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M C e o di n ca ti l nu CONTINUING MEDICAL EDUCATION E in du g ca ti on

Goals and Objectives Radiology of After completing this CME, the reader should be able to: • Discuss and recognize the radiographic features of os - Systemic Disorders teopenia. • Distinguish between the radiographic findings associat - Affecting the Foot ed with chronic and regional . • Describe and identify the radiographic features of and Ankle metabolic, endocrine, and nu - tritional disorders that affect the lower extremity. • Describe and recognize Here’s a review of the findings seen the characteristic radiographic appearance of skeletal dys - 165 on foot and ankle x-rays. plasias seen in the lower ex - tremity. • List disorders that are as - sociated with metastatic calci - BY ROBERT A. CHRISTMAN, DPM, EDM fication, calcinosis, and dys - trophic calcification.

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any systemic disor - osteoporosis, include several en - festations of systemic disorders are ders demonstrate as - docrine and nutritional disorders (hy - frequently encountered in the foot sociated radiographic perparathyroidism, acromegaly, and leg. findings in the lower scurvy, and rickets, for example). Decreased , or in - extremity. Although Paget’s disease may be localized in creased radiolucency of bone, 1,2 is a Mthese conditions typically are not the lower extremity. Skeletal dys - prominent radiographic feature of nu - clinically diagnosed by their foot or plasias present characteristic presen - merous metabolic disorders. Miscon - ankle manifestations, the practitioner tations that may be recognized as in - ceptions abound regarding the use of should be familiar with these radio - cidental findings; examples include terms relating to this finding; 3 there - logic presentations so they are not , , osteo - fore, the following definitions are misdiagnosed as other conditions. chondromatosis, and osteogenesis strictly adhered to in this article. The The metabolic diseases, in particular imperfecta. Finally, soft tissue mani - Continued on page 166 www.podiatrym.com JANUARY 2014 | PODIATRY MANAGEMENT n ng io ui at in c CME t du on E C al ic ed M Radiology (from page 165 )

term is used to refer to the non-specific radio - graphic finding of decreased bone density. The terms de - calcification, under-mineralization, and demineralization are not used, because they refer more specifically to the underlying physiology and pathology of bone. 4 Moreover, the term osteoporosis is reserved for the clinical entity. Generalized, diffuse osteopenia is a highly subjective radiographic finding; one must be careful with this “find - ing” because radiographic technique and/or processing can profoundly influence the visual appearance (that is, the darkness or lucency) of bones. For example, a dark film can result from high-kVp technique, high-mAs tech - nique, increased time in developer, or raised developer temperature. Instead, observe specific, more objective features involving the cortices and/or cancellous bone of the second, third, and fourth metatarsals in the dorso - plantar (DP) foot view. Patterns associated with cortical bone thinning in generalized (chronic, long-standing) os - teopenia include endosteal resorption, intracortical tun - Figure 4: Regional osteoporosis. A, Periarticular, spotty (acute) osteopenia of cancellous bone at metatarsophalangeal joints. B, Metaphyseal ill-defined transverse bands of decreased density, all metatarsals (acute osteopenia). C, 166 Severe acute osteopenia, with spotty, permeative decreased density of can - cellous and cortical bone, and subperiosteal resorption. D, Severe osteope - nia secondary to polio. Findings parallel those seen in chronic osteopenia (generalized osteoporosis).

neling, and/or subperiosteal resorption1 (Figure 1). A cancellous bone pattern associated with generalized osteopenia is prominent primary trabeculations, which may stand out in relief because secondary trabeculae are resorbed and subsequent bone is laid down on the re - Figure 1: Chronic osteopenia, cortical bone. A, Normally, the en - maining primary trabeculae (Figure 2). Cortical and can - dosteal and subperiosteal surfaces of the cortex are well defined and cellous is best continuous and the remainder of the cortex is radiopaque and homo - identified using the DP foot view geneous in density. B, In chronic cortical osteopenia, the endosteal and concentrating on the second, surfaces are ill defined, and lucent striations (intracortical tunneling) third, and fourth metatarsals. The may be seen running through the cortex, parallel to the shaft. C, En - medial oblique view should not be dosteal resorption, resulting in cortical thinning. used; striations that mimic intra - cortical tunneling normally are seen at the diametaphyseal region. Caution should be exercised so that these findings are not used to diagnose osteoporosis or other metabolic disease. Chronic os - teopenia is commonly associated with systemic disorders, which are primarily diagnosed by other, more characteristic, radiologic features. In contrast, the primary