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15b - Answer: 49-year-old male presents with left elbow pain, swelling, and redness

Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
Includes DICOM files

HISTORY: 

This 49-year-old male presents with left elbow pain, swelling, and redness. Status post surgery two weeks prior. Buerger's disease.

(QUIZ ANSWER) FAVORED DIAGNOSIS IN THIS CASE: 

Infarction and vascular insufficiency.

Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.

FINDINGS:

Diffuse signal intensity abnormality noted involving the pronator teres muscle of the left forearm. T1 images are hyperintense compatible with methemaglobin staining and T2 and STIR images also hyperintense compatible with edema and swelling. Smaller areas centrally demonstrate fluid signal intensity compatible with areas of liquefaction or necrotic change in the form of rounded and ovoid areas. In a patent with Buerger's disease, infarction and vascular insufficiency is favored over sickle cell anemia, defects of trauma (crush injury), DOMS or denervation syndrome. Various causes of rhabdomyolysis including drug-induced, toxic and autoimmune, diabetes are also on the differential. May also consider myositis (toxic, autoimmune, inclusion body) in the appropriate clinical setting.

Milder changes in palmaris longus.

No other abnormal muscles are noted. 

Bones demonstrate normal cancellous, endosteal and cortical compartments.  

Normal neurovascular bundles. 

CONCLUSION: 

Diffuse signal abnormality of the pronator teres includes methemoglobin staining and edema pattern with areas of focal liquefaction or necrosis involving the pronator teres noted which may be the sequella of vascular compromise and infarction in the appropriate clinical setting (Buerger's disease). Other conditions may include sickle cell crisis, trauma, inflammatory myopathies and myositis with connective tissue disorders, infectious myositis, diabetes and various causes of rhabdomyolysis.

LESSON 2, TOPIC 45

Case Challenge: Forearm MRI Cases

Case Challenge

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Content reviewed: July 19, 2021

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