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PODIATRIC RADIOLOGY Ward’s triangle – area of low trabecular density in the

anterior inferior portion of the calcaneus.

INTERPRETATION OF PEDAL RADIOGRAPHS Epiphyseal plates can look similar to fractures, if the X-ray
X-ray interpretation is a written notation of pathological passes through the plane of the plate. Closed epiphyseal plates
findings made in objective terminology. Correlation of also leave epiphyseal scars which may look like stress fxs.
radiographic findings along with clinical and lab findings These occur in predictable anatomical areas. Epiphyseal
allows a physician to arrive at differential diagnoses. X-ray plates tend to close from medial to lateral in teenagers.
interpretation follows the 5-step approach: Talar beaking is a finding on lateral of the distal neck of the
1. Quality of Film talus that occurs secondary to capsular pressure.
Trabeculae in some circumstances may be accentuated, and
• Too light or too dark (background/film density)
look possibly like a fx.
• Proper projection
The calcaneal apophysis is located at the posterior aspect of
• Proper positioning the calcaneus, and has irregular margins. It is often mistaken
• Adequate contrast for a fracture. It also may be normally bifid.
2. Soft Tissue Assessment Compact bony islands are normal and benign variants.
• Increased ST density (edema, obesity) A simulated fracture may occur in any bone w/ more than
• ST calcification (vascular, traumatic, chronic) one ossification center.
• ST contour – thicker medially and proximally The silver dollar navicular is a normal (small) variant of
• Foreign bodies (r/o artifact w/ multiple views) navicular development – be sure to r/o Kohler’s dz.
3. Bone Assessment A pronated foot may cause the spaces between bones in the
• Number of osseous structures – start distally and midfoot to be accentuated, causing a simulated lisfranc’s fx.
work proximally A pseudo-epiphysis is a secondary ossification center.
• Integrity and morphology of osseous structures – are The gun-barrel effect is seen when a bone (usually phalanx)
cortices intact? Are there structural changes? is perpendicular to the film plane. It may look like a cyst.
Distal phalangeal condyles are normal variants.
• Density of osseous structures – evaluate 2nd MT
Cone-shaped epiphyses may be normal but are frequently
o Rule of 1/3s – in individuals <40 y/o, syndromic as well.
middle 1/3 should be medullary, outer 2/3 should
o Rule of 1/2s – in individuals >40 y/o, half Accessory ossicles and sesamoids are normal variants in
bone should be cortical, half medullary anatomy that occur in predictable locations. Accessory
o 1/3 of bone is lost before apparent on X-ray ossicles usually arise earlier, are larger, and irregular
o Cortical bone lost at a rate of 2%/year (>35 compared to sesamoids (which are usually present in tendons.)
y/o) Os Trigonum (2-8%) – occurs posterior to the lateral tubercle
o Medullary bone lost at a rate or 1% per year of the talus. When fused (~18 y/o) is called steida’s process.
4. Joints and Joint Spaces Os Tibiale Externum (3-12%) – secondary ossification center
• Is there narrowing? Is it symmetrical/asymmetrical? of the navicular tuberosity. The pre-hallux type is pyramidal
• Absence of joint = coalition/joint fusion in shape, while the accessory navicular is in the PT tendon.
• Increased space is due to joint effusion Os Intermetatarsium (1-10%) – occurs btw the 1st cuneiform
5. Biomechanical Assessment and 1st and 2nd MT bases. May fuse.
• Measure of angular relationships for treatment goals Os Supranaviculare (1%) – located on the dorsal aspect of
the TN joint (may look like fx/osteophyte).
• Determines surgical procedure and post-op correction
Os Calcaneus Secundarius (1%) – located at the anterior
• Performed in angle and base of gait
process of the calcaneus – may be confused w/ rowe fx.
• Serial radiographs to check progression of healing Os Sustentaculi (<1%) – is located posterior to the
Conclusion – use systematic approach to avoid missing sustentaculum tali, often fused. Is assoc w/ STJ coalition.
details. Review the entire film. Do not let your eyes be drawn Os Supratalare is located on the dorsum of the talar head.
to the obvious. Cite only differentials which make sense and Os Vesalinum (<1%) – occurs at the proximal 5th MT base.
are defensible to you. Usually confused w/ apophysitis, or a stewart/jones fracture.
Accessory ossicle of the Hallux occurs usually at the base of
RADIOGRAPHIC VARIANTS the distal phalanx at the medial or lateral aspect.
Identification of variants requires knowledge of normal Os Subtibiale/Subfibulare (4%) - occur distal to the medial
anatomy. Often normal variants are mistaken for pathology. and lateral malleoli. R/o trauma
The simplest error in this regard is structural overlap due to Hallux IPJ Sesamoids (50%) – located at the IPJ of the
wrong projections ordered. hallux, may remain cartilaginous. Assoc w/ plantar HPKs.
Benign fibrocortical defect – small area of discontinuity Lesser IPJ Sesamoids occur in the joint capsule and short
usually in long bones. Eventually fades away over time. flexor tendons of the lesser digits. Does not occur in the 3rd.
Nutrient foramen – may look like a fx, but discontinuity Os Peroneum (20%) - a sesamoid in the PL tendon near the
“stops” halfway through the cortex. cuboid. Often is not ossified.
Constant Sesamoids occur in the MPJ of the hallux and affected area. This may be normal for the individual with
ossify around 10-12 y/o. The tibial sesamoid is larger and is congenital lymph blockage, as in lymphedema praecox, but
commonly bipartite. Partitions occur in cardinal body planes, with insidious onset of obstructive edema a previously
and their combined size is greater than a single sesamoid. You undiagnosed pathology may be at work. D/Dx include tumor,
must r/o fx when dxing a bipartite sesamoid. trauma, radiation (repeated exposure to radiation damages
lymphatic channels), inflammation, surgery, burns, infection,
or helminthic infestation. Inflammatory edema is associated
with systemic disorders, particularly arthridites and metabolic
disorders. D/Dx include A vitaminosis, RCPS, melorheotosis,
collagen vascular diseases, dilantin use, reynaud’s disease, and
thyroid dysfunction (thyroid acropachy – nodular myxedema.)
THE 5 STEP APPROACH TO PLAIN FILM ANALYSIS Traumatic edema will be localized to the site of trauma and
STEP 2: SOFT TISSUE ANALYSIS should be consistent with the history. Besides direct trauma,
The soft tissue analysis of plain film incorporates two main this type of edema is seen in stress fractures, infection, and in
features: surgical sites post-op. Of particular clinical significance is
1. Tissue Density edema in the posterior triangle (bordered by the posterior
2. Tissue Contour flexor hellucis longus, the anterior tendo Achilles, and the
First you want to determine what kind of view you posterior-superior calcaneus.) Edema or hematoma from
are looking at. The most common is of course the DP view of injury to the tendo Achilles will cause this triangle to
the foot, which may be taken WB or NWB. To tell the disappear, which is a pathologic finding. Another pathologic
difference, look at the joint spaces and see if they are clearly finding is the teardrop sign of the ankle, which is visible as
visible. If the MPJs are clearly visible the view is probably increased tissue density surrounding the ankle joint. This is
WB, which is taken at 15 degrees as opposed to NWB, which caused by extravasation of fluid to the ankle joint subsequent
is shot at 0. You may also look to see the ankle position (90 in to trauma. Ligamentous sprain is visible as diffuse edema
WB.) The view is important because WB views will show the surrounding the area of the affected ligament.
soft tissue somewhat distorted due to pressure. On the DP this Burns and frostbite cause areas of devitalized tissue
presents as extra thickness of the S.T. on the lateral column, to show up on radiographs as areas of increased density.
and on the lateral it presents as flatness on the plantar surface. Small localized areas of increased density are visible in the
The first point, density evaluation, requires case of focal gigantism associated with acromegaly. Bony
knowledge of different tissue densities to be of any use. The growth is also affected in this disorder and diagnosis should be
least dense material is of course gas or air, which is easy to make if it has not been made already.
pathologic. The next higher density is fat, typically seen in Heel pad thickening is a finding associated with a
kager’s/bohler’s/toygar’s triangle, as well as on the plantar number of pathologies, and as such measuring the heel pad is
surface. Next dense from fat is water, which is the primary recommended in routine analysis of NWB views. Possible
composition of the soft tissues including muscle and tendon. D/Dx include acromegaly, dilantin use, plantar edema, plantar
Muscular compartments of the foot as well as the tendo infection, obesity, trauma, myxedema, and thyroid acropachy.
Achilles will be of this density. Next dense is atrophied or The accepted limit for normal heel pad thickness is 25mm.
devitalized tissue, which is somewhat dehydrated. Like gas, Soft tissue emphysema is a decrease in radiodensity
tissues of this density are pathologic and should be explained due to the presence of air or gas in the tissues. Always
fully. Next dense is calcific density, which is the density of pathological and often the sign of an emergent situation, S.T.
calcium deposits in the tissues. This is most often pathologic. emphysema is a worthy finding. Gas is almost always
Next dense is ossific density, which is the density of bone. produced by bacteria, especially clostridium perfringens,
Bones are only slightly denser than calcified structures – they which may produce superficial emphysema (radiographic
are normally differentiated by their internal architecture. emphysema) or deep emphysema (deep intramuscular
Finally, the densest structures radiologically are metallic or emphysema). The only non-emergent emphysema finding is
glass structures, which are almost completely radioopaque. of a gas abscess which is a localized ulceration containing gas
Objects of this density are almost always foreign bodies, which does not spread to other areas. Gas abscesses are
although in many cases they simply represent fixation or typically found only in the distal part of the digits. It is
implants from prior surgery. important to distinguish emphysema from the decreased
Pathologic changes in soft tissue density may be radiographic density caused by a sinus tract leading to an
either an increase or decrease in character. Edema causes ulcer. A sinus tract will always track back to the surface of the
generally an increased radiodensity which matches that of skin, whereas emphysema is contained within the soft tissues.
muscle or tendon, usually in areas where fat density is normal. Some disorders which affect only soft tissue contour
This is important in the posterior triangle as well as on the are worthy of note as well. Ainhum’s disease is a thickening
plantar surface of the foot as extravasation of blood or fluid of fascial bands about the base of the proximal phalanges of
will show up as an obliteration of normal fat anatomy on film. the digits, causing a constriction of the underlying tissues that
Edema also causes an increase in soft tissue contour, which is is visible on x-ray. This constriction eventually leads to
the second point to evaluate in soft tissue analysis. Edema is autoamputation, and although it is easy to diagnose from X-
normally classified by its cause. Obstructive edema is ray, there is no known treatment for this disorder. The
caused by obstruction of the lymphatic channels draining the
sullivan’s sign sometimes seen on radiograph is a splaying of progressing deeper with time. It may affect any soft tissue,
digits which are abducted away from each other at the level of but calcifications are generally laid down in linear
the MPJ. This is caused usually by a space-occupying lesion aggregations parallel to the long axis of the limb. This
like a neuroma or interstitial fibrosis following surgery. condition is very rare and is diagnosed in youth. Calcinosis
Sometimes, however, the etiology is biomechanical, due to the circumscripta is a distal subcutaneous calcification that is
unequal pull of flexor tendons that can result from DM motor normally associated with collagen-vascular diseases,
neuropathy, or simply from closely positioned metatarsal particularly CREST syndrome. Calcinosis circumscripta
heads. associated with frank scleroderma is termed thiberge-
Vascular calcification is seen in varicose veins, weissenback syndrome. These distal calcifications
monckeberg’s sclerosis, ASO, thrombophlebitits, and DVT. predispose the digit to ulceration. Tumoral calcinosis is not
They appear on X-ray as thin parallel or curvilinear lines. associated with cancer as the name implies, but rather is a
Phleboliths are small round or oval calcifications that appear descriptive term referring to the presentation of the
within superficial veins. calcification. Seen in renally compromised patients (usually
Dracunculosis is a rare finding that is seen in DM type II), these calcifications begin near joints as small
patients who have had a history of filiaria medinasis infection. nodules that eventually grow in size to possibly impinge
These helminthes, which burrow into the dermis of the foot, neurovascular structures, limit ROM, and cause ulceration.
remain after death as bits of foreign tissue that sometimes The typical presentation is near the 5th MPJ. This type of
calcify. The dracunculosis is the radiographic finding of these growth is benign.
calcified helminthes, which present as curvilinear lines of The last form of calcinosis is calcified bursa
radiodensity that do not follow any vascular anatomy. secondary to irritation (usually posterior heel, medial 1st MPJ,
Hemosiderin deposits may calcify in tissues lateral 5th MPJ.)
following the trauma or disease state that caused them. This Soft tissue ossification is distinguished from soft
type of increased radiodensity is typically seen in periarticular tissue calcification by the degree of organization within the
tissue, arthritic joints, or the subcutaneous area of the ankle. ossified segment, typically with trabecular patterns.
General calcification of the soft tissues can be Additionally, ossifications that occur near bone
distinguished from ossification by the degree of organization characteristically do not cause periosteal reaction.
seen in the radiodense area. Calcification is non-homogenous Progressive myositis ossificans (aka fibrodysplasia ossificans
and disorganized, giving a “salt and pepper” appearance. progressive) is a rare childhood disorder in which there is
Ossification, in contrast, is highly organized, often exhibiting extensive and unexplained muscular ossification which causes
a trabecular pattern, and may have a cortex. In general, soft extraarticular ankylosis and disuse osteoporosis.
tissue calcification is much more common that ossification. Neurological myositis ossificans has a similar presentation
Calcification etiologies are organized into three broad but occurs in conjunction with a neurogenic lesion (stroke,
categories: metastatic, dystrophic, and calcinosis. spina bifida, encephalitis, syphilis, brain trauma,
Metastatic calcification is systemic calcification of a myelomeningocoele, spinal cord hemisection, tuberculosis,
metabolic derivative, such as hyperparathyroidism, and poliomyelitis). The calcifications occur at levels below
hypervitaminosis D, renal osteodystrophy, sarcoidosis, or the neurogenic lesion. Finally, myositis post-traumatica
cancer. The calcifications are caused by an imbalance in (circumscripta) is an area of localized ossification secondary
calcium or phosphorus metabolism. The calcifications may to acute trauma. Ossification begins soon after the traumatic
appear vascular, but are typically more numerous and less incident, but cortical formation is only seen 6-8 weeks after
organized than vascular calcifications. Advanced the incident. Ectopic bone within the muscle may also be seen
hyperparathyroidism causes chunky calcification, in which parallel to the muscle fibers. On X-ray the mass appears
separate calcifications conglomerate into calcified patches that similar to an egg, with well-defined borders. Histologically it
are prone to ulceration. contains the same sections as an epiphyseal plate.
Dystrophic calcification is calcification of Foreign body analysis in soft tissue is vital to
devitalized tissues without metabolic imbalance. localizing the foreign body for surgical removal. Analysis of
Theoretically calcium precipitates in devitalized tissue, giving the film typically calls for the ”tunnel technique” in which a
rise to this type of presentation. Examples of possible piece of paper is rolled up into a tube, which is used to analyze
etiologies include ehlers-danlos syndrome, pseudoxanthoma small segments of the film at a time. Often needles are placed
elasticum, fibromatosis, tumor, cyst, hematoma, focal in three planes near the affected area so that when films are
necrosis, trauma of any kind, and vascular disease. One taken the exact location of the object can be triangulated. For
peculiar finding is that of hemarthrosis, which is calcification some foreign bodies, particularly wood, advanced imaging
of blood exudate in a joint space. These calcifications may modalities (ultrasound, CT, MRI, xerogram) should be
aggregate as “pebbles” within the capsule, visible on x-ray, employed.
that can limit ROM of the affected joint (common in the
Calcinosis is the term applied to califications that are
idiopathic in nature. There are four syndromes associated
mainly with calcinosis. Calcinosis interstitialis universalis
presents as a calcification of subcutaneous structures,
osteoblast activity. Lab values show increased PTH. The
most common presenting symptom is extra-capsular hip fx.
