[ ISSN : 2576-5442 ]
Juvenile Idiopathic Arthritis (JIA) is an autoimmune disease that may lead to inflammation of multiple joints at a young age, often complicated by destruction and growth disturbances, including the craniofacial region. The annual incidence is reported as 0.008–0.226 per 1000 children.
Synovial and ganglion cysts are fluid-filled lesions within joints, most often occurring in the periarticular areas of the wrist, knees, and feet [1]. These cysts occur in the Temporomandibular Joint (TMJ), although they are rare [2]. A review of the literature by Steen et al. found thirty-six ganglion and thirteen synovial cysts in the TMJ (3). The distinction between a synovial and ganglion cyst can only be made by histological examination [2,4]. The primary clinical presentation of a TMJ cyst is pain and swelling.
Other possible findings include paresthesia, difficulty with mastication, limited mouth opening, click or pop during movement, and acute facial paralysis [3]. Although malocclusion due to cysts, masses and tumors in the TMJ have been reported [5-7], to the best of our knowledge, acute onset malocclusion as a manifestation of a TMJ cyst has not been described. The purpose of this report is to present an unusual case of a TMJ cyst presenting as sudden onset of malocclusion after trauma.
An otherwise healthy12-year-old patient presented with bilateral facial pain after being struck in the face with a shoulder during a basketball game. She reported restricted mouth opening and inability to occlude normally. A panoramic radiograph showed a dislocated mandible, but no fracture. The patient was discharged with a soft diet and rest; the pain and malocclusion spontaneously resolved. Nine months later, the patient presented with acute onset of jaw pain, trismus and mandibular deviation after being hit in the face with a volley ball. Examination demonstrated minor left preauricular swelling with associated tenderness to palpation. The mandible was deviated to the right resulting in a lateral cross bite (Figure 1).
Figure 1: Photo of the malocclusion with deviation of mandible to left.
Active maximal incises opening was 10 mm and passive opening with finger pressure was 25-30 mm with pain. A panoramic radiograph showed inferior displacement of the left condyle out of the glenoid fossa without mandibular fracture. An MRI with gadolinium contrast demonstrated an anteriorly subluxed mandibular condyle and a non-enhancing lesion measuring 12 x 8 x 8 mm at the medial aspect of the left condylar neck communicating with the articular space (Figure 2).
Figure 2: MRI axial T1 coupe with gadolinium contrast demonstrating cyst medial to TMJ.
The imaging appearance of this lesion was consistent with a ganglion or synovial cyst. The patient subsequently underwent a CT guided aspiration and steroid injection of the left TMJ cyst, under general anesthesia. Under biplane fluoroscopic guidance, a 21-gauge EchoTip needle was advanced into the cyst. Attempts to aspirate fluid from the cystic lesion had no yield. Ten milligrams of triamcinolone hexacetonide (steroid) and 1 mL of 1% lidocaine was instilled gently into the cyst. The malocclusion resolved 10 days after the procedure. No malignant cells were identified on cytology. Seven weeks later, after again being hit in the face with a dodge ball, the patient presented with a recurrent malocclusion. Examination showed deviation of the mandible to the right without facial swelling. Active maximum incisal opening was 6 mm and the mandibular dental midline was deviated 10 mm to the right of the midsagittal plane. MRI demonstated anteroinferior subluxation of the left condyle and a residual or re-accumulated non-enhancing cyst measuring 6 mm x 5 mm at the medial side of the glenoid fossa. Open surgical excision of the cyst was recommended, but the patient declined intervention. The patient was discharged with conservative treatment including soft diet, rest, moist heat, massage, physical therapy, and nonsteroidal anti-inflammatory medications. The pain and malocclusion resolved over the following 2 weeks. The patient has not had recurrence of these findings over 2-year follow-up.
The differential diagnosis for acute onset of malocclusion includes fracture, disc displacement, mandibular dislocation, primary and metastatic tumors of the TMJ, benign vascular or neural lesions, and joint effusion [6-8]. To our knowledge, there has been only one other report of a TMJ cyst causing malocclusion, and that lesion was ultimately found to be a ganglion cyst [7].
Steen et al. found that swelling and pain were the most common presenting findings of TMJ synovial and ganglion cysts in 49 cases [3]. Both ganglion and synovial cysts of the TMJ occur more frequently in females than males (3:1), at a median age of 46 years [3].
