RADD 2712 Yochum HO Pages 1-5

RADD 2712 Yochum HO Pages 1-5 - My»; 1, ,: We. - 0%“...

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Unformatted text preview: My»; 1, ,: We. - 0%“ 5:3: a 1:?! ‘L It“ It} Sim ) iin (W i A NEW SYSTEMATIC APPROACH TO BONE DISEASE FOUR RADIOGRAPHIC DENSITIES 1. Bone (the most dense —- radiopaque). 2. Water (muscle, tendons and organs — radiopaque). 3. Fat (juxa-articular, perirenal, flank stripe — radiolucent). 4, Air (lung, bowel, paranasal sinuses, least dense —the most radiolucent). THE SEVEN CATEGORIES OF BONE DISEASE: Congenital Arthritides Trauma Neoplasms Infections Nutritional, Metabolic and Endocrine (N, M, E) Vascular NQVU‘F‘WNT" PATTERNS OF PERIOSTEAL RESPONSE: 1. SOLID (Figure 1): A solid, uninterrupted proliferation of cortical bone which is often thick and at times wavy. This pattern of periosteal response usually denotes BENIGN disease. Some common causes ofthis type of periosteal proliferation are callus formation secondary to fracture, stasis varicosities in the lower extremities, and hypertrophic osteoarthropathy (pulmonary). 2. LAMINATED (ONION SKIN, INTERRUPTED) (Figure 2): This is a fine, delicate lamination of periosteal proliferation which assumes the appearance of finely layered onion skin. This pattern of periosteal response denotes AGGRESSIVE disease. The most common causes for such periosteal response are INFECTION and EWING’S SARCOMA. 3. SPICULATED (SUNBURST, RADIATING, SUNRAY) (Figure 3): This pattern of periosteal response is a very fine and delicate proliferation radiating from the cortex. These radiations are often at right ankles to the shaft of the bone, and in most cases represent a sign of a primary MALIGNANT bone tumor, such as OSTEOSARCOMA. This radiographic sign carries a very poor prognosis. 4. CODMAN’S REACTIVE TRIANGLE (Figure 4): This is created by a local and rapid periosteal response secondary to bone destruction, forming a sharp angle with the cortex, It may be produced by infection, malignant neoplasm and fracture repair. It is pathognomonic of no specific disease process. l l l l r t . . s y . Laminated l ’ spiculated Co’dman’s Triangle D. LODWlCK’S PATTERNS OF LYTlC BONE DESTRUCTION: 1. GEOGRAPHIC: This pattern of bone destruction presents as a large radiolucent hole with a very sharp zone of transition. Often a sclerotic border may encapsulate the lesion. it may be associated with bone expansion. This pattern of bone destruction suggests BENIGN disease. 2, MOTH—EATEN: This pattern of bone destruction presents as many radiolucent small holes with a hazy ill—defined zone of transition. There is no associated bony expansion. This pattern of destruction suggests an AGGRESSlVE disorder of bone, such as: a) Osteomyelitis b) Malignant bone tumors 3. PERMEATIVE: This pattern of bone destruction presents as many more radiolucent PlN—SlZED holes with hazy ill—defined zones of transition. No sclerotic border is associated with these radiolucent lesions and there is no evidence of bony expansion. This pattern of destruction suggests a MALIGNANT change in bone, the most common causes being: a) Osteolytic metastatic carcinoma (most common) b) Multiple myeioma c) Ewing’s sarcoma Geographic Motheaten Permeative ASSOCIATED SPECIAL STUDIES Radioisotopic bone scan is the most accurate and sensitive mechanism of detecting bone destruction. It requires approximately 30% destruction of bone before these aforementioned patterns of lytic bone destruction can be appreciated on plain film radiographs in the extremities and approximately 50% of destruction in the spine before lytic loss of bone density can be detected. However, bone scans are sensitive at a 36% rate of bone destruction, giving a much higher degree of accuracy, MRI scans are sensitive to 1~3% marrow replacement. Table i ‘ BENIGN VER_§US MALIGNANT LESIONS A A W iiiiiii w BENIGN MALIGNANT Geographic Moth—eaten and permeative Solid periosteal response 7 Laminated or spiculated periosteai response l Cortex intact Cortical disruption No soft tissue mass Soft tissue mass may be present Sharp zone_of transition Wide zone of transition INFECTION VERSUS NEOPLASM The patterns of bone destruction are often the same, being permeative or moth—eaten in nature. Periosteal responses are more consistently found in infections of bone than neoplasms; however, the pattern of periosteal response is the important finding, since a spiculated pattern is more common in malignant neoplasm and laminated being more common in the infectious disorders of bone. There are of course exceptions to this rule, since Ewing’s sarcoma or bone will often produce a laminated periosteal response. The soft tissue planes often are a helpful differential point when the clinician is faced with the decision of whether an appearance is infectious or neoplastic. With the presence of soft tissue extension from an osseous lesion, the following differential points are helpful: 1. Neoplasms will distort and push the myofascial planes, but they in fact will not obliterate the margins. 2. infectious disorders will obliterate the margins of the myofascial planes as a result of the water density (edema) associated with the infectious process (pus and effusion) silhouetting their margins. MRl scans will show the edema in the soft tissues very clearly. These subtle differences are often very difficult to appreciate on radiographs, but do provide a helpful differential point when present on optimum quality films. ROENTGEN SIGNS A. GROUND GLASS APPEARANCE: This roentgen sign is found associated with a radiolucent geographic lesion. There is a slight increase in density woven through this radiolucent lesion which is often of fibrous matrix and mixed superimposed osteoid tissue. This has often been referred to as a “smoky” or “wipe out of the trabeculae” appearance. The most common disorder associated with this appearance is fibrous dysplasia. B. TRABECULATION (SOAP BUBBLE, MULTLCHAMBERED OR COMPARTMENTALIZATION): This represents an apparent compartmentalization or chambering of a radiolucent lesion which is often geographic in its presentation. The FEGNOMASHIC mnemonic applies here: Fibrous dysplasia Enchondroma Giant cell tumor Non~ossifying fibroma Osteoblastoma Multiple myeloma, Metastasis Aneurysmal bone cyst Simple bone cyst Hyperparathyroidism, Hemophilic pseudotumor infection Chondroblastoma C. MATRlX TYPES: i. Cartilage: Cartilagenous lesions often show evidence of punctuate or snowflake calcifications. The rings or broken rings appearance is characteristic. 2. Fat: Radiolucent with no calcification usually noted. 3. Fibrous: Radiolucent in appearance, often with associated ground—glass appearance. 4. Bone: An increase in radiopacity with trabecular patterns and cortex. D. BONE EXPANSION: This sign does not denote benign or malignant disease. Often, the most benign disorders may show huge expansion of bone with the peripheral cortex intact. With minimal trauma, many benign expansile disorders may show pathological fracture through a single margin of the cortex. This should not be confused as a roentgen sign of malignant disease in those circumstances. References: 1. Yochum TR, Rowe LJ: Essential of Skeletal Radiology, 3” ed, Lippincott, Williams and Wilkins, Baltimore, Maryland, 2005. 2. Resnick D, Niwayama G: Radiographic and Pathological features of Spinal Involvement in Diffuse Idiopathic Skeletal Hyperostosis (DISH), Radiology 119:559, 1976. ...
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