A Compartmental Approach to the

Radiographic Evaluation of Soft-Tissue Calcifications

Kevin P. Banks, MD,* Liem T. Bui-Mansfield, MD,*,†,‡ Felix S. Chew,§ and
Frank Collinson, MD†

Musculoskeletal radiology, like most areas of diagnostic radiology, has seen a dramatic
increase in the use of cross-sectional imaging techniques over the last decade. However,
conventional radiography remains a vital role in the evaluation of disease involving the
spine and extremities. Given its widespread availability and low cost, radiography should
be the initial examination obtained when imaging is clinically indicated. Therefore it is
essential that the practicing radiologists be able to maximize the diagnostic value of this
common study to aid the clinicians with a focused differential diagnosis, if not a definitive
diagnosis. While much emphasis has been placed on radiographic interpretation of osse-
ous lesions, similar diagnostic yield can be often obtained about calcified or ossified
soft-tissue lesions. Detailed evaluation of the distribution and morphology of the soft-tissue
calcifications, combined with a thorough knowledge of the entities that may occur at the
site of the noted abnormality, provides significant interpretive value to provide a definitive
diagnosis or accurately recommend the next most effective management step. We provide
a compartmental-based approach to the interpretation of soft-tissue calcifications.
Semin Roentgenol 40:391-407 © 2005 Elsevier Inc. All rights reserved.

I n the evaluation of osseous lesions, location is often the

most important characteristic in determining the differen-
tial diagnosis. A lytic lesion in the epiphysis of the wrist
quickly focuses the differential diagnosis of chondroblastoma
or giant cell tumor. A similar appearing lesion in the metadi-
aphysis of the phalanges is highly suspect for an enchon-
droma. Similarly, location can provide essential information
about calcified or ossified soft-tissue lesions.
Calcium deposition in the soft tissues is a common finding
on conventional radiographs. The differential diagnosis of
these calcifications is broad and includes vascular, inflamma-
tory, infectious, metabolic, and neoplastic entities (Tables 1
and 2). While abnormal calcifications in the subcutaneous
*Department of Radiology, Brooke Army Medical Center, Fort Sam Hous-
ton, TX.
†Division of Radiologic Sciences, Department of Radiology, Wake Forest
University, Winston-Salem, NC.
‡Department of Radiology and Nuclear Medicine, Uniformed Services Uni-
versity of the Health Sciences, Bethesda, MD.
§Department of Radiology, University of Washington, Seattle, WA.
The opinions and assertions contained herein are those of the authors and
should not be construed as official or as representing the opinions of the
Department of the Air Force or the Department of Defense.
Address reprint requests to Kevin P. Banks, MD, MCHE-DR, Department of
Radiology, Brooke Army Medical Center, 3815 Roger Brooke Drive, Fort
Sam Houston, Texas 78234. E-mail: liem_mansfield@gmail.com
tissues of the appendicular skeleton generate one differential
list of diseases, similar densities in a periarticular distribution
or the axial skeleton produce a distinct list of pathology.
Therefore, the first step in the evaluation of soft-tissue calci-
fications involves a fundamental knowledge of the assorted
compartments in which these various entities may arise.
Depending on the portion of the body being assessed,
appendicular or axial skeleton, these compartments differ. In
the appendicular skeleton we subdivide the soft tissues into
subcutaneous, neurovascular, fascial, muscular, and periar-
ticular compartments (Figs. 1 and 2). In the case of the lower
leg, the subcutaneous tissues are thickest along the sides and
posteriorly, with only a thin layer present anteriorly over the
tibia. As elsewhere, it comprises predominantly fatty tissue
with small components of connective, vascular, and nervous
tissue. Just deep to this is the thin fascial compartment sep-
arating the subcutaneous and muscular compartments.
Composed of tough, fibrous tissue, the fascial compartment
also extends into the muscular compartment where, in the
case of the lower leg, it divides the muscular compartment
into anterior, lateral, posterior superficial, and posterior deep
compartments. The muscular compartment is defined as the
space occupied by the muscles of that extremity and support-
ing tissues. It extends from the fascia superficially down to
the underlying bones. In this example, major contributors to

0037-198X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. 391
doi:10.1053/j.ro.2005.01.021
392 K.P. Banks et al

Table 1 One Approach to Developing a Differential Diagnosis

of Soft-Tissue Calcifications Using VINDICATE (Vascular,
Infectious, Neoplastic, Drug, Autoimmune, Traumatic, and
Extraneous Etiologies of Disease)
Vascular Phleboliths
Infection Cysticercosis
Neoplasm Extraskeletal osteosarcoma or
chondrosarcoma
Synovial osteochondromatosis
Drugs Vitamin D
Autoimmune Dermatomyositis or polymyositis
Scleroderma
Trauma Tendonitis
Heterotopic ossification
Injection granuloma
Extra DISH Figure 1 Schematic representation of anatomical compartments
Ankylosing spondylitis essential to interpretation of soft-tissue calcifications encoun-
tered in musculoskeletal imaging. From superficial to deep: sub-
cutaneous, fascial, and muscular. The vascular distribution exists
as a subset found in within each of three aforementioned com-
partments as well as within periarticular compartment (not
this compartment include the gastrocnemius, soleus, and tib-
shown). (Color version of figure is available online.)
ial muscles. Interspersed within the muscular compartment
are vessels such as the anterior tibial and peroneal arteries,
which comprise the vascular compartment. Finally, there is
the periarticular compartment that is defined by the capsule
surrounding the joint and includes all internal structures. In Appendicular Skeleton
the shoulder joint (Fig. 2), this entails the articular cartilage
Subcutaneous
covering the humeral head and glenoid, labrum, synovium,
glenohumeral ligaments, and tendons. The subcutaneous compartment of the extremity com-
Distinct from those of the extremities are the compartments of prises predominantly adipose tissue with small amounts of
the axial skeleton (Fig. 3). In the spine, the soft-tissue compart- intermixed connective, vascular, and nervous tissue. It is
ments comprise the anterior longitudinal ligament (ALL), pos- bordered superficially by the dermis and deep by the fas-
terior longitudinal ligament (PLL), intervertebral disk, interspi- cial compartment. Given its predominantly fatty compo-
nous and supraspinous ligaments, and paravertebral soft tissues. sition, it is usually of little diagnostic interest on radio-
Unlike the compartments of the extremities, these tissues and graphs. The presence of abnormal calcifications is one of
subsequent calcified disease entities within these compartments the exceptions and their presence is quite conspicuous on
are more singular in nature. the relative lucent background of the subcutaneous tissue.
This anatomic approach allows for practical differentiation When seen, they often represent one of four etiologies:
of soft-tissue calcifications. In the evaluation of musculoskel- tumoral calcinosis, end-stage renal disease (ESRD), sclero-
etal diseases, this entails the subcutaneous, fascial, muscular, derma, or venous insufficiency. A thorough knowledge of
and periarticular compartments, as well as the axial skeletal the typical appearance of calcifications associated with
compartment and the vascular compartment, which is these entities, as well as the clinical context in which they
unique in that it is a subcompartment of each of the afore- present, is central to diagnostic accuracy and avoiding any
mentioned compartments. unnecessary and potentially harmful testing.

