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Giant cell tumor (GCT) of the bone is a benign tumor with a high incidence of recurrence. The majority of recurrence occurs in the bone, typically where curettage was performed previously. Soft tissue recurrence is much less common and often shows ossification at the periphery of the soft tissue mass. We report four cases of ossified soft tissue recurrence of giant cell tumor of the bone after surgery at follow-up examination using plain radiography, ultrasound, CT, and MR imagings. Imaging findings of soft tissue recurrence with peripheral or central ossification were reviewed with pathologic correlation. To the best of our knowledge, this is the first report to describe soft tissue tumor recurrence with ossification illustrated and monitored at various imaging modalities over an extended follow-up period.

Objective: The purpose of this study was to evaluate the association between distal ulnar morphology and extensor carpi ulnaris (ECU) tendon pathology., Materials and Methods: We retrospectively reviewed 71 adult wrist MRI studies with ECU tendon pathology (tenosynovitis, tendinopathy, or tear), and/or ECU subluxation. Subjects did not have a history of trauma, surgery, infection, or inflammatory arthritis. MRI studies from 46 subjects without ECU tendon pathology or subluxation were used as controls. The following morphological parameters of the distal ulna were measured independently by two readers: ulnar variance relative to radius, ulnar styloid process length, ECU groove depth and length. Subjects and controls were compared using Student's t test. Inter-observer agreement (ICC) was calculated., Results: There was a significant correlation between negative ulnar variance and ECU tendon pathology (reader 1 [R1], P = 0.01; reader 2 [R2], P < 0.0001; R1 and R2 averaged data, P < 0.0001) and ECU tendon subluxation (P = 0.001; P = 0.0001; P < 0.0001). In subjects with ECU tendon subluxation there was also a trend toward a shorter length (P = 0.3; P <0.0001; P = 0.001) and a shallower ECU groove (P = 0.01; P = 0.03; P = 0.01; R1 and R2 averaged data with Bonferroni correction, P = 0.08). ECU groove depth (P = 0.6; P = 0.8; P = 0.9) and groove length (P = 0.1; P = 0.4; P = 0.7) showed no significant correlation with ECU tendon pathology, and length of the ulnar styloid process showed no significant correlation with ECU tendon pathology (P = 0.2; P = 0.3; P = 0.2) or subluxation (P = 0.4; P = 0.5; P = 0.5). Inter-observer agreement (ICC) was >0.64 for all parameters., Conclusion: Distal ulnar morphology may be associated with ECU tendon abnormalities.

Chondromyxoid fibroma (CMF) is a rare benign cartilage congener tumor comprising less than 1 % of primary bone tumors. Although the age range is wide, it is most commonly seen in the second and third decades. The most frequent location of CMF is in the long tubular bones of the lower extremities, particularly the proximal tibia and distal femur. Although the majority of chondromyxoid fibromas present as intramedullary tumors, a subgroup of chondromyxoid fibromas arising as surface lesions of the bone has recently been described. These are associated with an older mean age and an increased incidence of matrix calcifications. Chondromyxoid fibromas are rare in the distal ulna. We report a CMF presenting as a surface lesion of the distal metaphysis of the left ulna in a 41-year-old woman. We reviewed the literature on chondromyxoid fibromas involving the ulna and found that out of 22 cases, 1 was in the distal ulna, 13 in the proximal ulna, and in the remaining 8 the ulnar sites were unspecified. No case of chondromyxoid fibroma in the published literature had been designated as a surface lesion. Our own unpublished data include 70 chondromyxoid fibromas, 4 of which are in the ulna. Two of these are in the distal portion.

Pain at the ulnar aspect of the wrist is a diagnostic challenge for hand surgeons and radiologists due to the small and complex anatomical structures involved. In this article, imaging modalities including radiography, arthrography, ultrasound (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography are compared with regard to differential diagnosis. Clinical imaging findings are reviewed for a more comprehensive understanding of this disorder. Treatments for the common diseases that cause the ulnar-sided wrist pain including extensor carpi ulnaris (ECU) tendonitis, flexor carpi ulnaris (FCU) tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex (TFCC) lesions, ulnar impaction, lunotriquetral (LT) instability, and distal radioulnar joint (DRUJ) instability are reviewed.

