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Slide 1-

Musculoskeletal imaging Rapid review of radiology Maw Maw Oo
Slide 2-

A 13-year-old male presented with pain in his left arm following a fall well defined lucent lesion of the proximal metaphysis of the left humerus. The lesion is centrally located with slight thinning of the cortex, mild expansion and several internal septae. It has a narrow zone of transition. There is a pathological fracture through the lesion with associated periosteal reaction and a ‘fallen fragment’ sign. The features are consistent with a benign lesion, specifically a simple bone cyst.
Slide 3-

Differential diagnosis fallen fragment’ sign Aneurysmal bone cyst (ABC) Giant cell tumour (GCT) Brown tumour. Fibrous dysplasia. Enchondroma
Slide 4-

Practical tips  Age –over 40 yr of age- metastases and myeloma common , young age – benign possibilities  Aggressive or nonaggressive – cortical destruction, lamellated, speculated periosteal reaction, wide zone of ransition, permeative lesion
Slide 5-

AP pelvis in a child with an aneurysmal bone cyst of the left iliac bone characteristically appearing as a lucent expansile lesion with a narrow zone of transition
Slide 6-

Sagittal T2 weighted MRI image shows a well defined high signal cystic lesion in the proximal left femur.
Slide 7-

A 40-year-old male patient with left hip pain There is right femoral head resurfacing in this patient. Arthropathy of the left hip is seen with loss of joint space and subchondral cysts. Sacroiliac joints are not well demonstrated but there is the suspicion of fusion along with ossification in the midline along the interspinous ligaments. There is also arthropathy at the pubic symphysis and ‘whiskering’ at the ischial tuberosities in keeping with enthesopathy. The features are characteristic of ankylosing spondylitis.
Slide 8-

Differential diagnosis Of sacroiliitis on plain film Ankylosing spondylitis. Inflammatory bowel disease. Hyperparathyroidism – tends to cause sacroiliac joint widening due to bone resorption. Rheumatoid. Gout. Psoriatic arthropathy. Reiter’s syndrome. Osteoarthritis (OA). Infection – TB.
Slide 9-

Lucent lesions of the anterosuperior aspects of the L3 and L4 vertebrae. These represent Romanus lesions in a young adult with early onset ankylosing spondylitis
Slide 10-

AP pelvis of a patient with ulcerative colitis. There is bilateral sacroiliitis with an oedematous thick walled sigmoid colon
Slide 11-

A 13-year-old male presented with pain in his left hip. unfused skeleton shows widening of the growth plate of the left hip with a slight decrease in height of the left femoral epiphysis compared to that on the right. Also, Klein’s line does not intersect the femoral epiphysis on the left. The appearances are consistent with a slipped left upper femoral epiphysis. A frog lateral should be done to check if there is a subtle slip on the right. Diagnosis Slipped upper femoral epiphysis (SUFE)
Slide 12-

Frog lateral in the same patient accentuates The slipped left femoral epiphysis
Slide 13-

A male patient presented with pain in amputation stump. permeative lucency with a wide zone of transition affecting the tibial stump. Periosteal reaction is visible along the posterior cortex and there is also a hint of this along the fibula. Furthermore, faint lucencies are suspected along the anterior cortex of the distal femur. These are the appearances of an aggressive lesion.The reason for amputation and the time interval since have not been stated. From the radiological findings alone, the main possibilities are that the amputation was for a distal malignancy such as bone lymphoma that has now recurred, or that the current findings are due to osteomyelitis in the stump following amputation for an unrelated reason. However, suspected involvement of the distal femur without joint destruction favours the former option
Slide 14-

Diagnosis Lymphoma recurrence following amputation Differential diagnosis Of permeative bone lesions: Metastases. Myeloma. Lymphoma. Leukaemia. Osteomyelitis
Slide 15-

A 4-year-old boy presented with a suspected chest infection diffuse osteosclerosis of the visible skeleton. Subtle widening of the dia- metaphysis of the proximal humeri are noted, suggestive of Erlenmeyer flask deformity. There is no lung abnormality. osteopetrosis.
Slide 16-

Differential diagnosis Of osteosclerosis in children Osteopetrosis. Pyknodysostosis. Renal osteodystrophy. Hypervitaminosis D. Hypervitaminosis A. Fluorosis.
Slide 17-

Of Erlenmeyer flask deformity (mnemonic – ‘Lead GNOME’): Lead. Gaucher’s. Niemann–Pick disease. Osteopetrosis. Metaphyseal dysplasia (Pyle’s) and craniometaphysealdysplasia (same as Pyle’s disease but there is a history of cranial nerve palsies). ‘E’matological!! – thalassaemia
Slide 18-

Pyknodysostosis hand showing osteosclerosis with pointing of the distal phalanges producing a ‘pointed chalk’ appearance
Slide 19-

Forearm of a patient with fluorosis showing diffuse osteosclerosis and Prominent ligamentous insertion calcification.
Slide 20-