Table 2 Common Causes of Soft-Tissue Calcifications, Their Appearance, and Their Relative Prevalence (not accounting for
vascular calcifications)
Prevalence
Causes Typical Appearance (%)
Dystrophic calcifications Small to large amorphous calcifications, may progress to ossification 95-98
CPPD Chondrocalcinosis 1-2
HADD Single glob of calcification at tendinous insertion 1-2
Metastatic calcifications Finely speckled calcifications 1-2
Tumoral calcinosis Multilobulated calcifications, predominantly near large joints <<1
Metastatic osteosarcoma Amorphous, fluffy, confluent collection of calcifications <<<1
Primary extraskeletal osteosarcoma Amorphous, fluffy, confluent collection of calcifications <<<<1
Radiographic evaluation of soft-tissue calcifications 393

Figure 2 Depiction of components comprising periarticular com-

partment in the evaluation of soft-tissue calcifications. (Color ver-
sion of figure is available online.)

Tumoral Calcinosis
Tumoral calcinosis is an uncommon entity first described in
1943 by Inclan and coworkers.1 It is a disease characterized
by the presence of large masses of metastatic calcifications
located in the subcutaneous juxta-articular soft tissues and
extensor aspect of the extremities.2 The cause is thought to be
due to an inborn error of phosphorus metabolism that results
in hyperphosphatemia and an associated high calcium-phos-
phate product (⬎75 mg2/dL2).3 The disease typically is first
seen in individuals by age 20 with a slight male predomi-
nance in some reports.4,5 Black individuals are most fre-
quently afflicted and about a third of cases have a familial
history with the remainder appearing to be sporadic.2 While
the majority of individuals are asymptomatic, diminished
range of motion is a known complication from large juxta-
articular masses as well as neuropathic symptoms due to
compression of nearby nerves.4
The characteristic imaging findings of tumoral calcinosis Figure 4 Idiopathic tumoral calcinosis. (A) Lateral radiograph shows
are calcified masses found in the subcutaneous tissues adja- amorphous calcification in plantar soft tissues of foot. (B) Coronal
cent to joints or along the extensor aspects of the extremities. CT shows calcification with occasional fluid levels. (Reprinted with
permission.38)
They are often multiple in numbers. When juxta-articular,
the lesions most often occur adjacent to large joints such as
the hips and shoulders with their presence having also been
reported around the elbows, knees, and joints of the feet2,3
(Fig. 4). Radiographically, they are lobulated masses ranging
in size from 1 to 20 cm2. They are composed of radiodense
calcified material with intervening radiolucent bands of fi-
brous septa, which has been called “chicken wire” in appear-
ance.3 The radiodense regions may be homogeneously dense
or occasionally show sedimentation on upright radiographs,
but is most readily demonstrated on computed tomography
(CT) or magnetic resonance (MR) imaging.4 If imaged early in
the course of the disease, juxta-articular lesions may be mis-
diagnosed as calcific bursitis. Subsequent studies will often
demonstrate maturation of the lesion to an appearance more
suggestive of tumoral calcinosis. This feature, as well as the
Figure 3 Schematic representation of axial skeletal compartments. frequent occurrence of multiple lesions, aid in proper diag-
(Color version of figure is available online.) nosis. It should be noted that the lesions can grow slowly over
394 K.P. Banks et al

