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(BQ) Part 1 book Bone and joint disorders differential diagnosis in conventional radiology presents the following contents: Osteopenia, osteosclerosis, periosteal reactions, trauma and fractures, localized bone lesions, joint diseases, joint and soft tissue calcification.
www.MedLibrary.info I www.MedLibrary.info II www.MedLibrary.info III Bone and Joint Disorders Differential Diagnosis in Conventional Radiology Francis A Burgener, M.D Martti Kormano, M.D Tomi Pudas, M.D Professor of Radiology University of Rochester Medical Center Rochester, N.Y., U.S.A Formerly Professor and Chairman Department of Radiology University of Turku Turku, Finland Department of Radiology University of Turku Turku, Finland 2nd revised edition 1108 illustrations Thieme Stuttgart · New York www.MedLibrary.info IV Library of Congress Cataloging-in-Publication Data is available from the publisher Important Note: Medicine is an ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book Nevertheless this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect of any dosage instructions and forms of application stated in the book Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed © 2006 Georg Thieme Verlag, Rüdigerstraße 14, D-70469 Stuttgart, Germany http://www.thieme.de Some of the product names, patents and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain This book, including all parts thereof, is legally protected by copyright Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage Thieme New York, 333 Seventh Avenue, New York, N.Y 10001, U.S.A http://www.thieme.de Cover design: Martina Berge, Erbach Typesetting by primustype Hurler GmbH, D-73274 Notzingen Printed in Germany by Grammlich, Pliezhausen ISBN 3-13-107392-6 (GTV, Stuttgart) ISBN 1-58890-445-8 (TMP, New York) 12345 www.MedLibrary.info V Preface Conventional radiography remains the backbone of musculoskeletal radiology despite the advent of newer and more exciting imaging techniques such as computed tomography, magnetic resonance imaging, and, most recently, positron emission tomography In contrast to many of these newer methods, conventional radiography is practiced not only by radiologists but also by a large number of clinicians and surgeons With each examination, one is confronted with radiologic findings that require interpretation in order to arrive at a general diagnostic impression and a reasonable differential diagnosis To assist the film reader in attaining this goal, this book is based upon radiographic findings unlike most other textbooks in radiology that are disease oriented Since many diseases present radiographically in a variety of manifestations, some overlap in the text is unavoidable To minimize repetition the differential diagnosis of a radiographic finding is presented in tabular form whenever feasible Most tables not only list the various diseases that my present radiologically in a a specific pattern, but also describe in succinct form other characteristically associated radiographic findings and pertinent clinical data Radiographic illustrations and drawings are included to demonstrate visually the radiographic features under discussion The transition from film to digital radiography had the greatest impact on conventional radiology since the publication of the last edition This change, however, did not affect the way radiologic diagnoses are ascertained Since the publication of the last edition the name of a few disorders has changed (e g., histiocytosis X to Langerhans cell histiocytosis) and a few disease are newly recognized (e g., femoroacetabular impingement) These facts were taken into account in the new edition The chapters “Localized Bone Lesions“ and “Joint Diseases“ were completely rewritten and newly illustrated, since I took them over from Dr Kormano The chapter “Trauma and Fractures“ also under went a major overhaul by the inclusion of specific fracture sites In the remaining chapters of the book the text was updated, many illustrations replaced, and large numbers of new illustrations added A changing of the guard has also taken place Since Dr Martti