Chapter 60 – 68 Report Bone and Joint Imaging by Resnick

Omar Naseef J. Abdua, MDLevel 1DORIS-SPMC

CHAPTER 60 – 68 Thermal, Iatrogenic,

Nutritional, and Neurogenic Diseases

Radiographic Findings Associated with Thermal andElectrical Injuries

Soft tissue swelling, loss, or contractureOsteoporosisAcro-osteolysisPeriostitisEpiphyseal injury and growth disturbanceArticular abnormalitiesPeriarticular calcification and ossificationOsteolysis, osteosclerosis, and fracture

CHAPTER 60 THERMAL AND ELECTRICAL INJURIES

Blood vessels are injured severely, thus circulation ofblood ceases, and the vascular beds within the frozen tissue are occluded by thrombi and cellular aggregation.

Musculoskeletal AbnormalitiesBony and articular manifestations of frostbite apparently

are related to cellular injury and necrosis from the freezing process itself or from the vascular insufficiency it produces.

Findings are most marked in the hands and the feet.

FROSTBITE

Early radiographic manifestations:- Soft tissue swelling and loss of tissue, especially at the

tips of the digits; - Osteoporosis and periostitis may occur at a slightly later

stage.Hand - findings predominate in the 4 medial digits*

Late skeletal manifestations: In children - epiphyseal abnormalities are frequent, involving primarily the distal phalanges. Fragmentation, destruction, and disappearance of epiphyseal centers are seen. Premature physeal fusion is

also noted, resulting in brachydactyly.

FROSTBITE

FROSTBITE

Late skeletal manifestations:- Interphalangeal joint abnormalities eventually may simulate those of osteoarthritis - Unilateral or bilateral changes, with joint space narrowing, sclerosis, osteophytosis, and soft

tissue hypertrophy, are seen.

FROSTBITE

FROSTBITE

DIFFERENTIAL DIAGNOSIS

Thiemann’s disease (epiphyseal acrodysplasia) Swelling of the fingers is associated with epiphyseal

irregularity, sclerosis, and fragmentation.Distribution of epiphyseal abnormalities, with sparing

of the distal phalanges, differs from that of frostbite. Unilateral changes and presence of subchondral cysts may aid

in differentiating frostbite arthritis from osteoarthritis.

FROSTBITE

Results in coagulative tissue necrosis with an inflammatory response.

2nd and 3rd degree burns Massive outpouring of protein-rich fluid results from

both endothelial capillary damage and interference with normal lymphatic absorption. Secondary bacterial invasion is frequent and contribute to ischemic necrosis of tissue.

THERMAL BURNS

Musculoskeletal Abnormalities Early Radiographic manifestations:

Soft tissue lossOsteoporosis – most frequent bony response Periostitis - appears within months after the injury

THERMAL BURNS

Musculoskeletal Abnormalities Late Radiographic manifestations:

Periarticular calcification* – not infrequent in 1 month and most common in the elbow

Periarticular ossification – evident in 2nd and 3rd month and most common in the elbow, less frequently in the hips and shoulder

Acromutilation w/ partial or complete loss ofphalanges may be a prominent finding when the hand orfoot is burned Contractures** are also frequently observed especially

about the elbow and hand.

THERMAL BURNS

THERMAL BURNS

THERMAL BURNS

DIFFERENTIAL DIAGNOSIS Radiographic findings of osteoporosis, periarticular calcification

and ossification, joint space loss, intra-articular bony ankylosis, and contracture that are encountered in burn patients may also be seen after paralysis (or immobilization)

Phalangeal tuftal resorption or destruction occurring after burns must be differentiated from similar changes occurring in association with frost bite, collagen vascular disorders, and articular diseases.

ELECTRICAL BURNS

Alternating currents, muscular contraction may prevent a person from releasing the source of electricity, leading to more prolonged and severe tissue damage

Resulting burns are accentuated by vascular spasm, leading to electrical necrosis.

Death from low-voltage electrical injury (<200 volts) usually is caused by ventricular fibrillation; death related to high-voltage electricity (>1000 volts) is caused by inhibition of the respiratory center in the brain

ELECTRICAL BURNS

Musculoskeletal Abnormalities

The hand, because of its grasping function, is the most commonly affected area

Osseous and articular changes are related to the effects of heat, mechanical trauma from accompanying uncoordinated muscle spasm, neural and vascular tissue damage, infection, disuse or immobilization

ELECTRICAL BURNS

Early Radiographic manifestations: loss of cutaneous, subcutaneous, and osseous tissues owing to tissue charring. Soft tissue hematomasDislocation of joints Avulsions at tendinous insertions related to muscle spasm;Various fractures resulting from accompanying falls

ELECTRICAL BURNS

Result of accidental exposure (e.g., radium dial workers) and of diagnostic (e.g., Thorotrast) and therapeutic procedures

Radiation therapy may affect bone growth, cause osseous necrosis, and induce neoplasia

CHAPTER 61 RADIATION CHANGES

Used therapeutically, both orally and intravenously in treatment of ailments between 1910 and 1930

Orally ingested radium is deposited mainly in the outer cortex of bone, and in the 1920s, it was found to cause radium jaw (a type of osteomyelitis), severe aplastic anemia, and osseous neoplasms in radium dial painters

Normal bone physiology becomes erratic, and large resorption cavities are formed.

