2 Medical Imaging

Randy E. Cohen, DP M

C o n t e n t s
2.1 2.2 2.3 2.4 2.5 2.6 2.7 Computed Tomography (CT) . . . . . . . . . . . . . . 34 Magnetic Resonance Imaging (MRI) . . . . . . . . 34 Bone Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Bone Tumors . . . . . . . . . . . . . . . . . . . . . . . . . 35 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . 44 Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . 44 Osteochondrosis. . . . . . . . . . . . . . . . . . . . . . . 46

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2.1

Computed Tomography (CT)

Cross sectional display Excellent density resolution

Advantages over Conventional Radiology

CT Numbers (Hounsfield Units HU)

Bone < 1000 white (radiodense) Air -1000 black (radiolucent)

Window Width and Window Level

Window width is the variations in gray Window level is the mid point in gray For evaluating bone pathology we use window widths of 400 or more and window levels of 50 or more. For evaluating soft tissue pathology we use narrower window widths of 100-200 and lower window levels of 20-50. To enhance contrast in soft tissue pathology iodine based dye is used. CT is superior to MRI in evaluating ossification, calcification and cortical bone. It is useful in evaluating articular disorders but not as accurate as MRI. CT is excellent to evaluate osseous coalitions. It can be used to evaluate the extent of soft tissue and osseous involvement in infections, but it is not tissue specific. For neoplasms it adds additional information that improves diagnostic accuracy.

2.2

Magnetic Resonance Imaging (MRI)

There is no ionizing radiation. A strong magnetic field and radio waves are used to produce the image. Spin density = hydrogen concentration TR = repetition time TE = time to echo T1 = short TR and short TE good for anatomy T2 = long TR and long TE good for pathology Increased signal intensity means bright or white. Decreased signal intensity means dark or black. STIR scans or fat suppression scans turn the fat black enhancing contrast in the bone marrow and soft tissue. Gadolinium is a paramagnetic contrast enhancing agent.

Advantages of MRI
Cortical bone is invisible Bone marrow visualizes well Better soft tissue contrast than CT Moving blood acts as a contrast medium

Disadvantages of MRI
Exam takes a long time Large magnets take up space and are expensive Requires wide area free of metallic material Magnetic materials in the body preclude scanning Cardiac pacemakers preclude scanning Claustrophobia precludes scanning Tissue appearance on MRI

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Tissue Appearance on MRI

Tissue Cortical Bone Calcification Ligaments Large Vessels Fibrosis Chronic Hemorrhage Fat Muscle Acute Hemorrhage Hemosiderin Exudate Edema T1 weighted dark dark dark dark dark white white gray gray black gray gray T2 weighted dark dark dark dark dark white gray dark black black white white

Molecules with strong molecular bonds such as ossification or calcification will not image well on MR giving a low signal intensity. Molecules with low water content such as ligaments will also give a low signal intensity. MR imaging provides superior soft tissue contrast without ionizing radiation. It is the most tissue specific diagnostic modality we have short of biopsy.

2.3

Bone Scan

A bone scan is highly sensitive but non-specific. It can detect osteogenesis well before it will show up on an xray. A bone scan is useful and effective for early detection of stress fractures and osteomyelitis. It can accurately evaluate delayed and non-union. In atrophic non-union of fractures there is diminished uptake at both ends of the fracture site as well as a gap in between. In hypertrophic non-union there is increased uptake at both ends of the fracture site with a clear gap in between. Delayed union will show up as diminished uptake. Pagets disease has a characteristic appearance on bone scans. Pagets has 3 stages: lytic, blastic, and quiescent. In the lytic stage the bone scan shows no increased uptake. In stage two, the blastic stage, there is confluent uptake starting at the end of the bone. Focal uptake is rare. In the third stage there is no increased uptake. Metastatic CA usually presents with focal uptake.

