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(BQ) Part 2 book Skeletal radiology the bare bones presents the following contents: Approach to joint disease, inflammatory arthritis, noninflammatory joint disease, developmental and congenital conditions, metabolic and systemic conditions, infection and marrow disease, postsurgical imaging.
PA RT I I I Joint Disease Chew_Chap11.indd 195 1/18/2010 10:59:05 AM CHAPTER 11 Approach to Joint Disease his chapter describes a pragmatic approach to the radiology of joint disease, based on anatomy, pathophysiology, and radiographic analysis This approach draws heavily on the work of Forrester, Brower, and Resnick (Table 11.1) Detailed discussions of specific clinical forms of arthritis are presented in Chapters 12 and 13 T GENERAL PRINCIPLES Radiographs mirror the pathologic processes that affect the joints and the functional adaptations that may follow In general, the radiologic diagnosis of arthritis can be highly specific and reliable when classic changes are present in the expected distributions but much less specific in the early stages before the disease process has fully evolved Regardless of the approach, however, several frustrations are unavoidable: A specific radiologic diagnosis is not always possible; many types of joint disease overlap in their radiologic and clinical features; two or more diseases may coexist in the same patient; and, finally, clinical disease may precede radiologic abnormalities and vice versa, sometimes by years Diseases that affect joints so by three broad pathophysiologic mechanisms, each with a distinctive radiographic appearance: degeneration, inflammation, and metabolic deposition For practical purposes, one mechanism is usually predominant Degeneration of a joint refers to mechanical damage and reparative adaptations; in essence, the joint is worn away Inflammation TAB LE 11.1 A B C D E S Distribution of Disease Laboratory Findings Bone Alignment Intervertebral Disk Joints Entheses General Principles Synovial Joints Soft Tissues Cartilage Approach to Radiographic Analysis of Arthritic Changes in the Hand Alignment Bone mineralization Bone production Cartilage (joint space) Calcification Distribution Erosions Soft-tissue swelling Source: Data from Brower AC Arthritis in Black and White 2nd Ed Philadelphia, PA: WB Saunders; 1997 and Forrester DM, Brown JC The Radiology of Joint Disease 3rd Ed Philadelphia, PA: WB Saunders; 1987 TAB LE 11.2 Characteristic Radiographic Signs of Arthritis Pathophysiology Characteristic Radiographic Signs Inflammation Acute erosions Osteoporosis Soft-tissue swelling Uniform loss of articular space Degeneration Osteophytes Subchondral sclerosis Uneven loss of articular space Chondrocalcinosis Metabolic deposition Lumpy-bumpy soft-tissue swelling Chronic bony erosions with overhanging edges of a joint may be acute, chronic, or both; the joint is dissolved by the inflammatory process Metabolic deposition refers to the infiltration of a joint by aberrant metabolic products Each of these mechanisms affects joints in radiographically distinctive ways (Table 11.2) SYNOVIAL JOINTS Most articulations of the appendicular skeleton are synovial joints In the axial skeleton, the facet joints of the spine, the atlantoaxial (C1–2) joint, the uncovertebral joints of the cervical spine, and the lower two thirds of the sacroiliac joints are synovial Soft Tissues Synovial joints have a joint cavity and are enclosed by a joint capsule consisting of an inner synovial layer (the synovium), a middle subsynovium, and an outer fibrous layer (Fig 11.1) The synovium is a cellular secretory mucosa that produces synovial fluid Synovial fluid is viscous because of a high concentration of hyaluronic acid Joint capsules have an active blood supply with a large capillary surface area The synovium has a mesenchymal rather than epithelial origin; therefore, no basement membrane or other structural barrier is present between the synovial fluid and the capillary bed The change from synovium to fibrous capsule is gradual; there are no distinct 196 Chew_Chap11.indd 196 1/18/2010 10:59:06 AM Chapter 11 • Approach to Joint Disease 197 FIGURE 11.1 Anatomy of a synovial joint boundaries between the layers Joint capsules are densely innervated Tendon sheaths invest tendons and reduce friction during motion Bursae are located where complete freedom of motion between structures is necessary, for example, where a tendon passes directly over the periosteum Because tendon sheaths and bursae are synovial structures, diseases that affect synovial joints may also involve them Soft-tissue swelling at a joint may reflect capsular distention from effusion, synovial hypertrophy, soft-tissue edema, or a mass Symmetric, fusiform swelling suggests an inflammatory process with effusion, synovial edema, synovial hypertrophy, or some combination thereof (Fig 11.2) Inflammatory distention of a tendon sheath may also produce soft-tissue swelling, but the swelling extends beyond the joint In a digit, this kind of swelling FIGURE 11.2 Fusiform soft-tissue swelling at the PIP joint (rheumatoid arthritis) Chew_Chap11.indd 197 FIGURE 11.3 “Sausage digit” soft-tissue swelling (psoriatic arthritis) produces an appearance that has been likened to a sausage (sausage digit) Generalized soft-tissue swelling may be caused by subcutaneous edema or hyperemia and suggests inflammation (Fig 11.3) Lumpy-bumpy swelling that is not symmetric or centered near a joint suggests masses and may be caused by metabolic deposition disease with masslike deposits of metabolic products in the periarticular soft tissues (Fig 11.4) Soft-tissue prominences at joints that FIGURE 11.4 Lumpy-bumpy soft-tissue swelling (tophaceous gout) 1/18/2010 10:59:06 AM 198 Part III • Joint Disease The ends of the articulating bones, that is, the joint surfaces, are covered with hyaline articular cartilage Hyaline cartilage is composed of a collagen fibril framework and a ground substance One set of densely packed collagen fibrils is oriented parallel to the articular surface, forming an armor-plate layer with tiny surface pores that allow the passage of water and small electrolytes A second, less densely packed set of collagen fibrils is oriented in arcades, linking the armor-plate layer to the subchondral bone (Fig 11.5) The ground substance is a gel that consists of water and large proteoglycan aggregate macromolecules that are loosely fixed to the collagen framework The proteoglycan macromolecules are too large to pass through the pores of the armor-plate layer The physical and chemical properties of these macromolecules allow them to attract and bind water, providing sufficient swelling pressure beneath the armor-plate layer to “inflate” the articular cartilage, even during weight bearing During motion, a thin layer of water is expressed through the small surface pores, providing a frictionless surface for a lifetime of mobility Articular cartilage has a loaddampening ability that spreads transmitted loads over a greater area of the subchondral bone Under rapid, transient loading, articular cartilage has elastic properties Under a steady load, it creeps and deforms like a sponge The portion of cartilage that is adjacent to the subchondral bone is calcified Interdigitations between the calcified cartilage and the subchondral bone provide a strong mechanical coupling Chondrocytes are the cells whose metabolic activity maintains the specialized structures of articular cartilage Less than 1% of articular cartilage volume is composed of cells Because cartilage is avascular and alymphatic, chondrocytes derive their nutrients by diffusion from the synovial fluid Articular cartilage has only a limited ability to repair itself Deep injuries may repair with cartilage that is densely fibrous Cartilage abnormalities are inferred from the radiolucent gap between articulating bones, the articular space, or the joint space The articular cartilage fills this space A potential space exists where the articulating surfaces meet Loss of articular cartilage causes the joint space to narrow Cartilage loss within a joint can be diffuse and concentric—indicating an inflammatory process (with enzymatic dissolution of cartilage)—or focal and uneven, indicating a mechanical one (Fig 11.6) If there is complete FIGURE 11.6 Asymmetric joint space narrowing, osteophytes, and subchondral sclerosis (osteoarthritis) FIGURE 11.7 Severe PIP joint subchondral bone erosions (psoriatic arthritis) FIGURE 11.5 Structure of articular cartilage are found on physical examination may actually result from bony or cartilaginous enlargements; the overlying soft tissues may be normal Heberden and Bouchard nodes are swellings of this kind at the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of the hand, respectively, and are characteristic of a degenerative process Calcification in the soft tissues may affect cartilage, skin, muscles, tendons, or other connective tissues and is associated with connective tissue diseases Soft-tissue atrophy or loss is present in various conditions Cartilage Chew_Chap11.indd 198 1/18/2010 10:59:07 AM Chapter 11 • Approach to Joint Disease 199 FIGURE 11.10 Chondrocalcinosis of the articular cartilage (arrow) FIGURE 11.8 Bony ankylosis (psoriatic arthritis) cartilage loss, the ends of the bones may become eroded, making the joint space appear wider The ends of the bone may form a pseudoarthrosis (Fig 11.7), or fibrous or bony ankylosis (fusion) of the joint may occur (Fig 11.8) Widening of the articular space may indicate abnormal cartilage proliferation or intra-articular fluid Weight-bearing views may be necessary to assess accurately FIGURE 11.9 Chondrocalcinosis of the menisci (arrowheads) Chew_Chap11.indd 199 the degree of cartilage loss at the knee Asymmetric cartilage loss may result in changes in radiographic joint space narrowing with changes in position Calcification of cartilage is called chondrocalcinosis Chondrocalcinosis may involve fibrocartilage structures such as the menisci of the knee (Fig 11.9) or the triangular fibrocartilage complex of the wrist Articular cartilage also may calcify (Fig 11.10) Bone Bone changes in arthritis include bone loss and bone proliferation Osteoporosis is the loss of bone through osteoclast action and may be generalized or regional, acute or chronic Osteoporosis reflects hyperemia from synovial inflammation or from the disuse of a body part Acute osteoporosis is recognized by the resorption of bone from subchondral trabeculae, a location where blood flow and metabolic activity are the greatest The process of osteoporosis affects the trabecular bone and the cortex However, because