Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

“Don’t Touch” Lesions

Auntminnie diagnosis that do not need a biopsy

– more importantly you the radiologist can

prevent any further painful or costly work-up.

Three categories :

Posttraumatic

Normal variants

Benign lesions

Dr Ahmed Esawy

Calcaneal

pseudocyst

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Conclusion

normal variants are common

but maintain high degree of

suspicion of pathology

Dr Ahmed Esawy

Myositis Ossificans

Findings: Circumferential calcification with a lucent center.

Best seen on CT

Sometimes associated with periosteal reaction.

Biopsy should be avoided since aggressive histologic appearance can mimic a sarcoma which then

can lead to unfortunate radical surgery! Dr Ahmed Esawy

Avusion Injury

Common in characteristic locations at ligament and tendon insertion sites. Biopsy can be misleading because healing avulsion may mimic malignant histology. Even further imaging like MRI can lead one towards biopsy. Rather good clinical correlation and at the most follow up films in several weeks are a better option. Dr Ahmed Esawy

Cortical desmoid

Dr Ahmed Esawy

Well Healed Cortical Desmoid

Dr Ahmed Esawy

Geodes

Young soccer player with painful hip.

Dr Ahmed Esawy

Fracture

Fracture mimiking osteosarcoma

Dr Ahmed Esawy

Pseudodislocation of the Humerus

Fracture with hemarthrosis causing distension of the joint and inferior subluxation of the

humerus.

AP view can mimic a posterior dislocation.

Get axillary or scapular Y view to asses for dislocation. Dr Ahmed Esawy

Dorsal Defect of the Patella

Normal variant

Dr Ahmed Esawy

Pseudocyst of the Humerus

Normal variant

Hyperemia and disuse caused by rotator cuff problems may increase the lucency in this region.

Very characteristic location for pseudocyst. However, chondroblastoma, infection ,or even

metastasis is still possible in this location Dr Ahmed Esawy

Os Odontoideum

Normal variant which demonstrates unfused dens to the body of C2. Although this still may cause instability especially in the setting of acute trauma, if well corticated then you can assume that there is no ACUTE fracture. Additional finding of densely corticated anterior arch of C1 presumably due to compesnatory hypertrophy.

Dr Ahmed Esawy

Os Odontoideum

Dr Ahmed Esawy

Os Odontoideum

Dr Ahmed Esawy

Non ossifying fibroma

Similar to fibrous cortical defect except for the larger size (greater than 2 cm)

Lytic lesion in the cortex of the metaphysis.

Well-defined with scalloped borders.

Always in younger patients (less than 30 years)

Involute as patient grows

Clinically asymptomatic and never leads to malignant degneration – no biopsy needed Dr Ahmed Esawy

Healing NOF

Cortically based lytic lesion with sclerotic margins indicating healing and involution.

May have increased radiotracer activity on bone scan.

Again, clinically patient is asymptomatic.

NO BIOPSY ! Dr Ahmed Esawy

Bone Islands

Always asymptomatic. Can it be metastatic disease? (especially when as large as the one we just looked at?) Two distinguishing characteristic A. Oblong in shape with long axis is along the axis of stress. B. Margins show bony trabeculae extending from the lesion into normal bone in a spiculated fashion.

Dr Ahmed Esawy

Bone Island

Spiculated appearance of bony trabeculae

Extending from the bone island

Dr Ahmed Esawy

Unicameral bone cyst

Characteristic location – anteroinferior portion

of the calcaneus

Only differential is psedocyst of the calcaneus.

Dr Ahmed Esawy

Dr Ahmed Esawy

Unicameral bone cyst

Dr Ahmed Esawy

Early Bone Infarct

Mixed lytic-sclerotic pattern which can resemble a permeative process.

Consider the diagnosis for patients with sickle cell anemia or systemic lupus erythematosus.

MRI can be helpful to avoid biopsy due to the characteristic serpiginous pattern

Dr Ahmed Esawy

MRI of Bone Infarction

Dr Ahmed Esawy

Bone Infarction

Dr Ahmed Esawy

Sorry, not bone infarct!!

