Miscellaneous Conditions

Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 15 – Miscellaneous Conditions

Chapter 15
Miscellaneous Conditions
Thomas H. Berquist
Bone Islands (Enostosis)
FIGURE 15-1 Bone island in the femoral neck in a 60-year-old man. Anteroposterior (AP) (A) and oblique (B) radiographs demonstrate a spiculated sclerotic focus (arrow). Coronal T1-weighted (C), axial proton density (D), and T2-weighted (E) images showing a low-intensity lesion on all sequences with irregular margins (arrow). There is a small bone island in the opposite femoral head (open arrow) on the axial images (D,E).


Suggested Reading
Hall FE, Goldberg RP, Davies JAK, et al. Scintigraphic assessment of bone islands. Radiology 1980;135:737–742.


Osteopoikilosis. AP radiograph of the pelvis and hips showing multiple
small sclerotic foci in the proximal femora, ischia, and acetabuli.
Note the femoral striations (arrows) (osteopathia striata is related to osteopoikilosis).
Suggested Reading
Green AE, Ellowood WH, Collins JR. Melorheostosis and osteopoikilosis. AJR Am J Roentgenol 1962;87:1096–1117.


Osteopathia Striata


FIGURE 15-3 Osteopathia striata. (A) AP radiograph of the pelvis and hips showing linear striations in the femoral neck (arrows) with cortical thickening medially from associated melorheostosis. (B) Coronal T1-weighted magnetic resonance (MR) image of the right hip showing the low signal intensity linear sclerosis (arrow).
Suggested Reading
Hurt RL. Osteopathia striata. Voorhoeve disease. J Bone Joint Surg 1953;35B:89–96.




FIGURE 15-4 Melorheostosis. Lateral (A) and AP (B)
views of the tibia showing sclerosis along the posteromedial cortex
resembling “dripping candle wax” that ends in the mid-diaphysis (arrow).


Melorheostosis. Standing views of the knees showing sclerosis and
cortical thickening that crosses the joint into the soft tissues. The
tibia also is involved.
Suggested Reading
Morris JM, Samilson RL, Corey CL. Melorheostosis. J Bone Joint Surg 1963;45A:1191–1206.


Progressive Diaphyseal Dysplasia (Engelmann Disease)


FIGURE 15-6 Engelmann disease. (A)
Radionuclide bone scan showing symmetric increased cortical uptake in
the femora, tibiae, and upper extremities. AP radiographs of the femur (B) and tibia (C) showing marked diaphyseal cortical thickening with sparing of the metaphyses and epiphyses.
Suggested Reading
B, Murphy WA, Whyte MP. Progressive diaphyseal dysplasia (Engelmann
disease): Scintigraphic-radiographic-clinical correlations. Radiology 1981;140:87–92.


Cleidocranial Dysplasia (Cleidocranial Dysostosis)


FIGURE 15-7 Cleidocranial dysplasia. (A) AP view of the skull showing multiple wormian bones along the suture lines. (B) AP view of the upper chest showing an absent right clavicle and small hypoplastic medial segment (arrow) on the left.
Suggested Reading
Jarvis JL, Keats TE. Cleidocranial dysostosis. A review of 40 new cases. AJR Am J Roentgenol 1974;121:5–16.




Osteopetrosis intermediate. AP radiographs of the tibia and femora
showing bone sclerosis with bone-within-a-bone appearance in the


FIGURE 15-9 Osteopetrosis tarda. AP (A) and lateral (B) radiographs of the lumbar spine showing a bone-within-a-bone appearance.
Suggested Reading
Shapiro F, Glimcher MJ, Holtrop ME, et al. Human osteopetrosis. J Bone Joint Surg 1980;62A:384–399.




FIGURE 15-10 Mastocytosis. (A)
AP radiograph of the lumbar spine and pelvis showing generalized bone
sclerosis and cortical thickening. There are more focal foci of
sclerosis in the femoral heads. AP (B) and lateral (C) radiographs of the lumbar spine and pelvis in a different patient showing diffuse small sclerotic foci.
Suggested Reading
McKenna MJ, Frame B. The mast cell and bone. Clin Orthop 1985;200:226–233.


Tuberous Sclerosis
FIGURE 15-11
Tuberous sclerosis. AP radiograph of the pelvis showing oval- or
flame-shaped areas of sclerosis in both iliac wings. There is an
impacted left femoral neck fracture with pin fixation unrelated to the
bone changes of tuberous sclerosis.


