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Recent Advances in MSK

Bone tumor mimickers: A pictorial essay
Jennifer Ni Mhuircheartaigh1, Yu‑Ching Lin1,2, Jim S Wu1
1
Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States,
2
Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung Chang Gung University, Taoyuan,
Taiwan

Correspondence: Dr. Yu‑Ching Lin, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, 5 Fu‑Shin Street,
Kueishan, Taoyuan ‑ 333, Taiwan. E‑mail: yuching1221@gmail.com

Abstract
Focal lesions in bone are very common and many of these lesions are not bone tumors. These bone tumor mimickers can include numerous
normal anatomic variants and non‑neoplastic processes. Many of these tumor mimickers can be left alone, while others can be due to
a significant disease process. It is important for the radiologist and clinician to be aware of these bone tumor mimickers and understand
the characteristic features which allow discrimination between them and true neoplasms in order to avoid unnecessary additional workup.
Knowing which lesions to leave alone or which ones require workup can prevent misdiagnosis and reduce patient anxiety.

Key words:  Bone tumors; MRI artifacts; osteomyelitis; traumatic lesions; tumor mimickers

Introduction discuss the key imaging and clinical features that can help
distinguish these entities from neoplasms. For the purpose
Focal lesions in bone are very common and are frequently of this pictorial essay, we performed a systematic search
encountered in routine imaging studies. While many lesions of the electronic database PubMed to identify relevant
are true neoplasms, a number of these abnormalities in studies published in the literature from 1991 to 2014 using
bone are not tumors. These lesions can include normal the terms “bone tumor mimickers,” “bone tumor mimics,”
variants, congenital abnormalities, traumatic/iatrogenic and “pseudolesions of bone.” Additional targeted searches
lesions, metabolic and arthritic changes, infection, and were performed for the specific disease conditions.
artifacts related to imaging technique. It is important for
the radiologist and clinician to be aware of this possibility Normal Variants
and to identify the characteristic features which allow
Red marrow
discrimination between bone tumors and bone tumor
Erythropoietic or red marrow can be a common cause for
mimickers. Subjecting the patient to an inappropriate
concern on magnetic resonance imaging (MRI). This can be
workup can lead to misdiagnosis, poor management,
particularly problematic if the area of red marrow is mass‑like
and anxiety for both the patient and physician. In many
in appearance. Red marrow should be hyperintense to
instances, these tumor mimickers can be left alone and
fatty marrow on fat‑suppressed T2‑weighted  (T2W) MRI
no treatment is necessary; however, in other cases, they
sequences and hypointense on T1‑weighted (T1W) MRI
can indicate a significant disease process. Although there
sequences.[1] The key feature is that the low signal intensity
are innumerable processes that can lead to focal lesions in on T1W MRI sequences should be higher than that of
bone, we present here a review of commonly encountered skeletal muscle or the intervertebral discs.[2] In‑phase and
bone lesions [Table 1] that can mimic bone tumors and out‑of‑phase T1W MRI images can be helpful in equivocal
cases as red marrow should have some intermixed fatty
Access this article online marrow and, consequently, should lose signal (become
Quick Response Code: darker) on out‑of‑phase compared to in‑phase MRI.[3] On
Website: the other hand, marrow‑replacing tumors, such as many
www.ijri.org
metastases, should replace all the fatty marrow and should
not lose signal on out‑of‑phase T1W imaging [Figure 1].
DOI:
Thus, when approaching marrow abnormalities on MRI, it is
10.4103/0971-3026.137026
important to have T1W images that include skeletal muscle
for comparison and in‑phase and out‑of‑phase T1W images
Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 225

