Musculoskeletal Imaging: 100 Cases (Common Diseases) US, CT and MRI

By Ammar Haouimi

The book includes 100 cases (common and rare) with highly organised radiological description of the diseases.
The cases are grouped into three chapters: Upper Limbs, Neck/Trunk/Spine and Lower Limbs.
High quality images (X-ray, US, CT and MRI).
It covers all imaging modalities including conventional radiology, ultrasound/Doppler, CT scan and MRI.
The topics covered in the book represent the common and important diseases encountered in musculoskeletal imaging.
The material presented for each case provides a thorough and comprehensive description of the disease entity, enabling the radiologist or the clinician to develop a clear concept of the entity through the different imaging modalities that are present.
What is interesting in this book is one case per page. The book can be used as a mean of rapid revision of a large number of cases in a short time or as a test of knowledge by masking the radiological description and diagnosis and trying by using the clinical data and radiological images to describe first the pathology then propose a diagnosis.

• Language: English
• Publisher: Austin Macauley Publishers
• Release date: Jul 30, 2021
• ISBN: 9781528971737

Ammar Haouimi

Dr. Ammar Haouimi is a French trained internationally renowned radiologist and educator. His authored publications are: - Radiology for FRCR and MRCP 111 Cases - Neuroradiology for FRCR and MRCP 111 Cases - Pediatric Radiology Case Report 111 Common Cases - Atlas of Pediatric Radiology 200 Common Cases - Atlas of Neuroradiology 200 Common Cases Those publications were very successful and were enthusiastically welcomed by candidates appearing for Royal College Examinations. Like all previous publications, the current “Abdominal-Pelvic Imaging” will no doubt be another exceptional one. This book will not only be extremely helpful for residents, but also for referring physicians and practicing radiologists internationally.

Book preview

Musculoskeletal Imaging

100 Cases (Common Diseases) US, CT and MRI

Austin Macauley Publishers

Musculoskeletal Imaging

About the Authors

Dedication

Copyright Information ©

Acknowledgements

Contributors

Foreword

Preface

Upper Limbs

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

Case 10

Case 11

Case 12

Case 13

Case 14

Case 15

Case 16

Case 17

Case 18

Case 19

Case 20

Case 21

Case 22

Case 23

Case 24

Case 25

Case 26

Case 27

Case 28

Spine and Trunk

Case 29

Case 30

Case 31

Case 32

Case 33

Case 34

Case 35

Case 36

Case 37

Case 38

Case 39

Case 40

Case 41

Case 42

Case 43

Case 44

Lower Limbs

Case 45

Case 46

Case 47

Case 48

Case 49

Case 50

Case 51

Case 52

Case 53

Case 54

Case 55

Case 56

Case 57

Case 58

Case 59

Case 60

Case 61

Case 62

Case 63

Case 64

Case 65

Case 66

Case 67

Case 68

Case 69

Case 70

Case 71

Case 72

Case 73

Case 74

Case 75

Case 76

Case 77

Case 78

Case 79

Case 80

Case 81

Case 82

Case 83

Case 84

Case 85

Case 86

Case 87

Case 88

Case 89

Case 90

Case 91

Case 92

Case 93

Case 94

Case 95

Case 96

Case 97

Case 98

Case 99

Case 100

References

About the Authors

Dr.Ammar Haouimi is a French trained internationally renowned radiologist and educator. His authored publications are:

- Radiology For FRCR and MRCP 111 Cases

- Neuroradiology For FRCR and MRCP 111 Cases

- Pediatric Radiology Case report 111 common Cases

- Atlas of Pediatric Radiology 200 Common Cases

- Atlas of Neuroradiology 200 Common Cases

Those publications were very successful and were enthusiastically welcomed by candidates appearing for Royal College Examinations. Like all previous publications, the current Musculoskeletal Imaging will no doubt be another exceptional one. This book will not only be extremely helpful for residents, but also for referring physicians and practicing radiologists internationally.

Dedication

The important people who are my life: my wife Saliha, my children Asmaa, Imane, Soumaia, Ahmed, Isra, Dania, and my little girl Oula. For their immense support provided to me during the preparation of this book.

Ammar HAOUIMI

I am glad to dedicate this work to my parents for their unconditional love and support.

To my siblings who have been extremely helpful and cooperative despite all the obstacles of life.

I am also thankful to almighty god for giving me the strength and wisdom needed to overcome the hardships.

