Study Of Choice For Evaluation Research Articles

A Rare Otological Presentation of Squamous Papilloma

Introduction:
 Squamous papillomas (SPs) are benign epithelial neoplastic lesions commonly found in skin, oral mucosa, upper aerodigestive tract and genitals. Involvement of external auditory canal (EAC) by SP is extremely rare and whatever scarce literature is available is in the form of case reports. The exact incidence of this entity is still unknown. Consequently, its etiology, histopathological features, differential diagnoses and optimal management merit a better understanding by the Otolaryngologists.
 Case report: We present a case of EAC SP in a 15 year old girl hailing from north-eastern India who presented to us with a mass in the EAC which was acutely painful. Contrast Enhanced Computed Tomography remained the gold standard and imaging study of choice for evaluation. However, the diagnosis was clinched only by histopathology. We also discuss our strategy of management along with a brief review of literature.
 Conclusion:
 Squamous papilloma has rarely been reported to affect the EAC. Human papilloma virus remains the most consistent etiological agent. Advanced imaging like contrast enhanced high resolution computed tomogram remains gold standard to evaluate any mass seen in EAC. Complete excision with cold steel technique or coblation with good post-operative care and follow up is the standard of care.

Scalpel Sign in Spine Pathology: Presentation in 3 Different Rare Diagnoses

The scalpel sign is a radiological finding observed on sagittal magnetic resonance imaging and computed tomography myelography corresponding to an indentation in the dorsal aspect of the spinal cord resembling a surgical scalpel blade. It is said to be a pathognomonic imaging discovery linked to dorsal arachnoid webs. However, other spine-related conditions may mimic dorsal arachnoid webs on magnetic resonance imaging, such as spinal arachnoid cysts or ventral spinal cord herniation, leading to misdiagnosis. A retrospective review was performed of cases involving 3 different diagnoses at our institution in the last 5 years that shared in common the characteristic focal dorsal indentation of the spinal cord. Of 7 cases identified, all but 1 were treated and confirmed intraoperatively. All lesions were located at the dorsal spinal cord. Magnetic resonance imaging was the study of choice for evaluation. Clinical manifestations included back pain and lower extremity numbness and weakness together with compressive myelopathy signs and urinary symptoms. Mean follow-up was 16.8 months with satisfactory postoperative results. Isolated radiological presentation of the scalpel sign is not sufficient to distinguish between dorsal arachnoid webs, arachnoid cysts, and ventral herniation of the spine. However, awareness of its importance is relevant for accurate curative surgical planning.

Comparative Evaluation of Clinical Findings in Temporomandibular Joint Pathology with Magnetic Resonance Imaging – A Cross-sectional Study

Background: Temporomandibular disorders (TMDs) are broad group of clinical problems involving the masticatory musculature, the temporomandibular joint (TMJ), and the surrounding hard and soft-tissue components or combination of these problems. It can also be secondary to muscle hyperfunction or parafunction, traumatic injuries, hormonal influences, and articular changes within the joint. Magnetic resonance imaging (MRI) is currently considered as the preferred method for imaging the soft-tissue structures of the TMJ and has been pointed out as the best imaging modality in diagnosing disc displacements. Aim: The aim of this study is to comparatively evaluate the clinical findings of temporomandibular pathology with the MRI. Methodology: This is a cross-sectional observational study with comprised multiethnic group. A total of 50 patients reporting to the dental OPD with TMJ pathology were selected. These subjects underwent thorough clinical examination of TMJ and MRI of the TMJ was taken for all the individuals and parameters such as change in disk position, condylar surface, and effusion were recorded with the help of the radiologist. Statistical Data Analysis: Statistical presentation and analysis of the present study were done using the P value and Chi-square test by SPSSV20. Results: The results obtained in this study showed that out of 50 individuals, pain was present only in 28, that is, 56% of population other complaints of jaw deviation, clicking sound, and restricted mouth opening. Disc displacement was found only in 57.14% of symptomatic individual and 72.72% of asymptomatic individuals. MRI revealed pain and effusion was present only in 28% of symptomatic patients. About 76% of the subjects had jaw deviation while mouth opening out of which 68.42% showed disc displacement in MRI. About 56% of the subjects had positive history of trauma out of which 50% showed disc displacement in MRI. About 56% of the subjects reported with the clicking sound out of which 64.28% showed disc displacement in MRI. Conclusion: TMJ is one of the complex joints in the entire body. Because of this complexity of the TMJ, the pathologies as well as normal anatomical patterns must be known before any diagnosis. The selection of the proper radiological technique for TMJ, as well as of the patient, must be carefully made by the practitioner, in correlation with the clinical signs and symptoms. MRI is the diagnostic study of choice for evaluation of disk position and internal derangement of the joint. Although already many studies had been done on MRI, such type of studies should be conducted on large scale in future based on specific parameters for early diagnosis and treatment planning for patients suffering with TMD to provide quality treatment to the patients at initial stage.

Rotator Cuff Tears in Polytrauma - A Hidden Lesion

A rotator cuff tear in a polytraumatized patient can be a devastating injury if not identified early. Traumatic rotator cuff tears are often massive, and generally retract within a short period of time. If the tear is missed, the consequences are profound especially if the tear becomes irreparable and especially in the younger, more active population. These consequences include pseudoparalysis, persistent pain, and rotator cuff tear arthropathy. Specific examination of the polytraumatized patient with shoulder pain on secondary/tertiary survey should include a detailed assessment of the rotator cuff. Ultrasound has been advocated as a potential adjunct to MRI but most surgeons would agree that MRI is imaging study of choice for evaluation of the rotator cuff. The treatment of acute or acute on chronic traumatic rotator cuff tear in the polytraumatized patient should be early rotator cuff repair when the patient’smedical status allows.

MR Imaging of Acute Right Lower Quadrant Pain in Pregnant and Nonpregnant Patients

The use of magnetic resonance (MR) imaging in the evaluation of acute abdominal pain is increasing, particularly in those circumstances where computed tomography (CT) is not desirable (eg, pregnancy, allergy to iodinated contrast material). Although ultrasonography (US) is considered the imaging study of choice for evaluation of abdominal pain in pregnant patients, MR imaging is a valuable adjunct to US in evaluation of pregnant patients with acute right lower quadrant (RLQ) pain who have inconclusive US results. MR imaging is also frequently used in patients with renal failure, in whom the use of iodinated contrast material is contraindicated, as well as in cases where CT results are inconclusive. In patients with acute RLQ pain, the breadth of abnormalities visible at MR imaging is very broad, with pathologic conditions potentially originating from multiple organ systems, but most commonly from the gastrointestinal and genitourinary systems. MR imaging is an excellent imaging modality for evaluation of RLQ pain and should be strongly considered in those patients in whom use of iodinated contrast media or radiation is not desirable.