A 62-year-old female presented with neck pain. Lateral flexion and extension views On flexion there is significant atlantoaxial joint subluxation. The odontoid peg is not clearly demarcated and is likely to be partially eroded. The remainder of the cervical spine is quite well preserved. The most likely diagnosis in a patient of this age is rheumatoid arthritis. Diagnosis Atlantoaxial subluxation in a patient with rheumatoid arthritis (RA)
Slide 21-

Differential diagnosis Of atlantoaxial subluxation: RA. Psoriatic arthropathy. Juvenile idiopathic arthritis. Ankylosing spondylitis. Systemic lupus erythematosus (SLE). Down’s syndrome. Morquio’s syndrome. Retropharyngeal abscess in a child.
Slide 22-

Atlantoaxial subluxation =the distance between the posterior aspect of the arch of the atlas and the anterior aspect of the odontoid peg exceeds 3 mm in adults and 5 mm in children. Erosion and destruction of the odontoid peg =inflammatory arthropathy. RA is the most common cause in adults.
Slide 23-

Practical tips Look for other signs of RA in the neck. Bamboo spine suggests ankylosing spondylitis. Posterior vertebral scalloping and anterior vertebral beaks in Morquio’s. Soft tissue swelling in a child – consider abscess
Slide 24-

Sagittal T1 weighted image of the cervical spine showing erosion of the odontoid peg and subsequent atlantoaxial subluxation
Slide 25-

Radiograph of both feet of a rheumatoid patient.
Slide 26-

A young Afro-Caribbean patient presented with left knee pain
Slide 27-

AP and lateral radiographs of the left knee show lobulated calcified masses in the soft tissues anterior to the left knee. Taking into consideration the age and ethnicity of the patient, tumoral calcinosis is the most likely diagnosis. Diagnosis Tumoral calcinosis
Slide 28-

Differential diagnosis Of periarticular soft tissue calcification: Haematoma. Myositis ossificans. Crystal arthropathy. Scleroderma (characteristic distal tuft resorption in finger). Dermatomyositis. Synovial osteochondromatosis. Tumoral calcinosis. Synovial sarcoma
Slide 29-

scleroderma shows the typical soft tissue calcification. Note the distal tuft resorption affecting the index finger
Slide 30-

Periarticular calcification arising from a Synovial sarcoma
Slide 31-

Practical tips Tumoral calcinosis – lobulated dense masses, fluid fluid levels. Myositis ossificans and synovial sarcoma may look similar but without fluid levels. Dermatomyositis – sheets of calcification. Synovial osteochondromatosis – several foci of calcification with lucent centres that are essentially loose bodies within the joint.
Slide 32-

A 40-year-old presented with knee discomfort right knee and upper tibia and fibula -marked cortical thickening of the diaphyses of the tibia and fibula, which has the appearance of ‘dripping candle wax’. There are also multiple small sclerotic foci within the metadiaphysis of the distal femur and the proximal tibia, which have the appearance of osteopoikilosis. Diagnosis Melorheostosis and osteopoikilosis
Slide 33-

in patients with multiple sclerotic foci alone, sclerotic metastases must always be considered. Sclerotic metastases in a patient with melorheostosis; this is much less likely. Osteopoikilosis tends to be distributed around joints, whereas multiple sclerotic metastases will not be so confined
Slide 34-

humerus and scapula demonstrating the typical ‘dripping candle wax’ appearance
Slide 35-

Male patient presented with rigidity and kyphosis This AP radiograph of the pelvis reveals thick linear columns of calcification and ossification around both hips and in the paravertebral regions bilaterally. The hip joints, sacroiliac joints and spine are fused. The patient has had previous internal fixation of the left hip. Diagnosis Myositis ossificans progressive/ fibrodysplasia ossificans progressiva
Slide 36-

Radiological features are: Linear columns of ossification and calcification. Ossified bridges between different bones. Ankylosis. Kyphosis – due to rigidity of the muscles of the spine and upper limbs.
Slide 37-

A child presented with retarded growth There is diffuse, coarse trabeculation of the visible bones causing a ‘cobweb-like’ appearance. Erlenmeyer flask deformity of the distal femurs is present. Diagnosis Thalassaemia major
Slide 38-

Peripheral skeleton: Coarse trabeculation causing ‘cobweb’ appearance Loss of concavity of tubular bones Erlenmeyer flask deformity of metaphyses of long bones Arthropathy and chondrocalcinosis as a result of haemochromatosis secondary to hypertransfusion. Fraying of metaphyses and dense metaphyseal bands secondary to iron chelation therapy. Skull: ‘Hair on end’ appearance. Frontal bossing due to diploic expansion. Obliteration of paranasal sinuses (except form ethmoid sinuses) due to marrow hyperplasia
Slide 39-

Axial skeleton: Coarse trabeculation causing ‘cobweb’ appearance Biconcave vertebrae. ‘Bone within bone’ appearance of spine and ribs. Paraspinal masses (due to extramedullary haematopoiesis). Expansion of the ribs posteriorly, particularly at the costochondral junctions, due to marrow hyperplasia
Slide 40-

thalassaemia; there is frontal bossing with expansion of the diploic space and obliteration of the maxillary sinuses
Slide 41-

