CHAPTER 14. * Principles of Radiographic Interpretation of the Appendicular Skeleton 263 Fig, 4-16 Later rograph of the dtl humerss of a dog with ax ‘oeorarcoma, There speculated to columnar periovtel reaction om the ‘rani surface of the bone (whe area) Fig. 14-17 Lateral radiogaph of she mid-daphyss ofthe femur ofa dog with iteral Graton of a dha facture uring an iteumedlay pin ‘There u extensive peisteal reaction (white arous) because of the fae: ture aod alto key becnuee of rebperrtea! hemorrhage, but the mang ‘ofthe peitel reactions smooth, and here eno indication of an ageee= ‘ve process inthis bone "The focus of soft tinue caliston lack aro) Is catsed by nerazation of hersators and is aot part ofthe penoseal = Fig. 4-18 A, Latenl radiograph ofthe femur ofa dog with a femonl ‘ostzosarcoma, The penosel feacion asocated ith ths Tumori ery ‘Smooth The lesion s characterized sb aggresive bees of the Ick of ined wassison zane ss the medullary enity between the normal apd the abnormal bone. B is» close-up view of the trsition rexion At Ab ‘the medallar evi is cleaty abnormal with a moth-eaten to permeate pater of ls and at N the medullary avy is lay norma. However, the wanstion port between Ab and N snot since ‘The finding of a smooth periosteal reaction does not mean that the lesion is not aggressive because there may be another sign of aggressiveness and that would place the lesion into the aggressive category. Thus, a lesion with a smooth periosteal reaction but an indistinet transition zone will «ill he consid- ered aggressive (see Fig, 14-18) Transition Zone ‘The character of the junction of the bone lesion with the adjacent normal bone is termed the transition zone. The trans tion zone is typically evaluated in the medullary cavity of the bone, and its character is a clue as to the aggressiveness of the264 SECTION Ill * The Appendicular Skeleton: lesion, The host bone is more able to contain a less aggressive bbone lesion, and in this instance the transition zane between sion and the host bone will be easy to define raiograph (Fig. 14-19; see Fig. 14-13). In aggressive bone lesions, the host bone is usually unable to contain the lesion, and there is no demarcation, or incomplete poorly defined demarcati between the lesion and the host bone (Fig 14-20; see Fig. 14-18). There are some bone lesions where the transition zone Fig. 4-19 Close-up view of an equine calcanese from a doroltes- plancaromedal radiograph There s 2 welldeSned txion of b the caleuneus The edge ofthe lesion is sharply defined (lack rows). {igus sharp demarestion ofthe wenston zone, There ae oo other Sips of geresivener—that m0 evidence of cortex deere and 90 ‘ence of peroneal reaction, Fig. 14-20 Later radiograph of the ‘oftorarcoma, Ar one evalate the proximal extent of the lesion, i I femur of & dog orth an al bone ends and the se the best Imponuble to ietify the point at which the abn sormal bone begs Ths ian ndstunet aston zone be ‘bone i incapable of containing the pear leon Canine, Feline, and Equine concept does not apply. One example would be an infected ft e medullary cavity has been disrupted by the orig- and singling out the effect ofthe infection versus the fracture on the appearance of the medulla ie usually not possible Consequences of an Aggressive Lesion ‘As mentioned earlier, it is not necessary for a lesion to have all three festures of radiographic aggressiveness (cortical ‘destruction, active periosteal reaction, and an indistine’ trans tion zone) to be characterized as aggressive. Any single crite- on 1 sifficient. Moreover, the combined radiographic atures ofthe aggressiveness ofa hone lesion area continuum rom a minor alteration in cortex integrity, periosteal response, or transition zone appearance, to major alterations in all three parameters, Importantly, there i# not a clinically applicable correlation betsveen the number of aggressive features of a lesion or the extent of their aggressiveness and the biologic Dehavior of the lesion. In other words, low radiographic aggressiveness does not mean low biclogic aggressiveness. But, importantly, the absence of radiographic evidence of aggres” siveness usuelly means no biologic aggressiveness. Finally, a already mentioned, the categorization of aggressiveness does not take into account whether the lesion ss primarily productive or primarily destructive, only the integrity of the cortex and the character of the periosteal response and transition zone. Determining whether a bone lesion is aggressive will be hlpfl an directing patient management, It is reasonable to observe nonaggressive bone lesions over time to determine their course, Conversely, if a feature of aggressiveness is found, the main considerations are neoplastic and septic etiologies In this instance, observing the lesion can jeopardize the patient. Identification of an aggressive bone lesion should prompt consideration of thoracic radiography and biologic smpling of the lesion for histopathologic and possibly micr biologic examinations Incidental Factors AAs in the axial skeleton, the most influential incidental factors sscociated vith appendicular