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SUBJECT: MUSCULOSKELETAL DRA. MARIE

NELL RAGUNJAN
RADIOLOGY PART 2

LUMBAR SPINE BASICS AND ANATOMY

IMAGING METHODS
 refers to the lower back, where the spine curves inward
toward the abdomen. 1. lumbar spine MRI (CHOICE OF MODALITY)
 It starts about five or six inches below the shoulder – assess lumbar pain and mass
blades, and connects with the thoracic spine at the top 2. CT-SCAN
and extends downward to the sacral spine. 3. Myelography – inject contrast (can observe
 Landmark: on xray, absence of rib (start of L1), then start narrowing/ballooning of SC, like protrusion)
counting... 4. Plain XRAY (standard views)
 Compose of 5 (L1-L5) - are the biggest unfused vertebrae Lumbar spine - Standard views
in the spinal column, enabling them to support the weight AP and Lateral *pictures taken from net  wala kc s book, so
of the entire torso I included pics for study guide 

 lumbar spine meets the sacrum at the lumbosacral joint

(L5-S1). This joint allows for considerable rotation L1 follows T12
 Intervertebral spaces – in between vertebral bodies T12 –has a rib
 Spinal canal – posterior to vertebral body attached to it
On MRI = as white area, with spinal fluid/CSF

Spinal canal

Each lumbar spine segment is comprised of: (see figure above)

1. Vertebral body
2. Joint facet
3. Pedicle
4. Lamina
5. Spinous processes
*Normal spine is LORDOTIC (curved anteriorly)

"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p

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NELL RAGUNJAN
RADIOLOGY PART 2

Lumbar spine systematic approach - Normal AP Dextro-kyphosis: rightward curve (like on the sample image of
kyphosis)

A FRACTURED LUMBAR VERTEBRAL (L1) BODY:

CT-SCAN MRI

NORMAL VS LORDOTIC

DISC PROTRUSION/HERNIATION/BULGING
REMEMBER:
Normal-just at the margin of the vertebral body
Stenosis- beyond the VB; has herniated and
extended/protrusion/bulging porsteriorly-> neural foramina
will be compromised
A bulge encroaching the spinal canal
Pre-fragment – separation from parent disc
THERE IS NO SPINAL CORD AT LUMBAR SPINE
 A broad-based disc bulge has been said to be a bulging
annulus fibrosus, and
 A focal disc bulge is a herniated nucleus pulposus.

KYPHOSIS

LEVO-KYPHOSIS: leftward curve

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T2-weighted image on MRI: spinal canal is white colored,
due to water content
If black-colored= dehydrated or unhealthy disc
SPINAL STENOSIS
 encroachment of the bony or soft tissue structures in the
spine on one or more of the neural elements, with
resulting symptoms.
 classification of stenosis is on an anatomic basis:
1. central canal
2. neuroforaminal
3. lateral recess
* degenerative disease of the facets with bony hypertrophy
 most common cause of central canal stenosis that
encroaches on the central canal.
 also the most common cause of lateral recess stenosis
Spinal stenosis
*so ang common ng lahat ng stenosis ay: degenerative disease
of the facets
*facet: joint either superior or inferior articulation
SPONDYLOLYSIS & SPONDYLOLISTHEIS
SPONDYLOLYSIS
 Defects in the bony pars interarticularis
 can be a source of low back pain and instability
*simply problem at articulation 
"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p
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DRA. MARIE
NELL RAGUNJAN
*pars articularis – the pillar connecting the vertebral
body to posterior element
*spotty dog sign – if there is a break/fracture in the
pillar or collar of dog, secondary to trauma, tumor
Spotty dog sign
 Pars
articularis
KEY-HOLE DEFORMITY
 Neural foraminal
stenosis
 (forward slippage of one vertebral body on a lower
one) occurs from either slippage of two vertebral
bodies following bilateral spondylolysis or from DJD of
the facets or pars articularis with slippage of the
facets. Resulting to ANGULATION OF SPINAL CORD
 Bilateral spondylolysis can result in a large amount of
slippage, but facet DJD will usually result in only
minimal slippage.
 If spondylolisthesis is severe, the result can be
central canal stenosis, neuroforaminal stenosis, or
both.
*if you have herniated disc, naturally you have spinal
canal stenosis. So pag may nagbu bulge, there is anterior
impingement of spinal canal, so meron kang spinal
stenosis
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NELL RAGUNJAN
RADIOLOGY PART 2

