Case Author(s): Samuel Wang, M.D., Tom R. Miller, M.D., Ph.D. , 9/22/95 . Rating: #D3, #Q3

Diagnosis: Neuroblastoma and spiral fracture of the right femur

Brief history:

8-month old boy who presented initially with constipation


Multiple spot images.

View main image(bm) in a separate image viewer

View second image(gu). Cystogram.

View third image(ct). CT of pelvis.

View fourth image(xr). Radiograph of femur.

Full history/Diagnosis is available below

Diagnosis: Neuroblastoma and spiral fracture of the right femur

Full history:

8-month old boy who presented initially with constipation and a palpable pelvic and lower abdominal mass. The patient was diagnosed with stage IV neuroblastoma with extension into the spinal canal. The patient had undergone an L3-L5 laminectomy and was receiving chemotherapy at the time of the bone scan. Bone scintigraphy performed two months prior to the present study had demonstrated the mass, but no evidence of osseous metastases.


Tc-99m MDP i.v.


Bone scintigraphy demonstrates increased uptake of the radiopharmaceutical in the soft tissues of the pelvis. The bladder is displaced to the right. These findings correspond to the site of the patient's known neuroblastoma, which contains foci of calcifications as seen on the CT study and on cystography. Additionally, there is an area of moderately increased tracer uptake in the right femoral diaphysis extending into the distal metaphysis. This lesion was thought to be suspicious for metastases.


Neuroblastoma is the most common solid abdominal neoplasm of infancy. It can occur anywhere within the sympathetic neural chain. Approximately two-thirds arise within the abdomen and of these, two-thirds are adrenal. The soft tissue masses will often (approximately 60%) be visualized on bone scintigraphy due to the presence of scattered calcifications. Metastatic neuroblastomas may produce areas of either focally increased or decreased uptake on bone scintigraphy. Metastases will often occur at the ends of the long bones and may be obscured by or simulate normal growth plate activity, particularly if image exposure on film is not controlled or if computer display is not utilized.


Plain films of the right femur were obtained and demonstrated a spiral fracture. Additional history revealed that the patient had been undergoing aggressive physical therapy. It was therefore uncertain whether this represented a true tramatic fracture or a pathologic fracture. Follow-up bone scintigraphy obtained approximately four months later demonstrated resolution of the previously noted uptake in the right femur. Follow-up plain radiographs (not shown) demonstrated a healed spiral fracture.

Major teaching point(s):

One of the teaching points to be made is that spiral fractures due to their longitudinal nature can mimic metastatic disease and again emphasizes the importance of radiographic and clinical correlation.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Neoplasm, Neoplastic-like condition)

Search for similar cases.

Edit this case

Add comments about this case

Read comments about this case

Return to the Teaching File home page.

Case number: bs029

Copyright by Wash U MO