Cystic Lesions of Bone #1 cause of Rib lesions, mostly Ossifying Fibroma - most in FIBROUS LESIONS OF BONE lytic, well circuscribed face Fibrous dysplasia - NO peri- slowly expanding & assoc w ex- Cortical based fibrous dysplasia osteal rxn or pain unless fx trapleural mass w same ground glass appear- Fx frequent but no pseudoarthro- Regress w puberty ance sis, no ST component Malignant degeneration reported homogeneous 1-5cm lesions, Elongated Diaphyseal lesion w in <1% maxilla & frontal #1 "Ground Glass" matrix MRI - Hyper T2 unlike most fi- assoc w loosening of the teeth in centered in medullary cav, "al- brous processes mandible phabet soup" of woven bone Malig degen to Osteosarc poss, Pt <10yrs, vascularized fibrous lucent, sclerotic, expasnsile, esp w polyostotic form stroma like FD patchy, etc... MRI high T2 No alphabet soup of woven bone Monostotic - #1 presentation, McCune-Albright syn - polyos- prox femur 78%, ribs, skull totic fibrous dysplasia Osteofibrous Dysplasia - fi- if in pelvis it will also be in ipsilat Florid disseminated form, usually brous lesion of tibia & fibula in prox femur unilat, female>male child <5yrs Diaphyseal if mild case, rarely assoc w cafe au lait spots and present w unilat bowing & pain- affects spine precocious puberty less enlargement of the leg Polyostotic - lesions usually trabecula surrounded by osteo- larger, freq Cafe-Au-Lait Adamantinoma - appears simi- blasts, mixed lytic Diaphyseal le- "Sheperds Crook" femur & cystic lar, mid tibia and jaw only sion pelvic lesions assoc can appear aggressive, 30+ yrs, no osteoclasts as in fibrous dys- Skull base thickening, CN en- trauma often assoc plasia croachment, asym orbits may be assoc w osteofibrous Juvenile Adamantinoma - possi- involvement of spine & soft tis- dysplasia, 15% met to lungs ble assoc sue myxoma more common Congenital Multiple Fibroma- Desmoplastic Fibroma - aggre- its clinical pres - pain tosis - Infantile Fibromatosis sive expansile con tis lesion 50% can degenerate to chondro- ST fibromas diagnosed at birth, Tibia #1, 10-20y/o, most benign sarcoma, histo identical stabalize by 4mo, regress by or low grade malignancy Diaphyseal long bone lesions 2yrs resembles soft tissue desmoid, more likely to deg forms lytic lesion along metaphy- 50% recur P resection Surgically excise, Bx is not a re- sis of long bones, variable size NO ST mass, never metastisize liable way to DDx DDx Giant Cell, ABC or Fibrosarc Juvenile Fibroma - benign fi- Very vascular, not easily distin- Ollier's Dz - mult enchondromas, brous tumors, cause pressure guished from FD NO inc in malig deg erosions Predominate Unilat, punctate can be aggressive, high T2 in- calc remain distinctive tensity, freq recur after resection ENCHONDROMA Bizzarre bulbous expansions of Juvenile Aponeurotic Fibroma - Lucent defect w Ring & arc tubular bones early subset w fibrochondral matrix chondroid, 40-50 Columnar growth of cartilage- occurs in deep palmar facia of Metaphyseal, unilat & solitary, nous tissue from epi young males never epiphyseal Become more rounded w older ST mass over wrist w stippled NO periostitis, central, eccentric Pts, Pathog calc, bone errosion poss & expansile Longitudinal striation - poss in Cartilage formed bones only, NO long bone metaphysis Cortical Desmoid - Reactive re- skull lesions pair at site of musc insertion #1 cystic lesion of phalanges, but Maffucci's syn - mult enchon- freq at adductor tubercle, "Don't no calc here dromas, Inc malig deg Touch" lesion. Sim bone infarct but not well de- Hemangiomas assoc, phleboliths fined or serpiginous seen. Chondrosarcoma differs only in LANGERHANS CELL HISTIO- of benign polyostotic ticular nodular in lungs CYTOSIS - HISTIOCYTOSIS X Periostitis freq, usually thick, wavy, & uniform Letterer-Siwe - Acute Dissemi- Birbeck Bodies - inclusions Fever poss similating osteo- nated Histiocytosis, <1y/o seen in cells on EM myelits Fulminate - 95% die, often bone Penilaminar Organnels also as- Skull #1, Beveled NONSCLE- lesions don't form soc ROTIC edges Permeative pattern sim to Ew- 50% have skin, eye, respiratory Calverial in 40%, often isolated ings sarc possible. & fever w enlarged nodes parietal, mandible 20% pts >2yrs w no organ dysfxn present as painful enlarging skull OTHER CAUSES OF BENIGN have 90% 5yr survival mass, rarely into dura CYSTIC LESIONS with organ dysfxn about 40% 5yr hearing loss & otitis type sx if Osteoblastoma - rare, Giant os- survival temporal bone involved teiod osteoma, >2cm Tx - chemo reserved only for Vertebra Plana - often effect post Expansile bubbly lesion, Scle- most severe cases elements as well, neuro sx rare rotic margins poss, sim ABC can have speckled calc or even Eosinophilic Granuloma - Non- Hand-schuller - Chronic Dis- blastic in long bones disseminated form, Bone only seminated Histiocytosis, <5y/o freq in post spine, predominatly 90% occur from 5-15yrs, 95% Triad of destructive lesions, lytic here white, 2:1 male, 70% in flat exophthalmos & diabetes insip- 30% are vertebral, may cause bones, idus cord compression femur & humerus #1 long bones, D. Insipidus II' to hypothalmus Appendicular are lytic w NO soft 60% diaphyseal, rare in hands involvement, hyper T2 in pit stalk tissue mass central bony sequestrum like os- 90% have cranial involvement, teomylitis & fibrosarc poss 15% have classic triad Osteoid Osteoma - not tumor or Monostotic usually but #1 cause NO osteopenia or erosions, Re- infection, unkown etiology Cortically based sclerotic lesion CT, very vascular w nidus <2cm, pt under 30 DDx - Osteomyelitis is always #1 Solitary Bone Cyst - Must be Metaphyseal 75%, 2/3 around in sclerotic lesion w nidus central in a pt under 30 knee may resemble sequestrum, can simple or unicamiral cyst, ex- Medulary - nidus in medula or also mimic stress Fx cluded if not central joint less sclerosis seen, 20% 2/3 occur prox humerus, prox Intrarticular - mimics synovitis, Aneurysmal Bone Cyst - must femur #2, any bone poss Sclerotic, joint eff seen be expansile in pt under 30 NOT most commonly seen Periosteal - minimal sclerosis, Tibia #1, 30% occur in assoc w a around knee unlike others cortical scalloping & ST swelling primary neoplasm Metaphyseal, grows in from phy- Spine - prefers appendages, freq Diaphyseal but usually near end, sis, rarely epiphyseal cause of Scoliosis extend to metaphysis Fallen fragment sign is pathag- unilat pars Fx still a more freq Markedly destructive esp in pel- nomonic cause though vic bones Asymptomatic unless fx, triangu- Spontaneous regression, can have densly sclerotic border, lar in calcaneus Recur if packed NEVER seen over age 30 Fx freq too early Resection curative, recurrance Can sim Osteoblastoma due to incomplete resection Spine appendages often in- Hyperparathyroidism - Pain at night releived by aspirin volved, lg soft tissue mass HYPERcalemia, HYPOphos- NUCS - Double Density sign Present w pain, may follow phatemia caused by hot nidus truama Subperiosteal Resorbtion - radial Angio - Nidus is hypervascular, CT - can show multiple com- aspect of dist phalanx rapid washout partments, fluid-fluid levels in dist clavicles, med prox tibia, & MRI - shows nidus lying in region 30% sacroilliac joints of marrow edema Can show rim enhancement w osteopenia & cortical resorb of nidus enhances on both MRI & cent low atten long bones late Brown Tumors - flat bones & ribs MDP, only seen w 50% in I' HPT Chondromyxoid fibroma - men- #1, sim ABC, giant cell Phosphate retained, Ca+ low tion w nonossifying fibroma most assoc w I' form, must have (Normal Ca+ 8.4-10.2, phos can present w pain in any age, other HPT Sx as well 2.2-4.5) most in dist toe phalange Parathyroid Adenoma may cause Diaphyseal w subendosteal tracheal deviation Chondroblastoma - must be thickening & scalloping Tx of HPT - all sx resolve, brown Epiphyseal in a pt under 30 Usually NO chondroid matrix, NO tumors scleros, resorb Most occur at Knee, Calc fre- malig degen Calcitonin - has opposite effect quently seen Difficult to distinguish from chon- as Parathyroid Hormone 50% will have sm extention droblastoma histologically decreases bone resorbtion, inc across the epi to metaphy renal Ca+ clearance 70% assoc w periostitis in dia- Cystic Angiomatosis - rare, as- causes Hypophosphatemia & phymetaphyseal region adjacent soc w Osler-Weber-Rendu, asym Hypocalcemia Lytic & epiphyseal: 1) infection, when isolated 2) this, 3) giant cell mult complex cystic lesions any- II' Hyperparathyroidism - Renal EG and ABC also but very rare, where, may spontaneously re- Osteodystrophy, more common mets & myeloma over 40 gress Soft tissue calc, Chondrocalcino- consider subchondral cyst if joint 70% w viceral involvement have sis & Osteosclerosis MORE DJD assoc bad prognosis. common carpal, tarsal bones, and patella kidney can't hydroxylate 25- behave like epihysis hydroxy to 1,25- Apophysis (ligamentous attach- dihydroxycholecalciferol ment) is similar causes compensatory elev in MRI - often low T2 in child due to parathyroid hormone cellular nature Freq cause of "Super Scan" w RARE CAUSES OF BENIGN seen in 15% w multiple mye- Synovitis -benign synovial swel- LYTIC LESIONS loma, preserves joint space ling 1.Inclusion Cyst - follows osteopenia & rib lesions com- Subarticular erosions poss w trauma to dist digits mostly mon, NO subperiosteal resorb joint pain & swelling Epidermoid lines cyst walls Course trabeculation in hands Lg subchondral cysts w NO joint poss, sim SLE space narrowing typical 2.Glomus Tumor - ST mass w Protenacious deposits in heart & CALC NEVER SEEN, no os- destructive lesion, sharp margins GI #1, bone rare teoperosis Dist phalanges #1 esp in female, may calc in lung & kidney see section on benign joint proc- elsewhere in male plaque like deposits may be seen esses Arise from glomeruli or pericytes in synovium in vessel wall II' Amyloidosis assoc w RA, ank 7. Sarcoid - 10%, lace-like de- spondylitis & others struction in metaphsis of phal 3. Hydatid Cyst - Dog tapeworm Periosteal rxn & endosteal scle- larvae, Pelvis & Spine #1 bone 5. Hemangioma - lytic w scle- rosis, NO errosions, penia Sharply demarcated & sclerotic rotic marg, esp in long bone margin, "bunch of grapes" head 8. Intraosseus Ganglion - sub- can simulate an aggresive lytic Spine or Calvaria #1, asym & chondral cytic lesion process solitary, pt >40y/o Sharply defined sclerotic border, 75% in liver, 15% lungs, freq calc Vertebral body - vertical lines NO calc, NO ST portion in ST, 2% in bone Calvaria - honeycomb or sun- Dist Tibia #1, Talus #2, presents Sheep & human intermediate to burst pattern w pain in ankle dog (definitive host) Soft tissue hemangiomas can Simulates a Geode, but no de- cause errosions generative changes 4. Primary Amyloidosis - can mucoid center, fibrous capsule in cause mult lytic bone lesions 6. Pigmented Villonodular both Knee #1, expansile w NO perios- roid or renal 9. Acroosteolysis - dist