Ischial tuberosity avulsion fractures, though not uncommon in adolescent athletes, are often overlooked or misdiagnosed. These fractures occur more frequently in males than females. Primary cause of this fracture type is usually a sudden eccentric load on the proximal hamstrings, typically seen during a kicking action in dance, football, or soccer. Due to the limited use of imaging in the evaluation of such injuries, these fractures often are misdiagnosed or underdiagnosed. Recent injuries warrant more conservative management, including rest and relative immobilization. In cases of late diagnosis, delayed healing, or persistent symptomatology, surgical intervention can be undertaken to restore normal anatomy, alleviate symptoms, and facilitate healing. Minimally invasive CT-guided percutaneous needle fenestration has been introduced for symptomatic delayed union ischial tuberosity fractures in adolescents. This percutaneous procedure involves the creation of multiple channels into the bone at the fracture site with an 18 gauge Chiba needle via image guided needle fenestration to enhance blood flow and promote healing of the target area. Following this, a tailored physical therapy program is implemented based on patient symptomatology, individual tissue healing rates, and the current literature related to proximal hamstring injuries. Outcomes to this minimally invasive approach have been promising including cases of complete pain relief, full functional recovery, and a return to sports without limitations. Outline of Teaching Points: Ischial tuberosity avulsion fractures are common in adolescent athletes, with a higher incidence in males, caused by sudden eccentric loads on proximal hamstrings during activities like dance, football, or soccer. Due to limited imaging use, these fractures are often overlooked or misdiagnosed, leading to delayed healing or persistent symptoms. Recent injuries may benefit from conservative management, involving rest and relative immobilization. Surgical intervention becomes necessary for late diagnoses, delayed healing, or persistent symptoms to restore normal anatomy and alleviate symptoms. Minimally invasive CT-guided percutaneous needle fenestration has shown promising outcomes, facilitating healing with complete pain relief and a return to sports without limitations. Read More

Meeting name: SPR 2024 Annual Meeting & Postgraduate Course , 2024

Authors: Malavia Mira, Rivard Douglas

Keywords: fracture, interventional radiology

Acroosteolysis (AO) is a rare manifestation of bone resorption that can occur in both genders and is not limited to a specific population. AO can be familial, idiopathic, occupational or secondary. It is marked by distal phalangeal bone resorption and often arises as a secondary manifestation of underlying musculoskeletal, dermatological, or endocrine conditions. Tuft resorption is often associated with conditions like systemic sclerosis, ischemia, hyperparathyroidism, and neurologic disorders, while the destruction of the distal interphalangeal joint is more frequently observed in inflammatory conditions like psoriatic arthritis. Familial AO affects only the feet and is associated with plantar ulcerations. AO due to vinyl chloride exposure is associated with papules and nodules on the hands and forearms and thickening of the skin of the hands. Clinically, AO is marked by a gradual tapering/thinning of the bones in the distal phalanges, resulting in a narrower appearance compared to normal digits. This process is accompanied by reduced bone density in the affected areas, which can be readily observed on radiographic imaging. It is often associated with distal digital ischemia, digital calcinosis, or severe sensory neuropathy. Nail changes in AO include brachyonychia, anonychia, atrophy, transverse ridges, discoloration, thickening of the nail plate, hyperkeratosis of the cuticles, pincer nail, pitted onycholysis, longitudinal ridging, and pterygium. X-ray images typically reveal distinctive bone resorption at the fingertips and toes, while CT scans may show areas of decreased bone density or erosions in the distal phalanges. MRI can detect soft tissue alterations, joint effusion, and inflammation. Beyond the physical changes, patients may experience pain, joint deformities, and reduced functionality in the affected extremities. Treatment mainly involved managing the primary disease causing AO. Learning Objectives: 1) To elucidate the clinical and radiological features of AO like the resorption seen in the distal phalanges. 2) To provide insight into the diverse underlying causes of AO, including associated medical conditions. 3) Understand cutaneous changes in AO to assist in the early recognition and prevention of disease progression. Conclusion: A comprehensive understanding of acroosteolysis, including its clinical presentation, radiological findings, and associated etiological factors, is crucial for accurate diagnosis and appropriate management. Read More