Cerebral Amyloid Angiopathy: CT and MR Imaging Findings

Cerebral amyloid angiopathy (CAA) is an important but underrecognized cause of cerebrovascular disorders that predominantly affect elderly patients. CAA results from deposition of beta-amyloid protein in cortical, subcortical, and leptomeningeal vessels. This deposition is responsible for the wide spectrum of clinical symptoms and neuroimaging findings. Many cases of CAA are asymptomatic. However, when cases are symptomatic, patients can present with transient neurologic events, progressive cognitive decline, or potentially devastating intracranial hemorrhage. Computed tomography is the imaging study of choice for evaluation of suspected acute cortical hemorrhage, which may be accompanied by subarachnoid, subdural, or intraventricular hemorrhage. Magnetic resonance imaging is best suited for identification of small or chronic cortical hemorrhages and ischemic sequelae of this disease, exclusion of other causes of acute cortical-subcortical hemorrhage, and assessment of disease progression. Accurate recognition of imaging findings is important in guiding clinical decision making in patients with CAA.

54-Year-Old Man With Hip Pain

A 54-year-old male farmer presented with a 4-week history of left hip pain. He described spontaneous onset of pain involving his left hip and groin. The pain was aggravated by ambulation and had worsened progressively over several weeks. The patient noted particular discomfort with hip flexion when getting on and off his tractor. The pain occasionally radiated anteriorly to the top of his knee. He denied worsening of pain with Valsalva maneuver, radiation of pain distal to the knee, and low back pain. Rest and avoidance of hip flexion briefly reduced the pain. The patient denied preceding trauma and any associated hypesthesia or paresthesia. He was a previous smoker, consumed alcohol occasionally, and had never used corticosteroids. The patient denied systemic signs of illness, weight loss, and nocturnal symptoms. Over-the-counter medications and complete avoidance of activity provided little relief. 1.Which one of the following is the most likely diagnosis based on our patient's history? a.Malignancyb.Meralgia parestheticac.Avascular necrosis of the hip (AVN)d.Polymyalgia rheumaticae.L4-5 radiculopathy Malignancy is unlikely without associated systemic signs and symptoms, weight loss, or night pain. Meralgia paresthetica, a localized area of pain described as a burning or an uncomfortable heightened sensation, is not influenced by direct pressure, hip movement, or lower back movement, which differs from the presentation in our patient. Avascular necrosis of the hip has been known by many terms including aseptic necrosis and osteonecrosis. Various factors leading to AVN have been identified, including corticosteroids and alcohol. Of the choices provided, AVN is the most likely diagnosis. Polymyalgia rheumatica is a common disorder that occurs often in persons older than 50 years. Classically, it presents with subacute onset of symmetrical aching and morning stiffness involving the shoulders, hip girdles, neck, and torso, symptoms inconsistent with those of our patient. Lumbar radiculopathy most commonly involves the L4-5 nerve roots and causes lateral hip pain that radiates down the leg and into the foot, with or without associated foot numbness. Our patient denies worsening of pain with Valsalva maneuver, paresthesias, or radiation of pain distal to the knee; thus, lumbar radiculopathy is an unlikely cause of his symptoms. Physical examination revealed normal vital signs. The patient had an antalgic gait without focal tenderness over the lateral hip or groin. There was no discrepancy in leg length. The patient had full range of motion of his hips and knees, although abduction and adduction of the left hip reproduced the pain. The pain was most marked with flexing, abducting, and externally rotating the patient's leg such that the ankle of that leg was on top of the opposite knee (fabere or Patrick test). Straight leg raise did not reproduce his pain or cause radicular symptoms. The patient had no spinal tenderness or scoliosis. Neurologic evaluation revealed only give-way weakness of the left hip secondary to pain. Findings on the rest of the examination were unremarkable. 2.Which one of the following is the next best step in the treatment of our patient? a.Local injection for presumed trochanteric bursitisb.Plain radiography of the lumbar spine, hip, and pelvisc.Reassurance with no further testingd.Bed rest for 1 week followed by physical therapy and strength traininge.Testing to determine serum protein electrophoresis, erythrocyte sedimentation rate, prostate-specific antigen level, and complete blood cell count Inflammation of the trochanteric bursa, one of the most common causes of hip pain, results from exaggerated movements of the gluteus medius tendon and the tensor fascia over the femur. Patients typically experience lateral hip and thigh pain that worsens with ambulation or direct pressure over the area. Our patient's symptoms do not correlate with trochanteric bursitis. Plain radiography, the correct choice, should be considered for all patients with both acute and chronic hip pain to exclude fracture and to provide information regarding arthritis or lytic lesions of the femur. Reassurance, bed rest, physical therapy, and further laboratory testing may be appropriate, but only after obtaining radiographs. Plain radiographs of the lumbar spine, hips, and pelvis revealed mild osteopenia of the femoral neck and head. Results of laboratory studies including serum protein electrophoresis were normal. Initially, our patient was treated conservatively, with limited weight bearing and nonsteroidal anti-inflammatory drugs (NSAIDs). Despite these measures, 3 weeks later he continued to have pain that limited his ability to complete his harvest. 3.Which one of the following is the most appropriate step at this time in our patient's evaluation? a.Continued conservative treatment and initiation of physical therapyb.Radionuclide bone scanningc.Magnetic resonance imaging (MRI) of the hipd.Ultrasonography of the hip with needle aspiration if effusion is presente.Referral to an orthopedic surgeon for hip replacement Our patient's pain has not responded to conservative measures for more than 8 weeks. The persistence of symptoms warrants further evaluation. Therefore, continued conservative treatment alone is incorrect. Radionuclide bone scanning usually is reserved for suspected pathology not revealed by plain radiography when MRI is not available. Magnetic resonance imaging is the radiographic study of choice for evaluation of hip joint pathology.1Zacher J Gursche A Regional musculoskeletal conditions: ‘hip’ pain.Best Pract Res Clin Rheumatol. 2003; 17: 71-85Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Besides allowing early diagnosis and staging of osteonecrosis, MRI enables the clinician to evaluate for potential infection, tumor, and pathology within the surrounding tissue. Immediate arthrocentesis is reserved usually for acute and severe hip pain in patients with findings suggestive of infection. An imaging technique such as ultrasonography for assistance with aspiration is advised. However, our patient's case does not warrant aspiration, and given the available information, there is no indication for surgical intervention. Magnetic resonance imaging of our patient's hip with and without gadolinium revealed diffusely increased T2 signal with partial loss of T1 signal involving the femoral neck and head. There was moderate soft tissue edema in the adjacent fat, vastus intermedius muscle, and adductor muscle, with little effusion. Our patient returned to see his physician the following day. 4.Based on MRI findings, which one of the following is the most likely diagnosis? a.AVNb.Bone marrow edema syndrome (BMES)/transient osteoporosis of the hipc.Ewing sarcomad.Osteoid osteomae.Adductor tendinitis Findings that suggest AVN/osteonecrosis include the pathognomonic double line or crescent sign (subchondral radiolucency), which represents evidence of subchondral collapse.2Mazières B Osteonecrosis.in: Hochberg MC Silman AJ Smolen JS Weinblatt ME Weisman MH 3rd ed. Rheumatology. Vol 2. Mosby, Edinburgh, Scotland2003: 1877-1890Google Scholar Such findings may be seen on plain radiographs or T2-weighted coronal MRI and represent a high-intensity rim within a low-intensity margin surrounding necrotic tissue.3Mitchell DG Rao VM Dalinka MK et al.Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.Radiology. 1987; 162: 709-715PubMed Google Scholar In our patient, these findings were not seen on MRI. Our patient's findings of increased T2-weighted signal with corresponding decreased signal intensity on T1-weighted images are characteristic of BMES and are present early in the disease course.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar, 6Harrington S Smith J Thompson J Laskowski E Idiopathic transient osteoporosis: a hidden cause of hip pain.Phys Sportsmed. 2000; 28 (87-91, 95-96.): 82-84Crossref PubMed Scopus (10) Google Scholar Therefore, BMES is the most likely diagnosis. Ewing sarcoma affects the long bones of the extremities, usually the femur and the pelvis. Patients typically experience localized pain or swelling for a few weeks or months and worsening nocturnal pain. Radiographically, the tumor is described as having a “moth-eaten” appearance. The classic finding of Codman triangle (expansion of the cortex with a displaced periosteum from the underlying tumor) was absent in our patient. Osteoid osteomas are benign bone-forming tumors that characteristically produce nocturnal bone pain relieved by aspirin. This is unique among bone tumors and absent in our patient. Tenderness over the involved tendon and pain with resisted adduction of the lower extremity are characteristic of adductor tendinitis and may reproduce the medial thigh and groin pain of hip disease. However, this disease does not explain the changes of the femoral head seen in our patient on MRI. Our patient's hip pain decreased with continued conservative treatment with NSAIDs and limited weight bearing, and repeated MRI 10 weeks later revealed improvement of the edema. The patient returned to his physician 5 months later with similar pain in his left knee. Because of his history, MRI of the knee was performed, which revealed patchy edema in the distal femur, in the lateral and medial femoral condyle, and in the proximal tibia on T2-weighted imaging with fat saturation. 5.Based on these new findings, which one of the following is the most likely diagnosis? a.Osteoarthritisb.Regional migratory osteoporosisc.Osteosarcomad.Occult knee fracturee.Pseudogout Our patient's MRI findings are not consistent with osteoarthritis and suggest this process is similar to the one identified in his hip. When bone marrow edema involves more than one joint or moves from one joint to another, it is referred to as regional migratory osteoporosis, which is a migrating arthralgia of the weight-bearing joints of the lower limbs. This is the most likely diagnosis, based on the new findings. Osteosarcomas are uncommon primary malignant tumors of bone and occur primarily in children and adolescents. In our patient, there was no radiographic evidence of osteosarcoma. Although MRI is the study of choice for occult knee fracture not identified on plain radiography, in our patient MRI indicated no discrete area of fracture. Furthermore, he had no findings consistent with pseudogout. After 4 additional months of taking NSAIDs, our patient's limited weight-bearing activity slowly advanced through physical therapy, and he had complete resolution of all symptoms. Our patient is now pain free and has no residual sequelae. Hip pain is extremely common in adults. Of those older than 60 years, 14% have reported substantial hip pain on most days.7Christmas C Crespo CJ Franckowiak SC Bathon JM Bartlett SJ Andersen RE How common is hip pain among older adults? results from the Third National Health and Nutrition Examination Survey.J Fam Pract. 2002; 51: 345-348PubMed Google Scholar There are numerous etiologies for hip pain, and we describe a potential diagnosis that may be overlooked. Curtiss and Kincaid8Curtiss Jr, PH Kincaid WE Transitory demineralization of the hip in pregnancy: a report of three cases.J Bone Joint Surg Am. 1959; 41: 1327-1333PubMed Google Scholar first described transient osteoporosis in 1959 after finding an association between hip pain in the third trimester of pregnancy and radiographic bone demineralization. Since this original description, the syndrome has been referred to by several different terms. Transient osteoporosis of the hip is the term credited to Lequesne from his 1968 report.9Lequesne M Transient osteoporosis of the hip: a nontraumatic variety of Sudeck's atrophy.Ann Rheum Dis. 1968; 27: 463-471Crossref PubMed Scopus (122) Google Scholar Although this condition is seen classically in the third trimester of pregnancy, men in their fourth through seventh decades of life account for more than 60% of reported cases.9Lequesne M Transient osteoporosis of the hip: a nontraumatic variety of Sudeck's atrophy.Ann Rheum Dis. 1968; 27: 463-471Crossref PubMed Scopus (122) Google Scholar, 10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar, 11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 12Guerra JJ Steinberg ME Distinguishing transient osteoporosis from avascular necrosis of the hip.J Bone Joint Surg Am. 1995; 77: 616-624PubMed Google Scholar The term bone marrow edema syndrome was introduced to replace transient osteoporosis of the hip and is based on characteristic MRI findings.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar, 13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 14Plenk Jr, H Hofmann S Eschberger J et al.Histomorphology and bone morphometry of the bone marrow edema syndrome of the hip.Clin Orthop Relat Res. 1997; 334: 73-84Crossref PubMed Google Scholar The joints of the lower extremities are affected much more frequently than the upper extremities, and symptoms occur most often in the hip followed by the knee, the foot, and the ankle.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar Bone marrow edema syndrome may affect the hip or knee as the single joint involved.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar, 11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 14Plenk Jr, H Hofmann S Eschberger J et al.Histomorphology and bone morphometry of the bone marrow edema syndrome of the hip.Clin Orthop Relat Res. 1997; 334: 73-84Crossref PubMed Google Scholar, 15Parker RK Ross GJ Urso JA Transient osteoporosis of the knee.Skeletal Radiol. 1997; 26: 306-309Crossref PubMed Scopus (40) Google Scholar, 16McAlindon TE Ward SA MacFarlane D Mathews JA Transient regional osteoporosis presenting as a septic arthritis.Postgrad Med J. 1993; 69: 871-873Crossref PubMed Scopus (8) Google Scholar Regional migratory osteoporosis (or migratory BMES17Lechevalier D Eulry F Crozes P Pattin S In situ migratory algo-dystrophies of the knee: value of modern imaging [in French].Rev Rhum Mal Osteoartic. 1992; 59: 29-33PubMed Google Scholar) was described first in 1967 as a migratory osteolysis, and its etiology remains unknown.18Duncan H Frame B Frost HM Arnstein AR Migratory osteolysis of the lower extremities.Ann Intern Med. 1967; 66: 1165-1173Crossref PubMed Scopus (62) Google Scholar It is characterized as a migrating arthralgia of the weightbearing joints of the lower extremities associated with a focal osteoporosis. The migration occurs from one articulation to another and is the feature that separates regional migratory osteoporosis from BMES involving the hip or knee alone.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar, 19Glockner JF Sundaram M Pierron RL Radiologic case study: transient migratory osteoporosis of the hip and knee.Orthopedics. 