DOI:10.2214/AJR.06.0398
AJR 2007; 189:S17-S20
© American Roentgen Ray Society
AJR Teaching File: Intermittent Claudication of the Lower Extremity in a Young Patient
Joseph B. Sutcliffe, III1 and
Liem T. Bui-Mansfield
1 Both authors: Department of Radiology, Brooke Army Medical Center, 3851 Roger
Brooke Dr., Fort Sam Houston, TX 78234.
Received March 18, 2006;
accepted after revision May 8, 2006.
Address correspondence to J. B. Sutcliffe III
(joseph.sutcliffe{at}amedd.army.mil).
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of
the Department of the Army or the Department of Defense.
Keywords: claudication • femur • osteochondroma • peripheral vascular disease
Case History
A 20-year-old male military trainee presents with intermittent right lower
extremity claudication which occurs with running.
Radiologic Description
A lateral right knee radiograph shows a sessile osseous mass arising from
the posterior aspect of the femur.
Differential Diagnosis
The differential diagnosis for a young patient with intermittent
claudication of a lower extremity includes popliteal artery entrapment
syndrome, cystic adventitial disease, arterial compression by an
osteochondroma or other bone lesion, fibromuscular dysplasia, Takayasu's
arteritis, and Buerger's disease.
Diagnosis
The correct diagnosis in this case is arterial compression by an
osteochondroma.
Commentary
Intermittent claudication of the lower extremities is a common symptom in
older patients suffering from atherosclerotic peripheral vascular disease.
However, intermittent claudication in a young patient is unusual and should
prompt a search for causes other than atherosclerosis. The imaging evaluation
should begin with a radiograph of the affected extremity to exclude a bone
lesion causing extrinsic compression of the nearby artery. The evaluation
should also include an angiographic study to localize and characterize the
arterial compromise. Choices include conventional angiography, CT angiography
(CTA), and MR angiography (MRA). MRI may be performed at the same time as MRA
and provides optimal soft-tissue characterization. Color Doppler sonography
can show patency, stenoses, and occlusions in these cases, but provides
limited anatomic detail [1,
2].
In this case, the patient's claudication symptoms resulted from extrinsic
compression of the distal superficial femoral artery by a large
osteochondroma. Although not a common cause of claudication, symptomatic
vascular compressions by osteochondromas have been well documented
[3–5].
The initial diagnosis of an osteochondroma of the distal femur was made on the
basis of characteristic radiographic (Fig.
1A) and MRI (Fig.
1B) appearance. Approximately 40% of osteochondromas arise from
the posterior aspect of the distal femur, which is also the region where the
superficial femoral artery passes through the adductor hiatus. In this case,
extrinsic compression of the distal superficial femoral artery by the
osteochondroma was shown by both MRI (Fig.
1C) and conventional angiography
(Fig. 1D). The relatively fixed
position of the superficial femoral artery within the adductor hiatus, and the
tethering effect of the popliteal artery and its distal branches, make the
superficial femoral artery particularly vulnerable to compression by
osteochondromas [6]. Treatment
of arterial compression by osteochondromas involves excision of the lesion
and, when necessary, repair of the affected artery
[3].
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Fig. 1A —20-year-old male military trainee with intermittent right
lower extremity claudication that occurs with running. Lateral knee radiograph
shows sessile osseous mass arising from posterior aspect of right femur.
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Fig. 1B —20-year-old male military trainee with intermittent right
lower extremity claudication that occurs with running. Sagittal gradient-echo
MR image shows that the mass is composed of cortical and medullary bone which
is continous with the cortex and medullary trabecula of the femur from which
it arises. The mass is covered by a high-signal-intensity cartilaginous
cap.
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Fig. 1C —20-year-old male military trainee with intermittent right
lower extremity claudication that occurs with running. Axial fat-suppressed
T2-weighted MR image shows posterior displacement and compression of distal
superficial femoral artery (arrow) and distal superficial femoral
vein (arrowhead) by osseous mass.
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Fig. 1D —20-year-old male military trainee with intermittent right
lower extremity claudication that occurs with running. Lateral view of right
lower extremity digital arteriogram shows posterior displacement and near
occlusion of distal superficial femoral artery by the mass.
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Popliteal artery entrapment syndrome (PAES) is a more common cause of lower
extremity claudication in young patients and is the cause in up to 60% of
young athletes who have claudication symptoms
[7]. It results from an
abnormal anatomic relationship between the popliteal artery and the medial
head of the gastrocnemius muscle, which results in compression of the
popliteal artery. Stress angiography is considered the gold standard imaging
technique to diagnose PAES. An arteriogram of the lower extremity is obtained
with the ankle in the neutral position, active dorsiflexion and active plantar
flexion. In PAES, flow is characteristically normal in the neutral position
and markedly decreased during plantar flexion and dorsiflexion
[8].
Cystic adventitial disease is the cause of lower extremity claudication in
about one of 1,200 cases of claudication. Most patients are men between the
ages of 20 and 50 years without typical risk factors for atherosclerosis. A
mucin-containing cystic structure forms in the wall of the popliteal artery,
speculated to be the result of repetitive microtrauma. Conventional
angiography typically reveals a smoothly tapered narrowing of the midpopliteal
artery with otherwise normal-appearing lower extremity arteries. Sonography,
CT, or MRI may also show the cystic structure in the arterial wall
[9].
Fibromuscular dysplasia is an arterial occlusive disease of medium-sized
arteries most often seen in young women of childbearing age. It typically
affects the renal, cerebrovascular, or visceral arteries, but may involve the
arteries of the limbs in up to 5% of cases with associated claudication
symptoms [10,
11]. In fibromuscular
dysplasia, angiographic studies will show a string-of-beads appearance
reflecting multiple adjacent stenoses and focal aneurysm
[12].
Takayasu's arteritis is a rare vasculitis most commonly seen in young Asian
and South American women. Stenoses of the abdominal aorta or iliac vessels are
present in 17% of cases, occasionally resulting in claudication symptoms
[13]. Conventional angiography
is the standard imaging tool in the evaluation of Takayasu's arteritis,
showing nonspecific focal stenoses. Sonography may show circumferential
arterial wall thickening. CT angiography, MRI, and MRA may show mural
thickening in addition to narrowing of the lumen.
Buerger's disease, or thomboangiitis obliterans, is a rare disease most
commonly seen in young Asian males who are heavy cigarette smokers. The
disease is characterized by inflammation and thrombosis of the arteries and
veins of the legs, feet, forearms, and hands. The initial symptoms often
include claudication and the disease usually progresses to severe skin
ulcerations and gangrene [14].
With Buerger's disease, conventional angiography shows multilevel occlusions
and segmental narrowing of the lower extremity arteries with extensive
collateral flow, which has a characteristic corkscrew or "tree
root" appearance
[15].
Objective
The objective of this article is to describe imaging findings associated
with intermittent claudication of a lower extremity due to an osteochondroma
in a young patient. In addition, the article discusses the differential
diagnoses of claudication symptoms in young patients to include the radiologic
and clinical characteristics of these disease processes.
Conclusion
Intermittent claudication of a lower extremity in a young patient is an
unusual symptom and should prompt a search for causes other than those
typically seen in older patients. The differential diagnosis include extrinsic
compression by an osteochondroma or other bone lesion, PAES, cystic
adventitial disease, fibromuscular dysplasia, Takayasu's arteritis, and
Buerger's disease.
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Case History
Radiologic Description
