Lecture prepared by UKM Radiology resident

1. {
Peadiatric MSK
Presenter: Dr Foo SY
Supervisor: Dr Erica

2. Ñ Child abuse, Shaken baby / infant syndrome,
battered child syndrome and non accidental
trauma
Ñ Whenever an injured child present to ED, NAI
needs to be suspected.
Ñ Fractures and injuries to brain and abdominal
parenchyma are serious manifestation of NAI
Ñ Normal radiograph does not exclude NAI
Non accidental injury
(NAI)

5. Ñ Awareness of child abuse
Ñ Detect occult NAI
Ñ Disrepancy between history and:
Ó Severity of fractures
Ó Fracture-mechanism
Ó Age of fracture
Ñ Be able to document child abuse
Role of radiologist

6. Ñ Axial skeleton
Ó Lateral thoracic & cervical
Ó Lateral skull
Ó AP / PA / RT and LT OBL chest
Ó AP pelvis
Ñ Appendicular skeleton
Ó AP bilateral upper limbs (humerus, ulna/radius
and hands)
Ó AP bilateral lower limbs (femur and tibia/fibula)
Ó AP/PA feet
Skeletal survey

7. Ñ CT scan
Ó Always necessary to evaluate other injuries e.g:
intracranial and solid organ injury, and is very
efficacious for confirmation of fracture that
might be subtle in radiograph.
Ó Always use 3D recon for suspected NAI or
fracture
Ñ Bone scintigraphy
Ó High sensitivity for more subtle fractures that is
not evident on radiograph
Ó However, fractures at physis may be obscured by
normal high uptake at this region
Other imaging option

8. Babygram

9. Ñ No value to clinician as:
Ó A degree of rotation of either the skeletal system
or chest and abdominal parenchyma
Ó The radiograph is either over- or underexposed
Ó There may be a degree of motion unsharpness as
baby could not be properly immobilized
resulting in repeat radiographs and unnecessary
exposure to ionizing radiation.
Babygram

12. Ñ Rib fractures in children <3 years, 95% indicator
of abuse especially posteromedial rib fracture
Ñ Because it is cause by squeezing the chest
anterior and posteriorly levering the
posteromedial ribs over transverse process
Ñ This causes multiple posteromedial rib
fractures
Posteromedial rib fracture

13. Ñ Note that CPR wont cause posteromedial rib
fracture as the back is supported during CPR
Ñ Multiple lateral rib fractures can be cause by
MVA or metabolic cause such as rickets
Ñ CT scan help to assess soft tissue changes such
as pulmonary contusions, pleural effusions and
extrapulmonary soft tissue swelling and
haemorrhage.
Posteromedial rib fracture

14. Posteromedial rib fracture

20. Ñ When small piece of bone is avulsed due to
shearing forces on the fragile growth plate
Ñ Often subtle and the likelihood of detection is
directly related to the quality of the studies
Metaphyseal corner
fracture

23. Ñ Same as corner fractures
Ñ Avulsed bone fragment is larger and seen ‘en
face’ as a disc or bucket handle.
Ñ Common in proximal humerus, distal femur,
and tibia
Ñ Frequently bilateral
Bucket handle fracture

26. Ñ Both bucket handle fracture and metaphyseal
corner fracture have high specificity for child
abuse in infant (Usually < 1year old) as they are
not yet walking
Ñ The mechanism is due to violent shaking of
young child

28. Ñ Non-specific as can happen in both accidental
and non-accidental injury
Ñ Therefore age of the child and history is very
important
Diaphyseal fracture

30. Ñ Callus generally forms no earlier than 5 days
after a fracture but will usually form by 14 days
Ñ So a fracture with minimal callus is at least 5
days old
Ñ And fractures without visible callus may be up
to 14 days old
Ñ Large amount callus indicate at least 2 weeks
old
Ñ Metaphyseal fractures do not typically heal
with callus as there is no periosteal reaction
Fracture healing

32. Ñ A child fell from bed yesterday will not have fracture with callus
formation

33. Ñ Infant skull is very resistant to trauma; any
fracture that is inconsistent with the history
should raise suspicious of NAI
Ñ Patterns of fracture suggestive of abuse:
Ó Fracture crossing suture
Ó Occipital impression fractures
Ó ‘eggshell’ fracture
Skull fracture

37. Ñ Leading cause of morbidity and mortality in
infants and children
Ñ Baby’s neck muscles are weak and its head is
larger and heavy in proportion to the rest of its
body.
Ñ Infant brain is poorly myelinated and
surrounded by larger subarachnoid spaces.
Ñ So when the baby is shaken, the neck snap back
and forth, much like whiplash
CNS injury

39. Ñ Subdural or subarachnoid bleeding
Ñ Diffuse axonal injury ad associated cerebral
edema
Ñ Subdural effusion
Imaging study

