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Soft Tissue Calcification and Ossification
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Soft-tissue Calcification Metastatic Calcification =deposit of calcium salts in previously normal tissue (1) as a result of elevation of Ca x P product above 60-70 (2) with normal Ca x P product after renal transplant Location:lung (alveolar septa, bronchial wall, vessel wall), kidney, gastric mucosa, heart, peripheral vessels Cause: (a)Skeletal deossification 1.1° HPT 2.Ectopic HPT production (lung / kidney tumor) 3.Renal osteodystrophy + 2° HPT 4.Hypoparathyroidism (b)Massive bone destruction 1.Widespread bone metastases 2.Plasma cell myeloma 3.Leukemia (c)Increased intestinal absorption 1.Hypervitaminosis D 2.Milk-alkali syndrome 3.Excess ingestion / IV administration of calcium salts 4.Prolonged immobilization 5.Sarcoidosis (d)Idiopathic hypercalcemia
Dystrophic Calcification =in presence of normal serum Ca + P levels secondary to local electrolyte / enzyme alterations in areas of tissue injury Cause: (a)Metabolic disorder without hypercalcemia 1.Renal osteodystrophy with 2° HPT 2.Hypoparathyroidism 3.Pseudohypoparathyroidism 4.Pseudopseudohypoparathyroidism 5.Gout 6.Pseudogout = chondrocalcinosis 7.Ochronosis = alkaptonuria 8.Diabetes mellitus (b) Connective tissue disorder 1.Scleroderma 2.Dermatomyositis 3.Systemic lupus erythematosus (c)Trauma 1.Neuropathic calcifications 2.Frostbite 3.Myositis ossificans progressiva 4.Calcific tendinitis / bursitis (d)Infestation 1.Cysticercosis 2.Dracunculosis (guinea worm) 3.Loiasis 4.Bancroft filariasis 5.Hydatid disease 6.Leprosy (e)Vascular disease 1.Atherosclerosis 2.Media sclerosis (Mönckeberg) 3.Venous calcifications 4.Tissue infarction (eg, myocardial infarction) (f)Miscellaneous 1.Ehlers-Danlos syndrome 2.Pseudoxanthoma elasticum 3.Werner syndrome = progeria 4.Calcinosis (circumscripta, universalis, tumoral calcinosis) 5.Necrotic tumor
Generalized Calcinosis (a)Collagen vascular disorders 1.Scleroderma 2.Dermatomyositis (b)Idiopathic tumoral calcinosis (c)Idiopathic calcinosis universalis
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Exclude underlying bone disease
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OMOM
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JCCJCC
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DEHDEH
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MafMaf
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ExcludeOSSIFICATION
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OssificationLook for:
• Trabeculation
• Cortico-medullary differentiation
• Fat on T1
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Soft TissueOssification
• Trauma
• Neoplastic
• Congenital
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ST Ossification
Traumatic• Post Operative
• Within scars
• Myositis Ossificans
• Burns
• Paraplegia
• Head Injury
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OssificationTraumatic
Post operative
• Following joint arthroplasty-heterotopic– Radiation, NSAIDs and Etindronate
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ASAS
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OssificationTraumatic
Myositis Ossificans
• Direct blow
• Adductor longus-Rider’s bone
• Brachialis-Fencer’s bone
• Soleus-Dancer’s bone
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Myositis Ossificans• 4/52 Faint peripheral Ca
– Periosteal reaction
• 8/52 Circumscribed cortex– Central lacy pattern
• 5/12 Maturity
• >6/12 Regression– Separate from bone
• 1 year Usually disappears– Periosteal reaction remains
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12/712/7 12/712/7 2/122/12
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Post Traumatic Myositis Ossificans
Centrifugal Ossification
Neoplastic Soft Tissue Ossification
Centripetal Ossification
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PTMOPTMO
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OssificationTraumatic
Tendons and Ligaments• Calcification common, Ossification rare
• MCL knee - Pellegrini-Stieda
• Coracoclavicular
• Achilles tendon
• Supraspinatus
• Stylohyoid ligament XS - Eagle syn.
