Skull Radiographs Research Articles

Use of Simple Skull Radiographs in Orbital Correlations in Nigeria

Introduction: Anthropometric measurements have been carried out in many studies to segregate people into races, ethnicity and various biological traits in the past. Such studies include cephalometry being deployed because of its significance in forensic and clinical evaluations of individuals. The objective of this study is to determine the correlation between the shape types of the orbit with different age groups and their prevalence using simple skull X-rays.
 Materials and Methods: Plain X-rays of the skull with posteroanterior exposures were obtained for a retrospective period of 5-year period from 2004 to 2009. The selected radiographs were those based on clear recognition of their orbital margins assessed by 2 experienced Radiologist who determined the shapes of the orbits as being oval, circular or quadrangular. Out of total of five hundred (500) plain X-rays of the skull obtained, only 255 satisfied the inclusion criteria.
 The data was analyzed statistically using INSTAT software to compare the mean values in relation to age distribution of the subjects with the Student’s T-Test. Chi-Square (with Yates correction) was used for the comparison of proportions.
 Results: In the first 30 years of postnatal life, the oval shape orbit had been found to be more predominant with values of 22(64.7%), 17(30.9%), and 27(38.0%) respectively. As from the age of 30 to 70 years, the circular type had values of 16(34.0%), 8(33.3%), and 8(61.5%) respectively in each of the decades. Between the age of 60 to 70 years, the oval and circular types had equal prevalences.
 Conclusions: In addition to the known oval and quadrangular (triangular) types of orbital shape, this study revealed a 3rd type of orbit which we described as circular in shaped. The oval type of orbit is found to be more common from birth to age of 30 years but from but from 40 to 70 years the circular type predominates.

A Comparative Analysis of Frontal, Maxillary Sinus and Pyriform Aperture as Gender Identification Tool Using Radiographic Morphometric Parameters

The study was done with the aim to check for the reliability of morphometric parameters of frontal and maxillary sinuses along with pyriform aperture for sexual dimorphism on posteroanterior skull radiograph in young adults. 30 individuals with equal distribution of females and males were selected considering inclusion and exclusion criteria and PA skull view of same were analyzed for frontal sinus, maxillary sinus and pyriform aperture parameters using Carestream Dental imaging software 6.14.7 CS 3D. Statistical analysis establishes frontal and maxillary sinus parameters in comparison to pyriform aperture parameters as reliable tool for gender assessment.

GNAQ/GNA11 Mosaicism Is Associated with Abnormal Serum Calcium Indices and Microvascular Neurocalcification

Mosaic mutations in genes GNAQ or GNA11 lead to a spectrum of diseases including Sturge-Weber syndrome and phakomatosis pigmentovascularis with dermal melanocytosis. The pathognomonic finding of localized "tramlining" on plain skull radiography, representing medium-sized neurovascular calcification and associated with postnatal neurological deterioration, led us to study calcium metabolism in a cohort of 42 children. In this study, we find that 74% of patients had at least one abnormal measurement of calcium metabolism, the commonest being moderately low serum ionized calcium (41%) or high parathyroid hormone (17%). Lower levels of ionized calcium even within the normal range were significantly associated with seizures, and with specific antiepileptics despite normal vitamin D levels. Successive measurements documented substantial intrapersonal fluctuation in indices over time, and DEXA scans were normal in patients with hypocalcemia. Neurohistology from epilepsy surgery in five patients revealed not only intravascular, but perivascular and intraparenchymal mineral deposition and intraparenchymal microvascular disease in addition to previously reported findings. Neuroradiology review clearly demonstrated progressive calcium deposition in individuals over time. These findings and those of the adjoining paper suggest that calcium deposition in the brain of patients with GNAQ/GNA11 mosaicism may not be a nonspecific sign of damage as was previously thought, but may instead reflect the central postnatal pathological process in this disease spectrum.