2.4

Bone Tumors
A membrane lined cavity containing a clear yellow fluid Occurs most often in children 4-10 years of age Lesions remain asymptomatic unless complicated by fracture They enlarge during skeletal growth and become inactive, or latent, after skeletal maturity

Unicameral Bone Cyst (Solitary)

Active Type Develops in patients under 10 years of age Cyst arises adjacent to growth plate and may grow to fill most of metaphysis Bone may be slightly expanded within cortical shell May cause pathologic fracture

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Passive Type Patients are usually over 12 years of age Cysts cease to expand Have thicker bony wall than active lesions May show evidence of healing or ossification Less likely to result in fracture Predilection for the Metaphysis of Long Bones Proximal humerus (50% of cases) Proximal tibia Proximal femur (40%) Radiographic Show a central, well marginated and symmetric radiolucent defect in metaphysis Usually no bony separations or loculations Thin rim of non-reactive bone borders the unicameral bone cyst Treatment Goal of treatment is prevention of pathologic fracture Simple cysts are treated with curettage and bone grafting Recurrence is high for active cysts (50%) and low for latent cysts (10%) Conventional teaching is that the cyst will heal and resolve if a fracture occurs through the cyst Steroids: 80=200 mg of rnethylprednisolone infused into cavity The failure in weight-bearing bones was high Autologous bone marrow injection multiple drill holes

Aneurysmal Bone Cyst

An uncommon expansile osteolytic lesion of bone consisting of a proliferation of vascular tissue that forms a lining around blood filled cystic lesion Develops in metaphyseal region of long bones, pelvis, vertebral body Most aneurysmal bone cysts occur in patients under 20 years of age, and it is uncommon after 30 years of age Grows rapidly and may attain considerable size Commonly involves the proximal humerus, femur, tibia, and pelvis Can cause paraplegia when it involves the vertebrae Radiographic Radiolucent lesion with expanded cortex arising in the medullary canal of the metaphysis Aneurysmal expanded appearance of cortex is contained by periosteum and thin shell of bone Marked cortical thinning and erosion and periosteal elevation Lesion rarely penetrates the articular surface or growth plate Diagnostic CT scan Has a density of about 20 Hounsfield units Spine: CT scan shows a cystic lesion not appreciated on the radiograph Bone Scan Shows intense uptake in the margin of the lesion with normal background or decreased uptake in its center Treatment Curettage and bone grafting has a 20%-40% recurrence rate

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 Recurrence can be managed with more aggressive curettage or excision Marginal excision or wide excision with bone grafting is preferable With pathologic fracture, successful resection may be difficult

Osteoid Osteoma
Benign osseous tumor usually less than 1.5 cm in diameter Comprising 11% of all benign hone tumors Occurs primarily in adolescents and less often in children Is rare in patients over 40 years of age Presenting symptom is well localized pain, which may be more severe at night and is relieved by aspirin or other prostaglandin inhibitors Because osteoid osteoma is a vascular tumor, substances that cause vasodilitation such as alcohol may precipitate an acute pain crisis Most common site is proximal femur and diaphysis of long bones Less often: foot (talus, navicular, or calcaneus) and in posterior spine Radiographic Intense bony reaction to small nidus is hallmark of osteoid osteoma, however, may be difficult to see on x-rays Look for oval radiolucent nidus only 3-5 mm in diameter that is surrounded by disproportionally large dense reactive zone Although usually located in cortex, nidus may occur subperiosteal and endosteal regions Radiographic Differential Diagnosis Garres osteomyelitis (chronic sclerosing osteomyelitis) Brodies abscess Stress fracture Bone Scan Bone scans usually shows moderate or intense radioisotope uptake Treatment When nidus is located in a low stress area such as metaphysis, treatment should consist of en bloc excision with surrounding small block of reactive bone Tetracycline localization: Using tetracycline at a dosage of 4 mg/kg, four times daily, two days preoperatively, the nidus will have a golden yellow fluorescence; the OR must be dark in order to see it Percutaneous radiofrequency coagulation Involves percutaneous insertion of a biopsy needle under CT scan guidance A tissue biopsy is taken in order to prove that the needle is properly located Then a radiofrequency electrode with a 5 mm exposed tip is introduced through the cannula The electrode is connected to a radiofrequency generator which raises the temperature of the tip to 90C (which is maintained for 6 minutes)

