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Radiology > MSK > Flashcards

MSK Flashcards

1
Q

Osteoarthritis

A
  • Articular cartilage breakdown
  • Can involve, bone, synovium, ligaments, menisci, joint capsule, and musculature
  • Imaging
    • Asymmetrical joint space narrowing
    • Sclerosis of subchondral bone
    • Osteophytosis
    • Subchondral cystic change
    • Lack of periarticular osteopenia
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2
Q

Hand Osteoarthritis

A
  • No Erosions
  • Most common site - 2nd DIP
  • DIP involvement most common with first CMC and PIPs following in order
  • NO MCPs
  • Heberden Nodule - Soft tissue swelling surrounding the DIP
  • Bouchard Nodule - Soft tissue swelling surrounding the PIP
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3
Q

Shoulder Osteoarthritis

A
  • Grashey View (Posterior view with 40 degree oblique/external rotation)
  • Narrowing of the cartilage space in that orientation is diagnostic
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4
Q

Foot Osteoarthritis

A
  • Most commonly affects the First MTP - causes hallux rigid with dorsal osteophytes
  • Also affects the talonaviucular joint - causes dorsal beaking
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5
Q

Knee Osteoarthritis

A
  • Three compartments in the knee
    • Medial Tibiofemoral
    • Lateral Tibiofemoral
    • Patellofemoral
  • Asymmetrical involvement of the medial tibiofemoral
  • Severe can include all
  • Osteophytes determine if OA is present
  • Degree of joint narrowing is severity
  • Best imaging - standing weight bearing, often in flexion
  • Bilateral involvement is typical
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6
Q

Hip Osteoarthritis

A
  • Bilateral involvement
  • Includes typical features of OA
  • Can have superolateral migration or medial migration
  • **Axial migration is only in inflammatory arthritis.
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7
Q

Spine Degenerative Changes

A
  • Osteoarthritic changes in spine can be i the facets, atlantoaxial, uncovertebral (C3-C7), and sacroiliac joints
  • Intervertebral disk degeneration is known as degenerative disk disease. Desiccation of the intervertebral discs, endplate sclerosis, and osteophytosis.
  • Vacuum phenomenon
  • Complications include spinal stenosis, neural foramina stenosis and degenerative spondylolisthesis
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8
Q

Kummel Disease

A
  • gas in there vertebral body compression fracture representing osteonecrosis
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9
Q

Diffuse Idiopathic Skeletal Hyperostosis

A
  • Exuberant osteophytosis
  • flowing bridging anterior ostreophytes at least four vertebral levels, with normal disc spaces and sacroiliac joint.
  • Can cause dysphagia when seen in the cervical spine
  • Associated with ossification of the posterior longitudinal ligament
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10
Q

OPLL ( ossification of the posterior longitudinal ligament)

A
  • As described
  • Can be associated with spinal stenosis
  • Difficult to identify on MRI
  • Better visualized on CT
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11
Q

SI Osteoarthritis

A
  • Superior portion is syndesmotic - no OA

- Inferior portion is synovial - OA

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12
Q

Erosive Osteoarthritis

A
  • Clinical Findings of rheumatoid arthritis (swelling) with distrubtion of imaging arthritis associated with OA
  • Same distribution as OA
    • DIP
    • CMC
    • PIP
  • GULL-WING of DIP- central erosion and marginal osteophytes
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13
Q

Rheumatoid Arthritis

A
  • Autoimmune disorder
  • Targets synovium waxing and waning inflammatory response
  • Antibody against IgG, which activated complementary cascade
  • Presents with symmetrical joint pain, swelling, and morning stiffness
  • Hands and wrist early, maybe foot
  • Late - cervical, knees, shoulder, hips
  • Imaging Findings
    • MARGINAL EROSIONS- within bare area (lateral area not covered by cartilage)
    • soft tissue swelling
    • diffuse, symmetric joint space narrowing
    • periarticular osteopenia
    • joint subluxations
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14
Q

Hand/Wrist RA

A
  • Involves MCP/PIP/Carpals
  • Earliest evidence - tissue swelling and periarticular osteopenia. reflects synovitis and hyperemia
  • Erosions occur early - radial aspects of 2nd and 3rd MCP.
  • Radial and Ulnar aspects of proximal phalanges
  • Ulnar and Radial Styloid
  • Joint subluxations not reducible
    • Boutonniere - PIP flexion DIP hyperextensions
    • Swan Neck - PIP hyperextension DIp flexion
  • Late Stage –> ankylosis of wrist
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15
Q

Feet RA

A
  • MTP and talocalcaneonavicular joint involvement

- 20% of patients have MTP involvement as first area

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16
Q

Hip RA

A
  • Concentric acetabular cartilage loss
  • Axial Migration of the femoral head
  • Protrusio deformity - >3mm(M) or > 6mm (F) deviation beyond the ilioischial line.
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17
Q

Knee RA

A
  • Involves all three joint spaces in the knee

- less likely to have erosions when compared to other joints with RA involvement

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18
Q

Spine RA

A
  • Cervical Spine, rarely lumbar and thoracic
  • 70% of patients have spinal involvement
  • Subluxation, osteopenia, erosions of the odontoid, facets, vertebral endplates, and spinous processes.
  • No bone production
  • Anterior Atlantoaxial subluxation - Flexion radiographs
    • secondary to laxity of the transverse ligaments
    • Atlantodental interval > 2.5mm
  • Vertical Atlantoaxial subluxation - protrusion of the odontoid through the Forman magnum. Can compress midbrain
    • Radiograph - Odontoid no visible. anterior arch of C1 sinks to level of C2
  • Posterior Atlantoaxial subluxation - Secondary to odontoid erosion/fracture
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19
Q

Shoulder RA

A
  • High riding humerus (chronic rotator cuff tears)
  • Erosions in lateral aspect of the humeral heads
  • Erosions of the AC joint - peniciling of the distal clavicle
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20
Q

Elbow RA

A
  • 1/3 of patients.
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21
Q

Seronegative Arthropathies

A
  • Ankylosing Spondylitis
  • Psoriatic Arthritis
  • Reactive Arthritis
  • IBD associated arthritis
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22
Q

Sacroilitis

A
  • Only involves the synovial portion (inferior SI)
  • Erosive changes on the iliac portion first
  • Symmetric - Ankylosing spondylitis, IBD associated
  • Asymmetric - Reactive arthritis, psoriatic arthritis
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23
Q

Septic Arthritis

A
  • Unilateral arthritis
  • Immunocompromised or IV drug user
  • Erosive changes associated with fever
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24
Q

Inflammatory Bowel Disease

A
  • Symmetrical

- Associated with ulcerative colitis, whipple disease, s/p gastric bypass, and Crohns

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25
Q

Ankylosing Spondylitis

A
  • HLA-B27, young men, back pain, stiffness
  • Associated with upper lobe pulmonary fibrosis, cardiac conduction defects, and aortitis
  • Symmetric erosions, widening and sclerosis of SI joint
  • Spine involved –> progression from lumbar to cervical
    • Romanus lesions - erosions of anterior superior/inferior edges caused by enthesitis (inflammation of tendon) at annulus fibrosis insertion site
    • Shiny corners - sclerosis of prior Romanus Lesions
    • Squaring of the vertebral body disc margins
    • Delicate syndesmophytes - bony bridging connective cerebral margins creating bamboo spine
  • Fully ankylosed spine - high risk of fracture with even minor trauma
    Andersson lesion - pseudoarthrosis of ankylosed spine
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26
Q

Psoriatic Arthritis

A
  • Arthropathy with skin psoriasis
  • Affects the hands
  • Mineralization is perserved
  • Asymmetric sacroilitis
  • Diffuse soft tissue swelling of the digit - SAUSAGE DIGIT
  • Pencil in cup erosions - characteristic affecting DIPs
    • starts as marginal erosions and progresses centrally
  • Bone proliferation may occur adjacent to the erosions
  • Severe arthritis form causes telescoping digits
  • FOOT- IP and MTP digits are involved. Ivory phalanx represents osteoscleorsis . Plantar calcaneus spur with periosteal reaction
    Spine - lateral bony outgrowths
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27
Q

