*

Cor T1 Sag PD

*

47F 5Y increasing stiffness and decreased ROM. Initial

presentation

4

Ankylosing SpondylitisDagger signBilateral hip inflammatory arthritis

*

Ankylosing Spondylitis

• Young white men

• When fuse posteriorly, may spare anterior

• Scalloping of Cx spine

• Dagger + Bamboo = Tram tracks

19M increasing mass on hand, refused treatment

3

Osteosarcoma

*

• Most common primary malignant bone tumor in young adults and children

• Second to MM in older

• Osteoid immature bone

• Bimodal

• Close to knee, away from elbow

• Young-cylindrical, Old-flat

Osteosarcoma

25M with wrist pain

3

Osteopoikilosis

*

Osteopoikilosis

• Juxtaarticular bone islands

• ?AD, M>F, asymptomatic

• Ovoid 2-10mm

• Benign sclerosing bone dysplasia

95 M pain R hip

4

Cor T1

Cor STIR

Pagets diseasePathological FxAsterix enhancement

*

Pagets disease

• O. deformans

• 3% >40, northern latitudes, >M

• Lytic, vascular fibrous connective tissue

• Inactive, decreased turnover with sclerosis

• Mixed, common, both together

40M painful knee

4

Cor T1

Sag PD

B thalassemia intermedia

*

• Major-Homozygous-Cooley anaemia

• lack of B

• Italian and Greek

• Skull, hair on end, widened diploic

• Porosis, thin cortex, Erlenmyer flask

• Arthropathy

B thalassemia

23M knee pain

1

Distal MCL injury

*

• Ossification points to joint

• MHE points away from joint

Distal MCL injury

Sag T1

Sag PDFS

Sag T1

Sag PDFS

C5

50M heel pain

2

Sag T1

Sag PDFS

*

Involuting lipoma

• Any age, equal sex

• Calcaneus>Femur>Tibia>Fibula

• Can have central dystrophic calcification

13F painful footNo trauma

Sag T1

Sag PDFS

*

57ML hip pain

3

Sandwich vertebraeOsteopetrosis

*

Osteopetrosis

• Marble bone, Defective osteoclasts

• AR, Infantile, Systemic, Leukaemia

• AD, Adult, Fxs, anaemia, CN palsy

• Sclerotic, peri and endosteal

• Erlenmyer flask

• Bone in bone, sandwich vertebrae

• Calvaria and mandible spared

Variable patients Same condition

*

Pseudohypoparathyroidism

• X-linked, renal and skeletal resistance to PTH

• Short, retarded,

• Decreased Ca, normal/increased PTH

• Brachydactyly 1,4,5 MC

• Ca basal ganglia, skin, SubQ

Variable patients Same condition

8

Dermatomyositis

• Damaged chondroitin sulfate

• Atrophy, oedema, necrosis of muscle

• 30-60, F>M

• Calcification extremities and girdles

• Pointing of tufts

• Ass. Malignancy, lung, kidney, ovary, breast

35M with recent traumaFlex / Ext

C5

C5

C6

C6 Fx subluxation

*

Signs of instability

• Spinous process fanning

• Widening of disk space

• Horizontal displacement >3.5mm

• Angulation >11 degrees

• Disruption of facets

• Multiple fractures at one level

*

*

*

*

*

*

10M painful neck

Transient disc calcification of children

*

• Painful

• Pain lasts weeks

• Calcification lasts months

• Adjacent vertebrae flattened

Transient disc calcification of children

28F pain in lumbar region

Anterior limbus with instability*

Limbus Vertebrae

• More often anterior and superior

• More significant posterior

• Disc herniates through ring apophysis

• Commonest lower lumbar

37F acute torticollis, stiffness and shortness of breath

Fibrodysplasia ossificans progressiva*

• MOP / Stone man

• Rare, AD, sporadic

• Presents in childhood

• Stiffness, Heterotopic ossification

• Malformed fingers and toes

• Bone morphogenic protein (BMP) signaling pathway problem

