Mini Pathria

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1986-1987

• Mini Pathria
• Michael Zlatkin
• Richard (Rick) G Stiles

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Mini Pathria

• Middle-aged male
• Hx of recent knee trauma

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Case 1

• Middle-aged male
• Hx of recent knee trauma

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Radiographs
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Sagittal
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Coronal
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Axial
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Thigh
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Differential diagnosis

• Neurofibromatosis
• Melorheostosis with soft tissue component

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Neurofibromatosis

• Further history obtained
• Skin nodules
• Neurofibromas on cranial CT 7 years previously
  (not acoustic neuroma)

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Case 2

• Middle-aged female with thigh mass

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Radiographs
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Coronal
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MR
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Follow-up

• Mass biopsied, benign plexiform neurofibroma
• Patient developed hip pain

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Hip MR
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Neurofibromatosis

• Plexiform neurofibroma at biopsy
• No evidence of malignancy

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Case 3

• 40 year old male with slowly growing painless mass

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Plexiform neurofibroma
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Plexiform neurofibroma

• Specific finding for NF1 (peripheral form)
• 5 of patients with NF1
• Approximately 5-10 degenerate to neurosarcoma

courtesy of Mark Murphey, AFIP
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Neurofibroma

• Localized
• Diffuse
• Plexiform
• Well-defined
• Bag of worms
• Infiltrating

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Elephantiasis neurofibromatosa

• Diffuse form of plexiform neurofibroma
• Overgrowth of epidermal and subcutaneous tissue
• Wrinkled and pendulous appearance

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Michael B. Zlatkin and Alfredo Arraut NMSI

• 27 year old male involved in a motor vehicle
  accident

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27 year old male involved in a motor vehicle
accident
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27 year old male involved in a motor vehicle
accident
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Findings

• Subscapularis tendon is avulsed with bone from
  the lesser tuberosity
• Humeral avulsion of the anterior band of the
  glenohumeral ligament (HAGL)
• Middle glenohumeral ligament and possibly the
  superior glenohumral ligament may be avulsed as
  well
• Possible reverse Hill-Sachs lesion

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Subscap Rupture and HAGL (BHAGL)

• Rupture of the subscapularis tendon uncommon but
  can be seen in younger patients injured by forced
  external rotation or extension of a partially
  abducted arm
• Tears occur near insertion on the lesser tub. May
  occur at sup margin, where tendon may be weakened
  by degeneration
• Avulsion fracture of the lesser tuberosity may
  occur, and is displaced medially and inferiorly
• Subscapularis avulsions are also associated with
  injury to the anterior capsule and glenohumeral
  ligaments (HAGL)
• When the AIGHL avulses a fragment of bone from
  the humerus, the lesion is known as a bony HAGL,
  or BHAGL
• ? With MGHL and SGHL torn Super BHAGL

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Michael B. Zlatkin and Alfredo Arraut NMSI

• 17 year old male with bony growth on the dorsum
  of hand

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17 year old male with bony growth on the dorsum
of hand
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17 year old male with bony growth on the dorsum
of hand
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Findings

• Bone prominence on the dorsum of the hand between
  the trapezoid, capitate, and bases of the 2nd and
  3rd metacarpals
• Associated with base of 3rd metacarpal, but no
  marrow continuity with it
• Sclerosis and cystic change at junction with 3rd
  metacarpal base

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Carpal Boss

• Bone protuberance on dorsum of the hand
• Degenerative osteophyte or os styloideum
• Located between trapezoid, capitate, and base of
  2nd and 3rd metacarpals
• Most often fused to a metacarpal base, but rarely
  (2) can be completely isolated
• Symptoms caused by degeneration, formation of
  ganglion or bursa, or snapping of an extensor
  tendon moving over it

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Carpal Boss

• Can be demonstrated on lateral radiograph with
  hand flexed and supinated 30-40 degrees best
  seen with mild ulnar deviation
• Alternatively can image with CT or MR
• MR can demonstrate marrow edema in the carpal
  boss and surrounding soft tissue changes