Diffuse coarse trabeculation producing a ‘cobweb’ appearance with expansion of the ribs due to marrow hyperplasia
Slide 42-

Practical tips The only sign may be a diffuse but subtle coarsening of the trabeculae. On an AXR look for evidence of hepatosplenomegaly (a result of extramedullary haematopoiesis) and gallstones. On a CXR look for cardiomegaly secondary to anaemia, as well a paraspinal mass due to extramedullary haematopoiesis
Slide 43-

A 10-year-old child presented with leg pain and fever There is a mostly sclerotic lesion arising in the diaphysis of the proximal fibula in this unfused skeleton. This has a wide zone of transition and demonstrates a florid ‘hair on end’ periosteal reaction. The features are in keeping with an aggressive lesion. Ewing’s sarcoma and osteosarcoma are the two main differential diagnoses.
Slide 44-

12-year-old child demonstrates a sclerotic lesion of the femoral metaphysis that has a wide zone of transition and aggressive periosteal reaction. This proved to be an osteosarcoma
Slide 45-

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Slide 46-

A 35-year-old male presented with shoulder pain There is a transverse fracture at the medial third of the clavicle, which is likely to be an insufficiency fracture as there are Looser zones at the lateral aspect of the clavicle and the lateral border of the body of the scapula. The bones are generally osteopenic with marked thinning of the cortices. The findings are consistent with a diagnosis of osteomalacia.
Slide 47-

Radiological features of osteomalacia include: Generalized osteopenia. Cortical thinning. Bowing of long bones. Protrusio acetabuli. Coarse trabecular pattern Looser zones: Pseudofractures that consist of transverse lucent clefts with sclerotic margins. These are mostly seen in the pelvis, femoral necks and scapula. Insufficiency fractures
Slide 48-

Practical tips related to renal failure and secondary hyperparathyroidism On an abdominal radiograph look for a peritoneal dialysis catheter or a tunnelled femoral haemodialysis line. On a chest radiograph look for a central haemodialysis line and eroded lateral clavicles. Prominent vascular and soft tissue calcification may be seen. Brown tumours may be present and appear as lytic lesions, which may also be associated with pathological fracture.
Slide 49-

Radiograph of both hands in a patient with osteomalacia demonstrates diffusely coarsened trabecular pattern
Slide 50-

AP pelvic radiograph with Looser zones in both proximal femora
Slide 51-

A 5-year-old child presented with marked bowing deformity of right leg. marked angulation deformity of the diaphyses of the lower tibia and fibula with the formation of pseudarthroses. The bones are also generally osteopenic.The most likely diagnoses are nonunion of previous fractures, neurofibromatosis or osteogenesis imperfecta. Diagnosis Neurofibromatosis
Slide 52-

Differential diagnosis Nonunion of a fracture. Osteogenesis imperfecta. Fibrous dysplasia. Congenital.
Slide 53-

Congenital – affects the middle to lower third of the tibia and fibula. Half of congenital pseudarthroses present in the first year of life and later on there may be cupping of the proximal bone end and pointing of the distal bone end. Pathological fracture with nonunion often results in pseudarthrosis of the tibia and fibula, with ‘pencil pointing’ of the bone fragments.
Slide 54-

Neurofibromatosis type 1 (NF1) is a common genetic disorder -cutaneous and neurological abnormalities, osseous lesions are also seen. There may be anterolateral bowing of the tibia with or without a hypoplastic fibula. Focal narrowing and intramedullary sclerosis or cystic change at the apex the angulation is due to hamartomatous fibrous tissue, typically at the junction of the middle and distal third of tibia.
Slide 55-

Osteogenesis imperfecta – all four types can result in bowing of the long bones due to bone softening and multiple fractures. Bowing typically involves all the long bones and can result in pseudarthroses. Cleidocranial dysplasia is associated with congenital pseudarthrosis of the femur. Ankylosing spondylitis can lead to pseudarthrosis in the spine.
Slide 56-

Practical tips Severe osteopenia and multiple fractures of differing ages that have exuberant formation suggest osteogenesis imperfecta. Remember that some osteopenia may result from disuse, however, e.g. in fracture nonunion. Look for soft tissue nodules indicative of neurofibromatosis. A ‘ground glass’ density lesion associated with the pseudarthrosis is suggestive of fibrous dysplasia
Slide 57-

A young adult with nail abnormalities There are bilateral posterior iliac horns consistent with Fong’s disease.
Slide 58-

Fong’s disease, nail–patella syndrome and osteoonychodysplasia. spooning and splitting of the fingernails or even hypoplasia or aplasia. This particularly affects the thumb and index fingernails. also have abnormal of the iris. bilateral posterior iliac horns is seen in 80% of cases and is diagnostic of the condition. Hypoplasia of the anterior half of the ilia can result in drooping of the iliac crests. The other major finding is aplasia or hypoplasia of the patellae. Hypoplasia of the capitellum and radial head may also be present and this can lead to an increase in the carrying angle at the elbow. Similarly, genu valgus can occur due to asymmetrical development of the femoral condyles. Some patients may have a short 5th metacarpal.
Slide 59-

