Glomangiomatosis: a case report.

Glomangiomatosis is a benign vascular variant of a glomus tumor. The lesion represents only 5% of glomus tumors with unusual or atypical features and even fewer glomus tumors with typical features. The lesions are most commonly located in the distal extremities and are multiple, deep, extensive, and often pain producing. They develop from small arteriovenous anastamoses and are most often identified in young adults. The lesions may recur. We present a case of a 33-year-old male who presented clinically with multiple slowly enlarging masses of the leg over a 5-year period, of which one caused significant pain. One of the lesions was reported to be present at birth. Imaging studies were performed and were suggestive of neurofibromatosis. Biopsies from multiple lesions led to an eventual diagnosis of multiple glomangiomatosis.

Displaceability of SLAP lesion on shoulder MR arthrography with external rotation position.

OBJECTIVE: To investigate the usefulness of the external rotation (ER) position on magnetic resonance (MR) arthrography for the diagnosis of superior labral anterior to posterior (SLAP) lesion. MATERIALS AND METHODS: Approval of institutional review board was obtained, and informed consent was waived. The MR arthrograms of 210 shoulders that were arthroscopically confirmed as SLAP lesion in 163 shoulders and intact superior labrum in 47 shoulders were retrospectively reviewed in each neutral and ER position for the diagnosis of SLAP lesion, the extent of distraction of the torn labrum, and the external rotation angle. The sensitivity, specificity, and diagnostic accuracy of MR arthrograms for determining SLAP lesion were assessed in each position. For the arthroscopically confirmed group, the diagnosis of SLAP lesion and the extent of distraction about the tear were compared between neutral and ER positions by Fisher's exact test and the paired t-test. The correlation between the external rotation angle and the diagnosis of SLAP lesion, and between the external rotation angle and the differences in the extent of distraction were evaluated in the ER position using the ANOVA test. RESULTS: Sensitivity and diagnostic accuracy of MR arthrography for SLAP lesion increased from 64.4% and 71.0% in the neutral position to 78.5% and 81.9% in the ER position, respectively, without change of specificity, which was 93.6% in both positions. The diagnosis of SLAP lesion was changed from negative to SLAP lesion in 16.0% of the arthroscopically confirmed group. Mean difference in the extent of distraction about the tear was 0.69 mm (range -1.40 ∼ 6.67 mm), which was statistically significant. There was no relationship between the external rotation angle and the diagnosis of SLAP lesion, and between the external rotation angle and the differences in the extent of distraction. CONCLUSION: Shoulder MR arthrography with additional ER positioning helps in the diagnosis of SLAP lesion and provides information about the displaceability of the torn labrum.

Primary alveolar soft part sarcoma of fibula demonstrating ASPL-TFE3 fusion: a case report and review of the literature.

Alveolar soft part sarcoma is a rare soft tissue tumor typically affecting young adults. These tumors are most often seen in the deep soft tissues of the extremities and patients generally present with advanced disease. Primary bone involvement is extremely rare and has only been reported in seven cases. This is the first case of alveolar soft part sarcoma in bone documenting the ASPL-TFE3 gene product. Herein, we report a rare presentation of alveolar soft part sarcoma presenting as a primary bone neoplasm involving the proximal fibula in a 41-year-old woman.

The accuracy of subacromial corticosteroid injections: a comparison of multiple methods.

Corticosteroids are commonly used in the treatment of the impingement syndrome. Efficacy, as well as accurate placement, have been questioned. The purpose of this prospective, randomized study is to assess the accuracy of subacromial injections and to correlate accuracy with short term clinical outcome at 3 months. Sixty shoulders, which were diagnosed with impingement syndrome, were randomized to receive a subacromial injection of corticosteroids, local anesthetic, and contrast dye from 1 of 3 locations: anterolateral, lateral, or posterior. Accuracy was confirmed by 3 radiographic views of the shoulder, while clinical ratings were assessed by the UCLA shoulder score and a 10-point visual pain analog scale during the initial, post-injection, and 3-month visits. The overall accuracy was 70%, with no difference among the 3 portals. Accuracy was not related to body mass index. Furthermore, accurate injections did not significantly improve the UCLA score, pain scale, or patient satisfaction at 3 months. In contrast, accurate injections produced a positive Neer's impingement test more often (35/39 vs 9/16; P = .009). Overall, there was an improvement in the UCLA score (26.2-32.2; P < .001) and a decrease in the pain scale (7.2-3.43; P < .001) at 3-month follow-up. In conclusion, the accuracy of injection was 70%. Clinical improvement did not correlate with accuracy; however, accuracy did reliably produce a positive impingement test. This multimodal treatment plan did produce significant improvement in shoulder function and pain level in the short term.

Traumatic sternal segment dislocation in a 19-month-old.

Sternal fractures in the pediatric population are uncommon. Traumatic sternal segment dislocation is even more unusual. Such injuries are typically considered to be the result of child abuse, until proven otherwise. A review of the few case reports documenting pediatric sternal segment dislocation, and the current report, demonstrate that this injury may, in fact, be more benign than previously considered. It is easily recognized with appropriate imaging, and treatment may only require observation, unless symptoms are severe enough to warrant surgical intervention.

