Commonly missed diagnosis in musculoskeletal

conditions
Franz Kainberger
Department of Diagnostic Radiology
Division of Neuro- & MSK Radiology with Imaging CAD Lab
Medical University of Vienna

Objectives

Indications To recognise the importance of insufficient consideration of

clinical information
To stress the importance of a systematic approach to the
Interpretation interpretation of imaging, particularly radiographs
To learn about the differential diagnosis between stress
injuries, inflammatory processes, necrosis and tumors –
exclusive soft tissue tumors
Commonly missed diagnosis in
musculoskeletal conditions

USMLE-style questions

Part 1: STRESS, REPETITIVE

TRAUMA, ARTHRITIS

What is “common”?
The majority of the selected cases are
from primary imaging centers.
 Groin pain in athletes

adolescent semi-professional
male soccer player
• during training, groin pain on his
right side since a few days
• feels exhausted
• projection radiographs: normal

(1) infection
(referring physician‘s diagnosis)
(2) pubic stress reaction
(radiologist‘s diagnosis)
(3) Reiter‘s disease (reactive
arthritis) or other rheumatologic
disorder

Your diagnosis, please – VOTE NOW

 (1) - correct:
pubic osteomyelitis
Blood cultures (results sent a few days
after MRI) were positive for staphylococcus
aureus.

• osteomyelitis of the pubis is a rare, but control after 5 weeks

nevertheless classical infective location of
bone infection.
• most common complaint in both infection
and inflammation: pain under load, local or
pseudoradicular
• Biochemistry: normal or slightly
inflammatory in osteitis pubis, frankly
inflammatory in osteomyelitis.

similar case in an adolescent male

 (2) - incorrect:
pubic stress reaction

Osteitis pubis is a noninfective inflammation of

the symphysis pubis
• after urological or gynaecological procedures,
• associated with overuse or trauma

Pauli S et al. Osteomyelitis pubis versus

osteitis pubis: a case presentation and
review of the literature. Br J Sports Med
2002; 36: 71–73
 (3) - incorrect:
rheumatologic disorder
The best fitting rheumatic disease would be
chronic recurrent multifokal osteomyelitis
(CRMO).
Average age 8.3 years (range, 2.5–24 ys).
Principally in every bone.
Soft tissue involvement in this case does not
fit to this diagnosis.

Khanna G et al. Imaging of chronic

recurrent multifocal osteomyelitis.
2009 Jul-Aug;29(4):1159-77
 Teaching point: Top DDx
in groin pain in athletes

5 – 18 % of all athletic injuries,

predominantly kicking sports
1/3 of soccer players will develop
groin pain.
• traumatic injury to the adductor and
rectus abdominis muscles adductor edema due to horse riding
• osteitis pubis
• insufficiency fractures of the pelvis,
• posterior inguinal wall deficiency,
hernias („sportsman‘s hernia“)
• osteomyelitis pubis
pectineus
adductor longus
Koulouris G. Imaging Review of Groin Pain
in Elite Athletes: An Anatomic Approach to gracilis
Imaging Findings. AJR 2008; 191:962–972
Interlude – your diagnosis, please

Matterhorn from Wikipedia

Matterhorn (Switzerland) in the cloud

 Wrist pain

60 ys old female with left-sided

wrist pain, no trauma

(1) normal
(radiologist‘s diagnosis)
(2) late onset rheumatoid arthritis
(referring physician‘s diagnosis)
(3) De Quervain‘s disease
(4) psoriatic arthopathy

Your diagnosis, please

– VOTE NOW
(3) - correct:
De Quervain‘s tendovaginitis

Overuse of the tendons of the first dorsal

compartment of the wrist; diagnosed by a specific
provocative test (Finkelstein test)

This patient was left-handed.

 First dorsal wrist compartment

One of the tendons within the first

dorsal wrist compartment are from
the
(1)Extensor pollicis longus
(2)Extensor carpi radialis longus
(3)Flexor carpi radialis
(4)Abductor pollicis longus
(5)Adductor pollicis

Your answer, please – VOTE NOW

extensor pollicis longus tendon

Correct: (4)
extensor pollicis brevis tendon
adductor pollicis longus tendon
(1) - incorrect: normal radiograph

Soft tissue involvement is a very important indicator of stress reactions,

inflammation, trauma, or neoplasm.

