0:02

Hello and welcome to Case Crunch Rapid case review

0:04

for the core exam hosted by modality.

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In this rapid fire format,

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faculty will show key images along

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with a multiple choice question,

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and you'll respond with your best answer via

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the live polling feature.

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After a quick answer explanation, it's onto the next case.

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You'll be able to access a recording of today's case review

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and previous case reviews

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by creating a free account using the

0:25

link provided in the chat.

0:27

Today. We are honored to welcome Dr.

0:29

Na Raji for an MSK Imaging Board Prep case review. Dr.

0:34

Raji is an MSK radiologist

0:35

and passionate educator at University Hospitals

0:37

and Cleveland, Ohio.

0:39

He's the Director of medical education in the Department

0:41

of Radiology and Associate Program Director

0:44

of Diagnostic Radiology Residency as well.

0:47

He's an assistant professor in the division of MSK radiology

0:50

and is heavenly involved in educating medical students

0:52

in radiologic anatomy.

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Questions will be covered at the end of time, allows,

0:57

please remember to use that q

0:59

and a feature to submit your questions.

1:01

With that, we are ready to begin today's board review. Dr.

1:03

Faraji, please take it from here.

1:06

Okay? Yes. Thanks for joining.

1:08

I see a lot of familiar names in the audience,

1:12

which means I cannot repurpose this for my residents,

1:15

unfortunately, but, uh, maybe in a future year.

1:18

Um, let's get started.

1:20

Yeah, we're gonna, so we got 24 cases

1:23

and, um, you know, multiple choice in the style of the

1:27

A BR core examination, at least in my view.

1:30

I don't write any board questions or anything like that, so,

1:33

but if I did, I would test on some of these concepts.

1:37

So let's see what we got.

1:38

We've got, I've got no relevant disclosures here.

1:43

Um, and we are gonna start with this question

1:48

to see some demographic information.

1:51

So if you could share, are you a resident studying

1:56

for the core, an attending physician just here for the cases

2:00

or other

2:09

Resident studying for the core?

2:10

80%. Got it. Correct.

2:12

Um, 10% are here for the cases and, okay. Six and four.

2:17

All right, lovely. Well, um, we're gonna, yeah,

2:20

we're gonna learn together and, uh, it's gonna be great.

2:24

So let's just do a quick review of some of the content.

2:28

Uh, I re this was from 2021,

2:31

but I did do a revisit of this information, um,

2:35

using the good old Google

2:36

and I did, you know, a BR core exam, uh, breakdown for MSK

2:41

and here is what I found.

2:43

Again, it doesn't look like it has changed much.

2:45

So about 20 to 25% is gonna be trauma.

2:48

Then we're gonna have infection

2:49

and neoplasm as the next two categories.

2:52

Metabolic marrow, post-op,

2:55

congenital arthritis and patches disease.

2:59

So we're gonna, I did distribute, uh,

3:02

before we start, I did distribute these questions, uh,

3:06

relative to these percentages.

3:08

Um, here's a hint.

3:10

There will be no cases

3:11

of pageant disease, so sorry for that.

3:16

Okay. Question one.

3:17

Um, 27-year-old male presents with anterior shoulder pain

3:21

and instability following a traumatic anterior shoulder

3:24

dislocation during a football game.

3:26

What is the most likely diagnosis,

3:44

If you guys have any I image issues

3:46

or you'd like me to zoom in on anything?

3:48

You don't see anything? Well,

3:49

'cause I realize I didn't make 'em full large pictures.

3:53

Um, let me know. Okay, so good.

3:56

This was a relatively challenging question it seems.

4:00

Um, and most folks thought either a haggle

4:03

or a retracted rotator cuff tear, um, with hill sax lesion

4:08

a third place.

4:10

And I very specifically changed some of the wording

4:13

or added, uh, modified the wording for this question.

4:16

So let's look at this. There is some signal in the cuff.

4:20

I, I will give that to you.

4:21

Now, technically for a rotator cuff tear, the rules

4:25

that I learned say that there needs

4:28

to be fluid signal intensity.

4:29

However, the morphology somewhat irregular,

4:31

so you could argue that there is a tear potentially.

4:34

However, the word retracted, I think, um, kind of makes

4:38

that the less ideal answer

4:40

because if there is a tear here, it is not retracted.

4:43

Because I see tendon and tendon,

4:45

I don't see any tendon retracted to the glenohumeral joint.

4:47

So that is would not have been the choice that I selected.

4:52

Um, let's go to the answer. The answer is haggle.

4:55

Um, so humeral avulsion of the inferior g glenohumeral liga,

4:58

and we can see a positive arrow sign here.

5:00

So the IGHL inferior g glenohumeral ligament forms this

5:05

U-shaped pouch of the inferior joint capsule.

5:09

And if we're gonna talk about the anatomy,

5:11

let's talk about it a little bit more in depth.

5:13

There are anterior and posterior bands

5:15

of the inferior glenohumeral ligaments.

5:16

The glenohumeral ligaments are not really in fact ligaments,

5:19

but rather thickenings of the joint capsule.

5:23

And the IGHL is very important for the, uh, static

5:28

stability of the glenohumeral joint.

5:31

And so, um, yeah, we can see

5:33

that rather than having a U-shaped pouch here,

5:36

we have a relatively J shaped pouch or yeah, JS shaped.

5:40

We're gonna go with J and there is fluid signal intensity

5:44

disrupting the humeral attachment of this,

5:48

uh, JS shaped structure.

5:49

And fluid is extending along the medial humeral shaft.

5:53

And so that is what a humeral avulsion

5:56

of the inferior glenohumeral ligament would look like.

5:59

You can also have a gaggle

6:00

or a glenoid avulsion of the inferior glenohumeral ligament,

6:03

which would appear similar,

6:05

but the um,

6:06

the fluid signal intensity would be actually going along

6:10

the glenoid.

6:11

You know what? I decided that I'm gonna move this over here.

6:14

It wasn't working how I was hope hoping, bear

6:18

with me, bear with me people.

6:20

I'm still here. Everything's fine. Okay.

6:23

Um, we would expect fluid signal intensity go along the

6:25

glenoid if it was a gaggle.

6:27

You could also have other alphabet soups like a b hagel

6:31

or a bagel, which is a bony humeral avulsion

6:33

of the inferior glenohumeral ligament,

6:35

where you might see a little chunk of bone attached to that.

6:38

Um, bang.

6:40

Heart lesion we know is a,

6:41

is a basically anterior labral tear.

6:44

I don't see any discreet labral tears on this

6:46

exam on this image.

6:48

Hill sac lesion would be a posterior humeral

6:50

head impaction injury.

6:52

And yeah, that's all the answer choices.

6:54

So that one I would call a haggle.

6:57

And if you have any questions as we go through, feel free

6:59

to drop 'em in the box

7:00

and I can try to clarify the best of my ability.

7:04

Let's move on.