Regional osteoporosis occurs only in a particular segment,
usually due to disuse atrophy. Localized osteoporosis affects
one part of a bone, and is due to tumor, arthritis, or infection.
Diagnosis of osteoporosis is preferred with a device
called a DEXA scanner, or dual-energy x-ray absorbiometry.
This measures the absolute density of bone via penetrance of
x-rays. CT can also be used to diagnose this disease.
Osteoporosis is graded using the calcaneal index:
Grade V (normal) – all trabeculae are uniformly present
Grade IV (normal) – posterior compressive trabeculae are
divided into two separate columns
Grade III (borderline) – posterior tensile trabeculae are lost
Grade II (osteoporotic) – anterior tensile trabeculae lost
Grade I (severe) – all tensile, most compression trabeculae
are lost
Regional Complex Pain Syndrome (RCPS) also
known as the “great mimicker,” manifests on x-ray as an acute
painful regional osteopenia following minor trauma. Males
and females are equally affected, and patients are typically
THE 5 STEP APPROACH TO PLAIN FILM ANALYSIS over age 50 and of type A personality. Presenting s/sx are
STEP 3: BONE EVALUATION progressive onset of pain, stiffness, swelling, and atrophy
distal to the site of injury over a 3-6 month period. The cause
OSTEOLYTIC DISORDERS is hyperactivity of the sympathetic nervous system. In type I
Osteoporosis is an absolute reduction in bone mass RCPS no specific nerve damage can be identified. In type II
and density. Osteopenia is a generalized term to denote a RCPS direct nerve injury has occurred. In 70% of pts, the
relative loss in bone density regardless of any etiology. disease can spread up the extremity, sometimes even to the
Osteoporosis is the most common skeletal pathology, common opposite limb. RCPS can also be staged.
in smaller older individuals who are less active. Females are Stage I describes localized edema, muscle pain, joint stiffness,
affected more commonly then males overall. (Age-related, or and vasospasm with duration of about 3mos. Additionally,
“senile” osteoporosis affects men and women equally.) trigger points form where touch causes pain out of character to
Environmental factors that contribute to osteoporosis include the stimulus (causalgia.) Osteopenia is noted on x-ray distal to
smoking, alcohol intake, estrogen deficiency, and the use of the lesion.
certain medications. The most common presentation of Stage 2 includes increased pain and area of involvement,
osteoporosis is vertebral fracture, followed by hip fracture. brawny edema, hair loss, brittle nails, and spotty osteopenia.
Bone loss in osteoporosis is mostly cortical (80%), (Osteopenia w/ areas of normal bone.)
but 33-50% of bone must be lost before the disease is evident Stage 3 trophic damage becomes irreversible at this stage, w/
on x-ray. Peak bone mass is realized at age 35, with intractable pain, muscle atrophy, joint weakness, flexor tendon
involutional bone loss due to age beginning at age 35-40. contracture (producing deformity) and deossification.
Cortical bone is lost at a rate of about 1% per year after this Tx for RCPS includes pain tx (NSAIDs, opiates), nerve
point. Bone has a gray appearance on x-ray w/ the primary blocks, physical therapy, and sx sympathectomy.
trabeculae accentuated and the secondary trabeculae reduced. Osteomalacia is a lack of calcium in osteoid matrix
Primary osteoporosis is that which has no underlying laid down by osteoblasts, resulting in improper bone
disorder. Secondary osteoporosis is caused secondary to a mineralization. Symptoms include muscle weakness, bone
pathology like steroid tx, myeloma, metastasis, gastric sx, pain on palpation, and bone deformity. X-ray shows osteoid
anticonvulsants, hyperparathyroidism, heparin, DM, seams, lines of unmineralized bone that appear as pseudofxs
alcoholism, disuse, hypogonadism, amenorrhea, and anorexia. (aka increment fx, looser line, umbua zonen, milkman
Generalized osteoporosis affects all bones, particularly of the syndrome). The cortex is thin and blurs into the medullary
axial skeleton, and may be post-menopausal or senile. Post- bone (endosteal blurring.)
menopausal osteoporosis affects females aged 51-75, and is Rickets is osteomalacia seen in children, usually due
caused by the increased osteoclastic action present in states of to vitamin D deficiency (but also due to renal dz.) It typically
estrogen deficiency. Mainly only medullary bone is lost, with affects children 6-12 months old, and will be accompanied by
coarsened trabeculae. It is particularly associated with muscle tetany, irritability, and weakness. Physical
vertebral, hip, and colle’s fx (wrist.) Lab values for this type development is impaired, bone growth is impaired and
of osteoporosis are normal except for a decrease in PTH. deforms. Cartilage in the epiphyseal plates hypertrophies and
Senile osteoporosis has about an equal distribution btw males is surrounded by edema. CXR shows a rachitic rosary about
and females over 70 y/o. There is a proportionate loss of the costo-chondral junctions. Proximal calcification of the
cortical and trabecular bone due to generalized loss of metaphyses is absent, and margins are frayed and cupped.
Pseudofractures are also seen in rickets as well as syndactyly), 20% have arthralgia. X-ray shows multiple
tibial/femoral bowing. compact bony islands in long bones with uniform density.
Scurvy is a disease caused by long-term deficiency Rarely, bone islands may have a radiolucent center.
of vit. C. It takes 4 months to be apparent on X-ray, and Compact Bone Islands are normal variants seen in regular
typically affects infants aged 4-8months. Scurvy is radiographs. They appear as small areas of radiodensity,
characterized by improper collagen formation, leading to usually in flat or tubular bones. What may appear normally as
spontaneous capillary hemorrhage, osteopenia, and poor a compact bone island can rarely be a osteoid osteoma.
cartilage. Radiographically, there is a dense zone of Osteoid Osteoma is a painful benign tumor that is typically
provisional calcification (line of frankel), ring epiphyses <1cm, appearing as a compact bone island with a radiolucent
(wimberger’s sign), irregular metaphyseal margins (corner center. They are usually located near the cortex. Symptoms
sign), metaphyseal protuberance (pelken’s spurs), scorbutic include pain at night, relieved by ASA. Dx w/ bone scan.
zones (trummerfield zones), and sub-periosteal hemorrhage. Heavy Metal Poisoning can be by lead (plumbism),
Hyperparathyroidism is ostepenia due to phosphorus, or bismuth. Lead lines at the metaphyses are
overactivity of the parathyroid gland. Primary visible on radiographs one month after exposure. Lead
hyperparathyroidism is caused by parathyroid deposition may also be seen at the distal ends of the digits.
adenoma/carcinoma/hyperplasia, or an ectopic PTH-secreting Lead line density is determined by the amount of lead
tumor. Secondary hyperparathyroidism is caused by renal ingested, the width is the single-time duration of exposure, and
disease. Typical presentation is female, 30-50 y/o, weakness, the number equals the number of exposures. What may
lethargy, polydipsia/uria, hypercalcemia and kidney stones. appear as lead lines in a 4 y/o or younger is actually a normal
Serum calcium and phosphate are elevated. The radiographic finding. Lead foreign bodies do not cause plumbism (unless
hallmark is sub-periosteal bone resorbtion (1), followed by located within a joint space.)
accentuated trabeculae and reduced medullary bone (2), and Hypervitaminiosis A presents with dermatitis, pruritis,
formation of brown tumors. (3) Bone resorbtion typically alopecia and skin yellowing. X-rays show solid periosteal
occurs first in the phalanges, and soft tissue ossifications may bone at the ulna and metacarpals.
also be seen. Brown tumors are “holes” in the bone that are Hypervitaminosis D presents with nausea, anorexia, polyuria
filled with osteoclast-laden fibrous tissue, seen in both primary and polydipsia. X-rays show extensive calcification of blood
and secondary forms. vessels, soft-tissue, kidney, and peri-articular spaces.
Melorheostosis of Leri – “flowing hyperostosis” that looks
like candlewax dripping down the bone. Etiology unknown.
No gender predilection. Joint effusion w/ decreased ROM and BONE AND FRACTURE HEALING
contracture, one limb (monomelic) affected, muscle wasting, Bone Characteristics: Bones support our frame as well as
lymphedema all are symptoms. X-ray shows wavy cortical protect the vital organs, provide a source of calcium, a site of
thickening, narrowing of endosteal space. insertion for tendons and ligaments, and provide the rigidity
Osteopathia Striata – “Voorhoeve’s Disease” most needed for movement against gravity. Bones comprise 1/10th
commonly seen in the hip metaphysic. Seen as a linear band of our body weight. They resist axial stresses very well but
of bone density of unknown etiology, typically coexisting with are weak against rotational forces. Tubular bones are built for
sclerosing dysplasias. axial support and locomotion. Flat bones are built for
Osteopetrosis – “Albers-Schoenberg Disease” also known as protection of vital organs.
“brittle bone disease.” Medulla is completely destroyed – all Bone Healing: Consists mainly of spontaneous regeneration.
bone is cortical. Existing bone thus has no shock absorbing Tubular bone forms by endochondral ossification, flat bones
ability and is very brittle. It is a hereditary disorder in which by intramembranous ossification. The periosteum surrounds
the osteochondroid tissue of developing bone fails to mature and protects the bone, and is made up of an outer fibrous layer
into medullary and lamellar bone. There are 2 types: and an inner “cambium” layer which contains osteocytes. It is
osteopetrosis tarda (benign, a dominant trait) and osteopetrosis this inner layer of the periosteum as well as the endosteum that
congenital (malignant, recessive trait w/ neck LAD and HSM.) are most closely associated with bone healing.
Lack of bone remodeling results in long bones having an FRACTURE TERMINOLOGY
Erlenmeyer flask deformity (flared metaphysis.) Variably, Avulsion Fx – pulloff fx consisting of a fragment of bone
some persons present with a spotty osteopetrosis which pulled off by a muscle, tendon, or ligament.
appears like a “bone within a bone” or as striations of normal Butterfly Fx – triangular shaped cortical fragment that is part
bone with osteopetrotic bone. of a communuted fracture.
Osteopoikilosis – “Osteopathia condensans disseminata” or Chip/Corner Fx – small fragment of bone from a joint
“spotty bone disease” is a hereditary disorder that presents as margin. Distinguish from a joint mouse, which is a piece of
multiple compact bone islands existing within normal bone. osteophytic bone that breaks off into a joint space.
The disease is asymptomatic and is usually an incidental Closed Fx – does not penetrate the skin.
finding. Turnover is also very high, such that two radiographs Comminuted Fx – consists of more than 2 pieces.
taken in the same year may show completely different Fleck Sign – avulsion fx by the lisfranc’s ligament of the base
presentations. 25% of patients have a coexisting of the 2nd metatarsal.
dermatological problem (dermatofibrosis, scleroderma,
Impaction Fx – telescoping of bone segments (also called Hypertrophic Non-Union may be of the elephant’s foot type,
“bayoneting”) that results in shortening of a segment. the horse’s hoof type, or the oligotrophic type. Elephant’s foot
Greenstick Fx – incomplete fx in which one cortex is affected type is usually due to early WB and inadequate stabilization.
and the fracture line follows down the axial line of the bone. Horse’s hoof is caused by inadequate internal fixation that has
Torus Fx – trabeculae are buckled inwards with a cortical allowed a small amount of movement. Oliogotrophic non-
bulge around the fracture site union has poor callus, and is usually due to inadequate
Insufficiency Fx – aka pathological fx, caused by normal alignment of fx ends.
physiological stresses through diseased bone. Avascular Non-Union – consists of four types; torsion
Oblique Fx – fx is 45 degrees from the long axis of the bone wedge, comminuted, defect, and atrophic. Torsion wedge is
Occult Fx – see also stress fx; subtle and difficult to identify incomplete healing of a fx in which there are three or more
Open/Compound Fx – skin is penetrated pieces, in which some pieces fuse together but others do not
Simple Fx – two bone fragments are involved because of inadequate vascularity. It is sometimes seen with
Spiral Fx – fx is circumferential and longitudinal in bone plate fixation, usually in the tibia. Comminuted non-union is
Stress Fx – due to repetitive stresses, no fx line is apparent but the presence of one or more fragments that become necrotic,
bony callus forms 10-14d on X-ray. Must rely on clinical Sx. the callus fails, and any involved fixation may break from
Transverse Fx – fx at 90 degrees to the long axis of bone. stress. Defect non-union is the loss of a devitalized fragment
FRACTURE REPAIR of cortical bone that leaves a dead space within the bone
Displacement/Distraction – requires reduction which cannot be bridged. Atrophic non-union is a long-term
Closed Reduction – realign fragments through manipulation result of insufficient vascularity that causes fx ends to become
of ST, stabilize w/ cast osteopenic and atrophic.
Open Reduction – realign fragments surgically, using ORIF Radiographic Findings of Nonunion
Inflammatory Phase – Periosteum, haversian system Sclerosis of the fracture ends, failure of changes of healing,
damaged, bleeds to form hematoma. Osteocytes die from progressive bowing, increased bone atrophy above and below
ischemia, creating necrotic tissue that induces the fx site, excessive callus formation, and absence of remodeling.
inflammatory response of vasodilation, edema, and Bone scans show up “hot” in non-union; increased uptake at
macrophage attraction. the fracture ends may be indicative of pseudoarthrosis
Reparative Phase – governed by vascularity, the reparative formation.
phase involves the formation of a callus which is mainly fibrin Pseudoarthrosis
from inflammation invaded w/ pluripotent cells for healing. A This is a variant of non-union characterized by scar tissue and
collar callus forms around the bone to stabilize, dictated by false joint formation. Congenital pseudoarthrosis is present
the periosteum, while the internal callus is dictated by the at birth and is assoc w/ neurofibromatosis. It typically occurs
endosteum and dictates bridging and union between the two in the distal tibia/fibula. Acquired pseudoarthrosis causes
segments. Compression encourages bone rather than fibrous pain, instability, and bowing, with sclerotic bone ends and
tissue formation. Necrotic tissue is simultaneously removed. lucency between fragments. It is most common in the distal
Clinical Union – the goal of reduction, clinical union is the tibia.
resolution of symptoms w/ palpable rigidity to the affected Malunion
bone. Clinical union precedes radiographic union. Bone healing that occurs in non-reduced fx, in which bones
Remodeling Phase – begins while the reparative phase is are in improper position. It can spontaneously correct in peds.
winding down, in the remodeling phase the callus is resorbed THE 5 STEP APPROACH TO PLAIN FILM ANALYSIS
and the trabecular bone remodeled along lines of stress, STEP 4: EVALUATION OF JOINT SPACE
resulting in a bone that is stronger than when it broke.
Cancellous bone heals faster than cortical bone, and has a PEDAL COALITIONS
smaller callus. Cortical healing is limited by vascularity and A coalition is a union of separate things into a single body or
the amount of movement permitted during the healing phase. group; true coalitions are intra-articular fusions of bones,
COMPLICATIONS OF FRACTURE REPAIR and bar/bridge coalitions are extra-articular fusions of bone.
Delayed Union – union is not achieved w/in the expected time A complete coalition is osseous and limits all motion. An
(6 wks.) This is due to inadequate reduction, soft-tissue incomplete coalition is a union by fibrous or cartilaginous
imposition in the fx, excess ST destruction, vascular tissue. A rudimentary coalition is an osseous projection
disruption, inadequate immobilization, fragment distraction, or which limits motion but does not produce a union of parts.
inadequate fixation. AO principles dictate that bone healing A synchondrosis is a cartilaginous union, a synostosis is a
fails in tension and heals in compression. bony union, and a syndesmosis is a fibous union of two parts.
