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Re: Interesting case
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Re: Interesting case - February 4, 2005 6:31:00 AM
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ehanso
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The new films show what appears to be a longitudinal fracture of the tibia extending to involve the lateral tibial plateau. But i have a lot of trouble with the multple shade of grey. Will they ever be able to do them in color for the rookies. LOL
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Re: Interesting case - February 4, 2005 7:51:00 AM
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SJBird55
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Just a side question... are these images in weightbearing or nonweightbearing? Do you tag them somehow to know which is what? You said he couldn't walk, so I'll assume nonweightbearing, but just curious. With the surgeons I worked with, radiographs were always tagged with white pencil arrows if weightbearing otherwise if the technician didn't do that then we all knew the film was nonweightbearing.
All my eyes are drawn to is a lotta swelling.
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Re: Interesting case - February 4, 2005 3:14:00 PM
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pablo w
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There seems to be a fracture of the distal fibula visible on the AP film, just proximal to where the shadows of the tibia and fibula intersect. It could be an artefact but I don't think so. I can't see it on the lateral view. It's as if the lateral tibial condyle has been displaced inferiorly, forcing the fibula down with it and causing a spiral fracture of the distal fibula. Did they do ore views of the ankle?
Pablo
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Re: Interesting case - February 7, 2005 12:39:00 AM
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Alex Brenner PT MPT OCS
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Radiology report: The study shows a vertical fracture at the right lateral tibial plateau. The
fracture line is extending into the proximal right tibia. Moderate right knee joint effusion is noted.
[IMG]http://img.photobucket.com/albums/v85/brennerak/kneelat2.jpg[/IMG]
Interestingly the radiologist did not call this a pathological fracture although myself and our local orthopod felt there was something there. After speaking with the radiologist, he felt strongly that the patient was not giving the entire story and that there had to be trauma involved to obtain a fracture like this one.
What would be a good follow on study to examine further?
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Alex Brenner, PT, MPT, OCS
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Re: Interesting case - February 7, 2005 1:07:00 AM
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SJBird55
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Would a CT scan be the next step?
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Re: Interesting case - February 7, 2005 4:13:00 AM
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jma
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How about a bone scan as well? I think thats what it is called. I have heard reports that x-rays, correlated with bone scans can really increase the chances for a good diagnosis.
JMA
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Re: Interesting case - February 7, 2005 6:06:00 AM
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chiroortho
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Any time you hear or feel a pop in a knee like this, an MR is a good idea.
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Re: Interesting case - February 7, 2005 9:50:00 AM
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JLS_PT_OCS
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Well, maybe not for every joint noise...
Greg, you do mean a pop with immediate pain/ effusion, etc, right?
MR would be the next step for a soft tissue injury, agreed.
A bone scan won't show more than a hotspot, we already know it's there, that won't help.
To best image the fracture, CT study is what you want.
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Interesting case - February 7, 2005 10:03:00 AM
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jma
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Although a bone scan may show a hotspot, as mentioned previously, "a bone scan may also be useful to detect a nondisplaced fracture or traumatic lesion of a type not easily seen on a radiograph" (Erkonen 2005).
JMA
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Re: Interesting case - February 7, 2005 10:27:00 AM
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chiroortho
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Jason,
As you stated, we already know that there's a fracture there. MR has such great capability to image tumors that it would be my image of choice for a knee like this...effusion, fx on plain films, atraumatic. MR is getting downright good for fractures.
A CT wouldn't be a bad idea, I'd just personally pick an MR first. I don't think there is an absolutlely right or wrong answer.
We'll know more when Army posts the 'rest of the story'. Then in retrospect we can see who was right.
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Greg Priest, DC, DABCO
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Re: Interesting case - February 7, 2005 2:33:00 PM
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SJBird55
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Well, if the patient was telling the truth... then why in the world would the bone just fracture? If there was direct blunt trauma, he'd potentially have a lot of ecchymosis (which wasn't mentioned). If he hadn't had a systems review yet, I guess I'd do that. If something came up from that line of questioning, it might help direct the next steps.
Greg, that's what is so confusing to me - MRI vs CT. I have quite a few family members either battling cancer or gone from cancer. CT is/was the imaging preferred by the various specialists.