A patient presented with head injury There is a ‘hair on end’ appearance to the skull vault and the diploic space is widened. This does not affect the calvaria below the level of the internal occipital protuberance. The maxillary sinuses are obliterated. The most likely cause is thalassaemia major.
Slide 60-

Of ‘hair on end’ appearance of skull: The mnemonic is ‘STAN’ Sickle cell disease. Thalassaemia major. Anaemia (other anaemias): Hereditary spherocytosis. Glucose-6-phosphate dehydrogenase deficiency. Severe iron deficiency anaemia. Neoplastic: Haemangioma Neuroblastoma metastases in children.
Slide 61-

Hair on end = alternating thickened trabeculae and radiolucent marrow hyperplasia The diploic space widens and the outer table thins and can become obliterated. Marrow hyperplasia begins in the frontal region and can affect the entire calvaria excluding that which is below the internal occipital protuberance, since there is no marrow in this area. Marrow hyperplasia in thalassaemia major is more marked than in any other anaemia and may cause hyperplasia of the facial bones resulting in obliteration of the paranasal sinuses.
Slide 62-

The trabeculations here are thickened and coarsened rather than thin, vertical trabeculations. Haemangioma tends to have this appearance
Slide 63-

A 45-year-old male presented with left sided chest pain for several weeks. He had suffered minor trauma to the arm Multiple bony exostoses are seen arising from the ribs on both sides of the chest. On the left, there is a large associated soft tissue mass projected over the lateral thorax. Given the history of chest pain, sarcomatous transformation must be suspected. Moreover, there is a small left pleural reaction, a large pulmonary nodule in the left upper zone and possible pulmonary nodules in the left lower zone and right costophrenic recess. The combination of findings suggests sarcomatous transformation in diaphyseal aclasis with pulmonary metastases.
Slide 64-

Diaphyseal aclasis is an autosomal dominant condition characterized by multiple exostoses (osteochondromas). ‘Diaphyseal’ aclasis is a misnomer as the exostoses arise from the metaphyses. They are often multiple and bilateral and point away from the nearest joint. The cartilage cap of the exostosis may be calcified.
Slide 65-

Ulna demonstrate multiple exostoses. Note how they point away from the joint.
Slide 66-

extensive flocculent calcification in a huge chondrosarcoma, which arose from the exostosis at the medial femoral condyle
Slide 67-

A 20-year-old male presented with knee pain Well defined defect in the lateral aspect of the medial femoral condyle. A separate bony fragment lies within the defect. Findings are those of osteochondritis dissecans. Differential diagnosis Spontaneous osteonecrosis.
Slide 68-

A middle aged female presented with painful hands soft tissue swelling at the metacarpophalangeal joints bilaterally and to a lesser extent at the proximal interphalangeal joints. This is not associated with any erosions, however there is subluxation of several joints including the metacarpophalangeal joint of the right index finger and the right first carpometacarpal joint. Degenerative changes are also noted at both wrists. In summary, there is a bilateral nonerosive arthropathy with evidence of joint subluxation. DDx- collagen vascular disease. Early rheumatoid arthritis
Slide 69-

Differential diagnosis Of nonerosive deforming arthropathy: Collagen vascular disease. SLE. Ehlers–Danlos syndrome. Scleroderma. Jaccoud’s arthropathy. Hypogammaglobulinaemia.
Slide 70-

Diagnosis Systemic lupus erythematosus (SLE). Over 90% of patients with SLE develop arthralgia. Nonerosive arthropathy is characteristically present, the main features of which are soft tissue swelling and joint subluxation. distribution is often bilateral and symmetrical but the main factor excluding rheumatoid arthritis is of course the absence of erosions.
Slide 71-

Practical tips nonerosive arthropathies -only periarticular soft tissue swelling in the early stages. Subluxation of joints is the major finding and this mostly affects the metacarpophalangeal and first carpometacarpal joints bilaterally. The appearances tend to be bilateral and symmetrical. Scleroderma (132c) and Ehlers–Danlos syndrome may be associated with soft tissue calcification on the hand radiograph.
Slide 72-

Jaccoud’s arthropathy demonstrating bilateral metacarpophalangeal joint subluxation
Slide 73-

scleroderma demonstrating florid soft tissue calcification
Slide 74-

A 15-year-old male presented with left shoulder pain
Slide 75-

AP and axial radiographs of the left shoulder -a well defined lesion in the upper humeral epiphysis. This has a thick sclerotic border and central lucency. The lesion has nonaggressive features including a narrow zone of transition and the likely diagnosis considering the age of the patient and the location of the lesion is chondroblastoma
Slide 76-

Differential diagnosis Of epiphyseal lesions: Chondroblastoma – well defined sclerotic border,calcification in 50%, may have periosteal reaction. Giant cell tumour (GCT) – closed epiphyses, abuts articular surface, eccentric, marginal sclerosis. No periosteal reaction unless fracture present. Geode – will be other signs of arthropathy; older patients. Metastases and myeloma. Infection – usually metaphyseal rather than epiphyseal
Slide 77-

