Radiology Case Presentation

1. Radiology Case Presentation by:Brad Moatz

2. CC: • 19-year-old female with right lower quadrant pain and vomiting.

5. Uterine Anomalies • Congenital anomalies of the uterus are often asymptomatic and therefore unrecognized • The incidence of congenital uterine anomalies is difficult to determine since many women with such anomalies are not diagnosed, especially if they are asymptomatic. Uterine anomalies occur in 2 to 4 percent of fertile women with normal reproductive outcomes

6. Septate/Arcuate Uterus •  A septate uterus has a normal external surface but two endometrial cavities • The septate uterus develops from a defect in canalization or resorption of the midline septum between the two müllerian ducts. The degree of septation varies from a small midline septum to total failure in resorption resulting in a septate uterus with longitudinal vaginal septum

7. Pregnancy • There appears to be a higher risk of recurrent miscarriage associated with longer septa, but this is controversial and many untreated women have good pregnancy outcomes. Pregnancy outcomes reported in such women revealed spontaneous abortion in 21-44 percent, preterm delivery in 12-33 percent, and live birth in 50-72 percent.

8. Treatment • Hysteroscopic metroplasty has become the method of choice for repair of most uterine septa. Benefits to the transcervical approach include less morbidity, no abdominal or transmyometrial incisions, and faster return to normal activity. • Various techniques and instruments are used either to incise or remove the septum. Two of the most common instruments are the semirigid or rigid scissors (7 French) or the 8 mm wire loop urologic resectoscope operated through the 21 French sheath. Potassium-titan-phosphate (KTP/532), neodynamic:yttrium aluminum garnet (Nd:YAG), and argon lasers also have been used. • If however the septum cannot be safely removed hysteroscopically, then an abdominal or laparoscopic approach, such as the Jones or Tompkins metroplasty, can be used.

9. 42 Foot • Two views of the right foot, two views of the left foot, two views of the right hand, two views of the left hand • history: Psoriasis. • Findings: There are no prior studies available for comparison. • Right hand: There is no fracture or dislocation. There is significant narrowing of the multiple joints in many wrist and hand, especially the radiocarpal, all of the carpal, metacarpal phalangeal joints, as well as proximal and distal interphalangeal joints. There are multiple erosions in the distal radius and ulna, with complete erosion of the ulna styloid. There are also multiple erosions in the carpus. Several subchondral lucency/erosions are visualized in the distal 2nd-5th metacarpals, as well as distal aspect of the third and fifth proximal phalanges. There is productive bony change at the metacarpophalangeal and interphalangeal joints. There is bony ankylosis of several of the carpal bones, specifically the lunotriquetral, lunocapitate, and lunohamate articulations. The bony mineralization is within normal limits. • Left hand: There is no fracture or dislocation. There is significant narrowing of the multiple joints in many wrist and hand, especially the radiocarpal, all of the carpal, metacarpal phalangeal joints, as well as proximal and distal interphalangeal joints. There are multiple erosions in the distal radius and ulna, with complete erosion of the ulna styloid. There are also multiple erosions in the carpus. Several subchondral lucency/erosions are visualized in the distal 2nd-5th metacarpals, as well as distal aspect of the third and fifth proximal phalanges. There is productive bony change at the metacarpophalangeal and interphalangeal joints. There is bony ankylosis of several of the carpal bones, specifically the lunotriquetral, lunocapitate, and lunohamate articulations. The bony mineralization is within normal limits. • Right foot: There is no fracture or dislocation. There are large central erosions in the first -- fifth metatarsophalangeal joints, with resultant pencil in cup deformity in these joints. There is metatarsus adductus primus, measuring 18°. There is also hallux valgus, measuring approximately 52°. There is also mild to moderate lateral deviation at the second - fourth metatarsophalangeal joints. There is bony ankylosis in the midfoot, specifically at the naviculocuneiform articulation, as well as navicular cuboid joint. There are diffuse enthesopathic changes throughout the foot, most prominent at the medial and lateral aspect of the hindfoot and midfoot. There is a prominent erosion in the dorsal aspect of the calcaneus at the site of the Achilles' tendon insertion. There is a small calcaneal enthesophyte at the site of the plantar fascia insertion. There is no ankle joint effusion. Bony mineralization is within normal limits. • Left foot: there is no fracture or dislocation. There are large central erosions in the 2nd metatarsophalangeal joint, with resultant pencil in cup deformity. There are marginal erosions at the medial and lateral aspect of the fifth metatarsal. There is bony ankylosis at the first interphalangeal joint. There is bony ankylosis in the midfoot, specifically at the naviculocuneiform articulation, as well as navicular cuboid joint. There are diffuse enthesopathic changes throughout the foot, most prominent at the medial and lateral aspect of the hindfoot and midfoot. There is a prominent erosion in the dorsal aspect of the calcaneus at the site of the Achilles' tendon insertion. There is a small calcaneal enthesophyte at the site of the plantar fascia insertion. There is no ankle joint effusion. Bony mineralization is within normal limits. • Impression: Findings consistent with psoriatic arthritis in both hands and both feet, as described above.

10. 41 hand • Opon review of the study, there is swelling and mild enthesopathy of the fifth proximal interphalangeal joint on the right. • Small erosions and enthesophytes are noted at the second metacarpal phalangeal joint on the right and the fifth metacarpal phalangeal joint on the left. • Addendum Ends • Two views of the right hand, two views of the left hand, three views of the right and left foot, two views of the right and left heel • History: Psoriasis versus tophaceous gout. • Findings: There are no prior studies for comparison. • Left foot: There is no fracture or dislocation. There are moderate to severe degenerative changes of the first MTP joint, with joint space narrowing, osteophytosis, and subchondral cystic changes and sclerosis. There also osteophytes at the tibiotalar joint anteriorly and posteriorly. There is mild osteophytosis at the talonavicular and naviculocuneiform joints. There is a small calcaneal enthesophyte at the site of the plantar fascia insertion. There are no marginal or peri-articular erosions, periosteal reaction, joint space narrowing, soft tissue swelling, or abnormal soft tissue calcifications. Bony mineralization is within normal limits. • Left heel: There is degenerative change at the tibiotalar and talonavicular articulations, as above. A small calcaneal enthesophyte is seen and the plantar fashion distortion. There are no erosive changes were abnormal soft tissue swelling. • Right foot: There is no fracture or dislocation. There are moderate to severe degenerative changes of the first MTP joint, with joint space narrowing, osteophytosis, and subchondral cystic changes and sclerosis. There also osteophytes at the tibiotalar joint anteriorly and posteriorly. There is mild osteophytosis at the talonavicular and naviculocuneiform joints. There is a small calcaneal enthesophyte at the site of the Achilles' tendon insertion. There are no marginal or peri-articular erosions, periosteal reaction, joint space narrowing, soft tissue swelling, or abnormal soft tissue calcifications. Bony mineralization is within normal limits. • Right heel: There is degenerative change at the tibiotalar and talonavicular articulations, as above. A small calcaneal enthesophyte is seen and the plantar fashion distortion. There are no erosive changes were abnormal soft tissue swelling. • Right hand: There is no fracture, dislocation, subluxation, marginal or periarticular erosions, soft tissue swelling, or soft tissue calcifications. Bony mineralization is within normal limits. • Left hand: There is no fracture, dislocation, subluxation, marginal or periarticular erosions, soft tissue swelling, or soft tissue calcifications. There is a degenerative cyst in the distal pole of the scaphoid. Bony mineralization is within normal limits. • Impression: Degenerative changes in both feet and in the left hand, as above. There are no radiographic findings to suggest gout or psoriasis.