Dear OCADERS,
Again I ask for your help.
12 years old football player. He quit in february due to pandemic, but also pain in the medial knee, no important trauma
Pain is persistent 10 month later, increased in intensity and also at night.
AINS helps relieve the pain very fast (paracetamol, ibuprofen) but after a while it re-appears
I find x ray unremarkable.
MRI shows epiphyseal BME but also on the diaphyseal side, asymmetric, clearly related to the growth plate in my opinion.
There is focal gadolinium enhancement on the epiphyseal side, but I suppose there are some impacted trabeculae there also?
What puzzles me the most is inflammation in the intercondylar notch close to the area of BME and around PCL origin (black arrows). Is this inflammation secondary to the bone modifications?
What are these metaphyseal modifications? I would suspect trauma (impacted trabeculae?), but why so focal, and why inflammation in the intercondylar notch?
Is it osteomielitis (child, cartilage plate vascularity..)? Routine blood is normal…
Any idea?
Thank you in advance!
Sorin
Hi, dear OCADERS, thanks a lot for your responses regarding my growth plate disturbance.
In summary:
– osteoid osteoma – 5 responses
– FOPE – 4 responses
– small abcess 1 response
– stress fracture 1 response
– salter harris III 1 response
– salter harris I 1 response
I reproduce below some of the answers
And re-attached one article about FOPE and cancelous bone osteoid osteoma (there is a link in gabriel legurguro email)
I found all the answers very useful, thank you all.
My first impression was stress fracture/ infection, but it looks indeed like OO (but the location is soooo unusual I would not dare to think of it… )
I will recall the patient for a CT as advised by some of you, and I will also do a sequence on the contralateral knee to see the symmetry if any
I will follow up this 3 month from now and ask the orthopedist to try and rule out infection if it is possible. I hope to convince him no to do a biopsy, it seems that my colleagues orthopedist want to biopsy all BME areas lately 🙂
Thank you again, I will keep you posted!
sorin
On Wed, Dec 30, 2020 at 3:19 PM hugo declercq wrote:
Hi ,
I think the clue is on the T1 coronal sequence. You see a small fracture line
It is a stress fracture in the epifysis with parallel course to the growtplate and reactive oedema.
Probably this is a stress fracture due to excessive sporting
grt
Hugo Declercq
Belgium
gabriel legurguro
Wed, Dec 30, 2020, 3:01 PM (3 days ago)
to me
Hello Dr. Have you think on atypical osteoid osteoma? Here some lines from a paper.
“Medullary (cancellous) osteoid osteoma: An osteoid osteoma within the spongy bone is called medullary osteoid osteoma. Carpal and tarsal bones and femoral neck are the most common locations for medullary lesions. Approximately 20 % of osteoid osteomas involve medulla [66]. Medullary osteoid osteomas often present as juxta-articular lesions, especially in the metaphysis of long bones and in carpal and tarsal bones”.
DOI: https://doi.org/10.1007/s00590-013-1291-1
Just a ddx. Think about that. Thank you for sharing this case.
FOPE_ajr.10.6243
Update on this case: patient had a CT today. It confirms the suspicion of the majority of ocaders: osteoid osteoma. Patient will be scheduled for RF ablation.
I will try and upload the CT image!
Thank you all !