radio - Figure 3: Generalized os - graphic feature of acute osteopenia teoporosis. This elderly, Figure 2: Chronic osteopenia, cancellous bone. A, Cancellous bone is is spotty (mottled, moth-eaten) postmenopausal patient made of primary and secondary trabeculae. The primary trabeculae— loss of bone density, particularly also known as stress trabeculae—are found along lines of stress. Sec - demonstrates the charac - teristic features of chronic in periarticular regions. Acute os - ondary trabeculae are found perpendicular or oblique to the primary teopenia is associated with causes or stress trabeculae. Secondary trabeculae give spongiosa a fine, ho - osteopenia, including en - of regional osteoporosis (discussed mogeneous appearance. B, With chronic osteopenia, secondary tra - dosteal resorption, intra - beculae are resorbed, leaving the primary trabeculae to stand out in cortical tunneling, and next), such as immobilization or relief. As bone is laid down on the remaining primary trabeculae, they prominent, coarsened pri - disuse. become coarse in appearance. mary trabeculae. Continued on page 167

JANUARY 2014 | PODIATRY MANAGEMENT www.podiatrym.com M C e o di n ca ti CME l nu E in du g ca ti Radiology (from page 166 ) menopause, medications (steroids), endocrine on states (hyperparathyroidism, diabetes mellitus), defi - Osteoporosis ciency states (scurvy, malnutrition), anemia, and alco - Osteoporosis is a metabolic disease that accompanies holism, to name a few. The radiographic features are many other disease processes, including most of the en - more commonly visualized in the axial skeleton. Typical docrine and nutritional disorders discussed later in this arti - radiographic findings in the lower extremity (Figure 3) in - cle. It is characterized by progressive loss of bone mass and clude one or any combination of the following: may result in pathologic fracture. Osteoporosis is not easily Prominent primary trabeculations diagnosed with plain films, because 30% to 50% of bone Thinning of the cortices calcium must be lost before osteopenia is visually apparent. Intracortical striations (tunneling) Quantitative methods are necessary to detect early osteo - porosis; studies include single-energy x-ray absorptiometry Normal radiographic anatomy may be misinterpreted (wrist and heel), radiographic absorptiometry (hand), sin - as osteopenia. For example, the trabeculations in the first- gle-photon absorptiometry (wrist), quantitative computed metatarsal head and neck are normally prominent and tomography (spine), and dual-photon absorptiometry appear coarsened. (spine, hip, body). It has been suggested that the appear - Regional osteoporosis affects one extremity. It is associ - ance of calcaneal trabecular patterns provide an index for ated with disuse (immobilization) and reflex sympathetic assessing osteoporosis; 5 however, controversy exists as to dystrophy syndrome (RSD). Typical radiographic findings whether or not these trabecular patterns correlate with ac - (Figure 4) include one or any combination of the following: tual bone density. 6 Osteoporosis has been classified accord - Spotty (moth-eaten, mottled, patchy) osteopenia in ing to its etiology: generalized, regional, and localized. 1 cancellous bone, especially periarticular regions Generalized osteoporosis affects the entire skeleton Ill-defined transverse bands of decreased density at and is associated with aging (senile osteoporosis), post- subchondral or metaphyseal locations Subperiosteal bone resorption 167 (in severe cases, especially RSD) Long-standing disuse (paralysis is often associated with coarse, prominent primary trabeculations and cortical thinning) Localized osteoporosis affects one bone. Examples of pathology demonstrating localized osteoporo - sis include , arthritis, and . The medial aspect of the fifth-metatarsal head is normal - ly radiolucent and should not be Figure 5: Rickets. A, Knee, lateral view. Characteristic features include an ill-defined, lucent and frayed zone of provisional calcification, with widening of the physis. B, Knee, anteroposterior (AP) view. Follow - mistaken as pathology. ing treatment, the zone of provisional calcification has become more defined, although still irregular and ill-defined medially. Rickets. C, Ankle, lateral view. Same date as A; similar findings demonstrated, with and Rickets additional metaphyseal cupping. D, Ankle, lateral view. Metaphyseal cupping very prominent following Osteomalacia and rickets are treatment; also note defect along surface of talar dome. characterized histologically as disor - ders with excessive amounts of un - Continued on page 168