40. Ñ Old subdural bleed (Yellow)
Ñ New subdural bleed (Red)
Subdural hematoma

41. Ñ Due todisruption of bridging veins extending from cortex to
dural sinuses
Subdural hematoma

42. Ñ T1W bilateral fluid
collection due to
acute on chronic
SDH

43. Ñ Seen in autopsy of young infant
Ñ Common injuries are liver laceration, duodenal hematoma /
visceral perforation, adrenal bleeding and pancreatic laceration
Visceral injury

44. Pancreatic laceration

45. Liver laceration

46. Ñ Retinal hemorrhage
Ó Seen nearly in all cases of infant NAI in which shaking is
documented.
Ñ Cervical spine compression
Ó Result from shaking
Ó Infant are prone to spinal cord injury because of their large head and
weak underdeveloped paraspinous and neck muscle
Other injury

47. Ñ Accidental injury
Ó Birth trauma (rib fractures) resulting from high birth weight however
rare
Ó SDH post MVA
Ñ Osteogenesis imperfecta (generalized osteoporosis, wormian
bones, bowing and angulation of healed fractures and progressive
scoliosis); other features such as blue sclera, hearing impairment,
bruising and short stature.
Ñ Rickets (Vit D deficiency, metaphyseal fraying, cupping and
irregularity along physeal margin)
Ñ Coagulopathy such as hemophilia and hypoprothrombinemia
cause by Vit K deficiency
Ñ Manke’s disease : a very uncommon inborn error of metabolism.
Patients small metaphyseal hooks can resemble corner fractures.
Ñ Metaphyseal dysplasia : the metaphysis is irregular resembling old
corner fracture
Differential diagnosis

48. Big baby with traumatic
delivery

49. Osteogenesis imperfecta

50. Salter Harris fracture

51. Ñ Unfused physis is the weakest part.
Ñ An injury that can cause ligament sprain in
adult may result in physeal fracture in a child.
Ñ Salter Harris classifies physeal fracture based
on involvement of physis and adjacent
metaphysis
Ñ The higher the classification the greater chance
of growth disturbance
Salter Harris classification

52. There are three major differences:
1. Children have growth plates that:
§ have the consistency of hard rubber and act as shock absorbers
§ protect the joint surface from sustaining a comminuted fracture
§ are weaker than the ligaments. Consequently the epiphysis will
separate before a dislocation (i.e. ligamentous disruption)
occurs.
2. Children have a thick periosteum that:
§ is not only thick but very strong
§ acts as a hinge, which inhibits displacement when a fracture
occurs.
3. Children’s bones have an inherently different structure to adults’
bones, being:
§ less brittle
§ flexible, elastic, and plastic, allowing an injured bone to bend
or to buckle.
Child VS adult skeleton

53. Ñ Injury limited to physis
Ñ Often radiographically occult if the epiphysis is
not displaced
Ñ Physis may be asymmetrically widened
Ñ Diagnosis can be suggested based on soft-tissue
swelling around the physis
SH type I

54. Ñ Fracture extends to metaphysis
Ñ Non-displaced fracture of ulnar aspect of the base of 3rd proximal
phalanx extends to physis
SH type II

55. Ñ Fracture extends to physis and lateral displacement of epiphyseal
fragment
SH type III

56. Ñ Fracture through
metaphysis, physis and
epiphysis
SH type IV

57. Ñ Resulting from axial loading forces exert along
the long axis of a long bone
Ñ “greenstick” fracture comes from the compison
with the ‘green’ supple tree branch as it breaks
if it is bent
Greenstick fracture

59. Ñ Also known as buckle fracture
Ñ Means protuberance in Latin
Ñ Caused by axial load induced
compression farctures which
manifest as buckling, kinking or
notching of cortex
Ñ Occur most frequently in
metaphysis of long bone due to
the weakest point of cortex
Torus fracture

60. Types of Torus fracture

61. Ñ Axial loading force (1)
exerted down the
length of the bone.
Ñ Other forces such as
valgus

62. Ñ Shifting of the axial load
axis (3) and compression
of the underlying
metaphysis (2)

63. Ñ Typical angled buckle
fracture of the distal radius

66. Ñ Injury to the elbow joint is due to
hyperextension or extreme valgus due to fall on
outstretched arm.
Ñ Supracondylar fracture is the most common
paediatric elbow fracture.
Ñ Follow by lateral condyle fracture
Ñ In adult, radial head fracture is the most
common
Elbow fracture

67. Mechanism

68. Mechanism

69. Mechanism

70. Mechanism

72. Ñ Normal elbow has valgus
positioning
Ñ When a child fall on
outstretched arm, this can
lead to extreme valgus
Extreme valgus

73. Ñ On the lateral side, this can
result in dislocation or
fracture of the radius with
or without involvement of
the lateral condyle
Extreme valgus

74. Ñ When the forces have more
effect on the humerus, it
may cause lateral condyle
fracture
Extreme valgus

75. Ñ On medial side, valgus
force can lead to avulsion
of medial epicondyle
Extreme valgus