7:09

Okay. Case two, 45-year-old male with a history

7:12

of longstanding hypertension

7:13

and hyperlipidemia presents with sudden right ankle pain

7:17

after minimal activity, denies direct trauma

7:19

but reports prior episodes

7:21

of mild posterior ankle discomfort.

7:23

MRI reveals this image.

7:25

Which of the following pathophysiological mechanisms

7:27

best explains this injury?

7:36

Boom. Okay, 88% got it right.

7:39

Hopefully they throw you some softballs like this too.

7:42

Um, on the actual exam.

7:44

So the correct response is degenerative collagen changes

7:49

and relative hypo vascularity.

7:51

So I think the two choices probably that most folks are

7:54

between, if they are between any choices are C and D.

7:59

And we know that, um,

8:01

the Achilles tendon tears at the critical zone,

8:04

which is approximately six centimeters proximal

8:07

to its calcaneal insertion as we see this kind

8:09

of undulating fiber here.

8:11

Um, and that area has relative hypovascular and, and

8:16

therefore it's more prone to degeneration and and tear

8:19

because of that, you know, lack of regenerative capacity

8:23

and hypovascular in that region.

8:26

Traumatic avulsions in the calcan insertions

8:28

are much less common.

8:30

Um, much, much less common such

8:31

that it's may constitute like 1% of the ones I've ever seen.

8:36

Uh, chronic inflammatory arthritis causing synovial erosion.

8:40

Nope, that's not it.

8:42

Uh, and acute bacterial infection weakening the tendon,

8:45

it wouldn't be the infection weakening the tendon,

8:47

but there are some antibiotics that we know such

8:49

as fluoroquinolones

8:51

or corticosteroids which can exacerbate collagen dysplasia.

8:56

So, um, if this had said antibiotic, you know, effect

9:01

or there was some history here

9:03

that suggested they might have been on antibiotics,

9:05

that would've been a reasonable response,

9:06

but not in this particular instance.

9:08

Um, let's see. Make sure there's any additional information.

9:14

Okay. No, I think that's pretty much it.

9:17

So yeah, that's the main thing

9:18

to know about the achilles tendon.

9:20

Um, just while we're here some anatomy,

9:23

this is the CAGR fat pad.

9:24

It can be a question that's asked this hypo intense, uh,

9:28

on this fat suppressed image,

9:30

fat pad triangular fat pad deep to the achilles tendon.

9:34

Um, okay, we'll go to the next question.

9:39

A 14-year-old soccer player presents

9:41

with acute right groin pain

9:43

after forcefully kicking a ball during a match.

9:45

Physical exam reveals pain with resisted extension,

9:48

which are the following as the most likely diagnosis.

9:58

Okay, lovely. Um, majority got it right.

10:01

61% rectus femes tendon avulsion at the A IIS.

10:06

Um, 11% said sartorius at the

10:09

as IS hamstring at the ischial tuberosity

10:12

or ilio sous tendon at the A IIS.

10:15

And I purposely put two with a IIS to see if people know,

10:19

um, 'cause you maybe you can identify the A IIS,

10:22

but do you know what originates there?

10:24

So I mean this is a relatively basic anatomy question.

10:27

However, they can test on basic anatomy

10:30

and I think it's important to know the anatomy.

10:33

Um, you know, we'd like to learn these really, for lack

10:37

of a better term off the top of my head,

10:39

sexy disease processes.

10:41

But you know, it's really important to know the basics.

10:44

Um, and we can see here at the anterior inferior iliac spine

10:48

there is an avulsion fracture of the, uh,

10:52

rectus femoral tendon origin.

10:53

So let's just really briefly review the

10:55

origins and insertions.

10:57

So rectus femoris from the A IIS sartorius is a little bit

11:01

higher at the A SIS.

11:03

We know the iio sous tendon inserts onto lesser trs.

11:08

We know that hamstring tendons originate from the

11:11

ischial tuberosities.

11:12

We know that the adductor tendons originate from the

11:14

pubic synthesis region.

11:16

We know the gluteus minimus

11:18

and medias tendons insert onto the greater choke

11:20

caners bilaterally.

11:22

Um, the, some of the rectus abdominus muscles and or insert

11:26

or origin insert onto the iliac crest bilaterally as well.

11:30

So you're gonna wanna know those things.

11:32

Um, another question they could ask just for a two, for one,

11:36

uh, is uh, let's say they can show an UL

11:41

fracture of the lesser trocanter in a skeletally mature

11:44

patient, an adult with fused apophysis.

11:48

That would be a pathologic fracture until proven otherwise

11:51

because we know that adults one in general don't UL bone,

11:55

uh, they tear tendons.

11:56

And so, but a classic question is lesser tr avulsions in

12:00

adults should prompt some sort of inquiry

12:02

for underlying neoplasm.

12:04

So what if, I don't know if it's a bone scan or MRI

12:06

or whatever choice they give you.

12:08

Um, you're gonna wanna look for some sort

12:11

of osseous neoplasm

12:12

and a pathologic fracture if you see a lesser

12:15

trocanter avulsion in an adult.

12:17

Actually, similarly, they could say on the last question

12:19

of if you had a calcaneal avulsion

12:22

of the achilles tendon in an adult,

12:23

that might be another thing that prompts further inquiry.

12:28

Okay,

12:33

case four, A 3-year-old female presents

12:36

to the emergency department after twisting her ankle

12:38

while stepping off a curb.

12:40

She reports immediate pain and difficulty bearing weight.

12:42

The lateral radiograph of the foot is

12:44

provided based on the radiographic findings.

12:46

Which of the following is the most likely diagnosis?

12:56

Um, okay, fracture of the anterior process

12:59

of the calcaneus 75%.

13:02

Um, got it right. And so let's show that finding here.

13:07

So there's some commonly missed ankle fractures

13:09

and this is also an anatomy type thing.

13:12

So we can see here that there's a linear lucency

13:14

through the anterior process of the calcaneus right there.

13:18

And that can be commonly missed if we're talking anatomy.

13:21

Let's go through the other things. So here's a Taylor neck.

13:25

The lisfranc injury,

13:26

if we were looking at a lateral foot radiograph

13:28

or a lisfranc injury, we want to look

13:30

for tarsal metatarsal mal alignment.

13:32

And sometimes you'll see that the metatarsals are a little

13:34

bit more elevated relative to the tarsal bones

13:36

or vice versa.

13:38

Any tarsal metatarsal mal alignment on the lateral view gets

13:41

my hackles up for a um, li Frank injury.

13:45

Cuboid fracture looks okay to me.

13:48

And then the lateral process of the TAUs is this triangular.

13:51

It's not really in plain as nicely as we'd like,

13:53

but this lateral triangular structure is the lateral process

13:57

of the talus, which is another commonly missed ankle

14:00

fracture and one that we're gonna wanna look for.

14:02

Make sure we don't miss that. So that is what that is.

14:06

Also, just know that an if you are presented

14:08

with ankle radiographs, the base

14:10

of the fifth metatarsal should be included

14:12

on an ankle series.

14:13

So that's something you're gonna want to clear

14:15

when you look at that.