-x ray -lucent tibial epiphyseal lesion -axial T2 weighted MRI image shows a well defined hypointense lesion in the tibial epiphysis -The high signal thoughout the tibial plateau =marrow oedema. -This reactive oedema is a common feature of chondroblastoma and can lead to overestimation of the aggressiveness of the lesion.
Slide 78-

demonstrating a lucent subarticular lesion typical of a GCT
Slide 79-

Practical tips With regard to epiphyseal lesions in young patients,the two main possibilities are chondroblastoma and GCT. However, many chondroblastomas will not have the prominent internal calcifications and sclerotic border. In such cases it is important to check whether the patient has unfused epiphyses as GCT will not normally be seen in this group. If doubt still exists as to the nature of an epiphyseal lesion, MRI may help. There is typically marked bony oedema seen surrounding a chondroblastoma but rarely around a GCT
Slide 80-

A 25-year-old male presented with knee pain and fever AP and lateral radiographs of the right knee reveal a well demarcated area of lucency in the metaphysis of the proximal tibia. This is surrounded by sclerosis and there is no evidence of extension through the growth plate into the epiphysis. A small amount of smooth periosteal reaction is seen medially. Together with the history of pyrexia, the findings best fit with the diagnosis of Brodie’s abscess
Slide 81-

Differential diagnosis Osteosarcoma. Giant cell tumour (GCT) (in child). Brodie’s abscess is the term used to describe a subacute pyogenic osteomyelitis.
Slide 82-

Practical tips Giant cell tumour in ch located in the metaphysis rather than its characteristic epiphyseal location in adults. Therefore GCT in children may look like a Brodie’s abscess when marginal sclerosis is limited. In more subtle cases where the abscess is present near the cortex of a bone, the lesion may mimic an osteoid osteoma. In difficult cases where the abscess is not well defined, the appearances may look like those of a malignant process and when considering the metaphyseal location of the disease the findings may look suspicious of an osteosarcoma. This is where local periosteal reaction is important and if smooth rather than aggressive, will suggest benign disease.
Slide 83-

A 28-year-old male with bilateral hip pain bilateral irregularity of the femoral heads with decreased joint space, sclerosis and large subchondral cysts. This is associated with multiple calcified foci adjacent to both hips. These foci have lucent centres and appearances are consistent with synovial osteochondromatosis
Slide 84-

In summary, there is irregularity of the femoral heads from an underlying condition that has led to premature osteoarthritis and secondary synovial osteochondromatosis. The main possibilities are epiphyseal dysplasia (including Meyer’s dysplasia) and previous avascular necrosis
Slide 85-

Differential diagnosis Of irregular epiphyses: Avascular necrosis. Multiple epiphyseal dysplasia. Meyer ’s dysplasia. Morquio’s syndrome. Congenital hypothyroidism. Chondrodysplasia punctata
Slide 86-

Practical tips Multiple epiphyseal dysplasia –seen in other joints and there may be a family history. Meyer ’s is confined to the hips. When irregular/stippled epiphyses identified: Look for ancillary signs of avascular necrosis: Signs of sickle cell anaemia, e.g. endplate infarctions of the vertebral bodies, and gallstones on an AXR. Associations with steroid therapy on a pelvic xray/ AXR, e.g. thumb-printing in colon, stoma bag or sacroiliitis. Associations with condition of immunosuppression on a pelvic ray, e.g. pelvic transplant kidney. Look for ancillary signs of Morquio’s syndrome: Posterior vertebral scalloping. Anterior vertebral body beaks.
Slide 87-

32-year-old male presented with thigh pain At the midshaft of the femur there is an ossific mass with mixed sclerosis and lysis lying lateral to the femoral shaft. A radiolucent line separates the mass from the cortex except at its attachment superiorly. Periosteal reaction is also noted. The features are characteristic for a parosteal osteosarcoma.
Slide 88-

Differential diagnosis Osteochondroma. Extraosseous osteosarcoma. Juxtacortical haematoma. Myositis ossificans
Slide 89-

Parosteal osteosarcoma of the distal radius of a child
Slide 90-

Conventional osteosarcoma affecting the metaphysis of the femur in a child Conventional osteosarcoma affects males more commonly than females and there is a bimodal age distribution with elderly patients being affected due to malignant transfor - mation in Paget’s disease
Slide 91-

A 58-year-old female presented with back pain homogeneous sclerosis of the L4 vertebral body producing the appearance of an ivory vertebra. Differential diagnosis (Mnemonic – ‘Mets…LP HIM’): Lymphoma. Paget’s disease. Haemangioma. Infection. Mastocytosis
Slide 92-

In children: The ivory vertebra sign is less common in children and frequently the result of lymphoma. Less commonly, osteoblastoma, neuroblastoma, osteosarcoma or medulloblastoma deposits can cause the appearance
Slide 93-

AP and lateral radiographs of the thoracolumbar spine following vertebroplasty in a patient with osteoporotic collapse
Slide 94-

A 67-year-old male presented with a swollen foot. marked abnormality at the midtarsal joint with dislocation, sclerosis and debris formation. Prominent vascular calcification is noted. The appearances are those of a Charcot joint and the most likely cause in view of the vascular calcification is diabetes mellitus. Diagnosis Diabetic neuropathic foot.
Slide 95-

