Osteonecrosis in acute lymphoid leukemia

Case contributed by Dr Jeremy Jones


History of ALL. Worsening left elbow pain. Normal range of movement.

Patient Data

Age: 14 years
Gender: Male

Normal appearances at the elbow with no abnormal sclerotic area, or subchondral lucency.  No evidence of avascular necrosis, infection or bone infiltration, although all these diagnoses may be occult on plain film imaging.

There are multiple T2 and PD hyper-intensities throughout the bones around the elbow. They have the classical appearances of bone infarcts. There is an associated elbow effusion and metaphyseal periosteal reaction.

Annotated image

Retrospectively, the elbow radiograph is not normal.  On the lateral portion of the metaphysis there is periosteal reaction and there is a focal area of sclerosis in the capitellum.

Case Discussion

The initial plain film was reported as normal.  Clinical suspicion was high, so an MRI was performed. This confirmed underlying multifocal osteonecrosisperiosteal reaction and an elbow effusion

Retrospective review of the plain film highlights areas that related to abnormalities demonstrated on the MRI although the likelihood of prospectively calling these on a plain film remains low.

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