Association between Bolton Analysis and Dentoskeletal Parameters of Patients with Malocclusion

The mesiodistal diameter of the teeth must be considered during orthodontic diagnosis; the implementation of measurement tools has made it possible to classify each patient into parameters that determine their treatment needs. The aim of this study is to analyze the association between the Bolton Index and dentoskeletal parameters in patients who come to receive orthodontic treatment at the University Polyclinic of the Mexicali Faculty of Dentistry of the Autonomous University of Baja California. A cross-sectional analytical observational study was carried out. The sample consisted of 45 initial plaster models that met the inclusion criteria. The models were measured to obtain the Bolton Index. Lateral skull radiographs were plotted to determine skeletal class according to Steiner's cephalometric analysis. The data were collected and tabulated in Microsoft Excel 365. A two-factor analysis of variance was performed with several samples per group to determine the association between the Bolton Index with dentoskeletal parameters and sex. To compare the mesiodistal measurements of the teeth, a test was performed. hypothesis for a two-tailed mean difference where the normal distribution was used in both with a significance level of α=0.05. No statistically significant results were found between the values of the analysis of variance and the normal distribution value with a confidence interval of α=0.05. In conclusion no statistically significant difference was found between the results of the dentoskeletal parameters between men and women that determine an association with Bolton index discrepancies.

Osteogenic and fibroblastic osteosarcoma associated with the alveolar bulla and zygomatic arch in a pet rabbit

AbstractA 2.5‐year‐old, 2.9 kg, neutered, male domestic rabbit presented for sudden onset of sneezing and wheezing of 2‐day duration. Upon physical examination, there was mild dyspnoea characterised by mild to moderate increased inspiratory effort and audible wheeze, without evidence of ocular or nasal discharge. An aggressive expansile lytic mass lesion of the right caudal maxilla extending into the zygomatic arch was identified on skull radiographs. Computed tomography confirmed a large heterogeneously contrast enhancing soft tissue mass associated with the lytic lesion, likely originating from the right alveolar bulla, extending into the zygomatic arch. Histopathological diagnosis was osteosarcoma with areas of osteogenic and fibroblastic patterns. Diseases of the nasal cavity are common in rabbits; while infectious rhinitis remains the most common diagnosis, increasing number of cases of neoplasms involving the maxilla and nasal cavity should remind clinicians to include it in the differential diagnosis list.

Determination of Gender Variations Based on Anatomical Shapes of the Orbit on Plain Radiographs of Nigerians: A 5-Year Retrospective Cross-Sectional Study

Introduction: Cephalometry has been widely used in substantial aspects of medicine. There exist obvious differences between male and female bony features from early development to adulthood. The morphometric examination of the orbit and familiarity with its anatomy are important clinically in the diagnosis of orbital lesions and face reconstructive surgery. Diagnostic radiology and ophthalmology have a close relationship. Most prior research assessed orbital dimensions using direct approaches on living, cadaveric, or dry bones.
 Aim: To determine the gender variations based on the shapes of the orbit using Plain Radiographs.
 Materials and Methods: A 5-year retrospective cross-sectional study using 255 normal skull radiographs obtained from the Department of Diagnostic Radiology of Usmanu Danfodiyo University Teaching Hospital Sokoto from 2004 40 2009 was carried out with male to female ratio of 4:1. The radiographs were mounted on a viewing box, and the orbital shapes were noted. Results: In the male subjects, the shape of the orbit was oval in 68 (33.0%), quadrangular in 55 (26.7%), and round in 83 (40.3%). In the female subjects, the oval-shaped orbit was found in 27 (55.1%), quadrangular shape in 12 (24.5%), and in round shape 10 (20.4%).
 Conclusions: The commonest type of orbit seen in males is the round type, followed by the oval type with the quadrangular being the least type. In females the predominant type of orbit seen was oval, followed by the quadrangular type, with the round type being the least common. However, the differences were not statistically significant. The round type of orbit shows the strongest tendency in sex identification.

