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The Case of the Painful Leg . David Mansoor Radiology, Feb 2004. HPI. 12 y.o. male with 1 year history left thigh pain Acute onset 1 year ago and has persisted since No inciting event “pressure” sensation on inner part of left thigh Denies sharp or shooting sensations

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The case of the painful leg l.jpg

The Case of the Painful Leg

David Mansoor

Radiology, Feb 2004


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HPI

  • 12 y.o. male with 1 year history left thigh pain

  • Acute onset 1 year ago and has persisted since

    • No inciting event

  • “pressure” sensation on inner part of left thigh

    • Denies sharp or shooting sensations

    • Denies numbness or weakness

    • Increases in severity with activity

  • Predominately at night, makes it hard to sleep

  • Denies constitutional sxs (fevers, weight loss, etc)


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None

Aspirin 225mg bid

Left proximal medial thigh tenderness

No limitations in ROM

No pain with movement

Normal gait

PMH PE


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Idiopathic (growing pain)

Trauma (muscle bruise, fracture, etc)

Bone tumor (malignant—osteosarcoma, Ewing’s tumor; benign—osteoblastoma, osteoid osteoma; metastatic)

Infection and inflammation (osteomylitis, myositis, TB, etc)

Other (slipped capital femoral epiphysis, Legg Calve Perthe’s Dz, etc)

DDx of Leg Pain in Children


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CBC

Electrolytes

X-Ray

ABG

More history

CT

Workup (you choose)…


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Diagnosis…

  • Osteoid Osteoma

    • A benign skeletal neoplasm of unknown etiology, usually smaller than 1.5cm

    • Consists of a central small nidus of osteoid surrounded by a zone of reactive sclerotic bone

      • (osteoid is immature bone that has not yet undergone calcification)


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Histology

  • Nidus of osteoblasts and osteoid arranged in a haphazard fashion

  • Sharp demarcation between nidus and reactive bone

  • The nidus is highly vascular


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Epidemiology

  • Accounts for 10% of all benign bone tumors

  • Males are effected twice as much as females

  • Age range 5-56

    • 90% are 5-25

  • Proximal femur>tibia>spine>humerus


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No malignant potential

Occasionally regresses spontaneously

May induce scoliosis if spinal column is involved

Pain, pain, pain

Skeletal bone pain

Worsens at night

Worsens with EtOH

Relieved by aspirin

Mortality/Morbidity


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Radiography

CT

MRI

Bone Scan

U/S

Angiography

Imaging Modalities


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Radiography

  • Can provide the best diagnostic capacity when coupled with clinical history

    • Ovoid lucent defect seen in 75%

  • Some areas are difficult to assess

    • Spine (but look for scoliosis), femoral neck, small bones of hands and feet, intraarticular (but look for joint effusion)

  • New bone formation can mask nidus

  • Osteomyelitis mimics


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CT

  • Ultimate diagnosis for precise localization of nidus and guiding percutaneous ablation

  • Great for areas with complex anatomy such as spine and femoral neck


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MRI

  • Nidus is usually masked by sclerotic bone

  • Presence of marrow and soft tissue edema closely simulate osteomyelitis on MRI

  • Good for intraarticular lesions, as the osteoma causes synovial thickening, inflammation, and joint effusion

  • Not usually utilized


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Bone Scan

  • Technetium-99 bone scan shows area of increased uptake

  • Very sensitive technique

    • Findings may be positive before radiographic changes are present

    • Specificity is low


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U/S

  • Limited studies to date

  • Duplex color Doppler U/S demonstrates the highly vascular nidus

  • Can help dx intra-articular osteoid osteomas, but not well studied

    • Cortical irregularity and focal synovitis


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Angiography

  • Useful because the osteoid osteoma is highly vascular

  • Characteristic blush seen in venous phase

  • May be useful in differentiating tumor from osteomyelitis

  • Invasive so rarely used


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Treatment

  • Removal of the nidus is the only way to cure

  • Surgical (invasive, not usually used)

  • Ablation is the mainstay of treatment

    • Percutaneous

      • Radiofrequency*

      • Ethanol

      • Laser

      • Thermocoagulation


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First report of success by Rosenthal et al. in 1992

Now considered to be safe, minimally invasive, and cost-effective treatment

Radiologists role is not only to diagnose but also treat!!