14:23

Okay. Case five

14:27

65-year-old male emergency department.

14:29

After fall, he's holding his right arm abducted

14:32

and reports severe pain and limited range of motion.

14:35

And AP RAF of the shoulder is obtained.

14:38

Which of the following is the most likely diagnosis?

14:48

Okay, great. The humeral head is located inferior

14:50

to the glenoid fossa is the correct answer.

14:54

Um, so this is an inferior glenohumeral dislocation,

14:58

inferior glenohumeral dislocation, also known as l lux.

15:03

Erecta is a very rare type of glenohumeral dislocation.

15:06

We know the anterior is the most common.

15:08

Posterior is probably the next most common in

15:11

inferior is the least common.

15:13

Uh, but it on it basically looks like the patient is raising

15:15

their hand and that's basically an abducted position

15:19

and it's kind of locked in that position.

15:22

Um, we don't really have,

15:24

and it's a very characteristic appearance

15:26

on an AP radiograph.

15:27

You don't really have a scapular y

15:29

or an axillary view to see if it's an anterior

15:32

or posterior gland humeral dislocation,

15:33

which may have been a good clue

15:34

that it's not one of those things.

15:36

Um, and bank heart lesion, we don't really have a good, um,

15:41

here's some of the other options.

15:42

Humeral has located at, uh, anterior,

15:44

we don't know posterior haggle.

15:46

You can't really tell if that's the case

15:48

because it's not a MRI and a B haggle.

15:51

You could technically look for some bony avulsion,

15:54

but we don't see anything like that.

15:55

So really it should be between these top three choices.

15:58

And given the AP view and the elevation

16:02

or abduction of the humerus, um, um, uh,

16:06

inferior humeral dislocation.

16:07

I've only seen one of these in clinical

16:09

practice and this is it.

16:11

So not very common.

16:18

Okay,

16:24

A 12-year-old boy presents with five day history of fever,

16:27

right lower leg pain and difficulty walking.

16:30

Physical examination reveals warmth, swelling, tenderness.

16:32

Proximal tip lab tests show elevated WBCs and CRP

16:37

and MRI of the right lower extremities performed,

16:39

which is the most specific

16:41

for acute osteomyelitis in this patient.

16:51

Great. Um, concordant low T one

16:54

and high T two signal in the bone

16:56

marrow is the correct answer.

17:01

Okay, so we know

17:04

that if we're talking about the most sensitive finding

17:06

for osteomyelitis, it's probably just T two hyperintensity

17:10

of the bone marrow, which is marrow edema.

17:12

But we know that marrow edema is

17:14

just swelling in the bone marrow.

17:16

That can happen for a number of reasons.

17:17

I can stub my toe, I can drop something on my toe,

17:22

I can fracture.

17:23

You know, many reasons why.

17:26

Um, bone marrow can be emer.

17:29

However, T one signal loss is more,

17:32

especially in a geographic distribution,

17:34

is much more specific for osteomyelitis,

17:37

particularly when it is associated with high T two signal.

17:41

You can have periostial reaction on T one weighted images

17:45

and the setting of osteomyelitis,

17:46

but you can have periostial reaction for stress injuries.

17:48

There's a lot of reasons one can have peri sitis

17:51

and osteomyelitis is not necessarily, uh,

17:54

the reason Soft tissue edema, again, nonspecific,

17:56

you can have cellulitis without osteomyelitis,

17:59

which is pretty common.

18:01

And so that would not be the most specific.

18:03

A joint effusion on fluid sensitive images.

18:06

Um, I mean that can indicate septic arthritis.

18:10

Um, but how, you know, you, one,

18:13

you can have septic arthritis without osteomyelitis

18:16

and two, um, just

18:18

because you have a joint effusion, you can have a joint

18:19

effusion as a reactive process from osteoarthritis

18:21

or you can have it due to inflammatory arthritis.

18:23

It's not specific. And then cortical thickening, again,

18:27

non-specific, that could be related to uh,

18:30

stress reaction osteomyelitis, any, you know, number

18:34

of things really here we can see

18:37

that within the marrow there is this relatively T two

18:39

hyperintense kind of multi likely related collection.

18:42

Uh, this could represent a brody's abscess

18:45

that's which could be seen in the setting

18:47

of chronic osteomyelitis.

18:48

So really you don't even need this image

18:49

to answer this question.

18:51

And I would encourage on the test actually, you know,

18:54

read the question stem,

18:56

see if you can answer the

18:57

question without looking at the image.

18:58

Not always is the image gonna be relevant, um,

19:00

but sometimes it will be relevant and all.

19:03

Also, also one thing I've noticed when I take, when I,

19:06

you know, just recalling my experience is that not,

19:11

I think most of the time you're gonna be able

19:12

to narrow it down to two questions

19:14

or two answer choices I should say.

19:17

And between those two it will be somewhat of a challenge

19:22

to figure out which one is the correct one.

19:24

And most of the time you'll have some piece of information

19:28

or something on the image that you can use

19:30

to delineate between those two.

19:33

They're both gonna seem appropriate an answer choices

19:35

and there's just something either in the image

19:38

or in the clinical history that makes one

19:40

of those answer choices better than the other.

19:43

And so if you're between two

19:44

and you can't figure out which one would be the best one,

19:46

just make sure you take a second look at the images

19:48

or the question stem to see if there's anything

19:51

that leans one way or the other.

19:53

Because a lot of the time I think what they're trying

19:56

to do is test our clinical reasoning, um,

19:59

and why we might choose two similar answer choices

20:01

between two similar answer choices,

20:03

why we would choose one or the other.

20:04

So see if there's anything in

20:05

those stems that might help you.

20:08

Um, I'll make sure,

20:09

just make sure there was no additional pieces

20:11

of information I wanted to share

20:12

with you guys here in my notes.

20:16

Uh, yep.

20:21

We know the MRI is most sensitive

20:22

and specific imaging modality for early diagnosis of osteo.

20:26

We can de detect bone marrow edema within three to five days

20:29

after disease onset, making it superior

20:32

to plain radiography, which may not show, uh, changes

20:36

until we have about 50% of the bone mineral density lost.

20:39

So, and that can be up to seven to 14 days even.

20:43

So, uh, all right, question seven,

20:48

A 55-year-old man with a history

20:49

of poorly controlled diabetes presents

20:53

with chronic osteo of the humerus.

20:54

MRI reveals a sequestrum indicating chronic osteomyelitis.

20:57

What is a sequestering?

21:07

Okay, piece of necrotic bone. That is correct. 78%.

21:11

Got it right. So yeah, so we have a number of findings.

21:14

Let's go to the, Ooh, look at that. That was pretty cool.

21:18

Um, alright, a piece of necrotic bone.

21:20

So let's talk about it.

21:21

Uh, kudos to radio pedia for this lovely image.

21:25

Um, but there are a number of findings for chronic osteo.

21:27

One is a sequester, which is a piece

21:29

of necrotic bone in the middle of this area of infection.

21:33

Lucrum is this dense sclerotic bone

21:35

that surrounds the sequestrum.

