1.
Mini Pathria
Michael Zlatkin
Richard (Rick) G Stiles

2. Mini Pathria
Middle-aged male
Hx of recent knee trauma

3. Case 1
Middle-aged male
Hx of recent knee trauma

4. Radiographs

5. Sagittal

6. Coronal

7. Axial

8. Thigh

9. Differential diagnosis
Neurofibromatosis
Melorheostosis with soft tissue component

10. Neurofibromatosis Further history obtained Skin nodules
Neurofibromas on cranial CT 7 years previously (not acoustic neuroma)

11. Case 2
Middle-aged female with thigh mass

12. Radiographs

13. Coronal

14. MR

15. Follow-up Mass biopsied, benign plexiform neurofibroma
Patient developed hip pain

16. Hip MR

17. Neurofibromatosis Plexiform neurofibroma at biopsy
No evidence of malignancy

18. Case 3
40 year old male with slowly growing painless mass

19. Plexiform neurofibroma

20. Plexiform neurofibroma
Specific finding for NF1 (peripheral form)
5% of patients with NF1
Approximately 5-10% degenerate to neurosarcoma
courtesy of Mark Murphey, AFIP

21. Neurofibroma Localized Diffuse Plexiform Well-defined Bag of worms
Infiltrating

22. Elephantiasis neurofibromatosa
Diffuse form of plexiform neurofibroma
Overgrowth of epidermal and subcutaneous tissue
Wrinkled and pendulous appearance

23. Michael B. Zlatkin and Alfredo Arraut NMSI
27 year old male involved in a motor vehicle accident

24. 27 year old male involved in a motor vehicle accident

25. 27 year old male involved in a motor vehicle accident

26. Findings
Subscapularis tendon is avulsed with bone from the lesser tuberosity
Humeral avulsion of the anterior band of the glenohumeral ligament (HAGL)
Middle glenohumeral ligament and possibly the superior glenohumral ligament may be avulsed as well
Possible reverse Hill-Sachs lesion

27. Subscap Rupture and HAGL (BHAGL)
Rupture of the subscapularis tendon uncommon but can be seen in younger patients injured by forced external rotation or extension of a partially abducted arm
Tears occur near insertion on the lesser tub. May occur at sup margin, where tendon may be weakened by degeneration
Avulsion fracture of the lesser tuberosity may occur, and is displaced medially and inferiorly
Subscapularis avulsions are also associated with injury to the anterior capsule and glenohumeral ligaments (HAGL)
When the AIGHL avulses a fragment of bone from the humerus, the lesion is known as a bony HAGL, or BHAGL
? With MGHL and SGHL torn = Super BHAGL

28. Michael B. Zlatkin and Alfredo Arraut NMSI
17 year old male with bony growth on the dorsum of hand

29. 17 year old male with bony growth on the dorsum of hand

30. 17 year old male with bony growth on the dorsum of hand

31. Findings
Bone prominence on the dorsum of the hand between the trapezoid, capitate, and bases of the 2nd and 3rd metacarpals
Associated with base of 3rd metacarpal, but no marrow continuity with it
Sclerosis and cystic change at junction with 3rd metacarpal base

32. Carpal Boss Bone protuberance on dorsum of the hand
Degenerative osteophyte or os styloideum
Located between trapezoid, capitate, and base of 2nd and 3rd metacarpals
Most often fused to a metacarpal base, but rarely (2%) can be completely isolated
Symptoms caused by degeneration, formation of ganglion or bursa, or snapping of an extensor tendon moving over it

33. Carpal Boss
Can be demonstrated on lateral radiograph with hand flexed and supinated degrees; best seen with mild ulnar deviation
Alternatively can image with CT or MR
MR can demonstrate marrow edema in the carpal boss and surrounding soft tissue changes

34. Carpal Boss – Companion Case
Carpal boss fused to base of third metacarpal with edema in overlying soft tissues

35. Carpal Boss - Companion Case
Carpal boss fused to third metacarpal with fracture at its base

36. Carpal Boss – Companion Case
Surface rendering of carpal boss with fracture at its base

37. Michael B. Zlatkin and Alfredo Arraut NMSI
33 year old professional hockey player with pain in the flank after practice

38. 33 year old professional hockey player with pain in the flank after practice

39. 33 year old professional hockey player with pain in the flank after practice

40. Findings
Partial thickness tear of the internal oblique muscle belly proximally, with surrounding edema and hematoma
Fluid tracking between internal and external obliques
Feathery pattern of edema at the more distal aspect of the internal oblique

41. Side Strain
Uncommon sporting injury presenting with pain and tenderness over anterolateral and posterolateral lower ribcage
Associated with cricket, golf, and ice hockey – eccentric contraction of trunk muscles
Partial or complete tear of lateral abdominal wall musculature (internal oblique > external oblique > transversus abdominis)
May also see avulsion at the muscular origins from the lower ribs
Recovery takes 6-10 weeks. Full recovery is the norm

42. Michael B. Zlatkin and Alfredo Arraut NMSI
19 year old injured while pitching, now has valgus instability of elbow on exam

43. 19 year old injured while pitching, now has valgus instability of elbow on exam

44. Findings
Thickened ulnar collateral ligament (UCL) with increased intrasubstance signal distally and at its midportion, indicating partial thickness tear
No complete disruption
Edema in the adjacent flexor/pronator musculature
Reactive marrow edema in the sublime tubercle

45. UCL Partial Tear
Most often injured in overhand throwing athletes, especially baseball pitchers
Pitching causes valgus stress on the elbow that can injure the UCL
MR arthrogram reportedly higher sensitivity than conventional MR for partial thickness tears
MR findings – thickening/irregularity/laxity of the ligament, edema in adjacent soft tissues
T sign – pathognomonic sign of contrast extending into a partial thickness tear, giving a sideways “T” shaped appearance
Tears tend to occur more distally in younger pitchers, more proximally in older pitchers

46. Michael B. Zlatkin and Alfredo Arraut NMSI
16 year old pitcher with elbow pain

47. 16 year old pitcher with elbow pain

48. Findings Delayed union of the olecranon apophysis
Persistent widening of physis with surrounding edema consistent with stress injury/stress fracture

49. Olecranon Stress Fracture/Apophysitis
May occur in young throwing athletes and gymnasts due to repetitive microtrauma
Present with pain localized to the tip of the olecranon
Imaging shows a widened physis or open physis after expected age of closure, and stress related edema
Normal fusion occurs at age 12-15, comparison to contralateral side may help

50. Michael B. Zlatkin and Alfredo Arraut NMSI
24 year old male with shoulder pain and suspected rotator cuff tear after fall on outstretched hand

51. 24 year old male with shoulder pain and suspected rotator cuff tear after fall on outstretched hand

52. Findings
Avulsion fracture of the greater tuberosity, with a small fracture fragment retracted medially with a torn supraspinatus tendon
Associated marrow edema

53. Greater Tuberosity Avulsion Fracture
RCT uncommon in younger patients
Usually occurs after trauma, may be concomitant fx
Great tub fx’s may be difficult to distinguish from RCT clinically. May be radiographically occult if non-displ
MR useful in differentiating contusion/nondisplaced fracture from RCT
Concomitant rotator cuff tears not common in nondisplaced fractures, but more common in more severe injuries with avulsions/displaced fractures