Fibrodysplasia ossificans progressiva

48M joint pains and dark pigmentation on ears

Alkaptonuria

*

Alkaptonuria / Ochronosis

• Absence of homogentisic acid oxidase

• Pigmentation

• Arthropathy

• Osteoporotic with dense disc calcification

• Larger joints show DJD

6mMCalcareous nodules

Idiopathic calcinosisuniversalis

*

28BF mass in shoulder

Idiopathic Tumoral Calcinosis

*

*

Ax PDFS Ax T1

*

Cor T1

Cor T2

*

*

1518960

*

Sag T1

*

81M shoulder pain

Chondrocalcinosis*

Chondrocalcinosis

• CPPD

• Hyperparathyroidism

• Hemochromatosis

• Acromegaly

• Gout

• Wilsons disease

45F swelling of arm with numbness of 2nd and 3rd fingers

Ax PDFS Ax T1

Fibrolipomatous hamartoma of the median nervewith macrodystrophia lipomatosis*

Fibrolipomatous hamartoma of the median nerve with macrodystrophia

lipomatosis• Nerve territory directed macrodactyly

• Localised form of gigantism

• Median or Plantar nerves

• Possible relation with neurofibromatosis

35M8w post injury

Cor T1

Cor T2

Post traumatic myositis ossificans

*

Post traumatic myositsis 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

25MBlocker

Myositis ossificans*

Sport related myositis ossificans

• Single direct blow

• Repeated minor trauma– Adductor longus-Rider’s bone– Brachialis-Fencer’s bone– Soleus-Dancer’s bone– Blocker’s arm

48MAlcohol ++

1518960

*

Grading of AVNSteinberg modification of

Arlet/Ficat

• 0 - Abnormal MRI no symptoms

• 1 - Abnormal MRI, pain

• 2 - Mixed sclerosis and lucency on x-ray

• 3 - Subchondral collapse

• 4 - Marked collapse

• 5 - Secondary acetabular OA

Causes of AVN• Trauma• Steroids• Alcohol• Pancreatitis• Protease inhibitors• Gauchers• Sickle cell• Caisson• Perthes / Idiopathic

34MDeveloping lump anterior to knee

Ax T1

Ax PDFS

Sag T1*

Soft tissue chondroma

• Rare

• 20-40Y

• Hands and feet

• Well demarcated and lobulated

• Curvilinear, ringlike or nodular calcification

• High signal T2

PDFS

*

*

*

1171948

*

1999621*

35M Knee injury

PDFS

*

ACL/MCL

• Empty lateral gutter

86MStiffness and Locking

Multiple bodies in Popliteal recess

• Primary V’s secondary osteochondromatosis

• Multiple similar size

• Origin

62MFullness in suprapatella region

*

Body growing in joint

• Laminated

• Slow growing

30MOutdoors man

*

Snake bite

• Venom not infection

• Due to proteases

36MPrior trauma

1171948

*

Florid reactive periostitis

• BPOP

• Bizarre parosteal osteochondromatous proliferation

• Manifestation of PTMO in hands

• Periosteal proliferation > ST ossification

50MTrauma

Whiplash injury

1

1999621*

Extension tear drop Fx

• Small fragment

• Usually more superior Cx spine

0850849

1*

*

2W earlier 2W later

1927160

*

2001785

*

36MTrauma 3Y ago

MVANow myelopathy

3

2001176

*

Chronic non-union of C2 Fx

• Type 1 steep oblique– Due to alar ligament

• Type 2 neck of odontoid process– Prone to non-union

• Type 3 extends into body– Often heal with conservative Rx

42MFall

1

0850849

1*

Anterior shoulder dislocation

• Hill Sach’s lesion (Hatchett )– Stryker view

• Bony or soft tissue Bankart– Westpoint view

• Posterior dislocation– Trough Fx– Bennet’s lesion

• Bony

21MInjury weeks agoRecent surgery

1

*

Volkmann’s ischaemic contracture

• Soft tissue contractures– Volkmann’s– Burns– Neurologic conditions– RhA, SLE– Arthrogryposis multiplex congenita