21:38

You can have a cloaca, which is an area of cortical defect

21:43

that allows the pus

21:45

or brody's abscess to decompress through the out of the bone

21:49

and into the soft tissues.

21:51

Um, and then a sinus tract can happen where that fluid

21:55

or pus decompresses through the skin surface.

21:58

Okay, so those are the main findings in chronic osteo, uh,

22:02

sequester and lucrum, OAK, uh, and sinus tracts.

22:06

Um, sequester is highly specific for chronic osteo

22:10

and can help differentiate from acute osteo

22:12

or other bone pathologies.

22:14

And CT not uncommonly is the best modality to kind

22:18

of visualize these findings.

22:21

Um, because you see, you know, dead pieces

22:23

of bone a lot better on CT than you would on an MRI

22:26

obviously 'cause of the contrast resolution of CT for uh,

22:31

with regard to bone and mineralization

22:33

and adjacent soft tissues.

22:38

Okay, so now we're gonna get into some que two part

22:43

questions that you'll encounter when you take the

22:45

core examination.

22:47

Um, sometimes they're fun when you get to the second part

22:50

of the question and you realize

22:51

that you got the first part correct.

22:52

Sometimes they're less fun when you get to the second part

22:54

of the question and you realize

22:56

that you unfortunately got the first part

22:58

incorrect but you can't go back.

23:00

So you know, this is just a good

23:02

to prepare for those emotions.

23:04

So let's start 14-year-old girl, right?

23:06

Clavicular pain and swelling has been gradually

23:09

worsening over the past three months.

23:11

A radiograph of the right knee is a, this is not a knee.

23:14

So let's just say the right clavicle was

23:17

obtained, followed by an MRI.

23:18

Which of the following is the most likely diagnosis?

23:31

A, B, C. Okay, that is potentially a correct answer,

23:35

but that is the most common, that's the 80% of folks at a,

23:38

B, C, 8% cholangio Chad.

23:41

Okay, here's part two.

23:43

Biopsy confirms diagnosis of an A, B, C.

23:47

Which of the following treatment options is most

23:48

appropriate for this patient?

23:57

Okay, intralesional cartage

23:59

with high speed buring and bone graft.

24:01

Alright, so let's talk about this. So yes, this is an A, BC.

24:05

We can see in the distal

24:07

or mid to distal clavicle there is a relatively expansile

24:11

radiolucent lesion.

24:13

I don't see any matrix or osteo, you know, osteo matrix.

24:17

We can see that this patient is skeletally immature.

24:20

It looks like a relatively narrow zone of transition.

24:25

Um, so it has some relatively non-aggressive

24:28

characteristics, narrow zone of transition.

24:31

Um, yeah, I mean there may be a little bit

24:34

of a pathologic fracture,

24:35

but you can get that sometimes in these ABCs

24:38

on MRI we see multiple fluid, fluid levels

24:41

and we know that that can indicate an A, B,

24:44

C when the plane film also suggests an A, B, C.

24:48

However, just given an MRIA tele angio te osteosarcoma would

24:52

remain in the differential.

24:54

And um, so let's talk about this a little bit.

24:58

So ABCs, you know, typically in the first two decades

25:01

of life they're usually expanse out.

25:02

They're usually multiloculated

25:04

and have this soap bubble appearance on MRI and radiographs.

25:08

We know that MRI fluid fluid levels, uh,

25:10

are not path mnemonic but a hallmark feature

25:13

and for the purposes of your test likely, um,

25:16

gonna be present in those.

25:18

And we know that the other test the questions,

25:21

giant cell tumor is usually in skeletally mature patients

25:24

and they're usually epi aile lesions.

25:26

Chondroblast are usually also epi aile lesions.

25:31

Uh, they would be in skeletally immature patients.

25:34

Um, but they're usually really inflammatory

25:36

and can cause a lot of bone marrow edema.

25:38

And simple or unicameral bone cyst would not have the fluid

25:41

fluid levels, but you can see like a fallen fragment sign

25:44

where a little piece of bone may be

25:45

broke off in the middle of it.

25:47

Um, but it's usually just cystic in appearance without

25:50

these fluid fluid levels.

25:53

The second, um, question is that intralesional securage

25:58

with high-speed burring and bone grafting.

25:59

So usually yeah, they'll curate these out,

26:01

throw some bone grafting in there, you can't, uh,

26:05

radiation therapy obviously has adverse effects

26:07

and for a non-aggressive process

26:09

or at least, uh, not not malignant process,

26:12

you don't really need to be doing things like that,

26:15

particularly in pediatric patients.

26:17

Observation with serial imaging is not recommended

26:20

because these things can get larger

26:23

and they can have pathologic fracture, uh,

26:27

systemic denosumab therapy, it has been shown

26:31

and they do use it for some bone lesions,

26:33

however, it's a systemic therapy

26:35

and can cause hypercalcemia.

26:38

Um, and so we wouldn't recommend

26:40

that in this, in this situation.

26:43

And then amputation is obviously super extreme,

26:45

particularly for a benign process.

26:47

So, um, that is correct.

26:49

Intralesional, curtilage, high speed burring

26:51

and bone grafting.

26:56

Alright, case 10 3-year-old woman,

27:01

slowly growing, painless mass,

27:03

six centimeter soft tissue mass as seen here on Mr.

27:07

Biopsy confirms desmoid fibromatosis,

27:10

which are the followings, the most appropriate initial

27:12

approach for this patient,

27:21

right?

27:22

I did it. I was, I didn't want you guys

27:25

to get everything right, so I wanted

27:27

to make it somewhat challenging.

27:29

So, um, active surveillance is the correct answer.

27:33

40% got it right, 31% wide surgical resection

27:37

and doin based chemotherapy as a third place at 13%.

27:42

So let's talk about it.

27:44

Here's the answer, active surveillance.

27:48

Okay, so desmoid fibromatosis, what is it?

27:51

It is a benign tumor,

27:55

however, it is locally aggressive and it tends to reoccur

28:00

after resection

28:02

and it tends to extend along like the surgical plane

28:07

and the other like fascial planes.

28:09

Okay? So in general, surgical resection is avoided,

28:14

um, unless absolutely necessary.

28:18

Um, but in vast majority of cases, the first

28:21

and initial treatment, um,

28:23

or management approach is active surveillance

28:26

because some of these will burn out on their own.

28:29

Okay? They, some of them they don't just

28:30

always continue to enlarge.

28:32

A certain percentage of 'em actually get smaller

28:35

or don't enlarge.

28:36

Oh, okay. Yeah. Here is the tumor. So good question.

28:39

Thank you. In the posterior aspect of the thigh,

28:42

there's this relatively pretty pronounced hypo intense

28:46

T two mass.

28:48

They can be heterogeneous on T two, um,

28:51

but they're usually T one hypo intense due

28:53

to the fibrous nature of the mass.

28:57

Um, so there's a lot of, you know, which is the,

29:00

so people are bringing up good points.

