Fever, sore shoulder

An 83-year-old woman was referred with a history of fevers/night sweats for 3 months. there was a recent onset of left shoulder pain (5 days). She had been extensively investigated.

A blood culture had demonstrated ‘staph’ but thought to be a contaminant.

Bone scan:

Rob bp

Nothing much on the whole body blood pool.

Rob boneFacet joint arthritis in the neck; known base of 5th fracture. Note the bone marrow biopsy in the posterior right iliac crest

Now a gallium scan:Rob WB gal

Avid uptake in the left shoulder typical of infection. On to the SPECT….

Rob SPECT

Septic arthritis of the left acromio-clavicular joint.

Nice.

 

Posted in Bone scan, Gallium scans, Infection, Orthopaedic, shoulder | Tagged ,

The basics help

When I was a boy, learning nuclear medicine in the good old days, I was schooled in the ‘basics’.

One of the basics was that to diagnose osteomyelitis on a bone scan with any specificity you had to have a typical appearance, which was: focal arterial blood flow on the dynamic phase of the study, focal blood pool, and intense focal uptake on the delayed images.

Oh, and be very cautious about diagnosing osteomyelis in a non-diabetic.

Case in point: a 78 year old man with a red distal phalange of the right 2nd toe and a small ulcer on the tip (present for 4 weeks). Not diabetic.

Flow:

ocon flow

The blood flow and pool images don’t demonstrate focal intense uptake. it’s a little increased but not enough to say that there is an acute inflammatory condition in the distal phalange.

Delayed:

ocon delayed

It’s ‘warm’ but not as ‘hot’ as the uptake in 1st MTP. Also it’s not right at the tip.

As always SPECT is required.

ocon spect

It’s in the joint. It’s arthritis (with slight subluxation). That’s why the toe was a little red.

Sure the basics help, but SPECT helps more.

Posted in Bone scan, Foot and ankle

More of the same, only different

The last post was an area of segmental osteonecrosis in the right hip.

Here’s another, only slightly different.

This is an 87-year-old woman with 2 weeks history of right hip pain of spontaneous onset.

med pool

There is mild diffuse blood pool uptake in the right hip.

med wb

Focal uptake in the right hip. Mild non-specific uptake around the right knee replacement. No pelvic fractures. No lumbar spine pathology.

med Spect

Focal subchondral uptake in the right superior femoral head, typical of osteonecrosis. Uptake in the hip joint is normal.

Just like the last blog post, only different; no central ‘cold’ area.

Okay, now as a special treat another case.

This is an 88-year-old woman with a knee replacement 2 years ago and a 3 month history of right anterior knee pain.

osborn planar

Linear uptake in the right patella(red arrow). We’ll get to the left knee later.

osborn Spect R

Linear uptake in the body of the right patella. I suspect it’s either a non-displaced fracture or a focus of osteonecrosis (no problem with the femoral or tibial components)…….but that’s not all.

When I was speaking to the woman she was adamant her left knee was worse. She had lateral knee pain for a month. As she saw the doctor who did her right knee replacemt he was more interested in that, probably assuming the problem with the left knee was osteoarthritis.

osborn Spect l

But in the left knee there is avid focal subchondral uptake in the posterior lateral tibial plateau, again typical of osteonecrosis.

So why a bone scan and not an MRI?

Several reasons including the fact that MRI tends to be only one region. In the first case they wanted to look at the hip, pelvis, spine and knee. in the second MRI is seriously degraded by the knee replacement.

Also there is about a 1 -2 week wait for an MRI in our region.

 

 

Posted in Bone scan, Hip, Knee, Orthopaedic | Tagged , , ,

Nice….

A 90 year old woman was referred for a bone scan.

I will be kind. The edited version of this patient’s history….

Pain in the right hip for about 2 weeks. She had an injection in the hip a week ago and the hip got better, but now it’s painful again. Also pain in the back, posterior hip and knee.

Ellem WB

The right hip demonstrates moderate uptake. In a 90 year-old this is most likely arthritis, however, of course, SPECT-CT is needed.

Ellem SPECT

A beautiful example of segmental osteonecrosis of the right femoral head.