pha- titis Renal cell ca said to always be langes erroded away lytic w thin sclerotic border, slight lytic Scleroderma, frost-bite, burn, scalloping Skull mets often lytic due to slow Hadju-Cheney. Fx poss esp if >2cm or occupy healing more than 50% of dia Sclerosis results from slow MALIGNANT CAUSES OF MRI - low T2 due to fibrous ma- growth allowing bone Rxn WELL DEFINED LYTIC BONE trix Carcinoid & Hodgkins frequently LESIONS 20% of children, spont regres- sclerotic Giant Cell Tumor - 15% malig- sion w calc of matrix late Breast Mets - often imitate mult nant, may recur even if not synonymous w fibrous cortical myeloma 1. Epiphyses must be closed, but defect & Fibroxanthoma rare in elderly >50y/o Involute by age 30, may be hot Myeloma - Aggressive, bubbly 2. Must abut the articular sur- during this time lytic pattern esp in ribs face, knee #1, spine rare Multiple NOF - freq assoc w Neu- #1 cause of extraplueral masses 3. A sharp zone of trans w a rofibromatosis @40 nonsclerotic margin Plasmacytoma can occur in 4. Must be eccentric, NO matrix Metastatic disease - consider w younger pt (over 35) calc, pathologic fx freq any lesion IF pt over 40 Pelvis, thoracic & lumbar spine Nonossifying Fibroma - must Hemopoetic marrow first, no X- freq, skull rare be under 30, Metaphyseal ray evidence initially collapses vert body, appendages Fibroxanthoma - AFIP name, NO soft tissue mass, less peri- not involved Whorls of fibrous tiss & osteal Rxn than I' mass preceed mult mye by 3-5 y Xanthoma Cells #1 site is lesser trochanter of fe- Occur in long bones, emanate mur from cortex any ca can be lytic, usually thy- Childhood Mets - Horizontal ra- Cystic Tuberculosis over 40 = mets diolucent bands freq Syphilis osteiod osteoma, fibrous dyspla- Neuroblastoma - freq lytic lesions Tabes dorsalis sia, infection, brown tumors. esp in skull Actinomycosis Sutures spread from Inc intrac- Sporotrichosis POSTTRAUMATIC LYTIC LE- ranial pres Brucellosis SIONS Pulm mets only late, Retinoblas- Leporsy Myositis ossificans - aggres- toma sim Salmonella Osteomyelitis sive histology can mimic sar- Leukemia - 50% w Metaphyseal Maternal Rubella Syndrome coma bands, less freq lytic Septic Hip circufrencial calc w lucent center Bands probably II' to nutritional pathognomonic deficiet, not infiltation CLASSIFICATION OF LYTIC CT shows best, can have peri- Diffuse periosteal Rxn & demin- BONE LESIONS osteal rxn eralization Under 30 lesions - EG, NOF, no ill-defined periph, or central DDx w blood: inc lymphoblasts ABC, SBC, & Chondroblastoma calc vs inc catacholeamines No Periostitis - Fibrous Dyspla- between muscle fibers, not within Wilms does NOT met to bone, sia, Enchondroma, NOF, SBC mostly pulmonary. Epiphyseal - Infection, Chondro, Avulsion injury - seen at inser- GCT, EG, mets & myeloma tion sites, delayed films help INFECTIONS consider subchondral cyst Cortical desmoid - prob an avul- ABC diaphyseal but may ap- sion of the medial Pyogenic Osteomyelitis proach end supracondylar ridge, periostitis Chronic Sclerosing Osteomyelitis Multiple - FEEMHI poss, hot on nuc Brodie's abscess Sclerotic lesions - often regress- often occur in young people, Septic Arthritis ing lytic lesions, under 30 histo can sim sarcoma TB NOF, EG, SBC, ABC, chondro, Subchondral cysts - geodes NORMAL VARIANTS Musculoskeletal Infections assoc w degenerative dz Dorsal Defect of the Patella - INFECTION assoc w joint narrowing, sclero- lytic defect in upper out quad NO discriminating factors, scle- sis, etc mimics chondroblastoma, inf, or rotic border #1 assoc w CPPD crystal dz, rheu- osteochondritis dissecan periostitis, soft tissue assoc, ex- matoid, & avasc nec pansile, all possible Pseudocysts - paucity of trabe- if adj to articular surface cartilage Discogenic Vertebral Dz - a cula at G tuberosity of Humerus loss & eff poss schmorl's node variant hyperimia II' to shoulder pain Bony Sequestra - seen w this, sclerosis of vert end plates, lytic causing dissuse EG, and fibrosarcoma or mixed poss no sclerotic margin or wide zone Crosses Disk like Gorham's Van- always assoc w osteophytosis of transition ishing Bone & Renal Osteodys- also seen in mid calcaneus, trophy Fracture - if not set can have tuberosity of radius also exuberant callus Pyogenic Osteomyelitis - 75% Pseudodislocation of the hu- Os Odontoideum - unfused in kids, blood born staph aureus merus - fx w hemarthrosis dens which may be post trauma No anas between metaph & epi- blood distends joint & displaces smooth well corticated inf margin phy plates at 2yrs to maturity head inf, no disloc More vigorous periosteal rxn in axial veiw key to detection, can Osteopoikilosis - mult sclerotic kids due to lose periost aspirate for blood foci assoc w epiphysis Main cause of nec bone due to familial bone islands, can mimic vasc disruption Soft tissue com- Tietze's Syn - costochodritis of mets but no lytic proc. ponent seen at 2-3days, fat the rib planes blur causes bulbous painful swelling Bone changes start after 10 due to periostitis. days, Lg ST component assoc Metaphysis #1, susceptability inc bacteria are phagocytized but not in spine w size of bone properly killed Septic Arthritis - cart errosion due NO joint involvement to collagenase from leukocyte Sequestrum - necrotic bone re- Chronic Sclerosing Osteomye- Autoimmune response to dam- sidual, forms late litis - often nearly sterile aged cart, further resorption Involucrum - Sheath enclosing Reactive process left over, lytic Fibrin deposits inhibit cart nutri- sequestrum component variable tion & metabolism Skull - Hx of frontal sinus Dz, Lg ST component w breaks in TB - hematogenous spread to Trauma or mastoiditis cortex Metaphysis, extends to Joint Moth eaten pattern, no sequestra Cartilage thinning & Juxtarticular Progressive bone destruction & Vertebral - usually involves end- osteoperosis assoc subarticular osteoperosis plates, can cross Disk Sinus tracts freq - fibrosarcoma Well localized Abcess, Cold due collapses symetrically due to can develop in tract to slow inflam process post element involvment Epidermoid ca also seen in tract Casseating lesions - calcify, pa- No kyphosis as seen w TB, less thog when paraspinous extensive Brodie's abscess - sclerotic Spine & Hip #1 - Always see Paraspinous abcess freq compli- sharp margins, freq periosteal R muscle atrophy cation, LOOK FOR IT Metaphyseal - dist tibia #1, cavity upper thoracic in kids, lower & Penetrating injury & drug abuse in spongiosa, elongated along lumbar in adults #1 causes shaft Kyphosis - errodes ant 1/3 of vert Pseudomonas - seen in penetra- freq serpentine tracts to cortex, body, 90% angle tion inj of foot good for DDx from osteoid os- preserve post elements Salmonella - assoc w sickle cell, teoma Non-casseating types - M. S. Aureus still #1 In-111 & Ga-67 less sensitive, Kansasei & Scrofulaceum Chronic Granulomatous Dz in detect acute osteomyelitis better Cervical nodes mostly, rare bone Child - mult sites of osteomyelitis Afebrile & pain free possible, rare involvement Cystic Tuberculosis - Symetric posits in cortex of ant tib Abdominal form starts in cecum long bone involvement in child thickening & increased density of or appendix - liver abcess Mult well defined ovoid lytic le- any long bone poss "Mycetoma" - tumorlike ST swel- sions Onset at 20-30 y/o, pathogno- ling & draining sinus NO periosteal rxn except in late monic if bilat most commonly seen in the foot phase Assoc w neuropathic process following puncture wound Aquired III' form - periosteal rxn Syphilis - bone changes w con- less evident Sporotrichosis - fungus aquired genital & III' aquired forms Clavicles - cortical & endosteal from plants thru skin wounds Gumma - oseous necrosis which new bone causes septic arthritis & joint de- heals w fibrosis & inflam Calvaria - Mixed lytic/sclerotic struction, lytic bone lesions poss Lytic lesions - Tibia, vomer & cal- lesions ant & lat Brucellosis - causes exuberant varia #1, adj thickening freq Neuropathic lesions - in Lower "parrot beak" osteophytes of can cause lucency in diaphysis ext & Spine spine of any long bone II' to trauma, Tabes Dorsalis as- Trophic lesions, symetric depos- soc w this Leprosy - 2 forms caused by its in periosteum Check Serology - VDRL, Trepo- mycobacterium leprae Congenital form - exuberant pe- nemal Antibody Lepromatous - 5% have bone riostitis @ birth changes, neuropathic type heal spontaneously or responds Actinomycosis - Anerobic G+ Neural leprosy - 64% have bone rapidly to PCN bacilli, permeative aggresive pat- destruction minimal soft tissue component tern Cystic lesions in fingers w II' Fragmentation & infarction of #1 in thorax, spine & metaphysis sclerosis severe contracture or long bone metaphysis of long bones bone loss, not both DDx scurvy Does not cross disk space, Calc in Radial or Ulnar nerve pa- Tabes dorsalis -Gummatous de- craniofacial form from tooth thognomonic Salmonella Osteomyelitis - esp Bone Forming Benign Lesions 4. Melorheostosis - Thickened in sickle cell child <2y/o & enlarged cortical bone 1. Enostosis -Bone islands can Haversian canals present but Maternal Rubella Syndrome - mimic sclerotic met if >1cm abn, inc marrow cellularity "Celery stick" around knee at 1) oblong w axis along stress "Candle Wax" excrescences 8mo plane along outer cortex longitudinal metaphyseal bands, 2) Well difined spicules extend to Pain, Contractures & limb short- NO periostitis N bone along margins ening occur 50% have PDA & hepatosple- May grow very slowly, can have often in a single lower limb nomegaly inc uptake on nucs Rare in chil- Scleroderma like skin lesions dren poss over osseus lesions Septic Hip - B strep in neonate, Bone scan intensly hot H. flu in infant, S. aureus in child 2. Osteopoikiolosis - Small is- present w fever and immobile lands of compact bone, ASYMP- 5. Bone infarct - Always diaphy- joint, X-ray N initially TOMATIC sometaphyseal in long bone Effusion displaces med aspect of involves spongy bone of epiphy- Dense amorphic calc initially, lu- head >1mm relative to opposite sis & metaphysis in long bone cent 10 days later Aspirtation for Dx, Emergent ar- NO inc activity on bone scan Sclerotic "serpentine" border throtomy & open drainage for Tx Important to surgeon due to inc good for DDx from EG high risk of cartilage destruction, Keloid formation Benign type pereosteal rxn poss, 15% assoc w head osteomyelitis. permeative app poss 3. Osteopathia Striata - linear NO endosteal scalloping, NO bands of sclerosis at metaphysis cysts, NO malig transformation assoc w osteopoikiolosis, no inc freq underlying disorders - sickle uptake on nuc scan cell, SLE, Gaucher's Pancreatitis, atherosclerosis, Emboli MRI - shows intact low intensity bones, Madelung wrist deformity MRI demonstrates a serpiginous cap on both T1 & T2 sharp black border Thicker the cap the more likely to 8. Osteoid Osteoma - not tumor Presents w Pain transform or infection, unkown