What is the unusual anatomic variant in this wrist case?

This 29-year-old male presented with a traumatic injury of the left palmar wrist. What anatomic variant seen in this patient must be taken into account?

Ulnar-sided pain in this case can be attributed to:

  • ECU tenosynovitis, tendinosis, and longitudinal partial-thickness tearing (images 3 and 4, arrows).
  • ECU subsheath inflammation (horizontal arrow-image 3).
  • Peripheral TFCC attachment sprain/swelling distal to ulna (image 4).

As for the unusual anatomic variant, this case is an example of an extensor digitorum brevis manus, which is indicated by the arrows in images 1 and 2. For more case review, visit MRI Online.

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What does this foot case have to do with a Bill Murray movie?

This 49-year-old presents with an ulcer, open wound and renal insufficiency. For some reason, this calls to mind Sergeant Hulka’s big toe. Which movie features Sergeant Hulka? What should you call this infection?

Sergeant Hulka appears in the movie ‘Stripes,’ with a cast that includes Bill Murray and John Candy. As for this infection, it’s a soft tissue infection with cortical irregularity (arrow) and edema. When you see those findings, without bone destruction or erasure, it’s consistent with cortical osteitis, superficial osteomyelitis or noninvasive osteomyelitis. For more case review, head to MRI Online.

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What does a farm animal have to do with this shoulder case?

A 68-year-old man presents with shoulder pain after many years of repetitive motion. His deformity shares a name with a farm animal, but which one is it?

This deformity is known as the “goat beard deformity” and it’s indicated by the arrow in the first image. More shoulder case review is available at MRI Online.

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What is this infant’s diagnosis after suspected Zika exposure?

This 3-month-old is suspected to have had Zika and toxoplasmosis exposure during pregnancy. Given these factors, and based on the four MRI images and one CT image (bottom) shown, what is her current diagnosis? Are there notable components of the brain that have been spared?

The sequela to this Zika/toxoplasmosis exposure is diffuse cortical dysplasia and dense periventricular calcification. There is also schizencephalic contour abnormality in the left frontal cortex. The posterior fossa and pontomedullary junction regions are spared. For more neuro case review, head to MRI Online.

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What is this nine-year-old’s unusual gymnastics injury?

This 9-year-old presents with an elbow injury from gymnastics. What is the mechanism? What does the solitary arrow indicate? What is the accompanying soft tissue injury? What do the double arrows indicate?

The findings are the result of an acute valgus insult. The capitellum (single arrow) is edematous, a sign of this mechanism. The soft tissue injury is that the ulnar collateral ligament is torn proximally, an unusual injury in a 9-year-old. There is an avulsed ulnar collateral ligament from its origin as stated above (double arrows). For more case review, head to MRI Online.

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What should you do with this tricky skull base case?

This 59-year-old woman presents with “fluid behind the ear and ear pain'” for months. Lots of physicians try to pass off a skull base middle ear case to another doctor in their group, but we seek to change that. In image one, the three arrows on the left identify what three regions of the middle ear? In image two, what is the ossicular “joint”? What does the vertical arrow show in image three?

 

 

In image one, the three arrows on the left identify epitympanum (upper arrow), mesotympanum (middle arrow) and hypotympanum (lower arrow). The arrow in image two points to the incus-malleus articulation. The arrow in image three shows a dehisced and destroyed tegmen tympani. For more neuro case review, check out MRI Online.

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What has happened to this man’s finger?

This is a 48-year-old man who fell nine months ago and now has swelling and pain in the right index finger.

  1. What do the paired arrows label in image 1?
  2. What does the single arrow label in image 1?
  3. What does the single vertical arrow label in image 2?
  4. What do the sets of three paired arrows label in image 2?
  5. With image three, what do you think is the patient’s story?

Answers

  1. The paired arrows point to a torn ulnar collateral ligament in the first image.
  2. The single long arrow points to periosteal perpendicular reaction (first image).
  3. The single vertical arrow (second image) points to an inflamed irregular destructive erosion.
  4. The multiple short-axis arrows on T1 coronal imaging (second image, three paired arrows) point to extensive periosteal reaction.
  5. The most plausible explanation for what has happened to this finger is a traumatic injury leading to instability, cartilage injury and collateral ligament injury resulting in chronic indolent infection of the joint space. To back this up, see short-axis axial T2 in which arrows point to a large proteinaceous palmar effusion (short-axis T2 arrows, third image).
  6. For more case review, head to MRI Online.

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Is there endometriosis in this 32-year-old woman?

This 32-year-old female presents with uterine fibroids, fertility problems and complaints of lower back pain with menstruation. There is questionable endometriosis, so what’s your call? And any other observations?

There are bilateral, thick-walled (T1 hyperintense, T2 iso- hypointense) cystic lesions present in the adnexal regions (arrows-images one and three). These are consistent with endometriomas. Hypointense focal thickening of the retrocervical region with small areas of T1 hyperintensities may represent deep endometriosis (arrows, images two, four and five). For more case review, visit MRI Online.

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What are the best MRI next steps for a stroke patient?

This 69-year-old male presents with visual deficit. The finding on CT is a left occipital stroke. In what vascular territory is it distributed? Would the MRI be positive? More specifically, would a FLAIR MRI be positive? What about a diffusion MRI?

The location of the stroke is the left posterior cerebral artery territory. FLAIR MRI would never be normal when CT is positive. It is inordinately more sensitive and positive in the first 24 hours after a stroke. The diffusion MRI is positive even earlier than the FLAIR, as early as three hours.

ProScan Pearl: To find blood in a stroke on MRI, consider blood-sensitive sequences like BSI (Hitachi), SWI (GE), SWAN (Siemens) or Venous BOLD (Philips). Blood in a small stroke may “hide” or obscure diffusion imaging findings – pseudonormality. For more neuro case review, head to MRI Online.

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What’s the life-threatening finding in this knee case?

This 57-year-old male presents with a large mass. What is it? But, more importantly, on these axial water-weighted MRI images, what is the potentially life-threatening finding?

Axial T2

Axial PD

 

The high signal mass is a gastrocnemius semimembranous bursal cyst (one of the many types of Baker’s cysts). The life-threatening finding is the absence of flow phenomena in the popliteal vein. This thrombosis (arrows) can eventually result in a pulmonary embolism. When a Baker’s cyst clinically simulates a popliteal thrombophlebitis, this is called pseudothrombophlebitis. But when it actually coexists with the thrombophlebitis due to compression (as in this case) it is called pseudo-pseudothrombophlebitis.

After you try to say pseudo-pseudothrombophlebitis five times fast, head to MRI Online for more knee case review.

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