Figure 8: Acromegaly. Charac - teristic features include enlarge - Figure 6: Hyperparathy - Figure 7: Renal ment of bones (especially Figure 9: Scurvy. A, Ankle. Note the transverse line of in - roidism. Subperiosteal . metatarsal heads and shafts and creased density along the . B, Knee (different pa - bone resorption along Soft tissue calcifi - phalangeal bases) and soft tissue tient). In addition to the sclerotic line across the metaphysis, the medial aspects of the cation throughout thickening (increased soft tissue beaks are visible at the metaphyseal margins, and Wimberg - metatarsal shafts. the leg. density and volume). er’s sign is evident. www.podiatrym.com JANUARY 2014 | PODIATRY MANAGEMENT n ng io ui at in c CME t du on E C al ic ed M Radiology (from page 167 ) ings include general retardation of lar, intracortical, endosteal, subchon - body growth, osteopenia, and bowing dral, and at entheses. calcified osteoid. 7 Etiologies include deformity of long tubular bones. Soft tissue calcification and geo - vitamin D deficiency and hypophos - Characteristic changes occur at the graphic, lucent lesions known as phatemia. When present in the adult growth plate region of tubular bones Brown tumors may also be seen. skeleton, osteomalacia is the name and include widening of the physis, given to this condition; in the grow - decreased density at the zone of pro - ing skeleton of infan - visional calcification, Patients with chronic renal failure cy and childhood, it is irregularity of the phy - demonstrate bony abnormalities called rickets. seal margin of the zone known as renal osteodystrophy. 1 The The radiographic of provisional calcifica - radiographic findings manifested may features of osteomala - tion (which has been parallel those of hyperparathy - cia are non-specific, described as “fraying” roidism, osteoporosis, and - consisting primarily and a “paint-brush ap - lacia (or rickets if in the child). Calci - of osteopenia. Bowing pearance”), and widen - fication of soft tissue and vessels is a deformity of long ing and cupping of the frequent finding (Figure 7). tubular bones may metaphysis. 1 occur. Transversely Acromegaly oriented, incomplete Hyperparathyroidism Excess pituitary somatotrophic radiolucencies, The general term growth hormone results in abnormal known as pseudofrac - hyperparathyroidism growth of bone, cartilage, and fibrous tures or Looser’s refers to increased lev - tissue. 7 In the adult, this is known as zones, may be seen in els of parathyroid hor - acromegaly; gigantism results in the 168 1 Figure 10: Paget’s disease. A, Mor - 1 tubular bones. tise view; B, lateral view. The bone mone. The character - child with open growth plates. Radio - The radiographic is predominantly sclerotic in the dia - istic feature of hyper - graphically (Figure 8), the patient features of rickets physis and metaphysis, with mixed parathyroidism is sub - with acromegaly has an increase in consist of both non- well-defined lucent areas inter - periosteal bone resorp - skin volume; the heel pad thickness is specific and character - mixed. Probably the third stage. tion (Figure 6). Other greater than 25 mm in the male and istic findings (Figure (Accompanying text on following sites of bone resorp - 23 mm in the female (when local 5). Non-specific find - page.) tion include periarticu - causes are excluded). The joint spaces are widened by cartilage thickening. Bones become promi - nent; the metatarsal heads and distal pha - lanx ungual tuberosities are enlarged, metatarsal shafts are thickened, and spurs are found at entheses. Interestingly, however, the proximal phalangeal shafts ap - Figure 11: Hereditary multiple exostoses. A, DP view, left foot. Small exostoses are becoming visible along the medial and pear narrow in girth. lateral aspects of the first-metatarsal distal metadiaphysis and along the lateral aspects of the third- and fourth-toe proxi - mal phalangeal bases. B, Same patient, DP view, right foot. Significant involvement of the second and third metatarsals, Hypovitaminosis C with shortening of the second. Hereditary multiple exostoses. C, Same patient, AP view, ankle. Exostoses are seen along (Scurvy) the medial aspect of the distal fibular and the medial and lateral aspects of the tibial diaphysis. D, Different pa - Scurvy is caused by tient, adult. Involvement of the second through fourth metatarsals and third-toe proximal phalanx. insufficient dietary intake of vitamin C. 8 The char - Figure 12: . A, DP view, foot. Character - acteristic radiographic istic features include narrowed girth of tubular bones and cancel - features (Figure 9) occur lous osteopenia. B-D, Different patient demonstrating severe os - in the developing child. teoporosis and severe deformity of the fibula. Osteogenesis im - In the metaphyseal re - perfecta. A, DP view, foot. Characteristic features include nar - rowed girth of tubular gion they include a trans - bones and cancellous verse line of increased osteopenia. B-D, Dif - density, a transverse line ferent patient demon - of decreased density adja - strating severe osteo - cent to this line of in - porosis and severe de - creased density (the formity of the fibula. Continued on page 169