etiology Arises from bone surface w hya- Cortically based sclerotic lesion Epiphyseal-metaphyseal Os- line cartilage cap <2cm, pt under 30 teonecrosis - infarct assoc w Cortical & Marrow CONTINUITY Nidus within a small central lu- steroid use key to Dx, away from epi cency, 2/3 around knee possible due to microscopic em- 30% on femur, Sx due to size, if nidus in medula or joint less boli from fatty liver or marrow ex- often lobulated sclerosis seen, 20% pansion Spine - can cause scoliosis, grow joint eff if lesion intracapsular into canal if nidus in periosteum see perios- 6. Juxtacortical Chondroma - Sessile form can sim Juxtacorti- titis like malig arise between cortex & perios- cal chondroma on humerus may resemble sequestrum or teum Aquired II' to truama also disappear if calcifies Medial aspect of prox humerus, Subungual Exostosis - assoc w Spine - prefers appendages, femur or tibia metaphysis NO trauma to fingers FREQ painful Scoliosis contiguous marrow cav, Sauceri- DDx - Brodies Abcess #1 in scle- zation of cortex Trevor's Dz - Osteochondroma rotic lesion w nidus variable ST mass, sclerosis & in joint, swell & deform, unilat use Bone scan, Double Density periosteal Rxn - Dx w Bx sign due to nidusNORMAL Hereditary Multiple Exostoses VARIANTS 7. Osteochondroma - Osteocar- - Auto dom, seen younger tilagenous Exostosis, to joint Variable severity, may be asym, Dorsal Defect of the Patella - Most common benign neoplasm, 20% malig transformation lytic defect in upper out quad rare malig transformation Bowing deformities, shortened mimics chondroblastoma, inf, or osteochondritis dissecan protruding mass of dense bone, EG, Bone infarct & infection oc- usually incidental casionally Pseudocysts - paucity of trabe- can cause sinusitus, HA or cula at G tuberosity of Humerus exophthalmos if lg 2) Cortical Destruction - can be hyperimia II' t Arises from cortex, freq no ha- missleading alone MRI - shows NO ST component versian sys cortex replaced by benign fibrous Spontaneous regression, Multiple Osteomas assoc w Gar- or chondroid matrix NEVER seen over age 30 dener's Syn infection, & EG also cause this Resection curative, NO malig- polyposis, dental lestions, des- giant cell tumor & ABC can thin nant potential moids & seb cysts also. cortex so not seen Pain at night releived by aspirin 3) Periostitis - II' to irritation, 9. Osteoblastoma - rare, Giant Malignant Bone Tumors very nonspecific patterns osteiod osteoma, >2cm DIFFERENTIATING MALIG- benign - thick wavy formation, Expansile bubbly lesion, Scle- NANT FROM BENIGN EG or inf may be agg rotic margins poss, sim ABC 1) Zone of transition - most re- aggresive - lamellated, amor- can have speckled calc liable, seen w every lesion phous, or sunburst Usually in post elements of Narrow - benign w few excep- Codman's triangle often seen at spine, NO soft tissue mass tions leading edge Can recur but more likely to be this includes sclerotic margins can not thicken if malignant osteosarcoma 2nd time Wide - aggresive, usually be- may thicken in late stages of more lace like osteoid matrix cause they are fast acting healing if benign seen Permeative - multiple sm holes w no clear border 4) Axis of orientation - unreli- 10. Osteoma - slow growing be- Round cell tumors - m myeloma, able nign tumor of sinuses & cranium reticulum cell sarc benign - in long axis of long bone Ewing's sarcoma is a clear ex- Major Long Bones - #1 in child, rosis, breakout from med ception Permeative & Diaphyseal ST component freq, cumulus malignant - round lesions 50% in flat bones - more com- cloud of calcified osteoid fibrous cortical defects are often mon in adolescents 75% cross epiphysis & joint, 20% round however NO bone or cart formation, freq w intramedullary skips hem & nec Diaphyseal form often present w 5) Arteriography - helps define Freq periostitis, Onion skin #1, Fx, bad prognosis ST vs bone involvement causes bone thickening MRI - evaluate ST component, Demonstrate Neovascularity - ST component in 90% - more encroachment on joint, vasc pathognomonic of malig freq & larger than osteosarc Pulmonary mets assoc w Pneu- Arterial cutoffs & Venous lakes Painful, severe systemic Sx early mothorax, skeletal mets rare Guide Bx away from necrotic re- in Dz Pain & elevated alk phos, Assoc gions 30% present w Mets - Lung #1, w Pagets Dz AGE GROUPS skeletal #2 1-30) Ewing' sarcoma, Osteosar- DDx - Reticulum cell & neuro- Well-Differentiated Osteosar- coma blastoma mets sim coma - #1 at dist femur 30-40) parosteal sarcoma, Fibro- EG or infection more likely if thick histo similar to low-grade pa- sarcoma, Malignant giant cell periostitis rosteal osteosarcoma Reticulum cell sarcoma (primary simulates desmoplastic fibroma lymphoma of bone) Intramedullary Osteosarcoma - 40+) Mets, Myeloma, Chondro- #1 primary bone tumor, 2:1 male Telangiectatic osteosarcoma - sarcoma Metaphyseal 80%, diaphyseal lytic only, better prognosis, sim 10%, 75% occur around knee ABC PATIENTS 1-30 YEARS OLD epiphyseal very rare, flat bones small areas of osteoid key to Dx, Ewing's Sarcoma - Mysenchy- 10% smaller tumor load mal prolif from marrow, 5-30y/o Destructive w freq reactive scle- Osteosarcomatosis - multifocal imitates a cortical desmoid (avul) Sequestrum poss, NO periosteal w very bad prognosis benign avul inj can appear very rxn, NO ST mass malig #1 around knee, Diaphyseal Burkitts Lymphoma - Sim ew- Dense Centrally w cleavage every where else ings or reticulum cell in child plane between it & cortex assoc w CMV virus, good sur- Cauliflower like, may not see Malignant Fibrous Histiocy- vival conection to cortex toma - same appearance, see ** DDx - Myositis ossificans can ST Rhabdomyosarcoma - present imitate but dense peripherally at 5yrs, 50% head & neck, pelvis Desmoid - low grade, usually #2 Periosteal Osteosarc - cotical, well defined, slow growing freq mets to lung, nodes & liver, no medul invasion, rare benign periostitis w thick spic- one in 20% but rare direct exten- Saucerized cortex, intense peri- ules, thick septa tion osteal Rxn no met, but extensive local inva- Poorly diferentiated, predomi- sion PATIENTS 30-40 YEARS OLD nately Chondroblastic Parosteal Osteosarcoma - less prognosis better than intramedul- Periosteal Fibrosarcoma - in- deadly, extracortical bone dep lary osteosarcoma vades cortex, medullary II' Originates form the periosteum & Fibrosarcoma of Soft Tissue - in- grows outside the bone Gnathic Osteosarcoma - older vade bone II' once cortex is penetrated it is a pts, less aggressive central osteosarc Malignant Giant Cell Tumor - ST calc with a central distribution Fibrosarcoma of Bone - usually 15% are malig, primarily 30-40 in the mass pure lytic, variable aggresive Dx w recurrance, or met to lungs Postmed dist femur #1 at site of Expansile in medullary cavity, histology is identical to benign adductor insertion freq associated calc variaty subarticular, closed epiphysis, PATIENT OVER 40 lytic & metaphyseal eccentric, sharp zone Metastatic Disease - include in can be aggressive, Perosteal any DDx if pt over 40 rxn, ST mass & path Fx in 25% Reticulum Cell Sarcoma - I' Pain presents in 60%, Fx if >2cm Hodgkin's - always met, assoc w lymphoma of bone, male 2:1 or >50% of dia sclerosis & Ivory Vert Permeative pattern identical to Hypercalcemia - mets #1 cause Neuroblastoma - Permeative ewings sarc in hosp pts metaphyseal lesion, periosteal #1 around knee & prox tibia, Hypertrophic Osteoarthropathy - Rxn Rarely expansile Lung #1, mesothelioma often symetric & sim Ewing's, can involve a lg amt of bone w Sclerotic multiple foci #1 for leukemia or osteomyelitis no sytemic symptoms breast and prostate I' Hodgkins & Lymphosarcoma Hodgkins - the only lymphoma w Myeloma - Aggressive, bubbly are variants, very rare sclerotic mets lytic pattern esp in ribs Hemagiopericytoma - rare vasc Ivory Vertebra - Paget's #1, mets Plasma cell prolif in red marrow, tumor, benign or malig & Hodkin's #2 edosteal errosion Lytic & expansile but permeating Prostate also presents w freq pe- Polyneuropathy, Organomeg, pattern poss riosteal rxn Enocrine, M-protien, Skin Histo sim to Glomus Tumor Renal Cell Ca - 90% Blown out #1 cause of extraplueral masses lytic expansion @40 Chordoma - 55% sacroiliac, 25% present w mets, NO calc, Pelvis, thoracic & lumbar spine 25% clivus, 20% cerv spine esp Periosteal Rxn freq, skull rare C2 Thyroid - Lytic, 8% present w collapses vert body, effects mar- Grossly expanding, highly ag- bone mets row not post elements gressive w lg ST mass Lung - 80% lytic, more often Diffuse Form - Osteoporosis #1 Slow growing, met late w NO blastic if sm cell, 15% w bone presentation, rarely sclerotic skeletal met, fatal. Lymphoma - NHL can be I', 75% Bone Survey nît nuc scan nucs, enchondroma not lands of malig cartilage Plasmacytoma - presents 10yrs Selenium75 - good for ID of tu- Myxoid type - also pure ST, poor younger (over 35) mors w cart matrix prognosis, avg 50yrs preceed mult mye by 3-5 y Freq cartilaginous lesion of ant Chondrosarcoma - Intramedul- ribs in adults lary type #1, geographic permea- Benign Causes of Periosteal tive Periosteal Chondrosarcoma - Elevation Lg lytic component, ring & arc larger ST mass, no medulary 1. Hypertrophic Pulmonary Os- chondroid matrix comp teoarthropathy - clubbing #1 in prox long bones, aggresive sim periosteal chondroma or Subperiosteal new bone, Meta- w flat bone sessile osteochondroma physis only, NO epiphyseal ST mass is large, slower growing Caused by pulm mass, I' bone or than osteosarcoma Clear Cell Chondrosarcoma - met, Benign cause poss lung mets #1, skeletal rare less aggresive w sclerotic rim Assoc w Enchondroma, Osteo- Present 30-40, improved prog- 2. Familial Pachydermoperios- chondroma & Pagets nosis, can be totally lytic tosis - assoc w clubbing Low grade lesions indistinguish- Epiphyseal & often confused w a able even w path chondroblastoma 3. Caffey's Dz - Infantil Cortical Also sim Bone Infarcts MRI - very high T2 Hyperostosis, before 6mo ST component is key to DDx ST swelling, Immature laminar from enchondroma Mesenchymal Chondrosar- bone adjacent to cortex Always presents w PAIN, en- coma - Very aggresive, lg ST Etiology may be viral chondroma may not component Lidocaine in joint stops DJD pain, Present 20-30, often assoc w 4. Scurvy - Subperiosteal Hem- not lesion pain prev intrmedullary chondrosarc orrage in healing phase, P 6mo hotter than ant iliac crest on Can be pure ST, multifocal is- 5. Sarcoid - Elevated phalangeal Synovial Sarcoma can also In general the deeper the growth, lytic lesions, Endosteal sclerosis cause scalloping the worse the prognosis Shoulder #1, errodes outer cor- 2. Liposarcoma - #2 ST mass, tex of bone if deep Soft Tissue Disease presents at 40-60yrs, rare in Aggressive Infantile Type - dis- MALIGNANT SOFT TISSUE child covered before 2yrs TUMORS Extremities & retroperitoneum, 5- no met but locally aggresive & 