MUSKULOSKELETAL IMAGING

BENIGN BONE TUMORS Osteoid osteoma The clinical hallmark of the lesion is pain especially at night, that is improved with aspirin. Age ± 5-25 years. Treatment ± surgical excision. Location ± femur and tibia 55%, hands and feet 20%, 80% intracortical Radiographic features Radiolucent nidus 2cm in diameter Nidus surrounded by sclerosis CT ± study of choice for identifying number and location of nidus Bone scan ± hot spot Angiography ± nidus has dense blush MRI ± may have extensive reactive marrow edema

Osteoblastoma Histologically similar to osteoid osteoma but radiologically distinct. Age 30 years. Treatment ± curettage. Two appearences ± expansile lytic + sclerotic " 2cm Location ± spine, long bones Radiographic features Dense sclerotic bone reaction Variable central calcification Malignant osteoblastoma may disrupt cortex and have a soft tissue component (may mimic osteosarcoma)

Osteoma Localized masses of mature bone on the endosteal or periostal surface of cortex, commonly in the skull or paranasal sinuses. Enchondroma Benign cartilaginous neoplasm in the medullary cavity. Most enchondromas are asymptomatic but may present clinically as a pathologic fracture. Peak age ± 10-30years. Location ± tubular bones 50% Radiographic features Lytic lesion in bones of the hand or feet Chondroid calcifications expansion of cortex but no cortical breakthrough No periostal reaction or soft tissue mass Enchondromatosis (Ollier¶s disease) Nonhereditary abnormality in which multiple enchondromas are present. Risk of malignant transformation to chondrosarcoma 25%. Radiographic features ± multiple radiolucent expansile masses in hand and feet, hand and foot deformity, tendency for unilaterality.

Ostaeochondroma Cartilage ±covered bony projection on the external surface of a bone.Age 20years. Location ± tibia, femur, humerus. Two types ± pedunculated + sessile. Characteristic findings ± continuous with parent bone, uninterrupted cortex, metaphyseal location, lesion grows away from joint. Chondroblastoma Uncommon benign neoplasm that occurs almost exclusively in the epiphysis. Location around the knee, proximal humerus.Treatment ± curettage.

osteocondroma

Fibrous cortical defect and nonossifying fibroma Are histologically identical cortically based lesions that differ only in the amount of medullary involvement. Radiographic features ± radiolucent cortical lesion with normal or sclerotic margins, well-demarcated peripheral osseous shell, metaphyseal location, tibia and fibula are most commonly affected. Gyant cell tumor ± arise from osteoclasts. Typically occur in epiphysis with metaphyseal extension.Location ± around knee. Lytic subarticular lesion, expansile, may erode into joint, pathologic fracture.

MALIGNANT BONE TUMORS Osteosarcoma Second most frequent primary malignant bone tumor after multiple myeloma. Age ± 10-30 years. Clinical ± pain, mass, fever. Location ± tubular bones 80% (femur, tibia) Radiographic features - Poorly defined, intramedullary, metaphyseal mass lesion that extends through the cortex - Matrix ± osteoid, chondroid, spindle cell (fibroblastic) - Aggressive periostal reaction ± Codman triangle, sunburst pattern - Pulmonary metastases

Chondrosarcoma Malignant cartilage-producing tumor. Age ±40-45years.Most are low-grade asymptomatic tumors that are found incidentally.Location ± metaphysis of long bones Radiographic features - Lytic mass that may or may not have chondroid matrix - Medullary chondrosarcomas arise within cancellous bone or the medullary cavity - Exostotic chondrosarcoma arises in the cartilage of a previously benign osteochondroma; these tumors commonly have a chondroid matrix and an extraossous soft tissue mass

Ewing¶s tumor Relatively common malignant tumor derived from undifferentiated mesenchymal cells of the bone marrow. Age 5-15years. Clinical ±mass, fever, leukocytosis, elevated ESR. Location ± diaphysis of lower extremity Radiographic features - Aggressive tumor, osteolytic, cortical erosion, periostitis - No tumor matrix - Extraosseous soft tissue mass is typical - Metastases ± lung and bone