Non-Union – complete arrest of bony repair, replaced instead Coalitions are caused by accessory ossicles (os trigonum, os
by fibrous, cartilaginous, or synovial compensation for the fx sustentaculi proprium), failure of mesenchyme to segment in
site. It is variably classified as being diagnosable 6-8 months development, trauma, DJD (causing a fibrocartilaginous
post-fx. Others say non-union is dx if no radiographic healing fusion), inflammatory rheumatoid conditions, and fxs.
changes are seen for 3 months. Classification of non-union is Tarsal coalitions occur in 1-2% of the population and consist
by Weber and Cech, and are divided into two major of the talo-calcaneal coalition (most common), calcaneo-
categories, hypertrophic and avascular (or hypotrophic.) navicular, and talonavicular (least common.)
Ossification of coalitions in the tarsus occur at different times.
The age of ossificiation determines when symptoms occur. planar analysis which may be used to determine the extent of
Talonavicular coalitions 3-5 y/o coalition and change to surrounding osseous structures.
Calcaneonavicular coalitions 8-12 y/o Nuclear Imaging is not very useful for the diagnosis of
Talocalcaneal coalitions 12-16 y/o coalition. Increased uptake is seen adjacent to areas fusing,
S/Sx of coalitions include stiffness, decreased ROM, pain, and decreased uptake in already fused areas.
peroneal spasm, anterior/posterior tibial spasm, local POP, MRI allows planar and oblique analysis to more fully explore
pronation, cavus deformity, and fixed RF valgus. the nature of a coalition. T2 weighted images are particularly
Peroneal spastic flatfoot is characterized by restricted STJ useful to note presence or absence of synovial fluid in an area.
motion, RF valgus (in OKC), FF abduction, bowstrung Syndromes associated with coalitions may aid in the
peroneal tendon, and extensor digitorum longus spasm. diagnosis of a bony union, and vice versa. Common coalitions
D/Dx of coalitions include RA, JRA, trauma, neoplasm, typically are axial, i.e. distal to proximal fusions, whereas
acromegaly, CCPV, casting (causing peroneal contracture), syndromic coalitions tend to be medial to lateral in position.
extra-articular arthrodesis, overcorrected flatfoot, Apert’s Syndrome results in massive tarsal synostoses, as
osteochondral dystrophy, infection, and N/M disease. well as cranial synostoses and midfacial hypoplasia (“mouse”
Plain film analysis of coalitions is cheap and able to identify facies). The distal phalanx of the hallux and pollux are broad.
most symptomatic coalitions. Feet tend to have valgus attitude. Footwear is a problem
IPJ coalition can be viewed on AP projection. Nievergelt-Perlman Syndrome typically has synphalangism
Synphalangism is a congenital fusion of the IPJs. and carpal fusion, moreso in the hands than feet. This
Intermetatarsal coalition may be viewed on AP and oblique syndrome may also present with an atypical clubfoot and
views. Diaphyseal fusions are typically the result of trauma. tarsal fusions, which causes a ball-and-socket type of ankle
Metatarsal cuneiform coalition may be viewed with AP, joint. Other findings include congenital dislocation of the
med oblique (medial column), or lat oblique (lateral column.) radial head and conduction deafness due to ear ossicle fusion.
Navicular cuneiform coalition may be viewed with the AP Phocomelia is defective development of the arms or legs,
and medial oblique projections. resulting in “flipper” extremities. Hemimelia is
Navicular cuboid coalition may be viwed w/ AP or oblique. underdevelopment of a specific extremity, usually a below-
Calcaneocuboid coalition may be viewed on lateral or lateral knee deformity. These conditions cause unusual fusions.
oblique views (typically it is osseous and easy to pick up.) Tx of coalition includes immobilization and supportive
Talonavicular coalition can be viewed on AP and medial therapy, orthotics, NSAIDs for pain, and possible surgical
oblique. AP shows a “putter sign” of the fusion. intervention (resection or arthrodesis.)
Calcaneonavicular coalition can be viewed on lateral and Conclusion – correlate coalitions w/ pts age. Be suspicious of
lateral obliqe, and shows an “anteater sign” on lateral. These changes in plain films. Consider advanced imaging to
fusions are more commonly cartilaginous or fibrous in nature. investigate further. (Special views, CT, MRI.)
STJ coalition is the most common tarsal fusion, and usually is
the middle facet (the posterior facet is least common.) Fusions
of the sustentaculum tali or posterior process are also possible
(though not common.) Anterior facet coalitions can be seen
on lateral oblique isherwood projections but are most
commonly dx though lateral CT. Middle and posterior
facets are viewed on harris and beath axial projections (30, 35,
40, and 45°) or broden views. The posterior and middle facets
should be parallel to one another, and the posterior facet
should be about 2/3 the width of the calcaneus. Posterior
fusion may be secondary to trauma involving the os trigonum.
(Achilles pain, end ROM plantarflexion, deep ankle pain.)
Radiographic Features of STJ coalition (lateral projection) ARTHRIDITIES
Talar beaking Inflammatory arthridities are RA, erosive arthritis, psoriatic
Posteior TC joint space narrowing arthritis, reiter’s disease, ankylosing spondylitis, and
Rounding of lateral process of the talus enteropathic arthritis.
Obscured middle facet Non-Inflammatory arthritis is degenerative joint disease.
“Halo” effect (Wait a minute – doesn’t arthritis mean joint inflammation?)
Do not confuse talar beaking w/ dorsal hyperostosis, which is Metabolic arthritis is gout and CPPD disease.
caused by pathomechanics. Talar beaking occurs at the Neuropathic arthritis is neuropathic joint disease.
distalmost aspect of the talar neck, near the TN joint. It is Miscellaneous arthridities are DISH, PHO, and pigmented
caused by stress on the talonavicular ligament and nodular synovitis.
impingement of the navicular on DF. The halo sign is a subtle
finding, which is a ring of trabeculae that form around the PSORIATIC ARTHRITIS
coalition secondary to altered compressive forces. Seen in 7-15% of pts w/ psoriasis (80% if pt has nail changes.)
Computerized Tomography is the modality of choice for Typically affects 20-50 y/o, M:F equal. HLA-B27 frequently
evaluation of coalitions (b/c of cortical definition.) It allows positive, particularly w/ SI involvement. Distribution is
asymmetrical and is most common in the DIPJs. Often Women only get gout after menopause. Characteristic of gout
confused w/ RA (for some reason.) is extreme paroxysmal pain in the middle of the night.
Classic radiographic features Primary gout is hyperuricemia due to over-production of uric
Joint margin erosions working in to the center (similar to RA) acid or under-excretion of it by the kidneys. Secondary gout
– eventually leads to “pencil in cup” appearance is due to medications (particularly HCTZ) and
Increased synovial fluid w/ increased intracapsular pressure hyperparathyroidism. Urate deposits in relatively avascular
Apparent wide joint space (due to erosions) tissues like cartilage, synovial tissue, ligaments, bursae, and
Acroosteolysis – resorbtion of the distal phalangeal tuft subQ tissue. Hyperuricemia may never become symptomatic,
Sausage digits and in fact may be reduced during an acute phase attack. A 24
Abundant periosteal activity (resulting in “whiskering”) hour urine collection is needed to diagnose accurately.
Ivory Phalanx – due to abundant endosteal activity X-ray findings of gouty arthritis only occur after several
Osteopenia secondary to reduced activity attacks. Thus radiographs in an early attack function mainly
Main-en-lorngette (telescoping) – long standing disease to r/o other pathologies (septic arthritis.) There is peri-
process resulting in collapse of diaphyses on themselves. articular swelling of the joint margins, erosions of the joint
Posterior/Inferior calcaneus hyperostosis (not heel spurs.) margins, punched-out lesions resembling RA, and complete
lysis of bone in the acute stages. Large tophi may form at
REITER’S DISEASE joint margins and produce “rat bite” erosions peri-articularly
Classic clinical triad – conjunctivitis, urethritis, arthritis. that leave overhanging shelves of bone called martel’s sign.
Also 4th – derm lesions (keratoderma blenorrhagicum) This is not seen for 5-10 years after the attack and merely
Usually preceded by diarrhea. signifies that a pt has had gout in the past. Tophus formation
Typically males, 18-40 y/o. HLA-B27 positive almost always. can occur in the absence of an acute gout attack, and
Asymmetric distribution, primarily lower extremity. subsequent erosions can cause subQ calcification and
Attributed to chlamydial infection (endemic) or dysentery pathological fxs. The joint space is preserved in gouty
(epidemic) which are the two main types of Reiter’s. arthritis. DJD may accompany the process, and the joint may
Epidemic form may affect women and children as well. be somewhat narrowed due to subchondral cyst formation, but
Arthritis long-term symptom; conjunctivitis/urethritis resolves is otherwise unaffected. Metastatic tumors of bone are an
in weeks. Arthritic changes may also become chronic. important d/dx to r/o when considering asymptomatic gout.
Acute Stage - weight-bearing joints are more commonly
affected. In the acute stage there is peri-articular ST edema, CHONDROCALCINOSIS
deossification of opposing articular structures, Achilles Pseudogout, or calcium pyrophosphate dihydranate disease, is
inflammation/widening, and periosteal reaction (metatarsal a symptom similar in presentation to gout that causes the
metaphyses, phalangeal diaphyses, inferior surface of the radiographic finding known as chondrocalcinosis. CPPD
calcaneus.) Retrocalcaneal bursitis is also common. crystals are weakly positive birefringent and simulate gout
Infracalcaneal exostoses (poorly defined or “fluffy”) form attacks when precipitated in joint spaces. The typical pt is
bilaterally and cause heel pain. over 30 y/o (usually ~60) and there is no gender predilection.
Chronic stage – periarticular deossification, small marginal The problem is associated with hyperparathyroidism,
erosions, symmetrical loss of joint space, ankylosis. pseudogout, acromegaly, DJD, and DM. The typically
Specific findings – heel spurs in young men, Achilles edema, affected joint is the knee, where the menisci as well as the
small joint space periosteal reactions, primarily foot s/sx. articular cartilage may calcify as a result. It also can be seen
in the wrist, hand, ankle, symphysis pubis, and elbow.
ANKYLOSING SPONDYLITIS True chondrocalcification is sometimes seen after trauma or
Affects pelvic and spinal joints, ligaments, and tendons. with hyperparathyroidism.
Affects 15-25 y/o, usually males. Almost always HLA-B27
positive. Characterized by lower back pain due to arthritis at DEGENERATIVE JOINT DISEASE
the sacroiliac joint, bony proliferation at enthesiopathies, Also called osteoarthritis, DJD is a local, mechanically
spinal osteophyte formation, and lateral syndesmophytes. caused degeneration of joint function that occurs in
conjunction with age and trauma, resulting in degradation of
ENTEROPATHIC ARTHROPATHY the articular cartilage. Primary DJD is the most common form
Joint changes secondary to GI disease. Seen in young adults, and is due to aging. Secondary DJD is early onset due to
w/ malaise, anorexia, wt. loss and arthritis. Typically trauma or injury to the joint. Joint space narrowing is
sacroiliac, bilateral periostitis. X-ray findings are nonspecific. asymmetric in DJD, the subchondral bone exhibits eburnation
(pathologic sclerosis), the articular surface becomes broad and
GOUTY ARTHRITIS flat, and osteophytes form at joint margins, often breaking off
Gout is the result of an inborn error of purine metabolism. It to become joint mice within the articular space. Osteophytes
typically affects men age 40-50 y/o, and is characterized by typically bend towards the joint space, which causes locking
elevated serum uric acid and negatively birefringent crystals in of the joint in areas where there are osteophytes on either side
the synovial fluid. The most commonly affected joint is the 1st of the articulation. Pseudocysts may also form in the
MPJ due to relative avascularity and lower temperature. subchondral bone in areas where the cartilage is completely
worn away. It is important to note that the disgnosis of hallux
rigidus and limitus, which are seen in patients with DJD of include main-en lorgnette deformity (“opera-glass hand”)
the 1st MPJ, cannot be diagnosed radiographically and are that is also seen in psoriatic arthritis.
purely clinical diagnoses. Additionally, the hands of patients Late radiographic findings in RA have obviously
with DJD clinically may present with enlarged IPJs which are no diagnostic value, but are used to track the progression of
called bouchard’s nodes (PIPJ) or heberden’s nodes (DIPJ) the disease. Characteristic features include subluxation and
that are simply the result of extensive osteophytosis in long- dislocation of the joints, ulnar deviation of the digits,
standing disease. destruction of joint space, and finally bony fusion and
Erosive osteoarthritis is a variant of DJD which ankylosis of the joints altogether. Pathological fxs secondary
affects primarily females aged 40-50 y/o. Clinically an to osteopenia may be seen. Overall, the MPJs are most
increased ESR may be seen because there is an inflammatory severely affected in RA, with the IPJs of the 1st and 5th digits a
component to the erosive component. The presentation is close second in frequency.
symmetrical and bilateral, and most commonly affects the IPJs
of the hands. Radiographically erosive osteoarthritis appears NEUROPATHIC JOINT DISEASE
like DJD except that the erosions are symmetric and take on More commonly known as charcot foot, neuropathic joint
the characteristic gull wing appearance that is specific to EO. disease is a destructive disease that occurs secondary to loss of
proprioception, seen in DM (5%) and syphilitics (20%.)
RHEUMATOID ARTHRITIS Clinically there is no protective sensation; instability and
RA is an inflammatory seropositive joint disease affecting crepitation are present in the joint, and neurologically the pt
primarily females between the ages of 20-40 y/o, but affect suffers from ataxia and loss of DTRs. Besides the more
men and women equally beyond the age of 40. 70% of pts w/ common pathology, neuropathic joint disease can occur
RA are seropositive for rheumatoid factor. The small joints of iatrogenically secondary to administration of indocin or
the hands and feet, and articulations of the spine are typically steroids over long periods of time (notable because of the tx
affected. Early presentation in the foot can easily be mistaken protocols for RA and gout recommend this.) The hypertrophic
for gout – most commonly small, C-shaped erosions appear at form of the disease affects large, WB joints, while the
the base of the proximal phalanges. Radiographic changes are hypotrophic (atrophic) form affects NWB joints. Clinically
seen in 65% of pts who have had some disease process for at both undergo 3 stages; fragmentation, coalescence, and
least 3 months (85% for >6 mos.) However, no clinical s/sx reconstruction. Radiographically the hypotrophic form is
may appear until the disease has been present for 3 years. characterized by bone resorption, diabetic osteolysis, and a
Early radiographic findings in RA include peri- “licked candy stick” appearance. The hypertrophic form is
articular edema that is fusiform in shape around the joint, characterized by the six D’s: joint distension, density
typically in IPJs and MPJs. Inflammation of the synovium increase, debris production, dislocation, disorganization, and
creates pannus which results in bone deossification peri- destruction.
articularly, which progressively extends proximally over time.