JANUARY 2014 | PODIATRY MANAGEMENT www.podiatrym.com M C e o di n ca ti CME l nu E in du g ca ti Radiology (from page 168 ) Figure 13: Osteopetrosis. A, DP view, 7-year- tumor , on old; B, Lateral view, same patient at 3 years of that is, multiple cartilage- scurvy line), and a small, age. Classic bone-within-bone appearance. capped exostoses adjacent to beaklike outgrowth of bone the diaphyseal side of the ph - along the margins of the metaph - ysis (Figure 11). This condition ysis. Extensive periostitis may be is autosomal dominant and ap - seen along the entire length of pears in the first two decades of the bone. The appears life as painless bumps near the as an outer shell of increased ends of long bones. Its distribu - density surrounding a central lu - tion is frequently symmetric, cency (Wimberger’s sign). 1 and it can cause bone deformity and shortening. Approximately Paget’s Disease ( Deformans) literature. 9 Four radiographic stages 5 percent of these lesions transform Paget’s disease (Figure 10) is char - have been recognized. The first stage is into . 7 acterized by excessive and abnormal re - described as osteolytic. It starts in the modeling of bone. 1 Its etiology is un - subchondral area, spreading to the Osteogenesis Imperfecta known, and occurs more frequently in metaphysis and eventually the diaph - An inherited skeletal dysplasia people who are 40 years and older. ysis resulting in what has been de - that is the result of abnormal meta - Paget’s disease is typically asymptomat - scribed as a “blade of grass” appear - physeal and periosteal ossification ic in the foot, which may explain the ance. The second stage demonstrates caused by deficient osteoid produc - infrequent reports at this location in the both and . The tion is osteogenesis imperfecta. 10 Ab - normal maturation of collagen oc - Figure 14: curs in both mineralized and non- . The 169 wavy, thickened en - mineralized tissues. Radiographic dosteal cortical sur - features include diffuse osteopenia face simulates wax (occasionally coarse trabeculae and a flowing down a can - honeycomb appearance), diminished dle. This patient also bone girth, and flared metaphyses has osteopoikilosis, (Figure 12). An obvious complication as demonstrated by is fracture. the circular in - creased densities in The Sclerosing Dysplasias periarticular regions. Figure 15: Osteopoikilosis. Multiple islands of Four skeletal dysplasias are the cortical bone density are identified in the less - result of abnormal metaphyseal and er-metatarsal heads. periosteal ossification caused by ei - Figure 16: Osteopathia ther excessive osteoid production or striata. Lateral view, diaphysis appears lucent, whereas the deficient osteolysis. The primary ra - ankle. Mixed linear epiphyseal and metaphyseal regions are diographic feature is increased bone bands of increased and sclerotic. Bone in the third stage is pre - density. They include osteopetrosis, decreased density run dominantly sclerotic. Findings include melorheostosis, osteopoikilosis, and through the metadia - physeal region of the cortical thickening, bone enlargement, osteopathia striata. distal tibia, parallel to and coarsened trabeculae. The fourth Osteopetrosis (Albers-Schönberg the bone’s long axis. phase is malignant degeneration, re - disease) is an inherited, autosomal ported in 1% to 10% of patients. 8 Other dominant (delayed type) condition complications associated with Paget’s presenting radiographically with dif - disease are fracture, osteomyelitis, and fuse bone sclerosis (Figure 13). Its 1 Figure 17: Fi - Figure 18: joint disease. characteristic feature has been de - brous dyspla - Metastatic calcifi - scribed as a “bone within a bone” 11 sia. The geo - cation: secondary Hereditary Multiple appearance. These patients are rela - graphic lesion hyperparathy - Exostoses tively aymptomatic. 1 in the distal roidism. The () Melorheostosis is a rare dysplasia fibular diaph - spectrum of ra - Hereditary multiple ex - that is not believed to be hereditary. 1 ysis demon - diographic abnor - ostoses is a skeletal dyspla - the patient may or may not have as - strates a hazy, mality may be sia resulting from a distur - sociated symptomatology. 9 The radio - ground glass seen in these pa - bance of chondroid pro - graphic presentation is typically limit - appearance tients. This exam - duction resulting in hetero - ed to a single limb and consists of centrally. No - ple demonstrates topic proliferation of epi - tice its in - significant soft tis - along the bone’s periph - 10 tramedullary sue calcification in physeal . ery, extending along its entire length location. the distal leg. The individual lesions ap - in many cases (Figure 14). This pic - pear identical to the bone Continued on page 170 www.podiatrym.com JANUARY 2014 | PODIATRY MANAGEMENT n ng io ui at in c CME t du on E C al ic ed M Radiology (from page 169 ) is small, the distinc - tion may be impossi - ture simulates wax flowing down ble to determine the side of a candle and has a wavy, visually. sclerotic bony contour usually along the bone’s endosteal surface. Calcification Osteopoikilosis is an inherited Conditions that skeletal dysplasia that is not associat - lead to soft tissue cal - ed with symptomatology. Numerous cification have been small, well-defined and homoge - categorized as neous circular foci of increased den - metastatic calcifica - sity are seen radiographically, mim - tion, generalized cal - Figure 20: Dystrophic calcification: trau - icking multiple bone islands (Figure cinosis, and dystroph - Figure 19: Generalized cal - ma. This patient related a recent injury to the heel. Multiple areas of ill-defined 15). The distribution of these lesions ic calcification. 