Rabah BOUGUELAA

Copyright Information ©

Ammar Haouimi & Rabah Bouguelaa (2021)

The right of Ammar Haouimi & Rabah Bouguelaa to be identified as authors of this work has been asserted by them in accordance with section 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publishers.

Any person who commits any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

A CIP catalogue record for this title is available from the British Library.

ISBN 9781528946339 (Paperback)

ISBN 9781528971737 (ePube-book)

www.austinmacauley.com

First Published (2021)

Austin Macauley Publishers Ltd

25 Canada Square

Canary Wharf London

E14 5LQ

Acknowledgements

I am grateful for the support and friendship of my colleagues: Abdelkrim Berrah professor and chairman, Department of Medicine at Bab El-oued University Hospital, Algiers, Nacer Kernane professor and chairman, Department of Orthopedic Surgery at Benflis University Hospital, Batna, Samir Rouabhia professor and chairman, Department of Medicine at Benflis University Hospital, Batna and Drs. Rida Okbi, Yassine Haouara and Nacer Eddine Hidouci.

I would like to thank my friend Zeghidi Djerouni for his friendship, support and encouragement as well as our mutual friends: Slimane Djouadi, Souleyman Bakhlili, Farid Abed, Fouad Ouamane, Soumaya Mobarek, Noura Algeteni, Nabila Snousaoui, Mohammed Touati, Mohammed Cadic, Ahmed Djalal, Faiza Hacine, Samar Eldjamili, Kamal Maati, Kenza Boulifa.

I want to thank my family especially my parents, parents-in-law, my brothers Nacer, Rachid, Abderrahmane, Noureddine, and Adel as well as my sisters Zouina, Nacira, Sabah, Saida and Hanane.

Finally, I would like to thank General Electric Healthcare for their contribution in publishing this book.

Ammar HAOUIMI

The completion of the book would not be possible without the hard work and the devotion of the team of CIM Aures who have been significantly supportive and cooperative.

A debt of gratitude is also owed to the patients I have treated throughout my life, every one of them had a great impact on my heart and consequently I decided to co-write this book.

Rabah BOUGUELAA

Contributors

Ziaul Haq CHOUDHURI. MD

Consultant radiologist

Chairman, Radiology and Medical Imaging Edmundston Regional Hospital New Brunswick, Canada

Nassim BARCHICHE. MD

Consultant radiologist

Centre D’imagerie Médicale Dr. Lekhal M Blida, Algeria

Amine RAMDANI. MD

Consultant radiologist

Centre D’imagerie Médicale Aurès Batna, Algeria

Chelia BOUKAABA. MD

Consultant radiologist

Centre D’imagerie Médicale Aurès Batna, Algeria

Zine-Eddine BOUDIAF. MD

Consultant radiologist

Centre Hospitalier Universitaire Constantine, Algeria

Fouzi BALA

Consultant interventional neuro-radiologist Roger Salengro Hospital Lille, France

Shahid HUSSEIN. MD

Consultant radiologist

Ohud Hospital Medinah, KSA

Foreword

It is with great interest that I have discovered the clinical cases proposed by Drs. Haouimi and Bouguelaa.

The images are clear with didactic and instructive explanations.

It is a perfect library which allows to progress well in the analysis of the lesions from case to case. I am feeling honoured to say congratulations for this great initiative.

Dr Jean-Louis Brasseur

GH Pitié-Salpetrière

Paris, France

Preface

The invention and the improvement of the image quality of ultrasound, computed tomography and magnetic resonance imaging have completely changed the morphological exploration of the musculoskeletal system and therefore have a very precise approach to diagnosis of the most musculoskeletal diseases.

The progress in musculoskeletal imaging need intensive further training to enable all radiologists and clinicians, the optimal use of these techniques.

The subject of musculoskeletal imaging is ever-changing and constantly growing in scope. Much of this growth relates not to the discovery of new processes or disorders but rather to the development and refinement of advanced imaging methods and techniques.

The topics covered in the book represent the common and important diseases encountered in musculoskeletal imaging. The material presented for each case provides a thorough and comprehensive description of the disease entity, enabling the radiologist or the clinician to develop a clear concept of the entity through the different imaging modalities that are present. We hope that it will be useful for residents in radiology, radiologists, and orthopedic surgeons.

What is interesting in this book is one case per page. The book can be used as a mean of rapid revision of a large number of cases in a short time or as a test of knowledge by masking the radiological description and diagnosis and trying by using the clinical data and radiological images to describe first, the pathology then propose a diagnosis.