Secondary trabeculae are resorbed while primary trabeculae DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH)
are enhanced. Fibular deviation of the digits occurs DISH is a disorder of ligamentous ossification and
secondary to bony deossification that destroys the medial calcification that affects the spinal and extra-spinal
collateral ligaments of the MPJs (except on the 5th MPJ.) articulations. Typically it affects males over 50 y/o. It is
Early on the joint space becomes noticeably widened as associatied (20%) w/ DM. 40% are HLA-B8 positive. All
effusion and pannus formation characterize the disease parts of the spine, particularly the SI joint, are affected.
process, and often this is the only presenting sign in Radiographically flowing hyperostosis is seen over 4
undiagnosed RA. Joint space changes are most easily seen in consecutive vertebral bodies, usually in the area of the anterior
the ankle joint radiographically. Near the joint periosteum longitudinal ligament. In any case, the disc is preserved,
may become irritated and periosteal elevation in the differentiating this process from syndesmoses seen in
epiphyseal/metaphyseal region is seen. This creates ankylosing spondylitis. Extra-spinal presentations may be at
lamellations which enlarge the bone near the articulation. any enthesis, producing whiskering at the bony attachment and
Entheses and bursae near the joint may also become inflamed ossification of the tendon or ligament while preserving the
and enlarge. Localized bony erosions occur near the joint due joint space.
to herniation of the pannus through capsule, producing an area
of radiolucency with poorly defined borders. Erosions seen en PULMONARY HYPERTROPHIC OSTEOARTHROPATHY (PHO)
face may appear completely within the bone, while laterally PHO is a disease caused by bronchogenic carcinoma that is
they may have a dot-dash appearance. Medial-plantar described by the triad of digital clubbing, symmetric
erosions of metatarsal heads 1-4 are most common. Later arthritis, and linear periostitis. It typically affects males 40-
symmetrical joint narrowing is seen, particularly in the IP and 60 y/o. The arthritis in this process, like many seronegative
TN joints (but never the CC joint.) diseases, is nondescript in its clinical and lab findings. The
RA-induced subluxations of MPJs and IPJs following arthritis is specific to the extremities only. Periostitis in long
ligamentous involvement cause the characteristic swan-neck bones occurs in the metaphseal/diaphyseal region, appearing
(like mallet-toe) and boutonneire (like HDS) deformities. as a “double strip sign” on bone scans (dual cortices.)
These deformities are also seen in SLE and post-rheumatic PIGMENTED VILLONODULAR SYNOVITIS
fever (jacoud’s) arthritis. Other deformities seen in RA
This disorder is a proliferative pathology of joints that does
not produce arthritis, but rather a mass within a joint or tendon
sheath which may affect the joints secondarily. Typically it THE 5 STEP APPROACH TO PLAIN FILM ANALYSIS
affects young males. Joint involvement is asymmetric. STEP 5: BIOMECHANICAL EVALUATION
Radiographically there is a soft-tissue mass evident with The biomechanical evaluation of radiographs is used for pre-
localized bony erosions that have well-defined sclerotic op planning and post-op assessment of correction as well as
borders. Calcification is unusual. for the evaluation of orthopedic pathology. Biomechanical
readings are most sensitive to positioning errors, and so great
SYSTEMIC LUPUS ERYTHEMATOSUS care must be taken to ensure proper positioning in patients
SLE is a connective tissue disorder involving nearly every needing a biomechanical evaluation.
organ system in the body. It is most common in females 20- AXES
40 y/o, and is characterized by elevated ESR and ANA titer Greater Tarsal Axis (GTA)
levels. Radiographic features are most readily assessed in the Line drawn parallel to the distolateral border of the calcaneus,
hands, and are characterized by reversible subluxation, most easily identifiable on AP radiograph.
dislocation, and varied deformity. Calcification and atrophy Lesser Tarsal Axis (LTA)
can occur secondary to deformity. Most radiographic findings Point A is placed on the distomedial aspect of the medial
are non-specific and there is no articular degeneration. cuneiform. Point B is placed at the medial proximal aspect of
the navicular articular surface. Point C is placed at the
SCLERODERMA proximal lateral aspect of the cuboid and point D at the distal
Scleroderma is a connective tissue disease that also involves lateral aspect of the cuboid. The midline between points A &
many organ systems and affects females predominantly (30-60 B and C & D are found and a line drawn between them. The
y/o.) Radiographic changes in scleroderma are most readily line perpendicular to this is the lesser tarsal axis.
appreciated in the CREST syndrome, in which soft tissue Metatarsal Axis (MTA)
calcification and acro-osteolysis may be seen. (r/o psoriasis) Line drawn through the midpoint of the shaft of the 2nd
metatarsal. (Or another metatarsal if specified.)
Digital Axis (DA)
Line drawn down the midpoint of the shaft of the digit in
Collum Tali Axis
Line drawn down the bisection of the talar neck.
Collum Calcanei Axis
Line drawn down the bisection of the distal 1/3 of the
Hallux Axis
Line drawn down bisection of the shaft of the proximal
phalanx of the hallux.
Calcaneal Pitch Axis
line drawn from distal inferior aspect of calcaneus to
anteriormost weight-bearing point of calcaneus

Lesser Tarsal Angle = GTA + LTA
Metatarsus Angle = LTA + MTA
Used to evaluate for metatarsus adductus
Digitus Angle = DA + MTA of measured digit
Forefoot Angle = GTA + MTA
Used to evaluate metatarsus adductus in peds
Talo-Calcaneal Angle = collum tali + collum calcanei axes
Used to evaluate pronation/supination
Cuneo-Metatarsal Angle = MTA(1-3) + long axis of
proximal cuneiform
Used to evaluate hypermobility, lisfranc’s injury
Calcaneocuboid Angle = Collum calcanei axis + line CD of
Used to evaluate lateral column integrity
Talometatarsal Angle = column tali axis + 1st MTA
Called Simmons Angle on AP
Used to evaluate pronation/supination
Intermetatarsal (IM) Angle = 1st MTA + 2nd MTA
Used to evaluate bunion deformity A TAA >30° should warrant consideration of a proximal
Hallux Abductus (HA) Angle = hallux axis + 1st MTA osteotomy in surgical bunion correction.
Used to evaluate bunion deformity
Hallux Interphalangeus Angle = hallux axis + bisection of Pre-Op Biomechanical Assessment
distal phalanx of the hallux IM angle HA TAA
Metatarsal Break Angle = line between center of 1st and 2nd PASA DASA Hallux Interphalangeus
metatarsal heads + line between center of 2nd and 5th metatarsal Metatarsus angle MPE Sesamoid position
heads. Joint status Bone density 1st MT protrusion
1 = Tibial sesamoid medially clear of 1st MTA OSTEOMYELITIS
2 = Tibial sesamoid laterally abuts 1st MTA Osteomyelitis is the infection of bone, most commonly by
3 = Tibial sesamoid laterally overlaps 1st MTA bacteria but also possibly by fungus, virus, or parasites. The
4 = Tibial sesamoid bisected by 1st MTA anatomy of vascular structures is most important when
5 = Tibial sesamoid medially overlaps 1st MTA considering osteo, and the vascular anatomy of bone changes
6 = Tibial sesamoid medially abuts 1st MTA with age. In infants (0-1 y/o), blood vessels pass through the
7 = Tibial sesamoid medially clear of 1st MTA epiphyseal plate in tubular bones. Because of this, it is more
Proximal Articular Set Angle (PASA) = line btw medial and common to see infection in the epiphysis because vascular
lateral borders of metatarsal head articulation + line channels here are more prominent than at a later age. In
perpendicular to MTA. children (1-16 y/o), metaphyseal vessels end at the epiphyseal
Distal Articular Set Angle (DASA) = line btw medial and plate, creating loops and blind-ended sacs in the metaphyseal
lateral borders of proximal phalanx MPJ articulation + line vasculature. The tortuosity of these vessels means that
perpendicular to digital axis. metaphyseal infection is much more common in children. The
adult pattern begins around age 16. As the physis closes, the
LATERAL ANGLES metaphyseal vessels can begin to cross back into the epiphysis
Talar Declination Angle = collum tali axis + ground again and so infection may be located anywhere in the bone.
Calcaneal Inclination Angle = calcaneal pitch axis + ground Sequestrum is an infected area that is dead due to
Talocalcaneal Angle = collum tali + calcaneal pitch axes cortical and medullary infarcts. Small sequestra can be
Talonavicular Angle = collum tali + bisection of navicular eventually resorbed by osteoclasts, while large sequestra are
Used to evaluate for metatarsal breaks walled off by the body and then expelled gradually through a
1st Metatarsal Declination Angle = 1st MTA + ground sinus tract. Involucrum is periosteal new bone formation that
Talometatarsal Angle = column tali axis + 1st MTA occurs in response to bone infection, and represents the body’s
Called Meary’s Angle on lateral projection attempt to prevent the spread of bacteria. Both sequestrum
Hallux Dorsiflexion Angle = 1st MTA + hallux axis and involucrum are most commonly seen in hematogenous
Cyma Line = position of the talonavicular joint with respect osteomyelitis. Cloaca is a defect in the involucrum that
to the calcaneo-cuboid joint on lateral projection. allows for drainage products of the infection to be expelled
from the infected area. The cloaca commonly receives small
Radiographic Evaluation of Supination bits of sequestrum that may have been broken down in the
Talar declination angle decreases disease process. Exudate from the cloaca with involucrum
Calcaneal inclination angle increases will feel like sand between the fingers when handled. The
Talocalcaneal angle decreases extent of the cloaca and its sinus tract to the outside of the
Cyma line posteriorly displaced body can be appreciated through the use of a sonogram,
Subtalar joint/sinus tarsi accentuated (bullet hole sinus tarsi) which is simply radiographic contrast media injected into the
sinus tract that can then be visualized radiographically.
Radiographic Evaluation of Pronation Marjolin’s ulcer is a malignant degeneration of soft tissue
Talar declination angle increases within the cloaca to a squamous cell carcinoma. This occurs
Calcaneal inclination angle decreases secondary to acidic pus and exudate from the cloaca irritating
Talocalcaneal angle increases the tissues of the sinus tract. The infection must be very
Cyma line anteriorly deviated chronic (up to 20-30 years) for a marjolin’s ulcer to form, and
Pseudo-sinus tarsi seen (posterior facet of STJ; real sinus it is only seen in long-standing osteomyelitis. Nevertheless, it
tarsi is obscured.) should be kept in mind when treating a patient with history of
bone infection.
Metatarsus Primus Elevatus (MPE) Brodie’s abscess is a localized suppurative infection of bone
Defined radiographically as an elevation of the 1st metatarsal which is successfully walled off and is sterile. A brodie’s
with respect to the 2nd metatarsal. Implied in the development abscess is usually an incidental finding and typically is seen in
of 1st MPJ OA, sub 2nd metatarsalgia. children after osteomyelitis has resolved. A similar finding is
an abscess that still contains bacteria, which can serve as a
Total Adductory Angle (TAA) reservoir for reinfection in the future (however, brodie’s
Sum of the IM angle + the metatarsus adductus angle, used in abscesses are sterile only.)
the evaluation of bunion deformities and in surgical planning.
Routes of infection in osteomyelitis include hematogenous most distal the infection is in the body, the most subtle the
spread (most common in children), direct periosteal response will be. Resolution of the infection will
implantation/inoculation, direct extension, and post-op leave the involucrum to be remodeled and resorbed, however
infection. The most common infecting organism in children is it may sometimes persist after the healing process is finished.
H. Influenzae, although it is now much less common than it Bony destruction appears “moth eaten” as there is a focal loss
once was. In adults staph aureus is by far the most common of bone density in the medullary bone, with sequestrum seen
infecting organism for all types of osteo (except plantar 3-6 wks after the infectious process has begun. Kissing
puncture wounds.) lesions are opposed lesions seen across articular surfaces when
Hematogenous osteomyelitis, being primarily a disorder of the joint has been involved. Often these changes are subtle
children, is most commonly seen in the metaphysis of long and may not be noticed unless serial radiographs are taken and
bones. Bone destruction begins internally, then weakens the analyzed. In slow-growing, rarer cases like fungal infections,
cortex, causes periosteal reaction, and finally breaks through the bone may be able to mount a more effective response
to soft tissue. Being confined within bone initially, the route against the causative agent, and sclerosis due to endosteal
of pus evacuation can be appreciated on X-ray. Initially pus proliferation may be seen. This type of infection-caused
fills the medullary space for some distance before pushing sclerosis is called sclerosing osteitis of Garre.
through the periosteum. The codman’s triangle is a
triangular space of pus bounded on one side by infected cortex Radiographic Signs Overview
and on another by elevated periosteum which attempts to lie Early Signs
down new bone. Notation of this on X-ray is usually Latent Period (10d extremities, 21d spine)
diagnostic for hematogenous osteomyleitis. Soft Tissue – fat plane elevation/displacement/obliteration,
Direct implantation osteomyelitis typically occurs as a result increased ST density
of puncture wounds, human or animal bites, or open fracture. Bone – motheaten cortical/medullary destruction, periosteal
Staph aureus is the most common infecting organism in all new bone formation (involucrum, codman’s triangle)
cases except those of plantar puncture wounds that pass Late Signs
through a shoe, in which case the infecting organism is Soft Tissue – draining sinus/cloaca, debris, marjolin’s ulcer
pseudomonas. E.Coli is sometimes implicated in direct osteo Bone – cortical destruction, involucrum, sequestrum, sclerosis
as well. In direct implantation there is no particular order to Joint – loss of joint space, ankylosis, kissing lesions.
the infectious process, as the traumatic injury has already
disrupted the cortex. Salmonella Osteomyelitis is a peculiar type of osteo that is
Direct extension osteomyelitis is spread of infection to bone sometimes seen in patients with sickle cell anemia. If a sickle
from a nearby soft tissue infection or ulcer. Nail infections cell crisis occurs in the intestinal vasculature, small infarcts
and infected ulcers are the most common causative factor in can allow salmonella bacteria to travel from the gut to the
this type. The order of infection tends to follow the opposite bloodstream where they can seed in bones across the body.
order as hematogenous osteomyelitis. The osteomyelitis associated with this bacterial seeding is
Post-op infections may be due to staph aureus (again most unique in that it predilects the diaphysis of long bones.
common) or pseudomonas. This type of osteo is most
commonly seen in the hip or knee following arthroplasty, BONE SCANS FOR INFECTION
especially when hardware is installed. Loosening of fixation Technetium-99m Phosphate is the prototypical bone scan,
with obvious radiolucency about the device indicates infection and is the most commonly used in clinical practice. It reacts
of this type and surgical removal is indicated. with calcium hydroxyapatite to form insoluble salts which
precipitate in areas of bony turnover. This makes the Tc-99
X-RAY FEATURES OF OSTEOMYELITIS scan ideal for infectious and/or traumatic processes of bone.
Initially, there are no osseous findings present on X-ray – Although classically infection and inflammation about a bone
plain film findings lag clinical findings 7-10d. In vertebral cause a bone scan to read positive in that area, an increase in
bones there may be up to a 21d lag. 30% of bone must be lost vasculature to an area may increase uptake of the isotope, as
before the changes can be appreciated on plain films. Initially well as the articular surfaces of an inflamed joint. Thus,
the only evidence of infection will be soft tissue changes, findings which would otherwise be normal clinically may
including deep ST swelling in hematogenous osteo adjacent to show up as positive on bone scan and must be separated from
the infected area. Fat planes will be elevated, displaced, or pathology. Distal bones seem to be more sensitive to Tc-99
obliterated altogether. Lines of lucency between muscles will uptake, and can more easily show up hot even if only
be obliterated. Infection tracks usually distal to proximal and sustaining minor trauma. Overall, Tc-99 exposes the patient
only rarely travels from medial to lateral (and vice versa.) to only a small radiation dose, and is renally excreted. For this
Breakthrough to a joint space will produce swelling of the reason, it is generally recommended that the patient be well-
capsule, which in the ankle produces the classic teardrop sign hydrated (this also aids in contrast), and care must be taken in
which is also seen in hemarthrosis. Periosteal response to individuals with renal disease, especially if they have DM.
infection occurs usually 7-10d after the initial process has The half-life of Tc-99 is 6 hours. Normal areas of increased
begun. The pattern of reaction is lamellar and progresses to uptake are the lacrimal glands, breasts, SI joint, kidneys,
formation of an involucrum. Involucrum tends to be less bladder, and the injection site of the isotope.
dense than the established cortical bone, even infected. The
Gallium-67 Citrate is another isotope that resembles the Biopsies of bone alone do not give the pathologist enough
ferric ion. It binds to iron-related plasma proteins as well as information to make a definitive diagnosis; clinical and
organelles of leukocytes. This makes Ga-67 useful for radiographic evidence is needed to support what is seen under
visualizing the peripheral tissues because it marks the areas the microscope. Some lesions also may become activated or
where leukocytes have localized. Ga-67 is also excreted react against an invasive biopsy technique.
renally, and has a long (78 hour) half-life. Basic approach to solitary bone lesions
Podiatric indications for bone scan 1) History – age, sex, and symptoms. Age of the patient is
Osteomyelitis important because many tumors predilect younger or older
Trauma patients. Ewing’s sarcoma, chondrosarcoma, and unicameral
Inflammatory Arthritis bone cysts are almost exclusively tumors of children, while
Stress Fracture (if >7 hours) metastatic tumors and multiple myeloma are only seen in older
Tumors individuals. Osteosarcoma tends to affect younger patients,
Non-specific pain (to check for occult causes) chondrosarcoma the middle aged, and fibrosarcoma the
Combined use of bone scan isotopes can be used to elderly. The tumors paraosteal osteosarcoma, giant cell tumor,
differentiate the infectious process. Soft tissue infection can and aneurismal bone cyst are the only tumors seen more
be distinguished from osteomyelitis by decreased uptake in commonly in women than men. Pain is the most common
the third phase of the Tc-99 scan, and will be strongly positive symptom in sarcomas. The character, onset, frequency, and
in Ga-67, whereas osteomyelitis shows up hot in all three Tc- aggravating factors should be assessed.
