iSBn: 978-1-4160-6261-5 Copyright © 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permission may be sought directly from elsevier’s Rights department: phone: (+1) 215 239 3804 (uS) or (+44) 1865 843830 (uK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the elsevier website at http://www.elsevier.com/permissions Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administrated, to verify the recommended dose or formula, the method and duration of administration, and contraindications. it is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data ouellette, Hugue. The teaching files. Musculoskeletal imaging/Hugue A. ouellette. — 1st ed. p. ; cm. includes bibliographical references. iSBn 978-1-4160-6261-5 1. Musculoskeletal system—imaging—case studies. 2. Musculoskeletal system—Disease— Diagnosis—case studies. i. Title. ii. Title: Musculoskeletal imaging. [DnlM: 1. Musculoskeletal Diseases—diagnosis—case Reports. 2. Diagnostic imaging—methods— case Reports. 3. Musculoskeletal System—injuries—case Reports. We 141 093t 2010] Rc925.7.094 2010 616.7’075—dc22 2009037444 Acquisitions Editor: Rebecca Gaertner Developmental Editor: colleen McGonigal Publishing Services Manager: Tina Rebane Project Manager: Amy cannon Design Direction: Steve Stave Printed in china last digit is the print number 9 8 7 6 5 4 3 2 1 To Gabrielle and Emanuelle Preface The Teaching Files: Musculoskeletal: expert consult uses concepts and technologies are provided. expert consult a case-based, visual approach to easier diagnosis. The comes with convenient access to the full text online, book is intended for the working general radiologist all of the book’s illustrations, and links to Medline at and musculoskeletal radiologist in fellowship training, expertconsult.com although radiology residents may also find it useful. Special thanks to James Thrall, MD, who in my opi- Practical and clinically focused, this musculoskeletal nion has built the greatest radiology department in the title in the new Teaching Files series provides 400 world aatt MMaassssaacchhuusseettttss GGeenneerraall HHoossppiittaall,, aaannnddd tttooo TTThhheeerrreeesssaaa interesting cases and over 700 high-quality images to Mcloud, MD, for her educational mentorship. Thank help you better diagnose any musculoskeletal disease you to Daniel Rosenthal, MD, Susan Kattapuram, MD, or disorder. The book organization is intended to make and William Palmer, MD, all my colleagues in the referencing of difficult diagnoses easy. every chapter musculoskeletal division of Massachusetts General consistently includes Demographics/clinical History, Hospital, and our fellows and residents for teaching Findings, Discussion, characteristic/clinical Features, me almost everything i know about musculoskeletal Radiologic Findings, Differential Diagnosis, and Suggested disease. Readings to make reference to the work optimal. Detailed up-to-date discussions of current musculoskeletal Hugue A. ouellette, MD vii Case 1 Demographics/clinical history Characteristic Clinical Features Patients have a history of significant flexion injury to the A 32-year-old man with a history of trauma, undergoing cervical spine. CT. Characteristic Radiologic Findings On radiography and CT, malalignment of the cervical FinDings spine at the affected level is visible. There is typically anterior displacement of the proximal articular facet rel- Sagittal reformatted CT images show anterior displace- ative to the more caudal level. ment of the C4 facet articular surfaces relative to C5 fac- ets, in keeping with bilateral locked facets (Figs. 1 and 2) Diagnosis and anterolisthesis of C4 over C5 (Fig. 3). Bilateral facet dislocation Suggested Readings Discussion Carrino JA, Manton GL, Morrison WB, et al: Posterior longitudinal ligament status in cervical spine bilateral facet dislocations. Skel- Definition/Background etal Radiol 35:510-514, 2006. Bilateral facet dislocation is a hyperflexion injury that results in an unstable cervical spine. Case 1 Figure 1. Sagittal reformatted CT image of the right aspect of the Figure 2. Sagittal reformatted CT image of the left aspect of the cervical spine. There is anterior displacement of the C4 facet ar- cervical spine. ticular surface relative to the C5 facet, in keeping with locked facets. A small fracture fragment is noted from the superior tip of the C5 articular facets. Figure 3. Sagittal reformatted CT image of midline. There is anterolisthesis of C4 over C5. Case 2 Demographics/clinical history Characteristic Clinical Features Disk bulges may be asymptomatic or may cause pain. A 50-year-old man with back pain. Characteristic Radiologic Findings On CT scan, there is typically broad protuberance of the FinDings disc material which may cause central canal or forami- nal stenosis. Sagittal reconstructed and axial CT scan images status post-discography. There is contrast in the L2/L3, L3/L4, Diagnosis and L4/L5 discs (Fig. 1). There is a diffuse annular bulge Disk/annular bulge at the L4/L5 with mild compression of the thecal sac (Figs. 1 and 2). Suggested Readings Anderson MW: Lumbar discography: An update. Semin Roentgenol 39(1):52-67, 2004. Discussion Definition/Background Discography is a provocative test that entails injecting contrast into a disk to elucidate which injected level reproduces the patient’s symptom. Case 2 Figure 2. Axial CT scan image status post-discography. There is contrast in the L4/L5 disks. There is a diffuse annular bulge at the L4/L5 with mild compression of the thecal sac. Figure 1. Sagittal reconstructed CT scan image status post-discog- raphy. There is contrast in the L2/L3, L3/L4, and L4/L5 disks. There is a diffuse annular bulge at L4/L5 with mild compression of the thecal sac. Case 3 Characteristic Clinical Features Demographics/clinical history Patients may have cord injury–related symptoms. A 16-year-old boy who was running on the beach and jumped into the water, undergoing MRI. Characteristic Radiologic Findings On MRI, there is decreased height of the affected verte- bral body. There is T2 hyperintense signal in the frac- tured vertebra, and sometimes a linear hypointense line FinDings can be seen, representing the fracture. There may be Sagittal gradient echo (Fig. 1), sagittal T2-weighted a retropulsed fragment, which may narrow the central (Fig. 2), sagittal T1-weighted (Fig. 3), and axial gradient canal and cause cord injury. echo (Fig. 4) MR images show a compression deformity at C5 with a retropulsed fragment causing moderate Diagnosis central canal stenosis. C5 burst fracture Suggested Readings Bensch FV, Koivikko MP, Kiuru MJ, et al: The incidence and distribu- Discussion tion of burst fractures. Emerg Radiol 12:124-129, 2006. Definition/Background Burst fractures are secondary to loading axial injuries. Case 3 Figure 2. Sagittal T2-weighted MR image of the cervical spine. In addition to a compression deformity at C5 and increased signal in the C5 vertebral body, there is enlargement of the cord with T2 Figure 1. Sagittal gradient echo MR image of the cervical spine. hyperintensity representing hemorrhage in a cord contusion. There is a compression deformity at C5 with a retropulsed frag- ment causing moderate central canal stenosis. There is increased signal in the C5 vertebral body representing edema. There also is enlargement of the cord with blooming, representing hemorrhage in a cord contusion. Figure 3. Sagittal T1-weighted MR image of the cervical spine. This image shows a compression deformity at C5 with a retropulsed Figure 4. Axial gradient echo MR image of the cervical spine shows fragment causing moderate central canal stenosis and enlargement a compression deformity at C5 with a retropulsed fragment causing of the cord representing a cord contusion. moderate central canal stenosis, increased signal in the C5 verte- bral body representing edema, and enlargement of the cord with hyperintensity representing hemorrhage in a cord contusion.
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