Determination of Age-Related Variations with Orbital Dimensions of the Orbit Based on Plain Radiographs of Nigerians: A 5-Year Retrospective Cross-Sectional Study

Introduction: Cephalometry has been widely used in substantial aspects of medicine. The morphometric assessment of the orbit and familiarity with its anatomy is significant clinically in the diagnosis of lesions in the orbit and reconstructive surgeries of the face. There is an important link between diagnostic radiology and ophthalmology. Most previous studies use direct techniques on living, cadaveric specimens, or dry bones to assess the orbital dimensions.
 Aim: To determine the relationship between the orbital dimensions and the increase in age.
 Materials and Methods: A 5-year retrospective cross-sectional study using 255 normal skull radiographs obtained from the Department of Diagnostic Radiology of Usmanu Danfodiyo University Teaching Hospital was done. The radiographs were visualized on an illuminator and measurements of the orbital dimensions were made with the aid of a transparent ruler and a pencil. Results: The orbital dimensions of the subjects used in this study in relation to their age groups revealed a steady rise in the dimensions with the increase in age until the age range of 51-60 years when it reaches the peak value and then gradually declines. In the measurement of the interorbital distance in relation to age, it was similarly found to increase with increasing age of the subjects however reaching its peak at the age range of 31-40 years then gradually dropping.
 Conclusions: The orbital dimensions show a positive correlation with increasing age.

Artificial intelligence and skull imaging advancements in forensic identification

ABSTRACT Managing the massive losses associated with large-scale disasters requires significant resources. The unexpected violence of these events generally remains a matter of casualties that urgently need to be identified in a reliable and cost-effective manner. To overcome these difficulties, many researchers have attempted to develop automated methods; moreover, a few recent research have investigated the applicability of artificial intelligence (AI)-based methods using skull, dental, and maxillofacial forensic imaging. In this review, we speculate on the advancement and potential of AI in Dental and Maxillofacial imaging that can help simplify person or victim identification and speed up the process with good accuracy. Using a few prefix search phrases, an online literature search was conducted (AI, Forensic, Skull, Dental, Imaging, Radiology) to identify papers about the advancement of AI in forensic dentistry in all kinds of radiographs, including two-dimensional (2D) and three-dimensional (3D) radiographs, cone beam computed tomography (CT) and CT. Most of the studies reported that automated methods of human identification based on 2D and 3D Dental and Skull radiographs using a convolutional neural network showed to assist in the fast and accurate identification by expertise evaluating a lot of images and quickly coming up with potential matches for identification. We advocate the application of AI techniques in the identification of individuals. However, there is a need to continue research with emphasis to validate models in skull identification.

Brownish limb tumor as a presentation of primary hyperparathyroidism

43-year-old male, with tumor in the anterior region of the right lower limb (figure 1) and biopsy compatible with brown tumor. He presented total serum calcium 12.3 mg/dl and 13 mg/dl (NR: 8.3-10.3), parathormone (PTH) 1057 pg/ml (NR 15-65). With the diagnosis of primary hyperparathyroidism, a 99mTc-MIBI parathyroid scintigraphy with SPECT was requested, which showed hyperfunctioning parathyroid tissue in the projection of the left inferior parathyroid gland. Hand radiographs showed a lytic lesion in punch in the distal phalanx of the first finger of the left hand (figure 2); in the clavicle radiograph: lytic lesion of 10 mm x 8 mm in the right clavicle, no alterations were evidenced in the skull radiograph.