time and have also been known to cause pressure erosions of

underlying bones and therefore these findings may mimic
malignancy.
End-Stage Renal Disease
ESRD is an extremely common disease in the United States
with approximately 8000 renal transplants being performed
each year and over 10 times that number of people undergo-
ing dialysis.6 It is the common end result of numerous enti-
ties, with common etiologies including diabetes and long-
standing hypertension. The systemic manifestations of this
disorder are widespread with musculoskeletal involvement
being one of the more recognized expressions. With contin-
ued advances in hemodialysis and transplantation leading to
improved survival, the radiographic findings of this disease
are encountered with increasing frequency.6 It is an inappro-
priately high level of calcium and phosphorus that result in
the soft-tissue calcifications commonly seen in these individ-
uals. Like patients suffering from tumoral calcinosis, the le-
sions are not generally seen unless the calcium-phosphorus
product exceeds 75 mg2/dL2 and there is a direct correlation
between their prevalence and duration of ESRD.3,6 While
many cases are asymptomatic, large lesions have been re-
ported to cause decreased range-of-motion as well as neuro-
pathic symptoms from the compression of adjacent nerves.
Given their similar etiology, it is not unexpected that the
calcified masses of tumoral calcinosis are closely related ra-
diographically to the soft-tissue lesions found in ESRD. The
lesions are found in the subcutaneous tissues in a juxta-artic-
ular distribution as well as less commonly along the extensor
aspect of the extremities.7 When occurring near a joint, the
masses are typically polyarticular and symmetric.6 On radi-
ography, they appear as well-defined, lobulated, calcified
masses with interwoven fibrous septa (Fig. 5). As in tumoral
calcinosis, fluid-calcium levels can be seen on upright films
or cross-sectional imaging.6 In addition to soft-tissue calcifi-
cations, cases of ESRD often have associated bone resorption
(subchondral, subligamentous), vascular calcifications, and
abnormal bone density (Fig. 6). Figure 5 Paraarticular calcinosis in a patient on hemodialysis for
Scleroderma renal failure. (A) Radiograph shows calcium deposits around hip
joint and gluteal muscles. (B) Axial CT scan shows multiple fluid–
Scleroderma is an idiopathic disorder of the connective tis-
fluid levels within calcium deposits. (Reprinted with permission.38)
sues with a wide range of systemic effects. It is a result of the
deposition of abnormal collagen, which initiates a cascade of
inflammation, fibrosis, and eventual atrophy that accounts
for its features. Women are most commonly affected with have been termed calcinosis. On radiographic evaluation, the
onset of disease usually seen in the third and fourth decades lesions are present in the hands and feet as well as areas of the
of life. Many of its clinical and radiographic manifestations extremities such as the elbow that frequently rub or experi-
are quite characteristic, such as the Raynaud phenomenon or ence other forms of mild trauma.9 Unlike the typical findings
the finding of a dilated esophagus with lower esophageal of tumoral calcinosis or ESRD, the soft-tissue calcifications of
sphincter incompetence during barium swallow examina- scleroderma may be either focal or diffuse with an irregular
tion. Because of this, many patients already carried a diagno- morphology. A cobblestone appearance is often noted, which
sis of scleroderma when soft-tissue manifestations in the ex- may seem similar to ESRD or tumoral calcinosis; however,
tremities are first noted. The calcinosis of scleroderma they are homogenously dense without the associated septa or
comprises calcium apatite crystals and is frequently, but not calcium-fluid levels3 (Fig. 7). Another key diagnostic feature
exclusively, found in areas of sclerodactyly.8 It is not associ- of scleroderma-related soft-tissue calcifications are their
ated with any underlying abnormality of calcium metabo- unique predilection for the hands, being seen in over 50% of
lism. afflicted individuals, a location rarely involved in their radio-
The subcutaneous soft-tissue calcifications of scleroderma graphic mimics.8 This, combined with the common presence
Radiographic evaluation of soft-tissue calcifications 395

of acroosteolysis and distal phalangeal soft-tissue wasting,

aids in the correct interpretation of these lesions.
Venous Insufficiency
While it would first seem that venous insufficiency should be
considered in the same category as the other vascular com-
partment calcifications, in the extremities, they are generally
seen in the superficial venous system and therefore mostly
limited to the subcutaneous compartment. Their develop-
ment occurs in the presence of long-standing varicosities
and/or thrombus formation. These factors result in venous
stasis, which in turn leads to calcium deposition along the
venous intimal layer.10 Due to this mechanism, it is apparent
that their incidence mirrors that of varicose veins, with
women more commonly afflicted than men and the lower
extremities almost exclusively affected except in cases of arm
venous stasis due to prior trauma, surgery, or other condition
that alters normal venous drainage.
On radiographs of the extremities, the calcifications of
chronic venous insufficiency most frequently appear as phle-
boliths in the subcutaneous tissue. These have a characteris-

Figure 6 (A, B) AP views of both shoulders show calcification depos-

ited within both supraspinatus tendon and subchondral bone re-
sorption in distal clavicles.

Figure 8 AP view of left leg in 76-year-old female with chronic ve-

nous insufficiency. There are irregular, large calcifications in medial
subcutaneous tissue that show linear distribution corresponding
Figure 7 Scleroderma with calcium hydroxyapatite deposits and as- with superficial veins. Typical phleboliths are seen inferiorly (ar-
sociated acroosteolysis. rowhead).
396
Figure 9 AP radiograph of ankle in 73-year-old female for follow-up
evaluation of medial malleolar fracture show reticular calcifications
throughout subcutaneous soft tissues consistent with venous insuf-
ficiency.
tic ring shape with central lucency that represents foci of
calcified thrombi. A second well-recognized appearance is
that of small, linear calcifications oriented along the long axis
of the extremity (Fig. 8). In these instances, numerous calci-
fications are typically present and often parallel each other or
show a branching or reticular pattern10 (Fig. 9). Associated
evidence of chronic venous stasis may be present such as
soft-tissue edema or even periosteal reaction of the bones.
Vascular
A subcompartment of the three aforementioned soft-tissue
compartments, the arteries are also subject to the develop-
ment of abnormal calcifications and are an extremely com-
mon radiographic finding in middle-aged and elderly indi-
viduals. Due to their common nature, they are radio-
graphically identical whether they arise in the subcutaneous
tissues or within the muscular portion of the extremities, and
therefore, we consider these lesions as a separate group from
those arising in their surrounding compartment. The calcium
deposits seen associated with arteries can be classified into
two subgroups, atherosclerotic plaques and Monckeberg’s
arteriosclerosis.10 Their distinct pathogenesis and subtle dif-
fering radiographic expression are illustrated below.
K.P. Banks et al
Atherosclerotic
Peripheral Vascular Disease (ASPVD)
Atherosclerotic plaque is the entity responsible for the well-
known disorder of peripheral vascular disease. It is a disease
of the arterial intima that arises from the abnormal deposition
of fatty substances, cellular waste, cholesterol, and calcium. It
typically involves the large- and medium-size arteries and
results in narrowing and possible occlusion of the vessel lu-
men. Additionally, like in the torso, arterial aneurysms are
subject to plaque deposition and its associated calcifications
allowing for their identification on radiography. The typical
clinical picture is of vascular insufficiency with claudication,
diminished pulses, pallor, and decreased extremity warmth.
In instances of aneurysms, patients may experience “blue toe
syndrome” due to distal embolus of microthrombi.
The presence of calcifications is what allows for the visu-
alization of atherosclerotic plaque at time of imaging. They
present as patchy, irregular, plaque-like or even tubular den-
sities of variable shape and size distributed along the path of
large- and medium-sized arteries. The calcifications usually
do not encircle the entire vessel lumen and this trait can aid in
distinction from the small artery calcifications associated
with diabetes mellitus.10 In instances of aneurysms, an oval-
or round-shape outline of calcium can be seen, often with
associated densities of diseased arteries leading to and from
the site of vascular dilation (Fig. 10).
Diabetes Mellitus (DM)
Diabetes is an extremely prevalent disease, being diagnosed
more and more frequently, and afflicting over 120 million
Figure 10 Lateral view of the thigh shows two oval-shaped densities
along the path of a diseased superficial femoral artery consistent
with multiple aneurysms.
Radiographic evaluation of soft-tissue calcifications 397