Osteoblastoma
Unusual benign osseous tumor It resembles osteoid osteoma but is usually larger (>2 cm) Occurs in older adolescents and young adults Usually does not cause localized night pain, and when pain occurs, pain is usually not relieved by ASA Intense bony reaction that is seen with osteoid osteoma, does not occur with osteoblastoma

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More often located in the posterior elements of vertebra Will not resolve spontaneously Sites of involvement: spine, femur, bones of the foot An associated soft tissue mass may be seen in about 25% of patients Malignant transformation is possible (rare)

Radiographic Show radiolucent lesion which is surrounded by a thin margin of reactive bone that may have expanded (aneurysmal appearance) Appear as a radiolucent defect with a central density due to ossification Treatment En bloc marginal excision is treatment of choice Active tumors are more likely to recur if intracapsular resection is performed

Fibrous Dysplasia
Clinical Presentation; Lesions may occur in one bone (monostotic) or in many (polyostotic) Occasionally, a child may present with pathologic fracture or angular deformity Polyostotic Fibrous Dysplasia: Children present around 10 years of age Findings include pain, pathologic fracture, limp, or limb deformity In general osseous abnormalities present before 20 years of age Lesion of bone that results in a haphazard mixture of immature fibrous tissue and small fragments of immature irabecular bone Angular deformities may result from defective mineralization of immature dysplastic bone Affected bone becomes widened and adjacent cortical bone becomes thin Radiographic Appearance of lesions is variable but most often will show: Intramedullary diaphyseal lesion that blends with thinned, bulged cortex Hazy or ground glass lesion which may occur with angular deformity Angular deformity in bone is often present at the level of lesion Sites of Involvement Rib is involved most often but any bone can be involved; also seen in proximal femur, proximal tibia, and mandible Bone becomes deformed by multiple stress fracture which may eventually lead to pathologic fracture Cystic type of lesion: radiolucent with a reactive rim, no trabeculae, and normal cortical thickness Pagetoid type of lesion: trabecular pattern which is more dense than normal bone Shepards crook deformity: extensive involvement of proximal femur results in a characteristic varus deformity which resembles a Shepards crook

Nonossifying Fibroma
Also known as fibrous cortical defect Most common bone lesion (40% children) Results from defect of periosteal cortical bone development which leads to a failure of ossification Lesion typically develops in childhood and adolescence During adolescence, nonossifying fibroma is an active Stage two lesion that persists or enlarges throughout childhood

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 With skeletal maturation, it becomes latent and either regresses or ultimately ossifies When tumor occupies > 50% of diameter of bone, it is prone to fracture Radiographic Well marginated radiolucent lesion, with a distinct multilocular appearance Is usually irregular and is surrounded by reactive rim of bone Benign cortical thinning, erosion, slight expansion There are two subtypes: Fibrous Cortical Defect (more common lesion), is small < 0.5 cm radiolucency within cortex with sharply defined cortex Metaphyseal Defect (lesion commonly develops in metaphysis of distal femur, in 90% of cases, or the distal tibia and is eccentrically located). The cortex may bulge over the lesion, as lack of remodeling and may be surrounded by a well-defined thin rim of reactive bone. No periosteal reaction is seen unless there has been a fracture. Nonossifying fibroma can act as a stress riser in bone, which can lead to stress fracture with heavy running and this will result in pain and increase uptake on bone scan. In children, closed treatment is the treatment of choice in most cases.

