X-RAY DIAGNOSTICS – DR



X-RAY DIAGNOSTICS – DR. KUHN

FINAL EXAM MATERIAL

I am under the impression that the final exam is cumulative and quite possibly the final slide exam as well. To be on the safe side, review all of my past notes, lines of mensuration and look back at main topics and pictures discussed in Yochum.

Good Luck!!

Now, back to where we left off…

SUDECK’S ATROPHY

- Also known as RSD – Reflex Sympathetic Dystrophy (trivial trauma that affects the Nervous System can cause sympathetic overdrive so, hence the name)

- Saw a left PA hand of a patient that complained of tactile sensitivity to touch and cold.

- We saw decreased bone density; especially around the cortex and w/in the medullary cavity.

- Sudeck’s Atrophy is characterized by decreased bone density and patchy osteopenia that’s regionalized to bones of the wrist and hand.

- Another view demonstrated a transverse fracture of the distal end of the radius and compaction. Again, we see regionalized osteopenia in the carpal bones.

- This case was found on a routine x-ray when a patient had a protective fall. RSD after a fracture is common.

- Another view demonstrated AP wrist and forearm. We saw a transverse fracture of distal radius and 2 screw holes in radius from previous plating. Surgery may have caused this case of RSD.

- This patient felt more bone pain, was unable to shake hands w/ this hand, was very sensitive to cold, the skin on the hand was thinner, the hand muscles began to atrophy. These are all common signs/symptoms of Sudeck’s Atrophy or RSD.

- This is considered self-limiting if caught early (w/in 1 yr.) – electric stim, ultrasound, acupuncture and Ca++ supplementation are all very beneficial.

NUTRITIONAL DEFICIENCIES

RICKETS

- This is a form of osteomalacia (bone softening) caused by a vitamin D deficiency. (Ca++ and phosphorus are usually deficient in Rickets as well… vit. D mainly)

- Produces…weaker, softer, bowed bones (from weight bearing)

- The ZPC will be interrupted/absent if Rickets is left untreated.

- “Rickets RARIFIES the ZPC”

- The ZPC will return to normal when deficiency is treated.

SCURVY

- This form of osteomalacia is caused by a vitamin C deficiency.

- Produces…bone softening and wide metaphysis

- The ZPC will be thick and white when untreated

- “Scurvy SCLEROSES the ZPC”

- The ZPC will return to normal when deficiency is treated.

- Look up Winberger’s Sign of Scurvy

Both Rickets and Scurvy produce bumps along the costocartilage junctions of the ribs (usually on the anterior chest)…called Ricketic Rosary w/ Rickets and Scorbitic Beads w/ Scurvy.

HPT – Hyperparathyroidism

- Chronic low serum levels of Ca++ trigger this disorder. These low serum Ca++ levels triggers parathormone to be released in increased amounts.

- Increased levels of parathormone causes the following…

1. The kidney will be more conservative w/ Ca++ retention

2. 1,25 dihydroxycolcalciferol will act on the small intestine to take out more Ca++

3. Ca++ will also be harvested from bone, leaving behind softer and weaker bone.

- Saw a PA hand view and it demonstrated the classic “metastatic calcification” that goes along w/ HPT. Metastatic calcification is Ca++ deposition along vessel walls.

- The hand is the most sensitive view on plain film for locating HPT.

- As explained above, increased parathormone will cause Ca++ to be retrieved from urine, diet and from bone.

- Acroosteolysis (thin, brittle and stumpy bones) and Rugger Jersey Spine are features or consequences of increased parathormone and HPT. Another feature of HPT is concavity formations along radial sides of proximal phalanges.

- HPT is an example of Generalized Osteopenia.

- 3 forms of HPT:

□ Primary – parathyroid tumor – parathormone is pumped out continuously.

□ Secondary – acute renal disease; kidney has hard time recovering Ca++ (hypercalcuria) – this leads to body’s perception of low serum Ca++ so it increases parathormone to harvest Ca++ from other sources. Acute renal disease will reverse if the underlying cause is treated. Chronic renal disease is life threatening.

□ Tertiary – this is end stage renal disease (90% or more of kidneys are damaged) and the patient is put on dialysis.

- Increasing Ca++ and vitamin D supplementation is good treatment advice.

