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(BQ) Part 2 the book Challenging cases in musculoskeletal imaging presents the following contents: Shoulder girdle and thoracic cage, anterior chest wall as a whole, upper limb, lower limb, equivocal MRI findings, predominantly osteosclerotic changes,...
Shoulder Girdle and Thoracic Cage Shoulder Girdle and Thoracic Cage 5.1 Clavicle Case 78 (▶ Fig 5.1) Case description ● ● Referring physician: orthopedist Prior history and clinical question: A 21-year-old man was examined radiologically for multiple injuries A radiograph of the left clavicle showed a defect in the inferior border just lateral to the head of the clavicle (the medial or sternal end of the clavicle) Before ordering biopsy, the orthopedist wanted to know what the defect might represent Radiologic Findings A semicircular defect is visible in the inferior border of the clavicle just lateral to the clavicular head (see arrows in ▶ Fig 5.1 a) A subsequent whole-body bone scan (▶ Fig 5.1 b) appears normal Slightly increased uptake in the manubriosternal synchondrosis is considered appropriate for age Location The defect is located at the attachment of the costoclavicular ligament This was also seen in CT scans, which are not reproduced here because the case can be solved without them (see Assignment to a Possible Basic Entity below) A similar but very subtle finding was also noted on the contralateral side Pathoanatomic Background of the Findings The tissue structure replacing the bone is not associated with increased bone turnover (negative bone scan)—that is, it does not incite a perifocal reaction, and it does not form a matrix (e.g., bone, cartilage, ossifying connective tissue) scan suggests a normal variant When we consider its location (see above), it is reasonable to assume that we are dealing with a normal variant ▶ Trauma, inflammation, tumor? The negative history and negative bone scan exclude these basic entities from a realistic differential diagnosis Synopsis and Discussion The apparent defect in the undersurface of the clavicle, just lateral to the medial end of the clavicule (clavicular head), is called a “ligament groove” in the literature and corresponds to the attachment of the costoclavicular ligament 17 This attachment site generally appears radiographically as a more or less pronounced irregularity in the contour of the bone In extreme cases it forms an actual groove and appears as a well-defined defect, especially when the shoulder girdle has been subjected to particularly high mechanical stresses This is not necessarily an insertional tendinopathy in the form of a rarefying fibro-ostosis, as this would show at least slightly increased tracer uptake on the bone scan Similar findings are known to occur in the femoral neck (see Case 69 and Case 73), the ischia, at the pectoralis attachment (see images in Case 102, Case 103, and Case 104), and at other sites Final Diagnosis Ligament groove at the attachment of the costoclavicular ligament, considered a normal variant Comments The key to the correct interpretation of a radiologic finding often lies in its location Assignment to a Possible Basic Entity ▶ Normal variant or malformation? Yes The very fact that the defect was detected incidentally and was negative on the bone Fig 5.1 a, b Tumor? Excisional biopsy? 185 Shoulder Girdle and Thoracic Cage Case 79 (▶ Fig 5.2) Case description ● ● Referring physician: radiologist Prior history and clinical question: A 37-year-old woman, otherwise healthy, felt a lump in her left supraclavicular fossa She stated that many years ago she had suffered head and neck sprains in a motor vehicle accident but could recall no further details The radiologist wanted to know the origin of the finger-shaped structure at the junction of the neck and shoulder Malformation? Radiologic Findings The radiograph in ▶ Fig 5.2 shows a finger-shaped bony structure that follows the lateral border of the trapezius muscle and widens from above downward in a trapezoidal pattern A kind of pseudarthrosis is noted at the center of the structure The acromial end of the clavicle shows pencil-like tapering and is surrounded by a club- or cuff-shaped ossification Location As stated above, the ossified structure follows the lateral border of the trapezius muscle The peripheral end of the left clavicle has vanished In terms of vascular anatomy, this area represents a terminal vascular bed with a critical blood supply The fingershaped ossification on the lateral side of trapezius appears connected to the lateral cuff-shaped structure by the clavicular attachment of the trapezius muscle Pathoanatomic Background of the Findings The oblong structure at the lateral junction of the neck and shoulder is composed of solid bone with a cortex and medullary cavity, causing it to resemble a finger The bony cuff around the tapered peripheral clavicle is also composed of solid bone Assignment to a Possible Basic Entity ▶ Normal variant or malformation? A kind of accessory bone called the os omovertebrale (Latin om = shoulder) located at the junction of the shoulder and lateral neck has been described in the literature.17 It is known to occur in Klippel–Feil syndrome The finger-shaped bony structure could very well be an os omovertebrale, but the cervical vertebrae that appear in the radiograph not show any gross signs of Klippel–Feil syndrome such as blocking Could this be due to trauma? The ossifications could be a result of old myositis ossificans (heterotopic ossification) caused by trauma This would be consistent with the patient’s history ▶ Inflammation or tumor? This diagnosis would not be consistent with the clinical presentation or radiologic findings Synopsis and Discussion The finger-shaped structure most likely represents a mature form of myositis ossificans traumatica The pseudarthrosis is explained by its location, which is the site that undergoes the greatest deformation when the arm is raised and lowered A diagnosis of myositis ossificans traumatica is also supported by the changes in the peripheral clavicle: The trauma probably caused a fracture of the peripheral clavicle or an acromioclavicular joint separation, leading to the development of avascular acro-osteolysis or acronecrosis (see also Case 93), which is a fairly common result of trauma to the peripheral clavicle The “licked candy stick” appearance is considered proof of acro-osteolysis or acronecrosis The club-shaped ossification around the tapered peripheral end of the clavicle probably also represents a mature myositis ossificans ▶ Fig 5.3 a–c illustrates another case of heterotopic ossification (myositis ossificans traumatica) in the shoulder girdle The 62year-old patient suffered a serious shoulder injury with rupture of the left acromioclavicular joint, as documented on the posttraumatic radiograph in ▶ Fig 5.3 c With a 10-kg weight held in each hand, the distance between the superior border of the coracoid process and the inferior border of the clavicle is two times greater on the left side than on the right—a sure sign of a Tossy stage III acromioclavicular joint rupture At follow-up year later, a radiograph of the left acromioclavicular joint (▶ Fig 5.3 b) showed bone formation between the left clavicle and coracoid process that followed the exact course of the coracoclavicular ligament and represented heterotopic ossification or myositis ossificans traumatica This case has another distinctive feature, however: the examining orthopedist noticed a ridgelike or barlike ossification at the superior border of the right scapula (arrow in ▶ Fig 5.3 c), which he could not identify That feature was most likely a congenital (variant) ossification of the transverse scapular ligament, which shows a familial occurrence (Giordano 1962, cited in Freyschmidt’s “Köhler/Zimmer” 2001).17,41 Final Diagnosis Fig 5.2 Malformation? 186 Posttraumatic myositis ossificans in the lateral portions of the trapezius muscle and surrounding an area of acro-osteolysis (avascular necrosis) at the peripheral end of the clavicle Shoulder Girdle and Thoracic Cage Fig 5.3 a–c Posttraumatic myositis ossificans in a 62-year-old man Comments Linking together the three key radiologic findings in this case (soft-tissue ossifications in the lateral portion of the trapezius and around the peripheral end of the clavicle, plus acro-osteolysis at the peripheral end of the clavicle) based on their topographic relationship to one another and to the patient’s history is sufficient to identify this condition as myositis ossificans and distinguish it from an os omovertebrale 187 Shoulder Girdle and Thoracic Cage Case 80 (▶ Fig 5.4) Case description ● ● Referring physician: pediatrician Prior history and clinical question: A 3-year-old girl presented with a painful, palpable, erythematous swelling over the left clavicle The swelling correlated radiographically with an area of gross bone destruction Radiologic Findings The radiograph (▶ Fig 5.4 a) demonstrates gross bone destruction in the medial half of the left clavicle The defect is bridged by a cuff of new bone formation The CT scan (▶ Fig 5.4 b) displays the spatial relationships and shows the soft-tissue swelling over the affected site Location The destructive process has destroyed the entire medial portion of the clavicle Its epicenter is in the medullary cavity, indicating that it may have originated from that area Pathoanatomic Background of the Findings The attenuation values of approximately 50 HU measured in the destructive process may stem from a solid tumor Assignment to a Possible Basic Entity ▶ Inflammation? The clinical presentation is suspicious for a nonbacterial inflammatory process, given the absence of systemic signs One possibility is chronic nonbacterial osteomyelitis (CNO; Fig 5.4 a, b Osteomyelitis? Tumor? Fig 5.5 a–c Two cases of fibrous dysplasia for comparison 188 see Case 82 and Case 153), which is typically manifested in the clavicle and often has few systemic signs This diagnosis is unlikely, however, because CNO generally runs a slower course in which bone destruction and proliferation, predominantly involving the cancellous bone, occur simultaneously and thus produce concurrent radiologic changes ▶ Tumor or tumorlike lesion? The bone destruction affecting the full thickness of the bone and the cuff of periosteal new bone formation are consistent with Langerhans-cell histiocytosis or eosinophilic granuloma Synopsis and Discussion The young age, minimal systemic signs, local clinical findings, and radiologic pattern of change in the left clavicle are fully consistent