Case Author(s): Lisa Oakley M.D. and Tom R. Miller M.D.,Ph.D. , 07/11/97 . Rating: #D3, #Q3

Diagnosis: Soft tissue hematoma

Brief history:

Elderly woman with hip pain after a fall.

Images:

ANTERIOR AND POSTERIOR DELAYED WHOLE BODY IMAGES

View main image(bs) in a separate image viewer

Full history/Diagnosis is available below

Diagnosis: Soft tissue hematoma

Full history:

94 year-old female who fell off the toilet this morning. The patient has a persistent externally rotated right leg and refuses to move. Radiographs of the right femur are reportedly negative from an outside hospital.

Radiopharmaceutical:

Tc-99m MDP

Findings:

There is faint, focally increased radiopharmaceutical uptake in the region of the right femoral greater trochanter. There is also diffusely increased soft tissue uptake in the right thigh. The right thigh appears asymmetrically enlarged when compared with the left thigh.

Discussion:

Skeletal fractures incite bone repair mechanisms usually within 24 hours of injury. This change (initially due to hyperemia) is seen on bone scans as focal increased activity. Matin found that 80% of patients with fractures have a positive bone scan by 24 hours and 92% by 72 hours. However, in elderly patients bone scans may take longer to become postive and also may return to normal more slowly. Therefore, in older patients with suspected fracture and negative initial studies (e.g. plain film, MRI, bone scan), repeat bone scan at 72 hours may unveil lesions which were previously occult.

Followup:

The patient continued to have pain, and an MRI was ordered the following day.

MRI images of the hips demonstrate normal bone marrow signal and no evidence of acute fracture. However, there is extensive right thigh soft tissue swelling and hematoma which is most impressive around the anterior and medial muscle compartments. This is seen as areas of increased signal on the proton density and STIR sequences, and intermediate signal on T1-weighted images.

View followup image(mr). MRI IMAGES OF THE HIPS

Major teaching point(s):

This study may have been falsely negative for fracture. Repeat bone scintigraphy at 72 hours may have been helpful because of the relatively long interval between fracture and the appearance of scintigraphic abnormalities, especially in elderly patients. One school of thought recommends deferring initial bone scintigraphy until at least 24 hours after the suspected fracture in older patients. Others recommend proceeding with imaging because the study might be positive or, as in this unusual case, reveal other abnormalities. In any case, bone scintigraphy could be repeated at a later date if initially negative.

The study was valuable, nevertheless, because the soft tissue findings suggested post-traumatic hematoma later confirmed by MRI.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Effect of Trauma)

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Case number: bs078

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