Reactive Arthritis

A
  • Inflammatory Arthritis associated with sequela of infectious diarrhea, urethritis, or cervicitis
  • Predominantly in the feet - similar to psoriatic
    • Diffuse soft tissue swelling
    • joint space loss
    • marginal erosions
    • juxta-articular osteopenia
  • Bony mineralization is perserved in later stages
  • Calcaneus most common site
    • erosions, enthesophytes, fluffy periosteal reactions
    • Posterior - superior aspect of the calcaneus
    • achilles tendinitis
  • HANDS - ITP and MTP erosions, diaphysial periostitis
  • SPINE - Lateral coarse bony bridging
  • Sacroilliac joints - Asymmetric joints.
  • Association with Chlamydia, Shigella, Salmonella, Yersinia, and Campylobacter
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28
Q

Systemic Lupus Erythematosus

A
  • 90% of patient have joint abnormalities
  • Reducible subluxation when hands are viewed on PA and hands are compressed against plate
  • Ballcatchers/Norgaard view and oblique view don’t put constraint on hands and how subluxations
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29
Q

Jaccoud Arthropathy

A
  • Secondary vs Rheumatic fever vs SLE
  • Type III hypersensitivity
  • Reducible subluxations
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30
Q

Scleroderma

A
  • Systemic collagen vascular disease
  • collagen deposition in skin and soft tissues
  • Soft tissue wasting
  • Osteoperosis
  • Acroosteolysis
  • Distal fingers affected first with atrophy of distal soft tissues
  • Dystrophic soft tissues and periarticular calcifications common in scleroderma tightening and fibrosis of the skin leading to joint contractures
  • After the skin the GI tract is most frequently involved.
    • Esophogeal dysmotility/dilation, patulous GE junction, dilated small bowel with closely spaced thin folds, wide mouthed sacculations.
  • Some develop pulmonary fibrosis
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31
Q

Acroosteolysis

A
  • resorption of the distal portion of the distal phalanges
  • can have associated calcifications
  • DDX
    • Collagen vascular disease (including scleroderma)
    • Neuropathy
    • Polyvinyl chloride exposure
    • Thermal (frost bite or burn) - thumb spared in frostbite
    • Hyperparathyroidism
    • Hajdu - Cheney - autosomal dom - short stature, craniofacial changes, progressive acroosteolysis
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32
Q

Polymyositis/dermatomyositis

A
  • Polymyositis - muscle inflammation
  • Dermatomyositis - muscle and skin inflammation
  • Soft tissue calcifications seen on imaging
    • predominantly intramuscular, can be seen subs
  • Periarticular Osteopenia
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33
Q

Calcium Hydroxyapatite disease

A
  • AKA calcific tendinitis
  • crystal deposited in the periarticular tissues
  • do not deposit in the joints but instead amorphous calcification within tendons
  • Shoulder - supraspinatus tendon
  • Longus Colli - causes neck pain, odynophagia, fever, precertebral effusions - mimics prevertebral abscess
  • Milwaukee Shoulder - INTRA-ARTICULAR rapid destruction of rotator cuff and glenohumeral joint
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34
Q

Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD)

A
  • Inflammatory arthropathy caused by INTRA-ARTICULAR deposition of CPPD crystals
  • 2/2 idiopathic, hemochromatosis, hyperparathyroidism, hypophosphatasia
  • Rhomboid positively birefringent
  • Imaging
    • chondrocalcinosis - calc of hyaline(articular) and Fibrosis(meniscal) cartilage
    • Radiographs of knees, hips, wrist are diangositc
  • Wrist - affects the triangular fibrocartilage complex. Advanced disease can cause SLAC wrist
  • Knee - Patelofemoral space first involved with all 3 compartments eventually involved. Prominent subchondral cysts
  • Hand - 2nd and 3rd MTP - hook like or drooping osteophytes
  • Spine - calcification of the ligaments of the dens
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35
Q

Scalpholunate Advanced Collapse Wrist (SLAC Wrist)

A
  • Proximal Migration of capitate between dissociated scaphoid and lunate
  • Capitate slips in between widened scaphoid and lunate
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36
Q

Gout

A
  • Needle negatively birefringent
  • Sodium urate deposition in joints - inflammatory arthropathy
  • Great toe commonly involved -
  • Imaging
    • sharply marinated erosions with overhanging margins, soft-tissue gouty top
  • joint spaces preserved until late into the disease.
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37
Q

Hemochromatosis

A
  • Impaired iron metabolism
  • Deposition of Iron and CPPD
  • MCP joints involved with hook like osteophytes
  • Mimic CPPD arthropathy but instead of just 2nd and 3rd MCP all MCPs are involved
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38
Q

Acromegaly

A
  • Arthropathy secondary to enlargement of the articular cartilage with subsequent degeneration
  • Initial disease - widening of the joint spaces
  • Later disease - narrowing of cartilage space
  • Beak like osteophytes of Metacarpal heads
  • Spade like enlargement of the terminal tufts
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39
Q

Hematogenous Osteomyelitis

A
  • High vascularity associated with high metabolic activity as well as slow flow in the venous sinusoids accounts for the trapping of hematogenous organisms and development of osteomyelitis.
  • Sagittal T2 fat-saturated MR image confirms bone marrow edema and soft tissue inflammatory changes centered within the metaphysis
  • AP radiograph of the ankle shows ill-defined bone resorption at the metaphysis with delicate periosteal reaction
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40
Q

Non- Accidental Trauma

A
  • Periosteal reaction may be the sole radiographic finding in cases of nonaccidental trauma, but it is nonspecific.
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41
Q

Charcot Joint

A
  • The rapid destruction of the talonavicular joint with large effusion and debris is typical of a neuropathic joint.
  • The calcaneal insufficiency fracture is also typical of diabetic patients.
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42
Q

FOOSH Pattern of Injury

A
  • Most frequently this injury results in Salter-Harris fracture of the distal radius in a child
  • Scaphoid fracture in a young adult
  • Colles fracture in an older adult.
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43
Q

Amyloid Athropathy

A
  • Rare non-inflammatory arthropathy
  • Infiltration of the soft tissues and bones by pleated B sheets of amino acids
  • Primary systemic - monoclonal plasma cell dyscrasia
  • Secondary - underlying inflammation or infection
  • B2 microgloblin secondary to chronic hemodyalysis
  • Bulky soft-tissue nodules in shoulder super-imposed on atrophic shoulder
  • Imaging
    • resembles RA
    • intra-articular deposition cause articular cartilage deposition
    • soft tissue nodules and erosions may be present
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44
Q

Ochronosis

A
  • Manifestations of the alkaptonuria within connective tissue
  • Alkaptonuria - defect in homogentisic acid oxidase- urine black on air exposure
  • Intervertebral calcification with disc height loss at every level
  • negative for significant osteophytosis along the cervical and thoracic spine.
  • Disease may involve the knees and glenohumeral joints, and hips. may also include the DIP and thumb CMC.
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45
Q

Multicentric reticulohistiocystosis

A
  • Lipid laden macrophages are deposited in soft tissues and periarticular tendons, forming skin nodules and erosions with sclerotic margins
  • well defined erosions tend to affect the DIP joints symmetrically
  • soft tissues nodules and preserved bone density
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46
Q

Hemophilic Athropathy

A
  • X linked inherited disorder
  • Recurrent hemarthrosis results in synovial hypertrophy and hyperemia.
  • Epiphyseal enlargement and early fusion.
  • Elbow - enlarged radial head and widening of the trochlear notch
  • Knee - Squaring of the patella and widened intercondylar notch.
  • Secondary arthritis may lead to marked joint space narrowing
  • Iron in synovium causes increased soft-tissue density around joints
  • Pseudotumor of Hemophilia - benign lesion caused b recurrent intraosseous or subperisoteal bleeding. Chronic cyclical bleeding leads to bony scalloping and pressure erosion, often with soft tissue mass.
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47
Q