the surface area subject to osteoclastic resorption is greater in the trabecular bone, the acute process is more evident there If the process continues, tunneling may become evident in the cortex and can be recognized as being porotic and thin In noninflammatory articular disease, the normal mineralization of bone is maintained Arthritic conditions are commonly treated with corticosteroids, which may cause osteoporosis Bone erosions represent focal losses of bone from the cortical surface Erosions with loss of the cortex indicate an acute, aggressive process In rheumatoid arthritis, for example, the cortical bone is eroded by the action of enzymes produced by inflamed synovial tissues (pannus) These enzymes literally dissolve the bone and produce acute erosions without cortex (Fig 11.11) Erosions with cortex indicate a nonaggressive, chronic process in which the bone remodels along the border of the erosion The chronic erosions seen in metabolic deposition disease are caused by abnormal masses of metabolic products causing the adjacent bone to remodel because of mechanical pressure The bone may attempt to encircle the deposit; such an incomplete attempt leaves an overhanging edge 1/18/2010 10:59:08 AM 200 Part III • Joint Disease FIGURE 11.13 Subchondral cyst formation (rheumatoid arthritis) (arrow) FIGURE 11.11 Acute marginal erosions (arrows), diffuse joint space narrowing, and osteoporosis (rheumatoid arthritis) (Fig 11.12) Other masslike processes in the joint may also cause chronic erosions of the bone The characteristic initial site of erosions in arthritis is at the margin of the articular cartilage where a gap between the cartilage and the attachment of the synovium leaves a “bare area” of bone contained within the joint capsule FIGURE 11.12 Chronic erosion and overhanging edges (tophaceous gout) Chew_Chap11.indd 200 Once cartilage has been destroyed, erosions may extend over the entire articular surface Subchondral cysts, also called geodes, occur when cracks or fissures in the articular surface allow the intrusion of synovial fluid into the subchondral cancellous bone or when necrosis of the subchondral bone is followed by collapse (Fig 11.13) Subchondral cysts may also result from erosions of the articular surface by inflamed synovial tissues Subchondral cysts are seen in virtually all types of arthritis and have no particular differential diagnostic significance Proliferative new bone may represent attempts at cyst healing Proliferative bone formation at arthritic synovial joints occurs in four ways Periostitis is the periosteal apposition of a new bone to the cortical surface (Fig 11.14) Sclerosis, also called eburnation, is FIGURE 11.14 Periostitis (psoriatic arthritis) (arrows) 1/18/2010 10:59:09 AM Chapter 11 • Approach to Joint Disease a new bone apposed to the trabeculae of the existing bone, usually in a subchondral location (immediately beneath the articular cartilage) but sometimes on the surface after the cartilage is gone Osteophytes occur in the presence of cartilage loss and represent new excrescences of cartilage and bone that enlarge the articular surface at its margins Bony proliferation may also occur at the attachment of joint capsules (discussed in the “Entheses”) Alignment Alignment becomes abnormal when joint capsules or ligaments are torn or lax, the normally balanced tension across joints becomes unbalanced, or articular surfaces lose their normal size or shape The result is deformity, subluxation, dislocation, and loss of function Continued use of a damaged, malaligned joint leads to functional adaptation and secondary anatomic changes; ultimately, it may become difficult to distinguish these functional adaptations from the primary arthritic process Loss of function and pain are the major causes of morbidity in arthritis Alignment deformities in the hand may lead to a functional disability of great clinical significance Deformities of the hand result from loss of the balanced muscular tension and ligamentous restriction that maintain its normal alignment Common deformities of the digit include the swan neck deformity (PIP hyperextension with DIP flexion) (Fig 11.15A), the boutonniere deformity (PIP flexion with DIP hyperextension) (Fig 11.15B), the mallet finger (isolated DIP flexion), and the hitchhiker thumb or Z-shaped collapse of the thumb (metacarpophalangeal [MCP] joint flexion, interphalangeal [IP] joint hyperextension) Subluxations and dislocations of individual joints may be seen, or the entire hand may collapse into a zigzag deformity (radial deviation of wrist with ulnar deviation of the MCP joints) These deformities reflect loss of normal functional anatomy from any underlying cause, one of which may be arthritis FIGURE 11.15 Rheumatoid arthritis A: Swan neck deformity B: Boutonniere deformity Chew_Chap11.indd 201 201 Abnormalities of alignment resulting from articular disease are common at the wrist, knee, and foot Alignment deformities of the wrist may follow or precede actual articular changes on radiographs; these misalignments may have great clinical significance because normal wrist function is a prerequisite for normal hand function The ligamentous instability patterns that may follow traumatic disruption of the carpal ligaments (see Chapter 2) may also result from the arthritic involvement of the carpal ligaments Selective involvement of the medial or lateral tibiofemoral compartment of the knee with asymmetric thinning of cartilage may lead to varus or valgus deformity In the foot, various digital deformities similar to those occurring in the hand may be found INTERVERTEBRAL DISK JOINTS Intervertebral disk joints are present along the anterior portion of the spine An intervertebral disk joint comprises cartilaginous end plates covering the articulating surfaces of adjacent vertebral bodies, a central nucleus pulposus, and a circumferential annulus fibrosus (Fig 11.16) In the child, the nucleus pulposus has a gelatinous character; in the adult, the nucleus pulposus has converted to fibrocartilage The annulus fibrosus contains an outer zone of collagenous fibers and an inner zone of fibrocartilage The annulus fibrosus is anchored to the cartilaginous end plates, the vertebral rim, and the periosteum of the vertebral body The anterior longitudinal ligament is applied to the anterior aspect of the vertebral column with firm attachments to the periosteum near the corners of the vertebral bodies A posterior longitudinal ligament is applied to the posterior aspect of the vertebral bodies The same structure and physiology are found at the symphysis pubis In the anterior column of the spine, one may evaluate alignment, intervertebral spaces, and bone changes Soft-tissue changes in the axial skeleton are difficult to recognize Abnormalities of alignment include intervertebral subluxation, exaggerated kyphosis or lordosis, kyphosis or lordosis at inappropriate levels, and scoliosis Films of the patient in flexion, extension, or lateral bending may be required to demonstrate abnormal mobility or loss of mobility The intervertebral disk spaces should be proportionate to the width of the vertebral body They are relatively small in the cervical FIGURE 11.16 Anatomy of an intervertebral disk joint 1/18/2010 10:59:12 AM 202 Part III • Joint Disease TAB LE 11.3 Vertebral Phytes: Associations With Specific Diseases Type of Phyte Associated Condition Syndesmophytes Diffuse, flowing paravertebral ossification Osteophytes Ankylosing spondylitis DISH Focal paravertebral ossification Degenerative disk disease, spondylosis deformans Psoriatic arthritis (common), Reiter syndrome (uncommon) region but gradually become thicker in the thoracic and lumbar regions Narrowing is characteristic of degenerative disk disease, and calcification or gas in the disk space is pathognomonic The morphology of bony outgrowths along the spine, called vertebral phytes, may be of great diagnostic value (Table 11.3) Ossification in the periphery of the annulus fibrosus may lead to a shell of bone that bridges the intervertebral space (Fig 11.17) These are called bridging syndesmophytes and are characteristic of ankylosing spondylitis Ossification of the anterior longitudinal ligament along multiple contiguous levels is characteristic of diffuse idiopathic skeletal hyperostosis (DISH) This ossification is often exuberant and adjacent to, but separate from, the vertebral body (Fig 11.18) Osteophytes are horizontal extensions of the vertebral end plates that have a triangular configuration (Fig 11.19) If sufficiently large osteophytes are present at adjacent end plates, they may form an extraarticular bridge across the intervertebral space Small osteophytes are associated with degenerative conditions Large, focal, paravertebral FIGURE 11.17 Syndesmophytes (arrow) formed by the ossification of the outer layers of the annulus fibrosus (ankylosing spondylitis) soft-tissue ossifications are seen in psoriatic arthritis and Reiter syndrome These bony excrescences often become coalescent and contiguous with the vertebral bodies, resulting in extra-articular FIGURE 11.18 Diffuse, flowing ossification (arrows) of the paravertebral soft tissues (DISH) A: Sagittal CT reformation shows the ossification (arrows) extending over multiple contiguous levels B: Axial CT shows the ossification (arrow) is asymmetric Chew_Chap11.indd 202 1/18/2010 10:59:13 AM Chapter 11 • Approach to Joint Disease 203 strong bands or sheets of collagen fibers in a parallel arrangement Near the attachment to bone, chondrocytes are interspersed between the collagen fibers The collagen fibers in the bands or sheets become more compact, then cartilaginous, and finally calcified as they enter the bone (Fig 11.21) The interdigitation of calcified cartilage and bone provides a strong attachment Entheses have an active blood supply and a prominent innervation Enthesopathy is a disease at an enthesis Enthesophytes and the calcification and ossification of an enthesis are the principal radiographic signs of enthesopathy (Fig 11.22) Ossification usually proceeds from the bony attachment into the substance of the inserting structure MRI may directly demonstrate inflammatory and degenerative changes of tendons and ligaments much earlier than radiographs Normal tendons and ligaments have low signal on both T1- and T2-weighted MRI Fluid, edema, and myxoid change within tendons or ligaments are identifiable as regions of high signal DISTRIBUTION OF DISEASE FIGURE 11.19 Triangular osteophytes (arrows) of spondylosis deformans with degenerative disk changes The disk space is narrowed and the subchondral bone is sclerotic bridges along the lateral aspect