1 cinosis: tumoral calcinosis. soft tissue calcification are identified (ar - is periarticular and symmetric, found Metastatic calcifica - A large periarticular mass demonstrates calcification rows). at the ends of long bones. 1 They may tion (Figure 18) re - adjacent to the proximal in - also be found in tarsal bones. sults from a distur - terphalangeal joint of a toe. Osteopathia striata is most likely bance in calcium or inherited and is typically asymp - phosphorus metabolism. Examples tion, and trauma. Soft tissue calcifi - tomatic. 9 Radiographically, linear, include hyperparathyroidism, hy - cation has been associated with regular bands of increased density poparathyroidism, renal osteodystro - local corticosteroid injection of the extend from the metaphysis to the di - phy, hypervitaminosis D, and sar - heel 16 and intra-articular corticos - aphysis, running parallel to the shaft coidosis. Generalized calcinosis (Fig - teroid injection of the small joints 170 (Figure 16). ure 19) presents as calcium deposi - of the hand. 17 Extensive involve - tion in the Figure 21: Vascular Figure 22: Vascular Fibrous Dysplasia skin and calcification: phle - calcification: Pathologically, normal bone un - subcuta - boliths. A, Phle - Moenckeberg’s scle - dergoing physiologic resorption is re - neous tissue boliths may be soli - rosis. The classic pre - 12 placed with fibrous tissue. It may in the pres - tary or multiple, as sentation is shown in occur in one (monostotic) or many ence of nor - demonstrated in this diabetic patient (polyostotic) bones. In tubular bones mal calcium this example of the (DP view). Tubular, its location is intramedullary and dia - metabolism. distal leg. B, Nu - serpiginous calcifica - physeal, with only occasional epiphy - Examples merous phleboliths tions are easily identi - seal involvement. 1 Radiographically include col - are seen throughout fied in the first inter - the lesion is somewhat radiolucent lagen vascu - the calf in this pa - metatarsal space fol - tient with chronic lowing the course of with a hazy, ground glass (homoge - lar disorders venous insufficiency. arterial vessels. neous) quality, and may appear ex - (scleroder -

Figure 23: Vascular Calcification appears as irregular punctate, calcification: atherosclerosis. In circular, linear, or plaque-like radiodense areas with contrast to Moenckeberg’s 1 no cortical or trabecular structure. sclerosis, the calcifi - cations that follow the course of arte - rial vessels are pansile with endosteal scalloping ma, dermatomyositis), idiopathic tu - patchy and solid. (Figure 17). moral calcinosis, and idiopathic calci - nosis universalis. Soft Tissue Manifestations of Tumoral calcinosis is rare in the Systemic Disorders foot but has been reported adjacent ment of the foot suggests . 18 The primary radiographic soft tis - to a sesamoid 13 and a first- Vascular calcifications are fre - sue findings are calcification and os - metatarsal-head medial eminence, 14 quently encountered in the foot and sification. Calcification appears as ir - at the tip of digits, 15 and posterior to leg. Phleboliths, found in veins, are regular punctate, circular, linear, or the ankle joint. With dystrophic cal - circular or elliptical in shape (Figure plaque-like radiodense areas with no cification (Figure 20), calcium is de - 21); they possess a thin calcific out - cortical or trabecular structure. 1 Ossi - posited in damaged or devitalized line with a relatively lucent center. fication, in contrast, demonstrates a tissue in the absence of a general - Phleboliths may be a solitary finding trabecular pattern and a thin, cortex- ized metabolic derangement. Exam - or multiple. Phleboliths have also like periphery. However, if the lesion ples include neoplasm, inflamma - Continued on page 171

JANUARY 2014 | PODIATRY MANAGEMENT www.podiatrym.com M C e o di n ca ti CME l nu Ed in uc g at io Radiology (from page 170 ) Figure 25: Soft tis - (myositis ossificans, ossify - n sue ossification: ing hematoma), and venous been described associated with he - Achilles tendon. insufficiency. mangioma of the foot. 19 Two types A, Notice the tra - Achilles tendon ossification (Fig - of arterial calcification have been beculations in the ure 25) is frequently associated with described: Moenckeberg’s sclerosis lesion, which dis - pain. 24-26 Interestingly, MRI analysis of and atherosclerosis. Moenckeberg’s tinguish it from several cases failed to demonstrate calcification. B, A sclerosis (Mönckeberg’s arterioscle - inflammatory changes, even with much larger ossifi - 27 rosis, medial calcific sclerosis) is cation; this image acute symptoms. Morris and associ - calcification of the vessel’s tunica also demonstrates ates have presented a classification of media layer. These lesions generally Moenckeberg’s Achilles tendon lesion based on do not obstruct blood flow through sclerosis. anatomic location, including calcifi - the vessel. They are commonly seen cation and ossification. 