x-ray case studies jim messerly d.o.. case #1 history 17 year-old female ballet dancer with...

X-Ray Case StudiesX-Ray Case Studies

Jim Messerly D.O.Jim Messerly D.O.

Case #1 HistoryCase #1 History

17 year-old female 17 year-old female ballet dancer with ballet dancer with snapping sensation snapping sensation along the medial along the medial aspect of her right aspect of her right knee when extending knee when extending her right knee during her right knee during jumps.jumps.

Case #1 Physical ExamCase #1 Physical Exam

Physical exam showed no Physical exam showed no evidence of effusion. evidence of effusion. There was full range of There was full range of motion of the right knee motion of the right knee with reproducible popping with reproducible popping of the posterior medial of the posterior medial hamstring with flexion and hamstring with flexion and extension which was extension which was minimally painful. No minimally painful. No joint line tenderness. joint line tenderness. McMurray’s testing was McMurray’s testing was negative.negative.

Case #1 X-RaysCase #1 X-Rays

Case #1 Diagnosis ?Case #1 Diagnosis ?

A. Stress fractureA. Stress fracture

B. Osteoid OsteomaB. Osteoid Osteoma

C. OsteochondromaC. Osteochondroma

D. OsteosarcomaD. Osteosarcoma

OsteochondromaOsteochondroma

Most common benign tumor of bone.Most common benign tumor of bone. Outgrowth of bone usually located in the Outgrowth of bone usually located in the

metaphysis projecting away from the joint.metaphysis projecting away from the joint. Malignant transformation rare except in Malignant transformation rare except in

Hereditary Multiple Exostosis (HME).Hereditary Multiple Exostosis (HME). Usually left alone unless interferes with Usually left alone unless interferes with

surrounding muscles, tendons or nerves or surrounding muscles, tendons or nerves or interferes with activity- then can be resected.interferes with activity- then can be resected.


16 year-old male football 16 year-old male football player who developed player who developed sudden onset of severe sudden onset of severe left shoulder pain while left shoulder pain while reaching with his left reaching with his left upper extremity during a upper extremity during a football drill. There was football drill. There was no contact. He no contact. He complained of pain in the complained of pain in the posterior aspect of his left posterior aspect of his left shoulder and proximal left shoulder and proximal left arm. He was evaluated by arm. He was evaluated by an athletic trainer and an athletic trainer and was placed in a sling.was placed in a sling.


The patient was in obvious The patient was in obvious discomfort due to his left discomfort due to his left shoulder pain. There was a shoulder pain. There was a questionable left shoulder questionable left shoulder effusion. Active flexion and effusion. Active flexion and abduction were limited to only abduction were limited to only 15° because of severe pain. 15° because of severe pain. There was severe pain with There was severe pain with any attempts of resisted any attempts of resisted internal or external rotation of internal or external rotation of the left shoulder.the left shoulder.

Case #2 X-raysCase #2 X-rays

Case #2 Diagnosis?Case #2 Diagnosis?

A.A. Aneurysmal Bone CystAneurysmal Bone Cyst

B.B. Metastatic lesionMetastatic lesion

C.C. Fibrous DysplasiaFibrous Dysplasia

D.D. Unicameral Bone CystUnicameral Bone Cyst

Unicameral Bone CystUnicameral Bone Cyst

Usually found in the proximal humerus, but Usually found in the proximal humerus, but also can be found in the proximal femur or also can be found in the proximal femur or calcaneus.calcaneus.

X-rays show well-defined lytic lesion with thin X-rays show well-defined lytic lesion with thin sclerotic margin with no periosteal reaction.sclerotic margin with no periosteal reaction.

Pathologic fracture may allow healing of cyst.Pathologic fracture may allow healing of cyst. Injection of steroid, bone marrow, Injection of steroid, bone marrow,

demineralized bone or surgical treatment may demineralized bone or surgical treatment may be needed.be needed.


16-year-old male with 6-9 16-year-old male with 6-9 month history of right elbow month history of right elbow pain and lack of full pain and lack of full extension. The patient is a extension. The patient is a snowmobile racer and snowmobile racer and wondered if he may have wondered if he may have injured the right elbow during injured the right elbow during one of his many wipe outs one of his many wipe outs during snowmobile races. during snowmobile races. Three days prior, he was Three days prior, he was lifting a heavy box and had a lifting a heavy box and had a forceful extension of his left forceful extension of his left elbow with associated elbow with associated increased pain and some increased pain and some swelling. swelling.


There was a moderate There was a moderate right elbow effusion. right elbow effusion. Range of motion was Range of motion was 40° to 105° with pain 40° to 105° with pain at end range motion. at end range motion. Moderate tenderness Moderate tenderness of the medial joint line. of the medial joint line. Ligaments were stable Ligaments were stable with some pain with with some pain with valgus stress.valgus stress.