of the spinal column (Fig 11.20) Typically, they occur along the lateral aspects of the vertebral bodies and not involve multiple, contiguous levels on the same side ENTHESES An enthesis is the site of bony insertion of a tendon, ligament, or articular capsule Tendons, ligaments, and articular capsules are There are two clinical situations: monarticular arthritis (one joint affected) and polyarticular arthritis (many joints affected) The differential diagnosis of monarticular arthritis is rather limited (Table 11.4) Each type of polyarticular arthritis has a predilection for specific sites in the skeleton and can often be recognized simply from the distribution of involvement (Table 11.5) The explanation for the highly specific distributions of disease is unknown There are some joints in the hand and foot where involvement can be virtually diagnostic of specific types of degenerative or inflammatory polyarticular arthritis (Table 11.6) In the hand, degenerative involvement of multiple DIP joints suggests osteoarthritis, whereas inflammatory involvement suggests psoriatic arthritis Degenerative involvement of multiple MCP joints suggests pyrophosphate arthropathy, whereas inflammatory involvement of the MCP joints suggests rheumatoid arthritis FIGURE 11.20 Ossification in the paraspinal soft tissues leading to a bridging phyte (arrows) (reactive arthritis) A: AP radiograph B: Axial CT and coronal reformation Chew_Chap11.indd 203 1/18/2010 10:59:15 AM 204 Part III • Joint Disease TAB LE 11.4 Common Causes of Monarticular Arthritis Crystal related Hemophiliac arthropathy Rheumatoid (including juvenile chronic arthritis) Infectious Synovial lesions (chondromatosis, PVNS) Traumatic tarsometatarsal (TMT) joint suggests osteoarthritis Inflammatory involvement of multiple intertarsal joints suggests rheumatoid arthritis Degenerative involvement of the talonavicular joint suggests pyrophosphate arthropathy FIGURE 11.21 Anatomy of an enthesis Degenerative involvement of the first carpometacarpal (CMC) joint suggests osteoarthritis Inflammatory involvement of multiple intercarpal joints suggests rheumatoid arthritis, psoriatic arthritis, or gouty arthritis Degenerative involvement of the radiocarpal joint suggests pyrophosphate arthropathy In the foot, degenerative involvement of the first metatarsophalangeal (MTP) joint suggests osteoarthritis Inflammatory involvement of the combination of multiple MTP and IP joints suggests psoriatic arthritis or Reiter syndrome, whereas inflammatory involvement of multiple MTP joints without IP joint involvement suggests ankylosing spondylitis or rheumatoid arthritis Degenerative involvement of the first FIGURE 11.22 Enthesophyte (arrow) at the insertion of the triceps tendon Chew_Chap11.indd 204 LABORATORY FINDINGS Abnormal findings on laboratory examinations are integral to the diagnosis of joint diseases They are most valuable when correlated with radiographs and other clinical information Material for laboratory analysis is usually obtained from blood or the joint Synovial fluid can be obtained by needle aspiration Samples of the synovial membrane, articular cartilage, or periarticular soft tissues are usually obtained by biopsy Rheumatoid factor (RF) is a group of nonspecific autoantibodies found not only in the serum of patients with rheumatoid arthritis but also in that of patients with other acute and chronic inflammatory diseases These include viral infections such as AIDS, mononucleosis, and influenza; chronic bacterial infections such as tuberculosis and subacute bacterial endocarditis; parasitic infections; neoplasms after chemotherapy or radiotherapy; and various hyperglobulinemic states The sensitivity and specificity of detecting RF vary with the particular method of measurement The most common method is the latex fixation test, in which the patient’s serum is challenged with latex particles coated with heat-treated human immunoglobulin G A positive result—that is, agglutination of the latex particles because of the presence of RF—makes the patient seropositive or RF positive A negative result also has a clinical importance because it is one factor that distinguishes rheumatoid arthritis from the clinically overlapping group of seronegative spondyloarthropathies The strength of a positive result has therapeutic and prognostic significance Nevertheless, only 80% of patients with classic rheumatoid arthritis are RF positive, as are 30% of patients with nonrheumatic diseases, 25% of patients with other rheumatic diseases, and 5% of the normal population ANA are a heterogeneous population of serum antibodies that react to various human nuclear components, including DNA They are detected by an immunofluorescence screening test A positive ANA test is an empiric marker for connective tissue disease The test is positive in nearly all patients with systemic lupus erythematosus, scleroderma, and mixed connective tissue disease and in approximately 80% of patients with polymyositis/dermatomyositis The actual pathogenetic significance is unclear Changes in serum ANA levels may parallel the clinical course and be used to follow the activity of the disease 1/18/2010 10:59:16 AM 330 Part IV • Miscellaneous Topics the proximal tibia It is possible for an amputation to be incisional or excisional depending on the level of the amputation relative to the tumor site Saucerization is a procedure in which the medullary cavity is exposed widely, typically for drainage of a bone abscess Following tumor treatment, imaging modalities for surveillance are chosen based on the type of resection performed, the nature of the complication being monitored for, and individual patient variables, such as tumor type or certain imaging contraindications (e.g., inability to undergo MRI due to a pacemaker) Radiographs, CT, and MRI are useful for following bone tumor resection sites for tumor recurrence CT and radiographs can also evaluate for periprosthetic fracture and hardware failure For soft-tissue tumor resection, MRI tends to be more useful than CT for tumor recurrence monitoring due to improved soft-tissue characterization Doppler ultrasound can be used to assess for local soft-tissue tumor recurrence when MRI is not an option, since recurrent tumor tends to have higher vascularity than the background soft tissues There are no widely accepted general guidelines for the timing of recurrent and metastatic disease surveillance due to variability in tumor type, location, and grade TRANSPLANTATION Tissue that is transplanted within the same individual is called autograft, tissue transplanted from one human to another is allograft (homograft), and tissue transplanted from one species to another is xenograft (heterograft) Bone for autografts is commonly obtained from the iliac crest, distal radial metaphysis, ribs, or fibula, depending on the site of surgery and the type of bone graft required Allograft bone is usually obtained from a bone bank Banked bone may be obtained from living donors or from cadavers Living donors typically donate femoral heads that have been resected incidental to hip replacement surgery Cadaver bone is harvested from donors under aseptic conditions by traveling surgical teams maintained by regional bone banks The tissue must be harvested within 24 hours of death before bacterial skin contamination becomes unacceptably high Careful donor selec- FIGURE 17.40 Massive intercalary tibial allograft for tumor reconstruction Surgical drains are still in place A: Lateral radiograph B: AP radiograph Chew_Chap17.indd 330 FIGURE 17.41 Modular total joint replacement for tumor reconstruction A: Hip radiograph B: Knee radiograph tion and microbial cultures of the harvested tissue reduce the risk of transmission of infectious diseases Depending on the planned use of the tissue, the harvested bone may include ligament and tendon insertions and articular cartilage The tissue is sterilized by irradiation or gas treatment Repeated washings during processing to remove the marrow and storage in the frozen or freeze-dried state render the bone tissue hypoallergenic Immunosuppression of recipients is not necessary When banked allograft bone is needed, an appropriate graft can be chosen from a radiographic catalog of available tissue Bone graft can stimulate osteogenesis, fill defects, provide mechanical stability, and form a scaffold for creeping substitution Common uses include spine fusion, cyst packing, long-bone replacement, osteoarticular replacement, and treatment for fracture and fracture nonunion Bone-forming cells may be transplanted with the graft itself (if an autograft) or inducted from local mesenchymal cells Bone tissue can be implanted as a powder, slurry (morselized bone), chips or fragments, intercalary segments or blocks, or entire intact structures, including an articular surface (Fig 17.40) When large allografts are used, the biologic effect is similar to an organ transplant rather than a tissue transplant Direct remodeling of large allografts that begins at the graft-host junction may ultimately encompass the entire implant after months or years Graft failure is recognized when there is progressive resorption of the graft or failure to unite to the host bone The alternative to a massive allograft is often a modular total joint replacement (Fig 17.41) Soft tissues such as tendons may also be harvested, banked, and used as implants, particularly for ligament reconstruction Autograft or allograft tendons are avascular when implanted but undergo a complex biologic process called ligamentization in which there is graft necrosis, revascularization, cellular repopulation, collagen deposition, and, finally, graft remodeling and maturation This process takes to years and is analogous to creeping substitution in bone remodeling The intra-articular injection of living chondrocytes from cell culture into patients with joint disease is a promising new transplantation technique 1/18/2010 11:04:36 AM Chapter 17 • Postsurgical Imaging 331 FIGURE 17.42 ACL reconstruction with interference screws securing the bony ends (arrows) of the graft (different patients) A: Lateral radiograph shows bioabsorbable screws B: AP radiograph shows metal screws Cruciate ligament tears are typically reconstructed with graft material One common autograft for ACL is the central third of the infrapatellar tendon, with the bony attachments on either end This graft is threaded through a tunnel that is drilled through the femur and tibia and secured with interference screws The interference screws compress the bony portions of the graft against the tunnel walls (Fig 17.42) Other grafts used for ACL repair include autograft or