RADIUM

These cavities contain gelatinous material with osteoid-like matrix and appear as sharply defined bone lesions resembling those of multiple myeloma.

They occur in the long bones and skull and increase in size over time.

Metaphyseal sclerosis is frequent, particularly in patients who ingest radium before physeal closure

Pathologic fractures can occur, and frequently they heal normally. Osteosarcomas, fibrosarcomas, carcinomas of PNS and mastoids have also been reported

RADIUM

RADIUM

THORIUM

Thorium dioxide in dextran (Thorotrast) was introduced as a contrast agent in 1928

Extravasation of Thorotrast at the site of injection leads to continuous alpha particle irradiation, resulting in an expanding cicatricial mass (Thorotrastoma) that invades contiguous structures, leading to tissue destruction and vascular compromise.

THORIUM

The injection of Thorotrast into growing children may give rise to a “bone-within-bone” or “ghost vertebra” appearance

Deposition causes constant alpha radiation and temporary growth arrest.

EFFECTS OF RADIATION THERAPY

Bone GrowthEffects include disruption of normal growth and maturation,

scoliosis, osteonecrosis, and neoplasmEpiphysis is the area of the bone that is most sensitive to

radiation. 400 cGy - Decreased growth 600 - 1200 cGy - rapid histologic recovery of radiation-

induced changes occurs1200 cGy or more - damage is increased and is maximal

to the chondroblasts The greater the growth potential of a particular bone, the

more drastic is the effect


Bone Growth Any skeletal part capable of growth that is exposed to 2000 cGy

or more will show growth disturbance In pediatric patients, irradiation of the growing epiphysis or

apophysis may cause shortening of long bones or hypoplasia of the ilium.

Metaphyseal changes, including irregularity, fraying, and sclerosis , may superficially resemble those of rickets.


Bone Growth


Slipped Capital Femoral EpiphysisThe damaged growth plate is unable to withstand the shearing

stresses of growth, leading to epiphyseal slippage


ScoliosisIrradiation to the spine is noted to produce this In general, a dose: < 2000 cGy - no deformity, 2000 - 3000 cGy - scoliosis of not > 20 degrees > 3000 - curvature > 20 degrees

Changes are more severe in patients treated before the age of 2 years


Scoliosis


Radiation Osteitis and OsteonecrosisEffects of radiation in mature bone are mainly on the

osteoblasts, with the primary event being decreased matrix production*

Historically, Ewing used the term radiation osteitis to define the effects of radiation on bone

Effects included temporary cessation of growth with recovery, periostitis, bone sclerosis with increased fragility, ischemic necrosis, and infection with osteoradionecrosis


Radiation Osteitis and OsteonecrosisDamage to mature bone;

<3000 cGy - very unusual 3000 to 5000 cGy - permanent damage, > 5000 cGy - cell death and permanent devitalization of bone

The vast majority of cases of radiation osteitis occur in the mandible (32%), with the clavicle (18%), humeral head (14%), ribs (9%), and femur (9%).


Regional EffectsMandible

Osteonecrosis is more common In children, may result in altered patterns of tooth eruption, including malformation of its rootNecrosis manifests as a poorly defined destructive lesion without sequestration


Regional EffectsSkull

Radiation injury after a maximum absorbed dose of 3600 cGy. Typical finding of is a mixed region

of lysis and sclerosis that starts in the epicenter of the radiation portal and extends outward to the margins of the portal*


Regional EffectsShoulder

Osteopenia is common after irradiation with a coarse, disorganized trabecular pattern, which may resemble Paget’s disease superficially.

Rib fractures and Clavicular fractures are also commonRadiation necrosis of the humerus can be seen 7 to 10

years after therapy, and usually symptomatic


Regional EffectsShoulder


Regional EffectsPelvis

Fractures of the femoral neck reported to occur in approximately 2%, 5 months therapy and usually subcapital in location Most fractures heal with routine treatment, with adequate callus formation



Although abnormalities about the sacroiliac joint (simulating those of osteitis condensans ilii and ankylosing spondylitis) are well documented after radiation, fractures represent a more significant complication.


Regional EffectsOther Sites

Radiation changes in other areas usually follow a similar pattern. Well-defined lucent shadows

are sometimes identified w/in the field of therapy. Small areas of trabecular

sclerosis or larger areas of ischemic necrosis may occur, and these may be complicated by superimposed infection.


Radiation-Induced NeoplasmsBenign Neoplasms.