Kormano‘s professional endeavors no longer include clinical radiology, he felt no longer up the task to update his original contributions to the text He was however very fortunate to find in Dr Tomi Pudas a very talented young radiologist to take over the revision of the chapters originally prepared by him I hope this new edition will be as well received as its predecessors in the past that were translated into five foreign languages The concept of an imaging pattern approach in tabular form rather than a disease oriented text was introduced in 1985 with our original edition Differential Diagnosis in Conventional Radiology and has since been adopted by many authors I feel complimented by the old cliché, “imitation is the sincerest form of flattery.“ This book is meant for physicians with some experience in musculoskeletal radiology who wish to strengthen their diagnostic acumen It is a comprehensive outline of radiographic findings and it should be particularity useful to radiology residents preparing for their specialist examination, especially since the exposure to conventional radiography during their training continuously decreased in the past in favor of newer imaging modalities Any physician involved in the interpretation of conventional bone radiographic examinations should find this book helpful in direct proportion to his or her curiosity It is my hope that this new edition will be as well received as the previous ones by medical students, residents, radiologists, and physicians involved in the interpretation of conventional bone radiographs www.MedLibrary.info Francis A Burgener, M D VI Acknowledgements It is impossible to thank individually all those who helped to prepare the third edition of this textbook I wish to acknowledge the staff of our publisher Thieme, in particular Dr Clifford Bergman and Mr Gert A Krüger I am deeply indebted to Dr Gertrud Gollman, Steinach am Attersee, Austria, who translated the last edition of this text into German and suggested many alterations and corrections, which have been incorporated into this new edition My gratitude goes to all the radiologists whose cooperation made available illustrative cases to compliment the original collection or to replace older illustrations I am indebted to Drs Steven P Meyers, Johnny U V Monu, and Gwy Suk Seo, all staff members of the University of Rochester Radiology Department, and to the former residents Drs John M Fitzgerald and Wael E A Saad for providing selected cases I wish to express also many thanks to Jeanette Griebel, Iona Mackey, and Marcella Maier for their assistance in preparing the references and to Shirley Cappiello for her general assistance Last, but not least, I am most grateful to Alyce Norder who left the University and me after 30 years for the richness of the industry She is the only person capable of deciphering my longhand and, as in the past, did a superb job in typing, editing, and proofreading the manuscript of the new edition of this text Despite her heavy workload as executive assistant in her new endeavor Alyce was kind enough to perform this task in her spare time, for which I am greatly appreciative Finally I appreciate the support of my wife Therese, who has generously given her precious family time for the preparation of this book Francis A Burgener, M.D I would like to express my deepest gratitude to honorary professor Martti Kormano who invited me to carry on his work in this new edition I continue to admire the massive work that he and Dr Burgener originally put into the project in the early nineteen-eighties The hundreds of hours which Dr Kormano and I have spent together editing this edition have been a great pleasure It was a fascinating time in my life I especially want to thank Drs Kimmo Mattila and Seppo Koskinen for introducing me to musculoskeletal radiology, and for their extraordinary teaching and support Many thanks also belong to Drs Erkki Svedström, Risto Elo, and Peter B Dean for encouraging me on my way in the field of radiology The many fascinating discussions I have had with Drs Seppo Kortelainen and Teemu Paavilainen brought me much delight, on non-radiological