76. Ñ Sometimes, medial
epicondyle becomes
trapped within the joint
Extreme valgus

78. Ñ Are the fat pad normal?
Ñ Is the anterior humeral line normal?
Ñ Is the radiocapitellar line normal?
Ñ Are the ossification centres normal?
Important questions while
assessing paediatric elbow

80. v

82. Ñ Nondisplaced spiral fracture through tibial
metadiaphysis
Ñ Caused by rotational force to the leg
Ñ Commonly occur when a child first begin to
walk and refuse to bear weight on the affected
side
Ñ Oblique view demonstrate the fracture better
Ñ Other types of toddler fracture include stress-
type fractures involving the calcaneus and
cuboid
Toddler fracture

85. Ñ Apophysis: growth plate that does not
contribute to longitudinal growth
Ñ Pelvic apophyses close relatively late in skeletal
development thus susceptible to avulsion
Ñ Apophyseal avulsion fractures occur most
commonly in athletic adolescents, who have
strong muscles and open apophyses
Ñ Acute injuries appear as an avulsed bone
fragment
Pelvis apophysis avulsion

86. Pelvis apophysis avulsion

87. Ñ Onset of infection less the 2 weeks
Ñ Primarily a disease of infant and children
Ñ Usually occur as hematogenous spread (recent URTI or otitis media)
Ñ Direct bone infection may occur with:
Ó Penetrating injury
Ó Compound fractures
Ó Extension of soft issue infection
Ó Post surgery
Ñ Common organism: Staphylococcus aureus
Ñ 75% involve metaphyses (due to rich and slow moving blood)
Ñ Metaphyseal blood supply varies with age:
Ó Infants: epiphysis receives blood supply from transphyseal vessels
arising from metaphysis infection can cross the physis
Ó Older children: capillaries do not cross the physis-transphyseal extension
is uncommon
Acute osteomyelitis

88. Ñ Common sites are femur, tibia and humerus
Ñ Or metaphyseal equivalent flat bone such as pelvis

89. Ñ Earliest radiographic findings:
Ó Deep soft tissue swelling causing displacement /
obliteration of fat planes adjacent to metaphysis
Ñ Bony changes may not be present until 10 days
after the onset
Ó Poorly defined lucency involving metaphyseal
area
Ó Progressive bony destruction
Ó Periosteal new bone formation at approximately
10 days

91. Ñ Reduced right shoulder
movements -5 -6 days.
Ñ Proximal humeral metaphyseal
lytic lesion with benign type
periosteal reaction in diaphysis
suggest osteomyelitis.

92. Ñ Ultrasound
Ó Fluid collection lying adjacent to the bone with
no intervening soft tissue indicates subperiosteal
abscess
Ó Collection can be high or low echogenicity
(nature exudate)
Ó Role in aspiration & drainage

93. Ñ Ultrasound of the right hip shows cortical destruction, the
formation of a subperiosteal fluid collection/abscess and
infiltration of soft tissue.

94. Ñ Proximal humerus ultrasound. Transverse (a) and
longitudinal (b) ultrasound images of the proximal humerus.
Ñ Focal thinning of the humeral cortex (thin white arrow) on the axial
images in keeping with a cortical penetration
Ñ Subperiosteal pus collection (asterisk). T
Ñ Increased Doppler signal (white arrow head) within the synovium of the
long head of the biceps tendon (large white arrow).

95. Ñ CT
Ó Localizing site of infection for drainage
Ó Superior to MRI in chronic OM
Ñ MRI
Ó High T2W signal within a metaphysis
Ó Large areas of surrounding edema-high T2-
weighted signal within the adjacent bone marrow &
soft tissues
Ó Gadolinium: areas of non-enhancement suspicious
for necrosis or abscess formation
Ñ Radionuclide Radiology
Ó 99mTc-MDP highly sensitive for OM (48-72hrs)
Ó 3phase bone scan –increase uptake on all phases

96. Ñ Brodie’s abscess is a unique form of subacute abscess
(intraosseous bone abscess)
Ñ Consisting of walled-off intraosseous infection
surrounded by granulation tissue and sclerotic bone.
Ñ Plain film
Ó Well-defined lucent metaphyseal lesion with sclerotic rim
Ó Finger-like extension into neighbouring bone
Ó 40% show periosteal new bone formation
Ñ MRI
Ó low to iso signal on T1, high on T2 and STIR. Sclerotic
margin appears as low signal in ALL seq
Ó Penumbra sign (T1), double line sign (T2 & STIR) –
characteristic, but NOT pathognomonic
Ñ DDx : osteoid osteoma, stress fracture
Subacute OM

98. Ñ Sagittal PDFS
Ñ Central fluid seignal within
distal femoral metaphysis and
surrounding edema
Ñ Fluid signal extend through
anterior cortex into prefemoral
fat
Ñ Moderate joint effusion