Dermatomyositis/Polymyositis
Fascial calcifications are almost invariably secondary to the
closely related diseases of dermatomyositis and polymyositis.
Each of these entities is an uncommon idiopathic inflamma-
tory myopathy found in both juvenile and adult forms with
women affected twice as often as men. The two diseases share
the main clinical features of chronic weakness and muscle
inflammation, though dermatomyositis also has prominent
cutaneous manifestations.14 The main difference between the
two disorders is seen in their underlying pathogenesis. Der-
matomyositis seems to be due to immune-complex deposi-
tion within small vessels, while polymyositis appears related
to immune-mediated muscle injury.15,16
It is in the chronic phase of these diseases that calcium
deposition in the soft tissues first occurs. During healing from
episodes of myositis, calcifications develop in areas of necro-
sis involving the fascial planes and sometimes the subcutane-
ous tissues.17 Radiographically, this manifests as numerous
small densities in the appendicular skeleton that go on to
coalesce and become sheet-like in appearance17,18 (Fig. 12). It
is this sheet-like configuration of calcium at the interface of
the subcutaneous and muscular compartments that is highly
specific for these entities. The findings are located predomi-
nantly in the proximal portions of the extremities and occa-
sionally, punctate calcifications also form in juxta-articular
Figure 11 Lateral radiograph of the foot ankle in a diabetic male
sites that go on to become macronodules.17 The accompany-
shows parallel linear calcifications of the posterior tibial artery due
to Monckeberg arteriosclerosis.
ing sheet-like calcifications and their proximal greater than
distal distribution in the extremities help distinguish these

individuals worldwide with a 33% increase in incidence seen

in the United States from the period of 1990 to 1998.11 Sub-
sequently, its sequela is also being encountered more often to
include calcified arteriosclerosis. In addition to an increased
incidence of ASPVD, individuals with DM are also prone to
the development of Monckeberg’s medial arteriosclerosis. As
the name implies, it involves the formation of calcified
plaques in the medial layer of the blood vessels.12 While these
lesions do not cause vaso-occlusion, they do cause dimin-
ished distensibility of the vessel with decreased pulses and a
“pipe stem” characteristic on physical examination and are
often associated with neuropathic symptoms.13
Radiographically, the soft-tissue calcifications of Monck-
eberg’s medial sclerosis predominate in the small arteries of
the distal extremities, particularly the feet. They are seen as a
series of concentric rings that may or may not be connected.10
When connected, they are seen as two parallel lines following
the arterial path, similar to that seen in ASPVD, but finer in
morphology and more continuous (Fig. 11).