Juvenile Idiopathic Arthritis

A
  • related chronic inflammatory arthropathies affecting children under age 16
  • Monoarticular - affects single joint usually in knees, ankles, elbows, wrist
  • Polyarticular - hands feet and cervical spine as well as monoarticular joints
  • Still Disease - variant of JIA, systemic disease in children younger than 5. acute febrile illness, rash, adenopathy, pericarditis, and mild arthralgias
  • Abnormal bone length air morphology 2/2 hyperemia.
  • Earlier onset of disease can cause growth disturbances
  • Epiphyseal overgrowth and enlargement of ends of bone. Premature skeletal maturation aphyseal fusions
  • Knee - widening intracondylar notch, metaphysical flaring, uniform joint space narrowing
  • Elbow- Radial head enlargement and widening of trochlear notch
  • Hip Symmetrical cartilage space narrowing, profusion deformities, and gracile of femoral shaft (thinning/narrowing).
  • Wrist - Ankylosis
  • Cervical Spine ankylosis of sygapophyseal joint.(DDX Kulippel Feil Syndrome
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48
Q

Heterotopic Ossification

A
  • Immature osteoid is seen in the first 4-6 weeks following injury, with the lesion developing more mature bone peripherally in the weeks following that.
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49
Q

Acro-osteolysis

A
  • Resorption of the great toe

- Hallmark in psoriatic arthritis

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50
Q

Acetabular Fracture Evaluation

A
  • Acetabular fractures can be identified on frontal views of the pelvis but are not optimally profiled for additional characterization and classification.
  • Bilateral 45° oblique images of the pelvis (Judet views) are considered standard for additional radiographic assessment, such as profiling of the posterior column component of an acetabular fracture.
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51
Q

Plastic/Bowing Fracture

A
  • Bowing fractures (also known as plastic bowing deformity) are the most subtle form of greenstick injury. Careful attention to the morphology of the developing skeleton is needed in order to detect the injury.
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52
Q

Supracondylar Fracture - Children

A
  • The combination of effusion, shown by the positive fat pad sign, and the posterior displacement of the distal humerus, indicated by the abnormal anterior humeral line, indicates a supracondylar fracture.
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53
Q

Anterior Humeral Line

A
  • The anterior humeral line (line extended down the anterior humeral cortex) should intersect the middle 1/3 of the capitellum.
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54
Q

Hill-Sachs Visualization

A
  • A Hill-Sachs fracture (impaction fracture of the superior, posterolateral humeral head) related to prior anterior shoulder dislocation.
  • These fractures are reliably and directly seen only on AP internal rotation views; they are often completely masked on the other views unless they are large
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55
Q

Boutonniere Fracture

A
  • Avulsion fractures of the fingers are most frequently seen on lateral views. If there is a “boutonniere” deformity (flexed proximal interphalangeal (PIP) and extended distal interphalangeal (DIP)) without fracture, it represents a disruption of the middle slip of the extensor tendon.
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56
Q

Soft - Tissue Mallet Finger

A
  • Distal interphalangeal (DIP) joint flexion, while the proximal interphalangeal (PIP) joint is in extension, is typical of mallet (or baseball injury). Without avulsion, a tendon rupture must be diagnosed.
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57
Q

Bisphosphonate Fracture

A
  • Many patients have started using bisphosphonates in an effort to maintain bone density. It is believed that in reducing the amount of bone turnover (suppressing the activity of osteoclasts), the therapy can lead to an accumulation of skeletal microfractures, increasing the risk of insufficiency fractures. Accordingly, there has been recent note of an increase in a very unusual fracture pattern in these patients: subtrochanteric and transverse, without significant trauma, as in this case.
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58
Q

Monteggia Fracture

A
  • The Monteggia fracture is used to describe any dislocation of the radius with an associated fracture of the ulnar shaft. The majority of injuries involve anterior displacement of the radius and a fracture of the proximal 1/3 of the ulnar diaphysis with apex anterior angulation. This fracture-dislocation pattern is more frequently seen in children than in adults.
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59
Q

Galeazzi Fracture

A
  • A Galeazzi fracture-dislocation consists of a radial shaft fracture plus distal radioulnar joint dislocation, both of which are not present in this case.
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60
Q

Unicompartemental Patellofemoral implant + Knee Implants.

A
  • These prostheses are placed when osteoarthritis is confined to a single compartment. These are contraindicated in patients with an inflammatory arthropathy. The other options are terms used for hardware in and around the knee but are not appropriate for this case. A semiconstrained component has a peg extending from the femur to the tibia that allows rotation of a total knee prosthesis. A modular prosthesis typically includes replacement of a portion of the distal femur or proximal tibia. Compress fit refers to a prosthesis fixation device, usually placed in the distal diaphysis of the femur that involves an intramedullary post with traversing pins.
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61
Q

Fabella, Cyamela, Meniscal Ossicle

A
  • the most common ossicles and seasmoid bones in the posterior knee
  • The meniscal ossicle is along the posteriomedial aspect of the knee. Can be intrameniscal appearance when looking at CT or MRI.
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62
Q

Achilles Tendon Tear - Caution

A
  • Plantaris tendon can make a full thickness tear of the ACL only seem partly ripped.
  • The tendon is present in 90% of people.
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63
Q

Periosteal Desmoid

A
  • AKA - avulsive cortical irregularity, distal metaphyseal femoral defect, cortical desmoid, medial supracondylar defect of the femur
  • seen along the posteromedial defect along the distal end of the femur
  • located near the adductor magnus aponeurosis or the origin of the medial head of the gastrocnemius tendon.
  • Ages 15-20, a reaction to trauma.
  • Imaging
    XR - lucent saucer-like defect
    T1 hypointense
    t2 hyperintense
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64
Q

Signs of infection in Tendon Sheath

A
  • Thickened enhancing rim of synovium with the tendon sheath.
  • Debris within the fluid
  • Increased T2 signal in the tendon
  • Tendon tear
  • Adjacent soft tissue infection
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65
Q

Sequestrum

A
  • Necrotic bone surrounded by purulent material or granulation tissue.
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66
Q

Involucrum

A
  • Bone shell surrounding the sequestrum and the infected tissue
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67
Q

Cloaca

A
  • Cortical and periosteal defect that allows pus to drain from the infected medullary cavity into the adjacent surrounding tissues.
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68
Q

Pyomyositis

A
  • intramuscular abscess with an enhancing peripheral rim.
  • Inflammation in the adjacent soft tissues
  • No changes in the bone marrow signal to suggest osteomyelitis
  • No enhancement of the deep fascia to suggest necrotizing fasciitis
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69
Q

MR characteristic of pedal osteomyelitis

A
  • T1 low signal in a geographic medullary distribution
  • T2 high signal in the same region with same distribution

T1 signal associated with reactive edema but not osteomyleltis
- Low, hazy reticulated, low subcortical low subchondral

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70
Q

Abscess Characteristics

A
  • Thick enhancing rim

- Central T1 low and T2 high signal

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71
Q

Chronic Recurrent Multifocal Osteomyelitis

A
  • Autoimmune disorder
  • Bone biopsy show inflammation with histiocytes, lymphocytes, and plasma cells.
  • Blood cultures typically negative.
  • Children aged 9-14
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72
Q

Osseous Changes of Osteomyelitis

A
  • First 1 -2 weeks - no osseous changes
  • Earliest sign is indistinctness of the cortex
  • Permeative osseous destruction, endosteal scalloping, and periosteal reaction follow after
  • Later - Formation of sequestrum, involucrum or abscess
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73
Q

MRI characteristics of Gangrene

A
  • Areas of non-enhancement
  • Indicates devitalized tissue.
  • Gas in itself is not enough to diagnose gangrene as there can be communications with the skin
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74
Q