99. Ñ Infection > 6 weeks duration
Ñ Plain radiograph
Ó Mixed lesion with both areas of cortical
destruction / focal cortical thickening periosteal
new bone formation, cortical defects and
sequestrum.
Ñ Scintigraphy
Ó Indium-labelled leucocytes (more specific than
MDP)
Chronic OM

100. Ñ Sequestrum: devascularized portion of bone
with necrosis and resorption of surrounding
bone leaving floating piece. May be encased by
involucrum
Ñ Involucrum: thick sheath of periosteal new
bone
Ñ Cloaca: space in which dead bone resides. May
develop sinus tract to skin
In untreated / partially
treated

101. Chronic OM

102. Ñ Growth plate destruction
Ñ Sinus tracks with discharge of sequestra
Ñ Extensive bone destruction with modelling
deformity
Ñ AVN (meningococcal spp)
Ñ Pathological fracture
Ñ Premature OA
Complication

103. Ñ Periosteal reaction
Ó Ewing’s sarcoma
Ó Leukaemia
Ó Minor injury
Ñ More reactive stage with bone destruction
Ó Eosinophilic granuloma
Ó Leukaemia
Ó Metastatic neuroblastoma
Differentials

104. Ñ Chronic Recurrent Multifocal Osteomyelitis
Ñ Sclerosing Osteomyelitis of Garre
Ñ Tuberculous Infection
Ñ TORCH Infection
Specific type of OM

105. Ñ Idiopathic inflammatory bone disorder seen primarily in
children and adolescents
Ñ Unknown aetiology but may be related to autoimmune
disorders
Ñ Often a diagnosis of exclusion once underlying infection and
neoplasia has been ruled out
Ñ Clinical features: history of chronic multifocal bone pain
Ñ Common sites: medial ends of clavicles (characteristic finding-
uncommon location for haematogenous OM), metaphyseal
ends of lower extremity, spine, pelvis and facial bones
Ñ Radiograph: early stages-osteolytic lesion, later stages-
progressive sclerosis
Ñ Associated with SAPHO Syndrome-Synovitis, Acne,
Pustulosis, Hyperostosis & Osteitis (seen in adult)
Chronic recurrent
multifocal OM

106. Ñ left clavicle shows sclerosis and expansion of its medial aspect
(arrow), while the lateral aspect is normal

107. Ñ An uncommon chronic form of osteomyelitis,
usually occurring in children, and commonly affects
the mandible.
Ñ Patients present with pain and hard swelling of the
mandible.
Ñ OPG: localized overgrowth of bone on outer surface
of cortex. It is supracortical but subperiosteal,
smooth, fairly calcified, often described as
dupplication of cortical layer of the mandible
Ñ Th eredundant cortical layering of the bone (Onion
skining) is pathognomonic
Sclerosing Osteomyelitis of
Garre

108. Ñ Sclerosis of the left mandible

109. Ñ Diffuse sclerotic changes with expansion of the left mandibular
body and diffuse soft tissue thickening

110. Ñ Follow haematogenous spread (and is usually
from the lung with active chest disease in < 50%
of cases)
Ñ Diagnosis is usually made after some delay,
with radiographic changes often seen at
presentation
Ñ Spine most common –over 50% of children
Tuberculous infection

111. Ñ Bone destruction is prominent, more rolonged
onset than with pyogenic bone destruction
Ñ Loss of disc height
Ñ Gibbus deformity : anterior vert body
involvement with normal posterior vertebral
body (Khyphosis)
Ñ Involvement of several adjacent vert bodies
with disc destruction
Ñ Large paraspinous abscess
Ñ Psoas abscess
Radiographic feature of
TB spine

113. Ñ T1: hypointense marrow in adjacent vertebrae
Ñ T2: hyperintense marrow, disc, soft tissue infection
Ñ T1 C+: marrow, subligamentous, discal and dural enhancement

115. Ñ Transplacentallyacquired infections by
TORCH: Toxoplasmosis, Other (syphilis),
Rubella, Cytomegalovirus, Herpes.
Ñ Congenital Rubella syndrome
Ó Onece common transplacental viral infection
before rubella vaccine
Ó Bony changes are present 50% of cases
Ó Irregular fraying of metaphyses of long bones
Ó Generalized lucency of metaphyses
Ó Celery stalk appearance
TORCHES infection

116. Celery stalk metaphysis

117. Ñ Congenital syphilis
Ó 2nd/3rdtrimester
Ó Bony changes are present in 95% of patients but
often do not appear until 6 to 8 weeks after the time
of infection
Ó Non specific metaphyseal lucent bands
Ó Serrated metaphyses
Ó Multiple fractures
Ó Lytic skull lesions
Ó Periosteal reactions involving multiple long bones
Ó Wimberger corner sign is most specific: destruction
of medial portion of the proximal metaphysis of
tibia resulting in an area of irregular lucency