POST-OPERATIVE CHANGES

 causes including inadequate surgery (including missed

free disc fragments), postoperative scarring, failure of
bone grafting for fusion, and recurrent disc
protrusion.
1. Marrow Changes
 patient with degenerative disc disease
 shows fat suppression which represents granulation
tissue
2. Disc Infection
 note the high signal in the disc

SKELETAL TRAUMA
Meyerding grading scale
 widely used to describe the degree of  be sure to detect fracture or injury to the cervical
spondylolisthesis spine
 The more caudal vertebral body is divided into  assess neural/spinal canal stenosis
fourths, and the posterior corner of the more
 determine spinal stability
cephalad vertebral body is marked at the position
where it has slipped forward.  obtain XR: AP and translateral views
Compression Fracture:
Grade 1: If it has slipped forward only into the first  Most frequent type of vertebral injury
quarter or 1/4 of the more caudal vertebral body.  Burst-fractures
Grade 2: slippage into the second quarter or 50%
 Seat-belt fractures
Grade 3: slippage into the third quarter or 75%
Grade 4: slippage into the tip
CERVICAL SPINE

 cervical spine is one of the most commonly filmed

parts of the body in a busy emergency department
and can be one of the most difficult examinations to
interpret.
 radiologist MUST HAVE the clinical history. If the
patient has been involved in an automobile accident
and has neck pain.
 in a trauma victim who has neck pain or neurologic
deficits, obtain a CT scan.
 Usually, a cross-table lateral view of the C-spine is
obtained first to avoid unduly moving the
 patient who might have a cervical fracture. If the
lateral C-spine appears normal, the remainder of the
C-spine series, including flexion and extension views
(if the patient can cooperate), is obtained.
*avoid much movement of neck post-trauma upon obtaining
xray

"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p

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RADIOLOGY PART 2

in their size and appearance, although C7 is consistently

the largest. A fracture of one of the spinous processes, by
itself, is not a serious injury, but it occasionally heralds
other, more serious injuries.

 additional info from the book:

five parallel (more or less) lines evaluation for step-
offs or discontinuity as follows EXAMPLES OF FRACTURES, DISLOCATIONS, AND OTHER
Line 1 - is the prevertebral soft tissue and extends down the ABNORMALITIES
posterior aspect of the airway; it should be several
millimeters from the first three or four vertebral bodies JEFFERSON FRACTURE
and then moves further away at the laryngeal cartilage. It
should be less than one vertebral body width from the  A blow to the top of the head, such as when an object
anterior vertebral bodies from C3 or C4 to C7, and it falls directly on the apex of the skull, can cause the
should be smooth in its contour. lateral masses of C1 to slide apart, splitting the bony
Line 2 - follows the anterior vertebral bodies and should be ring of C1.
smooth and uninterrupted. Anterior osteophytes can  DISPLACEMENT OF C1 laterally causing neck pain
encroach on this line and extend beyond it and should
therefore be ignored in drawing this line. Interruption of
the anterior vertebral body line is a sign of a serious
injury.
Line 3 - is similar to the anterior vertebral body line (line 2)
except that it connects the posterior vertebral bodies.
Like line 2, it should be smooth and uninterrupted, and
any disruption signifies a serious injury.
Line 4 - connects the posterior junction of the lamina with the
spinous processes and is called the spinolaminar line.
The spinal cord lies between lines 3 and 4; therefore, any
offset of either of these lines could mean a bony
structure is impinging the cord. It takes very little force
against the cord to cause severe neurologic deficits, and
any bony structure lying on the cord must be recognized
as soon as possible.
Line 5 - is not really a line so much as a collection of points—
the tips of the spinous processes. They are quite variable
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CLAY-SHOVELER FRACTURE
 a fracture of the C6 or C7 spinous process
 causing the ligaments attached to the spinous
processes (supraspinous ligaments) to undergo a
tremendous force, pulling on the spinous process and
avulsing it.
 This can occur at any of the lower cervical spinous
processes
HANGMAN FRACTURE
 is an unstable, serious fracture of the upper cervical
spine that is caused by hyperextension anD
distraction (such as hitting one’s head on a
dashboard). WHIPLASH INJURY
 This is a fracture of the posterior elements of C2 and,
usually, displacement of the C2 body anterior to C3.
 often escape neurologic impairment
"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p
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DRA. MARIE
NELL RAGUNJAN
FLEXION TEARDROP FRACTURE
 Severe flexion of the cervical spine can cause a
disruption of the Posterior ligaments with anterior
compression of a vertebral body.
 usually associated with spinal cord injury, often from
the posterior portion of the vertebral body being
displaced into the central canal.
UNILATERAL LOCKED FACETS
 Severe flexion associated with some rotation, result
in rupture of the apophyseal joint ligaments and facet
joint dislocation.
 This can result in locking of the facets in an overriding
position that, in effect, causes some stabilization to
protect against further injury.
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NELL RAGUNJAN
RADIOLOGY PART 2