[7] The increased fat in this region can be readily intermixed fatty marrow (arrow) seen on MRI and helps make the diagnosis [Figure 2]. 2015.8] Table 1: Common lesions mimicking bone tumors Lesion type Lesion Normal variants Red marrow Humeral pseudocyst Ward’s triangle Calcaneal pseudocyst C Congenital and Dorsal defect of the patella Figure 2 (A-C): Humeral pseudocyst. A 67 year old female with left hip Pulsation artifact on MRI pain.[7. the superolateral humeral head and may be misdiagnosed (A) In-phase T1W MRI image demonstrates the lesion (arrow) is as a chondroblastoma.168. He was recalled for in-phase and out-of-phase T1W MRI imaging. A round radiolucency in the greater abnormalities Avulsive cortical irregularity of the posterior femur tuberosity (arrow) on the external rotation shoulder radiograph Supracondylar process of the humerus (A) corresponds to normal fatty marrow (arrow) which is Soleal line hyperintense on the (B) T1W and hypointense on the (C) T2W Trauma and iatrogenic Subperiosteal hematoma fat-saturated coronal MRI images lesions Stress fracture Myositis ossificans Biceps tenodesis Bone marrow biopsy and bone graft donor sites Particle disease Radiation changes Metabolic disease and Brown tumor of hyperparathyroidism arthritic changes Melorheostosis Osteonecrosis Calcific tendinitis Subchondral cyst (geode) Infection Osteomyelitis/Brodie’s abscess Technical artifacts Humeral head-internal rotation view Radial tuberosity-lateral view A B Wrap‑around/aliasing in MRI Figure 3 (A and B): Ward’s triangle. giant cell tumor. As with the humeral pseudocyst. Langerhans slightly hyperintense to skeletal muscle (B) On the out-of-phase cell histiocytosis.[5] Humeral pseudocyst A B A radiolucent area in the humeral head may be seen due to Figure 1 (A and B): Island of red marrow in the sacrum. or even an osteolytic metastasis on T1W MRI image. red marrow should not extend past the physeal scar into the epiphysis and should not distort normal trabecular pattern. June 22.[6] Ward’s triangle A focal area of increased lucency is often seen in the femoral neck at the junction of the compressive and tensile A B trabeculae  [Figure  3].ijri.[Downloaded free from http://www. et al. which is due to the line of fusion between the epiphysis in the greater tuberosity and the shaft of the humerus. IP: 120. there is loss of signal due to the presence of radiographs. Yellow marrow can reconvert to red marrow with physiologic stressors such as anemia. increase in the amount of fat. (A) Anteroposterior (AP) radiograph of the hip demonstrates a External objects triangular radiolucency (arrows) in the femoral neck (B) The coronal CT MRI: Magnetic resonance imaging image shows a paucity of trabecular lines in the femoral neck (arrows) 226 Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 .[6] This radiolucency is seen in which demonstrated an incidental lesion in the sacrum.: Bone tumor mimickers to show the presence or absence of fat.org on Monday.1. On radiographs. this pseudolesion will be seen on an external rotation view of the shoulder and there is usually a sharp line of demarcation inferiorly between the pseudolesion and adjacent marrow.[4] Moreover. A 47 year old female developmental Synovial herniation pit in the proximal femur with left shoulder pain. this radiolucency can become less apparent if the patient is osteoporotic due to attenuation of the adjacent trabeculae.171] Mhuircheartaigh. The remainder of the margin is usually ill‑defined. A 49 year a normal decrease in the trabeculae often associated with an old man with recurrent bloating underwent a MR enterography.

