“Don’t touch” lesions new version Dr Ahmed Esawy
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Transcript of “Don’t touch” lesions new version Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
“Don’t Touch” Lesions
Auntminnie diagnosis that do not need a biopsy
– more importantly you the radiologist can
prevent any further painful or costly work-up.
Three categories :
Posttraumatic
Normal variants
Benign lesions
Dr Ahmed Esawy
Calcaneal
pseudocyst
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Conclusion
normal variants are common
but maintain high degree of
suspicion of pathology
Dr Ahmed Esawy
Myositis Ossificans
Findings: Circumferential calcification with a lucent center.
Best seen on CT
Sometimes associated with periosteal reaction.
Biopsy should be avoided since aggressive histologic appearance can mimic a sarcoma which then
can lead to unfortunate radical surgery! Dr Ahmed Esawy
Avusion Injury
Common in characteristic locations at ligament and tendon insertion sites. Biopsy can be misleading because healing avulsion may mimic malignant histology. Even further imaging like MRI can lead one towards biopsy. Rather good clinical correlation and at the most follow up films in several weeks are a better option. Dr Ahmed Esawy
Cortical desmoid
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Well Healed Cortical Desmoid
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Geodes
Young soccer player with painful hip.
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Fracture
Fracture mimiking osteosarcoma
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Pseudodislocation of the Humerus
Fracture with hemarthrosis causing distension of the joint and inferior subluxation of the
humerus.
AP view can mimic a posterior dislocation.
Get axillary or scapular Y view to asses for dislocation. Dr Ahmed Esawy
Dorsal Defect of the Patella
Normal variant
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Pseudocyst of the Humerus
Normal variant
Hyperemia and disuse caused by rotator cuff problems may increase the lucency in this region.
Very characteristic location for pseudocyst. However, chondroblastoma, infection ,or even
metastasis is still possible in this location Dr Ahmed Esawy
Os Odontoideum
Normal variant which demonstrates unfused dens to the body of C2. Although this still may cause instability especially in the setting of acute trauma, if well corticated then you can assume that there is no ACUTE fracture. Additional finding of densely corticated anterior arch of C1 presumably due to compesnatory hypertrophy.
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Os Odontoideum
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Os Odontoideum
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Non ossifying fibroma
Similar to fibrous cortical defect except for the larger size (greater than 2 cm)
Lytic lesion in the cortex of the metaphysis.
Well-defined with scalloped borders.
Always in younger patients (less than 30 years)
Involute as patient grows
Clinically asymptomatic and never leads to malignant degneration – no biopsy needed Dr Ahmed Esawy
Healing NOF
Cortically based lytic lesion with sclerotic margins indicating healing and involution.
May have increased radiotracer activity on bone scan.
Again, clinically patient is asymptomatic.
NO BIOPSY ! Dr Ahmed Esawy
Bone Islands
Always asymptomatic. Can it be metastatic disease? (especially when as large as the one we just looked at?) Two distinguishing characteristic A. Oblong in shape with long axis is along the axis of stress. B. Margins show bony trabeculae extending from the lesion into normal bone in a spiculated fashion.
Dr Ahmed Esawy
Bone Island
Spiculated appearance of bony trabeculae
Extending from the bone island
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Unicameral bone cyst
Characteristic location – anteroinferior portion
of the calcaneus
Only differential is psedocyst of the calcaneus.
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Unicameral bone cyst
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Early Bone Infarct
Mixed lytic-sclerotic pattern which can resemble a permeative process.
Consider the diagnosis for patients with sickle cell anemia or systemic lupus erythematosus.
MRI can be helpful to avoid biopsy due to the characteristic serpiginous pattern
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MRI of Bone Infarction
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Bone Infarction
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Sorry, not bone infarct!!
Enchondroma
Bone Infart!
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Dr Ahmed Esawy
Miscellaneous
non-touch Bone Lesions Achondroplasia
Avascular necrosis
Hypertrophic pulmonary osteoarthropathy
Melorheostosis
Mucopolysaccharidoses
Multiple Hereditary Exostosis
Osteoid Osteoma
Osteopathia Striata
Osteopoikilosis
Pachydermoperiostosis
Sarcoidosis
Transient Osteoporosis of the hip
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Melorheostosis
Thickened cortical new bone that accumulates near the ends of long bones, usually only on
one side of the bone
“Dripping candle wax”
Can be symptomatic Dr Ahmed Esawy
Hypertrophic pulmonary osteoarthropathy
Manifested by clubbing of the fingers and periostitis May or may not be associated with bone pain. Associated with lung cancer, bronchiectasis, GI disorders, and liver disease. The actual mechanism of formation of periostitis secondary to a distant malignancy or other process is unknown. Differential diagnosis for periostitis in a long bone without an underlying bony abnormality would include : venous stasis thyroid acropachy Pachydermoperiostosis trauma
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Achondroplasia
The most common cause of dwarfism is achondroplasia
Congenital, hereditary disease of failure of endochondral bone formation.
Characteristic finding is that the spine typically has narrowing of the interpedicular
distances in a caudal direction
Achondroplasia causes rhizomelic dwarfism Dr Ahmed Esawy
Achondroplasia
Narrowed AP canal.