The differential diagnosis of a TMJ cyst should also include synovial chondromatosis, parotid cyst, bone cyst, sebaceous cyst, osteochondroma, osteoma, osteoblastoma, sarcoma, plasma cell myeloma, pigmented villonodular synovitis, hemangioma, nonossifying fibroma, and Langerhans cell histiocytosis [2,9].
Ganglion and synovial cysts can be differentiated by histological evaluation and immune histochemistry [2]. A synovial cyst is a true cyst lined with cuboidal or flattened synovial cells [2]. The cyst forms due to displacement or herniation of synovial tissue from trauma or an inflammatory process [9]. Synovial cysts can be connected to the joint cavity, whereas ganglion cysts are not [10]. A ganglion cyst is a pseudocyst with a fibrous connective tissue wall without synovial cell lining. It forms due to myxoid degeneration of the collagenous tissue of the joint capsule [2].
Identifying synoviocytes in the lining of the cyst is essential to distinguishing between a ganglion and synovial cyst [4]. Differentiation between these cysts may be difficult due to limited knowledge of the immune histo chemistry architecture of the synovial membrane and morphological plasticity of the synovial cells [11]
In this case, histological evaluation could not be performed because the cyst was instilled with steroids, not excised. However, given that the cyst formed after trauma and was connected to the joint cavity, it is most likely to be synovial. Four cases of a TMJ cyst after trauma have been described in the literature, three of which were synovial [9,12-14]. In the single patient with a ganglion after trauma, the trauma had occurred 10 years before presentation [14].
In the literature, cysts of the TMJ are more often reported as ganglion than synovial [3,7,15-16]. However, the largest single center study of 12 patients with TMJ cysts found that synovial cysts are more common than ganglion cysts [17]. According to Partridge et al, poor accuracy of the histological evaluation may be responsible for this discrepancy [17].
Surgical excision is the recommended treatment for both ganglion and synovial cysts. Complete excision if possible is recommended since these cysts may recur [18]. In this case the patient and family chose to attempt percutaneous drainage after the first onset of findings and non-interventional treatment thereafter.
Although this is not the most commonly recommended management, Bonacci et al. suggested arthroscopic treatment and injection of anti-inflammatory for synovial cysts may lead to resolution of the synovitis with minimal joint injury [15]. This case demonstrates a unique presentation of a presumed synovial cyst of the TMJ that occurred after trauma. Injection of steroids in the cyst resulted in resolution of symptoms and malocclusion.
Becker T. Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis. SM Musculoskelet Disord. 2017; 2(3): 1020.
Occlusion is biologically defined as the coordinated functional interaction between the various cell populations forming the masticatory system as they differentiate, model, remodel, fail and repair
Talia Becker*
Achilles tendon is a common site of foot and ankle discomfort but its rupture is not frequent. It’s a superficial tendon and this lends it to excellent evaluation by sonography instead of magnetic resonance imaging. Recently ultrasonography has been widely used in musculoskeletal practice. We present a case of Achilles tendon ruptures diagnosed based on fundamental sonographic findings.
Arash Babaei-Ghazani¹,², Safoora Ebadi¹,², Bijan Forogh¹,³, and Bina Eftekharsadat⁴*
Osteoarthritis (OA), one of the most common skeletal disorders characterized by cartilage degradation and osteophyte formation in joints, is induced by accumulated mechanical stress; however, little is known about the underlying molecular mechanism. Several experimental OA models in mice by producing instability in the knee joints have been developed to apply approaches from mouse genetics. Although proteinases like matrix metalloproteases and aggrecanases have now been proven to be the principal initiators of OA progression, clinical trials of proteinase inhibitors have not been successful for the treatment, turning the interest of researchers to the upstream signals of proteinase induction. These signals include under graded and fragmented matrix proteins like type II collagen or fibronection that affects chondrocytes through distinct receptors. Another signal is pro inflammatory factors that are produced by chondrocytes and synovial cells; however, recent studies that used mouse OA models in knockout mice did not support that these factors have a role in the central contribution to OA development. Our mouse genetic approaches found that the induction of a transcriptional activator Runx2 in chondrocytes under mechanical stress contributes to the pathogenesis of OA through chondrocyte hypertrophy. In addition, chondrocyte apoptosis has recently been identified as being involved in OA progression. We hereby propose that these endochondral ossification signals may be important for the OA progression, suggesting that the related molecules can clinically be therapeutic targets of this disease.