Objective: To demonstrate how radial and ulnar deviation of the wrist can affect the visualization of the intrinsic intercarpal ligaments using magnetic resonance (MR) imaging, MR arthrography and gross anatomic inspection in cadavers., Materials and Methods: The detectability of the intrinsic intercarpal ligaments of ten fresh human wrists was analyzed in coronal, axial and sagittal images in the neutral position and in radial and ulnar deviation with MR imaging and MR arthrography. The findings were then correlated with gross anatomic inspection. Additionally, quantitative measurements including the radiocarpal distances and capitate angles were performed., Results: Differences were noted in the visual conspicuity of only the intercarpal ligaments of the proximal carpal row with different techniques and wrist positions. The average width of the radiocarpal joint was 0.62 mm, 1.55 mm and 2.0 mm (radial side) and 3.78 mm, 2.25 mm and 1.16 mm (ulnar side) in radial deviation, neutral position, and ulnar deviation of the wrist, respectively. Statistically, these maneuvers produced significant opening in the ulnar side during radial deviation (Student's t-test; P = 0.0005) and in the radial side in ulnar deviation (P = 0.007)., Conclusion: Significant differences in the width of the radiocarpal joint were observed during radial and ulnar deviation of the wrist, influencing the visualization of the intrinsic ligaments, mainly the scapholunate and lunotriquetral ligaments. The use of MR arthrography with radial and/or ulnar deviation has the potential to improve diagnosis in clinical cases in which injury to one or both of these ligaments is suggested.

Objective: The purpose of this study was to provide a detailed description of the anatomy of the coronoid process of the ulna and to use magnetic resonance (MR) images and anatomic correlation with cadavers to show the macroscopic configuration of this structure., Materials and Methods: Photography and high-resolution radiography were performed in 26 ulna specimens from the collection of a local museum. MR imaging of the coronoid process of 11 cadaveric elbows was performed. The images were compared with those seen on anatomic sectioning., Results: The anteromedial rim of the coronoid process of the ulna had a regular surface, without osseous irregularities or facets in 69.2% of the specimens. In 30.8% of the specimens, the anteromedial rim was not regular and a small ridge could be identified. The insertion site of the joint capsule was onto the anterior aspect of the coronoid process, at an average distance of 5.9 mm distal to the tip. The attachment of the anterior band of the ulnar collateral ligament at the sublime tubercle was flush with the articular margin in 63.6% of the specimens. In 36.4% of the specimens, a more distal attachment, with a separation between the undersurface of the ligament and the adjacent tubercle, was seen. The brachialis tendon was attached to the coronoid process at a mean distance of 12.1 mm distal to the tip., Conclusion: The coronoid process of the ulna is a small osseous structure with a complex anatomy and presents some anatomical variations.

Synovial sarcoma (SS) arises in soft tissues but may invade adjacent bone. We describe a case of SS presenting as aggressive lysis of the proximal ulna, the imaging of which suggested a primary bone lesion. Needle biopsy showed a "small round blue cell tumour", and a primitive neuroectodermal tumour (PNET)/Ewing sarcoma was suggested on the basis of the imaging appearances. The definitive diagnosis of synovial sarcoma was made following molecular genetic studies, which demonstrated a fusion product incorporating the genes SYT and SSX1. The importance of correct diagnosis to guide appropriate management, and, therefore, the necessity for molecular genetic studies, is discussed.

Late skeletal complications of meningococcal septicaemia and disseminated intravascular coagulation are well recognised in children and are largely centred on the growing epimetaphyseal region of long bones. In this article we describe a case of pseudarthrosis of the mid-ulna presenting 18 months following a devastating episode of meningococcal septicaemia in a 3-year-old boy. Radiographs and MRI demonstrated the ulna abnormality. We briefly review the late skeletal complications of the disease and other causes of pseudarthrosis.

Malignant peripheral nerve sheath tumor (MPNST) is almost always seen in soft tissue. Skeletal involvement by MPNST is uncommon and usually results from secondary invasion. Primary MPNSTs are exceptionally rare. We report a surgically proven case of intraosseous MPNST, with local recurrence and lung metastasis during follow-up. The imaging and histological features of the case are described and the literature on the subject briefly reviewed.

Objective: To evaluate the dynamic morphologic changes of the triangular fibrocartilage complex (TFCC) during pronation and supination of the forearm using high-resolution MR arthrography in cadavers and to evaluate the impact of these changes on the diagnostic assessment of the normal and abnormal TFCC. DESIGN AND SPECIMENS: High-resolution MR arthrography of 10 wrists of cadaveric specimens was obtained in maximum pronation, in the neutral position, and in maximum supination of the forearm. The structures of the TFCC were evaluated by two musculoskeletal radiologists and correlated with anatomic sections. The position of the forearm that allowed the best visualization of normal structures and lesions of the TFCC was determined., Results: The shape and extent of the articular disc as well as the radial portions of the radioulnar ligaments did not change with pronation and supination. The articular disc was horizontal in the neutral position and tilted more distally to align with the proximal carpal row in pronation and supination. The fibers of the ulnar part of the radioulnar ligaments (ulnar attachment of the articular disc) revealed the most significant changes: their orientation was coronal in the neutral position and sagittal in positions of pronation and supination. The ulnomeniscal homologue was largest in the neutral position and was reduced in size during pronation and supination. The extensor carpi ulnaris tendon was centered in its groove in the neutral position and pronation. In supination this tendon revealed subluxation from this groove. The dorsal capsule of the distal radioulnar joint was taut in pronation, and the palmar capsule was taut in supination. The preferred forearm position for analysis of most of the structures of the TFCC was the neutral position, followed by the pronated position. The neutral position was rated best for the detection of ulnar and radial detachments of the TFCC, followed by the pronated position, except for two central perforations of the TFCC which were best seen with supination., Conclusion: The articular disc and the surrounding radial portions of the radioulnar ligaments form a rigid, unified complex with the radius without change in their shape in positions of pronation and supination of the forearm, while the ulnar attachment of the TFCC shows important dynamic changes. The neutral forearm position is the best position to analyze both the normal and the abnormal TFCC.