FIGURE 15-12 Tuberous sclerosis with renal angiomyolipomas. (A,B) Computed tomography (CT) images showing characteristic fat density masses (arrows), the largest in the right kidney.


FIGURE 15-13 Tuberous sclerosis. Axial T2-weighted MR image showing multiple areas of signal abnormality (arrows) resulting from cortical tubers.
Suggested Reading
Medley BE, McLeod RA, Houser OW. Tuberous sclerosis. Semin Roentgenol 1976;11:35–54.
Wood B, Leiberman E, Larding B, et al. Tuberous sclerosis. AJR Am J Roentgenol 1992;158:750.


FIGURE 15-14 Neurofibromatosis Type 1. AP (A) and lateral (B) radiographs showing tibial bowing with a healed midtibial fracture.


FIGURE 15-15 Neurofibromatosis Type 1. Axial precontrast (A) and postcontrast (B) images showing enlargement of both optic nerves (arrows) caused by optic nerve gliomas.


FIGURE 15-16 Neurofibromatosis Type 2. Bilateral vestibular nerve schwannomas and multiple meningiomas. (A)
Postcontrast axial MR image showing bilateral large vestibular nerve
schwannomas extending into the internal auditory canals and compressing
the pons. Sagittal (B) and coronal enhanced (C) T1-weighted images showing multiple meningiomas (arrows).
Suggested Reading
Sevick RJ, Barkovich AJ, Edwards MS, et al. Evolution of white matter lesions in neurofibromatosis type 1: MR findings. AJR Am J Roentgenol 1992;159:171–175.


Ollier Disease (Enchondromatosis)


FIGURE 15-17 Ollier disease. (A) Posteroanterior (PA) chest radiographs showing multiple expanded calcified rib lesion (arrows). (B) PA view of the hand showing enchondromas in the second to fourth rays. AP radiographs of the pelvis (C) and femora (D) showing multiple enchondromas in the left femur. The largest expand the distal femur.
Suggested Reading
Milgram JW. The origins of osteochondromas and enchondromas. A histopathologic study. Clin Orthop 1983;174:264–284.


Maffucci Syndrome
FIGURE 15-18 Maffucci syndrome. Oblique radiograph showing multiple enchondromas and soft tissue masses with vascular calcifications.
Suggested Reading
Strang C, Ronnie I. Dyschondroplasia and hemangiomata (Maffucci’s syndrome). J Bone Joint Surg 1950;32B:376–383.


Hereditary Multiple Exostosis


FIGURE 15-19 Hereditary multiple exostosis. Radiographs of the humeri (A,B), left hand and wrist (C), both ankles (D), and feet (E) demonstrate multiple exostoses with bone and joint deformities most obvious in the hand and wrist.


Suggested Reading
Wilner D. Radiology of bone tumors and allied disorders. Philadelphia: WB Saunders; 1982.


Epiphyseal Dysplasias



FIGURE 15-20 Multiple epiphyseal dysplasia. Radiographs of the hip (A), left knee (B,C), left foot and ankle (D,E), and left wrist (F) show lack of epiphyseal ossification centers with punctate calcifications in the knee.


FIGURE 15-21 Multiple epiphyseal dysplasia in an adolescent. AP and lateral radiographs of the knee (A,B) and ankle (C,D) showing irregular epiphysis with joint deformities.
Suggested Reading
Berg PK. Dysplasia epiphyseal multiplex. AJR Am J Roentgenol 1966;97:31–38.


Metaphyseal Dysplasias
FIGURE 15-22 Metaphyseal dysplasia. Standing radiographs of the knees showing metaphyseal irregularity and flaring with femoral bowing.
Suggested Reading
WH, Herman TE. Osteochondrodysplasias, dysostosis, chromosomal
aberrations, mucopolysaccharidoses, and mucolipidosis. In: Resnick D,
Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:1298–1325.


Marfan Syndrome
FIGURE 15-23 Marfan syndrome. PA radiographs of the hands showing elongation and thin metacarpals and phalanges.
Suggested Reading
AB. Heritable diseases of connective tissue, epiphyseal dysplasias, and
related conditions. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:1279–1297.