with an osseous focus of Langerhans-cell histiocytosis (eosinophilic granuloma) Other cases that started with a single- organ involvement are presented in ▶ Fig 2.17 in Case 9, ▶ Fig 3.13 and ▶ Fig 3.14 in Case 24 and ▶ Fig 4.12 in Case 55) Langerhans-cell histiocytosis is classified as a tumorlike disease of bone The differential diagnosis includes the following: ● CNO (see section Inflammation? above) ● Primary bone tumor such as Ewing sarcoma or osteolytic osteosarcoma This can ultimately be excluded only by biopsy These entities, while rare, occur in the clavicle (Langerhans-cell histiocytosis in approximately 4% of cases, Ewing sarcoma in 2%, osteosarcoma in less than 1%) The diagnosis in the present case was confirmed by biopsy To aid in the differentiation of lytic clavicular lesions, two cases of fibrous dysplasia are illustrated in ▶ Fig 5.5: a 39-year-old man (a, b) and a 22-year-old man (c) The lesions are only slightly Shoulder Girdle and Thoracic Cage expansile, corresponding to Lodwick grade IB, and show some degree of ground-glass opacity; they were detected incidentally Age, radiology, and lack of clinical manifestations support a diagnosis of fibrous dysplasia (see also Case 7, Case 20, Case 36, Case 37, Case 112, and Case 139); biopsy is unnecessary Unilocular or simple bone cysts are excluded from the differential diagnosis because they practically never occur in the clavicle The groundglass appearance noted above is also inconsistent with this diagnosis In any case, the differential diagnosis of a “unilocular or simple bone cyst” is meaningless from an oncologic standpoint Surgical procedures are unnecessary in both cases, provided the lesions are clinically silent Comments Langerhans-cell histiocytosis (eosinophilic granuloma) should be the first diagnosis considered in a small child with an osteolytic lesion in the clavicle that has no systemic manifestations but very aggressive radiologic features On the other hand, well-circumscribed lytic lesions with a Lodwick grade I pattern that are detected incidentally in young adults are more consistent with fibrous dysplasia Final Diagnosis Focus of Langerhans-cell histiocytosis in the clavicle 189 Shoulder Girdle and Thoracic Cage Case 81 (▶ Fig 5.6) Case description ● ● Referring physician: radiologist Prior history and clinical question: A 64-year-old man had a tense, painful swelling above the right acromioclavicular joint The patient claimed to have had shoulder problems for many years MRI of the right shoulder showed unusual “cystic” structures in the region of the acromioclavicular joint and adjacent clavicle Ganglia? Location The pathologic changes described above have their epicenter in the region of the destroyed acromioclavicular joint Pathoanatomic Background of the Findings The multicentric hyperintense lesions are proton-rich and probably correspond anatomically to loculated synovial or bursal spaces Assignment to a Possible Basic Entity Radiologic Findings T1w MRI (▶ Fig 5.6 a) reveals a slightly inhomogeneous, hypointense mass in the region of the right acromioclavicular joint The mass shows multicentric, inhomogeneous high signal intensity in water-sensitive sequences (▶ Fig 5.6 b–h) ▶ Fig 5.6 d clearly shows that some of the hyperintense lesions are located in the peripheral portions of the clavicle and ▶ Fig 5.6 e–h demonstrates that they are located partly above and partly below the acromioclavicular joint, which is no longer delineated The rotator cuff shows marked degenerative changes Effusion is present in the glenohumeral joint The contralateral side, imaged a few days later (▶ Fig 5.6 i–k), shows regressive changes in the acromioclavicular joint plus degenerative changes in the rotator cuff Fig 5.6 a–k Soft-tissue tumor? 190 ▶ Trauma? No history of acute trauma, but possibly chronic trauma ▶ Inflammation? Yes (see Pathoanatomic Background of the Findings above) ▶ Tumor? No, at least not a solid tumor ▶ Regressive change? Yes, the rotator cuff is damaged and may well be responsible for the other changes Synopsis and Discussion This case, involving gross cystic changes in the right acromioclavicular joint, appears to be extremely rare In a search of the radiologic literature, we found only one publication,42 a retrospec- Shoulder Girdle and Thoracic Cage tive review of nine cases, which was helpful in understanding our case These authors related the pathogenesis of acromioclavicular joint cysts to a large rotator cuff tear, allowing effusion to extend from the glenohumeral joint through the tear into the acromioclavicular joint, eroded inferiorly by impingement, and then perforated outward from that joint Resorptive changes in the adjacent bones of the acromioclavicular joint are probably pressure-induced The inhomogeneity of the cystic changes can be explained by primary or secondary chondrocalcinosis or by small deposits similar to rice bodies Histologically, the cystic lesions were apparently synovial cysts, known also as ganglia All but one of the patients reviewed by Vogel et al42 were over 60 years of age To prove the spatial connections between the glenohumeral joint on the one hand and the cystic structures in the acromioclavicular joint and its surroundings on the other, we would have liked to inject radiographic contrast medium into the palpable pseudotumor or glenohumeral joint, but the patient declined This arthrogram would have shown leakage of contrast medium from the glenohumeral joint into the subdeltoid-subacromial bursa and from there into the acromioclavicular joint—a phenomenon known as the Geyser sign.42 Reportedly this sign confirms a longstanding full-thickness rotator cuff tear Craig (1984) 43 describes the pathogenic mechanism as follows: The muscle belly of the supraspinatus tendon lies directly below the acromioclavicular joint Only a thin layer of fat and the bursa separates the joint space from the rotator cuff On elevation of the arm, the rotator cuff glides directly beneath the anterior acromion, the coracoacromial arch, and the acromioclavicular joint A positive Geyser sign requires inferior capsular erosion of the acromioclavicular joint This erosion may result from a gradually enlarging osteophyte on the acromioclavicular joint due to posttraumatic or degenerative change, or there may be mechanical erosion of the undersurface of the acromioclavicular joint by friction from the humeral head—or both When the patient tries to elevate the arm, the humeral head may engage against the anterior acromion and acromioclavicular joint, increasing the impingement effect If the rotator cuff tear enlarges, this weakens the function of the external rotators more than that of the internal rotators, and the greater tuberosity is shifted medially and superiorly, causing further trauma to the undersurface of the acromioclavicular joint The articular cysts may also be interpreted as arthroceles (similar to a Baker cyst) The differential diagnosis includes synovial chondromatosis (see Case 72), which could also explain the rotator cuff tear, but the clinical presentation (patient age, long history, coexisting degenerative changes on the contralateral side) is more consistent with acromioclavicular cysts resulting from leakage in the rotator cuff and in the undersurface of the acromioclavicular joint Preliminary Diagnosis Arthrocele-like acromioclavicular joint cysts with pseudotumorlike extension into the adjacent extra-articular soft tissues and clavicle secondary to a longstanding rotator cuff tear Comments A glenohumeral joint effusion may spread through a rotator cuff tear and perforated into the acromioclavicular joint, producing a pseudotumor in that joint 191 Shoulder Girdle and Thoracic Cage Case 82 (▶ Fig 5.7) Case description ● ● Referring physicians: radiologist, surgeon Prior history and clinical question: A 21-year-old woman had a 3year history of a recurrent, moderately painful swelling over the left clavicle She had no significant systemic signs Her C-reactive protein level and erythrocyte sedimentation rate were slightly elevated Radiologic findings raised suspicion of osteomyelitis or a neoplasm (e.g., Ewing sarcoma) Radiologic Findings The radiograph suggests that medial and central portions of the clavicle have been resorbed and replaced by radiolucent new bone, which appears to have twice the width of the original clavicle (▶ Fig 5.7 a) Scintigraphy shows greatly increased uptake in the affected region (▶ Fig 5.7 b, c) The CT scans in ▶ Fig 5.7 d–f show inhomogeneous new bone formation and soft-tissue swelling on the anterior and posterior sides of the clavicle Pathoanatomic Background of the Findings Findings indicate an active or florid process that has destroyed the original clavicle and replaced it with irregular periosteal new bone Further differentiation between, say, a neoplastic or chronic inflammatory process cannot be made based on imaging findings alone Assignment to a Possible Basic Entity ▶ Inflammation? Very likely, occurring in a primary chronic form This is supported by the clinical presentation (long history, slightly elevated inflammatory markers) and radiologic findings (large volume of new bone, no gross sequestra as in acute osteomyelitis) Fig 5.7 a–g Osteomyelitis or a small- and round-cell tumor? 