118. Wimberger sign

119. Ñ Orthopedic emergency as joint destruction and
growth arrest may occur without prompt
washout and antibiotics
Ñ Usually secondary to hematogenously seeded
metaphyseal OM that infect the joint capsule
Ñ Presented with fever, irritability, painful &
swollen joint with failure to move the affected
limb
Ñ Commonly caused by Staph. Aureus
Ñ Most are monoarticular and hip is most
common follow by knee
Septic arthritis

120. Ñ Radiograph
Ó Widening of joint space (effusion) (Hip radiograph
measure from tear drop to medial cortex of femur
>2mm)
Ó Displacement of pericapsular fat plane
Ó Soft tissue swelling
Ó Delayed radiograph : erosion of articular cartilage
Ñ USG: demonstrate joint effusion, fluid aspiration
Ñ MRI: role to demonstrate joint effusion, marrow
changes of adjacent bones (i.e. Infective sacroiliitis)
Ñ Complication: AVN, epiphyseal slip, complete
disorganization of joint with growth disturbance,
secondary OM & OA changes

122. Ñ Isolated discitis is unique to children due to
direct blood supply to intervertebral disc
Ñ Common in childhood (2-6yrs old)
Ñ Hematogenous spread –Staph. Aureus via
arterial blood or backflow through the
perivertebral venous plexus
Ñ Begin in the anterior subchondral space (near
end plate), erodes disc space and adjacent
vertebral body
Ñ Present with back pain or refuse to sit
Ñ More common in lumbar
Spinal OM / discitis

123. Ñ Disc space narrowing with erosion of the adjacent
vertebral end-plate
Ñ Vertebral destruction with paravertebral abscess
seen as soft tissue mass adjacent to vertebral body
Ñ MRI –
Ó signal abnormalities in involved disc, adjacent end
plate changes and marked inflammatory oedema of
adjacent vertebral bodies.
Ó Post Gad shows complications –psoas abscess and
epidural collection
Ñ CT –guided drainage aspiration/drainage.
Ñ Poor respond despite treatment –suspect TB
Spinal OM / discitis

124. Ñ Sag T1 showed hypointense marrow signal
Ñ Sag T2 FS showed hyperintense marrow edema in affected
vertebral bodies with subtle focal narrowing of disc space
Ñ Sag T1 post gad FS showed avid enhancement traversing disc
space
Spinal OM / discitis

125. Ñ Cellulitis: superficial subcutaneous infection
Ó USG: Thickened skin and subcutaneous tissues, low
reflective septa (fluid tracking between
subcutaneous fat lobules)
Ó MRI T2WI: thickened septa yield increased SI,
increased SI within the skin and underlying fascia
Ñ Pyomyositis: muscular infection (usually in an
immunocompromised patient)
Ó USG: generalized alteration in muscle echogenicity
Ó MRI: T2WI heterogeneous increased SI throughout
the muscle, formation of fluid pockets with disease
progression (with similar imaging characteristics to
an abscess)
Soft tissue infection

126. Ñ Benign criteria of bone tumors
Ó Well-defined margin
Ó Sclerotic rim
Ó Expanding lesion
Ó No periosteal reaction
Ó No extraosseous soft tissue component
Ó Narrow zone of transition
Bone and tissue tumors

127. Ñ Malignant Criteria of Bone Tumors
Ó Ill defined margin
Ó Cortical destruction
Ó Periosteal destruction
Ó Extraosseous extension
Ó Intra articular invasion
Ó Wide zone transition.
Bone and tissue tumors

128. Ñ Bone forming tumors
Ñ Cartilage forming tumors
Ñ Fibrous lesion
Ñ Bone marrow tumors
Ñ Other bone tumors
Ñ Metastases
Ñ miscellaneous
Bone tumors

129. Ñ Bone island
Ñ Osteoblastoma
Ñ Osteoma
Ñ Osteoid osteoma
Benign bone forming
tumor

130. Ñ Rare bone tumor and may be locally aggressive
Ñ Larger in size (>2cm)
Ñ Histologically similar to osteod osteoma
Ñ Occur around 2nd to 3rd decade
Ñ More common in male
Ñ Location: posterior element of spine, may also
occur in femur and tibia
Osteoblastoma

131. Ñ Lytic lesion with mineralization
Ñ Expansile well-circumscribed lesion similar to
ABC
Ñ Lytic lesion in posterior element of young
person may represent osteoblastoma / ABC
Ñ If mineralization is present - osteoblastoma
Ñ Rarely aggressive with soft tissue mass but lack
metastatic potential
Radiographic features

132. Ñ A: expanding 3cm tumor in
L4 with ossified nidus
Ñ B: heavily mineralized
tumor involving body of T3
Ñ C: heavily mineralized
tumor of C4
Ñ D: lucent tumor of L1 with
expansion