28 in patients with diabetes. collections in the lower leg are asso - Generalized periostitis is associat - Radiographically, Moenckeberg’s ciated with tissue injury and com - ed with venous stasis (Figure 26), hy - sclerosis has a characteristic appear - partment syndrome. pertrophic osteoarthropathy (primary ance consisting of dual, curvilinear The term calcific tendinitis (Fig - and secondary), thyroid acropachy, tubular calcifications running parallel ure 24) has been used to describe and hypervitaminosis A. 1,11 Radio - to one another (Figure 22). They may tendon calcification re - Figure 26: Generalized pe - sulting from the depo - be serpiginous and follow the riostitis: venous stasis. A, Ir - anatomic course of the vessel. Not sition of calcium hy - regular, wavy periostitis is 20 uncommonly the path of calcification droxyapatite crystals. identified along the lateral is discontinuous. The term Its etiology is closely and medial margins of the atherosclerosis refers to plaque for - associated with trau - distal tibia and fibular diaph - 171 mation along the ma, but injury is not ysis, respectively. B, This tunica intima prerequisite. Pain is patient, with chronic venous layer of the vessel. the most common as - insufficiency (AP view), Progressive calcifi - sociated symptom. demonstrates solid periosti - tis along the distal tibial dia - cation at any par - Holt and Keats illus - physis with diffuse soft tissue trate ex - calcification (phleboliths). amples in - volving the Achilles, per - graphically, varying degrees of pe - oneus, and forefoot flexor riosteal new bone formation is possi - tendons. 20 Similar reports ble, but typically it is thick and undu - include examples involv - lating (irregular). ing the peroneal ten - The term myositis ossificans is Figure 24: Calcific tendonitis. A, Achilles tendon calcification near 21,22 its enthesis. B, Calcification of extensor tendons along the dorsum don, although they are used to describe non-neoplastic het - of the midfoot. not identified specifically erotopic soft tissue calcification. Four as calcific tendinitis. Ra - categories are described in the litera - ticular site can lead to obstruction of diographic evidence of adjacent bone ture, relating to underlying etiology the vessel. Radiographically, one erosion, mimicking malignancy, has (or lack of): notes patchy calcifications in the soft been reported. 23 1) Myositis ossificans progressi - tissues that follow the path of vessels va is a rare genetic dysplasia with (Figure 23). Ossification associated congenital osseous The site of soft tissue calcification Causes of soft tissue ossification abnormalities. 7 may provide a clue to the underlying include neoplasm (sarcoma), trauma 2) Myositis ossificans circum - systemic disorder. 1 Periarticular calci - scripta, caused by lo - fication is associated with hyper - calized trauma, is the parathyroidism, hypervitaminosis D, most common form and collagen vascular disease. Calcifi - (Figure 27A). Several cations of tendons and bursae are as - cases in the foot have sociated with calcium pyrophosphate been described. 29-32 dihydrate (CPPD) and calcium hy - 3) Myositis ossifi - droxyapatite crystal deposition dis - cans associated with ease. Arterial calcification is frequent - neurologic disease ly seen with diabetes mellitus, hyper - (Figure 27B) may be vitaminosis D, and renal osteodystro - Figure 27: Heterotopic soft tissue ossification. A, Myositis ossificans due to a variety of 7 phy. Calcification of cartilage (chon - circumscripta. A lesion identified in the plantar fascia musculature. B, neurologic causes. drocalcinosis) suggests CPPD deposi - Myositis ossificans associated with neuropathic osteoarthropathy, pos - 4) Pseudomalig - tion and hemochromatosis. Sheet-like terior ankle. Continued on page 172 www.podiatrym.com JANUARY 2014 | PODIATRY MANAGEMENT n ng io ui at in uc CME nt d o l E C ca di e 15 Black JR, Sladek GD: Tumoral calci - ficans: heterotopic new-bone formation M Radiology (from page 171 ) nosis in the foot and hand, J Am Podiatr without a history of trauma, J Bone Joint nant myositis ossificans is similar Assoc 73(3):153, Mar 1983. Surg 62A(8):1274, 1980. 16 34 to the circumscripta form but Conti RJ, Shinder M: Soft tissue cal - Yochum TR, Rowe LJ: Essentials of without a history of antecedent cifications induced by local corticosteroid skeletal radiology, vol 1, ed 3, Baltimore, injection, JFS 30(1):34, 1991. 2004, Williams & Wilkins. trauma. 33 17 Dalinka MK, Stewart V, Bomalaski Yochum and Rowe 34 warn that JS, et al: Periarticular calcifications in as - Additional References the early stages of myositis ossifi - sociation with intra-articular corticos - Martinez S: Tumoral calcinosis: 12 cans circumscripta may mimic sar - teroid injections, Radiology 153:615, years later. Semin Musculoskelet Radiol 6: coma. It initially presents as a soft 1984. 