- Be careful when looking at slides of HPT and Piknodysostosis. These 2 resemble each other but HPT is an endocrine disorder while Piknodysostosis is a skeletal dysplasia.

GROWTH HORMONE

❖ GH increase in a skeletally immature person will result in GIGANTISM. This occurs because GH targets enchondral bone. In a younger person, the growth plate is still intact, so the person becomes overly tall.

❖ GH increase in a skeletally mature person will result in ACROMEGALY. This occurs because GH will now target the flat, membranous bones because the growth plate has fused (this person is done growing).

❖ Features of acromegaly include…

□ Prognathism (lengthened, overgrown mandible – aka Lantern Jaw)

□ increased Sella Turcica size in AP(length) diameter along w/ Double Floor Sign

□ width of hands/fingers will be wider than normal,

□ joint spaces widen and enlarge as well

□ Finally we see increased heel pad thickness and often times a plantar spur.

HEAVY METAL INTOXICATION

- Saw an AP knee of a younger person and it demonstrated an overly bright ZPC. This was caused by lead poisoning. Lead likes to set up camp in active bones such as growth centers.

- Lead can be breathed in onto the mucus membranes of the mouth, nasal pharynx, throat as fine lead dust and can be swallowed which is small enough molecule to be digested

- Dense, white sclerotic lines at the growth centers are typical for lead and other heavy metal intoxications.

- Basostiplic bone changes

- Patients that have heavy metal intoxication will usually present as…

□ Have abdominal complaints, history of normal academic performance followed by a rapid decline and mood changes are typical. These patients will see a doctor for these signs/symptoms and if x-rays are taken, they will show the signs of heavy metal intoxication.

HISTIOCYTOSIS X

- There are 7 types of disorders under this category but we only focused on 2…Eosinophilic Granuloma and Hans Christian Schuler.

- Eosinophilic Granuloma

□ This fits into the NME category and is the most common form of Histiocytosis X. Was once considered a tumor even though it didn’t act like one. “Disappearing Bone” is the hallmark sign of EG. Femur is used as an example shown in class. Bilateral femurs: right leg lateral distal portion of leg, lt leg is at mid to proximal portion of bone. The cortical bone disappears and all we see is periosteal outline. Seen mainly at the ends of long bones. Once this disappearing occurs, a few months later will show reconstitution and reappearance of the bone.

□ EG in the spine is described as “Silver Dollar Sign”. We will see normal discs still.

- Hans Christian Schuler

□ There is a triad of this type of Histiocytosis X…

- Lytic skull lesions ‘Hear no evil’ keep them from losing their brains – Hold in brains

- Exophthalmos: (just remember the 3 monkeys he mentioned): see no evil keep eyes from popping out

- Diabetes Insipidus Holding their groin holding in their pee (hold in brains, eyes and pee)

Letterer-Siwe Type I Histocytosis X (pg 1533 Y & R)

HEMOCHROMATOSIS

- This is seen mainly in the hands as well. Characteristic “hooks of hemochromatosis” are seen at the distal ends of metacarpals most commonly. Hand x-ray also displays the gull wing sign.

TUMORS

Three groups: 1-metastatic: comes from somewhere else **(the lymphatic system is accurate for every other system but NOT the bones. Bones are fed only by arterial vascular or hematogenous spread and from there to the venous to anywhere else in the body)**

2- Primary benign tumors

3- Tumor like

1- Most common malignancy to bone = Metastases

2- Most common 1o malignancy to bone = multiple myeloma

3- Most common 1o benign tumor to bone = hemangioma

LYTIC TUMORS

The Battson’s Plexus (mentioned before) is a valveless venous system around the spine, skull, shoulders and pelvis. Bone tumors like to spread through this hematogenous route.

Quick tips before we move on…Tumors below the knee, we must think primary tumors. Lung tumors can spread anywhere. Lung tumors like to reside in cortex and are very aggressive. Most bone tumors can’t push cortex around so they reside in the trabecular metaphysis.

Typical metastasis patient…40’s, unexplained weight loss, cacchexic appearance and are anemic (b/c tumors reside in hemopoietic sites). First notice a problem when there is a fracture and the tumor shows up on film.