Cellulitis vs Soft tissue edema

A
  • Contrast enhancement of the involved area is more indicative of cellulitis than soft tissue edema
  • T1 hypointense to fat and T2 hyperintense to the muscle can be seen with both.
  • Skin ulceration not required to make diagnosis of cellulitis
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75
Q

MRI signs of Osteomyelitis superimposed on neuropathic joint

A
  • Sinus tracts
  • replacement of the soft tissue fat
  • Fluid collections
  • Disappearance of subchondral cysts on sequential imaging
  • Extensive marrow abnormalities
  • NO OSTEO Signs
    • thin rim enhancement of the joint effusions
    • presence of subchondral cysts
    • intrareticular loose bodies
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76
Q

Posterior Sternoclavicular dislocation

A
  • Posterior SC dislocation is less common than anterior and results from substantial force, either direct or indirect.
  • It is more common in males than females and may result in injury to the adjacent arch vessels or trachea.
  • Though the serendipity view, an angled AP view, historically was used to make this diagnosis and may be effective, CT is definitive; because of the clinical impact of this diagnosis, CT is the imaging method that should be used.
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77
Q

Calcanea Fatigue Fracture

A
  • Appears as a sclerotic line in the posterior calcaneus
  • Scenario of a older person who started taking up walking.
  • Do not expect to see a lucent fracture line in a calcaneal fatigue fracture.
78
Q

Intra-articular calcaneal fracture

A
  • The fracture within the mid calcaneus is presumed to be intraarticular because Boehler angle is reduced (normal value is 20-40 degrees) .
79
Q

Traumatic Osteolysis

A
  • A type of Salter-Harris I injury seen in children who participate in excessive activities. Wrists in gymnasts, ankles in runners, and proximal humeri in baseball pitchers are at risk.
80
Q

Low Velocity Knee Dislocations

A
  • Low-velocity knee dislocation, such as a misstep on stairs in the setting of morbid obesity, is less likely (about 5%) to be associated with an injury to the popliteal artery compared with high-velocity injuries (as high as 50% in some studies).
81
Q

Rheumatoid Arthritis Feet

A
  • The first finding is associated with the lateral aspect if the fifth metatarsal head. Progression then occurs medially (first toe ) to laterally.
82
Q

Syndesmophytes

A
  • Vertically oriented, thin ossification spanning adjacent vertebral bodies resulting from inflammation and subsequent ossification of Sharpey fibers which are the outer fibers of the annulus fibrosus portion.
83
Q

Pigmented Villonodular Synovitis

A
  • Benign neoplasm fo the synovium.
  • Causes hemosiderin deposition secondary to multiple interarticular hemorrhages.
  • EARLY - joint effusion, juxta-articular erosions, sparing of the joint space
  • LATE - secondary osteoarthritis can develop to receptive bleeding and altered joint mechanics.
  • Blood causes low T1 and T2 signal.
  • can look like amyloidosis but is monoarticular
  • NO Calcifications - not synovial osteochondromatosis.
84
Q

Hip Hardware loosening

A
  • Can lead to distention of the of the iliopsoas bursa.
  • Bursa can be laden with debris-laden macrophages associated with particle disease.
  • Aspirated material from the bursa out the joint is thick and gelatinous.
85
Q

Synovial Osteochondromatosis

A
  • Numerable calcified and ossified nodules in the joint and synovium with shallow well marinated erosions. Intracapsular nodules in swelling joint effusion and secondary degenerative arthritis.
  • usually monoarticular.
  • consider PVNS because of erosions but PVNS has no calcs
86
Q

Reverse total Shoulder Arthroplasty Complication

A
  • Scapular notching
  • Bone resorption at the inferior scapular border secondary to receptive contact between the medial aspect of the humeral cup and the inferior border for -the scapular during adduction.
  • anterior superior dislocation of the humerus
  • glenospohere dissociation
  • periprosthetic fracture
  • infection
  • hardware loosening
  • nerve injury
87
Q

Arthroplasty Loosening

A
  • Change in position is most sensitive and specific for the detection of loosening
  • Cement loosening must be greater than 2mm to be considered for loosening
88
Q

Axial Migration of the Hip

A
  • Seen in RA, CPPD, Ankylosing spondylitis.

- Acromegaly and ochronosis

89
Q

Superolateral and Medial Migration - HIP

A
  • Osteoarthritis
90
Q

Medial Migration - HIP

A

Osteoarthritis or post-traumatic osteoarthritis

91
Q

Turf Toe

A
  • Soft tissue injury along the first metatarsophalangeal joint
92
Q

Morton Toe

A
  • Second digit longer than the first toe, secondary to likely shortening of the first digit.
93
Q

Ollier Disease

A
  • non-hereditary dysplasia with presence of multiple enchondromas
  • commonly involve the metaphyseal regions of the long bones
  • Lesions are usually asymmetric.
  • Skull and spine are spared
  • Lesions regress with skeletal maturity
  • Can cause growth deformities, bowing, or sarcomatous degeneration
  • MR Imaging - lobulated with T2 internal hyperintensity
94
Q

Giant Cell Tumor

A
  • Located in the metaphysis with epiphyseal extension to the subarticular margin.
  • Occurs in ages 20-50
  • Well- defined lytic without a defined sclerotic margin, eccentric in location and extends to a subarticular margin.
  • Imaging - Aggressive appearance - expansile, remodeling, cortical thinning/breakthrough, soft tissue masses, wide zone of transition.
95
Q

Non-ossifying fibroma

A
  • AKA fibroxanthoma, benign fibrous cortical defect.
  • Fibrous tumor, > 3cm is usually called fibrous cortical defect.
  • Multiloculated with sclerotic rim.
  • ‘DO NOT TOUCH’
  • IF Fractured - treat with curettage and bone grafting
96
Q

Features of Malignant Bone Tumor

A
  • Ill defined lesion with permeative infiltrative pattern, wide zone of margin transition and lack of sclerotic margin, aggressive periosteal reaction, cortical destruction and soft tissue mass.
97
Q

Suspicious Features in a Lipoma

A
  • Thick separations measuring >2mm
  • Lesions larger than 10cm
  • Presence of globular/nodular non-adipose areas
98
Q

Multiple Hereditary Exostoses

A
  • Autosomal Dominant
  • Symmetric widening of the metaphases with multiple metaphyseal or metaphyseal equivalent osteochondromas.
  • Spinal involvement at 27% of patient
  • Increased risk of transformation to osteochondroma 1-3% due to increased number and increased risk of transformation per lesion.
99
Q

Pigmented Villonodular Synovitis (PVNS)

A
  • Synovial based lesion, joint effusions, and osseous erosions.
  • Usually seen in less capacious joints such as hip, shoulder, elbow, and ankle.
  • Tendency to bleed with hemosiderin deposition
  • Imaging
  • Low signal on T1 and T2 secondary to hemosiderin deposition
  • Blooming artifact on GRE/SWI imaging because of the hemosiderin deposition.
100
Q

Plantar Fibromatosis

A
  • Fibroblastic and myofibroplastic tumor
  • Medial non-weight bearing surface of the fascia
  • 2.3% of all benign tumors in the foot.
  • More common in men
  • Bilateral in 20-50% of cases
  • Imaging
    • US - hypoechoic or heterogenous
    • T1 - low to isointense
    • T2 - heterogenous signal intensity
101
Q

Forestier Disease

A

Diffuse Idiopathic Skeletal Hyperostosis

102
Q

Plantar Fasciitis

A
  • Heel pain
  • Thickening of the plantar fascia, usually at the calcanea margin
  • Variable degree of soft tissue and osseous inflammation
103
Q

Morton’s Neuroma

A
  • Mass-like fibrosis of the plantar digital nerve, at the level of the metatarsal heads, most commonly between the 3rd -4th and 2nd-3rd inter-metatarsal spaces.
104
Q

Osteosarcoma

A
  • Most common primary bone malignancy in childhood and adolescence
  • Metaphyseal in location
  • Permeative with a wide zone of transition
  • Cortical destruction
  • soft tissue mass
  • Aggressive metaphyseal lesion with densely mineralized osteoid matrix
105
Q