29:02

What about intra arterial doer was

29:05

limiting systemic distribution in this case?

29:08

I guess the main thing for me is which

29:10

of the following is the most appropriate initial

29:12

management approach for this patient?

29:14

Okay, so initially for the vast majority of these,

29:17

you're just gonna do active surveillance

29:18

to see how it behaves.

29:20

Okay, is it gonna enlarge and extend along more places?

29:23

Is it gonna not enlarge? Is it gonna get smaller?

29:26

You know, these things have unpredictable behavior

29:29

and some of them will just burn out on their own

29:32

and may not need additional therapy.

29:35

All of these other options are reasonable

29:40

treatment alternatives,

29:41

but they're not the best initial management approach.

29:44

You can do drebin based chemotherapy, you can do imatinib,

29:48

um, it's a second line treatment for failure

29:52

after observation,

29:53

radiation is considered for salvage therapy.

29:55

You can even do RFA or other types of ablations.

29:59

Wide surgical resection is no longer considered first line

30:02

due to high recurrence rates between 24 and 77%

30:06

and potential morbidity, um,

30:08

and radiation is considered a salvage

30:10

therapy when other options fail.

30:11

So there are, these are not unreasonable

30:14

eventual treatment options,

30:16

but they are not the best initial

30:18

management approach for this patient.

30:21

Um, uh, there is no predilection

30:25

for a site of this tumor.

30:26

It can be in the subcutaneous soft tissues,

30:28

it can be intraperitoneal.

30:31

Um, and there's a lot of other questions we'll get to,

30:34

hopefully at some point I can come back

30:36

and try to answer those,

30:38

but the main thing is you wanna watch these, um,

30:41

and you don't really want to do anything about them

30:44

unless you really have to.

30:46

I've been to a few sarcoma tumor boards in my day

30:49

and the surgeons generally, you know,

30:52

don't wanna really ize these.

30:54

And when a surgeon doesn't wanna ize something

30:57

that's usually, you know,

30:59

means it's probably not a very fun surgery to do.

31:02

So just something to think about.

31:05

Um, okay, great case.

31:09

1120 8-year-old woman presents

31:12

with a slowly growing painless mass in the posterior aspect

31:14

of her distal femur plane radiography that knee is obtained.

31:17

Which of the following radiographic findings

31:19

as the most likely diagnosis

31:28

or osteo osteosarcoma?

31:30

69% correct. Okay, lovely.

31:32

Myositis, ossificans

31:34

and osteo kma are the next, um,

31:38

best options are most frequently given options.

31:40

So here's this mass

31:42

and I think one thing you can see here is this relative

31:46

radiolucency undermining this mass, um, that kind

31:50

of radiolucent string sign we call it.

31:52

And that is a pretty characteristic appearance of a

31:58

osteosarcoma par, uh, par osteo osteosarcoma.

32:02

We can see that there's hyper dense

32:03

or mineralization within that

32:05

that would suggest osteoid matrix.

32:08

Um, so osteo kdr, you know,

32:12

we're not definitely seeing cortical medullary continuity.

32:14

So if you see an osteo kdr, we should see

32:17

that the cortex here stops and then goes around this mass

32:21

and the cortex here stops and goes out there.

32:24

There's, there's cortex disrupting the mass from the

32:28

underlying femur.

32:29

And so there's no

32:31

demonstrated cortico medullary con continuity there.

32:34

Conventional osteo does not usually have this pedunculated

32:37

appearance at the posterior aspect of the distal femur.

32:40

Relatively characteristic location

32:42

and appearance of a, um, of a par osteosarcoma, uh,

32:47

Lange osteosarcoma, uh, we will talk about that,

32:51

but it's more of an imaging, uh, MRI type diagnosis in myo.

32:54

It's OCI hands. It's not a bad option that tends

32:58

to have peripheral mineralization

33:01

and um, kind of central lucency in some

33:04

of this mineralization here.

33:06

And it doesn't really look like bone to me.

33:09

It looks like just hyper density and matrix,

33:11

but I don't see the architecture of a bone, uh, per se

33:15

as far as cortico and, you know, trabeculation

33:19

and given its intimate location in the string sign

33:22

with the underlying femur, uh,

33:24

I think the best option here is par osteo osteosarcoma.

33:32

Okay. Which of the following statements best describes the

33:34

prognosis of par osteos osteosarcoma compared

33:37

to other osteosarcoma subtypes

33:46

generally is a better prognosis than

33:48

conventional osteosarcoma.

33:49

That is correct. Okay,

33:51

so par osteos osteosarcoma has a relatively good

33:56

prognosis compared to the other subtypes of osteosarcoma.

34:00

Um, let me see here.

34:03

Yeah, so, uh, you know, similar prognosis,

34:07

conventional high-grade osteosarcoma, which is not true,

34:09

better prognosis than conventional osteosarcoma,

34:12

which is true significantly worse

34:14

prognosis than chondroblast.

34:15

Osteosarcoma not really even, you know,

34:19

con it's not worse.

34:21

Chondroblast osteosarcoma is worse.

34:23

And I don't even think you're expected to know

34:25

what chondroblast osteosarcoma is,

34:28

is a poorer prognosis than periosteal.

34:30

It actually has a better prognosis than periosteal.

34:32

Conventional is the worst.

34:33

Periosteal is next, um, best prognosis.

34:36

And then par is the best prognosis out of all of those.

34:40

And it's not equivalent to Lange osteosarcoma

34:43

because, um, that has a,

34:46

it doesn't have a significantly different prognosis than

34:49

conventional osteosarcoma.

34:51

So most of the good prognosis is

34:53

that these lesions are usually surface lesions

34:57

and you can resect the tumor.

34:58

There's not a lot of marrow infiltration generally speaking.

35:03

So you can fl resect the pedunculated soft tissue mass

35:06

and you know, maybe do some radiation or whatnot,

35:09

but you don't really ever need to do, or not ever,

35:12

but most con most of the time there's surface lesions

35:15

and not intra, you know,

35:18

intraosseous marrow replacing lesions.

35:22

Um, so let's see if there's any additional.

35:24

So the five year disease free survival

35:26

for pareo osteo is 90%,

35:28

which is significantly higher than conventional osteos.

35:32

Um, you know,

35:34

obviously if there's in d differentiation within the thing

35:38

that can impact the prognosis,

35:40

but if we're talking broadly speaking categories,

35:43

then par osteo or coma is generally gonna have a better

35:46

prognosis than conventional.

35:48

Um, okay.

35:57

And the string sign is the classic sign for that.

36:00

Alright, I think we're getting

36:01

to some hopefully harder ones.

36:03

I'm gonna go a little bit faster. Uh, we got 11 more.

36:06

So 37-year-old female following ct, most likely diagnosis.

36:19

All right, 63% answered correctly.

36:21

Tumoral, calcinosis, myositis, sifan 29%.

36:26

Okay, this is one of those questions that I alluded

36:30

to earlier where I tried

36:31

to give you two reasonable answer choices.

