1. X-Ray Case Studies
Jim Messerly D.O.

2. Case #1 History
17 year-old female ballet dancer with snapping sensation along the medial aspect of her right knee when extending her right knee during jumps.

3. Case #1 Physical Exam
Physical exam showed no evidence of effusion. There was full range of motion of the right knee with reproducible popping of the posterior medial hamstring with flexion and extension which was minimally painful. No joint line tenderness. McMurray’s testing was negative.

4. Case #1 X-Rays

5. Case #1 X-Rays

6. Case #1 Diagnosis ? A. Stress fracture B. Osteoid Osteoma
C. Osteochondroma
D. Osteosarcoma

7. Osteochondroma Most common benign tumor of bone.
Outgrowth of bone usually located in the metaphysis projecting away from the joint.
Malignant transformation rare except in Hereditary Multiple Exostosis (HME).
Usually left alone unless interferes with surrounding muscles, tendons or nerves or interferes with activity- then can be resected.

8. Case #2 History
16 year-old male football player who developed sudden onset of severe left shoulder pain while reaching with his left upper extremity during a football drill. There was no contact. He complained of pain in the posterior aspect of his left shoulder and proximal left arm. He was evaluated by an athletic trainer and was placed in a sling.

9. Case #2 Physical Exam
The patient was in obvious discomfort due to his left shoulder pain. There was a questionable left shoulder effusion. Active flexion and abduction were limited to only 15° because of severe pain. There was severe pain with any attempts of resisted internal or external rotation of the left shoulder.

10. Case #2 X-rays

11. Case #2 X-rays

12. Case #2 Diagnosis? Aneurysmal Bone Cyst Metastatic lesion
Fibrous Dysplasia
Unicameral Bone Cyst

13. Unicameral Bone Cyst
Usually found in the proximal humerus, but also can be found in the proximal femur or calcaneus.
X-rays show well-defined lytic lesion with thin sclerotic margin with no periosteal reaction.
Pathologic fracture may allow healing of cyst.
Injection of steroid, bone marrow, demineralized bone or surgical treatment may be needed.

14. Case #3 History
16-year-old male with 6-9 month history of right elbow pain and lack of full extension. The patient is a snowmobile racer and wondered if he may have injured the right elbow during one of his many wipe outs during snowmobile races. Three days prior, he was lifting a heavy box and had a forceful extension of his left elbow with associated increased pain and some swelling.

15. Case #3 Physical Exam
There was a moderate right elbow effusion. Range of motion was 40° to 105° with pain at end range motion. Moderate tenderness of the medial joint line. Ligaments were stable with some pain with valgus stress.

16. Case #3 X-rays

17. Case #3 X-Rays

18. Case #3 MRI

19. Case #3 Diagnosis? Osteoid Osteoma Fibrous Dysplasia
Aneurysmal Bone Cyst
Chondrosarcoma

20. Aneurysmal Bone Cyst
Usually located in long bones or spine in patients less than age 20.
X-rays show eccentrically located metaphyseal lytic lesion.
Typical complaints are swelling and pain which usually follows an injury.
Biopsy is frequently required to rule out malignant lesion.
Treatment is by curettage with bone grafting.

21. Case #4
20 year-old college female with anterior right leg pain for the past five months. The patient had been using the Stair Master and jogging for up to an hour a day during the summer. When her college classes started in the fall, she continued to workout in spite of the pain, but had been off running for the past two weeks without improvement of her pain.

22. Case #4 Physical Exam
There was mild firm swelling over the anterior aspect of the distal third of the right tibial shaft. Moderate tenderness to palpation and percussion. Full range of motion of the right knee and ankle. Arches of the feet were minimally pronated.

23. Case #4 X-Rays

24. Case #4 X-Rays

25. Case #4 CT Scan

26. Case #4 Diagnosis ? Osteoid Osteoma Fibrous Cortical Defect
Healing Stress Fracture
Hemangioma

27. Osteoid Osteoma
Frequently causes deep aching pain which is worse at night.
Pain is frequently relieved by aspirin/NSAIDs.
X-ray/CT shows radiolucent nidus surrounded by reactive sclerotic bone.
Treatment- Waiting, Radiofrequency ablation or excision.