Note that there is even a subchrondral ‘cold’ area. Note also that there is no evidence of arthritis of the hip joint.

Nice…..well not for the patient of course.

Posted in Hip, Orthopaedic | Tagged , ,

An easy one

A 74-year-old woman was referred with the following history:

Chronic ulcer over the tip of the right great toe for 3 months.
Diabetic for 10 years.  ? Osteomyelitis.

There was no history of trauma. On examination her toe was swollen and red but painless. There was a small ‘clean’ ulcer at the tip of the big toe.

The scan:

sadi flow

The flow demonstrates increased arterial blood flow and blood pool activity in the right 1st toe distal phalanx.

sadi planar

The delayed image demonstrates avid uptake in the distal phalanx.

These changes are typical of osteomyelitis.

sadi CT

Always do the SPECT-CT.  You don’t get paid to miss a fracture.

Posted in Bone scan, Infection, Orthopaedic

A mystery explained (and England’s to blame)

This is the case of a 38-year-old man who had pain in the right first MTP joint.

The request said: ‘Cellulitis in right 1st MTP region. Good response to antibiotics but relapse. ? osteomyelitis.’

The bone scan:

hider BP

mildly increased flow and pool to the right 1st MTP region but not exciting.

hider delayed.png

Focally increased tracer uptake in the right medial sesamoid which should be a fracture. It’s really not ‘hot’ enough to be osteomyelitis.

hider spect

A typical fracture. But why did it respond to antibiotics.

Time for close questioning.

Now, the first question I ask in these situations is, ‘When did you first notice pain in the foot?’

Answer: ‘On the plane’

So, to make the story short, the patient was back from that notorious hellhole, England. Yes, he had done lots of walking and traveled about for 3 weeks. By the time he had returned home he couldn’t put his foot on the ground and his first MTP was swollen and bruised looking.

First, treated for gout. No response.

Second, treated with antibiotics. Good response. Pain decreased, swelling went down but came back after a week. Hence the referral.

So why did a sesamoid fracture respond to antibiotics?

‘What did you do when you were taking the antibiotics?

‘Well the doctor said I had cellulitis and that I should take the week off and keep my foot elevated’. He had a job that kept him on his feet a lot. When he returned to work ‘relapse’

So he had a fracture that responded to rest, not cellulitis that responded to antibiotics.

 

 

Posted in Foot and ankle, Orthopaedic

The benefits of multiculturalism

No case today.

One of the problems of a multicultural country such as Australia is that we sometimes have a language barrier with the patients. This is reflected by an incident that happened a few years ago.

I was wandering back into the department after getting lunch when I noticed an old Chinese woman at the front desk who was having quite a time of it. It seems she had come in looking for directions. The problem was that she spoke absolutely no English, but was waving a piece of paper.

The front desk were having none of it. ‘Not here, ‘ they kept repeating, ‘try somewhere else’. Being an humanitarian at heart and, wanting to set an example, I intervened. The woman had one word written on the paper: ‘Liu’.

‘Is this your name? Are you trying to make an appointment?’ I asked with the greatest sympathy (think Mr Darcy – BBC adaption). This was greeted by incomprehension.

More waving of paper.

Now, at that time we had a relief wards-person who was a young, female, ABC (Australian Born Chinese). She just happened to be passing and seeing the problem, immediately offered her help. She was doing a degree at the university and was covering for two weeks as a holiday job. What luck.

‘Can I help?’ she asked me. ‘Great, of course you can. This woman seems lost.’

She turned to the woman, who also looked relieved.

‘WHAT DO YOU WANT ?’ she shouted at her.

‘Wait on,’ I said. ‘Don’t you speak Chinese?’

She turned to me with a look that said ‘Why would you think that?’.

‘No,’ she said quite reasonably. ‘I just thought you needed help’

Now, I’ve been yelling in English at non-English speaking patients for years, even before this young puppy was born. I’ve become quite accomplished at it. I didn’t need her help, thank you.

As it turned out a simple call to bed allocations found two Liu in the hospital. One in maternity just nearby. A simple miming of a pregnant belly and the old woman was on her way, hopefully right direction, with her ‘interpreter’.

Another triumph for multiculturalism.

Posted in Uncategorized