40MKnown medical condition

Recent trauma

2

2W earlier 2W later

2003485

2W later*

Hemophilic pseudotumor

• Uncommon manifestation of Hemophilia

• Femur > Pelvis > Tibia > Small bones of hands and feet

• Intraosseous or subperiosteal

• Lytic, expansile, can look aggressive, ST mass

75FLifelong limp

1

1927160

*

DDHAdults

DDHInfants

• Acetabular angle

• Lateral shift

• Superior shift

• Shenton’s

• Perkin’s

• Hilgenreiner’s

• Center Edge

40MWaterskier

1

2001785

*

Old ischial avulsion

• Avulse bone < 25Y

• Waterskier, Hurdler, Sprinter

1806380

*

2003226*

1995690

54FFall

2

1777100

*

Transverse Patella FX

• Direct or indirect

• Transverse 70%, indirect

• Longitudinal, stellate or comminuted

• Bipartite - superolateral

• Dorsal defect - superolateral– Direct

63FLongstanding decrease ROM

1

1806380

*

Chronic anterior shoulder dislocation, with neoglenoid

• Failure to diagnose

• May have increased ROM

19FSlowly growing (1Y) lump on

thigh

3

1998078

*

Alveolar Soft Part Sarcoma

• Malignant granular cell myoblastoma

• Young adult females

• Thigh muscles

• Slow growth, calcifcation, invade bone

• Metastasizes late

• Vascular, may have flow voids

• Path - similar to paraganglioma

19FMVA

20032261

2003226*

Odontoid Fx

• Type 1 - Steep oblique– Sometimes tip Fx also called type 1

• Type 2 - Neck– Prone to non-union

• Type 3 - Involves body– Usually heal conservatively

65MNeck pain

Myelopathy

19956903

1995690

1995690

1995690

**

CPPD arthropathy

• Deposited in transverse ligament

• Associated – Tumor like masses may compress cord– Atlanto axial subluxation – Spontaneous odontoid Fx

35MDeformity

Maffucci syndrome

• Multiple enchondromas

• ST Hemangiomas

• Malignant potential close to 100%– Olliers enchondromatosis 25-30%

• Developmental, not hereditary

• Growth deformities

12MDeformity

Noonans

• Short Metacarpal– Idiopathic– Post trauma

• Iatrogenic, Fx, Growth plate inj, Thermal, Electrical

– Turners, 4th +/- 3rd or 5th – Pseudo- and pseudopseudohypoparathyroidism

• 4th and 5th

14MDeformity

Carpal osteolysis

• Onset childhood

• Carpals, Tarsals, elbows

• Associated nephropathy

29FFOOSH

Scaphoid Fx on lateral view

• Many scaphoid fractures are best seen on lateral

68MWrist instability

VISI

• Suggests lunotriquetral ligament tear

• DISI- scapholunate ligament tear

• Angle between scaphoid and lunate < 30

• Pie shaped lunate

33FNo history of trauma

Keinbocks

• Ulna minus

• Trauma

• Osteonecrosis

45FHand pain

Acroosteolysis• Tuft

– CVD- Scleroderma, CREST, Raynauds– Psoriasis– Neuropathic

• DM, Leprosy, Myelomeningocele, Syrinx, Cong indifference to pain (Leesch Nyan)

– Trauma• Thermal, Burns, frostbite electrical

– Hyperparathyroidism– Epidermolysis bullosa– Porphyria, Subungal exostosis, – Snake and scorpion venom– Phenytoin toxicity in infants