192 Shoulder Girdle and Thoracic Cage Fig 5.8 a–k Pustular enthesio-osteitis in an 11-year-old girl ▶ Tumor? Possibilities would include a small and round-cell tumor (e.g Ewing-sarcoma), a bone-forming tumor (e.g., osteosarcoma, osteoblastoma) or a tumorlike lesion as in the reparative phase of Langerhans-cell histiocytosis (see also Case 80) Synopsis and Discussion When we consider the location of the process along with the clinical and radiologic findings, we are most likely dealing with a primary, chronic nonbacterial osteitis or osteomyelitis (CNO) This is known to occur as pustular arthro-osteitis (known more precisely as pustular enthesio-osteitis, PEO) in a setting of pustulosis palmoplantaris, but that condition is most common in children and adolescents We may also be dealing with an early stage of chronic recurrent multifocal osteomyelitis (CRMO), but we cannot realistically make this diagnosis at present because we not yet know whether additional foci are present CNO or CRMO is not a bacterial osteomyelitis but an autoimmune disease characterized by a nonspecific, reactive inflammation of the bone (osteitis) that is currently included in the category of rheumatoid diseases It is frequently associated with pustulosis palmoplantaris We tend to regard CNO or CRMO as a special form of pustular arthro-osteitis or enthesio-osteitis (see also Case 39, Case 40, Case 48, Case 49, Case 84, Case 97, and Case 145) The osseous changes in pustular arthro-osteitis or enthesio-osteitis occur predominantly at the entheses, or zones of attachment of tendons, ligaments, joint capsules, and periosteum to bone Osteitis develops in the underlying bone Imaging shows a mixed pattern of bone destruction and proliferation, which is best appreciated on 193 Shoulder Girdle and Thoracic Cage radiographs and CT scans Since the entheses are predominantly affected, the term pustular enthesio-osteitis (PEO) would be more appropriate than pustular arthro-osteitis (PAO) We feel that the more widely used term “SAPHO” is too vague and potentially misleading (see Case 40) In the present case, further questioning of the patient about her history showed that she did have pustulosis palmoplantaris This made it an easy matter to classify the clavicular changes as pustular arthro-osteitis or enthesio-osteitis At the urging of the surgeon, a CT-guided percutaneous biopsy was finally performed (▶ Fig 5.7 g) It yielded a nonspecific, nongranulocytic osteitis and a sterile smear, which confirmed our presumptive diagnosis ▶ Fig 5.8 illustrates a case that could still be classified as CRMO but ultimately represents pustular enthesio-osteitis, as we later learned that the 11-year-old girl had a severe pustular form of psoriasis Her symptoms began with a painful swelling over the left sternoclavicular region with no pronounced systemic signs The radiograph (▶ Fig 5.8 a) was interpreted as negative The swelling regressed over the next weeks but recurred weeks later A radiograph at that time (▶ Fig 5.8 b) showed definite destruction of the medial portions of the clavicle, and new bone formation was apparent at months (▶ Fig 5.8 c) CT (▶ Fig 5.8 d–g) showed a shell or cuff of periosteal new bone around the area of clavicular destruction, which formed a visible bulge Scintigraphy at that time showed significant tracer uptake in the left clavicle (▶ Fig 5.8 h) and abnormal uptake in the right tibial metaphysis 194 (▶ Fig 5.8 i) Radiographs showed only a minor structural irregularity proximal to the anteromedial epiphyseal plate (arrows in ▶ Fig 5.8 j, k) Langerhans-cell histiocytosis and CRMO were finally included in the differential diagnosis, although the tibial finding was considered to be more consistent with CRMO Finally an open excisional biopsy was performed, which indicated a nongranulocytic and thus nonbacterial osteitis Nevertheless, the patient was still placed on long-term antibiotic therapy, which was of no benefit Anti-inflammatory therapy was finally instituted and provided significant symptomatic relief Further details on CRMO including its diagnostic criteria are presented in Case 153 Final Diagnosis Pustular arthro-osteitis (PAO) or pustular enthesio-osteitis (PEO) with involvement of the left clavicle Comments Mixed destructive and proliferative changes in the clavicle of a young patient should raise suspicion of CNO or, if pustulosis palmoplantaris is present, of pustular arthro-osteitis (PAO) or enthesio-osteitis (PEO) The presence of additional lesions at other sites (e.g., the spine or the metaphyses of long bones) is more suggestive of CRMO Lower Limb Case 158 (▶ Fig 7.48) This gives us an apparent underlying entity, and we must consider that other possibilities are unrealistic Case description ● ● Referring physician: radiologist Prior history and clinical question: An 82-year-old woman complained of occasional pain and pressure sensation in her left lower leg She was hospitalized for extensive inflammatory and ulcerative changes in that region Radiographs showed a large, partially calcified mass, and biopsy was performed on the presumed calcified tumor Histologic examination was inconclusive, and the case was referred for consultation Radiologic Findings The postoperative radiographs (▶ Fig 7.48 a, b) show an extensive, elongated, partially calcified mass projected over the tibia and fibula The presence of a drain one day after open biopsy is also noted The preoperative radiograph was unavailable, but we assume that it did not look much different from the postoperative film The preoperative CT images (▶ Fig 7.48 d, e) show a mass with predominantly shell-like calcifications located between the tibia and fibula It has a heterogeneous interior density but is partially isointense to muscle and also contains fluid Numerous clumps of calcification are visible within the lesion In the MR image (▶ Fig 7.48 c), the mass is mostly devoid of signal but contains focal hyperintensities of fluid signal intensity The mass did not enhance after IV contrast administration Location The mass is related anatomically to the tibialis anterior muscle Pathoanatomic Background of the Findings Because the mass is located in the region of the tibialis anterior and appears to have replaced the muscle, it is reasonable to ask whether it represents a postnecrotic state with metaplastic and dystrophic calcifications or ossifications To answer this question, we need more information on the patient’s history since a muscle does not become necrotic without good cause When questioned, the patient did report that she had sustained a tibial fracture more than 20 years ago She also stated that complications arose, which we interpret as a compartment syndrome 358 Synopsis and Discussion When we review the main features of this case—a large, inhomogeneous calcified mass with fluid-filled cavities that is located in the region of the tibialis anterior muscle and has replaced it—we must consider the possibility of antecedent trauma Unless we had asked the patient specifically about a possible trauma history, this case would not have been solved, although a tumor with flocculent necrotic calcifications, for example, would have been unlikely on radiologic grounds alone Why would a tumor of this size, such as soft-tissue sarcoma, conform to the boundaries of the tibialis anterior compartment and completely replace the muscle? The absence of IV contrast enhancement would also be unusual for a tumor The correct term for this lesion is calcific myonecrosis This rare disease occurs almost exclusively in the lower limbs, is trauma-induced, and is usually mistaken for a tumor It results from cystic degeneration of the muscle, giving rise to a painful, calcifying mass that is often detected many years after an injury (?) or may take many years (up to 65) to fully develop (?) This contrasts with myositis ossificans (see Case 156), which usually becomes symptomatic within to weeks after an injury Patients with calcific myonecrosis often have a prior history of treatment for a compartment syndrome and/or a vascular lesion following the internal fixation of a fracture, for example, especially when a closed technique was used Radiographs typically show plaquelike calcifications in the periphery of the mass with possible erosion of the adjacent bone The mass contains fluid-filled spaces surrounded by a calcified pseudocapsule.64,65 In our case the fluid component was less pronounced ▶ Fig 7.49 illustrates another case of calcific myonecrosis The 47-year-old man had an infected left total hip replacement following a number of previous operations The last operation revealed fluid-filled spaces but showed no definite signs of infection An unusual feature of this case is that it involved all three compartments in the thigh, apparently because each of the previous operations had caused trauma leading to intracompartmental hemorrhage In each case there were no radiologic or histologic signs of myositis ossificans Lower Limb Fig 7.48 a–e Calcified soft-tissue tumor? 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initial imaging arthro-osteitis, pustulotic 102, 102 – resorption – clavicle 188 arthrocele, in form of Baker cyst 317, –– decreased by bisphosphonates 233 – diagnostic algorithm –– osteoclastic 37 – intervertebral disk herniation vs 62 –– primary hyperparathyroidism 315 – malignant, giant osteoma vs 51 –– radiation-induced 46, 46 – non-Hodgkin lymphoma 68, 68 arthropathy –– vanishing bone disease 131 – primary 3, 188, 220 – See also avascular necrosis – diabetic, initial imaging – spotty demineralization 95–96 –– initial imaging study – clavicle and ribs 216 – hemochromatosis 353, 353 – woven 20, 27 – WHO classification 22 –– trauma-induced 216, 216 – neurogenic, initial imaging –– ground-glass pattern (CT), see breast cancer, bone metastases differ- – clavicle, posttraumatic myositis ossi- – pyrophosphate, see chondrocalcino- imaging A acetabular labrum, tear 164, 164, 165 acetabulum, osteoid osteoma 176, 177 acro-osteolysis (acronecrosis) 44, 110, 186, 216 ficans with 186–187 317 arthrocele-like cysts, acromioclavicular joint 190, 190 sis ground-glass pattern –– Paget disease 29–30 ential diagnosis 86, 89, 125, 125, 183, 239 – neuropathic 286 aseptic necrosis (Friedrich disease) 227 –– perfusion changes 27 Brodie abscess 178, 198 acromioclavicular joint aspirin 113, 176, 336 bone bruise 346, 346 brown tumor of hyperparathyroidism – cysts, with pseudotumor-like exten- atlas (C1 vertebra), melorheostosis 48, bone cyst 129 – diagnostic features 315–316 – aneurysmal, see aneurysmal bone – forearm 262, 262 sion 190, 190 – rupture, traumatic myositis ossificans after 186, 187 49–50 autoimmune disease, chronic nonbacterial osteomyelitis 193 acrophysis 233, 274 avascular necrosis 129, 170 age – clavicle end 186, 186 cyst – juvenile, see juvenile bone cyst – old posttraumatic, in iliac wing 132, 132 – osteoid osteoma 178, 336 – femoral head, see femoral head – unicameral 305–306, 329 – Paget disease 250 axial skeleton, spotted bone disease –– fibrous dysplasia vs 319, 321 age-related atrophy (osteopoikilosis) 79, 80 – hand 284, 284 – lower limb 315, 315 – rib 209, 210 bull’s head sign 199, 225, 225 bursitis, calcifying, see calcifying bursitis bone in bone pattern 233 – of skull 41, 41 axis (C2 vertebra) bone island 50 – primary hyperparathyroidism vs 44, – melorheostosis 48, 49–50 bone marrow C – metastases from prostate cancer 95, – edema 10 Caffey disease (infantile cortical hyper- 44 alkaline phosphatase, elevated – osteomalacia 149 95 – spotty demineralization 95–96 – islands in distal femoral metadiaphysis 299, 299 – Paget disease 29–31, 323–324 – necrosis aneurysmal bone cyst 115, 137 ostosis) 295, 296 calcific myonecrosis, tibial anterior muscle 358, 359–360 – distal femoral metaphysis 312, 312 B –– circumscribed of lateral mass of sac- – forearm 263 bacillary angiomatosis 90 – perfusion disorders, initial