Look at the malignant bone neoplasms table in Yochum…Table 11.6

These tumors never appear in joints (if something is seen in these areas, think infection or septic arthritis). Multiple myeloma is an aggressive malignant bone tumor but it will not show up on bone scan b/c there is no osteoblastic activity.

70% of bone metastasis is lytic in nature – bone is destroyed. Exceptions to this rule include…

- Prostate tumors (10%), Carcinoid tumors (5%) and Hodgkin’s (40%)

Breast tumors are 80% lytic, 10% blastic and 10% mixed

Prostate tumors are 80% blastic

WINKING OWL SIGN

- We saw this before in congenital anomalies. This time it is due to Lytic Metastasis.

- In this case there is a normal contralateral pedicle. In the congenital WOS we saw a dense, sclerotic contralateral pedicle.

- W/ lytic metastasis, there is no time for the body to lay down more bone along the other pedicle. This bone is being destroyed.

- Whenever we see lytic bone destruction, must think lytic mets. After that we must look to other areas for primary involvement…(ex. if seen in a woman, check for breast cancer…if seen in a man, check the prostate)

- This lytic metastasis is usually secondary to a primary tumor elsewhere.

Saw a lateral lumbar view of a woman and one vertebra had a convex bump on the anterior body of a segment. Bone scan showed this level as a hot spot. She was checked for breast cancer and the test came back positive. This bony finding was a lytic metastasis of the breast cancer.

Lateral cervical view shows a normal cervical curve w/ intact endplates and normal prevertebral soft tissues. On the anterior portion of C2 we saw a bit of destruction going on. This was localized osteopenia and we must think infection or tumor.

BLASTIC TUMORS (look at table 11.10 in Yochum)

3 causes of Ivory Vertebra…(there are 6 but we only mentioned 3)

- Padgett’s – thickened cortex appears whiter and bigger on film Bone modeling Ivory white vertebra BUT BIGGER; skull is/gets thicker larger (the hat ‘gets’ smaller)

- Blastic Mets – in a man = prostate…in a woman = breast/lung…vertebrae will appear normal sized or smaller (PSA and mammograms are good tests to have done if suspecting this)

- Hodgkin’s Lymphoma – 20-40-year-old male or female. Characteristic anterior scalloping of vertebrae.

Ivory vertebra on MRI is a signal void (no mobile hydrogen in thickened cortical bone) – looks as if the vertebra is missing.

Alkaline Phosphatase is a characteristic serum substance in Blastic Mets.

Look at Table 11.11 in Yochum – Differential diagnosis of ivory vertebra

PRIMARY MALIGNANCIES

Lateral skull view demonstrated 3 things…

1. Multiple holes about the same size (raindrop appearance) widely dispersed throughout the calvarium (skull) Head ache which is actually head PAIN.

- This is indicative of Multiple Myeloma

2. One big hole and some medium sized holes (variable appearance)

- We would have to think Lytic Mets in this case

3. Two big holes (osteolytic)

- Both hemispheres appear “chewed out”. This was Osteoporosis Circumscripta or Padgett’s osteoporosis circum scripta

Lateral pelvis view demonstrated from L3 to the ilium. L4 was a lot smaller, less dense and appeared jagged. This was the lytic behavior of multiple myeloma. The patient was anemic but bone scan was normal…remember, MM has no blastic activity.

If you suspect multiple myeloma, look for the Bence Jones protein…this is seen in only 40% of MM case. From urine analysis

Immuno-proteins Electrophoresis studies will show immuno-proteins (immunoglobulin electrophoresis). IgG is the big one to look for. It is usually elevated in people w/ MM. Forms of MM include all of the immunoglobulins (GADEM).

Lab – a normochromic, normocytic anemia with decreased reticuloctye production

Diagnosis Multiple myeloma

Potential Differential Diagnosis

AP Humerus: moth eaten appearance Multiple Myeloma a permeatetive

A patient w/ MM will classically present w/…

- Low back pain and sciatica that goes away for a while but then return despite our every effort of adjusting.

- If MM is suspected, take another film and look at all the segments, see if the patient is anemic (normochromic/normocytic), look for infection, get lab tests done for BJ protein and finally get a biopsy if anything is found…this is the best way to diagnose MM.

