MSK Ultrasound cases file 12-2017

Steve. Ramsey,PhD. MSc,Rmsks,Rdms,Crvs.Crgs

 

This is a calcification in the right ischial glut tendon at origin causing pain.

Soft Tissue Calcifications

Soft tissue calcifications pop up all of the time, and it behooves the radiologist to say something intelligent about them. Fortunately, the differential diagnosis for this finding is not too difficult. Soft tissue calcifications are usually caused by one of the following six entities. These are listed below in the order of prevalence.

Soft Tissue CalcificationsCauseTypical AppearancePrevalenceDystrophicsmall to large amorphous Ca++ in the damaged tissue — may progress to ossification (formation of cortex and medullary space are then seen)95 – 98 %CPPDchondrocalcinosis; occasionally associated with calcifications in the soft tissues of the spine1 – 2 %Metastatic calcification finely speckled Ca++ throughout soft tissues1 – 2 %Tumoral calcinosis big globs of Ca++, usually near a joint<< 1 %Metastatic osteosarcoma amorphous, fluffy, confluent collection of Ca++<<< 1 %Primary soft tissue osteosarcoma amorphous, fluffy, confluent collection of Ca++ <<<< 1 %As you can see, almost every calcification that one sees in the soft tissues in actual radiographic practice is due to dystrophic calcification.

When tissue is damaged, the body responds to this injury in a nonspecific manner by invoking the generic inflammatory response reaction. This sometimes ends with calcification of the damaged tissue. This calcification is probably usually only microscopic but is occasionally enough to be seen radiographically.

Patient with dystrophic calcification in the Achilles tendon due to recurrent trauma and tendinitis.Again, dystrophic calcification means damaged tissue. Any kind of damage will do. Going through the universal differential diagnosis, we come up with the following possible causes:

Generic Differential Diagnosis of Dystrophic Soft Tissue Calcifications

  • Vascularvenous insufficiency
  • InfectionParasitic infestation cysticercosis
  • dracunculiasis
  • Armillifer
  • Neoplasm primary bone-forming tumor stroma
  • osteosarcoma
  • tumor necrosis
  • DrugsVitamin D
  • Autoimmunedermatomyositis
  • scleroderma
  • Traumaheterotopic ossification
  • injection granulomas

Since most calcifications are dystrophic, your biggest job now is to pick the most likely causes of it. The actual morphology of the calcification can help here. For example, consider venous thrombosis.

When this occurs around a venous valve, the resulting calcification (or even ossification) is round, dense, and sometimes lamellated, and is called a phlebolith. These are commonly seen in the complex venous plexus in the pelvis. They can also be seen in peripheral veins, especially in the lower extremities. Rarely, one may see them in soft tissue haemangioma.

While parasitic infestations are not exceedingly common, they are around for those who would see them. In our county hospital last year, we saw two patients with cysticercosis just passing across the regular orthopedic trauma board. With parasitic infestations, the morphology of the calcifications can be quite specific. With cysticercosis, the classic findings are multiple elongated foci of calcification just about the shape and size of grains of rice. These “rice grain” calcifications are usually oriented along the direction of the muscle fibers. Dracunculiasis, on the other hand, forms small crescentic calcifications.

Free fluid in the right elbow joint deep into annular ligament

Tear in the right RCL-Radial collateral ligament Right elbow.

Right colateral ligament calcification .

Tear at posterior common extensor tendon of the elbow.

Calcification at the triceps tendon insertion

Tear at the Radial collateral ligament

Left upper abdominal mass that pushed part of the stomach anterior lateral

Same abdominal cavity mass with fluid, solid tissue and it was having hyperemia

Ascites, fluid around left lobe of the liver, for the same case with the abdominal mass

Per choli fluid for the same case with the abdominal cavity mass.

Painful lymph node at the axillary area with hyperemia

Same Lymph node as above with irregular wall

Extended view scan of the lymph node to show any other nodes close to the solitary node.

Sof tissue Calcification at the right anterior upper thigh resulted from old injury

Sof tissue Calcification at the right anterior upper thigh resulted from an old injury.

Thank you for reading,

Steve Ramsey, Calgary, Alberta- Canada.

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