99 phases and is cold in Ga-67 scanning. When performed 2) Location should be described in relation to the position in
together, the Tc-99 test is done first because of the shorter long bones, cortical or medullary, and eccentric or centrally
half-life. Gallium is typically used to clarify the issue of located. Epiphyseal lesions include chondroblastoma, intra-
infection site, but is not as effective at determining the course osseous ganglion, and clear cell chondrosarcoma. Physeal
of an infection. The practice of using a gallium scan to lesions are only seen in giant cell tumors. Metaphyseal
determine when the infectious process (and thus the treatment lesions include metastatic tumors, osteomyelitis,
regimen) is finished has been thoroughly disproved. osteo/chondro/fibrosarcoma, malignant fibrous histiocytoma,
Indium-111 isotope is a rarer, more specialized bone scan that non-ossifying fibroma, and unicameral bone cysts.
tags WBCs in drawn blood with the isotope and re-injects Diaphyseal lesions include lymphoma, eosinophilic
them into the bloodstream. I-111 is useful in distinguishing granuloma, metastasis, multiple myeloma, and ewing’s
osteomyelitis from neurotrophic joint changes in the diabetic sarcoma. Peripheral/cortical lesions include
individual, which is normally a very difficult clinical osteochondroma and para or periosteal osteosarcoma.
diagnosis. A negative I-111 scan would tend to r/o osteo and 3) Rate of growth is characterized by the borders of the
provide for a positive diagnosis of charcot, while the reverse is lesion. Permeative lesions have a wide zone of transition and
also true. are typical of fast-growing lesions, typically malignant tumors
and osteomyelitis. Moth-eaten lesions have intermediate
COMPUTERIZED TOMOGRAPHY FOR INFECTION zones of transition with irregular borders. They may be
CT allows planar analysis of anatomy to determine the extent malignant or benign tumors. Geographic lesions have well-
of infection. Although sensitive for soft tissue infections, CT defined sclerotic borders with a short zone of transition. This
tends to overestimate their involvement, and is much more finding is typical of benign tumors and cysts (although low-
reliable at determining bony involvement. Very subtle cortical grade malignancies may also sometimes look like this.)
or periosteal changes may be appreciated on a CT scan. 4) Periosteal reaction appearance may give clues to the type
of tumor. Single-layer periosteal reaction is typical of
MAGNETIC RESONANCE IMAGING FOR INFECTION osteomyelitis, benign tumors, and lower-grade malignant
In contrast to CT, MRI is much better at evaluating soft tissue tumors. Onion-skinning is typical of repetitive insults to the
infection versus bone infection. MRI cannot distinguish periosteum, seen in osteosarcoma and ewing’s.
between infection in a joint space and effusion in a joint, Perpendicular periosteal reaction has a spiulcated, sunburst
however, and this is a major limitation if joint involvement is appearance that is almost always malignant. Codman’s
suspected. The infected area appears dull on a T1WI, and triangle is similarly a sign of malignancy in tumors.
more typically has greater intensity on a T2WI. 5) Tumor matrix description can help determine the tissue
type involved. Osseous lesions appear cloud-like and
THOUGHT PROCESS BEHIND THE RADIOLOGY OF INFECTION amorphous with usually a “fluffy” appearance. Cartilaginous
From plain films the distinction must be made as to the lesions appear punctuate w/ C-shaped lesions and numerous
location of an infection. If soft tissue is suspected, MRI is the small calcifications in the center are typical. Fibroosseous
best modality. If bone is suspected, CT is the best modality. If lesions have a ground-glass character with no discernible
the symptomatology is diffuse, the Tc-99 and Ga-67 bone trabeculae. No visible matrix is a pertinent negative and may
scans should be considered to determine involvement. be a giant cell tumor or cyst.
CT imaging of tumors is used to evaluate tumor matrix more
BONE TUMORS AND TUMOR-LIKE LESIONS effectively and determine cortical vs medullary lesions.
Evaluation of plain films – plain film analysis offers the most MRI of tumors in used to asses soft tissue and marrow
diagnostic information for the analysis of bone lesions. involvement, but does not provide much for osseous tumors.
Osteoid Osteoma (OO) is a fairly common tumor seen in 10- Chondromyxoid Fibroma (CF) is a very rare tumor that is
30 y/o. It is characterized by a visible central nidus of less metaphyseal, geographic, and multiloculated. It occurs in all
then 1cm that is seen in the tibia/fibula or spine (causing ages and is seen in the LE. Pain is “vague.” It may extend all
painful scoliosis.) The nidus may or may not have a central the way to the physis.
area of calcification. Pain is felt at night and is described as a Osteochondroma (OC) is a cartilage-capped exostosis of
dull pain which responds to ASA. It may take 6-24 months to bone. It is common in the general population, and is usually
make a Dx. If near a joint the OO can cause joint effusion and discovered in adolescence as a painless, hard “lump.” The
pain that can look clinically like JRA. The main D/dx is stress location is usually metaphyseal, and the exostoses
fx. MRI is frequently misleading in dx. Tx is sx or characteristically point away from the joint. Malignant
radiofrequency ablation (90° C.) transformation may have occurred if painful, greater then 2cm,
Osteoblastoma (OB) is a very large osteoid osteoma that is or growing after skeletal maturity. Multiple hereditary
also very rare. It is seen in the same populations and in the osteochondromatosis (MHO) is a multiple variant that is
same locations but with milder symptoms (despite greater autosomal dominant. It frequently causes growth disturbances
size.) The nidus may be greater than 1.5cm and can have in children and carries a 20% chance of malignancy.
multiple internal calcifications. It causes less reactive Benign Perosteal Osteochondromatous Proliferation
sclerosis than OO. (BPOP) is a very rare finding seen in adults aged 20-30 y/o.
Osteosarcoma (OS) has several variants. Paraosteal and Sometimes also called “nora’s lesion,” BPOP is benign, but
medullary (low grade) have good prognoses. Pagetoid and has a very high rate of recurrence if removed.
radiation-induced OS has a poor prognosis. Telangectatic OS Chondrosarcoma (CS) occurs de novo or secondarily from
causes many complications, but often responds to chemotx. conversion of a benign lesion. The average age is 40 y/o.
Classically, OS is a medullary tumor seen in the metaphysis of Pain is the primary s/sx. Lesions are typically geographic and
10-25 y/o. Most are seen in the femur near the knee. metaphyseal, with lucent centers filled with small
Diagnosis is by pain, X-ray, and elevated levels of alk phos. calcifications. Tx is w/ sx. Variants of CS include clear cell
Radiographically it appears cloud-like with sunburst periosteal chondrosarcoma (CCC) which is an epiphyseal lesion (looks
reaction and codman’s triangle. Skip lesions or lung like CB but in older patients) and dedifferentiated
metastasis indicates a poor prognosis. Paraosteal chondrosarcoma in which part of the lesion is low-grade and
osteosarcoma (PaOS) is seen 5-10 years later then medullary another part is high grade.
OS and is more common in females. It causes dull aching Non-Ossifying Fibroma (NOF) and its relative the Benign
pain and carries a better prognosis than OS, unless it extends Fibrocortical Defect (BFOD) differ only in their location; the
into the medulla. Periosteal osteosarcoma (PeOS) is a rarer NOF is medullary and the BFOD is cortical. It is most
lesion that has similar age, location, and s/sx as medullary, but common in children, and is usually asymptomatic unless there
is located in the diaphysis and carries a better prognosis. is a pathological fx. X-ray shows a sclerotic border in the
Paget’s Disease (P) is thought to have a viral cause, and is growth plate to the diaphysis. DO NOT BIOPSY NOFs.
seen primarily in English-speaking countries. Affected bones With age the lesion usually regresses. Jaffe-Campanacii
have a thick cortex and accentuated trabeculae. Paget’s syndrome is multiple NOFs with café au-lait spots.
predisposes an individual to OS, CS, FS, GCT, and MFH. Fibrous Dysplasia (FD) is a benign fibroosseous lesion of
Enchondroma (E) is a benign, intramedullary, cartilaginous bone that is usually unilateral (75%) and has a geographic
lesion. It occurs in any age and is characteristically painless. appearance. The hallmark radiographic feature of FD is a
It is normally seen in hands and feet and may cause ground glass matrix. Dense areas of calcification may also
pathological fx. The lesions appear geographic with central be seen. FD presents typically with deformity and sometimes
calcifications, possibly with endosteal scalloping or expansion. pain, secondary to fx. Albright’s syndrome is polyostotic FD
Ollier’s disease is the condition of multiple enchondromatosis with café au-lait spots and endocrine abnormalities. As
that may predispose to malignancy. It is more common in opposed to Jaffe-Campanacci syndrome, where the lesions
children and causes growth disturbances. Maffucci’s disease have a smooth border, albright’s syndrome lesions have a
is hereditary multiple enchondromatosis with soft tissue rough border. Mazabraud’s syndrome is polyostotic FD
telangiectasias as well. Prognosis for Maffucci’s is very poor, with intramuscular myxomas. The shepherd’s crook
with almost 100% malignancy. deformity is also a hallmark of this type of lesion.
Juxtacotical Chondroma (JC) is a solitary cartilaginous Osteofibrous Dysplasia is an intracortical FD of the tibia
tumor that causes erosion of surrounding bone. The average (usually) seen in childhood. It is very uncommon. It is
age is 22 y/o and is seen most commonly in long bones of the usually painless and has the characteristic ground glass
hands and feet. The tumor is symptomatic, causing pain and appearance. It is associated with adamantinomas.
swelling in the area. In 50% of cases ST calcification may Fibrosarcoma (FS) occurs in the 3rd to 6th decades of life and
also be seen, with erosion and “saucerization” of the bone. present as an aggressive lytic lesion with no matrix and no
Chondroblastoma (CB) is a benign cartilaginous tumor of the periosteal reaction. Its location is generally metaphyseal. It
epiphysis. It is seen in individuals with open growth plates may also arise secondary to other lesions as well (including
(teenaged) and is geographic in nature. Calcifications are seen infarcts.)
in 50% of cases. Pain and joint effusion may cause CB to be Giant Cell Tumor (GCT) is a locally aggressive lesion that is
mistaken for arthritis, much like OO. usually benign but not always. It presents as a lytic lesion in
the metaphysis extending into the epiphysis (and is the only
one to occur in this area.) There is no matrix associated with and without sclerosis. Bone scans and MRI are unreliable in
GCT. The lesion may destroy the cortex and invade the ST as dx. MM commonly has the POEMS syndrome –
well. It most commonly occurs in the femur, radius, humerus, polyneuropathy, oganomegaly, endocrine abnormalities, M
and sacrum. It is slightly more common in females. S/sx proteins, and skin lesions.
include pain. The Giant cell reparative granuloma is a Hemangioma is a common benign or congenital lesion most
cousin of GCT presenting with lucent lesions of the hands and commonly seen in the skull and spine. It appears to have
feet seen in children. It typically does not break through the vertical striations in the spine and radial spokes in the skull.
periosteum. It may mimic and be hard to distinguish from CT shows a polka-dot pattern. It is usually asymptomatic.
brown’s tumors, even on histology. It is also called a solid Hemangioendothelioma is a rare lesion seen in the lower
aneurismal bone cyst. extremities. It presents as a cortical defect similar to
Unicameral Bone Cyst (UBC) is a very common benign hemangioma. It is typically seen in the middle-aged.
lesion often seen in the distal calcaneus. It is medullary and Eosinophilic Granuloma (EG) is a non-infectious granuloma
fluid-filled, and may be an incidental finding (although it can with histiocytes and eosinophils proliferating. Most are seen
cause pathological fx.) It is geographic, with sclerotic borders. in the skull and vertebrae, but it may also occur in the lower
It typically arises at a growth plate, migrating later into the extremity. Langerhans Histiocytosis is unifocal EG in one
diaphysis with age. 90% are seen in the humerus and femur. organ system. Hand-Schuller-Christian Disease is
The hallmark of the UBC is the fallen fragment sign (piece of multifocal in one organ system. Letterer-Siwe Disease is
cortex within the center of the lesion.) Tx is observation, multifocal and multisystem. The average age of EG is 15 y/o.
steroid injection, of sx bone graft packing. There is little periosteal reaction, and there may be a
Aneurysmal Bone Cyst (ABC) is a lytic expansile lesion sequestrum (especially in the skull.) The lesions may appear
noted for the blood-filled cavities it forms. It may arise de punched-out. The typical presentation is with a spontaneous
novo or post trauma, or may be associated with CB, GCT, compression fx. They are typically diaphyseal. Bone scans
NOF, OB, CMF, or FD. It presents with pain in the long are unreliable in dx.
bones and axial skeleton. It is usually seen in teenagers. Its Adamantinoma is a rare, locally aggressive lesion seen
hallmark are fluid-fluid levels of two layers seen on MRI almost exclusively in the tibia. It appears in the 3rd to 5th
representing old coagulated blood and new, unsettled blood. decades as an eccentric, lobulated lesion. Periostitis is rare.
Fluid-fluid levels are also seen in telangectatic OS, MFH, and Local pain and swelling are apparent on examination.
FD. Metastatic bone tumors are the most common type of bone
Interosseous Lipoma (IL) is a benign asymptomatic lesion malignancy, primarily from the breast, prostate, lung, and
that is typically an incidental finding. It is usually seen in the kidney. Periosteal reaction is rare. Location is based on the
calcaneus. It can have a central area of calcification, but is tissue type. Blow-out lesions are renal and thyroid based.
noted for its central area of fat on CT and MRI. It is seen in Peripheral and cortical lesions are lung metastases.
the same locations as UBCs.