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SST OssSST Oss
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OssificationTraumatic
Burns
• Commonly elbow
• Occurs distal to burn
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BurnBurn
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Ossification
Traumatic
Paraplegia
• Approx. 40%
• Usually in paralyzed parts
• Muscles, tendons and ligaments
• Large joints
• Often causes ankylosis
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ParaplegiaParaplegia
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Ossification
Neoplastic• Parosteal osteosarcoma
• Liposarcoma
• Florid reactive periostitis
• Pseudomalignant osseous tumour of soft tissues
• Cortical desmoid
• Extra skeletal osteosarcoma
• Juxta cortical chondroma
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PaOSPaOS
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PMOTSTPMOTST
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CDCD
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OSOS
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Ossification
Congenital• Fibrodysplasia ossificans progressiva
– (Myositis OP)– (Fibrositis OP)
• Melorheostosis
• Osteoma cutis
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FDOPFDOP
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MM OCOC
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CALCIFICATION
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Calcification
• By cause
• By shape / morphology
• By site
• By distribution
• By age
• By Aunt Mini
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Soft Tissue Calcification
By Cause
• Metastatic– Disturbance in Calcium or Phosphate
• Generalized Calcinosis– Normal Calcium or Phosphate
• Dystrophic– Damaged or devitalized tissue
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Soft Tissue Calcification
By Cause Metastatic Calcification
• Hyperparathyroidism
• Hypoparathyroidism
• Renal Osteodystrophy
• Hypervitaminosis D
• Milk Alkali
• Sarcoidosis
• Massive bone destruction– Mets., Myeloma, Leukaemia
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HPTHPT
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HypoPTHypoPT
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Soft Tissue Calcification
By Cause Generalized Calcinosis
• Collagen disorders
• Idiopathic tumoral calcinosis
• Idiopathic calcinosis (interstitialis) universalis
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Soft Tissue Calcification
By Cause Generalized Calcinosis
Collagen Disorders• Systemic Lupus Erythematosus
• Dermatomyositis
• Scleroderma
• Raynauds
• CREST
• Ehlers Danlos
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Soft Tissue Calcification
By Cause Generalized Calcinosis
Collagen Disorders• Great variety of appearances
• Overlap in diseases and patterns MCTD
• May be local or generalized
• Linear, lacy,tumoral
• Deep or superficial
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SLE
• Diffuse • Linear, Streaky,
Nodular• Subcutaneous or deep• Uncommon• Lower limb
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Dermatomyositis• Childhood• Muscles and subcutaneous• Linear or lacy• Proximal
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Scleroderma
• Hands and pressure areas
• Acro-osteolysis• Soft tissue changes• Subluxations
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Ehlers-Danlos
• Subcutaneous• Spherules• 2-10mm• Random orientation• Distal
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Soft Tissue CalcificationBy Cause
Generalized Calcinosis Idiopathic Tumoral Calcinosis
• 10-30Yrs, black
• Elevated phosphate
• Single or multiple firm tumour like painless
• Hips, Shoulders, Elbows, Ankles
• Dense, Flocculent, Amorphous,
• 1-20cm, fluid levels
• Dx of exclusion
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ITCITC
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Soft Tissue CalcificationBy Cause
Generalized Calcinosis Idiopathic Calcinosis Universalis
• Infants and children, rare
• Initially subcutaneous fat of extremities
• Longitudinal bands
• DDxHyperparathyroidismDermatomyositisFat necrosisExtravasation of Ca gluconate
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Soft Tissue Calcification
By Cause Dystrophic Calcification
• Neoplastic
• Trauma
• Inflammatory
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Soft Tissue Calcification
By Cause Dystrophic Calcification
Neoplastic
• Synovial sarcoma
• Liposarcoma
• Any less commonly
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SSSS
Dystrophic NeoplasticDystrophic Neoplastic
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CSCSDystrophic NeoplasticDystrophic Neoplastic
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HADDHADD
Dystrophic TraumaticDystrophic Traumatic
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Dystrophic TraumaticDystrophic Traumatic
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TBTB
Dystrophic InflammatoryDystrophic Inflammatory
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Calcification
By ShapeMorphologic descriptive terms
• Calcinosis universalis– Widespread
• Calcinosis circumscripta– Localized
• Tumoral calcinosis– Mass like
• Add idiopathic prefix for a single disease entity
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Calcification
By Shape
Morphology
• Linear and Curvilinear
