Patella Fracture / Knee Pathology

Magnetic resonance image of an patellar fracture.













Magnetic resonance image of a healed patellar fracture.

A patella fracture is an injury that involves the bone located in front of the knee joint, also known as the knee cap.  The patella is a sesmoid bone, which means it is located within a tendon.  The function of the patella is to increase the leverage of the quadriceps muscle and it also protects the quadriceps and patellar tendons.  A patella fracture usually is caused by a forceful direct blow to the knee, it can also be caused by an indirect injury such as a sudden contraction of the quadriceps muscle.  When a patella fracture happens there is immediate intense knee pain, almost immediately the knee will become swollen and the patient is unlikely to be able to bend the affected knee.  If the fracture is right across the knee cap it may be possible to feel a gap.  

There are several classifications of a patella fracture.  They are classified according to the pattern of the fractures. 

Lower or upper pole fractures

Transverse - fracture occurs through the mid line dividing the bone into two parts upper and lower

Longitudinal - the bone has a verticle split

Comminuted - multiple pieces

Osteochondral - involving the cartilage

Displaced - bone fragments are separated

Undisplaced - bone fragments are not separated   

Treatment depends on the above factors.  It can include the following methods: ankle to groin plaster casts, as well as surgery.  Severely communited fractures may require a total patellectomy if they are unsalvageable.

The latest trend is to attempt to save as much of the patella as possible by gently holding the pieces in proper position and fixing them with flexible and stiff wires.  It usually takes four to six weeks for the bone to unite and it can take eight months to a year to reach the pre-fracture level.

In most patients rediographs are the most useful imaging tool for the initial examination.  Then x-ray is followed by CT scans, MRI imaging, and sometimes bone scans.  Fractures of the patella are responsible for approximmately 1% of all skeletal injuries in both adults and children.

Frozen Shoulder Syndrome

Adhesive capsulitis, also known as "frozen shoulder syndrome" is a painful condition characterized by stiffness in your shoulder joint and results in a severe loss of motion in the shoulder.  Signs and symptoms begin gradually, worsen over time, and then resolve usually within a 2 year period.  It may follow an injury or it can arise gradually with no injury or warning.  Frozen shoulder usually develops in three stages.  Each of these three stages can last up to a couple of months. 

Painful stage (pain occurs with any movement of your shoulder)    

Frozen stage (pain may begin to diminish however your shoulder becomes stiffer and range of motion decreases notabley)     

Thawing stage (the range of motion in your shoulder begins to improve)

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. In frozen shoulder, inflammation in the joint makes the normally loose parts of the joint capsule stick together.  The capsule thickens and tightens around the shoulder joint, restricting its range of motion and movement.  Doctors aren't sure of the exact cause of frozen shoulder syndrome and why it happens to some people and not others. Allthough through extensive research they have found that certain factors may increase the risk of developeing frozen shoulder.  These include age (people over 40 and 70% of cases are in  women), immobility example: people who have just had surgery on their shoulder, or have had their arm in a sling for long periods of time.  Research has shown that some autoimmune disorders are linked to frozen shoulder syndrome like diabetes, overactive and underactive thyroid, tuberculosis, and cardiovascular disease.

Frozen shoulder can usually be diagnosed from signs and symptomes alone.  However imaging tests such as x-ray and MRI  are usually done to rule out other structural problems.  Treatments include therapy involving applying heat or cold to the shoulder along with stretching exercises.  Nonsteroidal anti-inflammatory drugs are used along with corticosteroids injections, and in a small percentage of cases surgery may be needed to loosen the joint capsule so it can move more freely.  

          

                                                                          

                                                                                                                                                                                                                                                                                            

                                                                                   

Molar Pregnancy / Pelvic and Reproductive organs

Figure 1. Sagital T2-weighted MRI image of partial hydatidiform molar pregnancy.








 
Figure 2. Coronal T2-weighted MRI image of partial hydatidiform molar pregnancy 









A Molar pregnancy is an abnormality of the placenta, caused by a problem when the egg and sperm join together at fertilization. After a sperm fertilizes an egg, new tissues develop that normally form the fetus and placenta.  In a molar pregnancy the tissues that were suppose to form the placenta grow abnormally and can form a tumor that can spread beyond the womb or uterus.  The formal medical term for a molar pregnancy is "hydatidiform mole" and is also known as gestational trophoblastic disease.  There are two types of molar pregnancy: a complete mole where no normal fetal tissue forms, and a partial mole where incomplete fetal tissues develop alongside molar tissue.  Both forms are due to problems during fertilization.  A more aggressive tumor associated with molar pregnancies is an invasive mole.  The invasive mole contains many villi, but these may grow into or through the muscle layer of the uterus wall.  Sometimes, invasive moles can cause bleeding by perforating the uterus through its whole thickness.  This invasive mole can develop into a choriocarcinoma, a fast growing cancerous form of gestational trophoblastic disease. Potential causes may include defects in the egg, problems within the uterus, or a diet low in protein, animal fat, and vitamin A. For the most part it is idiopathic and not very easy to determine the cause. A women is also more likely to have a molar pregnancy if they have had one in the past.

My 30 yr old daughter has been diagnosed with molar pregnancies twice over the last 5 years.  Both of the moles were invasive and turned into choriocarcinomas.  She underwent chemo shots the first time and chemo infusions the second.  So far she has been cancer free since 12/2007, but may never be able to have children.  They have no clue what the cause is, they are thinking it might be her eggs, but really have no way of knowing.
 