1. Malignant Fibrous Histiocy- 10yrs earlier in extremities recurs toma - #1 malig ST tumor, 40-70 Low Grade - well differentiated, All are very vasc w intense en- Presents as painless soft tis cannot met, local recur hancement, NO necrosis mass >5cm synonymous w Atypical Lipoma, 3 cell types, spindles predomi- ALWAYS has fat Dupuytrens Contracture - Pal- nate, histiocytes retroperitoneal form assoc w freq mar Fibromatosis, ulnar side Giant cells also poss, malig or recur, bowel obs & death If removed while cellular will re- benign Myxoid Type - most common, cur, wait until fibrosed Poorly defined calc, poss in- 50% have visible fat by CT volvement of adj bone MRI - benign cyst like app poss, Infantile Myofibromatosis - Can cause scalloping of outer freq assoc hem Myoblastic & fibroblastic lesion cortex of adj bone Round Cell Type - poorly diff hy- Bone lesions common, poor Osseous MFH rare - geographic percellular form prognosis if mult & deep lytic lesions Dedifferentiated Liposarcoma - No periosteal rxn or sclerosis refers to mixed types 4. Synovioma - Synovial sar- Closely related to fibrosarcoma, coma, predominatly a spheroid identical app 3. Fibromatosis - Extraabd ST mass DDx - Liposarcoma, but no fat Desmoid of deep & superficial #1 at knee, hands & feet also present in MFH tissues Originate from tendon sheath, rarely assoc w joint Superficial ST & extremities cortical holes poss joint masses are not malig CT - sim liposarcoma but not cortex remains intact unlike per- Calc 30%, Bone errosion freq, seen in young pts meative round cell proc occur up to 2cm from joint Phlebliths often assoc Angiolipoma - encapsulated w MRI - flow voids, Lace like pat- BENIGN SOFT TISSUE TU- vasc stroma & fibrin, young tern of FAT in interstitium MORS adults Cavernous hemangiomas often 1. Lipoma - Mature fat in 40-60y/ rare infiltrating form seen w no larger w less nonvasc tissue o, female predominance capsule, hemangioma like 95% solitary, Tumor fat not avail- 3. Elastofibroma - Benign RE- able for metabolism Lipomatosis - diffuse over- ACTIVE tumor like lesion of CT - -65 to -120HU mass, well growth of mature adipose tissue chest circ w NO enhancement presents before 2yrs, often in Comma shaped mass under thin fibrous strands poss, if ex- foot or hand scapula & chest wall in elderly pt tensive think fibrosarc bony hypertrophy freq, nerve not II' to mechanical friction, usually affected asym, freq bilat Neural Fibrolipoma - aka lipo- matous hamartoma of median Hibernoma - brown fat lipoma, 4. Synovial osteochondroma- nerve extremely vascular on angio tosis - benign synovial metepla- Most in young adults, present w occur in young adults, scapula & sia pain & paresthesia axillary region #1 mult loose calc bodies in joint pa- Macrodactly - freq in 2nd or 3rd extremely rare in pure form thognomonic digit loose bodies not always calc, 2. Hemangiomas - Benign Vasc mimics villonodular syn Lipoblastoma - cellular imma- neoplasm, fibrous tiss & Fat freq erosions of the acetabulum may ture lipoma, infants before 3yrs Plain Film - ST mass w assoc be seen 8. Radiation Myositis - T1 im- changes sim but less marked 5. Pigmented Villonodular ages show N fibrofatty septations Joint contracture, but NO termi- Synovitis - benign synovial T2 shows inc signal due to in- nal tuft resorbtion swelling flama etc Assoc w malig, genital Ca in fe- Subarticular errosions w Joint males swelling & pain 9. Thickening of Heal Pad - NO assoc elevation in serum Lg subchondral cysts w NO joint seen w corticosteroid excess, calcium levels space narrowing typical Cushings Juvenile form - most resolve CALC NEVER SEEN assoc w also seen w acromegaly, abn if spontaneously, 40% mortality w/ this process, NO osteoperosis >21mm o Tx see section on benign joint proc- esses SOFT TISSUE CALCIFICTA- 3. Scleroderma - Fluffy calcific TION deposits 6. Baker's Cyst - synovial cyst 1. Myosistis Ossificans - Calcinosis Cutis - from tight over- between semitend & med gas- Trauma, rim of cortical bone lying skin troc m Dist phalangeal resorbtion, Pen- MRI will show fluid, II' to med 2. Dermatomyositis - Collagen ciling & Autoamputation meniscus tear vasc Dz, linear & confluent ST Ca+ 4. Werners Syndrome - Osteo- 7. Tumoral Calcinosis - mult Hands, Axilla, Inguinal & chest porosis, ST Atrophy & Calc calc deposits near major joints wall most freq Neuropathic changes & DJD Etiology unknown, occurs in Lymphadenopathy, Spe- Premature ageing, short stature young blacks nomegaly, Rash & eventual & arteriosclerotic probs Multilobular & Cystic, Milky Ca+ death phosphate fluid present atony & dilation of esophagus 5. Leporsy - Calcifiction in DDx scleroderma & RA - bony Nerves only Radiotherapy - usually lg holes II' hyperparathyroidism induced Metabolic Bone Disease but can be small by dec Ca+ level OSTEOPENIA Ca+ Def & hyper or hypophos- Osteoporosis - diminished bone Osteomalacia - due to defect in phatemia assoc quantity in otherwise N bone Vitamin D metabolism Changes of HPT more common Aging - 95%, postmenopausal Dietary, Absorbtion problem, in older pt rather than rickets females Liver Dz or Renal Dz Dietary - Inadequate Vit D intake, Steroids - Exogenous more excess nonmineralized osteoid, rare before 1y/o common than Cushing's always assoc w bone pain Defective fat uptake - prevents also assoc w exuberant callus Prominent trabeculae replace transport of Vit D formation normal small structural type Sprue or defective bile salts Plain Film - Cortical thinning #1 Looser's Zones - unmineralized Liver - fails to convert vit D to 25 sign, middiaphysis 2nd metacarp osteoid seam on concave side OH cholecalciferol Permeative Pattern - can result Hepatic Osteodystrophy - seen in from dissuse, sim Ewing Renal Osteodystrophy - #1, alcoholics cortex riddled w holes, Ewing fails to convert 25-OH-D3 to originates in medullary 1,25-OH-D3 Ricket's - Osteomalacia in an thin transverse trabeculae & ac- 2 mechanisms contribute to as- immature skeleton centuated vertical trabeculae soc osteopenia - Vit D prob & II' Cartilage fails to mature in en- No assoc lab abnormality, elev of HPT chondral bone growth urine hydroxyproline poss Renal tubular dysfxn causes Vit Loss of zone of provisional calci- D resistant type fication, Dist femur #1 Pseudopermeative pattern in cor- Fanconi Syn - tubules spill phos- Inc space between metaphysis & tex has 2 other causes phate epiphysis, wide physis Hemangioma - hyperemia II' to Glomerular Dz - Retain phos- Cartilage overgrows in long & lat inc flow & tunneling phate causing dec Ca+ dimensions Flared irreg epiphysis, Metaphy guishable from idiopathic type cupping, diaphy bow Infantile Form - always lethal, NO Hyperparathyroidism Squared & flattened post calvar- ossification of skull, AUNT MIN- Primary Hyperparathyroidism ium, basilar invag NIE 90% Adenomas, 10% hyperpla- Periosteal elev, pain, coarse tra- sia or mult glands bec X-Linked Hypophosphatemia - Osteoblasts stimulated to mobi- Rachitic Rosary - overgrowth of previously called vit D resistant lize Ca+ from bone cart in ant ribs & wrist rickets HYPERcalcemia results & Looser's Fx - poorly mineralized Proximal tubules fail to resorb causes HYPOphosphatemia bone laid w remodeling filtered phosphate Subperiosteal Bone Resorbtion - Osteomalacia & insufficiency Fx pathognomonic Hypophosphatemia - Inherited common, presents after 1st year Radial aspect of mid phalanges defect in alkaline phosphatase Periosteal Hyperostosis freq, ac- of 2nd & 3rd finger #1 activity tually see inc bone mass in can prog to spiculation & com- extracelluar accumulation of in- adults plete cortical resorb organic phosphate causes os- Enthesopathy - bone formation at Juxta-articular errosions - pubic teomalacia liagament & tendon attachment syph & sternoclavic Sx - same as rickets, symptoms freq Subchondral Bone Resorbtion - can improve with maturation Defective dentin formation involves axial skeleton Adult form - 50% have slow on- causes freq tooth problems osteoclastic resorbtion of trabe- set with no childhood Dz culae beneath cart ST calcification seen in all forms Non-Hereditary Hypophos- Microfractures result & can but most pronounced in adult phatemia - oncogenic osteomal- cause collapse Enthesopathy - prominent bone cia Brown Tumors - characteristic of spurs at tendinous insertions most commonly due to mesen- I' but seen w II' also CPPD arthropathy freq, indistin- chymal tumor Fibrous Tis & Giant cells replace bone, expansile congenital renal malform Vinyl Chloride Exposure - Tuft May become sclerotic after Tx of Adults - urinary tract obs or resorbtion & SI ankylosis HPT chronic pyelonephritis Returns to N after exposure Osteosclerosis - mostly in II', in- leads to glomerular failure & stopped volves axial skeleton phosphate retention "Salt & Pepper" skull - Trabecular Osteosclerosis more freq, Chon- OSTEOSCLEROSIS Resorb & scleros drocalcinosis less than I' R) Renal Osteodystrophy - or "Rugger Jersey" Spine - Sub- "Tumoral Calc" - extensive ST any cause of HPT, but this #1 chondral bone sclerosis calc, more freq than I' Subperiosteal bone resorb #1 Chondrocalcinosis - CPPD oc- Hyperuricemia can also result sign curs in 40% of pts w I' HPT causing II' Gout 10-20% have sclerosis, etiology Ligamentous laxity - atrophy of unkown ligament & attachment Scurvy - Impaired Osteoid For- Seen best at syph pubis & SI, mation, ST Ca+ phos deposites S) Sickle Cell Dz - sm percent- joints supported by ST Metaphyseal - Dense calc of age for unknown reason metaphysis w prox zone of attri- assoc w bone infarcts & vert end Renal Osteodystrophy - Sec- tion plate step-offs ondary Hyperparathyroidism Trummerfield zone w the white Phosphate retained, Ca+ drops line of Frankel M) Myelofibrosis - myeloprolif- HYPOcalcemia due to HYPER- Pelkin's Fractures - Corner Fx of erative syn, prog marrow fibrosis phosphatemia brittle metaphysis freq in pt over 50 Low Ca+ causes hyperplasia of Periostitis due to subperiosteal Anemia causes extramedullary Cheif Cells in Parathyroid bleeding hematopoesis & lg spleen N Vit D metabolism disrupted Never seen before 6mo, mater- Assoc w Mets, Poisoning, causing osteomalacia also nal Vit C protective chronic inf, AML, McCune- Children - usually caused by Albright dullary side, Axial skeleton I' O) Osteopetrosis - generalized P) Pyknodystosis - Toulouse- Scattered sharp sclerotic foci, dense amorphous bone Lautrec Syn, an artist w the Dz areas of rarefacation N trabecular structure obliter- Auto Dom, short w HYPOPLAS- assoc w thickened sm bowel ated, NORMAL MANDIBLE TIC MANDIBLE folds, bone pain seen in <30% Defective Osteoclasts - fine I' Dense pointed dist phal pathag- spicules persist nomonic, 2:1 male P) Paget's Dz - rarely diffuse, medulla filled, die from anemia & Sutures spread & persistent 20% monostotic, any bone can infection wormian bones seen be affected denser prox due to greater Bone ENLARGEMENT & cortical growth