Fascia
Deep to the subcutaneous tissue lays a thin, but tough layer of
fibrous tissue that constitutes the fascial compartment. It en-
compasses the underlying muscle compartment and, while Figure 12 Lateral radiograph of knee in a patient with dermatomyo-
rarely a focus of imaging studies, when the fascia is involved sitis shows sheet-like calcifications along fascial planes and subcu-
in a disease process, the findings can be quite distinctive. This taneous tissue, soft-tissue atrophy, and osteoporosis. (Reprinted
is particularly true of calcium deposition in the fascia. with permission.38)
398
juxta-articular lesions from those seen in scleroderma or tu-
moral calcinosis.
Muscle
The largest soft-tissue compartment of the extremities, the
muscular compartment, is bordered superficially by the fas-
cia and deep by the periosteum and joint capsules. As its
name implies, it is composed predominantly of myocytes,
but also has a rich supply of neurovascular tissue that is
central to many of the disease entities encountered in this
region. Numerous entities can lead to calcifications within
the intramuscular compartment, such as vascular diseases,
connective tissue disorders, and myopathies; however, these
disorders will frequently present with distinctive or at least
suggestive calcifications in the previously discussed compart-
ments and will not be further covered in this section. More
commonly, when evaluating intramuscular calcifications,
other pathologic processes are present and must be consid-
ered during radiographic interpretation. These include infec-
tion, neoplasms, and myositis ossificans.
Infection
Skeletal muscle is relatively resistant to infection and there-
fore infectious myositis is uncommon. In the past, it was
generally encountered primarily in tropical regions. Increas-
ingly, however, it is now being seen in temperate climates,
particularly in immunocompromised individuals such as
those with diabetes, AIDS, or undergoing chemotherapy.19
When caused by bacterial or viral pathogens, the radio-
graphic findings are almost always limited to soft-tissue
swelling or obliteration of fat planes, with the rare exception
being calcium deposition secondary to a chronic intramus-
cular abscess.20 More likely, if an infectious pathogen results
in intramuscular calcifications, it is the result of a parasitic
infection. The most common helminth responsible is the
Taenia solium, which is better known as cysticercosis. It is
found worldwide and infection occurs following ingestion of
the tapeworms’ eggs, usually secondary to fecal contamina-
tion of food and water.20 Patients are most likely to present
with neurological symptoms, particularly seizures, while
muscle involvement is usually asymptomatic and is diag-
nosed incidentally.
Correct radiographic assessment of the location, shape,
and size of these calcifications is integral to distinguishing
this entity from the calcium deposits seen in noninfectious
entities such as scleroderma or dermatomyositis. Viable cysts
are not appreciated during routine radiographic assessment.
When the larvae die, an inflammatory response ensues and
the cysts calcify, making them apparent during conventional
radiography. The dead larvae of cysticercosis produce nu-
merous small oval or linear intramuscular calcifications that
measure 5 to 7 millimeters in size19,20 (Fig. 13). The long axis
of these rice-shaped calcifications parallels that of the sur-
rounding muscle bundles.20 These findings are nearly patho-
gnomonic of this disease, and when encountered in a patient
without history of helminthic infection, it is important that
the patient’s clinician be notified so that definitive evaluation
and treatment be initiated.
K.P. Banks et al
Figure 13 Oblique and lateral views of the ankle demonstrate nu-
merous “rice-shaped” calcifications in the muscles of the lower leg.
The long axes of the calcifications are oriented along the direction of
the muscle bundles. This finding is consistent with cysticercosis.
(Courtesy of MedPix, Dr. Glenn Richard, D.O., National Naval
Medical Center, Bethesda, MD).
Neoplasms
Several benign and malignant tumors produce mineraliza-
tion that results in intramuscular calcifications. While often
unrewarding, radiography remains the initial imaging evalu-
ation of these lesions and can in some cases provide valuable
information that is highly suggestive if not diagnostic of cer-
tain entities. While a review of all calcified or ossified soft-
tissue tumors of the extremities is beyond the scope of this
article, certain lesions warrant mentioning since they have
characteristic appearance. These tumors include intramuscu-
lar hemangiomas, leiomyoma or leiomyosarcoma, giant cell
tumor of soft tissue (GCT-ST), synovial sarcoma, and ex-
traskeletal chondrosarcoma or osteosarcoma.
Hemangioma. Hemangiomas are benign vascular lesions
that histologically resemble normal blood vessels.21 Though
soft-tissue hemangiomas are commonly diagnosed in radio-
logic practice, they are most frequently encountered in solid
organs, with intramuscular hemangiomas accounting for
only 1 to 4% of all such vascular tumors.22 When they do
occur, it is most likely to occur in children and adolescents
with boys and girls equally affected.22 Rarely, they may be
found in association with an enchondroma, known as Maf-
fucci’s syndrome (Fig. 14).
Radiographs of hemangiomas demonstrate a soft-tissue
mass containing phleboliths, which are seen as round densi-
ties ranging from 2 to 8 mm in size with a characteristic
central lucency. Phleboliths are present in up to 90% of in-
tramuscular hemangiomas and is highly specific for this en-
tity21 (Fig. 14). Uncommonly, curvilinear or amorphous cal-
Radiographic evaluation of soft-tissue calcifications
Figure 14 Maffucci’s syndrome. AP radiograph of the knee shows
soft-tissue calcification consistent with phlebolith and a distal fem-
oral central lucent lesion with scalloped borders and chondroid
calcification. (From Chew FS, Maldjian C, Leffler SG: Musculoskel-
etal Imaging: A Teaching File. Philadelphia, PA: Lippincott Williams
& Wilkins, 1999, with permission.)
cifications are encountered and the diagnosis may only be
suggested with further imaging evaluation. Underlying bony
changes can be seen and should not necessarily be consid-
ered a sign of malignancy.
Leiomyoma/Leiomyosarcoma. Leiomyoma and leiomyosar-
coma are benign and malignant neoplasms of mesodermal
etiology with smooth muscle differentiation.23 While these
lesions are customarily found in the abdomen and retroperi-
toneum, occurrence in muscular portion of the extremities
has been reported, likely originating from smooth muscle
cells of deep veins. There is a male predominance when
found in the extremities, in contrast to those arising in the
retroperitoneum, and prognosis is also more favorable when
these lesions arise in the appendicular skeleton.21
Both of these intramuscular neoplasms have been shown
to occasionally demonstrate dystrophic calcifications on ra-
diography23,24 (Fig. 15). The calcifications in leiomyoma
have been described as a mulberry pattern, similar to that
seen in degenerated fibroids in the uterus. Sometimes its
appearance is nonspecific and thus cannot readily be distin-
guished from an extraskeletal osteosarcoma or other miner-
alized soft-tissue neoplasm.
399
Giant Cell Tumor of Soft Tissue. GCT-ST is a rare tumor
with a much less typical appearance than its more recognized
counterpart, GCT of bone. Comprising giant cells of oste-
oclast type, the tumor is clinically similar to its osteogenic
relative with a generally benign course and good response to
surgical excision.25 A wide age range of individuals is afflicted
with median age at diagnosis being 43 years.26 Men and
women are equally affected with the tumors occurring in the
lower extremities approximately 50% with the upper extrem-
ity only seen in 10% of cases.26
As with many soft-tissue tumors, the radiographic findings
are nonspecific. An infiltrative soft-tissue mass is seen with
dense dystrophic calcifications often noted, due to the pres-
ence of osteoclasts, aiding in its radiographic conspicuity
(Fig. 16). Malignant fibrous histiocytoma (MFH) is its most
frequent mimicker, usually necessitating biopsy.
Synovial Sarcoma. Synovial sarcoma is one of the more
common malignant soft-tissue tumors encountered in the
extremities. Synovial sarcoma is a misnomer because it does
not arise from the synovium but is usually located near a
joint; intraarticular synovial sarcomas are extremely rare. Sy-
novial sarcoma is highly aggressive with 25% of patients hav-
ing metastases by the time of diagnosis and median survival
being only 33 months.21 Synovial sarcoma is seen predomi-
nantly in the second through fourth decades of life with pa-
tients most commonly presenting with a palpable mass.21
When encountered, the tumor is located in the legs in 60 to
70% of cases.27
A nonspecific mineralized mass is seen on radiography in up
to a third of synovial sarcoma cases.21 The dystrophic calcifica-
tions are generally near a joint and many times are associated
Figure 15 Leiomyoma. Lateral view of the proximal femur shows a
densely calcified mass in the posteromedial thigh. (From Chew FS,
Maldjian C, Leffler SG: Musculoskeletal Imaging: A Teaching File.
Philadelphia, PA: Lippincott Williams & Wilkins, 1999, with per-
mission.)
400 K.P. Banks et al

Figure 17 Synovial sarcoma. Lateral radiograph of the knee shows

heavily calcified mass posterior to knee. (Reprinted with permis-
sion.38)

Figure 16 Giant cell tumor of soft tissue. Lateral radiograph of thumb

shows dystrophic calcifications throughout soft-tissue mass.

with adjacent bony changes that suggest a malignant process.