allograft hamstring tendons (semitendinosus and gracilis) and synthetic materials such as polytetrafluoroethylene (Gore-Tex) Hamstring tendon grafts are usually fixed to the bone by screws with washers Radiographs can assess the position of hardware or bony portions of a graft MRI can be used to visualize the graft itself (Fig 17.43) and is useful when graft failure is suspected (Fig 17.44) Reimplantation of a traumatically amputated limb or appendage is made possible by rapid transport of victims to a medical center and microsurgical techniques In cases in which critical structures such as the thumb or multiple fingers of the dominant hand have been lost, a functional hand may be reconstructed by reimplanting other digits such as toes Lengthening the bone with external fixators may be combined with implantation in a multistage procedure FIGURE 17.43 Sagittal PD-weighted fat-suppressed MRI of intact ACL graft FIGURE 17.44 Sagittal T2-weighted fat-suppressed MRI of ACL graft (arrow) with impingement Chew_Chap17.indd 331 SOFT-TISSUE OPERATIONS A soft-tissue release is performed by surgically dividing a soft-tissue structure The flexor retinaculum, for example, is incised in a carpal tunnel release Tendon transfer may be performed by mobilizing the bony insertion of a tendon (by osteotomy) and reattaching it 1/18/2010 11:04:37 AM 332 Part IV • Miscellaneous Topics FIGURE 17.45 Soft-tissue anchors used for fixation of the patellar tendon transfer (arrows) A: Lateral radiograph B: Axial T2-weighted fat-suppressed MRI in a different location or by releasing the tendon and reattaching it to another soft-tissue structure Transfer of the insertion of the infrapatellar tendon may be performed to treat problems related to abnormal patellar tracking Tendon transfers around the hip may improve function in spastic neuromuscular conditions such as cerebral palsy Soft-tissue structures without integral bone segments may be attached to the bone with sutures (sometimes metallic), bone staples, screws with washers, or soft-tissue anchors (Fig 17.45) Operations that involve only the soft tissues may not be evident on postsurgical radiographs For example, shoulder reconstructions—usually soft-tissue operations performed to correct instability or to repair the rotator cuff—generally repair the shoulder capsule (capsuloplasty) or a torn rotator cuff In cases in which metallic fixation is used, radiographs may be helpful in documenting the position of the hardware (Fig 17.46) Arthrography, CT, and MRI often retain their usefulness in imaging the reconstructed shoulder (Fig 17.47) SPINE FUSION FIGURE 17.46 Perilunate soft-tissue repair with loose soft-tissue anchor (arrow) Chew_Chap17.indd 332 Surgical fusion of the spine is performed in various circumstances Long-term stability of spinal fusion depends on bony fusion not instrumentation Instrumentation and external braces (orthoses) provide immediate postoperative stability Anterior fusion involves removal of the intervertebral disk joints and sometimes other structures, with insertion of bone graft (Fig 17.48) Anterior fusions are performed in the cervical region after the removal of herniated disks from an anterior approach Posterior fusions may include wiring or instrumentation and placement of onlay bone grafts after preparation of the host surfaces by decortication, resection of facet joints, and so forth Posterolateral or intertransverse fusion is used in the lumbar region, where the transverse processes and other posterior elements are incorporated into the posterior fusion Most thoracic and lumbar spine fusions use a combined anterior and posterior approach Pedicle screws inserted posteriorly are attached to rods Removal of the disk material from the involved levels is followed by insertion of the bone graft material Blocks of allograft bone may be used; alternatively, fusion cages filled with morselized bone graft may be inserted (Fig 17.49) Follow-up films of spinal fusions should document healing and incorporation of graft material, maintenance of postsurgical alignment, and integrity of wires and instrumentation Pseudoarthrosis, the most common complication, 1/18/2010 11:04:38 AM Chapter 17 • Postsurgical Imaging 333 FIGURE 17.47 Recurrent rotator cuff injury following surgery A: AP radiograph shows a soft tissue anchor (arrow) in the humeral head from previous operation B: Oblique coronal T2-weighted fat-suppressed MRI has the artifact from metallic soft-tissue anchor, but retracted supraspinatus tear (arrow) is evident is more likely to occur if excessive motion at the fusion site is present It may be suspected when there is localized pain, motion, or loss of correction or fixation If standard radiographs are unrevealing, CT with coronal, sagittal, or three-dimensional reconstructed images may be helpful in demonstrating the presence or the lack of bony bridging at sites of arthrodesis Lateral views in flexion and extension may reveal abnormal motion Scoliosis may be managed by observation, external bracing, or surgery Surgery is generally not indicated until the curvature has a Cobb angle of 45 degrees or more Spinal fusion may be performed using anterior and posterior approaches Instrumentation is typically combined with bone grafting for arthrodesis of FIGURE 17.48 Postoperative radiographs of an anterior fusion of C5–7 with internal fixation and bone graft FIGURE 17.49 Lumbar spine fusion with pedicle screws, rods, and anterior fusion cages Chew_Chap17.indd 333 SCOLIOSIS SURGERY 1/18/2010 11:04:39 AM 334 Part IV • Miscellaneous Topics FIGURE 17.50 Anterior spine fusion for thoracic scoliosis Bone graft and interbody fusion cages have been placed following removal of intervertebral disks Vertebral body screws are connected by a rod the involved vertebrae Incorporation of the bone graft provides long-term stability, so that late failures of hardware are generally unimportant In the anterior approach, the intervertebral disks are removed, the curvature is corrected in three dimensions, and the involved levels are fused and fixed Bone graft and fusion cages may be used in the disk spaces Vertebral body screws are connected to one or more rods over multiple levels (Fig 17.50) In the posterior approach, contoured rods are connected over multiple levels to the involved vertebrae using some combination of hooks, pedicle screws, or wires to achieve a three-dimensional correction (Fig 17.51) Combined anterior and posterior approaches may be required for severe curvatures Telescoping rods for treatment of children with significant remaining growth potential are also available SOURCES AND READINGS Adams JC, Stossel CA Standard Orthopedic Operations: A Guide for the Junior Surgeon 4th Ed Philadelphia, PA: Churchill Livingstone; 1992 Berquist TH Imaging of Orthopaedic Fixation Devices and Prostheses Philadelphia, PA: Lippincott Williams & Wilkins; 2008 Chew FS, Roberts CC Total knee replacement: Imaging of complications Contemp Diagn Radiol 2006; 29(21):1–6 Chew FS, Roberts CC Total knee replacement: Radiographic evaluation Contemp Diagn Radiol 2006; 29(20):1–6 eMedicine http://emedicine.medscape.com Griffin LY Essentials of Musculoskeletal Care 3rd Ed Rosemont, IL: American Academy of Orthopedics; 2005 Hoppenfeld S, Zeide MS Orthopaedic dictionary Philadelphia: JB Lippincott Co; 1994 Learmonth ID, Young C, Rorabeck C The operation of the century: Total hip replacement Lancet 2007;370(9597):1508–1519 Chew_Chap17.indd 334 FIGURE 17.51 Anterior and posterior spinal fusion for idiopathic scoliosis with pedicle screws and rods A: AP radiograph B: Lateral radiograph Mohaideen A, Nagarkatti D, Banta JV, et al Not all rods are Harrington—an overview of spinal instrumentation in scoliosis treatment Pediatr Radiol 2000;30:110–118 Roberts CC, Chew FS Radiographic imaging of hip replacement hardware Semin Roentgenol 2005; 40(3):320–332 Roberts CC, Ekelund AL, Renfree KJ, Liu PT, Chew FS Radiologic assessment of reverse shoulder arthroplasty Radiographics 2007;27(1):223–235 Shellock FG, Crues JV MR procedures: Biologic effects, safety, and patient care Radiology, 232:635–652, 2004 Taljanovic MS, Hunter TB, Miller MD, Sheppard JE Gallery of medical devices: Part 1: Orthopedic devices for the extremities and pelvis Radiographics 2005;25(3):859–870 Taljanovic MS, Hunter TB, O’Brien MJ, Schwartz SA Gallery of medical devices: Part 2: Devices of the head, neck, spine, chest, and abdomen Radiographics 2005;25(4):1119–1132 Tomford WW Musculoskeletal Tissue Banking New York, NY: Raven Press; 1993 Van Rijswijk CSP Follow-Up Imaging of Soft Tissue Tumors In: De Schepper AM, Vanhoenacker F, Gielen J, Parizel PM, eds Imaging of Soft Tissue Tumors 3rd Ed Berlin-Heidelberg-New York: Springer; 2006:485– 494 Weinstein SL, Dolan LA, Cheng JCY, Danielsson A, Morcuende JA Adolescent idiopathic scoliosis Lancet 2008;371(9623):1527–1537 Weissman BNW, Sledge CB Orthopedic Radiology 2nd Ed Philadelphia, PA: WB Saunders; 2002 Wheelees CR III, ed Wheeless’ Textbook of Orthopaedics http://www.wheelessonline.com 1/18/2010 11:04:41 AM INDEX Page numbers in “italics” denote figures; those followed by a “t” denote tables A Abduction in ankle fracture, 75 Abscess See also Brodie abscess osteomyelitis, 297–299 pyomyositis, 306, 306 spinal, 300 tuberculosis, 301 Absorptiometry, 279–281 Abuse, child, 103–105, 103t, 104–105 Acceleration spinal injury, 43, 44 Acetabular fractures, 59, 58, 59 Acetabulum acetabular fractures, 59, 58, 59 acetabular labrum, 61–62, 61 fracture of osteoarthritis, 230 hip, 61, 60, 61 hydroxyapatite arthropathy, 237 Achondroplasia, 254, 255–256 Acquired immunodeficiency syndrome (AIDS), 307 Acromegaly, 286, 287 Acromion, 208, 211 Acute osteomyelitis adults, 297 child, 299 femur, 298 humeral metaphysis, 298 involucrum, 297, 299 radionuclide bone scan, 298 Acutrak screw, 110, 110 Adamantinoma, 153, 154 Adduction in ankle injury, 72, 75 Adenoma, pituitary, 286, 287 Adrenal disorder, 285–287 Aggressive fibromatosis, 168 Alignment in fracture, 14 joint disease, 201 ALPSA lesion, 35, 36 Aluminum toxicity, 293 Amyloidosis, 238 Angulation of bone in adult, 3, 14 in child, 87 Ankle dermatomyositis of, 215 fracture of in child, 99–101, 100–101 mortise, 71–72, 75, 75–78, 75t replacement, 327, 327 sprain, 72, 75, 76 tendon injuries, 75–77, 79 Ankylosing hyperostosis, 245 Ankylosing spondylitis, 202, 216–218 Ankylosis osteoarthritis, 225 psoriatic arthritis, 199 Annulus fibrosus, 201, 245 Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion, 35, 36 Antibody, joint disease, 204 Antigen, human leukocyte, 205 Antinuclear antibody, 204 AO-Weber classification, 72, 75t Arthritis, 207–224 antibodies, 204 antigen, 205 