1998; 21 (594, 595.): 600PubMed Google Scholar, 20Banas MP Kaplan FS Fallon MD Haddad JG Regional migratory osteoporosis: a case report and review of the literature.Clin Orthop Relat Res. 1990; 250: 303-309PubMed Google Scholar, 21Dunstan CR Evans RA Somers NM Bone death in transient regional osteoporosis.Bone. 1992; 13: 161-165Abstract Full Text PDF PubMed Scopus (39) Google Scholar In BMES, patients present with progressive, ill-defined unilateral hip pain, usually described as a deep ache localizing to the medial or anterior thigh without radiation below the knee. Symptoms present acutely without inciting trauma and often render patients unable to ambulate without assistance. Pain worsens primarily with activity, whereas pain on resting, back pain, and neurologic dysfunction are not characteristic of BMES and suggest an alternative diagnosis. Physical examination findings of hip involvement most commonly include guarding during hip range of motion, especially with abduction or rotation of the hip, and an antalgic gait. Tenderness over the greater trochanter and adjacent adductor and hip flexor muscle groups may be present. Provocative tests with a fabere/Patrick test, resisted straight-leg raise, or hip joint compression or rotation loads may reproduce the pain. Results of spine and knee examinations and neurologic examination will be normal.6Harrington S Smith J Thompson J Laskowski E Idiopathic transient osteoporosis: a hidden cause of hip pain.Phys Sportsmed. 2000; 28 (87-91, 95-96.): 82-84Crossref PubMed Scopus (10) Google Scholar Laboratory tests generally do not help with the diagnosis. Plain radiographic findings obtained during the first 2 to 4 weeks of symptoms are usually normal. After 4 to 8 weeks of pain, osteopenia may be evident with a preserved joint space and no osseous erosion or subchondral collapse.5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar After this point, various degrees of cortical thinning and osteopenia around the intertrochanteric region and femoral head and neck have been described. This is in contrast to AVN, in which sclerosis progresses to articular surface flattening and eventual subchondral collapse.22Steinberg ME Brighton CT Steinberg DR Tooze SE Hayken GD Treatment of avascular necrosis of the femoral head by a combination of bone grafting, decompression, and electrical stimulation.Clin Orthop Relat Res. 1984; 186: 137-153PubMed Google Scholar Computed tomograms of BMES provide findings similar to those on plain radiographs.11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar Radionuclide bone scans are often positive within the first week of symptoms, revealing homogenously increased uptake of the area involved.11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 12Guerra JJ Steinberg ME Distinguishing transient osteoporosis from avascular necrosis of the hip.J Bone Joint Surg Am. 1995; 77: 616-624PubMed Google Scholar Magnetic resonance imaging is the modality of choice to exclude alternative diagnoses while revealing characteristic findings of bone marrow edema as early as 48 hours after onset of pain.13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 23Hayes CW Conway WF Daniel WW MR imaging of bone marrow edema pattern: transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis.Radiographics. 1993; 13: 1001-1011Crossref PubMed Scopus (205) Google Scholar, 24Daniel WW Sanders PC Alarcon GS The early diagnosis of transient osteoporosis by magnetic resonance imaging: a case report.J Bone Joint Surg Am. 1992; 74: 1262-1264PubMed Google Scholar Bone marrow edema identified with use of MRI is 100% sensitive but not specific for BMES,13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 25Hofmann S Bone-marrow oedema in transient osteoporosis, reflex sympathetic dystrophy and osteonecrosis.in: Jacob RP Fulford P Horan F European Instructional Course Lectures. Vol 4. British Editorial Society of Bone and Joint Surgery, London, England1999: 138-151Google Scholar which is identified best by a coronal plane section with increased T2-weighted signal with a corresponding low signal or decreased signal intensity on T1-weighted images.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar Use of gadolinium will result in marked enhancement without focal changes.26Hofmann S Kramer J Plenk H Kneeland JB Imaging of osteonecrosis.in: Urbaniak JR Jones Jr, JP Osteonecrosis: Etiology, Diagnosis, and Treatment. American Academy of Orthopaedic Surgeons, Rosemont, Ill1997: 213-223Google Scholar Also, edema seen with BMES usually is more extensive than that seen with AVN.5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar The bone cortex may appear thinned but intact. Unlike in AVN, there should be no evidence of subchondral defects. Avascular necrosis of the hip is a progressive condition resulting from an interruption of the vascular supply to the femoral head. The early features of transient osteoporosis/ BMES may be confused with AVN,3Mitchell DG Rao VM Dalinka MK et al.Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.Radiology. 1987; 162: 709-715PubMed Google Scholar which has fueled debate about whether BMES and AVN of the femoral head represent the same disease at different ends of a spectrum13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar or separate diseases.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar, 12Guerra JJ Steinberg ME Distinguishing transient osteoporosis from avascular necrosis of the hip.J Bone Joint Surg Am. 1995; 77: 616-624PubMed Google Scholar Clinically, this distinction is critical because each diagnosis has substantially different prognostic features, and incorrect diagnosis may lead to unnecessary surgical referral and potential intervention. Most reports suggest that BMES is a self-limited disease. The natural history of this entity is that of a symptom plateau followed by a gradual resolution of symptoms over 3 to 9 months. Migratory recurrence of symptoms occurs usually within the first 2 years after pain relief.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar Treatment includes supportive care, with initiation of pain management and physical therapy with use of protected weight bearing. Usually, NSAIDs ameliorate the symptoms sufficiently; however, opioids may be necessary during the acute setting. Physical therapy to provide gait retraining and protected weight-bearing techniques allow for easier pain control and increased function. As symptoms allow, a low-impact strengthening routine should be used, aimed at flexibility and increased range of motion to prevent deconditioning. The most feared complications are insufficiency and subcapital fractures of the femoral neck, which require orthopedic evaluation. For this reason, protected weight bearing is essential. One case report suggested that alendronate may provide significant pain relief and improve ambulatory function in patients with BMES.27Samdani A Lachmann E Nagler W Transient osteoporosis of the hip during pregnancy: a case report.Am J Phys Med Rehabil. 1998; 77: 153-156Crossref PubMed Scopus (45) Google Scholar Much like with the etiology of BMES, cautious observation vs intervention as treatment of BMES is controversial. Authors have suggested that surgical core decompression may be used in BMES, especially in patients with refractory pain despite use of conservative measures.13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar Bone marrow edema syndrome is an often-overlooked etiology for acute hip pain both in pregnant women and in middle-aged men. Conservative treatment is usually sufficient, but patients may require surgical intervention or alendronate for symptomatic relief. Correct identification of features consistent with BMES rather than AVN is critical to avoid unnecessary interventions or delays in therapy in patients with AVN. Bone marrow edema syndrome should be considered in the differential diagnosis of middle-aged men and young women with hip pain.