134. Ñ Slow growing lesion that may arise from cortex
of skull or frontal / ethmoid sinuses
Ñ Arise from cortex rather than the medullary
canal
Ñ Multiple osteomas, intestinal polyposis and
soft tissue dermoid tumors – Gardner
syndrome
Ñ Radiographic features: very radiodense lesion
Osteoma

135. Osteoma

136. Ñ Most occur in second decade of life and usually
present with pain
Ñ Classically pain worse at night and is relieved
by NSAID (Aspirin)
Ñ More common in male
Ñ Commonly occur within cortex of the
metadiaphysis or diaphyses of lower
extremities long bones
Osteoid osteoma

137. Ñ Radiograph:
Ó lucent cortical nidus surrounded by reactive
sclerosis (<2cm)
Ó Classically punctate radiodensity identify within
central lucency (dense dot within a lucent area)
Ñ CT better demonstration of the punctate central
radiodensity and CT guided ablation / drill
removal
Radiographic features

139. Ñ Osteosarcoma
Malignant bone forming
tumor

140. Ñ Most common primary bone malignancy of
childhood
Ñ Commonly between 10 and 15 years old and
more common in male.
Ñ Majority of osteosarcoma arise from medullary
cavity
Ñ Common site is metaphyses of long bone and
>60% in the region of knee (distal femur or
proximal tibia)
Osteosarcoma

141. Ñ Radiograph destructive lesion at
metaphysis of long bone, poorly
demarcated margin, Codman’s
triangle, aggressive periosteal
reaction (sunburst) & soft tissue
mass. May cross the growth plate
Radiographic features

142. Ñ MRI to evaluate extent of bone and soft tissue involvement for
presurgical planning.
Ñ Extent of marrow abnormality, soft tissue mass and cortical
destruction has increased signal intensity in T2W
Ñ MRI also accurate in depicting relationship of tumor and
adjacent nerves amd vascular structure
Ñ Entire length of long bone must included (joint to joint) as
osteosarcoma can have skip lesion
Radiographic features

143. Ñ T1W and post Gad showed
intramedullary lesion and
enhancement

144. Ñ Chondroblastoma
Ñ Enchondroma
Ñ Enchondromatosis
Ñ Maffucci’s syndrome
Ñ Osteochondroma (Exostosis)
Ñ Hereditary multiple exostoses
Ñ Chondromyxoid fibroma
Benign cartilage forming
tumors

145. Ñ Occurring predominantly in young patients
(<20 years of age) with an overall male
predilection
Ñ Located eccentrically in epiphysis of long
bone in skeletally immature patient
Ñ Commonly occur in proximal humerus / knee
Ñ Radiographic features: well defined lytic lesion
with either smooth or lobulated margins with a
thin sclerotic rim
Chondroblastoma

147. Ñ most frequently diagnosed in childhood to
early adulthood with a peak incidence of 10-30
years
Ñ 2nd commonest benign chondral lesion (after
osteochondroma)
Ñ Location
Ó small tubular bones of the hands and feet : 50%
more in the proximal phalanges.
Enchondroma

148. Ñ Radiographic features
Ó benign features
Ó Expansile lytic lesions in the bone of the hand
and foot
Ó Chondroid calcifications: Rings and arch patterns
(O and C)
Enchondroma

150. Ñ Multiple enchondromas
Ñ Multiple radiolucent expansile masses in hand and feet
Enchondromatosis (Ollier
disease)

151. Ñ Benign cartilage-capped bony growth
projecting outward from bone
Ñ Often pedunculated
Ñ May present clinically as palpable mass which
usually stops growing at skeletal maturity
Ñ Arise from metaphysis and grows away from
the epiphysis
Ñ Uncommon complication is malignant
transformation to chondrosarcoma
Osteochondroma

152. Ñ Radiograph and CT: 5C
Ó Continuous with parent bone
Ó Uninterrupted cortex
Ó Continuous medullary bone
Ó Calcification in the chondrous portion of cap,
may be cauliflower-like
Ó Metaphyseal location (Cartilaginous origin)
Ó Lesion grows away from joint
Radiographic features

153. Radiographic features

154. Ñ MRI:
Ó Cortical and medullary continuity between the
osteochondroma and the parent bone
Ó Cartilage cap has similar intensity as aother
cartilage with intermediate to low signal on T1
and high signal on T2
Ó Cartilage cap >1.5cm is suspicious of malignant
degeneration
Ó Post gad: enhancement in tissue that cover the
cartilaginous cap; however the cartilaginous cap
should not enhance
Radiographic features

156. Ñ Multiple osteochondromas
Ñ Most patient diagnosed by the age of 5 years
old
Ñ Autosomal dominant inheritance pattern
Ñ Malignant transformation is more common
Hereditary multiple
exostoses

157. Hereditary multiple
exostoses

158. Ñ Fibrous cortical defect (FCD) & Non-ossifying
fibroma (NOF)
Ñ Fibrous dysplasia
Ñ Ossifying fibroma
Ñ Liposclerosing Myxofibrous tumor (LSMFT)
Benign fibrous lesions