connective tissue disease dermatomyositis and polymyositis, 215–216 overlap syndromes, 216 scleroderma, 212, 214 systemic lupus erythematosus, 211–212 Crohn disease, 219, 220 gouty, 236 granulomatous synovitis, 224 juvenile idiopathic, 220–222 lyme disease, 224 monarticular, 203, 204t polyarticular, 203, 205t psoriatic, 218–219 foot, 220 hand and wrist, 208, 208–210 of hand and wrist, 197, 205 spinal, 201, 202 spine, 218–219 pyrophosphate arthropathy, 203, 234, 235 reactive, 218 rheumatoid extra-articular manifestations, 211 finger deformity in, 201, 201 hand and wrist, 208, 208–210 pathologic-radiologic features, 207–208 peripheral joints, 208–210, 208–210 spinal, 209, 210, 210–211 rheumatoid factor, 204 septic, 222–223 spondyloarthropathy ankylosing spondylitis, 216–218, 216–218 differential diagnosis, 220 enteropathic, 219–220 viral synovitis, 224 Arthritis mutilans, 219, 220 Arthrodesis, 317 Arthrogryposis multiplex congenita, 257, 257 Arthroplasty, 317, 318 Articular capsule, enthesis, 203 Aseptic necrosis See Osteonecrosis Atlantoaxial articulation, rheumatoid arthritis, 211 Atlantoaxial joint, osteoarthritis, 226 Atlanto-occipital joint, 44, 45 Autograft, 115 Autoimmune disease See also Arthritis, rheumatoid progressive systemic sclerosis, 212 systemic lupus erythematosus, 214 Avascular necrosis See Osteonecrosis Avulsion fracture forefoot, 83, 84 hand and forearm, 92–93, 93 of knee, 65, 66 in child, 98–99, 99 metastasis, 190 patella, 65, 66 spinal, in child, 97 sports-related injury, in child, 102 tibial, 99–101 Avulsion injury, finger and, 17, 18 Axial compression, 45 Axial compression in ankle injury, 72, 75 Axial loading calcaneal fracture and, 81 spinal injury and cervical, 43, 45, 47, 48 thoracolumbar, 53 B Baastrup disease, 247, 247 Babygram, 103 Baker cyst, 240–241 Bankart lesion, 32, 33, 35 Barton fractures, 25 Baseball finger, 17 Battered child, 103–105, 103t, 104–105 Bennett fracture of thumb, 18, 19 BHAGL lesion, 39 Bioabsorbable screw, 110, 110 Biomechanics of trauma bone, 2–5 in child, 87, 88 soft tissue, 6–8, 8, 8t Bisphosphonate-related insufficiency fracture, 293, 294 Bizarre parosteal osteochondromatous proliferation (BPOP), 179, 179 Blastic metastases, 183, 184, 190 Blount disease See Tibia vara Blunt chest trauma, 53 Body, osteochondral loose, 227 Bone biomechanics force and deformation, 2–3 load and fracture, 3–5 bruise, 67, 68, 68, 69, 70, 70, 71, 72 bruises, in child, 87 Codman triangle, 130, 131 335 Chew_index.indd 335 1/22/2010 3:41:18 PM 336 Index Bone (Continued) cyst aneurysmal, 172–173, 174 epidermoid inclusion cyst, 176 intraosseous ganglion, 175 simple bone cyst, 173, 175, 175 fracture of See Fracture infection of See Infection joint disease, 199–201, 200 lesions diagnosis, cardinal principle, 126, 126t incidence, 126 longitudinal location, 127, 128t metastases, 138, 138 patient factors, 126–127 precursors, 128t rate of growth, 127–130, 129–132, 132, 132t sex predominance, 127t staging, 135–136, 135t tissue characterization, 132–134, 133–135, 133t transverse location, 127, 128t treatment, 136, 136–138, 138 types, 127t metastases to, 181–193 See also Tumor, metastatic trauma See Trauma tumor of See Tumor entries vascular lesions, 176–177, 176–177 Bone bruise, 67–72, 68, 70 Bone grafts, 117, 117 Bone island, 160, 161 Bone marrow disease See Marrow disease metastasis and, 192 Borrelia burgdorferi, 224 Bouchard node, 198 Boutonniere deformity, 201, 201 Bowel disease, inflammatory, 219, 220 Bowing deformity adamantinoma, 153 in child, 93, 94 greenstick fracture, 87 Breast cancer, metastases, 181–186 Brodie abscess distal tibia, 300, 300 proximal tibia, 300, 301 radiologic feature, 300 symptoms, 299–300 Bruise, bone, 67, 68, 68, 69, 70, 70, 71, 72 Buford complex, 35, 37 Bunion, 242 Burn injury, 14 Bursa, retrocalcaneal, 210, 213 Bursitis, calcific, 234, 236 Burst fracture, vertebral, 53, 53 Buttress plates, 113, 113 C Caffey disease See Infantile cortical hyperostosis Cage, thoracic, trauma to, 53–54, 54 Calcaneal spurs, 242 Calcaneus, 81–83, 82, 83, 242 Calcification calcium hydroxyapatite, 213 Chew_index.indd 336 cartilage, 133 See also Chondrocalcinosis dermatomyositis of, 215 enthesis, 203 hydroxyapatite deposition disease, 234 joint disease, 198, 199, 203 scleroderma, 213 Calcinosis, periarticular, 234 Calcium hydroxyapatite, deposition disease, 233 Calcium pyrophosphate dihydrate crystal deposition disease, 233–234 Candidal osteomyelitis, 304 Capitate bone, 18, 20, 20 Capsule, articular, 203 Carpal coalitions, 260, 260 Carpal ligaments, 201 Carpometacarpal joint arthritis, 204 osteoarthritis, 226 Carpus biomechanics of wrist and, 18, 20, 20 fracture of, 21, 21 instability of, 24, 25, 25 Cartilage benign tumor of chondroblastoma, 164, 164 chondromyxoid fibroma, 164, 165 enchondroma, 160–161, 161–162 osteochondroma, 162, 163 osteochondromatosis, 162–163, 163 periosteal chondroma, 164, 164 chondrosarcoma, 144–147, 145–146 intra-articular fracture, 16 loading and, matrix mineralization, 134 osteoarthritis, 225 rheumatoid arthritis, 207 Casts for fracture, 106–108, 108 Cellulitis, 304, 305 Cemented THR, 319, 319 Cerclage wires, 112 Cerebral palsy, 256, 257 Cervical spine diffuse idiopathic skeletal hyperostosis, 246 injury to, 43–47, 44, 45, 46, 47 rheumatoid arthritis, 211–212 Chance fracture, 52, 53 Charcot joints, 232 Charcot-Marie-Tooth disease, 258, 258 Chauffeur’s fracture, 25 Chemical toxicity, 292, 292–293 Chest trauma, 53 Child See also Developmental and congenital conditions arthritis juvenile, 220–222, 221t, 222 septic arthritis, 222–223 battered, 103–105, 103t, 104–105 fracture ankle, 99–101, 100–101 biomechanics, 87, 88 elbow, 93–96, 94–95 Salter type II, 100, 100 stress, 102 tibia, 99–101, 100–101 toddler, 99, 100 triplane, 101, 101 growth plate injury, 87–89, 88–90, 91 hand and forearm injury, 92–93, 93–94 knee injury, 98–99, 99 pelvis and femur injury, 98, 98 shoulder and humerus injury, 96, 96 soft-tissue injury, 92 spine acute trauma, 96–97, 97 spondylolisthesis, 97, 97–98 spondylolysis, 97, 97–98 sports-related injury, 101–102, 102 tumor in metastatic, 181t neuroblastoma in, 187 Child abuse, 103–105, 103t, 104–105 Chlamyclia trackomatis, 218 Chondroblastoma, 164, 164 Chondrocalcinosis, 199, 199, 233 Chondromatosis, synovial, 240 Chondrometaplasia, synovial, 240 Chondrosarcoma clinical manifestation, 144–145 exostotic, 146, 146–147 medullary, 145–146, 145–146 variants, 147 Chopart fracture, 83, 84 Chordoma, 152–153, 154 Chronic osteomyelitis Brodie abscess distal tibia, 300, 300 proximal tibia, 300, 301 radiologic feature, 300 symptoms, 299–300 CT scan, clavicle, 299, 300 treatment, 298–299 Clavicle, fracture of, 37 Clay-shoveler’s fracture, 51, 51 Cleidocranial dysplasia, 258, 258 Clostridia myonecrosis, 306, 306–307 Cold injury, 14 Collagen enthesis, 203 fibrils, 198 Collateral ligament, 17, 18, 18, 19, 29, 29 Colles fracture, 25, 26 Comminuted fracture, 74 Compartment, patellofemoral, 225 Complex regional pain syndrome, 280 Compression ankle injury and, 72, 75 fracture, pelvic, 55, 56, 56, 57, 57 screw, 109, 109, 110, 110–111 Compressive loading of bone, 2–4, in child, 87 Computed tomography acetabular fracture and, 59, 59 ankle fracture, 77 fractures, 5, osteoblastoma, 160 plasmacytoma, 148 primitive neuroectodermal tumor, 151, 152 soft-tissue injury, 8, sternoclavicular dislocation and, 41 tibial fracture and, 70 1/22/2010 3:41:18 PM Index Congenital dwarfism, 254, 255–256 Congenital foot deformities congenital vertical talus, 272, 273 metatarsus adductus, 271 Talipes equinovarus, 271, 272 Congenital scoliosis, 274, 274 Congenital vertical talus, 272, 273 Connective tissue disease dermatomyositis and polymyositis, 215–216 overlap syndromes, 216 scleroderma, 212, 214 systemic lupus erythematosus, 211–212 Cortical plates, 112, 113–114 Craniocervical junction injury, 44, 44 Creep, biomechanical, Crohn disease, 219, 220 Crystal-associated diseases calcium pyrophosphate dihydrate crystal deposition disease, 233–234 gout, 236 hydroxyapatite deposition disease, 234–236 Crystal-associated joint disease, 233t Crystals precipitate, 233 Cushing syndrome See Hypercortisolism Cyst aneurysmal, 172–173, 174 bursitis, 176 epidermoid inclusion cyst, 176 ganglion, 176 intraosseous ganglion, 175 myxoma, 176 simple bone cyst, 173, 175, 175 subchondral, 200, 200 synovial cysts, 176 Cysticercosis, 306, 307 D Deceleration spinal injury, 43 Dedifferentiated chondrosarcoma, 147 Degenerative disease of synovial joint, 196–198 See also Arthritis pyrophosphate arthropathy Deposition disease calcium pyrophosphate, 233–234 hydroxyapatite, 234–236 joint and, 196 pyrophosphate crystal, 233 Dermatomyositis, 215–216 Developmental and congenital conditions congenital foot deformities See Congenital foot deformities heritable connective tissue disorders, 250–251, 251 hip conditions developmental dysplasia of the hip (DDH) See Developmental dysplasia of the hip (DDH) Legg-Calvé-Perthes disease, 264–266, 267 pediatric hip disease, 264, 264t slipped capital femoral epiphysis (SCFE), 267, 266–267, 268 limb length and rotational discrepancy, 262–264, 263 miscellaneous localized conditions accessory ossicles, 262, 262, 263 Chew_index.indd 337 carpal coalitions, 260, 260 cleidocranial dysplasia, 258, 258 digital anomalies, 260, 260 multiple epiphyseal dysplasia, 258, 258 muscle anomalies, 262, 262 proximal focal femoral deficiency, 259, 259 radioulnar synostosis, 258–259, 259 tarsal coalition, 260–261, 261 Tibia vara, 259, 259–260 osteochondroses See Osteochondroses premature physeal closure, 266–267, 268, 269 sclerosing skeletal dysplasias See Sclerosing skeletal dysplasias skeletal maturation, 250 spine conditions congenital scoliosis, 274, 274 idiopathic scoliosis, 272–273, 273 juvenile kyphosis, 274, 274–275 Developmental dysplasia of the hip (DDH) femoral head and acetabulum, 264 MRI, 266 old infant, 266 radiologic diagnosis, 266 restricted fetal movement, 264 sonography, 264, 265 Diabetes mellitus, 232 Dialysis amyloidosis, 238 hydroxyapatite deposition disease, 234, 236 Diffuse idiopathic skeletal hyperostosis (DISH), 202, 245–246 Digit See also Finger; Interphalangeal joint; Phalanx sausage, 197, 197, 219 Digital anomalies, 260, 260 Direct loading, Disc, intervertebral anatomy of, 201 metastases to, 182 Dislocation description of, 14–16, 15 elbow, 28, 29 in child, 93–94 of finger, 17 hip in adult, 61, 60, 61 shoulder, 31, 32, 32 spinal, cervical, 59–61, 60, 61 Distal interphalangeal joint See Interphalangeal joint, distal Distraction, 47 Divergent Lisfranc fracture-dislocation, 83, 84 Dorsal intercalated segment instability, 24, 25 Down syndrome, 257, 257–258 Dual-energy X-ray absorptiometry (DXA) artifacts, 279, 279 clinical interpretation, 277–279 lumbar spine, 278 osteopenia, 278, 279 Ductility, Dwarfism, congenital, 254, 255–256 Dynamic traction, 108 Dysplasia cleidocranial, 258, 258 developmental dysplasia of the hip (DDH) 337 femoral head and acetabulum, 264 MRI, 266 old infant, 266 radiologic diagnosis, 266 restricted fetal movement, 264 sonography, 264, 265 fibrous, 166–167, 167 multiple epiphyseal, 258, 258 osteoarthritis, 229 sclerosing skeletal dysplasias melorheostosis, 253, 254 osteopathia striata, 253, 253 osteopetrosis, 251–252, 252 osteopoikilosis, 252–253, 253 E Eburnation, 200 Effusion hip, 223 juvenile arthritis, 223 Elastofibroma, 170, 170 Elbow rheumatoid arthritis of, 208 trauma, adult, 27–29, 28–30 Elbow replacement, 326, 326 Enchondroma, 160–161, 161–162 Enders rod, 115, 115 Endocrine bone disease acromegaly and gigantism, 286–287, 287 diabetes mellitus diabetic myonecrosis, 289, 289 diabetic neuropathic arthropathy, 288, 288 diabetic osteomyelitis, 289, 289 gonadal disorders, 287, 287t hypercortisolism, 285–286 Paget disease femur, 290, 291, 291 insufficiency fractures, 291, 292 ivory vertebra, 291, 291 knee, 290, 290 sarcoma, 292, 292 vertebra appearance, 290, 290 thyroid disorders, 287 Enostosis, 160 Enteropathic spondyloarthropathy, 219–220 Enthesis, 203, 246 Erosion, bone, 208, 209 joint disease, 199 osteoarthritis, 225 Erosive osteoarthritis, 226 Essex-Lopresti fracture, 27, 27 Eversion, ankle fracture and, 75 Ewing sarcoma, 150–151, 150–151 Exostotic chondrosarcoma, 146, 146–147 Extension injury, spinal, 42, 43 Extensor mechanism of knee, 65–67, 66, 67 F Facet joint ankylosing spondylitis, 217 cervical, 50 Fat embolism, 120 1/22/2010 3:41:19 PM 338 Index Fatigue fractures, 11–12 Femur fracture of proximal, 63–65, 64, 65 stress, 11–12, 12 lymphoma, 149 metastases to, 183 shaft and distal, 65, 65 Fiber collagen, enthesis, 203 sharpey, 245 Fibril collagen, 198 osteoarthritis, 225 Fibroma chondromyxoid, 164, 165 desmoplastic, 167–168, 168 nonossifying, 164–165, 165–166 Fibrosis, rheumatoid arthritis and, 207 Fibrous cortical defects, 164–165, 165–166 Fibrous dysplasia, 166–167, 167 Finger dislocation of, 17 oblique fracture of, sausage digit, 197, 197 trauma to, 17, 18 Flatfoot, 242 Flexion injury, spinal, 42, 43 Floating anterior inferior glenohumeral ligament, 37, 39 Fluorosis, 293, 293 Foot calcaneus, 81–83, 82, 83 diabetic, 232 forefoot, 83–86, 84, 85 joint disease, inflammatory, 203 midfoot, 83, 83, 84 psoriatic arthritis, 220 rheumatoid arthritis, 210 talus, 77, 79, 80, 81, 81 Force to bone, 2, child abuse and, 103 Forearm fracture, in child, 92–93, 93–94 trauma to, 25–27, 26, 27, 28 Forefoot fracture, 83–86, 84, 85 Foreign body granuloma, 179 Fracture ankle, 72, 75, 75t, 76, 77 biomechanics in adults, 2–5 child, 87, 88 chance, 52, 53 closed treatment, 106–108, 107–108 complications, 118–123, 118t, 119–123 description of, 14–16, 15 femoral, 54, 58 fixation external, 115–116, 116 internal, 108–115, 108–115 spine, 117–118, 118 greenstick, 87, 94 growth plate, 87–89, 88–90, 91 hangman’s fracture, 45, 46 Chew_index.indd 338 healing, 106, 106t, 107 in child, 91, 91t, 92 imaging, 123–124, 124 loading and, 3–5, 3–6 lower extremity femoral, 63, 64, 65 Jones, 84, 85 Lisfranc, 83, 84, 232 Maisonneuve, 75, 77 patellar, 65, 67 pilon, 75, 78 tibial, 70 Tillaux, 75, 77 Wagstaffe-LeFort, 75 open in child, 91, 91 classification, 9–10, 10 mechanism of, reduction, 108, 108–109 pathologic, malignancy causing, 190, 190–191 pelvic, 54–57, 55, 56, 57, 58 rib, 53 spinal, cervical, 43–47, 44, 45, 46, 47 stress, 11–13, 14 in child, 102, 102 upper extremity clay-shoveler’s, 51, 51 Colles, 25, 26 distal radius and forearm, 25–27, 26–28 elbow and, 27–29, 28, 29, 30 Galeazzi, 27, 27 hand, 17–18, 18–19 wrist, 18, 20–25, 20–25, 22t Fracture-dislocation of ankle, 76 Lisfranc, neuropathic osteoarthropathy, 232 thoracic spinal, 51, 51–52 Freiberg infraction, 270, 271 Fungal infection, 224, 303–304, 304 G Galeazzi fracture, 27, 27 Gamekeeper’s thumb, 17, 18 Gas gangrene, 306, 306–307 Gaucher disease, 307–308, 308 Geodes, 200 Giant cell tumor of bone, 129, 132, 138 tendon sheath, 236 Gigantism, 286–287 GLAD lesion, 37, 40 Glenohumeral joint injury, 32, 96 rheumatoid arthritis of, 208 Gonadal disorders, 287, 287t Gonococcal arthritis, 223 Gout, 200, 236, 237 Grafts, bone, 117, 117 Granulomatous synovitis, 224 Great toe bunion, 242–243 Ground glass matrix mineralization, 133, 135 Ground substance, 198 Growth plate in battered child, 103–104, 104 fracture, 87–89, 88–90, 91 Gunshot wounds, 10–11 H Haemophilus influenzae, 222 HAGL lesion, 37, 38, 39 Hamate bone fracture, 21, 21 Hand fracture in adult, 17–18, 18–19 in child, 92–93, 93–94 juvenile arthritis, 221, 222 lupus arthropathy, 214 rheumatoid arthritis, 208, 208–210 sausage digit, 197, 197, 219 Hangman’s fracture, 45, 46 Head, fracture of, 27, 27, 28 Healing in child, 91, 91t, 92 fracture, 106, 106t, 107 failure, 118–120, 119–120 stress, 13, 14 rickets, 284 Heberden node, 198 Hemangiomatosis, synovial, 240 Hematologic disease, metastasis, 188–189 Hemodialysis, 237, 238 Hemophilia, 312–313, 313 Heritable connective tissue disorders Marfan syndrome, 251, 251 osteogenesis imperfecta, 250, 251 Hill-Sachs lesion, 32, 32, 34 Hip hydroxyapatite arthropathy, 237 osteoarthritis, 226 rheumatoid arthritis of, 217 trauma to in adult, 61, 60, 61 Hip screws, telescoping, 111, 111 HIV infection, 307 Hodgkin lymphoma, 190 Homolateral Lisfranc fracture, 83, 84 Human leukocyte antigen, joint disease, 205 Humerus in child, 96, 96 fracture, in adult, 29–31, 30, 31 rheumatoid arthritis of, 208 Hunter syndrome, 307, 308 Hyaline cartilage, 198 Hydroxyapatite deposition disease, 234–236 Hypercortisolism, 285–286 Hyperemia, synovial, 207 Hyperextension valgus loading, 69 varus loading, 69, 70 Hyperextension teardrop fracture, 46, 47 Hyperflexion injury, spinal cervical, 44, 46 seat belt causing, 52 Hyperflexion sprain, 47, 47, 48, 49 Hyperostosis, skeletal, 202 Hyperparathyroidism Brown tumor, 282, 282–283 1/22/2010 3:41:19 PM Index sacroiliac joint bone resorption, 281, 281 secondary, 281, 281 Hyperthyroidism, 287 Hypertrophic osteoarthropathy, 295, 295 Hypertrophy in rheumatoid arthritis, 207 Hyperuricemia, 236 Hypogonadism, 287 I Idiopathic scoliosis, 272–273, 273 Idiopathic skeletal hyperostosis, diffuse, 202, 245–246 Idiopathic tumoral calcinosis, 285 Immunoglobulin, 204 Indirect loading, 3–4 Infant See Child Infantile cortical hyperostosis, 295, 295 Infection acute osteomyelitis adults, 297 child, 299 femur, 298 humeral metaphysis, 298 involucrum, 297, 299 radionuclide bone scan, 298 cellulitis, 304, 305 chronic osteomyelitis Brodie abscess, 299–300, 301 CT scan, clavicle, 299, 300 treatment, 298–299 fracture, 120, 121 fungal, 224 fungal infections, 303–304, 304 gas gangrene, 306, 306–307 granulomatous synovitis, 224 HIV, 307 leprosy, 307 necrotizing fasciitis, 304–305, 305 parasitic infestation, 306, 307 pyomyositis, 305, 306 spine, 300–301, 301–302 tuberculosis osteomyelitis, 301, 303, 304 spondylitis, 301, 303 Infiltrate, leukemic, 189 Inflammation, crystal-induced, 233 Inflammatory arthritis, 207–224 See also Arthritis Inflammatory bowel disease, 219, 220 Inflammatory osteoarthritis, 226 Infrapatellar tendon entheses, 246 tear of, 66, 66 Insufficiency fractures, 12–13, 14 Intercalated segment instability, carpal, 24, 25 Intercondylar fracture, of elbow, 28 Interfragmentary screws, 110 Internal fixation, complications, 119–120, 119–120 Interphalangeal joint distal osteoarthritis, 225 rheumatoid arthritis, 201 juvenile, 220–222 proximal dislocation of, 17 Chew_index.indd 339 osteoarthritis of, 225 rheumatoid arthritis, 198, 207 swelling and, 198 psoriatic arthritis, 219 rheumatoid arthritis, 201, 207 Intertarsal joint, 232 Intertrochanteric fracture, 63–64, 65 Intervertebral disk anatomy of, 201 degeneration, 243–245 joint disease, 201–203, 201–203 metastases to, 182 Intra-articular fracture, metacarpal, 18, 19 Intracapsular fracture, 63, 64 Intramedullary rod, 114–115, 114–115 Intramuscular lymphoma, 149, 149 Intraosseous lipoma, 168, 168 Involutional osteoporosis, 276, 277 J Joint See also Joint disease Charcot, 232 metastases to, 182 prosthestic See Joint replacement trauma to glenohumeral, 31, 31–32, 32, 33, 34 sacroiliac, 54 Joint disease distribution of disease, 203–204 entheses, 203 general principles, 196, 196t intervertebral disk, 201–203, 201–203 laboratory findings, 204–205 non-inflammatory baastrup disease, 247, 247 crystal-associated diseases, 233–237 degenerative foot conditions, 242–243, 244 diffuse idiopathic skeletal hyperostosis, 245–246 intervertebral disk degeneration, 243, 245 metabolic deposition disease, 237–238 miscellaneous joint conditions, 238–242 osteoarthritis, 225–232 synovial, 196–201 alignment, 201, 201 bone, 199–201, 200 cartilage, 198–199, 198–199 soft tissues, 196–198, 197 Joint replacement See also Total hip replacement (THR) ankle, 327, 327 elbow, 326, 326 hip bilateral femoral endoprostheses, 319, 319 dislocated THR, 320, 320 heterotopic ossification, 321, 321 resurfacing hemiarthroplasty, 318, 319 total hip replacement (THR), 319–320, 319–320 knee See Total knee replacement (TKR) materials, 318 shoulder, 325, 326 small joint replacement, 327–328, 327–328 techniques, 318 wrist, 326–327, 326–327 339 Juvenile idiopathic arthritis, 221–222 Juvenile kyphosis, 274, 274–275 K Kienböck disease, 310, 310–311 Kirschner wires (K-wires), 111–112, 111–112 Knee complex injuries, 68, 68–70, 69, 70 extensor mechanism, 65–67, 66, 67 joint disease, 201 meniscal tears, 70, 71–74 osteoarthritis, 225 pyrophosphate arthropathy, 233, 234, 235 trauma to in child, 98–99, 99 Köhler disease, 270, 271 Kyphosis juvenile, 274, 274–275 Kyphosis, senile, 246 L Lag screw, 109–110, 110–111 Langerhans cell histiocytosis, 170–171, 171–172 Legg-Calvé-Perthes disease, 264–266, 267 Leprosy, 307 Lesser toes, 243 Leukemia, 189, 190 Leukocyte antigen, human joint disease, 205 psoriatic arthritis and, 218–219 Ligament of ankle, 71, 72, 75, 77 finger injury, 17 joint disease, 201 spinal cervical, 50 thoracic, 52 thoracolumbar, 53 thumb injury and, 17–18, 19 Lipoma, 170, 170 Liposclerosing myxofibrous tumor, 169, 169 Lisfranc fracture-dislocation, 83, 84, 232 Loading ankle injury and, 75 cervical spinal injury and, 43 fracture in adult, 3–5, 3–6 in child, 87 Loose body, osteochondral, 227 Lower cervical spine, 47–51, 47–52 Lower extremity See also specific part trauma to, 63–86 ankle and, 71–72, 75–77, 75–79, 75t foot, 77, 79, 80–85, 80–86 knee, 65–70, 66–74 proximal femur, 63–65, 64, 65 shaft and distal femur, 65, 65 tibia, 70, 74 Lower motor neuron, 232 Lumbar spine ankylosing