Radiological features of a Charcot joint include: Dense (i.e. sclerotic) bones. Destruction and fragmentation of articular surfaces. Degeneration. Debris (loose bodies). Dislocation. Deformity. Joint effusion. Excessive callus formation
Slide 96-

Shoulder and upper limb joints: Syringomyelia. Congenital insensitivity to pain. Leprosy. Syphilis. Ankle and foot: Diabetes mellitus. Alcoholism. Myelomeningocele. Congenital insensitivity to pain Hip and knee: Tabes dorsalis. Steroids. Spine: Trauma. Tabes dorsalis Differential diagnosis Of causes of neuropathic joint:
Slide 97-

Charcot elbow showing destruction, sclerosis and loose body formation
Slide 98-

A 30-year-old male patient presented with right hip pain and limitation of movement Irregularity, sclerosis and loss of height of the right femoral head Bilateral sacroiliac joint fusion is also present, though more prominent on the right side. This suggests a background seronegative arthropathy. avascular necrosis is drug induced by treatment for the seronegative arthropathy
Slide 99-

For causes of avascular necrosis (mnemonic – ‘DRIED HIP’) Diabetes and other metabolic conditions, e.g.hyperlipidaemia, gout, pancreatitis. Radiotherapy. Inflammatory disorders, e.g. rheumatoid, SLE,scleroderma. Endocrine disorders, e.g. Cushing’s. Drugs, e.g. steroids, anti-inflammatory and immunosuppressive drugs, alcohol. Haematological disorders, e.g. sickle cell, haemophilia,polycythaemia, Gaucher ’s. Infection and injury, e.g. fractures, burns and fat embolism. Perthe’s disease (idiopathic AVN in children).
Slide 100-

A 64-year-old patient presented with abdominal pain There is diffuse osteosclerosis affecting the visible skeleton. There is also massive splenomegaly making the likely diagnosis that of myelofibrosis. Lymphoma is another possibility and less likely, mastocytosis. Diagnosis Myelofibrosis.
Slide 101-

Differential diagnosis Of diffuse bony sclerosis and splenomegaly: Lymphoma. Mastocytosis Splenomegaly and small bowel thickening suggest mastocytosis.
Slide 102-

DDx Of generalized osteosclerosis in adults: Sclerotic metastases (especially breast or prostate carcinoma). Lymphoma. Myelofibrosis. Paget’s disease Renal osteodystrophy. Sickle cell disease. Mastocytosis. Osteopetrosis. Pyknodysostosis. Fluorosis.
Slide 103-

Osteosclerosis is often missed when the appearance is blamed on the quality of the film, i.e. when it is thought to be due to the radiograph being underpenetrated. Assessment of the intervertebral discs should be made – if they are visible then the appearance is likely to be real.
Slide 104-

A 34-year-old male presented with right hip pain. There is a large, expansile, mixed lytic/sclerotic destructive lesion involving the right anterior hemipelvis. marked cortical destruction with a soft tissue component. The lesion has a wide zone of transition. Diagnosis Chondrosarcoma. Differential diagnosis Lymphoma. Metastasis
Slide 105-

A 45-year-old male presented with severe back pain for several weeks
Slide 106-

AP and lateral images -marked deformity at the T12/L1 level with erosive destruction of the opposing vertebral endplates. There is anterior slip at this level with anterior angulation (gibbus deformity). Appearances are in keeping with a discitis. Axial and coronal T2 weighted MR images -demonstrate high signal in the T12/L1 intervertebral disc. Signal change extends throughout the adjacent vertebrae, and there is endplate destruction and partial vertebral collapse at T12. T11 vertebra has increased marrow signal suggesting it is also involved. The axial image demonstrates high-signal fluid collections in both psoas muscles consistent with bilateral psoas abscesses. Diagnosis Tuberculous spondylitis (Pott’s disease) with associated psoas abscess.
Slide 107-

Practical tips Discitis will cause bony abnormality of the superior and inferior endplates of the adjacent vertebral bodies, i.e. abnormality will be centred at the level of disc. The vertebral disc space is maintained longer in TB spondylitis than in pyogenic discitis. Look at the paraspinal regions to look for spread of infection. Infection can present as leg pain/swelling due to tracking of collections down the iliopsoas muscle. Look at, and around the spinal cord for extradural collections and spinal involvement.
Slide 108-

A 40-year-old male patient presented with painful fingers There is a bilateral symmetrical erosive arthropathy affecting the distal interphalangeal joints. Bone density is preserved and there is ‘pencil in cup’ deformity with bony proliferation. At the left little finger there are signs of ankylosis of the distal interphalangeal joint. The appearances are consistent with psoriatic arthropathy. Diagnosis Psoriatic arthropathy.
Slide 109-

Differential diagnosis Ankylosing spondylitis. Rheumatoid arthritis (RA).
Slide 110-