SEATBELT INJURY

 is seen secondary to hyperflexion at the waist (as

occurs in an automobile accident while restrained by
a lap belt).
 This causes distraction of the posterior elements and
ligaments and anterior compression of the vertebral
body.
 It usually involves the T12, Ll, or L2
 Several variations of this injury can occur:
1. a fracture of the posterior body is called a Smith MALLET FINGER OR BASEBALL FINGER
fracture and
2. a fracture through the spinous process is called a  is an avulsion injury at the base of the distal phalanx
Chance fracture. where the extensor digitorum tendon inserts.

GAMEKEEPER’S THUMB
 is an avulsion on the ulnar aspect of the first
metacarpophalangeal joint; this is where the ulnar
collateral ligament of the thumb inserts.

HAND AND WRIST

BENNETT FRACTURE

 A small corner fracture of the base of the thumb, into

the carpometacarpal joint

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NELL RAGUNJAN
RADIOLOGY PART 2

ROLANDO FRACTURE

 is a more serious type of Bennett fracture

 A comminuted fracture of the base of the thumb that
extends into the articular surface

LUNATE/PERILUNATE DISLOCATION

 Occurs when the ligaments between the capitate and

the lunate are disrupted, allowing the capitate to
dislocate from the cup-shaped articulation of the
lunate. AVASCULAR NECROSIS OF NAVICULAR
 This is best seen on lateral views.
 it is the proximal fragment that undergoes necrosis
 diagnosed by noting increased density of the proximal
pole of the navicular

NAVICULAR FRACTURE
ARMS
 MC fracture of the carpals
 is a potentially serious injury because of the high rate
 Colle’s Fracture
of avascular necrosis When avascular
 Smith Fracture
 usually requires surgical intervention with a metallic
 Monteggia’s Fracture
screw and bone grafting to obtain healing.
 Galeazzi’s Fracture
 Shoulder dislocation

"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p

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RADIOLOGY PART 2

COLLE’S FRACTURE deformity of the forearm and is often treated by breaking

the bones with the patient under anesthesia and resetting
 Fracture of distal radius with dorsal angulation of the distal them. Left untreated, a plastic bowing deformity can result
in reduced supination and pronation.
fragment; most common fx in the wrist

MONTEGGIA’S FRACTURE

 fx of the proximal ulna, associated with dislocation of

the proximal radius at the elbow joint

 Distal radius nafracture , with dorsal angulation, may lateral

view nag dorsally plate ang distal fragment
 One of the most common fractures of the forearm is a
fracture of the distal radius and ulna after a fall on an
outstretched arm.  How could you say this ulna and this is radius?
 This results in a dorsal angulation of the distal forearm and Olecranon process in the elbow joint – ulna
wrist and is called a Colles fracture
 In the forearm, a fracture of one bone should be
accompanied by a fracture of the other. If the second
SMITH FRACTURE (REVERSE COLLE’S) fracture is not present, a dislocation of the non fractured
bone usually occurs
 Fracture of distal radius with palmar/ventral  Most common example of this is a fracture of the ulna with
displacement a dislocation of the proximal radius
 The dislocated radial head can be missed clinically and
develop into avascular necrosis with subsequent elbow
dysfunction.
 Whenever the forearm is fractured, the elbow must be
examined to exclude a dislocation.