331, 2002. tissue swelling that proceeds to an 18 Wu KK: Tumoral calcinosis with ex - Bansal A: The dripping candle wax ill-defined calcific density followed tensive pedal involvement, JFS 29(4):388, sign. Radiology 246: 638, 2008. by ossification. A radiolucent zone 1990. Fotiadou A, Arvaniti M, Kiriakou V, 19 may be seen between the lesion and Miller SJ, Patton GW, Xenos D, et al.: Type II autosomal dominant os - adjacent bone, which helps to distin - Wulf MR: Multiple capillary hemangiomas teopetrosis: radiological features in two of the foot with associated phleboliths, J guish it from sarcomatous soft tissue families containing five members with Am Podiatr Assoc 70(7):364, 1980. asymptomatic and uncomplicated disease. extension. PM 20 Holt PD, Keats TE: Calcific tendini - Skeletal Radiol 38: 1015, 2009. tis: a review of the usual and unusual, Stoker DJ: Osteopetrosis. Semin Mus - References Skeletal Radiol 22:1, 1993. culoskelet Radiol 6: 299, 2002. 1 Resnick D: Bone and joint imaging, 21 Wirtz PD, Long DH, Vito GR: Calci - Williams HJ, Davies AM and Chap - ed 3, Philadelphia, 2004, Saunders. fication within the peroneus brevis ten - man S: Bone within a bone. Clinical Radi - 2 Bullough PG, Vigoria VJ: Or - don, J Am Podiatr Med Assoc 77(6):292, ology 59: 132, 2004. thopaedic pathology, ed 5, 2009, Mosby. 1987. Berry JL, Davies M and Mee AP: Vita - 172 3 Christman RA: Misconceptions re - 22 Lepow GM, Korfin DH: Calcification min D metabolism, rickets, and osteoma - garding use of the term “osteoporosis,” J of an accessory peroneal tendon in an ath - lacia. Semin Musculoskelet Radiol 6: 173, Cur Podiatr Med 35(10):11, 1986. lete, J Am Podiatr Med Assoc 75(6):323, 2002. 4 Genant HK, Vogler JB, Block JE: 1985. Morselli LL, Manetti L, Cosci C, et al.: Radiology of osteoporosis. In Riggs BL, 23 Hayes CW, Rosenthal DI, Plata MJ, Bone and joint alterations in acromegaly. Melton LJ, editors: Osteoporosis: etiolo - Hudson TM: Calcific tendinitis in unusual Journal of Orthopaedics and Traumatolo - gy, diagnosis, and management, sites associated with cortical bone ero - gy 7: 169, 2006. Philadelphia, 1995, Lippincott Williams & sion, AJR 149:967, 1987. Mughal Z: Rickets in childhood. Wilkins. 24 Lotke PA: Ossification of the Semin Musculoskelet Radiol 6: 183, 2002. 5 Jhamaria NL, Lal KB, Udawat M et Achilles tendon, J Bone Joint Surg Pitt MJ, Morgan SL, Lopez-Ben R, et al: The trabecular pattern of the calca - 52A(1):157, 1970. al.: Association of the presence of bone neum as an index of osteoporosis, J Bone 25 Raynor KJ, McDonald RJ, Edelman bars on radiographs and low bone mineral Joint Surg 65B(2):195, 1983. RD, Parkinson DE: Ossification of the density. Skeletal Radiol 40: 905, 2011. 6 Cockshott WP, Occleshaw CJ, Web - Achilles tendon, J Am Podiatr Med Assoc Quek ST and Peh WC: Radiology of ber C et al: Can a calcaneal morphologic 76(12):688, 1986. osteoporosis. Semin Musculoskelet Radiol index determine the degree of osteoporo - 26 Hatori M, Kita A, Hashimoto Y et al: 6: 197, 2002. sis? Skeletal Radiol 12:119, 1984. Ossification of the Achilles tendon: a case Whitehouse RW: Paget’s disease of 7 Greenfield GB: Radiology of bone report, Foot & Ankle 15(1):44, 1994. bone. Semin Musculoskelet Radiol 6: 313, diseases, ed 4, Philadelphia, 1986, Lippin - 27 Yu JS, Witte D, Resnick D, Pogue 2002. cott. W: Ossification of the Achilles tendon: Wilson LC and Hall CM: Albright’s 8 Jaffe HL: Metabolic, degenerative, imaging abnormalities in 12 patients, hereditary osteodystrophy and pseudohy - and inflammatory diseases of bones and Skeletal Radiol 23:127, 1994. poparathyroidism. Semin Musculoskelet joints, Philadelphia, 1972, Lea & Febiger. 28 Morris KL, Giacopelli JA, Granoff D: Radiol 6: 273, 2002. 9 Berquist TH: Imaging of the foot and Classification of radiopaque lesions of the ankle, ed 3, Philadelphia, 2010, Lippincott tendo Achillis, JFS 29(6):533, 1990. Williams & Wilkins. 29 Kaminsky SL, Corcoran D, Chubb Dr. Christman is cur - 10 Aegerter E, Kirkpatrick JA: Orthope - WF, Pulla RJ: Myositis ossificans: pedal rently a tenured pro - dic diseases, ed 4, Philadelphia, 1975, manifestations, JFS 31(2):173, 1992. fessor at Western Uni - Saunders. 30 Fuselier CO, Tlapek TA, Sowell RD: versity of Health Sci - 11 Forrester DM, Kricun ME, Kerr R: Heterotopic ossification (myositis ossifi - ences’ College of Po - Imaging of the foot and ankle, Rockville, cans) in the foot, J Am Podiatr Med Assoc diatric Medicine in Md, 1988, Aspen. 76(9):524, 1986. Pomona, CA. He is 12 Yochum TR, Rowe LJ: Essentials of 31 Herring KM, Levine BD: Myositis the editor and author skeletal radiology, vol 2, ed 3, Baltimore, ossificans of traumatic origin in the foot, of the textbook Foot 2004, Williams & Wilkins. JFS 31(1):30, 1992. and Ankle Radiology; 13 Slomowitz M, Nixon B, Mott RC: 32 Mandracchia V, Mahan KT, Pruzan - its 2nd edition will be published in 2014. His Tumoral calcinosis of the foot: case report sky J, Uricchio JN: Myositis ossificans: a new website, www.FootRad.com, is devoted and literature review, JFS 29(3):278, 1990. report of a case in the foot, J Am Podiatr to all things podiatric imaging; he shares his 14 Caspi I, Friedman B, Horoszovski Assoc 73(1):31, 1983. knowledge and expertise via innovative learn - H: Tumoral calcinosis simulating os - 33 Ogilvie-Harris DJ, Hons CB, For - ing environments to all interested learners teomyelitis, JFS 28(6):547, 1989. nasier VL: Pseudomalignant myositis ossi - worldwide.