imaging – intraosseous lipoma vs 312, 312 – tuberculous spondylitis vs 90 – transient edema 4, 180, 181 – hip joint 157, 157, 158 – juvenile bone cyst vs 137 Baker cyst 317, 317 –– migrating, femoral epimetaphy- – popcorn-like pattern 253, 254 – non-Hodgkin lymphoma of scapula basic entities (nosologic groups) 11 vs 202, 202 – sacrum 115, 115 – secondary 115, 263 rum 143, 143 – hand joints 157, 157 – soft-tissue, renal osteodystro- –– pathogenesis 181 benign intraosseous notochordal cell bone metastases 183–184 calcifying bursitis 255 – criteria not supporting diagnosis – shoulder 234, 234, 235 tumor 54 bisphosphonates 233 angiomatosis 82 – dense metaphyseal bands due – aggressive form 81–82, 82 – femoral neck 183 benign fibrous histiocytoma 308 angioma 82 – See also hemangiomatosis ses 180, 180 calcifications to 232, 232 bizarre parosteal osteochondromatous – bacillary, see bacillary angiomatosis proliferation (BPOP; Nora le- – burned-out, bone resorption 37 sion) 291, 291, 292 of 55–56 – differential diagnosis –– cystic angiomatosis vs 83, 83, 84 phy 157, 158 – trochanteric 183 calcifying discitis, cervical vertebrae 69, 69 –– fibrous dysplasia vs 55, 55, 56 calcifying enchondroma 254, 326 –– in breast cancer 86, 89, 125, 125, – of humerus 253, 253, 254 182, 183, 239 calcifying tendinitis – cystic, see cystic angiomatosis black occiput 46, 46 –– in prostate cancer 195 – pectoralis major 240, 240, 241, 241 – extensively disseminated 84, 85 Blount disease 344, 345 –– meningioma of parietal bone vs 17 – reactive ossifying process due to – metastatic angiosarcoma vs 82 bone –– osteoporosis circumscripta vs 31, 32 – minimal form 84, 85 – cancellous –– osteosclerotic, sphenoid meningio- – pathogenesis/origin 140 –– disseminated focal lesions 82 – regional, see vanishing bone disease –– moth-eaten destruction in non- – skeletal, sclerosing form 82, 82 angiosarcoma 81 – of spleen, bone metastases (spinal) 81, 81 ankle Hodgkin lymphoma 68 – circumscribed nonreactive destruction 37, 38 ma vs 16 –– Paget disease of pelvis vs 125, 125 (forearm) 265, 265 – shoulder 234, 234, 235, 240, 240, 255 – with bone erosion 232, 234, 234, 235, 240, 240, 241, 241 – in angiosarcoma of spleen 81, 81 calcium phosphate 157 – initial imaging study calcium pyrophosphate deposition dis- – location 55 ease, see chondrocalcinosis – erosion – PET-CT calvarium –– calcifying tendinitis or bursitis – spinal, in prostate cancer 95, 95 – age-related atrophy 41 – arthritis 340, 340, 341 with 232, 234, 234, 235, 240, 240, – supplemental imaging study – generalized thickening 29, 29 – hemochromatosis 353, 353 241, 241 bone scintigraphy 2, 183 – holes in 34 – as initial imaging study 3, – osteolytic lesions 29–30 – as supplemental imaging study –– intraosseous epidermoid 34, 35 ankylosing ossifications, DISH 71, 71 anorexia nervosa 153 anticoagulants, old subperiosteal hem- –– multicentric reticulohistiocytosis 287, 287 –– sarcoidosis 285, 286 – hot spots 20, 176, 178, 257 – salt-and-pepper pattern 44, 44 orrhage in ilium 134, 134 – formation, reactive vs tumor 331 – osteoporosis circumscripta 39–40 – thickening, mixed stage Paget dis- apophyseal plate closure 153 – multicentric honeycomb destruc- – Paget disease 30, 39 apple-core sign 169–171 ease 42, 42 tion 86, 89 363 Index cartilage cap, thickness, in chondrosarcoma 200 cartilage columns 270, 274, 280–281 cartilage ulcer, knee 317, 317 cartilage, loss, erosive osteoarthritis of hands 283 cartilaginous exostosis 155–156, 156, 200 chronic recurrent multifocal osteomyelitis (CRMO) 112, 193, 348 – tibial medullary cavity 325, 325 degenerative process, radiologic find- enchondroma protuberans 207, 279 chronic recurrent multifocal periostitis 296 ings 227 deltoid muscle attachment, silent stress clavicle 185 – acro-osteolysis (avascular necrosis) reactions 239, 239 – hands 289, 289, 290 – secondary chondrosarcoma vs 201, 201 deltoid tuberosity, prominent (nor- at end of 186, 186 – acromioclavicular joint cysts with – diagnostic features 289–290 mal) 237, 237, 238 enchondromatosis 259, 270, 282 dens – See also enchondroma – See also osteochondroma pseudotumor-like extension in- – crowded dens sign 105 – bilateral 282, 282 – pedunculated, upper arm 247, 247 to 190, 190 – destruction, gouty arthritis 55, 106 – forearm and humerus 269, 269 – fracture 95 – grade I chondrosarcoma and 303 dense metaphyseal bands, bisphospho- – hands 279, 279, 280–282 – ribs 207, 207 cartilaginous tumor, see chondroma, chondrosarcoma case review 12 cavernous hemangioma of bone, sternum 222, 222 cervical spine/vertebrae, see axis (C2 – end, club-shaped ossification around 186 – fibrous dysplasia 188, 188 – head, anterosuperior subluxation 227 – Langerhans-cell histiocytosis 188, nate-induced 232, 232 desmoid, periosteal 246 – legs 280, 281–282, 282 – polyostotic fibrous dysplasia vs 218– 219 diabetes mellitus, DISH in 71, 71 diabetic osteoarthropathy, initial imag- 188 ing – types/forms 270, 279 endosteal sclerosis 229, 230 – normal variants 185, 185, 186 diagnosis (radiological) entheseal stress 4, 239 – C2–C3 facet joint destruction 105 – primary bone tumors 188 dialysis, renal osteopathy and joint cal- enthesio-osteitis, pustulotic, see pustu- – calcifying discitis 69, 69 – pustular arthro-osteitis (enthesio-os- vertebra) – chondrocalcinosis 107, 107 – DISH 71, 71 – gouty arthritis 105, 106, 108 teitis) 192, 192, 193 teitis (PEO) diaphyseal lesion, distal metaphysis – trauma-induced acro-osteolysis 216, 216 lar arthro-osteitis (PAO)/enthesio-os- cifications 157, 157, 158 connection 267, 267 diffuse calvarial hyperostosis 13, 13 enthesiopathy 71, 239 – degenerative, see degenerative en- – melorheostosis 48, 49–50 clubbing of fingers 294, 294 – osteoblastoma 57, 57 compression fractures – spinous process expansion 55 – benign vs malignant cervical spondylitis 57 – spine 86, 94, 97 chest wall, anterior 223 computed tomography (CT) – diagnostic criteria 71 – trauma-induced 266 – anatomy 224 – advantages – initial imaging study enthesitis – chondrosarcoma 211, 212 – as initial imaging study diffuse plasmacytoma, see multiple – generalized, affecting anterior chest – fibrous dysplasia 209, 210 – as supplemental imaging study 3, 8– – osteoarthritis 227, 227 – psoriatic spondyloarthritis with involvement of 99 – undifferentiated spondyloarthritis 223 chondroblastoma – essential elements 167 – femoral epiphysis 166, 166 na 13, 13 diffuse idiopathic skeletal hyperostosis bra 59, 59 costoclavicular ligament, ligament – stress-induced, upper arm 242, 242, 243 wall 223 myeloma diffuse synovial giant cell tumor (PVNS) 168, 168 – proliferative, pelvic 119, 119 – psoriasis-associated 121, 121 discitis, calcifying 69, 69 –– knee 333, 333 DISH, see diffuse idiopathic skeletal hy- eosinophilic granuloma 31, 32, 57 coracoclavicular ligament, traumatic myositis ossificans 186, 187 – initial imaging study (DISH) 71, 71 – spiral congenital hemangioma, in T1 verte- thesiopathy diffuse hyperostosis cranialis inter- perostosis (DISH) – clavicle 188, 188 disks, see intervertebral disk – differential diagnosis 33, 133, 220 don’t touch me lesions 27, 139, 211– – ilium 133, 133 groove at attachment 185, 185 212, 308, 321, 330 – ribs 213, 213 chondrocalcinosis (CPPD) 69 costs, imaging modalities 10 dorsal patellar defects 317, 317 – scapula 204, 204 – diagnostic findings 105 crowded dens sign 105 double density sign 176, 240 epidermoid, intraosseous (epithelial – hands 297, 297 crystal synovitis, see chondrocalcinosis dysostosis epiphysealis multiplex (epi- – initial imaging study CUP syndrome 68 – spine 105, 107 cyst(s) 10 cyst; epidermoid cyst in bone) 34, 35–36 physeal dysplasia) 160, 160 dysplasia epiphysealis hemimelica 274, epilepsy, syndromic 13 chondroma 171, 270 – acromioclavicular joint 190, 190 – hands 289 – arachnoid, MRI 13, 13 – micronodular/macronodular 171 – Baker 317, 317 – periosteal, see periosteal chondroma – bone, see bone cyst chondrosarcoma 3, 156 – intraneural ganglion 357, 357 edema, bone marrow, see bone marrow – chest wall 211, 212 – posttraumatic, iliac wing 132, 132 edema-like hyperintensity 10 – development from enchondro- – subchondral (geodes) 283–284 edema-like signal cystic angiomatosis 82, 83, 83, 86, 140 – femoral neck 175–176 erythema nodosum 286 – diagnostic criteria 83–84 – humeral head region 234, 234 Ewing sarcoma – fatty defects 86, 89 – lower limb 301, 303, 318, 334, 336, exostosis 155–156, 207 ma 254–255 – exostotic, see exostotic chondrosarcoma 274, 275 epiphyseal dysplasia, systemic 160, 160 epiphyseal plate, see growth plate(s) E epithelial cyst (epidermoid cyst in bone) 34, 35–36 Erdheim–Chester disease, see lipoid granulomatosis – grade I – femur 86, 87, 309, 309 –– hands 290, 290 – multiple myeloma vs 86, 87–88 – sacral mass 111, 111, 112–113 –– lower limb 302, 302, 326 – spine and pelvis 86, 87, 140, 141– – spine 61, 86, 99, 102 – multiple 200, 207 142 336 – See also cartilaginous exostosis, osteochondroma – talus 340, 340 – turret 292 –– upper arm 254, 255 – splenic involvement with 83, 83 – upper arm 242, 242 exostotic chondrosarcoma – primary 303 – vascular malformation vs 310 enchondroma, see enchondromatosis – iliac wing 155, 155, 156 – rib 211, 211 cystic or cystlike lucency 10 – calcifying, see calcifying enchondro- – scapula 200, 200 – scapula 200, 200 cystic skeletal angiomatosis 82 –– radiological signs 254, 255 chordoma 54, 62 chronic expanding hematoma 135 chronic nonbacterial osteitis (CNO) 111, 192, 193 – See also osteomyelitis, chronic nonbacterial ma – chondrosarcoma development – secondary 200, 200, 207–208 D from 254–255 F – exophytic 201, 201 factitious myositis ossificans 25, 25 degenerative arthritis, initial imaging – hands 279, 283, 289 factitious trauma 25 degenerative enthesiopathy 179 – metaphyseal 167, 167 Fairbank disease (systemic epiphyseal – greater trochanters 183, 183 – protuberant, see enchondroma pro- – productive fibro-ostosis due to 178, 178 364 – scapular region 195 tuberans – ribs 207, 208, 218 dysplasia) 160, 160 fallen fragment sign 10, 306, 306 familial colonic polyposis 26 Index fat, tumor diagnostic exclusion and 67, 143, 173, 211 fatty tissue, congenital disorder, Nasu– Hakola disease 278 feet – Jansen type of metaphyseal dysplasia 271, 271 – multicentric reticulohistiocytosis 287, 287, 288 fibrogenesis imperfecta ossium 147 fracture(s) fibrolipomatous hamartoma 273 – avulsion 151 fibroma, nonossifying, in distal tibial –– iliac spine 149, 151, 151 metadiaphysis 329, 329 fibrous dysplasia 24, 27, 30, 94, 209, 259 – cartilaginous components in C5 vertebra 55, 55, 56 –– ischial tuberosity 153, 154 – compression, see compression fractures – healing, rapid acceleratory phenomenon 95 – changes with age 259, 261 – initial imaging study 4, 147 – multicentric reticulohistiocytosis 288 granulomatosis, lipoid, see lipoid granulomatosis gray cortex 242, 257 greater trochanters – calcifying bursitis around 183 – insertional tendinopathy 183, 183 ground-glass pattern (fibrous dyspla- – sarcoidosis 285, 285 – chest wall 209, 210 – insufficiency 147 femoral head – clavicle 188, 188 –– osteomalacia 147, 148–150 – clavicle 188, 188 – avascular necrosis 160, 167 – diagnostic criteria 94, 209, 259, 319 – osteoporotic, at thoracolumbar junc- – lumbar spine 94 –– diagnostic features 181 –– See also ground-glass pattern –– migrating transient bone-marrow – forearm 264, 264 – pathological, C2 95 – rib 209, 209, 218, 218 – frontal bone 20, 20 – recurrent 147, 148 – skull 20, 27 – hyperostosis of inner table of skull – spontaneous – sphenoid bone 95, 95 –– proximal humerus 255, 255 – tibia 319, 320 – intertrochanteric region 308 –– ribs 213, 215 growth plate(s) – lumbar spine 92, 92, 93 – stress, see stress fractures – spherical (acrophysis) 274 – oligo-ostotic, lower limb, brown tu- Friedrich disease 227 – stress effect 267, 267, 268 frontal bone – stress-induced displacement (radi- edema vs 180, 181 – erosion, synovial osteochondromatosis 170, 170 – flattened in epiphyseal dysplasia 160, 160 – terminal vascular bed and 182 – transient perfusion defect 182, 182 vs 14 mor vs 315, 315 tion 97, 98 sia) 55, 259 – proximal radius 259, 261 femoral neck – Paget disease vs 27, 30 – factitious myositis ossificans 25, 25 – atypical herniation pits 172, 172, – parietal bone 27, 28 – fibrous dysplasia 20, 20 growth rings 233 G H hamartoma, giant notochordal, see 173 – calcifications 183 – edema-like sign 175–176 us) 267, 267 – PET scan – polyostotic, see polyostotic fibrous dysplasia – ribs 209, 209, 210, 218, 218 ganglion cyst, intraneural 357, 357 – skull 20, 20, 30 ganglion, intraosseous 62, 62 – juvenile bone cyst 305, 305, 306 – sphenoid bone 95, 95 Garré osteomyelitis 16, 198–199 hamartomatous osteoma 25, 25 hand(s) 271 – erosion, synovial osteochondromatosis 170, 170 giant notochordal hamartoma – multicentric herniation pit 164, 164 – sphenoid meningioma vs 16 Gaucher disease, initial imaging – normal variant 172, 172, 173 – tibia 319, 320 Geyser sign 191 – age-related atrophy 44, 44 – osteoid osteoma 175, 175, 176 – trauma-induced regressive cystic giant cell tumor – brown tumor of hyperparathyroid- – osteosarcoma 120, 120 transformation 264, 264 – sparse trabeculae 172, 172, 173 – unicameral bone cyst vs 319, 321 – symmetrical “erosions” 172, 172, – with regressive changes 138, 138, 173 femur, see intertrochanteric region – aneurysmal bone cyst (distal metadiaphysis) 312, 312 – cortical osteoid osteoma (anterior diaphysis) 304, 304 – cystic angiomatosis 309, 309 – epiphysis 139 fibular nerve, intraneural ganglion cyst 357, 357 finger(s), see hand(s) – enchondroma protuberans 289, 289, 290 – gigantism, macrodystrophia lipomatosis 273, 273 – brown tumor of hyperparathyroidism vs –– forearm 262, 262, 263 – chondroma 289 –– lower limb 315, 315 – cystic lesions, differential diagno- – PET scan – tenosynovial, see pigmented villonodular synovitis (PVNS) giant notochordal hamartoma 51, 53, 53, 54 – enchondroma protuberans 289, 289, –– distal lateral, normal variant 342, – Nora lesion (BPOP) 291, 291, 292– – finger, macrodystrophia lipomato- placement 346, 346 – gouty tophus (juxta-articular portion) 313, 313, 314 – islands of red marrow (distal metadiaphysis) 299, 299 – metachronous myositis ossificans 355, 355 – metaphysis sis 273, 273 – epiphyseal dysplasia 160, 160 flowing candle wax appearance 4, 48, glenohumeral joint, in acromioclavicu- – erosive/destructive osteoarthri- 124, 230–231 lar joint cysts 191 GNAS-1 gene 20, 85, 94, 308 – gout 297–298, 298 focal fibrocartilaginous dysplasia 344, Gorham–Stout disease, see vanishing – gouty arthritis 283, 284 344 focal hematopoietic hyperplasia 23, 24 focal Langerhans-cell histiocytosis, see eosinophilic granuloma bone disease Gorlin–Goltz syndrome, initial imaging – macrodystrophia lipomatosis with – carpal involvement 297–298, 298 fibro-osseous lesion 308 – intertrochanteric region 307, 307 – pelvis 138, 138 – ribs 211, 211 fibro-ostosis, productive, due to degenerative enthesiopathy 178, 178 fibrocartilaginous dysplasia, focal 344, 344 sia 271, 271 – joint calcifications 157, 157, 298 – diagnostic findings 105 – shaft, stress fracture 300, 300 – grade I chondrosarcoma 290, 290 – Jansen type of metaphyseal dyspla- gout 168 – brown tumor (primary hyperpara- – sclerotic lesions 119–120 tis 283, 283 fluorosis, initial imaging forearm 262 edema 180, 180 282 – localized (upper limb) 273 –– enchondroma 167, 167 – migrating transient bone-marrow 290 – enchondromatosis 279, 279, 280– – osteolytic lesions 283, 283, 285 –– fracture, deformity after 232, 233 –– intraosseous lipoma 311, 311 ca 274, 274, 275 giant osteoma, T11 vertebra 50, 51 gigantism 293 279 – dysplasia epiphysealis hemimeli– enchondroma 279, 283, 289 – grade I chondrosarcoma 290, 290 342 sis 283–284, 289, 289 – developmental abnormalities 272, – diagnostic triad 54 –– chondroblastoma 166, 166 –– stress-induced destruction and dis- ism 284, 284 – chondrocalcinosis 297, 297 finger gigantism 273, 273 – DISH association 71, 71 – melorheostosis 229, 229 – enchondromatosis 269, 269 – initial imaging study – multicentric reticulohistiocyto- – reactive ossifying process, calcifying – knee 313, 313, 314 thyroidism) 262, 262 tendinitis 265, 265 – stress-induced epiphyseal plate cartilage displacement 267, 267 – trauma-induced regressive cystic transformation of fibrous dysplasia 264, 264 foreign-body reaction, epidermoid cyst after trauma as 34 Forestier disease, see diffuse idiopathic skeletal hyperostosis (DISH) sis 287, 287 gouty arthritis – Nasu–Hakola disease 277, 277 – hands 283, 284 – Nora lesion (BPOP) 291, 291, 292 – spine 105, 106, 108 – pulmonary hypertrophic osteoarthr- gouty tophus 283 – femur and tibia (juxta-articular) 313, 313, 314 granuloma – eosinophilic, see eosinophilic granuloma – in sarcoidosis 285–286 opathy 294, 294, 295 – renal osteodystrophy with erosive spondylopathy 110, 110 – rheumatoid arthritis 288, 288 – sarcoidosis 285, 285, 286 – spotted bone disease (osteopoikilosis) 80, 80 365 Index – synovial osteochondromatosis 297, 297 head injury – enchondromatosis 269, 269 – clinical evaluation 12 – proximal – epicenter of lesion 11 –– osteoid osteoma 243, 243 – lesion localization 10 sis 287, 287, 288 – rheumatoid arthritis 288, 288 – epidermoid cyst after 34, 36 –– Paget disease 250, 251–252 – pathoanatomic background 10 – sarcoidosis 285, 285, 286, 286 – ossified subdural hematoma 14 –– spontaneous fracture 255, 255 – solitary, bilateral or multiple/disse- – spinal, see spinal entheses and joints, hemangioma 310 – solitary pedunculated osteochondro- – cavernous, sternum 222, 222 – differential diagnosis 17, 18, 168 ma 247, 247, 248 – stress-induced enthesiopathy 242, –– meningioma of parietal bone vs 17, 19 242, 243 minated lesions 11 imaging modality diseases – swellings, in renal osteopathy 157, – See also individual modalities 157 – costs 10 – tumors, initial imaging study hyperintensity, ill-defined 10, 145 – selection juvenile bone cyst 137 –– metastastic angiosarcoma vs 82 hyperostosis imaging strategies – characteristic features 294, 305–306 –– vascular malformations vs 310, 351, – bisphosphonate-induced 232, 233 – follow-up imaging 10 – iliac wing 132–133, 136, 136, 138 – inner table of skull 13, 13, 15–16 – initial imaging study 3, – in femoral neck and intertrochanteric 352 – vertebral 59, 59, 222 – ivorylike, in ribs 205, 205, 206 – supplemental imaging study hemangiomatosis 310 – noncongenital, causes 119 immunocompromised patients, chronic – See also angiomatosis – stress-induced, anterior tibial mar- – cystic, see cystic angiomatosis 257 – metastastic angiosarcoma vs 82 – tibial, classification 339 incidental findings 12 – pelvis 140, 141–142 hyperostosis triangularis ilii 117 infantile cortical hyperostosis 295, 296 – vascular malformations vs 310 hyperostotic changes, proliferative en- inflammatory Andersson lesion 103 hemochromatosis 4, 160 thesitis of pelvis 119, 119 region 305, 305, 306 – non-Hodgkin lymphoma of scapula hematogenous osteomyelitis 257, gin 338, 338, 339 hematopoietic hyperplasia 173, 211 inflammatory bone diseases, initial imaging hyperostotic spondylosis deformans, vs 202 – nonossifying fibroma in distal tibial metadiaphysis vs 329, 329 K Klippel–Feil syndrome 186 knee, see lower limb – articular involvement 353, 353 see diffuse idiopathic skeletal hyper- inflammatory lesions/changes 257 hemophilic joint disease, initial imag- ostosis (DISH) – traumatic myositis ossificans and 75 – cartilage ulcer 317, 317 interphalangeal joints, multicentric re- – gout 313, 313, 314 ing hyperparathyroidism hemophilic pseudotumors 135 – initial imaging study hemorrhage, old subperiosteal, in – primary 263, 315 ilium 134, 134 herniation pit 162, 162 ticulohistiocytosis 287, 287 intersternocostoclavicular ossification, –– age-related atrophy vs 44, 44 see sternocostoclavicular hyperosto- –– brown tumors, see brown tumor of sis (SCCH) – atypical, femoral necks 172, 172 hyperparathyroidism – definition 162 –– diagnostic features 315–316 – multicentric 164, 164 –– insufficiency fractures in osteomala- hip joint cia vs 147 – melorheostosis 229, 230 – psoriatic-associated enthesitis 333, 333 – severe bowing of bones around 232, 233 intertrochanteric region – chronic nonbacterial osteomyelitis 348, 348 – fibro-osseous lesion 307, 307 L Langerhans-cell histiocytosis 64, 140, – calcifications 157, 157, 158 –– Paget disease vs 30 – fibrous dysplasia 308 – cam-type impingement 162–163, –– skull 44, 44 – juvenile bone cyst 305, 305, 306 – secondary, radiation-induced bone – lipoma 173, 173 – clavicle 188, 188 intervertebral disk – congenital defect of iliac wing 165 – chondroblastoma 166, 166 resorption 46, 46, 47 189 vs 129, 129 – enchondromatosis 280, 281 hyperperfusion 31 – calcifications 69 – fibro-ostosis due to degenerative en- hypertrophic osteoarthropathy 294 – herniation 61 – cystic angiomatosis vs 84 – pulmonary 294, 294 –– See also intravertebral disk hernia- – focal/focus, see eosinophilic granulo- thesiopathy 178, 178 – herniation pit 162, 162, 164, 164 ni 222, 222 edema 180, 180 – normal variants 162, 172, 172, 173 – pigmented villonodular synovitis 168, 168 – sparse trabeculae in femoral neck 172, 172, 173 – synovial