prox M) Metastatic Ca - prostate & thickening, 3 phases growth spurts cause lucent breast #1, Hodgkins also Osteolytic, Sclerotic bone forma- bands assoc w cortical destruction or tion & Mixed clasts keep only during slow lytic lesions II' bone has no haversian sys, Fx growth & avulse easily Infantile Form - CN compression, M) Mastocytosis - Mast cell ac- Thickened haphazard trabecula, throbocytopenia, death cum in mult organs, 50% occur freq bowing Adult Form - 50% asym, recur- at <6mo Prog end to center w Flame rent trans Fx II' to brittle Uticaria Pigmentosa- skin rash is shape, Tibia only exeption CN foramen narrow, mastoid air #1 Sx, 90% Fibula never involved cells obliterated assoc w LUEKEMIA, pancy- "Banana fractures" & partial frac- Erlenmeyer Flask long bones topenia, hepatomeg, lymphade- tures on convex side -clublike & flarring end nopathy SLOW progression, rapid Longitudinal metaphyseal stria- Hematopoetic marrow process, changes considered malig de- tions X-ray detectable in 70% generation end plate fibrosis, sandwich vert Trabecula Thickened from me- Pelvis - Ileopectineal line must be thickened bones OTHER CAUSES OF DENSE Medial migration of femoral head Tumors more likely to metasta- BONES poss, sim RA size Hypervitamanosis A - Cortical Skull - Osteoperosis Circum- Nucs - marked uptake w active thickening of Tubular bones scripta, early lytic process blastic Diaphyseal & symetric, diffuse "Cotton-wool" Thickening & En- Neoplasm - cold on bone scan, periosteal Rxn largement, blastic phase hot on gallium NO subperiosteal hem seen, NO Impingement of Cranial Nerves MRI - not indicated, inc fat inten- mandibular involvement assoc sity on T1 Metaphyseal spurring & In- Basilar Invagination, no inc ICP LAB - Increased Alkaline Phos- creased ICP assoc phatase levels Assoc w itching, dec appetite, Spine - Dense picture frame vert, Inc Ca+ causes renal calculi & hard tender lumps on ext appendages involved Nephrocalcinosis Hepatosplenomegaly, anorexia, Symetric collapse poss, "vertebra Urinary hydroxyproline levels alopecia plana", sim EG also inc never seen under 1y/o Striations may mimic heman- High output cardiac failure due to DDx - Ricketts, Caffey's, Syphil- gioma but usually sclerotic mult tiny AVM's lis, healing Scurvy Sarcomatous Degeneration - <1%, to Osteo, chondro or fibro A) Atheletes - II' to inc stress Hypervitaminosis D - affects undiff w elements of all 3 freq, adults & children opposite osteo #1 F) Flourosis - II' to dietary in- Child - Thickening of provisional Only time Sarcomas of Skull oc- take, rare zone of calc & Cortex cur assoc w ligamentous calcifica- Adult - Osteoporosis & tumoral Giant Cell Ca - Only time they tion, esp sacrotuberous ST calc esp at joints occur in older pt's ALL occur in the skull & facial Hyperphosphatemia - "Juvenile Paget's Dz", auto rec in Puerto phatemia but elevated PTH level occurs years after Tx for hyper- Rican's thyroidism Fusiform expansion of Pseudopseudohypoparathy- Spongiosa, no normal maturation roidism - clinical syndrome, Cretinism - Hypothryoid from Dwarfism, bowed bones, wide NORMAL labs birth, Delayed Skeletal matura- irreg epiphysis sim to rickets tion Skull enlarged w Sclerotic Cushings - Axial Osteoporosis Endosteal cortical thickening patches, Cranial Nerve deficits #1, 3:1 female obliterating marrow cavity Biconcave vert bodies, Cystic le- Assoc w adrenal hyperplasia in Irreg ossifacation esp in femoral sions poss adults epiphysis Vertebra - Prom vertical stria- Vert bodies flat & hypoplastic, Hypoparathyroidism - HY- tions, Dense cupped endplates esp T12-L1 causing KYPHOSIS POcalcemia & resulting neuro- Fx's heal w excessive callus (esp musc Sx RIBS), mult bone infarcts Acromegaly - Eosinophilic Ade- Parathyroid defeciency - usually Calveria stippled, demineralized noma #1 cause, equal in sexes II' type, Iatrogenic sella 50% show Skull thickening esp Osteosclerosis & calveral thick- Adrenal tumors in children - de- at base, 20% w N sella ening is I' manifestation layed skeletal maturation Periosteal Apositional bone for- Basal Ganglia & SubQ tissue mation in long bones calc also Thyroid Acropachy - periosteal Exagerated tuberosities, general- rxn & thickening of tubular bones ized ST thickening, esp heal pad Pseudohypoparathyroidism - fuzy periostitis on radial side of to >21mm end organ resistance metacarpals & mid phalanges Premature Oteoarthritis - carti- Characteristic short stature, very distinctive lage thickens then dies round face, obesity & MR result Present HYPO or euthyroid w due to inadequate blood supply, Hypocalcemia & Hyperphos- exopthalmos & pretibial edema post vert scalloping Vert - post scalloping in 30% Diaphyseal Dysplasia, not famil- Clavicle - thickend trabecula due Enthesopathy - "Spade Digits" & ial to stress lg spurs of distal metacarpals Rapid prolif of new cortical bone, normal joint space maintained, symetrical thickening clavicle head may be expanded Post Radiation Tx - Pattern Sim paget's but Diaphyseal only, increased density confined to matches ports, ST calc assoc stops at metaphyseal line lower medial clavicle, UNILAT pain & swelling but no skin in- Worth Syndrome - Auto Dom, Pachydermoperiostosis - Hy- flammation Endosteal Hyperostosis pertrophic Oteoarthopathy, Auto Endosteal thickening of tubular Dom bones obliterating marro M>>F, middle age, lg thick skin Congenital Bone Disease Osteosclerosis of skull begins at folds, enlarged paranasal si- CONGENITAL BONE DIS- base, extends to face nuses EASES Mandible freq involved, pelvis & Irreg periosteal proif of phalnges Subperiosteal new bone can be ribs not involved & dist long bones - CLUBBING seen in N infants Spine - primarily post elements Epiphysis & metphyseal regions thickened of tubular long bones #1 Scoliosis - Adolescent type most cortex thickens but NO narrowing common, multifactorial inheri- Lead Poisoning - can create of medullary cavity tance dense metaphyseal line can have acro-osteolysis, pro- Congenital Scoliosis - look for abnormal remodeling of tubular gression ceases after several assoc vert body anomalies, hemi bones possible years or butterfly widened cranial sutures due to DDx - pulm osteoarthropathy Idiopathic Scoliosis - usually inc intracranial pressure possible (painful) & thyroid acropachy convex to the right, L assoc w other anomali Englemann' Dz - Progressive Osteitis Condensans of the 15% assoc w congenital heart Dz Wedged vert body at apex of BLUE Sclera, least severe form Osteosclerosis, Calverial thicken- curve, NO congenital fractures but Rib- ing I' curve forms w II' curves above bon Ribs & Deafness Dwarfism - Shortened & bowed & below Long bones - Diaphyseal Bow- long bones 8:1 female, starts P 10y/o & ing, Cyst-like lesions Shortened 4th & 5th metacarpals stops w cessation of growth Skull - Wormian bones ALWAYS & distal thumb phalanx NF-1, TB, Osteoid Osteoma, seen, Basilar Invagination 2) Soft Tissue Calc - Basal Gan- Marfan's Fx freq w Exuberant callus for- glia, Dentate nuc, skin & subQ Wilm's - due to radiation necrosis mation, NO IUGR by US Broad Facies, Mental Retarda- of ipsilateral apophysis No further fx usually occur P pu- tion & Cataracts also assoc berty 3) Abn Blood Chemistry - LOW Infantile Cortical Hyperostosis "Popcorn" metaphysis - cystic le- Ca+, HIGH phos - marked cortical thickening sions pathog for OI Turner's Syndrome - XO, De- <6mo old, acutlely ill, irritable - Type IV - similar but mild deaf & layed epiphyseal fusion probably infectious bowing, No blue sclera Shortened 4th & 5th metacar- Metaphysis spared, Freq exac- Congenita - (Types II & III), Auto pals, Shortened ulna erbation & remission Rec, accordian bones, II lethal "Drumstick" metacarpals & pha- resolves completely within a few Thin skull langes months Wedge or bow-tie vert bodies Cubitus Valgus - large medial Vert bodies also spared femoral condyle Pseudohypoparathyroidism - Odontoid hypoplasia & small Osteogenesis Imperfecta - bad End organ resistance to hormone sella tursica osteoblasts, poor osteogenesis Heritable syndrome w 3 compo- "Squared" vertebra - shortened Collagen also abn, Fibroblast nents A-P diameter cultures for Dx 1) Skeletal abn - Manifestations Horseshoe Kidney, Coarctation Tarda - (Types I), Auto Dom, of HYPOparathyroidism of the aorta & Infantilism Tuberous Sclerosis - Cortical Bizarre facial dysplasia - Sphe- Syphilis - Trophic depostits of thickening, can sim pagets noid #1, orbit asymetry endochondral bone Flat osteomatous protuberances Post orbit does not develop, Zone of provisional Calc widens, on cortex Poss II' to optic gliomas lucent fibrous zone prox Paraventricular tubers, Renal Sharply angled Scoliosis - wors- "Saber shin" - severe form of masses, Pulm infiltrates ens even P growth stops subperiosteal bone growth Zits, Fits & Nitwits, lytic lesions Scalloped post vert bodies - mult occurs everywhere but ant tibia poss but rare spinal meningoceles most common small vert body, long sclerotic Charcot joints & minimal ST Neurofibromatosis - Von Reck- post elements component, rapid response to linghausens (NF-1) assoc w "Dumb-bell" tumors - widen for- PCN bone mena & erode pedicles DDx - scurvy & ricketts, but pt Family Hx #1 presentation, Fx w Focal Gigantism of a digit too young pseudoarthrosis also Cafe Au lait spots, gliomas, lesch ST dysplasia induced by abn nodules of iris Hereditary Osteocartilaginous nerves - Elephant Man Renal artery Stenosis & Neurofi- Exostoses - effects long bones ABN TRABECULATION PAT- brosarcoma poss exostoses are not as large or TERN, "Ribbon Ribs", mult NOF Blount's Dz - Osteochondrosis spike-like as isolated form Ossification centers & digits can Deformans Tibiae Madelung deformity of wrist - have marked overgrowth lat dilocation of tibia, wedge- Paired bones show dif growth UNILAT ANTERIOR bowing of shaped deformity of medial tibia Supernumary Digits & radial distal leg Infantile Form - physiologic bow- head dislocation (osteogenesis is bilat, fetal mal- ing fails to straighten w growth Chondrosarcomatous Degenera- position causes post bow) Histo shows disturbed medial tion - occurs in 20%, esp hips Extensive subperiosteal hem w epiphyseal endochondral oss exuberant callus poss Juvenile Form - less common, segmental arrest of medial Morquio's - the only one NOT marrow hyperplasia growth plate assoc w mental retardation Widened Spongiosa w coarse usually unilat, affects children 8- type IV, skeletal changes pre- trabecular pattern, thin cortex 15yrs dominate, auto rec "Bullet" shaped vert w gibbus Hadju-Cheney - Primary Acroos- Gaucher's Dz - Auto Rec, Dec due to dysplasia of L1 or T12 teolysis, tufts never develop, os- lysosomal Hydrolase "Wineglass" pelvis & iliac wing teoporosis Glucosyl Ceramide accumulates flaring, dwarfism Wormian bones & Kyphoscolio- in RES organs, 3 forms shortened & thickened metacar- sis Adult - #1, mult spleen nodes, pals & carpals Acroosteolysis