ExpertDDx: Musculoskeletal 2nd

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 SECOND EDITION

Davis | Blankenbaker
ii
 SECOND EDITION

Kirkland W. Davis, MD, FACR

Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Donna G. Blankenbaker, MD
Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

EXPERTDDX: MUSCULOSKELETAL, SECOND EDITION ISBN: 978-0-323-52483-4

Copyright © 2018 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

Publisher Cataloging-in-Publication Data

Names: Davis, Kirkland W. | Blankenbaker, Donna G.

Title: ExpertDDx. Musculoskeletal / [edited by] Kirkland W. Davis and Donna G. Blankenbaker.
Other titles: Musculoskeletal.
Description: Second edition. | Salt Lake City, UT : Elsevier, Inc., [2017] | Includes
bibliographical references and index.
Identifiers: ISBN 978-0-323-52483-4
Subjects: LCSH: Musculoskeletal system--Diseases--Diagnosis--Handbooks, manuals, etc. |
Diagnosis, Differential--Handbooks, manuals, etc. | MESH: Musculoskeletal Diseases--
diagnosis--Atlases. | Musculoskeletal System--Atlases.
Classification: LCC RC925.7.E96 2017 | NLM WE 17 | DDC 612.7022’2--dc23
International Standard Book Number: 978-0-323-52483-4

Cover Designer: Tom M. Olson, BA

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
I owe a debt to all the colleagues, fellows, and residents with whom I have worked
along the way and who have helped grow my knowledge and love for musculoskeletal
radiology. I especially offer thanks to my mentors: Drs. Felix S. Chew and Carol A.
Boles from residency, Charles S. Resnik and Michael E. Mulligan from fellowship, and
Arthur A. De Smet from my early career. In addition, Donna Blankenbaker has been
a fantastic partner on this project and remains a great teammate, as she has been
throughout my career. Finally, I couldn’t do any of this without the love and support of
my wonderful children and especially my lovely wife, Jenni. Thank you.

KWD

To CMS for all of your support. I want to thank all of the authors for their
dedication to this project as well as my co-editor Kirkland Davis for his unwavering
work on this project.

DGB

v
vi
Contributing Authors
Carol L. Andrews, MD
Associate Professor
University of Pittsburgh School of Medicine
Chief, Division of Musculoskeletal Radiology
UPMC Department of Radiology
Pittsburgh, Pennsylvania

Robert Downey Boutin, MD

Chief, Musculoskeletal Radiology
Clinical Professor of Radiology
University of California, Davis School of Medicine
Sacramento, California

Julia R. Crim, MD
Chief of Musculoskeletal Radiology
Vice Chair for Clinical Affairs
Professor of Radiology
University of Missouri at Columbia
Columbia, Missouri

Michael Mulligan, MD
Professor
Department of Radiology and Nuclear Medicine
University of Maryland School of Medicine
Chief, Radiology Kernan Hospital/UMROI
Assistant Chief of Musculoskeletal Imaging UMMC
MSK Fellowship Program Director
Baltimore, Maryland

Cheryl A. Petersilge, MD, MBA

Clinical Professor of Radiology
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Chair, Department of Radiology
Hillcrest Hospital
Cleveland, Ohio

Additional Contributors
B.J. Manaster, MD, PhD, FACR
Catherine C. Roberts, MD

vii
viii
 Preface
There is no doubt that interpreting radiology studies presents many challenges. One of those challenges
is the disparate array of diagnoses that may be responsible for a particular imaging finding, clinical sign, or
symptom. Musculoskeletal radiology is no exception to this rule; in fact, many of the differential diagnoses
that occur in musculoskeletal radiology are among the most lengthy and complex in the industry.

Radiologists and other practitioners who employ radiology in the care of their patients may develop their
own short lists of possible diagnoses for various radiologic findings and clinical presentations; however,
unique cases will always arise that fall outside a practitioner’s experience and knowledge base irrespective
of one’s level of expertise. When appropriate, one should still endeavor to generate a reasonable differential
diagnosis for the problem at hand. It is our ambition that this text/atlas will serve as the most helpful resource
for that purpose.