topics as much as on professional subjects I also express sincere thanks to the staff of the publishers, Thieme, especially to Dr Clifford Bergman and Mr Gert Krüger Finally, much gratitude is due to Mr Markku Livanaien for his valuable assistance with technical questions, and to Ms Pirjo Helanko for all her help with general matters Many other individuals helped in various ways with this project, and though I cannot name them all, I am grateful for their contributions Tomi Pudas, M.D www.MedLibrary.info VII Contents Osteopenia 10 Nasal Fossa and Paranasal Sinuses 237 Francis A Burgener Francis A Burgener Osteosclerosis 15 11 Francis A Burgener Jaws and Teeth 245 Francis A Burgener Periosteal Reactions 41 12 Francis A Burgener Spine and Pelvis 255 Martti Kormano and Tomi Pudas Trauma and Fractures 53 13 Francis A Burgener Clavicles, Ribs, and Sternum 305 Martti Kormano and Tomi Pudas Localized Bone Lesions 75 Francis A Burgener 14 Extremities 313 Francis A Burgener, Martti Kormano, and Tomi Pudas Joint Diseases 129 15 Hands and Feet 353 Francis A Burgener Martti Kormano and Tomi Pudas Joint and Soft-Tissue Calcification 189 References 392 Martti Kormano and Tomi Pudas Skull 203 Index 393 Francis A Burgener Orbits 233 Francis A Burgener www.MedLibrary.info VIII Abbreviations ABC AC ACTH AIDS ALL AML ANCA ANT AP AV AVF AVM AVN Bx Ca CLL CNS CPP CPPD aneurysmal bone cyst acromioclavicular (joint) adrenocorticotropic hormone acquired immune deficiencly syndrome acute lymphoblastic leukemia acute myeloblastic leukemia antineutrophil cytoplasmotic autoantibodies anterior anteroposterior arteriovenous arteriovenous fistula arteriovenous malformation avascular necrosis biopsy calcium chronic lymphatic leukemia central nervous system calcium pyrophosphate dihydrate crystals calcium pyrophosphate dihydrate deposition disease CRMO chronic recurrent multifocal osteomyelitis CT computed tomography D disease DD differential diagnosis DDH development dysplasia of the hip DIP distal interphalangeal (joint) DISH diffuse idiopathic skeletal hyperostosis DISI dorsal intercalated segmental instability EAC external auditory canal EG eosinophilic granuloma F female HAD calcium hydroxyapatite crystals HADD calcium hydroxyapatite crystal deposition disease Hb hemoglobin HD Hodgkin disease HIV human immunodeficiency virus Hx history IAC internal auditory canal IM intramuscular IP IV L LCH LE M MAI MCP MFH MPS MR MRI MS MTP NHL NUC PA PATH PET PIP PNET PVNS RA RBC RES RSD SC SI SLAC SLE STT TB TFC TFCC TMJ TNM VISI WBC interphalangeal (joint) intravenous left Langerhans cell histiocytosis lupus erythematosus male Mycobacterium avium intracellulare metacarpophalangeal (joint) malignant fibrous histiocytoma mucopolysaccharidosis magnetic resonance magnetic resonance imaging multiple sclerosis metatarsophalangeal (joint) non-Hodgkin lymphoma nuclear medicine posteroanterior pathology positron emission tomography proximal interphalangeal (joint) primitive neuroectodermal tumor pigmented villonodular synovitis rheumatoid arthritis red blood cell reticuloendothelial system reflex sympathetic dystrophy sternoclavicular (joint) sacroiliac (joint) scapholunate advanced collapse systemic lupus erythematosus scaphotrapeziotrapezoidal tuberculosis triangular fibrocartilage triangular fibrocartilage complex temporomandibular joint tumor-node-metastasis volar intercalated segmental instability white blood cells www.MedLibrary.info www.MedLibrary.info 188 Bone www.MedLibrary.info 189 Joint and Soft-Tissue Calcification Deposition of calcium in abnormal locations may take two forms: calcification or ossification They can be roentgenologically differentiated from each other Calcification is seen as structureless density; ossification shows organization into trabeculae and cortex (Figs 7.1 and 7.2) Calcification of soft tissues is classified as metastatic (disturbance of calcium or phosphorus metabolism leading to ectopic calcification in primarily normal tissue), calcinosis (deposition of calcium in soft tissues in the presence of normal calcium metabolism), or dystrophic (calcium deposition in damaged tissues without generalized