Sausage finger (right thumb) PVNS RA with extensor carpi

ulnaris tendovaginitis
(2) - incorrect: Late onset rheumatoid
arthritis (LORA)

Abnormalities in RA are typically

located on ulnar side, radial side
involvement is unusual.

The 4 common disease entities of the hand Rheumatoid Arthritis

a – osteoarthritis
b – rheumatoid arthritis
c – pyrophosphate arthropathy
d – psoriatic arthropathy
Early arthritis – a commonly
missed diagnosis
(4) - incorrect: psoriatic arthropathy

periosteal
appositions
 Teaching point:
radial-sided wrist pain
• De Quervain's tendovaginitis:
Synonyms: housewife‘s thumb,
oarsman‘s wrist, washer woman‘s Image gallery
sprain
• Repetitive activities leading to
increased friction
• Gender: female : male = 8-10 : 1
• Top DDx:
- Intersection syndrome (proximal)
- Wartenberg‘s syndrome (irritation
of superficial branch of radial nerve)
 Interlude – your
diagnosis, please

Synovial thickening & knee effusion

formed as Venetian carnival mask
 Atlantodental destruction

66 ys male with marked

restriction of neck motion
and radiological report of
rheumatoid arthritis. All
other joints were normal.
No trauma.

(1)Rheumatoid arthritis
(2)Ankylosing spondylitis
(3)Dens pseudarthrosis
(4)Pyrophosphate
arthropathy (CPPD)

Your diagnosis, please

– VOTE NOW
 (4) correct:
Pyrophosphate arthropathy

Synonyms: CPPD - calcium pyrophosphate

deposition disease, chondrocalcinosis
crowned dens

other
patient

Goto S et al. Crowned Dens syndrome.

JBJS Am 2007 Dec;89(12):2732-6
 (1) incorrect: Rheumatoid arthritis

• Dens destruction without other joint

involvement is unusual
• CPPD (synonyms: Pseudo-gout,
Pseudo-RA) is an important DDx of RA
• Pseudobasilar impression
• Rheumatic stepladder
 (2) incorrect: Ankylosing spondylitis

• Dens destruction in ankylosing

spondylitis is rare

Teaching point:
Pyrophosphate arthropathy =
Pseudo-gout = Pseudo-RA
 Bathing Ladies
Auguste Renoir, 1919

Interlude – your diagnosis, please

 Specific low back pain

33 ys female after breast carcinoma

a few years ago. Now low back pain
with bilateral extension. A previous
MRI 6 months before was normal.
(1)metastasis
(2)osteoporosis
(3)stress fracture
(4)sacroiliitis

Your diagnosis, please – VOTE NOW

 (3) correct: stress fracture

Recently, the patient had bought a puppy-

dog carrying it regularly up and down from
her 4th floor appartment (without lift).

MRI one year

• sacral stress fractures later normal
30 – 40 casuistic publications, females mostly involved:
extensive running, basket & volley ball, aerobics
Major NM, Helms CA. AJR 2000: 174: 727
Shah MK, Stewart GW. Spine. 2002: 15;:E104
White JH et al. Clin Radiol. 2003:58:914
• SI-joint overuse
often combined with leg-length differences and/or
piriformis syndrome:
rowers, cross-country skiers
Brolinson PG et al. Curr Sports Med Rep 2003;
 (2) incorrect: osteoporosis

Sacral insufficiency
fractures: common in
•patients with low bone
mineral density
•after irradiation

78 ys female
after colonic
carcinoma
 (4) incorrect: sacroiliitis

Distinctive sign:
the „varigated picture“ (Dihlmann):
erosion + sclerosis + ankylosis
occur synchronously
endstage ankylosis
 Sacroiliitis – yes or no?

27 ys male with low back

pain during night. HLA-
B27 positive. Projection
radiograph of lumbar
spine and pelvis was
reported normal.
What is your next step in
the imaging workup?