Ammar HAOUIMI

Rabah BOUGUELAA

Upper Limbs

Case 1

Clinical Presentation

A 29-year-old male patient with no past medical history had observed a rapidly growing mass of his left shoulder and slight soreness during a period of four weeks after having performed physical exercise for several weeks in a fitness studio. The mass was palpable but deeply located in the ventral shoulder.

Radiological Findings

c1

Diagnosis: Desmoid tumor

Desmoid tumors are benign lesions belonging to the group of fibromatoses. They arise from the connective tissue, fascia or muscular aponeurosis.

The etiology has not been sufficiently explained. Trauma, endocrine and genetic factors have been suggested to be predisposing factors. Although the tumors are benign, they show aggressive locoregional extension with destruction of surrounding structures leading to an increased morbidity. Tumors are mostly found in abdomen and by far are the commonest neoplasm of the abdominal wall. Only 7–15% occur in the head and neck areas.

Successful treatment can be achieved by surgical excision, radiation and with pharmacological agents. As this tumor is rare, recommendations for the optimal treatment algorithm is lacking.

Diagnosis can be made by US, CT, and MRI. Before planning any type of surgery, the extension of the tumor and its relation to neighboring neuro-vascular as well as functional structures need to be identified.

The lesions typically appear as hypoechoic homogeneous mass on ultrasound. They may appear isoechoic to muscle, may be lobulated, and may show signs of vascularity on color Doppler interrogation.

Most desmoid tumors are well-circumscribed lesions in CT, although in some cases they may appear more aggressive with ill-defined margins. Most lesions are relatively isodense and homogeneous or focally hyperattenuating compared to soft tissue on the non-contrast scan with enhancement following intravenous contrast.

On MRI, typically, the lesions appear of low signal intensity on T1 and T2 with homogeneous, non- homogeneous, or no significant enhancement following intravenous contrast. MRI is more sensitive to local tumor extension. Their appearance is accounted for their dense cellularity.

Case 2

Clinical Presentation

A 22-year-old male patient with history of repeated left shoulder dislocation, presented with shoulder pain and instability.

Radiological Findings

c2

Diagnosis: Bankart lesion (bony Bankart)

The Bankart lesion is named after the English orthopedic surgeon, Arthur Blundell Bankart. The lesion is a common complication of anterior shoulder dislocation and frequently associated with a Hill-Sachs lesion.

Those result from detachment of the anteroinferior labrum from the underlying glenoid as a result of the anteriorly dislocated humeral head compressing against the labrum. It may only be isolated labral injury Soft Bankart, or involve the bony glenoid margin Bony Bankart. Soft Bankarts are more common than bony lesions.

The same mechanism of compression results in a Hill-Sachs lesion. Bankart and Hill-Sachs lesions often occur together than to be isolated. Bankart lesions do heal, and early surgical intervention may not be required. The labral fragment needs to be sutured back to the glenoid rim using suture anchors.

Bankart Variants:

Perthes lesion of the shoulder: tear of the glenoid labrum with intact scapular periosteum

Anterior labroligamentous periosteal sleeve avulsion (ALPSA): mobilized labrum remains attached to the glenoid periosteum.

Only bony Bankart lesion may be seen on plain radiograph as a fracture of the anteroinferior aspect of the glenoid.

Non-contrast CT may show fracture at the anteroinferior glenoid Bony Bankart. However, CT arthrography may be needed to visualize Soft Bankart.

A linear T2/PD high signal intensity coursing through the normal low signal anteroinferior labrum can be seen in MRI. A number of lesions may have similar appearances. Double Axillary Pouch sign on coronal MR arthrogram is a specific sign for an anteroinferior labral tear. MR may show displaced anterior glenoid labrum with bone, small or absent anterior labrum.

Case 3

Clinical Presentation

A 34-year-old female patient complaining of non-specific posterior pain and weakness of the left shoulder.

Radiological Findings

c3

Diagnosis: Suprascapular neuropathy (or suprascapular nerve entrapment)

Suprascapular neuropathy results from compression or traction of the suprascapular nerve, typically at the suprascapular or spinoglenoid notch. Certain sports like weight lifting predisposes to this type of neuropathy. This may also be produced by mass effect from a ganglion cyst or any other neoplastic growth. The entrapment leads to supra and infraspinatus weakness and pain may be clinically difficult to differentiate from rotator cuff tear.