Intraosseous Ganglion (IG) is a benign lesion of the
subcortical bone typically seen in the middle-aged. It can RADIOLOGY OF SYSTEMIC DISORDERS
present with pain. It may resemble a subchondral cyst on x- Changes in the trabecular pattern in bone are indicative of
ray (but in the absence of DJD). It is most commonly seen in reconstructive mechanisms and may suggest systemic disease.
the medial malleolus. It may also look like GCT but with a Osteoporosis, osteomalacia, and hyperparathyroidism all cause
lobulated matrix. a generalized loss and coarsening of the trabeculae. In many
Ewing’s Sarcoma (ES) is a common primary bone tumor cases, this can also happen with anemias, storage diseases, and
seen in children, presenting with pain, low-grade fever, wt neoplastic disorders as well. Etiologies of abnormal bone
loss, and an elevated sed rate. It is rare in AAs. It has the texture include generalized overactivity of cancellous bone
appearance of a small blue-cell tumor which it shares with resorption, infarction due to disruption of blood supply, and
primary lymphoma and multiple myeloma. It is most common growth retardation due to localized hypoxia (in children.)
in the lower extremities. The lesion is permeative and has no ANEMIAS
matrix. It produces an onion-skin type periosteal reaction. Anemias that affect bone density include sickle cell
The location can be metaphyseal or metadiaphyseal, and anemia, thalassemias, and iron deficiency anemia. Sickle Cell
produces a soft tissue mass surrounding the lesion. A variant Anemia puts pts at risk for salmonella infections seeded
of Ewing’s is primitive neuroendothelial tumor (PNET) hematogenously, with osteomyelitis occurring in the
which has the same appearance, prognosis, and treatment, but diaphyseal region. Marked edema of the hands and feet may
is associated with a chromosome translocation. be seen secondary to this infection. Bone density is lost in the
Primary lymphoma of Bone appears similar to ES but in a spine, flat bones, and long bones with a coarse trabecular
much older patient. Pain is usually the presenting symptom, pattern. The hallmark is fish vertebrae that appears as a
but there are no systemic signs. biconcavity of the vertebral bodies on lateral x-ray (with disc
Multiple Myeloma (MM) is the most common primary space preserved.) Periostitis is also seen in the hands and feet.
malignancy of bone, seen in older individuals. It presents with Bones of the hands and feet can also be infracted in children
pain, weakness, or neurological symptoms. It sometimes with sickle cell – the hand and foot syndrome causes
presents with a solitary bone lesion called a plasmacytoma. localized infarction leading to early closure of growth plates in
On x-ray there are cookie-cutter lesions that appear osteopenic the affected bones. This causes periosteal new bone
formation (appearing 1-2wks post injury) and may lead to infiltrative/collagen diseases, infection and/or idiopathic. The
AVN. Cortical infarcts are more common, and the femoral increase in bone density seen in an infarct is due to crushing of
head is most affected. Infarcts within long bones may present the avascular debris, calcification of fat necrosis, hyperemic
on x-ray as calcified fat necrosis, which may look like a tumor removal of viable bone surrounding, bony apposition, and
(fibrous dysplasia.) The bone infarcts can also make the bone periosteal involucrum formation.
prone to infection and pathological fx. Infarct of the distal ENDOCRINE DISORDERS
tibia can lead to premature closure of the epiphysis laterally, Acromegaly/Gigantism are both disorders characterized by
causing a characteristic tibiotalar slant with a valgus attitude. excess in growth hormone. The result is joint space
Thalassemias are gene deletions of primary hemoglobin narrowing, bony sclerosis, cyst formation, and osteophytes
subunits, causing a microcytic hypochromic anemia. similar to DJD. It usually affects the acral skeleton most. In
Radiographically they present similarly to sickle-cell anemia, the foot there is seen sausage digits, enlarged sesamoids/MPJs,
with the notable exception that infarcts are generally not seen. prominent metatarsal heads, prominent tufts and bases of
Trabeculae may take on a “honeycomb” pattern and long phalanges, enthesis development, and constriction of proximal
bones typically take on an Erlenmeyer flask morphology. phalangeal shafts. Fat pad thickening is a radiographic
Secondary centers of ossification may be delayed. Iron hallmark of acromegaly. Hypertrophy of the bases and tufts of
Deficiency Anemia characteristically causes osteoporosis of the distal phalanges causes secondary bony fusion resulting in
the hands (in severe cases) and transverse striping of the pseudoforamina formation unique to this disease.
metaphyses. Radiographic changes are more readily apparent Hyperparathyroidism causes generalized bone resorption
in the pediatric population. subperiosteally, intracortically, endosteally, and sub-
LIPID STORAGE DISEASES ligamentous. Bone sclerosis and chondrocalcinosis are also
Gaucher’s Disease is a disorder characterized by the seen. Brown’s tumors are unique to hyperparathyroidism.
accumulation of cerebrosides in reticuloendothelial cells. The Renal Osteodystrophy is a disease of chronic renal failure
lower extremities are more commonly affected. The classic that causes hyperparathyroidism, rickets/osteomalacia,
presentation is ischemic necrosis of the proximal femur with osteoporosis, soft tissue calcification, and vascular
Erlenmeyer flask deformity. calcification. Osteomalacia and Rickets primarily are caused
Niemann-Pick Disease is an inherited abnormality of by Vitamin D disorders, and cause bowing of the tibia and
sphingomyelin metabolism seen most commonly in persons of periarticular calcification.
jewish descent. Radiographically a widening of the medullary Hypoparathyroidism may be primary (deficiency or
cavity, coarse trabecular pattern, thinned cortex, failure of destruction of the gland) or secondary (gland unresponsive.) It
tabulation, and loss of bone density are seen. The Erlenmeyer causes spinal calcifications that appear like osteophytes (of
flask deformity is also seen. DISH). Pseudohypoparathyroidism is the most common
Sarcoidosis is a systemic granulomatous disease involving the secondary disease, causing a short stature, round face,
skin, lungs, lymph nodes, and viscera. 10% of patients have brachydactyly, exostoses, cone epiphyses, and wide bones.
bone involvement. Children are rarely affected. Women are more affected than men.
Radiographically dx is made with CXR; in the extremities the Hyperthyroidism is characterized by a general catabolic state
middle and distal phalanges can show cyst-like punched out of the body, resulting in loss of connective tissue as well as
lesions in the cortex. increased bone turnover. Osteoporosis is a common initial
Pancreatitis causes fat necrosis of the bone marrow (which is finding. Other findings include accelerated skeletal
also seen in cancer of the head of the pancreas.) maturation and myopathy. Thyroid acropachy is a
Radiographically bone infarction follows the fat necrosis complication of hyperthyroidism that includes progressive
stage, with calcification and ossification of the affected exopthalmos, hand and foot swelling, digital clubbing,
marrow. The long bones of the hands and feet are most pretibial myxedema, and periosteal new bone formation (mid-
affected. diaphyseal), particularly of the 1st metatarsal. The edema has a
Dysbaric Osteonecrosis (Caisson disease) is a pressure- nodular appearance.
induced osteoarthopathy seen in deep-sea divers. It presents Hypothyroidism (Myxedema) is caused by a deficiency of
as small localized infarctions of bone due to the formation of TSH, thyroid hormone, or iodine. In infants the disorder is
nitrogen bubbles within the body. called cretinism. In adults the disorder causes edema, dry
Hemophilia is a disorder of blood coagulation due to plasma skin, coarse hair, lethargy, fatigue, paresthesia, and
clotting factor deficiency. Classic hemophilia (A) is due to bradycardia. Tarsal tunnel syndrome is also a common
factor VIII, Christmas disease (B) is due to factor IX. Both finding.
are X-linked diseases. Radiographically bleeding is apparent Paget’s Disease (Osteitis Deformans) is a disease of unknown
sub-periostally, intraosseously, and intra-articularly. The etiology. It, as well as fibrous dysplasia, are known as the
chronic hemarthrosis due to joint bleeding causes destruction great masqueraders of bone disease. (Outside of bone, gout
of the hyaline cartilage secondary to lysosomal enzyme release and syphilis are also known as great masqueraders.) Paget’s is
in the breakdown of blood products. Hemophilia can also normally seen in the axial skeleton, but can affect any bone.
cause premature closure of the epiphyseal plates, causing The pelvis, femur, skull, and tibia are most common. Its
tibiotalar slant seen also in sickle cell anemia. incidence is 4-6% in individuals over 40 y/o. Deformities
Metaphyseal and Diaphyseal Infarcts are usually due to associated with Paget’s include femoral bowing (shepherd’s
occlusive vascular disease, sickle-cell anemia, caisson disease, crook), tibial bowing (sabre shin), liontiasis (lion facies), and
pathological fracture (banana fxs.) Pseudofractures, seen normal bone density, increased joint space, capsular swelling,
also in osteomalacia/rickets, are also known as umbua zonen metaphyseal osteopenia, and a widened growth plate.
and looser’s lines – they represent demineralized areas of bone The Revascularization Phase sees infiltration of new blood
that are not actually fxs, although they appear that way on x- vessels and fragmentation of the dead parts. On x-ray you see
ray. The stages of Paget’s disease are a sclerotic rim, new bone deposited on old bone (snow cap
1) Destructive phase – increased osteoclastic activity and sign), fracture inferior to the articular cortex (crescent sign),
osteoporosis circumscripta, both difficult to dx early. clefts and fragmentation, flattening of articular surfaces, a
2) Combined phase – bone destruction/turnover and fibrous widened metaphysis, and “head within a head” appearance.
bone replacement. The Repair and Remodeling Phase includes new bone
3) Sclerotic stage – uniformly thickened trabeculae, ivory deposition replacing bone resorption. On x-ray you see
appearance of bone (see also psoriasis), and bone expansion. reconstitution of the epiphysis and the disappearance of clefts.
4) Malignant degeneration – metaplasia to osteosarcoma (rare) The Residual Deformity (stage 4) includes restitution of the
Lab findings for Paget’s show elevated alk phos (x20) and epiphysis, with the amount of deformity dependent on
hypercalcemia. UA may show urinary hydroxyproline. Bone compressive forces on the affected bone. On x-ray you see a
scan shows multiple hot spots (sometimes solitary). Course is deformed articular surface, usually flattened.
slow and treatement is with calcitonin and supportive therapy. Legg-Calve-Perthes Disease is a true AVN of the capital
Massive Osteolysis (Disappearing bone disease) is a disorder fragment of the femoral epiphysis in children. Males are more
causing sudden resorption of large areas of bone without commonly affected than females. 3-12 y/o is the average age.
malignancy. It is associated with lymphangioma or Prognosis worsens with later ages. 1 in 10 are bilateral.
hemangioma and clinically presents with pain. X-ray findings Clincally the pt has limp and a vague pain in the groin that
show apparent disappearance of bone, (tapering off in long may extend to the knee. Pain is exacerbated with activity.
bones), with no periosteal reaction noted. There is often muscle atrophy in the thigh and a history of
Diabetic Osteolysis is a disorder characterized by marked trauma in the affected individual. The etiology is unknown.
resorption with neuropathic changes. It is seen in the absence Blount’s Disease is not a true AVN, seen in infants affecting
of an infectious process, although that is usually a d/dx. It the medial tibial epiphysis. The failure of the growth plate in
may be the result of a viral infection. Radiographically a this area contributes to the formation of a tibia/genu varum.
decrease in ST density, local osteoporosis, distal resorption, Osgood-Schlatter Disease is not a true AVN either, affecting
licked candy stick appearance, and apparent bone the tibial tuberosity. It is caused by a partial disruption of the
“regeneration” are apparent on x-ray. tibial patellar ligament (w/ or w/o avulsion). Commonly
Poliomyelitis radiographically presents with severe cavus ossific nodules are seen with this disease, forming a large,
deformity, severe osteoporosis, short metatarsals and prominent tibial tuberosity. The course is self-limiting and
phalanges, and a ground glass appearance of medullary bone. affects mainly males 11-15 y/o.
Neurofibromatosis is a hereditary disease of mesodermal Sindig-Larsen-Johannson Disease is not an AVN, but is
origin causing café-au-lait spots, skin neurofibromas, bone looks similar to Osgood-schlatter disease. It is a traction
deformity, and local gigantism. Bone deformities include induced avulsion fragment of the lower patella.
kyphosis, bony erosion, local overgrowth, overtubulation of Diaz Disease is a true AVN of the talus. It is usually caused
long bones, pseudoarthroses, and lytic areas of bone. by trauma, graded by the Hawkin’s classification system. A
positive Hawkin’s sign indicates revascularization.
AVASCULAR NECROSIS AND Sever’s Disease is a non-AVN of the calcaneus. It is
OSTEOCHONDRITIS DESSICANS calcaneal apophysitis caused by traction of the calcaneus. It
Avascular Necrosis (AVN, epiphyseal ischemic necrosis, presents with heel pain and irregular ossification on x-ray. All
osteonecrosis, osteochondrosis, epiphysitis, and aseptic radiographic findings, however, may also be seen in normal
necrosis) is a disruption of the vascular supply of bone leading children. Examples include a sawtooth metaphysis, decreased
to the death of an osseous structure. Primary causes are metaphyseal density, increased density of the apophysis, and
unknown. Secondary causes can be fracture, sickle cell fragmentation of the apophysis. Males and females are
anemia, long-term corticosteroid use, and alcoholism. affected equally. The primary D/dx for sever’s disease is
Clinically, AVN is variable and relatively minor in spring heel (hematogenous osteomyelitis of the calcaneus.) In
symptomatology. Pain and disability progresses as it is spring heel, the plantar tubercles typically show signs of
untreated. AVN normally lasts about 9 mos, but in some cases deossification, not seen in sever’s disease.
(legg-calve-perthes) it can last up to 8 years. Spontaneous Kohler’s Disease is a true AVN of the navicular seen in males
AVN occurs in the distal femur, femoral head, and metatarsal around 5 y/o. It presents with localized pain, edema,
heads. Trauma-induced AVN occurs in the talus. tenderness, and decreased ROM. Some pts have a
Alcoholism-induced AVN occurs in the femoral head. congenitally small navicular – an incidental finding of a very
Surgery can also be a cause of AVN. small navicular on x-ray may not be kohler’s. The appearance
The Avascular Phase of AVN is the actual loss of blood should be patchy or uniform sclerosis, collapse (silver dollar
supply, leading to bone death, failure of epiphyseal growth, sign), and fragmentation of the bone. The joint space is
minimal bony deformity, reactive hyperemia, synovial usually preserved.
thickening, and edema. On x-ray you see a small epiphysis, Iselen’s Disease is a non-AVN of the fifth metatarsal base. It
is actually a tractional apophysitis and is self-limiting.
Freiberg’s Disease is a true AVN of the metatarsal heads. represented by increased TC angle, anterior Cyma line, and
The second metatarsal is most commonly affected, particularly sagging of the metatarsocuneiform joint.
in pts w/ a long 2nd metatarsal. There is tenderness and pain Heel Pain – Lateral: Lateral heel pain is the most rare
over the affected MPJ, and the pain is exacerbated with presentation. It can be caused by sural nerve entrapment,
activity. Infarction of the epiphysis leaves necrotic bone that calcaneo-fibular irregularities, peroneal tendon problems,
causes degenerative changes and cortical thickening. tarsal coalition, and ankle/RF varus deformities.
Adaptive changes occur on the juxta-articular surface Midfoot to Rearfoot Relationship: Calcaneal pitch is
(flattening and broadening of the joint space.) Theimann’s normally between 10-20 degrees – greater than this is pes
Disease is a non-AVN of the fingers and toes that is extremely cavus and less is pes planus. A supinated foot will have an
rare. It occurs secondary to trauma and is attributed to accentuated or bullet hole sinus tarsi, while the pronated foot
multiple ossification centers in the phalanx. will have a pseudo sinus tarsi which is in fact the posterior
Sesamoid AVN is called Trevor’s (fibular) or Renandier’s subtalar joint facet being brought into the plane of the film.
(tibial) and occur secondary to trauma and fracture. Cavus Foot Structure: Typically caused by neurological or
Osteochondritis Dessicans (OCD) is a disease of unknown muscular imbalance. Forefoot cavus has an apex at the
etiology affecting children and adolescents, typically male. A lisfranc’s joint. Midfoot cavus has its apex at the chopart’s
small segment of necrotic bone forms subchondrally, which joint. Rearfoot cavus is calcaneal in nature and has a
may heal spontaneously or become a joint mouse. Joint mice calcaneal inclination angle of >30 degrees (and claw toes.)
in these cases are typically symptomatic because the major Foot Faults are sections of the foot where adjacent segments
component is cartilage, which is not visible on x-ray. are improperly aligned. Hindfoot/Subtalar/Midtarsal Fault
Symptoms are joint effusion, pain on ROM, crepitation and Syndrome is characterized by an anterior Cyma line, pseudo
locking and localized tenderness (vague to the ankle). The sinus tarsi, increased talar declination angle, decreased
disease may be hereditary. There are two types of OCD – In- calcaneal inclination angle, everted cuboid, and less than 85%
situ and displaced according to the fragment. coverage of the talar head. The cuneiform-navicular fault
Radiographically they look similar to talar dome fractures. occurs at the CN joint. The medial cuneiform is plantarly
displaced, and the CC joint has decreased joint space dorsally
ADULT FOOT DISORDERS (with increased space plantarly.) The foot appears longer.
