Retrosternal displacement of the clavicle after medial physeal fracture in an adolescent: MRI.

Retrosternal displacement of the medial clavicular metaphysis after a medial physeal fracture is a rare and potentially fatal injury because of possible damage of neurovascular structures, trachea and oesophagus. As the medial clavicular epiphysis does not ossify until 18-20 years of age and the medial clavicular physis is the last to close, around 22-25 years of age, this injury is difficult to demonstrate with plain radiographs in younger patients and is often mistaken for a sternoclavicular joint dislocation. We report on a 16-year-old boy with a fracture of the medial clavicular physis with retrosternal displacement of the metaphysis that was diagnosed with MRI, and discuss the diagnostic tools and treatment options in this rare injury.

Pelvic MRI findings of juvenile-onset ankylosing spondylitis.

Ankylosing spondylitis (AS) is the most common clinical subgroup of sero-negative spondyloarthropathies. Radiographic and clinical signs of bilateral inflammatory involvement of sacroiliac joints are the gold standard for the diagnosis of juvenile AS. Although radiographic evidence of sacroiliitis is included in the definition, it is not mandatory for the diagnosis of juvenile AS. The aim of this study is to describe pelvic enthesitis-osteitis MRI findings accompanying sacroiliitis in a group of juvenile AS. Eleven patients suffering from low back pain underwent MRI of the pelvis and were enrolled in this retrospective study. The mean duration of symptoms was 12 months. The mean age of the 11 cases in our study was 12.18 years (range, 6-19). There were eight boys and three girls. Anteroposterior radiographs of the pelvis were obtained in all patients. Sacroiliac joint involvement was detected in all of the cases by pelvic MRI. Pathologic signal changes were detected in the pubic symphisis (osteitis pubis) in ten cases, trochanteric bursitis in six cases, coxofemoral joint in five cases, crista iliaca in three cases, and ischion pubis in three cases. There was increased T2 signal intensity in eight of the 11 cases (72.7%) relevant with soft tissue edema/inflammation. This high correlation between sacroiliitis and enthesitis suggests that enthesitis could be an important finding in juvenile AS.

[A case of brown tumor mimicking fibrous dysplasia in a patient with chronic renal failure]. / Kronik böbrek yetersizligi olan bir hastada fibröz displaziye benzeyen kahverengi (brown) tümör.

Renal osteodystrophy is one of the major causes of morbidity in patients receiving long-term dialysis treatment for renal failure and after transplantation. Its clinical implications include high-turnover bone disease, low-turnover bone disease, osteomalacia, osteosclerosis, and osteoporosis. A 13-year-old boy who had been on dialysis treatment for renal failure was admitted with a pathologic supracondylar femur fracture after a minor trauma. Radiological studies showed cystic lesions in the femoral supracondyle, left acetabular roof, and right proximal and distal tibia. Based on radiologic appearances of the lesions and on histopathologic findings of the lesion excised from the right distal tibia, brown tumor and fibrous dysplasia were considered in the differential diagnosis. Initially, serum parathyroid hormone level was slightly increased and calcium level was normal, but during follow-up, serum parathyroid hormone level increased significantly, enabling the diagnosis of brown tumor.

Diagnostic value of magnetic resonance imaging and scintigraphy in patients with metastatic breast cancer of the axial skeleton: a comparative study.

PURPOSE: The goal of this study was to compare the sensitivity of MRI and scintigraphy for detecting metastatic bone disease involving the axial skeleton. PATIENTS AND METHODS: A total of 59 patients (58 women and 1 man, age range 28-83 years, mean age 53.0 years) with histopathologically proven breast cancer during a 15-month period (between April 2003 and January 2004) were included in the study. All the patients underwent scintigraphy and MRI examinations for staging, follow-up, or evaluation of bone pain. RESULTS: MR imaging revealed 59 metastases in 59 patients (sensitivity, 95%; specificity, 100%; positive predictive value, 100%). Four lesions detected by MRI were classified as of uncertain origin (grade 2) and 36 lesions were regarded as definitely benign (grade 1). Scintigraphy revealed 44 metastases in 59 patients (sensitivity, 70%; specificity, 94%; positive predictive value, 95%). A total of 29 lesions were considered as of uncertain origin (grade 2), and 26 lesions were regarded as definitely benign (grade 1). About five lesions were graded as grade 2 in scintigraphy, while MRI graded them as degeneration or benign compression (Grade 1). For 11 lesions the same grade was regarded in both MRI and scintigraphy. Two lesions graded as grade 3, and eleven lesions graded as grade 2 in scintigraphy demonstrated no pathological signal intensity in MRI. In total, 18 lesions with no activity in scintigraphy were graded as grade 3 lesions in MRI. CONCLUSION: MRI is more sensitive than scintigraphy in the detection of bone metastases. MRI appears to be able to screen patients more effectively than scintigraphy if the spine and pelvis are included because metastases merely outside the axial skeleton are rare.