spondylitis, 216 burst fracture of, 53 metastases to, 182 trauma to, 42 1/22/2010 3:41:19 PM 340 Index Lunate bone dislocation of, 24 trauma to, 18, 20, 20 Lung metastases, 186 Lupus erythematosus, systemic, 211–212 Lyme disease, 224 Lymphoma, metastasis, 190 Lytic metastases, 182, 183, 190 M Maffucci syndrome, 161 Magnetic resonance imaging labral tear and, 38 metastatic tumor and, 185, 186, 188, 189, 191 primitive neuroectodermal tumor, 151, 152 rotator cuff tear and, 30, 33, 34 sprains and strains, 8–9, stress fracture, 5–6, Maisonneuve fracture, 75, 77 Malgaigne fracture, 56 Malignant fibrous histiocytoma (MFH), 152, 153 Mallet finger, 17, 18 Marfan syndrome, 251, 251 Marrow disease Gaucher disease, 307–308, 308 mucopolysaccharidoses, 307, 308 osteonecrosis See Osteonecrosis sickle cell disease vs hematogenous osteomyelitis, 312 hemosiderosis, 312, 312 H-shaped vertebral bodies, 311–312, 312 multiple small infarcts, 311, 311 Matrix mineralization, 132–133, 133t Medullary chondrosarcoma, 145–146, 145–146 Meniscus chondrocalcinosis, 199 tear of, 70, 71–74 Metabolic deposition disease amyloid arthropathy, 238 multicentric reticulohistiocytosis, 237–238 tophaceous gout, 237 Metabolic disorder, bone erosions, 199 Metacarpal, tophaceous gout of, 237 Metacarpophalangeal joint osteoarthritis, 225 rheumatoid arthritis, 201 of thumb, 17 Metacarpophalaugeal joint, lupus and, 212 Metastatic tumors See Tumor, metastatic Metatarsophalangeal joint gout, 236 neuropathic osteoarthropathy, 232 rheumatoid arthritis, 207 Metatarsus adductus, 271 Midfoot, 83, 83, 84 Migratory osteoporosis, 280 Milkman pseudofractures, 284 Mineralization, tumor, 132–133, 133t See also Calcification Monarticular arthritis, 203, 204t Monteggia fracture, 27, 28 Mortise, ankle, 71–72, 75, 75–78, 75t Morton neuroma, 178 Moth-eaten appearance of bone lesion, 128–129, 129 Chew_index.indd 340 Motor vehicle accident cervical spinal trauma and, 46, 47, 51 chest trauma from, 53 seat belt causing, 52 Mucopolysaccharidoses, 307, 308 Multicentric reticulohistiocytosis, 237–238 Multiple epiphyseal dysplasia, 258, 258 Multiple myeloma, 147, 147–148 Muscle anomalies, 262, 262 knee injury and, 68, 68–70, 69, 70 Muscular dystrophy, 256, 257 Mycobacteria, atypical, 224 Myeloma multiple, 147, 147–148 solitary, 148, 148 Myositis ossificans, posttraumatic, 122, 123, 178, 178 N Neck radial, 27, 28 spinal trauma and, 47 Necrotizing fasciitis, 304–305, 305 Nephrogenic systemic fibrosis (NSF), 294, 294 Neurofibromatosis adult, 256 pseudoarthrosis, 255, 256 subtypes, 254–255 Neurologic disorder in spinal trauma, 42t Neuropathic joints, 232 Neuropathic osteoarthropathy, 232 NEXUS criteria, 42t Nodule, pigmented villonodular synovitis, 238–240 Noncemented THR, 319–320, 319–320 Nongonococcal arthritis, 222 Non-Hodgkin lymphoma, 148, 190 Non-inflammatory joint disease, 225–247 See also Joint disease, non-inflammatory Nonunion of fracture, 46 Nucleus pulposus, 201 O Occult primary tumors, 181 Odontoid process, 45, 46, 46 Olecranon fracture of, 28, 28 tension band fixation, 111, 112 Ollier disease, 161 Open fracture classification, 9–10, 10 mechanism of, Os acromiale syndrome, 262, 262, 263 Osgood-Schlatter disease, 269 Osseous vascular lesions, 176, 176–177 Osteitis deformans See Paget disease Osteoarthritis, 225–232 femoroacetabular impingement, 229, 231, 232 neuropathic, 232 secondary, 227–229 subacromial impingement, 231, 232 Osteoarthropathy, neuropathic, 232 Osteoblastoma, 159–160, 160 Osteochondral defect, 77, 79 Osteochondral fracture, 77, 79, 80, 81 Osteochondral lesions, 37, 40, 80 Osteochondral loose body, 227 Osteochondritis dissecans, 79, 269, 270 Osteochondroma parosteal osteosarcomas, 142 pedunculated, 162, 163 radiation-induced, 193 Osteochondromatosis, 162–163, 163 Osteochondroses, 311 Freiberg infraction, 270, 271 Köhler disease, 270, 271 Osgood-Schlatter disease, 269 osteochondritis dissecans, 269, 270 panner disease, 269, 270 Sinding-Larsen-Johansson disease, 269–270 Osteogenesis imperfecta, 250, 251 Osteoid osteoma, 158–159, 159 Osteomalacia etiologies, 283 radiologic findings, 284, 284 vitamin D deficiency–induced, 282–283 Osteomyelitis, 232 abscess, 297–299 acute adults, 297 child, 299 femur, 298 humeral metaphysis, 298 involucrum, 297, 299 radionuclide bone scan, 298 candidal, 304 chronic distal tibia, 300, 300 proximal tibia, 300, 301 radiologic feature, 300 symptoms, 299–300 CT scan, clavicle, 299, 300 diabetic, 289, 289 streptococcus infection, 297 treatment, 298–299 tuberculosis, 301, 303, 304 Osteonecrosis calcified marrow infarcts, 311 femoral head clinical conditions, 308, 309t MRI, 309, 309 right femoral head, 308, 309 treatment, 309 fracture, 120, 120 humeral head, 310, 310 knee, 310, 310 lunate, 310, 310–311 lupus and, 212 medullary bone infarcts, 311 osteochondroses, 311 Osteopenia, 185 Osteophytes, 225 Osteoporosis, 199, 200 acute, 280, 280 arthritis, 207, 209–212 bone mineral densitometry (BMD) 1/22/2010 3:41:19 PM Index degenerative spine disease, 279, 280t dual-energy X-ray absorptiometry (DXA), 277–278, 278–279 radiographic measurement, 277 T-scores, 278 WHO criteria, 278t dermatomyositis, 215 involutional, 276, 277 migratory, 280 regional, 280 secondary, 280, 280t transient, 280, 281 Osteosarcoma, 127t, 131, 133, 133t classification, 140t Codman triangle, 130, 131 high-grade surface, 144 intracortical, 144 intramedullary clinical presentation, 140 ossification, 142, 143, 144 skip metastasis, 142 treatment, 142 intraosseous well-differentiated, 144 metastatic, 138 multifocal, 144 parosteal, 142–143, 144 periosteal, 143, 144 radiation-induced, 142, 143 small cell, 151, 152 telangiectatic, 142, 143 Osteotomy bunion repair, 316, 317 hallux valgus primus varus, 315–316 high tibial valgus osteotomy, 315, 317 rotational osteotomies, 315 Overhanging edges, 200, 237, 238 Overlap syndromes, 216 P Paget disease femur, 290, 291, 291 insufficiency fractures, 291, 292 ivory vertebra, 291, 291 knee, 290, 290 sarcoma, 292, 292 vertebra appearance, 290, 290 Panner disease, 269, 270 Pannus, 200 Parasitic infestation, 306, 307 Paraspinal soft tissue, 43 Pars interarticularis fracture, 45, 45 Patellar fracture, 65, 67 Patellofemoral compartment, 225 Pathologic fracture, 11 bone cyst, 175 malignancy causing, 190, 190–191 Pelvic fracture in adult, 54–57, 55, 56, 57, 58 child, 98, 98 Pelvic ring stable fractures, 55–56, 55 unstable injuries, 56–58, 56, 57, 58 Pelvis ankylosing spondylitis, 217 femur and, 98, 98 Chew_index.indd 341 stable injuries, 55 straddle fractures, 58 unstable injuries, 56 Pencil-in-cup appearance, 219 Periarticular calcinosis, 234 Perilunate injury, 22, 22–24, 22t, 23, 24 Periosteal bone expanded cortical shell, 129–130, 131 sickle cell disease, 311 Periosteal chondroma, 164, 164 Periosteal reaction, sunburst, 131 Periostitis, 200 infantile cortical hyperostosis, 295 juvenile idiopathic arthritis, 221 psoriatic arthritis, 219 Peripheral nerve sheath tumors, 177, 178 Permeated bone lesion, 128–129, 130 Perthes lesion, 35 Phalanx See also Interphalangeal joint rheumatoid arthritis of, 208 sausage digit, 197, 197, 208 Phytes, vertebral, 202t Pigmented villonodular synovitis, 238–239, 238–240 Pilon fracture, 75, 78 Pin fixators, 115, 116 Plasmacytoma, 148 Plateau, tibial, fracture of, 70, 74 Plexus, venous, 182 Poirier, space of, 20, 20, 22 POLPSA lesion, 35, 38 Polyarthritis lupus, 211 Polymyositis, 215–216 Posterior labroligamentous periosteal sleeve avulsion lesion, 35, 38 Posttraumatic osteolysis, 242, 242 Posttraumatic reflex sympathetic dystrophy, 121, 122 Precipitate, crystals, 233 Premature physeal closure, 268, 268, 269 Primary lymphoma, 148–149, 149 Primary osteoarthritis, 225–227 Primitive neuroectodermal tumor (PNET), 151, 152 Progressive systemic sclerosis, 212 Proliferative bone, tumor and, 129 Prostate cancer, metastases, 182, 184, 190 Proteoglycan, 198 Protrusio acetabuli, 237 Proximal femur fractures intertrochanteric, 63–64, 65 intracapsular, 63, 64 subtrochanteric, 64–65 trauma to in adult, 63–65, 64, 65 Proximal focal femoral deficiency, 259, 259 Proximal humerus trauma to in adult, 29, 30 Proximal interphalangeal joint See Interphalangeal joint, proximal Proximal radius fracture, 27, 28 Pseudoacetabulum, 230 341 Pseudoarthrosis, 199 Psoriatic arthritis, 218–219 foot, 220 hand and wrist, 208, 208–210 of hand and wrist, 197, 205 spinal, 201, 202, 218–219 Pyomyositis, 305, 306 Pyrophosphate arthropathy, 203, 234, 235 Pyrophosphate crystal deposition, 233 Q Quadriceps, entheses, 246 Quadriceps tears, 66, 66 R Radiation therapy, 192, 192–193, 193 Radiocarpal joint, 233 Radioulnar synostosis, 258–259, 259 Radius, fracture of distal, 25–27, 26–28 proximal, 27, 28 Reactive arthritis, 218 Regional osteoporosis, 280 Reiter syndrome, 202, 204 Relaxation, stress, Renal dialysis amyloidosis, 238 hydroxyapatite deposition, 234 Renal osteodystrophy, 284, 285 See also Osteomalacia; Rickets Reticulohistiocytosis, multicentric, 237–238 Retrocalcaneal bursa, 210, 213 Rhabdomyosarcoma, metastases, 181 Rheumatoid arthritis extra-articular manifestations, 211 finger deformity in, 201, 201 hand and wrist, 208, 208–210 pathologic-radiologic features, 207–208 peripheral joints, 208–210, 208–210 spinal, 209, 210, 210–211 Rheumatoid factor, 204 Rib fracture, 54 Rickets etiologies, 283 healing rickets, 284 radiographic findings, 284 vitamin D deficiency–induced, 282–283 Ring fixators, 115–116, 116 Ring, pelvic, 54–57, 55, 56, 57, 58 Rod, intramedullary, 114–115, 114–115 Rolando fracture, of thumb, 18, 19 Rotary subluxation, scaphoid, 22, 22, 25 Rotation injury of ankle, 72 spinal, 43, 43 Rotational loading, 4–5, 5–6 Rotator cuff injury, 32, 33, 34, 34–35, 35 S Sacroiliac joint, 211 trauma to, 54 Sacroiliitis, 218, 218 Sarcoidosis, 294, 294 1/22/2010 3:41:19 PM 342 Index Sarcoma osteosarcoma, 127t, 131, 133, 133t Codman triangle, 130, 131 metastatic, 138 radiation-induced, 193 small cell Ewing sarcoma, 150–151, 150–151 primitive neuroectodermal tumor, 151, 152 small cell osteosarcoma, 151, 152 soft-tissue, 153–156 anatomic distribution, 155t extremities and limb girdles, 155t liposarcoma, 154, 155 staging, 156, 156 synovial, 154, 155 Sausage digit, 219 Scaphoid fracture, 20, 20–21, 21, 110 Scaphoid subluxation, 22, 25 Scapholunate advanced collapse, 233 Scheuermann disease, 274, 274–275 Scleroderma, 212–215 Sclerosing skeletal dysplasias melorheostosis, 253, 254 osteopathia striata, 253, 253 osteopetrosis, 251–252, 252 osteopoikilosis, 252–253, 253 Sclerosis, 200 Scoliosis congenital, 274, 274 idiopathic, 272–273, 273 surgery, 333–334, 334 Screening for metastases, 187–188 Screw fixation of fracture, 109–111, 109–111 Scurvy, 292, 292 Seagull appearance