Enchondroma

Bone Infart!

Dr Ahmed Esawy

Dr Ahmed Esawy

Miscellaneous

non-touch Bone Lesions Achondroplasia

Avascular necrosis

Hypertrophic pulmonary osteoarthropathy

Melorheostosis

Mucopolysaccharidoses

Multiple Hereditary Exostosis

Osteoid Osteoma

Osteopathia Striata

Osteopoikilosis

Pachydermoperiostosis

Sarcoidosis

Transient Osteoporosis of the hip

Dr Ahmed Esawy

Melorheostosis

Thickened cortical new bone that accumulates near the ends of long bones, usually only on

one side of the bone

“Dripping candle wax”

Can be symptomatic Dr Ahmed Esawy

Hypertrophic pulmonary osteoarthropathy

Manifested by clubbing of the fingers and periostitis May or may not be associated with bone pain. Associated with lung cancer, bronchiectasis, GI disorders, and liver disease. The actual mechanism of formation of periostitis secondary to a distant malignancy or other process is unknown. Differential diagnosis for periostitis in a long bone without an underlying bony abnormality would include : venous stasis thyroid acropachy Pachydermoperiostosis trauma

Dr Ahmed Esawy

Achondroplasia

The most common cause of dwarfism is achondroplasia

Congenital, hereditary disease of failure of endochondral bone formation.

Characteristic finding is that the spine typically has narrowing of the interpedicular

distances in a caudal direction

Achondroplasia causes rhizomelic dwarfism Dr Ahmed Esawy

Achondroplasia

Narrowed AP canal.

Scalloped posterior vertebra

Dr Ahmed Esawy

Patient on steroids AVN

Lack of blood supply with subsequent bone death

and ensuing bony collapse in an articular surface

Etiology of AVN most commonly includes trauma,

steroids, aspirin, collagen vascular diseases,

alcoholism, and idiopathic causes Dr Ahmed Esawy

Avascular Necrosis

Dr Ahmed Esawy

Avascular Necrosis

Early

Late

Dr Ahmed Esawy

Hurler Syndrome

central anterior projection or “beak” off the vertebral body, as viewed on a lateral plain film

Dr Ahmed Esawy

Morquio

Dr Ahmed Esawy

Hurler

Notch at base of 5th MCB

Dr Ahmed Esawy

Transient Osteoporosis of the Hip

7 month later

Dr Ahmed Esawy

Multiple Hereditary Exostosis

diaphyseal aclasia

Dr Ahmed Esawy

Multiple Hereditary Exostosis

Dr Ahmed Esawy

Osteoid Osteoma

Dr Ahmed Esawy

Osteoid Osteoma

Dr Ahmed Esawy

Osteopathia Striata

Also known as Voorhoeve disease

This disorder is manifested by multiple 2- to 3-mm-thick linear bands of sclerotic bone aligned

parallel to the long axis of a bone

It usually affects multiple long bones and is asymptomatic; hence, it is usually an incidental finding. Dr Ahmed Esawy

Osteopoikilosis

Clue: Patient is asymptomatic

Osteopoikilosis is an hereditary, asymptomatic disorder that is usually an incidental finding of

multiple small (3 to 10 mm) sclerotic bony densities affecting primarily the ends of long bones and

the pelvis

It has no clinical significance other than that it can be confused for diffuse osteoblastic metastases.

Dr Ahmed Esawy

Sarcoid

When sarcoid affects the musculoskeletal system is involved, the hands are most often affected, with the spine and long bones only infrequently involved. Sarcoid causes a characteristic lacelike pattern of bony destruction in the hands. Multiple phalanges are typically affected in either one or both hands. Auntminnie diagnosis. Dr Ahmed Esawy

Hyoid bone:

The hyoid bone is considered a lingual bone

The hyoid bone consists of a central body and paired lateral

greater and lesser horns

The line of fusion of the body and greater horns of the hyoid

bone should not be mistaken for a fracture

Dr Ahmed Esawy

Normal lucency (white arrowhead) between the body and greater cornus of the hyoid bone is seen. Large arrow, omohyoid muscle; small arrow platysma muscle. Dr Ahmed Esawy

GOODBYE AND GOOD

IMAGING!