159. Ñ benign bony lesions and are a type of fibroxanthoma
Ñ Histologically identical to the larger NOF
Ñ Typically occur in children (2-15 years)
Ñ More common in male
Ñ Typically occur in the metaphysis or diametaphyseal
junction
Ñ Appear as small (<2-3 cm) lucent defects within the
cortex that over time become sclerotic as they heal.
Ñ Located in the distal femur or proximal or distal
tibia
Fibrous cortical defect (FCD) /
Non-ossifying fibroma (NOF)

160. Ñ Lucent intracortical defects
Ñ Thin rim of sclerosis
Ñ Small (<2-3cm), larger in NOF
Ñ No involvement of the underlying medullary
cavity
Ñ No periosteal reaction
Ñ MRI: T1 hypointense, T2 variable depending on
phase of healing
Radiographic features

162. • Non-neoplastic tumour-like congenital process,
manifested as a localised defect in osteoblastic
differentiation and maturation, with replacement
of normal bone with large fibrous stroma and
islands of immature woven bone.
• FD can affect any bone & divided into 4
subtypes 8:
▪ Monostotic: single bone
▪ Polyostotic: multiple bones
▪ Craniofacial fibrous dysplasia: skull and facial bones
alone
▪ Cherubism: mandible and maxilla alone (not true
fibrous dysplasia)
Fibrous dysplasia

163. Plain radiograph
• Ground-glass matrix
• May be completely lucent (cystic) or sclerotic
• Well circumscribed lesions
• No periosteal reaction
• Rind sign
Pelvis and ribs
•Ribs are the most common site of monostotic
•Bubbly cystic lesions
•Fusiform enlargement of ribs
Extremities
• May lead to premature fusion of growth plates leading to
short stature
• Bowing deformities; Shepherd crook deformity of the
femoral neck

165. Ñ Mixed lytic sclerotic lesion Some areas appear to have a ground-
glass appearance.

166. CT
▪ Ground-glass opacities: 56%
▪ Homogeneously sclerotic: 23%
▪ Cystic: 21%
▪ Well-defined borders
▪ Expansion of the bone, with intact overlying bone
▪ Endosteal scalloping may be seen
MRI
• MRI is not particularly useful in differentiating fibrous dysplasia from
other entities
• Marked variability in the appearance of the bone lesions, and they can
often resemble a tumour or more aggressive lesions.
• T1: heterogeneous signal, usually intermediate
• T2: heterogeneous signal, usually low, but may have regions of higher
signal
• T1 C+ (Gd): heterogeneous contrast enhancement

167. ÑRhabdomyosarcoma
ÑFibrosarcoma
Malignant tumor of
fibrous tissue

168. •Accounts for more than 50% of soft-tissue sarcomas in
children
•It can be found anywhere within the body, even in sites
that lack striated muscle
•Head & neck and GU system are the most commonly
affected regions, with less than 20% of the cases
occurring in the extremities
Rhabdomyosarcoma

169. •MRI:
▪ T1W: low or isointense
▪ T2W: high
▪ Post Gad: variable enhancement

170. •Rare soft tissue tumor in infants and children located in extremities
•10% of all sarcomas in children
•Mostly presented as a tumor of extremities, trunk, head & neck
•Plain radiograph
▪ Typically highly destructive with a wide zone of transition &
occasionally expansile
▪ Periosteal reaction is uncommon
▪ Often associated with a large soft tissue mass extending from the
bone
•MRI
▪ T1: isointense to muscle
▪ T2: hyperintense to muscle
▪ T1C+: avid contrast enhancement (may be uniform or
heterogeneous)
Fibrosarcoma

172. Ñ Eosinophilic granuloma
Ñ Primary Lymphoma
Ñ Ewing’s sarcoma (malignant)
Bone marrow tumors

173. • Also known Langerhans Cell Histiocytosis (LCH)
• Non-neoplastic intraosseous lesion which cause local
osteolysis
• May present as painless soft tissue swelling
• Frequent site : skull, vertebrae and pelvis. Lesion in
jaw – floating tooth appearance
• 75% of all cases occur in children and adolescene
• Plain radiograph – well/ill-defined osteolytic area,
cortical destruction, onion-like periosteal reaction.
• DDx : OM, Ewing’s sarcoma
Eosinophilic granuloma

174. •Plain radiograph
▪ Solitary or punch out lesion with or without sclerotic
rim
▪ Double contour or beveled edge appearance maybe
due to greater involvement of the inner compare to
outer table in skull
•CT – osseous lesion & assess extent of lesion (cortical
destruction & soft tissue involvement)
•MRI
▪ T1: iso to high signal
▪ T2: high
▪ Post gad: marked contrast enhancement. Good for
demonstrating marrow involvement and soft tissue
mass

