HPI - Symptoms started 2.5 years ago. History as below:
1) 01/2015: Pain at Right Ankle. No history of trauma. MRI: Bone marrow edema of Right Calcaneus. Non-weight bearing improved the clinical symptoms.
2) 10/2015: Pain at Right Hip. No history of Trauma. MRI: Bone marrow edema of Right Hip (Femoral head and small bone marrow edema of acetabulum). Non-weight bearing improved the symptoms.
3) 06/2016: Pain at Left Ankle. No history of trauma. MRI (Both ankles): Bone marrow edema of Left Calcaneus. No Bone marrow edema in Right Ankle.
4) 09/2016: Pain at Right Ankle. No history of trauma. MRI (on both ankles, images attached).
MRI(Right Ankle): Bone marrow edema of Cuboid, Base of 2nd metatarsal and medial cuneiform bone.
MRI(Left Ankle): Bone marrow edema of Cuboid, Middle & Medial cuneiform bones, base of 2nd and 4th metatarsal bone. Osteochondral dissecans of talar dome.
Non-weight bearing improved the symptoms.
5) 12/2017: Pain at Right ankle. No history of trauma. MRI of Right Ankle (images attached): Bone marrow edema of distal/metaphysis & epiphysis of right tibia.
CBC, Glucose, Urea, Creatinine, HDL, LDL, SGOT, SGPT, ALP, Fe, Ca, P, LDH, K, Na, PT, aPTT, d-dimers, TSH, FT4, CRP, ESR, Ra-Test, C3, C4, Anti-CCP, ANA, ACA-G/M, β2 GPI IgG/IgM: ALL NORMAL VALUES
What's your opinion? What's next in lab test/imaging/differential diagnosis?
HPI - Sustained a fall from height in December 2015 for which he was operated on with a DHS. Was made to weight bearing as tolerated after 2 months after which he had pain and shortening. At present, he is walking with a single crutch.
How would you manage this patient at this stage?
HPI - 68 year old male patient presents with the chief complaint of bilateral hip and sacral pain. He has bilateral lower extremity paralysis since the age of ~20 after receiving the rabies vaccination. He is admitted for management of a grade 4 pressure ulcer of the sacrum.
What is the underlying diagnosis?
HPI - 16F presents in January of 2015 with Left Ankle pain. No history of trauma/injury. Xrays are normal. MRI showed Bone Marrow Edema (BME). Non-weight bearing is advised.
In October of 2015, she presents with right hip pain/limited movement of her right hip because of pain. No history of trauma/injury. MRI’s (Right hip & Left ankle) show BME in her right hip and improved BME in her left ankle. Non-weight bearing and rest in advised.
In January of 2016 screening MRI’s (Right hip & Left ankle) are performed. They show an improvement of her previous BME in her right hip and eradication of the BME in her left ankle. Clinically, she is getting better.
In May of 2016 she presents with Right ankle pain with limited movement due to the pain. No history of trauma/injury. MRI is performed and it again shows BME of her Right ankle and Right calcaneus.
Lab tests (lupus, ACA, β2 GPI, thyroid hormones, protein electrophoresis, CRP, RA-test, C3, C4, Anti-CCP, ANA, FBC,ESR, PT/APTT, INR, D-dimers) are all normal.
Her symptoms were getting better until today. We have already planned MRIs of both her ankles and Right hip.
Xrays & MRI pics are attached.
What is the likely diagnosis in this patient?
HPI - Right hip pain x 4 weeks, worsened by ambulation
Do you agree this right hip fx is an atypical femur stress fracture associated with prolonged use of bisphosphonates?
HPI - Optd for closed fracture shaft femur in Jul 2014 - Open reduction + IL IM nailing femur done.
Dynamization of nail was done oin Oct 2014.
Was ambulant and no pain till Apr 2015.
Sustained slip in Apr 2015 and developed pain and swelling right thigh and painful weight bearing.
HPI - Delayed milestones
Most common association with this radiographic picture.
HPI - 58 y/o postmenopausal long distance runner with 3 month history of left groin pain. MRI shows stress lesion subtrochanteric proximal 1/3 of MEDIAL femoral cortex
How would you treat this patient at the current time?
HPI - Conservative treatment for 7 months
What is the best treatment?
HPI - 08 y/F. History of developing abscess left arm 02 yrs ago. Treated at different center with drainage. Reemergence of abscess after 02 months which had been again treated with drainage. Was given anti tubercular treatment for 09 months (Details of indications and medical records not available with patient at the time of presentation to us).
What is your preferred procedure for reconstruction of such cases in paediatric age group following resection of pseudoarthrosis.
HPI - h/ MVA 1 year ago treated elsewhere a year back with retrograde femur nailing patella tension band and tibial nailing. foot conservative casting. patient is walking without support .only complant is knee pain
How would you treat the femoral nonunion?
HPI - case of fall 3 mths ago.sustained injury tio left leg was diagnosed with left tibia fracture. was advised surgery by another surgeon.patient refused surgery and was put in a cast for 3 mths.now unable to bear weight on affected leg and complaining of pain
HPI - patient sustained an intraarticular distal humerus fracture a year back for which he was treated with a single screw(??).since then he has limited range of motion which he has difficulty for his toilet hygienic purposes.
the screw was removed under GA and range of motion was assessed. no difference in range of motion under GA and when patient is conscious.
patient has been on physiotherapy for long with no improvement in range of motion
operative intervention or leave it alone
HPI - case of fracture femur sustained 6 months ago .fixed with interlockin nail.now comes with occasional pain very minimal.patient is walking full weight bearing without any support
has the fracture healed completely or is this delayed healing
HPI - h/o RTA 5 mths ago treated by rt radius fixation nad left tibia nailing.radius healed uneventful.pain in leg since full weight bearing after 6 weeks.its 5 months since surgery. no intervention since then
What would be your treatment of choice
HPI - patient had sustained a fracture femur after fall from height 1year 2 mths ago. after which he was operated with locking nailing.
operative managemnt or conservative
HPI - pain right shoulder for two weeks duration..dull aching increased with carrying heavy objects.non radiating..relieved with NSAIDS..bowel bladder habit normal...no hx of fever in the past...developmental milestones normal..
what is your diagnosis???
HPI - History of trivial trauma to right thigh leading to pain and inability to bear weight.
Generalised muscular pain for last 5 years with weakness over both lower limbs for 3 years.
Cane assisted community ambulator for 3 years.
Non progressive swelling in the neck for last 7 years.
Further management of the Fracture Femur and Options for Prophylactic Fixation
HPI - Pain in L knee x3 years. Pain is 3/10 and increases to 10/10 with activity.
What would be your definitive procedure?
HPI - h/o fall down b4 a week, at present pt came with swelling, with no redness but swelling.
whats is the best investigation for this case?