36:34

I mean some of these are actually relatively reasonable,

36:36

but I think probably mo given that there's mineralization

36:40

and the soft tissues could be a reasonable option.

36:42

Tina synovial giant cell tumor usually isn't heavily

36:45

mineralized like that, so it's probably not the best option.

36:48

Telan osteosarcoma, there is a mass that is mineralized.

36:53

I guess that's not a terrible, um, choice either.

36:56

However, I think one of the keys here is these

37:00

terrible looking kidneys, right?

37:02

So my, um, tumoral calcinosis

37:05

or metastatic calcification is a disease process

37:09

that tends to happen.

37:11

Uh, it's a rare condition

37:13

by calcium character of the calcium deposition.

37:16

The peri articular soft tissues around the shoulders, hips

37:19

and elbow can be seen on CT and mr

37:22

and it's usually lobulated

37:24

and you can see fluid calcium levels distinguish it from

37:27

other soft tissue calcifications.

37:28

So you might see, um, kind of like milk

37:31

of calcium type appearance in the breasts

37:33

where you see layering mineralization.

37:36

And let's see, do I have, okay, yeah,

37:40

well damnit, what do you expect to see on MRCT?

37:44

Bet you can't get this one right.

37:52

Look at you guys. All right, fluid calcium levels.

37:55

Um, so here's that.

37:58

Okay, so similar patient,

38:00

we can see layering fluid calcium levels

38:02

and you can see how this, you may mistake this

38:04

for like a fluid, fluid level and an A BC

38:07

or tele angio osteo sar.

38:09

But in this case the main thing is the kidneys, right?

38:12

These patients, you know, these sort of disease entities,

38:15

um, in my clinical experience most commonly happen in

38:18

patients who have end stage renal disease

38:20

or so some sort of renal dysfunction

38:21

that does not allow them to metabolize the calcium salts as,

38:25

as well as they would like to.

38:27

Um, so it, it um,

38:31

it basically it presents in the soft tissues

38:34

and it can, in this case it's relatively inflammatory,

38:37

but you know, I've seen cases, you know, around the jaw

38:41

as well, but most commonly hips, shoulders

38:44

and kind of these grape like multi lobulated,

38:48

densely calcified soft tissue, perticular soft tissue masses

38:52

with these fluid, fluid levels.

38:54

And look at those kidneys,

38:55

see if there's any additional information that will lead you

38:58

to the most correct answer.

38:59

And in this case it was the appearance

39:01

of the patient's kidneys on the coronal CT

39:04

and the soft tissue windows.

39:14

Okay, what is the best diagnosis

39:16

of the patient's imaging findings?

39:26

Okay, great. I did it again.

39:29

Um, what is the best thing ask You don't ever want me being

39:31

a test question writer

39:33

because apparently I get very excited when

39:35

I make a difficult question,

39:37

but I think it's a fair, fair question.

39:39

I think brown tumor, 52% giant cell tumor

39:42

of bone, 41%.

39:45

Okay, so the best diagnosis

39:48

for this patient's imaging findings.

39:51

Um, I mean I think it would be fair

39:52

to have both giant cell tumor of bone

39:54

and brown tumor in the diff.

39:56

However, this patient has dialysis catheter,

39:59

they've got like some vascular stent here.

40:02

They're like a vascular path that has vascular path,

40:05

that has end stage green disease.

40:07

I mean I guess this is not a slam dunk that

40:09

that's why this is here,

40:11

but you know, it's not uncommon for that to be the case.

40:14

And we can see this large lytic lesion, um,

40:17

in the greater tubercle region,

40:21

which is a brown tumor in this case,

40:24

giant cell tumor of bone.

40:25

We know again, skeletally mature,

40:27

these patients are usually in their

40:29

like thirties or forties.

40:31

You know, I guess anything can happen to anybody.

40:34

Um, but this patient looks a little

40:35

bit older than that to me.

40:36

It's hard to say but you know, obviously the fey are close

40:40

so you know, it's, it's a reasonable answer choice.

40:43

A geode I would expect it's basically a

40:45

large subconscious cyst.

40:46

I would expect that to be closer

40:48

to the articular surface rather than in the

40:50

greater tuberosity.

40:52

O osteonecrosis usually has a more serpiginous curve linear

40:55

appearance rather than a well

40:57

circumscribed rounded appearance.

40:59

And a prior hill sex impaction injury should not have,

41:02

again, this well circumscribed, uh,

41:04

rounded radiolucent appearance.

41:06

So that, and for those reasons I feel that brown tumor, um,

41:10

is the best answer choice in this patient.

41:13

Um, which are osteoclastic tumors they call them.

41:19

Okay, 28-year-old female long distance runner MRI

41:23

of the knee for chronic knee pain.

41:25

The radiologist notes an unexpected pattern

41:28

of bone marrow signal in the distal femur.

41:29

Which of the following pains is most consistent

41:31

with physiologic marrow reconversion in this patient?

41:41

Okay, 49% symmetric areas of low T one signal

41:44

and e femoral metastasis sparing the epiphyses.

41:48

That is the correct answer. C. So let's talk about it.

41:52

So marrow reconversion occurs when there's increased

41:54

hematopoietic demand.

41:56

So we know adults, right?

41:58

Skeletally, mature people that are normal

42:00

have yellow marrow generally, which is fatty marrow,

42:03

which is gonna be hyperintense on a T one weighted

42:06

sequence, not uncommonly.

42:08

We see adult patients

42:09

who have a more heterogeneous appearance

42:11

of their bone marrow on T one weighted sequences

42:13

where there's some patchy islands of

42:15

what we call red marrow, um, due

42:18

to marrow reconversion most commonly clinically seen in in

42:21

like female patients who of menstrual age, um,

42:25

that may increase their knee hemoglobin demand

42:28

or replacement of the hemoglobin.

42:30

And so they can have some patchy red marrow,

42:32

however it should always spare the epiphyses in

42:34

adults like the epiphyses.

42:36

If those are involved, that's usually a bad sign

42:38

because those things are the last to reconvert.

42:41

Okay, so mar conversion occurs,

42:43

increase hematopoietic demand, high endurance athletes

42:46

that it can be seen in, uh,

42:47

it falls predictable pattern occurring in the reverse order

42:50

of normal maral conversion from central to peripheral

42:55

and from axial to appendicular skeleton, meaning

42:58

that it happens in the spine and pelvis

43:00

before it happens into the appendicular skeleton

43:03

and the long bones reconversion typically affects the

43:05

metaphysis first while sparing the epiphyses.

43:09

Um, symmetric is more common than asymmetric

43:12

and sparing the epiphyses obviously is important.

43:15

Um, yeah and usually these patterns respect the growth plate

43:21

and shows characteristic symmetry.

43:24

They may show it to you on,

43:25

so on T one it's relatively easy to figure out.

43:28

I think where it can look funny to a lot

43:30

of learners is on the T two fat suppress sequence

43:33

because it looks like there's these islands

43:36

of like T two hyperintense stuff,

43:38

but really what's happening is that those areas

43:40

of hematopoietic marrow are just not suppressing

43:43

as homogeneously as a normal fat.