JANUARY 2014 | PODIATRY MANAGEMENT www.podiatrym.com M C e o di n ca ti CME EXAMINATION l nu E in du g ca ti SEE ANSWER SHEET ON PAGE 175 . on

1) Osseous resorption in cortical 6) The following is NOT 11) Osteitis Deformans is also bone may appear as: one of the three classes of known as: A) band-like/transverse radi - osteoporosis: A) Paget’s disease. olucent areas in the metaph - A) generalized. B) intracortical tunneling. ysis. B) regional. C) endosteal bone B) subchondral spotty radi - C) localized. resorption. olucent areas. D) field. D) subperiosteal bone re - C) intracortical tunneling. sorption. D) diffuse, homogeneous 7) A radiographic finding “coarsening” of trabeculae. seen with reflex sympathetic 12) The radiographic finding dystrophy is: described, as a “blade of grass” 2) A major cause of diffuse os - A) spotty loss of bone appearance is associated with: teopenia is: density. A) osteogenesis imperfecta. A) osteoporosis. B) intracortical B) osteopoikilosis. B) osteoarthritis. tunneling. C) osteitis deformans C) . C) coarse trabeculations. (Paget’s). D) osteopoikilosis. D) cortical thinning. D) 173 (Ollier’s). 3) Generalized subperiosteal bone 8) A major cause of regional resorption is characteristic of: osteoporosis in the lower 13) Calcific tendinitis results A) pseudohypoparathy - extremity is: from the deposition of: roidism. A) swimming. A) uric acid. B) hyperparathyroidism. B) running. B) calcium hydroxyapatite C) fluorosis. C) walking. crystals. D) hypervitaminosis A. D) immobilization. C) bacteria. D) fungi. 4) Generalized soft tissue thick - 9) A radiographic feature of ening, increased girth of rickets is: 14) The term atherosclerosis metatarsals, decreased girth of A) straight, narrow tubular refers to plaque formation proximal phalanges, and joint bone. along the: space widening are best associ - B) sclerotic epiphysis. A) peristeum. ated with: C) narrowing of the B) tunica intima layer of the A) hyperparathyroidism. metaphysis. vessel. B) pseudohypoparathy - D) irregular outline or C) endothelium. roidism. zone of provisional D) mucosa. C) acromegaly. calcification. D) hypothyroidism. 15) The finding classically 10) Hypovitaminosis C is also associated with hyperparathy - 5) Short metatarsals or pha - known as: roidism is: langes are best associated with: A) rickets. A) periostitis. A) hypothyroidism. B) scurvy. B) intracortical tunnelling. B) pseudohypoparathyroidism. C) lead poisoning. C) endosteal bone resorption. C) hyperparathyroidism. D) hypervitaminosis D. D) subperiosteal bone D) hypervitaminosis A. resorption.

Continued on page 174 www.podiatrym.com JANUARY 2014 | PODIATRY MANAGEMENT n ng io ui at in c CME EXAMINATION t du on E PM’s C al ic ed M CPME Program 16) Numerous, small circular islands of Welcome to the innovative Continuing Education increased bone density that are clustered in Program brought to you by Podiatry Management peri-articular regions is characteristic of: Magazine. Our journal has been approved as a A) osteogenesis imperfecta. sponsor of Continuing Medical Education by the B) osteopetrosis. Council on Podiatric Medical Education. C) melorheostosis. D) osteopoikilosis. Now it’s even easier and more convenient to enroll in PM’s CE program! 17) Wavy, sclerotic osseous contours You can now enroll at any time during the year extending along the length of a tubular bone and submit eligible exams at any time during your simulating wax flowing down the side of a lit enrollment period. candle is characteristic of: PM enrollees are entitled to submit ten exams A) osteopoikilosis. published during their consecutive, twelve–month B) osteopetrosis. enrollment period. Your enrollment period begins C) osteogenesis imperfecta. with the month payment is received. For example, D) melorheostosis. if your payment is received on September 1, 2006, 174 your enrollment is valid through August 31, 2007. 18) Diffuse osteopenia and thin, tubular bones If you’re not enrolled, you may also submit any are characteristic of: exam(s) published in PM magazine within the past A) melorheostosis. twelve months. CME articles and examination B) osteopoikilosis. questions from past issues of Podiatry Manage - C) osteogenesis impefecta. ment can be found on the Internet at D) osteopetrosis. http://www.podiatrym.com/cme. Each lesson is approved for 1.5 hours continuing education con - 19) Arterial calcification is frequently seen in tact hours. Please read the testing, grading and pay - all these conditions EXCEPT: ment instructions to decide which method of par - A) diabetes mellitus. ticipation is best for you. B) onychomycosis. Please call (631) 563-1604 if you have any ques - C) hypervitaminosis D. tions. A personal operator will be happy to assist you. D) renal osteodystrophy. Each of the 10 lessons will count as 1.5 credits; thus a maximum of 15 CME credits may be earned 20) Achilles tendon ossification (Figure 25) is during any 12-month period. You may select any 10 frequently associated with: in a 24-month period. A) pruritis. B) skin discoloration. The Podiatry Management Magazine CME C) pain. program is approved by the Council on Podiatric D) edema. Education in all states where credits in instructional media are accepted. This article is approved for 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed.

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