The lesion (arrow) is femoral metaphysis (arrow) (B) Corresponding axial T2W fat-saturated hypointense on the (B) coronal T1W MRI image and hyperintense on MRI image shows marrow edema (arrowhead) at the area of cortical the (C) coronal T2W fat-saturated MRI image irregularity (arrow) Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 227 . June 22. a number of pathologic lesions can patellar ossification centers [Figure 5]. A 38 year old female with left knee pain.[Downloaded free from http://www. appears as an irregular focal A B Figure 4 (A and B): Calcaneal pseudocyst and intraosseous lipoma. known as a cortical desmoid. this lesion may be symptomatic.: Bone tumor mimickers Calcaneal pseudocyst is seen in approximately 1% of the population and can be In a similar pattern to Ward’s triangle.org on Monday. there A B is focal central calcification (arrowhead) due to fat necrosis Figure 5 (A and B): Dorsal defect of the patella. however.[7] Although this is patella and is believed to be due to incomplete fusion of the a normal appearance. a radiolucency in bilateral.[7] cell tumor. (A) AP radiograph of the knee demonstrates a focal radiolucency (arrow) in the superolateral aspect of patella (B) Sagittal PDW MRI image shows a focal area of cortical irregularity with intact overlying hyaline cartilage (arrow) A B C A B Figure 6 (A-C): Synovial herniation pit in the proximal femur. Occasionally.168.[9] Another potential occur in this location and form a radiolucent region on etiology is that it is due to traction at the insertion of vastus radiographs. chondroblastoma. (A) AP radiograph An 18 year old female with left knee pain.[9] The dorsal patellar defect can appear as a 1‑2 cm the anterior aspect of the calcaneus can be outlined by rounded area of lucency in the same location as a bipartite the major trabecular groups [Figure 4].[11] Avulsive cortical irregularity of the posterior femur An avulsive cortical irregularityof the posterior femur.[12] Although these lesions have been considered asymptomatic.ijri. although Dorsal defect of the patella it may represent a normal variant [Figure 6]. giant lateralis. These tumors include simple bone cyst. A 60 year Figure 7 (A and B): Avulsive cortical irregularity of the posterior femur. et al.1. IP: 120. (A) Lateral radiograph of knee shows a small round radiolucency (arrow) and sclerotic rim at the demonstrates an area of cortical irregularity at the medial aspect of the distal superior lateral aspect of the femoral neck. an association with femoracetabular impingement has been described. Intraosseous lipomas often develop central necrosis which Synovial herniation pit in the proximal femur can cause a central dystrophic calcification and tends to A well‑defined round or oval radiolucency in the proximal have well‑defined sclerotic margins. It to 2‑3 cm and may be lobulated.[7] superior femoral neck is known as a synovial herniation pit or Pitt’s pit.171] Mhuircheartaigh.[11] Typically A subarticular abnormality in the superolateral aspect of these lesions are less than 1 cm in size. but can grow up the patella is known as the dorsal defect of the patella. and intraosseous lipoma. old female with suspected hip fracture after a fall. 2015. (A) Lateral ankle radiograph of a 39 year old female with foot pain demonstrates a radiolucency (arrows) in the anterior calcaneus due to decrease in bony trabeculae (B) Lateral ankle radiograph of a 45 year old man with an intraosseous lipoma (arrows) shows a similar radiographic appearance to the calcaneal pseudocyst.[10] It is thought to represent herniation of Congenital and Developmental Abnormalities the synovium into cortical defects created by abrasion of the hip joint capsule against the femoral neck.