(1) angulated views of SI-joints

(2) MRI
(3) CT Your diagnosis, please
(4) Bone scan – VOTE NOW
(2) correct: MRI
 Diagnosis of ankylosing spondylitis

The mean duration from Your diagnosis, please

the first onset of symptoms
until the definite diagnosis – VOTE NOW
of ankylosing spondylitis is

(3) Correct
(1)2 ys
(2)4.5 ys
Feldtkeller E. [Age at disease onset and
(3)7 ys delayed diagnosis of
spondyloarthropathies] Z Rheumatol 99
(4)9 ys
Feb;58(1):21-30.

It may be anticipated that the majority of

these patients undergoes imaging which is
reported as being normal.
Interlude – your diagnosis, please

Wladimir Mihailowitsch BECHTEREW

(1857 – 1927), russian psychiatrist
and neurologist. He diagnosed Stalin
with “grave paranoia.” Later that day
Prof. Bekhterev suddenly died.
 Elbow swelling
T1 axial + CE

60 ys female with swelling of

her elbow. No detailed history.

(1)Vascular malformation or
other soft tissue tumor
(2)Synovial chondromatosis
(3)Tendon rupture

Your diagnosis, please

– VOTE NOW
(3) Correct: rupture of distal biceps tendon

68 ys male, enthusiastic tennis

player, now painfully impaired
elbow flexion after skiing.

bicipito-
radial
bursitis

radius ulna
 (1) incorrect: vascular malformation

• The typical location and configuration tendon inserts both

strongly suggest biceps tendon at radius and in
rupture with pseudotumorous muscle fascia
configuration.
• AVMs occur in children and
adolescents.
(2) incorrect: synovial chondromatosis
 Teaching point:
Pseudotumors of the MSK-system

• Fat pad necrosis after minor trauma

• Foreign body reaction
• Chronic hematoma
• Morel-Lavallée lesion
• Inflammatory pseudotumor after
tendon rupture
• Myositis ossificans (subacute phase)
• Pseudoaneurysm
• Tumorous calcinosis

rectus femoris rupture

Interlude – your diagnosis, please

Budapest
 Painful greater toe

tall young lady, long periods of

standing and walking with high
heeled shoes in her profession

(1)fracturedsesamoid
(2)OA of greater toe
(3)gout

Your diagnosis, please

 Sesamoiditis – an underdiagnosed entity

• Stress fractures of 1st metatarsal are rare.

• „Sesamoiditis“ is more common and at
least in part due to mechanical stress
• Specific sports related overuse in soccer
players and dancers along the course of
the flexor hallucis longus tendon including
os trigonum.

Sesamoid stress fracture

in a ballet dancer

• medial sesamoid is in 14% of foot

MRIs abnormal.
• common observation in diabetics
• typical disease in racehorses
Kulemann V et al. Abnormal findings
in hallucal sesamoids on MR
imaging. Europ J Radiol (in press)
 Teaching point:
1st ray stress reactions – a kinetic chain
flexor hallucis longus tendon

33 ys male with painful greater toe during walking

Os trigonum stress
reaction in a balletteuse
Os trigonum stress fracture
in a soccer player

Stress reaction MT I
 Occult fracture

55 ys male after wrist

injury with dorsiflexion
• diffuse wrist pain
• projection radiographs
(including scaphoid series )
were normal

(1) Scaphoid fracture

(2) other fracture
(3) no fracture, but posttraumatic
synovitis
(4) two fractures

Your diagnosis, please

Correct (5):
scaphoid fracture and hamulus fracture
normal hamulus
for comparison

Yalcinkaya M et al., A rare wrist injury:

simultaneous fractures of the hamate
body and scaphoid waist. Orthopedics.
2009 Aug;32(8).

• Incidence of hamulus fractures: 1 %

• Findings: Dislocation of hamulus, fracture line,
edema
• Etiology: high-energy trauma with dorsiflexion
(ball catching) of closed fist in ulnarduction
R. Schedl (contemporary Austrian expressionist): „In the same
boat“