Osteochondroma

A
  • Osseous excrescence with corticomedullary continuity
106
Q

Chondroblastoma

A
  • Benign Cartilage tumor most commonly a lytic epiphyseal lesion with sclerotic margin
107
Q

Chondrosarcoma

A
  • Malignant tumor of cartilage composed of chondroid matrix with a peak incidence ranging from 50-70 years
108
Q

Intramuscular Hemangioma

A
  • Benign Tumors with vascular channels.
  • High T2 weighted MR signal (slow flow– no flow voids)
  • Enhance on post-contrast T1 imaging
  • Phleboliths may be seen on radiographs.
109
Q

Osteofibrous Dysplasia

A
  • Developmental tumor-like, fibrosis-osseous condition with a tendency toward spontaneous regression.
  • No residual skeletal deformity.
  • Almost exclusively in the tibial diaphysis. Involves anterior cortex.
  • Imaging
    • Radiographs - Osseous bowing, osseous enlargement, intracortical osteolysis without adjacent sclerotic band
  • DDX - Adamantinoma, fibrous dysplasia
110
Q

Bizarre Parosteal Osteochondromatous Proliferation(BPOP)

A
  • Rare, exophytic, growths from osseous cortical surfaces consisting of bone, cartilage, and fibrous tissue.
  • Secondary to repair from trauma or benign proliferative process.
111
Q

Osteomas

A
  • Dense lesions involving the skull paranasal sinuses and mandible.
  • Associated with Gardner syndrome(intestinal polyposis)
  • No treatment is usually needed unless they become symptomatic.
112
Q

Schwannoma

A
  • Eccentrically positioned lesion in relation to the nerve.
  • Split fat sign - thin rim of fat surrounding the lesion
  • Fascicular Sign - Multiple small ring-like structures
113
Q

Peripheral Nerve Sheath Tumors

A
  • Target Sign

- Shows increased signal peripherally, with more intermediate signal centrally on T2

114
Q

Neurofibroma

A
  • Split fat sign - thin rim of fat surrounding the lesion

- Fascicular Sign - Multiple small ring-like structures

115
Q

Synovial Chondromatosis

A
  • Benign disorder characterize by formation of multiple contra-articular nodules composed of hyaline cartilage.
  • Imaging
    • T1 low to intermediate
    • T2 hyperintense
    • T1C+ enhancement of the nodules
116
Q

Synovial Sarcoma

A
  • Resemble synovial tissue but don’t arise from the synovial tissues
  • Occur near a tissue or within a tendon sheath
  • Most commonly occurs in the popliteal fossa about the knee
  • More common in young adults but in all age groups
  • Imaging
  • Has internal mineralization
  • T1 - intensity similar or slightly lower than muscle
  • T2 - hyperintense to skeletal muscle
  • T1 C+ - intense enhancement
117
Q

Simple Bone Cyst

A
  • Centrally located, intramedullary, geographic lucent lesions
  • Associated with endosteal scalloping and expansile remodeling.
  • Metaphyseal location but can be metadiaphyseal
  • Pathologic fracture through the lesions is seen >50% patients who present with pathologic fracture
  • ‘Fallen Fragment’ Sign- small fragment migrating through the fluid-filled cyst to the dependent portion of the lesion.
118
Q

Ganglion Cyst

A
  • Benign cystic lesion
  • Majority are located around the wrist
  • Can occur around other major joints
  • Imaging
    • T1 hypointense
    • T2 Hyperintense
    • US - Cystic
119
Q

Maffucci Syndrome

A
  • hereditary disease
  • multiple enchondromas and soft tissue vascular malformations
  • Usually involves short bone and surrounding soft tissue
  • High rate of conversion of enchondromas to malignant lesions
120
Q

Chondrosarcoma

A
  • Chondroid matrix (ring and arcs, popcorn, focal stippled and flocculent)
  • Endosteal scalloping
  • Pathologic fracture
  • Features that are more malignant
    • Cortical destruction
    • Soft tissue masses
121
Q

Enchondroma

A
  • Chondroid matrix (ring and arcs, popcorn, focal stippled, and flocculent)
  • Endosteal scalloping
  • Pathologic Fracture
  • No malignant features such as cortical destruction or soft tissue masses.
122
Q

Intraosseous Lipoma

A
  • Fat containing lesions
  • Mainly metaphyseal - rarely diaphysial or epiphyseal
  • Most prevalent in the proximal femur, but can occur in other long bones, calcaneus, ilium, and ribs
  • Central or ring like calcifications/ossification is pathognomonic
  • Benign - treatment is not indicated.
123
Q

Intraosseous Hemangioma

A
  • Most commonly in vertebral bodies.
  • Can involve posterior elements without body involvement
  • Imaging
  • Coarsened trabeculation
  • T1 and T2 - hyperintense
  • T1 C+ enhance avidly.
124
Q

Osteochondritis Dessican (Osteochondral lesions)

A
  • The MR images demonstrate a break in the cartilage and subchondral bone plate, high T2 signal surrounding the lesion, and cysts at the border of the lesion, all of which indicate an unstable osteochondral lesion (osteochondritis dissecans). Osteochondritis dissecans involves the articular surface, commonly affecting the lateral aspect of the medial femoral condyle.
125
Q

Lisfranc Ligament

A
  • Distal lateral aspect of medial cuneiform and 2nd metatarsal base
126
Q

Transient Patellar Dislocation

A

-The findings are classic for transient lateral patellar dislocation with contusion (edema) to the lateral femoral condyle, medial patella, medial patellofemoral ligament injury and lateral patella tilt.

127
Q

Calcium Hydroxyapatite

A
  • Older men with deposition of calcium dense material

- One of the few causes of shoulder arthritis in adults (esp males)

128
Q

Sartorius Avulsion Fracture

A
  • There is an avulsion fracture fragment lateral to the right anterior superior iliac spine (ASIS). This is where the sartorius attaches. The rectus femoris attaches to the anterior inferior iliac spine (AIIS), the iliopsoas attaches to the lesser tuberosity (and avulsion fractures here warrant a workup for a pathologic fracture), and the hamstrings attach to the ischial tuberosity.
129
Q

Hip Dysplasia

A
  • The femoral head ossification center is markedly hypoplastic. The acetabulum is shallow with cranial subluxation of the femur.
130
Q

Radial Meniscal Tear

A
  • Radial tears are also vertically oriented but occur perpendicular to the longitudinal circumferential fibers of the meniscus; they resemble a spoke on a wheel when viewed on axial images.
131
Q

Vertical- Longitudinal Meniscal Tears

A
  • Vertical-longitudinal tears are oriented straight up-and-down and usually lie near the peripheral edge of the meniscus, following the meniscal circumferential fibers.
132
Q

Vertical Flap Meniscal Tears

A
  • Vertical flap tears start in a radial orientation at the free edge of the meniscus and then turn longitudinal. They usually displace, hence the “flap” designation
133
Q

Madelung Deformity

A
  • Premature focal fusion of the ulnar aspect of the distal radial epiphysis, in turn promoted by the abnormal extrinsic ligaments that tether the carpus to the radius.
134
Q

Morton Neuroma

A
  • Most common location is the 3rd inter metatarsal space. 2nd most common location is the 2nd intermetatarsal space.
  • Non-neoplastic, painful, fibrosing process of the plantar digital nerve.
135
Q

Talar Dislocation

A
  • An isolated fracture of the sustentaculum, along with a bone bruise of the lateral process of the talus . These imply “kissing” injuries, which in turn imply transient dislocation at the subtalar joint. This diagnosis is supported by disruption of the talocalcaneal interosseous and cervical ligaments within the tarsal sinus
136
Q

Parosteal Sarcoma vs Myositis Ossificans

A
  • Differentiate using zoning patterns
  • Parosteal osteosarcoma is more mature centrally and myositis ossificans is more mature peripherally.
  • Both can have uptake on PET SCAN
  • Both can have enhancement on MR
  • Periosteal Reaction.
137
Q