radiography in the dog and cat are breed variation and common congenital anomalies. There re fewer incidental factors that influence the appearance of equine appendicular radiographs. The extent of the normal variation and anomalies that may be encountered in the appendicular skeleton of dogs and cats is great, and they cannot be covered adequately here. Comprehensive refer ences are available. The concept of radiographing the cot Tateral limb for comparative purposes when % questionable sing i encountered is valuable (Fig. 14-21) Interpretation Paradigm ‘An ofganized approach to radiographic interpretstion of the appendicslar skeleton is needed, a8 is the case for all body systems. Also similar to other body regions, asessing whether ‘here is an abnormality in the appendicular radiographs should be the last step in the interpretive process. The following questions should always be considered frst ‘Are the radiographic views adequate, and are all of the views that are needed present? If all of the necessary Views are not present, what is likely to be missed, and what additional views would help? Are oblique or other ancillary views needed? * Do the views available correspond to the clinical localization of the lesion? + Is the positioning adequate, or are there positioning problems that will interfere with interpretation? + Is the radiographic technique adequate, or are the images overexposed or underexposed?CHAPTER 14. ¢ Principles of Radiographic Interpretation of the Appendicular Skeleton 265 14-21 Lateral radiograph (A) ofthe right dal anterachiu ofa onth-old Ih setter with «right forcsa lnaness and pain on carpal palpation, Thee i a vegular perseatve appearance tothe dtl ley, specail caudally Ie would be ary to misinterpret ths ar an aggresive leon, bt ths the normal eatback ‘one because of remodeling ofthe dial vlna ar elongates [fone dacs not remember that isi = normal sme appearance lesen the chat + Has a grid been used, and how does this affect the ‘quality of the image? Is there excessive scattered radiation? Are there grid lines? + Ilas sedation or anesthesia been used? If not, how will this affect the utikty of the radiographs? + What is the species and breed of the patient, and how is this going to affect the appearance of the images? + Were the images acquired with a vertically directed scray beam with the cassette in an x-ray table, or on the floor for an snesthetized horse? Was a horizontally directed x-ray beam used with hangholding of the ceasette or a wall-mounted cassette holder? © Was the caseette held by hand? Is there motion artifact? + Are the images film-based or digital? Ifthe images sre film-based, was the radiographic technique a high ‘contrast of a low-contrast technigite? + Has the joint above and below suspected bone lesion been inchided in the imaging study? + Will radiographs of the contralateral limb be helpful? + [dealing with film images, isa hot light needed to assess the soft tissues and the edge of the bones? What congenital anomalies are present that alter the normal appearance of the bone but may not be clinically significant? Only after all ofthese things have been considered should one’s attention he directed at the identification of abnormal ties. As mentioned before, in addition to characterizing a bone lesion according to roentgen signs, considering whether # is aggressive or nonaggressive i necessary and this step must not bbe overlooked for any bone lesion, Unfortunately bone is very limited in its response to injury, ‘There will he either more or lese bone than normal, perios- teal response willbe either present or not, and the soft tissues will be either involved or not. Thus, the distribution within nding n young apy rowing dogs sadiographing the contest carpal region (B) and finding the ce tht this signcant lesion the skeleton and the assessment of the paticnt signalment become extremely important factors in formulating a reason- able differential diagnosis and for formulating a plan (Table 14-3), Regardless, especially for aggressive hone lesions, cyto- logic and/or microbiologic testing of a tissue sample, from hone or other involved tissue, will he needed for definitive diagnosis. ‘many patients, the answer to the clinical question will not be found in the appendicular radiographs. As in the axial skeleton, the staging of disease involving the appendicular skeleton is more accurate when based on CT or MRI than on radiographs This relates to the tomographic nature of CT and IRI and also to the superior soft tissue contrast resolution af RI, Enhanced contrast resolution can be highly informative swith regard to the detection of bone, cartilage, and soft useue Tesions that are not apparent radiographically. Ths is espe- cally applicable in the horse, where MRI has revolutionized the characterization of lesions involving the deep digital flexor tendon within the hoof capsule" Other than the equine digit, areas where musculoskeletal MRI hae proven value are the equine metacarpo(tarso)phalangeal joint, eqsine proximal setacarpal(tarsal) region, canine sfle for assessment of cru se ligament and