One of the difficulties associated with constructing a reference for differential diagnoses in radiology lies
with the question of scope: If one purely lists a series of differential diagnoses for a specific finding or
scenario, the reference will not provide enough information for the practitioner to narrow the differential
sufficiently. Alternatively, providing complete information about diagnosing every entity in every differential
list would make the reference far too voluminous to be practical. As with all the texts in the ExpertDDx series,
this second edition of ExpertDDx: Musculoskeletal seeks to strike an appropriate balance. The differential
diagnosis lists are complete though not always exhaustive. Within each list, the diagnoses are separated
into common, uncommon, and rare but important presentations. Each chapter provides additional details
about the individual diagnoses that may help the reader to recognize a specific entity or narrow the list of
possibilities by including some and excluding others, and sometimes suggest other imaging studies or body
parts to examine to further assess the possible diagnosis. Imaging examples are provided for most of the
diagnoses in every list. If the reader desires a more in-depth discussion of a diagnosis, the electronic version of
this text has links embedded to additional resources that allow for a more complete discussion of individual
entities.

Several new chapters have been added to the text since the first edition, and thousands of new cases have
been added to supplement the best of the cases from the first edition. We strove to achieve a fresh look at all
the material. To that end, although we have been fortunate to retain two of the authors from the first edition,
Carol L. Andrews, MD and Cheryl A. Petersilge, MD, they took on completely different sections of the work. In
addition, Michael E. Mulligan, MD, Robert Downey Boutin, MD, and Julia R. Crim, MD lent their considerable
expertise in musculoskeletal radiology to the work. We are grateful to all of the authors for contributing their
extensive knowledge and all of the time and effort they spent on the project.

When an oncologist, rheumatologist, or endocrinologist poses a question to us about a difficult case, we often
find our greatest satisfaction in guiding them to the correct diagnosis for their patients. It is our great hope
that this text will be a uniquely helpful resource for many and assist the reader in improving patients’ lives.

Kirkland W. Davis, MD, FACR

Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin

Donna G. Blankenbaker, MD
Professor of Radiology
Musculoskeletal Imaging and Intervention
Department of Radiology
University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
ix
x
Acknowledgments
Lead Editor
Nina I. Bennett, BA

Text Editors
Arthur G. Gelsinger, MA
Terry W. Ferrell, MS
Lisa A. Gervais, BS
Karen E. Concannon, MA, PhD
Matt W. Hoecherl, BS
Megg Morin, BA

Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

Illustrations
Richard Coombs, MS
Lane R. Bennion, MS
Laura C. Wissler, MA

Art Direction and Design

Tom M. Olson, BA
Laura C. Wissler, MA

Production Coordinators
Rebecca L. Bluth, BA
Angela M. G. Terry, BA
Emily C. Fassett, BA

xi
 Sections
PART I: Anatomy Based
SECTION 1: Flat Bones
SECTION 2: Long Bone, Epiphyseal
SECTION 3: Long Bone, Metaphyseal
SECTION 4: Long Bone, Metadiaphyseal and Diaphyseal
SECTION 5: Long Bone, Growth Plate
SECTION 6: Periosteum
SECTION 7: Joint Based
SECTION 8: Shoulder Girdle and Arm
SECTION 9: Elbow and Forearm
SECTION 10: Wrist and Hand
SECTION 11: Fingers and Toes
SECTION 12: Intervertebral Disc
SECTION 13: Paraspinal Abnormalities
SECTION 14: Vertebral Shape
SECTION 15: Vertebral Lesions
SECTION 16: Ribs
SECTION 17: Pelvis
SECTION 18: Hip and Thigh
SECTION 19: Knee and Leg
SECTION 20: Foot and Ankle

xii
 PART II: Image Based
SECTION 1: Radiograph/CT, Osseous
SECTION 2: Radiograph/CT, Soft Tissue
SECTION 3: MR, Osseous
SECTION 4: MR, Soft Tissue
SECTION 5: MR, Joint
SECTION 6: Ultrasound
SECTION 7: Nuclear Medicine

PART III: Clinically Based

SECTION 1: Shoulder and Arm
SECTION 2: Elbow and Forearm
SECTION 3: Wrist and Hand
SECTION 4: Pelvis, Hip, and Thigh
SECTION 5: Knee and Leg
SECTION 6: Ankle and Foot
SECTION 7: Spine
SECTION 8: Systemic Disease

