14 Y?O with months history of knee buckling and swelling

Here is another case that I am hoping Dr. Gorbachova will comment on. 14 y/o M with "months history" of swelling, instability and buckling. No history of specific antecedent trauma.

Looks in the spectrum of osteochondritis dissecans vs osteochondrosis to me. What do you think? Simultaneous patella and medial tibial plateau? One of each? Neither?

Another great article btw: https://pubs.rsna.org/doi/pdf/10.1148/rg.2018180044

-- 

Phillip Tirman MD
Renaissance Imaging Center Westlake Village

Two Dole Drive

Westlake Village, CA 91362

Tel: 818-575-8066

35M runner with chronic hip pain MRI 2016 and Now

From Feb 2016. Reported as Transient Osteoporosis / Subchondral Fracture. Follow-up was recommended to "r/o progression to AVN". WHAT???? New MRI today shows normal marrow signal. White arrow, might hallucinate residua of old healed fracture, or not.  No AVN.  Same anterosuperior labral tear. What is the current concept of TOP? Is the "Party Line" that it is subchondral fracture?  Conference talk suggests that, but I can't see that stated in the literature.  Some literature points to "potential risk of developing AVN" but I cannot find a single case of progression of TOP to AVN...what's THAT about??? Who can tell us what the truth is?

49M 2weeks severe knee pain, acute onset, no trauma

Test Yourself: What is your diagnosis?

Resorptive Phase HADD superficial to the FCL origin.

46F chronic ankle pain

What is your differential diagnosis?

Serous Atrophy aka Gelatinous Transformation of bone marrow.
Pathology reference
Open access pediatric reference of MRI "flip-flop" effect in anorexia nervosa

31F professional dancer, collided with another dancer weeks ago. Persistent volar pain when making a fist.

Red arrow: retracted RCL tear. Yellow arrow: extensor mechanism injury

Red arrow: retracted RCL tear

You can see the thickened retracted torn RCL at the level of the SF MC head

The Radial Sagittal Band (blue arrow) is intact.  Just distal to that the Yellow arrows indicate a tear of the Oblique fibers of the Extensor Mechanism, which originate at the lateral tendon of the deep head of the Interosseous tendon and lumbrical tendon and contribute to PIP extension.

Bright signal localizes to oblique fiber tear of extensor mechanism.  Orthopedist suspected volar plate injury; the volar plate is intact. 

Baseline available SIJ MRI 11 years ago at age 28

SIJ MRI 2014, only T1w and T2FSE non fat sat images done

1 year ago I reported chronic bilateral sacroilitis with questionable minimal synovial edema

Now, detailed hx reveals 15 yrs LBP in a 39F.  Carries a dx of RA and has tolerated multiple DMARDs poorly, currently not on therapy.  Referred by orthopedist who tells me she was diagnosed with "spondyloarthropathy in 2015, found to be HLA-B27 positive. All prior Lumbar MRI is essential normal; 2018 exam included Sag STIR images. 

I don't see any real interval change since Nov 2018.  I am told that she has never had other peripheral joint symptoms. Is this actually RA?  Can this be AS (the patient self reports history of AS now) without ankylosis over a course of 5 years?  How would you report this?

What would your DDx be? Is this neoplastic, infectious or inflammatory? What would you biopsy?

Can leukemia / lymphoma infiltrate the tendon sheath like this? Would you consider sarcoid? Other?

Femoral lymphadenopathy

Subcutaneous, intermuscular and intramuscular edema

Adenopathy with subcutaneous and intramuscular edema

RE: doubled crossed patellar tendon

Hi,

 

Here is the summary of my inquiry about the crossed-doubled patellar tendon.

 

5x confident about prior tendon translocation surgery (Roux-Goldthwait procedure)

 

2x favouring an anatomical variant, citing the below reference from Loizides A et al., 2017

 

 

Coincidentally, today I have received new clinical information that my patient was treated surgically in the 90s for repeated patellar dislocation. Bingo, case solved!

 

In fact, I now have serious doubts about the existence of a doubled crossed patellar tendon anatomic variant and I would like to open for discussion based on the following:

 

 

While I think there is consensus about patellar tendon variants, like the one published here:

 

The uncrossed-doubled patellar tendon: A novel imaging finding

Syed Mohammed Ali Haydar, Jonathan Miles, Rikin Hargunani

Radiol Case Rep. 2019 Dec; 14(12): 1509–1512. Published online 2019 Oct 18. doi: 10.1016/j.radcr.2019.09.029

 

I do have serious concerns that the crossed-doubled patellar tendon, as it is performed by the Roux-Goldthwait procedure, actually exists as a variant because there is only 1 (one!) publication on this finding and it is referenced over and over again. The patient in this case report actually had 2x knee surgery for 'hemangioma', when the patient was 15 y/o! I find that suspicious and I have serious concerns about some missing information.     