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Carpal Boss Companion Case
Carpal boss fused to base of third metacarpal
with edema in overlying soft tissues
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Carpal Boss - Companion Case
Carpal boss fused to third metacarpal with
fracture at its base
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Carpal Boss Companion Case
Surface rendering of carpal boss with fracture at
its base
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Michael B. Zlatkin and Alfredo Arraut NMSI

• 33 year old professional hockey player with pain
  in the flank after practice

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33 year old professional hockey player with pain
in the flank after practice
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33 year old professional hockey player with pain
in the flank after practice
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Findings

• Partial thickness tear of the internal oblique
  muscle belly proximally, with surrounding edema
  and hematoma
• Fluid tracking between internal and external
  obliques
• Feathery pattern of edema at the more distal
  aspect of the internal oblique

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Side Strain

• Uncommon sporting injury presenting with pain and
  tenderness over anterolateral and posterolateral
  lower ribcage
• Associated with cricket, golf, and ice hockey
  eccentric contraction of trunk muscles
• Partial or complete tear of lateral abdominal
  wall musculature (internal oblique gt external
  oblique gt transversus abdominis)
• May also see avulsion at the muscular origins
  from the lower ribs
• Recovery takes 6-10 weeks. Full recovery is the
  norm

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Michael B. Zlatkin and Alfredo Arraut NMSI

• 19 year old injured while pitching, now has
  valgus instability of elbow on exam

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19 year old injured while pitching, now has
valgus instability of elbow on exam
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Findings

• Thickened ulnar collateral ligament (UCL) with
  increased intrasubstance signal distally and at
  its midportion, indicating partial thickness tear
• No complete disruption
• Edema in the adjacent flexor/pronator musculature
• Reactive marrow edema in the sublime tubercle

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UCL Partial Tear

• Most often injured in overhand throwing athletes,
  especially baseball pitchers
• Pitching causes valgus stress on the elbow that
  can injure the UCL
• MR arthrogram reportedly higher sensitivity than
  conventional MR for partial thickness tears
• MR findings thickening/irregularity/laxity of
  the ligament, edema in adjacent soft tissues
• T sign pathognomonic sign of contrast extending
  into a partial thickness tear, giving a sideways
  T shaped appearance
• Tears tend to occur more distally in younger
  pitchers, more proximally in older pitchers

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Michael B. Zlatkin and Alfredo Arraut NMSI

• 16 year old pitcher with elbow pain

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16 year old pitcher with elbow pain
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Findings

• Delayed union of the olecranon apophysis
• Persistent widening of physis with surrounding
  edema consistent with stress injury/stress
  fracture

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Olecranon Stress Fracture/Apophysitis

• May occur in young throwing athletes and gymnasts
  due to repetitive microtrauma
• Present with pain localized to the tip of the
  olecranon
• Imaging shows a widened physis or open physis
  after expected age of closure, and stress related
  edema
• Normal fusion occurs at age 12-15, comparison to
  contralateral side may help

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Michael B. Zlatkin and Alfredo Arraut NMSI

• 24 year old male with shoulder pain and suspected
  rotator cuff tear after fall on outstretched hand

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24 year old male with shoulder pain and suspected
rotator cuff tear after fall on outstretched hand
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Findings

• Avulsion fracture of the greater tuberosity, with
  a small fracture fragment retracted medially with
  a torn supraspinatus tendon
• Associated marrow edema

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Greater Tuberosity Avulsion Fracture

• RCT uncommon in younger patients
• Usually occurs after trauma, may be concomitant
  fx
• Great tub fxs may be difficult to distinguish
  from RCT clinically. May be radiographically
  occult if non-displ
• MR useful in differentiating contusion/nondisplace
  d fracture from RCT
• Concomitant rotator cuff tears not common in
  nondisplaced fractures, but more common in more
  severe injuries with avulsions/displaced
  fractures