Plain radiography has a role to play in current clinical practice in Western Switzerland

AimThe aim of the study was to investigate the current role of conventional radiography examinations in Western Switzerland and the main clinical indications required to justify the use of this imaging examination. MethodsEthical approval was obtained from Vaud Ethics committee (Ref 2020–00311). An online questionnaire was specifically designed and implemented on the data collection tool LimeSurvey composed of two parts: a) to characterise the participants’ profile and their institutions and b) 169 projections for the different anatomical area (upper and lower limbs, pelvis, skull, spine, thorax, abdomen) were presented to collect data about the frequency and main clinical indications. Statistical analysis was performed using the software IBM SPSS® (Statistical Package for the Social Sciences) version 26. ResultsRadiographers from 60% (26/43) of the invited institutions participated in this survey, mainly from Vaud region. The upper and lower limbs were the most commonly examined by using conventional radiography mainly for trauma and degenerative disorders. The thorax was also an anatomical area commonly explored by X-rays, so were the spine (cervical and lumbar lateral). The skull radiographs were rarely performed in clinical practice and some of the projections were not being used, namely Hirtz, Tangential Nose Bones, Worms and Caldwell's views. ConclusionsPlain radiography is being used in clinical practice mainly for appendicular skeleton studies and for trauma and degenerative pathologies. Adaptations in radiographers’ education and training and other healthcare professionals are needed to provide the judicious use of data that radiographs can give to better manage the patients’ imaging pathway.

Spontaneous remission of skull Langerhans cell histiocytosis that had developed by repeated head injury: illustrative case.

Langerhans cell histiocytosis (LCH) was previously characterized as the proliferation of Langerhans-type histiocytes with a wide range of clinical presentations that arise mostly in children. The typical presentation is a gradually enlarging, painless skull mass. Rapid clinical deterioration is rare. A 3-year-old boy who had incurred a right frontal impact head injury demonstrated no apparent neurological deficits. He subsequently bruised the same region multiple times. The right frontal swelling gradually increased over the course of 6 days after the initial injury. Skull radiography showed no bony lesion. The same site enlarged markedly 12 days after the initial injury. Magnetic resonance imaging revealed a frontal bony tumorous lesion associated with multiple subcutaneous cystic mass lesions. The patient underwent open biopsy of the skull lesion and evacuation of the subcutaneous lesions. Histopathological examination confirmed the diagnosis of LCH. Immunohistochemical evaluation revealed positivity for CD1a and langerin and no immunopositivity for BRAF V600E. The skull lesion spontaneously disappeared 30 days after the biopsy without recurrence. Physicians should be aware of this rare clinical manifestation of LCH that developed by a repeat head injury.

Ultra-low-dose computed tomography with deep learning reconstruction for craniosynostosis at radiation doses comparable to skull radiographs: a pilot study.

Craniofacial computed tomography (CT) is the diagnostic investigation of choice for craniosynostosis, but high radiation dose remains a concern. To evaluate the image quality and diagnostic performance of an ultra-low-dose craniofacial CT protocol with deep learning reconstruction for diagnosis of craniosynostosis. All children who underwent initial craniofacial CT for suspected craniosynostosis between September 2021 and September 2022 were included in the study. The ultra-low-dose craniofacial CT protocol using 70 kVp, model-based iterative reconstruction and deep learning reconstruction techniques was compared with a routine-dose craniofacial CT protocol. Quantitative analysis of the signal-to-noise ratio and noise was performed. The 3-dimensional (D) volume-rendered images were independently evaluated by two radiologists with regard to surface coarseness, step-off artifacts and overall image quality on a 5-point scale. Sutural patency was assessed for each of six sutures. Radiation dose was compared between the two protocols. Among 29 patients (15 routine-dose CT and 14 ultra-low-dose CT), 23 patients had craniosynostosis. The 3-D volume-rendered images of ultra-low-dose CT without deep learning showed decreased image quality compared to routine-dose CT. The 3-D volume-rendered images of ultra-low-dose CT with deep learning reconstruction showed higher noise level, higher surface coarseness but decreased step-off artifacts, comparable signal-to-noise ratio and overall similar image quality compared to the routine-dose CT images. Diagnostic performance for detecting craniosynostosis at the suture level showed no significant difference between ultra-low-dose CT without deep learning reconstruction, ultra-low-dose CT with deep learning reconstruction and routine-dose CT. The estimated effective radiation dose for the ultra-low-dose CT was 0.05mSv (range, 0.03-0.06mSv), a 95% reduction in dose over the routine-dose CT at 1.15mSv (range, 0.54-1.74mSv). This radiation dose is comparable to 4-view skull radiography (0.05-0.1mSv) and lower than previously reported effective dose for craniosynostosis protocols (0.08-3.36mSv). In this pilot study, an ultra-low-dose CT protocol using radiation doses at a level similar to skull radiographs showed preserved diagnostic performance for craniosynostosis, but decreased image quality compared to the routine-dose CT protocol. However, by combining the ultra-low-dose CT protocol with deep learning reconstruction, image quality was improved to a level comparable to the routine-dose CT protocol, without sacrificing diagnostic performance for craniosynostosis.