- MM is very treatable today.

SOLITARY PLASMACYTOMA

- This is an aggressive tumor of one plasma cell and is found in only one bone. 70% of these tend to progress into MM.

- We saw an AP sacrum film and CT image…both showed the sacrum absolutely destroyed and barely there! You have to wonder how this person walks w/o a sacrum!

OSTEOSARCOMA

2 of the most common bone cancers seen in the 10 -25 yr old age group.

- Typically seen in people 10-25 years old, it loves the knee, metaphyseal portions of distal femur and proximal tibia, it is a poorly limited tumor, it destroys cortex and insights periosteal bone formation

- Classic x-ray appearance…mixed regions of lucency and density w/ “hair on end” periosteal reaction.

- 58% of the time it is a mixed tumor…25% it is sclerotic…17% it is lytic.

When we are given a case study of a person who is 10-25 years old and their films show lytic changes to the metaphysis…think osteosarcoma

When we are told there is blastic change of the diaphysis…think Ewing’s Sarcoma

Osteosarcoma loves to metastasize to the lungs and brain while Ewing’s loves to metastasize to lungs and bone.

Both Ewing’s Sarcoma and Osteosarcoma have the “hair on end appearance” but note the location on the bone. Metaphysis = osteosarcoma…Diaphysis = Ewing’s. Seen more often in Ewing’s

The lytic form of osteosarcoma is not common (17%) but it is extremely aggressive. We saw an AP view of tib/fib and most of the proximal portions were gone. The surgery option is to do a hemipelvectomy! They would take the entire ½ of this person’s pelvis and all of that leg to make sure the tumor doesn’t spread!

EWING’S SARCOMA

- Classic “hair on end” or “sunburst” pattern of periosteal reaction.

- This tumor is a mixture of bone and soft tissue. So, on film we will often see large soft tissue masses along w/ bony abnormalities. It likes to target the diaphysis of long bones in people 10-25.

- Saucerization is a finding on x-ray that is often seen w/ Ewing’s Sarcoma. It can also be caused by osteomyelitis and from stress fractures. This looks like a small concavity/indentation of the diaphysis of long bones in the shape of a small plate or saucer. Previously was an onion skin appearance with codmans’s angles. Differential are Ewing’s, Stress fracture, osteomyelitis.

- Osteomyelitis will do in days what Ewing’s will do in months/years.

- “Cannonball Metastasis” – this is a dense white lesion in the chest/lung from Ewing’s or Osteosarcoma. It can produce symptoms much like HPOA.

GIANT CELL TUMORS (GCT)

- These are quasi-malignant tumors. 80% of the time they are benign and slow growing. 20% of the time they become aggressive and thin the cortex of bone.

- The hallmark sign of GCT is that on plain film you will see it extending all the way to the joint surface. (a chondrosarcoma can do this as well but not as common as GCT)

- The tumor consists of multi-nucleated giant cells.

- Saw this on AP ankle, AP knee and lateral femur.

This is the end of primary malignancies

OSTEOCHONDROMA

- This is known as a “Coat Hanger Exostosis” – just a bony projection off of a long bone.

- This is the most common, benign bone projection

- We can differentiate this from the supercondylar process from before b/c the osteochondroma is an out growth from normal bone and therefore it has the same continuous line of cortical margin as the rest of the bone. Supracondylar process (points toward a joint) didn’t have a cortical margin to it and is only seen on the humerus.

- It consists of bone and cartilage and is most often a result of multiple and aggressive biopsies from the same area or multiple fractures in the same area.

- 2 Forms:

□ Pedunculated – has the continuous cortical margin described above. Is thin and pointy.

□ Sessile osteochondroma – this form is characterized by its wide base

HEMANGIOMA

- This is the most common, primary and benign spinal tumor. A Very bloody lesion. Barrel shaped vertebra. Vertical accentuations/trabeculae

- Only causes problems if it locates in the central canal (causing central canal stenosis) or if a surgeon decides to remove it. These things bleed like crazy and people have died (bled out) from surgeries to remove them or by accidental rupturing from inserting screws into bones w/o the doctor’s knowledge of its presence.

- These cause the bone to appear less dense than normal and the bone demonstrates a widened trabecular pattern.