Occur almost exclusively in patients who are treated during childhood, especially those who are < 2 yearsOsteochondromas (exostoses) are the most common benign radiation-induced tumors reportedMay be seen in any bone in the irradiated field usually within 5 years after therapy.


Malignant NeoplasmsOsseous changes usually

precede the development of radiation-induced tumors.

Radiation induced neoplasms form in areas that receive radiation sufficient to induce mutation but not enough to destroy the regenerating capacity of the bone.


Malignant NeoplasmsCriteria for the diagnosis of radiation-induced sarcoma : 1. There must be microscopic or radiographic evidence of a nonmalignant condition. 2. Sarcoma must arise within the irradiated field. 3. A long latent period must be present (at least 4 years). 4. Histologic proof of sarcoma must be available.On the basis of these criteria, radiation-induced sarcomas have

been documented in both soft tissue and bone.Sarcoma and malignant fibrous histiocytoma* were the most

common.


Magnetic Resonance ImagingUsed to assess the response of

malignant bone and soft tissue tumors to radiation therapy.

With regard to the marrow, studies indicate that both hemorrhage and fat contribute to the signal intensity characteristics seen on MR images after irradiation. Hemorrhage changes dominate in the early states (i.e., first few days) after radiation therapy. Subsequently, fat accumuates in the marrow.


Magnetic Resonance ImagingWith regard to soft tissues, MR imaging is useful in the

differentiation of radiation fibrosis from recurrent tumor. Radiation fibrosis usually has a low signal intensity similar to

that of muscle on both T1- and T2-weighted spin echo MR sequences;

In contrast, tumor clearly shows increased signal intensity, especially on T2-weighted spin echo images.

TERATOGENIC DRUGS

Thalidomide - When ingested during the 1st tri, produces reduction deformities of the limbs of the fetus.Anomalies - dysplasia of the thumb, radial hemimelia, phocomelia, or complete four-limb amelia; hypoplasia or aplasia of the external ear and canal, congenital heart defects, gastrointestinal tract atresia or stenosis, and capillary hemangioma of the face

CHAPTER 62 DISORDERS DUE TO MEDICATIONS AND

OTHER CHEMICAL AGENTS

Anticonvulsants - this (especially phenytoin) may lead to congenital anomalies in their infants, including hypoplasia of the distal phalanges, digitate thumb, cleft palate, decreased head circumference, and peculiar facies.

Alcohol - Infants born to severely and chronically alcoholic women may exhibit the fetal alcohol syndrome, consisting of prenatal and postnatal growth deficiency and delayed development. Findings may include clinodactyly, camptodactyly, congenital dislocation of the hip, pectus excavatum or carinatum, radioulnar synostosis, scoliosis, and vertebral fusion.

TERATOGENIC DRUGS

CHAPTER 68 OSTEOCHONDROSES

Definition:Disorders that are usually characterized by fragmentation

and sclerosis of an epiphyseal or apophyseal center in an immature skeleton

3 major categories:Conditions characterized by primary or secondary osteonecrosisConditions related to trauma or abnormal stress, without

evidence of osteonecrosisConditions that represent variations in normal patterns of

ossification

1. Legg-Calvé-Perthes Disease2. Freiberg’s Infraction3. Kienböck’s disease4. Köhler’s disease5. Panner’s disease6. Thiemann’s disease

CONDITIONS CHARACTERIZED BY PRIMARY OR SECONDARY OSTEONECROSIS

Aff ects children between the ages of 4 and 8 years, frequent in boys than girls (approximately 5:1)

Site: Femoral head with most cases involving one hipProbable Mechanism: Osteonecrosis, perhaps from

trauma

Clinical signs include:- Limping, pain, and l imitati on of joint moti on

Must be considered in any child with acute manifestati ons in the hip and those with chronic hip complaints

LEGG-CALVÉ-PERTHES DISEASE

Fundamental pathologic aberrati on:Femoral head osteonecrosis with structural failure

resulti ng to fl att ening and collapseHealing is characterized by revascularizati on of the

necroti c porti on of the femoral head

LEGG-CALVÉ-PERTHES DISEASEPATHOLOGIC ABNORMALITIES

LEGG-CALVÉ-PERTHES DISEASERADIOGRAPHIC ABNORMALITIES

Soft tissue distortion


Frog-leg projection


Metaphyseal “cysts”


Coxa plana and coxa magna

“Sagging rope” sign


Osteochondral fragment


LEGG-CALVÉ-PERTHES DISEASEOTHER DIAGNOSTIC METHODS

Arthrography Radionuclide examination

MRI:Used to identi fy infarcti on ofThe femoral head

Ultrasonography is used to: defi ne the presence of an eff usion & joint space widening in the hips Defi ne the extent of deformity of the femoral head

LEGG-CALVÉ-PERTHES DISEASEOTHER DIAGNOSTIC METHODS

Chapter 60 – 68 Report Bone and Joint Imaging by Resnick

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