Objective: To compare MR imaging techniques with differing contrast and spatial resolution for evaluation of complete disruption of the ulnar collateral ligament (UCL) anterior bundle in a cadaveric elbow model., Design: Complete UCL tears were surgically created at the typical location for clinical tears in eight of 28 fresh frozen cadaveric elbow specimens. All specimens underwent 1.5 T MR imaging in the oblique coronal plane, using an extremity coil. The sequences employed were: T1-weighted spin echo (T1 SE), proton density-weighted (PD) fast spin echo (FSE), fat-suppressed T2-weighted FSE (T2 FSE), gradient recalled echo (GRE) with a high matrix, PD FSE with a high matrix (HRPD), and fat suppressed T1-weighted SE with intra-articular gadolinium (MRAr). Two radiologists independently graded the UCL with separate and side-by-side assessments., Results: Sensitivity/specificity pairs were as follows for reader A and reader B, respectively: T1 SE: 0.25/0.95, 0.50/0.95; PD FSE: 0.38/1.00, 0.25/1.00; T2 FSE: 0.50/0.95, 0.63/0.95; GRE: 0.63/0.85, 0.63/0.60; MRAr: 0.88/1.00, 1.00/0.80; HRPD: 0.50/1.00, 0.88/0.80. Kappa statistics for measuring interobserver reliability for each sequence were poor under T1 SE (-0.13) and GRE (0.19), moderate under HRPD (0.41) and T2 FSE (0.44) and good under MRAr (0.62) and PD FSE (0.78). For both readers, the rating for overall image quality was highest for HRPD, and the rating for UCL lesion conspicuity was the highest for MRAr., Conclusions: Of the MR imaging pulse sequences tested, MRAr showed the greatest ability to identify complete ligamentous injuries with good agreement between readers and had the highest subjective preference for lesion conspicuity. However, HRPD had the least interobserver variability and the highest subjective preference for overall image quality.

An 18-year-old woman presented with left elbow joint pain. Radiographs and computed tomographic scan showed a well-defined osteolytic lesion of the left ulna associated with a honeycomb appearance on the radiographs. Magnetic resonance images showed intermediate signal intensity on T1-weighted images and mixed intermediate and high signal intensities on T2-weighted images. Only the periphery of the lesion enhanced with intravenously injected gadolinium-diethylenetriamine pentaacetic acid. The lesion was curetted to avoid pathologic fracture, and a histologic diagnosis of cavernous hemangioma of bone was made. Hemangioma involving the ulna is rare, but should be included in the differential diagnosis of a radiographic osteolytic lesion with a honeycomb appearance.

Objective: To compare the evaluation of fractures of the distal radius with MRI and conventional radiographs. To demonstrate the ability of MRI to detect unsuspected soft tissue derangement accompanying this common injury., Design and Patients: Twenty-one consecutive inpatients admitted following fracture of the distal radius underwent preoperative evaluation with both conventional radiographs and MRI. In each case, analysis was made of both the osseous and soft tissue injury. MRI findings were compared with those identified on conventional radiographs and at subsequent surgical fixation., Results: Of 21 patients with fractures of the distal radius, 20 had extension to the radiocarpal articulation, 14 had distal radio-ulnar joint extension and 5 had avulsion of the ulnar styloid. Occult carpal bone fractures accompanying fracture of the distal radius were identified in two patients: one of the capitate and the other of the second metacarpal base. Ten patients (48%) had associated soft tissue injury: six patients had scapholunate ligament rupture, two patients had disruption of the triangular fibrocartilage, one patient had extensor carpi ulnaris tenosynovitis and one patient had a tear of a dorsal radiocarpal ligament. Of five patients with ulnar styloid avulsions, none had evidence of triangular fibrocartilage tears., Conclusion: MRI affords better evaluation of osseous injury accompanying distal radial fractures than conventional radiographs. Intra-articular soft tissue injury accompanies distal radial fractures in almost 50% of cases. Scapholunate ligament disruption commonly accompanies intraarticular fracture through the lunate facet of the distal radius. Fracture of the ulnar styloid is infrequently associated with tear of the triangular fibrocartilage.