 

A case of crossed-doubled patellar tendon: an atavistic variant, simple mutation or pathologic finding?

Alexander Loizides, Carmelo Messina, Bernhard Glodny, Leonhard Gruber, Erich Brenner, Hannes Gruber, Benjamin Henninger

Surg Radiol Anat. 2017; 39(1): 111–114. Published online 2016 Jun 15. doi: 10.1007/s00276-016-1706-x

 

 

So with all of that said, I am really wondering, if we in this wonderful community of MSK experts, could find a consensus if a crossed-doubled patellar tendon actually exists as a variant or not? I am not aware of this variant being described in any anatomical textbook and I have not seen any cases published or posted cases in children which I find very suspicious. Please correct me if I am wrong.

 I am neither bored, nor looking for trouble but if we agree this specific anatomic variant does not exist, I question if this case report can or should stand any longer because it confuses people who search for this and always come up with the same paper!

 

BTW, this topic had been brought up previously on OCAD on Feb. 27^th 2019 by Avneesh and others, also posting at least two other cases of doubled patellar tendon without known prior surgery. At least one case also had patellar malalignment! The colleagues are cc'd.

 

Modified Roux-Goldthwait Procedure for Management of Patellar Dislocation in Skeletally Immature Patients with Down Syndrome

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394190/

 

 

 

Enjoy RSNA!

 

 

Björn

 

 

 

From: ocad-msk@googlegroups.com <ocad-msk@googlegroups.com> On Behalf Of Björn Jobke
Sent: 25 November 2019 15:52
To: OCAD <ocad-msk@googlegroups.com>
Subject: doubled crossed patellar tendon

 

---EXTERNAL EMAIL. Please exercise caution when opening attachments or clicking on links---

Hello OCAD,

 

My mystery case of the year.

 

52 y/o pat.

 

Relevant Clinical History: Recurrent patellar dislocation, since giving way whilst standing. Had injection for her pain few years back. Her pain has come back and bothering her too much. Diffuse tenderness present

No other history available.

No X-ray.

 

http://www.claripacs.com/a.php?a=125&mode=simple

 

 

What's going on? Variant or unknown prior surgical procedure?

 

Björn

 

 

 

--
Visit OCAD at xrayhead.com/ocad
---
You received this message because you are subscribed to the Google Groups "OCAD MSK" group.
To unsubscribe from this group and stop receiving emails from it, send an email to ocad-msk+unsubscribe@googlegroups.com.
To view this discussion on the web visit https://groups.google.com/d/msgid/ocad-msk/AM5P190MB0356C469C1B76409B6CD33A3A04A0%40AM5P190MB0356.EURP190.PROD.OUTLOOK.COM.

Happy Thanksgiving!

I hope you appreciate the absurdity of the clinical request.  This is an endstage retracted plantar plate tear with button hole protrusion of the MT head through the defect and dorsal dislocation of the 2nd toe.  

The blue arrow indicates the retracted, torn plantar plate.  Notice the lateral dislocation of the Flexor tendons at the level of the MT/neck; typically the tendons are centered in a midline plantar groove in the plantar plate and stabilized by a flexor pulley.  White arrow indicates flexor tenosynovitis, due to pathologic communication between the MTPJ and the tendon sheath as a result of the plantar plate tear.

Here's my question, what is the Red Arrow pointing to?

That's the terminal plantar fascia. In the forefoot, deep distal fibers insert onto the plantar plate, but superficial fibers insert onto the dermis.  That's interesting, isn't it?

No history of trauma, acute onset of pain, reported as subhcondral fracture. 

Reported as normal

Reported as normal

There is new subtle smooth articular flattening visible in the Dunn view only

Is there real mixed lucency and sclerosis, or is this shine through of the acetabulum? Do you think there might be evolving AVN, or just subtle articular collapse related to prior fracture without AVN?  Would you recommend follow up MRI? Would you recommend DEXA?

Hypermobile discoid Lateral Meniscus in 9yo M with 2 mos posterior knee pain

There is posterocentral subluxation of the complete discoid LM with bright intrasubstance signal and expansion of the posterior horn region, but no visible surface defect.  Wrisberg (which doesn't look thick) inserts onto the PH region.          

   I cannot see popliteomeniscal fascicles, which I presume are developmentally absent.