GALEAZZI’S FRACTURE

 fx radial shaft with dislocation of inferior radioulnar

joint proximally at the area of the wrist
o cause by direct blow or fall on
outstretched hand with pronation
of forearm

 When the fracture angulates volarly, it is called a

Smith fracture
 Sometimes the radius and ulna suffer a traumatic insult,
and the force on the bones causes bending instead of a
frank fracture. This has been termed a plastic bowing
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RADIOLOGY PART 2

 Anterior dislocation occurs when the arm is forcibly

externally rotated and abducted.
 This is commonly seen when football players “arm tackle,”
when kayakers “brace” with the paddle above their heads
and allow their arms to get too far posterior, when skiers
GLENOHUMERAL JOINT DISLOCATION plant their uphill pole and get it stuck, and from other
similar athletic positions.
 Radiographically, the diagnosis is easily made on an AP
 Anterior dislocation – most common (99%) shoulder film: the humeral head is seen to lie inferiorly and
o subcoracoid medial to the glenoid
o subglenoid
 Posterior dislocation can also be seen but rarely

 Posterior dislocation can be a difficult diagnosis to make,

both clinically and radiographically.
 An AP view may look completely normal, or nearly so. On
the AP view of a normal shoulder, the humeral head should
slightly overlap the glenoid forming what has been called a
“crescent sign.”
 In a patient with a posterior dislocation, this crescent of
bony overlap is usually absent and a small space is seen
between the glenoid and the humeral head
 The best way to unequivocally diagnose a dislocated
shoulder is to obtain a transscapular view.
 The transscapular view is obtained by angling the x-ray
beam across the shoulder in the same plane as the blade of
the scapula. This gives an en face view of the glenoid, and
the humeral head can easily be related to it as either
normal, anterior, or posterior.

"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p

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RADIOLOGY PART 2

NORMAL ANATOMY OF THE SHOULDER JOINT
 humeral head often impacts on the inferior lip of the
glenoid causing an indentation on theposterosuperior
portion of the humeral head;
 greater likelihood of recurrent dislocation, and some
surgeons use it as an indicator to intervene surgically to
prevent a recurrence

 Bankart deformity

 The humerus should be in the glenoid fossa. Once it

deviates from there, it is anteriorly located, it is
anterior / inferior dislocation of the shoulder joint

ANTERIOR DISLOCATION

 Hill Sach’s deformity

 deformity seen in the glenoid labrum on the inferior aspect

because of the dislocation
 Post reduction, there is a defect or deformity on the glenoid
labrum
 bony irregularity or fragment off the inferior glenoid, which
occurs from the same mechanism as the Hill–Sachs
deformity

 inferior displacement of the humerus in relation to

the glenohumeral joint but the deformity seen like an
invagination of the area of the humeral head

"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p

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RADIOLOGY PART 2

someone visits on Xray, therefore you have to subject your

patient into nuclear imaging.
 So, dun mo makikita yung HONDA SIGN, letter H sa sacrum.
PELVIS That is stress fracture on bone scan.

 Said to occur in half the cases that have pelvic fractures.

They can be difficult to see on even the best of films
FRACTURE OF THE PELVIS because the sacrum is often hidden by bowel gas. In looking
for sacral fractures, one should examine the arcuate lines of
the sacrum bilaterally to see whether they are intact.
 Fractures often interrupt these lines and, because of the
side-to-side asymmetry, can therefore be easily identified

SACRAL STRESS FRACTURES

 Fracture of the pelvic bone, you have your iliac bone,

ischium and the pubic area. You have the femoral head in
the acetabulum both side. There should be symmetrical
obturator foramen,superior pubic ramus, inferior pubic
ramus right and left side

POLYFRACTURES

 maybe simple or complex, maybe correlated with sacroiliac

joint dislocation. Very complex because of fracture in the
iliac bone, fracture of superior pubic ramus, dislocation of
symphysis pubis, that will be on Xray ha. Pag na CT scan,
there would be more findings like urinary bladder
pathology, iliac bone, dense spaces of symphysis pubis
 CT scanning should be considered in almost all acetabular
fractures because of the possibility of free fragments and
subtle fractures that plain films do not show
 in patients who are osteoporotic or who have undergone
SACRAL FRACTURES radiation therapy
 we may see them on Xray we may also need them  can present as patchy or linear sclerosis on the sacral ala
sometimes. that may or may not show cortical disruption on plain films
 CT scan – fracture of the sacrum, with angulation of the  These should be differentiated from metastatic disease
fragments, sequel of insufficiency fracture because more on because of their characteristic location, appearance, and
the heavy side there is stress fracture in the sacrum and if history of prior radiation and by seeing a cortical break.
"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p
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RADIOLOGY PART 2

