Amar Udare, MBBS

A 7-year-old male presented with pain after falling on an outstretched hand.
 


Radiograph of the forearm shows subtle buckling involving the lateral cortex of the radius in its metaphysis (arrow in Figure 2).

Torus fracture is a type of incomplete fracture

 Commonly seen in long bones of pediatric patients.

 Most common mechanism of injury is indirect trauma, like fall on an outstretched hand (FOOSH).

 Axial load causes trabecular compression resulting in cortical buckling without an obvious fracture line.

 Elasticity of the developing bones in children causes buckling of the cortex rather than a fracture along a single plane as in adults.

• Seen as a curved disruption of the cortex and periosteum along the convex aspect of the bone along the metaphysis of long bones, most commonly distal radius.

Best seen when bone is imaged in profile as opposed to en face.

• Can be associated with mild overlying soft tissue.

• Rest and immobilization in the form a splint suffices in most cases.

• If the angulation is significant, manipulation may be needed.

• Occur when the force applied to a bone is sufficient to overcome the integrity of the cortex resulting in fracture of the convex surface and bucking of the concave surface.

• Needs active management and can take a long time to heal as they tend to occur in the diaphysis which are relatively slowly growing portions of the bone.

1. Solan MC, Rees R, Daly K. Current management of torus fractures of the distal radius. 

2. Uzelac A, Davis R. Blueprints Radiology. LWW. ISBN:1405104600.

3. Trauma X-ray - Upper limb gallery 1 - Greenstick and Torus fractures [Internet]. Radiologymasterclass.co.uk. 2017 [cited 6 August 2017]. Available from: http://www.radiologymasterclass.co.uk/gallery/trauma/x-ray_arm_1/fractures_11

4. Weerakkody Y. Torus fracture | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2017 [cited 6 August 2017]. Available from: https://radiopaedia.org/articles/torus-fracture-1

5. The Radiology Assistant : Wrist - Fractures [Internet]. Radiologyassistant.nl. 2017 [cited 6 August 2017]. Available from: http://www.radiologyassistant.nl/en/p476a23436683b/wrist-fractures.html

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A 7-year-old male presented with pain after falling on an outstretched hand.

Image IQ: 7-year-old with Pain after Fall

A 32-year old male presents with abdominal discomfort.

Plain and post-contrast CT at the level of the abdomen reveals multiple well-defined homogeneously enhancing lymph nodes in the peritoneum and retroperitoneal compartment. The vessels are seen coursing through this nodal mass with mild narrowing of caliber without invasion (sandwich sign).

Lymphomas are defined as the clonal malignant proliferation of a mature lymphocyte from a secondary lymphoid structure, a lymph node, or an extranodal structure. They are further classified into Hodgkin’s (HD) and Non-Hodgkin’s lymphoma (NHL).

• HD has a bimodal age distribution: First peak occurs in the middle to late 20s and the second peak after the age 50. Males are affected as commonly as females

• Prevalence of NHLs increases steadily with age throughout life. M:F 2:1

• Initial evaluation and follow-up of involvement of superficial lymph nodes, and for testicular involvement.

• Involved nodes are seen as well-defined, rounded homogenous lesions with loss of fatty hilum.

• However, US examination may be affected by the patient’s obesity or bowel meteorism, hence cross section imaging is necessary.

• Allows detailed evaluation of the mediastinum, chest wall, pulmonary parenchyma, and pleura or pericardium.

• Enlarged nodes with moderate homogeneous enhancement typically seen.

â Refers to the characteristic appearance of enlarged mesenteric lymphadenopathy enveloping fat and tubular structures at cross-sectional imaging resembling a sandwich or a hamburger.

â Sign is specific to mesenteric lymphomas as they can grow to a large size and can envelop fat, bowel, and vessels without causing clinical symptoms.

â Carcinomas, sarcomas, and carcinoid tumors originate within the small bowel and then spread to the mesenteric nodes and can quickly invade the bowel wall, causing perforation, hemorrhage, and widespread disease

• Particularly useful for evaluating the CNS disease.

• Owing to their cellular content, lymphoma deposits show restricted diffusion and have homogeneous post contrast enhancement.

• Provides comprehensive staging of the disease process and is also useful for monitoring response to therapy


Causes of mesenteric lymphadenopathy include lymphoma, carcinoma, sarcoma, carcinoid tumor, tuberculosis, Whipple disease, lymphadenopathy syndrome associated with acquired immunodeficiency syndrome (AIDS), and inflammatory bowel disease.
 

Image IQ: 32-year-old Male with Abdominal Discomfort

A 24-year-old male presented with history of pain in the knee following trauma. Radiograph and MRI images have been provided.


Plain radiograph shows a well-defined lytic lesion involving the distal metaphysis of the femur with a narrow zone of transition. The lesion reaches into the epiphyses; however, it does not reach up to the cortical surface. There is no periosteal reaction or cortical break. MRI reveals a well-defined multiloculated cystic lesion with fluid-fluid levels in the distal femur. The lesion does not reach up to the subarticular surface and there is no periosteal reaction/cortical break.