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Re: Interesting case - February 7, 2005 2:47:00 PM
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Dr.Wagner
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Man I really try to avoid this discussion.
An MRI is what you want (based upon availability and unless if contraindications exist). A CT is not unreasonable, just not preferred in my area.
Done.
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Re: Interesting case - February 8, 2005 3:42:00 AM
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JLS_PT_OCS
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I guess if he's got an effusion and there is concern for intraarticular injury, then I would have to agree with Greg and DocWagner...
MRI it is.
Good points well taken, gentlemen...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Interesting case - February 8, 2005 9:56:00 AM
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SJBird55
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I'd like to ask a really stupid question... when ordering further diagnostic tests, does one kind of think about/consider what tissues to be analyzed?
I don't order diagnostic tests, but here's my thinking on this particular case...
The dude has a decent sized fracture with an atraumatic history. He's got a ton of weird swelling and that lateral joint space/tibial plateau region looks goofy. Why the heck did the tibia fracture? Does he have bone density issues? I'd doubt that vascular issues would be the culprit, but how is the vascularization of that proximal lateral tibia? Does he have some kind of tumor or space occupying lesion? Did he possibly lie and the fracture was actually traumatic because as he was putting the suitcase in the car his wife put the car into neutral and he got pinned between the bumper and something else? Those would be my first intial questions, in no particular order. Beats me what should be technically ordered - but whatever answers those questions would initially appease me.
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Re: Interesting case - February 8, 2005 10:30:00 AM
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UTDC
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SJ
There does appear to be a lesion (lytic tumor)at the lateral tibial plateau. My guess is a giant cell tumor. This appears to be a pathological fracture, which would explain the relatively trivial mechanism.
Given the nature of the fracture(osteochondral) the effusion (hemarthosis) is not weird, as previously mentioned, this is something you usually see with such fractures, ACL ruptures and/or patellar dislocations.
I hope that helps.
Jeff
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Re: Interesting case - February 8, 2005 2:28:00 PM
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Jeep
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I'm going to guess:
Tibial fracture secondary to osteoid osteoma(the density that army circled).
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Re: Interesting case - February 8, 2005 2:41:00 PM
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SJBird55
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Jeff, if that's the theory you'd assume - well, what diagnostic test do you do to verify your guess?
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Re: Interesting case - February 9, 2005 2:16:00 AM
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Jeep
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Per my guess above:
Since ostoid osteoma is a benign tumor( or, if it is not osteoid osteoma, I still believe it to be a benign lesion, weakening the bone, thus leading to secondary pathological fracture), I would lean to CT,(b/c I would want to visualize bone more than soft tissue) but it would not really affect the prognosis or treatment much:
Healing of the fracture and reduce secondary peri-patellar effusion/edema.
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Re: Interesting case - February 9, 2005 2:49:00 AM
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Dr.Wagner
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To answer a previous question, when ordering diagnostics several things must enter your mind
1. standard of care
2. visualization
3. time frame/acuity of injury
4. cost
5. contraindications
MRI's are beautiful, they create simply fantastic pictures of bone and soft tissue without radiation. But they are expensive, require specialized radiologists to read them, and require a scheduled appointment (except in utmost emergencies). CT's are very nice and enable fantastic reconstructions (on newer units), are far more common (usually hospitals have 2-3 CT's per MRI) and are less expensive. They do cause radiation but (for the most part) are limited to the slices they create and simply don't create the best pictures in long bones (based on slices).
In other words, you can use either one. But an MRI will create a beautiful picture and is usually the test of choice (barring contraindications). Hell...you can potentially use both.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Interesting case - February 9, 2005 5:35:00 AM
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chiroortho
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We have guesses of osteoid osteoma and giant cell tumor. What other possibilities could this include? One thing I've learned about DDX'ing tumors is that it's rare to be able to dx a tumor by radiographic appearance alone. We can get lucky once in a while to be sure, but I'm always more impressed with a good ddx than I am an 'it's got to be this' diagnosis.
This could include osteoblastoma, osteoid osteoma, GCT, even a bone infarct.
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Greg Priest, DC, DABCO
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