Chapter 60 - 68 Report Bone and Joint Imaging by Resnick

CHAPTER 60 68
Thermal,
Iatrogenic,
Nutritional, and
Neurogenic
Diseases
Omar
Naseef J.
Abdua, MD
Level 1
DORISSPMC
CHAPTER 60
THERMAL AND ELECTRICAL
INJURIES
Radiographic Findings Associated with
Thermal and
Electrical Injuries
Soft tissue swelling, loss, or contracture
Osteoporosis
Acro-osteolysis
Periostitis
Epiphyseal injury and growth disturbance
Articular abnormalities
Periarticular calcification and ossification
Osteolysis, osteosclerosis, and fracture
FROSTBITE
Blood vessels are injured severely, thus
circulation of
blood ceases, and the vascular beds within
the frozen tissue are occluded by thrombi and
cellular aggregation.
Musculoskeletal Abnormalities
Bony 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
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
Thiemanns 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
THERMAL BURNS
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
Early Radiographic manifestations:
Soft tissue loss
Osteoporosis most frequent bony response
Periostitis - appears within months after the
injury
THERMAL BURNS
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 of
phalanges may be a prominent finding when the
hand or
foot is burned
Contractures** are also frequently observed
especially about the elbow and hand.
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
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 hematomas
Dislocation of joints
Avulsions at tendinous insertions related to
muscle spasm;
Various fractures resulting from accompanying
falls
ELECTRICAL BURNS
CHAPTER 61
RADIATION CHANGES
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
RADIUM
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 osteoidlike 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
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 Growth
Effects include disruption of normal growth and
maturation, scoliosis, osteonecrosis, and neoplasm
Epiphysis 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 occurs
1200 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
THERAPY
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.
THERAPY
Bone Growth
THERAPY
Slipped Capital Femoral Epiphysis
The damaged growth plate is unable to withstand
the shearing stresses of growth, leading to
epiphyseal slippage
THERAPY
Scoliosis
Irradiation 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
THERAPY
Scoliosis
THERAPY
Radiation Osteitis and Osteonecrosis
Effects 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
THERAPY
Radiation Osteitis and Osteonecrosis
Damage 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%).
THERAPY
Regional Effects
Mandible
Osteonecrosis is
more common
In children, may result
in altered patterns of
tooth eruption, including
malformation of its root
Necrosis manifests as
a poorly defined
destructive lesion
without sequestration
THERAPY
Regional Effects
Skull
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*
THERAPY
Regional Effects
Shoulder
Osteopenia is common after irradiation with a
coarse, disorganized trabecular pattern, which may
resemble Pagets disease superficially.
Rib fractures and Clavicular fractures are also
common
Radiation necrosis of the humerus can be
seen 7 to 10 years after therapy, and usually
symptomatic
THERAPY
Regional Effects
Shoulder
THERAPY
Regional Effects
Pelvis
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
THERAPY
Regional Effects
Pelvis
THERAPY
Regional Effects
Pelvis
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.
THERAPY
Regional Effects
Other 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.
THERAPY
Radiation-Induced
Neoplasms
Benign Neoplasms.
Occur almost exclusively in
patients who are treated during
childhood, especially those who
are < 2 years
Osteochondromas (exostoses)
are the most common benign
radiation-induced tumors
reported
May be seen in any bone in the
irradiated field usually within 5
years after therapy.
THERAPY
Malignant Neoplasms
Osseous 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.
THERAPY
Malignant Neoplasms
Criteria 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.
THERAPY
Magnetic Resonance
Imaging
Used 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.
THERAPY
Magnetic Resonance Imaging
With 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.
CHAPTER 62
DISORDERS DUE TO MEDICATIONS AND
OTHER CHEMICAL AGENTS
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
TERATOGENIC DRUGS
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.
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
osteonecrosis
Conditions related to trauma or abnormal stress,
without evidence of osteonecrosis
Conditions that represent variations in normal
patterns of ossification
CONDITIONS CHARACTERIZED
BY PRIMARY OR SECONDARY
OSTEONECROSIS
1.
2.
3.
4.
5.
6.
Legg-Calv-Perthes Disease
Freibergs Infraction
Kienbcks disease
Khlers disease
Panners disease
Thiemanns disease
LEGG-CALV-PERTHES DISEASE
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
hip
Probable Mechanism: Osteonecrosis, perhaps from
trauma
Clinical signs include:
- Limping, pain, and limitation of joint motion
Must be considered in any child with acute
manifestations in the hip and those with chronic hip
complaints
PATHOLOGIC ABNORMALITIES
Fundamental pathologic aberration:
Femoral head osteonecrosis with structural
failure resulting to fl attening and collapse
Healing is characterized by revascularization of
the necrotic portion of the femoral head
RADIOGRAPHIC ABNORMALITIES
Soft tissue
distortion
Frog-leg projection
Metaphyseal cysts
Coxa plana and coxa
magna
Sagging rope sign
Osteochondral fragment
OTHER DIAGNOSTIC METHODS
Arthrograp
hy
Radionuclide examination
OTHER DIAGNOSTIC METHODS
MRI:
Used to identify infarction of
The 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

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CHAPTER 60 68

Swelling of the fingers is associated with

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