[19] On imaging.1. however. a ligament A fracture line may be visible on radiographs. The fracture line epicondyle (the ligament of Struthers). Moreover.[21] Initially. which lifts the periosteum off the bone and can resemble a focal mass such as a parosteal osteosarcoma or osteochondroma [Figure 10]. Figure 9 (A and B): Soleal line. from the joint.[17] The and evidence of healing on follow‑up studies should help soleal line begins 1‑2 cm below the fibular facet and may distinguish stress fractures from other entities. IP: 120. lack of a soft tissue mass. swelling.[Downloaded free from http://www. or stress fracture [Figure 9]. or an Subperiosteal hematoma The periosteum is a highly vascular thick fibrous membrane that is closely adherent to the bone . these lesions for this appearance includes osteomyelitis and surface have a non‑aggressive appearance and are centered in osteosarcoma. when excessive repetitive force is applied to a normal bone.[19] Injury to the periosteum can result in a subperiosteal hematoma. although of the soleus. the patient may be unable to recall the precipitating trauma.[15] It is usually an incidental stress fractures may not be visible on radiographs and are finding and should not be mistaken for an osteochondroma better detected on technetium‑99 m pyrophosphate  bone or surface osteosarcoma. usually in the lateral muscles. With time.[23] This commonly occurs in the upper and lower Trauma and Iatrogenic Lesions extremities. It has been proposed that this lesion may be marrow. A B A B Figure 8 (A and B): Supracondylar process of the humerus. but could be extends from the supracondylar process to the medial better seen on computed tomography (CT).[20] caused by traction due to the medial head of gastrocnemius or adductor magnus. from a tumor. present as a line or a ridge. If they ossify. Osteochondromas point away scintigraphy (bone scan) or MRI [Figure 11]. distal femur in children [Figure 7]. or insufficiency. Occasionally. Stress fractures may be related to fatigue. Patients may be asymptomatic or present with pain.org on Monday. Corresponding ultrasound image (B) demonstrates proximal tibia and fibula. Common sites for stress that arises from the anteromedial aspect of the humerus in fractures include the metatarsals. The tibial calcification extends lateral to Struthers (arrowhead) attached onto it medial along the posterior cortex 228 Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 . Radiographic features of leading to symptoms. (A) AP and (B) lateral radiographs of the shows an osseous process (arrow) arising from anteromedial aspect of proximal tibia demonstrate linear cortical thickening (arrows) along the the distal humerus. about 1‑3% of the population.ijri. Myositis ossificans is heterotopic ossification that Similar bony changes can be seen at the fibular attachment occurs in muscle usually following trauma. forming a tunnel that is usually perpendicular to the cortex. A 67 year old male with suspected A 45 year old male with right elbow pain.[13] Differential diagnosis they may ossify and persist.[22] tibia at the attachment of the soleus and mimics periostitis The presence of a fracture line. especially if the lesion has an aggressive the subperiosteum. whereas the supracondylar process points periosteal reaction and cortical resorption may be seen. (A) AP radiograph of elbow right leg fracture after fall. they can contain fatty appearance. and vertically oriented can entrap the median nerve and even the brachial artery. but can be differentiated from one another on CT Soleal line [Figure 12]. and tibia. they resolve without treatment.[18] This can arise from the tibial head of the soleus. June 22. Supracondylar process of the humerus when normal stress is applied to abnormal bone such as in A supracondylar process in the humerus is a bony spur osteoporosis or Paget’s disease. tarsals. toward the elbow joint [Figure 8]. with cortical thickening extending lateral Myositis ossificans to medial along the posterior upper one‑third of the tibia. et al.[14] This lesion should not be seen in Stress fracture skeletally mature individuals.: Bone tumor mimickers radiolucent lesion along the posteromedial aspect of the Most often. 2015.168.171] Mhuircheartaigh.[16] stress fracture in the tibia can resemble a soleal line or osteoid osteoma. which corresponds to an enthesophyte from an osseous excrescence (arrow) with a hyperintense ligament of the attachment of the soleus. if the periosteal reaction appears The soleal line is a bony “tug lesion” that can form on the aggressive. infection. it can mimic infection or an aggressive tumor. fractures can be difficult to detect.