metabolic derangement) Ossification of soft tissues is usually due to myositis ossificans or tumoral ossification of soft tissues Tables 7.1−6 present the differential diagnosis of calcification or ossification of joints and soft tissues of the extremities Fig 7.2 a Myositis ossificans Bone formation in the soft tissues of the upper arm after trauma Fig 7.1 Structureless calcifications (arrows) in the soft tissues of the hand Chronic renal failure Fig 7.2 b Total hip prosthesis is the most common reason of myositis ossificans (different patient than 7.2 a) www.MedLibrary.info 190 Bone Table 7.1 Intra-articular calcified or ossified body (single or multiple) Associated Disorders Common Locations and Remark Degenerative joint disease with detached spur Knee and other large joints May resemble synovial osteochondromatosis, but usually contains one or few calcifications Fracture with avulsed fragment in joint (bone, articular cartilage meniscus) Occurs especially in avulsed medial epicondyle of pediatric elbow Cartilaginous fragments may or may not calcify Osteochondrosis dissecans (Fig 7.5) Knee, elbow, hip, shoulder, ankle; similar to synovial osteochondromatosis, but only one or few calcifications A residual pit in the articular surface Synovial osteochondromatosis (Fig 7.3) Knee, hip, elbow, shoulder Multiple small calcified or ossified densities within the joint capsule Some of the synovial chondromas remain uncalcified and are not detected on plain films Neuropathic joint (Fig 7.4, 14.53) Knee, hip, ankle, shoulder Disintegration of joint surfaces, sclerosis and malalignment May occur in diabetes, syringomyelia, syphilis and leprosy Intra-articular tumor calcification (synovial sarcoma, intra-capsular chondroma) Knee Associated with a soft-tissue mass A tumor may simulate a loose body Sequestrum from tuberculous or pyogenic arthritis Rare Associated with arthritis or postarthritic deformity Fig 7.3 Synovial osteochondromatosis a Shoulder joint b, c Knee joint There is severe secondary osteoarthritis in the knee joint Fig 7.3 b, c ୴ a www.MedLibrary.info Joint and Soft-Tissue Calcification b 191 c Fig 7.3 b, c Fig 7.4 Syringomyelia Destruction of the glenoid fossa and humeral head, which is displaced inferiorly The joint cavity contains calcific fragments Fig 7.5 a Anteroposterior and b lateral views of the knee with osteochondrosis dissecans A residual pit in the articular surface of the medial femoral condyle is demonstrated (arrow) and the calcified loose body is seen above the patella (asterisk) www.MedLibrary.info 192 Bone Table 7.2 Calcification of articular cartilage or meniscus Associated Disorders Common Locations and Remark Calcium pyrophosphate dihydrate (CPPD deposition disease) “Pseudogout” (Figs 7.6 and 7.7) Knees, wrists, hips May be associated with various degrees of secondary osteoarthritis Idiopathic, primary osteoarthritis, trauma Calcification of cartilage without crystal arthropathy Secondary osteoarthritis Premature osteoarthritis with chondrocalcinosis Hyperparathyroidism, renal osteodystrophy Wrists, knees, hips, shoulders, elbows Seen also in oxalosis with secondary renal failure Gout Knee Chondrocalcinosis is a secondary manifestation Ochronosis (alkaptonuria) Menisci, intervertebral disks Intervertebral disk calcification is also seen in hypervitaminosis D, hypophosphatasia, ankylosing spondylitis, spondylosis and disk degeneration Acromegaly (Fig 7.8) Knee Cartilage proliferation widens joint spaces Calcification may happen Hemochromatosis Autosomal recessive hereditary disorder in which iron accumulation causes the diseace 20−60 % of patients may have chondrocalcinosis Calcification may be similar to CPPD Wilson’s disease Rare autosomal recessive disorder characterized by copper accumulation Affects particularly basal ganglia and liver In skeletal system it causes osteopenia, subchondral bone fragmentation and chondrocalcinosis Fig 7.6 Chondrocalcinosis in CPPD with calcification of menisci and articular cartilage of the knee Fig 7.8 Acromegaly Widening of the joint spaces and calcification of the proximal interphalangeal joint cartilage of the index