DEXA/BMD Scan: Interesting case doctor…..

Case Study: 

53 year old woman

163cm and 47kg

Premature menopause <45

Increasing hip pain

Decreasing mobility

Method: A standard BMD/DEXA scan was performed on a Duel Energy X-ray GE Lunar-Prodigy BMD/DEXA scanner including a scan of the lumbar spine and the left acetabulofemoral joint (including femoral shaft).

Results: Incidental findings of high density (radio-opaque) SPECKS. The SPECKS were distributed throughout the ischium, ilium, acetabulum, femoral head and femoral neck.

Discussion: What are the high density specks circled in red?

Clothing artifacts?

Items inside the pockets?

Foreign body on the BMD/DEXA bed?

Patient History:

At the age of 19 (34 years ago) while living overseas in a war zone she had been the victim of  a sniper attack.

A bullet was fired through the window of her apartment penetrating her pelvis on the left side anteriorly, passing through her pelvis and exiting through her right side.

She then underwent 7 abdominal surgeries over the next several years including initial surgery and bladder reconstruction.

A bullet, once it has entered the body, leaves a dust-like trail of broken pieces in its wake.

The SPECKS are most likely small bullet fragments that are impossible to remove by surgery.  The exact positioning of the fragments is unknown; they could be in soft tissue or embedded in compact bone (osteon).

Calcium phosphate deposition typically occurs around fragments in soft tissue or bone, possibly raising the density of these SPECKS (Maggio 2008).

It is assumed the SPECKS are lead however iron is also noted in similar wounds (Maggio 2008)

Bullet fragments have been known to cause localized and systemic plumbism (lead poisoning).

Fragments can also cause mechanical destruction of the joint leading to severe arthritis, synovitis or gout (Rehman, M.A 2007).

In soft tissue fragments can cause abscess/cyst formation as well as fragment migration are also noted (Maggio 2008).

In animal models uneven thickness of articular cartilage and the synovium showed both cellular and stromal hyperplasia (Harding, N.R 1999, Gaetano 2004).

The patient needs to be carefully monitored as her increasingly painful left hip has impaired lateral movement suggesting that some of these SPECKS are in the acetabulofemoral joint.

There is also a potential risk with future investigations such as MRI.

Subsequently the patient’s right acetabulofemoral joint was scanned.

There were no SPECKS noted, the results of which were used in the patient’s BMD scan results; osteopenia.

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