Similarly. IP: 120.[29] The long head of the biceps tendon is cut and the proximal arthroplasty components can incite a macrophage‑mediated portion of the tendon is reattached to the proximal granulomatous response. beginning peripherally Bone marrow aspiration and biopsy for hematological and progressing centrally. June 22.[28] Particle disease can mimic osteolytic tumors or radiolucent lesion with a sclerotic border [Figure 14].ijri. unlike mechanical loosening. if the area of ossification is adherent to the adjacent bone. bone graft donor sites can on. Myositis ossificans Particle disease can present as areas of radiolucency may be difficult to distinguish from an osteosarcoma even surrounding the hardware components.: Bone tumor mimickers elevated erythrocyte sedimentation rate (ESR). review of the patient’s clinical history is essential an osteochondroma or osteosarcoma may also be difficult to confirm that a procedure has been performed. In following contrast administration.171] Mhuircheartaigh. A B A B C Figure 10 (A-C): Subperiosteal hematoma. can mimic a sarcoma as there may be enhancement demonstrate edema in the early post‑procedure period.[28] However. A 68 year old female with right hip and cortex with central ossification (C) Axial T1W MRI image demonstrates thigh pain. usually following on biopsy specimens. which then stimulates osteoclast humeral diaphysis. Ossification Bone marrow biopsy and bone graft donor sites develops 3‑8 weeks after onset. a rim of a posterior approach. however. and earlier lesion [Figure 15]. The MRI appearance is variable changes in the region.org on Monday. there may be marrow edema or cystic develop [Figure 13].1.[Downloaded free from http://www.[27] If the biopsy has been recently mature lamellar bone and central osteoid matrix can performed. myositis ossificans diagnosis is most often obtained from the iliac bone via forms faint irregular densities. CT can be helpful in demonstrating a plane of soft tissue Particle disease between the mass and the bony cortex. by reviewing patients’ surgical notes.[26] The site of attachment can mimic a activity. This infection.[25] arthroplasty. Initially. Biceps tenodesis the lucent areas seen with particle disease typically do In biceps tenodesis. A 53 year old male with C history of remote thigh trauma. et al. (A) AP radiograph and (B) coronal CT image of left hip show a lesion (arrows) arising from the medial femoral Figure 11 (A-C): Stress fracture. the intra‑articular portion of the not follow the outline of the prosthesis [Figure 16]. 2015. which can be mistaken for a focal depending on the stage of development. (A) AP radiograph of the hip shows cortical thickening (arrow) a chronic subperiosteal hematoma that contains central fatty marrow in the lateral aspect of tibial shaft (B) Coronal and (C) axial CT images (arrowhead) and cortical bone (arrow) demonstrate a linear fracture line (arrows) within the cortical thickening Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 229 .[24] Differentiation from both cases. particle disease can be distinguished classic location along the proximal humerus should raise by the presence of hardware and the fact that abnormal suspicion for this tumor mimicker. which can be confirmed lucencies are seen on both sides of a joint. but with time.168.

ijri. Irradiated bone can be at increased lymphoma and recent left iliac bone biopsy.[30] This will cause decreased signal on T1W sequences and increased signal on T2W sequences [Figure 17]. and decreased cellularity in the bone marrow. A 23 year old female with the radiation field. radiotherapy causes vascular congestion.168. Suture anchor on the humeral head is also noted from rotator cuff surgery Radiation changes Initially. et al.[31] the left iliac bone. 2015. with high signal on T1W and intermediate signal on T2W sequences. osteonecrosis.[Downloaded free from http://www. Axial T2W fat-saturated risk for insufficiency factures.: Bone tumor mimickers A B Figure 12 (A and B): Axial CT images of the tibia show how CT can be helpful in distinguishing the soleal line (A) from a stress fracture (B) indicated by arrows A B C Figure 13 (A-C): Myositis ossificans. the bone marrow will be replaced with fat and occasionally with fibrosis. consistent with changes from a bone marrow biopsy 230 Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 . AP radiograph of right shoulder shows a focal lucent lesion (arrow) in the proximal humeral shaft from a biceps tenodesis.1.org on Monday. edema.171] Mhuircheartaigh. With time. June 22. (A) Lateral radiograph shows an oval nodule (arrow) with dense periphery at the anterior aspect of tibial shaft (B) Sagittal and (C) axial CT images demonstrate a peripheral rim of calcification and central ossification in the lesion (arrows) and a small cleft (black arrowheads) between the mass and the tibial cortex Figure 14: Biceps tenodesis. and MRI image shows a hyperintense lesion with irregular borders (arrow) in radiation‑induced sarcomas. A 58 year old female with history of rotator cuff and labral tear. IP: 120. A 53 year old female with a palpable mass along the right distal tibia. [30] There can be a clear line of demarcation along the borders of Figure 15: Bone marrow biopsy site.