finger (arrow) Fig 7.7 CPPD (pyrophosphate arthropathy) Calcification in the region of the triangular cartilage of the wrist (arrow) Osteoarthritic changes in the joint surfaces of the larger multangular bone www.MedLibrary.info Joint and Soft-Tissue Calcification Table 7.3 193 Periarticular soft tissue calcification or ossification Associated Disorders Common Locations and Remark Hyperparathyroidism (Fig 7.9) Renal osteodystrophy Associated with other radiographic signs of hyperparathyroidism Other disorders of calcium and phosphate metabolism (hypoparathyroidism, chronic hemo dialysis, widespread bone destruction, vitamin D intoxication, milk-alkali syndrome, etc.) Ligamentous subcutaneous and intracranial calcifications sometimes occur Not seen in postsurgical hypoparathyroidism Scleroderma (Fig 7.10) Most common in hands Association of generalized calcinosis of the skin with scleroderma is called Thibierge-Weissenbach syndrome The tetrad of skin calcification, Raynaud’s phenomenon, sclerodactyly, and telangiectasia (CRST syndrome) is a variant of scleroderma Dermatomyositis (Fig 7.11) Polymyositis (Fig 7.12) Associated with generalized or localized calcinosis of subcutaneous tissues Polyarteritis nodosa Raynaud’s syndrome Rheumatoid arthritis Systemic lupus erythematosus Periarticular calcifications in these connective tissue diseases are rare May be reversible in systemic lupus erythematosus Sarcoidosis Large periarticular soft-tissue masses with or without calcifications are a rare manifestation (continues on page 194) Fig 7.10 Scleroderma Periarticular soft-tissue calcification in one finger and a soft-tissue defect in another Fig 7.9 Periarticular (arrows) and vascular calcifications in hyperparathyroidism www.MedLibrary.info 194 Bone Table 7.3 (Cont.) Periarticular soft tissue calcification or ossification Associated Disorders Common Locations and Remark Gout Periarticular calcified lump associated with chondrocalcinosis is diagnostic of gout Most commonly occurs at the first metatarsophalangeal joint, the insertion of the Achilles tendon and the olecranon bursa Ochronosis (alkaptonuria) Periarticular calcification occurs in spine and large joints Ehlers-Danlos syndrome See subcutaneous calcifications, table 7.5 Werner’s syndrome (adult progeria) Periarticular ligamentous calcifications, especially about the knees, may occur in this rare condition Other radiographic findings include osteoporosis, premature atherosclerosis with calcification, and osteoarthritis HADD (hydroxyapatite deposition disease) (Fig 7.14) Examples: shoulder (calcific tendinitis, periarthrosis) Hip (calcified trochanteric bursa) (continues on page 195) Fig 7.11 Dermatomyositis in a child Periarticular soft-tissue calcifications around the knee have some resemblance to synovial osteochondromatosis Fig 7.12 Polymyositis and Raynaud’s syndrome Extensive soft tissue calcifications around thumb, fewer calcification at distal ends of other fingers Fig 7.13 Calcinosis Interstitialis universalis Calcific deposits in the toes are as in scleroderma, but there are no other abnormalities Fig 7.14 Hydroxyapatite deposition disease Calcification of the subacromial bursa of the shoulder www.MedLibrary.info Joint and Soft-Tissue Calcification Table 7.3 195 (Cont.) Periarticular soft tissue calcification or ossification Associated Disorders Common Locations and Remark Myositis ossificans (localisata) (Fig 7.15) Calcification occurs about one month after trauma (hematoma, capsular or ligamentous damage), later it ossifies Also common around joint replacement and in association with chronic neurological diseases (paraplegia) Ossification is always separated from bone by a radiolucent zone, unlike a malignant bone tumor Posttraumatic calcification (Fig 7.16) Pellegrini-Stieda calcification in the proximal attachment of the medial collateral ligament of the knee is a common presentation Synovial sarcoma (Fig 7.17) Most common in knee Only small percentage of these tumors are intra-articular The periarticular mass often contains calcific flecks, but not extensive calcification Pigmented villonodular synovitis Most common in knee A