40MKnife injury

Flexor tendon lacerationDisplaced sesamoid

• Sesamoid useful marker of tendon

*

*

*

*

20MHurt hand catching ball

Dislocations

• Need 2 views for trauma

22FDeformity

Boutonnierre

• Rupture of middle slip of extensor tendon as it passes over PIPJ

• Lateral slips migrate volarly

• Occasionally avulsion

• Needs early Dx

76FRhA

*

Cranial Settling

• Atlantoaxial settling

• Erosion of lateral masses

• Different from basilar invagination

57MBilateral shoulder pain

*

DDx• Unilateral

– Amyloid, TB

• Bilateral– Crystal

– Occupational OA

– Syrinx - neuropathic

– Previous inflammatory arthritis• Clavicles normal

– Hemophilia

24MFOOSH

*

Trans scaphoid/triquetrumperilunate Fx dislocation

• Pie shaped lunate

31MBlow to flexed thumb

*

Rolando Fx

• Axial blow

• More difficult to anatomically reduce

March 01

*

*

*

57MRight hip pain

March 01

May 01

Dec 02

*

Hepatic metastases

• Rare to bone

• Similar to other hypervascular mets

50MMVA

Anterior hip dislocation

• 5% of hip dislocations

• Can have associated impaction injuries

• Leg externally rotated

32MBilateral chronic hip pain

*

Perthes

• White boys

• 4-7y

• Younger onset – better outcome

• DDx for bilateral– MED, Morquios, SCD, Gauchers, – Hypothyroid, CDP, Warfarin embryopathy

17FMechanical symptoms

*

Osteochondroma

• Point away from joint

• Cartilage cap is hyaline

• Cap thickness > 1cm concerning

• Pain important to dx malignancy

75MKnee locking

*

Primary synovialosteochondromatosis

• Metaplasia of synovium

• May not be visible on X-ray

• Primary similar size

• Synovial hemangiomas have lucent centers

55M1Y post trauma

*

Dystrophic calcificationin Quadriceps tear

• Calcification– Metastatic– Dystrophic– Tumoral

Left Right

*

46MPrevious trauma

Chronic bowel problems

*

Hypertrophic Osteoarthropathy

• Pulmonary– CA bronchus, Lymphoma, Abscess, Bronchiectasis,

Metastases

• Pleural– LFTP (highest association), Mesothelioma

• Cardiovascular– CCHD

• GI– UC, Crohns, Dysentry, Lymphoma, Whipples, Coeliac,

Cirrhosis, Nasopharnygeal CA, Juvenile polyposis

16MSlowly increasing pain in tibia

T1FSGd

*

Osteosarcoma

• Conventional

• Telangiectatic

• Parosteal

• Periosteal

• Multicentric

• Soft tissue

14MPain with running

1m later

*

Stress Fracture

• Fatigue

• Insufficiency

• Pathologic

54MTwisting injury

*

Maisonneuve Fx

• Transverse fracture of medial malleolus without distal fibula Fx, ask for proximal fibula

31FArthritis

Left

Left Right

*

RhA noeostosis

• Reiters is more plantar and less symmetric

53MPain lower back

Ankylosing Spondylitis

• Enthesopathy

*

42FFoot stiffness

Compartment syndromeossification

• Extensive sheet like ossification

• Dystrophic

24FFall

Fracture blisters

• DDx pseudoaneurysm

8MSwelling of toe

Digital fibroma

• Recurring digital fibroma of infancy

• Can become large

• Painless

• Fingers and toes

• DDx– Enchondroma, Epidermoid inclusion, Digital

fibroma, Subungal lesions, Glomus

Melorrheostosis

• A benign sclerosing bone dysplasia

• Osteopathia striata

• Osteopoikilosis

• Dripping candle wax

• Sclerotomes

43MTrauma

Osteoma (Ivory)

• Gardeners syndrome– Adenomatous polyps, Dental lesions, ST

tumors, osteomas

67FLump

Fibrous Dysplasia

• Common

• Hamartomatous fibro-osseous metaplasia

• 70% monoostotic

• Polyostotic tends to be unilateral

• Usually expansile

• Shepherds crook, ground glass

• Any bone, but spine unusual

33MTackled at rugby

Anterior dislocationHill sachs

Bony Bankart• Stryker for Hill Sachs

• Westpoint for bony Bankart

• Can occur after one dislocation

56FLump and pain

GCT

• Multinucleated giant cells in fibroid stroma

• Knee, distal radius, proximal humerus

• Lytic, subarticular, narrow zone of transition without sclerosis

• Can look aggressive

• After epiphyseal fusion

42MMechanical symptoms

*

Sessile osteochondroma

• Anterior at knee

• Also have mechanical symptoms