Ehlers-Danlos Syndrome
FIGURE 15-24 Ehlers-Danlos syndrome. AP (A) and lateral (B) radiographs of the cervical spine showing exaggeration of the cervical curves.
Suggested Reading
AB. Heritable diseases of connective tissue, epiphyseal dysplasias, and
related conditions. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:1279–1297.


Osteogenesis Imperfecta


FIGURE 15-25
Osteogenesis imperfecta Type II. Radiograph of a newborn with short,
thick osteoporotic extremities and multiple fractures that occurred in


FIGURE 15-26 Osteogenesis imperfecta Type I (tarda). AP radiographs of the femora (A) and legs (B) showing thin, gracile osteoporotic bones with a healed fracture (arrow) in the right femur.
Suggested Reading
Sillence D. Osteogenesis imperfect: An expanding panorama of variants. Clin Orthop 1981;159:11–25.




FIGURE 15-27 Achondroplasia. (A) AP radiograph of the spine showing no change in lumbar interpedicular distance (black dots) progressing from L1 to L5. (B) AP radiograph of the pelvis and lower extremities showing small sciatic notches (arrowheads), flattening of the acetabular angles, iliac squaring, and short tubular bones with metaphyseal flaring in the knees. (C)
Lateral radiograph of the spine in an older patient showing short
pedicles and concave posterior vertebral margins. The narrowed spinal
canal has resulted in laminectomies (arrows).
Suggested Reading
Langer LO, Baumann PA, Gorlin RJ. Achondroplasia. AJR Am J Roentgenol 1967;100:12–26.




Type Enzyme Deficiency Features
Hurler syndrome (MPS-IH) α-L-iduronidase Mental retardation, clouded corneas, coarse facial features, heart disease
Scheie syndrome (MPS-IS) α-L-iduronidase Late onset, clouded corneas, aortic valve disease, mentally normal, mild facial changes
Hurler-Scheie syndrome α-L-iduronidase Between MPS-IH and MPS-IS
Hunter syndrome (MPS-II) Iduronidase-Z-sulfatase Severe: mental retardation, death in second decade
Mild: mental retardation, survive until adulthood
Sanfilippo syndrome (MPS-III) A: Heparin-N-sulfatase
B: α-N-acetyl glucosaminidase
C: Glucosaminide-N-acetyl transferase
D: N-acetyl glucosamine-6-sulfate sulfatase
Mental retardation, mild skeletal features
Morquio syndrome (MPS-IV) Galactosamine-6-sulfate sulfatase Severe dwarfism, short trunk and neck, mentally normal
Maroteaux-Lamy syndrome (MPS-VI) N-acetyl galactosamine-4-sulfatase Dwarfism, coarse facial features, corneal clouding, mentally normal
Sly syndrome (MPS-VII) β-glucuronidase Enlarged liver and spleen, mild to moderate mental retardation
MPS, mucopolysaccharidoses.


FIGURE 15-28 Hurler Syndrome (MPS-IH). (A) Lateral radiograph of the skull shows a large “J”-shaped sella and underdeveloped mastoids. Sinuses are hypoplastic. (B) AP radiograph of the spine and pelvis demonstrates expanded anterior ribs, hypoplastic ilia, and coxa valga. (C) Lateral radiograph of the spine shows hypoplastic vertebrae at the thoracolumbar junction with anterior beaking. (D) Hand radiograph demonstrates thick short metacarpals and phalanges with pointing of the proximal metacarpals.


FIGURE 15-29
Morquio syndrome (MPS-IV). Radiograph of the hand showing slanting of
the radial and ulnar articular surfaces and small irregular carpal
bones. The bones of the hand are short and widened.
Suggested Reading
Blighton D. Heritable disorders of connective tissue, 5th ed. St. Louis: CV Mosby; 1993.


Dyschondrosteosis (Leri-Weill Syndrome)


FIGURE 15-30 Dyschondrosteosis (Leri-Weill syndrome). AP (A) and lateral (B)
radiographs of the forearm showing Madelung deformity with bowing of
the radius and a V-shaped radioulnar articular surface with carpal
bones collapsed centrally.
Suggested Reading
Langer LO. Dyschondrosteosis of the inherited bone dysplasias with characteristic roentgenographic features. AJR Am J Roentgenol 1965;95:178–185.




FIGURE 15-31 Pachydermoperiostosis (primary hypertrophic osteoarthropathy). Radiographs of the hands (A,B)
demonstrate widening and bony proliferation involving the phalanges and
metacarpals with involvement of the radial and ulnar epiphyses.
Radiographs of the forearms (C,D) show cortical thickening and irregularity with widening of the radius and ulna.