Combined rapid sequence MRI protocol and skull radiography as an alternative to head CT in the evaluation of abusive head trauma in children: a pilot study.

The aim of our pilot study was to compare the performance of the RS-MRI protocol combined with skull radiography versus CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage in patients with abusive head trauma (AHT). Additionally, our study aimed to determine whether the presence of scalp hematoma predicts concurrent skull fracture. We conducted a pilot study through retrospective chart review of 24 patients between ages 0 and 15 months who experienced AHT and who received CT, MRI, and skull radiography between May 2020 and August 2021. Two blinded board certified neuroradiologists reviewed the skull radiographs alongside the rapid trauma MRI. Their impressions were documented and compared with findings derived from CT. Combination imaging detected ten out of the 12 skull fractures noted on CT (sensitivity 83.3%, specificity 100%, p=0.48). RS-MRI detected 15 out of the 16 intracranial hemorrhages detected by CT (sensitivity 93.75%, p >0.9). When scalp hematoma was detected on RS-MRI, nine out of the 12 had associated skull fractures when reviewed by radiologist 1 (sensitivity 75%, specificity 100%, p=0.22), and seven out of the 12 had associated skull fractures when reviewed by radiologist 2 (sensitivity 58%, specificity 92%, p=0.25). In pediatric patients with suspected AHT, we found that RS-MRI combined with skull radiographs was not significantly different than CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage. This combination has the potential to replace the use of CT as a screening tool for abusive head trauma, while avoiding the risks of sedation often required for routine MRI.

Pelvic radiation dose measurement for trauma patients in multifield radiographic examinations: A phantom-based TLD dosimetry study.

Trauma patients often suffer from multiple injuries and require undergoing various radiography which is referred to as multifield radiographic examinations. Protective measures may be ignored for these examinations due to stressful emergency situations or patients' conditions. This study was conducted to evaluate the scattered doses received by the pelvis during different common multifield radiographic examinations with an emphasis on field size adjustment. A whole-body phantom, PBU-50, resembling the body mass, was used to carry out the common examinations for trauma patients (extremities, skull, chest, abdomen, pelvis, femur, and lumbar radiography), using a Pars Pad X-ray machine. To measure the primary entrance skin doses, three calibrated GR 200 thermoluminescence dosimeter (TLD) chips were placed in the central X-ray beam of scanned organs. Three TLDs were also placed on the pelvis symphysis pubis to measure the scattered dose received by the pelvis due to each carried-out radiography for standard and clinically used field sizes. A Harshaw 3500 TLD Reader was used to read the chips. TLD readouts (nano-Coulomb) were converted to dose (milli Gray [mGy]) using the predefined calibration curve. The scattered doses to the pelvis due to scanning a single organ differed from 0.80 to 1.70, and 0.82 to 4.09 mGy for standard and clinically used field sizes, respectively. The scattered doses to the pelvis in multifield examinations varied from 0.80 to 8.43 and 0.82 to 13.6 mGy for standard and clinically used field sizes, respectively, depending on the number of scanned organs and their distances from the pelvis. Multiple and repeated radiographs combined with insufficient protective measures can increase the patient's dose. The findings indicate that the scattered doses received by the pelvis can exceed the reference values in multifield radiography, especially if the radiation field is not restricted properly to the scanned organ.

