Elderly male with leg pain Laura Avery, MD Massachusetts General Hospital Harvard Medical School Boston, MA, USA

What disease process if affecting the femur? Paget’s disease What adjectives do you want to use to describe the finding? cortical thickening Trabecular thickening Increased size of bone

Paget’s disease

What adjectives do you want to use to describe the finding?

cortical thickening

Trabecular thickening

Increased size of bone

Trabecular thickening cortical thickening Increased size of bone

What important finding is present?

What important finding is present?

Incomplete fracture

Patient returned with increased pain “ Banana fracture" = tiny horizontal cortical infractions (“Looser lines”) on convex surfaces of lower extremity long bones (lateral bowing of femur, anterior bowing of tibia)

Paget’s Disease The radiologic appearance of Paget's disease of the long bone reflects the pathologic stages of the disease: (1) destructive or active, (2) combined destructive and proliferative, and (3) sclerotic. Paget's disease of the long bones begins at one end of the bone (the shaft of the tibia may occasionally be involved by itself). Complications of Paget's disease are insufficiency and true fractures; sarcoma is a rare complication. Paget's disease does not require follow-up imaging unless complications occur.

The radiologic appearance of Paget's disease of the long bone reflects the pathologic stages of the disease:

(1) destructive or active,

(2) combined destructive and proliferative, and

(3) sclerotic. Paget's disease of the long bones begins at one end of the bone (the shaft of the tibia may occasionally be involved by itself).

Complications of Paget's disease are insufficiency and true fractures;

sarcoma is a rare complication.

Paget's disease does not require follow-up imaging unless complications occur.

Radiology slang "Cotton wool" appearance represents mixed lytic and blastic pattern of thickened calvarium (later stage) "Candle flame" or "blade of grass" pattern of lysis is the advancing tip of V-shaped lytic defect in diaphysis of long bone originating in subarticular site "Picture-frame vertebra" mimics bone-within-bone appearance Enlarged vertebral body with reinforced peripheral trabeculae and more lucent center, typically in lumbar spine "Ivory vertebra" is a blastic vertebra with increased density

"Cotton wool" appearance represents mixed lytic and blastic pattern of thickened calvarium (later stage)

"Candle flame" or "blade of grass" pattern of lysis is the advancing tip of V-shaped lytic defect in diaphysis of long bone originating in subarticular site

"Picture-frame vertebra" mimics bone-within-bone appearance

Enlarged vertebral body with reinforced peripheral trabeculae and more lucent center, typically in lumbar spine

"Ivory vertebra" is a blastic vertebra with increased density