Berlin Case Viewer

The obvious finding is not always the most important one.

A 64-year-old woman presents with moderate knee pain — but without any adequate trauma.

The MRI immediately draws your attention to a striking diffuse abnormality of the bone marrow.

But there is something else.

Something much smaller.
Something that could easily disappear against this abnormal background.

👉 Can you spot the additional finding that should be reported?

This contribution comes from Dr. André Philipp Czech from Essen, Germany. Thank you, André, for sharing this excellent example of how a dominant imaging finding can distract us from subtle focal pathology.

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🔎 The reveal

Hidden within the diffusely abnormal marrow is a small subchondral fracture of the lateral tibial plateau.

It can be recognized on the axial and coronal PD fat-suppressed images as a subtle subchondral fracture line with perifocal edema.

CT performed only two days later confirmed the fracture and made the subchondral disruption considerably more conspicuous.

Only afterwards did we learn an important part of the patient's history: she had B-cell chronic lymphocytic leukemia (CLL).

💡 The teaching point

When the entire bone marrow looks abnormal, focal pathology may become harder, not easier, to detect.

Don't allow a striking diffuse finding to terminate your search.

In a patient with unexplained focal pain — particularly without adequate trauma — carefully inspect the subchondral bone for subtle fracture lines.

🌍 Another case. Another colleague. Another lesson from the global radiology community.

Case 12 of the Summer of Cases takes us back to Tbilisi, Georgia 🇬🇪 — and to a truly striking pediatric case.

A 12-year-old girl presents with dramatic unilateral enlargement of the ankle, with massive infiltrative soft tissue overgrowth, encasement of key tendons, and striking osseous remodeling of the calcaneus and distal tibia. This is far more than simple swelling. What disease can transform a growing ankle this profoundly?

This fascinating case was provided by Dr. Sophio Chkhenkeli from Tbilisi, Georgia. Many thanks for contributing another memorable case to the series and for bringing the Georgian perspective into our international Summer of Cases.

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— only read further if you really need to —

The findings are characteristic of an extensive plexiform neurofibroma with elephantiasis neuromatosa, an extreme manifestation typically associated with neurofibromatosis type 1. The diffuse infiltrative growth causes massive soft tissue hypertrophy and can profoundly remodel adjacent bones and surrounding structures.

A striking illustration that some diseases do not simply form a mass — they can reshape an entire anatomical region.

Case 11 of our Summer of Cases 2026.

A 28-year-old woman was travelling in the front passenger seat on the busy road between Nairobi and Mombasa when her vehicle was involved in a collision. The initial radiograph showed a patellar fracture—but MRI revealed a much more complex injury pattern.

Can you reconstruct what happened to her knee at the moment of impact?

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This fascinating case was submitted by Dr. Osman Gaboose from Nairobi, Kenya 🇰🇪. Thank you very much for sharing it with us!

— only read further if you really need to —

MRI demonstrates a displaced patellar fracture with an additional small lateral fragment, together with an avulsion fracture at the tibial attachment of the posterior cruciate ligament. The PCL itself remains intact.

The combination tells the story of the collision: direct impact on the flexed knee fractured the patella, while a posteriorly directed force displaced the proximal tibia and avulsed the PCL attachment. Forceful contraction of the extensor mechanism likely contributed to the transverse patellar fracture pattern.

The case is a striking illustration that the most obvious fracture may be only one part of the injury—and that MRI can help reconstruct the exact mechanism of trauma.

CASE 010 | The Unforgiving Side of MSK Imaging

Some injuries are obvious. Others hide within a few pixels.

A 19-year-old competitive swimmer presents with progressive focal posterior elbow pain during training. There was no fall, no direct trauma, and ultrasound did not explain his symptoms.

MRI reveals the answer—but only if you look very closely.

This is the unforgiving side of MSK imaging: in competitive athletes, repetitive loading can produce clinically significant injuries with remarkably subtle imaging findings.

Will you spot the decisive sign?

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This case was contributed by Juan Pablo Muñoz.

— only read further if you really need to —

A subtle incomplete transverse-oblique fracture line is visible through the olecranon, accompanied by surrounding bone marrow edema. The findings indicate an incomplete olecranon stress fracture.

Olecranon stress fractures primarily affect adolescent and young adult athletes exposed to repetitive elbow loading. Although classically associated with throwing sports, they may also occur in swimmers. When the fracture line is difficult to characterize on MRI, CT is warranted to assess its precise morphology and determine whether sclerosis or osseous bridging is present.

One radiograph, one clinical clue.

This radiograph suggests a specific metabolic arthropathy. Which clinical sign is classically associated with it?

This femoral fracture is different. Watch out for Case 009 of our Summer of Cases series.

An 85-year-old woman hears a sudden “crack” in her thigh while simply walking—without any trauma. The fracture is stabilized and initially appears to heal well. But several months later, progressive thigh pain returns, and the next radiograph reveals that the story is far from over.

What should have raised suspicion from the beginning—and what failed next: the bone, the implant, or both?

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This case was submitted by Mehmet Fatih Tumer and Özgür Tosun. We particularly appreciated their detailed documentation and compelling presentation of this complex clinical course. Thank you both for this excellent contribution!

— only read further if you really need to —

This is an atypical femoral fracture associated with prolonged antiresorptive therapy. The characteristic transverse fracture pattern, focal lateral cortical thickening, medial spike, and absence of comminution provide the key clues.

Despite apparent healing, a new fracture developed distal to the original site, accompanied by fatigue failure of the implant. This case is a powerful reminder that healing of one fracture does not necessarily mean that the underlying biological process has resolved.

Case 008 of our Summer of Cases series

A 47-year-old patient presents with persistent pain at the front of the distal lower leg — no trauma, no clear neurological lesion, and no convincing explanation on the initial work-up.

The symptoms seem to point in one direction.

But the imaging clue is found somewhere else.

A small, focal abnormality above the ankle changes the whole story.

What is the diagnosis?

A huge thank you to Quentin Pedrini and Sana Boudabbous, both from Geneva, Switzerland 🇨🇭, for sharing this elegant and very teachable case.

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Keep learning — one case at a time.

–– Do not read the below if you want to quiz yourself ––

This case shows an uncommon mechanical problem around the tibialis anterior tendon. The key imaging feature is focal inflammatory change above the ankle, while the tendon itself remains intact and there is no convincing nerve lesion. The diagnosis is tibialis anterior friction syndrome — a small finding, but the kind of detail that rewards looking beyond the obvious