Enchondroma
Benign and asymptomatic cartilaginous tumor of bone, which most often occurs in adolescents or young adults Is an intramedullary cartilage lesion located in central metaphysis Intramedullary tumor develops in adjacent metaphysis and may eventually penetrate the diaphysis Results from failure of normal endochondral ossification below the growth plate and represents a dysplasia of the central growth plate If dysplastic process occurs in lateral growth plate, resulting tumor is called osteochondroma Most often affects small tubular bones of hands or feet (40%-65%) Frequent cause of pathologic fracture Most frequently involves the proximal phalanx, followed by the middle phalanx and the metacarpals Transformation Enchondroma usually become latent in adulthood and < 2% of asymptomatic solitary enchondromas will transform to chondrosarcoma Enchondromas of long bones have higher chance for malignant transformation In enchondromatosis, risk of malignant transformation is about 10%-25% In Maffucci disease (multiple enchondromas and hemangiomas) risk is near 100% Radiographic Central radiolucent lesion with well defined minimally thickened bony margin During active phase in adolescence, the lesion may slowly enlarge In children, cortex is usually thin and the lesion is radiolucent As lesion matures, it develops a reactive margin Bone Scans Demonstrate radioisotope uptake in margin, related to activity of lesion While there is moderate uptake in the active phase there will also be some activity in latent phase Treatment Asymptomatic solitary enchondromas may be followed non-operatively with serial radiographs prognosis for benign enchondroma is excellent

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Giant Cell Tumor

A common benign but locally aggressive lesion of unknown etiology Occurs chiefly in men between 20 and 50 years of age (after epiphyseal closure); Tumor is an expansile, lytic lesion that involves the epiphysis and metaphysis Tumor may erode & penetrate subchondral bone, articular cartilage and cruciate ligaments

Radiographic Large radiolucent lesion surrounded by distinct margin of reactive bone Often the lesion is eccentric Cortical thinning, endosteal erosion, and trabecularization or bony septation, of the cavity are associated findings Lesion will aggressively destroy medullary and cortical bone Scalloping and ridges in the wall of the tumor give it a soap bubble appearance on the radiograph Treatment Due to proximity to articular cartilage, excision of GCT of bone is difficult Because intra-lesional excision of GCT tends to leave tumor cells behind, past attempts of excision had been associated with a high recurrence rate (40%) Stage 1 or 2 lesions Intra-lesional excision is treatment of choice Use of phenol, polymethacrylate, and liquid nitrogen Phenol can be extremely toxic and, if used at all, its concentration should be limited to 5% Recurrent or stage 3 lesions En bloc excision with wide margin along with appropriate reconstruction 5% of patients will have pulmonary metastases Tumor is considered benign-ii if pulmonary lesions are histologically benign Pulmonary lesions may be cured with surgical resection

Osteochondroma
A developmental dysplasia of peripheral growth plate, which forms a cartilage capped projection of bone found near metaphyses of long bones It is the most common benign bone tumor Usually occurs in long bones, but may occur in any bone that is preformed in cartilage Tumor will continue to enlarge during skeletal growth, but will become latent at skeletal maturity The lesion may continue to grow into the third decade Occasionally a lesion grows more rapidly than expected Most common locations are proximal or distal femur, proximal humerus, proximal tibia, pelvis, and scapula In areas other than the knee, more likely to undergo malignant degeneration Risk of sarcomatous transformation in solitary exostosis is about 1%, but in multiple hereditary exostoses, the risk approaches 10% Clinical presentation Firm, non-tender, immovable mass arising near end of the long bone A symptomatic lesion may be caused by irritation of overlying soft tissues which may go on to form a fluid filled bursa Bursal fluid may be mistaken for a soft tissue mass Radiographic Exostosis is either fiat, sessile lesion, or pedunculated pedunculated osteochondromas are oriented in proximal direction

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 X-ray hallmark is blending of tumor into underlying metaphysis Cartilaginous cap displays irregular areas of calcification Treatment No treatment is required if the diagnosis is not in doubt and if the patient is relatively asymptomatic Surgical resection is indicated for persistent irritation (from bursitis) or for neurovascular compromise Surgical resection is also indicated for continued osteochondroma growth after skeletal maturity