meniscal lesions, and canine shoulder for assessment of lesions of the biceps and supraspinatus tendons Experienced radiologists may have a random search patter, bbut itis recommended that beginning radiologists develop ant organized approach to searching radiographs for abnormal: tuen’ Each bone shouild be scrutinized sn ss entiety, and the image evaluated with a hot light (analog image) or contrast and brightness adjusted to the extremes (digital image) s0 that small changes in contour, periosteal response, and soft ussue involvement will not be overlooked The following parameters can be evaluated in order: (1) number of bones invelved; (2) the region of bones involved, for example, diaphysis versus metaphysis vers epiphysis, ora combination; (3} whether or long bones or joints alone are involved o if bones and266 SECTION IIL + The Appendicular Skeleton: Canine, Feline, and Equine Cg Summary of Selected Orthopedic Diseases in Small Animals by Skeletal Distribution aand Patient Demographics* MONOSTOTICOR DISEASE PowvosTonic LOCATION IN BONE DEMOGRAPHICS Primary bone cancer Monostotie Metaphyseal Older patients Metestotic bone cancer Polyostotic ‘Metaphyseal or diaphyseol Older patients Mycotic osteomyelitis Polyostotie Metaphyseal Middle-aged patients Bacterial Polyostatic Young patients osteomyelits—hematogenous Bacterial osteomyelts—traumatic Monostotic Anywhere Variable Metabolicbone disease Polyostatie Metaphyseal or epiphyseal Young patients Panosteitis Polyostotic Diophyseal Young patients Hypertrophic osteodystrophy (HOD) Polyostotic Metaphyseal Young patients Osteochondros's Polyostotie Epiphyseal Young patients, Hypertrophic osteopathy (HO, HPO, Polyostatic Epiphyseal nd metophysecl Older petients HPOA) then diaphyseal “These dats ate generalizations and wall not apply to all patients joints are involved; (4) the overall opacity of the skeleton; {5} the relative appearance of the cortical bone versus medul- ‘bone; (6) the presence or absence of a periosteal reaction, and whether its irregular or not; (7) integrity of the cortex; (8) the shape of the bones compared with what would be expected in a comparable normal animal; (9) the character af the tansition zone; and finally, (10) character of adjacent soft tissues. If the same procedure is fellowed for every patient, the order of searching will become second nature, and 1 experience is gained, the search pattern will become random syathout a lose of effectiveness Until then, st may be beneficial for a checklist to be developed to make site that every ana- tomic region of the radiograph is examined Tn addition to having an organized search pattern, it also helpful to serutinze appendicular radiographs with a precon- ception of what disease might be found in a particular region in a particular patient This is particularly rue in young canine and feline patients, where developmental and juvenile bone diseases are often characterized by very specific findings, :xamples are close examination of the (1) proximal margin fof the anconeal process in dogs at risk of having fragmented ‘medial coronoid process, (2) proximal margin of the lateral ridge ofthe talus in doge at risk for tarsal osteochondrosis, and {G) distal radial and lnar physes in young dogs at nsk for hypertrophic osteodystrophy. Te is ential that this focused approach be used only as an ancillary method; it is a way of double checking, so to speak, that all possiblities have been iressed, Assessing radiographs with only preconceived idea of what wall be present wall certainly lead to overlooked lesions and missed diagnoses, REFERENCES 1. Thrall D, Robertson I Atlas of normal radiographic anatomy and anatomic variants im the dog and cat, St. Lovis, 201, Seunders sari C, Benassi §, Ponticelk Fetal: Role of MMP-9 and {ts tisue inhubitor TIMP-1 in human osteosarcoma: fn ings in 42 patients followed for 1-18 years, Acta Orthop Scand 75:487, 2004 3. Uchibori M, Nishida V, Nagasaka T, eta: Increased expres- sion of membrane-type matrix metaloproteinase-1 is cor related with poor peognosis in patients with osteosarcoma, Int J Oncol 28:33, 2008, 4. Avnet §, Longhi A, Salerno M, et activity is assaciated with aggre Jur J Oncol 33-1231, 2008. 5, Wright JA, Nair SP: interaction of staphylococci with bone, Int J Med Microbiol 300-193, 2010. 6. O'Donnell P: Evaluation of focal bone lesions: basic prin- ciples and clinical scenarios, Imaging 15:298, 2003 7. Murphey MD, wan Taovisidha §, Temple HT, et al: Telan- iectatic osteosarcoma radiologic-pathologic comparison, Radiology 228:545, 2003. Blunden A, Murray R, Dyson $: Lesions of the deep digital lexor tendon in the digit: a correlative MRI and post mortem study in control and lame horses, Equine Vet J 41:25, 2009. 