Efficacy and safety of hyaluronan treatment in combination therapy with home exercise for knee osteoarthritis pain.

OBJECTIVE: To assess the efficacy and safety of intra-articular injections of sodium hyaluronate combined with a home exercise program (HEP) in the management of pain associated with osteoarthritis (OA) of the knee. DESIGN: Single-blinded, parallel-design, 1-year clinical study with sequential enrollment. SETTING: University-based outpatient physiatric practice. PARTICIPANTS: Sixty patients (18 men, 42 women; age, > or =50 y) with moderate-to-severe pain associated with OA of the knee. INTERVENTIONS: (1) Five weekly intra-articular hyaluronate injections (5-HYL); (2) 3 weekly intra-articular hyaluronate injections (3-HYL); or (3) a combination of an HEP with 3 weekly intra-articular hyaluronate injections (3-HYL+HEP). MAIN OUTCOME MEASURES: The primary outcome measure was a 100-mm visual analog scale for pain after a 50-foot walk (15.24 m). Secondary measures included the Western Ontario and McMaster Universities Osteoarthritis Index subscales. RESULTS: The 3-HYL+HEP group had significantly faster onset of pain relief compared with the 3-HYL (P<.01) and 5-HYL groups (P=.01). All groups showed a mean symptomatic improvement from baseline (reduction in baseline pain at 3 mo was 59%, 49%, and 48% for the 3-HYL+HEP, 3-HYL, and 5-HYL groups, respectively) that was clinically and statistically significant. There were no between-group differences in the incidence or nature of adverse events. CONCLUSIONS: The combined use of hyaluronate injections with HEP should be considered for management of moderate-to-severe pain in patients with knee OA.

Reliability analysis for radiographic measurement of limb length discrepancy: full-length standing anteroposterior radiograph versus scanogram.

Patients with limb length discrepancy (LLD) often have associated angular deformities requiring a standing full-length radiograph of the lower limb in addition to a scanogram. The purpose of our study was to determine the intraobserver and interobserver reliability of measuring LLD with both techniques, using computed radiography. The LLD was measured on 70 supine scanograms and standing anteroposterior radiographs of the lower extremity by 5 blinded observers on 2 separate occasions. Intraclass correlation coefficient (ICC) and mean absolute difference (in millimeters) was calculated to assess intraobserver and interobserver reliability and found to be excellent for both radiographic techniques. Intraobserver ICC and mean absolute difference was 0.975 to 0.995 and 1.5 to 2.6 mm for scanogram and 0.939 to 0.996 and 1.5 to 4.6 mm for the standing radiograph, respectively. Repeated measurements for both radiographic studies were within 5 mm of the first measurement greater than 90% and within 10 mm greater than 95% of times. Interobserver ICC and mean absolute difference was 0.979 and 2.6 mm for scanogram and 0.968 and 3.0 mm for the standing radiograph. The reliability was excellent irrespective of age, sex, and underlying diagnosis other than Blount disease, which had good reliability. A standing anteroposterior radiograph of the lower extremity should be the imaging modality of choice when evaluating patients with limb length inequality who may have angular deformities because it allows a comprehensive evaluation of the extremity and is as reliable as a scanogram for measuring LLD. This approach may decrease the radiation exposure and financial burden involved in assessing patients with unequal limb lengths.

Muscle infarction in a 13 year-old female with type 1 diabetes mellitus of short duration.

A 13 year-old female with an 11-month history of type 1 diabetes mellitus (DM) was admitted to the hospital with a muscle infarction. Diagnosis of this rare complication of DM was suggested by clinical presentation, magnetic resonance imaging (MRI) and muscle biopsy. While diabetic muscle infarction (DMI) has been previously described in adult patients with long-standing DM associated with microangiopathy, it is an unexpected finding in this clinical setting.

Superficial soft-tissue masses of the extremities.

Superficial soft-tissue masses are among the most common indications for imaging of the extremities. A broad array of benign and malignant processes may be manifested in palpable cutaneous or subcutaneous masses or nodules. Most such lesions are treated with surgical excision, but some may be conservatively managed. The lesions can be differentiated according to their location in one or more skin layers (epidermis, dermis, and subcutis), their histologic composition, and the associated anatomic abnormality or disease process. Because the imaging characteristics of many benign soft-tissue lesions overlap with those of malignant ones, knowledge of the patient's clinical history (including any laboratory test results) and direct visual examination of the lesion often are important for differentiation. Histologic analysis may be necessary to achieve a definitive diagnosis.

A translocation involving the placental growth factor gene is identified in an epithelioid hemangioendothelioma.