Chondroblastoma
Most common primary epiphyseal tumor in children The adults counterpart of chondroblastoma is giant cell tumor Most common location is proximal tibial epiphysis and proximal humeral epiphysis Differential Diagnosis Only three tumors may invade physis: Chondroblastoma Giant cell tumor Clear cell chondrosarcoma Clinical Presentation Painful: motion limiting, benign tumor arising during adolescence Majority are active Stage 2 lesions Most lesions occur in the proximal part of the tibia (17%) and the proximal part of the humerus (15%) The hands and feet are the sites of 10% of chondroblastoma with the tumors having a particular predilection for the talus and calcaneus Chondroblastoma is the most common tumor affecting the patella, followed by giant cell tumor Radiographic Epiphyseal radiolucent lesion with fine punctate calcifications Oval osteolysis located eccentrically in the epiphysis Tumor is usually bordered by a well defined margin of reactive bone Stage 3 chondroblastoma may extend through growth plate into metaphysis or through articular cartilage into the joint Treatment Stage 2 Wide excision is the treatment of choice, if technically possible It is important to avoid joint penetration because chondroblastoma cells will grow in joint fluid Addition of methylmethacrylate to defect may be added to curettage to prevent recurrence Stage 3 Stage 3 will require en bloc excision These may metastasize to the lungs Patients with lesions around the hip (proximal femur, greater trochanter, and pelvis) are significantly more likely to develop recurrences as well as metastatic lesions

Chondromyxoid Fibroma
Locally painful benign cartilaginous lesion of bone Occurs in adolescents Located in metaphysis of major long bones This lesion most often presents as an active Stage 2 lesion that is are locally destructive and has a high recurrence rate (up to 25%)

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Does not undergo malignant transformation Eccentric radiolucent defect with NO calcification Adjacent cortex may be expanded, thinned or even absent Look for sclerotic and scalloped rim Typically located in the metaphyseal region of long bones and in some cases it is possible for it to invade the epiphyseal plate Treatment Curettage is indicated for well encapsulated Stage 2 lesions Stage 3 lesions, most often seen in the pelvis, require wide excision to prevent recurrence.

Chondromyxoid Fibroma Chondrosarcoma

Malignant cartilaginous tumor of bone It is less common and less aggressive than osteosarcoma Chondrosarcoma Primary Most often presents as a low grade - intracompartmental lesion They are slow to metastasize and may grow to immense proportions Tumor tends to destroy bone and to extend into the soft tissues Tumor may invade blood vessels and produce a long intravascular tumor that may extend into heart and pulmonary arteries Long-term survival rate of patients with treated chondrosarcoma is between 50%-75% Primary form occurs most often in men between 50 and 60 years of age whereas osteosarcoma occurs between 20 and 30 years of age Most common locations are the pelvis, proximal femur and shoulder girdle, whereas osteosarcoma occurs most often around the knee When chondrosarcoma occurs in the pelvis, it is often large, high grade, diagnosed late, and has a poor prognosis Secondary Secondary form occurs in about 25% of cases Malignant transformation from preexisting enchondroma or osteochondroma Variants of chondrosarcoma: (based on histology and location) Clear cell (intermediate grade) extraosseous Atypical enchondroma (juxtacortical chondroma) Clinical Presentation Persistent, dull, aching pain Found in an older age group peaking at 45 years of age Majority of chondrosarcomas occur about the hip and pelvis Radiographic Subtle, radiolucent, permeative lesion May have hazy or speckled calcifications with either a diffuse salt and pepper pattern or a more discrete popcorn pattern Pattern of calcification is usually diagnostic of cartilaginous tumor Treatment Tumor does not respond to x-ray therapy nor to currently available antineoplastic drugs Low grade tumors: Rarely metastasize Rarely recurs after wide limb salvaging excision The involved bone is resected along with a small cuff of surrounding muscle