Undifferentiated Pleomorphic Sarcoma

A
  • Undifferentiated pleomorphic sarcoma (formerly known as malignant fibrous histiocytoma) is a very common lesion in the adult population. With no specificity to its appearance, it should be considered in most cases of an aggressive soft tissue mass, though the most common site is in the deep soft tissues of the thigh.
138
Q

Super liberal anterior posterior tear

A
  • SLAP tears involve the superior glenoid labrum, where the long head of biceps tendon inserts. They can extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum.
  • type I: fraying of the superior labrum free margin
    commonly asymptomatic
    often due to degeneration
    type II: detachment of the superior labrum and biceps anchor from the underlying superior glenoid at the chondrolabral junction (undercuts the anchor)
    in younger patients (<40 years of age) these are associated with Bankart lesions
    in older patients (>40 years of age) they are associated with rotator cuff tears 2
    seen in overhead athletes
    type III: bucket handle tear of the superior labrum without extension into the long head of biceps tendon
    type IV: bucket handle tear of the superior labrum with extension into the long head of biceps tendon
139
Q

Calcaneal Insufficiency Avulsion Fracture - Diabetes

A
  • Posterior tubercle fracture of calcaneus in patients with diabetes.
  • LOOK FOR: The vascular calcifications suggest the diagnosis of diabetes. These patients are at risk for insufficiency fractures; posterior tubercle is a favorite location. This has been termed the calcaneal insufficiency avulsion (CIA) fracture.
140
Q

Femoral acetabular impingement, cam type, secondary osteoarthritis

A
  • Abnormal femoral head or neck morphology to suggest a cam-type of impingement.
141
Q

Femoral Acetabular Impingement, pincer type, secondary osteoarthritis

A
  • Overgrowth of the acetabulum, or retroversion suggests pincer type of impingement.
142
Q

Developmental Dysplasia of the Hip

A
  • Uncovering of the femoral head laterally and anteriorly.

- Arthrogram shows hypertrophy and degeneration of the labrum with severe cartilage thinning

143
Q

Osteopathia Striata

A
  • AP and lateral radiographs of the knees reveal linear bands of increased density that extend from the tibial and femoral metaphyses into the diaphyses, consistent with osteopathia striata. Osteopathia striata represents an uncommon sclerosing dysplasia and is usually bilateral in distribution.
144
Q

Buford Complex

A
  • The absence of an anterosuperior labrum with a thick, cord-like middle glenohumeral ligament (MGHL), simulating an anterior labral tear is diagnostic of the Buford labral variant. Though at first glance one might assume a Buford complex is an extensive tear of the anterosuperior labrum, one can use images in all 3 planes to confirm that the structure is the MGHL and joins the joint capsule; moreover, the anteroinferior labrum will reconstitute normally, The thickened MGHL is also demonstrated by on the coronal image. One should not mistakenly call this a torn labrum. The Buford complex seems to be adaptive for those patients who have them and past experience shows that if surgeons attach these to the glenoid rim the patients generally have poor outcomes.
145
Q

Hemophillic Arthropathy

A
  • Example –> The exam shows joint space loss, large subchondral cysts, and most importantly, overgrowth of the radial head .
  • Overgrowth should be seen only in arthropathy acquired during childhood, most commonly hemophilic arthropathy and juvenile idiopathic arthritis (JIA). It is not uncommon for hemophilic arthropathy to affect a single joint, whereas JIA usually affects several joints in a symmetric fashion. The ankle, elbow, and knee are the most frequently affected joints in hemophilic arthropathy.
146
Q

Chronic Osteomyelitis

A
  • The predominant sclerotic pattern mixed with non-aggressive lucency, in conjunction with evidence of slow enlargement of the bone and dense periosteal reaction secures the diagnosis of chronic osteomyelitis in this case.
  • The question then becomes whether the infection is active. Comparison to prior radiographs, evaluating for any changes, may provide critical information and should always be the 1st step.
  • MR is always going to appear abnormal and it may be difficult to evaluate for active inflammation superimposed on chronic disease. However, MR will demonstrate a sinus tract or abscess; if the clinical setting suggests ongoing infection, MR would be a useful 2nd step.
  • Biopsy may be considered if necessary for identification of a specific organism which would be useful for treatment management.
147
Q

Synovial Sarcoma

A
  • Malignant soft tissue tumor of uncertain differentiation
  • Imaging
    • Calcification in 1/3 but variable in extent
    • Changes involving adjacent bone in 11-25%
    • CT attenuation is similar or ↓ relative to muscle
    • Heterogeneous signal intensity on MR
    • Split fat sign, triple sign, bowl of grapes sign on MR
    • May have deceptively bland, well-defined, homogeneous appearance on imaging
  • Malignant extremity soft tissue neoplasms are rare in young adults. The most common in ages 15-40 is synovial sarcoma. Despite the name, which came from pathology descriptions many years ago, these lesions are almost never intraarticular but usually occur near joints.
  • Dystrophic calcification, not present here, is reported to occur in 30%. The lack of calcification argues against myositis ossificans (MO). Even in the early, noncalcified stages, there should be extensive edema surrounding MO due to its traumatic origin. Neurofibroma and myxoma are slow-growing benign lesions that should not have no-enhancing necrotic areas, which is visible on the postcontrast image.
148
Q

Desmoid Tumor

A
  • An oval lesion within the rectus abdominus. In a young woman, lesions at this site are usually desmoid tumors. The rapid enlargement of the lesion, might be concerning.
  • Signal characteristics are typical of desmoid tumor, which often contains homogeneous low-signal material on T2, but virtually always enhances avidly, as in this case. Pregnancy often results in rapid enlargement of this otherwise slowly growing benign lesion; the history assures the diagnosis in this case.
149
Q

Inflammatory Myopathy Dystrophic Calcifications

A
  • The dense, globular calcification is somewhat linear and extends along the fascial plane; this is a typical location in dermatomyositis, one of the inflammatory myopathies.
  • Similar calcific deposits could be seen in metastatic calcification of hyperparathyroidism (HPT); however, the term used in the incorrect answer of hyperparathyroidism is “neostosis,” which is bone formation along the cortex of bone in patients newly treated for renal osteodystrophy; the imaged calcification does not follow this pattern. In addition, large calcifications associated with HPT usually cluster in a periarticular location.
150
Q

Heavy metal ingestion - pediatrics

A
  • Heavy metal ingestion may result in formation of dense metaphyseal lines . In this case with a history of irritability and falling, a serum lead level should be obtained. An abdominal radiograph may demonstrate flecks of lead-based paint in the gastrointestinal tract.
  • Incidentally, a growing child may show dense metaphyseal lines normally; however, when the lines are physiologic, they generally are not seen in the fibula. This case clearly shows fibular abnormality as well, making normal physiologic bone deposition unlikely. Finally, there is no finding to suggest nonaccidental trauma, so skeletal survey is not recommended.
151
Q

Hypothenar Muscle Atrophy

A
  • Sequential axial T1 MR images show progressive enlargement of the ulnar nerve as it courses distally rather than gradual tapering, representing ulnar nerve neuropathy, which accounts for the atrophy of hypothenar musculature.
  • The history of cycling is convincing, so much so that this constellation of history and findings has been called bicyclist palsy.
152
Q

Imaging for Morton Neuroma

A
  • Coronal T1FS + gad, patient prone
  • MR imaging is the best imaging modality to demonstrate a Morton neuroma, but this imaging can be performed in multiple ways. Due to the location and characteristics of this mass, it is best demonstrated on coronal (short axis) sequences. Enhancement can vary but is often intense. Morton neuromas are usually difficult to perceive on T2 fat-saturated images. Placing the patient in a prone position increases the degree the mass extends into the plantar subcutaneous fat, increasing conspicuity.
153
Q

Cleidocranial dysostosis

A

The clavicles are diminutive bilaterally; this appearance or complete absence is characteristic of cleidocranial dysostosis, a disorder of failure of development of midline structures.