- These are said to have a “corduroy cloth appearance” on CT.

OSTEOMA

- This is your basic bone tumor that likes to occupy the skull and sinuses (membranous bone). We saw skull views w/ a thick white mass w/in the frontal sinus, a lump on the outside of the parietal bone and we also saw one on a lumbar pedicle (was bright white).

- These tend to be associated w/ Gardner’s Syndrome – this is a triad of abnormal growths…

□ Multiple osteomas, colonic polyps and soft tissue fibromas.

□ Have the patient get their colon checked if they’ve experienced any rectal bleeding. These polyps tend to go malignant.

- A benign bone island is an osteoma w/in a bone. This occurs in ages 20-40. If this is seen in older patients, it could be mets and then you would want to check the prostate and lung if it’s a male patient or do a breast and lung exam if it’s a woman.

OSTEOID OSTEOMA

- This was mentioned earlier when we looked at Brody’s Abscess. Solid looking appearance. The key clinical presentation is night pain relieved w/ aspirin. CT or tomograms will show the nidus.

- There is a periosteal rxn involved w/ this as well and it appears as a “cortical blister” on the bone. There is no treatment necessary b/c the bone is getting stronger.

NIDUS

- This is a lucent center in a bone tumor (looks like a hole in the middle of the tumor)

- Looks hot on bone scan b/c periosteum is creating new bone around this nidus.

Brody’s Abcess: Night pain relieved with aspirin. If inside the bone needs to be scraped out and if outside the bone just leave it alone it will correct itself.

ENCHONDROMA

- This is the most common, primary benign tumor of the hand.

- It is nothing more than chondral tissue deposited inside the bone (appears less dense on film)

- Occurs in people around 35 yrs old, pain is incidental and it sometimes mimics a fracture.

- There is no destruction of cortex – the margins remain intact.

- Path fractures are most common result of an enchondroma.

- If it goes malignant (not usually) it is called a chondrosarcoma. This is the most common, primary malignant tumor of the hand, can go to the foot.

BENIGN CORTICAL DEFECT

- Saw an AP wrist w/ a dark circle (hole) surrounded by a white rim on the radius.

- This could become a larger lesion called…Non-ossifying Fibroma (aka xanthoma)

The process of a benign cortical defect goes like this…starts out as a defect in cortical bone…then it enters the trabecular bone…then it resolves.

FIBROCORTICAL DEFECT (FCD) a whole in the cortical bone

Non Ossifying Fibroma

MOST COMMONS LIST:

MOCE = M: MULTIPLE MYELOMA

O: OSTEOSARCOMA

C: CHONDROSARCOMA

E: EWINGS

BLASTIC:

1- Breast

2- Lung

3- Thyroid

4- Prostate

5- Kidney

6- Hodgkin’s lymphoma

Skull:

1- lytic

a. rain drop = MM

b. Diff. size and many = Mets

2- Cotton wool = Pagets

O.SARC. & EWINGS

- 10-25 yrs of age

- Cannon Ball Mets & 0 lung

- “hair on end” periosteal Rxn

Review:

DISH calcified ALL n multiple segments >4; >50 yrs of age Males; Diabetes\

Erosive Osteoarthritis DIP, 1st metacarpal trapezium young females; sero –

Synovial Chondralplasia; unilateral, mono-articular, no trauma precedes it, joint mouse

The six “D”’s destruction, debris, disorganization, distention, dislocation, density

Pagets:

Cotton wool skull; larger skull; basilar invagination, could lose sense of smell, and lose hearing. UK has the highest population Australia 2nd Northern Canada then US. Lab value: increased alkaline phosphatase.

Vertebra: “picture frame vertebra” brighter cortical thickening.

Brim sign sclerosing of the pelvic rim. If Alk Phos is elevated then it is a disease in process

Ground glass appearance (associated with fibrous ds) associated with café au lait spots.

Coast of Maine sign rocky jagged edge fibrodysplagia

Coast of California sign Neuro fibromatosis “olive” shaped IVF

Focal Giantism ie x-ray of a hand and the middle finger is extra large.

What is the most common primary malignancy to cross the joint space: the chordoma, it likes the ends of the axial skeleton the base of the skull and the sacrum.

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