 CT will usually, but not always, demonstrate cortical

disruption
 These fractures have a characteristic appearance on
radionuclide bone scans, which is termed the Honda sign
because of its appearance to the logo of the car. The Honda
sign is seen only with bilateral stress fractures; unilateral
fractures will have increased radionuclide uptake
throughout one sacral ala.
 MR will demonstrate an area of diffuse low signal on T1WIs
corresponding to the area of involvement
 Sacral stress fractures have also been termed insufficiency
fractures, indicating that the underlying bone is abnormal,
similar to a pathologic fracture.
HIP FRACTURE
 Hip fractures in the elderly population can be very
LEGS  Difficult to detect, and a high index of suspicion should be
maintained.
 A negative plain film in an elderly patient with hip pain after
STRESS FRACTURES trauma (even relatively mild trauma) does not exclude a
 The most serious stress fracture, and fortunately, one of the femoral neck fracture.
rarest, is the femoral neck stress fracture  MR has been shown to be very useful in demonstrating
 Rarely, these progress to complete fractures that, with femoral neck fractures that are occult
continued weight bearing, can displace; these are very
serious lesions occur in the distal diaphysis of the femur and TIBIAL PLATEAU FRACTURE
in the proximal, middle, and distal thirds of the tibia.
 All of these stress fractures need to be treated with the
utmost caution because complete fractures are not
uncommon with continued stress.
 Sclerosis in a weight-bearing bone that has a horizontal or
oblique linear pattern should be considered a stress
fracture until proved otherwise.
 A history of repetitive stress is not always obtained, and
therefore, the diagnosis should not depend solely on the
history.
 A stress fracture occasionally will appear somewhat
aggressive, with aggressive periostitis and no definite
linearity to the sclerosis If this is mistaken for a tumor and
undergoes biopsy, it
can be confused with a malignancy, with subsequent radical
therapy.  Cross-table lateral plain film should be obtained in cases of
These should, therefore, not undergo biopsy under any knee trauma to look for a fat-fluid level; this indicates a
circumstance. If the clinical presentation is unusual for a fracture that allows fatty marrow to leak into the knee joint.
stress fracture and  In the appropriate clinical setting, MRI or CT may be
necessary to make the diagnosis.
 The plain films are not diagnostic, take additional films 1 or
2 weeks later.
 CT and MR sometimes will better delineate the lesion.
Stress fractures can be difficult to diagnose radiologically
early on but should be straightforward after several weeks.

"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p

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RADIOLOGY PART 2

LISFRANC FRACTURE  intertrochanteric - in between the greater and lesser

 Named after a surgeon in Napoleon’s army who would do trochanter
forefoot amputations in patients with gangrenous toes as a  subtrochanteric – below the trochanters
result of frostbite.
 A fracture-dislocation of the tarsometatarsals.
 If the dislocation is slight, it can be easily overlooked.
 A key to normal alignment is that the medial border of the
second metatarsal should always line up with the medial
border of the second cuneiform.
 If it does not, a Lisfranc fracture-dislocation should be
suspected.
 This fracture is seen most commonly in patients who catch
the forefoot in something such as a hole in the ground or a
horseback rider falling and hanging by the forefoot in the
stirrups.
 It is commonly seen as a neurotrophic or Charcot joint in
diabetics.

FRACTURE OF THE CALCANEUS

 It matters for the orthopaedic surgeon we will be advising
the patient whether they put a different ways or unless a
rod there

 Can be difficult to appreciate on routine radiographs.
 Böhler angle is a normal anatomic landmark that should be
looked for in every foot film when trauma has occurred
 If this angle is narrower than 20°, it indicates a compression
of the calcaneus, as seen in jumping injuries
FRACTURES OF THE FEMUR
 perisymmetrical dapat yan, kung ano makikita mo sa right,
makikita mo din sa left. Tingnan ang left and right hindi sila
pantay.
 There is an angulation of the femoral head in relation to
shaft of the femur. That is basicervical fracture. The greater
and lesser trochanter but the fracture is not there, superior
to that, which is basicervical area.