Modification to the Hartel Route Radiofrequency Technique for the Treatment of Trigeminal Neuralgia: A Technical Note

To evaluate a modification to the classical Hartel technique for the treatment of trigeminal neuralgia. Intraoperative radiographs of 30 patients with trigeminal neuralgia treated with radiofrequency were retrospectively reviewed. The distance between the needle and the anterior edge of the temporomandibular joint (TMJ) was measured on strict lateral skull radiographs. Surgical time was reviewed, and clinical outcomes were evaluated. All patients showed clinical improvement in pain (Visual Analog Scale). In all radiographs, the measurement between the needle and the anterior edge of the TMJ ranged from 10mm to 22mm. None of the measurements were below 10mm or above 22mm. In most cases, this distance was 18mm (9 patients), followed by 16mm in 5 patients. Considering the inclusion of the oval foramen in a Cartesian coordinate system with axes X, Y, and Z is useful. Directing the needle to a point located 1cm from the anterior edge of the TMJ, avoiding the medial aspect of the upper jaw ridge, allows for a safer and faster procedure.

Influence of the Severity of Osteogenesis Imperfecta on Cranial Measurements.

Osteogenesis Imperfecta (OI) is a disease that causes bone fragility and deformities, affecting both the cranial base and the craniocervical junction, and may lead to other neurological disorders. A retrospective cross-sectional study was carried out based on cephalometric analysis of the cranial base in a sample of patients with OI, in lateral skull radiographs and magnetic resonance imaging (MRI), comparing them with a sample of age-matched controls. When the different variables of the craniocervical junction were analyzed, significance was found in comparisons with the different age groups. All measurements of the variables studied stabilized as growth progressed. For most of the variables, the severity of the disease influences the measurements of the skull base, with statistically significant differences. Both age and severity of the disease are factors that directly influence the anatomy of the craniocervical junction in these patients and may serve as indicators in the early detection and prevention of other derived alterations.

A rare case of Coffin–Lowry syndrome accompanied by a copper-beaten skull appearance

Coffin-Lowry syndrome (CLS), usually a result of loss-of-function mutations in the RPS6KA3 gene located at Xp22.2, is a very rare genetic condition. It is associated with different phenotypes, including dysmorphic facial features, neuro-developmental impairment, short stature, and skeletal deformities. Here we describe a four-year-old boy who had distinct clinical features of CLS: moderate mental and motor retardation, brachycephaly, microcephaly, hypertelorism, low-set and prominent ears, down- slanted palpebral fissures, a depressed nasal bridge with thick nasal alae and septum, a high-arched palate, widely spaced teeth, and retrognathia. Genetic analysis revealed a pathogenic variant in the RPS6KA3 gene, NM_004586.3: exon 22: c.2186G>A: (p.Arg729Gln). His healthy mother was a heterozygous carrier of the variant. In addition to the clinical findings, the patient’s X-ray revealed a very rare feature of a copper-beaten skull appearance. The link between CLS and a copper-beaten skull has never been reported before. This case demonstrates the variability in presentation of CLS and signifies the association of a rare radiographic finding of copper-beaten skull with CLS. Based on this case, we recommend screening skull radiographs at the clinic for copper-beaten skulls in patients with CLS.