Heel Pain – Plantar: R/O soft tissue involvement, fissuring, Pes Valgo-Planus: The acquired form has a calcaneal
tumor, and nerve entrapment. Plantar fasciitis presents inclincation angle >10 degrees (normal) but the inferior
radiographically as increased ST density of the plantar fascia, surface of the calcaneus is concave. The congenital form
and deossification of the calcaneus with accentuation of the (CCPV) has a low calcaneal inclincation angle with a convex
tensile trabecular patterns (do not confuse w/ stress fx.) Heel inferior surface of the calcaneus.
spurs are sometimes seen in plantar fasciitis but also can be Diabetic Neuropathy occurs an average of 16 years after the
caused by the pull of the FDB, Abd hallucis, Abd digiti diagnosis of Type 2 DM (AODM). 74% present with a foot
minimi, and the long plantar ligament. Heel spurs account for ulcer, particularly if loss of proprioception is involved. The
15% of all adult foot complaints. They are typically directed forefoot ulcerates twice as commonly as the rearfoot. Charcot
forward from the medial tubercle. They are assoc w/ obesity, neuroarthropathy has three stages of destruction, coalescence,
pes cavus & pes planus, and osteophytosis. It is important to and remodeling.
note that the size of the spur has no effect on the symptoms, Stress Fractures (aka march/fatigue fx) occurs most
and oftentimes the contralateral (asymptomatic foot) will have commonly in the metatarsals, esp the 2nd (38%), then the
a spur of equal or greater size. 90% do not require any type of calcaneus (28%), and tibia (24%). Early X-rays appear
sx intervention to tx. Fluffy heel spurs are associated with normal, however it may appear radiographically over time and
certain arthropathies, particularly Reiter’s, ankylosing as symptoms persist.
spondylitis, psoriatic arthritis, RA, and Paget’s disease. Other Hallux Abducto-Valgus (HAV): Is evaluated
causes of plantar heel pain include calcified bursae, biomechanically by radiograph.
atrophied fat pad (measuring 15-23mm), steroid-induced Normals: IM 10-20 PASA 0-8
calcification, and nerve entrapment. Nerve entrapment can HA 0-15 DASA 0-5
be differentiated from plantar fasciitis by its response to MA 12-15
steroids (relief in plantar fasciitis, no change in nerve Other factors evaluated are tibial sesamoid position, total
entrapment), and with nuclear scanning (+ in plantar fasciitis). adductory angle, metatarsal break angle, and bone density.
Heel Pain – Posterior: Tendo-Achilles (partial tear or The joint status is described as congruous, deviated, or
complete tear/AODM), retro-achillean bursa (caused by subluxed. Positional HAV is one where PASA+DASA<HA.
shoe irritation), or retro-calcaneal bursae/Haglund’s Structural HAV is one where PASA+DASA>HA.
deformity (most common.) Combined HAV is if the PASA+DASA >>>HA.
Heel Pain – Medial: Tarsal Tunnel Syndrome is caused by Hallucial Sesamoids are located in the tendon of FHB and
chronic irritation of the posterior tibial nerve in the flexor ossify between the ages of 8-12 (earlier in females than
retinaculum and inferior to the medial malleolus (seen w/ RA, males.) Up to 1/3 are multipartite, esp the tibial.
AODM, trauma, fx, and dislocation.) Medial calcaneal nerve Osteonecrosis of the tibial is termed renandier’s, while that of
entrapment and posterior tibial tendon dysfunction are the fibular sesamoid is trevor’s. An interphalangeal sesamoid
other causes of medial heel pain. (Radiographically
is present in 43% of individuals (esp males), and is usually densities, congenital pseudoarthroses (mainly in fibula/tibia),
bilateral. It may contribute to IPJ HPK formation. marked cortical thickening, and a hypoplastic pelvis.
Dwarfism is a plastic condition of localized bony
PEDIATRIC RADIOLOGY undergrowth. It occurs when tumor, radiation, or primary
Ossification of bones in the foot occurs sequentially from birth developmental defects cause the epiphyseal plates to
to adolescence, and knowledge of this order is necessary for a prematurely close. The tibia is typically shorter than the
physician to determine the correct skeletal age of a patient. fibula, the distal femoral metaphysis is hypoplastic, and the
The talus, calcaneus, metatarsals, and sometimes cuboid are tibial and fibular metaphyses are cupped. Kyphosis is the
ossified at birth. Then the order of ossification is medial most common skeletal abnormality. Equinus is a common
cuneiform at 6 months, intermediate cuneiform at 1 year, foot deformity. There are 3 types of short-limb dwarfism:
medial cuneiform at 1.5 years, and finally the navicular at 2.5- Rhizomelic Dwarfism is a shortening of the proximal
5 years. The sesamoids ossify around 7-8 years of age. segment (humerus or femur)
Common variations include an independent ossification center Mesomelic Dwarfism is a shortening of the intermediate
of the medial malleolus (20%) or of the distal phalanx of the segment (tibia/fibula or radius/ulna)
hallux, irregular epiphyseal plates, absent epiphyseal Acromelic Dwarfism is a shortening of the distal
ossification in the middle phalanges, 5th digit synphalangism, segment (hand, foot)
bilateral/symmetric cone-shaped epiphyses (which fuse earlier Hurler’s Syndrome is a syndrome characterized by dwarfism,
than normal epiphyses), and pseudoepiphyses, fissues, and mental retardation, kyphosis, hepatosplenomegaly, and coarse
exostoses that may appear similar to fracture. facial features. Radiographically you see shortened shafts of
An accessory navicular is seen in 10% of children, posterior the long bones with tapered ends, particularly in the upper
to the navicular tuberosity, which can cause pes planovalgus extremities. There is also a coax valga and genu varum.
deformity that requires sx excision. The navicular itself Aplasia/Hypoplasia (dysmelia) describes any reduction
ossifies by multiple ossification centers which are malformation. The cause is unknown. They are classified by
asymmetrical and may look like kohler’s disease. extent and orientation. Phocomelia is loss of the intermediate
Similarly, the calcaneal apophysis has multiple ossification segment of a limb. Meromelia is partial absence of a limb.
centers which may look like sever’s disease. The calcaneus Hemimelia is absence of a half (longitudinally) of a limb.
may also have a pseudocyst called the ward’s or neutral They are a part of Fanconi’s anemia and thrombocytopenia-
triangle which appears as a radiolucent circle/triangle in the absent radius synd. Proximal femoral focal deficiency (PFFD)
anterior calcaneus (10%). The calcaneus often has compact is assoc w/ absence of the ipsilateral fibula as well.
bone islands as well. The apophysis of the 5th metatarsal base Polydactyly is the most common excess malformation. It can
runs parallel to the shaft, and should be distinguished from a be isolated or occur w/ syndromes. There is no sex
fracture. predilection and it is most common in the AA population.
RADIOGRAPHIC EVALUATION OF THE PEDIATRIC PATIENT 50% of cases are bilateral. The tetamy & McKusick
The standard AP in infants must use a simulated WB position classification is preaxial (tibial side of 2nd digit) or postaxial
which is accomplished with the knees flexed and held together (fibular side of 2nd digit – 80%). The venn-watson
and an additional 15 degree angulation of the tube. Lateral classification is that preaxial polydactyly has a short
views are positioned similarly, with the beam aimed at the metatarsal w/ wide metatarsal head. Postaxial has a Y or T
ankle. CT scanning is used in peds to determine tarsal shaped metatarsal, or complete metatarsal duplication.
coalitions as well as growth plate abnormalities. MRI can be Brachydactyly is shortening of the digits due to hypoplasia or
used to evaluate unossified structures. syndactyly. It is seen in pseudo(pseudo)hypoparathryroidism,
GROWTH VARIATIONS turner’s synd, sickle-cell, Down’s, and fetal dilantin synd.
Macrodactyly is a localized gigantism of the digits caused by Fusion deformities are errors of segmentation. Syndactyly
fat infiltration, long-standing hyperemia (leading to can be simple (only soft tissues fused) or complex (varying
hypertrophy), or neurofibromatosis. degrees of bony involvement).
Kippel-Trenaunay Syndrome is a localized gigantism of the Apert’s syndrome (discussed earlier) is manifested
hands or feet, usually in only one extremity. Varicose veins radiographically by multiple bony coalitions all over the body,
and port-wine hemangiomas are also present. leading to limitation of motion that is progressive.
Larsen’s Syndrome is characterized by a double ossification Nievergelt-Perlman syndrome is characterized by clubfoot,
center of the calcaneus with a cleft palate, joint dislocation, synphalangism, conduction deafness, ball&socket ankle joint,
equinovarus/valgus foot, broad thumbs, and vertebral flexion deformities, and phocomelia or hemimelia.
abnormalities. Carpenter’s syndrome is polysyndactyly w/ premature
Gorham’s Disease (vanishing bone disease) is massive synostosis of the skull.
osteolysis following episodes of trauma that can to opposing Poland’s syndrome is syndactyly and digital hypoplasia.
bones across joint spaces. Radiographically the bones will Amniotic band syndrome (streeter’s bands) is the formation
appear tapered with an absence of periosteal reaction. The of constriction rings around the limbs, present at birth, which
primary d/dx is charcot foot. leads to distal loss of the limb. The cause is unknown.
Neurofibromatosis is characterized by multiple
neurofibromas with café-au lait spots, lipomas, BIOMECHANICAL ABNORMALITIES
kyphoscoliosis, enlargement of the foot bones, multiple ST
Kite’s (TC) angle is normally 25-50° in peds; however, this lateral view there are two areas of radiolucency called the
angle requires the use of estimated axes for involved bones. retrosternal airspace and the retrocardial airspace – this is
Another method is to compare the long axis of the talus and 1st normal. You should be able to visualize 10 ribs in a normal
MT – they should line up. individual. Intercostal spaces are named by the rib superior.
Rearfoot Valgus is characterized by a high Kite’s and talar The Diaphragm is divided into two on the AP view by the
declination angles, and is seen in flatfoot deformities, vertebrae, making a left and right hemidiaphragm. The right
congenital vertical talus, and neuromuscular disease. side is normally higher due to the liver (and moreso in HSM.)
Rearfoot Equinus is a calcaneal inclincation angle >90°. It is The Pleura can only be appreciated with pathology (pleurisy.)
seen in congenital equinovarus and congenital vertical talus. The Lungs should be evaluated in more depth than the rest of
Rearfoot Varus is characterized by a low Kite’s angle and the chest X-ray because of subtleties that can be easily missed.
nearly parallel talar and calcaneal axes. It is seen in It is recommended to first do a “quick glance” of the lungs to
equinovarus and some neuromuscular diseases. determine if they are the normal shape and density. Then,
Pes Planovalgus is the most common cause of RF valgus. divide each lung into thirds in both the transverse and sagittal
The etiology is uncertain but thought to be related to planes. Then examine each third separately from each other
ligamentous laxity. On X-ray there is abduction of the with respect to the anatomy of each and densities seen therein.
forefoot, laterally displaced navicular, PF calcaneus, DF If pathology is suspected, determine if it is confined within
metatarsals, and PF talus. If seen w/ equinus or a short lobar divisions – almost all lung pathology except tumors are
Achilles, it is termed hypermobile flatfoot. HAV is also a lobar in nature. The costophrenic angles are also important to
common finding. Peroneal spasm may be seen if there is note, as blunting of these angles may be a sign of infection or
tarsal coalition. Most are asymptomatic and require no sx. left ventricular hypertrophy. Bronchi are not normally seen
Pes Cavus is most commonly seen w/ neuromuscular disease, on X-ray unless they are thickened, which is the case in cystic
particularly CMT. Typically there is high calcaneal fibrosis, CHF, or lymphatic obstruction secondary to tumor.
inclination, PF metatarsals, and clawed digits. Supporting structures of the lungs are similarly not seen
Talipes Equinovarus (Clubfoot) is most common in males, normally on X-ray, but in pathological processes these lung
Caucasians & Polynesians, and is hereditary. There are 3 septa, as well as lymphatic channels, can be seen and are
etiologies – intrauterine pressure (most flexible), abnormal referred to as Kerley lines. Kerley A lines are apically
tendon/ligament attachment (difficult to treat), and teratologic located, extending out from the hilum or upper margins.
(assoc w/ arthrogryphosis and myeolodysplasia. Clincally you Kerley B lines are basilar in location, found in the lower lung
see FF adduction, RF varus, equinus, and TN subluxation. On periphery, about the diaphragm. Kerley C lines appear
X-ray there is low Kite’s angle, FF adduction, PF calcaneus, anywhere in the lung, but have a crosshatch appearance.
and stair-stepping of the metatarsals. The talonavicular Kerley lines are seen in interstitial edema/fibrosis, sarcoidosis,
relationship is estimated – Simon’s angle should be btw 0-20°, pneumonia, lymphatic obstruction, connective tissue disease,
TC angle should be >15 and talometatarsal <15° for normal. RA, and scleroderma.
Tx is initially casting, then sx w/ FF correction first (then RF.) The Mediastinum is the last part of the CXR to examine.
Congenital Vertical Talus is assoc w/ arthrogryphosis, Primarily noted in the mediastinum are the heart and great
myelomeningocoele, and chromosomal abnormalities. It is blood vessels. An area of increased density is seen usually on
more common in males and it 50% bilateral. On X-ray it is the left side of the trachea and is called the aortic knob – this
similar to pes planovalgus, but talus is markedly PF, and is where the aorta turns back on itself. The size of the heart is
calcaneus may be in equinus. With DF metatarsals this makes estimated using the cardiothoracic ratio which is normally
for a rockerbottom foot. 2:1 (the heart should be half the width of the lungs in total.)
