MSK TOACS LT COL YASAR

SHAKEEL 18.10.22
Classified Radiologist
FCPS(Rad), FRCR (UK)
Armed Forces Institute of Radiology and Imaging
Case 1
Case 1
• X Ray
• Ill-defined large lytic lesion with a permeative/moth-eaten appearance in the metaphysis and
epiphysis of the right distal femur.
• Destruction of the cortex on the posterior aspect of the metaphysis.
• Periosteal new bone formation.
• Adjacent soft tissue mass, no visible calcifications.
• MRI
• Large diffuse lesion in the distal right femur associated with small soft tissue mass.
• Extensive cortical destruction.
• Abnormal signal (low T1-weighted signal and high signal on STIR) involving the epiphysis,
metaphysis and extends superiorly into the medulla of the diaphysis which represents an
infiltrative process and marrow replacement.
• Oblique fracture through the medial condyle of the right femur.
• Proximal tibia and joint space appear normal.
• No focal fluid collection seen.
Case 1
• Interpretation
• Destructive lytic lesion in the distal right femur with periosteal reaction and a
soft tissue mass.
• Extensive bone marrow infiltration.
• Pathological fracture through the medial femoral condyle.
• Differential diagnosis
• Metastasis.
• Osteomyelitis.
• Lymphoma.
• Primary bone neoplasm (reticulum cell sarcoma, myeloma, osteosarcoma,
Ewing's sarcoma in the younger age group).
Case 1
• Management
• Urgent referral to orthopaedic team
• Bone scan.
• CT chest and abdomen/pelvis with intravenous contrast for staging.
• MRI right femur to assess local spread.
• Biopsy to be performed by the sarcoma team.
Case 2
Case 2
• Observations and interpretations
• Ultrasound shows a normal longitudinal anterior view of the femoral head
and neck on both sides. In this case there is no evidence of a joint effusion.
• The plain film shows abnormality of the proximal left femoral epiphysis. It is
reduced in height, slightly sclerotic and irregular with subtle subchondral
lucency. There is inferomedial widening of the joint space but no acetabular
changes.
• The bone scan shows a focal photopenic area in the left proximal femoral
epiphysis.
• There is no evidence of slipped femoral epiphysis.
Case 2
• Diagnosis
• Early stage Legg-Calve-Perthes disease (idiopathic avascular necrosis of the
proximal femoral epiphysis).
• Differential diagnosis
• Osteonecrosis of the proximal femoral epiphysis (avascular necrosis) can be
due to other disorders/causes:
• Metabolic: renal disease, steroids (iatrogenic, Cushing's disorders) Trauma
• Haemoglobinopathies: Sickle cell, thalassaemia
• Hypercoagulable states: leukaemia, lymphoma
• Post-surgical
• Storage disorders: Gaucher's disease.
Case 2
• Management
• Ensure that the paediatric orthopaedic team knows the patient for
appropriate management and follow-up.
Case 3
Case 3
• Examinations
• Plain radiographs of the tibia and fibula
• Axial CT image of right tibia and fibula CT thorax lung windows
• Findings
• Plain radiographs and CT demonstrate a mixed sclerotic and lucent lesion of the
proximal right tibia.
• There is a permeative pattern of bone destruction. There is an elevated and
interrupted periosteal reaction with a Codman's triangle demonstrating rapid
growth. The zone of transition is indistinct. There is associated soft tissue swelling.
• The bone scan confirms that the lesion is solitary within the skeleton and shows
marked osteoblastic activity.
• The lung CT demonstrates a few small parenchymal nodules most likely consistent
with metastases within this clinical context.
Case 3
• Diagnosis
• Osteosarcoma of the right tibia with lung metastases.
• Differential diagnosis
• Ewing's sarcoma.
• Osteomyelitis.
• Other causes of pulmonary nodules, e.g. granulomas due to previous TB.
• Management
• An MRI of the affected bone including the joint above and below the lesion is
indicated to define local extent of the disease and pre-surgical assessment/planning.
• Biopsy should be planned.
• A review of the CT thorax using mediastinal and bone windows should be
undertaken to ascertain whether the nodules are calcified.
Case 4
Case 4
• Examination
• Plain ct axial and sagittal slices ,bone and soft tissue window 0.5 + 0.5
• Findings
• Lytic metaphyseal lesion 1
• Narrow zone of transition 1
• Endosteal scalloping 1
• Expansion of overlying cortex , no cortical breakthrough unless fracture 1
• Chondroid calcifications rings and arcs calcification / popcorn calcification1
• No periosteal reaction 1
• No soft tissue mass 1
Case 4
• Diagnosis
• Enchondroma 1
• Differentials
• Low grade chondrosarcoma 0.5
• Non ossifying fibroma 0.5
• Management
• Discuss the case in orthopedic MDT and rule out possibility of malignant
change 1
Case 5
Case 5
• Examination
• Lateral radiograph of the thoracic spine
• CT thorax on bone windows
• T1-weighted MRI of the thoracic spine
• Findings and interpretations
• Plain radiograph
• There is sclerosis of a mid thoracic vertebral body that extends into the pedicle.
There is loss of vertebral body height. The vertebral body superior to it also shows
areas of sclerosis in its posterior aspect.
• The cortex is ill defined and there is evidence of bone destruction.
• The appearances would be consistent with multiple sclerotic metastases from breast
carcinoma.