xiii
 TABLE OF CONTENTS

Part I: Anatomy Based SECTION 4: LONG BONE,

METADIAPHYSEAL AND DIAPHYSEAL
SECTION 1: FLAT BONES 76 Long Bone: Central Diaphyseal Lesion,
4 Flat Bones: Bubbly Lesion With Expansile Nonaggressive
Remodeling Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR 80 Long Bone: Diaphyseal Lesion, Aggressive: Adult
10 Flat Bones: Permeative Lesion Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR 86 Long Bone: Diaphyseal Lesion, Aggressive: Child
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
SECTION 2: LONG BONE, EPIPHYSEAL 90 Long Bone: Aggressive Diaphyseal Lesion With
Endosteal Thickening
18 Long Bone: Irregular or Stippled Epiphyses
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
92 Long Bone: Cortically Based Diaphyseal Lesion,
22 Long Bone: Epiphyseal Overgrowth/Ballooning
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR Sclerotic
24 Long Bone: Sclerotic/Ivory Epiphysis Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR 96 Long Bone: Cortically Based Diaphyseal Lesion, Lytic
28 Long Bone: Epiphyseal/Apophyseal/Subchondral Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
102 Tibial Metadiaphyseal Cortically Based Lesion
Lytic Lesion
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
104 Long Bone: Diffuse Cortical/Endosteal Thickening
SECTION 3: LONG BONE, METAPHYSEAL Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
34 Long Bone: Metaphyseal Bands & Lines 108 Long Bone: Undertubulation
Cheryl A. Petersilge, MD, MBA and Carol L. Andrews, MD Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
38 Long Bone: Metaphyseal Cupping 114 Long Bone: Overtubulation
Cheryl A. Petersilge, MD, MBA and Michael Mulligan, MD Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
40 Long Bone: Metaphyseal Fraying
Cheryl A. Petersilge, MD, MBA and Michael Mulligan, MD SECTION 5: LONG BONE, GROWTH PLATE
42 Long Bone: Central Metaphyseal Lesion,
120 Growth Plate: Premature Physeal Closure
Nonaggressive
Carol L. Andrews, MD
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
122 Growth Plate: Widened Physis
48 Long Bone: Central Metaphyseal Lesion, Aggressive
Robert Downey Boutin, MD and B.J. Manaster, MD, PhD,
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
52 Long Bone: Metaphyseal Lesion, Bubbly FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR SECTION 6: PERIOSTEUM
56 Long Bone: Eccentric Metaphyseal Lesion,
Nonaggressive 128 Periosteum: Aggressive Periosteal Reaction
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
60 Long Bone: Eccentric Metaphyseal Lesion, MD
Aggressive 132 Periosteum: Solid Periosteal Reaction
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
64 Long Bone: Cortically Based Metaphyseal Lesion MD
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR 138 Periosteum: Bizarre Horizontal Periosteal Reaction
68 Long Bone: Surface (Juxtacortical) Lesion Robert Downey Boutin, MD and B.J. Manaster, MD, PhD,
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR FACR
142 Periosteum: Periosteal Reaction Multiple
Bones/Acropachy, Adult
Robert Downey Boutin, MD and B.J. Manaster, MD, PhD,
FACR

xiv
 TABLE OF CONTENTS
146 Periosteum: Periosteal Reaction Multiple Bones, 236 Glenohumeral Malalignment
Child Robert Downey Boutin, MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR 238 Anterosuperior Glenoid Labrum
Variations/Pathology
SECTION 7: JOINT BASED Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
152 Arthritis With Normal Bone Density MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR 242 Fluid Collection About Shoulder
156 Arthritis With Osteopenia Michael Mulligan, MD and Carol L. Andrews, MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
160 Arthritis With Productive Changes SECTION 9: ELBOW AND FOREARM
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR 248 Dysplasia/Aplasia of Radius
164 Erosive Arthritis Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR MD
170 Mixed Erosive/Productive Arthritis 250 Forearm Deformity
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
172 Arthritis With Large Subchondral Cysts MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
176 Atrophic Joint Destruction SECTION 10: WRIST AND HAND
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 256 Cystic/Lytic Lesion in Carpal Bone
MD Kirkland W. Davis, MD, FACR and Cheryl A. Petersilge,
180 Arthritis Mutilans MD, MBA
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 258 Abnormal Radiocarpal Angle
MD Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
182 Neuropathic Osteoarthropathy MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
184 Arthritis With Preserved Joint Space SECTION 11: FINGERS AND TOES
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
264 Arachnodactyly
188 Widened Joint Space
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
266 Soft Tissue Mass in Finger
MD
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
194 Ankylosis
MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
272 Acro-Osteolysis
198 Intraarticular Mass
Carol L. Andrews, MD
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
276 Acro-Osteosclerosis
202 Calcified Intraarticular Body/Bodies
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
MD
206 Chondrocalcinosis
278 Cystic/Lytic Lesion in Phalanx
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
208 Periarticular Calcification
284 Sesamoiditis
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
214 Metacarpophalangeal Joint-Predominant Arthritis
286 Short Metacarpal/Metatarsal
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
216 Interphalangeal Joint-Predominant Arthritis
290 Ulnar Deviation of MCP Joints
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
220 Monoarthritis
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR MD
224 Joint Replacement With Lytic/Cystic Lesions 292 Swelling & Periosteal Reaction of Digit (Dactylitis)
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR

SECTION 8: SHOULDER GIRDLE AND ARM SECTION 12: INTERVERTEBRAL DISC

228 Clavicle Lesion, Nonarticular 296 Lesion Crossing Disc Space
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD, Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA
298 Disc Mineralization
MBA
Julia R. Crim, MD
232 Distal Clavicle Resorption
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
MBA
234 Proximal Humerus: Erosion of Medial Metaphysis
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD

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 TABLE OF CONTENTS
364 Symphysis Pubis Widening
SECTION 13: PARASPINAL Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
ABNORMALITIES MD
304 Ossification/Calcification Anterior to C1-C2 368 Supraacetabular Bone Destruction
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD, Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MBA MD
306 Paravertebral Ossification/Calcification
Donna G. Blankenbaker, MD SECTION 18: HIP AND THIGH
310 Linear Ossification Along Anterior Spine 374 Protrusio Acetabuli
Donna G. Blankenbaker, MD and Cheryl A. Petersilge, MD, Michael Mulligan, MD and Carol L. Andrews, MD
MBA 378 Coxa Magna Deformity
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
SECTION 14: VERTEBRAL SHAPE 380 Acetabular Labrum Tears, Etiology
314 Bullet-Shaped Vertebra/Anterior Vertebral Body Donna G. Blankenbaker, MD and B.J. Manaster, MD, PhD,
Beaking FACR
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
MBA SECTION 19: KNEE AND LEG
316 Congenital & Acquired Childhood Platyspondyly 388 Enlargement of Intercondylar Notch
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD, Michael Mulligan, MD and Carol L. Andrews, MD
MBA 390 Lytic Lesion of Patella
320 Fish (Biconcave) or H-Shaped Vertebra Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD, 394 Tibial Bowing
MBA Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
322 Squaring of 1 or More Vertebrae 398 Fluid Collection About the Knee
Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA Carol L. Andrews, MD
404 Popliteal Mass, Extraarticular
SECTION 15: VERTEBRAL LESIONS Carol L. Andrews, MD
326 Vertebral Body Sclerosis 408 Alterations in Meniscus Size
Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA Carol L. Andrews, MD
332 Spinal Osteophytes 412 Genu Valgum (Knock Knees)
Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA Carol L. Andrews, MD
334 Lesion Originating in Vertebral Body 414 Genu Varum (Bow Leg Deformity)
Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
340 Lesion Originating in Posterior Elements
Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA SECTION 20: FOOT AND ANKLE
418 Achilles Tendon Thickening/Enlargement
SECTION 16: RIBS Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
344 Rib Notching, Inferior 420 Calcaneus Erosion, Posterior Tuberosity
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
MD 424 Retrocalcaneal Bursitis
346 Rib Notching, Superior Michael Mulligan, MD and Carol L. Andrews, MD
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 426 Soft Tissue Mass in Foot
MD Michael Mulligan, MD and Carol L. Andrews, MD
348 Solitary Rib Lesion 432 Talar Beak
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
SECTION 17: PELVIS 434 Cystic/Lytic Lesions of Tarsal Bone
354 Sacroiliitis, Bilateral Symmetric Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR MD
358 Sacroiliitis, Bilateral Asymmetric
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR Part II: Image Based
360 Sacroiliitis, Unilateral
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR SECTION 1: RADIOGRAPH/CT, OSSEOUS
362 Symphysis Pubis With Productive Changes/Fusion
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 442 Polyostotic Lesions, Adult
MD Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
448 Polyostotic Lesions, Child
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR

xvi
 TABLE OF CONTENTS
454 Solitary Geographic Lytic Lesion
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
SECTION 2: RADIOGRAPH/CT, SOFT
MD
TISSUE
460 Sclerotic Bone Lesion, Solitary 548 Soft Tissue Ossification
Carol L. Andrews, MD Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
466 Sclerotic Bone Lesions, Multiple MD
Carol L. Andrews, MD 552 Nodular Calcification
472 Sclerotic Lesion With Central Lucency Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, MD
MD 558 Linear and Curvilinear Calcification
476 Sequestrum Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, MD
MD 564 Soft Tissue Neoplasm Containing Calcification
480 Target Lesion of Bone Carol L. Andrews, MD
Cheryl A. Petersilge, MD, MBA
484 Matrix-Containing Bone Lesion SECTION 3: MR, OSSEOUS
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR 570 Bone Marrow Edema Syndromes (Proximal Femur)
490 Benign Osseous Lesions That Can Appear Aggressive Michael Mulligan, MD and Carol L. Andrews, MD
Carol L. Andrews, MD 574 Subchondral Edema-Like Signal
496 Metastases to Bone Michael Mulligan, MD and Carol L. Andrews, MD
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 576 Abnormal Epiphyseal Marrow Signal
MD Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
500 Generalized Increased Bone Density, Adult 580 Increased Marrow Fat
Michael Mulligan, MD and Carol L. Andrews, MD Michael Mulligan, MD and Carol L. Andrews, MD
504 Generalized Increased Bone Density, Child 584 Marrow Hyperplasia
Michael Mulligan, MD and Carol L. Andrews, MD Michael Mulligan, MD and Carol L. Andrews, MD
508 Sclerosing Dysplasia 588 Bone Lesion With Fluid-Fluid Levels
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
514 Hypertrophic Callus Formation MD
Carol L. Andrews, MD and Cheryl A. Petersilge, MD, MBA
516 Bone-Within-Bone Appearance SECTION 4: MR, SOFT TISSUE
Cheryl A. Petersilge, MD, MBA 592 Lesion With Bright T1 Signal
520 Osteopenia Cheryl A. Petersilge, MD, MBA, Kirkland W. Davis, MD,
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
FACR, and Catherine C. Roberts, MD
MBA 596 Soft Tissue Lesion With Predominately Low T1 & T2
522 Osteoporosis, Generalized
Signal
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MBA
MD
528 Osteoporosis, Regional
600 Soft Tissue Lesion With Fluid-Fluid Levels
Kirkland W. Davis, MD, FACR and Robert Downey Boutin,
Cheryl A. Petersilge, MD, MBA
MD 604 Target Lesion of Soft Tissues
532 Cortical Tunneling Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
MD
MBA 606 Cystic Mass
534 Pseudoarthrosis Cheryl A. Petersilge, MD, MBA, Catherine C. Roberts, MD,
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
and Kirkland W. Davis, MD, FACR
MBA 612 Subcutaneous Mass
536 Enthesophyte Cheryl A. Petersilge, MD, MBA
Donna G. Blankenbaker, MD 618 Enlarged Muscle
540 Tendon & Ligament Ossification Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
MBA
MBA 622 Muscle Atrophy
542 Bone Age, Advanced Cheryl A. Petersilge, MD, MBA
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 626 Intermuscular Edema
MD Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
544 Bone Age, Delayed MD
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, 630 Tenosynovitis/Tenosynovial Fluid
MD Michael Mulligan, MD and Carol L. Andrews, MD

xvii
 TABLE OF CONTENTS
632 Enlarged Peripheral Nerves
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
SECTION 3: WRIST AND HAND
710 Wrist Clicking/Clunking/Instability
SECTION 5: MR, JOINT Michael Mulligan, MD and Carol L. Andrews, MD
638 Intraarticular Low-Signal Material, All Sequences 714 Ulnar-Sided Wrist Pain
Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR Michael Mulligan, MD and Carol L. Andrews, MD
720 Radial-Sided Wrist Pain
SECTION 6: ULTRASOUND Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
644 Anechoic Mass SECTION 4: PELVIS, HIP, AND THIGH
Michael Mulligan, MD and Carol L. Andrews, MD
646 Hypoechoic Mass 728 Groin/Hip Pain
Kirkland W. Davis, MD, FACR Donna G. Blankenbaker, MD
734 Lateral Hip Pain
SECTION 7: NUCLEAR MEDICINE Donna G. Blankenbaker, MD
738 Snapping Hip
654 Photopenic Lesions & False-Negative Scans
Donna G. Blankenbaker, MD
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
740 Hip Impingement
MBA
Donna G. Blankenbaker, MD
656 Soft Tissue Uptake on Bone Scan
744 Thigh Pain
Kirkland W. Davis, MD, FACR and Robert Downey Boutin,
Donna G. Blankenbaker, MD and Carol L. Andrews, MD
MD
748 Nerve Entrapment, Lower Extremity
662 Superscan
Carol L. Andrews, MD
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
752 Hip Pain, Elderly Patient
MBA Michael Mulligan, MD and Carol L. Andrews, MD
664 Hypermetabolic Lesion, Osseous 758 Painful Hip Replacement
Carol L. Andrews, MD Carol L. Andrews, MD and B.J. Manaster, MD, PhD, FACR
670 Hypermetabolic Lesion, Soft Tissue
Carol L. Andrews, MD SECTION 5: KNEE AND LEG
766 Anterior Knee Pain
Part III: Clinically Based Michael Mulligan, MD and Carol L. Andrews, MD
772 Medial Knee Pain
SECTION 1: SHOULDER AND ARM Michael Mulligan, MD and Carol L. Andrews, MD
778 Calf Pain
676 Painful or Enlarged Sternoclavicular Joint
Michael Mulligan, MD and Carol L. Andrews, MD
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
784 Painful Knee Replacement
MBA
Carol L. Andrews, MD
678 Rotator Cuff Symptoms
Michael Mulligan, MD and Carol L. Andrews, MD SECTION 6: ANKLE AND FOOT
682 Shoulder Instability
Michael Mulligan, MD and Carol L. Andrews, MD 792 Anterior Ankle Pain/Impingement
686 Anteroinferior Glenoid Labrum/Capsule Injury Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
Michael Mulligan, MD and Carol L. Andrews, MD MBA
688 Nerve Entrapment, Shoulder 796 Medial Ankle Pain
Michael Mulligan, MD and Carol L. Andrews, MD Michael Mulligan, MD and Carol L. Andrews, MD
802 Lateral Ankle Pain
SECTION 2: ELBOW AND FOREARM Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
692 Elbow Deformities in Children and Young Adults MBA
Carol L. Andrews, MD and Cheryl A. Petersilge, MD, MBA 808 Heel Pain
694 Lateral Elbow Pain Cheryl A. Petersilge, MD, MBA, Donna G. Blankenbaker,
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts, MD, and Catherine C. Roberts, MD
MD 814 Metatarsalgia
698 Medial Elbow Pain Robert Downey Boutin, MD and Cheryl A. Petersilge, MD,
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD, MBA
MBA 820 Flatfoot Deformity
702 Olecranon Bursitis Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
Robert Downey Boutin, MD and Cheryl A. Petersilge, MD, 824 Cavus Foot Deformity
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MBA
704 Nerve Entrapment, Elbow & Wrist MD
Michael Mulligan, MD and Carol L. Andrews, MD