No further characterization is usually possible with the tumor
being radiographically indistinguishable from an extraskeletal
osteosarcoma; however, typical location in a young adult can
suggest the correct diagnosis27 (Fig. 17).

Extraskeletal Chondrosarcoma and Osteosarcoma

Extraskeletal chondrosarcomas and osteosarcomas are both
rare variants of their osseous counterparts. They occur late in
life and are often encountered in the lower extremity.27 Prog-
nosis is generally worse with recurrence and metastasis being
the rule rather than the exception. Their nonspecific radio-
graphic appearance and generic clinical presentation yield
very little diagnostic value and a broad differential must be
applied at time of radiographic interpretation to include
MFH and other soft-tissue sarcoma.
Extraskeletal chondrosarcoma may present as either a
noncalcified or a calcified soft-tissue mass. Calcified masses
are common findings in extraskeletal chondrosarcoma, often
showing stippled and ring- or arc-like calcifications (Fig. 18).
These rare malignancies grow slowly and have a favorable
prognosis. In large joints, they can arise from the synovium as
a primary neoplasm or as a result of malignant transforma-
tion of synovial chondromatosis.
Extraskeletal osteosarcoma has a predilection for the lower
extremity, especially the thigh, and as many as 6% may have Figure 18 Extraskeletal chondrosarcoma. Lateral ankle radiograph
a history of previous radiation therapy. Although osteosarco- shows somewhat ovoid mass (arrows) containing stippled calcifica-
mas, in general, show calcified tumor, these soft-tissue le- tions and obliterating Kager’s fat pad. (Reprinted with permission
sions often do not demonstrate any visible calcific compo- from AJR.)
Radiographic evaluation of soft-tissue calcifications 401

seen as a soft-tissue mass with ill-defined mineralization that

can often be confused with a sarcomatous lesion. While non-
specific-appearing during this period, a key radiographic fea-
ture is that the mass is not in continuity with the adjacent
bone, nor with any associated cortical destruction or perios-
teal reaction. These findings are suggestive of the diagnosis,
which can be confirmed with short-term follow-up radiogra-
phy. Once mature (usually by 2 months following initial pre-
sentation) the lesion will demonstrate the diagnostic findings of
a soft-tissue lesion with a rim of calcification27,29 (Fig. 20).

Periarticular
The periarticular space is the most complex compartment of
the extremities, being composed of a variety of tissue types
and structures to accomplish the complex requirements of
functional motion combined with load bearing. It is defined
by its external boundary, the joint capsule, and contains fi-
brocartilage, hyaline cartilage, tendons, tenosynovium, and
synovial fluid. For the purpose of our compartmental ap-
proach, we include the nearby bursa, which are closely re-
lated to the function and pathology of the intraarticular struc-
tures. Given the distinct components that make up this
anatomical compartment, it is readily apparent that each of
the structures may be affected by different disorders.
Hydroxyapatite Deposition
Disease—Tendons and Bursae
Hydroxyapatite deposition disease (HADD), also known as
calcific tendinitis, is a common disorder that manifests itself
by the deposition of crystals in tendons and occasionally

Figure 19 (A, B) Extraskeletal osteosarcoma. Axial CT images reveal

a well-defined ossified mass, originating from the rectus sheath,
medial to the femoral vessels. Some muscle fibers have been dis-
placed medially by the mass. (From Chew FS, Maldjian C, Leffler
SG: Musculoskeletal Imaging: A Teaching File. Philadelphia, PA:
Lippincott Williams & Wilkins, 1999, with permission.)

nent. Their imaging features are nonspecific (Fig. 19) and the
diagnosis must be obtained by biopsy.
Myositis Ossificans
Myositis ossificans (MO) is the term used to denote a specific
form of heterotopic ossification that occurs in muscle. The
term “myositis” is a misnomer because the disorder is not an
inflammatory process.27 MO has no age, gender, or ethnic
predilection and may or may not be precluded by a history of
trauma. Patients may be asymptomatic or can present with
pain, swelling, or a palpable mass (usually in the large muscle
groups of the extremities) and it may be confused with an
infectious or neoplastic process.28 Certain precursors have
been noted in approximately 50% of individuals and include
trauma, neurologic injury, or bleeding disorders.28 Figure 20 Lateral radiograph of thigh 6 months after trauma shows
Radiographically, myositis ossificans undergoes a typical an ossified mass in the anterior soft tissues that appears to be at-
course of maturation that is key to its diagnosis. During the tached to femur proximally. Distally, note thin radiolucent plane
acute and subacute phases (up to 4 to 8 weeks), MO often is separating ossified mass from femur. (Reprinted with permission.38)
402 K.P. Banks et al

The crystal deposition of CPPD is typically noted on radio-

Figure 21 AP view of right elbow shows an amorphous calcification
(arrowhead) corresponding with origin of ulnar collateral ligament.
While this finding could be concerning for mineralization associ-
ated with neoplasm, radiographic findings and location of lesion are
consistent with HADD.
graphs as thin, linear, or wedge-shaped foci of increased den-
sity that parallels the articular surfaces of the joint. The most
often affected sites include the triangular fibrocartilage com-
plex (Fig. 23), lunotriquetral ligament, symphysis pubis, and
articular cartilage of the glenoid35 (Fig. 24). While it can
radiographically mimic numerous other intraarticular disor-
ders, its involvement of non-weight-bearing joints helps dif-
ferentiate the chondrocalcinosis of this disease from that of
other arthritides such as osteoarthritis.
Synovial/Tenosynovial Osteochondromatosis—Joint
Space and Tenosynovium
Synovial osteochondromatosis is a benign metaplastic prolif-
erative disorder of the synovium, which can affect the joints,
tendons, and bursae.31 In this disease, the connective tissue
of the synovium undergoes cartilaginous metaplasia with the
resultant formation of multiple loose bodies. The loose bod-

bursae.30 Initially, hydroxyapatite is deposited in tendons.