Training is offered to musculoskeletal & interventional fellows

Radiofrequency Thermal Ablation: CT Guided

Rosenthal D, Rosenberg A, Springfield D. Ablation of Osteoid Osteomas with a Percutaneously Placed Electrode: A New Procedure.

Radiology. 1992; 183:29-33


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RTA: Principle

  • Alternating current of high-frequency radio waves passes from the electrode tip in body tissue and dissipates its energy as heat

  • Different than electrocautery in that the tissue around the electrode (rather than the electrode itself) is the primary source of heat


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RTA cont’d

  • Should only be performed when definite nidus is visualized

  • CT guided affords best visualization of needle and probe placement directly within nidus

  • General anesthesia is used as entering the nidus is VERY painful; also to prevent patient movement


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Contraindicated in patients with cardiac pacemakers

Complications during needle passage: bleeding and nerve injury

Complications also include soft-tissue burns, infection, skin necrosis in superficially located tumors

RTA: Contraindications and Complications


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RTA: Technique

  • Determine precise location of lesion using CT

  • Plan an entry point perpendicular to the skin surface; aim is to puncture in the scan plane

  • Insert penetration cannula (confirm position with serial scans)

  • Insert drill through cannula and drill to the edge of nidus (confirm location with further scans)

  • Remove drill and insert RF probe


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RTA: Technique cont’d

  • Temperature at end of probe is 90 C, kept there for 4 minutes

  • 50% of ptnts will have a physiological reaction (increased HR, BP, etc)


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RTA: Postprocedure Healing

  • Pain afterwards is variable

    • Up to 1 or 2 days after the procedure

    • Analgesia is rarely required

  • Can bear weight immediately after and return to normal activities

  • Resolution of pain is used to define successful treatment

    • Success rate of 92% in 130 patients

Pinto et al. Technical Considerations in CT-guided Radiofrequency Thermal Ablation of Osteoid Osteoma: Tricks of the Trade.

American Journal of Radiology. December 2002.



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Growing Pains

  • Common in kids age 5-10

  • Not very well localized, worse at night

  • Not chronic

  • Should not keep kids up at night

  • Radiographic findings: normal


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Trauma

  • Not likely as there is no inciting event

  • However…stress fractures don’t have a clear inciting event

    • tibial stress fractures are most common in children, then metatarsal stress fractures

    • femoral stress fractures are rare and usually found in endurance athletes

  • Radiography: fracture may not appear for 2-10 weeks after symptom onset; MRI & bone scintigraphy more sensitive


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Tumor

  • Likely, given persistence as well as focal location of symptoms

  • Radiography: vary greatly


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Infection

  • Can be chronic osteomyelitis (despite lack of fever)

  • Radiography: areas of ill defined bone destruction with cortical thickening (causes sclerosis and widening of bone)


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Slipped capital femoral epiphysis

Most common hip disorder in teens, occurs during growth spurt

boys>girls, usually overweight

Fracture through growth plate of proximal femur with relative slip of the epiphysis (femoral head “slips” off neck of femur)*

Persistent pain with limp

radiography

Legg Calve Perthe’s Disease

Idiopathic avascular necrosis of the femoral head

Most common in boys 4-10

Persistent pain with limp, limited range of motion, atrophy of upper thigh muscles

radiography

Other


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SCFE

  • Widened physeal plate

  • Metaphysis displaced laterally


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LCPD

  • Femoral head appears mottled

  • Femoral neck is shortened and thickened

  • Acetabulum is flattened


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More History

  • Pain is relieved by aspirin but not tylenol or ibuprofen


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CBC

  • normal



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ABG

  • Normal




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Radiography

  • At base of femoral neck medially is a small lucent area surrounded by more dense bone

  • Nidus usually smaller than 1.5cm


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CT

  • Notice the radioluscent central nidus surrounded by the thickened cortex


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