Axial short tau inversion recovery (STIR) MRI image shows a regional distribution of bony edema in the iliac bone and sacrum with demarcated borders (dotted lines). osteolytic lesions known as brown tumors (osteoclastomas) If lesions fail to improve in appearance with treatment.ijri.”[34] Melorheostosis is not a hereditary disorder and is often asymptomatic. and can sometimes have aggressive features. often becoming sclerotic. 2015. Melorheostosis is a benign bone dysplasia characterized The typical appearance of a brown tumor is a well‑defined by sclerotic bone lesions. indicating the radiation field A B Figure 18 : Brown tumor of hyperparathyroidism. and facial bones.: Bone tumor mimickers Metabolic Disease and Arthritic Changes osteolytic lesion. Common sites Brown tumor of hyperparathyroidism include the long bones.171] Mhuircheartaigh. an [Figure 18]. (A) Lateral lower leg radiograph and (B) sagittal CT image of the humerus shows multiple well-defined lytic lesions (arrows) in the right tibia demonstrate dense cortical thickening (arrows) along the posterior humeral shaft fibula that simulates dripping candle wax Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 231 .1. An 82 year old male who had undergone total hip replacement for hip pain. the incidence has Melorheostosis decreased with improved early diagnosis of the disease. A 42-year-old female Figure 19 (A and B): Melorheostosis. which may have septations. pelvis. (A) AP radiograph of the right hip shows multiple lucent lesions (arrows) on both sides of the right hip joint. A 43 year old male with knee with history of parathyroid adenoma.[33] The Longstanding untreated hyperparathyroidism can result in lesions improve with treatment. however. hyperparathyroidism and are seen in 5% of patients with hyperparathyroidism. be expansile. which do not confine to the outline of the prosthesis Figure 17: Radiation changes. et al. They can be seen in either primary or secondary alternative diagnosis should be considered. often described as “dripping candle wax.168. Focused AP radiograph of the pain. [32] However. abutting both the femoral and acetabular components (B) Axial CT image demonstrates multiple cavities (arrows) around the prosthesis. when symptoms do A B Figure 16 (A and B): Particle disease. IP: 120. June 22.[Downloaded free from http://www. A 59 year old female with history of endometrial cancer Salpingohysterectomy and radiation therapy.org on Monday. ribs.

(A) AP radiograph of knee shows large subarticular Figure 20 (A and B): Calcific tendinitis (resorptive phase). there is characteristic flowing relief. There should be evidence of osteoarthritis in the as a central radiolucency with a sclerotic margin. June 22. and intracortical tunneling. sclerotic margin. steroids.[22] is sensitive for detection of bone infarcts. develop. However. During the resorptive phase. limb deformities and contractures tendinitis can be associated with erosions of the adjoining related to muscle and tendon shortening. skin disorders. stiffness. however. They are typically scintigraphy. it can involve any tendon. There is narrowing of the joint space and osteophytosis calcifications at the insertion site of the gluteus maximus tendon to the (arrowheads) consistent with degenerative osteoarthritis (B) Coronal posterior femur (arrow).171] Mhuircheartaigh. but needle lesions can be mistaken for a surface osteosarcoma or barbotage and steroid injection can provide symptomatic osteochondroma. cortical destruction. On MRI. [36] The diaphysis. This aggressive and poor circulation. osteonecrosis may enhancement may be seen if the lesions contain fibrous be occult on radiography. A 47 year lucencies with sclerotic rims (arrows) in the medial and lateral femoral old male with left thigh pain. The process is typically self‑limiting.: Bone tumor mimickers occur.[38] small. they can be large. they include pain. and internal bony collapse and osteoarthritis. mimicking a destructive bone lesion.[37] Low Subchondral cyst (geode) signal intensity is seen on all MRI sequences. Initially. calcific tendinitis can mimic an On radiographs. these lesions appear as single or aggressive process such as infection or neoplasm. these areas appear as non‑specific regions of marrow edema. radiotherapy. the radiographic findings include on non‑fat‑saturated T2W images (double line sign) can areas of aggressive periostitis.[41] commonly in the metaphysis of tubular bones [Figure 22]. it can manifest material. alcoholism.[43] Subacute or chronic osteomyelitis can cause an intraosseous abscess  (Brodie’s abscess). On imaging. and is caused by the deposition of calcium MRI and technetium‑99 m pyrophosphate bone scintigraphy hydroxyapatite crystals in the tendons.[22] endosteal scalloping. Initially. MRI seen on both sides of the joint. It may joint to support this diagnosis and changes are most often mimic enchondromas. but may Osteonecrosis extend down the shaft of a tubular bone mimicking a Ischemic necrosis of the bone and marrow can be neoplasm. The lesions may synovium and joint fluid to enter the subchondral bone also be active on technetium‑99 m pyrophosphate bone causing subchondral cysts (geodes). (A) Axial and (B) coronal CT images show condyles. [35] There is an association with pattern is common along the posterior proximal femoral soft tissue hemangiomas and neurofibromas.[Downloaded free from http://www. the lesion behaves like a cyst hemoglobinopathies. and and is typically isointense to muscle on T1W images and chemotherapy.org on Monday. the Calcific tendinitis is a common cause of joint pain and radiographic findings may not be present for 1‑2 weeks. [22] CT can be helpful in demonstrating the due to a variety of causes including trauma. defects in the overlying cartilage can allow may be surrounding soft tissue edema. commonly involved. Mild cortical erosion is also noted at the gluteal T2W fat-saturated MRI image demonstrates cystic lesions (arrows) insertion site (arrowhead) abutting the narrowed joint space (arrowheads) 232 Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 . about the articular surface. High T1 signal may occur in epiphysis (avascular necrosis). bone. IP: 120.[40] The tendons of (bone scintigraphy)  are more sensitive in the detection of the rotator cuff and around the hip  [Figure  20] are most early osteomyelitis. but lacks central calcifications. but there In osteoarthritis. [39] When osteonecrosis involves the hyperintense on T2W images. There Calcific tendinitis (resorptive phase) may be soft tissue swelling or gas formation.1. et al.ijri. However. the characteristic features of an outer band Osteomyelitis/Brodie’s abscess of low signal associated with an inner band of high signal In acute osteomyelitis.[42] cortical hyperostosis [Figure 19] and can involve multiple contiguous bones in a sclerotomal distribution. 2015. A 61 year old male with A B left knee pain. but over time. it can lead to subchondral lesions that contain proteinaceous material.[42] Calcific A B Figure 21 (A and B): Subchondral cyst. and have a sclerotic margin [Figure 21]. Infection but with time.168.