xviii
 TABLE OF CONTENTS
826 Congenital Foot Deformity
Michael Mulligan, MD and B.J. Manaster, MD, PhD, FACR
832 Diabetic Foot Complications
Carol L. Andrews, MD

SECTION 7: SPINE
836 Painful Scoliosis
Julia R. Crim, MD and Cheryl A. Petersilge, MD, MBA

SECTION 8: SYSTEMIC DISEASE

842 Arthritis in Teenager
Kirkland W. Davis, MD, FACR
846 Anemia With Musculoskeletal Manifestations
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
850 Osteonecrosis
Kirkland W. Davis, MD, FACR
856 Heterotopic Ossification
Cheryl A. Petersilge, MD, MBA
860 Rickets and Osteomalacia
Robert Downey Boutin, MD
864 Soft Tissue Contractures
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
866 Short Limb, Unilateral
Kirkland W. Davis, MD, FACR
872 Hemihypertrophy
Cheryl A. Petersilge, MD, MBA and Robert Downey
Boutin, MD
874 Focal Gigantism/Macrodactyly
Kirkland W. Davis, MD, FACR and Robert Downey Boutin,
MD
878 Dwarfism With Major Spine Involvement
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
880 Dwarfism With Short Extremities
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
882 Dwarfism With Short Ribs
Cheryl A. Petersilge, MD, MBA and Catherine C. Roberts,
MD
884 Dwarfism With Horizontal Acetabular Roof
Kirkland W. Davis, MD, FACR and Catherine C. Roberts,
MD

xix
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Hänen kanssaan Ilma ensi,
kirkas hänkin, taivaasen.

Siin' on pieni ruumis rukka

valju maahan vaipunut,
niinkuin arka orvonkukka
myrskysäässä murtunut.

Impi.

Aurinko nousi korkealle

sinitaivahalle.
Niityt ne loisti kullassansa,
kukkaverhossansa.

Impi se tuomistossa astui,

punaposket kastui,
kastuivat immen kyynelistä
taajaan vieryvistä.

"Miksikä itket, impi rukka,

suret kaunokukka?
Riemuhan kaikkialla kaikuu,
iloäänet raikuu."

"Tuotapa itken, tuost' on huoli:

Isä multa kuoli,
kuolipa armas äitiseni —
siitä kyyneleni!"
 "Oisiko valtavanhempasi
kuolleet armahasi,
itkisit heitä kalmistossa,
kirkon koivikossa."

"Kuolipa armas veikko multa,

kuoli sisko kulta.
Siksipä täällä astuskelen,
heitä kaipaelen."