54-Year-Old Man With Hip Pain

A 54-year-old male farmer presented with a 4-week history of left hip pain. He described spontaneous onset of pain involving his left hip and groin. The pain was aggravated by ambulation and had worsened progressively over several weeks. The patient noted particular discomfort with hip flexion when getting on and off his tractor. The pain occasionally radiated anteriorly to the top of his knee. He denied worsening of pain with Valsalva maneuver, radiation of pain distal to the knee, and low back pain. Rest and avoidance of hip flexion briefly reduced the pain. The patient denied preceding trauma and any associated hypesthesia or paresthesia. He was a previous smoker, consumed alcohol occasionally, and had never used corticosteroids. The patient denied systemic signs of illness, weight loss, and nocturnal symptoms. Over-the-counter medications and complete avoidance of activity provided little relief. 1.Which one of the following is the most likely diagnosis based on our patient's history? a.Malignancyb.Meralgia parestheticac.Avascular necrosis of the hip (AVN)d.Polymyalgia rheumaticae.L4-5 radiculopathy Malignancy is unlikely without associated systemic signs and symptoms, weight loss, or night pain. Meralgia paresthetica, a localized area of pain described as a burning or an uncomfortable heightened sensation, is not influenced by direct pressure, hip movement, or lower back movement, which differs from the presentation in our patient. Avascular necrosis of the hip has been known by many terms including aseptic necrosis and osteonecrosis. Various factors leading to AVN have been identified, including corticosteroids and alcohol. Of the choices provided, AVN is the most likely diagnosis. Polymyalgia rheumatica is a common disorder that occurs often in persons older than 50 years. Classically, it presents with subacute onset of symmetrical aching and morning stiffness involving the shoulders, hip girdles, neck, and torso, symptoms inconsistent with those of our patient. Lumbar radiculopathy most commonly involves the L4-5 nerve roots and causes lateral hip pain that radiates down the leg and into the foot, with or without associated foot numbness. Our patient denies worsening of pain with Valsalva maneuver, paresthesias, or radiation of pain distal to the knee; thus, lumbar radiculopathy is an unlikely cause of his symptoms. Physical examination revealed normal vital signs. The patient had an antalgic gait without focal tenderness over the lateral hip or groin. There was no discrepancy in leg length. The patient had full range of motion of his hips and knees, although abduction and adduction of the left hip reproduced the pain. The pain was most marked with flexing, abducting, and externally rotating the patient's leg such that the ankle of that leg was on top of the opposite knee (fabere or Patrick test). Straight leg raise did not reproduce his pain or cause radicular symptoms. The patient had no spinal tenderness or scoliosis. Neurologic evaluation revealed only give-way weakness of the left hip secondary to pain. Findings on the rest of the examination were unremarkable. 2.Which one of the following is the next best step in the treatment of our patient? a.Local injection for presumed trochanteric bursitisb.Plain radiography of the lumbar spine, hip, and pelvisc.Reassurance with no further testingd.Bed rest for 1 week followed by physical therapy and strength traininge.Testing to determine serum protein electrophoresis, erythrocyte sedimentation rate, prostate-specific antigen level, and complete blood cell count Inflammation of the trochanteric bursa, one of the most common causes of hip pain, results from exaggerated movements of the gluteus medius tendon and the tensor fascia over the femur. Patients typically experience lateral hip and thigh pain that worsens with ambulation or direct pressure over the area. Our patient's symptoms do not correlate with trochanteric bursitis. Plain radiography, the correct choice, should be considered for all patients with both acute and chronic hip pain to exclude fracture and to provide information regarding arthritis or lytic lesions of the femur. Reassurance, bed rest, physical therapy, and further laboratory testing may be appropriate, but only after obtaining radiographs. Plain radiographs of the lumbar spine, hips, and pelvis revealed mild osteopenia of the femoral neck and head. Results of laboratory studies including serum protein electrophoresis were normal. Initially, our patient was treated conservatively, with limited weight bearing and nonsteroidal anti-inflammatory drugs (NSAIDs). Despite these measures, 3 weeks later he continued to have pain that limited his ability to complete his harvest. 3.Which one of the following is the most appropriate step at this time in our patient's evaluation? a.Continued conservative treatment and initiation of physical therapyb.Radionuclide bone scanningc.Magnetic resonance imaging (MRI) of the hipd.Ultrasonography of the hip with needle aspiration if effusion is presente.Referral to an orthopedic surgeon for hip replacement Our patient's pain has not responded to conservative measures for more than 8 weeks. The persistence of symptoms warrants further evaluation. Therefore, continued conservative treatment alone is incorrect. Radionuclide bone scanning usually is reserved for suspected pathology not revealed by plain radiography when MRI is not available. Magnetic resonance imaging is the radiographic study of choice for evaluation of hip joint pathology.1Zacher J Gursche A Regional musculoskeletal conditions: ‘hip’ pain.Best Pract Res Clin Rheumatol. 2003; 17: 71-85Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Besides allowing early diagnosis and staging of osteonecrosis, MRI enables the clinician to evaluate for potential infection, tumor, and pathology within the surrounding tissue. Immediate arthrocentesis is reserved usually for acute and severe hip pain in patients with findings suggestive of infection. An imaging technique such as ultrasonography for assistance with aspiration is advised. However, our patient's case does not warrant aspiration, and given the available information, there is no indication for surgical intervention. Magnetic resonance imaging of our patient's hip with and without gadolinium revealed diffusely increased T2 signal with partial loss of T1 signal involving the femoral neck and head. There was moderate soft tissue edema in the adjacent fat, vastus intermedius muscle, and adductor muscle, with little effusion. Our patient returned to see his physician the following day. 4.Based on MRI findings, which one of the following is the most likely diagnosis? a.AVNb.Bone marrow edema syndrome (BMES)/transient osteoporosis of the hipc.Ewing sarcomad.Osteoid osteomae.Adductor tendinitis Findings that suggest AVN/osteonecrosis include the pathognomonic double line or crescent sign (subchondral radiolucency), which represents evidence of subchondral collapse.2Mazières B Osteonecrosis.in: Hochberg MC Silman AJ Smolen JS Weinblatt ME Weisman MH 3rd ed. Rheumatology. Vol 2. Mosby, Edinburgh, Scotland2003: 1877-1890Google Scholar Such findings may be seen on plain radiographs or T2-weighted coronal MRI and represent a high-intensity rim within a low-intensity margin surrounding necrotic tissue.3Mitchell DG Rao VM Dalinka MK et al.Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.Radiology. 1987; 162: 709-715PubMed Google Scholar In our patient, these findings were not seen on MRI. Our patient's findings of increased T2-weighted signal with corresponding decreased signal intensity on T1-weighted images are characteristic of BMES and are present early in the disease course.