Psoriatic arthropathy: Usually asymmetrical erosive. Interphalangeal joints, particularly the distal interphalangeal joints, are affected. Bony proliferation/ periosteal reaction and preserved bone density characteristic. ‘Pencil in cup’ deformity. Ankylosis. RA: – Bilateral symmetrical erosive arthropathy. Metacarpophalangeal and proximal interphalangeal joints affected, i.e. pro ximal small joints of digits. Marginal erosions. Subluxation with ulnar deviation of digits. Decreased bone density. Ankylosis.
Slide 111-

Gouty arthropathy: Asymmetrical erosive arthropathy. Erosions are juxta-articular with overhanging edges. Preserved bone density and joint space. Bony proliferation /periosteal reaction. Gouty tophi causing soft tissue masses in 50%.
Slide 112-

Bilateral symmetrical erosive destruction is present affecting the metacarpophalangeal joints and the wrists. Note the telescoping of bone ends and the periarticular osteoporosis. Rheumatoid arthritis of the feet with marginal erosions and lateral subluxation of the digits
Slide 113-

Radiograph of both feet in a patient with gout with characteristic ‘punched out’ erosions affecting the big toes
Slide 114-

Multiple lucent expansile lesions of the tubular bones of the hand represent enchondromas in this patient with Ollier’s disease. Note that the absence of phleboliths excludes the main differential diagnosis, Maffucci’s syndrome.
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Differential diagnosis For lytic lesion in the digits (mnemonic – ‘SEGA GAMEF’): Simple bone cyst – rare in the hand. Enchondroma is by far the most likely lesion with this appearance at this site. Giant cell tumour of tendon sheath. Aneurysmal bone cyst – rare in the hand. Glomus tumour – painful. Abscess/osteomyelitis. Metastases and myeloma. Epidermal inclusion cyst (intraosseous) – distal phalanx; history of trauma, erythema and swelling may be present. Fibrous dysplasia – rare in the hand.
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Follow-up hand x-ray in an older child. There is diffuse osteosclerosis with a ‘bone within bone’ appearance. The most likely diagnosis is osteopetrosis. Diagnosis Osteopetrosis causing a ‘bone within bone’ appearance
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Differential diagnosis Of ‘bone within bone’ appearance (mnemonic – ‘SHARPS POOL’): Sickle cell disease. Hypervitaminosis D. Acromegaly. Rickets. Paget’s disease. Scurvy. Post-radiation therapy/thorotrast/heavy metal poisoning. Osteopetrosis and oxalosis. Osteomyelitis. Leukaemia.
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Osteopetrosis -Erlenmeyer flask deformity of the ends of long bones and sclerotic vertebral endplates producing ‘sandwich vertebrae’. sickle cell disease -avascular necrosis of femoral and humeral heads, gallstones, H- shaped vertebrae due to endplate infarction and splenic atrophy or calcification. Acromegaly is associated with rectangular-shaped vertebrae and chondrocalcinosis. In children, consider rickets and look for splaying and fraying of the metaphyses. If the patient is elderly, consider Paget’s and look for increased trabeculation and cortical thickening.
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Adult patient presented with heel pain well-defined lucent lesion with a narrow zone of transition. The lesion has a very thin sclerotic border and centrally within the lesion is a clump of calcification. There is no periosteal reaction or overlying soft tissue mass. The lesion has a nonaggressive appearance and the findings are typical of an intraosseous lipoma.
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Differential diagnosis Unicameral bone cyst. Post-traumatic cyst. Giant cell tumour (GCT). Desmoplastic fibroma
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There is shortening of the 4th metacarpal. No acute bony injury is seen. The findings are most likely to be idiopathic or due to previous trauma. However, less common causes such as Turner’s syndrome, pseudohypoparathyroidism and pseudopseudohypoparathyroidism should also be considered. Diagnosis Idiopathic shortening of the 4th metacarpal
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Differential diagnosis For short 4th metacarpal/metatarsal: Post-traumatic. Postinfarction (e.g. from sickle cell disease). Turner’s syndrome. Pseudohypoparathyroidism. Pseudopseudohypoparathyroidism.
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The short 4th metacarpal is an ‘Aunt Minnie’ case but don’t be put off by the same finding in the feet! Figure 147c shows short 3rd–5th metatarsals in the same patient as seen in Figure 147b with pseudohypoparathyroidism.
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An adult female patient with back pain posterior vertebral scalloping of the lower lumbar vertebrae with a narrowed anteroposterior canal diameter. The AP film shows that the interpedicular distance is abnormally narrowed at L5 level and there is squaring of the iliac wings. The features are consistent with achondroplasia. Diagnosis Achondroplasia.
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Macrocephaly with bulging forehead .narrow foramen magnum may be associated with hydrocephalus. Small J-shaped sella due to flattening of tuberculum sellae. Short flared ribs. Posterior vertebral scalloping. Anterior-inferior vertebral body beaks. Short pedicles and caudal narrowing of interpedicular distance (this should normally increase in the caudal direction). These abnormalities can lead to spinal stenosis. Squared iliac wings. ‘Champagne glass’ pelvic inlet Horizontal sacrum. Shortening and bowing of long bones with a ‘trumpet’ appearance due to disproportionate metaphyseal flaring Brachydactyly leading to short stubby fingers