Suggested Reading
Neiman HL, Gompels BM, Martel W. Pachydermoperiostosis with bone marrow failure and gross extramedullary hematopoiesis. Radiology 1974;110:533–554.


Secondary Hypertrophic Osteoarthropathy
Condition Radiographic Features
Primary hypertrophic osteoarthropathy (Pachydermoperiostitis) Shaggy periostitis, ligament ossification tibia, fibula, tarsal, metatarsal diaphysis, and epiphysis
Secondary hypertrophic osteoarthropathy Smooth periosteal reaction, tibia, fibula radius, and ulnar diaphysis and metaphysis
Thyroid acropachy (see Chapter 14) Spiculated periosteal reaction in hands and less commonly the feet
Venous insufficiency Smooth undulating periosteal reaction most common in the tibia and fibula
Hypervitaminosis A Undulating periosteal reaction in the tibia, fibula, and metatarsal diaphyses


FIGURE 15-32 Secondary hypertrophic osteoarthropathy. AP (A) and lateral (B) radiographs in a patient with chronic pulmonary disease showing periosteal new bone along the lateral tibia (arrows), posterior tibia (open arrows), and medial tibia (arrowhead).
Suggested Reading
Segal AM, McKenzie AH. Hypertrophic osteoarthropathy. A 10-year retrospective analysis. Semin Arthritis Rheum 1982;12:220–231.


Vitaminosis: Vitamin A
Suggested Reading
Ruby LK, Mital MA. Skeletal deformities following chronic hypervitaminosis A. J Bone Joint Surg 1974;56:1283–1287.


Vitaminosis: Vitamin C
FIGURE 15-33
Hypovitaminosis C in a 10-month-old. Radiographs of the knees showing
ringed epiphyses and metaphyseal condensation with fractures (arrows) proximally.


FIGURE 15-34
Hypovitaminosis C in an 8-month-old. AP radiographs of the lower
extremities showing healing subperiosteal hemorrhages, more evident
along the femora.
Suggested Reading
Resnick D, Kransdorf MJ. Hypervitaminosis and hypovitaminosis. In: Resnick D, Kransdorf MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:1022–1027.


Vitaminosis: Vitamin D
Metastatic Calcification (Calcium/Phosphorus Metabolism)
  Renal osteodystrophy
  Hypervitaminosis D
  Multiple myeloma
Calcinosis (Normal Calcium Metabolism)
  Collagen vascular diseases (see Chapter 13)
  Tumoral calcinosis
  Calcinosis universalis
Dystrophic Calcification (Normal Calcium Metabolism)


FIGURE 15-35 Vitamin D intoxication. AP radiograph of the foot showing dense amorphous periarticular soft tissue calcification.
Suggested Reading
Resnick D, Kransdorf MJ. Hypervitaminosis and hypovitaminosis. In: Resnick D, Kransdor MJ, eds. Bone and joint imaging, 3rd ed. Philadelphia: Elsevier-Saunders; 2005:1022–1027.


Tumoral Calcinosis
FIGURE 15-36 Tumoral calcinosis. CT images (A–C) of the shoulder demonstrate large loculated calcium masses.
Suggested Reading
Kolawole TM, Bohrer SP. Tumoral calcinosis with fluid–fluid levels in tumoral masses. AJR Am J Roentgenol 1974;120:461–465.


Heavy Metal Disorders
FIGURE 15-37 Lead poisoning. AP radiographs of the knees (A) and both wrists (B,C) showing dense, thick metaphyseal bands.


FIGURE 15-38
Heavy metal intoxication. AP radiographs of the knees demonstrate broad
bands of sclerosis in the diaphyseal-metaphyseal regions of the tibias
and femurs.
Suggested Reading
Blickman JG, Wilkinson RH, Graef JW. The radiographic lead band revisited. AJR Am J Roentgenol 1986;146:245–247.


Hemoglobinopathies/Anemias: Basic Concepts
Suggested Reading
Musely JE. Skeletal changes in the anemias. Semin Roentgenol 1974;9:169–184.