The nerve at suprascapular notch contains both motor and sensory branches. Proximal entrapment cause denervation changes involving both muscles whereas distal entrapment along the course of the nerve only involves the infraspinatus. Familiarity with the neurovascular anatomy is essential in analyzing the nerve entrapment.

Electromyography and nerve conduction velocity studies remain the gold standard for confirmation of suprascapular neuropathy. However, negative findings do not exclude it. Initial management is usually nonoperative, consisting of activity modification, physiotherapy, and nonsteroidal anti-inflammatory drugs. Surgical intervention is considered for patients with nerve compression by an external source or for symptoms refractory to conservative measures. Decompression of the suprascapular nerve may be accomplished through an open approach, although arthroscopic surgical approaches have become more common in recent years.

As the clinical presentation is confusing, the patient may be sent for MRI to rule out rotator cuff tear or other more common shoulder abnormalities. MRI is also an indispensable tool for evaluation of peripheral nerve injuries at the shoulder and muscle denervation changes. MRI is capable of showing the lesions at supraclavicular or spinoglenoid notch directly.

Muscle denervation can have several MRI appearances. In subacute phase, the affected muscle demonstrates increased T2-signal resulting from muscle edema. In the chronic stages, fatty infiltration usually accompanied by muscle atrophy representing irreversible muscle injury.

Case 4

Clinical Presentation

A 54-year-old female patient presented with a left shoulder mass, known since last 10 years and progressively increasing in size.

Radiological Findings

c4

Diagnosis: Lipoma of left shoulder

Lipomas are well-capsulated benign soft tissue tumors representing almost 50% of all soft tissue tumors. They can be classified on the basis of their anatomical location, clinical evaluation or histological findings. Subcutaneous lipomas are the commonest. The intermuscular variants are also seen.

Superficial lipomas can be accurately diagnosed on the basis of clinical findings in up to 85% of cases. Those superficial lipomas are typically mobile, palpable, doughy, and solitary soft tissue mass. In 80% of cases, the superficial lipomas are smaller than 5 cm and only 1% is greater than 10 cm in size. They enlarge slowly and are frequently asymptomatic. Clinical symptoms are uncommon but they may cause local pain and tenderness, limitation of joint movement, and nerve compression.

It is unclear if a soft tissue lipoma represents a benign neoplasm or a local hyperplasia of fatty tissue or a combination of both. In 5–15% of patients, lipomas may be multiple. Multiple lipomas tend to be commoner in males. Lipomas commonly affect the upper back, neck, proximal extremities (particularly the shoulder), and abdomen. Lipomas around the shoulder are known to infiltrate between the muscles of the extremities and the thoracic wall. Surgical excision is still the best form of treatment if the lesion is symptomatic.

Small lipomas often may not be noticeable on radiography, while larger lipomas may show a typical radiolucency. Underlying osseous abnormalities are rare.

On US, lipomas appear as homogeneous hyperechoic lesion having no posterior acoustic enhancement.

Heterogeneity may be caused by septa or other non-lipomatous components.

CT appearance of a superficial lipoma is a circumscribed low-density lesion. Areas of calcification raise the suspicion of well-differentiated liposarcoma. Deeper and larger lesions may show scattered areas of intralesional soft tissue density. The possibility of liposarcoma needs to be considered when the lesion is heterogeneous. Intramuscular lipomas may invade and interdigitate with adjacent muscles.

Lipomas have a short relaxation time and they appear as high signal in both T1 and T2 in MRI. The T2 relaxation time is also short, but the fat still appears as a relative high signal in multi-echoes T2-sequences. Application of T1 Fat saturation technique completely suppresses the signal and can help to make a near histologic diagnosis of Lipoma.

Case 5

Clinical Presentation

A 57-year-old male presents with three months history of pain and limited range of motion of the right shoulder.

Radiological Findings

c5

Diagnosis: Total rupture with retracted proximal portion of long biceps tendon

Rupture of the biceps tendon often occurs after a sudden contraction of the biceps with resistance to flexion and supination of the forearm. Also, intrinsic degeneration of the tendon release and frictional wear of the tendon belly may have an impact.

The rupture mainly occurs in individuals between 40 and 60 years with chronic shoulder problems possibly due to overuse. Multiple tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. It can be worsened by repeating the same motions again and again. Overuse can cause a range of shoulder problems, including tendonitis, shoulder impingement,