also occurs w pulm & hepatic fail, death Premature degenerative arthritis, scleroderma, frost-bite & burn Juvenile - 2-6yrs, mild w pre- corneal opacities Pyknodysostosis, psorisis & dominate neurologic Sx Hurler's - type I, gargoylism, auto Pachydermoperiostitis Infantile - hepatosplenomeg, se- rec, dwarfism, MR after 1-3yrs vere neuro, early death main Sx are neuro, "bullet" ver- Holt-Oram Syn - Cardiomelic 90% have bone Sx - Avasc Nec, tebra are seen though less syndrome, Auto dom, effects up- Osteomyelits, Myelofibrosis calverial thickening, J shaped per ext only "Erlenmeyer Flask" - marked cor- sella, frontal bossing assoc w variety of clavicle, ster- tical thickenig at dist fem Scaphocephaly due to closure of num, radius anomalies "Fish Mouth" vertebra, bone in- sag suture Hands #1 - carpal coalition, ab- farcts, Periosteal Rxn Claw hands, thick flaring ribs sent thumb etc mult sharply demarcated lytic le- Heart defects predominatly con- sions poss Hemolytic Anemias - Thalas- ductive, septal #1 structural de- semia, sickle cell, Non- fects Mucopolysaccharidoses - lyso- spherocytic Marfan's Syndrome - auto dom somal storage disorder Congenital, causes profound defect in collagen cross linking Generalized Osteopenia, Doli- macrodactyly due to neural fi- space widened chocepahly, prominent jaw brolipoma forms a V shaped radial & ulnar Thumb & 1st toe dispropor- increase in size of all elements & articulartion w carpals tionatly long, pes planus structures of one or more digits carpal angle decreased, volar Scoliosis in 60%, Scheuremann fibrofatty tissue infiltrates epi- subluxation Dz, Dural ectasia w post scallop- neurium, growth stops at puberty II' to premature fusion of radial ing physis, assoc w trauma ligamentous laxity, premature os- Polydactyly - Preaxial means also seen w Turner's & multiple teoarthritis, slipped cap fem lateral, index or thumb duplica- enchondromatosis epiphysis tion Cardiovascular - cause of death Postaxial - medial, more com- Radial Ray Defects - rare, 40% in 90%, recurrent biliary obs mon 5th digit duplication assoc w VACTERL anomalies Occular lens dilocation, cystic Syndactyly - most commonly in- can be absent thumb or entire lung Dz, recurrent pneumothorax volves the 3rd & 4th digits radius

Homocystinuria - familial defect Infantile Coxa Vara - proximal Klippel-Feil Syndrome - Fused in collagen synthesis, simulates focal femoral neck defeciency, cerv & upper thoracic vertebra Marfan's unilat arachnodactaly, scoliosis & post causes varus deformity of femo- Sprengel's Deformity - scapula scalloping of vert bodies in both ral neck, widened growth plate elevated & fused to cervical ver- Osteoporosis occurs w this but child presents w lurching pain- tebra not Marfan's less gait ligamentous laxity present but no Congenital Posterior Bowing joint contracture as in Marfan's Madelung Deformity - volar an- of Tibia - foot dorsiflexed gulation of distal Radius etiology unkown, progressive im- Macrodystrophia Lipomatosa - relatively long ulna & radial-ulnar provement w growth eventually becomes staight w prob w minimal herniation shortening minimal shortenening Short pedicles & narrow intrape- Premature DJD, short palanges, dicular distance MUST be pre- auto rec w NO shortened life- sent span Skeletal Dysplasias Flattened Acetabular Angle & Il- minimal spine effects DDx from SKELETAL DYSPLASIAS iac wings Spondyloepiphyseal dysplasias Disturbance of bone growth DDx - stippled epiphysis also Rhizomelic Dwarfism - proximal Spondyloepiphyseal Dysplasia seen w cretinism & warfarin em- limbs, humerus & femur, achon- - Auto dom, dwarfism from spine bryopathy droplasia & hips Mesomelic Darfism - shortened DDx - Morquio's, several distin- Metaphyseal Chondrodyspla- intermediate seg guishing features sia - severe short limbed dwarfs Acromelic Darfism - distal short- presents at birth, morquio's seen all have Erlenmeyer flask de- ening, asphyxiating thoracic dys- at end of first year formity extending to diaphysis plasia deficient ossification of pubic Micromelic Dwarfism - shortened bones & narrow pelvic angle, not Schmid Type - most common, entire limb, jeune syn, thanato- flared AutoDom phoric varus deformity of hips, Mor- widened epiphysis, cupped quio's has valgus metaphysis & coxa vara Achondroplasia - Rhizomelic NO involvement of the hands mimics Vit D refractory Rickets Shortening (prox long bones) Corneal detachment rather than Scalloped post vert bodies as corneal clouding Metaphyseal Dysplasia - Pyle seen in acromegaly Dz, often tall & asymptomatic Foramen Magnum small - Hy- Multiple Epiphyseal Dysplasia effects long bones esp in hand & drocephalus causes lg head - irreg mottled calc of epiphysis medial clavicle, genu valgum Narrow dist spinal canal - causes late onset of dwarfism, mild limb splaying of ends w thinned cortex Demineralization but dense ver- 1st then stress during flexion & Chondroectodermal Dysplasia tebral margins adduction - Ellis-van Creveld Syn Calvarial thickening, caxa vara, Transverse view - head centered Accelerated Skeletal maturation wedge vert bodies in adulthood over & touching triradiate carti- Polydactyly & congenital heart NO skeletal change w adult on- lage Dz freq, Septal defects #1 set femoral metaphysis inferior & is- Nails, hair & teeth ALWAYS in- chium superior make cup for volved Angiovenous Dysplasia - AVM, head Cleidocranial Dysotosis - delayed hemangioma or venous malfor- Coronal view - gluteal muscles ossification of midline structures mation will be seen lat to iliac bone & large head w Wormian bones, most asym, may cause over- head hypoplastic sinuses, bossing, lg growth of affected limb due to inc Abduction will demonstrate if hip mandible flow is reducable hypoplastic chest, medial & lat can cause focal bone errosions, MRI - may show iliopsoas tendon portions of clavicle don't fuse look for phleboliths within joint if dislocated delayes ossification of symphysis Inverted Limbus - labrum hyper- pubis Hip Dysplasia - femoral head trophies & turns inward to joint spina bifida occulta, varus hip, cartilage <50% covered by ace- prevents relocation, arthrography short radius tabulum shows loss of "rose thorn" pg760 usually displaced post & lat, will ACR37 Cretinism - congenital Hypothry- eventuall migrate superior Femoral head ischemia - head roidism, Delayed skeletal matu- 1) seated at rest, lax w stress, rotates superior causing valgus ration 2)subluxated, 3)dislocated deformity Stippled Epiphysis, may remain Most important is to determine if occurs at younger age than open indefinetly, wide sutures & it is reducible or not Legg-Perthes fontanelles Dynamic US Scanning - neutral look for shallow acetabulum & widened "teardrop" seen w acetabulum shallow or absent tilage deposits on synovium chronic process due to dysplastic femoral head Calcium deposits in cartilage, Weberg Angle - adult head Apert's Syndrome - Acrocephalo- Knee, hips & elbows #1 should be centered in acetabu- syndactyly lum Craniosynostosis of coronal su- Pigmented Villonodular Syno- angle between vertical & line to ture resulting in brachiocephaly vitis upper margin of acetabulum also hypoplastic ant fossa, hemosiderin deposited causing both lines originate in center of prominent sella turcica & choroid fibrosis & Synovial prolif femoral head, 20-46deg N, calcification Monarticular degeneration of smaller bad midface hypoplasia, hypertelo- knee #1, hip #2 rism, hydrocephalus most commonly effects extraar- Proximal Focal Femoral Defi- Syndactyly - results in "mitten ticular tendon sheaths ciency - dysgenesis of prox fe- hand" & "sock foot" Periarticular cystic degeneration mur Symphalangism - progressive in hands & feet freq probably II' to in utero vasc acci- obliteration of interphalangeal 85% have osseous lytic lesions & dent, most unilat, isolated anom- joints cortical errosions aly fusion of other joints as well in- Lg subchondral cysts w NO joint 70% have ipsilat fibular agenesis cluding tarsals & carpals space narrowing typical prob due to same vasc accident NO CALC & NO Osteoperosis, present as unilat short limb, no articular cartilage preserved until pain Arthritis and Benign Joint late US - shows a cartilage connec- Processes Resembles nonossified synovial tion between head & shaft in mild BENIGN JOINT PROCESSES osteochondromatosis form Synovial Osteochondromatosis - DDx - Synovioma, sim distribu- severe form has no connection usually monoarticular tion & ST mass or no femoral head Metaplasia of the synovium - car- errosions more smooth & no pe- riosteal rxn H. flu in infant, S. aureus in child giomatous tissue, crosses joints present w fever and immobile & disk Sudec's Atrophy - Reflex Sym- joint, X-ray N initially effects children & young adults, pathetic Dystrophy, shoulder- Effusion displaces med aspect of any bone involved hand syn head >1mm relative to opposite no pain or expansile mass assoc, 1) onset of painful & stiff shoul- Aspirtation for Dx, Emergent ar- no Tx effective. der or hand joints, lasts 6mo throtomy & open drainage for Tx 2) Shoulder improves but hand high risk of cartilage destruction, continues to burn, ST wasting 15% assoc w head osteomyelitis Collagen Vascular Disease 3) last stage may be 3-6mo or X-ray - <35% sensitivity, 1mm is chronic, contractures, skin atro- sig for poss infection, need of NO joint destruction phy aspiration Nucs - shows inc flow & uptake, US - 90% sensitive for effusion, Scleroderma - Tight overlying plain film shows osteopenia P best in sagittal plane skin causes calcinosis cutis 6wks echogenicity of the fluid does not Dist phalangeal resorb - pencil- Trauma is often intial event, se- relate to need for aspiration ing & acroosteolysis verity does not influence out- ST calc but less than dermato- come Lyme Disease - JRA type pres- myositis Tx w corticosteroids & sympa- entation possible if no Tx NO osteoperosis thetic block w meds or surg Erythema Migrans rash at site of Aggressive Osteoporosis is hall- deer tick bite, Spirochet Dermatomyositis - nonsuppura- mark tive inflam myopathy DDx - dissuse osteoporosis, no Gorham's Vanishing Bone - Onset 4-11yrs, Edema of SubQ ST wasting or skin atrophy assoc massive osteolysis II' to hema- tissues first Sx giomatosis Muscle also presents w edema & Septic Hip - B strep in neonate, bone resorbed & replaced by an- loss of fat-musc planes Eventual fibrosis, calc & contrac- Mixed connective tis Dz - Rotary fixation of the atlantoaxial ture sclero, SLE, polymyositis & RA joint - follows mild tra ST calc in linear confluent pat- Osteoporosis & soft tissue wast- C1-C2 move en mass, lat spaces tern ing unequal even w/o rotation seen in hands, axilla, inguinal & No erosions chest wall Clay Shoveler's fx - avulsion of Bone undergoes dissuse resorb- Trauma lower spinous process tion CERVICAL SPINE excesive force to the su- NO terminal tuft resorbtion, malig Prevertebral soft tissue - 3mm peraspinous