Meeting name: SPR 2024 Annual Meeting & Postgraduate Course , 2024

Authors: Daggumati Lasya, Malavia Mira, Randhawa Hari, Towbin Richard

Keywords: Phalanges, bone resorption

Primary Hypertrophic Osteoarthropathy (PHO) is a self-limiting, rare condition that emerges in the pediatric or adolescent years with a predilection for males, especially of African descent. It is often accompanied with symptoms of arthralgias, hyperhidrosis, and acne. PHO manifests in various forms, with the complete presentation being the most severe, characterized by facial coarsening, periostosis, and digital clubbing. In contrast, incomplete PHO spares the scalp, and forme fruste PHO exhibits clubbing and facial coarsening with minimal periostitis, duly setting it apart from secondary hypertrophic osteoarthropathy that is commonly associated with cardiac or pulmonary conditions. Genetic mutations in the 15-hydroxyprostaglandin dehydrogenase (HPDG) and solute carrier organic anion transporter family 2A1 (SLCO2A1) genes introduce variability in the inheritance patterns of PHO. HPDG-related PHO is typically autosomal recessive, while SLCO2A1-related PHO can be either autosomal recessive or dominant. These mutations elevate prostaglandin E2 levels, intensifying osteoclast activity, and causing bone resorption, which, in turn, triggers VEGF release and leads to vascular hyperplasia, bone disturbances, and edema. A common radiographic finding is acroosteolysis, and key features to differentiate PHO from other causes of acroosteolysis include terminal tuft resorption and periostitis. Other distinctive radiographic findings in PHO include terminal tuft resorption in fingers and toes and shaggy periostosis in long bone diaphyses. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs) and bisphosphonates for pain relief and cosmetic surgery if desired. We will present a few cases from our institution to review classic imaging findings, diagnostic workup, and management. Teaching Points: 1. Understand the clinical variability in presentations of Primary Hypertrophic Osteoarthropathy (PHO). 2. Recognize the genetic basis of PHO and appreciate the variable inheritance patterns associated with the HPDG and SLCO2A1 genes. 3. Identify the distinct radiological features of PHO, including terminal tuft resorption and shaggy periostosis, enabling accurate diagnosis and differentiation from other conditions. 4. Emphasize the importance of early diagnosis, highlighting how prompt recognition of clinical and radiographic features can enhance patient outcomes and mitigate complications. Read More

Meeting name: SPR 2024 Annual Meeting & Postgraduate Course , 2024

Authors: Malavia Mira, Randhawa Hari, Dagumati Lasya, Towbin Richard

Keywords: digital clubbing, peristosis

Osteoid osteomas (OO) are benign osteoblastic tumors primarily afflicting individuals aged 5 to 30 years, ranking as the third most prevalent among benign bone tumors at around 10%. Patients typically present with persistent nighttime pain that responds positively to NSAIDs, along with potential complications like progressive discomfort, tenderness, swelling, and limited joint mobility with articular involvement. OO usually forms in the cortex of long bones, measuring less than 2 cm, exhibiting a central radiolucent nidus encased by surrounding sclerosis, best visualized using CT scans. The current standard-of-care entails CT-guided radiofrequency ablation (RFA), while surgery becomes an option for complex locations like the spine, extremities, or craniofacial bones. Moreover, advanced thermoprotective techniques have expanded RFA's applicability to previously unsuitable lesions. Cryoablation is a newly indicated for pediatric OO patients and involves controlled tumor freezing, preserving adjacent healthy tissue. It offers reduced pain, shorter recovery, and minimal scarring, enhancing the quality of life for young patients. This exhibit will discuss 3 cases that underscore the diverse management approaches required for osteoid osteomas in young patients. Case 1 featured initial relief with radiofrequency ablation (RFA) but recurrence, ultimately resolved with cryoablation. In Case 2, a CT-guided cryoablation was performed for an S2 osteoid osteoma, with limited follow-up data. Case 3 highlighted the complexity of treating a C1 osteoid osteoma, initially successful with intra-operative cryoablation, but it was followed by new neck muscular pain post-operation. Cryoablation's accuracy and less invasiveness make it a preferred choice in treating OO patients. Learning Objectives: Grasp cryoablation principles for pediatric osteoid osteoma. Recognize indications and contraindications. Assess benefits and risks in pediatric cases. Comprehend the pathophysiology of osteoid osteoma and cryoablation's role in treatment for pediatric patients. Read More

Meeting name: SPR 2024 Annual Meeting & Postgraduate Course , 2024

Authors: Malavia Mira, Le Viet, Rivard Douglas, Reading Brenton

Keywords: cancer, pain management, ablation