Comparison of Steiner Cephalometric analysis of lateral skull X-ray images with CBCT in a group of students of the dental school of the University of Cuenca

The Steiner analysis from images obtained from cone beam computed tomography is one of the essential tools today for diagnosis in the area of orthodontics, within this aspect its high value for the study of points, angles and cephalometric planes allows the prediction of the possible treatment plan for each patient according to the specific characteristics resulting in each patient. Objective: To compare the results in Steiner cephalometric measurements obtained in 2D lateral skull radiographs and in 3D cephalograms generated from Cone Beam Computed Tomography (CBCT). Methodology: Type of comparative analytical study. A non-probabilistic sample was established by convenience consisting of 29 diagnostic studies divided into: 29 lateral skull X-rays and 29 standardized CBCT. Subsequent localization, tracing and measurement of skeletal and dental angles were performed according to Steiner's cephalometric analysis using Nemostudio 2022 software. The study and analysis was performed using the Intraclass Correlation Coefficient. Results: The mean difference between the skeletal angles SNA, SNB, ANB, SND and Occlusal Plane Angle showed that there is no significant discrepancy when performing a cephalometric analysis in three-dimensional images compared to two-dimensional images. Conclusion: There is a high degree of reliability and accuracy of cephalometric measurements for obtaining skeletal and dental angles in two-dimensional images obtained from a CBCT with respect to a lateral radiograph.

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case.

After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home. Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection. In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

A case of tumoral calcinosis in hemodialysis

Dear Editor, Tumoral calcinosis is a rare syndrome which presents as painless, firm, tumor-like masses around the joints leading to pain, and limitation of joint movements. Commonly affected joints are shoulders, elbows, and hip joints. Spinal, temporomandibular joint, metacarpals, and metatarsal involvement have also been described. A 50-year-old female on twice weekly maintenance hemodialysis for the last 3 years presented with complaints of pain and restriction of movements at right hip joint and knee. On examination, range of movements was restricted at the hip joint. On palpation, there were subcutaneous hard nodules in the right hip region. Plain radiographic images of the pelvis were obtained and they showed irregular periarticular masses [Figure 1a]. Plain radiographs of hand, skull, and shoulder joins showed similar lesions [refer to adjoining Figure 1b-d]. On metabolic work, she had parathyroid hormone level of 162 pg/mL, phosphorus of 8.5 mg/dL, calcium of 9.8 mg/dL, albumin of 3.5 g/dL, and Vitamin D level of 29 ng/mL. She was poorly compliant with dietary restrictions and taking phosphate-binding medications. Diagnosis of secondary tumoral calcinosis was made. The patient was managed with phosphate-restricted diet, phosphate-binding medication, and increasing the dialysis frequency from twice weekly to thrice weekly.Figure 1: X-ray images showing (a) irregular peri articular masses around the hip joint. Similar findings were seen in X-ray images of (b) hand (c) skull and (d) shoulder joints as wellTeutschlaender initially described this disease in his studies in 1930’s and it came to be known as Teutschlaender disease.[1] The term tumoral calcinosis was coined by Inclan in 1943.[2] Smack et al. retrospectively studied 122 cases of tumoral calcinosis and proposed a classification system.[3] They classified it as (1) primary normophosphatemic type, (2) primary hyperphosphatemic type, and (3) secondary tumoral calcinosis. Secondary causes include renal insufficiency, hyperparathyroidism, or hypervitaminosis D, with renal insufficiency being the most common identifiable condition. Even though soft-tissue calcifications are common in hemodialysis patients, the prevalence of periarticular masses is low. Most of cases in chronic kidney disease are thought to occur due to the presence of hyperparathyroidism although it may occur in its absence as well. The calcification process results from elevated calcium–phosphorus product with hyperphosphatemia being the most important component. Diagnosis is based on characteristic imaging findings. Imaging typically shows amorphous, cystic, and multi-lobulated deposits in periarticular areas.[4] Computed tomography may show cystic loculi with fluid levels giving rise to sedimentation signs. Treatment of secondary tumoral calcinosis in the setting of renal failure is predominantly medical therapy. Calcium- and phosphate-restricted diets and phosphate binders are used as first-line management. Intravenous pamidronate is also shown to be effective.[5] Partial or total parathyroidectomy can be considered in refractory cases in case hyperparathyroidism is the cause.[6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.