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar, 6Harrington S Smith J Thompson J Laskowski E Idiopathic transient osteoporosis: a hidden cause of hip pain.Phys Sportsmed. 2000; 28 (87-91, 95-96.): 82-84Crossref PubMed Scopus (10) Google Scholar Therefore, BMES is the most likely diagnosis. Ewing sarcoma affects the long bones of the extremities, usually the femur and the pelvis. Patients typically experience localized pain or swelling for a few weeks or months and worsening nocturnal pain. Radiographically, the tumor is described as having a “moth-eaten” appearance. The classic finding of Codman triangle (expansion of the cortex with a displaced periosteum from the underlying tumor) was absent in our patient. Osteoid osteomas are benign bone-forming tumors that characteristically produce nocturnal bone pain relieved by aspirin. This is unique among bone tumors and absent in our patient. Tenderness over the involved tendon and pain with resisted adduction of the lower extremity are characteristic of adductor tendinitis and may reproduce the medial thigh and groin pain of hip disease. However, this disease does not explain the changes of the femoral head seen in our patient on MRI. Our patient's hip pain decreased with continued conservative treatment with NSAIDs and limited weight bearing, and repeated MRI 10 weeks later revealed improvement of the edema. The patient returned to his physician 5 months later with similar pain in his left knee. Because of his history, MRI of the knee was performed, which revealed patchy edema in the distal femur, in the lateral and medial femoral condyle, and in the proximal tibia on T2-weighted imaging with fat saturation. 5.Based on these new findings, which one of the following is the most likely diagnosis? a.Osteoarthritisb.Regional migratory osteoporosisc.Osteosarcomad.Occult knee fracturee.Pseudogout Our patient's MRI findings are not consistent with osteoarthritis and suggest this process is similar to the one identified in his hip. When bone marrow edema involves more than one joint or moves from one joint to another, it is referred to as regional migratory osteoporosis, which is a migrating arthralgia of the weight-bearing joints of the lower limbs. This is the most likely diagnosis, based on the new findings. Osteosarcomas are uncommon primary malignant tumors of bone and occur primarily in children and adolescents. In our patient, there was no radiographic evidence of osteosarcoma. Although MRI is the study of choice for occult knee fracture not identified on plain radiography, in our patient MRI indicated no discrete area of fracture. Furthermore, he had no findings consistent with pseudogout. After 4 additional months of taking NSAIDs, our patient's limited weight-bearing activity slowly advanced through physical therapy, and he had complete resolution of all symptoms. Our patient is now pain free and has no residual sequelae. Hip pain is extremely common in adults. Of those older than 60 years, 14% have reported substantial hip pain on most days.7Christmas C Crespo CJ Franckowiak SC Bathon JM Bartlett SJ Andersen RE How common is hip pain among older adults? results from the Third National Health and Nutrition Examination Survey.J Fam Pract. 2002; 51: 345-348PubMed Google Scholar There are numerous etiologies for hip pain, and we describe a potential diagnosis that may be overlooked. Curtiss and Kincaid8Curtiss Jr, PH Kincaid WE Transitory demineralization of the hip in pregnancy: a report of three cases.J Bone Joint Surg Am. 1959; 41: 1327-1333PubMed Google Scholar first described transient osteoporosis in 1959 after finding an association between hip pain in the third trimester of pregnancy and radiographic bone demineralization. Since this original description, the syndrome has been referred to by several different terms. Transient osteoporosis of the hip is the term credited to Lequesne from his 1968 report.9Lequesne M Transient osteoporosis of the hip: a nontraumatic variety of Sudeck's atrophy.Ann Rheum Dis. 1968; 27: 463-471Crossref PubMed Scopus (122) Google Scholar Although this condition is seen classically in the third trimester of pregnancy, men in their fourth through seventh decades of life account for more than 60% of reported cases.9Lequesne M Transient osteoporosis of the hip: a nontraumatic variety of Sudeck's atrophy.Ann Rheum Dis. 1968; 27: 463-471Crossref PubMed Scopus (122) Google Scholar, 10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar, 11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 12Guerra JJ Steinberg ME Distinguishing transient osteoporosis from avascular necrosis of the hip.J Bone Joint Surg Am. 1995; 77: 616-624PubMed Google Scholar The term bone marrow edema syndrome was introduced to replace transient osteoporosis of the hip and is based on characteristic MRI findings.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar, 13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 14Plenk Jr, H Hofmann S Eschberger J et al.Histomorphology and bone morphometry of the bone marrow edema syndrome of the hip.Clin Orthop Relat Res. 1997; 334: 73-84Crossref PubMed Google Scholar The joints of the lower extremities are affected much more frequently than the upper extremities, and symptoms occur most often in the hip followed by the knee, the foot, and the ankle.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar Bone marrow edema syndrome may affect the hip or knee as the single joint involved.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar, 11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 14Plenk Jr, H Hofmann S Eschberger J et al.Histomorphology and bone morphometry of the bone marrow edema syndrome of the hip.Clin Orthop Relat Res. 1997; 334: 73-84Crossref PubMed Google Scholar, 15Parker RK Ross GJ Urso JA Transient osteoporosis of the knee.Skeletal Radiol. 1997; 26: 306-309Crossref PubMed Scopus (40) Google Scholar, 16McAlindon TE Ward SA MacFarlane D Mathews JA Transient regional osteoporosis presenting as a septic arthritis.Postgrad Med J. 1993; 69: 871-873Crossref PubMed Scopus (8) Google Scholar Regional migratory osteoporosis (or migratory BMES17Lechevalier D Eulry F Crozes P Pattin S In situ migratory algo-dystrophies of the knee: value of modern imaging [in French].Rev Rhum Mal Osteoartic. 1992; 59: 29-33PubMed Google Scholar) was described first in 1967 as a migratory osteolysis, and its etiology remains unknown.18Duncan H Frame B Frost HM Arnstein AR Migratory osteolysis of the lower extremities.Ann Intern Med. 1967; 66: 1165-1173Crossref PubMed Scopus (62) Google Scholar It is characterized as a migrating arthralgia of the weightbearing joints of the lower extremities associated with a focal osteoporosis. The migration occurs from one articulation to another and is the feature that separates regional migratory osteoporosis from BMES involving the hip or knee alone.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar, 19Glockner JF Sundaram M Pierron RL Radiologic case study: transient migratory osteoporosis of the hip and knee.Orthopedics. 1998; 21 (594, 595.): 600PubMed Google Scholar, 20Banas MP Kaplan FS Fallon MD Haddad JG Regional migratory osteoporosis: a case report and review of the literature.Clin Orthop Relat Res. 1990; 250: 303-309PubMed Google Scholar, 21Dunstan CR Evans RA Somers NM Bone death in transient regional osteoporosis.Bone. 1992; 13: 161-165Abstract Full Text PDF PubMed Scopus (39) Google Scholar In BMES, patients present with progressive, ill-defined unilateral hip pain, usually described as a deep ache localizing to the medial or anterior thigh without radiation below the knee. Symptoms present acutely without inciting trauma and often render patients unable to ambulate without assistance. Pain worsens primarily with activity, whereas pain on resting, back pain, and neurologic dysfunction are not characteristic of BMES and suggest an alternative diagnosis. Physical examination findings of hip involvement most commonly include guarding during hip range of motion, especially with abduction or rotation of the hip, and an antalgic gait. Tenderness over the greater trochanter and adjacent adductor and hip flexor muscle groups may be present. Provocative tests with a fabere/Patrick test, resisted straight-leg raise, or hip joint compression or rotation loads may reproduce the pain. Results of spine and knee examinations and neurologic examination will be normal.6Harrington S Smith J Thompson J Laskowski E Idiopathic transient osteoporosis: a hidden cause of hip pain.Phys Sportsmed. 