Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

LETTERS TO THE EDITOR
Year
: 2019  |  Volume : 29  |  Issue : 1  |  Page : 104--106

Explanation of radiological signs and fracture indices in a unicameral bone cyst


Reddy Ravikanth, Kanagasabai Kamalasekar 
 Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala, India

Correspondence Address:
Reddy Ravikanth
Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala
India




How to cite this article:
Ravikanth R, Kamalasekar K. Explanation of radiological signs and fracture indices in a unicameral bone cyst.Indian J Radiol Imaging 2019;29:104-106


How to cite this URL:
Ravikanth R, Kamalasekar K. Explanation of radiological signs and fracture indices in a unicameral bone cyst. Indian J Radiol Imaging [serial online] 2019 [cited 2019 Nov 21 ];29:104-106
Available from: http://www.ijri.org/text.asp?2019/29/1/104/255236


Full Text



Dear Sir,

A 12-year-old boy had a history of fall and sustained pathological fracture of proximal humerus. He was further referred for MR imaging that showed a cystic lesion along the long axis of the humerus in the proximal meta-diaphyseal region with no extension across the epiphyseal plate. Lesion appeared heterogeneously hyperintense on T2-weighted images with dependent blooming on GRE images indicating blood-fluid levels. Few internal septa with multiple cortical breaks were demonstrated in the proximal aspect of the lesion with periosteal elevation and collection. Linear T2-weighted hypointense foci are seen within the lesion indicating fallen fracture fragments [Figure 1], [Figure 2], [Figure 3]. Unicameral bone cyst is described as a solitary, lytic metaphyseal lesion, which does not cross the epiphyseal plate.[1] The lesion has well defined margins with narrow transition zone with the long axis of the lesion parallel to the long axis of bone and is known to migrate towards diaphysis during growth of child. It commonly occurs below 20 years of age and is commonly located in proximal humerus and femur in skeletally immature individuals and lacks malignant potential.[2] Radiological signs described in unicameral bone cyst are fallen fragment,[3] trapped door [4] and rising bubble signs.[5] Fallen fragment sign results from a pathologic fracture of the cyst wall, with displacement of the fragment into the dependent portion of the cyst [Figure 1]. Trapped door sign is a variant of the fallen fragment sign described in literature in which a periosteal hinge keeps the fragment from falling dependently and allows it to change position with the patient[Figure 3]. The trapped door is seen due to hydrostatic pressure of the fluid contained within the cyst. After sustaining a pathological fracture, presence of a gas bubble at the most non-dependent portion of the lytic bone lesion implies the lesion is hollow. On MRI, fluid level may be noted with cortical thinning, periosteal hematoma, septations, and pathological fracture [Figure 1], [Figure 2], [Figure 3]. The periphery of the lesion and septa within may show enhancement on administration of contrast. Unicameral bone cysts appear to be geographic lucent lesions on radiography with a central location, cortical thinning, and gentle expansion. The bone cyst index described by Kaelin and MacEwan [6] can be used as an easy method to assess the mechanical resistance of the cyst wall. The bone cyst index is calculated by dividing the cyst area by the diameter of the diaphysis squared [Figure 4]. Kaelin and MacEwan found that unicameral bone cyst with a bone cyst index of more than 4 for the humerus and more than 3.5 for the femur were at high risk for fracture. Ahn and Park [7] reported a second predictor for fracture is the bone cyst diameter and is expressed as the percentage of bone occupied by the cyst in the transverse plane. Unicameral bone cyst is considered to be at a high risk for fracture when the bone cyst diameter reaches more than 85% in both the anteroposterior and lateral images [Figure 4]. A third predictor is the minimal cortical thickness with a value less than 2 mm predicting a high risk of fracture [Figure 4].[6] Differential diagnoses for unicameral bone cyst include aneurysmal bone cyst, eosinophlic granuloma, enchondroma, fibrous dysplasia, and intraosseous ganglia. MRI helps in differentiating unicameral bone cyst from aneurysmal bone cyst.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

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