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 High grade tumors Have higher rate of recurrence after limb salvage (requires amputation) Are prone to pulmonary metastases

Osteosarcoma
Malignant tumor of bone in which neoplastic osteoid is produced by a proliferating spindle cell stroma Most common primary malignant bone tumor of mesenchymal derivation Arises in adolescents and affects males slightly more often than females Locations Occurs in region of knee (distal femur or proximal tibia) in 50% of patients Other sites include proximal humerus, proximal femur, and pelvis Most osteosarcomas occur in the metaphysis Infrequently occurs in the spine Clinical Presentation Initial symptom is a painful bony mass Significant number of osteosarcomas in adults occur in association with Pagets disease Prognosis At time of diagnosis, most osteosarcomas are Stage 2b lesions that have infiltrated the soft tissue in 50% of adolescent patients; the tumor penetrates growth plate into epiphysis Metastasis Osteosarcoma tends to have early hematogenous metastasis Pulmonary or lymph node metastases are detected at presentation in about 10% of patients Pulmonary metastases are usually detected within and year after diagnosis Undetectable micrometastases are probably present in lungs of most patients at time they first seek medical attention Without control of micrometastatic disease, there will be x-ray evidence of lung metastases in up to 80% of patients after 1-2 years; following surgical resection, skip metastases are found in 25% of patients. Survival In the past survival rate was around 15%, but with adjunctive therapy survival is greater than 50%. Metastatic disease evident at presentation also indicates presence of more aggressive disease and poor prognosis Treatment Surgery alone as a treatment yields only a 20% survival rate; with adjuvant chemotherapy, the 5 year survival rate is > 50% Some surgeons insist on preoperative chemotherapy in the management of osteosarcoma Commonly used agents include doxorubicin, cisplatin, high-dose methotrexate, ifosfamide, and cyclophosphamide Limb Salvage versus Amputation Limb salvage surgery does not seem to have a higher local recurrence rate than amputation. Surgical resection of osteosarcoma pulmonary metastases Aggressive surgical resection will improve 5-year survival rate.

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2.5

Osteomyelitis

Initially we see soft tissue swelling with obliteration of fascial planes. Bony changes appear on x-ray in 10-14 days. Initial changes include decreased bone density or localized osteoporosis. Periosteal reaction with absence of Sharpys fibers is noted. Indistinct changes in bony appearance can occur such as a break in the cortex and a lack of bony definition. Sequestra involucrum and cloaca are relatively late changes seen in osteomyelitis. Sequestra is dead avascular bone that the body tries to wall off. Initially sequestra appears as the same density as normal bone. Due to hyperemia, the surrounding live viable bone will become diminished in density and the sequestra will appear relatively more dense. If involucrum (granulation tissue) is lied down over the sequestra, we will see an absolute increase in bone density. Involucrum is granulation tissue that appears radiolucent. As it consolidates and ossifies, it takes on the density of bone. Cloaca is a hole in the bone caused by proteolytic enzymes and pressure. It is more commonly seen in hematogenous OM than direct extension osteomyelitis.

Diagnosing OM
It takes 10-14 days for osteomyelitis to show up on x-ray. A technesium bone scan becomes positive for osteomyelitis 24-48 hours after symptoms appear. A triphasic technesium scan is useful in differentiating an acute cellulitis from acute OM. The three phases are the blood flow, blood pooling, and the delayed. The first two stages measure blood, the third stage measures osteogenesis. Acute cellulitis is hot in the first two stages and cool in the third stage. Acute OM is hot in all three stages, getting hotter in the third stage. Gallium, a soft tissue-scanning agent is often used in conjunction with a technesium scan. Gallium binds with the ferroproteins in white blood cells. It is better for chronic infections because it stays hot for a long time. Focal gallium uptake in bone is characteristic of OM. Indium is a soft tissue-scanning agent that is better for acute infections. Indium does not localize to bone well. The most sensitive nuclear medicine scan for osteomyelitis is a technesium labeled lymphocyte scan. Uptake in bone is highly suggestive for OM. The most reliable magnetic resonance study is a fat suppression (STIR), gadolinium-enhanced scan. Increased signal intensity in bone is highly suggestive of OM.

