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A 45-year-old female twists her knee suddenly while playing tennis. She denies any history of knee pain in the past. Radiographs are shown in Figure A. What is the diagnosis?
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Idiopathic bone infarcts often occur in the metaphysis of long bones such as the femur and tibia. They are often asymptomatic and found on imaging studies for other reasons. The infarcted area undergoes progressive, but incomplete resorptive replacement. The bone infarct becomes surrounded by a thick and calcified fibro-osseous wall in a healing attempt. This accounts for the blotchy medullary and linear peripheral shadows seen in radiographs of old bone infarcts resembling “smoke up the chimney”.
Bone scans are cold in the early stages and hot as revascularisation occurs. The etiology is thought to be related to intrinsic/extrinsic vascular compromise such as atherosclerosis, arteritis, and thrombosis. Biopsy (usually unnecessary) shows mineralization of necrotic marrow elements. Bone infarcts usually are asymptomatic, and no treatment is required. If a patient presents with pain, another etiology should be sought. Rarely, malignancy, such as a malignant fibrous histiocytoma, can occur at the site of a bone infarct
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