Different types:

 subcapital – below the humeral head

 transcervical – neck part
 basicervical – below the neck part

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With prosthesis
KNEE
 Comprises of femur, tibia, fibula, patella, superimposing the
patellar fossa
 Leg – tibia, medially located the right tibia, left tibia, fibula
on lateral aspect
 You see the tarsal bones, metatarsals and proximal, mid and
distal.
SPECIAL TYPES OF FRACTURES
 STRESS FRACTURES - will occur in normal bone or abnormal
bones subjected to repeated cyclic loading
 FATIGUE FRACTURE – if there is application of abnormal
stress bone with normal elastic resistance (constantly
marching, training as military recruits)
 INSUFFICIENCY FRACTURE – application of normal stress
kahit gaano kagaan yung load but then if the bone is
pathologic, or deficient in elastic resistance then
 LISFRANC FRACTURE DISLOCATION – dorsal dislocation of
the tarsometatarsal joint
"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p
Page 15 of 20
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DRA. MARIE
NELL RAGUNJAN
 most common dislocation of the foot
 A serious fracture in the foot that can be missed
radiographically when little or no displacement occurs is the
Lisfranc fracture.
 It is named after a surgeon in Napoleon’s army who would
do forefoot amputations in patients with gangrenous toes
as a result of frostbite.
 The Lisfranc fracture is a fracture-dislocation of the
tarsometatarsals. If the dislocation is slight, it can be easily
overlooked. A key to normal alignment is that the medial
border of the second metatarsal should always line up with
the medial border of the second cuneiform.
 If it does not, a Lisfranc fracture-dislocation should be
suspected.
 This fracture is seen most commonly in patients who catch
the forefoot in something such as a hole in the ground or a
horseback rider falling and hanging by the forefoot in the
stirrups. It is commonly seen as a neurotrophic or Charcot
joint in diabetics.
SKELETAL “DO NOT TOUCH” LESIONS
 Post traumatic lesions
 Normal variants
 Obviously benign lesions
 Be careful on reporting them because they are not
suppose to be biopsy or not suppose to be touch.
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RADIOLOGY PART 2

POST TRAUMATIC LESIONS AVULSION INJURY

 Myositis ossificans
 Avulsion injuries
 Cortical desmoid
 Trauma
 Discogenic vertebral sclerosis
 Fractures
 Pseudoislocation of the humerus

MYOSITIS OSSIFICANS

 If you have avulsion injury in the iliac bone, you don’t do

anything on it. Might give patient some analgesics
 These injuries can have an aggressive radiographic
appearance, but because of their characteristic location at
ligament and tendon insertion sites (e.g., anterior-inferior
iliac spine or ischial tuberosity), they should be recognized
as benign .
 As with myositis ossificans, delayed films of several weeks
will usually allow the problem case to become more
radiographically clear.
 Circumferential classification with lucent center. By clinical  Biopsy can lead to the mistaken diagnosis of a sarcoma and
alone, you will see calcification (black area) that will be a should therefore be avoided
benign tumor, no touchy lesion because it does not
CORTICAL DESMOIDS
necessitate biopsy
 an example of a lesion that should not undergo biopsy
because its aggressive histologic appearance can often
mimic a sarcoma
 The typical radiologic appearance of myositis ossificans is
circumferentialcalcification with a lucent center
 best appreciated on a computed tomographic scan.
 Occasionally, the peripheral calcification of myositis
ossificans can be too faint to appreciate; in these cases, a
computed tomographic scan should help, or delayed films 1
or 2 weeks later are recommended.

 Thickening on the posterior aspect of femur. Result to

avulsion of adductor magnus muscle if there is unusual
thickening that is cortical desmoids
 is a process on the medial supracondylar ridge of the distal
femur that is considered by many to be the result of an
avulsion of the adductor magnus muscle.
 It occasionally simulates an aggressive lesion
radiographically, and, histologically, it can look malignant.