Hemoglobinopathies/Anemias: Sickle Cell Anemia


FIGURE 15-39 Sickle cell dactylitis. AP radiographs of the feet (A) and right hand (B) showing necrosis of metatarsals with periosteal reaction (arrows) and similar changes in the hand.
FIGURE 15-40 H-shaped vertebrae. Lateral radiograph of the thoracic spine showing H-shaped vertebral bodies (arrow) caused by endplate ischemic changes.
Suggested Reading
Diggs LW. Bone and joint lesions in sickle cell anemia. Clin Orthop 1967;52:119–144.


Hemoglobinopathies/Anemias: Thalassemia


FIGURE 15-41 Thalassemia major. (A) Lateral radiograph of the skull demonstrating the “hair-on-end” appearance. AP (B) and lateral (C)
radiographs of the knee show marrow expansion, thin cortex with sparse
trabeculae, and the Erlenmeyer flask deformity in the femur (B). Radiograph of the hand (D) demonstrating marrow hyperplasia with cystic lesions. Axial CT image (E) shows expansion of the ribs and soft tissue masses caused by extramedullary hematopoiesis.


Suggested Reading
Caffey J. Cooley anemia. A review of roentgenographic findings in the skeleton. AJR Am J Roentgenol 1957;78:381–391.


Location Incidence
Pulmonary 90%
Mediastinum 85%
Ocular 80%
Liver/spleen 50%–80%
Muscles 50%–80%*
Cardiac 25%
Central nervous system 25%
Osseous 5%–13%
Parotid glands 6%
GU tract 5%
GI tract 1%
*Only 1.4% are symptomatic. GU, genitourinary; GI, gastrointestinal.
FIGURE 15-42 Sarcoidosis. (A) PA radiograph of the chest showing bilateral hilar and right paratracheal adenopathy. Note the tracheal deviation (arrows). (B)
Radiograph of the right hand showing lacelike trabecular pattern and
cystic changes in the third middle phalanx and fourth proximal phalanx.


FIGURE 15-43 Sagittal T1- (A) and T2-weighted (B) images of the spine demonstrate multiple lesion (arrows) that would be difficult to differentiate from metastasis.


Suggested Reading
Gunter B. Sarcoidosis. Orthopedics 1995;18:214–218.
Moore SL, Teirstein AE. Musculoskeletal sarcoidosis: Spectrum of appearances at MR imaging. Radiographics 2003;23:1389–1399.


Diffuse Idiopathic Skeletal Hyperostosis


FIGURE 15-44 DISH. (A)
Lateral view of the cervical spine with prominent anterior ossification
causing dysphagia. The disc spaces are preserved and at least four
segments are involved. (B) Lateral radiograph of the thoracic spine with flowing osteophytic ossification and preserved disc spaces. (C) Lateral view of the lumbar spine with anterior ossification and normal disc spaces. (D) AP radiograph of the pelvis with ischial whiskering and prominent enthesophytes, especially on the left greater trochanter.


Suggested Reading
D, Niwayama G. Radiographic and pathologic features of spinal
involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 1976;119:559–568.


Gorham Disease (Massive Osteolysis)
FIGURE 15-45 Gorham disease. (A) Radionuclide bone scan showing absent (no uptake) tenth and distal eighth ribs (arrows). (B) AP radiograph of the pelvis in a different patient with osteolysis of the medial left ilium.
Suggested Reading
Heyden G, Kindblom LG, Nielsen JM. Disappearing bone disease. A clinical and histologic study. J Bone Joint Surg 1977;59A:57–61.


Nonaccidental Trauma (Battered Child Syndrome)


FIGURE 15-46 Nonaccidental trauma. (A) Radiograph of the clavicles shows a fracture of the right midclavicle with abundant callus formation. (B) Radiograph of the forearm shows a subtle torus fracture (arrow). (C) AP radiograph of the skull demonstrating a skull fracture. (D) Renogram in a 14-month-old shows no perfusion in the left kidney (arrowhead). (E) CT image demonstrating fluid in the abdomen with renal (arrow) and splenic (arrowhead) injuries.


Suggested Reading
Dias MS, Backstrom J, Falk J, et al. Serial radiography in the infant shaken impact syndrome. Pediatr Neurosurg 1998;29:77–85.
Kogutt MS, Swischuk LE, Fagan CJ. Patterns of injury and significance of uncommon fractures in battered child syndrome. AJR Am J Roentgenol 1974;121:143–149.
Mogbo KI, Slovis TL, Canady AI, et al. Appropriate imaging in children with skull fractures and suspicion of abuse. Radiology 1998;208:521–524.

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More