154
Q

Giant Cell Tumor

A
  • AP and lateral radiographs demonstrate a geographic lucent lesion with a narrow zone of transition but no significant sclerosis at the margin.
  • Giant cell tumor originates within the metaphysis and extend into the epiphysis following physeal closure, often ending in a subchondral position. Chondroblastoma arises in the epiphysis and may extend into the metaphysis; it usually has a more sclerotic margin, is found in younger patients, and should not be strongly considered in the differential. Brodie abscess would elicit strong sclerotic reactive bone, not seen here. Aneurysmal bone cyst is generally more “aneurysmal” and also is extremely uncommon in patients older than 30 years of age.
155
Q

Achilles Tendinopathy

A
  • The morphology of the Achilles tendon is abnormal. It is thickened in a fusiform fashion ~ 5 cm proximal to its insertion on the calcaneus. This bulbous appearance is easily demonstrated with proper windowing of the image because the Achilles tendon is outlined by Kager fat pad anteriorly. The morphology and location are typical of either Achilles tendinopathy or tear. If there were an accessory soleus, it would bulge into Kager fat pad from the anterior side (the current outline of muscles and tendons is normal).
  • The morphology of the talus, calcaneus, and navicular is normal, helping to exclude coalition; moreover, the middle subtalar facet is visible, whereas it would not be in the setting of talocalcaneal coalition. The lateral process of the talus is discretely visible at the angle of Gissane and is intact without fracture line.
156
Q

Hypertrophic Osteoarthropathy

A
  • The dense, regular periosteal reaction involving all of the metatarsals in a similar way with no underlying osseous or joint pathology, as well as involving the tibia is typical of hypertrophic osteoarthropathy.
157
Q

Iliopsoas Bursitis

A
  • Iliopsoas bursa is located beneath and medial to the iliopsoas tendon and can communicate with the hip joint in approximately 15%.
  • Paralabral cysts, on the other hand, are typically located lateral to the iliopsoas tendon.
  • The 3 main causes of iliopsoas bursitis are acute trauma, overuse injuries, and rheumatoid arthritis. Those due to sport-related activity are likely the result of bursal trauma during overzealous hip flexion and extension. Athletes who participate in rowing, running uphill, competitive track and field, and strength training are particularly at risk for developing iliopsoas bursitis.
158
Q

Little Leaguer’s Shoulder

A
  • Little Leaguer’s shoulder is a Salter I injury. In this case there is widening of the physis that may make one consider the diagnosis.
    However, extension to the metaphysis is not part of Little Leaguer’s shoulder injury. Although there may be periosteal reaPriogction or sclerosis associated with Little Leaguer’s shoulder (which is often chronic), it is not required for the diagnosis.
159
Q

Freiberg Infraction

A
  • The radiographic flattening of the head of the 2nd metatarsal.
  • It is most commonly believed to occur related to chronic repetitive trauma.
160
Q

Pincer Type Impingement

A
  • Pincer impingement is the result of an acetabular abnormality, either local anterior overcoverage (acetabular retroversion) or, more often, generalized overcoverage (coxa profunda) by the acetabulum.
  • One radiographic sign of acetabular retroversion that has been described is the crossover sign, as seen here. The image shows the anterior acetabular rim “crossing over” the posterior rim. In normal morphology, the anterior rim should always project medial to the posterior rim on the AP pelvis.
161
Q

Pleomorphic Liposarcoma

A
  • Pleomorphic liposarcomas have markedly heterogeneous signal intensity on MR with little visible mature fat.
  • Atypical lipomatous tumors and hibernomas both have prominent mature fat. Myxoid liposarcomas have little mature fat, but have a relatively homogeneous appearance that can mimic a cyst.
162
Q

Progressive Systemic Scelrosis

A
  • The oblique radiograph of the fingertips shows acroosteosclerosis and tapering of the distal soft tissues in a patient with progressive systemic sclerosis (PSS).
  • Pulmonary interstitial disease associated with PSS may have a significant impact on patient survival and pulmonary screening is indicated.
163
Q

Brodie Abscess

A
  • Imaging in this case shows a change in the original benign-appearing lesion of the metatarsal (Fig. 2) with a new cortical breach with sequestrum and periosteal new bone (Fig. 1). These findings indicate reactivation of a Brodie abscess.
  • Osteoid osteoma does not fit the initial presentation, and neither enchondroma nor fibrous dysplasia would develop reactive characteristics without a fracture (not visualized here).
164
Q

Pigmented Vilonodular Synovitis

A
  • The mass predominantly (, Fig. 1) occupies the knee joint posterior to the cruciate ligaments. It contains no matrix on the radiograph and is predominantly low signal on both T1 and T2 images. There is mild enhancement following contrast administration.
  • On closer inspection, you will notice similar imaging characteristics of the mass within the suprapatellar recess. The findings are typical of diffuse pigmented villonodular synovitis (a.k.a. tenosynovial giant cell tumor). - Intraarticular chondroma usually shows chondroid matrix on radiograph and benign cartilage nodules on MR, neither of which is present in this case. Synovial hemangioma shows tubular vascular structures, also not demonstrated here. Synovial chondromatosis should demonstrate multiple round bodies or else a conglomerate mass that has characteristics of cartilage &/or bone on MR imaging; it may be calcified on radiographs.
165
Q

Rickets

A
  • The coarsened trabeculae are typical of rickets.
  • The widened and irregular zone of provisional calcification is an even more classic sign, indicating the lack of mineralization in growth centers that is seen in rickets.
  • Since the metaphyses about the knee contribute to bone lengthening to a larger extent than other long bone physes, an AP view of the knees is a sensitive screener to detect manifestations of rickets, including fraying of the metaphyses, widening and cupping of the physes, and bowing of the knees centered at the joint line.
166
Q

Blount Disease

A
  • The medial metaphyseal fragmentation, accompanied by unossified epiphyseal cartilage is typical of Blount disease.
  • Imaging Findings
    • Anteroposterior radiograph shows a vertically oriented irregular medial tibial growth plate , as well as a beak-like appearance of the proximal tibial metaphysis.
    • Coronal T1WI (#1) and PD FSE FS (#2) MR images emphasize the medial beaking of the metaphysis , as well as hypertrophy of the medial tibial plateau cartilage . There is also mild overgrowth of the medial femoral condyle.
167
Q

Simple Bone Cyst

A
  • The appearance of a central lytic geographic lesion in the distal radius of a child most frequently represents unicameral bone cyst. The “fallen fragment” sign secures the diagnosis.
  • The “fallen fragment” sign is infrequently seen in unicameral bone cyst but is fairly pathognomonic as long as it is not conflated with a sequestrum.
168
Q

Aneurysmal Bone Cyst

A
  • Aneurysmal bone cyst (ABC) is usually more eccentric than central in location. Also, ABC tends to be more bubbly or aneurysmal in appearance than the mildly expanded lesion seen in this case.
169
Q

Hematoma

A
  • A hematoma appears as a hypoechoic fluid collection and may contain debris .
  • Active hemorrhage may be hyperechoic, and within a few hours the bleeding will appear homogeneously hypoechoic.
  • Several hours later, serum, cellular elements, and fibrin elements will separate out, resulting in an identifiable fluid-fluid level (not seen here).
170
Q

Tarsal Coalition

A
  • Tarsal coalition is a condition in which 2 tarsal bones are abnormally connected because of incomplete segmentation during development. In osseous coalition, the tarsals have an abnormal bony connection and in nonosseous (a.k.a. fibrocartilaginous) coalition they are connected by cartilage, fibrous tissue, or both.
  • The 2 common types are calcaneonavicular and talocalcaneal coalition.
  • Anteater sign, in which the anterior process of the calcaneus is elongated in the setting of calcaneonavicular coalition. Though there is no true osseous connection, the anterior process of the calcaneus extends abnormally close to the navicular .
  • Irregularity and sclerosis at that interface confirms chronic stresses at the site because of coalition. Teenagers and young adults are the most common age group in which this abnormality becomes symptomatic.
171
Q