Scalloped posterior vertebra
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Patient on steroids AVN
Lack of blood supply with subsequent bone death
and ensuing bony collapse in an articular surface
Etiology of AVN most commonly includes trauma,
steroids, aspirin, collagen vascular diseases,
alcoholism, and idiopathic causes Dr Ahmed Esawy
Avascular Necrosis
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Avascular Necrosis
Early
Late
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Hurler Syndrome
central anterior projection or “beak” off the vertebral body, as viewed on a lateral plain film
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Morquio
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Hurler
Notch at base of 5th MCB
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Transient Osteoporosis of the Hip
7 month later
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Multiple Hereditary Exostosis
diaphyseal aclasia
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Multiple Hereditary Exostosis
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Osteoid Osteoma
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Osteoid Osteoma
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Osteopathia Striata
Also known as Voorhoeve disease
This disorder is manifested by multiple 2- to 3-mm-thick linear bands of sclerotic bone aligned
parallel to the long axis of a bone
It usually affects multiple long bones and is asymptomatic; hence, it is usually an incidental finding. Dr Ahmed Esawy
Osteopoikilosis
Clue: Patient is asymptomatic
Osteopoikilosis is an hereditary, asymptomatic disorder that is usually an incidental finding of
multiple small (3 to 10 mm) sclerotic bony densities affecting primarily the ends of long bones and
the pelvis
It has no clinical significance other than that it can be confused for diffuse osteoblastic metastases.
Dr Ahmed Esawy
Sarcoid
When sarcoid affects the musculoskeletal system is involved, the hands are most often affected, with the spine and long bones only infrequently involved. Sarcoid causes a characteristic lacelike pattern of bony destruction in the hands. Multiple phalanges are typically affected in either one or both hands. Auntminnie diagnosis. Dr Ahmed Esawy
Hyoid bone:
The hyoid bone is considered a lingual bone
The hyoid bone consists of a central body and paired lateral
greater and lesser horns
The line of fusion of the body and greater horns of the hyoid
bone should not be mistaken for a fracture
Dr Ahmed Esawy
Normal lucency (white arrowhead) between the body and greater cornus of the hyoid bone is seen. Large arrow, omohyoid muscle; small arrow platysma muscle. Dr Ahmed Esawy
GOODBYE AND GOOD
IMAGING!
Dr Ahmed Esawy
Accessory bones of the foot 21 accessory bones of the foot have been discovered (includes the sesamoid
bones)
25% of the feet of adults and 22% of the feet of children under 16 years of
age have roentgenographic evidence of one or more accessory bones.
Os trigonum – lokal pain (simptomatic treatment, excission)
Accessory Navicular bone – local tenderness from pressure of the shoe (
excision of bone and fixation of the posterior tibial tendon)
os tibiale
externum
os
peroneum
Accessory
Navicular
Os
Trigonum
Os
vesalinum
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Os Styloideum (Carpal Boss)
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os trigonum
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Os calcaneus secundarius
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Accessory Navicular (Os Tibiale
Externum, Os Naviculare
Secundarium)
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type II accessory navicular (arrow) articulating with the medial aspect
of the navicular bone, with irregular articulating surfaces and
osteophytes
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lateral radiographs show fragmentation/fracture of an os peroneum (arrows) and a transverse fracture of the fifth metatarsal base (arrowheads).
The os peroneum is an oval or round ossicle located within the substance of the distal peroneus longus tendon near the cuboid.
Dr Ahmed Esawy
Os Intermetatarseum
os intermetatarseum situated between the first and second
metatarsal bases (arrow). Dr Ahmed Esawy
Hallux Sesamoids
transverse fracture through the central portion of the tibial hallux
sesamoid bone, with mild distraction of the 2 fragments (arrows). Dr Ahmed Esawy
Hallux Sesamoids
Dr Ahmed Esawy
CHRONIC HINDFOOT PAIN
SUSPECT: Calcaneus stress fx
Talar neck stress fx
Subtalar arthritis
Painful os trigonum
Haglund’s deformity
Tarsal coalition (Calcaneonavicular coalition seen on foot oblique), Obtain foot 3-v as well
Calcaneus 2-v
Lateral, Harris-Beath
ACR: 9
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Incidental
finding on
knee xray
Fabella = posterior sesmoids or
little confused knee caps Dr Ahmed Esawy
Os Acromiale
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Os Subfibulare: Case report of a
painful fibular accessory ossicle
The AP and Oblique radiograph showing a large accessory ossicle or os subfibulare to the
tip of the lateral malleolus. The accessory ossicle is at the anterior medial portion of the
malleolus giving it a bifid appearance. Dr Ahmed Esawy
CT images show a fibular ossicle or os subfibulare at the
distal end of the fibular with pseudo-arthrosis. Dr Ahmed Esawy
3-dimensional CT reveals a large accessory ossicle or
os subfibulare to the tip of the lateral malleolus with
pseudo-arthrosis of the fragment
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Illustration of lateral foot shows os peroneum (white
arrow) and peroneus longus tendon (black arrows.)
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fracture of os peroneum and full-thickness tear of peroneus longus tendon . Dr Ahmed Esawy
os peroneum fracture and full-thickness peroneus longus tendon tear .(
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fracture of os peroneum and full-thickness peroneus longus tendon tear .(
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Unipartite os peroneum
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Bipartite os peroneum .
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We have reviewed a spectrum of pathology
involving accessory ossicles and sesamoid bones.
These normal anatomic variations may, in fact,
represent the source of patient symptomatology.
The identification of key imaging characteristics
can help determine whether or not to attribute
clinical symptoms to these structures
Dr Ahmed Esawy