in osteoarthritis, 227 Seat belt injury, spinal, 52 Secondary osteoarthritis, 227–229 Senile kyphosis, 246 Sex predominance in tumor incidence, 127t Sexually transmitted disease, 224 Sharpey fiber, 245 Shearing injury pelvic, 52 spinal, 42, 43 Shepherd fracture, 81 Shoulder hydroxyapatite deposition and, 235 pyrophosphate arthropathy, 233 replacement, 325, 326 trauma to in adult, 29–37, 30–40, 36t, 37t in child, 96, 96 Sickle cell disease vs hematogenous osteomyelitis, 312 hemosiderosis, 312, 312 H-shaped vertebral bodies, 311–312, 312 multiple small infarcts, 311, 311 Sinding-Larsen-Johansson disease, 269–270 Skeletal fluorosis, 293, 293 Skeletal hyperostosis, diffuse idiopathic, 202, 245–246 Skeletal maturation, 250 Skeletal metastases, 182 Skeletal traction, 108 Skin traction, 108 Chew_index.indd 342 SLAC wrist, 233 SLAP tear, 31, 35 Slipped capital femoral epiphysis (SCFE), 267, 266–267, 268 Small cell sarcoma, 149–151, 150–152 Small joint replacement, 327–328, 327–328 Smith fracture, 25 Soft tissue cystic, 176 dermatomyositis, 215, 215 healing and repair, 116–117 injury biomechanics, 6–8, 8, 8t in child, 92 imaging, 8–9, 8–9 metastases, 191–192 operations patellar tendon transfer, 332, 332 perilunate soft-tissue repair, 332, 332 recurrent rotator cuff injury, 332, 333 paraspinal, 43 sarcoma, 137, 153–154, 156, 155t, 155–156 synovial joints, 196–198, 197 tumor of, staging, 135t vascular lesions, 177, 177 Solitary myeloma, 148, 148 Sonography, soft-tissue injury, 9, Spine Crohn disease, 219, 220 fixation, 117–118, 118 complications, 123, 123 fusion, 332–333, 333 infections, 300–301, 301–302 intervertebral disk joints, 201 metastases to, 182, 185 osteoarthritis, 226 rheumatoid arthritis, 210–211 trauma to in child, 96–97, 97 general priniciples of, 42–43, 42t, 43, 43t lower cervical, 47, 47–51, 48, 49, 50, 51, 52 thoracic cage, 54–55, 54 thoracolumbar, 53, 52, 53 upper cervical, 43–47, 44, 45, 46, 47 Spondylitis ankylosing, 216–218 Crohn disease, 220 Spondyloarthropathy ankylosing spondylitis, 216–218, 216–218 differential diagnosis, 220 enteropathic, 219–220 psoriatic arthritis, 218–219 reactive arthritis, 218 Spondylolisthesis in child, 97, 97–98 traumatic, 45, 45 Spondylolysis, 97, 97–98 Sports-related injury, 101–102, 102 Sprain ankle, 72, 75, 76 grading, 7, 8t hyperflexion, 47, 47, 48, 49 infrapatellar tendon, 66, 66 Spur, calcaneal, 242 Stable pelvic fracture, 55–56, 55 Stener lesion, 18, 19 Sternum fracture, 54 Stiffness, Straddle fracture, 56, 58 Strain, grading, 7, 8t Streptococcus infection arthritis, 222 osteomyelitis, 297 pyomyositis, 306 Stress fracture in child, 102, 102 pelvic, 55 Stress injury, 11–13, 12–14 Stress relaxation, Subchondral cysts, 200, 200 Subchondral osteoarthritis, 227 Sublabral foramen, 35, 37 Sublabral sulcus, 35, 36 Subluxation carpal, 25 definition, 15 lupus, 212 Subtrochanteric fracture, 64–65 Sunburst periosteal reaction, 131 Superior labral anterior to posterior tear, 31, 35 Supraspinatus tendon, 235 Swan neck deformity, 201 Swelling, joint disease, 197, 197 Syndesmophytes, 202 Syndesmosis, ankle, 72, 75 Synovial chondromatosis, 240 Synovial chondrometaplasia, 240 Synovial hemangiomatosis, 240 Synovial hyperemia, 207 Synovial joint, 196–201 alignment, 201, 201 bone, 199–201, 200 cartilage, 198–199, 198–199 osteoarthritis, 226 Synovitis granulomatous, 224 pigmented villonodular, 238–239 viral, 224 Syringomyelia, 232 Systemic lupus erythematosus, 214 T Talipes equinovarus, 271, 272 Talus, 77, 79, 80, 81, 81 Tarsal coalition, 260–261, 261 Tarsometatarsal joints, 232 Teardrop spinal fracture, 46, 47, 47, 48, 48 Tears infrapatellar tendon, 66, 66 meniscal, 70, 71–74 quadriceps, 66, 66 Telescoping hip screws, 111, 111 Tendon enthesis, 203 finger injury and, 17, 18 hydroxyapatite deposition disease, 235 infrapatellar, 66, 66 Tensile loading of bone, Tension band fixation, 111–112, 112 1/22/2010 3:41:19 PM Index Tension fracture, vertebral, 54, 53 Tension injury, pelvic, 55 Thalassemia, 312, 312 Thermal trauma, 14 Thoracic cage, 54–55, 54 Thoracic spinal trauma, 51, 51–52, 52 Thoracolumbar spinal trauma, 53, 52, 53 Thumb gamekeeper’s, 17, 18 trauma to, 17–18, 18, 18–19, 19 Thyroid cancer, metastases, 185 Thyroid disorders, 287 Tibia plateau, 70, 74 shaft, 70 Tibia vara, 259, 259–260 Tibial valgus osteotomy, 315, 317 Tillaux fracture, 75, 77 Tophaceous gout, 200, 237 Total hip replacement (THR) cemented THR, 319, 319 dislocation, 320, 320 heterotopic ossification, 321, 321 loose cemented THR, cement-metal bond failure, 321, 321 noncemented THR, 319–320, 319–320 osteolysis, 321, 321 Total knee replacement (TKR) bicondylar, 321, 322 femur fracture, 324, 324 intercondylar stabilized, 322 metal synovitis, 325, 325 patellar component, 324, 324 polyethylene thinning, 324, 324–325 rotating hinge, 323, 323 unicompartmental, 323, 323 Trabecular bone, osteoporosis of, 199 Traction fracture definition, 4, healing and, 108 Translocation, ulnar, 209, 210 Transplantation, 330–331, 330–331 Trauma axial skeleton acetabulum, 57–61, 58, 59, 60, 61 general priniciples of, 42–43, 42t, 43, 43t lower cervical spine, 47, 47–51, 48, 49, 50, 51, 52 pelvic ring, 55–58, 55, 56, 57, 58 thoracic cage, 54–55, 54 thoracolumbar, 53, 52, 53 upper cervical spine, 43–47, 44, 45, 46, 47 biomechanics, bone, 2–5 in child, 87–105 See also Child fracture See Fracture gunshot wounds, 10–11 to lower extremity, 63–86 ankle and, 71–72, 75, 75–77, 75t, 76, 77, 78, 79 foot, 77, 79, 80, 81, 81–86, 82, 83, 84, 85 knee, 65–70, 66, 67, 68, 69, 70, 71, 72, 73, 74 proximal femur, 63–65, 64, 65 shaft and distal femur, 65, 65 tibia, 70, 74 radiologic reporting of, 16 stress injury, 11–13, 12–14 Chew_index.indd 343 thermal, 14 to upper body, 17–41 clavicle, 37, 40, 40–41 distal radius and forearm, 25–27, 26–28 elbow, 27–29, 28, 29, 30 hand, 17–18, 18, 19 humerus, 29–31, 30, 31 shoulder, 29–37, 30–40, 36t, 37t wrist and, 18–25, 20–25, 22t Triangular fibrocartilage complex forearm fracture and, 25 wrist biomechanics, 20 Tuberculosis osteomyelitis, 301, 303, 304 spondylitis, 301, 303 synovitis, 224 Tumor, benign of bone cystic, 172–176, 174–175 giant cell, 171–172, 173 bone-forming, 158t bone island, 160, 161 osteoblastoma, 159–160, 160 osteoid osteoma, 158–159, 159 cartilage chondroblastoma, 164, 164 chondromyxoid fibroma, 164, 165 enchondroma, 160–161, 161–162 osteochondroma, 162, 163 osteochondromatosis, 162–163, 163 periosteal chondroma, 164, 164 fatty elastofibroma, 170, 170 intraosseous lipoma, 168, 168 lipoma, 170, 170 liposclerosing myxofibrous tumor, 169, 169 fibrous aggressive fibromatosis, 168 desmoplastic fibroma, 167–168, 168 fibrous cortical defects, 164–165, 165–166 fibrous dysplasia, 166–167, 167 nonossifying fibromas, 164–165, 165–166 giant cell bone, 171–172, 173 tendon sheath, 238 Langerhans cell histiocytosis, 170–171, 171–172 neurogenic lesions Morton neuroma, 178 peripheral nerve sheath tumors, 177, 178 posttraumatic lesions Bizarre parosteal osteochondromatous proliferation (BPOP), 179, 179 foreign body granuloma, 179 myositis ossificans, 178, 178 soft tissues, 176 vascular lesions osseous vascular lesions, 176, 176–177 soft-tissue vascular lesions, 177, 177 Tumor, malignant See also specific conditions adamantinoma, 153, 154 of bone cardinal principle in diagnosis of, 126, 126t growth of, 127–130, 129–132, 132, 132t incidence of, 126 343 location of, 127, 128t metastatic, 138, 138 patient factors, 126–127, 127t–128t chondrosarcoma See Chondrosarcoma chordoma, 152–153, 154 lung, metastases, 186 malignant fibrous histiocytoma (MFH), 152, 153 osteosarcoma See Osteosarcoma primary marrow cell multiple myeloma, 147, 147–148 primary lymphoma, 148–149, 149 solitary myeloma, 148, 148 radiation-induced, 193 sarcoma See Sarcoma soft tissue sarcoma, 137 staging, 135t staging of, 135–136, 135t tissue characterization of, 132–134, 133–135, 133t treatment of, 136, 136–138, 138 Tumor, metastatic hematologic primary and, 188–190 incidence of, 181, 181t pathologic fracture, 190–191 percutaneous needle biopsy, 192 radiologic appearance of, 182–187, 182t radiotherapy changes, 192, 192–193, 193 screening for, 187–188, 188 soft-tissue metastases, 191, 191–192 treatment, 192 tumor spread, 182 Tumor resection below-knee amputation, 329–330 bone graft substitute, 329, 329 curettage, 328–329, 329 radiographs, 330 Twisting, effect of, 3, U Ulceration in diabetic foot, 288 Ulna fracture of, 25 rheumatoid arthritis and, 208 Ulnar collateral ligament, 17, 18, 18, 19, 29, 29 Ulnar translocation, 209, 210 Unstable pelvic fracture, 56–58, 56–58 Upper cervical spine, 43–47, 44–47 Upper extremity See also specific part hydroxyapatite deposition, 234 osteogenesis imperfecta, 251 osteopetrosis, 252 trauma to clavicle, 37, 40, 40–41 distal radius and forearm, 25–27, 26–28 elbow, 27–29, 28, 29, 30 hand, 17–18, 18, 19 humerus, 29–31, 30, 31 shoulder, 29–37, 30–40, 36t, 37t wrist and, 18, 20–25, 20–25, 22t Upper motor neuron disorder, 232 Uric acid, 236 1/22/2010 3:41:19 PM 344 Index V Valgus knee injury, 68 Valgus tibial osteotomy, 315, 317 Varus knee injury, 69 Vascular spread of tumor, 182 Vehicular accident cervical spinal trauma and, 46, 47, 51 chest trauma from, 53 seat belt injury and, 52 Venereal disease, arthritis, 218 Venous plexus, 182 Vertebra See also Spine joint disease, 201–203 metastasis, 183, 188 phytes, 202t tension fracture of, 52, 53 Vertebral ring apophyses, 96 Chew_index.indd 344 Vertical loading fracture, ankle and, 75 Vertical shear fracture, pelvic, 56, 57, 58 Vertical talus, 272, 273 Villonodular synovitis, pigmented, 238–239 Viral synovitis, 224 Viscous effects, Vitamin A toxicity, 268 Vitamin deficiency C, 292 D, 282 Volar intercalated segment instability, 25, 25 Voorhoeve disease, 253, 253 W Wagstaffe-LeFort fracture, 75 Whiplash injury, 51 Wing, iliac, 192 Wires, Kirschner, 111–112, 111–112 Wolff law, 11 Wrist biomechanics, 18, 20–25, 20–25, 22t ligaments, 20, 20 pyrophosphate arthropathy, 233 rheumatoid arthritis, 197, 205 trauma to, 18, 20–25, 20–25, 22t X Xenograft, 330 Z Zones, looser, 284, 284 1/22/2010 3:41:19 PM ... findings Chew_Chap 12. indd 22 1 1/18 /20 10 11:00:11 AM 22 2 Part III • Joint Disease FIGURE 12. 37 Sequelae of juvenile idiopathic arthritis in a young adult A: The hand has short bones whose growth... on MRI as the reversion of synovitis and marrow edema to normal MRI is 20 7 Chew_Chap 12. indd 20 7 1/18 /20 10 10:59:53 AM 20 8 Part III • Joint Disease also helpful in the evaluation of the complications... involves the MCP and PIP joints The earliest bone erosions are generally at the MCP joints (Fig 12. 3), often the second and third on the radial side The PIP joint of the middle finger is another