osteochondromatosis 170, 170, 171 – transient perfusion defect in femoral head 182, 182 – vulnerable zone 162, 164–165 hip region 160 tion hypervascular tumor, manubrium ster- – migrating transient bone-marrow I iliac spine, avulsion fracture 149, 151, 151 – initial imaging study intraosseous ganglion 62, 62 – multisystemic 213, 214 intraosseous lipoma 138, 311, 311 – pelvis 133, 133 – aneurysmal bone cyst vs 312, 312 – rib involvement 213, 214 – distal femoral metaphysis 311, 311 – systemic, spine in 63, 63, 64 – intertrochanteric region 173, 173, – tuberculous spondylitis vs 90 iliac wing – benign fibro-osseous lesion 138, 138 308 intravertebral disk herniation (deep – congenital bone defect 129, 129 – exostotic chondrosarcoma 155, 155, 156 – expansile lesion, old subperiosteal ma –– unhealed stress fracture with 146 Schmorl node) – deep chronic 66, 66, 67 – multiple 67, 67 – systemic Langerhans cell histiocyto- hemorrhage 134, 134 sis vs 63–64 latissimus dorsi, stress-induced enthesiopathy 242, 242, 243 leg(s), see lower limb – enchondromatosis 280, 281–282, 282 – shortening, juvenile bone cyst in iliac wing 136, 136 – epiphyseal dysplasia 160, 160 – insufficiency fracture 149, 150 – two-stage 61, 61 lesion HIV infection, tuberculous spondyli- – juvenile bone cyst 132–133, 136, 136 ischial tuberosity 153 – assigning to basic entity 11 – osteosarcoma secondary to Paget dis- – avulsion fractures 153, 154 – case and textbook comparison 11 ivory osteoma, see osteoma – epicenter of 11 J tis 90, 90 Honda sign 149, 149 ease 127, 127 humeral head – periostitis 121, 121 – localization 10 – anatomy 238 – vanishing bone disease 130, 130 – multiple or disseminated 11 – calcifying tendinitis or bursitis 232, iliofemoral ligament 178 234, 234, 235 – osteoid osteoma 243, 243 – patchy hyperintensities (MRI) 204, 204 – tumor differentiation 234, 234 humerus – productive fibro-ostosis at attachment site 178, 178 ilium – cystic lesions 132, 132, 133 – old subperiosteal hemorrhage 134, 134 – anatomy 238 – old unhealed stress fracture 145, 145 – calcifying enchondroma 253, 253, image interpretation 10 254 366 – multicentric reticulohistiocyto- – assigning lesion to basic entity 11 – solitary or bilateral 11 Jansen type of metaphyseal dysplasia 271, 271 joint diseases, see hand(s), specific joints – diagnostic algorithm – initial imaging study joint space, narrowing in osteoarthritis 283, 283 joint(s) lesion within a lesion 27, 28 lesser trochanter, double 179, 179 leukoencephalopathy, sclerosing, see sclerosing leukoencephalopathy licked candy stick appearance 186, 216–217 ligament groove 185 – at attachment of costoclavicular ligament 185, 185 Index lipoid granulomatosis 334, 335 – initial imaging study lipoma 312 – intraosseous, see intraosseous lipoma –– stress-induced hyperostosis of tibial margin 338, 338, 339 –– subcortical osteoid osteoma in tibia 336, 336 liposclerosing myxofibrous tumor 308 lumbar spine/vertebrae Lodwick grading 1, 312 – fibrous dysplasia 92, 92, 93 loose bodies 171 – intravertebral disk herniation 61, 61 Looser zones 147 – systemic Langerhans cell histiocyto- lower limb 299 – equivocal MRI findings 299 –– cortical osteoid osteoma of femoral diaphysis 304, 304 sis 63, 63, 64 lung cancer, pulmonary hypertrophic osteoarthropathy 294, 294, 295 lymphatic malformation 4, 310 metaphyseal dysplasia, Jansen type 271, 271 O metaphyseal enchondroma 167, 167 occipital bone, ivory osteoma 22, 22 metaphyseal sclerosis, bisphosphonates Ockham’s razor 11 and 232, 233 mononuclear phagocyte system (MPS) diseases multicentric reticulohistiocytosis 168, 287–288 – hands 287, 287 – rheumatoid arthritis vs 287–288, 288 – reverse 11, 16 Ollier disease 270, 279 oncologic radiology, initial imaging study onion-skin periosteal bone formation 327 os omovertebrale 186–187 ossicles, accessory (hand) 274 ossification, see periosteal new bone –– grade I chondrosarcoma 302, 302 multiple epiphyseal dysplasia 160, 160 –– islands of red marrow in femoral M multiple exostosis disease 200, 207 macrodactyly 273 – arachnoid diverticula (villi) vs 33 – heterotopic 77, 186, 274, 331, 331 macrodystrophia lipomatosis 273 – cystic angiomatosis vs 86, 87–88 –– See also myositis ossificans – extraosseous lesions 355 – pathogenesis 273 myonecrosis, calcific, tibial anterior – irregular, in Paget disease 29, 29 –– calcific myonecrosis of tibial anteri- – with finger gigantism 273, 273 metadiaphysis 299, 299 –– stress fracture in femoral shaft 300, 300 multiple myeloma muscle 358, 359–360 Maffucci syndrome 270, 279, 280, 281 myositis ossificans 48, 76, 76 –– intraneural ganglion cyst 357, 357 magnetic resonance imaging (MRI) – calcific myonecrosis vs 358 –– metachronous myositis ossificans – apparent diffusion coefficient (ADC), – diagnostic features 355 or muscle 358, 359–360 (femur) 355, 355 intraosseous epidermoid 34, 35–36 – factitious 25, 25 – mixed features, changes with 342 – as supplemental imaging study –– chronic nonbacterial osteomyeli- – contrast-enhanced – metachronous, on femur 355, 355 – equivocal findings in lower limb, see – pathogenesis 77 tis 348, 348 –– distal lateral femoral epiphysis variant 342, 342 –– focal fibrocartilaginous dysplasia 344, 344 –– hemochromatosis, articular involvement 353, 353 –– intraosseous venous vascular malformation 350, 350, 351 –– stress-induced destruction of femoral growth plate 346, 346 – normal variants 299, 317–318, 342, 342 – osteolytic changes (predominantly) 305 –– active enchondroma in tibial medullary cavity 325, 325 –– Baker cyst, and patellar defect 317, lower limb – initial imaging study – florid stage 73, 75 differentiated spondyloarthritis 223 manubriosternal synchondritis 225, 226 – plaque-like, sternocostoclavicular hyperostosis 225, 226 – spine, segmental unilateral distribution 48, 49–50 – traumatic myositis ossificans, see myositis ossificans osteitis – chronic nonbacterial 111, 192, 193 –– acromioclavicular joint rupture –– See also osteomyelitis and 186, 187 –– avulsion fracture of anterior inferior – osteoarthritis 227, 227 manubriocostal synchondrosis, in un- – Nora lesion 291, 291, 292 – traumatic 73, 73, 74, 77, 153 – protocols manubrioclavicular joint 227 formation – ankylosing, in DISH 71, 71 iliac spine 151–152 –– ossification site/process 73, 75 – scapula 197, 197 – sphenoid meningioma vs 16 osteitis condensans ilii (hyperostosis triangularis ilii) 117 –– pathogenesis 75, 77, 152 osteitis deformans, see Paget disease –– trapezius muscle 186, 186 osteoarthritis myositis ossificans-like lesion, melo- – erosive/destructive 283 manubrium sterni rheostosis of osteoma type in is- –– hands 283, 283 – undifferentiated spondyloarthri- chium 124 – manubrio- or sternoclavicular joint 227, 227 tis 223 – vascular malformation 222, 222 massive osteolysis syndrome, see vanishing bone disease mastocytosis, systemic, initial imaging N – polyarticular 283 Nasu–Hakola disease, see polycystic lip- osteoblastoma osteoarthropathy, diabetic omembranous osteodysplasia, with – cervical vertebrae 57, 57 sclerosing leukoencephalopathy – common sites 220 McCune–Albright syndrome 218 neck pain, yawning 48 – differential diagnosis 22, 23 melorheostosis 48, 51 nerve, lipomatosis 273 –– ivory osteoma vs 22 – bilateral involvement (upper neurofibromatosis type 4, 273 –– osteochondroma vs 57 neurofibromatosis type 19 –– osteoid osteoma vs 57 – C1 and C2 vertebrae 48, 49–50 neurogenic arthropathy –– osteosarcoma vs 57 –– fibro-osseous lesion 307, 307 – initial imaging study 4, 48 nidus in osteoid osteoma, see osteoid – skull 22, 23 –– fibrous dysplasia in tibia 319, 320 – ribs 205, 205, 206 osteoma, osteolytic nidus with cen- – sternum (body of sternum) 220, 220 –– gouty tophi, femur and tibia 313, – spotted bone disease (osteopoikilo- tral ossification osteochondritis dissecans 171 317 –– brown tumor of primary hyperparathyroidism 315, 315 –– cystic angiomatosis in femur 309, 309 313, 314 –– intraosseous lipoma 311, 311 –– juvenile bone cyst in femoral neck/ limb) 230, 231 sis) with 79 – types, and radiological patterns 48, 124 intertrochanteric region 305, 305, – upper arm 229, 229, 230–231 306 meningioma –– nonossifying fibroma in distal tibial metadiaphysis 329, 329 –– osteosarcoma of distal tibial diametaphysis 327, 327 –– Paget disease of tibia 322, 322, 323 – osteosclerotic changes (predominantly) 331 –– cortical osteoid osteoma 331, 331 – calvarium infiltration 18 –– meningioma of parietal bone vs 18– 19 –– proliferative enthesitis in pelvis vs 120 ral epiphysis vs 342, 342 osteochondroma 155–156, 156, 266, 274, 289 – See also cartilaginous exostosis – partially necrotic 202, 202 – broad-based 248, 249 – scapula 202, 202 – epiphyseal 275–276 menopause, premature, diffuse hyper- – spine 68, 68 –– Trevor disease 274, 274, 275 – stress-induced enthesiopathy in 242, – osteoblastoma vs 57 ostosis cranialis interna and 13, 14 metabolic skeletal diseases, initial imaging metacarpal heads – erosion, hemochromatosis 353, 354 – flattened in epiphyseal dyspla- (knee) 333, 333 – normal variant of distal lateral femo- – parietal bone infiltration 17, 17 –– osteoid osteoma of tibia 338, 338, –– psoriatic-associated enthesis – differential diagnosis 317, 318 – differential diagnosis 18, 18, 19 – sphenoid 15, 15 –– osteoid osteoma in talus 340, 340 339 non-Hodgkin lymphoma, of bone sia 160, 160 metaphyseal bands, dense, bisphosphonate therapy inducing 232, 232 metaphyseal cupping 271, 271, 272 242, 243 – upper arm 250, 252 nonossifying fibroma, in distal tibial metadiaphysis 329, 329 Nora lesion (BPOP) 291, 291, 292–293 – osteochondroma-like 292, 293 – productive fibro-ostosis in degenerative enthesiopathy vs 179 – ribs 207, 207, 208 – scapula 200, 200 – sessile, enchondroma protuberans vs 289 notochordal lesions 54 – solitary costal 207, 207 – hamartoma, see giant notochordal – solitary pedunculated, upper hamartoma arm 247, 247 367 Index – chronic nonbacterial 188, 192, 192 – differential diagnosis 39, 39 – hereditary 156 –– key features 348–349 –– fibrous dysplasia vs 27, 30 – synovial, see synovial osteochondro- –– lower limb 348, 348 –– hyperparathyroidism vs 30 – normal variants 117, 153 – chronic recurrent multifocal –– proliferative enthesitis in pelvis – osteolytic changes with decreased matosis osteochondrosis, erosive 109, 109, 110 (CRMO) 112, 193, 348 vs 119, 119 osteoclastic bone resorption 37 – diagnostic algorithm – humerus 250, 251–252 osteoid osteoma 177 – differential diagnosis 29 – initial imaging study – acetabulum 176, 177 –– calcifying bursitis or tendinitis – lytic stage 29, 31, 31, 39, 322, 322, – age range 178, 336 vs 234 323 – cortical (lower limb) 331, 331 –– Paget disease of tibia vs 322, 322 –– features 29, 31 –– femoral diaphysis 304, 304 –– sacrum, osteoid osteoma vs 113 – mixed (intermediate) stage 29, 29, – diagnostic findings 113, 176, 240, – Garré (chronic sclerosing) 16, 198– 242–243, 336 199 – differential diagnosis – initial imaging study –– calcifying bursitis or tendinitis – plasma cell 198 vs 234 –– ivory osteoma vs 22 – purulent necrotizing and caseating 90 –– osteoblastoma vs 57 – sclerosis with 198 –– stress-induced enthesiopathy – syphilitic 91 vs 242, 242, 243 – femoral neck 175, 175–176 osteomyelosclerosis syndrome, initial imaging 39, 39, 42, 42 –– features 29 – normal alkaline phosphatase and 323, 324 – pain and differential diagnosis 324 – pelvis 125, 125, 195, 196 –– osteosarcoma secondary to 127, 127 – polyostotic 250, 252 – sacrum 115, 116 ilium 145, 145 bone density 129 –– benign fibro-osseous lesion 138, 138 –– bone marrow necrosis with fatty replacement 143, 143 –– congenital bone defect in iliac wing 129, 129 –– cystic angiomatosis/hemangiomatosis 140, 141–142 –– cystic lesions 132, 132, 133 –– juvenile bone cyst 132–133, 136, 136 –– Langerhans cell histiocytosis 133, 133 –– old posttraumatic cyst in iliac wing 132, 132 –– old subperiosteal hemorrhage 134, 134 – femur 176 osteonecrosis, initial imaging – sarcoma risk 127–128 – proximal humerus 243, 243 osteopetrosis, initial imaging – scapula 195, 195, 196 – sacrum (left massa lateralis) 113, osteophytes 283 – sclerotic stage 30, 43, 43, 116, 116 osteopoikilosis 4, 78, 78, 79 – signs and features 29 – subcortical, tibia 336, 336 osteoporosis – spine 195, 196 – talus 340, 340 – advanced, radiological signs 97 – stages 29 – Paget disease 195, 196 – technical problems in radiologic di- – fractures 149, 150 – tibia 322, 322, 323 – sclerotic changes 117 –– insufficiency fractures in osteomala- – volume expansion related to trau- –– melorheostosis (osteoma type) 123, 113 agnosis 176, 177 – tibia 338, 338, 339 cia vs 147, 148 osteolysis –– thoracolumbar junction 97, 98 – intraosseous epidermoid 34, 35 – initial imaging study – Paget disease 29 – transient bone-marrow edema ma 128 Paget sarcoma, sphenoid meningioma vs 16 –– vanishing bone disease 129, 130, 130 – osteolytic lesion, unhealed stress fracture 145–146 123 –– osteosarcoma secondary to Paget disease 127, 127 paraosseous osteosarcoma 48, 292 –– Paget disease 125, 125 parasyndesmophytes 99 –– proliferative enthesitis 119, 119 osteoporosis circumcripta 31, 31, 39 parietal bone –– psoriasis-associated enthesitis or – See also Paget disease, lytic stage – fibrous dysplasia 27, 28 – enchondromatosis of hand 279, 279 osteosarcoma – meningioma 17, 17 – fibrous dysplasia, see fibrous dyspla- – osteoblastoma vs 57 – non-Hodgkin lymphoma in 18, 19 – osteosclerotic patella, dorsal defects 317, 317 – soft-tissue mineralization 157 – fingers 283, 283, 285 –– distal tibial diametaphysis 327, 327 pathoanatomic background, image in- –– renal osteopathy 157, 157 – metastases from angiosarcoma of –– femoral neck 120, 120 osteolytic areas, Lodwick grading osteolytic lesions, see lower limb, pelvis, skull sia with 180, 181 terpretation 10 – paraosseous 48, 292 pectoralis major – ribs 213, 213 –– cortical osteoid osteoma vs 332, 332 – calcifying tendinitis 240, 240, 241, osteolytic nidus with central ossifica- – periosteal, see periosteal osteosarco- spleen 81, 81 tion 113, 242–243, 304, 336, 339, 339, 340, 340 ma – PET scan – See also osteoid osteoma – radiologic features 327–328 – spindle-shaped 331, 331, 332 – scapula 198, 198 osteoma 22 – secondary to Paget disease (pel- – giant, T11 vertebra 50, 51 vis) 127, 127 – hamartomatous 25, 25 – skull 22 – ivory (classic) 22 – telangiectatic, aneurysmal bone cyst –– of occipital bone 22, 22 vs 115 – juxtacortical (paraosseous) 22 osteosclerosis 11 – lesion diagnosis 22, 24 – around osteoid osteoma of femoral – medullary 22 – osteoid, see osteoid osteoma osteomalacia 109 – bisphosphonate-induced dense metaphyseal bands 232, 232, 233 neck 176 – meningioma infiltrating bone and 17, 17 – metastases from angiosarcoma of spleen 81, 81 – diagnostic criteria 147 – in renal osteodystrophy 110 – initial imaging study – insufficiency fractures in pelvic ring with 147, 148–150 P Pacchionian granulations (arachnoid diverticula) 33, 33, 41 osteomyelitis – differential diagnosis 33–34 – chronic granulating (bacterial) 121– Paget disease 86 122 – chronic hematogenous, upper arm 257, 257 368 –– unhealed stress fracture in osteochondromatosis 168 – age association 250 – diagnostic findings 116, 195, 250, 322–323 241 – stress-induced enthesiopathy 242, 242, 243 pedunculated osteochondroma, upper arm 247, 247 periostitis 121, 121 –– reactive sclerosis around sacroiliac joints 117, 117 perfusion disorders, bone/bone marrow – acro-osteolysis, see acro-osteolysis – giant notochordal hamartoma 53 – initial imaging study – lytic stage of Paget disease vs 31 – radiation-induced bone resorption 46, 46 pelvic ring – regional bone loss 86 – insufficiency fractures in osteomala- – vanishing bone disease and 37, 131, cia 147, 148–150 – pregnancy-related loosening 117, 117 – stress-induced instability with asymmetric fusion of S1/S2 111, 111 pelvis 117 – bone lesions with extraosseous component 155 –– exostotic chondrosarcoma on iliac wing 155, 155 217 periosteal chondroma 23, 23, 246 – enchondromatosis association 280 – upper arm 245, 245 periosteal desmoid 246 periosteal new bone formation 294, 294 – differential diagnosis 294, 296 periosteal osteosarcoma 245–246, 292, 355 –– osteochondroma 156, 156 – characteristic features 355–356 – congenital defects 129, 129 – reactive ossifying process in calcify- – fractures 145 –– avulsion fracture of iliac spine 149, 151, 151 –– avulsion fractures of ischial tuberosity 153, 154 –– insufficiency, in osteomalacia 147, 148–150 ing tendinitis vs 265, 266 – traumatic myositis ossificans vs 75, 152 periostitis – florid reactive 292, 293 – psoriasis-associated, in iliac wing 121, 121 Perthes disease 160, 160, 161 Index pes anserinus, insertion, focal fibrocartilaginous dysplasia 344, 344 petrous bone, cystic angiomatosis/he- pustular arthro-osteitis (PAO)/enthe- – focus of Langerhans-cell histiocyto- sio-osteitis (PEO) 102, 102, 199, 225–226, 349 sis 213, 213 – fractures Scheuermann disease 66–67 Schmorl node, deep, see intravertebral disk herniation – clavicle 192, 192, 193 –– acro-osteolysis after 216, 216 phacomatoses, initial imaging – diagnostic features 198 –– nonhealing 216, 216 phantom bone disease, see vanishing – scapula 197, 197 –– spontaneous 213, 215 scleroderma en coup de sabre 37 pustulosis palmoplantaris 102, 103, – in multisystemic Langerhans cell his- scleroderma, circumscribed 37 mangiomatosis 140, 141, 142 bone disease pigmented villonodular synovitis (PVNS) 168, 168, 313 – gouty tophi of femur and tibia vs 313, 313, 314 plain radiography 1, – advantages 1, 184 112, 120, 193, 197 – clinical and CT findings 224 – melorheostosis 205, 205, 206 – manubriosternal synchondritis – osteochondroma/large exostosis 207, in 225, 226 – sternocostoclavicular hyperostosis 207, 208 – polyostotic fibrous dysplasia 218, in 225, 225 – as supplemental imaging study 3, – systemic, as psoriasis variant 198 – disadvantages pyrophosphate arthropathy, see chon- plasmacytoma, solitary, scapula 204, tiocytosis 213, 214 drocalcinosis 218 – trauma-induced acro-osteolysis 216, 216 Ribbing disease (systemic epiphyseal 204 polycystic lipomembranous osteodysplasia 278 – with sclerosing leukoencephalopathy –– hands 277, 277 polyostotic fibrous dysplasia dysplasia) 160, 160 R process 265, 265 radiography, plain, see plain radiography radiologist, role and responsibilities 12 – ribs and scapula 218, 218 radius – upper arm 259, 260–261 – enchondromatosis 269, 269 positron emission tomography (PET) 2, – proximal, cystic transformation of fi- 183 positron emission tomography-CT (PET-CT) – as initial imaging study brous dysplasia 264, 264 – stress-induced epiphyseal plate cartilage displacement 267, 267 rapid acceleratory phenomenon (RAP) 95 posttraumatic cyst, iliac wing 132, 132 reactive inflammatory bone pregnancy, hyperostosis triangularis ilii changes 331, 334–335 and 117 prevalence of diseases 11 prevertebral tendinitis 75 prostaglandins 113 prostate cancer, metastases 95, 95, 195 proteus syndrome 4, 273 pseudarthrosis, clavicle, traumatic myositis ossificans and 186 pseudo-Madelung deformity 279–280 pseudofractures 147 pseudogout, see chondrocalcinosis pseudohyperparathyroidism, initial imaging rickets, Jansen type of metaphyseal radial tuberosity, reactive ossifying – endochondromatosis vs 218–219 – as initial imaging study rice-body synovitis 170–171 – pelvis 119, 119 reactive ossifying process, due to calcifying tendinitis 265, 265 reactive osteitis, Paget disease of tibia vs 322 reactive sclerosis, around sacroiliac joints 117, 117 reflex sympathetic dystrophy, initial imaging regional angiomatosis, see vanishing bone disease Reichel disease (synovial osteochondromatosis) 170, 170 dysplasia vs 271, 272 rim sign 125 scintigraphy, bone, see bone scintigraphy sclerosing leukoencephalopathy 278 – See also polycystic lipomembranous osteodysplasia sclerosis, reactive, around sacroiliac joints 117, 117 sclerotic lesions – bone scintigraphy – C2 vertebra, giant notochordal hamartoma 53 – femur, differential diagnosis 119– 120 – in young people 123 sclerotomes, ossification arrangement in melorheostosis 231 rotator cuff tear 190, 190 selection of imaging modality rounded lucency 10 septic (infectious) arthritis, initial imag- S sequestrum (sequestra) 90–91 saber shin 323, 324 shoulder girdle 185 sacroiliac joints, reactive sclerosis Sinding–Larsen–Johansson syn- ing – tuberculous spondylitis 90 around 117, 117 sacrum 111 – aneurysmal bone cyst 115, 115 – asymmetric fusion of S1/S2 with stress-induced instability 111, 111 – bone marrow necrosis in lateral mass 143, 143 – edema-like signal in mass 111, 111, 112–113 – normal variants 112 – osteoid osteoma in left massa lateralis 113, 113 drome 317–318 skeletal hyperostoses, initial imaging study skeletal metastases, see bone metastases skull 13 – circumscribed “atrophic” changes 31 – cloudy (sclerotic stage of Paget disease) 43, 43 – crumb cake nodularity 25, 25 – depression in 37, 37 – mixed feature lesions 29 – osteomyelitis 113 –– Paget disease 29, 29, 39, 39, 42, 42 – Paget disease 115, 116 – normal variants 13, 13, 14, 16, 20, 34 salt-and-pepper pattern 44, 44 –– arachnoid diverticula 33, 33, 34 SAPHO syndrome 102, 104, 117, 194, – osteolytic lesions 29 225, 349 – diagnostic