Cardiomegaly, also known as a “boot-shaped heart,” can be
BASIC CXR INTERPRETATION caused by sports conditioning (normal), CHF, mitral valve
CXR positioning: Standard positioning is with the patient stenosis, chronic HTN, pericardial effusion, and left
facing the cassette for PA, or with their back to the cassette for ventricular hypertrophy. Masses in the medastinum usually
AP projections. The patient is instructed to inhale fully to represent aortic aneurysms. The trachea, located superiorly in
standardize the view. AP projections make the heart appear the mediastinum, is used to determine the midline of the body
magnified b/c it is farther from the cassette – the PA in the CXR. When compared with the aortic knob (which
projection shows clear lung fields and a normal-sized heart. should be slightly to the left) and the right atrium (which
Lateral films are taken with the pathological side closer to the should be slightly to the right), it can be determined if the
film. Normally the position of the patient is standing, w/ arms patient was standing in the correct position for the AP/PA
raised and chin up. However, depending on the condition of view. In peds it is sometimes necessary to visualize the
the patient, sitting or decubitus positioning may be necessary. thymus, however it is normally obscured by other mediastinal
The standard position decreases enlargement and distortion of contents. Therefore, it is the only case in which you take
the heart and vessels, allows the diaphragm to move down, expiratory CXR views, so that the thymus may be allowed to
and shows air-fluid levels better in the chest. When deviate away from the midline and be visualized before the
positioning the film on a viewbox, it should be placed as lung fields. Lastly, the hilar lymph nodes are located on
though the patient is facing you (i.e. heart facing their left.) either side of the medistinum and are readily appreciable on
Osseous Structures to be evaluated in the chest include the X-ray when adenopathy is present.
sternum, clavicles, scapulae, ribs, and thoracic vertebrae. On LUNG PATHOLOGY
Alveolar processes appear as triangular-shaped areas of
increased readiodensity, depending on the extent of
involvement. This presentation is seen in pneumonia,
advanced CHF, ARDS, and PE. Occasionally there may be
the addition of fluffy margins in the case of longer standing
pathology, due to extension of fluid through adjacent acini
through the pore of Kohn. The silhouette sign is the name
given to alveolar pathology that exists in close proximity to
the heart or great vessels – the water-density of the pathology NUCLEAR IMAGING
makes the outline of the heart and vessels (also water dense) to Nuclear imaging (scintigraphy) is used to analyze a number of
be indistinct. organ systems in the body, most commonly bone. This is due
CHF and pulmonary edema cause the hilar lymph nodes and to the fact that bone loss must reach 33-50% to be detected
vessels to become more distinct on X-ray. The fanning out of radiographically, whereas with nuclear imaging changes can
the lymphatic vessels bilaterally produces a “batwing” or be detected within hours. Nuclear imaging can also pick up
“butterfly” appearance and is described so radiographically. pathology that is not clinically visible. Most common
Interstitial processes are those that cause an increase in pathologies indicated are bone tumors, osteomyelitis, stress
radiodensity of the interstitium, meaning bronchi, septa, and fracture, non-specific bone pain, and AVN. The primary
lymphatics. This type of pathologic process is seen in disadvantage to nuclear imaging is poor resolution, which
interstitial pulmonary edema, fibrosis, TB, viral pneumonia, makes this imaging modality non-specific (despite high
metastatic tumor, connective tissue disease, and interstitial sensitivity.)
pneumonitis. Miliary TB is seen as multiple tiny focal areas Uptake of the nuclear tracer in a bone scan occurs in an
of increased radiodensity. Asbestosis appears as an interstitial area where the normal process of bony turnover is upset in any
process in the basilar lung fields. Emphysema is a loss of way. Areas where turnover is increased (typical in injury)
interstitial density due to loss of tissue in the interstitium. show up “hot” or darker on the image, whereas areas where
Besides a change in density, the diaphragm is pulled low infarction or compromised blood supply have occurred show
(making the lung fields appear “tall”), and the heart is deviated up “cold” or blank.
medially. On a lateral view, the sternal angle may be There are a variety of imaging agents available for use in
increased. bone scanning, each with advantages and disadvantages. In
Primary lung lesions may be seen virtually anywhere in the addition to availability and half-life, imaging agents also vary
lung fields. A general rule of thumb when assessing primary according to the carrier molecule that they bind. Technetium
lung tumor is that dense masses tend to be benign, while fluffy is the most common, and may be bound to phosphate (Tc-99,
and ill-defined masses are more likely malignant. Also, if a for bone), pernechate (for brain/blood flow, joint imaging), or
lesion is particularly dense (meaning possibly a calcified albumin (for lung perfusion/VQ scans). Also available are
center), it is increasingly likely that the lesion is a granuloma. gallium (Ga-67, for inflammation) and indium (I-111, also for
Another way to differentiate tumor from granuloma is by inflammation). A new agent, ceretec, uses Tc-labeled
looking at blood flow to the area – tumors tend to be leukocytes and has a shorter t½ as well as increased specificity
associated with blood vessels anatomically, whereas over I-111. For most agents, renal dysfunction is a
granulomas are not. Also important to keep in mind is that contraindication for use.
(for some reason) nipples are visible radiographically, and it is The most basic bone scan uses Tc-99, which incorporates
important to note where these are initially, so that they are not as phosphate in areas of new bone formation. The t½ is 6h,
mistaken for a tumor later. and requires adequate blood supply. Post-injection, uptake
If a lesion is metastatic, it may take on a localized metastasis will be greatest in the bladder, SI joint, ASIS, kidneys,
pattern (one large tumor surrounded by many small ones), or if nasopharynx, lacrimal glands, and epiphyseal plates.
from another source may be scattered throughout the lung Scanning for Tc-99 occurs in 4 phases. First is the
fields. Central cavitation in large tumors is indicative of rapid dynamic/blood flow phase which is taken immediately after
growth and carries a poor prognosis. injection. Little is seen in this phase normally. The second
phase, blood pool, occurs 1-6 minutes post-injection, and
shows vascularity to a particular region. The third phase,
bone imaging, is taken 2-4h post injection and shows bony
turnover (usually the most important.) The last phase,
delayed, is taken 24h post injection, and measures clearance
of the Tc-99 agent from the tissue. For osteomyeltits, Tc-99
can pick up changes w/in 24h (compared to 10d for X-ray.)
Gallium 67-citrate is a different agent which is not
sensitive to osteoblastic activity, and has a long (72h) t½. It is
used to image ST inflammation through binding to iron
binding proteins in WBCs. Normal uptake is seen in the liver,
spleen, stomach, lacrimal glands, intestine, salivary glands,
and breast. Ga-67 is taken up in tumors and abscesses w/in
2h, but is ideally scanned at 36-72h. It is less dependent on
vascular supply than Tc-99, but is only sensitive to infection.
Post-surgical sites can stay hot to Ga-67 for up to 2wks.
Chronic osteomyelitis is negative in Ga-67, + in acute. Tc-99
remains positive in both.
Indium is an agent that is tagged to leukocytes in the
patient’s blood and reintroduced via I.V. It is more specific
than Ga-67 but more dependent on leukocyte chemotaxis. T½
is 28d. I-111 is used to evaluate osteomyelitis (acute), DM
neuropathy, joint infections, bone marrow, and ST infection.
It may show false positives in inflammatory arthritis.
CT is an imaging modality that uses highly focused X-rays to
create detailed images with subtle changes in tissue density
and accurate descriptions of lesion location and size. MAGNETIC RESONANCE IMAGING (MRI)
Computerization also allows 3D reconstruction. The primary MRI is an imaging modality that allows for the visualization
disadvantages of CT are cost and increased radiation exposure. of hydrogen protons in the human body. Hydrogen protons
It is indicated for trauma, coaltions, ST masses, and infection. are present in nearly all materials and are electrically charged,
The X-ray tube rotates around the patient in a CT scan, while within a magnetic field, and spins on its own axis. This makes
opposite the tube are detectors that are used to create an it ideal for differentiating between different tissue types and
image. The image produced is divided into a grid, of which analysis of hydrogen proton concentration gives clues to the
each 2D segment is a pixel, which when coupled with the 3D chemical makeup of the tissues analyzed.
depth is called a voxel. The depth of the voxel is determined The most important component of an MRI scanner is the
by slice thickness. Each voxel is then assigned a number magnet, which can be permanent (exerting 0.4T) or super-
based on the amount of radiation that passed through that conducting (1.5-2.5T) and initiates the process by which the
segment. If the density of tissue is greater than water, the hydrogen protons may be visualized. In the first step of the
number is positive, whereas if the tissue is less dense than process, magnetic field, the magnet is activated around the
water it gets a negative number. (Bone is 1000-3000, air is patients body in the area to be visualized. The second step,
-1000.) In an image, the lowest density is represented by radiofrequency pulse, is a pulsing of electromagnetic energy
black, while the highest is white, and everything inbetween is in accordance with the precession (spin) of the hydrogen
a gray scale, as in X-ray. However, in CT particular densities atoms, which is a frequency called the larmor frequency.
can be windowed, that is, anything below the density window This pulsing at the larmor frequency causes all the hydrogen
is black and anything above is white. This means that great protons to spin in the direction of the magnetic field. Then, in
levels of contrast can be achieved if only the desired the last step, relaxation, the magnetic field is turned off, and
pathological tissue is windowed (others are ignored.) Larger the hydrogen atoms slowly return to their normal spin axes.
windows, then, have lower contrast values. The time which it takes for this to happen is termed relaxation
When ordering CT scans, the specific area of interest also, and each tissue type has different relaxation rates.
should be stated (possibly w/ bone scan), along w/ plain films. Measurement of spin relaxation is the basic principle
Any lesions should have a measurement request, and behind how the MRI produces an image, and the intensity with
reconstructions and magnification are avalible if appropriate. which tissues show up on the image relate to time values
CT scans include a scout film, which shows the location of associated with relaxation. One of these values is T1, which is
specific slices as well as slice thickness. The scout film looks the time it takes for a particular tissue to regain 63% of its
similar to a plain film x-ray. Image reconstruction in CT is longitudinal spin. Another value, T2, is the time it takes for a
used to view sagittal plane slices, which are out of phase with proton to lose 63% of its transverse spin. (Note: T2 is always
the CT scanner and thus must be calculated by the computer. a longer value than T2.) Other values include TR (time to
These reconstructed images are also called secondary slices. repeat – the duration of one imaging cycle), and TE (time to
Finally, there is a specialized CT you can order called a echo – time in which magnetization is converted to RF signal.)
scanogram, which is an image of the entire lower extremity Weighted images are those that emphasize a particular time
from the pelvis, used to measure LLD. A scanogram is value, to focus on a particular tissue type. A type of image
basically a scout film with measurements to determine called proton density is a balance of a long TR and short TE
absolute length of bony segments. interval, which does not emphasize any particular time value.
Overall, CT terminology and analysis is very similar to A STIR image is a special form of inversion recovery in
plain films. It is most effective at analyzing osseous which the T1 time is very short – this is also called “fat
pathology, and is often used in conjunction with bone scans. suppression” because fat tends to show up black. In addition
It is less expensive than MRI but inferior to MRI for analysis to weighting images, contrast can be added (gadolinium,
of soft tissues. gadolinium DTPA) to visualize vascular lesions.
Bone Marrow is mostly composed of fat, which has a short
relaxation time and thus shows up at high intensity for T1
images or low intensity on T2 images. It should be Lipomas tend to be superficial homogenous lesions with the
homogenous in appearance. same signal intensity as surrounding fat, unless calcifications
Cortical Bone lacks free hydrogen, so it appears to have low are present.
signal intensity on all images.
Tendons and Ligaments have low hydrogen content also, MISCELLANEOUS IMAGING MODALITIES
(though higher than bone) and has low intensity in all images. Xeroradiography is a dry process that uses electrostatic
Tendons are contrasted best in T1 weighted images, however. forces to produce an image. Positive xeroradiographs are used
Subcutaneous Fat and all other fatty areas have a high T1 to visualize bone and non-metallic foreign-bodies. Negative
signal intensity and low T2 signal intensity. xeroradiographs visualize soft tissue and metallic foreign
Vascular Supply to an area shows up with low intensity in bodies.
MRI due to movement, called a flow void. This is why Digital Radiography is an X-ray method by which plain films
contrast media are required to visualize blood vessels on MRI. are replaced with phosphor plates that transfer the image to a
Muscle is intermediate in hydrogen density, and thus shows digital signal. This process may produce very detailed images
up intermediate intensity in all images. and can zoom in or out to the tastes of the interpreter.
SAFETY CONSIDERATIONS Liquid Crystal Thermography produces an image dependent
MRI cannot be used with electrically or magnetically activated on skin surface temperature. This is useful in diabetic
implants like pacemakers, defibrillators, or cochlear implants. neuropathy to predict the location of future ulcers, as well as
Metallic objects located within the body will not cause harm, vascular and dermatologic pathologies. Digital
but cause artifact on the MRI readout which may render it thermography is a similar process that involves recording an
useless. If it is suspected that a patient may have a metallic image with a thermal camera.
foreign body in the vicinity of the eyes, an orbital X-ray is Ultrasonography produces an image converted from high-
indicated. Lastly, it has not yet been proven that MRI is safe energy sound waves. Contrast is produced by variations in the
to use on gravid females; for women in their first trimester, it way that different tissues reflect sound. It is most useful for
is advised that a risk/benefit analysis be done before making distinguishing solid from fluid-filled masses, and in most
the decision to go ahead with MRI. pathologies tissue alteration is significant enough for
PATHOLOGY ON MRI ultrasound to detect.
Osseous trauma, including stress fractures, will typically Sinography is an X-ray taken after injecting a sinus with
show up as a decrease in signal intensity on T1WI in the area radioopaque fluid. It is used to determine the size and extent
of trauma, with diffuse increase in intensity on T2WI due to of a sinus tract and the location of potential abscesses.
localized inflammation to the area. STIR images can be Sinography cannot be used if the patient is allergic to iodine.
utilized to see marrow edema. Local tissue necrosis and infection are other side effects.
Avascular necrosis will show a well-defined line of Arthrography is radiographic imaging of a joint space using
demarcation between viable bone and devascularized bone on injected contrast media. A single contrast arthrogram uses a
T1WI. single contrast agent, and is used to determine the extent of
Osteochondritis dessicans will show up as a decreased area acute injury or ligamentous damage. Double-contrast
of signal intensity on a T1WI in the acute stage, but as the arthrograms utilize both positive and negative (air) contrast
condition becomes chronic intensity increases. media, and is used for chronic processes (such as OCD.)
ST infection is best visualized as increased intensity on T2 or Arthrograms may not be taken if the patient has cellulitis in
STIR images due to inflammation in the area. The degree of the area, and joint sepsis is a potential side effect.
contrast seen can differentiate abscess from cellulitis. A normal arthrogram of the ankle should show smooth
Osteomyelitis shows high intensity on T2WI for cortical bone synovial lining with redundant ankle capsule, medial and
as well as low signal intensity on T1WI for medullary bone. lateral recesses, smooth and uniform articular cartilage, and a
Charcot neuroarthropathy shows up as a decrease in signal syndesmotic recess ~2.0cm to the interosseous membrane. In
intensity on T1 and T2WI for affected joints. 15% of pts, there is a communication btw the ankle and
Bone tumors typically have a low to intermediate signal on posterior STJ facet. In 15-20% there is a communication btw
T1WI and higher intensity on T2WI, although they may be the ankle and FHL/FDL sheaths.
high on T1WI if fat or blood-filled. Calcification within a Pathology seen in an arthrogram is typically due to lateral
tumor will also show up as lower intensity on all images. ankle injury, and must be imaged w/in 48h of the incident.
Soft tissue tumors also show up with low T1WI signal Contrast leakage is usually indicative of ligamentous injury.
intensity and high T2WI signal intensity, however, the Injury of the ATF ligament shows extravasation anterior and
composition of the tumor will affect this. Benign lesions tend lateral to the fibula. The CF ligament is close to the peroneal
to be well demarcated, homogenous, and have a less tendons and thus with CFL injury extravasation into these
pronounced change in signal intensity. tendon sheaths is seen. Chronic injury to the CFL will have a
Ganglion cysts are easy to pick out on MRI because of their persistent communication between these two structures. The
very low T1WI intensity and very high T2WI intensity. PTF ligament is rarely injured and is always seen with either
Enchondroma shows up as homogenous and loculated with a an ATFL or CFL rupture as well. Medial ankle injuries are
high T2WI and STIR intensity due to cartilage. Calcifications extremely uncommon. Syndesmotic tears are associated with
may show up as a heterogenous intensity. medial ankle ligament injury, and shows extravasation
superior to the syndesmotic recess.
Other uses for arthrography besides ligament injury may be to
visualize joint mice, synovial hypertrophy, joint infection
(which shows uptake of contrast to lymphatics), and capsulitis.
Tenography is the use of contrast media injected into a
tendon sheath to visualize the course of the tendon it encloses.
It is useful for visualizing post-traumatic tendon injury.
Venography is the use of contrast media to visualize the
course of a vein. It is the gold-standard for visualizing DVTs
but cannot be used in pts w/ an iodine allergy. Side effects
include allergic rxn, induced DVT, and localized skin
Arteriography is the use of contrast media to evaluate
vascular supply. Its use is contraindicated in trauma,
athrosclerosis, AV malformations, emboli, or tumors.
Angiography is visualization of the arterial supply using
computerized digial subtraction to remove non-vascular
structures from the picture. It is indicated in evaluation of
atherosclerosis and AV malformation.