Subsequently, the calcification may rupture into the adjacent
bursa, joint, or bone. Its pathogenesis is unclear with pro-
posed theories including degenerative changes due to recur-
rent trauma, local hypoxia leading to alterations in pH, or
occult neurologic factors.31 HADD can have a varied clinical
appearance from asymptomatic to acute or chronic pain with
fever, redness, swelling, and diminished range of motion.31
When tendons are affected, the disorder most commonly
strikes the shoulder, hip, elbow, wrist, and knee in decreas-
ing order of frequency.31 Afflicted bursae include the olecra-
non and subacromial.32
On conventional radiographs, the calcium deposits of
HADD have a distinct appearance. The calcifications typically
appear as homogeneous, discrete, and nodular densities.32
They may be linear, oval, or rounded in shape and are most
commonly found at the site of tendon insertions or origins
(Fig. 21). The supraspinatus is the most frequently encoun-
tered site of occurrence and bilateral involvement may be
present (Fig. 6). The calcifications may change with time,
either enlarging or occasionally resolving. On MR imaging,
bone marrow edema can be seen without cortical destruc-
tion, mimicking more ominous entities such as tumor and
infection.33,34
Calcium Pyrophosphate Deposition
Disease—Hyaline Cartilage and Fibrocartilage
Hyaline cartilage and fibrocartilage can mineralize due to a
variety of disorders, resulting in dystrophic calcifications that
may be seen on radiography. When present, this is termed
chondrocalcinosis, a general term used to relate the presence
of radiographically evident cartilage calcifications32 (Fig. 22).
CPPD is a specific inflammatory condition that is widespread
in the elderly population. It has a highly variable clinical Figure 22 CPPD. (A) AP view of the knee shows chondrocalcinosis
presentation from asymptomatic to acute episodes of severe within the lateral meniscus. (B) Lateral view of the knee shows
pain (known commonly as pseudogout) due to its associated synovial calcification and patellofemoral osteoarthritis, which is
destructive arthropathy. worse than the other compartments.
Radiographic evaluation of soft-tissue calcifications 403

Figure 23 Pyrophosphate arthropathy with scapholunate advanced

collapse wrist and chondrocalcinosis of the triangular fibrocartilage
complex.

ies go on to calcify or ossify, leading to the disorder’s charac-

teristic radiographic findings. Patients often present with
nonspecific symptoms of pain, decreased range of motion, or
a locking/catching sensation. While any joint may be af-
flicted, the knee, hip, elbow, and shoulder are most com-
monly involved. With the extraarticular form of tenosynovial
osteochondromatosis, involvement of the hands (Fig. 25),
feet, and wrists have been reported.
The radiographic appearance of synovial osteochondro-
matosis is often diagnostic with numerous rounded calcified
bodies within the joint space associated with an effusion (Fig.
26). The bodies may be anywhere from 1 to 20 mm in size,
but tend to be relatively uniform in size inside an individual
joint.35 Unfortunately, up to a third of patients may have
minimal or no calcification of the nodules, making advanced
imaging necessary. When tenosynovial osteochondromatosis
Figure 25 Tenosynovial chondromatosis. AP radiograph of ring fin-
ger shows soft-tissue swelling and calcified body (arrow) adjacent to
proximal interphalangeal joint. (Reprinted with permission from
AJR.)
is present, the radiographic findings are much less specific
and further evaluation with cross-sectional imaging is more
commonplace.
Heterotopic Ossification
Heterotopic ossification (HO) is due to the abnormal pres-
ence of extraskeletal osteoblastic cells and occurs in patients
with fractures, burns, joint replacements, paraplegia, and

Figure 26 Synovial chondromatosis. Lateral view of ankle shows

Figure 24 AP radiograph of left shoulder shows linear collection of multiple small calcified bodies in posterior ankle joint representing
chondrocalcinosis (arrows) within hyaline articular cartilage of hu- calcified fragments of synovium that had undergone cartilaginous
meral head (contributed by Dr. Sanders, USUHS, Bethesda, MD). metaplasia.
404 K.P. Banks et al

classic appearance is flowing linear density along the antero-

lateral aspects of the vertebral bodies that continues across
the disc space. A lucency is often seen separating the ossified
anterior longitudinal ligament and the anterior margin of the
adjacent vertebral body. Involvement in the spine and lum-
bar region is usually more prominent on the right side of the
spine, due to the pulsation effects of the aorta on the left.41

Posterior Longitudinal Ligament

Figure 27 Heterotopic ossification. Six weeks following extensive
burn injuries, well-defined focus of ossification is seen in olecranon
fossa. Individual complained of decreased elbow extension necessi-
tating surgical excision.
Often seen in conjunction with cervical DISH is an entity
termed ossification of the posterior longitudinal ligament
(OPLL). It is detected in approximately 50% of cases of cer-
vical DISH and may result in spinal canal narrowing and
neurologic deficits.38 OPLL almost exclusively involves the
cervical spine with other regions involved less than 10% of
the time.
The findings are striking and distinct enough on radio-
graphs to be diagnostic. A thick, smooth ribbon of increased
density is seen corresponding with the path of the posterior
longitudinal ligament (Fig. 29). Though degenerative changes
may be seen of the disk and intervertebral joints, these findings
are not necessarily part of the disorder and are frequently a
manifestation of concurrent chronic degenerative changes dis-
order given the advanced age of most patients. Associated spinal

poststroke hemiplegia.36 It is commonly seen in the region of

large joints and can result in limited range of motion as well
as pain and swelling.37
As in cases of myositis ossificans, there is rapid develop-
ment of soft-tissue calcifications. Unlike MO, HO is not con-
fined to skeletal muscle and no distinctive zone of peripheral
mineralization is demonstrated35 (Fig. 27). It will take up to 6
months to radiographically mature and thus interval radio-
graphic change during this period should be anticipated as a
benign feature of this lesion.