Hiroshi Kawaguchi
Estimating the Knee Functional Axis (KFA) is crucial to both correctly implanting the prosthesis and accessing the joint kinematics. Researchers have mainly reported KFA by manual management of flexion extension movements, which are passively performed without any voluntary movements. Active touch and movement refers to what is ordinarily called as touching, which is defined as variations in skin stimulation caused by variations in a person’s motor activity.
The difference is very important for the individual. However, it has not been emphasized in the biomechanical literatures. This study aims to confirm the distinction between touching and being touched. We are particularly interested in measuring the Instantaneous Axes of the Knee (IAK) during locomotion. This geometrical “pattern” of the IAK is altered along with the touch pattern by the mechanical necessities of terrestrial movement.
Wangdo Kim¹, Young Choi², and Hong-Gi Lee³*
Although fractures of the epiphyseal cartilage injuries are common in childhood, epiphyseal fractures involving the proximal tibia entities are very rare and are usually caused by high-energy trauma, with an incidence ranging between 0.5 and 3.1% of patients; peak incidence between the ages 12-14 years in male patients. The aim of this report is describe a case of fracture of the epiphyseal cartilage of a 13 year old boy, a victim of sports trauma showing lateral tibial plateau fracture and epiphyseal cartilage fracture at the same side, not compatible with the classifications of fractures in children.
Omar Ferreira Miguel
In the last few years, clinical applications of regenerative medicine have been increasing their way in medical practice.
Valerio Di Nicola¹,² and Mauro Di Pietrantonio³*
The twentieth century epidemic of low back pain has continued unabated into the 21st century. Up to 20% of the Australian population will experience low back pain at some stage of their lives
J Saunders¹, M Cusi¹,³ and H Van der Wall¹,²*
Music is the most essential ingredient of any entertainment. In order to create successful entertaining event musicians plays an imperative role. Musicians are wizards who spread the fragrance of joy by absorbing woes, in the form of Playing Related Musculoskeletal Disorders (PRMDs), for themselves. Like other occupations, musicians also suffer from work related musculoskeletal disorders which are often disabling
Wricha Mishra
Dupuytren’s Contracture (DC) is a fibro-proliferative tumor according to ICD 10 - fascial fibromatosis of unknown etiology (M 720), accompanied by a stable bending contracture of fingers. In CD in the postoperative period extremely high rate of surgical complications is observed: intraoperative (injury of blood vessels, nerves, tendons), general postoperative (hematoma, necrosis, odema, stiffness, etc.), late postoperative (recurrence, spread, progression). In the last case according to the data of different authors, complications frequency is depend upon the degree (from partial up to the total) and the accuracy of excision of the affected aponeurosis ?almaris. One of the problems in choosing the type of operation and technology is the complexity of the cutoff determination boundaries of the affected CD. Up to now there is no suitable for use in the practical CD surgery algorithm of the affected aponeurosis ?almaris spread non invasive visualization in a particular patient. The most appropriate method for the solution of this problem is a method of MRI. The technology of identifying the boundaries of surgery of the affected aponeurosis palmaris in Dupuytren’s contracture by means of MRI has been elaborated. It has been shown that MRI is a highly informative method in the assessment of topographic anatomy of aponeurosis palmaris in normal and CD states. PD, T1, T2 - weighed images allow objectively to visualize the border areas of the affected aponeurosis in I - III stages of CD. PD fsat (fat tissues signal saturation) MRI mode is not recommended for use.
Baikeev RF¹, Mikusev GI², Osmonaliyev IZh², Zakirov RH² and Afletonov EN²*
Metallosis is an aseptic fibrosis, local necrosis, inflammation, or loosening of an implant device secondary to metallic corrosion and release of wear debris. The condition has been highlighted recent years due to the clinical complications caused by metal-on-metal (MoM) hip replacement. Although some major types of MoM hip prostheses have been recalled from the market, metallosis is far from over as not only there are still a million implanted MoM hip prosthetic cases worldwide, but also it has been found in non-MoM hip prostheses and other metal implants. This mini review aims to provide recent findings of implants related metallosisin skeletal tissue.
Zhidao Xia