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Back pain…

October 7, 2014

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Back pain is one of the most frequent complaints in the ED.  The vast majority of patients do not have a life threatening or highly morbid pathology.  Unfortunately, this patient did:

 

CT LSpine 1 LS spine 2

This is a CT scan under bone windows.  It shows erosive changes based around the L4-L5 disc, eroding into the inferior endplate of L4 and the superior endplate of L5. These findings are concerning for discitis-osteomyelitis. It is favored to have both acute
and chronic components.

Finding this pathology is somewhat like finding a needle in a haystack.  However, pay attention to signs such as fever, repeat ED visits without a firm diagnosis, focal weakness, and predisposing factors such as IV drug abuse, history of endocarditis, or immunosuppression.  Sedimentation rate and C-reactive protein are often elevated in this disorder (among others).

CT is a readily available, quick way to diagnose this pathology but it isn’t as sensitive as MRI.  Plain films are not reliable but may show changes similar to the CT above.  Nuclear medicine bone scans as well as PET scans can be used but are not commonplace in the ED.

Author:  Russell Jones, MD

Image Contributor:  Zachary Skaggs

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Antibiotic beads in a knee…

May 26, 2014

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This patient had a history of osteomyelitis of his distal femur and a septic knee.  This caused significant destruction requiring knee replacement and antibiotic bead placement (the radio opaque spherical objects).  He re-presented several weeks later with fever and knee pain:

Antibiotic beads 1

Antibiotic beads 2

There are multiple issues with these radiographs that are chronic.  It was helpful clinically to have a comparison which showed that the hardware was all intact and unchanged.  The ACUTE finding on this radiograph is radiolucency under the patella (as well as proximal to the patella) concerning for gas.  This patient was taken to the operating room for a septic joint (again).

Author:  Russell Jones, MD

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Interesting osteomyelitis…

May 6, 2014

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This patient presented with multiple skin lesions with an ulcerative mass to his thumb…

OM hand

This patient had an ulcerative, indurated lesion to the distal thumb which can be seen on the above radiograph.  The radiograph also demonstrates periostitis and osseous erosion of the distal thumb and metacarpal joint of the thumb.  There are subtle periosteal changes to the third phalanx as well.

It turns out this patient has sporothrix schenkii osteomyelitis.

Author:  Russell Jones, MD

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Pediatric back pain…

March 3, 2014

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Early teen presents with back pain for several months…

ES of spine 1

ES spine 2

This thoracic spine series shows a loss of vertebral height at T11 and an indistinct right pedicle of T11.  What could cause this in an early teenager?  There was no history of trauma.

Answer to follow.

Author:  Russell Jones, MD

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Lumbar mets and fracture…

December 27, 2013

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Elderly male came in with acute onset pain in lumbar spine.  He indicentally has had weight loss over the past 6 months, about 40 lbs:

Path Fx L Spine 2 Path Fx L spine

This patient has a pathologic compression fracture of L1 vertebral body.  Also demonstrated are sclerotic lesions in L4 without a fracture. 

What is the most likely primary lesion?

Author:  Russell Jones, MD

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Hip pain after a fall…

November 12, 2013

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Middle-aged male presents with hip pain after a fall:

Hip pain

This is a pathologic fracture.  CT showed a 12 inch tumor found infiltrating the right pelvic structures.  The pelvis xray shows that his distal femur has displaced through the acetabulum and you can see there is ill-defined destruction of the inferior pubic ramus.  He has contrast in the bladder from a prior CT at a transferring institution.  What is your differential diagnosis for this Xray?

Author:  Russell Jones, MD

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Osteochondroma

March 15, 2013

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This person presented to the ED with pain in the legs after an acute trauma.  Here are his tibia/fibula views:

Osteochondroma 2Osteochondroma 1

There is no fracture or dislocation.  However, on the proximal fibula you can see a mass…what is that?

This is an example of an osteochondroma.  Osteochondromas are benign tumors of the growth plate that account for roughly 10-15% of all bone tumors.  They are a common incidental finding and occur mostly on the lower extremity.  Less frequently they can be seen on an upper extremity, and uncommonly on the spine.  Osteochondromas very rarely (<1%) transform to malignant lesions.

A great summary of osteochondromas can be found at Radiopaedia.org.  Their plain film appearance is described as:

“An osteochondroma can be either sessile or pedunculated, and is seen in the metaphyseal region typically projecting away from the epiphysis. There is often associated broadening of the metaphysis from which it arises. The cartilage cap is variable in appearance. It may be thin and difficult to identify, or thick with rings and arcs calcification and irregular subchondral bone.

New cortical irregularity or continued growth after skeletal maturity has been reached, as well as frankly aggressive features (e.g. bony destruction, large soft tissue component, metastases) are all worrying for malignant transformation.”

Author:  Russell Jones, M.D.

References

1.  Niknejad MT, Gaillard F, et al.  Osteochondroma.  http://radiopaedia.org/articles/osteochondroma

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Patella Fracture

December 20, 2012

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I saw a nice elderly female with anterior knee pain after tripping on the curb and falling to her knees. Here is her knee X-ray:

Patella fx 3Patella fx 2Patella fx 1

The AP and lateral knee radiographs demonstrate a non-displaced transverse patellar fracture. Sometimes these can be difficult to see on AP and lateral films. Another view that can sometimes be helpful is the “sunrise” view of the patella.

Most patella fractures are managed non-operatively.  If, however, the patella fragments are displaced more than 3-4 mm on xray there is a higher chance of retinacula compromise requiring operative repair (1).  Clinically if the patient cannot maintain their knee in extension against gravity this is concerning for retinacular tear. 

This patient has a high chance, despite age, of having a good outcome with non-operative management (she had intact extensor mechanism of the knee). 

References

1.  Wheeless’ Textbook of Orthopedics.  http://www.wheelessonline.com/ortho/fractures_of_the_patella

Author:  Russell Jones, MD

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