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SUBJECT: MUSCULOSKELETAL
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 In many instances, biopsy has led to amputation for this
benign, radiographically characteristic lesion.
 Cortical desmoids occur only on the posteromedial condyle
of the femur.
 They might or might not be associated with pain and can
have increased radionuclide uptake on a bone scan.
 They might or might not exhibit periosteal new bone and
usually occur in young people.
 Biopsy should be avoided in all cases.
 Painful cortical desmoids should become asymptomatic
with rest.
 They are often seen as an incidental finding on MRI of the
knee and have a characteristic appearance
TRAUMA
 Can lead to large, cystic geodes or subchondral cysts near
joints and can be mistaken for other lesions, resulting in a
biopsy being ordered. Although the biopsy specimen is not
likely to mimica malignant process, it is nevertheless
avoidable.
 Because geodes from degenerative disease almost always
are associated with additional findings such as joint space
narrowing, sclerosis, and osteophytes, a diagnosis should be
made radiographically
DISCOGENIC VERTEBRAL STENOSIS
 Sclerotic and focal adjacent to the endplate, narrowed disc
space and osteophytes. Often confused for metastatic
disease (gosh, nag RAP siya dito)
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DRA. MARIE
NELL RAGUNJAN
 May create worry to the attending physician but if there is
sclerosis of the adjoining endplates, narrowing that must be
discogenic vertebral sclerosis
 Most often is sclerotic and focal. It is always adjacent to the
endplate, and the associated disc space should be narrow.
 Osteophytosis is invariably present. It really is a variant of a
Schmorl node and should not be confused with a
metastatic focus.
 On occasion, it can be lytic or even mixed lytic-sclerotic.
 The typical clinical setting is a middle-aged woman with
chronic low back pain.
 Old films often confirm the benign nature of this process.
 In the setting of disc space narrowing and osteophytosis,
focal sclerosis adjacent to an endplate should not undergo
biopsy
FRACTURES
 Will be the cause of extensive osteosclerosis and periostitis,
which can mimic a primary bone tumor.
 Lack of immobilization can result in exuberant callus, which
can be misinterpreted as aggressive periostitis or even new
tumor bone.
 Results of a biopsy in such a case might resemble a
malignant lesion; therefore, any case associated with
trauma should be carefully reviewed for a fracture.
PSEUDODISLOCATION OF THE HUMERUS
 results from a fracture with hemarthrosis, which causes
distension of the joint and migration of the humeral head
inferiorly.
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RADIOLOGY PART 2

 An axial or transscapular view shows it is not anteriorly or PSEUDOCYST OF THE HUMERUS

posteriorly dislocated (the usual forms of shoulder
dislocation) but merely inferiorly subluxated.
 On an anteroposterior view, it can mimic a posterior  Another entity often confused for a lytic pathologic lesion is
dislocation in that the normal superimposition of the a pseudocyst of the humerus
humeral head and the glenoid is missing.  This is merely an anatomic variant caused by the increased
 Often, attempts are made to “relocate” the humeral ancellous bone in the region of the greater tuberosity of the
head, which, of course, are both fruitless (because it is not humerus that gives this region a more lucent appearance on
dislocated) and painful. radiographs
 A fracture is invariably present, and if not seen on the  With hyperemia and disuse caused by rotator cuff
initial films, it should be sought after with additional views. problems or any other shoulder disorder, this area of
lucency may appear strikingly more lucent and mimic a lytic
 The transscapular or the axial view is the key to making the
lesion.
diagnosis of a pseudodislocation.
 If necessary, the joint can be aspirated to confirm the
OS ODOINTODEUM
presence of a bloody effusion and to show the normal
position of the humeral head when fluid has been removed
from the joint

