Case Report

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American Journal of Emergency Medicine

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The pelvic digit anomaly in a patient with Multiple fractures: does it mimic the fracture?

Abstract

Pelvic digit is a rare congenital anomaly where bone develops in the soft tissue adjacent to normal skeletal bone. Pelvic digits are most often associated with the ilium but may also pseudoarticulate with other pelvic bones or the abdominal wall. Its importance lies in its differentiation from acquired abnormalities due to trauma such as myositis ossificans and avulsion injuries of pelvis. In this article, we present a case of pelvic digit with multiple fractures. To avoid un- necessary investigation methods and treatment, this entity should be kept in mind when an atypical bone structure is noted around the pelvis.

A 34-year-old man was referred to our emergency clinic severe complaining of left hip and back pain. He had a traffic accident. Examination revealed severe tenderness to palpation in the posterior sections of lumbar vertebrae and left iliac bone. Conventional radio- graphy showed a bony protuberance at the left Iliac crest (Fig. A). Multidetector computed tomography revealed multiple fractures of transverse processes of lumbar vertebrae and a phalanx-like bony protuberance at the left anterior superior iliac spine with fusion of the proximal bony nucleus to the adjacent bone (Fig. B-D). It had a clear corticomedullary differentiation and a pseudoarticulation at the iliac wing. These imaging findings together with the clinical picture were highly suggestive of a pelvic digit anomaly.

The pelvic digit was first determined by Sullivan and Cornwell in 1974; it can be located at any level of the pelvic bones, lower ribs, or even in the Anterior abdominal wall [1,2]. Morphologically, pelvic digits may present as rib-like and phalanx-like structures with 1 or more joints within [3]. Intermediate appearances with features of both rib and phalanx have also been reported [4]. The anomaly can originate from a displaced costal process, a displaced sternal center, or the ossification center at the anterior superior iliac spine [4,5]. The pelvic digit is usually identified via radiography. Multidetector com- puted tomography is a reliable, easily applicable, and Noninvasive tool for demonstration of abdominal organs and bone structures [6]. It confirms the presence of cortical bone in the pelvic digit anomaly [5]. Differential diagnosis of a pelvic digit includes posttraumatic myositis ossificans, heterotopic bone formation, ligamentous calcifications, and

fracture. Surgical removal is indicated in the case of symptoms such as functional impairment [4,5,7].

In conclusion, it is important to recognize and distinguish a pelvic digit from posttraumatic ossification and avulsion to avoid unneces- sary investigations. Therefore, although rare, pelvic digit should be kept in mind, in patients with multiple fractures.

Hayri Ogul MD Berhan Pirimoglu MD

Department of Radiology, Medical Faculty, Ataturk University

Erzurum, Turkey E-mail address: [email protected]

Berhan Genc MD

Department of Radiology, Medical Faculty, Sifa University

Izmir, Turkey

Ummugulsum Bayraktutan MD

Mecit Kantarci MD

Department of Radiology, Medical Faculty, Ataturk University

Erzurum, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.05.033

References

1. Sullivan D, Cornwell WS. Pelvic rib. Report of a case. Radiology 1974;110:355-7.
2. McGlone BS, Hamilton S, Fitzgerald MJ. Pelvic digit: an uncommon developmental anomaly. Eur Radiol 2000;10:89-91.
3. Granieri GF, Bacarini L. The pelvic digit: five new examples of an unusual anomaly. Skeletal Radiol 1996;25:723-6.
4. Van Derslice R, Gembala R, Zekavat PP. Case report: pelvic rib/digit. Spine 1992;17: 1264-6.
5. Nguyen VD, Matthes JD, Wunderlich CC. The pelvic digit: CT correlation and review of the literature. Comput Med Imaging Graph 1990;14:127-31.
6. Ogul H, Bayraktutan U, Kizrak Y, et al. Abdominal perfusion computed tomography. Eurasian J Med 2013;45:50-7.
7. Goyen MG, Barkhausen JB, Markschies NA, Debatin JF. The pelvic digit - a rare developmental anomaly. A case report with CT correlation and a review of literature. Acta Radiol 2000;41:317-9.

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   Fig. A, Plain radiography shows a bony protuberance at superior of the left iliac crest. Three-dimensional volume-rendered, reformatted (B), sagittal (C), and axial (D) multidetector computed tomographic images reveal a phalanx-like bony protuberance (arrow) at the left anterior superior iliac spine with fusion of the proximal bony nucleus to the adjacent bone. Three-dimensional volume-rendered, reformatted image also shows multiple fractures of transverse processes of lumbar vertebrae (dashed arrows).