findings 198 – scapula in 197, 198 sarcoidosis –– age-related atrophy 41, 41 –– Pacchionian granulations (arachnoid diverticula) 33, 33 pseudotumor(s) Reiter syndrome 99 – at site of pubic fracture 147 renal osteodystrophy – hands and feet 285, 285, 286 – hemophilic 135 – soft-tissue calcifications 157, 158 – mutilating form 285, 285, 286 –– Paget disease (lytic stage) 31, 31 pseudotumoral calcinosis 158 – with erosive spondylopathy 109, 109 – polyostotic form 285 –– primary hyperparathyroidism 44, – secondary chondrosarcoma vs 201, renal osteopathy 157, 157, 157 sarcoma, Paget disease associa- 201 psoriasis 99, 101 – enthesitis associated, see enthesitis – initial imaging reticulohistiocytosis, multicentric, see multicentric reticulohistiocytosis tion 127–128 scaphoid, Trevor disease 274, 274, 275, 275 – pustular 102–103, 103–104, 112 retropharyngeal tendinitis 75 scapula 195 – pustular enthesio-osteitis and 193, reverse trizonal pattern 75, 152, 355– – eosinophilic granuloma 204, 204 194 356 – exostosis (osteochondroma) 200, 200 –– Paget disease (early intermediate stage) 39, 39 44 –– vanishing bone disease 37, 37 –– vanishing occiput 46, 46 – sclerotic changes 13 –– diffuse hyperostosis cranialis interna 13, 13 –– factitious myositis ossificans-like os- psoriatic arthritis 335 rheumatic enthesitis 102, 102 psoriatic spondyloarthritis 99, 100 rheumatoid arthritis 168 – expansive osteolytic lesions 204, 204 – anterior chest wall involvement 224 – hands 288, 288 – non-Hodgkin lymphoma 202, 202 –– hamartomatous osteoma 25, 25 PTEN hamartoma tumor syn- – initial imaging study – osteosarcoma 198, 198 –– ivory osteoma of occipital bone 22, rib(s) 205 – Paget disease 195, 195 pubic ramus, fracture 147, 148 – benign fibro-osseous lesion 211, 211 – polyostotic fibrous dysplasia 218, pubic symphysis, reactive sclerosis – brown tumor 209, 210 dromes 273 around 117, 117 pulmonary hypertrophic osteoarthropathy 294, 294 punched out lesions 286 – chondrosarcoma 211, 211 – dysplasia 205, 205 218 – pustular arthro-osteitis (enthesio-osteitis) 197, 197 sifications 25, 25 –– fibrous dysplasia 20, 20 22 –– meningioma in parietal area 17, 17 –– osteoblastoma 22, 23 –– patchy ossification, differential diagnosis 14, 14 – enchondroma 207, 208 – secondary chondrosarcoma 200, 200 –– sphenoid wing meningioma 15, 15 – fibrous dysplasia 209, 209, 210 – solitary plasmacytoma 204, 204 smoking, Langerhans cell histiocytosis scapular ligament, transverse 186 and 64 369 Index soap-bubble appearance 20, 115, 218– 219, 259, 264 soft-tissue calcifications, renal osteodystrophy 157, 158 soft-tissue mass – calcific myonecrosis in tibial anterior muscle 358, 359–360 – metachronous myositis ossificans 355, 355 solitary plasmacytoma, scapula 204, 204 119 subperiosteal hemorrhage, old, in ilium 134, 134 trabeculae, blurring 109–110 trapezius muscle, traumatic myositis – psoriatic 99, 100 supplemental imaging study – pustulotic arthro-osteitis 102, 102 synovial chondromatosis 297 trauma – reactive sclerosis around sacroiliac – acromioclavicular joint cysts vs 191 – acro-osteolysis induced by, ribs and joints vs 117, 117 – undifferentiated, of anterior chest wall 223 spondyloarthropathies, seronegative 99, 120, 224–225, 335 synovial cysts, acromioclavicular joint 190 synovial osteochondromatosis 170, 171 – extra-articular 171 ossificans 186, 186 clavicle 216, 216 – enthesiopathies induced by 266 – factitious 25 – myositis ossificans after, see myositis ossificans spondylodiskitis 64, 66 – hands 297, 297 – skull 25, 25 Trevor disease (dysplasia epiphysealis sphenoid bone, fibrous dysplasia 95, 95 – inflammatory Andersson lesion 103 – hip 170, 170 sphenoid meningioma 15, 15 – lumbosacral junction 198 – phases 170 spicules of new bone 15, 16, 17 spondylopathy, erosive, renal osteodys- synovitis, rice-body 170–171 trizonal structure 355 syphilitic osteomyelitis 91 tuberculous spondylitis in AIDS 90, 90 systemic lupus erythematosus, initial tuberous sclerosis, initial imaging – giant osteoma of T11 vertebra 50 spinal entheses and joints, diseases 99 – chondrocalcinosis 105, 107 – gouty arthritis 105, 106, 108 – psoriatic spondyloarthritis 99, 100 – pustulotic arthro-osteitis (enthesioosteitis) 102, 102 – renal osteodystrophy with erosive spondylopathy 109, 109 spine 48 – mono- and bisegmental changes 48 –– deep chronic intravertebral disk trophy with 109, 109, 110 spondylophyte, ankylosing, in DISH 71, 71 spotted bone disease (osteopoikilo- imaging systemic sclerosis, initial imaging – osteoarthritis 227, 227 sternocostal arthro-osteitis, see sternocostoclavicular hyperostosis (SCCH) sternocostal synchondrosis, in undifferentiated spondyloarthritis 223 sternocostoclavicular hyperostosis tumor metabolism, PET scan tumoral calcinosis 158 tumorlike bone lesions sis) 78, 78, 79 sternoclavicular joint 227 hemimelica) 274, 274, 275 T – fibrous dysplasia, see fibrous dyspla- talus, osteoid osteoma 340, 340 – rib, fibro-osseous lesion 211, 211 technetium-99 m scanning, see bone turret exostosis 292 sia scintigraphy tendinitis – calcifying, see calcifying tendinitis U (SCCH) 99, 224–225, 225 – prevertebral (retropharyngeal) 75 ulcer, cartilage, knee 317, 317 –– fibrous dysplasia 55, 55, 56 – asymmetric onset 225, 225 tendinopathy, insertional, of greater upper arm 229 –– giant notochordal hamartoma 53, – plaque-like ossification (late herniation 66, 66, 67 53, 54 –– giant osteoma 50, 51 stage) 225, 226 sternum 220 –– hemangioma in T1 59, 59 – cavernous hemangioma 222, 222 –– melorheostosis 48, 49–50 – osteoblastoma (body of ster- –– non-Hodgkin lymphoma 68, 68 num) 220, 220 trochanters 183, 183 tenosynovial giant cell tumor, see pigmented villonodular synovitis (PVNS) teres major muscle, stress-induced enthesiopathy 242, 242, 243 –– osteoblastoma in C5 57, 57 – primary bone tumors 220 thoracic cage 185 –– two-stage intravertebral disk her- – thrill over 222, 222 thoracic spine/vertebrae – vascular malformation (manu- – myositis ossificans 76, 76 niation 61, 61 – normal variants brium) 222, 222 humerus 253, 253, 254 – calcifying tendinitis/bursitis with bone erosion 234, 234, 235, 240, 240, 241, 241 – chronic hematogenous osteomyelitis 257, 257 – dense metaphyseal bands due to bisphosphonates 232, 232 – melorheostosis 229, 229, 230–231 – non-Hodgkin lymphoma, of stress fractures 257 – T1, hemangioma 59, 59 –– melorheostosis 48, 49–50 – anterior superior corner of thoracolumbar junction, osteoporotic ilium 145, 145 – calcifying enchondroma of proximal – osteoporotic fractures 97, 98 –– hemangioma 60 – oligo- and multisegmental fractures 97, 98 bone 250, 252 – normal variants 239 – Paget disease 250, 251–252 – bone fragment separation 145, 145 thumb, melorheostosis 229, 229 –– calcifying diskitis 69, 69 – diagnostic algorithm tibia – periosteal chondroma 245, 245, 246 –– cystic angiomatosis, see cystic an- – in femoral shaft 300, 300 – chronic nonbacterial osteomyeli- – polyostotic fibrous dysplasia 259, changes 69 giomatosis – initial imaging study tis 348, 348 –– DISH 71, 71 – occult in femoral neck 175, 175 – fibrous dysplasia 319, 320 –– fibrous dysplasia (lumbar spine) 92, – osteoid osteoma of femoral neck – gouty tophus (juxta-articular por- 92, 93 –– metastases from prostate cancer 95, 95 –– metastases in angiosarcoma of spleen 81, 81 –– myositis ossificans 76, 76 –– osteopoikilosis 78, 78, 79 –– traumatic myositis ossificans 73, 73, 74 –– tuberculous spondylitis in AIDS 90, 90 – Paget disease 195, 196 splenic lesions, cystic angiomatosis with 83, 83 spondylitis 68 – cervical 57 – initial imaging study – renal osteodystrophy with erosive spondylopathy vs 109 vs 175, 175, 176 stress reactions, silent, at deltoid muscle attachment 239, 239 stress, chronic, effect on growth plates 267, 267, 268, 346, 346 stress-induced destruction, femoral growth plate 346, 346 stress-induced enthesiopathy – focal fibrocartilaginous dysplasia in lower limb 344, 344 – upper arm 242, 242, 243 stress-induced epiphyseal plate cartilage displacement, radius 267, 267 stress-induced hyperostosis, anterior tibial margin 338, 338, 339 stress-related skeletal changes, initial imaging subchondral cysts (geodes) 283–284 subdural hematoma 13 tion) 313, 313, 314 – hyperostoses, classification 339 – medullary cavity, active enchondroma 325, 325 – nonossifying fibroma (distal metadiaphysis) 329, 329 muscle attachment 239, 239 – solitary pedunculated osteochondroma 247, 247 – stress-induced enthesiopathy 242, 242, 243 – osteolytic osteosarcoma (distal dia- – See also forearm, upper arm metaphysis) 327, 327 – Paget disease 322, 322, 323 – stress-induced hyperostosis of anterior margin 338, 338, 339 – stress-related defect (medial metaphysis) 344 V vanishing bone disease 131, 217 – pelvis 129, 130, 130 – skull 37, 37 – subcortical osteoid osteoma 336, 336 – trauma inducing 217 tibial anterior muscle, calcific myonec- vanishing occiput 46, 46 rosis 358, 359–360 tibial nerve, intraneural ganglion cyst 357, 357 Tietze syndrome 211, 227 spondyloarthritis subperiosteal erosions, sarcoidosis 285, toddler’s disease (Blount disease) 344, 286 237, 238 – silent stress reaction at deltoid upper limb 229 – ossified 14 bar junction 97, 98 260–261 – prominent deltoid tuberosity 237, – osteoid osteoma 338, 338, 339 – tuberculous 90, 90 – osteoporotic fractures at thoracolum- 370 – proliferative enthesitis of pelvis 119, 345 torticollis 107, 107 vascular (vessel) prints 350, 350, 352 vascular malformations 140, 310 – cystic angiomatosis in pelvis 140, 141–142 – differential diagnosis –– cystic angiomatosis vs 310 –– hemangiomas vs 310, 351, 352 Index –– neoplastic vascular lesions vs 351 – posttraumatic 168 – initial imaging study vascular supply, disturbances, see acro- – intraosseous venous, lower limb 350, 350, 351 – manubrium sterni 222, 222 osteolysis, avascular necrosis venous malformation 351, 351 – intraosseous, lower limb 350, 350, 351 vertebral hemangioma 222 W wedged vertebra 69, 97 whole-body imaging techniques 11 – initial imaging study 371 ... (eosinophilic granuloma) Other cases that started with a single- organ involvement are presented in ▶ Fig 2. 17 in Case 9, ▶ Fig 3.13 and ▶ Fig 3.14 in Case 24 and ▶ Fig 4. 12 in Case 55) Langerhans-cell... a second opinion Radiologic Findings The imaging findings are described above It should be added that CT and MRI showed thinning and partial resorption of the scapular cortex, predominantly on... is indicated by the following findings: ● Clinical presence of pustulosis palmoplantaris (PPP) accompanied by pain in the left scapula and later in the lumbar spine ● Oligolocular pattern of increased