NORMAL VARIANTS

DORSAL DEFECT OF THE PATELLA

 There is a defect in patella, dorsal defect in patella there

should be thicken of the fracture. To another view, AP view
then correlate. If there is no trauma and incidentally, no
defect there, therefore must be due to dorsal defect of
patella. This may be mistaken as metastatic disease but if
you follow up the patient and does not show any increase in
size, changes in the character then it must be a benign
finding.
 A normal variant that has been described in the patella that
can be mistaken for a pathologic process is a lytic defect in
the upper, outer quadrant called a dorsal defect of the
patella  The dens maybe separated but in normal variant, what you
 It can mimic a focus of infection or osteochondritis called as os odointodeum, yung unfused dens, mimics
dissecans. fractured dens. Kapag nakakiyta kayo ng ganyan tapos wala
 It is a normal developmental anomaly, however, and naman trauma, likely anatomic variants yan.
because of its characteristic location, it should not undergo  A normal variant of the cervical spine that may, in fact, be
biopsy. posttraumatic.
 On MR, it will have an appearance similar to many other  It is an unfused dens that may move anterior to the C2 body
bony lesions, that is, low signal on T1-weighted images and with flexion and can mimic a fractured dens. Many of these
high signal on T2-weighted images require surgical fixation; some surgeons fuse every case,
believing that they are all unstable.
 Radiologists should recognize that this process is not acute
and, thus, save the patient halo fixation and possible
immediate surgical intervention.

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RADIOLOGY PART 2

 Most of these cases are seen after trauma, and if no

neurologic deficits are present, these patients can be seen BONE ISLANDS
electively and spared the morbidity associated with
treatment of the acutely fractured cervical spine.
 The radiologic signs for recognizing an os odontoideum are
the smooth, often well-corticated, inferior border of the
dens and the hypertrophied, densely corticated anterior
arch of C1

OBVIOUSLY BENIGN LESIONS

 Nonossifying fibroma
 Bone islands
 Early bone infarction

NON OSSIFYING FIBROMA

 usually oblong, usually assumes the coarse or long axis of

the bone, elongated, following the trabecula of the bone
and doesn’t show any changes
 Not a radiographic dilemma when they are 1 cm or less in
size.
 Occasionally, however, they grow to golf ball size or larger
and mimic sclerotic metastases (Fig.
 They are always asymptomatic.
 Radiographically, two signs can be found to help distinguish
giant bone islands from metastases:
 First, bone islands usually are oblong, with their long axis in
the axis of stress on the bone, for example, in a long bone
they align themselves along the axis of the diaphysis.
 Second, the margins of a bone island, if examined closely,
 usually reserved for defects larger than 2 cm. will show bony trabeculae extending from the lesion into
 They are, classically, lytic lesions located in the cortex of the the normal bone in a spiculated fashion
metaphysis of a long bone and have a well-defined, often
sclerotic, scalloped border with slight cortical expansion UNICAMERAL BONE CYST
 They are almost exclusively found in patients younger than
the age of 30 years; hence, the natural history of the lesion
is involution.
 As they involute, they fill in with newbone, giving it a
sclerotic appearance; thus, they can have some increased
radionuclide activity on bone scans.
 They are most often mistaken for an area of infection,
eosinophilic granuloma, fibrous dysplasia, or aneurysmal
bone cyst.
 They are asymptomatic and have never been reported to
be associated with malignant degeneration.
 On occasion, a pathologic fracture can occur through these
lesions, but most surgeons do not advocate prophylactic
curettage to prevent fracture, as with unicameral bone
cysts.
 Nonossifying fibromas can be quite large but invariably
have a benign appearance and biopsy should be avoided.
"YOU ARE GROOT! Repeat to self. YOU ARE GROOT!.":p
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RADIOLOGY PART 2

 are often prophylactically curettaged and packed so as to

prevent fracture with subsequent deformity.
 When these cysts occur in the calcaneus, however, they
should be left alone.
 They always occur in the anterior-inferior portion of the
calcaneus, an area that does not receive undue stress.
 In fact, a pseudotumor of the calcaneus is seen in the
identical position because of the absence of stress and the
resulting atrophy of bony trabeculae
 These lesions are asymptomatic, only rarely fracture, and
should not suffer the same fate as their counterparts in long
bones, that is, surgical removal.

BONE INFRACTION

 Early in the course of its development, a bone infarct can

have a patchy or a mixed lytic-sclerotic pattern or even
resemble a permeative process.
 In a patient with bone pain and a permeative bone lesion,
many aggressive disorders head the differential list and a
biopsy soon ensues.
 If this process can be noted to be multiple and in the
diametaphyseal region of a long bone, especially if the
patient has an underlying disorder such as sickle cell anemia
or systemic lupus erythematosus, areas of early bone
infarction should be considered.
 In some cases, the characteristic MR appearance of an
infarct may save a patient from biopsy when the plain films
are equivocal

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