43:46

So the normal marrow in those patients,

43:48

the normal yellow marrow is the dark stuff on the T two Fs

43:52

and the slightly brighter stuff is the reconverted marrow

43:56

because it doesn't have as much fat.

43:57

So it does not suppress as homogeneously as uh, normal,

44:02

you know, yellow marrow.

44:03

But this is important concept to learn, um,

44:06

and know for the test and just real life.

44:11

Okay, what is the most likely reason

44:13

for this patient's problem?

44:21

Mechanical loosening,

44:22

50% septic loosening 23% deltoid overuse 18%

44:27

and 9% Terry minor, uh, overuse.

44:29

Okay, so there, there is a reverse glo humeral arthroplasty.

44:33

Let's talk about what we know about those.

44:35

The, the clinical reasoning

44:37

for a reverse GLO humeral arthroplasty is

44:40

that the patient has a suboptimal rotator cuff muscle

44:45

bulk and tendons.

44:46

So when you rotator cuff is atrophied, um,

44:50

you know the problem here is

44:51

generally osteoarthritis, right?

44:52

You can replace the joint either

44:54

with an anatomic arthroplasty or reverse arthroplasty.

44:57

However, if in patients with cuff insufficiency,

45:00

a reverse arthroplasty allows for the deltoid

45:04

to assume the function of the normal rotator cuff as far

45:08

as abduction is concerned.

45:10

So you can also, while decreasing their pain,

45:12

you can restore some of their function.

45:15

And this may not even be a board's question,

45:17

but I thought it was a good question to put in there

45:20

because if you know the biomechanics

45:23

of why a reverse glenohumeral arthroplasty occurs, then

45:29

one can infer knowing the knowledge that one,

45:34

the origin of the deltoid is the acromion process.

45:38

And that if you have a reverse, you're using your deltoid

45:41

for abduction rather than the rotator cuff.

45:43

Then stress fractures of the acromion process are one

45:47

of the complications of a reverse glenohumeral arthroplasty,

45:50

which is a nice little fun thing to know I think.

45:53

So it has this question has many parts.

45:56

One is, you know, one is identifying

45:58

that there's a fracture of the acromion.

46:00

Two is ident knowing that the uh,

46:03

deltoid is overused in the setting of a reverse arthroplasty

46:06

or used more than it would otherwise be.

46:09

And three is knowing the anatomy

46:11

that the deltoid originates from the acromion process.

46:14

And so the answer here is deltoid overuse, um,

46:18

and a acromion stress fracture.

46:23

Okay, I'm moving on 'cause we got nine minutes.

46:26

Alright, 45-year-old man chronic knee pain, prior trauma.

46:31

Which of the following findings is most commonly associated

46:33

with this imaging appearance

46:41

Survey says meniscal root tear and loose int articular body.

46:46

53% intraarticular and 32% meniscal root tear.

46:51

The root tears are the winners.

46:53

Okay, so we see a well corticated acid density

46:57

and the region of the posterior aspect

46:59

of the medial meniscus at the posterior root region.

47:02

The proton density sagal images show that there is an area

47:07

of similar signal intensity as

47:10

to bone marrow within the medial meniscus, posterior root

47:14

or within where we would expect that thing to be.

47:17

That is the characteristic appearance of a meniscal ossicle

47:20

and meniscal ossicles are highly associated

47:23

or are associated with meniscal root tears, um,

47:27

which has been seen in up to 98% of cases

47:31

of a meniscal ossicle.

47:33

So that is, um, the test question here.

47:36

I think it just, you know, identifying

47:39

that this is this thing

47:40

and that it's bone marrow signal intensity

47:43

and knowing that a meniscal osl is an anatomic variant

47:46

and knowing that that anatomic variant can be associated

47:49

with disease and that is the test, um, taking strategy

47:54

or you know, knowledge in this particular case.

47:58

Let's just for fun while we're here, what originates here?

48:01

This is your popplet tendon origin.

48:03

If you see any erosion here, the lateral for Macondo,

48:07

you can see that in the setting of gout, if you ever

48:10

come across one of those pope origin, um,

48:14

deposits can cause erosions of that groove.

48:22

Okay, what is the most likely diagnosis?

48:26

Chronic spa, acute spa serous attribute

48:29

of the bone marrow perineural cyst or osteopenia?

48:39

Chronic spa. 97%. Yeah, I gave you guys some hard ones.

48:42

Felt bad so I threw a softball in there.

48:45

Um, so uh, the marrow we can see of the sacrum is contiguous

48:48

of the iliac bones that has a chronic

48:50

or structural manifestation.

48:52

Ankylosis of spondyloarthropathies such as ankylosing, spon,

48:57

spondylotic, ankylosing spondylitis.

49:00

Um, other structural findings.

49:01

So when we talk about um, spondyloarthropathies,

49:05

we talk about inflammatory changes

49:07

or acute inflammatory changes or structural findings.

49:10

Acute inflammatory changes would be, uh, joint effusion,

49:14

synovitis, um, capsulitis, if you see soft tissue edema,

49:18

bone marrow edema at either side of the joint

49:21

or just a few, uh,

49:22

whereas structural lesions are more like erosions or ankylos

49:26

or fat metaplasia.

49:28

If you see more fat on either focally, then

49:32

that can suggest chronic inflammatory process.

49:35

Similar in like inflammatory bowel disease

49:37

where you get like fat metaplasia

49:39

or deposition within the mucosa or submucosa.

49:42

Don't you know, I don't know exactly anymore

49:44

because it's been a while, but similar concept.

49:47

So this is, uh, okay,

49:52

I guess I didn't give an answer slide, but it's chronic spa.

49:54

That is the answer. Yep.

50:00

Okay. Can't see the images fast enough.

50:03

Mind waiting before sending the pulses,

50:06

what would you expect to see on this foot X-ray?

50:15

Okay, good. This is testing your concept.

50:18

A concept, A concept that had been very confusing to me

50:23

was the difference between marginal

50:24

and juxta articulate erosions.

50:26

Okay, so this is a gouty tophus

50:28

or at least that's why I put this here.

50:30

Um, you can see them, you know,

50:31

in the elbow obviously you can see them adjacent

50:34

to the first MTP, you can see them in the region

50:37

of the achilles tendon insertion.

50:39

Um, just to name a few.

50:41

And so this heterogeneous T two hypertense thing is a

50:45

G tophus, okay?

50:47

And whether or not you got this question right

50:49

or not, I guess it's not, doesn't matter,

50:51

it's not important today,

50:52

but it's important that we identify

50:55

and know the difference between marginal

50:57

and juxta articulate erosions.

50:59

So let's talk about that difference.

51:01

Alright, so, um, alright, so marginal erosions occur.

51:06

They're intra synovial, okay?

51:08

In the bear area where the bone is not covered by cartilage,

51:12

that's typically seen in RA and small joints in the hand

51:15

and feet and as a characteristic feature

51:17

of inflammatory arthritis, juxta articular

51:21

erosions are extra synovial.