Case 5
• MRI thoracic spine
• There are multiple areas of low signal intensites in a number of the thoracic vertebral bodies
on T1-weighted imaging. The anterior and posterior elements are involved which is highly
suspicious of a malignant process. On these sagittal sequences the spinal cord does not
appear compressed; however axial images would be needed to confirm this.
• The sclerotic areas on plain film correspond to the low signal on T1-weighted MRI sequence.
The fatty bone marrow usually demonstrates high signal on T1-weighted imaging but appears
replaced with tumour hence the low signal on the T1-weighted sequence.
• Diagnosis
• In this clinical context, this most probably represents multiple metastases from the past
history of breast carcinoma.
• Differential diagnosis
• Lymphoma.
• Lytic metastases post radiotherapy/chemotherapy.
• Multiple myeloma –
Case 5
• Management
• The entire spine should be imaged with MRI axial and sagittal T1-weighted,
T2-weighted and sagittal STIR assessing for cord compression and disease
extent. If the cord is compressed urgent radiotherapy and/or surgical
decompression may be needed. This needs to be communicated to the
referring clinician.
• The remainder of the skeleton can be imaged with a 99mTc MDP bone scan.
Case 6
Case 6
• Examination
• Sagittal T2-weighted MR lumbar spine
• Sagittal STIR MR lumbar spine
• Sagittal T1-weighted and fat saturated post contrast MRI lumbar spine
• Axial T1-weighted and fat saturated post-contrast MR lumbar spine
• Findings MR lumbar spine
• T1-weighted lumbar spine images demonstrates a diffuse reduction in bone marrow
signal, loss of disc height at L5/S1 level with irregularity and erosion of the posterior
aspect of the end plates in association with epidural extension.
• Post contrast demonstrates there is subtle peripheral enhancement of the end plate
erosions with diffuse enhancement of the epidural soft tissue extension consistent
with a phlegmon. The epidural phlegmon is causing indentation on the anterior
aspect of the theca and extends around both L5 nerve roots within the lateral
recesses.
Case 6
• Diagnosis
• Pyogenic discitis and associated epidural phlegmon at L5/S1.

• Differential diagnosis
• Tuberculous discitis.
• Management
• Diagnostic aspiration of joint/disc to obtain a sample for microbiology
(causative organism), culture and sensitivity.
• Imaging of the whole spine to exclude involvement of other vertebral levels.
• Treatment with IV antibiotics with appropriate sensitivity.
Case 7
Case 7
• OPG view 1
• Findings
• Large unilocular, well-defined radiolucency is seen at the left side of mandible
along the root of teeth 2
• Thin regular sclerotic margin without cortical breach. 2
• Differential
• Periapical/radicular cyst 1
• Dentigerous cyst /Follicular cyst 1
• Odontogenic keratocyst 1
• SBC 1
• ABC 1
Case 7
• Management
• This needs to be further evaluated by contrast enhanced MRI of the mandible
and discussed with maxillofacial surgeons for disposal
Case 8
Case 8
• Examinations
• AP lumbar spine radiograph .
• Axial CT lumbar spine (Figure 8.4.2).
• Sagittal CT lumbar spine
• Coronal CT lumbar spine
• Angiogram
• Findings and interpretations
• AP lumbar spine
• There is an expansile well-circumscribed sclerotic lesion involving the right L4 pedicle, transverse process
and right neural arch. There is a mild scoliosis centred at this level, with the lesion at the apex of the
concavity.
• MDCT lumbar spine
• Demonstrates a lesion with a central nidus within the right L4 neural arch with surrounding sclerotic
expanded reactive bone extending into the right transverse process and lateral vertebral body. There is
matrix mineralization within the lesion.
• Angiogram
• Demonstrating a blush at the right L4 pedicle.
Case 8
• Diagnosis
• Osteoblastoma.
• Differential diagnosis
• Osteoid osteoma.
• Management
• Histological confirmation with CT-guided biopsy.
• Radical surgical excision is the treatment of choice for osteoblastoma
• Pre-operative embolization.
Case 9
Case 9
• Examination
• X ray right hand AP view 1
• Findings
• Focal soft tissue swelling 2nd third digit 1
• Hypertrophy of phalanges 1
• Joint spaces narrowing and hypertrophy 1
• Diagnosis
• Focal gigantism (Macrodystrophia lipomatosa) (Hemihypertrophy) 1
Case 9
• D/D
• Hemangioma 1
• Maffuci syndrome 1
• Olliers disease 1
• AVM 1
• Management
• CE MRI to confirm accumulation of fat in the sub cutaneous tissue with out
capsule 1
Case 10
Case 10
• Examinations
• Left foot AP and oblique radiographs
• Reconstructed CT left foot images
• Findings and interpretations
• Left foot radiograph – there are comminuted intra-articular fractures through
the bases of the 2nd, 3rd and 4th metatarsals, lateral cuneiform and cuboid.
• There is a fracture-dislocation at the 3rd tarsometatarsal joint and a fracture
through the base of the great toe proximal phalanx.
• CT left foot
• This confirms the presence of fractures described on the radiographs.
Case 10
• Diagnosis
• Lisfranc injury with multiple foot fractures.
• Differential diagnosis
• In this particular case there is no other differential diagnosis.
• Management
• Surgery: open reduction and internal fixation.