28. Case #5 History
13-year-old male with one-year history of thoracic spine pain which had been worsening over the past two months. Severe night pain. The patient had been unable to participate in basketball because of his pain. Chiropractic care was not helpful for his pain. Previous x-rays had shown evidence of a moderate thoracic spine scoliosis.

29. Case #5 Physical Exam
Moderate right-sided thoracic spine scoliosis. Moderate tenderness on palpation from T6 to T10. Minimal restriction with flexion and extension of the thoracic spine. Lower extremity neurological exam was unremarkable.

30. Case #5 X-Rays

31. Case #5 MRI

32. Case #5 CT Sagittal

33. Case #5 CT Axial

34. Case #5 Diagnosis? Osteoid Osteoma Osteoblastoma Giant Cell Tumor
Hemangioma

35. Osteoid Osteoma Small round focus-nidus
Radiofrequency ablation is difficult when in the spine and resection may be best approach.

36. Case #6 History
17-year-old male with complaint of right knee pain which had been present for the past 4-5 months. He noted some right knee pain after playing basketball during the summer. He denied catching, locking or giving way. There was no significant swelling. He had been treating with physical therapy without significant improvement. He was currently participating on the curling team.

37. Case #6 Physical Exam
No evidence of right knee effusion. Mild soft tissue swelling in the region of the proximal tibia both medially and laterally with mild tenderness on palpation. Mild generalized knee pain with forced extension. There was full flexion without pain. Ligaments were stable. Mild lateral joint line tenderness. McMurray’s testing was negative.

38. Case #6 X-Rays

39. Case #6 X-Rays

40. Case #6 X-Rays

41. Case #6 MRI

42. Case #6 Diagnosis? Stress fracture Osteosarcoma Chondrosarcoma
I’m not sure, but it sure looks bad

43. Osteosarcoma
Most common malignant bone tumor in the pediatric population.
Most common location is in the tibia, femur or humerus.
Frequently causes bone pain.
X-rays frequently show combined lytic and sclerotic changes.
Treatment involves chemotherapy, possible radiation followed by surgery.

44. Case #7 History
60 year-old female with complaint of right knee pain which was worse over the past few weeks when she tried to increase her walking activities. She described anterior medial and lateral right knee pain. Her pain was worse with prolonged standing, driving or when walking stairs. There was no catching, locking or giving way. No swelling.

45. Case #7 Physical Exam
There was a trace effusion of the right knee. There was full range of motion with moderate patella crepitus. Mild patellar facet tenderness to palpation. Ligaments were stable. Mild medial joint line tenderness.

46. Case #7 X-Rays

47. Case #7 X-Rays

48. Case #7 X-Rays

49. Case #7 Diagnosis? Stress fracture Osteosarcoma Enchondroma
Mild to moderate patellofemoral osteoarthritis with patellofemoral pain

50. Enchondroma
Benign cartilage lesion centrally located within bones that can occur at any age.
Usually asymptomatic.
Frequently found in the bones of the hand.
X-ray follow-up recommended to document stability because occasionally difficult to distinguish enchondroma from low-grade chondrosarcoma

51. Chondrosarcoma

52. Case #8 History and Exam
History: 27 year-old female with complaint of left knee pain and swelling for two months. No history of injury. She describes lateral left knee pain with associated near giving way episodes. She frequently limps because of her left knee pain. She denies fevers, chills or night sweats.
Exam: The patient does walk with a limp favoring her left knee. There was a trace effusion of the left knee. Mild anterior lateral left knee pain with full flexion. Ligaments were stable. Moderate lateral joint line tenderness which was worse with McMurray testing.

53. Case #8 X-Rays

54. Case #8 X-Rays

55. Case #8 X-Rays

56. Case #8 MRI

57. Case #8 MRI

58. Case #8 Diagnosis? Stress fracture Fibrous cortical defect
Giant cell tumor
I don’t know, but it sure looks bad

59. I don’t know, but is sure looks bad
Referred to university center
Biopsy shows leiomyosarcoma
Treated with resection and knee replacement surgery

60. Thank you