The Teaching Files: Musculoskeletal: Expert Consult - Online and Print (Teaching Files in Radiology)

811 Pages·2009·90.589 MB·English

by  Hugue A. Ouellette MD

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THe TeAcHinG FileS: MuSculoSKeleTAl  iSBn: 978-1-4160-6261-5
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Library of Congress Cataloging-in-Publication Data
ouellette, Hugue.
 The teaching files. Musculoskeletal imaging/Hugue A. ouellette. — 1st ed.
   p. ; cm.
 includes bibliographical references.
 iSBn 978-1-4160-6261-5
 1. Musculoskeletal system—imaging—case studies. 2. Musculoskeletal system—Disease—
Diagnosis—case studies. i. Title. ii. Title: Musculoskeletal imaging.
 [DnlM: 1. Musculoskeletal Diseases—diagnosis—case Reports. 2. Diagnostic imaging—methods—
case Reports. 3. Musculoskeletal System—injuries—case Reports. We 141 093t 2010]
 Rc925.7.094 2010
 616.7’075—dc22  2009037444
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Printed in china
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To Gabrielle and Emanuelle

Preface
The Teaching Files: Musculoskeletal: expert consult uses  concepts and technologies are provided. expert consult 
a case-based, visual approach to easier diagnosis. The  comes with convenient access to the full text online, 
book is intended for the working general radiologist  all of the book’s illustrations, and links to Medline at 
and musculoskeletal radiologist in fellowship training,  expertconsult.com
although radiology residents may also find it useful. Special thanks to James Thrall, MD, who in my opi-
Practical and clinically focused, this musculoskeletal  nion has built the greatest radiology department in the 
title  in  the  new  Teaching  Files  series  provides  400  world aatt MMaassssaacchhuusseettttss GGeenneerraall HHoossppiittaall,, aaannnddd tttooo TTThhheeerrreeesssaaa 
interesting cases and over 700 high-quality images to  Mcloud, MD, for her educational mentorship. Thank  
help you better diagnose any musculoskeletal disease  you to Daniel Rosenthal, MD, Susan Kattapuram, MD, 
or disorder. The book organization is intended to make  and  William  Palmer,  MD,  all  my  colleagues  in  the 
referencing of difficult diagnoses easy. every chapter  musculoskeletal  division  of  Massachusetts  General 
consistently  includes  Demographics/clinical  History,  Hospital, and our fellows and residents for teaching 
Findings,  Discussion,  characteristic/clinical  Features,  me almost everything i know about musculoskeletal 
Radiologic Findings, Differential Diagnosis, and Suggested  disease.
Readings to make reference to the work optimal. Detailed 
up-to-date  discussions  of  current  musculoskeletal   Hugue A. ouellette, MD
vii
Case 1
Demographics/clinical history Characteristic Clinical Features
Patients have a history of significant flexion injury to the
A 32-year-old man with a history of trauma, undergoing
cervical spine.
CT.
Characteristic Radiologic Findings
On radiography and CT, malalignment of the cervical
FinDings spine at the affected level is visible. There is typically
anterior displacement of the proximal articular facet rel-
Sagittal reformatted CT images show anterior displace-
ative to the more caudal level.
ment of the C4 facet articular surfaces relative to C5 fac-
ets, in keeping with bilateral locked facets (Figs. 1 and 2)
Diagnosis
and anterolisthesis of C4 over C5 (Fig. 3).
Bilateral facet dislocation
Suggested Readings
Discussion Carrino JA, Manton GL, Morrison WB, et al: Posterior longitudinal
ligament status in cervical spine bilateral facet dislocations. Skel-
Definition/Background
etal Radiol 35:510-514, 2006.
Bilateral facet dislocation is a hyperflexion injury that
results in an unstable cervical spine.

Case 1 
Figure 1. Sagittal reformatted CT image of the right aspect of the Figure 2. Sagittal reformatted CT image of the left aspect of the
cervical spine. There is anterior displacement of the C4 facet ar- cervical spine.
ticular surface relative to the C5 facet, in keeping with locked
facets. A small fracture fragment is noted from the superior tip of
the C5 articular facets.
Figure 3. Sagittal reformatted CT image of midline. There is
anterolisthesis of C4 over C5.
Case 2
Demographics/clinical history Characteristic Clinical Features
Disk bulges may be asymptomatic or may cause pain.
A 50-year-old man with back pain.
Characteristic Radiologic Findings
On CT scan, there is typically broad protuberance of the
FinDings disc material which may cause central canal or forami-
nal stenosis.
Sagittal reconstructed and axial CT scan images status
post-discography. There is contrast in the L2/L3, L3/L4,
Diagnosis
and L4/L5 discs (Fig. 1). There is a diffuse annular bulge
Disk/annular bulge
at the L4/L5 with mild compression of the thecal sac
(Figs. 1 and 2).
Suggested Readings
Anderson MW: Lumbar discography: An update. Semin Roentgenol
39(1):52-67, 2004.
Discussion
Definition/Background
Discography is a provocative test that entails injecting
contrast into a disk to elucidate which injected level
reproduces the patient’s symptom.

Case 2 
Figure 2. Axial CT scan image status post-discography. There is
contrast in the L4/L5 disks. There is a diffuse annular bulge at the
L4/L5 with mild compression of the thecal sac.
Figure 1. Sagittal reconstructed CT scan image status post-discog-
raphy. There is contrast in the L2/L3, L3/L4, and L4/L5 disks.
There is a diffuse annular bulge at L4/L5 with mild compression
of the thecal sac.