Symptoms include abdominal swelling caused by the uterus becoming larger, excessive vomiting, fatigue, pelvic cramping with vaginal discharge, heavy bleeding, and in rare cases SOB with coughing and blood because choriocarcinoma can spread to the lungs before a molar pregnancy is diagnosed.

If a women is diagnosed with a molar pregnancy, further testing will be done to determine the type of mole and the possability of it having spread outside the uterus.  Testing may include chest x-rays, CT scans, MRI scans, and mostly ultrasound imaging.

Treatment may include a suction curettage (D and C) may be performed.  A hysterectomy, (removal of the uterus) may be an option for older women who do not wish to have future pregnancies.  Also chemotherapy with a single drug or multiple drugs, as well as radiation therapy.  With the appropriate treatment, all hydatidiform moles are curable, and nearly all cases of more aggressive invasive tumors can be cured with combination of surgery or chemotherapy.  It is important for women with molar pregnancies to be evaluated periodically after the mole has been treated.  Women are also advised not to attempt pregnancy for some time in order to be sure that levels of HCG remain at zero and that no further treatment is needed.  HCG levels should be checked periodically as an ongoing basis for follow up.

Wilms Tumor / Abodomen

              

                                                          
Magnetic resonance imaging (MRI) of Wilms Tumor on right kidney.

CT Scan of 11 cm Wilms' tumor of right kidney in 13 month old patient
 
   
 Wilm's tumor is a canerous tumor of the kidney that usually occurs in young children.  It is the fifth most common pediatric malignancy and the most common type of renal tumor in children. 

When and unborn baby is developing, the kidneys are formed from primitive cells.  Overtime these cells become more specialized.  The cells mature and organize into the normal kidney structure.  Sometimes clumps of these cells remain in their original primitive form.  If theses cells begin to multiply after birth, they may form a large mass of abnormal cells.  This formation is known as a Wilm's tumor or also called Nephroblastoma.  Wilm's tumor is a type of malignant tumor.  Which means it is made up of abnormal and immature cells.  These cells are also capable of invading other nearby structures within the kidney and can also travel out of the kidney into other structures.  Malignant cells can even travel through the body to invade other organ systems, most commonly the lungs and brain.

A Wilm's tumor occurs in about 1 out of 200,000 to 250,000 children.  It usually is diagnosed when a child is about 3 years old.  It rarely develops after age 8.  Symptoms include an abdominal mass, abdominal pain, fever, constipation, high blood pressure, increased growth on only one side of the body, loss of appetitie, nausea, vomiting, and abnormal urine color may also be associated with this disease.

Tests and diagnosis include: abnormal ultrasound, abdominal x-ray, CT scan of the abdomen, BUN, complete blood count, urinalysis, intravenous pyelogram, and MRI and other tests may be utilized to determine if the tumor has spread. The first step in treatment is to stage the tumor.  Staging helps the doctors determine how far the cancer has spread and to plan for the best treatment.  Surgery to remove the tumor is scheduled as soon as possible.  Radiation therapy and chemotherapy may be needed after surgery, depending on the stage of the tumor.  Follow up tests will be needed for future evaluation, however children whose tumor has not spread have a 90% cure rate with appropriate treatment.

Thymoma/ Lungs, Mediastinum, Heart

Contrast-enhanced coronal (left) and sagittal (right) reformatted CT images of the thorax demonstrate a lobulated mass in the anterior mediastinum (white and red arrows) with mixed attenuation consistent with a thymoma. The aorta is labeled Ao.

This computed tomography (CT) scan clearly illustrates the mass in the right anterolateral mediastinum.


A Thymoma is the most common neoplasm of the anterior mediastinum which originates within the cells of the thymus. The thymus gland is located behind the sternum in front of the great vessels and the pericardium. Thymomas are classified into three histologic types based on the predominant cell type: lymphocytic, epithelial, and lymphoepithelial. Thymomas affect men and women equally, they are most common in individuals in their fifth and sixth decades of life around age 52. They are rare in children. People with thymomas commonly have other diseases of the immune system.

The cause of thymoma is unknown, and the risk factors have not been identified. There is no clear histologic distinction between benign and malignant thymomas. The propensity of a thymoma to be malignant is determined by the invasiveness of the thymoma. Most benign thymomas are asymptomatic and most malignant thymomas are symtomatic. Symptoms include: cough, chest pain, dyspnea, dysphagia, hoarseness, superior vena caval syndrome, and about one-third of thymomas can present with systemic symptoms related to myasthenia gravis, such as muscle weakness.

Thymomas are usually diagnosed based on posterior and lateral chest x-rays, and CT images of the chest. If x-ray or CT images reveal the presence of a thymoma with uncommon features, or if there is a question of invasion into other nearby structures in the chest, it may be necessary to obtain a tissue sample of the mass or biopsey for examination.

Treatments for thymomas are surgery, radiation therapy, and chemotherapy depending on if the tumor is malignant or not. If malignant, treatment depends on the staging of the thymoma. Relapse after primary therapy for a thymoma may occur after 10 to 20 years. Therefore, long-term follow up should continue to be performed throughtout the patients life. The 15 year survival rate of a person with an invasive thymoma is 12.5%, and it is 47% for a person with a nonivasive thymoma. Death usually occurs from cardiorespiratory complications. The prognosis is based largly on the stage of the thymoma.