ligaments joint contracture assoc from C1-C4, smooth contour Fever, rash, lymphadenopathy, Anterior vertebral bodies - in- Hangman's fx - bilat neural arch splenomegaly & death assoc teruption indicates serious inj fx of C2, ant Sublux of C2 on C3 Atony & dilation of the esopha- Spinolaminal line - disruption hyperextention & extraction in- gus could indicate cord injury jury, unstable but cord decomp C1 ant arch should be no more prevertebral ST swelling but NO Systemic Lupus Erythemato- than 2.5mm from dens (5mm facet dilocation sus - Alignment changes, NO kids) ant inf corner fx of C2 ERROSIONS Nerve Root Avulsion - most Boutoneire Deformity - lax joint common in dist cerv spine Hyperextention Teardrop Fx - capsules esp at MCP joints avulsion of ant inf corner by ant reducable ulnar deviation typical Jefferson's fx - split C1, CT to long lig, C2 #1 Nonerrosive peripheral polyar- demonstrate all fx points Usually no displacement of vert thritis w sim distribution as RA Unstable only if Trans lig dis- body Calc of tendenous insertions rupted, seen if >7mm spread poss rarely assoc w an odontoid fx Hyperflextion Teardrop Fx - ant inf corner crushed anteriorly, body retropulsed Smith's fx - fx of post body Rolando's fx - com fx at base of one of the most severe & unsta- 1st met w joint involed ble, cause ant cord syn - quad & Chance fx - results from flexion, loss of pain 10% assoc w bowel damage Mallet Finger or Baseball Finger - failure of the post & middle spinal avul at dorsal base of dist phal Unilateral locked facet - apo- columns extensor digitorum insertion physeal ligaments rupture ant failure also poss makes surg fix mandatory flexion & rotation inf, facets flexs w/o opposition due to loss overide, rarely bilat Spondylolysis - fx of the pars in- of extensor terarticularis of lamina Ant Subluxation - hyperextention, fx in neck of scottie dog on obl Volar Plate Fx - fx at the base of 20% have delayed instability view the mid phalanx along the volar kyphotic angulation w narrowed often occurs in toddler yrs, not aspect ant disk space, wide post always significant Gamekeeper's thumb - avul of Instability - inability to withstand Spondylolisthesis - bilat pars fx, ulnar side of 1st prox phalanx physiologic loads sup sublux ant to inf Intervertebral space widened, WRIST horiz displacement >3.5mm HAND 80% of axial loading force on ra- angulation >11deg, disruption of Bennett's fx - fx at base of 1st dius facets, mult fx's metacarpal into carpomet joi any radial fx can result in positive thumb adductors cause sliding, ulnar variance LUMBAR SPINE must be surgically fixed Seat belt injury - ant compres- psuedo-bennett's fx - no in- Lunate/Perilunate Dislocation - sion of L1 or L2 volvement of the joint ligaments to capitate disrupt Dorsal perilunate dislocation - capitelum & carpals dorsal of lunate AP film - often shows widening of 3x more common than lunate assoc w negative ulnar variance, scapholunate joint disloc, 75% assoc w Fx short ulna Lat Film - key to diagnosis of dorsiflexion instability Lunate dislocation - lunate Hook of Hamate Fx - need carpal shows volar angulation of lunate pushed volar to radius tunnel view, parralel to palm & capitate displaced volar (post) manipulation can change one to usually due to fall onto an out- lines drawn thru vert axis of lu- the other streched hand nate & scaphoid angle >80deg pie shaped lunate seen on AP prof baseball, tennis, & golfers (N 30-60) view can lever of hook Palmarflexion instability - Ant permanent median nerve dam- Ulnar Nerve which lies adjacent displaced capitate & palmar an- age can result from lunate & outside tunnel often damaged gulation of lunate assoc w capitate, radial styloid, & CT may be helpful triquetrum fx Rotary sublux of Scaphoid - rup- Can cause dorsal instability of Fracture of Scaphoid - avasc nec tured scapholunate lig, scaphoid the wrist of prox frag common rotates volar lat view shows horizontal orienta- Ulnolunate Impaction Syn - pos Dorsal Instability of Wrist - dis- tion of scaphoid ulnar variance flattens med lu- ruption of dorsal radiocarpal gap between scaphoid and lu- nate ligaments nate on AP view - "Terry Thomas triangular fibrocartilage thinned & 60% due to scaphoid fx, 10% Sign" often torn by long ulna due to triquetral fx (dorsal chip subchondral degen cyst devel- seen) Triquetral fx - avul chip seen on ops in lunate due to impaction ligament inj such as rotary sublux dorsum of wrist patognomonic of scaphoid or perilunate disloc occurs at dorsum and may cause Kienbock's Malacia - avasc nec also dorsal instability of the wrist horizontal compresion assoc w most in young female during lac- fx w dislocation of dist radial ul- perilunate diloc, capitate &/or tation nar scaphoid Fx FOREARM Barton Fx - Fx of the dorsal ar- Carpal Tunnel - carries median & Colle's fx - dorsal ang of dist ticular margin of dist radius ulnar N, Radial & Ulnar art radius/ulnar styloid fx Flexor digitorum Profunda deep ELBOW & superficialis over Smith's fx - volar ang of dist Fat pad displaced from post Flexor dig Longus goes over radius/ulna fx fossa following fx flexor retinaculum, inserts to child usually supracondylar, adult palmar aponeurosis Plastic bowing deformity - bend usually radial head Carpal tunnel syndrome - most but no break Children can have effusion with- common in obese middle age must be surgicaly broken & reset out Fx - Dr. Ozonoff women or lose sup & pronation CRITOE 1,5,7,10,10,12 - order & Carpal-Ulnar Dislocation - ulna & Monteggia's Fx - ulna fx, (90% age of epiphysis ossification el- triquetrum no longer aligned proximal) & prox radius disloc bow must examine prox radius or Capitulum, Radius, Internal epi- deQuervain's Stenosing Teno- aseptic nec may result condyle (med),Trochlea synovitis - affects the extensors Positive Ulnar Variance - can re- Olecranon & External epicondyle over radial styloid sult from any radial fx (lat) abductor pollicus longus & bre- All but lat epi fuse by 16yrs, 18 - vis, MRI shows fat planes in- Galleazzi's Fx - radial fx w disloc lat fused flammed of distal ulna Come Rub My Tree Of Love - pain occurs w thumb movement, Erin Masada's pneumonic Essex-Lopressti Fx - radial head Ligamentous Injuries defect in postlat articulation on chondral injury to capitellum Ulnar Collateral Lig - most impor- MR due to repeated valgus stress tant, resists valgus stress mistaken for osteochondral le- Ant thick cordlike, middle apo- sion or fx SHOULDER neurotic, post thin & tran True osteochonritis would be lo- Neer Classifications for Fx's - freq stressed in pitchers cated more ant in cart based on # & angulation of frags Annular Ligament - stabalizes One Part - 80%, surgical neck fx radial head in pronation & sup Essex-Lopresti Fx - Radial head w no displacement Dislocation - radius & ulna to- Fx w dilocation of dist radial ulnar Two Part - Fx of surgical neck w gether #1 joint displacement Nursemaids - reduced w supina- >45deg angulation or >1cm tion & ext rotation Volkmann's Contracture - com- apart, ORIF required Radial head freq w ulnar Fx plication of a supracondylar fx Three Part - greater or lesser Common Flexor Tendon - from vascular compromise from bra- tuberosity avulsed & displaced med epicondyle, can avulse chial art injury or swelling Four Part - both greater & lesser Extensor Tendon - inflam causes muscle & nerve ischemia results tuberosity displaced Tennis Elbow, esp anconius in flexion contracture of hand & devascularization of humeral muscle wrist head

Olecranon Bursa Biceps Tendon Rupture - most Ant dislocation - #1, ext rotation Subcutaneous - freq assoc w common tendinous injury and abduction housemaids elbow & trauma pt unable to flex biceps, pain head seen inf and medial to the Subtendinous - assoc w pitcher over radial tuberosity glenoid injuries, chips in fossa Hill-Sachs deformity - Fx of Little Leaguer's Elbow - osteo- postlat head of hum, 50% Pseudodefect of the Capitulum - caused by inf lip of glenoid, dis- loc likely to recur PELVIS causeing labrum to flip down Bankart deformity - frag off inf Acetabulum - CT needed to II' acetabular dysplasia follows if glenoid, less common show free frags and subtle fx not corrected Axillary Nerve Injury assoc Pavlik Harness - holds in flexion Sacrum - fx 50% of time w pelvis & ext rotation Post dislocation - more dif to Dx, fx, dificult to see US - greater than 50% of fem use scapular Y or Axillary veiw look for interruption of the arcu- head should be in acetab AP view - may be N, lose overlap ate lines of glenoid & head, sm space stress fx can appear sclerotic in Femoral neck stress fx - dif to seen osteopenic pt, CT detect esp in elderly look for lesser tuberosity avul or type 1 - sclerosis w/o fx line evi- Fx of post rim of glenoid Malaigne Fx - SI diastasis assoc dent, bedrest for tx Reverse Hill-Sach's - trough Fx w pelvic ring Fx type 2 - sclerosis w fx line evi- of ant-medial aspect of humeral 60% chance of significant injury dent, int fixation head poss elsewhere in the body type 3 - displaced fx evident

Traumatic hemarthrosis - blood FEMUR Long Bone Stress Fx - may pre- displaces head inf medially Femoral Head Dysplasia - abn sent as sclerosis, NO Bx CT may be helpful in fully evalu- fem head & acetabular relation- repeat in 1-2 wks, CT & MRI ating a joint fx ship helpful Etiology - Familial or anatomic Rotator Cuff Tear - narrowed variance, crowding or breech Femoral Muscle Avulsions subacromial space when chronic 90% effect females Sartoius - ant sup iliac spine Contrast to subacromion & sub- Laxity of capsule allows head Rectus Femoris - ant in iliac deltoid bursa on arthrogram Sublux & compress posst labrum spine eventually may dislocate Hamstrings - ischial tuberosity KNEE ment insertions occasionally causes entrapment Collateral Ligaments - Medial at- Humphry's lig - passes just ant to of the peroneal nerve tached to the meniscus, tears PCL, inserts post lat meniscus rupture can cause pain & swel- more freq Wrisburg Lig - passes just post to ling similar to thrombophebitis Medial Collateral Ligament - tear PCL, inserts post lat meniscus assoc w segond & ACL injury oblique form post horn of lat me- Meniscal Cyst - comm w joint via Lateral has 3 parts - fibular col- niscus to med fem condyle meniscus tear, usually lateral lateral, iliotibial collateral & arcu- Transverse Lig - connects the gelatinous fluid prevents visuali- ate med & lat ant menisci zation w arthrography Popliteus Tendon - inserts on lat Inclusion Cyst - seen w an intact Meniscul Tears - horiz Tears de- fem condyle, passes postlat me- miniscus generative, vert tears post trau- niscus matic Ant medial meniscus is 1/2 the Plica - adhesive band to dist fe- Medial meniscus more likely to size of the posterior medial mur, seen best w effusion tear than lat, posterior > anterior Medial Patellar Plica - most likely assoc w med collateral, ACL & Synovial Cysts - extrusion