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Shortening of both legs is seen in this achondroplastic with flaring of the metaphyses producing a ‘trumpet’ appearance Radiograph of the 151f hand demonstrating short, stubby tubular bones.
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Differential diagnosis Of posterior vertebral scalloping: Pressure effect – tumours in spinal canal, syringomyelia and communicating hydrocephalus. Dural ectasia. This occurs in neurofibromatosis, Marfan’s and Ehlers–Danlos. Acromegaly. Achondroplasia. Congenital disorders such as mucopolysaccharidoses, e.g. Morquio’s syndrome
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A middle aged female presented with dysphagia Destruction of the distal right index finger is seen with almost complete absence of the distal phalanx. Resorption of the distal phalangeal tufts affects several other fingers, most notably the left index finger. There is also widespread soft tissue calcification. The features are characteristic of scleroderma
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Differential diagnosis Of acro-osteolysis (mnemonic – ‘SHARTEN’): Scleroderma. Hyperparathyroidism. Arthropathy – psoriasis, erosive osteoarthritis, rheumatoid, etc. Raynaud’s. Trauma and thermal injury. Epidermolysis bullosa. Neuropathy, e.g. syringomyelia and diabetes.
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Of fingertip calcification: Scleroderma. Raynaud’s. Hyperparathyroidism. Dermatomyositis.
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A child presented having had a fall on outstretched hand. There is relative shortening and ulnar curve of the distal radius with wedging of the carpus between the distal radius and ulna. The features are consistent with Madelung deformity. There are no exostoses to indicate diaphyseal aclasis, and a more specific cause cannot be established from this film. Diagnosis Madelung deformity.
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Differential diagnosis Of causes of Madelung deformity (mnemonic – ‘TILDti’): Turner ’s syndrome. Idiopathic. Leri–Weil disease (dyschondrosteosis). Diaphyseal aclasis. Trauma and Infection can lead to Madelung deformity.
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Practical tips Look for metaphyseal exostoses pointing away from the joints indicating diaphyseal aclasis. Look for shortening of the 4th metacarpal, which is associated with Turner’s syndrome
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An 15-year-old male presented with back pain There is uniform collapse of the L4 vertebral body causing the appearance of a vertebra plana. The most likely cause in a child for a solitary collapsed vertebra is eosinophilic granuloma. Diagnosis Eosinophilic granuloma causing vertebra plana
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Differential diagnosis For vertebra plana: Idiopathic. Infection. Neoplastic (metastasis, leukaemia). Trauma. Steroids. Haemangioma.
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An elderly patient presented with leg pains. There is diffuse, thick periosteal reaction along the metadiaphyses of the left tibia and fibula. an elongated soft tissue opacity in the upper medial leg may well indicate a varix. There is no arterial calcification of note. The most likely cause of the periosteal reaction is chronic venous insufficiency, though it is still advisable to obtain a chest radiograph to exclude hypertrophic pulmonary osteoarthropathy from an occult lung tumour. Diagnosis Venous insufficiency.
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Differential diagnosis Of diffuse bilateral periosteal reaction in adults: Hypertrophic pulmonary osteoarthropathy (HPOA). Vascular insufficiency. Pachydermoperiostosis. Thyroid acropachy. Fluorosis
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Hand radiograph of a patient with thyroid acropachy demonstrating periosteal reaction along the diaphyses of most of the phalanges and the 1st and 5th metacarpals
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A 14-year-old male presented with arm pain Within the midshaft of the diaphysis of the humerus there is a relatively well defined lytic lesion that has a narrow zone of transition. There is endosteal scalloping and smooth lamellated periosteal reaction. The lesion has nonaggressive features and in this age group eosinophilic granuloma or infection is the most likely diagnosis. Diagnosis Eosinophilic granuloma
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Differential diagnosis Osteomyelitis. Fibrous dysplasia. Leukaemia. Lymphoma
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A female patient presented with joint pains. There is subperiosteal resorption of the radial aspect of the middle phalanges of the index and middle fingers. No evidence of marginal erosions or brown tumours is seen though the trabecular pattern is coarsened. The findings are consistent with hyperparathyroidism
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Bone resorption: Radial aspect middle phalanx of 2nd and 3rd fingers Terminal phalangeal tufts . Distal end of clavicles and superior aspect of ribs on CXR. Medial aspect proximal tibia Medial femoral and humeral necks. Lamina dura of skull and teeth producing ‘floating teeth’. ‘Pepper-pot’ skull due to trabecular resorption. Pseudo-widening of joints, e.g. sacroiliac joints. Marginal erosions of the hands Bone softening: Wedged vertebrae. Kyphoscoliosis. Bowing of long bones Brown tumour Osteosclerosis (more common in secondary hyperparathyroidism)- ‘Rugger jersey’ spine. Renal calculi. Medullary nephrocalcinosis Soft tissue calcification: Periarticular. Chondrocalcinosis. Arterial.
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Left hand radiograph demonstrating lucent bands of resorption across the mid-portions of the distal phalanges of the first three digits
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Thank You.