2.6

Rheumatology

Osteoarthritis
Osteoarthritis is an insidious disease related to aging, although not all old people get it. It is associated with weight-bearing joints but is common in the shoulder. It is primarily a disease of the cartilage, which becomes soft and frayed. The primary radiographic changes are hypertrophic. Initially we see non-uniform joint space narrowing. There is subchondral sclerosis. Abnormal pressure in the joint results in subchondral cyst formation, which does not erode the cortex. Abnormal forces at the joint cause the capsule and ligaments to pull forming osteophytes and exostoses. Because OA is not an inflammatory arthritity, osteoporosis is not a primary part of the disease. However, if the patient stops ambulating because of the pain, disuse osteoporosis can occur. Joint fusions are not a primary part of the disease, although exostosis can impinge and inhibit range of motion.

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Rheumatoid Arthritis
Rheumatoid is a T-cell mediated collagen vascular disease, which affects joints. Although the full-blown disease is bilaterally symmetrica1, the initial onset can be unilateral. There is a predilection for young women 3:1 over young men. Rheumatoid is primarily an atrophic arthritity. There appears to be a predilection for the metatarsals before it affects the phalanges. Fusiform swelling of the digits is common. Initially effusion of the joints is noted giving uniform joint space widening. Periarticular osteoporosis is a common early radiographic feature. Uniform joint space narrowing due to consolidation of panus is a relatively late finding. Joint fusions are uncommon but possible. Periarticular erosions in the area of the synovium are common. Subluxations and dislocations are possible with fibula deviations. Subchondral cysts, which can erode through the cortex, are present.

Seronegative Arthritis
Ankylosing Spondylitis Ankylosing Spondylitis primarily affects the sacroiliac joints and the spine. The peripheral joints may also be involved. A high incidence of the HLA-B27 antigen is present. There is a predilection for young males 3:1 over females. Back pain is usually the first clinical manifestation. Bilateral sacroiliitis is common. Complete bony ankylosis is possible. Syndesmophyte formation can occur. Fusion of the vertebral column resulting in bamboo spine is an end result. Bony erosions at tendon insertions and synovium are possible, as in the other seronegative arthritities. Psoriatic Arthritis In 10% of the cases the arthritic lesions precede the skin lesions. A diagnosis of psoriatic arthritis cannot definitively be made without the skin lesions. There is an increased incidence of the HLA-B27 antigen in psoriatic arthritic patients. Entheseopathy is common especially of the tendoachilles and plantar fascia. In two-thirds of the patients mono or oligoarticular arthritis is present similar to that seen in the other sero negative arthritities. In one-third to onehalf of the patients, the disease will evolve into a symmetrical distribution similar to that of rheumatoid. Psoriatic arthritis characteristically has both atrophic and hypertrophic changes with a lack of osteoporosis. Pauciarticular erosions are present. Joint space widening with well-demarcated articular borders are characteristic. There are intraarticular erosions. Joint fusions are common. Saucer-in-cup or pencil-in-cup deformities are associated with psoriatic arthritis but occur less than 3% of the time. Hypertrophic changes of the base of one phalanx with atrophic changes of the head of the adjoining phalanx give this appearance. There is a predilection for the interphalangeal joints with lack of fibula deviation. There is no significant osteoporosis. Reiters Reactive Arthritis There is a marked increase in the presence of the HLA-B27 antigen. Young men have the highest incidence of the disease. The classic triad of symptoms is non-gonococcal urethritis, conjunctivitis, and arthritis. Keratoderma blennorrhagicum, a dermatological lesion of the palms and soles, can also occur. Dactylitis, or sausage-like soft tissue swelling of the digits, occurs. The lower extremity is affected more than the upper. Periarticular osteoporosis with intraarticular erosions are present. Erosions are also present at synovial and tendinous insertions.