of to cause Sx Segond injury synovium w no communiction Superior plica - between supra- Bucket Handle - inner portion of seen patellar tendon & femur lat meniscus displaced intracon- Ganglion Cyst - assoc w tendon- lateral placa - between lat coll dylar ous synovial compartments ligament & femur Discoid Meniscus - more likely to filled w gelatenous fluid, often be lat, prone to tear appear intramuscular Pes Anserinus - attachment of more common in children, ie lat Bakers Cyst - between semimem semitend, gracilic & saratorius tears #1 in child tendon & med gastroc head attaches to medial tibia, N bursa free communication to joint should not be seen Pitfalls of Meniscul Tears - liga- space, seen on arthrography ACL Tears - external rotation & collateral lig tears must be re- component placement or liga- abduction paired to reduce laxity ment laxity Segond's Fx - longitudinal fx of 50% require open reduction & Tibial loosens most often, tilts va- post & lat tibia internal fixation rus w subsidence of med plateau occurs just dist to tibial platue, Patellar component is the most always seen w ACL tear Patella Alta - pattella subluxed common site of arthroplasty Deepening of the lateral femoral superior due to pattellar ligament complication sulcus - 100% specific disrup subsidence occurs in 15% but it Medial Meniscus & Medial Col- often stabalizes (ie infrequent lateral lig complete triad Knee Prosthesis - anatomic "failure") Tibial Platue Fx - assoc fibular fx alignment crucial to stability Infection - most serious compli- tends to be adjacent to tibial fx femoral component 7deg valgus cation, occurs in <2% rarely cause damage to popliteal +/- 3deg, tibial 90deg to long axis 73% appear normal on plain film, art, 5% get peroneal nerve palsy tibial component also tilts 10deg abscence of signs does not ex- Types - compression, split, com- post to allow complete flexion clude infec bined or bicondylar Normal Long Term Appearance - Periprosthetic Fracture - assoc w knee instability develops in 30% two common changes osteopenia and rheumatoid ar- within 2yrs, 50% get DJD in Lucency bone prosthesis inter- thritis 15yrs face <2mm, esp at ant tibial re- usually incomplete and appear 20% assoc w meniscal tear, may gion as sclerotic lines of impaction interfer w reduction Stress Shielding of Femur - due Particle Disease - granulomatous Tx - if <4mm displaced use brief to nonuniform load transfer response to debris from wear & immobilization & range of motion linear band of inc bone density tear early extending from portion of pros- poor outcome assoc w >10deg of thesis FOOT & ANKLE varus angulation Failure - follows nonanatomic Cavus - elevation of the arch of the foot metatarsal seen in kids, Tx w immobilization Plantus - flattening of the arch of occurs II' to inversion-adduction the foot also Lisfanc's Fx - fx dislocation of the tarsometatarsals Maisonneuve Fx - proximal fibula Calcaneal Stress Fx - linear band Med border of 2nd metatarsal Fx which is often associated w of sclerosis in post calca aligns med border of 2nd cune ankle fractures Boehler's angle - 30-40 deg N, Bunkbed Fx - fx disloc of 1st proximal films must always be lines drawn post & ant metatarsal & medial(1st) cunei- obtained to rule this out not the best predictor of out- form Dr. Abrahams asked me this come, does not indicate ORIF question during oral boards Alignment of the post articular Chopart Dislocation - talo- surface predicts outcome navicular & calcaneo-cuboid Inversion-Adduction Injury - Lat Coronal thin section CT best for joints dilocated lig rupture or trans fx lat malleo- assesment mid tarsal dislocation lus Essex-Lopresti classification for angular forces from talus can Fx's - tounge type or joint de- Clubfoot - Usully Equinovarus, cause obl fx of medial malleolus pression type Navicular rotated med to talar result from forces at the angle of head Eversion Injury - Deltoid lig rup- Gissane lat veiw shows talus & calcaneus ture & med malleolus Fx 75% have some intra-articular parralel Dist tibiofibular lig tear, fx of dist component, all assoc w lumbar fx fib including spiral type Flatfoot - hindfoot valgus, navicu- does NOT cause trans fx of lat Talar Neck fx - forced dorsiflexion lar rotated lat to talar head malleolus Talus rotates downward in front Kohler's Malacia - avasc nec of w navicular near dorsum Jones Fx - trans thru base of 5th tarsal navicular, poss N var Halx Valgus - great toe turned lat communicates w joint, eff may joint Subtalr Dislocation - dist foot dis- migrate Claw toe is flexion of dist inter- locates from fall onto inverted Ant Tibial Tendon - rupture rare, phalangeal joint foot tenosynovitis in downhill hikers talonavicular & talocalcaneal Achilles - has no sheath so can PEDIATRIC TRAUMA joints disrupted, medial #1 be abn w no evidence of fluid on Birth Trauma - Clavicle fx #1, fe- calcaneocuboid joint & ankle in- MRI mur & humerus poss tact usually spiral fx of diaphysis II' to poor outcome if assoc w talar Fx Navicular Fx - avulsion of cortical breech margin #1 midtarsal Fx Undetected metaphyseal & Tillo Fx - lat epiphysis of distal deltoid ligament attachment in epiphyseal fx freq tibia mid upper margin Good prognosis, pseudoarthrosis occurs in adolescence when not significantly displaced, not a very rare fuseing from med to lat significant portion of articular sur- face Battered Child - Metaphyseal Tendon Tear on MRI - degenera- avul or "Corner Fx" pathog tion, partial tear & tendinitis ap- Hallux Valgus Deformity - lat de- may see squaring of metaphysis, pear sim viation of entire 1st toe "bucket handle" inc signal in substance of tendon, sesamoids not centered over Perisoteal rxn exuberant, perios- tendon enlargement seen w all 3 joint & medial 1st head promen- teum easily pulled free Peronius, Post Tibial & Flexor ince Visceral injury & subdural hem Digitorum - fluid seen in sheath Hallux Rigidus Deformity - DJD assoc Post Tibial - rupture in women w causeing loss of dorsiflexion rhuematoid, painful flat foot as- Bowing Fracture in Child - due to soc Hammertoe - fixed flexion con- longitudinal compressive force Flexor Hallucis Longus - sheath tracture at prox interphalangeal assoc w fx of parralel bone, oc- curs in naturaly bowing bone True fx radius is not aligned w met & epi, arrest & twist forearm #1, leg #2, fix w manual capitelum manipulation Apophyseal injuries to elbow, sup Type V - easiest to miss, only acetabulum & ischial tub germinal cells crushed Salter-Harris Fractures Type VI - periosteal only, not X- any fx involving the growth plate Type II - Fx thru metaphysis into ray Dx I-VI physis Type VII - Osteochondritis desi- Zone of degen & transformation Easy to reduce except at knee, cans weakest portion of plate tends to hem best place - no germ cells, sup- Osteochondritis Dissecans - ply from metaphysis Type III - Fx thru epiphysis into Type VII Salter-Harris Fx Epiphyseal blood supply critical physis chip Fx in articular surface of to germinal matrix growth Offset of articular surface com- epiphysis, growth plate Normal 20% of all childhood Fx, dist ra- plicates reduction Adolescent males - 15-20yrs, dius accounts for 50% Tillo Fx - most common, lat never seen before 10yrs or after Dist femur & prox tibia 3%, but epiphysis of distal tibia 50yrs 50% of growth arrest occurs in adolescence when present w locking, recurrent fuseing from med to lat swelling or aym Type I - growth plate shear, best Osteochondral Fx from "nut- prognosis Type IV - Fx thru all 3 structures, cracker" Hip injury can mimic disloc, ar- difficult to align Medial femoral condyle lat por- thro will show cart head Triplane Fx - prox tibial epiphysis tion in 75%, seen on tunnel view dist Humerus Fx can sim disloc, fx in sag plane talus & capitellum also, Lat femo- epiphysis shifts en bloc maetaphysis Fx in Coronal ral condyle very rarely affected Radius remains aligned to capi- Plane, epi in horiz plane predisposes to early osteoarthri- telum oss center Bony bar - cross union between tis DDx - N ossification variant, Hemorrhage - Susceptibility from Fatty marrow sustains a higher epiphyseal dysplasia Iron products also causes signal signal intensity than conventional loss Spin Echo Chondromalacia Patella - pain, increased difficulty distinguishing errosion of cartilage in adoles- STIR - Short Tau Inversion Re- fatty from red marrow cent covery, starts w an initial 180 improved sensitivity using fat due to mechanical stress, T1 a 90 is given when fat protons at suppresion techniques MRI best for evaluation their "null point", approx called osteoarthritis in an adult. 350msec Fat Suppresion Techniques - a second 180 then rephases the use chemical shift between fat & protons water protons MRI of Bone Marrow Lesions Increased marrow to lesion con- they resonate at slightly diff fre- MRI CHARACTERISTICS OF spicuity results, esp in fatty mar- quencies due to enviroment dif- BONE MARROW LESIONS row ferences Gradient Recalled Echo Im- Fat is suppresed by using low ages - partial flip angle followed FSE - Fast Aquisition Spin Echo, intensity RF centered on fat by 180 produces images w long TR in resonance effective trans relaxation (T2*) short time fat magnîn is rotated mult times instead of T2 k-space filling is altered by aquir- in the direction of the applied RF Susceptibility differences cause ing trains of 2-16 echoes after This nulls the Z component of fat irreversible dephaseing, shorten- one 90 pulse magnetization & blocks fat signal ing T2* the TE becomes a midline value routine spin echo or FSE se- Trabecula in marrow form inho- instead of a fixed value quence can then be performed mogeneous susceptibilities middle lines of k-space are assoc on water loss of marrow signal results, not w the greatest signal & highest seen in diaphyseal region contrast Marrow Distribution - Red is borders, fibrous interface intermediate T1 intensity, fatty is bright Sickle Cell - frequently have ex- Infant pattern - homogeneous in- tensive cellular replacement termediate intensity in all long Infarcts are freq complication due bones to sickles childhood pattern - intermediate Radiation Therapy - diffuse fatty metaphyseal intensity up to replacement in field of port 10yrs follows 2000-4000 rads, edema Ossifying epiphyses always con- & destruction of sinusoids intitally tain high intensity FATTY marrow DDx - anaplastic anemia, fatty Adolescent Pattern - patchy replacement also but more transformation of metaphyseal patchy marrow Adult Pattern - fatty marrow in all Lymphoma - focal regions of portions of long bone dec marrow signal due to cellu- Red Marrow can be N in prox larity fem & humeral metaphysis also seen in flat bones & axial Leukemic Bone - can have dif- skeleton, clivus is fatty though fuse inc cellularity in active stage

Medullary Bone Infarct - occurs II' to ischemia Acute appear as intermediate T1 & high T2 Chronic shows more defined