"Oisiko kuollut veikkosesi,

sulosiskosesi,
etpä sä itkisi näin heitä,
kätkein kyyneleitä.

Siitäpä tiedän, siitä arvaan

syyt tuon kaihon karvaan:
Kuollutpa onkin sulho sulta,
kuollut armas kulta!"

Impi se nuori mättähälle

vaipui vehreälle.
Kyynelten virrat kuumat kieri,
viljemmältä vieri.

Eräs virkamies.

On meillä virkamies! — tuo yksikö, vaan lienee? Hän

palkakseen, kentiesi, kuin suuret summat vienee.
 Hän maaten viettää yötä
ja syöden, juoden päivää.
Voi, onpa siinä työtä,
jos väsyttääkin räivää!

Hän kansanmies on hyvä —

ei kuule kansan mieltä!
On kielitaitona' syvä —
ei taida kansan kieltä!

On hermostonsa arka.
Jos "kansallista" vaan
hän aavistaa — mies parka
jo pyörtyy helpointaan!

Hän muistopatsaitansa
eläissään nähdä saapi.
Sen aina seurassansa
sylissään kuljettaapi.

Kun mainetyönsä karttuu,

niin muistopatsaskin,
tuo vatsa, aina varttuu,
kuin vuori uhkein.

Hän pääsi kuormastansa,

jo päättyi ikä kulta.
Hän nukkuu vaivoistansa,
jo lienee maa ja multa.

Tuon muistopatsahansa vei hautaan seurassaan, ja

kiittämätön kansa ei häntä muistakaan.
Suomen kansakoulukartta 1882.

Sain Kalenterin kauniskantisen, sain joululahjaks' sen. Sit'

ihaellen käännän, katselen ja luen ahmien. Jo luku luistain
puolikirjaan ehti. vaan tuossa, kas — on kummallinen lehti!

On lehti täynnä mustaa, mustaa vaan —

nimeksi valkeaa!
Kuin kansakoulukartta Suomenmaan
noin mustaa rakastaa?
Pois murhepuku tuo — on juhla joulun!
Pois tuo, vaikk' ootkin kartta — kansakoulun!

Vaan puvustaan ei taivu luopumaan

tuo uppiniskainen.
Se vaippaansa ei vaihda valkeaan,
jos kuinka käskenen.
On syynsä sillä olla murheissansa,
muut kuinka riemuinneekin joulunansa.

Myös minäkään — se täytyy tunnustaa —

en riemuita nyt voi.
Noin synkkä vielä armas synnyinmaa.
Se murheen mulle toi.
Mut jouluriemuihin tuo murhe haihtuu.
Ja Suomen yö se päivään viimein vaihtuu.

Wäinöläisten maa.
 Ja Pohjantähti kerran kohtas' Aamun koin: "Miks' hehkuu
poskipääsi joka aamu noin, ikäänkuin posket jalon
nuorukaisen hohtaa, kun sattumalta immen ihanimman
kohtaa?"

Näin innostuen tuohon lausui Aamunkoi: "En punastumatta

mä suinkaan olla voi, en tyvenillä mielin ihaella saata
lumoovan ihanaista sulo Suomenmaata!

Oi, itämeren tytär, Wäinöläisten maa! Maanpallon kaikki

maat mun silmän' nähdä saa. Ja sinuun joka päivä niitä
vertaelen, vaan vertaistasi turhaan niistä etsiskelen!"

Lintuselle.

Sun luoksesi lintunen pieni on laulusi johtanut tieni, ah,

laulaos vaan! Taas kaihojen kalvama rinta juo loihtua
lohdullisinta, kun kuulla sun saan.

Sä kiittelet taivahan luojaa, hyvyyksien kaikkien suojaa ja

suojelijaa, ja siitäpä toivoa uutta ja riemua, rauhallisuutta mun
rintani saa.

Henrik Gabriel Porthan.

[Lausuttu Jyväskylän seminarin Porthan-julilassa 8.11.1878.]

 Kauan astui armas Suomen kansa tietä synkkää, valotonta
varsin, pimeöitä kulki polkuloita, alkua ei tietänynnä tiensä,
määrää matkansa ei tuntenunna. Kauan kaihess' oli kansa
Wäinön, urosheimo unhotuksiin jäänyt, itse tuntenut ei
itseänsä, ei käsittänyt kuin vennon vieras usein anasteli
mainetyöt sen, omisteli kunnian sen kuulun, kielenkin sorean
sorrutteli. Suku Suomen kuolon teillä kulki, kadotustaan
kohden riensi armas, yöhön synkkään vaipua ol' aivan. Mutta
niinkuin nääntyneelle hoiva, eksyneelle tienopas ja niinkuin
erämaalla yössä kulkevalle aamunkoitto armas jouduttaikse,
niin myös sulle, Suomen kansa kallis, tähti koin on koitti
loistavainen, aamurusko kasvojansa nosti, valkeni valoinen
päivä vihdoin.