2000; 28 (87-91, 95-96.): 82-84Crossref PubMed Scopus (10) Google Scholar Laboratory tests generally do not help with the diagnosis. Plain radiographic findings obtained during the first 2 to 4 weeks of symptoms are usually normal. After 4 to 8 weeks of pain, osteopenia may be evident with a preserved joint space and no osseous erosion or subchondral collapse.5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar After this point, various degrees of cortical thinning and osteopenia around the intertrochanteric region and femoral head and neck have been described. This is in contrast to AVN, in which sclerosis progresses to articular surface flattening and eventual subchondral collapse.22Steinberg ME Brighton CT Steinberg DR Tooze SE Hayken GD Treatment of avascular necrosis of the femoral head by a combination of bone grafting, decompression, and electrical stimulation.Clin Orthop Relat Res. 1984; 186: 137-153PubMed Google Scholar Computed tomograms of BMES provide findings similar to those on plain radiographs.11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar Radionuclide bone scans are often positive within the first week of symptoms, revealing homogenously increased uptake of the area involved.11Schapira D Transient osteoporosis of the hip.Semin Arthritis Rheum. 1992; 22: 98-105Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 12Guerra JJ Steinberg ME Distinguishing transient osteoporosis from avascular necrosis of the hip.J Bone Joint Surg Am. 1995; 77: 616-624PubMed Google Scholar Magnetic resonance imaging is the modality of choice to exclude alternative diagnoses while revealing characteristic findings of bone marrow edema as early as 48 hours after onset of pain.13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 23Hayes CW Conway WF Daniel WW MR imaging of bone marrow edema pattern: transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis.Radiographics. 1993; 13: 1001-1011Crossref PubMed Scopus (207) Google Scholar, 24Daniel WW Sanders PC Alarcon GS The early diagnosis of transient osteoporosis by magnetic resonance imaging: a case report.J Bone Joint Surg Am. 1992; 74: 1262-1264PubMed Google Scholar Bone marrow edema identified with use of MRI is 100% sensitive but not specific for BMES,13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar, 25Hofmann S Bone-marrow oedema in transient osteoporosis, reflex sympathetic dystrophy and osteonecrosis.in: Jacob RP Fulford P Horan F European Instructional Course Lectures. Vol 4. British Editorial Society of Bone and Joint Surgery, London, England1999: 138-151Google Scholar which is identified best by a coronal plane section with increased T2-weighted signal with a corresponding low signal or decreased signal intensity on T1-weighted images.4Wilson AJ Murphy WA Hardy DC Totty WG Transient osteoporosis: transient bone marrow edema?.Radiology. 1988; 167: 757-760PubMed Google Scholar, 5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar Use of gadolinium will result in marked enhancement without focal changes.26Hofmann S Kramer J Plenk H Kneeland JB Imaging of osteonecrosis.in: Urbaniak JR Jones Jr, JP Osteonecrosis: Etiology, Diagnosis, and Treatment. American Academy of Orthopaedic Surgeons, Rosemont, Ill1997: 213-223Google Scholar Also, edema seen with BMES usually is more extensive than that seen with AVN.5Bloem JL Transient osteoporosis of the hip: MR imaging.Radiology. 1988; 167: 753-755PubMed Google Scholar The bone cortex may appear thinned but intact. Unlike in AVN, there should be no evidence of subchondral defects. Avascular necrosis of the hip is a progressive condition resulting from an interruption of the vascular supply to the femoral head. The early features of transient osteoporosis/ BMES may be confused with AVN,3Mitchell DG Rao VM Dalinka MK et al.Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.Radiology. 1987; 162: 709-715PubMed Google Scholar which has fueled debate about whether BMES and AVN of the femoral head represent the same disease at different ends of a spectrum13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar or separate diseases.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar, 12Guerra JJ Steinberg ME Distinguishing transient osteoporosis from avascular necrosis of the hip.J Bone Joint Surg Am. 1995; 77: 616-624PubMed Google Scholar Clinically, this distinction is critical because each diagnosis has substantially different prognostic features, and incorrect diagnosis may lead to unnecessary surgical referral and potential intervention. Most reports suggest that BMES is a self-limited disease. The natural history of this entity is that of a symptom plateau followed by a gradual resolution of symptoms over 3 to 9 months. Migratory recurrence of symptoms occurs usually within the first 2 years after pain relief.10Lakhanpal S Ginsburg WW Luthra HS Hunder GG Transient regional osteoporosis: a study of 56 cases and review of the literature.Ann Intern Med. 1987; 106: 444-450Crossref PubMed Scopus (196) Google Scholar Treatment includes supportive care, with initiation of pain management and physical therapy with use of protected weight bearing. Usually, NSAIDs ameliorate the symptoms sufficiently; however, opioids may be necessary during the acute setting. Physical therapy to provide gait retraining and protected weight-bearing techniques allow for easier pain control and increased function. As symptoms allow, a low-impact strengthening routine should be used, aimed at flexibility and increased range of motion to prevent deconditioning. The most feared complications are insufficiency and subcapital fractures of the femoral neck, which require orthopedic evaluation. For this reason, protected weight bearing is essential. One case report suggested that alendronate may provide significant pain relief and improve ambulatory function in patients with BMES.27Samdani A Lachmann E Nagler W Transient osteoporosis of the hip during pregnancy: a case report.Am J Phys Med Rehabil. 1998; 77: 153-156Crossref PubMed Scopus (45) Google Scholar Much like with the etiology of BMES, cautious observation vs intervention as treatment of BMES is controversial. Authors have suggested that surgical core decompression may be used in BMES, especially in patients with refractory pain despite use of conservative measures.13Hofmann S Engel A Neuhold A Leder K Kramer J Plenk Jr, H Bone-marrow oedema syndrome and transient osteoporosis of the hip: an MRI-controlled study of treatment by core decompression.J Bone Joint Surg Br. 1993; 75: 210-216PubMed Google Scholar Bone marrow edema syndrome is an often-overlooked etiology for acute hip pain both in pregnant women and in middle-aged men. Conservative treatment is usually sufficient, but patients may require surgical intervention or alendronate for symptomatic relief. Correct identification of features consistent with BMES rather than AVN is critical to avoid unnecessary interventions or delays in therapy in patients with AVN. Bone marrow edema syndrome should be considered in the differential diagnosis of middle-aged men and young women with hip pain.