51:22

They occur further away from the joint

51:24

outside of the joint capsule.

51:25

It's characteristic of gout.

51:27

That's why you get these punched out erosions

51:30

and like overhanging edges like the rat bite erosions.

51:33

And so if you get a like an MTP erosion

51:36

that's jugs the articular, then the, you know,

51:39

the articular surface kind of hangs out over it

51:41

and that's how you get this rat bite appearance.

51:44

So juxta articular erosions is most characteristic of gout,

51:48

whereas marginal erosions is more indicative

51:51

of inflammatory arthropathies such as rheumatoid arthritis.

51:55

Um, and the key again is their difference lies in their

51:58

location relative to the joint.

51:59

Whereas marginal erosions are at the edge

52:01

of the joint while juxta,

52:02

articular erosions are further away or outside of the joint

52:05

and can help you distinguish these two pathologies.

52:09

And here's the finding that should, um, have suggested

52:12

to me at least that it is gout that this patient has

52:17

um, negatively biore crystals under polarized light.

52:21

There's another thing that they could say, okay,

52:25

what is the cause of this patient's soft

52:26

tissue mineralization?

52:34

All right, calci tendonitis.

52:37

So the key here is differentiating calcification

52:40

versus ossification.

52:41

So I gave you two options that are ossification here.

52:44

Um, where we're ho

52:46

and mo, this to me looks like more globular calcification

52:51

rather than ossification in that there's no peripheral cor

52:54

or central trabeculation on mr.

52:57

If it was ossified it would not be really low signal

53:01

intensity, it would look like a bone, it would have intra,

53:04

you know, there would be bone marrow

53:05

generally in the middle of it.

53:07

So it should be hyper intense on this T one weighted image.

53:10

But we can see this is globular mineralization.

53:13

Um, and that is at the insertion

53:15

of the gluteus maximus tendon on the gluteal tubercle.

53:18

So just remember that you know,

53:20

if they show you calcific tendonitis,

53:22

it's probably not gonna be in a rotator cuff

53:23

because that's where everybody's

53:25

thinking calcific tendonitis.

53:26

But in real life these things can happen anywhere

53:29

that a tendon is inserting or originating.

53:32

So just keep it in mind no matter where you are.

53:35

Uh, we got two more we'll power through here.

53:38

What is the most likely cause

53:39

of the patient's wrist deformity?

53:48

Erosive osteoarthritis? Uh, 49% in pseudo gout.

53:52

35%. Okay.

53:54

The association that is being tested here is

53:57

that a slack risk deformity okay, is

54:01

commonly associated with pseudo gout

54:04

and you can see some faint mineralization here.

54:08

The triangular fibrocartilage complex which would,

54:10

which is also commonly seen in pseudo gout.

54:13

There's also some mineralization here, you know here, here

54:17

around the second MCP.

54:20

Um, so this patient has pseudo gout

54:22

or findings that would suggest CPPD

54:25

and knowing that a slack risk deformity is something

54:29

that is associated

54:30

with CPPD would be the key here against pseudo gout is

54:35

positively biore under polarized light.

54:38

Um, interestingly also treated

54:40

with colchicine in some instances

54:43

as I've learned from my rheumatology colleagues.

54:47

Okay, couple more.

54:48

25-year-old female presents with left hip pain.

54:51

What is the most likely diagnosis?

54:56

This one is kind of evil and I'm sorry for it.

55:05

Okay, great. Yeah,

55:06

so this maybe I'm just a crappy cat question writer.

55:10

That's also very realistic possibilities, so don't panic.

55:13

Um, but this is a case of marked widening

55:17

and irregularity of the left sacro iliac joint.

55:19

This patient had septic arthritis of their left SI joint.

55:23

Um, you know, hip pain people say they have hip pain all the

55:27

time doesn't necessarily mean it's from the hip.

55:30

Uh, I don't see any fractures.

55:32

This is probably just an oce tabula.

55:34

This mineralization here doesn't look like there's

55:36

really severe oa.

55:38

Um, there is CAM type F fish.

55:43

This doesn't look super cammy to me

55:45

and they're not giving us a done lateral view,

55:47

which would be the best way to see

55:49

that there's a CAM type morphology

55:51

and I don't see any linear sclerosis

55:53

or cortical thickening to suggest a stress fracture.

55:55

So just pay attention to those SI joints.

55:58

Uh, asymmetric irregularity and sclerosis

56:01

and widening of the left sacroiliac joint can, should, uh,

56:04

suggest septic arthritis until proven otherwise.

56:08

And then lastly, left and furor ramus fracture?

56:11

I don't think so. Probably projectional.

56:15

And lastly, oh, this was

56:18

that same patient just in case you didn't believe me.

56:24

Okay, 42-year-old man wrist pain.

56:28

What is the most specific positive laboratory finding?

56:38

Okay, good. Um, so the answer choice here

56:41

that is correct is anti CCP positivity.

56:44

And the main thing here for me is

56:46

that there's ulnar styloid process erosions,

56:49

obviously there's erosion or at least lucency of the lunate.

56:52

There's some erosion here of the triquetrum,

56:56

but rheumatoid arthritis loves the ulnar syl process.

57:00

And distal ulnar we can see foveal erosion.

57:03

And I guess the concept I was testing is that um,

57:09

RF positivity is relatively nonspecific.

57:12

Anti CCP positivity is relatively specific.

57:15

So, um, if you someone's anti CCCP positive

57:19

and they have ulnar style process erosion.

57:21

So this is just testing laboratory tests

57:23

and knowing what's sensitive, what's specific

57:26

HLAP 27 is non-specific

57:29

but can be seen in spondyloarthropathies.

57:31

Obviously increased serum uric acid can be seen in gout.

57:34

Leukocytosis would be indicative of septic arthritis,

57:37

but this is a pretty polyarticular process.

57:39

We can see some PIP involvement there too.

57:42

Okay, I think we had some easy ones.

57:44

We had some tougher ones. We had some good questions.

57:46

We had some, you know, not so good questions,

57:49

so I'll take the blame for some of those.

57:51

But hopefully you learned a thing or two

57:53

and, um, opened your mind to the different types

57:56

of questions you may be asked.

57:58

It's not all about imaging findings and ant minis,

58:00

but other clinical correlation as well.

58:03

So I appreciate everyone's iveness

58:05

and your attention on this lovely, uh, St.

58:08

Patrick's Day.

58:10

Dr. Raji, thank you so much for that awesome case review.

58:15

My pleasure. Thanks for everyone else for participating

58:18

and asking such great questions and being here tonight.

58:21

We really appreciate it.

58:23

You can access the replays of our previous reviews

58:25

by creating a free account.

58:27

And be sure to join us next Monday, March 24th.

58:30

Dr. Lindsay Negreti will lead us in a rapid review

58:32

of GI imaging cases.

58:34

You can register for that at the link provided in the chat.

58:37

Follow us on social media for updates on future meetings.

58:40

Thanks again for learning with us and we'll see you soon.