Dr Ahmed Esawy

Accessory bones of the foot 21 accessory bones of the foot have been discovered (includes the sesamoid

bones)

25% of the feet of adults and 22% of the feet of children under 16 years of

age have roentgenographic evidence of one or more accessory bones.

Os trigonum – lokal pain (simptomatic treatment, excission)

Accessory Navicular bone – local tenderness from pressure of the shoe (

excision of bone and fixation of the posterior tibial tendon)

os tibiale

externum

os

peroneum

Accessory

Navicular

Os

Trigonum

Os

vesalinum

Dr Ahmed Esawy

Os Styloideum (Carpal Boss)

Dr Ahmed Esawy

os trigonum

Dr Ahmed Esawy

Os calcaneus secundarius

Dr Ahmed Esawy

Accessory Navicular (Os Tibiale

Externum, Os Naviculare

Secundarium)

Dr Ahmed Esawy

type II accessory navicular (arrow) articulating with the medial aspect

of the navicular bone, with irregular articulating surfaces and

osteophytes

Dr Ahmed Esawy

lateral radiographs show fragmentation/fracture of an os peroneum (arrows) and a transverse fracture of the fifth metatarsal base (arrowheads).

The os peroneum is an oval or round ossicle located within the substance of the distal peroneus longus tendon near the cuboid.

Dr Ahmed Esawy

Os Intermetatarseum

os intermetatarseum situated between the first and second

metatarsal bases (arrow). Dr Ahmed Esawy

Hallux Sesamoids

transverse fracture through the central portion of the tibial hallux

sesamoid bone, with mild distraction of the 2 fragments (arrows). Dr Ahmed Esawy

Hallux Sesamoids

Dr Ahmed Esawy

CHRONIC HINDFOOT PAIN

SUSPECT: Calcaneus stress fx

Talar neck stress fx

Subtalar arthritis

Painful os trigonum

Haglund’s deformity

Tarsal coalition (Calcaneonavicular coalition seen on foot oblique), Obtain foot 3-v as well

Calcaneus 2-v

Lateral, Harris-Beath

ACR: 9

Dr Ahmed Esawy

Incidental

finding on

knee xray

Fabella = posterior sesmoids or

little confused knee caps Dr Ahmed Esawy

Os Acromiale

Dr Ahmed Esawy

Os Subfibulare: Case report of a

painful fibular accessory ossicle

The AP and Oblique radiograph showing a large accessory ossicle or os subfibulare to the

tip of the lateral malleolus. The accessory ossicle is at the anterior medial portion of the

malleolus giving it a bifid appearance. Dr Ahmed Esawy

CT images show a fibular ossicle or os subfibulare at the

distal end of the fibular with pseudo-arthrosis. Dr Ahmed Esawy

3-dimensional CT reveals a large accessory ossicle or

os subfibulare to the tip of the lateral malleolus with

pseudo-arthrosis of the fragment

Dr Ahmed Esawy

Illustration of lateral foot shows os peroneum (white

arrow) and peroneus longus tendon (black arrows.)

Dr Ahmed Esawy

fracture of os peroneum and full-thickness tear of peroneus longus tendon . Dr Ahmed Esawy

os peroneum fracture and full-thickness peroneus longus tendon tear .(

Dr Ahmed Esawy

fracture of os peroneum and full-thickness peroneus longus tendon tear .(

Dr Ahmed Esawy

Unipartite os peroneum

Dr Ahmed Esawy

Bipartite os peroneum .

Dr Ahmed Esawy

We have reviewed a spectrum of pathology

involving accessory ossicles and sesamoid bones.

These normal anatomic variations may, in fact,

represent the source of patient symptomatology.

The identification of key imaging characteristics

can help determine whether or not to attribute

clinical symptoms to these structures

Dr Ahmed Esawy