9. Halvorsen 1G, Swanson Di Interpreting office radiographs ‘A. guide to systematic evaluation, J Fam Bract 31.6 1990. Increased osteoclast leness of axteosarcoma, ELECTRONIC RESOURCES @volve ‘Additional information related to the content in Chapter 14 can be found on the companion Evolve website at http//evolve.elsevier com/Thrall/vetrad/ © Chapter QuizCHAPTER ® 15 Orthopedic Diseases of Young and Growing Dogs and Cats Rachel E. Pollard Erik R. Wisner weave are as varied as the cases of the disorders themselves, Box 15-] lists come common and uncom- ‘mon disorders of the immature skeleton, It is intended 0 provide some structure to this chapter and should not be considered a definitive classification scheme, Developmental lesions may be solitary and localized but ace often multifocal or generalized. Localized lesions, such as those seen with osteochondrosis, are often bilateral. Lesion location can be predicted on the basis of the characteristic anatomic distribution of many of these diseases. Although adiographic features of the various developmental skeletal diseases vary widely, they generally appear nonaggressive Degenerative jaint disease isa common sequel to develep- rental disorders of the immature skeleton, particularly when the primary lesion involves joints or produces limb deformity (Ofsen the most pronounced radiographic findings are those af the degenerative changes, which can mask the original deve~ ‘opmental lesion. To reach an accurate radiographic disgnoss, Aifferentition of the cause (developmental lesion) from the effect (degenerative lesion) is important whenever possible T: radiographic aspects of developmental skeletal DISORDERS PRIMARILY AFFECTING JOINTS Osteochondrosis and Osteochondritis Dissecans Osteochondrosis is a common cause of lameness in young, repidly growing, large-breed dogs. Clinical signs asvally develop hetween 6 and 9 months of age. Osteachondrosis cccurs from epiphyseal cartilage necrosis resulting in a failure of normal endochondral ossification. If the vascular bed of the adjacent subchondral bone can envelop and bypass the region of cartilage necrosis, endochondral ossification may resume without development of a clinical lesion, Otherwise, ‘progressive chondromalaci leads to development of clefts of fissures extending from the surface of the cartilage to the subchondral bone. When a chondral or osteochondral frag- ment separates from adjacent subchondral bone, the disorder should technically be referred to as osteochondritis dissecans! However, in most patients, determination of whethe lage fragment exists is impossible from survey radiographs; thus osteochondrosis ¢ an acceptable term. In dogs, osteochondosis occurs in specific anatomic loca- tions and often involves weight-bearing articular surfaces. It foccurs most érequently in the caudal aspect of the proximal humeral head (Fig. 15-1) but also occurs in the distomedial aspect of the humeral trochlea (Fig. 15-2, p. 270), the lateral and medial femoral condyles (Fig. 15-3, see page 270), the femoral wochlea, snd the medial and Iateral tochlear ridges of the talus (Fig. 15-4, see page 270)..° Osteochondrosis i fr aguently bilateral, but affected animals may have clinical signs sin one limb only: Large subchondral defects are frequently associated with the presence of separate osteochondral frag- rents, which tend to increase the seventy of clinical signs Radiographic Signs “Typical radiographic findings of osteachondrosis include fat tening or concavity of the affected subchondral bone surface swith surrounding subchondral bone sclerosis. This may result in nonuniformity and apparent widening of the joint space. When mineralized, a carulage fap is sometimes seen ‘within the subchondral defect, and separate osteochondral fragments (Joint mice) may migrate within the joint space. Fragments that have migrated often adhere to the synovial sing and may become vascularized and contine to mineral- snd enlarge over time. Joint effusion, of joint-capsule thickening, may appear as 2 localized region of soft tissue swelling centered on the affected joint. A subchondral bone defect is occasionally seen involving the articular surface opposite the primary lesion, ‘These defects are called lessing lesions. Degenerative joint disease is a common sequel 9 esteachondrasis, Gas is occasionally present within the joint space of dogs with shoulder osteachondrosis, This finding is referred to a8 the vacuum phenomenon and ss caused by the intraarticular accumulation of nitrogen gas from negative pressure induced by traction on the joint during positioning (see Fig 18-10). With osteochondrosis of the laters! ttochlea of the tulis, the superimposed caleanevs may obscure the lesion im the dorsoplantar view. In this instance, a dorsolateral- plantaromedial oblique, or a flexed dorsoplantar, view can the acquired to provide an unobstructed view of the lesion. Simularly, supinated projections of the shoulder may help with visualization of lesions on the caudal aspect of the humeral head, In the stifle, the fossa for the origin of the long. digital extensor muscle is sometimes mistaken for a lateral femoral condyle osteochondrosis lesion because i is superim- posed on the dorsolateral aspect of the condyle on both the Interomedial and the exudocranial views. Cartilage flaps are not visible on survey radiographs unless caleication or ossifiation of the ed, arthrogram can be used to outline the fap if con medium dissects hetween the fragment and the underlying 267