[47] Nearly any bone can be affected [Figure 23] and it is Ewing’s sarcoma. et al. IP: 120. 2015.org on Monday. (A) Lateral radiograph of elbow shows a lucent pseudolesion (arrows) in the radial tuberosity that disappears on the AP radiograph (B) however.ijri. June 22. (A) Coronal T1W and (B) coronal T2W fat-saturated MRI images show marrow signal abnormality in the sacrum (arrows) (C) Coronal T2W fat-saturated MRI image shows hyperintense abscess (arrowheads) abutting the inferior border of sacral lesion (arrows). excluding most commonly lung. CT can be helpful to delineate a sinus primarily caused by hematogenous spread from other sites. A 29 year old female with left lower leg pain. tuberculous osteomyelitis can mimic an osteoid osteoma or osteosarcoma. and adjacent Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 233 .[44] Lesions differs from pyogenic osteomyelitis as fever and pain without significant sclerosis can mimic Langerhans cell can be absent and the symptoms are more insidious in histiocytosis. MD) C Figure 22 (A-C): Osteomyelitis with Brodie’s abscess.171] Mhuircheartaigh. A 30 year old male with right shoulder pain. marrow enhancement. (A) AP radiograph of ankle demonstrates a faint radiolucency (arrow) in the distal tibial diaphysis (B) Coronal CT image shows that the lesion (arrow) is well demarcated with a non-sclerotic rim (C) Sagittal T2W fat-saturated MRI image shows the hyperintense intraosseous abscess (arrow) with surrounding marrow edema (arrowheads) A B Figure 25 (A and B): Radial tuberosity pseudolesion. These lesions in underdeveloped countries. and onset. (A) Internal rotation view of right shoulder and to identify an organism to guide appropriate antibiotic shows a lucent pseudolesion with a pseudosclerotic border (arrows) therapy.: Bone tumor mimickers A B A B C Figure 23 (A-C): Tuberculous osteomyelitis. tract extending away from the central abscess.[43] (B) This pseudolesion disappears on the external rotation view Tuberculosis infection of bone deserves special mention multilobulated radiolucent lesions with surrounding and has been called “the great mimicker.1.[45] Systemic signs of infection can be helpful.168. and other clinical signs B of infection. Aditya Daftary. chondroblastoma. pain. A 32 year old male with buttock pain. Bone biopsy is often necessary for diagnosis Figure 24 (A and B): Humeral head pseudolesion. T1 marrow signal.[Downloaded free from http://www.[47] Bony destruction. giant cell tumor. several of the lesions listed in the differential A can also present with fever.”[46] Most prevalent sclerosis that fades toward the periphery. (Images courtesy of Dr. A 33 year old female with medial elbow pain. loss of normal other lesions.