Ken se hoiva, tienopas lie ollut, kuka aamurusko, ken se

tähti?

Porthan, Henrik Gabriel se armas, Keski-Suomen lapsi

syntyjänsä, hänpä kansan nukkuvan herätti, siihen puhui
hengen hehkuvaisen, päivän saatti Pohjolan perille. Nimet
kuuluisimmat mainitaanko, kerrotaanko mainetyöt jaloimmat,
ansiot urosten lausutaanko, sijan totta siinä saapi Porthan,
sijan toisen, ellei ensimmäisen. Totta on: Ei voittanunna
Porthan kuuluansa tappotantereilla, mainettansa miekan
tutkaimella, arvoaan ei asein ansainnunna. Mutta miehevyyttä
eipä toki tarvittane tappeluissa yksin, kuntoisuutta kuolon
ahtehilla; miestä tarvitahan, missä suinkin suurta, loistavaa
ken luoda mielii, muiston arvoista ken tehdä aikoo. —

Suurta, ylevää mit' tuotti Porthan, mitä toimitteli muiston

syytä?
 Yö jo peitti meiltä muinaisuuden, unho varjosi jo entis-
aikaa. Astui silloin auttajaksi Porthan, mies tuo jalo joutui
johtajaksi, matkusteli hengen mahdillansa, sielun siivin
etähälle ehti, tunkeusi aikoin tuonoisihin. Todet totisetpa sieltä
tuotti, valehettomat vakaiset löysi, tosineemme taatoksi hän
nousi — hän on Suomen Historian isä. Hänen, armahaisen,
toimistaanpa järvein tuhansien maasta tästä,
synnyinmaastamme niin suloisesta vieri viestit maille
vierahille: kaikui kaskut maille kaukaisille, kansasta, mi talven
hyisen maassa sekä maassa heltehen kesäisen kätkee
sydämessään elon, lemmen, riemut, murheet laulaa
lauluissansa, runoin kertoo isäins' urotöitä. — Kosken
perkaaja ol' Porthan, hänpä senkin puhkoi purosen, mi ensin
vieri vienoisena ojasena, joeksi jo joutui voimakkaaksi,
vihdoin virtana jalona juoksi, kuohuu koskena nyt maltitonna,
murtain kaikki esteet edestänsä — se on koski
kansallisuutemme, suuri suomalaisuuden Imatra.

Kauan on jo poissa ollut Porthan, elävitten mailta mennyt

on hän, Tuonen tuville on matkaellut; mutta viel' on henkensä
hereillä, muisto Porthanin ei kuole koskaan suremast' ei
Suomi lakkaa häntä, ikävöimmästä ei isää moista,
kaipaamasta miestä kallistansa.

Elokuun ilta.

Elokuun oli ilta armas, päivä laskihe läntehen, linnut

laaksossa laulelivat, torvet kaikuivat paimenten.
 Kukkarannalle unelmiinsa
neitonen oli vaipunut,
kastehelmiä hiuksiinsa
hienosiin oli tiukkunut.

Pitkin pintaa lammin tyynen

poika souteli purressaan,
vuoroin vait oli nuorukainen,
vuoroin loihe hän laulamaan.

Eipä soutanut edemmäksi,

seista antoi hän venosen;
muuttui laulu vaan hellemmäksi —
liekö nähnyt hän neitosen?

Luonto nukkui — jo illan kuuhut hopeoitsevi maailmaa.

Vielä soutaja immeltänsä tuhat ottaavi suudelmaa.

Puolueoloistamme.

Liperaalit — heistä viis! — Roskat kuivat varisevat. Viikingit

— se hyv' on niis — he kuin yks mies taistelevat. Kansalliset
— ties sen hiis. miks he toistaan raatelevat!

Miks, kuin midianien,

miekkaan kuolla ystäväinsä
täytyis miesten uljasten
kesken töinsä, tehtäväinsä?
Ken loi kiistan tyhmän sen?
Veljet, tää tok' ei käy päinsä!

Pois nuo kiistat katalat! Miks te käytte eri teitä, johtajamme

uljahat! Yhtenä taas viekää meitä, rivit muuten horjuvat —
miel' yks vie vaan voittoon heitä!
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