Axial Skeleton
Anterior Longitudinal Ligament
Diffuse idiopathic skeletal hyperostosis (DISH) is an idio-
pathic disease manifest by noninflammatory ossification of
the spinal ligaments. Also known as Forestier’s disease, the
disorder afflicts individuals greater than 40 years of age with
a male predominance.38 Those affected may be asymptomatic
or present with spinal pain and decreased range of motion.
Severe cases of cervical involvement have resulted in dyspha-
gia due to the bulk effect of the osteophytes impinging of the
esophagus.39
The classical radiographic appearance of DISH is that of
ossification of the anterior spinal longitudinal ligament in-
volving four or more contiguous vertebrae and hyperostosis
of some of the ligamentous attachments.40 Radiographs of the
axial skeleton reveal an undulating ribbon of bone along a
portion of the spine involving several intervertebral discs of
normal or near normal height.40 Most commonly, this is seen Figure 28 DISH. Lateral view of the spine shows bulky flowing os-
in the thoracic spine (Fig. 28); however, abnormalities may teophytes along anterolateral portion of vertebral bodies. Note the
also be present in the cervical and lumbosacral spine. The absence of significant degenerative disk disease.
Radiographic evaluation of soft-tissue calcifications 405

culoskeletal manifestation of a common immune-mediated

chronic skin disease, while Reiter’s syndrome is a defined by
a group of symptoms consisting of conjunctivitis, urethritis,
and arthritis.
Despite their distinct clinical nature, Reiter’s syndrome
and psoriatic arthritis can have strikingly similar radio-
graphic findings in the axial skeleton. Both of these disorders
may result in paravertebral ossification about the lower tho-
racic and upper lumbar spine.44 The densities can have a very
varied appearance, with both well-defined and irregular os-
sifications having been reported which appear to bridge the
disk space but do not actually contact the annulus fibrosus or
vertebral cortex until late in the disease (Fig. 31). The osseous
bodies may appear linear or ovoid in morphology and will
typically extend along the lateral margin of the vertebral bod-
ies with a unilateral or asymmetric distribution.45 The large
size and one-side predominant occurrence allow for distinc-
tion from the annular fibrosis calcifications of ankylosing
spondylitis (AS).
Perispinal Ligaments
Mineralization of the interspinous and supraspinous liga-
ments can be a diagnostic clue to the presence of AS. A
well-known member of the seronegative spondyloarthropa-
thies, AS is a disease of young individuals with onset between
Figure 29 Lateral view of cervical spine shows smooth, thick ribbon 15 and 35 years of age.46 Its musculoskeletal manifestations
of calcification along posterior longitudinal ligament. No associated are numerous, but clinically it often presents with chronic
DISH was present. back pain associated with decreased range of motion and loss
of thoracic expansion.
Calcification and ossification of the interspinous and su-
canal stenosis is seen, which may result in finding of cord im-
praspinous ligaments are prominent radiographic features
pingement on CT or MR evaluation.
that increase in conspicuity as disease advances. On frontal
Intervertebral Disk views of the chest or abdomen, a central radiodense stripe
Intervertebral disk calcifications (IDC) are a well-known ra- may be identified, known as the dagger sign46,47 (Fig. 32).
diographic entity, often being incidentally encountered dur-
ing plain film evaluation of the chest and abdomen.42 It has a
large number of predisposing systemic conditions that result
in biochemical alterations (eg, hemochromatosis, CPPD, hy-
perparathyroidism, acromegaly, ochronosis, and amyloid-
osis) or altered mechanics of the spine (eg, Klippel–Feil, ju-
venile rheumatoid arthritis, ankylosing spondylitis, and post-
traumatic/operative vertebral fusion, advanced degenerative
changes).42,43 The disorder is seen more commonly in men
than women and increases steadily in prevalence with ad-
vancing age.42
Radiographic evaluation of the torso will depict IDC in 5 to
6% of individuals with the lower thoracic spine most com-
monly affected.42 The typical appearance is of dense, amor-
phous calcification in the disk space. It is usually located at
the disk’s margin, entailing the annulus fibrosus, though cal-
cification of the nucleus pulposus and entire disk can also be
seen42 (Fig. 30). Given the typical afflicted individual and
predisposing conditions, it is readily apparent that concur-
rent degenerative changes are often seen.
Paravertebral Soft Tissues
Reiter’s syndrome and psoriatic arthritis are both members of
the seronegative spondyloarthropathies, yet they are quite Figure 30 Lateral view of cervical spine shows C2-3 intervertebral
distinct clinical entities. Psoriatic arthritis is a particular mus- disc calcification.
406
Figure 31 Reiter syndrome. AP radiograph of lumbar spine shows
ossification in the left L3-4 paraspinal soft tissues leading to a bridg-
ing phyte. (Reprinted with permission.38)
Figure 32 Ankylosing spondylitis. (A) Lateral radiograph of cervical spine shows syndesmophytes bridging the entire
cervical spine and ankylosis of the posterior elements. (B) AP radiograph of lumbar spine shows syndesmophytes and
ossification of the posterior ligamentous structure, the “dagger” sign. The sacroiliac joints have fused. (Reprinted with
permission.38)
K.P. Banks et al
This is often seen in conjunction with other typical findings
such as sacroiliac joint disease, syndesmophytes, and anky-
losis, aiding in proper radiographic interpretation.
Conclusion
While MR imaging has become the imaging technique of
choice in the evaluation of soft-tissue lesions, conventional
radiography remains vital in the initial assessment of such
abnormalities given their inexpensive cost and widespread
availability. Given this, it is necessary that practicing radiol-
ogists maximize the diagnostic utility of conventional radiog-
raphy to aid the clinician in improved patient management
and the avoidance of unnecessary interventions. We provide
a review of many of the common soft-tissue calcifications
encountered in clinical practice with a compartmental-based
approach to their interpretation to illustrate the subtle, but
important information that can be yielded about these lesions
from radiographs. While not designed to be all-inclusive, it is
felt that with sound knowledge of the entities discussed and
their most characteristic features, one should be able to assess
the majority of soft-tissue calcifications encountered during
routine radiographic assessment of the extremities.
Acknowledgment
The authors thank Mr. Michael C. Vernon and the Depart-
ment of Medical Illustration of Brooke Army Medical Center
for providing us with the beautiful illustrations.
Radiographic evaluation of soft-tissue calcifications
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