the tuberosity becomes clear and the artifactual radiolucency disappears. The pseudolesion should not be buttock pain.[49] This can mimic bone lesions as artifactual image data from the vessels are superimposed onto bone [Figure 27]. wrap‑around or aliasing artifacts can occur.[49] This can lead to image data that are Figure 27: Pulsation artifact.org on Monday.: Bone tumor mimickers abscess or septic arthritis can occur. (A) Frog view of left hip shows a tiny radiolucency (arrow) in External objects proximal femoral shaft. A 31 year old male with right knee pain. Wrap‑around/aliasing in MRI The field of view (FOV) in MRI refers to the anatomic region being imaged. This can be corrected in fibula. which disappears on (B) AP radiograph of left External objects lying on a patient’s skin can mimic bone hip. IP: 120.[Downloaded free from http://www. one can place a saturation band over the vessels or not align the vessel and target lesion in the same A B phase‑encoding direction. it is important to review additional projections. A 60 year old female with left hip pain. it is imaged en face and can appear as an ovoid radiolucent lesion [Figure 25]. due to the hematogenous nature of spread.[47.[47. on lateral projections.48] Technical Artifacts Humeral head ‑ internal rotation view On internal rotation radiographs of the shoulder.168. The radiolucency is caused by a small hole in the side locator tag 234 Indian Journal of Radiology and Imaging / August 2014 / Vol 24 / Issue 3 . et al.48] Finally. The bony protuberance of an osteochondroma can mimic a radiolucent lesion when seen en face as well. outside the FOV being “wrapped around” and artifactually Axial T1W MRI image shows a low signal rounded focus (arrow) included within the image [Figure 26]. A sharp sclerotic border is seen at the humeral neck as the diameter of the Figure 26: Wrap-around/aliasing in MRI.171] Mhuircheartaigh.1. A 47 year old male with lower bone changes abruptly. however.ijri. To avoid this pitfall. Axial STIR MRI image shows a wrap-around/aliasing artifact from right hand (arrowhead) and mimicking a focal lesion of seen on the external rotation or other views and should not right femoral head (arrow) be mistaken for an osteolytic lesion. multifocal lesions can occur in the spine and appendicular skeleton. mimicking malignancy. June 22. Repeating the imaging sequence after swapping the phase‑ and frequency‑encoding directions can help to determine whether or not the lesion is real. 2015. On other projections. To reduce pulsation artifact. Spinal involvement by tuberculosis is not uncommon and can differ from bacterial spinal infection in that the disc spaces are preserved until late in the disease due to the lack of proteolytic destructive enzymes by Mycobacterium tuberculosis.[50] Figure 28 (A and B): External object. a pseudolesion with a sclerotic border and radiolucent center can appear in the humeral head [Figure 24]. Radial tuberosity ‑ lateral view The radial tuberosity is a normal anatomic structure in the proximal radius. If a FOV is chosen which is smaller than the anatomy being imaged. Deciding on an appropriate FOV depends on the size of the structure being imaged and taking into account the trade‑offs between spatial resolution and the signal‑to‑noise ratio. Pulsation artifact on MRI Pulsation of vascular structures can cause “ghosting” on MRI. which is caused by pulsation artifact from popliteal artery by using a large enough FOV in the phase‑encoding (arrowhead) and mimics a tumor direction to include the entire body part or by using phase oversampling techniques during imaging.

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