Have a look at the images below. Shoulder pain.
Got your diagnosis? Good. Now look at the following image- taken a few weeks before the ultrasound above
So- still think it's calcific tendinitis?
The patient suffered an anterior dislocation previously. See the defect on the inferior glenoid rim on the radiograph above? That's a bony Bankart.
And if you go up to the fragment shown above, it does look suspiciously like a piece from the glenoid defect. It's too well-circumscribed and well demarcated. Also, with such a large calcific fragment, shouldn't there be more swelling of the tendon?
So, knowing what you now know, it's likely the bone fragment from the bony Bankart displaced up into the supraspinatus tendon! Take home message: if it's too sharp, look again. Calcific tendinosis is fluffy.
72/male with TKR done about 9 months ago, recent minor trauma and this is the radiograph.
Fractured patella, post total knee replacement.
The reported incidence of patellar fracture after total knee replacement varies markedly, ranging from 0.5% to 3.8%. Most fractures present within a year of TKR, and in elderly patients, suggesting that there is underlying bone weakness. Technical factors are important and include patellofemoral malalignment, femoralor tibial component rotational malalignment, patellar devascularization,lateral retinacular release, and excessive or inadequate patellar resection. In this case, the patellar is shaved very thin.
Osteonecrosis of the patella is another consideration. The vascular network of the patella is at risk during total knee replacement surgery. Median parapatellar arthrotomy, fatpad removal, and lateral release all contribute to patellar devascularization.
A nice review of the topic can be found here.
- Thanks to Dr Ian Tsou for a very nice contribution.
Here's a pelvic radiograph. 78-year old male with pain.
There are coarse trabeculae with cortical thickening, and enlarged pelvic bones. The rest of his skeleton was unremarkable except for vertebral osteopaenia and compression fractures. There's a pathological fracture of the inferior right acetabular rim. Findings are likely related to Paget's disease. His alkaline phosphatase was normal.
The pelvis and femur are common sites for Paget's. Strange places for Paget's to present include monostotic Paget's of the patella and also the fingers!
The high bone turnover that characterises this syndrome accounts for increased alkaline phosphatase (but not always raised). Vascular steal syndromes of the skull and vertebrae can result in somnolence, and compression fractures. Bony overgrowth leads to accelerated osteoarthritis, and nerve impingement (such as loss of hearing). And the dreaded complication of osteo or even chondrosarcomas must be looked out for (under 1% of patients). Pathological fractures are a frequent complication and may be the presenting feature, with a reported incidence of between 10% and 30%
It's easy to forget the tentative link Paget's has with bird ownership (paramyxovirus).
Forestier's disease, or disseminated idiopathic hyperostosis (DISH), may affect patients with PD, and should not be confused with focal Pagetic bone formation.
RSS Feed