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Gout Gout is the symptomatic deposition of uric acid crystals in the joint. It has its highest incidence in older males. Females with gout are usually post-menopausal. Gout has a predilection for the smaller joints with the highest incidence at the first metatarsal phalangeal joint. It takes many years and multiple attacks for gouty erosions to show up on x-ray. The classic lesion is an erosion with overhanging cortical margin (Martels Sign) with a rat bite-like appearance. Martels Sign appears less than 10% of the time. Urate tophi may calcify, giving it a cloudy amorphous appearance in the soft tissue. Pseudogout (Calcium Pyrophosphate Dihydrate Deposition) Pseudogout is the symptomatic deposition of calcium pyrophosphate dihydrate crystals. Pseudogout has a predilection for the knee and other large joints. The classic radiographic appearance is calcification in articular cartilage, as well as in articular capsule ligaments and tendons.

2.7

Osteochondrosis

An osteochondrosis is an aseptic necrosis-like process at a growth center (epiphysis or apophysis). A true osteochondrosis will undergo a sequence of events characteristic of an infarct. Initially there will be an infarct followed by reabsorption, revascularization, and remodeling. All true osteochondrosis undergo this sequence of events and show characteristic radiographic changes. An early diagnostic sign in a true osteochondritity is a crescent sign. This is a crescent or triangular shape radiodensity in the subchondral bone that is an early indicator of infarct. Immobilization is required to prevent joint destruction and allow healing with minimal sequela. Sequela result in joint flattening, neck broadening, and degenerative joint disease. True Osteochondrosis Legg-Calve-Perthes Disease This is an osteochondrosis of the proximal femoral epiphysis. It is more common in males than females with a peak incidence of about 5 yrs of age. Freibergs Disease This is an osteochondrosis of the metatarsal head seen in young females between the age of 10 and 15 yrs of age. It is most common in the second metatarsal bead. Studies show this is likely a stress fracture of the epiphyseal plate. This results in a flattening of the metatarsal head with an S-shaped joint and degenerative joint disease. Osteochondrosis of the Sesamoids Radiographically, we see cystic erosions in the sesamoids. Abnormalities in Osteogenesis and Chondrogenesis Osgood Schlatters Disease (Osteochondrosis of the Tibial Tuberosity) This is a tendonitis of the patella tendon with bone formation in the tendon. A normal tibial tubercle may be fragmented and teardrop-shaped. This is not an x-ray diagnosis. This is most commonly seen in young boys with pain on palpation of the tibial tuberosity. There is pain upon squatting and going up and down steps. Blounts Disease (Osteochondrosis of the Medial Tibial Condyle) This is an abnormality of chondrogenesis of the proximal medial tibial epiphysis. This is most likely seen in young black males. The infantile form of the disease is much more severe than the juvenile. Significant tibial bowing may result.

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Anatomical Variants Kohlers Disease This is associated with delayed ossification of the navicular. We see a disk-shaped navicular narrowed in its A/P diameter. It may be fragmented, sclerotic, hazy, and out of focus. It will eventually ossify normally. There is no real pathology. Islins Disease This is a normally fragmented or multi-partite apophysis at the base of the fifth metatarsal. Severs Disease The calcaneal apophysis is the most sclerotic apophysis in the body. Irregularity, fragmentation, and new bone formation is normal. There are no reported cases of long-term deformity associated with this disorder. The three most common etiologies of heel pain in children are plantar fasciitis, Achilles tendonitis, and Haglund's deformity. The heel pain is not caused by the fragmented calcaneus but usually by one of these pathologies. Osteochondritis Dissecans This is a localized ischemic necrosis that occurs more frequently in young men and boys often following injury. It is an osteochondral fracture that results in a button of necrotic bone separating from the joint surface. It is seen most commonly in the knee.

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