• Conglomerate (Tumoral)
• Sheets
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Calcification
By Shape
Linear and Curvilinear• Arterial
– Atheroma,Aneurysm,Diabetes, HPT, Progeria,Werner’s
• Nerve– Leprosy, Neurofibromatosis
• Tendon and Ligament– Tendinitis, AS, Ochronosis, Fluorosis,Diabetes
• Injection– Bismuth, Arsenic, Quinidine
• Parasite– Cysticercosis,Guinea worm, Loa Loa, Armillifer armillatus
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PAPAPhlPhl
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FluFluCPPDCPPD
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CCCC
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GWGW
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LLLL
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Calcification
By Shape Tumoral calcinosis
DDX
• Idiopathic
• Renal osteodystrophy
• Gout
• Hypervitaminosis D
• Hyperparathyroidism
• Collagen vascular Disease
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ITCITC
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CAPDCAPD
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TGTG
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SclScl
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CalcificationBy shape
Sheets of Calcification
• Dermatomyositis
• Fibrodysplasia ossificans progressiva
• Venous stasis
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VSVS
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CalcificationBy shape
Some characteristic shapes
• Circle or oval, lucent centre– Phlebolith, Spherule, Cysterci
• Reticulated– Dermatomyositis
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EDED
PhlPhl
CCCC
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Calcification
By site• Generalized
• Localized– Periarticular– Tendons and bursa– Finger tips– Articular cartilage– Disc– Pinna
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Calcification By site
Periarticular• Hyperparathyroidism
• Renal osteodystrophy
• Milk alkali syndrome
• Hypervitaminosis D
• Collagen vascular disease
• Exclude intraarticular
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HPTHPT
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SclScl
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IABIAB
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PSOCPSOC
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Calcification By site
Tendons and Bursa
• Calcium hydroxyapatite deposition disease
• Calcium pyrophosphate dihydrate deposition disease
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Calcification By site
Tendons and Bursa
CPPD MCPCDD HADD• Linear
• Articular• Achilles,Quads,Tri• Ass. arthritis
• Rounded• Amorphous• Tendons and Bursa• Rotator cuff
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HADDHADD
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HADDHADD
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HADDHADD
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HADDHADD
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HADDHADD
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HADDHADD
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CPPDCPPD
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CPPDCPPD
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CPPDCPPD
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Calcification By site
Finger Tips
• Scleroderma
• CREST
• Dermatomyositis
• Trauma
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Calcification By site
Articular cartilage• Osteoarthrosis
• CPPD
• HADD
• Hyperparathyroidism
• Haemochromatosis
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CPPDCPPD
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CPPDCPPD
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Calcification By site
Pinna• Thermal
• Endocrine
• Perichondritis
• CPPDGout
• Dermatomyositis
• Alkaptonuria
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AlkapAlkap
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Calcification By site
Intervertebral disc• Trauma
• CPPD
• Hyperparathyroidism
• Immobilization
• Alkaptonuria
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Calcification By site
Intervertebral Disc Calcification
• Nucleus pulposus
• Annulus fibrosis– Inner– Outer
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Calcification By site
Intervertebral Disc Calcification
Nucleus Pulposus• Degenerative spondylosis (Dorsal)
• Ankylosing spondylitis
• Juvenile chronic arthritis
• DISH
• Gout
• Idiopathic– Children - transient– Adults - persistent
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IdioIdio
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Calcification By site
Intervertebral Disc Calcification
Annulus Fibrosis• Inner fibres– Alkaptonuria (Ochronosis)
• Outer fibres– CPPD– Haemochromatosis– Following spinal fusion
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Calcification By site
Distribution of Collagen Vascular disease
• Proximal– Dermatomyositis
• Distal– Ehlers Danlos– Scleroderma
• Lower limb– SLE
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Calcification
By age• Idiopathic calcinosis universalis
• Dermatomyositis
• Hyperparathyroidism
• Osteoma cutis
• Albright’s hereditary osteodystrophy
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By Aunt Mini
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