Aneurysmal bone cyst (ABC) is a non-neoplastic solitary lesion of bone consisting of a cystic cavity filled with blood. It is a misnomer as it is neither an aneurysm nor a true cyst but is made of blood filled channels. It occurs in patients between 5 and 20 years. The common symptom is pain. It affects the long tubular bones and spine. Lesions are located in the epiphyses and are eccentric.

• It is seen as an expanding, rapidly growing, saccular lytic, sharply demarcated by a thin subperiosteal shell

• It has multiple fine septae internally and sharply demarcated  bulging, scalloped borders

• Most lesions are metaphyseal; however, they extend to the epiphyseal end of the bone after the growth plate has closed

• It is associated with ballooning and thinning of the cortex (known as the "blown-out" appearance)

• Fluid-fluid levels in multicystic lesions are characteristic for ABC and are probably owing to settling of degraded blood products. Although this is classic for an ABC, these can also be seen in osteosarcoma, giant cell tumor, and chondroblastoma

• Individual chambers are separated by septae surrounded by a thin peripheral rim of low signal intensity on T1- and T2-weighted images. The septae may show enhancement on postcontrast scans; however, the lesion itself does not enhance

• Bone scan may show increased update peripherally with a photopenic center (doughnut sign)

1. Yochum T, Rowe L. Yochum and Rowe's essentials of skeletal radiology. Philadelphia, PA: Lippincott WIlliams & Wilkins; 2005.

2. Gailard F. Aneurysmal bone cust. Radiopaedia.org. Available from http://radiopaedia.org/articles/aneurysmal-bone-cyst. Accessed July 31, 2015

24-year-old male with history of pain in the knee following trauma.

Image IQ: 24 y/o, History of Knee Pain Following Trauma

 A 45-year-old female presented with vague pain in the abdomen. A USG was ordered, which revealed that both kidneys were enlarged and had innumerable cysts with minimal intervening parenchyma (Figure 1A and 1B). An ill-defined hyperechoic area with posterior acoustic shadowing was seen in the left kidney. The ureters and bladder were normal. A few similar cysts were also seen in the liver (Figure 2). The findings were confirmed on a plain CT scan which revealed bilateral nephromegaly and cysts in both kidneys and the liver. Multiple calculi were also seen in the in the left kidney (Figures 3-5). No cysts were identified in the pancreas and spleen. Features were suggestive of autosomal dominant polycystic kidney disease.

 Ultrasound image shows that the right and left kidney are enlarged in size and have innumerable cysts. No definite renal parenchyma is identified. Ill-defined shadowing is seen in the left kidney.

 Ultrasound of the liver shows cysts in the liver.

 Non-contrast CT scan axial sections reveal multiple cysts in the liver and kidney. Multiple calculi are also noted at the lower pole of the left kidney.

 Autosomal dominant polycystic kidney disease

Presents late in life: 30-50 years (as compared to ARPKD which presents in early childhood)

Autosomal dominant (90 percent); spontaneous mutations (10 percent)

Intracranial dolichoectasia: hypertension: up to 80 percent adults

Increased renal size with curvillinear wall calcification

"Swiss cheese" pattern: smoothly marginated radiolucencies in cortex and medulla seen on nephrographic phase

Shows increased renal size, innumerable cysts in both kidneys

Simple cysts will have anechoic walls with posterior acoustic enhancement

Hemorrhagic cysts show echogenic material devoid of blood flow

CT will also confirm the presence of cysts in other organs.

Post contrast: no contrast enhancement in simple cysts

No family history of renal cystic disease

Multiple renal and pancreatic cysts, pheochromocytomas, and frequently multiple and bilateral RCCs

Associated lesions include retinal angiomas and cerebellar hemangioblastomas

Multiple renal cysts and multiple fat containing angiomyolipoma

Cutaneous, retinal and cerebral hamartomas are associated

Development of multiple cysts in the native kidneys of patients on long-term hemodialysis

Affected kidneys are usually small, reflecting the chronic renal disease

Cysts are predominantly cortical and rarely exceed 2cm


1. Weerakkody Y, Gilliard. Autosomal dominant polycystic kidney disease.

http://radiopaedia.org/articles/autosomal-dominant-polycystic-kidney-disease-1

. Accessed November 25, 2013.
2. Federle M, Jeffrey R, Desser T, Anne V, Eraso A, et al. Diagnostic Imaging: Abdomen, 1st edition. Salt Lake City, UT: Amirsys; 2004.
3. Brant W, Helms C. Fundamentals of Diagnostic Radiology. 3rd Edition. Philadelphia: Lippincott Williams and Wilkins; 2005. Chapter 33, Adrenal Glands and Kidneys.

Articles

Case History: 45-year-old female with vague pain in the abdomen.

Author | Amar Udare, MBBS

Articles

Image IQ: 7-year-old with Pain after Fall

Image IQ: 32-year-old Male with Abdominal Discomfort

Image IQ: 24 y/o, History of Knee Pain Following Trauma

Autosomal Dominant Polycystic Kidney Disease