Lumbosacral osseous tumors in children.

A wide variety of benign and malignant neoplasms in children involve the lumbosacral region. When a solitary lesion of the lower spine occurs, tumors or tumor-like lesions represent an important group of entities for diagnostic consideration. Diagnostic investigation should begin with a patient history, physical examination, laboratory testing, and radiography. Roentgenograms, which demonstrate bone deviations, should be used as an initial examination. The results should direct further imaging studies, such as computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy. CT should be the chosen modality for delineating tumoral osteoid matrix formation. MRI shows soft-tissue masses and medullary infiltration better than any other radiological modality. A multimodal radiological approach is helpful in the overall evaluation and differential diagnosis of vertebral lesions in children. Although imaging features, especially of benign lesions, may yield a high percentage of accurate diagnoses, in cases with radiological findings highly suggestive of malignancy, a specific diagnosis cannot always be made, and histopathological findings are essential to achieve the diagnosis that will guide the therapy.

Pain & resistance in patients with adhesive capsulitis during contrast material injection phase of MR arthrography.

BACKGROUND & OBJECTIVE: Adhesive capsulitis of the shoulder is a condition of unknown aetiology that results in the development of restricted active and passive glenohumeral motion. It has been reported that magnetic resonance (MR) imaging is useful in diagnosing adhesive capsulitis. We carried out this study to assess how pain and/or resistance during contrast material injection affects the diagnosis of adhesive capsulitis on magnetic resonance (MR) arthrography. METHODS: The study included MR arthrography examinations of 21 patients with a diagnosis of adhesive capsulitis. The control group consisted of 20 patients who presented clinically with rotator cuff tear. The pain (visual analog scale, VAS), resistance to injection and the amount of contrast material that could be injected during injection phase of MR arthrography was assessed and compared between groups. RESULTS: The patients in adhesive capsulitis group (mean VAS score 66.5+/-25.5) experienced more pain when compared with the control group (mean VAS score 34.9+/-27.7, P<0.001). A statistically significant difference (P<0.001) in terms of the amount of the injected fluid (4.3+/-2.6 ml for adhesive capsulitis group, and 10.9+/-4.1 ml for control group) was seen into the joint cavity. Resistance to injection was significantly more (P<0.001) in patients with adhesive capsulitis when compared to control group. INTERPRETATION & CONCLUSION: Experience of pain during injection, a decreased amount of contrast material injected and resistance to injection in patients during injection phase of MR arthrography may suggest adhesive capsulitis.

Skeletal muscle: an unusual site of distant metastasis in gastric carcinoma.

UNLABELLED: Gastric cancer metastatic to skeletal muscle is an unusual entity. Surgery, systemic chemotherapy, or radiotherapy to the metastatic mass can be treatment options for achiving palliation. CASE REPORT: A patient with multiple skeletal muscle metastases that occurred during follow-up after gastrectomy and adjuvant chemo-radiotherapy is reported. Magnetic resonance imaging (MRI) demonstrated soft-tissue masses involving the posterior right paralumbar and posterior left paradorsal muscles. Biopsy showed metastatic infiltrating adenocarcinoma. The patient did not respond to palliative chemotherapy. Palliative radiotherapy was administered to the painful mass. Based on this case, the diagnosis of muscle metastases and treatment options for palliation are discussed.

Arthroscopic microfracture treatment for osteonecrosis of the knee.