176. • Lymphoma potentially involves all segments, but diaphysis of
tubular bones are most common site
• Plain radiograph
▪ Affected bone may be normal or
affected by lytic, sclerotic or mixed
pattern
▪ Most common: lytic pattern
with permeative bone destruction and a
wide zone of transition
• MRI: Associated soft tissue masses are common. Bone
marrow changes include:
ÔT1: low signal
ÔT2: high signal
Primary lymphoma of bone

178. Ñ Second most common primary peadiatric bone
tumor
Ñ It is an aggressive, small round cell tumor of
neuroectodermal differentiation
Ñ Commonly arise from femoral diaphysis
followed by flat bones of the pelvis.
Ñ May also involve tibia, humerus and ribs
Ñ Often causes soft tissue mass
Ñ Lung is the most common site of metastasis
Ewing sarcoma

179. Ñ Occur in children and adolescents between 10
and 20 years old (95% between 4 and 25 years
old)
Ñ Common in male than female.
Ewing sarcoma

180. Ñ Radiograph: permeative lesion in medullary
cavity with wide zone of transition and
associated aggressive lamellated (onion-skin)
or spiculated periosteal reaction
Ñ Occasionally have codman triangles
Ñ MRI demonstrate destructive bony mass often
with associated soft tissue component
Radiographic features

182. ÑSimple bone cyst
ÑAneurysmal bony cyst
Other bone tumors

183. • Juvenile bone cyst/ solitary/ unicameral cyst
• Benign lesion – originate from centre of metaphysis, migrates
down to shaft of bone when matures
• Common site : femur, humerus near to the epiphyseal plate
• Expands the bone, causing thinning of cortex
• Fallen fragment sign
• Cyst: Smooth margin, filled with clear or sanguinous fluid
• MRI – iso on T1, high on T2.
• Usually incidental finding
Simple bone cyst

185. • Benign, solitary expansile lesion
• Occur at vertebral appendages, flat bone and metaphysis of long
bones of femur, tibia/humerus; developed eccentrically, without
crossing the growth plate
• Usually multilocular with poorly defined margins
• Plain radiograph – characteristic in metaphysis of long bones,
adjacent to unfused growth plate
• CT – bone destruction
• MRI – Cor T2 for visualization main cystic lesion, additional cyst
and fluid filled within the lesion. Gradient echo better contrast
between cyst and bone marrow
Aneurysmal bone cyst
(ABC)

189. Ñ DDH
Ñ Slipped upper femoral epiphysis (SUFE) or
slipped capital femoral epiphysis (SCFE)
Ñ Perthes disease
Hip disorder

190. Ñ A condition related to abnormal development
and configuration of the acetabulum and to
increased ligamentous laxity around the hip
Ñ Ultrasound is used to evaluate the hips
suggestive of DDH. Normal alpha angle is > 60
(bony portion of the acetabular roof should
cover at least 50% of the femoral head).
Ñ Both the morphology of the acetabulum and
any abnormal mobility of the hip are evaluated.
DDH

192. Ñ Radiograph assessment after femoral head ossify (after 6 months)

193. Ñ Acetabular angle formed by the Hilgenreiner line and a line
drawn through the acetabular roof
Ñ A neonate should normally have an acetabular angle of <30
degree
Ñ At beyong 1 year old should be < 22 degree

194. Ñ Idiopathic type I Salter Harris fracture through
proximal physis of femur results in
displacement (slippage of femoral epiphysis)
Ñ Common in obese child
Ñ More in male
Ñ Typical age between 12 to 15 years old
Ñ Hip can be involved bilaterally in up to one
third of patients
Ñ Complications include AVN and chondrolysis
SUFE

195. Ñ The slippage femoral head is posterior and to
lesser extent medial
Ñ More prominent in frog-leg lateral view
Ñ On the AP view, a line drawn up the lateral
edge of the femoral neck (Klein’s line) fails to
intersect the epiphysis

197. Ñ Idiopathic avascular necrosis of the proximal femoral epiphysis
Ñ commonly in boys
Ñ typically between 5 and 8 years old
Ñ Affected children present with pain in the groin, hip, or ipsilateral
knee
Ñ Can be bilateral in 13% of cases. Often associated with skeletal
immaturity (decreased bone age), sickle cell disease or steroids.
Ñ Radiographs are usually positive even in early disease:
Ó asymmetric, small, ossified femoral epiphysis
Ó Widening of the joint space
Ó Subchondrallinear lucency(crescent sign) -represents a fracture through
the necrotic bone
Ñ Late findings: changes in the femoral epiphysis-fragmentation,
areas of increased sclerosis and lucency & loss of height
Perthes disease

198. Perthes disease

199. Ñ If suspected and radiograph is nondiagnostic,
diagnosis can be made with MRI / bone
scintigraphy
Ñ T1W loss of fatty marrow signal
Ñ T2W high signal marrow edema
Ñ Post Gad asymmetric decreased enhancement
Ñ Bone scintigraphy: asymmetric lack of uptake
Perthes disease

201. Thank you