Granuloma annulare, a relatively common cutaneous disorder of unknown origin, is named for its predominantly papular lesions, which tend to group and coalesce in an annular fashion. Clinically distinct subtypes are divided into localized, generalized, perforating, and subcutaneous forms. Only the superficial granulomata of the extremities in subcutaneous granuloma annulare have been radiographically depicted in the literature. We describe and illustrate what we believe is the first radiographic presentation of bone and joint involvement with advanced, generalized granuloma annulare.

This report describes a low-grade parosteal osteosarcoma of the ulna with dedifferentiation into high-grade osteosarcoma. The clinical, pathological, and imaging findings are described and discussed.

The ulnar impaction syndrome of the wrist is a well-recognized clinical entity, usually showing distinct radiographic features including a positive ulnar variance and degenerative subchondral changes of the distal ulna, proximal lunate, and proximal triquetrum. Confirmation of the clinical and plain film findings with advanced imaging is often necessary to exclude other entities with a similar clinical presentation. Although arthrography and bone scintigraphy are helpful in this work-up, magnetic resonance imaging (MRI) appears to be both a sensitive and a specific means of evaluation. The imaging studies in four patients with clinically and surgically diagnosed ulnar impaction are described, with emphasis on MRI findings. MRI appears to be the modality of choice in the evaluation of patients with suspected ulnolunate impingement.

Previously developed criteria of normal distal radioulnar joint (DRUJ) axial geometry were applied to routine magnetic resonance (MR) images of 50 wrists. All wrists lacked clinically evident DRUJ instability. An attempt to apply the three geometric criteria to seven of the cases was not possible, since the prescribed landmarks were not visible. The remaining 43 cases were retrospectively divided into a symptomatic group (25 wrists), with clinical abnormalities referable to the ulnar side of the wrist, and an asymptomatic group (18 wrists), with no such abnormalities. Abnormal DRUJ geometry was found in 12 symptomatic and 2 asymptomatic wrists. This difference between the groups is significant (p = 0.02), suggesting that many symptomatic wrists exhibit different DRUJ geometry than is found in most asymptomatic wrists.

Eight cases of calcification following anterior dislocation of the head of the radius are described. It was demonstrated as early as 2 weeks after injury and in 7 cases appeared in the form of a shell on the volar aspect of the head. The other type exhibits a cuff of calcification related to the radial neck. Parallel cases are drawn from a literature review, and the distinction is made between calcification in the disrupted annular ligament/capsule or oblique cord and myositis ossificans. Regression in several cases may be a consequence of open reduction.

Sixteen patients with 20 forearm deformities were reviewed. The deformities were classified into three types. The degree of ulnar tilt of the radius, ulnar displacement of the carpus, and relative ulnar shortening were determined. The severity of the deformity correlated with these measurements. Metacarpal lengths were also measured. Significant metacarpal shortening without exostoses was seen in 10 of 11 patients and with exostoses remote from the metaphysis in 10 of 13 patients. Metacarpal shortening correlated with the type and severity of deformity.

Six cases of osteoid osteoma of the elbow were reviewed to determine the spectrum of clinical, pathologic and radiologic findings. Since osteoid osteoma of the elbow may masquerade as a nonspecific synovitis, the diagnosis is challenging and frequently delayed. The histology is, however, indistinguishable from that of osteoid osteoma occurring in typical locations. The radiologic features of osteoid osteoma of the elbow include the following triad: (a) osteosclerosis, usually a dominant feature at initial imaging and typically enveloping the nidus; (b) joint effusion; and (c) periosteal reaction that can involve both the bone in which the osteoid osteoma arises and adjacent bones. Awareness of these features will facilitate correct diagnosis, thereby facilitating timely and appropriate treatment.

Radiologic and histologic analysis of transphyseal linear ossific striations of the distal ulna and radius showed that these striations consist of trabecular bone extending from the metaphysis across all zones of the physis into a small focus of fibrous and necrotic tissue within the epiphyseal cartilage. The focus appears to be a discrete area of epiphyseal ischemia with subsequent necrosis within and around the vasculature of a cartilage canal and probably represents a microscopic response to antecedent trauma that was insufficient to cause macrofailure (fracture) of the physis. The striations did not continue into the epiphyseal ossification center. The consequence is partial osseous bridging across the physis. This bridging is unlikely to cause significant growth damage, since in most cases it does not appear to extend farther into the secondary ossification center.