PHYSICAL EXAMINATION FINDINGS IN DEEP VENOUS THROMBOSIS

DVT is a potentially serious disease and can serve as a marker for PE, an entity with even higher morbidity. Thus, it is critically important that emergency physicians consider this diagnosis in patients who present with suspicious symptoms. Recognition of alternative conditions, such as compartment syndrome, septic arthritis, and cellulitis, is also important for optimal care. Because physical examination is only 30% accurate for DVT, it serves to increase clinical suspicion in patients at risk but cannot be used to eliminate the possibility of thromboembolic disease. Because of this limitation, the diagnosis of DVT should be pursued using adjunctive testing in any patient with unexplained limb pain or swelling. Duplex sonography is currently the initial diagnostic study of choice for evaluation of DVT and, if test results are negative, it should be repeated serially if the clinical suspicion is high.

Radiographic staging of renal injuries.

Radiographic staging of renal injuries is the orderly process of establishing an immediate diagnosis so as to expedite effective treatment. Adult patients with gross hematuria or microhematuria associated with shock should undergo urgent imaging. Computerized tomography (CT scan) is the study of choice for evaluation of stable adult and pediatric patients with suspected renal trauma. Those in need of immediate surgical intervention are best evaluated by one-shot intravenous pyelogram (IVP) to determine the extent of the injured kidney and to document the normal function of the contralateral unit. Successful management of renal trauma is guided to a major degree by appropriate renal imaging.

Ultrasound in the assessment of the acute scrotum.

Color Doppler imaging (CDI) has become the study of choice in evaluation of the scrotum due to technological advances resulting in superior resolution and sensitive Doppler systems. CDI has become particularly helpful in evaluating the scrotum in the setting of acute disorders, such as torsion of the spermatic cord, epididymal and testicular inflammation, and scrotal trauma. CDI should be the study of choice to evaluate for torsion of the spermatic cord and demonstrates a high degree of accuracy. CDI in such a setting, however, does require operator experience, sensitive Doppler ultrasound equipment, and operator knowledge of the limitations of CDI. With epididymitis or epididymo-orchitis, CDI has proven to be quite helpful in evaluating the scrotal contents for the presence of inflammation and associated complications. In scrotal trauma, CDI's utility remains somewhat controversial, but with further investigation its appropriate application in this situation may become clear.

Kernspintomographie des Akustikusneurinoms (Schwannoms): Eine retrospektive Studie von 89 Tumoren

Magnetic resonance imaging (MRI) is now considered the diagnostic study of choice for evaluation of patients with suspected acoustic schwannoma. This retrospective study of 118 MR examinations presents an analysis of the MR findings of 89 acoustic tumours in 86 patients. The method of examination included precontrast and gadolinium(Gd)-enhanced MRI in 72 and plain MRI in 14 patients. The common MR-appearances of acoustic schwannomas were: on T1-weighted images (WI) isointense (36%) or slightly hypointense (64%) relative to the brainstem; intense and homogeneous contrast enhancement in 62%; the shape of the tumour was round or oval in 71%; the tumour was centred at/or located in the internal auditory canal (IAC) in 80%. The small acoustic schwannomas were mostly round or oval in shape and showed homogeneous signal intensity (SI) both before and after Gd. The larger acoustic tumours were more heterogeneous in morphology and SI. The significance of these and other signs, early diagnosis and differential diagnosis are discussed.

The temporal bone

MRI has made a remarkable impact upon diagnostic evaluation of the temporal bone and its diseases. Although high resolution CT is preferable for study of common maladies of the middle ear and optic capsule, MRI is currently the study of choice for evaluation of the internal auditory canal, cerebellopontine angle, and brainstem. MRI is also very useful in evaluations of complications of chronic otitis media. This manuscript is divided into sections on inflammatory disease, internal auditory canal/cerebellopontine angle, vascular compartments, facial nerve, and trauma. In addition, several miscellaneous entities are discussed.