Hemangioendothelioma is a relatively rare vascular tumor that is considered a low- to intermediate-grade malignant neoplasm. Cytogenetic reports of hemangioendothelioma are rare. Two reports with translocations involving chromosomes 1 and 3 have been described. Here we report a case of an epithelioid hemangioendothelioma arising in the foot of a 56-year-old female, with a 46,XX,-6,t(10;14)(p13;q24),+r. The regions in 10p13 and 14q24 encompass genes that participate in growth regulation. One of the genes at 14q24 encodes for placental growth factor [PlGF, also called vascular endothelial growth factor (VEGF)-related protein]. Placental growth factor is a member of the VEGF growth factor family. Placenta growth factor binds only to VEGF receptor-1 (FLT-1). It has been suggested that PlGF may modulate VEGF-induced angiogenesis by the formation of PlGF/VEGF heterodimers in cells producing both factors. It has been postulated that PlGF is involved in intra- and intermolecular cross-talk between VEGF receptor-1 (FLT) and receptor-2 (FLK-1/KDR). Since expression of VEGF and its receptor, FLK-1, is seen in several cases of epithelioid hemangioendothelioma and plasma VEGF level is also used to follow-up this tumor, we performed immunohistochemical analysis for PlGF and VEGF in our case. The strong positivity for both PlGF and VEGF observed in our case implies that the t(10;14)(p13;q24) most likely involves PlGF, which may be one of the genes driving oncogenesis in these tumors.

Cortical chondroblastoma: report of a case and literature review of this lesion reported in unusual locations.

Chondroblastoma is a rare benign tumor occurring in adolescence and young adulthood, almost always involving the epiphysis of long bones. A 24-year-old man presented with a discrete soft-tissue lesion penetrating the cortex of the right distal femoral metadiaphyseal region. Biopsy revealed a chondroblastoma, and the patient subsequently underwent a total curettage of the lesion with cancellous bone graft from the iliac crest.

Granular cell tumor of the extremity: magnetic resonance imaging characteristics with pathologic correlation.

OBJECTIVE: The purpose of this study is to delineate the magnetic resonance (MR) appearance of a granular cell tumor (GrCT) of the extremity and to correlate the imaging appearance with the microscopic findings. DESIGN AND PATIENTS: A retrospective review of five patients with a histopathologic diagnosis of GrCT and pre-operative MR imaging of the neoplasm was done. The images were reviewed by two musculoskeletal radiologists in a consensus fashion. Lesion location, size, shape, margination, and signal intensity characteristics were assessed. MR findings were correlated with histopathological examination. RESULTS: The benign subtype of GrCT is usually isointense or brighter than muscle on T1-weighted sequences, round or oval in shape, superficial in location, and 4 cm or less in size. On T2-weighted sequences, benign lesions may demonstrate a high peripheral signal, as well as a central signal intensity that is isointense to muscle or suppressed fat. A significant stromal component in the tumor and, hypothetically, a ribbon-like arrangement of tumor cells may influence the signal intensity demonstrated on the T1 and T2-weighted sequences. The malignant subtype may demonstrate signal intensity characteristics and invasion of adjacent structures often seen with other aggressive neoplasms; sizes larger than 4 cm and association with major nerve trunks can be seen. CONCLUSION: Benign GrCT has imaging characteristics which may distinguish this tumor from other soft tissue neoplasms, as well as the malignant type of this tumor.

Complications after limb salvage surgery.

Orthopedic oncology patients gain a chance at an active, disease-free life through the use of limb salvage surgery. This goal is reached with meticulous technique, detailed operative planning, and the use of endoprosthetic replacements and/or bone grafting. This article will address the late complications of limb salvage surgery, including aseptic loosening, prosthetic fracture and dislocation, as well as graft fracture and nonunion.

Traumatic venous varix causing sciatic neuropathy: case report.

OBJECTIVE AND IMPORTANCE: Sciatic neuropathy rarely presents in nonpenetrating trauma because of protection of the nerve by the pelvis, the gluteal muscles, and the tissues in the posterior thigh. We present the case of a patient who fell and subsequently developed a traumatic venous varix of the inferior gluteal vein that caused compression sciatic neuropathy. CLINICAL PRESENTATION: Seven days after a fall onto her right buttock, the patient developed a painful burning paresthesia in her leg and numbness on the dorsum of her foot. Numerous studies ruled out lumbar spine pathological abnormalities as the cause of the pain. Conventional magnetic resonance imaging revealed a lesion adjacent to the sciatic nerve. Gradient echo and two-dimensional time-of-flight magnetic resonance imaging sequences confirmed this to be a vascular lesion originating from the inferior gluteal vein and compressing the sciatic nerve. INTERVENTION: Operative resection obliterated the venous varix, thereby relieving the patient's pain and neurological deficit. CONCLUSION: No case of a traumatic venous varix of the inferior gluteal vein compressing the sciatic nerve has been reported to date. Surgical resection was successful in obliterating the lesion and relieving the symptoms.

Cervical Vertebral Trauma: Plain Film Approach.

The plain film assessment of cervical vertebral trauma remains a cornerstone of emergency radiology. An understanding of proper film technique, as well as a familiarity with the significant signs of cervical column injury will enable the radiologist to interpret the radiograph accurately. If further imaging studies are warranted, accurate interpretation of the plain films will insure that the proper study is obtained.