high-density lobulated mass may sometimes appear calcified due to hemosiderin deposits, although the tumor calcifies extremely rare Large joints, spine Fibrous ankylosis and extensive soft-tissue calcification often occurs Healed tuberculous arthritis (Fig 7.18) (Caries sicca) Pseudotumoral calcinosis (lipocalcinogranulomatosis) Usually painless calcifications, most often of the bursae in the vicinity of joints (hip, elbow, shoulder) or near bony protuberances If cystic, may show layering of calcific fluid Small calcific nodules may progress to a large solid lobulated tumor The joint is not involved Fig 7.16 Pellegrini-Stieda calcification Curvilinear soft tissue calcification at medial aspect of the femoral condyle Fig 7.15 Calcified hematoma near the ankle joint www.MedLibrary.info 196 Bone Fig 7.17 Synovial sarcoma of the knee joint A large soft- tissue mass and small calcifications near the joint space (arrows) Table 7.4 Fig 7.18 Healed tuberculous arthritis of the right shoulder Severe deformity and soft-tissue calcifications (arrows) Connective tissue and muscular calcification or ossification (Figs 7.19−7.26) Associated Disorders Common Locations and Remark Idiopathic universal calcinosis (Fig 7.13) Scleroderma Dermatomyositis (Figs 7.19−20) systemic lupus erythematosus (rarely) Carbon monoxide poisoning (rare) Variable: neck, thorax, limbs Usually no ossification takes place Myositis ossificans progressiva (rare) (Fig 7.2) A rare hereditary connective tissue disorder Ectopic ossification in early childhood Neck, shoulders, proximal arms, pelvis Associated with short first metacarpals and metatarsals and finger or toe anomalies Parasitic calcifications: − Cysticercosis (Taenia solium) (Fig 7.22) Multiple, ovoid (about cm long and mm thick) calcifications have their long axis along muscle planes − Hydatid disease (Echinococcus) If calcifications occur in muscle, they tend to parallel the long axis of the limb − Guinea worm disease (Dracunculus medinensis) Small irregular or linear serpinginous calcifications measuring up to several cm (calcified female worm) in legs, abdominal, or thoracic muscles − Loiasis (Filaria loa loa) U- or V-shaped calcific dots in web spaces − Schistosomiasis (Schistosoma haematobium) Fibrosis and granulomatous calcification, more commonly in the lower urinary tract − Trichinosis (Trichinella spiralis) mm or less, rarely visible radiographically − Armillifer armillatus Multiple, comma-shaped peritoneal or pleural calcifications (continues on page 198) www.MedLibrary.info Joint and Soft-Tissue Calcification Fig 7.19 Dermatomyositis Extensive connective tissue calcification in the leg 197 Fig 7.20 Dermatomyositis Calcification of connective tissues Fig 7.22 Cysticercosis Multiple ovoid calcifications in the soft tissues of the leg Fig 7.21 Myositis ossificans progressiva Paraspinal soft-tissue ossification (arrows) associated with myositis in this region www.MedLibrary.info 198 Bone Table 7.4 (Cont.) Connective tissue and muscular calcification or ossification (Figs 7.19−7.26) Associated Disorders Common Locations and Remark Idiopathic or degenerative (Fig 7.23) Ligaments of the shoulder girdle and pelvis often calcify in normal individuals Fluorosis Paraspinal sacrotuberal and iliolumbal ligaments can calcify extensively in fluorosis Sclerosis of the axial skeleton is more diagnostic Traumatic or postoperative (Fig 7.2 B) Common around total hip replacement Periosteal due to hematoma (Fig 7.24) In early phase may mimic periosteal sarcoma, but is denser at the periphery, whereas sarcoma is denser at the center Neurological causes, especially paraplegia Myositis ossificans around hip joints is a common presentation Tumors: − Osteosarcoma − Chondrosarcoma Rarely develops in the soft tissues, and may show fuzzy or spicular calcification − Fibroma Small calcific flecks may be present in both benign and malignant tumors − Fibrosarcoma − Synovial sarcoma Most tumors are extra-articular and commonly show calcific flecks − Lipoma (Fig 7.25) Both benign and malignant tumor may contain extensive ossification Predilection in medial thigh and popliteal areas − Liposarcoma (Fig 7.26) − Metastases Bone-forming metastases occur in the carcinomas of the colon, breast, and urinary tract Leprosy Nerve abscesses of tuberculous leprosy are seen as soft-tissue masses which may calcify Fig 7.23 Calcified sacrotuberous ligaments (arrows), an incidental finding www.MedLibrary.info Fig 7.24 Calcification of periosteum and the interosseus ligament following hematoma Joint and Soft-Tissue Calcification Fig 7.25 Lipoma A low-density mass in the arm has a well-defined outline It contains a calcified spot characteristic of fat necrosis (arrow) Fig 7.26 Liposarcoma of the thigh with calcification www.MedLibrary.info 199 200 Bone Table 7.5 Subcutaneous calcification or ossification Associated Disorders Common Locations and Remark Dermatomyositis and other causes of generalized or circumscribed interstitial calcinosis (Fig 7.27) Thighs, abdomen, thorax, shoulders, neck, hands, feet Ehlers-Danlos syndrome Generalized inherited disorder of connective tissue and loose joints Fatty nodules in the subcutaneous tissue of the extremities may calcify They may mimic phleboliths, having central lucencies Pseudoxanthoma elasticum Hereditary systemic disorder with widespread premature degeneration of elastic fibers Middle and deep layers of the dermis may calcify, as well as tendons, ligaments, and large vessels Basal cell nevus syndrome Soft-tissue calcification can be a feature of this inherited disorder characterized by multiple basal cell carcinomas, palmar pits, dentigerous cysts of the mandible, anomalies of the spine and ribs, and brachydactyly, as well as neurologic abnormalities Postinjection or traumatic fat necrosis (or heavy metals) Irregular dense deposits in buttocks may contain heavy metals, but calcification of fat necrosis may follow injections of antibiotics etc Venous thrombosis Varicose veins Lower extremities, subcutaneous ossification secondary to chronic venous stasis Fig 7.27 Dermatomyositis with extensive subcutaneous calcification Fig 7.28 thigh www.MedLibrary.info Atheromatous calcifications in the arteries of the Joint and Soft-Tissue Calcification Table 7.6 201 Differential Diagnosis of Vascular calcifications Findings Associated Disorders Common Locations and Remarks Atheromatous calcifications (patchy) (Fig 7.28) Arteriosclerosis Aneurysm Takayasu’s arteritis Causes of premature atherosclerosis: familial hyperlipemia; secondary hyperlipemia (e.g., diabetes) Mainly medial sclerosis of arteries evident as parallel lines (Monckeberg’s medial sclerosis) (Fig 7.29) Idiopathic hypercalcemia syndromes Nephropathies Hypercalcemia syndromes: hyperparathyroidism, hypervitaminosis D, immobilization, milk-alkali syndrome, sarcoidosis, idiopathic, paraneoplastic, or secondary to massive bone destruction Calcified thrombus (rare) Venous thrombosis, varicose veins Seen as an irregular calcification along the course at an artery or, more commonly, a vein Phlebolith (small rounded opacities, characteristically with central lucencies) (Fig 7.30) Normal Common in pelvis, more rarely spleen, ankle, orbits Usually a localized collection of phleboliths Cavernous hemangioma associated with enchondromatosis is called Mafucci’s syndrome Lower extremities Angiomatous malformation Hemangioma Varicose veins Fig 7.29 Medial sclerosis of the branches of the femoral artery A case of renal failure Fig 7.30 Soft-tissue calcification associated with varicose veins Both ossifications (myositis ossificans) and calcified phleboliths (arrow) are seen www.MedLibrary.info 202 Bone www.MedLibrary.info ... with disability lasting to months Shoulder-hand syndrome (Fig 1. 18) Pain and stiffness in the shoulder combined with pain, swelling and vasomotor phenomena in the hand following an acute illness... breast carcinoma Fig 1. 20 Multiple myeloma Demineralization is most pronounced near the joints, as in reflex sympathetic dystrophy in Fig 1. 17 www.MedLibrary.info 14 Bone Table 1. 2 (Cont.) Differential. .. rickets (x-linked hypophosphatemia) and pseudo-vitamin D deficiency rickets (Figs 1. 11 and 1. 12) Proximal tubular resorption of phosphorus decreased Inherited (X-linked dominant and autosomal