Case #3 X-raysCase #3 X-rays

Case #3 MRICase #3 MRI


A.A. Osteoid OsteomaOsteoid Osteoma

B.B. Fibrous DysplasiaFibrous Dysplasia

C.C. Aneurysmal Bone CystAneurysmal Bone Cyst

D.D. ChondrosarcomaChondrosarcoma

Aneurysmal Bone CystAneurysmal Bone Cyst

Usually located in long bones or spine in Usually located in long bones or spine in patients less than age 20.patients less than age 20.

X-rays show eccentrically located metaphyseal X-rays show eccentrically located metaphyseal lytic lesion.lytic lesion.

Typical complaints are swelling and pain which Typical complaints are swelling and pain which usually follows an injury.usually follows an injury.

Biopsy is frequently required to rule out Biopsy is frequently required to rule out malignant lesion.malignant lesion.

Treatment is by curettage with bone grafting.Treatment is by curettage with bone grafting.

Case #4Case #4

20 year-old college 20 year-old college female with anterior right female with anterior right leg pain for the past five leg pain for the past five months. The patient had months. The patient had been using the Stair been using the Stair Master and jogging for up Master and jogging for up to an hour a day during to an hour a day during the summer. When her the summer. When her college classes started in college classes started in the fall, she continued to the fall, she continued to workout in spite of the workout in spite of the pain, but had been off pain, but had been off running for the past two running for the past two weeks without weeks without improvement of her pain.improvement of her pain.


There was mild firm There was mild firm swelling over the anterior swelling over the anterior aspect of the distal third aspect of the distal third of the right tibial shaft. of the right tibial shaft. Moderate tenderness to Moderate tenderness to palpation and palpation and percussion. Full range percussion. Full range of motion of the right of motion of the right knee and ankle. Arches knee and ankle. Arches of the feet were of the feet were minimally pronated.minimally pronated.

Case #4 CT ScanCase #4 CT Scan

Case #4 Diagnosis ?Case #4 Diagnosis ?


B.B. Fibrous Cortical DefectFibrous Cortical Defect

C.C. Healing Stress FractureHealing Stress Fracture

D.D. HemangiomaHemangioma

Osteoid OsteomaOsteoid Osteoma

Frequently causes deep aching pain Frequently causes deep aching pain which is worse at night.which is worse at night.

Pain is frequently relieved by Pain is frequently relieved by aspirin/NSAIDs.aspirin/NSAIDs.

X-ray/CT shows radiolucent nidus X-ray/CT shows radiolucent nidus surrounded by reactive sclerotic bone.surrounded by reactive sclerotic bone.

Treatment- Waiting, Radiofrequency Treatment- Waiting, Radiofrequency ablation or excision.ablation or excision.


13-year-old male with 13-year-old male with one-year history of one-year history of thoracic spine pain which thoracic spine pain which had been worsening over had been worsening over the past two months. the past two months. Severe night pain. The Severe night pain. The patient had been unable patient had been unable to participate in to participate in basketball because of his basketball because of his pain. Chiropractic care pain. Chiropractic care was not helpful for his was not helpful for his pain. Previous x-rays had pain. Previous x-rays had shown evidence of a shown evidence of a moderate thoracic spine moderate thoracic spine scoliosis.scoliosis.


Moderate right-sided Moderate right-sided thoracic spine scoliosis. thoracic spine scoliosis. Moderate tenderness on Moderate tenderness on palpation from T6 to palpation from T6 to T10. Minimal restriction T10. Minimal restriction with flexion and with flexion and extension of the thoracic extension of the thoracic spine. Lower extremity spine. Lower extremity neurological exam was neurological exam was unremarkable.unremarkable.

Case #5 CT SagittalCase #5 CT Sagittal

Case #5 CT Axial Case #5 CT Axial



B.B. OsteoblastomaOsteoblastoma

C.C. Giant Cell TumorGiant Cell Tumor

D.D. HemangiomaHemangioma

Osteoid OsteomaOsteoid Osteoma

Small round focus-nidusSmall round focus-nidus Radiofrequency ablation is difficult when Radiofrequency ablation is difficult when

in the spine and resection may be best in the spine and resection may be best approach.approach.


17-year-old male with 17-year-old male with complaint of right knee pain complaint of right knee pain which had been present for which had been present for the past 4-5 months. He the past 4-5 months. He noted some right knee pain noted some right knee pain after playing basketball during after playing basketball during the summer. He denied the summer. He denied catching, locking or giving catching, locking or giving way. There was no way. There was no significant swelling. He had significant swelling. He had been treating with physical been treating with physical therapy without significant therapy without significant improvement. He was improvement. He was currently participating on the currently participating on the curling team.curling team.