Metastases - Hematogeneous spread through arterial circulation to vascular red marrow; common around shoulders and hip joints due to residual red marrow - Hematogeneous spread through retrograde venous flow (e.g. prostate) - Direct extension ± uncommon - Lymphangitic ± rare Commonly lytic metastases ± kidney, lung, thyroid, breast Commonly sclerotic metastases ± prostate, breast Other sclerotic metastases ± Hodgkin¶s lymphoma, carcinoid, medulloblastoma, neuroblastoma, transitional cell cancer

Multiple myeloma Most common primary bone tumor. Age " 45 years. Composed of plasmacytes with a distribution identical to that of red marrow. Vertebral bodies are destroyed before the pedicles are as opposed to metastases in which pedicles are destroyed first Axis skeleton is most commonly affected ± skull, spine, ribs, pelvis Clinical findings ± IgA and/or IgG peak by electrophoresis, Bence-Jones proteins in urine, reversed albumin/globulin ratio, bone pain, anemia Radiographic features - Multiple well-defined lytic lesions 80% - Generalized osteopenia with vertebral compression fractures - Large soft tissue mass

DEGENERATIVE ARTHRITIS Five hallmarks : - Narrowing of joint space, usually asymmetric - Subchondral sclerosis - Subchondral cysts - Osteophytes - Lack of osteoporosis

DEGENERATIVE DISK DISEASE - Disk space narrowing - Vacuum phenomenon in disk space - Endplate osteophytes and sclerosis - MRI ± imaging method of choice

ANKYLOSING SPONDYLITIS Seronegative spondyloarthropathy of the axial skeleton and proximal large joints. HLA ±B27 in 95%. Insidious onset of back pain and stiffness.Onset ± 20years. Radiographic features Sacroiliac joint is the initial site of involvement : bilateral, symmetric Erosions ± early, sclerosis ± intermediate, ankylosis ± late Contigous thoracolumber involvement ± vertebral body ³squaring´(early osteitis), syndesmophytes, bamboo spine (late fusion and ligamentous ossification) Enthesopathy is common Arthritis of proximal joints in 50% Associations ± inflammatory bowel disease, iritis, aortitis, pulmonary fibrosis of upper lobes.

TUBERCULOUS ARTHRITIS Phemister triad ± cartilage destruction + marginal erosions + osteoporosis Kissing sequestra in bones adjacent to joints Location ± hip, knee, tarsal joints, spine (Pott¶s disease)

OSTEOMYELITIS - Hematogeneous osteomyelitis - Implantation osteomyelitis caused by bacteria implanted or introduced with an open fracture, penetrating wound, surgical procedure - Secondary osteomyelitis with the bone involvement secondary to a contigous focus of soft-tissue infection. Pathogenesis ± S.aureus enter the bloodstream and become entrapped in the terminal vascular networks of long bones, the site and consequences depending on the age of pacient. Radiographic features ± acute osteomyelitis There is a latent period of 10 to 12 days between the time of onset of clinical symptoms and the development of radiographic changes. First ± swelling of soft-tissues ± displacement or obliteration of the normal fat planes. First bone sign ± area of indefinite rarefaction or destruction in the metaphysis, poorly defined, granular or mottled Periostal reaction parallel to the outer margin of the cortex

Subacute and chronic osteomyelitis - Bone abscess ± Brodie¶s abscess ± area of radiolucency surrounded by an irregular zone of dense sclerosis.The cortex is usually thickened by periostal new-bone formation - Sequestrum formation ± segment of cortical bone isolated and devoid of blood supply ± area of dense bone surrounded by zones of rarefaction or lucency - The end result of chronic osteomyelitis is a thickened bone with a sclerotic cortex and a vawy outer margin interspersed with lucent areas where sequestra have been absorbed or surgically removed.

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