Osteogenesis Imperfecta

A
  • The gracile, osteoporotic bones with multiple old fractures and hypertrophic callus formation are typical of osteogenesis imperfecta.
  • Osteogenesis imperfecta has several subtypes ranging from relatively mild to severe; lethal soon after birth. Hypertrophic callus formation may be seen throughout this range of subtypes.
172
Q

Schwannoma on US

A
  • Continuity with the parent nerve is the most suggestive

- centrally hypoechoic, posterior acoustic enhancement, echogenic peripheral capsule

173
Q

Lipomatosis of Median Nerve

A
  • The median nerve fascicles are enlarged and seen in cross section on the axial images and give the appearance of a cable on sagittal; the appearance of these fascicles surrounded by fatty stroma is classic for this diagnosis. It is not a true lipoma but has prominent fatty stroma in which the individual fascicles of the enlarged nerve sit.
174
Q

Madelung Deformity

A
  • The decreased carpal angle, without evidence of trauma but rather a modeling deformity of the distal radial physis, is typical of Madelung deformity. The extrinsic ligament thickening and tethering is a constant feature.
  • The presence of soft tissue (ligamentous) abnormalities can be used to differentiate congenital Madelung deformity from post-traumatic. Coronal MR imaging is best for identifying the thickened radiolunate ligament seen with this diagnosis.
175
Q

Soft tissue hemangioma/ Vascular malformation

A
  • The presence of phleboliths within a soft tissue mass, as well as fatty stroma, allows a radiographic diagnosis of hemangioma/vascular malformation.
  • The multiple round calcifications have lucent centers, typical of phleboliths. These phleboliths indicate that the soft tissue mass is a hemangioma/vascular malformation.
  • Uncommonly, a hemangioma may cause extrinsic scalloping of the adjacent osseous structure, weakening the cortex enough to result in pathologic fracture.
176
Q

Parosteal Osteosarcoma

A
  • Low-grade osteosarcoma (OS) arising on surface of bone
  • Imaging
    Metaphyseal in 90%
    Fusiform along length of bone, with tendency to “wrap around” circumference as it enlarges
    Bone is mature at site of origin, less mature at periphery
    MR fluid-sensitive sequences
    Enhancement of soft tissue and involved marrow
    Marrow involvement in 40-50%, best seen on MR
    Any regions of differentially prominent nonnecrotic soft tissue mass should be biopsied
  • Tx - Wide margin resection
  • Better long term outcomes vs other osteosarcomas
177
Q

Fibroxanthoma

A
  • Fibroxanthoma (nonossifying fibroma) often demonstrates sclerosis around the outer margins. This is especially frequently seen in older teenagers or young adults and suggests that the lesion is starting to fill in with normal bone; this is the usual (though not invariable) natural history of these lesions.
178
Q

Chondromyxoid Fibroma

A
  • Benign cartilaginous neoplasms.
  • CMF is a very rare lesion. In the long bones, it is usually found within the tibia rather than the femur. It may be eccentric but is not cortically based. Finally, CMF does not spontaneously undergo regression or healing, as is seen in the proximal portion of this lesion.
179
Q

Synovial Chondramatosis

A
  • The signal of the bodies in synovial chondromatosis is variable, depending on their maturity and whether they have developed a vascular supply.
  • They may develop normal marrow signal if they are fully ossified or may appear cartilaginous.
  • They can remain immature and remain low signal on all sequences while being uncalcified on radiograph.
  • The multiple round bodies packing the bursa are diagnostic of synovial chondromatosis.
180
Q

Pes Anserine Bursitis

A
  • Pes anserinus bursitis is highly location-specific. Fluid is seen surrounding the pes tendons (sartorius, gracilis, semitendinosus) within several centimeters of their insertion on the anteromedial tibia in this bursitis. Clinically, the mass may be fluctuant and may change in size, generally depending on the length of time spent standing.
  • The location of a fluid collection at the anteromedial tibia, surrounding any of the pes tendons (sartorius, gracilis, semitendinosus), is typical for pes anserine bursitis.
181
Q

Semimembraneous Bursitis

A
  • Bursitis relating to the semimembranosus tendon occurs at the level of the knee joint. The bursal fluid also assumes a crescentic shape in semimembranosus bursitis.
182
Q

Hemophillic Pseudotumor

A
  • The ballooned epiphyses and destructive arthritis at the knee, as seen in this case, is typical of hemophilia. Hemophilic patients may develop pseudotumors due to osseous, subperiosteal, or soft tissue bleeds. These pseudotumors occur most frequently in the iliac wing and femur, as in this case. The soft tissue mass, scalloping of the bone, and bizarre horizontal periosteal reaction is typical of a hemophilic pseudotumor.
183
Q

Tibialis Posterior Injury

A
  • New onset of painful flatfoot in an older woman should raise the question of tibialis posterior injury.
184
Q

Little Leaguer’s Elbow

A
  • The medial epicondylar apophysis has been avulsed and pulled into the joint, now entrapped. The absence of the medial epicondylar apophysis in normal position and presence of an ossification center where one might expect the trochlear epiphysis makes this diagnosis.
  • The 1st to ossify is the capitellum, followed by the radial head. The medial epicondyle is the 3rd center to ossify, followed by the trochlea. A medial epicondylar fragment may be pulled into the joint by the forearm flexors, where it might be mistaken for a trochlear ossification center and therefore overlooked. As a generalization, one should never see a “trochlea” if there is not a normally placed medial epicondylar apophysis.
185
Q

Plantar Fibromatosis

A
  • Often consists of multiple nodules, though the patient may complain of only a single dominant mass. A careful search on MR should identify the other sites of abnormality.
  • Multiple nodules adjacent to the plantar aponeurosis are typical of plantar fibromatosis. Although in many cases these fibrous lesions show low signal on T2 imaging, they may be hyperintense as in this case. The degree of contrast enhancement is also variable; though little enhancement is seen in this case, it may be intense.
186
Q

Second Fracture

A
  • This represents avulsion of the lateral capsular ligament from the lateral tibial rim. There is close to 100% association with anterior cruciate ligament disruption.
187
Q

Fibroxanthoma

A
  • Non-ossifying fibroma/fibrous cortical defect
  • MR Imaging
    MR images of the lesion show it to have hypointense elements on all sequences . The fluid-sensitive sequences also show hyperintense regions of the lesion. In addition, there is predominant hypointensity along the posteromedial cortical portion of the lesion . The is no cortical breakthrough or indication of aggressiveness.
  • XR Imaging.
    • cortical-based metadiaphyseal lesion . The lesion has a thin sclerotic margin and is lytic with the exception of sclerosis along the posterior and medial aspects .
188
Q

Osseous Sarcoid

A
  • radiographs show multiple lacy, lytic, nonaggressive lesions within the phalanges of the hand.
189
Q

Giant Cell Tumor Tendon Sheath

A
  • This lesion most frequently is found in the phalanges and often results in extrinsic scalloping of the adjacent bones that may mimic erosions. With the cartilage space appearing normal, most types or arthritis should not be considered. Therefore, giant cell tumor of the tendon sheath is the most reasonable and likely diagnosis.
190
Q

Lunate Osteonecrosis

A
  • Altered signal within the lunate in the presence of ulnar minus variance (the ulna is > 2 mm shorter than the radius) indicates edema and stage 1 Kienbock disease (osteonecrosis) of the lunate. There is a high statistical association of ulnar negative variance and lunate osteonecrosis.
191
Q

Medullary Infarct

A
  • Radiographs show serpiginous sclerotic densities within the femoral diametaphysis. These imaging findings are typical of medullary infarct. In places, there appears to be a sclerotic margin . The serpiginous morphology is typical of bone infarct. Although one might consider the diagnosis of enchondroma because some of the density is in the form of “dots,” an enchondroma does not present radiographically with a sclerotic margin. This type of matrix is not found in either fibrous dysplasia or Paget disease; neither of these diagnoses is a serious consideration.

Radiology (4 decks)

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