PURPOSE: This study evaluated the results of arthroscopic subchondral microfracture performed on patients with spontaneous osteonecrosis (ON) (group 1) or secondary ON (group 2) of the knee joint. TYPE OF STUDY: Retrospective clinical study. METHODS: Group 1 included 26 patients (mean age, 48 years) who had spontaneous ON. Group 2 included 15 patients (mean age, 32 years) with ON secondary to inflammatory disease or steroid therapy. Seventy-six percent of the chondral defects were located in the medial femoral condyle. The average defect sizes in group 1 was 162 mm2 and in group 2 was 362 mm2. After debridement of the necrotic tissues, multiple perforations were placed into the subchondral bone to obtain revascularization. RESULTS: There was an increase in the average Lysholm scores from 57 to 90 in group 1 after 27 months of mean follow-up (P < .05); 71% of patients could participate in strenuous sports with no or minimal limitation. The mean activity level in group 1 according to Cincinnati Knee Rating System was 6 preoperatively and 13.54 postoperatively. For group 2, the average scores showed significant improvement and patient satisfaction after surgery (preoperative and postoperative average Lysholm scores were 41 and 75, respectively, with mean follow-up of 37 months). Average activity level in group 2 increased from 2.67 to 11.73. Control magnetic resonance imaging scans of the cases revealed the continuity of normal cartilage with cartilage-like tissue in the treated areas. However, an increase of the size of ON in the subchondral bone was detected in 27% of the knees. CONCLUSIONS: The microfracture technique is safe, simple, and cost-effective, and may be an alternative procedure for treatment of ON of the knee, especially in young patients, before possible subsequent replacement surgery. LEVEL OF EVIDENCE: Level IV.

Association of conjunctival and corneal calcification with vascular calcification in dialysis patients.

BACKGROUND: Conjunctival and corneal calcification (CCC) is a well-known and easily detectable extraskeletal calcification, but its association with vascular calcification was not investigated previously. The aim of this study is to investigate the relationship of CCC with vascular calcification and bone metabolism parameters in dialysis patients. METHODS: We evaluated 63 patients (30 men, 33 women; mean age, 43.5 +/- 13.4 years) who were on dialysis therapy for more than 6 months. Forty-four patients were on peritoneal dialysis and 19 patients were on hemodialysis therapy. The same observer evaluated the presence of CCC by using a slit-lamp microscope, and a total CCC score was recorded for each patient. Fifty-two age- and sex-matched healthy controls also were evaluated by using the same method. Biochemical data were collected from patient files. Bone mineral density (BMD) of the lumbar spine and femoral neck was measured, and the presence of vascular calcification was assessed by using x-ray examinations of the pelvis and hands. RESULTS: Mean CCC score in patients was significantly higher than that in controls (6.2 +/- 5.1 versus 1.3 +/- 1.8; P = 0.001). CCC score correlated significantly with duration of renal replacement therapy ( r s = 0.392; P = 0.002), serum phosphorus level ( r s = 0.259; P = 0.042), and calcium x phosphorus product ( r s = 0.337; P = 0.007). However, we did not find a significant correlation with calcium, parathyroid hormone, alkaline phosphatase, albumin, or C-reactive protein level or BMD. The frequency of vascular calcification was significantly greater in patients with a high CCC score (CCC score > or = 10) compared with a low CCC score (< or =3; 56.3% versus 5.6%; P = 0.002). CONCLUSION: Evaluation of CCC score is an easy, fast, and noninvasive method. It seems that CCC score can be used as an additional tool to assess the status of extraskeletal calcification in dialysis patients.

Multifocal skeletal tuberculosis.

Multifocal skeletal tuberculosis is defined as osteoarticular lesions that occur simultaneously at two or more locations. We present radiologic findings in two cases of multifocal osteoarticular tuberculosis. Differential diagnoses of such lesions, based on different radiologic modalities, can include metastatic disease, eosinophilic granuloma, or lymphoma. Since tuberculosis can be present in multiple sites, especially in patients from areas where tuberculosis is endemic, it is essential to avoid a delay in diagnosis.

MRI appearances of inflammatory vertebral osteitis in early ankylosing spondylitis.

BACKGROUND: Undiagnosed and early ankylosing spondylitis (AS), especially in adolescent patients suffering from back pain, may present with the finding of vertebral osteitis on MRI. AIMS: To identify the early MRI changes of vertebral osteitis in AS. PATIENTS AND METHODS: Five patients (three boys, two girls) aged 11-20 years (mean 15.4 years) suffering from back pain underwent MRI of the thoracolumbar spine. There was no initial diagnosis of AS. After clinical and radiological suspicion of AS, MRI of the sacroiliac (SI) joints was performed. RESULTS: During the course of AS, destructive and reactive changes affect the discovertebral junctions that are initially seen in the thoracolumbar area. At this stage plain radiography of the spinal column may be normal. On MR images, inflammatory osteitis of the vertebrae is seen as hypointense areas on T1-weighted images and hyperintense areas on T2-W images. The lesions enhance homogenously with contrast material. CONCLUSIONS: Awareness of the MRI appearances of vertebral osteitis is helpful in suspecting AS. Radiological examination of the SI facilitates the diagnosis and unnecessary further imaging can be avoided.