No evidence of right knee No evidence of right knee effusion. Mild soft tissue effusion. Mild soft tissue swelling in the region of swelling in the region of the proximal tibia both the proximal tibia both medially and laterally with medially and laterally with mild tenderness on mild tenderness on palpation. Mild palpation. Mild generalized knee pain generalized knee pain with forced extension. with forced extension. There was full flexion There was full flexion without pain. Ligaments without pain. Ligaments were stable. Mild lateral were stable. Mild lateral joint line tenderness. joint line tenderness. McMurray’s testing was McMurray’s testing was negative.negative.


A.A. Stress fractureStress fracture

B.B. OsteosarcomaOsteosarcoma

C.C. ChondrosarcomaChondrosarcoma

D.D. I’m not sure, but it sure looks badI’m not sure, but it sure looks bad

OsteosarcomaOsteosarcoma

Most common malignant bone tumor in the Most common malignant bone tumor in the pediatric population.pediatric population.

Most common location is in the tibia, femur Most common location is in the tibia, femur or humerus.or humerus.

Frequently causes bone pain.Frequently causes bone pain. X-rays frequently show combined lytic and X-rays frequently show combined lytic and

sclerotic changes.sclerotic changes. Treatment involves chemotherapy, Treatment involves chemotherapy,

possible radiation followed by surgery.possible radiation followed by surgery.


60 year-old female with 60 year-old female with complaint of right knee complaint of right knee pain which was worse pain which was worse over the past few weeks over the past few weeks when she tried to when she tried to increase her walking increase her walking activities. She described activities. She described anterior medial and lateral anterior medial and lateral right knee pain. Her pain right knee pain. Her pain was worse with prolonged was worse with prolonged standing, driving or when standing, driving or when walking stairs. There was walking stairs. There was no catching, locking or no catching, locking or giving way. No swelling.giving way. No swelling.


There was a trace There was a trace effusion of the right effusion of the right knee. There was full knee. There was full range of motion with range of motion with moderate patella moderate patella crepitus. Mild patellar crepitus. Mild patellar facet tenderness to facet tenderness to palpation. Ligaments palpation. Ligaments were stable. Mild were stable. Mild medial joint line medial joint line tenderness.tenderness.



B.B. OsteosarcomaOsteosarcoma

C.C. EnchondromaEnchondroma

D.D. Mild to moderate patellofemoral Mild to moderate patellofemoral osteoarthritis with patellofemoral painosteoarthritis with patellofemoral pain

EnchondromaEnchondroma

Benign cartilage lesion centrally located Benign cartilage lesion centrally located within bones that can occur at any age.within bones that can occur at any age.

Usually asymptomatic.Usually asymptomatic. Frequently found in the bones of the hand.Frequently found in the bones of the hand. X-ray follow-up recommended to X-ray follow-up recommended to

document stability because occasionally document stability because occasionally difficult to distinguish enchondroma from difficult to distinguish enchondroma from low-grade chondrosarcomalow-grade chondrosarcoma

ChondrosarcomaChondrosarcoma

Case #8 History and Case #8 History and ExamExam

History: 27 year-old female History: 27 year-old female with complaint of left knee with complaint of left knee pain and swelling for two pain and swelling for two months. No history of months. No history of injury. She describes injury. She describes lateral left knee pain with lateral left knee pain with associated near giving way associated near giving way episodes. She frequently episodes. She frequently limps because of her left limps because of her left knee pain. She denies knee pain. She denies fevers, chills or night fevers, chills or night sweats.sweats.

Exam: The patient does Exam: The patient does walk with a limp favoring walk with a limp favoring her left knee. There was her left knee. There was a trace effusion of the left a trace effusion of the left knee. Mild anterior lateral knee. Mild anterior lateral left knee pain with full left knee pain with full flexion. Ligaments were flexion. Ligaments were stable. Moderate lateral stable. Moderate lateral joint line tenderness joint line tenderness which was worse with which was worse with McMurray testing.McMurray testing.



B.B. Fibrous cortical defectFibrous cortical defect

C.C. Giant cell tumorGiant cell tumor

D.D. I don’t know, but it sure looks badI don’t know, but it sure looks bad

I don’t know, but is sure I don’t know, but is sure looks badlooks bad

Referred to university centerReferred to university center Biopsy shows leiomyosarcomaBiopsy shows leiomyosarcoma Treated with resection and knee Treated with resection and knee

replacement surgeryreplacement surgery

Thank youThank you

x-ray case studies jim messerly d.o.. case #1 history 17 year-old female ballet dancer with...

Documents

mri slide

chondrosarcoma slide

osteosarcoma slide

hemangioma slide

unicameral bone cyst

ct sagittal slide

ct scan slide

severe pain